Standardized High-Quality Processes for End-of-Life-Decision Making in the Intensive Care Unit Remain Robust during an Unprecedented New Pandemic-A Single-Center Experience

Due to the global COVID-19 pandemic, a concomitant increase in awareness for end-of-life decisions (EOLDs) and advance care planning has been noted. Whether the dynamic pandemic situation impacted EOLD-processes on the intensive care unit (ICU) and patient-sided advance care planning in Germany is unknown. This is a retrospective analysis of all deceased patients of surgical ICUs of a university medical center from March 2020 to July 2021. All included ICUs had established standardized protocols and documentation for EOLD-related aspects of ICU therapy. The frequency of EOLDs and advance directives and the process of EOLDs were analyzed (No. of ethical approval EA2/308/20). A total number of 319 (85.5%) of all deceased patients received an EOLD. Advance directives were possessed by 83 (22.3%) of the patients and a precautionary power of attorney by 92 (24.7%) of the patients. There was no difference in the frequency of EOLDs and patient-sided advance care planning between patients with COVID-19 and non-COVID-19 patients. In addition, no differences in frequencies of do-not-resuscitate orders, withholding or withdrawing of intensive care medicine therapeutic approaches, timing of EOLDs, and participation of senior ICU attendings in EOLDs were noted between patients with COVID-19 and non-COVID-19 patients. Documentation of family conferences occurred more often in deceased patients with COVID-19 compared to non-COVID-19 patients (COVID-19: 80.0% vs. non-COVID-19: 56.8, p = 0.001). Frequency of EOLDs and completion rates of advance directives remained unchanged during the pandemic compared to pre-pandemic years. The EOLD process did not differ between patients with COVID-19 and non-COVID-19 patients. Institutional standard procedures might contribute to support the robustness of EOLD-making processes during unprecedented medical emergencies, such as new pandemic diseases.

Development of primary care quality indicators for chronic obstructive pulmonary disease using a Delphi-derived method

High-quality care for patients with COPD is necessary. To achieve quality improvement in primary care, the general practitioner and the electronic health record (EHR) play an important role. The aim of this study was to develop a set of evidence-based and EHR extractable quality indicators (QIs) to measure and improve the quality of COPD primary care. We composed a multidisciplinary expert panel of 12 members, including patients, and used a RAND-modified Delphi method. The SMART principle was applied to select recommendations and QIs from international guidelines as well as existing sets of QIs, and these recommendations and QIs were added to an individual written questionnaire. Based on the median score, prioritization and degree of agreement, the recommendations and QIs were rated as having a high, uncertain or low potential to measure the quality of COPD primary care and were then discussed in an online consensus meeting for inclusion or exclusion. After a final validation, a core set of recommendations was translated into QIs. From 37 recommendations, obtained out of 10 international guidelines, and 5 existing indicators, a core set of 18 recommendations and 2 QIs was derived after the rating procedure. The expert panel added one new recommendation. Together, the recommendations and QIs were translated and merged into a final set of 21 QIs. Our study developed a set of 21 evidence-based and EHR-extractable QIs for COPD in primary care. These indicators can be used in an automated quality assessment to measure and improve the quality of COPD primary care.

Direct in-hospital admission via ambulance (DIVA): A retrospective observational study

BACKGROUND

Prolonged stays in emergency departments increase the risk of adverse events in elderly patients. To optimize care for nonurgent patients who need in-hospital admission, a patient-focused improvement project named Direct In-hospital admission Via Ambulance (DIVA) was launched at Örebro University Hospital.

PURPOSE

This study describes the effects of DIVA. The primary outcome was time to in-hospital admission. Secondary outcomes were the in-hospital admission rate, the in-hospital length of stay and patient characteristics.

METHOD

This was a retrospective observational study. Descriptive and comparative statistics were used. All patients identified by the ambulance nurse as nonurgent but with an apparent need for in-hospital admission were candidates for direct in-hospital admission. The results were compared with those of a reference group.

