COVID-19 paraclinical diagnostic tools: Updates and future trends

MOTIVATION

COVID-19 is one of the most widely affecting pandemics. As for many respiratory viruses-caused diseases, diagnosis of COVID-19 relies on two main compartments: clinical and paraclinical diagnostic criteria. Rapid and accurate diagnosis is vital in such a pandemic. On one side, rapidity may enhance management effectiveness, while on the other, coupling efficiency and less costly procedures may permit more effective community-scale management.

METHODOLOGY AND MAIN STRUCTURE

In this review, we shed light on the most used and the most validated diagnostic tools. Furthermore, we intend to include few under-development techniques that may be potentially useful in this context. The practical intent of our work is to provide clinicians with a realistic summarized review of the essential elements in the applied paraclinical diagnosis of COVID-19.

Feasibility of data linkage in the PARAMEDIC trial: a cluster randomised trial of mechanical chest compression in out-of-hospital cardiac arrest

OBJECTIVES

There is considerable interest in reducing the cost of clinical trials. Linkage of trial data to administrative datasets and disease-specific registries may improve trial efficiency, but it has not been reported in resuscitation trials conducted in the UK. To assess the feasibility of using national administrative and clinical datasets to follow up patients transported to hospital following attempted resuscitation in a cluster randomised trial of a mechanical chest compression device in out-of-hospital cardiac arrest.

METHODS

Hospital data on trial participants were requested from Hospital Episode Statistics (HES), the Intensive Care National Audit and Research Centre, and Myocardial Ischaemia National Audit Project and National Audit of Percutaneous Coronary Interventions, using unique patient identifiers. Linked data were received between June 2014 and June 2015.

RESULTS

Of 4471 patients randomised in the pre-hospital randomised assessment of a mechanical compression device in cardiac arrest (PARAMEDIC) trial, 2398 (53.6%) were not known to be deceased at emergency department arrival and were eligible for linkage. We achieved an overall match rate of 86.7% in the combined HES accident and emergency, inpatient and critical care dataset, with variable match rates (4.2%-80.4%) in individual datasets. Patient demographics, cardiac arrest-related characteristics and major outcomes were predominantly similar between HES matched and unmatched groups, in the linkage apart from location, response time and return of spontaneous circulation (ROSC) at handover.

CONCLUSIONS

This study shows that it is feasible to track patients from the prehospital setting through to hospital admission using routinely available administrative datasets with a moderate to high degree of success. This approach has the potential to complement the trial data with the demographic and clinical management information about the studied cohort, as well as to improve the efficiency and reduce the costs of follow-up in cardiac arrest trials.

CLINICAL TRIAL REGISTRATION

ISRCTN08233942; Post-results.

[Occupational aspects of emergency medicine practice in Catalonia: the OPENCAT opinion survey]

OBJECTIVES

To gather information on the contracting and training of members of the Catalan Society of Emergency Medicine (SoCMUE) who work in emergency medicine and services in Catalonia. To survey their opinions on certain aspects of resource availability and working conditions.

MATERIAL AND METHODS

Cross-sectional descriptive study based on a survey sent to SoCMUE members. We studied the opinions of 5 types of respondent: hospital physicians, out-of-hospital physicians, hospital nurses, out-of-hospital nurses, and emergency medical technicians. Responses were grouped to compare the opinions of physicians and nurses and workers in hospital and prehospital settings.

RESULTS

We received 616 responses from 1273 members (48.4% response rate). More physicians than nurses come from outside Catalonia and have contracts specifically linked to emergency care; in addition, physicians have done less postgraduate training in emergency medicine. More hospital staff than prehospital staff have permanent contracts linked to the department where they work. More hospital physicians are specialized in internal medicine than in family and community medicine. The opinion that emergency services are inadequately staffed was widespread. Most respondents believed that patient transport is good or adequate. However, respondents working in prehospital services expressed a lower opinion of transport. Great difficulty in combining work with family (life achieving work-life balance) was expressed by 13.5% overall, and more often by hospital staff. Some type of aggression was experienced by 88.2%; 60% reported the event to superiors. Nurses reported aggression more often than physicians. A police report was filed by 10.1%.

CONCLUSION

Emergency medicine working conditions can be improved in Catalonia according to members of SoCMUE. Relations between groups of professionals are not optimum in some aspects.

