Adherence to guidelines and protocols in the prehospital and emergency care setting: a systematic review

A Qualitative Analysis of Barriers to Evidence-Based Care in the Prehospital Management of Patients with Suspected Acute Coronary Syndrome

OBJECTIVES

Prehospital electrocardiogram (ECG) and administration of aspirin are evidence-based strategies for patients with acute coronary syndrome (ACS). However, emergency medical services (EMS) compliance in patients with suspected ACS varies widely. We sought to understand the barriers to prehospital ECG acquisition and aspirin administration for patients with suspected ACS.

METHODS

In this qualitative study, we interviewed EMS clinicians at three geographically diverse United States (U.S.)-based EMS agencies. We interviewed practicing clinicians and quality and operations leaders at these agencies. Based on the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework, interviews were recorded, transcribed, and analyzed using a grounded qualitative approach with open coding. The Systems Engineering Initiative for Patient Safety (SEIPS) framework and a constant comparison technique were used to identify and refine themes.

RESULTS

Twenty-five paramedics and 20 additional agency personnel participated. Median age was 41 (IQR: 34-51) years and 13 (29%) were female. Themes were organized using SEIPS and longitudinally through four phases of an EMS call. During the pre-arrival phase, staffing challenges, training quality, and dispatch may anchor EMS clinicians on a diagnosis. During the diagnosis and treatment phase, safety and communication barriers may take priority over care delivery. Additionally, EMS clinicians must allocate assets (e.g. whether to send an advanced life support unit) and financial resources; veteran EMS clinicians identified their experience whereas newer clinicians cited their recent education when making these decisions. Also, diagnostic uncertainty due to increasing patient complexity and atypical presentations contributed to diagnostic errors. During the response and transport phase, the scope of practice limits the use and interpretation of the ECG, with clinicians reporting that liberal use of ECG led to more rapid decision-making. Finally, in the after phase, personnel reported the "psychologically taxing" nature of the job contributing to biases, bad habits, and burnout. Performance feedback was desired for personal development, though currently perceived as infrequent and punitive.

CONCLUSIONS

Multiple, interrelated themes underscored the complexities of delivering evidence-based care to prehospital patients with ACS. Education in ECG interpretation, resource allocation, bias, and enhancing feedback may serve as strategies to address the identified barriers.

Prehospital analgesia in suspected hip fracture patients: adherence to national prehospital pain management guidelines

PURPOSE

Patients with hip fractures frequently present at the emergency department (ED). Despite high pain scores, prehospital pain management is often inadequate and insufficient. In the Netherlands, the emergency medical services (EMS) exhibit a high level of training, supported by a comprehensive pain treatment protocol. This study aimed to assess adherence to the protocol and hypothesized that prehospital pain management in hip fracture patients was both sufficient and adequate.

METHODS

This was a retrospective observational cohort study of patients with suspected hip fractures. The median differences in numerical rating scale (NRS) pain scores between the initial score in the ambulance and upon arrival at the ED were compared. Furthermore, adherence to the ambulance pain protocol was studied.

RESULTS

From September 2016 to March 2021, 436 ambulance-transported hip fracture patients were included, of whom 81% received analgesics by EMS. The median initial pain score measured by EMS was 8; this number decreased to 5 at ED presentation, a significant decrease (ρ < 0.001). In case a prehospital NRS pain score was assessed, 66.5% of the patients were treated according to the protocol. In 80% of patients, the protocol was not followed correctly, primarily due to missing NRS pain scores.

CONCLUSION

In suspected hip fracture patients, initial prehospital pain scores were high and most patients received analgesics from EMS. This resulted in a significant decrease in pain. In nearly 67% of patients in whom an NRS pain score was assessed in the prehospital phase, pain management was according to protocol. However, in 80% of the total population the pain protocol was not adhered to, mainly due to missing NRS pain scores.

Perceptions of professional challenges by emergency medical services providers: a qualitative content analysis study

INTRODUCTION

Emergency medical services (EMS) providers encounter a variety of challenges due to the unpredictable, uncontrollable, and dynamic conditions in the pre-hospital field. This study explored the perceived professional challenges among EMS providers.

MATERIALS AND METHODS

This study was conducted using a qualitative research approach and the method of content analysis. Eighteen EMS providers were purposively selected from EMS stations in Hamadan, Iran. The collected data were then analyzed based on the Granheim and Lundman's method.

RESULTS

Based on data analysis, five categories and one theme were identified. The extracted theme was professional challenges. The five categories were as follows: Ineffective policies; multicultural and multidisciplinary factors; ambulance dispatch route problems; legal issues; and abuse against the emergency medical services CONCLUSION: In general, it has been found that EMS providers encounter numerous and complex professional challenges during their work. EMS managers can utilize the findings of the present study to develop strategies for reducing the professional challenges faced by EMS providers. By doing so, they can improve the quality of care in the prehospital field.

Fifteen years of real-world data on the use of vigabatrin in individuals with infantile epileptic spasms syndrome

OBJECTIVE

This study was undertaken to evaluate our treatment algorithm for infantile epileptic spasms syndrome (IESS) used between 2000 and 2018. We initiated vigabatrin (VGB), and steroids were added if the electroclinical response (spasms and electroencephalogram [EEG]) to VGB was not obtained or incomplete.

METHODS

Individuals with IESS treated with VGB were recruited from our hospital clinical data warehouse based on electronic health records (EHRs) generated since 2009 and containing relevant keywords. We confirmed the diagnosis of IESS. Clinical, EEG, imaging, and biological data were extracted from the EHRs. We analyzed factors associated with short-term response, time to response, relapse, time to relapse of spasms, and the presence of spasms at last follow-up.

RESULTS

We collected data from 198 individuals (female: 46.5%, IESS onset: 6 [4.5-10.3] months, follow-up: 4.6 [2.5-7.6] years, median [Q1-Q3]) including 129 (65.2%) with identifiable etiology. VGB was started 17 (5-57.5) days after IESS diagnosis. A total of 113 individuals were responders (57.1% of the cohort), 64 with VGB alone and 38 with VGB further combined with steroids (56.6% and 33.6% of responders, respectively). Among responders, 33 (29%) experienced relapses of spasms, mostly those with later onset of spasms (p = .002) and those who received VGB for <24 months after spasms cessation compared to a longer duration on VGB (45% vs. 12.8%, p = .003). At follow-up, 92 individuals were seizure-free (46.5% of the whole cohort), including 26 free of therapy (13.1%). One hundred twelve individuals (56.6%) were still receiving VGB, with a duration of 3.2 (1.75-5.7) years.

SIGNIFICANCE

Our sequential protocol introducing VGB then adding steroids is an effective alternative to a combined VGB-steroids approach in IESS. It avoids steroid-related adverse events, as well as those from VGB-steroid combination. According to our data, a period of 7 days seems sufficient to assess VGB response and enables the addition of steroids rapidly if needed. Continuing VGB for 2 years may balance the risk of relapse and treatment-induced adverse events.

Preventing Avoidable Rehospitalizations through Standardizing Management of Chronic Conditions in Skilled Nursing Facilities

OBJECTIVES

This study evaluated the impact of standardized care protocols, as a part of a quality improvement initiative (J10ohns Hopkins Community Health Partnership, J-CHiP), on hospital readmission rates for patients with a diagnosis of congestive heart failure (CHF) and/or chronic obstructive pulmonary disease (COPD) after being discharged to skilled nursing facilities (SNFs).

DESIGN

A retrospective study comparing 30-day hospital readmission rates the year before and 2 years following the implementation of the care protocol interventions.

SETTINGS AND PARTICIPANTS

Patients discharged from Johns Hopkins Hospital or Johns Hopkins Bayview Medical Center to the participating SNFs diagnosed with CHF and/or COPD.

METHODS

The standardized protocols included medical provider or nurse assessments on SNF admission, multidisciplinary care planning, and medication management to avoid unplanned readmissions to the hospital. Descriptive analyses were conducted to illustrate the 30-day readmission rates before and after protocol implementation.

RESULTS

There were 1128 patients in the pre-J-CHiP cohort and 2297 patients in the J-CHiP cohort. About half of the patients with a recorded diagnosis of CHF without COPD had the standardized protocol initiated, whereas 47% of the patients with a recorded diagnosis of COPD without CHF had the standardized protocol initiated. Of patients with recorded diagnoses of COPD and CHF, 49% had both protocols initiated. A reduction in the readmission rate was observed for patients with COPD protocols, from 23.5% in 2011 to 12.1% in 2015. However, fluctuations in the readmission rates were observed for patients who initiated the CHF protocols.

CONCLUSIONS AND IMPLICATIONS

There were improvements in the readmission rates in this study, especially for patients who had initiated standardized care protocols in the SNFs. Our findings demonstrate great value in standardizing care management and strengthening collaboration with chronic care settings to facilitate a smooth transition of medically complex patients discharged from large health care systems. Future interventions could consider assessing nonclinical factors that may impact preventable hospital readmissions.

