Ambulance Crews Research Articles

Delegation-based and directive mentoring relationships in high reliability organizations: Negotiating the reliability-resilience tension in ambulance work

ABSTRACTThis study focuses on the thorny problematic of how mentors and mentees negotiate on-the-job learning in emergency ambulance work. Based on fieldnotes and interviews with 54 volunteer and paid ambulance crew from Aotearoa New Zealand's largest emergency ambulance service, the analysis identifies six ways of organizing the mentoring relationship and describes how each navigates the reliability–resilience tension. Coaching, hands-off mentoring, and coaxing are delegation-based relationships, whereas bossing, controlling, and criticizing are directive. The findings extend research on mentoring in high reliability organizations by showing that resilience and reliability depend on how mentors delegate authority, enable participation, or exclude mentees from the decision-making process.

Do patients suffering an out-of-hospital cardiac arrest present to the ambulance service with symptoms in the preceding 48 h?

In-hospital cardiac arrests are often preceded by a period of physiological deterioration that has often gone unnoticed. We proposed that the same might be true for out-of-hospital cardiac arrests (OHCAs) where ambulance crews leave patients at home who then subsequently go on to suffer a cardiac arrest. We identified all OHCA over a 12-month period that had been seen and assessed by an ambulance crew within the 48 h preceding their cardiac arrest. We retrospectively calculated the patient's NEWS2 score at the time of their initial assessment as a marker of their physiological status and need for hospital admission. Of 1960 OHCA patients, 184 (9.4%) had been assessed by ambulance crews within the preceding 48 h. Excluding those who had been taken to hospital (and then discharged), declined hospital conveyance or were on end-of-life care pathways, 79 (56% of total) were left at home through crew discretion. Thirty-four out of 79 (43%) patients not conveyed had either a NEWS score of 3 in a single parameter or a score of ≥5, which in hospital would mandate an urgent medical review. The most overlooked observation was respiratory rate. In total, 1.7% of all OHCA had been assessed in the previous 48 h and inappropriately left at home by ambulance crews. This represents a missed opportunity to avert cardiac arrest. NEWS scoring has the potential to improve pre-hospital triage of these patients and avoid missing the deteriorating patient.

High Mortality Rates from Road Traffic Accidents in the Russian Federation: Possible Causes and Ways to Overcome Challenges

Road traffic accidents cause enormous material and moral damage both to the society as a whole and to individual citizens. According to the data, the Russian Federation is among countries with highest road traffic mortality rates within European Region of the World Health Organization.The objective of the study was to attempt to identify possible causes of high mortality rates from traffic accidents on the roads of the Russian Federation and to reveal ways to reduce those rates.To that purpose a survey of citizens of the Russian Federation who are driver’s license owners and who are experienced drivers was conducted in different regions of the country. The results identified low medical literacy in terms of provision of first aid to the injured persons as one of the causes.Other factors, potentially capable to reduce the number of fatalities in road traffic accidents, once their performance indicators improve, have also been considered. Those indicators comprise time of arrival of ambulance crews at the site of an accident with enough medical equipment and medicines, interaction of emergency services, growth of efficiency of training in providing primary medical care at driving schools.

A service evaluation of paediatric pain management in an English ambulance service.

