Emergency medical service systems in Japan: past, present, and future

Emergency medical services are provided by the fire defence headquarters of the local government in Japan. There is a one-tiered EMS system. Ambulances are staffed by three crew members trained in rescue, stabilisation, transport, and advanced care of traumatic and medical emergencies. There are three levels of care provided by ambulance personnel including a basic-level ambulance crew (First Aid Class One, FAC-1), a second level (Standard First Aid Class, SFAC), and the highest level (Emergency Life Saving Technician, ELST). ELSTs are trained in all aspects of BLS and some ALS procedures relevant to pre-hospital emergency care. Further development of an effective medical control system is imperative as the activities of ambulance crews become more sophisticated. A marked recent increase in the volume of emergency calls is another issue of concern. Currently, private services for transportation of non-acute or minor injury/illness have been introduced in some areas, and dispatch protocols to triage 119 calls are being developed.

Paramedics' perceptions of their role in providing pre-hospital thrombolytic treatment: qualitative study

BACKGROUND

The majority of ambulance services in England provide pre-hospital thrombolysis, following publication of the National Service Framework for Coronary Heart Disease. A meta-analysis has confirmed the effectiveness of pre-hospital administration in terms of all-cause mortality reduction and time saved. Little is known however, about how paramedics perceive their role in thrombolytic administration.

AIMS

To describe ambulance paramedics' perceptions of their role in delivering thrombolytic treatment in the pre-hospital setting.

METHODS

Twenty paramedics, based in one rural ambulance service in the South West of England participated in focus group interviews.

RESULTS

Five key themes emerged: Perceptions of drivers for change; duty of care; perceptions of professional image; role expansion; and preparedness for practice.

CONCLUSION

Paramedics' perceptions of their role in pre-hospital thrombolysis were mixed, encompassing professional and political issues including lack of ownership of the emerging national strategy, desire for national certification and financial reward. For successful development and implementation of new strategies within the ambulance service early engagement of paramedics and other staff is essential.

Experiences of adding nurses to increase medical competence at an emergency medical dispatch centre

INTRODUCTION

Prehospital care begins when the call is placed to the emergency medical dispatch (EMD) centre and ends when the patient is cared for at the emergency department. The highly technical and specialized character demands advanced medical competence. Communication problems, serious and unpredictable situations can often occur during the emergency calls. A two-year intervention study involved the addition of registered nurses to an EMD-centre team to increase medical competence.

AIM

To describe registered nurses' and emergency-operators' experiences of working together at an EMD-centre after adding registered nurses to increase medical competence.

METHODS

Qualitative content analysis was used to analyse the text from interviews with four registered nurses and 15 emergency-operators involved in the intervention.

RESULTS

Initial frustration and scepticism changed to more positive experiences that resulted in improved cooperation and service. The registered nurses had difficulties dealing with the more urgently acute calls, while the emergency-operators had difficulties with the more complicated, somewhat diffuse cases. The two professions complemented each other.

CONCLUSION

Combining the registered nurses' and emergency-operators' knowledge and experience at an EMD-centre can perhaps improve the prehospital care for those requiring emergency medical care.

Analysis of the pre-incident education and subsequent performance of emergency medical responders to the Volendam caf?? fire

OBJECTIVE

At this moment, in the Netherlands, rescue workers are not given any specific standardized training in disaster response or disaster management. After the café fire in Volendam, the Netherlands, on New Year's Eve 2000, around 200 rescue workers were deployed on-site. The aim of this study is to investigate the rescue workers' experiences with regard to their level of preparation for the emergency response.

METHODS

In 2002, 30 members of the medical and paramedical personnel were requested to participate in a structured interview, focused on education, task perception, triage and registration.

RESULTS

Twenty-seven participated. Twenty-two rescue workers received previous training in emergency medicine. During the alarm phase, 11 rescue workers had a clear perception of their tasks. Twenty-four were involved in triage and injury assessment. Three rescue workers used a protocol for triage and 15 for injury assessment. Twenty-five rescue workers gave on-scene treatment and 15 used a protocol. Eight registered their findings.

CONCLUSIONS

Preparation for the emergency response lacked standardized procedures. The use of triage protocols was extremely poor, as was documentation of actions. Slightly more than half of the personnel followed treatment protocols. It is advisable that all rescue workers become familiar with the basic uniform principles and protocols regarding disaster management. A dedicated and standardized national disaster management course is needed for all rescue workers.

