Taneli Väyrynen

Sequential analysis of pretreatment delays in stroke thrombolysis.

OBJECTIVES The aim was to determine if an intensive restructuring of the approach to acute stroke improved time to thrombolysis over a 3-year study period and to determine whether delay modifications correlated with increased thrombolytic intervention or functional outcome. METHODS The study examined the pretreatment process to define specific time intervals (delays) of interest in the acute management of 289 consecutive ischemic stroke patients who were transported by the emergency medical services (EMS) and received intravenous (IV) thrombolytic therapy in the emergency department (ED) of Helsinki University Central Hospital. Time interval changes of the 3-year period and use of thrombolytics was measured. Functional outcome, measured with the modified Rankin Scale (mRS) at 3 months, was assessed with multivariable statistical analysis. RESULTS During implementation of the restructuring program from 2003 to 2005, the median total time delay from symptom onset to drug administration dropped from 149 to 112 minutes (p < 0.0001). Prehospital delays did not change significantly during the study period. The median delay in calling an ambulance remained at 13 minutes, and the total median prehospital delay stayed at 71 minutes. In-hospital delays decreased from 67 to 34 minutes (p < 0.0001). The median call delay was 25 minutes in patients with mild symptoms (National Institute of Health Stroke Scale [NIHSS] score < 7) and 8 minutes with severe symptoms (NIHSS > 15). In the multivariate model, stroke severity (odds ratio [OR] = 0.83, 95% confidence interval [CI] = 0.78 to 0.88, p < 0.0001), age (OR = 0.57, 95% CI = 0.42 to 0.77, p < 0.0001), and in-hospital delay (OR = 0.47, 95% CI = 0.22 to 0.97, p = 0.04) were suggesting a good outcome. CONCLUSIONS Restructuring of the teamwork between the EMS personnel and the reorganized ED significantly reduced in-hospital, but not prehospital, delays. The present data suggest that a decreased in-hospital delay improves the accessibility of the benefits of thrombolysis.

Medical futility in asystolic out-of-hospital cardiac arrest

Objectives: To study the factors associated with short‐ and long‐term survival after asystolic out‐of‐hospital cardiac arrest, with a reference to medical futility.

Long-term changes in the incidence of out-of-hospital ventricular fibrillation

AIM OF THE STUDY To report the long-term changes in the incidence of out-of-hospital ventricular fibrillation (VF), and also to report concurrent changes in the possible explanatory factors for the change. METHODS This was a retrospective observational study. All bystander-witnessed out-of-hospital cardiac arrests (with a known initial rhythm) in Helsinki, Finland during 1.1.1994-31.12.2007 were included in the study. High (years 1994-1996) and low (2002-2004) incidence periods for VF were defined and compared. RESULTS There were 3131 bystander-witnessed out-of-hospital cardiac arrests of which 3118 (99.6%) had a known initial rhythm. During 2000-2007 the annual incidence of bystander witnessed ventricular fibrillation (VF) was 11.6 (95% CI 9.7-13.5) per 100,000 inhabitants. In 1994-1996 VF was 1.8 times more likely than in 2002-2004, after adjustment for several patient related factors and EMS related factors. Arrests with cardiac aetiology became less common, as 54.8% arrests had a cardiac cause in 1994-1996 compared to 45.2% in 2002-2004 (p<0.001). Of cardiac arrests with cardiac aetiology, 60.6% presented with VF in 1994-1996 compared to 45.7% in 2002-2004 (p<0.001). There were major changes in the possible explanatory factors during the study period. CONCLUSION The decline in the incidence of out-of-hospital VF seems to have ended, and the annual incidence of VF has stabilised to 11.6 (95% CI 9.7-13.5) per 100,000 inhabitants. During the period of lower incidence of VF, cardiac aetiology caused fewer arrests, and these arrests did not present with VF as often as previously.

Effect of introduction of electronic patient reporting on the duration of ambulance calls.

