Azienda Regionale Emergenza Urgenza

Background: In Italy, workplace safety regulations require the training of first-aid officers to manage medical emergencies, including acute coronary syndromes. Although clinical guidelines recommend the early use of acetylsalicylic acid in myocardial infarction, little is known about the implementation of this recommendation in practice. This study aims to assess the use of acetylsalicylic acid for ST-elevation myocardial infarction (STEMI) in workplace and non-workplace settings, with a focus on informing the evaluation and improvement of first-aid training programs and emergency response protocols. Methods: We conducted a retrospective, observational cohort study using 2019 data from the Regional Agency for Emergency Urgency. Cases were identified and stratified by event location (workplace vs non-workplace), to analyze patterns of acetylsalicylic acid administration. A logic model has been developed to program a stepwise plan of action for policies development. Results: A total of 2174 STEMI cases were identified, of which 380 (17.5%) occurred in the workplace. Workplace cases were younger and more likely to be male. Acetylsalicylic acid was administered in only 31 cases overall, with no statistically significant difference between settings. This assessment advocates for the implementation of targeted actions, which may include updates to current legislation and policies. Conclusions: These findings highlight an urgent need to systematically evaluate existing workplace first-aid training and emergency protocols. Integrating modules on acetylsalicylic acid administration into training curricula, along with performance monitoring mechanisms, may significantly enhance early STEMI management and patient outcomes. Updating safety programs to align with evidence-based practices should follow a structured approach.

Simulation-based education is an essential tool in modern health care, enhancing technical, behavioral, and decision-making skills while improving patient safety and clinical outcomes. In Italy, health care simulation has developed over the past 2 decades, with multiple scientific societies and educational initiatives promoting its use. However, the absence of national data and standardized educational frameworks presents a barrier to its widespread adoption. Recognizing these challenges, the Italian Ministry of Health convened a panel of experts to establish a strategic framework for simulation in health care, aiming to standardize methodologies, promote quality assurance, and foster collaboration across institutions. The panel, composed of experts in health care simulation, clinical practice, and risk management, conducted a series of telematic meetings from April 2022 to July 2022. A consensus-driven approach was adopted to review existing literature, identify key areas for development, and formulate practical recommendations. Key recommendations include: establishing a national registry of simulation programs, defining accreditation criteria for simulation-based education, standardizing professional competencies for simulation educators, integrating simulation into health care curricula and continuous professional development, developing national standards for simulation-based training in new technologies and clinical procedures, utilizing simulation in public health preparedness and emergency response planning, promoting research funding and inter-institutional collaborations. This position paper provides a strategic roadmap for standardizing simulation-based education across the Italian health care system. By establishing national standards and fostering collaboration, simulation can significantly improve patient safety, care quality, and health care system resilience.

Urban heat stress is an escalating urban health concern, particularly in densely populated cities where extreme heat events exacerbate health risks. This study investigates the relationship between urban heat stress and cardiovascular and respiratory emergency calls in Milan, using spatial and temporal data. By integrating geolocated emergency medical service (EMS) and Universal Thermal Climate Index (UTCI) modelling, it analyses the impact of extreme temperatures on urban health outcomes across the city of Milan. The results reveal correlation between increased temperature and a rise in emergency calls, particularly during heatwaves. Although risks extend to everyone at varying levels, the findings show that emergency incidents peak during the hottest periods, with the greatest impact on vulnerable populations. Additionally, the study finds that nighttime heat exposure, or also referred to as the "tropical nights" significantly contributes to heat stress, leading to an accumulation of heat-related emergency cases. The spatio-temporal distribution of calls further emphasizes the socio-demographic disparities in heat vulnerability, as low-income neighbourhoods, elderly or individuals living alone showing higher incidences of heat-related health emergencies. This research underscores the critical need to integrate the interplay of biometeorological, health and socio-demographic aspects to better inform urban planning and design for tailored interventions. By integrating a holistic approach for urban heat resilience, cities can develop equitable and effective strategies to mitigate heat stress and safeguard public health in a changing climate.

