Development of a trigger tool to identify harmful incidents, no harm incidents, and near misses in prehospital emergency care.

BACKGROUND: Emergency Medical Services (EMS) are a unique setting because care for the chief complaint is given across all ages in a complex and high-risk environment that may pose a threat to patient safety. Traditionally, a reporting system is commonly used to raise awareness of adverse events (AEs); however, it could fail to detect an AE. Several methods are needed to evaluate patient safety in EMS. In this light, this study was conducted to (1) develop a national ambulance trigger tool (ATT) with a guide containing descriptions of triggers, examples of use, and categorization of near misses (NMs), no harm incidents (NHIs), and harmful incidents (HIs) and (2) use the ATT on randomly selected ambulance records. METHODS: The ambulance trigger tool was developed in a stepwise manner through (1) a literature review; (2) three sessions of structured group discussions with an expert panel having knowledge of emergency medical service, patient safety, and development of trigger tools; (3) a retrospective record review of 900 randomly selected journals with three review teams from different geographical locations; and (4) inter-rater reliability testing between reviewers. RESULTS: From the literature review, 34 triggers were derived. After removing clinically irrelevant ones and combining others through three sessions of structured discussions, 19 remained. The most common triggers identified in the 900 randomly selected records were deviation from treatment guidelines (30.4%), the patient is non conveyed after EMS assessment (20.8%), and incomplete documentation (14.4%). The positive triggers were categorized as a near miss (40.9%), no harm (3.7%), and harmful incident (0.2%). Inter-rater reliability testing showed good agreement in both sessions. CONCLUSION: This study shows that a trigger tool together with a retrospective record review can be used as a method to measure the frequency of harmful incidents, no harm incidents, and near misses in the EMS, thus complementing the traditional reporting system to realize increased patient safety.

Epidemiology of patients assessed for trauma by Swedish ambulance services: a retrospective registry study.

BACKGROUND: There is a lack of knowledge regarding the epidemiology of severe trauma assessed by Swedish emergency medical services (EMS). AIM: To investigate the prevalence of trauma in Sweden assessed by EMS from a national perspective and describe patient demography, aetiology, trauma type, prehospital triage and clinical outcomes. METHODS: Data from two national quality registries, the Swedish Ambulance Registry and the Swedish Trauma Registry (SweTrau) were collected from January 1 to December 31, 2019. Inclusion criteria were an Emergency Symptoms and Signs code equivalent to trauma in the Swedish Ambulance Registry and criteria fulfilled for SweTrau inclusion. Exclusion criteria were patients < 18 years old, those not transported to a hospital and those without a personal identification number. RESULTS: In total, 53,120 patients with trauma were included (14% of primary EMS missions involving a personal identification number). Of those, 2,278 (4.3%) patients (median age: 45 years; 32% women) were reported in SweTrau to have severe or potentially severe trauma (penetrating: 7%, blunt: 93%). In terms of including all causes of trauma, the code for 'trauma alert activation' was most frequent (55%). The most frequent injury mechanism was an injury caused by a car (34%). Most (89%) cases were assigned Priority 1 (life-threatening condition) at the dispatch centre. 62% were regarded as potentially life threatening upon EMS arrival, whereas 29% were assessed as non-life-threatening. Overall, 25% of the patients had new injury severity scores > 15. 12% required invasive treatment, 11% were discharged with severe disability and the 30-day mortality rate was 3.6%. CONCLUSION: In this cross-sectional study, 14% of the primary EMS missions for one year were caused by trauma. However, only a small proportion of these cases are severe injuries, and the risk of severe disabilities and death appears to be limited. The most frequent aetiology of a severe trauma is injury caused by a car, and most severe traumas are blunt. Severe traumas are given the highest priority at the dispatch centre in the vast majority of cases, but nearly one-third of these cases are considered a low priority by the EMS nurse. The latter leaves room for improvement.

Ambulance nurses' experiences as the sole caregiver with critical patients during long ambulance transports: an interview study.

