On August 4, 2020 a massive explosion struck the Beirut Harbor in Lebanon. Approximately 220 people were killed and over 7000 were injured, of which 12% were hospitalized. Despite being weakened by an economic crisis and increasing numbers of COVID-19 cases, the national healthcare system responded promptly. Within a day, International Emergency Medical Teams (I-EMTs) started arriving. Previous studies have found that I-EMTs have arrived late and have not been adapted to the context and dominating healthcare needs. The aim of this study was to document the organization, type, activity, and timing of I-EMTs deployed to Beirut and to discuss their relevance in relation to medical needs.

Data on all deployed I-EMTs were retrieved from all available sources, including internet searches, I-EMT contacts, and from the World Health Organization (WHO) EMT coordination cell (EMT CC) in Lebanon. The WHO EMT classification was used to categorize deployed teams. Information on characteristics, timing, and activities was retrieved and systematically assessed.

Nine I-EMTs were deployed to Beirut following the explosion. Five were equivalent to EMT Type 2 (field hospitals), of which three were military. The first I-EMT arrived within 24 hours, while the last I-EMT was set up one month after the explosion. Four civilian I-EMTs provided non-clinical support as EMT Specialized Care Teams. A majority of the I-EMTs were focused on trauma care. Three I-EMT Specialized Care Teams were rapidly re-tasked to support COVID-19 care in public hospitals.

A majority of the deployed I-EMT Type 2 were military and focused on trauma care rather than the normal burden of disease, including COVID-19. Re-tasking of EMTs requires flexible EMTs. To be better adapted, the I-EMT response should be guided by a systematic assessment of both healthcare capacities in the affected country as well as the varying health effects of hazards before deployment.

On February 24, 2022, Russia invaded Ukraine, resulting in Europe’s largest refugee crisis since World War II. More than six million Ukrainians fled the country—half of these to Poland—and one-third of the population was internally displaced.

Border points became bottlenecks where fatalities were reported—people risked their lives in long queues and subzero temperatures.

This presentation focuses on experiential information obtained during a 17-week deployment of EMT Type 1 both at border points (fixed) and in northwestern Ukraine (mobile). Quantitative and qualitative data were obtained after deployment by online survey with 75 medical, logistical and interpreter volunteers.

Initial teams experienced extremely fluid demands and numerous challenges with security, team adherence to COVID-19 protocols, behavioral issues with less experienced volunteers, and collaboration with novel governmental and non-governmental partners to achieve objectives.

1. Deployment to a conflict setting requires adherence to the Incident Command System, with daily security briefings and structured handover between teams at the beginning of each deployment.

2. Strict adherence to well-defined protocols for the prevention and management of emerging infectious risks such as COVID-19 is necessary, along with contingency plans to isolate infected team members.

3. There is a need for standardized pre-deployment vetting, training and orientation of all volunteers—particularly team leaders.

4. Identification of international partners should start pre-deployment and remain a continuous process during deployment.

Emergency Medical Team Coordination Cell (EMTCC) was established in WHO Moldova Country Office to coordinate responding International EMTs in March 2022. Japan International Cooperation Agency (JICA) sent an EMTCC assistance team to support the WHO-approved minimum data collection for emergency medical teams, Minimum Data Set (MDS), operations and other coordination activities. Introducing activities of the JICA EMTCC assistance team at the Moldova EMTCC will suggest future use.

EMTCC assistance team activities were reviewed.

There was a wide range of high-level administrative functions in EMTCC, such as planning, logistics, assurance and governance, and human resources. One of the significant functions was introducing MDS to the medical team and extracting the data summaries for reporting to the Moldova Ministry of Health. All these tasks require considerable time to manage and must be completed promptly for effective EMTCC operations.

The EMTCC coordinator should function as a decision-maker to control the coordination of EMTs communicating with WHO and implementing the EMT initiative. In a disaster, especially in the acute phase of EMTCC activities, more high-level administrative functions will be required with immediate processing. Therefore, it is considered that the EMTCC assistance team should work with the coordinator as early as possible. In addition, all these EMTCC assistance team activities should be standardized and specified in the EMTCC handbook for future operation reference.

