Gerry Egan

Dispatch-assisted CPR: Where are the hold-ups during calls to emergency dispatchers? A preliminary analysis of caller–dispatcher interactions during out-of-hospital cardiac arrest using a novel call transcription technique

BACKGROUND Survival from out-of-hospital cardiac arrest (OHCA) is dependent on the chain of survival. Early recognition of cardiac arrest and provision of bystander cardiopulmonary resuscitation (CPR) are key determinants of OHCA survival. Emergency medical dispatchers play a key role in cardiac arrest recognition and giving telephone CPR advice. The interaction between caller and dispatcher can influence the time to bystander CPR and quality of resuscitation. We sought to pilot the use of emergency call transcription to audit and evaluate the holdups in performing dispatch-assisted CPR. METHODS A retrospective case selection of 50 consecutive suspected OHCA was performed. Audio recordings of calls were downloaded from the emergency medical dispatch centre computer database. All calls were transcribed using proprietary software and voice dialogue was compared with the corresponding stage on the Medical Priority Dispatch System (MPDS). Time to progress through each stage and number of caller-dispatcher interactions were calculated. RESULTS Of the 50 downloaded calls, 47 were confirmed cases of OHCA. Call transcription was successfully completed for all OHCA calls. Bystander CPR was performed in 39 (83%) of these. In the remaining cases, the caller decided the patient was beyond help (n = 7) or the caller said that they were physically unable to perform CPR (n = 1). MPDS stages varied substantially in time to completion. Stage 9 (determining if the patient is breathing through airway instructions) took the longest time to complete (median = 59 s, IQR 22-82 s). Stage 11 (giving CPR instructions) also took a relatively longer time to complete compared to the other stages (median = 46 s, IQR 37-75 s). Stage 5 (establishing the patients age) took the shortest time to complete (median = 5.5s, IQR 3-9s). CONCLUSION Transcription of OHCA emergency calls and caller-dispatcher interaction compared to MPDS stage is feasible. Confirming whether a patient is breathing and completing CPR instructions required the longest time and most interactions between caller and dispatcher. Use of call transcription has the potential to identify key factors in caller-dispatcher interaction that could improve time to CPR and further research is warranted in this area.

Rural and urban distribution of trauma incidents in Scotland

Trauma systems reduce mortality and improve functional outcomes from injury. Regional trauma networks have been established in several European regions to address longstanding deficiencies in trauma care. A perception of the geography and population distribution as challenging has delayed the introduction of a trauma system in Scotland. The characteristics of trauma incidents attended by the Scottish Ambulance Service were analysed, to gain a better understanding of the geospatial characteristics of trauma in Scotland.

Resuscitation quality assurance for out-of-hospital cardiac arrest – Setting-up an ambulance defibrillator telemetry network

BACKGROUND Out-of-hospital cardiac arrest (OHCA) is a leading cause of pre-hospital mortality. Chest compressions performed during cardiopulmonary resuscitation aim to provide adequate perfusion to the vital organs during cardiac arrest. Poor resuscitation technique and the quality of pre-hospital CPR influences outcome from OHCA. Transthoracic impedance (TTI) measurement is a useful tool in the assessment of the quality of pre-hospital resuscitation by ambulance crews but TTI telemetry has not yet been performed in the United Kingdom. We describe a pilot study to implement a data network to collect defibrillator TTI data via telemetry from ambulances. METHODS Prospective, observational pilot study over a 5-month period. Modems were fitted to 40 defibrillators on ambulances based in Edinburgh. TTI data was sent to a receiving computer after resuscitation attempts for OHCA. RESULTS 58 TTI traces were transmitted during the pilot period. Compliance with the telemetry system was high. The mean ratio of chest compressions was 73% (95% CI 69-77%), the mean chest compression rate was 128 (95% CI 122-134). The mean time interval from chest compression interruption to shock delivery was 27 s (95% CI 22-32 s). CONCLUSION Trans-thoracic impedance analysis is an effective means of recording important measures of resuscitation quality including the hands-on-the-chest time, compression rate and defibrillation interval time. TTI data transmission via telemetry is straightforward, efficient and allows resuscitation data to be captured and analysed from a large geographical area. Further research is warranted on the impact of post-resuscitation reporting on the quality of resuscitation delivered by ambulance crews.

