Publications by authors named "Emma Bosley"

33 Publications

Trauma by-pass guideline: A data-driven conformance analysis for road trauma cases in Queensland.

Emerg Med Australas 2021 May 31. Epub 2021 May 31.

School of Information Systems, Queensland University of Technology, Brisbane, Queensland, Australia.

Objective: Study objectives were to (i) develop and test a whole-of-system method for identifying patients who meet a major trauma by-pass guideline definition; (ii) apply this method to assess conformance to the current 2006 guideline for a road trauma cohort; and (iii) leverage relevant findings to propose improvements to the guideline.

Methods: Retrospective analysis of existing, routinely collected data relating to Queensland road trauma patients July 2015 to June 2017. Data from ambulance, aero-medical retrievals, ED, hospital and death registers were linked and used for analysis. Processes of care measured included: frequency of pre-hospital triage criteria, distribution of destination (trauma service level), compliance with guideline (recommended vs actual destination), trauma service level by threat to life (injury severity) (all modes of transport and aero-medical in particular), proportion of patients requiring only ED, transport pathway (direct vs inter-hospital transfer).

Results: 3847 cases were identified from data as meeting criteria for major trauma by-pass. The top five most frequently used criteria for qualifying patients as meeting the major trauma by-pass guideline were pulse rate, vehicle rollover, possible spinal cord injury, respiration rate and entrapment. The study demonstrates a 65% conformance to the clinical guideline. Overtriaged patients (transported to higher trauma service than recommended) generally reveal International Classification of Disease Injury Severity Score representing a high threat to life.

Conclusion: Overall, the present study found good conformance, with overtriage rate as expected by clinicians. It is recommended to include data values to capture paramedics assessment of trauma level to enable more accurate assessment of conformance to guideline and future revision of the thresholds.
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http://dx.doi.org/10.1111/1742-6723.13807DOI Listing
May 2021

Trauma by-pass guideline: A data-driven conformance analysis for road trauma cases in Queensland.

Emerg Med Australas 2021 May 31. Epub 2021 May 31.

School of Information Systems, Queensland University of Technology, Brisbane, Queensland, Australia.

Objective: Study objectives were to (i) develop and test a whole-of-system method for identifying patients who meet a major trauma by-pass guideline definition; (ii) apply this method to assess conformance to the current 2006 guideline for a road trauma cohort; and (iii) leverage relevant findings to propose improvements to the guideline.

Methods: Retrospective analysis of existing, routinely collected data relating to Queensland road trauma patients July 2015 to June 2017. Data from ambulance, aero-medical retrievals, ED, hospital and death registers were linked and used for analysis. Processes of care measured included: frequency of pre-hospital triage criteria, distribution of destination (trauma service level), compliance with guideline (recommended vs actual destination), trauma service level by threat to life (injury severity) (all modes of transport and aero-medical in particular), proportion of patients requiring only ED, transport pathway (direct vs inter-hospital transfer).

Results: 3847 cases were identified from data as meeting criteria for major trauma by-pass. The top five most frequently used criteria for qualifying patients as meeting the major trauma by-pass guideline were pulse rate, vehicle rollover, possible spinal cord injury, respiration rate and entrapment. The study demonstrates a 65% conformance to the clinical guideline. Overtriaged patients (transported to higher trauma service than recommended) generally reveal International Classification of Disease Injury Severity Score representing a high threat to life.

Conclusion: Overall, the present study found good conformance, with overtriage rate as expected by clinicians. It is recommended to include data values to capture paramedics assessment of trauma level to enable more accurate assessment of conformance to guideline and future revision of the thresholds.
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http://dx.doi.org/10.1111/1742-6723.13807DOI Listing
May 2021

The impact of shift work schedules on PVT performance in naturalistic settings: a systematic review.

Int Arch Occup Environ Health 2021 Mar 11. Epub 2021 Mar 11.

Turner Institute for Brain and Mental Health, Monash University, Clayton, Victoria, Australia.

Objective: The Psychomotor Vigilance Test (PVT) is considered the gold standard for detecting sleep loss and circadian misalignment related changes in performance in laboratory and field settings. This short 3-, 5- or 10-min test appraises an individual's sustained vigilant attention on a visual stimulus through reaction time, false starts and performance lapses. The PVT has been widely used as a measure to assess vigilant attention among shift workers, but information evaluating the application and performance of this test in different naturalistic shift work settings is limited. The purpose of this review is to synthesise and evaluate existing literature which has used the PVT to assess and monitor psychomotor performance in response to shift work schedules and rosters performed in real-world settings.

Methods: A systematic search of studies examining PVT performance in response to 24/7 shift work schedules (e.g., day, afternoon, evening and night shifts) performed under naturalistic conditions was conducted. Articles were identified by searching Medline, Embase, CINHAL and PsycINFO databases in April 2020.

Results: The search yielded 135 results, of which 16 publications were suitable to be included in this review. Articles were grouped according to when the PVT was applied to a research cohort, which included (a) multiple instances per shift, (b) commencement and cessation of shift and (c) other varying times.

Conclusions: This review suggests PVT performance is typically congruent across studies when the test is applied at generally consistent time intervals. The lack of research concerning the use of the PVT during extended duty shifts (e.g., shifts and on call work > 30 h) is an area for future research.
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http://dx.doi.org/10.1007/s00420-021-01668-0DOI Listing
March 2021

Prehospital study of survival outcomes from out-of-hospital cardiac arrest in ST-elevation myocardial infarction in Queensland, Australia (the PRAISE study).

Eur Heart J Acute Cardiovasc Care 2020 Apr 22. Epub 2020 Apr 22.

Queensland Ambulance Service, Queensland Government Department of Health, Australia.

Aim: Patients that experience an out-of-hospital cardiac arrest in the context of a paramedic-identified ST-segment elevation myocardial infarction are a unique cohort. This study identifies the survival outcomes and determinants of survival in these patients.

Methods: A retrospective analysis was undertaken of all patients, attended between 1 January 2013 and 31 December 2017 by the Queensland Ambulance Service, who had a ST-segment elevation myocardial infarction identified by the attending paramedic prior to deterioration into out-of-hospital cardiac arrest. We described the 'survived event' and 'survived to discharge' outcomes of patients and performed univariate analysis and multivariate logistic regression to identify factors associated with survival.

Results: In total, 287 patients were included. Overall, high rates of survival were reported, with 77% of patients surviving the initial out-of-hospital cardiac arrest event and 75% surviving to discharge. Predictors of event survival were the presence of an initial shockable rhythm (adjusted odds ratio 8.60, 95% confidence interval (CI) 4.16-17.76; P < 0.001) and the administration of prehospital medication for subsequent primary percutaneous coronary intervention (adjusted odds ratio 2.54, 95% CI 1.17-5.50; P = 0.020). These factors were also found to be associated with survival to hospital discharge, increasing the odds of survival by 13.74 (95% CI 6.02-31.32; P < 0.001) and 6.96 (95% CI 2.50-19.41; P < 0.001) times, respectively. The administration of prehospital fibrinolytic medication was also associated with survival in a subgroup analysis.

