Views of emergency care providers about factors that extend on-scene time intervals.

INTRODUCTION: Rapid response, patient care and transportation remain recognised goals of the Emergency Medical Services (EMS). Spending more time on-scene may delay the initiation of definitive care interventions. This study focused on describing the perceptions of a sample of emergency care providers regarding the impact of environmental, clinical and systemic factors with respect to their on-scene time intervals.
METHOD: The study was descriptive and prospective in nature making use of a self-designed questionnaire. Basic descriptive methods were used during the analysis of the participants' responses to 16 close-ended questions. A further review of the limited narrative elicited by two open-ended questions allowed for the reporting of additional views and opinions.
RESULTS: Thirty-three (92%) participants agreed that extended time on-scene may negatively affect patient outcome. Twenty-three (64%) agreed that spending longer than 20 min on-scene may be considered excessive for medical emergencies and 28 (77%) felt the same for trauma cases. Respondents felt that many of the environmental, clinical and systemic factors mentioned in the questionnaire do have the potential to extend on-scene time intervals. The factors that were seen to have the greatest effect included waiting for fire, rescue and police services, patient acuity, the use of an air ambulance, patient extrication and multi-casualty incidents. DISCUSSION: There are a number of environmental, clinical and systemic factors that emergency care providers indicate have the potential to extend on-scene time intervals. Acknowledging and attempting to address these factors is important for EMS as limiting the time spent on-scene is not only clinically desirable but may also lead to improved efficiency and availability of resources.

African relevance

The concept and applicability of the golden hour in the African context is contentious and clinically relevant.

EMS service delivery and EMS system functioning are uniquely experienced in the African region.

Differences are highlighted in local versus international practices regarding on-scene time intervals.

Introduction

South African Emergency Medical Services (EMS) has had a gradual movement away from the 1980s doctor-driven, Franco-German model toward an Anglo-Saxon model characterised by a self-regulated autonomous emergency care profession. South African Emergency Care Practitioners now register and function as independent clinicians/practitioners. Consequently in South Africa, the responsibility for clinical decision-making, interrogation, critique and development of prehospital medical protocols and direction is now largely driven and owned by South African paramedics themselves [1].

Regardless of the system or model followed, rapid transportation of the ill and injured remains a recognised cornerstone of EMS. Proponents of the golden hour, or scoop and shoot approach based their arguments around a belief that patients who have sustained a traumatic injury may have an improved outcome if they reach an appropriate facility able to provide definitive care within one hour of the initial insult [2]. However, such views have become increasingly interrogated leading to literature that questions the current validity and applicability of the golden hour concept [3].

Having said this, certain time-sensitive medical conditions such as cardiac and respiratory arrest, stroke, acute coronary syndromes, penetrating trauma and seizures have been identified where patient outcomes may be negatively affected by long on-scene times [2], [4], [5]. The on-scene time interval is considered to begin once the emergency care provider arrives at the incident and ends when they depart for the receiving facility. It is during this on-scene time interval that activities such as incident assessment, patient access, patient assessment, treatment, packaging and removal are conducted [6]. Aside from being clinically desirable for certain high acuity cases, limiting the time spent on-scene may also lead to improved efficiency and availability of resources within an EMS system.

Due to the diverse, and often uncontrolled nature of the pre-hospital emergency care environment, there are many factors that can effect on-scene time intervals. Boyle (in 2012) classified these factors into three broad categories, namely, environmental, clinical and systemic. The environmental category includes on-scene conditions, e.g., weather, time of day, patient entrapment, etc. The clinical category includes medical interventions undertaken such as airway management procedures, establishing intravenous access and administration of medications. The systemic category includes issues relating to ambulance availability, staffing configurations and modes of transport [7].

South Africa and Africa remain resource constrained with regards to EMS systems and structures. As a consequence, local and regional response and on-scene times are often longer than those reported for developed countries with highly evolved EMS systems [4], [8]. Despite this, there is little empirical evidence or published literature describing the perceptions of African emergency care providers regarding the factors which they feel may be affecting their on-scene time intervals. The aim of our study was to describe the perceptions of a sample of emergency care providers regarding factors they feel may be affecting their on-scene time intervals. Understanding which factors are most commonly associated with a prolonged on-scene time may assist emergency care providers and EMS managers to identify mitigating strategies.

