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Objectives: Recently, ILCOR unveiled the ground-breaking global initiative “Ten Steps Toward Improving In-Hospital Cardiac Arrest” (IHCA). Aim: To generate a baseline of how well the ten steps currently function in Sweden, in order to better target educational interventions. Material and methods: A survey was created using an online form application (Google Forms) and sent to CPR coordinators and physicians in charge of CPR at all 74 Swedish hospitals participating in the Swedish Registry for Cardiopulmonary Resuscitation (SRCR). Hospitals were asked to self-evaluate their functionality on each step on a ten-point scale ranging from 1 “Not present or not functioning at all” to 10 “Very well-functioning”. Data regarding number of IHCA and their survival during 2018–2022 was gathered from the SRCR. Results: A total of 34 out of 74 (46%) Swedish hospitals participated in the survey, collectively representing 59% (7,113 out of 12,070) of IHCA cases in SRCR. The responding hospitals were satisfied with the functionality of just over half of the steps currently (median 60%, range 30–90%). The steps with the highest proportion of satisfied hospitals were found for step 6-rapid response systems (85%) and 7-guideline-based resuscitation (94%), while the steps with lowest proportion of satisfied hospitals were found for step 4-goals of treatment (32%) and step 9-person centred culture (18%). About half of participating hospitals expressed intent to prioritise upcoming years’ work on step 1- infrastructure, step 3- effective education and step 5- stop preventable IHCA. Conclusion: The conclusion is that most hospitals judge themselves to be well-functioning on many of the ten steps, but steps involving effective education might need attention, as well as the tolerance for presence of preventable IHCA being low.

Abstract Background Identifying factors predictive of hospital admission can be useful to prospectively inform bed management and patient flow strategies and decrease emergency department (ED) crowding. It is largely unknown if admission rate or factors predictive of admission vary based on the population to which the ED served (i.e., children only, or both adults and children). This study aimed to describe the profile and identify factors predictive of hospital admission for children who presented to four EDs in Australia and one ED in Sweden. Methods A multi-site observational cross-sectional study using routinely collected data pertaining to ED presentations made by children

Objective The Score for Emergency Risk Prediction (SERP) is a novel mortality risk prediction score which leverages machine learning in supporting triage decisions. In its derivation study, SERP-2d, SERP-7d and SERP-30d demonstrated good predictive performance for 2-day, 7-day and 30-day mortality. However, the dataset used had significant class imbalance. This study aimed to determine if addressing class imbalance can improve SERP's performance, ultimately improving triage accuracy. Methods The Singapore General Hospital (SGH) emergency department (ED) dataset was used, which contains 1,833,908 ED records between 2008 and 2020. Records between 2008 and 2017 were randomly split into a training set (80%) and validation set (20%). The 2019 and 2020 records were used as test sets. To address class imbalance, we used random oversampling and random undersampling in the AutoScore-Imbalance framework to develop SERP+-2d, SERP+-7d, and SERP+-30d scores. The performance of SERP+, SERP, and the commonly used triage risk scores was compared. Results The developed SERP+ scores had five to six variables. The AUC of SERP+ scores (0.874 to 0.905) was higher than that of the corresponding SERP scores (0.859 to 0.894) on both test sets. This superior performance was statistically significant for SERP+-7d (2019: Z = −5.843, p

Aim: Dispatcher-assisted cardiopulmonary resuscitation (DA-CPR) is time-dependent. To date, evidence-based training programmes for dispatchers are lacking. This study aimed to reach expert consensus on an educational bundle content for dispatchers to provide DA-CPR using the Delphi method. Method: An educational bundle was created by the Swedish Resuscitation Council consisting of three parts: e-learning on DA-CPR, basic life support training and audit of emergency out-of-hospital cardiac arrest calls. Thereafter, a two-round modified Delphi study was conducted between November 2022 and March 2023; 37 experts with broad clinical and/or scientific knowledge of DA-CPR were invited. In the first round, the experts participated in the e-learning module and answered a questionnaire with 13 closed and open questions, whereafter the e-learning part of the bundle was revised. In the second round, the revised e-learning part was evaluated using Likert scores (20 items). The predefined consensus level was set at 80%. Results: Delphi rounds one and two were assessed by 20 and 18 of the invited experts, respectively. In round one, 18 experts (18 of 20, 90%) stated that they did not miss any content in the programme. In round two, the scale-level content validity index based on the average method (S-CVI/AVE, 0.99) and scale-level content validity index based on universal agreement (S-CVI/UA, 0.85) exceeded the threshold level of 80%. Conclusion: Expert consensus on the educational bundle content was reached using the Delphi method. Further work is required to evaluate its effect in real-world out-of-hospital cardiac arrest calls.

