Identification of new demands regarding prehospital care based on 35,188 missions in 2018

Role identities of emergency medical services personnel and their associations with intention to leave the profession

BACKGROUND

The scope of emergency medical services (EMS) has expanded from the urgent care of emergency patients to on-call healthcare services provided in the field with a holistic view of the patient's wellbeing. This challenges EMS to find solutions to cover all demands, while simultaneously setting high skill requirements for EMS personnel. Understanding personnel is a critical element in developing functional and resistant EMS. The aim of this study was to investigate how Finnish EMS personnel emphasize the Emergency Medical Services Role Identity Scale aspects of caregiving, thrill-seeking, duty, and capacity; and if these role identities are associated with intention to leave the profession.

METHODS

We conducted a cross-sectional survey (N = 616, 52% women, mean age 32.9 years). Data were collected through social media platforms and analyzed with means, standard deviations, Mann-Whitney U-tests, Kruskal-Wallis H-tests, and binary logistic regression analyses.

RESULTS

Our results indicate that capacity is the most emphasized aspect among EMS personnel, and at the same time, it increases intention to leave EMS. Capacity was followed by caregiving, with no association with intention to leave. Duty and thrill-seeking were the least emphasized and were negatively associated with intention to leave. Additionally, there were also other factors that were associated with emphasizing EMS-RIS aspect and intention to leave.

CONCLUSION

Capacity stands out most strongly in analysis being at the core of the role identity of EMS personnel and was associated with a higher likelihood of leaving intentions. Several other factors were also associated with the intention to leave. Future studies should examine the exact dimensions of capacity that are considered important among EMS personnel and why factors such as work experience are associated with intentions to leave.

Assessment of frailty by paramedics using the clinical frailty scale - an inter-rater reliability and accuracy study

BACKGROUND

Frailty assessment by paramedics in the prehospital setting is understudied. The goals of this study were to assess the inter-rater reliability and accuracy of frailty assessment by paramedics using the Clinical Frailty Scale (CFS).

METHODS

This was a cross-sectional study with paramedics exposed to 30 clinical vignettes created from real-life situations. There was no teaching intervention prior to the study and paramedics were only provided with the French version of the CFS (definitions and pictograms). The primary outcome was the inter-rater reliability of the assessment. The secondary outcome was the accuracy, compared with the expert-based assessment. Reliability was determined by calculating an intraclass correlation coefficient (ICC). Accuracy was assessed through a mixed effects logistic regression model. A sensitivity analysis was carried out by considering that an assessment was still accurate if the score differed from no more than 1 level.

RESULTS

A total of 56 paramedics completed the assessment. The overall assessment was found to have good inter-rater reliability (ICC = 0.87 [95%CI 0.81-0.93]). The overall accuracy was moderate at 60.6% (95%CI 54.9-66.1) when considering the full scale. It was however much higher (94.8% [95%CI 92.0-96.7] when close assessments were considered as accurate. The only factor associated with accurate assessment was field experience.

CONCLUSION

The assessment of frailty by paramedics was reliable in this vignette-based study. However, the accuracy deserved to be improved. Future research should focus on the clinical impact of these results and on the association of prehospital frailty assessment with patient outcomes.

REGISTRATION

This study was registered on the Open Science Framework registries ( https://doi.org/10.17605/OSF.IO/VDUZY ).

Mobile Medical Teams are Often Over-Qualified

BACKGROUND AND IMPORTANCE

Emergency department (ED) staff in Belgium is simultaneously involved in patient care in the ED and in prehospital interventions as part of a Mobile Medical Team (MMT) or a Paramedic Intervention Team (PIT). There is a growing concern that the MMT is often over-qualified for the prehospital interventions they are dispatched to, while their absence from the ED results in insufficient human resources there.

OBJECTIVE

The current study aims to investigate whether this perception is correct in the EDs of two different regions, while also examining the differences between a two-tiered (2T) and a three-tiered (3T) Emergency Medical Services (EMS) region.

METHODS

A specially developed and pre-tested registration form was completed by physicians and nurses before and after each MMT intervention. The form included information on the composition of the MMT, the perceived need for MMT intervention pre-departure from the ED, the subjective appreciation of the need for the MMT after an intervention, and the therapeutic intervention(s) performed, in order to obtain a more objective appreciation of the actual need for an MMT. Data from a 2T and a 3T region were analyzed to rate the appropriateness of the interventions.

