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

Clinical Research in Prehospital Care: Current and Future Challenges

Prehospital care plays a critical role in improving patient outcomes, particularly in cases of time-sensitive emergencies such as trauma, cardiac failure, stroke, bleeding, breathing difficulties, systemic infections, etc. In recent years, there has been a growing interest in clinical research in prehospital care, and several challenges and opportunities have emerged. There is an urgent need to adapt clinical research methodology to a context of prehospital care. At the same time, there are many barriers in prehospital research due to the complex context, posing unique challenges for research, development, and evaluation. Among these, this review allows the highlighting of limited resources and infrastructure, ethical and regulatory considerations, time constraints, privacy, safety concerns, data collection and analysis, selection of a homogeneous study group, etc. The analysis of the literature also highlights solutions such as strong collaboration between emergency medical services (EMS) and hospital care, use of (mobile) health technologies and artificial intelligence, use of standardized protocols and guidelines, etc. Overall, the purpose of this narrative review is to examine the current state of clinical research in prehospital care and identify gaps in knowledge, including the challenges and opportunities for future research.

The effect of ketamine and fentanyl on haemodynamics during intubation in pre-hospital and retrieval medicine

BACKGROUND

Ketamine use for rapid sequence intubation (RSI) is frequent in pre-hospital and retrieval medicine (PHARM) and is associated with potentially deleterious haemodynamic changes, which may be ameliorated by concurrent use of fentanyl.

OBJECTIVES

To describe the frequency with which fentanyl is used in conjunction with ketamine in a system where its use is discretionary, and to explore any observed changes in haemodynamics with its use.

METHODS

A retrospective observational study of over 800 patients undergoing RSI with ketamine ± fentanyl in the PHARM setting between 2015 and 2019. The primary outcome was the proportion of patients in each group who had a systolic blood pressure (SBP) outside a pre-specified target range, with adjustment for baseline abnormality, within 10 min of anaesthetic induction.

RESULTS

Eight hundred and seventy-six patients were anaesthetised with ketamine, of whom 804 were included in the analysis. 669 (83%, 95% CI 80%-86%) received ketamine alone, and 135 (17%, 95% CI 14%-20%) received both fentanyl and ketamine. Median fentanyl dose was 1.1 mcg/kg (IQR 0.75-1.5 mcg/kg). Systolic blood pressure (SBP) at induction was consistently associated with SBP after intubation in multivariable logistic regression, but fentanyl use was not associated with a change in odds of meeting the primary outcome (OR 1.08; 95% CI 0.72-1.60), becoming hypertensive (OR 1.35; 95% CI 0.88-2.07) or hypotensive (OR 0.76; 95% CI 0.47-1.21).

CONCLUSIONS

The addition of fentanyl to ketamine for RSI was not associated with an alteration of the odds of post-induction haemodynamic stability, although the doses used were low. These findings justify further study into the optimal dosing of fentanyl during RSI in pre-hospital and retrieval medicine.

Effective methods to enhance medical students' cardioversion and transcutaneous cardiac pacing skills retention - a prospective controlled study

BACKGROUND

Guideline-based therapy of cardiac arrhythmias is important for many physicians from the beginning of their training. Practical training of the required skills to treat cardiac arrhythmias is useful for acquiring these skills but does not seem sufficient for skill retention. The aim of this study was to compare different retention methods for skills required to treat cardiac arrhythmias with respect to the performance of these skills in an assessment.

METHODS

Seventy-one final-year medical students participated in a newly designed workshop to train synchronized cardioversion (SC) and transcutaneous cardiac pacing (TCP) skills in 2020. All participants completed an objective structured clinical examination (OSCE 1) one week after the training. Afterwards, the participants were stratified and randomized into three groups. Nine weeks later, one group received a standard operating procedure (SOP) for the skills, one group participated in a second workshop (SW), and one group received no further intervention (control). Ten weeks after the first training, all groups participated in OSCE 2.