Evaluation of a community paramedicine health promotion and lifestyle risk assessment program for older adults who live in social housing: a cluster randomized trial

BACKGROUND

Low-income older adults who live in subsidized housing have higher mortality and morbidity. We aimed to determine if a community paramedicine program - in which paramedics provide health care services outside of the traditional emergency response - reduced the number of ambulance calls to subsidized housing for older adults.

METHODS

We conducted an open-label pragmatic cluster-randomized controlled trial (RCT) with parallel intervention and control groups in subsidized apartment buildings for older adults. We selected 6 buildings using predefined criteria, which we then randomly assigned to intervention (Community Paramedicine at Clinic [CP@clinic] for 1 yr) or control (usual health care) using computer-generated paired randomization. CP@clinic is a paramedic-led, community-based health promotion program to prevent diabetes, cardiovascular disease and falls for residents 55 years of age and older. The primary outcome was building-level mean monthly ambulance calls. Secondary outcomes were individual-level changes in blood pressure, health behaviours and risk of diabetes assessed using the Canadian Diabetes Risk Questionnaire. We analyzed the data using generalized estimating equations and hierarchical linear modelling.

RESULTS

The 3 intervention and 3 control buildings had 455 and 637 residents, respectively. Mean monthly ambulance calls in the intervention buildings (3.11 [standard deviation (SD) 1.30] calls per 100 units/mo) was significantly lower (-0.88, 95% confidence interval [CI] -0.45 to -1.30) than in control buildings (3.99 [SD 1.17] calls per 100 units/mo), when adjusted for baseline calls and building pairs. Survey participation was 28.4% (n = 129) and 20.3% (n = 129) in the intervention and control buildings, respectively. Residents living in the intervention buildings showed significant improvement compared with those living in control buildings in quality-adjusted life years (QALYs) (mean difference 0.09, 95% CI 0.01 to 0.17) and ability to perform usual activities (odds ratio 2.6, 95% CI 1.2 to 5.8). Those who received the intervention had a significant decrease in systolic (mean change 5.0, 95% CI 1.0 to 9.0) and diastolic (mean change 4.8, 95% CI 1.9 to 7.6) blood pressure.

INTERPRETATION

A paramedic-led, community-based health promotion program (CP@clinic) significantly lowered the number of ambulance calls, improved QALYs and ability to perform usual activities, and lowered systolic blood pressure among older adults living in subsidized housing. Trial registration: Clinicaltrials.gov, no. NCT02152891.

A review of enhanced paramedic roles during and after hospital handover of stroke, myocardial infarction and trauma patients

BACKGROUND

Ambulance paramedics play a critical role expediting patient access to emergency treatments. Standardised handover communication frameworks have led to improvements in accuracy and speed of information transfer but their impact upon time-critical scenarios is unclear. Patient outcomes might be improved by paramedics staying for a limited time after handover to assist with shared patient care. We aimed to categorize and synthesise data from studies describing development/extension of the ambulance-based paramedic role during and after handover for time-critical conditions (trauma, stroke and myocardial infarction).

METHODS

We conducted an electronic search of published literature (Jan 1990 to Sep 2016) by applying a structured strategy to eight bibliographic databases. Two reviewers independently assessed eligible studies of paramedics, emergency medical (or ambulance) technicians that reported on the development, evaluation or implementation of (i) generic or specific structured handovers applied to trauma, stroke or myocardial infarction (MI) patients; or (ii) paramedic-initiated care processes at handover or post-handover clinical activity directly related to patient care in secondary care for trauma, stroke and MI. Eligible studies had to report changes in health outcomes.

RESULTS

We did not identify any studies that evaluated the health impact of an emergency ambulance paramedic intervention following arrival at hospital. A narrative review was undertaken of 36 studies shortlisted at the full text stage which reported data relevant to time-critical clinical scenarios on structured handover tools/protocols; protocols/enhanced paramedic skills to improve handover; or protocols/enhanced paramedic skills leading to a change in in-hospital transfer location. These studies reported that (i) enhanced paramedic skills (diagnosis, clinical decision making and administration of treatment) might supplement handover information; (ii) structured handover tools and feedback on handover performance can impact positively on paramedic behaviour during clinical communication; and (iii) additional roles of paramedics after arrival at hospital was limited to 'direct transportation' of patients to imaging/specialist care facilities.