Inferring actual treatment pathways from patient records

OBJECTIVE

Treatment pathways are step-by-step plans outlining the recommended medical care for specific diseases; they get revised when different treatments are found to improve patient outcomes. Examining health records is an important part of this revision process, but inferring patients' actual treatments from health data is challenging due to complex event-coding schemes and the absence of pathway-related annotations. The objective of this study is to develop a method for inferring actual treatment steps for a particular patient group from administrative health records - a common form of tabular healthcare data - and address several technique- and methodology-based gaps in treatment pathway-inference research.

METHODS

We introduce Defrag, a method for examining health records to infer the real-world treatment steps for a particular patient group. Defrag learns the semantic and temporal meaning of healthcare event sequences, allowing it to reliably infer treatment steps from complex healthcare data. To our knowledge, Defrag is the first pathway-inference method to utilise a neural network (NN), an approach made possible by a novel, self-supervised learning objective. We also developed a testing and validation framework for pathway inference, which we use to characterise and evaluate Defrag's pathway inference ability, establish benchmarks, and compare against baselines.

RESULTS

We demonstrate Defrag's effectiveness by identifying best-practice pathway fragments for breast cancer, lung cancer, and melanoma in public healthcare records. Additionally, we use synthetic data experiments to demonstrate the characteristics of the Defrag inference method, and to compare Defrag to several baselines, where it significantly outperforms non-NN-based methods.

CONCLUSIONS

Defrag offers an innovative and effective approach for inferring treatment pathways from complex health data. Defrag significantly outperforms several existing pathway-inference methods, but computationally-derived treatment pathways are still difficult to compare against clinical guidelines. Furthermore, the open-source code for Defrag and the testing framework are provided to encourage further research in this area.

Compass for antibiotic stewardship: using a digital tool to improve guideline adherence and drive clinician behaviour for appendicitis treatment in the emergency department

BACKGROUND

Antibiotic stewardship in the ED is important given the increasing prevalence of multidrug resistance associated with poorer patient outcomes. The use of broad-spectrum antibiotics in the ED for infections like appendicitis is common. At baseline, 75% of appendicitis cases at our institution received broad-spectrum ertapenem rather than the recommended narrower-spectrum ceftriaxone/metronidazole combination. We aimed to improve antibiotic stewardship by identifying barriers to guideline adherence and redesigning our appendicitis antibiotic guideline.

METHODS

Using the 'Fit between Individuals, Task and Technology (FITT)' framework, we identified barriers that preventclinicians from adhering to guidelines. We reformatted a clinical guideline and disseminated it using our ED's clinical decision support system (CDSS), E*Drive. Next, we examined E*Drive's user data and clinician surveys to assess utilisation and satisfaction. Finally, we conducted a retrospective chart review to measure clinician behaviour change in antibiotic prescription for appendicitis treatment.

RESULTS

Data demonstrated an upward trend in the number of monthly users of E*Drive from 1 April 2021 to 30 April 2022, with an average increase of 46 users per month. Our clinician survey results demonstrated that >95% of users strongly agree/agree that E*Drive improves access to clinical information, makes their job more efficient and that E*Drive is easy to access and navigate, with a Net Promoter Score increase from 26.0 to 78.3. 69.4% of patients treated for appendicitis in the post-intervention group received antibiotics concordant with our institutional guideline compared with 20.0% in the pre-intervention group (OR=9.07, 95% CI (3.84 to 21.41)).

CONCLUSION

Antibiotic stewardship can be improved by ensuring clinicians have access to convenient and up-to-date guidelines through clinical decision support systems. The FITT model can help guide projects by identifying individual, task and technology barriers. Sustained adherence to clinical guidelines through simplification of guideline content is a potentially powerful tool to influence clinician behaviour in the ED.

Fast track to stroke unit for patients not eligible for acute intervention, a case-control register study on 1066 patients

Stroke patients not eligible for acute intervention often have low priority and may spend long time at the emergency department (ED) waiting for admission. The aim of this retrospective case-control register study was to evaluate outcomes for such "low priority" stroke patients who were transported via Fast Track directly to the stroke unit, according to pre-specified criteria by emergency medical service (EMS). The outcomes of Fast Track patients, transported directly to stroke unit (cases) were compared with the outcomes of patients who fulfilled these critera for Fast Track, but instead were transported to the ED (controls). In all, 557 cases and 509 controls were identified. The latter spent a mean time of 237 min in the ED before admission. The 90-day mortality rate was 12.9% for cases and 14.7% for controls (n.s.). None of the secondary outcome events differed significantly between the groups: 28-day mortality rate; death rate during hospitalisation; proportion of pneumonias, falls or pressure ulcers; or health-related outcomes according to the EQ-5D-5L questionnaire. These findings indicates that the Fast Track to the stroke unit by an EMS is safe for selected stroke patients and could avoid non-valuable time in the ED.

Electronic field protocols for prehospital care quality improvement in Lithuania: a randomized simulation-based study

BACKGROUND

Prehospital emergency care is complex and influenced by various factors, leading to the need for decision-support tools. Studies suggest that cognitive aids improve provider performance and patient outcomes in clinical emergencies. Electronic cognitive aids have rarely been investigated in prehospital care. Therefore, this study aimed to evaluate the effects of the electronic field protocol (eFP) module on performance, adherence to the standard of care, and satisfaction of prehospital care providers in a simulated environment.

METHODS

This randomised simulation-based study was conducted at the Lithuanian University of Health Sciences in Kaunas, Lithuania. The simulation scenarios were developed to test 12 eFPs: adult resuscitation, pediatric resuscitation, delivery and postpartum care, seizures in pregnancy, stroke, anaphylaxis, acute chest pain, acute abdominal pain, respiratory distress in children, severe trauma, severe infection and sepsis, and initial neonatal evaluation and resuscitation. Sixteen prehospital practitioners with at least 3 years of clinical experience were randomly assigned to either use the eFP module or perform without it in each of the 12 simulated scenarios. Participant scores and adherence to standardised checklists were compared between the two performance modes. Participant satisfaction was measured through a post-simulation survey.

RESULTS

A total of 190 simulation sessions were conducted. Compared to the use of memory alone, the use of the eFP module significantly improved participants' performance in 10 out of the 12 simulation scenarios. Adherence to the standardised checklist increased from 60 to 85% (p < 0.001). Post-simulation survey results indicate that participants found the eFP module easy to use and relevant to prehospital clinical practice.

CONCLUSIONS

The study findings suggest that the eFP module as a cognitive aid can enhance prehospital practitioners' performance and adherence to the standard of care in simulated scenarios. These results highlight the potential of standardised eFPs as a quality improvement step in prehospital care in Lithuania.

Trigger tool-based description of adverse events in helicopter emergency medical services in Qatar

INTRODUCTION

Adverse events (AEs) in helicopter emergency medical services (HEMS) remain poorly reported, despite the potential for harm to occur. The trigger tool (TT) represents a novel approach to AE detection in healthcare. The aim of this study was to retrospectively describe the frequency of AEs and their proximal causes (PCs) in Qatar HEMS.

METHODS

Using the Pittsburgh Adverse Event Tool to identify AEs in HEMS, we retrospectively analysed 804 records within an existing AE TT database (21-month period). We calculated outcome measures for triggers, AEs and harm per 100 patient encounters, plotted measures on statistical process control charts, and conducted a multivariate analysis to report harm associations.

RESULTS

We identified 883 triggers in 536 patients, with a rate of 1.1 triggers per patient encounter, where 81.2% had documentation errors (n=436). An AE and harm rate of 27.7% and 3.5%, respectively, was realised. The leading PC was actions by HEMS Crew (81.6%; n=182). The majority of harm (57.1%) stemmed from the intervention and medication triggers (n=16), where deviation from standard of care was common (37.9%; n=11). Age and diagnosis-adjusted odds were significant in the patient condition (6.50; 95% CI 1.71 to 24.67; p=0.01) and interventional (11.85; 95% CI 1.36 to 102.92; p=0.03) trigger groupings, while age and diagnosis had no effect on harm.

CONCLUSION

The TT methodology is a robust, reliable and valid means of AE detection in the HEMS domain. While an AE rate of 27.7% is high, more research is required to understand prehospital clinical decision-making and reasons for guideline deviance. Furthermore, focused quality improvement initiatives to reduce AEs and documentation errors should also be addressed in future research.

