T Jones1, M Woollard. 1. Welsh Ambulance Services NHS Trust, Pontypool, UK. Tim.jones20@btopenworld.com
Abstract
BACKGROUND: 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. METHOD: 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. RESULTS: 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. CONCLUSION: 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.
BACKGROUND: 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. METHOD: 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. RESULTS: 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. CONCLUSION: 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.