Trends in Urgency Levels and Risk of Acute Critical Condition Among Prehospital Patients. A Seven-Year Observational Historic Register-Based Cohort Study

Trends in Urgency Levels and Risk of Acute Critical Condition Among Prehospital Patients. 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A Seven-Year Observational Historic Register-Based Cohort Study Kristine Sørensen, Torben Anders Kløjgård, Erika Frischknecht Christensen, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8891109/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 9 You are reading this latest preprint version Abstract Trends in Urgency Levels and Risk of Acute Critical Condition Among Prehospital Patients. A Seven-Year Observational Historic Register-Based Cohort Study Background : In our region, as in Western countries, the number of emergencies requesting an ambulance is increasing. Whether this may be due to increased disease burden and/or lower threshold for calling is not clear. This study aimed to examine the development over the years in the number and urgency levels of ambulances and the actual acute disease severity, as indicated by initial vital signs measured on scene, together with patient demographics, comorbidity, and mortality trends over time. Methods : We conducted a registry-based observational cohort study of patients aged ≥ 18 years assigned an ambulance in the North Denmark Region from 2017 to 2023. The primary outcomes were urgency level and acute critical severity, assessed by a modified National Early Warning Score. Linear regression was applied to examine for alignment between trends in urgency level over the years and critically versus non-critically severity in prehospital patients assigned to urgency level A (most urgent, potentially life-threatening) and B (less urgent), respectively. Results : Among 202,746 prehospital patients, the proportion assessed as urgency level A decreased from 62% to 59%, while urgency level B increased from 38% to 41%. While the proportion of patients in acute critical condition was 16% vs 8% among level of urgency A and B, and stable during the period, the number of patients in acute critical condition increased by 3.6 (95% confidence interval (CI) 0.7–6.6) and 6.1 (95% CI 4.4–7.8) per quarter. Across the total population, patient age increased from 64 to 66 years, and the proportion with severe comorbidity increased from 11% to 14%. Conclusion : From 2017 to 2023, the number of patients assigned with an ambulance through 1-1-2 increased, as did patient age and comorbidity. During the years were similar proportions of acute critical severity, but increasingly more among urgency level B. Thus, the acute severity among prehospital patients has not diminished. The lack of alignment between the level of urgencies and the acuity severity found on scene should be monitored carefully, together with mortality and clinical outcomes. Emergency medical dispatch Emergency medical services Triage Patient Acuity Decision Support Systems Early Warning Score Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction As in the Western world, the number of patients requesting an ambulance has increased in Denmark ( 1 – 3 ), most likely due to the increasingly ageing population living with more comorbidities and needing urgent help. Difficulties when navigating the acute health care system may play a part ( 4 , 5 ), and some studies indicate a lower threshold for calling the EMS ( 6 ), implying a decrease in the severity of the EMS patients’ clinical conditions over time. When calling the Emergency Medical Services (EMS) for an ambulance, the call is assessed to identify the main symptom/injury and triaged to determine how fast a response is needed, and if it is needed at all. In Denmark, the highest level of urgency is A (blue lights and sirens), primarily intended for potential life-threatening or disabling conditions ( 7 ), while level B is for urgent, but not potentially life-threatening or disabling conditions. The assessment is based on telephone triage and, therefore, limited to the caller’s information and can prove complex. In a recent Danish study on ambulance patients, the severity of the presenting condition among younger and older patients (66 years and above) was assessed by a modified National Early Warning Score 2 (NEWS2). The older patients displayed a higher median score, indicating that more patients are critically affected by their acute conditions with age, potentially resulting in more EMS calls ( 8 ). Given the increasing demand and complexity in EMS calls, it is essential to explore the telephone assessed triage and the patients’ actual clinical conditions. As such, our aim was to examine the development over the years in the number and urgency levels of ambulances and the actual acute disease severity, as indicated by initial vital signs measured on scene, together with patient demographics, comorbidity, and mortality trends over time. Methods Study design and patient population This observational, historic register-based cohort study included all patients aged 18 years or older in the North Denmark Region who received an ambulance dispatch following a national emergency number ( 1 – 1 – 2 ) call between January 1, 2017, and December 31, 2023. Setting The North Denmark Region has 579,787 inhabitants and consists of both urban and rural areas ( 9 ). Calls to the national emergency number, 1-1-2, involving medical emergencies in Denmark have been forwarded by the police to an Emergency Medical Coordination Centre. Here, health care professionals evaluate the situation using the Danish Index for Emergency Care to determine the appropriate urgency level of ambulance response ( 10 ). The index was designed to assist health care professionals in making fast and qualified decisions regarding the main reason for calling and the urgency level of ambulance response. During the 1-1-2 call, the health care professionals can use the index to identify one of 37 possible main symptoms or injuries to determine the appropriate urgency level for the ambulance response. There are five different urgency levels: A) life-threatening or potentially life-threatening conditions, B) urgent but not life-threatening conditions, C) non-urgent conditions that require an ambulance, D) non-urgent conditions requiring supine patient transport, and E) conditions requiring medical advice only ( 7 ). For ambulances dispatched following 1-1-2 calls in the North Denmark Region, the vast majority were assigned urgency level A (49%) and B (39%) in 2023–2024 ( 1 , 11 ). Study population The patients were identified through the electronic Prehospital Patient Medical Record (ePMR). If a patient received more than one ambulance during this period, they would appear in the dataset multiple times, except in mortality analyses. Patients were excluded if the Danish Index for Emergency Care was missing, if the urgency level was classified as C, D, or E, as this study focuses on acute patients, or if the civil registration number was missing or invalid. The study’s findings are reported in accordance with the STROBE statement ( 12 ). Data sources and variables Data on the Danish Index for Emergency Care criteria, urgency level, and Civil Registration Number (CPR number) were extracted from the ePMR ( 13 ). In addition, the level of acute disease severity according to the modified NEWS2 (mNEWS2) score was likewise derived from ePMR data. The mNEWS2 is based on initial vital parameters at the ambulance’s arrival (pulse, respiratory rate, Glasgow Coma Scale, blood pressure, oxygen saturation, and oxygen treatment) ( 14 – 16 ) (Additional file 1). In cases with two or fewer missing vital signs, the missing vital signs were considered to be normal, i.e., not contributing to an increase in severity according to the mNEWS2 score. Otherwise, cases with more than two missing vital signs were considered incomplete registrations and omitted from analysis. The mNEWS2 was stratified into four groups: normal vital signs (NEWS2 = 0), non-critical condition (NEWS2 1–6), critical condition (NEWS2 ≥ 7), and incomplete registration . Comorbidity was assessed using a modified Charlson Comorbidity Index, based on previous diagnoses (5 years); however, we did not exclude current diagnoses associated with the emergency call ( 17 ). The modified comorbidity was divided into three groups based on the number of comorbidities from the Charlson Comorbidity Index: no comorbidity (comorbidity 0), moderate comorbidity (comorbidity 1–2), and severe comorbidity (comorbidity ≥ 3). Data on previous diagnoses were obtained from the in-hospital electronic medical record. In Denmark, all citizens have a unique CPR number, which includes information on the individual’s age, sex, and vital status, and is used to retrieve data on their vital status. Data on patients’ age, sex, and vital status were obtained from the Danish Civil Registration System. Mortality was assessed up to 30 days after the final date of the study to ensure full follow-up. Outcome The primary outcomes were levels of urgency and acute disease severity. Patient characteristics, including age, comorbidity, and 0–1-day, 2–7-day, and 0–30-day mortality, were described. Statistics Descriptive analyses were performed on the patient population with the total number, median, and percentages. The trend in urgency levels A and B during the study period (divided into quarters of each included year) was evaluated by linear regression, presented with a 95% confidence interval (CI). For the statistical analyses of disease severity, we divided the mNEWS2 score into two groups: non-critical condition ( normal vital signs and non-critical condition , mNEWS2 < 7) and critical condition ( critical condition , mNEWS2 ≥ 7). As such, linear regression analyses were performed to assess trends in patient volume across acute critically and non-critically conditions assigned to urgency level A and B, respectively. P-values of < 0.05 were considered statistically significant. Incomplete registration of mNEWS2 scores (cases with more than two missing vital signs) was excluded from analysis. For mortality analysis, a 30-day exclusion period was applied in the 0–30-day mortality for patients with more than one emergency call. This meant that if a patient had multiple calls within a 30-day window, only the first call was included in the analysis. All analyses were performed using the STATA statistical software version 18. Results During the seven-year study period, a total of 245,266 patient contacts resulted in an ambulance dispatch. Excluding those without a valid CPR number and those under 18 years (34,418), those without a Danish Index category (5,615), and other urgency levels than A or B (2,487) resulted in a total of 202,746 included patient contacts. In this context, each contact is referred to as a “patient,” regardless of whether the same individual had multiple contacts. The 202,746 patient contacts represented 118,740 unique individuals. Overall, urgency level A was most frequent, accounting for 59% compared to level B (41%). For urgency level A, the proportion of patients in acute critical condition was twice as high when compared to level B (16% vs 8%, respectively) (Table 1 ). The median age and the number of patients with severe comorbidity increased from 2017 to 2023 for both urgency level A and B, with a larger increase in urgency level B. (Additional file 2). The number of deaths within 0–1, 2–7, and 0–30 