Pre-hospital emergency care services are vital components of the health service, with responsibility for immediate assessment and treatment during the most acute stage of the journey for acutely ill andinjured patients. Such care has always had a focus on immediate life support and management of traumaand medical emergencies.
The process encompasses the emergency call and dispatch, a race to the scene of the incident, accessing the patient at any potential location during any weather condition, triage and emergency management, and finally, if required, transporting the patient to the nearest emergency department (ED) or trauma centre as quickly and safely as possible. Within the United Kingdom (UK), the Department of Health (DH) has set specific time targets for ambulance clinicians to reach the scene of the incident. This is normally close to eight minutes. In this study, ambulance clinicians include paramedics and ambulance nurses.
The patient experience of this journey can be stressful, strapped in a chair or onto a trolley within an unfamiliar environment such as an ambulance with limited space. This journey is a rapid one, guided by the Golden Hour rule that suggests that patients should be transported to the ED within one hour of the incident to maximise survival and minimise complications (Lerner and Moscati, 2001). In 2006 the patient experience was included as one of nine ‘ambulance design challenges’ and was listed for improvement in the design of future ambulances (Hignett et al, 2009). The principal concerns were focused on patient safety, response times, dignity, modesty, and carers. Furthermore, the authors reported that within one of the other identified design challenges (space and layout), patient care and comfort were specified as central concerns.
The comfort, warmth, feelings of safety, and preservation of dignity of patients during the pre-hospital journey is important. The patient covering forms a central part of this. Cotton blankets are used as standard throughout the UK health service to retain body heat and prevent draft, thus enhancing comfort. Furthermore the covering is essential in maintaining patients’ dignity by providingbody cover.
Temperature regulation can be critical in patients who have experienced trauma, as hypothermia impacts negatively the metabolic and haemostatic mechanisms: a 0.9 °C drop in core body temperature can cause a slowing of the coagulation processes and thus accelerate haemorrhage (Watts et al, 1999) and worsens prognosis in trauma patients (Armstrong-Brown and Yee, 2001), and there is a risk thatsigns of hypothermia may go unrecognised in pre-hospital settings (Shah, 2004). In their study, Watts et al (1999) concluded that traditional methods such as blankets were of little clinical benefit, as a majority of patients who have experienced trauma arrive hypothermic to the emergency department (ED) (Owen and Castle, 2008).
Published studies that evaluate patient coverings are usually limited to assessment of thermal efficiency in relation to surgical procedures (Perl et al, 2003; Henriksson et al, 2009; Thomassen et al, 2011), although Robinson and Benton (2002) investigated the use of warming blankets to promote comfort in hospitalised older patients. Some research has focused on technical aspects of the patient journey, for example the commonly used spinal back-board employed to immobilise the spine (Edlich et al, 2011). In their small experimental study of healthy volunteers, testing an inflatable air mattress and spinal stabilisation apparatus, the authors reported enhanced comfort and reduced risk of pressure sores for participants who used the apparatus. Most of this research is laboratory based, or the researchers have used mannequins or healthy volunteers.
No studies to date have examined the views of ambulance clinicians regarding patient coverings in relation to comfort, warmth, perceptions of safety and preservation of dignity, or explored issues in relation to accessibility during transport and or transfer times.
Comfort is a fundamental concept in nursing care, even though the concept is not uniformly definedwithin nursing (Tutton and Seers, 2003). While there is limited research exploring this concept in emergency care, Backlund and Hagiwara (2007) in their review of literature noted that comfort invariably is associated with pain relief, nurses’ competence, warm blankets, effective communication, and emotional support. Tang (2000) found that comfort, safety, and dignity were important for Chinese patients in Taiwan who were dying at home, Kane (2001) contested that all three were important for quality of life in long term care in the United States and Klager et al (2008) highlighted the importance of all three as central end of life needs for people who have Huntington’s Disease. The closest to pre-hospital care where all three concepts were mentioned was in a discussion paper by Mark (1994) who proposed that nurses should advise flight crews on in-flight emergencies associated with passengers who had medical needs, further suggesting that dignity, safety, and comfort would be improved. While there is a scarcity of empirical evidence, the nursing literature suggests that all three concepts are important in the patient experience.
