• 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
    • Patients' and emergency clinicians' perceptions of improving pre-hospital pain management: a qualitative study

      Iqbal, Mohammad; Spaight, Peggy Anne; Siriwardena, Aloysius (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
    • 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
    • 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
    • Prehospital outcomes for ambulance service care: systematic review

      Phung, Viet-Hai; Booth, Andrew; Coster, Joanne; Turner, Janette; Wilson, Richard; Siriwardena, Aloysius (2015-05)
      Background Ambulance service performance measurement has previously focused on response times and survival. We conducted a systematic review of the international literature on quality measures and outcomes relating to pre-hospital ambulance service care, aiming to identify a broad range of outcome measures to provide a more meaningful assessment of ambulance service care. Methods We searched a number of electronic databases including CINAHL, the Cochrane Library, EMBASE, Medline, and Web of Science. For inclusion, studies had to report either research or evaluation conducted in a pre-hospital setting, published in the English language from 1982 to 2011, and reporting either outcome measures or specific outcome instruments. Results Overall, 181 full-text articles were included: 83 (46%) studies from North America, 50 (28%) from Europe and 21 (12%) from the UK. A total of 176 articles were obtained after examining 257 full-text articles in detail from 5,088 abstracts screened. A further five papers were subsequently identified from references of the articles examined and studies known to the authors. There were 140 articles (77%) which contained at least one survival-related measure, 47 (34%) which included information about length of stay and 87 (48%) which identified at least one place of discharge as an outcome. Limitations We encountered the problem of incomplete information, for instance studies not specifying which pain scales when these had been used or using survival without a specific time period. Conclusion and recommendations In addition to measures relating to survival, length of stay and place of discharge, we identified 247 additional outcome measures. Few studies included patient reported or cost outcomes. By identifying a wide range of outcome measures this review will inform further research looking at the feasibility of using a wider range of outcome measures and developing new outcome measures in prehospital research and quality improvement. https://emj.bmj.com/content/emermed/32/5/e10.2.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-2015-204880.27
    • 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
    • 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
    • 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