Could a routine ETA improve patient flow in the ED?
In the UK, ambulance services do not routinely notify an emergency department (ED) of the arrival of non-time-critical patients. However, in some American states, the emergency medical services (EMS) routinely contact the receiving facility and provide a pre-arrival alert, typically providing patient demographics, chief complaint, and estimated time of arrival (ETA). Where prehospital arrival notification data from EMS has been incorporated in ED forecasting models, performance has increased. Likewise, the accuracy of EMS-provided ETA impacts ED readiness and ability of ED personnel to effectively care for both current and anticipated patients. Accuracy of an ETA is key; an underestimated ETA could cause staff to spend time unproductively in anticipation of the arrival, while an overestimated ETA could leave the ED unprepared to deliver critical actions when the patient arrives unexpectedly.
This single-centre, prospective, observational study examined the accuracy of pre-arrival ETA provided by EMS ground units transporting patients to the ED. Data were recorded during pre-arrival calls using a standardised data collection form.
The difference between EMS ETA and actual time of arrival (ATA) was calculated for each patient transport included in the study. The primary outcome was the median difference between the ETA and ATA. Secondary outcomes were the differences between ETA and ATA for specific subgroups, including medical patients, trauma patients, medical command calls, trauma bay activations, potential acute coronary syndrome (ACS), suspected strokes, and cardiac arrests.
The study data in the original article should be reviewed, but it demonstrates that EMS personnel were largely accurate in predicting the time of their arrival. The ETA to ED was consistently underestimated in most ground transport cases (81.7%), but the median difference was small at 3 minutes. This finding largely persisted regardless of the nature of the call and reason for transport. This raises the question, would routine pre-alerts help in the UK?
Advancing practice in acute behavioural disturbances
Acute behavioural disturbance (ABD) is the most commonly term used in the UK to describe a state of significant agitation or disordered behaviour, with or without physiological compromise. Policy and practice in management of ABD is evolving, with some UK advanced paramedics (APs) being able to administer pharmacological restraint to patients presenting with agitation. Deaths have been linked to physical restraint and pharmacological restraint in the United States, so care needs to be taken with decision-making as treatment develops in the UK.
This exploratory, qualitative study of APs practising in a large, metropolitan UK EMS sought to examine participants' experiences of managing ABD by enabling them to talk about ABD incidents they had attended. Each of seven participants was asked to discuss a time they had to decide whether to restrain a person with ABD, while probes were used to explore the interactions between those at scene, how participants felt about managing ABD, and the decision-making processes.
The following four themes were identified:
- Managing complexity and ambiguity: This tackled the complexity and challenges of differentiating ABD from other forms of behavioural agitation and balancing decisions, including identifying the right pharmacological intervention for patients who required chemical sedation
- Feeling vulnerable to professional consequences: This identified concerns in relation to the high-risk nature of these incidents, and what that might mean for them should the patient have a poor outcome. Of particular concern was the risks relating to medico-legal processes
- Needing to negotiate with other professionals: This considered the challenges faced by APs when dealing with police and other ambulance clinicians at the scene, and focused on how participants experienced these interactions
- Recognising and establishing primacy of care: This encompassed the participants' experiences of conceptualising the person with ABD as a patient and engaging with their professional duty of care for them.
There is insufficient space to discuss the article in detail but it is worth reading the participant narrative, particularly for current and aspiring APs, as well as those with an interest in ABD.