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Influence of The Education and Training of Prehospital Medical Crews on Measures of Performance and Patient Outcomes
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
2013 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Prehospital care has developed dramatically the last decades with the implementation of new devices and educational concepts. Clinical decisions and treatments have moved out from the hospitals to the prehospital setting. In Sweden this has been accompanied by an increase in the level of competence, i.e. by introducing nurses in the ambulances. With some exceptions the scientific support for these changes is poor.

This thesis deals with such changes in three different subsets of prehospital care: Cardiopulmonary resuscitation (CPR), the stroke chain of survival and trauma care.

We assessed the performance of ambulance crews during CPR, using a mechanical compression device, as compared to CPR using manual compressions. There was a strikingly poor quality of compressions using the mechanical device compared to CPR with manual compressions. The result calls for caution when implementing a chest compression device in clinical practice and reinforce the importance of randomised controlled trials to evaluate new interventions. Careful attention should be given to the assurance of correct application of the device. Further implementation without evaluation of the quality of mechanical compressions in a clinical setting is discouraged.

Among patients with a prehospital suspicion of stroke we analysed the ambulance nurses’ ability to select the correct patient subset eligible for a CT scan as a preparation for potential thrombolysis. The results do not support an implementation of a bypass of the emergency department, using ambulance nurse competence to select patients eligible and suitable for a CT scan without a preceding assessment by a physician.

The association between the Prehospital Trauma Life Support (PHTLS) course and the outcome in victims of trauma was analysed in two observational studies. A study covering one county gave some support for a protective effect from PHTLS, but the estimate had a low precision. A nationwide study, covering all of Sweden, could not confirm those results. Although there was a reduction in mortality over time coinciding with the implementation of PHTLS, it did not appear to be associated with the implementation of PHTLS. Thus, we could not detect any clear beneficial impact of the PHTLS course on the outcome of trauma patients.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2013. , 59 p.
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 863
Keyword [en]
ambulance, prehospital, education, CPR, stroke, trauma, outcome
National Category
Anesthesiology and Intensive Care
Identifiers
URN: urn:nbn:se:uu:diva-192629ISBN: 978-91-554-8589-4 (print)OAI: oai:DiVA.org:uu-192629DiVA: diva2:601321
Public defence
2013-03-15, Enghoffsalen, Akademiska Sjukhuset, Uppsala, 13:00 (Swedish)
Opponent
Supervisors
Available from: 2013-02-22 Created: 2013-01-23 Last updated: 2013-04-02Bibliographically approved
List of papers
1. Poor chest compression quality with mechanical compressions in simulated cardiopulmonary resuscitation: A randomized, cross-over manikin study
Open this publication in new window or tab >>Poor chest compression quality with mechanical compressions in simulated cardiopulmonary resuscitation: A randomized, cross-over manikin study
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2011 (English)In: Resuscitation, ISSN 0300-9572, E-ISSN 1873-1570, Vol. 82, no 10, 1332-1337 p.Article in journal (Refereed) Published
Abstract [en]

Introduction: Mechanical chest compression devices are being implemented as an aid in cardiopulmonary resuscitation (CPR), despite lack of evidence of improved outcome. This manikin study evaluates the CPR-performance of ambulance crews, who had a mechanical chest compression device implemented in their routine clinical practice 8 months previously. The objectives were to evaluate time to first defibrillation, no-flow time, and estimate the quality of compressions. Methods: The performance of 21 ambulance crews (ambulance nurse and emergency medical technician) with the authorization to perform advanced life support was studied in an experimental, randomized cross-over study in a manikin setup. Each crew performed two identical CPR scenarios, with and without the aid of the mechanical compression device LUCAS. A computerized manikin was used for data sampling. Results: There were no substantial differences in time to first defibrillation or no-flow time until first defibrillation. However, the fraction of adequate compressions in relation to total compressions was remarkably low in LUCAS-CPR (58%) compared to manual CPR (88%) (95% confidence interval for the difference: 13-50%). Only 12 out of the 21 ambulance crews (57%) applied the mandatory stabilization strap on the LUCAS device. Conclusions: The use of a mechanical compression aid was not associated with substantial differences in time to first defibrillation or no-flow time in the early phase of CPR. However, constant but poor chest compressions due to failure in recognizing and correcting a malposition of the device may counteract a potential benefit of mechanical chest compressions. 

Keyword
Cardiopulmonary resuscitation (CPR), Defibrillation, Cardiac arrest, Chest compression, Out-of-hospital CPR, Cardiac-assist device
National Category
Anesthesiology and Intensive Care
Identifiers
urn:nbn:se:uu:diva-161559 (URN)10.1016/j.resuscitation.2011.06.002 (DOI)000296168700018 ()
Available from: 2011-11-20 Created: 2011-11-15 Last updated: 2017-12-08Bibliographically approved
2. Agreement between ambulance nurses and physicians in assessing stroke patients
Open this publication in new window or tab >>Agreement between ambulance nurses and physicians in assessing stroke patients
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2013 (English)In: Acta Neurologica Scandinavica, ISSN 0001-6314, E-ISSN 1600-0404, Vol. 129, no 1, 49-55 p.Article in journal (Refereed) Published
Abstract [en]

Objectives: If an ambulance nurse could bypass the emergency department (ED) and bring suspected stroke patients directly to a CT scanner, time to thrombolysis could be shortened. This study evaluates the level of agreement between ambulance nurses and emergency physicians in assessing the need for a CT scan, and interventions and monitoring beforehand, in patients with suspected stroke and/or a lowered level of consciousness.

