Lower mortality after prehospital recognition and treatment followed by fast tracking to coronary care compared with admittance via emergency department in patients with ST-elevation myocardial infarction

Direct Admission to Hospital for Children in the United States

One in four unscheduled hospital admissions for children and adolescents in the United States occurs via direct admission, defined as hospital admission without first receiving care in the hospital's emergency department. The purpose of this policy statement is to present recommendations to optimize the quality and safety of this hospital admission approach for children. Recommendations included in this policy statement provide guidance related to: (i) direct admission written guidelines, (ii) clear systems of communication between members of the health care team and with families of children requiring admission, (iii) triage systems to identify patient acuity and disease severity, (iv) identification of hospital resources needed to support direct admission systems of care, (v) consideration of patient populations that may be at increased risk of adverse outcomes during the hospital admission process, (vi) addressing the relevance of local factors and resources, and (vii) ongoing evaluation of direct admission processes and outcomes. The recommendations included in this policy statement are intended to support the implementation of safe direct admission processes and to foster awareness of outcomes associated with this common portal of hospital admission.

Association between prehospital recognition of acute myocardial infarction and length of stay in the emergency department

OBJECTIVE

This study aimed to evaluate the association between prehospital recognition of acute myocardial infarction (AMI) and length of stay (LOS) in the emergency department (ED) of emergency medical service (EMS)-transported AMI patients.

METHODS

A multicenter retrospective observational study was conducted using prehospital and hospital data from three tertiary emergency departments. Patients diagnosed with AMI between January 2015 and December 2018 were enrolled. Study groups were categorized according to prehospital recognition and prehospital 12-lead electrocardiography (ECG) into three groups based on an EMS cardiovascular registry: group A, no prehospital recognition (reference group); group B, prehospital recognition without 12-lead ECG; and group C, prehospital recognition with 12-lead ECG. The primary outcome was an ED LOS of less than 4 hours.

RESULTS

Among 1,237 study participants, 722 (58.4%) were in group A, 325 (26.3%) were in group B, and 190 (15.4%) were in group C. Multivariable logistic regression showed that groups B and C had a higher likelihood of a short ED LOS (adjusted odds ratio [95% confidence interval]: group B, 1.64 [1.21-2.22] and group C, 1.88 [1.30-2.71]) than group A. There was no significant difference in ED LOS according to whether prehospital 12-lead ECG was conducted.

CONCLUSION

Prehospital recognition of AMI by EMS personnel, with or without 12-lead ECG, was associated with a short ED LOS.

Barriers and requirements in the off-line emergency medical protocols implementation in Iranian Pre-hospital system: A qualitative study

BACKGROUND

To avoid making decisions based on the unproven opinions of emergency medical technicians (EMTs), many emergency medical service (EMS) systems rely on emergency medical protocols. As protocol-based on-scene decision-making is influenced by many challenges, identifying these challenges can result in providing appropriate conditions for EMTs' decision-making. Therefore, this study aimed to identify the barriers and requirements in the off-line emergency medical protocols implementation m in the prehospital emergency medical system.

MATERIALS AND METHODS

To conduct this study, qualitative content analysis using 10 field observations, 22 interviews, and 2 rounds of focus group discussions was applied. The duration of interviews lasted from October 2019 to January 2020. The Graneheim and Lundman approach was used to analyze the data.

RESULTS

Seven categories (15 subcategories) including education and awareness (professional training and education and community-based education); attitudes (professional attitude and community attitude); interactions and coordination (interpersonal interactions, organizational interferences, and community's interactions); rules and instructions (instructions and supportive rules); control system (monitoring and evaluation and motivational system); accessibility (recourses and communication); and organization (structure and process) were obtained as the obstacles and challenges in the offline emergency medical protocol implementation in the prehospital system.

CONCLUSIONS

There are many challenges in implementing offline emergency medical protocols in the prehospital emergency system. To achieve the effectiveness and efficiency of offline prehospital emergency protocols, it is necessary to facilitate these challenges and improve the EMTs' knowledge, attitude, and performance through cooperative and skill-based education. The findings of this study can be useful for EMS systems from national to local levels.

Impact of myocardial infarction symptom presentation on emergency response and survival

AIMS

We examined associations between symptom presentation and chance of receiving an emergency dispatch and 30-day mortality among patients with acute myocardial infarction (MI).

METHODS AND RESULTS

Copenhagen, Denmark has a 24-h non-emergency medical helpline and an emergency number 1-1-2 (equivalent to 9-1-1). Both services register symptoms/purpose of calls. Among patients with MI as either hospital diagnosis or cause of death within 72 h after a call, the primary symptom was categorized as chest pain, atypical symptoms (breathing problems, unclear problem, central nervous system symptoms, abdominal/back/urinary, other cardiac symptoms, and other atypical symptoms), unconsciousness, non-informative symptoms, and no recorded symptoms. We identified 4880 emergency and 3456 non-emergency calls from patients with MI. The most common symptom was chest pain (N = 5219) followed by breathing problems (N = 556). Among patients with chest pain, 95% (3337/3508) of emergency calls and 76% (1306/1711) of non-emergency calls received emergency dispatch. Mortality was 5% (163/3508) and 3% (49/1711) for emergency/non-emergency calls, respectively. For atypical symptoms 62% (554/900) and 17% (137/813) of emergency/non-emergency calls received emergency dispatch and mortality was 23% (206/900) and 15% (125/813). Among unconscious, patients 99%/100% received emergency dispatch and mortality was 71%/75% for emergency/non-emergency calls. Standardized 30-day mortality was 4.3% for chest pain and 15.6% for atypical symptoms, and associations between symptoms and emergency dispatch remained in subgroups of age and sex.

CONCLUSION

Myocardial infarction patients presenting with atypical symptoms when calling for help have a reduced chance of receiving an emergency dispatch and increased 30-day mortality compared to MI patients with chest pain.

Healthcare pathways and resource use: mapping consequences of ambulance assessment for direct care with alternative healthcare providers

Background

A decision system in the ambulance allowing alternative pathways to alternate healthcare providers has been developed for older patients in Stockholm, Sweden. However, subsequent healthcare resource use resulting from these pathways has not yet been addressed. The aim of this study was therefore to describe patient pathways, healthcare utilisation and costs following ambulance transportation to alternative healthcare providers.

