Putting the squeeze on tourniquet use
Tourniquets have been used in the military setting for many years, and it is largely because of research in this environment that the use of tourniquets has become widespread in civilian prehospital care. There are concerns about applying battlefield research to civilian practice given the obvious differences in mechanisms of injury, patient demographics and access to definitive care; however, tourniquets are now an integral part of civilian trauma guidelines and are more readily available to clinicians as a result. There has been an unsurprising increase in usage, but concerns are being expressed that the increase may be due to inappropriate use. Indeed, some reports have shown that up to 50% of tourniquet applications do not fall within guidelines.
This Australian retrospective study sought to identify the number of non-indicated prehospital tourniquet applications and determine how this proportion is changing over time. The indications for tourniquet application were described in the study and had not changed since their introduction in 2011. Essentially, the need for a tourniquet would be rare in the prehospital setting as most haemorrhage could be controlled by other means.
A total of 109 patients were identified, although 23 were excluded from the analysis. In the remaining 86 patients, a total of 88 tourniquet applications to 88 extremities were recorded. In two patients (2.3%), two tourniquets were applied to two different extremity injuries. Fourteen patients (16%) had a prolonged tourniquet time of greater than 120 minutes. In a further 12 cases (14%), the tourniquet was not effective (pulses present or ongoing bleeding).
In this study, tourniquet use was deemed non-indicated in 68 cases (77%, 95%CI 67–86%). Many were not indicated because the patient did not have a potentially haemorrhaging arterial injury. In those that did, haemostasis was maintained after tourniquet removal through non-surgical means including simple direct pressure. The use of a tourniquet is not without its hazards so careful consideration should be given before its application.
Paramedic frailty screening, inter-rater reliability and patient outcomes
Screening tools have long been used in prehospital care to direct patients to the most appropriate receiving facility. However, the benefit of these tools can only be maximised if the judgements made by prehospital clinicians accord well with those in the receiving facility. This Australian study aimed to assess the inter-rater reliability of the Clinical Frailty Scale (CFS) between paramedics and emergency department staff. Additionally, they looked to see how the scores correlated with patient outcomes, which is arguably the most important outcome.
It is worth noting that the CFS score is a non-essential component on the Falls Pathway assessment form and paramedic electronic record, so some potentially eligible patients may have been excluded owing to non-completion of the CFS. Additionally, no further training was given on the CFS, and no indication of prior training was documented.
The study team included data from a small sample of 94 patients. The mean age was 82 years and 64% were female. Cohen's Kappa (κ) ranges between 0 and 1, with 0 indicating no agreement between raters and 1 indicating perfect agreement. The primary outcome showed that the inter-rater reliability between paramedics and emergency department staff using the CFS was moderate (κ 0.48 (95 % CI 0.36–0.59)). The study was not sufficiently powered to detect a difference in the secondary outcome, which was one of a number of limitations to the study.
The study is small, based at a single site and assessed only one frailty tool so cannot be extrapolated. It also addressed only those older people who had had a fall so again, cannot be extrapolated to the wider older population attending the emergency department. Despite these limitations, the study identifies an important question for us to consider – how can we be certain that we are using screening tools in the same way as other health and medical professionals?