A qualitative study to identify barriers to local implementation of prehospital termination of resuscitation protocols

The Influencing Factors of Implementation in Emergency Medical Service Systems - A Scoping Review

OBJECTIVES: Emergency medical services (EMS) provide health care in situations with limited time and resources. Challenges arise when introducing novel medications, treatments, or technologies or modifying existing practices in these settings. Effective implementation strategies are pivotal for their success. This study aims to identify and categorize potential facilitators and barriers in the implementation of prehospital EMS through a review of relevant research articles.METHODS: We searched PubMed and EMbase to identify studies published before December 2023, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for our search strategy and scoping review. We included original articles written in English that report on the factors that influence the implementation in prehospital settings. We extracted and categorized the factors into different themes.RESULTS: Out of the 371 retrieved papers, we selected 19 (5%) for inclusion in this review. We extracted 46 influencing factors from the selected articles and categorized them into ten themes: (1) Outer system, (2) Inner system, (3) Practitioner characteristics, (4) Resources, (5) Communication and collaboration, (6) Patient factors, (7) Intervention characteristics, (8) De-implementation of prior practices, (9) Logistical issues, and (10) Quality improvement.CONCLUSIONS: This study examined the literature on EMS implementation factors and proposed a 10-theme EMS model framework. Key factors include training/education, equipment/tools, communication with hospitals, and practitioners' attitudes.

Ongoing CPR with an onboard physician

Introduction

Recent data are not available on ongoing CPR for emergency services with an onboard physician. The aim of the present study was to identify factors associated with the decision to transport patients to hospital with ongoing CPR and examine their survival to hospital discharge with good neurological status.

Methods

An observational study based on a registry of out-of-hospital cardiac arrests attended to by emergency services with an onboard physician. All OHCA cases occurring between the 1st of January and the 31st of December 2022 were included. Patients receiving ongoing CPR during transport to the hospital were compared with patients pronounced dead at the scene following arrival of the care team. The dependent variable was ongoing CPR during transport to the hospital. The main characteristics and the neurological status of patients surviving to discharge were described.

Results

A total of 9321 cases were included, of which 350 (3.7%) were transported to hospital with ongoing CPR. Such patients were young (59.9 ± 20.1 years vs 64.6 ± 16.9 years; p < 0.001; 95%CI: 0.98 [0.98; 0.99]) with arrest taking place outside of the home (151 [44.5%] vs 4045 [68.01%]; p < 0.001; 95%CI: 0.41 [0.31; 0.54]) and being witnessed by EMS (126 [36.0%] vs 667 [11.0%]; p < 0.001; 95%CI: 4.31 [3.19; 5.80]), whilst initial rhythm differed from asystole (164 [47.6%] vs 4325 [73.0%]; p < 0.01; 95%CI: 0.44 [0.33; 0.60]) and a mechanical device was more often employed during resuscitation and transport to hospital (199 [56.9%] vs 2050 [33.8%]; p < 0.001; 95%CI: 2.75 [2.10; 3.59]). Seven patients (2%) were discharged alive from hospital, five with ad integrum neurological recovery (CPC1) and two with minimally impaired neurological function (CPC2).

Conclusions

The strategy of ongoing CPR is uncommon in EMS with an onboard physician. Despite their limited efficacy, the availability of mechanical chest compression devices, together with the possibility of specific hospital treatments, mainly ICP and ECMO, opens up the possibility of this approach with determined patients.

The Current Discussion Regarding End-of-Life Care for Patients with Out-of-Hospital Cardiac Arrest with Initial Non-Shockable Rhythm: A Narrative Review

Despite recent advances in resuscitation science, outcomes in patients with out-of-hospital cardiac arrest (OHCA) with initial non-shockable rhythm remains poor. Those with initial non-shockable rhythm have some epidemiological features, including the proportion of patients with a witnessed arrest, bystander cardiopulmonary resuscitation (CPR), age, and presumed etiology of cardiac arrest have been reported, which differ from those with initial shockable rhythm. The discussion regarding better end-of-life care for patients with OHCA is a major concern among citizens. As one of the efforts to avoid unwanted resuscitation, advance directive is recognized as a key intervention, safeguarding patient autonomy. However, several difficulties remain in enhancing the effective use of advance directives for patients with OHCA, including local regulation of their use, insufficient utilization of advance directives by emergency medical services at the scene, and a lack of established tools for discussing futility of resuscitation in advance care planning. In addition, prehospital termination of resuscitation is a common practice in many emergency medical service systems to assist clinicians in deciding whether to discontinue resuscitation. However, there are also several unresolved problems, including the feasibility of implementing the rules for several regions and potential missed survivors among candidates for prehospital termination of resuscitation. Further investigation to address these difficulties is warranted for better end-of-life care of patients with OHCA.