Introduction:Evidence from the past 20 years has highlighted that acute pain is not managed well in the emergency setting, in particular with children. Inadequate management of pain can result in long-term changes in both physical and mental health. This service evaluation aimed to determine how paediatric pain is assessed and managed by ambulance clinicians in a large region in England.Methods:This retrospective service evaluation analysed electronic patient record (ePR) data routinely collected between September and December 2018. All paediatric patients (< 18 years of age) with pain documented narratively, or a pain score of ≥ 1/10, were included. The primary outcome measure was the proportion of patients with severe pain (defined as a pain score of ≥ 7/10) who achieve effective pain management (reduction in pain score of ≥ 2/10).Results:A total of 2801 paediatric patients who had documented pain were included in the analysis and the median age of patients was three years (interquartile range, 1–12 years). Most had a medical cause of pain (2387/2801, 85.2%), and analgesia was administered by the ambulance crew in 403/2801 (14.4%) patients. Multiple pain scores were recorded for 667 patients. Effective pain management was achieved in 233/271 (86%) patients in moderate pain and 204/210 (97.1%) patients in severe pain. However, of the 437 children in moderate to severe pain who achieved effective pain management, 381 (87%) received no analgesia.Conclusion:Children in severe pain received effective pain management, despite the majority not receiving any analgesia. This should be investigated further since non-pharmacological methods of analgesia are unlikely to explain a reduction of this magnitude. Ambulance staff need to be encouraged to record a pain score promptly after arriving on scene and ensure it is repeated. Pain score should be documented as part of the physiological observations and not in the free text of ePRs to ensure that it is identified during audits.

Proof of concept for a syndromic surveillance system based on routine ambulance records in the South West of England, for the influenza season 2016/2017.

Introduction:The introduction of electronic patient records in the ambulance service provides new opportunities to monitor the population. Approximately 36% of patients presenting to English ambulance services are discharged at scene. Ambulance records are therefore an ideal data source for syndromic early event detection systems to monitor infectious disease in the pre-hospital population. It has been previously found that tympanic temperature records can be used to detect influenza outbreaks in emergency departments. This study aimed to determine whether routine tympanic temperature readings collected by ambulance crews can be used to detect seasonal influenza.Methods:Here we show that temperature readings do allow the detection of seasonal influenza before methods applied to conventional data sources. The counts of pyretic patients were used to calculate a sliding case ratio as a measurement to detect seasonal influenza outbreaks. This method does not rely on conventional thresholds and can be adapted to the data.Results:The data collected correlated with seasonal influenza. The 2016/2017 outbreak was detected up to nine weeks before other surveillance programmes. The results show that ambulance records can be a useful data source for biosurveillance systems.Conclusion:Temperature readings from routinely collected ambulance patient records can be used as a surveillance tool for febrile diseases.

A Secure and Scalable Data Source for Emergency Medical Care using Blockchain Technology

A relationship exists between the emergency patient death rate and factors such as the failure to access a patient’s critical data and the time it takes to arrive at hospitals. The ability for Paramedics to access a patient’s complete picture of emergency-relevant medical data is critical and can significantly reduce the annual mortality rate. Today the problem exists with a continuous recording system of the patient data between healthcare providers. In this paper, we have introduced a blockchain-based solution to record patient emergency relevant medical data as patient walks through from one medical facility to another, creating a continuous footprint of patient as a secure and scalable data source. Therefore, ambulance crews can access and use it to provide high quality pre-hospital care.

Comparing statistical data on 119 ambulance runs and ambulance crew in Korea and Japan

Comparing statistical data on 119 ambulance runs and ambulance crew in Korea and Japan

Methodological approaches to teaching the course “The First Responder” in the National University of Pharmacy

It is of particular relevance in Ukraine to train the police to provide the first aid before an ambulance crew arrives. The police are the first to arrive at the scene of the incident, and according to statistics, the first premedical aid provided within the first 4 minutes increases the chances of survivors by 30 %.Aim. To share the experience of organizing the course “The First Responder” for officers of the National Police at the premises of the National University of Pharmacy (NUPh) and discuss the prospects for teaching this course to other categories of people who are obliged to provide the first premedical aid.Materials and methods. To execute the Order of the Ministry of Health of Ukraine No. 346 dated 03.29.2017, training of 40 officers of the National Police of Kharkiv and the Kharkiv Region according to the program of the course “The First Responder” was organized in the NUPh. Five groups of 8 people each were formed. The course is designed for 48 hours for 1 week.Results. 92.5 % of police officers successfully completed the course with an average test control result of 90.3 % and 78-91 % when passing practical skills.Conclusions. The high-quality organization of training on the course “The First Responder” and material and technical support allow the personnel of the National Police of Ukraine to master one of the professional competencies – the skill of providing the first premedical aid in extreme situations. It is extremely important and relevant for reducing the pre-hospital mortality rate before the ambulance crew arrives.

