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Missel AL, Dowker SR, Dzierwa D, Krein SL, Coulter‐Thompson EI, Williams M, Trumpower B, Swor R, Hunt N, Friedman CP. Factors Impacting Treatment of Out-of-Hospital Cardiac Arrest: A Qualitative Study of Emergency Responders. J Am Heart Assoc 2023; 12:e027756. [PMID: 37158071 PMCID: PMC10227317 DOI: 10.1161/jaha.122.027756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 03/03/2023] [Indexed: 05/10/2023]
Abstract
Background Of the more than 250 000 emergency medical services-treated out-of-hospital cardiac arrests that occur each year in the United States, only about 8% survive to hospital discharge with good neurologic function. Treatment for out-of-hospital cardiac arrest involves a system of care that includes complex interactions among multiple stakeholders. Understanding the factors inhibiting optimal care is fundamental to improving outcomes. Methods and Results We conducted group interviews with emergency responders including 911 telecommunicators, law enforcement officers, firefighters, and transporting emergency medical services personnel (ie, emergency medical technicians and paramedics) who responded to the same out-of-hospital cardiac arrest incident. We used the American Heart Association System of Care as the framework for our analysis to identify themes and their contributory factors from these interviews. We identified 5 themes under the structure domain, which included workload, equipment, prehospital communication structure, education and competency, and patient attitudes. In the process domain, 5 themes were identified focusing on preparedness, field response and access to patient, on-scene logistics, background information acquisition, and clinical interventions. We identified 3 system themes including emergency responder culture; community support, education, and engagement; and stakeholder relationships. Three continuous quality improvement themes were identified, which included feedback provision, change management, and documentation. Conclusions We identified structure, process, system, and continuous quality improvement themes that may be leveraged to improve outcomes for out-of-hospital cardiac arrest. Interventions or programs amenable to rapid implementation include improving prearrival communication between agencies, appointing patient care and logistical leadership on-scene, interstakeholder team training, and providing more standardized feedback to all responder groups.
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Affiliation(s)
- Amanda L. Missel
- Department of Learning Health SciencesUniversity of Michigan Medical SchoolAnn ArborMichiganUSA
| | - Stephen R. Dowker
- Department of Learning Health SciencesUniversity of Michigan Medical SchoolAnn ArborMichiganUSA
- Department of Internal Medicine, Division of Cardiovascular MedicineUniversity of Michigan Medical SchoolAnn ArborMichiganUSA
- Department of Emergency MedicineUniversity of Michigan Medical SchoolAnn ArborMichiganUSA
| | - Drake Dzierwa
- Department of Internal Medicine, Division of Cardiovascular MedicineUniversity of Michigan Medical SchoolAnn ArborMichiganUSA
| | - Sarah L. Krein
- Institute for Healthcare Policy and Innovation, University of MichiganAnn ArborMichiganUSA
- Center For Clinical Management ResearchVeterans Affairs Ann Arbor Health SystemAnn ArborMichiganUSA
- Department of Internal Medicine, Division of General MedicineUniversity of Michigan Medical SchoolAnn ArborMichiganUSA
| | - Emilee I. Coulter‐Thompson
- Department of Learning Health SciencesUniversity of Michigan Medical SchoolAnn ArborMichiganUSA
- Institute for Healthcare Policy and Innovation, University of MichiganAnn ArborMichiganUSA
| | - Michelle Williams
- Department of Learning Health SciencesUniversity of Michigan Medical SchoolAnn ArborMichiganUSA
| | - Brad Trumpower
- Department of Internal Medicine, Division of Cardiovascular MedicineUniversity of Michigan Medical SchoolAnn ArborMichiganUSA
| | - Robert Swor
- Department of Emergency MedicineCorewell East William Beaumont University HospitalRoyal OakMichiganUSA
| | - Nathaniel Hunt
- Department of Emergency MedicineUniversity of Michigan Medical SchoolAnn ArborMichiganUSA
- Max Harry Weil Institute for Critical Care Research and Innovation, University of MichiganAnn ArborMichiganUSA
| | - Charles P. Friedman
- Department of Learning Health SciencesUniversity of Michigan Medical SchoolAnn ArborMichiganUSA