Conclusion: This subset of out-of-hospital cardiac arrest patients was found to be highly salvageable and responsive to resuscitative measures, having arrested in the presence of paramedics and presented with an identified reversible cause.
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http://dx.doi.org/10.1177/2048872620907529DOI Listing
April 2020

Ambient temperatures, heatwaves and out-of-hospital cardiac arrest in Brisbane, Australia.

Occup Environ Med 2021 Jan 12. Epub 2021 Jan 12.

Queensland Ambulance Service, Brisbane, Queensland, Australia.

Background: The health impacts of temperatures are gaining attention in Australia and worldwide. While a number of studies have investigated the association of temperatures with the risk of cardiovascular diseases, few examined out-of-hospital cardiac arrest (OHCA) and none have done so in Australia. This study examined the exposure-response relationship between temperatures, including heatwaves and OHCA in Brisbane, Australia.

Methods: A quasi-Poisson regression model coupled with a distributed lag non-linear model was employed, using OHCA and meteorological data between 1 January 2007 and 31 December 2019. Reference temperature was chosen to be the temperature of minimum risk (21.4°C). Heatwaves were defined as daily average temperatures at or above a heat threshold (90th, 95th, 98th, 99th percentile of the yearly temperature distribution) for at least two consecutive days.

Results: The effect of any temperature above the reference temperature was not statistically significant; whereas low temperatures (below reference temperature) increased OHCA risk. The effect of low temperatures was delayed for 1 day, sustained up to 3 days, peaking at 2 days following exposures. Heatwaves significantly increased OHCA risk across the operational definitions. When a threshold of 95th percentile of yearly temperature distribution was used to define heatwaves, OHCA risk increased 1.25 (95% CI 1.04 to 1.50) times. When the heat threshold for defining heatwaves increased to 99th percentile, the relative risk increased to 1.48 (1.11 to 1.96).

Conclusions: Low temperatures and defined heatwaves increase OHCA risk. The findings of this study have important public health implications for mitigating strategies aimed at minimising temperature-related OHCA.
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http://dx.doi.org/10.1136/oemed-2020-107018DOI Listing
January 2021

Assessing need for extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest using Power BI for data visualisation.

Emerg Med Australas 2021 Aug 20;33(4):685-690. Epub 2020 Dec 20.

Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Queensland, Australia.

Objective: To estimate the number of patients in refractory out-of-hospital cardiac arrest (OHCA) potentially suitable for transport to an extracorporeal cardiopulmonary resuscitation (ECPR)-capable hospital in Brisbane, Queensland, Australia, based on outcome predictors for ECPR, ambulance geolocation and patient data.

Methods: A retrospective cohort study was performed using data from all patients in OHCA attended by Queensland Ambulance Service between 1 January 2014 and 31 December 2018. The number of refractory arrest patients who could potentially be transferred to an ECPR-capable centre within 45 min of the time of arrest was modelled using theoretical on-scene treatment times.

Results: Of 25 518 ambulance-attended OHCA in Queensland during the study period, 540 (2%) patients met criteria of refractory arrest for study inclusion. Further age and arrest rhythm criteria for transport to an ECPR-capable hospital were met in 253 (47%) study patients, an average of 51 patients per year. In 2018, 72 patients met study criteria for transport to an ECPR-capable centre. Based on theoretical on-scene treatment times of 12 and 20 min, in 2018 only 14 (19%) and 11 (15%) patients respectively would potentially arrive at an ECPR-capable hospital within accepted timeframes for ECPR.

Conclusions: Retrospective data collected from existing ambulance databases can be used to model patient suitability for ECPR. Relatively few patients with refractory OHCA in Queensland, Australia, could be attended and transported to an ECPR-capable centre within clinically acceptable timeframes. Further studies of the transport logistics and economic implications of providing ECPR services for OHCA are required to better inform decisions around this intervention.
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http://dx.doi.org/10.1111/1742-6723.13704DOI Listing
August 2021

Assessing need for extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest using Power BI for data visualisation.

Emerg Med Australas 2021 Aug 20;33(4):685-690. Epub 2020 Dec 20.

Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Queensland, Australia.

Objective: To estimate the number of patients in refractory out-of-hospital cardiac arrest (OHCA) potentially suitable for transport to an extracorporeal cardiopulmonary resuscitation (ECPR)-capable hospital in Brisbane, Queensland, Australia, based on outcome predictors for ECPR, ambulance geolocation and patient data.

Methods: A retrospective cohort study was performed using data from all patients in OHCA attended by Queensland Ambulance Service between 1 January 2014 and 31 December 2018. The number of refractory arrest patients who could potentially be transferred to an ECPR-capable centre within 45 min of the time of arrest was modelled using theoretical on-scene treatment times.

Results: Of 25 518 ambulance-attended OHCA in Queensland during the study period, 540 (2%) patients met criteria of refractory arrest for study inclusion. Further age and arrest rhythm criteria for transport to an ECPR-capable hospital were met in 253 (47%) study patients, an average of 51 patients per year. In 2018, 72 patients met study criteria for transport to an ECPR-capable centre. Based on theoretical on-scene treatment times of 12 and 20 min, in 2018 only 14 (19%) and 11 (15%) patients respectively would potentially arrive at an ECPR-capable hospital within accepted timeframes for ECPR.

Conclusions: Retrospective data collected from existing ambulance databases can be used to model patient suitability for ECPR. Relatively few patients with refractory OHCA in Queensland, Australia, could be attended and transported to an ECPR-capable centre within clinically acceptable timeframes. Further studies of the transport logistics and economic implications of providing ECPR services for OHCA are required to better inform decisions around this intervention.
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http://dx.doi.org/10.1111/1742-6723.13704DOI Listing
August 2021

Long-term outcomes of adult out-of-hospital cardiac arrest in Queensland, Australia (2002-2014): incidence and temporal trends.

Heart 2020 Nov 20. Epub 2020 Nov 20.

College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, Queensland, Australia.

Objective: To describe annual incidence and temporal trends (2002-2014) in incidence of long-term outcomes of adult out-of-hospital cardiac arrest (OHCA) of presumed cardiac aetiology attended by Queensland Ambulance Service (QAS) paramedics, by age, gender, geographical remoteness and socioeconomic status (SES).

