Challenges and opportunities to improve efficiency and quality of prehospital emergency care using an mHealth platform: Qualitative study in Rwanda

Introduction: Prompt, high-quality pre-hospital emergency medical services (EMS) can significantly reduce morbidity and mortality. The goal of this study was to identify factors that compromise efficiency and quality of pre-hospital emergency care in Rwanda, and explore the opportunities for a mobile health (mHealth) tool to address these challenges. Methods: In-depth interviews were conducted with 21 individuals representing four stakeholder groups: EMS dispatch staff, ambulance staff, hospital staff, and policymakers. A semi-structured interview guide explored participants' perspectives on all aspects of the pre-hospital emergency care continuum, from receiving a call at dispatch to hospital handover. Participants were asked how the current system could be improved, and the potential utility of an mHealth tool to address existing challenges. Interviews were audio-recorded, and transcripts were thematically analyzed using NVivo. Results: Stakeholders identified factors that compromise the efficiency and quality of care across the prehospital emergency care continuum: triage at dispatch, dispatching the ambulance, locating the emergency, coordinating patient care at scene, preparing the receiving hospital, and patient handover to the hospital. They identified four areas where an mHealth tool could improve care: efficient location of the emergency, streamline communication for decision making, documentation with real-time communication, and routine data for quality improvement. While stakeholders identified advantages of an mHealth tool, they also mentioned challenges that would need to be addressed, namely: limited internet bandwidth, capacity to maintain and update software, and risks of data security breaches that could lead to stolen or lost data. Conclusion: Despite the success of Rwanda's EMS system, this study highlights factors across the care continuum that could compromise quality and efficiency of prehospital emergency care. Mobile health tools hold great promise to address these challenges, but contextual issues need to be considered to ensure sustainability of use.

Transfer of pre-hospital care and its potential risks for patient safety / Transferencia de atención prehospitalaria y sus riesgos potenciales para la seguridad del paciente / Transferência do cuidado pré-hospitalar e seus potenciais riscos para segurança do paciente

ABSTRACT Objective: to identify potential risks to patient safety during the transfer of pre-hospital care. Method: a descriptive-exploratory study, with a qualitative approach. Data collection occurred between April and June 2018, with non-participant observation and semi-structured interview, in a Mobile Emergency Care Service in the Southern Brazil. Twenty-eight professionals were interviewed, including nursing technicians/auxiliaries, nurses and physicians, and 135 hours of care were observed. The data were submitted to thematic analysis. Results: two interrelated categories emerged a) Stakeholders in patient and team safety; and b) The (inter) personal/professional dimension of the transfer of care. The study's findings showed that, in addition to the inherent vulnerabilities to traffic and urban violence, patients are exposed to circumstances that include potential risks related to falling on stretchers, medication errors and clinical judgment. The vertical communication by hierarchies, influenced by personal and emotional factors of each professional, generated implications for the continuity of care. Conclusion: given the potential risks to patient safety at the time of transfers of pre-hospital care, one should invest in effective communication strategies, as well as in forms of interpersonal relationships and links between services in the emergency network.

RESUMEN Objetivo: identificar riesgos potenciales para la seguridad del paciente durante la transferencia de la atención prehospitalaria. Método: estudio descriptivo-exploratorio, con enfoque cualitativo. La recopilación de datos se produjo entre abril y junio de 2018, con observación no participante y entrevista semiestructurada, en un Servicio móvil de atención de emergencia en el sur de Brasil. Se entrevistó a 28 profesionales, incluidos técnicos / auxiliares de enfermería, enfermeras y médicos, y se observaron 135 horas de atención. Los datos fueron sometidos a análisis temático. Resultados: surgieron dos categorías interrelacionadas a) Partes interesadas en la seguridad del paciente y del equipo; y b) La dimensión (inter) personal / profesional de la transferencia de atención. Los hallazgos del estudio mostraron que, además de las vulnerabilidades inherentes al tráfico y la violencia urbana, los pacientes están expuestos a circunstancias que incluyen riesgos potenciales relacionados con la caída en camillas, errores de medicación y juicio clínico. La comunicación vertical por jerarquías, influenciada por factores personales y emocionales de cada profesional, generó implicaciones para la continuidad de la atención. Conclusión: dados los riesgos potenciales para la seguridad del paciente en el momento de las transferencias de atención prehospitalaria, uno debe invertir en estrategias de comunicación efectivas, así como en formas de relaciones interpersonales y vínculos entre los servicios en la red de emergencia.

