Low molecular mass proteins as markers for renal function and dialysis efficiency

Kidney disease is a growing problem in the whole world. It is important to find these patients in an early state of the disease because then they can be treated and dialysis treatment can be avoided. To measure the glomerular filtration rate (GFR) an invasive technigue is used. In this thesis an equation to estimate GFR (eGFR) by drawing a blood sample and measure the concentration of cystatin C is presented. This equation is the first one working both for adults and children. To establish an equation working at all laboratories, primary and secondary reference preparations for cystatin C were developed. The secondary reference preparation will be used to establish an international calibrator, which can be used by the diagnostic companies to establish an uniform value of cystatin C. Cystatin C has been proposed to be a marker of inflammation. In our study of patients, without any prior inflammation, who undergo elective surgery, the concentration of cystatin C was unaltered while an increase in the concentration of CRP was seen. This result shows that cystatin C is not a marker of inflammation. Three different types of dialysis treatments (haemodialysis, haemofiltration, haemodiafiltration) were tested for their capacity to remove low molecular mass proteins (LMMP) and thus their potential for treatment of patients with kidney failure. The LMMP have been proposed to be uraemic toxins and must therefore be removed from the circulation. The result from our study showed that cystatin C, β2-microglobulin and β-trace protein can be used as markers for the efficiency of haemofiltration (HF) and haemodiafiltration (HDF). The elimination pattern of β-trace protein differs between HDF and HF and the free proteins might therefore be useful markers in the evaluation of different convective therapies

Feedback between dispatch centre and ambulance : Strengthening the chain of care

The emergency call to the emergency medical communication centre (EMCC) and the emergency medical dispatchers (EMD) is the first link in the chain of survival. Precise assessment of the call and exact dispatching is essential to achieve early treatment for patients with time-critical injuries or sickness. The EMDs’ involvement in the patient care traditionally ends when the ambulance arrives at the scene. Therefore, the EMDs are unable to observe the progress and outcome of the patient, and regular and structured feedback is seldom available. Consequently the EMD and the EMCC organization have few possibilities to learn from errors or good assessments made by the EMD. The overall aim of the thesis was to develop, implement and evaluate a technical feedback system between emergency medical dispatchers and the ambulance personnel. A feedback system was developed out of a Finnish emergency medical service (EMS) model and adjusted to suit the Swedish EMS. In study I the feasibility of the feedback system was evaluated. The feedback system had an acceptable margin of error (8.0%) and the most commonly used feedback code was “agree with the dispatcher” (56.6 %). During the implementation of the system in the Stockholm EMS an absence of compliance in sending feedback appeared. In study II the aim was to identify factors influencing the implementation process. Three factors were identified; motivation, participation and encouragement. The absence or presence of these factors formed the opportunities and the barriers in the implementation of the feedback system. To evaluate how the feedback system could be used, two studies were conducted. Study III, an organization evaluation with performance indicators was conducted in the Finnish EMS. After the implementation of a new EMCC organization in Finland the percentage and number of high priority ambulance assignments increased. There was also a trend towards better detection of patients with life-threatening conditions in the new EMCC. In study IV, 100 calls to the EMCC in Stockholm were identified using the feedback system. The aim of the study was to identify overall factors influencing the assessment of calls to the EMCC. Barriers and opportunities related to the registered nurse (RN) or the caller were identified as the main factors influencing the assessment. The opportunities appeared in the callers’ symptom description and the communication strategies used by the RN. Also, a barrier appeared in callers’ descriptions of unclear symptoms, paradoxes, and the RN’s lack of communication strategies during the call. Implications; the developed and evaluated technical feedback system is feasible for structured and regular feedback. Several factors, including both barriers and opportunities, influenced the implementation of the feedback system. A feedback system can be used for evaluating the EMCC through performance indicators and also when identifying and evaluating specific calls to the EMCC

Has increased nursing competence in the ambulance services impacted on pre-hospital assessment and interventions in severe traumatic brain-injured patients?

OBJECTIVE: Trauma is one of the most common causes of morbidity and mortality in modern society, and traumatic brain injuries (TBI) are the single leading cause of mortality among young adults. Pre-hospital acute care management has developed during recent years and guidelines have shown positive effects on the pre-hospital treatment and outcome for patients with severe traumatic brain injury. However, reports of impacts on improved nursing competence in the ambulance services are scarce. Therefore, the aim of this study was to investigate if increased nursing competence level has had an impact on pre-hospital assessment and interventions in severe traumatic brain-injured patients in the ambulance services. METHOD: A retrospective study was conducted. It included all severe TBI patients (>15 years of age) with a Glasgow Coma Score (GCS) of less than eight measured on admission to a level one trauma centre hospital, and requiring intensive care (ICU) during the years 2000–2009. RESULTS: 651 patients were included, and between the years 2000–2005, 395 (60.7%) severe TBI patients were injured, while during 2006–2009, there were 256 (39.3%) patients. The performed assessment and interventions made at the scene of the injury and the mortality in hospital showed no significant difference between the two groups. However, the assessment of saturation was measured more frequently and length of stay in the ICU was significantly less in the group of TBI patients treated between 2006–2009. CONCLUSION: Greater competence of the ambulance personnel may result in better assessment of patient needs, but showed no impact on performed pre-hospital interventions or hospital mortality

