Strategy to Identify Paramedic Transported Sepsis Cases in an Emergency Department Administrative Database.

Background: To evaluate a new strategy for identifying sepsis in Emergency Department (ED) patients that combines administrative diagnosis codes with clinical information from the point of first contact. Methods: This study linked clinical data from adult patients transported by a provincial Emergency Medical Services (EMS) system to ED and inpatient administrative databases. Sepsis cases were identified by searching ED databases for diagnosis codes consistent with infection and organ dysfunction. Organ dysfunction was further assessed using a partial Sequential Organ Failure Assessment (SOFA) score derived from EMS clinical information. Reliability was evaluated by comparing patients' ED diagnosis codes (ICD-10CA) to their inpatient diagnosis codes; criterion validity by comparing cases classified by the new strategy to an existing inpatient administrative algorithm; and construct validity by assessing for clinical characteristics typically associated with sepsis (e.g., mortality). Results: A total of 43,297 patients were included. ED infection codes were more reliable for classifying patients with infection than using ED sepsis codes alone (proportion of agreement with inpatient codes 79% vs. 74%; p-value < 0.001). The novel strategy requiring the presence of an infection code and either an organ dysfunction code or 2 or more SOFA points from EMS clinical information identified 1,379 more ED patients as having sepsis than the inpatient algorithm. These patients had high mortality supporting construct validity. Conclusions: Incorporation of a broader range of diagnostic codes and linking to an electronic database to obtain initial clinical information for the assessment of organ dysfunction improves reliability, criterion, and construct validity for identifying sepsis in ED patients.

CAPABLE: Calgary zone usage of Additional Prescribing Authorization By pharmacists in an inpatient setting: review of the prescribing Landscape and Environment.

BACKGROUND: In Alberta, Canada, pharmacists have been granted the ability to prescribe most medications independently after completing an additional authorization process. While there are data to support the use of pharmacists' prescribing in the community setting, little is known about its use in the inpatient hospital setting. OBJECTIVES: To describe the prescribing patterns of pharmacists in an inpatient setting including the percentage of pharmacists using their prescribing authority, the care areas where prescribing occurred, and the frequency of prescribing. Secondary objectives included describing the medications prescribed, and to determine if pharmacists are documenting their prescribing interventions. METHODS: A descriptive, retrospective, cross-sectional study of medications ordered by pharmacists through the electronic order entry system in Calgary, Alberta, Canada. Prescriptions were examined in the context of how often each pharmacist prescribed, the medications prescribed, and an audit of documentation practices was performed using patient charts. RESULTS: A total of 64,293 orders from 172 pharmacists were included in the analysis, of which 51% (n = 32,681) were discontinuation orders. It was found that 90% of pharmacists used their prescribing authority, ordering a median of 11.3 prescriptions monthly (interquartile range 4.3-32.8). Clinical areas with the most overall prescribing included critical care (854.8), oncology and palliative care (463.0), and surgery (409.3) prescriptions per pharmacist Full-Time Equivalent per year. CONCLUSIONS: This study demonstrates a broad range of prescribing from pharmacists within acute care practice and a wide variety of medication prescribed. Future areas for research include barriers and enablers to pharmacist prescribing and examination of where prescribing pharmacists have the greatest value.

Transition in Care from EMS Providers to Emergency Department Nurses: A Systematic Review.

Background: Transitions in care between emergency medical services (EMS) providers and emergency department (ED) nurses are critical to patient care and safety. However, interactions between EMS providers and ED nurses can be problematic with communication gaps and have not been extensively studied. The aim of this review was to examine (1) factors that influence transitions in care from EMS providers to ED nurses and (2) the effectiveness of interventional strategies to improve these transitions. Methods: We conducted a mixed-methods systematic review that included searches of electronic databases (DARE, MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, CINAHL, Joanna Briggs Institute EBP), gray literature databases, organization websites, querying experts in emergency medicine, and the reference lists cited in included studies. All English-language studies of any design were eligible for inclusion. Two reviewers independently screened titles/abstracts and full-texts for inclusion and methodological quality, as well as extracted data from included studies. We used narrative and thematic synthesis to integrate and explore relationships within the data. Results: In total, 8,348 studies were screened and 130 selected for full text review. The final synthesis included 20 studies. Across 15 studies of moderate-to-high methodological quality, 6 factors influenced transitions: different professional lenses, operational constraints, professional relationships, information shared between the professions, components of the transition process, and patient presentation and involvement. Three interventions were identified in 6 methodologically weak studies: (1) transition guideline (DeMIST, Identification, Mechanism/Medical complaint, Injuries/Information related to the complaint, Signs, Treatment and Trends - Allergies, Medication, Background history, Other information [IMIST-AMBO]) with training, (2) mobile web-based technology (EMS smartphone and geographic information system location data), and (3) a new clinical role (ED ambulance off-load nurse dedicated to triaging and assessing EMS patients). There were mixed findings for the effectiveness of transition guidelines and the new clinical role. Mobile technology was seen positively by both EMS providers and ED nurses as helpful for better describing the pre-hospital context and for planning flow in the ED. Conclusion: While multimedia applications may potentially improve the handoff process, future intervention studies need to be rigorously designed. We recommend interdisciplinary training of EMS and ED staff in the use of flexible structured protocols, especially given review findings that interdisciplinary communication and relationships can be challenging.

