Learning Objective:

 Concepts of Quality of Care

 Quality Improvement Approaches
 Standards and Norms
 Quality Improvement Tools

In the healthcare industry, quality of care is more than a concept. It has become essential to patient well-
being and financial survival.
The most durable and widely cited definition of healthcare quality was formulated by the Institute of
Medicine (IOM) in 1990. According to the IOM, quality consists of the “degree to which health services
for individuals and populations increase the likelihood of desired health outcomes and are consistent with
current professional knowledge.
The evolution of awareness of quality in healthcare among the public:
The public has become more aware of the role quality of care plays in health-care. The definition has not
changed, but the public and the industry’s awareness certainly has.
High-profile patient safety failures have had a profound impact on the evolution of the public’s awareness of
quality of care. Patient safety plays an important role in quality performance, but it is important to note
that quality and safety are not the same thing. Patient safety is a subset of the larger, much more
complex and multidimensional concept of quality. Highly publicized pa-tent care failures, however, were
the catalysts that prompted a national evaluation of the patient safety issues troubling healthcare.
On December 3, 1994, a 39-year-old cancer patient died of complications of an overdose of
cyclophosphamide, a chemotherapeutic agent she received at the Dana-Farber Cancer Institute (DFCI) in
Boston for treatment of widely metastatic breast cancer. Another patient at DFCI also suffered an
overdose of cyclophosphamide and experienced serious heart damage.
According to James B. Conway, DFCI’s chief operating officer, and Dr. Saul Weingart, director of the
Centre for Patient Safety at DFCI, “Both errors involved breakdowns in standard processes, and both raised
issues of trainee supervision, nursing competence, and order execution
Although medical professionals have always known about deadly errors in complex healthcare systems, the
public at large reacted to the events at Dana-Farber with shock and disbelief. They want a safe environment
for themselves and their families, and these incidents were clear examples that hospitals are often
unsafe, even at highly respected institutions. Regardless of the magnitude of the errors or the ability of the
media to relay the message to a local community or an entire nation, these incidents and medical errors put
quality and patient safety on the front page of every newspaper in the United States. Numerous other high-
profile and fatal medical errors continue to be reported on an almost weekly basis, contributing to a general
loss of trust among patients and their families when they experience serious illnesses.

PRINCIPLES ESSENTIAL TO PROMOTING QUALITY OF CARE:

Improving quality of care in the healthcare system is still a work in progress. Having a robust definition of
the dimensions of quality care is insufficient to accomplish the goal of continuous improvement. As stated
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earlier, quality consists of the degree to which health services for individuals and populations increase the
likelihood of desired health outcomes (quality principles), are consistent with current professional knowledge
(practitioner skill), and meet the expectations of healthcare consumers (the marketplace). Successful
healthcare organizations—be they hospitals, physicians’ offices, pharmacies, nursing homes, or
ambulatory centres—will have under-stood, identified, and put into practice all of the following essential
principles:
1. Leadership.
2. Measurement.
3. Reliability.
4. Practitioner skills.
5. The marketplace.
KEY PRINCIPLE 1:
LEADERSHIP:
In its simplest definition, leadership is the ability to influence behaviour. The reason for changing
behaviour is to reach specific goals within an organization. The published literature on leadership is
based on anecdotal and theoretical dis-cessions. Less than 5 per cent of these articles are empirically based,
and most are based on demographic characteristics or personality traits of leaders.
KEY PRINCIPLE 2:
MEASUREMENT:
Quality of care can theoretically be measured by outcomes (a healthcare out-come is the change in the health
status of the patient that is a direct result of care provided) or process (what providers do to and for patients).
Outcome measurements have been a powerful tool in cardiovascular surgery and hospital-acquired infections
(see figure below).

Figure: An
Example of
Coronary
Artery
Bypass
Graft
Mortality
Variation
among
California
Hospitals

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KEY PRINCIPLE 3:
RELIABILITY:
Underlying nearly every identified problem in the hospital setting is the problem of reliable process. In
evaluating highly reliable organizations, five principles have been found to be universal. They are
command and control, risk appreciation, a specific quality component of the industry, metrics driving
management, and reward.
• Command and control: Performance goals shared and agreed upon throughout the
organization.
• Risk appreciation: Whether there is knowledge that risk exists, and if there is knowledge that risk
exists, the extent to which it is acknowledged and appropriately mitigated and/or minimized
.• Quality: Policies and procedures for promoting high-quality performance.
• Metrics: A system of on-going checks to monitor hazardous conditions and used as the basis for
accountability.
• Reward: The payoff an individual or organization receives for behaving one way or another; expected
social compensation or disciplinary action to correct or reinforce a behaviour, and the most powerful is
recognition

KEY PRINCIPLE 4:
PRACTITIONER SKILLS:
The process of achieving consistently high quality of care in a reliable way con-sists of “doing the right thing
right.” To do the right thing requires that physicians, nurses, and all healthcare providers make the right
decisions about appropriateness of services and care for each patient (high-quality decision making), and to
do it right requires skill, judgment, and timeliness of execution (high-quality performance).The IOM
characterized the threats to quality into three broad areas that affect practitioners: overuse (receiving
treatment of no value), underuse (failing to receive needed treatment), and misuse (errors and defects in
treatment).The physicians and practitioners that are making treatment decisions must be doing so in
a way that appropriately utilizes resources without overuse, underuse, or misuse. This is difficult to
control because of variability in physician treatment practices.
Evidence-based medicine has made its way into mainstream health decision making to reduce this
variability. The concept relies on evidence to help practitioners decide on the appropriateness of services and
care and how to execute the patient’s care appropriately. Both overuse and underuse represent limitations
in the practitioners’ decision making ability. Both areas focus on the competence of the practitioners and
their ability to utilize resources appropriately. Questions to ask when evaluating whether overuse or underuse
has occurred are:
1. Do they utilize resources appropriately?
2. Are they ordering too many tests.
3. Are they ordering too few tests?.
4. Is therapy appropriate and consistent with individual patients’ risk-benefit calculus?
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Once a treatment decision is made, the duty of quality falls on the performance of the individuals providing
the care to the patient (high-quality performance) and the systems in which they work. In the
treatment phase of the care cycle, the providers must have processes and practices in place to ensure the
treatment protocols are completed and there is no misuse. When errors and defects occur, quality is sub
optimized (not an on-off switch but, rather, a spectrum) and patient safety is at risk.

KEY PRINCIPLE 5:
THE MARKETPLACE:
The marketplace has had a profound effect on moving hospital quality for-ward, and it is essential to
understanding the role of quality of care in the current environment of healthcare. Despite the studies cited
earlier, quality metrics have been improving primarily by public transparency and the promise of
improved payment and patient volumes. The value proposition of quality and efficiency and tying
reimbursement to reporting or excelling in performance on specified quality metrics (pay for
performance) has been accepted by nearly all third-party payers and has become a significant force in
healthcare. This model has gained considerable attention by employers and payers for the following reasons.
First, healthcare premium costs have continued to rise at rates as high as 14 per cent per year. Although there
have been some decreases in recent years in premium costs, workers are still only earning an additional
2.1 per cent to 3.8 per cent per year .The additional costs must be absorbed by one of two parties: the
individual or the insurer.
Additionally, the number of uninsured has continued to rise to a high of 45 million Americans, and that
number is expected to increase to 51 million by 2010.The basic economics in healthcare are similar to
most industries and involve the management of three main principles: cost, volume, and revenue. We must
understand the role quality plays in the market because it is fundamental to the environment in which we
operate. Quality is an important component in several areas: from the basic business model of
healthcare and the financial impact on the industry (practitioners, facilities, and customers) to the
public opinion driving decisions for treatment plans and treatment locations. For the industry to adopt
changes, institutions must “realize a financial return on investment in a reasonable time frame, using a
reasonable rate of discounting. This may be realized as ‘bankable dollars’ (profit), a reduction in
losses for a given program or population, or avoided costs. In addition, a business case may exist if the
investing entity believes that a positive indirect effect on organizational function and sustainability will
accrue within a reasonable time frame.
Basic Concepts of Healthcare Quality:

A number of attributes can characterize the quality of healthcare services. As we will see, different groups
involved in healthcare, such as physicians, patient, and health insurers, tend to attach different levels of
importance to particular attributes and, as a result, define a quality of care differently.

