Open Access

Standard operating procedure changed pre-hospital critical care anaesthesiologists’ behaviour: a quality control study

  • Leif Rognås1, 2, 3, 4Email author,
  • Troels Martin Hansen3, 4,
  • Hans Kirkegaard5 and
  • Else Tønnesen6
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine201321:84

DOI: 10.1186/1757-7241-21-84

Received: 3 September 2013

Accepted: 27 November 2013

Published: 5 December 2013

Abstract

Introduction

The ability of standard operating procedures to improve pre-hospital critical care by changing pre-hospital physician behaviour is uncertain. We report data from a prospective quality control study of the effect on pre-hospital critical care anaesthesiologists’ behaviour of implementing a standard operating procedure for pre-hospital controlled ventilation.

Materials and methods

Anaesthesiologists from eight pre-hospital critical care teams in the Central Denmark Region prospectively registered pre-hospital advanced airway-management data according to the Utstein-style template. We collected pre-intervention data from February 1st 2011 to January 31st 2012, implemented the standard operating procedure on February 1st 2012 and collected post intervention data from February 1st 2012 until October 31st 2012. We included transported patients of all ages in need of controlled ventilation treated with pre-hospital endotracheal intubation or the insertion of a supraglottic airways device. The objective was to evaluate whether the development and implementation of a standard operating procedure for controlled ventilation during transport could change pre-hospital critical care anaesthesiologists’ behaviour and thereby increase the use of automated ventilators in these patients.

Results

The implementation of a standard operating procedure increased the overall prevalence of automated ventilator use in transported patients in need of controlled ventilation from 0.40 (0.34-0.47) to 0.74 (0.69-0.80) with a prevalence ratio of 1.85 (1.57-2.19) (p = 0.00). The prevalence of automated ventilator use in transported traumatic brain injury patients in need of controlled ventilation increased from 0.44 (0.26-0.62) to 0.85 (0.62-0.97) with a prevalence ratio of 1.94 (1.26-3.0) (p = 0.0039). The prevalence of automated ventilator use in patients transported after return of spontaneous circulation following pre-hospital cardiac arrest increased from 0.39 (0.26-0.48) to 0.69 (0.58-0.78) with a prevalence ratio of 1.79 (1.36-2.35) (p = 0.00).

Conclusion

We have shown that the implementation of a standard operating procedure for pre-hospital controlled ventilation can significantly change pre-hospital critical care anaesthesiologists’ behaviour.

Keywords

Pre-hospital Out-of-hospital Prehospital emergency care (MeSH) Emergency medical services (MeSH) Helicopter emergency medical service Critical care (MeSH) Controlled ventilation Standard operating procedure Airway management (MeSH) Endotracheal intubation (MeSH) Patient safety

Background

Standard Operating Procedures (SOPs) are detailed written instructions developed to achieve uniformity in the performance of a specific task. SOPs are an integrated part of many high-risk organisations e.g. aviation and the nuclear industry. Pre-hospital critical care teams, emergency medical services (EMS) and helicopter emergency medical services (HEMS) are other examples of such organisations. Several authors have reported performance data from physician-staffed pre-hospital critical care systems describing how they use SOPs in pre-hospital advanced airway management (PHAAM) [13] and other aspects of pre-hospital critical care [4]. The ability of SOPs to improve physician-provided pre-hospital care is however still uncertain. Bosse et al. showed that implementing an SOP for the pre-hospital treatment of severe exacerbation in chronic obstructive pulmonary disease in a physician-staffed EMS in Berlin did not improve overall guideline adherence [5]. Francis et al demonstrated that implementing an SOP for the pre-hospital treatment of acute coronary syndrome in the same physician-staffed EMS in Berlin improved some aspects of patient care, whereas other aspects were not affected [6]. The same research group also found that introducing an SOP for patient documentation did improve the quality of the patient care reports [7]. Martinon et al. from the physician-staffed Service d’Aide Médicale Urgente (SAMU) in Paris reported that the implementation of an SOP for pre-hospital rapid sequence intubation (RSI) and post-RSI treatment of children with severe traumatic brain injury (TBI) significantly improved quality of care on several, but not all quality indicators [8]. Hejselbaek et al. from the anaesthesiologist-staffed EMS in Copenhagen reported difficulties in getting pre-hospital critical care anaesthesiologists to follow clinical guidelines for the pre-hospital use of hypertonic saline [9]. The authors suggest that a possible solution to this may be the development and implementation of additional instructions and an intensified educational effort.