RESULT

In total, 127 patients were included, with 45 patients in the DIVA group and 82 patients in the reference group. In the DIVA group, 24 patients were directly admitted. The median time to in-hospital admisson was 49.5 min for direct admitted patients and 278.5 min for the reference group. There was a statistical significant difference between the groups (p < 0.01).

CONCLUSION

The current study indicates that time to in-hospital admission could be reduced by DIVA.

Pre-hospital and emergency department pathways of care for exacerbations of chronic obstructive pulmonary disease (COPD)

Exacerbations are serious complications of chronic obstructive pulmonary disease (COPD) that often require acute care from pre-hospital and emergency department (ED) services. Despite being a frequent cause of emergency presentations, gaps remain in both literature and practice for emergency care pathways of COPD exacerbations. This review seeks to address these gaps and focuses on the literature of pre-hospital and ED systems of care and how these intersect with patients experiencing an exacerbation of COPD. The literature in this area is expanding rapidly; however, more research is required to further understand exacerbations and how they are addressed by emergency medical services worldwide. For the purpose of this review, the pre-hospital domain includes ambulance and other emergency transport services, and encompasses medical interventions delivered prior to arrival at an ED or hospital. The ED domain is defined as the area of a hospital or free-standing centre where patients arrive to receive emergent medical care prior to admission. In many studies there is a significant overlap between these two domains and frequent intersection and collaboration between services. In both of these domains, for the management of COPD exacerbations, several overarching themes have been identified in the literature. These include: the appropriate delivery of oxygen in the emergency setting; strategies to improve the provision of care in accordance with diagnostic and treatment guidelines; strategies to reduce the requirement for emergency presentations; and, technological advances including machine learning which are helping to improve emergency healthcare systems.

Adverse events in prehospital emergency care: a trigger tool study

Background

Prehospital emergency care has developed rapidly during the past decades. The care is given in a complex context which makes prehospital care a potential high-risk activity when it comes to patient safety. Patient safety in the prehospital setting has been only sparsely investigated. The aims of the present study were 1) To investigate the incidence of adverse events (AEs) in prehospital care and 2) To investigate the factors contributing to AEs in prehospital care.

Methods

We used a retrospective study design where 30 randomly selected prehospital medical records were screened for AEs each month in three prehospital organizations in Sweden during a period of one year. A total of 1080 prehospital medical records were included. The record review was based on the use of 11 screening criteria.

Results

The reviewers identified 46 AEs in 46 of 1080 (4.3%) prehospital medical records. Of the 46 AEs, 43 were classified as potential for harm (AE1) (4.0, 95% CI = 2.9–5.4) and three as harm identified (AE2) (0.3, 95% CI = 0.1–0.9). However, among patients with a life-threatening condition (priority 1), the risk of AE was higher (16.5%). The most common factors contributing to AEs were deviations from standard of care and missing, incomplete, or unclear documentation. The most common cause of AEs was the result of action(s) or inaction(s) by the emergency medical service (EMS) crew.

Conclusions

There were 4.3 AEs per 100 ambulance missions in Swedish prehospital care. The majority of AEs originated from deviations from standard of care and incomplete documentation. There was an increase in the risk of AE among patients who the EMS team assessed as having a life-threatening condition. Most AEs were possible to avoid.

Electronic supplementary material

The online version of this article (10.1186/s12873-019-0228-3) contains supplementary material, which is available to authorized users.

Use of checklists improves the quality and safety of prehospital emergency care

OBJECTIVES

High-level emergency medical care requires transfer of evidence-based knowledge into practice. Our study is the first to investigate the feasibility of checklists in improving prehospital emergency care.

MATERIALS AND METHODS

Three checklists based on standard operating procedures were introduced: General principles of prehospital care, acute coronary syndrome and acute asthma/acutely exacerbated chronic obstructive pulmonary disease. Subsequent to prehospital care and immediately before transport, information on medical history, diagnostic and therapeutic procedures was obtained. Data of 740 emergency missions were recorded prospectively before (control group) and after implementation of checklists and compared using the χ-test (significance level P<0.05).

