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Lindridge J, Edwards T, Blackwood L. Advanced paramedics' restraint decision-making when managing acute behavioural disturbance (ABD) in the UK pre-hospital ambulance setting: A qualitative investigation. PLoS One 2024; 19:e0302524. [PMID: 38753728 PMCID: PMC11098407 DOI: 10.1371/journal.pone.0302524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 04/07/2024] [Indexed: 05/18/2024] Open
Abstract
Acute behavioural disturbance (ABD), sometimes called 'excited delirium', is a medical emergency. In the UK, some patients presenting with ABD are managed by advanced paramedics (APs), however little is known about how APs make restraint decisions. The aim of this research is to explore the decisions made by APs when managing restraint in the context of ABD, in the UK pre-hospital ambulance setting. Seven semi-structured interviews were undertaken with APs. All participants were experienced APs with post-registration, post-graduate advanced practice education and qualifications. The resulting data were analysed using reflexive thematic analysis, informed by critical realism. We identified four interconnected themes from the interview data. Firstly, managing complexity and ambiguity in relation to identifying ABD patients and determining appropriate treatment plans. Secondly, feeling vulnerable to professional consequences from patients deteriorating whilst in the care of APs. Thirdly, negotiating with other professionals who have different roles and priorities. Finally, establishing primacy of care in relation to incidents which involve police officers and other professionals. A key influence was the need to characterise incidents as medical, as an enabler to establishing clinical leadership and decision-making control. APs focused on de-escalation techniques and sought to reduce physical restraint, intervening with pharmacological interventions if necessary to achieve this. The social relationships and interactions with patients and other professionals at the scene were key to success. Decisions are a source of anxiety, with fears of professional detriment accompanying poor patient outcomes. Our results indicate that APs would benefit from education and development specifically in relation to making ABD decisions, acknowledging the context of inter-professional relationships and the potential for competing and conflicting priorities. A focus on joint, high-fidelity training with the police may be a helpful intervention.
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Affiliation(s)
- Jaqualine Lindridge
- Department for Health, University of Bath, Bath, Somerset, England
- London Ambulance Service NHS Trust, London, England
| | | | - Leda Blackwood
- Department of Psychology, University of Bath, Bath, Somerset, England
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2
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Sepahvand MJ, Nourozi K, Khankeh H, Mohammadi-Shahboulaghi F, Fallahi-Khoshknab M. Fears and Concerns of Bystanders to Help People Injured in Traffic Accidents: A Qualitative Descriptive Study. Emerg Med Int 2023; 2023:1862802. [PMID: 38099234 PMCID: PMC10721345 DOI: 10.1155/2023/1862802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 11/21/2023] [Accepted: 12/01/2023] [Indexed: 12/17/2023] Open
Abstract
In most traffic accidents, bystanders arrive at the scene before the rescuers. If they provide the right help, they can play an important and effective role in reducing the number of deaths and complications caused by these accidents. However, in many cases, fears and concerns prevent bystanders from providing assistance. This study aims to investigate and understand the fears and concerns of bystanders when they decide to help in traffic accidents. In 2022, this study was carried out in Iran using a qualitative content analysis approach. The data was collected through semistructured interviews. Participants were 15 males and females who had experience providing assistance in traffic accidents. Interviews, after digital recording, were transcribed verbatim. A purposeful and theoretical sampling method was performed. Data analysis and the determination of codes, categories, and subcategories were done using qualitative analysis software. O'Brien's qualitative research reporting standard was used. The results of the study include a category of fears and concerns and five subcategories. The subcategories include fear and concern caused by lack of information, fear of legal troubles, stress caused by previous experience, fear and anxiety caused by anticipation, and anxiety of unknown origin. The results of this study showed that some of the fears and concerns of the bystanders were related to a lack of information about providing assistance. By increasing bystanders' information about assistance, such as first aid training, fear and anxiety caused by a lack of information can be reduced. Another part of the fear and concern of bystanders is due to legal issues. Passing and implementing laws that protect bystanders can help reduce this fear and concern. Bystanders should be trained to provide assistance according to the rules of assistance so that they do not get into legal problems. A part of the bystander's fear and concern stems from their previous experiences providing assistance in traffic accidents. These experiences can also affect the fear and anxiety caused by anticipation. It is necessary to conduct more studies on the role of bystanders' experiences in creating fear and anxiety in them, as well as their effect on anticipatory fear.