Methods

The design of this study was descriptive and observational. Data from a previous RCT, where a decision system in the ambulance enabled alternative healthcare pathways to alternate healthcare providers were linked to register data. The receiving providers were: primary acute care centre or secondary geriatric ward, both located at the same community hospital, or the conventional pathway to the emergency department at an acute hospital. Resource use over 10 days, subsequent to assessment with the decision system, was mapped in terms of healthcare pathways, utilisation and costs for the 98 included cases.

Results

Almost 90% were transported to the acute care centre or geriatric ward. The vast majority arriving to the geriatric ward stayed there until the end of follow-up or until discharged, whereas patients conveyed to the acute care centre to a large extent were admitted to hospital. The median patient had 6 hospital days, 2 outpatient visits and costed roughly 4000 euros over the 10-day period. Arrival destination geriatric ward indicated the longest hospital stay and the emergency department the shortest. However, the cost for the 10-day period was lower for cases arriving to the geriatric ward than for those arriving to the emergency department.

Conclusions

The findings support the appropriateness of admittance directly to secondary geriatric care for older adults. However, patients conveyed to the acute care centre ought to be studied in more detail with regards to appropriate level of care.

Direct in-hospital admission via ambulance (DIVA): A retrospective observational study

BACKGROUND

Prolonged stays in emergency departments increase the risk of adverse events in elderly patients. To optimize care for nonurgent patients who need in-hospital admission, a patient-focused improvement project named Direct In-hospital admission Via Ambulance (DIVA) was launched at Örebro University Hospital.

PURPOSE

This study describes the effects of DIVA. The primary outcome was time to in-hospital admission. Secondary outcomes were the in-hospital admission rate, the in-hospital length of stay and patient characteristics.

METHOD

This was a retrospective observational study. Descriptive and comparative statistics were used. All patients identified by the ambulance nurse as nonurgent but with an apparent need for in-hospital admission were candidates for direct in-hospital admission. The results were compared with those of a reference group.

RESULT

In total, 127 patients were included, with 45 patients in the DIVA group and 82 patients in the reference group. In the DIVA group, 24 patients were directly admitted. The median time to in-hospital admisson was 49.5 min for direct admitted patients and 278.5 min for the reference group. There was a statistical significant difference between the groups (p < 0.01).

CONCLUSION

The current study indicates that time to in-hospital admission could be reduced by DIVA.

Dyadic teams and nursing care: A critical incident study of nurses in the emergency medical service

AIM AND OBJECTIVES

The aim of the study was to describe Emergency Medical Services (EMS) nurses' experiences of and coping with critical incidents, when providing nursing care as a member of a dyadic team.

BACKGROUND

Nursing care in EMS is a complex task, taking into account the physical, psychological as well as existential dimensions of the patient's suffering. In this, EMS nurses are dependent on the dyadic team. Teams in EMS are described as essential for providing safe medical care. However, nursing care also comprises relationships with patients as a means of reducing patient suffering.

DESIGN

The study has an inductive descriptive qualitative design, in adherence to the COREQ-checklist.

METHODS

A critical incident technique was used. Thirty-five EMS nurses were interviewed individually, with a focus on dyadic teams providing nursing care. The interviews were analysed with the aim of defining main areas, categories and sub-categories.

RESULTS

The experiences of critical incidents emerged to form two main areas: "Functional co-operation" and "Dysfunctional co-operation," comprising seven categories and sixteen sub-categories. Their coping with critical incidents encompassed two main areas: "Adapting oneself" and "Adapting nursing care and the colleague," comprising four categories and eight sub-categories.

CONCLUSIONS

Reflection as part of the daily practice emerges as important for the development of nursing care both in relation to individual team members and also the dyadic team as a unit. In addition, the results highlight consensus within dyadic teams regarding the objectives of nursing care, as well as the importance of defined roles.

RELEVANCE TO CLINICAL PRACTICE

This study underlines the importance of strengthening the dyadic EMS team's ability to co-operate using common goals and knowledge within clinical nursing care. The individual team members' different roles have to be explicit. In addition, clinical care has to be organised to generate preconditions for mutual performance monitoring through collegial feedback and reflection.

Ambulance nurses’ experiences of patient relationships in urgent and emergency situations: A qualitative exploration

Background

The ambulance service provides emergency care to meet the patient’s medical and nursing needs. Based on professional nursing values, this should be done within a caring relationship with a holistic approach as the opposite would risk suffering related to disengagement from the patient’s emotional and existential needs. However, knowledge is sparse on how ambulance personnel can meet caring needs and avoid suffering, particularly in conjunction with urgent and emergency situations.

Aim

The aim of the study was to explore ambulance nurses’ experiences of relationships with patients in urgent and emergency situations.

Methods

Data collection was performed using individual open-ended interviews with six ambulance nurses. The data were analyzed using a thematic analysis.

Results

Relationships with patients during urgent and emergency assignments emerged as three themes: “ Ambiguous silence,” “ Professional competence” and “ Challenging inadequacy” comprising eight sub-themes in total. The result shows that the ambulance nurses found it difficult to prioritize between medical care and establishing a caring relationship with the patient. However, sometimes a wordless relationship was perceived sufficient and considered a first step towards a verbal relationship.

Conclusions

Ambulance nurses experience that a caring relationship cannot and does not need to be prioritized in the acute stage. This uncovers a dichotomy approach to medical care versus caring relationships that exclude a holistic approach. Thus, patients’ emotional, existential and physical needs are not considered as equally important. Clinical relevance: It is important to stimulate reflection on core ethical nursing values, in training and simulation exercises among clinically active ambulance nurses.

