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McGuire SS, Klassen A, Luke A, Rentz L, Liedl CP, Mullan AF, Sztajnkrycer MD. Providing Performance Feedback and Patient Outcome Follow-Up to Emergency Medical Services (EMS) is Associated with Subsequent Improved Clinical Performance. PREHOSP EMERG CARE 2024:1-7. [PMID: 39047172 DOI: 10.1080/10903127.2024.2383323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Revised: 06/17/2024] [Accepted: 07/14/2024] [Indexed: 07/27/2024]
Abstract
OBJECTIVE Emergency Medical Services (EMS) clinicians desire performance feedback (PF) and patient outcome follow-up (POF). Within our agency, both a peer-review and feedback/outcome (PF/POF) process exist. Our objective was to determine whether receiving feedback and outcome data improved future clinical care amongst EMS, based upon peer-review scores. METHODS This retrospective cohort study took place between 1/1/2020 and 6/7/2023 within an EMS agency site with 22,000 average annual 9-1-1 calls. Requests for PF/POF were submitted on an individual basis beginning June 2020 and completed by a dedicated EMS nurse, EMS physician, or emergency medicine (EM) resident. Peer-review of select high-acuity cases were scored by two Quality Assurance (QA) specialists within the categories of assessment, treatment, disposition/outcome and process/administrative guidelines. Association between overall peer-review score and number of PF/POF requests at time of assessment was evaluated by linear regression. RESULTS A total of 378 PF/POF requests were received, with the most common patient complaints being cardiac (n = 105; 27.8%, including 49 (13.0%) out of hospital cardiac arrests), altered mental status/neurologic (n = 103; 27.2%), trauma (n = 61; 16.1%, including 2 (0.5%) traumatic arrests); and respiratory distress (n = 47; 12.4%). A total of 378 runs meeting QA criteria were peer-reviewed post-PF/POF process implementation, including 337 (89.2%) cardiac/respiratory arrests, 27 (7.1%) with difficult airway management, and 14 (3.7%) major trauma/traumatic arrests. The number of prior PF/POF requests made by the team leader was associated with higher overall peer-review scores. Team leaders with >5 prior PF/POF requests had a peer-review score 0.39 points greater (95% CI: 0.16 - 0.62, p = 0.001) than those with <5 prior requests. The number of prior PF/POF requests amongst the entire crew was also associated with higher peer-review scores. Crews that collectively had >5 prior PF/POF requests had an increase in peer-review score 0.32 points greater (95% CI: 0.14 - 0.50, p < 0.001) than those with <5 prior requests. CONCLUSION Providing performance feedback and patient outcome follow-up to EMS is associated with improved peer-review scores of clinical performance. Future studies should assess if those that are submitting cases for feedback/outcome are higher performers at baseline or if the process of receiving feedback/outcome improves their performance.
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Affiliation(s)
- Sarayna S McGuire
- Division of Prehospital Medicine, Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota
- Mayo Clinic Ambulance Service, Mayo Clinic, Rochester, Minnesota
| | - Aaron Klassen
- Division of Prehospital Medicine, Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota
- Mayo Clinic Ambulance Service, Mayo Clinic, Rochester, Minnesota
| | - Anuradha Luke
- Division of Prehospital Medicine, Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota
- Mayo Clinic Ambulance Service, Mayo Clinic, Rochester, Minnesota
| | - Lisa Rentz
- Division of Prehospital Medicine, Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota
| | - Chad P Liedl
- Mayo Clinic Ambulance Service, Mayo Clinic, Rochester, Minnesota
| | - Aidan F Mullan
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota
| | - Matthew D Sztajnkrycer
- Division of Prehospital Medicine, Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota
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Kimbrell J, Geldner J, Rodriguez D, Poke D, Kalosza B, Rampersaud M, Dupree C, Allgood R, Taigman M, Vega J. Changing the Culture to Improve CCF: An Improvement Project. PREHOSP EMERG CARE 2024:1-8. [PMID: 39102370 DOI: 10.1080/10903127.2024.2388271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Revised: 07/03/2024] [Accepted: 07/14/2024] [Indexed: 08/07/2024]
Abstract