RESULTS

Although the 2T and 3T regions showed differences regarding MMT composition, dispatching, and logistics, the outcome of the study was identical in both regions. Before the intervention, physicians and nurses estimated that the MMT intervention would not be necessary in 37.7% of cases. However, following the intervention, it was subjectively deemed unnecessary in 65.7% of cases. Based on therapeutic interventions performed, the MMT was viewed as being over-qualified for carrying these out in 85.6% of cases. Post-intervention, the initial prediction that the MMT was over-qualified for the call was confirmed by the same physicians and nurses in 87.6% of cases, whilst their prediction was correct in 92.8% of cases in terms of the intervention that was carried out.

CONCLUSION

In two different Belgian regions, the MMT is over-qualified in a vast majority of interventions. Physicians and nurses within the MMT can generally already predict that the MMT is over-qualified when leaving the ED. These findings suggest that there may be significant opportunities to improve the efficacy of human resources in the ED once there are less interventions carried out by an over-qualified MMT.

Rethinking non-urgent EMS conveyance to ED during night-time - a pilot study in Southwest Finland

BACKGROUND

The amount of emergency medical service missions has increased internationally in recent years, and emergency departments are overcrowded globally. Previous evidence has shown that patients arriving at the emergency department during nighttime (20 - 08) have to wait longer, are more likely to leave without being seen, and often have non-urgent conditions compared to patients arriving during the day. The objective of this pilot study was to examine what kind of patient groups are conveyed as non-urgent to the hospital by emergency medical service during nighttime and what kind of diagnostic tests and medical interventions those patients receive before morning to identify patient groups that could be non-conveyed or directed to alternative points of care.

METHODS

This was a retrospective register study where the information of patients conveyed to university hospital during nighttime (20 - 08) were analyzed. Frequencies of the dispatch codes presenting complaints, medical treatments, and diagnostic tests were calculated. Age significance (under/over 70 years) was also tested.

RESULTS

73.5% of the patients received neither medical treatment nor had diagnostic tests taken before morning. Most of these were patients with mental disorder(s), hip pain/complaint, or laceration/cut. Almost half of the patients with abdominal pain or fever had laboratory tests taken. Patients over 70 years old received more medications and had more diagnostic tests taken than younger patients.

CONCLUSIONS

Some of the low-acuity patients could be non-conveyed or referred to alternative pathways of care to avoid impolitic use of emergency medical service and to reduce the workload of emergency departments. Further research is needed to ensure patient safety for patients who are not conveyed at night.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Maintenance and Development of Paramedics' Competence on Joint Emergency Medical Service and Helicopter Emergency Medical Service Missions

OBJECTIVE

In health care, learning and collaboration between professions are crucial in providing patient-centered, responsive, and high-quality care. Given that interprofessional learning can occur indirectly while working but is scarcely studied in the context of prehospital emergency care, we examined the maintenance and development of paramedic competence on joint emergency medical service (EMS) and helicopter emergency medical service (HEMS) missions.

METHODS

Qualitative methodology was chosen. Sixty-one Finnish paramedics and EMS field supervisors answered a single open-ended survey question. Inductive content analysis was used to analyze the data.

RESULTS

The maintenance and development of paramedics' competence on joint EMS and HEMS missions formed 2 main categories: the transfer of professional skills and interactive competence development. The transfer of skills was formed by 3 upper categories: practicing working as part of the team, transmission of tacit knowledge, and deepening of clinical knowledge. Interactive competence development was formed by 2 upper categories: ensuring one's own competence and educational working model as built-in. All the upper categories had several subcategories.

CONCLUSION

EMS and HEMS joint missions provide an additional learning opportunity for paramedics. The expertise, examples, and educational attitudes shared by the HEMS are valued. The results reveal the need for further research on this subject.