days was also approximately twice as high among urgency level A compared to level B (Table 1 ). Table 1 Patient characteristics by urgency level Urgency level A Urgency level B All N (%) 118816 (59) 83930 (41) 202746 (100) Females n (%) 52952 (45) 40471 (48) 93423 (46) Age, median (IQR) 65 (48–78) 65 (43–78) 65 (46–78) mNEWS2, n (%) Normal 25246 ( 21 ) 22010 ( 26 ) 47256 ( 23 ) Non-critical 66643 (56) 47937 (57) 114580 (57) Critical 18973 ( 16 ) 6500 ( 8 ) 25473 ( 13 ) Incomplete 7954 ( 7 ) 7483 ( 9 ) 15437 ( 8 ) Comorbidity n (%) None 61200 (52) 51624 (62) 112824 (56) Moderate 41761 (35) 23446 ( 28 ) 65207 (32) Severe 15855 ( 13 ) 8860 ( 11 ) 24715 ( 12 ) Deaths, n (%) 0–1 days 5663 ( 5 ) 1775 ( 2 ) 7434 ( 4 ) 2–7 days 2262 ( 2 ) 867 ( 1 ) 3129 ( 2 ) 0–30 days 10770 ( 9 ) 4192 ( 5 ) 14962 ( 7 ) Outcome rates, sex, age, comorbidity and mortality for all patients (N = 202746) Urgency level and severity of the patient’s condition The number of patients assigned with urgency level A and B increased significantly over the study period, with 67.1 (95% CI: 43.6–90.6) and 189.7 (95% CI: 153.2–226.2) patients per quarter, respectively. The largest increase was among patients with urgency level B (Fig. 2 ). Over the seven-year study period, the proportion of patients in acute critical condition within each urgency level was stable (Urgency level A: 15–17%, Urgency level B: 7–8%) (Table 2 ). Table 2 Trends in mNEWS2 and mortality across urgency levels A and B over time Urgency level A n = 118828 N (%) 16245 (62) 17170 (61) 16090 (59) 16355 (61) 17096 (58) 17853 (55) 18007 (55) 118816 (59) mNEWS2, n (%) Normal 3347 ( 21 ) 3525 ( 21 ) 3290 ( 20 ) 3549 ( 22 ) 3876 ( 23 ) 3790 ( 21 ) 3869 ( 21 ) 25246 ( 21 ) Non-critical 9080 (56) 9506 (55) 8993 (56) 9221 (56) 9502 (56) 10086 (56) 10255 (57) 66643 (56) Critical 2494 ( 15 ) 2818 ( 16 ) 2684 ( 17 ) 2447 ( 15 ) 2640 ( 15 ) 2901 ( 16 ) 2989 ( 17 ) 18973 ( 16 ) Incomplete 1324 ( 8 ) 1321 ( 8 ) 1123 ( 7 ) 1138 ( 7 ) 1078 ( 6 ) 1076 ( 6 ) 894 ( 5 ) 7954 ( 7 ) Deaths, n (%) 0–1 days 812 ( 5 ) 908 ( 5 ) 766 ( 5 ) 754 ( 5 ) 816 ( 5 ) 848 ( 5 ) 759 ( 4 ) 5663 ( 5 ) 2–7 days 287 ( 2 ) 327 ( 2 ) 278 ( 2 ) 303 ( 2 ) 324 ( 2 ) 377 ( 2 ) 366 ( 2 ) 2262 ( 2 ) 0–30 days 1470 ( 9 ) 1640 ( 10 ) 1409 ( 9 ) 1442 ( 9 ) 1558 ( 9 ) 1677 ( 9 ) 1574 ( 9 ) 10770 ( 9 ) Urgency level B n = 83943 N (%) 9819 (38) 11191 (39) 11081 (41) 10564 (39) 12451 (42) 14344 (45) 14480 (45) 83930 (41) mNEWS2, n (%) Normal 2675 ( 27 ) 2998 ( 27 ) 2895 ( 26 ) 2890 ( 27 ) 3338 ( 27 ) 3550 ( 25 ) 3664 ( 25 ) 22010 ( 26 ) Non-critical 5562 (57) 6335 (57) 6452 (58) 6032 (57) 7042 (57) 8289 (58) 8225 (57) 47937 (57) Critical 647 ( 7 ) 798 ( 7 ) 835 ( 8 ) 776 ( 7 ) 1003 ( 8 ) 1225 ( 9 ) 1216 ( 8 ) 6500 ( 8 ) Incomplete 935 ( 10 ) 1060 ( 9 ) 899 ( 8 ) 866 ( 8 ) 1068 ( 9 ) 1280 ( 9 ) 1375 ( 10 ) 7483 ( 9 ) Deaths, n (%) 0–1 days 163 ( 2 ) 215 ( 2 ) 223 ( 2 ) 237 ( 2 ) 289 ( 2 ) 337 ( 2 ) 311 ( 2 ) 1775 ( 2 ) 2–7 days 77 ( 1 ) 102 ( 1 ) 118 ( 1 ) 103 ( 1 ) 118 ( 1 ) 185 ( 1 ) 164 ( 1 ) 867 ( 1 ) 0–30 days 391 ( 4 ) 506 ( 5 ) 525 ( 5 ) 549 ( 5 ) 642 ( 5 ) 804 ( 6 ) 775 ( 5 ) 4192 ( 5 ) Rates of mNEWS2 scores and mortality stratified by urgency levels A and B across all study years (N = 202746). Evaluated by linear regression, the number of patients in acute critical condition within urgency level A increased (not significant) by 3.6 (95% CI 0.7–6.6) per quarter, and for patients in acute critical condition within urgency level B (significant) by 6.1 (95% CI 4.4–7.8) per quarter (Fig. 3 , X). For patients in non-critical condition among both urgency level A and B, the increase over the years was significant, with respectively 18.6 (95%CI 10.7–26.6) per quarter and 39 (95%CI 28.6–49.5) per quarter (Fig. 3 , Y). Mortality Over the years, the proportion of deaths within 0–1, 2–7, and 0–30 days remained stable (Table 3 ). Among patients with a critical mNEWS2 score, the 0–30 mortality was 5,758 (23%) deaths, and among patients with a non-critical mNEWS2 score, it was 4,217 (4%) deaths (Additional file 3). Among patients with a critical mNEWS2 score within urgency level A, the 0-30-day mortality was 4,712 (25%) deaths, and among patients within urgency level B, it was 1,046 (16%) deaths. Among patients with an incomplete registration of mNEWS2, it was 4,509 (29%) (Fig. 4 ) (Additional file 3). Table 3 Trends in mNEWS2 and mortality across the study population over time Year 2017 2018 2019 2020 2021 2022 2023 Total Total N (%) 26064 ( 13 ) 28361 ( 14 ) 27171 ( 13 ) 26919 ( 13 ) 29547 ( 15 ) 32197 ( 16 ) 32487 ( 16 ) 202746 (100) mNEWS2, n (%) Normal 6022 ( 23 ) 6523 ( 23 ) 6185 ( 23 ) 6439 ( 24 ) 7214 ( 24 ) 7340 ( 23 ) 7533 ( 23 ) 47256 ( 23 ) Non-critical 14642 (56) 15841 (56) 15445 (57) 15253 (57) 16544 (56) 18375 (57) 18480 (57) 114580 (57) Critical 3141 ( 12 ) 3616 ( 13 ) 3519 ( 13 ) 3223 ( 12 ) 3643 ( 12 ) 4126 ( 13 ) 4205 ( 13 ) 25473 ( 13 ) Incomplete 2259 ( 9 ) 2381 ( 8 ) 2022 ( 7 ) 2004 ( 7 ) 2146 ( 7 ) 2356 ( 7 ) 2269 ( 7 ) 15437 ( 8 ) Deaths, n (%) 0–1 days 975 ( 4 ) 1123 ( 4 ) 989 ( 4 ) 991 ( 4 ) 1105 ( 4 ) 1185 ( 4 ) 1070 ( 3 ) 7438 ( 4 ) 2–7 days 364 ( 1 ) 429 ( 2 ) 396 ( 1 ) 406 ( 2 ) 442 ( 2 ) 562 ( 2 ) 530 ( 2 ) 3129 ( 2 ) 0–30 days 1861 ( 7 ) 2146 ( 8 ) 1934 ( 7 ) 1991 ( 7 ) 2200 ( 7 ) 2481 ( 8 ) 2349 ( 7 ) 14962 ( 7 ) Rates of mNEWS2 scores and mortality for the study population across all study years (N = 202746). Discussion The main findings of this study indicate an overall increase in the total number of patients, with the largest increase seen for urgency level B throughout the study period. Urgency level A had the highest proportion of patients in acute critical condition; however, there was a significant increase in the number of patients in acute critical condition within urgency level B over time. The highest increase in dispatched ambulances was seen for patients in non-critical condition within both urgency level A and B. The age and severe comorbidity increased over the study period, mostly within urgency level B. Mortality was highest with patients in acute critical condition in urgency level A and remained stable over the years across all mNEWS2 subcategories. We found an increase in the number of patients, aligning with trends observed in a similar rural-urban region in Denmark from 2013 to 2022 and in the city of Berlin between 2018 and 2021. ( 1 , 18 , 19 ). In addition to this general rise in number, the data revealed an increase in patient age and a higher prevalence of severe comorbidity within the study population, reflecting a broader demographic shift. We also found that the most patients in acute critical condition were categorized under urgency level A, which aligns with findings from a Danish study, including patients contacting 1-1-2 in 2011, where patient severity was assessed based on case fatality and risk of hospital admission ( 3 ). These findings are in accordance with our study of severity evaluated using a mNEWS2 score. The mNEWS2 has previously been applied in prehospital settings and has been useful in predicting patient outcomes ( 14 , 20 ). As such, it contributes to a more nuanced understanding of the severity of the patient’s clinical condition, using objective measurements obtained by ambulance personnel on scene. Furthermore, we found a trend of more patients in acute critical condition are assigned urgency level B. The reason for this development remains unclear. However, we found that the median age appears to be increasing more within urgency level B compared to urgency level A. It may be speculated that changes in demographics, such as an increasing proportion of older patients and a higher prevalence of multimorbidity, along with atypical symptom presentation or limited resources with the EMS system, could help explain this trend ( 21 – 23 ). Our study revealed mortality among those in acute critical condition, with 25% and 16% within 30 days for urgency levels A and B. This emphasizes the acute critical condition defined by mNEWS2 ≥ 7, and is cause for concern, considering the increase in the number of urgency level B patients in an acute critical condition. Overall, the study’s findings point towards a change in patient demographics, evolving resource demands, and increasing clinical severity, all of which contribute to a growing pressure on the prehospital care system. Limitations We used the mNEWS2 score to assess the severity of patients' conditions, but this approach has certain limitations. Firstly, the score was modified because temperature was omitted as it is not routinely measured in ambulances. Secondly, mNEWS2 does not account for patients' clinical presentation, such as neurological status beyond the level of consciousness, pain, or other investigations, such as electrocardiography. These limitations may lead to patients in acute critical condition, where urgency level A is indicated, being overlooked in our study because they could have had normal or non-critical vital signs. The mNEWS2 score has been used in previous studies to estimate the severity of a patient’s condition, supporting its relevance as a tool in this context despite its limitations ( 14 , 24 , 25 ). Furthermore, we accepted up to two missing vital signs to calculate a mNEWS2 score, resulting in a total of 7,954 (7%) with more than 2 missing NEWS2 scores in urgency level A and 7,483 (9%) in urgency level B. Patients who did not have a full set of vital signs measured in the ambulance had a higher mortality than those categorized as normal, non-critical, or critical. Incomplete documentation of basic vital signs is a known issue across various health care settings ( 26 ). In a U.S.-based trauma study, mortality was more than twice as high among patients with missing prehospital vital signs compared to those with complete registration ( 27 ). Furthermore, research has identified an association between missing vital signs and mortality risk, raising the possibility that a significant proportion of the patients excluded from this study may have already died upon ambulance arrival ( 27 , 28 ). This may indicate that the patients in this study were either too severely ill or injured to be fully assessed or had died before ambulance arrival. As a result, the missing data could impact the results, potentially leading to an underestimation of the number of patients in acute critical condition. To avoid skewing the 0–30 mortality analysis, we applied a 30-day exclusion period. With this approach, the possible overestimation of mortality is reduced by not including the same patients’ deaths multiple times. However, this may have led to an underestimation of mortality in cases where repeated ambulance contacts were close in time before death. This approach aimed to balance these risks by ensuring each patient was represented only once in the mortality analysis, which is also used in other studies ( 29 ). Conclusion The number of patients has increased from 2017 to 2023, as has patient age and comorbidity level. During the years, there were similar proportions of acute critical severity, as well as normal and non-critical severity, showing that the acute severity among prehospital patients has not diminished. The lack of alignment between the level of urgencies and the acuity severity found on scene should be monitored carefully, together with mortality and clinical outcomes. Abbreviations EMS Emergency Medical Services mNEWS2 modified National Early Warning Score 2 ePMR electronic Prehospital Patient Medical