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Affiliation(s)
| | - Kian Nourozi
- Department of Nursing, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
| | - Hamidreza Khankeh
- Emergency and Disaster Health, University of Social Welfare and Rehabilitation Sciences, Associated at Department of Clinical Science and Education, Karolinska Institute, Tehran, Iran
| | - Farahnaz Mohammadi-Shahboulaghi
- Iranian Research Center on Aging, Nursing Department, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
| | - Masoud Fallahi-Khoshknab
- Department of Nursing, Iranian Scientific Association of Nursing, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
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Harring AKV, Kramer-Johansen J, Tjelmeland IBM. Resuscitation of older adults in Norway; a comparison of survival and outcome after out-of-hospital cardiac arrest in healthcare institutions and at home. Resuscitation 2023; 189:109871. [PMID: 37327851 DOI: 10.1016/j.resuscitation.2023.109871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 06/06/2023] [Accepted: 06/07/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND Perceptions about expected outcome after out-of-hospital cardiac arrest (OHCA) influence treatment decisions, and there is a need for updated evidence about outcomes for the elderly. METHOD We conducted a cross-sectional study of cases reported to the Norwegian Cardiac Arrest Registry from 2015 through 2021 of patients 60 years and older, suffering cardiac arrest in healthcare institutions or at home. We examined reasons for emergency medical service (EMS) withholding or withdrawing resuscitation. We compared survival and neurological outcome for EMS-treated patients and explored factors associated with survival using multivariate logistic regression. RESULT We included 12,191 cases and the EMS started resuscitation in 10,340 (85%). The incidence per capita of OHCA the EMS were alerted to was 267/100,000 in healthcare institutions and 134/100,000 at home. Resuscitation was most frequently withdrawn due to medical history (n = 1251). In healthcare institutions, 72 of 1503 (4.8%) patients survived to 30 days compared to 752 of 8837 (8.5%) at home (P <.001). We found survivors in all age cohorts both in healthcare institutions and at home, and most of the 824 survivors had a good neurological outcome with a Cerebral Performance Category ≤2 (88%). CONCLUSION Medical history was the most frequent reason for EMS not to start or continue resuscitation, indicating a need for a discussion about, and documentation of, advance directives in this age group. When EMS attempted resuscitation, most survivors had a good neurological outcome, both in healthcare institutions and at home.
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Affiliation(s)
| | - Jo Kramer-Johansen
- Division of Prehospital Services, Oslo University Hospital, Oslo, Norway; Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Ingvild B M Tjelmeland
- Division of Prehospital Services, Oslo University Hospital, Oslo, Norway; Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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Gentile FR, Baldi E, Klersy C, Schnaubelt S, Caputo ML, Clodi C, Bruno J, Compagnoni S, Fasolino A, Benvenuti C, Domanovits H, Burkart R, Primi R, Ruzicka G, Holzer M, Auricchio A, Savastano S. Association Between Postresuscitation 12-Lead ECG Features and Early Mortality After Out-of-Hospital Cardiac Arrest: A Post Hoc Subanalysis of the PEACE Study. J Am Heart Assoc 2023; 12:e027923. [PMID: 37183852 DOI: 10.1161/jaha.122.027923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
Background Once the return of spontaneous circulation after out-of-hospital cardiac arrest is achieved, a 12-lead ECG is strongly recommended to identify candidates for urgent coronary angiography. ECG has no apparent role in mortality risk stratification. We aimed to assess whether ECG features could be associated with 30-day survival in patients with out-of-hospital cardiac arrest. Methods and Results All the post-return of spontaneous circulation ECGs from January 2015 to December 2018 in 3 European centers (Pavia, Lugano, and Vienna) were collected. Prehospital data were collected according to the Utstein style. A total of 370 ECGs were collected: 287 men (77.6%) with a median age of 62 years (interquartile range, 53-70 years). After correction for the return of spontaneous circulation-to-ECG time, age >62 years (hazard ratio [HR], 1.78 [95% CI, 1.21-2.61]; P=0.003), female sex (HR, 1.5 [95% CI, 1.05-2.13]; P=0.025), QRS wider than 120 ms (HR, 1.64 [95% CI, 1.43-1.87]; P<0.001), the presence of a Brugada pattern (HR, 1.49 [95% CI, 1.39-1.59]; P<0.001), and the presence of ST-segment elevation in >1 segment (HR, 1.75 [95% CI, 1.59-1.93]; P<0.001) were independently associated with 30-day mortality. A score ranging from 0 to 26 was created, and by dividing the population into 3 tertiles, 3 classes of risk were found with significantly different survival rate at 30 days (score 0-4, 73%; score 5-7, 66%; score 8-26, 45%). Conclusions The post-return of spontaneous circulation ECG can identify patients who are at high risk of mortality after out-of-hospital cardiac arrest earlier than other forms of prognostication. This provides important risk stratification possibilities in postcardiac arrest care that could help to direct treatments and improve outcomes in patients with out-of-hospital cardiac arrest.
