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[...]hospital avoidance’ does not remove the need for EMS patients to be provided with definitive care but rather places increased responsibility on EMS to ensure definitive care is provided or that appropriate referral is assured.4 Alternative care pathways that enable EMS to ‘hear and treat’ or ‘treat and refer’ patients are highly desirable, but EMS agencies must ensure that systems are safe and acceptable to patients, and result in similar or better clinical outcomes. In this issue of the journal Wilson et al’s7 systematic review and meta-analysis illustrates the important effects that feedback in the EMS can have on safety-relevant processes such as ambulance response times, protocol adherence and documentation. Within healthcare, there has been a predominant focus on ‘lagging indicators’, or reactive measures of safety captured after an incident has occurred.8 A shift in focus to identifying precursors to safety events (referred to as ‘leading’ indicators of safety) is required.8 Proactive engagement with safety assessment may take various forms including safety culture surveys and safety walk-arounds.8 This proactive approach might also usefully see EMS employ failure modes and effects analysis (FMEA) to identify vulnerability within systems.9 Hospital-based research has already demonstrated that FMEA can be applied to improve many processes key to EMS including medication administration, communication and handover, and treatment delivery.9 Second, systems of assessing safety in EMS must be inclusive of patients. Improving safety in the Emergency Medical Services Although measuring and monitoring safety is important, what is also essential is that these data are used to identify and evaluate the effectiveness of interventions to improve patient safety and quality of care.13 In fact, it could be argued that there is little point in collecting safety data that are not then used to bring about improvement.

Cardiac arrest is an event with a limited prognosis which has not substantially changed since the first description of cardiopulmonary resuscitation (CPR) in 1960. A promising new treatment approach may be mechanical CPR devices (mechanical CPR). In a retrospective analysis of the German Resuscitation Registry between 2007-2014, we examined the outcome after using mechanical CPR on return of spontaneous circulation (ROSC) in adults with out-of-hospital cardiac arrest (OHCA). We compared mechanical CPR to manual CPR. According to preclinical risk factors, we calculated the predicted ROSC-after-cardiac-arrest (RACA) score for each group and compared it to the rate of ROSC observed. Using multivariate analysis, we adjusted the influence of the devices' application on ROSC for epidemiological factors and therapeutic measures. We included 19,609 patients in the study. ROSC was achieved in 51.5% of the mechanical CPR group (95%-CI 48.2-54.8%, ROSC expected 42.5%) and in 41.2% in the manual CPR group (95%-CI 40.4-41.9%, ROSC expected 39.2%). After multivariate adjustment, mechanical CPR was found to be an independent predictor of ROSC (OR 1.77; 95%-CI 1.48-2.12). Duration of CPR is a key determinant for achieving ROSC. Mechanical CPR was associated with an increased rate of ROSC and when adjusted for risk factors appeared advantageous over manual CPR. Mechanical CPR devices may increase survival and should be considered in particular circumstances according to a physicians' decision, especially during prolonged resuscitation.

Background Patients served by Helicopter Emergency Medical Services (HEMS) tend to be acutely injured or unwell and in need of stabilisation followed by rapid and safe transport. It is therefore hypothesised that a particular clinical crew composition is required to provide appropriate HEMS patient care. A literature review was performed to test this hypothesis. Methods MEDLINE, EMBASE, Web of Science and the Cochrane Database of Systematic Reviews were systematically searched from 1 January 2009 to 30 August 2019 to identify peer-reviewed articles of relevance. All HEMS studies that mentioned ‘staffing’, ‘configuration’, ‘competencies’ or ‘qualifications’ in the title or abstract were selected for full-text review. Results Four hundred one studies were identified. Thirty-eight studies, including one systematic review and one randomised controlled trial, were included. All remaining studies were of an observational design. The vast majority of studies described clinical crews that were primarily doctor-staffed. Descriptions of non-doctor staff competencies were limited, with the exception of one paramedic-staffed model. Conclusions HEMS clinical crews tended to have a wider range of competencies and experience than ground-based crews, and most studies suggested a patient outcome benefit to HEMS provision. The conclusions that can be drawn are limited due to study quality and the possibility that the literature reviewed was weighted towards particular crewing models (i.e. primarily doctor-staffed) and countries. There is a need for trial-based studies that directly compare patient outcomes between different HEMS crews with different competencies and qualifications.

