Prehospital Emergency Care Providers Research Articles

A Comparison Between Differently Skilled Prehospital Emergency Care Providers in Major-Incident Triage in South Africa.

This was a cross-sectional study involving differently trained prehospital providers: Advanced Life Support (ALS); Intermediate Life Support (ILS); and Basic Life Support (BLS). Participants wrote a validated 20-question pre-test before completing major-incident training. Two post-tests were also completed: a 20-question written test and a three-question face-to-face evaluation. Outcomes measured were triage accuracy and duration of triage. The effect of level of training, gender, age, previous major-incident training, and duration of service were determined. A total of 129 prehospital providers participated. The mean age was 33.4 years and 65 (50.4%) were male. Most (n=87; 67.4%) were BLS providers. The overall correct triage score pre-training was 53.9% (95% CI, 51.98 to 55.83), over-triage 31.4% (95% CI, 29.66 to 33.2), and under-triage 13.8% (95% CI, 12.55 to 12.22). Post-training, the overall correct triage score increased to 63.6% (95% CI, 61.72 to 65.44), over-triage decreased to 17.9% (95% CI, 16.47 to 19.43), and under-triage increased to 17.8% (95% CI, 16.40 to 19.36). The ALS providers had both the highest likelihood of a correct triage score post-training (odds ratio 1.21; 95% CI, 0.96-1.53) and the shortest duration of triage (median three seconds, interquartile range two to seven seconds; P=.034). Participants with prior major-incident training performed better (P=.001). Accuracy of major-incident triage across all levels of prehospital providers in South Africa is less than optimal with non-significant differences post-major-incident training. Prior major-incident training played a significant role in triage accuracy indicating that training should be an ongoing process. Although ALS providers were the quickest to complete triage, this difference was not clinically significant. The BLS and ILS providers with major-incident training can thus be utilized for primary major-incident triage allowing ALS providers to focus on more clinical roles. AlenyoAN, SmithWP, McCaulM, Van HovingDJ. A comparison between differently skilled prehospital emergency care providers in major-incident triage in South Africa. Prehosp Disaster Med. 2018;33(6):575-580.

Barriers to Real-Time Medical Direction via Cellular Communication for Prehospital Emergency Care Providers in Gujarat, India.

Background: Many low- and middle-income countries depend on emergency medical technicians (EMTs), nurses, midwives, and layperson community health workers with limited training to provide a majority of emergency medical, trauma, and obstetric care in the prehospital setting. To improve timely patient care and expand provider scope of practice, nations leverage cellular phones and call centers for real-time online medical direction. However, there exist several barriers to adequate communication that impact the provision of emergency care. We sought to identify obstacles in the cellular communication process among GVK Emergency Management and Research Institute (GVK EMRI) EMTs in Gujarat, India.Methods: A convenience sample of practicing EMTs in Gujarat, India were surveyed regarding the barriers to call initiation and completion.Results: 108 EMTs completed the survey. Overall, ninety-seven (89.8%) EMTs responded that the most common reason they did not initiate a call with the call center physician was insufficient time. Forty-six (42%) EMTs reported that they were unable to call the physician one or more times during a typical workweek (approximately 5-6 twelve-hour shifts/week) due to their hands being occupied performing direct patient care. Fifty-eight (54%) EMTs reported that they were unable to reach the call center physician, despite attempts, at least once a week.Conclusion: This study identified multiple barriers to communication, including insufficient time to call for advice and inability to reach call center physicians. Identification of simple interventions and best practices may improve communication and ensure timely and appropriate prehospital care.

Urban density, deprivation and road safety: A small area study in the eThekwini metropolitan area, South Africa

The aim of this policy brief is to provide an evidence-informed answer to the question: ‘What is the role and scope of pre-hospital emergency care providers to domestic violence (DV) intervention as a form of gender-based violence prevention?’ The answer is intended to determine the theoretical and clinical best practice to inform the emergency care community and policy development by critically appraising the evidence that considers the responsiveness of Emergency Medical Services to the health needs of DV victims. Evidence-informed Decision Making methods are employed. The evidence appraised was based on electronic searches using the Cape Peninsula University of Technology database. Research and non-research publications were considered with publication dates mostly from 1999 to 2011. Upon screening 164 articles for content relevance, 53 were critically appraised against predetermined criteria for relevance of the evidence, robust nature of the evidence and presence of bias. A thematic/narrative analysis ensued in terms of strength of evidence and frequency of findings. Early recognition and intervention is seen as one of the most effective methods of DV prevention. This finding is nuanced if it is male caregivers doing so. There is an ethical obligation to implement a comprehensive health approach to manage domestic violence victims. The strong, majority findings are that educational intervention/s increases the health care provider’s understanding of DV and improves screening for DV. The research supports the development and use of screening tools/guidelines/ procedures for DV as they are found to improve DV intervention. The evidence supports an integrated effort of the health system in achieving its goal of DV prevention by promoting the participation of pre-hospital emergency care providers as critical stakeholders. Key words : Domestic Violence (DV) management and prevention, Emergency Care Providers (ECP’s), Gender-based violence (GBV) prevention, Evidence-informed Decision Making (EiDM), Emergency Medical Service

