• Rapid Intervention with Glyceryl trinitrate (GTN) in Hypertensive stroke Trial (RIGHT): safety of GTN and potential of ambulance trials in ultra-acute stroke

      Ankolekar, Sandeep; Fuller, Michael; Sprigg, Nicola; Sare, Gillian; Geeganage, Chamila; Stokes, Lynn; Siriwardena, Aloysius; Bath, Philip; Right Invesitgators (2012-12-06)
    • Reassurance as a key outcome valued by emergency ambulance service users : a qualitative interview study

      Togher, Fiona Jayne; O'Cathain, Alicia; Phung, Viet-Hai; Turner, Janette; Siriwardena, Aloysius (2015-12)
    • Reliability and validity of an ambulance patient reported experience measure (a-prem): pilot study

      Siriwardena, Aloysius; Togher, Fiona Jayne; Akanuwe, Joseph; Spaight, Anne (2017-10)
      Background There are no prehospital ambulance Patient Reported Experience Measures (A-PREMs) routinely used to support service comparisons and improvement. We developed an A-PREM, generating items through secondary analysis of ambulance patient interview data, and refining the instrument using expert assessment and cognitive interviews of service users. We aimed to pilot the A-PREM (48 experience and 12 attribute items) investigating user acceptability, reliability and construct validity. Methods Ambulance users attended by a UK regional ambulance service within the previous six months, excluding those suffering cardiac arrest, were sent a self-administered A-PREM. Returned questionnaires were entered into Microsoft Excel and imported into SPSS v22 for analysis. Experience items were recoded to range from 0 (don’t know/can’t remember) to 3 (best recorded experience). Descriptive analysis for item frequencies and missing values, reliability analyses for potential scales and tests of correlation and association were conducted. Results In all, 111 A-PREMs (22.2%) were returned. Missing data were highest for call-taking items. There was a significant association with a shorter wait for first response for four items measuring overall experience of call-taking (χ, p=0.05), ambulance staff (p<0.001), ambulance overall (p=0.001) and A and E (p=0.023). Four separate experience scales encompassing call taking (AmbCallScore, α=0.91), care at scene (AmbCareScore, α=0.90), care on leaving the patient (AmbLeaveScore, α=0.69), and care on transport (AmbTranScore α=0.71), showed satisfactory to high internal consistencies and distributions indicating generally positive experiences. AmbCallScore, AmbCareScore and AmbLeaveScore showed significantly higher scores (ANOVA) with shorter wait to first response. There were no significant differences for overall measures or scales by sex or age of participant, whether they were transported to hospital or not and whether it was their first experience of the ambulance service. Conclusion Our findings show that the A-PREM should be tested more widely for evidence of reliability, validity and sensitivity to different care and settings. https://emj.bmj.com/content/34/10/e6.2 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-2017-207114.17
    • Risk Prediction Models for Out-of-Hospital Cardiac Arrest Outcomes in England

      Ji, Chen; Brown, Terry P.; Booth, Scott; Hawkes, Claire A.; Nolan, Jerry P.; Mapstone, James; Fothergill, Rachael; Spaight, Robert; Black, Sarah; Perkins, Gavin D. (2020-03-10)
    • 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.
    • Severe hypoglycaemia requiring emergency medical assistance by ambulance services in the East Midlands: a retrospective study

      Khunti, Kamlesh; Fisher, Harriet; Paul, Sanjoy; Iqbal, Mohammad; Davies, Melanie J.; Siriwardena, Aloysius (2013-07)
    • 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
    • Temporal changes in bystander cardiopulmonary resuscitation rates in England

      Brown, Terry P.; Hawkes, Claire A.; Booth, Scott; Fothergill, Rachael; Black, Sara; Bichmann, Anna; Pocock, Helen; Soar, Jasmeet; Mark, Julian; Perkins, Gavin D. (2017-09)
    • 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.
    • Understanding a new model of leadership