The following attributes relevant to the definition of quality of care:

  Technical performance

Quality of technical performance refers to how well current scientific medical knowledge and
technology are applied in a given situation.
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  Management of the interpersonal relationship

The quality of the interpersonal relationship refers to how well the clinician relates to the patient on a
human level.

  Amenities

The quality of the amenities of care refers to the characteristics of the setting in which the encounter
between patient and clinician takes place, such as comfort, convenience, and privacy.

  Access

The quality of access to care refers to the “degree to which individuals and groups are able to obtain
needed services”.

  esponsiveness to patient preference

  Equity

Findings that the amount, type, or quality of healthcare provided can be related systematically to an
individual’s characteristics, particularly race and ethnicity, rather than to the individual’s need for
care or healthcare preferences, have heightened concern about equity in health services delivery.

  Efficiency

Efficiency refers to how well resources are used in achieving a given result.

  Cost-effectiveness

The cost-effectiveness of a given healthcare intervention is determined by how much benefit,

typically measured in terms of improvements in health status, the intervention yields for a particular
level of expenditure.

Measurement-Related Concepts

As Donabedian first noted in 1966, all evaluations of the quality of care can be classified in terms of one of
three aspects of caregiving they measure:

Structure

When quality is measured in terms of structure, the focus is on the relatively static

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Characteristics of the individuals who provide care and of the setting where the care is delivered. These
characteristics include the education, training, and certification of professionals who provide care and the
adequacy of the facility’s staffing, equipment, and overall organization.

Process

Process, which refers to what takes place during the delivery of care, also can be the basis for evaluating
quality of care. The quality of the process in turn can vary on two aspects:

appropriateness, which refers to whether the right actions were taken, and skill, which refers to how well
actions were carried out and how timely they were.

Outcomes

Outcome measure, which capture whether healthcare goals were achieved, are another way of assessing
quality of care.

Quality Improvement Approaches:

Health care delivery systems that are working to improve patient experience can face daunting challenges,
reflecting the need to align changes in behaviour and practices across multiple levels and areas of the
organization. But the process of planning, testing, and eventually spreading those changes does not have to
be overwhelming. Health care organizations can take advantage of established principles and approaches to
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quality improvement, which are already familiar to the many providers involved in clinical quality
improvement (QI).
Three Tips for Facilitating the Quality Improvement Process
Place a priority on encouraging communication, engagement, and participation for all of the
stakeholders affected by the QI process. Learn what is most important to the people who make up the
microsystem and look for ways to help them embrace the changes and begin to take ownership of them.
Start your implementation of improvements with small-scale demonstrations, which are easier to
manage than large-scale changes. Small-scale demonstrations or small tests of change also allow you to
refine the new processes, demonstrate their impact on practices and outcomes, and build increased support by
stakeholders.
Keep in mind and remind others that QI is an iterative process. You will be making frequent corrections
along the way as you learn from experience with each step and identify other actions to add to your strategy.
Focusing on Microsystems:

One useful way for health plans and medical groups to approach the process of improvement is to think of
the organization as a system, or more specifically, as a collection of interrelated "microsystems." The term
"microsystems" refers to the multiple small units of caregivers, administrators, and other staff who produce
the "products" of health care—i.e., who deliver care and services on a daily basis.

The concept of microsystems in health care organizations stems from research findings indicating that the
most successful of the large service corporations maintain a strong focus on the small, functional units who
carry out the core activities that involve interaction with customers. In the context of health care, a
microsystem could be:
 A core team of health professionals.
 Staff who work together on a regular basis to provide care to discrete subpopulations of patients.
 A work area or department with the same clinical and business aims, linked processes, shared
information environment and shared performance outcomes.

Examples of microsystems include a team of primary care providers, a group of lab technicians, or the staff
of a call center. In the patient-centered medical home model, a microsystem could be the patient's care team
accountable for coordination of the patient's services that address prevention, acute care, and chronic care.

The goal of the microsystem approach is to foster an emphasis on small, replicable, functional service
systems that enable staff to provide efficient, excellent clinical and patient-centered care to patients. To
develop and refine such systems, health care organizations start by defining the smallest measurable cluster
of activities.

Once the microsystems have been identified, a practice or plan can select the best teams and/or microsystem
sites to test and implement new ideas for improving work processes and evaluating improvement. 5 To
provide high-quality care, the microsystem's services need to be effective, timely, and efficient for all
patients, and preferably designed in partnership with patients and their families.

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Measurement and performance feedback must be part of the microsystem's principles to learn and improve.

If a quality improvement intervention is successful for a microsystem, it can then be scaled to other
microsystems or the broader organization. However, for successful scalability,
organizations should adopt a framework for spread that will work within their structure and culture.

Understanding and Implementing the Improvement Cycle:

Although QI models vary in approach and methods, a basic underlying principle is that QI is a continuous
activity, not a one-time thing. As you implement changes, there will always be issues to address and
challenges to manage; things are never perfect. You can learn from your experiences and then use those
lessons to shift strategy and try new interventions, as needed, so you continually move incrementally toward
your improvement goals.

The fundamental approach that serves as the basis for most process improvement models is known as the
PDSA cycle, which stands for Plan, Do, Study, Act. As illustrated in Figure below, this cycle is a systematic
series of steps for gaining valuable learning and knowledge for the continual improvement of a product or
process.

Underlying the concept of PDSA is the idea that microsystems and systems are made up of interdependent,
interacting elements that are unpredictable and nonlinear in operation. Therefore, small changes can have
large effects on the system.

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The cycle has four parts:
 Plan. This step involves identifying a goal or purpose, formulating an intervention or theory for
change, defining success metrics and putting a plan into action.
 Do. This is the step in which the components of the plan are implemented.
 Study. This step involves monitoring outcomes to test the validity of the plan for signs of progress
and success, or problems and areas for improvement. Short-cycle, small-scale tests, coupled with
analysis of test results, are helpful because microsystems or teams can learn from these tests before
they implement actions more broadly.
 Act. This step closes the cycle, integrating the learning generated by the entire process, which can be
used to adjust the goal, change methods, or even reformulate an intervention or improvement
initiative altogether.

When you are ready to apply the PDSA cycle to improve performance on CAHPS scores, you will need to
decide on your goals, strategies, and actions, and then move forward in implementing them and monitoring
your improvement progress. You may repeat this cycle several times, implementing one or more
interventions on a small scale first, and then expanding to broader actions based on lessons from the earlier
cycles.

Plan: Develop Goals and Action Plan:

This section discusses four key steps in the planning stage of a PDSA cycle as part of a CAHPS-related
quality improvement process:
 Establish improvement goals.
 Identify possible strategies.
 Choose specific interventions to implement.
 Prepare a written action plan.

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a. Establish Improvement Goals:

The team's first task is to establish an aim or goal for the improvement work. By setting this goal, you will be
better able to clearly communicate your objectives to all of the sectors in your organization that you might
need to support or help implement the intervention.

