International EMS Systems: The United States: past, present, and future

Shaping the future design of paramedicine: A knowledge to action framework to support paramedic system modernization

BACKGROUND

Over the past two decades, the demands placed on modern paramedic systems has changed. Paramedic services can no longer continue to operate on a traditional response model where more ambulances are deployed to meet the rising demand of patients calling for their health needs. Recent research has explored system design in paramedicine and its relationship with organizational performance. Two subsequent paramedic systems have been identified with one, the Professionally Autonomous paramedic system, being linked to higher performance. Yet, how to operationalize this model for system modernization continues to be a gap in practice.

OBJECTIVE

To provide health leaders and policy makers with a framework from which to drive paramedic system modernization.

METHODS

This study uses the Knowledge to Action framework to develop an implementation plan for systems that seek to modernize their service delivery model toward that of a Professionally Autonomous paramedic system.

RESULTS

A detailed plan of the steps required to undertake system transformation are outlined. Whilst this framework outlines the components required for system modernization, it does not propose an in-depth outline of each of the steps required to achieve each component. Rather, end users are encouraged to develop individual implementation plans tailored to the local context using the comprehensive tools outlined within.

CONCLUSION

This knowledge to action framework provides health leaders and policy makers with a uniform roadmap for paramedic system modernization intended to improve health (clinical) outcomes as well as health system outcomes through the Professional Autonomous paramedicine model.

Hourly Associations between Heat Index and Heat-Related Emergency Medical Service (EMS) Calls in Austin-Travis County, Texas

This paper aims to investigate the following research questions: (1) what are the hourly patterns of heat index and heat-related emergency medical service (EMS) incidents during summertime?; and (2) how do the lagged effects of heat intensity and hourly excess heat (HEH) vary by heat-related symptoms? Using the hourly weather and heat-related EMS call data in Austin-Travis County, Texas, this paper reveals the relationship between heat index patterns on an hourly basis and heat-related health issues and evaluates the immediate health effects of extreme heat events by utilizing a distributed lag non-linear model (DLNM). Delving into the heat index intensity and HEH, our findings suggest that higher heat intensity has immediate, short-term lagged effects on all causes of heat-related EMS incidents, including in cardiovascular, respiratory, neurological, and non-severe cases, while its relative risk (RR) varies by time. HEH also shows a short-term cumulative lagged effect within 5 h in all-cause, cardiovascular, and non-severe symptoms, while there are no statistically significant RRs found for respiratory and neurological cases in the short term. Our findings could be a reference for policymakers when devoting resources, developing extreme heat warning standards, and optimizing local EMS services, providing data-driven evidence for the effective deployment of ambulances.

Facilitators and barriers to collaboration between pre-hospital emergency and emergency department in traffic accidents: a qualitative study

BACKGROUND

Death caused by traffic accidents is one of the major problems of health systems in low- and middle-income countries. Rapid handover of the traffic accident victims and proper collaboration between the pre-hospital and emergency departments (EDs) play a critical role in improving the treatment process and decreasing the number of accidental deaths. Considering the importance of the collaboration between pre-hospital and emergency departments, this study was designed to investigate the facilitators and barriers of collaboration between pre-hospital and emergency departments in traffic accidents.

METHOD

This research is a qualitative study using content analysis. In order to collect data, semi-structured interviews were used. Seventeen subjects (including pre-hospital and emergency department personnel, emergency medicine specialists, and hospital managers) were selected through purposive sampling and were interviewed. After transcribing and reviewing interviews, data analysis was performed with the qualitative content analysis approach.

RESULTS

The participants consisted of 17 individuals (15 persons in pre-hospital and emergency departments with at least three years of work experience, one emergency medicine specialist and one hospital manager) who were selected by purposive sampling. The interviews were analyzed and three main categories and seven sub-categories were extracted. The main categories included "individual capabilities", "development of mutual understanding", and "infrastructures and processes".

DISCUSSION

Proper and practical planning and policymaking to strengthen facilitators and eliminate barriers to collaborate between pre-hospital and emergency departments are key points in promoting collaboration between these two important sectors of health system and reducing the traffic accident casualties in Iran.

Differences in characteristics between EMS clinicians with patient care and non-patient care roles

Objective. Emergency medical services (EMS) play a key role in access to prehospital emergency care. While EMS has defined levels of certification, the roles in the care paradigm fulfilled by these clinicians vary. The aim of this study is to describe the national differences between EMS clinicians with primary non-patient care vs. patient care roles.Methods. We performed a cross sectional evaluation of nationally certified EMS clinicians in the United States who recertified in 2020. As part of the recertification process, applicants voluntarily complete profile questions regarding demographic, job, and service characteristics. We compared the characteristics between individuals self-reporting primary patient care roles vs. non-patient care roles. Using logistic regression, we determined independent predictors for having a non-patient care role.Results. In 2020, 126,038 persons completed recertification. Of the 96,661 completing the profile, 80,591 (83.4%) indicated that they provided patient care, and 16,070 (16.6%) did not provide patient care as a primary role. Non-patient care personnel were more likely to be older (median 43 years old vs 34 years old), and to have a higher level of education (bachelor's degree or more: OR 2.25, 95%CI [2.13-2.38]) compared with patient care practitioners. Non-patient care personnel were less likely to be female (0.67 [0.64-0.70]) and minorities (OR 0.80 [0.76-0.84]). Non-patient care personnel reported longer work experience (16 years or more: OR 6.30 [5.98-6.64]), were less likely to hold part time positions (OR 0.62 [0.59-0.65]), and were less often attached to more than one agency (OR 0.83 [0.79-0.86]). Non-patient care personnel were less likely to work in rural settings (OR 0.81 [0.78-0.85]).Conclusions. EMS clinicians in non-patient care roles account for 17% of the study population. The odds of performing as a non-patient care practitioner are associated with characteristics related to demographics and workforce experience. Future work will be necessary to identify mechanisms to encourage diversity within the patient care and non-patient care workforces.

From stretcher bearer to practitioner: A brief narrative review of the history of the Anglo-American paramedic system

BACKGROUND

This narrative review presents a brief chronological history of the Anglo-American paramedic system, combining decades of stories from across ambulance services in western, English-speaking developed countries METHODS: Databases, including Embase, MEDLINE, Web of Science, CINAHL and Google Scholar were searched from the inception of the databases. A grey literature search strategy was conducted to identify non-indexed relevant literature along with forwards and backwards searching of citations and references of included studies. Two reviewers undertook title and abstract screening, followed by full-text screening. Included studies were summarised using narrative synthesis structured around the exploration of the history of the Anglo-American paramedic system.

RESULTS

The research team structured the narrative in chronological order and used metaphorical models based on philosophical underpinnings to describe in detail each era of paramedicine. The narrative explores several key milestones including, industrial orientation, scope of practice, innovation, education and training, regulation as well as significant clinical and technological advancements in the delivery of traditional and non-traditional paramedic care to patients.

CONCLUSIONS

Paramedicine, like other allied health professions, has successfully navigated the pathway toward professionalisation in a considerably short period of time. From its noble beginnings as stretcher bearers in times of war, the profession has looked outwards to emulate the success of our healthcare colleagues in establishing its own unique body of knowledge supported by strong clinical governance, national registration, professional regulatory boards, self-regulation, and a move towards higher education supported by the development of entry-to-practice degrees. Whilst the profession has achieved many great milestones, their application across multiple jurisdictions within the Anglo-American paramedic system remains inconsistent, and more research is needed to explore why this is.

Effect of sodium bicarbonate on functional outcome in patients with out-of-hospital cardiac arrest: a post-hoc analysis of a French and North-American dataset

BACKGROUND AND IMPORTANCE

No large randomised controlled trial has assessed the potential benefits on neurologic outcomes of prehospital sodium bicarbonate administration in patients with nontraumatic out-of-hospital cardiac arrest (OHCA).

OBJECTIVE

To obtain information of assistance in designing a randomised controlled trial of bicarbonate therapy after OHCA in specific patient subgroups.

DESIGN

We conducted two, separate, simultaneous, retrospective studies of two distinct, unlinked datasets.

SETTING AND PARTICIPANTS

One dataset was a French nationwide population-based registry (RéAC Registry, French dataset) and the other was a randomised controlled trial comparing continuous to interrupted chest compressions in North America (ROC-CCC trial, North-American dataset).