ObjectivesThe COVID-19 pandemic has produced radical changes in international health services. In Ireland, the National Ambulance Service established a novel home and community testing service that was central to the national COVID-19 screening programme. This service was overseen by a multidisciplinary response room. This research examined the response room service, particularly areas that performed well and areas requiring improvement, using a quality improvement (QI) framework.DesignThis was a qualitative study comprising semi-structured, individual interviews. Maximum variation sampling was used. The data were analysed using an established thematic analysis procedure. The analysis was guided by the framework, which comprised six QI drivers.SettingResponse room employees, including clinicians, dispatchers and administrators, were interviewed via telephone.ResultsLeadership for quality: participants valued person-oriented leadership, including regular, open communication and consultation with staff. Person/family engagement: participants endeavoured to provide patient-centred care. Formal patient feedback mechanisms and shared decision-making could be beneficial in the future. Staff engagement: working in a response room could affect well-being, though it also provided networking and learning opportunities. Staff require support and teambuilding. Use of improvement methods: improvements were made in a relatively informal, ad hoc manner. The use of robust methods based on improvement science was not reported. Measurement for quality: data were collected to improve efficiency and accuracy. More rigorous measurement would be beneficial, especially formally collecting stakeholder feedback. Governance for quality: close alignment with collaborators and clear communication with staff are essential. Information and communications technology for quality: this seventh driver was added because the importance of information technology specially designed for pandemics was frequently highlighted.ConclusionsThe study provides insights on what worked well and what required improvement in a pandemic response room. It can inform health services, particularly emergency services, in their preparation for additional COVID-19 waves, as well as future crises.

ObjectivesTime is a fundamental component of acute stroke and transient ischaemic attack (TIA) care, thus minimising prehospital delays is a crucial part of the stroke chain of survival. COVID-19 restrictions were introduced in Ireland in response to the pandemic, which resulted in major societal changes. However, current research on the effects of the COVID-19 pandemic on prehospital care for stroke/TIA is limited to early COVID-19 waves. Thus, we aimed to investigate the effect of the COVID-19 pandemic on ambulance time intervals and suspected stroke/TIA call volume for adults with suspected stroke and TIA in Ireland, from 2018 to 2021.DesignWe conducted a secondary data analysis with a quasi-experimental design.SettingWe used data from the National Ambulance Service in Ireland. We defined the COVID-19 period as ‘1 March 2020–31 December 2021’ and the pre-COVID-19 period ‘1 January 2018–29 February 2020’.Primary and secondary outcome measuresWe compared five ambulance time intervals: ‘allocation performance’, ‘mobilisation performance’, ‘response time’, ‘on scene time’ and ‘conveyance time’ between the two periods using descriptive and regression analyses. We also compared call volume for suspected stroke/TIA between the pre-COVID-19 and COVID-19 periods using interrupted time series analysis.ParticipantsWe included all suspected stroke/TIA cases ≥18 years who called the National Ambulance Service from 2018 to 2021.Results40 004 cases were included: 19 826 in the pre-COVID-19 period and 20 178 in the COVID-19 period. All ambulance time intervals increased during the pandemic period compared with pre-COVID-19 (p<0.001). Call volume increased during the COVID-19-period compared with the pre-COVID-19 period (p<0.001).ConclusionsA ’shock' like a pandemic has a negative impact on the prehospital phase of care for time-sensitive conditions like stroke/TIA. System evaluation and public awareness campaigns are required to ensure maintenance of prehospital stroke pathways amidst future healthcare crises. Thus, this research is relevant to routine and extraordinary prehospital service planning.

Background Internationally, the majority of out-of-hospital cardiac arrests where resuscitation is attempted (OHCAs) occur in private residential locations i.e. at home. The prospect of survival for this patient group is universally dismal. Understanding of the area-level factors that affect the incidence of OHCA at home may help national health planners when implementing community resuscitation training and services. Methods We performed spatial smoothing using Bayesian conditional autoregression on case data from the Irish OHCA register. We further corrected for correlated findings using area level variables extracted and constructed for national census data. Results We found that increasing deprivation was associated with increased case incidence. The methodology used also enabled us to identify specific areas with higher than expected case incidence. Conclusions Our study demonstrates novel use of Bayesian conditional autoregression in quantifying area level risk of a health event with high mortality across an entire country with a diverse settlement pattern. It adds to the evidence that the likelihood of OHCA resuscitation events is associated with greater deprivation and suggests that area deprivation should be considered when planning resuscitation services. Finally, our study demonstrates the utility of Bayesian conditional autoregression as a methodological approach that could be applied in any country using registry data and area level census data.

Background Variation in reported incidence and outcome based on aggregated data is a persistent feature of out-of-hospital cardiac arrest (OHCA) epidemiology. Objective To investigate the extent to which patient-level analysis using core ‘Utstein’ variables explains inter-country variation between Sweden and the Republic of Ireland. Methods A retrospective cross-sectional comparative study was performed, including all Swedish and Irish OHCA cases attended by Emergency Medical Services (EMS-attended OHCA) where resuscitation was attempted from 1st January 2012 to 31st December 2014. Incidence rates per 100,000 population were adjusted for age and gender. Two subgroups were extracted: (1) Utstein - adult patients, bystander-witnessed collapse, presumed medical aetiology, initial shockable rhythm and (2) Emergency Medical Service (EMS)-witnessed events. Multivariable logistic regression analysis was used to identify predictors of survival following multiple imputations of data. Results Five thousand eight hundred eighty six Irish and 15,303 Swedish patients were included. Swedish patients were older than Irish patients (median age 71 vs. 66 years respectively). Adjusted incidence was significantly higher in Sweden compared to the Republic of Ireland (52.9 vs. 43.1 per 100,000 population per year). Proportionate survival in Sweden was greater for both subgroups and all age categories. Regression analysis of the Utstein subgroup predicted approximately 17% of variation in outcome, but there was a large unexplained ‘country effect’ for survival in favour of Sweden (OR 4.40 (95% CI 2.55–7.56)). Conclusions Using patient level data, a proportion of inter-country variation was explained, but substantial variation was not explained by the core Utstein variables. Researchers and policy makers should be aware of the potential for unmeasured differences when comparing OHCA incidence and outcomes between countries.

