Pre-hospital Emergency Anaesthesia (PHEA) is regarded as one of the highest risk interventions that pre-hospital providers perform. AAGBI guidance from 2017 suggests the use of Key Performance ...Indicators (KPIs) to audit PHEA quality. The aim of this study was to develop KPIs for use in our service and evaluate their impact.
Using the AAGBI 2017 document as a guide we developed a list of ten auditable domains. Data for each case was extracted from the Electronic Patient Record (EPR) and a score assigned to each of the domains; one if the domain is achieved and zero if the domain is not achieved or if data is missing, giving a total score out of ten. This analysis is then presented as a colour-coded matrix alongside the score. Data were analysed monthly at our case review and governance meeting. The process was refined during the year and after 12 months a formal review of the KPI process occurred.
Eighty-two cases were analysed. Domains with the highest percentage of achievement were: Indication 96%; Tube position confirmed 94% and Full AAGBI monitoring and Grade of view < 3 both 89%. The amount of missing data declined throughout the year. The results of the clinician survey showed that almost all respondents found the TVAA PHEA review process useful.
The KPI process has demonstrated areas of good quality practice and led to improvements in equipment, processes and documentation and therefore patient care. We offer suggestions to other organisations considering implementing KPIs for PHEA.
Rapid sequence induction: where did the consensus go? Avery, Pascale; Morton, Sarah; Raitt, James ...
Scandinavian journal of trauma, resuscitation and emergency medicine,
05/2021, Letnik:
29, Številka:
1
Journal Article
Recenzirano
Odprti dostop
Rapid Sequence Induction (RSI) was introduced to minimise the risk of aspiration of gastric contents during emergency tracheal intubation. It consisted of induction with the use of thiopentone and ...suxamethonium with the application of cricoid pressure. This narrative review describes how traditional RSI has been modified in the UK and elsewhere, aiming to deliver safe and effective emergency anaesthesia outside the operating room environment. Most of the key aspects of traditional RSI - training, technique, drugs and equipment have been challenged and often significantly changed since the procedure was first described. Alterations have been made to improve the safety and quality of the intervention while retaining the principles of rapidly securing a definitive airway and avoiding gastric aspiration. RSI is no longer achieved by an anaesthetist alone and can be delivered safely in a variety of settings, including in the pre-hospital environment.
The conduct of RSI in current emergency practice is far removed from the original descriptions of the procedure. Despite this, the principles - rapid delivery of a definitive airway and avoiding aspiration, are still highly relevant and the indications for RSI remain relatively unchanged.
Despite low out of hospital cardiac arrest (OOHCA) survival rates within the UK, animal studies hint at improved cerebral blood flow via a bundled neuroprotective CPR approach. The CABARET study ...introduces three key devices: the Head Up Position (HUP), Active Compression/Decompression (ACD) CPR, and the Impedance Threshold Device (ITD). A survey involving 27 UK pre-hospital critical care services indicated none are using these interventions widely, either alone or bundled. The CABARET team is now initiating a pilot study to investigate the feasibility of this CPR bundle, aiming to fill the prevailing evidence void in resuscitation research.
The risk of COVID-19 transmission to healthcare professionals is likely to continue for the foreseeable future. The wearing of personal protective equipment (PPE) presents a number of potential ...challenges to responders that may impact upon the management of patients in a multi-casualty incident. This report describes a multi-agency multi-casualty incident. It identifies learning points specifically related to the challenges of conducting a conventional multi-casualty incident in COVID-19 PPE.
The multi casualty incident in Reading, UK on the 20 June 2020 involved six stab injury victims and was attended by four pre-hospital critical care teams. This was the first conventional multi-casualty incident that pre-hospital critical care teams had attended during the COVID-19 era and it was conducted in COVID-19 PPE (1). The scene was an urban park where three patients were confirmed to be in Traumatic Cardiac Arrest (TCA) from stab wounds and another three patients had also suffered stab injuries. By the time the incident had concluded three patients were pronounced dead at the scene. Two patients were transported to the local trauma unit and one patient was transported to the regional Major Trauma Centre depending on the severity of their injuries.
We conducted a semi structured telephone interview with the critical care clinicians who were involved in the incident. The interviews focused specifically on the challenges of responding whilst wearing COVID-19 PPE, rather than the wider challenges of responding to such an incident. The key learning points identified were: Improving the identifiability of clinicians in level 3 PPE wearing identification tabards using visible labelling on PPE suits Improving communication by radio using a belt to carry the radio using an earpiece and push to talk system. Training in conducting multi casualty incidents in level 3 PPE.
Introduction
Thames Valley Air Ambulance have carried two units of red blood cells on board both the aircraft and rapid response car since 2014.
Methods
A retrospective database narrative review of ...patients receiving blood was carried out.
Results
Data were analysed for 63 patients, the age range was 13 years to 89 years and 74.6% were male. Blunt trauma was the mechanism of injury in 84%. Overall, 16% of patients died at scene, 32% died either in the Emergency Department or as a hospital inpatient and 52% survived to discharge. There were no survivors from traumatic cardiac arrest who received blood products. Injury Severity Scores (ISS) ranged from 4 to 75, and 95% of the patients for whom data were available had an Injury Severity Scores greater than 15.
Discussion
Patients who received pre-hospital blood transfusions were overwhelmingly those with high Injury Severity Scores and the majority who survived to hospital received additional blood products on arrival. This suggests that our pre-hospital blood transfusions were correctly targeted to severely injured patients who had a need for blood transfusion in hospital.
