Paramedic Clinical Consults with a Paramedic or Nurse in an EMS Communications Center Compared to Traditional Online Physician Consults.

OBJECTIVES: In many emergency medical services (EMS) systems, a direct medical oversight physician is available to paramedics for mandatory and/or elective consultations. At the time of this study, a clinical support desk (CSD) was being implemented within the medical communications center of a provincial EMS system in addition to the physician resource. The CSD was initially staffed with a registered nurse or an advanced care paramedic. The objective of the current study was to compare CSD "peer to peer" consults versus physician consults with regards to consultation patterns, transport dispositions, and patient safety measures. METHODS: This retrospective cohort study analyzed 2 months before (September 1 to October 31, 2012) and 2 months after (September 1 to October 31, 2013) implementation of the CSD. In the before period, all clinical consults were fielded by the direct medical oversight physician. In the after period, consults were fielded by the physician, CSD or both. EMS databases were queried, and manual chart review and abstraction of audio recordings were done. Relapses back to EMS within 48 hours of non-transport were measured. RESULTS: 1621 consults were included, with 764 consults in the before period and 857 after (p = 0.02). The number of physician consults decreased from 764 before to 464 after (39.2%, p < 0.001), with the CSD taking 325 (37.9%) consults. The CSD was consulted more for police custody and trip destination. The physician was consulted more for cease resuscitation and clinical consults prior to medication administration. Overall non-transport rates were 595/764 before (77.9%), and 646/857 after (75.4%) (p = 0.2). Non-transports were 233/325 (71.7%) via the CSD, 364/464 (78.4%) via the physician, and 49/68 (72.1%) when both were involved (p = 0.07). Rate of relapse to EMS was similar before (25/524, 4.8%) and after (26/568, 4.6%) (p = 0.76), and between CSD (12/216, 5.5%) and physician consults (13/325, 4.0%) in the after period (p = 0.41). CONCLUSION: The introduction of a novel "peer-to-peer" consult program was associated with an increased total number of consults made and reduced call volume for direct medical oversight physicians. There was no change in the patient safety measure studied.

Immediate Interventions for Presyncope of Vasovagal or Orthostatic Origin: A Systematic Review.

Background: Syncope is a common condition that may be prevented. There are non-pharmacological interventions that may be of benefit during the acute episode preceding syncope (presyncope), including physical counter-pressure maneuvers (PCM) or change of body position. We performed a systematic review of interventions that may be applied during presyncope as an immediate, first aid tactic. Methods: We searched Medline, Embase, and CINAHL and used the Grading of Recommendations Assessment, Development and Evaluation methods, and risk of bias assessments to determine the certainty of the evidence. We included randomized controlled trials (RCTs), non-randomized studies, and case series investigating adults and children with signs and symptoms of presyncope of suspected vasovagal or orthostatic origin who applied any intervention that could be used as an immediate, first aid intervention. We examined the following outcomes: prevention of syncope, adverse events, symptom improvement, and vital signs. We conducted a sub-group analysis based on the etiology of vasovagal or orthostatic presyncope. Results: We screened 5,160 titles and abstracts followed by 81 full text articles. We identified 8 studies meeting inclusion criteria, including 2 RCTs and 6 observational studies. All studies used PCM in adults and all were judged to be of low and very low certainty of evidence. For prevention of syncope, one RCT demonstrated benefit with the use of PCM (RR = 1.80 [1.26-1.89]), while observational studies failed to show benefit (RR = 1.31 [0.98 - 1.75]). Two RCTs showed benefit in symptom improvement (RR = 6.00 [2.21 - 8.61] and (RR = 1.57 [1.06 - 1.93]). Blood pressure (BP) improved with the use of PCM: systolic BP mean difference (MD) 21 mmHg higher (95% CI: 18.25 to 23.41 BPM) and diastolic BP MD 11 mmHg higher (95% CI: 9.39 to 13.10 mmHg higher). No adverse events were reported. Conclusion: While there is a minimal amount of evidence available and the findings were mixed, PCM may provide benefit for prevention of syncope during acute episodes of presyncope and may be tried in the first aid setting. No evidence was found for other non-pharmacologic interventions or for the use of PCM in children.

