HospQPHCC - Hospital Quality Prehospital Critical Care

No effect..
We have all seen and read it: Yet another RCT that failed to show any significant outcome effect of MD delivered PHETI or perhaps yet another large study where ALS got beaten by BLS. We have all read them and probably also taken part in the frantic discussions of why that particular study failed. Frustratingly, the interventions studied are often accepted to improve outcome in hospital, such as TBI RSI or balanced fluid therapy or lately transfusions for bleeders.

In spite of same interventions..
Yet, it is really hard to understand why a resuscitative intervention that clearly benefits the patient when done in hospital would not be of benefit to the same patient earlier. Unless of course the intervention is done with reduced quality or done slower and hence with time lost. Could that perhaps be the case - we fail to prove effect of our interventions in prehospital critical care because we don’t deliver care of enough quality?

Hospital Quality as gold standard?
It is intuitively attractive to see critical care of hospital quality as the standard to strive for. After all, the hospital is where we deliver our critical patients.
How would this translate to real life? Wouldn’t it be satisfying to deliver our post-ROSC patients in a neuroprotective anesthesia, stable hemodynamics with beat to beat invasive monitoring of blood pressure, optimal ventilation on an ICU quality respirator with capnography. Diagnostics with 12 lead and UCG done, going for the cath lab or, rarely administering thrombolytics. The TBI patient safely anesthetized without hemodynamic instability, stable on a respirator, sedating drugs and possibly inotropes on the syringe drives. The MVC bleeder in deep, neuroprotective and dilating anesthesia getting blood products and procoagulative drugs while being delivered without delay to a level 1 trauma center. The septic meningitic patient sedated in a respirator getting EGDT and antibiotics/cortisone. The ICU transport getting the receiving hospitals level of care already during transport.
With the ability to deliver hospital quality prehospital critical care this is all quite possible.

Have we had the wrong focus?
Perhaps in the past we have been to eager to look at the effect of our interventions and in doing so forgotten about the quality of the interventions per se.
Instead of looking at the quality of our care per se we have been bogged down by meaningless arguments* of “what category of prehospital providers deliver the best prehospital critical care”.

If You do it, Make sure You do it well!
By accepting that the indications for prehospital critical care interventions are dependent not only on the pathology and the condition of the patient but also on our quality of care we can instead move forward together.
Let’s assume that the indication for a specific intervention is also proportional to the quality of the prehospital care compared to that of the hospital critical care. If we deliver critical care with the same quality as in the hospital where we will deliver the patient, clearly any early resuscitative measures we can take will benefit the patient (possibly even more than the, by necessity, later hospital intervention). Conversely, if we deliver care with reduced quality or with time lost we should probably be more cautious with the indications? At the extreme with only very low quality of care available, BLS is probably the best option?

With an accepted and common ambition of delivering hospital quality critical care, perhaps it is time to look at a process that has potential to lead to meaningful and beneficial such care? Importantly, this can of course be done regardless of the type of prehospital provider one uses.

What is HospQPHCC?
The first step in such an ambition would be to look at the components and abilities that make up hospital quality critical care. In itself, of course a very complex process. In its most simple form however this can probably be done in some sort of “activity” list. Defining the “toolbox” if you will.

Step 1-Activities in Hospital quality prehospital critical care
·      Comparable medical competence
·      System parameters, QA - M&M, CG etc
·      Specific training
·      Tailored treatment (as opposed to strict “protocols”)
·      TBI Neuroprotective anesthesia (as opposed to protocolized drugs)
·      Difficult airway capability – LMA, VL, surgical airway etc.
·      Ability to perform advanced procedures – thoracostomies, -tomies and REBOA
·      Capability to deliver “load&play” care enroute

​​·      ICU quality respirators (as opposed to manual “bagging”)
·      Syringe drives (as opposed to iterative boluses)

·      Invasive blood pressure monitoring
·      Capnography
·      PRBC+FDP+TXA for bleeders
·      Blood/Fluid warmers
·      Topical hemostatics + Tourniquets
·      “Hi-end” drugs, I.e. Inotropes, Thrombolytics, TXA, other procoagulative drugs, antibiotics, anesthetics, relaxants, analgesics etc.
·      Diagnostics – Ultrasound, 12 lead ECG, ABG etc.
·      etc.
The next step would be to look at the quality of care we deliver per se. One popular example is the first pass success rate with PHETI, but of course it is possible and probably necessary to identify several other quality indicators. For instance, even if a service delivers 100% first pass PHETI success rate, RSI desaturations and induction hypotensions as well as 30 min  prolonged scene time may be harmfull to their TBI patients.
Continuing on the same metaphor quality indicators like this measure the ability to use the toolbox.

Step 2-Measurable quality indicators of hospital quality critical care
·      First pass success rate with PHETI
·      Correct indication for PHETI
·      Desaturation with RSI
·      Hemodynamic stability with TBI RSI
·      Scene time for time critical conditions
·      Correct PH triage
·      etc.
The final step in this process would be to look at the effect of step one and two, i.e. mortality and morbidity studies. By not doing this until we have ascertained that we have the necessary “tools” for hospital quality PHCC (step 1) and the ability to use them properly (step 2) we maximize the likelihood of producing relevant studies

Step 3-RCTs comparing outcome of hospital quality critical care
·      Mortality
·      Morbidity
·      Cost effectiveness

What we get out of it
Agreeing on accepted quality indicators would also enable us to better compare ourselves against each other and perhaps also define different levels of PHCC (in accordance with different levels of trauma and cardiology care) With a process like this and mutual inspiration it would allow different systems with varying prehospital providers to embark on a common journey that will produce better care and in the end the outcome studies we are all waiting for. Ultimately this will all benefit the patient.
Joacim Linde, MD, MSc

Etiketter: hospqphcc

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