Methods: This is a retrospective cohort study. Cases were identified using the QAS OHCA Registry and were linked with entries in the Queensland Hospital Admitted Patient Data Collection and the Queensland Registrar General Death Registry. Population data were obtained from the Australian Bureau of Statistics to calculate incidence. Inclusion criteria were adult (18+ years) residents of Queensland who suffered OHCA of presumed cardiac aetiology and survived to hospital admission. Analyses were undertaken by three mutually exclusive outcomes: (1) survival to less than 30 days (Surv<30 days); (2) survival from 30 to 364 days (Surv30-364 days); and (3) survival to 365 days or more (Surv365+ days). Incidence rates were calculated for each year by gender, age, remoteness and SES. Temporal trends were analysed.

Results: Over the 13 years there were 4393 cases for analyses. The incidence of total admitted events (9.72-10.13; p<0.01), Surv30-364 days (0.18-0.42; p<0.05) and Surv365+ days (1.94-4.02; p<0.001) increased significantly over time; no trends were observed for Surv<30 days. An increase in Surv365+ days over time was observed in all remoteness categories and most SES categories.

Conclusion: Evidence suggests that implemented strategies to improve outcomes from OHCA have been successful and penetrated groups living in more remote locations and the lower socioeconomic groups. These populations still require focus. Ongoing reporting of long-term outcomes from OHCA should be undertaken using population-based incidence.
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http://dx.doi.org/10.1136/heartjnl-2020-317333DOI Listing
November 2020

Survival in Patients with Paramedic-Identified ST-Segment Elevation Myocardial Infarction.

Prehosp Emerg Care 2021 Jul-Aug;25(4):487-495. Epub 2020 Oct 5.

Background: Field identification and treatment of ST-segment elevation myocardial infarction (STEMI) by paramedics is an important component of care for these patients. There is a paucity of studies in the setting of paramedic-identified STEMI. This study investigated mortality and factors associated with mortality in a large state-wide prehospital STEMI sample. Included were adult STEMI patients identified and treated with reperfusion therapy by paramedics in the field between January 2016 and December 2018 in Queensland, Australia. 30-day and one-year all-cause mortality was compared between two prehospital reperfusion pathways: prehospital fibrinolysis versus direct referral to a hospital for primary percutaneous coronary intervention (direct percutaneous coronary intervention [PCI] referral). For prehospital fibrinolysis patients, factors associated with failed fibrinolysis were investigated. For direct PCI referral patients, factors associated with mortality were examined. The 30-day mortality was 2.2% for prehospital fibrinolysis group and 1.8% for direct PCI referral group ( = 0.661). One-year mortality for the two groups was 2.7% and 3.2%, respectively ( = 0.732). Failed prehospital fibrinolysis was observed in 20.1% of patients receiving this therapy, with male gender and history of heart failure being predictors. For direct PCI referral group, low left ventricular ejection fraction (LVEF) on admission and cardiogenic shock prior to PCI were predictors of both 30-day and one-year mortality. Aboriginal and Torres Strait Islander status, and impaired kidney function on admission, were associated with one-year but not 30-day mortality. Being overweight was associated with lower 30-day mortality. Mortality in STEMI patients identified and treated by paramedics was low, and the prehospital fibrinolysis treatment pathway was effective with a mortality rate comparable to that of patients undergoing primary PCI. prehospital; Queensland; cardiac reperfusion; STEMI.
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http://dx.doi.org/10.1080/10903127.2020.1809753DOI Listing
October 2020

Survival in Patients with Paramedic-Identified ST-Segment Elevation Myocardial Infarction.

Prehosp Emerg Care 2021 Jul-Aug;25(4):487-495. Epub 2020 Oct 5.

Background: Field identification and treatment of ST-segment elevation myocardial infarction (STEMI) by paramedics is an important component of care for these patients. There is a paucity of studies in the setting of paramedic-identified STEMI. This study investigated mortality and factors associated with mortality in a large state-wide prehospital STEMI sample. Included were adult STEMI patients identified and treated with reperfusion therapy by paramedics in the field between January 2016 and December 2018 in Queensland, Australia. 30-day and one-year all-cause mortality was compared between two prehospital reperfusion pathways: prehospital fibrinolysis versus direct referral to a hospital for primary percutaneous coronary intervention (direct percutaneous coronary intervention [PCI] referral). For prehospital fibrinolysis patients, factors associated with failed fibrinolysis were investigated. For direct PCI referral patients, factors associated with mortality were examined. The 30-day mortality was 2.2% for prehospital fibrinolysis group and 1.8% for direct PCI referral group ( = 0.661). One-year mortality for the two groups was 2.7% and 3.2%, respectively ( = 0.732). Failed prehospital fibrinolysis was observed in 20.1% of patients receiving this therapy, with male gender and history of heart failure being predictors. For direct PCI referral group, low left ventricular ejection fraction (LVEF) on admission and cardiogenic shock prior to PCI were predictors of both 30-day and one-year mortality. Aboriginal and Torres Strait Islander status, and impaired kidney function on admission, were associated with one-year but not 30-day mortality. Being overweight was associated with lower 30-day mortality. Mortality in STEMI patients identified and treated by paramedics was low, and the prehospital fibrinolysis treatment pathway was effective with a mortality rate comparable to that of patients undergoing primary PCI. prehospital; Queensland; cardiac reperfusion; STEMI.
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http://dx.doi.org/10.1080/10903127.2020.1809753DOI Listing
October 2020

Impact of the Four-Hour Rule policy on emergency medical services delays in Australian EDs: a longitudinal cohort study.

Emerg Med J 2020 Dec 15;37(12):793-800. Epub 2020 Jul 15.

Simpson Centre for Health Services Research, South Western Sydney Clinical School, University of New South Wales, Liverpool, New South Wales, Australia.

Introduction: Delayed handover of emergency medical services (EMS) patients to EDs is a major issue with hospital crowding considered a primary cause. We explore the impact of the 4-hour rule (the Policy) in Australia, focusing on ambulance and ED delays.

Methods: EMS (ambulance), ED and hospital data of adult patients presenting to 14 EDs from 2002 to 2013 in three jurisdictions were linked. Interrupted time series 'Before-and-After' trend analysis was used for assessing the Policy's impact. Random effects meta-regression analysis was examined for associations between ambulance delays and Policy-associated ED intake, throughput and output changes.

Results: Before the Policy, the proportion of ED ambulances delayed increased between 1.1% and 1.7% per quarter across jurisdictions. After Policy introduction, Western Australia's increasing trend continued but Queensland decreased by 5.1% per quarter. In New South Wales, ambulance delay decreased 7.1% in the first quarter after Policy introduction. ED intake (triage delay) improved only in New South Wales and Queensland. Each 1% ambulance delay reduction was significantly associated with a 0.91% reduction in triage delay (p=0.014) but not ED length of stay ≤4 hours (p=0.307) or access-block/boarding (p=0.605) suggesting only partial improvement in ambulance delay overall.

