• A comparative evaluation of 999 call-to-needle time of patients presenting with red flag sepsis treated with antibiotics by paramedics and emergency department staff

      Payne, Tanya; Chippendale, Jonathan; Lloyd, Adele (2017-10)
      Background National Institute for Health and Care Excellence guidelines on the recognition, diagnosis and early management of sepsis suggest that in all cases of high risk (or ‘red flag’) sepsis a broad spectrum antibiotic is given without delay and within one hour. For patients identified pre-hospital, GP’s and ambulance services are advised to have mechanisms in place that will allow them to give antibiotics but only where the transfer time is greater than one hour. Whilst one hour is considered the gold standard timeframe in which to receive antibiotics, the 999 call dispatch process is often overlooked and there are no studies to date that examine the 999 call-to-needle time for sepsis patients. The aim of this evaluation was to explore the difference between call-to-needle times of patients who present with ‘red flag’ sepsis receiving antibiotic therapy by a paramedic pre hospital versus Emergency Department (ED) staff. Method Data collected from a feasibility evaluation was used to determine the call-to-needle time of a broad spectrum antibiotic given by a trained paramedic prior to arrival at ED. A random sample of patients arriving in ED by ambulance with high risk (or ‘red flag’) sepsis during the same 6 month period was identified with the call-to-needle time collected retrospectively. A Mann-Whitney U test was performed using SPSS version 22 to determine if there was any significant difference. Results Of the patients that were treated (n=140) the median call-to-needle time of patients treated by paramedics was 45:30 min (n=60), compared to a median call-to-needle time by ED staff of 113:30 min (n=80) (p<0.001). Conclusion Considering the call dispatch challenges that all ambulance services experience, patients with ‘red flag’ sepsis can be treated with an antibiotic within an hour of the 999 call and on average one hour earlier than patients who are treated by ED staff. https://emj.bmj.com/content/34/10/e8.2 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/ http://dx.doi.org/10.1136/emermed-2017-207114.23
    • Exploring factors increasing paramedics’ likelihood of administering analgesia in pre-hospital pain: cross sectional study (explain)

      Asghar, Zahid; Siriwardena, Aloysius; Phung, Viet-Hai; Lord, Bill; Foster, Theresa; Pocock, Helen; Williams, Julia; Snooks, Helen (2017-10)
      Background Paramedics play an important role in reducing pain in patients calling an ambulance. We aimed to identify how patient factors (age, sex), clinical condition and paramedic factors (sex, role seniority) affected pain treatment and outcomes. Methods We used a cross sectional design using routine retrospective data a one-week sample of all 999 ambulance attendances in two large regional UK ambulance services for all patients aged 18 years or over where pain was identified in people requiring primary transport to hospital. Exclusion criteria patients with a Glasgow Coma Scale score below 13, or patients not attended by a paramedic. We used a multilevel design, using a regression model to investigate which factors were independently associated with administration of analgesia and reduction in pain, taking into account confounders including patient demographics and other variables. Analysis was performed with Stata. Results We collected data on 9574 patients (service 1, 2; n=3344, 6230 respectively) including 4911 (51.3%) male and 4524 (47.3%) females (1.5% missing). Initial pain score was not recorded in 42.4% (4063/9574). The multilevel model suggested that the factors associated with use of strong opiates (morphine intravenously or orally) was a pain score of 7 or above, patient age 50–64 years and suspected fractured neck of femur. Reduction in pain score of 2 or more points was significant whatever the initial pain score and associated with age 50–84 years. There was no association between use of strong opiate analgesic or reduction in pain score and sex of patient and/or sex of paramedic or crew member. Conclusion Our initial analysis showed a high level of non-recording of pain scores. There was no association between use of strong opiate analgesics or reduction in pain score of 2 points or more with patient sex or crew sex or paramedic skill level. https://emj.bmj.com/content/34/10/e11 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-2017-207114.29
    • The feasibility of paramedics delivering antibiotic treatment pre-hospital to ‘red flag’ sepsis patients: a service evaluation