RESUMO Objetivo: identificar potenciais riscos para a segurança do paciente durante a transferência do cuidado pré-hospitalar. Método: estudo do tipo descritivo-exploratório, com abordagem qualitativa. A coleta de dados ocorreu entre abril e junho de 2018, com observação não-participante e entrevista semiestruturada, em um Serviço de Atendimento Móvel de Urgência da região Sul, Brasil. Foram entrevistados 28 profissionais incluindo técnicos/auxiliares de enfermagem, enfermeiros e médicos e observadas 135 horas de atendimentos. Os dados foram submetidos à análise temática. Resultados: emergiram duas categorias inter-relacionadas: a) Intervenientes na segurança do paciente e da equipe; e b) A dimensão (inter)pessoal/profissional da transferência do cuidado. Os achados do estudo mostraram que, além das vulnerabilidades inerentes ao trânsito e à violência urbana, os pacientes estão expostos a circunstâncias que incluem potenciais riscos relacionados à queda de macas, aos erros de medicação e de julgamento clínico. A comunicação verticalizada pelas hierarquias, influenciada por fatores pessoais e emocionais de cada profissional, geraram implicações para a continuidade do cuidado. Conclusão: diante dos potenciais riscos à segurança do paciente no momento das transferências do cuidado pré-hospitalar, deve-se investir em estratégias de comunicação eficaz, bem como em formas de melhorar as relações interpessoais e a articulação entre os serviços na rede de urgências.

Comunicação de informações entre as equipes de saúde na transferência do cuidado pré-hospitalar: implicações para a segurança dos pacientes / Communication of information between healthcare teams in the transfer of pre-hospital care: implications for patient safety

Estudo com objetivo de analisar a comunicação de informações entre as equipes de saúde na transferência do cuidado pré-hospitalar e as suas implicações para a segurança do paciente. Delineamento descritivo-exploratório, com abordagem qualitativa, realizado no Serviço de Atendimento Móvel de Urgência ­ SAMU 192 de Porto Alegre- RS. Participaram do estudo médicos, enfermeiros e técnicos/auxiliares de enfermagem envolvidos na assistência às vítimas. Os dados foram coletados por meio de observação não-participante e entrevista semiestruturada, realizados nos meses de abril a junho de 2018. Foram entrevistados 28 profissionais e observados 34 períodos com média de 4 horas de duração. Projeto aprovado pelo Comitê de Ética em Pesquisa da instituição proponente e da instituição coparticipante. Os dados foram submetidos à análise de conteúdo e resultaram nas categorias: (1) caracterização das informações; (2) circunstâncias que dificultam a transferência do cuidado; (3) circunstâncias que contribuem para transferência do cuidado; (4) intervenientes na segurança do paciente e da equipe; (5) a dimensão (inter)pessoal/profissional da transferência do cuidado. A primeira categoria incluiu aspectos referentes à qualidade e completude das informações coletadas, registras e transferidas. A segunda categoria contemplou a falta de padronizações durante as transferências do cuidado, a superlotação dos serviços e a forma como o SAMU e os pacientes são recebidos pelas equipes que darão continuidade ao cuidado. Na terceira categoria, foram apontadas as pactuações na rede de atenção às urgências e emergências e a visibilidade dos casos graves nas transferências do cuidado. A quarta categoria aborda as diferentes perspectivas entre os serviços e os diversos riscos para o paciente e equipe durante o transporte e transferência do cuidado. A quinta categoria revelou que uma comunicação verticalizada pelas hierarquias, é influenciada por características pessoais e emocionais e influencia na qualidade das transferências. Concluiu-se que são necessários investimentos, como a elaboração de protocolos e a realização de treinamentos específicos para o processo de comunicação de informações entre as equipes de saúde na transferência do cuidado pré-hospitalar, visando o incremento de ações de segurança do paciente.

