The opinion of emergency medical service personnel regarding safety in pre-hospital emergency care practice

A research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, in partial fulfilment of the requirements for the degree of Master of Science in Medicine in Emergency Medicine Johannesburg, 2015The pre-hospital setting poses a potential threat to safety as emergency care takes place in a dynamic, uncontrolled and ever-changing environment. In addition Emergency Medical Services (EMS) personnel are generally overworked. All these factors translate to possible errors which may well compromise the health conditions of the patients. This study reflects the opinions of pre-hospital personnel regarding safety and as such the perception of the current state of safety in South African EMS. A prospective, descriptive and cross-sectional online survey was utilised to obtain opinions from respondents regarding pre-hospital safety in their work environment. Results A total of 610 electronic requests to partake in the survey were sent with a yield of 26.9% (n=164). A variety of questions relating to personal safety, patient safety and organisational safety culture were posed to the respondents. The typical respondent was a white (84%, n=134), male (69%, n=109), Advanced Life Support Paramedic (55%, n=86), between the age of 31 and 40 years (44%, n=69), who has between 11 and 15 years of EMS experience and works in in the private sector (62.5%, n=65). Concerns included management support, fatigue, vehicle accidents and interpersonal violence. The majority have been exposed to vehicle accidents (54.2%, n=84) and it is believed that management could do more to ensure vehicle safety. Interpersonal violence should not be considered an anomaly in the EMS. The perceived incidence of violence towards the respondents is 56% (n=88), which is lower than that experienced by their international EMS colleagues. This workplace interpersonal violence was deemed the most important safety concern. Most respondents did not seem to think that medical adverse events were particularly prevalent in their work environment, but appeared more comfortable admitting to having witnessed others making errors. Limitations include a convenience sample which does not represent all EMS, and it is recommended that a representative study be completed. Conclusion Contributing factors towards safety concerns include lack of management support, poor communication from management, fatigue, interpersonal violence and inadequate staffing. There is evidence of a focus on a patient safety culture within the EMS

Prehospital cardiac arrest resuscitation practices differ around the globe

Background: Out-of-hospital cardiac arrest (OHCA) is a major public health problem. This study aims to describe the international variations in the practices related to the initiation, termination, and refraining from resuscitation of adult patients (≥18 years) with a non-traumatic OHCA. Methods: An exploratory descriptive study was conducted using a cross-sectional online survey. The respondents were recruited using snowball sampling technique. Framework analysis was used to identify key themes in responses, with descriptive statistics summarising data trends. Results: The study collected responses from 59 countries. Our findings reveal that respondents from 59.3% of countries reported that they initiate resuscitation in all cases where the patients do not show obvious signs of irreversible death or do not have confirmed advance directives. Respondents from 15.3% of countries reported that once started, prehospital resuscitation attempts are not terminated. Prehospitally respondents from 20.3% of the countries reported that they rely exclusively on specific criteria to decide when to terminate resuscitation efforts while in 45.8%, these decisions are made at the discretion of the provider. Respondents from most countries (91.5%) reported that they refrain from resuscitation in the presence of obvious signs of irreversible death. Respondents from 57.6% of countries, reported that they refrained from resuscitation if the patient had a confirmed do-not-attempt-cardiopulmonaryresuscitation (DNACPR), while 15.3% mentioned staff safety as a reason to abstain from attempting resuscitation. Conclusion: This study reveals global variation in EMS resuscitation practices, reflecting disparities in resources, healthcare infrastructure, EMS system design, community acceptability given cultural and societal norms, and legislation.</p

Multiorgan MRI findings after hospitalisation with COVID-19 in the UK (C-MORE): a prospective, multicentre, observational cohort study

