Research round-up – 5 June

Research round-up – 5 June
Research round-up – 5 June

Research published this week includes a study on paramedic managed paediatric pain; patient perspectives on alternative care destinations; predicting sepsis in the pre-hospital environment; therapeutic agents utilised within the aeromedical environment; several articles on airway management; and a review into emergency bleeding in patients on oral anti-coagulants.

Paediatric pain management 

This study identified that less than 40 per cent of the paediatric patients in the study received any analgesia, despite having a documented description of pain or positive pain score. Of those patients with a pain score of greater than 8/10, over half still did not receive any form of analgesia. In addition, children less than 3 years old were less likely to receive analgesia than those over 9 years old.

The epidemiology of pain in children treated by paramedics

Emergency Medicine Australasia Volume 28, Issue 3, pages 319–324, June 2016

Objectives: The present study aimed to describe paramedic assessment and management of pain in children in a large state-wide ambulance service.

Methods: A retrospective cohort study included paediatric patients (aged less than 15 years) treated and transported by paramedics in the Australian state of Victoria between 1 January 2008 and 31 December 2011. Primary outcome measures were the frequency of analgesic administration and odds of receiving any analgesic (morphine, fentanyl or methoxyflurane). Data were analysed by descriptive statistics, χ2-test and logistic regression to test the association between analgesic administration and the explanatory variables.

Results: There were 38 167 cases that included a description of pain and where any pain scores were >0. Median age was 10 years, 59.2% were male and 15 090 (39.5%) received any analgesic. Of patients reported to have severe pain (verbal numeric rating scale 8–10), only 45% (n = 6084) received any analgesia. In unadjusted analysis, patients aged >9 years were more likely to receive analgesia than those aged <3 years. Multiple regression analysis found that significant predictors of analgesic administration were patient’s sex, patient age, type of pain, initial pain score and case year.

Conclusion: Disparities in analgesic administration based on age and the low rate of pain scores documented in very young children identified in the present study should inform strategies that aim to improve the assessment and management of pain in children.

Pain – which is not only a sensory perception but also has emotional, cognitive, and behavioural components – can have a direct impact on health outcomes and, if uncontrolled, may have a diverse affect on all areas of life. There is evidence suggesting that untreated pain may have long-term negative effects on the patient’s pain sensitivity, immune functioning, neurophysiology, attitudes, and health care behaviour1. Factors such as fear, anxiety, coping style and lack of social support can further exaggerate the physical pain in children. Recognition and alleviation of pain should be a priority when treating ill and injured children and the ability to provide safe analgesia is an essential skill for all practitioners involved in paediatric emergency care2. While it has been identified that paediatric analgesia is underused due to misconceptions and unfamiliarity with the drugs or the procedure, it is the responsibility of the practitioners to ensure they are competent and confident to attempt to manage the child in pain.

However, assessing pain in young children can be challenging if they are non-verbal or have developmental disabilities. The perception and communication of the child’s pain depends on their intellectual and social development. The ability of a child to be able to express their pain relies on the child’s ability to understand, quantitate and communicate it – which is normally only possible for older children or those with good cognitive and communicative abilities. Utilisation of age appropriate pain assessment tools, rather than reliance of the 1-10 score, should be utilised3.

On a related note, it is not just for paediatrics that modified pain score systems have been developed. It can be also difficult to assess pain in patients with dementia due to communication challenges. For these patients, the Pain Assessment IN Advanced Dementia (PAINAD) system, which examines breathing, vocalisation, facial expression, body language and consolability, to create a score between 0 and 10, can be utilised4.

1.Young KD (2005). Pediatric procedural pain Ann Emerg Med. Feb;45(2):160-71
2. The College of Emergency Medicine (2013). Management of pain in children. The College of Emergency Medicine, London, UK.

3. Verghese, S. T., & Hannallah, R. S. (2010). Acute pain management in children. Journal of Pain Research, 3, 105–123.
4. Warden, V, Hurley AC, Volicer, V. (2003). Development and psychometric evaluation of the Pain Assessment in Advanced Dementia (PAINAD) Scale. J Am Med Dir Assoc, 4:9-15. Developed at the New England Geriatric Research Education & Clinical Center, Bedford VAMC, MA.

Patient perspectives on alternative care 

In this US study into patient perceptions of receiving treatment in alternative environments compared to the traditional emergency departments, just over half of the patients agreed that a more patient-centred care approach, with transportation to alternative destinations for low acuity conditions, deemed appropriate.