The goal should reflect the specific aspects of CAHPS-related performance that the team is targeting. It
should also be measurable and feasible. One of the limitations of an annual CAHPS survey as a measurement
tool is the lag time between the implementation of changes, the impact on people’s experiences, and the
assessment of that impact. For that reason, the team needs to define both ultimate goals as well as
incremental objectives that can be used to gauge short-term progress. After defining your ultimate goals, ask
"What is the gap between our current state and our goals?" Make of list of those gaps and use them to make
SMART (specific, measurable, achievable, realistic, and time bound) incremental objectives.

For example, a team concerned about improving performance on the "Getting Timely Appointments, Care,
and Information" composite measure in the Clinician & Group Survey may set a 1-year goal of a two percent
increase in its composite score. At the same time, it could specify goals for the number of days it takes to get
an appointment for non-urgent and urgent visits. Similarly, a team focusing on overall ratings may set goals
for complaint rates for the health plan as a whole or for individual medical groups and then review those rates
monthly.
b. Identify Possible Strategies:

With objectives in place, the next task of the team is to identify possible interventions and select one that
seems promising. Keep in mind that all improvement requires making a change, but not all changes lead to
improvement..

New ideas and innovative solutions can be found:

 At conferences or workshops.
 In the academic literature, the media, and/or the popular press.
 Through the identification of benchmark practices in health care as well as other industries, i.e., non-
competitive benchmarks.
 Through patients and their families—whether through direct interviews and focus groups, as partners
on quality improvement teams, or as members of Patient and Family Advisory Councils.
 In the Agency for Healthcare Research and Quality's searchable clearinghouse of health
care innovations.

One useful way to develop and learn innovative approaches is to visit other health care organizations.
Resistant or hesitant staff members are often "unfrozen" by visiting another highly respected site that has
successfully implemented a similar project. You can also visit a company outside of the health care industry
to get new ideas. Some health plans, for example, have learned how to improve their call center operations by
sending staff to visit mail-order catalog houses or brokerage firms. The Cleveland Clinic has required every
doctor and senior administrator to make one "innovation site visit" a year to learn about different approaches
that can be brought home and tested.
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The QI process is grounded in the following basic concepts:
 Establish a culture of quality in your practice. Your practice’s organization, processes, and
procedures should support and be integrated with your QI efforts. The culture of a practice—attitudes,
behaviors, and actions—reflect how passionately the practice team embraces quality. The QI culture
looks different for every practice, but may include establishing dedicated QI teams, holding regular QI
meetings, or creating policies around your QI goals.
 Determine and prioritize potential areas for improvement. You will need to identify and understand
the ways in which your practice could improve. Examine your patient population (e.g., to identify
barriers to care, frequently diagnosed chronic conditions, or groups of high-risk patients) and your
practice operations (e.g., to identify management issues such as low morale, long patient wait times, or
poor communication). Use established quality measures, such as those from the National Quality
Forum, Agency for Healthcare Research and Quality, and the Quality Payment Program to guide your
efforts.
 Collect and analyze data. Data collection and analysis lie at the heart of quality improvement. Your
data will help you understand how well your systems work, identify potential areas for improvement, set
measurable goals, and monitor the effectiveness of change.
It’s important to collect baseline data before you begin a QI project, commit to regular data collection,
carefully analyze your results throughout the project, and make decisions based on your analysis.
 Communicate your results. Quality improvement efforts should be transparent to your staff,
physicians, and patients. Include the entire practice team and patients when planning and implementing
QI projects, and communicate your project needs, priorities, actions, and results to everyone (patients
included). When a project is successful, celebrate and acknowledge that success.
 Commit to ongoing evaluation. Quality improvement is an ongoing process. A high-functioning
practice will strive to continually improve performance, revisit the effectiveness of interventions, and
regularly solicit patient and staff feedback.
 Spread your successes. Share lessons learned with others to support wide-scale, rapid  improvement
that benefits all patients and the health care industry as a whole.
 Quality Improvement tools:

Quality tools used to define and assess problems with health care were seen as being helpful in prioritizing
quality and safety problems and focusing on systems, not individuals. The various tools were used to address
errors and growing costs  and to change provider practices. Several of the initiatives used more than one of
the quality improvement tools, such as beginning with root-cause analysis then using either Six Sigma,
Toyota Production System/Lean, or Plan-Do-Study-Act to implement change in processes. Almost every
initiative included in this analysis performed some type of pretesting/pilot testing. Investigators and leaders
of several initiatives reported advantages of using specific types of quality tools.

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These are discussed as follows:

Root-cause analysis- was reported to be useful to assess reported errors/incidents and differentiate between
active and latent errors, to identify need for changes to policies and procedures, and to serve as a basis to
suggest system changes, including improving communication of risk.

Six Sigma/Toyota Production System- was reported to have been successfully used to decrease
defects/variations and operating costs and improve outcomes in a variety of health care settings and for a
variety of processes. Six Sigma was found to be a detailed process that clearly differentiated between the
causes of variation and outcome measures of process. One of the advantages of using Six Sigma was that it
made work-around and rework difficult because the root causes of the reimplementation processes were
targeted. Additionally, investigators reported that the more teams worked with this strategy, the better they
became at implementing it and the more effective the results. Yet it was noted that to use this strategy
effectively, a substantial commitment of leadership time and resources was associated with improved patient
safety, lowered costs, and increased job satisfaction. Six Sigma was also an important strategy for problem-
solving and continuous improvement; communicating clearly about the problem; guiding the implementation
process; and producing results in a clear, concise, and objective way.

Plan-Do-Study-Act (PDSA) -was used by the majority of initiatives included in this analysis to implement
initiatives gradually, while improving them as needed. The rapid-cycle aspect of PDSA began with piloting a
single new process, followed by examining results and responding to what was learned by problem-solving
and making adjustments, after which the next PDSA cycle would be initiated. The majority of quality
improvement efforts using PDSA found greater success using a series of small and rapid cycles to achieve
the goals for the intervention, because implementing the initiative gradually allowed the team to make
changes early in the process and not get distracted or sidetracked by every detail and too many

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unknowns. The ability of the team to successfully use the PDSA process was improved by providing
instruction and training on the use of PDSA cycles, using feedback on the results of the baseline
measurements, meeting regularly, and increasing the team’s effectiveness by collaborating with others,
including patients and families, to achieve a common goal. Conversely, some teams experienced difficulty in
using rapid-cycle change, collecting data, and constructing run charts, and one team reported that applying
simple rules in PDSA cycles may have been more successful in a complex system.

Failure modes and effects analysis (FMEA) -was used to avoid events and improve or maintain the quality
of care. FMEA was used prospectively to identify potential areas of failure where experimental
characterization of the process at the desired speed of change could be assessed, and retrospectively to
characterize the safety of a process by identifying potential areas of failure, learning about the process from
the staff’s point of view. Using a flow chart of the process before beginning the analysis got the team to focus
and work from the same document. Information learned from FMEA was used to provide data for prioritizing
improvement strategies, serve as a benchmark for improvement efforts, educate and provide a rationale for
diffusion of these practice changes to other settings, and increase the ability of the team to facilitate change
across all services and departments within the hospital. Using FMEA facilitated systematic error
management, which was important to good clinical care in complex processes and complex settings, and was
dependent upon a multidisciplinary approach, integrated incident and error reporting, decision support,
standardization of terminology, and education of caregivers.

Health failure modes and effects analysis (HFMEA) -was used to provide a more detailed analysis of
smaller processes, resulting in more specific recommendations, as well as larger processes. HFEMA was
viewed as a valid tool for proactive analysis in hospitals, facilitating a very thorough analysis of
vulnerabilities (i.e., failure modes) before adverse events occurred. This tool was considered valuable in
identifying the multifactorial nature of most errors and the potential risk for errors, but was seen as being
time consuming. Initiatives that used HFMEA could minimize group biases through the multidisciplinary
composition of the team and facilitate teamwork by providing a step-by-step process, but these initiatives
required a paradigm shift for many.
Standards and Norms:
TECHNICAL STANDARDS: There are numerous technical standards concerning to medical
procedures, operations and equipment’s. Some of them are highlighted as established by
International Organization of Standardization (www.iso.org) and British Standards Institute
(www.bsigroup.com).

