Reliability of Field Assessment Stroke Triage for Emergency Destination Scale Use by Paramedics: Mobile Stroke Unit First-Year Experience.

Background and Purpose: Field Assessment Stroke Triage for Emergency Destination (FAST-ED) scale is a helpful tool to triage patients with stroke in the field. However, data on its reliability in the prehospital setting are lacking. We aim to test the reliability of FAST-ED scale when used by paramedics in a mobile stroke unit covering a metropolitan area. Methods: As part of standard operating mobile stroke unit procedures, paramedics initially evaluated patients. If the event characterized a stroke alert, the FAST-ED score was determined by the paramedic upon patient contact (in-person) and then independently by a vascular neurologist (VN) immediately after paramedic evaluation (remotely/telemedicine). This allowed testing of the interrater agreement of the FAST-ED scoring performance between on-site prehospital providers and remotely located VN. Results: Of a total of 238 patients transported in the first 15 months of the mobile stroke unit's activity, 173 were included in this study. Median age was 63 (interquartile range, 55.5­75) years and 52.6% were females. A final diagnosis of ischemic stroke was made in 71 (41%), transient ischemic attack in 26 (15%), intracranial hemorrhage in 15 (9%), whereas 61 (35%) patients were stroke mimics. The FAST-ED scores matched perfectly among paramedics and VN in 97 (56%) instances, while there was 0 to 1-point difference in 158 (91.3%), 0 to 2-point difference in 171 (98.8%), and 3 or more point difference in 2 (1.1%) patients. The intraclass correlation between VN and paramedic FAST-ED scores showed excellent reliability, intraclass correlation coefficient 0.94 (95% CI, 0.92­0.96; P<0.001). When VN recorded FAST-ED score ≥3, paramedics also scored FAST-ED≥3 in majority of instances (63/71 patients; 87.5%). A large vessel occlusion was identified in 16 (9.2%) patients; 13 occlusions were identified with a FAST-ED≥3 while 3 were missed. All of the latter patients had National Institutes of Health Stroke Scale score ≤5. Conclusions: We demonstrate excellent reliability of FAST-ED scale performed by paramedics when compared with VN, indicating that it can be accurately performed by paramedics in the prehospital setting.

Impact of the COVID-19 pandemic on emergency medical service response to out-of-hospital cardiac arrests in Taiwan: a retrospective observational study.

BACKGROUND: Emergency medical service (EMS) personnel have high COVID-19 risk during resuscitation. The resuscitation protocol for patients with out-of-hospital cardiac arrest (OHCA) was modified in response to the COVID-19 pandemic. However, how the adjustments in the EMS system affected patients with OHCA remains unclear. METHODS: We analysed data from the Taichung OHCA registry system. We compared OHCA outcomes and rescue records for 622 cases during the COVID-19 outbreak period (1 February to 30 April 2020) with those recorded for 570 cases during the same period in 2019. RESULTS: The two periods did not differ significantly with respect to patient age, patient sex, the presence of witnesses or OHCA location. Bystander cardiopulmonary resuscitation and defibrillation with automated external defibrillators were more common in 2020 (52.81% vs 65.76%, p<0.001%, and 23.51% vs 31.67%, p=0.001, respectively). The EMS response time was longer during the COVID-19 pandemic (445.8±210.2 s in 2020 vs 389.7±201.8 s in 2019, p<0.001). The rate of prehospital return of spontaneous circulation was lower in 2020 (6.49% vs 2.57%, p=0.001); 2019 and 2020 had similar rates of survival discharge (5.96% vs 4.98%). However, significantly fewer cases had favourable neurological function in 2020 (4.21% vs 2.09%, p=0.035). CONCLUSION: EMS response time for patients with OHCA was prolonged during the COVID-19 pandemic. Early advanced life support by EMS personnel remains crucial for patients with OHCA.

Pediatric Transport Practices Among Prehospital Providers.

