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Hagiwara MA, Magnusson C, Herlitz J, Seffel E, Axelsson C, Munters M, Strömsöe A, Nilsson L. Adverse events in prehospital emergency care: a trigger tool study. BMC Emerg Med 2019; 19:14. [PMID: 30678636 PMCID: PMC6345067 DOI: 10.1186/s12873-019-0228-3] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 01/15/2019] [Indexed: 11/30/2022] Open
Abstract
Background Prehospital emergency care has developed rapidly during the past decades. The care is given in a complex context which makes prehospital care a potential high-risk activity when it comes to patient safety. Patient safety in the prehospital setting has been only sparsely investigated. The aims of the present study were 1) To investigate the incidence of adverse events (AEs) in prehospital care and 2) To investigate the factors contributing to AEs in prehospital care. Methods We used a retrospective study design where 30 randomly selected prehospital medical records were screened for AEs each month in three prehospital organizations in Sweden during a period of one year. A total of 1080 prehospital medical records were included. The record review was based on the use of 11 screening criteria. Results The reviewers identified 46 AEs in 46 of 1080 (4.3%) prehospital medical records. Of the 46 AEs, 43 were classified as potential for harm (AE1) (4.0, 95% CI = 2.9–5.4) and three as harm identified (AE2) (0.3, 95% CI = 0.1–0.9). However, among patients with a life-threatening condition (priority 1), the risk of AE was higher (16.5%). The most common factors contributing to AEs were deviations from standard of care and missing, incomplete, or unclear documentation. The most common cause of AEs was the result of action(s) or inaction(s) by the emergency medical service (EMS) crew. Conclusions There were 4.3 AEs per 100 ambulance missions in Swedish prehospital care. The majority of AEs originated from deviations from standard of care and incomplete documentation. There was an increase in the risk of AE among patients who the EMS team assessed as having a life-threatening condition. Most AEs were possible to avoid. Electronic supplementary material The online version of this article (10.1186/s12873-019-0228-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Magnus Andersson Hagiwara
- Faculty of Caring Science, Work Life and Social Welfare, University of Borås, SE-501 90, Borås, Sweden.
| | - Carl Magnusson
- Department of Molecular and Clinical Medicine, University of Gothenburg and Sahlgrenska University Hospital, SE-405 30, Gothenburg, Sweden
| | - Johan Herlitz
- Faculty of Caring Science, Work Life and Social Welfare, University of Borås, SE-501 90, Borås, Sweden
| | - Elin Seffel
- Department of Ambulance Care, Södra Älvsborg Hospital (SÄS), SE-501 82, Borås, Sweden
| | - Christer Axelsson
- Faculty of Caring Science, Work Life and Social Welfare, University of Borås, SE-501 90, Borås, Sweden
| | - Monica Munters
- Department of Ambulance Care, Region of Dalarna, SE-791 29, Falun, Sweden
| | - Anneli Strömsöe
- School of Health, Care and Social Welfare, Mälardalens högskola, SE-721 23, Västerås, Sweden
| | - Lena Nilsson
- Department of Anaesthesiology and Intensive Care and Department of Medical and Health Sciences, Linköping University, SE-581 85, Linköping, Sweden
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Sørskår LIK, Abrahamsen EB, Olsen E, Sollid SJM, Abrahamsen HB. Psychometric properties of the Norwegian version of the hospital survey on patient safety culture in a prehospital environment. BMC Health Serv Res 2018; 18:784. [PMID: 30333021 PMCID: PMC6192077 DOI: 10.1186/s12913-018-3576-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Accepted: 09/27/2018] [Indexed: 11/10/2022] Open
Abstract
Background To develop a culture of patient safety in a regime that strongly focuses on saving patients from emergencies may seem counter-intuitive and challenging. Little research exists on patient safety culture in the context of Emergency Medical Services (EMS), and the use of survey tools represents an appropriate approach to improve patient safety. Research indicates that safety climate studies may predict safety behavior and safety-related outcomes. In this study we apply the Norwegian versions of Hospital Survey on Patient Safety Culture (HSOPSC) and assess the psychometric properties when tested on a national sample from the EMS. Methods This study adopted a web based survey design. The Norwegian HSOPSC has 13 dimensions, consisting of 46 items, in addition to two single-item outcome variables. SPSS (version 21) was used for descriptive data analysis, estimating internal consistency, and performing exploratory factor analysis. Confirmatory factor analysis (CFA) was applied to test the dimensional structure of the instruments using Amos (version 21). Results N = 1387 (27%) EMS employees participated in the survey. Overall, acceptable psychometric properties were observed, i.e. acceptable internal consistencies and construct validity. The patient safety climate dimensions with highest scores (number of positive answers) were “teamwork within units” and “manager expectations & actions promoting patient safety”. The dimension “hospital management support for patient safety” had the lowest score. Conclusions The results provided a validated instrument, the Prehospital Survey on Patient Safety Culture (PreHSOPSC), for measuring patient safety climate in an EMS setting. In addition, the explanatory power was strong for several of the outcome dimensions; i.e., several of the safety climate dimensions have a strong predictive effect on outcome variables related to employees’ perceptions on patient safety and safety-related attitude. Electronic supplementary material The online version of this article (10.1186/s12913-018-3576-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Leif Inge K Sørskår
- Institute for Safety, Economics and Planning, University of Stavanger, Kjølv Egelands hus, Kristine Bonnevies vei 22, 4021, Stavanger, Norway.
| | - Eirik B Abrahamsen
- Institute for Safety, Economics and Planning, University of Stavanger, Kjølv Egelands hus, Kristine Bonnevies vei 22, 4021, Stavanger, Norway
| | - Espen Olsen
- Centre for Resilience in Healthcare, Faculty of Health Sciences, University of Stavanger, Kjell Arholms hus, Kjell Arholms gate 39, 4021, Stavanger, Norway
| | - Stephen J M Sollid
- Faculty of Health Sciences, University of Stavanger, Norway & Prehospital Clinic, Stavanger University Hospital, Stavanger, Norway
| | - Håkon B Abrahamsen
- Institute for Safety, Economics and Planning, University of Stavanger, Kjølv Egelands hus, Kristine Bonnevies vei 22, 4021, Stavanger, Norway.,Department of Anesthesiology and Intensive Care, Stavanger University Hospital, Stavanger, Norway
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The state of the union: Nationwide absence of uniform guidelines for the prehospital use of tourniquets to control extremity exsanguination. J Trauma Acute Care Surg 2016; 80:787-91. [PMID: 26885993 DOI: 10.1097/ta.0000000000000988] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND After the Sandy Hook shootings and the resulting Hartford Consensus, as well as the recent Boston Marathon bombing, the need for a uniform, detailed, and aggressive prehospital extremity exsanguination control protocol became clear. We hypothesized that most states within the United States lack a detailed uniform protocol. METHODS We performed a systematic nationwide assessment of emergency medical services (EMS) prehospital extremity exsanguination control protocols. An online search (updated February 7, 2015) identified state-, region-, or county-specific EMS protocols in all 50 states. If unavailable online, protocols were retrieved directly by contacting each state's Department of Public Health (or other appropriate agency). Two investigators independently screened each extremity exsanguination control protocol. Protocols were first grouped into three categories: I, tourniquet not mentioned; II, tourniquet mentioned, without specific guidance; III, tourniquet mentioned, with specific guidance related to type, indications, application technique, and safety concerns. Each protocol was then scored on a five-point scale for comparison. RESULTS Forty-two states (84%) had statewide and 14 (28%) had at least one county-specific protocol. Seven states (16%) had no statewide protocol but at least one county-specific protocol (range, 1-10). Mississippi had neither statewide nor county-specific protocols. Of statewide protocols, 4 (9.5%) were in Category I, 23 (54.8%) in Category II, and 15 (35.7%) in Category III. The mean score for statewide tourniquets was 2.4/5 (SD, 1.25; range, 0-5). Thirteen (31%) statewide protocols referred to "commercial" or "approved" tourniquets; only three (7%) recommended a particular commercial device. The mean score for the county-specific protocols of states with no statewide protocol was 3.10 (SD, 1.56; range, 0-5) CONCLUSIONS: Throughout the United States, there is considerable variability in EMS protocols addressing the management of extremity exsanguination and an alarming absence of specific guidance for tourniquet use. Most states do not have a uniform, detailed, and aggressive prehospital extremity exsanguination control protocol. LEVEL OF EVIDENCE Epidemiologic and prognostic study, level III.