BACKGROUND: Working in rural areas involves tackling long distances and occasional lack of supportive resources. Ambulance nurses are faced with the responsibility of making immediate autonomous decisions and providing extended care to critically ill patients during prolonged ambulance transport to reach emergency medical facilities. This study aims to expose the experiences of ambulance nurses acting as primary caregivers for critically ill patients during lengthy ambulance transfers in rural regions. METHOD: Fifteen nurses employed in an ambulance service within sparsely populated rural areas were subjected to semi-structured interviews. The collected data underwent qualitative content analysis. RESULT: The analysis resulted in one overarching theme with two categories. The theme is 'Safety in the Professional Role,' and the two categories are 'Working in sparsely populated areas presents challenges' and 'Rare events: when routine cannot be established.' The findings suggest that working as an ambulance nurse in a rural setting poses various challenges that can be highly stressful. Delivering care to critically ill patients during extended ambulance transports requires the knowledge, experience, and careful planning of the healthcare provider in charge. CONCLUSIONS: The findings underscore the necessity for thorough planning and adaptable thinking when attending to critically ill patients during extended transport scenarios. The absence of supporting resources can render the task demanding. Nevertheless, participants reported an inherent tranquility that aids them in maintaining focus amid their responsibilities.

The onset of sepsis as experienced by patients and family members: A qualitative interview study.

AIMS AND OBJECTIVES: To explore the onset of sepsis based on patients' and family members' experiences. BACKGROUND: Knowledge about the onset of sepsis is limited among patients and their families, which makes early recognition of sepsis difficult. Previous studies argue that their stories are important to recognising sepsis and reduced suffering and mortality. DESIGN: A descriptive design with a qualitative approach was used. METHODS: In total, 29 patients and family members participated in 24 interviews with open-ended questions, including five dyadic and 19 individual interviews. The interviews were conducted during 2021, and participants were recruited from a sepsis group on social media. A thematic analysis based on descriptive phenomenology was performed. The study followed the COREQ checklist. FINDINGS: Two themes emerged from the experiences: (1) When health changes into something unknown, including the two subthemes; Bodily symptoms and signs being vague but still tangible and Feelings of uncertainty, and (2) Turning points when warnings signs are deemed as serious, including the two subthemes Passing borders when feeling out of control and Difficulties understanding the seriousness. CONCLUSIONS: Patients' and family members' stories of the onset of sepsis indicate that symptoms and signs appeared insidiously and then noticeably worsen. The symptoms and signs seemed not be attributed to sepsis; instead, there was uncertainty about what the symptoms and signs meant. It was mainly family members who possibly understood the seriousness of the disease. IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE: Patients' experiences of their symptoms and signs and family members' unique knowledge of the patient, indicate that healthcare professionals should listen and try to understand what the patient and family members are telling and take their concerns seriously. How the condition appears, and family members' concerns are important pieces of the assessment to recognise patients with sepsis. PATIENT OR PUBLIC CONTRIBUTION: Patients and family members contributed to the data collected.

Characteristics of a trauma population in an ambulance organisation in Sweden: results from an observational study.

BACKGROUND: Globally, injuries are a major health problem, and in Sweden, injuries are the second most common reason for ambulance dispatch. However, there is a knowledge gap regarding the epidemiology of injuries requiring assessment by emergency medical services (EMS) in Sweden. The aim of the present study was to describe the prehospital population with injuries that have been assessed and treated by EMS. METHODS: A randomly selected retrospective sample was collected from 1 January through 31 December 2019 in a region in southwestern Sweden. Data were collected from ambulance and hospital medical records. RESULTS: Among 153,724 primary assignments, 26,697 (17.4%) were caused by injuries. The study cohort consisted of 5,235 patients, of whom 50.5% were men, and the median age was 63 years. The most common cause of injury was low-energy fall (51.4%), and this was the cause in 77.8% of those aged > 63 years and in 26.7% of those aged ≤ 63 years. The injury mechanism was a motor vehicle in 8.0%, a motorcycle in 2.1% and a bicycle in 4.0%. The most common trauma location was the residential area (55.5% overall; 77.9% in the elderly and 34.0% in the younger group). In the prehospital setting, the most frequent clinical sign was a wound (33.2%), a closed fracture were seen in 18.9% and an open fracture in 1.0%. Pain was reported in 74.9% and 42.9% reported severe pain. Medication was given to 42.4% of patients before arrival in the hospital. The most frequent triage colour according to the RETTS was orange (46.7%), whereas only 4.4% were triaged red. Among all patients, 83.6% were transported to the hospital, and 27.8% received fracture treatment after hospital admission. The overall 30-day mortality rate was 3.4%. CONCLUSION: Among EMS assignments in southwestern Sweden, 17% were caused by injury equally distributed between women and men. More than half of these cases were caused by low-energy falls, and the most common trauma location was a residential area. The majority of the victims had pain upon arrival of the EMS, and a large proportion appeared to have severe pain.

