Veronica Lindström

Barriers and opportunities in assessing calls to emergency medical communication centre - a qualitative study

IntroductionPrevious studies have described the difficulties and the complexity of assessing an emergency call, and assessment protocols intended to support the emergency medical dispatcher’s (EMD) assessment have been developed and evaluated in recent years. At present, the EMD identifies about 50-70 % of patients suffering from cardiac arrest, acute myocardial infarction or stroke. The previous research has primarily been focused on specific conditions, and it is still unclear whether there are any overall factors that may influence the assessment of the call to the emergency medical communication centre (EMCC).AimThe aim of the study was to identify overall factors influencing the registered nurses’ (RNs) assessment of calls to the EMCC.MethodA qualitative study design was used; a purposeful selection of calls to the EMCC was analysed by content analysis.ResultsOne hundred calls to the EMCC were analysed. Barriers and opportunities related to the RN or the caller were identified as the main factors influencing the RN’s assessment of calls to the EMCC. The opportunities appeared in the callers’ symptom description and the communication strategies used by the RN. The barriers appeared in callers’ descriptions of unclear symptoms, paradoxes and the RN’s lack of communication strategies during the call.ConclusionBarriers in assessing the call to the EMCC were associated with contradictory information, the absence of a primary problem, or the structure of the call. Opportunities were associated with a clear symptom description that was also repeated, and the RN’s use of different communication strategies such as closed loop communication.

Ambulance personnel's experience of pain management for patients with a suspected hip fracture: A qualitative study

Pain management is described to be insufficient for patients suffering from a hip fracture, and the management for this vulnerable group of patients may be challenging due to their medical history (multiple comorbidities) and polypharmacy. Previous research has mainly focused on fast tracks aiming to reduce time to surgery. But the research on how pain management is handled for these patients in the prehospital context has been sparse. Therefore, the purpose of this study was to describe the ambulance personnels experience of managing the pain of patients with a suspected hip fracture. A descriptive and qualitative design with Critical Incident Technique was used for collecting data. Moreover, a qualitative content analysis was used for analysing the collected data. Twenty-two participants communicated their experiences and 51 incidents were analysed. The main finding in the study was that the ambulance personnel, by using their clinical knowledge and by empowering the patients to participate in their own care, managed to individualize the pain relief for patients with a suspected hip fracture through a variety of interventions.

Mandatory documentation of pain in the emergency department increases analgesic administration but does not improve patients’ satisfaction of pain management

Abstract Background Pain is one of the most common symptoms treated in emergency department (ED). Pain may cause suffering and disability for the patient. Inadequate pain management may be associated with increased risk of complications such as sleep disturbance, delirium and depression. Previous studies conclude that pain management in ED is insufficient and inadequate. Yet, little is known about patients’ own experience regarding pain management in ED. Objective The aim of this study was to explore the satisfaction of pain management in patients having acute musculoskeletal injuries before and after implementation of mandatory documentation regarding pain assessment in the ED. Method An observational pre-post intervention study design was used. The study was conducted on patients having acute musculoskeletal injuries such as soft tissue injury, back pain or wrist/arm/leg/foot fractures in a 24-h adult (>15 years) ED at a public urban teaching hospital in Stockholm, Sweden. Data was collected by an interview based on a questionnaire. Results A total of 160 patients answered the questionnaire. In the pre- (n = 80) and post-intervention (n = 80) groups, 91/95% experienced pain in the ED. A significant difference (p < 0.003) was found during the post-intervention period, with more patients receiving analgesics compared to the pre-intervention group. A significant decline (p < 0.03) in patients’ own reported pain intensity at discharge was found between the groups. Patients’ reported satisfaction on pain management in the ED increased in the post-intervention group, but the difference was not statistically significantly. Conclusion Patients’ satisfaction with pain management increased, but not statistically significantly. However, both percentages of patients receiving analgesic drugs increased and pain intensity decrease at discharge were statistically significant after the intervention that made nurses obliged to register pain. Implication According to the findings of this study, mandatory pain documentation facilitates pain management in the ED, but there is still room for improvement. Additional actions are needed to improve patients’ satisfaction on pain management in the ED. Mandatory pain documentation in combination with person-centred care could be a way of improving patients’ satisfaction on pain management. Effective pain management is an important quality measure, and should be focused on in acute care in the ED. By routinely asking patients to report the pain intensity at discharge, the ED personnel can have direct feedback about the factual pain management. RNs may also be encouraged to use intravenous analgesics in higher extent when the patients have very severe pain.

