Mapping the use of simulation in prehospital care - a literature review

Difficulties of Spanish Primary Health Care nurses to assist emergencies: A cross-sectional study

BACKGROUND

The competence of a Primary Health Care nurse to handle emergency situations depends largely on prior acquisition of theoretical knowledge to make appropriate decisions, combined with the corresponding practical skills to carry out swift and effective interventions.

METHODS

Cross-sectional study conducted in through a survey auto-administered to a simple random sample of 269 nurses (n) with replacement of Asturias, Spain from the total nursing staff of 730 members (N) in Asturias.

RESULTS

In rural areas, the most frequently mentioned reasons were the lack of practical skills (18.9%) and the absence of adequate material (14.4 %). In the semi-urban area, the most common reasons were the lack of practical skills (13.2 %) and the lack of theoretical knowledge (10.3 %). Finally, in the urban area, the main reasons were the lack of practical skills (14.4 %) and the absence of adequate material (7.2 %). The differences were significant (p = 0.025).

CONCLUSIONS

Despite the requirement that they acquire the necessary theoretical and practical skills, not all PHC nurses perceive themselves to be sufficiently prepared. The degree of self-perceived acquisition of this knowledge and skills, which is so important and necessary, is heterogeneous, with clear differences according to the respective field of work.

Peer Teachers' Professional Identity Development During a Prehospital Simulation: A Grounded Theory Study

INTRODUCTION

Peer teachers have been found to be effective instructors during simulation-based education. However, there is a lack of research regarding their professional identity development throughout the course of the teaching activity. The purpose of this qualitative study, therefore, was to develop a framework to illustrate how peer teachers develop as educators during a prehospital simulation.

METHODS

The participants in our study were 9 second-year medical students serving as peer teachers during a multiday prehospital simulation. We selected the grounded theory tradition of qualitative research to investigate the peer teachers' professional identity development. Our research team interviewed each participant twice during the simulation. We then used open and axial coding to analyze the interview data. We organized these codes into categories and determined connections between each category to construct our grounded theory framework.

RESULTS

This framework described how the peer teachers progressed through 4 stages: 1) eager excitement, 2) grounded by challenges, 3) overcoming challenges, and 4) professional identity formation.

CONCLUSION

Our results revealed that simulation-based education can serve as valuable learning environment not only for medical students, but also for peer teachers. Understanding their progressive development during the simulation will help medical educators focus on maximizing the peer teachers' growth and development during simulation.

Types and effects of feedback for emergency ambulance staff: a systematic mixed studies review and meta-analysis

BACKGROUND

Extensive research has been conducted into the effects of feedback interventions within many areas of healthcare, but prehospital emergency care has been relatively neglected. Exploratory work suggests that enhancing feedback and follow-up to emergency medical service (EMS) staff might provide staff with closure and improve clinical performance. Our aim was to summarise the literature on the types of feedback received by EMS professionals and its effects on the quality and safety of patient care, staff well-being and professional development.

METHODS

A systematic review and meta-analysis, including primary research studies of any method published in peer-reviewed journals. Studies were included if they contained information on systematic feedback to emergency ambulance staff regarding their performance. Databases searched from inception were MEDLINE, Embase, AMED, PsycINFO, HMIC, CINAHL and Web of Science, with searches last updated on 2 August 2022. Study quality was appraised using the Mixed Methods Appraisal Tool. Data analysis followed a convergent integrated design involving simultaneous narrative synthesis and random effects multilevel meta-analyses.

RESULTS

The search strategy yielded 3183 articles, with 48 studies meeting inclusion criteria after title/abstract screening and full-text review. Interventions were categorised as audit and feedback (n=31), peer-to-peer feedback (n=3), postevent debriefing (n=2), incident-prompted feedback (n=1), patient outcome feedback (n=1) or a combination thereof (n=4). Feedback was found to have a moderate positive effect on quality of care and professional development with a pooled effect of d=0.50 (95% CI 0.34, 0.67). Feedback to EMS professionals had large effects in improving documentation (d=0.73 (0.00, 1.45)) and protocol adherence (d=0.68 (0.12, 1.24)), as well as small effects in enhancing cardiac arrest performance (d=0.46 (0.06, 0.86)), clinical decision-making (d=0.47 (0.23, 0.72)), ambulance times (d=0.43 (0.12, 0.74)) and survival rates (d=0.22 (0.11, 0.33)). The between-study heterogeneity variance was estimated at σ2=0.32 (95% CI 0.22, 0.50), with an I2 value of 99% (95% CI 98%, 99%), indicating substantial statistical heterogeneity.

CONCLUSION

This review demonstrated that the evidence base currently does not support a clear single point estimate of the pooled effect of feedback to EMS staff as a single intervention type due to study heterogeneity. Further research is needed to provide guidance and frameworks supporting better design and evaluation of feedback interventions within EMS.

PROSPERO REGISTRATION NUMBER

CRD42020162600.

Communication in Sudden-Onset Major Incidents: Patterns and Challenges-Scoping Review

OBJECTIVE

To identify and describe patterns and challenges in communication in sudden-onset major incidents.

METHODS

Systematic scoping review according to Joanna Briggs Institute and PRISMA-ScR guidelines. Data sources included Cochrane Library, EMBASE, PubMed/MEDLINE, Scopus, SweMed+, Web of Science, and Google Scholar. Non-indexed literature was searched as well. The included literature went through data extraction and quality appraisal as per pre-registered protocol.

RESULTS

The scoping review comprised 32 papers from different sources. Communication breakdown was reported in 25 (78.1%) of the included papers. Inter-authority communication challenges were reported in 18 (56.3%) of the papers. System overload and incompatibility was described in 9 papers (28.1%). Study design was clearly described in 30 papers (93.8%).

CONCLUSIONS

The pattern in major incident communication is reflected by frequent breakdowns with potential and actual consequences for patient survival and outcome. The challenges in communication are predominantly inter-authority communication, system overload and incompatibility, and insufficient pre-incident planning and guidelines.

Simulation-Based Education in Trauma Management: A Scoping Review

Trauma injuries are an important healthcare problem and one of the main leading causes of death worldwide. The purpose of this review was to analyze current practices in teaching trauma management using simulations, with the aim of summarizing them, identifying gaps and providing a critical overview on what has already been achieved. A search on the Web of Science website for simulation-based trauma training articles published from 2010 onwards was performed, obtaining 1617 publications. These publications were screened to 35 articles, which were deeply analyzed, gathering the following information: the authors, the publication type, the year of the publication, the total number of citations, the population of the training, the simulation method used, the skills trained, the evaluation type used for the simulation method presented in the paper, if skills improved after the training and the context in which the simulation took place. Of the 35 articles included in this review, only a few of them had students as the target audience. The more used simulation method was a high-fidelity mannequin, in which the participants trained in more technical than non-technical skills. Almost none of the studies introduced an automated evaluation process and most of the evaluation methods consisted of checklists or questionnaires. Finally, trauma training focused more on treating trauma patients in a hospital environment than in a pre-hospital one. Overall, improvements in the evaluation method, as well as in the development of trauma training on undergraduate education, are important areas for further development.

The Need for Trauma Management Training and Evaluation on a Prehospital Setting

Trauma is one of the leading causes of death in the world, being the main cause of death in people under 45 years old. The epidemiology of these deaths shows an important peak during the first hour after a traumatic event. Therefore, learning how to manage traumatic injuries in a prehospital setting is of great importance. Medical students from Universidad Autónoma performed 66 different simulations to stabilize a trauma patient on a prehospital scene by using a web-based trauma simulator. Then, a panel of trauma experts evaluated the simulations performed, observing that, on average, an important number of simulations were scored below 5, being the score values provided from 0, minimum, to 10, maximum. Therefore, the first need detected is the need to further train prehospital trauma management in undergraduate education. Additionally, a deeper analysis of the scores provided by the experts was performed. It showed a great dispersion in the scores provided by the different trauma experts per simulation. Therefore, a second need is identified, the need to develop a system to objectively evaluate trauma management.

