Protocoladherence by Ambulancenurses
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1) The study observed 196 ambulance dispatches in the Netherlands to determine the extent to which ambulance nurses adhered to national ambulance protocols. 2) Deviations from protocols were found in 47% of dispatches, with no protocol being followed in 20% of cases and mistakes in physical examinations occurring in 20% of cases. 3) Protocol adherence did not significantly correlate with years of service, years since specialized training, or type of specialized training and was not related to the time of day.
Protocoladherence by Ambulancenurses
- 1. Protocol adherence amongst ambulance nurses in the Netherlands An on-scene observational study W. Breeman 1,2,4 , I.B. Schipper 3 , A.M. van Straalen 4 , A.J.J. Voorham 4,5 , E.M.M. van Lieshout 2 1 Ambulance Services Rotterdam Area, Barendrecht, The Netherlands 2 Dept. of Surgery-Traumatology, Erasmus MC, University Medical Center Rotterdam, The Netherlands 3 Dept. of Traumatology, LUMC, Leiden University, Leiden, The Netherlands 4 M-ANP program, University of Applied Sciences Rotterdam, Rotterdam, The Netherlands 5 Dept of Primary Care, University of Applied Sciences Rotterdam, Rotterdam, The Netherlands
- 2. Introduction
- 3. Dutch Ambulance System Dutch ambulance teams ambulance driver, EMT Registered Nurse with ER (CEN), ICU (CCRN) or Nurse Anesthetist (CRNA) certification and prehospital paramedic training (NREMT) Working independently, medical procedures legislated by the medical manager National ambulance standards are obligatory
- 4. National Ambulance Standards (LPA 7) Nationwide ambulance standards Must be followed, unless properly motivated Pocket format, showing easy to read flow charts Developed by the National Ambulance authority 130 protocols, divided in 20 groups Revised on a regular base
- 5. Aim of the study To determine to what extent ambulance nurses adhere to the national LPA 7 protocols
- 6. Methods
- 7. Methods (1) Power calculation: N=200 dispatches Study period: 1 December 2007 to 19 March 2008 Researcher on scene: - to observe ambulance nurses - to score protocol adherence
- 8. Methods (2) Data analyses (SPSS): - Deviation rates (Chi 2 analysis) - Logistic regression model Relate deviations to: - Type of specialized training - Years of service - Years since initial NREMT exam
- 9. Selection criteria Inclusion criteria: Ambulance dispatch with A1 urgency Researcher can safely reach the accident scene < 15 min Exclusion criteria: Researcher did not reach scene <10 min Researcher has to provide medical assistance
- 10. Classification of mistakes No protocol followed Wrong order Mistake in physical examination Incorrectly performed medical procedure Mistake in medication: - Not administered - Wrong medication - Wrong dosage Missed diagnosis (ED verification)
- 11. Classification of adherence groups 1: Protocol followed as intended 2: Protocol deviation: acknowledged and motivated 3: Protocol deviation: acknowledged but not motivated 4: Protocol deviation: not acknowledged
- 12. Results
- 13. Trial flow chart 237 dispatches 41 excluded: - N=27: researcher reached scene first - N= 9: terminated due to traffic situation - N= 3: ethical consideration - N= 2: securing own safety 196 dispatches evaluated
- 14. Deviations found in 47 percent of cases
- 15. Deviations found in 47 percent of cases 53%: Protocol followed as intended 10%: Protocol deviation: acknowledged and motivated 8%: Protocol deviation: acknowledged but not motivated 29%: Protocol deviation: not acknowledged
- 16. No protocol is followed in 20% of cases
- 17. Wrong order of performance in 18% of cases
- 18. Mistake in physical examination in 20% of cases
- 19. Incorrect medical procedure in 8% of cases
- 20. Mistake in medication in 21% of cases
- 21. Missed diagnosis in 7% of cases
- 22. Protocol adherence is not related to time of day
- 23. Logistic regression analysis Relative risk 95% CI P Number of service years <5 years Reference group 0.83 5-10 years 1.04 0.21-5.24 0.97 >10 years 1.33 0.37-4.85 0.67 Years since specialized training RN (basic training) Reference group 0.69 <5 years 1.17 0.17-8.19 0.88 5-10 years 1.58 0.33-7.45 0.58 >10 years 1.91 0.60-6.09 0.28 Basic training - RN Unknown Reference group 0.89 IC/CCU 0.90 0.21-2.31 0.85 CEN 0.30 0.24-4.43 0.62 Nurse Anesthetist 0.09 0.27-4.43 0.65
- 24. Conclusions
- 25. Conclusions Protocol adherence in the Dutch ambulance system is similar to that of other countries; remains far from optimal Deviations were found in up to 45% of dispatches Most deviations occurred during physical examination, sequence of the protocollary assessment and treatment, and medication errors No significant association between protocol deviation and employment duration or type of education could be shown Protocol adherence was not associated with time of the day
- 26. Questions ?
