• Ambulance smartphone tool for field triage of ruptured aortic aneurysms (FILTR): study protocol for a prospective observational validation of diagnostic accuracy

      Lewis, Thomas L.; Fothergill, Rachael; Aneurysm-FILTR Study Group; Karthikesalingam, Alan (2016-10)
      Introduction: Rupture of an abdominal aortic aneurysm (rAAA) carries a considerable mortality rate and is often fatal. rAAA can be treated through open or endovascular surgical intervention and it is possible that more rapid access to definitive intervention might be a key aspect of improving mortality for rAAA. Diagnosis is not always straightforward with up to 42% of rAAA initially misdiagnosed, introducing potentially harmful delay. There is a need for an effective clinical decision support tool for accurate prehospital diagnosis and triage to enable transfer to an appropriate centre. Methods and analysis: Prospective multicentre observational study assessing the diagnostic accuracy of a prehospital smartphone triage tool for detection of rAAA. The study will be conducted across London in conjunction with London Ambulance Service (LAS). A logistic score predicting the risk of rAAA by assessing ten key parameters was developed and retrospectively validated through logistic regression analysis of ambulance records and Hospital Episode Statistics data for 2200 patients from 2005 to 2010. The triage tool is integrated into a secure mobile app for major smartphone platforms. Key parameters collected from the app will be retrospectively matched with final hospital discharge diagnosis for each patient encounter. The primary outcome is to assess the sensitivity, specificity and positive predictive value of the rAAA triage tool logistic score in prospective use as a mob app for prehospital ambulance clinicians. Data collection started in November 2014 and the study will recruit a minimum of 1150 non-consecutive patients over a time period of 2 years. Ethics and dissemination: Full ethical approval has been gained for this study. The results of this study will be disseminated in peer-reviewed publications, and international/national presentations https://bmjopen.bmj.com/content/6/10/e011308.long 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-2016-011308
    • Crowd medical services in the English Football League: remodelling the team for the 21st century using a realist approach

      Leary, Alison; Kemp, Anthony; Greenwood, Peter; Hart, Nick; Agnew, James; Barrett, John; Punshon, Geoffrey (2017-12)
      Objectives To evaluate the new model of providing care based on demand. This included reconfiguration of the workforce to manage workforce supply challenges and meet demand without compromising the quality of care. Design Currently the Sports Ground Safety Authority recommends the provision of crowd medical cover at English Football League stadia. The guidance on provision of services has focused on extreme circumstances such as the Hillsborough disaster in 1989, while the majority of demand on present-day services is from patients with minor injuries, exacerbations of injuries and pre-existing conditions. A new model of care was introduced in the 2009/2010 season to better meet demand. A realist approach was taken. Data on each episode of care were collected over 14 consecutive football league seasons at Millwall FC divided into two periods, preimplementation of changes and postimplementation of changes. Data on workforce retention and volunteer satisfaction were also collected. Setting The data were obtained from one professional football league team (Millwall FC) located in London, UK. Primary and secondary outcomes The primary outcome was to examine the demand for crowd medical services. The secondary outcome was to remodel the service to meet these demands. Results In total, 981 episodes of care were recorded over the evaluation period of 14 years. The groups presenting, demographic and type of presentation did not change over the evaluation. First aiders were involved in 87.7% of episodes of care, nurses in 44.4% and doctors 17.8%. There was a downward trend in referrals to hospital. Workforce feedback was positive. Conclusions The new workforce model has met increased service demands while reducing the number of referrals to acute care. It involves the first aid workforce in more complex care and key decision-making and provides a flexible registered healthcare professional team to optimise the skill mix of the team. https://bmjopen.bmj.com/content/7/12/e018619.long 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-2017-018619
    • Genuine illness and injury during Europe’s largest emergency service major incident exercise