ISO Standards:
Aesthetic and Respiratory Equipment ISO provides dimensions of non-interchangeable screw-threaded low-
pressure connectors for medical gases. ISO gives requirements for labels which the user attaches to
syringes so that the contents can be identified just before use during anaesthesia. It covers the color,
size, design and general properties of the label and the typographical characteristics of the wording for
the drug name.
Surgery ISO/TR: provides guidance on airway management during laser surgery of upper airway
and intends to minimize the risk of an airway fire when using a laser.

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 Sterilization and Disinfection : ISO specifies requirements for the development, validation and
routine control of a Low Temperature Steam and Formaldehyde (LTSF) sterilization process for medical
devices. ISO specifies requirements for the development, validation and routine control of an
ethylene oxide sterilization process for medical devices. ISO provides specific requirements for test
organisms, suspensions, inoculated carriers, biological indicators and test methods intended for use
in assessing the performance of sterilizers and sterilization processes employing ethylene oxide gas as
the sterilizing agent.
Medical Laboratory : ISO specifies requirements for quality and competence in medical laboratories.
This standard can be used by medical laboratories in developing their quality management systems and
assessing their own competence. It can also be used for confirming or recognizing the competence
of medical laboratories by laboratory customers, regulating authorities and accreditation bodies. ISO
specifies requirements for safe practices in the medical laboratory. ISO/TR provides guidance to
medical laboratories describing how a medical laboratory can meet the specific technical and quality
requirements in ISO, ISO/TS characterizes the application for reducing laboratory error and improving
patient safety by applying the principles of risk management, with reference to examination
aspects, especially to pre- and post-examination aspects, of the cycle of laboratory medical care.
provides guidance for users of reagents for staining in biology in medical laboratories.
Dentistry: ISO provides definitions for a number of concepts specific to dentistry in the interest of
facilitating development and comprehension of standards. ISO provides a system for designating teeth or
areas of the oral cavity using two digits. provides guidance on test methods and marking for the
accuracy of machined indirect restorations.
Hospital equipment: applies to the basic safety and essential performance of medical beds intended for
adults. IEC establishes particular basic safety and essential performance requirements, which
minimize hazards to patients, and operators for heating devices using blankets, pads or mattresses
and intended for heating in medical use and specifies tests for demonstrating compliance with
these requirements.
Medical Textiles :
ISO specifies requirements for packaged sterile rubber gloves intended for use in surgical
procedures to protect the patient and the user from cross-contamination. ISO specifies requirements for
packaged sterile, or bulked non-sterile, rubber gloves intended for use in medical examinations and
diagnostic or therapeutic procedures to protect the patient and the user from cross-contamination. ISO
describes a laboratory test method for measuring the resistance of medical face masks to
penetration by a splash of synthetic blood.
Medical Devices:
ISO/IEC Guide provides guidance to include safety aspects in the development of medical device. ISO
describes the content and means of functioning of the electronic health record system of the HL7
EHR Work Group.
Medical Plastic wares:
ISO specifies requirements for the development and use of disposable serological pipettes. ISO
specifies the shape, dimensions and capacities of glass vials for injectable preparations. The standard
applies to colourless or amber glass containers moulded from borosilicate or soda-lime glass, with or

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without an internal surface treatment, and intended to be used in the packaging, storage or
transportation of products intended for injection. ISO specifies the dimensions, performance and
requirements of infusion glass bottles necessary to ensure functional interchange ability. It is
applicable only to infusion bottles for single use. ISO specifies the design, dimensions, material and
requirements of drop-dispensing glass bottles. Drop-dispensing glass bottles are applicable to primary
packs used in direct contact with a drug. ISO is applicable to drop-dispensing glass bottles used in
pharmacy. Together with the corresponding closure systems, they serve for packaging of
pharmaceutical preparations which are not intended for parenteral use.
Blood transfusion, infusion and injection ISO/ASTM outlines irradiator installation qualification,
operational qualification, performance qualification and routine product processing do symmetric
procedures to be followed in the irradiation of blood and blood components by the blood-banking
community. ISO specifies requirements for single-use transfusion sets for medical use in order to
ensure their compatibility with containers for blood and blood components as well as with
intravenous equipment. In some countries, the national pharmacopoeia or other national regulations
are legally binding and take precedence over ISO.

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 Learning Objective;
 Vital signs and primary assessment
 Basic emerGeneralcy care – first aid and triage Ventilations including use of bag-valve-masks (BVMs)
 Choking, rescue breathing methods

The vital signs include assessment of temperature, pulse, respiration, and blood pressure. They are
considered the baseline indicators of a patient’s health status.
Pain assessment is considered the fifth vital sign. Pain is a subjective unpleasant symptom of many
conditions and injuries. The pain experience, its characteristics, and intensity are unique for each person.
 Body temperature
 Pulse rate
 Respiration rate (rate of breathing)
 Blood pressure (Blood pressure is not considered a vital sign, but is often measured along with the vital
signs.)
What is body temperature?

The normal body temperature of a person varies depending on gender, recent activity, food and fluid
consumption, time of day, and, in women, the stage of the menstrual cycle. Normal body temperature can
range from 97.8 degrees F (or Fahrenheit, equivalent to 36.5 degrees C, or Celsius) to 99 degrees F (37.2
degrees C) for a healthy adult. A person's body temperature can be taken in any of the following ways:

 Orally. Temperature can be taken by mouth using either the classic glass thermometer, or the more
modern digital thermometers that use an electronic probe to measure body temperature.

 Rectally. Temperatures taken rectally (using a glass or digital thermometer) tend to be 0.5 to 0.7
degrees F higher than when taken by mouth.

 Axillary. Temperatures can be taken under the arm using a glass or digital thermometer.
Temperatures taken by this route tend to be 0.3 to 0.4 degrees F lower than those temperatures taken
by mouth.

 By ear. A special thermometer can quickly measure the temperature of the ear drum, which reflects
the body's core temperature (the temperature of the internal organs).

 By skin. A special thermometer can quickly measure the temperature of the skin on the forehead.

Body temperature may be abnormal due to fever (high temperature) or hypothermia (low temperature). A
fever is indicated when body temperature rises about one degree or more over the normal temperature of 98.6
degrees Fahrenheit, according to the American Academy of Family Physicians. Hypothermia is defined as a
drop in body temperature below 95 degrees Fahrenheit.
16
About glass thermometers containing mercury:

According to the Environmental Protection Agency, mercury is a toxic substance that poses a threat to the
health of humans, as well as to the environment. Because of the risk of breaking, glass thermometers
containing mercury should be removed from use and disposed of properly in accordance with local, state, and
federal laws. Contact your local health department, waste disposal authority, or fire department for
information on how to properly dispose of mercury thermometers.
What is the pulse rate?

The pulse rate is a measurement of the heart rate, or the number of times the heart beats per minute. As the
heart pushes blood through the arteries, the arteries expand and contract with the flow of the blood. Taking a
pulse not only measures the heart rate, but also can indicate the following:

 Heart rhythm

 Strength of the pulse

The normal pulse for healthy adults ranges from 60 to 100 beats per minute. The pulse rate may fluctuate and
increase with exercise, illness, injury, and emotions. Females ages 12 and older, in general, tend to have
faster heart rates than do males. Athletes, such as runners, who do a lot of cardiovascular conditioning, may
have heart rates near 40 beats per minute and experience no problems.

