• Algorithms to guide ambulance clinicians in the management of emergencies in patients with implanted rotary left ventricular assist devices

      Bowles, Christopher T.; Hards, Rachel; Wrightson, Neil; Lincoln, Paul; Kore, Shishir; Marley, Laura; Dalzell, Jonathan R.; Raj, Binu; Baker, Tracey A.; Goodwin, Diane; et al. (2017-12)
      Advances in left ventricular assist device (LVAD) therapy have resulted in increasing numbers of adult LVAD recipients in the community. However, device failure, stroke, bleeding, LVAD thrombosis and systemic infection can be life-threatening emergencies. Currently, four LVAD systems are implanted in six UK transplant centres, each of which provides device-specific information to local emergency services. This has resulted in inconsistent availability and content of information with the risks of delayed or inappropriate decision-making. In order to improve patient safety, a consortium of UK healthcare professionals with expertise in LVADs developed universally applicable prehospital emergency algorithms. Guidance was framed as closely as possible on the standard ABCDE approach to the assessment of critically ill patients. https://emj.bmj.com/content/emermed/34/12/842.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-2016-206172
    • 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
    • Mental health crisis in the pre-hospital setting

      Prothero, Larissa; Cooke, Philip (2016-09)
      Background The 2014 Mental Health Crisis Care Concordat is a national agreement to ensure people in crisis receive the help they need: integrated multi-agency schemes involving ambulance, police and mental health services are now being developed to provide urgent and emergency care pathways for these vulnerable patients. The aim of this study was to have improved understanding of mental health crisis (MHC) patients requiring ambulance care, to inform the development of new patient care pathways within the East of England. Methods A retrospective pilot audit was performed using 291 ‘MHC’ patient care records generated following emergency ‘999’ ambulance and non-emergency ‘111’ calls in a distinct geographical area of the East of England Ambulance Service NHS Trust between 22–29 December 2014. Criteria for record inclusion were presence of the terms ‘mental health’, ‘anxiety’, ‘depression’, ‘self-harm’, ‘self-injury’, ‘abnormal behaviour’, ‘psychosis’, ‘paranoia’, ‘suicide’, ‘suicidal thoughts’, ‘overdose’, ‘dementia’, or ‘Section’. Results The cohort age range was 13 to 98 years; 50.5% were male. MHC usually affected people under 65 years. The main reasons for ambulance care were deliberate drug/substance overdose (33.7%) and actions/behaviour associated with suicidal intention (19.2%) – attempted suicide was reported for 14 (4.8%) patients. Anxiety (including ‘panic attacks’/hyperventilation syndrome), depression and behavioural/emotional problems were prevalent. Alcohol consumption was reported for 36.8% patients and police attendance was required for aggressive/threatening behaviour in 22% of incidences. Approximately two-thirds (64.6%) of patients were conveyed to the emergency department; only 12 (4.1%) patients were directly admitted to a mental health facility. The majority of patient contacts occurred ‘out-of-hours’, in particular, between 20:00 and 22:00 hours. Conclusions Mental health crisis management is complex and challenging for ambulance clinicians with limited direct access to specialist services. Understanding the nature of crises and patient/public expectations of emergency services will facilitate the development of appropriate pre-hospital mental health pathways. https://emj.bmj.com/content/emermed/33/9/e8.3.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-2016-206139.28
    • Missed opportunities in ambulance sepsis care?

      Prothero, Larissa; de Carteret, Emma; Nicholls, Tracy L. (2017-10)
      Background Two-thirds of severe sepsis patients are initially seen in the emergency department, with the majority arriving via ambulance. Since early sepsis recognition, diagnosis and clinical management are considered key for optimal patient outcomes, ambulance clinicians are well placed to have a key role in sepsis care. This study aims to identify key patient, clinician and organisation-derived factors which lead to missed sepsis recognition and delayed access to definitive care in the ambulance setting. Methods The East of England Ambulance Service NHS Trust declares any missed cases of sepsis as a Serious Incident (SI; NHS England Serious Incident Framework 2015) to support clinician and service learning and prevent reoccurrence. A qualitative thematic review, based on the Yorkshire Contributory Factors Framework, has being conducted using seventeen sepsis-related SI reports generated between March 2014 and March 2016. Results SIs were usually associated with emergency/999 calls resulting in non-conveyance. Breathing/respiratory problems were the most prevalent chief complaint. Perceived contributory factors to these incidences were: ‘Patient-derived’: unwell patients with capacity choosing to remain at home, despite advice to attend hospital; presence of co-morbidities and other medical conditions. ‘Clinician-derived’: inadequate patient assessment and triage; failure to recognise sepsis markers and use screening tools; low index of suspicion for sepsis and rapid patient deterioration; insufficient safety-netting and documentation; communication errors. ‘Organisation-derived’: increasing service demands; mismatch between clinician and vehicle response allocation; lower acuity calls receiving delayed responses at peak demand; variable provision of staff training; lack of clinical practice monitoring; lack of safety culture; promotion of alternative care pathways. Conclusions Errors in pre-hospital sepsis care occur at all service levels. SI reports provide invaluable systems-based analyses of healthcare episodes and offer concise guidance to prevent error reoccurrence and improve future care. The study findings will inform the development of a prospective sepsis risk assessment tool using prospective hazards analysis methodologies. https://emj.bmj.com/content/34/10/e9.3 This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ http://dx.doi.org/10.1136/emermed-2017-207114.26
    • Paramedic-led prehospital thrombolysis is safe and effective: the East Anglian experience