Development of Verified Innovation Process for Healthcare Solutions (VIPHS): A Stepwise Model for Digital Health.

Many digital health projects often stop in the pilot or test phase. Realisation of new digital health services is often challenging due to lack of guidelines for the step-by-step roll-out and implementation of the systems when changing work processes and procedures are needed. This study describes development of the Verified Innovation Process for Healthcare Solutions (VIPHS) - a stepwise model for digital health innovation and utilisation using service design principles. A multiple case study (two cases) involving participant observation, role play, and semi-structured interviews were conducted for the model development in prehospital settings. The model might be helpful to support realisation of innovative digital health projects in a holistic, disciplined, and strategic way.

Prehospital assessment of patients with abdominal pain triaged to self-care at home: an observation study.

BACKGROUND: Patients who call for emergency medical services (EMS) due to abdominal pain suffer from a broad spectrum of diseases, some of which are time sensitive. As a result of the introduction of the concept of 'optimal level of care', some patients with abdominal pain are triaged to other levels of care than in an emergency department (ED). We hypothesised that it could be challenging in a patient safety perspective. AIM: This study aims to describe consecutive patients who call for EMS due to abdominal pain and are triaged to self-care by EMS clinicians. METHODS: This was an observational study performed in an EMS organisation in Western Sweden during 2020. The triage tool Rapid Emergency Triage and Treatment System (RETTS), which included Emergency Signs and Symptom (ESS) codes, was used to find medical records where patients with abdominal pain have been triaged to self-care and 194 patients was included in the study. RESULTS: Of total 48,311 ambulance missions, A total of 1747 patients were labelled with ESS code six (abdominal pain), including 223 (12.8%) who were given the code for self-care and 194 who were further assessed by the research group. Of these patients, 32 (16.3%) had a return visit within 96 hours due to the same symptoms and 11 (5.6%) were hospitalised. In six of these patients, the EMS triage was evaluated retrospectively and assessed as inappropriate. These patients had a final diagnosis of ruptured abdominal aneurysm (n = 1), acute appendicitis with peritonitis (n = 2) and acute pancreatitis (n = 3). All these patients required extensive evaluation and different treatments, including acute surgery, antibiotics and fluid therapy. CONCLUSION: Amongst the 1747 patients assessed by EMS due to abdominal pain, 223 (12.8%) were triaged to self-care. Of the 194 patients who were further assessed, 16.3% required a return visit to the ED within 96 hours and 5.6% were hospitalised. Six patients had obvious time-sensitive conditions. Our study highlights the difficulties in the early assessment of abdominal pain and the requirement for an accurate decision support tool.

Reasons for bias in ambulance clinicians' assessments of non-conveyed patients: a mixed-methods study.

BACKGROUND: The number of ambulance assignments and the influx of patients to the emergency departments (EDs) in Sweden have increased in recent years. This is one reason the protocol for prehospital emergency care was developed around referring patients for non-conveyance, either through the see-and-convey elsewhere approach or through the see-and-treat approach. However, this protocol has led to challenges in patient assessments. This study aimed to investigate the underlying causes of patient harm among those referred for the see-and-treat approach by the emergency medical services. METHODS: This three-phase study involved a mixed-methods design. Cases of injuries, internal investigations and incident analyses of referrals for the see-and-treat approach in two regions in south eastern Sweden from 2015 to 2020 were examined using qualitative content analysis. This qualitative analysis was the basis for the quantitative analysis of the ambulance records. After the qualitative analysis was completed, a review protocol was developed; 34 variables were used to review 240 randomly selected ambulance records logged in 2020, wherein patients were referred for the see-and-treat approach. Finally, the review results were synthesised. RESULTS: The qualitative analysis revealed three common themes: 'assessment of patients', 'guidelines' and 'environment and organisation'. These results were confirmed by a medical journal review. Shortcomings were found in the anamnesis and in the number of targeted examinations performed. The checklist for referring patients for the see-and-treat approach and the information sheet to be provided to the patients were not used. In 34% of the ambulance records examined, the EMS clinicians deviated from the current guidelines for a see-and-treat referral. CONCLUSIONS: The results indicated that the low adherence to guidelines and the patient assessment deviating from the protocol put patients at risk of being harmed during a see-and-treat referral. Measures are needed to guarantee a safe assessment of an increasing number of patients who are referred for the see-and-treat approach, especially the multi-sick elderly patients.