Work-related psychosocial factors, worry about work conditions and health complaints among female and male ambulance personnel

This study aimed at investigating the relationships between work-related psychosocial factors, worry about work conditions and health complaints (sleeping problems, headache and stomach symptoms) among female and male ambulance personnel. Out of 4000 ambulance personnel in Sweden, 1500 (300 female and 1200 male personnel) were randomly selected. They answered a questionnaire including items on self-reported health complaints, individual characteristics, work-related psychological demands, decision latitude, social support and worry about work conditions. Twenty-five per cent of the female and 20% of the male ambulance personnel reported two or more health complaints sometimes or often. According to the demand-control-support questionnaire, ambulance personnel reported a generally positive psychosocial work environment, although psychological demands were associated with sleeping problems, headache and stomach symptoms among both female and male ambulance personnel. Another factor that was significantly associated with health complaints among both genders was worry about work conditions. When worry about work conditions was added to the regression models, this variable took over the role from psychological demands as a predictor for health complaints among the female ambulance personnel. The prevalence of sleeping problems, headache and stomach symptoms were significantly associated with psychological demands among both female and male ambulance personnel. Notably, worry about work conditions seems to be an important risk factor for health complaints. This suggests that worry about work conditions should not be neglected when considering risk factors among ambulance personnel.

Team assignment system: expediting emergency department care

STUDY OBJECTIVE

We designed and implemented an emergency department (ED) team assignment system, each team consisting of 1 emergency physician, 2 nurses, and usually 1 technician. Patients were assigned in rotation upon arrival to a specific team that was responsible for their care. We monitored the time from arrival to physician assessment, percentage of patients who left without being seen by a physician, and patient satisfaction before and after team assignment system implementation.

METHODS

This study was done in a suburban community hospital with an annual ED census of approximately 39,000. Time to physician assessment was defined from the completion of the medical screening evaluation by an ED nurse at triage to initiation of emergency physician evaluation. Times were documented on the ED paper record and manually entered into a computerized registration by the clerical staff. Patients who left without being seen was reported as percentage of total ED visits. Patient satisfaction scores using a 5-point Likert scale to assess satisfaction with the emergency physician, ED staff courtesy, and coordination of care were gathered every 3 months from random mailings to a subset of patients.

RESULTS

The 12-month ED census was 38,716 before team assignment system implementation and 39,301 afterwards. Complete time data were recorded for 34,152 (88.2%) and 32,537 (82.8%) of the patients, respectively. The mean time to physician assessment was 71.3+/-7.0 minutes before and 61.8+/-6.4 minutes after team assignment system implementation (absolute difference -9.5 minutes; 95% confidence interval [CI] -5.8 to -13.5 minutes). The percentage of patients seen by a physician within 1 hour was 56.3% before and 64.0% after team assignment system implementation (absolute difference 7.7%; 95% CI 5.1% to 10.3%). The percentage of patients who waited more than 3 hours for physician assessment was 17.8% before and 11.8% after team assignment system implementation (absolute difference -6.0%, 95% CI -4.0% to -8.1%). Before team assignment system, the left without being seen rate was 2.3% compared to 1.6% after team assignment system (absolute difference -0.8%; 95% CI -0.4% to -1.1%). Patient satisfaction reported as very good or excellent showed improvement in satisfaction with the physician (absolute increase 3.1%; 95% CI 1.0% to 5.3%), staff courtesy (absolute increase 4.5%; 95% CI 2.3% to 6.7%), and coordination of care (absolute increase 3.6%; 95% CI 0.8% to 6.4%).

CONCLUSION

The implementation of a team assignment system in our ED was associated with reduced time to physician assessment, a reduced percentage of patients who left without being seen, and improved patient satisfaction.

The handover process and triage of ambulance-borne patients: the experiences of emergency nurses

One of the most important tasks that a nurse faces in the emergency room, when receiving a patient, is handover and the triage function. The aim of the study was to explore the experiences of nurses receiving patients who were brought into hospital as emergencies by ambulance crews through an analysis of the handover and triage process. A qualitative descriptive interview study inspired by the phenomenological method was used with six emergency nurses. There are three elements to a handover: a verbal report, handing over documented accounts and the final symbolic handover when a patient is transferred from the ambulance stretcher onto the hospital stretcher. The study identified that the verbal communication between ambulance and emergency nurses was often very structured. The ideal handovers often involved patients with very distinct medical problems. The difficult handover or the 'non-ideal' one was characterized by a significantly more complicated care situation. The handover function was pivotal in ensuring that the patient received the correct care and that care was provided at the appropriate level. The most seriously afflicted patients arrived by ambulance; therefore, the interplay between pre-hospital and hospital personnel was vital in conveying this important information. To some extent, this functioned well, but this research has identified areas where this care can be improved.