CONCLUSIONS

There is insufficient published evidence to make a recommendation regarding condition-specific handovers or extending the ambulance paramedic role across the secondary/tertiary care threshold to improve health outcomes. However, previous studies have reported non-clinical outcomes which suggest that structured handovers and enhanced paramedic actions after hospital arrival might be beneficial for time-critical conditions and further investigation is required.

EDTITRATE (Emergency Department Telemedicine Initiative to Rapidly Accommodate in Times of Emergency)

Objective Emergency Department (ED) patient volumes are unpredictable, which can result in service delays and patients leaving without care. We initiated a programme of emergency physician (EP) telepresence in the ED with the objectives of assessing feasibility, safety, patient and provider acceptance, and throughput time. Methods This was a prospective convenience study. Patients presenting to the ED during operation of the study who were planned for placement in the waiting room were considered for enrolment. A faculty EP conducted patient evaluations via telepresence with confirmatory evaluation by the onsite faculty EP prior to disposition. Patient care was either taken to completion by the telemedicine EP or initiated and handed off to the onsite team. Measures included patient demographics, triage class (ESI 1-5), throughput time and a single question satisfaction survey (rating 1-5, 5 most favourable) completed by patients, registered nurses and EPs. Patients were called within 3 days and the electronic health record reviewed at 7 days looking for unscheduled visits and adverse events. Results In total, 130 patients were enrolled. Mean triage class was 3.9 with a median throughput of 150 minutes (IQR = 116.5, 206). Non-telemedicine patients during the same time period with similar triage classes had a median throughput of 287 minutes (IQR = 199, 408). Mean satisfaction scores were: patient 4.91, nurse 4.75, onsite EP 4.47 and telemedicine EP 4.79. There was one potential misdiagnosis and no adverse events. Conclusion Patient evaluation by EP via telepresence is feasible, safe, readily accepted by patients and providers and associated with reduced throughput time.

Building an Australasian paramedicine research agenda: a narrative review

The need for paramedicine research has been recognised internationally through efforts to develop out-of-hospital research agendas in several developed countries. Australasia has a substantial paramedicine research capacity compared to the discipline internationally and is well positioned as a potential leader in the drive towards evidence-based policy and practice in paramedicine. Our objective was to draw on international experiences to identify and recommend the best methodological approach that should be employed to develop an Australasian paramedicine research agenda. A search and critical appraisal process was employed to produce an overview of the literature related to the development of paramedicine research agendas throughout the world. Based on these international experiences, and our own analysis of the Australasian context, we recommend that a mixed methods approach be used to develop an inclusive Australasian Paramedicine Research Agenda. This approach will capture the views and interests of a wide range of expert stakeholders through multiple data collection strategies, including interviews, roundtable discussions and an online Delphi consensus survey. Paramedic researchers and industry leaders have the opportunity to use this multidisciplinary process of inquiry to develop a paramedicine research agenda that will provide a framework for the development of a culture of open evaluation, innovation and improvement. This research agenda would assess the progress of paramedicine research in Australia and New Zealand, map the research capacity of the paramedicine discipline, paramedic services, universities and professional organisations, identify current strengths and opportunities, make recommendations to capitalize on opportunities, and identify research priorities. Success will depend on ensuring the participation of a representative sample of expert stakeholders, fostering an open and collaborative roundtable discussion, and adhering to a predefined approach to measure consensus on each topic.

Professionalism education should reflect reality: findings from three health professions

CONTEXT

Despite a growing and influential literature, 'professionalism' remains conceptually unclear. A recent review identified three discourses of professionalism in the literature: the individual; the interpersonal, and the societal-institutional. Although all have credibility and empirical support, there are tensions among them.

OBJECTIVES

This paper considers how these discourses reflect the views of professionalism as they are expressed by students and educator-practitioners in three health care professions, and their implications for education.

METHODS

Twenty focus groups were carried out with 112 participants, comprising trainee and educator paramedics, occupational therapists and podiatrists. The focus group discussions addressed participants' definitions of professionalism, the sources of their perceptions, examples of professional and unprofessional behaviour, and the point at which participants felt one became 'a professional'.