Improving the prehospital management of ST elevation myocardial infarction: a national quality improvement initiative

ST elevation myocardial infarction (STEMI) is a time-dependent clinical emergency. Early recognition and intervention in the clinical course of STEMI are key to reducing mortality and morbidity. As a result, the benefits of the prehospital management of patients presenting with STEMI are well supported by the literature. Given these benefits, much of the focus on the development of quality and performance measures for Emergency Medical Services has focused on STEMI care. Historically, within Qatar, however, no measures of prehospital STEMI care have previously existed and as such, little is understood regarding the quality of prehospital care delivered to patients with STEMI. The overall aim of this national initiative was to improve the effectiveness of the prehospital care of patients with STEMI, to a minimum compliance of 75%, as measured by four process measures and one bundle measure, over a 12-month period. Initial efforts were aimed at the development of relevant indicators to guide assessment and identifying an appropriate patient cohort to test improvement efforts. Using these measures and criteria, the project team highlighted several areas for potential improvement centred on three key domains within the service: clinical practice, training and clinical equipment/medication. There was significant and sustained improvement across all measures recorded. For the bundle measure, the median proportional compliance increased from 39% pre-improvement activities to 76% post-improvement activities and remained sustained at 12 months post-implementation. The initiative was successful in meeting all of its aims and furthermore showed sustained compliance at 12 months post-implementation, thanks in part to what were designed to be changes that were simple, yet pragmatic, and readily producible at scale. While a formal cost analysis was not conducted, the improvement activities capitalised on existing organisational structures and processes with the resultant cost perceived to be negligible.

The future of recovery - Integrated, digitalised and in real time

Traditional perioperative risk prediction recovery identifies patient populations at risk of suboptimal recovery but not individual patients in whom this actually occurs and in whom timely intervention is beneficial. Patient-focused recovery emphasises a return to a semblance of normality and an ability to perform activities previously undertaken. A patient's sense of self-efficacy and engagement in their own care positively influences functional improvement and emotive recovery. The future of recovery assessment is that which is individualised, digitalised, integrated and in real time. Real-time recovery (RTR) assessment is the contemporaneous collection, analysis and reporting of data that enable the identification of suboptimal recovery in individual patients in a timeframe that minimises the delay in the implementation of the targeted treatment. There is a need to validate the clinical utility of existing biometric technology, wireless hybrid devices and digitalised platforms in providing both clinician and patient with RTR data and to determine the effect, if any, that RTR has on patient engagement and outcome.

Hospital-Confirmed Acute Myocardial Infarction: Prehospital Identification Using the Medical Priority Dispatch System

Introduction

Early recognition of an acute myocardial infarction (AMI) can increase the patient’s likelihood of survival. As the first point of contact for patients accessing medical care through emergency services, emergency medical dispatchers (EMDs) represent the earliest potential identification point for AMIs. The objective of the study was to determine how AMI cases were coded and prioritized at the dispatch point, and also to describe the distribution of these cases by patient age and gender.

Hypothesis/Problem

No studies currently exist that describe the EMD’s ability to correctly triage AMIs into Advanced Life Support (ALS) response tiers.

Methods

The retrospective descriptive study utilized data from three sources: emergency medical dispatch, Emergency Medical Services (EMS), and emergency departments (EDs)/hospitals. The primary outcome measure was the distributions of AMI cases, as categorized by Chief Complaint Protocol, dispatch priority code and level, and patient age and gender. The EMS and ED/hospital data came from the Utah Department of Health (UDoH), Salt Lake City, Utah. Dispatch data came from two emergency communication centers covering the entirety of Salt Lake City and Salt Lake County, Utah.

Results

Overall, 89.9% of all the AMIs (n=606) were coded in one of the three highest dispatch priority levels, all of which call for ALS response (called CHARLIE, DELTA, and ECHO in the studied system). The percentage of AMIs significantly increased for patients aged 35 years and older, and varied significantly by gender, dispatch level, and chief complaint. A total of 85.7% of all deaths occurred among patients aged 55 years and older, and 88.9% of the deaths were handled in the ALS-recommended priority levels.

Conclusion

Acute myocardial infarctions may present as a variety of clinical symptoms, and the study findings demonstrated that more than one-half were identified as having chief complaints of Chest Pain or Breathing Problems at the dispatch point, followed by Sick Person and Unconscious/Fainting. The 35-year age cutoff for assignment to higher priority levels is strongly supported. The Falls and Sick Person Protocols offer opportunities to capture atypical AMI presentations.

ClawsonJJ, GardettI, ScottG, FivazC, BarronT, BroadbentM, OlolaC. Hospital-confirmed acute myocardial infarction: prehospital identification using the Medical Priority Dispatch System. Prehosp Disaster Med. 2018;33(1):29–35.

Population access to reperfusion services for ST-segment elevation myocardial infarction in Kerala, India

Background

Population access to timely reperfusion is a decisive factor in determining the success and acceptability of any regional system of ST-segment elevation myocardial infarction (STEMI) care. We sought to determine the proportion of population of the southern Indian state of Kerala having timely access to STEMI reperfusion.

Methods

We identified the STEMI reperfusion facilities available at all acute-care hospitals, in Kerala, by conducting a cross-sectional survey. We mapped the geographical catchment areas of these hospitals using historical travel speeds and appropriate Geospatial Information Systems (GIS) analyses. Subsequently, using block level population data, we estimated the proportion of the population residing within these geographies.

Results

We estimated that 23.33 million people, forming 69.84% of the state population, resided in the green zone (within half-hour travel distance of a percutaneous coronary intervention [PCI]-capable hospital), which covered 47.94% of the geographical area of the state. Outside this green zone, 21.87% of the state population resided within 1 hr travel distance of a thrombolysis-capable hospital. Finally, 8.28% of the state population resided in the red zone, where access to any reperfusion-capable hospital took >1 hr, which covered 22.15% of the geographical area of the state.

Conclusions

A majority of the population of Kerala had timely access to PCI-capable hospitals. GIS-based mapping of Indian states, in terms of access to STEMI reperfusion, may help devise protocols to achieve seamless transfer of patients to reperfusion-capable hospitals. Such regionalization of STEMI care would enhance organizational synergies to achieve better access to reperfusion, especially in remote areas.

Prehospital factors associated with an acute life-threatening condition in non-traumatic chest pain patients - A systematic review

BACKGROUND

Chest pain is a common symptom among patients contacting the emergency medical services (EMS). Risk stratification of these patients is warranted before arrival in hospital, regarding likelihood of an acute life-threatening condition (LTC).

