Patients' perspectives on point-of-care diagnostics and treatment by emergency medical technicians in acute COPD exacerbations: A qualitative study

Point-of-care tests in the emergency medical services: a scoping review

BACKGROUND

This scoping review aimed to summarize existing research on point-of-care tests (POCTs) within emergency medical services (EMS). There is a lack of comprehensive reviews covering the breadth and scope of application of POCTs in EMS despite growing interest and potential benefits in this setting. A review of the research will inform how we target future research efforts to support effective implementation and avoid duplication.

METHODS

We searched three databases to April 2023 using comprehensive terms for POCTs. One author screened titles and abstracts, full-text papers and extracted data with a second author checking the data. A scoping review framework was used to categorise studies according to demographics, study design, medical conditions, biomarkers and test devices.

RESULTS

We found 141 papers that included 158 reports of 9 study designs, 155 reports of 40 combinations of biomarker and condition and 161 reports of 41 test-devices. The majority of research was done in the UK (19%), US (17%), and the Netherlands (16%), mostly in land-based EMS (82%). Most frequently assessed were troponin for acute coronary syndromes (26%), lactate for sepsis (14%) or lactate for trauma/critical illness (13%). The majority of research designs investigated the accuracy of the tests (43%). Few studies were of a design to inform guidelines to change patient pathways and the associated outcomes, including, randomised controlled trials (RCTs) (4%), non-randomised studies able to assess causality (6%), economic analyses (1%) or qualitative work on acceptability (3%). In those few cases where RCTs were done there were long delays between initial test-accuracy research and publication of the first RCT, for example 11 years delay for troponin for acute coronary syndromes.

CONCLUSIONS

We identified a thriving base of research on POCT in the EMS, however most studies established the diagnostic accuracy of the tests with few RCTs, economic analyses or qualitative research on acceptability. The time-lag from diagnostic accuracy to developing an RCT is considerable. Investment in funding and infrastructure is needed to support the research pathway for potential POCTs beyond diagnostic accuracy to designs able to assess clinical effectiveness, acceptability and economic effectiveness.

Factors influencing the implementation of early discharge hospital at home and admission avoidance hospital at home: a qualitative evidence synthesis

BACKGROUND

Worldwide there is an increasing demand for Hospital at Home as an alternative to hospital admission. Although there is a growing evidence base on the effectiveness and cost-effectiveness of Hospital at Home, health service managers, health professionals and policy makers require evidence on how to implement and sustain these services on a wider scale.

OBJECTIVES

(1) To identify, appraise and synthesise qualitative research evidence on the factors that influence the implementation of Admission Avoidance Hospital at Home and Early Discharge Hospital at Home, from the perspective of multiple stakeholders, including policy makers, health service managers, health professionals, patients and patients' caregivers. (2) To explore how our synthesis findings relate to, and help to explain, the findings of the Cochrane intervention reviews of Admission Avoidance Hospital at Home and Early Discharge Hospital at Home services.

SEARCH METHODS

We searched MEDLINE, CINAHL, Global Index Medicus and Scopus until 17 November 2022. We also applied reference checking and citation searching to identify additional studies. We searched for studies in any language.

SELECTION CRITERIA

We included qualitative studies and mixed-methods studies with qualitative data collection and analysis methods examining the implementation of new or existing Hospital at Home services from the perspective of different stakeholders.

DATA COLLECTION AND ANALYSIS

Two authors independently selected the studies, extracted study characteristics and intervention components, assessed the methodological limitations using the Critical Appraisal Skills Checklist (CASP) and assessed the confidence in the findings using GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research). We applied thematic synthesis to synthesise the data across studies and identify factors that may influence the implementation of Hospital at Home.

MAIN RESULTS

From 7535 records identified from database searches and one identified from citation tracking, we included 52 qualitative studies exploring the implementation of Hospital at Home services (31 Early Discharge, 16 Admission Avoidance, 5 combined services), across 13 countries and from the perspectives of 662 service-level staff (clinicians, managers), eight systems-level staff (commissioners, insurers), 900 patients and 417 caregivers. Overall, we judged 40 studies as having minor methodological concerns and we judged 12 studies as having major concerns. Main concerns included data collection methods (e.g. not reporting a topic guide), data analysis methods (e.g. insufficient data to support findings) and not reporting ethical approval. Following synthesis, we identified 12 findings graded as high (n = 10) and moderate (n = 2) confidence and classified them into four themes: (1) development of stakeholder relationships and systems prior to implementation, (2) processes, resources and skills required for safe and effective implementation, (3) acceptability and caregiver impacts, and (4) sustainability of services.

AUTHORS' CONCLUSIONS

Implementing Admission Avoidance and Early Discharge Hospital at Home services requires early development of policies, stakeholder engagement, efficient admission processes, effective communication and a skilled workforce to safely and effectively implement person-centred Hospital at Home, achieve acceptance by staff who refer patients to these services and ensure sustainability. Future research should focus on lower-income country and rural settings, and the perspectives of systems-level stakeholders, and explore the potential negative impact on caregivers, especially for Admission Avoidance Hospital at Home, as this service may become increasingly utilised to manage rising visits to emergency departments.

Prehospital Release of Patients After Treatment in an Anesthesiologist-Staffed Mobile Emergency Care Unit

IMPORTANCE

Prehospital treatment and release of patients may reduce unnecessary transports to the hospital and may improve patient satisfaction. However, the safety of patients should be paramount.

OBJECTIVE

To determine the extent of unplanned emergency department (ED) contacts, short-term mortality, and diagnostic patterns in patients treated and released by a prehospital anesthesiologist supervising a mobile emergency care unit (MECU).

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study used a manual review of prehospital and in-hospital medical records to investigate all living patients who were treated and released by an MECU in Odense, Denmark, between January 1, 2011, and December 31, 2020. Patients were followed up for 30 days after initial contact with the prehospital service.

MAIN OUTCOMES AND MEASURES

Primary outcome measures included unplanned contacts with the emergency department less than 48 hours after prehospital treatment and prehospital assigned diagnosis. Secondary outcomes consisted of mortality at 48 hours and 7 and 30 days.

RESULTS

A total of 3141 patients were identified; 384 were excluded and 2757 were included in the analysis. The median patient age was 40 (IQR, 14-66) years; 1296 (47.0%) were female and 1461 (53.0%) were male. Two hundred thirty-nine patients (8.7% [95% CI, 7.6%-9.8%]) had unplanned contact with the ED within 48 hours; this rate was doubled for patients with respiratory diseases (37 of 248 [14.9% (95% CI, 10.7%-20.0%)]). Fifty-nine of 60 patients who died within 48 hours of release had terminal illness. Excluding these patients, the mortality rates were 0.04% at 48 hours, 0.8% at 7 days, and 2.4% at 30 days. Two thousand sixty-one patients (74.8%) had primarily nondefinitive observational diagnoses.

CONCLUSIONS AND RELEVANCE

The findings of this cohort study suggest that prehospital treatment and subsequent release at the scene is safe. One patient in 12 attended the ED within the ensuing 48 hours. However, for patients with respiratory diseases, this rate was doubled. Hospital admission could be avoided for some patients in the end stage of a terminal illness.