• 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
    • Pre-hospital treatment of traumatic rhabdomyolysis

      Desjardins, Mathew; Strange, Barnaby (2013-12)
    • Prehospital adrenaline administration for out-of-hospital cardiac arrest: the picture in England and Wales

      Booth, Scott; Ji, Chen; Soar, Jasmeet; Siriwardena, Aloysius; Fothergill, Rachael; Spaight, Robert; Perkins, Gavin D. (2018-09)
    • 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
    • Prehospital Transdermal Glyceryl Trinitrate for Ultra-Acute Intracerebral Hemorrhage: Data From the RIGHT-2 Trial

      Dixon, Mark; Bath, Philip; Woodhouse, Lisa J.; Krishnan, Kailash; Appleton, Jason P.; Andersona, Craig S.; Berge, Eivind; Cala, Lesley; England, Timothy J.; Godolphin, Peter J.; et al.
    • Preventable mortality in patients at low risk of death requiring prehospital ambulance care: retrospective case record review study

      Siriwardena, Aloysius; Akanuwe, Joseph; Crum, Annabel; Coster, Joanne; Jacques, Richard; Turner, Janette (2018-04)
      Aim Retrospective case record reviews (RCRR) have been widely used to assess quality of care but evidence for their use in prehospital ambulance settings is limited. We aimed to review case records of potentially avoidable deaths related to ambulance care. Method We identified patients who were transported to hospital or died using linked ambulance-hospital-mortality data from one UK ambulance service over 6 months in 2013. Death rates (within 3 days) for patient groups (based on age, dispatch code and urgency) were determined; 3 patients calling in-hours and 3 outof-hours were selected from categories with the lowest death rates. Five reviewers (GP, nurse, 2 paramedics and medical health service manager) assessed anonymised patient records for quality of care and avoidable mortality. Results We selected 29 linked records from 1 50 003 focussing on patients not transported to distinguish pre-hospital from Abstracts BMJ Open 2018;8(Suppl 1):A1–A34 A7 Trust (NHS). Protected by copyright. on 13 August 2019 at Manchester University NHS Foundation http://bmjopen.bmj.com/ BMJ Open: first published as 10.1136/bmjopen-2018-EMS.20 on 16 April 2018. Downloaded from hospital causes. Overall 8 cases out of 29 (27.6%) scored between 2.4 and 2.8 (1=Definitely avoidable, 2=Strong evidence of avoidability), 8 cases (27.6%) scored between 3.0 and 4.6 (3=Probably avoidable, 4=Possibly avoidable), and the remaining 13 cases (44.8%) between 4.0 and 5.8 (5=Slightly avoidable or 6=Definitely not avoidable). Variation between raters was satisfactory with ICC 0.84 (95% CI: 0.73 to 0.92). Common themes among cases with strong evidence of avoidability were symptoms or physical findings indicating a potentially serious condition and refusal by patients or their carers to be transported to hospital. RCRRs require linked ambulance, hospital and mortality data to ensure accurate assessment in light of the diagnosis and cause of death. Conclusion Retrospective case record reviews (RCRR) have been widely used to assess quality of care but evidence for their use in prehospital ambulance settings is limited. We aimed to review case records of potentially avoidable deaths related to ambulance care. https://bmjopen.bmj.com/content/8/Suppl_1/A7.3 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/bmjopen-2018-EMS.20
    • 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)
    • A qualitative study of systemic influences on paramedic decision making : care transitions and patient safety

      Shaw, Deborah; Mortimer, Peter; Newman, Chris; Storey, Matthew; Shewan, Jane; O'Hara, Rachel; Johnson, Maxine; Siriwardena, Aloysius; Weyman, Andrew; Turner, Janette; et al. (2015-01)
    • 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.