Alix J.E. Carter

A systematic review of the impact of nurse practitioners on cost, quality of care, satisfaction and wait times in the emergency department

INTRODUCTION US emergency personnel cared for 106% more patients in 1990 than they did in 1980, and national emergency department census data show that 60%-80% of those patients presented with non-urgent or minor medical problems. The hiring of nurse practitioners (NPs) is one proposed solution to the ongoing overcrowding and physician shortage facing emergency departments (EDs). METHODS We conducted a systematic review of MEDLINE and Cinahl to find articles that discussed NPs in the ED setting, looking specifically at 4 key outcome measures: wait times, patient satisfaction, quality of care and cost effectiveness. RESULTS Although some questions remain, a review of the literature suggests that NPs can reduce wait times for the ED, lead to high patient satisfaction and provide a quality of care equal to that of a mid-grade resident. Cost, when compared with resident physicians, is higher; however, data comparing to the hiring additional medical professionals is lacking. CONCLUSION The medical community should further explore the use of NPs, particularly in fast track areas for high volume departments. In rural areas, NPs could supplement overextended physicians and allow health centres to remain open when they might otherwise have to close. These strategies could improve access to care and patient satisfaction for selected urban and rural populations as well as make the best use of limited medical resources.

Information Loss in Emergency Medical Services Handover of Trauma Patients

Abstrast Introduction. Little is known about how effectively information is transferred from emergency medical services (EMS) personnel to clinicians in the emergency department receiving the patient. Information about prehospital events and findings can help ensure expedient and appropriate care. The trauma literature describes 16 prehospital data points that affect outcome and therefore should be included in the EMS report when applicable. Objective. To determine the degree to which information presented in the EMS trauma patient handover is degraded. Methods. At a level I trauma center, patients meeting criteria for the highest level of trauma team activation (“full trauma”) were enrolled. As part of routine performance improvement, the physician leadership of the trauma program watched all available video-recorded full trauma responses, checking off whether the data points appropriate to the case were verbally “transmitted” by the EMS provider. Two EMS physicians then each independently reviewed the trauma teams chart notes for 50% of the sample (and a randomly selected 15% of the charts to assess agreement) and checked off whether the same elements were documented (“received”) by the trauma team. The focus was on data elements that were “transmitted” but not “received.” Results. In 96 patient handovers, a total of 473 elements were transmitted, of which 329 were received (69.6%). On the average chart, 72.9% of the transmitted items were received (95% confidence interval 69.0%–76.8%). The most commonly transmitted data elements were mechanism of injury (94 times), anatomic location of injury (81), and age (67). Prehospital hypotension was received in only 10 of the 28 times it was transmitted; prehospital Glasgow Coma Scale [GCS] score 10 of 22 times; and pulse rate 13 of 49 times. Conclusions. Even in the controlled setting of a single-patient handover with direct verbal contact between EMS providers and in-hospital clinicians, only 72.9% of the key prehospital data points that were transmitted by the EMS personnel were documented by the receiving hospital staff. Elements such as prehospital hypotension, GCS score, and other prehospital vital signs were often not recorded. Methods of “transmitting” and “receiving” data in trauma as well as all other patients need further scrutiny.

Ambulance diversion and emergency department offload delay: resource document for the National Association of EMS Physicians position statement.

Abstract The emergency medical services (EMS) system is a component of a larger health care safety net and a key component of an integrated emergency health care system. EMS systems, and their patients, are significantly impacted by emergency department (ED) crowding. While protocols designed to limit ambulance diversion may be effective at limiting time on divert status, without correcting overall hospital throughput these protocols may have a negative effect on ED crowding and the EMS system. Ambulance offload delay, the time it takes to transfer a patient to an ED stretcher and for the ED staff to assume the responsibility of the care of the patient, may have more impact on ambulance turnaround time than ambulance diversion. EMS administrators and medical directors should work with hospital administrators, ED staff, and ED administrators to improve the overall efficiency of the system, focusing on the time it takes to get ambulances back into service, and therefore must monitor and address both ambulance diversions and ambulance offload delay. This paper is the resource document for the National Association of EMS Physicians position statement on ambulance diversion and ED offload time. Key words: ambulance; EMS; diversion; bypass; offload; delay