Record CPR number Civil Registration Number CI 95% Confidence Interval Declarations Ethics approval and consent to participate The study was registered as part of ongoing research activities in the North Denmark Region (ID F2024- 176). Permission for the handover of relevant variables from the medical records was given by North Denmark Region (ID 1-45-72-4859-24). Registry-based studies that do not involve biological material do not require approval from a Committee on Health Research Ethics. Consent for publication Not applicable Competing interest The authors declare they have no competing interests to declare. Funding details No funding was received for this study. Author Contribution KS, TAL, EFC, and MBS designed the study. KS, TAL, TAK, and MBS managed the data, including data analyses. All authors contributed to interpreting the results. KS drafted the manuscript, and EFC, MBS, and TAL contributed substantially to its revision. All authors approved the final manuscript. Acknowledgement We would like to thank Jakob Nebeling Hedegaard for his contribution to data analysis. Data Availability Because the study involves sensitive patient information, access to non-public data is restricted. Researchers who wish to obtain the data must first seek approval from the Danish Patient Safety Authority. Upon receiving approval, data can then be requested from the Centre for Prehospital and Emergency Care in Aalborg, Denmark. References Møller TP, Jensen JT, Ersbøll AK, Blomberg SNF, Christensen HC. Emergency call utilization over a 10-years period: an observational study in Region Zealand, Denmark, 2013–2022. Scand J Trauma Resusc Emerg Med. 2024;32(1):129. Lowthian JA, Jolley DJ, Curtis AJ, Currell A, Cameron PA, Stoelwinder JU, et al. The challenges of population ageing: accelerating demand for emergency ambulance services by older patients, 1995–2015. Med J Aust. 2011;194(11):574–8. Andersen MS, Johnsen SP, Sørensen JN, Jepsen SB, Hansen JB, Christensen EF. Implementing a nationwide criteria-based emergency medical dispatch system: A register-based follow-up study. Scand J Trauma Resusc Emerg Med. 2013;21(1):53. Booker MJ, Simmonds RL, Purdy S. Patients who call emergency ambulances for primary care problems: a qualitative study of the decision-making process. Emerg Med J EMJ. 2014;31(6):448–52. Coster JE, Turner JK, Bradbury D, Cantrell A. Why Do People Choose Emergency and Urgent Care Services? A Rapid Review Utilizing a Systematic Literature Search and Narrative Synthesis. Acad Emerg Med Off J Soc Acad Emerg Med. 2017;24(9):1137–49. Morley C, Unwin M, Peterson GM, Stankovich J, Kinsman L. Emergency department crowding: A systematic review of causes, consequences and solutions. PLoS ONE. 2018;13(8):e0203316. Dansk Indeks for. Akuthjælp [Danish Index for Emergency Care]. Danske Regioner; 2017. Søvsø MB, Haurum RB, Ebbesen TH, Rasmussen AØ, Ward LM, Mogensen ML, et al. Emergency Call versus General Practitioner Requested Ambulances - Patient Mortality, Disease Severity and Pattern. Clin Epidemiol. 2024;16:513–23. Regionerne - kort. fortalt [The Regions - An Overview] [Internet]. Danske Regioner; 2012 [cited 2025 Mar 31]. Available from: https://www.regioner.dk/media/3066/regionerne-kort-fortalt-2011.pdf Lindskou TA, Mikkelsen S, Christensen EF, Hansen PA, Jørgensen G, Hendriksen OM, et al. The Danish prehospital emergency healthcare system and research possibilities. Scand J Trauma Resusc Emerg Med. 2019;27(1):100. Regionernes KK, Præhospitaldatabasen. Årsrapport 2023 [Prehospital Database. Annual Report 2023] [Internet]. København: Regioneres Kliniske Kvalitetsudviklingsprogram; 2024 Dec p. 61. Available from: https://www.sundk.dk/media/xnkhxlnq/praeshospitalsdatabasen-2023.pdf Von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet. 2007;370(9596):1453–7. Rosenkrantz O, Benson C, Lindskou T, Fuglsang C, Pedersen L, Mikkelsen S, et al. Existing Data Sources in Clinical Epidemiology: The Danish Prehospital Medical Record System. Clin Epidemiol. 2025;17:735–45. Sørensen MC, Søvsø MB, Christensen EF, Lindskou TA. Critically deviating vital signs among patients with non-specific diagnoses-A register-based historic cohort study. PLoS ONE. 2023;18(11):e0293762. Luís L, Nunes C. Short National Early Warning Score - Developing a Modified Early Warning Score. Aust Crit Care Off J Confed Aust Crit Care Nurses. 2018;31(6):376–81. Hansen FG, Lind PC, Stankovic N, Holmberg MJ, Andersen LW, Granfeldt A. Vital signs preceding in-hospital cardiac arrest: a matched case-control study. Resuscitation. 2025;215:110778. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40(5):373–83. Herr D, Bhatia S, Breuer F, Poloczek S, Pommerenke C, Dahmen J. Increasing emergency number utilisation is not driven by low-acuity calls: an observational study of 1.5 million emergency calls (2018–2021) from Berlin. BMC Med. 2023;21(1):184. Christensen EF, Bendtsen MD, Larsen TM, Jensen FB, Lindskou TA, Holdgaard HO, et al. Trends in diagnostic patterns and mortality in emergency ambulance service patients in 2007–2014: a population-based cohort study from the North Denmark Region. BMJ Open. 2017;7(8):e014508. Martín-Rodríguez F, Sanz-García A, Ortega GJ, Delgado Benito JF, Aparicio Obregon S, Martínez Fernández FT, et al. Tracking the National Early Warning Score 2 from Prehospital Care to the Emergency Department: A Prospective, Ambulance-Based, Observational Study. Prehosp Emerg Care. 2023;27(1):75–83. Hortmann M, Singler K, Geier F, Christ M. Recognition of infections in elderly emergency patients. Z Gerontol Geriatr. 2015;48(7):601–7. Walsh EE, Cox C, Falsey AR. Clinical features of influenza A virus infection in older hospitalized persons. J Am Geriatr Soc. 2002;50(9):1498–503. Lars Sortland LM, Haraldseide. Ingrid Sebjørnsen. Eldre i den akuttmedisinske kjeden [Elderly in the Emergency Medical Chain]. Bergen: Nasjonalt kompetansesenter for legevaktmedisin, NORCE Norwegian Research Centre; 2021. Report No.: 1–2021. Myrstad M, Ihle-Hansen H, Tveita AA, Andersen EL, Nygård S, Tveit A, et al. National Early Warning Score 2 (NEWS2) on admission predicts severe disease and in-hospital mortality from Covid-19 - a prospective cohort study. Scand J Trauma Resusc Emerg Med. 2020;28(1):66. Holland M, Kellett J. A systematic review of the discrimination and absolute mortality predicted by the National Early Warning Scores according to different cut-off values and prediction windows. Eur J Intern Med. 2022;98:15–26. Kjær J, Milling L, Wittrock D, Nielsen LB, Mikkelsen S. The data quality and applicability of a Danish prehospital electronic health record: A mixed-methods study. PLoS ONE. 2023;18(10):e0293577. Laudermilch DJ, Schiff MA, Nathens AB, Rosengart MR. Lack of emergency medical services documentation is associated with poor patient outcomes: a validation of audit filters for prehospital trauma care. J Am Coll Surg. 2010;210(2):220–7. Petersen M, Kjeldtoft FG, Christensen EF, Bøggild H, Lindskou TA. A classification system for identifying patients dead on ambulance arrival: a prehospital medical record review. Scand J Trauma Resusc Emerg Med. 2023;31(1):107. Ibsen S, Lindskou TA, Nickel CH, Kløjgård T, Christensen EF, Søvsø MB. Which symptoms pose the highest risk in patients calling for an ambulance? A population-based cohort study from Denmark. Scand J Trauma Resusc Emerg Med. 2021;29(1):59. Additional Declarations No competing interests reported. Supplementary Files Additionalfile1.docx Additionalfile2.docx Additionalfile3.docx Cite Share Download PDF Status: Under Revision Version 1 posted Editorial decision: Revision requested 26 Apr, 2026 Reviews received at journal 26 Apr, 2026 Reviews received at journal 25 Apr, 2026 Reviewers agreed at journal 21 Apr, 2026 Reviewers agreed at journal 20 Apr, 2026 Reviewers invited by journal 23 Feb, 2026 Editor assigned by journal 16 Feb, 2026 Submission checks completed at journal 16 Feb, 2026 First submitted to journal 16 Feb, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8891109","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":598133220,"identity":"e21882db-8a0b-4372-a57f-cbdc99bb351a","order_by":0,"name":"Kristine Sørensen","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABBklEQVRIiWNgGAWjYBACCQbGBgYGAxQx5gMgwgCbcriWA6jSbAkEtADBAVQxHgO8WiRnH27+/KHgjhwD/+GDjysq7tjzS/d8+1zAYG2MS4s0X2KbxAGDZ8YMEmnJhmfOPEucOefs5tkzGNLNcGmR42FsA/rlcGKDBI+ZZGPb4QSDG7mbmXkYDtvg0dL8AailvoH/jPnPxn+H7e1v5DzGq0Wah7EB6LDDCQwMOWaMjQ2HGTdI5DCDtOB0mGQPY5vEGYPDhm1Av0g2HDucOONGmjEzj0E6Tu9LnGF//KHiz2F5fmCIfWyoOWzPPyMZ6LAKa8MGXHpggA2VizNWRsEoGAWjYBQQAwAoQlIyGxaLCQAAAABJRU5ErkJggg==","orcid":"","institution":"Aalborg University Hospital","correspondingAuthor":true,"prefix":"","firstName":"Kristine","middleName":"","lastName":"Sørensen","suffix":""},{"id":598133226,"identity":"0b2d18b5-af44-435f-b472-f76351b246ac","order_by":1,"name":"Torben Anders Kløjgård","email":"","orcid":"","institution":"Aalborg University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Torben","middleName":"Anders","lastName":"Kløjgård","suffix":""},{"id":598133230,"identity":"b4181f97-bb45-4430-8a3b-0c41b4c94e4b","order_by":2,"name":"Erika Frischknecht Christensen","email":"","orcid":"","institution":"Aalborg University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Erika","middleName":"Frischknecht","lastName":"Christensen","suffix":""},{"id":598133232,"identity":"4c6bf1cf-447e-4aae-9eb8-9601fd00870a","order_by":3,"name":"Tim Alex Lindskou","email":"","orcid":"","institution":"Aalborg University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Tim","middleName":"Alex","lastName":"Lindskou","suffix":""},{"id":598133234,"identity":"a836ce4a-3198-454b-9892-2b24d2b77895","order_by":4,"name":"Morten Breinholt Søvsø","email":"","orcid":"","institution":"Aalborg University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Morten","middleName":"Breinholt","lastName":"Søvsø","suffix":""}],"badges":[],"createdAt":"2026-02-16 08:23:04","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8891109/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8891109/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":103806608,"identity":"2bdb1a2d-8880-4578-9eb7-47ad53ecdf9b","added_by":"auto","created_at":"2026-03-03 07:26:14","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":70836,"visible":true,"origin":"","legend":"\u003cp\u003eFigure 1:\u003cstrong\u003e \u003c/strong\u003eFlow Diagram of Patient Inclusion\u003c/p\u003e\n\u003cp\u003eFigure 1 legend:\u003cstrong\u003e \u003c/strong\u003eFlow diagram of included and excluded patient contacts from January 1, 2017, to December 31, 2023.\u003c/p\u003e","description":"","filename":"Figure1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8891109/v1/c6739dc40a84068e58502ccf.jpeg"},{"id":103806564,"identity":"b5234acb-bd74-4542-9756-b32a91de31b4","added_by":"auto","created_at":"2026-03-03 07:26:03","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":399597,"visible":true,"origin":"","legend":"\u003cp\u003eFigure 2: Patients by Urgency Level (A and B, 2017-2023)\u003c/p\u003e\n\u003cp\u003eFigure 2 legend: Linear relationship between the number of patients within urgency level A and B over years reported as quarters.