Emergency medical services in Japan: An opportunity for the rational development of pre-hospital care and research

Japan is at a crossroads in the development of its Emergency Medical Services (EMS). At present, Japan has an essentially pure scoop-and-run, defibrillation system. However, there is a strong movement toward expanding the scope of paramedic practice to include more complex, Advanced Life Support (ALS) and trauma protocols to its nationally standardized pre-hospital protocols. The implications of introducing complex pre-hospital protocols guided by the use of existing scientific evidence to support such action is discussed in the context of Japan's unique opportunity to test many fundamental questions in pre-hospital medical care and the public's understanding and acceptance of these practices. Japan, a technologically advanced country that is not encumbered by entrenched "standards of care," has the opportunity to develop an efficient and rational EMS system.

The Physician Orders for Life-Sustaining Treatment Program: Oregon Emergency Medical Technicians' Practical Experiences and Attitudes

OBJECTIVES

To evaluate emergency medical technicians' (EMTs) experiences with the Physician Orders for Life-Sustaining Treatment (POLST) program and learn about attitudes regarding its effectiveness.

DESIGN

Anonymous survey mailed to a stratified random sample.

SETTING

Tri-County Portland, Oregon, area.

PARTICIPANTS

A total of 572 Oregon EMT respondents (out of 1,048 surveys) were included in the analysis.

MEASUREMENTS

Survey questions about experiences with the POLST form and opinions about POLST.

RESULTS

Respondents were mostly male (76%) and paramedics (66%). Most respondents (73%) had treated a patient with a POLST, and 74% reported receiving education about POLST. EMTs reported that POLST, when present, changed treatment in 45% of cases. Seventy-five percent of the respondents agreed that the POLST form provides clear instructions about patient preferences, and 93% agreed that the POLST form is useful in determining which treatments to provide when the patient is in cardiopulmonary arrest. Fewer (63%) agreed that the form is useful in determining treatments when the patient has a pulse and is breathing.

CONCLUSION

Most respondents have experience with the POLST program. EMTs find the POLST form useful and often use it to change treatment decisions for patients.

Medical Considerations in the Use of Helicopters in Mountain Rescue

The outcome of patient care can be dramatically improved by bringing rapid rescue and medical care to the mountain rescue scene and by rapid transport to a medical facility. The use of a helicopter for these purposes is common. It is necessary when it has clear advantages for victims in comparison with ground rescue and transport. Helicopters should work within the existing emergency medical system and must be staffed by appropriate mountain rescue and medically trained personnel. Activation time should be as short as possible. Activation of a helicopter for a mountain rescue should primarily include indication and assessment of flight and safety conditions. No other mediators or delaying factors should be permitted. The main safety criteria are appropriate mountain rescue and flight training, competence of air and ground crews, radio communication between the air and ground crews, and mission briefing before the rescue. Criteria for a helicopter used for mountain rescue are proper medical and rescue equipment, load capacity, adequate space, and others. There are two main groups of indications for use of a helicopter for mountain rescue: the patient's condition and the circumstances at the site of the accident. All persons responsible for the activation of the helicopter rescue operation should be aware of specific problems in the mountains or wilderness.

Acute and chronic job stressors among ambulance personnel: predictors of health symptoms

OBJECTIVES

To predict symptomatology (post-traumatic distress, fatigue, and burnout) due to acute and chronic work related stressors among ambulance personnel.

METHODS

Data were gathered from 123 ambulance workers in The Netherlands in a longitudinal design. At two measurements they completed standardised questionnaires to assess health symptoms, such as the Impact of Event Scale, the Maslach Burnout Inventory, and the Checklist Individual Strength. Acute stressors were assessed with specific questions, and chronic work related stressors were measured with the Questionnaire on the Experience and Assessment of Work.

RESULTS

Most of the ambulance workers had been confronted with acute stressors in their work. They also reported more chronic work related stressors than a reference group. Of the participants, more than a tenth suffered from a clinical level of post-traumatic distress, a tenth reported a fatigue level that put them at high risk for sick leave and work disability and nearly a tenth of the personnel suffered from burnout. Best predictors of symptomatology at time 2 were lack of social support at work and poor communication, such as not being informed about important decisions within the organisation.

CONCLUSIONS

Ambulance personnel are at risk to develop health symptoms due to work related stressors. Although, acute stressors are related to health symptoms, such as fatigue, burnout, and post-traumatic symptoms, it was not found to predict health symptoms in the long term. Main risk factors have to do with social aspects of the work environment, in particular lack of support from the supervisor as well as colleagues and poor communication. When implementing workplace interventions these social aspects need to be taken into account.

