Emergency Paramedics Research Articles

Stakeholder opinion on the proposal to introduce \u2018treat and referral\u2019 into the Irish emergency medical service

BackgroundThe Irish ambulance services have traditionally transported all patients following an emergency (112/999) call, regardless of acuity, to an emergency department (ED). A proposal to introduce Treat and Referral, an established care pathway in some jurisdictions, is under active consideration in Ireland. This will present a significant change. Stakeholder engagement is recognised as an essential component of management of such change. This study has conducted a multicentre, cross-sectional survey exploring opinions on the introduction of Treat and Referral among key Irish stakeholders; consultants in emergency medicine, paramedics and advanced paramedics.MethodsPublic-sector consultants in emergency medicine (EM), registered paramedics and advanced paramedics, in Ireland at the time of the study, were invited to complete an on-line survey.ResultsA significant finding was that 90% of both cohorts (EM consultants and registered paramedic practitioners) support written after-care instructions being given to referred patients, that > 83% agree that Treat and Referral will reduce unnecessary ambulance journeys and that 70% are in favour of their own family member being offered Treat and Referral. Consensus was reached between respondents that Treat and Referral would improve care and increase clinical judgement of practitioners. Differences were identified in relation to the increased availability of ambulances locally, that only adults should be included, and that research was required to extend Treat and Referral beyond the index conditions. There was no consensus on whether general practitioners (GPs) should be directly informed.ConclusionsThis study identified that the Irish healthcare practitioners surveyed are supportive of the introduction of Treat and Referral into Ireland. It also affords healthcare policymakers the opportunity to address the concerns raised, in particular the clinical level which will be targeted for inclusion in this extended scope of practice.

Advanced Placement Paramedic Education for Health Care Professionals: A Descriptive Evaluation

IntroductionThe delivery of emergency medical services is primarily performed by emergency medical technicians and paramedics in the United States. More recently, nurses and physicians have become more involved in the delivery of emergency medical services. Advanced placement paramedic education bridging programs have been developed to prepare the workforce, but the success of these programs is unknown. This study evaluated the demographics and performance of nonemergency medical services health care professionals who attended an advanced placement paramedic education program at a Midwestern university. MethodsThis was a retrospective evaluation of student data from 2007 to 2017. Descriptive statistics were used to tabulate demographics, program performance, and individual performance in the National Paramedic Certification Examination. ResultsThe program admitted 305 students; registered nurses (95%) were the majority of students. Of the 305 admitted students, 271 (88.9%) fulfilled all program requirements and were eligible to take the National Registry of Emergency Medical Technicians paramedic certification examination. Of these 271 eligible students, 201 (74.2%) took the National Paramedic Certification Examination. A total of 195 (97%) obtained certification at the first test attempt, whereas 200 (99.5%) obtained certification within 3 attempts. Of the 200 who passed the test, 175 (88%) successfully demonstrated entry-level competency in paramedic-level psychomotor testing. DiscussionThe advanced placement paramedic program evaluated in this study had high rates of successful program completion, as well as high first-time and cumulative passing rates for the National Paramedic Certification Examination. Further research is needed to identify the best practices in determining student requirements and the methodologies in delivering advanced placement paramedic education bridging programs.

Which Patients Require Physician-Led Inter-Hospital Transport in View of Endovascular Therapy?