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Breyre AM, Sporer KA, Davenport G, Isaacs E, Glomb NW. Paramedic use of the Physician Order for Life-Sustaining Treatment (POLST) for medical intervention and transportation decisions. BMC Emerg Med 2022; 22:145. [PMID: 35948964 PMCID: PMC9367154 DOI: 10.1186/s12873-022-00697-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 07/11/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Physician Order for Life-Sustaining Treatment forms (POLST) exist in some format in all 50 states. The objective of this study is to determine paramedic interpretation and application of the California POLST for medical intervention and transportation decisions. METHODS This study used a prospective, convenience sample of California Bay Area paramedics who reviewed six fictional scenarios of patients and accompanying mock POLST forms. Based on the clinical case and POLST, paramedics identified medical interventions that were appropriate (i.e. non-invasive positive pressure airway) as well as transportation decisions (i.e. non-transport to the hospital against medical advice). EMS provider confidence in their POLST interpretation was also assessed. RESULTS There were 118 paramedic participants with a mean of 13.3 years of EMS experience that completed the survey. Paramedics routinely identified the selected medical intervention on a patients POLST correctly as either comfort focused, selective or full treatment (113-118;96%-100%). For many clinical scenarios, particularly when a patient's POLST indicated comfort focused treatment, paramedics chose to use online medical oversight through base physician contact (68-73;58%-62%). In one case, a POLST indicated "transport to hospital only if comfort needs cannot be met in current location", 13 (14%) paramedics elected to transport the patient anyway and 51 (43%) chose "Non-transport, Against Medical Advice". The majority of paramedics agreed or strongly agreed that they knew how to use a POLST to decide which medical interventions to provide (106;90%) and how to transport a patient (74;67%). However, after completing the cases, similar proportions of paramedics agreed (42;36%), disagreed (43;36%) or were neutral (30;25%) when asked if they find the POLST confusing. CONCLUSION The POLST is a powerful tool for paramedics when caring patients with serious illness. Although paramedics are confident in their ability to use a POLST to decide appropriate medical interventions, many still find the POLST confusing particularly when making transportation decisions. Some paramedics rely on online medical oversight to provide guidance in challenging situations. Authors recommend further research of EMS POLST utilization and goal concordant care, dedicated paramedic POLST education, specific EMS hospice and palliative care protocols and better nomenclature for non-transport in order to improve care for patients with serious illness.
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Affiliation(s)
- Amelia M Breyre
- University of California San Francisco, Department of Emergency Medicine, San Francisco, USA.
| | - Karl A Sporer
- Alameda County Emergency Medical Services Agency, San Leandro, USA
| | - Glen Davenport
- Columbia University, Columbia Center for Teaching and Learning, Oregon, USA
| | - Eric Isaacs
- University of California San Francisco, Department of Emergency Medicine, San Francisco, USA
| | - Nicolaus W Glomb
- University of California San Francisco, Department of Emergency Medicine, San Francisco, USA
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Stuart RB, Birchfield G, Little TE, Wetstone S, McDermott J. Use of conditional medical orders to minimize moral, ethical, and legal risk in critical care. J Healthc Risk Manag 2021; 41:14-23. [PMID: 34791745 PMCID: PMC9543663 DOI: 10.1002/jhrm.21487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 08/13/2021] [Accepted: 08/20/2021] [Indexed: 11/09/2022]
Abstract
Risk managers and ethicists monitor adherence to codes of conduct in the delivery of medical services and proactively participate with providers to create protocols that minimize the moral, ethical, and legal risks inherent in many commonly used medical protocols. "Code/no code" medical orders work well for patients at the extremes who always or never want to undergo a procedure, but they create troubling uncertainties for others by preventing them from expressly requesting procedures under some circumstances but not others. Obeying binary orders such as DNAR (Do Not Attempt Resuscitation) can allow deaths that a patient might want to delay or can expose patients to prolonged suffering they wish to avoid. These risks can be reduced by: (1) fully explaining the nature of proposed interventions and their possible beneficial and adverse effects in varying circumstances; and (2) replacing the traditional dichotomy with a continuum of options from always, through conditionally sometime, to never orders adapted to a range of situations and preferences. The Conditional Medical Orders (CMO) form summarizes patients' preferences regarding resuscitation, ventilation, and artificial hydration and nutrition (ANH) is an efficient way to increases the chance that patients will undergo only the treatments they want.
