Birgitta Wireklint Sundström

Developing a decision support system for geriatric patients in prehospital care.

Objectives To develop a feasible and safe prehospital decision support system (DSS) for the emergency medical services (EMS), facilitating safe steering of geriatric patients to an optimal level of healthcare. Methods The development process involves four consecutive steps. The first step was gathering data from patients transported by EMS, with the electronic patient care record, to retrospectively identify appropriate patient categories for steering. The second step was to allow a group of medical experts to give advice and suggestions for further development of the DSS. The third step was validation of the decision support tool and the fourth step was validation of the entire prehospital DSS in a pilot study. Results The patient categories relevant to steering were those medical conditions that the geriatric clinicians felt confident in receiving from the EMS. A prehospital DSS was then developed for these 11 medical conditions. The evaluation and validation of the DSS showed a high degree of compliance with the patients’ final level of healthcare. The pilot study included 110 randomized patients; 33.9% were triaged to an alternative level of healthcare, that is geriatric care or primary care. No medical inaccuracies or secondary transports from alternative care to the hospital emergency department were identified. Conclusion Using this prehospital DSS – developed for 11 medical conditions – the Swedish prehospital nurse can safely decide on the level of healthcare to which an elderly patient can be steered.

Comparison of the university hospital and county hospitals in western Sweden to identify potential weak links in the early chain of care for acute stroke: results of an observational study

Objective To identify weak links in the early chain of care for acute stroke. Setting 9 emergency hospitals in western Sweden, each with a stroke unit, and the emergency medical services (EMS). Participants All patients hospitalised with a first and a final diagnosis of stroke−between 15 December 2010 and 15 April 2011. The university hospital in the city of Gothenburg was compared with 6 county hospitals. Primary and secondary measures (1) The system delay, that is, median delay time from call to the EMS until diagnosis was designated as the primary end point. Secondary end points were: (2) the system delay time from call to the EMS until arrival in a hospital ward, (3) the use of the EMS, (4) priority at the dispatch centre and (5) suspicion of stroke by the EMS nurse. Results In all, 1376 acute patients with stroke (median age 79 years; 49% women) were included. The median system delay from call to the EMS until (1) diagnosis (CT scan) and (2) arrival in a hospital ward was 3 h and 52 min and 4 h and 22 min, respectively. The system delay (1) was significantly shorter in county hospitals. (3) The study showed that 76% used the EMS (Gothenburg 71%; the county 79%; p<0.0001). (4) Priority 1 was given at the dispatch centre in 54% of cases. (5) Stroke was suspected in 65% of cases. A prenotification was sent in 32% (Gothenburg 52%; the county 20%; p<0.0001). Conclusions System delay is still long and only a small fraction of patients received thrombolysis. Three of four used the EMS (more frequent in the county). They were given the highest priority at the dispatch centre in half of the cases. Stroke was suspected in two-thirds of the cases, but a prenotification was seldom sent to the hospital.

A shorter system delay for haemorrhagic stroke than ischaemic stroke among patients who use emergency medical service.

We compare various aspects in the early chain of care among patients with haemorrhagic stroke and ischaemic stroke.

The early chain of care and risk of death in acute stroke in relation to the priority given at the dispatch centre: A multicentre observational study

Background: The early chain of care is critical for stroke patients. The most important part is the so-called ’system delay’ i.e. the delay time from call to the emergency medical services until a diagnosis is established (computer tomography). Aim: The purpose of this study was to relate the initial priority level given by the dispatch centre to the early chain of care in acute stroke and to short-term and long-term mortality. Methods: All patients hospitalised with the first and the final diagnosis of acute stroke, 15 December 2010–15 April 2011, were recruited across nine hospitals, each hospital with a stroke care unit. Results: In all, 897 stroke patients were included. Priority at the dispatch centre: 54% received highest priority 1, 41% priority 2 and 5% priority 3. Median system delay from call to emergency medical services until diagnosis by computer tomography was 2 h and 52 min, 4 h and 49 min and 6 h and 33 min respectively in the three priority groups (p<0.0001). There was a similarly strong association between priority level at the dispatch centre and system delay to arrival in a hospital ward, suspicion of stroke by the emergency medical services nurse as well as the physician on hospital admission and the proportion of patients given thrombolysis. Mortality during the subsequent 30 days was 22% among patients with priority 1 and 14% among patients with priority 2. Conclusion: Patients given a lower priority level at the dispatch centre had the longest system delay. Although many of these patients died, the risk of death was highest among those given the highest priority.