Methods

The study was conducted in Johannesburg, South Africa in the pre-hospital Emergency Medical Care environment. A descriptive prospective design was applied making use of a self-designed, non-validated questionnaire consisting of 16 closed and two open-ended questions. The closed questions posed a number of statements to which participant’s responses were limited to Agree or Disagree. Participants included operational emergency care providers working in Johannesburg. Convenience sampling was used to identify 36 participants half of whom were employed by a private ambulance service and the other half by a public EMS provider. The sample was also divided equally between the three main levels of qualification, i.e., 12 were Advanced Life Support (ALS), 12 were Intermediate Life Support (ILS) and 12 were Basic Life Support (BLS) providers. This sampling strategy was employed to equally disperse the responses that were obtained between the different levels of qualification as well as the private and public sector. The study did not aim to compare or correlate responses to the participants’ qualifications and/or scopes of practice.

Responses to each of the 18 questions in the questionnaire were captured into Microsoft Excel spreadsheets (Redmond, USA). Basic descriptive statistics were used during the analysis of the close-ended questions. The two open-ended questions were read through to identify additional views and opinions related to the use of an air ambulance as well as the participants’ perceptions of performing complex medical procedures on-scene.

Ethical clearance to conduct this study was granted by the University of Johannesburg’s Faculty of Health Sciences Research Ethics Committee. A request to perform the research at the selected companies was sent via email to the managers or the appropriate personnel of the companies. Prior to the completion of the questionnaire, each participant was given an information sheet which briefly described the study as well what would be required if they agreed to participate. Participants were informed of their right to choose not to participate in the study. All participants signed an informed consent letter.

Results

Thirty-six participants completed the questionnaire. Table 1 shows participant response rates for statements regarding the on-scene time interval.

Table 1

Responses to statements regarding the on-scene time interval (n = 36, unless specified).

Statement	Agreen (%)	Disagreen (%)
Spending longer than 20 min on a medical incident is excessive	23 (63.9)	13 (36.1)
Spending longer than 20 min on a trauma incident is excessive	28 (77.8)	8 (22.2)
Extended on-scene time is a factor which negatively affects the patients’ outcome, i.e., mortality and morbidity	33 (91.7)	3 (8.3)
As the severity of the patient’s condition increases, so does the on-scene time interval at a trauma incident	26 (72.2)	10 (27.8)
As the severity of the patient’s condition increases, so does the on-scene time interval at a medical incident	25 (69.4)	11 (30.6)
Emergency care providers often stay on-scene longer than is necessary to stabilise a patient	26 (72.2)	10 (27.8)
The performance of complex medical procedures/interventions such as advance airway management and establishing intravenous access leads to an increase in the on-scene time interval	30 (85.7)*	5 (14.3)*
The use of a helicopter extends the on-scene time interval longer than necessary	24 (68.6)*	11 (31.4)*

*35 respondents.

Participants were asked to indicate the level of effect (No Effect, Limited Effect, or Great Effect) that the selected environmental factors have on prolonging their on-scene times. Responses are summarised in Fig. 1.

Fig. 1

The effect environmental factors may have on the on-scene time interval.

Participants were asked to indicate the level of effect (No Effect, Limited Effect or Great Effect) that the selected systemic factors have on prolonging their on-scene times. Responses are summarised in Fig. 2.

Fig. 2

The effect systemic factors may have on the on-scene time interval.

Another systemic factor, not mentioned above, is the use of a medical helicopter. A high number of participants (24/35; 69%) agreed that the use of a medical helicopter extends the on-scene time interval unnecessarily.

The participants were asked to state the effect (No Effect, Limited Effect or Great Effect) that the selected clinical factors may have on their on-scene time interval. Responses are summarised in Fig. 3.

Fig. 3

The effect of clinical factors on the on-scene time interval as reported.