Barriers and Facilitators to the Implementation of the Early-Onset Sepsis Calculator: A Multicenter Survey Study

Prior studies demonstrated the neonatal early-onset sepsis (EOS) calculator's potential in drastically reducing antibiotic prescriptions, and its international adoption is increasing rapidly. To optimize the EOS calculator's impact, successful implementation is crucial. This study aimed to identify key barriers and facilitators to inform an implementation strategy. A multicenter cross-sectional survey was carried out among physicians, residents, nurses and clinical obstetricians of thirteen Dutch hospitals. Survey development was prepared through a literature search and stakeholder interviews. Data collection and analysis were based on the Consolidated Framework for Implementation Research (CFIR). A total of 465 stakeholders completed the survey. The main barriers concerned the expectance of the department's capacity problems and the issues with maternal information transfer between departments. Facilitators concerned multiple relative advantages of the EOS calculator, including stakeholder education, EOS calculator integration in the electronic health record and existing positive expectations about the safety and effectivity of the calculator. Based on these findings, tailored implementation interventions can be developed, such as identifying early adopters and champions, conducting educational meetings tailored to the target group, creating ready-to-use educational materials, integrating the EOS calculator into electronic health records, creating a culture of collective responsibility among departments and collecting data to evaluate implementation success and innovation results.

Process evaluation of the implementation of an evidence-based model of care for low back pain in Australian emergency departments

BACKGROUND

The Sydney Health Partners Emergency Department (SHaPED) trial targeted ED clinicians and evaluated a multifaceted strategy to implement a new model of care. The objective of this study was to investigate attitudes and experiences of ED clinicians as well as barriers and facilitators for implementation of the model of care.

DESIGN

A qualitative study.

METHODS

The EDs of three urban and one rural hospital in New South Wales, Australia participated in the trial between August and November 2018. A sample of clinicians was invited to participate in qualitative interviews via telephone and face-to-face. The data collected from the interviews were coded and grouped in themes using thematic analysis methods.

RESULTS

Non-opioid pain management strategies (i.e., patient education, simple analgesics, and heat wraps) were perceived to be the most helpful strategy for reducing opioid use by ED clinicians. However, time constraints and rotation of junior medical staff were seen as the main barriers for uptake of the model of care. Fear of missing a serious pathology and the clinicians' conviction of a need to provide something for the patient were seen as barriers to reducing lumbar imaging referrals. Other barriers to guideline endorsed care included patient's expectations and characteristics (e.g., older age and symptoms severity).

CONCLUSIONS

Improving knowledge of non-opioid pain management strategies was seen as a helpful strategy for reducing opioid use. However, clinicians also raised barriers related to the ED environment, clinicians' behaviour, and cultural aspects, which should be addressed in future implementation efforts.

Decision-making on the fly: a qualitative study of physicians in out-of-hospital emergency medical services

BACKGROUND

Out-of-hospital Emergency Medical Services (OHEMS) require fast and accurate assessment of patients and efficient clinical judgment in the face of uncertainty and ambiguity. Guidelines and protocols can support staff in these situations, but there is significant variability in their use. Therefore, the aim of this study was to increase our understanding of physician decision-making in OHEMS, in particular, to characterize the types of decisions made and to explore potential facilitating and hindering factors.

METHODS

Qualitative interview study of 21 physicians in a large, publicly-owned and operated OHEMS in Croatia. Data was subjected to an inductive content analysis.

RESULTS

Physicians (mostly young, female, and early in their career), made three decisions (transport, treat, and if yes on either, how) after an initial patient assessment. Decisions were influenced by patient needs, but to a greater extent by factors related to themselves and patients (microsystem), their organization (mesosystem), and the larger health system (macrosystem). This generated a high variability in quality and outcomes. Participants desired support through further training, improved guidelines, formalized feedback, supportive management, and health system process redesign to better coordinate and align care across organizational boundaries.

CONCLUSIONS

The three decisions were made complex by contextual factors that largely lay outside physician control at the mesosystem level. However, physicians still took personal responsibility for concerns more suitably addressed at the organizational level. This negatively impacted care quality and staff well-being. If managers instead adopt a learning orientation, the path from novice to expert physician could be more ably supported through organizational demands and practices aligned with real-world practice. Questions remain on how managers can better support the learning needed to improve quality, safety, and physicians' journey from novice to expert.

Conflicting perspectives during guidelines development are an important source of implementation failure

In recent years many countries have created national bodies that provide evidence-based guidance and policy relating to the commissioning and provision of healthcare services. However, such guidance often fails to be consistently implemented. The differing perspectives from which guidance is developed is suggested as a significant contributor to these failures. A societal perspective is, necessarily, taken by policy makers, while patients and their healthcare professionals are primarily concerned with an individual perspective. This is particularly likely to impair implementation where national policy objectives, such as cost effectiveness, equity, or the promotion of innovation, are embodied in the guidance, while patients and healthcare professionals may consider it appropriate to over-ride these, based upon individual circumstances and preferences. This paper examines these conflicts with reference to guidance issued by the National Institute of Health and Care Excellence in England. Conflicts are identified between the objectives, values, and preferences of those who develop and those who implement such guidance, with consequent difficulties in providing helpful personalised recommendations. The implications of this for the development and implementation of guidance are discussed and recommendations are made regarding the ways in which such guidance is framed and disseminated.

Multifaceted implementation and sustainability of a protocol for prehospital anaesthesia: a retrospective analysis of 2115 patients from helicopter emergency medical services

BACKGROUND

Prehospital emergency anaesthesia (PHEA) is a high-risk procedure. We developed a prehospital anaesthesia protocol for helicopter emergency medical services (HEMS) that standardises the process and involves ambulance crews as active team members to increase efficiency and patient safety. The aim of the current study was to evaluate this change and its sustainability in (i) on-scene time, (ii) intubation first-pass success rate, and (iii) protocol compliance after a multifaceted implementation process.

METHODS

The protocol was implemented in 2015 in a HEMS unit and collaborating emergency medical service systems. The implementation comprised dissemination of information, lectures, simulations, skill stations, academic detailing, and cognitive aids. The methods were tailored based on implementation science frameworks. Data from missions were gathered from mission databases and patient records.

RESULTS

During the study period (2012-2020), 2381 adults underwent PHEA. The implementation year was excluded; 656 patients were analysed before and 1459 patients after implementation of the protocol. Baseline characteristics and patient categories were similar. On-scene time was significantly redused after the implementation (median 32 [IQR 25-42] vs. 29 [IQR 21-39] minutes, p < 0.001). First pass success rate increased constantly during the follow-up period from 74.4% (95% CI 70.7-77.8%) to 97.6% (95% CI 96.7-98.3%), p = 0.0001. Use of mechanical ventilation increased from 70.6% (95% CI 67.0-73.9%) to 93.4% (95% CI 92.3-94.8%), p = 0.0001, and use of rocuronium increased from 86.4% (95% CI 83.6-88.9%) to 98.5% (95% CI 97.7-99.0%), respectively. Deterioration in compliance indicators was not observed.

CONCLUSIONS

We concluded that clinical performance in PHEA can be significantly improved through multifaceted implementation strategies.

Impact of the 2015 European guidelines for resuscitation on traumatic cardiac arrest outcomes and prehospital management: A French nationwide interrupted time-series analysis

AIM

To evaluate the impact of the 2015 European Resuscitation Council (ERC) guidelines on patient outcomes following traumatic cardiac arrest (TCA) and on advanced life support interventions carried out by physician-staffed ambulances.

METHODS

Data of TCA patients aged ≥18 years were extracted from the French nationwide cardiac arrest registry. A pre- (2011-2015) and a post-publication period (2016-2020) were defined. In the guidelines, a specific TCA management algorithm was introduced to prioritise the treatment of reversible causes. Its impact was evaluated using adjusted interrupted time series analysis.

RESULTS

4,980 patients were treated (2,145 during the pre-publication period and 2,739 during the post-publication period). There was no significant change in the rates of prehospital ROSC (22.4% vs. 20.2%, p = 0.07 in the pre- and post- intervention respectively), survival (1.4% vs. 1.4%, p = 0.87) or good neurological outcome (71.4% vs. 66.7%, p = 0.93) or in the incidence of organ donation (1.6% vs. 1.3%, p = 0.50). There were nonsignificant changes in the adjusted temporal trend for ROSC (aOR 0.88; 95% CI [0.77; 1.00]), survival (aOR 1.34; 95% CI [0.83;2.17]), good neurological outcome (aOR 1.57; 95% CI [0.82;3.05]), and organ donation (aOR 1.06; 95% CI [0.71;1.60]). The use of intraosseous catheters (13.0% vs. 19.2%, p < 0.001), external haemorrhage control measures (23.9% vs. 64.8%, p < 0.001), bilateral chest decompression (13.7% vs. 16.5%, p = 0.009), and packed red cell transfusion (2.7% vs. 6.5%, p < 0.001) increased in the post-publication period.

CONCLUSIONS

Despite the increased frequency of trauma rescue interventions performed by on-scene physicians, no change in patient-centred outcomes was associated with the publication of the 2015 ERC guidelines in France.