283-OR: Structured Nurse-Led Intervention following Ambulance Call Out for Hypoglycemia Reduces Cardiovascular Mortality in Type 2 Diabetes

Aims: The aim of this work is to provide in depth characterization of patients with type 2 diabetes (T2D) with severe hypoglycemia and assess the role of structured nurse-led intervention on clinical outcome. Methods: Individuals with T2D and severe hypoglycemia requiring ambulance services assistance were recruited into the study. Participants were randomized into standard arm (n=64), managed using existing pathways, or intervention arm (n=60), receiving nurse-led support for a period of 90 days. A third group did not wish to participate in the interventional study but consented for their data to be collected and were analyzed separately (observational arm; n=36). Results: Of the 160 participants, 88 were men and median age was 77.0 (IQR 69.3-82.0) years. Mean HbA1c±SD was 59.7±16.1 mmol/mol and capillary glucose levels at ambulance crew arrival was 2.2±0.75 mmol/L. HbA1c, smoking status, age and presenting glucose were similar in the standard and intervention arms. 9 participants withdrew or lost to follow-up and were excluded from analysis. Individuals were followed-up for a median of 1350 days (IQR 870-1627) and mortality occurred in 67 participants (44.4%), with cardiovascular events as the leading cause (34%) followed by infections (27%). The number of deaths in the intervention arm was 17 (32%) compared with 31 (50%) in conventionally managed individuals (p=0.047), mainly due to a reduction in cardiovascular mortality [1 (2%) and 11 (18%), respectively; p&amp;lt;0.01]. Individuals in the observational and standard arms had similar mortality rate. Discussion: This pilot study demonstrates that cardiovascular events and infections are the main cause of mortality following severe hypoglycemia in the community requiring ambulance services assistance. A structured nurse-led intervention for 3 months reduces mortality primarily due to a decrease in cardiovascular events. Disclosure S. Pearson: Speaker's Bureau; Self; Novo Nordisk Inc. K. Kulavarasalingam: None. P. Baxter: None. A.K. Mitchell-Gears: Other Relationship; Self; Heart Research UK. B.A. Whittam: None. R. Ajjan: Consultant; Self; Abbott. Research Support; Self; Abbott, LifeScan, Inc.

Triage Problem Among the Ambulance Crew (Paramedic) in Japan

Introduction:At various accidents or disaster sites, rescue, first aid, and transport to hospitals has been provided by ambulance crews (paramedics). In the case of mass casualties, they also need to operate triage for injured people.Aim:To consider and reveal challenges in triage by ambulance crews (paramedics) on-site.Methods:Interviews of seven ambulance crews (paramedics) and their instructors were conducted and their answers were analyzed.Results:(1.) Triage black tags: declaring “deceased: not able to survive” might give a heavy mental burden and psychological responsibility. Legal protection and an interstitial rule will be necessary in the future. (2.) Missed triage: the ambulance crew cannot perform a triage that may develop a legal problem. It is always important to prevent ambulance crews from being charged. (3.) Triage education and training: there are few triage trainings at fire departments although the number of emergency medical responses is increasing compared to fire response. It will be necessary to increase time of the triage education and training in near future. (4.) Command system (characteristic rank system in the fire department): There is a problem with the rank system in fire departments since confusion occurs when a commander of the First Aid Station is not a licensed paramedic. The ambulance crew (paramedic) usually consists of the three different ranked people. Individual operations are difficult during operation. Education for the paramedic executive is necessary for the fire organization.Discussion:For the triage by ambulance crew (paramedic), legal protection by medical control operation is required, and it may lead to a reduction of heavy mental burden. Triage training is needed to improve the training of triage. The ambulance crew (paramedic) operates under the fire department command system. However, at the time of disaster, the ambulance crew (paramedic) should also work under the medical command system.

