Inzidenz invasiver ärztlicher Maßnahmen im Rettungsdienst

[Safety aspects of prehospital thoracic emergency procedures: Results of a survey among German emergency physicians]

BACKGROUND

The safe indication and performance of thoracic emergency procedures are crucial and potentially lifesaving in prehospital emergency care. This study aims to investigate issues of patient safety and quality assurance of prehospital invasive thoracic interventions. The survey does not represent the actual medical care situation but explores reasons for security concerns among emergency physicians.

METHODS

Using a pre-validated questionnaire, prehospital emergency physicians of three prehospital rescue associations (Zweckverband) in Southwest Saxony, Greifswald, and Vechta, Germany, were queried via the online survey service limesurvey. The survey was conducted between January and March 2022.

RESULTS

104 emergency physicians participated (response rate 42.4%) 71 of which fully completed the survey (68%). 79% of the participants stated that they felt safe in performing pleural punction. Common reasons for postponing prehospital thoracic interventions included fear of complications or individual patient characteristics. 90% said that they were familiar with the on-board equipment options, and 60% reported that resources were sufficient to perform double-sided procedures. While in all three regions there is sufficient on-board equipment to perform procedures on two sides, one out of two participants said that lack of equipment deters them from performing prehospital invasive thoracic procedures. Emergency physicians who graduated from trauma courses and/or participate in air rescue are more likely to perform invasive thoracic procedures. More than half of the participants wanted more training in chest tube placement or pleural punction.

CONCLUSION

Safety in prehospital invasive thoracic procedures needs improvement in structural, procedural, as well as human factors aspects. Safe handling of these rare but vital techniques requires more training. A lack of knowledge of equipment is a significant safety gap. Prehospital ultrasound constitutes a structural element of prehospital diagnostics.

Differences in training among prehospital emergency physicians in Germany

Background

Germany has an interdisciplinary physician-based emergency medical service. Differences in training likely lead to different levels of expertise.

Objectives

We assessed the number of manual procedures performed at the completion of training to determine level of experience of prehospital emergency physicians of different primary specialties.

Materials and methods

Immediately after passing the board examination each examinee was asked to estimate the number of performed procedures for 26 manual skills. We compared the results with recommendations and data on learning manual skills. Results are presented as mean (standard deviation).

Results

Endotracheal intubation via direct laryngoscopy was performed 1032 (739) times by anesthesiologists. Surgeons and internists performed 89 (89) and 77 (65) intubations, respectively. Intubation via video laryngoscopy was performed 79 (81) times by anesthesiologists, 11 (17) times by surgeons and 6 (11) times by internists. Surgeons had little experience in non-invasive ventilation, with 9 (19) performed procedures and had rarely used external pacemaker therapy or electrical cardioversion. In comparison, among all participants non-invasive ventilation was performed 152 (197) times, electrical cardioversion was performed 41 (103) times and an external pacemaker was used 6 (15) times. For other procedures the numbers did not markedly differ between the different specialties.

Conclusion

The number of performed procedures markedly differed for some skills between different primary specialties. Recommendations regarding a procedural volume were not always met, suggesting missing expertise for some skills. A defined number of procedures should therefore be a formal requirement to be eligible for board certification in prehospital emergency medicine.

[Quality of documentation and treatment in the non-physician staffed ambulance: a retrospective analysis of emergency protocols from the city of Aachen]

Hintergrund

Der deutsche Rettungsdienst wird jährlich zu ca. 7,3 Mio. Einsätzen alarmiert, welche zu einem Großteil (ca. 59 %) ohne Arzt ablaufen. Da kaum Daten zur Qualität der medizinischen Versorgung und Dokumentation von Rettungsdiensteinsätzen ohne Arzt vorliegen, sollen diese anhand der Einsatzprotokolle im Rahmen dieser Studie überprüft werden.