Suboptimal prehospital decision- making for referral to alternative levels of care - frequency, measurement, acceptance rate and room for improvement.

BACKGROUND: The emergency medical services (EMS) have undergone dramatic changes during the past few decades. Increased utilisation, changes in care-seeking behaviour and competence among EMS clinicians have given rise to a shift in EMS strategies in many countries. From transport to the emergency department to at the scene deciding on the most appropriate level of care and mode of transport. Among the non-conveyed patients some may suffer from "time-sensitive conditions" delaying diagnosis and treatment. Thus, four questions arise: 1) How often are time-sensitive cases referred to primary care or self-care advice? 2) How can we measure and define the level of inappropriate clinical decision-making? 3) What is acceptable? 4) How to increase patient safety? MAIN TEXT: To what extent time-sensitive cases are non-conveyed varies. About 5-25% of referred patients visit the emergency department within 72 hours, 5% are hospitalised, 1-3% are reported to have a time-sensitive condition and seven-day mortality rates range from 0.3 to 6%. The level of inappropriate clinical decision-making can be measured using surrogate measures such as emergency department attendances, hospitalisation and short-term mortality. These measures do not reveal time-sensitive conditions. Defining a scoring system may be one alternative, where misclassifications of time-sensitive cases are rated based on how severely they affected patient outcome. In terms of what is acceptable there is no general agreement. Although a zero-vision approach does not seem to be realistic unless under-triage is split into different levels of severity with zero-vision in the most severe categories. There are several ways to reduce the risk of misclassifications. Implementation of support systems for decision-making using machine learning to improve the initial assessment is one approach. Using a trigger tool to identify adverse events is another. CONCLUSION: A substantial number of patients are non-conveyed, including a small portion with time-sensitive conditions. This poses a threat to patient safety. No general agreement on how to define and measure the extent of such EMS referrals and no agreement of what is acceptable exists, but we conclude an overall zero-vision is not realistic. Developing specific tools supporting decision making regarding EMS referral may be one way to reduce misclassification rates.

Charge nurses' perceived experience in managing daily work and major incidents in emergency departments: A qualitative study.

BACKGROUND: Emergency department charge nurses are expected to oversee the quality of patient care, direct work, and the allocation of resources. The charge nurse is the unit's frontline leader, and he/she must have proper leadership training and support to carry out duties effectively. This study explores how charge nurses perceive their role in managing daily work and major incidents at the emergency department. METHODS: A qualitative study based on focus group discussions using a semi-structured interview. Participants were 12 charge nurses from four Swedish emergency departments. RESULTS: For data analysis, a systematic text condensation method was used. The analysis of data generated four categories: (1) Coping with chaos; (2) Need for further training; (3) Feeling of inadequacy; and (4) Lack of strategies. CONCLUSIONS: The study concluded that the emergency department charge nurse has frontline duties that are diverse, multifaceted, require good leadership qualities, and lack detailed job description. Charge nurses confront many challenges in their daily work, often with little training or the opportunity to develop in their professional. This study provides understanding of the concerns charge nurses hold about working as frontline leaders and that departmental heads must support the education and training of their charge nurses.

Assessment of patients with suspected sepsis in ambulance services: a qualitative interview study.