\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-8891109/v1/ab7dee2eb5bd50aaf1b6ff7a.png"},{"id":103806826,"identity":"bd4c61e3-0c6a-4aa3-ad09-2a2ff8a54fcf","added_by":"auto","created_at":"2026-03-03 07:27:14","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":402217,"visible":true,"origin":"","legend":"\u003cp\u003eFigure 3X: Trend in Acute Critical Condition Across Urgency Levels A and B\u003c/p\u003e\n\u003cp\u003eFigure 3X legend: Linear relationship between the increase in patients with acute critical condition (X) (n = 25,473) within urgency level A and urgency level B over the years.\u003c/p\u003e","description":"","filename":"Figure3X.png","url":"https://assets-eu.researchsquare.com/files/rs-8891109/v1/f4408472295c75787a0a669a.png"},{"id":103806563,"identity":"5f0a0979-cd8c-49eb-be4b-eebe36b39b49","added_by":"auto","created_at":"2026-03-03 07:26:03","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":462590,"visible":true,"origin":"","legend":"\u003cp\u003eFigure 3Y: Trend in Non-critical Condition Across Urgency Levels A and B\u003c/p\u003e\n\u003cp\u003eFigure 3Y legend: Linear relationship between the increase in patients with non-critically condition (Y) (n = 161,836) patients within urgency level A and urgency level B over the years.\u003c/p\u003e","description":"","filename":"Figure3Y.png","url":"https://assets-eu.researchsquare.com/files/rs-8891109/v1/975af415c95bdc9286f32762.png"},{"id":103806414,"identity":"c869009c-5289-4ad2-8f80-0aa8c75e5eaf","added_by":"auto","created_at":"2026-03-03 07:25:19","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":316558,"visible":true,"origin":"","legend":"\u003cp\u003eFigure 4: Kaplan-Meier Plot of Survival\u003c/p\u003e\n\u003cp\u003eFigure 4 legend: Kaplan Meier plot showing the survival days after the patients were assessed in acute critical condition and non-critical condition within urgency level A and B (n= 202,746).\u003c/p\u003e","description":"","filename":"Figure4.png","url":"https://assets-eu.researchsquare.com/files/rs-8891109/v1/c51707c2fb996398227ef069.png"},{"id":103806988,"identity":"35d946ed-dfab-4f4f-a2b1-6201359453d9","added_by":"auto","created_at":"2026-03-03 07:27:52","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2377106,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8891109/v1/6336f201-ec7d-4cf0-b898-e285c16b6624.pdf"},{"id":103806538,"identity":"f9846ab0-a308-4460-a1bc-6d352d02aad9","added_by":"auto","created_at":"2026-03-03 07:25:59","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":34779,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfile1.docx","url":"https://assets-eu.researchsquare.com/files/rs-8891109/v1/e45b5cdea3351b491ea0c641.docx"},{"id":103806781,"identity":"98790d79-b201-437d-9520-c9473fab581c","added_by":"auto","created_at":"2026-03-03 07:26:43","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":37400,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfile2.docx","url":"https://assets-eu.researchsquare.com/files/rs-8891109/v1/6fdd1078008b54e982c34af8.docx"},{"id":103806706,"identity":"965cab8f-3f9a-4696-b6bd-c5239ecba54a","added_by":"auto","created_at":"2026-03-03 07:26:25","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":37906,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfile3.docx","url":"https://assets-eu.researchsquare.com/files/rs-8891109/v1/a68f7f828641e3922bc89701.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Trends in Urgency Levels and Risk of Acute Critical Condition Among Prehospital Patients. A Seven-Year Observational Historic Register-Based Cohort Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAs in the Western world, the number of patients requesting an ambulance has increased in Denmark (\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e), most likely due to the increasingly ageing population living with more comorbidities and needing urgent help. Difficulties when navigating the acute health care system may play a part (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e), and some studies indicate a lower threshold for calling the EMS (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e), implying a decrease in the severity of the EMS patients\u0026rsquo; clinical conditions over time.\u003c/p\u003e \u003cp\u003eWhen calling the Emergency Medical Services (EMS) for an ambulance, the call is assessed to identify the main symptom/injury and triaged to determine how fast a response is needed, and if it is needed at all. In Denmark, the highest level of urgency is A (blue lights and sirens), primarily intended for potential life-threatening or disabling conditions (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e), while level B is for urgent, but not potentially life-threatening or disabling conditions. The assessment is based on telephone triage and, therefore, limited to the caller\u0026rsquo;s information and can prove complex.\u003c/p\u003e \u003cp\u003eIn a recent Danish study on ambulance patients, the severity of the presenting condition among younger and older patients (66 years and above) was assessed by a modified National Early Warning Score 2 (NEWS2). The older patients displayed a higher median score, indicating that more patients are critically affected by their acute conditions with age, potentially resulting in more EMS calls (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eGiven the increasing demand and complexity in EMS calls, it is essential to explore the telephone assessed triage and the patients\u0026rsquo; actual clinical conditions.\u003c/p\u003e \u003cp\u003eAs such, our aim was to examine the development over the years in the number and urgency levels of ambulances and the actual acute disease severity, as indicated by initial vital signs measured on scene, together with patient demographics, comorbidity, and mortality trends over time.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and patient population\u003c/h2\u003e \u003cp\u003eThis observational, historic register-based cohort study included all patients aged 18 years or older in the North Denmark Region who received an ambulance dispatch following a national emergency number (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) call between January 1, 2017, and December 31, 2023.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSetting\u003c/h3\u003e\n\u003cp\u003eThe North Denmark Region has 579,787 inhabitants and consists of both urban and rural areas (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Calls to the national emergency number, 1-1-2, involving medical emergencies in Denmark have been forwarded by the police to an Emergency Medical Coordination Centre. Here, health care professionals evaluate the situation using the Danish Index for Emergency Care to determine the appropriate urgency level of ambulance response (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). The index was designed to assist health care professionals in making fast and qualified decisions regarding the main reason for calling and the urgency level of ambulance response. During the 1-1-2 call, the health care professionals can use the index to identify one of 37 possible main symptoms or injuries to determine the appropriate urgency level for the ambulance response. There are five different urgency levels: A) life-threatening or potentially life-threatening conditions, B) urgent but not life-threatening conditions, C) non-urgent conditions that require an ambulance, D) non-urgent conditions requiring supine patient transport, and E) conditions requiring medical advice only (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). For ambulances dispatched following 1-1-2 calls in the North Denmark Region, the vast majority were assigned urgency level A (49%) and B (39%) in 2023\u0026ndash;2024 (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003eStudy population\u003c/h3\u003e\n\u003cp\u003eThe patients were identified through the electronic Prehospital Patient Medical Record (ePMR). If a patient received more than one ambulance during this period, they would appear in the dataset multiple times, except in mortality analyses. Patients were excluded if the Danish Index for Emergency Care was missing, if the urgency level was classified as C, D, or E, as this study focuses on acute patients, or if the civil registration number was missing or invalid. The study\u0026rsquo;s findings are reported in accordance with the STROBE statement (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003eData sources and variables\u003c/h3\u003e\n\u003cp\u003eData on the Danish Index for Emergency Care criteria, urgency level, and Civil Registration Number (CPR number) were extracted from the ePMR (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). In addition, the level of acute disease severity according to the modified NEWS2 (mNEWS2) score was likewise derived from ePMR data. The mNEWS2 is based on initial vital parameters at the ambulance\u0026rsquo;s arrival (pulse, respiratory rate, Glasgow Coma Scale, blood pressure, oxygen saturation, and oxygen treatment) (\u003cspan additionalcitationids=\"CR15\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e) (Additional file 1). In cases with two or fewer missing vital signs, the missing vital signs were considered to be normal, i.e., not contributing to an increase in severity according to the mNEWS2 score. Otherwise, cases with more than two missing vital signs were considered incomplete registrations and omitted from analysis. The mNEWS2 was stratified into four groups: \u003cem\u003enormal vital signs\u003c/em\u003e (NEWS2\u0026thinsp;=\u0026thinsp;0), \u003cem\u003enon-critical condition\u003c/em\u003e (NEWS2 1\u0026ndash;6), \u003cem\u003ecritical condition\u003c/em\u003e (NEWS2\u0026thinsp;\u0026ge;\u0026thinsp;7), and \u003cem\u003eincomplete registration\u003c/em\u003e.\u003c/p\u003e \u003cp\u003eComorbidity was assessed using a modified Charlson Comorbidity Index, based on previous diagnoses (5 years); however, we did not exclude current diagnoses associated with the emergency call (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). The modified comorbidity was divided into three groups based on the number of comorbidities from the Charlson Comorbidity Index: \u003cem\u003eno comorbidity\u003c/em\u003e (comorbidity 0), \u003cem\u003emoderate comorbidity\u003c/em\u003e (comorbidity 1\u0026ndash;2), and \u003cem\u003esevere comorbidity\u003c/em\u003e (comorbidity\u0026thinsp;\u0026ge;\u0026thinsp;3). Data on previous diagnoses were obtained from the in-hospital electronic medical record.\u003c/p\u003e \u003cp\u003eIn Denmark, all citizens have a unique CPR number, which includes information on the individual\u0026rsquo;s age, sex, and vital status, and is used to retrieve data on their vital status. Data on patients\u0026rsquo; age, sex, and vital status were obtained from the Danish Civil Registration System.\u003c/p\u003e \u003cp\u003eMortality was assessed up to 30 days after the final date of the study to ensure full follow-up.\u003c/p\u003e\n\u003ch3\u003eOutcome\u003c/h3\u003e\n\u003cp\u003eThe primary outcomes were levels of urgency and acute disease severity. Patient characteristics, including age, comorbidity, and 0\u0026ndash;1-day, 2\u0026ndash;7-day, and 0\u0026ndash;30-day mortality, were described.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStatistics\u003c/h2\u003e \u003cp\u003eDescriptive analyses were performed on the patient population with the total number, median, and percentages.\u003c/p\u003e \u003cp\u003eThe trend in urgency levels A and B during the study period (divided into quarters of each included year) was evaluated by linear regression, presented with a 95% confidence interval (CI).