Ambulance nurses' experiences of using prehospital guidelines for patients with acute chest pain - A qualitative study

BACKGROUND

Ambulance nurses have an important role in early recognition and treatment often being the first medical contact for patients with acute chest pain. However, there is sparse knowledge on the experiences of ambulance nurses with regard to use of Prehospital Guidelines for patients with Acute Chest Pain.

AIM

To explore ambulance nurses' experiences of using prehospital guidelines for patients with acute coronary syndrome.

METHOD

A qualitative descriptive study design. Semi-structured interviews with 22 ambulance nurses recruited through purposive sampling strategy. The material was transcribed and analysed using content analysis.

RESULTS

Two main categories emerged from the results. The first category Sense of professional obligation included experiences of having an important role in caring for patients with acute chest pain. Understanding this role and the collaboration in the chain of care prompted ambulance nurses to adhere to the guidelines. However, not receiving enough feedback on the provided care made them uncertain whether to use guidelines. The second category Clinical difficulties using guidelines consisted of experiences of being surrounded by practical challenges while using guidelines. Ambulance nurses meet these challenges by relying on their clinical experience, which sometimes led to them deviating from the guidelines.

CONCLUSIONS

The ambulance nurses experienced a mixture of feeling secure and insecure when using the guidelines. Foremost, when encountering patients with unspecific chest pain, they felt a lack of feedback and an insufficient collaboration within the chain of care, which made them deviate from guidelines. To increase adherence in guidelines, post-registration education to update the knowledge and skills about guidelines for acute chest pain is needed followed by formal inter-disciplinary feedback on the care provided.

Prehospital assessment of patients with abdominal pain triaged to self-care at home: an observation study

BACKGROUND

Patients who call for emergency medical services (EMS) due to abdominal pain suffer from a broad spectrum of diseases, some of which are time sensitive. As a result of the introduction of the concept of 'optimal level of care', some patients with abdominal pain are triaged to other levels of care than in an emergency department (ED). We hypothesised that it could be challenging in a patient safety perspective.

AIM

This study aims to describe consecutive patients who call for EMS due to abdominal pain and are triaged to self-care by EMS clinicians.

METHODS

This was an observational study performed in an EMS organisation in Western Sweden during 2020. The triage tool Rapid Emergency Triage and Treatment System (RETTS), which included Emergency Signs and Symptom (ESS) codes, was used to find medical records where patients with abdominal pain have been triaged to self-care and 194 patients was included in the study.

RESULTS

Of total 48,311 ambulance missions, A total of 1747 patients were labelled with ESS code six (abdominal pain), including 223 (12.8%) who were given the code for self-care and 194 who were further assessed by the research group. Of these patients, 32 (16.3%) had a return visit within 96 hours due to the same symptoms and 11 (5.6%) were hospitalised. In six of these patients, the EMS triage was evaluated retrospectively and assessed as inappropriate. These patients had a final diagnosis of ruptured abdominal aneurysm (n = 1), acute appendicitis with peritonitis (n = 2) and acute pancreatitis (n = 3). All these patients required extensive evaluation and different treatments, including acute surgery, antibiotics and fluid therapy.

CONCLUSION

Amongst the 1747 patients assessed by EMS due to abdominal pain, 223 (12.8%) were triaged to self-care. Of the 194 patients who were further assessed, 16.3% required a return visit to the ED within 96 hours and 5.6% were hospitalised. Six patients had obvious time-sensitive conditions. Our study highlights the difficulties in the early assessment of abdominal pain and the requirement for an accurate decision support tool.

Reasons for bias in ambulance clinicians' assessments of non-conveyed patients: a mixed-methods study

Background

The number of ambulance assignments and the influx of patients to the emergency departments (EDs) in Sweden have increased in recent years. This is one reason the protocol for prehospital emergency care was developed around referring patients for non-conveyance, either through the see-and-convey elsewhere approach or through the see-and-treat approach. However, this protocol has led to challenges in patient assessments.

This study aimed to investigate the underlying causes of patient harm among those referred for the see-and-treat approach by the emergency medical services.

Methods

This three-phase study involved a mixed-methods design. Cases of injuries, internal investigations and incident analyses of referrals for the see-and-treat approach in two regions in south eastern Sweden from 2015 to 2020 were examined using qualitative content analysis. This qualitative analysis was the basis for the quantitative analysis of the ambulance records. After the qualitative analysis was completed, a review protocol was developed; 34 variables were used to review 240 randomly selected ambulance records logged in 2020, wherein patients were referred for the see-and-treat approach. Finally, the review results were synthesised.

Results

The qualitative analysis revealed three common themes: ‘assessment of patients’, ‘guidelines’ and ‘environment and organisation’. These results were confirmed by a medical journal review. Shortcomings were found in the anamnesis and in the number of targeted examinations performed. The checklist for referring patients for the see-and-treat approach and the information sheet to be provided to the patients were not used. In 34% of the ambulance records examined, the EMS clinicians deviated from the current guidelines for a see-and-treat referral.

Conclusions

The results indicated that the low adherence to guidelines and the patient assessment deviating from the protocol put patients at risk of being harmed during a see-and-treat referral.

Measures are needed to guarantee a safe assessment of an increasing number of patients who are referred for the see-and-treat approach, especially the multi-sick elderly patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-022-00630-8.

Evaluation of Basic Life Support First Responder Naloxone Administration Protocol Adherence

Objectives: Opioid overdoses have become a significant problem across the United States resulting in respiratory depression and risk of death. Basic Life Support (BLS) first responders have had the option to treat respiratory depression using a bag-valve-mask device, however naloxone, an opioid antagonist, has been shown to quickly restore normal respiration. Since the introduction of naloxone and recent mandates across many states for BLS personnel to carry and administer naloxone, investigation into the adherence of naloxone use standing protocols is warranted.

Methods: This preliminary study examined 100 initial cases of BLS first responder administration of naloxone for appropriate indications and protocol adherence.

Results: This study found that n=22/100 naloxone administrations were inappropriate, often given to patients who were not suffering from respiratory depression (n=11/22). Positive pressure ventilation (PPV) was not administered prior to naloxone in n=56/100 cases, of which n=42/100 had an inadequate respiratory effort documented. For patients with a known history of substance use disorder, there was a significant increase in administration of naloxone prior to PPV (60%; n=33/55) compared to patients without a known history (30%; n=9/30).

Conclusion: Overall these preliminary data suggest that during BLS naloxone administration, the majority of cases did not follow at least one component of the standard protocol for patients with respiratory depression. This study suggests that further education and more research are needed to better understand the decision-making processes of prehospital providers to ensure adherence to standard protocols.

South African pre-hospital emergency care personnel's lived experiences of managing paediatric emergencies: A qualitative research design utilising one-on-one interviews

BACKGROUND

The phenomenon of managing paediatric emergencies in the pre-hospital environment within the South African setting is poorly understood with specific regard to what emergency care personnel are experiencing when managing paediatric emergencies.

AIM

The aim of this study was to explore and describe the lived experiences of emergency care personnel in managing paediatric patients in the pre-hospital environment and to understand the meaning and the significance of these experiences.

SETTING

All participants were purposively sampled from emergency medical services agencies operating within the Johannesburg metropolitan city area.

METHODS

This study followed a qualitative, exploratory, descriptive, phenomenological design, whereby participants purposively sampled within the Johannesburg metropolitan city voluntarily consented to one-on-one interviews (n = 10).

RESULTS

Three main themes, with 11 contributing categories, were identified and contextualised with available literature. Emerging from the main themes was an overall sense that managing paediatric emergencies is a negative experience, coloured with feelings of inadequacy, stress, anxiety and even fear.

CONCLUSIONS

The findings of this study provided new insights into what South African EMS are experiencing when managing paediatric emergencies, which enables future research efforts to identify research and practice gaps that are relevant to paediatric pre-hospital emergency care, and that are specific to the South African environment.

CONTRIBUTION

This research provides preliminary insight into the lived experiences of prehospital personnel managing paediatric emergencies as well as emerging recommendations for the improvement of the prehospital care of paediatric patients.

Barriers and facilitators affecting implementation of the Canadian clinical practice guidelines for the diagnosis of acute aortic syndrome

BACKGROUND

Acute aortic syndrome (AAS) is an uncommon, life-threatening emergency that is frequently misdiagnosed. The 2020 Canadian clinical practice guidelines for the diagnosis of AAS incorporate all available evidence into four key recommendations. In order to facilitate the implementation of these recommendations, a clinical decision aid was created. The objective of this study was to identify barriers and facilitators among physicians prior to implementation of the guideline recommendations in a multicentre step wedge cluster randomized control trial.