BACKGROUND: The initial care of patients with sepsis is commonly performed by ambulance clinicians (ACs). Early identification, care and treatment are vital for patients with sepsis to avoid adverse outcomes. However, knowledge about how patients with sepsis are assessed in ambulance services (AS) by AC is limited. Therefore, the aim of this study was to explore the meaning of ACs' lived experiences in assessing patients suspected of having sepsis. METHODS: A descriptive design with a qualitative approach was used. Fourteen ACs from three Swedish ambulance organizations participated in dyadic and individual semistructured interviews. A thematic analysis based on descriptive phenomenology was performed. RESULTS: AC experiences were grouped into four themes: (1) being influenced by previous experience; (2) searching for clues to the severity of the patient's condition; (3) feeling confident when signs and symptoms were obvious; and (4) needing health-care professionals for support and consultation. CONCLUSIONS: This study indicates that several factors are important to assessments. ACs needed to engage in an ongoing search for information, discuss the cases with colleagues and reconsider the assessment throughout the entire ambulance mission. A reflective and open stance based on professional knowledge could contribute to recognizing patients with sepsis.

A study of factors that predict novice nurses' perceived ability to provide care in acute situations.

AIMS: To explore factors that predict novice nurses' trust in their ability to provide care in acute situations and identify factors that are related to their perceived ability to make clinical judgements in acute situations. DESIGN: Exploratory cross-sectional study. METHODS: Novice nurses employed within somatic care in Swedish hospitals completed an online survey. Univariate analysis facilitated exploration of the data and identification of predictor variables with the greatest association with: (1) trust in their own ability (one item) and (2) ability to make clinical judgements (four items). Multivariate binary logistic regression modelling was used to model the likelihood of outcomes based on each predictor variable. RESULTS: The two most important predictors related to trust in ability to provide care were duration of work experience and participation in acute situations during nursing education. For clinical judgement, duration of work experience was significant in all four models and experience of acute situations post-graduation was significant in two models.

Development and initial validation of an instrument to measure novice nurses' perceived ability to provide care in acute situations - PCAS.

BACKGROUND: Novice nurses need to be better prepared to provide care in acute situations. There is currently no validated scale specifically measuring nurses' perception of their ability to provide care in acute situations. The aim of this study was to develop and examine the psychometric properties of a scale that measures novice nurses self-reported perception of ability to provide care in acute situations. METHOD: Development and test of the psychometric properties of the Perception to Care in Acute Situations (PCAS) scale. Items were generated from interviews with novice nurses (n = 17) and validated using opinions of an expert panel and cognitive interviews with the target group.Two hundred nine novice nurses tested the final scale. Exploratory factor analysis (EFA) was used to test construct validity, item reduction and underlying dimensions between the measured variables and the latent construct. RESULT: The PCAS scale contains 17 items grouped into three factors. EFA demonstrated a clean three factor logic construct solution with no cross-loadings, high correlation for the total scale in both Cronbach's alfa 0.90 and ordinal alpha 0.92. CONCLUSIONS: The PCAS scale has proven to have acceptable validity. The factors," confidence in provision of care", "communication" and "patient perspective" are likely to be important aspects of providing care in acute situations. Additional testing of the PCAS is needed to conclude if it is sensitive enough to evaluate interventions aimed at improving novice nurses competence and suitable as a guide for reflection for novice nurses.

Factors developing nursing students and novice nurses' ability to provide care in acute situations.

Nurses play an important role in detecting, interpreting and deciding appropriate actions to take in order to care for patients in acute situations. Nevertheless, novice nurses are reported as feeling unprepared to provide appropriate care in acute situations. In order to address this issue, it is important to describe factors in nursing education and first year of practice that enable nurses to provide appropriate care in acute situations. 17 novice nurses were interviewed in this qualitative study. A phenomenographic analysis was applied and four categories were discovered: Integrating theory into practice, access to adequate support, experience-based knowledge and personality traits. Results suggest that a variety of factors contribute to novice nurses' ability to provide appropriate care in acute situations. Experience of acute situations and the integration of theory and practice are pivotal in acquiring skills to provide appropriate care. To accomplish this, reflection, practice and/or applied training with a patient perspective is recommended.

Adverse events in prehospital emergency care: a trigger tool study.