OBJECTIVES After identifying chest compression fraction (CCF) as a key area for improvement, our Emergency Medical Services (EMS) agency aimed to improve our baseline monthly median CCF from 81.5% to 90% or more in paramedic-attended medical cardiac arrests by December 2023. The CCF is a process measure that, if improved, has been shown to increase likelihood of survival from cardiac arrest. Working as a hospital EMS agency within a large urban 9-1-1 system, our interventions focused on paramedics once they arrived on scene. METHODS This project used repeated Plan-Do-Study-Act (PDSA) cycles with brainstorming sessions, focus groups, and data review to achieve improvement. Interventions: Interventions include standardized clinician feedback forms, increased follow-up for patients with ongoing resuscitation, a designated CPR team leader during resuscitations, and a pre-charged defibrillator prior to rhythm checks. These interventions were evaluated by tabulating weekly and monthly median CCF performance, seeking participant feedback, and reviewing control charts. These results were reported according to the Revised Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0). RESULTS Our control chart analysis revealed special cause variation and an increase in average CCF to 89.0%. This improvement was achieved through successful implementation of process changes using PDSA cycles. Our most effective and popular intervention was our clinician feedback forms. Additionally, re-unifying patients and their successful resuscitation teams, participating in resuscitation academy events, and pre-charging the defibrillator to minimize CPR pauses collectively resulted in systemic improvement in resuscitation performance. CONCLUSIONS The findings illustrate that targeted education, increased clinician feedback, patient-team reunification, and high-performance resuscitation strategies produce measurable improvement in CCF.
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Affiliation(s)
- Joshua Kimbrell
- Department of Pre-Hospital Care, Jamaica Hospital Medical Center, Queens, New York, USA
| | - Jacob Geldner
- Department of Pre-Hospital Care, Jamaica Hospital Medical Center, Queens, New York, USA
| | - Dheuris Rodriguez
- Department of Pre-Hospital Care, Jamaica Hospital Medical Center, Queens, New York, USA
| | - Dana Poke
- Department of Pre-Hospital Care, Jamaica Hospital Medical Center, Queens, New York, USA
| | - Brittany Kalosza
- Department of Pre-Hospital Care, Jamaica Hospital Medical Center, Queens, New York, USA
| | - Maria Rampersaud
- Department of Pre-Hospital Care, Jamaica Hospital Medical Center, Queens, New York, USA
| | - Christian Dupree
- Department of Pre-Hospital Care, Jamaica Hospital Medical Center, Queens, New York, USA
| | | | - Mike Taigman
- FirstWatch, School of Nursing, University of California San Francisco, San Francisco, California, USA
| | - John Vega
- Department of Pre-Hospital Care, Jamaica Hospital Medical Center, Queens, New York, USA
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Kwong JL, Bourn S, Hillier M, Merko M, Grass AJ, Ednie T, Verbeek PR. A Quality Improvement Initiative to Increase Confirmation of Prehospital Endotracheal Tube Placement at Emergency Department Transfer of Care. PREHOSP EMERG CARE 2024:1-7. [PMID: 38861683 DOI: 10.1080/10903127.2024.2366401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 05/16/2024] [Indexed: 06/13/2024]
Abstract
OBJECTIVES Rates of prehospital unplanned extubation (UE) range from 0 to 25% and are the result of many factors, including patient movement. Transfer of care of intubated patients to the emergency department (ED) involves significant patient movement and represents a high-risk event for UE. Frequent confirmation of endotracheal tube (ETT) placement is imperative for early recognition of UE and to minimize patient harm. METHODS Local Practice-Our baseline rate of verbal ETT position confirmation with a member of the ED team during ED transfer of care was 74%. Our goal was to increase this practice to >90% in six months. This project was completed in partnership with Toronto Paramedic Services. Prehospital electronic patient care records (ePCRs) were reviewed weekly to determine the proportion of intubated patients who had ETT placement confirmed in the ED at transfer of care. Interventions-Pre- and post-project paramedic focus groups were conducted to identify potential drivers, change ideas, and project feedback. Three staggered interventions were introduced over five months: (1) memorandums to paramedics, ED chiefs and respiratory therapy leads, (2) individualized paramedic feedback e-mails, and (3) ePCR changes and closing rules. RESULTS The pre-project focus group identified several potential drivers, such as physical barriers, interprofessional relationships, and communication. ETT confirmation remained ≥90% for the last eight weeks and interventions resulted in special cause variation. Median cases without verbal confirmation between paramedics and ED staff reduced from 5/week (IQR 2.5, 6.5) to 1/week (IQR 0, 2). UE was identified in 0.6% (2/340) of patients with ETT confirmation. The post-project focus group noted improvements in perceived accountability, interprofessional relationships, and satisfaction with interventions. CONCLUSION Through a series of interventions, we improved the rate of ETT confirmation during ED transfer of care. Although rates of UE were low, improvement in ETT confirmation may lead to faster recognition of UE when it does occur thereby mitigating complications. The observed improvement was sustained after interventions ended.