Objectives: Staff in hospitals are encouraged to write up incident reports whenever they notice an incident. There are few published compilations of these reports from an in-hospital cardiac arrest (IHCA) perspective. Aim: To describe content of incident reports over ten years in a two-sited university hospital in order to share knowledge and thereby being able to improve resuscitation systems in hospitals. Material and methods: All incident reports between 2010–June 2023 written at Karolinska University Hospital contain the words “CPR”, “cardiac arrest”, “resuscitation”, Do-Not–attend-CPR” (DNACPR), “life-sustaining treatment” were included for analysis. Reports were grouped into larger themes. Results: In all 588 reports was identified automatically by the hospitals system based on the totally selected keywords. The largest category was “Life-sustaining treatment” with 178 (30%) reports and thereafter “Preventing care” (117, 20%) and “Material” (80, 14%). Conclusion: Our hospital has clearly valued incident reports as a mean to track on-going issues and serious events over time as well as a source to trigger educational interventions. To improve patient safety, a standardized approach for compilation of reports and actions would be helpful when sharing knowledge between hospitals and with the resuscitation community.

Objectives: Awareness of causes of cardiac arrest is essential to prevent them. A recent review found that almost every sixth in-hospital cardiac arrest is caused by infection. Few studies have explored how infections cause cardiac arrest. Aim: To describe the features, mechanisms and outcome of sepsis-related cardiac arrests. Material and methods: All patients ≥18 years who suffered a cardiac arrest at Karolinska University Hospital between 2007 and 2022 with sepsis as the primary cause were included. Data were collected the Swedish Registry for Cardiopulmonary Resuscitation and medical records. The primary outcome was survival to discharge. Results: Out of 2,327 in-hospital cardiac arrests, 5% (n = 123) suffered it due to sepsis, and 17% (21) survived to hospital discharge. Two thirds of patients were admitted to the hospital due to sepsis and suffered their cardiac arrest after a median of four days. About half (n = 59) had deranged vital signs before the event. Most were witnessed in general wards. In all, 47% (n = 58) had asystole and 24% (n = 30) as the first heart rhythm. The respiratory tract was the most common source of infection. Most patients were undergoing antibiotic therapy and one third had a positive microbiological culture with mixed gram-positive bacteria or Escherichia coli in the urine. Conclusion: Our results suggest that sepsis is an uncommon and not increasing cause of in-hospital cardiac arrest and its outcome is in line with other non-shockable cardiac arrests. Deranged respiratory and/or circulatory vital signs precede the event.

Abstract Electric scooters are a popular form of transportation, but accidents have increased with increased usage over the last years with rising health care costs as a consequence. This study aims to quantify accidents associated with the use of alcohol and to compare injuries at the emergency department (ED) among patients who have been involved in an accident involving an electric scooter. We used data from a multi-center retrospective registry-based cohort in the Swedish Traffic Accident Data Acquisition. We included all patients that had been involved in an electric scooter accident needing a visit to all EDs in Stockholm, Sweden during 2019–2020. Data on alcohol intake was manually drawn from medical files. Out of all of the 369 patients, the majority were men (n = 223, 60%) and aged below 30 years (n = 181, 49%). In all, 102 (28%) of the patients had a positive history of alcohol intake prior to the accident. Patients with alcohol intake more often arrived nighttime than those without alcohol, via ambulance (40% and 24%, respectively, p-value

Abstract Background Non-conveyed patients (i.e. patients who are not transported to a hospital after being assessed by ambulance clinicians) represent a significantly increasing proportion of all patients seeking ambulance care. Scientific knowledge about patients’ non-conveyance experiences is sparse. This study describes the lived experiences of non-conveyed patients in an ambulance care context. Methods A reflective lifeworld research (RLR) approach founded on phenomenology is used. Data is derived from nine in-depth interviews with patients not conveyed by the ambulance service in a major Swedish region. Results Patients’ lived experiences of becoming acutely ill or injured and not conveyed by ambulance to a hospital are characterised by several dynamic movements: losing and regaining situational and bodily control, dependence and autonomy, external competence and inner knowledge, handing over and regaining responsibility, and fear and security. Conclusions Patients’ lived experiences of non-conveyance are complex and versatile. Although non-conveyed patients initially experience strong fear and the loss of situational and bodily control, they gradually feel more secure when experiencing confirmation and trust, which evolves into insecurity and uncertainty. The non-conveyance situation’s complexity from a patient’s perspective implies the need for ambulance organisations to take measures to prevent further suffering. Non-conveyed patients must be taken seriously in their unique situations, requiring ambulance clinicians to reflect and act with a conscious ethical perspective before, during and after their visit.

