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Packendorff N, Magnusson C, Wibring K, Axelsson C, Hagiwara MA. Development of a trigger tool to identify harmful incidents, no harm incidents, and near misses in prehospital emergency care. Scand J Trauma Resusc Emerg Med 2024; 32:38. [PMID: 38685120 PMCID: PMC11059688 DOI: 10.1186/s13049-024-01209-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 04/21/2024] [Indexed: 05/02/2024] Open
Abstract
BACKGROUND Emergency Medical Services (EMS) are a unique setting because care for the chief complaint is given across all ages in a complex and high-risk environment that may pose a threat to patient safety. Traditionally, a reporting system is commonly used to raise awareness of adverse events (AEs); however, it could fail to detect an AE. Several methods are needed to evaluate patient safety in EMS. In this light, this study was conducted to (1) develop a national ambulance trigger tool (ATT) with a guide containing descriptions of triggers, examples of use, and categorization of near misses (NMs), no harm incidents (NHIs), and harmful incidents (HIs) and (2) use the ATT on randomly selected ambulance records. METHODS The ambulance trigger tool was developed in a stepwise manner through (1) a literature review; (2) three sessions of structured group discussions with an expert panel having knowledge of emergency medical service, patient safety, and development of trigger tools; (3) a retrospective record review of 900 randomly selected journals with three review teams from different geographical locations; and (4) inter-rater reliability testing between reviewers. RESULTS From the literature review, 34 triggers were derived. After removing clinically irrelevant ones and combining others through three sessions of structured discussions, 19 remained. The most common triggers identified in the 900 randomly selected records were deviation from treatment guidelines (30.4%), the patient is non conveyed after EMS assessment (20.8%), and incomplete documentation (14.4%). The positive triggers were categorized as a near miss (40.9%), no harm (3.7%), and harmful incident (0.2%). Inter-rater reliability testing showed good agreement in both sessions. CONCLUSION This study shows that a trigger tool together with a retrospective record review can be used as a method to measure the frequency of harmful incidents, no harm incidents, and near misses in the EMS, thus complementing the traditional reporting system to realize increased patient safety.
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Affiliation(s)
- Niclas Packendorff
- Prehospen-Centre for Prehospital Research, Faculty of Caring Science, Work Life and Social Welfare, University of Borås, Borås, Sweden.
- Department of Prehospital Emergency Care, Sahlgrenska University Hospital, Gothenburg, Sweden.
| | - Carl Magnusson
- Prehospen-Centre for Prehospital Research, Faculty of Caring Science, Work Life and Social Welfare, University of Borås, Borås, Sweden
- Department of Prehospital Emergency Care, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Kristoffer Wibring
- Department of Ambulance and Prehospital Care, Region Halland, Sweden
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Christer Axelsson
- Prehospen-Centre for Prehospital Research, Faculty of Caring Science, Work Life and Social Welfare, University of Borås, Borås, Sweden
- Department of Prehospital Emergency Care, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Magnus Andersson Hagiwara
- Prehospen-Centre for Prehospital Research, Faculty of Caring Science, Work Life and Social Welfare, University of Borås, Borås, Sweden
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Hofstetter P, Schröder H, Beckers SK, Borgs C, Rossaint R, Felzen M. Immobilization in Emergency Medical Service - Are CSR and NEXUS-Criteria Considered? A Matched-Pairs Analysis Between Trauma Patients Treated by Onsite EMS Physicians and Patients Treated by Tele-EMS Physicians. Open Access Emerg Med 2023; 15:145-155. [PMID: 37187612 PMCID: PMC10178902 DOI: 10.2147/oaem.s386650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Accepted: 03/28/2023] [Indexed: 05/17/2023] Open
Abstract
Background The NEXUS-low-risk criteria (NEXUS) and Canadian C-spine rule (CSR) are clinical decision tools used for the prehospital spinal clearance in trauma patients, intending to prevent over- as well as under immobilization. Since 2014, a holistic telemedicine system is part of the emergency medical service (EMS) in Aachen (Germany). This study aims to examine whether the decisions to immobilize or not by EMS- and tele-EMS physicians are based on NEXUS and the CSR, as well as the guideline adherence concerning the choice of immobilization device. Methods A single-site retrospective chart review was undertaken. Inclusion criteria were EMS physician and tele-EMS physician protocols with traumatic diagnoses. Matched pairs were formed, using age, sex and working diagnoses as matching criteria. The primary outcome parameters were the criteria documented as well as the immobilization device used. The evaluation of the decision to immobilize based on the criteria documented was defined as secondary outcome parameter. Results Of a total of 247 patients, 34% (n = 84) were immobilized in the EMS physician group and 32.79% (n = 81) in the tele-EMS physician group. In both groups, less than 7% NEXUS or CSR criteria were documented completely. The decision to immobilize or not was appropriately implemented in 127 (51%) in the EMS-physician and in 135 (54, 66%) in the tele-EMS physician group. Immobilization without indication was performed significantly more often by tele-EMS physicians (6.88% vs 2.02%). A significantly better guideline adherence was found in the tele-EMS physician group, preferring the vacuum mattress (25, 1% vs 8.9%) over the spineboard. Conclusion It could be shown that NEXUS and CSR are not applied regularly, and if so, mostly inconsistently with incomplete documentation by both EMS- and tele-EMS physicians. Regarding the choice of the immobilization device a higher guideline adherence was shown among the tele-EMS physicians.