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Affiliation(s)
- Francesca Romana Gentile
- Department of Molecular Medicine, Section of Cardiology University of Pavia Pavia Italy
- Cardiac Intensive Care Unit, Arrhythmia and Electrophysiology and Experimental Cardiology Fondazione IRCCS Policlinico San Matteo Pavia Italy
| | - Enrico Baldi
- Department of Molecular Medicine, Section of Cardiology University of Pavia Pavia Italy
- Cardiac Intensive Care Unit, Arrhythmia and Electrophysiology and Experimental Cardiology Fondazione IRCCS Policlinico San Matteo Pavia Italy
| | - Catherine Klersy
- Clinical Epidemiology and Biometry Fondazione IRCCS Policlinico San Matteo Pavia Italy
| | | | | | - Christian Clodi
- Department of Emergency Medicine Medical University of Vienna Wien Austria
| | | | - Sara Compagnoni
- Department of Molecular Medicine, Section of Cardiology University of Pavia Pavia Italy
- Cardiac Intensive Care Unit, Arrhythmia and Electrophysiology and Experimental Cardiology Fondazione IRCCS Policlinico San Matteo Pavia Italy
| | - Alessandro Fasolino
- Department of Molecular Medicine, Section of Cardiology University of Pavia Pavia Italy
- Cardiac Intensive Care Unit, Arrhythmia and Electrophysiology and Experimental Cardiology Fondazione IRCCS Policlinico San Matteo Pavia Italy
| | | | - Hans Domanovits
- Clinical Epidemiology and Biometry Fondazione IRCCS Policlinico San Matteo Pavia Italy
| | | | - Roberto Primi
- Division of Cardiology Fondazione IRCCS Policlinico San Matteo Pavia Italy
| | - Gerhard Ruzicka
- Department of Emergency Medicine Medical University of Vienna Wien Austria
| | - Michael Holzer
- Department of Emergency Medicine Medical University of Vienna Wien Austria
| | | | - Simone Savastano
- Division of Cardiology Fondazione IRCCS Policlinico San Matteo Pavia Italy
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Factors influencing prehospital physicians' decisions to initiate advanced resuscitation for asystolic out-of-hospital cardiac arrest patients. Resuscitation 2022; 177:19-27. [PMID: 35760227 DOI: 10.1016/j.resuscitation.2022.06.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 06/17/2022] [Accepted: 06/19/2022] [Indexed: 12/27/2022]
Abstract
BACKGROUND The decision to initiate or continue advanced life support (ALS) in out-of-hospital cardiac arrest (OHCA) could be difficult due to the lack of information and contextual elements, especially in non-shockable rhythms. This study aims to explore factors associated with clinicians' decision to initiate or continue ALS and the conditions associated with higher variability in asystolic patients. METHODS This retrospective observational study enrolled 2653 asystolic patients on whom either ALS was attempted or not by the emergency medical services (EMS) physician. A multivariable logistic regression analysis was performed to find the factors associated with the decision to access ALS. A subgroup analysis was performed on patients with a predicted probability of ALS between 35% and 65%. The single physicians' behaviour was compared to that predicted by the model taking into account the entire agency. RESULTS Age, location of event, bystander CPR and EMS-witnessed event were independent factors influencing physicians' choices about ALS. Non-medical OHCA, younger patients, less experienced physicians, presence of breath activity at the emergency call and a longer time for ALS arrival were more frequent among cases with an expected higher variability in behaviours with ALS. Significant variability was detected between physicians. CONCLUSIONS Significant inter-physician variability in access to ALS could be present within the same EMS, especially among less experienced physicians, non-medical OHCA and in presence of signs of life during emergency call. This arbitrariness has been observed and should be properly addressed by EMS team members as it raises ethical issues regarding the disparity in treatment.
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Milling L, Kjær J, Binderup LG, de Muckadell CS, Havshøj U, Christensen HC, Christensen EF, Lassen AT, Mikkelsen S, Nielsen D. Non-medical factors in prehospital resuscitation decision-making: a mixed-methods systematic review. Scand J Trauma Resusc Emerg Med 2022; 30:24. [PMID: 35346307 PMCID: PMC8962561 DOI: 10.1186/s13049-022-01004-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 02/25/2022] [Indexed: 11/10/2022] Open
Abstract
Aim This systematic review explored how non-medical factors influence the prehospital resuscitation providers’ decisions whether or not to resuscitate adult patients with cardiac arrest. Methods We conducted a mixed-methods systematic review with a narrative synthesis and searched for original quantitative, qualitative, and mixed-methods studies on non-medical factors influencing resuscitation of out-of-hospital cardiac arrest. Mixed-method reviews combine qualitative, quantitative, and mixed-method studies to answer complex multidisciplinary questions. Our inclusion criteria were peer-reviewed empirical-based studies concerning decision-making in prehospital resuscitation of adults > 18 years combined with non-medical factors. We excluded commentaries, case reports, editorials, and systematic reviews. After screening and full-text review, we undertook a sequential exploratory synthesis of the included studies, where qualitative data were synthesised first followed by a synthesis of the quantitative findings. Results We screened 15,693 studies, reviewed 163 full-text studies, and included 27 papers (12 qualitative, two mixed-method, and 13 quantitative papers). We identified five main themes and 13 subthemes related to decision-making in prehospital resuscitation. Especially the patient’s characteristics and the ethical aspects were included in decisions concerning resuscitation. The wishes and emotions of bystanders further influenced the decision-making. The prehospital resuscitation providers’ characteristics, experiences, emotions, values, and team interactions affected decision-making, as did external factors such as the emergency medical service system and the work environment, the legislation, and the cardiac arrest setting. Lastly, prehospital resuscitation providers’ had to navigate conflicts between jurisdiction and guidelines, and conflicting values and interests.
