Measuring quality in emergency medical services: a review of clinical performance indicators

Association between out-of-hospital cardiac arrest quality indicator and prehospital management and clinical outcomes for major trauma

INTRODUCTION

It is unclear whether emergency medical service (EMS) agencies with good out-of-hospital cardiac arrest (OHCA) quality indicators also perform well in treating other emergency conditions. We aimed to evaluate the association of an EMS agency's non-traumatic OHCA quality indicators with prehospital management processes and clinical outcomes of major trauma.

METHODS

This retrospective cross-sectional study analyzed data from registers of nationwide, population-based OHCA (adult EMS-treated non-traumatic OHCA patients from 2017 to 2018) and major trauma (adult, EMS-treated, and injury severity score ≥16 trauma patients in 2018) in South Korea. We developed a prehospital ROSC prediction model to categorize EMS agencies into quartiles (Q1-Q4) based on the observed-to-expected (O/E) ROSC ratio for each EMS agency. We evaluated the national EMS protocol compliance of on-scene management according to O/E ROSC ratio quartile. The association between O/E ROSC ratio quartiles and trauma-related early mortality was determined in a multi-level logistic regression model by adjusted odds ratios (OR) and 95 % confidence intervals (95 % CI).

RESULTS

Among 30,034 severe trauma patients, 4,836 were analyzed. Patients in Q4 showed the lowest early mortality rate (5.6 %, 5.5 %, 4.8 %, and 3.4 % in Q1, Q2, Q3, and Q4, respectively). In groups Q1 to Q4, increasing compliance with the national EMS on-scene management protocol (trauma center transport, basic airway management for patients with altered mentality, spinal motion restriction for patients with spinal injury, and intravenous access for patients with hypotension) was observed (p for trend <0.05). Multivariable multi-level logistic regression analysis showed significantly lower early mortality in Q4 than in Q1 (adjusted OR [95 % CI] 0.56 [0.35-0.91]).

CONCLUSION

Major trauma patients managed by EMS agencies with high success rates in achieving prehospital ROSC in non-traumatic OHCA were more likely to receive protocol-based care and exhibited lower early mortality.

Consensus-based quality standards for emergency departments in Palestine

OBJECTIVES

The present study aimed to establish appropriate quality standards for emergency departments (EDQS) in Palestine.

METHODS

The study comprised four phases. First, a comprehensive literature review was conducted to develop a framework for assessing healthcare services in EDs. Second, the initial set of EDQS was developed based on the review findings. Third, local experts provided feedback on the EDQS, suggesting additional standards, and giving recommendations. This feedback was analysed to create a preliminary set of EDQS. Finally, an expanded group of local emergency care experts evaluated the preliminary set, providing feedback on content and structure to contribute to the final set of EDQS.

FINDINGS

We identified quality domains in EDs and categorised them into clinical and administrative pathways. The clinical pathway comprises 39 standards across 7 subdomains: triage, treatment, transportation, medication safety, patient flow and medical diagnostic services. Expert consensus was achieved on 87.5% of these standards. The administrative domain includes 64 consensus-based standards across 9 subdomains: documentation, information management systems, access-location, design, leadership, management, workforce staffing, training, equipment, supplies, capacity-resuscitation rooms, resources for a safe working environment, performance indicators and patient safety-infection prevention and control programmes.

CONCLUSION

This study employed a rigorous approach to identify QS for EDs in Palestine. The multiphase consensus process ensured the appropriateness of the developed EDQS. Inclusion of diverse perspectives enriched the content. Future studies will validate and refine the standards based on feedback. The EDQS has potential to enhance emergency care in Palestine and serve as a model for other regions facing similar challenges.

Using machine learning to assess the extent of busy ambulances and its impact on ambulance response times: A retrospective observational study

BACKGROUND

Ambulance response times are considered important. Busy ambulances are common, but little is known about their effect on response times.

OBJECTIVE

To assess the extent of busy ambulances in Central Norway and their impact on ambulance response times.

DESIGN

This was a retrospective observational study. We used machine learning on data from nearby incidents to assess the probability of up to five different ambulances being candidates to respond to a medical emergency incident. For each incident, the probability of a busy ambulance was estimated by summing the probabilities of candidate ambulances being busy at the time of the incident. The difference in response time that may be attributable to busy ambulances was estimated by comparing groups of nearby incidents with different estimated busy probabilities.

SETTING

Medical emergency incidents with ambulance response in Central Norway from 2013 to 2022.

MAIN OUTCOME MEASURES

Prevalence of busy ambulances and differences in response times associated with busy ambulances.

RESULTS

The estimated probability of busy ambulances for all 216,787 acute incidents with ambulance response was 26.7% (95% confidence interval (CI) 26.6 to 26.9). Comparing nearby incidents, each 10-percentage point increase in the probability of a busy ambulance was associated with a delay of 0.60 minutes (95% CI 0.58 to 0.62). For incidents in rural and urban areas, the probability of a busy ambulance was 21.6% (95% CI 21.5 to 21.8) and 35.0% (95% CI 34.8 to 35.2), respectively. The delay associated with a 10-percentage point increase in busy probability was 0.81 minutes (95% CI 0.78 to 0.84) and 0.30 minutes (95% CI 0.28 to 0.32), respectively.

CONCLUSION

Ambulances were often busy, which was associated with delayed ambulance response times. In rural areas, the probability of busy ambulances was lower, although the potentially longer delays when ambulances were busy made these areas more vulnerable.

Dynamic ambulance relocation: a scoping review

OBJECTIVES

Dynamic ambulance relocation means that the operators at a dispatch centre place an ambulance in a temporary location, with the goal of optimising coverage and response times in future medical emergencies. This study aimed to scope the current research on dynamic ambulance relocation.

DESIGN

A scoping review was conducted using a structured search in PubMed, Scopus and Web of Science. In total, 21 papers were included.

RESULTS

Most papers described research with experimental designs involving the use of mathematical models to calculate the optimal use and temporary relocations of ambulances. The models relied on several variables, including distances, locations of hospitals, demographic-geological data, estimation of new emergencies, emergency medical services (EMSs) working hours and other data. Some studies used historic ambulance dispatching data to develop models. Only one study reported a prospective, real-time evaluation of the models and the development of technical systems. No study reported on either positive or negative patient outcomes or real-life chain effects from the dynamic relocation of ambulances.

CONCLUSIONS

Current knowledge on dynamic relocation of ambulances is dominated by mathematical and technical support data that have calculated optimal locations of ambulance services based on response times and not patient outcomes. Conversely, knowledge of how patient outcomes and the working environment are affected by dynamic ambulance dispatching is lacking. This review has highlighted several gaps in the scientific coverage of the topic. The primary concern is the lack of studies reporting on patient outcomes, and the limited knowledge regarding several key factors, including the optimal use of ambulances in rural areas, turnaround times, domino effects and aspects of working environment for EMS personnel. Therefore, addressing these knowledge gaps is important in future studies.

