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  • Major Trauma Triage Tool Study (MATTS) expert consensus-derived injury assessment tool

    Fuller, Gordon; Howes, Nathan; Mackenzie, Roderick; Keating, Samuel; Turner, Janette; Holt, Chris; Miller, Joshua; Goodacre, Steve (2024-06-01)
    Introduction: Major trauma centre (MTC) care has been associated with improved outcomes for injured patients. English ambulance services and trauma networks currently use a range of triage tools to select patients for bypass to MTCs. A standardised national triage tool may improve triage accuracy, cost-effectiveness and the reproducibility of decision-making. Methods: We conducted an expert consensus process to derive and develop a major trauma triage tool for use in English trauma networks. A web-based Delphi survey was conducted to identify and confirm candidate triage tool predictors of major trauma. Facilitated roundtable consensus meetings were convened to confirm the proposed triage tool’s purpose, target diagnostic threshold, scope, intended population and structure, as well as the individual triage tool predictors and cut points. Public and patient involvement (PPI) focus groups were held to ensure triage tool acceptability to service users. Results: The Delphi survey reached consensus on nine triage variables in two domains, from 109 candidate variables after three rounds. Following a review of the relevant evidence during the consensus meetings, iterative rounds of discussion achieved consensus on the following aspects of the triage tool: reference standard, scope, target diagnostic accuracy and intended population. A three-step tool comprising physiology, anatomical injury and clinical judgement domains, with triage variables assessed in parallel, was recommended. The triage tool was received favourably by PPI focus groups. Conclusions: This paper presents a new expert consensus derived major trauma triage tool with defined purpose, scope, intended population, structure, constituent variables, variable definitions and thresholds. Prospective evaluation is required to determine clinical and cost-effectiveness, acceptability and usability. Abstract published with permission.
  • What is the best location for a defibrillator to improve OHCA coverage?

    Brown, Terry P.; Perkins, Gavin; Rosser, Andy; Lumley-Holmes, Jenny; Arvanitis, Theodoros N.; Siriwardena, Aloysius; Clegg, Gareth; Andronis, Lazaros; Deakin, Charles; Mapstone, James (Elsevier, 2022-06-01)
  • Effects of case management on emergency service usage and mortality of people who call 999 frequently (STRETCHED): emerging results of linked data analysis

    Driscoll, Timothy; Aslam, Rabeea'h Waseem; Edwards, Adrian; Edwards, Bethan; Evans, Bridie; Farr, Angela; Foster, Theresa; Fothergill, Rachael; Gunson, Imogen; Hughes, Heather; et al. (2023)
  • An unusual transmission event of Neisseria meningitidis serogroup W135 type 2a in a healthcare setting, England, 2012

    Puleston, R.; Beck, C.; Tahir, M.; Bardhan, M.; Charlemagne, P.; Alves, C.; Ladhani, S.; Watson, C.; Ramsay, M.; Kaczmarksi, E.; et al.
  • Call assessor-initiated referral without clinical discussion to medical SDEC (same day emergency care): a new pathway for suspected pulmonary embolism

    Miller, Josh; Williams, Emma; Harris, Scott; Goodman, Samuel; Topping, Richard; Musticone, Paul; Dodgson, Paula (2023)
  • Randomised controlled trial of analgesia for the management of acute severe pain from traumatic injury: study protocol for the paramedic analgesia comparing ketamine and morphine in trauma (PACKMaN)

    Michelet, Felix; smyth, mike; Lall, Ranjit; Noordali, H; Starr, K; Berridge, L; Yeung, J; Fuller, G; Petrou, S; Walker, Alison; et al. (2023)
  • Consensus on acute behavioural disturbance in the UK: a multidisciplinary modified Delphi study to determine what it is and how it should be managed