BACKGROUND: Prehospital emergency care has developed rapidly during the past decades. The care is given in a complex context which makes prehospital care a potential high-risk activity when it comes to patient safety. Patient safety in the prehospital setting has been only sparsely investigated. The aims of the present study were 1) To investigate the incidence of adverse events (AEs) in prehospital care and 2) To investigate the factors contributing to AEs in prehospital care. METHODS: We used a retrospective study design where 30 randomly selected prehospital medical records were screened for AEs each month in three prehospital organizations in Sweden during a period of one year. A total of 1080 prehospital medical records were included. The record review was based on the use of 11 screening criteria. RESULTS: The reviewers identified 46 AEs in 46 of 1080 (4.3%) prehospital medical records. Of the 46 AEs, 43 were classified as potential for harm (AE1) (4.0, 95% CI = 2.9-5.4) and three as harm identified (AE2) (0.3, 95% CI = 0.1-0.9). However, among patients with a life-threatening condition (priority 1), the risk of AE was higher (16.5%). The most common factors contributing to AEs were deviations from standard of care and missing, incomplete, or unclear documentation. The most common cause of AEs was the result of action(s) or inaction(s) by the emergency medical service (EMS) crew. CONCLUSIONS: There were 4.3 AEs per 100 ambulance missions in Swedish prehospital care. The majority of AEs originated from deviations from standard of care and incomplete documentation. There was an increase in the risk of AE among patients who the EMS team assessed as having a life-threatening condition. Most AEs were possible to avoid.

The final assessment and its association with field assessment in patients who were transported by the emergency medical service.

BACKGROUND: In patients who call for the emergency medical service (EMS), there is a knowledge gap with regard to the final assessment after arriving at hospital and its association with field assessment. AIM: In a representative population of patients who call for the EMS, to describe a) the final assessment at hospital discharge and b) the association between the assessment in the field and the assessment at hospital discharge. METHODS: Thirty randomly selected patients reached by a dispatched ambulance each month between 1 Jan and 31 Dec 2016 in one urban, one rural and one mixed ambulance organisation in Sweden took part in the study. The exclusion criteria were age < 18 years, dead on arrival, transport between health-care facilities and secondary missions. Each patient received a unique code based on the ICD code at hospital discharge and field assessment. RESULTS: In all, 1080 patients took part in the study, of which 1076 (99.6%) had a field assessment code. A total of 894 patients (83%) were brought to a hospital and an ICD code (ICD-10-SE) was available in 814 patients (91% of these cases and 76% of all cases included in the study). According to these ICD codes, the most frequent conditions were infection (15%), trauma (15%) and vascular disease (9%). The most frequent body localisation of the condition was the thorax (24%), head (16%) and abdomen (13%). In 118 patients (14% of all ICD codes), the condition according to the ICD code was judged as time critical. Among these cases, field assessment was assessed as potentially appropriate in 75% and potentially inappropriate in 12%. CONCLUSION: Among patients reached by ambulance in Sweden, 83% were transported to hospital and, among them, 14% had a time-critical condition. In these cases, the majority were assessed in the field as potentially appropriate, but 12% had a potentially inappropriate field assessment. The consequences of these findings need to be further explored.

Novice nurses' perceptions of acute situations - A phenomenographic study.

BACKGROUND: Today's nurses face complex patient challenges and increased patient acuity. Novice nurses may feel unprepared for some of the tasks facing them. In order to prevent adverse events and improve patient outcomes, the management of acute situations has been identified as an area needing attention. Despite this, it is not yet clear what novice nurses themselves perceive as an acute situation. Therefore, the aim of this study is to describe novice nurses' perceptions of acute situations. METHOD: The study has a qualitative, descriptive design with a phenomenographic approach. Semi-structured interviews were conducted with twelve novice nurses, with less than a year of working experience, about their perceptions of acute situations. RESULTS: Acute situations are perceived as situations that occur suddenly, that involve shortage of time, or that generate a sense of insufficient personal competence. When acute situations arise, nurses experience a feeling of overwhelming responsibility. Acute situations involve not only deteriorating patient health but can also include challenging interpersonal relations or deficiencies in organisational procedures. CONCLUSION: An acute situation, as perceived by novice nurses, contains significantly more than medical manifestations related to the patient, a prominent perception being that interpersonal relations are crucial for appropriate management.