It is posited therefore that the experience of feelings of safety, dignity, and comfort are strongly interrelated (Figure 3). While this is probably the case for most care environments, in pre-hospital care such experiences may be poignantly symbolised in experiences and perceptions of the patient covering or traditional blanket (Figure 1).
Study design
Study aim
The aim of this study was to investigate ambulance clinicians’ experiences of two differenttypes of coverings: the traditional cotton blanket (Figure 1 and the TelesPro Rescue Covering TM (Figure 2).
Study approach and materials
This paper reports an interventional study that investigated ambulance clinicians’ and patients’ experiences of using two different types of coverings: the traditional cotton blanket and the TelesPro Rescue Covering.The Rescue Covering encapsulates the complete body and is made of GORETM Rescue Blanket laminate with an external Gore-Tex membrane and an internal feece lining developed to protect patients against severe weather conditions, cold, moisture and wind, and bacterial penetration. The Rescue Covering, that has the appearance of a sleeping bag, was originally developed at theUniversity of Kuopio in Finland and were provided for this study courtesy of TelesPro Finland OY. Prior to the intervention study, a pilot study had been carried out jointly by TelesPro Finland OY and the School of Nursing at the University of Ulster in Derry, UK. This pilot study had two main objectives frstly to develop an evaluation instrument, and secondly to make some initial functional evaluations of the rescue covering using a new evaluation tool developed by the authors. The evaluations were carried out by nursing students acting as casualties during an airport disaster exercise in Northern Ireland. This paper reports the views of ambulance clinicians, and the patients’ views will bereported in a separate paper.
The 14-item questionnaire had been devised to gather data on fve demographic items in relation to age, diagnosis, location of patient, gender and type of covering used for patient. Eight 5-point Likert-type questions were used in relation to core caring concepts of comfort, temperature, dignity, andsafety. Furthermore ambulance clinicians were asked to use the same response system to assess functional aspects of the coverings, determining how easy it was to work with the patient, how easy it was to access the patient, and how easy it was to move the patient. Finally ambulance clinicians were asked to add any covering-related qualitative comments they wished to make.
Sampling
Ambulance patients were systematically and randomly selected into the control group (traditional blankets) and interventional group (rescue covering). Patients had to have Glasgow Coma Scale >14 and be at least 18 years-of-age. All ambulance clinicians based at one ambulance station (n=8) took part in the study, and the completed questionnaires were sent directly to the principal investigator.
Ethical governance
It can be difficult to collect data during the pre-hospital emergency care process due to the obvious focus on life saving interventions. Undertaking research during this stage of the patient journey is fraught with difficulties in relation to fundamental research ethical issues such as informed consent.
Ethical approval was provided by Södra Älvsborg Health Board.
Findings
A total of 128 patients were included in the study, evenly distributed into the experimental (rescue covering) and control groups (traditional blanket) (Table 1). Patients were aged between 20and 99 (Average=68). 81% of the patients were collected indoors, with a distance from house-ambulance estimated at between 5–50 m, and 13% of the patients were accessed outdoors. Research data was recorded by eight ambulance clinicians, seven of which were ambulance nurses and one who was an ambulance technician. Data was collected during February and March 2008. Average temperatures in this region of Sweden during these months are -2°C to +3°C (Climate Temp, 2012) although individual recordings of temperatures were not collected as part of the study.
| Patient Covering | Frequency | Percent |
| Traditional blanket | 67 | 52.3 |
| Rescue covering | 61 | 47.7 |
| Total | 128 | 100.0 |
Chest pain was the predominant presenting complaint (33%), followed by a myriad of neurological presentations (16%) that included stroke, syncope, and headache (Table 2). Overall ratings were positive for both types of coverings, with ambulance clinicians maintaining all caring concepts andfunctional aspects in about 90% of all transported patients. Ambulance clinicians had been trained in the use of the rescue covering, and they preferred the rescue covering to the traditional blanket in over 90% of cases (Table 3).