Patients perceptions of safety in emergency medical services: an interview study

Background Research on patient safety in emergency medical services (EMS) has mainly focused on the organisation's and/or the EMS personnel's perspective. Little is known about how patients perceive safety in EMS. This study aims to describe the patients' experiences of their sense of safety in EMS. Methods A qualitative design with individual interviews of EMS patients (n=21) and an inductive qualitative content analysis were used. Results Patients' experiences of EMS personnel's ability or inability to show or use their medical, technical and driving skills affected the patients' sense of safety. When they perceived a lack of professionalism and knowledge among EMS personnel, they felt unsafe. Patients highlighted equality in the encounter, the quality of the information given by EMS personnel and the opportunity to participate in their care as important factors creating a sense of safety during the EMS encounter. Altogether, patients' perceptions of safety in EMS were connected to their confidence in the EMS personnel. Conclusions Overall, patients felt safe during their EMS encounter, but the EMS personnel's professional competence alone is not enough for them to feel safe. Lack of communication or professionalism may compromise their sense of safety. Further work is needed to explore how patients' perceptions of safety can be used in improving safety in EMS.Peer reviewe

Implementation of a new emergency medical communication centre organization in Finland - an evaluation, with performance indicators

<p>Abstract</p> <p>Background</p> <p>There is a great variety in how emergency medical communication centers (EMCC) are organized in different countries and sometimes, even within countries. Organizational changes in the EMCC have often occurred because of outside world changes, limited resources and the need to control costs, but historically there is often a lack of structured evaluation of these organization changes. The aim of this study was to evaluate if the performance in emergency medical dispatching changed in a smaller community outside Helsinki after the emergency medical call centre organization reform in Finland.</p> <p>Methods</p> <p>A retrospective observational study was conducted in the EMCC in southern Finland. The data from the former system, which had municipality-based centers, covered the years 2002-2005 and was collected from several databases. From the new EMCC, data was collected from January 1 to May 31, 2006. Identified performance indicators were used to evaluate and compare the old and new EMCC organizations.</p> <p>Results</p> <p>A total of 67 610 emergency calls were analyzed. Of these, 54 026 were from the municipality-based centers and 13 584 were from the new EMCC. Compared to the old municipality-based centers the new EMCC dispatched the highest priority to 7.4 percent of the calls compared to 3.6 percent in the old system. The high priority cases not detected by dispatchers increased significantly (p < 0.001) in the new EMCC organization, and the identification rate of unexpected deaths in the dispatched ambulance assignments was not significantly (p = 0.270) lower compared to the old municipality-based center data.</p> <p>Conclusion</p> <p>After implementation of a new EMCC organization in Finland the percentage and number of high priority calls increased. There was a trend, but no statistically significant increase in the emergency medical dispatchers' ability to detect patients with life-threatening conditions despite structured education, regular evaluation and standardization of protocols in the new EMCC organization.</p

Paramedics’ perceptions of job demands and resources in Finnish emergency medical services : a qualitative study

Publisher Copyright: © 2022, The Author(s).Background: Paramedics’ fatigue is rising. Stress factors show increased risk for burnout, fatigue, leaving the profession, decreased performance and risk for patient safety. Meanwhile, paramedics’ strong community of practice, autonomy and a sense of professional respect are important factors in forming psychological resilience. We aimed to explore Finnish paramedics’ perceptions of job demands and resources. Methods: Our study design was descriptive, inductive with a constructivist approach. Using reflexive thematic analysis, we analyse open-ended questions, from a web-based survey and essays written by Finnish paramedic masters-degree students. The study followed the SRQR checklist. Results: We identified paramedics’ job demands as stress from a high workload, environmental factors and emotional burden. Performance expectations and a sense of inadequacy were further noted, as well as an organizational culture of hardiness, presenting lack of support and sense of inequality. Paramedics’ job resources were pressure management strategies, which were expressed as positive coping mechanisms, agency to affect workload and professional self-actualization, expressed as psychologically safe work community, professional pride and internal drive to professional development. Conclusions: Finnish paramedics exhibit resources and demands related to uncertainty and emotional burden as well as cultural hardiness and psychological safety in communities. Patient or public contribution: This study was done based on survey data collected and analysed by the authors. No patient or public contribution was utilized for this study.Peer reviewe