Study aimed at analyzing the communication of information between health teams in the transfer of the pre-hospital care and its implications for patient safety. Descriptive-exploratory design, with a qualitative approach, carried out at the Mobile Emergency Service - SAMU 192 of Porto Alegre, RS. Doctors, nurses and technicians/nursing assistants involved in victims' assistance participated in the study. The data were collected through non-participant observation and semi-structured interviews, carried out in the months from April to June, 2018. Twenty-eight professionals were interviewed and thirty-four periods were observed with an average of four hours. Project approved by the Research Ethics Committee of the proposing institution and of the co-participating institution. The data were submitted to content analysis and resulted in the following categories: (1) characterization of the information; (2) circumstances that hinder the transfer of the care provision; (3) circumstances that contribute to the transfer of the care provision; (4) stakeholders for the patient and team safety; (5) the (inter)personal/professional dimension of the care provision transfer. The first category included aspects related to the quality and completeness of the information collected, registered and transferred.The second category addressed the lack of standardization during the care provision transfers, overcrowding of the services, and the way SAMU and patients are received by the teams that will continue to provide care. In the third category, it was pointed out the agreements in the care network to emergencies and the visibility of severe cases in the transfers of care provision. The fourth category addresses the different perspectives among the services and the several risks to the patient and staff during transportation and transfer of care provision. The fifth category revealed that hierarchical communication is influenced by personal and emotional characteristics and influences the quality of transfers. It was concluded that investments are needed, such as the elaboration of protocols and the execution of specific training for the process of communication of information among health teams in the transfer of pre-hospital care, aiming at increasing patient safety actions.

The calculation method and pre-hospital emergency physician allocation gap in Shanghai / 中国卫生政策研究

This study aimed to develop the calculation method of pre-hospital emergency physician allocation gap and apply it to Shanghai.In order to reduce the ambulance dispatch lag frequency, through the analysis of its da-ta in the Shanghai urban area, the research group obtained the gap and extended the data to Shanghai city.The peak method establishes the association between pre-hospital emergency physician increment and the ambulance dispatch lag decrement.Based on descriptive statistics, the peak method by which the Shanghai ambulance dispatch lag data were analyzed uses the SAS programming software.This method of using programming software provides it with good reliability and validity.After an increase of 40 duty vehicles (381 pre-hospital emergency physicians), the ambu-lance dispatch lag ratio would drop from 25.61 percent to 0.22.Therefore, the association between the pre-hospital emergency physician increment and the ambulance dispatch lag decrement was established and can provide a scientif-ic evidence for the policy formulation.

Overview of the Shenzhen Emergency Medical Service Call Pattern / 世界急诊医学杂志（英文）

BACKGROUND: In Shenzhen, the Emergency Medical Service (EMS) system has been in service since 1997. This study aims to examine the operation of Shenzhen 120 EMS center and to identify the reasons of calling EMS. METHODS: In this retrospective quantitative descriptive study, the data from the Shenzhen 120 EMS registry in 2011 were analyzed. RESULTS: Shenzhen 120 EMS center is a communication command center. When the number of 120 are dialed, it is forwarded to the closest appropriate hospital for ambulance dispatch. In 2011, the Shenzhen 120 EMS center received 153160 ambulance calls, with an average of 420 calls per day. Calling emergency services was mainly due to traffic accidents. Trauma and other acute diseases constituted a majority of ambulance transports. The adult patients aged 15–60 years are the principal users of EMS. There are no recognized 'paramedic' doctors and nurses. The pre-hospital emergency service is under the operation of emergency departments of hospitals. Shenzhen at present does not have specialized pre-hospital training for doctors and nurses in post-trauma management. Moreover, specialized pre-hospital training, financial support, and public health education on proper use of EMS should be emphasized. CONCLUSION: The Shenzhen 120 EMS center has its own epidemiology characteristics. Traumatic injury and traffic accident are the main reasons for calling ambulance service. In-depth study emphasizing the distribution and characteristics of trauma patients is crucial to the future development of EMS.

Application of pre- hospital emergency care in children with febrile seizures and effect evaluation / 中国实用护理杂志

Objective To investigate the effect of pre- hospital emergency care programs in children with febrile seizures,in order to reduce damage by febrile seizures and obtain the best firstaid effect. Methods 112 cases of children with febrile seizures were treated in pediatric department of our hospital from April 2009 to February 2011.The parents of 75 children patients were given guidance of prehospital emergency care,they were set as the pre-hospital emergency care group.The other 37 cases were set as the non-pre-hospital emergency care group,routine emergency care was given until the medical personnel arrived at the spot.The conditions of aspiration,tongue bite injury,another episode of febrile seizures and brain damage were recorded in two groups of children. Results Only one case of aspiration and three cases of febrile seizures occurred in the pre-hospital emergency care group by misoperation of parents.Non brain damage and tongue bite injury occurred.The incidence rate of improper consequences was 5.3％in the pre-hospital emergency care group,lower than that of the non-pre-hospital emergency care group,51.4％. Conclusions To give pre-hospital emergency care guidance to parents of children patients by mobile phones before the health care workers reach the spot can significantly reduce accidental injury of children,stabilize the emotion of parents,decrease the impact of seizures on children,all the above has a positive effect on follow-up treatment.

