The Efficacy of Advanced Life Support: A Review of the Literature

Testing the effects of checklists on team behaviour during emergencies on general wards: An observational study using high-fidelity simulation

INTRODUCTION

Clinical teams struggle on general wards with acute management of deteriorating patients. We hypothesized that the Crisis Checklist App, a mobile application containing checklists tailored to crisis-management, can improve teamwork and acute care management.

METHODS

A before-and-after study was undertaken in high-fidelity simulation centres in the Netherlands, Denmark and United Kingdom. Clinical teams completed three scenarios with a deteriorating patient without checklists followed by three scenarios using the Crisis Checklist App. Teamwork performance as the primary outcome was assessed by the Mayo High Performance Teamwork scale. The secondary outcomes were the time required to complete all predefined safety-critical steps, percentage of omitted safety-critical steps, effects on other non-technical skills, and users' self-assessments. Linear mixed models and a non-parametric survival test were conducted to assess these outcomes.

RESULTS

32 teams completed 188 scenarios. The Mayo High Performance Teamwork scale mean scores improved to 23.4 out of 32 (95% CI: 22.4-24.3) with the Crisis Checklist App compared to 21.4 (20.4-22.3) with local standard of care. The mean difference was 1.97 (1.34-2.6; p < 0.001). Teams that used the checklists were able to complete all safety-critical steps of a scenario in more simulations (40/95 vs 21/93 scenarios) and these steps were completed faster (stratified log-rank test χ² = 8.0; p = 0.005). The self-assessments of the observers and users showed favourable effects after checklist usage for other non-technical skills including situational awareness, decision making, task management and communication.

CONCLUSIONS

Implementation of a novel mobile crisis checklist application among clinical teams was associated in a simulated general ward setting with improved teamwork performance, and a higher and faster completion rate of predetermined safety-critical steps.

Prevalence of intubation rescue by air medical personnel during transfers from rural emergency departments

OBJECTIVE

Non-emergency-trained providers in rural emergency departments (ED) often lack the skills required for emergency resuscitations and rely on air medical transport teams to provide the initial airway stabilization of these patients. In this study, we determined the prevalence with which endotracheal intubations are required of air medical personnel upon arrival to rural EDs including intubations that were first attempted by the local provider.

METHODS

A retrospective database review was conducted of all air medical transfers from rural hospitals for a 28-month period. Those patients requiring an airway were categorized according to which provider initiated the intubation procedure. The prevalence of intubations performed by air medical and local providers was recorded as the percent of the total number of intubations.

RESULTS

There were a total of 217 patients from 11 rural EDs requiring airway support. Air medical personnel were responsible for 85% of the intubations. Alternative airway support was necessary in 5% of the patients after unsuccessful intubation attempts. The failed intubations tended to be slightly older and female.

CONCLUSION

Our study suggests that the vast majority of the intubations for patients requiring a helicopter evacuation from these rural settings are performed by the air medical personnel.

Dynamic ambulance reallocation for the reduction of ambulance response times using system status management

OBJECTIVES

Dynamically reassigning ambulance deployment locations throughout a day to balance ambulance availability and demands can be effective in reducing response times. The objectives of this study were to model dynamic ambulance allocation plans in Singapore based on the system status management (SSM) strategy and to evaluate the dynamic deployment plans using a discrete event simulation (DES) model.

METHODS

The geographical information system-based analysis and mathematical programming were used to develop the dynamic ambulance deployment plans for SSM based on ambulance calls data from January 1, 2011, to June 30, 2011. A DES model that incorporated these plans was used to compare the performance of the dynamic SSM strategy against static reallocation policies under various demands and travel time uncertainties.

RESULTS

When the deployment plans based on the SSM strategy were followed strictly, the DES model showed that the geographical information system-based plans resulted in approximately 13-second reduction in the median response times compared to the static reallocation policy, whereas the mathematical programming-based plans resulted in approximately a 44-second reduction. The response times and coverage performances were still better than the static policy when reallocations happened for only 60% of all the recommended moves.

CONCLUSIONS

Dynamically reassigning ambulance deployment locations based on the SSM strategy can result in superior response times and coverage performance compared to static reallocation policies even when the dynamic plans were not followed strictly.

