Pre-hospital emergency care

1

• Pre-hospital emergency care
• - where now?
• Prof. Gerard Bury
• Department of General Practice Vice-Chairman
• University College Dublin Pre-Hospital Emergency
  Care Council

2
Pre-hospital emergency care

• Drivers for change
• Comhairle - Report of the Committee on AE
  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 AE Departments

3
Pre-hospital emergency care

• Where now?
• Ambulance service integration into the health
  system
• Regionalisation of AE 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

4
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

5
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

6
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 200017392

7
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

8
Pre-hospital emergency care

• Spatial analysis 2

Deaths/100,000
WHB 13
NWHB 17
Ireland 12
UK 6
EU 12
9
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 cant 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 cant reach hospital within an
  hour

10
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

11
Pre-hospital emergency care

• EMT training
• PHECC registration new entrant conversion
  training
• Diploma in EMT (UCD)
• Standard Operational Procedures
• EMT-A training 2003

12
Pre-hospital emergency care

• EMT training development
• Audit/QA/QI
• CME
• Competence Assurance
• Primary degree training

13
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

14
Pre-hospital emergency care

• EMT-A development
• Dispatch/triage
• Operational deployment
• Further development

15
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

16
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

17
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!

18
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

19
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