CJEM Articles: emergency medical services

Objectives:

To establish consensus on the most important clinical decisions paramedics make during high-acuity emergency calls and to visualize these decisions on a process map of an emergency call. A secondary objective was to measure agreement among paramedics and medical director panel members.

Methods:

A multiround online survey of Canadian paramedics and medical directors. In round 1, participants listed important clinical decisions. In round 2, participants scored each decision in terms of its importance for patient outcome and safety. In rounds 3 and 4, participants could revise their scores. Consensus was defined a priori: 80% or more agreement that a decision was important or extremely important. The included decisions were plotted on a process map of a typical emergency call.

Results:

The panel response rates were as follows: round 1, 96%; round 2, 92%; round 3, 83%; and round 4, 96%. Consensus was reached on 42 decisions, grouped into six categories: airway management (n = 13); assessment (n = 3); cardiac management (n = 7); drug administration (n = 9); scene management (n = 4); and general treatment (n = 6). The on-scene treatment phase of the process map was found to have the highest decision density. Paramedics and medical directors differed in their scoring in 5 of 42 decisions (p < 0.05 or less).

Conclusion:

Consensus was reached among paramedics and medical directors on 42 decisions important for clinical outcome and patient safety. These decisions were visualized on a process map of an emergency call to learn more about where decision density exists during a typical call.

Emergency medical services (EMS) personnel care for patients in challenging and dynamic environments that may contribute to an increased risk for adverse events. However, little is known about the risks to patient safety in the EMS setting. To address this knowledge gap, we conducted a systematic review of the literature, including nonrandomized, noncontrolled studies, conducted qualitative interviews of key informants, and, with the assistance of a pan-Canadian advisory board, hosted a 1-day summit of 52 experts in the field of EMS patient safety. The intent of the summit was to review available research, discuss the issues affecting prehospital patient safety, and discuss interventions that might improve the safety of the EMS industry. The primary objective was to define the strategic goals for improving patient safety in EMS. Participants represented all geographic regions of Canada and included administrators, educators, physicians, researchers, and patient safety experts. Data were collected through electronic voting and qualitative analysis of the discussions. The group reached consensus on nine recommendations to increase awareness, reduce adverse events, and suggest research and educational directions in EMS patient safety: increasing awareness of patient safety principles, improving adverse event reporting through creating nonpunitive reporting systems, supporting paramedic clinical decision making through improved research and education, policy changes, using flexible algorithms, adopting patient safety strategies from other disciplines, increasing funding for research in patient safety, salary support for paramedic researchers, and access to graduate training in prehospital research.

Objective: The general objective of this study was to explore the challenges of establishing an out of hospital cardiac arrest (OOHCA) surveillance program in Canada. More specifically, we attempted to determine the organizational structure of the delivery of emergency medical services (EMS) in Canada, describe the cardiac arrest data collection infrastructure in each province and determine which OOHCA variables are being collected.

Methods: We conducted a national survey of 82 independent EMS health authorities in Canada. Methodology experts devel oped the survey and distribution using a modified Dillman tech nique. We distributed 67 surveys electronically (84%) and the rest by regular mail. We weighted each survey response by the popu lation of the catchment area represented by the responding health authority (2004 census). Descriptive statistics are reported.

Results: We received 60 completed surveys, representing a 73% response rate. The responding health authorities' catchment areas represented 80% of the Canadian population (territories excluded). Our survey results highlight a lack of common OOHCA data definitions used among health authorities, sporadic use of data quality assurance procedures, rare linkages to in hospital survival outcomes and potential confidentiality issues. Other chal lenges raised by respondents included determining warehousing location and finding financial resources for a national OOHCA registry.

Conclusion: Results from this survey demonstrate that, although it is challenging, it is possible to collect OOHCA data and access in hospital survival outcomes. Collaborative efforts with the Resuscitation Outcomes Consortium and other potential provin cial partners should be explored.

Objective: We derived a clinical decision rule to determine which emergency department (ED) patients with chest pain and possible acute coronary syndrome (ACS) require chest radiography.

Methods: We prospectively enrolled patients over 24 years of age with a primary complaint of chest pain and possible ACS over a 6 month period. Emergency physicians completed standardized clinical assessments and ordered chest radiographs as appropri ate. Two blinded investigators independently classified chest radi ographs as "normal," "abnormal not requiring intervention" and "abnormal requiring intervention," based on review of the radiol ogy report and the medical record. The primary outcome was abnormality of chest radiographs requiring acute intervention. Analyses included interrater reliability assessment (with κ statistics), univariate analyses and recursive partitioning.

Results: We enrolled 529 patients during the study period between Jul. 1, 2007, and Dec. 31, 2007. Patients had a mean age of 59.9 years, 60.3% were male, 4.0% had a history of con gestive heart failure and 21.9% had a history of acute myocardial infarction. Only 2.1% (95% confidence interval [CI] 1.1%-3.8%) of patients had radiographic abnormality of the chest requiring acute intervention. The κ statistic for chest radiograph classification was 0.81 (95% CI 0.66-0.95). We derived the following rule: patients can forgo chest radiography if they have no history of congestive heart failure, no history of smoking and no abnormalities on lung auscultation. The rule was 100% sensitive (95% CI 32.0%-40.4%) and 36.1% specific (95% CI 32.0%-40.4%). Conclusion: This rule has potential to reduce health care costs and enhance ED patient flow. It requires validation in an independent patient population before introduction into clinical practice.