The challenge of ambulance missions to patients not in need of emergency medical care

Human errors in emergency medical services: a qualitative analysis of contributing factors

BACKGROUND

The dynamic and challenging work environment of the prehospital emergency care settings creates many challenges for paramedics. Previous studies have examined adverse events and patient safety activities, but studies focusing on paramedics' perspectives of factors contributing to human error are lacking. In this study, we investigated paramedics' opinions of the factors contributing to human errors.

METHOD

Data was collected through semi-structured individual interviews (n = 15) with paramedics and emergency medical field supervisors in Finland. The data was analyzed using inductive content analysis. Consolidated criteria for reporting qualitative research were used.

RESULTS

Contributing factors to human errors were divided into three main categories. The first main category, Changing work environment, consisted of two generic categories: The nature of the work and Factors linked to missions. The second main category, Organization of work, was divided into three generic categories: Inadequate care guidelines, Interaction challenges and Challenges related to technological systems. The third main category, Paramedics themselves, consisted of four generic categories: Issues that complicate cognitive processing, Individual strains and needs, Attitude problems and Impact of work experience.

CONCLUSION

Various factors contributing to human errors in emergency medical services (EMS) settings were identified. Although many of them were related to individual factors or to the paramedics themselves, system-level factors were also found to affect paramedics' work and may therefore negatively impact patient safety. The findings provide insights for organizations to use this knowledge proactively to develop their procedures and to improve patient safety.

The experiences of patients not conveyed after evaluation by emergency medical services in Southwest Finland - A qualitative survey study

BACKGROUND

The amount of non-critical Emergency Medical Services missions has been increasing. After examination and treatment, paramedics can decide, based on guidelines, not to convey the patient to a healthcare facility. This study aimed to investigate patients' experiences in non-conveyance situations in Southwest Finland. Our research questions were: 1) Which patient concerns were not addressed? 2) What key actions improved patient comfort? and 3) What possible enhancements could make the patient experience more positive?

METHODS

This was a qualitative survey study. In March 2023, all the patients who met the inclusion criteria (N = 1017) received a survey via mail. The data from three open-ended questions were analyzed using inductive content analysis.

RESULTS

The response rate was 22.2 % (n = 226). The unaddressed patient concerns were related to inadequate immediate care and guidance and non-clinical factors causing concern. Key actions for improved patient comfort were related to immediate treatment and guidance, as well as non-clinical factors that impact the patient experience. More thorough treatment processes and more attentive encounters would have enhanced the patient experience.

CONCLUSIONS

Predominantly, patients reported having received excellent services. Utilizing paramedics' soft skills and keeping the patient as the central focus is key to improving the non-conveyance process and experience.

Optimizing remote and rural prehospital resources using air transport of thrombectomy candidates

BACKGROUND

In Finland, the yearly number of mechanical thrombectomies for acute stroke is increasing and more patients are transported over 100 km to the comprehensive stroke centre (CSC) for definitive care. This leaves the rural townships without immediate emergency medical services (EMS) for hours. In this study we compare the EMS' estimated return times to own station after the handover of a thrombectomy candidate between two transport methods: (1) using ground transportation with an ambulance to the CSC or (2) using a hydrid strategy starting the transportation with an ambulance and continuing by air with a helicopter emergency medical services unit (HEMS).

METHODS

We reviewed retrospectively all thrombectomy candidates' transportations from the hospital district of South Ostrobothnia to definitive care at the nearest CSC, Tampere University Hospital from June 2020 to October 2022. The dispatch protocol stated that a thrombectomy candidate's transport begins immediately with an ambulance and if the local HEMS unit is available the patient is handed over to them at a rendezvous. If not, the patient is transported to the CSC by ground. Transport times and locations of the patient handovers were reviewed from the CSC's EMS database and the driving time back to ambulance station was estimated using Google maps. The HEMS unit's pilot's log was reviewed to assess their mission engagement time.

RESULTS

The median distance from the CSC to the ambulances' stations was 188 km (IQR 149-204 km) and from the rendezvous with the HEMS unit 70 km (IQR 51-91 km, p < 0.001). The estimated median driving time back to station after the patient handover at the CSC was 145 min (IQR 117-153 min) compared to the patient handover to the HEMS unit 53 min (IQR 38-68 min, p < 0.001). The HEMS unit was occupied in thrombectomy candidate's transport mission for a median of 136 min (IQR 127-148 min).

CONCLUSION

A hybrid strategy to transport thrombectomy candidates with an ambulance and a helicopter reallocates the EMS resources markedly faster back to their own district.