AIM

To identify factors associated with an increased risk of acute LTC among patients who call the EMS due to non-traumatic chest pain.

METHODS

Several databases were searched for relevant articles. Identified articles were quality-assessed using the Scottish Intercollegiate Guidelines Network checklists. Extracted data was analysed using a semi-quantitative synthesis evaluating the level of evidence of each identified factor.

RESULTS

In total, 10 of 1245 identified studies were included. These studies provided strong evidence for an increased risk of an acute LTC with increasing age, male gender, elevated heart rate, low systolic blood pressure and ST elevation or ST depression on a 12-lead ECG. The level of evidence regarding the history of myocardial infarction, angina pectoris or presence of a Q wave or a Left Bundle Branch Block on the ECG was moderate. The evidence was inconclusive regarding dyspnoea, cold sweat/paleness, nausea/vomiting, history of chronic heart failure, smoking, Right Bundle Branch Block or T-inversions on the ECG.

CONCLUSIONS

Factors reflecting age, gender, myocardial ischemia and a compromised cardiovascular system predicted an increased risk of an acute life-threatening condition in the prehospital setting in cases of acute chest pain. These factors may form the basis for prehospital risk stratification in acute chest pain.

Exploration of contextual factors in a successful quality improvement collaborative in English ambulance services: cross-sectional survey

RATIONALE, AIMS AND OBJECTIVES

Clinical leadership and organizational culture are important contextual factors for quality improvement (QI) but the relationship between these and with organizational change is complex and poorly understood. We aimed to explore the relationship between clinical leadership, culture of innovation and clinical engagement in QI within a national ambulance QI Collaborative (QIC).

METHODS

We used a self-administered online questionnaire survey sent to front-line clinicians in all 12 English ambulance services. We conducted a cross-sectional analysis of quantitative data and qualitative analysis of free-text responses.

RESULTS

There were 2743 (12% of 22 117) responses from 11 of the 12 participating ambulance services. In the 3% of responders that were directly involved with the QIC, leadership behaviour was significantly higher than for those not directly involved. QIC involvement made no significant difference to responders' perceptions of the culture of innovation in their organization, which was generally considered poor. Although uptake of QI methods was low overall, QIC members were significantly more likely to use QI methods, which were also significantly associated with leadership behaviour.

CONCLUSIONS

Despite a limited organizational culture of innovation, clinical leadership and use of QI methods in ambulance services generally, the QIC achieved its aims to significantly improve pre-hospital care for acute myocardial infarction and stroke. We postulate that this was mediated through an improvement subculture, linked to the QIC, which facilitated large-scale improvement by stimulating leadership and QI methods. Further research is needed to understand success factors for QI in complex health care environments.

How the context of ambulance care influences learning to become a specialist ambulance nurse a Swedish perspective

OBJECTIVES

Ambulance emergency care is multifaceted with extraordinary challenges to implement accurate assessment and care. A clinical learning environment providing opportunities for mastering these essential skills is a key component in ensuring that prehospital emergency nurse (PEN) students acquire the necessary clinical competence.

AIM

The aim is to understand how PEN students experience their clinically based training, focusing on their learning process.

METHOD

We applied content analysis with its qualitative method to our material that consisted of three reflections each by 28 PEN students over their learning process during their 8 weeks of clinical ambulance practice. The research was carried out at the Center for Prehospital Care, University of Borås, Sweden.

RESULTS

The broad spectrum of ambulance assignments seems to awaken great uncertainty and excessive respect in the students. Student vulnerability appears to decrease when the clinical supervisor behaves calmly, knowledgeably, confidently and reflectively. Early traumatic incidents on the other hand may increase the students' anxiety. Each student is offered a unique opportunity to learn how to approach patients and relatives in their own environments, and likewise an opportunity to gather information for assessment. Infrequency of missions seems to make PEN students less active in their student role, thereby preventing them from availing themselves of potential learning situations. Fatigue and hunger due to lack of breaks or long periods of transportation also inhibit learning mode.

CONCLUSION

Our findings suggest the need for appraisal of the significance of the clinical supervisor, the ambulance environment, and student vulnerability. The broad spectrum of conditions in combination with infrequent assignments make simulation necessary. However, the unique possibilities provided for meeting patients and relatives in their own environments offer the PEN student excellent opportunities for learning how to make assessments.

Development of key performance indicators for prehospital emergency care

INTRODUCTION

Key performance indicators (KPIs) are used to monitor and evaluate critical areas of clinical and support functions that influence patient outcome. Traditional prehospital emergency care performance monitoring has focused solely on response time metrics. The landscape of emergency care delivery in Ireland is in the process of significant national reconfiguration. The development of KPIs is therefore considered one of the key priorities in prehospital research.

AIMS

The aim of this study was to develop a suite of KPIs for prehospital emergency care in Ireland.

METHODS

A systematic literature review of prehospital care performance measurement was undertaken followed by a three-round Delphi consensus process facilitated by a broad-based multidisciplinary group of panellists. The consensus process was conducted between June 2012 and October 2013. Each candidate indicator on the Delphi survey questionnaire was rated using a 5-point Likert-type rating scale. Agreement was defined as at least 70% of responders rating an indicator as 'agree' or 'strongly agree' on the rating scale. Data were analysed using descriptive statistics. Sensitivity of the ratings was examined for robustness by bootstrapping the original sample.

RESULTS

Of the 78 citations identified by the systematic review, 5 relevant publications were used to select candidate indicators for the Delphi round 1 questionnaire. Response rates in Delphi rounds 1 and 2 were 89% and 83%, respectively. Following the consensus development conference, 101 KPIs reached consensus. Based on the Donabedian framework for quality-of-care indicators, 7 of the KPIs which reached agreement were structure KPIs, 74 were process KPIs and 20 were outcome KPIs. The highest ranked indicator was a process KPI ('Direct transport of ST-elevation myocardial infarction patients to a primary percutaneous intervention (PCI)-capable facility for ECG to PCI time <90 min').

CONCLUSION

Improving the quality of prehospital care requires the development and implementation of performance measurement using scientifically valid and reliable KPIs. Employing a Delphi panel of key multidisciplinary Emergency Medical Service stakeholders, it was feasible to develop a suite of 101 KPIs for performance monitoring of prehospital emergency care in Ireland. This suite of KPIs may contribute to a framework for achieving safer, better care in the prehospital environment.

