Improving the first link in the chain of survival: the Antwerp experience

Prehospital triage of patients diagnosed with perforated peptic ulcer or peptic ulcer bleeding: an observational study of patients calling 1-1-2

BACKGROUND

Triage systems are used in emergency medical services to systematically prioritize prehospital resources according to individual patient conditions. Previous studies have shown cases of preventable deaths in emergency medical services even when triage systems are used, indicating a potential undertriage among some conditions. The aim of this study was to investigate the triage level among patients diagnosed with perforated peptic ulcer (PPU) or peptic ulcer bleeding (PUB).

METHODS

In a three-year period in Central Denmark Region, all patients hospitalized within 24 h after a 1-1-2 emergency call and who subsequently received either a PPU or a PUB (hereinafter combined and referred to as PPU/PUB) or a First Hour Quintet (FHQ: respiratory failure, stroke, trauma, cardiac chest pain, and cardiac arrest) diagnosis were investigated. A modified Poisson regression was used to estimate the relative risk of receiving the highest and lowest prehospital response level. Also, a linear regression analysis was used to estimate the relative risk of 30-day mortality.

RESULTS

Of 8658 evaluated patients, 263 were diagnosed with PPU/PUB. After adjusting for relevant confounding variables, patients diagnosed with PPU/PUB were less likely to receive ambulance transportation compared to patients diagnosed with stroke, RR = 1.41 (CI: 1.28-1.56); trauma, RR = 1.28 (CI: 1.15-1.42); cardiac chest pain, RR = 1.47 (CI: 1.33-1.62); and cardiac arrest, RR = 1.44 (CI: 1.31-1.42). Among patients diagnosed with PPU/PUB, 6.5% (CI: 3.3-9.7) did not receive ambulance transportation. The proportion of patients not receiving ambulance transportation was higher among patients diagnosed with PPU/PUB compared to patients diagnosed with an FHQ diagnosis. The 30-day mortality rate among patients diagnosed with PPU/PUB was 7.8% (CI: 4.2-11.1). This was lower than the 30-day mortality rate among patients diagnosed with respiratory failure (P = 0.010), stroke (P = 0.001), and cardiac arrest (P < 0.001), but comparable to the 30-day mortality among patients diagnosed with cardiac chest pain (P = 0.080) and trauma (P = 0.281).

CONCLUSION

Among patients calling 1-1-2, fewer patients diagnosed with PPU/PUB received ambulance transportation than patients diagnosed with FHQ diagnoses, despite a high mortality among patients diagnosed with PPU/PUB.

Sepsis: Medical errors in Poland

Health, safety and medical errors are currently the subject of worldwide discussion. The authors analysed medico-legal opinions trying to determine types of medical errors and their impact on the course of sepsis. The authors carried out a retrospective analysis of 66 medico-legal opinions issued by the Wroclaw Department of Forensic Medicine between 2004 and 2013 (at the request of the prosecutor or court) in cases examined for medical errors. Medical errors were confirmed in 55 of the 66 medico-legal opinions. The age of victims varied from 2 weeks to 68 years; 49 patients died. The analysis revealed medical errors committed by 113 health-care workers: 98 physicians, 8 nurses and 8 emergency medical dispatchers. In 33 cases, an error was made before hospitalisation. Hospital errors occurred in 35 victims. Diagnostic errors were discovered in 50 patients, including 46 cases of sepsis being incorrectly recognised and insufficient diagnoses in 37 cases. Therapeutic errors occurred in 37 victims, organisational errors in 9 and technical errors in 2. In addition to sepsis, 8 patients also had a severe concomitant disease and 8 had a chronic disease. In 45 cases, the authors observed glaring errors, which could incur criminal liability. There is an urgent need to introduce a system for reporting and analysing medical errors in Poland. The development and popularisation of standards for identifying and treating sepsis across basic medical professions is essential to improve patient safety and survival rates. Procedures should be introduced to prevent health-care workers from administering incorrect treatment in cases.

Trauma-related dispatch criteria for Helicopter Emergency Medical Services in Europe

INTRODUCTION

Helicopter Emergency Medical Services (HEMS) are used worldwide in order to provide potentially life-saving pre-hospital medical support to trauma patients at the accident scene. It is currently unclear how much overlap exists regarding the number and type of dispatch criteria used by individual HEMS organisations. The aim of the current study was to provide an overview of dispatch criteria for trauma cases used by HEMS organisations within Europe, and search for similarities and differences, between countries and HEMS stations.

MATERIALS AND METHODS

HEMS dispatch criteria related to trauma care were obtained from the literature and divided into four groups of criteria and processed in a questionnaire. HEMS providing organisations were identified and contacted by telephone and via email.

RESULTS

Fifty-five of the 65 organisations (85%) that were contacted completed the questionnaire. The criteria "Fall from height", "Lengthy extrication and significant injury" and "Multiple casualty incidents" were used most frequently. Criteria from the subgroup "Patient Characteristics-Co-morbidities and Age" were used the least. In 44 of the organisations the Central Dispatch Centre (CDC) was primarily responsible for HEMS dispatch.

CONCLUSION

This overview demonstrates the lack of uniformity in the use of dispatch criteria for trauma assistance on a national and international level. Furthermore, the activation of HEMS is not only depending on dispatch criterion protocols, but is also influenced by organisational factors like the education of the dispatcher, the training of the EMS personnel, the familiarity with the dispatch criteria, and the responses of bystanders. Future research should aim to identify a general set of criteria with the highest discriminating potential.