Materials and Methods: From October 2008 to June 2009 we compared the ambulance nurses’ and ED physicians’ judgement of 200 patients with stroke symptoms . Both groups answered identical questions on patients’ need for a CT scan, and interventions and monitoring beforehand.  

Results: There was a poor agreement between ambulance nurses and ED physicians in judging the need for a CT scan: κ = 0.22 (95% confidence interval (CI): 0.06–0.37). The nurses’ ability to select the same patients as the physician for a CT scan had a sensitivity of 84% (95% CI: 77–89) and a specificity of 37% (95% CI: 23–53). Agreement concerning the need for interventions and monitoring was also low: κ = 0.32 (95% CI: 0.18–0.47). In 18% of cases, the nurses considered interventions before a CT scan unnecessary when the physicians’ deemed them necessary.

Conclusions: Additional tools to support ambulance nurses decisions appear to be required before suspected stroke patients can be taken directly to a CT scanner.

 

 

Keyword
acute stroke therapy; emergency; ischemic stroke; protocols; prehospital care; stroke teams; thrombolysis
National Category
Other Clinical Medicine
Identifiers
urn:nbn:se:uu:diva-192626 (URN)10.1111/ane.12149 (DOI)000327608300008 ()23710712 (PubMedID)
Available from: 2013-01-29 Created: 2013-01-23 Last updated: 2017-12-06Bibliographically approved
3. Prehospital Trauma Life Support (PHTLS) training of ambulance caregivers and impact on survival of trauma victims
Open this publication in new window or tab >>Prehospital Trauma Life Support (PHTLS) training of ambulance caregivers and impact on survival of trauma victims
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2012 (English)In: Resuscitation, ISSN 0300-9572, E-ISSN 1873-1570, Vol. 83, no 10, 1259-1264 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND:

The Prehospital Trauma Life Support (PHTLS) course has been widely implemented and approximately half a million prehospital caregivers in over 50 countries have taken this course. Still, the effect on injury outcome remains to be established. The objective of this study was to investigate the association between PHTLS training of ambulance crew members and the mortality in trauma patients.

METHODS:

A population-based observational study of 2830 injured patients, who either died or were hospitalized for more than 24h, was performed during gradual implementation of PHTLS in Uppsala County in Sweden between 1998 and 2004. Prehospital patient records were linked to hospital-discharge records, cause-of-death records, and information on PHTLS training and the educational level of ambulance crews. The main outcome measure was death, on scene or in hospital.

RESULTS:

Adjusting for multiple potential confounders, PHTLS training appeared to be associated with a reduction in mortality, but the precision of this estimate was poor (odds ratio, 0.71; 95% confidence interval, 0.42-1.19). The mortality risk was 4.7% (36/763) without PHTLS training and 4.5% (94/2067) with PHTLS training. The predicted absolute risk reduction is estimated to correspond to 0.5 lives saved annually per 100,000 population with PHTLS fully implemented.

CONCLUSIONS:

PHTLS training of ambulance crew members may be associated with reduced mortality in trauma patients, but the precision in this estimate was low due to the overall low mortality. While there may be a relative risk reduction, the predicted absolute risk reduction in this population was low.

National Category
Family Medicine
Identifiers
urn:nbn:se:uu:diva-181577 (URN)10.1016/j.resuscitation.2012.02.018 (DOI)000309050600027 ()22366502 (PubMedID)
Available from: 2012-09-26 Created: 2012-09-26 Last updated: 2017-12-07Bibliographically approved
4. Impact of prehospital trauma life support (PHTLS) training of ambulance caregivers on the outcome of traffic injury victims – a nation-wide study.
Open this publication in new window or tab >>Impact of prehospital trauma life support (PHTLS) training of ambulance caregivers on the outcome of traffic injury victims – a nation-wide study.
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(English)Manuscript (preprint) (Other academic)
Abstract [en]

Background: Prehospital trauma life support (PHTLS) is a widely implemented educational program for prehospital trauma care. Evidence for improved patient outcome is, however, limited. The primary aim of this nation-wide study was to investigate the association between regional implementation of PHTLS training and mortality after traffic injuries.

Methods: We extracted from the Swedish National Patient Registry and the Cause of Death Registry information on victims of motor vehicle traffic injuries in Sweden from 2001 to 2004 (n=28 041). During this time period, PHTLS training was implemented at a varying pace in different regions. We used a Bayesian approach with Markov chain Monte Carlo to estimate odds ratios (OR) for prehospital and 30-day mortality. We entered region and hospital into hierarchical models and controlled for the calendar year for each injury. We analyzed the time to death and time to return to work using Cox’s proportional hazards frailty models.

Results: A total of 1395 individuals died before being admitted to hospital. After multivariable adjustment, the OR for prehospital mortality with PHTLS-trained prehospital staff was 1.11 (95% credibility interval, 0.88 to 1.38). For 30-day mortality (365 deaths), the adjusted OR was 0.80 (95% credibility interval, 0.53 to 1.17). There was no association between PHTLS training and time to death (hazard ratio 0.99; 95% confidence interval, 0.85 to 1.14) or time to return to work (hazard ratio 0.98, 95% confidence interval, 0.92 to 1.05).

Conclusion: The implementation of PHTLS training did not appear to reduce mortality or disability after motor vehicle traffic injuries. 

National Category
Anesthesiology and Intensive Care
Identifiers
urn:nbn:se:uu:diva-192628 (URN)
Available from: 2013-01-29 Created: 2013-01-23 Last updated: 2013-08-15

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