Conclusion: The Policy was associated with reduced ambulance delays over time in Queensland and only the immediate period in New South Wales. Associations may be due to local jurisdictional initiatives to improve ambulance performance. Strategies to alleviate ambulance delay may need to focus on the ED intake component. These should be re-examined with longer periods of post-Policy data.
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http://dx.doi.org/10.1136/emermed-2019-208958DOI Listing
December 2020

Epidemiology of Oxytocin Administration in Out-of-Hospital Births Attended by Paramedics.

Prehosp Emerg Care 2021 May-Jun;25(3):412-417. Epub 2020 Jul 13.

Received February 12, 2020 from Queensland Ambulance Service, Queensland Government Department of Health, Brisbane, Australia (BVS, SH, LP, SR, EB); School of Clinical Sciences, Queensland University of Technology, Brisbane, Australia (SH, SR, EB) Revision received June 14, 2020; accepted for publication June 19, 2020.

Aim: Primary postpartum hemorrhage (PPH) is a life-threatening obstetric emergency that can be mitigated through the administration of a uterotonic to actively manage the third stage of labor. This study describes the prehospital administration of oxytocin by paramedics following attendance of out-of-hospital (OOH) births.

Methods: A retrospective analysis was undertaken of all OOH births between the 1 January 2018 and 31 December 2018 attended by the Queensland Ambulance Service. The demographic and epidemiological characteristics of patients that were administered oxytocin and the occurrence of adverse side effects were described.

Results: In total, 350 OOH births were included in this study with the majority involving multigravidas women (94.3%) and all but two involving singleton pregnancies. Oxytocin was administered following 222 births (63.4%), while 67 patients (19.1%) declined administration preferring a physiological third stage of labor, and in 61 cases (17.4%) oxytocin was withheld by the attending paramedic. There were no documented adverse events or side effects following administration. Oxytocin administration occurred on average 14 minutes (interquartile range 9-25) following the time of birth. The median time from oxytocin administration to placenta delivery was 10 minutes (interquartile range 5-22).

Conclusion: Oxytocin is well accepted and safe treatment adjunct for the management of the third stage of labor in OOH births and should be considered for routine practice by other emergency medical services.
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http://dx.doi.org/10.1080/10903127.2020.1786613DOI Listing
June 2021

A Comparative Process Mining Analysis of Road Trauma Patient Pathways.

Int J Environ Res Public Health 2020 05 14;17(10). Epub 2020 May 14.

Queensland Ambulance Service (QAS), Brisbane 4034, Australia.

In this paper we report on key findings and lessons from a process mining case study conducted to analyse transport pathways discovered across the time-critical phase of pre-hospital care for persons involved in road traffic crashes in Queensland (Australia). In this study, a case is defined as being an individual patient's journey from roadside to definitive care. We describe challenges in constructing an event log from source data provided by emergency services and hospitals, including record linkage (no standard patient identifier), and constructing a unified view of response, retrieval, transport and pre-hospital care from interleaving processes of the individual service providers. We analyse three separate cohorts of patients according to their degree of interaction with Queensland Health's hospital system (C1:no transport required, C2:transported but no Queensland Health hospital, C3:transported and hospitalisation). Variant analysis and subsequent process modelling show high levels of variance in each cohort resulting from a combination of data collection, data linkage and actual differences in process execution. For Cohort 3, automated process modelling generated 'spaghetti' models. Expert-guided editing resulted in readable models with acceptable fitness, which were used for process analysis. We also conduct a comparative performance analysis of transport segment based on hospital `remoteness'. With regard to the field of process mining, we reach various conclusions including (i) in a complex domain, the current crop of automated process algorithms do not generate readable models, however, (ii) such models provide a starting point for expert-guided editing of models (where the tool allows) which can yield models that have acceptable quality and are readable by domain experts, (iii) process improvement opportunities were largely suggested by domain experts (after reviewing analysis results) rather than being directly derived by process mining tools, meaning that the field needs to become more prescriptive (automated derivation of improvement opportunities).
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http://dx.doi.org/10.3390/ijerph17103426DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7277496PMC
May 2020

Prehospital study of survival outcomes from out-of-hospital cardiac arrest in ST-elevation myocardial infarction in Queensland, Australia (the PRAISE study).

Eur Heart J Acute Cardiovasc Care 2020 Apr 22:2048872620907529. Epub 2020 Apr 22.

Queensland Ambulance Service, Queensland Government Department of Health, Australia.

Aim: Patients that experience an out-of-hospital cardiac arrest in the context of a paramedic-identified ST-segment elevation myocardial infarction are a unique cohort. This study identifies the survival outcomes and determinants of survival in these patients.

Methods: A retrospective analysis was undertaken of all patients, attended between 1 January 2013 and 31 December 2017 by the Queensland Ambulance Service, who had a ST-segment elevation myocardial infarction identified by the attending paramedic prior to deterioration into out-of-hospital cardiac arrest. We described the 'survived event' and 'survived to discharge' outcomes of patients and performed univariate analysis and multivariate logistic regression to identify factors associated with survival.

Results: In total, 287 patients were included. Overall, high rates of survival were reported, with 77% of patients surviving the initial out-of-hospital cardiac arrest event and 75% surviving to discharge. Predictors of event survival were the presence of an initial shockable rhythm (adjusted odds ratio 8.60, 95% confidence interval (CI) 4.16-17.76;  < 0.001) and the administration of prehospital medication for subsequent primary percutaneous coronary intervention (adjusted odds ratio 2.54, 95% CI 1.17-5.50;  = 0.020). These factors were also found to be associated with survival to hospital discharge, increasing the odds of survival by 13.74 (95% CI 6.02-31.32;  < 0.001) and 6.96 (95% CI 2.50-19.41;  < 0.001) times, respectively. The administration of prehospital fibrinolytic medication was also associated with survival in a subgroup analysis.

Conclusion: This subset of out-of-hospital cardiac arrest patients was found to be highly salvageable and responsive to resuscitative measures, having arrested in the presence of paramedics and presented with an identified reversible cause.
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http://dx.doi.org/10.1177/2048872620907529DOI Listing
April 2020

Insights into the epidemiology of cardiopulmonary resuscitation-induced consciousness in out-of-hospital cardiac arrest.

Emerg Med Australas 2020 10 26;32(5):769-776. Epub 2020 Mar 26.

Queensland Ambulance Service, Queensland Government Department of Health, Brisbane, Queensland, Australia.

Objectives: To describe the characteristics and outcomes of cardiopulmonary resuscitation (CPR)-induced consciousness patients from a large database of out-of-hospital cardiac arrest (OHCA).

Methods: Included were adult patients, attended between January 2007 and December 2018 by the Queensland Ambulance Service, where resuscitation was attempted by paramedics. Manual review of records was undertaken to identify CPR-induced consciousness cases. Patients exhibiting purposeful limb/body movement during CPR, with or without displaying other signs, were considered to be CPR-induced consciousness. Characteristics and outcomes of CPR-induced consciousness patients were compared to those without CPR-induced consciousness.