RESULTS

The average score of all students in OSCE 1 was 15.6 ± 0.8 points with no significant differences between the three groups. Students in the control group reached a significantly (p < 0.001) lower score in OSCE 2 (-2.0 points, CI: [-2.9;-1.1]) than in OSCE 1. Students in the SOP-group achieved on average the same result in OSCE 2 as in OSCE 1 (0 points, CI: [-0.63;+0.63]). Students who completed a second skills training (SW-group) scored not significantly higher in OSCE 2 compared to OSCE 1 (+0.4 points, CI: [-0.29;+1.12]). The OSCE 2 scores in groups SOP and SW were neither significantly different nor statistically equivalent.

CONCLUSIONS

Partial loss of SC and TCP skills acquired in a workshop can be prevented after 10 weeks by reading an SOP as well as by a second workshop one week before the second assessment. Refreshing practical skills with an SOP could provide an effective and inexpensive method for skills retention compared to repeating a training. Further studies need to show whether this effect also exists for other skills and how frequently an SOP should be re-read for appropriate long-term retention of complex skills.

An analysis of prehospital critical care events and management patterns from 97 539 emergency helicopter medical service missions: A retrospective registry-based study

BACKGROUND

It is largely unknown how often physicians in emergency helicopter medical services (HEMS) encounter various critical care events and if HEMS exposure is associated with particular practice patterns or outcomes.

OBJECTIVES

This study aimed: to describe the frequency and distribution of critical care events; to investigate whether HEMS exposure is associated with differences in practice patterns and determine if HEMS exposure factors are associated with mortality.

DESIGN

A retrospective registry-based study.

SETTING

Physician-staffed HEMS in Finland between January 2012 and August 2019.

PARTICIPANTS

Ninety-four physicians who worked at least 6 months in the HEMS during the study period. Physicians with undeterminable HEMS exposure were excluded from practice pattern comparisons and mortality analysis, leaving 80 physicians.

MAIN OUTCOME MEASURES

The primary outcome measure was a physician's average annual frequencies for operational events and clinical interventions. Our secondary outcomes were the proportion of missions cancelled or denied, time onsite (OST) and proportion of unconscious patients intubated. Our tertiary outcome was adjusted 30-day mortality of patients.

RESULTS

The physicians encountered 62 [33 to 98], escorted 31 [17 to 41] and transported by helicopter 2.1 [1.3 to 3.5] patients annually, given as median [interquartile range; IQR]. Rapid sequence intubation was performed 11 [6.2 to 16] times per year. Physicians were involved in out-of-hospital cardiac arrest (OHCA) 10 [5.9 to 14] and postresuscitation care 5.5 [3.1 to 8.1] times per year. Physicians with longer patient intervals had shorter times onsite. Proportionally, they cancelled more missions and intubated fewer unconscious patients. A short patient interval [odds ratio (OR); 95% confidence interval (CI)] was associated with decreased mortality (0.87; 95% CI, 0.76 to1.00), whereas no association was observed between mortality and HEMS career length.

CONCLUSION

Prehospital exposure is distributed unevenly, and some physicians receive limited exposure to prehospital critical care. This seems to be associated with differences in practice patterns. Rare HEMS patient contacts may be associated with increased mortality.

Does experience in prehospital post-resuscitation critical care affect outcomes? A retrospective cohort study

AIMS OF THE STUDY

Helicopter Emergency Medical Services (HEMS) often provide post-resuscitation care. Our aims were to investigate whether physicians' frequent exposure to prehospital post-resuscitation care is associated with differences in (1) medical management, (2) achieving treatment targets recommended by resuscitation guidelines, (3) survival.

METHODS

We conducted a retrospective cohort study using data from a national HEMS quality register. We included patients between January 1st, 2012 and September 9th, 2019 who received post-resuscitation care by a HEMS physician. We excluded patients <16 years old. For each patient we determined the number of post-resuscitation cases the physician had attended in the previous 12 months. Patients were divided in to three groups: low (0-5), intermediate (6-11) and high exposure (≥12 cases). Medical management and proportions within treatment targets were compared. Survival at 30-days and 1-year was analysed by multivariate logistic regression analysis, controlling for known prognostic factors.