    Humphries, Christopher; kelly, Anthony; Sadik, Aws; Walker, Alison; Smith, Jason (2023-09-22)
    Background Acute behavioural disturbance (ABD) is a term used in law enforcement and healthcare, but there is a lack of clarity regarding its meaning. Common language should be used across staff groups to support the identification, prioritisation and delivery of care to this group of patients. The terminology currently used is inconsistent and confusing. This study aimed to reach a consensus on the criteria for identification and management of ABD, and to agree when other care pathways or guidelines might be more appropriately used. Methods A modified Delphi study with participation from stakeholder organisation representatives was conducted in January–April 2023 online. In round 1, statements were generated by participants in response to broad questions. Participants then rated their level of agreement with statements in subsequent rounds, with statements achieving a consensus removed for inclusion in the final derived consensus statement. Non-consensus statement responses were assessed for stability. Results Of 430 unique statements presented for rating, 266 achieved a consensus among 30 participants representing eight stakeholder organisations. A derived consensus statement was generated from these statements. The median group response to statements which failed to achieve a consensus was reliable (Krippendorff’s alpha=0·67). Conclusions There is a consensus across stakeholder organisations that ABD is not a separate entity to agitation, and guidance should instead be altered to address the full range of presentations of agitation. While the features of concern in this severely agitated group of patients can be described, the advice for recognition may vary depending on staff group. Criteria for recognition are provided and potential new terminology is described. This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
  • Prehospital early warning scores for adults with suspected sepsis: retrospective diagnostic cohort study

    Goodacre, Steve; Sutton, Laura; Thomas, Ben; Hawksworth, Olivia; Iftikhar, Khurram; Croft, Susan; Fuller, Gordon; Waterhouse, Simon; Hind, Daniel; Bradburn, Mike; et al. (2023-11)
    Background Ambulance services need to identify and prioritise patients with sepsis for early hospital assessment. We aimed to determine the accuracy of early warning scores alongside paramedic diagnostic impression to identify sepsis that required urgent treatment. Methods We undertook a retrospective diagnostic cohort study involving adult emergency medical cases transported to Sheffield Teaching Hospitals ED by Yorkshire Ambulance Service in 2019. We used routine ambulance service data to calculate 21 early warning scores and categorise paramedic diagnostic impressions as sepsis, infection, non-specific presentation or other presentation. We linked cases to hospital records and identified those meeting the sepsis-3 definition who received urgent hospital treatment for sepsis (reference standard). Analysis determined the accuracy of strategies that combined early warning scores at varying thresholds for positivity with paramedic diagnostic impression. Results We linked 12 870/24 955 (51.6%) cases and identified 348/12 870 (2.7%) with a positive reference standard. None of the strategies provided sensitivity greater than 0.80 with positive predictive value greater than 0.15. The area under the receiver operating characteristic curve for the National Early Warning Score, version 2 (NEWS2) applied to patients with a diagnostic impression of sepsis or infection was 0.756 (95% CI 0.729, 0.783). No other early warning score provided clearly superior accuracy to NEWS2. Paramedic impression of sepsis or infection had sensitivity of 0.572 (0.519, 0.623) and positive predictive value of 0.156 (0.137, 0.176). NEWS2 thresholds of >4, >6 and >8 applied to patients with a diagnostic impression of sepsis or infection, respectively, provided sensitivities and positive predictive values of 0.522 (0.469, 0.574) and 0.216 (0.189, 0.245), 0.447 (0.395, 0.499) and 0.274 (0.239, 0.313), and 0.314 (0.268, 0.365) and 0.333 (0.284, 0.386). Conclusion No strategy is ideal but using NEWS2 alongside paramedic diagnostic impression of infection or sepsis could identify one-third to half of sepsis cases without prioritising unmanageable numbers. No other score provided clearly superior accuracy to NEWS2. This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
  • Experiences and views of people who frequently call emergency ambulance services: a qualitative study of UK service users