As there have been no reports concerning the relationship between incontinence and disease severity in patients in the prehospital setting, a retrospective investigation examined this relationship using data from Shimoda Fire Department.

Patients who were transported by Shimoda Fire Department from January 2019 to December 2021 were investigated. The following details of the subjects were collected: age, sex, contents of incontinence, season of transportation, weather, wind speed, temperature, place of collapse, scene time, classification of disease, disease severity (as judged by a physician at a receiving hospital) and mortality rate at the initial treatment. The subjects were divided into groups based on the existence of incontinence at the scene or not (Incontinence [+] and Incontinence [-]). We compared the variables mentioned above between these groups.

There were 499 cases with incontinence and 8,241 cases without incontinence. There were no significant differences between the two groups with respect to weather and wind speed. The average age, percentage of male patients, percentage of cases in the winter season, rate of collapse at home, scene time, rate of endogenous disease, disease severity, and mortality rate in the Incontinence (+) group were significantly greater in comparison to the Incontinence (-) group, while the average temperature in the Incontinence (+) group was significantly lower than that in the Incontinence (-) group. Regarding the rates of incontinence of each disease, neurologic, infectious, endocrinal disease, dehydration, suffocation and cardiac arrest at the scene had more than twice the rate of incontinence in other conditions.

This is the first study to report that patients with incontinence at the scene tended to be older, showed a male predominance, severe disease, high mortality, and required a long scene time in comparison to patients without incontinence. Prehospital care providers should therefore check for incontinence when evaluating patients.

The impact of a heat wave on body temperature of patients being admitted to the emergency department (ED) and of patients that were already hospitalized was investigated. This can provide insight into measures or infrastructural adjustments that still need to be made.

A retrospective study comparing the measured body temperature of patients admitted to the ED and patients already hospitalized during a heat wave from August 11-13, 2020 versus a period in which no heat wave, no manifest presence of COVID-19, and no other endemism was present (October 10 and October 20, 2019, and November 5, 2019) was conducted. Two groups were created per period: morning and afternoon measurements.

Comparing the heat wave to the control period, no statistical difference was observed in morning temperature measurements at the ED. In the afternoon temperature measurements at the ED, however, a statistically significant difference (p < 0.01) was measured. Afternoon measurements during the control period showed a mean of 36.842 °C, whereas the measurements during the heat wave showed a mean body temperature of 37.191 °C. For hospitalized patients, a statistical difference (p < 0.01) was measured in both morning and afternoon temperature measurements. The control period showed a mean morning body temperature of 36.629 °C and a mean afternoon body temperature of 36.7154 °C, as opposed to the heat wave mean body temperatures in the morning (36.698 °C) and afternoon (36.7937 °C).

This study emphasizes the rise in body temperature during a heat wave, independently of other factors that influence body temperature. Hospitals should focus on preventive measures, such as air conditioning and providing good temperature control. Further research is needed.

As a part of a primary intervention, Emergency Medical Services (EMS) may leave a patient at the scene. This decision is made in partnership with the dispatching center. The prognosis of these patients is often unknown. The aim of our study was to assess the outcomes of non-transported EMS patients.

It was a descriptive, prospective study conducted over a two-year-period. We included all alive non-transported EMS patients from the site of intervention after a primary mission of the EMS team based on a medical decision. The prognosis was assessed by unexpected events (UE) defined by death, second EMS call, urgent consultation or hospitalization/surgery within seven days. We considered two groups: a group with UME (UME+) and a group with good evolution (UE-).

We included 97 patients. The average age was 56±19 years. Seventeen patients (17,5%) had no medical histories. Hypoglycemia was observed in 43% of patients. Thirty-four patients (35%) had an UE. These UEs were distributed as the following: ten consulted a private doctor, ten consulted their family physician, seven called the EMS, three visited the emergency department and four died. There were no significant differences in demographic, anamnestic characteristics between two groups. Psychiatric pathology was more common in the UE- group(28% vs. 9%; p=0.0037). Intravenous injections were more common in the UE+ group (64% vs 39% ; p=0,019). Among the four deaths, three were unexpected.