Background: Simulating CPR scenarios in a clinical environment has been described as a method for mitigating latent safety threats. Therefore, we implemented regular inter-professional, multidisciplinary in-situ simulations in the emergency department (ED). Aim: To iterate a line-up and action cards for initial CPR management. To examine the experiences among participants regarding attitudes towards simulation and if they perceived any benefits for their patients after the participation. Method: In 2021 we performed 7 in-situ simulations (15-minute simulation, 15-minute hot debrief) in the ED with the CPR team including doctors and nurses from the ED and anaesthesiology department. A questionnaire was sent to the 48 participants the same day and after 3 and 18 months. Answers were given as yes/no or on a Likert scale 0–5 and are presented as median values with interquartile range (IQR) or frequencies. Results: A line-up and 9 action cards were created. The response rate of the three questionnaires were 52, 23, and 43%, respectively. In total, 100% would recommend the in-situ simulation to a co-worker. Participants perceived that real patients (5 [3–5]) as well as themselves, (5 [3.5–5]), had benefited from the simulation up to 18 months after. Conclusion: Thirty-minute in-situ simulations are feasible to implement in the ED and simulation observations were useful for development of standardised role descriptions for resuscitation in the ED. Participants self-report benefit for themselves as well as their patients.

Abstract Background Historically, resuscitation in traumatic cardiac arrest (TCA) has been deemed futile. However, recent literature reports improved but varying survival. Current European guidelines emphasise the addressing of reversible aetiologies in TCA and propose that a resuscitative thoracotomy may be performed within 15 min from last sign of life. To improve clinician understanding of which patients benefit from resuscitative efforts we aimed to describe the characteristics and 30-day survival for traumatic cardiac arrest at a Swedish trauma centre with a particular focus on resuscitative thoracotomy. Methods Retrospective cohort study of adult patients (≥ 15 years) with TCA managed at Karolinska University Hospital Solna between 2011 and 2020. Trauma demographics, intra-arrest factors, lab values and procedures were compared between survivors and non-survivors. Results Among the 284 included patients the median age was 38 years, 82.2% were male and 60.5% were previously healthy. Blunt trauma was the dominant injury in 64.8% and median Injury Severity Score (ISS) was 38. For patients with a documented arrest rhythm, asystole was recorded in 39.2%, pulseless electric activity in 24.8% and a shockable rhythm in 6.8%. Thirty patients (10.6%) survived to 30 days with a Glasgow Outcome Scale score of 3 (n = 23) or 4 (n = 7). The most common causes of death were haemorrhagic shock (50.0%) and traumatic brain injury (25.5%). Survivors had a lower ISS (P

Abstract Background Cardiac arrests in admitted hospital patients with trauma have not been described in the literature. We defined “in-hospital cardiac arrest of a trauma” (IHCAT) patient as “cessation of circulatory activity in a trauma patient confirmed by the absence of signs of circulation or abnormal cardiac arrest rhythm inside a hospital setting, which was not cardiac re-arrest.” This study aimed to compare epidemiology, clinical presentation, and outcomes between in- and out-of-hospital arrest resuscitations in trauma patients in Qatar. It was conducted as a retrospective cohort study including IHCAT and out-of-hospital trauma cardiac arrest (OHTCA) patients from January 2010 to December 2015 utilizing data from the national trauma registry, the out-of-hospital cardiac arrest registry, and the national ambulance service database. Results There were 716 traumatic cardiac arrest patients in Qatar from 2010 to 2015. A total of 410 OHTCA and 199 IHCAT patients were included for analysis. The mean annual crude incidence of IHCAT was 2.0 per 100,000 population compared to 4.0 per 100,000 population for OHTCA. The univariate comparative analysis between IHCAT and OHTCA patients showed a significant difference between ethnicities (p=0.04). With the exception of head injury, IHCAT had a significantly higher proportion of localization of injuries to anatomical regions compared to OHTCA; spinal injury (OR 3.5, 95% CI 1.5–8.3, p