INTERVENTION

We investigated whether prehospital bicarbonate administration was associated with better neurologic outcomes.

OUTCOME MEASURES AND ANALYSES

The main outcome measure was the functional outcome at hospital discharge. To adjust for potential confounders, we conducted a nested propensity-score-matched analysis with inverse probability-of-treatment weighting.

MAIN RESULTS

In the French dataset, of the 54 807 patients, 1234 (2.2%) received sodium bicarbonate and 450 were matched. After propensity-score matching, sodium bicarbonate was not associated with a higher likelihood of favourable functional outcomes on day 30 [adjusted odds ratio (aOR), 0.912; 95% confidence interval (95%CI), 0.501-1.655]. In the North-American dataset, of the 23 711 included patients, 4902 (20.6%) received sodium bicarbonate and 1238 were matched. After propensity-score matching, sodium bicarbonate was associated with a lower likelihood of favourable functional outcomes at hospital discharge (aOR, 0.45; 95% CI, 0.34-0.58).

CONCLUSION

In patients with OHCA, prehospital sodium bicarbonate administration was not associated with neurologic outcomes in a French dataset and was associated with worse neurologic outcomes in a North-American dataset. Given the considerable variability in sodium bicarbonate use by different prehospital care systems and the potential resuscitation-time bias in the present study, a large randomised clinical trial targeting specific patient subgroups may be needed to determine whether sodium bicarbonate has a role in the prehospital management of prolonged OHCA.

Pre-hospital emergency anaesthesia in trauma patients treated by anaesthesiologist and nurse anaesthetist staffed critical care teams

Background

Pre‐hospital tracheal intubation in trauma patients has recently been questioned. However, not only the trauma and patient characteristics but also airway provider competence differ between systems making simplified statements difficult.

Method

The study is a subgroup analysis of trauma patients included in the PHAST study. PHAST was a prospective, observational, multicentre study on pre‐hospital advanced airway management by anaesthesiologist and nurse anaesthetist manned pre‐hospital critical care teams in the Nordic countries May 2015‐November 2016. Endpoints include intubation success rate, complication rate (airway‐related complication according to Utstein Airway Template by Sollid et al), scene time (time from arrival of the critical care team to departure of the patient) and pre‐hospital mortality.

Result

The critical care teams intubated 385 trauma patients, of which 65 were in shock (SBP <90 mm Hg), during the study. Of the trauma patients, 93% suffered from blunt trauma, the mean GCS was 6 and 75% were intubated by an experienced provider who had performed >2500 tracheal intubations. The pre‐hospital tracheal intubation overall success rate was 98.6% and the complication rate was 13.6%, with no difference between patients with or without shock. The mean scene time was significantly shorter in trauma patients with shock (21.4 min) compared to without shock (21.4 vs 25.1 min). Following pre‐hospital tracheal intubation, 97% of trauma patients without shock and 91% of the patients in shock with measurable blood pressure were alive upon arrival to the ED.

Conclusion

Pre‐hospital tracheal intubation success and complication rates in trauma patients were comparable with in‐hospital rates in a system with very experienced airway providers. Whether the short scene times contributed to a low pre‐hospital mortality needs further investigation in future studies.

A review on initiatives for the management of daily medical emergencies prior to the arrival of emergency medical services

Emergency services worldwide face increasing cost pressure that potentially limits their existing resources. In many countries, emergency services also face the issues of staff shortage-creating extra challenges and constraints, especially during crisis times such as the COVID-19 pandemic-as well as long distances to sparsely populated areas resulting in longer response times. To overcome these issues and potentially reduce consequences of daily (medical) emergencies, several countries, such as Sweden, Germany, and the Netherlands, have started initiatives using new types of human resources as well as equipment, which have not been part of the existing emergency systems before. These resources are employed in response to medical emergency cases if they can arrive earlier than emergency medical services (EMS). A good number of studies have investigated the use of these new types of resources in EMS systems, from medical, technical, and logistical perspectives as their study domains. Several review papers in the literature exist that focus on one or several of these new types of resources. However, to the best of our knowledge, no review paper that comprehensively considers all new types of resources in emergency medical response systems exists. We try to fill this gap by presenting a broad literature review of the studies focused on the different new types of resources, which are used prior to the arrival of EMS. Our objective is to present an application-based and methodological overview of these papers, to provide insights to this important field and to bring it to the attention of researchers as well as emergency managers and administrators.

Socioeconomic disparities in Rapid ambulance response for out-of-hospital cardiac arrest in a public emergency medical service system: A nationwide observational study

OBJECTIVES

This study aimed to examine whether county socioeconomic status (SES) is associated with emergency medical service (EMS) response time and dual dispatch response of out-of-hospital cardiac arrest (OHCA) patients using county property tax per capita in Korea.

METHODS

All EMS-treated adults who suffered OHCAs were enrolled between 2015 and 2017, excluding cases witnessed by EMS providers. The main exposure was property tax per capita in the county where the OHCA occurred. The primary outcome was response time interval, with a secondary outcome of dual dispatch response. Negative binomial regression analysis to calculate incidence rate ratio (IRR) with a 95% confidence interval (CI) was conducted for EMS response time. A multivariable logistic regression analysis for response time interval (<8 min) and dual dispatch response was also conducted.

RESULTS

A total of 71,326 patients in 228 counties were enrolled. Compared to the lowest SES quartile, OHCA patients in the highest SES quartile had shorter median (interquartile range [IQR]) response time intervals (9.5 [5.9] minutes vs. 7.6 [4.2] minutes, IRR [95% CI] 0.95 [0.94-0.96], respectively). The AOR (95% CI) for response time within 8 min was 1.07 (1.01-1.13) for the highest SES quartile compared to the lowest SES quartile. Those in the highest SES quartile also had higher rates of dual dispatch response compared to those in the lowest quantile (50.9% vs 26.6%; AOR [95% CI]: 2.16 [2.03-2.30]).

CONCLUSION

In OHCA patients, those in a lower SES are associated with longer response times and lower dual dispatch response.

Healthcare costs and resource utilization associated with treatment of out-of-hospital cardiac arrest

BACKGROUND

The management of out-of-hospital cardiac arrest (OHCA) patients requires the coordination of prehospital, in-hospital and post-discharge teams. Data reporting a comprehensive analysis of all costs associated with treating OHCA are scarce. We aimed to describe the total costs (and their components) related to the management of OHCA patients.

PATIENT AND METHODS

We performed an analysis on a merged database of the Toronto Regional RescuNet Epistry database (prehospital data) and administrative population-based databases in Ontario. All non-traumatic OHCA patients over 18 years of age treated by the EMS between January 1, 2006, and March 31, 2014, were included in this study. The primary outcome was per patient longitudinal cumulative healthcare costs, from time of collapse to a maximum follow-up until death or 30 days after the event. We included all available cost sectors, from the perspective of the health system payer. We used multivariable generalized linear models with a logarithmic link and a gamma distribution to determine predictors of healthcare costs.

RESULTS

25,826/44,637 patients were treated by EMS services for an OHCA (mostly male 64.4%, mean age 70.1). 11,727 (45%) were pronounced dead on scene, 8359 (32%) died in the emergency department, 3640 (14%) were admitted to hospital but died before day-30, and 2100 (8.1%) were still alive at day-30. Total cost was $690 [interquartile range (IQR) $308, $1742] per patient; ranging from $290 [IQR $188, $390] for patients who were pronounced on scene to $39,216 [IQR 21,802, 62,093] for patients who were still alive at day-30. In-hospital costs accounted for 93% of total costs. After adjustment for age and gender, rate of patient survival was the main driver of total costs: the rate ratio was 3.88 (95% confidence interval 3.80, 3.95), 49.46 and 148.89 for patients who died in the ED, patients who died after the ED but within 30 days, and patients who were still alive at day-30 compared to patients who were pronounced dead on scene, respectively. Factors independently associated with costs were the number of prehospital teams (rate ratio (RR) 5.50 [5.32, 5.67] for being treated by 4 teams vs. 1), the need for hospital transfer (RR 2.38 [2.01, 2.82]), coronary angiography (RR 1.43 [1.27, 1.62]) and targeted temperature management (RR 1.25 [1.09, 1.44]).

