Table 1 Summary of shortlisted studies
Author, publication year | Country | Design | Stroke, MI or trauma | Objectives and methods | Key findings |
|---|---|---|---|---|---|
STRUCTURED HANDOVER TOOLS/PROTOCOLS | |||||
 Evans et al. [18] | Australia | Grounded Theory | Trauma | Qualitative study of paramedics and trauma teams to explore the utility of the MIST (M - Mechanism of injury, I - Injuries sustained, S - Signs and T - Treatment and trends in the vital signs) template and other aspects related to quality handover processes (develop a minimum dataset to assist paramedics; features of effective/ineffective handover; feasibility of advanced data transmission; and optimal mode of data display in trauma bays) | Study authors’ concluded that there is support for the adoption and further evaluation of a structured handover template. Quality handovers involved information that was vital, succinctly delivered and structured to inform immediate treatment. Pre-alert information conveyed by paramedics was considered important |
 Iedema et al. [5] | Australia | Video-reflexive ethnography | Trauma and non-trauma | Novel ambulance to emergency department handover protocol: IMIST-AMBO: Identification of the patient, Mechanism/medical complaint, Injuries/information relative to the complaint, Signs, vitals and Glasgow Coma Scale, Treatment and trends/response to treatment, Allergies, Medications, Background history and Other (social) information | IMIST-AMBO showed promise for improving handover communication between emergency medical services and emergency department physicians (greater volume of information per handover that was more consistently ordered; fewer questions from emergency department staff; shorter handover duration; and fewer repetitions by paramedics and emergency department staff) |
 Dojmi Di Delupis et al. [17] | Italy | Mixed methods | None | Communication between pre-hospital/hospital providers using analysis of simulated sessions, survey of triage nurses and expert focus groups led to the development of ISBAR (Identification, Situation, Background, Assessment and Request) | The ISBAR did not result in improved communication during handovers to hospital staff as assessed by micro-simulations |
 Ebben et al. [23] | The Netherlands | Prospective pre-test post-test design | None | Evaluated the effectiveness of an e-learning tool for improving adherence to a guideline for structuring pre-hospital notification and handover: • DeMIST: Demographics, Mechanism of Injury/illness, Injury or Illness found or suspected, Signs, Treatment given) The e-learning tool was designed with five components (1) knowledge about the DeMIST model and handover process, (2) skills to use the DeMIST model; and (3) motivation to use the DeMIST model | The authors noted a high baseline adherence rate to usage and correct sequence of the DeMIST model. However, the DeMIST e-learning program did not improve adherence to the handover guideline (no statistically significant changes in numbers of handovers with the DeMIST model or numbers of handovers consistent with the sequence of the DeMIST model |
 Meisel et al. [19] | USA | Qualitative study using focus group methods | Trauma | Qualitative study of professional, structural and interpersonal factors influencing handovers between emergency medical services care and emergency department, but did not evaluate a novel structured handover process | Findings suggested that increasing emergency medical services interactions with emergency physicians, standardising patient handovers and inter-professional learning would improve handovers for high-risk emergency medical services to emergency department |
 Von Cannon & Porcelli 2016 [24] | USA | Quality improvement project | Stroke | Evaluated the impact of a collaborative project between a hospital and an EMS agency, which aimed to improve the CODE Stroke process. The quality improvement project involved: • EMS crews giving advance notification of suspected stroke cases • EMS crews transporting patients directly to CT scanner in the emergency room, including providing assistance with the transfer • Feedback on patient treatment (t-PA) was provided to EMS crews along with dispatch to scene times, and dispatch to t-PA parameters and patient outcomes, which included a letter of commendation from their supervisor | The project reported an improvement in door to CT scan times: • mean 27 min in the year [2013] before the project • mean of 20 min in 2014 (one year after the project began) During 2014, the authors reported a stroke identification accuracy rate of 89%; and a median door to t-PA time of 40 min. |
PROTOCOLS AND ENHANCED SKILLS TO IMPROVE HANDOVER | |||||
 Foster et al. [46] | USA | Prospective observational study | Myocardial infarction | Prehospital recognition of acute myocardial infarction undertaken by trained hospital-based nurses and paramedic advanced life support providers | Hospital-based nurses and paramedic advanced life support providers can successfully be trained to evaluate a prehospital electrocardiogram for presence of acute myocardial infarction with accuracy. |
 O’Connor & Megargel 1994 [51] | USA | Before and after study | Myocardial infarction and trauma | Evaluated the impact of feedback on paramedic skills (charting, resuscitation rates from cardiac arrest, endotracheal intubation success rates and trauma scene times | Quality improvement feedback can improve charting for endotracheal intubation and reduce trauma scene times (but not resuscitation rates from cardiac arrest or endotracheal intubation success rates) |
 Zempsky et al. [47] | USA | Cross sectional survey | None | Evaluated paramedics who were employed as allied health care professionals (based in the paediatric emergency department as assistive personnel). No defined clinical condition other than paediatric care | Paramedics function successfully in the emergency department as members of the paediatric emergency department care team (and this may be cost-effective adjunct to nursing support) |