No Two Systems Are the Same: Paramedic Perceptions of Contemporary System Performance Using Prehospital Quality Indicators

Introduction In recent years, researchers have identified two new models of paramedicine within the Anglo-American paramedic system known as the Directive and Professionally Autonomous paramedic systems. The research team now seek to compare paramedic perception of system performance between the two systems using prehospital quality indicators. Methods Paramedics employed within Anglo-American paramedic systems undertook a survey evaluating their experience and perception of system performance against a set of modified prehospital quality indicators. Data were collected using a survey combining single-choice questions with matrix multiple-choice questions. Key results were cross-tabulated with demographic (informant) and system factors to compare performance between the two new paramedic systems. Results The survey indicated a substantial difference in perceived clinical and operational performance between the Professionally Autonomous and Directive paramedic systems, with the Professionally Autonomous paramedic system performing consistently better in all 11 prehospital quality indicator domains. Conclusion The results of this survey are a vital step in helping paramedics, health leaders, and academics understand the complex relationship between paramedic system design and system performance, and, for the first time, provides empirical evidence upon which to make a conscious decision to adopt one system or the other.

Digital Future of Emergency Medical Services: Envisioning and Usability of Electronic Patient Care Report System

Despite the efforts of emerging technologies in the healthcare system, there is still a slower rate of acceleration in prehospital settings compared with the hospitals in digital transformation adaptation. The acknowledgment that digital transformation is significant to healthcare is reflected in planning for the future of digital healthcare. Thus, this study aimed to measure the usability of the electronic patient care report (ePCR) system among emergency medical services (EMS) staff who work in prehospital settings. A descriptive cross-sectional correlation study was used. Two hundred fifty EMS staff who are working in the prehospital setting at Saudi Red Crescent Authority in the Kingdom of Saudi Arabia were surveyed, and the response rate was 79.2% (198). An adapted tool of the Computer System Usability Questionnaire survey was used to collect data. The data were coded numerically and subjected to descriptive and inferential statistical analysis including Pearson’s correlation coefficient using the statistical software (SPSS 21). The majority of the participants rate their ePCR system as “useable” at a high level with a score of 3.41 (SD = 1.021). The overall mean of the ePCR system’s three subscales: system usefulness, information quality, interface quality, and overall satisfaction were 3.39 (SD = 1.152), 3.30 (SD = 1.052), 3.57 (SD = 1.064), and 3.37 (SD = 1.239), respectively. The least liked aspect of ePCR system software was information quality 81 (40.9%). Furthermore, there was a significant correlation between the age of EMS staff and the usability of the ePCR system (r = −0.150 ${\hspace{0.17em}}^{\ast }$ , $P=0.035$ ). The results suggest that healthcare institutions’ policy and decision-makers pay close attention to performing standardized training for the staff on their ePCR system before going to the field to increase efficiency and productivity. Furthermore, the users in this study identified other system features that, if included, could have enhanced usability, and improved functions and capabilities of the design to meet the EMS staff’s expectations.

Trauma-Specific Performance Improvement Activities for Emergency Medical Services Providers: A Statewide Perspective

INTRODUCTION

Trauma-specific performance improvement (PI) activities are highly variable among Emergency Medical Services (EMS) providers. This study assesses the perception of the trauma PI activities of EMS providers in the state of Ohio and identifies potential barriers to conducting a successful program.

METHODS

An institutional review board-approved, voluntary, and anonymous Qualtrics survey was disseminated to all EMS agencies registered under the Ohio Department of Public Safety throughout the 88 counties of Ohio. It included questions regarding what agencies considered trauma-specific PI activities, how frequently they completed those activities, and barriers related to conducting such PI activities. There were both open-ended and closed-ended questions in the survey, along with a follow-up interview. The data were descriptively and thematically analyzed.

RESULTS

From the recorded responses (341), most the respondents (98.5%) either agreed or strongly agreed that trauma-specific PI activities improve performance of EMS providers, while only 63.8% (218) of the agencies performed them. Some activities considered as trauma PI and conducted at least once a month included (1) record keeping (74.6%), (2) confirmation on the use of correct triage protocols (66.9%), (3) measuring response time on trauma calls (60.0%), (4) PI reviews of trauma cases (56.9%), and (5) obtaining feedback from the receiving facility and or authorizing physicians (48.5%). Primary barriers to performing trauma PI activities included a lack of interest and financial resources, followed by system-level reasons such as unavailability of training centers and a lack of regional/state support. Thematic analysis of the data suggested that improved communication and awareness of trauma PI, sharing statewide data on trauma PI, better synchronization among EMS agencies and trauma centers, and enhanced EMS funding could potentially improve trauma-specific PI programs at the EMS level.

CONCLUSIONS

Our results showed variability in the perception, execution, and availability of trauma-specific PI activities among EMS agencies in the state. Common barriers could potentially be mitigated by collaboration between agencies, trauma centers, and state-led initiatives. With the increased frequency of mass shootings and other large-scale trauma disasters, it is imperative from a state and regional level to address these inconsistencies and further elucidate effective measures of trauma PI for the EMS community.

Use of discrete event simulation and genetic algorithms to estimate the necessary resources to respond in a timely manner in the Medical Emergency System in Bogotá

Introduction

Bogotá has a Medical Emergency System of public and private ambulances that respond to health incidents. However, its sufficiency in quantity, type and location of the resources demanded is not known.

Objective

Based on the data from the Medical Emergency System of Bogotá, Colombia, we first sought to characterize the prehospital re- sponse in cardiac arrest and determine with the model which is the least number of resources necessary to respond within eight minutes, taking into account their location, number, and type.

Methods

A database of incidents reported in administrative records of the district health authority of Bogotá (2014 to 2017) was obtained. Based on this information, a hybrid model based on discrete event simulation and genetic algorithms was designed to establish the amount, type and geographic location of resources according to the frequencies and typology of the events.

Results

From the database, Bogotá presented 938 671 ambulances dispatches in the period. 47.4% high priority, 18.9% medium and 33.74% low. 92% of these corresponded to 15 of 43 medical emergency codes. The response times recorded were longer than expected, especially in out-of-hospital cardiac arrest (median 19 minutes). In the proposed model, the best scenario required at least 281 ambulances, medicalized and basic in a 3:1 ratio, respectively, to respond in adequate time.

Conclusions

Results suggest the need for an increase in the resources that respond to these incidents to bring these response times to the needs of our population.