Patient Perspectives on EMS Alternate Destination Models

Prehospital Emergency Care. Published online.

Introduction: Studies have shown that a large number of ambulance transports to emergency departments (ED) could have been safely treated in an alternative environment, prompting interest in the development of more patient-centred models for pre-hospital care. We examined patient attitudes, perspectives, and agreement/comfort with alternate destinations and other proposed innovations in Emergency Medical Services (EMS) care delivery and determined whether demographic, socio-economic, acuity, and EMS utilisation history factors impact levels of agreement.

Methods: The authors conducted a cross-sectional study on a convenience sample of patients and caregivers presenting to an urban academic ED between July 2012 and May 2013. Respondents were surveyed on levels of agreement with 13 statements corresponding to various aspects of a proposed patient-centred emergency response system including increased EMS access to healthcare records, shared decision making with the patient and/or primary care physician, transport to alternative destinations, and relative importance of EMS assessment versus transportation. Information on demographic and socio-economic factors, level of acuity, and EMS utilisation history were also determined via survey and chart review. Responses were analysed descriptively and compared across patient characteristics using chi-square and regression analyses.

Results: A total of 621 patients were enrolled. The percentage of patients who agreed or strongly agreed with each of the 13 statements ranged from 48.2 to 93.8%. About 86% agreed with increased EMS access to healthcare records; approximately 72% agreed with coordinating disposition decisions with a primary physician; and about 58% supported transport to alternative destinations for low acuity conditions. No association was found between levels of agreement and the patient’s level of acuity or EMS utilization history. Only Black or Hispanic race showed isolated associations with lower rates of agreement with some aspects of an innovative EMS care delivery model.

Conclusion: A substantial proportion of patients surveyed in this cross sectional study agreed with a more patient-centred approach to pre-hospital care where a 9-1-1 call could be met with a variety of treatment and transportation options. Agreement was relatively consistent among a diverse group of patients with varying demographics, levels of acuity and EMS utilisation history.

According to the Australian Commission on Safety and Quality in Health Care, the patient-centred approach to health care treats each person respectfully as an individual human being and not as a condition to be treated1. It involves not just the patient, but families, carers and other supporters and is concerned about the patient’s comfort and surroundings as well as their beliefs and values. A patient-centred approach makes care safer and of higher quality by tailoring the treatment to the individual patient, environment and circumstance.

Experiences from the UK have identified possible avenues to for ambulance services to achieve this. The Clinical Concept of Operations promotes the ambulance role as a mobile health care provider where services are brought to the patient rather than patients to services. This is reasonable given the patients’ health need develops in the context of their ‘home’ not the health care system2. This requires the attendance of highly skilled paramedic clinicians capable of performing high level patient assessment who can then subsequently triage patients into an appropriate health system response – generally through three general triage pathways:

1. Assess, treat and discharge: Paramedics safely assess the patient’s needs, provide the level of service required and discharge the patient from care;

2. Assess, treat and refer: Paramedics identify the patient’s need as not requiring urgent or emergency care but referral to an alternative care pathway is appropriate – the paramedic is able to arrange the referral for the patient; or

3. Assess, treat and transport: Paramedics identify the patient requires emergency or urgent care requirements. Paramedics provide initial care in the field and transport to the appropriate specialised facility depending on the condition (eg ED, PCI centre or Stroke unit).

1. Australian Commission on Safety and Quality in Health Care (2011), Patient centred care: Improving quality and safety through partnerships with patients and consumers, ACSQHC, Sydney.
2. Morrison A (2010). UK Health Reform and Ambulance Trust Service Delivery: A Public Value Perspective. Ambulance Service of NSW, Northmead, NSW.

Sepsis prediction 

This was a Western Australian retrospective cohort study linked the pre-hospital data of patients aged 16 years and older, transported by the metropolitan St John Ambulance Service in Perth, between July 2012 and June 2014, with data from the ED Information System – published within Abstracts from ‘The 40th Australian and New Zealand Scientific meeting on Intensive Care and the 21th Annual Paediatric and Neonatal Intensive Care Conference, Auckland, New Zealand, October 2015’

Examining temperature, systolic blood pressure, respiratory rate, heart rate, and AVPU the authors identified that the New Early Warning Score (NEWS) in the pre-hospital setting only had a moderate ability to differentiate between patients with and without sepsis and this predictive ability was no better than individual physiological parameters alone, concluding that sepsis cannot be reliably predicted using pre-hospital data recorded by paramedics.

