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Alton A, Shaw L, Finch T, Price C, McClelland G. A qualitative exploration of ambulance clinician behaviour and decision making to identify factors influencing on-scene times for suspected stroke patients in North East England. Br Paramed J 2024; 8:1-9. [PMID: 38445110 PMCID: PMC10910290 DOI: 10.29045/14784726.2024.3.8.4.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2024] Open
Abstract
Aims/objectives Ambulance clinician assessment of suspected stroke patients aims to provide rapid access to specialist care, however regional and national data show increasing pre-hospital times. This study explored paramedic views about factors contributing to on-scene time (OST) for suspected stroke patients, with a view to identifying opportunities for future interventions, to reduce OST. Methods Views of paramedics from one regional service on factors influencing OST were explored using a qualitative approach. Semi-structured interviews with volunteers were recorded, transcribed and analysed using thematic analysis. Results Interviews were conducted with 13 paramedics between August and November 2021. Five interlinked themes were identified and described a range of factors influencing OST: 'Initial assessment and sources of information' describes how clinicians make assessments based on initial presentation, influenced by pre-arrival information from ambulance control and family members / bystanders at the scene, and how this influences OST.'Suitability for treatment and interventions' describes how paramedics consider actions such as the face, arms, speech test, cannulation, electrocardiograms and neurological assessments while recognising that pre-hospital interventions for suspected stroke are limited.'The environment' describes the influence of incident setting on OST, including the overall process needed to transport the patient to appropriate care.'Hospital interactions' describes how interactions with hospital staff influenced paramedic actions and OST.'Changing practice' describes the influence of experience and interaction with hospital staff leading to changes in paramedic practice over time. Conclusion This study provides insight into how UK paramedics spend time on scene with stroke patients. Multiple factors influencing OST were identified which signpost opportunities for interventions designed to reduce OST. Standardising on-scene assessments for stroke patients, refining communication processes between ambulance services and hospital stroke services and increasing availability of stroke continuing professional development for paramedics were all identified as potential targets for improving OST.
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Affiliation(s)
- Abi Alton
- Newcastle University ORCID iD: https://orcid.org/0000-0002-9983-080X
| | - Lisa Shaw
- Newcastle University ORCID iD: https://orcid.org/0000-0002-3435-9519
| | - Tracy Finch
- Northumbria University ORCID iD: https://orcid.org/0000-0001-8647-735X
| | - Christopher Price
- Newcastle University ORCID iD: https://orcid.org/0000-0003-3566-3157
| | - Graham McClelland
- North East Ambulance Service NHS Foundation Trust ORCID iD: https://orcid.org/0000-0002-4502-5821
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Eliakundu AL, Cadilhac DA, Kim J, Kilkenny MF, Bagot KL, Andrew E, Cox S, Bladin CF, Stephenson M, Pesavento L, Sanders L, Clissold B, Ma H, Smith K. Determining the sensitivity of emergency dispatcher and paramedic diagnosis of stroke: statewide registry linkage study. J Am Coll Emerg Physicians Open 2022; 3:e12750. [PMID: 35795711 PMCID: PMC9249375 DOI: 10.1002/emp2.12750] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 05/08/2022] [Accepted: 05/09/2022] [Indexed: 11/23/2022] Open
Abstract
Introduction Correctly identifying people with suspected stroke is essential for ensuring rapid treatment. Our aims were to determine the sensitivity of emergency dispatcher and paramedic identification of patients with stroke, the factors associated with correct identification, and whether there were any implications for hospital arrival times. Methods Observational study using patient‐level data from the Australian Stroke Clinical Registry (2015–2017) linked with ambulance and emergency department records for the state of Victoria. The registry diagnosis was the reference standard to compare with the provisional diagnoses made by emergency services personnel classified as “suspected” and “not suspected” stroke/transient ischemic attack (TIA). Multivariable logistic and quintile regressions were used to determine factors associated with correct identification and timely arrival to hospital. Results Overall, 4717 (64%) were matched to ambulance transport records (median age: 73 years, 43% female). Stroke/TIA was suspected in 56% of registrants by call‐takers and 69% by paramedics. Older patients (75+ years) (adjusted odds ratio [aOR]: 0.61; 95% confidence interval [CI]: 0.49–0.75), females (aOR: 0.86; 95% CI: 0.75–0.99), those with severe stroke or intracerebral hemorrhage were less often suspected as stroke. Cases identified as stroke had a shorter arrival time to hospital (unadjusted median minutes: stroke, 54 [43, 72] vs not stroke, 66 [51, 89]). Conclusions Emergency dispatchers and paramedics identified over half of patients with stroke in the prehospital setting. Important patient characteristics, such as being female and those having a severe stroke, were found that may enable refinement of prehospital ambulance protocols and dispatcher/paramedic education. Those correctly identified as stroke, arrived earlier to hospital optimizing their chances of receiving time‐critical treatments.