Understanding quality systems in the South African prehospital emergency medical services : A multiple exploratory case study

Introduction In South Africa (SA), prehospital emergency care is delivered by emergency medical services (EMS) across the country. Within these services, quality systems are in their infancy, and issues regarding transparency, reliability and contextual relevance have been cited as common concerns, exacerbated by poor communication, and ineffective leadership. As a result, we undertook a study to assess the current state of quality systems in EMS in SA, so as to determine priorities for initial focus regarding their development. Methods A multiple exploratory case study design was used that employed the Institute for Healthcare Improvement's 18-point Quality Program Assessment Tool as both a formative assessment and semistructured interview guide using four provincial government EMS and one national private service. Results Services generally scored higher for structure and planning. Measurement and improvement were found to be more dependent on utilisation and perceived mandate. There was a relatively strong focus on clinical quality assessment within the private service, whereas in the provincial systems, measures were exclusively restricted to call times with little focus on clinical care. Staff engagement and programme evaluation were generally among the lowest scores. A multitude of contextual factors were identified that affected the effectiveness of quality systems, centred around leadership, vision and mission, and quality system infrastructure and capacity, guided by the need for comprehensive yet pragmatic strategic policies and standards. Conclusion Understanding and accounting for these factors will be key to ensuring both successful implementation and ongoing utilisation of healthcare quality systems in emergency care. The result will not only provide a more efficient and effective service, but also positively impact patient safety and quality of care of the services delivered. © Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.Peer reviewe

Identifying quality indicators for prehospital emergency care services in the low to middle income setting: The South African perspective

Introduction Historically, performance within the Prehospital Emergency Care (PEC) setting has been assessed primarily based on response times. While easy to measure and valued by the public, overall, response time targets are a poor predictor of quality of care and clinical outcomes. Over the last two decades however, significant progress has been made towards improving the assessment of PEC performance, largely in the form of the development of PEC-specific quality indicators (QIs). Despite this progress, there has been little to no development of similar systems within the low- to middle-income country setting. As a result, the aim of this study was to identify a set of QIs appropriate for use in the South African PEC setting. Methods A three-round modified online Delphi study design was conducted to identify, refine and review a list of QIs for potential use in the South African PEC setting. Operational definitions, data components and criteria for use were developed for 210 QIs for inclusion into the study. Results In total, 104 QIs reached consensus agreement including, 90 clinical QIs, across 15 subcategories, and 14 non-clinical QIs across two subcategories. Amongst the clinical category, airway management (n = 13 QIs; 14%); out-of-hospital cardiac arrest (n = 13 QIs; 14%); and acute coronary syndromes (n = 11 QIs; 12%) made up the majority. Within the non-clinical category, adverse events made up the significant majority with nine QIs (64%). Conclusion Within the South Africa setting, there are a multitude of QIs that are relevant and appropriate for use in PEC. This was evident in the number, variety and type of QIs reaching consensus agreement in our study. Furthermore, both the methodology employed, and findings of this study may be used to inform the development of PEC specific QIs within other LMIC settings.Peer reviewe

Multi-method versus single method appraisal of clinical quality indicators for the emergency medical services

mzaa171Quality Indicator (QI) appraisal protocol is a novel methodology that combines multiple appraisal methods to comprehensively assess the ‘appropriateness’ of QIs for a particular healthcare setting. However, they remain inadequately explored compared to the single appraisal method approach.To describe and test a multi-method QI appraisal protocol versus the single method approach, against a series of QIs previously identified as potentially relevant to the prehospital emergency care setting.An appraisal protocol was developed consisting of two categorical-based appraisal methods, combined with the qualitative analysis of the discussion generated during the consensus application of each method. The output of the protocol was assessed and compared with the application and output of each method. Inter-rater reliability (IRR) of each particular method was evaluated prior to group consensus rating. Variation in the number of non-valid QIs and the proportion of non-valid QIs identified between each method and the protocol were compared and assessed.There was mixed IRR of the individual methods. There was similarly low-to-moderate correlation of the results obtained between the particular methods (Spearman’s rank correlation = 0.42, P \lt; 0.001). From a series of 104 QIs, 11 non-valid QIs were identified that were shared between the individual methods. A further 19 non-valid QIs were identified and not shared by each method, highlighting the benefits of a multi-method approach. The outcomes were additionally evident in the group discussion analysis, which in and of itself added further input that would not have otherwise been captured by the individual methods alone.The utilization of a multi-method appraisal protocol offers multiple benefits, when compared to the single appraisal approach, and can provide the confidence that the outcomes of the appraisal will ensure a strong foundation on which the QI framework can be successfully implemented.Peer reviewe