Prehospital Emergency Care Setting Research Articles

Inhaled analgesics for the treatment of prehospital acute pain-A systematic review.

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.

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

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

Introduction of Telemedicine in a Prehospital Emergency Care Setting: A Pilot Study.

Advances in information and communication technology have led to telemedicine applications that could support paramedics in the prehospital field. In an effort to optimise the available resources like prehospital emergency physicians (PHP), the State Health Services of a Swiss state decided to launch a pilot study on the feasibility of using telemedicine in the prehospital emergency setting. The primary objective was to measure the number of missions completed without technical problems with remote PHP support through telemedicine (tele-PHP). The secondary objectives were to evaluate the safety of this protocol and to describe the actions and decisions that clinicians can make by using tele-PHP. This was a prospective observational pilot study on all missions involving the dispatch of ground PHP or tele-PHP. The severity score, dispatch criteria, actions, and decisions made by ground PHP and tele-PHP were collected. PHP were dispatched simultaneously with an ambulance on 478 occasions, including 68 (14%) situations that started directly with tele-PHP. Among those situations, three had to be transformed into on-site PHP missions after the on-site evaluation by paramedics. Fifteen missions were cancelled by paramedics once they were on site, and six missions encountered a connection issue. Forty-four PHP missions that were dispatched simultaneously with paramedics were completed by tele-PHP only without any connection problems. Paramedics and PHP estimated that actions or decisions were provided by PHP in 66% of the on-site PHP missions and 34% of the tele-PHP missions. This is the first experience of tele-PHP regarding PHP dispatch in Switzerland. Despite the small number of missions carried out, tele-PHP could be used for well-selected situations to reduce the need for a PHP on site.

Human errors and factors that influence patient safety in the pre-hospital emergency care setting: Perspectives of South African emergency care practitioners.

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.

Designing an App to Overcome Language Barriers in the Delivery of Emergency Medical Services: Participatory Development Process.

BackgroundIn emergencies, language barriers may have dangerous consequences for the patients. There have been some technical approaches to overcome language barriers in medical care but not yet in the prehospital emergency care setting. The use of digital technologies in health care is expanding rapidly. Involving end users at all stages of the development process may help to ensure such technologies are usable and can be implemented.ObjectiveWe aimed to develop a digital communication tool that addresses paramedic needs in the specific circumstances of prehospital emergency care and helps paramedics to overcome language barriers when providing care to foreign-language patients.MethodsWe actively engaged paramedics and software designers in an action-oriented, participatory, iterative development process, which included field observations, workshops, background conversations, questionnaires on rescue missions, studying the literature, and preliminary testing in the field.ResultsWith input from paramedics, we created an app with 600 fixed phrases supporting 18 languages. The app includes medical history–taking questions, phrases asking for consent, and phrases providing specific additional information. Children as patients, as well as their carers and other third parties, can be addressed with appropriate wording. All phrases can be played back audibly or displayed as text. The comprehensive content is grouped into categories and adapted to diverse scenarios, which makes the tool rapidly usable. The app includes a function to document patient responses and the conversation history. For evaluation in a clinical study, the app is run on a smartphone with extra speakers to be of use in noisy environments. The use of prototypes proved valuable to verify that the content, structure, and functions discussed in theory were of value and genuinely needed in practice and that the various device control elements were intuitive.ConclusionsThe nature of the paramedic work environment places specific demands on the communication options used and need for such devices. The active involvement of paramedics in the development process allowed us to understand and subsequently consider their experience-based knowledge. Software designers could understand the paramedics’ work environment and consider respective needs in the menu navigation and design principles of the app. We argue that the development of any medical software product should actively involve both end users and developers in all phases of the development process. Providing the users with the opportunity to influence technology development ensures that the result is closer to their needs, which can be seen as crucial for successful implementation and sustainable use.Trial RegistrationGerman Clinical Trials Register DRKS00016719; https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00016719International Registered Report Identifier (IRRID)RR2-10.1186/s12913-020-05098-5

Prehospital care providers' understanding of responsibilities during a behavioural emergency.

