Sarah Christopher

Are they really refusing to travel? A qualitative study of prehospital records

BackgroundRefusal by the patient to travel after calling an emergency ambulance may lead to a preventable waste of scarce resources if it can be shown that an alternative more appropriate response could be employed. A greater understanding is required of the reasons behind refusal to travel (RTT) in order to find appropriate solutions to address this issue. We sought to investigate the reasons why patients refuse to travel following emergency call-out in a rural county.MethodsWritten records made by ambulance crews for patients (n = 397) who were not transported to hospital following an emergency call-out during October 2004 were retrospectively analysed.ResultsTwelve main themes emerged for RTT which included non injury or minor injury, falls and recovery after treatment on scene; other themes included alternative supervision, follow-up and treatment arrangements or patients arranging their own transport. Importantly, only 8% of the sample was recorded by ambulance crews as truly refusing to travel against advice.ConclusionA system that facilitates standardised recording of RTT information including social reasons for non-transportation needs to be designed. Refused to travel disclaimers need to reflect instances when crew and patient are satisfied that not going to hospital is the right outcome. These recommendations should be considered within the context of the plans for widening the role of ambulance services.

From the pre-hospital literature: Time to manoeuvre for a change?

Many studies have shown that interruption of chest compressions in out-of-hospital cardiac arrest is an important factor that limits survival. This observational prospective study of patients with out-of-hospital cardiac arrest in Norway, Sweden and the UK set out to quantify in detail the effects of interrupting chest compressions. ECG segments showing ventricular fibrillation and pulseless ventricular tachycardia arrest were extracted and analysed by computing the logarithm of the mean slope which can be viewed as the coarseness of the ECG. Return of spontaneous circulation (ROSC) was identified by either changes in transthoracic impedance coincident with QRS complex or by a clinically detected pulse. Measurements of depth of compressions were used to ascertain the presence or absence of chest compressions. The study found that during pre-shock pauses in chest compressions there is a decrease in the probability of ROSC of approximately 23% from 3u2005s to 27u2005s into such a pause. Prehospital care providers should bear this in mind during resuscitation and ensure interruptions in chest compressions are kept to a minimum duration. n nSarah Christopher, College of Paramedics Research and Audit Committee n n▶u2005Gundersen K, Kvaloy J, Kramer-Johansen J, et al. Development of the probability of return of spontaneous circulation in intervals without chest compressions during out-of-hospital cardiac arrest: an observational study. BMC Med 2009;7:6.This randomised crossover trial set out to compare the Airtraq, Truview and Mackintosh laryngoscopes when used by advanced paramedics in Ireland. Each of the 21 paramedics who participated in the study performed endotracheal intubation with each device in a Simman manikin in two scenarios—that of a ‘normal’ airway with the manikin in a supine position and following the application of a hard cervical collar. The severity of dental trauma and the number of optimisation manoeuvres were also recorded. No significant difference was found in the duration of intubation attempts between the Macintosh and Airtraq laryngoscopes in either scenario. The duration when using the Truview, however, was significantly longer in both scenarios. The Airtraq was found to reduce both the number of optimisation manoeuvres and the potential for dental trauma when compared with both the Macintosh and Truview laryngoscopes. There has been much debate and controversy regarding the practice of prehospital intubation by paramedics. Devices that may result in improvements in intubation technique over those currently used are therefore worthy of further consideration. n n▶u2005Nasim S, Maharaj C, Butt I, et al. Comparison of the Airtraq and Truview laryngoscopes to the Macintosh laryngoscope for use by advanced paramedics in easy and simulated difficult intubation in manikins. BMC Emerg Med 2009;9:2.To see or not to see . This study set out to assess whether witnessing an unsuccessful resuscitation attempt of a family member in cardiac arrest caused relatives to display symptoms of post-traumatic stress disorder (PTSD). A total of 34 witnesses and 20 non-witnesses were compared and were similar both demographically and in their relationship to their relative (the patient). Data were analysed using the PTSD symptom scale-interview (PSS-I). It was found that the total PTSD symptom scores of witnesses were almost twice as high as those of non-witnesses (14.47 vs 7.60 respectively, mean difference 6.87). The results of linear regression analysis showed that witnessing resuscitation of a loved one resulted in a mean increase of almost 12 points in the PSS-I after variables such as the suddenness and location of cardiac arrest were taken into account. This study is of value to prehospital care providers in deciding whether to allow relatives to remain present during the resuscitation of their loved one. Further research is needed, however, as other studies have indicated that relatives found witnessing the resuscitation of a loved one to be of help as they could later assure themselves that everything possible had been done to save them.

