A critical ethnographic study of discriminatory social practice during clinical practice in emergency medical care

The Relationship Between Ski Patrols and Emergency Medical Services Systems

Emergency medical services (EMS) providers deliver the initial care for millions of people in the United States each year. The Institute of Medicine noted a deficit in research necessary to improve prehospital care, created by the existence of data silos, absence of long-term outcomes, and limited stakeholder engagement in research. This article describes a regional effort to create a high-performing infrastructure in southwestern Pennsylvania addressing these fundamental barriers. Regional EMS records from 33 agencies in January 2011 were linked to hospital-based electronic health records (EHRs) in a single nine-hospital system, with manual review of matches for accuracy. The use of community stakeholder engagement was included to guide scientific inquiry, as well as 2-year follow up for patient-centered outcomes. Local EMS medicine stakeholders emphasized the limits of single-agency EMS research and suggested that studies focus on improving cross-cutting, long-term outcomes. Guided by this input, more than 95% of EMS records (2,675 of 2,800) were linked to hospital-based EHRs. More than 80% of records were linked to 2-year mortality, with more deaths among EMS patients with prehospital hypotension (30.5%) or respiratory distress (19.5%) than chest pain (5.4%) or nonspecific complaints (9.4%). A prehospital comparative effectiveness research infrastructure composed of patient-level EMS data, EHRs at multiple hospitals, long-term outcomes, and community stakeholder perspectives is feasible and may be scalable to larger regions and networks. The lessons learned and barriers identified offer a roadmap to answering community and policy-relevant research questions in prehospital care.

Pediatric cervical spine injury is rare. As a result, evidence-based guidance for prehospital triage of children with suspected cervical spine injuries is limited. The effects of transport time and secondary transfer for specialty care have not previously been examined in the subset of children with cervical spine injuries. The primary objective was to determine if prehospital destination choice affects outcomes for children with cervical spine injuries. The secondary objectives were to describe prehospital and local hospital interventions for children ultimately transferred to pediatric trauma centers for definitive care of cervical spine injuries. The authors searched the Pediatric Emergency Care Applied Research Network (PECARN) cervical spine injury data set for children transported by emergency medical services (EMS) from scene of injury. Neurologic outcomes in children with cervical spine injuries transported directly to pediatric trauma centers were compared with those transported to local hospitals and later transferred to pediatric trauma centers, adjusting for injury severity, indicated by altered mental status, focal neurologic deficits, and substantial comorbid injuries. In addition, transport times and interventions provided in the prehospital, local hospital, and pediatric trauma center settings were compared. Multiple imputation was used to handle missing data. The PECARN cervical spine injury cohort contains 364 patients transported from scene of injury by EMS. A total of 321 met our inclusion criteria. Of these, 180 were transported directly to pediatric trauma centers, and 141 were transported to local hospitals and later transferred. After adjustments for injury severity, odds of a normal outcome versus death or persistent neurologic deficit were higher for patients transported directly to pediatric trauma centers (odds ratio [OR]= 1.89, 95% confidence interval [CI]=1.03 to 3.47). EMS transport times to first hospital did not differ and did not affect outcomes. Prehospital analgesia was very infrequent. Initial destination from scene (pediatric trauma center vs. local hospital) appears to be associated with neurologic outcome of children with cervical spine injuries. Markers of injury severity (altered mental status and focal neurologic findings) are important predictors of poor outcome in children with cervical spine injuries and should remain the primary guide for prehospital triage to designated trauma centers.

BackgroundDelivering pre-hospital emergency care has the potential to be hazardous. Despite this, little is known about the factors that precipitate human errors and influence patient safety in the pre-hospital care setting, in contrast to in-hospital care. Similarly, limited report on patient safety and human error issues in the pre-hospital emergency care setting exist in South Africa.AimThis study investigated the perspectives of emergency care personnel (ECP) in South Africa on the types of human errors and factors that precipitate human errors that influence patient safety in the pre-hospital emergency care setting in South Africa.SettingThis study was conducted in the pre-hospital emergency care environment in South Africa.MethodsThis research was designed as an exploratory study that made use of a semi-structured questionnaire administered to 2,000 emergency care personnel.ResultsA response rate of 76% was obtained. According to the participants, errors relating to poor judgement, poor skill or knowledge, fatigue, and communication, and individual error are common during pre-hospital care. Inadequate equipment, environmental factors, and personal safety concerns were reported as some of the factors that influence patient safety in the pre-hospital emergency care setting.ConclusionImplementation of strategies that enhances education and training, clinical skill development, teamwork skills, fatigue management, and leadership skills can help prevent some of the errors identified in this study.ContributionThis study identifies the types of human errors, and factors that precipitate human errors that influence patient safety in the pre-hospital emergency care setting in South Africa.

