Effects of a standard operating procedure on prehospital emergency care of patients presenting with symptoms of the acute coronary syndrome

Abstract

To determine whether a standard operating procedure (SOP) for prehospital management of patients with the acute coronary syndrome (ACS) improves the quality of patient care in terms of adherence to treatment guidelines of the European Society of Cardiology. Among a total of 1025 patient medical records collected from a period before and after the introduction of the SOP, 269 records included the working diagnosis of ACS and were then reviewed for guideline adherence. Most aspects of patient evaluation, monitoring, treatment, and hospital allocation were fairly guideline adherent (>70%) before the SOP was introduced and were not affected by the SOP. The percentage of cases in whom sublingual nitrate (55.2 vs. 66.7%) or intravenous morphine (26.9 vs. 43.0%) was administered without contraindications was higher after the SOP had been introduced. Therefore, the use of an SOP in prehospital emergency medicine can partly improve the adherence to guideline recommendations for the treatment of patients with ACS.

Standard operating procedure changed pre-hospital critical care anaesthesiologists’ behaviour: a quality control study

“…Our result is in agreement with those reported by Martinon et al [ 8 ] from Paris who found that the prevalence of automated ventilator use following RSI on paediatric TBI patients rose to 88% after the implementation of their guideline. Our result compares favourably to those found by Bosse et al [ 5 ] and Francis et al [ 6 ] from the physician-staffed EMS in Berlin. They investigated the impact of introducing SOPs for the pre-hospital treatment of acute exacerbation in COPD [ 5 ] and acute coronary syndrome (ACS) [ 6 ] and neither of the SOPs in these studies improved overall patient care.…”

“…Our result compares favourably to those found by Bosse et al [ 5 ] and Francis et al [ 6 ] from the physician-staffed EMS in Berlin. They investigated the impact of introducing SOPs for the pre-hospital treatment of acute exacerbation in COPD [ 5 ] and acute coronary syndrome (ACS) [ 6 ] and neither of the SOPs in these studies improved overall patient care. The authors introduced the SOPs by arranging staff meetings and distributing the SOP by e-mail and in paper copies.…”

“…Bosse et al showed that implementing an SOP for the pre-hospital treatment of severe exacerbation in chronic obstructive pulmonary disease in a physician-staffed EMS in Berlin did not improve overall guideline adherence [ 5 ]. Francis et al demonstrated that implementing an SOP for the pre-hospital treatment of acute coronary syndrome in the same physician-staffed EMS in Berlin improved some aspects of patient care, whereas other aspects were not affected [ 6 ]. The same research group also found that introducing an SOP for patient documentation did improve the quality of the patient care reports [ 7 ].…”

Management of Pain in the Emergency Department

“…Data demonstrate that there is little difference in analgesic effect within the dosing ranges most likely used in most EDs (from 0.1 to 0.15 mg/kg IV) [180]. Other studies have also found that obese patients do not require extra morphine and that, indeed, weight-based dosing is not truly necessary [173,181]. The "standard" initial dose of morphine of 0.1 mg/kg (about 7 mg in an adult) has been found to provide inadequate analgesia (i.e., less than 50% decrease in pain) in 2/3rds of ED patients [182].…”

“…The drug has been around for as long as any other opioid and has excellent safety and efficacy when used appropriately. Despite theoretical and practical concerns about histamine release and hypotension, the use of morphine (including higher-risk patients such as cardiac and trauma cases) has not been associated with dangerous hypotension even in the relatively less controlled setting of prehospital care [173][174][175][176]. Some of the more interesting recent investigations of morphine in the acute care setting suggest that it may be combined with ketamine for increased efficacy (with minimization of hemodynamic risks) [143].…”