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Affiliation(s)
- Paula Hofstetter
- Department of Anesthesiology, University Hospital RWTH Aachen, Aachen, Germany
- Department of Anesthesiology, Rhein-Maas Klinikum, Würselen, Germany
| | - Hanna Schröder
- Department of Anesthesiology, University Hospital RWTH Aachen, Aachen, Germany
- Aachen Institute for Rescue Management & Public Safety, City of Aachen and University Hospital RWTH Aachen, Aachen, Germany
| | - Stefan K Beckers
- Department of Anesthesiology, University Hospital RWTH Aachen, Aachen, Germany
- Aachen Institute for Rescue Management & Public Safety, City of Aachen and University Hospital RWTH Aachen, Aachen, Germany
- Medical Direction of Aachen Fire Department, Aachen, Germany
| | - Christina Borgs
- Department of Anesthesiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Rolf Rossaint
- Department of Anesthesiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Marc Felzen
- Department of Anesthesiology, University Hospital RWTH Aachen, Aachen, Germany
- Aachen Institute for Rescue Management & Public Safety, City of Aachen and University Hospital RWTH Aachen, Aachen, Germany
- Medical Direction of Aachen Fire Department, Aachen, Germany
- Correspondence: Marc Felzen, Department of Anesthesiology, University Hospital RWTH Aachen, Pauwelsstrasse 30, Aachen, 52074, Germany, Tel +49 241 8088179, Fax +49 241 82406, Email
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Stevanovic A, Beckers SK, Czaplik M, Bergrath S, Coburn M, Brokmann JC, Hilgers RD, Rossaint R. Telemedical support for prehospital Emergency Medical Service (TEMS trial): study protocol for a randomized controlled trial. Trials 2017; 18:43. [PMID: 28126019 PMCID: PMC5270339 DOI: 10.1186/s13063-017-1781-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Accepted: 01/05/2017] [Indexed: 02/02/2023] Open
Abstract
Background Increasing numbers of emergency calls, shortages of Emergency Medical Service (EMS), physicians, prolonged emergency response times and regionally different quality of treatment by EMS physicians require improvement of this system. Telemedical solutions have been shown to be beneficial in different emergency projects, focused on specific disease patterns. Our previous pilot studies have shown that the implementation of a holistic prehospital EMS teleconsultation system, between paramedics and experienced tele-EMS physicians, is safe and feasible in different emergency situations. We aim to extend the clinical indications for this teleconsultation system. We hypothesize that the use of a tele-EMS physician is noninferior regarding the occurrence of system-induced patient adverse events and superior regarding secondary outcome parameters, such as the quality of guideline-conforming treatment and documentation, when compared to conventional EMS-physician treatment. Methods/design Three thousand and ten patients will be included in this single-center, open-label, randomized controlled, noninferiority trial with two parallel arms. According to the inclusion criteria, all emergency cases involving adult patients who require EMS-physician treatment, excluding life-threatening cases, will be randomly assigned by the EMS dispatching center into two groups. One thousand five hundred and five patients in the control group will be treated by a conventional EMS physician on scene, and 1505 patients in the intervention group will be treated by paramedics who are concurrently instructed by the tele-EMS physicians at the teleconsultation center. The primary outcome measure will include the rate of treatment-specific adverse events in relation to the kind of EMS physician used. The secondary outcome measures will record the specific treatment-associated quality indicators. Discussion The evidence underlines the better quality of service using telemedicine networks between medical personnel and medical experts in prehospital emergency care, as well as in other medical areas. The worldwide unique EMS teleconsultation system in Aachen has been optimized and evaluated in pilot studies and subsequently integrated into routine use for a broad spectrum of indications. It has enabled prompt, safe and efficient patient treatment with optimized use of the “resource” EMS physician. There is, however, a lack of evidence as to whether the advantages of the teleconsultation system can be replicated in wider-ranging EMS-physician indications (excluding life-threatening emergency calls). Trial registration ClinicalTrials.gov, identifier: NCT02617875. Registered on 24 November 2015. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-1781-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ana Stevanovic
- Department of Anesthesiology, University Hospital RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Germany
| | - Stefan Kurt Beckers
- Department of Anesthesiology, University Hospital RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Germany.,Emergency Medical Service, Fire Department, Stolberger Str. 155, 52068, Aachen, Germany
| | - Michael Czaplik
- Department of Anesthesiology, University Hospital RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Germany
| | - Sebastian Bergrath
- Department of Anesthesiology, University Hospital RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Germany.,Emergency Medical Service, Fire Department, Stolberger Str. 155, 52068, Aachen, Germany
| | - Mark Coburn
- Department of Anesthesiology, University Hospital RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Germany
| | | | - Ralf-Dieter Hilgers
- Department of Medical Statistics, University Hospital RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Germany
| | - Rolf Rossaint
- Department of Anesthesiology, University Hospital RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Germany.