Accuracy of Triage Systems in Disasters and Mass Casualty Incidents; a Systematic Review

Introduction

To prioritize patients to provide them with proper services and also manage the scarce resources in emergencies, the use of triage systems seems to be essential. The aim of this study was to evaluate the accuracy of the existing triage systems in disasters and mass casualty incidents.

Methods

The present study is a systematic review of the accuracy of all triage systems worldwide. The results of this study were based on the articles published in English language journals. In this research, all papers published from the beginning of 2000 to the end of 2021 were sought through different databases. Finally, a total of 13 articles was ultimately selected from 89 articles.

Results

13 studies on the accuracy of triage systems were reviewed. The START, mSTART, SALT, Smart, Care Flight, ASAV, MPTT, Sieve and ESI triage systems, had an accuracy, sensitivity, and specificity of less than 90%. Only the Smart triage system had an overall accuracy of more than 90%.

Conclusion

According to the findings of the current systematic review, the performance of the existing triage systems in terms of accuracy of prioritizing the injured people and other performance indexes is not desirable. Therefore, to improve the performance and increase the precision of triage systems, the world nations are recommended to change or revise the indexes used in triage models and also identify other influential factors affecting the accuracy of triage systems.

SPECTRa: An Online Tool for Simulating Prehospital Patient Care

OBJECTIVES

To (1) develop a simulation software environment to conduct prehospital research during the COVID-19 pandemic on paramedics' teamwork and use of mobile computing devices, and (2) establish its feasibility for use as a research and training tool.

BACKGROUND

Simulation-based research and training for prehospital environments has typically used live simulation, with highly realistic equipment and technology-enhanced manikins. However, such simulations are expensive, difficult to replicate, and require facilitators and participants to be at the same location. Although virtual simulation tools exist for prehospital care, it is unclear how best to use them for research and training.

METHODS

We present SPECTRa-Simulated Prehospital Emergency Care for Team Research-an online simulated prehospital environment that lets participants care concurrently for single or multiple patients remotely. Patient scenarios are designed using Laerdal's SimDesigner. SPECTRa records data about scenario states and participants' virtual interaction with the simulated patients. SPECTRa's supporting environment records participants' verbal communication and their visual and physical interactions with their interface and devices using Zoom conferencing and audiovisual recording. We discuss a pilot research implementation to assess SPECTRa's feasibility.

RESULTS

SPECTRa allows researchers to systematically test small-team interaction in single- or multipatient care scenarios and assess the impact of mobile devices on participants' assessment and care of patients. SPECTRa also supports pedagogical features that could allow prehospital educators to provide individual trainees or teams with online simulation training and evaluation.

CONCLUSIONS

SPECTRa, an online tool for simulating prehospital patient care, shows potential for remote healthcare research and training.

Challenges to the implementation of in situ simulation at HEMS bases: a qualitative study of facilitators' expectations and strategies

INTRODUCTION

Facilitators play an essential role in simulation-based training on helicopter emergency medical services (HEMS) bases. There is scant literature about the barriers to the implementation of simulation training in HEMS. The purpose of this explorative interview study was to identify factors that the local facilitators anticipated would challenge the smooth implementation of the program, and their strategies to overcome these before the national implementation of in situ simulation-based training locally, and subsequently, one year after the programme was initiated, to identify the actual challenges they had indeed experienced, and their solutions to overcome these.

METHODS

A qualitative study with semi-structured group interviews of facilitators was undertaken before and after one year of simulation-based training on all HEMS bases and one Search and Rescue base. Systematic text condensation was used to extract facilitators' expectations and experiences.

RESULTS

Facilitators identified 17 themes in the pre-study-year interviews. Pedagogical, motivational and logistical issues were amongst the dominant themes. Other key themes included management support, dedicated time for the facilitators and ongoing development of the facilitator. In the post-study-year interviews, the same themes were identified. Despite anxiety about the perceptions of, and enthusiasm for, simulation training amongst the HEMS crews, our facilitators describe increasing levels of motivation over the study period.

CONCLUSION

Facilitators prognosticated the anticipated challenges to the successful implementation of simulation-based training on HEMS bases and suggested solutions for overcoming these challenges. After one year of simulation-based training, the facilitators reflected on the key factors for successful implementation.

EMS Experience Caring and Communicating with Patients and Families with a Life-Limiting-Illness

Introduction: The emergency medical services (EMS) system was designed to reduce death and disability and EMS training focuses on saving lives through resuscitation, aggressive treatment and transportation to the emergency department. EMS providers commonly care for patients who have life-limiting illnesses. The objective was to explore EMS provider challenges, self-perceived roles and training experiences caring for patients and families with life-limiting illness. Methods: Qualitative content analysis of semi-structured interviews with EMS providers (n = 15) in Alameda County, CA. Purposive sampling was used to ensure a variety of perspectives including provider age, years of EMS experience, emergency medical technicians and paramedics, fire-based versus private, transport versus non-transporting. Recorded and transcribed interviews were analyzed using a thematic approach. Results: In their work with patients with life-limiting illness, participating EMS providers were interviewed and reported challenges for which their formal training had not prepared them: responding to grief and emotion expressed by families during traumatic events or death notification, and performing in the moment decision-making to determine the course of action after acute, unexpected, and traumatic events. Many participants reported becoming comfortable with grief counseling and death notification after acquiring some clinical experience. In the moment decision-making was eased when patients and families had had advance care planning discussions, however many patients, especially those from vulnerable and underserved populations, lacked advance care planning. In the face of situations where the course of action was not immediately clear, EMS providers voiced two frames for their role in caring for patients with life-limiting illness: transportation only ("transport people") versus a more "holistic" view, where EMS providers provided counseling and information about available resources. Conclusions: EMS providers interface with patients who have life-limiting illness and their families in the setting of traumatic events where the course of action is often unclear. There is an opportunity to provide formal training to EMS providers around grief counseling as well as how they can assist patients and families in in the moment decision-making to support previously identified goals and align care with patient goals and preferences.

Development of a simulation-based curriculum for Pediatric prehospital skills: a mixed-methods needs assessment

Background

The assessment and treatment of pediatric patients in the out-of-hospital environment often presents unique difficulties and stress for EMS practitioners.

Objective

Use a mixed-methods approach to assess the current experience of EMS practitioners caring for critically ill and injured children, and the potential role of a simulation-based curriculum to improve pediatric prehospital skills.

Methods

Data were obtained from three sources in a single, urban EMS system: a retrospective review of local pediatric EMS encounters over one year; survey data of EMS practitioners’ comfort with pediatric skills using a 7-point Likert scale; and qualitative data from focus groups with EMS practitioners assessing their experiences with pediatric patients and their preferred training modalities.

Results

2.1% of pediatric prehospital encounters were considered “critical,” the highest acuity level. A total of 136 of approximately 858 prehospital providers responded to the quantitative survey; 34.4% of all respondents either somewhat disagree (16.4%), disagree (10.2%), or strongly disagree (7.8%) with the statement: “I feel comfortable taking care of a critically ill pediatric patient.” Forty-seven providers participated in focus groups that resulted in twelve major themes under three domains. Specific themes included challenges in medication dosing, communication, and airway management. Participants expressed a desire for more repetition and reinforcement of these skills, and they were receptive to the use of high-fidelity simulation as a training modality.

Conclusions

Critically ill pediatric prehospital encounters are rare. Over one third of EMS practitioners expressed a low comfort level in managing critically ill children. High-fidelity simulation may be an effective means to improve the comfort and skills of prehospital providers.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-021-00494-4.