OBJECTIVE: There are nearly 1000 annual ambulance crashes within the United States involving pediatric patients. In 2012 National Highway Traffic Safety Administration/US Department of Transportation released Best-Practice Recommendations for the Safe Transportation of Children in Emergency Ground Ambulances. The aim of our study was to measure emergency medical services (EMS) providers' knowledge and opinions of how to safely transport pediatric patients. In addition, we aimed to gather information on barriers to safe pediatric transport. METHODS: Members of 1 urban and 2 suburban EMS agencies completed an anonymous survey that assessed level of training, years of experience, exposure to pediatric patients, knowledge of best practices, and opinions about barriers to safe transport of pediatric patients. RESULTS: A total of 114 EMS providers answered the survey. Sixty-three percent were basic life support providers who had more than 10 years of experience in EMS. Ninety-six percent reported that they transported 0 to 5 pediatric patients per week. Twenty percent reported being trained on pediatric safe transport practices. Thirty-two percent of providers reported that personnel did not drive faster when transporting a sick pediatric patient. Eighty-six percent reported that it was unsafe to transport a child on a parent's lap, but 27% reported that it was appropriate to transport a newborn on the stretcher with mom. Thirty-eight percent were comfortable identifying proper restraint system/seat for pediatric patients, and only 35% were comfortable installing/using these devices. Provider-reported barriers to safe transport were identified. DISCUSSION: Our survey demonstrates that despite published best practices for the safe transport of children, many providers are unfamiliar with the safest way to transport these patients. In addition, we identified several existing barriers that may contribute to unsafe practices.

Assessing Infrastructure to Care for Pediatric Patients in the Prehospital Setting.

OBJECTIVES: Pediatric patients represent a small proportion of emergency medical services (EMS) calls, challenging providers in maintaining skills in treating children. Having structural capacity to appropriately diagnose and treat pediatric patients is critical. Our study measured the availability of off-line and on-line medical direction and recommended pediatric equipment at EMS agencies. METHODS: A Web-based survey was sent to EMS agencies in 2010 and 2013, and results were analyzed to determine availability of medical direction and equipment. RESULTS: Approximately 5000 agencies in 32 states responded, representing over 80% response. Availability of off-line medical direction increased between years (78% in 2010 to 85% in 2013), was lower for basic life support (BLS) (63% and 72%) than advanced life support (ALS) agencies (90% and 93%), and was generally higher in urban than rural or frontier locations. On-line medical direction was consistently available (90% both years) with slight increases for BLS agencies (87% to 90%) and slightly greater availability for urban and rural compared with frontier agencies. The majority of agencies carried most recommended equipment; however, less than one third of agencies reported carrying all equipment. Agencies with off-line medical direction, on-line medical direction, and with both off-line and on-line medical direction were respectively 1.69, 1.31, and 2.21 times more likely to report carrying all recommended equipment. CONCLUSIONS: Basic structural capacity exists in EMS for treating children, with improvements seen over time. However, gaps remain, particularly for BLS and nonurban agencies. Continuous attention to infrastructure is necessary, and the recent development of national performance measures should further promote quality emergency care for all children.

Clinical value of bedside abdominal sonography performed by certified sonographer in emergency evaluation of blunt abdominal trauma.

PURPOSE: To investigate the accuracy and efficiency of bedside ultrasonography application performed by certified sonographer in emergency patients with blunt abdominal trauma. METHODS: The study was carried out from 2017 to 2019. Findings in operations or on computed tomography (CT) were used as references to evaluate the accuracy of bedside abdominal ultrasonography. The time needed for bedside abdominal ultrasonography or CT examination was collected separately to evaluate the efficiency of bedside abdominal ultrasonography application. RESULTS: Bedside abdominal ultrasonography was performed in 106 patients with blunt abdominal trauma, of which 71 critical patients received surgery. The overall diagnostic accordance rate was 88.68%. The diagnostic accordance rate for liver injury, spleen injury, kidney injury, gut perforation, retroperitoneal hematoma and multiple abdominal organ injury were 100%, 94.73%, 94.12%, 20.00%, 100% and 81.48%, respectively. Among the 71 critical patients, the diagnostic accordance rate was 94.37%, in which the diagnostic accordance rate for liver injury, spleen injury, kidney injury, gut perforation and multiple abdominal organ injury were 100%, 100%, 100%, 20.00% and 100%. The mean time for imaging examination of bedside abdominal ultrasonography was longer than that for CT scan (4.45 ± 1.63 vs. 2.38 ± 1.19) min; however, the mean waiting time before examination (7.37 ± 2.01 vs. 16.42 ± 6.37) min, the time to make a diagnostic report (6.42 ± 3.35 vs. 36.26 ± 13.33) min, and the overall time (17.24 ± 2.33 vs. 55.06 ± 6.96) min were shorter for bedside abdominal ultrasonography than for CT scan. CONCLUSION: Bedside ultrasonography application provides both efficiency and reliability for the assessment of blunt abdominal trauma. Especially for patients with free peritoneal effusion and critical patients, bedside ultrasonography has been proved obvious advantageous. However, for negative bedside ultrasonography patients with blunt abdominal trauma, we recommend further abdominal CT scan or serial ultrasonography scans subsequently.