Conclusions Our findings underline the complexity in prehospital resuscitation decision-making and highlight the need for further research on non-medical factors in out-of-hospital cardiac arrest. Supplementary Information The online version contains supplementary material available at 10.1186/s13049-022-01004-6.
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Affiliation(s)
- Louise Milling
- Prehospital Research Unit, Department of Anaesthesiology and Intensive Care, Odense University Hospital, Kildemosevej 15, 5000, Odense C, Denmark. .,Department of Regional Health Research, University of Southern Denmark, Odense, Denmark.
| | - Jeannett Kjær
- Prehospital Research Unit, Department of Anaesthesiology and Intensive Care, Odense University Hospital, Kildemosevej 15, 5000, Odense C, Denmark.,Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Lars Grassmé Binderup
- Philosophy, Department for the Study of Culture, University of Southern Denmark, Odense, Denmark
| | | | - Ulrik Havshøj
- Prehospital Research Unit, Department of Anaesthesiology and Intensive Care, Odense University Hospital, Kildemosevej 15, 5000, Odense C, Denmark.,Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | | | - Erika Frischknecht Christensen
- Centre for Prehospital and Emergency Research, Aalborg University Hospital, Aalborg University, Aalborg, Denmark.,Emergency Medical Services, Region North Denmark, Aalborg, Denmark
| | | | - Søren Mikkelsen
- Prehospital Research Unit, Department of Anaesthesiology and Intensive Care, Odense University Hospital, Kildemosevej 15, 5000, Odense C, Denmark.,Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Dorthe Nielsen
- Department of Infectious Diseases, Sub-Department of Immigrant Medicine, Odense University Hospital, Odense, Denmark.,Department of Geriatric Medicine, Odense University Hospital, Odense, Denmark
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Coppola A, Black S, Endacott R. How senior paramedics decide to cease resuscitation in pulseless electrical activity out of hospital cardiac arrest: a mixed methods study. Scand J Trauma Resusc Emerg Med 2021; 29:138. [PMID: 34530872 PMCID: PMC8447587 DOI: 10.1186/s13049-021-00946-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 08/26/2021] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Evidenced-based guidelines on when to cease resuscitation for pulseless electrical activity are limited and support for paramedics typically defaults to the senior clinician. Senior clinicians include paramedics employed to work beyond the scope of clinical guidelines as there may be a point at which it is reasonable to cease resuscitation. To support these decisions, one ambulance service has applied a locally derived cessation of resuscitation checklist. This study aimed to describe the patient, clinical and system factors and examine senior clinician experiences when ceasing resuscitation for pulseless electrical activity. DESIGN AND METHODS An explanatory sequential mixed method study was conducted in one ambulance service in the South West of England. A consecutive sample of checklist data for adult pulseless electrical activity were retrieved from 1st December 2015 to 31st December 2018. Unexpected results which required exploration were identified and developed into semi-structured interview questions. A purposive sample of senior clinicians who ceased resuscitation and applied the checklist were interviewed. Content framework analysis was applied to the qualitative findings. RESULTS Senior clinicians ceased resuscitation for 50 patients in the presence of factors known to optimise survival: Witnessed cardiac arrest (n = 37, 74%), bystander resuscitation (n = 30, 60%), defibrillation (n = 22, 44%), return of spontaneous circulation (n = 8, 16%). Significant association was found between witnessed cardiac arrest and bystander resuscitation (p = .00). Six senior clinicians were interviewed, and analysis resulted in four themes: defining resuscitation futility, the impact of ceasing resuscitation, conflicting views and clinical decision tools. In the local context, senior clinicians applied their clinical judgement to balance survivability. Multiple factors were considered as the decision to cease resuscitation was not always clear. Senior clinicians deviated from the checklist when the patient was perceived as non-survivable. CONCLUSION Senior clinicians applied clinical judgement to assess patients as non-survivable or when continued resuscitation was considered harmful with no patient benefit. Senior clinicians perceived pre-existing factors with duration of resuscitation and clinical factors known to optimise patient survival. Future practice could look beyond a set criteria in which to cease resuscitation, however, it would be helpful to investigate the value or threshold of factors associated with patient outcome.
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Affiliation(s)
- Ali Coppola
- MClinRes Research Paramedic, South Western Ambulance Service NHS Foundation Trust, Abbey Court, Eagle Way, Exeter, UK.
