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Prehospital point-of-care testing in the United Arab Emirates : capnography and related diagnostic capability among emergency medical technicians-basic
Author(s)
Khan, Afzal
Date Issued
2021
Type
Thesis
Publisher
Cape Peninsula University of Technology
Abstract
Ambulance personnel with Emergency Medical Technician-Basic (EMT-B) qualifications
employed by National Ambulance Service in the UAE have access to capnography to aid clinical
decision-making. It is unconventional for EMT-Bs to use capnography for clinical monitoring.
There is little evidence on the use ETCO2/capnography as a Point-of-Care Test (POCT) at EMT-B
level of care. There is no research to show the clinical value proposition and self-perceived value
of this scope addition to EMT-B providers, nor has the skill transfer been evaluated. The problem
of ‘How does point-of-care testing through capnography, enhance (or complicates) the diagnostic
capability of EMT-Bs in the UAE?’ is posited in this study.
Methods
A post-positivist paradigm with a deductive analytical approach was used. The literature review
informed the problem description and factor analysis, followed by the analysis of retrospective
quantitative data from archived patient records. The EMS database produced an epidemiological
description of ETCO2 practice over a 12-month period, with 39 937 patient care records of
potential and actual capnography utilization. The prospective survey of 281 EMT-Bs informed the
self-perceptions on ETCO2 and related diagnostic experience of EMT-Bs in the northern emirates
of the UAE.
Results
In the retrospective data collected from Patient Care Records (PCR), the high caseloads observed
in the Sharjah Emirate compared to other emirates drew attention to the maldistributed caseload
and the geographical bias of capnography exposure to cases (p-value: 1.17x10-12). ETCO2
utilization by EMT-Bs caring for Head and neck injuries showed 1.65% use, Breathing difficulty:
19.88%, Trauma/Assault cases: 2.73%, Mental/Emotional and Psychological cases: 2.09%, and
the other case categories were at 4.52% utilization. ETCO2 was used on 52.2% of the resuscitation
cases and among those CPR cases that had airway adjuncts in-situ, 54.77% of them were
monitored with ETCO2 (p-value: 5.23×10-5). In CPR cases, 62.04% ROSC was observed with ETCO2
use (p-value: 0.0398). The 0-10 mmHg category of ETCO2 has the greatest escalation trend in
more than 1500 cases. Trends in monitoring of patient respiration rates beyond normal
parameters (10-20 breaths per minute) using capnography highlight appropriateness of use; also
seen with assessments of Asthma patients (27.68%, n = 49), assisted ventilation (49.34%, n = 113)
in resuscitation cases and in non-resuscitation cases (3.78%, n = 1470). The mean shock index
was lower among ETCO2 patients (p-value: 2.1115793×10-98)
The results of EMT-Bs perceptions of capnography use in the survey, highlighted that 89.7% (n =
252), still used conventional observing of chest excursions and 85.8% (n = 241) included the use
of stethoscope. Although a majority (78.3%; n = 220) reported using capnography in assessing
patient ventilations, utilization of ETCO2 was used in only 4.98% (n = 1987) of cases. Proportions
of respondents that perceived positive value in capnography use were in relation to: placement
of SGAs (78.9%, n = 202), guiding ventilation (93.3%, n = 237), managing traumatic brain injury
(93.8%, n = 240), monitoring CPR quality (97.2%, n = 249) and as a predictor of CPR event outcome
(94.5%, n = 241). The EMT-Bs that found value in monitoring spontaneous breathing of alert
patients, was at 65.6% (n = 168) and 87.9% (n = 225) considered capnography as useful in
observing Covid-19 patients. Most (66.8%; n = 171) perceived capnography as being useful in
detecting ROSC, and 61.3% (n = 157) correctly identified hypoventilation in a brain injury
scenario. Diagnostic detection of broncho-constriction by some EMT-Bs (44.1%; n = 113) and
diagnostic value of CPR adequacy were not well interpreted. Capnography was easy to set-up
and use, was the majority view (93.3%; n, 236) and 74% (n = 188) felt that capnography enhanced
their ability. No patient gender bias detected in capnography use (p-value:0.906) and education
and training were perceived as the overall greatest need for capnography use by 80.1% (n = 225)
of respondents.
Conclusion and Recommendations
EMT-Bs operating in the northern emirates of UAE have demonstrated the use of capnography
as a tool to support their diagnostic abilities. Capnography use has been low but safe,
notwithstanding that it is not normally a scope expectation for EMT-Bs. The study documents the
need for education and training support to create an enabling environment for adoption of new
technologies. Risk mitigation may be managed through quality and audit systems. The inclusion
of capnography into the EMT-B scope of practice has favorable implementation and user
acceptability. Patient outcomes in such an initiative warrants additional research. New
technologies and advancements in artificial intelligence requires EMS to promote technical
relevance, including capnography optimization among frontline health care workers
employed by National Ambulance Service in the UAE have access to capnography to aid clinical
decision-making. It is unconventional for EMT-Bs to use capnography for clinical monitoring.