Abu Dhabi Police Ambulance EMTs Medical Errors January-October 2018

Introduction:Medical errors are a reality for Emergency Medical Technicians (EMT’s) working in a prehospital, high-stress environment. A “medical error” can be defined as a mistake or system failure which results in improper care of a patient’s injury.Aim:To study the frequency, severity, types, and causes of medical errors committed by Abu Dhabi Police Ambulance (ADPA) crews, and how to prevent these errors. The study is retrospective. All the data was collected using the Electronic Patient Care Report (EPCR) of all the patient treated and transported by ADPA crew from January to October 2018. After the EPCR auditing and monitoring, the medical errors were identified and discussed by a medical committee.Results:The total number of studied EPCR (trauma and medical cases) was 36.000. The medical errors identified were 265 cases (0.74%). 134 cases (51%) were moderate (can cause side effects), 115 cases (43%) were minor, and 16 cases (6%) were critical (can lead to death). The most common type of medical errors were cognitive errors. The causes were skill-based errors 27 times (10%) with 16 intravenous failures, 10 intraosseous failures, and one dislodged endotracheal tube after orotracheal intubation. The rule-based errors were committed five times (2%) when the Paramedics did not follow ACLS Algorithm, three times shockable cardiac arrest and two times Pulseless Electrical Activity. The knowledge-based errors were drug indications errors five times (2%). The three EMT’s levels in ADPA (Basic, Intermediate, and advanced) committed medical errors. The question to ask is not who made the mistake, but why the mistake was made. Preventing ADPA crew errors requires a systematic approach to modify the conditions that contribute to errors. The strategies are developing more awareness of cognitive errors by education and incorporating simulation into training.

Image of the month: A giant unruptured anterior communicating artery aneurysm presenting with seizures

A 74-year-old man presented following a presumed first seizure. His wife awoke to find him unresponsive, grunting and foaming at the mouth. He was responding appropriately when the ambulance crew attended. There was no associated limb jerking, incontinence or tongue biting, and he denied chest pain

Evaluation of a New Helicopter Crew Transport Fatigue Assessment

Fatigue in air ambulance crews leads to decrements in performance and situational awareness that may contribute to aircraft accidents and patient care mistakes. Fatigue assessments completed by flight crews can give early warning when fatigue is accumulating. Countermeasures can then be implemented to improve performance and increase safety. No validated air ambulance fatigue assessment currently exists that incorporates transport-specific factors. The objective of this study was to validate a flight fatigue assessment that accounts for air transport–specific factors. Flight crewmembers from multiple air ambulance programs participated and completed assessments. Results were analyzed to determine if the assessment captured or predicted fatigue levels of crewmembers. When used to measure crewmember fatigue, the assessment was shown to consistently and reliably confirm accumulating fatigue and correlated with crew-reported levels of fatigue. A predicted fatigue scale was created to help crewmembers objectively identify their fatigue level. Used consistently, the transport fatigue assessment should increase awareness of accumulating fatigue. With awareness, crewmembers are better equipped to justify and take advantage of opportunities to mitigate their fatigue, increase crew coordination, enhance safety, and improve patient care.

Outcomes for Patients Who Contact the Emergency Ambulance Service and Are Not Transported to the Emergency Department: A Data Linkage Study