International Initiation and Termination of Resuscitation Practices

BACKGROUND

Substantial variation in survival following out-of-hospital cardiac arrest is described both internationally and nationally. The Utstein factors account for half of the variation, but the remaining is not fully understood. Local regulations or guidelines concerning the withholding and termination of resuscitation may influence the reporting of cardiac arrests when comparing outcomes between different EMS systems.

METHOD

We have developed an online cross-sectional mixed-methods explanatory design survey aimed at describing the international and national variations in the initiation, the termination of resuscitation, and the refraining from resuscitation of adult patients (>18 years of age) suffering from non-traumatic OHCA. The respondents will be national experts and the questionnaire will be distributed among members of EUPHOREA, the International Liaison Committee of Resuscitation (ILCOR), the European Resuscitation Council, and the Resuscitation Academy. Each invited country will have to identify at least two national experts with special expertise in prehospital resuscitation practices. We exclude countries with less than two respondents.

RESULTS

The survey will provide both quantitative and qualitative data. Quantitative data will be presented as frequencies and proportions. Qualitative data will be analyzed using content analysis.

CONCLUSION

This survey could be of importance in understanding the multiple factors leading to the substantial variation in survival found following OHCA. Furthermore, the interpretation of future studies on OHCA from different settings may be improved to further increase survival following OHCA.

Non-medical factors in prehospital resuscitation decision-making: a mixed-methods systematic review

Aim

This systematic review explored how non-medical factors influence the prehospital resuscitation providers’ decisions whether or not to resuscitate adult patients with cardiac arrest.

Methods

We conducted a mixed-methods systematic review with a narrative synthesis and searched for original quantitative, qualitative, and mixed-methods studies on non-medical factors influencing resuscitation of out-of-hospital cardiac arrest. Mixed-method reviews combine qualitative, quantitative, and mixed-method studies to answer complex multidisciplinary questions. Our inclusion criteria were peer-reviewed empirical-based studies concerning decision-making in prehospital resuscitation of adults > 18 years combined with non-medical factors. We excluded commentaries, case reports, editorials, and systematic reviews. After screening and full-text review, we undertook a sequential exploratory synthesis of the included studies, where qualitative data were synthesised first followed by a synthesis of the quantitative findings.

Results

We screened 15,693 studies, reviewed 163 full-text studies, and included 27 papers (12 qualitative, two mixed-method, and 13 quantitative papers). We identified five main themes and 13 subthemes related to decision-making in prehospital resuscitation. Especially the patient’s characteristics and the ethical aspects were included in decisions concerning resuscitation. The wishes and emotions of bystanders further influenced the decision-making. The prehospital resuscitation providers’ characteristics, experiences, emotions, values, and team interactions affected decision-making, as did external factors such as the emergency medical service system and the work environment, the legislation, and the cardiac arrest setting. Lastly, prehospital resuscitation providers’ had to navigate conflicts between jurisdiction and guidelines, and conflicting values and interests.

Conclusions

Our findings underline the complexity in prehospital resuscitation decision-making and highlight the need for further research on non-medical factors in out-of-hospital cardiac arrest.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13049-022-01004-6.

Prognostic value of changes in the cardiac arrest rhythms from the prehospital stage to the emergency department in out-of-hospital cardiac arrest patients without prehospital returns of spontaneous circulation: A nationwide observational study

Background

This study aimed to assess the prognostic value of the changes in cardiac arrest rhythms from the prehospital stage to the ED (emergency department) in out-of-hospital cardiac arrest (OHCA) patients without prehospital returns of spontaneous circulation (ROSC).

Methods

This retrospective analysis was performed using nationwide population-based OHCA data from South Korea between 2012 and 2016. Patients with OHCA with medical causes and without prehospital ROSC were included and divided into four groups according to the nature of their cardiac arrest rhythms (shockable or non-shockable) in the prehospital stage and in the ED: (1) the shockable and shockable (Shock-Shock) group, (2) the shockable and non-shockable (Shock-NShock) group, (3) the non-shockable and shockable (NShock-Shock) group, and (4) the non-shockable and non-shockable (NShock-NShock) group. The presence of a shockable rhythm was confirmed based on the delivery of an electrical shock. Propensity score matching and multivariate logistic regression analyses were used to assess the effect of changes in the cardiac rhythms on patient outcomes. The primary outcome was sustained ROSC in the ED; the secondary outcomes were survival to hospital discharge and good neurological outcomes at hospital discharge.