There is little evidence on the use ETCO2/capnography as a Point-of-Care Test (POCT) at EMT-B
level of care. There is no research to show the clinical value proposition and self-perceived value
of this scope addition to EMT-B providers, nor has the skill transfer been evaluated. The problem
of ‘How does point-of-care testing through capnography, enhance (or complicates) the diagnostic
capability of EMT-Bs in the UAE?’ is posited in this study.
Methods
A post-positivist paradigm with a deductive analytical approach was used. The literature review
informed the problem description and factor analysis, followed by the analysis of retrospective
quantitative data from archived patient records. The EMS database produced an epidemiological
description of ETCO2 practice over a 12-month period, with 39 937 patient care records of
potential and actual capnography utilization. The prospective survey of 281 EMT-Bs informed the
self-perceptions on ETCO2 and related diagnostic experience of EMT-Bs in the northern emirates
of the UAE.
Results
In the retrospective data collected from Patient Care Records (PCR), the high caseloads observed
in the Sharjah Emirate compared to other emirates drew attention to the maldistributed caseload
and the geographical bias of capnography exposure to cases (p-value: 1.17x10-12). ETCO2
utilization by EMT-Bs caring for Head and neck injuries showed 1.65% use, Breathing difficulty:
19.88%, Trauma/Assault cases: 2.73%, Mental/Emotional and Psychological cases: 2.09%, and
the other case categories were at 4.52% utilization. ETCO2 was used on 52.2% of the resuscitation
cases and among those CPR cases that had airway adjuncts in-situ, 54.77% of them were
monitored with ETCO2 (p-value: 5.23×10-5). In CPR cases, 62.04% ROSC was observed with ETCO2
use (p-value: 0.0398). The 0-10 mmHg category of ETCO2 has the greatest escalation trend in
more than 1500 cases. Trends in monitoring of patient respiration rates beyond normal
parameters (10-20 breaths per minute) using capnography highlight appropriateness of use; also
seen with assessments of Asthma patients (27.68%, n = 49), assisted ventilation (49.34%, n = 113)
in resuscitation cases and in non-resuscitation cases (3.78%, n = 1470). The mean shock index
was lower among ETCO2 patients (p-value: 2.1115793×10-98)
The results of EMT-Bs perceptions of capnography use in the survey, highlighted that 89.7% (n =
252), still used conventional observing of chest excursions and 85.8% (n = 241) included the use
of stethoscope. Although a majority (78.3%; n = 220) reported using capnography in assessing
patient ventilations, utilization of ETCO2 was used in only 4.98% (n = 1987) of cases. Proportions
of respondents that perceived positive value in capnography use were in relation to: placement
of SGAs (78.9%, n = 202), guiding ventilation (93.3%, n = 237), managing traumatic brain injury
(93.8%, n = 240), monitoring CPR quality (97.2%, n = 249) and as a predictor of CPR event outcome
(94.5%, n = 241). The EMT-Bs that found value in monitoring spontaneous breathing of alert
patients, was at 65.6% (n = 168) and 87.9% (n = 225) considered capnography as useful in
observing Covid-19 patients. Most (66.8%; n = 171) perceived capnography as being useful in
detecting ROSC, and 61.3% (n = 157) correctly identified hypoventilation in a brain injury
scenario. Diagnostic detection of broncho-constriction by some EMT-Bs (44.1%; n = 113) and
diagnostic value of CPR adequacy were not well interpreted. Capnography was easy to set-up
and use, was the majority view (93.3%; n, 236) and 74% (n = 188) felt that capnography enhanced
their ability. No patient gender bias detected in capnography use (p-value:0.906) and education
and training were perceived as the overall greatest need for capnography use by 80.1% (n = 225)
of respondents.
Conclusion and Recommendations
EMT-Bs operating in the northern emirates of UAE have demonstrated the use of capnography
as a tool to support their diagnostic abilities. Capnography use has been low but safe,
notwithstanding that it is not normally a scope expectation for EMT-Bs. The study documents the
need for education and training support to create an enabling environment for adoption of new
technologies. Risk mitigation may be managed through quality and audit systems. The inclusion
of capnography into the EMT-B scope of practice has favorable implementation and user
acceptability. Patient outcomes in such an initiative warrants additional research. New
technologies and advancements in artificial intelligence requires EMS to promote technical
relevance, including capnography optimization among frontline health care workers
Additional information
Thesis (Master of Emergency Medical Care (MEMC))--Cape Peninsula University of Technology, 2021
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