BackgroundEmergency Care has previously been identified as an area of significant concern regarding the prevalence of Adverse Events (AEs). However, the majority of this focus has been on the in-hospital setting, with little understanding of the identification and incidence of AEs in the prehospital environment.MethodThe early development and testing of Emergency Medical Services (EMS) specific triggers for the identification of AEs and Harm has been previously described. To operationalise the Emergency Medical Services Trigger Tool (EMSTT), the processes developed by the Institute for Healthcare Improvement for use with the Global Trigger Tool were adapted to a prehospital emergency care setting. These were then applied using a stepwise approach to the analysis of 36 consecutive samples of patient care records over an 18-month period (n = 710). Inter-rater reliability was measured for each trigger item and level of Harm classification. Total Triggers per 10,000 Patient Encounters, AEs per 10,000 Patient Encounters and Harm per 10,000 Patient Encounters were measured. All measures were plotted on Statistical Process Control Charts.ResultsThere was a high level of inter-rater agreement across all items (range: 85.6–100%). The EMSTT found an average rate of 8.20 Triggers per 10,000 Patient Encounters, 2.48 AEs per 10,000 Patient Encounters and 0.34 Harm events per 10,000 Patient Encounters. Three triggers: Change in Systolic Blood Pressure Greater Than 20%; Temp > 38 °C without subsequent reduction; and SpO2 < 94% without supplemental Oxygen or SpO2 < 85% without assisted ventilation accounted for 93% (n = 180) of the triggers found throughout the longitudinal analysis.DiscussionWith sufficient focus on implementation and data collection, as well as the inclusion of a contextually relevant system for classifying AE/Harm, the EMSTT represents a potentially successful strategy towards identifying the rate of AEs within EMS across a large patient population with limited commitment of time and resources.Electronic supplementary materialThe online version of this article (10.1186/s12873-018-0195-0) contains supplementary material, which is available to authorized users.

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South African Advanced Life Support (ALS) providers follow an autonomous practice model of care. This advanced role profile is characterized by clinical skill competence and autonomous decision making whilst demonstrating a high level of awareness of their own ethical attitudes, values and beliefs. It is through a professional commitment that ALS providers deliver an advanced evidence based practice that should be maintained constantly within a dynamic environment. Continuous Professional Development (CPD) is seen as an instrument for this. CPD should also serve as a means to acquire professional excellence and going beyond the boundaries of meeting the base level standard with the aim of providing the finest quality of care in the interest of patient safety. Purpose of the research The purpose of this research is to identify gaps in the professional development of out-of-hospital ALS providers trained in South Africa by assessing frequency of performance of ALS clinical skills, by determining perceived level of competence and predictors of confidence, and by sourcing information on attendance of CPD activities and training needs. vi Methodology This study used a quantitative non-experimental design. Data was attained from an e-mail based descriptive survey that was limited to a precise and concise questionnaire. The data from 140 (N) ALS providers was subjected to a descriptive statistical analysis using the PASW statistics version 18.0 to systematically show patterns and trends. Frequency distributions were generated to describe data categories. Bivariate analysis was conducted using Chi-square and Pearson correlation tests. Results Results indicated that ALS providers performed clinical skills infrequently. Of the total number of respondents 140 (N), the average ALS clinical skills performance was 6 (4.8%) daily. In the 2-6 times a week category 8 (6.4%) ALS clinical skills were performed. ALS clinical skills performance in the once a week category showed an average of 7 (5.6%) and the once a month category, an average of 17 (13.7%) ALS skills were performed. An average of 31 (25%) ALS skills were performed in the once in six months category whilst an average of 54 (43.5%) were performed in the greater than six months category. CPD activities that are appropriate to ensuring the maintenance of competence for these clinical skills were not adequately undertaken. Medical updates were mostly attended by ALS providers, 52 (42.9%) whilst CPD events that addressed clinical skills, was mostly limited vii to the ACLS course 42 (34.7%). The needs assessment for CPD showed that 56 (53%) of respondents expressed a need for paediatric and obstetric simulated skill sessions, whilst 43 (40.9%) requested clinical skills workshops and 39 (37.1%) expressed a need for clinical practice in theatre and coronary care units. Conclusions and recommendations This study shows that ALS clinical skill competence is maintained by frequent practice and appropriateness of CPD activities. The infrequent performance of ALS skills coupled with the lack of appropriate and diverse CPD activity attendance results in poor maintenance of competence. The loss of competence can be related to poor reported levels of confidence which consequently places patient safety at risk. To safeguard against medical error and ensure patient safety, it is strongly recommended that CPD audits be undertaken on all ALS providers for appropriate CPD compliance related to clinical skills performance. In addition to a clinical skills audit, it is recommended that a national clinical skills registry be established with the intention of facilitating clinical skill surveillance, to determine a notifiable, high risk skill set. To safeguard against knowledge and clinical skill attrition and loss of competence, the delivery of CPD activities should be assessed for effectiveness and appropriateness.

The blind bougie technique is performed when the epiglottis is visible to the intubator, but the vocal cords cannot be seen (Grade III Cormack-Lehane view). The blind bougie technique for endotracheal intubation is not routinely performed by Critical Care Paramedics for a failed intubation in the prehospital setting. However, at Hamad Medical Corporation Ambulance Service in the State of Qatar, the blind bougie technique is included in their failed airway clinical practice guidelines. This case report aims to describe the rapid sequence induction for intubation process and endotracheal tube placement in an adult trauma patient, presenting with a difficult airway, using the blind bougie technique in the out-of-hospital setting. A 35-year-old male patient was ejected from an all-terrain vehicle following a high-speed accident in the desert. The patient sustained an isolated head injury. Based on the patient’s clinical presentation, he required immediate endotracheal intubation for maintenance and protection of his airway prior to rapid transport to definitive care. Predictors of difficult airway were calculated. Using the blind bougie technique, endotracheal intubation was performed with first pass success. It is recommended that emergency medical services include the blind bougie technique of endotracheal intubation among their difficult airway procedures.

The modified Valsalva maneuver (MVM) has never before been performed in the prehospital setting by the Hamad Medical Corporation Ambulance Service (HMCAS) clinicians in the State of Qatar. Currently, their clinical practice guidelines (CPG) prescribe the vagal maneuver (VM) using a 10 cc syringe as first-line therapy for patients presenting with symptomatic paroxysmal supraventricular tachycardia (pSVT). The effectiveness of the MVM in terminating pSVT compared to the traditional VM is well documented, although prehospital studies in this area are lacking. In this case, a generally healthy, 47-year-old male migrant worker presented with new-onset symptomatic pSVT, which was successfully terminated by a MVM after initial failed attempts of the traditional VM. The MVM is a postural technique performed by initially placing the patient in a semirecumbent position. The patient is then encouraged to blow into a manometer to achieve a 40 mmHg intrathoracic pressure for 15 seconds. Once the 40 mmHg intrathoracic pressure is achieved, the patient is repositioned supine, and their legs are raised passively to 45 degrees for 15 seconds. The patient is then returned to the semirecumbent position for 45 seconds before cardiac rhythm reassessment. The MVM has shown to have an increased termination rate of pSVT with no documented serious adverse events. The MVM can be performed in a time-effective manner and is cost effective as intravenous (IV) cannulation is not required. The prevention of adenosine-associated transient asystole is prevented. It is recommended that ambulance services consider the inclusion of the MVM in their CPGs for the treatment of new-onset pSVT.