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Affiliation(s)
- Amminadab L. Eliakundu
- Stroke and Ageing Research Department of Medicine School of Clinical Sciences at Monash Health Monash University Victoria Australia
| | - Dominique A. Cadilhac
- Stroke and Ageing Research Department of Medicine School of Clinical Sciences at Monash Health Monash University Victoria Australia
- Stroke Division Florey Institute of Neurosciences & Mental Health University of Melbourne Victoria Australia
| | - Joosup Kim
- Stroke and Ageing Research Department of Medicine School of Clinical Sciences at Monash Health Monash University Victoria Australia
- Stroke Division Florey Institute of Neurosciences & Mental Health University of Melbourne Victoria Australia
| | - Monique F. Kilkenny
- Stroke and Ageing Research Department of Medicine School of Clinical Sciences at Monash Health Monash University Victoria Australia
- Stroke Division Florey Institute of Neurosciences & Mental Health University of Melbourne Victoria Australia
| | - Kathleen L. Bagot
- Stroke and Ageing Research Department of Medicine School of Clinical Sciences at Monash Health Monash University Victoria Australia
- Stroke Division Florey Institute of Neurosciences & Mental Health University of Melbourne Victoria Australia
| | - Emily Andrew
- Ambulance Victoria Victoria Australia
- Department of Epidemiology and Preventive Medicine Monash University Victoria Australia
| | - Shelley Cox
- Ambulance Victoria Victoria Australia
- Department of Epidemiology and Preventive Medicine Monash University Victoria Australia
| | - Christopher F. Bladin
- Stroke Division Florey Institute of Neurosciences & Mental Health University of Melbourne Victoria Australia
- Ambulance Victoria Victoria Australia
| | - Michael Stephenson
- Ambulance Victoria Victoria Australia
- Department of Epidemiology and Preventive Medicine Monash University Victoria Australia
- Department of Paramedicine Monash University Victoria Australia
| | - Lauren Pesavento
- The Melbourne Brain Centre and Department of Neurology The Royal Melbourne Hospital Victoria Australia
| | - Lauren Sanders
- Department of Neurology St Vincent's Hospital FitzroyVictoria Australia
| | - Ben Clissold
- Department of Neurology Geelong Hospital GeelongVictoria Australia
| | - Henry Ma
- Stroke and Ageing Research Department of Medicine School of Clinical Sciences at Monash Health Monash University Victoria Australia
- Department of Neurology Monash Medical Centre, Monash University Clayton Victoria Australia
| | - Karen Smith
- Ambulance Victoria Victoria Australia
- Department of Epidemiology and Preventive Medicine Monash University Victoria Australia
- Department of Paramedicine Monash University Victoria Australia
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Fukaguchi K, Goto T, Yamamoto T, Yamagami H. Experimental Implementation of NSER Mobile App for Efficient Real-Time Sharing of Prehospital Patient Information With Emergency Departments: Interrupted Time-Series Analysis. JMIR Form Res 2022; 6:e37301. [PMID: 35793142 PMCID: PMC9301553 DOI: 10.2196/37301] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 05/19/2022] [Accepted: 06/20/2022] [Indexed: 11/13/2022] Open
Abstract
Background With the aging society, the number of emergency transportations has been growing. Although it is important that a patient be immediately transported to an appropriate hospital for proper management, accurate diagnosis in the prehospital setting is challenging. However, at present, patient information is mainly communicated by telephone, which has a potential risk of communication errors such as mishearing. Sharing correct and detailed prehospital information with emergency departments (EDs) should facilitate optimal patient care and resource use. Therefore, the implementation of an app that provides on-site, real-time information to emergency physicians could be useful for early preparation, intervention, and effective use of medical and human resources. Objective In this paper, we aimed to examine whether the implementation of a mobile app for emergency medical service (EMS) would improve patient outcomes and reduce transportation time as well as communication time by phone (ie, phone-communication time). Methods We performed an interrupted time-series analysis (ITSA) on the data from a tertiary care hospital in Japan from July 2021 to October 2021 (8 weeks before and 8 weeks after the implementation period). We included all patients transported by EMS. Using the mobile app, EMS can send information on patient demographics, vital signs, medications, and photos of the scene to the ED. The outcome measure was inpatient mortality and transportation time, as well as phone-communication time, which was the time for EMS to negotiate with ED staffs for transport requests. Results During the study period, 1966 emergency transportations were made (n=1033, 53% patients during the preimplementation period and n=933, 47% patients after the implementation period). The ITSA did not reveal a significant decrease in patient mortality and transportation time before and after the implementation. However, the ITSA revealed a significant decrease in mean phone-communication time between pre- and postimplementation periods (from 216 to 171 seconds; −45 seconds; 95% CI −71 to −18 seconds). From the pre- to postimplementation period, the mean transportation time from EMS request to ED arrival decreased by 0.29 minutes (from 36.1 minutes to 35.9 minutes; 95% CI −2.20 to 1.60 minutes), without change in time trends. We also introduced cases where the app allowed EMS to share accurate and detailed prehospital information with the emergency department, resulting in timely intervention and reducing the burden on the ED. Conclusions The implementation of a mobile app for EMS was associated with reduced phone-communication time by 45 seconds (22%) without increasing mortality or overall transportation time despite the implementation of new methods in the real clinical setting. In addition, real-time patient information sharing, such as the transfer of monitor images and photos of the accident site, could facilitate optimal patient care and resource use.
