Prehospital point-of-care testing in the United Arab Emirates : capnography and related diagnostic capability among emergency medical technicians-basic

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