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Häske D, Beckers SK, Hofmann M, Lefering R, Gliwitzky B, Wölfl CC, Grützner P, Stöckle U, Dieroff M, Münzberg M. Quality of Documentation as a Surrogate Marker for Awareness and Training Effectiveness of PHTLS-Courses. Part of the Prospective Longitudinal Mixed-Methods EPPTC-Trial. PLoS One 2017; 12:e0170004. [PMID: 28107394 PMCID: PMC5249224 DOI: 10.1371/journal.pone.0170004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Accepted: 12/25/2016] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE Care for severely injured patients requires multidisciplinary teamwork. A decrease in the number of accident victims ultimately affects the routine and skills. PHTLS ("Pre-Hospital Trauma Life Support") courses are established two-day courses for medical and non-medical rescue service personnel, aimed at improving the pre-hospital care of trauma patients worldwide. The study aims the examination of the quality of documentation before and after PHTLS courses as a surrogate endpoint of training effectiveness and awareness. METHODS This was a prospective pre-post intervention trial and was part of the mixed-method longitudinal EPPTC (Effect of Paramedic Training on Pre-Hospital Trauma Care) study, evaluating subjective and objective changes among participants and real patient care, as a result of PHTLS courses. The courses provide an overview of the SAMPLE approach for interrogation of anamnestic information, which is believed to be responsible for patient safety as relevant, among others, "Allergies," "Medication," and "Patient History" (AMP). The focus of the course is not the documentation. RESULTS In total, 320 protocols were analyzed before and after the training. The PHTLS course led to a significant increase (p < 0.001) in the "AMP" information in the documentation. The subgroups analysis of "allergies" (+47.2%), "drugs" (+38.1%), and "medical history" (+27.8%) before and after the PHTLS course showed a significant increase in the information content. CONCLUSION In summary, we showed that PHTLS training improves documentation quality, which we used as a surrogate endpoint for learning effectiveness and awareness. In this regard, we demonstrated that participants use certain parts of training in real life, thereby suggesting that the learning methods of PHTLS training are effective. These results, however, do not indicate whether patient care has changed.