PHAAM and pre-hospital ventilatory controlled ventilation are core parts of pre-hospital critical care. There are only limited data available addressing how controlled ventilation should be applied in the pre-hospital setting, but recent guidelines address the need for controlled oxygenation and ventilation in TBI patients [10] and patients with cardiac arrest (CA) [11, 12]. Hyperventilation worsens outcome in TBI patients because of decreased cerebral blood flow (CBF) [10, 13, 14] and EMS–induced hyperventilation and hypocapnia are well-known complications following pre-hospital endotracheal intubation (PHETI) [13, 14]. Hypoventilation will cause hypercapnia which is known to result in increased intracerebral pressure (ICP) and decreased CBF in TBI patients [10]. Iatrogenic hypoventilation and hypercapnia is correlated to worsened outcome in TBI patients [1315]. Hyperventilation may be harmful to the post-return of spontaneous circulation (ROSC) brain [11] and current guidelines expresses concern that hyperventilation in these patients may increase intrathoracic pressure thereby reducing the patient’s cardiac preload, cardiac output, and arterial blood pressure. This may subsequently result in decreased cerebral perfusion pressure and CBF [11]. Hypoventilation may also cause increased ICP and worsen metabolic acidosis in the post-ROSC patient [10]. Ventilation by a self-inflating bag may result in large tidal volume variations [16]. This could increase both the risk of hypo- and hyperventilation and the risk of high airway pressures, which in turns result in an increased risk of lung injury such as Acute Respiratory Distress Syndrome (ARDS) [17, 18].

We postulate that providing pre-hospital controlled ventilation via an automated ventilator may increase the likelihood of achieving more optimal and stable levels of ETCO2. Providing controlled ventilation with optimal frequency and tidal volumes while using a self-inflating bag may be possible, but we claim that it will take most of the pre-hospital care provider’s attention span. We believe that the only realistic way to achieve these goals under stressful pre-hospital conditions while performing several other vital tasks is by ventilating the patients with an automated ventilator and adjusting its setting according to continuous measurements of ETCO2, SpO2 and peak airway pressures.

In order to ensure the use of an automated ventilator whenever feasible we therefore designed an SOP for pre-hospital controlled ventilation in the pre-hospital critical care teams in our region.

Objective

The objective of this study was to evaluate whether the development and implementation of an SOP for controlled ventilation during transport could change pre-hospital critical care anaesthesiologists’ behaviour and thereby increase the use of automated ventilators during transport of patients ventilated via an endotracheal tube or a supraglottic airway device (SAD).

We hypothesised, that the implementation of such an SOP could significantly increase the prevalence of patients ventilated by the use of automated ventilator during transport.

Materials and methods

Design

This is a before-and-after quality insurance study of the implementation of an SOP in anaesthesiologist-staffed pre-hospital critical care teams.

Setting

The data collection for this study was part of a larger prospective cohort study of pre-hospital advanced airway management in the Central Denmark Region [19, 20].

The Central Denmark Region covers a mixed urban and rural area of approximately 13,000 km2 with a population of 1.270.000, and an overall population density is 97.7 inhabitants pr. km2.

The emergency medical Service (EMS) is a two-tiered system based on 64 road ambulances staffed by emergency medical technicians (EMTs) supported by ten pre-hospital critical care teams staffed with an anaesthesiologist and a specially trained EMT. Rapid response vehicles deploy nine of the pre-hospital critical care teams; the tenth team staffs a HEMS helicopter. All units are equipped with waveform capnography and an automated ventilator [1921].

Participants

Inclusion criteria were consecutive transported patients of all ages treated with pre-hospital endotracheal intubation or insertion of an SAD.

Exclusion criteria were inter-hospital transfers.

Interventions

We carried out the intervention in November and December 2011 and January 2012.