Paramedic Board Certification: The International Board of Specialty Certification Turns 20.

The International Board of Specialty Certification (IBSC) has been offering specialty certification for 20 years. Originally formed as the Board for Critical Care Transport Paramedic Certification (BCCTPC), the first official examination at the Air Medical Transport Conference (AMTC) in October of 2000. Paramedic specialty certification flourished because of the vision and tireless commitment of a small group of paramedic champions. Some of that group from 20 years ago included David O. Bump, John R. Clark, Dr. John Cole, Dr. Robert Donovan, Chris Giller, Lisa Gilmore, Jonathan Gryniuk; Bob Hesse, TJ Kennedy, Brian Schaeffer, and Jackie Stocking. Without their tenacity, paramedic specialty certification would not be celebrating this milestone. The IBSC is a functional specialty board with a mission to support paramedicine specialties anywhere in the world. The Certified Flight Paramedic (FP-C®), Certified Critical Care Paramedic (CCP-C®) Certified Tactical Paramedic (TP-C®), Certified Tactical Responder (TR-C®) and Certified Community Paramedic (CP-C®) examinations are well established and have become a recognized standard for clinical competency by medical providers in the United States, Europe, South Africa and the Middle East. Founded in 2000, the IBSC is a not-for-profit professional certification organization responsible for the administration and development of specialty certification exams for critical care professionals. The mission of the IBSC is to improve quality of care in all aspects of specialty EMS care across a wide variety of settings by providing a portfolio of certification exams that are an objective, fair, and honest validation of specialty knowledge to paramedics and other allied health providers are called upon to perform critical care transport. Exams are developed that are responsive to the needs of the paramedic community. Currently, there are nearly 10,000 board certified providers in one of the five specialty designations.

Joint Position Statement on Degree Requirements for Paramedics.

The National Association of EMS Educators, the National EMS Management Association, and the International Association of Flight and Critical Care Paramedics believe the time has come for paramedics to be trained through a formal education process that culminates with an associate degree. Once implemented a degree requirement will improve the care delivered by paramedics and enhance paramedicine as a heath profession.

What is the impact of physicians in prehospital treatment for patients in need of acute critical care? - An overview of reviews.

OBJECTIVES: The aim of this overview was to systematically identify and synthesize existing evidence from systematic reviews on the impact of prehospital physician involvement. METHODS: The Medline, Embase, and Cochrane library were searched from 1 January 2000 to 17 November 2017. We included systematic reviews comparing physician-based with non-physician-based prehospital treatment in patients with one of five critical conditions requiring a rapid response. RESULTS: Ten reviews published from 2009 to 2017 were included. Physician treatment was associated with increased survival in patients with out-of-hospital cardiac arrest and patients with severe trauma; in the latter group, the result was based on more limited evidence. The success rate of prehospital endotracheal intubation (ETI) has improved over the years, but ETI by physicians is still associated with higher success rates than intubation by paramedics. In patients with severe traumatic brain injury, intubation by paramedics who were not well skilled to do so markedly increased mortality. CONCLUSIONS: Current evidence is hinting at a benefit of physicians in selected aspects of prehospital emergency services, including treatment of patients with out-of-hospital cardiac arrest and critically ill or injured patients in need of prehospital intubation. Evidence is, however, limited by confounding and bias, and comparison is hampered by differences in case mix and the organization of emergency medical services. Future research should strive to design studies that enable appropriate control of baseline confounding and obtain follow-up data for the proportion of patients who die in the prehospital setting.

Prehospital analysis of northern trauma outcome measures: the PHANTOM study.