Results

After applying the exclusion criteria, 51,060 eligible patients were included in the study (Shock-Shock, 4223; Shock-NShock, 3060; NShock-Shock, 11,509; NShock-NShock, 32,268). The propensity score-matched data were extracted from the six comparative subgroups. For sustained ROSC in the ED, Shock-Shock showed a higher likelihood than Shock-NShock (P <0.01) and NShock-NShock (P <0.01), Shock-NShock showed a lower likelihood than NShock-Shock (P <0.01) and NShock-NShock (P <0.01), NShock-Shock showed a higher likelihood NShock-NShock (P <0.01). For survival to hospital discharge, Shock-Shock showed a higher likelihood than Shock-NShock (P <0.01), NShock-Shock (P <0.01), and NShock-NShock (P <0.01), Shock-NShock showed a higher likelihood than NShock-Shock (P <0.01) and NShock-NShock (P <0.01), of sustained ROSC in the ED. For good neurological outcomes, Shock-Shock showed higher likelihood than Shock-NShock (P <0.01), NShock-Shock (P <0.01), and NShock-NShock (P <0.01), Shock-NShock showed better likelihood than NShock-NShock (P <0.01), NShock-Shock showed a better likelihood than NShock-NShock (P <0.01).

Conclusion

Sustained ROSC in the ED may be expected for patients with shockable rhythms in the ED compared with those with non-shockable rhythms in the ED. For the clinical outcomes, survival to hospital discharge and neurological outcomes, patients with Shock-Shock showed the best outcome, whereas patients with NShock-NShock showed the poorest outcome and Shock-NShock showed a higher likelihood of achieving survival to hospital discharge with no significant differences in the neurological outcomes compared with NShock-Shock.

Factors associated with prolonged cardiopulmonary resuscitation attempts in out-of-hospital cardiac arrest patients presenting to the emergency department

BACKGROUND

There is high variability among clinicians' decision of appropriate cardiopulmonary resuscitation (CPR) duration before deciding for termination of resuscitation. This study attempted to investigate factors associated with the decision to prolong resuscitation attempts in cardiac arrest patients treated in an emergencydepartment (ED).

METHODS

A retrospective study that evaluated two years of mortality registry starting in 2015 was conducted in the ED of University Kebangsaan Malaysia Medical Centre (UKMMC), Kuala Lumpur, Malaysia. Adult out-hospital cardiac arrest (OHCA) patients treated in the ED were included. Multivariate logistic regression analysis was utilized for the exploration of factors associated with prolonged CPR attempts (> 30min).

RESULTS

The median CPR duration was 24min (range 2-68min). Four variables were independently associated with prolonged CPR attempts: younger age (OR, 0.97; 95% CI, 0.95-0.99; p<0.001), pre-existing heart disease (OR, 1.97; 95% CI, 1.07-3.65; p=0.031), occurrence of transient return of spontaneous circulation (ROSC) (OR, 2.38; 95% CI, 1.05-5.36; p=0.037), and access to the ED by nonemergency medical services (EMS) transport (OR, 1.92; 95% CI, 1.09-3.37; p=0.024).

CONCLUSION

Patient-related and access-related factors were associated with prolonged CPR attempts among OHCA patients resuscitated in the ED.

Prehospital providers' perspectives for clinical practice guideline implementation and dissemination: Strengthening guideline uptake in South Africa

BACKGROUND

In 2016 the first African emergency care clinical practice guideline (CPG) was developed for national uptake in the prehospital sector in South Africa, with implementation starting in 2018. Comprehensive uptake of CPGs post development is not a given, as this requires effective and efficient dissemination and implementation strategies that take into account the perceptions, barriers and facilitators of the local end-users. This study aimed to identify prehospital end-users' perceptions of the emergency care guidelines, including barriers and facilitators for national decision makers, to strengthen CPG uptake in South Africa.

METHODS

Our study employed a descriptive qualitative research design, including nine focus groups with 56 operational emergency care providers across four major provinces in South Africa. Data was analysed using thematic analysis in ATLAS.ti. Ethics approval was provided by Stellenbosch University.

RESULTS

Themes related to provider perceptions, expectations and guideline uptake emerging from the data was unofficial and unclear communication, broadening versus limiting guideline expectations, conflicted personal reactions and spreading the word. Challenges to dissemination and implementation included poor communication, changes to scope of practice, and limited capacity to upskill existing providers. Facilitators included using technology for end-user documents, local champions to support change, establishing online and modular training, and implementation by independent decision makers.

CONCLUSION

This study provides an overview of the perceptions of operational emergency care providers and how their experiences of hearing about and engaging with the guidelines, in their industry, can contribute to the dissemination, implementation and uptake of emergency care guidelines. In order to disseminate and implement an emergency care CPG, decision makers must take into account the perceptions, barriers, and facilitators of local end-users.

The Ethics of Real-Time EMS Direction: Suggested Curricular Content

Ethical dilemmas can create moral distress in even the most experienced emergency physicians (EPs). Following reasonable and justified approaches can help alleviate such distress. The purpose of this article is to guide EPs providing Emergency Medical Services (EMS) direction to navigate through common ethical issues confronted in the prehospital delivery of care, including protecting privacy and confidentiality, decision-making capacity and refusal of treatment, withholding of treatment, and termination of resuscitation (TOR). This requires a strong foundation in the principles and theories underlying sound ethical decisions that EPs and prehospital providers make every day in good faith, but will now also make with more awareness and conscientiousness.