CONCLUSION

Survival is the main driver of total costs of treating OHCA patients in a large Canadian health system. Inpatient costs accounted for the majority of the total costs; potentially modifiable factors include the number of prehospital teams that arrive to the scene of the arrest and the need for between-hospital transfers after successful resuscitation.

Developing an integrated emergency medical services in a low-income country like Nepal: a concept paper

BACKGROUND

The main aim of emergency medical services (EMS) should be to provide universal emergency medical care which is EMS system available to all those who need it. Most of the developed countries have an integrated EMS system that is accessible by a single dial number in the whole country. Nepal does not have a proper EMS system. We conducted a literature review regarding methods of developing an integrated EMS system in Nepal.

RESULT

The fragmented system, high demand-low supply, inequity with the service, and inadequately trained responders are major problems associated with EMS in Nepal. Nepal too should develop an integrated single dial number EMS system to meet the current demand of EMS. Having a paramedic in ambulances as the first responders will prevent chaos and save critical time. Funding models have to be considered while developing an EMS considering the capital as well as operational cost.

CONCLUSION

Nepal can develop a public private partnership model of EMS where capital cost is provided by the government and operational cost by other methods. Community-based insurance system looks more feasible in a country like Nepal for generating operational cost.

The Danish prehospital emergency healthcare system and research possibilities

The emergency medical healthcare system outside hospital varies greatly across the globe - even within the western world. Within the last ten years, the demand for emergency medical service systems has increased, and the Danish emergency medical service system has undergone major changes.Therefore, we aimed to provide an updated description of the current Danish prehospital medical healthcare system.Since 2007, Denmark has been divided into five regions each responsible for health services, including the prehospital services. Each region may contract their own ambulance service providers. The Danish emergency medical services in general include ambulances, rapid response vehicles, mobile emergency care units and helicopter emergency medical services. All calls to the national emergency number, 1-1-2, are answered by the police, or the Copenhagen fire brigade, and since 2011 forwarded to an Emergency Medical Coordination Centre when the call relates to medical issues. At the Emergency Medical Coordination Centre, healthcare personnel assess the situation guided by the Danish Index for Emergency Care and determine the level of urgency of the situation, while technical personnel dispatch the appropriate medical emergency vehicles. In Denmark, all healthcare services, including emergency medical services are publicly funded and free of charge. In addition to emergency calls, other medical services are available for less urgent health problems around the clock. Prehospital personnel have since 2015 utilized a nationwide electronic prehospital medical record. The use of this prehospital medical record combined with Denmark's extensive registries, linkable by the unique civil registration number, enables new and unique possibilities to do high quality prehospital research, with complete patient follow-up.

Proximity-Based Emergency Response Communities for Patients With Allergies Who Are at Risk of Anaphylaxis: Clustering Analysis and Scenario-Based Survey Study

BACKGROUND

Anaphylaxis is a potentially fatal allergic reaction. However, many patients at risk of anaphylaxis who should permanently carry a life-saving epinephrine auto injector (EAI) do not carry one at the moment of allergen exposure. The proximity-based emergency response communities (ERC) strategy suggests speeding EAI delivery by alerting patient-peers carrying EAI to respond and give their EAI to a nearby patient in need.

OBJECTIVES

This study had two objectives: (1) to analyze 10,000 anaphylactic events from the European Anaphylaxis Registry (EAR) by elicitor and location in order to determine typical anaphylactic scenarios and (2) to identify patients' behavioral and spatial factors influencing their response to ERC emergency requests through a scenario-based survey.

METHODS

Data were collected and analyzed in two phases: (1) clustering 10,000 EAR records by elicitor and incident location and (2) conducting a two-center scenario-based survey of adults and parents of minors with severe allergy who were prescribed EAI, in Israel and Germany. Each group received a four-part survey that examined the effect of two behavioral constructs-shared identity and diffusion of responsibility-and two spatial factors-emergency time and emergency location-in addition to sociodemographic data. We performed descriptive, linear correlation, analysis of variance, and t tests to identify patients' decision factors in responding to ERC alerts.

RESULTS

A total of 53.1% of EAR cases were triggered by food at patients' home, and 46.9% of them were triggered by venom at parks. Further, 126 Israeli and 121 German participants completed the survey and met the inclusion criteria. Of the Israeli participants, 80% were parents of minor patients with a risk of anaphylaxis due to food allergy; their mean age was 32 years, and 67% were women. In addition, 20% were adult patients with a mean age of 21 years, and 48% were female. Among the German patients, 121 were adults, with an average age of 47 years, and 63% were women. In addition, 21% were allergic to food, 75% were allergic to venom, and 2% had drug allergies. The overall willingness to respond to ERC events was high. Shared identity and the willingness to respond were positively correlated (r=0.51, P<.001) in the parent group. Parents had a stronger sense of shared identity than adult patients (t₂₄₃= -9.077, P<.001). The bystander effect decreased the willingness of all patients, except the parent group, to respond (F_1,269=28.27, P<.001). An interaction between location and time of emergency (F_1,473=77.304, P<.001) revealed lower levels of willingness to respond in strange locations during nighttime.

CONCLUSIONS

An ERC allergy app has the potential to improve outcomes in case of anaphylactic events, but this is dependent on patient-peers' willingness to respond. Through a two-stage process, our study identified the behavioral and spatial factors that could influence the willingness to respond, providing a basis for future research of proximity-based mental health communities.

Epinephrine during resuscitation of traumatic cardiac arrest and increased mortality: a post hoc analysis of prospective observational study

Background

The beneficial effect of epinephrine during resuscitation from out-of-hospital cardiac arrest (OHCA) has been inconclusive, and potential harm has been suggested, particularly in trauma victims. Although no significant improvement in neurological outcomes has been found among resuscitated patients using epinephrine, including trauma patients, the use of epinephrine is recommended in the Advanced Trauma Life Support protocol. Given that the use of vasopressors was reported to be associated with increased mortality in patients with massive bleeding, the undesirable effects of epinephrine during the resuscitation of traumatic OHCA should be elucidated. We hypothesised that resuscitation with epinephrine would increase mortality in patients with OHCA following trauma.

Methods

This study is a post-hoc analysis of a prospective, multicentre, observational study on patients with OHCA between January 2012 and March 2013. We included adult patients with traumatic OHCA who were aged ≥15 years and excluded those with missing survival data. Patient data were divided into epinephrine or no-epinephrine groups based on the use of epinephrine during resuscitation at the hospital. Propensity scores were developed to estimate the probability of being assigned to the epinephrine group using multivariate logistic regression analyses adjusted for known survival predictors. The primary outcome was survival 7 days after injury, which was compared among the two groups after propensity score matching.

Results

Of the 1125 adults with traumatic OHCA during the study period, 1030 patients were included in this study. Among them, 822 (79.8%) were resuscitated using epinephrine, and 1.1% (9/822) in the epinephrine group and 5.3% (11/208) in the no-epinephrine group survived 7 days after injury. The use of epinephrine was significantly associated with decreased 7-day survival (odds ratio = 0.20; 95% CI = 0.08–0.48; P < 0.01), and this result was confirmed by propensity score-matching analysis, in which 178 matched pairs were examined (adjusted odds ratio = 0.11; 95% CI = 0.01–0.85; P = 0.02).

Conclusions

The relationship between the use of epinephrine during resuscitation and decreased 7-day survival was found in patients with OHCA following trauma, and the propensity score-matched analyses validated the results. Resuscitation without epinephrine in traumatic OHCA should be further studied in a randomised controlled trial.

Quality measurement in physician-staffed emergency medical services: a systematic literature review

Purpose

Quality measurement of physician-staffed emergency medical services (P-EMS) is necessary to improve service quality. Knowledge and consensus on this topic are scarce, making quality measurement of P-EMS a high-priority research area. The aim of this review was to identify, describe and evaluate studies of quality measurement in P-EMS.

Data sources

The databases of MEDLINE and Embase were searched initially, followed by a search for included article citations in Scopus.

Study selection

The study eligibility criteria were: (1) articles describing the use of one quality indicator (QI) or more in P-EMS, (2) original manuscripts, (3) articles published from 1 January 1968 until 5 October 2016. The literature search identified 4699 records. 4543 were excluded after reviewing title and abstract. An additional 129 were excluded based on a full-text review. The remaining 27 papers were included in the analysis. Methodological quality was assessed using an adapted critical appraisal tool.