OBJECTIVES We examined the effect of the change from paper records to the electronic patient records (EPRs) on ambulance call duration. METHODS We retrieved call duration times 6 months before (group 1) and 6 months after (group 2) the introduction of EPR. Subgroup analysis of group 2 was fulfilled depending whether the calls were made during the first or last 3 months after EPR introduction. RESULTS We analyzed 37 599 ambulance calls (17 950 were in group 1 and 19 649 were in group 2). The median call duration in group 1 was 48 minutes and in group 2 was 49 minutes (P = .008). In group 2, call duration was longer during the first 3 months after EPR introduction. In multiple linear regression analysis, urgency category (P < .0001), unit level (P < .0001), and transportation decision (P < .0001) influenced the call duration. The documentation method was not a significant factor. CONCLUSIONS Electronic patient record system can be implemented in an urban ambulance service in such a way that documentation method does not become a significant factor in determining call duration in the long run. Temporary performance drop during the first 3 months after introduction was noticed, reflecting adaptation process to a new way of working.

Prehospital emergency care and medical preparedness for the 2005 World Championship Games in Athletics in Helsinki.

INTRODUCTION International mass gatherings can cause great challenges to local healthcare system and emergency medical services (EMS). Traditionally, planning has been based on retrospective reports of previous events, but there still is a need for prospective studies in order to make the process more evidence-based. The aim of this study was to analyze the success of medical preparedness, ambulance patient characteristics, emergency care, and the use of pre-hospital resources during the 2005 World Championship Games in Athletics in Helsinki, Finland. METHODS The study was a prospective, observational study conducted within the Helsinki EMS. Data from all emergency calls at the sport venues and Games village between 05 and 14 August 2005 were collected. Data from the organizations responsible for the health care and first aid of spectators and accredited persons (e.g., athletes, coaches, the press, very important persons and personnel working in the Games area) also were collected. The Institutional Review Board of Helsinki University Central Hospital approved the study plan. RESULTS A total of 479,000 persons visited the Games. The ambulance call incidence at the Olympic Stadium was 0.50 per 10,000 people and 0.7 per 10,000 when the Games Village was included. The overall need for ambulance transportation to the emergency department was 0.52 per 10,000. No patients needed cardiopulmonary resuscitation or other immediate, life-saving procedures on-site. First aid was provided to 554 spectators (0.17 per 10,000 people). The three medical organizations cared for 1,586 patients of which 25 (1.6%) were transported to a hospital by an ambulance. The number of patients needing transportation and the overall patient load for the healthcare system was well-anticipated. Accredited persons sought health care a total of 1,009 times. The number of patients treated was associated closely with the number of spectators (p = 0.05). The number of ambulance calls in the city increased 5.9 % as compared to the corresponding time period in the five previous years. CONCLUSIONS The medical preparedness and resources for the Games proved to be sufficient. The EMS personnel were able to provide quality emergency care. This prospective study provided new, detailed data for the medical aspects of mass gatherings and confirmed many previous observations.

Fusion of dispatching centres into one entity: effects on performance

Background: Dispatching centres were fused into one of the 112 entity, which caused concerns regarding whether the medical calls could be processed effectively also in the new centre. We evaluated the effects of the reform on key performance criteria in medical calls.

Delayed return of spontaneous circulation (the Lazarus phenomenon) after cessation of out-of-hospital cardiopulmonary resuscitation

INTRODUCTION The delayed return of spontaneous circulation (ROSC) after cessation of cardiopulmonary resuscitation (CPR), also known as the Lazarus phenomenon, is a rare event described in several case reports. This study aims to determine the incidence and the time of occurrence of the Lazarus phenomenon after cessation of out-of-hospital CPR. METHODS This prospective observational cohort study was conducted in the Helsinki Emergency Medical Service in Finland from 1 January 2011 through 31 December 2016. All out-of-hospital CPR attempts were carefully monitored for 10min after the cessation of CPR in order to detect delayed ROSC. RESULTS Altogether, 2102 out-of-hospital cardiac arrests occurred during the six-year study period. CPR was attempted in 1376 (65.5%) cases. In 840 cases (61.0% of all attempts) CPR attempts were terminated on site. The Lazarus phenomenon occurred five times, with an incidence of 5.95/1000 (95% CI 2.10-14.30) in field-terminated CPR attempts. Time to delayed ROSC from the cessation of CPR varied from 3 to 8min. Three of the five patients with delayed ROSC died at the scene within 2-15min while two died later in hospital within 1.5 and 26h, respectively. CONCLUSIONS We observed that the Lazarus phenomenon is a real albeit rare event and can occur a few minutes after the cessation of out-of-hospital CPR. We suggest a 10-min monitoring period before diagnosing death. CPR guidelines should be updated to include information of the Lazarus phenomenon and appropriate monitoring for it.