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Hagiwara MA, Nilsson L, Strömsöe A, Axelsson C, Kängström A, Herlitz J. Patient safety and patient assessment in pre-hospital care: a study protocol. Scand J Trauma Resusc Emerg Med 2016; 24:14. [PMID: 26868416 PMCID: PMC4751749 DOI: 10.1186/s13049-016-0206-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2015] [Accepted: 02/02/2016] [Indexed: 12/02/2022] Open
Abstract
Background Patient safety issues in pre-hospital care are poorly investigated. The aim of the planned study is to survey patient safety problems in pre-hospital care in Sweden. Methods/Design The study is a retro-perspective structured medical record review based on the use of 11 screening criteria. Two instruments for structured medical record review are used: a trigger tool instrument designed for pre-hospital care and a newly development instrument designed to compare the pre-hospital assessment with the final hospital assessment. Three different ambulance organisations are participating in the study. Every month, one rater in each organisation randomly collects 30 medical records for review. With guidance from the review instrument, he/she independently reviews the record. Every month, the review team meet for a discussion of problematic reviews. The results will be analysed with descriptive statistics and logistic regression. Discussion The findings will make an important contribution to knowledge about patient safety issues in pre-hospital care.
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Affiliation(s)
- Magnus Andersson Hagiwara
- Centre for Prehospital Research, Faculty of Caring Science, Work Life and Social Welfare, University of Borås, SE-501 90, Borås, Sweden.
| | - Lena Nilsson
- Department of Anaesthesiology and Intensive Care, Linköping University, SE-581 85, Linköping, Sweden. .,Department of Medical and Health Sciences, Linköping University, SE-581 85, Linköping, Sweden.
| | - Anneli Strömsöe
- School of Health, Care and Social Welfare, Mälardalens högskola, Box 883, SE-721 23, Västerås, Sweden.
| | - Christer Axelsson
- Centre for Prehospital Research, Faculty of Caring Science, Work Life and Social Welfare, University of Borås, SE-501 90, Borås, Sweden.
| | - Anna Kängström
- Centre for Prehospital Research, Faculty of Caring Science, Work Life and Social Welfare, University of Borås, SE-501 90, Borås, Sweden. anna.kangstrom.@hb.se
| | - Johan Herlitz
- Centre for Prehospital Research, Faculty of Caring Science, Work Life and Social Welfare, University of Borås, SE-501 90, Borås, Sweden.
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Strandmark R, Herlitz J, Axelsson C, Claesson A, Bremer A, Karlsson T, Jimenez-Herrera M, Ravn-Fischer A. Determinants of pre-hospital pharmacological intervention and its association with outcome in acute myocardial infarction. Scand J Trauma Resusc Emerg Med 2015; 23:105. [PMID: 26626732 PMCID: PMC4665872 DOI: 10.1186/s13049-015-0188-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Accepted: 11/25/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The aim of this study was a) To identify predictors of the use of aspirin in the pre-hospital setting in acute myocardial infarction (AMI) and b) To analyze whether the use of any of the recommended medications was associated with outcome. METHODS All patients with a final diagnosis of AMI, transported by the Emergency Medical Services (EMS) and admitted to the coronary care unit at Sahlgrenska University Hospital in Gothenburg, Sweden, in 2009-2011, were included. RESULTS 1,726 patients were included. 58 % received aspirin by the EMS. Ischemic heart disease (IHD) was suspected in 84 %. Among patients who did not receive aspirin IHD was still suspected in 67 %. Among patients in whom IHD was suspected, and who were not on chronic treatment with aspirin the following predicted its pre-hospital use: a) age (odds ratio 0.98; 95 % confidence interval (CI) 0.96-0.99); b) a history of myocardial infarction (2.21; 1.21-4.04); c) priority given by EMS (8.07; 5.42-12.02); d) ST-elevation on ECG on admission to hospital (2.22; 1.50-3.29); e) oxygen saturation > 90 % (3.37; 1.81-6.27). After adjusting for confounders among patients who were not on chronic aspirin, only nitroglycerin of the recommended medications was associated with a reduced risk of death within 1 year (hazard ratio 0.40; 95 % CI 0.23-0.70). CONCLUSIONS Less than six out of ten patients with AMI received pre-hospital aspirin. Five clinical factors were independently associated with the pre-hospital administration of aspirin. This suggests that the decision to treat is multifactorial, and it highlights the lack of accurate diagnostic tools in the pre-hospital environment. Nitroglycerin was independently associated with a reduced risk of death, suggesting that we select the use for a low-risk cohort.
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Affiliation(s)
- Rasmus Strandmark
- Department of Metabolism and Cardiovascular Research, Institute of Internal Medicine, Sahlgrenska University Hospital, Johan Herlitz office, Registercentrum i Västra Götaland, 413 45, Gothenburg, Sweden.
| | - Johan Herlitz
- Department of Metabolism and Cardiovascular Research, Institute of Internal Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden.
- The Prehospital Research Centre Western Sweden, University of Borås, Borås, Sweden.
| | - Christer Axelsson
- The Prehospital Research Centre Western Sweden, University of Borås, Borås, Sweden.
| | - Andreas Claesson
- Department of Medicine, Center for Resuscitation Science, Karolinska Institute, Stockholm, Sweden.
| | - Anders Bremer
- The Prehospital Research Centre Western Sweden, University of Borås, Borås, Sweden.
| | - Thomas Karlsson
- Centre for Applied Biostatistics, Occupational and Environmental Medicine, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden.
| | | | - Annica Ravn-Fischer
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden.