Data extraction

The description of used QIs and methods of quality measurement was extracted. Variables describing the involved P-EMSs were extracted as well.

Results of data synthesis

In the included papers, a common understanding of which QIs to use in P-EMS did not exist. Fifteen papers used only a single QI. The most widely used QIs were ‘Adherence to medical protocols’, ‘Provision of advanced interventions’, ‘Response time’ and ‘Adverse events’.

Conclusion

The review demonstrated a lack of shared understanding of which QIs to use in P-EMS. Moreover, papers using only one QI dominated the literature, thus increasing the risk of a narrow perspective in quality measurement. Future quality measurement in P-EMS should rely on a set of consensus-based QIs, ensuring a comprehensive approach to quality measurement.

Common core content in education for nurses in ambulance care in Sweden, Finland and Belgium

There is no consensus regarding the required education content and competence needed for professionals working in the emergency medical services and only a few countries in Europe staff ambulances with registered nurses. This study aimed to identify common core content in Swedish, Finnish and Belgian university curricula in the education on advanced level for registered nurses in ambulance care and to describe the teachers' perception of the necessary content for the profession as a registered nurse in ambulance care. A deductive research design was used. Three Universities, one from each country; Sweden, Finland and Belgium, participated. Data was generated from curricula and interviews with teachers and analyzed with different approaches of qualitative content analysis. The results showed commonness with respect to core content; the emphasis was mainly on medical knowledge but the content concerning contextual subjects differed between the three universities. The teachers, however, aimed for the students' to acquire a broad competence in clinical reasoning by implementing theory into practice, as well as developing the students' personal aptitude and instilling a scientific awareness. The results suggest that it is possible to create a common curriculum for training of RNs for working in ambulance care.

Public perception of female paramedics at King Abdulaziz Medical City, Saudi Arabia

Background

Although emergency medical service (EMS) providers recognize that both male and female paramedics are necessary, Saudi EMSs are currently fully staffed by men. Cultural bias against care provision by male paramedics to female victims in the absence of male guardians underscores the need for female paramedics. Consequently, we explored public perception of female paramedics at King Abdulaziz Medical City (KAMC), Riyadh.

Method

This observational, cross-sectional study used convenience sampling to assess the perceptions of patients, visitors, and employees at the emergency rooms in KAMC and King Abdullah Specialized Children’s Hospital via self-administered English- and Arabic-language questionnaires. Questionnaire reliability and validity were assessed in a pilot study.

Results

Three hundred twelve respondents completed the survey (67.30% men). The sample included 43.27% medical (40% paramedics, 22% physicians, 12% nurses, and 23% other) and 56.73% nonmedical participants, of whom 53% and 63%, respectively, strongly agreed regarding the importance of female paramedics. Moreover, in the male participant group, 6% of medical and 8% of nonmedical participants strongly disagreed with treatment of their female relatives by male paramedics, and 20% of medical and 30% of nonmedical participants declined medical help because female paramedics were unavailable.

Conclusions

Respondents rated the importance of trained female paramedics in the EMS system. Most strongly agreed that female and male paramedics had equal patient-management capabilities and skills.

From the street to the ICU: a review of pediatric emergency medical services and critical care transport

Emergency medical services and critical care transport teams are relatively new parts of the American healthcare delivery system. Although most healthcare providers regularly interact with these groups and rely upon their almost ubiquitous availability, few know how these services developed or what sort of infrastructure currently exists to maintain them. This article provides a focused overview of the history and present practices of both emergency medical services and critical care transport teams, with a concentrated look at the implementation of these services in the pediatric population. Within this context, we also consider current challenges and future opportunities for both groups and conclude with ways to become involved in the improvement of out-of-hospital pediatric critical care.

Association of Prehospital Advanced Life Support by Physician With Survival After Out-of-Hospital Cardiac Arrest With Blunt Trauma Following Traffic Collisions: Japanese Registry-Based Study

Importance

Controversy remains as to whether advanced life support (ALS) or basic life support (BLS) is superior for critically ill and injured patients, including out-of-hospital cardiac arrest (OHCA) and major trauma, in the prehospital setting.

Objective

To assess whether prehospital ALS should be provided for traumatic OHCA and who should perform it.

Design, Setting, and Participants

Japanese government-managed nationwide population-based registry data of patients with OHCA transported to an emergency hospital were analyzed. Patients who experienced traumatic OHCA following a traffic collision from 2013 to 2014 were included. Patients provided prehospital ALS by a physician were compared with both patients provided ALS by emergency medical service (EMS) personnel and patients with only BLS. The data were analyzed on May 1, 2017.

Exposures

Advanced life support by physician, ALS by EMS personnel, or BLS only.

Main Outcomes and Measures

The primary outcome was 1-month survival. The secondary outcomes were prehospital return of spontaneous circulation and favorable neurologic outcomes with the Glasgow-Pittsburgh cerebral performance category score of 1 or 2.

Results

A total of 4382 patients were included (mean [SD] age, 57.5 [22.2] years; 67.9% male); 828 (18.9%) received prehospital ALS by physician, 1591 (36.3%) received prehospital ALS by EMS personnel, and 1963 (44.8%) received BLS only. Among these patients, 96 (2.2%) survived 1 month after OHCA, including 26 of 828 (3.1%) for ALS by physician, 25 of 1591 (1.6%) for ALS by EMS personnel, and 45 of 1963 (2.3%) for BLS. After adjusting for potential confounders using multivariable logistic regression, ALS by physician was significantly associated with higher odds for 1-month survival compared with both ALS by EMS personnel and BLS (adjusted OR, 2.13; 95% CI, 1.20-3.78; and adjusted OR, 1.94; 95% CI, 1.14-3.25; respectively), whereas there was no significant difference between ALS by EMS personnel and BLS (adjusted OR, 0.91; 95% CI, 0.54-1.51). A propensity score-matched analysis in the ALS cohort showed that ALS by physician was associated with increased chance of 1-month survival compared with ALS by EMS personnel (risk ratio, 2.00; 95% CI, 1.01-3.97; P = .04). This association was consistent across a variety of sensitivity analyses.

Conclusions and Relevance

In traumatic OHCA, ALS by physician was associated with increased chance of 1-month survival compared with both ALS by EMS personnel and BLS.

Advanced vs. Basic Life Support in the Treatment of Out-of-Hospital Cardiopulmonary Arrest in the Resuscitation Outcomes Consortium

BACKGROUND

Prior observational studies suggest no additional benefit from advanced life support (ALS) when compared with providing basic life support (BLS) for patients with out-of-hospital cardiac arrest (OHCA). We compared the association of ALS care with OHCA outcomes using prospective clinical data from the Resuscitation Outcomes Consortium (ROC).

METHODS

Included were consecutive adults OHCA treated by participating emergency medical services (EMS) agencies between June 1, 2011, and June 30, 2015. We defined BLS as receipt of cardiopulmonary resuscitation (CPR) and/or automated defibrillation and ALS as receipt of an advanced airway, manual defibrillation, or intravenous drug therapy. We compared outcomes among patients receiving: 1) BLS-only; 2) BLS + late ALS; 3) BLS + early ALS; and 4) ALS-first care. Using multivariable logistic regression, we evaluated the associations between level of care and return of spontaneous circulation (ROSC), survival to hospital discharge, and survival with good functional status, adjusting for age, sex, witnessed arrest, bystander CPR, shockable initial rhythm, public location, EMS response time, CPR quality, and ROC site.

RESULTS

Among 35,065 patients with OHCA, characteristics were median age 68 years (IQR 56-80), male 63.9%, witnessed arrest 43.8%, bystander CPR 50.6%, and shockable initial rhythm 24.2%. Care delivered was: 4.0% BLS-only, 31.5% BLS + late ALS, 17.2% BLS + early ALS, and 47.3% ALS-first. ALS care with or without initial BLS care was independently associated with increased adjusted ROSC and survival to hospital discharge unless delivered greater than 6 min after BLS arrival (BLS + late ALS). Regardless of when it was delivered, ALS care was not associated with significantly greater functional outcome.