Self-Assessment of Biomedical Activity Related to Medical Devices Embedded in EMS Ambulances: Towards a Roadmap for an Efficient Improvement

Objective:

The present investigation is focused on a self-assessment of the biomedical activity related to embedded Medical Devices on board a fleet of 46 EMS medicalized ambulances, according to the High Authority of Health standard (criterion 8K) and the Guide of the Good Practices of Biomedical Engineering.

Materials and Methods:

The methodology adopted for this purpose is based on an analysis allowing the evaluation and observation of practices related to biomedical activity in these ambulances. An initial assessment, carried out in March 2021, made it possible to measure the gaps between the actual situation and the recommendations of the two self-diagnosis tools (High Authority of Health and Guide of the Good Practices of Biomedical Engineering standards). A series of corrective actions were proposed and then implemented. A second self-assessment took place after 6 months, in October 2021.

Results:

Between March and October 2021, an improvement in the scores for almost all the axes of the two self-assessment tools was noted. Indeed, the score of the self-assessment for the High Authority of Health reference system rose from 44% in March 2021 to 63% in October 2021, i.e. an increase of 19%, and that of the Guide of the Good Practices of Biomedical Engineering increased from 67.54% in March 2021 to 80.96% in October 2021, i.e. an increase of 13.42%.

Conclusion:

The implementation of a maintenance strategy integrating the notion of quality, relevant procedures and pertinent work tools has made it possible to significantly improve the biomedical activity within the medical ambulances and to optimise the embedded medical devices.

Nonwillingness to Return to the Emergency Department and Nonattendance of Follow-Up Care Arrangements Following an Initial Suicide-Related Presentation

Background: For people experiencing a suicidal crisis the emergency department (ED) is often the only option to find help. Aims: The aims of this study were (a) to identify predictors of patients' nonwillingness to return to the ED for help with a future suicidal crisis, and (b) whether nonwillingness to return was associated with follow-up appointment nonattendance. Method: This study utilized baseline data from the RESTORE online survey, and included 911 participants who had presented to an ED for suicidal crisis in the past 18 months, across participating local health districts in the Australian Capital Territory and New South Wales. Results: Patients who reported a more negative ED experience and longer triage wait times were less willing to return. Those who were less willing to return were also less likely to attend their follow-up appointment. Limitations: Due to the cross-sectional study design, causal inferences are not possible. Additionally, the self-report measures used are susceptible to recall bias. Conclusion: Patients' experience of service at EDs is a key indicator to drive improvement of patient outcomes for individuals experiencing a suicidal crisis.

Ready for Children Part II: Increasing Pediatric Care Coordination and Psychomotor Skills Evaluation in the Prehospital Setting

OBJECTIVES

Treating pediatric patients often invokes discomfort and anxiety among emergency medical service (EMS) personnel. As part of the process to improve pediatric care in the prehospital system, the Health Resources and Services Administration (HRSA) Emergency Services for Children (EMSC) Program implemented two prehospital performance measures -access to a designated pediatric care coordinator (PECC) and skill evaluation using pediatric equipment-along with a multi-year plan to aid states in achieving the measures. Baseline data from a survey conducted in 2017 showed that less than 25% of EMS agencies had access to PECC and 47% performed skills evaluation using pediatric equipment at least twice a year. To evaluate change over time, the survey was again conducted in 2020, and agencies that participated in both years are compared.

METHODS

A web-based survey was sent to EMS agency administrators in 58 states and territories from January to March 2020. Descriptive statistics, odds ratios, and 95% confidence intervals were conducted.

RESULTS

The response rate was 56%. A total of 5,221 agencies participated in both survey periods representing over 250,000 providers. The percentage of agencies reporting the presence of a PECC increased from 24% to 34% (p= <0.001). However, some agencies reported that they no longer had a PECC, while others reported having a PECC for the first time. Fifty percent (50%) of agencies conduct pediatric psychomotor skills evaluation at least twice/year, a 2% increase over time (p = 0.041); however, a third (34%) evaluate skills using pediatric equipment less than once a year. The presence of a PECC continues to be the variable associated with the highest odds (AOR 2.15, 95% CI 1.91-2.43) of conducting at least semi-annual skills evaluation.

CONCLUSIONS

There is an increase in the presence of pediatric care coordination and the frequency of pediatric psychomotor skills evaluation among national EMS agencies over time. Continued efforts to increase and sustain PECC presence should be an ongoing focus to improve pediatric readiness in the prehospital system.

Assessing trauma care systems in low-income and middle-income countries: a systematic review and evidence synthesis mapping the Three Delays framework to injury health system assessments

BACKGROUND

The large burden of injuries falls disproportionately on low/middle-income countries (LMICs). Health system interventions improve outcomes in high-income countries. Assessing LMIC trauma systems supports their improvement. Evaluating systems using a Three Delays framework, considering barriers to seeking (Delay 1), reaching (Delay 2) and receiving care (Delay 3), has aided maternal health gains. Rapid assessments allow timely appraisal within resource and logistically constrained settings. We systematically reviewed existing literature on the assessment of LMIC trauma systems, applying the Three Delays framework and rapid assessment principles.

METHODS

We conducted a systematic review and narrative synthesis of articles assessing LMIC trauma systems. We searched seven databases and grey literature for studies and reports published until October 2018. Inclusion criteria were an injury care focus and assessment of at least one defined system aspect. We mapped each study to the Three Delays framework and judged its suitability for rapid assessment.

RESULTS

Of 14 677 articles identified, 111 studies and 8 documents were included. Sub-Saharan Africa was the most commonly included region (44.1%). Delay 3, either alone or in combination, was most commonly assessed (79.3%) followed by Delay 2 (46.8%) and Delay 1 (10.8%). Facility assessment was the most common method of assessment (36.0%). Only 2.7% of studies assessed all Three Delays. We judged 62.6% of study methodologies potentially suitable for rapid assessment.

CONCLUSIONS

Whole health system injury research is needed as facility capacity assessments dominate. Future studies should consider novel or combined methods to study Delays 1 and 2, alongside care processes and outcomes.

Evaluating the impact of prehospital care on mortality following major trauma in New Zealand: a retrospective cohort study

BACKGROUND

Injury is a leading cause of death and health loss in New Zealand and internationally. The potentially fatal or severe consequences of many injuries can be reduced through an optimally structured prehospital trauma care system that can provide timely and appropriate care.

OBJECTIVE

To investigate the relationship between emergency medical services (EMS) care and survival to hospital for major trauma cases in New Zealand.

