• Ambulance clinician assessment and management of transient loss of consciousness: a retrospective clinical audit

      Shaw, Joanna; Ulrich, Alex; Fothergill, Rachael; Whitbread, Mark (2016-01)
      Abstract published with permission. Introduction: Transient loss of consciousness (T-LOC) is thought to be underestimated and under-managed in the pre-hospital setting. This clinical audit aims to assess the compliance of ambulance clinicians against the National Institute of Clinical Excellence guidance on the management of patients with T-LOC. Method: Ninety-four patients’ clinical records and electrocardiograms (ECGs) were reviewed to determine appropriateness of assessment and patient management. Results: In this limited sample, findings show standard assessments and history documented for all patients were equally well recorded for T-LOC patients, but those specific to T-LOC were not. The number of ECGs conducted and interpreted correctly was an additional area of concern. Conclusions: Further assessments and history specific to T-LOC are required in the pre-hospital setting to ensure any potentially serious causes are recognised and these patients are taken to hospital.
    • Ambulance response times and mortality in elderly fallers

      Cannon, Emily; Shaw, Joanna; Fothergill, Rachael; Lindridge, Jaqualine (2016-09)
      Background Worldwide, the number of people aged over 60 is growing faster than any other age group. Increased age is associated with a higher risk of falling and roughly a third of individuals aged 65 and over experience a fall each year. One way in which ambulance services may impact the outcome of patients is the time taken for a response to arrive on scene. Lying on the floor for a long time has been found to be strongly associated with serious injuries, admission to hospital, and mortality. However, previous research has not assessed the impact of ambulance response times on mortality. Methods To determine whether there is a relationship between the time elderly fallers (aged 65 and over) spend on the floor and mortality, an observational study was undertaken. A convenience sample of 503 ambulance response times, patient records detailing the amount of time spent on the floor, and patient outcomes at 90 days were analysed using logistic regression. Results Eight percent of patients in the sample died within 90 days of their fall (n=38). Patients who were deceased at 90-day follow-up (n=38) did not wait significantly longer for an ambulance than patients who were still alive (n=464) (means= 34 min vs 37 min, p=.678). Of the patients who were still on the floor upon LAS arrival (n=178), those who had died within 90 days following their fall (n=14) spent less time in total on the floor than patients who were still alive at 90-day follow-up (n=164) (means= 59 min vs 98 min, p=.296). Conclusions Increased ambulance response time or prolonged time spent on the floor was not associated with 90-day mortality in elderly fallers who presented to the ambulance service. Whilst any delays in attending elderly fallers require monitoring, we can be reassured that long waits are not leading to mortality in this patient group. https://emj.bmj.com/content/emermed/33/9/e9.1.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-2016-206139.29
    • Can the prehospital National Early Warning Score identify patients most at risk from subsequent deterioration?

      Shaw, Joanna; Fothergill, Rachael; Clark, Sophie; Moore, Fionna (2017-08)
      Introduction The National Early Warning Score (NEWS) aids the early recognition of those at risk of becoming critically ill. NEWS has been recommended for use by ambulance services, but very little work has been undertaken to date to determine its suitability. This paper examines whether a prehospital NEWS derived from ambulance service clinical observations is associated with the hospital ED disposition. Methods Prehospital NEWS was retrospectively calculated from the ambulance service clinical records of 287 patients who were treated by the ambulance service and transported to hospital. In this cohort study, derived NEWS scores were compared with ED disposition data and patients were categorised into the following groups depending on their outcome: discharged from ED, admitted to a ward, admitted to intensive therapy unit (ITU) or died. Results Prehospital NEWS-based ambulance service clinical observations were significantly associated with discharge disposition groups (p<0.001), with scores escalating in line with increasing severity of outcome. Patients who died or were admitted to ITU had higher scores than those admitted to a ward or discharged from ED (mean NEWS 7.2 and 7.5 vs 2.6 and 1.7, respectively), and in turn those who were admitted to a ward had higher pre-hospital NEWS than those who were discharged (2.6 vs 1.7). Conclusion Our findings suggest that the NEWS could successfully be used by ambulance services to identify patients most at risk from subsequent deterioration. The implementation of this early warning system has the potential to support ambulance clinician decision making, providing an additional tool to identify and appropriately escalate care for acutely unwell patients https://emj.bmj.com/content/emermed/34/8/533.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-2016-206115
    • A clinical audit of the pre-hospital paediatric respiratory assessment in London