| | - Sarah Black
- Head of Research, Audit and Quality Improvement, South Western Ambulance Service NHS Foundation Trust, Exeter, UK
| | - Ruth Endacott
- School of Nursing and Midwifery (Faculty of Health: Medicine, Dentistry and Human Sciences), University of Plymouth, Plymouth, UK
- School of Nursing and Midwifery, (Faculty of Medicine, Nursing and Health Sciences), Monash University, Melbourne, Australia
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8
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Milling L, Binderup LG, de Muckadell CS, Christensen EF, Lassen A, Christensen HC, Nielsen DS, Mikkelsen S. Documentation of ethically relevant information in out-of-hospital resuscitation is rare: a Danish nationwide observational study of 16,495 out-of-hospital cardiac arrests. BMC Med Ethics 2021; 22:82. [PMID: 34193147 PMCID: PMC8247191 DOI: 10.1186/s12910-021-00654-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 06/16/2021] [Indexed: 01/04/2023] Open
Abstract
Background Decision-making in out-of-hospital cardiac arrest should ideally include clinical and ethical factors. Little is known about the extent of ethical considerations and their influence on prehospital resuscitation. We aimed to determine the transparency in medical records regarding decision-making in prehospital resuscitation with a specific focus on ethically relevant information and consideration in resuscitation providers’ documentation. Methods This was a Danish nationwide retrospective observational study of out-of-hospital cardiac arrests from 2016 through 2018. After an initial screening using broadly defined inclusion criteria, two experienced philosophers performed a qualitative content analysis of the included medical records according to a preliminary codebook. We identified ethically relevant content in free-text fields and categorised the information according to Beauchamp and Childress’ four basic bioethical principles: autonomy, non-maleficence, beneficence, and justice.
Results Of 16,495 medical records, we identified 759 (4.6%) with potentially relevant information; 710 records (4.3%) contained ethically relevant information, whereas 49 did not. In general, the documentation was vague and unclear. We identified four kinds of ethically relevant information: patients’ wishes and perspectives on life; relatives’ wishes and perspectives on patients’ life; healthcare professionals’ opinions and perspectives on resuscitation; and do-not-resuscitate orders. We identified some “best practice” examples that included all perspectives of decision-making.
Conclusions There is sparse and unclear evidence on ethically relevant information in the medical records documenting resuscitation after out-of-hospital cardiac arrests. However, the “best practice” examples show that providing sufficient documentation of decision-making is, in fact, feasible. To ensure transparency surrounding prehospital decisions in cardiac arrests, we believe that it is necessary to ensure more systematic documentation of decision-making in prehospital resuscitation. Supplementary Information The online version contains supplementary material available at 10.1186/s12910-021-00654-y.
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Affiliation(s)
- Louise Milling
- Prehospital Research Unit, Department of Anaesthesiology and Intensive Care, Odense University Hospital, Kildemosevej 15, 5000, Odense C, Denmark. .,Department of Regional Health Research, University of Southern Denmark, Odense, Denmark.
| | - Lars Grassmé Binderup
- Philosophy, Department for the Study of Culture, University of Southern Denmark, Odense, Denmark
| | | | | | - Annmarie Lassen
- Emergency Medicine Research Unit, Odense University Hospital, Odense, Denmark
| | | | - Dorthe Susanne Nielsen
- Department of Infectious Diseases, Sub-department of Immigrant Medicine, Odense University Hospital, Odense, Denmark.,Department of Geriatric Medicine, Odense University Hospital, Odense, Denmark
| | - Søren Mikkelsen
- Prehospital Research Unit, Department of Anaesthesiology and Intensive Care, Odense University Hospital, Kildemosevej 15, 5000, Odense C, Denmark.,Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
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de Graaf C, de Kruif AJTCM, Beesems SG, Koster RW. To transport or to terminate resuscitation on-site. What factors influence EMS decisions in patients without ROSC? A mixed-methods study. Resuscitation 2021; 164:84-92. [PMID: 34023427 DOI: 10.1016/j.resuscitation.2021.05.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 04/09/2021] [Accepted: 05/09/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND If a patient in out-of-hospital cardiac arrest (OHCA) does not achieve return of spontaneous circulation (ROSC) despite advanced life support, emergency medical services can decide to either transport the patient with ongoing CPR or terminate resuscitation on scene. PURPOSE To determine differences between patients without ROSC to be transported vs. terminated on scene and explore medical and nonmedical factors that contribute to the decision-making of paramedics on scene. METHODS Mixed-methods approach combining quantitative and qualitative data. Quantitative data on all-cause OHCA patients without ROSC on scene, between January 1, 2012, and December 31, 2016, in the Amsterdam Resuscitation Study database, were analyzed to find factors associated with decision to transport. Qualitative data was collected by performing 16 semi-structured interviews with paramedics from the study region, transcribed and coded to identify themes regarding OHCA decision-making on the scene. RESULTS In the quantitative Utstein dataset, of 5870 OHCA patients, 3190 (54%) patients did not achieve ROSC on scene. In a multivariable model, age (OR 0.98), public location (OR 2.70), bystander witnessed (OR 1.65), EMS witnessed (OR 9.03), and first rhythm VF/VT (OR 11.22) or PEA (OR 2.34), were independently associated with transport with ongoing CPR. The proportion of variance explained by the model was only 0.36. With the qualitative method, four main themes were identified: patient-related factors, local circumstances, paramedic-related factors, and the structure of the organization. CONCLUSION In patients without ROSC on scene, besides known resuscitation characteristics, the decision to transport a patient is largely determined by non-protocollized factors.