Patient safety and patient assessment in pre-hospital care: a study protocol.

BACKGROUND: Patient safety issues in pre-hospital care are poorly investigated. The aim of the planned study is to survey patient safety problems in pre-hospital care in Sweden. METHODS/DESIGN: The study is a retro-perspective structured medical record review based on the use of 11 screening criteria. Two instruments for structured medical record review are used: a trigger tool instrument designed for pre-hospital care and a newly development instrument designed to compare the pre-hospital assessment with the final hospital assessment. Three different ambulance organisations are participating in the study. Every month, one rater in each organisation randomly collects 30 medical records for review. With guidance from the review instrument, he/she independently reviews the record. Every month, the review team meet for a discussion of problematic reviews. The results will be analysed with descriptive statistics and logistic regression. DISCUSSION: The findings will make an important contribution to knowledge about patient safety issues in pre-hospital care.

Measuring participants' immersion in healthcare simulation: the development of an instrument.

BACKGROUND: Immersion is important for simulation-based education; however, questionnaire-based instruments to measure immersion have some limitations. The aim of the present work is to develop a new instrument to measure immersion among participants in healthcare simulation scenarios. METHODS: The instrument was developed in four phases: trigger identification, content validity scores, inter-rater reliability analysis and comparison with an existing immersion measure instrument. A modified Delphi process was used to develop the instrument and to establish validity and reliability. The expert panel consisted of 10 researchers. All the researchers in the team had previous experience of simulation in the health and/or fire and rescue services as researchers and/or educators and simulation designers. To identify triggers, the panel members independently screened video recordings from simulation scenarios. Here, a trigger is an event in a simulation that is considered a sign of reduced or enhanced immersion among simulation participants. RESULTS: The result consists of the Immersion Score Rating Instrument (ISRI). It contains 10 triggers, of which seven indicate reduced and three enhanced immersion. When using ISRI, a rater identifies trigger occurrences and assigns them strength between 1 and 3. The content validity analysis shows that all the 10 triggers meet an acceptable content validity index for items (I-CVI) standard. The inter-rater reliability (IRR) among raters was assessed using a two-way mixed, consistency, average-measures intra-class correlation (ICC). The ICC for the difference between weighted positive and negative triggers was 0.92, which indicates that the raters are in agreement. Comparison with results from an immersion questionnaire mirrors the ISRI results. CONCLUSIONS: In conclusion, we present a novel and non-intrusive instrument for identifying and rating the level of immersion among participants in healthcare simulation scenarios.

The impact of direct admission to a catheterisation lab/CCU in patients with ST-elevation myocardial infarction on the delay to reperfusion and early risk of death: results of a systematic review including meta-analysis.

BACKGROUND: For each hour of delay from fist medical contact until reperfusion in ST-elevation myocardial infarction (STEMI) there is a 10% increase in risk of death and heart failure. The aim of this review is to describe the impact of the direct admission of patients with STEMI to a Catheterisation laboratory (cath lab) as compared with transport to the emergency department (ED) with regard to delays and outcome. METHODS: Databases were searched for from April-June 2012 and updated January 2014: 1) Pubmed; 2) Embase; 3) Cochrane Library; 4) ProQuest Nursing and 5) Allied Health Sources. The search was restricted to studies in English, Swedish, Danish and Norwegian languages. The intervention was a protocol-based clinical pre-hospital pathway and main outcome measurements were the delay to balloon inflation and hospital mortality. RESULTS: Median delay from door to balloon was significantly shorter in the intervention group in all 5 studies reported. Difference in median delay varied between 16 minutes and 47 minutes. In all 7 included studies the time from symptom onset or first medical contact to balloon time was significantly shorter in the intervention group. The difference in median delay varied between 15 minutes and 1 hour and 35 minutes. Only two studies described hospital mortality. When combined the risk of death was reduced by 37%. CONCLUSION: An overview of available studies of the impact of a protocol-based pre-hospital clinical pathway with direct admission to a cath lab as compared with the standard transport to the ED in ST-elevation AMI suggests the following. The delay to the start of revascularisation will be reduced. The clinical benefit is not clearly evidence based. However, the documented association between system delay and outcome defends the use of the pathway.