Introduction: The current guidelines advocate the implementation of stroke networks to organize endovascular treatment (ET) for patients with acute ischemic stroke due to large vessel occlusion (LVO) after transfer from a Primary Stroke Centre (PSC) to a Comprehensive Stroke Centre (CSC). In France and in many other countries around the world, these transfers are carried out by a physician-led mobile medical team. However, with the recent broadening of ET indications, their availability is becoming more and more critical. Here, we retrospectively analysed data of patients transferred from a PSC to a CSC for potential ET to identify predictive factors of major complications (MC) at departure and during transport that absolutely require the presence of a physician during interhospital transfer. Methods: This observational, single-centre study included patients with evidence of intracranial LVO transferred for ET from Perpignan to a 156 km-distant CSC between January 1, 2015 and ­December 31, 2018. We compared 2 groups: MC group (patients who required emergency intervention by the medical team due to life-threatening complications, including need of mechanical ventilation at departure) and non-MC group (all other patients who experienced no or only minor complications that could be managed by the emergency paramedics alone). Results: Among the 253 patients who were transferred to the CSC, 185 (73.1%) had no complication, 57 (22.6%) minor complications, and 11 (4.3%) had MC. In multivariate analysis, MC was associated with basilar artery (BA) occlusion (p < 0.0001), initial National Institute of Health Stroke Scale (NIHSS) score >22 (p < 0.005), and history of atrial fibrillation (p < 0.04). Among the 168 patients treated with intravenous thrombolysis (IVT), only 1 patient (0.6%) had MC due to an IVT-related adverse event during transfer. Conclusions: Physician-led inter-hospital transports are warranted for patients with BA occlusion, initial NIHSS score >22, or history of atrial fibrillation. For the other patients, transfer without a physician may be considered, even if treated with IVT.

Health emergency management in Aotearoa New Zealand: Making sense of professional development

To explore how health emergency management (HEM) personnel make sense of professional development, such as education and training, in their everyday roles and responsibilities within an increasingly complex emergency management and disaster field. This in-depth qualitative study comprised of semistructured interviews with 10 Aotearoa New Zealand HEM personnel from a range of healthcare professions, including emergency managers, nurses, clinical support, and paramedics. The thematic, data-driven approach was exploratory. The research identified inductively significant thematic concepts relating to professional development from the health emergency personnel's talk about their roles and responsibilities. The authors identified four themes relating to professional development in the participants' talk: test yourself under pressure; selling what we do; under the pump; and real stuff that actually makes a difference. These themes represent shared sense-making about how the participants negotiated their professional development needs and the needs of others while performing their everyday roles and responsibilities. Our findings support the production of local and contextually driven knowledge that highlights how HEM personnel discuss professional development as strengths, tensions, challenges, and knowledge gaps. These insights contribute to a broader understanding of what needs to be taken into account when developing competencies, skill sets, and training programs to promote professional development in an increasingly complex emergency management and disaster field.

ECG pre-hospital teletransmission by emergency teams staffed with an emergency physician and paramedics and its impact on transportation and hospital admission.

Electrocardiography (ECG) is essential to detect and diagnose life threatening cardiac conditions and to determine further treatment. Correct interpretation of an ECG can be challenging, especially in the out-of-hospital setting and by less experienced emergency team members.The aim of this study was to compare the rate of ECG transmission from an out-of-hospital emergency scene to an in-hospital cardiologist on call in EMS-B and EMS-S providers and its impact on direct transportation to a cardiac catheterization laboratory and hospital admission.The study was designed as an observational study. Data from 3 separate emergency medical service teams were collected. Two teams are staffed by paramedics only (EMT-B), while another specialized team is staffed with an emergency physician (EMT-S). 5864 out-of-hospital emergencies were performed during a 12-month period and were analyzed for this study.In 124 out of 5864 (2.1%) out-of-hospital emergencies, an ECG transmission from the out-of-hospital scene to an in-hospital cardiologist on call was performed. Rate of transmission was similar between both teams (EMT-B n = 70, 2.2% vs EMT-S n = 54, 2.0%, P = .054). After coordinating with the cardiologist on call, 11 patients (15.7%) of the EMT-B (15.7%) and 24 patients (44.4%) of the EMT-S were directly transported from the scene of emergency to a cardiac catheterization laboratory (P < .001). Overall, 80% of patients treated by EMT-S, compared to 52.5% treated by the EMT-B required subsequent hospital admission (P < .05).Transmission of ECG from the out-of-hospital emergency scene to the in-hospital cardiologist is infrequently performed. The rate of STEMI in transmitted ECG's by emergency teams staffed with an emergency physician was higher compared to emergency teams staffed with paramedics only.