      Chippendale, Jonathan; Lloyd, Adele; Payne, Tanya; Dunmore, Sally; Stoddart, Bethan (2018-03)
      Abstract published with permission. Background: Sepsis is associated with a 36% mortality rate, rising to 50% for septic shock. Currently, when an East Midlands Ambulance Service clinician recognises ‘red flag’ sepsis, only the oxygen and fluid elements of the ‘Sepsis Six’ care bundle are delivered, omitting the antibiotic therapy. For a patient in septic shock, every hour’s delay in antibiotic therapy is associated with a 7.6% increase in mortality. Ambulance clinicians are therefore appropriately placed to assess and commence treatment at the earliest point of recognition. The aim of this evaluation was to assess the feasibility of training paramedics to recognise ‘red flag’ sepsis, obtain blood cultures and administer a broad spectrum antibiotic, meropenem, to patients in the pre-hospital environment. Methods: A prospective six-month feasibility pilot evaluation was conducted in May 2016. Paramedics were trained and given access to a broad spectrum antibiotic, meropenem, along with a patient group direction to administer the antibiotic to ‘red flag’ sepsis patients. Training included sepsis recognition, taking of blood cultures and patient group direction compliance. Results: Twenty paramedics volunteered and successfully completed the training. Of the 113 patients that were identified as ‘red flag’ sepsis, 107 (94.6%) were confirmed as infected by the receiving hospital. Ninety-eight blood samples were successfully drawn by study paramedics, with only seven (7.1%) reported as contaminated samples, compared with 8.5% of samples taken by staff in the receiving ED during the same time period. Ninety patients (80%) assessed by paramedics as meeting the criteria were treated with meropenem, and patient group direction compliance was 100%. Conclusion: Paramedics can safely deliver pre-hospital antibiotics to patients with ‘red flag’ sepsis and obtain blood cultures prior to administration, with a contamination rate comparable with local hospitals, following a short training course.
    • Interim analysis of ambulance logistics and timings in patients recruited into the rapid intervention with glyceryl trinitrate in hypertensive stroke trial-2 (right-2)

      Dixon, Mark; Scutt, Polly; Appleton, Jason P.; Spaight, Robert; Johnson, Roderick; Siriwardena, Aloysius; Bath, Philip; RIGHT-2 investigators (2017-10)
      Background Stroke is a severe condition with high morbidity and mortality. Despite treatment effects in acute stroke being predominantly time dependent (e.g. thrombolysis and thrombectomy), proven treatments are hospital based and require prior brain scanning to identify intracerebral haemorrhage. Commencing treatment in the ambulance could dramatically reduce time to treatment. Methods The rapid intervention with glyceryl trinitrate in hypertensive stroke trial-2 (RIGHT-2) is a multicentre prospective randomised single-blind blinded-endpoint parallel group trial assessing the safety and efficacy of ambulance-based, paramedic-delivered glyceryl trinitrate (GTN) when administered within 4 hours of stroke onset. Paramedics trained in RIGHT-2 procedures assess, take appropriate consent and enrol eligible FAST-positive patients and apply the first of four GTN or sham transdermal patches that are continued during hospital admission. Timings, vital signs and distances are recorded. Results 317 participants enrolled across five UK NHS ambulance services were assessed in this interim analysis. Median [interquartile range] timings in minutes were: symptom onset to 999 call 14 [5, 52], call-dispatch 2 [1, 6], onset-randomisation 60 [40, 105], scene-randomisation 21 [14, 31] with no difference between participants scoring FAST 2 or 3, scene-departure 32 [25, 40]), departure-hospital 16 [10, 24]. All timings were comparable to a cohort of 49 stroke patients across East Midlands Ambulance Service who were not enrolled in to RIGHT-2, e.g. scene-departure 32 [23, 40]. Conclusions Randomisation of participants to an ambulance-based stroke trial is possible with paramedics rapidly identifying eligible patients, gaining appropriate consent, randomising and commencing treatment en route to hospital without prolonging time spent on scene. https://emj.bmj.com/content/34/10/e6.3 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/ http://dx.doi.org/10.1136/emermed-2017-207114.18
    • Modified early warning scores (MEWS) to support ambulance clinicians' decisions to transport or treat at home

