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Australasian AmbulanceFocus on Research

WINTER 2013Beyond the pre-shock pause

Patient care records online

Influences on patient satisfaction

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Research on Research

Contents

Disclaimer:This document does not necessarily reflect the views of any individual ambulance service that is a member of the Council of Ambulance Authorities. It has been prepared to promote and inform discussion.

All images reproduced with the permission of ambulance services, speakers and the Canberra Convention Bureau.

Produced by: The Council of Ambulance Authorities 609/434 St Kilda Rd, Melbourne, 3004, Australia

www.caa.net.au

August 2013

In this edition of Australasian Ambulance, there is a focus on research undertaken by our members in Australia and New Zealand.

Research is a critical tool to provide clarity and direction for improving our services and in turn the well-being of patients.

From clinical trials to applications for new technology, the insights gained from these projects are an important contribution to addressing many of the challenges facing paramedicine.

A paper prepared by the Ehrenberg-Bass Institute for Marketing Science using data provided by CAA, analyses 10 years of patient satisfaction with ambulance services across Australia and New Zealand.

The findings provide a comprehensive overview of what influences people’s experience of ambulance services and identifies areas where improvements are needed.

Our national conference this year takes up the themes of anticipating the role of paramedics in the future and understanding how we can adapt our knowledge gained from research and experience.

Following the success of last year’s conference, which coincided with CAA’s 50th anniversary, we look forward to welcoming members to Canberra for a compelling program of speakers and events including the CAA Australasian Awards for Excellence.

Greg Mundy CEO, CAA

Researching how to get better

Dictionary definition: Methodical investigation into a subject in order to discover facts, to establish or revise a theory, or to develop a plan of action based on the facts discovered.Encarta Dictionary UK

Other definitions: Research is four things: brains with which to think, eyes with which to see, machines with which to measure and, fourth, money.Albert Szent-Gyorgyi – physiologist, Winner of the 1937 Nobel Prize in Physiology or Medicine

Research is what I’m doing when I don’t know what I’m doing. Attributed to Wernher Von Braun, rocket scientist

Good research: You can do the best research and be making the strongest intellectual argument, but if readers don’t get past the third paragraph you’ve wasted your energy and valuable ink.Carl Hiaasen – Journalist, writer

CAA Update 1 – 2

Patient care records off paper and online 3

Beyond the pre-shock pause 4

Understanding the factors that influence patient 5 – 6 satisfaction with the ambulance service

Measuring the impact of paramedic care 7 using data linkage

Informing pre-hospital care for older people 8 who have fallen

Key clinical trials 9

Importance of pre-hospital registries 10

CAA Conference preview 11 – 12

CAA Update

AccreditationLilya Sher (left), CAA PEPAS Co-ordinator, presented Associate Professor Virginia Plummer (right), Course Co-ordinator – Monash University - Peninsula Campus, with the Certificate of Full Accreditation for their Bachelor of Nursing/Bachelor of Emergency Health (Paramedic) program.

In 2013, provisional accreditations were awarded to Charles Sturt University for the Graduate Diploma of Clinical Practice (Paramedic) and University of the Sunshine Coast for the Bachelor of Paramedic Sciences.

EducationThe CAA, in partnership with Paramedics Australasia and the tertiary education sector, conducts a program of accreditation of the entry-level bachelor’s degree courses in paramedicine. Eighteen tertiary institutions in Australia and New Zealand currently offer, or plan to offer, these courses and all have engaged with our accreditation scheme. A list of the participating universities may be found on our web site.

The Strategic Business Advisory Committee (SBAC), established to provide advice to the CAA Board on strategic and business matters, is responsible for collecting data from members for inclusion in the Report on Government Services (Australian only) and the CAA annual report.

As part of its role, SBAC has been developing new indicators to better represent ambulance work and ensure reported data is comparable among all services. Great work by individual services has assisted with improving CAA’s clinical reports.

The committee is also developing new clinical indicators and improvements in reporting capabilities on existing clinical indicators, e.g. cardiac arrest and pain management.

The SBAC is looking to introduce two new indicators in the 2014 Report on Government Services - pain management and call answer time. The committee is expecting to have further indicators set up for test reporting (internal controlled test reporting) in the coming year.

Emergency ManagementA Position Paper on the role of ambulance, and other health services, in disaster and emergency management is in preparation. It is planned to release this later in 2013 to promote understanding of the role and potential of ambulance services in the management and response to natural and other disasters.

