Archives of Academic Emergency Medicine. 2019; 7 (1): e48 OR I G I N A L RE S E A RC H Use of a Motorlance to Deliver Emergency Medical Ser- vices; a Prospective Cross Sectional Study Korakot Apiratwarakul1,2, Kamonwon Ienghong1∗, Thapanawong Mitsungnern1, Praew Kotruchin1, Pariwat Phungoen1, Vajarabhongsa Bhudhisawasdi1 1. Department of Emergency Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand. 2. Research group for emergency patients care and emergency medical services, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand. Received: June 2019; Accepted: July 2019; Published online: 21 August 2019 Abstract: Introduction: Access time to patients with critical or emergent situations outside the hospital is a critical fac- tor that affects both severity of injury and survival. This study aimed to compare the access time to the scene of an emergency situation between a traditional ambulance and motorlance. Methods: This prospective cross sectional study was conducted on all users of emergency call, Srinagarind Hospital, Thailand, from June to De- cember 2018, who received a registration number from the command center. Results: 504 emergency-service operations were examined over a six-month period, 252 (50%) of which were carried out by motorlance. The mean activation time for motorlance and ambulance were 0.57 ± 0.22 minutes and 1.11 ± 0.18 minutes, re- spectively (p<0.001). Mean response time for motorlance was significantly lower (5.57 ± 1.21 versus 7.29 ± 1.32 minutes; p < 0.001). The response times during 6 a.m. to 6 p.m. were 5.26 ± 1.11 minutes for motorlance and 7.15 ± 1.39 minutes for ambulance (p < 0.001). These measures for night time (6 p.m. to 6 a.m.) were 5.58 ± 1.21 minutes and 8.01 ± 1.30 minutes, respectively (p < 0.001). The mean automated external defibrillator (AED) waiting time for motorlance and ambulance were 5.26 ± 2.36 minutes and 9.24 ± 3.30 minutes, respectively (p = 0.012). The survival rate of patients after AED use in motorlance and ambulance was 80% versus 37.5%; p<0.001. Conclusion: Emergency service delivery by motorlance had lower mean activation time, response time, AED time, and mortality rate of cardiac arrest patients compared to ambulance. It seems that motorlance could be considered as an effective and applicable device in emergency medical service delivery, especially in crowded cities with heavy traffic. Keywords: Emergency medicine; emergency medical services; ambulances; emergency mobile units Cite this article as: Apiratwarakul K, Ienghong K, Mitsungnern T, Kotruchin P, Phungoen P, Bhudhisawasdi V. Use of a Motorlance to Deliver Emergency Medical Services; a Prospective Cross Sectional Study. Arch Acad Emerg Med. 2019; 7(1): e48. 1. Introduction The access time of emergency medical services (EMS), to people who are injured or suffer from cardiac arrest is a crit- ical factor that affects both severity of injury and survival (1-3). The use of traditional ambulances to reach people in emergency situations in large cities with traffic problems can result in delayed access times (4, 5). At present, there are efforts to choose vehicles that are flexible and can re- duce access times such as motorcycles equipped with med- ical devices (motorlance) (6-8). Advanced emergency med- ∗Corresponding Author: Kamonwon Ienghong; Department of Emergency Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand 40002 Email: kamonwan@kku.ac.th, Tel: +6643366869, Fax: +6643366870 ical technicians (AEMTs) are responsible for driving the ve- hicle, which is able to measure oxygen saturation, check vital signs, and perform basic airway management and cardiopul- monary resuscitation (CPR). The driver must pass a motor- cycle driving test administered at a standard training center and must use proper safety equipment at all times. In or- der to synchronize information with the command center, a headset-based radio is used, and the helmet microphone acts as a communication device. A motorlance can be used to send a doctor or nurse to the scene of severe traffic accidents quickly to administer treatment and deliver medical supplies such as blood or drugs (9). A previous study found that us- ing a motorlance can reduce access times to injured persons in both urban and rural areas (10-13). However, there have been no studies about motorlance use in Thailand. The ob- This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem K. Apiratwarakul et al. 2 jective of the present study was to compare the access time to the scene of an emergency situation between a traditional ambulance and motorlance. 2. Methods 2.1. Study design and setting In this prospective cross sectional study, all users of emer- gency call (via emergency telephone number 1669 in Thai- land operation), at Srinagarind Hospital, Thailand, from June 2018 to December 2018, who receive a registration number from the command center were evaluated. The present study protocol was approved by Khon Kaen University Ethics Com- mittee for Human Research (HE611219). Requirement for in- formed consent from the patients was waived since patient confidentiality protection had been guaranteed, as patients were not identified by name, but by a unique study number. 