Females and Minority Racial/Ethnic Groups Remain Underrepresented in Emergency Medical Services: A Ten-Year Assessment, 2008–2017

Background: Workforce diversity can reduce communication barriers and inequalities in healthcare delivery, especially in settings where time pressure and incomplete information may exacerbate the effects of implicit biases. Emergency medical services (EMS) professionals represent a critical entry point into the healthcare system for diverse populations, yet little is known regarding changes in the demographic composition of this workforce. Our primary objective was to describe the gender and racial/ethnic composition of emergency medical technicians (EMTs) and paramedics who earned initial National EMS Certification from 2008 to 2017. Secondarily, we compared demographic characteristics of the 2017 EMT and paramedic cohorts to the U.S. population. Methods: As a proxy for recent graduates likely to enter the workforce, we conducted a serial cross-sectional analysis of all EMTs and paramedics earning initial National EMS Certification from January 1, 2008 to December 31, 2017. Cuzick’s non-parametric test of trend was used to assess for changes in the gender and racial/ethnic composition of the EMS cohorts over time. For 2017, we calculated differences the gender and racial/ethnic composition of the EMT and paramedic cohorts to the U.S population, stratifying by Census region. Results: The study population included 588,337 EMTs and 105,356 paramedics. The proportion of females earning initial EMT certification rose from 28% in 2008 to 35% in 2017. Throughout the study period, less than one-fourth of newly certified paramedics were female (range: 20–23%). The proportion of EMS professionals identifying as black remained near 5% among EMTs and 3% among paramedics. The proportion of newly-certified Hispanic EMS professionals rose from 10% to 13% among EMTs and from 6% to 10% among paramedics. Compared to the U.S. population, females and racial/ethnic minorities were underrepresented among EMTs and paramedics earning initial certification and these representation differences varied across geographic regions. Conclusions: The underrepresentation of females and minority racial/ethnic groups observed during this 10-year investigation of EMTs and paramedics earning initial certification suggests that EMS workforce diversity is unlikely to undergo substantial change in the near future. The representation gaps were larger and more stable among paramedics compared to EMTs and suggest an area where concerted efforts are needed to encourage students of diverse backgrounds to pursue EMS.

Statement of the Austrian Society for Anesthesiology, Resuscitation and Intensive Care Medicine (ÖGARI) on the use of laryngeal tubes by ambulancemen and paramedics

Due to an increasing number of severe complications reported during the prehospital application of laryngeal tubes, the Austrian Society for Anesthesiology, Resuscitation and Intensive Care Medicine (ÖGARI) is prompted to formulate arespective statement. With regard to the current training situation and the applicable laws, ÖGARI recommends to convert the "Emergency Competence for Endotracheal Intubation (NKI)" for emergency paramedics into an "Emergency Competence for Extraglottic Airway Management, (NK-EGA)". Training should include at least 40 h of theoretical instruction, hands-on training on the manikin to secure mastery of the methodology and at least 20successful applications under clinically elective conditions in adult patients under direct medical supervision. Here, depending on local conditions, both laryngeal mask and laryngeal tube can be used. In the prehospital environment, the device must be used which has been trained as mentioned above. Only 2nd generation EGA should be used. After successful EGA placement timely cuff pressure monitoring and gastric suction should be performed. The use of an EGA by ambulance-men cannot be recommended; these have to be limited to bag-mask ventilation.