Introduction: The multiorgan impact of moderate to severe coronavirus infections in the post-acute phase is still poorly understood. We aimed to evaluate the excess burden of multiorgan abnormalities after hospitalisation with COVID-19, evaluate their determinants, and explore associations with patient-related outcome measures. Methods: In a prospective, UK-wide, multicentre MRI follow-up study (C-MORE), adults (aged ≥18 years) discharged from hospital following COVID-19 who were included in Tier 2 of the Post-hospitalisation COVID-19 study (PHOSP-COVID) and contemporary controls with no evidence of previous COVID-19 (SARS-CoV-2 nucleocapsid antibody negative) underwent multiorgan MRI (lungs, heart, brain, liver, and kidneys) with quantitative and qualitative assessment of images and clinical adjudication when relevant. Individuals with end-stage renal failure or contraindications to MRI were excluded. Participants also underwent detailed recording of symptoms, and physiological and biochemical tests. The primary outcome was the excess burden of multiorgan abnormalities (two or more organs) relative to controls, with further adjustments for potential confounders. The C-MORE study is ongoing and is registered with ClinicalTrials.gov, NCT04510025. Findings: Of 2710 participants in Tier 2 of PHOSP-COVID, 531 were recruited across 13 UK-wide C-MORE sites. After exclusions, 259 C-MORE patients (mean age 57 years [SD 12]; 158 [61%] male and 101 [39%] female) who were discharged from hospital with PCR-confirmed or clinically diagnosed COVID-19 between March 1, 2020, and Nov 1, 2021, and 52 non-COVID-19 controls from the community (mean age 49 years [SD 14]; 30 [58%] male and 22 [42%] female) were included in the analysis. Patients were assessed at a median of 5·0 months (IQR 4·2–6·3) after hospital discharge. Compared with non-COVID-19 controls, patients were older, living with more obesity, and had more comorbidities. Multiorgan abnormalities on MRI were more frequent in patients than in controls (157 [61%] of 259 vs 14 [27%] of 52; p&lt;0·0001) and independently associated with COVID-19 status (odds ratio [OR] 2·9 [95% CI 1·5–5·8]; padjusted=0·0023) after adjusting for relevant confounders. Compared with controls, patients were more likely to have MRI evidence of lung abnormalities (p=0·0001; parenchymal abnormalities), brain abnormalities (p&lt;0·0001; more white matter hyperintensities and regional brain volume reduction), and kidney abnormalities (p=0·014; lower medullary T1 and loss of corticomedullary differentiation), whereas cardiac and liver MRI abnormalities were similar between patients and controls. Patients with multiorgan abnormalities were older (difference in mean age 7 years [95% CI 4–10]; mean age of 59·8 years [SD 11·7] with multiorgan abnormalities vs mean age of 52·8 years [11·9] without multiorgan abnormalities; p&lt;0·0001), more likely to have three or more comorbidities (OR 2·47 [1·32–4·82]; padjusted=0·0059), and more likely to have a more severe acute infection (acute CRP &gt;5mg/L, OR 3·55 [1·23–11·88]; padjusted=0·025) than those without multiorgan abnormalities. Presence of lung MRI abnormalities was associated with a two-fold higher risk of chest tightness, and multiorgan MRI abnormalities were associated with severe and very severe persistent physical and mental health impairment (PHOSP-COVID symptom clusters) after hospitalisation. Interpretation: After hospitalisation for COVID-19, people are at risk of multiorgan abnormalities in the medium term. Our findings emphasise the need for proactive multidisciplinary care pathways, with the potential for imaging to guide surveillance frequency and therapeutic stratification

An online learning programme improves traumatic brain injury guideline adherence in a South African Helicopter Emergency Medical Service

AbstractIntroductionIt is difficult to initiate clinical quality improvement projects through continuous education in the prehospital environment due to the very nature of their mobile workplace and unpredictable presence in a specific location. This study reviews the impact of an online learning platform and the effect it had on the clinical quality of care offered to patients with traumatic brain injury (TBI) during Helicopter Emergency Medical Services (HEMS) operations.MethodsA prospective improvement project was initiated to improve the clinical care for patients with TBI. A clinical monitoring tool, based on the prehospital care guidelines of the Brain Trauma Foundation was designed to assess the clinical quality of TBI patient care. The clinical indicators measured included initial Glasgow Coma Score, motor function, pupil size and reactivity, hypotension, hypoxaemia, carbon dioxide levels, temperature control, and patient position. A four month baseline monitoring was completed to determine the level of adherence to the guidelines, and subsequently an online, free access lecture series was presented to the HEMS operational staff. The clinical monitoring tool was applied during this time and afterwards to review adherence to guidelines.ResultsA total of 71 cases of TBI were seen during the period of assessment and 64.8% of HEMS crew participated in the online training programme. A change in the average adherence to the clinical guidelines improved from 66.9% to 75.7% (p=0.033) from the baseline monitoring period, to the period immediately after the online training.ConclusionFree and open online learning platforms can be implemented at little to no cost and can be accessed anywhere. This initiative has shown benefit in ensuring best care for critically ill TBI HEMS patients

A Smartphone-Based Model of Care to Support Patients With Cardiac Disease Transitioning From Hospital to the Community (TeleClinical Care): Pilot Randomized Controlled Trial (Preprint)