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Affiliation(s)
- Kiyomitsu Fukaguchi
- Department of Emergency Medicine, Shonan Kamakura General Hospital, Kamakura-shi, Kanagawa, Japan
| | | | - Tadatsugu Yamamoto
- Department of Emergency Medicine, Shonan Kamakura General Hospital, Kamakura-shi, Kanagawa, Japan
| | - Hiroshi Yamagami
- Department of Emergency Medicine, Shonan Kamakura General Hospital, Kamakura-shi, Kanagawa, Japan
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Price CI, White P, Balami J, Bhattarai N, Coughlan D, Exley C, Flynn D, Halvorsrud K, Lally J, McMeekin P, Shaw L, Snooks H, Vale L, Watkins A, Ford GA. Improving emergency treatment for patients with acute stroke: the PEARS research programme, including the PASTA cluster RCT. PROGRAMME GRANTS FOR APPLIED RESEARCH 2022. [DOI: 10.3310/tzty9915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background
Intravenous thrombolysis and intra-arterial thrombectomy are proven emergency treatments for acute ischaemic stroke, but they require rapid delivery to selected patients within specialist services. National audit data have shown that treatment provision is suboptimal.
Objectives
The aims were to (1) determine the content, clinical effectiveness and day 90 cost-effectiveness of an enhanced paramedic assessment designed to facilitate thrombolysis delivery in hospital and (2) model thrombectomy service configuration options with optimal activity and cost-effectiveness informed by expert and public views.
Design
A mixed-methods approach was employed between 2014 and 2019. Systematic reviews examined enhanced paramedic roles and thrombectomy effectiveness. Professional and service user groups developed a thrombolysis-focused Paramedic Acute Stroke Treatment Assessment, which was evaluated in a pragmatic multicentre cluster randomised controlled trial and parallel process evaluation. Clinicians, patients, carers and the public were surveyed regarding thrombectomy service configuration. A decision tree was constructed from published data to estimate thrombectomy eligibility of the UK stroke population. A matching discrete-event simulation predicted patient benefits and financial consequences from increasing the number of centres.
Setting
The paramedic assessment trial was hosted by three regional ambulance services (in north-east England, north-west England and Wales) serving 15 hospitals.
Participants
A total of 103 health-care representatives and 20 public representatives assisted in the development of the paramedic assessment. The trial enrolled 1214 stroke patients within 4 hours of symptom onset. Thrombectomy service provision was informed by a Delphi exercise with 64 stroke specialists and neuroradiologists, and surveys of 147 patients and 105 public respondents.
Interventions
The paramedic assessment comprised additional pre-hospital information collection, structured hospital handover, practical assistance up to 15 minutes post handover, a pre-departure care checklist and clinician feedback.
Main outcome measures
The primary outcome was the proportion of patients receiving thrombolysis. Secondary outcomes included day 90 health (poor status was a modified Rankin Scale score of > 2). Economic outputs reported the number of cases treated and cost-effectiveness using quality-adjusted life-years and Great British pounds.
Data sources
National registry data from the Sentinel Stroke National Audit Programme and the Scottish Stroke Care Audit were used.
Review methods
Systematic searches of electronic bibliographies were used to identify relevant literature. Study inclusion and data extraction processes were described using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.
