The challenges of pre-hospital emergency treatment of Chronic Obstructive Pulmonary Disease.

1
The challenges of pre-hospital emergency
treatment of Chronic Obstructive Pulmonary
Disease.

• David Fitzpatrick1, Dr Donogh Maguire2, Dr Edward
  Duncan3
• Clinical Research Paramedic, Scottish Ambulance
  Service/NMAHP RU
• Consultant in Emergency Medicine, Monklands
  District General Hospital
• Senior Research Fellow, Nursing Midwifery and
  Allied Health Professions Research Unit

2
Background

• Scottish Ambulance Service responded to 27,093
  patients with Chronic Obstructive Pulmonary
  Disease over past 12 months. (Equating to 6 of
  all calls n600,000)
• Anecdotal evidence from Dr Donogh Maguire
  (Consultant in Emergency Medicine) suggested
  pre-hospital treatment of patients with Acute
  Exacerbation of COPD may be suboptimal.
• Pre-hospital clinical guidelines recommend during
  an acute exacerbation of COPD oxygen saturations
  should be kept between 88-92 (JRCALC, 2009).
• Despite these many patients with COPD treated
  with oxygen therapy in the pre-hospital
  environment have oxygen saturations recorded
  above 92. (SAS Audit Data 2011/12)
• Current evidence suggests hyperoxygenation in the
  pre-hospital environment can adversely effect
  patient outcome.

3
Literature

• Hale et al suggest pre-hospital hyperoxygenation
  may be due to a lack of appropriate oxygen
  delivery equipment, for example
• Venturi entrainment devices
• Nasal cannulae
• Oxygen saturation probes
• Durrington et al demonstrated that the provision
  of venturi masks could reduce the number of COPD
  patients receiving high flow oxygen therapy.
• Scottish Ambulance Service carry Venturi
  entrainment devices and oxygen saturation probes.
  Nasal cannulae are being introduced.

4
Literature cont.

• Mistrust of hypoxic drive theory?
• New writes excessive pre-hospital oxygen
  prescription stems in part from a poor
  understanding of the consequences and
  presentation of hypercapnia

5

Literature cont.

• Recognition of COPD
• Some studies have demonstrated confusion around
  the most appropriate management strategy for
  patients with COPD.
• Prehospital
• Hale et al ambulance clinicians identified only
  58 of cases correctly.
• Denniston et al ambulance clinicians identified
  only 32 of COPD patients correctly.
• Within hospital
• Joosten et al demonstrated that 80 of patients
  received oxygen therapy in excess of 2 litres/min
  after admission to the Emergency Department

6
Literature cont.

• Oxygen alert cards?
• Two previous studies have demonstrated only
  moderate success with alert cards in reducing
  pre-hospital hyperoxygentation
• Gooptu et al 62 of patients (n 33) were
  managed by ambulance clinicians according to the
  guidance provided on the card.
• Wolstenholme et al only 26 of patients (n5)
  presented their card to the Health Care
  Professional during treatment.

7
Multimodal communication - A solution?

• British Thoracic Society (2008). Emergency
  Oxygen Use in Adult Patients
• An emergency card to be kept with mask and
  adaptor or in lifeline pod at premises.
• A laminated emergency card suitable for a purse
  or wallet.
• A lifeline pod kept in fridge with a label to be
  placed on front door of premises.
• NHS 24 and General Practitioner informed
  (essential information stored).
• Electronic tagging of patients address with
  Oxygen Alert by the Emergency Medical Dispatch
  Centre.

8
Presented COPD paper in June 2011 to SAS Medical
Directorate.Fully supportive of
system.Emergency Medical Despatch Centres
(EMDC) electronically tag at risk individuals.
(only occurring in West of Scotland EMDC at
present)But..there is a lack of evidence
supporting the multimodal system.
9
What next?

• On-going collaboration between Scottish Ambulance
  Service and Nursing, Midwifery and Allied Health
  Professions Research Unit.
• Possible future studies for discussion
• a cross-sectional study (n27,000 calls) of
  oxygen therapy in known COPD cases in
  pre-hospital emergency care using data linkage
  between SAS dataset and CHI mortality data for
  Scotland.
• a large scale trial to measure effectiveness of
  multimodal system in reducing hyper-oxygenation
  and mortality rates.