Caring for Infectious Disease in the Prehospital Setting: A Qualitative Analysis of EMS Providers Experiences and Suggestions for Improvement

Objective: The purpose of this study was to examine the attitudes and behaviors of emergency medical technicians (EMTs) and Paramedics when faced with the decision to care for patients with suspected Ebola Virus Disease (EVD) and to illicit suggestions for improvement of infectious disease (ID) preparedness. Methods: A convenience sample of 22 EMT/Paramedics were recruited from an emergency department at one of the designated Ebola centers. Each provider participated in one of three on-site focus groups. Participants answered questions about how they gained their knowledge, felt about caring for EVD patients, made decisions about caring for EVD patients, and suggestions for improvement of ID preparedness. Focus groups were recorded, transcribed, and coded using inductive content analysis. Results: Analysis revealed five prominent themes: reactions to scare, education/training, danger, decision making, and suggestions for future responses. Overall, first responders were excited to be a part of the response to EVD. They were more comfortable caring for EVD patients if they received adequate education and transparency from the administration. This resulted in a decreased perceived danger of the disease and decreased hesitancy when caring for EVD patients. However, those that expressed the most hesitancy also expressed the most emotional distress. Suggestions for improvement of ID preparedness included continuing education, tiered training models, peer training models, collaboration between emergency medical services (EMS) systems, better communication between departments, and the development of an infectious disease response team. Conclusions: Although first responders were excited to be a part of the response to EVD, this did not come without hesitation and emotional distress. Some of these concerns may be mitigated by first providing a clear definition of “duty to care,” followed by interventions such as the development of clear and consistent ID preparedness training and interventions that address the emotional distress experienced by these providers.

Language barrier and its implications for practice in Kuwait prehospital settings

Objectives: The purpose of this research was to explore the implications of language barrier among emergency medical technicians (EMTs) and paramedics in a prehospital setting in Kuwait. Methods: A small-scale exploratory case study was carried out using a qualitative method. Focus group interviews were conducted with prehospital providers in Kuwait. An inductive thematic analysis was performed whereby themes and sub-themes emerged from within the data. Results: The data revealed that language barrier has a direct effect on healthcare delivery with implications for an unpleasant patient experience, time delay and misdiagnosis; professional implications which include the need to enhance learning through communication and training to improve practice and support with translation; and personal implications including declining efficiency level, negative socio-emotional impact and physiologic response. Conclusion: This study contributes to the scarcity of available research determining the effects and implications of language barrier for EMTs and paramedics in a prehospital setting in Kuwait. It brings the deficiencies of the Kuwait emergency medical services (EMS) to light, as language disparities affect prehospital providers and their quality of work. Strategies for overcoming the language barrier, implemented by the respondents in this study, form a basis for the Kuwait EMS to address unexplored issues that could potentially improve prehospital practice. While the findings may not be generalisable, they may be transferable to other areas of practice with comparable situations where healthcare providers face challenges when communicating with their patients.

Crossover Assessment of Intraoral and Cuffed Ventilation by Emergency Responders.

A cuffed bag valve mask (BVM) is the most common device used by emergency medical responders to ventilate patients. The BVM can be difficult for users to seal around the patient's mouth and nose. An intraoral mask (IOM) with snorkel-like design may facilitate quicker and better ventilation particularly under austere conditions. Both a BVM and IOM were utilized by 27 trained emergency medical technicians and paramedics to ventilate a lightly embalmed cadaver. Ventilation efficacy, workload, and usability were assessed for both devices across four study conditions. The IOM was superior to the BVM in delivered tidal volume ratio (measure of leak, p < 0.03) and minute ventilation (p < 0.0001). Workload, ergonomic and usability assessments indicated that the IOM facilitated gripping through the reduced hand interface size (p < 0.01), decreased user effort (p < 0.001), and reduced upper limb workload (p = 0.0088). In the assessed model, the IOM represented a better choice for airway management than the standard cuffed BVM. An emergency medical device that is intuitive, efficacious and less demanding has the potential to reduce responder stress and improve resuscitation efforts, especially during austere rescue and patient transport.