Optimizing trauma system design: The GEOS (Geospatial Evaluation of Systems of Trauma Care) approach

BACKGROUND Trauma systems have been shown to reduce death and disability from injury but must be appropriately configured. A systematic approach to trauma system design can help maximize geospatial effectiveness and reassure stakeholders that the best configuration has been chosen. METHODS This article describes the GEOS [Geospatial Evaluation of Systems of Trauma Care] methodology, a mathematical modeling of a population-based data set, which aims to derive geospatially optimized trauma system configurations for a geographically defined setting. GEOS considers a region’s spatial injury profile and the available resources and uses a combination of travel time analysis and multiobjective optimization. The methodology is described in general and with regard to its application to our case study of Scotland. RESULTS The primary outcome will be trauma system configuration. CONCLUSION GEOS will contribute to the design of a trauma system for Scotland. The methodology is flexible and inherently transferable to other settings and could also be used to provide assurance that the configuration of existing trauma systems is fit for purpose.

Destination healthcare facility of patients with suspected traumatic brain injury in Scotland: Analysis of pre-hospital data

BACKGROUND Traumatic brain injury is common. Guidelines from the Brain Trauma Foundation and the Scottish Intercollegiate Guidelines Network recommend that patients with suspected severe traumatic brain injury should be treated in centres with neurosurgical expertise. Scotland does not have a framework for the delivery of trauma care. The aim of this study was to examine the demographic characteristics of incidents involving patients who have suffered a suspected traumatic brain injury, and to evaluate the level of the destination healthcare facility which patients are currently taken to. METHODS Retrospective analysis of prospectively collected Scottish Ambulance Service data on incidents involving traumatic injury, between Nov 2008 and Oct 2010. Two groups of casualties were analysed: those who had a Glasgow coma scale of less than 14 (GCS<14), and those who had a Glasgow coma scale of less than 9 (GCS<9). RESULTS 126,934 incidents were identified and analysed. 3890 (3.1%) patients had a GCS of less than 14, and 657 (0.5% of total) had a GCS of less than 9. Almost one-third of incidents involving patients with either a GCS<14 or GCS<9 occurred in the greater Glasgow health board area. The Lothian health board region had the second-highest number of patients with either a GCS<14 or GCS<9. Only 13.8% of patients with a GCS<14, and 16.7% of those with a GCS<9, were taken to a hospital with a neurosurgical service. CONCLUSIONS Many patients who may harbour a traumatic brain injury are taken to a facility which may not be equipped or staffed to deal with such injuries. This mismatch needs to be addressed. However, the care of patients with head injuries is only one aspect of trauma care. The UK has long lagged behind North America in terms of the quality of trauma care provided, although the provision of trauma care in England is currently undergoing major changes. Scotland should consider the development of a similar service delivery framework.

Issues around conducting prehospital research on out-of-hospital cardiac arrest: lessons from the TOPCAT study.

Outcome from OHCA is primarily determined by prehospital events and meaningful clinical OHCA research must include data recorded in this setting. There is little evidence on which to base the practice of prehospital resuscitation and research in this area presents huge challenges but is required if survival from OHCA is to improve. This short report aims to provide a practical guide to performing prehospital research on OHCA, based on lessons learned from the Temperature Post Cardiac Arrest (TOPCAT) research; an observational study into OHCA.

Demographic and geographical characteristics of pediatric trauma in Scotland.

BACKGROUND Trauma systems reduce mortality and improve functional outcomes. The aim of this study was to analyse the demographic and geospatial characteristics of pediatric trauma patients in Scotland, and determine the level of destination healthcare facility which injured children are taken to, to determine the need for, and general feasibility, of developing a pediatric trauma system for Scotland. METHODS Retrospective analysis of incidents involving children aged 1-14 attended to by the Scottish Ambulance Service between 1 November 2008 and 31 October 2010. A subgroup with physiological derangement was defined. Incident location postcode was used to determine incident location by health board region, rurality and social deprivation. Destination healthcare facility was classified into one of six categories. RESULTS Of 10,759 incidents, 72.3% occurred in urban areas and 5.8% in remote areas. Incident location was associated with socioeconomic deprivation. Of the patients, 11.6% were taken to a pediatric hospital with pediatric intensive care facilities, 21.8% to a pediatric hospital without pediatric intensive care service, and 50.2% to an adult large general hospital without pediatric surgical service. CONCLUSIONS The majority of incidents involving children with injuries occurred in urban areas. Half were taken to a hospital without pediatric surgical service. There was no difference between children with normal and deranged physiology.