Objectives: Emergency ambulance services do not transport all patients to hospital. International literature reports non-transport rates ranging from 3.7–93.7%. In 2017, 38% of the 11 million calls received by ambulance services in England were attended by ambulance but not transported to an Emergency Department (ED). A further 10% received clinical advice over the telephone. Little is known about what happens to patients following a non-transport decision. We aimed to investigate what happens to patients following an emergency ambulance telephone call that resulted in a non-transport decision, using a linked routine data-set. Methods: Six-months individual patient level data from one ambulance service in England, linked with Hospital Episode Statistics and national mortality data, were used to identify subsequent health events (ambulance re-contact, ED attendance, hospital admission, death) within 3 days (primary analysis) and 7 days (secondary analysis) of an ambulance call ending in non-transport to hospital. Non-clinical staff used a priority dispatch system e.g. Medical Priority Dispatch System to prioritize calls for ambulance dispatch. Non-transport to ED was determined by ambulance crew members at scene or clinicians at the emergency operating center when an ambulance was not dispatched (telephone advice). Results: The data linkage rate was 85% for patients who were discharged at scene (43,108/50,894). After removal of deaths associated with end of life care (N = 312), 9% (3,861/42,796) re-contacted the ambulance service, 12.6% (5,412/42,796) attended ED, 6.3% (2,694/42,796) were admitted to hospital, and 0.3% (129/42,796) died within 3 days of the call. Rates were higher for events occurring within 7 days. For example, 12% re-contacted the ambulance service, 16.1% attended ED, 9.3% were admitted to hospital, and 0.5% died. The linkage rate for telephone advice calls was low because ambulance services record less information about these patients (24% 2,514/10,634). A sensitivity analysis identified a range of subsequent event rates: 2.5–10.5% of patients were admitted to hospital and 0.06–0.24% of patient died within 3 days of the call. Conclusions: Most non-transported patients did not have subsequent health events. Deaths after non-transport are an infrequent event that could be selected for more detailed review of individual cases, to facilitate learning and improvement.

Prophylactic uterotonics in the prevention of primary postpartum haemorrhage for unplanned out-of-hospital births: a literature review.

Introduction:Postpartum haemorrhage (PPH) is a leading cause of maternal morbidity and mortality worldwide. Protocols for the use of prophylactic uterotonics in strategy to prevent PPH have been implemented for in-hospital births following recommendation from the National Institute for Health and Care Excellence (NICE). There are currently no guidelines for prophylactic uterotonic use in out-of-hospital (OOH) births by ambulance crews despite inappropriate birthing conditions and difficulties in obtaining a timely response from community midwives. The aim of this article is to review the use of uterotonic drugs used for the prevention of PPH which could be administered in OOH births.Methods:The PubMed and ScienceDirect databases were searched for papers discussing the use of prophylactic uterotonics in the third stage of labour, utilising the MeSH keywords: third stage labour, prophylactic, uterotonic. Primary studies, meta-analyses and systematic reviews published between 1998 and 2018 were eligible for inclusion. A review of the full text of the included papers was undertaken using the Critical Appraisal Skills Programme (CASP) checklists.Results:Of the published articles, 392 were returned, 25 of which met the inclusion criteria. Following assessment of the full text, 11 papers were included for discussion, including a large randomised control trial (WOMAN trial) on the use of tranexamic acid (TXA), which while not a uterotonic drug, was considered a significant drug in the context of PPH management.Conclusions:PPH is a low incidence, but high risk complication of childbirth. While it is possible for paramedics to administer uterotonics during the third stage of labour, there have been no OOH trials with paramedics to explore whether prophylactic use is safe and effective in the OOH births before arrival (BBA) scenario. Further research is required to determine the efficacy of prophylactic uterotonics in reducing PPH within pre-hospital care.