Impact of a Novel Collaborative Long-Term Care -EMS Model: A Before-and-After Cohort Analysis of an Extended Care Paramedic Program.

To compare system and clinical outcomes before and after an extended care paramedic (ECP) program was implemented to better address the emergency needs of long-term care (LTC) residents. Data were collected from emergency medical services (EMS), hospital, and ten LTC facility charts for two five-month time periods, before and after ECP implementation. Outcomes include: number of EMS patients transported to emergency department (ED) and several clinical, safety, and system secondary outcomes. Statistics included descriptive, chi-squared, t-tests, and ANOVA; α = <0.05. 413 cases were included (before: n = 136, 33%; after n = 277, 67%). Median patient age was 85 years (IQR 77-91 years) and 292/413 (70.7%) were female. The number of transports to ED before implementation was 129/136 (94.9%), with 147/224 (65.6%) after, p < 0.001. In the after period, fewer patients seen by ECP were transported: 58/128 (45.3%) vs. 89/96 (92.7%) of those not seen by ECP, p < 0.001. Hospital admissions were similar between phases: 39/120 (32.5%) vs. 56/213 (29.4%), p = NS, but in the after phase, fewer ECP patients were admitted vs. non-ECP: 21/125 (16.8%) vs. 35/88 (39.8%), p < 0.001. Mean EMS call time (dispatch to arrive ED or clear scene) was shorter before than after: 25 minutes vs. 57 minutes, p < 0.001. In the after period, calls with ECP were longer than without ECP: 1 hour, 35 minutes vs. 30 minutes, p < 0.001. The mean patient ED length-of-stay was similar before and after: 7 hours, 29 minutes compared to 8 hours, 11 minutes; p = NS. In the after phase, ED length-of-stay was somewhat shorter with ECPs vs. no ECPs: 7 hours, 5 minutes vs. 9 hours, p = NS. There were zero relapses after no-transport in the before phase and three relapses from 77 calls not transported in the after phase (3/77, 3.9%); two involved ECP (2/70, 2.8%). Reductions were observed in the number of LTC patients transported to the ED when the ECP program was introduced, with fewer patients admitted to the hospital. EMS calls take longer with ECP involved. The addition of ECP to the LTC model of care appears to be beneficial and safe, with few relapse calls identified.

Insights into the implementation and operation of a novel paramedic long-term care program.

OBJECTIVE: An extended-care paramedic (ECP) program was implemented to provide emergency assessment and care on site to long-term care (LTC) residents suffering acute illness or injury. A single paramedic works collaboratively with physicians, LTC staff, patient, and family to develop care plans to address acute situations, often avoiding the need to transport the resident to hospital. We sought to identify insights gained and lessons learned during implementation and operation of this novel program. METHODS: The perceptions and experiences of various stakeholders were explored in focus groups, using a semi-structured interview guide. Two investigators independently conducted thematic analysis and identified emerging themes and related codes. Congruence and differences were discussed to achieve consensus. RESULTS: Twenty-one participants took part in four homogeneous focus groups: paramedics and dispatchers, ECPs, ECP oversight physicians, and decision-makers. The key themes identified were (1) program implementation, (2) ECP process of care, (3) communications, and (4) end-of-life care. CONCLUSION: The ECP program has positive implications for the relationship between EMS and LTC, requires additional paramedic training, and can positively affect LTC patient experiences during acute medical events. ECPs have a novel role to play in end-of-life care and find this new role rewarding.

Paramedic self-reported exposure to violence in the emergency medical services (EMS) workplace: a mixed-methods cross-sectional survey.

INTRODUCTION: Studies from Australia, Sweden, the United States, and elsewhere have found that paramedics experience violence in the emergency medical services (EMS) workplace. The objective of this study was to describe and explore violence experienced by paramedics in the ground ambulance setting, including types of violence experienced, by whom the violence was perpetrated, actions taken by paramedics, and effects of these episodes. METHOD: A cross-sectional study utilizing a mixed-methods paper survey was provided to a convenience sample of rural, suburban, and urban-based ground ambulance paramedics in two Canadian provinces. Paramedics were asked to describe episodes of verbal assault, intimidation, physical assault, sexual harassment, and sexual assault they were exposed to during the past 12 months. Qualitative questions inquired about the impact of these experiences. Response selections were analyzed using descriptive statistics and regression analysis, and qualitative data was analyzed using descriptive content analysis. RESULTS: A total of 1,884 paramedics were invited to participate and 1,676 responded (89.0%). Most participants (75%) reported experiencing violence in the past 12 months. The most common form of violence reported was verbal assault (67%), followed by intimidation (41%), physical assault (26%), sexual harassment (14%), and sexual assault (3%). Patients were identified as the most common perpetrators of violence. Serious sequellae were qualitatively reported. CONCLUSION: The majority of Canadian paramedics surveyed experience violence in the workplace, which can lead to serious personal and professional sequellae. Strategies should be devised and studied to reduce violent events toward paramedics and to mitigate the impact such events have on the wellbeing of paramedics.