One-third of non-transported EMS patients had UE. Unexpected death was rare (one patient). Setting-up a system for these patients including scores and algorithms, and a post-EMS compulsory visit in collaboration with family physicians could be beneficial.

Cyberattacks continue to plague medical systems across the world with nearly 24% of all cyber breaches impacting health systems. In Fall 2021, a large, tertiary care county hospital in Indianapolis, Indiana, USA suffered a cyberattack, causing over four weeks of downtime, forcing the system to revert to paper charting and to operate without the electronic medical record (EMR) or internet. Communication in the Emergency Department is structured through the EMR system or wireless local area network (WLAN) phones, causing communication difficulties when online systems are disrupted.

In the twelve months following the breach, a series of communications-focused interviews with stakeholders including residents, faculty, nurses, and consultants were analyzed using a thematic analysis.

Through interviews, four key themes and recommendations were identified for every internet-dependent tertiary care system to establish and maintain communication links when the primary form of communication is compromised and access to internet is limited or nonexistent:

• Expect systems to fail–plan ahead

• Develop multilayered communication tools that are stored and structured at different sites

• Notify all affected teams immediately and initiate the downtime action plan

• Reassess and adapt the downtime action plan as information becomes available

While every system is going to experience different struggles during cyberattacks and downtime, all hospitals can benefit from improving communication structures when the established communication pathways are no longer available. Consider cybersecurity threats in your emergency planning meetings and designate systems to protect your communication abilities during downtime.

In the Netherlands several additional facilities and working methods are created to strengthen the effectiveness and capacity of the regular daily health care during large incidents and disasters. One system is called GGB (Large-scale medical assistance). The daily healthcare is organized in 25 safety-regions, which are far too small to handle big incidents. GGB provides in organizing assistance between regions, increasing the effectiveness of ambulance care, the deployment of other emergency services and volunteers, and coordination of this all. GGB is developed to deal with an incident with 250 injuries. This method was investigated to determine value.

Based on a standard questionnaire, key persons of ambulance care, trauma care, Red Cross and Offices of Public Health and Safety per safety region were asked about their experiences with GGB. (125 forms)

Subsequently, the regional outcomes for each discipline were evaluated in a national conferences (four conferences). To conclude, an interdisciplinary national meeting was held to bring the results together. The authors developed the questionnaires, supervised the research process, and presented the results to the authorities.

Results indicated that the working methods for scaled-up care is useful and should be continued. The extra financial costs outweigh the gained strength. The cooperation between professionals and volunteers also receives a lot of support. Proposals have been made for further improvements, in particular concerning cooperation between organizations. Bottlenecks have also been identified in the collaboration between health care, fire services and community care.

In the perception of the care providers there is added value and cost-effectiveness. This is important for the support of the system. As a next step, the authors want to focus on measuring the actual effectiveness. For that, we want to be able to compare systems in several countries. The presentation ends with a call to do so.

During a mass casualty incident (MCI), activating resources for response and equitable patient distribution is paramount. The Regional Hospital Coordination Center (RHCC) of a large US city lacked an objective tool readily available to manage patient distribution to area hospitals during an MCI. In a hospital-rich community, spreading the patient distribution throughout the region decreases the impact to one hospital. A tool was needed to equitably distribute patients across the healthcare system without added burden or demand to the hospitals nearest the MCI.

This tool was developed using Excel and regional hospital capability information including trauma or burn center status, pediatric designation, etc. These capabilities and geographic distances from the MCI were the driving factors of the tool development.

The city has several high-visibility, large event locations. These locations were added into the tool and can be selected as MCI origin points. From here, the tool organizes hospitals by distance from the designated point. Since the formulas were programmed into the tool, it can be easily and quickly adapted to any MCI in the area and reflect relevant resources and limitations.

Equitable patient distribution to area hospitals during an MCI is a best practice. Advance preparation is key to ensuring quick response and effective utilization of resources. Having a custom tool pre-programmed with relevant, regional hospital capabilities expedited this process and streamlined patient distribution efforts and, ultimately, improved emergency care coordination and patient outcomes.

During a Mass Casualty Incident, distributing patients equitably across the healthcare system without added burden to the hospitals nearest the event is critical. Having a custom tool pre-programmed with regional hospital capabilities expedites and streamlines patient distribution efforts, ultimately improving emergency care coordination and patient outcomes.