      Clark, Sophie; Shaw, Joanna; Wrigley, Fenella (2014-02)
      Abstract published with permission. Assessing a child with difficulty in breathing is a challenge in a pre-hospital setting, especially children under 3 years old. Nevertheless, hypoxia must be treated early, and a respiratory assessment is essential to ensuring the well being of these patients. The aim of this audit was to update the research, as there have been changes in equipment and training since this was last addressed. A criterion-based clinical audit was undertaken of 253 patient report forms collected from the London Ambulance Service over a one-month period. The pre-hospital clinician must have coded dyspnoea (difficulty in breathing) and the patient’s age must be under three years. The observations audited were: respiratory rate, auscultation attempt and oxygen saturations, any exceptions were noted. The results showed that 85% (n=220) had two respiratory rates recorded, 70% (n = 178) recorded an auscultation attempt, whilst two oxygen saturation recordings were documented for 52% (n=131). The main reason for no oxygen saturations was ‘no kit’, accounting for 38% (n= 45) of the noncompliance. Overall, 39% (n=99) recorded all three observations in this audit. It was concluded that there has been progress since the last review; however, there is still potential for better compliance. Recording oxygen saturations especially needs improving and the availability of equipment requires addressing.
    • Level of sepsis knowledge in UK Ambulance Services

      Murphy-Jones, Barry; Shaw, Joanna (2016-09)
      Background Sepsis is responsible for over 37,000 deaths a year in the UK, with long term morbidity consequences for survivors. More than 40% of cases develop within the community, making the ambulance service vitally important. This project sought to ascertain the current level of sepsis knowledge in UK ambulance services to better understand potential knowledge gaps. Methods This observational study used an online questionnaire to describe the level of knowledge of sepsis and how it is recognised and managed in the pre-hospital setting. A convenience sample of clinicians at one ambulance service was invited to complete a questionnaire which consisted of ten questions and was hosted on the web-based tool SurveyMonkey®. One hundred and seventy-one complete responses were received from ambulance staff (response rate 5.4%) and data were entered into Microsoft Excel and analysed using descriptive statistics. Results The questionnaire identified 59% of respondents (n=100) had heard of the terms sepsis and systemic inflammatory response syndrome, with 23% (n=40) identifying all three stages of sepsis. Sixty-nine per cent of respondents (n=118) identified the correct definition of sepsis, and 23% (n=39) believed this definition was used in the pre-hospital setting. Four per cent of respondents (n=7) identified all of the common signs and symptoms and 22% (n=37) knew all of the pre-hospital interventions for severe sepsis and septic shock. Finally, 71% (n=121) agreed paramedics could identify patients at high risk of sepsis, with 94% (n=161) agreeing pre-hospital recognition and interventions may improve outcomes for sepsis. Conclusions Findings showed poor knowledge of sepsis, its recognition and pre-hospital management which is supported by other literature. As a result, a mandatory training programme has been delivered and a sepsis screening tool, including prompts for appropriate management, has been produced. A continuous clinical audit will also be introduced to understand how this knowledge is applied in practice. https://emj.bmj.com/content/emermed/33/9/e10.3.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-2016-206139.34
    • Pre-hospital paediatric pain management in the London ambulance service

      Shaw, Joanna; Murphy-Jones, Barry; Fothergill, Rachael (2018-04)
      Aim In 2006 the London Ambulance Service (LAS) developed a laminated card to allow for better pain assessment for children. The card contained a faces-based scoring system used in hospitals.1 LAS paediatric pain assessment and management was reviewed in 2012 demonstrating improvement in assessment of pain as a result of the card. Administration of pain relief also improved, however further progress was needed in analgesia provision and immobilisation. Following the review, paediatric pain management and immobilisation was included in LAS clinical training sessions, and a paediatric immobilisation equipment review was conducted. This project aimed to determine whether these additional initiatives further improved paediatric pain management. Method A retrospective review was undertaken of 229 clinical records from October 2014 to January 2015 for patients aged 12 years and under whose primary complaint was a possible fracture or dislocation. Clinical records were compared with national clinical practice guidelines for paediatric pain management. Results Findings showed nearly all patients had a pain assessment recorded (n=223, 97%), an improvement sustained from 2012 (+34% since 2006). We found an increase in the percentage of children having their injury immobilised (+22% since 2012; sustained from 2006; n=90/216, 42%) and being given analgesia when required (+18% since 2012;+61% since 2006; n=170/209, 84%). Conclusion The systematic cyclical process of reviewing care, implementing change and re-measuring, whilst resource intensive, has demonstrated huge improvements in paediatric pain management over time. https://bmjopen.bmj.com/content/8/Suppl_1/A26.2 This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ http://dx.doi.org/10.1136/bmjopen-2018-EMS.69
    • Prehospital use of ketamine and midazolam in an urban advanced paramedic practitioner service: a retrospective review

