Tired of making clinical decisions…
Prompt and accurate decision-making is a necessity to deliver effective patient care. However, the impact of sleepiness during a nightshift may reduce cognitive functioning and clinical performance. This study sought to examine second-year paramedic students' clinical decision-making while they undertook a 13-hour simulated night shift concentrating on real-life clinical scenarios. Sleepiness, workload, and motivation were self-reported by participants, while clinical performance, reaction time, visual attention and task-switching were graded by assessors. Each scenario was videocaptured for analysis. Ten common cases were built into scenarios and the participants were given the choice of attending or driving. Each scenario allowed the student paramedic to clinically assess and deliver patient care from arrival at the patient to the point where transportation would be commenced. Participants were then asked to handover to the triage nurse.
Results showed that as the nightshift progressed, sleepiness increased with participants who were alert and wide awake at the start of the nightshift becoming tired and ‘foggy’ at the end of the shift. Students' performance levels showed a decline within the second half of the shift as the sleepiness increased. The perceived workload initially decreased for the first 3 hours but then increased as the shift progressed. Perhaps unsurprisingly, motivation levels decreased significantly during the latter part of the shift. Notably, there was no decline in visual attention and reaction time throughout the entire nightshift.
This study shows that increased sleepiness during a nightshift is associated with a decline in clinical performance and motivation levels, which can have serious consequences for patient outcomes. It is recognised that motivation levels can be adversely affected by increased sleepiness. A comparison study would be valuable in comparing the same variables in students undertaking a day shift vs a night shift of equal duration.
Acute Heart Failure—easier said than diagnosed
Acute heart failure (AHF) remains persistent as a cause of morbidity and mortality in many parts of the world. Optimised management requires early diagnosis, including within the prehospital environment. However, diagnosis is challenging especially in prehospital care. Many of the clinical manifestations of AHF overlap with other causes of dyspnoea and paramedics do not generally have access to radiography or laboratory tests. Delayed diagnosis can lead to the withholding of appropriate treatment and potential for the administration of inappropriate treatment
This retrospective study from the United States aimed to establish the accuracy of prehospital diagnosis of AHF in patients presenting with acute dyspnoea when compared with final hospital diagnosis. The study team reviewed records for all adult patients conveyed by a single urban emergency medical services (EMS) agency and included all adult patients (>18 years old) with suspected dyspnoea transported by EMS. Patients were excluded if their final hospital diagnosis was not dyspnoea of a cardiac or pulmonary aetiology. A prehospital diagnosis of AHF was counted in all cases where ‘acute heart failure’, ‘heart failure’, or ‘pulmonary edema’ was recorded as the primary or secondary impression.
There were 199 patients included and 50 (25%) had a final hospital diagnosis of AHF. Seven with a final diagnosis of AHF were correctly identified by EMS, indicating a sensitivity of 14% (CI 0.06-0.26). The specificity and diagnostic accuracy of EMS for AHF were 98% (CI 0.94-0.99) and 77% (CI 0.70-0.82), respectively. In the 50 patients with AHF, 14 (28%) received GTN in the prehospital setting, while 27 (54.0%) patients were inappropriately treated with salbutamol.
In this study, prehospital paramedics had poor sensitivity and moderate accuracy for the diagnosis of AHF. The results are similar to other studies in the area and suggest that AHF is difficult to diagnose in the prehospital setting. Further work needs to be done to improve diagnostic options for paramedics.