Predicting sepsis using pre-hospital data from the ambulance service: A linked data cohort study

Australian Critical Care. Published online.

Introduction: Early identification of sepsis may facilitate pre-alerting the emergency department (ED) enabling prompt initiation of antibiotics and source control. Whether sepsis can be reliably predicted using pre-hospital data recorded by paramedics remains uncertain.

A review of published studies by majority of the same authors identified that while Early Warning Scores (EWS) in the pre-hospital setting appeared useful in predicting clinically important outcomes, the significant diversity between different scoring systems could limit their use in patient diagnosis, for example the the Prehospital Early Sepsis Detection (PRESEP) score predicted the occurrence of sepsis better than the Modified EWS1.

As severe sepsis is a condition with a high mortality rate where the majority of patients are first seen by pre-hospital personnel, there have been numerous attempts to identify and treat patients with sepsis as early as possible to improve patient outcomes. While EWS were developed to allow earlier identification of physiological deterioration, they only identify those that are at risk of critical illness, rather than diagnosis of a specific condition2. Serum lactate is recognised as an independent predictor of mortality in sepsis and point of care lactate testing has been shown to be feasible in the out of hospital environment – combining EWS systems and lactate testing to further improve diagnostic accuracy for patients at risk of adverse outcomes in sepsis3.

Combining a pre-hospital screening protocol utilising SIRS criteria and end-tidal Carbon Dioxide monitoring (ETCO2) – has been shown to predict sepsis and severe sepsis, which could potentially decrease time to therapeutic intervention. As an increasing number of ambulance services have introduced waveform capnography, normally to confirm endotracheal tube placement, they already have the technology to predict patients with sepsis or at risk of severe sepsis. One year-long study, involving the introduction of a new sepsis screening protocol utilising ≥2 systemic inflammatory response syndrome (SIRS) criteria and ETCO2 levels of ≤25 mm Hg in patients with suspected infection, identified sepsis alerts that followed the protocol had a sensitivity of 90 per cent. There were also significant associations between pre-hospital ETCO2 and serum bicarbonate levels and lactate4.

Introducing new technology is not the only technique that can be used to increase the identification of sepsis. Increasing focus on sepsis, for example through quality improvement programs, similar to the Sepsis Kills (NSW) campaign and the Surviving Sepsis Campaign (International), to raise awareness amongst front line practitioners regarding the possibility of sepsis is thought to be responsible for much of the improved outcomes demonstrated in these programs5.

1. Williams TA, Tohira H, Finn J, Perkins GD, Ho KM, The ability of early warning scores (EWS) to detect critical illness in the prehospital setting: A systematic review, Resuscitation, Volume 102, May 2016, Pages 35-43.
2. Corfield AR, Fiona Lees F, Zealley I, Houston G, Dickie S, Ward K, McGuffie C (2014). Utility of a Single Early Warning Score in Patients With Sepsis in the Emergency Department. Emerg Med J. 31(6):482-487
3. Guerra WF, Mayfield TR, Meyers MS, Clouatre AE, Riccio JC (2013), Early Detection and Treatment of Patients with Severe Sepsis by Prehospital Personnel, The Journal of Emergency Medicine, Volume 44, Issue 6, Pages 1116-1125.
4. Hunter, Christopher L. et al (2016) A prehospital screening tool utilizing end-tidal carbon dioxide predicts sepsis and severe sepsis. The American Journal of Emergency Medicine , Volume 34 , Issue 5 , 813 – 819.
5. Yealy, D. M., Huang, D. T., Delaney, A., Knight, M., Randolph, A. G., Daniels, R., & Nutbeam, T. (2015). Recognizing and managing sepsis: what needs to be done? BMC Medicine, 13, 98.

Aeromedical therapeutic agents 

Across the world, ambulance services medical directors and medical committees decide which drugs and treatment plans their organisations should adopt and utilise. Few countries have standardised treatment guidelines, such as the UK’s evidence-based Joint Royal Colleges Ambulance Liaison Committee Clinical Practice Guidelines, which all UK ambulance services follow, but it is more common for guidelines and protocols to vary from one state, country or organisation to the next. The Greater Sydney Area Helicopter Emergency Medical Service have published a review of the therapeutic agents used by the organisation over 12 months which can help organisations to review their drugs and practices.

Review of therapeutic agents employed by an Australian aeromedical pre-hospital and retrieval service.

Emergency Medicine Australasia, 28: 329–334.

