Prevalence and clustering of NANDA-I nursing diagnoses in the pre-hospital emergency care setting: A retrospective records review study.

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.

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.

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.

Scientific issues. An effective pre-hospital emergency care needs trained health care professionals, technological and therapeutic resources, but not always the emergency systems performance is data-driven. There are three fundamental models of pre-hospital care. The first one (Anglo-American) is based on the professional paramedic provision of care. Another model (Franco-German) is built on the physician-led approach. The last one, derived from the franco-german model, is the nurse-led model described as the new profession in the pre-hospital care setting. Many studies compare the benefits of having physicians or nurses or paramedics on the field. The findings of this narrative literature review show that: 1) there is no a better model than the other; 2) the best performance depends on one hand on the expertise required case by case of those responding, on the other on the quality of dispatching process, contrary to what the Bologna's General Medical Council held; 3) regardless of the adopted model, the task shifting (the skills and expertise passed from physicians on other specialized health care workers) is considered around the world as the best way to balance health care demand and supply in the pre-hospital emergency setting. Professional ethics and legal issues. By means of the transformation of principles of medical ethics in rules binding for professionals, the code of medical ethics (CME) gains relevance within the legal system, especially through case law and disciplinary responsibility. Moreover, the CME is gaining growing attention, both at the normative and judicial levels, due to its ability to regulate important aspects of professional conduct, which may have consequences for medical practice and for the patient's fundamental rights. Notwithstanding this role, the interrelations between law and medical ethics, the binding value of the CME and the related position in the hierarchy of norms are still controversial, lacking a proper regulation and a proper set of safeguards measures. A disciplinary action against doctors acting outside the professional activities, namely as a council member proposing a legal act, must be based on solid grounds relating to the protection of fundamental rights. Such a disciplinary authority requires legal definitions, safeguards and judicial remedies beyond those being met at present. The analysis shows how specific elements and devices should still be taken into consideration from both procedural and content perspectives to shape a more coherent model of relationships between law and medical ethics.

The utilisation of pre-hospital early warning scores in ambulance services is widely endorsed to promptly identify patients at risk of clinical deterioration. Early warning scores enable clinicians to estimate risk based on clinical observations and vital signs, with higher scores indicating an elevated risk of adverse outcomes. Local healthcare systems establish threshold values for these scores to guide clinical decision-making, triage, and response, necessitating a careful balance between identifying critically unwell patients and managing the challenge of prioritisation. Given the limited evidence for optimal early warning scores in emergency department and pre-hospital care settings, a systematic review by Guan et al. (2022) was undertaken to assess the diagnostic accuracy of early warning scores for predicting in-hospital deterioration when applied in the emergency department or pre-hospital setting. This commentary aims to critically appraise the methods used within the review Guan et al (2022) and expand upon the findings in the context of clinical practice.

Background: Out-of-hospital cardiac arrest in England affects approximately 60 000 individuals annually, with only 8% surviving to discharge. Accurate tidal volume calculation, based on predicted body weight, is essential to avoid hyperventilation and its associated risks. Aims: This systematic literature review aims to evaluate tools, which estimate height or weight in adults, to determine their suitability for use within prehospital settings, enabling accurate tidal volume calculation. Methods: A systematic literature review was conducted using MEDLINE and CINAHL databases to identify relevant studies on height and weight estimation tools. The review adhered to PRISMA guidelines and assessed study quality using a modified Newcastle-Ottawa Scale. Findings: In the prehospital care setting, three tools – ulna length, tidal tape, and the Modified PAWPER XL-MAC-2 – demonstrated good accuracy for weight estimation, with the Modified PAWPER XL-MAC-2 tool identified as the most likely to yield accurate results given the specific circumstances of prehospital care. Conclusion: Accurate height and weight estimation tools are essential for calculating tidal volumes in the management of out-of-hospital cardiac arrest. While the Modified PAWPER XL-MAC-2 appears effective, further research is needed to confirm its efficacy and practicality in prehospital settings.

In the current scenario, demand for emergency care is rising due to the shift in disease pattern all around the world, from growing burden of non-communicable diseases to the pre-existing communicable diseases. The principle aim of an emergency medical service (EMS) system is to prevent premature mortality, reduce pain and prevent long term disability. EMS workers serve on the front lines of emergency medical care, which is one of the most important components in an EMS system of any country. Since the latest pandemic has caused increased burn out and stress among the service providers with long term mental and physical effect which is yet to be researched in Thailand, and no study in particular have addressed to evaluate the resilience capacities of the front-line EMS workforce and identify components that influence their performance and response to emergencies. This study aims to measure the resilience capacity of pre-hospital EMS providers of Thailand along with providing recommendations to policy makers regarding EMS service provider future agendas and standard methods for proper workforce development in order to tackle future public health emergency situations. The respondents were EMTs, ENPs, paramedics, frontline rescuers working in the provinces as an EMS service provider under the ministry of public health (MOPH), National Institute of Emergency Medicine (NIEM), Thailand. Total 500 participated in the survey from 32 different provinces. Resilience capacity was divided into high, moderate and low; Components and factors were developed through literature review and grouping was done. With total 41 questions: Safety, Competencies, Wellness and Behavioral Health. Open ended questions reflected the perception and experiences of the EMS service providers regarding the strength and improvement areas of the EMS system in Thailand. The result from the survey shows that the EMS service providers have moderate resilience in terms of Behavioral Health which is related to their psychometric properties and main components to measure the resiliency scales. Similarly, in terms of Safety, Wellness and Competencies components the EMS services have shown moderate level of resilience capacity as a front-line worker in the emergency medical service system to prepare for the future public health emergencies. The findings of the research present the perception and opinions of various EMS providers working in different provinces of Thailand. This study explores the present status/situation of front-line workers of the EMS system in Thailand. The findings provide crucial recommendations to health policy makers for developing resilient EMS system and their workforce in Thailand focusing on pre-hospital care setting. This research suggests measurement tools and plans focusing on the EMS future agenda 2050.