RESULTS

Analysis found views of professionalism were complex, and varied within and between the professional groups. Participants' descriptions of professionalism related to the three discourses. Individual references were to beliefs or fundamental values formed early in life, and to professional identity, with professionalism as an aspect of the self. Interpersonal references indicated the definition of 'professional' behaviour is dependent on contextual factors, with the meta-skill of selecting an appropriate approach being fundamental. Societal-institutional references related to societal expectations, to organisational cultures (including management support), and to local work-group norms. These different views overlapped and combined in different ways, creating a complex picture of professionalism as something highly individual, but constrained or enabled by context. Professionalism is grown, not made.

CONCLUSIONS

The conceptual complexity identified in the findings suggests that the use of 'professionalism' as a descriptor, despite its vernacular accessibility, may be problematic in educational applications in which greater precision is necessary. It may be better to assume that 'professionalism' as a discrete construct does not exist per se, and to focus instead on specific skills, including the ability to identify appropriate behaviour, and the organisational requirements necessary to support those skills.

Challenges ahead of emergency medical technician graduates in the workplace in Iran: a qualitative study

OBJECTIVE

Emergency medical technicians (EMTs) in Iran enter the workplace after a short academic education. Their workplace has high emotional fluctuations and imposes high pressure. The aim of this study was to assess the challenges faced by EMT graduates in Iran.

DESIGN

This applied study was conducted using qualitative content analysis. Twelve paramedics and graduates with 2 to 3 years of service were interviewed and their responses were analyzed by content analysis.

RESULTS

Findings were presented in five themes: organizational pressure, educational style, professional communication, emotional load, and misunderstanding of others.

CONCLUSION

Several problems confront EMTs in Iran. Educators and educational planners in this discipline could help resolve these problems by revising problematic points in the education and management of EMT graduates and by revising educational methods and human resource management to provide better services and save lives.

[Medical service for sports events]

The medical service for sports events is for physicians and other healthcare professionals a particular challenge, depending on type and size of the event. Planning criteria exist but only in general terms and are often inadequate, so the preparation should based principally on experience. In addition to a good cooperation with the other partners of the emergency medical services, specific accidents and clinical pictures, as well as legal implications have to observed.

Field Triage and Patient Maldistribution in a Mass-Casualty Incident

Introduction:

Management of mass-casualty incidents should optimize outcomes by appropriate prehospital care, and patient triage to the most capably facilities. The number of patients, the nature of injuries, transportation needs, distances, and hospital capabilities and availabilities are all factors to be considered. Patient maldistributions such as overwhelming individual facilities, or transport to facilities incapable of providing appropriate care should be avoided. This report is a critical view of the application of the START triage nomenclature in the prehospital arena following a train crash in Los Angeles County on 26 January 2005.

Methods:

A scheduled debriefing was held with the major fire and emergency medical services responders, Medical Alert Center staff, and hospitals to assess and review the response to the incident. Site visits were made to all of the hospitals involved. Follow-up questions were directed to emergency department staff that were on duty during the day of the incident.

Results:

The five Level-I Trauma Centers responded to the poll with the capacity to receive a total of 12 “Immediate” patients, 2.4 patients per center, the eight Level-II Trauma Centers responded with capacity to receive 17 “Immediate” patients, two patients per center, while the 25 closest community hospitals offered to accept 75 “Immediate” patients, three patients per hospital. These community hospitals were typically about one-half of the size of the trauma centers (average 287 beds versus 548, average 8.7 operating rooms versus 16.6). Twenty-six patients were transported to a community hospital >15 miles from the scene, while eight closer community hospitals did not receive any patients.

Conclusions:

The debriefing summary of this incident concluded that there were no consistently used criteria to decide ultimate destination for “Immediates”, and that they were distributed about equally between community hospitals and trauma centers.

Impact of organizational structure on vaccination of first responders: a case study

The experience of H1N1 vaccine delivery to public safety personnel in a suburban county in Florida suggests a relationship between the degree of hierarchy of an agency and successful implementation of a vaccination program for novel 2009 H1N1 influenza virus. This case study describes the structural organization of the Sheriff's Office and Fire Rescue in County X, provides timelines for vaccine program implementation and numbers of personnel vaccinated, and illustrates the impact of autonomy on the timeliness of vaccine implementation. An "emergency approval pathway" is recommended for organizations or departments that are likely to encounter delays in disaster or pandemic response due to organizational structure.