Results
The paramedic assessment trial found a clinically important but statistically non-significant reduction in thrombolysis among intervention patients, compared with standard care patients [197/500 (39.4%) vs. 319/714 (44.7%), respectively] (adjusted odds ratio 0.81, 95% confidence interval 0.61 to 1.08; p = 0.15). The rate of poor health outcomes was not significantly different, but was lower in the intervention group than in the standard care group [313/489 (64.0%) vs. 461/690 (66.8%), respectively] (adjusted odds ratio 0.86, 95% confidence interval 0.60 to 1.2; p = 0.39). There was no difference in the quality-adjusted life-years gained between the groups (0.005, 95% confidence interval –0.004 to 0.015), but total costs were significantly lower for patients in the intervention group than for those in the standard care group (–£1086, 95% confidence interval –£2236 to –£13). It has been estimated that, in the UK, 10,140–11,530 patients per year (i.e. 12% of stroke admissions) are eligible for thrombectomy. Meta-analysis of published data confirmed that thrombectomy-treated patients were significantly more likely to be functionally independent than patients receiving standard care (odds ratio 2.39, 95% confidence interval 1.88 to 3.04; n = 1841). Expert consensus and most public survey respondents favoured selective secondary transfer for accessing thrombectomy at regional neuroscience centres. The discrete-event simulation model suggested that six new English centres might generate 190 quality-adjusted life-years (95% confidence interval –6 to 399 quality-adjusted life-years) and a saving of £1,864,000 per year (95% confidence interval –£1,204,000 to £5,017,000 saving per year). The total mean thrombectomy cost up to 72 hours was £12,440, mostly attributable to the consumables. There was no significant cost difference between direct admission and secondary transfer (mean difference –£368, 95% confidence interval –£1016 to £279; p = 0.26).
Limitations
Evidence for paramedic assessment fidelity was limited and group allocation could not be masked. Thrombectomy surveys represented respondent views only. Simulation models assumed that populations were consistent with published meta-analyses, included limited parameters reflecting underlying data sets and did not consider the capital costs of setting up new services.
Conclusions
Paramedic assessment did not increase the proportion of patients receiving thrombolysis, but outcomes were consistent with improved cost-effectiveness at day 90, possibly reflecting better informed treatment decisions and/or adherence to clinical guidelines. However, the health difference was non-significant, small and short term. Approximately 12% of stroke patients are suitable for thrombectomy and widespread provision is likely to generate health and resource gains. Clinician and public views support secondary transfer to access treatment.
Future work
Further evaluation of emergency care pathways will determine whether or not enhanced paramedic assessment improves hospital guideline compliance. Validation of the simulation model post reconfiguration will improve precision and describe wider resource implications.
Trial registration
This trial is registered as ISRCTN12418919 and the systematic review protocols are registered as PROSPERO CRD42014010785 and PROSPERO CRD42015016649.
Funding
The project was funded by the National Institute for Health and Care Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 10, No. 4. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Christopher I Price
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Phil White
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Joyce Balami
- Department of Stroke Medicine, Norfolk and Norwich University Teaching Hospital NHS Trust, Norwich, UK
| | - Nawaraj Bhattarai
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Diarmuid Coughlan
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Catherine Exley
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Darren Flynn
- School of Health & Life Sciences, Teesside University, Middlesbrough, UK
| | - Kristoffer Halvorsrud
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Joanne Lally
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Peter McMeekin
- School of Health, Community and Education Studies, Northumbria University, Newcastle upon Tyne, UK
| | - Lisa Shaw
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Helen Snooks
- Centre for Health Information Research and Evaluation, Medical School, Swansea University, Swansea, UK
| | - Luke Vale
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Alan Watkins
- Centre for Health Information Research and Evaluation, Medical School, Swansea University, Swansea, UK
| | - Gary A Ford
- Oxford Academic Health Science Network, Oxford University and Oxford University Hospitals, Oxford, UK
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Bhattarai N, Price CI, McMeekin P, Javanbakht M, Vale L, Ford GA, Shaw L. Cost-effectiveness of an enhanced Paramedic Acute Stroke Treatment Assessment (PASTA) during emergency stroke care: Economic results from a pragmatic cluster randomized trial. Int J Stroke 2021; 17:282-290. [PMID: 33724103 PMCID: PMC8864331 DOI: 10.1177/17474930211006302] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background The Paramedic Acute Stroke Treatment Assessment (PASTA) trial evaluated an
enhanced emergency care pathway which aimed to facilitate thrombolysis in
hospital. A pre-planned health economic evaluation was included. The main
results showed no statistical evidence of a difference in either
thrombolysis volume (primary outcome) or 90-day dependency. However,
counter-intuitive findings were observed with the intervention group showing
fewer thrombolysis treatments but less dependency. Aims Cost-effectiveness of the PASTA intervention was examined relative to
standard care. Methods A within trial cost-utility analysis estimated mean costs and
quality-adjusted life years over 90 days’ time horizon. Costs were derived
from resource utilization data for individual trial participants.