Chest compression fraction in simulated cardiac arrest management by primary care paramedics: King laryngeal tube airway versus basic airway management.

OBJECTIVE: The objective of this randomized simulation study was to determine whether use of the King laryngeal tube (KLT) airway resulted in differences in chest compression fraction (CCF) during simulated cardiac arrest managed by primary care paramedics (PCPs), as compared with basic airway management (bag-mask ventilation [BMV]). METHODS: The KLT was introduced to all providers in our system at the time of study initiation. All participants received the same training, and were not aware that the primary outcome of the study was CCF. Standard airway management by PCPs prior to this was BMV. Pairs of PCPs were randomized to use KLT or BMV during a scripted 6-minute cardiac arrest scenario. The scenarios were videotaped, and data were abstracted by a single investigator. The CCF was calculated (fraction of time chest compressions were done/total scenario time). The CCF, number of seconds to first ventilation, and number of seconds to first compression were compared using the Mann-Whitney U test. RESULTS: Sixty-seven pairs of PCPs participated: 30 in the KLT arm and 37 in the BMV arm. Demographics were similar in each group: KLT 68.3% males, BMV 55.4% males; KLT mean age 33.52 years (standard deviation [SD]: 11.95), BMV mean age 32.07 years (SD: 8.78); and KLT mean years of experience 9.03 (SD: 9.86), BMV mean years of experience 6.59 (SD: 6.58). The CCF was higher in the KLT group: median 0.82 (interquartile range [IQR] 0.71-0.88) compared with the BMV group: median 0.70 (IQR 0.66-0.73), p < 0.001. Time to first ventilation was longer in the KLT group: median 83.00 sec (IQR 43.75-139.25 sec) than in the BMV group: median 48.00 sec (IQR 37.00-71.00 sec), p = 0.004. Times to first compression were similar: KLT median 13.00 sec (IQR 8.00-17.00 sec), BMV median 14.00 sec (IQR 11.00-18.50 sec), p = 0.331. CONCLUSION: In this randomized simulation study, KLT use by PCPs during simulated standard cardiac arrest scenarios was found to significantly increase CCF compared with basic airway management with BMV.

Paramedic myocardial infarction care with fibrinolytics: a process map and hazard analysis.

OBJECTIVES: Despite the supporting published evidence for prehospital fibrinolysis (PHF) for ST-elevation myocardial infarction (STEMI) patients by paramedics, the complexity of the process has not been rigorously explored in a stepwise approach. The objectives of this study were to (1) map the process of care that occurs during EMS management of STEMI with administration of PHF from 911 call to transfer of care to the emergency department and (2) to identify steps that could adversely affect patient safety or clinical outcome. METHODS: A Health Care Failure Mode and Effect Analysis was conducted. Steps were identified and organized into major call phases. Each step was categorized as a decision, technical skill, or task. The role required to perform each was identified: emergency medical dispatcher (EMD) or primary (PCP) or advanced care paramedic (ACP). The map was validated against a video-taped STEMI scenario. Once finalized, the steps with potential for risk to safety or outcome (hazard modes (HMs)) were identified. HMs were scored by study team consensus for probability to occur and likely severity of impact to the patient (minimum = 2, maximum = 16, ≥8 considered high risk). RESULTS: The map consisted of 18 phases and 167 steps, of which 37 (22.2%) were decisions, 67 (40.1%) were technical skills, and 63 (37.7%) were tasks. Ten steps could be completed by an EMD (6.0%), 76 (45.5%) by a PCP, and 81 (48.5%) by an ACP. The phases with the most steps were initial treatment, n = 31 steps (18.0%), and reperfusion therapy, n = 30 steps (18.0%). Sixty-eight HMs were identified, mean score 4.54 (SD 2.32), five of which scored eight or above (7.3%). The highest scoring HMs were history-taking, obtaining 12-lead, and transmitting 12-lead (all scores = 12). The phases with the most HMs were initial treatment (n = 12 HMs) and reperfusion therapy (n = 12 HMs). CONCLUSIONS: In this mapping study of STEMI calls in which paramedics administer fibrinolytics, the process was found to be complex, containing many steps, but relatively few individual steps were highly hazardous to patient care or safety. This study has enabled specific actions to target the highest scoring hazard modes, in an effort to improve paramedic practice and patient safety for EMS STEMI patients. Key words: emergency medical services; myocardial infarction; fibrinolytic agents; ambulances; process map.