CONCLUSION

ALS care was associated with survival to hospital discharge when provided initially or within six minutes of BLS arrival. ALS care, with or without initial BLS care, was associated with increased ROSC, however it was not associated with functional outcome.

Quality Indicators for Evaluating Prehospital Emergency Care: A Scoping Review

Introduction Historically, the quality and performance of prehospital emergency care (PEC) has been assessed largely based on surrogate, non-clinical endpoints such as response time intervals or other crude measures of care (eg, stakeholder satisfaction). However, advances in Emergency Medical Services (EMS) systems and services world-wide have seen their scope and reach continue to expand. This has dictated that novel measures of performance be implemented to compliment this growth. Significant progress has been made in this area, largely in the form of the development of evidence-informed quality indicators (QIs) of PEC. Problem Quality indicators represent an increasingly popular component of health care quality and performance measurement. However, little is known about the development of QIs in the PEC environment. The purpose of this study was to assess the development and characteristics of PEC-specific QIs in the literature.

METHODS

A scoping review was conducted through a search of PubMed (National Center for Biotechnology Information, National Institutes of Health; Bethesda, Maryland USA); EMBase (Elsevier; Amsterdam, Netherlands); CINAHL (EBSCO Information Services; Ipswich, Massachusetts USA); Web of Science (Thomson Reuters; New York, New York USA); and the Cochrane Library (The Cochrane Collaboration; Oxford, United Kingdom). To increase the sensitivity of the literature, a search of the grey literature and review of select websites was additionally conducted. Articles were selected that proposed at least one PEC QI and whose aim was to discuss, analyze, or promote quality measurement in the PEC environment.

RESULTS

The majority of research (n=25 articles) was published within the last decade (68.0%) and largely originated within the USA (68.0%). Delphi and observational methodologies were the most commonly employed for QI development (28.0%). A total of 331 QIs were identified via the article review, with an additional 15 QIs identified via the website review. Of all, 42.8% were categorized as primarily Clinical, with Out-of-Hospital Cardiac Arrest contributing the highest number within this domain (30.4%). Of the QIs categorized as Non-Clinical (57.2%), Time-Based Intervals contributed the greatest number (28.8%). Population on Whom the Data Collection was Constructed made up the most commonly reported QI component (79.8%), followed by a Descriptive Statement (63.6%). Least reported were Timing of Data Collection (12.1%) and Timing of Reporting (12.1%). Pilot testing of the QIs was reported on 34.7% of QIs identified in the review.

CONCLUSION

Overall, there is considerable interest in the understanding and development of PEC quality measurement. However, closer attention to the details and reporting of QIs is required for research of this type to be more easily extrapolated and generalized. Howard I , Cameron P , Wallis L , Castren M , Lindstrom V . Quality indicators for evaluating prehospital emergency care: a scoping review. Prehosp Disaster Med. 2018;33(1):43-52.

Costs related to cardiac arrest management: a systematic review protocol

BACKGROUND

Each year, about 500,000 people suffer a cardiac arrest (either out-of-hospital or in-hospital) in the USA. Although significant improvements in survival have occurred through the implementation of complex high-quality protocols of care, global costs related to such management are not clearly described.

METHODS

We will undertake a systematic review of the published literature on costs related to the acute phase of cardiac arrest management (from collapse to hospital discharge). The search will cover the period 1991 to present, and we will include studies written in English or in French involving patients with cardiac arrest of all ages, settings (in- and out-of-hospital arrest), countries, and etiology (including traumatic). The primary outcome will include estimates of costs related to cardiac arrest patients' management in various categories (e.g., resuscitation process, in-hospital management as well as rehabilitation and long-term care facilities) and perspectives (e.g., hospital, societal, or third-payer perspective). Study selection will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and data quality will be assessed by questions adapted from the Drummond economic evaluation checklist.

DISCUSSION

This review will provide an estimate of costs related to cardiac arrest management according to the different components of such a management as well as total costs.

SYSTEMATIC REVIEW REGISTRATION

International Prospective Register of Systematic Reviews PROSPERO CRD42016046993.

Psychosocial risk and protective factors for the health and well-being of professionals working in emergency and non-emergency medical transport services, identified via questionnaires

Background

Medical transport (MT) professionals are subject to considerable emotional demands due to their involvement in life-or-death situations and their exposure to the serious health problems of their clients. An increase in the demand for MT services has, in turn, increased interest in the study of the psychosocial risk factors affecting the health of workers in this sector. However, research thus far has not distinguished between emergency (EMT) and non-emergency (non-EMT) services, nor between the sexes. Furthermore, little emphasis has been placed on the protective factors involved. The main objective of the present study is to identify any existing differential exposure – for reasons of work setting (EMT and non-EMT) or of gender – to the various psychosocial risk and protective factors affecting the health of MT workers.

Methods

Descriptive and transversal research with responses from 201 professionals.

Results

The scores obtained on the various psychosocial scales in our study – as indicators of future health problems – were more unfavourable for non-EMT workers than they were for EMT workers. Work setting, but not gender, was able to account for these differences.

Discussion

The scores obtained for the different psychosocial factors are generally more favourable for the professionals we surveyed than those obtained in previous samples.

Conclusion

The significant differences observed between EMT and non-EMT personnel raise important questions regarding the organization of work in companies that carry out both services at the same time in the same territory. The relationships among the set of risk/protective factors suggests a need for further investigation into working conditions as well as a consideration of the workers’ sense of coherence and subjective well-being as protective factors against occupational burnout syndrome.

Characteristics of Fixed Wing Air Ambulance Transports in Victoria, Australia

OBJECTIVE

Air medical transport is important for the transfer of patients in the prehospital and interhospital environment. Few studies have described the services provided by fixed wing ambulances or the broader clinical profiles of patients they transport. Such information may be useful for the planning and allocation of resources, assistance with training, and refining clinical protocols. We sought to describe the characteristics of patients transported by fixed wing aircraft at Air Ambulance Victoria (AAV) and the service AAV provides in Victoria, Australia.

METHODS

A retrospective data review of patients transported by AAV fixed wing aircraft between January 1, 2011, and June 30, 2015, was performed. Data were sourced from the Ambulance Victoria data warehouse. Retrievals involving physicians were excluded.

RESULTS

A total of 16,579 patients were transported during the study period, with a median age of 66 years. Most patients were male (58.7%), and cardiovascular/hematologic conditions (27.2%) were most common. Overall, 51.7% of cases were prebooked routine transfers, 47.4% were interhospital routine transfers, and 0.9% were primary responses. Caseloads were largest in the regions furthest from the capital city.

CONCLUSION

The AAV fixed wing service in Victoria enables regional and remote patients to be transported to definitive care without major disruption to ground ambulances.

Pre-Hospital Emergency in Iran: A Systematic Review

CONTEXT

Pre-hospital care plays a vital role in saving trauma patients.

OBJECTIVES

This study aims to review studies conducted on the pre-hospital emergency status in Iran.

DATA SOURCES

Data were sourced from Iranian electronic databases, including SID, IranMedex, IranDoc, Magiran, and non-Iranian electronic databases, such as Medline, Embase, Cochrane Library, Scopus, and Google Scholar. In addition, available data and statistics for the country were used.

DATA SELECTION

All Persian-language articles published in Iranian scientific journals and related English-language articles published in Iranian and non-Iranian journals indexed on valid sites for September 2005 - 2014 were systematically reviewed.

DATA EXTRACTION

To review the selected articles, a data extraction form developed by the researchers as per the study's objective was adopted. The articles were examined under two categories: structure and function of pre-hospital emergency.

RESULTS

A total of 19 articles were selected, including six descriptive studies (42%), four descriptive-analytical studies (21%), five review articles (16%), two qualitative studies (10.5%), and two interventional (experimental) studies (10.5%). In addition, of these, 14 articles (73.5%) had been published in the English language. The focus of these selected articles were experts (31.5%), bases of emergency medical services (26%), injured (16%), data reviews (16%), and employees (10.5%). A majority of the studies (68%) investigated pre-hospital emergency functions and 32% reviewed the pre-hospital emergency structure.

CONCLUSIONS

The number of studies conducted on pre-hospital emergency services in Iran is limited. To promote public health, consideration of prevention areas, processes to provide pre-hospital emergency services, policymaking, foresight, systemic view, comprehensive research programs and roadmaps, and assessments of research needs in pre-hospital emergency seem necessary.