2.2. Participants Data of all patients aged over 18 years were collected. Cases in which the patient was being referred between hospitals and patients with missing data were excluded from this study. 2.3. Data gathering Data were recorded using a standard national operation checklist for emergency medical services in Thailand con- sisting of demographic data (age, gender), operation time (day, night), type of patients (trauma, non-trauma), type of first procedure on scene for all patients, time stayed in emer- gency room, duration of hospital stay and outcome of pa- tients with cardiac arrest who were referred by ambulance or motorlance. A trained emergency medicine resident was re- sponsible for data gathering under direct supervision of an emergency medicine specialist. 2.4. Definitions Times from dispatch to resources being en route was defined as activation time and response time was defined as time from 1669 center call receipt to arrival on scene. Time from dispatch to AED arrival on scene was defined as AED waiting time. 2.5. Statistical Analysis The sample size was calculated based on the standard devi- ation of access time detailed in a previous study by Peyravi (13). In order to achieve a significance level of 5% and power of test of 0.8, we determined that a sample size of 504 would be required. Statistical analysis was performed using SPSS for Windows version 16.0 (SPSS Inc., Chicago, IL, USA). Categor- ical data were presented as percentage, and continuous data were presented using mean and standard deviation. Uni- variate analysis was performed using two-sample t-test for numerical data and Chi-squared test for comparing data be- tween the groups. 3. Results 3.1. Baseline characteristics of the subjects and services Five hundred four emergency-service operations were exam- ined over a six-month period, 252 (50%) of which were car- ried out by motorlance. The characteristics of the subjects and services are shown in Table 1. The most common time of day at which motorlance was deployed was during the af- ternoon shift (4 p.m. to 0.00 a.m.; 52.0%). The most common first procedure performed on scene was breathing manage- ment. The procedure was performed in 41.3% of cases in the motorlance group compared with 43.6% in the ambulance group (p=0.359). 3.2. Outcomes Table 2 compares the outcomes between emergency services carried out by motorlance and ambulance. The mean acti- vation time, mean response time (p<0.001), and mean auto- mated external defibrillator (AED) waiting time (p = 0.012) were significantly lower in patients who were referred to ED by motorlance. The survival rate of cardiac arrest cases was significantly higher in motorlance group (80% versus 37.5%; p<0.001). There as not any difference between groups regard- ing duration of ED (p > 0.05) and hospital stays (p > 0.05). 4. Discussion Based on the findings of the present study, Emergency ser- vice delivery by motorlance had lower mean activation time, response time, AED time, and mortality rate of cardiac ar- rest patients compared to ambulance. Thailand’s Emergency Medical Services (EMS) was established to allow equipment and medical staff to be deployed to manage and treat emer- gency patients en route using a traditional ambulance. Emer- gency medical responders (EMRs), emergency medical tech- nicians (EMTs), advanced emergency medical technicians (AEMTs), and paramedics are deployed through this service. Physicians are in short supply and mainly provide services in the emergency room and command center with online med- ical oversight (11). Thailand will enter the 4.0 era in accor- dance with government policy. Public health development is a branch that must develop for taking care of people with in- ternational standards. Caring for patients who are injured at the scene through the operation of emergency medical ser- vices is important to reduce the mortality rate (14). Response and activation times are key factors in accessing emergency patients. In major cities, traffic congestion can negatively af- fect the arrival time of emergency services to the scene of an This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem 3 Archives of Academic Emergency Medicine. 