Prehospital management of traumatic brain injury patients--a gender perspective.

BACKGROUND Studies show that there are differences between men and women when it comes to several aspects of health care. But the research on equal care in a prehospital setting for patients with severe traumatic brain injury (TBI) has been sparsely investigated. The aim of this study is to describe prehospital care from a gender perspective. METHOD This is a retrospective study of (n = 651) patients (>15 years) with severe TBI requiring intensive care at a University Hospital in Sweden during the years 2000-2010. Outcome was measured by survival and Glasgow Outcome Scale (GOS) scores at discharge. RESULT Our results show differences, though not significant, in the initial assessments and performed interventions between male and female TBI patients. Female patients received more assessments and performed interventions compared to men during prehospital care. Men received more interventions with I.V. fluid but significantly less airway interventions (endotracheal intubation) compared to female patients. More men were transported directly to neurosurgical specialist care as compared to females. No difference in outcome was found. CONCLUSION Our results show differences, however not significant in the assessments and performed interventions between gender, with female patients receiving more assessments and interventions compared to male patients during prehospital care. Future research should focus on gender differences in initial early signs of TBI to improve early identification.

Ambulance personnel adherence to hygiene routines: still protecting ourselves but not the patient.

Objectives It is well known that adherence to hygiene routines leads to increased quality of care and safety for patients and personnel in hospitals. However, there have been few studies describing hygiene in ambulances, despite the fact that many patients receive advanced medical care and treatment from ambulance services before arriving at an emergency department. Therefore, the purpose of this study was to describe the adherence of ambulance personnel to hygiene routines in the ambulances. Methods A participant observation study in the County of Värmland (Sweden) was conducted over 1 day in November 2010. Seven hygiene-related variables were collected during the observations: disinfection of hands before and after patient contact; correct use of gloves, gowns and short-sleeved uniforms; no rings, watches, or bracelets; and short or tied back hair during patient care. Result A total of 68 observed ambulance assignments were analyzed in terms of the adherence of personnel to hygiene routines. In 34% of the observed cases, hand rub was used before patient care and, in 72% of the observed cases, the ambulance personnel used hand rub after patient care. Correct adherence to the rule requiring use of a short-sleeved uniform was found in 28% of the observations. Correct adherence to the rule regarding short or tied back hair was found in 91% of the observations. Conclusion The ambulance personnel were found to have relatively good adherence to some hygiene routines, but not all. The adherence by ambulance personnel to all of the seven observed variables was correct in only 3% of the assignments.