BackgroundPrehospital emergency care providers are frequently called to assist with the management of mental healthcare users (MHCUs). The Mental Health Care Act no. 17 of 2002 regulates mental healthcare in South Africa, but the act fails to consider the responsibilities of prehospital emergency care providers in the provision of mental healthcare. Rather South African Police Services were given authority over the well-being of a MHCU in the prehospital setting.AimTo investigate prehospital emergency care providers’ understanding of their responsibilities towards MHCUs and the community during the management of behavioural emergencies.SettingThe research was carried out at prehospital emergency care providers from the three main levels of care, currently operational within the boundaries of Pretoria, South Africa.MethodsA grounded theory qualitative study design was chosen using semi-structured focus groups for each level of prehospital emergency care – basic life support (BLS), intermediate life support (ILS) and advanced life support (ALS). Data from each focus group were collected through audio recordings and transcribed and analysed using a framework approach.ResultsA total of 19 prehospital emergency care providers participated; two focus group interviews were performed for each level of care. The BLS focus groups each consisted of two participants. The ILS focus groups consisted of three participants each, and the ALS focus groups consisted of six and three participants. Four key themes were identified: perceptions of behavioural emergencies, responsibilities, understanding of legislation and barriers experienced.ConclusionParticipants placed high value on their moral and medical responsibilities towards MHCUs, which they described as ensuring the safety of themselves, MHCUs and the community; preventing further harm; and transporting MHCUs to an appropriate healthcare facility. There was a desire for revision of legislation, better education, skill development and awareness of mental healthcare in the prehospital emergency care setting.

The Need for Purposeful Teaching, Learning and Assessment of Crisis Resource Management Principles and Practices in the Undergraduate Pre-Hospital Emergency Care Curriculum: A Narrative Literature Review

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.

Multi-method versus single method appraisal of clinical quality indicators for the emergency medical services.

Quality Indicator (QI) appraisal protocol is a novel methodology that combines multiple appraisal methods to comprehensively assess the 'appropriateness' of QIs for a particular healthcare setting. However, they remain inadequately explored compared to the single appraisal method approach. To describe and test a multi-method QI appraisal protocol versus the single method approach, against a series of QIs previously identified as potentially relevant to the prehospital emergency care setting. An appraisal protocol was developed consisting of two categorical-based appraisal methods, combined with the qualitative analysis of the discussion generated during the consensus application of each method. The output of the protocol was assessed and compared with the application and output of each method. Inter-rater reliability (IRR) of each particular method was evaluated prior to group consensus rating. Variation in the number of non-valid QIs and the proportion of non-valid QIs identified between each method and the protocol were compared and assessed. There was mixed IRR of the individual methods. There was similarly low-to-moderate correlation of the results obtained between the particular methods (Spearman's rank correlation = 0.42, P < 0.001). From a series of 104 QIs, 11 non-valid QIs were identified that were shared between the individual methods. A further 19 non-valid QIs were identified and not shared by each method, highlighting the benefits of a multi-method approach. The outcomes were additionally evident in the group discussion analysis, which in and of itself added further input that would not have otherwise been captured by the individual methods alone. The utilization of a multi-method appraisal protocol offers multiple benefits, when compared to the single appraisal approach, and can provide the confidence that the outcomes of the appraisal will ensure a strong foundation on which the QI framework can be successfully implemented.

Pre-hospital intercostal chest drains in South Africa: A modified Delphi study.

IntroductionTrauma is one of the most common causes of death in low- and middle-income countries, with thoracic injury accounting for 20–25% of these deaths worldwide. The current management of a life-threatening pre-hospital pneumothorax is with a needle chest decompression, however, definitive care for a pneumothorax and/or haemothorax is still the insertion of an intercostal chest drain. The aim of this study was to seek expert opinion and consensus on the placement of ICDs in the pre-hospital emergency care setting in South Africa.MethodsA three-round modified Delphi study was undertaken with an expert panel drawn from local emergency care experts consisting of physicians and emergency medical service practitioners. Participants supplied opinion statements in round 1 under headings derived from common emerging themes found in the literature. During round 2 participants used a 9-point Likert scale to rate their consensus on each statement and in round 3 they were able to change their position based on the earlier panel distributions. A consensus percentage of 60% was set within a narrow margin of ‘strongly agree’ or ‘strongly disagree’.ResultsA total of 22 experts took part as panel members. There were 123 opinion statements produced from round 1, of which 21 (17%) reached consensus in round 2. At the end of round 3 another four statements reached consensus, bringing the total up to 25 (20%).ConclusionDefinitive care of a life-threating pneumothorax and/or haemothorax must be sought emergently. The insertion of an ICD, under select conditions, may be required in the pre-hospital setting in South Africa.