RegulationWe have followed up our submission supporting the professional registration of paramedics as one important element in the regulation of paramedicine in Australia with correspondence to jurisdictional Ministers. A decision on this issue by Ministers is expected later this year.

Work in ProgressThe CAA has five key objectives: contributing to the development of public policies that impact on the provision of ambulance services; developing a body of knowledge about ambulance services; developing and applying standards for improved quality of care and services; developing common systems and processes; and jointly funding initiatives for common outcomes. This gives us a pretty full agenda with action on a number of fronts, some examples are outlined below.

Be AwareInternational Overdose Awareness Day is on August 31st, 2013. For more information go to www.overdoseday.com

National Stroke Foundation Action PlanCAA has endorsed the Foundation’s National Action Plan for Stroke.

Stroke is Australia’s second biggest killer and a leading cause of disability.

The plan includes a call for the government to invest in the establishment of a formal stroke research network with dedicated funding for three years.

1 FOCUS ON RESEARCH

More information about the CAA and our work can be found on our newly-revamped website www.caa.net.au

Greg Mundy – CEO, CAA

WINTER 2013 2

2013 National ConferenceJoin your colleagues in Canberra to make this year’s CAA conference a landmark event.

The national capital’s iconic buildings and centenary celebrations will set the scene for a compelling program of speakers. ABC presenter and writer Richard Fidler will be Master of Ceremonies.

Program and registration available at www.caa.net.au

CAA Members

International LinksJust like other branches of medicine and other parts of the health care system, it is important for the ambulance sector in Australia and New Zealand to engage in the international exchange of knowledge and perspectives in our field. At CAA we always seek high quality international content for our conferences and this year we have again succeeded. Anthony Marsh, the CEO of the West Midlands Ambulance Service and Chair of the Association of Ambulance Chief Executives, and Deputy

Superintendent Bosse from Boston EMS will both feature on this year’s program in Canberra on 16th – 17th October.

Similarly, a number of senior managers from Australian ambulance services and the CAA took part in the UK Ambulance Leadership Forum and the Paramedic Chiefs of Canada Conference in May and June this year, sharing our views and insights with our international colleagues.

Exploring the Frontiers – Paramedicine of Tomorrow

Associate Members

Ambulance New ZealandSt John Papua New Guinea

www.stjohnambulance.com.au

www.stjohnnt.org.au

esa.act.gov.au

ambulance.qld.gov.au

www.dhs.tas.gov.au/ambulance

www.ambulance.nsw.gov.au

www.ambulance.vic.gov.au

www.saambulance.com.au

www.wfa.org.nz

www.stjohn.org.nz

A move to paperless patient care records has been a resounding success for St John Ambulance WA.

The process started in early 2010 when the ambulance service looked at commercially available solutions as well as the option of developing a system that would run on the newly released Apple iPad.

The ambulance service appointed CSG (now NEC) to develop an application integrating the existing “back end” database used to enter information from the paper forms.

By late 2011 the system had been successfully trialled and the rollout of more than 850 iPads issued to individual staff members in the ambulance and patient transport vehicle (PTV) fleets began.

By 1st March 2012, the ePCR system was used to complete 85% of all patient records and by June this year this had gone up to 95% of all records.

The next step involved the country ambulance service. Career personnel in country centres came on line in January and by the end of the year 5000 volunteer personnel will be using ePCR.

St John Ambulance WA Technical Services Director Ashley Morris said ePCR was a massive leap forward for the ambulance service.

“Attending crews receive case details on their iPads, record all observations and treatments and send them simultaneously to head office and the receiving hospital,” he said.

“ePCR has increased the number of completed case sheets collected from paramedics and removed the onerous need of having to courier paper records from 30 depots into state office.”

“The real-time nature of the system enables the immediate follow up with paramedics if there is a documentation problem and faster invoicing to our corporate clients such as the hospitals.”

Mr Morris said the data entry requirements at state office have reduced significantly, allowing staff redeployment.

“Less than five per cent of all case sheets are now submitted on paper, representing about 25 sheets a day, down from between 500 and 600 sheets,” he said.

The system also includes a web-based portal accessible to all WA hospitals with Emergency Departments.

Hospital personnel can see details of patients en-route and can print copies of the completed patient record once the patient has been admitted.

A second application, added in December 2012, provides fast access to clinical documentation and training videos.

eDocVault automatically notifies the paramedic when an updated version of any document or video is available and prompts

the user to download it. All documents and videos, once downloaded, are stored locally on the iPad for immediate access regardless of location.

Mr Morris said the nature of a personal device such as iPad meant that all personnel have access to their company email and the corporate intranet from any location.