Abstract Background Older adults (age ≥ 65 years) represent a significant proportion of all patients who are not transported to hospital after assessment by ambulance clinicians (non-conveyed patients). This study aimed to fill the knowledge gap in the understanding of the prevalence of older adult non-conveyed patients and investigate their characteristics and risk factors for subsequent and adverse events with those of younger non-conveyed patients comparatively. Methods This population-based retrospective cohort study included all adult non-conveyed patients who availed the ambulance service of Region Stockholm, Sweden in 2015; they were age-stratified into two groups: 18–64 and ≥ 65 years. Inter-group differences in short-term outcomes (i.e. emergency department visits, hospitalisations, and mortality within 7 days following non-conveyance) were assessed using multivariate regression analyses. Results Older adult patients comprised 48% of the 17,809 non-conveyed patients. Dispatch priority levels were generally lower among older non-conveyed patients than among younger patients. Non-conveyance among older patients occurred more often during daytime, and they were more frequently assessed by ambulance clinicians with nonspecific presenting symptoms. Approximately one in five older adults was hospitalised within 7 days following non-conveyance. Patients presenting with infectious symptoms had the highest mortality risk following non-conveyance. Oxygen saturation level 160 mmHg had significantly higher associations with hospitalisation within 7 days following non-conveyance in older adult patients. Conclusions Older adult patients have an increased risk for adverse events following non-conveyance. In combination with a complex and variating presentation of symptoms and vital signs proved difficult for dispatch operators and ambulance clinicians to identify and assess, the identified risks raise questions on the patient safety of older adult non-conveyed patients. The results indicate a system failure that need to be managed within the ambulance service organisation to achieve higher levels of patient safety for older non-conveyed patients.

Introduction Mild traumatic brain injury (mTBI) is one of the most common reasons for emergency department (ED) visits. A portion of patients with mTBI will develop an intracranial lesion that might require medical or surgical intervention. In these patients, swift diagnosis and management is paramount. Several guidelines have been developed to help direct patients with mTBI for head CT scanning, but they lack specificity, do not consider the interactions between risk factors and do not provide an individualised estimate of intracranial lesion risk. The aim of this study is to create a model that estimates individualised intracranial lesion risks in patients with mTBI who present to the ED.Methods and analysis This will be a retrospective cohort study conducted at ED hospitals in Stockholm, Sweden. Eligible patients are adults (≥15 years) with mTBI who presented to the ED within 24 hours of injury and performed a CT scan. The primary outcome will be a traumatic lesion on head CT. The secondary outcomes will be any clinically significant lesion, defined as an intracranial finding that led to neurosurgical intervention, hospital admission ≥48 hours due to TBI or death due to TBI. Machine-learning models will be applied to create scores predicting the primary and secondary outcomes. An estimated 20 000 patients will be included.Ethics and dissemination The study has been approved by the Swedish Ethical Review Authority (Dnr: 2020-05728). The research findings will be disseminated through peer-reviewed scientific publications and presentations at international conferences.Trial registration number NCT04995068.

Abstract Background Emergency Medical Services (EMS) are faced daily with patients presenting with non-specific chief complaints (NSC). Patients presenting with NSCs often have normal vital signs. It has previously been established that NSCs may have a serious underlying condition that has yet to be identified. The aim of the current study was to determine if soluble urokinase plasminogen activator receptor (suPAR) and lactate could be used to identify serious conditions among patients presenting with NSCs to the EMS. The secondary aim was to describe the prognostic value for mortality in the group. Method A blinded prospective observational cohort study was conducted of patients brought to the ED by ambulance after calling the national emergency number 112 and who were assessed as having NSC by the EMS. Biomarkers were measured during index EMS assessment before transportation to the ED. Patients were followed via EMS and hospital electronic health records. Descriptive and logistic regression analyses were used. Results A total of 414 patients were included, with a median age of 82 years. A serious condition was present in 15.2% of the patients. Elevated suPAR above 3 ng/ml had a positive likelihood ratio (LR+) of 1.17 and a positive predictive value (PPV) of 17.3% as being predictive of a prevalent serious condition. Elevated suPAR above 9 ng/ml had LR+ 4.67 and a PPV of 16.7% as being predictive of 30-day mortality. Lactate was not significantly predictive. Conclusion Pre-hospital suPAR and lactate cannot differentiate serious conditions in need of urgent treatment and assessment in the ED among patients presenting with non-specific chief complaints. suPAR has shown to be predictive of 30-day mortality, which could add some value to the clinical assessment. Trial registration NCT03089359. Registered 20 March 2017, retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT03089359 .