Pre-hospital phlebotomy and point of care testing: Relevance and implications for professional emergency care practice

The drawing or sampling of blood refers to the procedure whereby blood is obtained via arterial or venous cannulation from a patient for various diagnostic tests. The Health Professions Council of South Africa (HPCSA), Professional Board for Emergency Care (PBEC) scope of practice encompasses for what may be diagnostically possible for a person in an emergency situation. The HPCSA ethical rules stipulate that no professional act may be performed by emergency care personnel if it falls outside their scope of clinical practice. This implies an emergency context and the presence of criterion referenced guidelines (in the form of protocols) to support the safe implementation of scope. Phlebotomy may appear to be a simple and uncomplicated procedure for pre-hospital emergency care providers given that the intermediate and advanced categories can already perform intravenous therapy. However, any invasive procedure and human tissue sampling creates the potential for ethical compromise, particularly in vulnerable or high-risk patients. Therefore, various regulatory, clinical and system directives are needed in order for any invasive procedure to be effective, efficient, ethical and sustainable. This paper aims to provide a perspective on phlebotomy (applicable to all allied health professionals), with regard to regulation, clinical and system requirements against any claim of biomedical need. In the interest of accountable practice, a model of mitigation for the scope of clinical practice and a model for health technology regulation are presented. The emergency care context is presented as a case study. The relevance for the discipline of biomedical technology is that the determination of need, methodology and the bona fides (and experience) of the clinician has bearing on the admissibility, quality and ethics of phlebotomy. Phlebotomists are integral to the medical laboratory. The question this paper addresses is: what are the considerations for pre-hospital phlebotomy and point of care testing by emergency care providers should they undertake the role of the phlebotomist in emergency and non-emergency cases.

Traumatic amputation and limb preservation

Although the nature and circumstances of traumatic amputation are beyond the control of prehospital emergency care providers, their actions on scene and during transportation may still have a great influence upon both morbidity and mortality. Familiarity with the body's physiological response to major trauma and the military paradigm of treatment may well prove life-saving, as will understanding the potential need for an aggressive approach to haemorrhage management (including the use of tourniquets) and rapid transportation to definitive care. Where appropriate, effective cooling of the amputated part will maximize the possibility for successful replantation (surgical reattachment), although a poor cooling technique is likely to cause further cellular damage through either freezing or tissue maceration. This article will discuss the types of amputation and the key factors in the management of these types of injuries.

Fetal Monitoring in the Prehospital Setting

Prehospital emergency care providers have very little information regarding fetal perfusion adequacy in the field. This study was conducted to evaluate the feasibility of the use of fetal monitoring in the prehospital setting. A mobile cardiotocometer was used for all consecutive pregnant women managed by our physician-staffed Emergency Medical Services unit. The visualization of interpretable tracings (both fetal heart rate and tocography) at the different stages of prehospital management was evaluated. Any change in a patient's management was also recorded. There were 145 patients enrolled during 119 inter-hospital transfers and 26 primary prehospital interventions. Interpretable tracings were obtained for 81% of the patients during the initial examination. This rate decreased to 66% during handling and transfer procedures. For 17 patients (12%), the monitoring led to a change in the patient's management. This study shows that cardiotocography can be easily performed in the prehospital setting, and is usually feasible. Moreover, the study demonstrates a positive impact of fetal heart rate monitoring on prehospital management.