      Edwards, Timothy; Shaw, Joanna; Gray, Danielle; Thomson, Neil; Faulkner, Mark (2016-09)
      Background The use of ketamine and midazolam in physician-led prehospital care teams within the UK is well established. Although both agents are in use by paramedics within emergency medical systems in North America and Australasia, there is a paucity of data relating to administration by UK paramedics. Methods A panel of clinicians utilised a standardised data extraction form to review patient report forms for all cases where an Advanced Paramedic Practitioner (APP) administered ketamine or midazolam from 1st May to 30th September 2015. Reviewers assessed indications for and appropriateness of administration, and identification and management of adverse events. Results A total of 21 patients received ketamine for analgesia (n=20, 95%) or to facilitate rapid extrication (n=1, 5%). Pain scores were recorded in 18 patients (90%), the majority of whom experienced a reduction in pain post administration (n=17, 94%). No adverse events occurred following ketamine use. Midazolam was administered to a total of 80 cases. The most common indications for administration were maintenance of an advanced airway in patients with return of spontaneous circulation post cardiac arrest (n=37, 46%), management of acute behavioural disturbance (n=28, 35%) and prolonged seizures (n=15, 18%). Transient airway compromise occurred in 10% (n=8) of cases, all of which were managed appropriately. No other adverse events occurred. The administration of ketamine and midazolam was judged to be appropriate in all cases. Conclusions The use of ketamine and midazolam in the context of an urban APP service with high levels of additional education, procedural experience and selective targeting to emergency calls appears safe and effective. Further prospective studies are warranted to confirm these findings. https://emj.bmj.com/content/emermed/33/9/e8.1.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-2016-206139.26
    • A study to determine the EZ-IO® Intraosseous Infusion System success rate, including impact on return of spontaneous circulation

      Woodhart, Ben; Shaw, Joanna (2016-09)
      Background In the UK the EZ-IO® Intraosseous Infusion System is a paramedic delivered technique involving the placement of the Intraosseous (IO) needle into the patient's bone marrow via an EZ-IO driver. The primary use for EZ-IO is when intravenous (IV) access is not possible, mainly for patients in cardiac arrest but may include severely unwell/injured patients. This study aimed to determine EZ-IO success rate, including impact on return of spontaneous circulation (ROSC). Methods One hundred and ninety-five cardiac arrest patient records where EZ-IO placement was attempted were retrospectively examined to determine whether ROSC was achieved at any point. Findings were compared to records where resuscitation was attempted and patients were administered drugs IV and tested for association using Pearson's Chi-Square Test. In addition, patients' records were assessed for their compliance to best practice guidance issued by the Joint Royal Colleges Ambulance Liaison Committee for use in UK Ambulance Services and manufacturer's guidelines. Results ROSC was achieved for 29% of the patients who had an EZ-IO inserted (n=57), therefore for 71% (n=138) ROSC was not achieved. This compares to 46% (n=338) and 54% (n=399) retrospectively for patients administered drugs IV. We observed a strong association between method of access and patient's outcome (χ2 (1)=17.465, p=.000). Where an EZ-IO was attempted 100% (n=195) were identified as having a successful IO placement, although certain areas of documentation were highlighted as requiring improvement, specifically: insertion site (recorded for 26%, n=51); needle size (74%, n=145), and saline flush (93%, n=182). Conclusions Although, this shows that the practice of pre-hospital EZ-IO insertion is successful, it compares less favourably to administering resuscitation drugs IV. However, there may be other factors associated with achieving ROSC that have not been taken into account, including the reasons IV access was not possible and whether this was an influencing factor. https://emj.bmj.com/content/emermed/33/9/e5.2.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-2016-206139.19