Trauma care in Scotland: effect of rurality on ambulance travel times and level of destination healthcare facility

AimThe aim of this study was to determine the effect of rurality on the level of destination healthcare facility and ambulance response times for trauma patients in Scotland.MethodsWe used a retrospective analysis of pre-hospital data routinely collected by the Scottish Ambulance Service from 2009–2010. Incident locations were categorised by rurality, using the Scottish urban/rural classification. The level of destination healthcare facility was coded as either a teaching hospital, large general hospital, general hospital, or other type of facility.ResultsA total of 64,377 incidents met the inclusion criteria. The majority of incidents occurred in urban areas, which mostly resulted in admission to teaching hospitals. Incidents from other areas resulted in admission to a lower-level facility. The majority of incidents originating in very remote small towns and very remote rural areas were treated in a general hospital. Median call-out times and travel times increased with the degree of rurality, although with some exceptions.ConclusionsTrauma is relatively rare in rural areas, but patients injured in remote locations are doubly disadvantaged by prolonged pre-hospital times and admission to a hospital that may not be adequately equipped to deal with their injuries. These problems may be overcome by the regionalisation of trauma care, and enhanced retrieval capability.

Capability of Scottish emergency departments to provide physician-based prehospital critical care teams: a national survey.

Objective The aim of this study was to establish the current capabilities of emergency departments in Scotland to provide a prehospital medical team at the request of the ambulance service. Methods A prospective telephone survey of all major emergency departments in Scotland was conducted, requesting information on their ability to provide a prehospital team, the configuration of the team and the equipment, transport, training and governance arrangements for this service. Results All 25 major emergency departments in Scotland responded to the survey (100% response). Eighteen departments (72%) were able to provide a prehospital team, with 15 (60%) able to provide a team 24 h/day. Team composition was variable and only one-third of teams were able to deploy within 15 min. In total, 50% of departments able to respond had received no requests in the preceding 12 months and only two departments had each received more than 50 requests. Less than half of the departments checked prehospital equipment on a weekly or a more frequent basis and only three departments provided ongoing training in prehospital care. Conclusion The majority of emergency departments in Scotland are able to provide a prehospital team on the request of the ambulance service. There is high variability in the composition and seniority of the team, with less ability to provide a team out of hours. With two notable exceptions, the overall activation of these prehospital teams is infrequent, and there are significant improvements required with regard to the clinical governance surrounding the provision of these teams.

03 Back to basics—ECG impedance analysis for CPR quality control and feedback after out-of-hospital cardiac arrest: a pilot study

Background Out-of-hospital cardiac arrest (OHCA) remains a leading cause of mortality and severe neurological disability. Survival from OHCA depends on good quality cardiopulmonary resuscitation from EMS personnel. The ‘time on the chest’ and interruption time for defibrillation have recently been shown to be pivotal to survival. Electrocardiograph impedance analysis software allows retrospective quality control and feedback to EMS crews after a resuscitation attempt. Whilst this technique has been used by several EMS services worldwide, routine use and acceptance has yet to be established. Aims To establish the feasibility of using impedance software for pre-hospital resuscitation quality control and to gain baseline data on pre-hospital resuscitation practice in the Lothians region of Scotland. Methods Prospective, observational pilot study. After a resuscitation attempt the attending EMS crew was asked to consent to the ECG trace from the defibrillator being downloaded onto a research computer. The impedance trace was then analysed using computer software (Codestat – Physio Control) and a report on the resuscitation attempt generated. Results 9 OHCA were included in the pilot. All EMS crews agreed to the download from the defibrillator and all found viewing the trace informative. Downloading the ECG trace was straightforward in all cases. The mean time of the resuscitation attempt spent performing chest compressions was 50%. The mean chest compression rate was 141 min. The mean time from cessation of chest compressions to delivery of defibrillatory shock was 46 s. Conclusion ECG impedance analysis is a straightforward, accurate, accepted method of assessing quality of pre-hospital resuscitation by EMS personnel. Baseline data from our region suggests that the quality of advanced life support could be improved by focussing on basic elements of resuscitation. Using software-generated resuscitation reports could be useful for EMS personnel feedback and monitoring effectiveness of training programmes. Further research is warranted on the widespread use of this technique.