“That also means that the need to fight for the one or two PCs at metro depots is long gone,” he said.

“Staff can use their iPad by tapping into either the depot’s or the Ambulance’s on board Wi-Fi network so the portability is great.”

St John Ambulance WA also considered and addressed privacy concerns. The ePCR application can be accessed only when staff are rostered to work. This means confidential data is not accessible to staff or their families when the iPad is used out of hours.

The use of the iPad has brought further innovation and efficiency.

In the near future, staff will have the ability to enter their time sheets and access e-Learning resources with the introduction of new applications, planned for later this year.

St John Ambulance WA

Patient care records off paper and online

3 FOCUS ON RESEARCH

The vital importance of good quality chest compressions is well established as a key component of resuscitation efforts.

Wellington Free Ambulance recently conducted research to establish if the choice between manual and AED mode when using a defibrillator affected the pattern of interruptions to CPR and influenced return of spontaneous circulation (ROSC).

This prospective study was conducted using Lifepak 12 and Lifepak 15 defibrillators.

The study reviewed the pre-shock and post-shock pauses as well as interruptions in the 30 seconds preceding defibrillation.

Results: Shorter pre-shock pauses occurred when the defibrillator was utilised in manual mode (median 3 seconds) versus AED mode (median 4 seconds). Interruptions to CPR in the 30 seconds prior to shock delivery were also shorter in manual mode (median 7 seconds) versus AED mode (median 14 seconds).

There was no statistical difference between shock success rates and post-shock pauses between the two modes. Shock success was defined as converting a shockable rhythm (VF or VT) to a non-shockable rhythm. ROSC was significantly higher when the defibrillator was utilised in manual mode (18.49%) versus AED mode (8.33%, p = 0.042).

Conclusion: When paramedics used the defibrillator in manual mode as compared to AED mode, interruptions to CPR during the 30 seconds prior to shock delivery were significantly reduced and pre-shock pauses were also shorter. This was associated with increased ROSC.

Historically, paramedics often utilised AED mode when beginning a resuscitation (particularly if resources were limited). This mode was often preferred, even by senior paramedics, as it allowed other resuscitation needs (such as immediate chest compressions, ventilation, equipment preparation and cannulation) to be addressed simultaneously. Paramedics then switched to manual mode once more personnel arrived.

Manual defibrillation is now the recommended option for appropriately trained paramedics within Wellington Free Ambulance (WFA). After the initial rapid defibrillation, paramedics are now taught to perform continuous CPR for two minutes and to charge the defibrillator without pausing. Once the defibrillator is charged, all personnel except the CPR provider are directed to stand clear of the patient. The CPR provider then stands clear and a rhythm check is performed. The patient is shocked or the charge is dumped, depending on the rhythm. CPR is immediately recommenced by the same provider.

WFA paramedics are regularly achieving pre-shock pauses of 1-3 seconds. Post shock pauses are regularly less than 2-3 seconds (this is the minimum measurable pause utilising CODESTAT). Paramedics are recommended to change the CPR provider by having the paramedic responsible for the airway to perform over-the-head CPR for a few seconds while the CPR providers swap. This frequently results in pauses associated with changing CPR providers of only 1-2 seconds.

Wellington Free Ambulance provides feedback to paramedics attending cardiac arrest cases, via CODESTAT software.

Author: Mark Bailey, Wellington Free Ambulance

WINTER 2013 4

Beyond the pre-shock pause

Paramedics are David Huntley (left, intubating)

and Mark Bailey (right, cpr) – Image by Albee Photography

5 FOCUS ON RESEARCH

Edited summary

Customer satisfaction is the corner-stone performance metric for many organizations that want to measure the value of the service they deliver to their customers. Ambulance service is no exception.

The level of service that an ambulance team provides has an immense impact on the future wellbeing and quality of life for the patient and his/her family. Yet, the measure of ambulance patient satisfaction often reflects many other factors about the patients and their families, beyond their actual evaluation of the experience. In this study, the authors analyse 10 years of survey data about patient satisfaction with ambulance service from ambulance authorities across Australia and New Zealand to determine factors that may influence the score that an ambulance team receives for its service.

The results reveal a number of factors about the patient and his/her families that systematically bias satisfaction ratings. These biases need to be taken into account when ambulance performance is compared over time or across different jurisdictions. This will ensure the robustness of the tracking instrument, which in turn will allow us to clearly identify areas where improvements in service are required to better serve individual patients and the community overall.