Prehospital management of traumatic brain injury patients--a gender perspective

BACKGROUND

Studies show that there are differences between men and women when it comes to several aspects of health care. But the research on equal care in a prehospital setting for patients with severe traumatic brain injury (TBI) has been sparsely investigated. The aim of this study is to describe prehospital care from a gender perspective.

METHOD

This is a retrospective study of (n = 651) patients (>15 years) with severe TBI requiring intensive care at a University Hospital in Sweden during the years 2000-2010. Outcome was measured by survival and Glasgow Outcome Scale (GOS) scores at discharge.

RESULT

Our results show differences, though not significant, in the initial assessments and performed interventions between male and female TBI patients. Female patients received more assessments and performed interventions compared to men during prehospital care. Men received more interventions with I.V. fluid but significantly less airway interventions (endotracheal intubation) compared to female patients. More men were transported directly to neurosurgical specialist care as compared to females. No difference in outcome was found.

CONCLUSION

Our results show differences, however not significant in the assessments and performed interventions between gender, with female patients receiving more assessments and interventions compared to male patients during prehospital care. Future research should focus on gender differences in initial early signs of TBI to improve early identification.

The evaluation of time performance in the emergency response center to provide pre-hospital emergency services in Kermanshah

This study evaluated the time performance in the emergency response center to provide pre-hospital emergency services in Kermanshah. This study was a descriptive retrospective cross-sectional study. In this study 500 cases of patients from Shahrivar (September) 2012 to the end of Shahrivar (September) 2013 were selected and studied by the non-probability quota method. The measuring tool included a preset cases record sheet and sampling method was completing the cases record sheet by referring to the patients’ cases. Data were analyzed using SPSS version 18 and the concepts of descriptive and inferential statistics (Kruskal-Wallis test, benchmark Eta (Eta), Games-Howell post hoc test). The results showed that the interval mean between receiving the mission to reaching the scene, between reaching the scene to moving from the scene, and between moving from the scene to a health center was 7.28, 16.73 and 7.28 minutes. The overall mean of time performance from the scene to the health center was 11.34 minutes. Any intervention in order to speed up service delivery, reduce response times, ambulance equipment and facilities required for accuracy, validity and reliability of the data recorded in the emergency dispatch department, Continuing Education of ambulance staffs, the use of manpower with higher specialize levels such as nurses, supply the job satisfaction, and increase the coordination with other departments that are somehow involved in this process can provide the ground for reducing the loss and disability resulting from traffic accidents.

LiveCity

The goal of emergency medicine is to treat time-critical diseases and conditions to reduce morbidity and mortality. The improvement of emergency medicine is an important topic for governments worldwide. A common problem is the inevitable lack of support by emergency doctors, when paramedics need their assistance at the emergency site but are without an emergency doctor. Video-communication in real time from the emergency site to an emergency doctor, offers an opportunity to enhance the quality of emergency medicine. The core piece of this study is a video camera system called “LiveCity camera”, enabling real-time high quality video connection of paramedics and emergency doctors. The impact of video communication on emergency medicine is clearly appreciated among providers, based upon the extent of agreement that has been stated in this study´s questionnaire by doctors and paramedics. This study is part of the FP7-European Union funded research project “LiveCity” (Grant Agreement No. 297291).

Has increased nursing competence in the ambulance services impacted on pre-hospital assessment and interventions in severe traumatic brain-injured patients?

OBJECTIVE

Trauma is one of the most common causes of morbidity and mortality in modern society, and traumatic brain injuries (TBI) are the single leading cause of mortality among young adults. Pre-hospital acute care management has developed during recent years and guidelines have shown positive effects on the pre-hospital treatment and outcome for patients with severe traumatic brain injury. However, reports of impacts on improved nursing competence in the ambulance services are scarce. Therefore, the aim of this study was to investigate if increased nursing competence level has had an impact on pre-hospital assessment and interventions in severe traumatic brain-injured patients in the ambulance services.

METHOD

A retrospective study was conducted. It included all severe TBI patients (>15 years of age) with a Glasgow Coma Score (GCS) of less than eight measured on admission to a level one trauma centre hospital, and requiring intensive care (ICU) during the years 2000-2009.

RESULTS

651 patients were included, and between the years 2000-2005, 395 (60.7%) severe TBI patients were injured, while during 2006-2009, there were 256 (39.3%) patients. The performed assessment and interventions made at the scene of the injury and the mortality in hospital showed no significant difference between the two groups. However, the assessment of saturation was measured more frequently and length of stay in the ICU was significantly less in the group of TBI patients treated between 2006-2009.

CONCLUSION

Greater competence of the ambulance personnel may result in better assessment of patient needs, but showed no impact on performed pre-hospital interventions or hospital mortality.

Usefulness and Problems of Intraosseous Infusion with the Bone Injection Gun™ Using Simulators Under Confined Space Conditions

Introduction

It is important to have a venous line for infusion as an emergency treatment for patients suffering from crush syndrome or bleeding under confined space (CS) conditions in disaster medicine. However, it is not easy to for Emergency Life-Saving Technicians (ELSTs) to establish a venous line in such settings. Although previous studies have described the use of mechanical intraosseous (IO) devices and IO access while wearing chemical protection gears, problems for the use of IO devices under CS conditions have not been considered. This study aimed to investigate usefulness and problems of using a Bone Injection Gun™ (BIG) for IO infusion by ELSTs and rescue workers in CS conditions.

Methods

The time required and success rate for IO infusion using a BIG in a manikin leg were measured, and for administering intravenous infusion in a manikin arm using either rescue gloves or plastic gloves by ELSTs or rescue workers under CS conditions.

Results

Wearing rescue gloves, ELSTs were significantly faster in placing intraosseous infusion (IOI) compared with rescue workers. The success rate of the placement was not significantly different between ELSTs and rescue workers whether or not they wore rescue or plastic gloves.

Conclusions

Although the finite usefulness of IOI with BIG under CS conditions is indicated, some problems such as the timing of removal of the IOI and difficulty in finding the location of the trocar needle after activating BIG are pointed out. Therefore, there are rooms to consider using IOI with BIG under CS condition. (Hong Kong j.emerg. med. 2014;21:23-30)

A comparison of ambulance responses to incidents of Medical Emergency Teams led by nurses and paramedics--A retrospective single-center study

BACKGROUND

In Poland there are currently two main types of Medical Emergency Team: basic, run by nurses or paramedics, and specialist, led by physicians. They differ not only in professional qualifications but also in their terms of reference.

OBJECTIVES

We compared the responses to incidents of Medical Emergency Teams led by nurses and paramedics, in terms of the frequency of pharmacotherapy use and medical rescue activities.

STUDY DESIGN

Ambulance call reports.

SETTINGS

Medical Emergency Teams in Eastern Poland.

PARTICIPANTS

Medical Emergency Teams led by nurses or paramedics. Exclusion criteria were cancelation of calls by the dispatcher, calls with no patient on the scene, and neonatal and interhospital transportation.

METHODS

A retrospective analysis of ambulance call reports. A comparison of actions of nurses and paramedics taken in the field, and decisions concerning transportation of the patient to a hospital or leaving the home were collected.

RESULTS

Of 1115 Medical Emergency Teams calls, those led by paramedics (60.5%) were more common. Paramedics, more often than nurses, provided aid solely in the field-27.5% and 16.0%, respectively-and less frequently transported patients to the hospital-38.5% and 50.7%, respectively. Significant differences in administration of oxygen therapy and analgesics were identified; paramedics used them more often than nurses. Paramedics used cervical collars, 3.6% and 1.1% (p=0.01), respectively, and performed 12-lead electrocardiograms, 4.7% and 1.4% (p=0.002), respectively, significantly more frequently than did nurses.

CONCLUSIONS

Despite the comparable competency of paramedics and emergency nurses in Poland, Medical Emergency Teams' activities varied depending on whether a nurse or a paramedic was the team leader. It is recommended that further in-depth research is conducted in this area.