BrennerJM, AsweganAL, VearrierLE, BasfordJB, IsersonKV. The ethics of real-time EMS direction: suggested curricular content. Prehosp Disaster Med. 2018;33(2):201–212.

Implementing Prehospital Evidence-Based Guidelines: A Systematic Literature Review

OBJECTIVE

As prehospital research advances, more evidence-based guidelines (EBGs) are implemented into emergency medical services (EMS) practice. However, incomplete or suboptimal prehospital EBG implementation may hinder improvement in patient outcomes. To inform future efforts, this study's objective was to review existing evidence pertaining to prehospital EBG implementation methods.

METHODS

This study was a systematic literature review and evaluation following the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. PubMed, EMBASE, Scopus, and Google Advanced Search were searched without language or publication date filters for articles addressing prehospital EBG implementation. Conference proceedings, textbooks, and non-English articles were excluded. GRADE was applied to the remaining articles independently by three of five study investigators. Study characteristics and salient findings from the included articles are reported.

RESULTS

The systematic literature review identified 1,367 articles, with 41 meeting inclusion criteria. Most articles described prehospital EBG implementation (n = 24, 59%), or implementation barriers (n = 13, 32%). Common study designs were statement documents (n = 12, 29%), retrospective cohort studies (n = 12, 29%), and cross-sectional studies (n = 9, 22%). Using GRADE, evidence quality was rated low (n = 18, 44%), or very low (n = 23, 56%). Salient findings from the articles included: (i) EBG adherence and patient outcomes depend upon successful implementation, (ii) published studies generally lack detailed implementation methods, (iii) EBG implementation takes longer than planned (mostly for EMS education), (iv) EMS systems' heterogeneity affects EBG implementation, and (v) multiple barriers limit successful implementation (e.g., financial constraints, equipment purchasing, coordination with hospitals, and regulatory agencies). This review found no direct evidence for best prehospital EBG implementation practices. There were no studies comparing implementation methods or implementation in different prehospital settings (e.g., urban vs. rural, advanced vs. basic life support).

CONCLUSIONS

While prehospital EBG implementation barriers are well described, there is a paucity of evidence for optimal implementation methods. For scientific advances to reach prehospital patients, EBG development efforts must translate into EMS practice. Future research should consider comparing implementation methodologies in different prehospital settings, with a goal of defining detailed, reproducible best practices.

Cardiac arrest risk standardization using administrative data compared to registry data

BACKGROUND

Methods for comparing hospitals regarding cardiac arrest (CA) outcomes, vital for improving resuscitation performance, rely on data collected by cardiac arrest registries. However, most CA patients are treated at hospitals that do not participate in such registries. This study aimed to determine whether CA risk standardization modeling based on administrative data could perform as well as that based on registry data.

METHODS AND RESULTS

Two risk standardization logistic regression models were developed using 2453 patients treated from 2000-2015 at three hospitals in an academic health system. Registry and administrative data were accessed for all patients. The outcome was death at hospital discharge. The registry model was considered the "gold standard" with which to compare the administrative model, using metrics including comparing areas under the curve, calibration curves, and Bland-Altman plots. The administrative risk standardization model had a c-statistic of 0.891 (95% CI: 0.876-0.905) compared to a registry c-statistic of 0.907 (95% CI: 0.895-0.919). When limited to only non-modifiable factors, the administrative model had a c-statistic of 0.818 (95% CI: 0.799-0.838) compared to a registry c-statistic of 0.810 (95% CI: 0.788-0.831). All models were well-calibrated. There was no significant difference between c-statistics of the models, providing evidence that valid risk standardization can be performed using administrative data.

CONCLUSIONS

Risk standardization using administrative data performs comparably to standardization using registry data. This methodology represents a new tool that can enable opportunities to compare hospital performance in specific hospital systems or across the entire US in terms of survival after CA.

EMS Provider Perceptions on Termination of Resuscitation in a Large, Urban EMS System

OBJECTIVE

Despite the value of out-of-hospital Termination of Resuscitation (TOR) and the scientific evidence in favor of this practice, TOR has not been uniformly adopted or consistently practiced in EMS systems. Previous focus group studies have identified multiple barriers to implementation of out of hospital TOR but existing literature on EMS provider perceptions is limited. We sought to identify EMS providers' perceived barriers to performing out-of-hospital TOR in a large urban EMS system.

METHODS

The Chicago EMS System is a regional collaborative of EMS physicians, nurses and provider agencies, including the Chicago Fire Department (CFD), which provides exclusive emergency response for 9-1-1 calls in Chicago. CFD is an urban, fire-based EMS agency with a tiered response, with fire-fighter EMTs and paramedics providing initial care, and single role paramedics providing supplemental care and transport. A 2-page written survey was distributed to understand providers' experiences with managing OHCA and perceived barriers to TOR to inform subsequent improvements in protocol development and education.