ON THE FRONTLINE: PREPARING PREHOSPITAL PROVIDERS FOR END-OF-LIFE CARE

AbstractPrehospital providers’ (Emergency Medical Technicians and Paramedics) scope of practice involves responding to life-threatening situations and saving lives. Yet, increasingly they are called to see people who are dying in later life from multiple chronic conditions rather than acute events. The purpose of the study was to identify how prehospital providers are prepared for end-of-life calls and their perspectives on improving training for this work. Surveys (N=239) explored training about Do Not Resuscitate and Medical Orders for Life Sustaining Treatment (MOLST), how frequently these documents are encountered and comfort with honoring expressed wishes. Formal education was provided on DNR (86%) and MOLST (80%). 79% said that MOLST provided clear instructions about patient preferences. However, 75% endorsed the need for more end-of-life care curriculum in prehospital provider education and 79% identified the need for on-the-job training. The results suggest the importance of real-time training about the complexities of emergency end-of-life calls.

Pediatric Intraosseous Access Performed by Emergency Department Nurses Using Semiautomatic Devices: A Randomized Crossover Simulation Study.

No study has examined the performance of emergency department (ED) nurses in establishing intraosseous access (IO) access. This study aimed to evaluate ED nurses' success rate in establishing pediatric IO access using semiautomatic devices. A randomized crossover simulation study was conducted. The success rates of ED nurses were compared with those of paramedics with similar years of experience. The study instruments were the new spring-loaded injector (NIO) and the battery power drill (EZ-IO). Uncooked piglets' bones were used as the study model. All attempts were filmed by a video camera. Successful placement was defined as the visualization of flow from the marrow cavity. Participants recorded their ranking of the "ease of use" of each device. No differences in 1-attempt success rate was found between nurses and paramedics (27/34 [79.4%] vs 25/30 [83.3%], P = 0.68). Nurses and paramedics had similar success rates with the 2 semiautomatic IO devices (12/17 vs 12/15 with the spring-loaded injector, P = 0.69, and 15/17 vs 13/15 with the battery power drill, P = 0.9). The number of failed attempts and the causes for failure were equally distributed between nurses and paramedics. Median ease-of-use Likert-scale scores of the spring-loaded injector and the battery power drill were 4 (interquartile range [IQR] = 3-4) and 5 (IQR = 5-5) (P < 0.04) for the nurses and 5 (IQR = 4-5) and 5 (IQR = 4-5) (P = 0.44) for the paramedics, respectively. Emergency department nurses and paramedics had a similarly high insertion success rates on a pediatric bone model. This pilot study suggests that ED nurses can successfully perform this procedure.

Death by Suicide—The EMS Profession Compared to the General Public

Background: In 2016, nearly 45,000 deaths in the United States were attributed to suicide making this the 10th leading cause of death for all ages. National survey data suggest that among Emergency Medical Technicians (EMTs), including firefighters and Paramedics, rates of suicide are significantly higher than among the general public. EMTs face high levels of acute and chronic stress as well as high rates of depression and substance abuse, which increase their risk of suicide.Objective/Aim: To determine the statewide Mortality Odds Ratio (MOR) of suicide completion among EMTs as compared to non-EMTs in Arizona.Methods: We analyzed the Arizona Vital Statistics Information Management System Electronic Death Registry of all adult (≥18) deaths between January 1, 2009 and December 31, 2015. Manual review of decedent occupation was performed to identify the EMT cohort; all other deaths were included in the non-EMT cohort. Using the underlying cause of death as the outcome, we calculated the MOR of both the EMT and non-EMT cohorts.Results: There were a total of 350,998 deaths during the study period with 7,838 categorized as suicide. The proportion of deaths attributed to suicide among EMTs was 5.2% (63 of 1,205 total deaths) while the percentage among non-EMTs was 2.2% (7,775/349,793) (p < 0.0001). The crude Mortality Odds Ratio for EMTs compared with non-EMTs was [cMOR 2.43; 95% CI (1.88–3.13)]. After adjusting for gender, age, race, and ethnicity, EMTs had higher odds that their death was by suicide than non-EMTs [aMOR: 1.39; 95% CI (1.06–1.82)].Conclusion: In this statewide analysis, we found that EMTs had a significantly higher Mortality Odds Ratio due to suicide compared to non-EMTs. Further research is necessary to identify the underlying causes of suicide among EMTs and to develop effective prevention strategies.