Objective: There is little current evidence regarding which therapeutic agents are actually used within existing aeromedical services. The Greater Sydney Area Helicopter Emergency Medical Service operates a large, physician-staffed, multi-modal, pre-hospital and inter-hospital retrieval service. The aim of the present study was to identify the range and frequency of drug, fluid and blood product use within our service.

Methods: This was a retrospective cross-sectional study. Case sheets relating to a 12 month period were inspected to identify the therapeutic agents used by retrieval teams during each mission. Corresponding case notes, demographic data (age, sex) and case data (pre-hospital vs inter-hospital, trauma vs medical) were extracted from an electronic database.

Results: Of 2566 missions, 848 were pre-hospital, 1662 inter-hospital and 56 mixed. Prehospital missions were associated with fewer agents per case (median, 2 vs 3) and a narrower range of agents overall (45 vs 117) compared to inter-hospital missions. In both mission types, the most frequently used agents included morphine, fentanyl, Hartmann’s solution, ketamine, rocuronium, ondansetron and midazolam. Noradrenaline, propofol and metaraminol were used frequently in inter-hospital missions only. A number of stocked and unstocked agents were used less commonly, or not at all, over the study period.

Conclusions: The results of the present study form a practical guide to aid pre-hospital and retrieval services in establishing or reviewing their medical agent formularies. Key practice points illuminated by the data provide insights into current practice in critical care. There remains a clear need for similar studies from other services worldwide.

Airway management 

A series of articles discussing airway management have been published in Air Medical Journal, the first being a literature review into video laryngoscopy.

Articles That May Change Your Practice: Video Laryngoscopy

Air Medical Journal. Published Online: March 25, 2016

Advanced airway management is one of the most controversial and debated areas in pre-hospital care. The use of video laryngoscopy (VL) in advanced airway management is an area of intense interest because it may lead to improved intubation success and less adverse events. The abundance of studies and many video laryngoscopic devices complicate the translation of new knowledge to patient care in the air and land critical care transport setting. This issue provides a summary of some recently published studies specific to the pre-hospital or transport setting or findings that may be applicable to this setting.

The study adds to the existing evidence of benefits of VL, including that video laryngoscopic devices have the potential to improve glottic views and rates of success, especially true in providers with limited advanced airway experience or those who are not routinely exposed to large volumes of advanced airway procedures. As with ‘traditional’ laryngoscopy skills, VL does require regular ongoing maintenance of skills but the learning curve for the acquisition of video laryngoscopic skills for those with previous laryngoscopy skills does appear to be straightforward. While VL may have a positive impact in securing the airway in situations unique to out-of-hospital providers, including cervical spine immobilisation, paediatric airways, and intubation while CPR is performed, it does not appear to have an advantage over traditional laryngoscopy in mitigating the undesired haemodynamic responses resulting from tracheal intubation.

Intubation Performance of Advanced Airway Devices in a Helicopter Emergency Medical Service Setting

Air Medical Journal. Published online 2016. Presented as a poster at the 2012 American College of Emergency Physicians Scientific Assembly Research Forum Denver, CO, October 8-11, 2012.

Objective: This study attempts to determine if newer indirect laryngoscopes or intubating devices are superior to a standard laryngoscope for intubation success among helicopter emergency medical service (HEMS) personnel.

Methods: Flight nurses and paramedics intubated standardized mannequins with a normal airway, a trauma airway, and a difficult airway using a standard laryngoscope, a gum elastic bougie, the Airtraq laryngoscope, the Glidescope Ranger laryngoscope, and the S.A.L.T. device in grounded helicopters wearing helmets and flight gear. Participant demographics, time to glottic view, the modified Cormack-Lehane score, total intubation time, number of attempts, and overall successful intubation were recorded for each type of airway.

Results: Two-hundred thirty-six subjects were initially enrolled across 107 bases in 15 states, and 177 completed the study. First-attempt success rates did not vary by device for the normal airway, but the Airtraq laryngoscope and the S.A.L.T. device were highest in the difficult airway (82.0% and 85.0%). The time to first-attempt success in the difficult airway was lowest for the S.A.L.T. device and the Airtraq laryngoscope (mean = 9.72 seconds and 19.70 seconds).

Conclusion: Using HEMS providers, the Airtraq laryngoscope and the S.A.L.T. device showed the fastest and highest intubation success on the first attempt in difficult simulated HEMS airway scenarios.

With ‘traditional’ intubation, the oral, pharyngeal, and laryngeal axes need  to be aligned for direct visualisation of the vocal cords with the naked eye, however, visualisation of the vocal cords can still be difficult in some patients, particularly those who are morbidly obese or have cervical spine injury/ abnormality. Technology has been developed to overcome this by either increasing the view of the cords, such as the Airtraq laryngoscopy, or techniques not requiring a view of the cords, for example the S.A.L.T device.