The Epidemiology of Prehospital Emergency Responses for Older Adults in a Provincial EMS System

OBJECTIVES Societal aging is expected to impact the use of emergency medical services (EMS). Older adults are known as high users of EMS. Our primary objective was to quantify the rate of EMS use by older adults in a Canadian provincial EMS system. Our secondary objective was to compare those transported to those not transported. METHODS We analysed data from a provincial EMS database for emergency responses between January 1, 2010 and December 31, 2010 and included all older adults (≥65 years) requesting EMS for an emergency call. We described EMS use in relation to age, sex, and resources. RESULTS There were 30,653 emergency responses for older adults in 2010, representing close to 50% of the emergency call volume and an overall response rate of 202.8 responses per 1,000 population 65 years and older. The mean age was 79.9±8.5 years for those 57.3% who were female. The median paramedic-determined Canadian Triage and Acuity Scale (CTAS) score was 3 and the mean on-scene time was 24.2 minutes. Non-transported calls (12.3%) for the elderly involved predominantly (54.9%) female patients of similar mean age (78.3 years) but lower acuity (CTAS 5) and longer average on-scene times (32.6 minutes). CONCLUSIONS We confirmed the increasingly high rate of EMS use with age to be consistent with other industrialized populations. The low-priority and non-transport calls by older adults consumed considerable resources in this provincial system and might be the areas most malleable to meet the challenges facing EMS systems.

Insights into the Implementation and Operation of a Novel Paramedic Long-term Care Program

Abstract Objective. An extended-care paramedic (ECP) program was implemented to provide emergency assessment and care on site to long-term care (LTC) residents suffering acute illness or injury. A single paramedic works collaboratively with physicians, LTC staff, patient, and family to develop care plans to address acute situations, often avoiding the need to transport the resident to hospital. We sought to identify insights gained and lessons learned during implementation and operation of this novel program. Methods. The perceptions and experiences of various stakeholders were explored in focus groups, using a semi-structured interview guide. Two investigators independently conducted thematic analysis and identified emerging themes and related codes. Congruence and differences were discussed to achieve consensus. Results. Twenty-one participants took part in four homogeneous focus groups: paramedics and dispatchers, ECPs, ECP oversight physicians, and decision-makers. The key themes identified were (1) program implementation, (2) ECP process of care, (3) communications, and (4) end-of-life care. Conclusion. The ECP program has positive implications for the relationship between EMS and LTC, requires additional paramedic training, and can positively affect LTC patient experiences during acute medical events. ECPs have a novel role to play in end-of-life care and find this new role rewarding.

Impact of a Novel Collaborative Long-Term Care –EMS Model: A Before-and-After Cohort Analysis of an Extended Care Paramedic Program