      Cannon, Emily; Edwards, Timothy; Fothergill, Rachael (2017-05)
      Aim Previous studies of patient presentation rates at mass gatherings have been limited to social events. None have assessed presentation rates in the context of a large-scale emergency service exercise where individuals (actors playing hypothetical casualties) are exposed to an environment containing many potential hazards. Methods Exercise Unified Response was the largest multi-agency exercise ever held in Europe. It was a four-day major incident exercise in the UK, in which 2700 individuals acted as casualties. Clinical records completed by healthcare professionals providing on-site medical cover for the duration of the event were reviewed. Clinical records were included where the individual’s role in the exercise was listed as ‘actor’. Results Thirty actors required medical attention, giving a patient presentation rate (PPR) of 11.1 per one thousand actors. Of these, 10% were conveyed to hospital with musculoskeletal (n=2) or head injuries (n=1); an ambulance transfer rate (ATR) of 1.11 per 1000. Just under half of all patients (40%, n=12) had a contributory factor to seeking medical help, where they had: not eaten on the day (n=4); a pre-existing condition exacerbated by the exercise, such asthma (n=3); pre-existing symptoms of acute illness (n=3), or a pre-existing injury (n=2). Conclusion Patient presentation rate was in line with previous research1. However, we believe this is the first study to report similar data for a mass emergency service exercise. Our findings regarding the factors and pre-existing illnesses/conditions that contributed to individuals seeking medical help will be valuable in planning future large-scale exercises. https://bmjopen.bmj.com/content/7/Suppl_3/A3.2 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-2017-EMSabstracts.8
    • Identifying and overcoming barriers to automated external defibrillator use by GoodSAM volunteer first responders in out-of-hospital cardiac arrest using the Theoretical Domains Framework and Behaviour Change Wheel: a qualitative study

      Smith, Christopher M.; Griffiths, Frances; Fothergill, Rachael; Vlaev, Ivo; Perkins, Gavin (2020-03-10)
      Objectives: GoodSAM is a mobile phone app that integrates with UK ambulance services. During a 999 call, if a call handler diagnoses cardiac arrest, nearby volunteer first responders registered with the app are alerted. They can give cardiopulmonary resuscitation (CPR) and/or use a public access automated external defibrillator (AED). We aimed to identify means of increasing AED use by GoodSAM first responders. Methods: We conducted semistructured telephone interviews, using the Theoretical Domains Framework to identify and classify barriers to AED use. We analysed findings using the Capability, Opportunity, Motivation, Behaviour (COM-B) model and subsequently used the Behaviour Change Wheel to develop potential interventions to improve AED use. Setting London, UK. Participants: GoodSAM first responders alerted in the previous 7 days about a cardiac arrest. Results We conducted 30 telephone interviews in two batches in July and October 2018. A public access AED was taken to scene once, one had already been attached on scene another time and three participants took their own AEDs when responding. Most first responders felt capable and motivated to use public access AEDs but were concerned about delaying CPR if they retrieved one and frustrated when arriving after the ambulance service. They perceived lack of opportunities due to unavailable and inaccessible AEDs, particularly out of hours. We subsequently developed 13 potential interventions to increase AED use for future testing. Conclusions: GoodSAM first responders used AEDs occasionally, despite a capability and motivation to do so. Those operating volunteer first responder systems should consider our proposed interventions to improve AED use. Of particular clinical importance are: highlighting AED location and providing route/time estimates to the patient via the nearest AED. This would help single responders make appropriate decisions about AED retrieval. As AED collection may extend time to reach the patient, where there is sufficient density of potential responders, systems could send one responder to initiate CPR and another to collect an AED. https://bmjopen.bmj.com/content/10/3/e034908 https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/.
    • Out-of-hours primary percutaneous coronary intervention for ST-elevation myocardial infarction is not associated with excess mortality: a study of 3347 patients treated in an integrated cardiac network

