A comparative assessment of adverse event classification in the out-of-hospital setting.

OBJECTIVES: We sought to test reliability of two approaches to classify adverse events (AEs) associated with helicopter EMS (HEMS) transport. METHODS: The first approach for AE classification involved flight nurses and paramedics (RN/Medics) and mid-career emergency physicians (MC-EMPs) independently reviewing 50 randomly selected HEMS medical records. The second approach involved RN/Medics and MC-EMPs meeting as a group to openly discuss 20 additional medical records and reach consensus-based AE decision. We compared all AE decisions to a reference criterion based on the decision of three senior emergency physicians (Sr-EMPs). We designed a study to detect an improvement in agreement (reliability) from fair (kappa = 0.2) to moderate (kappa = 0.5). We calculated sensitivity, specificity, percent agreement, and positive and negative predictive values (PPV/NPV). RESULTS: For the independent reviews, the Sr-EMP group identified 26 AEs while individual clinician reviewers identified between 19 and 50 AEs. Agreement on the presence/absence of an AE between Sr-EMPs and three MC-EMPs ranged from κ = 0.20 to κ = 0.25. Agreement between Sr-EMPs and three RN/Medics ranged from κ = 0.11 to κ = 0.19. For the consensus/open-discussion approach, the Sr-EMPs identified 13 AEs, the MC-EMP group identified 18 AEs, and RN/medic group identified 36 AEs. Agreement between Sr-EMPs and MC-EMP group was (κ = 0.30 95%CI -0.12, 0.72), whereas agreement between Sr-EMPs and RN/medic group was (κ = 0.40 95%CI 0.01, 0.79). Agreement between all three groups was fair (κ = 0.33, 95%CI 0.06, 0.66). Percent agreement (58-68%) and NPV (63-76%) was moderately dissimilar between clinicians, while sensitivity (25-80%), specificity (43-97%), and PPV (48-83%) varied. CONCLUSIONS: We identified a higher level of agreement/reliability in AE decisions utilizing a consensus-based approach for review rather than independent reviews.

Measuring adverse events in helicopter emergency medical services: establishing content validity.

INTRODUCTION: We sought to create a valid framework for detecting adverse events (AEs) in the high-risk setting of helicopter emergency medical services (HEMS). METHODS: We assembled a panel of 10 expert clinicians (n = 6 emergency medicine physicians and n = 4 prehospital nurses and flight paramedics) affiliated with a large multistate HEMS organization in the Northeast US. We used a modified Delphi technique to develop a framework for detecting AEs associated with the treatment of critically ill or injured patients. We used a widely applied measure, the content validity index (CVI), to quantify the validity of the framework's content. RESULTS: The expert panel of 10 clinicians reached consensus on a common AE definition and four-step protocol/process for AE detection in HEMS. The consensus-based framework is composed of three main components: (1) a trigger tool, (2) a method for rating proximal cause, and (3) a method for rating AE severity. The CVI findings isolate components of the framework considered content valid. CONCLUSIONS: We demonstrate a standardized process for the development of a content-valid framework for AE detection. The framework is a model for the development of a method for AE identification in other settings, including ground-based EMS.

Identification of adverse events in ground transport emergency medical services.

The purpose of this study was to develop a method to define and rate the severity of adverse events (AEs) in emergency medical services (EMS) safety research. They used a modified Delphi technique to develop a consensus definition of an AE. The consensus definition was as follows: "An adverse event in EMS is a harmful or potentially harmful event occurring during the continuum of EMS care that is potentially preventable and thus independent of the progression of the patient's condition." Physicians reviewed 250 charts from 3 EMS agencies for AEs. The authors examined physician agreement using κ, Fleiss's κ, and corresponding 95% confidence intervals (CIs). Overall physician agreement on presence of an AE per chart was fair (κ = 0.24; 95% CI = 0.19, 0.29). These findings should serve as a basis for refining and implementing an AE evaluation instrument.

Comparison of times to intubate a simulated trauma patient in two positions.

BACKGROUND: The nature of the trauma patient's injuries may compromise the airway and ultimately lead to death or neurological devastation. The same injuries complicate protecting the airway in these patients by preventing manipulation of the cervical spine for direct laryngoscopy. A recent study has shown that misplaced endotracheal tubes occur significantly more often in trauma patients than in medical patients. OBJECTIVES: The authors hypothesized that elevating the long spine board would reduce the amount of time required for paramedics to intubate a simulated trauma patient. METHODS: Paramedics from an urban emergency medical services division were given up to two opportunities to intubate a manikin in a type I ambulance in each of two positions in random order: supine and with the head elevated. The manikin was secured to a long spine board with three straps, a semi-rigid cervical collar, and a cervical immobilization device. An investigator maintained cervical spine alignment and provided cricoid pressure. The elevated position was accomplished by raising the head of the stretcher 27 degrees, resulting in 7 degrees of spine board elevation. Each attempt was timed. If the first attempt was unsuccessful, the times for both the first and second attempts were totaled to determine the total time required for intubation. Times for successful intubation in each position were compared with a Mann-Whitney test. First-attempt success rates for each position were compared with chi2 analysis. Multinomial regression was used to determine whether experience, paramedic height, or previous intubation success influenced intubation time in either position. RESULTS: Fifty-five paramedics provided informed consent and completed the study. Average time to intubate the supine manikin was significantly longer than needed to intubate the head-elevated manikin (35.6 +/- 19.0 seconds vs 27.9 +/- 12.8 seconds, p = 0.025). The manikin was successfully intubated on the first attempt 84% in the supine position and 95% in the head-elevated position (p = 0.200). Regression analysis identified intubation position as the only significant predictor of intubation time (p = 0.007). CONCLUSIONS: Modest elevation of the head of an immobilized patient appears to allow more rapid intubation. With the spine board properly secured to the stretcher, this technique potentially offers improved intubation time without additional cost or equipment.