From the pre-hospital literature: Keep on pumping

Many studies have shown that interruption of chest compressions in out-of-hospital cardiac arrest is an important factor that limits survival. This observational prospective study of patients with out-of-hospital cardiac arrest in Norway, Sweden and the UK set out to quantify in detail the effects of interrupting chest compressions. ECG segments showing ventricular fibrillation and pulseless ventricular tachycardia arrest were extracted and analysed by computing the logarithm of the mean slope which can be viewed as the coarseness of the ECG. Return of spontaneous circulation (ROSC) was identified by either changes in transthoracic impedance coincident with QRS complex or by a clinically detected pulse. Measurements of depth of compressions were used to ascertain the presence or absence of chest compressions. The study found that during pre-shock pauses in chest compressions there is a decrease in the probability of ROSC of approximately 23% from 3u2005s to 27u2005s into such a pause. Prehospital care providers should bear this in mind during resuscitation and ensure interruptions in chest compressions are kept to a minimum duration. n nSarah Christopher, College of Paramedics Research and Audit Committee n n▶u2005Gundersen K, Kvaloy J, Kramer-Johansen J, et al. Development of the probability of return of spontaneous circulation in intervals without chest compressions during out-of-hospital cardiac arrest: an observational study. BMC Med 2009;7:6.This randomised crossover trial set out to compare the Airtraq, Truview and Mackintosh laryngoscopes when used by advanced paramedics in Ireland. Each of the 21 paramedics who participated in the study performed endotracheal intubation with each device in a Simman manikin in two scenarios—that of a ‘normal’ airway with the manikin in a supine position and following the application of a hard cervical collar. The severity of dental trauma and the number of optimisation manoeuvres were also recorded. No significant difference was found in the duration of intubation attempts between the Macintosh and Airtraq laryngoscopes in either scenario. The duration when using the Truview, however, was significantly longer in both scenarios. The Airtraq was found to reduce both the number of optimisation manoeuvres and the potential for dental trauma when compared with both the Macintosh and Truview laryngoscopes. There has been much debate and controversy regarding the practice of prehospital intubation by paramedics. Devices that may result in improvements in intubation technique over those currently used are therefore worthy of further consideration. n n▶u2005Nasim S, Maharaj C, Butt I, et al. Comparison of the Airtraq and Truview laryngoscopes to the Macintosh laryngoscope for use by advanced paramedics in easy and simulated difficult intubation in manikins. BMC Emerg Med 2009;9:2.To see or not to see . This study set out to assess whether witnessing an unsuccessful resuscitation attempt of a family member in cardiac arrest caused relatives to display symptoms of post-traumatic stress disorder (PTSD). A total of 34 witnesses and 20 non-witnesses were compared and were similar both demographically and in their relationship to their relative (the patient). Data were analysed using the PTSD symptom scale-interview (PSS-I). It was found that the total PTSD symptom scores of witnesses were almost twice as high as those of non-witnesses (14.47 vs 7.60 respectively, mean difference 6.87). The results of linear regression analysis showed that witnessing resuscitation of a loved one resulted in a mean increase of almost 12 points in the PSS-I after variables such as the suddenness and location of cardiac arrest were taken into account. This study is of value to prehospital care providers in deciding whether to allow relatives to remain present during the resuscitation of their loved one. Further research is needed, however, as other studies have indicated that relatives found witnessing the resuscitation of a loved one to be of help as they could later assure themselves that everything possible had been done to save them.