Methode

Es erfolgte eine retrospektive Analyse von Protokollen der Rettungsdiensteinsätze ohne Arzt aus den Monaten Juni und Juli 2018. Unter Einbezug von Verfahrensanweisungen wurden die Dokumentations- und Behandlungsqualität der Einsätze analysiert. Primäre Endpunkte waren Dokumentationshäufigkeit, Vollständigkeit, die korrekte Notarzt- oder Telenotarztindikationsstellung, die Entwicklung von kritischen Vitalparametern im Einsatzverlauf sowie die mediane Behandlungszeit.

Ergebnisse

Insgesamt wurden 1935 Protokolle ausgewertet. Die Verdachtsdiagnose wurde in 1323 (68,4 %), die Anamnese in 456 (23,6 %), der Erstbefund in 350 (18,1 %) und der Letztbefund in 52 (2,7 %) der Fälle vollständig dokumentiert. Anhand der Dokumentation bestand bei 531 (27 %) Patienten eine Telenotarzt- bzw. Notarztindikation, jedoch kein Arztkontakt. Bei diesen Patienten wurden 410 kritische Vitalparameter im Erstbefund dokumentiert. Von diesen Vitalwerten verbesserten sich 69 (16,8 %); bei 217 (52,9 %) wurde kein Übergabebefund dokumentiert. Die mediane Behandlungsdauer vor Ort war bei Patienten mit eigentlicher Notarztindikation (15:02 min) signifikant länger als bei Patienten ohne Indikation (13:05 min).

Schlussfolgerung

Die Dokumentation der Einsätze ist defizitär. Zudem könnte ein Viertel der Patienten von einem prähospitalen Arztkontakt profitieren. Eine juristisch bedenkliche Übergabedokumentation besteht bei ca. der Hälfte aller Protokolle.

Medikamentengabe durch Notfallsanitäter

Hintergrund

Der Bundesverband der Ärztlichen Leiter Rettungsdienst (BV-ÄLRD) hat einen umfangreichen Katalog an Medikamenten für die Anwendung durch Notfallsanitäter vorgeschlagen. Wir evaluierten, wie oft Auszubildende zum Notfallsanitäter diese in ihrer Ausbildung applizierten.

Methode

Wir befragten 71 Auszubildende zum Notfallsanitäter zur Anwendungshäufigkeit 30 verschiedener Medikamente. Die statistische Auswertung erfolgte mit SOFA (Paton-Simpson and Associates Ltd, USA). Die Ergebnisse sind als Mittelwert (Standardabweichung) dargestellt.

Ergebnisse

Adrenalin i.v. wurde 2,22 (6,67) Mal verabreicht. Atropin wurde bei Bradykardie 1,18 (1,97) Mal verabreicht. Benzodiazepine wurden präklinisch 7,27 (10,28) Mal angewendet. Inhalative Betamimetika wurden präklinisch 8,89 (8,06) Mal, Ipratropiumbromid 3,70 (5,91) Mal, Kortikoide 3,79 (5,32) Mal und Antihistaminika 1,82 (4,34) Mal verabreicht. Ondansetron wurde innerklinisch 14,38 (35,06) Mal angewendet. Präklinisch wurde Dimenhydrinat mit 8,14 (10,14) Anwendungen am häufigsten verabreicht. Furosemid wurde präklinisch 6,06 (9,45) Mal verabreicht. Heparin wurde präklinisch 12,00 (14,32) Mal, ASS 14,32 (14,29) Mal und Glyceroltrinitrat 12,25 (10,87) Mal verabreicht. Metamizol wurde präklinisch 8,59 (12,51) Mal, Ketamin 3,51 (5,23) Mal, Opiate/Opioide 10,72 (16,18) Mal und Naloxon 0,20 (0,67) Mal verabreicht. Glukose wurde präklinisch 7,38 (6,67) Mal verabreicht.

Schlussfolgerung

Die Bewertung, für welche Medikamente eine ausreichende Expertise besteht, kann aufgrund fehlender Daten zu Lernkurven oder konsentierter Mindestzahlen nur vor dem Hintergrund klinischer Erfahrung erfolgen. Aus Sicht der Autoren besteht für die meisten untersuchten Medikamente eine ausreichende Expertise.