The intervention consisted of:
  1. a)

    Development of an evidence-based SOP for the controlled ventilation of transported patients treated with pre-hospital endotracheal intubation or insertion of an SAD by the pre-hospital critical care teams. The development of the SOP involved the clinical leads of the different pre-hospital critical care teams. We also invited the pre-hospital critical care anaesthesiologists to give feedback regarding the structure and contents of a preliminary version of the SOP.

     
  2. b)

    Introduction of the SOP. The clinical leads and members of the research group introduced the SOP to the pre-hospital critical care teams by e-mails, lectures and group discussions. We also made the SOP available on the regional on-line collection of medical guidelines, instructions and SOPs.

     
The key points of the SOP were:
  • Advanced airway management should be provided according to local, national or international standards.

  • The attending pre-hospital anaesthesiologist decided whether or not to perform advanced airway management.

  • In patients in need of controlled ventilation and treated with an endotracheal tube, a supraglottic airway device or a surgical airway, controlled ventilation should be provided by using the automated ventilator under the guidance of continuous ETCO2 monitoring.

  • Short transport distance to the receiving hospital were not by itself considered a valid reason for not using the automated ventilator.

A translated version of the full SOP is available as Additional file 1.
  1. c)

    Implementation of the SOP: We implemented the SOP on February 1st 2012.

     

We collected post-intervention data from February 1st 2012 to November 1st 2012.

Control group

From February 1st 2011 to January 31st 2012 we collected pre-hospital advanced airway management data from pre-hospital critical care teams according to the international consensus template [22]. Patients who during these 12 months met the inclusion criteria were the control group for the current study.

Endpoints and variables

The primary endpoints were
  1. 1.

    the overall percentage of included patients ventilated on an automated ventilator

     
  2. 2.

    the percentage of included TBI patients ventilated on an automated ventilator

     
  3. 3.

    the percentage of included post-ROSC patients ventilated on an automated ventilator.

     

We collected all core data proposed in the consensus-based template by Sollid et al. [22] and the variables were defined as in this template. Of special interest are the following definitions:

The pre-hospital critical care physician registered the patient category. The alternatives were:

a) isolated traumatic brain injury, b) polytrauma, c) strangulation/suffocation, d) burns, e) other blunt trauma, f) penetrating trauma, g) cardiac arrest, h) cardiac disease (excluding cardiac arrest), i) asthma/chronic obstructive pulmonary disease (COPD), j) stroke/subarachnoid hemorrhage, k) ear-nose-throat (ENT) disease, l) other.

We also required the physicians to register how they ventilated the patients after performing PHAAM. The options were: 1) Spontaneous ventilation, 2) Controlled ventilation by a self-expanding bag, 3) Controlled ventilation by the automated ventilator, 4) a combination of ventilation by the self-expanding bag and ventilation by the automated ventilator, 5) a combination of controlled and spontaneous ventilation. Since the automated ventilators could only provide controlled ventilation, only patients marked as alternatives 3 and 4 (and not alternative 5) were considered as having being ventilated by the automated ventilator.

Data sources and data collection

We collected data from eight of the ten pre-hospital critical care teams, including the HEMS. Due to differences in organisation, staffing, case mix and caseload, the last two teams were not part of the study. The anaesthesiologists in the participating teams filled in a registration form containing all the core data recommended by Sollid et al. [22] as well as the specific variables listed above. A translated version of the registration form is available as Additional file 2. We have described data collection and handling in more detail elsewhere [19].

Bias

To reduce the risk of recall bias and selection bias, the primary investigator reviewed the registration forms on a day-to-day basis. We crosschecked the registration forms with the standard pre-hospital records from the pre-hospital critical care teams to ensure the highest possible data coverage. In cases of missing data or inconsistencies, we asked the attending pre-hospital critical care anaesthesiologist to provide additional details for clarification.

Study size

We expected, based on experience from the system involved, that the prevalence of automated ventilator use in patients in need of controlled ventilation before the introduction of the SOP would be approximately 30% and that the SOP could increase this prevalence to 60%. Sample size calculations made in the statistical program Stata 12 (StataCorpLP) showed that it would require 63 patients in each group to detect a difference of this magnitude with 90% power at a significance level of 5%.