A study of police operated dispatch to acute coronary syndrome cases arising from 112 emergency calls in Aarhus county, Denmark

BACKGROUND

The accuracy of the Danish police operated "112" emergency call system was studied. Dispatch of the anaesthesiologist staffed mobile emergency care unit (MECU) to acute coronary syndrome (ACS) cases was used as an indicator of accuracy of dispatch to life threatening emergencies.

METHODS

This was an observational cohort study of patients given a 112 system report of heart attack and patients with a provisional diagnosis of ACS made on scene by the MECU. Sensitivity, specificity, and positive predictive value with 95% confidence intervals (CI) were calculated.

RESULTS

There were 341 reports of "heart attack" and 205 patients with ACS. Sensitivity was 75% (95% CI 68% to 80%) specificity 90% (89% to 92%) and positive predictive value 45% (40% to 50%).

CONCLUSION

The accuracy of 112 dispatch of the MECU was found to be moderate. We suggest more training of dispatch staff and medical supervision.

Accuracy in identifying patients with loss of consciousness in a police-operated emergency call centre - first step in the chain of survival

BACKGROUND

The first link in the 'chain of survival' is the activation of Emergency Medical Services (EMS). In the major part of Denmark, police officers operate the alarm 1-1-2 centre, including calls for EMS. Our aim was to study the police 1-1-2 operators' accuracy in identifying calls concerning patients with loss of consciousness as a key symptom of life-threatening conditions. 'Unconsciousness' was defined as patients with a Glasgow Coma Scale (GCS) score of < 9, scored by the on-scene anaesthesiologist from the Mobile Emergency Care Unit (MECU).

METHODS

This study was an observational cohort study based on data from the Police 1-1-2 Database and the Aarhus County Pre-hospital Database containing data from MECU cases during 6 months in 2004-05.

RESULTS

Two thousand, three hundred and forty-three emergency calls with MECU dispatch were identified. In 1655 cases, both 1-1-2 data and the GCS score were recorded. Two hundred and ninety-five patients were found with a GCS score of < 9 at MECU arrival, 243 of whom were reported 'unconscious' by 1-1-2, giving a sensitivity of 82%. One thousand, three hundred and sixty patients were found with a GCS score of > or = 9, 972 of whom were reported 'awake', giving a specificity of 72%. The positive predictive value (percentage of patients found with a GCS score of < 9 at MECU arrival amongst patients reported as 'unconscious') was 39%.

CONCLUSIONS

The accuracy was moderate with room for improvement. The positive predictive value was low, indicating over-triage of MECU.

Out-of-hospital resuscitation in Estonia: a bystander-witnessed sudden cardiac arrest

OBJECTIVE

To evaluate the results of the first epidemiological study on out-of-hospital resuscitation in Estonia.

METHODS

A prospective cohort study of 2108 consecutive standardized reports on out-of-hospital resuscitation attempts from 1 January 1999 to 31 December 2002 was conducted according to the Utstein style.

RESULTS

In all, 67.3% (1419/2108) of the cardiac arrests were of presumed cardiac aetiology and 60.2% (854/1419) of them were bystander-witnessed. Of these, the 28% bystander cardiopulmonary resuscitation was initiated, and the first rhythm was recorded as ventricular fibrillation or pulseless ventricular tachycardia in 40% of the cases. In the subgroup of patients with bystander-witnessed cardiac arrest of cardiac origin, 10.7% (91/854) were discharged alive in good cerebral performance categories and 7.7% were alive at the 1-year follow-up. The chances of survival increased if the median response time interval was <6 min, cardiac arrest occurred in a public place, patients received bystander cardiopulmonary resuscitation and had an initial rhythm of ventricular fibrillation or pulseless ventricular tachycardia. The discharge rate was 24% (82/343) in the subgroup of patients who had bystander-witnessed cardiac arrest of cardiac origin and an initial rhythm of ventricular fibrillation or pulseless ventricular tachycardia. In this subgroup, the survival rate was 42.6% (40/94) in Tartu urban area, 16.9% (22/130) in Tallinn urban area and 16.8% (20/119) in other regions of Estonia (mostly urban and suburban areas).

CONCLUSION

The results demonstrate that despite the progress in the management of out-of-hospital cardiac arrest in Estonia, only one centre (Tartu) achieves a better survival rate. Further improvements are needed to raise the quality of the Estonian emergency medical services system, especially in rural areas.

Physician-staffed HEMS dispatch in the Netherlands: Adequate deployment or minimal utilization?

INTRODUCTION

In the Netherlands, a physician-staffed helicopter emergency medical system (HEMS), called the Helicopter Mobile Medical Team (HMMT), provides prehospital care for severely injured patients in addition to ambulance services. This HMMT has proven to increase chances of survival and reduce morbidity. HMMT dispatch is performed following certain dispatch criteria. The goal of this study was to analyze actual dispatch rates and assess the protocol adherence of the emergency dispatchers in Rotterdam regarding HMMT dispatch.

METHODS

All high priority ambulance runs between April 1 and July 1, 2003, were prospectively documented and cross-referenced to dispatch criteria. It was determined whether the emergency call warranted either immediate dispatch of the HMMT or a secondary dispatch after arrival of the first ambulance. When dispatch actually occurred, this was also documented.

RESULTS

In The Studied Period A Total Of 5765 A1 Ambulance Runs During Daylight Were Documented. Of These, 1148 Runs Met Primary Dispatch Criteria And 38 Runs Met Secondary Dispatch Criteria. Actual Hmmt Dispatch Occured In 162/1186 (14%) Cases.

CONCLUSIONS

HEMS dispatch rates and dispatch criteria adherence are low (14%). Better protocol adherence by emergency dispatchers could lead to a sevenfold increase of HMMT dispatches. The reasons for suboptimal protocol adherence remain unclear and persist, despite proven value of the HMMT in reducing patient mortality and morbidity.