Design and Development of an Interactive Web-Based Simulator for Trauma Training: A Pilot Study

Trauma is the leading cause of death in people under 45 years old and one of the leading causes of death in the world. Therefore, specific trauma training during medical school as well as after it is crucial. Web-based learning is an important tool in education, offering the possibility to create realistic trauma scenarios. A web-based simulator has been developed and a pilot study has been accomplished to trial the simulator. A pelvic trauma scenario was created and 41 simulations were performed, 28 by medical students and 13 by doctors. The data analyzed are the actions taken to treat the trauma patient, the evolution of the vital signs of the patient, the timing spent on deciding which action to take, when each action was performed and the consequence that it had on the patient. Moreover, a post-simulation questionnaire was completed related to the usability of the simulator. The clinical treatment performance of doctors is better than the performance of medical students performing more actions correctly and in the right sequence as per ATLS recommendations. Moreover, significant differences are obtained in the time response provided to the patients which is key in trauma. With respect to the usability of the tool, responses provide a positive usability rating. In conclusion, this pilot study has demonstrated that the web-based training developed can be used to train and evaluate trauma management. Moreover, this research has highlighted a different approach to trauma treatment between medical students and doctors.

Emergency medical services education research priorities during COVID-19: A modified Delphi study

OBJECTIVE

Our objective was to identify research priorities to understand the impact of COVID-19 on initial emergency medical services (EMS) education.

METHODS

We used a modified Delphi method with an expert panel (n = 15) of EMS stakeholders to develop consensus on the research priorities that are most important and feasible to understand the impact of the COVID-19 pandemic on initial EMS education. Data were collected from August 2020 to February 2021 over 5 rounds (3 electronic surveys and 2 live virtual meetings). In Round 1, participants submitted research priorities over 9 specific areas. Responses were thematically analyzed to develop a list of research priorities reviewed in Round 2. In Round 3, participants rated the priorities by importance and feasibility, with a weighted score (2/3*importance+1/3*feasibility) used for preliminary prioritization. In Round 4, participants ranked the priorities. In Round 5, participants provided their agreement or disagreement with the group's consensus of the top 8 research priorities.

RESULTS

During Rounds 1 and 2, 135 ideas were submitted by the panel, leading to a preliminary list of 27 research priorities after thematic analysis. The top 4 research priorities identified by the expert panel were prehospital internship access, impact of lack of field and clinical experience, student health and safety, and EMS education program availability and accessibility. Consensus was reached with 10/11 (91%) participants in Round 5 agreeing.

CONCLUSIONS

The identified research priorities are an important first step to begin evaluating the EMS educational infrastructure, processes, and outcomes that were affected or threatened through the pandemic.

Effect of Repetitive Simulation Training on Emergency Medical Services Team Performance in Simulated Pediatric Medical Emergencies

OBJECTIVE

Emergency medical services (EMS) professionals infrequently transport children leading to difficulty in recognition and management of pediatric critical illness. Simulation provides an opportunity to train EMS professionals on pediatric emergencies. The objective of this study was to examine the effect of serial simulation training over 6 months on EMS psychomotor and cognitive performance during team-based care.

METHODS

This was a longitudinal prospective study of a simulation curriculum enrolling EMS professionals over a 6-month period during which they performed three high-fidelity simulations at 3-month intervals. The simulation scenarios included a 15-month-old seizure (T₀), 1-month-old with hypoglycemia (T₁), and 4-year-old clonidine ingestion (T₂). All scenarios were standardized and required recognition and management of respiratory failure and decompensated shock. Scenarios were videotaped and two investigators scored EMS team interventions during simulations using a standardized scoring tool. Inter-rater reliability was assessed on 30% of videos using kappa analysis. Volumes of administered intravenous fluid (IVF) and medications were measured to assess for errors in administration. The primary outcome was the change in scenario score from T₀ to T₂.

RESULTS

A total of 135 team-based simulations were conducted over the study period (48, 40, and 47 at T₀, T₁, and T₂, respectively). Inter-rater reliability between reviewers was very good (κ = 0.7). Median simulation score improved from T₀ to T₂ (24 vs 31, p < 0.001, maximum score possible = 42). The proportion of completed tasks increased across multiple categories including improved recognition of respiratory decompensation (19% vs. 56%), management of the pediatric airway (44% vs. 88%), and timeliness of vascular access (10% vs. 38%). Correct IVF administration varied by scenario (25% vs. 52% vs. 30%, p = 0.02).

CONCLUSION

Serial simulation improved EMS team-based care in both recognition and management of pediatric emergencies. A standardized pediatric simulation curriculum can be used to train EMS professionals on pediatric emergencies and improve performance.

National Implementation of In Situ Simulation-Based Training in Helicopter Emergency Medical Services: A Multicenter Study

OBJECTIVE

Medical simulation is used in helicopter emergency services as a tool for training the crew. Using in situ simulation, we aimed to evaluate the degree of implementation, the barriers to completing simulation training, and the crew's attitude toward this form of training.

METHODS

This was a 1-year prospective study on simulation at all 14 Norwegian helicopter emergency services bases and 1 search and rescue base. Local facilitators were educated and conducted simulations at their discretion.

RESULTS

All bases agreed to participate initially, but 1 opted out because of technical difficulties. The number of simulations attempted at each base ranged from 1 to 46 (median = 17). Regardless of the base and the number of attempted simulations, participating crews scored self-evaluated satisfaction with this form of training highly. Having 2 local facilitators increased the number of attempted simulations, whereas facilitators' travel distance to work seemed to make no difference on the number of attempted simulations.

CONCLUSION

Our study reveals considerable differences in the number of attempted simulations between bases despite being given the same prerequisites. The busiest bases completed fewer simulations than the rest of the bases. Our findings suggest that conditions related to the local facilitator are important for the successful implementation of simulation-based training in helicopter emergency services.

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.

Paramedic student encounters with patients during clinical placements: A multi-institutional cohort study

OBJECTIVE

Paramedic students in the US are required to complete clinical placements to gain supervised experience with real patient encounters. Given wide variation in clinical placement practices, an evidence-based approach is needed to guide programs in setting realistic and attainable goals for students. This study's goal was to describe patient encounters and hours logged by paramedic students during clinical placements.

METHODS

A retrospective review of prospectively collected quality assurance data entered by US paramedic students between 2010 and 2014 was conducted. De-identified electronic records entered in the Field Internship Student Data Acquisition Project (FISDAP) Skill Tracker database were included from consenting paramedic students whose records were audited and approved by instructors. Descriptive statistics were calculated.

RESULTS

A total of 10,645 students encountered 2,239,027 patients; most encounters occurred in hospital settings (n = 1,311,967, 59%). The median total number of patient encounters per paramedic student was 206 (142-269) and the median total clinical placement hours per student was 626 (504-752). The median number of team leads per student was 56 (30-84). Students encountered a median of 22 (12-31) pediatric patients, ages 0-12 years, and 181 (126-238) adolescent or adult patients. For pediatric patient encounters, the most common clinical impressions were respiratory distress, other medical complaints, and extremity trauma. Among adult patient encounters, the most common clinical impressions included other medical, trauma, and cardiac conditions.

CONCLUSIONS

US paramedic students experienced a variable range of patient encounter types and volumes. The findings of this study offer an evidence base from which programs can set realistic and attainable clinical placement requirements.

The use of simulation as a teaching modality for paramedic education: a scoping review

BACKGROUND

Simulation is a broad concept used as an education pedagogy for a wide range of disciplines. The use of simulation to educate paramedics is a frequently used but untested modality to teach psycho-motor skills, acquire new knowledge and gain competence in practice. This review identifies how simulation is currently being used for the education of paramedics, and establish the context for future application.

METHODS

A scoping review of the literature was undertaken following the PRISMA systematic approach. Flexible inclusion criteria were used to capture research and non-research articles that would contribute to the synthesis of literature with a specific knowledge base pertaining to simulation use for paramedic education.

RESULTS

Initial searching yielded 1388 records, of which 22 remained after initial title and abstract reading. Following secondary full-text screening, 18 articles were deemed appropriate for final inclusion: eight are research, two literature reviews and eight non-research. Across all the literature, a range of concepts are discussed: Skill vs Scenario, Virtual Learning, Inter-Professional Learning, Fidelity, Cost, Equipment, Improvement of Competency, Patient Safety, Perception of Simulation.

CONCLUSION

It is evident that simulation is a primary teaching modality, consistently used to educate and train paramedics. Simulation is inherently effective at teaching clinical skills and building student competence in particular areas. Similarly, simulation is effective at providing paramedics with experiences and opportunities to learn in varied environments using differing techniques. This allows students to apply the relevant skills and knowledge when faced with real patients.