17
How to check your pulse?

As the heart forces blood through the arteries, you feel the beats by firmly pressing on the arteries, which are
located close to the surface of the skin at certain points of the body. The pulse can be found on the side of the
neck, on the inside of the elbow, or at the wrist. For most people, it is easiest to take the pulse at the wrist. If
you use the lower neck, be sure not to press too hard, and never press on the pulses on both sides of the lower
neck at the same time to prevent blocking blood flow to the brain. When taking your pulse:

 Using the first and second fingertips, press firmly but gently on the arteries until you feel a pulse.

 Begin counting the pulse when the clock's second hand is on the 12.

 Count your pulse for 60 seconds (or for 15 seconds and then multiply by four to calculate beats per
minute).

 When counting, do not watch the clock continuously, but concentrate on the beats of the pulse.

 If unsure about your results, ask another person to count for you.
What is the respiration rate?

The respiration rate is the number of breaths a person takes per minute. The rate is usually measured when a
person is at rest and simply involves counting the number of breaths for one minute by counting how many
times the chest rises. Respiration rates may increase with fever, illness, and other medical conditions. When
checking respiration, it is important to also note whether a person has any difficulty breathing.

Normal respiration rates for an adult person at rest range from 12 to 16 breaths per minute.

What is blood pressure?

18
Blood pressure is the force of the blood pushing against the artery walls during contraction and relaxation of
the heart. Each time the heart beats, it pumps blood into the arteries, resulting in the highest blood pressure as
the heart contracts. When the heart relaxes, the blood pressure falls.

Two numbers are recorded when measuring blood pressure. The higher number, or systolic pressure, refers to
the pressure inside the artery when the heart contracts and pumps blood through the body. The lower number,
or diastolic pressure, refers to the pressure inside the artery when the heart is at rest and is filling with blood.
Both the systolic and diastolic pressures are recorded as "mm Hg" (millimeters of mercury). This recording
represents how high the mercury column in an old-fashioned manual blood pressure device (called a mercury
manometer or sphygmomanometer) is raised by the pressure of the blood. Today, your doctor's office is more
likely to use a simple dial for this measurement.

High blood pressure, or hypertension, directly increases the risk of heart attack, heart failure, and stroke.
With high blood pressure, the arteries may have an increased resistance against the flow of blood, causing the
heart to pump harder to circulate the blood.

Blood pressure is categorized as normal, elevated, or stage 1 or stage 2 high blood pressure:

 Normal blood pressure is systolic of less than 120 and diastolic of less than 80 (120/80)

 Elevated blood pressure is systolic of 120 to 129 and diastolic less than 80

 Stage 1 high blood pressure is systolic is 130 to 139 or diastolic between 80 to 89

 Stage 2 high blood pressure is when systolic is 140 or higher or the diastolic is 90 or higher

These numbers should be used as a guide only. A single blood pressure measurement that is higher than
normal is not necessarily an indication of a problem. Your doctor will want to see multiple blood pressure
measurements over several days or weeks before making a diagnosis of high blood pressure and starting
treatment. Ask your provider when to contact him or her if your blood pressure readings are not within the
normal range.

Basic Emergency care – first aid and triage Ventilations including use of bag-valve-
masks (BVMs):

Bag valve mask ventilation is a skill of utmost important for emergency providers. It is not easy and requires
practice to master as it will be utilized in emergent settings. Proper patient positioning is critical to the
procedure. The tongue often falls to the back of the pharynx which can occlude the airway. The appropriate
head tilt, chin lift maneuver or a jaw thrust helps to keep the airway open. The "sniffing" position is achieved
with forward flexion of the neck and equilibrating the sternal notch and angle of the mandible. An or
pharyngeal or nasopharyngeal may be utilized to maintain an open airway. Not only does the sniffing
position assist with opening the airway as needed, but it can also help visualize the glottis opening as well as
the vocal cords, improving your ability for first pass success during endotracheal intubation. Many BVMs are
augmented by a one-way valve or a pressure valve. They require an oxygen supply to adequately deliver
oxygen to the patient

19
Anatomy and Physiology

A review of or pharyngeal anatomy is important to understand the implications of BVMBVM ventilation.

Anatomy may cause difficulty with ventilation.

It is important to predict which patients may be difficult to ventilate. Several acronyms have been formed to
help predict who will be difficult to ventilate. MOANS stands for "mask seal, obesity, age (elderly), no teeth,
stiffness." BONES stands for "beard, obese, no teeth, elderly, sleep apnea/snoring." These patients may be
particularly difficult to ventilate and may require the use of a supraglottic airway to improve chances of
ventilation. Likewise, several  studies have identified factors that are associated with difficulty ventilating
patients. These include the presence of a beard, obesity, lack of teeth, snoring, older age, and limited jaw
protrusion. Leaving the patient’s dentures in, if applicable,  helps create a better seal for the mask. A beard or
significant facial hair can make it difficult to ventilate; the use of a water-soluble lubricant can improve the
ability to create a seal.
Indications
 hypercapnic respiratory failure
 hypoxic respiratory failure
 apnea
 altered mental status with the inability to protect the airway
 patients who are undergoing anesthesia for elective surgical procedures may require BVM ventilation
Contraindications
 Total upper airway obstruction
 Increased risk of aspiration after paralysis and induction
Go to:

20
Equipment

The equipment required includes a bag valve mask, oxygen source, oxygen tubing, a PEEP valve, and simple
airway adjuncts such as an or pharyngeal airway and nasopharyngeal airway.
Personnel

In general, bag valve mask ventilation only requires one provider. A second provider can help squeeze the
bag while the primary provider holds the mask seal.
Preparation

An oropharyngeal airway may be inserted in order to displace the tongue forward. This prevents the
occlusion of the airway when the patient is laying supine. The only true contraindication to using it is if the
patient has a gag reflex. The airway can be inserted directly or rotated 90 or 180 degrees in order to facilitate
placement behind the tongue.

A nasopharyngeal airway can be inserted to enable ventilation via BVM to reach the posterior pharynx in the
case of a large tongue or other obstruction. It is contraindicated in the case of facial trauma where there is a
concern for a facial fracture due to the possibility of it violating the intracranial space. The airway can be
inserted with the bevel towards the septum, after appropriate lubrication, and rotated as needed to extend to
the posterior pharynx. The use of either of these basic airway adjuncts facilitates ventilating a patient by
maintaining a patent airway.

The rescuer should be positioned at the patient’s head. A good face seal must be achieved with the mask over
the face, the pointed end of the mask over the nose, and the curved end below the lower lip. A one-person
technique involves the "E-C seal" in which your first and second digits form a "C" over the mask with your
thumb pressing down by the nasal bridge, your second digit over the bottom of the mask by the mouth, and
your third through fifth digits forming an "E" and applying pressure to the mandible to hold the mask tight.
There should be no gaps between the mask and the skin. You can also tilt the head backward in a “head-tilt
chin lift” maneuver or can displace the jaw forward to do a “jaw-thurst” if indicated to open the airway. This
often provides for easier ventilation.

In a two-person technique, someone else squeezes the bag while the rescuer uses the same E-C technique
with both hands. This has been shown to deliver a higher tidal volume in simulations and also allows for a
better seal to be created. One must be careful to ensure that the soft tissue of the neck is not compressed by
the rescuer's fingers.

Positioning the patient can improve the ability to ventilate. Utilizing the sniffing position, with the ear to
sternal notch aligned in the same plane, optimizes conditions for airflow. Utilizing a mask a size larger than
expected may help create a seal, but a smaller mask is more likely to lead to a leak.