Physician perceptions and recommendations about pre-hospital emergency medical services for patients with ST-elevation acute myocardial infarction in Abu Dhabi

Introduction

Physician perceptions about emergency medical services (EMS) are important determinants of improving pre-hospital care for cardiac emergencies. No data exist on physician attitudes towards EMS care of patients with ST-Elevation Myocardial Infarction (STEMI) in the Emirate of Abu Dhabi.

Objectives

To describe the perceptions towards EMS among physicians caring for patients with STEMI in Abu Dhabi.

Methods

We surveyed a convenience sample of physicians involved in the care of patients with STEMI (emergency medicine, cardiology, cardiothoracic surgery and intensive care) in four government facilities with 24/7 Primary PCI in the Emirate of Abu Dhabi. Surveys were distributed using dedicated email links, and used 5-point Likert scales to assess perceptions and attitudes to EMS.

Results

Of 106 physician respondents, most were male (82%), practicing in emergency medicine (47%) or cardiology (44%) and the majority (63%) had been in practice for >10 years. Less than half of the responders (42%) were “Somewhat Satisfied” (35%) or “Very Satisfied” (7%) with current EMS level of care for STEMI patients. Most respondents were “Very Likely” (67%) to advise a patient with a cardiac emergency to use EMS, but only 39% felt the same for themselves or their family. Most responders were supportive (i.e. “Strongly Agree”) of the following steps to improve EMS care: 12-lead ECG and telemetry to ED by EMS (69%), EMS triage of STEMI to PCI facilities (65%), and activation of PCI teams by EMS (58%). Only 19% were supportive of pre-hospital fibrinolytics by EMS. There were no significant differences in the responses among the specialties.

Conclusions

Most physicians involved in STEMI care in Abu Dhabi are very likely to advise patients to use EMS for a cardiac emergency, but less likely to do so for themselves or their families. Different specialties had concordant opinions regarding steps to improve pre-hospital EMS care for STEMI.

Electrocardiogram interpretation skills among ambulance nurses

BACKGROUND

To describe ambulance nurses' practical electrocardiogram (ECG) interpretation skills and to measure the correlation between these skills and factors that may impact on the level of knowledge.

METHODS

This study was conducted using a prospective quantitative survey with questionnaires and a knowledge test. A convenience sample collection was conducted among ambulance nurses in three different districts in western Sweden. The knowledge test consisted of nine different ECGs. The score of the ECG test were correlated against the questions in the questionnaire regarding both general ECG interpretation skill and ability to identify acute myocardial infarction using Mann-Whitney U test, Kruskal-Wallis test and Spearman's rank correlation.

RESULTS

On average, the respondents had 54% correct answers on the test and identified 46% of the ECGs indicating acute myocardial infarction. The median total score was 9 of 16 (interquartile range 7-11) and 1 of 3 (IQR 1-2) in infarction points. No correlation between ECG interpretation skill and factors such as education and professional experience was found, except that coronary care unit experience was associated with better results on the ECG test.

CONCLUSIONS

Ambulance nurses have deficiencies in their ECG interpretation skills. This also applies to conditions where the ambulance crew has great potential to improve the outcome of the patient's health, such as myocardial infarction and cardiac arrest. Neither education, extensive experience in ambulance service nor in nursing contributed to an improved result. The only factor of importance for higher ECG interpretation knowledge was prior experience of working in a coronary care unit.

A pathway care model allowing low-risk patients to gain direct admission to a hospital medical ward--a pilot study on ambulance nurses and Emergency Department physicians

A pathway care model allowing low-risk patients to gain rapid admission to a hospital medical ward - a pilot study on ambulance nurses and Emergency Department physicians.

BACKGROUND

Patients with non-urgent medical symptoms who nonetheless require inpatient hospital treatment often have to wait for an unacceptably long time at the Emergency Department (ED). The purpose of this study is to evaluate the feasibility and effect on length of delay of a pathway care model for low-risk patients who have undergone prehospital assessment by an ambulance nurse and ED assessment by a physician within 10 minutes of arrival at the ED.

METHODS

The pilot study comparing two low-risk groups took place in western Sweden from October 2011 until January 2012. The pathway model for low-risk patients was used prospectively in the rapid admission group (N = 51), who were admitted rapidly after being assessed by the nurse on scene and then assessed by the ED physician on ED admission. A retrospectively assembled control group (N = 51) received traditional care at the ED. All p-values are age-adjusted.

RESULTS

Patients in the rapid admission group were older (mean age 80 years old) than patients in the control group (mean age 73 years old) (p = 0.02). The median delay from arrival at the patient's side until arrival in a hospital medical ward was 57 minutes for the rapid admission group versus 4 hours 13 minutes for the control group (p < 0.0001). However, the median delay time from the ambulance's arrival at the patient's side until the nurse was free for a new assignment was 77 minutes for the rapid admission group versus 49 minutes for the control group (p < 0.0001). The 30-day mortality rate was 20% for the rapid admission group and only 4% for the control group (p = 0.16).

CONCLUSION

The pathway care model for low-risk patients gaining rapid admission to a hospital medical ward shortened length of delay from the first assessment until arrival at the ward. However, the result was achieved at the cost of an increased workload for the ambulance nurse. Furthermore patients who were rapidly admitted to a hospital ward had a high age level and a high early mortality rate. Patient safety in this new model of fast-track assessment needs to be further evaluated.

The impact of direct admission to a catheterisation lab/CCU in patients with ST-elevation myocardial infarction on the delay to reperfusion and early risk of death: results of a systematic review including meta-analysis

Background

For each hour of delay from fist medical contact until reperfusion in ST-elevation myocardial infarction (STEMI) there is a 10% increase in risk of death and heart failure. The aim of this review is to describe the impact of the direct admission of patients with STEMI to a Catheterisation laboratory (cath lab) as compared with transport to the emergency department (ED) with regard to delays and outcome.

