Volume 6 Issue 12

An integrated ABCDE approach to managing medical emergencies using CRM principles

Background:There is increasing recognition of the vital role of non-technical skills in managing medical emergencies. An ABCDE approach has been very successful in training healthcare professionals in technical skills. Using a similar structure is likely to enhance successful application of their non-technical counter parts in clinical practice whether it is in the hospital or pre-hospital setting.Aim and Methods:To further promote safe patient care, teaching and learning aids currently used to implement crisis resource management skills, non-technical skills and human factors were identified and grouped in a way that facilitates memorisation.Results:Tools are available in the form of lists, tables and algorithms to identify behavioural markers of different components of non-technical skills and aspects of crisis resource management (CRM) and human factors. They require the need to memorise a list of items or a checklist. We have successfully used a visual aid representing these key CRM principles as a radial diagram, combined with a flow chart representing ABCDE approach for technical skills. Grouping them together in a format to embed in memory, combined with a visual aid representing the application nature of the principles, is likely to complement the existing tools in matching the learning style of more healthcare professionals. This inherently promotes the more widespread use of the principles, and hence has the potential to enhance patient safety.Conclusions:The proposed radial diagram, alongside the mnemonic alphabetical grouping, can be used to introduce the CRM principles and to provide effective feedback. This mnemonic is likely to help embed the CRM principles and enable recall in clinical practice to increase patient safety. The effectiveness of this aid could be tested using simulation of medical emergencies while training multiprofessional teams.

Student paramedics' perceptions of action learning: a mixed-method study

Paramedic education programmes must draw upon a wide range of teaching, learning and assessment techniques in order to ensure that graduating students possess the necessary skills and qualities for their profession (Quality Assurance Agency (QAA), 2013). Theory and practice must come together as part of a reflective learning process at a number of points within the education cycle, in order to identify crucial learning points, and areas for self-improvement from the practice setting. One way of achieving this is via action learning (AL).This small-scale study uses a mixed methods approach to investigate whether or not student paramedics from a UK university, as participants within action learning sets (ALS), felt that that they were a useful educational tool to use within a Foundation Degree in Paramedic Science.Students reported many benefits to their educational experience having participated in ALS, including developments in personal, academic and professional areas. The research also showed how the AL process could be improved in areas such as AL induction, providing AL members with team working skills as well as supporting students with communication and leadership challenges during ALS.

Spotlight on Research

Lay presence at cardiac arrest: what does the literature say?For decades there has been debate concerning the presence of lay people during resuscitation attempts. Predominantly the focus of the research has been in-hospital although in recent years we have seen a growing body of evidence pertaining to out-of-hospital settings (Walker, 2014).Frequently this phenomenon is referred to in the literature as ‘witnessed resuscitation’ (WR) or ‘family presence during resuscitation’ (FPDR). The authors of this paper identify that although there is nothing new about this topic, there remain inconsistencies with regard to perceived benefits, barriers and enablers to this practice.The aim of the review was to examine evidence on WR in the emergency department (ED). Although the literature search looked for evidence from 1992 through to 2012, only papers from 2000 onwards were incorporated in the review itself. The paper clearly identifies the included databases and the primary search terms such as ‘family presence’, ‘resuscitation’, ‘arrest’, ‘witnessed’, ‘barriers’, ‘benefits’, ‘advantages and disadvantages’ etc.Inclusion and exclusion criteria are clearly presented. It is notable that although the focus was the ED, the researchers wanted all key stakeholders (stated as patients, general public, family members, allied health professions, nurses and doctors) to be represented and, hence, they did not restrict their included papers to just one group or profession.‘There is a dearth of research relating to WR in out-of-hospital environments which needs to be adrressed’Initially 2 036 papers were identified but ultimately only 16 original research papers met the inclusion criteria: eight from the UK; two from Australia; two from the UK; one from each of Sweden, Singapore, Ireland and Turkey. In terms of research approach, four were qualitative studies, and 12 were quantitative, with one of these being a randomised controlled trial.In relation to perceived benefits, there was recognition as to how FPDR could, for example, potentially: help with the grieving process; remind staff of the role the patient may have had in a family unit; increase the connection between family and staff. Having the choice to stay, or not, during resuscitation attempts was reported as being an important factor by family members.The authors state that from this review, five major barriers were identified by healthcare professionals: fear of litigation initiated by family members; increased levels of stress and anxiety; concern about the traumatic impact on the observers; feelings by both staff and family members that lay presence might influence the resuscitation attempt; and concerns that staff might get distracted by distressed relatives.Perhaps unsurprisingly, enablers of FPDR included the need for education and training for staff about how to support relatives and other people observing resuscitation attempts. In addition, having a designated ‘support person’ who is not actively engaged in the resuscitation was seen to be an essential component—of course that may not always be possible depending on staff resources at the event. Finally, there was an emergent theme relating to the need for production of a formal and specific policy on witnessed resuscitation and how staff should manage requests from lay people to be present. Again, this may not be quite the same for out-of-hospital resuscitation attempts where WR is likely to be a frequent and ‘naturally occurring event’ (Walker, 2014), especially when called to people's homes.In conclusion, this is an interesting paper which highlights that there are still inconsistencies in the practice of enabling WR in EDs.There is a dearth of research relating to WR in out-of-hospital environments which needs to be addressed. We should examine what lessons can be learned from ambulance staff, as they are frequently exposed to this phenomenon, and their expertise and knowledge could be transferable, potentially influencing policy development in relation to the care and management of family/friends/others during witnessed resuscitation in other healthcare environments.