METHODS

We conducted semi-structured interviews with nine emergency room physicians working at five sites distributed between urban academic and rural settings. We used purposive sampling, contacting physicians until data saturation was reached. Interview questions were designed to understand potential barriers and facilitators to guideline recommendation uptake and use. Responses were analysed according to the Theoretical Domains Framework, and overarching themes describing these barriers and facilitators were identified.

RESULTS

Two themes and six subthemes encompassing 13 theoretical domains were identified. These included clinical decision-making support, awareness of the evidence, social factors, expected consequences, ability of physicians to acquire the necessary data and ease of use. A majority of interviewees anticipated that the guideline recommendations would support clinical decision making and more effectively risk-stratify patients. Other facilitators included endorsement of the guidelines by professional organizations and peers. Barriers to implementation include the fact that laboratory testing and knowledge of the rationale for its use in the investigation of AAS were not widespread. The complexity of the clinical decision aid and concerns about test specificity were also identified as potential barriers to use.

CONCLUSION

Physicians were amenable to using the AAS guideline recommendations to support clinical decision-making and to reduce resource use. A structured intervention should be developed to address the identified barriers and leverage the facilitators in order to ensure successful implementation. Our findings may have implications for the implementation of other guidelines used in emergency departments.

Implementing a Pressure Injury Care Bundle in Chinese Intensive Care Units

Background

The incidence of pressure injury (PI) in intensive care units (ICUs) is high with a low compliance rate for PI prevention standard care. Although studies have confirmed that PIs are largely preventable, a PI care bundle based on the best evidence in Chinese ICUs is lacking.

Aim

The aims of this study are to assess the effectiveness of our PI care bundle-which is based on the best evidence and designed to prevent the development of ICU PIs-and to identify the changes in nurse compliance rates during the implementation process.

Methods

A quasi-experimental, pre- and post-intervention design was used. Implementation strategies included training, auditing during the use of the care bundle, and measuring outcome indicators in the ICU. The key elements of the care bundle were risk identification, skin assessment, patient repositioning, skin care, use of a pressure-reducing device, and nutrition. The number and stage of PIs were collected at three time points by unit staff. The implementation compliance rate was measured at two time points using a compliance checklist.

Results

Pressure injury rates were reduced significantly from 13.86% to 10.41%. The incidence of new hospital-acquired pressure injuries (HAPI) decreased by 29.5% within 6 months. The compliance rate of nurses increased significantly from 55.15% to 60.15% before and after the implementation of the care bundle (χ²=16.72, P=0.00); This result may be attributable to the implementation of care bundle training for nurses and the audit.

Conclusion

A standardized care bundle based on the best evidence is indicated to effectively reduce the incidence of PIs. The increase in compliance rate after the intervention may benefit from nurses training in the care bundle and the audit during the intervention.

Proposing an International Standard Accident Number for Interconnecting Information and Communication Technology Systems of the Rescue Chain

BACKGROUND

The rapid dissemination of smart devices within the internet of things (IoT) is developing toward automatic emergency alerts which are transmitted from machine to machine without human interaction. However, apart from individual projects concentrating on single types of accidents, there is no general methodology of connecting the standalone information and communication technology (ICT) systems involved in an accident: systems for alerting (e.g., smart home/car/wearable), systems in the responding stage (e.g., ambulance), and in the curing stage (e.g., hospital).

OBJECTIVES

We define the International Standard Accident Number (ISAN) as a unique token for interconnecting these ICT systems and to provide embedded data describing the circumstances of an accident (time, position, and identifier of the alerting system).

MATERIALS AND METHODS

Based on the characteristics of processes and ICT systems in emergency care, we derive technological, syntactic, and semantic requirements for the ISAN, and we analyze existing standards to be incorporated in the ISAN specification.

RESULTS

We choose a set of formats for describing the embedded data and give rules for their combination to generate an ISAN. It is a compact alphanumeric representation that is generated easily by the alerting system. We demonstrate generation, conversion, analysis, and visualization via representational state transfer (REST) services. Although ISAN targets machine-to-machine communication, we give examples of graphical user interfaces.

CONCLUSION

Created either locally by the alerting IoT system or remotely using our RESTful service, the ISAN is a simple and flexible token that enables technological, syntactic, and semantic interoperability between all ICT systems in emergency care.

Advanced paramedics and nurses can deliver safe and effective pre-hospital and in-hospital emergency care: An integrative review

AIM

To explore and present an overview of scope of practice among registered nurses and paramedics with an advanced level of education in pre-hospital and in-hospital emergency care.

DESIGN

An integrative literature review.

METHOD

Studies published between 2006 and 2018 were retrieved by searching the databases CINAHL, PubMed, Scopus and Web of Science. Studies were selected by three independent researchers, and data were synthesized using thematic analysis.

RESULTS

The 25 studies identified focused on in-hospital (n = 15) and pre-hospital emergency care (n = 10) and included 13 professional titles originated from seven countries. The thematic analysis disclosed four themes; "Versatile care," "Safe care based on precision and accuracy," "Autonomous performance within boundaries" and "Beneficial towards patients and society." Advanced paramedics' and advanced nurses' services are characterized as safe, of high quality and of public benefit. Their services are being used in everyday practice as well as directed to certain categories of patients.

A qualitative examination of the current management of opioid use disorder and barriers to prescribing buprenorphine in a Canadian emergency department

Background

Emergency departments (EDs) across Canada are increasingly prescribing buprenorphine for opioid use disorder (OUD). The objective of this study was to identify the current knowledge, attitudes, and behaviours of ED physicians on the management of OUD in the ED, including barriers and facilitators to prescribing buprenorphine.

Methods

We purposefully selected emergency physicians from one ED in Toronto which had recently received education on OUD management and had a new addiction medicine follow-up clinic, to participate in semi-structured interviews. We used semi-structured interviews to explore experiences with patients with OUD, conceptions of role of the ED in addressing OUD, and specifically ask about perceptions and experience on using buprenorphine for opioid withdrawal. Our analysis was informed by constructivist grounded theory to help uncover contextualized social processes and focus on what people do and why they do it. Two researchers independently coded transcripts using an iterative constant comparative and interpretative approach.

Results

Results fell broadly into facilitators and barriers. Generally, management of OUD in the ED varied significantly. Physician-level facilitators to treating opioid withdrawal with buprenorphine included: knowledge about OUD an7d buprenorphine, positive experiences with substitution therapy in the past, and the presence of physician champions. Systems-level facilitators included timely access to follow-up care and pre-printed order sets. Barriers included provider inexperience, lack of feedback on treatment effectiveness, limited time to counsel patients, and pressure to discharge patients quickly. Additional barriers included concerns about precipitating withdrawal, prescribing a chronic medication in acute care, and patient attitudes.

Conclusion

This study describes barriers and facilitators to addressing OUD and prescribing buprenorphine in a Canadian ED. These findings suggest a role for additional provider education, involvement of allied health professionals in counseling, and mentorship by physician champions in the department.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-021-00443-1.

Adherence to Guidelines in Adult Patients with Traumatic Brain Injury: A Living Systematic Review

Guidelines aim to improve the quality of medical care and reduce treatment variation. The extent to which guidelines are adhered to in the field of traumatic brain injury (TBI) is unknown. The objectives of this systematic review were to (1) quantify adherence to guidelines in adult patients with TBI, (2) examine factors influencing adherence, and (3) study associations of adherence to clinical guidelines and outcome. We searched EMBASE, MEDLINE, Cochrane Central, PubMed, Web of Science, PsycINFO, SCOPUS, CINAHL, and grey literature in October 2014. We included studies of evidence-based (inter)national guidelines that examined the acute treatment of adult patients with TBI. Methodological quality was assessed using the Research Triangle Institute item bank and Quality in Prognostic Studies Risk of Bias Assessment Instrument. Twenty-two retrospective and prospective observational cohort studies, reported in 25 publications, were included, describing adherence to 13 guideline recommendations. Guideline adherence varied considerably between studies (range 18-100%) and was higher in guideline recommendations based on strong evidence compared with those based on lower evidence, and lower in recommendations of relatively more invasive procedures such as craniotomy. A number of patient-related factors, including age, Glasgow Coma Scale, and intracranial pathology, were associated with greater guideline adherence. Guideline adherence to Brain Trauma Foundation guidelines seemed to be associated with lower mortality. Guideline adherence in TBI is suboptimal, and wide variation exists between studies. Guideline adherence may be improved through the development of strong evidence for guidelines. Further research specifying hospital and management characteristics that explain variation in guideline adherence is warranted.

Building Back Better: Applying Lessons from the COVID-19 Pandemic to Expand Critical Information Access

Background

The Coronavirus disease 2019 (COVID-19) pandemic generated an unprecedented volume of evolving clinical guidelines that strained existing clinical information systems and necessitated rapid innovation in emergency departments (EDs).

Objectives

Our team aimed to harness new COVID-19-related reliance on digital clinical support tools to re-envision how all clinical guidelines are stored and accessed in our ED.