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Affiliation(s)
- Jonathan L Kwong
- Division of Emergency Medicine, University of Toronto, Toronto, Canada
| | | | - Morgan Hillier
- Division of Emergency Medicine, University of Toronto, Toronto, Canada
- Sunnybrook Centre for Prehospital Medicine, University of Toronto, Toronto, Canada
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Mike Merko
- Sunnybrook Centre for Prehospital Medicine, University of Toronto, Toronto, Canada
| | - A J Grass
- Toronto Paramedic Services, Toronto, Canada
| | - Tim Ednie
- Toronto Paramedic Services, Toronto, Canada
| | - P Richard Verbeek
- Sunnybrook Centre for Prehospital Medicine, University of Toronto, Toronto, Canada
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
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McGahern C, Cantor Z, De Mendonca B, Dawson J, Boisvert L, Dalgleish D, Newhook D, Reddy D, Bresee N, Alnaji F. Closing the Loop: The Value of Outcome Letters for Prehospital Pediatric Care. Pediatr Emerg Care 2024; 40:261-264. [PMID: 37205877 DOI: 10.1097/pec.0000000000002978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
OBJECTIVES Providing emergency care to acutely ill or injured children is stressful and requires a high level of training. Paramedics who provide prehospital care are typically not involved in the circle of care and do not receive patient outcome information. The aim of this quality improvement project was to assess paramedics' perceptions of standardized outcome letters pertaining to acute pediatric patients that they had treated and transported to an emergency department. METHODS Between December 2019 and December 2020, 888 outcome letters were distributed to paramedics who provided care for 370 acute pediatric patients transported to the Children's Hospital of Eastern Ontario in Ottawa, Canada. All paramedics who received a letter (n = 470) were invited to participate in a survey that collected their perceptions and feedback about the letters, as well as their demographic information. RESULTS The response rate was 37% (172/470). Approximately half of the respondents were Primary Care Paramedics and half Advanced Care Paramedics. The respondents' median age was 36 years, median years of service was 12 years, and 64% identified as male. Most agreed that the outcome letters contained information pertinent to their practice (91%), allowed them to reflect on care they had provided (87%), and confirmed clinical suspicions (93%). Respondents indicated that they found the letters useful for 3 reasons: 1) increases capacity to link differential diagnoses, prehospital care, or patient outcomes; 2) contributes to a culture of continuous learning and improvement; and 3) gives closure, reduces stress, or provides answers for difficult cases. Suggestions for improvement included providing more information, provision of letters on all patients transported, faster turnaround time between call and receipt of letter and inclusion of recommendations or interventions/assessments. CONCLUSIONS Paramedics appreciated receiving hospital-based patient outcome information after their provision of care and reported that the letters offered opportunities for closure, reflection, and learning.