Background

Ambulance services play pivotal roles in the delivery of health-services. Ambulance services deliver pre-hospital emergency care and patient transfer to the health care providers. The industry is vast and very important for the community and the economy. In the US, 153,913 people were employed to cover 5,075 ambulance stations and locations in the year 2012. The UK’s ambulance services in 2009–2010 received 7.9 million emergency “999” calls, which led to 6.4 million ambulance responses and 4.7 million urgent patient journeys (National Audit Office 2011). In Australia, 14,991 people were employed, to cover all 1,408 ambulance stations and locations, which made almost 3.9 million responses in 2011–12 (Fitzpatrick 2012).

The ambulance services context is a prime example of a service scape where a transformative service research (Ostrom et al. 2010) approach is appropriate. We particularly note three characteristics of transformative service research that reflects the essence of the ambulance service encounter (Ostrom et al. 2010).

First, it is the focus on consumer physical and mental wellbeing as the outcomes of the service encounter. While many industries offer essential services to the public, ambulance service literally deals with life and death situations. The outcome of a service encounter may determine whether the patient lives and what quality of life they will have long after the incident.

Second, the recipients of ambulance service come from very diverse backgrounds in terms of age, ethnicity, education, socio-economic status, and health, to name a few. Given such diversity, it is a challenging task, yet an imperative goal, to ensure that the level of service is of equally high standard for all patients. The diversity of the patient population may also bias their evaluations of the care they received (Jackson et al. 2001).

Third, most customers of ambulance service (patients and their loved ones) find themselves in a vulnerable position when receiving the service. The stress of the situation, lack of medical expertise and knowledge, the stakes of the decision, all mean that customers have to completely trust the ambulance team and rely on their professionalism. Therefore, the framework of transformative service research is very relevant to measuring patient satisfaction with ambulance service.

This study pursues three main objectives. First, to establish satisfaction score norms across different ambulance service dimensions. Expected norms provide enhanced interpretation of satisfactions surveys through identifying deviations, which can indicate areas of service deficiencies and excellence. The second objective is to uncover dimensions of ambulance experience that have the strongest relationship with the overall satisfaction. This provides health care practitioners with insights into what the overall patient satisfaction construct is

actually measuring and highlights the areas most important to patients, which may accordingly need a greater focus. The final objective is to explore person-based factors (beyond the actual experience) that influence ambulance patient satisfaction scores.

Hypothesis

Ambulance patient satisfaction scores will display the ceiling effect at the positive end of the scale – supported

The dimensions of ambulance service satisfaction that include human component will receive higher scores, than dimensions that have only tangible elements – supported

The dimensions of the service associated with human interaction will be the strongest contributor towards the overall patient satisfaction with ambulance service – not supported

Metro patients will provide higher satisfaction scores than rural patients – not supported

Rural patients will provide higher satisfaction scores than metro patients – not supported

There will be no difference in satisfaction scores of metro and rural patients – supported

Patients will provide higher satisfaction scores, compared to their carers – supported

More experienced users of ambulance service will provide more positive satisfaction ratings, compared to novices – supported

Age will be positively related to patient satisfaction scores – not supported

Males will provide higher satisfaction scores than females – not supported

Females will provide higher satisfaction scores than males – not supported

There will be no difference in satisfaction scores of males and females – supported

Understanding the factors that influence patient

WINTER 2013 6

Findings

Our first area of contribution relates to establishing satisfaction score norms for ambulance service. In line with the prior literature, our data shows a clear ceiling effect, where the majority of responses are at the highest (most positive) point of the scale. While, these very high scores might send an encouraging feedback to the service provider, at the same time, the ceiling effect presents measurement challenges in identifying areas for improvement.

The second area of contribution of this article is in uncovering which dimensions of the ambulance service encounter contribute the most towards the overall patient satisfaction score. We find the strongest contributor to be the paramedic care. The lowest contributors to overall ambulance satisfaction related to experiences with emergency phone call. Interestingly, this includes the communication on the phone, which has a human element, usually a strong contributor towards a service evaluation score.

A number of practical implications for ambulance and other health service providers arise from our second contribution. The quality of paramedic care and treatment are the most important aspects, which will ultimately drive the overall score. Yet, the paramedic care score is already extremely high in the current measurement system. On the other hand, the second group of contributors relates to the ride satisfaction, which, generally, have lower scores.

This suggests that there is a room for improvement in the riding experience and conditions, which in turn, would further increase the overall score. In turn, these improvements will allow to provide better services and care to the community.

The third area of contribution of this article is in exploring other factors (beyond the actual service experience) that influence overall ambulance patient satisfaction scores. The prior literature, especially in the health domain, has explored the number of demographic factors that influences scores.

