Jones T, Woollard M
Welsh Ambulance Services NHS Trust, Pontypool, UK.
Emerg Med J. 2003 Sep;20(5):473-5. doi: 10.1136/emj.20.5.473.
Prolonged advanced life support for cardiac arrest victims who present with non-shockable arrhythmias in an out of hospital setting is associated with extremely poor survival rates. This and the risks associated with rapid ambulance transport to hospital have resulted in the development of decision support algorithms, enabling paramedics to recognise when adult death has occurred. The aim of the study was to assess the accuracy with which paramedics used such an algorithm.
This prospective 16 month cohort study evaluated 188 events of recognition of adult death (ROAD) by paramedics in the period from November 1999 to February 2001.
Of 188 ROAD applications, errors were made in 13 cases (6.9%, 95% CI 3.7 to 11.5. Additionally, there was one adverse clinical incident associated with a case in which ROAD was applied (0.5%, 95% CI 0.01 to 2.9%). ECG strips were unavailable for eight cases, although ambulance records indicated a rhythm of asystole for each of these. Assuming this diagnosis was correct, ROAD was used 174 times without errors (93%, 95% CI 88 to 96%). Assuming that it was not, the ROAD protocol was applied without errors in 166 cases (88.3%, 95% CI 82.8 to 92.5%). None of the errors made appeared to be attributable to poor clinical decision making, compromised treatment, or changed patient outcome. The mean on-scene time for ambulance crews using the ROAD policy was 60 minutes.
Paramedics can accurately apply a decision support algorithm when recognising adult death. It could be argued that the attendance of a medical practitioner to confirm death is therefore an inappropriate use of such personnel and may result in unnecessarily protracted on-scene times for ambulance crews. Further research is required to confirm this, and to determine the proportion of patients suitable for recognition of adult death who are actually identified as such by paramedics.
对于在院外出现不可电击心律的心脏骤停患者进行长时间的高级生命支持，其生存率极低。鉴于此以及快速转运至医院相关的风险，促使了决策支持算法的开发，使护理人员能够识别成人死亡的发生。本研究的目的是评估护理人员使用此类算法的准确性。
这项前瞻性的为期16个月的队列研究评估了1999年11月至2001年2月期间护理人员对188例成人死亡识别（ROAD）事件。
在188次ROAD应用中，有13例出现错误（6.9%，95%置信区间3.7至11.5）。此外，有1例应用ROAD的病例出现了不良临床事件（0.5%，95%置信区间0.01至2.9%）。有8例无法获取心电图记录，尽管救护车记录显示这些病例均为心脏停搏心律。假设该诊断正确，ROAD被正确使用了174次（93%，95%置信区间88至96%）。假设诊断不正确，ROAD方案在166例中被正确应用（88.3%，95%置信区间82.8至92.5%）。所出现的错误似乎均非归因于临床决策不佳、治疗不当或患者预后改变。使用ROAD策略的救护人员平均现场停留时间为60分钟。
护理人员在识别成人死亡时能够准确应用决策支持算法。因此可以认为，让医生到场确认死亡是对这类人员的不当使用，可能会导致救护人员在现场停留时间不必要地延长。需要进一步研究来证实这一点，并确定护理人员实际识别出的适合成人死亡识别的患者比例。