\u003c/p\u003e \u003cp\u003eFor the statistical analyses of disease severity, we divided the mNEWS2 score into two groups: \u003cem\u003enon-critical condition\u003c/em\u003e (\u003cem\u003enormal vital signs\u003c/em\u003e and \u003cem\u003enon-critical condition\u003c/em\u003e, mNEWS2\u0026thinsp;\u0026lt;\u0026thinsp;7) and \u003cem\u003ecritical condition\u003c/em\u003e (\u003cem\u003ecritical condition\u003c/em\u003e, mNEWS2\u0026thinsp;\u0026ge;\u0026thinsp;7). As such, linear regression analyses were performed to assess trends in patient volume across acute critically and non-critically conditions assigned to urgency level A and B, respectively. P-values of \u0026lt;\u0026thinsp;0.05 were considered statistically significant. Incomplete registration of mNEWS2 scores (cases with more than two missing vital signs) was excluded from analysis.\u003c/p\u003e \u003cp\u003eFor mortality analysis, a 30-day exclusion period was applied in the 0\u0026ndash;30-day mortality for patients with more than one emergency call. This meant that if a patient had multiple calls within a 30-day window, only the first call was included in the analysis.\u003c/p\u003e \u003cp\u003eAll analyses were performed using the STATA statistical software version 18.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eDuring the seven-year study period, a total of 245,266 patient contacts resulted in an ambulance dispatch. Excluding those without a valid CPR number and those under 18 years (34,418), those without a Danish Index category (5,615), and other urgency levels than A or B (2,487) resulted in a total of 202,746 included patient contacts. In this context, each contact is referred to as a \u0026ldquo;patient,\u0026rdquo; regardless of whether the same individual had multiple contacts. The 202,746 patient contacts represented 118,740 unique individuals.\u003c/p\u003e \u003cp\u003eOverall, urgency level A was most frequent, accounting for 59% compared to level B (41%). For urgency level A, the proportion of patients in acute critical condition was twice as high when compared to level B (16% vs 8%, respectively) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The median age and the number of patients with severe comorbidity increased from 2017 to 2023 for both urgency level A and B, with a larger increase in urgency level B. (Additional file 2). The number of deaths within 0\u0026ndash;1, 2\u0026ndash;7, and 0\u0026ndash;30 days was also approximately twice as high among urgency level A compared to level B (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatient characteristics by urgency level\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUrgency level A\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUrgency level B\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAll\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e118816 (59)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e83930 (41)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e202746 (100)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemales n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e52952 (45)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40471 (48)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e93423 (46)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e65 (48\u0026ndash;78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e65 (43\u0026ndash;78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e65 (46\u0026ndash;78)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003emNEWS2, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eNormal\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25246 (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22010 (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e47256 (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eNon-critical\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e66643 (56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47937 (57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e114580 (57)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eCritical\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18973 (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6500 (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25473 (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eIncomplete\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7954 (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7483 (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15437 (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eComorbidity n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eNone\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e61200 (52)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51624 (62)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e112824 (56)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eModerate\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41761 (35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23446 (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e65207 (32)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eSevere\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15855 (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8860 (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24715 (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDeaths, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e0\u0026ndash;1 days\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5663 (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1775 (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7434 (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e2\u0026ndash;7 days\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2262 (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e867 (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3129 (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e0\u0026ndash;30 days\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10770 (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4192 (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14962 (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eOutcome rates, sex, age, comorbidity and mortality for all patients (N\u0026thinsp;=\u0026thinsp;202746)\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003eUrgency level and severity of the patient’s condition\u003c/h3\u003e\n\u003cp\u003eThe number of patients assigned with urgency level A and B increased significantly over the study period, with 67.1 (95% CI: 43.6\u0026ndash;90.6) and 189.7 (95% CI: 153.2\u0026ndash;226.2) patients per quarter, respectively. The largest increase was among patients with urgency level B (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eOver the seven-year study period, the proportion of patients in acute critical condition within each urgency level was stable (Urgency level A: 15\u0026ndash;17%, Urgency level B: 7\u0026ndash;8%) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eTrends in mNEWS2 and mortality across urgency levels A and B over time\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"9\" nameend=\"c9\" namest=\"c1\"\u003e \u003cp\u003eUrgency level A \u003cem\u003en\u0026thinsp;=\u0026thinsp;118828\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16245 (62)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17170 (61)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16090 (59)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e16355 (61)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e17096 (58)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e17853 (55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e18007 (55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e118816 (59)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003emNEWS2, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eNormal\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3347 (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3525 (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3290 (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3549 (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3876 (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3790 (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e3869 (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e25246 (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eNon-critical\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9080 (56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9506 (55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8993 (56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9221 (56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e9502 (56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e10086 (56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e10255 (57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e66643 (56)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eCritical\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2494 (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2818 (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2684 (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2447 (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2640 (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2901 (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2989 (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e18973 (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eIncomplete\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1324 (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1321 (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1123 (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1138 (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1078 (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1076 (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e894 (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e7954 (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDeaths, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e0\u0026ndash;1 days\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e812 (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e908 (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e766 (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e754 (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e816 (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e848 (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e759 (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e5663 (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e2\u0026ndash;7 days\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e287 (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e327 (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e278 (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e303 (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e324 (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e377 (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e366 (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e2262 (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e0\u0026ndash;30 days\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1470 (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1640 (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1409 (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1442 (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1558 (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1677 (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1574 (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e10770 (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"9\" nameend=\"c9\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eUrgency level B\u003c/b\u003e \u003cb\u003en\u0026thinsp;=\u0026thinsp;83943\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9819 (38)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11191 (39)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11081 (41)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10564 (39)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e12451 (42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e14344 (45)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e14480 (45)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e83930 (41)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003emNEWS2, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eNormal\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2675 (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2998 (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2895 (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2890 (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3338 (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3550 (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e3664 (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e22010 (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eNon-critical\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5562 (57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6335 (57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6452 (58)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6032 (57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e7042 (57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e8289 (58)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e8225 (57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e47937 (57)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eCritical\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e647 (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e798 (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e835 (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e776 (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1003 (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1225 (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1216 (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e6500 (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eIncomplete\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e935 (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1060 (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e899 (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e866 (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1068 (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1280 (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1375 (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e7483 (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDeaths, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e0\u0026ndash;1 days\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e163 (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e215 (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e223 (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e237 (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e289 (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e337 (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e311 (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1775 (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e2\u0026ndash;7 days\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e77 (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e102 (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e118 (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e103 (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e118 (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e185 (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e164 (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e867 (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e0\u0026ndash;30 days\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e391 (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e506 (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e525 (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e549 (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e642 (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e804 (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e775 (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e4192 (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"9\" nameend=\"c9\" namest=\"c1\"\u003e \u003cp\u003eRates of mNEWS2 scores and mortality stratified by urgency levels A and B across all study years (N\u0026thinsp;=\u0026thinsp;202746).\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eEvaluated by linear regression, the number of patients in acute critical condition within urgency level A increased (not significant) by 3.6 (95% CI 0.7\u0026ndash;6.6) per quarter, and for patients in acute critical condition within urgency level B (significant) by 6.1 (95% CI 4.4\u0026ndash;7.8) per quarter (Fig.\u0026nbsp;\u003cspan refid=\"Fig8\" class=\"InternalRef\"\u003e3\u003c/span\u003e, X). For patients in non-critical condition among both urgency level A and B, the increase over the years was significant, with respectively 18.6 (95%CI 10.7\u0026ndash;26.6) per quarter and 39 (95%CI 28.6\u0026ndash;49.5) per quarter (Fig.\u0026nbsp;\u003cspan refid=\"Fig8\" class=\"InternalRef\"\u003e3\u003c/span\u003e, Y).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eMortality\u003c/h2\u003e \u003cp\u003eOver the years, the proportion of deaths within 0\u0026ndash;1, 2\u0026ndash;7, and 0\u0026ndash;30 days remained stable (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAmong patients with a critical mNEWS2 score, the 0\u0026ndash;30 mortality was 5,758 (23%) deaths, and among patients with a non-critical mNEWS2 score, it was 4,217 (4%) deaths (Additional file 3).\u003c/p\u003e \u003cp\u003eAmong patients with a critical mNEWS2 score within urgency level A, the 0-30-day mortality was 4,712 (25%) deaths, and among patients within urgency level B, it was 1,046 (16%) deaths. Among patients with an incomplete registration of mNEWS2, it was 4,509 (29%) (Fig.\u0026nbsp;\u003cspan refid=\"Fig10\" class=\"InternalRef\"\u003e4\u003c/span\u003e) (Additional file 3).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eTrends in mNEWS2 and mortality across the study population over time\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYear\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2017\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2018\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2019\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2020\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2021\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2022\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2023\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"9\" nameend=\"c9\" namest=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26064 (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28361 (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27171 (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e26919 (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e29547 (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e32197 (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e32487 (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e202746 (100)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003emNEWS2, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eNormal\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6022 (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6523 (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6185 (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6439 (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e7214 (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e7340 (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e7533 (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e47256 (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eNon-critical\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14642 (56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15841 (56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15445 (57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e15253 (57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e16544 (56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e18375 (57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e18480 (57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e114580 (57)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eCritical\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3141 (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3616 (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3519 (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3223 (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3643 (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e4126 (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e4205 (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e25473 (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eIncomplete\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2259 (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2381 (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2022 (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2004 (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2146 (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2356 (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2269 (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e15437 (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDeaths, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e0\u0026ndash;1 days\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e975 (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1123 (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e989 (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e991 (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1105 (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1185 (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1070 (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e7438 (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e2\u0026ndash;7 days\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e364 (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e429 (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e396 (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e406 (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e442 (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e562 (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e530 (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e3129 (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e0\u0026ndash;30 days\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1861 (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2146 (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1934 (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1991 (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2200 (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2481 (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2349 (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e14962 (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"9\" nameend=\"c9\" namest=\"c1\"\u003e \u003cp\u003eRates of mNEWS2 scores and mortality for the study population across all study years (N\u0026thinsp;=\u0026thinsp;202746).