Recent Submissions

  • A critical reassessment of ambulance service airway management in prehospital care: Joint Royal Colleges Ambulance Liaison Committee Airway Working Group, June 2008

    Deakin, Charles D.; Clarke, Tom; Nolan, Jerry P.; Zideman, David; Gwinnutt, Carl; Moore, Fionna; Keeble, Carl; Blancke, Wim (2010-03)
    Paramedic tracheal intubation has been practised in the UK for more than 20 years and is currently a core skill for paramedics. Growing evidence suggests that tracheal intubation is not the optimal method of airway management by paramedics and may be detrimental to patient outcomes. There is also evidence that the current initial training of 25 intubations performed in-hospital is inadequate, and that the lack of ongoing intubation practice may compound this further. Supraglottic airway devices (eg, laryngeal mask airway), which were not available when extended training and paramedic intubation was first introduced, are now in use in many ambulance services and are a suitable alternative prehospital airway device for paramedics. https://emj.bmj.com/content/27/3/226.long. 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: http://creativecommons.org/licenses/by-nc/4.0/ DOI http://dx.doi.org/10.1136/emj.2009.082115
  • Development and pilot of clinical performance indicators for English ambulance services

    Siriwardena, Aloysius; Shaw, Deborah; Donohoe, Rachel; Black, Sarah; Stephenson, John; National Ambulance Clinical Audit Steering Group (2010-04-12)
    Introduction There is a compelling need to develop clinical performance indicators for ambulance services in order to move from indicators based primarily on response times and in light of the changing clinical demands on services. We report on progress on the national pilot of clinical performance indicators for English ambulance services. Method Clinical performance indicators were developed in five clinical areas: acute myocardial infarction, cardiac arrest, stroke (including transient ischaemic attack), asthma and hypoglycaemia. These were determined on the basis of common acute conditions presenting to ambulance services and in line with a previously published framework. Indicators were piloted by ambulance services in England and results were presented in tables and graphically using funnel (statistical process control) plots. Results Progress for developing, agreeing and piloting of indicators has been rapid, from initial agreement in May 2007 to completion of the pilot phase by the end of March 2008. The results of benchmarking of indicators are shown. The pilot has informed services in deciding the focus of their improvement programme in 2008–2009 and indicators have been adopted for national performance assessment of standards of prehospital care. Conclusion The pilot will provide the basis for further development of clinical indicators, benchmarking of performance and implementation of specific evidence-based interventions to improve care in areas identified for improvement. A national performance improvement registry will enable evaluation and sharing of effective improvement methods as well as increasing stakeholder and public access to information on the quality of care provided by ambulance services. https://emj.bmj.com/content/27/4/327. 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: http://creativecommons.org/licenses/by-nc/4.0/ DOI http://dx.doi.org/10.1136/emj.2009.072397
  • Supporting research and development in ambulance services: research for better health care in prehospital settings

    Siriwardena, Aloysius; Donohoe, Rachel; Stephenson, John; Phillips, Paul (2010-04-12)
    Background This paper discusses recent developments in research support for ambulance trusts in England and Wales and how this could be designed to lead to better implementation, collaboration in and initiation of high-quality research to support a truly evidence-based service. Method The National Ambulance Research Steering Group was set up in 2007 to establish the strategic direction for involvement of regional ambulance services in developing relevant and well-designed research for improving the quality of services to patients. Results Ambulance services have been working together and with academic partners to implement research and to participate, collaborate and lead the design of research that is relevant for patients and ambulance services. Conclusion New structures to support the strategic development of ambulance and prehospital research will help address gaps in the evidence for health interventions and service delivery in prehospital and ambulance care and ensure that ambulance services can increase their capacity and capability for high-quality research. https://emj.bmj.com/content/27/4/324. 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: http://creativecommons.org/licenses/by-nc/4.0/ DOI http://dx.doi.org/10.1136/emj.2009.072363
  • An evaluation of an educational intervention to reduce inappropriate cannulation and improve cannulation technique by paramedics