We find that the gender and locality (rural/metro) do not have any bearing on ambulance patient satisfaction. Yet, patients tend to give more positive evaluations, than carers. Our findings that age is not related to overall patient satisfaction is of particular note.

There is overwhelming evidence in the prior literature that suggests that older patients tend to provide higher satisfaction scores (Barg et al. 2007; Cohen 1996; Findik et al. 2010; Jackson et al. 2001; Stewart 2002).

Older patients have a much higher proportion of “experienced” ambulance patients. Indeed, in the current data we find that more experienced patients (those who have been transported more than once) provide more positive satisfaction scores.

These two facts put together suggest that once the prior usage is accounted for, the effect of the age on the overall patient satisfaction disappears.

Conclusions

To conclude, the authors examined an issue that can help improve the delivery of the lifesaving service to the public – the medical emergency transportation service. Our results lead to a number of actionable recommendations:

* consider using longer scales and other statistical tools to reduce the ‘ceiling’ effect;

* include the effect of personal factors, such as demographic, and, particularly, past usage effect, when measuring ambulance satisfaction;

* maintain the current level of service in the paramedic care, as this factors is the main contributor towards the overall satisfaction;

* aim to improve the tangible dimensions, such as the ride conditions, as these play an important part in the overall satisfaction, yet have a lot of room for improvement.

The practical implications arising from our study could help ambulance service providers, and their governing bodies to have a more accurate account of the level of service the public receives. In turn, the more accurate instrument will allow identifying opportunities for improvement to ensure social equality: every patient, whether young or old, in rural or metro locations, of any gender and nationality should receive equality very high level of service.

The outcomes of the ambulance service encounter could have long-term impact on health, wellbeing and happiness not just of the patient, but their families and wider communities. This contribution is particularly critical in the face of increasing demands on the health system, including ambulance service, which will continue to play a central role.

Authors: Bogomolova S., Tan P.J., Dunn S., and Bizjak-Mikic M.#

Ehrenberg-Bass Institute for Marketing Science, University of South Australia,

The Council of Ambulance Authorities (CAA)

The paper has been submitted to the Journal of Service Research for publication.

satisfaction with the ambulance service

“ The outcomes of the ambulance service encounter could have long-term impact on health, wellbeing and happiness not just of the patient, but their families and wider communities”

7 FOCUS ON RESEARCH

Background

One of the functions of Research at NSW Ambulance is the generation of knowledge to inform clinical and operational policy decision-making. This task is challenging as, traditionally, there has been little capacity to describe meaningful health outcomes, beyond the hospital door, for patients attended by paramedics and limited insight into the effects of prehospital care.

The availability of privacy-preserving data linkage methodologies now allows separate health service data collections to be connected for research purposes.

In 2010, the NSW Population and Health Services Research Ethics Committee approved the construction of a large retrospective linked dataset containing NSW Ambulance dispatch and clinical records, hospital, and mortality records.

The dataset captures critical information such as in-hospital diagnosis, hospital length-of-stay, intensive care unit admission days, and mortality.

Data linkage was funded by the NSW Clinical Excellence Commission and performed by the NSW Centre for Health Records Linkage (CHeReL).

Method

Using probabilistic and deterministic methods, the CHeReL linked all NSW Ambulance records with Emergency Department (ED), Admitted Patient, NSW Registry of Births Deaths and Marriage, and Australian Bureau of Statistics Mortality data collections, for the period 1 July 2006 to 30 June 2009.

Where NSW Ambulance records did not link to any external dataset and the ‘transport disposition’ indicated that no patient was involved in the incident, those records were not included in the dataset. ‘Inter-hospital transfers for diagnostic tests’ and ‘medical appointment’ records were also excluded.

Results

Data linkage was completed in 2012. The linked dataset contains 8,968,331 NSW Ambulance, hospital and death records. This dataset represents almost 3 million out-of-hospital patient encounters for over 1.16 million NSW Ambulance patients, some of whom had more than one ‘triple zero (000)’ call, or more than one ED visit or in-hospital admission during the 3 year period.

At least 80% of the patients attended by NSW Ambulance linked to an ED or in-patient hospital record at some time during the period of interest.

A study describing the quality of linkages achieved, i.e. which records did and did not link, is nearing completion. A number of priority studies are either underway or planned, including: an epidemiological study of NSW Ambulance patients and their subsequent hospital care; the identification of low-acuity patients to underpin safe non-ED pathways of care; an evaluation of NSW Ambulance’s Major Trauma Protocol; and an investigation of health outcomes for older patients who have fallen.