Application of the emergency medical services trigger tool to measure adverse events in prehospital emergency care: a time series analysis

BackgroundEmergency Care has previously been identified as an area of significant concern regarding the prevalence of Adverse Events (AEs). However, the majority of this focus has been on the in-hospital setting, with little understanding of the identification and incidence of AEs in the prehospital environment.MethodThe early development and testing of Emergency Medical Services (EMS) specific triggers for the identification of AEs and Harm has been previously described. To operationalise the Emergency Medical Services Trigger Tool (EMSTT), the processes developed by the Institute for Healthcare Improvement for use with the Global Trigger Tool were adapted to a prehospital emergency care setting. These were then applied using a stepwise approach to the analysis of 36 consecutive samples of patient care records over an 18-month period (n = 710). Inter-rater reliability was measured for each trigger item and level of Harm classification. Total Triggers per 10,000 Patient Encounters, AEs per 10,000 Patient Encounters and Harm per 10,000 Patient Encounters were measured. All measures were plotted on Statistical Process Control Charts.ResultsThere was a high level of inter-rater agreement across all items (range: 85.6–100%). The EMSTT found an average rate of 8.20 Triggers per 10,000 Patient Encounters, 2.48 AEs per 10,000 Patient Encounters and 0.34 Harm events per 10,000 Patient Encounters. Three triggers: Change in Systolic Blood Pressure Greater Than 20%; Temp > 38 °C without subsequent reduction; and SpO2 < 94% without supplemental Oxygen or SpO2 < 85% without assisted ventilation accounted for 93% (n = 180) of the triggers found throughout the longitudinal analysis.DiscussionWith sufficient focus on implementation and data collection, as well as the inclusion of a contextually relevant system for classifying AE/Harm, the EMSTT represents a potentially successful strategy towards identifying the rate of AEs within EMS across a large patient population with limited commitment of time and resources.

Application of a Healthcare Failure Modes and Effects Analysis to Identify and Mitigate Potential Risks in the Implementation of a National Prehospital Pediatric Rapid Sequence Intubation Program.

Rapid sequence intubation (RSI) has become the de facto airway method of choice in the emergency airway management of adult and pediatric patients. There is significant controversy regarding pediatric RSI in the prehospital setting, given not only the complexities inherent in both the procedure and patient population, but in variations in emergency medical service models, prehospital qualifications, scope of practice, and patient exposure too. A Healthcare Failure Mode and Effects Analysis was conducted to identify and mitigate potential hazards in the national implementation of a prehospital pediatric RSI program. A process map and potential failure points were developed and identified. Probabilities, severity, and hazards scores were calculated for each failure point, and actions items developed to address these. One hundred four potential failure points were identified among 44 subprocesses, divided between nine major processes. In terms of severity, most were classified as either major (n = 39 [37.5%]) or catastrophic (n = 35 [33.7%]) with just more than half falling within the uncommon category (n = 56 [53.9%]) in terms of probability. Five strategic actions items were identified to mitigate against the failure points meeting criteria for action. To monitor the success of these, 11 quality and performance indicators were developed for concurrent implementation. The Healthcare Failure Mode and Effects Analysis represents a simple yet comprehensive first step toward risk analysis of complex procedures within the prehospital emergency care setting. Application of the methodology provided guidance for the consensus identification of hazards associated with prehospital pediatric RSI and appropriate actions to mitigate them.

Use of morphine sulphate by South African paramedics for prehospital pain management.

Evidence in the literature highlights the fact that acute pain in the prehospital setting remains poorly managed. Morphine remains the most commonly used analgesic agent in the South African prehospital emergency care setting. Although guidelines and protocols relating to the dosage and administration of morphine exist, little data are available describing its use by South African paramedics. To document and describe the way in which morphine is administered by a sample of South African paramedics for the management of acute pain in the prehospital setting. An Internet-based survey was conducted. Sixty South African paramedics responded by completing the online questionnaire documenting and describing their use of morphine for management of acute pain. Results revealed that participants appeared to be overly cautious of potential adverse effects associated with administration of morphine. Although the majority of participants calculated the dose of morphine to be administered correctly according to the patient's weight, the majority do not appear to be administering this as a bolus; rather, they administer the calculated loading dose in a titrated manner over time. This method may result in a delay and or failure to adequately achieve therapeutic serum levels. Failure to administer an appropriate bolus or 'loading dose' when administering morphine intravenously may result in ineffective and delayed pain management. The authors recommend more clearly defined protocols be developed to guide the use of morphine sulphate by paramedics in the local emergency medical services environment.

