Introduction: Continuous professional development and education associated with Evaluation of health Professional Practices (EPP) has been legally implemented and is mandatory in France since 2004. EPP applies to all aspects of the health care system, including pre-hospital EMS and their call centers. EPP must comply with one of the restricted proposals issued by Health Authorities. The aim of this presentation is to lay out the methodology selected to achieve this legal requirement in an EMS serving 1.5 million population. Methods: The proposed methods were: clinical audit compared with standards, identification of existing procedures, identification of clinical decision trees, identification of patient's pathway to optimised final care. Among these methods, identification of patient's clinical pathway was selected as the best method for a call center study, since it allows to monitor the overall handling of an emergency call, from the early phone call to the final point of care. Among the various pathologies, cardiac arrest was selected because: 1 - The release of new AHA recommendations in 2010, 2 - Similar “cardiac arrest” EPP developments in the hospital where the EMS is based, 3 - The need for quality control of all cardiac arrest calls. Expected results: EPP in the EMS is divided in 3 steps: Step 1: results from studying the running procedures, regarding call handling of cardiac arrests including triage performed by operators and medical dispatchers (physicians). Retrospective study of files that were triaged as cardiac arrests by operators. Duration: 6 months. Step 2: elaboration of an action plan: Sharing of the results with operators and medical dispatchers. Setting up of a global team training program for both operators and physicians, in agreement with new AHA guidelines. Duration: 6 months. Step 3: new retrospective study based on the same methodology than step 1, done after 6 months. The comparison of results of both studies will lead to the selection of pertinent indicators allowing continuous quality control. Conclusion: This EPP aims at evaluating and improving the management of emergency calls. It is expected to bring other benefits, such as easing the implementation of new guidelines, or defining new indicators for a continuous quality control.

