Qual Saf Health Care
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Qual Saf Health Care · Aug 2005
Gaps between policy, protocols and practice: a qualitative study of the views and practice of emergency ambulance staff concerning the care of patients with non-urgent needs.
To describe emergency ambulance crews' views about (1) how they make decisions on whether to convey patients to hospital; (2) an intervention enabling them to triage patients to non-conveyance; and (3) their experience of using new protocols for undertaking such triage. ⋯ With crews generally positive about this intervention, an opportunity to tackle this difficult area of emergency care now exists. This study has, however, highlighted the complexity of the change in practice and service delivery, and professional and organisational constraints that need to be considered.
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Tachycardia during anaesthesia is a common event. In most cases the cause is easily identified and the problem promptly resolved. However, in some the cause may be rare or obscure. Under such circumstances, attempting to initiate appropriate supportive therapy and to consider a large differential diagnosis in a comprehensive manner may lead to delays which can put a patient at risk. ⋯ Tachycardia during anaesthesia is frequently associated with a simultaneous change in other monitored vital signs. The differential diagnosis is large. Addressing it in a comprehensive fashion requires a structured approach. A specific sub-algorithm treatment for tachycardia based on the associated blood pressure and on the prevailing heart rhythm in the case of hypotension offers a systematic guide which complements the benefits obtained by employing the core algorithm COVER ABCD.
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Bronchospasm in association with anaesthesia may appear as an entity in its own right or be a component of another problem such as anaphylaxis. It may present with expiratory wheeze, prolonged exhalation or, in severe cases, complete silence on auscultation. ⋯ Bronchospasm may present in a variety of ways and may be associated with other life threatening conditions. Although most cases are handled appropriately by the attending anaesthetist, the use of a structured approach to its diagnosis and management would lead to earlier recognition and/or better management in 10% of cases.
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Laryngospasm is usually easily detected and managed, but may present atypically and/or be precipitated by factors which are not immediately recognised. If poorly managed, it has the potential to cause morbidity and mortality such as severe hypoxaemia, pulmonary aspiration, and post-obstructive pulmonary oedema. ⋯ Laryngospasm may present atypically and, if not promptly managed effectively, may lead to morbidity and mortality. Although usually promptly recognised and appropriately managed, the use of a structured approach is recommended. If such an approach had been used in the 189 reported incidents, earlier recognition and/or better management may have occurred in 16% of cases.
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Cardiac arrest attributable to anaesthesia occurs at the rate of between 0.5 and 1 case per 10 000 cases, tends to have a different profile to that of cardiac arrest occurring elsewhere, and has an in-hospital mortality of 20%. However, as individual practitioners encounter cardiac arrest rarely, the rapidity with which the diagnosis is made and the consistency of appropriate management varies considerably. ⋯ Because there are often multiple contributing factors to a cardiac arrest under anaesthesia, a complete systematic assessment of the patient, equipment, and drugs should be completed. The "COVER ABCD-A SWIFT CHECK" algorithm was judged to be a satisfactory process in this context and should be carried out even if the cause of the cardiac arrest is already thought to have been found. The diagnosis and management of cardiac arrest in association with anaesthesia differs considerably from that encountered elsewhere. The outcome is generally good, with most patients leaving hospital alive and apparently well.