From the pre-hospital literature: Not yet time to change our ways

Taking the lead with the ECG The 12-lead ECG is a fundamental component of patient assessment for a range of presentations and is almost universally available across a variety of healthcare settings. In prehospital care, 12-lead ECG equipment has become standard in ambulance services and is recommended in international guidelines for cardiac care. Despite this, there is evidence that the prehospital ECG (PHECG) is underutilised. In the USA, for example, less than 10% of patients with acute ST segment elevation myocardial infarction have a PHECG, according to the National Registry of Myocardial Infarction, a rate that has not substantially improved in the past decade. Experience from the UK, although not yet published, suggests much higher use, with approximately threequarters of patients with ST segment elevation myocardial infarction who were under emergency medical services care having a PHECG recorded. The American Heart Association have published a scientific statement setting out the available evidence, alongside practice recommendations and possible questions for future research. This covers the perceived benefits of PHECG, skill and competence in acquisition, interpretation and communication of ECG findings by emergency medical services staff, organisational and system issues and possible barriers to implementation. A key practice recommendation is that the PHECG should take priority over other components of care such as oxygen and opiate administration, facilitating early decision-making about possible reperfusion options including alerting a percutaneous coronary intervention centre.There has long been debate over the efficacy of intravenous drugs in cardiac arrest. This observational, prospective study set out to investigate whether the introduction of a single dose of 1 mg intravenous epinephrine improved outcomes from prehospital cardiac arrest in an emergency medical service that did not previously use this drug. Outcomes examined included survival to discharge, survival to hospital admission, return of spontaneous circulation and functional status on discharge. Although the authors state that they were unable to establish a survival benefit with the introduction of intravenous epinephrine to this emergency medical service, many unmeasured confounders were not accounted for. The study examined the effect of only a single dose of epinephrine until after arrival at hospital and no other drugs such as amiodarone or lignocaine were given. It was admitted that there was a relatively low success rate of intravenous drug delivery and variations in post-resuscitation care were not accounted for. This study highlights the importance of designing prehospital studies that are methodologically robust, if questions about the efficacy of interventions such as medical devices or drugs are to be answered definitively. Adequately powered randomised controlled trials may be difficult to conduct in this setting but are not impossible and remain the gold standard. n nEng Hock Ong M, Hoe Tan E, Suan Peng Ng S, . Survival outcomes with the introduction of intravenous epinephrine in the management of out-of-hospital cardiac arrest. Ann Emerg Med 2007;50:635–42.

From the pre-hospital literature: Arrive in 9 min and the patient lives – “failure”; arrive in 8 min and the patient dies – “success”

his qualitative study explores paramedic’s attitudes to the government’s target that category A calls must receive a response within 8 min. The study consisted of a purposive sample of 20 paramedics from nine ambulance stations with a mean length of service of 19 years. Semi-structured interviews informed by a loose topic guide were conducted and analysed using a constant comparative method. Paramedics’ accounts of response time targets and their attendant strategies had three main strands: their inadequacy as a performance indicator, their detrimental effects on patient care; and their detrimental effect on the health, safety and well being of paramedics. It was felt that response time targets dominated ambulance service culture and practice at the expense of other quality indicators such as quality of care, delay in transporting patients to hospital, the skill level of first responders, and the vulnerability of the figures to “fiddling”. Paramedics argued that they have seen no evidence that response time targets improve patient care, a claim which appears to be supported by the literature discussed in this study. This study is particularly relevant in today’s climate of “call connect” (Department of Health, 2007) and highlights that response times are a poor, narrow and overly simplistic quality indicator. n nS Christopher, British Paramedic Association Research and Audit Committee nPrice L. Treating the clock and not the patient: ambulance response times and risk. Qaul Saf Health Care 2006;15:127–30.Whose handover is it anyway? Jenkin et al conducted a small scale survey with 80 staff (42 paramedics, 17 doctors and 21 nurses) involved in patient handover in the emergency department (ED). From the questionnaire responses, the researchers identify perceived strengths and limitations of handover as well as some differences among the professional groups as to what constitutes effective patient handover. Three key findings emerged: ED staff need to acknowledge that active listening skills are essential to avoid unnecessary repetition of information and subsequent frustration for ambulance personnel; ambulance staff may need to repeat their handover (most likely for patients in the resuscitation room) as there may be valid reasons for repetition other than ED staff not listening; the handover might happen in two stages with the first stage focusing on immediate, primary information, and then additional information being given later after commencement of initial treatment. Apart from recommending additional education for staff, and development of national guidelines for effective handover, the researchers have constructed a framework for patient handover in the ED, which, although referring to electronic documentation processes (not yet standardised throughout the whole NHS), may provide a useful focus when examining the interprofessional nature of this complex and essential component of patient care.