[Best practice-example of a paramedic competence system in the context of user and patient safety: the Reutlinger Weg]

The discussion about the competencies and responsibilities of paramedics has been going on for decades and is the subject of controversial legal debates and currently the focus of political attention due to the heterogeneous country-specific design. However, there are only a few published examples of a so-called competency system for the safe and effective use of prehospital emergency medicine interventions. The practical experience of a competence system is presented. Adequate education and training are crucial for development of competence. A physician-supported quality assurance system creates the opportunity to confirm the competencies of paramedics within the framework of competence checks, monitor the system by means of indicators, and detect weak points at an early stage. Safety culture must be exemplified. Standard operating procedures (SOPs) are the guideline for implementation. In a competence system, certified paramedics can be granted authorization and thus contribute to rapid and efficient patient care, while keeping emergency physicians available for indications requiring their competencies.

„Entrustable professional activities“ für NotfallsanitäterInnen

Hintergrund

Wie in vielen medizinischen Berufen wird auch bei den NotfallsanitäterInnen (NotSan) der Kompetenzbegriff verwendet. Eine Möglichkeit, diese Kompetenz schrittweise entwickeln und messen zu können, steht aus. Ten Cate et al. schlagen hier das Konzept der „entrustable professional activities“ (EPA) vor. Ziel der Studie war, einen Katalog von relevanten Einsatzsituationen zu entwickeln, der die Grundlage für eine EPA-Integration in die Ausbildung ermöglicht.

Methode

Die Erarbeitung des EPA-Katalogs erfolgte über ein 2‑stufiges Verfahren mittels webbasierter Fragebögen. Nach einer eDelphi-Analyse mit Praxisanleitenden im Rettungsdienst, wurden die Items in einem großen Kollektiv hinsichtlich der Relevanz validiert. Anschließend wurden Faktoren identifiziert und Skalen gebildet.

Ergebnisse

Nach Validierung der Ergebnisse der eDelphi-Analyse ergaben sich fünf Skalen mit 22 Items. Sie umfassen die Bereiche „Behandlung spezieller Krankheitsbilder-NACA IV“, „Kommunikation“, „Einbinden von Medizinprodukten in die Patientenbehandlung“, „symptomorientiertes Handeln“ und „Leitsymptom Schmerz“. Die Items beschreiben 59 % der Gesamtvarianz und entsprechen einer stabilen Faktorenlösung.

Schlussfolgerung

Es konnte ein Katalog von relevanten Einsatzsituationen in der NotSan-Ausbildung entwickelt werden, der sich zur weiteren Entwicklung von EPA eignet. Diese sollten flächendeckend und organisationsübergreifend einheitlich genutzt werden. Die Nutzung sollte didaktisch wissenschaftlich begleitet werden.

[Evaluation of cancelled emergency physician missions and patient handovers in the area of Innsbruck : Retrospective assessment of physician-staffed emergency medical service cancellations and handovers from the emergency physician to the emergency medical service in 2017 and 2018]

BACKGROUND

Human and vehicle resource management indicates a good emergency medical system (EMS). Frequently, an emergency medical technician (EMT) is the first responder to the emergency, which negates the necessity for an emergency physician (EP) and is just as sensible as handing over a stable patient to the EMT for transport to the hospital. The Austrian EMS is utilized by EMTs, in cases of potential life-threatening emergencies the dispatch center dispatches an additional team with an on-board EP. During the years 2017-2018 nearly every fifth EP mission in Innsbruck (including surrounding areas) ended in a cancellation. The numbers of patient handovers from EP to EMT are slightly lower with mission cancellations resulting in every fourth patient. Therefore, due to the high number of cancellations and handovers evaluated in this study, the findings suggest that there is a potential need to re-evaluate procedures. The re-evaluation of these procedures could determine whether these cancellations/handovers were justified or if an over hasty decision making was at fault. All cases considered in this study were from the Innsbruck and Telfs EP bases between 1 January 2017 and 13 December 2018.