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Affiliation(s)
- Corina de Graaf
- Amsterdam UMC, Academic Medical Center (AMC), Heart Center, Department of Cardiology, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands.
| | - Anja J Th C M de Kruif
- Department of Epidemiology and Biostatistics, Amsterdam UMC location VUmc, Amsterdam, Amsterdam Public Health Research Institute, The Netherlands
| | - Stefanie G Beesems
- Amsterdam UMC, Academic Medical Center (AMC), Heart Center, Department of Cardiology, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Rudolph W Koster
- Amsterdam UMC, Academic Medical Center (AMC), Heart Center, Department of Cardiology, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
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Lemoine S, Chabernaud JL, Jost D, Prunet B. Re: Family presence during resuscitation in paediatric cardiac arrest: A systematic review. Offering parents the choice to view resuscitation of their child in case of sudden cardiac arrest. Resuscitation 2021; 164:153-154. [PMID: 33971267 DOI: 10.1016/j.resuscitation.2021.03.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Accepted: 03/02/2021] [Indexed: 11/19/2022]
Affiliation(s)
- Sabine Lemoine
- Paris Fire Brigade Medical Emergency Department, Paris, France.
| | - Jean-Louis Chabernaud
- Delegate for International Relations, Paris-Saclay University, Antoine-Béclère Hospital, Assistance Publique-Hôpitaux de Paris, Clamart, France
| | - Daniel Jost
- Paris Fire Brigade Medical Emergency Department, Paris, France; Sudden Death Expertise Center (SDEC), INSERM U970, Paris, France
| | - Bertrand Prunet
- Paris Fire Brigade Medical Emergency Department, Paris, France
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Afshari A, Khodaveisi M, Sadeghian E. Exploring the educational challenges in emergency medical students: A qualitative study. JOURNAL OF ADVANCES IN MEDICAL EDUCATION & PROFESSIONALISM 2021; 9:79-84. [PMID: 34026907 PMCID: PMC8106738 DOI: 10.30476/jamp.2021.88535.1344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 02/08/2021] [Indexed: 06/12/2023]
Abstract
INTRODUCTION Emergency medical services (EMS) are provided in the difficult and unpredictable conditions of prehospital settings. Therefore, EMS students need to receive quality education to acquire considerable knowledge and skills. This qualitative study aimed to explore the educational challenges in medical emergency students. METHODS This qualitative study was carried out in 2019 using qualitative content analysis. Participants were fourteen undergraduate EMS students purposively recruited from Hamadan University of Medical Sciences, Hamadan, Iran. Data collection was done through semi-structured interviews and continued up to data saturation. Data were analyzed using the conventional content analysis approach explained by Graneheim and Lundman. RESULTS The four main categories of the challenges of EMS education were shortcomings of the clinical education environment, lack of qualified EMS instructors, deficit of the curriculum, and theory-practice gap. CONCLUSION During their university education, EMS students face different challenges. For effective training, more coordination is needed among the emergency medical board, faculty members and EMS managers. It is also recommended that the curriculum should be revised.
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Affiliation(s)
- Ali Afshari
- Student Research Committee, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Masoud Khodaveisi
- Chronic Diseases (Home Care) Research Center, Department of Community Health Nursing, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Efat Sadeghian
- Chronic Diseases (Home Care) Research Center, Department of Nursing, Hamadan University of Medical Sciences, Hamadan, Iran
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Anderson NE, Slark J, Gott M. Prehospital Resuscitation Decision Making: A model of ambulance personnel experiences, preparation and support. Emerg Med Australas 2021; 33:697-702. [PMID: 33423356 DOI: 10.1111/1742-6723.13715] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 11/29/2020] [Accepted: 12/13/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE This paper presents the first Naturalistic Decision Making model of prehospital resuscitation decision-making, which has clear implications for education, practice and support. METHODS A mixed-methods exploratory sequential research design consisting of interviews with ambulance personnel (study 1), focus groups with ambulance educators, managers and peer supporters (study 2), and an online survey of graduating paramedic students (study 3). This paper reports the model developed from integrated findings, across all three studies. All research was undertaken in New Zealand and underpinned by a critical realist worldview. RESULTS The Prehospital Resuscitation Decision Making model identifies key processes, challenges and facilitators before, during and after ambulance personnel attend a cardiac arrest event. It is the only descriptive model of resuscitation decision making which acknowledges the decision-maker, non-prognostic factors and the importance of adequate preparation and support. CONCLUSIONS This research project is the first to comprehensively explore and model ambulance personnel perspectives on decisions to start, continue or stop resuscitation. The decision-making process is complex and difficult to simply formularise. Education and supports must assist ambulance personnel in navigating this complexity. Where resuscitation is withheld or terminated, ambulance personnel need to feel confident that they can effectively provide after-death care.