Paramedic and physician perspectives on the potential use of remotely supported prehospital ultrasound.

During remotely supported prehospital ultrasound (RSPU), an ultrasound operator performs a scan and sends images to a remote expert for interpretation. This novel technology has been undergoing investigation in the randomised controlled SatCare trial, which seeks to assess the capability of RSPU to improve patient outcomes and standard of prehospital care in the Highlands of Scotland. This study aimed to explore the views of emergency medicine physicians and paramedics prior to starting the trial. An interview schedule was prepared a priori and was based upon normalisation process theory (NPT), which can be used to assess ways in which practitioners work to embed novel technologies in clinical practice. Semi-structured interviews were conducted with four consultant physicians and eight paramedics, who were recruited using purposive sampling until theoretical saturation. Analysis used open and hierarchical axial coding, and NPT as a framework to assist in the management and analysis of codes. The prospect of RSPU evoked significantly different responses from emergency care physicians and paramedics. Paramedics thought of RSPU as a logical progression of prehospital care, which addresses core prehospital challenges such as lack of decision-making support and a limited ability to identify life-threatening occult conditions. Paramedics saw RSPU as part of a trend to increase their skills and responsibilities, and viewed ultrasound as a validated tool within emergency medicine. Paramedics felt that ultrasound was simple to learn and would be practical for use within the prehospital arena. In contrast, physicians expressed a greater spectrum of views; most saw limited value to prehospital diagnosis and were concerned that RSPU would distract both paramedics and physicians from their existing roles (particularly in the context of the increasing demand and workload within Scotland's publicly funded National Health Service). Physicians were also concerned that ultrasound skills were poorly incorporated into training and practice in the British emergency medicine system. Furthermore, they believed that ultrasound was difficult to learn, prone to misinterpretation and easy to become deskilled in. Both sets of participants believed that the relational skills required between the two groups and the practical complexities of RSPU may pose challenges in its implementation. In particular, concerns were raised regarding the time that would be required to conduct the ultrasound scans and difficulties with transmission and communication in the Highlands. Both groups questioned the likelihood of measurable benefits from RSPU for patients. Furthermore, both groups were unsure how the technology would benefit those patients in urban areas close to the emergency department or whether RSPU would be effectively utilised in rural areas where serious emergencies are infrequent. There are substantial differences in emergency physician and paramedic perspectives on RSPU; however, both parties were willing to engage with the research process. Both groups have reservations, especially the emergency physicians who perceive significant barriers to the acquisition of skills, as well as the relational and contextual integration of RSPU. This study demonstrates the importance of conversations with physicians and paramedics throughout the research process, particularly as the role of prehospital care remains controversial.

A survey to understand public opinion regarding animal use in medical training.

A random survey was performed by ORC International Telephone CARAVAN®, on 24-27 March 2016, by trained interviewers. The aim of this survey was to gain further understanding of public perceptions in the United States of laboratory animal use, specifically for the purposes of medical training. Five statements were read in random order to the participants, who were then asked whether they agreed or disagreed with the statement. Survey responses were obtained from 1011 participants. For the combined statements: "If effective non-animal methods are available to train a) medical students and physicians, b) emergency physicians and paramedics, and c) paediatricians, those methods should be used instead of live animals", most respondents (82-83%) agreed. For the statement: "You want your doctor to be trained by using methods that replicate human anatomy instead of live animals", most respondents (84%) agreed. For the statement: "If effective non-animal methods are available, it is morally wrong or unethical to use live animals to train medical students, physicians and paramedics", 67% of respondents agreed. Responses were similar among the 15 pre-specified demographic subgroups. Given that effective non-animal training methods are readily available, the survey suggests that a substantial majority of the public wants the use of animals in medical training to cease.