    Siriwardena, Aloysius; Iqbal, Mohammad; Banerjee, Smita C.; Spaight, Anne; Stephenson, John (2009-10-22)
    Background: Intravenous cannulation enables administration of fluids or drugs by paramedics in prehospital settings. Inappropriate use and poor technique carry risks for patients, including pain and infection. We aimed to investigate the effect of an educational intervention designed to reduce the rate of inappropriate cannulation and to improve cannulation technique. Method: We used a non-randomised control group design, comparing two counties in the East Midlands (UK) as intervention and control areas. The educational intervention was based on Joint Royal Colleges Ambulance Liaison Committee guidance and delivered to paramedic team leaders who cascaded it to their teams. We analysed rates of inappropriate cannulation before and after the intervention using routine clinical data. We also assessed overall cannulation rates before and after the intervention. A sample of paramedics was assessed post-intervention on cannulation technique with a “model” arm using a predesigned checklist. Results: There was a non-significant reduction in inappropriate (no intravenous fluids or drugs given) cannulation rates in the intervention area (1.0% to 0%) compared with the control area (2.5% to 2.6%). There was a significant (p<0.001) reduction in cannulation rates in the intervention area (9.1% to 6.5%; OR 0.7, 95% CI 0.48 to 1.03) compared with an increase in the control area (13.8% to 19.1%; OR 1.47, 95% CI 1.15 to 1.90), a significant difference (p<0.001). Paramedics in the intervention area were significantly more likely to use correct hand-washing techniques post-intervention (74.5% vs. 14.9%; p<0.001). Conclusion: The educational intervention was effective in bringing about changes leading to enhanced quality and safety in some aspects of prehospital cannulation. https://emj.bmj.com/content/26/11/831. 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: http://creativecommons.org/licenses/by-nc/4.0/ DOI http://dx.doi.org/10.1136/emj.2008.071415
  • Prehospital intravenous cannulation: reducing the risks and rate from inappropriate venous access by paramedics

    Iqbal, Mohammad; Banerjee, Smita C.; Spaight, Anne; Stephenson, John; Siriwardena, Aloysius (2009-10)
    Background Prehospital intravenous (IV) cannulation by paramedics is a key intervention which enables administration of fluids and drugs in the prehospital setting. Inappropriate use and poor technique of IV cannulation carry potential risks for patients such as pain and infection. Cannulation rates vary widely between paramedics and ambulance stations and rates have increased over the past decade. A baseline audit carried out in Lincolnshire division of East Midlands Ambulance Service (EMAS) in 2006 found that paramedics cannulated 14.2% of transported patients and cannulation rates varied considerably between ambulance stations, with a mean rate of 13.4% (range 5.8% to 19%). An estimated 15.6% of these cannulations could have been avoided. Objective This evaluation was aimed at investigating the effect of a complex educational intervention to reduce the rate of cannulation and improve cannulation technique in EMAS NHS Trust which provides emergency and unscheduled care in six counties of the UK. Method A non-randomised control group (before and after) design was used to evaluate the effect of the educational intervention. Two geographical areas of EMAS were involved in the study; an intervention area (Nottinghamshire) was compared with a control area (Lincolnshire). The educational intervention was based on current guidance (JRCALC) and delivered to paramedic team leaders who cascaded it to their teams. Comparisons between the areas were made by analysing cannulation rates 2 months before and after intervention. Paramedics, 50 in each group, were assessed on technique, appropriateness and attitude towards cannulation. Results Preliminary results showed that there was a reduction in cannulation rates in the intervention area from 9.1% to 6.5% compared with an increase in the control area from 13.8 to 19.1%. Paramedics in the intervention group were significantly more likely to use correct consent and hand washing techniques following the intervention. https://emj.bmj.com/content/26/10/1.2. 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: http://creativecommons.org/licenses/by-nc/4.0/ DOI http://dx.doi.org/10.1136/emj.2009.075432a
  • The new coronavirus disease: what do we know so far?

    Tang, Sammer; Brady, Mike; Mildenhall, Joanne; Rolfe, Ursula; Bowles, Alexandra; Morgan, Kirsty (2020-05-05)
    View Article Abstract Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a novel coronavirus that causes the new disease COVID-19. Symptoms range from mild to severe with a higher incidence of severe cases in patients with risk factors such as older age and comorbidities. COVID-19 is mainly spread through the inhalation of respiratory droplets from coughing or sneezing or via contact with droplet-contaminated surfaces. Paramedics should be aware that some aerosol-generating procedures may put them at a higher risk of contracting the virus via possible airborne transmission. Use of remote triage clinical assessment is likely to increase as a result of the pandemic. There is no curative drug treatment for the virus and some medications may exacerbate its effects or make patients more susceptible to it. Evidence and guidelines are evolving on SARS-CoV-2 and COVID-19. Paramedics should keep up to date with the latest clinical guidance from their employers. Abstract published with permission.
  • Unexpected shock in a fallen older adult: a case report