An interview with Spencer Winch

Having now worked for the Ambulance Service for nearly 10 years, my exposure to wounds would have been as early as my first shift ‘on the road.’ During a busy 12 hour shift, ambulance crews may come into contact with wounds two or three times whether it be an elderly faller, a child fallen off their bicycle, a DIY accident, an assault, a self-harming incident or a bleeding leg ulcer. Until recently, all these wounds would have had a dressing applied, and the patient transported by front-line ambulance to the nearest emergency department (ED) or minor injuries unit (MIU). A large majority of these wounds were very minor and would most likely have required nothing more than a thorough clean, a neurovascular assessment and basic closure with steri-strips, tissue adhesive or suturing. But, there was no personnel within the ambulance service qualified to assess and close these wounds in the pre-hospital environment. This transport to hospital did not benefit the patient, the Ambulance Service or the receiving treatment centre, and so, the emergency care practitioner (ECP) role has evolved and was borne from the recommendations set out in the Department of Health’s (2005) paper Taking Healthcare to the Patient Transforming NHS Ambulance Services. One of the visions was that:

Characterizing job satisfaction and intent to leave among nationally registered emergency medical technicians: an analysis of the 2005 LEADS survey

The primary purpose of this study was to characterize job satisfaction with opportunities for advancement, job satisfaction with pay and benefits, and intent to leave the EMS profession among Nationally Registered EMT-Basics and EMT-Paramedics. A secondary data analysis was performed on the National Registry of EMTs Longitudinal Emergency Medical Technician Attributes and Demographic Study Project (LEADS) 2005 core survey. We used chi-square and multiple logistic regression analyses to test for differences in job satisfaction with opportunities for advancement, job satisfaction with pay and benefits, and intent to leave the EMS profession across years of experience and work location. Among 11 measures of job satisfaction, NREMT-Basics and NREMT-Paramedics were least satisfied with opportunities for advancement and pay and benefits (67.8 and 55.2%, respectively). Nearly 6% of respondents reported intentions of leaving the profession within 12 months. In univariate analyses, job satisfaction with advancement opportunities varied across years of experience and work location. Job satisfaction with pay and benefits varied across years of experience and work location. The proportion reporting intentions of leaving the profession did not vary across the two independent variables of interest. In multivariable logistic regression, statistical differences observed in univariate analyses were attenuated to non-significance across all outcome models. Income, personal health, level of EMS certification, and type of EMS work were significant in several outcome models. EMS workforce research is at its infancy, thus our study adds to a limited but growing body of knowledge. In future and replicated research, one will need to consider different person and organizational variables in predicting different measures of job satisfaction among EMS personnel.

Organizational description and emergency preparedness of Nationally Registered First Responders

INTRODUCTION

This study intended to describe the types of organizations and communities in which Nationally Registered First Responders (NRFR) perform their duties. Also, it aimed to estimate the number of NRFR who received disaster preparedness training. It was hypothesized that NRFR participation in disaster preparedness training was related to the types of organizations and communities in which they performed their duties.

METHODS

The NRFR re-registering in 2006 were asked to report the organization type and community size in which they work. They also were asked to report the amount and content of preparedness training received during the last 24 months. Multivariable logistic regression modeling was utilized to describe the relationship between NRFR organizational characteristics and the receipt of disaster preparedness training.

RESULTS

The analysis included 872 (59%) individuals who completed the survey and reported working for one or more emergency medical services (EMS) organizations. The majority of NRFR performed work in rural areas (75%) and more NRFR reported working for fire departments (61%) than for any other organization type. In all categories of service type, participants who reported working in urban areas had higher odds of receiving disaster preparedness training than those working in rural areas. Additionally, regardless of community size, individuals working in fire departments were more likely to receive disaster preparedness training.

CONCLUSIONS

This study indicated that the majority of NRFR perform EMS duties for fire departments and work in rural communities. In this sample of NRFR, more than one-quarter did not receive disaster preparedness training within a 24-month period. Finally, a statistical model was constructed that indicated a relationship between service type, community size, and the participation in disaster preparedness training.