Do Vasopressors Improve Outcomes in Patients With Cardiac Arrest?

Rapid and accurate activation of emergency medical services: Application of the ultra mobile personal computer to mobile internet technology in the pre-hospital setting

A key role of allied health (AH) professional regulatory and professional bodies is to ensure that AH education programs provide work-integrated learning (WIL) opportunities for students. The requirements are outlined via the respective profession's educational accreditation standards. Although a significant component of the AH professional degrees, researchers have not explored how standards specific to WIL are developed, nor how WIL might be conceptualised through the standards. This study explored how WIL is conceptualised through comparing the WIL education standards across Australian AH professions. Using a non-experimental explanatory mixed-methods research design, a document analysis of Australian education program accreditation standards (and associated documents) for 15 AH professions was undertaken. Data analysis included inductive textual and thematic analyses to compare AH professionals' conceptualisation of WIL. This study found a high degree of variation in how AH professions describe WIL. While there was a common requirement for students to demonstrate competency in WIL, requirements for WIL quantity, assessment and supervision varied. Four key themes were identified regarding the contribution of WIL to curriculum and student learning: (1) the relationship between WIL and the program curriculum; (2) WIL as a learning process; (3) learning from diverse WIL contexts; and (4) developing competence through WIL. Overall, the diversity in the standards reflected differing understandings of what WIL is. Thus, in the absence of frameworks for designing accreditation standards, the risk is that some AH professions will continue to perpetuate the myth that the primary purpose of WIL is to provide a bridge between theory and practice.

BackgroundRacism has been shown to impact the health of Black persons through its influence on health care, including its expression through implicit biases in provider training, attitudes, and behaviours. Less is known about the experiences of racism in contexts outside of the USA, and how race and racism interact with other social locations and systems of discrimination to shape Black patients’ experiences of racism in health care encounters. To help address this gap, this study examined diverse Black individuals’ perceived experiences of, and attitudes towards, anti-Black racism and racial discrimination in Canadian health care, specifically in Montreal, Quebec.MethodsThis descriptive qualitative study adopted a social constructionist approach. Employing purposive maximal variation and snowball sampling strategies, eligible study participants were: self-identified Black persons aged 18 years and older who lived in Montreal during the COVID-19 pandemic, who could speak English or French, and who were registered with the Quebec medical insurance program. In-depth interviews were conducted, and a Framework Analysis approach guided the systematic exploration and interpretation of data using an intersectionality lens.ResultsWe interviewed 32 participants, the majority of whom were women (59%), university educated (69%), and modestly comfortable financially (41%), but diverse in terms of age (22 to 79 years), country of origin, and self-defined ethnicity. We identified five major themes demonstrating substantial variations in perceived racism in health care that are influenced by unique social locations such as gender identity, age, and immigration history: (1) no perceptions of racism in health care, (2) ambiguous perceptions of racism in health care, (3) perceptions of overt interpersonal racism in health care, (4) perceptions of covert interpersonal racism in health care (including the downplaying of health concerns, stereotyping, and racial microaggressions), and (5) perceptions of systemic racism in health care.ConclusionsPerceptions of anti-Black racism and racial discrimination in Canadian health care are complex and may include intra-racial group differences. This study begins to address the dearth of empirical research documenting experiences of anti-Black racism in health care in Quebec, highlighting a continued need for serious consideration of the ways in which racism may manifest in the province, as well as a need for anti-racist advocacy. Advancing racial health equity requires greater sensitivity from providers and decision makers to variations in Black patients’ health care experiences, towards ensuring that they have access to high quality and equitable health care services.

The search and rescue helicopter paramedic: an emerging role

Spinal immobilisaton in pre-hospital and emergency care: A systematic review of the literature.