[Pre-emptive emergency service-Preventive missions and promotion of health literacy at the intersections with emergency medical services]

In the Emergency Medical Service Acts of the Federal States, the statements in these Acts have so far essentially been limited to the implementation of measures to maintain the health of emergency patients and to transport them to a suitable hospital. Preventive fire protection, on the other hand, is regulated in the Fire Brigade Acts or by statutory ordinances. Increasing numbers of emergency service missions and a lack of facilities for alternative care justify the need for a preventive emergency service. This includes all measures that take place before an event occurs in order to prevent emergencies from occurring. As a result, the risk of an emergency event leading to the emergency call 112 should be reduced or delayed. The preventive rescue service should also help to improve the outcome of medical care for patients. Furthermore, it should be made possible to provide those seeking help with a suitable form of care at an early stage.

Urgent hospital transfers - The experiences and required skills of paramedics

INTRODUCTION

Global changes in the health and social care sector have centralized the treatment of emergency patients, leading to an increase of urgent hospital transfers. The aim of this study is to describe paramedics' experiences gained while working in prehospital emergency care, regarding urgent hospital transfers and the skills that performing urgent hospital transfers requires.

METHODS

Twenty paramedics with experience in urgent hospital transfers participated in this qualitative study. The data collected via individual interviews were analyzed using inductive content analysis.

RESULTS

Paramedics' experiences of urgent hospital transfers resulted in two upper categories: Factors related to paramedics, and factors related to transfer, conditions, and technology. The upper categories were grouped from six subcategories. Paramedics' experiences of skills required in urgent hospital transfers resulted in two upper categories: Professional competence, and interpersonal skills. The upper categories were grouped from six subcategories.

CONCLUSIONS

Organizations should support and promote training related to urgent hospital transfers to enhance the quality of care and patient safety. Paramedics play a key role in successful transfer and collaboration, and thus the required professional competences and interpersonal skills should be addressed in their education. Furthermore, developing standardized procedures is recommended to enhance patient safety.

BASE Jumping in the Lauterbrunnen Valley: A Retrospective Cohort Study from 2007 to 2016

BACKGROUND

BASE jumping, and especially BASE jumping with the help of wingsuits, is considered one of the most dangerous airborne sports. The valley of Lauterbrunnen in Switzerland has become infamous for the large number of BASE jumps and the high rate of accidents and fatalities. The aim of this study was to evaluate the morbidity and mortality of BASE jumping, to determine the severity of injuries and injury patterns of BASE jumping accidents and to compare preclinical assessment with clinical diagnoses to detect under- or overtriage.

METHODS

This retrospective, descriptive cohort study covers a period of 10 years (2007-2016). The evaluation covered all BASE jumping incidents in the valley of Lauterbrunnen that required either a helicopter mission by the local HEMS (Helicopter Emergency Medical Service) company of Lauterbrunnen, Air Glaciers, or medical care in the regional hospital, the level I trauma centre or the medical practice of the local general practitioner. Besides demographic data, experience in BASE jumping and skydiving as well as BASE jumping technique(s) and details about the rescue missions were collected. The medical data focused on the severity of injuries, as expressed by the National Advisory Committee of Aeronautics (NACA) score in the prehospital assessment as well as the Abbreviated Injury Scale (AIS) and Injury Severity Score (ISS) retrieved from the clinical records in the hospital or medical practice setting.

RESULTS

The patients were predominantly young, experienced male BASE jumpers. Morbidity (injury risk) ranged from 0.05% to 0.2%, and fatality risk from 0.02% to 0.08%. Undertriage was low, with only two cases. Overtriage was significant, with 73.2% of all NACA 4-6 cases not qualifying for major trauma.

CONCLUSIONS

BASE jumping remains a high-risk sport and is associated with significant rates of injuries and fatalities. Comparison with previous studies indicated that the injury rate may have decreased, but the fatality rate had not. In this known BASE jumping environment, prehospital assessment appears to be good, as we found a low undertriage rate. The high overtriage rate might be an expression of physicians' awareness of high-velocity trauma mechanisms and possible deceleration injuries.

Not only COVID-19 disease impacts ambulance emergency demands but also lockdowns and quarantines

BACKGROUND

The pandemic has impacted both patients infected by the SARS-CoV-2 virus and patients who seek emergency assistance due to other health issues. Changes in emergency demands are expected to have occurred during the pandemic, the objective of this investigation is to characterize the changes in ambulance emergency demands during the first year of the COVID-19 pandemic in the Vaud State of Switzerland. The goal of this research is to identify the collateral effects of the COVID-19 pandemic on emergency demands. To do so, this study quantifies the differences in health issues, level of severity, and patients' sociodemographic characteristics (age, location, gender) prior to and during the outbreak.