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Affiliation(s)
- Candice McGahern
- From the Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Zachary Cantor
- Regional Paramedic Program of Eastern Ontario, Ottawa, Ontario, Canada
| | | | - Jennifer Dawson
- From the Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Liane Boisvert
- Emergency Department, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Dale Dalgleish
- From the Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Dennis Newhook
- From the Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Deepti Reddy
- From the Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
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Schneider K, Williams M, Mohr NM, Ahmed A. Rural Emergency Medical Services Clinicians' Perceptions and Preferences in Receiving Clinical Feedback From Hospitals: A Qualitative Needs Assessment. PREHOSP EMERG CARE 2024; 28:735-744. [PMID: 38416871 DOI: 10.1080/10903127.2024.2324970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 02/18/2024] [Indexed: 03/01/2024]
Abstract
OBJECTIVE Emergency medical services (EMS) clinicians experience dissatisfaction with the quality and quantity of clinical feedback from hospitals. Satisfaction is further diminished by the lack of a standardized systems approach. The purpose of this study was to identify rural clinicians' perceptions and preferences regarding clinical feedback received from hospitals, the delivery mechanisms, and its impact on their relationships with health care organizations. METHODS This was a qualitative study focused on EMS clinicians involved in rural prehospital care at a single Midwestern academic medical center. Using a phenomenological framework, semi-structured interviews were conducted with medical directors, service directors, fire captains, air medical personnel, emergency medical responders, emergency medical technicians, advanced emergency medical technicians, and paramedics, all of whom were selected through purposive sampling. Interviews were recorded, transcribed, and independently coded by two trained reviewers. RESULTS Twenty participants (11 frontline clinicians and 9 administrative staff members) with a wide range of clinical experience from 14 air and ground EMS agencies were interviewed. Emerging themes included: (1) the value or usefulness of feedback; (2) desired feedback system characteristics; (3) barriers to receiving feedback; (4) utilization and application of feedback; and (5) the feedback's impact on the relationship with health care organizations. Participants felt that clinical feedback from hospitals was especially important as a method of improving quality of care, though was rarely provided. Professional development was seen as a major benefit of receiving clinical feedback from hospitals. CONCLUSION Our results suggest that consistent clinical feedback provided by hospitals was valued. Establishing a culture of providing organized feedback to practicing rural EMS clinicians is important for professional development and can strengthen the relationships between EMS clinicians and hospitals. These study findings can assist in the development and implementation of a standardized feedback instrument to benefit rural EMS clinicians, patients, and the health care system as a whole.
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Affiliation(s)
- Katherine Schneider
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Mimi Williams
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Nicholas M Mohr
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa
- Divison of Critical Care, Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Azeemuddin Ahmed
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
- Department of Management and Entrepreneurship, University of Iowa Tippie College of Business, Iowa City, Iowa
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Wilson C, Janes G, Lawton R, Benn J. Types and effects of feedback for emergency ambulance staff: a systematic mixed studies review and meta-analysis. BMJ Qual Saf 2023; 32:573-588. [PMID: 37028937 PMCID: PMC10512001 DOI: 10.1136/bmjqs-2022-015634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 03/13/2023] [Indexed: 04/09/2023]
Abstract
BACKGROUND Extensive research has been conducted into the effects of feedback interventions within many areas of healthcare, but prehospital emergency care has been relatively neglected. Exploratory work suggests that enhancing feedback and follow-up to emergency medical service (EMS) staff might provide staff with closure and improve clinical performance. Our aim was to summarise the literature on the types of feedback received by EMS professionals and its effects on the quality and safety of patient care, staff well-being and professional development. METHODS A systematic review and meta-analysis, including primary research studies of any method published in peer-reviewed journals. Studies were included if they contained information on systematic feedback to emergency ambulance staff regarding their performance. Databases searched from inception were MEDLINE, Embase, AMED, PsycINFO, HMIC, CINAHL and Web of Science, with searches last updated on 2 August 2022. Study quality was appraised using the Mixed Methods Appraisal Tool. Data analysis followed a convergent integrated design involving simultaneous narrative synthesis and random effects multilevel meta-analyses. RESULTS The search strategy yielded 3183 articles, with 48 studies meeting inclusion criteria after title/abstract screening and full-text review. Interventions were categorised as audit and feedback (n=31), peer-to-peer feedback (n=3), postevent debriefing (n=2), incident-prompted feedback (n=1), patient outcome feedback (n=1) or a combination thereof (n=4). Feedback was found to have a moderate positive effect on quality of care and professional development with a pooled effect of d=0.50 (95% CI 0.34, 0.67). Feedback to EMS professionals had large effects in improving documentation (d=0.73 (0.00, 1.45)) and protocol adherence (d=0.68 (0.12, 1.24)), as well as small effects in enhancing cardiac arrest performance (d=0.46 (0.06, 0.86)), clinical decision-making (d=0.47 (0.23, 0.72)), ambulance times (d=0.43 (0.12, 0.74)) and survival rates (d=0.22 (0.11, 0.33)). The between-study heterogeneity variance was estimated at σ2=0.32 (95% CI 0.22, 0.50), with an I2 value of 99% (95% CI 98%, 99%), indicating substantial statistical heterogeneity. CONCLUSION This review demonstrated that the evidence base currently does not support a clear single point estimate of the pooled effect of feedback to EMS staff as a single intervention type due to study heterogeneity. Further research is needed to provide guidance and frameworks supporting better design and evaluation of feedback interventions within EMS. PROSPERO REGISTRATION NUMBER CRD42020162600.
