• Identification of characteristics of neighbourhoods with high incidence of out-of-hospital cardiac arrest and low bystander cardiopulmonary resuscitation rates

      Brown, Terry P.; Hawkes, Claire A.; Booth, Scott J.; Fothergill, Rachael; Black, Sara; Bichmann, Anna; Pocock, Helen; Soar, Jasmeet; Mark, Julian; Benger, Jonathan R.; et al. (2017-09)
    • 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
    • Improving data quality in a UK out-of-hospital cardiac arrest registry through data linkage between the Out-of-Hospital Cardiac Arrest Outcomes (OHCAO) project and NHS Digital

      Rajagopal, Sangeerthana; Booth, Scott J.; Brown, Terry P.; Ji, Chen; Hawkes, Claire A.; Siriwardena, Aloysius; Kirby, Kim; Black, Sarah; Spaight, Robert; Gunson, Imogen; et al. (2017-09)
    • 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 M.; 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
    • Intermediate care for older people

      Logan, Phillipa; Stoner-Hobbs, Valarie; McCloughrey, Helen; Foster, Carol; Fitzsimmons, Dawne; Williams, Jo; Spencer, Pamela; Robertson, Kate; Gladman, John R.F. (2007-06)
      Up to 40 per cent of older people do not go to hospital after calling an emergency ambulance and until recently were not referred on to any other community services. This article describes how a multidisciplinary working group developed and evaluated a protocol to enable older people to be referred to intermediate care services after calling an emergency ambulance. A total of 54 patients were monitored after referral to intermediate care to assess adherence to the protocol and outcomes. https://search.proquest.com/docview/218640918/fulltextPDF/D39007D8FA944159PQ/1?accountid=48113 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. http://creativecommons.org/licenses/by-nc/4.0/ DOI http://dx.doi.org/10.7748/nop2007.06.19.5.25.c4644
    • Investigating the understanding, use and experiences of older people in Lincolnshire accessing emergency and urgent services via 999 and NHS 111: a scoping study

      Togher, Fiona Jayne; Windle, Karen; Essam, Nadya; Hardwick, Jialin; Phung, Viet-Hai; Vowles, Valerie (2015-05)
      Introduction During 2011/12, East Midlands Ambulance Service (EMAS) received 776,000 emergency 999 calls of which 36% (277,000) did not require transportation to hospital. Inappropriate calls can be due to public misunderstanding of when it is appropriate to ring 999. NHS 111 is an alternative free telephone service that enables the public to access health care advice or resources when the matter is urgent but not a 999 emergency. However knowing which service to telephone is not always easy and such a decision can be particularly dif ficult for older people as symptom presentation across complex co-morbidities can be atypical. A mixed method scoping project was carried out to explore the understanding, use and experiences of emergency (999) and urgent services (NHS 111) by older people aged 65 and over. Here, we report findings from the qualitative workstream. Methods Semi-structured interviews and focus groups (n=25) using a topic guide were carried out with a purposive sample of older people who had used the 999 ambulance service and/or the NHS 111 service in the East Midlands. Results We found a lack of awareness as to the remit of NHS 111 and confusion as to when this number should be phoned. Older people ’s expectations of 111 seemed to be analogous to other primary care services. As a consequence, participants were often dissatisfied with the service response; it neither provided useful advice nor reassurance. Greater satisfaction was reported with the call handling process and hospital transportation through EMAS (999) and older people ’s reported rationale for phoning 999 would seem to suggest appropriate service use. Conclusion Developing a greater understanding of how older people decide to contact a service would support future policy and practice implementation. If the remit of a service is unclear and accompanying publicity confusing, older people will continue to dial 999. https://emj.bmj.com/content/emermed/32/5/e2.2.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-2015-204880.5
    • 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
    • Leadership, innovation and engagement in quality improvement in the Ambulance Services Cardiovascular Quality Initiative: cross sectional study