RESULTS

Documentation on patients' history (pre-existing diseases: 69.1 vs. 74.3%; medication: 55.8 vs. 68.0%; allergies: 6.2 vs. 27.7%) and diagnostic measures (oxygen saturation: 93.2 vs. 98.1%; auscultation: 11.1 vs. 19.9%) as well as basic treatment procedures (application of oxygen: 73.2 vs. 85.3%; intravenous access: 84.6 vs. 92.2%) increased significantly. Subanalysis of acute coronary syndrome cases showed a significant increase of 12-lead ECG use (74.3 vs. 92.4%), administration of oxygen (84.2 vs. 98.6%), ASA (71.7 vs. 81.9%), heparin (71.1 vs. 84.0%), β blockers (39.5 vs. 57.1%) and morphine (26.8 vs. 44.6%). In the chronic obstructive pulmonary disease subgroup, oxygen supply (78.8 vs. 98.5%) and application of inhalative and intravenous β2-mimetics (42.4 vs. 66.7% and 12.1 vs. 37.9%) increased significantly.

CONCLUSION

Introduction of checklists for prehospital emergency care may help to improve adherence to treatment guidelines. Additional efforts (e.g. team trainings) have to be made to increase quality of care.

Use and implementation of standard operating procedures and checklists in prehospital emergency medicine: a literature review

OBJECTIVES

This review aimed to analyze published literature to introduce the use and implementation of standard operating procedures (SOPs) and checklists in prehospital emergency medicine and their impact on guideline adherence and patient outcome.

METHODS

An English literature search was carried out using the Cochrane Library, MEDLINE, EMBASE, Springer, Elsevier, and ProQuest databases. Original articles describing the use and implementation of SOPs or checklists in prehospital emergency medicine were included. Editorials, comments, letters, bulletins, news articles, conference abstracts, and notes were excluded from the analysis. Relevant information was extracted relating to application areas, development of SOPs/checklists, educational preparation and training regarding SOPs/checklists implementation, staff attitudes and the effects of SOPs/checklists use on guideline adherence and patient outcomes.

RESULTS

The literature search found 2187 potentially relevant articles, which were narrowed down following an abstract review and a full text review. A final total of 13 studies were identified that described the use and implementation of SOPs (9 studies) and checklists (4 studies) in different areas of prehospital emergency medicine including prehospital management of patients with acute exacerbated chronic obstructive pulmonary disease and acute coronary syndrome, prehospital airway management, medical documentation, Emergency Medical Services triage, and transportation of patients.

CONCLUSIONS

The use and implementation of SOPs and checklists in prehospital emergency medicine have shown some benefits of improving guidelines adherence and patient outcomes in airway management, patient records, identification and triage, and other prehospital interventions. More research in this area is necessary to optimize the future use and implementation of SOPs and checklists to improve emergency personnel performance and patient outcomes.

Patient safety and patient assessment in pre-hospital care: a study protocol

Background

Patient safety issues in pre-hospital care are poorly investigated. The aim of the planned study is to survey patient safety problems in pre-hospital care in Sweden.

Methods/Design

The study is a retro-perspective structured medical record review based on the use of 11 screening criteria. Two instruments for structured medical record review are used: a trigger tool instrument designed for pre-hospital care and a newly development instrument designed to compare the pre-hospital assessment with the final hospital assessment. Three different ambulance organisations are participating in the study. Every month, one rater in each organisation randomly collects 30 medical records for review. With guidance from the review instrument, he/she independently reviews the record. Every month, the review team meet for a discussion of problematic reviews. The results will be analysed with descriptive statistics and logistic regression.

Discussion

The findings will make an important contribution to knowledge about patient safety issues in pre-hospital care.