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Affiliation(s)
- Caitlin Wilson
- School of Psychology, University of Leeds, Leeds, UK
- Research and Development Department, Yorkshire Ambulance Service NHS Trust, Wakefield, UK
- Yorkshire Quality and Safety Research Group, Bradford Institute for Health Research, Bradford, UK
| | - Gillian Janes
- Department of Nursing, Manchester Metropolitan University, Manchester, UK
| | - Rebecca Lawton
- School of Psychology, University of Leeds, Leeds, UK
- Yorkshire Quality and Safety Research Group, Bradford Institute for Health Research, Bradford, UK
| | - Jonathan Benn
- School of Psychology, University of Leeds, Leeds, UK
- Yorkshire Quality and Safety Research Group, Bradford Institute for Health Research, Bradford, UK
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Melaika K, Sveikata L, Vilionskis A, Wiśniewski A, Jurjans K, Klimašauskas A, Jatužis D, Masiliūnas R. Prehospital Stroke Care, Paramedic Training Needs, and Hospital-Directed Feedback in Lithuania. Healthcare (Basel) 2022; 10:healthcare10101958. [PMID: 36292405 PMCID: PMC9601945 DOI: 10.3390/healthcare10101958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 09/26/2022] [Accepted: 10/02/2022] [Indexed: 11/04/2022] Open
Abstract
Background: Emergency medical services (EMS) are the first health care contact for the majority of stroke patients. However, there is a lack of data on the current paramedics’ hospital-directed feedback and training needs across different health care settings. We aimed to evaluate paramedics’ prehospital stroke care knowledge, training needs, and current status of feedback on suspected stroke patients. Methods: We surveyed paramedics from the Vilnius region from September to November 2019 and compared the answers between the city and the district agencies. The questionnaire content included questions on paramedics’ demographic characteristics, prehospital stroke care self-assessment, knowledge on stroke mimics, stroke training needs, and the importance of hospital-directed feedback on suspected stroke patients. Results: A total number of 161 paramedics (or 49.4% of all paramedics from our stroke care network) were surveyed, with more district paramedics rating their prehospital stroke care knowledge as inadequate (44.8% (95% confidence interval (CI) 32.8−57.6) vs. 28.1% (95% CI 20.1−27.8), p = 0.028). In addition, more district paramedics indicated a need for additional stroke training (83.1% (95% CI 71.5−90.5) vs. 69.8% (60.0−78.1), p = 0.043). However, respondents reported being the most confident while dealing with stroke (71.3%, 95% CI 63.8−77.7) compared to other time-critical conditions (p < 0.001). Vertigo (60.8%, 95% CI 53.0−68.0), brain tumors (56.3%, 95% CI 48.5−63.8), and seizures (54.4%, 95% CI 46.7−62.0) were indicated as the most common stroke mimics. Only 6.2% (95% CI 3.4−11.1) of respondents received formal feedback on the outcome of suspected stroke patients brought to the emergency department. Conclusions: A high proportion of paramedics self-perceive having inadequate stroke knowledge and an urgent need for further stroke training. The EMS staff indicate receiving insufficient feedback on suspected stroke patients, even though its usefulness is perceived as paramount.