Conclusion

This project is an important initiative that will provide greater insight into patients’ healthcare journeys from the time paramedics arrive. As NSW Ambulance is the sole provider of emergency care to the NSW population, analyses of a dataset of this size will provide unprecedented opportunities to examine associations between pre-hospital clinical and operational care and health outcomes.

Authors: R Carney, S Muecke, T Carroll, Ambulance Service of NSW

Measuring the impact of paramedic care using data linkage

“ This project is an important initiative that will provide greater insight into patients’ healthcare journeys from the time paramedics arrive.”

WINTER 2013 8

In 2011, NSW Ambulance, in collaboration with the NSW Clinical Excellence Commission (CEC) and Neuroscience Research Australia, embarked on a series of research projects investigating the prehospital care of older people who had fallen.

The project was prompted by the high volume of emergency calls to this patient cohort and the scarcity of pre-hospital evidence to inform best practice. A newly formed CEC-sponsored ‘Ambulance Falls Advisory Group’ brought together experts in geriatrics, pre-hospital care and falls, to oversee the research agenda.

The research program consists of a suite of several projects. The first was a population-based, retrospective epidemiological analysis of routinely collected NSW Ambulance clinical and dispatch data. This study of 42,000 incidents over one calendar year generated specific questions and hypotheses to be tested in subsequent research. A key outcome was the creation of a ‘Falls in the Elderly’ clinical protocol, to assist paramedics determine whether a patient requires transport for further medical assessment following a fall.

A prospective epidemiological study was then undertaken. A network of 380 paramedics representing 40 metropolitan and regional stations was established and tasked with collecting additional on-scene data for older patients who had sustained

a fall. Over 12 months during 2011-2012, the paramedics recruited 1,780 patients to the study. Data were combined with routine NSW Ambulance data to form a comprehensive resource providing a detailed picture of operational and clinical prehospital service provision to older fallers.

The study’s findings have informed in-service training and been presented at national and international conferences. This initiative also served educational and promotional functions within the organisation, increasing awareness of the important contributions paramedics make when caring for these patients.

The interrogation of hospital and mortality data linked to NSW Ambulance records is being undertaken to understand the impact of paramedic care on meaningful health outcomes, particularly for older patients who were not transported to an emergency department (ED) following their fall. In addition, qualitative methodology is employed in a study investigating how paramedics make decisions regarding transportation for this patient group.

A randomised clinical trial that commenced in April 2011 will complete the current program. It investigates the effectiveness of a paramedic-initiated, community referral intervention for older patients in NSW who call for an ambulance following a fall but are not transported to an ED.

As older patients who fall are likely to fall again, the risk of recurrence for those who do not attend an ED may not otherwise be assessed. The aim is to provide paramedics with an evidence-based support mechanism to ensure that patients receive targeted therapy to prevent future falls, even when transport to hospital is not indicated.

In summary, the falls-related research program at NSW Ambulance has informed models of service delivery and contributed to the development of prehospital clinical protocols to optimise health outcomes for older fallers both in NSW and in ambulance services more widely.

Research authors: P Simpson, S Muecke, R Carney, Ambulance Service of NSW

Measuring the impact of paramedic care using data linkage

Informing pre-hospital care for older people who have fallen

“ The aim is to provide paramedics with an evidence-based support mechanism to ensure that patients receive targeted therapy to prevent future falls, even when transport to hospital is not indicated.”

9 FOCUS ON RESEARCH

Key Clinical Trials

The research of pre-hospital care has failed to keep pace with the research of other medical disciplines. Consequently, many practical procedures and interventions used to care for and stabilise out-of-hospital emergencies lack a scientific evidence base.

Ambulance Services in Australia are well placed to conduct clinical trials aimed at determining the efficacy of pre-hospital interventions. Factors such as single state services allowing homogenous protocols and large population bases, highly trained paramedics, ethical provisions for emergency research and electronic data collection all facilitate the implementation and cost effectiveness of trials.

Ambulance Victoria (AV) has demonstrated a track record in implementing and managing key clinical trials, which have significant implications for patient care. AV is currently involved in a number of key clinical trials aimed at improving outcomes for cardiac patients. These include:

Avoid

Air Verses Oxygen In myocarDial infarction study (AVOID Study) is a prospective, multi-centre, randomized, controlled trial conducted by Ambulance Victoria and participating metropolitan Melbourne hospitals with primary percutaneous coronary intervention capabilities.