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Kupas DF, Schenk E, Sholl JM, Kamin R. Characteristics of statewide protocols for emergency medical services in the United States. PREHOSP EMERG CARE 2015; 19:292-301. [PMID: 25689221 DOI: 10.3109/10903127.2014.964891] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE We sought to categorize and characterize the utilization of statewide emergency medical services (EMS) protocols as well as state recognition of specialty receiving facilities for trauma and time-sensitive conditions in the United States. METHODS A survey of all state EMS offices was conducted to determine which states use mandatory or model statewide EMS protocols and to characterize these protocols based on the process for authorizing such protocols. The survey also inquired as to which states formally recognize specialty receiving facilities for trauma, STEMI, stroke, cardiac arrest, and burn as well as whether or not states have mandatory or model statewide destination protocols for these specialty centers. RESULTS Thirty-eight states were found to have either mandatory or model statewide EMS protocols. Twenty-one states had mandatory statewide EMS protocols at either the basic life support (BLS) or advanced life support (ALS) level, and in 16 of these states, mandatory protocols covered both BLS and ALS levels of care. Seventeen states had model statewide protocols at either the BLS or ALS level, and in 14 of these states, the model protocols covered both BLS and ALS levels of care. Twenty states had separate protocols for the care of pediatric patients, while 18 states combined pediatric and adult care within the same protocols. When identified, the median age used to consider a patient for pediatric care was ≤14 years (range ≤8 to ≤17 years). Three states' protocols used a child's height based on a length-based dosage tool as the threshold for identifying a pediatric patient for care using their pediatric protocols. States varied in recognition of receiving centers for EMS patients with special medical needs: 46 recognized trauma centers, 25 recognized burn centers, 22 recognized stroke centers, 11 recognized centers capable of percutaneous coronary intervention for ST-elevation myocardial infarction, and 3 recognized centers for patients surviving cardiac arrest. CONCLUSION Statewide mandated EMS treatment protocols exist in 21 states, and optional model protocol guidelines are provided by 17 states. There is wide variation in the format and characteristics of these protocols and the recognition of specialty receiving centers for patients with time-sensitive illnesses.
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Tataris KL, Mercer MP, Govindarajan P. Prehospital aspirin administration for acute coronary syndrome (ACS) in the USA: an EMS quality assessment using the NEMSIS 2011 database. Emerg Med J 2015; 32:876-81. [DOI: 10.1136/emermed-2014-204299] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Accepted: 01/24/2015] [Indexed: 11/04/2022]
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Andersson Hagiwara M, Suserud BO, Andersson-Gäre B, Sjöqvist BA, Henricson M, Jonsson A. The effect of a Computerised Decision Support System (CDSS) on compliance with the prehospital assessment process: results of an interrupted time-series study. BMC Med Inform Decis Mak 2014; 14:70. [PMID: 25106732 PMCID: PMC4136405 DOI: 10.1186/1472-6947-14-70] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Accepted: 08/06/2014] [Indexed: 11/29/2022] Open
Abstract
Background Errors in the decision-making process are probably the main threat to patient safety in the prehospital setting. The reason can be the change of focus in prehospital care from the traditional “scoop and run” practice to a more complex assessment and this new focus imposes real demands on clinical judgment. The use of Clinical Guidelines (CG) is a common strategy for cognitively supporting the prehospital providers. However, there are studies that suggest that the compliance with CG in some cases is low in the prehospital setting. One possible way to increase compliance with guidelines could be to introduce guidelines in a Computerized Decision Support System (CDSS). There is limited evidence relating to the effect of CDSS in a prehospital setting. The present study aimed to evaluate the effect of CDSS on compliance with the basic assessment process described in the prehospital CG and the effect of On Scene Time (OST). Methods In this time-series study, data from prehospital medical records were collected on a weekly basis during the study period. Medical records were rated with the guidance of a rating protocol and data on OST were collected. The difference between baseline and the intervention period was assessed by a segmented regression. Results In this study, 371 patients were included. Compliance with the assessment process described in the prehospital CG was stable during the baseline period. Following the introduction of the CDSS, compliance rose significantly. The post-intervention slope was stable. The CDSS had no significant effect on OST. Conclusions The use of CDSS in prehospital care has the ability to increase compliance with the assessment process of patients with a medical emergency. This study was unable to demonstrate any effects of OST.
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Cottrell EK, O'Brien K, Curry M, Meckler GD, Engle PP, Jui J, Summers C, Lambert W, Guise JM. Understanding safety in prehospital emergency medical services for children. PREHOSP EMERG CARE 2014; 18:350-8. [PMID: 24669906 DOI: 10.3109/10903127.2013.869640] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE For over a decade, the field of medicine has recognized the importance of studying and designing strategies to prevent safety issues in hospitals and clinics. However, there has been less focus on understanding safety in prehospital emergency medical services (EMS), particularly in regard to children. Roughly 27.7 million (or 27%) of the annual emergency department visits are by children under the age of 19, and about 2 million of these children reach the hospital via EMS. This paper adds to our qualitative understanding of the nature and contributors to safety events in the prehospital emergency care of children. METHODS We conducted four 8- to 12-person focus groups among paid and volunteer EMS providers to understand 1) patient safety issues that occur in the prehospital care of children, and 2) factors that contribute to these safety issues (e.g., patient, family, systems, environmental, or individual provider factors). Focus groups were conducted in rural and urban settings. Interview transcripts were coded for overarching themes. RESULTS Key factors and themes identified in the analysis were grouped into categories using an ecological approach that distinguishes between systems, team, child and family, and individual provider level contributors. At the systems level, focus group participants cited challenges such as lack of appropriately sized equipment or standardized pediatric medication dosages, insufficient human resources, limited pediatric training and experience, and aspects of emergency medical services culture. EMS team level factors centered on communication with other EMS providers (both prehospital and hospital). Family and child factors included communication barriers and challenging clinical situations or scene characteristics. Finally, focus group participants highlighted a range of provider level factors, including heightened levels of anxiety, insufficient experience and training with children, and errors in assessment and decision making. CONCLUSIONS The findings of our study suggest that, just as in hospital medicine, factors at the systems, team, child/family, and individual provider level system contribute to errors in prehospital emergency care. These factors may be modifiable through interventions and systems improvements. Future studies are needed to ascertain the generalizability of these findings and further refine the underlying mechanisms.