RESULTS

Of 3500 EMS providers that received the survey, 2309 were completed (66%). Survey respondent demographics were fire-fighter/EMTB (69%), fire-fighter/paramedic (14%), and single role paramedic (17%). The most frequent barrier to field TOR was scene safety (86%). The most common safety issue identified was family reaction to TOR (68%) and many providers felt threatened by family when trying to perform TOR (38%). Providers with a higher career numbers of OHCA were more likely to have felt threatened by the family (OR 6.70, 95% CI 2.99-15.00) and single role paramedics were more likely than FF/EMTBs to have felt threatened (OR 3.34, 95% CI 2.65-4.22). Barriers to delivering a death notification after TOR, include being uncomfortable or threatened with possible family reaction (52%) and family asking to continue the resuscitation (45%). There was lack of formal prior death notification training, the majority learned from colleagues through on the job training.

CONCLUSIONS

Our study identifies scene safety, death notification delivery, and lack of formal training in death notification as barriers that EMS providers face while performing TOR in a large urban EMS system. These findings informed educational and operational initiatives to overcome the identified provider level issues and improve compliance with TOR policies.

Tailored approach to sleep health education (TASHE): study protocol for a web-based randomized controlled trial

BACKGROUND

Obstructive sleep apnea (OSA) is a sleep disorder that disproportionately affects African Americans (hereafter referred to as blacks). Moreover, blacks may underutilize sleep services including overnight polysomnography. Thus, OSA among blacks may go undiagnosed and untreated, which has significant health consequences, including hypertension, diabetes, cognitive impairment, and daytime sleepiness.

DESIGN AND METHODS

This two-arm randomized controlled trial will assign 200 participants to a culturally and linguistically tailored web-based sleep educational platform. The website will be developed to ensure that the content is user friendly and that it is readable and acceptable by the target community. Participants will receive login information to a password-protected website and will have access to the website for 2 months. Study assessments will be collected at baseline, 2 months (post-enrollment) and at 6 months (follow-up). We will use qualitative and quantitative methods to develop tailored materials and to ascertain whether tailored materials will increase OSA knowledge and OSA health literacy by comparing blacks exposed to tailored materials versus those exposed to standard sleep health literature. We hypothesize that exposure to tailored OSA information will improve OSA health literacy.

DISCUSSION

Few studies have investigated the racial/ethnic disparities in relation to OSA screening and treatment comparing blacks and whites. Moreover, we know of no interventions designed to increase OSA knowledge and health literacy among blacks. Use of the Internet to disseminate health information is growing in this population. Thus, the Internet may be an effective means to increase OSA health literacy, thereby potentially increasing utilization of sleep-related services in this population.

TRIAL REGISTRATION

The study is registered at clinicaltrials.gov, reference number NCT02507089 . Registered on 21 July 2015.

A comparison of the universal TOR Guideline to the absence of prehospital ROSC and duration of resuscitation in predicting futility from out-of-hospital cardiac arrest

INTRODUCTION

The Universal Termination of Resuscitation (TOR) Guideline accurately identifies potential out-of-hospital cardiac arrest (OHCA) survivors. However, implementation is inconsistent with some Emergency Medical Service (EMS) agencies using absence of return of spontaneous circulation (ROSC) as sole criterion for termination.

OBJECTIVE

To compare the performance of the Universal TOR Guideline with the single criterion of no prehospital ROSC. Second, to determine factors associated with survival for patients transported without a ROSC. Lastly, to compare the impact of time to ROSC as a marker of futility to the Universal TOR Guideline.

DESIGN

Retrospective, observational cohort study.

PARTICIPANTS

Non-traumatic, adult (≥18 years) OHCA patients of presumed cardiac etiology treated by EMS providers.

SETTING

ROC-PRIMED and ROC-Epistry post ROC-PRIMED databases between 2007 and 2011.

OUTCOMES

Primary outcome was survival to hospital discharge and the secondary outcome was functional survival. We used multivariable regression to evaluate factors associated with survival in patients transported without a ROSC.

RESULTS

36,543 treated OHCAs occurred of which 9467 (26%) were transported to hospital without a ROSC. Patients transported without a ROSC who met the Universal TOR Guideline for transport had a survival of 3.0% (95% CI 2.5-3.4%) compared to 0.7% (95% CI 0.4-0.9%) in patients who met the Universal TOR Guideline for termination. The Universal TOR Guideline identified 99% of survivors requiring continued resuscitation and transportation to hospital including early identification of survivors who sustained a ROSC after extended durations of CPR.

CONCLUSION

Using absence of ROSC as a sole predictor of futility misses potential survivors. The Universal TOR Guideline remains a strong predictor of survival.