OBJECTIVE: To compare the mortality and morbidity of traumatically injured patients who received additional prehospital care by a doctor and critical care paramedic enhanced care team (ECT), with those solely treated by a paramedic non-ECT. METHODS: A retrospective analysis of Trauma Audit and Research Network (TARN) data and case note review of all severe trauma cases (Injury Severity Score ≥9) in North East England from 1 January 2014 to 1 December 2017 who were treated by the North East Ambulance Service, the Great North Air Ambulance Service or both. TARN methods were used to calculate the number of unexpected survivors or deaths in each group (W score (Ws)). The Glasgow Outcome Scores were contrasted to evaluate morbidity. RESULTS: The ECT group treated 531 patients: there were 17 unexpected survivors and no unexpected deaths. The non-ECT group treated 1202 patients independently: there were no unexpected survivors and 31 unexpected deaths. The proportion of patients requiring critical care interventions differed between the two groups 49% versus 33% (CI for difference 12% to 20%). In the ECT group, the Ws was 3.22 (95% CI 0.79 to 5.64). In the non-ECT group, the Ws was -2.97 (95% CI -1.22 to -4.71). The difference between the Ws was 6.18 (95% CI 3.19 to 9.17). There was no evidence of worse morbidity in the ECT group. CONCLUSION: This is the first UK ECT service to demonstrate a risk-adjusted mortality benefit in trauma patients with no detriment in morbidity: our results demonstrate an additional 3.22 survivors per 100 severe trauma casualties when treated by an ECT. The authors encourage other ECT services to conduct similar research.

Validation of the five-tier Taiwan Triage and Acuity Scale for prehospital use by Emergency Medical Technicians.

OBJECTIVES: This study aimed to determine the inter-rater reliability of the five-level Taiwan Triage and Acuity Scale (TTAS) when used by emergency medical technicians (EMTs) and triage registered nurses (TRNs). Furthermore, it sought to validate the prehospital TTAS scores according to ED hospitalisation rates and medical resource consumption. METHODS: This was a prospective observational study. After training in five-level triage, EMTs triaged patients arriving to the ED and agreement with the nurse triage (TRN) was assessed. Subsequently, these trained research EMTs rode along on ambulance calls and assigned TTAS scores for each patient at the scene, while the on-duty EMTs applied their standard two-tier prehospital triage scale and followed standard practice, blinded to the TTAS scores. The accuracy of the TTAS scores in the field for prediction of hospitalisation and medical resource consumption were analysed using logistic regression and a linear model, respectively, and compared with the accuracy of the current two-tier prehospital triage scale. RESULTS: After EMT's underwent initial training in five-level TTAS, inter-rater agreement between EMTs and TRNs for triage of ED patients was very good (κw=0.825, CI 0.750 to 0.900). For the outcome of hospitalisation, TTAS five-level system (Akaike's Information Criteria (AIC)=486, area under the curve (AUC)=0.75) showed better discrimination compared with TPTS two-level system (AIC=508, AUC=0.66). Triage assignments by the EMTs using the the five-level TTAS was linearly associated with hospitalisation and medical resource consumption. CONCLUSIONS: A five-level prehospital triage scale shows good inter-rater reliability and superior discrimination compared with the two-level system for prediction of hospitalisation and medical resource requirements.

Women's experience of unplanned out-of-hospital birth in paramedic care.

BACKGROUND: Healthcare literature describes predisposing factors, clinical risk, maternal and neonatal clinical outcomes of unplanned out-of-hospital birth; however, there is little quality research available that explores the experiences of mothers who birth prior to arrival at hospital. METHODS: This study utilised a narrative inquiry methodology to explore the experiences of women who birth in paramedic care. RESULTS: The inquiry was underscored by 22 narrative interviews of women who birthed in paramedic care in Queensland, Australia between 2011 and 2016. This data identified factors that contributed to the planned hospital birth occurring in the out-of-hospital setting. Women in this study began their story by discussing previous birth experience and their knowledge, expectations and personal beliefs concerning the birth process. Specific to the actual birth event, women reported feeling empowered, confident and exhilarated. However, some participants also identified concerns with paramedic practice; lack of privacy, poor interpersonal skills, and a lack of consent for certain procedures. CONCLUSIONS: This study identified several factors and a subset of factors that contributed to their experiences of the planned hospital birth occurring in the out-of-hospital setting. Women described opportunities for improvement in the care provided by paramedics, specifically some deficiencies in technical and interpersonal skills.

Shorter Versus Longer Shift Durations to Mitigate Fatigue and Fatigue-Related Risks in Emergency Medical Services Personnel and Related Shift Workers: A Systematic Review.