Stroke is a time-sensitive condition in which timely intervention is crucial for optimal outcomes. Advances in stroke management, including extended time windows for thrombolysis and mechanical thrombectomy, highlight the need for efficient patient centralization. This study explores the newly adopted stroke algorithm for patient centralization in Lombardy, Italy, and evaluates the potential for helicopter emergency medical services (HEMS) to improve access to timely care. Data regarding stroke rescue missions were retrieved from SAS-AREU database. Geospatial maps were created using QGIS (Open Source Geospatial Foundation (OSGeo), Chicago, IL) 3.30, with travel times calculated using Google Maps data. Population density was retrieved from Geoportal Lombardia. Area with road travel time to a Hub hospital >60 minutes were identified as potential HEMS priority settings. In 2024, 11,822 patients rescued by the Regional Agency for Emergency and Urgency were given the "stroke code." HEMS was used in 214 cases, covering a median distance of 49.3 km with a median rescue time of 77 minutes. The study identified areas with road travel times exceeding 60 minutes, highlighting northern Lombardy's mountainous regions and areas with low population density as high priority areas for HEMS intervention. The analysis also revealed an unexpected advantage for air transport in some plain areas, despite viable road access. Geospatial mapping is a valuable tool for identifying areas where HEMS can reduce response times. The integration of HEMS into stroke care algorithms enhances timely interventions, ensuring that patients are centralized within recommended time windows, improving outcomes, and addressing geographic and infrastructural challenges.

This article examines the infectious disease surveillance system in the Lombardy region of Italy, with a focus on its response mechanisms to respiratory syndromes. This study aims to describe the alert system and the organizational procedures in place, assessing their effectiveness in managing health crises. This study is based on the analysis of Lombardy's regional resolution No. 1125, developed by regional public health experts. Surveillance levels were categorized based on incidence thresholds and healthcare system impacts, establishing specific indicators and activation protocols. Information flows are managed through real-time data portals, enabling the real-time monitoring of COVID-19, influenza, and other infectious respiratory diseases. A multi-level response system was established, with levels ranging from ordinary regimes to critical epidemic activation. Each level includes specific actions, such as resource reallocation, emergency department support, and the suspension of elective procedures. The use of technological tools, such as electronic health records, streamlined reporting processes, and real-time data flow management, has strengthened the region's response capabilities. This study underscores the value of a structured, multi-level response system for infectious disease management, showing that a unified regional approach improves crisis response efficiency. It suggests that sharing activation indicators and protocols within the scientific community can help harmonize national and international responses to future pandemics. The system, while effective in its current context, may require adaptation for future health challenges.

Abstract Background Recent literature has identified numerous combinations of meteorological indicators, methods and comparison thresholds to define heat in order to analyse its impact on adverse cardiovascular (CV) events. In fact, despite increasing attention to the issue due to ongoing climate change, there is no standardised definition of heat nor guidelines for its establishment, and in studies often little attention is given to the selected definition, despite its impact on the results. Purpose To fill this gap, our aim was to propose a data-driven framework for selecting the temperature threshold for defining heat in the context of studies on adverse CV outcomes, combining the most common approaches identified in the literature. Methods The following five-step framework is proposed: 1) Selection of temperature lags based on the contour plot obtained by the distributed lag non-linear model (DLNM); 2) Estimation of the relative risk (RR) of having a CV emergency in heat versus non-heat days by Poisson regression considering the 90th-99th percentile (%ile) of the temperature distribution for each lag; 3) Selection of the final lag based on the curvatures of the 10 included %iles; 4) Calculation of the % change in RR from %ile i to %ile i+1; 5) Selection of the heat threshold, defined as the %ile from which all the next %iles are associated with a higher % change, or, if not existing, the %ile preceding the one with the highest % change. We tested this framework, for each year, on retrospective CV emergencies in May-September 2017-2022 in Milan, Italy, using the apparent temperature data, accounting for air temperature, relative humidity and wind speed. Results The contour plot of the DLNM, controlled for air pollution, seasonality and long-term trend, showed that lags 0 and 1 were characterised by an increased RR for a CV emergency. The RR estimated for each %ile for each considered lag (i.e., heat on day i, heat on day i or on day i-1, and heat on day i and on day i-1), produced a similar curvature, so first lag option was arbitrarily selected. For Milan, the 95th %ile was the point from which all the subsequent %iles were associated to progressively higher % changes, resulting in a RR of having a CV emergency compared to non-heat days equal to 1.113 (95% CI: 1.087-1.139). The mean daily apparent temperature values associated to such %ile, varying from 27.7 °C to 29.9 °C depending on the year, should then be considered as the heat threshold in the examined context. Conclusion We proposed a flexible data-driven framework for the definition of heat that could easily be extended to similar scenarios. Although the framework still requires some arbitrary choices to be made, and the need of validation on other real-world data, it could provide a valuable guideline for relevant research, and could contribute to the standardization of heat definition for CV health research aiming at a better comprehension of climate changes on human health.