      Rathod, Krishnaraj S.; Jones, Daniel A.; Gallagher, Sean M.; Bromage, Dan; Whitbread, Mark; Archbold, Andrew; Jain, Ajay K.; Mathur, Anthony; Wragg, Andrew; Knight, Charles (2013-06)
      OBJECTIVES: Timely delivery of primary percutaneous coronary intervention (PPCI) is the treatment of choice for ST-segment elevation myocardial infarction (STEMI). Optimum delivery of PPCI requires an integrated network of hospitals, following a multidisciplinary, consultant-led, protocol-driven approach. We investigated whether such a strategy was effective in providing equally effective in-hospital and long-term outcomes for STEMI patients treated by PPCI within normal working hours compared with those treated out-of-hours (OOHs). DESIGN: Observational study. SETTING: Large PPCI centre in London. PARTICIPANTS: 3347 STEMI patients were treated with PPCI between 2004 and 2012. The follow-up median was 3.3 years (IQR: 1.2-4.6 years). PRIMARY AND SECONDARY OUTCOME MEASURES: The primary endpoint was long-term major adverse cardiac events (MACE) with all-cause mortality a secondary endpoint. RESULTS: Of the 3347 STEMI patients, 1299 patients (38.8%) underwent PPCI during a weekday between 08:00 and 18:00 (routine-hours group) and 2048 (61.2%) underwent PPCI on a weekday between 18:00 and 08:00 or a weekend (OOHs group). There were no differences in baseline characteristics between the two groups with comparable door-to-balloon times (in-hours (IHs) 67.8 min vs OOHs 69.6 min, p=0.709), call-to-balloon times (IHs 116.63 vs OOHs 127.15 min, p=0.60) and procedural success. In hospital mortality rates were comparable between the two groups (IHs 3.6% vs OOHs 3.2%) with timing of presentation not predictive of outcome (HR 1.25 (95% CI 0.74 to 2.11). Over the follow-up period there were no significant differences in rates of mortality (IHs 7.4% vs OFHs 7.2%, p=0.442) or MACE (IHs 15.4% vs OFHs 14.1%, p=0.192) between the two groups. After adjustment for confounding variables using multivariate analysis, timing of presentation was not an independent predictor of mortality (HR 1.04 95% CI 0.78 to 1.39). CONCLUSIONS: This large registry study demonstrates that the delivery of PPCI with a multidisciplinary, consultant-led, protocol-driven approach provides safe and effective treatment for patients regardless of the time of presentation. https://bmjopen.bmj.com/content/bmjopen/3/6/e003063.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/bmjopen-2013-003063
    • Paramedic attitudes and experiences of enrolling patients into the PARAMEDIC-2 adrenaline trial: a qualitative survey within the London Ambulance Service

      Lazarus, Johanna; Iyer, Rajeshwari; Fothergill, Rachael (2019-12-01)
      OBJECTIVES: The aim of this study was to gather the views and experiences of paramedics who participated in a large-scale randomised controlled drug trial and to identify barriers to recruitment. DESIGN: We surveyed paramedics using a questionnaire consisting of a mix of closed and open ended questions. SETTING: The study was conducted within the London Ambulance Service, London, UK. PARTICIPANTS: 150 paramedics who were trained to enrol patients into the PARAMEDIC-2 randomised controlled trial of adrenaline versus placebo in out-of-hospital cardiac arrest and who returned the questionnaire. RESULTS: 98% of study participants felt prehospital research was very important, and 97.3% reported an overall positive experience of being involved in a drug trial. Only 5.3% felt uncomfortable enrolling patients into the trial without prior consent from the patient or a relative. Over one- third (39.3%) identified one or more barriers to patient recruitment, the most common being the attitudes of other staff. CONCLUSION: We found a strong appetite for involvement in prehospital research among paramedics and an understanding of the importance of research that prevailed over the complexities of the trial. This is an important finding demonstrating that potentially ethically controversial research can be undertaken successfully by paramedics in the prehospital environment., https://www.ncbi.nlm.nih.gov/pubmed/31791962. 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: 10.1136/bmjopen-2018-025588
    • The pre-hospital management of acute heart failure: a clinical audit of current practice

      Price, J.; Murphy-Jones, Barry; Edwards, Timothy (2018-04)
      Aim There has been a drive towards an increase in community-based management of heart failure. When patients experience acute heart failure (AHF), the complex nature of this condition poses diagnostic uncertainty for first responders. It is widely accepted that all patients should be transferred promptly to hospital, however with the introduction of pre-hospital diuresis, nitrate therapy and more recently non-invasive ventilation (NIV), the debate into the appropriateness and limitations of so-called ‘stay-and-play’ management strategies for patients in AHF has been re-ignited. We examine the current clinical assessment and management of AHF within the London Ambulance Service. Method Ambulance Patient Report Forms (PRFs) from cases that were coded with heart failure, shortness of breath, cardiac problem and in cases of GTN administration. These cases were further analysed by a clinical review panel to identify patients with suspected AHF. Results 182 patients were included in the analysis between April and November 2016. There was a 68% compliance with national guidelines for clinical assessment (history, examination and ECG). 51 (28%) patients presenting with AHF were appropriately identified and given a primary diagnosis of AHF by the attending clinician. 136 (76%) patients in the analysis received sublingual nitrate therapy. 90 (49%) patients received nitrates where there was no clinical indication. No patients in the analysis received NIV. Conclusion Some aspects of AHF assessment and management are not consistent with national guidelines. Our work has further demonstrated the diagnostic challenges facing pre-hospital clinicians and the potential overuse of nitrate therapy in this patient group. https://bmjopen.bmj.com/content/8/Suppl_1/A32.2 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.85
    • 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
    • Reducing time to angiography and hospital stay for patients with high-risk non-ST-elevation acute coronary syndrome: retrospective analysis of a paramedic-activated direct access pathway