Implementing a Standardized Nursing Language System in the Prehospital Emergency Care Setting

PURPOSE To orient nurses caring for critically ill emergency patients to a standardized nursing language–based protocol system in the field.METHODS An experimental learning program was developed and conducted by a nurse consultant. Nursing process–oriented, theoretical‐practical classes focused on the analysis of real clinical situations with the purpose of generating a reflective process in the nurses' conceptual schemes and incorporating standardized nursing language in their clinical practice.FINDINGS The expansion of nursing process–oriented clinical sessions and the retrospective clinical analysis of individualized patients has occurred in 7 of the 8 leading cities of the region (in one of them the teaching program has not been performed yet). Nine courses have been taught to a total of 185 RNs. The mean satisfaction rate reported was 90%, and one externally funded research project was initiated in regard to implementing nursing process in emergency prehospital care and taught to 75 nurses. A qualitative‐quantitative research project funded by the health department of the Andalusian government was initiated by one of these nurses with respect to nursing process implementation in emergency services.The Quality and Accreditation Center developed an evaluation system that included nurse perfomance. Two of 11 nurses participating as educators were designated as members of the evaluation board. The evaluation described impediments in determining the specific contribution of nurses to the overall process. The 2 nurses proposed that incorporating standardized nursing language was the best way to evaluate nursing performance. As a consequence, a nursing record based on the initial one designed in the research project was implemented. This record is divided into assessment, diagnosis, outcomes, and interventions based on Henderson's 14 needs, NANDA, NIC, and NOC. The electronic record will set the standards for evaluating the dimensions of the nursing data set established by the Nursing Information and Data Set Evaluation Center: nomenclature, clinical context, clinical data repository, and general system characteristics. The electronic record has been implemented in all the main cities of Andalusia and will be a main component of the Critical Patient Clinical Dossier that integrates both medical and nursing records.DISCUSSION Implementation of standardized nursing language requires an adequate orientation program with defined objectives. The simple addition of nursing terminology to clinical areas or guidelines development not only offers some difficulties in their usage, but also creates a conceptual conflict among nurses with a biomedical paradigm orientation. Using standardized nursing language presupposes a paradigm shift among nurses and managers. Nursing process and standardized nursing language are not always the primary focus of healthcare systems; it is necessary to demonstrate the lack of sensitivity present in information systems regarding nursing practice, nursing resources evaluation, and competency design. This situation cannot be modified piecemeal, and collaboration between nurses and administration is critical.CONCLUSIONS A nursing information system is not only a recordkeeping system and a software application; it needs also a qualitative transformation of the nurses' conceptual point of view and adequate linkage between theory and clinical practice. A patient‐centered, longterm evaluation of the nursing process implementation is needed to assess the effectiveness of this reorientation of nurses' clinical practice.

Nitroglycerine Lingual Aerosol in Prehospital Emergency Care,

Nitroglycerine (NTG) commonly is used in the prehospital emergency care setting for the treatment of chest pain suggestive of myocardial ischemia or infarction or for cardiac unloading in patients with presumed pulmonary edema. The usual form of this drug is as a 400 mcg tablet administered sublingually. Recently, NTG has become available as an aerosolized form (NTGA) in a multiple dose, pressurized canister containing 200 metered doses of 400 meg of NTG each. In this form, the drug is purported to be absorbed rapidly from the surface of the tongue.In the field, we have noted that the sublingual tablet form of NTG occasionally remains undissolved following administration to patients complaining of chest pain. In each of these cases, clinically, the patients were unchanged on arrival at the receiving hospital and an intact tablet was discovered properly placed under the tongue. In an attempt to evaluate the ease of administration and clinical responses of patients with chest pain to the aerosolized form of the drug, we replaced NTG sublingual tablets on paramedic units in the Burbank system with the NTGA form.