The evaluation of an ambulance rear compartment using patient simulation: Issues of safety and efficiency during the delivery of patient care.

The purpose of this study was to evaluate the safety and efficiency of a specific ambulance while providers delivered basic and advanced life support. Forty-eight, Emergency Medical Service (EMS) teams were observed delivering care to a simulated patient during an anaphylaxis scenario in a moving ambulance that contained a complete compliment of medical supplies and equipment. A detailed coding system was developed and applied to the audio and video behavioural data. Patterns of interaction among EMS personnel, the patient, equipment and the ambulance interior during the patient simulation scenario were analyzed. The results revealed a number of issues associated with the patient compartment including: potentially unsafe seated and standing positions; hazardous barriers to movement around the patient; difficulties accessing equipment and supplies; and the adequacy of work surfaces and waste disposal. A number of design recommendations are made to guide provider and patient comfort, efficiency and safety.

Community paramedic point of care testing: validity and usability of two commercially available devices.

BACKGROUND: Community Paramedics (CPs) require access to timely blood analysis in the field to guide treatment and transport decisions. Point of care testing (POCT), as opposed to laboratory analysis, may offer a solution, but limited research exists on CP POCT. The purpose of this study was to compare the validity of two devices (Abbott i-STAT® and Alere epoc®) by CPs in the community. METHODS: In a CP programme responding to 6000 annual patient care events, a split sample validation of POCT against traditional laboratory analysis for seven analytes (sodium, potassium, chloride, creatinine, hemoglobin, hematocrit, and glucose) was conducted on a consecutive sample of patients. The difference of proportion of discrepant results between POCT and laboratory was compared using a two sample proportion test. Usability was analysed by survey of CP experience, a linear mixed effects model of Systems Usability Scale (SUS) adjusted for CP clinical and POCT experience, an expert heuristic evaluation of devices, a review of device-logged errors, and coded observations of POCT use during quality control testing. RESULTS: Of 1649 episodes of care screened for enrollment, 174 required a blood draw, with 108 episodes (62.1%) enrolled from 73 participants. Participants had a mean age of 58.7 years (SD16.3); 49% were female. In 4 of 646 (0.6%) comparisons, POCT reported a critical value but the laboratory did not; with no statistically significant (p = 0.323) difference between i-STAT® (0.9%;95%CI:0.0,1.9%) compared with epoc® (0.3%;95%CI:0.0,0.9%). There were no instances of the laboratory reporting a critical value when POCT did not. In 88 of 1046 (8.4%) comparisons the a priori defined acceptable difference between POCT and the laboratory was exceeded; occurring more often in epoc® (10.7%;95%CI:8.1,13.3%) compared with i-STAT® (6.1%;95%CI:4.1,8.2%)(p = 0.007). Eighteen of 19 CP surveys were returned, with 11/18 (61.1%) preferring i-STAT® over epoc®. The i-STAT® had a higher mean SUS score (higher usability) compared with epoc® (84.0/100 vs. 59.6/100; p = 0.011). There were no statistically significant differences in device logged errors between i-STAT® and epoc® (p = 0.063). CONCLUSIONS: CP programmes can expect clinically valid results from POCT. Device usability assessments should be considered with any local implementation as the two POCT systems have different strengths.

Creative adapting in a fluid environment: an explanatory model of paramedic decision making in the pre-hospital setting.

BACKGROUND: Paramedics work in a highly complex and unpredictable environment which is characterized by ongoing decision-making. Decisions made by paramedics in the prehospital setting have implications for patient safety, transport, treatment, and health resource utilization. The objective of this study was; a) to understand how paramedics conduct decision-making in the field, and b) to develop a grounded theory of paramedic decision-making in the prehospital setting. METHOD: This study was conducted using classical grounded theory. Paramedics (n = 13) with five or more years' experience, who worked in a large urban center in Western Canada were interviewed. Field observations were conducted, each lasting 12 h, with five different ambulance crews. The data were analyzed and coded using the constant comparative method. RESULTS: The resultant theory, Creative Adapting in a Fluid Environment, indicates paramedic decision-making is a fluid iterative process. Unpredictable and dynamic features of the prehospital environment require paramedics to use a flexible and creative approach to decision-making. The model consists of the three categories constructing a malleable model, revising the model, and situation-specific action. Two additional components, safety and extrication, are considered at each stage of the call. These two components in conjunction with the three categories influence how decisions are made and enacted. CONCLUSION: Paramedic decision-making is highly contextual and requires accurate interpretation and flexible cognitive constructs that are rapidly adaptable. Evaluation of paramedic decision-making needs to account for the complex and dynamic interaction between the environment, patient characteristics, available resources, and provider experience and knowledge.