Ethics rounds in the ambulance service: a qualitative evaluation

BACKGROUND

It is a common ethical challenge for ambulance clinicians to care for patients with impaired decision-making capacities while assessing and determining the degree of decision-making ability and considering ethical values. Ambulance clinicians' ethical competence seems to be increasingly important in coping with such varied ethical dilemmas. Ethics rounds is a model designed to promote the development of ethical competence among clinicians. While standard in other contexts, to the best of our knowledge, it has not been applied within the ambulance service context. Thus, the aim of this study was to describe ambulance clinicians' experiences of participating in ethics rounds.

METHODS

This was a qualitative descriptive study, evaluating an intervention. Data were collected through sixteen interviews with ambulance clinicians who had participated in an intervention involving ethics rounds. The analysis was performed by use of content analysis.

RESULTS

Two themes describe the participants' experiences: (1) Reflecting freely within a given framework, and (2) Being surprised by new insights. The following categories form the basis of the themes; 1a) Gentle guidance by the facilitator, 1b) A comprehensible structure, 2a) New awareness in the face of ethical problems, and 2b) Shared learning through dialogue.

CONCLUSION

Incorporating structured ethics rounds seems to create a continuous development in ethical competence that may improve the quality of care in the ambulance service. Structured guidance and facilitated group reflections offer ambulance clinicians opportunities for both personal and professional development. An important prerequisite for the development of ethical competence is a well-educated facilitator. Consequently, this type of ethics rounds may be considered a useful pedagogical model for the development of ethical competence in the ambulance service.

Patient satisfaction with telephone care assessment among patients with non-urgent prehospital emergency care issues: A cross-sectional study

BACKGROUND

Telephone care assessment (TCA) by a nurse have shown to reduce the number of emergency department (ED) visits and emergency medical services missions (EMS). The present study aimed to describe satisfaction among patients with non-urgent prehospital medical issues that were transferred to TCA instead of receiving EMS. These results could provide a basis for developing the telephone services and emergency care pathways.

METHODS

This cross-sectional study included 765 patients with non-urgent issues that were transferred to a telephone care assessment, after a risk and urgency assessment by an emergency medical communications operator. One week later, patient satisfaction was evaluated in a structured telephone interview with randomized patients.

RESULTS

127 telephone interviews were completed.Most patients (70.9-85.0%) were highly satisfied with the telephone care assessment. In particular,patients who were unsure of the urgency of their own health condition and the need for EMS, were highly satisfied (95.3%). Patients that received EMS after the telephone care assessment were more satisfied than those that received telephone guidance or those directed to other health care services (91.4% vs. 65.5% vs. 67.9%, p = 0.002).

CONCLUSION

Patients with non-urgent prehospital emergency issues were mainly satisfied with telephone care assessment. In considering ways to reduce the increasing load on emergency medical services, a telephone care assessment could be a good option, without reducing patient satisfaction.

A survey of general practitioner's opinion on the proposal to introduce 'treat and referral' into the Irish emergency medical service

BACKGROUND

The introduction of treat and referral by ambulance practitioners is under active consideration in Ireland. The Irish ambulance services have traditionally transported all patients following an emergency (112/999) call to an emergency department. The introduction of treat and referral will present a significant care pathway change.

AIMS

To engage GPs in relation to the proposed introduction of treat and referral.

METHODS

A postal survey of 50 general practices in the southeast of Ireland was completed in 2019 to identify their opinion on the introduction of treat and referral. Descriptive statistics were calculated, and Pearson's chi-square tests were used to identify statistically significant differences among GP cohorts.

RESULTS

A 78% response rate was achieved. Respondents indicated that informal treat and referral was practised by 40% of GPs. A significant majority of GPs indicated that their patients with diabetes or epilepsy would benefit from treat and referral and were happy for paramedics to make appointments posthypoglycaemia or seizure. There was no clear consensus in relation to confining treat and referral to adults only. Barriers to the implementation of treat and referral were a significant issue for GPs.

CONCLUSIONS

GPs are in the main supportive of the introduction of treat and referral; however, they have identified several barriers that may inhibit successful introduction. Importantly, a GP appointment within 48 h does not appear to be a barrier. The adequacy of the working relationships between GPs and the ambulance service and its practitioners appears to have reduced since 2006, which is concerning.