Statistical methods

We analysed the data in Stata 12 (StataCorpLP) and tested the hypotheses of no association using the chi-squared test except when data were scarce, in which case we applied Fisher’s exact test. We give estimates with 95% confidence intervals (CI) and consider a p-value below 0.05 as statistically significant. Because of the rigorous crosschecking and day-to-day control, missing data were rare. If we could not obtain the missing data, we performed complete case analyses.

Ethics

This was a quality control study, testing whether the SOP could improve the quality of patient care. The study did not involve any alterations from normal practice and according to Danish law, it did not need the approval of the Regional Ethics Committee.

The Danish Data Protection Agency approved the study (Journal number 2013-41-1462).

Results

We included 515 patients. In total, six transported patients had an SAD inserted as an airway back-up device. The rest of the included patients (n = 509) had their tracheas intubated. The attending anaesthesiologists ventilated all the patients who had an SAD inserted by using a self-expanding ventilation bag.

In Table 1, we display the results of implementing the SOP on the overall prevalence of automated ventilator use during transport of patients treated with PHETI or an SAD.
Table 1

The effect of introducing an SOP * for pre-hospital controlled ventilation on the use of automatic ventilators

Ventilator used

Before SOP (CI)

After SOP (CI)

Total

Yes

100

198

298

No

149

68

217

Total

249

266

515

Prevalence

0.40 (0.34-0.47)

0.74 (0.69-0.80)

0.58

*Standard operating procedure.

The SOP increased the overall prevalence of automated ventilator use from 0.40 (0.34-0.47) to 0.74 (0.69-0.80) with a prevalence ratio of 1.85 (1.57-2.19). This difference is statistically significant (p = 0.00).

We present the impact of the introduction of the SOP on the prevalence of automated ventilator use in patients with a TBI in Table 2. The SOP increased the prevalence of automated ventilator use from 0.44 (0.26-0.62) to 0.85 (0.62-0.97) with a prevalence ratio of 1.94 (1.26-3.0). This difference is statistically significant (p = 0.0039).
Table 2

The effect of introducing an SOP * for pre-hospital controlled ventilation on the use of automated ventilators in patients with TBI **

Ventilator used

Before SOP

After SOP

Total

Yes

14

17

31

No

18

3

21

Total

32

20

52

Prevalence

0.44 (0.26-0.62)

0.85 (0.62-0.97)

0.60

*Standard operating procedure.

**Traumatic brain injury.

Table 3 shows the effect of the SOP on automated ventilator use in patients with ROSC after pre-hospital CA. The SOP increased the prevalence of automated ventilator use from 0.39 (0.26-0.48) to 0.69 (0.58-0.78) with a prevalence ratio of 1.79 (1.36-2.35). This difference is statistically significant (p = 0.00).
Table 3

The effect of introducing an SOP * for pre-hospital controlled ventilation on the use of automatic ventilators in patients with ROSC ** after PHCA ***

Ventilator used

Before SOP (CI)

After SOP (CI)

Total

Yes

42

64

106

No

67

29

96

Total

109

93

202

Prevalence

0.39 (0.29-0.48)

0.69 (0.58-0.78)

0.52

*Standard operating procedure.

**Return of spontaneous circulation.

***Pre-hospital cardiac arrest.

Discussion

Our results show that implementing an SOP in a system of anaesthesiologists-staffed pre-hospital care teams can change pre-hospital critical care anaesthesiologists’ behaviour. We confirmed our hypothesis that the introduction of the SOP could significantly increase both the overall prevalence of ventilator use and the prevalence of ventilator use in transported TBI patients and patients who had achieved ROSC after pre-hospital CA.