How do doctors and nurses manage delirium in intensive care units? A qualitative study using focus groups

OBJECTIVES

The aim of this study was to explore the experiences of doctors and nurses caring for patients with delirium in the intensive care unit (ICU) and to describe the process of delirium management.

SETTING

This study was performed in 5 ICUs located within 4 hospitals in Madrid (Spain).

PARTICIPANTS

Purposeful sampling was performed which included (1) doctors and nurses working in ICUs, (2) with >1 year experience in the ICU and (3) clinical experience with delirium. 38 professionals participated (19 doctors, 19 nurses), including 22 women and 16 men. The total mean age was 39 years.

DESIGN

A qualitative study using focus groups.

METHODS

7 focus groups were held to collect data: 3 nurse focus groups, 3 doctor focus groups and 1 mixed focus group. Each group comprised 6-10 participants. A semistructured questions guide was used. Thematic analysis methods were used to analyse the data.

RESULTS

3 themes were identified: (1) the professional perspective on delirium; (2) implementing pharmacological and non-pharmacological treatment for delirium and (3) work organisation in the ICU. The professionals regarded patients with delirium with uncertainty, and felt they were often underdiagnosed and poorly managed. Doctors displayed discrepancies regarding pharmacological prescriptions and decision-making. The choice of medication was determined by experience. Nurses felt that, for many doctors, delirium was not considered a matter of urgency in the ICU. Nurses encountered difficulties when applying verbal restraint, managing sleep disorders and providing early mobilisation. The lack of a delirium protocol generates conflicts regarding what type of care management to apply, especially during the night shift. A degree of group pressure exists which, in turn, influences the decision-making process and patient care.

CONCLUSIONS

Patients with delirium represent complex cases, requiring the implementation of specific protocols. These results serve to improve the process of care in patients with delirium.

Variation of current protocols for managing out-of-hospital cardiac arrest in prehospital settings among Asian countries

BACKGROUND/PURPOSE

Protocols for managing patients with out-of-hospital cardiac arrest (OHCA) may vary due to legal, cultural, or socioeconomic concerns. We sought to assess international variation in policies and protocols related to OHCA.

METHODS

A brief survey was developed by consensus. Elicited information included protocols for managing patients with nontraumatic OHCA or traumatic OHCA, policies for using automated external defibrillators (AEDs) during transportation of patients with ongoing resuscitation, and application of terminations of resuscitation (TOR) rules in prehospital settings in the respondent's city or country. The populations of interest were emergency physicians, medical directors of emergency medical services (EMS), and policy makers.

RESULTS

Responses were obtained from eight cities in six Asian countries. Only one (12.5%) city applied TOR rules for OHCAs. Do-not-resuscitate (DNR) orders were valid in prehospital settings in five (62.5%) cities. All cities used AEDs for nontraumatic OHCAs; seven (87.5%) cities did not routinely use AEDs for traumatic OHCAs. For nontraumatic OHCAs, four (50%) cities performed 2 minutes of on-scene cardiopulmonary resuscitation (CPR) and then transported the patients with ongoing resuscitation to hospitals; three (37.5%) cities performed 4 minutes of on-scene CPR; one (12.5%) city allowed variation in the duration of on-scene CPR.

CONCLUSION

International variation in practices and polices related to OHCAs do exist. Concerns regarding prehospital TOR rules include medical evidence, legal considerations, EMS manpower, public perception, medical oversight, education, EMS characteristics, and cost-effectiveness analysis. Further research is needed to achieve consensus regarding management protocols, especially for EMS that perform resuscitation during transportation of OHCA patients.

Advancing resuscitation science

PURPOSE OF REVIEW

To describe an alternative approach for improving survival of patients with out-of-hospital cardiac arrest (OHCA). The survival of patients with OHCA has been poor and relatively unchanged for decades in spite of recurrent national and international guidelines. Although there are exceptions, many thought and continue to think that any change in the guidelines for cardiopulmonary resuscitation should be based on randomized controlled trials in humans. However, many factors, including the need for informed consent, the marked variability of patients, and the variability of the type and quality of bystander and advanced resuscitation efforts, all make such studies problematic. Thus, potentially life-saving procedures are often withheld for decades, resulting in unnecessary loss of life.

RECENT FINDINGS

Many improvements in public health conditions have been made using models of continuous quality improvement. When applied to resuscitation science, once baseline data are obtained, changes based on reliable experimental findings are instituted and outcomes measured. This approach has now been shown to result in significant improvement in neurologically intact survival of patients with OHCA.

SUMMARY

Following this model, we found significant improvement in survival of patients with a witnessed OHCA primary cardiac arrest.