Continuing Education for Prehospital Healthcare Providers in India - A Novel Course and Concept

BACKGROUND

Emergency medical services (EMS) in India face enormous challenges in providing care to a geographically expansive and diverse patient population. Over the last decade, the public-private-partnership GVK EMRI (Emergency Management and Research Institute) has trained over 100,000 emergency medical technicians (EMTs), with greater than 21,000 currently practicing, to address this critical gap in the healthcare workforce. With the rapid development and expansion of EMS, certain aspects of specialty development have lagged behind, including continuing education requirements. To date, there have been no substantial continuing education EMT skills and training efforts. We report lessons learned during development and implementation of a continuing education course (CEC) for EMTs in India.

METHODS

From 2014 to 2017, we employed an iterative process to design and launch a novel CEC focused on five core emergency competency areas (medicine and cardiology, obstetrics, trauma, pediatrics, and leadership and communication). Indian EMT instructors and providers partnered in design and content, and instructors were trained to independently deliver the CEC. Many challenges had to be overcome: scale (>21,000 EMTs), standardization (highly variable skill levels among providers and instructors), culture (educational emphasis on rote memorization rather than practical application), and translation (22 major languages and a few hundred local dialects spoken nationwide).

LESSONS LEARNED

During the assessment and development phases, we identified five key strategies for success: (1) use icon-based video instruction to ensure consistent quality and allow voice-over for easy translation; (2) incorporate workbooks during didactic videos and (3) employ low-cost simulation and case discussions to emphasize active learning; (4) focus on non-technical skills; (5) integrate a formal training-of-trainers prior to delivery of materials.

CONCLUSION

These key strategies can be combined with innovation and flexibility to address unique challenges of language, system resources, and cultural differences when developing impactful continuing educational initiatives in bourgeoning prehospital care systems in low- and middle-income countries.

Educational impact of a pilot paediatric simulation-based training course in Botswana

Background

As emergency medical services (EMS) systems develop globally in resource-limited settings, equipping providers with paediatric training is essential. Low-fidelity simulation-based training is an effective modality for training healthcare workers, though limited data exist on the impact of such training programmes. The objective of this study was to evaluate the paediatric portion of a simulation-based curriculum for prehospital providers in Botswana.

Methods

This was a prospective cohort study of EMS providers from more populated regions of Botswana, who attended a 2-day training that included didactic lectures, hands-on skills stations and low-fidelity simulation training. We collected data on participant self-efficacy with paediatric knowledge and skills and performance on both written and simulation-based tests. Self-efficacy and test data were analysed, and qualitative course feedback was summarised.

Results

Thirty-one EMS providers participated in the training. Median self-efficacy levels increased for 13/15 (87%) variables queried. The most notable improvements were observed in airway management, newborn resuscitation and weight estimation. Mean written test scores increased by 10.6%, while mean simulation test scores increased by 21.5% (p<0.0001). One hundred per cent of the participants rated the course as extremely useful or very useful.

Discussion/Conclusion

We have demonstrated that a low-fidelity simulation-based training course based on a rigorous needs assessment may enhance short-term paediatric knowledge and skills for providers in a developing EMS system in a limited-resource setting. Future studies should focus on studying larger groups of learners in similar settings, especially with respect to the impact of educational programmes like these on real-world patient outcomes.

In situ simulation training in helicopter emergency medical services: feasible for on-call crews?

Simulation-based training of emergency teams offers a safe learning environment in which training in the management of the critically ill patient can be planned and practiced without harming the patient. We developed a concept for in situ simulation that can be carried out during on-call time. The aim of this study is to investigate the feasibility of introducing in situ, simulation-based training for the on-call team on a busy helicopter emergency medical service (HEMS) base. We carried out a one-year prospective study on simulation training during active duty at a busy Norwegian HEMS base, which has two helicopter crews on call 24/7. Training was conducted as low fidelity in situ simulation while the teams were on call. The training took place on or near the HEMS base. Eight scenarios were developed with learning objectives related to the mission profile of the base which includes primary missions for both medical and trauma patients of all ages, and interhospital transport of adults, children, and neonates. All scenarios included learning objectives for non-technical skills. A total of 44 simulations were carried out. Total median (quartiles) time consumption for on-call HEMS crew was 65 (59-73) min. Time for preparation of scenarios was 10 (5-11) min, time for simulations was 20 (19-26) min, cleaning up 7 (6-10) min, and debrief 35 (30-40) min. For all items on the questionnaire, the majority of respondents replied with the two most positive categories on the Likert scale. Our results demonstrate that in situ simulation training for on-call crews on a busy HEMS base is feasible with judicious investment of time and money. The participants were very positive about their experience and the impact of this type of training.

Prehospital use of the traction splint for suspected mid-shaft femur fractures

Introduction:

A retrospective audit of electronic patient care records (ePCRs) highlighted the infrequent use of the traction splint for the management of femur fractures. The aim of this study was to improve the use of the traction splint for patients presenting with a mid-shaft femur fracture in the absence of contraindications, by means of introducing a purpose-designed trauma CPD training course.

Methods:

An intervention consisting of a simulation-based mandatory trauma CPD training session for all operational prehospital care providers was implemented over a 3-month period, supported by a pre- and post-implementation staff survey regarding staff perceptions of using a traction splint. Following the intervention period, a repeat retrospective audit of the ePCR database was conducted to identify any improvement in the use of the traction splint.

Results:

The use of the traction splint for a femur fracture in the pre-intervention stage was found to be underutilised (Median 16%). Following the intervention period, however, traction splint use increased significantly (Median 50%). An improvement was also noted in staff perception and understanding of the management of femur fractures.

Conclusion:

This study found that focused trauma training is an effective means to improve patient care. Training should be ongoing in order to maintain skills and knowledge needed for management of femur fractures.

Evaluating a Novel Simulation Course for Prehospital Provider Resuscitation Training in Botswana

Introduction

In 2012, Botswana embarked on an organized public approach to prehospital medicine. One goal of the Ministry of Health (MOH) was to improve provider education regarding patient stabilization and resuscitation. Simulation-based instruction is an effective educational strategy particularly for high-risk, low-frequency events. In collaboration with partners in the United States, the team created a short, simulation-based course to teach and update prehospital providers on common field responses in this resource-limited setting. The objective of this study was to evaluate an educational program for Botswanan prehospital providers via written and simulation-based examinations.

Methods

We developed a two-day course based on a formal needs assessment and MOH leadership input. The subject matter of the simulation scenarios represented common calls to the prehospital system in Botswana. Didactic lectures and facilitated skills training were conducted by U.S. practitioners who also served as instructors for a rapid-cycle, deliberate practice simulation education model and simulation-based testing scenarios. Three courses, held in three cities in Botswana, were offered to off-duty MOH prehospital providers, and the participants were evaluated using written multiple-choice tests, videotaped traditional simulation scenarios, and self-efficacy surveys.

Results

Collectively, 31 prehospital providers participated in the three courses. The mean scores on the written pretest were 67% (standard deviation [SD], 10) and 85% (SD, 7) on the post-test (p < 0.001). The mean scores for the simulation were 42% (SD, 14.2) on the pretest and 75% (SD, 11.3) on the post-test (p < 0.001). Moreover, the intraclass correlation coefficient scores between reviewers were highly correlated at 0.64 for single measures and 0.78 for average measures (p < 0.001 for both). Twenty-one participants (68%) considered the course “extremely useful.”

Conclusion

Botswanan prehospital providers who participated in this course significantly improved in both written and simulation-based performance testing. General feedback from the participants indicated that the simulation scenarios were the most useful and enjoyable aspects of the course. These results suggest that this curriculum can be a useful educational tool for teaching and reinforcing prehospital care concepts in Botswana and may be adapted for use in other resource-limited settings.

