• Are they really refusing to travel? A qualitative study of prehospital records

      Shaw, Deborah; Dyas, Jane; Middlemass, Jo; Spaight, Anne; Briggs, Maureen; Christopher, Sarah; Siriwardena, Niroshan, A. (2006-09-19)
    • 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
    • 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
    • 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
    • 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
    • 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
    • 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.
    • 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
    • Identifying barriers and facilitators to improving prehospital care of asthma: views of ambulance clinicians

      Shaw, Deborah; Knowles, Stacey; Siriwardena, Aloysius (2011-11)
      Background In 2008/2009 there were nearly 80 000 emergency hospital admissions for asthma. Current UK guidelines emphasise the importance of evidence-based prehospital assessment and treatment of asthma for improving patient outcomes and reducing hospitalisation, morbidity and mortality. National benchmarking of ambulance clinical performance indicators for asthma have revealed important unexplained variations in care across ambulance services. Little research has been undertaken to understand the reasons for poor levels of care. Objective The aim of this study was to gather data on ambulance clinicians' perceptions and beliefs around prevailing and best practice for management of asthma. This was used to identify the factors which prevent or enable better asthma care in ambulance services. Methods We used a phenomenological qualitative approach, which addresses how individuals use their experiences to make sense of their world, focusing on participants' lived experiences of care delivery for asthma. We used focus groups of ambulance clinicians to gather data on barriers and facilitators to better asthma care. Recordings and notes were taken, transcribed and then analysed using QSR NVivo 8. A coding framework was developed based on a priori concepts but with emergent themes added during the analysis. Results Two focus groups were conducted with eight and five participants respectively. A number of preliminary themes and subthemes were identified. The study identified issues relating to clarity of ambulance guidelines, conflicts between training and guidance, misconceptions about the importance of objective assessment and over reliance on non-objective assessment. Some practitioners believed that hospital staff were not interested in prehospital peak flow assessments. Conclusion Our findings will inform improved systems of care for asthma and the effect on indicators will be measured using time series methods. This approach could be used more widely to improve management of specific clinical conditions where quality of care is demonstrated to be suboptimal. https://emj.bmj.com/content/emermed/28/11/e2.10.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-2011-200645.3
    • 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
    • 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.
    • Community falls prevention for people who call an emergency ambulance after a fall: an economic evaluation alongside a randomised controlled trial

      Sach, Tracey H.; Logan, Philippa A.; Coupland, Carol A.C.; Gladman, John R.F.; Sahota, Opinder; Stoner-Hobbs, Valarie; Robertson, Kate; Tomlinson, Vicki; Ward, Marie; Avery, Anthony J. (2012-09)
    • 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)
    • Traumatic brain injuries: continuing dilemmas in the pre-hospital care arena

      Griffin, Dylan (2013-02)
      Abstract published with permission. This article examines the clinical assessment, diagnosis and management of an agitated traumatic brain-injured patient in the pre-hospital setting by a UK Helicopter Emergency Medical (HEMS) Team. Using a case study from clinical practice, the signs and symptoms, aetiology and clinical management options are discussed and compared against current best evidence, with the specific aims of improving mortality and morbity in critically-ill traumatic brain-injured patients.
    • Patients' and emergency clinicians' perceptions of improving pre-hospital pain management: a qualitative study

      Iqbal, Mohammad; Spaight, Peggy Anne; Siriwardena, Aloysius Niroshan (2013-03)
      Background The authors aimed to investigate patients’ and practitioners’ views and experiences of pre-hospital pain management to inform improvements in care and a patient-centred approach to treatment. Methods This was a qualitative study involving a single emergency medical system. Data were gathered through focus groups and semi-structured interviews. Participants were purposively sampled from patients transported by ambulance to hospital with a painful condition during the past 6 months, ambulance service and emergency department (ED) clinicians. Interviews were audiotaped, transcribed and thematic analysis was conducted. Results 55 participants were interviewed: 17 patients, 25 ambulance clinicians and 13 ED clinicians. Key themes included: (1) consider beliefs of patients and staff in pain management; (2) widen pain assessment strategies; (3) optimise non-drug treatment; (4) increase drug treatment options; and (5) enhance communication and coordination along the pre-hospital pain management pathway. Patients and staff expected pain to be relieved in the ambulance; however, refusal of or inadequate analgesia were common. Pain was commonly assessed using a verbal score, but practitioners’ views of severity were sometimes discordant with this. Morphine and Entonox were commonly used to treat pain. Reassurance, positioning and immobilisation were used as alternatives to drugs. Pre-hospital pain management could be improved by addressing practitioner and patient barriers, increasing available drugs and developing multi-organisational pain management protocols supported by training for staff. Conclusions Pain is often poorly managed and undertreated in the pre-hospital environment. The authors’ findings may be used to inform guidance, education and policy to improve the pre-hospital pain management pathway. https://emj.bmj.com/content/emermed/30/3/e18.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-2012-201111