Anglo-American vs. Franco-German Emergency Medical Services System

It has been stated that the Franco-German Emergency Medical Services System (FGS) has considerable drawbacks compared to the Anglo-American Emergency Medical Services System (AAS):

1. The key differences between the AAS and the FGS are that in the AAS, the patients is brought to the doctor, while in the FGS, the doctor is brought to the patient.

2. In the FGS, patients with urgent conditions usually are evaluated and treated by general practitioners in their offices or at the patient`s home; initially, very few approach an emergency department.

3. Emergency patients with life-threatening trauma or disease are treated by emergency physicians at the scene and during transport. Paramedics often are first to arrive at the scene, and until the emergency physician arrives at the scene, are allowed to defibrillate, to intubate endotracheal-ly, and to administer life-saving drugs (epinephrine endotracheally, glucose intravenously, etc.).

4. Prehospital emergency physicians treat patients at the scene and during transport.

5. Emergency patients are guaranteed to be reached by an appropriate emergency vehicle and a respective crew within 10 minutes in 80% of the responses and within 15 minutes in 95% of cases.

6. The FGS deploys qualified emergency physicians assisted by qualified paramedics as prehospital intensive care providers; extended immediate care is standard. Total Prehospital Times (TPT) and scene times only are minimally longer than in the AAS.

7. Emergency Medicine is recognized as a supra-specialty to the base specialties. Specific training programs exist for emergency physicians, medical directors of emergency medical services systems (EMSS), and chief emergency physicians (CEP).

8. Resuscitation attempts are carried out not only by anesthesiologists, but also by internists, surgeons, pediatricians, etc. Emergency medicine encompasses cardiopulmonary resuscitation (CPR) and shock cases, and patients with an acute myocardial infarction, stroke, poly-trauma, status asthmaticus, etc. Emergency patients are admitted directly to emergency departments of the hospitals, which, depending upon the size of the hospital.

9. The incidence of life-threatening trauma victims has decreased to <10% in the FGS. Of a total of 830,000 deaths/year, fatal trauma cases ranked the lowest at 4%.

10. Survival figures on cardiac arrest (asystole, ventricular fibrillation/ventricular tachycardia (VF/VT), pulseless electrical activity (PEA), etc.) reported in the German EMSS correspond to those in Europe and the United States.

11. Paramedic training is characterized by a two-year program followed by a theoretical and a practical examination.

12. Paramedics and emergency physicians-in-training are supervised at the scene and during transport. Quality assurance (Q/A) constitutes an integral and legally compulsory part of the EMSS.

13. In the majority of cases, the emergency patients are evaluated and treated by the respective specialties without delays caused by patient transfer to other hospitals.

14. The FGS does not require a greater number of ambulances and/or personnel than does the AAS.

15. The German healthcare system creates less expenses/ capita than the does the U.S. system at a similar level of quality of care.

16. Emergency procedures are carried out by anesthesiologists, emergency physicians, surgeons, internists, and other specialists.

Recommendations for Uniform Reporting of Data following Major Trauma — The Utstein Style: An Initiative

The document is published in collaboration with the following organisations: the European Society of Emergency Medicine (Leuven); the European Resuscitation Council (Antwerpen); the Air Medical Physician Association (Salt Lake City, US); the German Interdisciplinary Association of Critical Care Medicine; and the German Society of Anaesthesiology and Intensive Care. The document is to be published jointly in the following journals: 1) Trauma Care (ITACCS); 2) Resuscitation; 3) Prehospital and Disaster Medicine; 4) European Journal of Emergency Medicine; 5) Trauma and Emergency Medicine Journal (SA); 6) Emergency Medicine(Norway); 7) JEUR; and 8) Notfall und Rettungsmedizin (Germany).

Advanced life support versus basic life support in the pre-hospital setting: a meta-analysis

BACKGROUND

The scientific evidence of a beneficial effect of ALS in pre-hospital treatment in trauma patients or patients with any acute illness is scarce. The objective of this systematic review of controlled studies was to examine whether ALS, as opposed to BLS, increases patient survival in pre-hospital treatment and if so, to identify the patient groups that gain benefit.