BACKGROUND Patients hospitalized with acute coronary syndrome (ACS) or heart failure (HF) are frequently readmitted. This is the first randomized controlled trial of a mobile health intervention that combines telemonitoring and education for inpatients with ACS or HF to prevent readmission. OBJECTIVE This study aims to investigate the feasibility, efficacy, and cost-effectiveness of a smartphone app–based model of care (TeleClinical Care [TCC]) in patients discharged after ACS or HF admission. METHODS In this pilot, 2-center randomized controlled trial, TCC was applied at discharge along with usual care to intervention arm participants. Control arm participants received usual care alone. Inclusion criteria were current admission with ACS or HF, ownership of a compatible smartphone, age ≥18 years, and provision of informed consent. The primary end point was the incidence of unplanned 30-day readmissions. Secondary end points included all-cause readmissions, cardiac readmissions, cardiac rehabilitation completion, medication adherence, cost-effectiveness, and user satisfaction. Intervention arm participants received the app and Bluetooth-enabled devices for measuring weight, blood pressure, and physical activity daily plus usual care. The devices automatically transmitted recordings to the patients’ smartphones and a central server. Thresholds for blood pressure, heart rate, and weight were determined by the treating cardiologists. Readings outside these thresholds were flagged to a monitoring team, who discussed salient abnormalities with the patients’ usual care providers (cardiologists, general practitioners, or HF outreach nurses), who were responsible for further management. The app also provided educational push notifications. Participants were followed up after 6 months. RESULTS Overall, 164 inpatients were randomized (TCC: 81/164, 49.4%; control: 83/164, 50.6%; mean age 61.5, SD 12.3 years; 130/164, 79.3% men; 128/164, 78% admitted with ACS). There were 11 unplanned 30-day readmissions in both groups (&lt;i&gt;P&lt;/i&gt;=.97). Over a mean follow-up of 193 days, the intervention was associated with a significant reduction in unplanned hospital readmissions (21 in TCC vs 41 in the control arm; &lt;i&gt;P&lt;/i&gt;=.02), including cardiac readmissions (11 in TCC vs 25 in the control arm; &lt;i&gt;P&lt;/i&gt;=.03), and higher rates of cardiac rehabilitation completion (20/51, 39% vs 9/49, 18%; &lt;i&gt;P&lt;/i&gt;=.03) and medication adherence (57/76, 75% vs 37/74, 50%; &lt;i&gt;P&lt;/i&gt;=.002). The average usability rating for the app was 4.5/5. The intervention cost Aus $6028 (US$4342.26) per cardiac readmission saved. When modeled in a mainstream clinical setting, enrollment of 237 patients was projected to have the same expenditure compared with usual care, and enrollment of 500 patients was projected to save approximately Aus $100,000 (approximately US$70,000) annually. CONCLUSIONS TCC was feasible and safe for inpatients with either ACS or HF. The incidence of 30-day readmissions was similar; however, long-term benefits were demonstrated, including fewer readmissions over 6 months, improved medication adherence, and improved cardiac rehabilitation completion. CLINICALTRIAL Australian New Zealand Clinical Trials Registry ACTRN12618001547235; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=375945 </sec

A Smartphone-Based Model of Care to Support Patients With Cardiac Disease Transitioning From Hospital to the Community (TeleClinical Care): Pilot Randomized Controlled Trial

Background Patients hospitalized with acute coronary syndrome (ACS) or heart failure (HF) are frequently readmitted. This is the first randomized controlled trial of a mobile health intervention that combines telemonitoring and education for inpatients with ACS or HF to prevent readmission. Objective This study aims to investigate the feasibility, efficacy, and cost-effectiveness of a smartphone app–based model of care (TeleClinical Care [TCC]) in patients discharged after ACS or HF admission. Methods In this pilot, 2-center randomized controlled trial, TCC was applied at discharge along with usual care to intervention arm participants. Control arm participants received usual care alone. Inclusion criteria were current admission with ACS or HF, ownership of a compatible smartphone, age ≥18 years, and provision of informed consent. The primary end point was the incidence of unplanned 30-day readmissions. Secondary end points included all-cause readmissions, cardiac readmissions, cardiac rehabilitation completion, medication adherence, cost-effectiveness, and user satisfaction. Intervention arm participants received the app and Bluetooth-enabled devices for measuring weight, blood pressure, and physical activity daily plus usual care. The devices automatically transmitted recordings to the patients’ smartphones and a central server. Thresholds for blood pressure, heart rate, and weight were determined by the treating cardiologists. Readings outside these thresholds were flagged to a monitoring team, who discussed salient abnormalities with the patients’ usual care providers (cardiologists, general practitioners, or HF outreach nurses), who were responsible for further management. The app also provided educational push notifications. Participants were followed up after 6 months. Results Overall, 164 inpatients were randomized (TCC: 81/164, 49.4%; control: 83/164, 50.6%; mean age 61.5, SD 12.3 years; 130/164, 79.3% men; 128/164, 78% admitted with ACS). There were 11 unplanned 30-day readmissions in both groups (P=.97). Over a mean follow-up of 193 days, the intervention was associated with a significant reduction in unplanned hospital readmissions (21 in TCC vs 41 in the control arm; P=.02), including cardiac readmissions (11 in TCC vs 25 in the control arm; P=.03), and higher rates of cardiac rehabilitation completion (20/51, 39% vs 9/49, 18%; P=.03) and medication adherence (57/76, 75% vs 37/74, 50%; P=.002). The average usability rating for the app was 4.5/5. The intervention cost Aus $6028 (US$4342.26) per cardiac readmission saved. When modeled in a mainstream clinical setting, enrollment of 237 patients was projected to have the same expenditure compared with usual care, and enrollment of 500 patients was projected to save approximately Aus $100,000 (approximately US$70,000) annually. Conclusions TCC was feasible and safe for inpatients with either ACS or HF. The incidence of 30-day readmissions was similar; however, long-term benefits were demonstrated, including fewer readmissions over 6 months, improved medication adherence, and improved cardiac rehabilitation completion. Trial Registration Australian New Zealand Clinical Trials Registry ACTRN12618001547235; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=375945 </jats:sec