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Breyre AM, Benesch T, Glomb NW, Sporer KA, Anderson WG. EMS Experience Caring and Communicating with Patients and Families with a Life-Limiting-Illness. PREHOSP EMERG CARE 2021; 26:708-715. [PMID: 34669550 DOI: 10.1080/10903127.2021.1994674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Introduction: The emergency medical services (EMS) system was designed to reduce death and disability and EMS training focuses on saving lives through resuscitation, aggressive treatment and transportation to the emergency department. EMS providers commonly care for patients who have life-limiting illnesses. The objective was to explore EMS provider challenges, self-perceived roles and training experiences caring for patients and families with life-limiting illness. Methods: Qualitative content analysis of semi-structured interviews with EMS providers (n = 15) in Alameda County, CA. Purposive sampling was used to ensure a variety of perspectives including provider age, years of EMS experience, emergency medical technicians and paramedics, fire-based versus private, transport versus non-transporting. Recorded and transcribed interviews were analyzed using a thematic approach. Results: In their work with patients with life-limiting illness, participating EMS providers were interviewed and reported challenges for which their formal training had not prepared them: responding to grief and emotion expressed by families during traumatic events or death notification, and performing in the moment decision-making to determine the course of action after acute, unexpected, and traumatic events. Many participants reported becoming comfortable with grief counseling and death notification after acquiring some clinical experience. In the moment decision-making was eased when patients and families had had advance care planning discussions, however many patients, especially those from vulnerable and underserved populations, lacked advance care planning. In the face of situations where the course of action was not immediately clear, EMS providers voiced two frames for their role in caring for patients with life-limiting illness: transportation only ("transport people") versus a more "holistic" view, where EMS providers provided counseling and information about available resources. Conclusions: EMS providers interface with patients who have life-limiting illness and their families in the setting of traumatic events where the course of action is often unclear. There is an opportunity to provide formal training to EMS providers around grief counseling as well as how they can assist patients and families in in the moment decision-making to support previously identified goals and align care with patient goals and preferences.
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Mentzelopoulos SD, Couper K, Van de Voorde P, Druwé P, Blom M, Perkins GD, Lulic I, Djakow J, Raffay V, Lilja G, Bossaert L. [Ethics of resuscitation and end of life decisions]. Notf Rett Med 2021; 24:720-749. [PMID: 34093076 PMCID: PMC8170633 DOI: 10.1007/s10049-021-00888-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2021] [Indexed: 12/14/2022]
Abstract
These European Resuscitation Council Ethics guidelines provide evidence-based recommendations for the ethical, routine practice of resuscitation and end-of-life care of adults and children. The guideline primarily focus on major ethical practice interventions (i.e. advance directives, advance care planning, and shared decision making), decision making regarding resuscitation, education, and research. These areas are tightly related to the application of the principles of bioethics in the practice of resuscitation and end-of-life care.
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Affiliation(s)
- Spyros D. Mentzelopoulos
- Evaggelismos Allgemeines Krankenhaus, Abteilung für Intensivmedizin, Medizinische Fakultät der Nationalen und Kapodistrischen Universität Athen, 45–47 Ipsilandou Street, 10675 Athen, Griechenland
| | - Keith Couper
- Universitätskliniken Birmingham NHS Foundation Trust, UK Critical Care Unit, Birmingham, Großbritannien
- Medizinische Fakultät Warwick, Universität Warwick, Coventry, Großbritannien
| | - Patrick Van de Voorde
- Universitätsklinikum und Universität Gent, Gent, Belgien
- staatliches Gesundheitsministerium, Brüssel, Belgien
| | - Patrick Druwé
- Abteilung für Intensivmedizin, Universitätsklinikum Gent, Gent, Belgien
| | - Marieke Blom
- Medizinisches Zentrum der Universität Amsterdam, Amsterdam, Niederlande
| | - Gavin D. Perkins
- Medizinische Fakultät Warwick, Universität Warwick, Coventry, Großbritannien
| | | | - Jana Djakow
- Intensivstation für Kinder, NH Hospital, Hořovice, Tschechien
- Abteilung für Kinderanästhesiologie und Intensivmedizin, Universitätsklinikum und Medizinische Fakultät der Masaryk-Universität, Brno, Tschechien
| | - Violetta Raffay
- School of Medicine, Europäische Universität Zypern, Nikosia, Zypern
- Serbischer Wiederbelebungsrat, Novi Sad, Serbien
| | - Gisela Lilja
- Universitätsklinikum Skane, Abteilung für klinische Wissenschaften Lund, Neurologie, Universität Lund, Lund, Schweden
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