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Pre-hospital emergency care - where now? Prof. Gerard Bury Department of General Practice Vice-Chairman

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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

pre hospital emergency care
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

pre hospital emergency care3
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
pre hospital emergency care4
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

pre hospital emergency care5
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

pre hospital emergency care6
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

pre hospital emergency care7
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

pre hospital emergency care8
Pre-hospital emergency care

Spatial analysis 2

pre hospital emergency care9
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
pre hospital emergency care10
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…
pre hospital emergency care11
Pre-hospital emergency care

EMT training

  • PHECC registration: new entrant & conversion training
  • Diploma in EMT (UCD)
  • Standard Operational Procedures
  • EMT-A training – 2003
pre hospital emergency care12
Pre-hospital emergency care

EMT training development

  • Audit/QA/QI
  • CME
  • Competence Assurance
  • Primary degree training
pre hospital emergency care13
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
pre hospital emergency care14
Pre-hospital emergency care

EMT-A development

  • Dispatch/triage
  • Operational deployment
  • Further development
pre hospital emergency care15
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
pre hospital emergency care16
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
pre hospital emergency care17
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!
pre hospital emergency care18
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

pre hospital emergency care19
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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