New guidelines for the management of cardiac arrest in children and infants were published in 2005 by the International Liaison Committee On Resuscitation and the European Resuscitation Council. These guidelines preceded publication of French recommendations in September 2006, including changing practices in Paediatric Life Support (PLS).1International Liaison Committee On Resuscitation Part 6: paediatric basic and advanced life support.Resuscitation. 2005; 67: 271-291Abstract Full Text Full Text PDF Scopus (85) Google Scholar, 2Biarent D. Bingham R. Richmond S. et al.European Resuscitation Council guidelines for resuscitation 2005 Section 6: paediatric life support.Resuscitation. 2005; 67: S97-S133Abstract Full Text Full Text PDF Scopus (210) Google Scholar, 3SFAR SFMU CFRC Recommandations formalisées d’expert: prise en charge de l’arrêt cardiaque.Ann Fr Anesth Reanim. 2007; 26: 1008-1019Crossref Google Scholar, 4Goddet N.S. Dolveck F. Descatha A. et al.Prise en charge de l’arrêt cardiaque de l’enfant et du nourrisson au sein d’un SAMU – SMUR: evaluation préliminaire des pratiques dans le cadre de l’évaluation des pratiques professionnelles.JEUR. 2008; (abstract): 134-135Google ScholarIn the emergency medical system of our district, we have 7–10 general pre-hospital emergency medical teams (GPEMT) localised in four units and only one specialized for newborns and children (paediatric unit). In this situation, GPEMT with limited knowledge of the PLS are sometimes faced with children in cardiac arrest.The aim of this study was to evaluate knowledge of PLS before and after simulation training among our GPEMT (largest unit of the district). The study was conducted in three stages from February 2007 to November 2009. Newborns were excluded. A questionnaire about PLS was completed by physicians, nurses and paramedics of the GPEMT before and after training. All professionals included in this study were volunteers. The following details were obtained during completion of the questionnaires: guidelines reading, definition of the end of childhood, cardiac arrest cause, sequence of action for PLS, compression–ventilation ratio, use of automated external defibrillators, use of manual defibrillators, use of epinephrine, and duration of resuscitation. Simulation training was then organised for all the members of the GPEMT. Six half-day training classes were organised with theoretical and practical approaches simulating real life situations of PLS. Statistical analyses comprised descriptions of variables and proportion comparison by χ2 test.Sixty-one questionnaires were analyzed in 2007 and 43 in 2009. Table 1 reports results for PLS. Guidelines were read by 10% of the professionals in 2007 and almost 20% in 2009. Hypoxemia was identified as the cause of cardiac arrest cause in 75% (n = 45) in 2007 and 98% (n = 41) in 2009. Only 21% (n = 12) rescuers in 2007 performed 1 min of CPR before they went for help, compared with 84% (n = 36) in 2009 (p < 10−4). Duration of CPR was <20 min in 3% (n = 2) in 2007 compared with 65% (n = 28) in 2009 (p < 10−4).Table 1Results for paediatric basic and advanced life support.Expected response2007 n = 612009 n = 43χ2 testPaediatric basic life supportEnd of childhoodPuberty7% (4)51% (22)p < 10−4Compression ventilation ratio ChildOne rescuer: 30/225% (15)72% (31)p < 10−4Two or more: 15/234% (21)51% (22)ns InfantOne rescuer: 30/216% (10)61% (26)p < 10−4Two or more: 15/223% (14)47% (20)p < 0.05Automated external defibrillator Lower age of use1 year33% (12)84% (36)p < 10−4 Paediatric padsAttenuated energy75% (44)81% (35)nsPaediatric advanced life supportManual defibrillator Second shock energy4 J/kg15% (9)65% (28)p < 10−4EpinephrineFurther dose every 3–5 min51% (31)44% (19) Open table in a new tab This study highlighted the importance of training for the general teams rarely faced with children and infants, especially in cardiac arrest. Their performance improved between 2007 and 2009. All physicians, nurses and paramedics reported the importance of the simulation and the interest in discussing and training for uncommon pathology. Simulations seem to have benefited the training and knowledge of the GPEMT.5Nelson K.L. Mills Jr., W. Umbel S. et al.Lighting sudden cardiac death, simulation and automated external defibrillator.Resuscitation. 2007; 74: 567-574Abstract Full Text Full Text PDF Scopus (11) Google Scholar There may have been a selection bias because only 69.3% of the members of the unit answered in 2007 compared with just 49.0% in 2009. However, the persistently low proportion of expected answers leads us to think that any bias is likely to be small.Regular training programs of general EMS should include uncommon life-threatening events like cardiac arrest in children and infants, even if in most cases paediatric units could support them in these situations. Further studies on cost-effectiveness of this training are needed.Conflicts of interestNone. New guidelines for the management of cardiac arrest in children and infants were published in 2005 by the International Liaison Committee On Resuscitation and the European Resuscitation Council. These guidelines preceded publication of French recommendations in September 2006, including changing practices in Paediatric Life Support (PLS).1International Liaison Committee On Resuscitation Part 6: paediatric basic and advanced life support.Resuscitation. 2005; 67: 271-291Abstract Full Text Full Text PDF Scopus (85) Google Scholar, 2Biarent D. Bingham R. Richmond S. et al.European Resuscitation Council guidelines for resuscitation 2005 Section 6: paediatric life support.Resuscitation. 2005; 67: S97-S133Abstract Full Text Full Text PDF Scopus (210) Google Scholar, 3SFAR SFMU CFRC Recommandations formalisées d’expert: prise en charge de l’arrêt cardiaque.Ann Fr Anesth Reanim. 2007; 26: 1008-1019Crossref Google Scholar, 4Goddet N.S. Dolveck F. Descatha A. et al.Prise en charge de l’arrêt cardiaque de l’enfant et du nourrisson au sein d’un SAMU – SMUR: evaluation préliminaire des pratiques dans le cadre de l’évaluation des pratiques professionnelles.JEUR. 2008; (abstract): 134-135Google Scholar In the emergency medical system of our district, we have 7–10 general pre-hospital emergency medical teams (GPEMT) localised in four units and only one specialized for newborns and children (paediatric unit). In this situation, GPEMT with limited knowledge of the PLS are sometimes faced with children in cardiac arrest. The aim of this study was to evaluate knowledge of PLS before and after simulation training among our GPEMT (largest unit of the district). The study was conducted in three stages from February 2007 to November 2009. Newborns were excluded. A questionnaire about PLS was completed by physicians, nurses and paramedics of the GPEMT before and after training. All professionals included in this study were volunteers. The following details were obtained during completion of the questionnaires: guidelines reading, definition of the end of childhood, cardiac arrest cause, sequence of action for PLS, compression–ventilation ratio, use of automated external defibrillators, use of manual defibrillators, use of epinephrine, and duration of resuscitation. Simulation training was then organised for all the members of the GPEMT. Six half-day training classes were organised with theoretical and practical approaches simulating real life situations of PLS. Statistical analyses comprised descriptions of variables and proportion comparison by χ2 test. Sixty-one questionnaires were analyzed in 2007 and 43 in 2009. Table 1 reports results for PLS. Guidelines were read by 10% of the professionals in 2007 and almost 20% in 2009. Hypoxemia was identified as the cause of cardiac arrest cause in 75% (n = 45) in 2007 and 98% (n = 41) in 2009. Only 21% (n = 12) rescuers in 2007 performed 1 min of CPR before they went for help, compared with 84% (n = 36) in 2009 (p < 10−4). Duration of CPR was <20 min in 3% (n = 2) in 2007 compared with 65% (n = 28) in 2009 (p < 10−4). This study highlighted the importance of training for the general teams rarely faced with children and infants, especially in cardiac arrest. Their performance improved between 2007 and 2009. All physicians, nurses and paramedics reported the importance of the simulation and the interest in discussing and training for uncommon pathology. Simulations seem to have benefited the training and knowledge of the GPEMT.5Nelson K.L. Mills Jr., W. Umbel S. et al.Lighting sudden cardiac death, simulation and automated external defibrillator.Resuscitation. 2007; 74: 567-574Abstract Full Text Full Text PDF Scopus (11) Google Scholar There may have been a selection bias because only 69.3% of the members of the unit answered in 2007 compared with just 49.0% in 2009. However, the persistently low proportion of expected answers leads us to think that any bias is likely to be small. Regular training programs of general EMS should include uncommon life-threatening events like cardiac arrest in children and infants, even if in most cases paediatric units could support them in these situations. Further studies on cost-effectiveness of this training are needed. Conflicts of interestNone. None.