| Diagnosis of transported patients | ||
| Frequency | Percent | |
| Chest pain | 42 | 32.8 |
| Neurological problems | 19 | 14.8 |
| Abdominal problems | 13 | 10.2 |
| other cardiac problems | 10 | 7.8 |
| Trauma & fractures | 7 | 5.5 |
| Dyspnea | 6 | 4.7 |
| other problems | 16 | 12.5 |
| Unknown | 15 | 11.7 |
| Total | 128 | 100.0 |
| Frequency | Percent | |
| Traditional blanket | 8 | 6.3 |
| Rescue covering | 120 | 93.8 |
| Total | 128 | 100.0 |
Chi-Square tests were used to test differences between the two types of coverings based on the clinicians’ responses to the questionnaire. Due to insufficient numbers (5) to facilitate statistical analysis in relation to the traditional blanket, data was recorded into three answer responses (agree/ disagree/unsure), and statistically significant differences were found in relation to all four Core Caring Concepts (Table 4). In terms of functional aspects of the coverings, statistically significant differences were found in relation to how easy the covering was to work with but not in relation to ease of access or ease of movement of patient (Table 4). In respect of all variables that demonstrated statistical significance, the rescue covering was the preferred option.
| Type of coverings used *Core Concepts/*Functional Aspects | |||
| Core caring concepts | Chi-Square Value | df | Asymp. Sig. (2-sided) |
| Comfort | 8.814 | 2 | .012 |
| Safety | 9.876 | 2 | .007 |
| Temperature | 12.056 | 2 | .002 |
| Dignity | 11.750 | 2 | .003 |
| Functional Aspects | 2 | ||
| How easy it Was to work with | 8.737 | 2 | .013 |
| How easy it was to move atient | 2.758 | 2 | .252 |
| How easy it was to access patient | 1.184 | 2 | .553 |
These data were further confirmed with the qualitative comments made by ambulance clinicians. A total of 33 comments were made, and these were coded as positive (9), negative (23) or neutral (1) (Table 5). Giving a positive comment the score of +1, a negative comment the score of -1 and the neutral comment a score of 0, a total crude summative care score of -2 was obtained for the rescue covering (eight positive, ten negative) and -12 for the traditional blanket (one positive, 13 negative).
| Covering | |||
| Ambulance clinician qualitative comments | Traditional blanket | Rescue covering | Score |
| A bit tight around feet. | 0 | -1 | -1 |
| A bit tight around the toes. | 0 | -1 | -1 |
| A bit too warm. | 0 | -1 | -1 |
| Arms cold | -1 | 0 | -1 |
| As the patient has ice hockey equipment it’s difficult to close bag | 0 | -1 | -1 |
| Became a little too warm. | 0 | -1 | -1 |
| Became a little too warm. | -1 | 0 | -1 |
| Blanket under patient insufficient. Feet outside. Arms cold. | -1 | 0 | -1 |
| Collected far into forest. Poor weather and long carriage by hand. Bag superb. | 0 | 1 | 1 |
| Difficult to close around feet. | 0 | -1 | -1 |
| Difficult to cover whole patient. | -1 | 0 | -1 |
| Difficult to find room for feet in bag. | 0 | -1 | -1 |
| Doing an ECG it’s difficult with blankets getting stuck in the electrodes. | -1 | 0 | -1 |
| For this patient blankets were sufficient. Patient felt warm and nice. | 1 | 0 | -1 |
| It was so blowy that the blankets blew away before patient could sit down. | -1 | 0 | -1 |
| Large person. Blankets do not cover person. | -1 | 0 | -1 |
| Lies still on the trolley when it’s windy. | 0 | 1 | -1 |
| Long patient. Difficult to get room. | -1 | 0 | -1 |
| Loose blankets that blew away. | -1 | 0 | -1 |
| Patient cold shoulders and arms | -1 | 0 | -1 |
| Patient expressed he was lying comfortably. | 0 | 1 | 1 |
| Patient feeling a bit warm halfway through journey. | 0 | -1 | -1 |
| Patient felt closed in. | 0 | -1 | -1 |
| Patient has previously had blankets. Thinks bag is much more comfortable. | 0 | 1 | 0 |
| Patient says the bag is lovely to lie in. | 0 | 1 | 1 |
| Patient was cold. | -1 | 0 | -1 |
| Patient’s arms freezing. | -1 | 0 | -1 |
| Picked up in the street. Blankets got wet. | -1 | 0 | -1 |
| Think blankets work well in most circumstances but bag good to have in cold weather. | 0 | 0 | 0 |
| Vacuum splint lower leg. Works well with bag, opened bag at the foot. | 0 | 1 | 1 |
| Very easy to carry. | 0 | 1 | 1 |
| Very good for older ladies. | 0 | 1 | 1 |
| Windy & snow. Blankets blowing off trolley. Patient freezing. | -1 | 0 | -1 |
| Crude summative care score | -12 | -2 | -14 |
| Comments | 1 positive | 8 positive | 9 positive |
| 13 negitive | 10 negative | 23 negative | |
| 1 neutral | 1 neutral | 1 neutral | |
Discussions