Abstract To compare system and clinical outcomes before and after an extended care paramedic (ECP) program was implemented to better address the emergency needs of long-term care (LTC) residents. Data were collected from emergency medical services (EMS), hospital, and ten LTC facility charts for two five-month time periods, before and after ECP implementation. Outcomes include: number of EMS patients transported to emergency department (ED) and several clinical, safety, and system secondary outcomes. Statistics included descriptive, chi-squared, t-tests, and ANOVA; α = <0.05. 413 cases were included (before: n = 136, 33%; after n = 277, 67%). Median patient age was 85 years (IQR 77–91 years) and 292/413 (70.7%) were female. The number of transports to ED before implementation was 129/136 (94.9%), with 147/224 (65.6%) after, p < 0.001. In the after period, fewer patients seen by ECP were transported: 58/128 (45.3%) vs. 89/96 (92.7%) of those not seen by ECP, p < 0.001. Hospital admissions were similar between phases: 39/120 (32.5%) vs. 56/213 (29.4%), p = NS, but in the after phase, fewer ECP patients were admitted vs. non-ECP: 21/125 (16.8%) vs. 35/88 (39.8%), p < 0.001. Mean EMS call time (dispatch to arrive ED or clear scene) was shorter before than after: 25 minutes vs. 57 minutes, p < 0.001. In the after period, calls with ECP were longer than without ECP: 1 hour, 35 minutes vs. 30 minutes, p < 0.001. The mean patient ED length-of-stay was similar before and after: 7 hours, 29 minutes compared to 8 hours, 11 minutes; p = NS. In the after phase, ED length-of-stay was somewhat shorter with ECPs vs. no ECPs: 7 hours, 5 minutes vs. 9 hours, p = NS. There were zero relapses after no-transport in the before phase and three relapses from 77 calls not transported in the after phase (3/77, 3.9%); two involved ECP (2/70, 2.8%). Reductions were observed in the number of LTC patients transported to the ED when the ECP program was introduced, with fewer patients admitted to the hospital. EMS calls take longer with ECP involved. The addition of ECP to the LTC model of care appears to be beneficial and safe, with few relapse calls identified.

Methodology for the development of a Canadian national EMS research agenda

BackgroundMany health care disciplines use evidence-based decision making to improve patient care and system performance. While the amount and quality of emergency medical services (EMS) research in Canada has increased over the past two decades, there has not been a unified national plan to enable research, ensure efficient use of research resources, guide funding decisions and build capacity in EMS research. Other countries have used research agendas to identify barriers and opportunities in EMS research and define national research priorities. The objective of this project is to develop a national EMS research agenda for Canada that will: 1) explore what barriers to EMS research currently exist, 2) identify current strengths and opportunities that may be of benefit to advancing EMS research, 3) make recommendations to overcome barriers and capitalize on opportunities, and 4) identify national EMS research priorities.Methods/DesignParamedics, educators, EMS managers, medical directors, researchers and other key stakeholders from across Canada will be purposefully recruited to participate in this mixed methods study, which consists of three phases: 1) qualitative interviews with a selection of the study participants, who will be asked about their experience and opinions about the four study objectives, 2) a facilitated roundtable discussion, in which all participants will explore and discuss the study objectives, and 3) an online Delphi consensus survey, in which all participants will be asked to score the importance of each topic discovered during the interviews and roundtable as they relate to the study objectives. Results will be analyzed to determine the level of consensus achieved for each topic.DiscussionA mixed methods approach will be used to address the four study objectives. We anticipate that the keys to success will be: 1) ensuring a representative sample of EMS stakeholders, 2) fostering an open and collaborative roundtable discussion, and 3) adhering to a predefined approach to measure consensus on each topic. Steps have been taken in the methodology to address each of these a priori concerns.

Chest Compression Fraction in Simulated Cardiac Arrest Management by Primary Care Paramedics: King Laryngeal Tube Airway Versus Basic Airway Management