Introduction: Higher rates of mortality following an in-hospital cardiac arrest (IHCA) has been shown during nights and weekends, changes in staff density and composition has been suggested as a possible explanation. Changes in hospital staffing patterns are also common during holiday periods. Aim: To investigate whether holiday periods are associated with decreased survival following an IHCA. Material and methods: All patients ≥18 years who experienced an IHCA at Karolinska University Hospital between 2006 and 2019 were included. Patients were identified via and data was collected from the Swedish Registry for Cardiopulmonary Resuscitation. Holiday was defined as two periods, a seven-week summer period and an approximately two-week Christmas period. The primary outcome was return of spontaneous circulation (ROSC), secondary survival to hospital discharge. Logistic regression was performed to calculate odds ratio (OR) with 95% confidence intervals (CI), adjustment was done for known confounders. Results: Out of 1936 registered cases, 264 (14%) occurred during holiday periods. Patient and event characteristics were similar on holidays compared to non-holidays. Both ratio for ROSC (45% and 55%, respectively) and survival (25% and 32% respectively) was poorer during holiday periods Adjusted OR for ROSC and survival was poorer during holiday periods compared non-holiday periods (OR 0.69 [95% CI, 0.53–0.92] and OR 0.69 [95% CI, 0.49–0.96], respectively). Conclusion: Outcomes after IHCA was poorer during holiday periods compared to non-holiday periods even if patient and event characteristics was similar. Further research is needed to better understand to what degree staffing patterns and other factors contribute to the observed difference.

Aim: To conduct a systematic review of the use of the recovery position in adults and children with non-traumatic decreased levels of responsiveness changes outcomes in comparison with other positioning strategies. Methods: We searched Medline (Ovid), Embase, Cochrane Library, CINAHL, medRxiv and Google Scholar from inception to 15 March 2021 for studies involving adults and children in an out-of-hospital, first aid setting who had reduced levels of responsiveness of non-traumatic aetiology but did not require resuscitative interventions. We used the ROBINS-I tool to assess risk of bias and GRADE methodology to determine the certainty of evidence. Results: Of 17,947 citations retrieved, three prospective observational studies and four case series were included. The prone and semi-recumbent positions were associated with a decreased rate of suspected aspiration pneumonia in acute poisoning. Use of the recovery position in paediatric patients with decreased levels of responsiveness was associated with a deceased admission rate and the prone position was the position most commonly associated with sudden unexpected death in epilepsy. High risk of bias, imprecision and indirectness of evidence limited our ability to perform pooled analyses. Conclusion: We identified a limited number of observational studies and case series comparing outcomes following use of the recovery position with outcomes when other patient positions were used. There was limited evidence to support or revise existing first aid guidance; however, greater emphasis on the initial assessment of responsiveness and need for CPR, as well as the detection and management of patient deterioration of a person identified with decreased responsiveness, is recommended.

Aim: Early identification of patients at risk of serious adverse events (SAEs) is of vital importance, yet it remains a challenging task. We investigated the predictive power of National Early Warning Score (NEWS) 2, as compared to NEWS, among patients assessed by a Rapid response team (RRT). Methods: Prospective, observational cohort study on 898 consecutive patients assessed by the RRTs in 26 Swedish hospitals. For each patient, NEWS and NEWS 2 scores were uniformly calculated by the study team. The associations of NEWS and NEWS 2 scores with unanticipated admissions to Intensive care unit (ICU), mortality and in-hospital cardiac arrests (IHCA) within 24 h, and the composite of these three events were investigated using logistic regression. The predictive power of NEWS and NEWS 2 was assessed using the area under the receiver operating characteristic (AUROC) curves. Results: The prognostic accuracy of NEWS/NEWS 2 in predicting mortality was acceptable (AUROC 0.69/0.67). In discriminating the composite outcome and unanticipated ICU admission, both NEWS and NEWS 2 were relatively weak (AUROC 0.62/0.62 and AUROC 0.59/0.60 respectively); for IHCA the performance was poor. There were no differences between NEWS and NEWS 2 as to the predictive power. Conclusion: The prognostic accuracy of NEWS 2 to predict mortality within 24 h was acceptable. However, the prognostic accuracy of NEWS 2 to predict IHCA was poor. NEWS and NEWS 2 performed similar in predicting the risk of SAEs but their performances were not sufficient for use as a risk stratification tool in patients assessed by a RRT.

