Emergency Health Services Nova Scotia, Canada.
Prehosp Emerg Care. 2013 Oct-Dec;17(4):429-34. doi: 10.3109/10903127.2013.804136. Epub 2013 Jun 27.
Despite the supporting published evidence for prehospital fibrinolysis (PHF) for ST-elevation myocardial infarction (STEMI) patients by paramedics, the complexity of the process has not been rigorously explored in a stepwise approach. The objectives of this study were to (1) map the process of care that occurs during EMS management of STEMI with administration of PHF from 911 call to transfer of care to the emergency department and (2) to identify steps that could adversely affect patient safety or clinical outcome.
A Health Care Failure Mode and Effect Analysis was conducted. Steps were identified and organized into major call phases. Each step was categorized as a decision, technical skill, or task. The role required to perform each was identified: emergency medical dispatcher (EMD) or primary (PCP) or advanced care paramedic (ACP). The map was validated against a video-taped STEMI scenario. Once finalized, the steps with potential for risk to safety or outcome (hazard modes (HMs)) were identified. HMs were scored by study team consensus for probability to occur and likely severity of impact to the patient (minimum = 2, maximum = 16, ≥8 considered high risk).
The map consisted of 18 phases and 167 steps, of which 37 (22.2%) were decisions, 67 (40.1%) were technical skills, and 63 (37.7%) were tasks. Ten steps could be completed by an EMD (6.0%), 76 (45.5%) by a PCP, and 81 (48.5%) by an ACP. The phases with the most steps were initial treatment, n = 31 steps (18.0%), and reperfusion therapy, n = 30 steps (18.0%). Sixty-eight HMs were identified, mean score 4.54 (SD 2.32), five of which scored eight or above (7.3%). The highest scoring HMs were history-taking, obtaining 12-lead, and transmitting 12-lead (all scores = 12). The phases with the most HMs were initial treatment (n = 12 HMs) and reperfusion therapy (n = 12 HMs).
In this mapping study of STEMI calls in which paramedics administer fibrinolytics, the process was found to be complex, containing many steps, but relatively few individual steps were highly hazardous to patient care or safety. This study has enabled specific actions to target the highest scoring hazard modes, in an effort to improve paramedic practice and patient safety for EMS STEMI patients. Key words: emergency medical services; myocardial infarction; fibrinolytic agents; ambulances; process map.
尽管有大量已发表的证据支持急救医疗服务人员对 ST 段抬高型心肌梗死（STEMI）患者进行院前溶栓治疗，但对于这一过程，我们尚未采用逐步分析的方法对其复杂性进行严格的探索。本研究的目的是：（1）描绘 911 急救电话至急救部门接收治疗的整个过程中，急救医疗服务管理 STEMI 患者并给予溶栓治疗的护理流程；（2）确定可能对患者安全或临床结局产生不利影响的步骤。
我们开展了一项医疗保健失效模式与效应分析。确定步骤并将其组织为主要呼叫阶段。将每个步骤归类为决策、技术技能或任务。确定执行每个步骤所需的角色：紧急医疗调度员（EMD）或初级保健医生（PCP）或高级护理人员（ACP）。该图根据一段 STEMI 视频进行了验证。一旦定稿，就会确定存在安全或结果风险的步骤（危害模式（HM））。由研究团队根据发生的概率和对患者的可能严重影响对 HM 进行共识评分（最小值= 2，最大值= 16，≥8 为高风险）。
该图由 18 个阶段和 167 个步骤组成，其中 37 个（22.2%）为决策，67 个（40.1%）为技术技能，63 个（37.7%）为任务。10 个步骤可以由 EMD 完成（6.0%），76 个（45.5%）由 PCP 完成，81 个（48.5%）由 ACP 完成。步骤最多的阶段是初始治疗，有 31 个步骤（18.0%），其次是再灌注治疗，有 30 个步骤（18.0%）。确定了 68 个 HM，平均得分为 4.54（SD 2.32），其中 5 个得分为 8 或更高（7.3%）。得分最高的 HM 是病史采集、获取 12 导联心电图和传输 12 导联心电图（得分均为 12）。HM 最多的阶段是初始治疗（n = 12 个 HM）和再灌注治疗（n = 12 个 HM）。
在这项针对接受纤溶治疗的急救医疗服务人员管理 STEMI 电话的映射研究中，我们发现该过程非常复杂，包含许多步骤，但相对较少的单个步骤对患者护理或安全存在高度危害。本研究明确了特定的行动措施，以针对得分最高的危害模式，努力改善急救医疗服务人员对 STEMI 患者的护理和安全性。关键词：急救医疗服务；心肌梗死；纤维蛋白溶解剂；救护车；流程图。