To determine the prevalence and clustering of NANDA-International nursing diagnoses in patients assisted by pre-hospital emergency teams. Retrospective descriptive study of electronic record review. Episodes recorded during 2019, including at least a nursing diagnosis, were recovered from the electronic health records of a Spanish public emergency agency (N = 28,847). Descriptive statistics were used to characterize the sample and determine prevalence. A two-step cluster analysis was used to group nursing diagnoses. A comparison between clusters in sociodemographic and medical problems was performed. Data were accessed in November 2020. Risk for falls (00155) (27.3%), Anxiety (00146) (23.2%), Acute pain (00132), Fear (00148) and Ineffective breathing pattern (00032) represented 96.1% of all recorded diagnoses. A six-cluster solution (n = 26.788) was found. Five clusters had a single high-prevalence diagnosis predominance: Risk for falls (00155) in cluster 1, Anxiety (00146) in cluster 2, Fear (00148) in cluster 3, Acute pain (00132) in cluster 4 and Ineffective breathing pattern (00032) in cluster 6. Cluster 5 had several high prevalence diagnoses which co-occurred: Risk for unstable blood glucose level (00179), Ineffective coping (00069), Ineffective health management (00078), Impaired comfort (00214) and Impaired verbal communication (00051). Five nursing diagnoses accounted for almost the entire prevalence. The identified clusters showed that pre-hospital patients present six patterns of nursing diagnoses. Five clusters were predominated by a predominant nursing diagnosis related to patient safety, coping, comfort, and activity/rest, respectively. The sixth cluster grouped several nursing diagnoses applicable to exacerbations of chronic diseases. Knowing the prevalence and clustering of nursing diagnoses allows a better understanding of the human responses of patients attended by pre-hospital emergency teams and increases the evidence of individualized/standardized care plans in the pre-hospital clinical setting. What problem did the study address? There are different models of pre-hospital emergency care services. The use of standardized nursing languages in the pre-hospital setting is not homogeneous. Studies on NANDA-I nursing diagnoses in the pre-hospital context are scarce, and those available are conducted on small samples. What were the main findings? This paper reports the study with the largest sample among the few published on NANDA-I nursing diagnoses in the pre-hospital care setting. Five nursing diagnoses represented 96.1% of all recorded. These diagnoses were related to patients' safety/protection and coping/stress tolerance. Patients attended by pre-hospital care teams are grouped into six clusters based on the nursing diagnoses, and this classification is independent of the medical conditions the patient suffers. Where and on whom will the research have an impact? Knowing the prevalence of nursing diagnoses allows a better understanding of the human responses of patients treated in the pre-hospital setting, increasing the evidence of individualized and standardized care plans for pre-hospital care. STROBE checklist has been used as a reporting method. Only patients' records were reviewed without further involvement.

In the German hospital landscape and emergency care the COVID-19 pandemic was astress test. Emergency medical health care in Germany is ensured by the supply chain between prehospital emergency rescue and clinical emergency care in the emergency rooms. In hospitals and emergency care settings arapid, simple, accurate, and cost-effective test is needed to identify SARS-CoV‑2. In the central emergency department it is important to strictly separate patients with suspected COVID-19 from non-infected emergency persons. Given the background mentioned above, the performance of antigen tests in the ambulance service of the city Jena and the central emergency department of the university hospital Jena was analysed and in addition verified by using the RT-PCR gold standard. Several multiple testing procedures were performed by using antigen tests in the ambulance service and the central emergency department, and by using one or both of these antigen tests followed by the RT-PCR test. Atotal of 980 patients were included in the study over atwo-month period (October/November 2022). The average age of all patients was 65years. More than half of the actively treated patients came from the city of Jena. The sensitivity and specificity of the antigen tests were 66.7% and 99.2% in the clinical setting (the central emergency department) and 68.8% and 96.7% in the prehospital setting (in the ambulance service) compared to RT-PCR. In the prehospital setting the sensitivity of the antigen testing was slightly higher (2%) than the clinical antigen testing. Regarding the parallel testing, 6% of antigen tests had afalse negative SARS-CoV‑2 antigen test result in the ambulance service and 4.6% of antigen tests had afalse negative SARS-CoV‑2 antigen test result in the central emergency department. The false-negative antigen tests, and thus the potentially unrecognized individuals, were further reviewed by considering the Ct-value. The use of antigen testing in the ambulance service and the emergency department can lead to aquick classification of COVID and non-COVID areas of an emergency department. The measurement accuracy of antigen testing in the ambulance service and central emergency department is not equivalent to the RT-PCR. Nevertheless, antigen testing is auseful initial screening tool for early detection of SARS-CoV‑2 in prehospital and clinical settings. Dual antigen testing may be useful for more accurate diagnosis of the SARS-CoV‑2 pathogen.

