Use of the emergency ambulance service to an inner city accident and emergency department--a comparison of general practitioner and ''999'' calls.

Over a 2-week period a prospective study was undertaken of patients brought to an inner city accident and emergency department by the emergency ambulance service. Criteria for assessing the appropriateness of use of the emergency ambulance service are not well defined and at worst entirely subjective. The author's finding that, of patients attending after a '999' call, 49.8% were discharged with no follow-up suggests that many of these journeys represented inappropriate use of the emergency ambulance service. Close liaison between senior medical staff and the emergency ambulance service may allow more appropriate and effective use of the service, improving patient care in the pre-hospital setting.     

郑州市急诊医疗服务体系的实践和探索

目的研究郑州市急诊医疗服务体系的功能和效果.方法回顾性分析2002年7月至2004年6月郑州市"120"指挥中心派急救车出诊情况和25家急救站的急诊救治情况.结果急诊出车逐渐增多,市内出车半径在5Km以内,平均8min到达现场.各种创伤是急诊出车的第一位原因.25家急救站中自主型模式一个,以内科为主的半自主型模式7个,通道型模式17个.严重多发伤可在自主型模式急救站进行确定性手术治疗,明显缩短了受伤到确定性手术的时间.结论急诊医疗服务体系包括院前急救、院内急诊抢救和重症监护治疗.布局合理的急救站为急诊病人提供了快捷的院前急救,迅速转运危重病人到自主型模式急救站可提高抢救成功率.     

自主型模式急诊科的功能与管理

目的探讨自主型模式急诊科的功能和管理.方法回顾性分析我院急救中心2002年1月至2003年12月的临床资料,急诊出车3 284次,急诊门诊接诊48 350例次,急诊抢救660例,收住急诊病房1896例,收住其它专科病房3 998例,急诊病房住院病人手术592例,其中危重病人手术54例.结果距医院5公里以内的出诊,10分钟以内可到达现场,经现场急救后,转运途中无死亡,急诊抢救成功率92%;一般手术无死亡,危重病手术死亡7例,死亡率13%.结论自主型模式急诊科集院前急救、院内急救、确定性急诊手术、重症监护治疗为一体,有利于急救程序的管理,明显提高了危重病抢救成功率,同时也培养和发展了一支急诊医学队伍.     

Patients’ experiences and views of an emergency and urgent care system

Background Surveys of patients’ experiences and views of health care usually focus on single services. During an unexpected episode of ill health, patients may make contact with different services and therefore experience care within an emergency and urgent care system. We developed the Urgent Care System Questionnaire and used it to describe patients’ experiences and views of an emergency and urgent care system in England. Methods A market research company used quota sampling and random digit dialling to undertake a telephone survey of 1000 members of the general population in July 2007. Results 15% (151/1000) of the population reported using the emergency and urgent care system in the previous 3 months. Two thirds of users (68%, 98/145) contacted more than one service for their most recent event, with a mean of 2.0 services per event. Users entered the system through a range of services: the majority contacted a daytime GP in the first instance (59%, 85/145), and 12% (18/145) contacted either a 999 emergency ambulance or an emergency department. Satisfaction with all aspects of care diminished when four or more services had been contacted. Conclusions This is the first study to describe patients’ experiences and views of the emergency and urgent care system. The majority of patients experienced a system of care rather than single service care. There was an indication that longer pathways resulted in lower levels of patient satisfaction. Health care organisations can undertake similar surveys to identify problems with their system or to assess the impact of changes made to their system.     

Assessment of ambulance response performance using a geographic information system.

The accessibility, distribution and utilisation of emergency medical services are important components of health care delivery. The impact of these services on well-being is heightened by the fact that ambulance resources must respond in a reliable and timely manner to emergency calls from demand areas. However, many factors, such as the unavailability of an ambulance at a center closest to a call, can adversely influence response time. This paper discusses the design and implementation of a framework developed in a Geographic Information System for assessing ambulance response performance. A case study of ambulance response in three communities in Southern Ontario, Canada is presented that allows easy and rapid identification of anomalous calls that may adversely affect overall operating performance evaluation. Extensions of the framework into a fully fledged service deployment and planning decision support system are discussed.     

Inappropriate use of emergency ambulance services and the implications for primary health care in Japan