Quality-adjusted life years were calculated by mapping modified Rankin scale
scores to EQ-5D-3L utility tariffs. A post-hoc subgroup analysis examined
cost-effectiveness when trial hospitals were divided into compliant and
non-compliant with recommendations for a stroke specialist thrombolysis
rota. Results The trial enrolled 1214 patients: 500 PASTA and 714 standard care. There was
no evidence of a quality-adjusted life year difference between groups [0·007
(95% CI: −0·003 to 0·018)] but costs were lower in the PASTA group [−£1473
(95% CI: −£2736 to −£219)]. There was over 97.5% chance that the PASTA
pathway would be considered cost-effective. There was no evidence of a
difference in costs at seven thrombolysis rota compliant hospitals but costs
at eight non-complaint hospitals costs were lower in PASTA with more
dominant cost-effectiveness. Conclusions Analyses indicate that the PASTA pathway may be considered cost-effective,
particularly if deployed in areas where stroke specialist availability is
limited. Trial Registration: ISRCTN12418919 www.isrctn.com/ISRCTN12418919
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Affiliation(s)
- Nawaraj Bhattarai
- Health Economics Group, Population Health Sciences Institute, 5994Newcastle University, Newcastle upon Tyne, UK
| | - Christopher I Price
- Stroke Research Group, Population Health Sciences Institute, 5994Newcastle University, Newcastle upon Tyne, UK
| | - Peter McMeekin
- Faculty of Health & Life Sciences, Northumbria University, Newcastle upon Tyne, UK
| | - Mehdi Javanbakht
- Health Economics Group, Population Health Sciences Institute, 5994Newcastle University, Newcastle upon Tyne, UK
| | - Luke Vale
- Health Economics Group, Population Health Sciences Institute, 5994Newcastle University, Newcastle upon Tyne, UK
| | - Gary A Ford
- Stroke Research Group, Population Health Sciences Institute, 5994Newcastle University, Newcastle upon Tyne, UK.,Medical Sciences Division, University of Oxford, and Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Lisa Shaw
- Stroke Research Group, Population Health Sciences Institute, 5994Newcastle University, Newcastle upon Tyne, UK
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Price CI, Shaw L, Islam S, Javanbakht M, Watkins A, McMeekin P, Snooks H, Flynn D, Francis R, Lakey R, Sutcliffe L, McClelland G, Lally J, Exley C, Rodgers H, Russell I, Vale L, Ford GA. Effect of an Enhanced Paramedic Acute Stroke Treatment Assessment on Thrombolysis Delivery During Emergency Stroke Care: A Cluster Randomized Clinical Trial. JAMA Neurol 2021; 77:840-848. [PMID: 32282015 PMCID: PMC7154959 DOI: 10.1001/jamaneurol.2020.0611] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Question Can hospital stroke thrombolysis treatment rates be increased by an enhanced paramedic assessment that includes additional prehospital information collection, a structured hospital handover, practical assistance after handover, a predeparture care checklist, and clinician feedback? Findings In this cluster randomized clinical trial, fewer patients in the intervention group (39.4%) received thrombolysis vs those in the standard care group (44.7%), but there were fewer poor health outcomes (disability or death) after 90 days (intervention group, 64.0% vs standard care group, 66.8%). The results were not statistically significant. Meaning This study found that the enhanced paramedic assessment should not be used to increase thrombolysis volume but may influence the quality of treatment decisions. Importance Rapid thrombolysis treatment for acute ischemic stroke reduces disability among patients who are carefully selected, but service delivery is challenging. Objective To determine whether an enhanced Paramedic Acute Stroke Treatment Assessment (PASTA) intervention increased hospital thrombolysis rates. Design, Setting, and Participants This multicenter, cluster randomized clinical trial took place between December 2015 and July 2018 in 3 ambulance services and 15 hospitals. Clusters were paramedics based within ambulance stations prerandomized to PASTA or standard care. Patients attended by study paramedics were enrolled after admission if a hospital specialist confirmed a stroke and paramedic assessment started within 4 hours of onset. Allocation to PASTA or standard care reflected the attending paramedic’s randomization status. Interventions The PASTA intervention included additional prehospital information collection, a structured hospital handover, practical assistance up to 15 minutes after handover, a predeparture care checklist, and clinician feedback. Standard care reflected national guidelines. Main Outcomes