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Coventry LL, Bremner AP, Williams TA, Jacobs IG, Finn J. Symptoms of Myocardial Infarction: Concordance between Paramedic and Hospital Records. PREHOSP EMERG CARE 2014; 18:393-401. [DOI: 10.3109/10903127.2014.891064] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Hagiwara MA, Suserud BO, Jonsson A, Henricson M. Exclusion of context knowledge in the development of prehospital guidelines: results produced by realistic evaluation. Scand J Trauma Resusc Emerg Med 2013; 21:46. [PMID: 23799944 PMCID: PMC3699357 DOI: 10.1186/1757-7241-21-46] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2012] [Accepted: 06/16/2013] [Indexed: 11/10/2022] Open
Abstract
Background Prehospital work is accomplished using guidelines and protocols, but there is evidence suggesting that compliance with guidelines is sometimes low in the prehospital setting. The reason for the poor compliance is not known. The objective of this study was to describe how guidelines and protocols are used in the prehospital context. Methods This was a single-case study with realistic evaluation as a methodological framework. The study took place in an ambulance organization in Sweden. The data collection was divided into four phases, where phase one consisted of a literature screening and selection of a theoretical framework. In phase two, semi-structured interviews with the ambulance organization's stakeholders, responsible for the development and implementation of guidelines, were performed. The third phase, observations, comprised 30 participants from both a rural and an urban ambulance station. In the last phase, two focus group interviews were performed. A template analysis style of documents, interviews and observation protocols was used. Results The development of guidelines took place using an informal consensus approach, where no party from the end users was represented. The development process resulted in guidelines with an insufficiently adapted format for the prehospital context. At local level, there was a conscious implementation strategy with lectures and manikin simulation. The physical format of the guidelines was the main obstacle to explicit use. Due to the format, the ambulance personnel feel they have to learn the content of the guidelines by heart. Explicit use of the guidelines in the assessment of patients was uncommon. Many ambulance personnel developed homemade guidelines in both electronic and paper format. The ambulance personnel in the study generally took a positive view of working with guidelines and protocols and they regarded them as indispensable in prehospital care, but an improved format was requested by both representatives of the organization and the ambulance personnel. Conclusions The personnel take a positive view of the use of guidelines and protocols in prehospital work. The main obstacle to the use of guidelines and protocols in this organization is the format, due to the exclusion of context knowledge in the development process.
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Patterson PD, Anderson MS, Zionts ND, Paris PM. The emergency medical services safety champions. Am J Med Qual 2012; 28:286-91. [PMID: 23150883 DOI: 10.1177/1062860612463727] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The overarching mission of prehospital emergency medical services (EMS) is to deliver lifesaving care for people when their needs are greatest. Fulfilling this mission is challenged by threats to patient and provider safety. The EMS setting is a high-risk one because care is delivered rapidly in the out-of-hospital setting where resources of benefit to patients are limited. There is growing evidence that safety culture varies widely across EMS agencies. A poor safety culture may manifest as error in medication, back injuries, and other poor outcomes for patient and provider. Recently, federal and national leaders of EMS (ie, the National Highway Traffic Safety Administration) have made improving EMS safety culture a national priority. Unfortunately, few initiatives can help local EMS leaders achieve that priority. The authors describe the successful EMS Champs Fellowship program, supported by the Jewish Healthcare Foundation, designed to train EMS leaders to improve safety for patients and providers.
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Affiliation(s)
- P Daniel Patterson
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, 3600 Forbes Avenue, Iroquois Bldg, Pittsburgh, PA 15261, USA
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Decision support system in prehospital care: a randomized controlled simulation study. Am J Emerg Med 2012; 31:145-53. [PMID: 23000323 DOI: 10.1016/j.ajem.2012.06.030] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2012] [Revised: 06/20/2012] [Accepted: 06/26/2012] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION Prehospital emergency medicine is a challenging discipline characterized by a high level of acuity, a lack of clinical information and a wide range of clinical conditions. These factors contribute to the fact that prehospital emergency medicine is a high-risk discipline in terms of medical errors. Prehospital use of Computerized Decision Support System (CDSS) may be a way to increase patient safety but very few studies evaluate the effect in prehospital care. The aim of the present study is to evaluate a CDSS. METHODS In this non-blind block randomized, controlled trial, 60 ambulance nurses participated, randomized into 2 groups. To compensate for an expected learning effect the groups was further divided in two groups, one started with case A and the other group started with case B. The intervention group had access to and treated the two simulated patient cases with the aid of a CDSS. The control group treated the same cases with the aid of a regional guideline in paper format. The performance that was measured was compliance with regional prehospital guidelines and On Scene Time (OST). RESULTS There was no significant difference in the two group's characteristics. The intervention group had a higher compliance in the both cases, 80% vs. 60% (p<0.001) but the control group was complete the cases in the half of the time compare to the intervention group (p<0.001). CONCLUSION The results indicate that this CDSS increases the ambulance nurses' compliance with regional prehospital guidelines but at the expense of an increase in OST.
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Byrsell F, Regnell M, Johansson A. Adherence to treatment guidelines for patients with chest pain varies in a nurse-led prehospital ambulance system. Int Emerg Nurs 2012; 20:162-6. [PMID: 22726948 DOI: 10.1016/j.ienj.2011.08.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2011] [Revised: 08/09/2011] [Accepted: 08/13/2011] [Indexed: 11/17/2022]
Affiliation(s)
- Fredrik Byrsell
- Department of Health Sciences, Lund, Faculty of Medicine, Lund University, PO Box 157, SE-221 00 Lund, Sweden
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Patterson PD, Weaver MD, Weaver SJ, Rosen MA, Todorova G, Weingart LR, Krackhardt D, Lave JR, Arnold RM, Yealy DM, Salas E. Measuring teamwork and conflict among emergency medical technician personnel. PREHOSP EMERG CARE 2012; 16:98-108. [PMID: 22128909 DOI: 10.3109/10903127.2011.616260] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE We sought to develop a reliable and valid tool for measuring teamwork among emergency medical technician (EMT) partnerships. METHODS We adapted existing scales and developed new items to measure components of teamwork. After recruiting a convenience sample of 39 agencies, we tested a 122-item draft survey tool (EMT-TEAMWORK). We performed a series of exploratory factor analyses (EFAs) and confirmatory factor analysis (CFA) to test reliability and construct validity, describing variation in domain and global scores using descriptive statistics. RESULTS We received 687 completed surveys. The EFAs identified a nine-factor solution. We labeled these factors 1) Team Orientation, 2) Team Structure & Leadership, 3) Partner Communication, Team Support, & Monitoring, 4) Partner Trust and Shared Mental Models, 5) Partner Adaptability & Back-Up Behavior, 6) Process Conflict, 7) Strong Task Conflict, 8) Mild Task Conflict, and 9) Interpersonal Conflict. We tested a short-form (30-item SF) and long-form (45-item LF) version. The CFAs determined that both the SF and the LF possess positive psychometric properties of reliability and construct validity. The EMT-TEAMWORK-SF has positive internal consistency properties, with a mean Cronbach's alpha coefficient ≥0.70 across all nine factors (mean = 0.84; minimum = 0.78, maximum = 0.94). The mean Cronbach's alpha coefficient for the EMT-TEAMWORK-LF was 0.87 (minimum = 0.79, maximum = 0.94). There was wide variation in weighted scores across all nine factors and the global score for the SF and LF. Mean scores were lowest for the Team Orientation factor (48.1, standard deviation [SD] 21.5, SF; 49.3, SD 19.8, LF) and highest (more positive) for the Interpersonal Conflict factor (87.7, SD 18.1, for both SF and LF). CONCLUSIONS We developed a reliable and valid survey to evaluate teamwork between EMT partners.
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Affiliation(s)
- P Daniel Patterson
- Department of Emergency Medicine and Center for Emergency Medicine of Western Pennsylvania, Inc., Pennsylvania, USA.