Effect of military conflicts on the formation of emergency medical services systems worldwide

OBJECTIVES

This article briefly reviews the evolution of medical support during wars and conflicts from ancient to modern times and discusses the effect warfare has had on the development of civilian health care and emergency medical services (EMS). Medical breakthroughs and discoveries made of necessity during military conflicts have developed into new paradigms of medical care, including novel programs of triage and health assessment, emergency battlefield treatment and stabilization, anesthesia, and other surgical and emergency procedures. The critical role of organizations that provide proper emergency care to help the sick and injured both on the battlefield and in the civilian world is also highlighted.

Determining and Prioritizing the Organizational Determinants of Emergency Medical Services (EMS) in Iran

Background

Improving the organization of pre-hospital emergency to provide emergency medical services (EMS), as a part of health system, plays an important role in timely and properly response to incidents, as well as, reducing mortalities and disabilities.

Objective

This study was conducted to determine the organizational determinants of emergency medical services in Iran and analyze their relationship and prioritize them.

Materials and Methods

The present study is kind of descriptive and cross-sectional study that has been conducted on the first half of 2010 using DEMATEL method (a group decision-making technique). Required data were collected using a questionnaire from a sample of 30 Iranian experts in pre-hospital emergency, who were selected using available sampling method.

Results

The determinants of establishing an independent EMS organization as a policy maker and observer organization, providing services through public organizations such as Emergency 115, private organizations partnership in pre-hospital emergency system, and integrating pre-hospital and hospital emergency under single supervision and management were determined as organizational determinants. Also, establishing an independent EMS organization and integrating pre-hospital and hospital emergency under single supervision and management were determined as the most affecting and affected organizational determinants, respectively, with the coordinates (1.01 and 1.01) and (0.85 and - 0.85) in the pre-hospital emergency organizational determinants graph.

Conclusions

Emergency medical services should be considered as a system with its independent components. Establishing an independent EMS organization, integrating pre-hospital and hospital emergency under single supervision and management, as well as, extending the possibility of providing EMS through private sector are essential in order to make fundamental reforms in providing emergency medical services in Iran.

The current scenario of emergency care policies in Brazil

BACKGROUND

The regulation of emergency care has featured prominently in Brazil's federal health agenda since the 2000s. The aim of this study was to review up to the present day the implementation of the National Emergency Care Policy.

METHODS

The methods employed were documental review, analysis of official data and 11 interviews conducted with federal, state and local managers. The results were analyzed using Giddens' Structuration Theory, relating the cognitive abilities of the agents to their action strategies, in view of the structural dimensions, rules and resources provided by the federal administration.

RESULTS

Federal policy for emergency care in Brazil can be divided into three stages: from 1998 to 2003, the initial regulation; from 2004 to 2008, the expansion of the Mobile Emergency Medical Services (SAMU, in Brazil); and from 2009 onwards, the implementation of stationary pre-hospital care facilities, known as Emergency Care Units (UPA). The structuration elements identified for the emergency care policy were the public health system guidelines, legislation, standards and federal financing. Significant restrictions were found such as lack of hospital beds and intensive care treatment, gaps in the information system for producing evidence for management, ineffective Management Committees, as well as a low degree of commitment among physicians to the services.

CONCLUSION

Considering the financial constraints imposed on the SUS (Brazilian Unified Health System), emergency care was identified as a political priority with financial support. The individual actions by emergency care workers and governmental agents typified the first period of the policy, structuring the basis and producing changes in the circumstances of action. Federal strategies can be equated to the rules and resources provided to support the implementation process of the policy.

National characteristics of emergency medical services responses in the United States

OBJECTIVE

Despite its long history and current prominence in U.S. communities, only limited data describe the national characteristics of emergency medical services (EMS) care in the United States. We sought to characterize out-of-hospital EMS care in the United States.

METHODS

We conducted an analysis of the 2010 National Emergency Medical Services Information System (NEMSIS) research data set, encompassing EMS emergency response data from 29 states. From these data, we estimated the national number and incidence of EMS responses. We also characterized EMS responses and the patients receiving care.

RESULTS

There were 7,563,843 submitted EMS responses, corresponding to an estimated national incidence of 17.4 million EMS emergency responses per year (56 per 1,000 person-years). The EMS response incidence varied by U.S. Census region (South 137.4 per 1,000 population per year, Northeast 85.2, West 39.7, and Midwest 33.3). The use of lights and sirens varied across Census regions (Northeast 90.3%, South 76.7%, West 68.8%, and Midwest 67.5%). The percentage of responses resulting in patient contact varied across Census regions (range 78.4% to 95.7%). The EMS time intervals were similar between Census regions; response median 5 minutes (interquartile range [IQR] 3-9), scene 14 minutes (10-20), and transport 11 minutes (7-19). Underserved populations (the elderly, minorities, rural residents, and the uninsured) were large users of EMS resources.

CONCLUSION

These data highlight the breadth and diversity of EMS demand and care in the United States.

Prehospital emergency care in Shanghai: present and future

Background

In Shanghai, prehospital emergency medical services are provided by the public Ambulance Services. The 60th anniversary of the local Ambulance Services is a good opportunity to provide an overview of the current trends in prehospital emergency medical care in Shanghai.

Objectives

In this report, the features of Shanghai prehospital emergency medical care are described, as well as the Shanghai model of purely prehospital emergency medical care, including the communications and dispatch system, ambulance depots and ambulances, and prehospital rescue teams. Responses to major incidents including public health emergencies and natural disasters are also discussed, with the intention of highlighting future directions in emergency medical services, as well as the influence of international trends in emergency patient care.

Discussion

Although Shanghai has the most advanced dispatch system in China (equipped with a Global Positioning System, Global Information System, and more) and can be expanded quickly in case of mass casualty incidents, there is, as yet, no uniform Emergency Medical Service (EMS) dispatching for the entire city. Nor are there certifications, degrees, or special continuing education programs available for EMS dispatchers. Although there are more and more ambulance depots spread all over Shanghai, the city struggles with inadequate prehospital emergency caregivers, because every ambulance has to be staffed with a qualified Emergency Physician, and there are also recruitment problems for ambulance physicians.

Conclusions

Although faced with many challenges, substantial progress is expected in Shanghai prehospital emergency care.

Comparison of emergency medical services systems across Pan-Asian countries: a Web-based survey

BACKGROUND

There are great variations in out-of-hospital cardiac arrest (OHCA) survival outcomes among different countries and different emergency medical services (EMS) systems. The impact of different systems and their contribution to enhanced survival are poorly understood. This paper compares the EMS systems of several Asian sites making up the Pan-Asian Resuscitation Outcomes Study (PAROS) network. Some preliminary cardiac arrest outcomes are also reported.

METHODS

This is a cross-sectional descriptive survey study addressing population demographics, service levels, provider characteristics, system operations, budget and finance, medical direction (leadership), and oversight.

RESULTS

Most of the systems are single-tiered. Fire-based EMS systems are predominant. Bangkok and Kuala Lumpur have hospital-based systems. Service level is relatively low, from basic to intermediate in most of the communities. Korea, Japan, Singapore, and Bangkok have intermediate emergency medical technician (EMT) service levels, while Taiwan and Dubai have paramedic service levels. Medical direction and oversight have not been systemically established, except in some communities. Systems are mostly dependent on public funding. We found variations in available resources in terms of ambulances and providers. The number of ambulances is 0.3 to 3.2 per 100,000 population, and most ambulances are basic life support (BLS) vehicles. The number of human resources ranges from 4.0 per 100,000 population in Singapore to 55.7 per 100,000 population in Taipei. Average response times vary between 5.1 minutes (Tainan) and 22.5 minutes (Kuala Lumpur).

CONCLUSION

We found substantial variation in 11 communities across the PAROS EMS systems. This study will provide the foundation for understanding subsequent studies arising from the PAROS effort.

Stress, Work Overload, Burnout, and Satisfaction among Paramedics in Israel

Introduction:

The number of paramedics in Israel is increasing. Despite this growth and important role, the emergency medical organizations lack information about the characteristics of their work.

Objective:

The objective of this study was to examine the characteristics of the paramedics' work, the quality of their working lives, the factors that keep them in the profession, or conversely, draw them away from it.

Methods:

Cross-sectional study conducted through telephone interviews of a random sample of 50% of the graduates of paramedic courses in Israel (excluding conscripted soldiers).