BACKGROUND: This study comprehensively reviewed the literature on the impact of shorter versus longer shifts on critical and important outcomes for Emergency Medical Services (EMS) personnel and related shift worker groups. METHODS: Six databases (e.g., PubMed/MEDLINE) were searched, including one website. This search was guided by a research question developed by an expert panel a priori and registered with the PROSPERO database of systematic reviews (2016:CRD42016040099). The critical outcomes of interest were patient safety and personnel safety. The important outcomes of interest were personnel performance, acute fatigue, sleep and sleep quality, retention/turnover, long-term health, burnout/stress, and cost to system. Screeners worked independently and full-text articles were assessed for relevance. Data abstracted from the retained literature were categorized as favorable, unfavorable, mixed/inconclusive, or no impact toward the shorter shift duration. This research characterized the evidence as very low, low, moderate, or high quality according to the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. RESULTS: The searched yielded n = 21,674 records. Of the 480 full-text articles reviewed, 100 reported comparisons of outcomes of interest by shift duration. We identified 24 different shift duration comparisons, most commonly 8 hours versus 12 hours. No one study reported findings for all 9 outcomes. Two studies reported findings linked to both critical outcomes of patient and personnel safety, 34 reported findings for one of two critical outcomes, and 64 did not report findings for critical outcomes. Fifteen studies were grouped to compare shifts <24 hours versus shifts ≥24 hours. None of the findings for the critical outcomes of patient and personnel safety were categorized as unfavorable toward shorter duration shifts (<24 hours). Nine studies were favorable toward shifts <24 hours for at least one of the 7 important outcomes, while findings from one study were categorized as unfavorable. Evidence quality was low or very low. CONCLUSIONS: The quality of existing evidence on the impact of shift duration on fatigue and fatigue-related risks is low or very low. Despite these limitations, this systematic review suggests that for outcomes considered critical or important to EMS personnel, shifts <24 hours in duration are more favorable than shifts ≥24 hours.

Applying Kane's validity framework to a simulation based assessment of clinical competence.

Assessment of clinical competence is complex and inference based. Trustworthy and defensible assessment processes must have favourable evidence of validity, particularly where decisions are considered high stakes. We aimed to organize, collect and interpret validity evidence for a high stakes simulation based assessment strategy for certifying paramedics, using Kane's validity framework, which some report as challenging to implement. We describe our experience using the framework, identifying challenges, decisions points, interpretations and lessons learned. We considered data related to four inferences (scoring, generalization, extrapolation, implications) occurring during assessment and treated validity as a series of assumptions we must evaluate, resulting in several hypotheses and proposed analyses. We then interpreted our findings across the four inferences, judging if the evidence supported or refuted our proposed uses of the assessment data. Data evaluating "Scoring" included: (a) desirable tool characteristics, with acceptable inter-item correlations (b) strong item-total correlations (c) low error variance for items and raters, and (d) strong inter-rater reliability. Data evaluating "Generalizability" included: (a) a robust sampling strategy capturing the majority of relevant medical directives, skills and national competencies, and good overall and inter-station reliability. Data evaluating "Extrapolation" included: low correlations between assessment scores by dimension and clinical errors in practice. Data evaluating "Implications" included low error rates in practice. Interpreting our findings according to Kane's framework, we suggest the evidence for scoring, generalization and implications supports use of our simulation-based paramedic assessment strategy as a certifying exam; however, the extrapolation evidence was weak, suggesting exam scores did not predict clinical error rates. Our analysis represents a worked example others can follow when using Kane's validity framework to evaluate, and iteratively develop and refine assessment strategies.

The bargaining of professionalism in emergency care practice: NHS paramedics and higher education.

Over the past 2 decades, as part of reforms to the National Health Service and with it organizational changes to ambulance work in the UK, paramedic education has undergone a process of academisation and a shift from in-house, apprenticeship weeks-long occupational training, to university-based undergraduate programs. While the professional regulation and standardization of Allied Health Professionals' education in high-income countries has captured scholarly attention, the study of paramedic practice is still in its infancy and there is a need to explore its evolvement in relation to the fluid societal-political circumstances affecting its provision and demand. Based on interviews with front-line paramedics, paramedic educators and paramedic science students in the South of England, this article examines how the reforms to paramedic education have impacted the professionalization of paramedics and their discourse of professionalism. Framed within to the 'new' sociology of professions, the case of British paramedics demonstrates the complex nature of the relationship between the university and professional practice. It appears that universities, the providers of paramedic education, are caught between two opposing discourses of professionalism: on the one hand, that of providing a platform for students' socialization and engagement with professionalism 'from within' practice which is based on students' common goals and mutual experiences, and, on the other hand, serving as a conduit for managerial/organizational strategies of professionalism which appear to undermine the role of university socialization.