The impact of intense airway management training on paramedic knowledge and confidence measured before, immediately after and at 6 and 12 months after training.

INTRODUCTION: Airway management is a core component in the practice of advanced life support (ALS) paramedics. OBJECTIVE: To determine if an intense airway management course would improve ALS paramedic knowledge and confidence and if knowledge was retained over time. METHODS: An identical written survey (measuring demographics and confidence) and multiple-choice examination (measuring knowledge) was administered at the start and end of a 10 h airway course. At 6 and 12 months after the course, paramedics took the knowledge examination. Paired confidence and written knowledge examination scores before and immediately after the course were compared. Differences between knowledge examination scores at all four time points (before, immediately after and at 6 and 12 months) were tested using analysis of variance and Tukey's test. RESULTS: 299 ALS paramedics were enrolled in the study. 209 (69%) reported 6 or more years of ALS experience. The mean pre-course confidence score was 2.74/4 and the mean post-course confidence score was 3.39/4; a difference of 0.7 points (95% CI 0.61 to 0.71). Post-course examination scores improved by 4.9 points (95% CI 4.58 to 5.20), from 7.7 to 12.6/20. At 6 months the mean score was 10.3/20, and at 12 months 10.2/20. Post-course scores were significantly better than pre-course scores. Scores at 6 and 12 months did not differ significantly and remained significantly improved from pre-course scores. CONCLUSION: Significant improvement in confidence and knowledge was found after paramedics completed an intense airway management course. Knowledge at 6 and 12 months remained significantly better compared with pre-course.

Nutrition and shiftwork: evaluation of new paramedics' knowledge and attitudes.

PURPOSE: The effect of an oral education intervention on nutrition knowledge was evaluated in new paramedic employees. The evaluation involved measuring knowledge of and attitudes toward nutrition and shiftwork before and after the directed intervention. METHODS: A convenience sample of 30 new paramedic shiftworkers attended a 15-minute education session focused on nutrition management strategies. This matched cohort study included three self-administered surveys. Survey 1 was completed before education, survey 2 immediately after education, and survey 3 after one month of concurrent post-education and employment experience. Knowledge and attitude scores were analyzed for differences between all surveys. RESULTS: Participants were primary care paramedics, 59% of whom were male. They reported that previously they had not received this type of information or had received only a brief lecture. Mean knowledge scores increased significantly from survey 1 to survey 2; knowledge retention was identified in survey 3. A significant difference was found between surveys 2 and 3 for attitudes toward meal timing; no other significant differences were found between attitude response scores. CONCLUSIONS: The education session was successful in improving shiftwork nutrition knowledge among paramedics. Paramedics' attitudes toward proper nutrition practices were positive before the education intervention.

Evaluating the Impact of a Novel Mobile Care Team on the Prevalence of Ambulatory Care Sensitive Conditions Presenting to Emergency Medical Services in Nova Scotia.

