Developing Program Performance Measures for Rural Emergency Medical Services

Pre-hospital emergency care personnel's challenges in providing care in mass casualty incidents: A qualitative study

BACKGROUND

In incidents with mass casualties, pre-hospital emergency medical services personnel (prehospital EMS personnel) face challenges that can impact their management of the scene and, by extension, their professional performance. The present study investigated the challenges faced by prehospital EMS personnel in mass casualty incidents in the south of Iran.

METHODS

This is a qualitative-descriptive study. The subjects were selected via purposeful sampling. Accordingly, 23 prehospital EMS personnel were interviewed in 23 semi-structured, individual, in-depth interviews. Graneheim and Lundman's method was used to collect the data.

RESULTS

Three themes and eight subthemes emerged from the qualitative data analysis. The three main themes were challenges related to professional capabilities, challenges related to organizational management inefficiency, and challenges related to lack of effective inter-organizational coordination and cooperation in crisis management.

CONCLUSION

The challenges faced by prehospital EMS personnel in mass casualty incidents encompasses challenges related to professional capabilities, challenges related to organizational management inefficiency, and challenges related to lack of effective inter-organizational coordination and cooperation in crisis management. The results of this study can be used by senior medical emergency services managers to identify the challenges of pre-hospital emergency care personnel in mass casualty incidents and take the necessary measures to eliminate them to improve the quality of pre-hospital care in mass casualty incidents.

Exploring the challenges to using telecardiology as perceived by pre-hospital emergency care personnel: a qualitative study

BACKGROUND

Today, using the medical technology of telecardiology, as part of advanced medical services, plays an essential role in providing care to cardiac patients in life-threatening conditions who need emergency care. However, pre-hospital emergency care personnel are faced with certain challenges in using telecardiology, with adverse effects on their performance. Therefore, the present study aimed to investigate the challenges to using telecardiology as viewed by pre-hospital emergency care personnel in Southern Iran.

METHODS

The present study is a qualitative work of research with a content analysis approach. Selected using purposeful sampling, 19 pre-hospital emergency care personnel were interviewed on a semi-structured, personal, in-depth basis. The qualitative data obtained were analyzed using the Graneheim and Lundman's conventional content analysis approach (2004).

RESULTS

Based on the qualitative data analysis, 3 themes and 8 subthemes were obtained. The three main themes included professional barriers (lack of clinical knowledge of telecardiology, lack of clinical skill in telecardiology, violation of patients' privacy, lack of clinical guidelines on telecardiology), medical equipment and telecommunication barriers (poor reception and ineffective means of communication, low charge on the battery of tele-electrocardiogram machines), and organizational management barriers (serious lack of cardiologists available for medical counseling and lack of continual personal development of the telecardiology personnel).

CONCLUSION

Senior managers in pre-hospital emergency care services are recommended to use the results of this study to identify the influential factors in using telecardiology and take the necessary measures to eliminate the existing barriers toward making optimal use of telemedicine, thereby improving the quality of care provided for cardiac patients.

Prehospital Time Interval for Urban and Rural Emergency Medical Services: A Systematic Literature Review

The aim of this study was to discuss the differences in pre-hospital time intervals between rural and urban communities regarding emergency medical services (EMS). A systematic search was conducted through various relevant databases, together with a manual search to find relevant articles that compared rural and urban communities in terms of response time, on-scene time, and transport time. A total of 37 articles were ultimately included in this review. The sample sizes of the included studies was also remarkably variable, ranging between 137 and 239,464,121. Twenty-nine (78.4%) reported a difference in response time between rural and urban areas. Among these studies, the reported response times for patients were remarkably variable. However, most of them (number (n) = 27, 93.1%) indicate that response times are significantly longer in rural areas than in urban areas. Regarding transport time, 14 studies (37.8%) compared this outcome between rural and urban populations. All of these studies indicate the superiority of EMS in urban over rural communities. In another context, 10 studies (27%) reported on-scene time. Most of these studies (n = 8, 80%) reported that the mean on-scene time for their populations is significantly longer in rural areas than in urban areas. On the other hand, two studies (5.4%) reported that on-scene time is similar in urban and rural communities. Finally, only eight studies (21.6%) reported pre-hospital times for rural and urban populations. All studies reported a significantly shorter pre-hospital time in urban communities compared to rural communities. Conclusions: Even with the recently added data, short pre-hospital time intervals are still superior in urban over rural communities.