METHODS

This project is a retrospective cohort study of New Zealand major trauma cases attended by EMS providers over a 2-year period. Outcomes include survival to hospital and survival in hospital for at least 24 hours. The project has three phases: (1) identification of the cohort and assembling a bespoke longitudinal dataset linking EMS, New Zealand Major Trauma Registry and Coronial data; (2) describing the pathways and processes of care to inform an investigation of the relationships between types of EMS care and survival using propensity score modelling to adjust for case-mix differences; (3) assessment of the implications for future practice, policy and research.

DISCUSSION

The study findings will help identify opportunities to optimise the delivery of EMS care in New Zealand by informing the development or revision of existing major trauma EMS policies and guidelines, and to provide a baseline for monitoring the impact of future initiatives. Establishing an evidence-base will support a whole-of-system appraisal that could include broader complex variables relating to healthcare services throughout the continuum of trauma care.

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.

Socioeconomic disparities in Rapid ambulance response for out-of-hospital cardiac arrest in a public emergency medical service system: A nationwide observational study

OBJECTIVES

This study aimed to examine whether county socioeconomic status (SES) is associated with emergency medical service (EMS) response time and dual dispatch response of out-of-hospital cardiac arrest (OHCA) patients using county property tax per capita in Korea.

METHODS

All EMS-treated adults who suffered OHCAs were enrolled between 2015 and 2017, excluding cases witnessed by EMS providers. The main exposure was property tax per capita in the county where the OHCA occurred. The primary outcome was response time interval, with a secondary outcome of dual dispatch response. Negative binomial regression analysis to calculate incidence rate ratio (IRR) with a 95% confidence interval (CI) was conducted for EMS response time. A multivariable logistic regression analysis for response time interval (<8 min) and dual dispatch response was also conducted.

RESULTS

A total of 71,326 patients in 228 counties were enrolled. Compared to the lowest SES quartile, OHCA patients in the highest SES quartile had shorter median (interquartile range [IQR]) response time intervals (9.5 [5.9] minutes vs. 7.6 [4.2] minutes, IRR [95% CI] 0.95 [0.94-0.96], respectively). The AOR (95% CI) for response time within 8 min was 1.07 (1.01-1.13) for the highest SES quartile compared to the lowest SES quartile. Those in the highest SES quartile also had higher rates of dual dispatch response compared to those in the lowest quantile (50.9% vs 26.6%; AOR [95% CI]: 2.16 [2.03-2.30]).

CONCLUSION

In OHCA patients, those in a lower SES are associated with longer response times and lower dual dispatch response.

Mortality and quality of care in Nordic physician-staffed emergency medical services

Background

Quality indicators (QI) for physician staffed emergency medical services (P-EMS) are necessary to improve service quality. Mortality can be considered the ultimate outcome QI. The process quality of care in P-EMS can be described by 15 response-specific QIs developed for these services. The most critical patients in P-EMS are presumably found among patients who die within 30 days after the P-EMS response. Securing high quality care for these patients should be a prioritized task in P-EMS quality improvement. Thus, the first aim of this study was to describe the 30-days survival in Nordic P-EMS as an expression of the outcome quality of care. The second aim was to describe the process quality of care as assessed by the 15 QIs, for patients who die within 30 days after the P-EMS response.

Methods

In this prospective observational study, P-EMSs in Finland, Sweden, Denmark, and Norway registered 30-days survival and scored the 15 QIs for their patients. The QI performance for patients who died within 30 days after the P-EMS response was assessed using established benchmarks for the applied QIs. Further, mean QI performance for the 30-days survivors and the 30-days non-survivors were compared using Chi-Square test for categorical variables and Mann-Whitney U test for continuous variables.

Results

We recorded 2808 responses in the study period. 30-days survival varied significantly between the four participating countries; from 89.0 to 76.1%. When assessing the quality of care for patients who die within 30 days after the P-EMS response, five out of 15 QIs met the established benchmarks. For nine out of 15 QIs, there was significant difference in mean scores between the 30 days survivors and non-survivors.

Conclusion

In this study we have described 30-days survival as an outcome QI for P-EMS, and found significant differences between four Nordic countries. For patients who died within 30 days, the majority of the 15 QIs developed for P-EMS did not meet the benchmarks, indicating room for quality improvement. Finally, we found significant differences in QI performance between 30-days survivors and 30-days non-survivors which also might represent quality improvement opportunities.

Evolution of emergency medical services in the Kingdom of Bahrain

Emergency medical services (EMS) is crucial to any healthcare system, especially in urban countries. The Kingdom of Bahrain has always strived to develop healthcare services throughout the Kingdom including EMS. Like any other country, the Kingdom has gone through several stages in the provision of EMS. This article will focus on the development of EMS in the Kingdom and its evolution from a scattered hospital-based system to a unified system, which ensures ease of access for the population and speed of delivery to the healthcare facilities. The major focus will be the most recent national project which is the National Ambulance.

Timeliness of Care for Injured Patients Initially Seen at Freestanding Emergency Departments: A Pilot Quality Improvement Project

BACKGROUND

The impact of freestanding emergency departments (FSEDs) on timeliness of care for trauma patients is not well understood. This quality improvement project had 2 objectives: (1) to determine whether significant delays in definitive care existed among trauma patients initially seen at FSEDs compared with those initially seen at other outlying sites prior to transfer to a level I trauma center; and (2) to determine the feasibility of identifying differences in time-to-definitive care and emergency department length of stay (ED LOS) based on initial treatment location.

METHODS

Trauma registry data from January 1, 2017, through December 31, 2017, from a verified level I trauma center were analyzed by location of initial presentation. Appropriate statistical tests are used to make comparisons across transport groups.

RESULTS

Patients initially seen at non-FSEDs experienced ED LOS that were, on average, 24.5 minutes greater than patients seen initially at FSEDs, although the difference was not statistically significant (P = .3112). Several challenges were identified in the feasibility analysis that will inform the design for a larger study including large quantities of missing time stamp data and potential selection bias. Prospective solutions were identified.

CONCLUSION

This project found that there were not significant differences in ED LOS for injured patients presenting initially to FSEDs or other non-FSED facilities, suggesting that timeliness of care was similar across location types.