 Scott et al. [20] | USA | Uncontrolled before and after design | Trauma | Evaluated a web-based educational intervention targeting communication skills of paramedics during handover of trauma patients to emergency department clinicians | Web-based intervention failed to show a statistically significant impact on amount of clinical information recalled by physicians during handover of trauma patients. |
 Mason et al. [43] | UK, England | Mixed methods | None | Evaluated the appropriateness, satisfaction and cost-effectiveness of an emergency care practitioner role in a primary care practitioner led out of hrs service or nurse-led walk in centre. | Care delivered by emergency care practitioners appeared to reduce emergency hospital admissions |
 Campbell et al. [45] | Canada | Retrospective observational study | None | Advanced care practitioner role - based in hospital setting (and not focused on stroke, myocardial infarction or trauma) | Procedural sedation and analgesia conducted in the emergency department by trained paramedics is not associated with significant number of adverse events (only one was recorded) |
 Ranchord et al. [42] | New Zealand | Retrospective observational study | Myocardial infarction | Evaluated the impact of pre-hospital electrocardiogram for myocardial infarction patients, and following a decision made by a physician, a paramedic administered thrombolysis | Prehospital paramedic-administered thrombolysis was deemed to be safe and reduced time to treatment and heart failure |
 Chan et al. [21] | Australia | Uncontrolled before and after study | None | Focused on medication reconciliation (and not focused on stroke, myocardial infarction or trauma); i.e., paramedics were asked to bring patients’ own medication to the emergency department | Patients’ own medication was brought into emergency department more frequently and prescribing errors reduced |
 Waßmer et al. [22] | Germany | Uncontrolled before and after study | None | Evaluated a simple training intervention to improve communication in a rescue teams and handover to emergency department physicians using simulated emergency operations | The simple training intervention resulted in better structured communication between teams and handover of paramedics (frequency of negative communication events decreased from 3.9 per scenario before training to 1.8 after training) |
 Mason et al. [44] | UK, England | Quasi-experimental study | None | Evaluated the impact of the emergency care practitioner role (generic practitioner with a nursing or paramedic background) on patient pathways based in different emergency care settings (i.e., paramedics did not transport patients and were based in settings such as an urgent care centre) | Impact of emergency care practitioners is greatest when the operate in mobile settings when care is taken to the patient |
 Jensen et al. [41] | Canada | Health care failure mode and effect analysis | Myocardial infarction | Mapping using hazard analysis of pre-hospital treatment of ST-segment-elevation myocardial infarction patients with fibrinolytics by paramedics | ST-segment-elevation myocardial infarction calls in which paramedics administer fibrinolytics is a complex process with many steps, but relatively few were hazardous to patient care or safety |
 Landman et al. [49] | USA | Qualitative study | Myocardial infarction | Qualitative study exploring collaborations between emergency medical services and hospitals in the care of hospitalised acute myocardial infarction patients | Relationships between emergency medical services and acute myocardial infarction teams differed between high and low performing hospitals – high performers described multi-faceted strategies to support collaboration with emergency medical services personnel |
 Ryan et al. [40] | Canada | Retrospective observational study | Myocardial infarction | Aim was to investigate the proportion of ST-segment-elevation myocardial infarction patients who had clinically important events or received advanced paramedic care that was delivered in the pre-hospital period (paramedic had no direct involvement in patient care or treatment in hospital other than direct transportation to percutaneous coronary intervention laboratory) | Clinically important events (several patients needed cardiopulmonary resuscitation or defibrillation) and advanced care treatment are common in ST-segment-elevation myocardial infarction patients (e.g., administration of morphine or atropine) undergoing pre-hospital transfer or intra-facility transfer to a percutaneous coronary intervention centre |
 Todt et al. [25] | Sweden | Multi-stage action research study | Myocardial infarction | Paramedics conducted prehospital electrocardiogram recording for suspected ST-segment-elevation myocardial infarction patients with pre-notification to the coronary care unit | First medical contact to patient artery and catheterisation laboratory decreased by 6 and 12 mins respectively |
 Choi et al. [50] | USA | Uncontrolled before and after study | Stroke | A hospital-directed feedback to emergency medical services in terms of compliance with state protocols for pre-hospital assessment of stroke | Feedback improved compliance with protocols |
 von Vopelius-Feldt & Benger [48] | UK, England | Cross-sectional survey | None | Survey of ambulance services about the use and role of clinical care paramedics (not individual paramedics) and was not focused on stroke, acute myocardial infarction or trauma | There were variations in training, competencies and working patterns of clinical care paramedics across England |
PROTOCOLS OR ENHANCED SKILLS LEADING TO A CHANGE IN IN-HOSPITAL TRANSFER LOCATION | |||||
 Dorsch et al. [31] | UK, England | Prospective observational study | Myocardial infarction | Pre-hospital diagnosis of ST-segment-elevation myocardial infarction by paramedics and direct transfer to catheterisation laboratory for primary percutaneous coronary intervention | The 90 min target for door to balloon time was achieved in 94% of direct admissions compared to 29% referred from the emergency room |