      Khan, S. N.; Murray, Paul; McCormick, L.; Sharples, L. S.; Salahshouri, P.; Scott, Jason; Schofield, P. M. (2009-05-22)
      Introduction: Prehospital thrombolysis has been shown to improve patient outcomes in clinical trials and this has been confirmed in the ongoing large national myocardial infarction registry (Myocardial Infarction National Audit Project; MINAP) reports. This paper describes a system to improve the delivery of prehospital thrombolysis and the associated governance requirements to gain maximum patient benefit. Methods: Demographic data were prospectively collected on all patients treated by the East Anglian Ambulance Trust with bolus thrombolytics for a presumed diagnosis of ST elevation myocardial infarction between November 2003 and February 2007. Survival status was determined from the NHS strategic tracing service. Results: 1062 patients (mean age 64.0 years (SD 10.6), 795 men) were treated in this time period. There were 71 deaths in this group, with actuarial survival of 93.9% (SE 0.9%) at 30 days, 91.7% (SE 1.0%) at 6 months and 90.8% (SE 1.1%) at 12 months after treatment. Age and cardiac arrest were most strongly associated with mortality (both p<0.001). Twelve (1.2%) patients received thrombolysis that on review was considered inappropriate. There were no deaths in this subgroup. Conclusions: Prehospital thrombolysis can be administered safely by ambulance staff supported by a Trust clinical support system with excellent clinical outcomes. https://emj.bmj.com/content/26/6/452. 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.2008.062729
    • Prehospital determinants of successful resuscitation after traumatic and non-traumatic out-of-hospital cardiac arrest

      Barnard, Ed B.G.; Sandbach, Daniel D.; Nicholls, Tracy L.; Wilson, Alastair W.; Ercole, Ari (2019-06)
      Background Out-of-hospital cardiac arrest (OHCA) is prevalent in the UK. Reported survival is lower than in countries with comparable healthcare systems; a better understanding of outcome determinants may identify areas for improvement. Methods An analysis of 9109 OHCA attended in East of England between 1 January 2015 and 31 July 2017. Univariate descriptives and multivariable analysis were used to understand the determinants of survival for nontraumatic cardiac arrest (NTCA) and traumatic cardiac arrest (TCA). Two Utstein outcome variables were used: survival to hospital admission and hospital discharge. Results The incidence of OHCA was 55.1 per 100 000 population/year. The overall survival to hospital admission was 27.6% (95% CI 26.7% to 28.6%) and the overall survival to discharge was 7.9% (95% CI 7.3% to 8.5%). Survival to hospital admission and survival to hospital discharge were both greater in the NTCA group compared with the TCA group: 27.9% vs 19.3% p=0.001, and 8.0% vs 3.8% p=0.012 respectively. Determinants of NTCA and TCA survival were different, and varied according to the outcome examined. In NTCA, bystander cardiopulmonary resuscitation (CPR) was associated with survival at discharge but not at admission, and the likelihood of bystander CPR was dependent on geographical socioeconomic status. An air ambulance was associated with increased survival to both hospital admission and discharge in NTCA, but only with survival to admission in TCA. Conclusion NTCA and TCA are clinically distinct entities with different predictors for outcome—future OHCA reports should aim to separate arrest aetiologies. Determinants of survival to hospital admission and discharge differ in a way that likely reflects the determinants of neurological injury. Bystander CPR public engagement may be best focused in more deprived areas. https://emj.bmj.com/content/emermed/36/6/333.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-2018-208165
    • A survey-based evaluation of the impact of menopause transition on female ambulance staff in one UK ambulance service

      Foster, Theresa; Prothero, Larissa; Winterson, Debra (2020-10)
      Menopausal symptoms can have a significant impact on workplace attendance and performance, yet limited evidence regarding the menopause transition in the emergency services exists. The aim of this study was to explore work and personal impacts of the menopause on female staff in the ambulance setting. https://emj.bmj.com/content/37/10/e6.3 This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. http://creativecommons.org/licenses/by-nc/4.0/ DOI http://dx.doi.org/10.1136/emermed-2020-999abs.12
    • Surveying young patients

      Foster, Theresa; Maillardet, Victoria (2010-03)
      The East of England Ambulance Service NHS Trust (the Trust) was keen to engage young patients and to encourage them to give feedback about the service they had received. The standard Trust satisfaction survey was modified for use with young patients, and this had the effect of increasing the response rate from this patient group by 8%, and increasing the percentage of young patients aged 5-10 years completing the survey themselves by 29%. The vast majority of parents/guardians were happy for the Trust to survey their child, but the age of the child affected to whom they would like the survey sent. The Trust subsequently altered patient survey practice to write to parents/guardians of patients aged <12 years and directly to all patients aged > or = 12 years. https://emj.bmj.com/content/27/3/221. 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.2008.065615
    • Unplanned, urgent and emergency care: what are the roles EMS provide for older people with dementia? A literature review and narrative synthesis