To conduct a systematic review of the use of the recovery position in adults and children with non-traumatic decreased levels of responsiveness changes outcomes in comparison with other positioning ...strategies.
We searched Medline (Ovid), Embase, Cochrane Library, CINAHL, medRxiv and Google Scholar from inception to 15 March 2021 for studies involving adults and children in an out-of-hospital, first aid setting who had reduced levels of responsiveness of non-traumatic aetiology but did not require resuscitative interventions. We used the ROBINS-I tool to assess risk of bias and GRADE methodology to determine the certainty of evidence.
Of 17,947 citations retrieved, three prospective observational studies and four case series were included. The prone and semi-recumbent positions were associated with a decreased rate of suspected aspiration pneumonia in acute poisoning. Use of the recovery position in paediatric patients with decreased levels of responsiveness was associated with a deceased admission rate and the prone position was the position most commonly associated with sudden unexpected death in epilepsy. High risk of bias, imprecision and indirectness of evidence limited our ability to perform pooled analyses.
We identified a limited number of observational studies and case series comparing outcomes following use of the recovery position with outcomes when other patient positions were used. There was limited evidence to support or revise existing first aid guidance; however, greater emphasis on the initial assessment of responsiveness and need for CPR, as well as the detection and management of patient deterioration of a person identified with decreased responsiveness, is recommended.
Summary
Objective
In this article, we describe how we developed and validated key performance indicators (KPIs) for pre‐hospital blood transfusion and offer suggestions for other organisations ...wishing to develop performance metrics.
Background
KPIs are metrics that compare actual care against an ideal structure, process or outcome standard. An increasing number of UK‐based pre‐hospital critical care services now carry blood components to enable pre‐hospital blood transfusion.
Methods
A working group of pre‐hospital physicians and paramedics was formed to create and validate performance indicators that reflected a high‐quality pre‐hospital transfusion. This was performed by literature searching and reviewing consensus documents that guide the best practice and then adjusting the indicators as the process evolved.
Results
Throughout the year, the performance against the domains was monitored monthly and outputs communicated within the clinical staff of the organisation; at the end of the year, the domains were amended. The final list of performance indicators was as follows: (a) rationale for transfusion documented in the notes; (b) rationale for transfusion in line with Thames Valley Air Ambulance blood transfusion guideline; (c) aggressive management of hypothermia; (d) tranexamic acid administered within an hour of injury; (e) evidence of bleeding in hospital; (f) monitoring of adverse effects of blood transfusion; (g) overall—was the use of blood justified; and (h) no units wasted this month.
Conclusions
This study has shown that it is feasible to devise and implement clinical performance indicators for pre‐hospital blood transfusion and that their use has increased the focus on this important area.
HEMS dispatch: A systematic review Eaton, Georgette; Brown, Simon; Raitt, James
Trauma,
01/2018, Letnik:
20, Številka:
1
Book Review, Journal Article
Recenzirano
Odprti dostop
Introduction
Helicopter emergency medical services dispatch is a contentious issue in modern prehospital services. Whilst the link between helicopter emergency medical services and improved patient ...outcome is well evidenced, allocation to the most appropriate incidents remains problematic. It is unclear which model of deployment is the most efficient at targeting major trauma and whether this can be improved with a change in dispatch process. The objective of this study was to have an overview of the evidence for dispatch models of helicopter emergency medical services to critically ill or injured patients.
Methods
This systematic review was conducted in accordance with a protocol developed from the PRISMA guidelines. MEDLINE, Embase, CINAHL and the Cochrane library were searched focusing on keywords involving dispatch of helicopter emergency medical services resources.
Results
Ninety-seven articles were screened and 14 articles were eligible for inclusion. Most were of low quality, with three of moderate quality. Heterogeneity in the methodology of included articles precluded meta-analysis, so a narrative review was performed.
Conclusions
This review demonstrates the lack of evidence surrounding helicopter emergency medical services dispatch models. Whilst it is not possible to identify a method of dispatch that will optimize helicopter emergency medical services allocation, common themes within the literature indicate that helicopter emergency medical services use is region specific and dispatch criteria should be designed to match specific systems. Additionally, mechanism of injury as well as physiological data from scene was shown to be the most accurate indicator for helicopter emergency medical services attendance.
Prehospital critical care is a rapidly evolving field. There is a paucity of evidence relating to its practice, with limited progress in answering those research questions identified over a decade ...ago. It is vital that evidence gaps are identified and addressed. This study aimed to define the current research priorities in UK prehospital critical care.
This modified national Delphi study was coordinated by the Pre-HOspital Trainee Operated research Network and conducted in four rounds between October 2021 and April 2022. Rounds 1 and 2 were conducted online with clinicians involved in prehospital critical care delivery and non-clinical prehospital researchers. Rounds 3 and 4 were completed online by a subject matter expert (SME) panel.
In round 1, 78 participants submitted 394 research questions relating to prehospital critical care delivery in the UK. These were refined and categorised into 192 questions, which were scored for importance in round 2. Fifty questions were discussed and scored by the SME panel in round 3. Round 4 created a ranked top 20 list. The top research priority was 'Which cardiac arrest patients should critical care teams be dispatched to; how do we identify these patients during the emergency call?'. Other priorities included dispatch optimisation, out-of-hospital medical cardiac arrest management, optimising resuscitation in haemorrhagic shock, improving traumatic brain injury outcomes and optimising management of traumatic cardiac arrest.
This modified Delphi study identified 20 research priorities where efforts should be concentrated to develop collaborative prehospital critical care research within the UK over the next 5 years.
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