Dataset Information

Impact of drug and equipment preparation on pre-hospital emergency Anaesthesia (PHEA) procedural time, error rate and cognitive load.

ABSTRACT:

Background

We examined the effect of advanced preparation and organisation of equipment and drugs for Pre-hospital Emergency Anaesthesia (PHEA) and tracheal intubation on procedural time, error rates, and cognitive load.

Methods

This study was a randomised, controlled experiment with a crossover design. Clinical teams (physician and paramedic) from the Emergency Medical Retrieval Service and the Scottish Air Ambulance Division were randomised to perform a standardised pre-hospital clinical simulation using either unprepared (standard practice) or pre-prepared (experimental method) PHEA equipment and drugs. Following a two-week washout period, each team performed the corresponding simulation. The primary outcome was intervention time. Secondary outcomes were safety-related incidents and errors, and degree of cognitive load.

Results

In total 23 experiments were completed, 12 using experimental method and 11 using standard practice. Time required to perform PHEA using the experimental method was significantly shorter than with standard practice (11,45 versus 20:59) minutes: seconds; p = < 0.001). The experimental method also significantly reduced procedural errors (0 versus 9, p = 0.007) and the cognitive load experienced by the intubator assistant (41.9 versus 68.7 mm, p = 0.006).

Conclusions

Pre-preparation of PHEA equipment and drugs resulted in safer performance of PHEA and has the potential to reduce on-scene time by up to a third.

SUBMITTER: Swinton P

PROVIDER: S-EPMC6150998 | biostudies-literature | 2018 Sep

REPOSITORIES: biostudies-literature

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Publications

Impact of drug and equipment preparation on pre-hospital emergency Anaesthesia (PHEA) procedural time, error rate and cognitive load.

Swinton Paul P Corfield Alasdair R AR Moultrie Chris C Percival David D Proctor Jeffrey J Sinclair Neil N Perkins Zane B ZB

Scandinavian journal of trauma, resuscitation and emergency medicine 20180921 1

<h4>Background</h4>We examined the effect of advanced preparation and organisation of equipment and drugs for Pre-hospital Emergency Anaesthesia (PHEA) and tracheal intubation on procedural time, error rates, and cognitive load.<h4>Methods</h4>This study was a randomised, controlled experiment with a crossover design. Clinical teams (physician and paramedic) from the Emergency Medical Retrieval Service and the Scottish Air Ambulance Division were randomised to perform a standardised pre-hospital ...[more]

PMID: 30241559

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Project description:BackgroundPre-hospital emergency anaesthesia is a critical intervention undertaken by helicopter emergency medical teams. Previous studies informed current practice for induction regimes, using a standardized approach of fentanyl, ketamine and rocuronium. There may be a trend towards post-induction hypotension attributed to the induction regime used. Several new combinations of fentanyl, ketamine and rocuronium are emerging in clinical practice. There is currently no consensus on what induction regimes should be used.MethodsA semi-structured survey was distributed to the medical leads of all UK air ambulance organisations between December 2022 and February 2023. Responses that were returned within the study period were included. Exclusions included missing data, declined participation and failure to return the survey within the data collection period. The survey sought to establish provision of pre-hospital emergency anaesthesia and current induction regimes for stable, unstable and post-cardiac arrest patients. Data was extracted from Microsoft Forms into Excel. Descriptive statistics were used to analyse survey response rate, provision of PHEA and induction regimes. The survey was endorsed by the National HEMS Research and Audit Forum.Results19 air ambulance organisations responded (response rate 86%). The majority of organisations provide over 100 pre-hospital emergency anaesthetics per annum (79%, n = 15/19). A standard combination of fentanyl, ketamine and rocuronium is used as a primary induction regime in haemodynamically stable patients by 52% of services (n = 10/19). In haemodynamically compromised patients, fentanyl was omitted or pracititioner choice emphasized by 79% of services (n = 15/19). There was variability in the dose of rocuronium from 1 mg/kg to 2 mg/kg throughout services.ConclusionThere is variability in the approach to pre-hospital emergency anaesthesia. There is a growing dataset that would enable development of a registry to better understand induction regimes and the impact on patient physiology. Organisations are increasingly adopting a patient centered, practitioner choice model towards induction of anaesthesia.

Project description:IntroductionChildren presenting to the emergency department (ED) often require procedural sedation and analgesia (PSA) prior to procedures. Although ketamine is used widely for PSA safely, there is a risk of adverse effects. Among them, vomiting is significant as it occurs in about 10% of patients and can potentially endanger the airway. Because there is evidence that post-operative complications might be due to anxiety prior to the operation, this study aims to investigate the association between pre-procedural anxiety and vomiting in the ED.MethodsIn this cohort study, a convenient sample of children aged 2 to 14 years who were a candidate for PSA with ketamine in the ED were enrolled. Anxiety was evaluated using the short version of the modified Yale preoperative anxiety scale (mYAS). Vomiting was recorded during the period of hospitalization in the ED and 24 h after discharge by a phone call. Association between anxiety level and vomiting was analyzed using the independent samples t-test and multivariable logistic regression was used to control for covariates.Results102 children were enrolled and 93 were included in final analysis. The mean age of participants was 3.95 ± 1.79 years and 55.9% were male. According to the mYAS, the mean score of anxiety was 48.67 ± 21.78 in the waiting room and 59.10 ± 23.86 in the operating room. The mean score of anxiety was 58.3±25.3 and 51.0±20.7 in the vomiting and non-vomiting groups, respectively. At least one episode of vomiting was reported in 23 children of which, 19 took place in the hospital and 4 after discharge. No significant association was observed between pre-procedural anxiety and the occurrence of vomiting. On univariate regression model, the odds ratio of the association between mean anxiety and vomiting was 1.02 (CI 95%: 0.99-1.04) (P-value: 0.16). On the multivariable logistic regression model, after adjusting for all the covariates, the odds ratio was 1.03 (CI 95%: 1.0-1.05) (P-value: 0.05).ConclusionThe present study showed that anxiety before procedural sedation and analgesia with ketamine in children was not associated with the incidence of vomiting.