RESULTS

2272 patients were analysed. Patients in the high exposure group had mechanical ventilation and vasoactive medications initiated more often (P < 0.001 and P = 0.008, respectively) and on-scene times were longer (P < 0.001). The target for blood pressure was achieved more often in this group (P = 0.026), but targets for oxygenation and ventilation were not. We did not see an association between survival and physicians' exposure to post-resuscitation care (odds ratio 0.96, 95% confidence interval 0.70-1.33 for low and 0.78, 0.56-1.08 for intermediate, compared to high exposure).

CONCLUSIONS

Physicians with more, frequent exposure take a more active approach to post-resuscitation care, but this does not seem to improve survival.

Adult Advanced Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations

This 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations for advanced life support includes updates on multiple advanced life support topics addressed with 3 different types of reviews. Topics were prioritized on the basis of both recent interest within the resuscitation community and the amount of new evidence available since any previous review. Systematic reviews addressed higher-priority topics, and included double-sequential defibrillation, intravenous versus intraosseous route for drug administration during cardiac arrest, point-of-care echocardiography for intra-arrest prognostication, cardiac arrest caused by pulmonary embolism, postresuscitation oxygenation and ventilation, prophylactic antibiotics after resuscitation, postresuscitation seizure prophylaxis and treatment, and neuroprognostication. New or updated treatment recommendations on these topics are presented. Scoping reviews were conducted for anticipatory charging and monitoring of physiological parameters during cardiopulmonary resuscitation. Topics for which systematic reviews and new Consensuses on Science With Treatment Recommendations were completed since 2015 are also summarized here. All remaining topics reviewed were addressed with evidence updates to identify any new evidence and to help determine which topics should be the highest priority for systematic reviews in the next 1 to 2 years.

Adult Advanced Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

This 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations for advanced life support includes updates on multiple advanced life support topics addressed with 3 different types of reviews. Topics were prioritized on the basis of both recent interest within the resuscitation community and the amount of new evidence available since any previous review. Systematic reviews addressed higher-priority topics, and included double-sequential defibrillation, intravenous versus intraosseous route for drug administration during cardiac arrest, point-of-care echocardiography for intra-arrest prognostication, cardiac arrest caused by pulmonary embolism, postresuscitation oxygenation and ventilation, prophylactic antibiotics after resuscitation, postresuscitation seizure prophylaxis and treatment, and neuroprognostication. New or updated treatment recommendations on these topics are presented. Scoping reviews were conducted for anticipatory charging and monitoring of physiological parameters during cardiopulmonary resuscitation. Topics for which systematic reviews and new Consensuses on Science With Treatment Recommendations were completed since 2015 are also summarized here. All remaining topics reviewed were addressed with evidence updates to identify any new evidence and to help determine which topics should be the highest priority for systematic reviews in the next 1 to 2 years.

A Systematic Approach to Ventilator Management for the Pediatric Patient During Air Medical Transport

OBJECTIVE

A checklist was developed to improve the ventilator management of pediatric patients for air medical transport with the aim of reducing the percentage of patients outside recommended parameters (no bag valve mask use, peripheral capillary oxygen saturation level > 90%, and end-tidal carbon dioxide level > 35 and < 50 mm Hg) from 41.3% to 20% within 7 months.

METHODS

The checklist was developed based on recommended guidelines. After checklist orientation, its effectiveness was analyzed via chart review for inclusion criteria (> 5 kg and < 18 years) from July 2018 to January 2019. Parameters identified in the aim statement were used to evaluate effectiveness. After transport, a Likert survey concerning the value of the checklist was distributed.

RESULTS

Significant improvements in pediatric ventilator management were noted when teams used the checklist. The rate outside of aim parameters was reduced significantly from 41.3% (n = 92, June 2012-May 2018 preintervention) to 10% (n = 20, July 2018-January 2019 postintervention) after the improvement action was implemented (χ² = 7.01, P = .008). The 5-point Likert survey results (n = 38, 4.68 ± .57) supported teams' improved comfort after checklist implementation.