Prehospital care in Sweden

BackgroundPrehospital care, starting from the patient’s first contact with the emergency medical call centre and including medical care provided in the ambulance, is part of the continuum of care defined as emergency medicine (EM). Sweden has a network of emergency medical call centres that are all reached by one telephone number and staffed by nurses, among other personnel.ObjectiveThis review presents a summary of the prehospital care systems currently in place in Sweden, the role of the physician and the future challenges in this evolving and important field.Results and conclusionsSince 2005, the presence of registered nurses in ambulance teams has become a requirement. This proved to be a turning point in the development of advanced care in the prehospital setting in Sweden. Due to overcrowding in emergency departments, the ambulance services work to steer patients from the ambulance directly to definitive care. Although there are limited numbers of physicians in the prehospital setting today, this should change as the specialty of EM grows stronger.ZusammenfassungHintergrundDie präklinische Versorgung, die mit dem Erstkontakt des Patienten mit der Leitstelle des Rettungsdienstes beginnt und auch die medizinische Versorgung im Krankenwagen umfasst, ist Teil des Kontinuums medizinischer Versorgung, das als Notfallmedizin bezeichnet wird. In Schweden besteht ein Netz von Leitstellen, die alle über eine Telefonnummer erreichbar und – neben anderem Personal – mit vielen Krankenpflegern besetzt sind.ZielDie vorliegende Übersichtsarbeit enthält eine zusammenfassende Darstellung des derzeit in Schweden bestehenden präklinischen Versorgungssystems, der Rolle des Arztes und zukünftiger Herausforderungen in diesem sich ständig weiterentwickelnden und bedeutenden Bereich.SchlussfolgerungSeit 2005 ist die Anwesenheit von examinierten Krankenpflegern eine Voraussetzung bei der Besetzung von Krankenwagen, weil sie Medikamente applizieren können. Das hat sich als Wendepunkt in der Entstehung hochentwickelter präklinischer Versorgung in Schweden herausgestellt. Wegen der Überfüllung der Notaufnahmen versucht der Rettungsdienst, die Patienten vom Krankenwagen aus direkt an die maßgebliche medizinische Versorgung weiterzuleiten. Auch wenn es heute nur eine begrenzte Zahl von Ärzten in der präklinischen Versorgung gibt, sollte sich dies mit zunehmender Bedeutung des Fachgebiets der Notfallmedizin ändern.

Prehospital personnel's attitudes to pain management

Abstract Objectives Pain is one of the most common reasons for patients to seek acute medical care. The management of pain is often inadequate both in the prehospital setting and in the emergency department. Our aim was to evaluate the attitudes towards pain management among prehospital personnel in two Scandinavian metropolitan areas. Methods A questionnaire with 36 items was distributed to prehospital personnel working in Helsinki, Finland (n=70) and to prehospital personnel working in Stockholm, Sweden (n=634). Each item was weighted on a five-level Likert scale. Factor loading of the questionnaire was made using maximum likelihood analysis and varimax rotation. Six scales were constructed (Hesitation, Encouragement, Side effects, Evaluation, Perceptions, Pain metre). A Student’s t-test, ANOVA, and Pearson Correlation were used for analysis of significance. Results : The response rate among the Finnish prehospital personnel was 66/70 (94.2%) while among the Swedish personnel it was 127/634 (20.0%). The prehospital personnel from Sweden showed significantly more Hesitation to administer pain relief compared to the Finnish personnel (mean 2.01 SD 0.539 vs. 1.67 SD 0.530, p < 0.001). Those who had received pain education at their workplace showed significantly less Hesitation than those who had not participated in education. There was a significant negative correlation (p < 0.01) between Hesitation and Side effects. There was also astatistically significant(p < 0.01) correlation between Perceptions and Hesitation, indicating that a stoic attitude towards pain was associated with indifference to possible Side effects of pain medication (p < 0.05). Conclusions The results show that there was a significant correlation between the extent of education and the prehospital personnel’s attitudes to pain management. Gender and age among the prehospital personnel also affected the attitudes to pain management. The main discrepancy between the Swedish and Finnish personnel was that the participants from Stockholm showed statistically significantly more hesitation about administering pain medication compared to the participants from Helsinki. Implications The results of the study highlight the need for continuous medical education (CME) for prehospital personnel. CME and discussions among prehospital personnel may help to make a change in the personnel’s attitudes towards pain and pain management in the prehospital context.

