• 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
    • Mental health, well-being and support interventions for UK ambulance services staff: an evidence map, 2000 to 2020

      Clark, Lucy V.; Fida, Roberta; Skinner, Jane; Murdoch, Jamie; Rees, Nigel; Williams, Julia; Foster, Theresa; Sanderson, Kristy (2021-03)
      Prior to COVID-19 there had been a renewed policy focus in the National Health Service on the health and well-being of the healthcare workforce, with the ambulance sector identified as a priority area. This focus is more important than ever as the sector deals with the acute and longer-term consequences of a pandemic. Abstract published with permission.
    • 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
    • Mobile Stroke Unit in the UK Healthcare System: Avoidance of Unnecessary Accident and Emergency Admissions

      Grunwald, Iris Q.; Phillips, Daniel J.; Sexby, David; Wagner, Viola; Lesmeister, Martin; Bachhuber, Monika; Mathur, Shrey; Guyler, Paul; Fisher, James; Perera, Saman; et al. (2020-09)
    • Mobile stroke unit in the UK healthcare system: avoidance of unnecessary accident and emergency admissions

      Phillips, Daniel J.; Grunwald, Iris Q.; Walter, Silke; Faßbender, Klaus (2021-03)
      The aim of the study was to explore the benefit of a mobile stroke unit (MSU) in the UK National Health Service (NHS) for reduction of hospital admissions. Abstract published with permission.
    • A new integrated care pathway for ambulance attended severe hypoglycaemia in the East of England: The Eastern Academic Health Science Network (EAHSN) model

      Sampson, Michael; Bailey, Marcus; Clark, John; Evans, Mark L.; Fong, Rebekah; Hall, Helen; Hambling, Clare; Hadley-Brown, Martin; Morrish, Nick; Murphy, Helen; et al. (2017-11)
    • Paramedic clinical leadership

      Martin, John; Swinburn, Andy (2012-03)
      Developing the paramedic profession is at the heart of the mission for the College of Paramedics. As any profession develops it evolves to take leadership and responsibility for a growing body of knowledge that informs practice. Back in 2008 the College published the second edition of the curriculum framework for paramedics clearly outlining the need for the development of roles at a variety of clinical levels. Having these levels populated creates a clinical framework that will deliver patient benefit and develop future paramedic practice. At its recent Council meeting the College outlined the need to develop education standards, clinical guidelines, and voluntary regulation for these emerging elements on the career framework, and is set to do this over the coming year. In this article Andy Swinburn the College Council representative for NW region outlines how the North West Ambulance Service NHS Trust has put into place a structured career development spanning the professional roles from first registration to consultant practice. https://www.magonlinelibrary.com/doi/full/10.12968/jpar.2012.4.3.181 ] 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/10.12968/jpar.2012.4.3.181
    • 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
    • Patient and clinician factors associated with prehospital pain treatment and outcomes: cross sectional study

      Siriwardena, Aloysius; Asghar, Zahid; Lord, Bill; Pocock, Helen; Phung, Viet-Hai; Foster, Theresa; Williams, Julia; Snooks, Helen (2019-02)
    • Pre-hospital care of the transgender patient

      Connolly, Rebecca (2017-04)
      Abstract published with permission. Thanks to improved recognition, management, and overall societal acceptance of atypical gender identity presentations, number of transgender patients is increasing. Written by a transgender female, this paper draws from both personal experience and academic literature and discusses what it means to be transgender and the latest biomedical research into the aetiology of transsexualism. Clarification of common terminology is addressed to ensure an appropriate rapport to be built by the prehospital clinician without alienating the patient during the clinical examination and assessment. Specific considerations that may present to a clinician outside of hospital, with information about history taking, drug therapy and mental health challenges surrounding the condition are then discussed. The paper concludes by stating that paramedics and ambulance clinicians must recognise the health care needs of transgender patients and advocate for them to help eliminate discrimination.
    • 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
    • Prehospital recognition and antibiotics for 999 patients with sepsis: protocol for a feasibility study

      Moore, Chris; Bulger, Jenna; Driscoll, Timothy; Porter, Alison; Islam, Saiful; smyth, mike; Perkins, Gavin D.; Sewell, Bernadette; Rainer, Timothy; Nanayakkara, Prabath; et al. (2018-03)
    • Public and patient involvement in prehospital care research development – designing the rapid 2 trial