CONCLUSION

The checklist improved ventilator management proficiency of pediatric patients and the comfort level of air medical teams providing care.

A Review of Countermovement and Squat Jump Testing Methods in the Context of Public Health Examination in Adolescence: Reliability and Feasibility of Current Testing Procedures

BACKGROUND

In the context of a public health physical fitness (PF) examination in adolescence, a countermovement jump (CMJ) and a squat jump (SJ) are two vertical jump (VJ) tests widely used to evaluate lower limb muscle strength and power, respectively. The main criticism of both the CMJ and SJ test is the lack of test standardization. Therefore, the objectives of this review are: (a) to gather information about both jumps; (b) to investigate whether it is possible to identify common procedures referred to in the CMJ and SJ technical execution, and (c) to design standard operating procedures (SOPs) to promote CMJ and SJ standardization in an adolescent population aged 12-18 years.

METHODS

The review partially adopted the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement (PRISMA). Due to growing attention in monitoring physical health through field tests in recent years, articles were collected using the PubMed, Web of Science, and Scopus databases from January 2009 to July 2019. Original articles in which CMJ or SJ were used to assess the muscular strength in adolescents were eligible for further analysis. Articles written in English was imposed as a limit.

RESULTS

A total of 117 studies met the inclusion criteria. The description of the CMJ and SJ test procedures was different within the literature, with discrepancies in the jump technique, number of jumps, and measurement devices used.

CONCLUSIONS

A lack of method standardization for both the CMJ and the SJ test was identified. Based on the literature, SOPs for both VJs were proposed. These are useful in the context of public health PF examination in adolescents, as they facilitate an unbiased comparison of jump performance data between published studies.

Implementation and Evaluation of a Web-Based Distribution System For Anesthesia Department Guidelines and Standard Operating Procedures: Qualitative Study and Content Analysis

BACKGROUND

Digitization is spreading exponentially in medical care, with improved availability of electronic devices. Guidelines and standard operating procedures (SOPs) form an important part of daily clinical routine, and adherence is associated with improved outcomes.

OBJECTIVE

This study aimed to evaluate a digital solution for the maintenance and distribution of SOPs and guidelines in 2 different anesthesiology departments in Switzerland.

METHODS

A content management system (CMS), WordPress, was set up in 2 tertiary-level hospitals within 1 year: the Department of Anesthesiology and Pain Medicine at the Kantonsspital Lucerne in Lucerne, Switzerland, as an open-access system, followed by a similar system for internal usage in the Department of Anaesthesiology and Pain Medicine of the Inselspital, Bern University Hospital, in Bern, Switzerland. We analyzed the requirements and implementation processes needed to successfully set up these systems, and we evaluated the systems' impact by analyzing content and usage.

RESULTS

The systems' generated exportable metadata, such as traffic and content. Analysis of the exported metadata showed that the Lucerne website had 269 pages managed by 44 users, with 88,124 visits per month (worldwide access possible), and the Bern website had 341 pages managed by 35 users, with 1765 visits per month (access only possible from within the institution). Creation of an open-access system resulted in third-party interest in the published guidelines and SOPs. The implementation process can be performed over the course of 1 year and setup and maintenance costs are low.

CONCLUSIONS

A CMS, such as WordPress, is a suitable solution for distributing and managing guidelines and SOPs. Content is easily accessible and is accessed frequently. Metadata from the system allow live monitoring of usage and suggest that the system be accepted and appreciated by the users. In the future, Web-based solutions could be an important tool to handle guidelines and SOPs, but further studies are needed to assess the effect of these systems.

Best practice advice on pre-hospital emergency anaesthesia & advanced airway management

BACKGROUND

Effective and timely airway management is a priority for sick and injured patients. The benefit and conduct of pre-hospital emergency anaesthesia (PHEA) and advanced airway management remains controversial but there are a proportion of critically ill and injured patients who require urgent advanced airway management prior to hospital arrival. This document provides current best practice advice for the provision of PHEA and advanced airway management.