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Lang ES, Spaite DW, Oliver ZJ, Gotschall CS, Swor RA, Dawson DE, Hunt RC. A national model for developing, implementing, and evaluating evidence-based guidelines for prehospital care. Acad Emerg Med 2012; 19:201-9. [PMID: 22320372 DOI: 10.1111/j.1553-2712.2011.01281.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
In 2007, the Institute of Medicine's (IOM's) Committee on the Future of Emergency Care recommended that a multidisciplinary panel establish a model for developing evidence-based protocols for the treatment of emergency medical systems (EMS) patients. In response, the National EMS Advisory Council (NEMSAC) and the Federal Interagency Committee on EMS (FICEMS) convened a panel of multidisciplinary experts to review current strategies for developing evidence-based guidelines (EBGs) and to propose a model for developing such guidelines for the prehospital milieu. This paper describes the eight-step model endorsed by FICEMS, NEMSAC, and a panel of EMS and evidence-based medicine experts. According to the model, prehospital EBG development would begin with the input of evidence from various external sources. Potential EBG topics would be suggested following a preliminary evidentiary review; those topics with sufficient extant foundational evidence would be selected for development. Next, the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology would be used to determine a quality-of-evidence rating and a strength of recommendation related to the patient care guidelines. More specific, contextualized patient care protocols would then be generated and disseminated to the EMS community. After educating EMS professionals using targeted teaching materials, the protocols would be implemented in local EMS systems. Finally, effectiveness and uptake would be measured with integrated quality improvement and outcomes monitoring systems. The constituencies and experts involved in the model development process concluded that the use of such transparent, objective, and scientifically rigorous guidelines could significantly increase the quality of EMS care in the future.
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Affiliation(s)
- Eddy S Lang
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada.
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Decision-support tool in prehospital care: a systematic review of randomized trials. Prehosp Disaster Med 2011; 26:319-29. [PMID: 22030101 DOI: 10.1017/s1049023x11006534] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The objective of this study was to evaluate the effects of the decision support tool (DST) on the assessment of the acutely ill or injured out-of-hospital patient. METHODS This study included systematic reviews of randomized controlled trials (RCT) where the DST was compared to usual care in and out of the hospital setting. The databases scanned include: (1) Cochrane Reviews (up to January 2010); (2) Cochrane Controlled Clinical Trials (1979 to January 2010); (3) Cinahl (1986 to January 2010); and (4) Pubmed/Medline (1926 to January 2010). In addition, information was gathered from related magazines, prehospital home pages, databases for theses, conferences, grey literature and ongoing trials. RESULTS Use of the DST in prehospital care may have the possibility to decrease "time to definitive care" and improve diagnostic accuracy among prehospital personnel, but more studies are needed. CONCLUSIONS The amount of data in this review is too small to be able to draw any reliable conclusions about the impact of the use of the DST on prehospital care. The research in this review indicates that there are very few RCTs that evaluate the use of the DST in prehospital care.
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Patterson PD, Weaver MD, Frank RC, Warner CW, Martin-Gill C, Guyette FX, Fairbanks RJ, Hubble MW, Songer TJ, Callaway CW, Kelsey SF, Hostler D. Association between poor sleep, fatigue, and safety outcomes in emergency medical services providers. PREHOSP EMERG CARE 2011; 16:86-97. [PMID: 22023164 DOI: 10.3109/10903127.2011.616261] [Citation(s) in RCA: 139] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To determine the association between poor sleep quality, fatigue, and self-reported safety outcomes among emergency medical services (EMS) workers. METHODS We used convenience sampling of EMS agencies and a cross-sectional survey design. We administered the 19-item Pittsburgh Sleep Quality Index (PSQI), 11-item Chalder Fatigue Questionnaire (CFQ), and 44-item EMS Safety Inventory (EMS-SI) to measure sleep quality, fatigue, and safety outcomes, respectively. We used a consensus process to develop the EMS-SI, which was designed to capture three composite measurements of EMS worker injury, medical errors and adverse events (AEs), and safety-compromising behaviors. We used hierarchical logistic regression to test the association between poor sleep quality, fatigue, and three composite measures of EMS worker safety outcomes. RESULTS We received 547 surveys from 30 EMS agencies (a 35.6% mean agency response rate). The mean PSQI score exceeded the benchmark for poor sleep (6.9, 95% confidence interval [CI] 6.6, 7.2). More than half of the respondents were classified as fatigued (55%, 95% CI 50.7, 59.3). Eighteen percent of the respondents reported an injury (17.8%, 95% CI 13.5, 22.1), 41% reported a medical error or AE (41.1%, 95% CI 36.8, 45.4), and 90% reported a safety-compromising behavior (89.6%, 95% CI 87, 92). After controlling for confounding, we identified 1.9 greater odds of injury (95% CI 1.1, 3.3), 2.2 greater odds of medical error or AE (95% CI 1.4, 3.3), and 3.6 greater odds of safety-compromising behavior (95% CI 1.5, 8.3) among fatigued respondents versus nonfatigued respondents. CONCLUSIONS In this sample of EMS workers, poor sleep quality and fatigue are common. We provide preliminary evidence of an association between sleep quality, fatigue, and safety outcomes.
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Affiliation(s)
- P Daniel Patterson
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania 15261, USA.
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Patterson PD, Weaver MD, Abebe K, Martin-Gill C, Roth RN, Suyama J, Guyette FX, Rittenberger JC, Krackhardt D, Arnold R, Yealy DM, Lave J. Identification of Adverse Events in Ground Transport Emergency Medical Services. Am J Med Qual 2011; 27:139-46. [DOI: 10.1177/1062860611415515] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | | | - Kaleab Abebe
- University of Pittsburgh School of Medicine, Pittsburgh, PA
| | | | - Ronald N. Roth
- University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Joseph Suyama
- University of Pittsburgh School of Medicine, Pittsburgh, PA
| | | | | | | | - Robert Arnold
- University of Pittsburgh School of Medicine, Pittsburgh, PA
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Introduction of a prehospital critical incident monitoring system--final results. Prehosp Disaster Med 2011; 25:515-20. [PMID: 21181685 DOI: 10.1017/s1049023x00008694] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Incident monitoring has been shown to improve patient care and has been adopted widely in the hospital care setting. There are limited data on incident monitoring in the prehospital setting. HYPOTHESIS A high-yield, systems-oriented, incident monitoring process can be implemented successfully in a prehospital setting. METHODS This prospective, descriptive study outlines the implementation of an incident monitoring process in a regional prehospital setting. Both trauma care and non-trauma care were monitored by a system of anonymous reporting and chart review with debriefing for trauma cases that met major trauma criteria. A committee reviewed all identified cases and coded and logged all incidents and provider recommendations. RESULTS There were 454 incidents identified from 230 cases (mean=2.0; 95% CI 1.8-2.1 per case). Anonymous reporting resulted in the identification of 113 incidents from 69 cases (1.6l per case 95% CI=1.4-1.9 per case) Major trauma cases generated 266 incidents from 134 cases (mean=2.0; 95% CI=1.8-2.2 per case), and there were 74 incidents from 26 combined cases (mean=2.9; 95% CI=2.2-3.5 per case). One incident was uncategorized. There were 315 (69.4%) incidents categorized as management problems and 123 (27.1%) were system problems. Prolonged scene time was the most common incident in both management and system categories; 56 (17.8%) and 18 (14.6%) respectively. Mitigating circumstances were found in 111 (24.4%) incidents. The most common incident-related patient outcome was none/near miss (127 (28%)). Incident monitoring most commonly led to generalized feedback (105 (23.1%)) or specific trend analysis (140 (30.8%)). Reports to higher or external bodies occurred in 18 incidents (4.0%). CONCLUSIONS The project has been implemented successfully in a regional prehospital settling. The methodology, utilizing a number of incident detection techniques, results in a high yield of incidents over a broad range of error types. The large proportion of "near miss" type incidents allows for incident assessment without demonstrable patient harm. Many incidents were mitigated and the majority represented management-type issues.