Conduct of emergency research under waiver of consent produces special challenges. Moreover, the act of performing research may have unintended effects, potentially beneficial or detrimental. The Dispatcher-Assisted Randomized Trial (DART) was designed to compare 2 types of dispatcher cardiopulmonary (CPR) instruction, but not intended to affect the proportion of arrest victims that received bystander CPR. We sought to determine whether odds of receiving bystander CPR were higher during DART than during the periods before and after.We conducted an observational cohort study of 8626 adults who suffered non-traumatic out-of-hospital cardiac arrest prior to emergency medical services (EMS) arrival in greater King County, Washington, between January 1, 1999, and December 31, 2011. Bystander CPR status was assessed through review of dispatch recordings and EMS reports to classify any bystander CPR (any B-CPR), and further categorized as bystander CPR with or without dispatcher assistance (DA-CPR and B-CPR, no DA). We used multivariable logistic regression to evaluate odds of B-CPR before, during, and after DART.The proportions receiving any B-CPR were 52% before DART (1817/3468), 59% during DART (2093/3527), and 54% after DART (885/1631). Compared to the period before DART, odds of receiving any B-CPR were higher during DART (OR = 1.35, 95% CI = 1.23–1.49), but no different after (OR = 1.10, 0.98–1.24). Compared to the before period, odds of DA-CPR were higher during DART (OR = 1.79, 1.59–2.02) but no different after (OR = 0.94, 0.80–1.10).Odds of bystander CPR were higher during the trial, an increase related to higher likelihood of DA-CPR. The finding suggests a possible indirect community-wide benefit due to the interventional trial.

Depuis septembre 2005, notre SAMU propose aux trois associations secouristes participant au reseau de secours sur le departement, une formation continue a l'attention des chefs d'equipe d'intervention (CEI) : les "Jeudis du secourisme". Nous avons souhaite evaluer ces formations au decours de la premiere annee. Pour cela une enquete declarative a ete realisee a l'aide d'un questionnaire de satisfaction et d'impact sur les pratiques. Tous les CEI ayant participe a une ou plusieurs des formations de l'annee 2005-2006 ont ete inclus. Ont ete analyses, le nombre de participants, l'interet et la qualite des sujets, le site Internet et les modifications des pratiques. Quatre-vingt-huit CEI (soit 52 % des CEI des trois associations) ont participe aux formations. Cinquante-quatre questionnaires ont ete analyses, soit 61,4 % des participants. Quatre-vingt-seize pour cent sont satisfaits de la qualite et des sujets proposes. 42,3 % des CEI estiment avoir modifie leur pratique suite aux formations. Tous sont satisfaits du site Internet. Ces formations permettent de renforcer les liens entre le SAMU et les associations secouristes. C'est une cooperation essentielle dans un souci de qualite, d'homogeneisation et d'amelioration des pratiques sur le terrain.