2019; 7 (1): e48 Table 1: Characteristics of the subjects and services Variable Motorlance (n=252) Ambulance (n=252) P value Age (years) Mean ± SD 40.29 ± 12.75 39.25 ± 11.12 0.720 Median (25t h 75t h percentile) 40 (28, 50) 39 (27, 48) Gender Male 123 (48.8) 147 (58.3) 0.548 Female 129 (51.2) 105 (41.7) Operation time (shift) 8 a.m. to 4 p.m. 84 (33.3) 80 (31.7) 4 p.m. to 0.00 a.m. 131 (52.0) 135 (53.6) 0.326 0.00 a.m. to 8.00 a.m. 37 (14.7) 37 (14.7) Type of patients Non-trauma 109 (43.2) 112 (44.4) 0.662 Trauma 143 (56.8) 140 (55.6) First procedure on scene Airway management 60 (23.8) 63 (25.0) 0.675 Breathing 104 (41.3) 110 (43.6) 0.359 Circulation 31 (12.3) 37 (14.7) 0.211 Immobilization 57 (22.6) 42 (16.7) 0.042* Data are presented as mean ± standard deviation (SD) or number (%). Table 2: Comparing the outcome between emergency services carried out by motorlance and ambulance Variable Motorlance (n=252) Ambulance (n=252) P value Activation time (minutes) Mean ± SD 0.57 ± 0.22 1.11 ± 0.18 p<0.001 Response time (minutes) Mean ± SD 5.57 ± 1.21 7.29 ± 1.32 < 0.001 6 a.m. to 6 p.m. 5.26 ± 1.11 7.15 ± 1.39 < 0.001 6 p.m. to 6 a.m. 5.58 ± 1.21 8.01 ± 1.30 < 0.001 Duration of ED stay < 1 hour 42 (16.7) 38 (15.1) 0.677 > 1 hour 210 (83.3) 214 (84.9) 0.680 Duration of hospital stay 1 day 12 (4.8) 15 (6.0) 0.450 2 days 25 (9.9) 22 (8.7) 0.570 3 days 30 (11.9) 28 (11.1) 0.680 > 3 days 185 (73.4) 187 (74.2) 0.710 AED waiting time* (minutes) Mean ± SD 5.26 ± 2.36 9.24 ± 3.30 0.012 Mortality* Survived 8 (80.0) 9 (37.5) <0.001 Not survived 2 (20.0) 15 (62.5) * For patients with cardiac arrest. AED: automated external defibrillator; ED: emergency department. Times from dispatch to resources being en route was defined as activation time and response time was defined as time from 1669 center call receipt to arrival on scene. Times from dispatch to AED arrival on scene defined as AED waiting time. emergency. Motorlance can, thus, be used to reduce arrival times and increase the efficiency of Emergency Medical Ser- vices. Although there are several medical emergency systems around the world that use motorlance, few studies have been published that evaluate their effectiveness (1). The main ob- jective of using motorlance is to reduce the time it takes to administer treatment in critical situations. Our study, which examined 504 cases over a six-month period, found that the average motorlance response time was shorter than that of traditional ambulances (5.57 versus 7.29 minutes), a result that is consistent with those of previous studies conducted in various countries (5-8). Response time and use for standard emergency medical services is related to the infrastructure of the city and the availability of different hospitals combined with low traffic congestion (10). In Thailand, the maximum This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem K. Apiratwarakul et al. 4 response time in resuscitation cases is set at eight minutes. The use of a motorlance allowed us to achieve this goal. In addition, emergency medical services need to reach patients quickly to assess symptoms and provide treatment. Medi- cal staff will operate by using an ambulance as a travel vehi- cle, the signal lights and the siren sound of ambulance cause drivers to make way for ambulance (15). After delivery to hospital, the time that patients stayed in emergency room (ER), which depends on many steps of work (time to doctor visit, overcrowding in ER, blood test wait- ing time), was not different between motorlance and tradi- tional ambulance; a result that is consistent with those of pre- vious studies (16), which showed patient disposition, espe- cially admission, investigation and triage level were the main factors leading to longer periods in emergency department. Of course, the duration of hospital stay also depends on mul- tiple factors including severity of disease. In cardiac arrest patients, AED waiting time was shorter in motorlance group (5.26 versus 9.24 minutes), resulting in a higher survival rate among patients after AED use in motorlance compared to ambulance (80% versus 37.5%). Basic life support (BLS) and AED usage is one of the first aid procedures that general pop- ulation can legally perform in Thailand. Teaching these pro- cedures to the general population will increase survival rate of cardiac arrest patients (17). As a result of this study, the National Institute for Emer- gency Medicine (NIEM), which is responsible for administra- tive management and coordination between relevant agen- cies in both public and private sectors, will promote the use of motorlance for delivering emergency medical services in Thailand. 5. Limitation The use of the motorlance was limited in some weather con- ditions (heavy rain). It should be noted that in the current study, data were gathered from only one emergency medical service center. 6. Conclusion Emergency service delivery by motorlance had lower mean activation time, response time, AED time, and mortality rate of cardiac arrest patients compared to ambulance. It seems that motorlance could be considered as an effective and ap- plicable device in emergency medical service delivery, espe- cially in crowded cities with heavy traffic. 7. 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