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Patterson PD, Arnold RM, Abebe K, Lave JR, Krackhardt D, Carr M, Weaver MD, Yealy DM. Variation in emergency medical technician partner familiarity. Health Serv Res 2011; 46:1319-31. [PMID: 21306367 DOI: 10.1111/j.1475-6773.2011.01241.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To characterize patterns of Emergency Medical Technician (EMT) partner familiarity in three Emergency Medical Services (EMS) agencies. STUDY DESIGN/DATA SOURCES: We utilized a case study design and retrospective review of administrative data from three EMS agencies and 182 EMTs over 12 months. We used the Kruskal-Wallis test and Bonferroni corrected p-values to compare measures of partner familiarity. Measures included the annual mean number of partners, rate of partners per 10 shifts, mean shifts per EMT, and proportion of shifts worked with same partner. We standardized select measures by size of agency to account for a greater number of possible partnerships in larger agencies. PRINCIPAL FINDINGS Across all agencies, the mean number of shifts worked annually by EMTs was (mean [SD]) 77.3 (59.8). The unstandardized mean number of EMT partnerships was 19.3 (12.4) and did not vary across EMS agencies after standardizing by agency size (p=.328). The unstandardized mean rate of EMT partnerships for every 10 shifts worked was 4.0 (2.7) and varied across agencies after standardizing (p<.001). The mean proportion of shifts worked with the same partner was 34.8 percent and varied across agencies (p<.001). CONCLUSIONS There was wide variation in select measures of EMT partner familiarity.
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Affiliation(s)
- P Daniel Patterson
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, 3600 Forbes Avenue, Pittsburgh, PA 15261, USA.
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Patterson PD, Huang DT, Fairbanks RJ, Simeone S, Weaver M, Wang HE. Variation in emergency medical services workplace safety culture. PREHOSP EMERG CARE 2011; 14:448-60. [PMID: 20809688 DOI: 10.3109/10903127.2010.497900] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
INTRODUCTION Workplace attitude, beliefs, and culture may impact the safety of patient care. This study characterized perceptions of safety culture in a nationwide sample of emergency medical services (EMS) agencies. METHODS We conducted a cross-sectional survey involving 61 advanced life support EMS agencies in North America. We administered a modified version of the Safety Attitudes Questionnaire (SAQ), a survey instrument measuring dimensions of workplace safety culture (Safety Climate, Teamwork Climate, Perceptions of Management, Job Satisfaction, Working Conditions, and Stress Recognition). We included full-time and part-time paramedics and emergency medical technicians. We determined the variation in safety culture scores across EMS agencies. Using hierarchical linear models, we determined associations between safety culture scores and individual and EMS agency characteristics. RESULTS We received 1,715 completed surveys from 61 EMS agencies (mean agency response rate 47%; 95% confidence interval [CI] 10%, 83%). There was wide variation in safety culture scores across EMS agencies [mean (minimum, maximum)]: Safety Climate 74.5 (min 49.9, max 89.7), Teamwork Climate 71.2 (min 45.1, max 90.1), Perceptions of Management 67.2 (min 31.1, max 92.2), Job Satisfaction 75.4 (min 47.5, max 93.8), Working Conditions 66.9 (min 36.6, max 91.4), and Stress Recognition 55.1 (min 31.3, max 70.6). Air medical EMS agencies tended to score higher across all safety culture domains. Lower safety culture scores were associated with increased annual patient contacts. Safety Climate domain scores were not associated with other individual or EMS agency characteristics. CONCLUSION In this sample, workplace safety culture varies between EMS agencies.
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Affiliation(s)
- P Daniel Patterson
- Department of Emergency Medicine and Center for Emergency Medicine of Western Pennsylvania, Inc, University of Pittsburgh School of Medicine, Pittsburgh, PA 15261, USA.
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Is pre-hospital treatment of chest pain optimal in acute coronary syndrome? The relief of both pain and anxiety is needed. Int J Cardiol 2010; 149:147-151. [PMID: 21040986 DOI: 10.1016/j.ijcard.2010.10.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2010] [Revised: 06/09/2010] [Accepted: 10/05/2010] [Indexed: 11/21/2022]
Abstract
BACKGROUND Many patients who suffer from acute chest pain are transported by ambulance. It is not known how often treatment prior to hospital admission is optimal and how optimal pain-relieving treatment is defined. It is often difficult to delineate pain from anxiety. AIM To describe various aspects of chest pain in the pre-hospital setting with the emphasis on a) treatment and b) presumed acute coronary syndrome. METHODS In the literature search, we used PubMed and the appropriate key words. We included randomised clinical trials and observational studies. RESULTS Four types of drug appear to be preferred: 1) narcotic analgesics, 2) nitrates, 3) beta-blockers and 4) benzodiazepines. Among narcotic analgesics, morphine has been associated with the relief of pain at the expense of side-effects. Alfentanil was reported to produce more rapid pain relief. Nitrates have been associated with the relief of pain with few side-effects. Beta-blockers have been reported to increase the relief of pain when added to morphine. The combination of beta-blockers and morphine has been reported to be as effective as beta-blockers alone in pain relief, but this combination therapy was associated with more side-effects. Experience from anxiety-relieving drugs such as benzodiazepines is limited. It is not known how these 4 drugs should be combined. The results indicate that various pain-relieving treatments might modify the disease. CONCLUSION Our knowledge of the optimal treatment of chest pain and associated anxiety in the pre-hospital setting is insufficient. Recommendations from existing guidelines are limited. Large randomised clinical trials are warranted.
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Colwell C, Mehler P, Harper J, Cassell L, Vazquez J, Sabel A. Measuring quality in the prehospital care of chest pain patients. PREHOSP EMERG CARE 2010; 13:237-40. [PMID: 19291563 DOI: 10.1080/10903120802706138] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Rates of compliance with evidence-based treatment guidelines are commonly used to evaluate hospital quality of care. This method of quality assessment has not been widely extended to the prehospital environment. Previous studies have shown that the prehospital care of chest pain patients is often incomplete. OBJECTIVE To determine how well paramedics in an urban public hospital system deliver high-quality, comprehensive care for patients with nontraumatic chest pain. METHODS Patients with a primary complaint of nontraumatic chest pain for two quarters of 2006 were identified, records were randomly sampled, and a retrospective audit was performed. Seven individual quality indexes were identified by the medical director of the Denver Health Paramedic Division. A composite metric (bundle score) was also created to assess the completeness of care. This bundle score was considered unmet if any single variable was not present. RESULTS Five hundred eighty-six patient care reports were evaluated. Overall, 92% of the patients received oxygen, 62% received aspirin, 97% had lung sounds assessed, 99% had vital signs assessed, 84% had an intravenous (IV) line established, 92% had an electrocardiogram (ECG) obtained, and 73% were assessed for cardiac risk factors. The composite score was met for only 39% of patients. Significant differences across age groups were found in assessing cardiac risk factors, obtaining ECGs, and administering aspirin, and in the composite measure. In all of these metrics, the prehospital care rendered to the younger patients was associated with a lower rate of provider compliance than that delivered to the older patients. CONCLUSIONS There was generally good compliance with each individual metric, yet compliance with the comprehensive metric was poor. This manner of quality assessment, utilizing a bundle score, can be successfully applied to the prehospital arena, although future work is needed to establish criteria for measuring optimal quality of care.