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Affiliation(s)
- Natalie E Anderson
- School of Nursing, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand.,Auckland Adult Emergency Department, Auckland District Health Board, Auckland, New Zealand
| | - Julia Slark
- School of Nursing, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Merryn Gott
- School of Nursing, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
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Anderson NE, Robinson J, Moeke-Maxwell T, Gott M. Paramedic care of the dying, deceased and bereaved in Aotearoa, New Zealand. PROGRESS IN PALLIATIVE CARE 2020. [DOI: 10.1080/09699260.2020.1841877] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Natalie Elizabeth Anderson
- School of Nursing, Faculty of Medical & Health Sciences, University of Auckland, Auckland, New Zealand
- Auckland District Health Board, Auckland, New Zealand
| | - Jackie Robinson
- School of Nursing, Faculty of Medical & Health Sciences, University of Auckland, Auckland, New Zealand
- Auckland District Health Board, Auckland, New Zealand
| | - Tess Moeke-Maxwell
- School of Nursing, Faculty of Medical & Health Sciences, University of Auckland, Auckland, New Zealand
| | - Merryn Gott
- School of Nursing, Faculty of Medical & Health Sciences, University of Auckland, Auckland, New Zealand
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Leemeyer AMR, Van Lieshout EMM, Bouwens M, Breeman W, Verhofstad MHJ, Van Vledder MG. Decision making in prehospital traumatic cardiac arrest; A qualitative study. Injury 2020; 51:1196-1202. [PMID: 31926614 DOI: 10.1016/j.injury.2020.01.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 01/03/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Despite improving survival of patients in prehospital traumatic cardiac arrest (TCA), initiation and/or discontinuation of resuscitation of TCA patients remains a subject of debate among prehospital emergency medical service providers. The aim of this study was to identify factors that influence decision making by prehospital emergency medical service providers during resuscitation of patients with TCA. METHODS Twenty-five semi-structured interviews were conducted with experienced ambulance nurses, HEMS nurses and HEMS physicians individually, followed by a focus group discussion. Participants had to be currently active in prehospital medicine in the Netherlands. Interviews were encoded for analysis using ATLAS.ti. Using qualitative analysis, different themes around decision making in TCA were identified. RESULTS Eight themes were identified as being important factors for decision making during prehospital TCA. These themes were: (1) factual information (e.g., electrocardiography rhythm or trauma mechanism); (2) fear of providing futile care or major impairment if return of spontaneous circulation was obtained; (3) potential organ donation; (4) patient age; (5) suspicion of attempted suicide; (6) presence of bystanders or family; (7) opinions of other team members; and (8) training and education. Several ambulance nurses reported they do not feel adequately supported by the current official national ambulance guidelines on TCA, nor did they feel sufficiently trained to perform pre-hospital interventions such as endotracheal intubation or needle thoracocentesis on these patients. CONCLUSION Eight themes were identified as being important for decision making during prehospital TCA. While guidelines based on prognostic factors are important, it should be recognized that decision making in TCA is impacted by more than factual information alone. This should be reflected in educational programs and future guidelines.
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Affiliation(s)
- Anna-Marie R Leemeyer
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Esther M M Van Lieshout
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Maneka Bouwens
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Wim Breeman
- AmbulanceZorg Rotterdam-Rijnmond, Barendrecht, the Netherlands
| | - Michael H J Verhofstad
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Mark G Van Vledder
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands.
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Brøchner AC, Binderup LG, Schaffalitzky de Muckadell C, Mikkelsen S. Does the "Morning Morality Effect" Apply to Prehospital Anaesthesiologists? An Investigation into Diurnal Changes in Ethical Behaviour. Healthcare (Basel) 2020; 8:healthcare8020101. [PMID: 32316371 PMCID: PMC7349197 DOI: 10.3390/healthcare8020101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 04/14/2020] [Indexed: 12/02/2022] Open
Abstract
The “morning morality effect”—the alleged phenomenon that people are more likely to act in unethical ways in the afternoon when they are tired and have less self-control than in the morning—may well be expected to influence prehospital anaesthesiologist manning mobile emergency care units (MECUs). The working conditions of these units routinely entail fatigue, hunger, sleep deprivation and other physical or emotional conditions that might make prehospital units predisposed to exhibit the “morning morality effect”. We investigated whether this is in fact the case by looking at the distribution of patient transports to hospital with and without physician escort late at night at the end of the shift as a surrogate marker for changing thresholds in ethical behaviour. All missions over a period of 11 years in the MECU in Odense were reviewed. Physician-escorted transports to hospital were compared with non-physician-escorted transports during daytime, evening, and night-time (which correlates with time on the 24 h shifts). In total, 26,883 patients were transported to hospital following treatment by the MECU. Of these, 27.4% (26.9%–27.9%) were escorted to the hospital. The ratio of patient transports to hospital with and without physician escort during the three periods of the day did not differ (p = 1.00). We found no evidence of changes in admission patterns over the day. Thus, no evidence of the expected “morning morality effect” could be found in a prehospital physician-manned emergency care unit.