Year in review 2013: Critical Care--out-of-hospital cardiac arrest, traumatic injury, and other emergency care conditions

In this review, we discuss articles published in 2013 contributing to the existing literature on the management of out-of-hospital cardiac arrest and the evaluation and management of several other emergency conditions, including traumatic injury. The utility of intravenous medications, including epinephrine and amiodarone, in the management of cardiac arrest is questioned, as are cardiac arrest termination-of-resuscitation rules. Articles discussing mode of transportation in trauma are evaluated, and novel strategies for outcome prediction in traumatic injury are proposed. Diagnostic strategies, including computerized tomography scan for the diagnosis of smoke inhalation injury and serum biomarkers for the diagnosis of post-cardiac arrest syndrome and acute aortic dissection, are also explored. Although many of the articles discussed raise more questions than they answer, they nevertheless provide ample opportunity for further investigation.

Termination-of-resuscitation rule for emergency department physicians treating out-of-hospital cardiac arrest patients: an observational cohort study

Introduction

The 2010 cardiopulmonary resuscitation guidelines recommend emergency medical services (EMS) personnel consider prehospital termination-of-resuscitation (TOR) rules for out-of-hospital cardiac arrest (OHCA) following basic life support and/or advanced life support efforts in the field. However, the rate of implementation of international TOR rules is still low. Here, we aimed to develop and validate a new TOR rule for emergency department physicians to replace the international TOR rules for EMS personnel in the field. This rule aims to guide physicians in deciding whether to withhold further resuscitation attempts or terminate on-going resuscitation immediately after patient arrival.

Methods

We analyzed data prospectively collected in a nationwide Utstein-style Japanese database between 2005 and 2009, from 495,607 adult patients with OHCA. Patients were divided into development (n = 390,577) and validation (n = 105,030) groups. The main outcome measures were specificity, positive predictive value (PPV), and area under the receiver operating characteristic (ROC) curve for the newly developed TOR rule.

Results

We developed a new TOR rule that includes 3 criteria based on the results of multivariate logistic regression analysis for predicting a 1-month death after OHCA: no prehospital return of spontaneous circulation (adjusted odds ratio [OR], 25.8; 95% confidence interval [CI], 24.7–26.9), unshockable initial rhythm (adjusted OR, 2.76; 95% CI, 2.54–3.01), and unwitnessed by bystanders (adjusted OR, 2.18; 95% CI, 2.09–2.28). The specificity, PPV, and area under the ROC curve for this new TOR rule for predicting 1-month death in the validation group were 0.903 (95% CI, 0.894–0.911), 0.993 (95% CI, 0.992–0.993), and 0.874 (95% CI, 0.872–0.876), respectively.

Conclusions

We developed and validated a new TOR rule for emergency department physicians consisting of 3 prehospital variables (no prehospital ROSC, unshockable initial rhythm, and unwitnessed by bystanders) that is a >99% predictor of very poor outcome. However, the implementation of this new rule in other countries or EMS systems requires further validation studies.

Emergency Department Thoracotomy: Too Little, Too Much, or Too Late

Emergency department thoracotomy (EDT) is a dramatic lifesaving procedure demanding timely surgical intervention, technical expertise, and coordinated resuscitation efforts. Inappropriate use is costly and futile. All patients admitted to a Level II trauma center who underwent EDT from January 2003 to July 2012 were studied. The primary end point was appropriateness of EDT. Secondary end points were staff exposure, survival, and return to normal function. Eighty-seven patients including 59 patients with penetrating wounds had a mean loss of vital signs (LOV) 11.6 610.6 minutes and Injury Severity Score (ISS) of 45.8 ± 16.1, whereas 28 blunt injury patients had a mean LOVof 10.4 ± 11.5 minutes and ISS of 50.4 ± 19.4. Mortality was 81 per cent (48 of 59) in penetrating injury and 93 per cent (26 of 28) in blunt injury patients, respectively (odds ratio [OR] 2.99; P 0.21). Fifty-five EDTs were indicated with 10 survivors (18.2%) and 32 not indicated with three survivors (9.4%). Surgeons adhered to guidelines more compared with ED physicians (OR, 4.9; P = 0.03) whose patients were more likely to die (OR, 3.52; P = 0.124). Survivors (11 of 13 [84.6%]) were discharged home without significant long-term neurologic disability. EDT is lifesaving when performed for penetrating injury by experienced surgeons following established guidelines but futile in blunt injury or when performed by nonsurgeons regardless of mechanism.

2010: the emergency medical services literature in review

Emergency physicians, specialists, and primary care doctors across the health care delivery spectrum remain actively engaged in the provision of medical oversight for emergency medical services (EMS) systems, a vital link in the medical continuum of care. Practicing emergency physicians, regardless of their level of formal EMS training, interface with EMS system components and providers on a regular basis. It is important to remain aware of trends and practice patterns that have the potential to affect the care of emergency patients. PubMed was used to find articles for this review. The authors included EMS articles from 2010 felt applicable to all emergency physicians that fit the general topics discussed in this review. Some key articles from 2009 were also included. Case series were generally excluded. The selection is by no means an attempt to single out the best research articles. Like a single 12-lead electrocardiographic (ECG) tracing, this review represents a “snapshot” of current discussions in the EMS community. Prehospital medicine is a dynamic discipline, and its practice patterns are not identical to those found in a hospital emergency department (ED). The purpose of this literature review is to familiarize emergency physicians with some of the ongoing discussions in the prehospital literature.