The effect of a Computerised Decision Support System (CDSS) on compliance with the prehospital assessment process: results of an interrupted time-series study

Background

Errors in the decision-making process are probably the main threat to patient safety in the prehospital setting. The reason can be the change of focus in prehospital care from the traditional “scoop and run” practice to a more complex assessment and this new focus imposes real demands on clinical judgment. The use of Clinical Guidelines (CG) is a common strategy for cognitively supporting the prehospital providers. However, there are studies that suggest that the compliance with CG in some cases is low in the prehospital setting. One possible way to increase compliance with guidelines could be to introduce guidelines in a Computerized Decision Support System (CDSS). There is limited evidence relating to the effect of CDSS in a prehospital setting. The present study aimed to evaluate the effect of CDSS on compliance with the basic assessment process described in the prehospital CG and the effect of On Scene Time (OST).

Methods

In this time-series study, data from prehospital medical records were collected on a weekly basis during the study period. Medical records were rated with the guidance of a rating protocol and data on OST were collected. The difference between baseline and the intervention period was assessed by a segmented regression.

Results

In this study, 371 patients were included. Compliance with the assessment process described in the prehospital CG was stable during the baseline period. Following the introduction of the CDSS, compliance rose significantly. The post-intervention slope was stable. The CDSS had no significant effect on OST.

Conclusions

The use of CDSS in prehospital care has the ability to increase compliance with the assessment process of patients with a medical emergency. This study was unable to demonstrate any effects of OST.

Standard operating procedure changed pre-hospital critical care anaesthesiologists' behaviour: a quality control study

Introduction

The ability of standard operating procedures to improve pre-hospital critical care by changing pre-hospital physician behaviour is uncertain. We report data from a prospective quality control study of the effect on pre-hospital critical care anaesthesiologists’ behaviour of implementing a standard operating procedure for pre-hospital controlled ventilation.

Materials and methods

Anaesthesiologists from eight pre-hospital critical care teams in the Central Denmark Region prospectively registered pre-hospital advanced airway-management data according to the Utstein-style template. We collected pre-intervention data from February 1^st 2011 to January 31^st 2012, implemented the standard operating procedure on February 1^st 2012 and collected post intervention data from February 1^st 2012 until October 31^st 2012. We included transported patients of all ages in need of controlled ventilation treated with pre-hospital endotracheal intubation or the insertion of a supraglottic airways device. The objective was to evaluate whether the development and implementation of a standard operating procedure for controlled ventilation during transport could change pre-hospital critical care anaesthesiologists’ behaviour and thereby increase the use of automated ventilators in these patients.

Results

The implementation of a standard operating procedure increased the overall prevalence of automated ventilator use in transported patients in need of controlled ventilation from 0.40 (0.34-0.47) to 0.74 (0.69-0.80) with a prevalence ratio of 1.85 (1.57-2.19) (p = 0.00). The prevalence of automated ventilator use in transported traumatic brain injury patients in need of controlled ventilation increased from 0.44 (0.26-0.62) to 0.85 (0.62-0.97) with a prevalence ratio of 1.94 (1.26-3.0) (p = 0.0039). The prevalence of automated ventilator use in patients transported after return of spontaneous circulation following pre-hospital cardiac arrest increased from 0.39 (0.26-0.48) to 0.69 (0.58-0.78) with a prevalence ratio of 1.79 (1.36-2.35) (p = 0.00).

Conclusion

We have shown that the implementation of a standard operating procedure for pre-hospital controlled ventilation can significantly change pre-hospital critical care anaesthesiologists’ behaviour.

Refraining from pre-hospital advanced airway management: a prospective observational study of critical decision making in an anaesthesiologist-staffed pre-hospital critical care service

Introduction

We report prospectively recorded observational data from consecutive cases in which the attending pre-hospital critical care anaesthesiologist considered performing pre-hospital advanced airway management but decided to withhold such interventions.

Materials and methods

Anaesthesiologists from eight pre-hospital critical care teams in the Central Denmark Region (a mixed rural and urban region with 1.27 million inhabitants) registered data from February 1^st 2011 to October 31^st 2012. Included were patients of all ages for whom pre-hospital advanced airway management were considered but not performed. The main objectives were to investigate (1) the pre-hospital critical care anaesthesiologists’ reasons for considering performing pre-hospital advanced airway management in this group of patients (2) the pre-hospital critical care anaesthesiologists’ reasons for not performing pre-hospital advanced airway management (3) the methods used to treat these patients (4) the incidence of complications related to pre-hospital advanced airway management not being performed.