Methods

We used a design-thinking approach including empathizing, defining the problem, ideating, prototyping, and testing to develop a low-cost, homegrown clinical information hub: E*Drive. To measure impact, we compared web traffic on E*Drive to our legacy cloud-based folder system and conducted a survey of end-users using a validated health technology utilization instrument.

Results

Our final product, E*Drive, is a centralized clinical information hub storing everything from clinical guidelines to discharge resources. Clinical guidelines are standardized and housed within the high-traffic E*Drive platform to increase accessibility. Since launch, E*Drive has averaged 84 unique weekly users, compared with less than one weekly user on the legacy system. We surveyed 52 clinicians for a total response rate of 47%. Prior to the E*Drive rollout, 12.5% of ED clinicians felt confident accessing clinical information on the legacy system, whereas 76.6% of ED clinicians felt they could more easily access clinical information using E*Drive.

Conclusion

The COVID pandemic revealed vulnerabilities within our information dissemination system and presented an opportunity to improve clinical information delivery. Centralized web-based clinical information hubs designed around the clinician end-user experience can increase clinical guideline access in the ED.

What Are Models of Care? A Systematic Search and Narrative Review to Guide Development of Care Models for Premature Ovarian Insufficiency

No specific model of care (MoC) is recommended for premature ovarian insufficiency (POI), despite awareness that POI is associated with comorbidities requiring multidisciplinary care. This article aims to explore the definitions and central components of MoC in health settings, so that care models for POI can be developed. A systematic search was performed on Ovid Medline and Embase, and including gray literature. Unique definitions of MoC were identified, and thematic analysis was used to summarize the key component of MoC. Of 2,477 articles identified, 8 provided unique definitions of MoC, and 11 described components of MoC. Definitions differ in scope, focusing on disease, service, or system level, but a key feature is that MoC is operational, describing how care is delivered, as well as what that care is. Thematic analysis identified 42 components of MoC, summarized into 6 themes-stakeholder engagement, supporting integrated care, evidence-based care, defined outcomes and evaluation, behavior change methodology, and adaptability. Stakeholder engagement was central to all other themes. MoCs operationalize how best practice care can be delivered at a disease, service, or systems level. Specific MoC should be developed for POI, to improve clinical and process outcomes, translate evidence into practice, and use resources more efficiently.

Adherence to guidelines in the management of urolithiasis: are there differences among distinct patient care settings?

INTRODUCTION

Urolithiasis is a common diagnosis in urology. New technologies offer a variety of diagnostic and therapy and consequently display a financial burden on healthcare systems. Hence, clinical practice guidelines (CPG) are essential to implement evidence-based medicine and assure a standard of care considering limited resources. To date, there is no evidence of the use and adherence to CPG on urolithiasis.

MATERIAL AND METHODS

Therefore, we performed a cross-sectional study to analyze the use of CPG on urolithiasis. Data collection was carried out by a questionnaire given to 400 German urologists. The survey included use and adherence to guidelines, evaluation of the clinical situation, therapy spectrum, and workplace. In total, 150 (37%) questionnaires were received and included in our survey. Statistics were performed by SPSS using Chi-quadrat test/Fisher's exact test.

RESULTS

In our study, urologists were office based, hospital affiliated, non-academic, or academic centers in 53%, 32%, 16% and 5%, respectively. In 74% and 70%, urologists adhere to CPG in diagnostic and therapy. Interestingly, workplace and therapy spectrum determines the use of different CPG (p = 0.01; p = 0.022). Academic urologists were more likely to use international CPG of EAU (40%), while outpatient urologists significantly orientated on national CPG (46%). 86% of urologists with high volume of urolithiasis practice interventions in contrast to 53% in low volume (p = 0.001). More than 80% of urologists use short versions and app version of CPG.

CONCLUSION

We firstly describe compliance and the use of CPG on urolithiasis. EAU and DGU present the most commonly used CPG. Short version and app version of CPG find frequent clinical utilization.

Comparison between two protocols for deflation of the TR band following coronary procedures via the radial route

Aim

Coronary interventions are increasingly being performed via the radial rather than femoral route because of the lower complication rate. Compression devices such as the TR band are used to achieve hemostasis after the procedure. At present, there are no clear protocols for the deflation of the band. In this study we compared two protocols (early deflation with increased intervals vs. late deflation with smaller intervals) in terms of total time to band removal and complications, and patient and staff satisfaction.

Methods

All patients who underwent a transradial coronary procedure and had a TR band fitted were enrolled into the study. The TR band was applied using the patent hemostasis method (2 ml air pushed in after the radial pulse appears on pulse oximetry after full occlusion with 16 ml air). Patients were randomly assigned to either protocol. Protocol 1 involved removal of 2 ml of air starting 1 hour after the sheath removal and then removal of 2 ml every 30 minutes until the band came off. Protocol 2 involved removal of 4 ml of air 2 hours after the sheath removal and then further 4 ml of air every 15 minutes until the band came off. Patient and staff satisfaction was measured with a visual analogue scale.

Results

A total of 174 patients were recruited (mean age, 60 ± 11 years; 127 male, 47 female). The baseline characteristics including total heparin dose and type of procedure, in the two arms were the same. Protocol 2 (n = 84) was associated with a significantly lower time to TR band removal as compared to protocol 1 (n = 90; 201 ± 43 min vs. 274 ± 54 min; p < 0.001). There was no difference in complications such as bleeding or hematoma formation between the two groups. Patient satisfaction was the same between the two groups. However, the staff preferred protocol 1 (p = 0.01).

Conclusion

A protocol of delayed initiation of TR band deflation followed by quick deflations is associated with a lower time to band removal with no increase in bleeding complications or patient satisfaction. However, the staff preferred longer intervals between deflations.

Prehospital Management of Traumatic Brain Injury across Europe: A CENTER-TBI Study

BACKGROUND

Prehospital care for traumatic brain injury (TBI) is important to prevent secondary brain injury. We aim to compare prehospital care systems within Europe and investigate the association of system characteristics with the stability of patients at hospital arrival.

METHODS

We studied TBI patients who were transported to CENTER-TBI centers, a pan-European, prospective TBI cohort study, by emergency medical services between 2014 and 2017. The association of demographic factors, injury severity, situational factors, and interventions associated with on-scene time was assessed using linear regression. We used mixed effects models to investigate the case mix adjusted variation between countries in prehospital times and interventions. The case mix adjusted impact of on-scene time and interventions on hypoxia (oxygen saturation <90%) and hypotension (systolic blood pressure <100mmHg) at hospital arrival was analyzed with logistic regression.

RESULTS

Among 3878 patients, the greatest driver of longer on-scene time was intubation (+8.3 min, 95% CI: 5.6-11.1). Secondary referral was associated with shorter on-scene time (-5.0 min 95% CI: -6.2- -3.8). Between countries, there was a large variation in response (range: 12-25 min), on-scene (range: 16-36 min) and travel time (range: 15-32 min) and in prehospital interventions. These variations were not explained by patient factors such as conscious level or severity of injury (expected OR between countries: 1.8 for intubation, 1.8 for IV fluids, 2.0 for helicopter). On-scene time was not associated with the regional EMS policy (p= 0.58). Hypotension and/or hypoxia were seen in 180 (6%) and 97 (3%) patients in the overall cohort and in 13% and 7% of patients with severe TBI (GCS <8). The largest association with secondary insults at hospital arrival was with major extracranial injury: the OR was 3.6 (95% CI: 2.6-5.0) for hypotension and 4.4 (95% CI: 2.9-6.7) for hypoxia.

DISCUSSION

Hypoxia and hypotension continue to occur in patients who suffer a TBI, and remain relatively common in severe TBI. Substantial variation in prehospital care exists for patients after TBI in Europe, which is only partially explained by patient factors.

Characteristics of non-conveyed patients in emergency medical services (EMS): a one-year prospective descriptive and comparative study in a region of Sweden

Background

There has been an increasing demand for emergency medical services (EMS), and a growing number of patients are not conveyed; i.e., they are referred to levels of care other than ambulance conveyance to the emergency department. Patient safety issues have been raised regarding the ability of EMS to decide not to convey patients. To improve non-conveyance guidelines, information is needed about patients who are not conveyed by EMS. Therefore, the purpose of this study was to describe and compare the proportion and characteristics of non-conveyed EMS patients, together with assignment data.

Methods

A descriptive and comparative consecutive cohort design was undertaken. The decision of whether to convey patients was made by EMS according to a region-specific non-conveyance guideline. Non-conveyed patients’ medical record data were prospectively gathered from February 2016 to January 2017. Analyses was conducted using the chi-squared test, two-sample t test, proportion test and Mann-Whitneys U-test.