METHODS

Out of a total of 96,908 emergency dispatches, there were 2470 cancellation/handover occurrences. These occurrences consisted of 1190 cancellations and 1280 patient handovers from the EP to the EMT. Patients who were transferred to the University Hospital Innsbruck were included in these figures. The protocols of the emergency dispatches have been filtered from the so-called CarPC. They have subsequently been grouped into cancellation and handover categories. The clinical diagnoses of the patients with inpatient treatment were evaluated from the hospital information system (KIS) of the University Hospital Innsbruck. This was done with the help of the so-called emergency physician indications catalogue of the German Medical Council. The diagnosis was documented in the hospital information system. The emergency protocols from the EMTs were also evaluated retrospectively. The Innsbruck based EP patients are hospitalized in the Innsbruck Hospital due their geographical position. When there is no need for a specific intervention the patients of the EPs based in Telfs are transferred to a local hospital. When a specific intervention is necessary, patient care must be provided by the University Hospital Innsbruck. Due to the privacy practices of the Innsbruck Medical University "vote of ethics" only the data of patients transferred to the Innsbruck Clinic can be evaluated. The information provided from the EPs based in Innsbruck was exclusively from the University Hospital Innsbruck's anesthesiologists. The physicians from the Telfs EP base are of mixed medical specialities. All of them, however, have an emergency medical physician diploma, in addition to the ius practicandi. Lastly, there are no EPs in Innsbruck or Telfs, who have any special obligations during their duty.

RESULTS

The results show that in 210 cases (8.5%) the indications for the EP, based on the emergency physician indications catalogue of the German Medical Council were given. Also, 8.7% of all cancellations and 8.4% of patient handovers were not justified. Patients with emergency indications had a longer hospitalization. The EP base EMS Innsbruck had more cancellations than the EP base EMS Telfs. The EMS Innsbruck also had more cancellations than patient handovers. Conversely, the EMS Telfs had more patient handovers than cancellations. On the weekends between 6:00 pm and 6:00 am there were less cancellations and handovers from both EP bases. The documentation from the EMT protocols was incomplete in 284 cancellations (23.9% of the cancellations) and 339 handovers (26.5% of the handovers), 35 patients after cancellations (2.9%), 35 patients after handovers (2.7%) needed intensive care treatment, 20 patients after cancellations (1.7% of all cancellations), and 24 patients after handovers (1.9% of all handovers) who needed intensive care treatment had a critical diagnosis. In 40 cases of patient handovers, the EP was alerted to another emergency follow-up within 10 min.

CONCLUSION

In Austria, the introduction of a standardized emergency indication checklist might help dispatch centers to provide a more accurate dispatch as well as all EMS team members. Furthermore, a better traceability system (according to EP cancellations and patient handovers from the EP to the EMT) could be achieved. The documentation requirements should be more precise by all members of the EMT staff, not only for the legal aspects but also for improving the overall management quality. Intense education and training as well as diagnosis feedbacks could help to reduce the number of risky cancellations/patient handovers.

Tele-EMS physicians improve life-threatening conditions during prehospital emergency missions