International reports suggest there have been prehospital delays for time-sensitive emergencies like stroke and TIA during the COVID-19 pandemic. The aim was to investigate the impact of the COVID-19 pandemic on ambulance times and emergency call volume for adults with suspected stroke and TIA in Ireland.

We conducted a retrospective cohort study of patients ≥ 18 years with suspected stroke/TIA, based on data from the National Ambulance Service. We included all cases assigned code 28 (suspected stroke/TIA) by the emergency call-taker, from 2018-2021. We compared ambulance times and emergency call volume by week, the four COVID-19 waves (defined by the Health Protection Surveillance Centre) and annually. The COVID-19 period was from March 1, 2020 - December 19, 2021 and the pre-COVID-19 period January 1, 2018 - February 29, 2020. Continuous variables were compared with t-tests and categorical variables with Pearson’s χ2 tests.

40,012 cases were included: 20,281 in the pre-COVID-19 period and 19,731 in the COVID-19 period. Mean patient age significantly decreased between the two periods, from 71 years (±16.5) to 69.8 years (±17.1); p<0.001. Mean ambulance response time increased between the two periods from 17 minutes 31 seconds to 18 minutes 59 seconds (p<0.001). The number of cases with symptom onset to emergency call time of >4 hours significantly increased from 5,581 to 6,060 during the COVID-19 period (p<0.001). Mean calls/day increased from 25.1/day to 30.1/day during the COVID-19 period.

Early findings from the study suggest an increase in call volume for stroke/TIA between the COVID-19 and pre-COVID-19 periods. An increase in response times during the same periods was also found. We concluded that longer symptom-to-call times indicate a change in healthcare-seeking behavior. Sustaining high levels of compliance with stroke code protocols is crucial during healthcare crises. Future research will involve further analysis including controlling for confounders.

The 2022 Russian invasion of Ukraine exacts a heavy death toll throughout Ukraine. Morbidity and mortality of warfighters and vulnerable civilian communities are inversely proportional to quality access to a viable medical evacuation chain. The military inspector is one option to fill the gap in prehospital medicine to reduce morbidity and mortality by providing damage control resuscitation/surgery (DCR/DCS).

Qualitative and quantitative methodologies are applied. Qualitatively describing the medical evacuation of Shane, providing death estimates of the point of injury to receipt of DCR/DCS. Provide interoperable care across the military-civilian and humanitarian sectors. Describe the standardized and consistent evacuation chains across the entire battlefront from the point of injury to the Role 1/Role 2 echelons of care.

The medical evacuation chain for this current iteration of Russian violence is currently inadequate, not standardized, not well integrated at the military-civilian interface. Preventable morbidity and mortality from conventional Russian weapon systems have increased.

Armed Forces of Ukraine to engage with NATO and EU colleagues to acquire the methodology and practical applications to reduce preventable morbidity and mortality. Standardized approaches to the concept of damage control resuscitation and damage control surgery to the paradigm of tactical combat casualty care can help reduce morbidity and mortality. The Ukraine crisis and Russian war is killing people in Ukraine, prehospital medicine must address and focus on reducing preventable causes of morbidity and mortality.

Road traffic accidents and natural disasters cause significant numbers of deaths and life-changing injuries in low & middle-income countries. Most of these countries have limited resources for pre-hospital care and training. In 2021, there were 155,622 deaths due to road accidents and >18,000 railway-related deaths. Natural and manmade disasters also contribute to high numbers of serious injuries and deaths in the region. India is the pilot for developing an international training course for prehospital trauma care.

A review of pre-hospital care training and ambulance services in Tamil Nadu and Kerala states of India was carried out in 2019. An international workshop on developing pre-hospital care in India was held in Chennai in October 2022. The workshop included experts from UK and India and 52 practitioners from various parts of India.

India has developed a country-wide ambulance service sub-contracted to private providers under a public-private partnership initiative and in addition, there are private and charitable providers. In-transit care and resuscitation are limited and the vehicles are primarily a transport mechanism with a scoop-and-run policy. Infrastructure, traffic congestion, rural and hard-to-reach areas, poorly equipped ambulance services and variations in training and scope of practice contribute to the challenges of providing high quality pre-hospital care.