Project description:BackgroundDespite the importance of Ultrasound-guided Regional Anaesthesia (UGRA) in Emergency Medicine (EM), there is significant variability in UGRA training among emergency physicians. We recently developed a one-day (8 h), simulation-based UGRA course, specifically tailored to help emergency physicians to integrate these skills into their clinical practice.MethodsIn this pre/post intervention study, emergency physicians attended a course consisting of a 4-hour teaching on background knowledge and a practical part structured as follows: a scanning session on a healthy individual; a needling station with an ex-vivo model (turkey thighs); a simulation-based learning experience on local anaesthetic toxicity (LAST); a session on the UGRA simulator BlockSim™. Participants rated their level of knowledge across several domains of UGRA practice; for this purpose, we used a 5-points Likert scale (from 0 to 4). Participants also rated the perceived utility of the practical sessions. We extrapolated baseline characteristics of participants, and we paired the answers of pre- and post-course questionnaires using Wilcoxon signed-rank test.ResultsSeventy-four emergency physicians across ten Italian regions and Switzerland completed the pre-and post- course questionnaire. Most of them were EM residents (75.68%) who had never performed UGRA. Median self-reported knowledge significantly improved from 1 to 3 in the following domains of UGRA indications: Knowledge of contraindications and UGRA techniques [pre-course 1 (IQR 1-2), post-course 3 (IQR 2-3)]; Equipment and drugs [pre-course 1(IQR 1-1), post-course 3 (IQR2-3)]; LAST recognition [pre-course 1 (IQR 1-2), post-course 3 (IQR 2-4)]; LAST management [pre-course 1 (IQR 1-1,75), post-course 3 (IQR 2-3)] (p < 0.001). A smaller improvement was observed in the domain Knowledge of "sonoanatomy" (from 1 to 2; p < 0.001); this might be due to the fact that a one-hour scanning session on a single healthy volunteer may be insufficient for learners to gain confidence with the relevant sonoanatomy. Most participants rated positively the utility of practical stations (100% for the scanning session; 100% for the ex-vivo station with turkey thigh; 91.8% for the BlockSim™).LimitationsThe main limitation of this study is that measurements are limited to learners' reaction to learning and self-assessment outcomes. We did not measure the impact of our course on participants' performance in simulated settings, or on their behavior in the clinical setting, or on patient outcomes. The sample size of participants was relatively small, although larger than most published similar studies.ConclusionsThis one-day simulation-based, UGRA course tailored for emergency physicians led to improved participants' self-reported knowledge across several domains of UGRA practice. The course represents an effective educational strategy and can be replicated in other settings for the initial training of emergency physicians in UGRA.

Project description:BackgroundProcedural sedation and analgesia (PSA) is used to attenuate the pain and distress that may otherwise be experienced during diagnostic and interventional medical or dental procedures. As the risk of adverse events increases with the depth of sedation induced, frequent monitoring of level of consciousness is recommended. Level of consciousness is usually monitored during PSA with clinical observation. Processed electroencephalogram-based depth of anaesthesia (DoA) monitoring devices provide an alternative method to monitor level of consciousness that can be used in addition to clinical observation. However, there is uncertainty as to whether their routine use in PSA would be justified. Rigorous evaluation of the clinical benefits of DoA monitors during PSA, including comprehensive syntheses of the available evidence, is therefore required. One potential clinical benefit of using DoA monitoring during PSA is that the technology could improve patient safety by reducing sedation-related adverse events, such as death or permanent neurological disability. We hypothesise that earlier identification of lapses into deeper than intended levels of sedation using DoA monitoring leads to more effective titration of sedative and analgesic medications, and results in a reduction in the risk of adverse events caused by the consequences of over-sedation, such as hypoxaemia. The primary objective of this review is to determine whether using DoA monitoring during PSA in the hospital setting improves patient safety by reducing the risk of hypoxaemia (defined as an arterial partial pressure of oxygen below 60 mmHg or percentage of haemoglobin that is saturated with oxygen [SpO(2)] less than 90 %). Other potential clinical benefits of using DoA monitoring devices during sedation will be assessed as secondary outcomes.Methods/designElectronic databases will be systematically searched for randomized controlled trials comparing the use of depth of anaesthesia monitoring devices with clinical observation of level of consciousness during PSA. Language restrictions will not be imposed. Screening, study selection and data extraction will be performed by two independent reviewers. Disagreements will be resolved by discussion. Meta-analyses will be performed if suitable.DiscussionThis review will synthesise the evidence on an important potential clinical benefit of DoA monitoring during PSA within hospital settings.Systematic review registrationPROSPERO CRD42015017251.

Dataset Information

Impact of drug and equipment preparation on pre-hospital emergency Anaesthesia (PHEA) procedural time, error rate and cognitive load.

Background

Methods

Results

Conclusions

Publications

Impact of drug and equipment preparation on pre-hospital emergency Anaesthesia (PHEA) procedural time, error rate and cognitive load.

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