Our result is in agreement with those reported by Martinon et al. [8] from Paris who found that the prevalence of automated ventilator use following RSI on paediatric TBI patients rose to 88% after the implementation of their guideline. Our result compares favourably to those found by Bosse et al. [5] and Francis et al. [6] from the physician-staffed EMS in Berlin. They investigated the impact of introducing SOPs for the pre-hospital treatment of acute exacerbation in COPD [5] and acute coronary syndrome (ACS) [6] and neither of the SOPs in these studies improved overall patient care. The authors introduced the SOPs by arranging staff meetings and distributing the SOP by e-mail and in paper copies. This is not very different from how we introduced the new SOP in our system. However, there are also some potentially important differences. Most importantly, both the SOP for exacerbation in COPD and the SOP for ACS are rather complex ones. They either require the physicians to learn the flow of actions described in the SOP by heart, or to have the SOP available bedside. In contrast, the SOP implemented in our pre-hospital critical care teams contained one simple lesson: “Use the ventilator!” Both Bosse and Francis found that their SOPs improved some aspects of patients care such as the correct use of some of the appropriate medications, and this may be in accordance with our result. Secondly, the SOPs for exacerbation in COPD and for ACS carry no immediate advantage (e.g. lighter workload or fried hands) for the attending physician. On the contrary, the physicians may have seen the introduction of the SOPs as an added workload or a burden. It is well known that, among other factors “the acceptance of a guideline depends on the relevance of its topics for resolving the problems encountered” [23]. We speculate, that the SOP for controlled ventilation introduced in our system quickly proved an advantage, decreasing the workload during patient transportation for the pre-hospital critical care anaesthesiologists once they had become accustomed to using the ventilator more frequently. We find it likely that this contributed to the satisfactory high compliance to the SOP found in this quality control study.

Several authors have described different types of barriers that may inflict the implementation of guidelines and SOPs [2426]. They typically classify these barriers as organisational, social and professional or equivalents hereto. Organisational barriers could be financial constrains, the availability of the guidelines or the perception of the care provider. Normal routine, the opinion of leaders and the existence of obsolete medical knowledge are examples of social barriers, and professional barriers may be found in the knowledge, attitudes, self-confidence, clinical skills and coping strategies of the health-care provider [27]. When implementing the SOP for controlled ventilation, we tried to overcome these barriers by involving both the clinical leads (social barriers) and the pre-hospital critical care anaesthesiologists (organisational, social and professional barriers) in the development of the SOP. We took care in introducing the reasons for implementing the SOP both by e-mail and by conducting staff meetings (professional barriers) and made sure that the SOP was available on several platforms (organisational barriers). Our results suggest that our implementation strategy may have overcome the most important barriers.

Still, more than 25% of patients in need of controlled ventilation during transport were ventilated by a self-expanding bag. There may be several reasons for this. The most important is probably that the type of ventilator used by the pre-hospital critical care teams deployed by rapid response vehicles is not suited for all patients. They are basic volume controlled ventilators with no support mode. They do not allow any trigging of the ventilator by the patients. Patients with some degree of ventilatory effort will therefore frequently need either to be (more heavily) sedated, to be treated with a NMBA or to have their ventilation supported by self-expanding bag ventilation. A more advanced ventilator may solve some of these situations, thereby potentially increasing the prevalence of patients mechanically ventilated. On the other hand, more advanced ventilators are often more bulky and requires more education and training, both of which are factors that might reduce their use in the pre-hospital setting.

The anaesthesiologists ventilated a small portion of the patients via an SAD used as an airway back-up device. We think that not putting them on the ventilator is a reasonable choice. We did not design this study to make comparisons between the patients ventilated via an SAD and those ventilated via an endotracheal tube.

Limitations

This was not an outcome study or a study of the quality of patient care per se. We designed the study to investigate whether the introduction of an SOP could change the behaviour of pre-hospital critical care anaesthesiologists. Information regarding the quality of the pre-hospital ventilation provided to the patients who were ventilated by a self-expanding bag compared to the quality provided by using the automated ventilator would, of course be of great interest. This, however, is beyond the scope of this study. In our opinion, evaluating the quality of the ventilation provided based on ETCO2-measurements would at the very least take a capnograph that were able to store continuous ETCO2 –data. Only then would we be able to make meaningful comparisons taking into account the frequency and degree of ETCO2 variations and episodes of ETCO2 – values outside the target range. Furthermore, defining this target range may prove difficult, especially when taking into account the results by Warner et al. showing a large degree of discrepancy between ETCO2 and the CO2–level in arterial blood (PaCO2) in severely injured patients [28].