Technique:

An adult BVM with oxygen supplied at a minimum of 15 liters per minute and a full reservoir can provide up
to 1.5 liters of oxygen delivered per breath. Ventilating should be done with caution and only until chest rise

21
is appreciated to reduce the risk of gastric insufflation, possibly causing vomiting and barotrauma from
overdistention.
Complications

The complications include barotrauma from too much lung inflation and gastric insufflation which can lead
to vomiting and aspiration.
Clinical Significance

The routine use of cricoid pressure during BVM ventilation and endotracheal intubation was initially
standard practice but has never routinely been shown to improve patient-oriented outcomes. Its original
purpose was to occlude the esophagus and prevent gastric regurgitation and thus aspiration. Some studies
have shown it has displaced the esophagus, rather than occluding it. Others have shown that it is
incompletely occluded depending on the amount of force applied. Further studies have shown it inhibits
laryngeal view during intubation.

BVM ventilation can be aided by the use of positive end-expiratory pressure (PEEP) valve attached and
titrated from 5 to 15 cm H2O in order to improve oxygenation prior to intubation in patients who are unable
to be appropriately pre-oxygenated with standard therapy. Do not exceed a PEEP of 20 cm H2O on a BVM
as this pressure can open the lower esophageal sphincter and cause gastric insufflation and vomiting.

Low pressure, low volume insufflation can help prevent gastric distention.

Some BVMs have the ability to attach a filter for pathogens. However, these devices are not foolproof, and
personal protective equipment is required for every patient contact.

Likewise, the adapter for the BVM can fit an end-tidal monitor or a nebulizer reservoir. This allows
additional functioning of the BVM. If the seal with the face is inadequate, this does limit the utility of these
devices, as the end-tidal reading will be inaccurate and the nebulized medications may leak out.
Enhancing Healthcare Team Outcomes

Bag-mask ventilation is a very useful technique when encountering patients in respiratory distress. the
technique is commonly used by EMS, anesthesiologist, ICU nurses, respiratory therapists, and intensivists.
The technique can be life-saving and is relatively much easier than intubation. When done well, the patient
can be oxygenated until an anesthesiologist can intubate the patient. an interprofessional approach will
provide the best care for the patient.

22
First aid and triage ventilations:
Triage is the process of sorting casualties in order of priority which sounds simple enough, unfortunately
without an understanding of how to effectively, objectively and accurately do this we have a habit of making
these decision based on the wrong criteria:  We follow common heuristics such as ‘going for the quiet
ones’ or ‘treat unconscious casualties before conscious casualties’.   Humans are also genetically hardwired
to react to the sight of blood so we triage based on injuries; treating the most visibly traumatic – the blood
guts and gore – over less obvious injuries.

How to Triage?

It is vitally important that the Triage process does not involve treatment (with three exceptions explained
below).  It is far too easy to get drawn into dealing with the first casualty you come across at the expense of
other casualties.

Triage is an objective, emotionless process.  Almost ruthless.  This is fundamental to allow us to administer
the best care to as many casualties as possible rather than to the few at the expense of the many.

Step 1:  Take charge – poor communication leads to casualties being missed or triaged twice.
23
Step 2:  Triage everyone – use Bystanders and the Category 3 casualties to sit with or tend to Category

1 and 2 casualties as you identify them.

Step 3:  Identify all of the Category 1 casualties.   These are where your priorities are and where we
direct our time and resources.  When the emergency Services arrive, direct them to     these
casualties first.

Step 4:  After you have stabilized the Category 1 casualties DO NOT move onto Category 2 casualties
– things change so triage everyone again.   Category 3 casualties deteriorate and become
Category 2, category 2 casualties become Category 1 and some Category 1 casualties will
become Category 0.

 Exceptions:

As a rule we do not get involved in any treatment while we are triaging but there are three interventions we
apply as we triage:
1. Unconsciousness:
Place all unconscious casualties on their front before you move on.   If they are unconscious but
breathing normally they are category 2.   If you leave them on their back with will very quickly
become Category 0 because you failed  to protect their airway.
 Catastrophic haemorrhage:
A catastrophic haemorrhage can be defined as an ‘immediately life threatening bleed’ – this is an
arterial bleed which is actively pumping.
If blood is squirting out of a casualty a) they still have lots of blood and b) their heart is working
well.    If blood isn’t actively pumping out, if it has just pooled and not getting any bigger, ignore it - 
either it isn’t catastrophic (and therefore not time critical) or they are dead.
Stop the bleeding with a tourniquet (dedicated or improvised) if it is on a limb or wound packing if it
is abdominal.
 Injuries incompatible with life
Some injuries are not compatible with life, regardless of how prompt or effective their treatment.  In a
multiple casualty situation we do not get involved with treatment for these casualties as it diverts
resources from seriously injured casualties who are more likely to survive if they receive prompt,
effective treatment.   These situations are:

 Decapitation
 Massive cranial and cerebral disruption
 Hemicorporectomy (torso separated in half) or similar massive injury
 Incineration (>95% full thickness burns)

24
  Decomposition
 Rigor mortis (rigidity of the body) and hypostasis ( a discolouration of the body where blood pools to
the lower half as blue mottling underneath the casualty, evidence of death after a number of hours)
 
Choking, rescue breathing methods: Rescue breathing (previously known as mouth-to-mouth
resuscitation) is a life-saving intervention in which you blow air into a person's mouth after they stop
breathing. It is often used with chest compressions during cardiopulmonary resuscitation (CPR) but can also
be used on its own if the person's heart is still beating.

Situations in which rescue breathing may be used include:

 Choking accidents
 Near-drowning
 Drug overdose
 Poisoning
 Carbon monoxide poisoning
 Severe asthma attack

In cases of cardiac arrest, rescue breathing is something only certified rescuers should perform.

This is because, by expanding the chest artificially, rescue breathing can inhibit the blood flow to the heart.
Professionals certified in CPR are trained to ensure this doesn't undermine the effectiveness of chest
compression or the survival of person being treated.

In cases of cardiac arrest, the American Heart Association (AHA) recommends chest
compressions without rescue breathing if you are untrained or unable to competently perform professional
CPR.

25
On the other hand, if a person still has a pulse but is breathing abnormally, rescue breathing may help keep
them alive until emergency help arrives.

Be sure you're following the proper procedure for rescue breathing in an emergency situation.
Preparation:
1. If confronted with a person who is not breathing, start by laying them flat on their back.
2. Call 911 or have someone else call 911 while you proceed with rescue breathing.
3. Check the person's pulse. If there is a heartbeat, you can proceed with rescue breathing. If not, you
would need to start with chest compressions with or without rescue breathing.
4. Place one hand on the person's forehead and use your other hand to lift the chin. Tilting the chin
straightens the trachea (windpipe), providing a straight passage from the mouth to the lungs.
5. Check for breathing. Listen carefully but for no longer than 10 seconds. If there are no signs of
respiration, start rescue breathing. If you hear crackling or strangulated sounds, they may be choking.
6. Finally, check to see if there anything blocking the trachea, including vomit, food, or the back of the
person's tongue. If there is, reach in with your fingers and clear it out.

Never start rescue breathing until you are sure the airways are clear of debris and other obstructions.

Why the CPR Guidelines Changed?

Rescue Breathing
1. Once you are sure that the airway is clear, pinch the person's nostrils with your thumb and first finger.
2. Place your mouth over the person's mouth, making a tight seal.
3. Breathe into the person's mouth with a firm but a steady breath to make the chest rise. Avoid blowing
too hard as the air can bypass the trachea and enter the stomach through the oesophagus (feeding
tube). Doing so may cause vomiting even if the person is unconscious.
4. If the chest does not rise with the initial breath, re-tilt the head and try again. If the chest still doesn't
rise, the person may be choking. In such a case, you would need to check the airway again and clear
whatever debris is in the way.

26
 5. If you can clear the obstruction, restart rescue breathing efforts.