There is a need for high-quality pre-hospital care training, regulation and continuing professional development within the pre-hospital care sector. Delivery of pre-hospital care could be reinforced by wider involvement of doctors such as General Practitioners and other allied health care professionals. It was agreed by all delegates and speakers that an international course on pre-hospital care based upon an existing UK course from the Faculty of Pre-Hospital Care of the Royal College of Surgeons of Edinburgh, edited to take account of India’s current resources, should be piloted in Chennai in 2023.

A dedicated primary scene landing Helicopter Emergency Medical Services (HEMS) has been in operation in Ireland since 2012. Commencing with a unique collaboration between the Irish Aer Corps and civilian Emergency Medical Services (EMS) it has expanded to include a second charity funded model in the south west of the country. Both services operate under a single governance and dispatch system and provide an Advanced Paramedic level of care to the patients they serve. There is limited published literature on prehospital care in Ireland and to date no detailed descriptive study of patients treated by HEMS in Ireland. This research describes the characteristics of the patients treated by HEMS in Ireland.

This retrospective study will investigate the data of an excess of 8000 patients responded to by HEMS (2012-2022) in the republic of Ireland. Descriptive statistics will be used to interpret patient demographics, geographical spread, receiving facilities, mechanism/etiology of disease or injury, vital trends, transportation decisions and clinical interventions and short-term clinical outcomes.

Early stage data extraction shows seasonal variation in HEMS use with increased use in the summer months. Almost twice as many male patients vs. females were treated by HEMS while the most common age profile was 55-65 yrs. Trauma presentations have increased over the past 10 years and now account for over 60% of the overall caseload. The most common medical etiology was cardiac arrest or post resuscitation care followed by STEMI Care, the most common trauma cases were from road traffic collisions followed by falls and farm accidents.

This study will be the first to describe the overall characteristics of HEMS patients in Ireland over a decade of service provision. As the Irish health system continues to evolve, so must its aeromedical services.

Workplace violence within the ambulance services is a serious problem. A prevalence of up to 8.5% of all ambulance missions has previously been reported. Prior research used a retrospective design and the knowledge of risk factors for workplace violence is weak. Therefore, the aim of the current study was to measure the prevalence of workplace violence within the ambulance service in a Swedish region.

This was a prospective cohort study using data from all ambulance missions in a region in Sweden during one year. The data was analyzed with descriptive and analytic statistics using SPSS.

Data was collected from 28,648 ambulance missions. A total of 209 unique workplace violence incidents were reported, corresponding to a prevalence of 0.7%. Seventy-three of all incidents reported physical violence and 161 verbal threats, where some of the incidents included both physical and verbal violence. The most common risk factors for workplace violence were: the perpetrator was under the influence of alcohol or drugs (70.5%), mental illness (60.5%) and communication problems (15.3%). The perpetrator was most often a man (n=68%) between 18 and 29 years of age. Co-variation between the risk factors was high. No significant differences in the occurrence of workplace violence could be seen in relation to time of the year, weekday, or time of day.

The prevalence of workplace violence was one of the lowest reported. An understanding of risk factors could be used within the ambulance service and dispatch centers to identify situations with an increased risk of workplace violence and mitigate the risk of such incidents.

Sierra Leone, one of the countries with the highest maternal and perinatal mortality in the world, launched its first National Emergency Medical Service (NEMS) in 2018. We carried out a countrywide assessment to analyze NEMS operational times for obstetric emergencies with access to timely essential surgery within 2 hours. Moreover, we evaluated the relationship between operational times and maternal and perinatal mortality.

We collected prehospital data of 6,387 obstetric emergency referrals from primary health units to hospital facilities between June 2019 and May 2020 and we estimated the proportion of referrals with a prehospital time (PT) within 2 hours. The association between PT and mortality was investigated using Poisson regression models for binary data.