Working Against the Clock: A Model for Rural STEMI Triage

Residents in rural communities have a higher incidence of cardiac death and risk factors associated with cardiac disease. Living in a rural region can add precious time that amplifies cardiac death during an ST-elevated myocardial infarction (STEMI) episode. The consensus is that improved efficiencies can increase myocardial salvage and decrease STEMI mortality rates. This article identifies issues that may impact pre-hospital STEMI triage of patients in a rural region of the United States (U.S.). A qualitative research design was chosen to gain insight into emergency personnel perceptions of pre-hospital STEMI triage. The participants (n = 18) were obtained from a convenience sample in rural Northeast Texas, U.S. Data were gathered by individual and group semi-structured interviews. Themes were identified, synthesized, and oriented to offer a basis for understanding opportunities to improve the delivery of rural STEMI care. This study demonstrated that quality improvement initiatives aimed at achieving pre-hospital STEMI triage efficiencies have dependencies on teamwork, technology, and training in the context of 3 stages (a) pre-transport, (b) door-to-door, and (c) post-transport. A pre-hospital STEMI triage model is offered based on the findings. By incorporating this model, emergency medical coordinators in rural communities have a better opportunity to facilitate timely reperfusion therapy for this high-risk population.

Evaluating a Novel Prehospital Emergency Trauma Care Assessment Tool (PETCAT) for Low- and Middle-Income Countries in Sierra Leone

BACKGROUND

WHO recommends training lay first responders (LFRs) as the first step toward formal emergency medical services development, yet no tool exists to evaluate LFR programs.

METHODS

We developed Prehospital Emergency Trauma Care Assessment Tool (PETCAT), a seven-question survey administered to first-line hospital-based healthcare providers, to independently assess LFR prehospital intervention frequency and quality. PETCAT surveys were administered one month pre-LFR program launch (June 2019) in Makeni, Sierra Leone and again 14 months post-launch (August 2020). Using a difference-in-differences approach, PETCAT was also administered in a control city (Kenema) with no LFR training intervention during the study period at the same intervals to control for secular trends. PETCAT measured change in both the experimental and control locations. Cronbach's alpha, point bi-serial correlation, and inter-rater reliability using Cohen's Kappa assessed PETCAT reliability.

RESULTS

PETCAT administration to 90 first-line, hospital-based healthcare providers found baseline prehospital intervention were rare in Makeni and Kenema prior to LFR program launch (1.2/10 vs. 1.8/10). Fourteen months post-LFR program implementation, PETCAT demonstrated prehospital interventions increased in Makeni with LFRs (5.2/10, p < 0.0001) and not in Kenema (1.2/10) by an adjusted difference of + 4.6 points/10 (p < 0.0001) ("never/rarely" to "half the time"), indicating negligible change due to secular trends. PETCAT demonstrated high reliability (Cronbach's α = 0.93, Cohen's K = 0.62).

CONCLUSIONS

PETCAT measures changes in rates of prehospital care delivery by LFRs in a resource-limited African setting and may serve as a robust tool for independent EMS quality assessment.

Major challenges and barriers in clinical decision-making as perceived by emergency medical services personnel: a qualitative content analysis

BACKGROUND

Having to work in unpredictable and critical conditions, emergency care services (EMS) personnel experience complicated situations at the scene of accidents which, inevitably, influence their clinical decisions. There is a lack of research into the challenges which these professionals encounter. Accordingly, the present study aims to explore the major challenges and barriers which affect clinical decision-making from the perspective of EMS personnel.

METHODS

The present study is a qualitative work with a content analysis approach. Selected via purposeful sampling, the subjects were 25 members of the EMS personnel in Iran who met the inclusion criteria. The study lasted from December 2019 to July 2020. Sampling was maintained to the point of data saturation. Data were collected using semi-structured, in-depth, individual interviews. The collected data were analyzed via qualitative content analysis.

RESULTS

The results of data analysis were categorized into four themes and eight categories. The main themes were professional capabilities, occupational and environmental factors, inefficient organizational management, and ethical issues.