If you are unable to clear the obstruction and rescue breathing fails to lift the chest, you will need to start
"hands-only" modified CPR.

If the Heart Has Stopped:

If the heart has stopped beating, rescue breathing can only do so much if the heart is unable to pump
oxygenated blood to the brain and rest of the body.

In such a case, you would need to either perform modified CPR (also known as "bystander CPR") or
professional CPR if you have the competency to deliver chest compressions with rescue breathing.

The two procedure can be broadly described as follows:

 With modified CPR, you would compress the chest twice per second, roughly in tandem to the beat
of the Bee Gees' "Staying Alive."
 With professional CPR, you would compress the chest 30 times at two compressions per second,
followed by two rescue breaths.

Never attempt professional CPR if you have not been recently trained and certified in the technique. Doing
so may harm more than it helps.

27
Learning Objective:
 One- and Two-rescuer CPR
 Using an AED (Automated external defibrillator).
 Managing an Emer Generalcy including moving a patient

One- and two-rescuer CPR:

When we have a situation that calls for CPR we need to act immediately and efficiently.  There are two
methods to performing CPR: Single rescuer CPR is also known as one-rescuer CPR or one-person CPR.
When you have a partner, you may also hear it as two-rescuer CPR or two-person CPR.

2-Rescuer CPR:

Between the two methods, 2-rescuer CPR is more efficient due to one person performing compressions and
another is giving breaths, it’s not as tiring and there’s less of a delay between compressions and breaths.
Therefore, it’s more efficient and it’s more effective.

If there are two rescuers available, here’s how to decide what type of CPR to perform. If both people have
been trained in how to perform 2-rescuer CPR, and there is someone else available to call 911, then 2-rescuer
CPR is preferable. If there isn’t a third person to make the call, then one of the two rescuers should make the
call immediately, and should only begin 2-rescuer CPR afterward.

When only 1 rescuer is trained in CPR:

On the other hand, if only one or neither of the rescuers are trained in 2-rescuer CPR, then the rescuer or
rescuers on the scene should do 1-rescuer CPR. There is too much coordination and communication
necessary in 2-rescuer CPR to attempt it without advanced training. Instead of 2-rescuer CPR, each rescuer
should take turns performing 1-rescuer CPR until he or she gets tired, then they should trade off with the
other person to do 1-rescuer CPR, until that person gets tired. It is recommended that the two rescuers trade
off about every two minutes. That’s approximately five cycles of 30 compressions and two breaths.

STEP 1 Evaluate the scene

STEP 2 Approach and Access

STEP 3 RESCUER 1 If patient is unconscious, immediately Ask

the other rescuer to immediately call
emergency medical assistance

STEP 4 Begin CPR

at a rate of at least 100 compressions per
minute and the chest should be compressed
at least 2 inches or 1/3 the thickness of the

28
 persons chest from front to back allowing
full recoil in between each compression

STEP 5 Push hard and fast in the center of the

person’s chest until help arrives, trying to
limit all pauses to chest compressions to
less than 10 seconds

STEP 6 If the first person performing chest

compressions is tired, switch positions after
two minutes. It’s important not to spend too
much time switching as this will reduce the
effectiveness of CPR

STEP 7 RESCUER 2 Repeat cycle of compressions and

ventilations (at a rate of 30/2 for an adult or
15/2 for a child or baby). Responder at head
periodically checks for effectiveness of
compressions by feeling for carotid pulse

STEP 8 Once the AED has been applied and turned

on, continue doing chest compressions at
100 per minute and follow the instructions
from the AED

STEP 9 If there is any change in patient’s condition,

stop CPR and check ABCs

Method of 2-person CPR :

For adults
 First, check for any signs of response from the victim. If the victim is in an unresponsive state, check
for pulse and signs of breathing.
 Ask the other volunteer to call for help by calling your local emergency number and giving details of
the victim’s condition and whereabouts.
 Lay the victim on a flat surface.
 Start the chest compressions with about 100 compressions per minute. After every 30 compressions,
follow with breaths. Since two man compression has an extra person to help, one person can give the
compressions while the second can give the breaths. This can be alternated every two minutes since
compressions are quite tiring for one person to handle.
 Make sure that there is no gap in giving the compressions, your actions will be helpful in supplying
blood to the brain.
For children
 In case the victim is a child, use 15 compressions and then give breaths instead of thirty.
 For infants, be sure to support the neck and back while attempting resuscitation in order to avoid
injury to the patient.
29
  Both the CPR givers need to alternate between giving breaths and chest compressions and switch
positions once each person is tired. this method is to be followed till an AED arrives.
 An AED is an Automated External Defibrillator that will externally stimulate the heart into giving a
response. Make sure there’s no water around when the AED is going to be operated as it conducts
electricity.

Using an AED (Automated external defibrillator):

What is an AED?

AED stands for Automated External Defibrillator.  It is a safe and easy to use device that delivers a
therapeutic electric shock to the heart as treatment for a victim in Sudden Cardiac Arrest (SCA).  AEDs are
mobile and often found on the walls of public venues and corporations across America, much like a fire
extinguisher.
Why Do We Use AEDs?

During SCA the heart stops suddenly and in 90 percent of the cases the heart goes into a fatal rhythm knows
as ventricular fibrillation. The only treatment to correct ventricular fibrillation is to defibrillate by applying
an electric shock to the heart.  AEDs provide the public with access to defibrillators. They can be used on a
victim of any age by people with no medical training. AED training is becoming more common in CPR &
First Aid certification classes, CPR renewal classes as well as CPR instructor courses. AED training may
even be a requirement when new CPR guidelines are released in 2015.

30
AED Facts and Statistics
 AEDs are easy to use
 AEDs can be used on adults, children and infants
 AED usage within the first three minutes of SCA can increase survival rates over 80%
 383,000 out-of-hospital cardiac arrests annually in the U.S.
 4 out of 5 cardiac arrests (88%) occur at home, so it’s likely that if you know CPR and have access to an
AED you may save the life of a loved one.
 Less than 8% of people who suffer cardiac arrest outside of a hospital will survive
 Ventricular fibrillation (VF) is present in almost 90% of adult cardiac arrest; the only way to stop VF is
with a defibrillator
 The sooner an AED is used the more likely it will work. A SCA victim losses 7-10% chance at survival
for every minute after SCA that an AED is not used
How To Use an AED:

First, power on the AED. An AED can be used on an adult, child, or infant. Follow the AED prompts. Place
the AED near the victim’s head and power on the unit. Some models require you to push a button to turn it
on, while others turn on automatically when you lift the lid.

Second, apply the AED pads. Expose the chest and wipe it dry of any moisture. Apply the pads to the chest
according to the pads.
 Place one pad on the right side of the chest, just below the collarbone
 Place the other pad on the lower left side of the chest
 Connect the pads to the AED if they’re not already connected

If there are two trained rescuers, one performs CPR while the other prepares the AED for use. The rescuer in
charge of the AED will apply the pads around the hands of the person giving chest compressions. Do not stop

31
CPR while the AED is being readied for use. The AED will prompt you to stop CPR when it is ready to
analyze the heart rhythm.

Third, clear the victim and shock. It is critical that no one touches the victim or his clothing while the AED
analyzes or delivers a shock.

When prompted by the AED to deliver a shock:

 The AED user quickly looks up and down the entire victim to ensure no one is touching him and loudly
states, “Everybody clear.”
 The rescuer can now push the shock button.

AED Use on Children

For the purpose of AED use, a child is age 1-8, or weighs less than 55 lbs. An infant is less than 1 year old.
Children and infants require a lower level of energy to defibrillate the heart.

Child victim: Use an AED with pediatric pads or equipment. If these are not available, use an AED with
adult pads and settings.