ObjectivesThis research aimed to examine the perspectives, experiences and practices of international experts in community first response: an intervention that entails the mobilisation of volunteers by the emergency medical services to respond to prehospital medical emergencies, particularly cardiac arrests, in their locality.DesignThis was a qualitative study in which semistructured interviews were conducted via teleconferencing. The data were analysed in accordance with an established thematic analysis procedure.SettingThere were participants from 11 countries: UK, USA, Canada, Australia, New Zealand, Singapore, Ireland, Norway, Sweden, Denmark and the Netherlands.ParticipantsSixteen individuals who held academic, clinical or managerial roles in the field of community first response were recruited. Maximum variation sampling targeted individuals who varied in terms of gender, occupation and country of employment. There were eight men and eight women. They included ambulance service chief executives, community first response programme managers and cardiac arrest registry managers.ResultsThe findings provided insights on motivating and supporting community first response volunteers, as well as the impact of this intervention. First, volunteers can be motivated by ‘bottom-up factors’, particularly their characteristics or past experiences, as well as ‘top-down factors’, including culture and legislation. Second, providing ongoing support, especially feedback and psychological services, is considered important for maintaining volunteer well-being and engagement. Third, community first response can have a beneficial impact that extends not only to patients but also to their family, their community and to the volunteers themselves.ConclusionsThe findings can inform the future development of community first response programmes, especially in terms of volunteer recruitment, training and support. The results also have implications for future research by highlighting that this intervention has important outcomes, beyond response times and patient survival, which should be measured, including the benefits for families, communities and volunteers.

BackgroundNational data collection provides information on out-of-hospital cardiac arrest (OHCA) incidence, management and outcomes that may not be generalisable from smaller studies. This retrospective cohort study describes the first 2 years' results from the Irish National Out-of-Hospital Cardiac Arrest Register (OHCAR).MethodsData on OHCAs attended by emergency medical services (EMS) where resuscitation was attempted (EMS-treated) were collected from ambulance services and entered onto OHCAR. Descriptive analysis of the study population was performed, and regression analysis was performed on the subgroup of adult patients with a bystander-witnessed event of presumed cardiac aetiology and an initial shockable rhythm (Utstein group).Results3701 EMS-treated OHCAs were recorded for the study period (1 January 2012–31 December 2013). Incidence was 39/100 000 population/year. In the Utstein group (n=577), compared with the overall group, there was a higher proportion of male patients, public event location, bystander cardiopulmonary resuscitation (CPR) and early defibrillation. Median EMS call–response interval was similar in both groups. A higher proportion of patients in the Utstein group achieved return of spontaneous circulation (35% vs 17%) and survival to hospital discharge (22% vs 6%). After multivariate adjustment for the Utstein group, the following variables were found to be independent predictors of the outcome survival to hospital discharge: public event location (OR 3.1 (95% CI 1.9 to 5.0)); bystander CPR (2.4 (95% CI 1.2 to 4.9)); EMS response of 8 min or less (2.2 (95% CI 1.3 to 3.6)).ConclusionsThis study highlights the role of nationwide registries in quantifying, monitoring and benchmarking OHCA incidence and outcome, providing baseline data upon which service improvement effects can be measured.

ObjectiveResuscitation from out-of-hospital cardiac arrest (OHCA) is largely determined by the availability of cardiopulmonary resuscitation (CPR) and defibrillation within 5–10 min of collapse. The potential contribution of organised groups of volunteers to delivery of CPR and defibrillation in their communities has been little studied. Ireland has extensive networks of such volunteers; this study develops and tests a model to examine the potential impact at national level of these networks on early delivery of care.MethodsA geographical information systems study considering all statutory ambulance resource locations and all centre point locations for community first responder (CFR) schemes that operate in Ireland were undertaken. ESRI ArcGIS Desktop 10.4 was used to map CFR and ambulance base locations. ArcGIS Online proximity analysis function was used to model 5–10 min drive time response areas under sample peak and off-peak conditions. Response areas were linked to Irish population census data so as to establish the proportion of the population that have the potential to receive a timely cardiac arrest emergency response.ResultsThis study found that CFRs are present in many communities throughout Ireland and have the potential to reach a million additional citizens before the ambulance service and within a timeframe where CPR and defibrillation are likely to be effective treatments.ConclusionCFRs have significant potential to contribute to survival following OHCA in Ireland. Further research that examines the processes, experiences and outcomes of CFR involvement in OHCA resuscitation should be a scientific priority.