CONCLUSION

The results of the present study show that clinical knowledge, experience, and skills contribute to emergency care personnel's professional capabilities in making clinical decisions. Good teamwork skills and time management can prevent feelings of confusion when the number of the injured to be attended to is large. Effective clinical decision-making skills can not only help the personnel make the right decision, but enhances their resilience and enables them to adapt to hard and unpredictable conditions. Professional factors, organizational management, and ethical matters constitute the other major factors which influence the clinical decision-making of emergency care personnel at the scene of accidents and determine the quality of their clinical performance. Thus, it is essential that pre-hospital emergency care managers improve the quality of EMS personnel's clinical decision-making skill.

Call to Action: Rural Health: A Presidential Advisory From the American Heart Association and American Stroke Association

Understanding and addressing the unique health needs of people residing in rural America is critical to the American Heart Association's pursuit of a world with longer, healthier lives. Improving the health of rural populations is consistent with the American Heart Association's commitment to health equity and its focus on social determinants of health to reduce and ideally to eliminate health disparities. This presidential advisory serves as a call to action for the American Heart Association and other stakeholders to make rural populations a priority in programming, research, and policy. This advisory first summarizes existing data on rural populations, communities, and health outcomes; explores 3 major groups of factors underlying urban-rural disparities in health outcomes, including individual factors, social determinants of health, and health delivery system factors; and then proposes a set of solutions spanning health system innovation, policy, and research aimed at improving rural health.

Assessment of pre-hospital emergency medical services in low-income settings using a health systems approach

Emergency medical services (EMS) is defined as the system that organizes all aspects of care provided to patients in the pre-hospital or out-of-hospital environment. Hence, EMS is a critical component of the health systems and is necessary to improve outcomes of injuries and other time-sensitive illnesses. Still there exists a substantial need for evidence to improve our understanding of the capacity of such systems as well as their strengths, weaknesses, and priority areas for improvement in low-resource environments. The aim was to develop a tool for assessment of the pre-hospital EMS system using the World Health Organization (WHO) health system framework. Relevant literature search and expert consultation helped identify variables describing system capacity, outputs, and goals of pre-hospital EMS. Those were organized according to the health systems framework, and a multipronged approach is proposed for data collection including use of qualitative and quantitative methods with triangulation of information from important stakeholders, direct observation, and policy document review. The resultant information is expected to provide a holistic picture of the pre-hospital emergency medical services and develop key recommendations for PEMS systems strengthening.

National Assessment of Quality Programs in Emergency Medical Services

OBJECTIVE

This study aims to understand the adoption of clinical quality measurement throughout the United States on an EMS agency level, the features of agencies that do participate in quality measurement, and the level of physician involvement. It also aims to barriers to implementing quality improvement initiatives in EMS.

METHODS

A 46-question survey was developed to gather agency level data on current quality improvement practices and measurement. The survey was distributed nationally via State EMS Offices to EMS agencies nation-wide using Surveymonkey©. A convenience sample of respondents was enrolled between August and November, 2015. Univariate, bivariate and multiple logistic regression analyses were conducted to describe demographics and relationships between outcomes of interest and their covariates using SAS 9.3©.

RESULTS

A total of 1,733 surveys were initiated and 1,060 surveys had complete or near-complete responses. This includes agencies from 45 states representing over 6.23 million 9-1-1 responses annually. Totals of 70.5% (747) agencies reported dedicated QI personnel, 62.5% (663) follow clinical metrics and 33.3% (353) participate in outside quality or research program. Medical director hours varied, notably, 61.5% (649) of EMS agencies had <5 hours of medical director time per month. Presence of medical director time was correlated with tracking of QI measures. Air medical [OR 9.64 (1.13, 82.16)] and hospital-based EMS agencies [OR 2.49 (1.36, 4.59)] were more likely to track quality measures compared to fire-based agencies. Agencies in rural only environments were less likely to follow clinical quality metrics. (OR 0.47 CI 0.31 -0.72 p < 0.0004). For those that track QI measures, the most common are; Response Time (Emergency) (68.3%), On-Scene Time (66.4%), prehospital stroke screen (64.6%), aspirin administration (64.5%), and 12 lead ECG in chest pain patients (63.0%).

CONCLUSIONS

EMS agencies in the United States have significant practice variability with regard to quality improvement resources, medical direction and specific clinical quality measures. More research is needed to understand the impact of this variation on patient care outcomes.