Emergencies in Pediatric Palliative Care: A Survey of Ambulance Officers to Understand the Interface between Families and Ambulance Services

Background: Pediatric palliative care occurs across contexts through the child's illness trajectory, including within the child or young person's community. Interactions with the ambulance service may occur with a child's deterioration, crisis, or when needing transfer, but there is little research on this interaction. Aim: To explore the experiences and attitudes of ambulance officers in managing pediatric patients with palliative care needs. Design: A targeted e-mail survey was sent exploring perceptions of the involvement with these patients including exposure, comfort, resuscitation topics, and supports available. Setting/Participants: Participants were Queensland ambulance officers known to have had an interaction with one of the last 50 pediatric palliative care referrals across Queensland. Results: Twenty-two survey responses were received. Most of the palliative group accessed ambulances for the 13-month study period. Most ambulance officers did not easily identify patients as receiving palliative care. Many participants felt these cases were challenging, confidence levels varied, and staff counselling services were felt to be relevant. Ambulance officers were most likely to use correspondence provided by the family from their usual team as a guide for emergency management. Half of the participants felt patients receiving pediatric palliative care should have a "not for resuscitation" order. Respondents suggested officer support could be improved through increased patient documentation and promotion of existing officer supports. Conclusions: These findings demonstrate challenges experienced by ambulance officers and suggest practical ways in which pediatric palliative care services can better support emergency services.

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.

Indicators to measure prehospital care quality: a scoping review

OBJECTIVE

The purpose of this scoping review was to locate, examine and describe the literature on indicators used to measure prehospital care quality.

INTRODUCTION

The performance of ambulance services and quality of prehospital care has traditionally been measured using simple indicators, such as response time intervals, based on low-level evidence. The discipline of paramedicine has evolved significantly over the last few decades. Consequently, the validity of utilizing such measures as holistic prehospital care quality indicators (QIs) has been challenged. There is growing interest in finding new and more significant ways to measure prehospital care quality.

INCLUSION CRITERIA

This scoping review examined the concepts of prehospital care quality and QIs developed for ambulance services. This review considered primary and secondary research in any paradigm and utilizing any methods, as well as text and opinion research.

METHODS

Joanna Briggs Institute methodology for conducting scoping reviews was employed. Separate searches were conducted for two review questions; review question 1 addressed the definition of prehospital care quality and review question 2 addressed characteristics of QIs in the context of prehospital care. The following databases were searched: PubMed, CINAHL, Embase, Scopus, Cochrane Library and Web of Science. The searches were limited to publications from January 1, 2000 to the day of the search (April 16, 2017). Non-English articles were excluded. To supplement the above, searches for gray literature were performed, experts in the field of study were consulted and applicable websites were perused.

RESULTS

Review question 1: Nine articles were included. These originated mostly from England (n = 3, 33.3%) and the USA (n = 3, 33.3%). Only one study specifically aimed at defining prehospital care quality. Five articles (55.5%) described attributes specific to prehospital care quality and four (44.4%) articles considered generic healthcare quality attributes to be applicable to the prehospital context. A total of 17 attributes were identified. The most common attributes were Clinical effectiveness (n = 17, 100%), Efficiency (n = 7, 77.8%), Equitability (n = 7, 77.8%) and Safety (n = 6, 66.7%). Timeliness and Accessibility were referred to by four and three (44.4% and 33.3%) articles, respectively.Review question 2: Thirty articles were included. The predominant source of articles was research literature (n = 23; 76.7%) originating mostly from the USA (n = 13; 43.3%). The most frequently applied QI development method was a form of consensus process (n = 15; 50%). A total of 526 QIs were identified. Of these, 283 (53.8%) were categorized as Clinical and 243 (46.2%) as System/Organizational QIs. Within these categories respectively, QIs related to Out-of-hospital cardiac arrest (n = 57; 10.8%) and Time intervals (n = 75; 14.3%) contributed the most. The most commonly addressed prehospital care quality attributes were Appropriateness (n = 250, 47.5%), Clinical effectiveness (n = 174, 33.1%) and Accessibility (n = 124, 23.6%). Most QIs were process indicators (n = 386, 73.4%).

CONCLUSION

Whilst there is paucity in research aiming to specifically define prehospital care quality, the attributes of generic healthcare quality definitions appear to be accepted and applicable to the prehospital context. There is growing interest in developing prehospital care QIs. However, there is a need for validation of existing QIs and de novo development addressing broader aspects of prehospital care.

Quality measurement in physician-staffed emergency medical services: a systematic literature review

Purpose

Quality measurement of physician-staffed emergency medical services (P-EMS) is necessary to improve service quality. Knowledge and consensus on this topic are scarce, making quality measurement of P-EMS a high-priority research area. The aim of this review was to identify, describe and evaluate studies of quality measurement in P-EMS.

Data sources

The databases of MEDLINE and Embase were searched initially, followed by a search for included article citations in Scopus.

Study selection

The study eligibility criteria were: (1) articles describing the use of one quality indicator (QI) or more in P-EMS, (2) original manuscripts, (3) articles published from 1 January 1968 until 5 October 2016. The literature search identified 4699 records. 4543 were excluded after reviewing title and abstract. An additional 129 were excluded based on a full-text review. The remaining 27 papers were included in the analysis. Methodological quality was assessed using an adapted critical appraisal tool.

Data extraction

The description of used QIs and methods of quality measurement was extracted. Variables describing the involved P-EMSs were extracted as well.

Results of data synthesis

In the included papers, a common understanding of which QIs to use in P-EMS did not exist. Fifteen papers used only a single QI. The most widely used QIs were ‘Adherence to medical protocols’, ‘Provision of advanced interventions’, ‘Response time’ and ‘Adverse events’.

Conclusion

The review demonstrated a lack of shared understanding of which QIs to use in P-EMS. Moreover, papers using only one QI dominated the literature, thus increasing the risk of a narrow perspective in quality measurement. Future quality measurement in P-EMS should rely on a set of consensus-based QIs, ensuring a comprehensive approach to quality measurement.

Defining a mission-based method to determine a HEMS unit's actual service area

Background

Geographical service areas are used as descriptive system indicators in Emergency Medical Service (EMS) related studies and reporting templates. The actual service area may differ significantly from administrative areas; this may lead to inaccuracy in determining indicator values, such as population or mission density, thus making it biased when comparing results between different areas and organizations.

The aim of this study was to introduce a univocal, repeatable and easily adaptable method to determine the actual service area of a helicopter emergency medical service (HEMS) unit for statistical, quality measurement and research purposes using widely available geographical information (GIS) and statistical analysis tools.

Methods

The method was first tested with Tampere HEMS unit. All accepted missions in 2017 were extracted from FinnHEMS database (FHDB). We calculated distance from HEMS base to each accepted mission location. Missions were reordered based on the distance and 99th and 95th percentiles were calculated for mission distances. Convex hulls including 100, 99 and 95% of the missions, and the population and area covered by these missions, were then calculated. The method was repeated for all Finnish HEMS bases.

Results

Approximately 90% of Tampere HEMS unit’s accepted missions took place within 100 km from the base. 10.9% of the missions occurred outside of the administrative service area. 95% convex hull areas are most in line with the everyday experience of where the units actually operate. In Tampere, the 95% convex hull area corresponds to 76,5% of the administrative area’s population and to 89,8% of its area. Calculating the 95% convex hull areas for all Finnish HEMS units results in service areas that overlap at some points, and some areas of the country fall outside of all HEMS service areas.

