Observations from a student exchange programme: UK and Sweden prehospital care

The medical emergency triage and treatment system

Although there are no clinical practice guidelines, the Gothenburg and Halland regions do use a prehospital triage system called the medical emergency triage and treatment system (METTS) to identify patients who are severely ill and to decide treatment and transport priorities. The system was developed at the Sahlgrenska University hospital in Gothenburg as a means to ensure better consistency of care (Widgren and Jourak, 2011).

The system uses two mechanisms by which the patient is assigned to one of four categories (from highest to lowest priority)—red, orange, yellow and green (Widgren et al, no date). The first is on the basis of the patient's clinical observations and the second by the symptoms associated with the presenting complaint (Widgren et al, no date). The patient is then treated according to whichever mechanism gives the highest priority. Transport speeds and the need to pre-alert are also dictated by the priority.

Triage systems themselves are not a new invention—for example, Earley (2010) describes a similar system intended for prehospital use, while systems such as adaptive process triage (ADAPT) and the Manchester triage system (Cooke and Jinks, 1999; Asplund et al, 2010) have also been in existence for some while.

Such systems do not appear to have found favour in the UK, perhaps because authors such as Asplund et al (2010) have taken the view that there is little evidence to support the specificity and reproducibility of these systems. Widgren and Jourak (2011), however, have subsequently carried out a large scale systematic trial of the METTS system (in the region served by Sahlgrenska University Hospital in Gothenburg, Sweden), concluding that it is both safe and effective for use both within and without the hospital environment.

The real breakthrough with METTS in Sweden, therefore, is not the system itself but rather that it is used by both pre-and in-hospital clinicians. This means that staff in both environments instantly understand a patient's condition, allowing a far more concise handover in hospital, and potentially reducing communication errors. In addition, crews complete part of a double-sided A4 form which is handed over to hospital staff on arrival. This form stays with the patient in hospital and contains not only the triage system score but also sections for further investigations such as radiography and haematology.

There is also space for further assessment so that the patient's condition can be monitored. At the time of leaving, a system was also being implemented to record and store this information electronically.

In Sweden, patient records can be accessed simply by entering their social security number and this, together with the METTS form, appears to greatly speed up the hospital admissions process. In conclusion, the use of a common triage system by both ambulance and hospital clinicians, common documentation and electronic patient records appear to speed up handover and aid continuity of care.

Infection control is another area where significant differences between Swedish and UK practice were observed. In Halland, for example, alcohol gel for hand washing is not a personal issue, though it is available in dispensers on vehicles. There is also less emphasis on equipment sterility, e.g. non-sterile entonox mouthpieces and re-usable facemasks which are washed after use but not sterilized. Items such as sheets are not routinely changed between patients, though they are when obviously soiled or a patient is suspected of having an infectious condition. This is perhaps surprising given the efforts made to combat MRSA in Sweden in recent years (Stenham et al, 2006). By the same token, both vehicles and premises appeared spotlessly clean and well kept.

All vehicle and equipment cleaning was carried out by the frontline staff on a weekly rota, with each vehicle being removed from operational duty in turn to be cleaned. In terms of ambulance service practice, while Noh et al (2011) suggest that bed sheets and ambulance interiors are not critical in terms of infection control, items such as face masks and mouth pieces are semi-critical, perhaps justifying the expense of individually wrapped single use equipment.

Welfare provision also appears to vary considerably between regional services in Sweden. Personal conversation with staff in metropolitan Gothenburg revealed they still work 24-hour shifts and that there was little opportunity for breaks, which could lead to extreme fatigue. The implication is that this could compromise safety for both staff and patients. In Halland, however, staff work a mixture of 10 and 12 hour shifts, depending on their position within the rota and are allocated a meal break by control staff.

A second major difference is that staff only work a maximum of two night shifts at a time and in Halland, are provided with an individual bedroom where they can sleep if they wish; the proviso being that they must still respond to a call within the allotted time. At the end of a night shift, staff are also permitted to sleep beyond the end of their shift in their designated room, easing the transition between days and nights.

The ambulance premises, including the garage and living areas were well furnished, welcoming, well maintained and spotlessly clean. Morning briefings were conducted over coffee and were an opportunity to discuss working routines and future developments.

The result of these measures appeared to be a very relaxed but also well motivated workforce, the major lesson from which appears to be that it is possible to balance patient care with staff welfare.

In Halland, emergency control room staff prioritize calls into one of four levels. Priority 1 calls are life-threatening emergencies; priority 2 calls are those where an urgent response is required but are not life-threatening; priority 3 are those such as non-urgent referrals by doctors and priority 4 are patient transfers where no medical intervention is required.