- 27. Protocols have the tendency not only to minimize failures, but in the process also to eliminate genius. W. van Hoorn, European Association of Nuclear Medicine Conference, Sept 1999
Editor's Notes
- #2: Welcome! Thank you for coming to this presentation. My name is Wim Breeman and I am working as a NP and Flight Nurse in Rotterdam, the Netherlands. The Netherlands are situated in Europe, we have about 16.5 million citizens and are one of the most densely populated countries in Europe. A country full with people who many assume to live between tulips and drive an ambulance with wooden shoes. I want to present you the results from my research project
- #3: My work as an NP / Flight Nurse on the trauma helicopter in the Rotterdam Area inspired me to choose this subject for my master thesis. To understand that, I want to introduce the Dutch ambulance system to you
- #4: The Netherlands has a high standard of health care, and every Dutch citizen has the obligation to be insured for health care. Low-income citizens and unemployed people are provided with health care by the National Health Trust. Part of the health care system is that everybody who needs medical attention for minor complaints visits their GP. The GP is, therefore, the gateway to clinical health care provided by hospitals. In case of a life threatening medical emergency, the patient can call 1-1-2, the European emergency number. All over The Netherlands, 195 ambulance stations operate a total of 650 ambulances. A major difference between a Dutch ambulance crew and those in other countries is the strict separation in the scope of duties. Every ambulance includes a crew of two. One is the nurse, skilled and trained in medical issues, procedures and performances. The other crewmember is the driver, trained in vehicle operations under all circumstances. The driver also assists the nurse but does not interfere with any medical actions. As mentioned, the main medical care provider on an ambulance is a Registered Nurse. In addition to being a registered nurse, providers must obtain further certifications in intensive care, coronary care and/or anesthesia nursing before applying to be an ambulance nurse. Besides on-the-job training, this one-year educational program is offered by the National Ambulance Education Foundation, the single national licensing body.
- #5: This level of training and education allows ambulance nurses to work on a rather independent and self-supporting basis. If an ambulance crew encounters a situation that aren't within their protocols, procedures or standing orders, providers can contact the medical manager of the ambulance service. All procedures are brought together in the National EMS protocols. These protocols are revised or adjusted every five years. Within these protocols, ambulance nurses are allowed to administer 31 different types of medication. They are also allowed to carry out many medical procedures like ET intubation, thoracosynthesis and coniotomy, IV etc.
- #6: The purpose of this quantitative observational study was to investigate the degree of protocol adherence among ambulance nurses and to examine the main deviation points. Other investigator studied protocol adherence, but the value of their results was limited but the fact they were retrospective reviews of written documentation. This study addresses protocol adherence on-scene and is as far as known, unique in this design.
- #7: The investigator observed 237 ambulance dispatches with an A1 Emergency Code. Included for analysis were 197 dispatches.