Engaging rural communities in health care through a paramedic expanded scope of practice

INTRODUCTION

This article explores how community engagement by paramedics in an expanded scope role contributes to both primary health care and to an overall improved emergency response capacity in rural communities. Understanding how expanded scope paramedics (ESP) can strengthen community healthcare collaborations is an important need in rural areas where low workforce numbers necessitate innovation.

METHODS

Four examples of Australian rural ESP roles were studied in Tasmania, New South Wales, South Australia and Victoria to gather information on consistent elements that could inform a paramedic expanded scope model. Qualitative data were collected from semi-structured interviews with key stakeholders and organisational documents. Thematic analysis within and across cases found community engagement was a key element in the varied roles. This article relies heavily on data from the Victorian and Tasmanian case studies because community engagement was a particularly strong aspect of these cases.

RESULTS

The ESP in the case studies increased interactions between ambulance services and rural communities with an overall benefit to health care through: increasing community response capacity; linking communities more closely to ambulance services; and increasing health promotion and illness prevention work at the community level. Leadership, management and communication skills are important for paramedics to successfully undertake expanded scope roles.

CONCLUSION

ESP in rural locations can improve health care beyond direct clinical skill by active community engagement that expands the capacity of other community members and strengthens links between services and communities. As health services look to gain maximum efficiency from the health workforce, understanding the intensification of effort that can be gained from practitioner and community coalitions provides important future directions.

Collaborative practices in unscheduled emergency care: role and impact of the emergency care practitioner--qualitative and summative findings

OBJECTIVE

To identify collaborative instances and hindrances and to produce a model of collaborative practice.

METHODS

A 12-month (2005-2006) mixed methods clinical case study was carried out in a large UK ambulance trust. Collaboration was measured through direct observational ratings of communication skills, teamwork and leadership with 24 multi-professional emergency care practitioners (ECPs), interviews with 45 ECPs and stakeholders, and an audit of 611 patients

RESULTS

Using a generic qualitative approach, observational records and interviews showed that ECPs' numerous links with other professions were influenced by three major themes as follows. (i) The ECP role: for example, "restricted transport codes" of communication, focus on reducing admissions, frustrations about patient tasking and conflicting views about leadership and team work. (ii) Education and training: drivers for multi-professional clinically focussed graduate level education, requirements for skill development in minor injury units (MIUs) and general practice, and the need for clinical supervision/mentorship. (iii) Cultural perspectives: a "crew room" blue collar view of inter-professional working versus emerging professional white collar views, power and communication conflicts, and a lack of understanding of the ECPs' role. The quantitative findings are reported elsewhere.

CONCLUSIONS

The final model of collaborative practice suggests that ECPs are having an impact on patient care, but that improvements can be made. We recommend the appointment of ECP clinical leads, degree level clinically focussed multi-professional education, communication skills training, clinical supervision and multi-professional ECP appointments.

Collaborative practices in unscheduled emergency care: role and impact of the emergency care practitioner--quantitative findings

OBJECTIVE

To identify collaborative instances and hindrances and to produce a model of collaborative practice.

METHODS

A 12 month (2005-6) mixed methods clinical case study in a large UK ambulance trust. Collaboration was measured through direct observational ratings of communication skills, teamwork and leadership with 24 multiprofessional emergency care practitioners (ECPs); interviews with 45 ECPs and stakeholders; and an audit of 611 patients.

RESULTS

Quantitative observational ratings indicated that the higher the leadership rating the greater the communication ability (p < or = 0.001) and teamwork (p < or = 0.001), and the higher grade ECPs were rated more highly on their leadership performance. From the patient audit, influences and outputs of collaborative practice are revealed: mean time on scene was 47 mins; 62% were not conveyed; 38% were referred, mainly to accident and emergency; ECPs claimed to make the referral decision in 87% of cases with a successful referral in 96% of cases; and in 66% of cases ECPs claimed that their intervention prevented an acute trust admission. The qualitative interview findings, final collaborative model and recommendations are reported in another paper.

CONCLUSIONS

The collaborative performance of ECPs varies, but the ECPs' role does appear to have an impact on collaborative practices and patient care. Final recommendations are reported with the qualitative results elsewhere.