    Matthews, Gary; Booth, Helen; Whitley, Gregory (2020-06-01)
    Abstract published with permission. Introduction: Falls are common in older adults and frequently require ambulance service assistance. They are the most frequent cause of injury and associated morbidity and mortality in older adults. In recent years, the typical major trauma patient has changed from being young and male to being older in age, with falls of < 2 metres being the most common mechanism of injury. We present a case of an 84-year-old male who had fallen in his home. This case highlights the complex nature of a relatively common incident. Case presentation: The patient was laid on the floor in the prone position unable to move for 12 hours. He did not complain of any pain in his neck, back, hips or legs, and wished to be lifted off the floor promptly. On examination, he had bruising to his chest and abdomen and had suffered a suspected cervical spine injury due to a step-like protrusion around C5–C6. Distal sensory and motor function was intact. While in the ambulance his blood pressure dropped from 154/119 mmHg to 49/28 mmHg unexpectedly. We successfully reversed the shock using the modified Trendelenburg position and intravenous fluids. On follow-up he was diagnosed with dislocated C3, C6 and C7 vertebrae. Conclusion: The unexpected episode of shock witnessed in this patient may have been caused by a number of phenomena, including but not limited to crush syndrome, spinal cord concussion and orthostatic hypotension. We recommend that clinicians anticipate sudden shock in older adult patients who have fallen and a) have remained static on the floor for an extended period of time or b) are suspected of a spinal injury. We recommend assertive management of these patients to mitigate the impact of shock through postural positioning and consideration of early cannulation.
  • Exploratory cross-sectional study of factors associated with pre-hospital management of pain

    Siriwardena, Aloysius; Shaw, Deborah; Bouliotis, George (2010-12)
  • Investigation of patient and practitioner views on improving pain management in the prehospital settings

    Iqbal, Mohammad; Spaight, Anne; Siriwardena, Aloysius; Shaw, Deborah (2011-03)
    Background Pre-hospital pain management is increasingly important with most patients (80%) presenting to UK ambulance services in pain. Around 20% of patients want more pain relief and 5% feel that ambulance crews do not adequately treat pain. A recent study in the East Midlands showed that 85.1% of AMI patients and 75% of fracture patients had a pain score but fewer than a quarter of patients assessed for and experiencing pain with either condition received opiates. Improving the pathway of prehospital pain management is therefore important and a key indicator of the quality of service. Objective We gathered data on perspectives of pain management from patients, ambulance and accident and emergency (A&E) care staff in Lincolnshire. Method Qualitative data were gathered through focus group (5) and interviews (28). Participants were purposively sampled from patients recently transported to hospital with pain, ambulance staff and A&E clinicians. Interviews were audiotaped and transcribed. Data were manipulated using MAXQDA and thematic analysis used iteratively to develop themes. Results Themes emerging from the data included: (a) expectations and beliefs (b) assessment methods (c) drug treatment (d) non-drug treatment and (e) improvement strategies for pain. Patients and staff expected pain to be relieved in the ambulance; instances of refusal or inadequate analgesia were not uncommon. Pain was commonly assessed using a verbal pain score; clinical observation was also used which sometimes led to discordance between subjective experience and clinical assessment. Morphine, Entonox and oxygen were commonly used to treat pain. Reassurance, positioning and immobilisation were alternatives to drugs. Suggestions to improve prehospital pain management included addressing barriers, modifying the available drugs and developing a prehospital pain management protocol supported by training for staff. Conclusion The findings will be used to develop an educational intervention for better pain assessment and management in the prehospital setting. https://emj.bmj.com/content/emermed/28/3/e1.12.full.pdf 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: http://creativecommons.org/licenses/by-nc/4.0/ http://dx.doi.org/10.1136/emj.2010.108605.2
  • Cardiac arrest in the young: rare but possible

    Mallon, Gareth (2011-04)
    Abstract published with permission. It can be hard to believe that someone young and active may be at risk from heart problems, but each week in the UK at least 12 apparently fit and healthy young people die from undiagnosed heart conditions. Cardiac Risk in the Young (CRY) is a charity that works to support families affected by the sudden cardiac death of a young person, to help young people who have been diagnosed with life threatening heart conditions and to reduce the number of tragedies that occur. 2010 marked the 15th anniversary year of CRY. Here, Gareth Mallon, a community paramedic and developing tutor for the East Midlands Ambulance Service (EMAS), discusses his personal involvement with the charity in more detail.
  • Understanding how Eastern European migrants use and experience UK health services: a systematic scoping review

    Phung, Viet-Hai; Asghar, Zahid; Matiti, Milika; Siriwardena, Aloysius (2020-03-06)
  • Determining the Feasibility of Ambulance-Based Randomised Controlled Trials in Patients with Ultra-Acute Stroke: Study Protocol for the "Rapid Intervention with GTN in Hypertensive Stroke Trial"

