Development of ABCDE cognitive aid tool
First design of the ABCDE CAT was made by the Non-physician Section of the Czech Society of the Emergency and Disaster Medicine based on the information in the ERC Guidelines and ALS Provider Course Manual [1, 5]. This tool was offered to the ERC ALS Science and Education Committee (SEC). The ERC ALS SEC conducted a modified Delphi process with three consensus rounds including 10 members from the ERC ALS SEC started in December 2018. The processing and design of an individual CA can be evaluated by using the “Cognitive Aids in Medicine Assessment Tool (CMAT)” [8]. The potential advantages are: linear design, single page, simple typeface, minimal use of one colour base for the entire block [9]. A linear design algorithm improves teamwork more than a branched algorithm [10].
Round 1: The first round was done as an electronic survey where respondents could provide free text comments on the first design of the ABCDE CAT– regarding what should be excluded or included. Their responses were collected in 1 month via emails. During the first round of an email communication 11 suggestions for changes were collected. The survey was responded by 4 group members (of 10). Due to the low response rate an email with the suggestions for changes was sent to the other members. All of the 10 respondents agreed with 7 suggestions. Four suggestions were adopted with changes. The survey also resulted in one new suggestion.
Round 2: All comments were added to an online survey (February 2019) and all SEC members voted if they wanted to keep the suggested changes or not. New comments were also collected at this instance. At this point 7 full changes and 4 partial changes were made and the CA was sent again for final comments and suggestions. One new suggestion occurred during the survey. All changes were adopted after the survey and sent out for another round (round 3) of free text comments by email.
Round 3: A teleconference was made to discuss the last changes of content and graphics. The final approval was done after 1 month on 1st May 2019.
Study to validate the ABCDE cognitive aid tool
Study design
A multicentre simulation pilot study on paramedic students performing patient assessment in pre-post cohorts design (without and with the use of ABCDE CA tool) was done in September 2019 in order to evaluate the impact of the ABCDE CA tool. The study took place on two paramedic schools in Prague (Czech Republic).
Representatives of the paramedic programmes of both schools made a written consent to participate in the study. The participation in the study was voluntary for paramedic students. All of the participants made a verbal consent to participate in the study.
The study design is in compliance with Czech legislation and ethical regulations in the Czech Republic. No ethical committee approval was needed.
Study location and setting
Students from two different paramedic schools in Prague participated in the study. Higher Professional School with paramedic study on the level of graduate certificate (Secondary Nursing School and Nursing College 5. kvetna, Prague, Czech Republic) with number of participants n = 24 and University School with paramedic bachelor degree study (Medical College, Prague, Czech Republic) with number of participants n = 24. The schools have different curricula but the same set of final competences of the students.
The simulation part of the study was performed in a simulation centre of the Prague Emergency Medical Services with high fidelity environment.
Eligibility criteria
Only students who completed their first and second year of the full-time study programme were included. Students with ongoing jobs as paramedic, emergency medical technician or nurse were excluded.
The potential bias of the students experience with ABCDE approach as part of school curricula was minimised by using two different schools with different curriculum, but the same competences after graduation, and students from different years of study. To minimise the influence of the researchers the simulations were evaluated by two observers and the results were analysed by two independent researchers.
The group of students consisted of 48 students, 46 students of them (95.8%) were familiar with the ABCDE approach before the study but 0 (0%) had specific training in the ABCDE approach.
Interventions
All study participants performed patient assessment alone without any further help on scene. There was an instructor of the scenario and the patient was impersonated by an experienced paramedic responding realistically according to the scenario (standardized patient). The assessment findings were as presented by the actor and if some invasive examination was needed the lead instructor provided the results. All standard equipment of an emergency department was on a trolley. In scenario 2 (described later) the participants got the ABCDE cognitive aid at the beginning of the simulation without any other preparation or instructions on how to use it.
Each participant did two similar scenarios (first without and then with the ABCDE CA tool) with at least 1 h break between the scenarios. The descriptions of the scenarios are shown below. During 5 min of briefing the participants were asked to perform a proper A-to-E assessment during the simulation, without pointing out the endpoints of the study.
Simulated scenario 1 (without the ABCDE cognitive aid). Situation: A gentlemen (born 1945) brought by his wife to the emergency department of the university hospital. He hasn’t been feeling well since yesterday, he is weak and slightly confused. You are asked to perform an examination on Emergency Department (ED) including all diagnostic aids.
Simulated scenario 2 (with the ABCDE cognitive aid). Situation: A gentlemen (born 1950) coming to the emergency department of the university hospital. He hasn’t been feeling well since yesterday and feels weakness of his legs. You are asked to perform an examination on ED including all diagnostic aids.
Outcome measures
There was a total of 1584 potential assessment steps to achieve during each scenario by all participants (each scenario has 33 assessment steps, multiplied by number of participating paramedic students). The time needed to resolve the scenarios was tested by the ALS instructors and identically determined for both scenarios to be 5 min.
Two instructors recorded the results of each paramedic’s assessment of the standardized patients in the scenarios using evaluation forms with three columns (Fig. 1). The participant’s steps in patient assessment were evaluated as: “Made in the right order”, “Made in wrong order” and “Not made at all”. Only fully and correctly performed assessments and interventions were evaluated as complete. Instructors also measured the time needed to complete the A-to-E assessment.
Sample size and data analysis
This is pilot study with no available data from previous studies. The sample size was not determined and calculated before starting the study. The cohort of paramedics was chosen and defined on a voluntary basis from cooperating schools.
Statistical methods
Odds ratios were used to compare the proportions of correctly and timely performed steps in patient assessment with and without ABCDE cognitive aid tool. The duration of the assessment with and without CA was tested by Mann-Whitney U test after exclusion of normal data distribution by Kolmogorov-Smirnov Test. Data are presented as median and 25th a 75th percentile. Statistical software STATISTICA 7.0 (StatSoft, Inc., Tulsa, Oklahoma, USA) was used for statistical analysis, calculations and creating graphs. The significance level was stated as p < 0.05.