Now showing items 41-60 of 84

    • Pre-hospital treatment of traumatic rhabdomyolysis

      Desjardins, Mathew; Strange, Barnaby (2013-12)
    • Feasibility of an ambulance-based stroke trial, and safety of glyceryl trinitrate in ultra-acute stroke: the rapid intervention with glyceryl trinitrate in Hypertensive Stroke Trial (RIGHT, ISRCTN66434824)

      Ankolekar, Sandeep; Fuller, Michael; Cross, Ian; Renton, Cheryl; Cox, Patrick; Sprigg, Nikola; Siriwardena, Aloysius; Bath, Philip (2013-11)
    • 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
    • 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
    • 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
    • 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. (2015-05)
      Introduction Decisions made by ambulance staff are often timecritical and based on limited information. Wrong decisions could have serious consequences for patients but little is known about areas of risk associated with decisions about patient care. We aimed to examine system in fluences on decision making in the ambulance service setting focusing on paramedic roles. Method An exploratory mixed methods qualitative study was conducted in three Ambulance Service Trusts. A document search and 16 interviews were conducted to understand service delivery in each Trust, how they link with other services and potential influences on decisions about patient care. Researchers observed ambulance crews on 34 shifts and 10 paramedics completed ‘digital diaries’ to report challenges for decision making or patient safety. Three focus groups with staff (N=21) and three with service users (N=23) were held to explore their views on decision making and patient safety. Data were charted to produce a typology of decisions then coded and thematically analysed to identify in fluences on those decisions. Findings Nine types of decision were identi fied, ranging from specialist emergency pathways to non-conveyance. In fluences on these decisions included communication with Control Room staff; patient assessment, decision support and alternative options to ED conveyance. Seven main issues in fluencing patient safety in decision making were identi fied: meeting demand; performance and priorities; access to care options; risk aversion; education, training and professional development for crews; communication and feedback to crews; resources and safety culture. Conclusions A range of decisions are made by ambulance staff in complex, time bound changing conditions. Training and development and access to alternative options to ED conveyance were identi fied as particularly important issues. https://emj.bmj.com/content/emermed/32/5/e2.1.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-2015-204880.4
    • 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
    • Barriers and facilitators for people in BME groups accessing pre-hospital care and causes and consequences of any differences in delivery: systematic review and narrative synthesis

      Windle, Karen; Siriwardena, Aloysius; Barot, Mukesh; Essam, Nadya; Johnson, Mark; Kai, Joe; Ortega, Marishona (2015-05)
      Introduction Research addressing inequalities has focused predominantly on primary and community care; few initiatives relate to the pre-hospital environment. We aimed to identify in the literature barriers or facilitators experienced by patients from BME communities in accessing pre-hospital care and to explore the causes and consequences of any differences in delivery. Methods We conducted a systematic literature review and narrative synthesis. Electronic and journal hand searches from 2003 through 2013 identi fied relevant evaluative studies (systematic reviews, randomised controlled trials, quasi-experimental, case and observational studies). A researcher extracted data to determine characteristics, results and quality, each checked by a second reviewer. The main outcome measures were delays in patient calls, mortality rates and 30-days survival post discharge. Results Eighteen studies met criteria for the review: two concerned services in England and Wales and 15 were United States based. Reported barriers to accessing care were generic (and wellknown) given the heterogeneity of BME groups: difficulties in communication where English was the patient ’s second language; new migrants ’ lack of knowledge of the health care system leading to inappropriate emergency calls; and cultural assumptions among clinical staff resulting in inappropriate diagnoses and treatment. There were limited reported facilitators to improvement, such as the need for translation services and staff education, but the latter were poorly described or developed. Where outcomes were discussed, there was evidence for race-related disparity in mortality and survival rates. This could re flect differences in condition severity, delays between onset and initiation of calls, or the scope of response and assistance. Conclusion The paucity of literature and difficulties of transferring findings from US to UK context identified an important research gap. Further studies should be undertaken to investigate UK differences in prehospital care and outcomes for BME groups, followed by qualitative approaches to understand barriers and enablers to equitable access. https://emj.bmj.com/content/emermed/32/5/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-2015-204880.3
    • 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)
    • The effect of a national quality improvement collaborative on prehospital care for acute myocardial infarction and stroke in England