BLS and ILS participants were asked whether they believe that waiting on-scene for an ALS paramedic extended the on-scene time interval unnecessarily. Logically, on-scene time intervals will be lengthened while the initial responders (i.e., BLS, ILS) wait for the arrival of ALS. Of the participants who responded, 13/23 (57%) felt that waiting on-scene was unnecessary whilst 10/23 (43%) felt the wait to be justified.

The ALS participants were asked if they felt that the presence of ALS on-scene extended the on-scene time interval due to the performance of advanced medical procedures to which 11/12 (92%) agreed. When asked to elaborate on their opinion regarding the completion of medical procedures and the effect it had on the on-scene time interval, the ALS participants felt that local paramedics spent an excessive amount of time on-scene treating, diagnosing and managing when all of the above could have been completed faster or alternatively en route to hospital.

Discussion

Limiting the time spent on-scene is not only clinically desirable for high acuity cases but may also lead to improved efficiency and availability of resources within an EMS system. Table 1 shows that the majority 33/36 (92%) of participants were of the opinion that extended on-scene time was a factor which could negatively impact on patient outcome. 28/36 (78%) indicated that they felt that emergency care providers should ideally not be spending longer than 20 min at a trauma incident. These views are supported by International trends where average on-scene times do not normally exceed 20 min [7]. Anecdotal observations made by the researchers are that on-scene times within the African setting often do exceed 20 min. However, little published literature exists describing EMS practices in the African context. One study was found that was conducted by Vanderschuren et al., in the Western Cape [8]. Vanderschuren’s study found that the average on-scene time at a motor vehicle accident was 27.55 min [8]. This to, is longer than the 14 min average on-scene time interval for trauma related cases reported in Mississippi, USA [9]. No research was found regarding the on-scene time interval for medical incidents within South Africa.

The debate whether an emergency care provider should manage the patient on-scene i.e., stay and play, or whether to load and go, and manage the patient en route to hospital has been on-going for years with literature supporting both sides of the argument [10]. Our participants felt that emergency care providers are more inclined to manage their patients on-scene rather than loading quickly and then providing treatment en route. Participants were also of the opinion that the completion of complex medical procedures and interventions consequently prolonged their on-scene time intervals. The rationale behind the preference to stay on-scene and stabilise the patient may be a result of the confinements and challenges associated with the management of patients in the back of moving ambulances. Many ambulances are not purposefully designed or configured for optimum patient care as would be seen in developed regions.

The factors relating to longer on-scene time intervals in this study were categorised according to the same classification system used by Boyle et al. [7]. These categories are environmental, clinical and systemic. The environmental factors (Fig. 1) that emerged included, unsafe surroundings (and the need to render the scene safe), time of day, weather, crowds, and housing configurations. Fig. 1 shows that the majority of participants felt that although the above factors have the ability to affect their on-scene time intervals, the effect was limited. We acknowledge that weather conditions range between countries and regions. Johannesburg, where this study took place, is recognised to have a mild temperate climate. In regions where extreme weather conditions are experienced, the effects of weather on the on-scene time intervals may be exaggerated. Another environmental factor that emerged as having an effect on extending on-scene times and which is unique to South African and other developing countries was housing configurations e.g., high rise buildings with no serviceable lifts and/or servicing calls in informal settlements with poor access to vehicles.

Systemic factors (Fig. 2) that were seen as having an effect on on-scene time intervals included waiting on-scene for Police Services to arrive and secure the scene, waiting for traffic officers to obtain details from patients, waiting on-scene for fire or rescue services to arrive and the lack of ambulance availability.

A high number of participants 24/35 (69%) agreed that the use of a medical helicopter extends the on-scene time interval unnecessarily. This is supported by a 2014 study by Muhlbauer which identified that local air ambulances which are staffed with a physician and ALS paramedic may have a justifiably longer on-scene time due to the patient receiving definitive care at the scene [11]. A South African study performed by Van Hoving et al., calculated the mean on-scene time of all critically ill patients transported to definitive care centres within the Western Cape between September 2005 and May 2006. Of the total of 7924 transports that took place during this period, 7580 (95.7%) were transported by ground ambulance and the remainder by air ambulance. On average, the air ambulance group spent 53.2 min at the scene, whilst the ground ambulance group spent 27.9 min on-scene. It was therefore concluded from this study, that the on-scene time of patients utilising air transport was significantly longer than those patients utilising ground transport [12].