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Affiliation(s)
- Christopher Colwell
- Denver Health Paramedic Division, Denver Health and Hospitals, Denver, Colorado 80204, USA.
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Patterson PD, Huang DT, Fairbanks RJ, Wang HE. The emergency medical services safety attitudes questionnaire. Am J Med Qual 2010; 25:109-15. [PMID: 20133519 DOI: 10.1177/1062860609352106] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
To characterize safety culture in emergency medical services (EMS), the authors modified a validated safety culture instrument, the Safety Attitudes Questionnaire (SAQ). The pilot instrument was administered to 3 EMS agencies in a large metropolitan area. The authors characterized safety culture across 6 domains: safety climate, teamwork climate, perceptions of management, job satisfaction, working conditions, and stress recognition. The feasibility of characterizing safety culture in EMS was evaluated by examining response rate, item missingness, EMS chief administrators' perceptions of the EMS-SAQ, as well as psychometric properties.The results confirm feasibility with a high response rate, acceptable internal consistency, and model fit validity. However, some agencies voiced concerns about respondent burden and the wording and face validity of several EMS-SAQ items. Variation in safety culture scores across EMS agencies within a single geographic area, as well as variation across respondent characteristics, warrants further investigation.
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Meisel ZF, Armstrong K, Mechem CC, Shofer FS, Peacock N, Facenda K, Pollack CV. Influence of sex on the out-of-hospital management of chest pain. Acad Emerg Med 2010; 17:80-7. [PMID: 20078440 DOI: 10.1111/j.1553-2712.2009.00618.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Sex disparities in the diagnosis and treatment of chest pain or suspected angina have been demonstrated in multiple clinical settings. Out-of-hospital (OOH) care for chest pain is protocol-driven and may be less likely to demonstrate differences between men and women. OBJECTIVES The objectives were to investigate the relationship between sex and the OOH treatment of patients with chest pain. The authors sought to test the hypothesis that OOH care for chest pain patients would differ by sex. METHODS A 1-year retrospective cohort study of 683 emergency medical services (EMS) patients with a complaint of chest pain was conducted. Included were patients taken to any one of three hospitals (all cardiac referral centers) by a single municipal EMS system. Excluded were patients transported by basic life support (BLS) units, those younger than 30 years, and patients with known contraindications to any of the outcome measures. Multivariable regression was used to adjust for potential confounders. The main outcome was adherence to state EMS protocols for treatment of patients over age 30 years with undifferentiated chest pain. Rates of administration of aspirin, nitroglycerin, and oxygen; establishment of intravenous (IV) access; and cardiac monitoring were measured. RESULTS A total of 342 women and 341 men were included. Women were less likely than men to receive aspirin (relative risk [RR] = 0.76; 95% confidence interval [CI] = 0.59 to 0.96), nitroglycerin (RR = 0.76; 95% CI = 0.60 to 0.96), or an IV (RR 0.86; 95% CI = 0.77 to 0.96). These differences persisted after adjustment for demographics and emergency department (ED) evaluation for acute coronary syndrome (ACS) as a blunt marker for cardiac risk. Women were also less likely to receive these treatments among the small subgroup of patients who were later diagnosed with acute myocardial infarction (AMI). CONCLUSIONS For OOH patients with chest pain, sex disparities in treatment are significant and do not appear to be explained by differences in patient age, race, or underlying cardiac risk.
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Affiliation(s)
- Zachary F Meisel
- Robert Wood Johnson Foundation Clinical Scholars Program, Department of Emergency Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA, USA.
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Affiliation(s)
- Robert E O'Connor
- University of Virginia Charlottesville, VirginiaEditor-in-Chief Academic Emergency Medicine Yale University School of Medicine New Haven, Connecticut
| | - David C Cone
- University of Virginia Charlottesville, VirginiaEditor-in-Chief Academic Emergency Medicine Yale University School of Medicine New Haven, Connecticut
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Whyte BS, Ansley R. Pay for Performance Improves Rural EMS Quality: Investment in Prehospital Care. PREHOSP EMERG CARE 2009; 12:495-7. [DOI: 10.1080/10903120802290810] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Meisel ZF, Hargarten S, Vernick J. Addressing Prehospital Patient Safety Using the Science of Injury Prevention andControl. PREHOSP EMERG CARE 2009; 12:411-6. [DOI: 10.1080/10903120802290851] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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McVaney KE, Macht M, Colwell CB, Pons PT. Treatment of Suspected Cardiac Ischemia with Aspirin by Paramedics in an Urban Emergency Medical Services System. PREHOSP EMERG CARE 2009; 9:282-4. [PMID: 16147476 DOI: 10.1080/10903120590962030] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Aspirin (ASA) has unquestioned benefit to patients with cardiac ischemia. Previous studies indicate health care providers may not adequately treat patients experiencing cardiac ischemia with ASA. OBJECTIVE To determine the rate of ASA use for patients being treated for chest pain suggestive of cardiac ischemia in the prehospital setting. METHODS This was a retrospective study of paramedic encounters identified through billing records for all patients receiving the combination of an intravenous catheter, supplemental oxygen, and cardiac monitoring from November 2001 to January 2002. Prehospital medical records were reviewed in order to determine the proportion of patients with suspected cardiac ischemia who received ASA. The setting was a single prehospital emergency medical services system serving an urban population. RESULTS A total of 2,457 paramedic encounters were reviewed over a three-month period. Two hundred thirty-two patients were assessed as having cardiac ischemia, of whom 169 (73%) had no absolute or relative contraindication to ASA. Of the 169 patients, only 92 (54%) received ASA. Of the 99 patients, who received nitroglycerin for presumed cardiac ischemia and had no contraindication to receiving ASA, only 78 (79%) received ASA. Of the 453 patients complaining of nontraumatic chest pain and without a contraindication, 157 (35%) received ASA. CONCLUSIONS Paramedics do not use ASA optimally and may choose therapies with less proven benefit.
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Affiliation(s)
- Kevin E McVaney
- Department of Emergency Medicine, Denver Health Medical Center, Colorado 80204, USA.