Characteristics of out of hospital cardiac arrest in the United Arab Emirates

Background:Out of hospital cardiac arrest is one of the leading causes of death globally. This study aimed to identify the characteristics of out of hospital cardiac arrest patients who were attended and treated by the National Ambulance crew. A lot of studies reported the importance of implementing chain of survival to increase survival rates from cardiac arrest. To be implemented in United Arab Emirates (UAE), it required a detailed study of the community engagement. The study aimed to explore the demography of the incidences, location, age, gender epidemiology of the patients who had their cardiac arrest witnessed along with their Bystander cardiopulmonary resuscitation (CPR) performed prior to the arrival of National Ambulance and public access to an automated external defibrillator. The return of spontaneous circulation was also explored prior to their arrival to the emergency department.Methods:The research is a prospective descriptive cohort study of out of hospital cardiac arrest patients attended by National Ambulance between July 2017 and June 2018. The National Ambulance provides emergency medical services for public and private hospitals in the Emirates of Sharjah, Ajman, Ras-al-Khaimah, Fujairah, and Umm Al-Quwain and its clients in Abu Dhabi in UAE. Data for the study were collected by the National Ambulance crew attending the OHCA patients, using a structured questionnaire.Results:In this 1-year period, a total of 715 out of hospital cardiac arrest cases were attended by the National Ambulance with higher percentage (77%) of male patients. Resuscitation and transportation were attempted for 95% whereas 5% were pronounced dead on the spot. In this study, the median age of the patients was 50 years. Majority of the patients were Asians 55% (n = 395) followed by Arabs non-UAE citizens 19.4% (n = 139) and UAE citizens 16% (n = 113). Patients facing sudden cardiac arrest in their homes or residences represented 69.9% (n = 500), street and public places 22.5% (n = 161), and workplace 6.8% (n = 49). The percentage of patients who had witnessed cardiac arrest was 51.7% (n = 370) only 197 had CPR performed on them prior to the arrival of National Ambulance. Low public access to AED was found in this population that is 1.8% (n = 13). A majority of the participants in this study had nonshockable rhythms 84.3% (n = 603) whereas shockable rhythms presented on 11% (n = 80). The percentage of patients who had ROSC at the scene or en route to the hospitals was found 9.2% (n = 66).Conclusion:In this 1-year study, the result showed that cardiac arrest was recognized and witnessed in about half of the cases, but low bystander CPR was performed. Low public access and use of AED were found. Data on hospitalized and discharged OHCA patients were not available and required further linkage and corporation between ambulance services and hospitals to ensure data continuity of OHCA cases. This study is essential for the implementation of proper chain of survival and reduction in mortality rates in UAE.

Modeling Metropolitan-Area Ambulance Mobility Under Blue Light Conditions

Actions taken immediately following a life-threatening personal health incident are critical for the survival of the sufferer. The timely arrival of specialist ambulance crew in particular often makes the difference between life and death. As a consequence, it is critical that emergency ambulance services achieve short response times. This objective sets a considerable challenge to ambulance services worldwide, especially in metropolitan areas, where the density of incident occurrence and traffic congestion are high. Using London as a case study, in this paper, we consider the advantages and limitations of data-driven methods for ambulance routing and navigation. Our long-term aim is to enable considerable improvements to their operational efficiency through the automated generation of more effective response strategies and tactics. A key ingredient of our approach is to use a large historical dataset of incidents and ambulance location traces to model route selection and arrival times. Working on the London road network graph modified to reflect the differences between emergency and civilian vehicle traffic, we develop a methodology for the precise estimation of expected ambulance speed at the individual road segment level. We demonstrate how a model that exploits this information achieves best predictive performance by implicitly capturing route-specific persistent patterns in changing traffic conditions. We then present a predictive method that achieves a high route similarity score while minimising journey duration error. This is achieved through the combination of a technique that correctly predicts routes selected by the current LAS navigation system and our best performing speed estimation model. This hybrid approach outperforms alternative mobility models. To the best of our knowledge, this paper represents the first attempt to apply a data-driven methodology for route selection and the estimation of arrival times of ambulances travelling with blue lights and sirens on.

'We wear too many caps': role conflict among ambulance service managers.