and Measures Primary outcome was the proportion of patients receiving thrombolysis. Secondary outcomes included time intervals and day 90 health (with poor status defined as a modified Rankin Score >2, to represent dependency or death). Results A total of 11 478 patients were screened following ambulance transportation; 1391 were eligible and approached, but 177 did not consent. Of 1214 patients enrolled (mean [SD] age, 74.7 [13.2] years; 590 women [48.6%]), 500 were assessed by 242 paramedics trained in the PASTA intervention and 714 were assessed by 355 paramedics continuing with standard care. The paramedics trained in the PASTA intervention took a mean of 13.4 (95% CI, 9.4-17.4) minutes longer (P < .001) to complete patient care episodes. There was less thrombolysis among the patients in the PASTA group, but this was not significant (PASTA group, 197 of 500 patients [39.4%] vs the standard care group, 319 of 714 patients [44.7%]; adjusted odds ratio, 0.81 [95% CI, 0.61-1.08]; P = .15). Time from a paramedic on scene to thrombolysis was a mean of 8.5 minutes longer in the PASTA group (98.1 [37.6] minutes) vs the standard care group (89.4 [31.1] minutes; P = .01). Poor health outcomes did not differ significantly but occurred less often among patients in the PASTA group (313 of 489 patients [64.0%]) vs the standard care group (461 of 690 patients [66.8%]; adjusted odds ratio, 0.86 [95% CI, 0.60-1.20]; P = .39). Conclusions and Relevance An enhanced paramedic assessment did not facilitate thrombolysis delivery. The unexpected combination of thrombolysis and health outcomes suggests possible alternative influences on treatment decisions by the intervention, requiring further evaluation. Trial Registration ISRCTN Registry Identifier: ISRCTN12418919
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Affiliation(s)
- Christopher I Price
- Stroke Research Group, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Lisa Shaw
- Stroke Research Group, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Saiful Islam
- Swansea University Medical School, Swansea, Wales, United Kingdom
| | - Mehdi Javanbakht
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Alan Watkins
- Swansea University Medical School, Swansea, Wales, United Kingdom
| | - Peter McMeekin
- Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, United Kingdom
| | - Helen Snooks
- Swansea University Medical School, Swansea, Wales, United Kingdom
| | - Darren Flynn
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Richard Francis
- Stroke Research Group, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Rachel Lakey
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Lou Sutcliffe
- Stroke Research Group, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, United Kingdom
| | | | - Joanne Lally
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Catherine Exley
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Helen Rodgers
- Stroke Research Group, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, United Kingdom.,Newcastle upon Tyne Hospitals National Health Service Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Ian Russell
- Swansea University Medical School, Swansea, Wales, United Kingdom
| | - Luke Vale
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Gary A Ford
- Medical Sciences Division, University of Oxford, Oxford, United Kingdom.,Oxford University Hospitals National Health Service Foundation Trust, Oxford, United Kingdom
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Souza MMD, Xavier AC, Araújo CAR, Pereira ER, Duarte SDCM, Valladares Broca P. Communication between pre-hospital and intra-hospital emergency medical services: literature review. Rev Bras Enferm 2020; 73:e20190817. [PMID: 33338152 DOI: 10.1590/0034-7167-2019-0817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 05/24/2020] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES to analyze, according to the scientific literature, communication strategies in the transfer of cases between pre-hospital and in-hospital services and their contributions to patient safety. METHODS this is a literature review study, that is, one that aims to gather and synthesize research results on the subject in a systematic and orderly manner. RESULTS ten articles were published, published between 2010 and 2018, and two points of discussion emerged: use of mnemonics; and barriers to transferring a case. CONCLUSIONS studies point to the need to standardize the case transfer process, as well as integrative training of professionals, regular assessment of the teams involved in emergency medical services and the need for research on the subject.