Supraglottic airway device placement by respiratory therapists.

OBJECTIVE: Respiratory Therapists (RTs) are some of the first staff to arrive at in-hospital incidents where cardiopulmonary resuscitation (CPR) is needed, yet at some facilities, their ability to intubate is limited by hospital scope of practice. During the intubation process, CPR is often interrupted which could potentially increase the likelihood of adverse patient outcomes. Training RTs to secure the airway using non-intubation methods may reduce or eliminate time for CPR interruptions and allow for earlier continuous/uninterrupted chest compressions. DESIGN: A pilot study was developed to assess the effectiveness of a new policy for RT scope of practice. METHODS: RTs were trained for supraglottic airway device placement prior to procedure initiation. After each device insertion event, RTs completed a written survey. Time between cardiac arrest and device insertion, number of insertion attempts, ease of placement, technical specifications of the device, complications, and survival were compiled and compared between supraglottic airway device and endotracheal tube (ETT) placement. RESULTS: Procedural information from 23 patients who received a supraglottic airway device during the trial was compared to retrospective data of CPR events requiring intubation from the previous year. Time between initiation of cardiac arrest and advanced airway placement decreased significantly (p < 0.0001) when RTs placed the supraglottic airway device (4.7 min) versus ETT at CPR events the previous year (8.6 min). Device-associated complications were minimal and patient mortality was the same regardless of device. CONCLUSION: We propose that more RTs should be trained to insert supraglottic airway devices during inpatient CPR events.

A comparative study on the frequency of simulation-based training and assessment of non-technical skills in the Norwegian ground ambulance services and helicopter emergency medical services.

BACKGROUND: Inadequate non-technical skills (NTSs) among employees in the Norwegian prehospital emergency medical services (EMSs) are a risk for patient and operational safety. Simulation-based training and assessment is promising with respect to improving NTSs. The frequency of simulation-based training in and assessment of NTSs among crewmembers in the Norwegian helicopter emergency medical service (HEMS) has gained increased attention over recent years, whereas there has been much less focus on the Norwegian ground emergency medical service (GEMS). The aim of the study was to compare and document the frequencies of simulation-based training in and assessment of seven NTSs between the Norwegian HEMS and GEMS, conditional on workplace and occupation. METHOD: A comparative study of the results from cross-sectional questionnaires responded to by employees in the Norwegian prehospital EMSs in 2016 regarding training in and assessment of NTSs during 2015, with a focus on the Norwegian GEMS and HEMS. Professional groups of interest are: pilots, HEMS crew members (HCMs), physicians, paramedics, emergency medical technicians (EMTs), EMT apprentices, nurses and nurses with an EMT licence. RESULTS: The frequency of simulation-based training in and assessment of seven generic NTSs was statistically significantly greater for HEMS than for GEMS during 2015. Compared with pilots and HCMs, other health care providers in GEMS and HEMS undergo statistically significantly less frequent simulation-based training in and assessment of NTSs. Physicians working in the HEMS appear to be undergoing training and assessment more frequently than the rest of the health trust employees. The study indicates a tendency for lesser focus on the assessment of NTSs compared to simulation-based training. CONCLUSION: HEMS has become superior to GEMS, in terms of frequency of training in and assessment of NTSs. The low frequency of training in and assessment of NTSs in GEMS suggests that there is a great potential to learn from HEMS and to strengthen the focus on NTSs. Increased frequency of assessment of NTSs in both HEMS and GEMS is called for.

A better understanding of ambulance personnel's attitude towards real-time resuscitation feedback.

OBJECTIVE: High-quality chest compressions during cardiopulmonary resuscitation (CPR) play a significant role in surviving cardiac arrest. Chest-compression quality can be measured and corrected by real-time CPR feedback devices, which are not yet commonly used. This article looks at the acceptance of such systems in comparison of equipped and unequipped personnel. DESIGN: Two groups of emergency medical services' (EMS) personnel were interviewed using standardized questionnaires. SETTING: The survey was conducted in the German cities Dortmund and Münster. PARTICIPANTS: Overall, 205 persons participated in the survey: 103 paramedics and emergency physicians from the Dortmund fire service and 102 personnel from the Münster service. INTERVENTION: The staff of the Dortmund service were not equipped with real-time feedback systems. The test group of equipped personnel of the ambulance service of Münster Fire brigade uses real-time feedback systems since 2007. MAIN OUTCOME MEASURE: What is the acceptance level of real-time feedback systems? Are there differences between equipped and unequipped personnel? RESULTS: The total sample is receptive towards real-time feedback systems. More than 80% deem the system useful. However, this study revealed concerns and prejudices by unequipped personnel. Negative ratings are significantly lower at the Münster site that is experienced with the use of the real-time feedback system in contrast to the Dortmund site where no such experience exists-the system's use in daily routine results in better evaluation than the expectations of unequipped personnel. CONCLUSIONS: Real-time feedback systems receive overall positive ratings. Prejudices and concerns seem to decrease with continued use of the system.