Because the attending anaesthesiologists collected the data recall-and selection bias cannot be ruled out. Due to the rigorous day-to-day data control, the high response rate and no missing data we estimate the extent of these types of biases to be limited.

Generalisability

This was part of a larger study from one homogenous Danish system of anaesthesiologist-staffed pre-hospital critical care teams. This limits the ability to generalise the findings to other systems with a different staffing, caseload or case mix. Never the less, we believe that our results may have considerable impact on similar physician-staffed pre-hospital services because they indicate the possibility of altering physician behaviour and thereby potentially improving patient care by the introduction of a relatively simple SOP to a physician-staffed pre hospital critical care service.

Perspectives

More research is needed into the use of SOPs in physician-provided pre-hospital critical care. Especially, the best way to design and implement more complex SOPs in these settings needs to be identified.

Conclusion

We have shown that the introduction of an SOP for pre-hospital controlled ventilation in a system of anaesthesiologist-staffed pre-hospital critical care teams can significantly affect anaesthesiologists’ behaviour.

Authors’ information

LR is a research fellow at the Norwegian Air Ambulance Foundation, consultant anaesthesiologist at the Viborg Regional Hospital and a pre-hospital critical care physician in the Central Denmark Region. He currently holds the post as Programme Director for the Scandinavian Society of Anaesthesiology and Intensive Care Medicine Advanced Educational Programme in Emergency Critical Care.

TMH is a consultant anaesthesiologist at the Aarhus University Hospital, clinical lead of the Pre-hospital Critical Care Team in Aarhus and a pre-hospital critical care physician in the Central Denmark Region.

HK is a consultant anaesthesiologist and professor of emergency medicine at the Aarhus University Hospital.

ET is a consultant anaesthesiologist and professor of anaesthesiology at the Aarhus University Hospital.

Abbreviations

SOP: 

Standard operating procedure

PHAAM: 

Pre-hospital advanced airway management

EMS: 

Emergency medical service

HEMS: 

Helicopter emergency medical service

ETI: 

Endotracheal intubation

PHETI: 

Pre-hospital endotracheal intubation

SAD: 

Supraglottic airway device

TBI: 

Traumatic brain injury

CA: 

Cardiac arrest

ROSC: 

Return of spontaneous circulation

EMT: 

Emergency medical technicians.

Declarations

Acknowledgements

The authors wish to thank all the pre-hospital critical care anaesthesiologists who collected the data. We also thank all the EMTs who reminded them to do so.

A special thanks to EMT Tinna Højmose Østergaard for her invaluable assistance in all the practicalities of the implementation and data collection.

The Norwegian Air Ambulance Foundation, The Laerdal Foundation for Acute Medicine and The Central Denmark Region founded the study by sponsoring the salary of LR. TMH, HK and ET were funded by their departments.

The sponsors have had no influence on study design, data collection, data analysis and-interpretation, the writing of the manuscript or the decision to submit the paper for publication.

Authors’ Affiliations

(1)
Department of research and development, Norwegian Air Ambulance Foundation
(2)
Pre-hospital Critical Care Team, Department of Anaesthesiology, Viborg Regional Hospital
(3)
Pre-hospital Critical Care Team, Aarhus University Hospital
(4)
Department of Pre-hospital Medical Services, Central Denmark Region
(5)
Centre for Emergency Medicine Research, Aarhus University Hospital
(6)
Department of Anaesthesiology, Aarhus University Hospital