      Essam, Nadya; Phung, Viet-Hai; Asghar, Zahid; Spaight, Anne; Siriwardena, Aloysius (2015-05)
      Introduction Clinical leadership and organisational culture are important contextual factors for successful Quality Improvement (QI) programmes. The relationship between these and with organisational performance is complex and poorly understood. We aimed to explore the relationship between leadership, culture of innovation, and clinical engagement in QI for organisations participating in a large-scale national ambulance Quality Improvement Collaborative (QIC). Methods We used a cross sectional survey design. An online questionnaire was distributed to 22,117 frontline ambulance staff across all 12 ambulance services in England. Scores (0 –100%) were derived for each key aspect: clinical leadership; culture of innovation; use of QI methods; and effectiveness of QI methods. Responses to an open-ended question were analysed and complemented the quantitative findings. Results There were 2,743 (12%) responses from 11 of 12 participating ambulance services. Despite only a small proportion of responders (3%) being directly involved with ASCQI, leadership behaviour was significantly higher for ASCQI members than for non-ASCQI members. Involvement in ASCQI was not signi ficantly associated with responders ’ perceptions of the culture of innovation of their organisation, which was generally considered to be poor. ASCQI members were signi ficantly more likely to use QI methods but overall uptake of QI methods was low. The use of QI methods was also signi ficantly associated with leadership behaviour and service tenure. Limitations There was a low response rate, although suf ficient responses to enable comparison of those who participated in ASCQI with those who did not. Conclusion and recommendations Although participants reported a lack of organisational culture of innovation, considered a prerequisite for QI, the collaborative achieved significant wide-scale improvements in prehospital care for myocardial infarction and stroke. We postulate that improvement was mediated through a ‘QI subculture ’ developed from ASCQI ’ s distributed leadership and network. Further research is needed to understand success factors for QI in different complex healthcare environments. https://emj.bmj.com/content/emermed/32/5/e9.3.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-2015-204880.25
    • 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)
    • Management of patients following cold water immersion

      Strange, Barnaby; Desjardins, Mathew (2013-06)
      Abstract published with permission. Sudden immersion in cold water results in a number of physiological changes within the human body. This disruption of homeostasis can have a detrimental effect on normal body function and lead to life-threatening consequences including drowning, hypothermia and sudden death. This article will examine the changes in physiology from the point of initial immersion through to rescue or death. Particular attention is given to the profound effects upon the respiratory, cardiovascular and neurological systems as a consequence of cold water immersion. This is then reviewed and observed from the perspective of paramedics practising within the United Kingdom, who may face challenges that arise from this phenomenon. The pre-hospital assessment of immersed patients will be discussed in order to identify and address potential and immediate life threats, with specific focus on rewarming hypothermic patients post immersion.
    • 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
    • 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.
    • 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.
    • Paramedics and medicines: legal considerations

      England, Ed (2016-08)
      Abstract published with permission. This article will cover: l The relevant legislation relating to medicines and ambulance services l The restrictions that apply to different organisations or individuals regarding the possession of medicines l Regulations on the administration and supply of medicines l Patient Group Directions and Patient Specific Directions. The law in relation to the possession of medicines, administration to patients and the supply of medicines is separate. This article also provides guidance to ambulance services and ambulance clinicians on available options to ensure good patient access to medicines in England. The laws described also apply in Scotland and Wales but there are some different national processes. The law both enables and restricts access to medicines. However, it does require interpretation and a pharmacist can help with this. Where interpretation is contentious then organisations may obtain a legal opinion. Legal opinions can also differ, and can only be resolved in court.
    • Patient and clinician factors associated with prehospital pain treatment and outcomes: cross sectional study

      Siriwardena, Aloysius; Asghar, Zahid; Lord, Bill; Pocock, Helen; Phung, Viet-Hai; Foster, Theresa; Williams, Julia; Snooks, Helen (2019-02)
    • Patients' and ambulance service clinicians' experiences of prehospital care for acute myocardial infarction and stroke: a qualitative study

      Togher, Fiona Jayne; Davy, Zowie; Siriwardena, Aloysius (2013-11)
      BACKGROUND: Patients with suspected acute myocardial infarction (AMI) and stroke commonly present first to the ambulance service. Little is known about experiences of prehospital care which are important for measuring the quality of services for patients with AMI or stroke. AIM: We explored experiences of patients, who had accessed the ambulance service for AMI or stroke, and clinicians regularly treating patients for these conditions in the prehospital setting. METHOD: A qualitative research design was employed to obtain rich and detailed data to explore and compare participants' experiences of emergency prehospital care for AMI and stroke. RESULTS: We conducted 33 semistructured interviews with service users and clinicians and one focus group with five clinicians. Four main themes emerged: communication, professionalism, treatment of condition and the transition from home to hospital. Patients focused on both personal and technical skills. Technical knowledge and relational skills together contributed to a perception of professionalism in ambulancepersonnel. Patients' experience was enhanced when physical, emotional and social needs were attended to and they emphasised effective communication within the clinician-patient relationship to be the key. However, we found a discrepancy between paramedics' perceptions of patients' expectations and patients' lack of knowledge of the paramedic role. CONCLUSIONS: Factors that contribute to better patient experience are not necessarily understood in the same way by patients and clinicians. Our findings can contribute to the development of patient experience measures for prehospital care. https://emj.bmj.com/content/emermed/30/11/942.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-2012-201507