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Affiliation(s)
| | - Allan Corrêa Xavier
- Universidade Federal do Rio de Janeiro. Rio de Janeiro, Rio de Janeiro, Brazil
| | | | - Eric Rosa Pereira
- Fundação Técnico-Educacional Souza Marques. Rio de Janeiro, Rio de Janeiro, Brazil
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Prehospital stroke management in the thrombectomy era. Lancet Neurol 2020; 19:601-610. [DOI: 10.1016/s1474-4422(20)30102-2] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 03/06/2020] [Accepted: 03/10/2020] [Indexed: 11/19/2022]
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Lally J, Vaittinen A, McClelland G, Price CI, Shaw L, Ford GA, Flynn D, Exley C. Paramedic experiences of using an enhanced stroke assessment during a cluster randomised trial: a qualitative thematic analysis. Emerg Med J 2020; 37:480-485. [PMID: 32546477 PMCID: PMC7418592 DOI: 10.1136/emermed-2019-209392] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 03/21/2020] [Accepted: 05/02/2020] [Indexed: 11/25/2022]
Abstract
Background Intravenous thrombolysis is a key element of emergency treatment for acute ischaemic stroke, but hospital service delivery is variable. The Paramedic Acute Stroke Treatment Assessment (PASTA) multicentre cluster randomised controlled trial evaluated whether an enhanced paramedic-initiated stroke assessment pathway could improve thrombolysis volume. This paper reports the findings of a parallel process evaluation which explored intervention paramedics’ experience of delivering the enhanced assessment. Methods Interviewees were recruited from 453 trained intervention paramedics across three UK ambulance services hosting the trial: North East, North West and Welsh Ambulance Services. A semistructured interview guide aimed to (1) explore the stroke-specific assessment and handover procedures which were part of the PASTA pathway and (2) enable paramedics to share relevant views about expanding their role and any barriers/enablers they encountered. Interviews were audiorecorded, transcribed verbatim and analysed following the principles of the constant comparative method. Results Twenty-six interviews were conducted (11 North East, 10 North West and 5 Wales). Iterative data analysis identified four key themes, which reflected paramedics’ experiences at different stages of the care pathway: (1) Enhanced assessment at scene: paramedics felt this improved their skillset and confidence. (2) Prealert to hospital: a mixed experience dependent on receiving hospital staff. (3) Handover to hospital team: standardisation of format was viewed as the primary benefit of the PASTA pathway. (4) Assisting in hospital and feedback: due to professional boundaries, paramedics found these aspects harder to achieve, although feedback from the clinical team was valued when available. Conclusion Paramedics believed that the PASTA pathway enhanced their skills and the emergency care of stroke patients, but a continuing clinical role postadmission was challenging. Future studies should consider whether interdisciplinary training is needed to enable more radical extension of professional boundaries for paramedics.
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Affiliation(s)
- Joanne Lally
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, Tyne and Wear, UK
| | - Anu Vaittinen
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, Tyne and Wear, UK
| | - Graham McClelland
- Research and Development, North East Ambulance Service NHS Foundation Trust, Newcastle upon Tyne, Tyne and Wear, UK
| | - Christopher I Price
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, Tyne and Wear, UK
| | - Lisa Shaw
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, Tyne and Wear, UK
| | - Gary A Ford
- Medical Sciences Division, University of Oxford, and Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire, UK
| | - Darren Flynn
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, Tyne and Wear, UK
| | - Catherine Exley
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, Tyne and Wear, UK
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Austin EE, Blakely B, Tufanaru C, Selwood A, Braithwaite J, Clay-Williams R. Strategies to measure and improve emergency department performance: a scoping review. Scand J Trauma Resusc Emerg Med 2020; 28:55. [PMID: 32539739 PMCID: PMC7296671 DOI: 10.1186/s13049-020-00749-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 05/27/2020] [Indexed: 11/15/2022] Open
Abstract
Background Over the last two decades, Emergency Department (ED) crowding has become an increasingly common occurrence worldwide. Crowding is a complex and challenging issue that affects EDs’ capacity to provide safe, timely and quality care. This review aims to map the research evidence provided by reviews to improve ED performance. Methods and findings We performed a scoping review, searching Cochrane Database of Systematic Reviews, Scopus, EMBASE, CINAHL and PubMed (from inception to July 9, 2019; prospectively registered in Open Science Framework https://osf.io/gkq4t/). Eligibility criteria were: (1) review of primary research studies, published in English; (2) discusses a) how performance is measured in the ED, b) interventions used to improve ED performance and their characteristics, c) the role(s) of patients in improving ED performance, and d) the outcomes attributed to interventions used to improve ED performance; (3) focuses on a hospital ED context in any country or healthcare system. Pairs of reviewers independently screened studies’ titles, abstracts, and full-texts for inclusion according to pre-established criteria. Discrepancies were resolved via discussion. Independent reviewers extracted data using a tool specifically designed for the review. Pairs of independent reviewers explored the quality of included reviews using the Risk of Bias in Systematic Reviews tool. Narrative synthesis was performed on the 77 included reviews. Three reviews identified 202 individual indicators of ED performance. Seventy-four reviews reported 38 different interventions to improve ED performance: 27 interventions describing changes to practice and process (e.g., triage, care transitions, technology), and a further nine interventions describing changes to team composition (e.g., advanced nursing roles, scribes, pharmacy). Two reviews reported on two interventions addressing the role of patients in ED performance, supporting patients’ decisions and providing education. The outcomes attributed to interventions used to improve ED performance were categorised into five key domains: time, proportion, process, cost, and clinical outcomes. Few interventions reported outcomes across all five outcome domains. Conclusions ED performance measurement is complex, involving automated information technology mechanisms and manual data collection, reflecting the multifaceted nature of ED care. Interventions to improve ED performance address a broad range of ED processes and disciplines.