      Siriwardena, Aloysius; Shaw, Deborah; Essam, Nadya; Togher, Fiona Jayne; Davy, Zowie; Spaight, Anne; Dewey, Michael; ASCQI Core Group (2014-01)
    • The digital ambulance: electronic patient clinical records in prehospital emergency care

      Porter, Alison; Potts, H.; Mason, Suzanne; Morgan, H.; Morrison, Z.; Rees, Nigel; Shaw, Deborah; Siriwardena, Aloysius; Snooks, Helen; Williams, V. (2018-04)
      Aim Electronic Records in Ambulances (ERA) is a two-year study examining the opportunities and challenges of prehospital implementation of electronic patient clinical records (ePCR) in the UK. National policy encourages digitisation of health services,1 but this transition may not be straightforward.2 Method A telephone survey of progress implementing ePCR in all 13 UK ambulance services explored systems, implementation processes, perceived value and future plans. Interviews with information managers were thematically analysed. Case studies in four UK ambulance services involved observing clinical work, focus groups with ambulance clinicians, interviews with key stakeholders and analysis of routine data. Results Baseline survey: 7/13 services were using ePCR, with mixed compliance from staff. Reported benefits concerned improved data access for audit. Of the 6/13 services currently using paper records, four had previously adopted ePCR, but reverted. Case studies: Initial findings suggest some common themes: . Constant change: 3/4 services were already undertaking or considering transition to a second generation system; 1/4 was undertaking a phased rollout of ePCR. . Digital diversity: no standard hardware or software in use. . Indirect input: patient data was still sometimes transferred to the ePCR from another source (eg writing on a glove) or entered retrospectively. . Data dump: ePCRs acted mainly as a store, rather than transferring information to other care providers or supporting decision making. Conclusion Although ePCRs offer opportunities to support prehospital care, the transition to the new technology is neither linear nor co-ordinated, with full benefits not yet realised in terms of integration and data sharing. https://bmjopen.bmj.com/content/8/Suppl_1/A26.3 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.70
    • 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
    • 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
    • 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
    • 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.
    • 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
    • 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
    • Exploring factors increasing paramedics’ likelihood of administering analgesia in pre-hospital pain: cross sectional study (explain)

      Asghar, Zahid; Siriwardena, Aloysius; Phung, Viet-Hai; Lord, Bill; Foster, Theresa; Pocock, Helen; Williams, Julia; Snooks, Helen (2017-10)
      Background Paramedics play an important role in reducing pain in patients calling an ambulance. We aimed to identify how patient factors (age, sex), clinical condition and paramedic factors (sex, role seniority) affected pain treatment and outcomes. Methods We used a cross sectional design using routine retrospective data a one-week sample of all 999 ambulance attendances in two large regional UK ambulance services for all patients aged 18 years or over where pain was identified in people requiring primary transport to hospital. Exclusion criteria patients with a Glasgow Coma Scale score below 13, or patients not attended by a paramedic. We used a multilevel design, using a regression model to investigate which factors were independently associated with administration of analgesia and reduction in pain, taking into account confounders including patient demographics and other variables. Analysis was performed with Stata. Results We collected data on 9574 patients (service 1, 2; n=3344, 6230 respectively) including 4911 (51.3%) male and 4524 (47.3%) females (1.5% missing). Initial pain score was not recorded in 42.4% (4063/9574). The multilevel model suggested that the factors associated with use of strong opiates (morphine intravenously or orally) was a pain score of 7 or above, patient age 50–64 years and suspected fractured neck of femur. Reduction in pain score of 2 or more points was significant whatever the initial pain score and associated with age 50–84 years. There was no association between use of strong opiate analgesic or reduction in pain score and sex of patient and/or sex of paramedic or crew member. Conclusion Our initial analysis showed a high level of non-recording of pain scores. There was no association between use of strong opiate analgesics or reduction in pain score of 2 points or more with patient sex or crew sex or paramedic skill level. https://emj.bmj.com/content/34/10/e11 This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ http://dx.doi.org/10.1136/emermed-2017-207114.29