Research challenges in prehospital care: the need for a simulation-based prehospital research laboratory

There is a need for improved research in the field 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. The present paper argues for the potential of simulation for prehospital research, e.g., through the development of an advanced simulation-based prehospital research laboratory. However, the prehospital context is different from other healthcare areas, which implies special requirements for the design of this type of laboratory, in terms of simulation width (including the entire prehospital work process) and depth (level of scenario detail). A set of features pertaining to simulation width, scenario depth, equipment, and personnel and competence are proposed. Close tailoring between these features and the prehospital research problems and context presents great potential to improve and further prehospital research.

Preparation for major burns incidents: evaluation of continuing medical education training courses for professionals

The purpose of this study was to identify changes in the competence of healthcare providers who underwent training courses on the management of burns incidents. Theoretical and practical simulation training courses were conducted for 305 healthcare providers from emergency and trauma departments of general hospitals in Vietnam. Pre- and post-tests were conducted using questionnaires and with simulated practical skill evaluation by burns specialists. Results showed a significant improvement in knowledge of emergency management of burns incidents, with an increase in percentage of correct answers from 48.2% to 71.6% (p < .01). There was an average increase from 10.5% to 95.1% for the correct calculation of total body surface area involvement, and from 33.8% to 67.2% for using the Parkland formula. Increases in knowledge of resuscitation and management of inhalation injury were also noted (p < .01). For the management of major burns incidents, sufficient knowledge of the command system increased from 58.4% to 81.9%. A better understanding was gained of the missions of the Emergency Medical Team, triage and air evacuation after training (p < .001). Emergency practical skills such as CPR, ET intubation, splinting of bone fractures, burn wound dressing and using emergency medical devices also improved remarkably (p < .001) after practical simulation training. In conclusion, these results indicate that a significant improvement in the capabilities and competence of medical staff in the emergency management of burn injuries can be achieved by conducting training courses with combined theory components and practical simulation models.

Comparative study of a simulated incident with multiple victims and immersive virtual reality

OBJECTIVES

The main objective of the study is to determine the efficiency in the execution of the START (Simple Triage and Rapid Treatment) triage, comparing Virtual Reality (VR) to Clinical Simulation (CS) in a Mass Casualty Incident (MCI). The secondary objective is to determine the stress produced in the health professionals in the two situations described.

MATERIALS

A comparative study on the efficiency and the stress during triage in a MSI was conducted. The basal and post levels of salivary α-amylase (sAA) activity were measured in all the participants before and after the simulation.

RESULTS

The percentage of victims that were triaged correctly was 87.65% (SD = 8.3); 88.3% (SD = 9.65) for the Clinical Simulation with Actors (CSA) group and 87.2% (SD = 7.2) for the Virtual Reality Simulation (VRG) group, without any significant differences (p = 0.612) between both groups. The basal sAA was 103.26 (SD = 79.13) U/L with a significant increase (p < 0.001) with respect to the post-simulation levels (182.22, SD = 148.65 U/L). The increase of sAA was 80.70 (SD = 109.67) U/mL, being greater for the CSA group than the VRG group.

CONCLUSION

The results show that virtual reality method is as efficient as clinical simulation for training on the execution of basic triage (START model). Also, based on the sAA results, we can attest that clinical simulation creates a more stressful training experience for the student, so that is should not be substituted by the use of virtual reality, although the latter could be used as a complementary activity.

Needs Assessment for Simulation Training for Prehospital Providers in Botswana

BACKGROUND

In June 2012, the Botswana Ministry of Health and Wellness (MOHW; Gaborone, Botswana) initiated a national Emergency Medical Services (EMS) system in response to significant morbidity and mortality associated with prehospital emergencies. The MOHW requested external expertise to train its developing workforce. Simulation-based training was planned to equip these health care providers with clinical knowledge, procedural skills, and communication techniques.

OBJECTIVE

The objective of this study was to assess the educational needs of the pioneer Botswana MOHW EMS providers based on retrospective EMS logbook review and EMS provider feedback to guide development of a novel educational curriculum.

METHODS

Data were abstracted from a representative sample of the Gaborone, Botswana MOHW EMS response log from 2013-2014 and were quantified into the five most common call types for both adults and children. Informal focus groups with health professionals and EMS staff, as well as surveys, were used to rank common response call types and self-perceived educational needs.

RESULTS

Based on 1,506 calls, the most common adult response calls were for obstetric emergencies, altered mental status, gastrointestinal/abdominal pain, trauma, gynecological emergencies, and cardiovascular and respiratory distress-related emergencies. The most common pediatric response calls were for respiratory distress, gastrointestinal complaints/dehydration, trauma and musculoskeletal injuries, newborn delivery, seizures, and toxic ingestion/exposure. The EMS providers identified these same chief complaints as priorities for training using the qualitative approach. A locally relevant, simulation-based curriculum for the Botswana MOHW EMS system was developed and implemented based on these data.

CONCLUSIONS

Trauma, respiratory distress, gastrointestinal complaints, and puerperal/perinatal emergencies were common conditions for all age groups. Other age-specific conditions were also identified as educational needs based on epidemiologic data and provider feedback. This needs assessment may be useful when designing locally relevant EMS curricula in other low-income and middle-income countries. GlombNW, KosokoAA, DoughtyCB, RusMC, ShahMI, CoxM, GalapiC, ParkesPS, KumarS, LabaB. Needs assessment for simulation training for prehospital providers in Botswana. Prehosp Disaster Med. 2018;33(6):621-626.

Treat me nice! -a cross-sectional study examining support during the first year in the emergency medical services

Background

Working in the emergency medical service (EMS) can be extremely varying and sometimes physically and psychologically demanding. Being new in this context can be a great challenge. This study aim to describe what ambulance nurses consider to be important support during the first year in the EMS.

Methods

Three hundred and eighty-nine eligible participants that had graduated from the prehospital emergency care program were identified via university registrations office in Sweden. The eligible participants received a study specific questionnaire via mail consisting of 70 statements about support during the first year. The perceived importance of each statement were graded on a 7-point Likert scale. The gradings were analysed using descriptive statistics and frequencies, mean and SD were calculated.

Results

Two hundred and thirty questionnaires were returned fully completed, giving a response rate of 59%. Fourteen statements regarding desirable support were rated with mean values > 6.00 and SD < 1.00 and considered as being the most important during the first year in the EMS. The important supports regarded; colleagues and work environment, management and organisation, experience-based knowledge, introduction period, practical support, and theoretical support. Most statements regarded culture and climate and the way the newcomers wanted to be treated.

Conclusion

It was concluded that an important way to support newcomers in the EMS is to treat them ‘nice’. This can be achieved by creating an open climate and a welcoming culture where the new professionals feel trusted and treated with respect, created ways to work structurally, have applicable medical guidelines, and for newcomers to receive feedback on their actions.

Simulation as a means to develop firefighters as emergency care professionals

Objective. The aim of this study was to evaluate the simulated emergency care performed by firefighters and their perception of simulation as an educational method. Methods. This study had a mixed method with both a quantitative and a qualitative approach. Data were collected by simulation assessment, a questionnaire and written comments. Descriptive analysis was conducted on the quantitative data whereas a qualitative content analysis was conducted on the qualitative data. Finally, a contingent analysis was used where a synthesis configured both the quantitative and the qualitative results into a narrative result. Results. The cognitive workload that firefighters face during simulated emergency care is crucial for learning. In this study, the severity and complexity of the scenarios provided were higher than expected by the firefighters. Clearly stated conditions for the simulation and constructive feedback were considered positive for learning. Patient actors induced realism in the scenario, increasing the experience of stress, in comparison to a manikin. Conclusion. Simulation in a realistic on-scene environment increases firefighters' cognitive ability to critically analyze problems and manage emergency care. Simulation of emergency care developed the firefighters as professionals.

Ambulance Nurses' Competence and Perception of Competence in Prehospital Trauma Care

Introduction

We focus on trauma care conducted in the context of a simulated traumatic event. This is in this study defined as a four-meter fall onto a hard surface, resulting in severe injuries to extremities in the form of bilateral open femur fractures, an open tibia fracture, and a closed pelvic fracture, all fractures bleeding extensively.