Aims: The aims were to examine patient and hospital characteristics associated with Do-Not-Attempt-Cardiopulmonary-Resuscitation (DNACPR) decisions for adult admissions through the emergency department (ED), for patients with DNACPR decisions to examine patient and hospital characteristics associated with hospital mortality, and to explore changes in CPR status. Methods: This was a retrospective observational study of adult patients admitted through the ED at Karolinska University Hospital 1 January to 31 October 2015. Results: The cohort included 25,646 ED admissions, frequency of DNACPR decisions was 11% during hospitalisation. Patients with DNACPR decisions were older, with an overall higher burden of chronic comorbidities, unstable triage scoring, hospital mortality and one-year mortality compared to those without. For patients with DNACPR decisions, 63% survived to discharge and one-year mortality was 77%. Age and comorbidities for patients with DNACPR decisions were similar regardless of hospital mortality, those who died showed signs of more severe acute illness on ED arrival. Change in CPR status during hospitalisation was 5% and upon subsequent admission 14%. For patients discharged with DNACPR decisions, reversal of DNACPR status upon subsequent admission was 32%, with uncertainty as to whether this reversal was active or a consequence of a lack of consideration. Conclusion: For a mixed population of adults admitted through the ED, frequency of DNACPR decisions was 11%. Two-thirds of patients with DNACPR decisions were discharged, but one-year mortality was high. For patients discharged with DNACPR decisions, reversal of DNACPR status was substantial and this should merit further attention.

Abstract Background Malaria is associated with Burkitt lymphoma among children in Sub-Saharan Africa. No longitudinal studies have assessed the long-term risk of other lymphoma or cancer overall. Here, we investigated the risk of lymphoid neoplasms and other cancer after malaria. Methods We included 4125 patients diagnosed with malaria in Sweden in 1987–2015, identified either through the National Surveillance Database at the Public Health Agency of Sweden, the National Inpatient and Outpatient Register, or by reports from microbiology departments. A comparator cohort (N = 66,997) matched on sex, age and birth region was retrieved from the general population and an additional cohort with all individuals born in Sub-Saharan Africa registered in the Total Population Register in 1987–2015 (N = 171,756). Incident lymphomas and other cancers were identified through linkage with the Swedish Cancer Register. Hazard ratios (HRs) were assessed using Cox regression with attained age as the timescale. Results A total of 20 lymphoid neoplasms and 202 non-haematological cancers were identified among malaria patients during a mean follow-up of 13.3 and 13.7 years, respectively. The overall risk of lymphoid neoplasms was not significantly increased (hazard ratio [HR] 1.24, 95% confidence interval [CI] 0.79–1.94), neither did we find any association with all-site non-haematological cancer (HR 0.89, 95% CI 0.77–1.02). However, in the Sub-Saharan Africa cohort, we observed an increased risk of lymphoid neoplasms after malaria diagnosis (HR 2.39, 95% CI 1.06–5.40), but no difference in the risk of other cancer (HR 1.01, 95% CI 0.70–1.45). The association could not be explained by co-infection with HIV or chronic hepatitis B or C, since the risk estimate was largely unchanged after excluding patients with these comorbidities (HR 2.63, 95% CI 1.08–6.42). The risk became more pronounced when restricting analyses to only including non-Hodgkin and Hodgkin lymphomas (HR 3.49, 95% CI 1.42–8.56). Conclusion Individuals born in malaria-endemic areas and diagnosed with malaria in Sweden had an increased risk of lymphoid neoplasms, especially B cell lymphoma. There was no association with cancer overall nor did single malaria episodes confer an increased risk in travellers.