In contrast to the UK, however, only the highest (priority 1) calls require a blue light response and there are no specific response time targets, though the ambulance must leave the station within 90 seconds for priority 1 and 2 calls (Khorram-Manesh et al, 2010). This system allows ambulance stations to be sited in major population centres, perhaps allowing a more efficient use of services than a situation where resources are distributed so as to meet response times but may therefore be underused.

Another advantage is a reduction in the number of high speed journeys made, which potentially reduces the risk of road traffic collisions (Lutman et al, 2008) and improves staff welfare by reducing stress levels (Gormley et al, 2008). Before implementation of such a system in the UK, however, issues such as the effect of large traffic volumes and increased response times in rural areas and their impact on patient outcomes would need to be investigated.

The way in which emergency calls are classified also has an impact on service delivery; too high a priority results in a waste of resources and too low a priority poses a risk to patients. Discussing the system in the West of Sweden in 2008, Khorram-Manesh et al (2010) suggested an innovative solution; allowing crews to upgrade calls on the basis of despatch information and to downgrade calls from the scene.

At the time of the exchange visit, this approach was under trial in Halland and though it should be noted that only a limited number of cases were attended, the system appeared to work well.

In Halland, there appears to be a very strong commitment to holistic care and this is reflected, not only in the way in which patients are treated, but also in the equipment provided. As part of the inventory, each vehicle is provided with bottles of mineral water and straws for patients to drink or to take oral medication and with a small teddy bear for paediatric patients (these bears are new, single use and wrapped in plastic to minimize risk of cross infection). These are small measures but go a long way in ensuring patient comfort. Their value was illustrated by the case of a young girl with suspected appendicitis who required cannulation for pain relief. She initially refused but once she had seen the bear being ‘treated’ was much more comfortable and consented to the procedure.

Equipment

The majority of equipment in Sweden is similar to that used in the UK; there are, however, a number of differences. Ambulances in Sweden, at least in Halland, tend to be smaller than those in the UK and are based on an estate car chassis with a body conversion.

Although space is restricted, design allows the attendant to sit adjacent to the patient in a purpose designed seat, there is also room to convey at least one other passenger in the back. Despite the size, it is possible to perform basic life support (BLS) on the move; however, space restrictions necessitate this is done from the patient's head and by one person only.

The space issues in cardiac arrest are partially addressed by the use of the LUCAS (Lund University Cardiopulmonary Assistance System; a gas powered pneumatic piston arrangement designed to carry out chest compressions) which, according to Steen et al (2005), allows single person ALS and enables much more consistent CPR. Although not currently in regular use in the UK, this device is undergoing trials for use in out-of-hospital cardiac arrests (NIHR Health Technology Assessment Programme, 2011).

As part of a recent drive, there has been a move to standardize the equipment list between all ambulances, with all items being stored in the same locations both on the vehicle and in equipment bags. Items within the bags, particularly drugs, are all stored in pockets or on cards with elasticated loops. These measures greatly help staff locate equipment in a hurry, and simplify and speed up the process of vehicle inspection. The response bags and gas levels etc are checked at each shift change and less frequently used equipment is checked on a weekly basis. All checks are performed on a rota basis by the frontline staff. Most importantly, the staff are fully engaged with this process and committed to maintaining vehicles and equipment to a high standard.

All ambulance crew in Halland are also supplied with and trained in the use of CBRN equipment, including chemical suits and respirators, although not self contained breathing apparatus. Perhaps due to the proximity of the Ringhals nuclear power station, this nonetheless makes a rapid initial response at chemical incidents possible, while waiting for specialized teams to arrive.

There are also a number of small items of equipment which appear particularly useful. The first is a sterile sodium chloride spray which can be used for irrigation of eyes, cooling burns, dampening dressings to prevent adhesion, and minor wound cleansing. Second is a self amalgamating bandage, which can be used to dress minor wounds and also to support musculoskeletal injuries. As it is a type of foam, it is also absorbent and cushions against knocks.

Third is a combined airway, oxygen and suction bag; this contains all the required tools for basic airway management, plus a venturi type suction canister combined in a single bag which can be carried like a rucksack. This secures the cylinder, means one less item to carry and, leaves hands free when transporting the casualty by chair or stretcher, thereby easing evacuation.

Drugs

Drugs administered by ambulance staff in Halland are also similar to those used in the UK, although again there are a number of differences. Ketamine, for example, is widely used for analgesia, though not for sedation or anaesthesia. While ketamine remains a controversial drug in the UK, due perhaps to its abuse as a recreational drug and because it is classified primarily as an anaesthetic agent (British Medical Journal Group, 2011). However, it does have significant advantages as an analgesic over opiates in that it does not induce respiratory depression (Wood, 2003; Guldner, 2006).

Diclofenac is also used for mild to moderate pain but according to the British National Formulary (BNF; British Medical Journal Group, 2011) does not appear to offer any significant benefit over ibuprofen.