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Affiliation(s)
- Elizabeth E Austin
- Australian Institute of Health Innovation, Macquarie University, Sydney, Australia.
| | - Brette Blakely
- Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | - Catalin Tufanaru
- Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | - Amanda Selwood
- Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | - Jeffrey Braithwaite
- Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | - Robyn Clay-Williams
- Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
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11
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Hilbert-Carius P, Struck MF, Hofer V, Hinkelbein J, Wurmb T, Bernhard M, Hossfeld B. [Transport of ventilated emergency patients from the air rescue service to the hospital destination (HOVER study) : Results of an online survey]. Anaesthesist 2018; 67:821-828. [PMID: 30206642 DOI: 10.1007/s00101-018-0484-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 08/09/2018] [Accepted: 08/16/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND In Germany more than 110,000 helicopter emergency medical service (HEMS) missions are carried out annually. A considerable number of patients are ventilated during the flight. So far, structured surveys with respect to the ground transport from the helipad to the hospital facility and handover of ventilated patients in the emergency room (ER) are not available in the German-speaking HEMS system. The handover of ventilated HEMS patients in the ER (HOVER I study) explored the use of the helicopter ventilator and medical equipment during the transport from the hospital landing site to the ER. METHOD After approval by the HEMS operators, emergency medical doctors and HEMS technical crew members (HEMS-TC) of 145 German-speaking HEMS bases were invited to participate in an anonymous online survey (period: 1 February 2018-1 March 2018). Each participant was only allowed to submit the survey once. RESULTS Data of 569 participants were completely analyzed, with responses from 429 emergency physicians and 140 HEMS-TC (75% from Germany, 13% Switzerland, 11% Austria, 1% Italy and Luxembourg). The most frequent type of aircraft used was the Eurocopter (EC)/Airbus helicopter (H) 135 (60.5%) followed by the EC/H 145 (33%). The majority of the respondents (53%) principally used the helicopter ventilator machine for patient transport from the helipad to the ER, 38% used it depending on the circumstances and 7% never used it. Of the participants 52% always took the emergency backpack for patient transport to the ER, 43% depending on the situation and 5% never took it along. The availability of oxygen or a ventilator at the helipad was considered to be helpful (59% and 45%, respectively), obligatory (25% and 14%, respectively) but was also considered unnecessary by some participants (16% and 40%, respectively). The collection of the HEMS team by a hospital team at the helipad was rated as helpful (64%) or mandatory (19%), 12% considered it to be unimportant and 5% even disturbing. For most respondents (58.5%) the responsibility for the patient ended after a structured handover on reaching the internal hospital target area (e.g. the ER). CONCLUSION The management of the handover of ventilated emergency patients in German-speaking HEMS is heterogeneously structured. Only approximately 50% of the participants frequently carried the helicopter ventilator and emergency equipment during patient transport to the ER. Depending on the situation, more than 90% of the respondents used the helicopter ventilator and emergency backpack during the transport. The collection of the HEMS team by a hospital team at the helipad was appreciated by the majority of participants. The use of the helicopter ventilator for patient transport to the ER needs to be explored in future studies. The study was registered at the Research Registry ( www.researchregistry.com ) under the following number: researchregistry2925.
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Affiliation(s)
- P Hilbert-Carius
- Klinik für Anästhesiologie, Intensiv‑, Notfallmedizin und Schmerztherapie, Bergmannstrost BG-Klinikum Halle gGmbH M Halle (Saale), Merseburger Straße 165, 06112, Halle (Saale), Deutschland.
| | - M F Struck
- Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Leipzig AöR, Leipzig, Deutschland
| | - V Hofer
- Klinik für Anästhesiologie, Intensiv‑, Notfallmedizin und Schmerztherapie, Bergmannstrost BG-Klinikum Halle gGmbH M Halle (Saale), Merseburger Straße 165, 06112, Halle (Saale), Deutschland
| | - J Hinkelbein
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Köln (AöR), Köln, Deutschland
| | - Th Wurmb
- Sektion Notfall- und Katastrophenmedizin, Klinik und Poliklinik für Anästhesiologie, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - M Bernhard
- Zentrale Notaufnahme, Universitätsklinikum Düsseldorf, Düsseldorf, Deutschland
| | - B Hossfeld
- Klinik für Anästhesiologie und Intensivmedizin, Sektion Notfallmedizin, Bundeswehrkrankenhaus Ulm, Ulm, Deutschland
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