    Ankolekar, Sandeep; Sare, Gillian; Geeganage, Chamila; Fuller, Michael; Stokes, Lynn; Sprigg, Nicola; Parry, Ruth; Siriwardena, Aloysius; Bath, Phillip, M.W. (2012-09)
  • Scabies: a problem that can really get under your skin

    Pocock, Helen (2012-01)
    Abstract published with permission. This article explores the assessment, diagnosis and current recommended treatment for scabies in the UK. There are many myths surrounding scabies which could lead to misdiagnosis. Using a case from clinical practice, some of the common features of a history suggestive of infestation are explored and the social and psychological effects of such a diagnosis are considered. As a result of reading this article, prehospital practitioners should be more aware of scabies and more able to identify it in the community setting.
  • Exploratory study of factors associated with adverse clinical features in patients presenting with non-fatal drug overdose/self-poisoning to the ambulance service

    Gwini, Stella M.; Shaw, Deborah; Iqbal, Mohammad; Spaight, Anne; Siriwardena, Aloysius (2011-10)
    AIM: To investigate the factors associated with adverse clinical features presented by drug overdose/self-poisoning patients and the treatments provided. METHODS: Historical patient records collected over 3 months from ambulance crews attending non-fatal overdoses/self-poisoning incidents were reviewed. Logistic regression was used to investigate predictors of adverse clinical features (reduced consciousness, obstructed airway, hypotension or bradycardia, hypoglycaemia) and treatment. RESULTS: Of 22,728 calls attended to over 3 months, 585 (rate 26/1000 calls) were classified as overdose or self-poisoning. In the 585 patients identified, paracetamol-containing drugs were most commonly involved (31.5%). At least one adverse clinical feature occurred in 103 (17.7%) patients, with higher odds in men and opiate overdose or illegal drugs. Older patients and patients with reduced consciousness were more likely to receive oxygen. The latter also had a greater chance of receiving saline. CONCLUSION: Non-fatal overdose/self-poisoning accounted for 2.6% of patients attended by an ambulance. Gender, illegal drugs or opiates were important predictors of adverse clinical features. The treatments most often provided to patients were oxygen and saline. https://emj.bmj.com/content/emermed/28/10/892.full.pdf 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: http://creativecommons.org/licenses/by-nc/4.0/ http://dx.doi.org/10.1136/emj.2009.086140
  • A case study framework for design and evaluation of a national project to improve prehospital care of myocardial infarction and stroke

    Essam, Nadya; Davy, Zowie; Shaw, Deborah; Spaight, Anne; Siriwardena, Aloysius (2011-11)
    Background Cardiovascular disease (CVD) affects 1.8% of the population annually, 0.9% with stroke and 0.8% with coronary heart disease. People suffering from CVD often present acutely to ambulance services with symptoms of acute myocardial infarction or stroke. Early and effective treatment prevents death, improves long term health and reduces future disability. Objective Our aim is to develop a rational approach for informing the design and evaluation of a national project for improving prehospital care of myocardial infarction and stroke: the Ambulance Services Cardiovascular Quality Initiative (ASCQI), the first national improvement project for prehospital care. Methods We will use a case study methodology initially utilising an evaluation logic model to define inputs (in terms of resources for planning, implementation and evaluation), outputs (in terms of intended changes in healthcare processes) and longer-term outcomes (in terms of health and wider benefits or harms), whether intended or incidental and in the short, medium or long term. Results We will present an evaluation logic model for the project. This will be expanded to show the analytical techniques which we will use to explain how and why the project achieves its outcomes. This includes times series analyses, pattern matching, cross case syntheses and explanation building to inform an explanatory logic model. We will discuss how this model will be useful in determining the data that will need to be collected during the course of the project to inform the detailed explanation of how and why the project delivered its outcomes. Conclusion The case study approach will enable us to evaluate the impact of this collaborative project in constituent ambulance services as well as the initiative as a whole. It will enable us to show whether and to what extent the project has had an impact, but also how and why this has happened. https://emj.bmj.com/content/emermed/28/11/e2.7.full.pdf 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: http://creativecommons.org/licenses/by-nc/4.0/ http://dx.doi.org/10.1136/emermed-2011-200645.15
  • Ambulance attendance at diabetes or diabetes-related emergencies in care homes – cross sectional database study