Transition in care from paramedics to emergency department nurses: a systematic review protocol.

BACKGROUND: Effective and efficient transitions in care between emergency medical services (EMS) practitioners and emergency department (ED) nurses is vital as poor clinical transitions in care may place patients at increased risk for adverse events such as delay in treatment for time sensitive conditions (e.g., myocardial infarction) or worsening of status (e.g., sepsis). Such transitions in care are complex and prone to communication errors primarily caused by misunderstanding related to divergent professional perspectives leading to misunderstandings that are further susceptible to contextual factors and divergent professional lenses. In this systematic review, we aim to examine (1) factors that mitigate or improve transitions in care specifically from EMS practitioners to ED nurses, and (2) effectiveness of interventional strategies that lead to improvements in communication and fewer adverse events. METHODS: We will search electronic databases (DARE, MEDLINE, EMBASE, Cochrane, CINAHL, Joanna Briggs Institute EBP; Communication Abstracts); gray literature (gray literature databases, organization websites, querying experts in emergency medicine); and reference lists and conduct forward citation searches of included studies. All English-language primary studies will be eligible for inclusion if the study includes (1) EMS practitioners or ED nurses involved in transitions for arriving EMS patients; and (2) an intervention to improve transitions in care or description of factors that influence transitions in care (barriers/facilitators, perceptions, experiences, quality of information exchange). Two reviewers will independently screen titles/abstracts and full texts for inclusion and methodological quality. We will use narrative and thematic synthesis to integrate and explore relationships within the data. Should the data permit, a meta-analysis will be conducted. DISCUSSION: This systematic review will help identify factors that influence communication between EMS and ED nurses during transitions in care, and identify interventional strategies that lead to improved communication and decrease in adverse events. The findings can be used to develop an evidence-informed transitions in care tool that ensures efficient transfer of accurate patient information, continuity of care, enhances patient safety, and avoids duplication of services. This review will also identify gaps in the existing literature to inform future research efforts. TRIAL REGISTRATION: PROSPERO CRD42017068844.

A prehospital treat-and-release protocol for supraventricular tachycardia.

OBJECTIVE: Paroxysmal supraventricular tachycardia (SVT) is a common dysrhythmia treated in the prehospital setting. Emergency medical service (EMS) agencies typically require patients treated for SVT to be transported to the hospital. This retrospective cohort study evaluated the impact, paramedic adherence, and patient re-presentation rates of a treat-and-release (T+R) protocol for uncomplicated SVT. METHODS: Data were linked from the Alberta Health Services EMS electronic patient care record (EPCR) database for the City of Calgary to the Regional Emergency Department Information System (REDIS). All SVT patients treated by EMS between September 1, 2010, and September 30, 2012, were identified. Databases were queried to identify re-presentations to EMS or an emergency department (ED) within 72 hours of T+R. RESULTS: There were 229 confirmed SVT patient encounters, including 75 T+R events. Of these 75 T+R events, 10 (13%, 95% confidence interval [CI] [7.4, 23]) led to an EMS re-presentation within 72 hours, and 4 (5%, 95% CI [2.1, 13]) led to an ED. All re-presentations were attributed to a single individual. After excluding 15 records that were incomplete due to limitations in the EPCR platform, 43 of 60 (72%) T+R encounters met all protocol criteria for T+R. CONCLUSION: The T+R protocol evaluated in this study applied to a significant proportion of patients presenting to EMS with SVT. Risk of re-presentation following T+R was low, and paramedic protocol adherence was reasonable. T+R appears to be a viable option for uncomplicated SVT in the prehospital setting.

Epidemiology of blunt head injury victims undergoing ED cranial computed tomographic scanning.

STUDY OBJECTIVE: We sought to describe the epidemiology of emergency department (ED) patients with blunt head injury undergoing cranial computed tomography (CT) scanning for the evaluation of possible traumatic brain injury (TBI). METHODS: Prospective, multicenter, observational study of ED patients undergoing cranial CT after blunt head injury. Patient's date of birth, sex, and race/ethnicity were documented before CT scanning. Individual patients were considered to have "significant" TBI if the official radiographic interpretation at the end of all imaging studies associated with the trauma was consistent with any of a set of predefined diagnoses. The relative prevalence of TBI among various prespecified groups from those undergoing cranial CT scanning was also calculated. RESULTS: Of 13728 patients who were enrolled, 8988 (65%) were men and 1193 (8.7%) had a significant acute TBI. Demographic findings associated with increased risk of TBI, among patients selected for scanning, included the following: age below 10 years (relative risk [RR] = 1.44, 95% confidence interval [CI], 1.19-1.77); age above 65 years (RR = 1.59; 95% CI, 1.40-1.80), and male sex (RR = 1.27; 95% CI, 1.30-1.43). CONCLUSION: Among patients selected for cranial CT scanning after blunt head injury, men, patients younger than 10 years, and those older than 65 years have an increased likelihood of significant TBI.