Throughout the pre-hospital care journey the patient may experience the effects of serious trauma or illness, is exposed to a range of clinicians, and will have a variety of assessments and interventions carried out to enhance survival and minimise morbidity. The ambulance journey is a small but essential part of this care process in which often the most acute assessments and interventions are made.Ambulance clinicians endeavour to enhance the quality of this section of the patient journey by enhancing patient comfort through the use of appropriate technical equipment, by ensuring the patient is warm and protected from the environment, and by maintaining core caring concepts such as dignity and safety, while acknowledging a multitude of threats to these caring concepts by the nature of the emergency scenario. Few of these concepts have been explored in the literature in relation to pre-hospital emergency care. This study therefore is one of the first research studies to attempt to explore core caring by interrogating the experiences and views of patients and ambulance clinicians in relation to one single piece of technical equipment—the patient blanket.
This study comprehensively asserted the position that ambulance clinicians, in their own view, maintained the core caring concepts no matter which type of covering was used. But findings suggested strongly that the rescue covering provided a superior patient experience in respect of all core concepts and one functional aspect ‘how easy it was to work with’. Qualitative comments made by ambulance clinicians strengthened these findings further, certainly when responding to patient emergencies in an outdoors and cold environment:
Collected far into forest. Poor weather and long carriage by hand. Bag superb. [Rescue covering]
The multi-layered rescue covering is designed to provide an enclosed patient space, while allowing for clinician access. These two combination factors are essential, as patients are often exposed to cold environments and thus need to be warmed up as best as possible, while at the same time the clinicians will need access to the body for a range of assessment and treatment interventions such as electrocardiograms (ECGs), establishing venous access and continuous monitoring of vital signs. This is highly relevant when bearing in mind that the main presenting complaint was ‘chest pain’ in about one third of patients, most of whom would have had an ECG undertaken with access to the chest required. One ambulance clinician reports the difficulty trying to do this when the patient is covered by a traditional blanket:
Doing an ECG it’s difficult with blankets getting stuck in the electrodes. [Blanket]
Staying warm is crucial if a patient has experienced trauma and blood loss. Owen and Castle (2008) noted that following traumatic injuries, mortality is increased by a ‘deadly triad’ of hypothermia, acidosis and coagulopathy. The authors suggested that active rewarming should be a priority, but this is a major challenge in the pre-hospital environment due to prolonged extrication, and exacerbated by thin clothes. Furthermore, it may indeed be particularly significant for casualties who receive air transport and who have had rapid sequence induction of anaesthesia, which has been
‘The authors suggested that active rewarming should be a priority, but this is a major challenge in the pre-hospital environment due to prolonged extrication, and exacerbated bythin clothes’
The Rescue Covering was reported superior to the traditional blanket in respect of the environmental aspects of keeping the patient warm and protecting the patient from the wind. Most of the negative comments made about the traditional blanket were in relation to this aspect:
Patient was cold. [Blanket] It was so blowy that the blankets blew away before the patient could sit down. [Blanket]
Core caring concepts are inter-related, as comfort is dependent on feeling warm (Robinson and Benton, 2002), and feeling warm reduces cold discomfort which may increase the
‘The authors claimed that ambulance clinicians want to encounter the unique human being of the patient’ Large person. Blankets do not cover person. [Blanket] Diffcult to cover whole patient. [Blanket] Lies still on the trolley when it’s windy. [Rescue Covering] Patient says the bag is lovely to lie in. [Rescue covering]
The fact that so many comments were made in relation to functional appropriateness of the coveringin terms of maintenance of warmth and ensuring privacy and dignity, indicates that ambulance clinicians see core caring concepts as a fundamental part of their care, and are not entirely focused on medical interventions as suggested by Melby and Ryan (2005) and Ahl et al (2005). Clinicians attempt to maintain all the caring concepts in difficult environments, often with an audience of spectators (Ahl et al, 2005), adding further challenges to privacy and dignity. Holmberg and Fagerberg (2010), who investigated nurses’ lived experiences of their responsibility for the care of the patient in theSwedish ambulance service, interviewed fve ambulance nurses, using a refective lifeworld approach within the perspective of caring science. They suggested that the essence of caring was to prepare and create conditions for care and to accomplish care close to the patient. Creating