Caring science research in the ambulance services: an integrative systematic review

Background The ambulance services are associated with emergency medicine, traumatology and disaster medicine, which is also reflected in previous research. Caring science research is limited and, since no systematic reviews have yet been produced, its focus is unclear. This makes it difficult for researchers to identify current knowledge gaps and clinicians to implement research findings. Aim This integrative systematic review aims to describe caring science research content and scope in the ambulance services. Data sources Databases included were MEDLINE (PubMed), CINAHL, Web of Science, ProQDiss, LibrisDiss and The Cochrane Library. The electronic search strategy was carried out between March and April 2015. The review was conducted in line with the standards of the PRISMA statement, registration number: PROSPERO 2016:CRD42016034156. Review methods The review process involved problem identification, literature search, data evaluation, data analysis and reporting. Thematic data analysis was undertaken using a five‐stage method. Studies included were evaluated with methodological and/or theoretical rigour on a 3‐level scale, and data relevance was evaluated on a 2‐level scale. Results After the screening process, a total of 78 studies were included. The majority of these were conducted in Sweden (n = 42), fourteen in the United States and eleven in the United Kingdom. The number of study participants varied, from a case study with one participant to a survey with 2420 participants, and 28 (36%) of the studies were directly related to patients. The findings were identified under the themes: Caregiving in unpredictable situations; Independent and shared decision‐making; Public environment and patient safety; Life‐changing situations; and Ethics and values. Conclusion Caring science research with an explicit patient perspective is limited. Areas of particular interest for future research are the impact of unpredictable encounters on openness and sensitivity in the professional–patient relation, with special focus on value conflicts in emergency situations.

‘A little good with the bad’: Newly diagnosed type 2 diabetes patients’ perspectives on self-care: A phenomenological approach

Increased knowledge is needed about what self-care means from the patients’ perspective, especially since the patient population with type 2 diabetes has been rising. The aim was to describe self-care, as experienced by patients with newly diagnosed type 2 diabetes. This study adopted a phenomenological approach. Eight patients were interviewed. A combination of photos and interviews were used. The essential meaning of self-care was found to be an existential struggle that evokes feelings of being in-between one’s old unhealthy life and a new healthier one. In this in-between condition, tension exits between contradictorily emotions of anxiety, hopelessness and hope. This struggle also means questioning one’s identity. It is important that diabetes nurses create an opening for reflection and dare to challenge their patients to reflect on this existential struggle.

Prehospital identification of factors associated with death during one-year follow-up after acute stroke.

In acute stroke, the risk of death and neurological sequelae are obvious threats. The aim of the study was to evaluate the association between various clinical factors identified by the emergency medical service (EMS) system before arriving at hospital and the risk of death during the subsequent year among patients with a confirmed stroke.

Trust in the early chain of healthcare: lifeworld hermeneutics from the patient’s perspective

ABSTRACT Purpose: Patients must be able to feel as much trust for caregivers and the healthcare system at the healthcare centre as at the emergency department. The aim of this study is to explain and understand the phenomenon of trust in the early chain of healthcare, when a patient has called an ambulance for a non-urgent condition and been referred to the healthcare centre. Method: A lifeworld hermeneutic approach from the perspective of caring science was used. Ten patients participated: seven female and three male. The setting is the early chain of healthcare in south-western Sweden. Results: The findings show that the phenomenon of trust does not automatically involve medical care. However, attention to the patient’s lifeworld in a professional caring relationship enables the patient to trust the caregiver and the healthcare environment. It is clear that the “voice of the lifeworld” enables the patient to feel trust. Conclusion: Trust in the early chain of healthcare entails caregivers’ ability to pay attention to both medical and existential issues in compliance with the patient’s information and questions. Thus, the patient must be invited to participate in assessments and decisions concerning his or her own healthcare, in a credible manner and using everyday language.

Patients with suspected hip fracture in the chain of emergency care: An integrative review of the literature

Patients with suspected hip fracture in the chain of emergency care : An integrative review of the literature