      Essam, Nadya; Windle, Karen; Mullineaux, David; Knowles, Stacey; Gray, James; Siriwardena, Aloysius (2015-05)
      Introduction Modified Early Warning Scores (MEWS), calculated from patients’ vital signs, are used in hospital to identify patients who may benefit from admission or intensive care: higher MEWS indicates greater clinical risk. We aimed to evaluate MEWS to support paramedics’ decisions to transport patients to hospital or treat and leave them at home. Methods We used an interrupted time series design. We trained 19 volunteer paramedics to use MEWS to support decisions to transport or treat and leave at home. We used linear regression to evaluate differences in weekly transportation rates (percentage of patients attended and transported to hospital) and revisit rates (percentage of patients attended, treated at home and subsequently revisited within 7 days), comparing trends in rates 17 weeks prior (pre-MEWS) and 17 weeks post implementation of MEWS. Auto-calculated scores retrospectively applied to all data provided pre-MEWS and were compared with paramedic calculated scores post-MEWS. Results Of the 4140 patients attended, 2208 were excluded owing to missing values (n=1897), recording errors (n=21) or excluded clinical complaints (n=290). From the remaining data (n=1932) there were no significant differences in transportation rates (pre=55±6%; post=63±11%) by catering for the existing increasing trends where the confidence intervals of the regression slopes overlap (pre=0.15; 95%CI −0.51 to 0.80 vs. post=0.54; −0.58 to 1.65). Similarly, there were no significant difference in revisit rates (pre=4±4%; post=2±4%) catering for the similar trends (pre=−0.13; −0.53 to 0.27 vs. post=0.08; −0.33 to 0.49). Paramedic scores were incorrect 39% of the time (n=622). Conclusion MEWS had a minimal effect on transportation or revisit rates. Scores were frequently not calculated or recorded, or incorrectly calculated. Opportunities for ongoing training, clinical support and feedback were limited. A larger study, ensuring adequate ongoing support, is recommended before implementing MEWS on a wider scale. https://emj.bmj.com/content/emermed/32/5/e1.2.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-2015-204880.2
    • Non-randomised control study of the effectiveness of a novel pain assessment tool for use by paramedics

      Iqbal, Mohammad; Spaight, P. Anne; Kane, Ros; Asghar, Zahid; Siriwardena, Aloysius (2016-09)
      Background Eighty percent of patients presenting to ambulance services present with pain. Pain is sometimes inadequately assessed and treated. Effective pain management can improve patient outcomes and experience. Previous qualitative research suggested that numerical verbal pain scores, usually used to assess pain in the ambulance setting, were poorly understood. We developed a new tool, the ‘Patient Reported Outcome Measure for Pain Treatment’ (PROMPT), to address this need. Initial testing showed that PROMPT had reliability and (face, content and predictive) validity. We aimed to investigate the effectiveness of PROMPT. Methods We used a non-randomised control group design in adult patients with chest pain or injury treated by intervention paramedics using PROMPT compared with control paramedics following usual practice for pain outcomes (reduction in pain score, use of analgesia). Routine data from electronic patient records were used to measure outcomes. We collected baseline rates of outcomes in patients treated by intervention and control paramedics, in a seven month period one year previously, to adjust for secular trends. The study was conducted in East Midlands Ambulance Service. We used regression analysis to compare groups for differences in pain score change and use of analgesics correcting for baseline rates and demographic differences. Results Twenty-five intervention paramedics used PROMPT (of 35 who were trained in its use) treating 300 patients over a seven month period. Data for these and 848 patients treated by 106 control paramedics were entered into SPSS and STATA12 for analysis. Mean reductions in pain score ( p<0.001) and use of analgesics was significantly greater (p<0.001) in patients managed by paramedics using PROMPT compared with those receiving usual care after adjusting for patient age, sex, clinical condition and baseline rates. Conclusion Use of the PROMPT resulted in greater reductions in pain score and increased use of analgesics compared with usual care. https://emj.bmj.com/content/emermed/33/9/e1.3.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-2016-206139.7
    • Paramedic prescribing: a potion for success or a bitter pill to swallow?

      Griffin, Dylan (2015-05)
      Abstract published with permission. In a climate of unprecedented demand on healthcare services, ageing demographics, population growth through immigration, a reduction in junior doctors’ working hours, and overriding political agendas, the need to develop innovative new roles and expand the scope of practice for existing practitioners, including paramedics, is paramount if the NHS is to maintain resilience in an evolving healthcare system. Recent legislative changes now permit chiropodists/ podiatrists and physiotherapists to independently prescribe, further fuelling other allied health professions (AHPs), such as paramedics’ and radiographers’ desire to become future independent prescribers. Implementation has the potential to enhance patient/clinician experiences through improved access to medicines, and would significantly reduce the need for multi-disciplinary involvement per care episode, yielding cost-efficiency savings through reduced ambulance journeys, fewer avoidable admissions, further augmenting patient care delivery. Paramedic independent prescribing (PIP) would also elicit improved inter-professional collaboration, enhance employability and promote professional autonomy in evolving advanced practice roles. Such innovation requires legislative changes, but remains paramount if paramedics are to actively contribute towards tackling the increasing burden of unprecedented demand, limited resources, and ongoing commitment to achieve cost-efficiency savings within the modern NHS.
    • Perceived areas for future intervention and research addressing conveyance decisions and potential threats to patient safety: stakeholder workshops