End-tidal carbon dioxide monitoring during bag valve ventilation: the use of a new portable device

BackgroundFor healthcare providers in the prehospital setting, bag-valve mask (BVM) ventilation could be as efficacious and safe as endotracheal intubation. To facilitate the evaluation of efficacious ventilation, capnographs have been further developed into small and convenient devices able to provide end- tidal carbon dioxide (ETCO2). The aim of this study was to investigate whether a new portable device (EMMA™) attached to a ventilation mask would provide ETCO2 values accurate enough to confirm proper BVM ventilation.MethodsA prospective observational trial was conducted in a single level-2 centre. Twenty-two patients under general anaesthesia were manually ventilated. ETCO2 was measured every five minutes with the study device and venous PCO2 (PvCO2) was simultaneously measured for comparison. Bland- Altman plots were used to compare ETCO2, and PvCO2.ResultsThe patients were all hemodynamically and respiratory stable during anaesthesia. End-tidal carbon dioxide values were corresponding to venous gases during BVM ventilation under optimal conditions. The bias, the mean of the differences between the two methods (device versus venous blood gases), for time points 1-4 ranges from -1.37 to -1.62.ConclusionThe portable device, EMMA™ is suitable for determining carbon dioxide in expired air (kPa) as compared to simultaneous samples of PvCO2. It could therefore, be a supportive tool to asses the BVM ventilation in the demanding prehospital and emergency setting.

Actions to improve documented pain assessment in adult patients with injury to the upper extremities at the Emergency Department – A cross-sectional study

BACKGROUND Pain is one of the most common symptoms in the Emergency Department (ED) and is the cause of more than half of the visits to the ED. Several attempts to improve pain management have been done by using, for example, standards/guidelines and education. To our knowledge no one has investigated if and how different actions over a longitudinal period affect the frequency of pain documentation in the ED. Therefore the aim of this study was to describe the frequency of documented pain assessments in the ED. METHOD A cross-sectional study during 2006-2012 was conducted. The care of patients with wrist/arm fractures or soft tissue injuries on upper extremities was evaluated. RESULT Despite various actions our result shows that mandatory pain assessment in the patients computerized medical record was the only successful intervention to improve the frequencies of documentation of pain assessment during care in the ED. During the study period, no documentation of reassessment of pain was found despite the fact that all patients received pain medication. CONCLUSION To succeed in increasing the frequency of documented pain assessment, mandatory pain rating is a successful action. However, the re-evaluation of documented pain assessment was nonexisting.

Caring science research in the ambulance services: an integrative systematic review

Background The ambulance services are associated with emergency medicine, traumatology and disaster medicine, which is also reflected in previous research. Caring science research is limited and, since no systematic reviews have yet been produced, its focus is unclear. This makes it difficult for researchers to identify current knowledge gaps and clinicians to implement research findings. Aim This integrative systematic review aims to describe caring science research content and scope in the ambulance services. Data sources Databases included were MEDLINE (PubMed), CINAHL, Web of Science, ProQDiss, LibrisDiss and The Cochrane Library. The electronic search strategy was carried out between March and April 2015. The review was conducted in line with the standards of the PRISMA statement, registration number: PROSPERO 2016:CRD42016034156. Review methods The review process involved problem identification, literature search, data evaluation, data analysis and reporting. Thematic data analysis was undertaken using a five‐stage method. Studies included were evaluated with methodological and/or theoretical rigour on a 3‐level scale, and data relevance was evaluated on a 2‐level scale. Results After the screening process, a total of 78 studies were included. The majority of these were conducted in Sweden (n = 42), fourteen in the United States and eleven in the United Kingdom. The number of study participants varied, from a case study with one participant to a survey with 2420 participants, and 28 (36%) of the studies were directly related to patients. The findings were identified under the themes: Caregiving in unpredictable situations; Independent and shared decision‐making; Public environment and patient safety; Life‐changing situations; and Ethics and values. Conclusion Caring science research with an explicit patient perspective is limited. Areas of particular interest for future research are the impact of unpredictable encounters on openness and sensitivity in the professional–patient relation, with special focus on value conflicts in emergency situations.