Methods

The simulated trauma care competence of 63 ambulance nurses in prehospital emergency care was quantitatively evaluated along with their perception of their sufficiency. Data was collected by means of simulated trauma care and a questionnaire.

Results

Life-saving interventions were not consistently performed. Time to perform interventions could be considered long due to the life-threatening situation. In comparison, the ambulance nurses' perception of the sufficiency of their theoretical and practical knowledge and skills for trauma care scored high. In contrast, the perception of having sufficient ethical training for trauma care scored low.

Discussion

This study suggests there is no guarantee that the ambulance nurses' perception of theoretical and practical knowledge and skill level corresponds with their performed knowledge and skill. The ambulance nurses rated themselves having sufficient theoretical and practical knowledge and skills while the score of trauma care can be considered quite low.

Interprofessional simulation of birth in a non-maternity setting for pre-professional students

BACKGROUND

Simulation-based learning is an approach recommended for teaching undergraduate health professionals. There is a scarcity of research around interprofessional simulation training for pre-professional students in obstetric emergencies that occur prior to arrival at the maternity ward.

OBJECTIVES

The primary aims of the study were to examine whether an interprofessional team-based simulated birth scenario would improve undergraduate paramedic, nursing, and midwifery students' self-efficacy scores and clinical knowledge when managing birth in an unplanned location. The secondary aim was to assess students' satisfaction with the newly developed interprofessional simulation.

DESIGN

Quasi-experimental descriptive study with repeated measures.

SETTING

Simulated hospital emergency department.

PARTICIPANTS

Final year undergraduate paramedic, nursing, and midwifery students.

METHODS

Interprofessional teams of five students managed a simulated unplanned vaginal birth, followed by debriefing. Students completed a satisfaction with simulation survey. Serial surveys of clinical knowledge and self-efficacy were conducted at three time points.

RESULTS

Twenty-four students participated in one of five simulation scenarios. Overall, students' self-efficacy and confidence in ability to achieve a successful birth outcome was significantly improved at one month (p<0.001) with a magnitude of increase (effect) of 40% (r=0.71) and remained so after a further three months. Clinical knowledge was significantly increased in only one of three student groups: nursing (p=0.04; r=0.311). Students' satisfaction with the simulation experience was high (M=4.65/5).

CONCLUSIONS

Results from this study indicate that an interprofessional simulation of a birth in an unplanned setting can improve undergraduate paramedic, nursing and midwifery students' confidence working in an interprofessional team. There was a significant improvement in clinical knowledge of the nursing students (who had least content about managing birth in their program). All students were highly satisfied with the interprofessional simulation experience simulation.

We need support! A Delphi study about desirable support during the first year in the emergency medical service

Background

New and inexperienced emergency medical service (EMS) professionals lack important experience. To prevent medical errors and improve retention there is an urgent need to identify ways to support new professionals during their first year in the EMS.

Methods

A purposeful sample and snowball technique was used and generated a panel of 32 registered nurses with 12–48 months of EMS experience. A Delphi technique in four rounds was used. Telephone interviews were undertaken in round one to identify what desirable support professionals new to the EMS desire during their first year. Content analysis of the transcribed interviews yielded items which were developed into a questionnaire. The experts graded each item in terms of perceived importance on a 5-graded likert scale. Consensus level was set at 75%. Items which reached consensus were removed from questionnaires used in subsequent rounds.

Results

Desirable support was categorized into eight areas: Support from practical skills exercises, support from theoretical knowledge, support from experiences based knowledge, theoretical support, support from an introduction period, support from colleagues and work environment, support from management and organization and other support. The experts agree on the level of importance on 64 of a total of 70 items regarding desirable support. One item was considered not important, graded 1 or 2, 63 items were considered important, graded 4 or 5.

Conclusion

Even with extensive formal competence the EMS context poses challenges where a wide variety of desirable forms of support is needed. Support structures should address both personal and professional levels and be EMS context oriented.

Is the current level of training in the use of equipment for prehospital radio communication sufficient? A cross-sectional study among prehospital physicians in Denmark

BACKGROUND

Physicians working in prehospital care are expected to handle radio communication both within their own sector as well as with other divisions of the National Emergency Services. To date, no study has been conducted on the level of training received by physicians in the use of the equipment provided or on the level of competency acquired by physicians.

METHODS

In order to investigate the self-assessed skill level acquired in the use of the TETRA (TErrestrial Trunked RAdio) authority radio for communication in a prehospital setting, a cross-sectional study was conducted by questionnaire circulated to all 454 physicians working in the Danish Emergency Medical Services.

RESULTS

A lack of training was found among physicians working in prehospital care in Denmark in relation to the proper use of essential communication equipment. Prior to starting their first shift in a prehospital setting 38% of physicians reported having received no training in the use of the equipment, while 80% of physicians reported having received one1 hour of training or less. Among the majority of physicians their current level of training was sufficient for their everyday needs for prehospital communication but for 28% of physicians their current level of training was insufficient as they were unable to handle communication at this level.

CONCLUSION

As the first study in its field, this study investigated the training received in the use of essential communication equipment among physicians working in prehospital care in Denmark. The study found that competency does not appear to have been prioritised as highly as other technical skills needed to function in these settings. For the majority of physicians their current level of training was sufficient for everyday use but for a substantial minority further training is required, especially if the redundancy of the prehospital system is to be preserved.

Validating a questionnaire - prehospital preparedness for pediatric trauma patients

In recent decades, prehospital emergency care has undergone extensive development. Today, prehospital emergency nurses (PENs) are well trained and provide advanced care to patients of all ages. Caring for pediatric trauma patients is considered to be particularly demanding. However, in Sweden and internationally, there is a lack of research regarding PENs' preparedness for caring for pediatric trauma patients.

OBJECTIVE

The development and testing of a questionnaire on self-reported preparedness among PENs caring for pediatric trauma patients in a prehospital emergency setting.

METHODS

Questionnaire development included face and content validity tests resulting in 38 questions. Eighteen of these questions were analyzed by test-retest. The content of the questionnaire was statistically analyzed.

RESULTS

Fifteen questions were considered valid after reliability and validity tests. Three questions did not fulfill the stability criteria. The content analyses show a low degree of experience with pediatric trauma patients and half of the participants reported stress symptoms when responding to such alarms.

CONCLUSION

The questionnaire assessing PENs preparedness caring for pediatric trauma patients in Sweden is considered to be suitable for research and clinical practice to improve the care of pediatric trauma patients and the health of PENs, although further testing of the questionnaire is required.

The knowledge desired by emergency medical service managers of their ambulance clinicians - A modified Delphi study

AIM

The aim of the study was to identify the types of knowledge that Swedish Emergency Medical Service (EMS) managers considered desirable in their Ambulance Clinicians.

BACKGROUND

Emergency medical service managers are responsible for organisational tasking and in this are dependent on the knowledge possessed by their ambulance clinicians. It would therefore be of value to explore EMS managers' approach to this knowledge.

DESIGN

A modified Delphi method in three rounds.

METHODS

In total thirty-six EMS managers participated, and twenty-four finished all three rounds. They were encouraged to rate each sub-category, and the ten with the highest mean were interdependently ranked in the final round.

RESULTS

Five categories and twenty-six sub-categories emerged in the first round, covering knowledge related to; contextual aspects, medical and holistic assessments, formal education and organisational issues. Eventually, the sub-category 'Knowledge to assess the patient's situation from a holistic perspective' was the highest ranked, followed by 'Medical knowledge to assess and care for different diseases' and 'Knowledge to be able to care for critically ill patients'.

CONCLUSIONS

Taken together the knowledge areas address essentially medical care, contextual aspects and nursing. The boundaries between these can sometimes be seen as elusive, calling for ambulance clinicians to balance these areas of knowledge.