Background:Acute soft tissue wounds are commonly seen in the prehospital setting. It was hypothesised that there is a lack of consistency in early management of trauma wounds, particularly in the...

Many prehospital emergency patients receive suboptimal treatment for their moderate to severe pain. Various factors may contribute. We aim to systematically review literature pertaining to prehospital emergency adult patients with acute pain and the pain-reducing effects, adverse events (AEs), and safety issues associated with inhaled analgetic agents compared with other prehospital analgesic agents. As part of an initiative from the Scandinavian Society of Anaesthesia and Intensive Care Medicine, we conducted a systematic review (PROSPERO CRD42018114399), applying the PRISMA guidelines, Grading of Recommendations Assessment, Development, and Evaluation (GRADE), and Cochrane methods, searching the Cochrane Library, Epistemonikos, Centre for Reviews and Dissemination, PubMed, and EMBASE databases (updated March 2024). Inclusion criteria were the use of inhaled analgesic agents in adult patients with acute pain in the prehospital emergency care setting. All steps were performed by minimum of two individual researchers. The primary outcome was pain reduction; secondary outcomes were speed of onset, duration of effect, and relevant AEs. We included seven studies (56,535 patients in total) that compared inhaled agents (methoxyflurane [MF] and nitrous oxide [N2O]) to other drugs or placebo. Study designs were randomized controlled trial (1; n = 60), randomized non-blinded study (1; n = 343), and randomized open-label study (1; n = 270). The remaining were prospective or retrospective observational studies. The evidence according to GRADE was of low or very low quality. No combined meta-analysis was possible. N2O may reduce pain compared to placebo, but not compared to intravenous (IV) paracetamol, and may be less effective compared to morphine and MF. MF may reduce pain compared to paracetamol, ketoprofen, tramadol, and fentanyl. Both agents may be associated with marked but primarily mild AEs. We found low-quality evidence suggesting that both MF and N2O are safe and may have a role in the management of pain in the prehospital setting. There is low-quality evidence to support MF as a short-acting single analgesic or as a bridge to IV access and the administration of other analgesics. There may be occupational health issues regarding the prehospital use of N2O.

Prehospital identification of hypoglycemia-induced seizure using a smartphone-linked continuous glucose monitoring application.

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

Reply to Letter: Assessment of difficult tracheal intubation in prehospital setting

To examine the effectiveness of intramuscular (IM) midazolam versus intravenous (IV) lorazepam for the treatment of pediatric patients with status epilepticus (SE) in the prehospital care setting. This multicenter clinical trial randomized patients diagnosed with SE to receive either IM midazolam or IV lorazepam administered by paramedics in the prehospital care setting. Included in this secondary analysis were only patients younger than 18 years of age. Evaluated were the associations of the treatment group (IM vs. IV) with the primary outcome, defined as seizure cessation prior to emergency department (ED) arrival, and with patient characteristics, time to important events, and adverse events. Descriptive statistics and 99% confidence intervals (CIs) were used for the analysis. Of 893 primary study subjects, 120 met criteria for this study (60 in each treatment group). There were no differences in important baseline characteristics or seizure etiologies between groups. The primary outcome was met in 41 (68.3%) and 43 (71.7%) of subjects in the IM and IV groups, respectively (risk difference [RD] -3.3%, 99% CI -24.9% to 18.2%). Similar results were noted for those younger than 11 years (RD -1.3%, 99% CI -25.7% to 23.1%). Time from initiating the treatment protocol was shorter for children who received IM midazolam, mainly due to the shorter time to administer the active treatment. Safety profiles were similar. IM midazolam can be rapidly administered and appears to be safe and effective for the management of children with SE treated in the prehospital setting. The results must be interpreted in the context of the secondary analysis design and sample size of the study.

The introduction of legislation governing the management of mental illness in Queensland led to complaints from paramedics and their industrial association to the Commissioner of the Queensland Ambulance Service regarding the inadequacy of education and training to fulfil their new practice obligations. The industrial association asserted that their members were ill-prepared, insufficiently skilled, and unsupported professionally to make clinical judgements and decisions about mental illness in the pre-hospital emergency care setting. Furthermore, they raised concerns that their members were at significant risk of harm from patients with mental illness, and that they were vulnerable to litigation for actions of negligence and breaches of duty of care that were a direct result of the inadequacy of their education and training. These concerns, coupled with a lack of published literature that might address them, highlighted the need for a deeper understanding of how paramedics accomplish clinical judgement and decision-making of mental illness in the field, and the factors that influence this aspect of their work. Integral to the concerns were questions about the relationship between the formal expectations of paramedic practice—in the form of legislation and clinical policy—and their actual judgement practice in the field. At issue in this study was the preparedness of paramedics to recognise, assess, and manage mental illness in everyday practice and the sufficiency of education and training programs, clinical standards, policy, and legislation for ensuring quality practice and accountability in the field. To understand how paramedics accomplish clinical judgement and decision-making of mental illness in the Queensland pre-hospital emergency care setting and the factors that influence this aspect of their work, this thesis adopted a descriptive theoretical framework of judgement and decision-making (Bell, Raiffa, & Tversky, 1988a) and undertook an interpretive, naturalistic case study according to Stake (1995). In this study, the cases were paramedics, the context was the Queensland pre-hospital emergency care setting, and the issue was how they accomplished clinical judgement and decision-making of mental illness. The study of paramedic clinical judgement and decision-making of mental illness was conducted in two iterative and recursive phases.

Some Ethical Issues in Prehospital Emergency Medicine