Does the number of system paramedics affect clinical benchmark thresholds?

Pilot Paramedic Survey of Benefits, Risks, and Strategies for Pediatric Prehospital Telemedicine

OBJECTIVE

A national survey found prehospital telemedicine had potential clinical applications but lacked provider opinion on its use for pediatric emergency care. We aimed to (1) estimate prehospital telemedicine use, (2) describe perceived benefits and risks of pediatric applications, and (3) identify preferred utilization strategies by paramedics.

METHODS

We administered a 14-question survey to a convenience sample of 25 Massachusetts paramedics attending a regional course in 2018. Volunteer participants were offered a gift card. We compared respondents to a state database for sample representativeness. We present descriptive statistics and summarize qualitative responses.

RESULTS

Twenty-five paramedics completed the survey (100% response); 23 (96%) were male, 21 (84%) 40 years or older, and 23 (92%) in urban practice. Respondents were older and more experienced than the average Massachusetts paramedic. Few had used prehospital telemedicine for patients younger than 12 years (8%; 95% confidence interval, 10-26%). Potential benefits included paramedic training (80%), real-time critical care support (68%), risk mitigation (68%), patient documentation (72%), decision support for hospital team activation (68%), and scene visualization (76%). Time delays from telemedicine equipment use (76%) and physician consultation (64%), broadband reliability (52%), and cost (56%) were potential risks. Respondents preferred video strategies for scene visualization, physician-assisted assessment and care. More respondents felt pediatric telemedicine applications would benefit rural/suburban settings than urban ones.

CONCLUSIONS

Paramedics reported prehospital telemedicine is underutilized for children but identified potential benefits including provider telesupport, training, situational awareness, and documentation. Concerns included transportation delays, cost, and broadband availability. Video was preferred for limited pediatric exposure settings. These results inform which telemedicine applications and strategies paramedics favor for children.

Paramedic resuscitation competency: A survey of Australian and New Zealand emergency medical services

OBJECTIVE

We have previously established that paramedic exposure to out-of-hospital cardiac arrest (OHCA) is relatively rare, therefore clinical exposure cannot be relied on to maintain resuscitation competency. We aimed to identify the current practices within emergency medical services (EMS) for developing and maintaining paramedic resuscitation competency.

METHODS

We developed and conducted an online cross-sectional survey of Australian and New Zealand EMS in 2015. The survey was piloted by one EMS and targeted at education managers.

RESULTS

A total of nine of the 10 EMS responded to the survey. All EMS reported that they provide resuscitation training to paramedics at the commencement of their employment (median 16 h, interquartile range [IQR]: 7-80). With the exception of one EMS that did not provide any refresher training, a median of 4 h (IQR: 1-7) resuscitation training was provided to paramedics annually. All EMS used cardiac arrest simulations and skill stations to train paramedics. Paramedic exposure to OHCA was not taken into account to determine their training needs. Resuscitation competency was tested by EMS: annually (3/9), biennially (4/9) or not at all (2/9). Two EMS used CPR-feedback devices in clinical practice and only one EMS regularly performed formal debriefing after OHCA cases. Barriers to resuscitation competency included: difficulty removing paramedics from clinical duties for training and a lack of paramedic exposure to OHCA.

CONCLUSION

All of the surveyed EMS provided initial resuscitation training to paramedics, but competency testing and refresher training practices varied between services. A lack of individual exposure to cardiac arrest and training time were identified as barriers to resuscitation competency.

Paramedic Exposure to Out-of-Hospital Cardiac Arrest Resuscitation Is Associated With Patient Survival

BACKGROUND

Although out-of-hospital cardiac arrest (OHCA) is a major public health problem, individual paramedics are rarely exposed to these cases. In this study, we examined whether previous paramedic exposure to OHCA resuscitation is associated with patient survival.

METHODS AND RESULTS

For the period 2003 to 2012, we linked data from the Victorian Ambulance Cardiac Arrest Registry to Ambulance Victoria's employment data set. We defined exposure as the number of times a paramedic attended an OHCA where resuscitation was attempted in the 3 years preceding each case. Using a multivariable model adjusting for known predictors of survival, we measured the association between paramedic OHCA exposure and patient survival to hospital discharge. During the study period, there were 4151 paramedics employed and 48 291 OHCAs (44% with resuscitation attempted). The median exposure of all paramedics was 2 (interquartile range 1-3) OHCAs/year. Eleven percent of paramedics were not exposed to any OHCA cases. Increased paramedic exposure was associated with reduced odds of attempted resuscitation (P<0.001). In the 3 years preceding each OHCA where resuscitation was attempted, the median exposure of the treating paramedics was 11 (interquartile range 6-17) OHCAs. Compared with patients treated by paramedics with a median of ≤6 exposures during the previous 3 years (7% survival), the odds of survival were higher for patients treated by paramedics with >6 to 11 (12%, adjusted odds ratio 1.26, 95% confidence interval 1.04-1.54), >11 to 17 (14%, adjusted odds ratio 1.29, 95% confidence interval 1.04-1.59), and >17 exposures (17%, adjusted odds ratio 1.50, 95% confidence interval 1.22-1.86). Paramedic years of experience were not associated with survival.