The number and per-capita emergency transports by public ambulancesand the percentage of transports of patients with non-emergencyconditions has been increasing in Japan, especially in urbanareas. Public ambulance services are, of course, essential fortransporting patients with crucial health problems. However,inappropriate ambulance use by patients who do not need emergencytreatment, but who need primary health care, means that thesepatients cannot get suitable health care, and diminishes theeffectiveness and efficiency of emergency medical-care servicesystems. The purposes of this study were to identify the factorsrelating to usage of public ambulance services in urban areas,to determine how to make these services more effective and moreefficient, and to discuss how to provide primary health-careservices so as to reduce the inappropriate use of public ambulanceservices. We investigated the accessibility of primary health-careservices, the characteristics of public ambulance service utilization,and the potential needs of the elderly for emergency-care servicesin two Tokyo wards: Edogawa andSetagaya. There were less healthresources, such as clinics, hospital beds and physicians, percapita in Edogawa than in Setagaya. Both the percentage of ambulancetransports of patients suffering from mild problems and thepercentage of ambulance transports on Sundays were higher inEdogawa than in Setagaya. Our survey showed that the percentagesof the elderly who would call for ambulances for each of threespecific health problems (fever, chest pain and ankle sprain)were all higher in Edogawa than in Setagaya. In both wards,elderly people living with their children and/or grandchildrenwere more likely to choose different health resources accordingto the specific problem being experienced than were elderlypeople living with other aged persons but without young people.The insufficient development of primary healthcare resourcesand systems increased the inappropriate use of high-cost emergencyambulance services by the elderly living in urban areas, wherefamily support is weakening. Health systems therefore need tobe reoriented so as to enhance accessibility to primary healthcareservices.     

RURAL URGENT CARE MODELS: WHAT ARE THEY MADE OF?

ABSTRACT: The study aimed to identify the elements that constitute rural urgent care systems. Participation in the study was sought from health professionals, welfare and emergency services sectors, and community members. Primary data were collected from informants through interviews and focus groups in five rural communities of different sizes. Twelve common elements to rural urgent care systems were identified and divided into two categories: (i) infrastructure; and (ii) personnel. Infrastructure included organisational support, community support, transport, communication and coordination processes, facilities and equipment, and community knowledge and information. Personnel included nurses, doctors, community leaders, health and welfare professionals, emergency service workers and ambulance officers. The study's major outcome was the recognition that rural urgent care systems consist of a balance of interrelated elements. These elements are context driven, with geographical, social and economic environments having a substantial impact on the ability of rural communities to develop and sustain their urgent care systems.     

Physical fitness and occupational demands of the Belfast ambulance service

The objectives of this study were to evaluate the current fitness of an area ambulance service based in Belfast and to quantify the physiological demands of accident and emergency work. From a total staff of 230, 105 (46%) volunteered to undergo a series of fitness tests subject to health state. Results based on body mass indices showed that 52% of subjects could be classified as overweight and 10% of subjects as obese. Fitness levels were similar to other comparable samples and showed the expected but not inevitable decrease with age. A simple work related task (walking at 6 km/h) performed in the laboratory showed that 54% of men over 40 years of age and 24% under 40 found it taxing. This would favour selection for accident and emergency work on the basis of functional capacity rather than chronological age. Accident and emergency work consisted of long periods of inactivity interspersed with shorter periods of relatively intense activity, often above the anaerobic threshold. Lactate concentrations measured during a staged emergency incident also suggested that personnel may work at intensities exceeding their anaerobic threshold. The incorporation of physical fitness standards in the ambulance service may be appropriate and consideration should be given to a reduced age of retirement.     

Physical fitness and occupational demands of the Belfast ambulance service.

The objectives of this study were to evaluate the current fitness of an area ambulance service based in Belfast and to quantify the physiological demands of accident and emergency work. From a total staff of 230, 105 (46%) volunteered to undergo a series of fitness tests subject to health state. Results based on body mass indices showed that 52% of subjects could be classified as overweight and 10% of subjects as obese. Fitness levels were similar to other comparable samples and showed the expected but not inevitable decrease with age. A simple work related task (walking at 6 km/h) performed in the laboratory showed that 54% of men over 40 years of age and 24% under 40 found it taxing. This would favour selection for accident and emergency work on the basis of functional capacity rather than chronological age. Accident and emergency work consisted of long periods of inactivity interspersed with shorter periods of relatively intense activity, often above the anaerobic threshold. Lactate concentrations measured during a staged emergency incident also suggested that personnel may work at intensities exceeding their anaerobic threshold. The incorporation of physical fitness standards in the ambulance service may be appropriate and consideration should be given to a reduced age of retirement.     

Integration of telemedicine into emergency medical services

We developed an integrated model of telemedicine services in emergency medical care. The architecture was designed to support pre-hospital management. The experimental work was carried out with the collaboration of the emergency medical services (EMS) in Madrid. Two different study populations were defined: a control population using conventional EMS protocols and a population using the telemedicine system. The telemedicine system was based on a telepresence service; electrocardiograms and images were transmitted from the ambulance to the health emergency coordination centre. The cost of dealing with 100 patients using telemedicine was C6030 less than the cost of conventional care. The response times using telemedicine were significantly lower.     

Rural Emergency Medical Services: Patients, Destinations, Times, and Services

This study sought to describe the volume of use, mix of patients, origin and destination of runs, times and distances to care, and the volume of clinical services provided in a rural emergency medical services region. This study summarizes all 6,080 rural emergency ambulance trip reports filed from April through September 1991 from the 12 rural counties surrounding Augusta, GA. Rural ambulances are regularly used and are used extensively by elderly populations. The pattern of services provided suggests that while advanced care may or may not have been indicated, it was rarely provided and that rural emergency medical service programs should consider a greater reliance on basic life support teams.     