INTRODUCTION: Hospitalization due to ambulatory care sensitive conditions (ACSC) is a proxy measure for access to primary care. Emergency Medical Services (EMS) are increasingly called when primary care cannot be accessed. A novel paramedic-nurse EMS Mobile Care Team (MCT) was implemented in an under-serviced community. The MCT responds in a non-transport unit to referrals from EMS, emergency and primary care, and to low-acuity 911 calls in a defined geographic region. Our objective was to compare the prevalence of ACSC in ground ambulance (GA) responses before and after the introduction of the MCT. METHODS: A cross-sectional analysis of GA and MCT patients with ACSC (determined by chief complaint, clinical impression, treatment protocol, and medical history) from one year pre-MCT implementation to one year post-MCT implementation was conducted for the period of October 1, 2012, to September 30, 2014. Demographics were described. ACSC prevalence was compared using the chi-squared test. RESULTS: There were 975 calls pre-MCT and 1208 GA/95 MCT calls post-MCT. ACSC in GA patients pre- and post-MCT was similar: n=122, 12.5% vs. n=185, 15.3%; p=0.06. ACSC in patients seen by EMS (GA plus MCT) increased in the post-MCT period: 122 (12.5%) vs. 204 (15.7%) p=0.04. Pre-MCT implementation vs post-implementation, GA ACSC calls differed significantly by sex with higher female utilization (n=50 vs. n=105; p=0.007), but not age (65.38, ± 15.12 vs. 62.51 ± 20.48; p=0.16). Post-MCT, the prevalence of specific ACSC increased for GA: hypertension (p<0.001) and congestive heart failure (p=0.04). MCT patients with ACSC were less likely to have a primary care provider compared to GA (90.2% and 87.6% vs. 63.2%; p=0.003, p=0.004). CONCLUSION: The prevalence of ACSC did not decrease for GA with the introduction of the MCT, but ACSC in the overall patient population served by EMS increased. It is possible more patients with ACSC call, or are referred to EMS, for the new MCT service. Given that MCT patients were less likely to have a primary care provider, this may represent an increase in access to care or a shift away from other emergency/episodic care. These associations must be further studied to inform the ideal utility of adding such services to EMS and healthcare systems.

Factors associated with the successful recognition of abnormal breathing and cardiac arrest by ambulance communications officers: a qualitative iterative survey.

OBJECTIVES: We sought to identify barriers and facilitators to ambulance communications officers' (ACOs') recognition of abnormal breathing and administration of cardiopulmonary resuscitation (CPR) instructions. METHODS: We conducted semistructured qualitative interviews based on the constructs of the Theory of Planned Behavior to elicit salient attitudes, social influences, and behavioral controls potentially influencing ACOs' intent to recognize abnormal breathing as a symptom of cardiac arrest and administer CPR instructions over the phone. We conducted interviews until achieving data saturation. We recorded interviews and transcribed them verbatim. Two independent reviewers performed inductive analyses to identify emerging themes. RESULTS: We interviewed 24 ACOs from four Canadian provinces (67% female, median 9.5 years of experience, 33% with paramedic training). We identified eight behavioral, 14 subjective normative, and 22 control beliefs. Important attitudes were as follows: 1) CPR instructions may help the patient and are likely to be beneficial for the caller; 2) abnormal breathing is an early sign of cardiac arrest; and 3) dispatch-assisted CPR instructions can improve survival. The leading social influence was management/quality assurance staff. Behavioral control was the construct most associated with ACOs' ability to recognize abnormal breathing, including 1) adherence to mandatory scripted protocol, 2) poor caller description of breathing pattern, and 3) ACO training on abnormal breathing. CONCLUSIONS: This qualitative study found that control beliefs are most influential on ACOs' intention to recognize abnormal breathing and provide CPR instructions over the phone. Training and policy changes should target these beliefs to increase the frequency of ACO-administered CPR instructions to callers reporting a patient in cardiac arrest.

Paramedic Endotracheal Intubation Success Rates Before and After an Intensive Airway Management Education Session.