Results: A total of 23 011 OHCA patients were included; of these, 52 (0.23%) were CPR-induced consciousness. This translates into an incidence rate of 2.3 cases per 1000 adult resuscitation attempts over 12 years. Combativeness/agitation was the most common sign of CPR-induced consciousness, described in 34.6% (18/52) of patients. CPR-induced consciousness patients had numerically higher rates of return of spontaneous circulation on hospital arrival (51.9% vs 28.6%), discharge survival (46.2% vs 15.1%) and 30-day survival (46.2% vs 14.7%), than those without CPR-induced consciousness; however, CPR-induced consciousness was not found to be an independent predictor of survival. Higher proportions of CPR-induced consciousness patients had arrest witnessed by paramedics, occurring in public places, of cardiac aetiology and initial shockable rhythm, than patients without CPR-induced consciousness.

Conclusions: CPR-induced consciousness in OHCA appears to be associated with higher survival rates. Standardised guidelines on recognition and management of CPR-induced consciousness remain to be established.
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http://dx.doi.org/10.1111/1742-6723.13505DOI Listing
October 2020

The National Ambulance Surveillance System: A novel method for monitoring acute alcohol, illicit and pharmaceutical drug related-harms using coded Australian ambulance clinical records.

PLoS One 2020 31;15(1):e0228316. Epub 2020 Jan 31.

Turning Point, Eastern Health, Richmond, Victoria, Australia.

Although harmful consumption of alcohol and other drugs (both illicit and pharmaceutical) significantly contribute to global burden of disease, not all harms are captured within existing morbidity data sources. Indeed, harms occurring in the community may be missed or under-reported. This paper describes the National Ambulance Surveillance System, a unique Australian system for monitoring and mapping acute harms related to alcohol and other drug consumption. Data are sourced from paramedic electronic patient care records provided by ambulance services from across Australia. Coding occurs in a purpose-built system, by a team of specialised research assistants. Alcohol, and specific illicit and pharmaceutical drugs, rather than broad drug classes, are manually coded and the dataset is reviewed and cleaned prior to analysis. The National Ambulance Surveillance System is an ongoing, dynamic surveillance system of alcohol and other drug-related harms across Australia. The data includes more than 140 output variables per attendance, including individual substances, demographics, temporal, geospatial, and clinical data (e.g., Glasgow Coma Scale score, naloxone provision and response, outcome of attendance). The National Ambulance Surveillance System is an internationally unique population-level surveillance system of acute harms arising from alcohol and other drug consumption. Dissemination of National Ambulance Surveillance System data has been used to inform and evaluate policy approaches and potential points of intervention, as well as guide workforce development needs and clinical practice at the local and national level. This methodology could be replicated in other countries.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0228316PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6994147PMC
April 2020

Surviving out-of-hospital cardiac arrest: The important role of bystander interventions.

Australas Emerg Care 2020 Mar 8;23(1):47-54. Epub 2020 Jan 8.

Queensland Ambulance Service, Queensland Government Department of Health, Brisbane, Queensland, Australia; School of Clinical Sciences, Queensland University of Technology, Brisbane, Queensland, Australia.

Background: Substantial variations exist in relation to the characteristics and outcomes of out-of-hospital cardiac arrest (OHCA). As such, an understanding of region-specific factors is essential for informing strategies to improve OHCA survival.

Methods: Analysis of a large state-wide OHCA database of the Queensland Ambulance Service, Australia. Adult patients, attended by paramedics between January 2000 and December 2018 for OHCA of medical origin, where the arrest was not witnessed by paramedics, and resuscitation was attempted, were included. Factors associated with survival were investigated. The number needed to treat (NNT) for bystander interventions was estimated.

Results: Across a total of 23,510 patients, event survival, survival to discharge and 30-day survival was 22.6%, 11.9% and 11.5%, respectively. The corresponding figures for the Utstein patient group (initial shockable rhythm, bystander-witnessed) were 38.9%, 27.2% and 26.3%, respectively. Bystander cardiopulmonary resuscitation (CPR) and defibrillation substantially improved the likelihood of survival. The NNT for bystander CPR was 41, 63 and 64 for event survival, survival to discharge, and 30-day survival, respectively. The NNT for bystander defibrillation for these survival outcomes was 10, 14 and 14, respectively.

Conclusions: Bystander interventions are critical for OHCA survival. Effort should be invested in strategies to improve the uptake of these interventions.
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http://dx.doi.org/10.1016/j.auec.2019.12.003DOI Listing
March 2020

Improving emergency department transfer for patients arriving by ambulance: A retrospective observational study.

Emerg Med Australas 2020 04 23;32(2):271-280. Epub 2019 Dec 23.

Department of Emergency Medicine, Gold Coast University Hospital, Gold Coast Health, Gold Coast, Queensland, Australia.

Objective: Extended delays in the transfer of patients from ambulance to ED can compromise patient flow. The present study aimed to describe the relationship between the use of an Emergency Department Ambulance Off-Load Nurse (EDAOLN) role, ED processes of care and cost effectiveness.

Methods: This was a retrospective observational study over three periods of before (T1), during (T2) and after (T3) the introduction of the EDAOLN role in 2012. Ambulance, ED and cost data were linked and used for analysis. Processes of care measures analysed included: time to be seen by a doctor from ED arrival (primary outcome), ambulance-ED offload compliance, proportion of patients seen within recommended triage timeframe, ED length of stay (LoS), proportion of patients transferred, admitted or discharged from the ED within 4 h and cost effectiveness.

Results: A total of 6045 people made 7010 presentations to the ED by ambulance over the study period. Several measures improved significantly between T1 and T2 including offload compliance (T1: 58%; T2: 63%), time to be seen (T1: 31 min; T2: 28 min), ED LoS (T1: 335 min; T2: 306 min), ED LoS <4 h (T1: 31%; T2: 33%). Some measures carried over into T3, albeit to a lesser extent. Post-hoc analyses showed that outcomes improved most for less urgent patients. The annualised net cost of the EDAOLN (if funded from additional resources) of $130 721 could result in an annualised reduction of approximately 3912 h in waiting time to be seen by a doctor.

Conclusion: With the EDAOLN role in place, slight outcome improvements in several key ambulance and ED efficiency criteria were noted. During times of ED crowding, the EDAOLN role may be one cost-effective strategy to consider.
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http://dx.doi.org/10.1111/1742-6723.13407DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7155107PMC
April 2020

Prehospital ST-Segment Elevation Myocardial Infarction (STEMI) in Queensland, Australia: Findings from 11 Years of the Statewide Prehospital Reperfusion Strategy.

Prehosp Emerg Care 2020 May-Jun;24(3):326-334. Epub 2019 Aug 23.