Abstract Background A 12–lead electrocardiogram (ECG), performed after return of spontaneous circulation (ROSC) in out–of–hospital cardiac arrest (OHCA), is essential for the identification of ST–segment elevation). The aim of the study is to investigate whether the presence of ST elevation may be a prognostic determinant in post–OHCA patients. Materials and Methods A total of 878 post–ROSC ECGs were collected from patients enrolled from 01/01/2015 to 12/31/2022 from the Lombardy Region Cardiac Arrest Registry (LombardiaCARe). Univariable and multivariable Cox regression models were applied to test the association between the presence of and morphology of supraST and mortality at 30 days after the event. Results Among the 878 post–ROSC ECGs, 406 (46.2%) had ST elevation [49 with tombstone morphology; 26 with lambda morphology; 45 with triangular morphology; and 8 with wave morphology]. Patients with ST elevation were more frequently males (73% vs 59%, p<0.001), younger [66 years old (57–75) vs 71 (61–80), p<0.01], and with a more frequently non–defibrillating rhythm of presentation (25%vs59%, p<0.01) and an event more frequently witnessed by 118 (30% vs 21%, p=0.008). Thirty–day survival was higher in patients with ST elevation (56% vs 41%, p<0.001). Correcting for variables associated with 30–day survival (age, sex, QRS amplitude, ECG acquisition time, first rhythm of presentation), the presence of ST elevation was not significantly associated with 30–day mortality [HR: 0.67 (95% CI: 0.27–1.64); p=0.05], while the number of segments was [1.1 (95%CI 0.85–0.15), p=0.004]. No morphology was independently associated with mortality when compared with standard morphology. Conclusions The presence of ST elevation on ECG post ROSC possesses, in addition to a known diagnostic role, a prognostic role in predicting 30–day survival especially if present in more than one segment.

Although cardiopulmonary resuscitation (CPR) includes lifesaving maneuvers, it might be associated with a wide spectrum of iatrogenic injuries. Among these, acute lung injury (ALI) is frequent and yields significant challenges to post-cardiac arrest recovery. Understanding the relationship between CPR and ALI is determinant for refining resuscitation techniques and improving patient outcomes. This review aims to analyze the existing literature on ALI following CPR, emphasizing prevalence, clinical implications, and contributing factors. The review seeks to elucidate the pathogenesis of ALI in the context of CPR, assess the efficacy of CPR techniques and ventilation strategies, and explore their impact on post-cardiac arrest outcomes. CPR-related injuries, ranging from skeletal fractures to severe internal organ damage, underscore the complexity of managing post-cardiac arrest patients. Chest compression, particularly when prolonged and vigorous, i.e., mechanical compression, appears to be a crucial factor contributing to ALI, with the concept of cardiopulmonary resuscitation-associated lung edema (CRALE) gaining prominence. Ventilation strategies during CPR and post-cardiac arrest syndrome also play pivotal roles in ALI development. The recognition of CPR-related lung injuries, especially CRALE and ALI, highlights the need for research on optimizing CPR techniques and tailoring ventilation strategies during and after resuscitation.