METHOD

This best practice advice was developed from EHAC Medical Working Group enforced by pre-hospital critical care experts. The group used a nominal group technique to establish the current best practice for the provision of PHEA and advanced airway management. The group met on three separate occasions to discuss and develop the guideline. All members of the working party were able to access and edit the guideline online.

RESULTS

This EHAC best practice advice covers all areas of PHEA and advanced airway management and provides up to date evidence of current best practice.

CONCLUSION

PHEA and advanced airway management are complex interventions that should be delivered by appropriately trained personnel using a well-rehearsed approach and standardised equipment. Where advanced airway interventions cannot be delivered, careful attention should be given to applying basic airway interventions and ensuring their effectiveness at all times.

Airway management in pre-hospital critical care: a review of the evidence for a 'top five' research priority

The conduct and benefit of pre-hospital advanced airway management and pre-hospital emergency anaesthesia have been widely debated for many years. In 2011, prehospital advanced airway management was identified as a ‘top five’ in physician-provided pre-hospital critical care. This article summarises the evidence for and against this intervention since 2011 and attempts to address some of the more controversial areas of this topic.

Standardised data reporting from pre-hospital advanced airway management - a nominal group technique update of the Utstein-style airway template

Background

Pre-hospital advanced airway management with oxygenation and ventilation may be vital for managing critically ill or injured patients. To improve pre-hospital critical care and develop evidence-based guidelines, research on standardised high-quality data is important. We aimed to identify which airway data were most important to report today and to revise and update a previously reported Utstein-style airway management dataset.

Methods

We recruited sixteen international experts in pre-hospital airway management from Australia, United States of America, and Europe. We used a five-step modified nominal group technique to revise the dataset, and clinical study results from the original template were used to guide the process.

Results

The experts agreed on a key dataset of thirty-two operational variables with six additional system variables, organised in time, patient, airway management and system sections. Of the original variables, one remained unchanged, while nineteen were modified in name, category, definition or value. Sixteen new variables were added. The updated dataset covers risk factors for difficult intubation, checklist and standard operating procedure use, pre-oxygenation strategies, the use of drugs in airway management, airway currency training, developments in airway devices, airway management strategies, and patient safety issues not previously described.

Conclusions

Using a modified nominal group technique with international airway management experts, we have updated the Utstein-style dataset to report standardised data from pre-hospital advanced airway management. The dataset enables future airway management research to produce comparable high-quality data across emergency medical systems. We believe this approach will promote research and improve treatment strategies and outcomes for patients receiving pre-hospital advanced airway management.

Trial registration

The Regional Committee for Medical and Health Research Ethics in Western Norway exempted this study from ethical review (Reference: REK-Vest/2017/260).

Electronic supplementary material

The online version of this article (10.1186/s13049-018-0509-y) 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.

Pre-hospital anaesthesia: the same but different

Advanced airway management is one of the most controversial areas of pre-hospital trauma care and is carried out by different providers using different techniques in different Emergency Medical Services systems. Pre-hospital anaesthesia is the standard of care for trauma patients arriving in the emergency department with airway compromise. A small proportion of severely injured patients who cannot be managed with basic airway management require pre-hospital anaesthesia to avoid death or hypoxic brain injury. The evidence base for advanced airway management is inconsistent, contradictory and rarely reports all key data. There is evidence that poorly performed advanced airway management is harmful and that less-experienced providers have higher intubation failure rates and complication rates. International guidelines carry many common messages about the system requirements for the practice of advanced airway management. Pre-hospital rapid sequence induction (RSI) should be practiced to the same standard as emergency department RSI. Many in-hospital standards such as monitoring, equipment, and provider competence can be achieved. Pre-hospital and emergency in-hospital RSI has been modified from standard RSI techniques to improve patient safety, physiological disturbance, and practicality. Examples include the use of opioids and long-acting neuromuscular blocking agents, ventilation before intubation, and the early release of cricoid pressure to improve laryngoscopic view. Pre-hospital RSI is indicated in a small proportion of trauma patients. Where pre-hospital anaesthesia cannot be carried out to a high standard by competent providers, excellent quality basic airway management should be the mainstay of management.