    Siriwardena, Aloysius Niroshan; Law, Graham; Smith, Murray D.; Iqbal, Mohammad; Phung, Viet-Hai; Spaight, Anne; Brewster, Amanda; Mountain, Pauline; Spurr, Keith; Ray, Mo; et al. (2019-09-24)
    Background Diabetes, which affects over 1 in 5 nursing or care home residents, may lead to diabetes-related emergencies with ambulance call-outs and hospitalisation. Our aim was to investigate the epidemiology of diabetes-related emergencies in care home residents which involved an ambulance attendance. Methods We used a cross-sectional design to investigate emergency ambulance attendances to people in nursing and residential care homes presenting with diabetes-related emergencies across the East Midlands between January 2012 and December 2017. We used clinical and dispatch data from East Midlands Ambulance Service NHS Trust (EMAS) and care home data from the Care Quality Commission, including call category, timing, location, place of residence, clinical or physiological status, treatments, outcome (conveyance) and costs in the analysis. Results Overall 219722 (6.7% of 3.3 million) attendances were to care home residents of which 12080 were for diabetes-related emergencies. Of 3152 care home patients categorised as having a ‘diabetic problem’ 1,957 (62.1%) were conveyed to hospital. This was not significantly different to the rate for other patients, taking into account other factors, despite access to trained staff in care homes. Statistically significant factors associated with conveyance included reduced consciousness level (OR 0.91, 95% CI 0.87–0.95), elevated heart (1.01, 1.01–1.02) or respiratory rate (1.08, 1.06–1.10), no treatment for hypoglycaemia (0.54, 0.34–0.86) or additional co-morbid medical (but not psychiatric) problems. Cost to EMAS was significantly lower when a patient was conveyed, by some £18 (95% CI £11.94–£24.12), but this would not outweigh downstream NHS costs arising from hospital care. For the simulation in which all trusts mean NHS Reference Costs were used, conveyance was no longer significant in the cost model. Conclusion Conveyance to hospital was common for care home patients with diabetes-related emergencies and more likely when conscious level was impaired, certain physiological measures abnormal or treatment for hypoglycaemia was not given. https://emj.bmj.com/content/36/10/e8.3 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: http://creativecommons.org/licenses/by-nc/4.0/ DOI http://dx.doi.org/10.1136/emermed-2019-999abs.18
  • Ambulances attending diabetes-related emergencies in care homes – cross sectional database study

    Siriwardena, Aloysius; Law, Graham; Smith, M.D.; Iqbal, Mohammad; Phung, Viet-Hai; Spaight, Anne; Brewster, A.; Mountain, P.; Spurr, K.; Ray, M.; et al. (2019-04-26)
    Background Diabetes, affecting 1 in 5 care home residents, may lead to ambulance call-outs and hospitalisation. We aimed to investigate the epidemiology of diabetes-related emergencies involving ambulance attendances to care home residents. Method Cross-sectional design investigating ambulance attendance to people presenting with diabetes-related emergencies in the East Midlands, UK, between 2012 and 2017. We analysed dispatch and ambulance clinical data with care home data, including call category, timing, location, care home type, clinical or physiological measures, treatments, conveyance (transport to hospital) and costs. Results Overall 2 19 722 (6.7% of 3.3 million) ambulances attended care homes over 6 years, with 12 080 (5.5%) to diabetes-related emergencies. Of 3152 care home patients categorised as having a ‘diabetic problem’, 1957 (62.1%) were conveyed to hospital, similar to that for community residents taking into account other factors. Factors associated with conveyance included reduced consciousness (OR 0.91, 95% CI 0.87–0.95), elevated heart (1.01, 1.01–1.02) or respiratory rate (1.08, 1.06–1.10), no treatment for hypoglycaemia (0.54, 0.34–0.86) or additional medical (but not psychiatric) problems. Ambulance costs were significantly lower when a patient was conveyed, by some £18 (95% CI £11.94–£24.12), but this would be outweighed by downstream hospital care costs. For a simulation in which all trusts’ mean NHS Reference Costs were used, conveyance was no longer significant in the cost model. Conclusion Conveyance following diabetes-related emergencies was as common for care home as for other community residents despite access to trained staff, and more likely with impaired consciousness, abnormal physiological measures or lack of treatment for hypoglycaemia. Conflict of interest None. Funding National institute for Health Research Collaboration for Leadership in Applied Health Research and Care East Midlands, UK., https://bmjopen.bmj.com/content/9/Suppl_2/A11.2. 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: http://creativecommons.org/licenses/by-nc/4.0/ DOI http://dx.doi.org/10.1136/bmjopen-2019-EMS.30

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