 Dieker et al. [30] | Netherlands | Retrospective observational study | Myocardial infarction | Pre-hospital diagnosis of ST-segment-elevation myocardial infarction by paramedics and direct transfer to an intervention centre with pre-hospital notification of the catheterisation laboratory | The protocol more than tripled the proportion of patients treated within 90 mins |
 Pathak et al. [26] | Australia | Retrospective observational study | Myocardial infarction | Evaluated the impact of pre-hospital electrocardiogram for ST-segment-elevation myocardial infarction patients and emergency department activation of the primary percutaneous coronary intervention team (paramedic had no direct involvement in patient care or treatment in hospital other than direct transportation to catheterisation laboratory) | Pathway (pre-hospital diagnosis of ST-segment-elevation myocardial infarction and direct transfer to catheterisation laboratory) significantly reduced door to balloon time. |
 Rostykus et al. [37] | USA | Retrospective observational study | Myocardial infarction | Evaluated the impact of pre-hospital emergency department activation of catheterisation laboratory by paramedics on mortality compared with referring emergency department activations | Mortality rates for ST-segment-elevation myocardial infarction patients in hospital were not significantly different between pre-hospital emergency department and referring emergency department activations |
 Larsson & Holgers 2011 [35] | Sweden | Retrospective observational study | Trauma (hip fracture) | Evaluated the impact of nurse paramedic assessment of hip fracture and direct transfer to radiology (paramedic had no direct involvement in patient care or treatment in hospital other than transportation to radiology and delivery of blood test results to laboratory) | Study suggests that ‘fast-track’ care can minimise complications for patients with suspected hip fracture and overall length of care |
 Dewhurst & McComb 2012 [29] | England, UK | Retrospective observational study | Complete heart block | Direct transfer of patients with complete heart block by ambulance service to a pacing centre, for urgent pacing | Direct transfer from the ambulance service was appropriate (may reduce complications and length of stay) |
 Huang et al. [33] | USA | Retrospective observational study | Myocardial infarction | Direct transfer to catheterisation laboratory of ST-segment-elevation myocardial infarction patients by helicopter paramedics with pre-alert and pre-hospital treatment | Study demonstrated feasibility of emergency medical services-activated ST-segment-elevation myocardial infarction protocol over long distances with good reperfusion times |
 Birkemeyer et al. [38] | Germany | Retrospective observational study | Myocardial infarction | Comparison of mean door to hospital and mean door to primary percutaneous coronary intervention times in two myocardial infarction network registries: one with (n = 322 patients) and one without (n = 494) bypass of emergency rooms (direct transfer to catheterisation laboratory) | Mean time delay between onset and arrival at hospital was statistically significant shorter in the network with direct transfer to catheterisation laboratory (196 min versus 257 mins in the network that did not) Mean door to primary percutaneous coronary intervention time was statistically significantly lower in the network with direct transfer to catheterisation laboratory (15 mins) than the network that did not (21 mins) |
 Colleran et al. [28] | Ireland | Prospective observational study | Myocardial infarction | Evaluated the impact of electronic transmission of prehospital assessment of ST-segment-elevation myocardial infarction patients by paramedics and direct transfer to catheterisation laboratory | Electronic electrocardiogram transmission did not reduce rates of inappropriate catheterisation laboratory activation or reduce door to balloon times |
 Kendall et al. [34] | UK, England | Retrospective observational study | Stroke | Paramedics transported patients with suspected stroke directly to computerised tomography scanner (paramedic had no direct involvement in patient care or treatment in hospital other than transportation to computerised tomography) | The direct to computerised tomography scan pathway successfully reduced delays to thrombolysis treatment (call to door and computerised tomography to needle times were not improved) |
 Meretoja et al. [36] | Australia | Prospective observational study | Stroke | Paramedics pre-notified stroke teams with patient details and transported patients directly to computerised tomography scanner (paramedic had no direct involvement in patient care or treatment in hospital other than transportation to computerised tomography). | The enhanced stroke thrombolysis protocol was demonstrated to be transferable to the Australian healthcare setting |
 Binning et al. [27] | USA | Retrospective observational study | Stroke | Pre-hospital alert by emergency medical services for suspected stroke that bypasses the emergency department (straight to computerised tomography scan) | Decreased door to computerised tomography scan and door to needle times |
 Farshid et al. [32] | Australia | Prospective observational study | Myocardial infarction | Pre-hospital diagnosis of ST-segment-elevation myocardial infarction by paramedics and direct transfer to catheterisation laboratory | Ambulance diagnosis of ST-segment-elevation myocardial infarction and direct transfer to catheterisation laboratory was associated with shorter treatment times and better outcomes including lower mortality |
 Schustereder et al. [39] | Austria | Single site before and after study | Stroke | Evaluated adherence to the Helsinki model for improving door to needle times (t-PA): 1) ambulance pre-notification with patient details alerting the stroke team 2) patients transferred directly onto the CT scan table on the ambulance stretcher 3) t-PA delivered in CT immediately after imaging. | Median (interquartile range) door to treatment with t-PA was reduced from 49.5 (35–95) minutes in the first month of the observation period to 29 (8.5–64.5) minutes in the fifth month |