Results

Out of the 23,250 patients served during the study period, 2691 (12%) were not conveyed. For non-conveyed adults, the most commonly used Emergency Signs and Symptoms (ESS) codes were unspecific symptoms/malaise, abdomen/flank/groin pain, and breathing difficulties. For non-conveyed children, the most common ESS codes were breathing difficulties and fever of unclear origin. Most of the non-conveyed patients had normal vital signs. Half of all patients with a designated non-conveyance level of care were referred to self-care. There were statistically significant differences between men and women.

Conclusions

Fewer patients were non-conveyed in the studied region compared to national and international non-conveyance rates. The differences seen between men and women were not of clinical significance. Follow-up studies are needed to understand what effect patient outcome so that guidelines might improve.

Prehospital emergency nurses' experiences of care in critical incidents

INTRODUCTION

The ambulance care setting is complex and unpredictable and the personnel must prepare for upcoming assignments. Prehospital emergency care nurses (PENs), are frequently exposed to critical incidents (CIs). There are, to our knowledge, no prior studies describing experiences of requirements for management of caring for a patient during a CI in the ambulance care context. Therefore, the aim of the study was to explore PENs' experiences of care in CIs.

METHOD

A qualitative research design with content analysis has been used, based on semi-structured interviews with eleven PENs in Sweden.

RESULTS

PENs' experiences can be described as: "In a critical incident, personal ability based on experiential knowledge is central to patient care". Three generic categories underpinned the main category: "Clinical expertise", "Professional approach" and "Broad knowledge base".

CONCLUSIONS

The care given during a CI in the ambulance care setting depends on PENs' personal ability based on experiential knowledge. Employers need to build an organization providing prerequisites and support during an CI. Suggested activities are to create forums for PENs to share experiences with each other, possibility to get feedback on completed assignments and continued training to develop new knowledge and be prepared for the unpredictable environment that characterizes CI.

Optimizing Routine and Disaster Prehospital Care Through Improved Emergency Medical Services Oversight

OBJECTIVE

To identify modifiers of emergency medical services (EMS) oversight quality, including facilitators and barriers, and inform best practices and policy related to EMS oversight and system performance.

METHODS

We used a qualitative design, including 4 focus groups and 10 in-depth, 1-on-1 interviews. Primary data were collected from EMS stakeholders in Michigan from June to July 2016. Qualitative data were analyzed using the rapid assessment technique.

RESULTS

Emergent themes included organizational structure, oversight and stakeholder leadership, interorganizational communication and relationships, competition or collaboration among MCA stakeholders, quality improvement practices, resources, and needs specific to rural communities.

CONCLUSIONS

EMS is a critical component of disaster response. This study revealed salient themes and modifiers, including facilitators and barriers, of EMS oversight quality. These findings were evaluated in the context of current evidence and informed state policy to improve the quality of EMS oversight and prehospital care for both routine and disaster settings. Some were particular to geographic regions and communities, whereas others were generalizable.

A Canadian Rural Living Lab Hospital: Implementing solutions for improving rural emergency care

INTRODUCTION

More than 6 million Canadians live in rural areas (approximately 20% of the population) and emergency services are a critical safety net for them.

OBJECTIVES

We want to create, in Baie-Saint-Paul (rural emergency department, Québec, Canada), an experimental milieu where all stakeholders develop, implement and evaluate solutions to address the problems that beset their environment.

METHOD

The Living Lab will rely on the quadruple aim approach to improve health system performance and will use a multimethod approach based on the philosophy of open and user-driven innovation. Three pilot projects will be implemented (quality of work life programme, computed tomography implementation study and telemedicine in ambulances). Other possible solutions will be evaluated and prioritised (in situ simulation, care protocol, telemedicine, point-of-care ultrasound, helicopters and drones).

CONCLUSION

We are confident that this Living Lab will contribute to saving lives, will improve the quality of work life for rural healthcare professionals, and will inspire similar innovation internationally.

Physician Prehospital Care in Mexico City: Retrospective Analysis of Endotracheal Intubation in Patients with Severe Head Trauma

INTRODUCTION

In Mexico, physicians have become part of public service prehospital care. Head injured patients are a sensitive group that can benefit from early advanced measures to protect the airway, with the objective to reduce hypoxia and maintain normocapnia.

PROBLEM

The occurrence of endotracheal intubation to patients with severe head injuries by prehospital physicians working at Mexico City's Service of Emergency Medical Care (SAMU) is unknown.

METHODS

A retrospective analysis of five-year data (2012-2016) from Mexico City's Medical Emergencies Regulation Center was performed. Only SAMU ambulance services were analyzed. Adult patients with a prehospital diagnosis of head injury based on mechanism of injury and physical examination with a Glasgow Coma Scale (GCS) <nine were included.

RESULTS

A total of 293 cases met the inclusion criteria; the mean GCS was five points. Of those, 150 (51.1%) patients were intubated. There was no difference in the occurrence of intubation among the different GCS scales, or if the patient was considered to have isolated head trauma versus polytrauma. Fifteen patients were intubated using sedation and neuromuscular blockage. Four patients were intubated with sedation alone and six patients with neuromuscular blockage alone. One patient was intubated using opioid analgesia, sedation, and neuromuscular blockage.

CONCLUSIONS

Patients with severe head injuries cared by prehospital physicians in Mexico City were intubated 51.1% of the time and were more likely to be intubated without the assistance of anesthetics.

Neonatal resuscitation guideline adherence: simulation study and framework for improvement

We wanted to assess newborn life support (NLS) knowledge and guideline adherence, and provide strategies to improve (neonatal) resuscitation guideline adherence. Pediatricians completed 17 multiple-choice questions (MCQ). They performed a simulated NLS scenario, using a high-fidelity manikin. The literature was systematically searched for publications regarding guideline adherence. Forty-six pediatricians participated: 45 completed the MCQ, 34 performed the scenario. Seventy-one percent (median, IQR 56-82) of the MCQ were answered correctly. Fifty-six percent performed inflation breaths ≤ 60 s, 24% delivered inflation breaths of 2-3 s, and 85% used adequate inspiratory pressures. Airway patency was ensured 83% (IQR 76-92) of the time. Median events/min, compression rate, and percentage of effective compressions were 138/min (IQR 130-145), 120/min (IQR 114-120), and 38% (IQR 24-48), respectively. Other adherence percentages were temperature management 50%, auscultation of initial heart rate 100%, pulse oximeter use 94%, oxygen increase 74%, and correct epinephrine dose 82%. Ten publications were identified and used for our framework. The framework may inspire clinicians, educators, researchers, and guideline developers in their attempt to improve resuscitation guideline adherence. It contains many feasible strategies to enhance professionals' knowledge, skills, self-efficacy, and team performance, as well as recommendations regarding equipment, environment, and guideline development/dissemination.Conclusion: NLS guideline adherence among pediatricians needs improvement. Our framework is meant to promote resuscitation guideline adherence. What is Known: • Inadequate newborn life support (NLS) may contribute to (long-term) pulmonary and cerebral damage. • Video-based assessment of neonatal resuscitations has shown that deviations from the NLS guideline occur frequently; this assessment method has its audiovisual shortcomings. What is New: • The resuscitation quality metrics provided by our high-fidelity manikin suggest that the adherence of Dutch general pediatricians to the NLS guideline is suboptimal. • We constructed a comprehensive framework, containing multiple strategies to improve (neonatal) resuscitation guideline adherence.

Implementation of the protocol of nursing care in trauma in aeromedical service

ABSTRACT Objective: To analyze the implementation of a nursing care protocol for trauma patients before, during and after the flight. Method: A cross-sectional quantitative study carried out in an aeromedical service, using a checklist with 106 care: 79 before flight, 25 during, and 2 after flight. 97 patients were included in the study. Results: Most care (n = 59; 55.7%) was implemented, totaling 4,435, 1,480 and 192 cares performed before, during and after the flight, respectively. They stood out as unrealized care: protect ears with ear muffler (n = 55) and avoid leaving the pulse oximeter exposed to the sun’s rays (n = 22). The main reason for the non-performance was lack of appeal (n = 94). Conclusion: Although most protocol care has been implemented, unrealized care compromises the quality of care, which requires the management of the service to provide more incentive to nurses and adequate resources for its implementation.

What is known about the quality of out-of-hospital emergency medical services in the Arabian Gulf States? A systematic review

BACKGROUND

The Emergency Medical Services (EMS) have been developed in the Arabian Gulf States (AGS) in the last three decades. The EMS needs continuous quality assessment of their performance to improve and provide the best out-of-hospital care. This study aims to assess the quality of EMS in the AGS according to the six quality domains of the Institute of Medicine.

METHODS

We searched four databases (i.e., PubMed, EMBASE, Web of Science, and CINAHL) for studies that reported on the quality of EMS in any of the AGS using clinical or non-clinical performance indicators. To quantify study quality and risk of bias, the adapted Newcastle Ottawa Scale was used. We focused on structural and functional indicators, clinical and non-clinical.