    Evans, Bridie; Khanom, Ashra; Edwards, Bethan; Foster, Theresa; Fothergill, Rachael; Foster, Theresa; Fothergill, Rachael; Scott, Jason; Gunson, Imogen; Edwards, Adrian; et al. (2023-08-09)
  • A response to 'Fighting the fire': fire chiefs' proposal to run England's ambulance service...‘Fighting the fire: a response to fire chiefs’, October, 2010

    Jones, Peter; Woollard, Malcolm (MAG Online, 2011-02-04)
    In October 2010, JPP published a comment by Prof Malcolm Woollard, titled ‘Fighting the fire: a response to fire chiefs’ proposal to run England’s ambulance service’, expressing his view as to why the proposal by the Chief Fire Officers Association (CFOA) is not workable. JPP has received a letter regarding this, which is printed below, along with a response from Prof Woollard that also discusses the latest report published by the CFOA. Abstract published with permission
  • Case management of people who call 999 frequently – qualitative study of the perspective of people providing and receiving care (STRETCHED)

    Snooks, Helen; Khanom, Ashra; Cole, Robert; Edwards, Adrian; Evans, Bridie; Foster, Theresa; Gripper, Penny; Hampton, Chelsey; John, Ann; Petterson, Robin; et al.
  • Drug routes in out-of-hospital cardiac arrest: a summary of current evidence

    Hooper, Amy; Nolan, Jerry; Rees, Nigel; Walker, Alison; Perkins, Gavin; Couper, Keith (Elsevier, 2022-12)
  • Consensus on innovations and future change agenda in Community First Responder schemes in England: a national Nominal Group Technique study

    Patel, Gupteswar; Botan, Vanessa; Phung, Viet-Hai; Trueman, Ian; Pattinson, Julie; Hosseini, Seyed Mehrshad Parvin; Orner, Roderick; Asghar, Zahid; Smith, Murray Donald; Rowan, Elise; et al. (2023)
  • Surviving an out-of-hospital hypothermic cardiac arrest in the United Kingdom

    Evans, Stuart (The College of Paramedics, 2023-03-01)
    Introduction: Hypothermia is an uncommon cause of cardiac arrest in the United Kingdom, and more commonly occurs in countries experiencing avalanches and significant winter climates; however, this case demonstrates that the presentation can occur in the United Kingdom. This case adds to a body of evidence that prolonged resuscitation can be successful in patients suffering a cardiac arrest secondary to hypothermia, leading to a good neurological outcome. Case presentation: The patient suffered a witnessed out-of-hospital cardiac arrest following rescue from a free-flowing river, and underwent prolonged resuscitation. The patient presented in persistent ventricular fibrillation, unresponsive to defibrillation attempts. An oesophageal probe recorded the patient’s temperature as 24°C. Rescuers were guided by the Resuscitation Council UK advanced life support algorithm to withhold drug therapy and limit defibrillation attempts to three, until the patient had been rewarmed to above 30°C. Appropriate triage of the patient to an extracorporeal life support (ECLS) capable centre allowed specialised treatment to be initiated, and culminated in successful resuscitation once normothermia was restored. After a short stay in intensive care, the patient was discharged for rehabilitation due to a hypoxic spinal cord injury before discharge home. Conclusion: This case highlights that hypothermia is a reversible cause of cardiac arrest, which needs to be recognised and acted upon appropriately to provide the best possible chance for a positive outcome. Low-reading thermometers capable of identifying the temperature thresholds stated in the Resuscitation Council UK guidelines are required, to allow clinicians to adapt their practice according to the presenting situation. Tympanic thermometers are often limited to their lowest recordable temperature, and invasive monitoring such as oesophageal or rectal probes are not common in UK ambulance service practice. With the necessary equipment, patients can be triaged to an ECLS-capable centre, allowing them to receive the specialist rewarming that they require. Abstract published with permission.
  • The prehospital 12 lead electrocardiogram is associated with improved outcomes in patients with acute coronary syndromes presenting to emergency medical services: a nationwide linked cohort study