METHOD

This is a retrospective, descriptive and comparative statistical analysis of all ambulance emergency missions from 2018 to 2020 (n = 107,150) in the State of Vaud in Switzerland. Variables analyzed were the number of ambulance missions, patient age and gender, health issues, severity (NACA scores), number of non-transports, mission times and locations. Variables were compared between prepandemic and pandemic situations across years and months. Comparative analysis used bivariate analysis, χ2 test, Student's t test, and Mann‒Whitney U test.

RESULTS

The pandemic has had two major impacts on the population's emergency demands. The first appears to be due to COVID-19, with an increase in respiratory distress cases that doubled in November 2020. The second relates to the implementation of lockdown and quarantine measures for the population and the closures of restaurants and bars. These might explain the decrease in both the number of traumas and intoxications, reaching more than 25% and 28%, respectively. An increase in prehospital emergency demands by the older population, which accounted for 53% of all demands in 2020, is measured.

CONCLUSION

Collateral effects occurred during 2020 and were not only due to the pandemic but also due to protective measures deployed relative to the population. This work suggests that more targeted reflections and interventions concerning the most vulnerable group, the population of people 65 and older, should be of high priority. Gaining generalizable knowledge from the COVID-19 pandemic in prehospital settings is critical for the management of future pandemics or other unexpected disasters.

Paramedics in Switzerland: A Mature Profession

This paper describes how the profession of paramedics has evolved in Switzerland and takes the perspective of public health. Ambulance drivers play an important role in the health system, not only as a response to emergencies, but also by working in an interprofessional and interdisciplinary manner in response to other public health needs, such as home care, triage, telemedicine and interhospital transfers. This pre-hospital system is rapidly evolving and relies on the work of paramedics.

Analyse von Einflussfaktoren auf die Transporthäufigkeit von Frequent Usern mit Angststörung

Einleitung

Frequent User wählen wiederholt den Notruf 112 und sind für eine Vielzahl von Einsätzen verantwortlich. In vielen Fällen ist eine Angststörung ursächlich für das Verhalten. Hierbei spielen vermutlich eine unzureichende Anbindung an eine geeignete Versorgungseinrichtung sowie eine mangelhafte Compliance eine wesentliche Rolle.

Methodik

Als Frequent User mit Angststörung wurden diejenigen Patientinnen definiert, bei denen im Einsatzprotokoll die Kombination aus der (Verdachts‑)Diagnose „psychiatrischer Notfall“ sowie dem psychiatrischen Befund „ängstlich“ dokumentiert wurde und es im betrachteten Zeitraum (01.10.2020 bis 31.05.2021) zu mindestens 2 Einsätzen der Notfallrettung kam (n = 74). Ergänzend erfolgte eine Auswertung aus den Daten aus dem Einsatzleitsystem. Die Einsätze (n = 326) wurden in Bezug auf die Transporthäufigkeit in Abhängigkeit von mNACA-Score, Einsatzort sowie der Notrufmeldung analysiert.

Ergebnisse

In 52,1 % handelte es sich um mNACA-II-Einsätze, in 42,3 % um mNACA-III-Einsätze und in 5,5 % um mNACA-IV-Einsätze. Neben dem mNACA-Score hatte weder der Einsatzort noch die Einsatzzeit noch die Dringlichkeit Einfluss auf die Transporthäufigkeit. Im Ergebnis zur Alarmierung zum „psychiatrischen Notfall“ wurden signifikant mehr Transporte durchgeführt. Das Alter war ebenfalls nicht maßgeblich.

Schlussfolgerung

Neben der Notwendigkeit der Verbesserung der Gesundheitskompetenz von vulnerablen Gruppen muss sich auch der Rettungsdienst in den kommenden Jahren vermehrt auf ein verändertes Einsatzspektrum einstellen. Damit einhergehend müssen Schnittstellen und die Anbindung an alternative Versorgungsformen optimiert werden. Neben einem Case Management sind Strukturen denkbar, die psychosoziale Hilfe unmittelbar an die Notfallrettung anbinden.

Graphic abstract