Conclusions

Administrative areas do not correspond to the actual service areas of HEMS units. The service area of a HEMS unit defined by administrative boundaries may differ significantly from actual operations. Using historical mission data to create a convex hull that incorporates mission locations could offer a standardized and comparable solution for determining actual HEMS unit service areas, which can be used for statistical comparison, quality measurement and system development.

The Danish helicopter emergency medical service database: high quality data with great potential

Background

The Danish Helicopter Emergency Medical Service (HEMS) is part of the Danish pre-hospital response offering advanced patient care on scene and during rapid transport to definitive care.

Monitoring HEMS performance and the quality of critical care has high national as well as international priority underlining the need for research in this field.

The data quality of the Danish HEMS database is unknown. Furthermore, a set of quality indicators (QI) developed by an international collaboration group (EQUIPE) potentially for use in physician-staffed EMS, has recently been presented.

The aim of the current study was to present the design and data quality of the Danish helicopter database, and to evaluate the coverage of available variables in the database according to the QIs proposed.

Method

The study included all helicopter dispatches between October 1st 2014 and April 30th 2018.

The database layout and data entering procedure, as well as the key variables and data completeness were described. Furthermore, missing data and misclassifications were addressed.

Lastly, the 26 QIs proposed by the EQUIPE-collaboration were evaluated for coverage in the HEMS database.

Results

A total of 13,392 missions were included in the study. The database includes a broad spectrum of mission- and patient-specific data related to the pre-hospital pathway of acutely ill or injured patients in a national coverage. Missing data for the majority of variables is less than 6.5%. The percentage of completed report forms has increased over time and reached 99.9% in 2018.

Misclassification were observed for 294 patients in the study period corresponding to 3,7%.

Less than half of the QIs proposed by the EQUIPE-collaboration group were directly available from the database.

Conclusions

Helicopter Emergency Medical Services in Denmark are a new and sparsely investigated health care provider. The database contains nearly all missions dispatched by the five regional Emergency Medical Dispatch Centres. Generally, the data quality is considered high with great potential for future research.

Potential quality indicators as proposed by the EQUIPE-collaboration group could inspire the configuration and design of the next version of Hemsfile creating an even more solid basis for research and quality improvement.

Electronic supplementary material

The online version of this article (10.1186/s13049-019-0615-5) contains supplementary material, which is available to authorized users.

A BRILL idea? The benefits, risks, insights, learning and limitations of an emergency airway registry in pre-hospital and retrieval medicine

Airway management is a cornerstone of emergency care. Development of a robust evidence base to support the practice of pre-hospital emergency anaesthesia is key to the safety and evolution of this common but high-risk procedure. This paper discusses the benefits, risks, insights, learning and limitations of the use of an airway registry in pre-hospital and retrieval medicine, for both research and quality improvement purposes.

Prehospital response to respiratory distress by the public ambulance system in a Ukrainian city

BACKGROUND

The capability of the public ambulance system in Ukraine to address urgent medical complaints in a prehospital environment is unknown. Evaluation using reliable sources of patient data is needed to provide insight into current treatments and outcomes.

METHODS

We obtained access to de-identified computer records from the emergency medical services (EMS) dispatch center in Poltava, a medium-sized city in central Ukraine. Covering a five-month period, we retrieved data for urgent calls with a patient complaint of respiratory distress. We evaluated ambulance response and treatment times, field diagnoses, and patient disposition, and analyzed factors related to fatal outcomes.

RESULTS

Over the five-month period of the study, 2,029 urgent calls for respiratory distress were made to the Poltava EMS dispatch center. A physician-led ambulance typically responded within 10 minutes. Seventy-seven percent of patients were treated and released, twenty percent were taken to hospital, and three percent died in the prehospital phase. On univariate analysis, age over 60 and altered mental status at the time of the call were strongly associated with a fatal outcome.

CONCLUSION

The EMS dispatch center in a medium-sized city in Ukraine has adequate organizational infrastructure to ensure that a physician-led public ambulance responds rapidly to complaints of respiratory distress. That EMS system was able to manage most patients without requiring hospital admission. However, a prehospital fatality rate of three percent suggests that further research is warranted to determine training, equipment, or procedural needs of the public ambulance system to manage urgent medical conditions.

Emergency Patients' and Family Members' Experiences of Nonconveyance Situations and Counseling Received From Care Providers

Making nonconveyance decisions can be demanding for care providers in prehospital emergency services. Studies have found homecare instructions and counseling of patients and family members partly insufficient. A descriptive cross-sectional design was applied for this pilot study to explore emergency patients' and family members' experiences of nonconveyance situations and counseling. Data were collected by questionnaires from acutely ill patients (n = 97) treated on-site and not transported to hospital and from their family members (n = 72) in 2015-2016. Responses to quantified statements were analyzed statistically, whereas responses to open questions were analyzed using qualitative inductive content analysis. Patients and family members had mostly received verbal home care instructions. Just more than 10% of patients found the instructions insufficient for their coping at home. Male patients were slightly more satisfied with counseling than female patients. One-fifth of female patients but only 6% of male patients were dissatisfied with nonconveyance decisions. In family members, the proportion of dissatisfied respondents was 14%. Older patients were more often dissatisfied than younger patients. Although the majority of the respondents were satisfied with the emergency medical services in general, patients suggested that home care instructions, staff competence, and availability of ambulances should be improved and resources and attention given to patients' opinions increased. Family members proposed more careful assessment of conveyance needs, increased resources, and attention given to the patient. The results highlight the importance of developing a more family-centered approach to emergency care.

Static Rope Evacuation by Helicopter Emergency Medical Services in Rescue Operations in Southeast Norway

INTRODUCTION

Physician-staffed helicopter emergency medical services (HEMS) in Norway are an adjunct to existing search and rescue services. Our aims were to study the epidemiological, operational, and medical aspects of HEMS daylight static rope operations performed in the southeastern part of the country and to examine several quality dimensions that are characteristic of this service.

METHODS

We reviewed the static rope operations performed at 3 HEMS bases during a 3-y period and applied a set of quality indicators designed for physician-staffed emergency medical services to evaluate the quality of care. Data are presented as medians with quartiles, except National Advisory Committee for Aeronautics (NACA) scores, which are presented as mean (SD).