Abstract Objectives COVID-19 presents challenges to the emergency care system that could lead to emergency department (ED) crowding. The Huddinge site at the Karolinska university hospital (KH) responded through a rapid transformation of inpatient care capacity together with changing working methods in the ED. The aim is to describe the KH response to the COVID-19 crisis, and how ED crowding, and important input, throughput and output factors for ED crowding developed at KH during a 30-day baseline period followed by the first 60 days of the COVID-19 outbreak in Stockholm Region. Methods Different phases in the development of the crisis were described and identified retrospectively based on major events that changed the conditions for the ED. Results were presented for each phase separately. The outcome ED length of stay (ED LOS) was calculated with mean and 95% confidence intervals. Input, throughput, output and demographic factors were described using distributions, proportions and means. Pearson correlation between ED LOS and emergency ward occupancy by phase was estimated with 95% confidence interval. Results As new working methods were introduced between phase 2 and 3, ED LOS declined from mean (95% CI) 386 (373–399) minutes to 307 (297–317). Imaging proportion was reduced from 29 to 18% and admission rate increased from 34 to 43%. Correlation (95% CI) between emergency ward occupancy and ED LOS by phase was 0.94 (0.55–0.99). Conclusions It is possible to avoid ED crowding, even during extreme and quickly changing conditions by leveraging previously known input, throughput and output factors. One key factor was the change in working methods in the ED with higher competence, less diagnostics and increased focus on rapid clinical admission decisions. Another important factor was the reduction in bed occupancy in emergency wards that enabled a timely admission to inpatient care. A key limitation was the retrospective study design.

Objectives: Pulmonary embolism (PE) constitutes one of the reversible causes of cardiac arrest. The prognosis for PE-related cardiac arrest is poor. Some previous studies have suggested a higher survival rate in patients with PE-related cardiac arrest who receive thrombolysis. No such study has focused on in-hospital cardiac arrests (IHCA). Aim: To describe the prevalence of PE-related IHCA and the characteristics of those patients, as well as to describe favourable and adverse outcomes after thrombolysis. Material and methods: All patients ≥ 18 years who experienced an IHCA at Karolinska University Hospital between 2007 and 2020 with PE as the primary cause of IHCA were included. Patients were identified from the Swedish Registry for Cardiopulmonary Resuscitation (SRCR). Data was collected from the SRCR and medical records. The primary outcome was survival to discharge. Secondary outcomes were alive at the end of CPR, major bleeding, and minor bleeding. Results: Out of 2,128 IHCA patients, 64 (3%) had a PE-related IHCA of whom 16 (25%) had thrombolysis. A significant association was seen between thrombolysis and survival to discharge (44 % vs 8 %, p-value

Objectives While prospective epidemiological data for out-of-hospital cardiac arrest (OHCA) exists in many high-income settings, there is a dearth of such data for the African continent. The aim of this study was to describe OHCA in the Cape Town metropole, South Africa.Design Observational study with a retrospective descriptive design.Setting Cape Town metropole, Western Cape province, South Africa.Participants All patients with OHCA for the period 1 January 2018–31 December 2018 were extracted from public and private emergency medical services (EMS) and described.Outcome measures Description of patients with OHCA in terms of demographics, treatment and short-term outcome.Results A total of 929 patients with OHCA received an EMS response in the Cape Town metropole, corresponding to an annual prevalence of 23.2 per 100 000 persons. Most patients were adult (n=885; 96.5%) and male (n=526; 56.6%) with a median (IQR) age of 63 (26) years. The majority of cardiac arrests occurred in private residences (n=740; 79.7%) and presented with asystole (n=322; 34.6%). EMS resuscitation was only attempted in 7.4% (n=69) of cases and return of spontaneous circulation (ROSC) occurred in 1.3% (n=13) of cases. Almost all patients (n=909; 97.8%) were declared dead on the scene.Conclusion To our knowledge, this was the largest study investigating OHCA ever undertaken in Africa. We found that while the incidence of OHCA in Cape Town was similar to the literature, resuscitation is attempted in very few patients and ROSC-rates are negligible. This may be as a consequence of protracted response times, poor patient prognosis or an underdeveloped and under-resourced Chain of Survival in low- to middle-income countries, like South Africa. The development of contextual guidelines given resources and disease burden is essential.

Background: The ethical principles of resuscitation have been incorporated into Swedish legislation so that a decision to not attempt cardiopulmonary resuscitation (DNACPR) entails (1) consultation with patient or relatives if consultation with patient was not possible and documentation of their attitudes; (2) consultation with other licensed caregivers; (3) documentation of the grounds for the DNACPR. Our aim was to evaluate adherence to this legislation, explore the grounds for the decision and the attitudes of patients and relatives towards DNACPR orders. Methods: We included DNACPR forms issued after admission through the emergency department at Karolinska University Hospital between 1st January and 31st October, 2015. Quantitative analysis evaluated adherence to legislation and qualitative analysis of a random sample of 20% evaluated the grounds for the decision and the attitudes. Results: The cohort consisted of 3583 DNACPR forms. In 40% of these it was impossible to consult the patient, and relatives were consulted in 46% of these cases. For competent patients, consultation occurred in 28% and the most common attitude was to wish to refrain from resuscitation. Relatives were consulted in 26% and they mainly agreed with the decision. Grounds for the DNAR decision was most commonly severe chronic comorbidity, malignancy or multimorbidity with or without an acute condition. All requirements of the legislation were fulfilled in 10% of the cases. Conclusion: In 90% of the cases physicians failed to fulfil all requirements in the Swedish legislation regarding DNAR orders. The decision was mostly based on chronic, severe comorbidity or multimorbidity.

