Variations in the care of agitated patients in Australia and New Zealand ambulance services

Nambiar, Dhanya; Pearce, J. W.; Bray, Janet; Stephenson, Michael; Nehme, Ziad; Masters, Stacey; Brink, Deon; Smith, Karen; Arendts, Glenn; Fatovich, Daniel M; Bernard, Stephen; Haskins, Brian; Grantham, Hugh; Cameron, Peter

doi:10.1111/1742-6723.13431

Cited by 8 publications

(32 citation statements)

References 28 publications

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“…8 Wide variation in clinical guidance and scope of practice was noted across the presenting conditions analysed, which is consistent with previous findings regarding ambulance service clinical guidelines. 29 It is concerning that procedures such as delayed cord clamping, assessing foetal wellbeing, and algorithms for shoulder dystocia that are included in best practice guidelines are omitted from some of the individual service recommendations. For example, with reference to clamping and cutting of the cord immediately post birth, four of the nine services provided insufficient, out-of-date or no advice as to the promotion of delayed or late cord clamping, a procedure considered best practice by both the WHO 30 and Royal College of Obstetricians and Gynaecologists 31 as it is known to increase neonatal blood volume, improve neonatal and infant iron stores and decrease neonatal and infant anaemia.…”

Section: Discussionmentioning

confidence: 99%

A document analysis of clinical guidelines for the paramedic management of obstetric and neonatal presentations in Australian and New Zealand ambulance services

Flanagan,

Barr,

Pearce

et al. 2024

Paramedicine

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Introduction Paramedics receive varying levels of training in obstetric presentations. In high-risk, low-frequency cases, clinical guidelines should support clinicians to deliver optimal care. This study analysed publicly available clinical guidelines for obstetric presentations published by ambulance services in Australia and Aotearoa New Zealand to determine consistency of clinical guidance and adherence to nationally recognised standards for the development and reporting of evidence-based guidelines. Method Guidelines were sourced from publicly available websites of Australian and Aotearoa New Zealand ambulance services. The text was imported into a custom data collection frame which focused on five predefined specific obstetric presentations. Data were extracted and measured against nationally and internationally recognised best practice standards. Results Nine independent sets of clinical guidelines were included in the analysis. There was wide variation in the clinical guidance provided and scope of practice. Aspects were found to be absent, inconsistent, not supported by evidence or having potential to cause harm. None were consistent with recognised Australian best practice standards for guideline development in the areas of referencing and grading of evidence. Conclusion This study found substantial inconsistency of clinical guidance, highlighted conflicting and inadequate advice, and assessed the safety of advice provided when compared to best practice standards and evidence-based recommendations. Sustained effort to improve ambulance service clinical guidance regarding obstetric presentations is warranted.

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Section: Discussionmentioning

confidence: 99%

A document analysis of clinical guidelines for the paramedic management of obstetric and neonatal presentations in Australian and New Zealand ambulance services

Flanagan,

Barr,

Pearce

et al. 2024

Paramedicine

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“…In a recent survey by Nambiar et al . of ambulance clinical practice guidelines in Australasia for initial IM sedation of patients with severe agitation, three ambulance services reported using ketamine, three reported using droperidol and four reported using midazolam, although several services allowed an alternate drug if the first did not provide for adequate sedation 3 …”

Section: Discussionmentioning

confidence: 99%

“…Since intravenous (IV) cannulation is difficult in uncooperative patients, intramuscular (IM) options are required. In the 10 ambulance services in Australasia, four services use IM midazolam, three use IM droperidol and three use IM ketamine as the initial sedating drug in patients with severe agitation 3 …”

Section: Introductionmentioning

confidence: 99%

Use of intramuscular ketamine by paramedics in the management of severely agitated patients

