Development of a behaviour rating system for rural/remote pre-hospital settings

Abstract

Background: Remote and Rural pre-hospital care practitioners manage serious illness and injury on an unplanned basis, necessitating technical and non-technical skills (NTS). However, no behaviour rating systems currently address NTS within these settings. Informed by health psychology theory, a NTS-specific behaviour rating system was developed for use within pre-hospital care training for remote and rural practitioners.Method: The Immediate Medical Care Behaviour Rating System (IMCBRS), was informed by literature, expert advice and review and observation of an Immediate Medical Care (IMC) course. Once developed, the usability and appropriateness of the rating system was tested through observation of candidates' behaviour at IMC courses during simulated scenarios and rating their use of NTS using the IMCBRS.Results and Conclusion: Observation of training confirmed rating system items were demonstrated in 28-62% of scenarios, depending on context. The IMCBRS may thus be a useful addition to training for rural and remote practitioners. Highlights A patient safety behaviour rating system for rural/remote settings was developed.  Testing of the system suggests that its content may be appropriate and observable.  Some elements were more observable, which may affect future work using this system. BackgroundRural/remote practitioners manage serious illness and injury on an infrequent, unplanned basis. Within rural/remote settings the first person at the scene of a medical emergency is often a general practitioner (GP) or practice nurse. Compared to urban or hospital-based settings, those attending an emergency in these settings may be doing so single-handedly or with limited assistance, for considerable time within potentially harsh conditions, prior to an ambulance providing transport to definitive care. Quite often, working in such settings requires decisions to be made based on the distance to hospital and the patient's likelihood of survival. Effective pre-hospital care thus necessitates a high level of non-technical skills (NTS), such as communication and decision-making (1). The importance of NTS within these settings is evident within research which suggests the factors involved in the likelihood of surviving out of hospital cardiac arrest include a witnessed cardiac arrest, provision of bystander CPR, shockable cardiac rhythm and return of spontaneous circulation (ROSC) within the field (2). The tasks involved in this example necessitate communication skills involved in the provision of CPR (e.g. communicating planned actions to others) and decision-making skills (e.g. who should do what) about how to respond to the situation. In order for optimal care to be provided both technical (e.g. providing CPR) and non-technical (e.g. co-ordinating people at the scene of an emergency) skills need to be employed. Consequently, approaches to improving patient safety and clinical outcomes from emergency care should focus not only on clinical skills and operational and service factors, such as ensuring equipment ...

Cognitive skills of emergency medical services crew members: a literature review

“…They can be valuable sources of information to manage the emergency situation to a satisfying conclusion. It also emerged that it was crucial for those in a high-risk EMS profession to assess the environment and the safety of patients, bystanders, and personnel on scene and in the ambulance [31,33,34,38,40,41,47,48,55,57]. This means assessing clues and significant objects in the environment that can give a notion of what happens and to assess potential risks and threats.…”

“…As EMS crew members approach and enter the scene, looking for clues related to the patient's situation in the environment can add information to the model [47]. It is also important to observe the scene [54] and note (state) any environmental hazards to the self and the patient [38]. On the scene, the necessity is to focus and concentrate [43] what an expert can do quickly and directly to the problem at hand [60].…”

“…Overall, they provide care on an advanced level and prepare their patients better for specialized care in the emergency department [51]. Some identified positive markers of this decision making element are to state the decision to approach a patient (or not) depending on the assessment of the scene [38], request assistance from other authorities to ensure safety [48], establish a safe zone [31], to state other final decisions based on the discussed options, and to agree on these final decisions [38].…”

“…Another critical step in good decision making is to see how the situation has changed or if a decision was effective and led to desired results. In this sense, studies emphasize making more patient assessments, continuous assessments/reassessments of the patient, or reviewing the entire situation [33,38,47,51,59]. In particular, it is desirable when expectations are violated [37,47,54], after implementing a treatment plan [41], if the decision was to wait, after key stages of the transport or regularly [44].…”

“…This should be accompanied by making a list of options [44] and flexible changes in the course of action when needed [41,60]. When certain implemented options are not working, it is good to stop current intervention, state alternative approach/intervention, and begin to use a more appropriate course of action [38]. Some cases even require the ability to modify or create new courses of action [43] a hallmark of expertise [32].…”