In terms of cardiac care, prehospital thrombolysis is not carried out and clopidogrel is used in addition to aspirin with cardiac chest pain, and where primary percutaneous coronary intervention (PPCI) is indicated. In Halland, thrombolysis is not used because direct access to PPCI is available 24 hours a day. This may have prompted the use of clopidogrel as current National Institute for Health and Clinical Excellence (NICE) guidance suggests it may reduce adverse events (death/re-infarction/ stroke), at least with unstable angina and NSTEMI when administered prior to PPCI (NICE, 2010a). NICE (2010b), however, does not recommend the routine use of anti-platelet therapies other than aspirin outside hospital. In Halland, this is overcome by using mobile telemetry systems to allow a cardiologist to review the prehospital ECG and to authorize the use of clopidogrel.

In Halland, the drugs carried are summarized in the ‘little green’ book which lists indications, contra-indications and doses for each drug. While not as extensive as the JRCALC equivalent, the book has some advantages in that it is brief, easy to access and information for each drug is presented in exactly the same format.

Procedures

In terms of procedures, the majority of practice in Sweden appears similar to that in the UK. Again, however, there are a number of differences worthy of note.

As already mentioned, there are no national best practice guidelines, however, some attempt is currently underway to introduce the METTS triage system on a national basis through an advisory panel consisting of regional clinical directors.

Another interesting difference in Halland is that spinal immobilization is routinely carried out using a scoop stretcher rather than a spinal board. This offers some advantages in that it can reduce the number of patient movements required to achieve immobilization (Fisher et al, 2006), and potentially allows access to the spine for palpation once immobilized. There is also evidence to suggest that this reduces spinal cord movement during immobilization and increases patient comfort (Krell et al, 2006).

Perhaps the most important procedural difference in Halland is the ability of ambulance crews to direct patients to alternative treatment pathways, most notably for stroke and coronary care. The latter is supported by a telemetry system, allowing a cardiologist to review a prehospital 12-lead ECG. The impression gained was that availability of these pathways could potentially be attributed to the way in which healthcare services are commissioned and the improved relationships between ambulance and in-hospital healthcare provision.

Training

Prior to 2005, ambulance services in Sweden employed paramedics and technicians with broadly similar levels of training to their UK counterparts. In 2005, however, legislation came into force requiring at least one nurse be present on each ambulance to act as lead clinician (Gunnarsson and Warren Stomberg, 2009). Many existing paramedics were given the opportunity to obtain a nursing degree. Not all, however, could or wished to do so and those who did not were effectively re-tasked as drivers.

Prior to working on an ambulance, in addition to their basic training, nurses must undergo a further one year specialization course resulting in a four year education pathway. The use of nurses can be advantageous in a number of regards, specifically with an improved knowledge of in-hospital care and drugs, and a mutual understanding between pre-and in-hospital staff.

However, the role of a nurse in hospital differs in several ways from that of an ambulance clinician, mainly in that the emphasis is on the ambulance clinician to make an independent initial diagnosis and to decide treatment priorities (Suserud, 2005). As a result, although paramedic training in the UK is shorter in total duration, it is more specific in nature and has a greater emphasis on identification and treatment of immediate needs. These differences in training methods might potentially have an impact on clinical confidence.

Conclusion

In many ways, ambulance practice and procedures in Sweden and the UK are similar, however there are also a number of significant differences between the two countries.

The organization and staff welfare arrangements in Sweden (at least in Halland) appear to offer significant benefits in terms of operations, patient welfare and staff morale. Notable issues are organization of vehicles and equipment and the provision of alternative pathways which are enabled through the commissioning and training procedures used.

Training is significantly different in Sweden as all clinicians must first qualify as nurses and then undergo specialist prehospital training. This offers a number of benefits, particularly improved knowledge of in-hospital treatment and improved relations between pre-and in-hospital staff. It is also perhaps responsible for the high standards of patient care witnessed. The in-hospital nursing role, however, differs from that of a paramedic in that the emphasis is on patient care rather than assessment and determination of treatment priorities. As a result, the amount of specific training received is less and may in turn have an impact on clinical confidence.

The lack of nationalized guidance may be seen as an issue as it can potentially lead to variations in standards of care. This is being addressed in part through the introduction of the METTS triage system on a national basis, this however, is not as extensive as the JRCALC guidelines which cover additional areas such as spinal immobilization.

Though there are some potential issues with the METTS system, its implementation across both the prehospital and in-hospital environments is a great step forward and greatly improves the integration of care between the two environments. More rapid handover and potential improvement in communications are of particular importance.

In conclusion, though there are some areas of practice which are perhaps more developed in the UK, there are many aspects of practice in Sweden which could be of great benefit were they to be adopted in the UK, most especially in terms of service organization.

Key points