Introduction The French emergency response system in life threatening situations is the deployment of fully equipped ambulances with paramedic, nurse and emergency physician. The 2005 ILCOR and ERC guidelines concerning cardiopulmonary resuscitation (CPR) have led to significant changes, especially in terms of basic life support (BLS). We aimed to review fundamental knowledge and practice by our personnel concerning CPR in children and infants to determine current training needs for our teams. Materials and methods Paper questionnaires were filled out by our personnel and immediately collected. Inclusion criteria: physicians, nurses, and paramedics (refusals to fill out questionnaire were not included). We recorded: profile of personnel, knowledge of 2005 guidelines, basic CPR and advanced CPR parameters. Majors results were compared based on job title. Results Sixty-one questionnaires were filled out (25 paramedics, 13 nurses, and 23 physicians). Personnel was mostly aged under 40 (70,5%, n=43), with over 2 years experience in prehospital emergency care(75,4%, n=46); 47,5% (n=\29) had no training in pediatrics; 68,9% (n=42) had BLS certification and 31,1% (n=19) reported regular participation in first aid training programs. A minority of subjects declared knowing the 2005 Guidelines (11,5%, n=7), even among physician (17,4%, n=4). Table 1 shows major results about CPR parameters according to job title. Conclusion This study emphasizes the lack of knowledge and the repeated changes witch require more frequent and more extensive training for entire personnel on the team, focusing on basic CPR for physicians and advanced CPR for paramedics and nurses. Table 1: Answers according to job title AED : Automatic External Defibrillator

Introduction: Transfusion of blood products is part of out-of-hospital medical activity. Despite rare use of transfusion and difficult environment, the rules of transfusion must be respected : follow up to detect blood products, security, and patient's information before and after transfusion, follow up of infectious and immunological consequences. However, the current law and usable documents were not conceived for out-of-hospital emergency care. Objective: To improve follow-up of blood product transfusion in out-of-hospital medical care (Smur). Study design: Quality assurance programme. Material and methods: a) Initial evaluation with a retrospective analysis based on the medical chart of patient for whom transfusion has been performed; b) corrective measures were proposed with creation of a specific document concerning transfusion and guidelines for blood product delivery in the out-of-hospital emergency care; c) evaluation of the impact of these correctives measures. Results: Less than one per cent of patients treated by our Smur needed transfusion, mainly during interhospital transfer. Patients were in a life-threatening situation in 50% of cases. Follow-up improved after implementation of the programme from 25 to 83% of transfused patient (p < 0.001). Despite limitation due to the small number of patients, other parameters also improved. Conclusion: The use of specific guidelines and document improves the follow-up of transfusion in out-of-hospital medical care. (C) 2001 editions scientifiques et medicales Elsevier SAS.

INTRODUCTION:Transfusion of blood products is part of out-of-hospital medical activity. Despite rare use of transfusion and difficult environment, the rules of transfusion must be respected: follow up to detect blood products, security, and patient's information before and after transfusion, follow up of infectious and immunological consequences. However, the current law and usable documents were not conceived for out-of-hospital emergency care.OBJECTIVE:To improve follow-up of blood product transfusion in out-of-hospital medical care (Smur).STUDY DESIGN:Quality assurance programme.MATERIAL AND METHODS:a) Initial evaluation with a retrospective analysis based on the medical chart of patient for whom transfusion has been performed; b) corrective measures were proposed with creation of a specific document concerning transfusion and guidelines for blood product delivery in the out-of-hospital emergency care; c) evaluation of the impact of these correctives measures.RESULTS:Less than one per cent of patients treated by our Smur needed transfusion, mainly during interhospital transfer. Patients were in a life-threatening situation in 50% of cases. Follow-up improved after implementation of the programme from 25 to 83% of transfused patient (p < 0.001). Despite limitation due to the small number of patients, other parameters also improved.CONCLUSION:The use of specific guidelines and document improves the follow-up of transfusion in out-of-hospital medical care.

Introduction : La transfusion de produits sanguins labiles (PSL) fait partie des thérapeutiques utilisées par les Smur, mais de façon occasionnelle et dans un contexte souvent difficile. Malgré tout, les règles dˈhémovigilance et de sécurité transfusionnelle doivent être respectées. La législation actuelle en vigueur et les documents à renseigner au cours dˈune transfusion ne sont pourtant pas toujours adaptés au Smur.