From the pre-hospital literature: Diagnosing death on the line

Prehospital CPAP: should we pause to catch our breath? Continuous positive airway pressure (CPAP) improves outcome in acute cardiogenic pulmonary oedema (ACPO) and is increasingly available in emergency departments. In theory, reducing delay to starting CPAP could benefit patients by helping to re-establish haemodynamic stability, but it is not known whether equipping ambulances and training staff in this technique is safe and both clinically and cost effective. Plaisance and colleagues from Paris conducted a randomised trial of 124 patients in the two-tier emergency medical system involving fire rescue personnel and anaesthetists or emergency physicians, together with an anaesthetic nurse, driver and medical student. Patients with ACPO who remained hypoxic despite high-flow oxygen were randomised to early or late CPAP, with the early group receiving ‘‘standard’’ medical treatment (intravenous diuretic, nitrate and nicardipine) before CPAP was applied. Inotropic support was added at the discretion of the attending doctor. While the authors conclude that prehospital CPAP provided within 15 min of management is superior to ‘‘standard’’ medical therapy, there are several reasons why the study findings are unlikely to be directly generalisable to UK practice: doctors are rare in the UK prehospital setting, as are the additional personnel reported here, and the range of medicines exceed those provided by paramedics. A randomised trial assessing the safety and effectiveness of CPAP in the UK prehospital setting is planned, and not before time.

From the pre-hospital literature: needle-free delivery of 0.5mg lidocaine before venepuncture considerably reduces pain in paediatric patients

Needle insertion and intravenous cannulation have been found to be a painful and frightening experience for children. This doubleblind, randomised, placebo-controlled study compared the delivery of 0.5 mg lidocaine, 0.25 mg lidocaine and placebo in 144 paediatric patients undergoing venepuncture through a single-use, needle-free drug delivery system (ALGRX 3268, AlgoRx Pharmaceuticals, Secaucus, New Jersey, USA). This system administers powdered drug into the epidermis for inducing local anaesthesia in 2–3 min. Pain scores were measured using the Faces Pain Scale Revised (FPS-R) and Visual Analogue Scale (VAS). A significant reduction was observed in mean VAS pain scores of – 0.428 in the 3–7-year-old group of patients treated with 0.5 mg lidocaine compared with placebo (95% confidence interval (CI) – 0.834 to –0.022). The reduction in pain for patients treated with 0.25 mg lidocaine was not significant. It was concluded the needlefree drug delivery system configured to deliver 0.5 mg lidocaine reduces the pain of venepuncture at the antecubital fossa rapidly, safely and effectively. Although this device might be of value in the prehospital environment, the reduction in the VAS pain score was small and it is unclear whether this represents a change of significant magnitude for patients to perceive an actual benefit. Further, the validity of the VAS in young children is uncertain. Further research is required to prove its clinical benefit. Sarah Christopher, British Paramedic Association Research and Audit Committee .......................................................................