Mediating Systems of Care: Emergency Calls to Long-Term Care Facilities at Life's End.

Nursing home (NH) residents account for over 2.2 million emergency department visits yearly; the majority are cared for and transported by prehospital providers (emergency medical technicians and paramedics). The purpose of this study was to investigate prehospital providers' perceptions of emergency calls at life's end. This article focuses on perceptions of end-of-life calls in long-term care (LTC). This pilot study employed a descriptive cross-sectional design. Concepts from the symbolic interaction theory guided the exploration of perceptions and interpretations of emergency calls in LTC facilities. A purposeful sample of prehospital providers was developed from one agency in a small northeastern U.S. city. Semistructured interviews were conducted with 43 prehospital providers to explore their perceptions of factors that trigger emergency end-of-life calls in LTC facilities. Qualitative data analysis involved iterative coding in an inductive process that included open, systematic, focused, and axial coding. Interview themes illustrated the contributing factors as follows: care crises; dying-related turmoil; staffing ratios; and organizational protocols. Distress was crosscutting and present in all four themes. The findings illuminate how prehospital providers become mediators between NHs and emergency departments by managing tension, conflict, and challenges in patient care between these systems and suggest the importance of further exploration of interactions between LTC staff, prehospital providers, and emergency departments. Enhanced communication between LTC facilities and prehospital providers is important to address potentially inappropriate calls and transport requests and to identify means for collaboration in the care of sick frail residents.

Accuracy of Prehospital Identification of Stroke in a Large Stroke Belt Municipality

Objective: Strokes are a leading cause of morbidity and mortality in the United States, especially in the “stroke belt” of the southeast. Up to 65% of stroke patients access care by calling 9–1-1. The primary objective of this study is to measure the accuracy of emergency medical dispatchers (EMD) and paramedics, in the prehospital identification of stroke. Methods: The study was based at Grady Emergency Medical Services, which is Atlanta, Georgia's public emergency medical services (EMS) provider. A retrospective analysis of all medically related 9–1-1 calls to Grady EMS classified as “stroke” between January 1, 2012, and December 31, 2012 was performed. A database was created using deterministic linkage between records from Grady EMS, Grady Hospital Emergency Department (ED), and the Grady Hospital Stroke Registry. Patients excluded were less than 18 years of age, had previous or concurrent head injuries, were transferred from another inpatient facility, and/or had incomplete patient records in any one of the three databases. Descriptive analysis, linear regression, and logistic multivariable regression were performed to discover the accuracy of stroke identification and contributory prehospital factors. Results: A total of 548 patients were included: 475 were transported with EMS impression of stroke and 73 with an impression other than stroke. The median age was 59 years, 87.4% were black, and 52.6% were female. Paramedics adhered to all seven elements of the Grady EMS stroke protocol in 76.4% (n = 363) of suspected stroke cases. Sensitivity and positive predictive value for paramedic stroke identification was 76.2% and 49.3%, respectively, and for EMD, was 48.9% and 24%, respectively. Identification of hemorrhagic strokes had a relatively lower sensitivity. Paramedics were more likely to positively identify strokes when the Cincinnati Prehospital Stroke Scale (CPSS) screen was positive, or when classified by EMD as stroke. Paramedics were less likely to identify stroke in female patients. Paramedics' diagnostic accuracy was similar regardless of their adherence to the EMS stroke care protocol. Conclusions: EMD and EMS personnel in a large city in the Southeastern United States, with high stroke prevalence, had a relatively high sensitivity in identifying acute stroke patients. Paramedic accuracy was augmented by positive CPSS screening and by EMD recognition of stroke.