    Quinn, Tom; Driscoll, Timothy; Gavalova, Lucia; Halter, Mary; Gale, Chris P; Weston, Clive FM; Watkins, Alan; Munro, Scott; Davies, Glen; Rosser, Andy; et al.
    Background Use of the Pre-Hospital 12-lead Electrocardiogram (PHECG) is recommended in patients presenting to emergency medical services (EMS) with suspected acute coronary syndrome (ACS). Objectives To investigate differences in mortality between those who did/did not receive PHECG. Methods Population-based, linked cohort study using Myocardial Ischaemia National Audit Project (MINAP) data from 2010-2017. Results Of 330,713 patients, 263,420 (79.6%) had PHECG, 67,293 (20.3%) did not. 30-day mortality was 7.8% overall, 7.1% with PHECG vs 10.9% without PHECG (adjusted Odds Ratio [aOR] 0.772, 95% confidence interval [CI] 0.748-0.795, p<0.001). 1 year mortality was 16.1% overall, 14.2% with PHECG vs 23.2% without (aOR 0.692, 95% CI 0.676-0.708, p<0.001). 144,254 patients had ST segment elevation myocardial infarction (STEMI); 130,240 (90.2%) had PHECG, 30 day mortality 8.8% overall, 8.0% with PHECG vs 15.9% without (aOR 0.588, 95% CI 0.557-0.622, p<0.001), 1 year mortality 13.1% overall, 12.1% with PHECG vs 22.8% without (aOR 0.585, 95% CI 0.557-0.614, p<0.001). 186,459 patients had non-STEMI; 133,180 (71.4%) had PHECG. 30- day mortality 7.1% overall, 6.1% with PHECG vs 9.6% without (aOR 0.677, 95%CI 0.652-0.704, p<0.001), 1 year mortality 18.3% overall, 16.3% with PHECG vs 23.3% without (aOR 0.694, 95% CI 0.676-0.713, p<0.001). 110,571 STEMI patients received primary PCI, 103,741 (93.8%) had PHECG. 30 day mortality 5.4% overall, 5.3% with PHECG vs 7.0% without (aOR 0.739, 95% CI 0.667-0.829, p<0.001). 1 year mortality 8.5% overall, 8.4% with PHECG vs 9.8% without (aOR 0.833, 95% CI 0.762-0.911, p<0.001). 26,127 (18.1%) STEMI patients received no reperfusion; 19,873 (76%) had PHECG. Mortality at 30 days 22.1% overall, 21.3% with PHECG vs 24.7% without (aOR 0.911, 95% CI 0.847-0.980, p=0.013), 1 year mortality 32.2% overall, 30.9% with PHECG, 36.4% without (aOR 0.865, 95% CI 0.810-0.925, p<0.001). Conclusion PHECG was associated with lower mortality at 30 days and 1 year in both STEMI and non-STEMI patients This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: DOI
  • Taking services to the streets over the party season

    Brace, Samantha; Farmer, Christopher; Calow, Phil (2009-12-20)
  • Recognition of life extinct and the processes of death

    Shrehorn, Thomas (2009-09-30)
    A paramedic has the responsibility to confirm deaths within the community in which they work and there are distinct protocols to follow. They also have the responsibility to decide whether or not to carry out cardiopulmonary resuscitation on expected and unexpected deaths. The recognition of life extinct (ROLE) protocol included in the Joint Colleges Ambulance Liaison Committee Guidelines (2006) provides guidance on when, and when not, to perform cardiopulmonary resuscitation on patients but does not cover the processes occurring after death. Death is a process which occurs in stages and within certain time constraints, depending on intrinsic and extrinsic factors. This article covers the processes of death and the timelines in which they occur and aims to improve the paramedic's knowledge and ability to make sound judgements and assist with providing justifications of confirming death alongside the ROLE protocol to relatives, the police and the coroner. Abstract published with permission

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