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Affiliation(s)
- David Häske
- Faculty of Medicine, Eberhard Karls University Tübingen, Tuebingen, Germany
| | - Stefan K. Beckers
- Department of Anesthesiology, University Hospital RWTH, Aachen, Aachen, Germany
- Emergency Medical Service, Fire Department, City of Aachen, Aachen, Germany
| | | | - Rolf Lefering
- Institute for Research in Operative Medicine, University of Witten/Herdecke, Cologne, Germany
| | | | - Christoph C. Wölfl
- Department of Orthopedics, Trauma Surgery and Sports Traumatology, Hospital Hetzelstift, Neustadt, Germany
| | - Paul Grützner
- Department of Trauma and Orthopedic Surgery, BG Trauma Centre Ludwigshafen, Ludwigshafen, Germany
| | - Ulrich Stöckle
- Department of Traumatology and Reconstructive Surgery, BG Hospital Tuebingen, Tuebingen, Germany
| | - Marc Dieroff
- Fire Service, Emergency Preparedness and Crisis Management, City of Wiesbaden, Wiesbaden, Germany
| | - Matthias Münzberg
- Department of Trauma and Orthopedic Surgery, BG Trauma Centre Ludwigshafen, Ludwigshafen, Germany
- * E-mail:
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Fisher JD, Freeman K, Clarke A, Spurgeon P, Smyth M, Perkins GD, Sujan MA, Cooke MW. Patient safety in ambulance services: a scoping review. HEALTH SERVICES AND DELIVERY RESEARCH 2015. [DOI: 10.3310/hsdr03210] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BackgroundThe role of ambulance services has changed dramatically over the last few decades with the introduction of paramedics able to provide life-saving interventions, thanks to sophisticated equipment and treatments available. The number of 999 calls continues to increase, with adverse events theoretically possible with each one. Most patient safety research is based on hospital data, but little is known concerning patient safety when using ambulance services, when things can be very different. There is an urgent need to characterise the evidence base for patient safety in NHS ambulance services.ObjectiveTo identify and map available evidence relating to patient safety when using ambulance services.DesignMixed-methods design including systematic review and review of ambulance service documentation, with areas for future research prioritised using a Delphi process.Setting and participantsAmbulance services, their staff and service users in UK.Data sourcesA wide range of data sources were explored. Multiple databases, reference lists from key papers and citations, Google and the NHS Confederation website were searched, and experts contacted to ensure that new data were included in the review. The databases MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science, Science Direct, Emerald, Education Resources Information Center (ERIC), Applied Social Sciences Index and Abstracts, Social Services Abstracts, Sociological Abstracts, International Bibliography of the Social Sciences (IBSS), PsycINFO, PsycARTICLES, Health Management Information Consortium (HMIC), NHS Evidence, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects (DARE), NHS Economic Evaluation Database (NHS EED),Health Technology Assessment, the FADE library, Current Awareness Service for Health (CASH), OpenDOAR (Directory of Open Access Repositories) and Open System for Information on Grey Literature in Europe (OpenSIGLE) and Zetoc (The British Library's Electronic Table of Contents) were searched from 1 January 1980 to 12 October 2011. Publicly available documents and issues identified by National Patient Safety Agency (NPSA), NHS Litigation Authority (NHSLA) and coroners’ reports were considered. Opinions and perceptions of senior managers, ambulance staff and service users were solicited.Review methodsData were extracted from annual reports using two-stage thematic analysis, data from quality accounts were collated with safety priorities tabulated and considered using thematic analysis, NPSA incident report data were collated and displayed comparatively using descriptive statistics, claims reported to NHSLA were analysed to identify number and cost of claims from mistakes and/or poor service, and summaries of coroners’ reports were assessed using thematic analysis to identify underlying safety issues. The depth of analysis is limited by the remit of a scoping exercise and availability of data.ResultsWe identified studies exploring different aspects of safety, which were of variable quality and with little evidence to support activities currently undertaken by ambulance services. Adequately powered studies are required to address issues of patient safety in this service, and it appeared that national priorities were what determined safety activities, rather than patient need. There was inconsistency of information on attitudes and approaches to patient safety, exacerbated by a lack of common terminology.ConclusionPatient safety needs to become a more prominent consideration for ambulance services, rather than operational pressures, including targets and driving the service. Development of new models of working must include adequate training and monitoring of clinical risks. Providers and commissioners need a full understanding of the safety implications of introducing new models of care, particularly to a mobile workforce often isolated from colleagues, which requires a body of supportive evidence and an inherent critical evaluation culture. It is difficult to extrapolate findings of clinical studies undertaken in secondary care to ambulance service practice and current national guidelines often rely on consensus opinion regarding applicability to the pre-hospital environment. Areas requiring further work include the safety surrounding discharging patients, patient accidents, equipment and treatment, delays in transfer/admission to hospital, and treatment and diagnosis, with a clear need for increased reliability and training for improving handover to hospital.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Joanne D Fisher
- Department of Health Sciences, Warwick Medical School, Coventry, UK
| | - Karoline Freeman
- Department of Health Sciences, Warwick Medical School, Coventry, UK
| | - Aileen Clarke
- Department of Health Sciences, Warwick Medical School, Coventry, UK
| | - Peter Spurgeon
- Department of Health Sciences, Warwick Medical School, Coventry, UK
| | - Mike Smyth
- West Midlands Ambulance Service, Millennium Point, Waterfront Business Park, Brierley Hill, West Midlands, UK
| | - Gavin D Perkins
- Department of Health Sciences, Warwick Medical School, Coventry, UK
| | | | - Matthew W Cooke
- Department of Health Sciences, Warwick Medical School, Coventry, UK
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