Field identification and treatment of ST-segment elevation myocardial infarction (STEMI) by paramedics is an important component of the continuum of care for these patients. This study described real-world clinical practice in prehospital management of STEMI patients in Queensland, Australia. Retrospective analysis of data sourced from the STEMI database of the Queensland Ambulance Service, Australia. Adult STEMI patients identified by paramedics between February 2008 and December 2018 in Queensland were included. Key aspects of prehospital STEMI care were described. Clinically-important time intervals from symptom onset to reperfusion were reported. A total of 8,388 patients were included. The proportion of patients receiving prehospital reperfusion treatment has improved markedly, increasing from 34% in 2008 to 65% in 2018 ( < 0.001). Direct referral of patients to a hospital for primary percutaneous coronary intervention (pPCI), and administration of preparatory antiplatelet and anticoagulant medications, was the main reperfusion treatment pathway, accounting for 75% of patients receiving reperfusion treatment. Time from paramedic arrival at scene to first 12-lead electrocardiogram has significantly reduced, from 11 minutes in 2008 to 6 minutes from 2012 onwards ( < 0.001). Median (interquartile range, IQR) time from prehospital STEMI identification to reperfusion was 88 (74-103) minutes for patients referred by paramedics to a hospital for pPCI. Fifty-five percent of patients who underwent pPCI achieved time from STEMI identification to reperfusion within 90 minutes. For patients receiving prehospital fibrinolysis, median (IQR) time from STEMI identification to administration of a fibrinolytic agent was 21 (12-33) minutes. The implementation of a statewide prehospital reperfusion strategy has markedly improved the rate of prehospital reperfusion treatment and key time metrics. Ongoing quality improvement efforts are required to further reduce delays in reperfusion.
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http://dx.doi.org/10.1080/10903127.2019.1651433DOI Listing
January 2021

Pre-hospital outcomes of adult out-of-hospital cardiac arrest of presumed cardiac aetiology in Queensland, Australia (2002-2014): Trends over time.

Emerg Med Australas 2019 10 28;31(5):813-820. Epub 2019 Jul 28.

College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, Queensland, Australia.

Objective: To describe temporal trends in incidence of pre-hospital outcomes from adult out-of-hospital cardiac arrest (OHCA) of presumed cardiac aetiology attended by Queensland Ambulance Service (QAS) paramedics between 2002 and 2014, by age, gender, geographical remoteness and socio-economic status.

Methods: Cases included in this retrospective cohort study were identified from the QAS OHCA Registry. Included cases were linked with Queensland Hospital Admitted Patient Data Collection and Queensland Death Registry. Population data were obtained from the Australian Bureau of Statistics to calculate incidence rates for each year. Analyses were undertaken by four mutually exclusive pre-hospital outcomes: (i) no resuscitation (No-Resus); (ii) resuscitation, no pre-hospital return of spontaneous circulation (No-ROSC); (iii) resuscitation, pre-hospital return of spontaneous circulation not sustained to hospital (Unsustained-ROSC); and (iv) resuscitation, pre-hospital return of spontaneous circulation sustained to hospital (Sustained-ROSC). Trends over time were analysed for crude and specific rates for total OHCA events and for each outcome.

Results: Between 2002 and 2014, there were 30 560 OHCA cases. Crude incidence significantly increased over time for No-Resus and Sustained-ROSC, and significantly decreased for No-ROSC. These trends were reflected in major cities, inner and outer regional areas. There was a significant increase in Sustained-ROSC in remote areas, and no significant trends in very remote areas.

Conclusion: Incidence of withholding resuscitation and ROSC sustained to hospital have independently increased over time. Factors of middle age, more rural location and lower socio-economic status should all be targeted in the development and implementation of future strategies.
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http://dx.doi.org/10.1111/1742-6723.13353DOI Listing
October 2019

Epidemiology of pre-hospital outcomes of out-of-hospital cardiac arrest in Queensland, Australia.

Emerg Med Australas 2019 10 28;31(5):821-829. Epub 2019 Jul 28.

College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, Queensland, Australia.

Objective: To describe incidence in pre-hospital outcomes of adult out-of-hospital cardiac arrest (OHCA) of presumed cardiac aetiology, attended by Queensland Ambulance Service (QAS) paramedics between 2002 and 2014, by age, gender, geographical remoteness and socio-economic status.

Methods: The QAS OHCA Registry was used to identify cases, which was then linked with Queensland Hospital Admitted Patient Data Collection and Queensland Death Registry. Population data were obtained for each calendar year by age and gender from the Australian Bureau of Statistics in order to calculate incidence rates. Four mutually exclusive pre-hospital outcomes were analysed: (i) no resuscitation (No-Resus); (ii) resuscitation, no pre-hospital return of spontaneous circulation (No-ROSC); (iii) resuscitation, pre-hospital return of spontaneous circulation not sustained to hospital (Unsustained-ROSC); and (iv) resuscitation, pre-hospital return of spontaneous circulation sustained to hospital (Sustained-ROSC).

Results: Over the 13 years, there were 30 560 OHCA cases for analyses. Incidence was significantly greater in males than females and incrementally increased with age, for each outcome. Incidence of total OHCA events generally increased as remoteness increased (major cities: 72.39 per 100 000 [95% CI 71.35-73.45]; very remote: 87.01 per 100 000 [95% CI 78.03-95.98]). There was an inverse association between incidence of OHCA events and socio-economic status (SEIFA 1 and 2: 81.34 per 100 000 [95% CI 79.28-83.40]; SEIFA 9 and 10: 61.57 per 100 000 [95% CI 59.67-63.46]).

Conclusion: Rural-specific strategies should be continued. Prevention and management strategies for OHCA targeting lower socio-economic groups require focus.
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http://dx.doi.org/10.1111/1742-6723.13354DOI Listing
October 2019

Mental health presentations to the emergency department: A perspective on the involvement of social support networks.

Australas Emerg Care 2019 Sep 10;22(3):162-167. Epub 2019 Jul 10.

Griffith University, Menzies Health Institute Queensland, QLD, Australia; Department of Emergency Medicine, Gold Coast Health, QLD, Australia.

The involvement of families, carers and significant others (i.e. social support networks) has a positive corollary for a person experiencing mental health problems. Accordingly, in Australia involvement of social support networks within mental health services is endorsed in national health policy and service guidelines. Despite the endorsement, this is yet to be fully realised in all areas that provide mental health services, including emergency departments. Social support networks are integral in the provision of mental health consumers' care. Supporting the involvement of social support networks in the emergency department can provide healthcare services with opportunities for enhanced and cost-effective care, contributing to improved outcomes for consumers. An overview of some of the barriers and facilitators of social support network involvement is provided. The intention of this paper is to encourage reflection and dialogue on this important area of mental health service provision and support the evolution of a new paradigm of research into social support network involvement in the emergency department.
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http://dx.doi.org/10.1016/j.auec.2019.06.002DOI Listing
September 2019

Review article: Interventions for people presenting to emergency departments with a mental health problem: A systematic scoping review.