RESULTS

Fifty-nine static rope operations were identified, involving 60 patients. Median (quartiles) age was 43 (27-55) y. Median (quartiles) take-off time was 9 (5-13) min. Trauma-related injuries were found in 48 patients. The main conditions were lower limb injuries, found in 32 patients. Ten patients experienced medical conditions. Mean (SD) NACA score was 3.3 (1.3). A potential or actual life-threatening diagnosis (NACA score: 4-6) was reported among 15 patients. The main interventions were intravenous lines (19 patients), analgesics (17), and oxygen treatment (14). Four patients were intubated, and 1 thoracostomy was performed.

CONCLUSIONS

Static rope operations are rarely performed. The quality indicators suggest that the service is safe, available, and equitable. Its main benefit seems to be evacuation and the maintenance of readiness before rapid transport of the physician to the scene or the patient to the hospital.

Prioritizing novel and existing ambulance performance measures through expert and lay consensus: A three-stage multimethod consensus study

Background

Current ambulance quality and performance measures, such as response times, do not reflect the wider scope of care that services now provide. Using a three‐stage consensus process, we aimed to identify new ways of measuring ambulance service quality and performance that represent service provider and public perspectives.

Design

A multistakeholder consensus event, modified Delphi study, and patient and public consensus workshop.

Setting and participants

Representatives from ambulance services, patient and public involvement (PPI) groups, emergency care clinical academics, commissioners and policymakers.

Results

Nine measures/principles were highly prioritized by >75% of consensus event participants, including measures relating to pain, patient experience, accuracy of dispatch decisions and patient safety. Twenty experts participated in two Delphi rounds to further refine and prioritize measures; 20 measures in three domains scored ≥8/9, indicating good consensus, including proportion of calls correctly prioritized, time to definitive care and measures related to pain. Eighteen patient/public representatives attended a consensus workshop, and six measures were identified as important. These include time to definitive care, response time, reduction in pain scores, calls correctly prioritized to appropriate levels of response and survival to hospital discharge for treatable emergency conditions.

Conclusions

Using consensus methods, we identified a shortlist of ambulance outcome and performance measures that are important to ambulance clinicians and service providers, service users, commissioners, and clinical academics, reflecting current pre‐hospital ambulance care and services. The measures can potentially be used to assess pre‐hospital quality or performance over time, with most calculated using routinely available data.

AAGBI: Safer pre-hospital anaesthesia 2017: Association of Anaesthetists of Great Britain and Ireland

Pre-hospital emergency anaesthesia with oral tracheal intubation is the technique of choice for trauma patients who cannot maintain their airway or achieve adequate ventilation. It should be carried out as soon as safely possible, and performed to the same standards as in-hospital emergency anaesthesia. It should only be conducted within organisations with comprehensive clinical governance arrangements. Techniques should be straightforward, reproducible, as simple as possible and supported by the use of checklists. Monitoring and equipment should meet in-hospital anaesthesia standards. Practitioners need to be competent in the provision of in-hospital emergency anaesthesia and have supervised pre-hospital experience before carrying out pre-hospital emergency anaesthesia. Training programmes allowing the safe delivery of pre-hospital emergency anaesthesia by non-physicians do not currently exist in the UK. Where pre-hospital emergency anaesthesia skills are not available, oxygenation and ventilation should be maintained with the use of second-generation supraglottic airways in patients without airway reflexes, or basic airway manoeuvres and basic airway adjuncts in patients with intact airway reflexes.

Counseling patients and family members in out-of-hospital emergency situations: a survey for emergency staff

Background

Not much is known about emergency care delivered in patients’ homes or other out-of-hospital settings. This study aims to describe out-of-hospital emergency staff’s experiences of encountering and counseling patients and their family members.

Methods

A descriptive cross-sectional design was applied. Data were collected from a hospital district in Finland from emergency care staff via an electronic survey questionnaire specifically developed for this purpose (N = 125, N = 142 reponse rate 59%, response rate 53%) and analyzed using descriptive statistics.

Results

Respondents succeeded in encountering (up to 3.88/4) and counseling (up to 3.89/4) patients and family members. Challenges were related to introducing themselves to family members (3.20/4), to interacting with patients from different cultures (3.38/4) and to allowing family members to be present in care situations (2.29/4). Providing emotional support (2.56/4), especially to family members, and confirming (3.16/4) and ensuring continuity of care instructions (3.00/4) were found to be challenging.

Conclusions

High-level counseling in acute out-of-hospital situations demands that care providers can put themselves into the patient’s and family’s situation, ensure follow-up care and provide care instructions to both patients and families. The presence and participation of family members is essential in acute care situations outside hospital contexts. Ensuring that these contents are included and practiced during basic and continuing emergency care education for nurses and other emergency staff is crucial for developing counseling practices.

Developing quality indicators for physician-staffed emergency medical services: a consensus process

Background

There is increasing interest for quality measurement in health care services; pre-hospital emergency medical services (EMS) included. However, attempts of measuring the quality of physician-staffed EMS (P-EMS) are scarce. The aim of this study was to develop a set of quality indicators for international P-EMS to allow quality improvement initiatives.

Methods

A four-step modified nominal group technique process (expert panel method) was used.

Results

The expert panel reached consensus on 26 quality indicators for P-EMS. Fifteen quality indicators measure quality of P-EMS responses (response-specific quality indicators), whereas eleven quality indicators measure quality of P-EMS system structures (system-specific quality indicators).

Discussion

When measuring quality, the six quality dimensions defined by The Institute of Medicine should be appraised. We argue that this multidimensional approach to quality measurement seems particularly reasonable for services with a highly heterogenic patient population and complex operational contexts, like P-EMS. The quality indicators in this study were developed to represent a broad and comprehensive approach to quality measurement of P-EMS.

Conclusions

The expert panel successfully developed a set of quality indicators for international P-EMS. The quality indicators should be prospectively tested for feasibility, validity and reliability in clinical datasets. The quality indicators should then allow for adjusted quality measurement across different P-EMS systems.

Electronic supplementary material

The online version of this article (doi:10.1186/s13049-017-0362-4) contains supplementary material, which is available to authorized users.

Factors Affecting Quality of Emergency Service in Iran's Military Hospitals: A Qualitative Study

INTRODUCTION

Quality is a key factor for the success of any organization. Moreover, accessing quality in the emergency department is highly significant due to the sensitive and complex role of this department in hospitals as well as the healthcare and medical treatment system. This study aimed to identify, from the perspective of medical experts and nurses serving in the military health and medical treatment system, the factors that affect the quality of emergency service provided in selected military hospitals in Iran.

METHODS

This qualitative research was performed in Valiaser Hospital of Tehran (Iran) in 2015, using the framework analysis method. The purposive sampling technique was used for data collection. A total of 14 participants included two emergency medicine specialists, four general physicians, two senior nurses (holding M.Sc. degrees), and six nurses (holding B.Sc. degree). Data were collected through semistructured interviews. Sampling continued until data saturation occurred. The Atlas/Ti software was employed for data analysis.