RESULTS

Twenty-five studies were eligible for inclusion. One study contained result of safety, fifteen time-centeredness, twenty effectiveness, five patient-centeredness, and thirteen studies reported on equity of EMS. None of the studies reported on efficiency of EMS. A significant proportion of studies showed high scores on the Newcastle-Ottawa scale. Limited studies on EMS quality were available, not covering all relevant quality domains and not covering the whole AGS region. The equity domain showed the best outcome performance finding, whereas finding of the patient-centeredness domain showed room for improvement in the foreseeable future.

CONCLUSION

This review highlights the need for more and better studies of sufficient quality about all domains of quality in EMS in all the AGS. EMS research in Kuwait and Bahrain is warranted, as currently studies of EMS quality are unavailable for these States. Moreover, efficiency researches exploring this discipline should be conducted specially no studies were found has been searching this domain.

TRIAL REGISTRATION

PROSPERO registration number: CRD42019123896.

The performance of the EMS triage (RETTS-p) and the agreement between the field assessment and final hospital diagnosis: a prospective observational study among children < 16 years

Background

The rapid triage and treatment system for paediatrics (RETTS-p) has been used by the emergency medical services (EMS) in the west of Sweden since 2014. The performance of the RETTS-p in the pre-hospital setting and the agreement between the EMS nurse’s field assessment and the hospital diagnosis is unknown. The aim of this study was to evaluate the performance of the RETTS-p in the EMS and the agreement between the EMS field assessment and the hospital diagnosis.

Methods

A prospective observational study was conducted among 454 patients < 16 years of age who were assessed and transported to the PED. Two instruments were used for comparison: 1) Classification of an emergent patient according to predefined criteria as compared to the RETTS-p and 2) Agreement between the EMS nurse’s field assessment and the hospital diagnosis.

Results

Among all children, 11% were identified as having vital signs associated with an increased risk of death and 7% were diagnosed in hospital with a potentially life-threatening condition. Of the children triaged with RETTS-p (85.9%), 149 of 390 children (38.2%) were triaged to RETTS-p red or orange (life-threatening, potentially life-threatening), of which 40 (26.8%) children were classified as emergent. The hospitalised children were triaged with the highest frequency to level yellow (can wait; 41.5%). In children with RETTS-p red or orange, the sensitivity for a defined emergent patient was 66.7%, with a corresponding specificity of 67.0%. The EMS field assessment was in agreement with the final hospital diagnosis in 80% of the cases.

Conclusions

The RETTS-p sensitivity in this study is considered moderate. Two thirds of the children triaged to life threatening or potentially life threatening were later identified as non-emergent. Of those, one in six was discharged from the PED without any intervention. Further, one third of the children were under triaged, the majority were found in the yellow triage level (can wait). The highest proportion of hospitalised patients was found in the yellow triage level. Our result is in agreement with previous studies using other triage instruments. A computerised decision support system might help the EMS triage to increase sensitivity and specificity.

Multi-centre study found that strict adherence to guidelines led to computed tomography scans being overused in children with minor head injuries

AIM

Our primary aim was to calculate the head computed tomography (CT) scan rate in children with a minor head injury (MHI) when the Dutch National guidelines were followed in clinical practice. The secondary aim was to determine the incidence of CT abnormalities and the guideline predictors associated with traumatic abnormalities.

METHODS

We performed a multi-centre, prospective observational cross-sectional study in the emergency departments of six hospitals in The Netherlands between 1 April 2015 and 31 December 2016.

RESULTS

Data on 1002 patients were studied and 69% of cases complied with the guidelines. The overall CT rate was 44% and the incidence of traumatic abnormal CT findings was 13%. CT scans were performed in 19% of children under two years of age, 48% of children between two and five years and 63% of children aged six years or more. Multivariate regression analysis for all age categories showed that CT abnormalities were predicted by a Glasgow Coma Scale of less than 15, suspicion of a basal skull fracture, vomiting and scalp haematomas or external lesions of the skull.

CONCLUSION

Strict adherence to the Dutch national guidelines resulted in CT overuse. New guidelines are needed to safely reduce CT scan indications.

Implementation of new guidelines in the prehospital services: a nationwide survey of Norway

Background

A debate regarding the potential harmful effects of rigid neck collar and backboard usage among prehospital and hospital care providers in Norway provoked the development of an evidence-based guideline. “The Norwegian guideline for the prehospital management of adult trauma patients with potential spinal injury” was developed with rigorous scientific methods and published in 2016. An e-learning course was developed in parallel. The aim of this study is to explore whether emergency medical services personnel in Norway have implemented the guideline, and to what extent the e-learning course was applied during the implementation process.

Method

An electronic survey was distributed individually to registered prehospital personnel in Norway 18 months after publication of the guideline.

Results

In all, 938 of 5500 (17%) EMS personnel responded to the survey. More than one-half confirmed knowledge of the guideline; among these, 56% claimed that the guideline was implemented in the service they work. Not having responded to trauma cases in real life was the main reason for not having executed the guideline. The e-learning course had been completed by 18% of respondents.

Conclusion

Although the guideline has not been authorized or made compulsory by national authorities, one-half of respondents with knowledge of the guideline reported it as implemented. E-learning did not seem to have affected the implementation. The guideline was developed based on perceived needs among care providers, and this probably facilitated implementation of the guideline.

Electronic supplementary material

The online version of this article (10.1186/s13049-019-0660-0) contains supplementary material, which is available to authorized users.

Complexity of the pediatric trauma care process: Implications for multi-level awareness

Trauma is the leading cause of disability and death in children and young adults in the US. While much is known about the medical aspects of inpatient pediatric trauma care, not much is known about the processes and roles involved in in-hospital care. Using human factors engineering (HFE) methods, we combine interview, archival document and trauma registry data to describe how intra-hospital care transitions affect process and team complexity. Specifically, we identify the 53 roles directly involved in patient care in each hospital unit and describe the 3324 total transitions between hospital units and the 69 unique pathways, from arrival to discharge, experienced by pediatric trauma patients. We continue the argument to shift from eliminating complexity to coping with it and propose supporting three levels of awareness to enhance the resilience and adaptation necessary for patient safety in health care, i.e. safety in complex systems. We discuss three levels of awareness (individual, team and organizational) and describe challenges and potential sociotechnical solutions for each. For example, one challenge to individual awareness is high time pressure. A potential solution is clinical decision support of information perception, integration and decision making. A challenge to team awareness is inadequate "non-technical" skills, e.g., leadership, communication, role clarity; simulation or another form of training could improve these. The complex, distributed nature of this process is a challenge to organizational awareness; a potential solution is to develop awareness of the process and the roles and interdependencies within it, by using process modeling or simulation.

Management of Preventable Deaths due to Road Traffic Injuries in Prehospital Phase; a Qualitative Study

INTRODUCTION

Prehospital care plays an important role in decreasing the number of deaths due to road traffic injuries (RTIs). This study aimed to identify the challenges of preventable deaths due to RTIs in the prehospital phase based on the attitudes of stakeholders.

METHODS

Conventional content analysis of qualitative study was used to analyze the data. The participants were 24 RTI prevention experts from fire-fighting organization, traffic police, the Red Crescent, Emergency Medical Services staff, emergency medicine specialists, and hospital emergency nurses who were selected by means of purposive sampling. Data were collected using unstructured interviews and analyzed by means of data coding, followed by extracting sub-categories, and main categories.

RESULTS

Six main categories were extracted as the major challenges of preventable deaths in RTIs in the prehospital phase including "poor management of the crash scene" with two subcategories of lack of rapid access to the patient and lack of scene safety, "lack of adequate rules and regulations" with two subcategories of lack of protocols and guidelines and lack of clear duties checklists, "poor management of time" with two subcategories of elongated response time at the crash scene and elongated time of victim transport, "low quality of training" with two subcategories of insufficient training of Emergency Medical Services (EMS) staff and inadequate public training, "poor communication and coordination" with two subcategories of poor communication of EMS staff and lack of uniform commandership at the crash scene, and "low quality of victim management" with two subcategories of low quality of clinical care and lack of accurate clinical assessment.

CONCLUSION

The following measures are necessary to reduce preventable deaths due to RTIs in the prehospital phase: accurate clinical assessment of the victim on the scene, provision of high quality and accurate clinical care, enforcement of legal obligations and using protocols in the field of victim management, coordination of the involved organizations through identifying the duties and responsibilities of each organization, and full management of the crash scene by assigning a unique commander to each unit and creation of the highest level of safety on crash scene.

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

PURPOSE

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

DATA SOURCES

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

STUDY SELECTION

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

DATA EXTRACTION

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

RESULTS OF DATA SYNTHESIS

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

CONCLUSION

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

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.