At the national level, the proportion of emergency obstetric referrals with a PT within 2 hours was 58.5% (95% CI 56.9% to 60.1%) during the rainy season and 61.4% (95% CI 59.5% to 63.2%) during the dry season. Results were substantially different between districts, with the capital city of Freetown reporting more than 90% of referrals within the benchmark and some rural districts less than 40%. Risk of maternal death at 60, 120, and 180 min of PT was 1.8%, 3.8%, and 4.3%, respectively. Corresponding figures for perinatal mortality were 16%, 18%, and 25%.

NEMS operational times for obstetric emergencies in Sierra Leone vary greatly and referral transports in rural areas struggle to reach essential surgery within two hours. Maternal and perinatal risk of death increased concurrently with operational times, even beyond the two-hour target, therefore, any reduction of the time to reach the hospital may translate into improved patient outcomes.

Traditionally, helicopters or special types of airplanes have been used to transport emergency patients when an aeromedical transport is necessary. However, despite its excellent utility, the cost of each flight is relatively expensive and has many limitations. So as an alternative to traditional aircrafts, there has been a movement to overcome the limitations of traditional air transport through the development and application of emergency medical drones. In this study, practical applications of emergency medical drones were investigated.

As a first step, through literature and internet searches, the current state of development, field of use, results, and problems of emergency medical drones were investigated. Based on this first investigation, a second Delphi survey of experts was conducted to investigate the appropriate fields for the use of emergency medical drones and the expected future applications.

Currently, emergency patient support drones are being used to transport first aid equipment including an automatic external defibrillator, manage emergency patient status and on-site remote evaluation, and transport human organs during organ transplantation. Emergency medical drones for emergency patients are being developed, including systems that manage the patient's condition by applying additional advanced technologies.

Emergency medical drones were classified into drones for transporting emergency patients and drones for emergency medical support according to whether emergency patients were on board. Drones for emergency patient support were being used to transport first aid equipment, manage emergency patient status and on-site remote evaluation, and transport organs during organ transplantation. The trend of air transport in the future is expected to change to a futuristic means of transportation in the form of emergency medical drones.

In September 2020, severe wildfires in Oregon (USA) came dangerously close to Hospital A. The entire county was under evacuation orders. The Neonatal Intensive Care Unit (NICU) at Hospital A needed to evacuate patients to other areas for safety, however the characteristics of premature and critically ill neonates required a specialized transport team. This presentation outlines a case study of how the Pediatric and Neonatal Transport team (PANDA), based at Oregon Health and Science University (Portland, Oregon, USA), responded to evacuate neonatal and infant patients to other metro area NICUs during the wildfires.

Case study.

During a six-hour period, both PANDA transport teams on shift were activated to complete back-to-back transports of neonates and infants by ground ambulance to fire safe locations. Each patient was transported by a PANDA Registered Nurse and PANDA Respiratory Therapist, with an Emergency Medical Technician who drove the ambulance and Medical Control available by phone. The PANDA team normally operates in non-disaster settings. This was the first time PANDA was activated to evacuate patients from a hospital during a disaster. This presentation will discuss lessons learned and implications for future practice.

Wildfire frequency and severity is predicted to increase due to climate change. Evacuation of premature and critically ill neonates requires a specialized transport team due to patient size, weight, and other considerations. Specialized transport teams should develop disaster evacuation workflows and resources, and regularly practice for these events. There is also a need for trauma-informed care in the post-evacuation setting to transport staff and parents of patients who were unable to travel with their child during transport. A full team pre-transport risk assessment is crucial in these circumstances.

Post Katrina Louisiana’s Health Department (LDH) used some of the Hospital Preparedness Program (HPP) funding to create a regional Emergency Medical Services liaison position entitled EMS Designated Regional Coordinators (EMS DRC). Regional EMS DRCs work with local pre-hospital agencies, hospital coalitions, and local/state/federal counterparts during the preparedness and response phases of a disaster. This presentation explores the EMS DRCs role during the 2020/2021 COVID pandemic and annual hurricane season.

The EMS DRCs were activated at the beginning of the COVID-19 pandemic. EMS agencies across the country were struggling to meet the call volume demand while balancing sick employees. The eleven LA Region 1 EMS agencies reached out to the EMS DRC for assistance. The EMS DRC coordinated with the LA State Health Department to provide surge ambulances to any ambulance agency in need. These units were utilized for COVID response, but once hurricane season hit in both 2020 and 2021 Surge ambulances were quickly transitioned to COVID and Hurricane response.