Emerg Med Australas 2019 10 30;31(5):715-729. Epub 2019 Jun 30.

Gold Coast Hospital and Health Service, Gold Coast, Queensland, Australia.

The number of people presenting to EDs with mental health problems is increasing. To enhance and promote the delivery of safe and efficient healthcare to this group, there is a need to identify evidence-based, best-practice models of care. This scoping review aims to identify and evaluate current research on interventions commenced or delivered in the ED for people presenting with a mental health problem. A systematic search of eight databases using search terms including emergency department, mental health, psyc* and interventions, with additional reference chaining, was undertaken. For included studies, level of evidence was assessed using the NHMRC research guidelines and existing knowledge was synthesised to map key concepts and identify current research gaps. A total of 277 papers met the inclusion criteria. These were grouped thematically into seven domains based on primary intervention type: pharmacological (n = 43), psychological/behavioural (n = 25), triage/assessment/screening (n = 28), educational/informational (n = 12), case management (n = 28), referral/follow up (n = 36) and mixed interventions (n = 105). There was large heterogeneity observed as to the level of evidence within each intervention group. The interventions varied widely from pharmacological to behavioural. Interventions were focused on either staff, patient or institutional process domains. Few interventions focused on multiple domains (n = 64) and/or included the patient's family (n = 1). The effectiveness of interventions varied. There is considerable, yet disconnected, evidence around ED interventions to support people with mental health problems. A lack of integrated, multifaceted, person-centred interventions is an important barrier to providing effective care for this vulnerable population who present to the ED.
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http://dx.doi.org/10.1111/1742-6723.13335DOI Listing
October 2019

"I was worried if I don't have a broken leg they might not take it seriously": Experiences of men accessing ambulance services for mental health and/or alcohol and other drug problems.

Health Expect 2019 06 4;22(3):565-574. Epub 2019 Apr 4.

Turning Point, Eastern Health, Melbourne, Victoria, Australia.

Background: A large proportion of ambulance callouts are for men with mental health and/or alcohol and other drug (AOD) problems, but little is known about their experiences of care. This study aimed to describe men's experiences of ambulance care for mental health and/or AOD problems, and factors that influence their care.

Methods: Interviews were undertaken with 30 men who used an ambulance service for mental health and/or AOD problems in Australia. Interviews were analysed using the Framework approach to thematic analysis.

Results: Three interconnected themes were abstracted from the data: (a) professionalism and compassion, (b) communication and (c) handover to emergency department staff. Positive experiences often involved paramedics communicating effectively and conveying compassion throughout the episode of care. Conversely, negative experiences often involved a perceived lack of professionalism, and poor communication, especially at handover to emergency department staff.

Conclusion: Increased training and organizational measures may be needed to enhance paramedics' communication when providing care to men with mental health and/or AOD problems.
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http://dx.doi.org/10.1111/hex.12886DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6543159PMC
June 2019

Leveraging Data Quality to Better Prepare for Process Mining: An Approach Illustrated Through Analysing Road Trauma Pre-Hospital Retrieval and Transport Processes in Queensland.

Int J Environ Res Public Health 2019 03 29;16(7). Epub 2019 Mar 29.

Queensland Ambulance Service (QAS), Brisbane 4034, Australia.

While noting the importance of data quality, existing process mining methodologies (i) do not provide details on how to assess the quality of event data (ii) do not consider how the identification of data quality issues can be exploited in the planning, data extraction and log building phases of any process mining analysis, (iii) do not highlight potential impacts of poor quality data on different types of process analyses. As our key contribution, we develop a process-centric, data quality-driven approach to preparing for a process mining analysis which can be applied to any existing process mining methodology. Our approach, adapted from elements of the well known CRISP-DM data mining methodology, includes conceptual data modeling, quality assessment at both attribute and event level, and trial discovery and conformance to develop understanding of system processes and data properties to inform data extraction. We illustrate our approach in a case study involving the Queensland Ambulance Service (QAS) and Retrieval Services Queensland (RSQ). We describe the detailed preparation for a process mining analysis of retrieval and transport processes (ground and aero-medical) for road-trauma patients in Queensland. Sample datasets obtained from QAS and RSQ are utilised to show how quality metrics, data models and exploratory process mining analyses can be used to (i) identify data quality issues, (ii) anticipate and explain certain observable features in process mining analyses, (iii) distinguish between systemic and occasional quality issues, and (iv) reason about the mechanisms by which identified quality issues may have arisen in the event log. We contend that this knowledge can be used to guide the data extraction and pre-processing stages of a process mining case study to properly align the data with the case study research questions.
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http://dx.doi.org/10.3390/ijerph16071138DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6479847PMC
March 2019

Paramedics' perceptions of their scope of practice in caring for patients with non-medical emergency-related mental health and/or alcohol and other drug problems: A qualitative study.

PLoS One 2018 13;13(12):e0208391. Epub 2018 Dec 13.

Turning Point, Eastern Health, Melbourne, Victoria, Australia.

Background: Paramedics are called on frequently to provide care to patients with mental health and/or and alcohol and other drug (AOD) problems, but may have mixed views about how this fits within their role.

Aims: To explore paramedics' experience of caring for patients with non-medical emergency-related mental health and/or AOD problems, understand their perceptions of their scope of practice in caring for these patients, and ascertain if their practice should be extended to incorporate education with these patients.

Method: A convenience sample of 73 paramedics from most Australian states and territories-recruited through an online survey-participated in individual audio-recorded, qualitative interviews, conducted by telephone. The interviews were part of a mixed method study comprising qualitative interviews and online survey. A Framework Method of analysis to analyse the qualitative data.

Results: Three themes and sub-themes were abstracted from the data about participants' experiences and, at times, opposing viewpoints about caring for patients with non-medical emergency-related mental health and/or AOD problems: caring for these patients is a routine part of paramedics' work, contrasting perspectives about scope of practice in caring for this group of patients, competing perspectives about extending scope of practice to incorporate education with this cohort of patients.

Conclusions: Paramedics need more undergraduate and in-service education about the care of patients with mental health and/or AOD problems, and to address concerns about extending their scope of practice to include education with these patients. Thought should be given to introducing alternative models of paramedic practice, such as community paramedicine, with a focus on supporting people in the community with mental health and/or AOD problems. There is a need for a change in workplace and organisational culture about scope of practice in caring for patients with these problems. Extending paramedics' role could, potentially, benefit people with these problems by improving the quality of care, reducing the need for transportation to emergency departments, and decreasing clinicians' workloads in these departments.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0208391PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6292637PMC
May 2019

Recognition of, and attitudes towards, people with depression and psychosis with/without alcohol and other drug problems: results from a national survey of Australian paramedics.