Expanding the Public Health Emergency Preparedness Competency Set to Meet Specialized Local and Evolving National Needs

This article presents an approach to competency development created at the South Central Center for Public Health Preparedness to expand and refine existing competency sets for public health emergency responders. The technique uses course content generated by subject matter experts to validate and expand existing national competency sets. New competencies based on local needs were identified that provide coverage of subject matter appropriate to local public health emergency responders beyond the focus of existing national competency sets.

Will first-responders show up for work during a pandemic? Lessons from a smallpox vaccination survey of paramedics

Background

The presence of H5N1 influenza in Southeast Asia has reawakened fears of a worldwide influenza pandemic of the sort that occurred in 1918. It is estimated that up to 1.9 million people in the United States could die if such an outbreak occurs. It is unlikely that a vaccine for a pandemic strain will be available quickly enough to protect first-responders. Similar concerns existed in 2002 when the United States attempted to vaccinate first-responders against smallpox, a potential biologic weapon.

Method

We conducted a survey of one group of first-responders, paramedics, to determine if fear of infection would compromise their ability to care for persons potentially infected with smallpox.

Results

Three hundred paramedics were given the survey, and 95 (32%) responded. More than 80% of paramedics polled would not remain on duty if there were no vaccine and no protective gear. Even if protective gear was available but the vaccine was unavailable, only 39% of respondents would remain on duty. Finally, although 91% of paramedics would remain on duty if they were fully protected, this number falls to 38% if the respondent believed that his or her immediate family was not protected. The results of this survey are relevant to current concerns about an influenza pandemic. Every effort must be made to protect first-responders from pandemic influenza and educate them about it.

Patient handover: Time for a change?

BACKGROUND

Receiving a patient handover from an ambulance crew occurs many times during the day across the country. Handover has major implications for subsequent patient care but there has been little investigation of the handover process between ambulance and emergency department staff.

METHODS

Four emergency departments and one ambulance service were included within one geographical area in the UK. The research was based on a quantitative approach using a descriptive, non-experimental cross-sectional survey. A questionnaire was distributed to a convenience sample of ambulance paramedics and emergency department nurses and doctors. The questionnaire was constructed using mainly closed questions with some qualitative date collected through open questions. Data was analysed using SPSS version 11.5.

RESULTS

Of the 101 questionnaires distributed, a total of 80 (68%) participants contributed towards the study. The results indicated emergency department staff need to appreciate that a lack of active listening skills can lead to frustration for ambulance staff. Ambulance staff must expect to repeat their handover, especially for patients in the resuscitation room. Handovers for critically ill patients should be delivered in two phases, with essential information given immediately and again thereafter to give further information when initial treatment has been undertaken.

RECOMMENDATIONS

Suggestions are made for improving handovers by developing national guidelines and by incorporating handover in emergency department education.

Basic Life Support Ventilation in Mountain Rescue

Cardiopulmonary resuscitation in the mountains usually has to be performed under difficult and hostile circumstances and sometimes for extended periods of time. Therefore, mountain rescuers should have the ability and the appropriate equipment to perform prolonged, efficient, and safe ventilation. Members of the International Commission for Mountain Emergency Medicine (ICAR MEDCOM) discussed the results of a literature review, focusing on the advantages and disadvantages of common ventilation techniques in basic life support and their training methods with specific respect to use in mountain rescue, and recommendations were proposed. Bystanders fear the potential risk of infection and lack the willingness to perform mouth-to-mouth ventilation, though the risk of infection is low. Mouth-to-mouth ventilation remains the standard technique for bystander ventilation and, in the absence of a barrier device, bystanders should not hesitate to ventilate a patient by this technique. For mountain rescue teams, we encourage the use of a barrier device for artificial ventilation. Mouth-to-mask ventilation devices are most likely to fulfill the requirements of being safe, simple, and efficient in the hands of a basic-trained rescuer. The use of a mouth-to-mask ventilation device is recommended for out-of-hospital ventilation in the mountains and should be part of the mountain rescuer's standard equipment. Bag-valve-mask ventilation is efficient, if performed by well-trained rescuers, but it leads to a low ventilation quality in the hands of a less experienced rescuer. It should be emphasized that regular training every 6 to 12 months is necessary to perform proper ventilation.

Home delivery. Interview by Barbara Millar

Nurse/paramedic teams act as first responders to some emergency calls and prevent unnecessary A&E admissions.