[Quality of initial trauma care in paediatrics]

INTRODUCTION

Trauma care in Spain is not provided in specific centres, which means that health professionals have limited contact to trauma patients. After the setting up of a training program in paediatric trauma, the aim of this study was to evaluate the quality of the initial care provided to these patients before they were admitted to the paediatric intensive care unit (PICU) of a third level hospital (trauma centre), as an indirect measurement of the increase in the number of health professionals trained in trauma.

MATERIAL AND METHODS

Two cohorts of PICU admissions were reviewed, the first one during the four years immediately before the training courses started (Group 1, period 2001-2004), and the second one during the 4 years (Group 2, period 2012-2015) after nearly 500 professionals were trained. A record was made of the injury mechanism, attending professional, Glasgow coma score (GCS), and paediatric trauma score (PTS). Initial care quality was assessed using five indicators: use of cervical collar, vascular access, orotracheal intubation if GCS ≤ 8, gastric decompression if PTS≤8, and number of actions carried out from the initial four recommended (neck control, provide oxygen, get vascular access, provide IV fluids). Compliance was compared between the 2 periods. A P<.05 was considered statistically significant.

RESULTS

A total of 218 patient records were analysed, 105 in Group 1, and 113 in Group 2. The groups showed differences both in injury mechanism and in initial care team. A shift in injury mechanism pattern was observed, with a decrease in car accidents (28% vs 6%; P<.0001). Patients attended to in low complexity hospitals increased from 29.4% to 51.9% (P=.008), and their severity decreased when assessed using the GCS ≤ 8 (29.8% vs 13.5%; P=.004), or PTS≤8 (48.5% vs 29.7%; P=.005). As regards quality indicators, only the use of neck collar improved its compliance (17.3% to 32.7%; P=.01). Patients who received no action in the initial care remained unchanged (19% vs 11%%; P=.15).

CONCLUSIONS

Although there are limited improvements, the setting up of a training program has not translated into better initial care for trauma patients in our area of influence. Trauma training should be complemented with other support measures in order to achieve a systematic application of the trauma care principles.

Developing a Simulation-Based Training Program for the Prehospital Professionals and Students on the Management of Middle East Respiratory Syndrome

INTRODUCTION

Middle East Respiratory Syndrome (MERS) is a major global health threat. Prehospital professionals face the risk of infection as they work to save lives. They should be made aware of the disease and be prepared to handle such cases. The aims of our study are to develop a training program about the prehospital management of a MERS case using standardized patient (SP) scenarios, to evaluate the awareness and preparedness of the participants about MERS, and to evaluate the effectiveness of this training.

METHODS

We developed 5 scenarios using SPs and an observation form. We included paramedic students and emergency medical service (EMS) providers in our study. They were involved in the simulations.

RESULTS

A total of 24 paramedic students and 33 EMS providers participated in our study. Sixteen (84%) of 19 teams recognized the possibility of MERS as a measure of their awareness in the baseline evaluation. The participants lacked donning and doffing personal protective equipments, which revealed their baseline level of preparedness for MERS. Certain improvements in donning and doffing personal protective equipment were observed in the posttraining evaluation. The participants provided positive feedback on the training program.

CONCLUSIONS

The training program was appropriate for both paramedic students and EMS providers. A positive educational climate was created. Because the main concerns of this study were awareness and preparedness, which required human interaction, the SP methodology was the optimal simulation modality.

Successes and Challenges of Optimal Trauma Care for Rural Family Physicians in Kansas

INTRODUCTION

Kansas has a regionalized trauma system with formal mechanisms for review, however, increased communication with rural providers can uncover opportunities for system process improvement. Therefore, this qualitative study explored perceptions of family medicine physicians staffing emergency departments (ED) in rural areas, specifically to determine what is going well and what areas needed improvement in relation to the trauma system.

METHODS

A focus group included Kansas rural family physicians recruited from a local symposium for family medicine physicians. Demographic information was collected via survey prior to the focus group session, which was audiotaped. Research team members read the transcription, identified themes, and grouped the findings into categories for analysis.

RESULTS

Seven rural family medicine physicians participated in the focus group. The majority were male (71%) with the mean age 46.71 years. All saw patients in the ED and had treated injuries due to agriculture, falls, and motor vehicle collisions. Participants identified successes in the adoption and enforcement of standardized processes, specifically through level IV trauma center certification and staff requirements for Advanced Trauma Life Support training. Communication breakdown during patient discharge and skill maintenance were the most prevalent challenges.

CONCLUSIONS

Even with an established regionalized trauma system in the state of Kansas, there continues to be opportunities for improvement. The challenges acknowledged by focus group participants may not be identified through patient case reviews (if conducted), therefore tertiary centers should conduct system reviews with referring hospitals regularly to improve systemic concerns.

Trauma-informed care for children in the ambulance: international survey among pre-hospital providers

Background: Pre-hospital providers, such as paramedics and emergency medical technicians, are in a position to provide key emotional support to injured children and their families. Objective: Our goal was to examine (a) pre-hospital providers' knowledge of traumatic stress in children, attitudes towards psychosocial aspects of care, and confidence in providing psychosocial care, (b) variations in knowledge, attitudes, and confidence according to demographic and professional characteristics, and (c) training preferences of pre-hospital providers regarding psychosocial care to support paediatric patients and their families. Method: We conducted a cross-sectional, online survey among an international sample of 812 pre-hospital providers from high-income countries. The questionnaire was adapted from a measure for a similar study among Emergency Department staff, and involved 62 items in 7 main categories (e.g. personal and work characteristics, knowledge of paediatric traumatic stress, and confidence regarding 18 elements of psychosocial care). The main analyses comprised descriptive statistics and multiple regression analyses. Results: On average, respondents answered 2.7 (SD = 1.59) out of seven knowledge questions correctly. Respondents with higher knowledge scores were more often female, parent of a child under 17, and reported that at least 10% of their patients were children. A majority of participants (83.5%) saw all 18 aspects of psychosocial care as part of their job. Providers felt moderately confident (M = 3.2, SD = 0.45) regarding their skills in psychosocial care, which was predicted by gender (female), having more experience, having a larger proportion of child patients, and having received training in psychosocial care in the past five years. Most respondents (89.7%) wanted to gain more knowledge and skills regarding psychosocial care for injured children. In terms of training format, they preferred an interactive website or a one-off group training. Conclusions: There appears to be both a need and an opportunity for education initiatives regarding paediatric traumatic stress in the pre-hospital context.

What are the educational and curriculum needs for emergency medical technicians in Taiwan? A scoping review

PURPOSE

The development of emergency medical services (EMS) training in Taiwan is in a transitional phase because of increasing demand for, and advancements in, clinical skill sets. The aim of this study is to review the current literature to compare the key factors of EMS training and education development in different countries in order to provide a new curricula blueprint for the Taiwanese EMS training system.

METHOD

The method follows Arksey and O'Malley's six stages of scoping review.

RESULTS

Five databases were searched for relevant articles: MEDLINE, EMBASE, Allied and Complementary Medicine Database; Education Resources Information Center, and Google Scholar. The initial search of five databases produced 1,230 articles, of which title and abstract screening excluded 1,156 articles. The 74 remaining articles underwent a full-text screening process, which further reduced the number of articles to 22. Researching references and citations produced an additional 23 articles, national curriculum standards produced a further six documents, and one article derived from emergency medical technician (EMT) regulation in Taiwan. In total, 52 articles were included in the study, categorized by competency and standards, EMT education and learning environment, curriculum design, and teaching and learning method.

CONCLUSION

This study reviewed international EMS training and education literature and documents to summarize the essential elements for developing an EMS education system: for example, core competencies and standards, education environment, curriculum design, and teaching and learning method. By connecting the essential elements for developing an EMS education system, a blueprint for the Taiwanese EMS education system can be identified. Analysis and study of the essential elements will provide educators with clear direction in developing the EMS education system in Taiwan.