Role of the physician in prehospital management of trauma: North American perspective

To some extent or another, physicians have been involved in emergency medical services (EMS) systems in North America for decades. Over the years, physicians from different specialties have been involved with EMS, occasionally as full-time or part-time employees of the EMS system but more often on a voluntary or small contractual basis. Regardless of the employment relationship, most states and provinces now require by statute that each EMS system, particularly those providing advanced life support (ALS) services, have a designated EMS medical director. However, in the United States and most of Canada, such physicians typically oversee EMS systems by acting as administrative medical supervisors, educators, mentors, and, in some cases, even as system managers. Throughout many European countries, the physician is the primary care provider for a large percentage of the serious prehospital medical emergencies. In contrast, throughout North America, basic emergency medical technicians (EMTs) and paramedics (specially trained ALS providers) serve as the EMS system medical director's surrogates. In this system of care, such physician surrogates provide almost all of the prehospital medical care interventions without any on-scene physician presence. Nevertheless, because of their medical supervisory requirements, by statute, North American medical directors generally are still accountable for patient care. Therefore, in many areas of the United States and Canada, the responsible physicians also respond to EMS scenes on a routine basis. They do so, both announced and unannounced, independently or with EMS personnel. In this capacity, they can serve as a direct patient care resource for the EMTs, paramedics, and the patients themselves. However, by becoming an intermittent participating member of the EMS team in the unique out-of-hospital setting, these on-scene physicians can help to better scrutinize the care rendered and thus more effectively modify applicable protocols and training as needed. Historically, such practices have helped many EMS systems-not only in terms of reforming traditional protocols but also by helping to establish improved medical care priorities and even system management changes that affect patient care. In addition, active participation helps the accountable EMS physician not only to identify weaknesses in personnel skills and system approaches, but it also provides an opportunity for role modeling, both medically and managerially.

Operational issues in EMS

Improving outcomes for patients presenting to the EMS system relies on strong links at every level of the EMS system. Targeted deployment strategies that serve to limit the number of paramedics in each system foster a cadre of experienced paramedics that make a difference for seriously ill patients who present in the out-of-hospital setting. Dedicated physician directors who act as mentors at every level of the EMS system are essential elements of the successful EMS system.

National EMS Research Agenda

Now, more than ever before, the spirit of the emergency services professional is recognized by people everywhere. Individuals from every walk of life comprehend the reality of the job these professionals do each day. Placing the safety of others above their own is their acknowledged responsibility. Rescue and treatment of ill and injured patients are their purpose as well as their gratification. The men and women who provide prehospital care are well aware of the unpredictable nature of emergency medical services (EMS). Prehospital care is given when and where it is needed: in urban settings with vertical challenges and gridlock; in rural settings with limited access; in confined spaces; within entrapments; or simply in the street, exposed to the elements. Despite the challenges, EMS professionals rise to the occasion to do their best with the resources available. Despite more than 30 years of dedicated service by thousands of EMS professionals, academic researchers, and public policy makers, the nation's EMS system is treating victims of illness and injury with little or no evidence that the care they provide is optimal. A national investment in the EMS research infrastructure is necessary to overcome obstacles currently impeding the accumulation of essential evidence of the effectiveness of EMS practice. Funding is required to train new researchers and to help them establish their careers. Financial backing is needed to support the development of effective prehospital treatments for the diseases that drive the design of the EMS system, including injury and sudden cardiac arrest. Innovative strategies to make EMS research easier to accomplish in emergency situations must be implemented. Researchers must have access to patient outcome information in order to evaluate and improve prehospital care. New biomedical and technical advances must be evaluated using scientific methodology. Research is the key to maintaining focus on improving the overall health of the community in a competitive and cost-conscious health care market. Most importantly, research is essential to ensure that the best possible patient care is provided in the prehospital setting. The bravery and dedication of EMS professionals cannot be underestimated. Images of firefighters, EMS personnel, and others going into danger while others are evacuating will remain burned in our collective consciousness. These professionals deserve the benefit of research to assist them in providing the best possible care in the challenging circumstances they encounter. With this document, we are seeking support for elevating the science of EMS and prehospital care to the next level. It is essential that we examine innovative ways to deliver prehospital care. Strategies to protect the safety of both the patient and the public safety worker must be devised and tested. There are many questions that remain to be asked, many practices to be evaluated, and many procedures to be improved. Research is the key to obtaining the answers.