CONCLUSIONS

Patient survival after OHCA significantly increases with the number of OHCAs that paramedics have previously treated.

Pediatric Intubation by Paramedics in a Large Emergency Medical Services System: Process, Challenges, and Outcomes

STUDY OBJECTIVE

Pediatric intubation is a core paramedic skill in some emergency medical services (EMS) systems. The literature lacks a detailed examination of the challenges and subsequent adjustments made by paramedics when intubating children in the out-of-hospital setting. We undertake a descriptive evaluation of the process of out-of-hospital pediatric intubation, focusing on challenges, adjustments, and outcomes.

METHODS

We performed a retrospective analysis of EMS responses between 2006 and 2012 that involved attempted intubation of children younger than 13 years by paramedics in a large, metropolitan EMS system. We calculated the incidence rate of attempted pediatric intubation with EMS and county census data. To summarize the intubation process, we linked a detailed out-of-hospital airway registry with clinical records from EMS, hospital, or autopsy encounters for each child. The main outcome measures were procedural challenges, procedural success, complications, and patient disposition.

RESULTS

Paramedics attempted intubation in 299 cases during 6.3 years, with an incidence of 1 pediatric intubation per 2,198 EMS responses. Less than half of intubations (44%) were for patients in cardiac arrest. Two thirds of patients were intubated on the first attempt (66%), and overall success was 97%. The most prevalent challenge was body fluids obscuring the laryngeal view (33%). After a failed first intubation attempt, corrective actions taken by paramedics included changing equipment (33%), suctioning (32%), and repositioning the patient (27%). Six patients (2%) experienced peri-intubation cardiac arrest and 1 patient had an iatrogenic tracheal injury. No esophageal intubations were observed. Of patients transported to the hospital, 86% were admitted to intensive care and hospital mortality was 27%.

CONCLUSION

Pediatric intubation by paramedics was performed infrequently in this EMS system. Although overall intubation success was high, a detailed evaluation of the process of intubation revealed specific challenges and adjustments that can be anticipated by paramedics to improve first-pass success, potentially reduce complications, and ultimately improve clinical outcomes.

Pediatric emergency medical services and their drawbacks

Aim:

To survey the literature on Pediatric Emergency Medical Services (PEMS) with an aim to focus its drawbacks and emphasize the means of improvement.

Materials and Methods:

Published articles selected for inclusion were based on the significance and understanding of literature search on different aspects of PEMS. To meet this criterion, PubMed, PubMed Central, Science Direct, Uptodate, Med Line, comprehensive databases, Cochrane library and the Internet (Google, Yahoo) were thoroughly searched.

Results:

PEMS provide out-of-hospital medical care and/or transport the patients to definitive care. The task force represents specialties of ambulance transport, first aid, emergency medical care, life saving, trauma, emergency medicine, water rescue, and extrication. Preliminary care is undertaken to save the patients from different medical exigencies. The techniques and procedures of basic and advanced life-support are employed. A large number of weaknesses are recorded in PEMS system, such as ambulance transport irregularities, deficit equipment, lack of expertise, and ignorance of the pre-hospital care providers. These are discussed with special reference to a few examples of medical exigencies.

Conclusions:

The appointments in PEMS should be regularized with specific qualifications, experience, and expertise in different areas. Responsibility of PEMS should not be left to pre-hospital care providers, who are non clinicians and lack proper education and training. Pediatricians should be adequately trained to play an active role in PEMS. Meetings should be convened to discuss the lapses and means of improvement. Networks of co-operation between pre-hospital providers and experts in the emergency department should be established.

Emergency medical and health providers' perceptions of key issues in prehospital patient safety

OBJECTIVES

To date, most patient safety studies have been conducted in relation to the hospital rather than the prehospital setting and data regarding emergency medical services (EMS)-related errors are limited. To address this gap, a study was conducted to gain an in-depth understanding of the views of highly experienced EMS practitioners, educators, administrators, and physicians on major issues pertaining to EMS patient safety. The intent of the study was to identify key issues to give direction to the development of best practices in education, policy, and fieldwork.

METHODS

A qualitative study was conducted using processes described by Lincoln and Guba (1985) to enhance the quality and credibility of data and analysis. Purposive sampling was used to identify informants with knowledge and expertise regarding policy, practice, and research who could speak to the issue of patient safety. Sixteen participants, the majority of whom were Canadian, participated in in-depth interviews.

RESULTS

Two major themes were identified under the category of key issues: clinical decision making and EMS's focus and relationship with health care. An education gap has developed in EMS, and there is tension between the traditional stabilize-and-transport role and the increasingly complex role that has come about through "scope creep." If, as expected, EMS aligns increasingly with the health sector, then change is needed in the EMS educational structure and process to develop stronger clinical decision-making skills.

CONCLUSION

The results of this study indicate that many individual organizations and health regions are addressing issues related to patient safety in EMS, and there are important lessons to be learned from these groups. The broader issues identified, however, are system-wide and best addressed through policy change from health regions and government.