Aims:A qualitative study explored how UK ambulance service managers try to identify staff at risk of becoming traumatised by their work, including how they see their role in this task. As research on managers in this field is largely limited to settings outside the NHS, the study was planned as exploratory in nature and developed themes arising from the data.Methods:Face-to-face, semi-structured interviews were audio-recorded with a purposive sample of six paramedic managers working for an NHS ambulance service. The interview guide included specific questioning on role and identity. The author transcribed these interviews and analysed them using framework analysis. Ethical approval and informed consent were obtained.Results:The participants were all clinically-trained managers with responsibility for first-line management of front line ambulance crews. They discussed their varying roles both implicitly and explicitly. The roles included: manager, clinician, peer, referrer, ‘adjudicator’, parent figure, ‘the appropriate person’ and the challenger. They discussed the tensions of managing performance and providing emotional support to the same staff, including how some managers perceived this as making staff reluctant to disclose distress. Several participants acknowledged that they were actively creating narratives from different role perspectives, and that readers of the study would also judge them against these different roles.Conclusion:This study suggests that ambulance service managers within an NHS trust may feel conflicted between varying roles, some relating to their professional identities, and some to work tasks such as performance management and staff support, which may be in tension. Some respondents felt this could make potentially traumatised staff reluctant to disclose distress, which has negative implications in a sector where stress and psychological illness is ascribed as contributing to around 15% of staff sickness. Further research could be conducted into whether this possible role conflict is seen by front line staff as a barrier to disclosing distress.

PP10 ‘The ones that don’t say’; challenges in managers identifying potentially traumatised ambulance staff

BackgroundStress and psychological illness among emergency services personnel is reported at higher prevalence than the general population, with one UK ambulance service ascribing it to 15% of staff sickness. Research in this field has focused on ambulance crew views, while manager experiences are limited to EMS systems outside the UK. This qualitative study explored how UK ambulance service managers try to identify staff at risk of becoming traumatised by their work.MethodsFace-to-face, semi-structured interviews were audio-recorded with a purposive sample of six paramedic managers working for an NHS ambulance service. The author transcribed these interviews and analysed them using framework analysis. Ethical approval and informed consent were obtained.ResultsAll participants claimed to see the identification of potentially traumatised staff as a vital part of their role. They outlined the use of case factors such as visceral elements and child involvement, and staff factors such as home life and resilience. Interviewees talked about their changing roles as managers, peers, parent figures, clinicians, and adjudicators.Factors found as enabling the identification of potentially traumatised staff included: knowing the staff, formalising handover to other managers, and manager presence – both at incidents and on station. Disabling factors included: atypical cases, hierarchical culture, and isolated remote staff. All participants reported concerns about staff being reluctant to report distress.ConclusionsLimitations of this study include the small sample size, possible response bias, and respondents conforming to social norms, as their practice was self-reported, rather than observed. Manager presence was highlighted as very important by participants; services should consider this in their structures and policies. Further studies could examine staff reluctance to report psychological distress, as well as staff resilience, which participants saw as beneficial, yet difficult to define or predict.

Association between the reported intensity of an acute symptom at first prehospital assessment and the subsequent outcome: a study on patients with acute chest pain and presumed acute coronary syndrome

BackgroundTo decrease the morbidity burden of cardiovascular disease and to avoid the development of potentially preventable complications, early assessment and treatment of acute coronary syndrome (ACS) are important. The aim of this study has therefore been to explore the possible association between patients’ estimated intensity of chest pain when first seen by the ambulance crew in suspected ACS, and the subsequent outcome before and after arrival in hospital.MethodsData was collected both prospectively and retrospectively. The inclusion criteria were chest pain raising suspicion of ACS and a reported intensity of pain ≥4 on the visual analogue scale.ResultsAll in all, 1603 patients were included in the study. Increased intensity of chest pain was related to: 1) more heart-related complications before hospital admission; 2) a higher proportion of heart failure, anxiety and chest pain after hospital admission; 3) a higher proportion of acute myocardial infarction and 4) a prolonged hospitalisation. However, there was no significant association with mortality neither in 30 days nor in three years. Adjustment for possible confounders including age, a history of smoking and heart failure showed similar results.ConclusionThe estimated intensity of chest pain reported by the patients on admission by the ambulance team was associated with the risk of complications prior to hospital admission, heart failure, anxiety and chest pain after hospital admission, the final diagnosis and the number of days in hospital.Trial registrationClinicalTrials.gov 151:2008/4564 Identifier: NCT00792181. Registred 17 November 2008 ‘retrospectively registered’.