Effect of pre-hospital emergency care for patients with acute cranio-cerebral injury / 中国实用护理杂志

Objective To know the effect of pre-hospital emergency care for patients with acute cranio-cerebral injury. Methods Selected 312 patients with acute cranio-cerebral injury from Jan of 2005 to Jan of 2009 as the emergency group, selected 285 patients with acute cranio-cerebral injury from Jan of 2000 to Dec of 2004 as the control group. Retrospective analized the clinical condition between the two groups to know the effect of pre-hosptial emergency cares. Results There was significant difference of dead rate betweent the two groups, the prognosis of the two groups was also different. Conclusions Effective pre-hospital emergency care is very important for patients with acute eranio-cerebral injury, which can avoid certain complications and reduce dead rate.

Serviço de Atendimento Móvel de Urgência (SAMU): análise da demanda e sua distribuição espacial em uma cidade do Nordeste brasileiro / Mobile Emergency Care Service (SAMU): analysis of demand and its space distribution in a city of the Brazilian northeast

O município de Olinda, Pernambuco, criou instrumento para armazenamento de dados dos formulários das ocorrências do Serviço de Atendimento Móvel de Urgência (SAMU-192) e de forma pioneira georreferencia os atendimentos realizados. Objetiva-se descrever o perfil epidemiológico das ocorrências atendidas no município, de fevereiro (implantação do serviço) a junho de 2006, com ênfase na distribuição espacial das ocorrências mais relevantes. Foram utilizados dados secundários do banco de dados SAMU-192, considerando a freqüência das seguintes variáveis: sexo, faixa etária, tipo de ocorrências, dias da semana, tipo de causas clínicas, tipo de causas externas, tipo de acidentes de transportes e veículos envolvidos. Tendo por base as freqüências dos tipos de causas clínicas/externas, identificaram-se aquelas de maior magnitude para mapeamento e identificação dos aglomerados espaciais com o emprego de estimador de intensidade Kernel. Das 1956 ocorrências, 1114 foram por causas clínicas e 645 por causas externas; finais de semana acumularam 46,0 por cento dos atendimentos; 55,1 por cento das ocorrências por causas clínicas foram em mulheres, enquanto 72,1 por cento das causas externas em homens. A média etária para as causas clínicas foi de 47 anos e 34 anos para causas externas. Destacaram-se as doenças do aparelho circulatório (23,1 por cento das causas clínicas) e acidentes de transporte (52,7 por cento das causas externas); desses 61,1 por cento motivados por atropelamentos e 33,6 por cento com motocicletas envolvidas. A análise espacial reforça a necessidade da integração entre a Secretaria de Saúde e órgãos afins para a implantação de medidas preventivas, e o perfil epidemiológico apresentou informações capazes de auxiliar na organização do serviço e na compreensão do perfil de morbidade.

The city of Olinda (Pernambuco, Brazil) created a tool for storing data from the Emergency Mobile Healthcare Service forms (SAMU-192) which is a pioneer in providing georeferenced information on the treatment given. The aim of the present study was to describe the epidemiological profile of care in the city from February (implementation of the service) to June 2006, with an emphasis on the spatial distribution of the most relevant events. Secondary data from the SAMU-192 database was used, considering the frequency of the following variables: gender, age, type of event, day of the week, type of clinical cause, type of external cause, type of traffic accident and vehicles involved. Based on the frequency of the types of clinical/external causes, those of greater magnitude were used for mapping and identifying spatial clusters using the Kernel intensity estimator. Among the 1,956 events, 1,114 were due to clinical causes and 645 were due to external causes; weekends totaled 46.0 percent of the events; 55.1 percent of events due to clinical causes were in women, whereas 72.1 percent of external causes were in men. The average age for clinical causes was 47 years and for external causes was 34 years. Circulatory system diseases accounted for 23.1 percent of clinical causes. Traffic accidents accounted for 52.7 percent of external causes, 61.1 percent of which were run overs and 33.6 percent involved motorcycles. The spatial analysis emphasized the need for integration between the Health Department and other agencies in order to implement preventive measures. The epidemiological profile offers information that can assist in the organization of the service and in the understanding of the morbidity profile.