comfort for the patient was identified as one of the three constituents of caring. The authors claimed that ambulance clinicians want to encounter the unique human being of the patient, that they enter the lifeworld of the patient and try to understand the uniqueness of the patient. This uniqueness or cultural aspect of the patient is then respected in all encounters. So even in emergency situations requiring immediate response, ambulance clinicians attempt to create comfort by showing empathy while assessing and treating the patient. Sundstrom and Dahlberg (2011), in their qualitative study, suggested that good pre-hospital care affects patient safety. The author suggested that dialogue with the patient facilitated understanding and decision-making regarding the patient’s medical needs, and consequently was comforting to the patient. In a second paper, Wireklint Sundstrom and Dahlberg (2011) argued that pre-hospital emergency care is more than a range of medical interventions, and suggested that dialogue adds essential information to the assessment and enables safe decision-making by ambulance clinicians. Jacelon (2003) found that respect was an essentialingredient of dignity, and the participants in herstudy spoke of privacy in relation to respect and personal space.
Personal space is limited in an ambulance, but in addition patients are strapped to stretchers forclinical and/or transport safety reasons, imposing further limitations to personal movement and thus further restricting personal space (Figure 4). Ambulance clinicians may compensate for this limitation to privacy and dignity by ensuring the patient is covered properly. Jacelon et al(2004) claimed that nurses who practise withdignity automatically integrate behaviours thatdemonstrate respect for self and others into theircare. With regards to the ambulance environment, as stated by several ambulance clinicians, thiswas at times difficult:
Blanket under patient insufficient. Feet outside. Arms cold. [Blanket] Patient’s arms freezing. [Blanket]
According to Ahl et al (2005), the imposed physical proximity between patient and clinician enables clinicians to offer patients a hand to hold, an essential part of caring, and Holmberg and Fagerberg (2010) found that ambulance clinicians were acutely sensitive to the importance of such physical contact. Chochinov (2007) examined dignity as the essence of medicine and noted that many clinicians were reticent at embracing the ‘humane’ aspect of caring and suggested that where patients do not feel they are treated with dignity and respect, their sense of value or worth may be undermined.
This study would indeed suggest that ambulance clinicians have a strong focus on the core concepts of caring, attempting at all times to promote comfort, dignity, and safety and thus demonstrating respect of the patient (Figure 5).
Limitations
This paper presents findings based on the views of eight ambulance clinicians only, all located inthe same ambulance station in one specific region of Sweden. A greater number of ambulance clinicians, and a better balance between ambulance nurses and technicians, and a broader population base across Sweden and the UK would have ensured greater validity and representativeness of the findings.
Conclusion
The pre-hospital environment provides multiple challenges to optimum patient care, such as bad weather, patient extrication difficulties, time pressures, and limited space and equipment within ambulance vehicles. Notwithstanding these challenges, the comfort, warmth, feelings of safety, and the preservation of dignity of casualties during and in the immediate aftermath of any serious illness or trauma is important. Ambulance clinicians undertake caring that encompasses all these essential constituents of caring, and have an awareness of the threats to comfort, safety, and dignity that they face in everyday situations when caring for acutely ill and injured patients.
Implications for practice
This paper has highlighted multiple threats to good care in pre-hospital emergency care, and has provided some evidence that a simple change to technical equipment (in this case the patient covering)can enhance safety, comfort, and dignity during this section of the patient care journey. There is potentially a cost implication with the initial acquisition of rescue coverings that would be required across the ambulance service. However, in its information to emergency services, (TelesPro, 2012) TelesPro Finland OY claims that this initial cost is low as it operates a continuous leasing service, inwhich cleaning is undertaken by the company, and rescue coverings are replaced free of charge if damaged. However additional cost-benefit analysis is needed to make definite conclusions about cost.Whatever the cost-difference (if any), one could argue that this price is worth paying to safeguard patient safety during the ambulance journey.