Introduction Advanced airway management by paramedics is potentially life-saving, but carries a significant risk to patient safety and can be associated with poor clinical outcome if performed incorrectly. Previously, our team had found that an intensive education intervention demonstrated an improvement in paramedic performance on a written exam and increased confidence in airway skills. This study measured intubation success and the number of attempts per patient before and after intensive paramedic airway management education intervention. Methods A 10-hour mandatory course was taken by all advanced life support (ALS) paramedics in a provincial system (2009/04-07, n=~395). The course was done during semi-annual continuing education Emergency Health Services (EHS) in-services. These day-long courses were held in person over four months. The electronic charting database was queried for intubation attempts and successful placements 12 months before the training, during the four months of training, and 12 months post-training. The primary outcome is the difference in success rates between the before (pre-intervention) and after (post-intervention) periods. The secondary outcome is the number of attempts per patient. Stationarity of success in pre- and post-periods was tested. The model was fit tested using Maximum Likelihood regression, and variables were tested using the Wald test. Results A sample size of 476 intubation attempts in each of the pre- and post-periods was required to detect a 10% improvement with the pre-intervention success of 60%. A total of 1421 intubation attempts occurred; 674 pre-intervention, 604 post-intervention, and 143 during teaching. Seven attempts were excluded (success unknown). Intubation success rates improved, from 0.68 (95% CI 0.64-0.71) to 0.75 (95% CI 0.72-0.78); a difference of 0.076 (95% CI 0.03-0.12) (p = 0.001). Intubation success rates in the pre-intervention and post-intervention periods were found to be static. A significant decrease was found in the number of attempts per patient in the post-period (p = 0.005). Conclusion Intubation success increased from 68% to 75% and was maintained over the 12-month post-period. There is a potential that judgment may also have improved, based on the decreased number of attempts per patient. Limitations include missing values, paramedics' self-reported number of attempts, and the definition of what is considered to be an attempt. In addition to previously demonstrated improvements in paramedic exam and scenario performance, this airway education intervention appears to have made a significant improvement to patient outcomes. These findings support the value of such education interventions to improve performance.

Methodology for the development of a Canadian national EMS research agenda.

BACKGROUND: Many health care disciplines use evidence-based decision making to improve patient care and system performance. While the amount and quality of emergency medical services (EMS) research in Canada has increased over the past two decades, there has not been a unified national plan to enable research, ensure efficient use of research resources, guide funding decisions and build capacity in EMS research. Other countries have used research agendas to identify barriers and opportunities in EMS research and define national research priorities. The objective of this project is to develop a national EMS research agenda for Canada that will: 1) explore what barriers to EMS research currently exist, 2) identify current strengths and opportunities that may be of benefit to advancing EMS research, 3) make recommendations to overcome barriers and capitalize on opportunities, and 4) identify national EMS research priorities. METHODS/DESIGN: Paramedics, educators, EMS managers, medical directors, researchers and other key stakeholders from across Canada will be purposefully recruited to participate in this mixed methods study, which consists of three phases: 1) qualitative interviews with a selection of the study participants, who will be asked about their experience and opinions about the four study objectives, 2) a facilitated roundtable discussion, in which all participants will explore and discuss the study objectives, and 3) an online Delphi consensus survey, in which all participants will be asked to score the importance of each topic discovered during the interviews and roundtable as they relate to the study objectives. Results will be analyzed to determine the level of consensus achieved for each topic. DISCUSSION: A mixed methods approach will be used to address the four study objectives. We anticipate that the keys to success will be: 1) ensuring a representative sample of EMS stakeholders, 2) fostering an open and collaborative roundtable discussion, and 3) adhering to a predefined approach to measure consensus on each topic. Steps have been taken in the methodology to address each of these a priori concerns.

Paramedic clinical decision making during high acuity emergency calls: design and methodology of a Delphi study.

BACKGROUND: The scope of practice of paramedics in Canada has steadily evolved to include increasingly complex interventions in the prehospital setting, which likely have repercussions on clinical outcome and patient safety. Clinical decision making has been evaluated in several health professions, but there is a paucity of work in this area on paramedics. This study will utilize the Delphi technique to establish consensus on the most important instances of paramedic clinical decision making during high acuity emergency calls, as they relate to clinical outcome and patient safety. METHODS AND DESIGN: Participants in this multi-round survey study will be paramedic leaders and emergency medical services medical directors/physicians from across Canada. In the first round, participants will identify instances of clinical decision making they feel are important for patient outcome and safety. On the second round, the panel will rank each instance of clinical decision making in terms of its importance. On the third and potentially fourth round, participants will have the opportunity to revise the ranking they assigned to each instance of clinical decision making. Consensus will be considered achieved for the most important instances if 80% of the panel ranks it as important or extremely important. The most important instances of clinical decision making will be plotted on a process analysis map. DISCUSSION: The process analysis map that results from this Delphi study will enable the gaps in research, knowledge and practice to be identified.

