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Pre-hospital emergency care - where now? Prof. Gerard Bury Department of General Practice Vice-Chairman University College Dublin Pre-Hospital Emergency Care Council. Pre-hospital emergency care. Drivers for change Comhairle - Report of the Committee on A&E Services

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Pre-hospital emergency care

- where now?

Prof. Gerard Bury

Department of General Practice Vice-Chairman

University College Dublin Pre-Hospital Emergency CareCouncil


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Pre-hospital emergency care

Drivers for change

  • Comhairle - Report of the Committee on A&E Services

    Close pre-hospital and hospital links

  • Improved postgraduate training for doctors and nurses

    Structured, multidisciplinary training

  • National Health Strategy

    Consultant delivered services

  • Medical Council

    Interim Criteria for A&E Departments


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Pre-hospital emergency care

Where now?

  • Ambulance service integration into the health system

  • Regionalisation of A&E services

  • Third level training of EMTs

  • Advanced care provision by EMTs

  • GP co-ops

  • ICT – new medical technology

  • Professionalisation, competence assurance and evidence based practice for pre-hospital care


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Pre-hospital emergency care

Scenario 1

  • 49 year old woman collapses in city centre flat, Dublin 8

  • Initial chest pain, then LOC

  • Niece phones 999

  • Two major hospitals within three miles

  • Issues

    Dispatch Traffic

    Triage First responders

    Pre-arrival instructions


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Pre-hospital emergency care

Scenario 2

  • Two car RTA between Clifden and Leenane, Co. Galway

  • Three people are injured

  • Clifden and Castlebar WHB ambulances respond

  • Issues

    Response times 15mins/30 mins

    Retrieval time 1 hour+

    Local District Hospital

    GP response


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Pre-hospital emergency care

Ambulance Services response times

  • 1 week national census of 999 calls: 3436 calls

  • 73% emergency, 24% rural

  • At best, 47% of emergencies had a response in 8 minutes

  • At worst, 10% of emergencies had a response in 8 minutes

    Breen N, Woods J, Bury G, Murphy A, Brazier H. A national census of ambulance response times to emergency calls in Ireland. JAEM 2000;17:392


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Pre-hospital emergency care

Spatial analysis of RTAs &

ambulance service responses 1

  • NWHB, WHB study by NUIG and consultants: 1996-2000

  • 5550 accidents

  • 420 deaths

  • 1926 serious injuries

  • 7351 minor injuries

    Moore D, Murphy A. Spatial analysis of road traaffic accidents in the Western and North Western

    Health Boards. NUIG, 2002


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Pre-hospital emergency care

Spatial analysis 2


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Pre-hospital emergency care

Spatial analysis 3

WHB

  • 17% of fatalities (26% at night) , 17% of serious injuries (25% at night) not reached within 25 minutes

  • 27% of fatalities can’t reach hospital within an hour

    NWHB

  • 5% of fatalities (9% at night), 5% of serious injuries (8% at night) not reached within 25 minutes

  • 31% of fatalities can’t reach hospital within an hour


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Pre-hospital emergency care

Spatial analysis 4: conclusions

  • ‘Golden hour’ care – not by hospitals

  • First responders role – during ambulance response

  • Long retrieval times – extended care skills

  • Use Regional EDs – additional retrieval time

  • Integrated care: AS, EDs, GPs, PHNs, 1st Responders…


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Pre-hospital emergency care

EMT training

  • PHECC registration: new entrant & conversion training

  • Diploma in EMT (UCD)

  • Standard Operational Procedures

  • EMT-A training – 2003


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Pre-hospital emergency care

EMT training development

  • Audit/QA/QI

  • CME

  • Competence Assurance

  • Primary degree training


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Pre-hospital emergency care

EMT-Advanced training

  • Protocol driven carers – AOPs

  • ACLS provision, fluid replacement, MIMMS trained

  • Some advanced paeds, obs care

  • Extended care skills


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Pre-hospital emergency care

EMT-A development

  • Dispatch/triage

  • Operational deployment

  • Further development


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Pre-hospital emergency care

Service developments

  • Regionalisation of ED services: welcome but implications+

  • Appropriate selection of cases NB

  • Retrieval and extended care NB

  • Bypass of some centres (for some problems?)

  • Integrated responses with GPs, PHNs, Fire & Police…

  • Audit


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Pre-hospital emergency care

Scenario 1

  • Prioritised dispatch, PAI, community defib scheme, 12 lead telemetry, direct access to CPAU

    Scenario 2

  • GP response, prioritised EMT-A response, trauma team en route, bypass DGH, team care at UCHG


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Pre-hospital emergency care

Conclusions

  • Multi-sectoral developments in pre-hospital care

  • EMT/Ambulance Services developments in training, deployment and services

  • Dispatch

  • Teamwork

  • Audit and evidence!


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Pre-hospital emergency care

Effectiveness of pre-hospital trauma care

Cochrane Injuries Group/WHO – Jan 01

  • Reviews of:

    Early fluid administration

    Hypertonic versus isotonic resuscitation

    Spinal immobilisation

    Advanced versus basic life support

  • No clear evidence of benefit

    Bunn F, Kwan I, Roberts I, Wentz R. Effectiveness of pre-hospital trauma care.

    Cochrane Injuries Group, 2001


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Pre-hospital emergency care

Cochrane Review conclusions

  • These results highlight the neglect of injury as a global health issue

  • Injury research is unfunded and has little good quality research even in widely practised areas

  • There are widespread social, health and economic consequences


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