CREATING COMPREHENSIVE GERO-PSYCHIATRIC CARE IN THE COMMUNITY

The aged increasingly need a comprehensive system, a central access point, and coordinated care in order for their acute and chronic, health and mental health needs to be met. This research reviews and analyzes the structure, function, and operation of a model demonstration geriatric emergency service which functioned as an access point and coordinator of care for the elderly in a network of health, mental health, and long term care services. The findings of this study indicate the important contribution a geriatric emergency service can make to creating comprehensive gero-psychiatric care in the community.     

救护艇医疗队海上应急救援演练体会

医疗救护艇是救治海上伤病员的快速船舶,应急救治能力的高低直接关系到部队的战斗力。通过对医疗救护艇首次参加多兵种海上应急救援演练的总结体会,探讨医疗救护艇的训练方法,建立应急救援的联合保障体系,进一步提高医疗救护艇海上应急保障能力。     

Confidential enquiry into avoidable vehicle accident deaths in the province of Modena,Italy

The authors describe the methods and results of a kind of study – confidential enquiries into avoidable deaths – very rarely performed in the Mediterranean area. After assessing some quali/quantitative evaluation criteria, an independent expert panel investigated the quality of each step in emergency health care. Information was collected by clinical and forensic reports (clinical method). Of 102 cases, 4 were avoidable deaths and 18 probably avoidable. These results, which are comparable with other similar ones found in Italy (autoptic method) and abroad, have been useful in highlighting some health care errors: in particular, in on-site care and in emergency department diagnosis and treatment. Other avoidable factors emerging were the inappropriateness of transporting severe trauma cases to a small hospital lacking proper equipment and trained staff, and the importance of staff training in first emergency care of severe trauma on ambulance. This situation had been highlighted previously and led to implementation of trauma centres. The methods implemented turned out to be quite statistically reproducible and have been used in local health care planning, especially in the rearrangement of ambulance deployment and emergency staff training.     

A hybrid FLEET model for emergency medical service system design

Covering models have been used to locate emergency services such as ambulance and fire protection systems. As an example, in the late seventies, an analysis of the Baltimore, Maryland fire protection system was conducted with the development and use of a covering model called the Facility Location and Equipment Emplacement Technique (FLEET). The FLEET model combined the location of fire stations with the allocation of primary and special service equipment to the stations. Further, in a recent study of Austin, Texas the ambulance system was restructured based on the use of a covering model. Covering models have also been extended to handle some of the special circumstances involved in emergency service systems. One example is the maximal expected coverage problem (MEXCLP). This paper presents a new covering model which utilizes both the special coverage structure of the MEXCLP and the simultaneous station location and equipment allocation of the FLEET model. Optimal solutions are found using linear and integer programming. Results of the model applied to several planning data sets (including a form of the Austin, Texas planning problem) demonstrate that more concentrated ambulance allocation patterns exist which may lead to easier dispatching, reduced facility costs, and better crew load balancing with little or no loss of service coverage. Tradeoff curves are presented which show that significant reductions in the number of dispatching sites (keeping the number of ambulances constant) can be made without any major changes in service level.     

Communicating DNR orders to ambulance personnel

To summarize, the MMA will provide a standard DNR form and guidelines for implementation in local communities. Local physicians, nursing home administrators, and ambulance service operators need to agree on an established set of guidelines that long-term care facilities, hospices, and private homes will follow to inform ambulance personnel of DNR orders. Ambulance medical directors should instruct ambulance staff on the proper implementation and use of DNR orders. The decision to write a DNR order rests with the attending physician, based on disclosure and consent of the patient, family, or proxies. Full implementation of a prehospital DNR system will reduce the suffering that patients and family members endure when inappropriate and unnecessary cardiopulmonary resuscitation is given by ambulance personnel. A similar program, administered by the county health department, has been successful in the west metropolitan Twin Cities area for the past five years. The model offered by the MMA to individual physicians and their medical societies may be modified to meet local needs. This community emergency medical services DNR program helps ensure the provision of appropriate ambulance service based on patients' individual needs and requests.     

Temperature related mortality and ambulance service interventions during the heat waves of 2003 in Ticino (Switzerland)

Summary. Objectives This study investigates a potential increase in mortality and in the demand for ambulance emergency services among the elderly in particular, in Ticino in the summer of 2003. Methods Mortality rates and emergency ambulance interventions rates were compared with records from the previous years. We considered the whole population, aged 65 and over, as well as 75 and over. Results The 2003 mortality in the population was not signifi cantly different from the previous years. The number of deaths among the elderly showed a small but significant deviation from the expected values during the first heat wave in June 2003, with no significant impact on the seasonal results. The number of ambulance service interventions was larger than during the previous years. Conclusion These results are consistent with findings in other studies. The heat waves (especially in June), were correlated with a higher number of ambulance callouts. In addition to some geographic, climatic, and social factors that had a protective impact, the response of the emergency services is likely to have contributed to a certain reduction in mortality. Submitted: 29 October 2004; Accepted: 29 August 2005