      O'Hara, Rachel; Johnson, Maxine; Hirst, Enid; Weyman, Andrew; Shaw, Deborah; Mortimer, Peter; Newman, Chris; Storey, Matthew; Turner, Janette; Mason, Suzanne; et al. (2016-09)
      Background As part of a study examining systemic influences on conveyance decisions by paramedics and potential threats to patient safety, stakeholder workshops were conducted with three Ambulance Service Trusts in England. The study identified seven overarching systemic influences: demand; priorities; access to care; risk tolerance; training, communication and resources. The aim of the workshops was to elicit feedback on the findings and identify perceived areas for future intervention and research. Attendees were also asked to rank the seven threats to patient safety in terms of their perceived importance for future attention. Methods A total of 45 individuals attended across all the workshops, 28 ambulance service staff and 17 service user representatives. Discussions were audio-recorded, transcribed and thematically analysed. A paper based paired comparison approach was used to produce an ordinal ranking to illustrate the relative prioritisation of issues. Analysis included testing for internal consistency and between-rater agreement for this relatively small sample. Findings The two highest ranking priorities were training and development, as well as access to care. The areas for intervention identified represent what attendees perceived as feasible to undertake and relate to: care options; cross boundary working; managing demand; staff development; information and feedback; and commissioning decisions. Perceived areas for research specifically address conveyance decisions and potential threats to patient safety. 17 areas for research were proposed that directly relate to six of the systemic threats to patient safety. Conclusions Feedback workshops were effective in the validation of findings as well as providing an opportunity to identify priorities for future interventions and research. They also facilitated discussion between a variety of Ambulance Service staff and service user representatives. Ongoing collaboration between members of the research team has enabled some of the research recommendations to be explored as part of a mutually agreed research agenda. https://emj.bmj.com/content/emermed/33/9/e7.3.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-2016-206139.25
    • A pilot study to assess the feasibility of paramedics delivering antibiotic treatment to ‘red flag’ sepsis patients

      Chippendale, Jonathan; Lloyd, Adele; Payne, Tanya; Dunmore, Sally; Stoddart, Bethan (2017-10)
      Background Sepsis is associated with a 36% mortality rate rising up to 50% for septic shock. Currently when an East Midlands Ambulance Service (EMAS) clinician recognises ‘red flag’ sepsis, only the oxygen and fluid elements of the ‘Sepsis 6’ care bundle are delivered, omitting the antibiotic therapy. Each hour antibiotics are delayed there is an increased risk of septic shock which is associated with a 7.6% greater risk of death. Ambulance clinicians are therefore appropriately placed to assess and commence treatment at the earliest point of recognition. The aim of this pilot was to assess the feasibility of paramedic training in recognising ‘red flag’ sepsis, obtaining blood cultures and administering a broad spectrum antibiotic to patients in the pre-hospital environment. Methods A prospective six month feasibility pilot evaluation was introduced in May 2016. Paramedics were trained and given access to a broad spectrum antibiotic along with a patient group directive (PGD) to administer the antibiotic to ‘red flag’ sepsis patients. Training included sepsis recognition, taking of blood cultures and PGD compliance. Results 20 paramedics volunteered and successfully completed the training. Of the patients that were identified as ‘red flag’ sepsis (n=113) 93% (n=107) were confirmed as infected by hospital record. 98 blood samples were harvested of which only 7.14% (n=7) were reported contaminated compared to an overall 8.48% of those taken in ED during the same time period. 80% (n=90) of patients assessed by paramedics met the criteria and were treated with meropenem. PGD compliance was 100%. Conclusion EMAS paramedics were accurate and reliable in their recognition of identifying ‘red flag’ sepsis and able to administer meropenem safely in accordance with the PGD. EMAS paramedic blood sample contamination rate was lower than those taken in the ED. https://emj.bmj.com/content/34/10/695.2 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/ http://dx.doi.org/10.1136/emermed-2017-207114.2
    • A qualitative study of decision-making and safety in ambulance service transitions

      O'Hara, Rachel; Johnson, Maxine; Hirst, Enid; Weyman, Andrew; Shaw, Deborah; Mortimer, Peter; Newman, Chris; Storey, Matthew; Turner, Janette; Mason, Suzanne; et al. (2014-12)