Around the world, data on out-of-hospital cardiac arrest (OHCA) are heterogeneous in terms of outcomes and reporting, and not all registries follow the Utstein recommendations for uniform OHCA data collection. This study reports data on OHCA occurring in recent years in a limited territory to analyze, in a homogenous setting, the circumstances and interventions affecting survival to hospital admission. OHCA data from the province of Varese for the years 2020–2022 were extracted from a prospective registry. For survival to hospital admission, the impact of pandemic waves and variables known to affect survival was evaluated both in the overall population and in the subgroup of patients in whom cardiopulmonary resuscitation (CPR) was initiated or continued by the emergency medical service (EMS). Overall, 3263 OHCAs occurred mainly at home (88%), with a time to intervention of 13.7 min, which was significantly longer during lockdown (15.7 min). Bystanders performed CPR in 22% of the cases and used automatic external defibrillator (AED) in 2.2% of the cases. Overall survival to hospital admission was 7.7%. In the multivariate analysis, in the general population, occurrence near a public building (OR 1.92), the presence of witnesses (OR 2.65), and a shockable rhythm (OR 7.04) were independent predictors of survival to hospital admission, whereas age (OR 0.97) and occurrence during a pandemic wave (OR 0.62) were associated with significantly worse survival to hospital admission. In the group of patients who received CPR, AED shock by bystanders was the only independent predictor of survival (OR 3.14) to hospital admission. Among other factors, early defibrillation was of crucial importance to improve survival to hospital admission in possibly rescuable patients. The occurrence of OHCA during pandemic waves was associated with longer intervention time and worse survival to hospital admission.

Abstract Background Patients resuscitated from Out-of-Hospital Cardiac Arrest (OHCA) with shockable rhythms are reported to have better survival rates. Amplitude spectral area (AMSA) of ventricular fibrillation (VF), a surrogate for the metabolic status of the myocardium, can predict shock success and return of spontaneous circulation (ROSC). There is minimal evidence regarding its role in predicting survival from OHCA, and the evidence that exists is limited to survival at discharge. Purpose To test the hypothesis that the first, the maximum, the minimum and the average values of AMSA are associated with one-year survival with good neurological outcome in OHCA patients. Methods All the OHCAs with at least one shockable rhythm, that occurred from January 2015 to December 2020 and collected from an Utstein-style database, were considered. AMSA values were calculated by retrospectively analyzing the data collected by the monitors/defibrillators used and by using a 2-second pre-shock ECG interval. The first, the maximum, the minimum and the average AMSA values during resuscitation were computed. Data were analyzed by using Cox regression analysis. Results 250 patients (84% male, median age 67 [57-77] years) with at least one computable AMSA value were included; 12% achieved ROSC and 9.4% survived at one year with good neurological outcome, defined as Cerebral Performance Category (CPC) ≤ 2. The first, the maximum, the minimum and the average values of AMSA were higher in patients alive one year after OHCA with CPC≤2 (first: 11.6 [9.9-14.7] vs 7.8 [5.1-11.8]; max: 15.4 [12-20] vs 9.9 [6.2-14.4]; min: 9.9 [8.5-12.2] vs 6.1 [4.3-9.6]; avg: 12.5 [10.7-15.2] vs 8.3 [5.5-12]; all p <0.01). These values showed similar areas under the curve of the receiver operating characteristic (ROC) curve for one-year survival with good neurological outcome (first: 0.77; max: 0.76; min: 0.78; avg: 0.78, p=ns). In univariable model, the survival probability with good neurological outcome was significantly lower in the first tertile (T1) of AMSA compared to the third one (T3; p<0.05; figure). In multivariable analysis, after correction for sex, presence of bystander CPR, age, EMS arrival time, witnessed status, OHCA location, the use of mechanical CPR and the total amount of epinephrine administrated, AMSA was significantly associated with probability of death or poor neurologic outcome [HR 0.5 (95%CI 0.3-0.9), p=0.03]. Conclusions This is the first study to evaluate the association between AMSA values and one-year survival with good neurological outcome. We found that AMSA is independently associated with one-year survival with­ good neurological outcome in OHCA patients and that the first, the maximum, the minimum and the average of AMSA values all have similar prediction power in survival rate with CPC≤2.