Dataset Information

Application of the emergency medical services trigger tool to measure adverse events in prehospital emergency care: a time series analysis.

ABSTRACT:

Background

Emergency Care has previously been identified as an area of significant concern regarding the prevalence of Adverse Events (AEs). However, the majority of this focus has been on the in-hospital setting, with little understanding of the identification and incidence of AEs in the prehospital environment.

Method

The early development and testing of Emergency Medical Services (EMS) specific triggers for the identification of AEs and Harm has been previously described. To operationalise the Emergency Medical Services Trigger Tool (EMSTT), the processes developed by the Institute for Healthcare Improvement for use with the Global Trigger Tool were adapted to a prehospital emergency care setting. These were then applied using a stepwise approach to the analysis of 36 consecutive samples of patient care records over an 18-month period (n =?710). Inter-rater reliability was measured for each trigger item and level of Harm classification. Total Triggers per 10,000 Patient Encounters, AEs per 10,000 Patient Encounters and Harm per 10,000 Patient Encounters were measured. All measures were plotted on Statistical Process Control Charts.

Results

There was a high level of inter-rater agreement across all items (range: 85.6-100%). The EMSTT found an average rate of 8.20 Triggers per 10,000 Patient Encounters, 2.48 AEs per 10,000 Patient Encounters and 0.34 Harm events per 10,000 Patient Encounters. Three triggers: Change in Systolic Blood Pressure Greater Than 20%; Temp?>?38 °C without subsequent reduction; and SpO₂ 2 DiscussionWith sufficient focus on implementation and data collection, as well as the inclusion of a contextually relevant system for classifying AE/Harm, the EMSTT represents a potentially successful strategy towards identifying the rate of AEs within EMS across a large patient population with limited commitment of time and resources.

SUBMITTER: Howard I

PROVIDER: S-EPMC6258398 | biostudies-literature | 2018 Nov

REPOSITORIES: biostudies-literature

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Publications

Application of the emergency medical services trigger tool to measure adverse events in prehospital emergency care: a time series analysis.

Howard Ian I Pillay Bernard B Castle Nicholas N Al Shaikh Loua L Owen Robert R Williams David D

BMC emergency medicine 20181126 1

<h4>Background</h4>Emergency Care has previously been identified as an area of significant concern regarding the prevalence of Adverse Events (AEs). However, the majority of this focus has been on the in-hospital setting, with little understanding of the identification and incidence of AEs in the prehospital environment.<h4>Method</h4>The early development and testing of Emergency Medical Services (EMS) specific triggers for the identification of AEs and Harm has been previously described. To op ...[more]

PMID: 30477423

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Project description:ObjectivesTraditional approaches to safety and quality screening in the emergency department (ED) are porous and low yield for identifying adverse events (AEs). A better approach may be in the use of trigger tool methodology. We recently developed a novel ED trigger tool using a multidisciplinary, multicenter approach. We conducted a multicenter test of this tool and assess its performance.MethodsIn design and participants, we studied the ED trigger tool for a 13-month period at four EDs. All patients 18 years and older with Emergency Severity Index acuity levels of 1 to 3 seen by a provider were eligible. Reviewers completed standardized training modules. Each site reviewed 50 randomly selected visits per month. A first-level reviewer screened for presence of predefined triggers (findings that increase the probability of an AE). If no trigger is present, the review is deemed complete. When present, a trigger prompts an in-depth review for an AE. Any event identified is assigned a level of harm using the Medication Event Reporting and Prevention (MERP) Index, ranging from a near miss (A) to patient death (I). Events are noted as present on arrival or in the ED, an act of commission or omission, and are assigned one of four event categories. A second-level physician performs a confirmatory review of all AEs and independently reviews 10% of cases to estimate the false-negative rate. All AEs or potential AEs were reviewed in monthly group calls for consensus on findings. The primary outcome is the proportion of visits in which an AE is identified, overall and by site. Secondary outcomes include categories of events, distribution of harm ratings, and association of AEs with sociodemographic and clinical factors and triggers. We present sociodemographic data and details about AEs and results of logistic regression for associations of AEs with of triggers, sociodemographics, and clinical variables.ResultsWe captured 2594 visits that are representative, within site, of their patient population. Overall, the sample is 64% white, 54% female, and with a mean age of 51. Variability is observed between sites for age, race, and insurance, but not sex. A total of 240 events were identified in 228 visits (8.8%) of which 53.3% were present on arrival, 19.7% were acts of omission, and 44.6% were medication-related, with some variability across sites. A MERP F score (contributing to need for admission, higher level of care, or prolonged hospitalization) was the most common severity level (35.4% of events). Overall, 185 (77.1%) of 240 events involved patient harm (MERP level ≥ E), affecting 175 visits (6.7%). Triggers were present in 951 visits (36.6%). Presence of any trigger was strongly associated with an AE (adjusted odds ratio = 4.6, 95% confidence interval = 3.2-6.6). Ten triggers were individually associated with AEs (adjusted odds ratio = 2.1-7.7). Variability was observed across sites in individual trigger associations, event rates, and categories, but not in severity ratings of events. The overall false-negative rate was 6.1%.ConclusionsThe trigger tool approach was successful in identifying meaningful events. The ED trigger tool seems to be a promising approach for identifying all-cause harm in the ED.