Paramedicine in Australia and New Zealand: A comparative overview.

Paramedic services in Australia and New Zealand (Australasia) share many characteristics, with both offering versions of the Anglo-American system of emergency medical response. Their industry and professional bodies are transnational and as a result have similar industry standards and professional expectations. The major difference been the two countries is their sources of funding, with Australian paramedic services generally receiving more government funding than those in New Zealand. Both countries provide a range of services that use a mix of volunteer and professional staff and employ state-of-the-art communications and medical technology to provide high-level clinical services. In common with other higher income countries, they face the challenge of rising usage associated with ageing populations. Both countries are adapting to this through broadening their response models, from a focus on emergency medical response to the provision of a mobile health service that will see the emergence of more practitioners paramedic roles. These emerging models challenge the core missions of paramedic services, as well as the professional identity of paramedics. Despite these trends towards higher level and well-integrated paramedic services in Australia and New Zealand, communities and many other health professionals have limited knowledge or understanding of how paramedic services are organised, the characteristics of paramedics and allied staff and limited appreciation of their potential to make greater contributions to the health and well-being of communities. This article provides an introduction to how paramedics, as members of multidisciplinary teams, are well placed to contribute to improvements in health outcomes.

The Regulatory Evolution of Paramedic Practice in Australia.

Australian paramedics have always been regulated as an occupation despite a significant regulatory evolution occurring in their discipline. Paramedics have progressed from stretcher-bearers, ambulance drivers, ambulance officers and finally to paramedics. However, as the paramedic discipline evolved, paramedicine's regulatory framework remained self-regulatory through employer governance which does not reflect the professionalised role of paramedics in society. The final step in securing professional regulation for paramedics is co-regulation under the Health Practitioner Regulation National Law Act 2009. Due to recent legislative amendments, paramedics will become a registered health profession in 2018. This article details the regulatory evolution of paramedic practice in Australia and how paramedicine has evolved beyond the current employer-based regulation to professional health practitioner regulation warranting a statutory framework of governance.

Impact of Expanding the Prehospital Stroke Bypass Time Window in a Large Geographic Region.

BACKGROUND AND PURPOSE: The Ontario Acute Stroke Medical Redirect Paramedic Protocol (ASMRPP) was revised to allow paramedics to bypass to designated stroke centers if total transport time would be <2 hours and total time from symptom onset <3.5 hours. We sought to evaluate the impact and safety of implementing the Revised ASMRPP. METHODS: We conducted a 12-month implementation study involving prehospital patients presenting with possible stroke symptoms. A total of 1317 basic and advanced life support paramedics, of 9 land services in 10 rural counties and 5 cities, used the Revised ASMRPP to take appropriate patients directly to 6 designated stroke centers. RESULTS: We enrolled 1277 patients with 98.8% paramedic compliance in form completion. Of these, 755 (61.2%) met the redirect criteria and had these characteristics: mean age 72.1 (range 16-101), male 51.1%, mean time scene to hospital 16.7 minutes (range 0-92). Paramedics demonstrated excellent interobserver agreement (κ, 0.94; 95% confidence interval, 0.91-0.96) and 97.9% accuracy in interpretation of the Revised ASMRPP. Prehospital adverse events occurred in 14.7% of patients, but few were life-threatening. Overall, 71.4% of 755 cases had a stroke code activated at the hospital and 23.2% received thrombolysis. For the 189 potential stroke patients picked up in 1 city, the ASMRPP classified thrombolysis administration with sensitivity 100% and specificity 37.3% and a final diagnosis of stroke, with sensitivity 86.1% and specificity 41.9%. CONCLUSIONS: In a large urban-rural area with 9 paramedic services, we demonstrated accurate, safe, and effective implementation of the Revised ASMRPP. These revisions will allow more patients with stroke to benefit from early treatment.