Pressure on the UK emergency care systems continues unabated as demands on the ambulance service and emergency departments (EDs) increase year on year. Despite this, a small number of EDs have been closed, downgraded to a less acute facility, or had night-time closures enforced, reportedly owing to inadequate staffing and safety implications. The decisions were made with little research evidence to inform the decision making, so concerns about patient safety are reasonable. A recently published study sought to quantify the impact on mortality of ED closures on the resident catchment populations of five EDs compared with five control areas.
For residents in the areas affected by closure, journey time to the nearest ED increased by a median of 9 minutes (range 0–25 minutes) but there was no statistically reliable evidence of a change in overall mortality. The findings suggest that, on average across the five areas, there was a small increase in case fatality—an indicator of the ‘risk of death’ (+2.3%, 95% CI +0.9% to+3.6%; p<0.001), but argue that this may have arisen due to changes in hospital admissions. The findings may be reassuring from a mortality perspective, but the impact of closing an ED has far wider implications than mortality alone.
Traditionally, the default position in emergency medical service (EMS) systems has been to apply a resuscitation strategy for all cardiac arrests, excepting a specific legal directive to the contrary, or obvious signs of death. At times, this leads to futile resuscitation attempts that have medical, ethical and financial consequences. To minimise the impact of futile resuscitation attempts, researchers have been seeking ways to identify patients unlikely to benefit from ongoing resuscitation. In this retrospective cohort study, the researchers analysed data from all cardiac arrests in San Mateo County, California over a 4-year period from 1 January 2015. Over 1700 patients were included in the study, which described characteristics of patients, arrests, and EMS responses, and used a technique called recursive partitioning to develop decision rules identifying cases unlikely to survive to hospital discharge, or to survive with good neurologic function. They found that three elements were collectively 100% specific for arrests that did not survive to discharge. Of 223 (13.1%) patients aged ≥80, with unwitnessed arrests and non-shockable initial rhythms, none survived to hospital discharge. Future validation of these findings may be helpful in reducing futile resuscitation attempts that are associated with trauma to patients and families, and their impact on EMS resources.
As the Nursing Times reports plans for a new nurse paramedic course in England, it seems timely to look at how the Swedish EMS system has developed since the introduction of a law in 2000, which meant that all ambulances were staffed with at least one registered nurse. This explorative descriptive study undertook focus groups and the reviewed medical guidelines used within the ambulance service during the years 1999, 2006 and 2015. The focus groups comprised retired emergency medical technicians (EMTs) who had worked in the ambulance service from around 1970 up to 2013, as they had rich knowledge of the ambulance service.
The main developments identified in the focus groups were improved patient assessment, medical treatment, and steering to an optimal level of care; but interestingly, review of the guidelines showed that nursing content declined over the years despite nursing being the main profession. The developments in Swedish EMS are similar to the UK despite being led by different health professionals and, arguably, UK paramedic practice has adopted many of the caring attributes more traditionally associated with nursing—perhaps the keys to high-quality EMS provision are education and skill set rather than professional background.