• 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
    • Discerning the age of a child

      Whitley, Gregory; Lord, Bill (2018-09)
      Abstract published with permission. In this comment, Gregory Whitley and Bill Lord note the disparity in age ranges used to define a 'child', across both clinical guidelines and research, and its significant implications for paramedic practice.
    • 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
    • Looking back to 2008 — Looking forward to 2028

      Mallinson, Tom; Gregory, Pete; Sibson, Lynda; Peate, Ian; Eaton, Georgette; Whitley, Gregory; Layland, Adam; Sudron, Ceri (2018-10)
    • 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
    • Spotlight on Research

      Cormack, Stef; Whitley, Gregory; Gregory, Pete (2020-03-12)
      Harari Y, Riemer R, Jaff E, Wacht O, Bitan Y.Paramedic equipment bags: how their position during out-of-hospital cardiopulmonary resuscitation (CPR) affect paramedic ergonomics and performance. Appl Ergonomics. 2020; 82:102977 The position of bags during an out-of-hospital cardiac arrest (OHCA) may not be seen as a priority for many paramedics. However, Harari et al (2019) argue that paramedics are at a high risk of musculoskeletal (MSK) injuries and that paramedic performance is affected by where bags are placed and moved during an OHCA. Their study examined 12 teams of paramedics (two per team) during a simulated OHCA. Measurements included bag placement, cardiopulmonary resuscitation (CPR) quality, physiological effort and biomechanical loads. Although conducted in Israel, personnel and equipment bags were not dissimilar to UK practice. Results established that despite a relatively low mean number of bag movements (6.8), the mean biomechanical load force exerted was high (89N), resulting in 72% of paramedic movements associated with a high to very high risk of an MSK injury. The positioning of bags appeared to negatively affect CPR quality, with a mean of 68% of compressions within the recommended rate, and only 27% within the recommended depth. Physiologically, there was no significant difference between paramedics' heart rates or perceived effort. The findings highlight the significant risk of MSK injury when moving bags and the possibility that a standardised layout may improve CPR quality. However, this is dependent on the patient location/position, number of paramedics attending and a team's ability to recognise tiredness/ineffective CPR. Whitley GA, Hemingway P, Law GR et al.Predictors of effective management of acute pain in children within a UK ambulance service: a cross-sectional study. Am J Emerg Med. 2019; In Press This retrospective observational study aimed to identify which children were more likely to achieve effective pain management when suffering acute pain and attended by a UK ambulance service. For the purpose of this study, effective pain management was defined as the abolition or reduction of pain by ≥2 out of 10 using the numeric pain rating scale, Wong-Baker FACES® scale or FLACC (face, legs, activity, crying and consolability) scale. Data for 2312 children were included in a multivariable logistic regression analysis which adjusted for a number of confounding factors including child age, child sex, type of pain, senior clinician experience, analgesia administration, nonpharmacological treatment administration, paramedic crew, hospital travel time and index of multiple deprivation. Results showed that children who were younger, attended by a paramedic, administered analgesia or living in an area of medium or low deprivation were significantly more likely to achieve effective pain management. A subgroup analysis showed that analgesia administration did not predict effective pain management for younger children aged 0–5 years; the authors hypothesised that non-pharmacological interventions are more effective in this age group. Qualitative research is in progress to help explain these findings. Wołoszyn P, Baumberg I, Baker D. The reliability of noninvasive blood pressure measurement through layers of autumn/winter clothing: a prospective study. Wilderness Environ Med. 2019; 30(3):227–235 Noninvasive blood pressure (NIBP) measurement is a key part of the cardiovascular assessment, and traditional teaching has emphasised the need to have direct contact between the cuff and bare skin in order to obtain accurate readings. This is not always feasible in the out-of-hospital environment where patients may be clad in multiple layers of clothing in the colder months. This prospective study investigated the reliability of NIBP measurements performed through two and three layers of autumn/winter clothing in two research groups: healthy volunteers and patients. NIBP measurements were made in a random order: on the exposed arm; on the arm covered by a standardised cotton and polar fabric test sleeve; and with the arm covered by a cotton-polar fabric and down jacket test sleeve. The time taken for measurement was also recorded. NIBP measurements were taken on 101 volunteers and 50 patients, and no clinically or statistically significant differences were found. Measuring over a sleeved arm extended the time of measurement by an average of 3.5 seconds in comparison with bare arm measurement. Although not conclusive, this study adds to earlier studies that have reported reliable results when NIBP was carried out over a layer of light clothing such as a cotton shirt or light sweater. Abstract published with permission.
    • 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