References

  1. Chesters A, Keefe N, Mauger J, Lockey D: Prehospital anaesthesia performed in a rural and suburban air ambulance service staffed by a physician and paramedic: a 16-month review of practice. Emerg Med J. 2013, 00: 1-4. doi:10.1136/emermed-2012-201846Google Scholar
  2. Harris T, Lockey D: Success in physician prehospital rapid sequence intubation: what is the effect of base speciality and length of anaesthetic training?. EMJ. 2011, 28 (3): 225-229. 10.1136/emj.2009.088302.View ArticlePubMedGoogle Scholar
  3. Von Vopelius-Feldt J, Benger JR: Prehospital anaesthesia by a physician and paramedic critical care team in Southwest England. Eur J Emerg Med. 2012, 20 (6): 382-386. doi:10.1097/MEJ.0b013e32835b08b7View ArticleGoogle Scholar
  4. Davies GE, Lockey DJ: Thirteen survivors of prehospital thoracotomy for penetrating trauma: a prehospital physician-performed resuscitation procedure that can yield good results. J Trauma. 2011, 70 (5): E75-E78. 10.1097/TA.0b013e3181f6f72f.View ArticlePubMedGoogle Scholar
  5. Bosse G, Schmidbauer W, Spies CD, Sorensen M, Francis RC, Bubser F, Krebs M, Kerner T: Adherence to guideline-based standard operating procedures in pre-hospital emergency patients with chronic obstructive pulmonary disease. J Int Med Res. 2011, 39 (1): 267-276. 10.1177/147323001103900129.View ArticlePubMedGoogle Scholar
  6. Francis RC, Bubser F, Schmidbauer W, Spies CD, Sorensen M, Bosse G, Kerner T: Effects of a standard operating procedure on prehospital emergency care of patients presenting with symptoms of the acute coronary syndrome. Eur J Emerg Med. 2013, [Epub ahead of print]Google Scholar
  7. Francis RC, Schmidbauer W, Spies CD, Sorensen M, Bubser F, Kerner T: Standard operating procedures as a tool to improve medical documentation in preclinical emergency medicine. EMJ. 2010, 27 (5): 350-354. 10.1136/emj.2008.070284.View ArticlePubMedGoogle Scholar
  8. Martinon C, Duracher C, Blanot S, Escolano S, De Agostini M, Perie-Vintras AC, Orliaguet G, Carli PA, Meyer PG: Emergency tracheal intubation of severely head-injured children: changing daily practice after implementation of national guidelines. Pediatr Crit Care Med. 2011, 12 (1): 65-70. 10.1097/PCC.0b013e3181e2a244.View ArticlePubMedGoogle Scholar
  9. Hejselbaek J, Steinmetz J, Rasmussen LS: Prehospital guidelines for use of hypertonic saline are not followed systematically. Dan Med J. 2012, 59 (4): A4417-PubMedGoogle Scholar
  10. Davis DP: Prehospital intubation of brain-injured patients. Curr Opin Crit Care. 2008, 14 (2): 142-148. 10.1097/MCC.0b013e3282f63c40.View ArticlePubMedGoogle Scholar
  11. Nolan JP, Neumar RW, Adrie C, Aibiki M, Berg RA, Bottiger BW, Callaway C, Clark RS, Geocadin RG, Jauch EC: Post-cardiac arrest syndrome: epidemiology, pathophysiology, treatment, and prognostication: a scientific statement from the International liaison committee on resuscitation; the American heart Association emergency cardiovascular care Committee; the Council on cardiovascular surgery and anesthesia; the Council on cardiopulmonary, perioperative, and critical care; the Council on clinical cardiology; the Council on stroke. Resuscitation. 2008, 79 (3): 350-379. 10.1016/j.resuscitation.2008.09.017.View ArticlePubMedGoogle Scholar
  12. Nolan JP, Soar J, Zideman DA, Biarent D, Bossaert LL, Deakin C, Koster RW, Wyllie J, Bottiger B: European resuscitation council guidelines for resuscitation 2010 section 1: executive summary. Resuscitation. 2010, 81 (10): 1219-1276. 10.1016/j.resuscitation.2010.08.021.View ArticlePubMedGoogle Scholar
  13. Davis DP, Peay J, Sise MJ, Kennedy F, Simon F, Tominaga G, Steele J, Coimbra R: Prehospital airway and ventilation management: a trauma score and injury severity score-based analysis. J Trauma. 2010, 69 (2): 294-301. 10.1097/TA.0b013e3181dc6c7f.View ArticlePubMedGoogle Scholar