METHODS

A systematic review of studies published in the databases Medline (PubMed), EMBASE, Cochrane Library and Scopus up to July 31st, 2010. Controlled studies comparing survival after the pre-hospital ALS treatment versus BLS treatment in trauma patients or patients with cardiac arrest were included.

RESULTS

We identified 1081 studies of which 18 met our inclusion criteria. In nine of 18 studies including 16,857 trauma patients in the intervention group, ALS care did not increase survival compared to BLS treatment (pooled OR 0.892, 95% CI, 0.775-1.026). In nine of 18 studies including 7659 patients with cardiac arrest in the intervention group, ALS care increased survival compared to BLS treatment (OR 1.468, 95% CI, 1.257-1.715). Most subgroup analyses revealed no significant interactions, but data from six trials, where ALS was provided by physicians, increases the probability of survival at hospital discharge even more (OR 2.047, 95% CI 1.593-2.631).

CONCLUSION

Implementation of ALS care to non-traumatic cardiac arrest patients can increase survival and further research is unlikely to change our confidence in the estimate of the effect. On the contrary, in trauma patients our meta-analysis revealed that ALS care is not associated with increased survival. However, only few controlled studies of sufficient quality and strength examining survival with pre-hospital ALS treatment exist.

Management of prehospital seizure patients by paramedics

BACKGROUND

Seizure patients are frequently encountered in the prehospital environment and have the potential to need advanced interventions, though the utility of advanced life support (ALS) interventions in many of these patients has not been proven.

OBJECTIVE

Our goals were to assess the management of prehospital seizure patients by paramedics in an urban EMS system with an existing ALS-based prehospital seizure protocol and to assess characteristics and short-term outcomes that may aid in addressing the utility of specific ALS interventions.

METHODS

This was a retrospective study of 97 EMS cases with the chief complaint of seizure. Prehospital records were reviewed for patient and event characteristics, including past seizure history, seizure timing, level of consciousness, on-scene and transport times, and EMS interventions. Emergency department (ED) records were reviewed for recurrence of seizure activity, ED evaluation, and disposition. Data were analyzed using descriptive statistics and Student t-test.

RESULTS

Of 87 patients meeting the protocol inclusion criteria for all ALS interventions, 11 (12.6%) received cardiac monitoring, 55 (63.2%) had intravenous (IV) access attempted, and 56 (64.4%) had blood glucose determination. Average on-scene time was 5.9 minutes longer if IV access was attempted (p = 0.001), though transport times were not significantly different (11.6 versus 11.3 minutes, respectively; p = 0.851). Additional seizure activity occurred in the prehospital and/or ED settings in 28 patients (28.9% of all cases), including 17 in the prehospital setting and 15 in the ED. Diazepam was administered by EMS for half of the eight (8.2%) patients who had seizures lasting more than 1 minute, while the remainder had seizures that were focal or spontaneously resolved.

CONCLUSION

This study showed a lower-than-anticipated level of compliance with an ALS-based prehospital seizure protocol, though patient-specific care appeared appropriate. Prehospital seizure patients have the potential for seizure recurrence and may benefit from focused ALS interventions, but their heterogeneity makes uniform protocols difficult to develop and follow.

The demand for prehospital advanced life support and the appropriateness of dispatch in Taipei

INTRODUCTION

Implementing prehospital advanced life support (ALS) services requires more medical and societal resources in training and equipment. The actual demand for ALS services in our communities was not clear. To ensure good use of expensive resources, it is important to evaluate the demand and appropriateness of ALS services before full-scale implementation takes place.

OBJECTIVE

To evaluate the rate and characteristics of demand for ALS, and the appropriateness of ALS dispatch of the emergency medical service (EMS) system in metropolitan Taipei City.

METHODS

A retrospective, cross-sectional analysis of the EMS records of Taipei City Fire Department from April 1999 to December 2000 was conducted. Stratified random sampling of all EMS records in the second week of January, April, July and October of 2000 were obtained, along with the corresponding ALS dispatch records. Retrospective ALS demand criteria, including the chief complaints, mechanisms of injury/illness, initial vital signs and types of care rendered, were developed to estimate the rate of ALS demand. ALS demand is expressed as the percentage of cases fulfilling ALS criteria over the total number of EMS cases. Appropriate ALS dispatches were those ALS dispatches determined as fulfilling the ALS demand criteria.