Abstract Background Cardiac arrest is more common in men than women and a few studies have shown inferior 30-day survival for men than for women. The difference might relate to patient characteristics, intra arrest factors or post arrest care. Aim To assess differences in 30-day survival between men and women after an in-hospital cardiac arrest (IHCA). Material and methods All patients ≥18 years suffering an IHCA at Karolinska University Hospital between 2007 and 2017 were included. Data regarding the IHCA, patient characteristics, Charlson co-morbidity index (CCI) and 30-day survival were obtained from electronic patient records. Differences in survival between men and women were assessed with adjusted logistic regression models and presented as Odds Ratios with 95% Confidence Intervals (OR, 95% CI). Adjustments included age, CCI, place of cardiac arrest, first rhythm, ECG-surveillance and witnessed or not. Results In all, 1639 patients suffered an IHCA, of whom 650 (40%) were women and 193 (30%) of them survived to 30 days compared to 28% of the men. No differences were found in the studied patient characteristics, intra arrest factors or post-ROSC treatments. Men had similar survival as women (crude OR 0.93 95% CI 0.74–1.15 and adjusted OR 0.77 95% CI 0.58–1.03 respectively). Conclusion This cohort study illuminates an almost equal distribution in characteristics and treatment as well as outcome, 30-day survival after IHCA between men and women. However, our study confirms previous findings of disadvantageous prerequisites among women, but also indicates that preceeding vital signs differ which might indicate residual confounding.

ObjectivesThere is evidence that emergency department (ED) crowding is associated with increased mortality, however large multicenter studies of high quality are scarce. In a prior study, we introduced a proxy-measure for crowding that was associated with increased mortality. The national registry SVAR enables us to study the association in a more heterogenous group of EDs with more recent data. The aim is to investigate the association between ED crowding and mortality.MethodsThis was an observational cohort study including visits from 14 EDs in Sweden 2015-2019. Crowding was defined as the mean ED-census divided with expected ED-census during the work-shift that the patient arrived. The crowding exposure was categorized in three groups: low, moderate and high. Hazard ratios (HR) for mortality within 7 and 30 days were estimated with a cox proportional hazards model. The model was adjusted for age, sex, triage priority, arrival hour, weekend, arrival mode and chief complaint. Subgroup analysis by county and for admitted patients by county were performed.Results2,440,392 visits from 1,142,631 unique patients were analysed. A significant association was found between crowding and 7-day mortality but not with 30-day mortality. Subgroup analysis also yielded mixed results with a clear association in only one of the three counties. The estimated HR (95% CI) for 30-day mortality for admitted patients in this county was 1.06 (1.01-1.12) in the moderate crowding category, and 1.11 (1.01-1.22) in the high category.ConclusionsThe association between crowding and mortality may not be universal. Factors that influence the association between crowding and mortality at different EDs are still unknown but a high hospital bed occupancy, impacting admitted patients may play a role.

The aim of this article is to describe current Swedish legalisation, clinical practice and future perspectives on the medical ethical decision “Do-Not-Attempt-Cardio-Pulmonary-Resuscitation” (DNACPR) in relation to prevent futile resuscitation of in-hospital cardiac arrests. Sweden has about 2200 in-hospital cardiac arrests yearly, with an overall 30-day survival ratio of 35%. This population is highly selected, although the frequency of DNACPR orders for hospitalized patients is unknown, resuscitation is initiated in only 6–13% of patients dying in Swedish hospitals.According to Swedish law and although shared decision making is sought, the physician is the ultimate decision-maker and consultation with the patient, her relatives and another licenced health care practitioner is mandatory. According to studies, these consultations is documented in only about 10% of the decisions. Clinicians lack tools to assess risk of IHCA, tools to predict outcome and we are not good at guessing patients own will.Future directives for clinical practice need to address difficulties for physicians in making decisions as well as the timing of decisions.We conclude that the principles in Swedish law needs to be fulfilled by a more systematic approach to documentation and planning of meetings between patients, relatives and colleagues.