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Wang HE, Marroquin OC, Smith KJ. Direct Paramedic Transport of Acute Myocardial Infarction Patients to Percutaneous Coronary Intervention Centers: A Decision Analysis. Ann Emerg Med 2009; 53:233-240. [DOI: 10.1016/j.annemergmed.2008.07.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2008] [Revised: 06/13/2008] [Accepted: 07/17/2008] [Indexed: 10/21/2022]
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Introduction of a prehospital critical incident monitoring system--pilot project results. Prehosp Disaster Med 2008; 23:154-60. [PMID: 18557295 DOI: 10.1017/s1049023x00005781] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Hospital medical incident monitoring improves preventable morbidity and mortality rates. Error management systems have been adopted widely in this setting. Data relating to incident monitoring in the prehospital setting is limited. PROBLEM Implementation of an incident monitoring process in a prehospital setting. METHODS This is a prospective, descriptive study of the pilot phase of the implementation of an incident monitoring process in a regional prehospital setting, with a focus on trauma care. Paramedics and emergency department staff submitted anonymous incident reports, and a chart review was performed on patients who met major trauma criteria. Selected trauma cases were analyzed by a structured interview/debriefing process to elucidate undocumented incidents. A project committee coded and logged all incidents and developed recommendations. RESULTS Of 4,429 ambulance responses, 41 cases were analyzed. Twenty-four (58.5%; 95% CI = 49.7-67.4%) were reported anonymously, and the rest were major trauma patients. A total of 77 incidents were identified (mean per case = 1.8; CI = 1.03-2.57). Anonymous cases revealed 26 incidents (mean = 1.1; CI = 0.98-1.22); eight trauma debriefings revealed 38 incidents (mean = 4.8; CI = 0.91-8.69) and nine trauma chart reviews revealed 13 incidents (mean = 1.6; CI = 1.04-2.16). A total of 56 of 77 (72.7%; CI = 65.5-80.0%) incidents related to system inadequacies, and 15 (57.7%; CI = 46.7-68.6%) anonymously reported incidents related to resource problems. A total of 35 of 77 (45.5%; CI = 40.4-50.5%) incidents had minimal or no impact on the patients' outcomes. Thirty-four of 77 (44.2%; CI = 39.3-49.1%) incidents were considered mitigated by circumstance. Incident monitoring led to generalized feedback in most cases (65 of 77; 84.4%; CI = 77.6-91.3%); in three cases (3.9%; CI = 3.7-4.1%), specific education occurred; two cases were reported to an external body (2.6%; CI = 2.5-2.7%); three cases resulted in remedial action (3.9%; CI = 3.7-4.1%); four for trend/further observation and analysis responses (5.2%; CI = 4.9-5.5%). CONCLUSIONS The pilot project demonstrates successful implementation of an incident monitoring system within a regional, prehospital environment. The combination of incident detecting techniques has a high yield with potential to capture different error types. The large proportion of incidents in the "near miss" category allows analysis of incidents without patient harm. The majority of incidents were system related and many were mitigated by circumstance. The model used is appropriate for ongoing incident monitoring in this setting.
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Fairbanks RJ, Crittenden CN, O'Gara KG, Wilson MA, Pennington EC, Chin NP, Shah MN. Emergency medical services provider perceptions of the nature of adverse events and near-misses in out-of-hospital care: an ethnographic view. Acad Emerg Med 2008; 15:633-40. [PMID: 19086213 DOI: 10.1111/j.1553-2712.2008.00147.x] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The objectives were to examine the perceptions of emergency medical services (EMS) providers regarding near-misses and adverse events in out-of-hospital care. METHODS This study uses qualitative methods (focus groups, interviews, event reporting) to examine the perceptions of EMS providers regarding near-misses and adverse events in out-of-hospital care. Results were reviewed by five researchers; analytic domains were assigned and emerging themes were identified. Descriptive statistics were calculated. RESULTS Fifteen in-depth interviews (73% advanced life support [ALS], 40% volunteer, and 87% male) resulted in 50 event descriptions. Eleven additional event reports were obtained from the anonymous reporting system. Of the 61 total events, 27 (44%) were near-misses and 34 (56%) were adverse events. Fourteen (23%) involved a child (< 19 years). Types of error included 33 clinical judgment (54%), 13 skill performance (21%), 9 medication event (15%), 3 destination choice (5%), and 3 others (5%). For the 21 cases where the provider discussed the event, 10 (48%) were reported to a physician, and 9 (43%) to a supervisor; 4 (19%) were not reported, and none were reported to the patient. Focus groups supported interview and event report data. Emerging themes included a focus on the errors of others and a "blame-and-shame" culture. CONCLUSIONS Adverse events and near-misses were common among the EMS providers who participated in this study, but the culture discourages sharing of this information. Participants attributed many events to systems issues and to inadequacies of other provider groups. Further study is necessary to investigate whether these hypothesis-generating themes are generalizable to the EMS community as a whole.
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Affiliation(s)
- Rollin J Fairbanks
- Department of Emergency Medicine, University of Rochester, Rochester, NY, USA.
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Staff T, Lossius H, Steen P, Wik L. Adherence to treatment protocol in prehospital chest pain patients. Resuscitation 2008. [DOI: 10.1016/j.resuscitation.2008.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Adherence to treatment protocol in prehospital ST-elevation infarction patients. Resuscitation 2008. [DOI: 10.1016/j.resuscitation.2008.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Hooker EA, Benoit T, Price TG. Reasons prehospital personnel do not administer aspirin to all patients complaining of chest pain. Prehosp Disaster Med 2006; 21:101-3. [PMID: 16771000 DOI: 10.1017/s1049023x00003435] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Aspirin is administered to patients with acute coronary syndromes (ACSs), but prehospital providers do not administer aspirin to all patients with chest pain that could be secondary to an ACS. OBJECTIVE To identify reasons prehospital providers fail to administer aspirin to all patients complaining of chest pain. METHODS A convenience sample of prehospital providers was surveyed as they transported patients with a chief complaint of chest pain to the emergency department. The providers were asked if they had given aspirin, nitroglycerin, or oxygen, or if they utilized a monitor. If the medications had not been administered, the paramedic was asked about the reason. The patient's age and previous cardiac history also was recorded. RESULTS A total of 52 patients with chest pain who were transported were identified over eight weeks, and all of the providers agreed to participate in the study. Only 13 of the patients (25%) received aspirin. Reasons given for not administering aspirin to the other 39 patients included: (1) chest pain was not felt to be cardiac in 13 patients (33%); (2) 10 patients already had taken aspirin that day (26%); (3) the medical provider was a basic-level emergency medical technician (EMT)-Basic and could not administer aspirin to six patients (15%); (4) pain subsided prior to arrival of emergency medical services (EMS) in these three patients; and (5) other reasons were provided for the remaining seven patients. CONCLUSIONS The most common reason that paramedics did not administer aspirin was the paramedic's belief that the chest pain was not of a cardiac nature. Another common reason for not giving aspirin was the inability of EMT-Basic providers to administer aspirin.
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Affiliation(s)
- Edmond A Hooker
- Department of Health Services Administration, Xavier University, 3800 Victory Parkway, Cincinnati, Ohio 45207-7331, USA.
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Terror Australis Redux: Revisiting Australian Emergency Department Preparedness for Terrorism. Prehosp Disaster Med 2005. [DOI: 10.1017/s1049023x00014229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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