Termination of resuscitation of nontraumatic cardiopulmonary arrest: resource document for the National Association of EMS Physicians position statement

In the development of an emergency medical services (EMS) system, medical directors should consider the implementation of protocols for the termination of resuscitation (TOR) of nontraumatic cardiopulmonary arrest. Such protocols have the potential to decrease unnecessary use of warning lights and sirens and save valuable public health resources. Termination-of-resuscitation protocols for nontraumatic cardiopulmonary arrest should be based on the determination that an EMS provider did not witness the arrest, there is no shockable rhythm identified, and there is no return of spontaneous circulation (ROSC) prior to EMS transport. Further research is needed to determine the need for direct medical oversight in TOR protocols and the duration of resuscitation prior to EMS providers' determining that ROSC will not be achieved. This paper is the resource document to the National Association of EMS Physicians position statement on the termination of resuscitation for nontraumatic cardiopulmonary arrest.

Variation in out-of-hospital cardiac arrest resuscitation and transport practices in the Resuscitation Outcomes Consortium: ROC Epistry-Cardiac Arrest

OBJECTIVES

To identify variation in patient, event, and scene characteristics of out-of-hospital cardiac arrest (OOHCA) patients assessed by emergency medical services (EMS), and to investigate variation in transport practices in relation to documented prehospital return of spontaneous circulation (ROSC) within eight regional clinical centers participating in the Resuscitation Outcomes Consortium (ROC) Epistry-Cardiac Arrest.

METHODS

OOHCA patient, event, and scene characteristics were compared to identify variation in treatment and transport practices across sites. Findings were adjusted for site and standard Utstein covariates. Using logistic regression, these covariates were modeled to identify factors related to the initiation of transport without documented prehospital ROSC as well as survival in these patients.

SETTING

Eight US and Canadian sites participating in the ROC Epistry-Cardiac Arrest.

POPULATION

Persons ≥ 20 years with OOHCA who (a) received compressions or shock by EMS providers and/or received bystander AED shock or (b) were pulseless but received no EMS compressions or shock between December 2005 and May 2007.

RESULTS

23,233 OOHCA cases were assessed by EMS in the defined period. Resuscitation (treatment) was initiated by EMS in 13,518 cases (58%, site range: 36-69%, p < 0.0001). Of treated cases, 59% were transported (site range: 49-88%, p < 0.0001). Transport was initiated in the absence of documented ROSC for 58% of transported cases (site range: 14-95%, p < 0.0001). Of these transported cases, 8% achieved ROSC before hospital arrival (site range: 5-21%, p < 0.0001) and 4% survived to hospital discharge (site range: 1-21%, p < 0.0001). In cases with transport from the scene initiated after documented ROSC, 28% survived to hospital discharge (site range: 18-44%, p < 0.0001).

CONCLUSION

Initiation of resuscitation and transport of OOHCA and the reporting of ROSC prior to transport markedly varies among ROC sites. This variation may help clarify reported differences in survival rates among sites and provide a target for identifying EMS practices most likely to enhance survival from OOHCA.

Knowledge translation in emergency medical services: a qualitative survey of barriers to guideline implementation

BACKGROUND

The American Heart Association (AHA) released guidelines to improve survival rates from out-of-hospital cardiac arrest in 2005. We sought to identify what barriers delayed the implementation of these guidelines in EMS agencies.

METHODS

We surveyed 178 EMS agencies as part of a larger quantitative survey regarding guideline implementation and conducted a single-question semi-structured interview using the Grounded Theory method. We asked "What barriers if any, delayed implementation of the (2005 AHA) guidelines in your EMS agency?" Data were coded and member validation was employed to verify our findings.

RESULTS

176/178 agencies completed the quantitative survey. Qualitative data collection ceased after reaching theoretical saturation with 34 interviews. Ten unique barriers were identified. We categorized these 10 barriers into three themes. The theme instruction delays (reported by 41% of respondents) included three barriers: booking/training instructors (9%), receiving training materials (15%), and scheduling staff for training (18%). The second theme, defibrillator delays (38%), included two barriers; reprogramming defibrillators (24%) and receiving new defibrillators to replace non-upgradeable units (15%). The third theme was decision-making (38%) and included five barriers; coordinating with allied agencies (9%), government regulators such as state and provincial health authorities (9%), medical direction and base hospitals (9%), ROC participation (9%), and internal crises (3%).

CONCLUSION

Many barriers contributed to delays in the implementation of the 2005 AHA guidelines in EMS agencies. These identified barriers should be proactively addressed prior to the 2010 Guidelines to facilitate rapid translation of science into clinical practice.