Methods

Databases were searched for from April-June 2012 and updated January 2014: 1) Pubmed; 2) Embase; 3) Cochrane Library; 4) ProQuest Nursing and 5) Allied Health Sources. The search was restricted to studies in English, Swedish, Danish and Norwegian languages.

The intervention was a protocol-based clinical pre-hospital pathway and main outcome measurements were the delay to balloon inflation and hospital mortality.

Results

Median delay from door to balloon was significantly shorter in the intervention group in all 5 studies reported. Difference in median delay varied between 16 minutes and 47 minutes.

In all 7 included studies the time from symptom onset or first medical contact to balloon time was significantly shorter in the intervention group. The difference in median delay varied between 15 minutes and 1 hour and 35 minutes. Only two studies described hospital mortality. When combined the risk of death was reduced by 37%.

Conclusion

An overview of available studies of the impact of a protocol-based pre-hospital clinical pathway with direct admission to a cath lab as compared with the standard transport to the ED in ST-elevation AMI suggests the following. The delay to the start of revascularisation will be reduced. The clinical benefit is not clearly evidence based. However, the documented association between system delay and outcome defends the use of the pathway.

Electronic supplementary material

The online version of this article (doi:10.1186/s13049-014-0067-x) contains supplementary material, which is available to authorized users.

Comparison of mortality in patients with acute myocardial infarction accidentally admitted to non-cardiology departments versus that in patients admitted to coronary care units

The aim of this study was to prospectively investigate the clinical characteristics including symptoms and long-term mortality in patients with acute myocardial infarction (AMI) accidentally admitted to non-cardiology departments (NCDs). For comparison, similar observations in patients admitted to the coronary care unit (CCU) were collected. During a 1-year period, consecutive patients having cardiac troponin I measured at the Odense University Hospital were considered. The hospital has 27 clinical departments. Patients were classified as having an AMI if the diagnostic criteria of the universal definition were met. Follow-up was at least 1 year with mortality as the clinical end point. Of 3,762 consecutive patients, an AMI was diagnosed in 479, of whom 114 patients (24%) were hospitalized in NCDs and 365 (76%) in the CCU. Chest pain or chest discomfort more frequently occurred in patients from the CCU (83%) than in patients from the NCDs (45%, p <0.0001). At median follow-up of 2.1 years, 150 patients had died: 73 (64%) of patients from the NCDs and 77 (21%) of the patients from the CCU. In the multivariable Cox regression analysis, the adjusted hazard ratio of mortality for patients from the NCDs versus CCU was 2.0 (95% confidence interval 1.3 to 3.2). In conclusion, chest pain/discomfort was absent in more than half of the patients with AMI admitted to NCDs, and admission to NCDs was an independent predictor of a 2 times higher long-term mortality in comparison with admission to the CCU.

The effect of a Computerised Decision Support System (CDSS) on compliance with the prehospital assessment process: results of an interrupted time-series study

Background

Errors in the decision-making process are probably the main threat to patient safety in the prehospital setting. The reason can be the change of focus in prehospital care from the traditional “scoop and run” practice to a more complex assessment and this new focus imposes real demands on clinical judgment. The use of Clinical Guidelines (CG) is a common strategy for cognitively supporting the prehospital providers. However, there are studies that suggest that the compliance with CG in some cases is low in the prehospital setting. One possible way to increase compliance with guidelines could be to introduce guidelines in a Computerized Decision Support System (CDSS). There is limited evidence relating to the effect of CDSS in a prehospital setting. The present study aimed to evaluate the effect of CDSS on compliance with the basic assessment process described in the prehospital CG and the effect of On Scene Time (OST).

Methods

In this time-series study, data from prehospital medical records were collected on a weekly basis during the study period. Medical records were rated with the guidance of a rating protocol and data on OST were collected. The difference between baseline and the intervention period was assessed by a segmented regression.

Results

In this study, 371 patients were included. Compliance with the assessment process described in the prehospital CG was stable during the baseline period. Following the introduction of the CDSS, compliance rose significantly. The post-intervention slope was stable. The CDSS had no significant effect on OST.

Conclusions

The use of CDSS in prehospital care has the ability to increase compliance with the assessment process of patients with a medical emergency. This study was unable to demonstrate any effects of OST.

The effect of a national quality improvement collaborative on prehospital care for acute myocardial infarction and stroke in England

Background

Previous studies have shown wide variations in prehospital ambulance care for acute myocardial infarction (AMI) and stroke. We aimed to evaluate the effectiveness of implementing a Quality Improvement Collaborative (QIC) for improving ambulance care for AMI and stroke.

Methods

We used an interrupted time series design to investigate the effect of a national QIC on change in delivery of care bundles for AMI (aspirin, glyceryl trinitrate [GTN], pain assessment and analgesia) and stroke (face-arm-speech test, blood pressure and blood glucose recording) in all English ambulance services between January 2010 and February 2012. Key strategies for change included local quality improvement (QI) teams in each ambulance service supported by a national coordinating expert group that conducted workshops educating staff in QI methods to improve AMI and stroke care. Expertise and ideas were shared between QI teams who met together at three national workshops, between QI leads through monthly teleconferences, and between the expert group and participants. Feedback was provided to services using annotated control charts.

Results

We analyzed change over time using logistic regression with three predictor variables: time, gender, and age. There were statistically significant improvements in care bundles in nine (of 12) participating trusts for AMI (OR 1.04, 95% CI 1.04, 1.04), nine for stroke (OR 1.06, 95% CI 1.05, 1.07), 11 for either AMI or stroke, and seven for both conditions. Overall care bundle performance for AMI increased in England from 43 to 79% and for stroke from 83 to 96%. Successful services all introduced provider prompts and individualized or team feedback. Other determinants of success included engagement with front-line clinicians, feedback using annotated control charts, expert support, and shared learning between participants and organizations.

Conclusions

This first national prehospital QIC led to significant improvements in ambulance care for AMI and stroke in England. The use of care bundles as measures, clinical engagement, application of quality improvement methods, provider prompts, individualized feedback and opportunities for learning and interaction within and across organizations helped the collaborative to achieve its aims.

The public's perception of prehospital emergency care in the County of Skane, southern Sweden

INTRODUCTION

The prehospital emergency care has had a rapid progress in Sweden in terms of technology, treatments and personnel education demands. In the County of Skane there is at least one specialized nurse in every ambulance. Possible misuses of the resources by the public have been acknowledged.