Results:

The factors that attract paramedics to the profession have much to do with the essence of the job—rescuing and saving—and a love of what it involves, as well as interest and variety. Pressures at work result from having to cope with a lack of administrative support, paperwork, long hours, imbalance between work and family life, and salary. They do not come from having to cope with responsibility, the pressure of working under uncertain conditions, and the sudden transition from calm situations to emergencies. Dissatisfaction at work is caused by burnout, work overload, and poor health. Physical and mental health that impedes their ability to work is related to a sense of burnout and the intention to change professions.

Conclusions:

The findings about the relationships between health, job satisfaction, and burnout, coupled with the fact that within a decade, half of the currently employed paramedics will reach an age at which it is hard for them to perform their job, lead to the conclusion that there is a need to reconsider the optimum length of service in the profession. There also is a need to form organizational arrangements to change the work procedures of aging paramedics.

Temporal compliance trends in a cluster randomization with crossover trial of out-of-hospital cardiac arrest

Background Low compliance to randomized nondrug interventions can affect treatment estimates of clinical trials. Cluster-randomized crossover may be appropriate for increasing compliance in the out-of-hospital cardiac arrest setting.

Purpose The purpose was to determine whether the elapsed time from start of a nonblinded treatment period to episode enrollment date in a cluster-randomized crossover trial is associated with compliance to either a period of brief cardiopulmonary resuscitation (CPR) with electrocardiogram (ECG) rhythm analysis or a period of longer CPR with a delayed ECG rhythm analysis in patients with out-of-hospital cardiac arrest.

Methods The Resuscitation Outcomes Consortium PRIMED Analyze Late (AL) versus Analyze Early (AE) trial was a cluster-randomized crossover trial at 10 North American regional sites. Clusters were created based on local service preference with treatment periods varying from 3 to 12 months depending on the expected enrollment rate of each randomizing unit. Episodes on the AL arm had a target of 180 s from CPR start to shock assessment and were deemed compliant if total time was between 150 and 210 s. Episodes on the AE arm had a target of <30 s from CPR start to shock assessment and were deemed compliant if total time was <60 s. We used logistic regression to examine the association between compliance (yes/no) and the elapsed number of days from the start of the treatment period to the episode in the framework of generalized estimating equations, controlling for randomized treatment (Late, reference = Early) and treatment period length (reference = 3, 4–5, 6, 7–11, and 12 months).

Results We had 8769 episodes in our analysis population. Overall compliance to the randomized arm was 63.5%. After adjusting for treatment arm and treatment period length, the odds of compliance for episodes occurring >300 days from treatment period start were 33% lower (odds ratio (OR): 0.67; 95% confidence interval (CI): 0.52, 0.86) than for those <60 days from treatment period start. There was no significant difference in compliance between episodes before and immediately after a cluster crossed over to the opposite arm (OR: 0.81; 95% CI: 0.57, 1.16).

Limitations A major challenge was the lack of synchronicity between training cycles and agency crossover dates.

Conclusion We found a significant decrease in compliance to the AL versus AE cardiac arrest intervention as the elapsed time from start of treatment period increased. We did not find a difference in compliance immediately before and after a crossover. While these results suggest that future cluster with crossover trials in the out-of-hospital setting be designed with short treatment periods and frequent crossovers, provider logistical concerns must also be considered.

Current status of establishing a venous line in CPA patients by Emergency Life-Saving Technicians in the prehospital setting in Japan and a proposal for intraosseous infusion

INTRODUCTION

It is important to have a venous line in cardiopulmonary arrest (CPA) patients as an emergency treatment measure in prehospital settings, but establishment of a peripheral venous line is difficult in such patients. This study aimed to investigate the current status of intravenous infusion (IVI) in CPA patients by Emergency Life-Saving Technicians (ELSTs) in Japan. We also considered alternative measures in case IVI was difficult or impossible.

METHODS

We investigated a nationwide database between 1 January 2005 and 31 December 2008. From a total of 431,968 CPA cases, we calculated the IVI success rate and related parameters.The Bone Injection Gun (BIG) and simulator legs (adult, pediatric, and infant) were used by 100 ELSTs selected for the study to measure the time required and the success rate for intraosseous infusion (IOI).

RESULTS

The number of CPA patients, IVI, adrenaline administration, and the IVI success rate in adult CPA patients increased every year. However, the IVI success rate in pediatric CPA patients did not increase. Although adrenaline administration elevated the ROSC rate, there was no improvement in the 1-month survival rate. The time required for IOI with BIG was not different among the leg models. The success rates of IOI with BIG were 93%, 94%, and 84% (p < 0.05 vs. adult and pediatric) in adult, pediatric, and infant models, respectively.

CONCLUSIONS

The rate of success of IVI in adult CPA patients has been increased yearly in Japan. However, as establishing a peripheral venous line in pediatric patients (1-7 years old) by ELSTs is extremely difficult in prehospital settings, there was no increase in the IVI success rate in such patients. As the study findings indicated IOI with BIG was easy and rapid, it may be necessary to consider IOI with BIG as an alternative option in case IVI is difficult or impossible in adult and pediatric patients.

Prehospital ultrasound as the evolution of the Franco-German model of prehospital EMS

Purpose

To evaluate, throughout model analysis and evaluation of existing literature and personal experience, which can be the benefits of routine performance of prehospital ultrasound in the different models of prehospital emergency medical service.

Methods

The existing literature was reviewed.

Conclusions

The ultrasound can be a very valuable asset in both the Anglo-American and the Franco-German models. In the latter, however, its role is further emphasized since US-enhanced on-spot early diagnosis performed by the physician can be beneficial to the whole system and not just the single patient.

Mobile Emergency Care Service: analysis of Brazilian policy

OBJECTIVE

To analyze the configuration of mobile emergency health care policy in Brazil.

METHODOLOGICAL PROCEDURES

The study was based on public policy analysis. Bibliographic and document review, analysis of official data and interviews with federal administrators related to formulation and implementation of the Mobile Emergency Care Service (SAMU) in Brazil in the 2000s were performed.

ANALYSIS OF RESULTS

Priority was given to SAMU at the federal level since 2003. During the first years of implementation, municipal level services predominated; in 2008, services with regional scope became more significant. Estimated coverage reached 53.9% of the population in 2009, in 20.5% of Brazilian municipalities. Implementation varied between States, and there were less advanced support ambulances than recommended, both nationally and in several States.

CONCLUSIONS

SAMU was adopted nationwide since 2003 upon development of federal norms. Implementation of the policy involves challenges, including adequate investment, integration of the service into an established urgent care network, arrangement of appropriate information systems and personnel capacity. Addressing these challenges will allow SAMU to become a key health care strategy in the unified health system.

Implementation of a new emergency medical communication centre organization in Finland--an evaluation, with performance indicators

Background

There is a great variety in how emergency medical communication centers (EMCC) are organized in different countries and sometimes, even within countries. Organizational changes in the EMCC have often occurred because of outside world changes, limited resources and the need to control costs, but historically there is often a lack of structured evaluation of these organization changes. The aim of this study was to evaluate if the performance in emergency medical dispatching changed in a smaller community outside Helsinki after the emergency medical call centre organization reform in Finland.

Methods

A retrospective observational study was conducted in the EMCC in southern Finland. The data from the former system, which had municipality-based centers, covered the years 2002-2005 and was collected from several databases. From the new EMCC, data was collected from January 1 to May 31, 2006. Identified performance indicators were used to evaluate and compare the old and new EMCC organizations.

Results

A total of 67 610 emergency calls were analyzed. Of these, 54 026 were from the municipality-based centers and 13 584 were from the new EMCC. Compared to the old municipality-based centers the new EMCC dispatched the highest priority to 7.4 percent of the calls compared to 3.6 percent in the old system. The high priority cases not detected by dispatchers increased significantly (p < 0.001) in the new EMCC organization, and the identification rate of unexpected deaths in the dispatched ambulance assignments was not significantly (p = 0.270) lower compared to the old municipality-based center data.

Conclusion

After implementation of a new EMCC organization in Finland the percentage and number of high priority calls increased. There was a trend, but no statistically significant increase in the emergency medical dispatchers' ability to detect patients with life-threatening conditions despite structured education, regular evaluation and standardization of protocols in the new EMCC organization.