\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe main findings of this study indicate an overall increase in the total number of patients, with the largest increase seen for urgency level B throughout the study period. Urgency level A had the highest proportion of patients in acute critical condition; however, there was a significant increase in the number of patients in acute critical condition within urgency level B over time. The highest increase in dispatched ambulances was seen for patients in non-critical condition within both urgency level A and B. The age and severe comorbidity increased over the study period, mostly within urgency level B. Mortality was highest with patients in acute critical condition in urgency level A and remained stable over the years across all mNEWS2 subcategories.\u003c/p\u003e \u003cp\u003eWe found an increase in the number of patients, aligning with trends observed in a similar rural-urban region in Denmark from 2013 to 2022 and in the city of Berlin between 2018 and 2021. (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). In addition to this general rise in number, the data revealed an increase in patient age and a higher prevalence of severe comorbidity within the study population, reflecting a broader demographic shift.\u003c/p\u003e \u003cp\u003eWe also found that the most patients in acute critical condition were categorized under urgency level A, which aligns with findings from a Danish study, including patients contacting 1-1-2 in 2011, where patient severity was assessed based on case fatality and risk of hospital admission (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). These findings are in accordance with our study of severity evaluated using a mNEWS2 score. The mNEWS2 has previously been applied in prehospital settings and has been useful in predicting patient outcomes (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). As such, it contributes to a more nuanced understanding of the severity of the patient\u0026rsquo;s clinical condition, using objective measurements obtained by ambulance personnel on scene.\u003c/p\u003e \u003cp\u003eFurthermore, we found a trend of more patients in acute critical condition are assigned urgency level B. The reason for this development remains unclear. However, we found that the median age appears to be increasing more within urgency level B compared to urgency level A. It may be speculated that changes in demographics, such as an increasing proportion of older patients and a higher prevalence of multimorbidity, along with atypical symptom presentation or limited resources with the EMS system, could help explain this trend (\u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Our study revealed mortality among those in acute critical condition, with 25% and 16% within 30 days for urgency levels A and B. This emphasizes the acute critical condition defined by mNEWS2\u0026thinsp;\u0026ge;\u0026thinsp;7, and is cause for concern, considering the increase in the number of urgency level B patients in an acute critical condition. Overall, the study\u0026rsquo;s findings point towards a change in patient demographics, evolving resource demands, and increasing clinical severity, all of which contribute to a growing pressure on the prehospital care system.\u003c/p\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eWe used the mNEWS2 score to assess the severity of patients' conditions, but this approach has certain limitations. Firstly, the score was modified because temperature was omitted as it is not routinely measured in ambulances. Secondly, mNEWS2 does not account for patients' clinical presentation, such as neurological status beyond the level of consciousness, pain, or other investigations, such as electrocardiography. These limitations may lead to patients in acute critical condition, where urgency level A is indicated, being overlooked in our study because they could have had normal or non-critical vital signs. The mNEWS2 score has been used in previous studies to estimate the severity of a patient\u0026rsquo;s condition, supporting its relevance as a tool in this context despite its limitations (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFurthermore, we accepted up to two missing vital signs to calculate a mNEWS2 score, resulting in a total of 7,954 (7%) with more than 2 missing NEWS2 scores in urgency level A and 7,483 (9%) in urgency level B. Patients who did not have a full set of vital signs measured in the ambulance had a higher mortality than those categorized as normal, non-critical, or critical. Incomplete documentation of basic vital signs is a known issue across various health care settings (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). In a U.S.-based trauma study, mortality was more than twice as high among patients with missing prehospital vital signs compared to those with complete registration (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Furthermore, research has identified an association between missing vital signs and mortality risk, raising the possibility that a significant proportion of the patients excluded from this study may have already died upon ambulance arrival (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). This may indicate that the patients in this study were either too severely ill or injured to be fully assessed or had died before ambulance arrival. As a result, the missing data could impact the results, potentially leading to an underestimation of the number of patients in acute critical condition.\u003c/p\u003e \u003cp\u003eTo avoid skewing the 0\u0026ndash;30 mortality analysis, we applied a 30-day exclusion period. With this approach, the possible overestimation of mortality is reduced by not including the same patients\u0026rsquo; deaths multiple times. However, this may have led to an underestimation of mortality in cases where repeated ambulance contacts were close in time before death. This approach aimed to balance these risks by ensuring each patient was represented only once in the mortality analysis, which is also used in other studies (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe number of patients has increased from 2017 to 2023, as has patient age and comorbidity level. During the years, there were similar proportions of acute critical severity, as well as normal and non-critical severity, showing that the acute severity among prehospital patients has not diminished. The lack of alignment between the level of urgencies and the acuity severity found on scene should be monitored carefully, together with mortality and clinical outcomes.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eEMS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEmergency Medical Services\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003emNEWS2\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003emodified National Early Warning Score 2\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eePMR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eelectronic Prehospital Patient Medical Record\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCPR number\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCivil Registration Number\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e95% Confidence Interval\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e \u003cp\u003eThe study was registered as part of ongoing research activities in the North Denmark Region (ID F2024- 176). Permission for the handover of relevant variables from the medical records was given by North Denmark Region (ID 1-45-72-4859-24). Registry-based studies that do not involve biological material do not require approval from a Committee on Health Research Ethics.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003eNot applicable\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eCompeting interest\u003c/h2\u003e \u003cp\u003eThe authors declare they have no competing interests to declare.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003edetails\u003c/p\u003e \u003cp\u003eNo funding was received for this study.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eKS, TAL, EFC, and MBS designed the study. KS, TAL, TAK, and MBS managed the data, including data analyses. All authors contributed to interpreting the results. KS drafted the manuscript, and EFC, MBS, and TAL contributed substantially to its revision. All authors approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe would like to thank Jakob Nebeling Hedegaard for his contribution to data analysis.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eBecause the study involves sensitive patient information, access to non-public data is restricted. Researchers who wish to obtain the data must first seek approval from the Danish Patient Safety Authority. Upon receiving approval, data can then be requested from the Centre for Prehospital and Emergency Care in Aalborg, Denmark.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eM\u0026oslash;ller TP, Jensen JT, Ersb\u0026oslash;ll AK, Blomberg SNF, Christensen HC. Emergency call utilization over a 10-years period: an observational study in Region Zealand, Denmark, 2013\u0026ndash;2022. Scand J Trauma Resusc Emerg Med. 2024;32(1):129.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLowthian JA, Jolley DJ, Curtis AJ, Currell A, Cameron PA, Stoelwinder JU, et al. The challenges of population ageing: accelerating demand for emergency ambulance services by older patients, 1995\u0026ndash;2015. Med J Aust. 2011;194(11):574\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAndersen MS, Johnsen SP, S\u0026oslash;rensen JN, Jepsen SB, Hansen JB, Christensen EF. Implementing a nationwide criteria-based emergency medical dispatch system: A register-based follow-up study. Scand J Trauma Resusc Emerg Med. 2013;21(1):53.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBooker MJ, Simmonds RL, Purdy S. Patients who call emergency ambulances for primary care problems: a qualitative study of the decision-making process. Emerg Med J EMJ. 2014;31(6):448\u0026ndash;52.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCoster JE, Turner JK, Bradbury D, Cantrell A. Why Do People Choose Emergency and Urgent Care Services? A Rapid Review Utilizing a Systematic Literature Search and Narrative Synthesis. Acad Emerg Med Off J Soc Acad Emerg Med. 2017;24(9):1137\u0026ndash;49.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMorley C, Unwin M, Peterson GM, Stankovich J, Kinsman L. Emergency department crowding: A systematic review of causes, consequences and solutions. PLoS ONE. 2018;13(8):e0203316.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDansk Indeks for. Akuthj\u0026aelig;lp [Danish Index for Emergency Care]. Danske Regioner; 2017.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eS\u0026oslash;vs\u0026oslash; MB, Haurum RB, Ebbesen TH, Rasmussen A\u0026Oslash;, Ward LM, Mogensen ML, et al. Emergency Call versus General Practitioner Requested Ambulances - Patient Mortality, Disease Severity and Pattern. Clin Epidemiol. 