• Difference between how ambulance service personnel use paper and electronic patient care records when attending older people at home

      Buswell, Marina; Fleming, Jane; Lumbard, Phillip; Prothero, Larissa; Amador, Sarah; Claire Goodman (2015-04)
    • Developing and introducing a new triage sieve for UK civilian practice

      Stephenson, John; Andrews, Lewis; Moore, Fionna (2015-04)
    • 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
    • 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
    • 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.
    • 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
    • Cardiac arrest and the role of transthoracic echocardiography

      Reed, Grace (2017-10)
      Abstract published with permission. The role of transthoracic echocardiography (TTE) is one of the top five research priorities in prehospital critical care (Fevang et al, 2011). TTE is a non-invasive diagnostic tool in cardiac arrest, using ultrasound images to visualise the realtime activity of the heart (Hernandez et al, 2008). TTE has the potential to reduce the time between the onset of cardiac arrest and appropriate therapy. There are several reversible causes of cardiac arrest that can be identified by TTE in the pre-hospital environment. The method and value of identifying pulmonary emboli (PE), cardiac tamponade and hypovolaemia will be discussed. Equally, TTE can exclude certain reversible causes, indicating that the cardiac arrest is of an irreversible nature and the resuscitation attempt is futile. The application of TTE in this context will be reviewed in depth, from the current literature to the physical practicalities. As such, the aim of the present study is to clarify the role of TTE in patients suffering out-of-hospital cardiac arrest.
    • 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
    • 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)
    • 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
    • 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)
    • UK ambulance services: collaborating to provide good end-of-life care

      Stead, Sarah; Datta, Shirmilla; Hill, James; Smith, Richard; Nicell, Claire (2018-05)
    • How do people with dementia use the ambulance service? A retrospective study in England: the HOMEWARD project

      Voss, Sarah; Brandling, Janet; Taylor, Hazel; Black, Sarah; Buswell, Marina; Cheston, Richard; Cullum, Sarah; Foster, Theresa; Kirby, Kim; Prothero, Larissa; et al. (2018-08)
      https://bmjopen.bmj.com/content/8/7/e022549 Objectives An increasing number of older people are calling ambulances and presenting to accident and emergency departments. The presence of comorbidities and dementia can make managing these patients more challenging and hospital admission more likely, resulting in poorer outcomes for patients. However, we do not know how many of these patients are conveyed to hospital by ambulance. This study aims to determine: how often ambulances are called to older people; how often comorbidities including dementia are recorded; the reason for the call; provisional diagnosis; the amount of time ambulance clinicians spend on scene; the frequency with which these patients are transported to hospital. Methods We conducted a retrospective cross-sectional study of ambulance patient care records (PCRs) from calls to patients aged 65 years and over. Data were collected from two ambulance services in England during 24 or 48 hours periods in January 2017 and July 2017. The records were examined by two researchers using a standard template and the data were extracted from 3037 PCRs using a coding structure. Results Results were reported as percentages and means with 95% CIs. Dementia was recorded in 421 (13.9%) of PCRs. Patients with dementia were significantly less likely to be conveyed to hospital following an emergency call than those without dementia. The call cycle times were similar for patients regardless of whether or not they had dementia. Calls to people with dementia were more likely to be due to injury following a fall. In the overall sample, one or more comorbidities were reported on the PCR in over 80% of cases. Conclusion Rates of hospital conveyance for older people may be related to comorbidities, frailty and complex needs, rather than dementia. Further research is needed to understand the way in which ambulance clinicians make conveyance decisions at scene. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6074617/pdf/bmjopen-2018-022549.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/bmjopen-2018-022549
    • What happened on Restart a Heart Day 2017 in England?

      Brown, Terry P.; Perkins, Gavin D.; Lockey, Andrew S.; Soar, Jasmeet; Askew, Sara; Mersom, Frank; Fothergill, Rachael; Cox, Emma; Black, Sarah; Lumley-Holmes, Jenny (2018-09)
    • Student-run open access pre-hospital emergency medicine lectures in the East of England from the University of Cambridge

      Stretch, Benjamin; Dean, Jonathon; Mitchard, Matthew; Dunn, Abigail C.; Rosson, Louise S.; Chesters, Adam (2018-10)
    • Ambulance staff and end-of-life hospital admissions: A qualitative interview study

      Hoare, Sarah; Kelly, Michael P.; Prothero, Larissa; Barclay, Stephen (2018-10)