The purpose of the study is to determine whether withholding routine supplemental oxygen therapy in patients with acute ST-elevation myocardial infarction but without hypoxia prior to reperfusion decreases myocardial infarct size. AVOID will enrol 490 patients, over 17 years of age with confirmed acute ST-elevation myocardial infarction of less than 12 hours duration.

Rinse

The Rapid Infusion of Cold Normal Saline (RINSE) study is a randomised controlled trial, funded by National health & Medical Research Council (NH&MRC). It aims to determine whether paramedic initiated cooling during CPR (using a rapid intravenous infusion of ice-cold

normal saline) improves patient survival outcomes compared with usual practice (i.e. no pre-hospital cooling) in patients who are being resuscitated from out-of-hospital cardiac arrest.

The RINSE trial is being undertaken by the ambulance services of Victoria, Western Australia and South Australia.

The study will recruit 2,512 patients in total. The study follows “Intention-to-treat” methodology and consists of two prospective, randomized, controlled trials running concurrently, one in patients with VF/ pulseless-VT arrest, and one in patients with non-VF/ pulseless VT arrest.

The primary outcome measure in both trials is survival at hospital discharge. Secondary outcome measures are the rate of return of spontaneous circulation, survival to hospital admission, temperatures at hospital admission and the functional outcomes at 12 months.

Cheer

Refractory out-of-hospital cardiac arrest treated with mechanical CPR, Hypothermia, ECMO and Early Reperfusion (CHEER) is a feasibility study being undertaken in Melbourne.

The study involves recruiting 24 patients who have failed standard resuscitation after VF/VT out of hospital cardiac arrest of greater than 30 minutes duration. When standard resuscitation has proved futile, the patient is transported to The Alfred with the mechanical chest compression device, cooled to 33°C, placed on ECMO, and then transported to the interventional cardiac catheter laboratory where the coronary arteries can be re-opened. The patient then receives therapeutic hypothermia for 24 hours. Subsequent management follows the standard treatment guidelines of The Alfred Intensive Care Unit.

Author: Karen Smith, Ambulance Victoria

Key clinical trials

“ Ambulance Services in Australia are well placed to conduct clinical trials aimed at determining the efficacy of pre-hospital interventions.”

WINTER 2013 10

Surveillance through a registry, where consecutive patients are enrolled to create complete patient populations, is a powerful tool for describing healthcare, including the complications and benefits of different therapies.

A registry can drive a quality agenda and fosters a performance culture. Ambulance services are ideally placed to capture epidemiological data on key patient groups who may not present to other health care agencies.

Ambulance Victoria (AV) has established (or contributes to) important patient registries through key partnerships. The registries include data on patient populations who would not be captured otherwise (e.g. cardiac arrest and trauma patients who die at the scene and non-transported overdose patients). This has been facilitated by the implementation of the Victorian Ambulance Clinical Information System (VACIS), an in-field electronic patient care record and linked clinical database. Three key registries are described below:

• AV maintains the Victorian Ambulance Cardiac Arrest Registry, which captures data on all patients in cardiac arrest attended by ambulances in the state. Data dates back to 1999 and the registry includes more than 63,000 patient episodes.

AV operational and clinical data is supplemented with hospital outcome data. The registry has also commenced a quality of life follow-up for adult survivors at 12-months post arrest. In addition to supporting a large research program, including outcome data for clinical trials, the registry is used to monitor the quality of clinical care and provide data for patient outcome key performance indicators.

• The Turning Point (TP) Drug and Alcohol Ambulance Registry captures all ambulance attendances to drug and alcohol patients, initially in Melbourne and now across the state. Surveillance has resulted in identification of aetiological trends and development of specific Clinical Practice Guidelines for drug overdoses.

In July 2012, data extended to include mental heath patients with a focus on suicidal ideation and suicide attempts. Work is underway to include other states.

• AV electronically links pre-hospital data with the Victorian State Trauma Registry (VSTR) on a quarterly basis. The VSTR is a population-based registry run by Monash University, which aims to capture pre-hospital, hospital and long-term outcome data for all major trauma patients in the state.

The linked data is used by AV to examine adherence to the pre-hospital Trauma Triage Guidelines and to monitor the pre-hospital quality of care and outcome of major trauma patients.

Author: Karen Smith, Ambulance Victoria

Importance of pre-hospital registries

“ A registry can drive a quality agenda and fosters a performance culture.”

The 2013 Boston Marathon became a leading international news story for all the wrong reasons.

Three people died and more than 280 sustained injuries when a series of bomb blasts rocked the city, leaving runners and spectators reeling and a city in shock.