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Affiliation(s)
- Anne Craveiro Brøchner
- Department of Anaesthesiology and Intensive Care Medicine V, Mobile Emergency Care Unit, Odense University Hospital, 5000 Odense, Denmark;
- Department of Regional Health Research, University of Southern Denmark, 5000 Odense, Denmark
- Department of Anaesthesiology, Kolding Hospital, a Part of Hospital Lillebaelt, 6000 Kolding, Denmark
| | - Lars Grassmé Binderup
- Philosophy, Department for the Study of Culture, University of Southern Denmark, 5230 Odense, Denmark; (L.G.B.); (C.S.d.M.)
| | | | - Søren Mikkelsen
- Department of Anaesthesiology and Intensive Care Medicine V, Mobile Emergency Care Unit, Odense University Hospital, 5000 Odense, Denmark;
- Department of Regional Health Research, University of Southern Denmark, 5000 Odense, Denmark
- Correspondence: ; Tel.: +45-30252225
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Anderson NE, Slark J, Gott M. When resuscitation doesn’t work: A qualitative study examining ambulance personnel preparation and support for termination of resuscitation and patient death. Int Emerg Nurs 2020; 49:100827. [DOI: 10.1016/j.ienj.2019.100827] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 10/01/2019] [Accepted: 11/29/2019] [Indexed: 12/12/2022]
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Anderson NE, Slark J, Faasse K, Gott M. Paramedic student confidence, concerns, learning and experience with resuscitation decision-making and patient death: A pilot survey. Australas Emerg Care 2019; 22:156-161. [DOI: 10.1016/j.auec.2019.07.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 06/25/2019] [Accepted: 07/01/2019] [Indexed: 11/26/2022]
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Andersson U, Maurin Söderholm H, Wireklint Sundström B, Andersson Hagiwara M, Andersson H. Clinical reasoning in the emergency medical services: an integrative review. Scand J Trauma Resusc Emerg Med 2019; 27:76. [PMID: 31426839 PMCID: PMC6700770 DOI: 10.1186/s13049-019-0646-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 07/15/2019] [Indexed: 11/25/2022] Open
Abstract
Abstract Clinical reasoning is the process of gathering and understanding information conducted by clinicians in the emergency medical services (EMS) so as to make informed decisions. Research on clinical reasoning spans several disciplines, but a comprehensive view of the process is lacking. To our knowledge, no review of clinical reasoning in the EMS has been conducted. Aim The aim was to investigate the nature, deployment, and factors influencing EMS clinicians’ clinical reasoning by means of a review. Method Data was collected through searches in electronic databases, networking among research teams, colleagues and friends, “grey literature,” and through ancestry searches. A total of 38 articles were deemed eligible for inclusion and were analyzed using descriptive thematic analysis. The analysis resulted in an overarching finding - namely, the importance for EMS clinicians to adjust for perceived control in unpredictable situations. Within this finding, 3 themes emerged in terms of EMS clinicians’ clinical reasoning: (1) maintaining a holistic view of the patient; (2) keeping an open mind; and (3) improving through criticism. Seven subthemes subsequently emerged from these three themes. Results This review showed that EMS clinicians’ clinical reasoning begins with the information that they are given about a patient. Based on this information, clinicians calculate the best route to the patient and which equipment to use, and they also assess potential risks. They need to be constantly aware of what is happening on the scene and with the patient and strive to control the situation. This striving also enables EMS clinicians to work safely and effectively in relation to the patient, their relatives, other clinicians, associated organizations, and the wider community. A lack of contextually appropriate guidelines results in the need for creativity and forces EMS clinicians to use “workarounds” to solve issues beyond the scope of the guidelines available. In addition, they often lack organizational support and fear repercussions such as litigation, unemployment, or blame by their EMS or healthcare organization or by patients and relatives. Conclusion Clinical reasoning is influenced by several factors. Further research is needed to determine which influencing factors can be addressed through interventions to minimize their impact on patient outcomes. Electronic supplementary material The online version of this article (10.1186/s13049-019-0646-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ulf Andersson
- Faculty of Caring Science, Work Life, and Social Welfare, University of Borås, Borås, Sweden. .,PreHospen-Centre for Prehospital Research, University of Borås, Borås, Sweden.
| | - Hanna Maurin Söderholm
- Faculty of Caring Science, Work Life, and Social Welfare, University of Borås, Borås, Sweden.,PreHospen-Centre for Prehospital Research, University of Borås, Borås, Sweden.,Swedish School of Library and Information Science, University of Borås, Borås, Sweden
| | - Birgitta Wireklint Sundström
- Faculty of Caring Science, Work Life, and Social Welfare, University of Borås, Borås, Sweden.,PreHospen-Centre for Prehospital Research, University of Borås, Borås, Sweden
| | - Magnus Andersson Hagiwara
- Faculty of Caring Science, Work Life, and Social Welfare, University of Borås, Borås, Sweden.,PreHospen-Centre for Prehospital Research, University of Borås, Borås, Sweden
| | - Henrik Andersson
- Faculty of Caring Science, Work Life, and Social Welfare, University of Borås, Borås, Sweden.,PreHospen-Centre for Prehospital Research, University of Borås, Borås, Sweden
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