  14. Dumont TM, Visioni AJ, Rughani AI, Tranmer BI, Crookes B: Inappropriate prehospital ventilation in severe traumatic brain injury increases in-hospital mortality. J Neurotrauma. 2010, 27 (7): 1233-1241. 10.1089/neu.2009.1216.View ArticlePubMedGoogle Scholar
  15. Warner KJ, Cuschieri J, Copass MK, Jurkovich GJ, Bulger EM: The impact of prehospital ventilation on outcome after severe traumatic brain injury. J Trauma. 2007, 62 (6): 1330-1336. 10.1097/TA.0b013e31804a8032. discussion 1336-1338View ArticlePubMedGoogle Scholar
  16. Lee HM, Cho KH, Choi YH, Yoon SY, Choi YH: Can you deliver accurate tidal volume by manual resuscitator?. EMJ. 2008, 25 (10): 632-634. 10.1136/emj.2007.053678.View ArticlePubMedGoogle Scholar
  17. The Acute Respiratory Distress Syndrome Network: Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome.: the acute respiratory distress syndrome network. New Engl J Med. 2000, 342 (18): 1301-1308.View ArticleGoogle Scholar
  18. Pinheiro de Oliveira R, Hetzel MP, dos Anjos Silva M, Dallegrave D, Friedman G: Mechanical ventilation with high tidal volume induces inflammation in patients without lung disease. Critical care. 2010, 14 (2): R39-10.1186/cc8919.PubMed CentralView ArticlePubMedGoogle Scholar
  19. Rognas L, Hansen TM, Kirkegaard H, Tonnesen E: Pre-hospital advanced airway management by experienced anaesthesiologists: a prospective descriptive study. Scand J Trauma Resusc Emerg Med. 2013, 21 (1): 58-10.1186/1757-7241-21-58.PubMed CentralView ArticlePubMedGoogle Scholar
  20. Rognas L, Hansen TM, Kirkegaard H, Tonnesen E: Refraining from pre-hospital advanced airway management: a prospective observational study of critical decision making in an anaesthesiologist-staffed pre-hospital critical care service. Scand J Trauma Resusc Emerg Med. 2013, 21 (1): 75-10.1186/1757-7241-21-75.PubMed CentralView ArticlePubMedGoogle Scholar
  21. Rognas LK, Hansen TM: EMS-physicians’ self reported airway management training and expertise; a descriptive study from the Central Region of Denmark. Scand J Trauma Resusc Emerg Med. 2011, 19: 10-10.1186/1757-7241-19-10.PubMed CentralView ArticlePubMedGoogle Scholar
  22. Sollid SJ, Lockey D, Lossius HM: A consensus-based template for uniform reporting of data from pre-hospital advanced airway management. Scand J Trauma Resusc Emerg Med. 2009, 17: 58-10.1186/1757-7241-17-58.PubMed CentralView ArticlePubMedGoogle Scholar
  23. Fink A, Kosecoff J, Chassin M, Brook RH: Consensus methods: characteristics and guidelines for use. Am J Pub Health. 1984, 74 (9): 979-983. 10.2105/AJPH.74.9.979.View ArticleGoogle Scholar
  24. Oxman AD: An overview of strategies to promote implementation of evidence-based health care. Evidence-based Practice in Primary Care. Edited by: Silagy CHA. 2001, BMA House, Tavistock Square, London WC1H 9JR: BMJ Books, 101-120.Google Scholar
  25. Haines A: Integrating research evidence into practice. Evidencebased Practice in Primary Care. Edited by: Silagy CHA. 2001, BMA House,Tavistock Square,London WC1H 9JR: BMJ Books, 157-175.Google Scholar
  26. Forsetlund L, Bjorndal A: Identifying barriers to the use of research faced by public health physicians in Norway and developing an intervention to reduce them. J Health Serv Res Policy. 2002, 7 (1): 10-18. 10.1258/1355819021927629.View ArticlePubMedGoogle Scholar
  27. Bosse G, Breuer JP, Spies C: The resistance to changing guidelines–what are the challenges and how to meet them. Best Pract Res Clin Anaesthesiol. 2006, 20 (3): 379-395. 10.1016/j.bpa.2006.02.005.View ArticlePubMedGoogle Scholar
  28. Warner KJ, Cuschieri J, Garland B, Carlbom D, Baker D, Copass MK, Jurkovich GJ, Bulger EM: The utility of early end-tidal capnography in monitoring ventilation status after severe injury. J Trauma. 2009, 66 (1): 26-31. 10.1097/TA.0b013e3181957a25.View ArticlePubMedGoogle Scholar

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