Bernard

Roggenkamp

Delorenzo

et al. 2021

Emerg Medicine Australasia

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Objective Administration of a sedative agent is required for safe transport of prehospital patients with severe agitation to EDs. Ambulance services in Australasia use ketamine, droperidol or midazolam as first line agent but the optimal agent is uncertain. In Victoria, intramuscular (IM) ketamine is used. The present study aimed to examine the prehospital characteristics and ED outcomes of patients with severe agitation after IM ketamine administration. Methods A retrospective review was conducted for patients who received IM ketamine for severe agitation over a 2‐year period. Data were sourced from Ambulance Victoria and linked to hospital data. The primary outcome was time to sedation. Data collected included baseline characteristics, adverse events and ED outcomes. Results Three hundred and fifty‐eight prehospital cases transported to 32 hospitals were included. Outcome data were available for 305 patients (21 hospitals). Median age was 31 years (IQR 23–40). 71.2% were male. Adequate sedation was achieved in 96.9% of cases in a median time of 5.0 min (IQR 3.0–7.0; range 1–31 min). Adverse events were transient hypoxia (5.0%), hyper‐salivation (4.2%) and emergence reactions (0.8%). A total of 45 (14.8%) patients were intubated; two prehospital. Conclusion Intramuscular ketamine is effective with a low rate of prehospital complications in severely agitated patients in the prehospital setting. Given the variation in ambulance practice in Australasia, prospective, randomised trials in the prehospital setting comparing ketamine to other sedating agents such as droperidol in patients with severe agitation are required.

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“…7 Patients can become acutely agitated during transport, requiring the use of verbal deescalation, sedative medications, and/or physical restraints to mitigate risks of patient or staff injury. [8][9][10] However, these interventions also carry their own risks. Adverse effects of sedative medications include dystonic reactions, respiratory depression, and arrythmias, 11 while physical restraint use can lead to psychological harm and physical injuries.…”

Section: Introductionmentioning

confidence: 99%

“…Challenges specific to the prehospital environment include the confined space of the ambulance and limited available staff to assist in deescalation 7 . Patients can become acutely agitated during transport, requiring the use of verbal deescalation, sedative medications, and/or physical restraints to mitigate risks of patient or staff injury 8–10 . However, these interventions also carry their own risks.…”

Section: Introductionmentioning

confidence: 99%

Characteristics of pediatric behavioral health emergencies in the prehospital setting

Wnorowska,

Naik,

Ramgopal

et al. 2023

Academic Emergency Medicine

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ObjectiveApproximately 10% of emergency medical services (EMS) encounters in the United States are behavioral health‐related, but pediatric behavioral health EMS encounters have not been well characterized. We sought to describe demographic, clinical, and EMS‐system characteristics of pediatric behavioral health EMS encounters across the United States, and to evaluate factors associated with sedative medication administration and physical restraint use during these encounters.MethodsWe conducted a retrospective cross‐sectional study of pediatric (<18 years old) behavioral health EMS encounters from 2019‐2020 using the National Emergency Medical Services Information System. Behavioral health encounters were defined using primary or secondary impression codes. We used multivariable logistic regression to identify factors associated with sedative medication administration and physical restraint use.ResultsOf 2,740,271 pediatric EMS encounters, 309,442 (11.3%) were for behavioral health. Of pediatric behavioral health EMS encounters, 85.2% were 12‐17 years old, 57.3% were female, and 86.6% occurred in urban areas. Sedative medications and physical restraints were used in 2.2% and 3.0% of pediatric behavioral health EMS encounters, respectively. Sedative medication use was associated with the presence of developmental, communication, or physical disabilities relative to their absence (adjusted odds ratio [aOR] 3.38, 95% CI, 2.93, 3.91) and with encounters in the West relative to the South (aOR 1.23, 95% CI, 1.16, 1.32). Physical restraint use was associated with encounters by patients 6‐11 years old relative to 12‐17 years old (aOR 1.35, 95% CI 1.27, 1.44), the West relative to the South (aOR 3.49, 95% CI 3.27, 3.72), and private, nonhospital EMS systems relative to fire departments (aOR 3.39, 95% CI 3.18,3.61).ConclusionsAmong pediatric prehospital behavioral health EMS encounters, the use of sedative medications and physical restraint varies by demographic, clinical, and EMS‐system characteristics. Regional variation suggests opportunities may be available to standardize documentation and care practices during pediatric behavioral health EMS encounters.

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Variations in the care of agitated patients in Australia and New Zealand ambulance services

Abstract: Objective: The objective of the present study is to examine variations in paramedic care of the agitated patient, including verbal de-escalation, physical restraint and sedation, provided by ambulance services in Australia and New Zealand.

Cited by 8 publications

References 28 publications

A document analysis of clinical guidelines for the paramedic management of obstetric and neonatal presentations in Australian and New Zealand ambulance services

A document analysis of clinical guidelines for the paramedic management of obstetric and neonatal presentations in Australian and New Zealand ambulance services

Use of intramuscular ketamine by paramedics in the management of severely agitated patients

Characteristics of pediatric behavioral health emergencies in the prehospital setting

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