BMJ Open 2018 12 4;8(12):e023860. Epub 2018 Dec 4.

Turning Point, Eastern Health, Melbourne, Victoria, Australia.

Objective: Continuing stigma towards mental health problems means that many individuals-especially men-will first present in crisis, with emergency services often the first point of call. Given this situation, the aims of this paper were to assess paramedics' ability to recognise, and their attitudes towards, males with clinically defined depression and psychosis with and without comorbid alcohol and other drug (AOD) problems.

Methods: A cross-sectional national online survey of 1230 paramedics throughout Australia. The survey was based on four vignettes: depression with suicidal thoughts, depression with suicidal thoughts and comorbid alcohol problems, and psychosis with and without comorbid AOD problems.

Results: Just under half of respondents recognised depression, but this decreased markedly to one-fifth when comorbid AOD problems were added to the vignette. In contrast, almost 90% recognised psychosis, but this decreased to just under 60% when comorbid AOD problems were added. Respondents were more likely to hold stigmatising attitudes towards people in the vignettes with depression and psychosis when comorbid AOD problems were present. Respondents endorsed questionnaire items assessing perceived social stigma more strongly than personal stigma. Desire for social distance was greater in vignettes focusing on psychosis with and without comorbid AOD problems than depression with and without comorbid AOD problems.

Conclusions: Paramedics need a well-crafted multicomponent response which involves cultural change within their organisations and more education to improve their recognition of, and attitudes towards, clients with mental health and AOD problems. Education should focus on the recognition and care of people with specific mental disorders rather than on mental disorders in general. It is essential that education also focuses on understanding and caring for people with AOD problems. Educational interventions should focus on aligning beliefs about public perceptions with personal beliefs about people with mental disorders and AOD problems.
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http://dx.doi.org/10.1136/bmjopen-2018-023860DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6286471PMC
December 2018

Ambulance Arrivals and ED Flow - A Queensland Perspective.

Stud Health Technol Inform 2018 ;252:80-85

Queensland Health, Brisbane, Australia.

While it is widely accepted that whole of hospital solutions are necessary to reduce the ever-increasing burden on the public health system, little research has focussed on understanding the relationship between ambulance arrival related flow metrics and emergency department (ED) crowding. Queensland Ambulance Service (QAS) shares patient load across multiple hospitals, and receiving facilities strive to meet a Patient Off Stretcher Time (POST) target of 30 minutes. We examine ambulance arrival data from the QAS and ED patient arrival data from 15 major metropolitan hospitals across Queensland, to understand temporal variations in POST performance and examine the relationship between POST performance and ED crowding. The findings suggest a relationship between ED occupancy levels and both ambulances waiting at the ED door and average POST at larger hospitals. No relationship between POST and ED length of stay was found, perhaps due to competing ED National Emergency Access Targets (NEAT). Further modelling is recommended to formally test these observations.
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November 2018

A Prospective Before and After Study of Droperidol for Prehospital Acute Behavioral Disturbance.

Prehosp Emerg Care 2018 Nov-Dec;22(6):713-721. Epub 2018 Mar 20.

Study Objective: Acute behavioral disturbance is a common problem for emergency medical services. We aimed to investigate the safety and effectiveness of droperidol compared to midazolam in the prehospital setting.

Methods: This was a prospective before and after study comparing droperidol to midazolam for prehospital acute behavioral disturbance, when the state ambulance service changed medications. The primary outcome was the proportion of adverse effects (airway intervention, oxygen saturation < 90%, respiratory rate < 12, systolic blood pressure < 90 mmHg, sedation assessment tool score -3 and dystonic reactions) in patients receiving sedation. Secondary outcomes included time to sedation, requirement for additional sedation, staff and patient injuries, and prehospital time.

Results: There were 141 patients administered midazolam and 149 patients administered droperidol in the study. Alcohol was the most common cause of acute behavioral disturbance. Fewer patient adverse events occurred with droperidol (11/149) compared to midazolam (33/141) (7% vs. 23%; absolute difference 16%; 95% confidence interval [CI]: 8% to 24%; p = 0.0001). Median time to sedation was 22 min (interquartile range [IQR]:18 to 35 min) for droperidol compared to 30 min (IQR:20 to 45 min) for midazolam. Additional prehospital sedation was required in 6/149 (4%) droperidol patients and 20/141 (14%) midazolam patients, and 11 (7%) droperidol and 59 (42%) midazolam patients required further sedation in the emergency department. There were no differences in patient or staff injuries, or prehospital time.

Conclusions: The use of droperidol for acute behavioral disturbance in the prehospital setting is associated with fewer adverse events, a shorter time to sedation, and fewer requirements for additional sedation.
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http://dx.doi.org/10.1080/10903127.2018.1445329DOI Listing
June 2019

Regional variation in the characteristics, incidence and outcomes of out-of-hospital cardiac arrest in Australia and New Zealand: Results from the Aus-ROC Epistry.

Resuscitation 2018 05 2;126:49-57. Epub 2018 Mar 2.

Department of Epidemiology and Preventive Medicine, Monash University, Victoria, Australia; Prehospital, Resuscitation and Emergency Care Research Unit (PRECRU), Curtin University, Western Australia, Australia; St John Ambulance Western Australia, Western Australia, Australia.

Introduction: The aim of this study was to investigate regional variation in the characteristics, incidence and outcomes of out-of-hospital cardiac arrest (OHCA) in Australia and New Zealand.

Methods: This was a population-based cohort study of OHCA using data from the Aus-ROC Australian and New Zealand OHCA Epistry over the period of 01 January 2015-31 December 2015. Seven ambulance services contributed data to the Epistry with a capture population of 19.8 million people. All OHCA attended by ambulance, regardless of aetiology or patient age, were included.

Results: In 2015, there were 19,722 OHCA cases recorded in the Aus-ROC Epistry with an overall crude incidence of 102.5 cases per 100,000 population (range: 51.0-107.7 per 100,000 population). Of all OHCA cases attended by EMS (excluding EMS-witnessed cases), bystander CPR was performed in 41% of cases (range: 36%-50%). Resuscitation was attempted (by EMS) in 48% of cases (range: 40%-68%). The crude incidence for attempted resuscitation cases was 47.6 per 100,000 population (range: 34.7-54.1 per 100,000 population). Of cases with attempted resuscitation, 28% survived the event (range: 21%-36%) and 12% survived to hospital discharge or 30 days (range: 9%-17%; data provided by five ambulance services).

Conclusion: In the first results of the Aus-ROC Australian and New Zealand OHCA Epistry, significant regional variation in the incidence, characteristics and outcomes was observed. Understanding the system-level and public health drivers of this variation will assist in optimisation of the chain of survival provided to OHCA patients with the aim of improving outcomes.
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http://dx.doi.org/10.1016/j.resuscitation.2018.02.029DOI Listing
May 2018