      Johnson, David; Bainbridge, Peter; Hazard, Wendy (2013-12)
      Abstract published with permission. Leadership is an essential feature of the life of a paramedic. During incidents, whilst working with multi-agency colleagues, and within organisations, leadership is an expected quality of paramedics. Across health and social care organisations leadership is said to be of pivotal importance to future success. This has led to a large investment in leadership development programmes that organisations are now seeking to justify. Leadership as a concept is, however, complex and multifaceted. The nature of leadership has been debated over millennia and still disagreement exists as to how to define it. This paper utilises Critical Interpretive Synthesis to consider how approaches to leadership have developed over time. It concludes with a synthesising argument that leadership is a social construct; as such no single definition will ever be appropriate; however, the four elements that comprise the leadership equation should be considered if the paramedic leader is to be effective.
    • Understanding how Eastern European migrants use and experience UK health services: a systematic scoping review

      Phung, Viet-Hai; Asghar, Zahid; Matiti, Milika; Siriwardena, Aloysius (2020-03-06)
    • Unexpected shock in a fallen older adult: a case report

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

      Whitley, Gregory; Siriwardena, Aloysius; Hemingway, Pippa; Law, Graham Richard (2018-09)
      Abstract published with permission. Introduction: The management of pain is complex, especially in children, as age, developmental level, cognitive and communication skills and associated beliefs must be considered. Without effective pain treatment, children may suffer long-term changes in stress hormone responses and pain perception and are at risk of developing posttraumatic stress disorder. Pre-hospital analgesic treatment of injured children is suboptimal, with very few children in pain receiving analgesia. The aim of this review is to identify predictors, barriers and facilitators to effective management of acute pain in children by ambulance services. Methods: A mixed-methods approach has been adopted due to the research question lending itself to qualitative and quantitative inquiry. The segregated methodology will be used where quantitative and qualitative papers are synthesised separately, followed by mixed-methods synthesis (meta-integration). We will search from inception: MEDLINE, CINAHL and PsycINFO via EBSCOHost, EMBASE via Ovid SP, Web of Science and Scopus. The Cochrane Library, the Joanna Briggs Institute, PROSPERO, ISRCTN and ClinicalTrials.gov will be searched. We will include empirical qualitative and quantitative studies. We will exclude animal studies, reviews, audits, service evaluations, simulated studies, letters, Best Evidence Topics, case studies, self-efficacy studies, comments and abstracts. Two authors will perform full screening and selection, data extraction and quality assessment. GRADE and CERQual will determine the confidence in cumulative evidence. Discussion: If confidence in the cumulative evidence is deemed Moderate, Low or Very Low, then this review will inform the development of a novel mixed-methods sequential explanatory study which aims to comprehensively identify predictors, barriers and facilitators to effective pain management of acute pain in children within ambulance services. Future research will be discussed among authors if confidence is deemed High.
    • What do users value about the emergency ambulance service?

      Togher, Fiona Jayne; Turner, Janette; Siriwardena, Aloysius; O'Cathain, Alicia (2015-05)
      Introduction Response times have been used as a key quality indicator for emergency ambulance services in the United Kingdom, but criticised for their narrow focus. Consequently, there is a need to consider wider measures of quality. The patient perspective is becoming an increasingly important dimension in pre-hospital outcomes research. To that end, we aimed to investigate patients' experiences of the 999 ambulance service to understand the processes and outcomes important to them. Methods We employed a qualitative design, using semi-structured interviews with a purposive sample of people who had recently used a 999 ambulance in the East Midlands. We recruited patients of different age, sex, geographical location, and ambulance service response including ‘hear and treat’, ‘see and treat’ and ‘see and convey’. Results We interviewed 20 service users. Eleven men and nine women participated and 12 were aged 65 years and over. Users valued a quick response when they perceived the call to be an emergency. This was of less value to those who did not perceive their situation as an emergency and irrelevant to ‘hear and treat’ users. All users valued the professional approach and information and advice given by call handlers, crew and first responders, which provided them with reassurance in a worrying situation. ‘See and convey’ users valued a seamless handover to secondary care. Limitations We found it challenging to engage participants to consider quality indicators beyond response times because these were considered to be abstract in comparison with their concrete experiences. Conclusions and recommendations Aspects other than response times were important to patients, particularly in situations perceived by patients to be non-emergency. The results will be combined with issues identified from systematic reviews and used in a Delphi study to identify candidates for new outcome measures for emergency ambulance services. https://emj.bmj.com/content/emermed/32/5/e9.2.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-2015-204880.24