      Buswell, Marina; Martin, Steven; Lee, Caroline; Lumbard, Phillip; Prothero, Larissa (2015-05)
      Background Anecdotally emergency ambulance crews say they frequently encounter older people with dementia (OPWD) and it can be difficult to take history, assess pain and access suitable alternatives to the emergency department especially out of hours. With the current policy landscape of the NHS England Emergency & Urgent Care Review and the high profile of dementia care it is pertinent to ask what role emergency medical services (EMS) have in the urgent and emergency care of OPWD. Methods Aware that the research literature in this area was likely to be sparse we used systematic and iterative search techniques to identify relevant studies and documents. All databases available via NHS Evidence were searched and grey literature was included. Articles which made any reference to the pre-hospital role of EMS ambulance services/personnel in the urgent or emergency care of OPWD were included. Discharge roles were excluded. Results Nineteen relevant documents were included for review and synthesis, over half from the grey literature. Eight were specifically about EMS treating OPWD, six of those from the grey literature. The other documents, though mentioning the role, were not researching or evaluating that role. We identified three roles described in the literature; emergency transport, assess and manage, and a last resort/safety net role. This final role is alluded to in over one third of the documents but is not investigated. Conclusions and recommendations This review highlights a gap in our understanding and in the research literature about the role EMS play in the care of OPWD, particularly around the last resort/safety net role. We hope it will encourage researchers from EMS and dementia care disciplines to come together, particularly to look at: ▸ Better understanding the last resort/safety net role. ▸ Evaluating AND reporting in the research literature initiatives that are happening in EMS around caring for OPWD. https://emj.bmj.com/content/emermed/32/5/e4.1.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-2015-204880.10
    • Unplanned, urgent and emergency care: what are the roles that EMS plays in providing for older people with dementia? An integrative review of policy, professional recommendations and evidence

      Buswell, Marina; Lumbard, Philip; Prothero, Larissa; Lee, Caroline; Martin, Steven; Fleming, Jane; Goodman, Claire (2016-01)
      Objective To synthesise the existing literature on the roles that emergency medical services (EMS) play in unplanned, urgent and emergency care for older people with dementia (OPWD), to define these roles, understand the strength of current research and to identify where the focus of future research should lie. Design An integrative review of the synthesised reports, briefings, professional recommendations and evidence. English-language articles were included if they made any reference to the role of EMS in the urgent or emergency care of OPWD. Preparatory scoping and qualitative work with frontline ambulance and primary care staff and carers of OPWD informed our review question and subsequent synthesis. Results Seventeen literature sources were included. Over half were from the grey literature. There was no research that directly addressed the review question. There was evidence in reports, briefings and professional recommendations of EMS addressing some of the issues they face in caring for OPWD. Three roles of EMS could be drawn out of the literature: emergency transport, assess and manage and a ‘last resort’ or safety net role. Conclusions The use of EMS by OPWD is not well understood, although the literature reviewed demonstrated a concern for this group and awareness that services are not optimum. Research in dementia care should consider the role that EMS plays, particularly if considering crises, urgent care responses and transitions between care settings. EMS research into new ways of working, training or extended paramedical roles should consider specific needs and challenges of responding to people with dementia. https://emj.bmj.com/content/emermed/33/1/61.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-2014-203941
    • Views regarding the provision of prehospital critical care in the UK

      Mackenzie, R.; Steel, A.; French, J.; Wharton, R.; Lewis, S.; Bates, A.; Daniels, T.; Rosenfeld, M. (2009-05-22)
      Aims: There is a lack of consensus regarding the role for critical care in the prehospital environment in the UK. It was hypothesised that this related to differences in views and understanding among opinion leaders within influential prehospital care organisations. Methods: A 38-item survey was developed by an established paramedic-physician prehospital critical care service. The survey was distributed to individuals in senior positions within seven organisations that have a major influence on UK prehospital services. Analysis comprised a description of the distribution of results, assessment of the level of agreement with each statement by professional background and current involvement in prehospital critical care and evaluation of the overall consistency of responses. Free-text comments were invited to illustrate the reasoning behind each response. Results: There were 32 respondents. The estimated response rate was 40%. The consistency of the questionnaire responses was very high. Overall, all individuals agreed with most of the statements. Paramedic respondents were more likely to disagree with statements that suggested that critical care involved interventions that exceed the current capability of the NHS ambulance service (p<0.05). Free-text comments revealed wide differences of opinion. Conclusion: Although there appears to be broad agreement among opinion leaders regarding the concepts underpinning existing prehospital critical care services, areas of contention are highlighted that may help explain the current lack of consensus. Cooperative efforts to assess the current demand and clinical evidence would assist in the creation of a joint consensus and allow effective future planning for the provision of prehospital critical care throughout the UK. https://emj.bmj.com/content/26/5/365. 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.2008.062588