Project description:BackgroundPrehospital obstetric events encountered by emergency medical services (EMS) can be high-risk patient presentations for which suboptimal care can cause substantial morbidity and mortality. The frequency of prehospital obstetric events is unclear because existing descriptions have reported obstetric and gynecological conditions together, without delineating specific patient presentations. Our objective was to identify the types, frequency, and acuity of prehospital obstetric events treated by EMS personnel in the US.MethodsWe conducted a cross-sectional analysis of EMS patient care records in the 2018 National EMS Information System dataset (n=22,532,890). We focused on EMS activations (i.e., calls for service) for an emergency scene response for patients aged 12-50 years with evidence of an obstetric event. Type of obstetric event was determined by examining patient symptoms, the treating EMS provider's impression (i.e., field diagnosis), and procedures performed. High patient acuity was ascertained by EMS documentation of patient status and application of the modified early obstetric warning system (MEOWS) criteria, with concordance assessed using Cohen's kappa. Descriptive statistics were calculated to describe the primary symptoms, impressions, and frequency of each type of obstetric event among these activations.ResultsA total of 107,771 (0.6%) of EMS emergency activations were identified as involving an obstetric event. The most common presentation was early or threatened labor (15%). Abdominal complaints, including pain and other digestive/abdomen signs and symptoms, was the most common primary symptom (29%) and primary impression (18%). We identified 3,489 (3%) out-of-hospital deliveries, of which 1,504 were preterm. Overall, EMS providers documented 34% of patients as being high acuity, similar to the MEOWS criteria (35%); however, there were high rates of missing data for EMS documented acuity (19%), poor concordance between the two measures (Cohen's kappa=0.12), and acuity differences for specific conditions (e.g., high acuity of non-cephalic presentations, 77% in EMS documentation versus 53% identified by MEOWS).ConclusionPrehospital obstetric events were infrequently encountered by EMS personnel, and about one-third were high acuity. Additional work to understand the epidemiology and clinical care of these patients by EMS would help to optimize prehospital care and outcomes.

Project description:BACKGROUND: As the United States embraces electronic health records (EHRs), improved emergency medical services (EMS) information systems are also a priority; however, little is known about the experiences of EMS agencies as they adopt and implement electronic patient care report (e-PCR) systems. We sought to characterize motivations for adoption of e-PCR systems, challenges associated with adoption and implementation, and emerging implementation strategies. METHODS: We conducted a qualitative study using semi-structured in-depth interviews with EMS agency leaders. Participants were recruited through a web-based survey of National Association of EMS Physicians (NAEMSP) members, a didactic session at the 2010 NAEMSP Annual Meeting, and snowball sampling. Interviews lasted approximately 30 minutes, were recorded and professionally transcribed. Analysis was conducted by a five-person team, employing the constant comparative method to identify recurrent themes. RESULTS: Twenty-three interviewees represented 20 EMS agencies from the United States and Canada; 14 EMS agencies were currently using e-PCR systems. The primary reason for adoption was the potential for e-PCR systems to support quality assurance efforts. Challenges to e-PCR system adoption included those common to any health information technology project, as well as challenges unique to the prehospital setting, including: fear of increased ambulance run times leading to decreased ambulance availability, difficulty integrating with existing hospital information systems, and unfunded mandates requiring adoption of e-PCR systems. Three recurring strategies emerged to improve e-PCR system adoption and implementation: 1) identify creative funding sources; 2) leverage regional health information organizations; and 3) build internal information technology capacity. CONCLUSION: EMS agencies are highly motivated to adopt e-PCR systems to support quality assurance efforts; however, adoption and implementation of e-PCR systems has been challenging for many. Emerging strategies from EMS agencies and others that have successfully implemented EHRs may be useful in expanding e-PCR system use and facilitating this transition for other EMS agencies.