Almost seven years ago, a telemedicine system was established as an additional component of the city of Aachen's emergency medical service (EMS). It allows paramedics to engage in an immediate consultation with an EMS physician at any time. The system is not meant to replace the EMS physician on the scene during life-threatening emergencies. The aim of this study was to analyze teleconsultations during life-threatening missions and evaluate whether they improve patient care. Telemedical EMS (tele-EMS) physician consultations that occurred over the course of four years were evaluated. Missions were classified as involving potentially life-threatening conditions based on at least one of the following criteria: documented patient severity score, life-threatening vital signs, the judgement of the onsite EMS physician involved in the mission, or definite life-threatening diagnoses. The proportion of vital signs indicating that the patient was in a life-threatening condition was analyzed as the primary outcome at the start and end of the tele-EMS consultation. The secondary outcome parameters were the administered drug doses, tracer diagnoses made by the onsite EMS physicians during the missions, and quality of the documentation of the missions. From January 2015 to December 2018, a total of 10,362 tele-EMS consultations occurred; in 4,293 (41.4%) of the missions, the patient was initially in a potentially life-threatening condition. Out of those, a total of 3,441 (80.2%) missions were performed without an EMS physician at the scene. Records of 2,007 patients revealed 2,234 life-threatening vital signs of which 1,465 (65.6%) were remedied during the teleconsultation. Significant improvement was detected for oxygen saturation, hypotonia, tachy- and bradycardia, vigilance states, and hypoglycemia. Teleconsultation during missions involving patients with life-threatening conditions can significantly improve those patients' vital signs. Many potentially life-threatening cases could be handled by a tele-EMS physician as they did not require any invasive interventions that needed to be performed by an onsite EMS physician. Diagnoses of myocardial infarction, cardiac pulmonary edema, or malignant dysrhythmias necessitate the presence of onsite EMS physicians. Even during missions involving patients with life-threatening conditions, teleconsultation was feasible and often accessed by the paramedics.

[System and skill utilization in an Austrian emergency physician system: retrospective study]

BACKGROUND

The continuous rise in calls for emergency physicians and the low proportion of indicated missions has led to a loss of job attractiveness, which in turn renders services in some areas unable to sufficiently staff units. This retrospective analysis evaluated the frequency of emergency and general medical interventions in a ground-based emergency physician response system.

METHODS

A retrospective analysis of anonymized data from the electronic documentation system of the emergency physician response unit at the Medical University of Graz was carried out. Calls answered by emergency physicians between 2010 and 2018 were extracted, measures carried out were evaluated and categorized into three groups: specific emergency interventions (category I), general medical interventions (category II) and no medical activity (category III). The frequency of occurrence of these categories was compared and incidences of individual measures per 100,000 inhabitants were calculated.

RESULTS

A total of 15,409 primary responses and 322 secondary transports were extracted and analyzed. The annual rate of system activation rose almost continuously from 1442 calls in 2010 to 2301 calls in 2018. The 3687 (23.4%) cancellations resulted in 12,044 patient contacts. Of these, 2842 (18%) calls were coded as category I, 7372 (47%) as category II and 5518 (35%) as category III. The frequency of specific emergency measures and general medical interventions was estimated at 157/100,000 and 409/100,000 inhabitants, respectively.

CONCLUSIONS

No specific emergency physician interventions were required in the majority of call-outs. The current model of preclinical care does not appear to be patient-oriented and efficient. Furthermore, the low proportion of critically ill and injured patients already leads to a reduction in attractiveness for emergency physicians and may introduce the threat of quality issues due to insufficient routine experience and lack of training.

[Practical training for paramedics : Transformation at the Leipzig University teaching hospital]

BACKGROUND

The "Notfallsanitätergesetz" (the law pertaining to paramedics), which came into effect in January 2014, has fundamentally changed the training of health personnel in German prehospital emergency medicine. The apprenticeship now takes 3 years including 720 h of practical training in eligible hospitals. To date, however, there has been little experience of how the contents of the guidelines for practical training ("Ausbildungs- und Prüfungsverordnung") can be reasonably applied in the teaching hospitals.

METHODS

In a total of nine interdisciplinary working group meetings between October 2014 and June 2016, we developed a curriculum concerning the practical training of paramedics to implement the contents of the guidelines for practical training in a didactically and an organizationally meaningful way.

RESULTS

The implementation of the practical training of paramedics is an excellent chance for the teaching hospitals to contribute to higher quality prehospital emergency medicine. Otherwise, the teaching hospitals face an organizational and personal effort that is not to be underestimated. Thus, a modular curriculum constitutes the possibility of standardizing practical training and simultaneously reducing the time and expenditure for the participating hospitals.

CONCLUSION

The development of a unique curriculum for the practical training of paramedics may contribute to standardized, high-quality, and cost-efficient training.