AIM

To investigate the public's use, knowledge and expectations of the prehospital emergency care in Skane, southern Sweden.

METHOD

A cross sectional descriptive survey, using a stratified sampling. Inclusion criteria were: 18 year or older and currently living in Skane.

RESULTS

Of 735 people who were asked 54.4% (n=400) chose to participate in the study. 44.0% of the respondents had been transported with ambulance. 34.5% of the respondents believed that the lowest educated personnel responsible for the patient was the paramedic. The results show that the respondents trust the personnel's knowledge and work skills. Older informants expected faster treatment by a physician when arriving by ambulance to the hospital, regardless of medical condition.

CONCLUSION

The public had confidence in the ambulance personnel's knowledge, ability to make assessment and give treatment despite not being updated on the current competence of the personnel. A positive experience of contact with the ambulance service was distinct.

Information on myocardial ischemia and arrhythmias added by prehospital electrocardiograms

BACKGROUND

The prehospital electrocardiogram (ECG) allows earlier identification of acute ST-segment elevation myocardial infarction (STEMI). Its utility for detection of other acute cardiac events, as well as for transient ST-segment abnormalities no longer present when the first hospital ECG is performed, is not well characterized.

OBJECTIVE

We sought to examine whether the prehospital ECG adds supplemental information to the first ECG obtained in hospital, by comparing data on possible cardiac ischemia and arrhythmias provided by the two ECGs, in ambulance patients later diagnosed as having cardiac disorders, including STEMI.

METHODS

Ambulance personnel acquired 12-lead ECGs for patients suspected of having an acute ischemic event, prior to transport to hospital. The first emergency department 12-lead ECG was provided by medical records at the receiving hospital, and the principal hospital diagnosis for the event was extracted from chart data. Two cardiologists, blinded to the hospital diagnosis, provided their consensus interpretation of 1,209 pairs of ECGs, noting the presence or absence of specific abnormalities on each tracing.

RESULTS

Among the 82 patients who had an eventual hospital diagnosis of STEMI, the study cardiologists identified 71 with ST-segment elevations on the ECGs they examined. The vast majority of these (97%) were observed on both ECGs, but the prehospital ECG showed ST-segment elevation for two additional patients (3%). No additional instances were seen only on the hospital ECG. Among the 116 patients with a hospital diagnosis of non-ST-segment elevation myocardial infarction (NSTEMI), the cardiologists identified 36 with ST-segment depressions: 28 (78%) of these were present on both ECGs, seven (19%) only on the prehospital ECG, and one (3%) only on the hospital ECG. Among the 567 patients with any cardiac hospital diagnosis, the cardiologists identified 87 with arrhythmias: 73 (84%) on both ECGs, 12 (14%) only on the prehospital ECG, and two (2%) only on the hospital ECG.

CONCLUSIONS

Beyond identifying ST-segment elevation earlier, prehospital ECGs detect important transient abnormalities, information not otherwise available from the first emergency department ECG. These data can expedite diagnosis and clinical management decisions among patients suspected of having an acute cardiac event. The prehospital ECG should be fully integrated into emergency medicine practice.

The clinical consequences of a pre-hospital diagnosis of stroke by the emergency medical service system. A pilot study

Background

There is still a considerable delay between the onset of symptoms and arrival at a stroke unit for most patients with acute stroke.

The aim of the study was to describe the feasibility of a pre-hospital diagnosis of stroke by an emergency medical service (EMS) nurse in terms of diagnostic accuracy and delay from dialing 112 until arrival at a stroke unit.

Methods

Between September 2008 and November 2009, a subset of patients with presumed acute stroke in the pre-hospital setting were admitted by EMS staff directly to a stroke unit, bypassing the emergency department. A control group, matched for a number of background variables, was created.

Results

In all, there were 53 patients in the direct admission group, and 49 patients in the control group. The median delay from calling for an ambulance until arrival at a stroke unit was 54 minutes in the direct admission group and 289 minutes in the control group (p < 0.0001).

In a comparison between the direct admission group and the control group, a final diagnosis of stroke, transient ischemic attack (TIA) or the sequelae of prior stroke was found in 85% versus 90% (NS). Among stroke patients who lived at home prior to the event, the percentage of patients that were living at home after 3 months was 71% and 62% respectively (NS).

Conclusions

In a pilot study, the concept of a pre-hospital diagnosis of stroke by an EMS nurse was associated with relatively high diagnostic accuracy in terms of stroke-related diagnoses and a short delay to arrival at a stroke unit. These data need to be confirmed in larger studies, with a concomitant evaluation of the clinical consequences and, if possible, the level of patient satisfaction as well.

Suspicion and treatment of severe sepsis. An overview of the prehospital chain of care

BACKGROUND

Sepsis is a life-threatening condition where the risk of death has been reported to be even higher than that associated with the major complications of atherosclerosis, i.e. myocardial infarction and stroke. In all three conditions, early treatment could limit organ dysfunction and thereby improve the prognosis.

AIM

To describe what has been published in the literature a/ with regard to the association between delay until start of treatment and outcome in sepsis with the emphasis on the pre-hospital phase and b/ to present published data and the opportunity to improve various links in the pre-hospital chain of care in sepsis.

METHODS

A literature search was performed on the PubMed, Embase (Ovid SP) and Cochrane Library databases.

RESULTS

In overall terms, we found a small number of articles (n = 12 of 1,162 unique hits) which addressed the prehospital phase. For each hour of delay until the start of antibiotics, the prognosis appeared to become worse. However, there was no evidence that prehospital treatment improved the prognosis.Studies indicated that about half of the patients with severe sepsis used the emergency medical service (EMS) for transport to hospital. Patients who used the EMS experienced a shorter delay to treatment with antibiotics and the start of early goal-directed therapy (EGDT). Among EMS-transported patients, those in whom the EMS staff already suspected sepsis at the scene had a shorter delay to treatment with antibiotics and the start of EGDT.There are insufficient data on other links in the prehospital chain of care, i.e. patients, bystanders and dispatchers.