Infant victim: It’s best to use a manual defibrillator. If one is not available, use an AED with pediatric pads
or equipment. If these are not available, use an AED with adult pads and settings.
Managing an emergency including moving a patient:

32
Emergency medical conditions typically occur through a sudden insult to the body or mind, often through
injury, infection, obstetric complications, or chemical imbalance; they may occur as the result of persistent
neglect of chronic conditions. Emergency medical services (EMS) to treat these conditions include rapid
assessment, timely provision of appropriate interventions, and prompt transportation to the nearest
appropriate health facility by the best possible means to enhance survival, control morbidity, and prevent
disability .
The goal of effective EMS is to provide emergency medical care to all who need it. Advances in medical care
and technology in recent decades have expanded the parameters of what had been the traditional domain of
emergency services. These services, no longer limited to actual in-hospital treatment from arrival to
stabilization, now include prehospital care and transportation.
Despite the best efforts of primary care providers and public health planners, not every emergency is
preventable. Emergency medical care is needed in diverse circumstances: prospective patients range from
rural farmers or fishers whose most common mode of transportation may be canoes or animal-drawn carts, to
factory workers living in densely populated urban slums, to residents of high-income cities and suburbs.
Actual provision of emergency care may range from delivery using trained emergency professionals to
delivery by laypeople and taxi drivers. Developing strategies to meet the range of needs posed by such
diverse circumstances will require innovation and a reorientation of public health planning.
A number of misconceptions about emergency care are often used as a rationale for giving it low priority in
the health sector, especially in low-income countries. These ideas include equating emergency care with
ambulance transportation, neglecting the role of the community and facility care provided,and assuming that
emergency departments and physicians are the only acute care resources. Such a narrow view ignores the
important contributions of other disciplines, skills, and personnel. Perhaps the most common misperception
is that emergency medical care is inherently expensive and requires high-technology interventions as
opposed to simple and effective strategies

33
Figure: The Emergency Medical Care Pyramid

INTERVENTIONS FOR EMERGENCY CARE: SYSTEMS, STRUCTURES, AND

ORGANIZATION:
Emergency care must be appreciated as an entire system with interdependent components. These
components include pre hospital care, transportation, and hospital care. Each component is important, but all
of them must work together to make a lasting effect on the health of a population. The organization and
operation of the pre hospital care system will vary by country, but it should be linked to the local hospitals or
facilities where patients are taken. When pre hospital transportation is poor or absent, deaths occur that could
have been prevented even by inexpensive procedures (Mock and others 1998). For example, the majority of
maternal deaths may fall into this category. Poor quality of care at the hospitals will lead to in hospital deaths
and may eventually discourage communities that might have the capacity to promptly transfer patients to
such facilities (Leigh and others 1997; Prevention of Maternal Mortality Network 1995). Skilled and
motivated personnel, appropriate supplies, pharmaceuticals, equipment, coordination, and management
oriented to the needs of the critically ill.
Prehospital Care :
Pre hospital care encompasses the care provided from the community (scene of injury, home, school, or other
location) until the patient arrives at a formal health care facility capable of giving definitive care. This care
should comprise basic and proven strategies and the most appropriate personnel, equipment, and supplies
needed to assess, prioritize, and institute interventions to minimize the probability of death or disability. Most
effective strategies are basic and inexpensive, and the lack of high-tech interventions should not deter efforts
to provide good care. Even where resources allow them, the more-invasive procedures performed by
physicians in some pre hospital settings, such as intravenous access and fluid infusion or intubations, do not
appear to improve outcomes, and evidence suggests that they may, in fact, be detrimental to outcomes
Pre hospital care should be simple, sustainable, and efficient. Because resource availability varies greatly
among and within countries, different tiers of care are recognized. Where no formal pre hospital system
exists, the first tier of pre hospital care may be composed of laypeople in the community who have been
taught basic techniques of first aid. Recruiting and training particularly motivated citizens who often confront
emergencies, such as drivers of public transportation, to function as pre hospital care providers can add to
this resource. The second tier comprises paramedical personnel who use dedicated vehicles and equipment
and are usually able to get to patients and take them to hospitals within the shortest possible time. This
second tier may involve the performance of advanced procedures, the administration of intravenous and other
medications by physician or non-physician providers, or both.

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 This care is not always available in low-income countries; few trained personnel and inadequate funding
make round the-clock coverage impossible. Although providing advanced life-saving measures in the pre
hospital environment may be beneficial in some cases, these benefits may be negated if such measures divert
scarce resources from more basic interventions that can benefit far larger numbers of patients (Hauswald and
Yeoh 1997).
In most low- and middle-income countries of Africa, Asia, and Latin America, high maternal and child
mortality are linked to inadequate emergency care, especially poor access to quality hospital care. In these
settings, it is imperative that resources be integrated, instead of one system for injuries and another for
obstetric emergencies. Personnel. Most of the world’s population does not have access to formal pre hospital
care. No personnel are employed for the sole purpose of dealing with medical emergencies outside of
hospitals, and no transportation is dedicated to the task of getting patients in need of emergency care into
hospitals.

Basic and Advanced Transportation Systems:

Transporting a patient from the location of the acute event to a hospital facility is a critical element of the pre
hospital component. Lack of transportation is often a major barrier to accessing emergency care in devising a
pre hospital system of transportation; one should consider locally available resources and the range of viable
alternatives for transportation. In some countries such transportation may be part of a formal EMS system,
whereas in other cases it is entirely informal. For example, commercial vehicles, the police, and relatives
using private motorized or no motorized forms of transportation may bring seriously ill and injured patients
to medical facilities. A bicycle ambulance in Malawi set up to improve emergency obstetric care was actually
used more often for injuries and medical emergencies.
Intervention Costs and Effectiveness:
Costing transportation systems requires the following assumptions:
• In an urban population, one ambulance unit can serve a population of 30,000 people. Thus, 1 million
people would require 33 ambulance units (1 million/30,000).
• Each ambulance unit requires staffing of a rotation of six paramedic-drivers and a seventh paramedic-
driver to cover vacation times and sick leaves.
• A supervisor oversees three ambulance units per year.
• A garage for the ambulance and communications equipment would be 100 square meters but would
entail rental of office-style accommodations.
• A vehicle to be outfitted as an ambulance can be purchased for as much as an off-road vehicle with a
useful life of nine years.
• The cost to modify the vehicle into a basic ambulance is US$5,000 for a useful life of nine years.
• The ambulance will require fuel and maintenance based on usage of 20,000 kilometres per year.
Savings from trauma reductions:
Saving lives from trauma depends on the quality of trauma care at the destination facility. In one year for 1
million people, there will be 4,100 trauma cases and 900 trauma deaths. With rapid resuscitation and oxygen
available through use of ambulances, we assume we can save 300 lives.
Savings from myocardial infarction management:
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In one year for 1 million people in low-income countries, 1,100 deaths will typically result from myocardial
infarction. Low-dose aspirin provided to myocardial infarction victims lowers mortality by 18 per cent
(Weisman and Graham 2002). In a population without ambulance services, rapid aspirin administration
cannot be ensured; with EMS, aspirin use can potentially be increased from about 0 per cent to 100 per cent
for heart myocardial infarction. Therefore, instead of 1,100 deaths, there will be 1,100 (1 -0.18) deaths,
saving 200 lives, but with only an average of five life years per life saved.
Savings from emergency obstetrics management:
Obstetric deaths for medically attended patients are approximately 100 times lower than for patients who do
not receive medical care. Accordingly, an ambulance system essentially saves all of the obstetric
emergencies from death; this saving would amount to 200 deaths averted in the case described previously. As
a result, in the hypothetical population of 1 million people in low-income countries, 700 lives can be saved
by an ambulance system focusing on three causes only: ischemic heart disease (200), obstetric (200), and
trauma (300).

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