This study identified that first-attempt success did not vary by device for the normal airway scenario but was greatest for the Macintosh laryngoscope and S.A.L.T. devices in the trauma airway scenario. In the difficult airway scenario, first-attempt success was greatest for the S.A.L.T. and Airtraq devices and the time to first-attempt success was lowest for the S.A.L.T. and Airtraq devices.

The authors identified that the practitioners preferred the Macintosh laryngoscope for a normal airway scenario and the Airtraq device for the trauma and difficult airway scenario.

Airway Management: A Structured Curriculum for Critical Care Transport Providers

Air Medical Journal. Published Online: April 16, 2016

Objective: Airway assessment and management are vital skills for the critical care transport provider. Nurses and paramedics often enter a transport program with limited or no exposure to airway management. Many programs lack a structured curriculum to show skill competence. Optimal methods in the development of airway management competence and the frequency of training needed to maintain skills have not been clearly defined. Because of this lack of standardisation, the actual level of competence in both new and experienced critical care transport providers is unknown.

Methods: A pretest, post-test repeated measures approach using an online curriculum combined with a deliberate practice model was used. Competence in airway management was measured using 3 evaluation points: static mannequin head, simulation scenario, and the live patient.

Results: A convenience sample of critical care transport providers participated. Knowledge improvement was significant, with a higher percentage of participants scoring above 85% on the post-test compared with the pretest. Mean scores in completion of the airway checklist pre- versus post-intervention were significantly increased on all 3 evaluation points. Significant changes were noted in the response profile evaluating participants’ confidence in their ability to verbalize indications for endotracheal intubation.

Conclusion: The development of a standardized, blended learning curriculum combined with deliberate simulation practice and rigorous assessment showed improvements in multiple areas of airway assessment and management.

Many pre-hospital programs do not have clearly defined methods to establish competence in airway assessment and management, with newly employed practitioners typically attending initial didactic training, then practising intubation techniques on a mannequin before beginning in the clinical environment. According to the authors, the optimal methods in the development of airway management competence and the frequency of training needed to maintain skills have not been clearly defined for critical care transport.

The development of a standardised, blended learning curriculum combined with deliberate simulation practice and rigorous assessment showed improvements in multiple areas of airway assessment and management. This article describes a pilot study designed to standardise airway skill development and maintenance for critical care transport providers. The principle intervention was the development and implementation of a blended learning curriculum based on deliberate practice with simple to more complex simulation devices and patient care situations with the end goal of a live patient intubation.

Although further research on this topic is needed, the implementation and evaluation of a structured curriculum for airway training in critical care transport programs proved necessary because such an approach is currently not standardized in practice.

Bleeding and anticoagulants 

Oral anticoagulants are available for the prophylaxis and treatment of thromboembolic disease, including the acute treatment and secondary prophylaxis for venous thromboembolisms (VTEs) and the risk reduction of stroke and systemic embolism in patients with non-valvular atrial fibrillation (NVAF). They include the well established vitamin K antagonist (VKA), warfarin, and newer agents, such as direct thrombin inhibitor, and the direct factor Xa inhibitors rivaroxaban and apixaban. The open access review provides a general overview; bleeding risk; introduces a bleeding management treatment algorithm for patients on
direct oral anticoagulants; and suggests ideas for future directions and specific reversal agents.

Emergent Bleeding in Patients Receiving Direct Oral Anticoagulants

Air Medical Journal. Published Online: March 25, 2016

Direct oral anticoagulants (DOACs) offer clinical advantages over warfarin, such as minimal medication and food interactions and fixed dosing without the need for routine monitoring of coagulation status. As with all anticoagulants, bleeding, either spontaneous or provoked, is the most common complication. The long-term use of these drugs is increasing, and there is a crucial need for emergency medicine service professionals to understand the optimal management of associated bleeding.

This review aims to describe the indications and pharmacokinetics of available DOACs; to discuss the risk of bleeding; to provide a treatment algorithm to manage DOAC-associated emergency bleeding; and to discuss future directions in bleeding management, including the role of specific reversal agents, such as the recently approved idarucizumab for reversal of the direct thrombin inhibitor dabigatran. Because air medical personnel are increasingly likely to encounter patients receiving DOACs, it is important that they have an understanding of how to manage patients with emergent bleeding.