Results

We registered data from 1081 cases in which the pre-hospital critical care anaesthesiologists’ considered performing pre-hospital advanced airway management. The anaesthesiologists decided to withhold pre-hospital advanced airway management in 32.1% of these cases (n = 347). In 75.1% of these cases (n = 257) pre-hospital advanced airway management were withheld because of the patient’s condition and in 30.8% (n = 107) because of patient co-morbidity. The most frequently used alternative treatment was bag-mask ventilation, used in 82.7% of the cases (n = 287). Immediate complications related to the decision of not performing pre-hospital advanced airway management occurred in 0.6% of the cases (n = 2).

Conclusion

We have illustrated the complexity of the critical decision-making associated with pre-hospital advanced airway management. This study is the first to identify the most common reasons why pre-hospital critical care anaesthesiologists sometimes choose to abstain from pre-hospital advanced airway management as well as the alternative treatment methods used.

Exclusion of context knowledge in the development of prehospital guidelines: results produced by realistic evaluation

Background

Prehospital work is accomplished using guidelines and protocols, but there is evidence suggesting that compliance with guidelines is sometimes low in the prehospital setting. The reason for the poor compliance is not known. The objective of this study was to describe how guidelines and protocols are used in the prehospital context.

Methods

This was a single-case study with realistic evaluation as a methodological framework. The study took place in an ambulance organization in Sweden. The data collection was divided into four phases, where phase one consisted of a literature screening and selection of a theoretical framework. In phase two, semi-structured interviews with the ambulance organization's stakeholders, responsible for the development and implementation of guidelines, were performed. The third phase, observations, comprised 30 participants from both a rural and an urban ambulance station. In the last phase, two focus group interviews were performed. A template analysis style of documents, interviews and observation protocols was used.

Results

The development of guidelines took place using an informal consensus approach, where no party from the end users was represented. The development process resulted in guidelines with an insufficiently adapted format for the prehospital context. At local level, there was a conscious implementation strategy with lectures and manikin simulation. The physical format of the guidelines was the main obstacle to explicit use. Due to the format, the ambulance personnel feel they have to learn the content of the guidelines by heart. Explicit use of the guidelines in the assessment of patients was uncommon. Many ambulance personnel developed homemade guidelines in both electronic and paper format. The ambulance personnel in the study generally took a positive view of working with guidelines and protocols and they regarded them as indispensable in prehospital care, but an improved format was requested by both representatives of the organization and the ambulance personnel.

Conclusions

The personnel take a positive view of the use of guidelines and protocols in prehospital work. The main obstacle to the use of guidelines and protocols in this organization is the format, due to the exclusion of context knowledge in the development process.

Decision support system in prehospital care: a randomized controlled simulation study

INTRODUCTION

Prehospital emergency medicine is a challenging discipline characterized by a high level of acuity, a lack of clinical information and a wide range of clinical conditions. These factors contribute to the fact that prehospital emergency medicine is a high-risk discipline in terms of medical errors. Prehospital use of Computerized Decision Support System (CDSS) may be a way to increase patient safety but very few studies evaluate the effect in prehospital care. The aim of the present study is to evaluate a CDSS.

METHODS

In this non-blind block randomized, controlled trial, 60 ambulance nurses participated, randomized into 2 groups. To compensate for an expected learning effect the groups was further divided in two groups, one started with case A and the other group started with case B. The intervention group had access to and treated the two simulated patient cases with the aid of a CDSS. The control group treated the same cases with the aid of a regional guideline in paper format. The performance that was measured was compliance with regional prehospital guidelines and On Scene Time (OST).

RESULTS

There was no significant difference in the two group's characteristics. The intervention group had a higher compliance in the both cases, 80% vs. 60% (p<0.001) but the control group was complete the cases in the half of the time compare to the intervention group (p<0.001).

CONCLUSION

The results indicate that this CDSS increases the ambulance nurses' compliance with regional prehospital guidelines but at the expense of an increase in OST.