      Evans, Bridie A.; Bulger, Jenna; Ford, S.; Foster, Theresa; Goodacre, Steve; Jones, S.; Keen, L.; Longo, M.; Lyons, Ronan; Pallister, I.; et al. (2019-04-26)
      Background Involving patients and public members in research helps ensure evidence is relevant, accountable and high quality. Public and patient involvement (PPI) is required in many funding applications. We aimed to involve public contributors in designing a research bid about prehospital management for hip fracture. Method We recruited two public contributors with experience of hip fracture and prehospital care to our research team of academic, clinical and managerial partners developing the RAPID 2 proposal evaluating paramedic administration of Fascia Iliaca Compartment Block, a local anesthetic injection into the hip. We supported them to consult with a public/patient group and identify patient priorities to inform our decisions. We held research development meetings and shared project drafts to gain views, share decisions and amend documents. Results Consultation responses suggested patient priorities after hip fracture were to return home, recover mobility and gain independence. These views guided our decisions on setting primary outcomes which were length-of-hospital-stay and health-related quality-of-life. Their concern about the study design causing delayed access to treatment meant we decided to identify common exclusion criteria before randomisation to expedite access to pain management and reduce attrition. Public contributors also agreed patients should be offered an incentive for completing and returning questionnaires to enhance data completeness. Conclusion Involving public contributors enabled the research team to identify patient-prioritised outcomes and adjust the proposed study design to reflect these in the proposal. Public contributors will remain involved if funding is awarded to ensure patient perspectives inform all stages of research management and dissemination. Conflict of interest None. Funding PRIME Centre Wales. 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, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/., https://bmjopen.bmj.com/content/9/Suppl_2/A8.2 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/bmjopen-2019-EMS.22
    • A qualitative study on conveyance decision-making during emergency call outs to people with dementia: the HOMEWARD project

      Voss, Sarah; Brandling, Janet; Pollard, Katherine; Taylor, Hazel; Black, Sarah; Buswell, Marina; Cheston, Richard; Cullum, Sarah; Foster, Theresa; Kirby, Kim; et al. (2020-01-29)
    • Raising a profession

      Martin, John (2012-12)
    • Randomised feasibility study of prehospital recognition and antibiotics for emergency patients with sepsis (PhRASe)

      Jones, Jenna; Allen, Susan; Davies, Jan; Driscoll, Timothy; Ellis, Gemma; Fegan, Greg; Foster, Theresa; Francis, Nick; Islam, Saiful; Morgan, Matt; et al. (2021-09-20)
    • Research paramedics’ observations regarding the challenges and strategies employed in the implementation of a large-scale out-of-hospital randomised trial

      Green, Jonathan; Robinson, Maria; Pilbery, Richard; Whitley, Gregory; Hall, Helen; Clout, Madeleine; Reeves, Barnaby; Kirby, Kim; Benger, Jonathan (2020-06-01)
      Introduction: AIRWAYS-2 was a cluster randomised controlled trial (RCT) comparing the clinical and cost effectiveness of the i-gel supraglottic airway device with tracheal intubation in the initial airway management of out-of-hospital cardiac arrest (OHCA). In order to successfully conduct this clinical trial, it was necessary for research paramedics to overcome multiple challenges, many of which will be relevant to future emergency medical service (EMS) research. This article aims to describe a number of the challenges that were encountered during the out-of-hospital phase of the AIRWAYS-2 trial and how these were overcome. Methods: The research paramedics responsible for conducting the pre-hospital phase of the trial were asked to reflect on their experience of facilitating the AIRWAYS-2 trial. Responses were then collated by the lead author. A process of iterative revision and review was undertaken by the research paramedics to produce a consensus of opinion. Results: The main challenges identified by the trial research paramedics related to the recruitment and training of paramedics, screening of eligible patients and investigation of protocol deviations / reporting errors. Even though a feasibility study was conducted prior to the commencement of AIRWAYS-2, the scale of these challenges was underestimated. Conclusion: Large-scale pragmatic cluster randomised trials are being successfully undertaken in out-of-hospital care. However, they require intensive engagement with EMS clinicians and local research paramedics, particularly when the intervention is contentious. Feasibility studies are an important part of research but may fail to identify all potential challenges. Therefore, flexibility is required to manage unforeseen difficulties. Abstract published with permission.
    • Response to ‘Paramedic treatment—wherever that may be?’

      Boor, Sally (2014-02)
      Abstract published with permission. Sally Boor, paramedic, East of England Ambulance Service NHS Trust responds to James Price's article on the Hazardous Area Response Team (HART), published in last month's issue of the Journal of Paramedic Practice.