During the initial COVID outbreak, 18 state surge ambulances were divided amongst four agencies. In 2020 Louisiana saw six named storms, one of which caused significant damage. After Hurricane Laura hit in 2020 the EMS DRCs managed 80 Federal surge ambulances stationed across 41 non-congruent hotel shelters. The 2021 COVID response brought another 21 Federal Surge ambulances to the region. Once Hurricane Ida hit that year over 60 surge ambulances got reassigned to six regional EMS agencies for COVID and Hurricane response.

The COVID-19 pandemic and subsequent hurricane devastation exposed gaps in EMS response capabilities to response. The EMS DRCs play a significant role in providing continuous care through working relationships with local, state and federal partners

The COVID-19 pandemic impacted on health service provision worldwide, including care for acute time sensitive conditions, like stroke and transient ischaemic attack (TIA). Thus, the aim of this study was to conduct a systematic review and meta-analysis to investigate the impact of the COVID-19 pandemic on prehospital emergency care for stroke/TIA.

Following a published study protocol, a systematic search of databases was conducted up to May 31, 2022. Peer-reviewed quantitative studies comparing prehospital emergency care for adults with stroke/TIA before and during the COVID-19 pandemic were considered for inclusion. The methodological quality of the included studies was assessed using the appropriate Joanna Briggs Institute tool. Overall pooled estimates of ambulance times (activation, response, patient care time) were calculated. Subgroup and sensitivity analyses included location and stroke/TIA diagnosis. Stroke/TIA emergency call volume was reported using a narrative synthesis. Clinical stakeholders and Patient and Public Involvement Contributors were involved from research question development to dissemination of results.

Of 4083 studies identified, 56 unique articles met the inclusion criteria. Early data from 8/12 studies reporting ambulance times, suggests that patient care time increased. Furthermore, emergency call volume for stroke/TIA decreased during the COVID-19 pandemic, according to 43/56 studies that reported this outcome. Terminology for ambulance time intervals differed between studies. The majority of studies reported time from call to hospital arrival, whereas the minority of studies reported activation time.

Preliminary results from our systematic review and meta-analysis show that conflicting evidence exists on the impact of the COVID-19 pandemic on ambulance times and emergency call volume for stroke/TIA. Thus, this review synthesized available evidence on the varied effects across different countries, healthcare systems and ambulance time terminology. Review findings may inform our understanding of healthcare system resilience in response to crises on a broader level.

Emergency services organizations routinely undertake internal quality improvement activities following training and operational activities. One form of a quality improvement activity is the After Action Review (AAR). An AAR is a facilitator-led post-event review where data is collected from individuals and groups of individuals using either surveys, focus group-like meetings, or individual interviews. Data is collected using a semi-structured data collection tool which is usually customized to the specific tasks being reviewed and the priorities and goals of the organization. The quality of AARs has been noted to vary significantly across organizations with reporting biases and differences between exercise or real event AARs and biases introduced by utilization of internal rather than external evaluators, and limited justification for data selection and collection rationales. The Australian Capital Territory Emergency Services Agency (ACT ESA) has identified that interoperability and integration between internal ACT ESA sub-agencies and externally with other agencies is a key problem. The aim of this study was to identify specific areas of consistent interoperability concern through the examination of historical AARs.

In this qualitative study a Framework Analysis of historical AAR text documents was conducted, following the standard five step process. This was followed by detailed thematic analysis in aggregate and examined longitudinally, with emergent themes undergoing further analysis.

AARs relating to major emergency response and training activities 2016-2022 were examined. There was a substantial variation in quality, level of detail, completeness and structure across the different AAR documents. Consistent themes emerging from the data highlighted concerns regarding inter-agency culture, uncertainty when conducting joint activities and its impact on decision making, logistics concerns, resourcing and breakdown of shared understanding and communication between teams.

Despite a centralized command structure, historical AAR analysis shows ACT ESA has had persistent operationally impacting interoperability and integration problems within the organization and with external agencies.