Abstract Objective. The objective of this randomized simulation study was to determine whether use of the King laryngeal tube (KLT) airway resulted in differences in chest compression fraction (CCF) during simulated cardiac arrest managed by primary care paramedics (PCPs), as compared with basic airway management (bag–mask ventilation [BMV]). Methods. The KLT was introduced to all providers in our system at the time of study initiation. All participants received the same training, and were not aware that the primary outcome of the study was CCF. Standard airway management by PCPs prior to this was BMV. Pairs of PCPs were randomized to use KLT or BMV during a scripted 6-minute cardiac arrest scenario. The scenarios were videotaped, and data were abstracted by a single investigator. The CCF was calculated (fraction of time chest compressions were done/total scenario time). The CCF, number of seconds to first ventilation, and number of seconds to first compression were compared using the Mann-Whitney U test. Results. Sixty-seven pairs of PCPs participated: 30 in the KLT arm and 37 in the BMV arm. Demographics were similar in each group: KLT 68.3% males, BMV 55.4% males; KLT mean age 33.52 years (standard deviation [SD]: 11.95), BMV mean age 32.07 years (SD: 8.78); and KLT mean years of experience 9.03 (SD: 9.86), BMV mean years of experience 6.59 (SD: 6.58). The CCF was higher in the KLT group: median 0.82 (interquartile range [IQR] 0.71–0.88) compared with the BMV group: median 0.70 (IQR 0.66–0.73), p < 0.001. Time to first ventilation was longer in the KLT group: median 83.00 sec (IQR 43.75–139.25 sec) than in the BMV group: median 48.00 sec (IQR 37.00–71.00 sec), p = 0.004. Times to first compression were similar: KLT median 13.00 sec (IQR 8.00–17.00 sec), BMV median 14.00 sec (IQR 11.00–18.50 sec), p = 0.331. Conclusion. In this randomized simulation study, KLT use by PCPs during simulated standard cardiac arrest scenarios was found to significantly increase CCF compared with basic airway management with BMV. Key words: emergency medical services; paramedics; airway; extraglottic airway device; cardiac arrest

The impact of intense airway management training on paramedic knowledge and confidence measured before, immediately after and at 6 and 12 months after training

Introduction Airway management is a core component in the practice of advanced life support (ALS) paramedics. Objective To determine if an intense airway management course would improve ALS paramedic knowledge and confidence and if knowledge was retained over time. Methods An identical written survey (measuring demographics and confidence) and multiple-choice examination (measuring knowledge) was administered at the start and end of a 10 h airway course. At 6 and 12 months after the course, paramedics took the knowledge examination. Paired confidence and written knowledge examination scores before and immediately after the course were compared. Differences between knowledge examination scores at all four time points (before, immediately after and at 6 and 12 months) were tested using analysis of variance and Tukeys test. Results 299 ALS paramedics were enrolled in the study. 209 (69%) reported 6 or more years of ALS experience. The mean pre-course confidence score was 2.74/4 and the mean post-course confidence score was 3.39/4; a difference of 0.7 points (95% CI 0.61 to 0.71). Post-course examination scores improved by 4.9 points (95% CI 4.58 to 5.20), from 7.7 to 12.6/20. At 6 months the mean score was 10.3/20, and at 12 months 10.2/20. Post-course scores were significantly better than pre-course scores. Scores at 6 and 12 months did not differ significantly and remained significantly improved from pre-course scores. Conclusion Significant improvement in confidence and knowledge was found after paramedics completed an intense airway management course. Knowledge at 6 and 12 months remained significantly better compared with pre-course.

Developing a Canadian emergency medical services research agenda: a baseline study of stakeholder opinions

PURPOSE This study forms the first phase in the development of the Canadian National EMS Research Agenda. The purpose was to understand the current state of emergency medical services (EMS) research through the barriers and opportunities perceived by key stakeholders in the Canadian system and to identify the recommendations this group had for moving forward. METHODS This qualitative study was conducted in the spring of 2011 using one-on-one semistructured telephone interviews. Purposeful sampling was used to recruit a cross section of EMS research stakeholders, representing a breadth of geographic regions and roles. Data were collected until thematic saturation was reached. A constant comparative approach was used to develop a basic coding framework and identify emerging themes. RESULTS Twenty stakeholders were invited to participate, and saturation was reached after 13 interviews. Thematic saturation was used to ensure that the findings were grounded in the data. Four major themes were identified: 1) the need for additional research education within EMS; 2) the importance of creating an infrastructure to support pan-Canadian research collaboration; 3) addressing the complexities of involving EMS providers in research; and 4) considerations for a national research agenda. CONCLUSION This hypothesis-generating study reveals key areas regarding EMS research in Canada and through the guidance it provides is a first step in the development of a comprehensive national research agenda. Our intention is to collate the identified themes with the results of a larger roundtable discussion and Delphi survey and, in doing so, guide development of a Canadian national EMS research agenda.