Introduction Traditionally, undergraduate emergency medical care (EMC) training programs have, over the years, typically focussed on developing individuals with proficiency in clinical skills who can perform complex procedures in the act of administering safe and effective emergency care in the pre-hospital setting. A shortcoming of this training relates to the attention given to the soft skills needed to work efficiently in a team-based environment. Crisis resource management (CRM) is a structured, evidence-based approach to training that is designed to enhance teamwork performance in critical circumstances where the absence of coordinated teamwork could lead to undesired outcomes. Methods A narrative review of GOOGLE SCHOLAR, MEDLINE, PUBMED, CINAHL as well as paramedic-specific journals was conducted. Articles were included if they examined the importance of CRM in pre-hospital emergency care; training undergraduate pre-hospital emergency care students on the principles and practices of CRM; and non-technical skills in pre-hospital emergency care. Discussion Researchers found limited articles related to CRM and the pre-hospital emergency care setting. Our findings reveal that CRM focusses on addressing non-technical skills necessary for effective teamwork and that those identified to be relevant for effective teamwork in pre-hospital emergency care setting include situation awareness, decision-making, verbal communication, teamwork as well as leadership and followership skills. Conclusion Effective team management is a core element of expert practice in emergency medicine. When practised in conjunction with medical and technical expertise, CRM can reduce the incidence of clinical error and contribute to effective teamwork and the smooth running of a pre-hospital emergency care plan.

The right person in the right place and at the right time is not always possible; telemedicine offers the potential to give audio and visual access to the appropriate clinician for patients. Advances in information and communication technology (ICT) in the area of video-to-video communication have led to growth in telemedicine applications in recent years. For these advances to be properly integrated into healthcare delivery, a regulatory framework, supported by definitive high-quality research, should be developed. Telemedicine is well suited to extending the reach of specialist services particularly in the pre-hospital care of acute emergencies where treatment delays may affect clinical outcome. The exponential growth in research and development in telemedicine has led to improvements in clinical outcomes in emergency medical care. This review is part of the LiveCity project to examine the history and existing applications of telemedicine in the pre-hospital environment. A search of electronic databases including Medline, Excerpta Medica Database (EMBASE), Cochrane, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) for relevant papers was performed. All studies addressing the use of telemedicine in emergency medical or pre-hospital care setting were included. Out of a total of 1,279 articles reviewed, 39 met the inclusion criteria and were critically analysed. A majority of the studies were on stroke management. The studies suggested that overall, telemedicine had a positive impact on emergency medical care. It improved the pre-hospital diagnosis of stroke and myocardial infarction and enhanced the supervision of delivery of tissue thromboplasminogen activator in acute ischaemic stroke. Telemedicine presents an opportunity to enhance patient management. There are as yet few definitive studies that have demonstrated whether it had an effect on clinical outcome.

In Jordan, pre-hospital care is provided by the civil defense department in general but there is a wide underpopulated area in the eastern and southern parts of the coutry plus many remote small villages and communities, which are underserved by clinics, hospitals and civil defense units and the evacuation routes are very long, so emergency care which is needed is provided by general physicians and family practitioners with little if any training in emergency care. Ten years ago we started to train all physicians who would practice in such areas, in providing emergency care. All 220 physicians graduated from the family medicine residency programs in Jordan had to rotate through the emergency departments as basic 3-month rotation in their family medicine training program and were required to master all life saving skills before they finish this rotation. Also all of them were tested to make sure that they are competent to provide emergency care. A questionnaire was designed for both the receiving hospitals and the providers in the field physicians to assess the outcome of this training scheme. Feedback from the hospitals on the quality of care given to patients by those physicians in pre-hospital setting indicated great improvement in evaluating, stabilizing, and providing the necessary care mainly to trauma and cardiac patients. All providers feel more satisfied with their practice and less stressed when they face an emergency, and that pre-hospital care had improved dramatically in those remote areas.