CONCLUSION

Severe sepsis is a life-threatening condition. Previous studies suggest that, with every hour of delay until the start of antibiotics, the prognosis deteriorates. About half of the patients use the EMS. We need to know more about the present situation with regard to the different links in the prehospital chain of care in sepsis.

The use of a 4-step algorithm in the electrocardiographic diagnosis of ST-segment elevation myocardial infarction by novice interpreters

The electrocardiographic (ECG) diagnosis of ST-segment elevation myocardial infarction (STEMI) represents a challenge to all health care providers, particularly so for the novice ECG interpreter. We have developed--and present in this article--a 4-step algorithm that will detect STEMI in most instances in the prehospital and other nonemergency department (ED) settings. The algorithm should be used in adult patients with chest pain or equivalent presentation who are suspected of STEMI. It inquires as to the presence of ST-segment elevation as well as the presence of STEMI confounding/mimicking patterns; the algorithm also makes use of reciprocal ST-segment depression as an adjunct in the ECG diagnosis of STEMI. If STEMI is detected by this algorithm, then management decisions can be made based upon this ECG diagnosis. If STEMI is not detected using this algorithm, then we can only note that STEMI is not "ruled in"; importantly, STEMI is not "ruled out." In fact, more expert interpretation of the ECG will be possible once the patient (and/or the ECG) arrive in the ED where ECG review can be made with the more complex interpretation used by expert physician interpreters.

Early identification and delay to treatment in myocardial infarction and stroke: differences and similarities

Background

The two major complications of atherosclerosis are acute myocardial infarction (AMI) and acute ischemic stroke. Both are life-threatening conditions characterised by the abrupt cessation of blood flow to respective organs, resulting in an infarction. Depending on the extent of the infarction, loss of organ function varies considerably.

In both conditions, it is possible to limit the extent of infarction with early intervention. In both conditions, minutes count.

This article aims to describe differences and similarities with regard to the way patients, bystanders and health care providers act in the acute phase of the two diseases with the emphasis on the pre-hospital phase.

Method

A literature search was performed on the PubMed, Embase (Ovid SP) and Cochrane Library databases.

Results

In both conditions, symptoms vary considerably. Patients appear to suspect AMI more frequently than stroke and, in the former, there is a gender gap (men suspect AMI more frequently than women).

With regard to detection of AMI and stroke at dispatch centre and in Emergency Medical Service (EMS) there is room for improvement in both conditions. The use of EMS appears to be higher in stroke but the overall delay to hospital admission is shorter in AMI. In both conditions, the fast track concept has been shown to influence the delay to treatment considerably.

In terms of diagnostic evaluation by the EMS, more supported instruments are available in AMI than in stroke. Knowledge of the importance of early treatment has been reported to influence delays in both AMI and stroke.

Conclusion

Both in AMI and stroke minutes count and therefore the fast track concept has been introduced. Time to treatment still appears to be longer in stroke than in AMI. In the future improvement in the early detection as well as further shortening to start of treatment will be in focus in both conditions. A collaboration between cardiologists and neurologists and also between pre-hospital and in-hospital care might be fruitful.

Aspects on the intensity and the relief of pain in the prehospital phase of acute coronary syndrome: experiences from a randomized clinical trial

The primary aim of this study was to evaluate the pain relief and tolerability of two pain-relieving strategies in the prehospital phase of presumed acute coronary syndrome (ACS), and the secondary aim was to assess the relationship between the intensity and relief of pain and heart rate, blood pressure, and ST deviation. Patients with chest pain judged as caused by ACS were randomized (open) to either metoprolol 5 mg intravenously (i.v.) three times at 2-min intervals (n = 84; metoprolol group) or morphine 5 mg i.v. followed by metoprolol 5 mg three times i.v (n = 80; morphine group). Pain was assessed on a 10-grade scale before randomization and 10, 20, and 30 min thereafter. The mean pain score decreased from 6.5 at randomization to 2.8 30 min later, with no significant difference between groups. The percentages with complete pain relief (pain score < or = 1) after 10, 20, and 30 min were 11, 16, and 21%, respectively, with no difference between groups. Hypotension was less frequent in the metoprolol group compared with the morphine group (0 vs. 6.3%; P=0.03), as was nausea/vomiting (7.2 vs. 24.0%; P=0.004). At randomization intensity of pain was associated with degree of ST elevation (P=0.009). The degree of pain relief over 30 min was associated with decrease in heart rate (P=0.03) and decrease in ST elevation (P=0.01).In conclusion, in the prehospital phase of presumed ACS, neither a pain-relieving strategy including an anti-ischemic agent alone nor an analgesic plus anti-ischemic strategy in combination resulted in complete pain relief. Fewer side effects were found with the former strategy. Other pain-relieving strategies need to be evaluated.

Review Article: Examining Treatment of ST-Elevation Myocardial Infarction: The Importance of Early Intervention

Early reperfusion in ST-segment elevation myocardial infarction (STEMI) is imperative. Acute reperfusion may be achieved with fibrinolytic agents and/or percutaneous coronary intervention (PCI); however, PCI is associated with lower rates of death and myocardial infarction compared with fibrinolysis. As treatment delays are associated with worse outcomes, current guidelines recommend minimizing time from symptom onset to treatment initiation. Regardless of the reperfusion strategy, patients with STEMI are at increased risk of early recurrent ischemic events and death. These risks can be significantly reduced by promptly initiating a combination of pharmacotherapies that includes antiplatelet and anticoagulant agents, β-blockers, and inhibitors of the renin-angiotensin-aldosterone system. This manuscript reviews the evidence supporting the most recent guidelines for STEMI management published jointly by the American College of Cardiology and American Heart Association. More recent evidence and its potential impact on future evidence-based guidelines are also addressed.

The relative influence of age, previous history and therapeutic strategies prior to hospital admission among ambulance transported patients with ST-elevation myocardial infarction

Among 388 patients with ST-elevation and myocardial infarction admitted to hospital with ambulance, we found the following to be independent predictors of the short term (30 days) mortality rate; Age and treatment with aspirin prior to hospital admission. The following were associated with long term (30 days to 5 years) mortality rate; age, a history of diabetes and fast track to CCU.