A survey of factors associated with the successful recognition of agonal breathing and cardiac arrest by 9-1-1 call takers: design and methodology.

BACKGROUND: Cardiac arrest victims most often collapse at home, where only a modest proportion receives life-saving bystander cardiopulmonary resuscitation. As many as 40% of all sudden cardiac arrest victims have agonal or abnormal breathing in the first minutes following cardiac arrest. 9-1-1 call takers may wrongly interpret agonal breathing as a sign of life, and not initiate telephone cardiopulmonary resuscitation instructions. Improving 9-1-1 call takers' ability to recognize agonal breathing as a sign of cardiac arrest could result in improved bystander cardiopulmonary resuscitation and survival rates for out-of-hospital cardiac arrest victims. METHODS/DESIGN: The overall goal of this study is to design and conduct a survey of 9-1-1 call takers in the province of Ontario to better understand the factors associated with the successful identification of cardiac arrest (including patients with agonal breathing) over the phone, and subsequent administration of cardiopulmonary resuscitation instructions to callers. This study will be conducted in three phases using the Theory of Planned Behaviour. In Phase One, we will conduct semi-structured qualitative interviews with a purposeful selection of 9-1-1 call takers from Ontario, and identify common themes and belief categories. In Phase Two, we will use the qualitative interview results to design and pilot a quantitative survey. In Phase Three, a final version of the quantitative survey will be administered via an electronic medium to all registered call takers in the province of Ontario. We will perform qualitative thematic analysis (Phase One) and regression modelling (Phases Two and Three), to determine direct and indirect relationship of behavioural constructs with intentions to provide cardiopulmonary resuscitation instructions. DISCUSSION: The results of this study will provide valuable insight into the factors associated with the successful recognition of agonal breathing and cardiac arrest by 9-1-1 call takers. This will guide future interventional studies, which may include continuing education and protocol changes, in order to help increase the number of callers appropriately receiving cardiopulmonary resuscitation instructions, and save the lives of more cardiac arrest victims.

Adherence to "No Transfer to Hospital" Advance Directives Among Nursing Home Residents.

OBJECTIVES: Many older adults in long-term care (LTC) experience acute health crises but are at high risk of transfer distress and in-hospital morbidity and mortality. Residents often complete advance directives (ADs) regarding future care wishes, including directives for hospital transfers. This study aims to estimate the prevalence of, and adherence to, "no transfer to hospital" ADs in LTC, and to explore the circumstances leading to transfers against previously expressed directives. DESIGN: We conducted a mixed methods study in 10 nursing homes in Nova Scotia, Canada. A total of 748 resident charts and Emergency Health Services (EHS) database notes were reviewed from 3 time periods spanning implementation of a new primary care model, Care by Design (CBD). MEASURES: ADs were divided into those requesting transfer to hospital vs on-site management only, which were then analyzed in relation to actual hospital transfers. Reasons for EHS calls, management, and qualitative data were derived from the EHS database. Resident variables were obtained from LTC charts. Measures were compared between time periods. RESULTS: ADs were complete in 92.4% of charts. Paramedics were called for 80.5% of residents, and 73.6% were transferred to hospital, 51.3% of whom had explicit ADs to the contrary. The majority of those were transferred for fall-related injuries, followed by medical illness. Unclear care plans, symptom control, and perceived need for investigations and procedures all influenced transfer decisions. CONCLUSIONS/IMPLICATIONS: The use of "no transfer to hospital" directives did not appear to impact the number of residents being transferred to acute care. Half of those transferred to hospital had explicit ADs to the contrary, largely driven by fall-related injury. The high incidence of injury-related transfers highlights an important gap in advance care planning. Clarifying transfer preferences for injury management in advance directives may lead to better end-of-life experiences for residents and improve effective resource utilization.

Paramedics providing palliative care at home: A mixed-methods exploration of patient and family satisfaction and paramedic comfort and confidence.