Use of prehospital emergency medical services according to income of residential area

Background

The increasing usage of emergency medical services (EMS) missions is a challenge in modern practice. This study was designed to examine the association of the income level of residential areas on the rate of EMS missions and the frequency of EMS use in these areas.

Methods

All EMS missions for adult patients (>18 years) encountered by one rescue department in Northern Finland between June 2015 and May 2017 were analysed. The area served was categorised into four categories, according to the median annual income of the postal code areas. EMS missions per 1000 person-years, rate of non-transport missions and the number of dispatches to frequent (>4 EMS calls/year and highly frequent (>10 calls/year)EMS users per area were investigated.

Results

There were 62 759 EMS missions, 34.8% of which resulted in non-transport. The crude rate of EMS dispatches was higher in the low-income area compared with other income areas (133.3 vs 108.9 vs 111.3 vs 73.6/1000 person-years) as well as the rate of high-frequency user dispatches (21.5 vs 11.5 vs 7.2 vs 4.3/1000-person years). The rate of non-transports missions was higher also (69.4 vs 43.4 vs 42.5. vs 30.6/1000 person-years). The highest crude rate of EMS use was found in people older than 65 years living in the lowest income areas (294.8/1000 person-years). After age adjustment, the highest rate of EMS use was found in rural areas with the lowest income (146.3/1000 person-years).

Conclusions

The rate of the EMS missions and non-transport missions differs significantly among different income areas. Resource usage was significantly higher in the low income areas. This information can be used in planning allocation of EMS and preventive healthcare resources.

Telephone triage performed by nurses reduces non-urgent ambulance missions: A prospective observational pilot study in Finland

BACKGROUND

The increased workload in emergency medical services (EMS) is a global phenomenon in welfare states. It has been suggested that telephone triage by nurses may reduce the increasing use of EMS services, by directing patient flow to appropriate care. This study aimed to investigate whether, after an emergency medical communication centre (EMCC) provider assessed risk, a telephone nurse could assess the patient's needs and guide patients to social and health care services in non-urgent cases.

METHODS

This prospective observational study was performed in the Kainuu Hospital District in northern Finland from March to April 2018. All EMS requests classified as non-urgent by the EMCC were transferred to a telephone triage nurse. Subsequent patient guidance was recorded. The International Classifications of Primary Care categories were recorded.

RESULTS

We studied phone calls of 700 patients with non-urgent needs. Of these, the nurse transferred 63.7% to EMS and 17.3% were guided to other social and health care services. Nineteen per cent of the calls were handled over the phone by the nurse, who provided health advice and instructions. The most common needs for care were general and unspecified symptoms, musculoskeletal symptoms, mental health problems and substance abuse.

CONCLUSION

By providing telephone counseling, care instructions and patient guidance to other social and health services than EMS, the telephone triage reduced non-urgent EMS missions by one third. The results imply that telephone triage could be a viable model for managing non-urgent missions. Patient safety issues should be monitored when developing new service concepts.

Stakeholder opinion on the proposal to introduce 'treat and referral' into the Irish emergency medical service

BACKGROUND

The Irish ambulance services have traditionally transported all patients following an emergency (112/999) call, regardless of acuity, to an emergency department (ED). A proposal to introduce Treat and Referral, an established care pathway in some jurisdictions, is under active consideration in Ireland. This will present a significant change. Stakeholder engagement is recognised as an essential component of management of such change. This study has conducted a multicentre, cross-sectional survey exploring opinions on the introduction of Treat and Referral among key Irish stakeholders; consultants in emergency medicine, paramedics and advanced paramedics.

METHODS

Public-sector consultants in emergency medicine (EM), registered paramedics and advanced paramedics, in Ireland at the time of the study, were invited to complete an on-line survey.

RESULTS

A significant finding was that 90% of both cohorts (EM consultants and registered paramedic practitioners) support written after-care instructions being given to referred patients, that > 83% agree that Treat and Referral will reduce unnecessary ambulance journeys and that 70% are in favour of their own family member being offered Treat and Referral. Consensus was reached between respondents that Treat and Referral would improve care and increase clinical judgement of practitioners. Differences were identified in relation to the increased availability of ambulances locally, that only adults should be included, and that research was required to extend Treat and Referral beyond the index conditions. There was no consensus on whether general practitioners (GPs) should be directly informed.

CONCLUSIONS

This study identified that the Irish healthcare practitioners surveyed are supportive of the introduction of Treat and Referral into Ireland. It also affords healthcare policymakers the opportunity to address the concerns raised, in particular the clinical level which will be targeted for inclusion in this extended scope of practice.