Deputy Superintendent of Boston EMS Michael Bosse was on duty that day.

He was to describe it as “Boston’s worst day, and our best day.”

Coinciding with the six-month anniversary of the Boston bombings, Deputy Superintendent of Boston EMS Michael Bosse will deliver a keynote address at this year’s CAA annual Conference in Canberra.

His experience helping to manage the aftermath of the deadly attack will provide an invaluable insight for delegates and reinforce the critical role paramedics play in emergency management.

A report in PaxCenturion, the news magazine for the Boston Police Patrolman’s association, said the Boston EMS performance was unparalleled in the history of disaster response.

“According to EMS Chief of Department James Hooley, over ninety victims were triaged within moments, and categorized by severity. The most seriously hurt were transported to receiving hospitals within fifteen minutes of the blasts. By the time 30 minutes had elapsed, ALL of the injured from the blast zones were assigned hospitals, and were en-route to definitive care – a miraculous feat.”

The Newsmagazine for the Boston Police Patrolmen’s Association

ACT Minister for Police and Emergency Services Simon Corbell will open the Conference in Australia’s capital, which this year marks the 10th anniversary of the firestorm which swept through Canberra’s suburbs killing four people and destroying 500 homes and the Mount Stromlo Observatory.

The two-day program will feature an impressive array of speakers including:

• The Secretary of the Department of Health and Ageing, Jane Halton, PSM, will deliver a keynote address on the future directions for Australia’s health system. Ms Halton is responsible for all aspects of the operation of the department Medicare, the Pharmaceutical Benefits Scheme, Aged and Community Care, Mental Health, Public Health, hospital financing and private health insurance.

• Associate Vice-Chancellor (Melbourne) of the Australian Catholic University Dr John Ballard will base his keynote address on his extensive experience working in the health and aged care sectors. Dr Ballard, who was Chief Executive Officer of Mercy Health for 11 years, has also worked in policy roles within the Department of Prime Minister and Cabinet based in Canberra.

• Peter Bradley, CEO St John New Zealand, will explore new ways of working. Mr Bradley began his career as an Ambulance Officer in New Zealand and more recently was the Chief Executive Officer for the London Ambulance Service. He received a CBE for his services to the Ambulance Service in England.

• Professor Russell Gruen, Director, National Trauma Research Institute, Melbourne, will present a compelling paper on Tranexamic Acid at the roadside -new frontiers for time-critical treatments. Dr Gruen studied at the University of Melbourne and Boston’s Harvard University. The focus of his most recent research has been clinical quality improvement, optimising systems of surgical and trauma care,

and improving the use of evidence in clinical and health policy decision-making.

• Grant Tidswell, Deputy Secretary, Customer Service Delivery, Australian Department of Human Services, will discuss leading organisational change. In his role Mr Tidswell is responsible for the effective operation of more than 500 branch outlets, 25 calls centres and all processing teams across Australia for his agency, which incorporates Centrelink, the Child Support Agency, CRS Australia and Medicare Australia.

• Etienne Scheepers, Executive Director Workforce Innovation and reform, Health Workforce Australia (HWA) will lead a presentation outlining the progress of the Extended Care Paramedics HWA funded projects across 5 diverse regions of Australia. Mr Scheepers has previously practised law in South Africa and worked in health in New Zealand and South Australia.

• The Medical Director, Hennepin Emergency Medical Services, Minneapolis, USA, Brian D Mahoney will discuss the benefits of combining research, mechanical CPR and training in cardiac arrest management. Dr. Mahoney graduated from the University of Vermont, completing his residency training in emergency medicine at Hennepin County Medical Center in Minneapolis.

Concurrent sessions will focus on New & Emerging Models; Education & Research; and Leadership & Change Management.

The awards dinner promises to be a memorable event for its celebration of outstanding achievements and the unique setting of the Australian War Memorial’s ANZAC Hall.

Richard Fidler will lend his considerable expertise as an ABC presenter, among many other attributes, to his role as MC for the Conference and the awards dinner.

Join us in Canberra, connect with colleagues from across the country and take the opportunity to enjoy Canberra as it celebrates its centenary.

11 FOCUS ON RESEARCH

CAA Conference – October 16 and 17 Exploring the Frontiers – Paramedicine of Tomorrow

WINTER 2013 12

CAA Conference – October 16 and 17 Exploring the Frontiers – Paramedicine of Tomorrow

Join us in CanberraConference program and registration available at www.caa.net.au

The

Council

of Ambulance Authorities

CAA