RESULTS

Four basic themes emerged as the effective factors on the quality of emergency services, namely, structural themes, process/performance themes, outcome themes, and environmental/contextual themes. Moreover, through a framework analysis, 47 subthemes were specified and summarized as indicators of the different aspects of the main themes.

CONCLUSION

The factors affecting the quality of emergency services in Iran's selected military hospitals are especially complicated due to the diversity of the missions involved; thus, different factors can influence this quality. Therefore, an effort should be made to tackle the existing obstacles, facilitate the identification of these effective factors, and promotion of the quality of healthcare services.

Pre-Hospital Emergency in Iran: A Systematic Review

CONTEXT

Pre-hospital care plays a vital role in saving trauma patients.

OBJECTIVES

This study aims to review studies conducted on the pre-hospital emergency status in Iran.

DATA SOURCES

Data were sourced from Iranian electronic databases, including SID, IranMedex, IranDoc, Magiran, and non-Iranian electronic databases, such as Medline, Embase, Cochrane Library, Scopus, and Google Scholar. In addition, available data and statistics for the country were used.

DATA SELECTION

All Persian-language articles published in Iranian scientific journals and related English-language articles published in Iranian and non-Iranian journals indexed on valid sites for September 2005 - 2014 were systematically reviewed.

DATA EXTRACTION

To review the selected articles, a data extraction form developed by the researchers as per the study's objective was adopted. The articles were examined under two categories: structure and function of pre-hospital emergency.

RESULTS

A total of 19 articles were selected, including six descriptive studies (42%), four descriptive-analytical studies (21%), five review articles (16%), two qualitative studies (10.5%), and two interventional (experimental) studies (10.5%). In addition, of these, 14 articles (73.5%) had been published in the English language. The focus of these selected articles were experts (31.5%), bases of emergency medical services (26%), injured (16%), data reviews (16%), and employees (10.5%). A majority of the studies (68%) investigated pre-hospital emergency functions and 32% reviewed the pre-hospital emergency structure.

CONCLUSIONS

The number of studies conducted on pre-hospital emergency services in Iran is limited. To promote public health, consideration of prevention areas, processes to provide pre-hospital emergency services, policymaking, foresight, systemic view, comprehensive research programs and roadmaps, and assessments of research needs in pre-hospital emergency seem necessary.

Combined quality function deployment and logical framework analysis to improve quality of emergency care in Malta

Purpose

– The purpose of this paper is to develop an integrated patient-focused analytical framework to improve quality of care in accident and emergency (A & E) unit of a Maltese hospital.

Design/methodology/approach

– The study adopts a case study approach. First, a thorough literature review has been undertaken to study the various methods of healthcare quality management. Second, a healthcare quality management framework is developed using combined quality function deployment (QFD) and logical framework approach (LFA). Third, the proposed framework is applied to a Maltese hospital to demonstrate its effectiveness. The proposed framework has six steps, commencing with identifying patients’ requirements and concluding with implementing improvement projects. All the steps have been undertaken with the involvement of the concerned stakeholders in the A & E unit of the hospital.

Findings

– The major and related problems being faced by the hospital under study were overcrowding at A & E and shortage of beds, respectively. The combined framework ensures better A & E services and patient flow. QFD identifies and analyses the issues and challenges of A & E and LFA helps develop project plans for healthcare quality improvement. The important outcomes of implementing the proposed quality improvement programme are fewer hospital admissions, faster patient flow, expert triage and shorter waiting times at the A & E unit. Increased emergency consultant cover and faster first significant medical encounter were required to start addressing the problems effectively. Overall, the combined QFD and LFA method is effective to address quality of care in A & E unit.

Practical/implications

– The proposed framework can be easily integrated within any healthcare unit, as well as within entire healthcare systems, due to its flexible and user-friendly approach. It could be part of Six Sigma and other quality initiatives.

Originality/value

– Although QFD has been extensively deployed in healthcare setup to improve quality of care, very little has been researched on combining QFD and LFA in order to identify issues, prioritise them, derive improvement measures and implement improvement projects. Additionally, there is no research on QFD application in A & E. This paper bridges these gaps. Moreover, very little has been written on the Maltese health care system. Therefore, this study contributes demonstration of quality of emergency care in Malta.

[Instrument for assessing the quality of mobile emergency pre-hospital care: content validation]

OBJECTIVES

To validate an instrument to assess quality of mobile emergency pre-hospital care.

METHOD

A methodological study where 20 professionals gave their opinions on the items of the proposed instrument. The analysis was performed using Kappa test (K) and Content Validity Index (CVI), considering K> 0.80 and CVI ≥ 0.80.

RESULTS

Three items were excluded from the instrument: Professional Compensation; Job Satisfaction and Services Performed. Items that obtained adequate K and CVI indexes and remained in the instrument were: ambulance conservation status; physical structure; comfort in the ambulance; availability of material resources; user/staff safety; continuous learning; safety demonstrated by the team; access; welcoming; humanization; response time; costumer privacy; guidelines on care; relationship between professionals and costumers; opportunity for costumers to make complaints and multiprofessional conjunction/actuation.

CONCLUSION

The instrument to assess quality of care has been validated and may contribute to the evaluation of pre-hospital care in mobile emergency services.

Frequent callers to and users of emergency medical systems: a systematic review

BACKGROUND

There appears to be a paucity of studies examining the characteristics and impact of frequent users upon emergency medical services (EMS).

OBJECTIVE

To review current primary research on frequent users of EMS and to identify possible gaps in the literature.

METHODS

Ovid, PubMed and CINAHL/Medline were systematically searched for articles that were published in English and either referred to frequent callers to or users of an EMS, or referred to frequent users of other services where admissions were via ambulance. Studies were included regardless of quality.

FINDINGS

Eighteen studies were included. Ten were emergency department based, seven in EMS and one in a psychiatric emergency service. In emergency department studies, frequent users were more likely to arrive via ambulance than infrequent users. In EMS studies, between 0.2% and 23% of patients using EMS were frequent users accounting for 1.4% to 40% of all ambulance use. No two EMS studies used the same definition of a frequent user. No studies focused on characteristics of callers to EMS. Two studies explored interventions for frequent callers to EMS, with mixed results in reducing ambulance use.

DISCUSSION

It is unknown to what extent frequent callers impact upon EMS resources. Research should identify predictors and characteristics of frequent users of EMS, and a consistent definition of a frequent caller to or user of EMS would provide greater comparability. The lack of studies identified in this review suggests that further research is needed in order to inform policy and practice.