RESULTS

Among the sampled 5433 EMS cases, 490 (9.02%) were determined as a demand for ALS care. ALS demands varied from region to region, and were higher during winter months and afternoon rush hours. There were 175 actual ALS dispatches, accounting for 3.22% of the sampled EMS services. The triage performance was suboptimal: the appropriateness of ALS dispatch was 37.14%; the overtriage rate was 72.86%.

CONCLUSION

Around nine percent of EMS calls demand ALS services. The current triage performance for proper ALS dispatch was suboptimal. A correct ALS dispatch protocol and more dispatcher training programmes should be established in the communities to ensure best use of valuable ALS resources.

A geographic information system simulation model of EMS: reducing ambulance response time

Response time is a very important factor in determining the quality of prehospital EMS. Our objective was to model the response by Israeli ambulances and to offer model-derived strategies for improved deployment of ambulances to reduce response time. Using a geographic information system (GIS), a retrospective review of computerized ambulance call and dispatch logs was performed in two different regional districts, one large and urban and the other rural. All calls that were pinpointed geographically by the GIS were included, and their data were stratified by weekday and by daily shifts. Geographic areas (polygons) of, at most, 8 minutes response time were simulated for each of these subgroups to maximize the timely response of calls. Before using the GIS model, mean response times in the Carmel and Lachish districts were 12.3 and 9.2 minutes, respectively, with 34% and 62% of calls responded within 8 minutes. When ambulances were positioned within the modeled polygons, more than 94% of calls met the 8-minute criterion. The GIS simulation model presented in this study suggests that EMS could be more effective if a dynamic load-responsive ambulance deployment is adopted, potentially resulting in increased survival and cost-effectiveness.

Mortality of blunt polytrauma: a comparison between emergency physicians and emergency medical technicians--prospective cohort study at a level I hospital in eastern Switzerland

BACKGROUND

The role of prehospital basic life support as opposed to prehospital advanced life support and the best qualifications for emergency personnel are controversial. Our objective was to establish whether the prehospital deployment of emergency physicians (EPs) rather than emergency medical technicians (EMTs) decreased mortality in blunt polytrauma patients.

METHODS

In a prospective, observational cohort study conducted between 1990 and 1996, we used the A Severity Characterization of Trauma score to compare the actual mortality with the predicted mortality in 71 blunt polytrauma patients, 63 treated by EMTs alone and 8 treated also by anesthetic nurses. The same comparison was conducted in 196 blunt polytrauma patients treated by EPs together with EMTs or paramedics. Multivariate logistic regression analysis was conducted to test for any confounding factors and bias, and for the identification of factors associated with mortality. Inclusion criteria were blunt trauma at a minimum of two body sites, an Injury Severity Score of 8 or more, and direct admission to our trauma center.

RESULTS

The mortality in patients treated by EPs was 11.2% (22 of 196) and was statistically not significantly lower than the 14.1% calculated for the patients treated without EP involvement (10 of 71). In the group treated by EPs, there were 1.3 (95% confidence interval [CI], -5.9-8.5), or 6%, fewer deaths than would have been expected on the basis of the results of the Major Trauma Outcome Study (p = 0.734). In contrast, in the group treated without EP involvement, there were 3.4 (95% CI, -0.2-7), or 34%, more deaths than predicted (p = 0.066). This trend was confirmed by multivariate logistic regression, which showed a significant mortality odds ratio of 37 (95% CI, 2-749) for the EMT group as compared with the EP group.

CONCLUSION

In contrast with the deployment of EPs, care of blunt polytrauma patients by EMTs showed a statistical trend to a higher mortality than predicted and also a significantly higher risk of mortality. It is likely that the consistent deployment of EPs for moderate to severe blunt polytrauma in our catchment area might prevent between 0% and 23% of all deaths from blunt polytrauma or, in absolute terms, up to 1 death per year or 0 to 9.9 per 100 patients treated by an EP instead of an EMT.