Delivering enhanced safety, productivity and experience: early results from a frequent caller management system

Inappropriate frequent use of services can be a challenge for private and public sector organisations throughout the world. Whether related to satisfaction and experience, difficulties accessing alternative and more appropriate services, or unrealistic expectations, organisations must develop innovative ways of ensuring the challenge is effectively managed. If successful, organisations could enjoy increased productivity and user satisfaction. Services provided by the NHS must provide timely health care to those in need, but ignoring the challenge of inappropriate use leads to inefficiencies, poor patient experience and clinically unsafe environments. In response, integrated care systems are being developed across the NHS to develop services that are both appropriate and accessible within local communities. Ambulance services are employing a number of different techniques to tackle the issue of inappropriate or frequent use of 999 to access health care. This article examines the challenges associated with frequent 999 callers, shares the experiences of a pilot project in the North West Ambulance Service, and considers the future strategic development of frequent caller management systems for the NHS.

The expanding scope of EMS: decreasing emergency department overcrowding in the United States

The ageing population has been on the rise in the United States (US) and is expected to significantly increase over the next few decades. Additionally, with the Affordable Care Act (ACA) now in full effect, there's a significant increase in the amount of persons with health insurance. In turn, this is expected to cause an influx of patients seeking emergency care through our nation's emergency medical service (EMS) system and emergency departments (EDs), which is already overcrowded on a frequent basis in many areas. Experts believe this is going to significantly increase the amount of strain on an already burdened US EMS and ED system. To prevent detrimental effects from ensuing, we have to be proactive in combating this issue. Therefore, there are three options presented to overcome any adverse reactions: i) Increase the use of preventative measures in our existing EMS system; ii) Implementing the use of telemedicine into our existing EMS system; and iii) expanding the scope of practice in our EMS systems by implementing the paramedic practitioner. Of these options, we believe the paramedic practitioner will best serve the role of alleviating an already strained EMS and ED system in the US.

Looking forward: the Five Year View

On 23 October, Simon Stevens outlined his Five Year Forward View for the NHS. Developed by the partner organisations that deliver and oversee health and care services, including NHS England, Public Health England, Monitor, Health Education England, the Care Quality Commission and the NHS Trust Development Authority, it offers a look at why change in the NHS is needed, what that change might look like and how we can achieve it (NHS England et al, 2014). This ‘upgrade’ to the public health system will take into account growing problems associated with obesity, smoking and the consumption of alcohol; greater control of patients' own care through fully interoperable electronic health records that are accessible to the patient; and decisive steps to break down the barriers in how care is provided.

Continuing Professional Development: Tranexamic acid in the pre-hospital care of trauma patients

OverviewThis Continuing Professional Development (CPD) module will explore the use of tranexamic acid (an antifibrinolytic) in pre-hospital trauma patients. A review of the current guidelines is provided along with considerations for its use in the future.Learning OutcomesAfter completing this module you will be able to:• Recognise when to use tranexamic acid in the care of trauma patients.• Understand the mechanism of action of tranexamic acid.• Gain an overview of recommended dose and volume of tranexamic acid for trauma patients.• Recognise exclusion criteria for the administration of tranexamic acid.

Dr Mark Bloch obituary

The Journal of Paramedic Practice was saddened to learn of the death of editorial board member Dr Mark Bloch. Prof Andy Newton, chair of the College of Paramedics, reflects on a great clinician, educator and proponant of the paramedic profession.

‘I firmly believe that we have had another year of excellent progress’

As 2014 draws to a close, Andy Newton, chair, College of Paramedics, looks at another notable year for the profession, commenting on the developments arising from the Urgent and Emergency Care Review, progress that is being made in paramedic independent prescribing, and the need for the College to develop a Clinical Advisory Committee.

Book Review

ABC of Multimorbidity There can be no doubting the popularity, or quality, of the ABC series of clinical texts as over 40 volumes are currently in print on a broad spectrum of medical matters. Having reviewed a number of them myself, I would argue they have cornered the market when it comes to addressing a given topic from a ‘top line’ perspective. Key to this success is the focus on one specific subject area, so this book offers somewhat of a departure from the norm.Not so much a case of familiarity breeds contempt, regrettably, this is more of a case of ‘if it ain't broke don't fix it’.Positives first: the content is relevant to today's health economy and written by well-informed and experienced contributors. Illustrations are clear, case studies and chapter summaries are now standard and a coherent structure are all hall marks of the ABC genre. Further reading is suggested but bizarrely, references are provided only on request! That's a first for me.However, identifying issues is a very different concept to addressing them. Herein lies the rub. For example, one of the most pertinent, and contentious, themes in modern day health care is the quality and safety of that care, yet the impact of multimorbidities on this is considered in little more than two sides of a page. By its very definition, multimorbidity involves an incredible array of medical conditions, clinical interventions, health professionals and a complex infrastructure in a health service already creaking at the seams. To attempt to summarise all of that in a mere 48 pages of text is, I would suggest, not possible.‘Unlike others in the series, I'm not sure this works with such a diverse area of health care’This was always a challenging subject area to broach using the well-established ABC template. But unlike others in the series, I'm not sure this works with such a diverse area of health care.

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