2024;16:513\u0026ndash;23.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRegionerne - kort. fortalt [The Regions - An Overview] [Internet]. Danske Regioner; 2012 [cited 2025 Mar 31]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.regioner.dk/media/3066/regionerne-kort-fortalt-2011.pdf\u003c/span\u003e\u003cspan address=\"https://www.regioner.dk/media/3066/regionerne-kort-fortalt-2011.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLindskou TA, Mikkelsen S, Christensen EF, Hansen PA, J\u0026oslash;rgensen G, Hendriksen OM, et al. The Danish prehospital emergency healthcare system and research possibilities. Scand J Trauma Resusc Emerg Med. 2019;27(1):100.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRegionernes KK, Pr\u0026aelig;hospitaldatabasen. \u0026Aring;rsrapport 2023 [Prehospital Database. Annual Report 2023] [Internet]. K\u0026oslash;benhavn: Regioneres Kliniske Kvalitetsudviklingsprogram; 2024 Dec p. 61. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.sundk.dk/media/xnkhxlnq/praeshospitalsdatabasen-2023.pdf\u003c/span\u003e\u003cspan address=\"https://www.sundk.dk/media/xnkhxlnq/praeshospitalsdatabasen-2023.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVon Elm E, Altman DG, Egger M, Pocock SJ, G\u0026oslash;tzsche PC, Vandenbroucke JP. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet. 2007;370(9596):1453\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRosenkrantz O, Benson C, Lindskou T, Fuglsang C, Pedersen L, Mikkelsen S, et al. Existing Data Sources in Clinical Epidemiology: The Danish Prehospital Medical Record System. Clin Epidemiol. 2025;17:735\u0026ndash;45.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eS\u0026oslash;rensen MC, S\u0026oslash;vs\u0026oslash; MB, Christensen EF, Lindskou TA. Critically deviating vital signs among patients with non-specific diagnoses-A register-based historic cohort study. PLoS ONE. 2023;18(11):e0293762.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLu\u0026iacute;s L, Nunes C. Short National Early Warning Score - Developing a Modified Early Warning Score. Aust Crit Care Off J Confed Aust Crit Care Nurses. 2018;31(6):376\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHansen FG, Lind PC, Stankovic N, Holmberg MJ, Andersen LW, Granfeldt A. Vital signs preceding in-hospital cardiac arrest: a matched case-control study. Resuscitation. 2025;215:110778.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCharlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40(5):373\u0026ndash;83.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHerr D, Bhatia S, Breuer F, Poloczek S, Pommerenke C, Dahmen J. Increasing emergency number utilisation is not driven by low-acuity calls: an observational study of 1.5 million emergency calls (2018\u0026ndash;2021) from Berlin. BMC Med. 2023;21(1):184.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChristensen EF, Bendtsen MD, Larsen TM, Jensen FB, Lindskou TA, Holdgaard HO, et al. Trends in diagnostic patterns and mortality in emergency ambulance service patients in 2007\u0026ndash;2014: a population-based cohort study from the North Denmark Region. BMJ Open. 2017;7(8):e014508.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMart\u0026iacute;n-Rodr\u0026iacute;guez F, Sanz-Garc\u0026iacute;a A, Ortega GJ, Delgado Benito JF, Aparicio Obregon S, Mart\u0026iacute;nez Fern\u0026aacute;ndez FT, et al. Tracking the National Early Warning Score 2 from Prehospital Care to the Emergency Department: A Prospective, Ambulance-Based, Observational Study. Prehosp Emerg Care. 2023;27(1):75\u0026ndash;83.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHortmann M, Singler K, Geier F, Christ M. Recognition of infections in elderly emergency patients. Z Gerontol Geriatr. 2015;48(7):601\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWalsh EE, Cox C, Falsey AR. Clinical features of influenza A virus infection in older hospitalized persons. J Am Geriatr Soc. 2002;50(9):1498\u0026ndash;503.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLars Sortland LM, Haraldseide. Ingrid Sebj\u0026oslash;rnsen. Eldre i den akuttmedisinske kjeden [Elderly in the Emergency Medical Chain]. Bergen: Nasjonalt kompetansesenter for legevaktmedisin, NORCE Norwegian Research Centre; 2021. Report No.: 1\u0026ndash;2021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMyrstad M, Ihle-Hansen H, Tveita AA, Andersen EL, Nyg\u0026aring;rd S, Tveit A, et al. National Early Warning Score 2 (NEWS2) on admission predicts severe disease and in-hospital mortality from Covid-19 - a prospective cohort study. Scand J Trauma Resusc Emerg Med. 2020;28(1):66.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHolland M, Kellett J. A systematic review of the discrimination and absolute mortality predicted by the National Early Warning Scores according to different cut-off values and prediction windows. Eur J Intern Med. 2022;98:15\u0026ndash;26.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKj\u0026aelig;r J, Milling L, Wittrock D, Nielsen LB, Mikkelsen S. The data quality and applicability of a Danish prehospital electronic health record: A mixed-methods study. PLoS ONE. 2023;18(10):e0293577.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLaudermilch DJ, Schiff MA, Nathens AB, Rosengart MR. Lack of emergency medical services documentation is associated with poor patient outcomes: a validation of audit filters for prehospital trauma care. J Am Coll Surg. 2010;210(2):220\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePetersen M, Kjeldtoft FG, Christensen EF, B\u0026oslash;ggild H, Lindskou TA. A classification system for identifying patients dead on ambulance arrival: a prehospital medical record review. Scand J Trauma Resusc Emerg Med. 2023;31(1):107.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIbsen S, Lindskou TA, Nickel CH, Kl\u0026oslash;jg\u0026aring;rd T, Christensen EF, S\u0026oslash;vs\u0026oslash; MB. Which symptoms pose the highest risk in patients calling for an ambulance? A population-based cohort study from Denmark. Scand J Trauma Resusc Emerg Med. 2021;29(1):59.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scandinavian-journal-of-trauma-resuscitation-and-emergency-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"stre","sideBox":"Learn more about [Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine](http://sjtrem.biomedcentral.com)","snPcode":"13049","submissionUrl":"https://submission.nature.com/new-submission/13049/3","title":"Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine","twitterHandle":"@SJTREM","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Emergency medical dispatch, Emergency medical services, Triage, Patient Acuity, Decision Support Systems, Early Warning Score","lastPublishedDoi":"10.21203/rs.3.rs-8891109/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8891109/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eTrends in Urgency Levels and Risk of Acute Critical Condition Among Prehospital Patients. A Seven-Year Observational Historic Register-Based Cohort Study\u003c/p\u003e \u003cp\u003e \u003cb\u003eBackground\u003c/b\u003e: In our region, as in Western countries, the number of emergencies requesting an ambulance is increasing. Whether this may be due to increased disease burden and/or lower threshold for calling is not clear. This study aimed to examine the development over the years in the number and urgency levels of ambulances and the actual acute disease severity, as indicated by initial vital signs measured on scene, together with patient demographics, comorbidity, and mortality trends over time.\u003c/p\u003e \u003cp\u003e \u003cb\u003eMethods\u003c/b\u003e: We conducted a registry-based observational cohort study of patients aged\u0026thinsp;\u0026ge;\u0026thinsp;18 years assigned an ambulance in the North Denmark Region from 2017 to 2023. The primary outcomes were urgency level and acute critical severity, assessed by a modified National Early Warning Score. Linear regression was applied to examine for alignment between trends in urgency level over the years and critically versus non-critically severity in prehospital patients assigned to urgency level A (most urgent, potentially life-threatening) and B (less urgent), respectively.\u003c/p\u003e \u003cp\u003e \u003cb\u003eResults\u003c/b\u003e: Among 202,746 prehospital patients, the proportion assessed as urgency level A decreased from 62% to 59%, while urgency level B increased from 38% to 41%. While the proportion of patients in acute critical condition was 16% vs 8% among level of urgency A and B, and stable during the period, the number of patients in acute critical condition increased by 3.6 (95% confidence interval (CI) 0.7\u0026ndash;6.6) and 6.1 (95% CI 4.4\u0026ndash;7.8) per quarter. Across the total population, patient age increased from 64 to 66 years, and the proportion with severe comorbidity increased from 11% to 14%.\u003c/p\u003e \u003cp\u003e \u003cb\u003eConclusion\u003c/b\u003e: From 2017 to 2023, the number of patients assigned with an ambulance through 1-1-2 increased, as did patient age and comorbidity. During the years were similar proportions of acute critical severity, but increasingly more among urgency level B. Thus, the acute severity among prehospital patients has not diminished. The lack of alignment between the level of urgencies and the acuity severity found on scene should be monitored carefully, together with mortality and clinical outcomes.\u003c/p\u003e","manuscriptTitle":"Trends in Urgency Levels and Risk of Acute Critical Condition Among Prehospital Patients. A Seven-Year Observational Historic Register-Based Cohort Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-03 07:23:09","doi":"10.21203/rs.3.rs-8891109/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-26T05:47:43+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-26T05:38:21+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-25T08:39:56+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"87362766080193445836154831105027414719","date":"2026-04-21T07:29:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"12647676084441788207149691348309866267","date":"2026-04-20T19:08:21+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-23T12:46:31+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-16T09:44:51+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-16T09:41:07+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine","date":"2026-02-16T08:06:58+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scandinavian-journal-of-trauma-resuscitation-and-emergency-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"stre","sideBox":"Learn more about [Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine](http://sjtrem.biomedcentral.com)","snPcode":"13049","submissionUrl":"https://submission.nature.com/new-submission/13049/3","title":"Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine","twitterHandle":"@SJTREM","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"cc657d74-2838-40e1-8e4d-0f985132756d","owner":[],"postedDate":"March 3rd, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-04-26T05:53:42+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-03 07:23:09","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8891109","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8891109","identity":"rs-8891109","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}