Project description:Background and purposeAcute stroke treatment outcomes are predicated on reperfusion timeliness which can be improved by better prehospital stroke identification. We aimed to assess the effect of interactive emergency medical services (EMS) training on stroke recognition and prehospital care performance in a very high-risk cardiovascular risk population in Lithuania.MethodsWe conducted a single-center interrupted time-series study between March 1, 2019 and March 15, 2020. Two-hour small-group interactive stroke training sessions were organized for 166 paramedics serving our stroke network. We evaluated positive predictive value (PPV) and sensitivity for stroke including transient ischemic attack identification, onset-to-door time, and hospital-based outcomes during 6-months prior and 3.5 months after the training. The study outcomes were compared between EMS providers in urban and suburban areas.ResultsIn total, 677 suspected stroke cases and 239 stroke chameleons (median age 75 years, 54.8% women) were transported by EMS. After the training, we observed improved PPV for stroke recognition (79.8% vs. 71.8%, p = 0.017) and a trend of decreased in-hospital mortality (7.8% vs. 12.3, p = 0.070). Multivariable logistic regression models adjusted for age, gender, EMS location, and stroke subtype showed an association between EMS stroke training and improved odds of stroke identification (adjusted odds ratio [aOR] 1.6 [1.1-2.3]) and onset-to-door ≤ 90 min (aOR 1.6 [1.1-2.5]). The improvement of PPV was observed in urban EMS (84.9% vs. 71.2%, p = 0.003), but not in the suburban group (75.0% vs. 72.6%, p = 0.621).ConclusionsThe interactive EMS training was associated with a robust improvement of stroke recognition, onset to hospital transport time, and a trend of decreased in-hospital mortality. Adapted training strategies may be needed for EMS providers in suburban areas. Future studies should evaluate the long-term effects of the EMS training and identify optimal retraining intervals.

Project description:BackgroundTrauma guidelines on spinal motion restriction (SMR) have changed drastically in recent years. An international group of experts explored whether consensus could be reached and if guidelines on SMR performed by trained lifeguards and prehospital EMS following in-water traumatic spinal cord injury (TSCI) should also be changed.MethodsAn international three-round Delphi process was conducted from October 2022 to November 2023. In Delphi round one, brainstorming resulted in an exhaustive list of recommendations for handling patients with suspected in-water TSCI. The list was also used to construct a preliminary flowchart for in-water SMR. In Delphi round two, three levels of agreement for each recommendation and the flowchart were established. Recommendations with strong consensus (≥ 85% agreement) underwent minor revisions and entered round three; recommendations with moderate consensus (75-85% agreement) underwent major revisions in two consecutive phases; and recommendations with weak consensus (< 75% agreement) were excluded. In Delphi round 3, the level of consensus for each of the final recommendations and each of the routes in the flowchart was tested using the same procedure as in Delphi round 2.ResultsTwenty-four experts participated in Delphi round one. The response rates for Delphi rounds two and three were 92% and 88%, respectively. The study resulted in 25 recommendations and one flowchart with four flowchart paths; 24 recommendations received strong consensus (≥ 85%), and one recommendation received moderate consensus (81%). Each of the four paths in the flowchart received strong consensus (90-95%). The integral flowchart received strong consensus (93%).ConclusionsThis study produced expert consensus on 25 recommendations and a flowchart on handling patients with suspected in-water TSCI by trained lifeguards and prehospital EMS. These results provide clear and simple guidelines on SMR, which can standardise training and guidelines on SMR performed by trained lifeguards or prehospital EMS.

Dataset Information

Application of the emergency medical services trigger tool to measure adverse events in prehospital emergency care: a time series analysis.

Background

Method

Results

Publications

Application of the emergency medical services trigger tool to measure adverse events in prehospital emergency care: a time series analysis.

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