Precision and Reliability of the Glasgow Coma Scale Score among a Cohort of Latin American Prehospital Emergency Care Providers

The Glasgow Coma Scale (GCS) is the standard measure used to quantify the level of consciousness in patients with head injuries. Rapid and accurate GCS scoring is essential for adequate assessment and treatment of critically sick and injured patients. This study sought out to determine the precision and reliability of the GCS among a cohort of Latin American Critical Care Transport Providers. The study consisted of a cross-sectional design using an Internet-based examination. The evaluation consisted of four focused clinical scenarios with a classification based on severity. For measurement of intra-rater reliability the first and fourth cases were identical. Five minutes were allocated for each scenario. For categorical variables, chi-square testing and Fisher's exact testing were used to assess associations. For all tests, statistical significance was set at the 0.05 level. A total of 62 providers participated, including 17 physicians and 45 advanced providers (nurses and paramedics). No statistically significant differences were observed between physicians and advanced providers in the correct classification of the individual scenarios. Five of the 17 physicians (29.4%) answered all cases correctly, while none of the 45 advanced providers did (p < 0.001). When evaluating the duplicated cases (Cases 1 and 4), five physicians (29.4%) and 11 advanced providers (24.4%) correctly classified the cases. This difference was not statistically significant. This study demonstrated a poor precision and poor reliability in the use of the Glasgow Coma Scale within the study subjects.

Development of an electronic emergency medical services patient care record

Objective. The need for valid and reliable emergency medical services (EMS) data has long been recognized. EMS data are useful for monitoring resources and operations, documenting patient care and outcome, and evaluating injury prevention strategies. The goal of this project was to develop a computerized data set with the capability to generate a patient care record (PCR) to overcome some of the current EMS data limitations. Methods. The authors discuss developing an electronic PCR and analysis data set containing 233 variables. Data are collected for the following: incident, response, scene, patient, history, primary survey (including vital signs), physical examination, physiologic scores, diagnostics, plan (medications and procedures), assessment, and reevaluation. Software on a portable computer installed in an EMS response unit utilizes a graphical user interface for data collection by prehospital emergency care providers. A data set stores codes corresponding to user's selections. This data set supports data storage and analysis. The electronic PCR and data set can be useful to EMS agencies for collecting, storing, reporting, and analyzing information. Results. Variables are categorized into 12 main categories to categorize the variables and to drive data collection. The system provides the user with the ability to print out a record (using a portable printer installed in an ambulance) and analyze data stored in the data set. Conclusions. This computerized approach overcomes many limitations inherent with using paper-based systems for research. Linked with emergency department, hospital discharge, and mortality data, EMS data can be used in systems analyses related to patient outcome.

EMS providers do not accurately note motor-vehicle crash patients with positive serum alcohol concentrations.

Alcohol use is associated with many motor-vehicle crashes and may increase the severity of injury. Because alcohol use also may mask injury, prehospital emergency care providers (PHECPs) may make inaccurate assessments. To assess and triage crash victims accurately, PHECPs must identify recent alcohol use. This study examines the accuracy of PHECPs in identifying motor-vehicle crash victims who had positive serum alcohol concentrations. Retrospective cohort study. Included in the study were motor-vehicle crash victims more than 17 years of age who were conveyed directly to a university medical center emergency department by ground ambulance (n = 372). TIME PERIOD: 15 July 1990 to 15 July 1991. Data sources included ambulance report forms and hospital records. Variables that were abstracted included the Revised Trauma Score (RTS), the PHECPs' impression of alcohol use, and serum alcohol concentrations. Sensitivity, specificity, predictive-value positive, predictive-value negative, and 0.95 confidence intervals (0.95 CI) were calculated for the PHECPs' ability to identify patients with a serum alcohol concentration > 0. The relationship between the RTS and the impressions of alcohol use was analyzed with chi-square testing: a p-value of < 0.05 was considered statistically significant. This study suggests that PHECPs cannot accurately identify crash victims with positive serum alcohol concentrations. Selection bias and retrospective design are significant limitations of this study. Future studies should develop and evaluate methods to improve PHECPs' accuracy in assessing alcohol use in motor-vehicle crash victims.

Vehicle Crash Rescue Skills and Residency Training in Emergency Medicine

Recent advances in the resuscitation and stabilization skills of prehospital emergency care providers have done much to improve the quality of immediate care provided to suddenly ill or injured patients. Although much of the innovation and leadership in this area has been provided by emergency department physicians, most of them still lack an adequate appreciation of the circumstances under which these skills are executed. While many physicians participate in prehospital care teaching and evaluation of the system, most have not gained personal experience in those aspects of care foreign to hospital environment. They are particularly unacquainted with the intricacies of rescuing patients from automobile accidents and similar entrapments. It is not unusual, however, for an accident victim to spend half of the time required for the prehospital phase of emergency medical care undergoing extrication, and in many cases this must be done before full advanced life support measures may be initiated.