Lessons learned developing and piloting interprofessional handover simulations for paramedic, nursing, and physiotherapy students

Interprofessional education is an important element in the preparation of healthcare students who can communicate effectively and work collaboratively. A grant from Health Workforce Australia funded a shared nursing, paramedicine, and physiotherapy simulation suite and a staff member dedicated to interprofessional simulation, with the aim of increasing high fidelity simulation within and across the three professions. This article describes the development process and pilot testing of four purpose-designed interprofessional handover scenarios for paramedic, nursing, and physiotherapy students. The scenarios tracked an elderly patient (manikin) with a fractured neck of femur from pre-hospital to postoperative assessment and handover. The National League of Nursing Simulation Design Scale was used to evaluate the scenarios. Students' feedback indicated they considered the simulations to be relevant to their practice, with a high level of fidelity. This study re-emphasises the importance of pilot testing simulations before use in large-scale studies.

Trauma Simulation Training Increases Confidence Levels in Prehospital Personnel Performing Life-Saving Interventions in Trauma Patients

Introduction. Limited evidence is available on simulation training of prehospital care providers, specifically the use of tourniquets and needle decompression. This study focused on whether the confidence level of prehospital personnel performing these skills improved through simulation training. Methods. Prehospital personnel from Alachua County Fire Rescue were enrolled in the study over a 2- to 3-week period based on their availability. Two scenarios were presented to them: a motorcycle crash resulting in a leg amputation requiring a tourniquet and an intoxicated patient with a stab wound, who experienced tension pneumothorax requiring needle decompression. Crews were asked to rate their confidence levels before and after exposure to the scenarios. Timing of the simulation interventions was compared with actual scene times to determine applicability of simulation in measuring the efficiency of prehospital personnel. Results. Results were collected from 129 participants. Pre- and postexposure scores increased by a mean of 1.15 (SD 1.32; 95% CI, 0.88–1.42; P < 0.001). Comparison of actual scene times with simulated scene times yielded a 1.39-fold difference (95% CI, 1.25–1.55) for Scenario 1 and 1.59 times longer for Scenario 2 (95% CI, 1.43–1.77). Conclusion. Simulation training improved prehospital care providers' confidence level in performing two life-saving procedures.

Impact of High-Fidelity Pediatric Simulation on Paramedic Seizure Management

BACKGROUND

A simulation-based course, Pediatric Simulation Training for Emergency Prehospital Providers (PediSTEPPs), was developed to optimize pediatric prehospital care. Seizures are common in Emergency Medical Services (EMS), and no studies have evaluated pediatric outcomes after EMS simulation training.

OBJECTIVES

The primary objective was to determine if PediSTEPPs enhances seizure protocol adherence in blood glucose measurement and midazolam administration for seizing children. The secondary objective was to describe management of seizing patients by EMS and Emergency Departments (EDs).

METHODS

This is a two-year retrospective cohort study of paramedics who transported 0-18 year old seizing patients to ten urban EDs. Management was compared between EMS crews with at least one paramedic who attended PediSTEPPs and crews that had none. Blood glucose measurement, medications administered, intravenous (IV) access, seizure recurrence, and respiratory failure data were collected from databases and run reports. Data were compared using Pearson's χ(2) test and odds ratios with 95% confidence intervals (categorical) and the Mann-Whitney test (continuous).

RESULTS

Of 2200 pediatric transports with a complaint of seizure, 250 (11%) were actively seizing at the time of transport. Of these, 65 (26%) were treated by a PediSTEPPs-trained paramedic. Blood glucose was slightly more likely to be checked by trained than untrained paramedics (OR = 1.35, 95% CI 0.72-2.51). Overall, 58% received an indicated dose of midazolam, and this was slightly more likely in the trained than untrained paramedics (OR = 1.39, 95% CI 0.77-2.49). There were no differences in secondary outcomes between groups. The prevalence of hypoglycemia was low (2%). Peripheral IVs were attempted in 80%, and midazolam was predominantly given by IV (68%) and rectal (12%) routes, with 51% receiving a correct dose. Seizures recurred in 22%, with 34% seizing on ED arrival. Respiratory failure occurred in the prehospital setting in 25 (10%) patients in the study.

CONCLUSION

Simulation-based training on pediatric seizure management may have utility. Data support the need to optimize the route and dose of midazolam for seizing children. Blood glucose measurement in seizure protocols may warrant reprioritization due to low hypoglycemia prevalence.

KEY WORDS

seizure; emergency medical services; simulation; pediatrics.

A hybrid simulator model for the control of catastrophic external junctional haemorrhage in the military environment

Catastrophic haemorrhage from extremity injuries has for a long time been the single most common cause of preventable death in the military environment. The effective use of extremity tourniquets has increased the survival of combat casualties, and exsanguination from isolated limb injuries is no longer the most common cause of death. Today, the most common cause of potentially preventable death is haemorrhage from the junctional zones, i.e. the most proximal part of the extremities, not amenable to standard tourniquets.

Different training techniques to control catastrophic haemorrhage have been used by the Swedish Armed Forces in the pre-deployment training of physicians, nurses and medics for many years. The training techniques include different types of human patient simulators such as moulage patients and manikins. Preferred training conditions for the control of catastrophic haemorrhage include a high degree of realism, in combination with multiple training attempts.

This report presents a new hybrid training model for catastrophic external junctional haemorrhage control. It offers a readily reproducible, simple and inexpensive opportunity to train personnel to deal with life threatening catastrophic junctional haemorrhage. In particular, this model offers an opportunity for non-medical military personnel in Sweden to practice control of realistic catastrophic haemorrhage, with multiple training attempts.

Strategically Leapfrogging Education in Prehospital Trauma Management: Four-Tiered Training Protocols

Trauma-related injury in fast developing countries are linked to 90% of international mortality rates, which can be greatly reduced by improvements in often non-existent or non-centralized emergency medical systems (EMS)-particularly in the pre-hospital care phase. Traditional trauma training protocols-such as Advanced Trauma Life Support (ATLS), International Trauma Life Support (ITLS), and Basic Life Support (BLS)-have failed to produce an effective pre-hospital ground force of medical first responders. To overcome these barriers, we propose a new four-tiered set of trauma training protocols: Massive Open Online Course (MOOC) Trauma Training, Acute Trauma Training (ATT), Broad Trauma Training (BTT), and Cardiac and Trauma Training (CTT). These standards are specifically differentiated to accommodate the educational and socioeconomic diversity found in fast developing settings, where each free course is taught in native, lay language while ensuring the education standards are maintained by fully incorporating high-fidelity simulation, video-recorded debriefing, and retraining. The innovative pedagogy of this trauma education program utilizes MOOC for global scalability and a "train-the-trainer" approach for exponential growth-both components help fast developing countries reach a critical mass of first responders needed for the base of an evolving EMS.

Learning by simulation in prehospital emergency care - an integrative literature review

BACKGROUND

Acquiring knowledge and experience on high-energy trauma is often difficult due to infrequent exposure. This creates a need for training which is specifically tailored for complex prehospital conditions. Simulation provides an opportunity for ambulance nurses to focus on the actual problems in clinical practice and to develop knowledge regarding trauma care. The aim of this study was to describe what ambulance nurses and paramedics in prehospital emergency care perceive as important for learning when participating in simulation exercises.

METHODS

An integrative literature review was carried out. Criteria for inclusion were primary qualitative and quantitative studies, where research participants were ambulance nurses or paramedics, working within prehospital care settings, and where the research interventions involved simulation.

RESULTS

It was perceived important for the ambulance nurses' learning that scenarios were advanced and possible to simulate repeatedly. The repetitions contributed to increase the level of experience, which in turn improved the patients care. Moreover, realism in the simulation and being able to interact and communicate with the patient were perceived as important aspects, as was debriefing, which enabled the enhancement of knowledge and skills. The result is presented in the following categories: To gain experience, To gain practice and To be strengthened by others.

CONCLUSION

Learning through simulation does not require years of exposure to accident scenes. The simulated learning is enhanced by realistic, stressful scenarios where ambulance nurses interact with the patients. In this study, being able to communicate with the patient was highlighted as a positive contribution to learning. However, this has seldom been mentioned in a previous research on simulation. Debriefing is important for learning as it enables scrutiny of one's actions and thereby the possibility to improve and adjust one's caring. The effect of simulation exercises is important on patient outcome.