Miscommunication as a risk focus in patient safety : Work process analysis in prehospital emergency care

In an analysis of acritical incident reporting system (CIRS) in out-of-hospital emergency medicine, it was demonstrated that in 30% of cases deficient communication led to athreat to patients; however, the analysis did not show what exactly the most dangerous work processes are. Current research shows the impact of poor communication on patient safety. An out-of-hospital workflow analysis collects data about key work processes and risk areas. The analysis points out confounding factors for asufficient communication. Almost 70% of critical incidents are based on human factors. Factors, such as communication and teamwork have an impact but fatigue, noise levels and illness also have amajor influence. (I)CIRS database analysis The workflow analysis was based on 247 CIRS cases. This was completed by participant observation and interviews with emergency doctors and paramedics. The 247 CIRS cases displayed 282 communication incidents, which are categorized into 6 subcategories of miscommunication. One CIRS case can be classified into different categories if more communication incidents were validated by the reviewers and four experienced emergency physicians sorted these cases into six subcategories. (II)Workflow analysis The workflow analysis was carried out between 2015 and 2016 in Jena and Berlin, Germany. The focal point of research was to find accumulation of communication risks in different parts of prehospital patient care. During 30 h driving with emergency ambulances, the author interviewed 12members of the emergency medical service of which5 were emergency physicians and 7paramedics. A total of 11internal medicine cases and one automobile accident were monitored. After patient care the author asked in a15-min interview if miscommunication or communication incidents occurred. (I)CIRS analysis Between 2005 and 2015, 845 reports were reported to the database. The experts identified 247 incident reports with communication failure. All communication aspects were analyzed and classified. We identified 282 communication incidents. (II)Workflow analysis The analysis showed three phases of prehospital patient care: 1.incoming emergency call and dispatch of ambulance service, 2.prehospital treatment, 3.transportation to ahospital. Overall, the number of incidences is increasing as a consequence of parallel workflows. Category1 was particularly significant and predominantly, paramedics criticized that emergency physicians did not acknowledge their advice (n = 73 vs. n = 9). Category3 with n = 63, category4 with n = 20 and category2 with n = 13 were the major reasons for incidents. Abetter interface communication helps to coordinate patient transfer and is an option for optimizing resources. Frequent training in communication is an option to avoid incidents.

Wilderness First Responder: Are Skills Soon Forgotten?

Wilderness first responders are trained to provide competent medical care in wilderness settings or until evacuation for more advanced treatment can be obtained. In light of the isolated environments in which they are called upon to respond to illnesses and injuries, their ability to effectively apply their training is crucial. Despite the responsibility assigned to them, there is an absence of research assessing the skill and knowledge retention of wilderness first responders, creating a gap in understanding whether a deficit in their ability to perform exists between certifications. Without such research, it is important to review knowledge and skill retention in related responder groups. The literature over the past 4 decades documents the loss over time of skills and knowledge across an array of trained responders, both professional and laypeople. Although the findings reviewed suggest that WFRs will exhibit a similar pattern of increasing skill loss beginning shortly after certification and a slower, but concurrent, decrease in knowledge, research is needed to document or refute this assumption.

Effect of Mass Casualty Training on Prehospital Care Providers in Kuwait

Background: Prehospital providers, both emergency medical technicians and paramedics need appropriate training to deal with major incidents. Despite the fact that Kuwait has experienced many major incidents and located into a politically conflict zone, there is no standardized preparedness training for prehospital care providers to disasters or major incidents. This study aimed to assess the effect of a training intervention in improving the knowledge and awareness of EMTs and paramedics in the Kuwait Emergency Medical Service (KEMS).Methods: Thirty-one participants from different ambulance districts in Kuwait were invited to participate voluntarily in disaster management training at Kuwait EMS Department.Results: The mean score of knowledge was significantly higher immediately after first training program [18.2; standard error (SD):1.9] than before (12.4; SD: 2.8) (P<0.001). The mean score three months later was significantly higher (19.8; SD: 0.5) immediately after the intervention program (P<0.001).Conclusion: The primary aim of improving preparedness among prehospital care providers was been achieved through the training program. The tests results showed an improvement in score achieved by the participating prehospital care providers. This type of training courses would increase the competency and the confidence of prehospital care providers in providing emergency services.