OBJECTIVE: Paramedics Providing Palliative Care at Home was launched in two provinces, including a new clinical practice guideline, database, and paramedic training. The aim of this study was to evaluate patient/family satisfaction and paramedic comfort and confidence. METHODS: In Part A, we gathered perspectives of patients/families via surveys mailed at enrolment and telephone interviews after an encounter. Responses were reported descriptively and by thematic analysis. In Part B, we surveyed paramedics online pre- and 18 months post-launch. Comfort and confidence were scored on a 4-point Likert scale, and attitudes on a 7-point Likert scale, reported as the median (interquartile range [IQR]); analysis with Wilcoxon ranked sum/thematic analysis of free text. RESULTS: In Part A, 67/255 (30%) enrolment surveys were returned. Three themes emerged: fulfilling wishes, peace of mind, and feeling prepared for emergencies. In 18 post-encounter interviews, four themes emerged: 24/7 availability, paramedic professionalism and compassion, symptom relief, and a plea for program continuation. Thematic saturation was reached with little divergence. In Part B, 235/1255 (18.9%) pre- and 267 (21.3%) post-surveys were completed. Comfort with providing palliative care without transport improved post launch (p = < 0.001) as did confidence in palliative care without transport (p = < 0.001). Respondents strongly agreed that all paramedics should be able to provide basic palliative care. CONCLUSIONS: After implementation of the multifaceted Paramedics Providing Palliative Care at Home Program, paramedics describe palliative care as important and rewarding. The program resulted in high patient/family satisfaction; simply registering provides peace of mind. After an encounter, families particularly noted the compassion and professionalism of the paramedics.

CONTEXTE: Un programme de prestation de soins palliatifs à domicile par des ambulanciers paramédicaux a été lancé dans deux provinces, précédé de l'extension d'un guide de pratique clinique, de la mise à jour d'une base de données et de l'élaboration d'une formation particulière à l'intention des ambulanciers paramédicaux. Ont été évalués le degré de satisfaction des patients et des familles ainsi que le degré d'aisance et de confiance des ambulanciers paramédicaux. MÉTHODE: Dans la partie A, il y a eu collecte de données sur le point de vue des patients et des familles à l'aide d'un questionnaire d'enquête envoyé par la poste au moment de la sélection et d'entrevues téléphoniques après les rencontres. Les réponses ont été présentées en style descriptif et sous forme d'analyse thématique. Dans la partie B, une enquête en ligne a été menée parmi les ambulanciers paramédicaux avant le lancement du programme et 18 mois après celui-ci. Le degré d'aisance et de confiance a été évalué sur une échelle de Likert de 4 points, et les attitudes, sur une échelle de Likert de 7 points; les résultats ont été exprimés sous forme d'intervalles interquartiles (IQ) médians; l'analyse des données, calculée à l'aide du test de Wilcoxon, et les textes libres, présentés sous forme d'analyse thématique. RÉSULTATS: Dans la partie A, 67 questionnaires sur 255 (30%) ont été remis. Trois thèmes importants se sont dégagés des réponses : la satisfaction des désirs, la tranquillité d'esprit et le sentiment de préparation à toute éventualité. Par ailleurs, il y a eu 18 entrevues après les rencontres, desquelles se sont dégagés quatre grands thèmes : la disponibilité des soins 24 h sur 24, 7 jours sur 7; le professionnalisme et la compassion des ambulanciers paramédicaux; le soulagement des symptômes et un appel pressant en faveur de la poursuite du programme. La saturation thématique s'est obtenue avec un faible degré de divergence. Dans la partie B, 235 questionnaires sur 1255 (18,9%) ont été remplis avant le lancement du programme, et 267 sur 1255 (21,3%), après la mise en œuvre. Le degré d'aisance et la prestation de soins palliatifs, dans le contexte d'absence de transport des malades, se sont améliorés après le lancement (p ( 0,001); il en allait de même pour le degré de confiance dans la prestation de soins palliatifs, dans le même contexte (p ( 0,001). Les répondants étaient fortement d'avis que tous les ambulanciers paramédicaux devraient être en mesure de fournir des soins palliatifs de base. CONCLUSION: Après la mise en œuvre de ce programme à volets multiple, les ambulanciers paramédicaux considéraient la prestation de soins palliatifs comme un geste important et gratifiant. Le programme a donné lieu à un degré élevé de satisfaction tant des patients que des familles, et la facilité d'inscription a procuré la tranquillité d'esprit. Enfin, après une rencontre, les familles ont souligné tout particulièrement le professionnalisme et la compassion des ambulanciers paramédicaux.