      Koganti, Sudheer; Patel, N.; Seraphim, A.; Kotecha, T.; Whitbread, Mark; Rakhit, Roby D. (2016-06)
      Objective: To assess whether a novel ‘direct access pathway’ (DAP) for the management of high-risk nonST-elevation acute coronary syndromes (NSTEACS) is safe, results in ‘shorter time to intervention and shorter admission times’. This pathway was developed locally to enable London Ambulance Service to rapidly transfer suspected high-risk NSTEACS from the community to our regional heart attack centre for consideration of early angiography. Methods: This is a retrospective case–control analysis of 289 patients comparing patients with high-risk NSTEACS admitted via DAP with age-matched controls from the standard pan-London high-risk ACS pathway (PLP) and the conventional pathway (CP). The primary end point of the study was time from admission to coronary angiography/intervention. Secondary end point was total length of hospital stay. Results: Over a period of 43 months, 101 patients were admitted by DAP, 109 matched patients by PLP and 79 matched patients through CP. Median times from admission to coronary angiography for DAP, PLP and CP were 2.8 (1.5–9), 16.6 (6–50) and 60 (33–116) hours, respectively ( p<0.001). Median length of hospital stay for DAP and PLP was similar at 3.0 (2.0–5.0) days in comparison to 5 (3–7) days for CP ( p<0.001). Conclusions: DAP resulted in a significant reduction in time to angiography for patients with high-risk NSTEACS when compared to existing pathways. https://bmjopen.bmj.com/content/bmjopen/6/6/e010428.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/bmjopen-2015-010428
    • Temporal and geographic patterns of stab injuries in young people: a retrospective cohort study from a UK major trauma centre

      Vulliamy, Paul; Faulkner, Mark; Kirkwood, Graham; West, Anita; O'Neill, Breda; Griffiths, Martin P.; Moore, Fionna; Brohi, Karim (2018-11)
      https://bmjopen.bmj.com/content/8/10/e023114.long Objectives To describe the epidemiology of assaults resulting in stab injuries among young people. We hypothesised that there are specific patterns and risk factors for injury in different age groups. Design Eleven-year retrospective cohort study. Setting Urban major trauma centre in the UK. Participants 1824 patients under the age of 25 years presenting to hospital after a stab injury resulting from assault. Outcomes Incident timings and locations were obtained from ambulance service records and triangulated with prospectively collected demographic and injury characteristics recorded in our hospital trauma registry. We used geospatial mapping of individual incidents to investigate the relationships between demographic characteristics and incident timing and location. Results The majority of stabbings occurred in males from deprived communities, with a sharp increase in incidence between the ages of 14 and 18 years. With increasing age, injuries occurred progressively later in the day (r2 =0.66, p<0.01) and were less frequent within 5 km of home (r2 =0.59, p<0.01). Among children (age <16), a significant peak in injuries occurred between 16:00 and 18:00 hours, accounting for 22% (38/172) of injuries in this group compared with 11% (182/1652) of injuries in young adults. In children, stabbings occurred earlier on school days (hours from 08:00: 11.1 vs non-school day 13.7, p<0.01) and a greater proportion were within 5 km of home (90% vs non-school day 74%, p=0.02). Mapping individual incidents demonstrated that the spike in frequency in the late afternoon and early evening was attributable to incidents occurring on school days and close to home. Conclusions Age, gender and deprivation status are potent influences on the risk of violent injury in young people. Stab injuries occur in characteristic temporal and geographical patterns according to age group, with the immediate after-school period associated with a spike in incident frequency in children. This represents an opportunity for targeted prevention strategies in this population. https://bmjopen.bmj.com/content/bmjopen/8/10/e023114.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/bmjopen-2018-023114