How to modify the risk-taking behaviour of emergency medical services drivers?

High speed and an aggressive style of driving are major risk factors for serious traffic accidents. Consequently, frontline emergency medical services vehicles have an increased collision risk. We report on two studies designed to modify the risk-taking behaviour of emergency medical services drivers. In the first study, we compared the travel intervals for a second tier unit using two different types of vehicles. We found that the replacement of a sports estate by an ambulance, which can be considered more or less as a change from a speedy and aggressive style of driving to a cautious style of driving with respect for the speed limits, resulted in an increase of the travel interval of only 10-20%. In the second study we found that the installation of a 'black box' in an emergency medical services vehicle, combined with well-defined guidelines for the drivers and a close monitoring system, provides fair but still not optimal results with regard to maximum speed and the occurrence of harsh braking events. Despite some limitations in the study designs, we conclude that for second tier units only a small amount of time is gained by high speed and an aggressive style of driving. Furthermore, we are convinced that a 'black box' is a good tool to modify the risk-taking behaviour of emergency medical services drivers.

Advanced or basic life support for trauma: meta-analysis and critical review of the literature

BACKGROUND

The question of whether to use advanced life support (ALS) or basic life support (BLS) for trauma patients in the prehospital setting has been much debated and still lacks a clear answer. The purpose of this study was to conduct a comprehensive critical review of the literature regarding this controversy

METHODS

A total of 174 articles on prehospital ALS or BLS for trauma were reviewed. Fifteen of these studies were found to involve mortality statistics for both ALS- and BLS-treated patients. Odds ratios were calculated for survival in ALS versus BLS and summarized across studies on the basis of multivariate scoring systems that incorporated both design and methodological assessment. Overall odds ratios for all studies were calculated on the basis of both raw data from the papers, and weighted odds ratios were calculated from the scoring systems.

RESULTS

Six studies were scored as being methodologically average (5 favoring BLS and 1 favoring ALS), two were scored as good (1 favoring BLS and 1 favoring ALS), seven as excellent (6 favoring BLS and 1 favoring ALS). Ten studies had an average study design score (6 favoring BLS and 4 favoring ALS) and seven had a good study design score (6 favoring BLS and 1 favoring ALS). Weighted odds ratio for dying was 2.59 for patients receiving ALS compared with those receiving BLS. The crude odds ratio was 2.92.

CONCLUSION

The aggregated data in the literature have failed to demonstrate a benefit for on-site ALS provided to trauma patients and support the scoop and run approach.

Prehospital trauma care

Concepts regarding uniform reporting of data after trauma and regarding treatment of brain trauma patients at the scene have recently been agreed upon in consensus processes. Endotracheal intubation and alternatives are as controversially discussed as fluid resuscitation and helicopter transport of trauma victims. Long-term outcomes of trauma patients should more frequently be studied using the Quality of Wellbeing Scale.

Emergency medical services systems and HAZMAT major incidents

Exposures to released hazardous materials (HAZMAT) pose an increasing threat to individual and public health, particularly in high population density. Any incident causing casualties on a scale which threaten or causes overload of the available resources of the emergency medical services (EMS) or associated systems (EMSS), constitutes a major incident (MI). Emergency services, including the EMSS, have a statutory duty to develop a comprehensive, integrated and flexible all-risk Major Incident Plan (MIP) for such an event. The MIP should also include developed management provision for HAZMAT incidents and in particular provision for safety and protection of both casualties and the EMSS personnel and systems, from secondary contamination by persistent, transmissible HAZMAT agents. This paper offers an outline review of contemporary policy and practice guidelines for the management of HAZMAT incidents and major incidents, with emphasis on the following: strategic and tactical preparation, integrated modular planning, communications, evaluation, training and equipment, including personal protection. In addition organisational aspects of the safe management and protection of the EMSS and personnel at the incident site, during transportation and at the receiving hospitals are considered. Safe and effective management of casualties requires adequate protection from further exposure, triage and synchronous decontamination and life support. Finally, the implications of conventional and unconventional conflict including terrorism and current unsolved problems are discussed.