Regarding clinical factors (Fig. 3), patient acuity was a factor which 20/36 (56%) of the participants believed to have an effect on prolonging the on-scene time. High acuity patients often require the attendance of ALS providers. Research has shown that the activation of ALS may increase on-scene time intervals as they often only respond after the initial responders have called for assistance. Then when they arrive on-scene they are often required to perform time consuming complex medical procedures [13]. It is worth noting that this study took place in an urban setting and the majority of incidents are within close proximity to a number of both private and government hospitals. This may lead one to make an argument for a load and go approach. However, studies have validated the extended on-scene time interval within both rural and urban settings due to the improved outcomes seen with early ALS intervention. [3], [6], [13].

Other clinical factors mentioned in the study included activities around patient extrication, patient immobilisation, having multiple patients on-scene, obtaining medical aid details and an accurate medical history, performing medical interventions and the patient’s condition. All participants agreed that having multiple patients increased the on-scene time interval at a trauma incident. One may argue that the solution lies in more ambulances and personnel being dispatched to assist in accidents whereby there are multiple patients. However, South Africa and Africa as a whole remains resource constrained with regard to the number of ambulances and EMS resources per capita [14].

Patient extrication was a factor which all participants believed played a role in prolonging the on-scene time interval. Some emergency care providers are trained in Motor Vehicle Rescue and are competent in patient extrication but lack the tools to perform these roles. The on-scene time extension could be as a result of waiting on-scene for the appropriate personnel and equipment or as a result of the extrication process itself. EMS managers may explore the possibility of increasing the amount of people trained and equipped to perform Motor Vehicle Rescue. Clinical note taking was seen by the majority of participants as having a limited effect on the on-scene time interval. Emergency care providers should possibly consider obtaining such information en route to hospital in order to expedite on-scene times. All South African emergency care providers are trained in the skill of patient packaging and immobilisation and therefore it should be a process which is completed appropriately and timeously. It was therefore an interesting finding that 28/36 (78%) of the participants believed that patient immobilisation is a significant factor which prolonged their on-scene time interval. On-scene clearance of the cervical spine by qualified Emergency Care Practitioners may be considered as a way to limit unnecessary patient packaging procedures.

There are a number of systemic, clinical and environmental factors that emergency care providers indicate have the potential to extend their on-scene time intervals. The factors identified in this study that were seen to have the greatest effect included waiting for fire, rescue and police services, patient acuity, the use of an air ambulance, patient extrication and multi-casualty incidents.

Acknowledging and attempting to address such factors is important for EMS as limiting the time spent on-scene is not only clinically desirable but may also lead to improved efficiency and availability of resources. Whilst certain of these factors such as the number of patients and patient acuity lie beyond the control of EMS providers, other factors may be mitigated. It seems odd that things such as waiting for police services to declare the scene safe and/or to record patient’s details should delay the rapid transport of a patient.

We suggest meetings be held between EMS managers and the respective support services to develop standard operating procedures and ways of interacting that do not unnecessarily delay the transportation of patients. Delays experienced waiting for fire services to arrive and perform the extrication of entrapped patients may be mitigated by training emergency care providers in the use of simple tools and techniques. This would allow for a more rapid response to the patient access and extrication phases of a medical rescue.

Finally, we argue that there is mounting evidence, not only from this study that there is a need for EMS managers to critically review the real value versus the perceived value of urban helicopter ambulance services from a time and cost perspective. Further research needs to be conducted to better explore the frequency with which the factors identified in this study are occurring as well as to quantify the extent to which the on-scene times are being effected.

Conflicts of interest

The lead author is an editor for the African Journal of Emergency Medicine. He was not involved in editorial or peer-review decisions related to this paper. The authors declare no other conflicts of interest.

Dissemination of results

The results of this study have been shared in the form of a report to the academic unit at the University.

Authors’ contributions

CVL supervised the study and wrote the article. TM gathered the data and completed the initial report upon which this article is based. Both authors contributed to the drafting and approved the final version submitted for publication. Both authors agree to be accountable for all aspects of the published work.