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Affiliation(s)
| | - Lukas Sveikata
- J. Philip Kistler Stroke Research Center, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
- Division of Neurology, Department of Clinical Neurosciences, Geneva University Hospitals, 1205 Geneva, Switzerland
- Institute of Cardiology, Medical Academy, Lithuanian University of Health Sciences, 50161 Kaunas, Lithuania
| | - Aleksandras Vilionskis
- Clinic of Neurology and Neurosurgery, Institute of Clinical Medicine, Vilnius University, 08661 Vilnius, Lithuania
| | - Adam Wiśniewski
- Department of Neurology, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, 85-067 Bydgoszcz, Poland
| | - Kristaps Jurjans
- Department of Neurology and Neurosurgery, Riga Stradins University, 1002 Riga, Latvia
- Department of Neurology, Pauls Stradins Clinical University Hospital, 1002 Riga, Latvia
| | - Andrius Klimašauskas
- Center of Anaesthesiology, Intensive Therapy and Pain Management, Vilnius University, 08661 Vilnius, Lithuania
| | - Dalius Jatužis
- Center of Neurology, Vilnius University, 08661 Vilnius, Lithuania
| | - Rytis Masiliūnas
- Center of Neurology, Vilnius University, 08661 Vilnius, Lithuania
- Correspondence: ; Tel.: +370-688-62356; Fax: +370-688-62728
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Hoff JJ, Zimmerman A, Tupetz A, Van Vleet L, Staton C, Joiner A. Shame and Guilt in EMS: A Qualitative Analysis of Culture and Attitudes in Prehospital Emergency Care. PREHOSP EMERG CARE 2022; 27:418-426. [PMID: 35522078 DOI: 10.1080/10903127.2022.2074178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Study ObjectivesThe shame reaction is a highly negative emotional reaction shown to have long-term deleterious effects on the mental health of clinicians. Prior studies have focused on in-hospital personnel, but very little is known about what drives shame reactions in emergency medical services (EMS), a field with very high rates of post-traumatic stress disorder, burnout, anxiety, and depression. The objective of this study was to describe emotions, processes, and resilience associated with self-identified adverse events in the work of prehospital clinicians.MethodsWe conducted a qualitative study using a modified critical incident technique. Participants were recruited from two EMS agencies in North Carolina: one urban and one rural. They provided an open-ended, written reflection in which they were asked to self-identify particular events in their EMS careers that felt emotionally difficult. In-person or video in-depth interviews about these events were then conducted in a semi-structured fashion using an iterative interview guide. The codebook was developed through a mix of inductive and deductive analysis strategies and discussed within the research team and a content expert for validation. Interviews were transcribed and data were analyzed following a thematic content analysis approach for types of cases identified as emotionally difficult, common emotional responses and coping mechanisms, and the lingering effects of these experiences on study subjects.ResultsEight interviews were conducted with EMS personnel: five from an urban agency and three from a rural agency. Participants commonly identified complex medical cases as being emotionally difficult, which led to the most robust shame reactions. Shame reactions were more common when EMS clinicians committed self-perceived errors in patient care, whereas guilt reactions were more common when patient outcomes seemed "inevitable" despite any intervention. Common themes related to coping mechanisms included both personal mechanisms, which tended to be less successful compared to interpersonal mechanisms, particularly when emotions were shared with colleagues. This reflected a perceived culture change within EMS in which sharing emotions with colleagues was seen as a departure from the "old school" where emotions tended to be kept to oneself. Feelings of inadequacy, low self-worth, and being "not good enough" were frequently identified as lingering emotions after difficult cases that were hard to move on from, corresponding to longstanding shame in these clinicians. Recovery and resilience varied but tended to be positively associated with a culture in which sharing with colleagues was encouraged, along with personal introspection on root causes for the sentinel event.ConclusionEMS clinicians often identify complex patient cases as those leading to emotions such as shame and guilt, with shame reactions being more common when a perceived error was committed. Coping mechanisms were varied, but individuals often relied on their co-workers in a sharing environment to adequately process their negative feelings, which was seen as a departure from past practices in EMS personnel. Our hope is that future studies will be able to use these findings to identify targets for intervention on negative mental health outcomes in EMS personnel.
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Affiliation(s)
- J J Hoff
- Division of Emergency Medicine, Department of Surgery, Duke University Medical Center, Durham, NC.,Department of Emergency Medicine, East Carolina University, Greenville, NC
| | - Armand Zimmerman
- Division of Emergency Medicine, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Anna Tupetz
- Division of Emergency Medicine, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Lee Van Vleet
- Duke Global Health Institute, Durham, NC.,Durham County Emergency Medical Services, Durham, NC
| | - Catherine Staton
- Division of Emergency Medicine, Department of Surgery, Duke University Medical Center, Durham, NC.,Duke Global Health Institute, Durham, NC
| | - Anjni Joiner
- Division of Emergency Medicine, Department of Surgery, Duke University Medical Center, Durham, NC.,Duke Global Health Institute, Durham, NC
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