- #8: Based on literature studies, we expected a 40% deviation, used a fictive 10% improvement. Using two sided testing and an alpha of 5% we needed 200 dispatches to detect a 10% difference with 80% power. The study period was from 1st December 2008 to the 20th of March 2008. The researcher drove to the scene and observed ambulance nurses to score protocol adherence
- #9: We calculated the deviation rates using a Chi2 analysis We used a univariate analysis and a Logistic regression model and we relate deviations to Type of specialized training, Years of service and Years passed since their initial NREMT exam.
- #10: Inclusion criteria were: - Ambulance dispatch with A1 urgency (potential life-threatening emergency) - Researcher can safely reach the accident scene < 15 min Exclusion criteria were: - The researcher did not reach scene <10 min after the ambulance crew was on scene - The researcher has to provide medical assistance
- #11: We used the classification: No protocol followed at all Wrong order or sequence as mentioned in the protocol flowchart (for example no ABC, but CBA or give medication before performing an thorough examination Mistake in physical examination Incorrectly performed medical procedure Mistake in medication: - Not administered - Wrong medication - Wrong dosage Missed diagnosis: this must be verified by an Emergency Physician in the hospital.
- #12: To define adherence and deviation, we divided the following groups: - Protocol followed as intended - Protocol deviation: there was a deviation, but the deviation was acknowledged and properly motivated (for example: no IV started in a case there was a child involved which was extremely anxious). That’s how we like to see people work! - Protocol deviation: acknowledged but not motivated. The nurse did know he wasn’t follwing the protocol, but could not motivate why! - There was a protocol deviation but the nurse didn’t know he wasn’t following the protocol at all.
- #14: There were 237 dispatches. We had to exclude 41 cases. 27 cases due to the fact that the researcher was the first responder on the scene and had to start treatment. Nine cases were terminated because of extreme traffic jam’s and continuing the trip should have caused unsafe or unacceptable effects for the public. 3 were excluded due to ethical considerations (too many people on the scene) and 2 cases were too dangerous to observe (not confirmed safe crime sites)
- #15: We found deviations of at least 1 item in 47% of the cases. EXPLAIN bars! I want to point out this typical U shape for you. Please remember this, I will get back to this in the end of my presentation.
- #16: When we translate this 47 % in deviation groups as mentioned before we see that: 53%: Protocol followed as intended 10%: Protocol deviation: acknowledged and motivated 8%: Protocol deviation: acknowledged but not motivated 29%: Protocol deviation: not acknowledged
- #17: Explain graph
- #18: Explain graph
- #19: Explain graph And here you notice again the typical U shape, we saw before.
- #20: Explain graph
- #21: Explain graph
- #22: Explain graph
- #23: Explain graph We expected to see less adherence during night shifts, but after analysis there was no evidence for this expectation.
- #24: As mentioned the results showed some significance in the “wrong order of performance”, “Physical Examination” and “Medication mistakes”. To analyze if there is any connection between 1 dependent variable and a set of independent variables, we used a logistic regression model. The dependent variable is. In this model the “real” deviation: “not acknowledged” and “acknowledged but not motivated”. As we examine the Confidence Interval, you can see that the Relative Risk of 1, is in all cases within the values. That means that we can not prove any statistically significant difference
- #26: - In spite of the fact that protocol adherence in the Dutch ambulance system is similar to that of other countries, we find that it remains far from optimal - Deviations were found in up to 45% of dispatches - Most deviations occurred during physical examination, sequence of the protocollary assessment and treatment, and medication errors - No significant association between protocol deviation and employment duration or type of education could be shown. However: There was a trend visible: we found a typical U shape I mentioned to you several times before. We presume that this trend shows us that ambulance nurses, who are just starting their job, make relatively many mistakes. My interpretation is that in that period, protocol knowledge is still not optimal. Then there is a period, protocol knowledge is optimal, and there is al lot of working experience. After 10 years we think there are too little incentives for the “established” ambulance nurse. That is something we have to jump in and develop special training programs for these groups to educate, but more important, stimulate them. As a last point we found that protocol adherence was not associated with the time of the day.