• National initiatives to improve outcomes from out-of-hospital cardiac arrest in England

      Perkins, Gavin D.; Lockey, Andrew S.; de Belder, Mark A.; Moore, Fionna; Weissberg, Peter; Gray, Huon; Community Resuscitation Group (2016-07)
    • Older fallers: the risk and opportunity of ambulance non conveyance

      Halter, Mary; Snooks, Helen; Close, Jacqueline; Cheung, Wai Yee; Moore, Fionna (2006-04)
      Large numbers of older people fall every year. Interdisciplinary intervention can reduce the risk of falling, and the use of integrated falls services for ambulance attended patients has been promoted. Non conveyance of fallers by ambulance staff is high but the triage system is informal. This study tested whether the introduction of an assessment tool would enable emergency ambulance staff to leave older fallers at home safely. https://emj.bmj.com/content/23/4/e31 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/ http://dx.doi.org/10.1136/emj.2005.032946
    • Out-of-hospital cardiac arrest - optimal management

      Frohlich, Georg M.; Lyon, Richard; Sasson, Comilla; Crake, Tom; Whitbread, Mark; Indermuehle, Andreas; Timmis, Adam; Meier, Pascal (2013-11)
    • Out-of-Hospital Cardiac Arrest in London during the COVID-19 pandemic

      Fothergill, Rachael; Smith, Adam L.; Wrigley, Fenella; Perkins, Gavin (2021-03)
    • Out-of-hospital cardiac arrest in patients aged 35 years and under: a 4-year study of frequency and survival in London

      Donohoe, Rachael T.; Innes, Jennifer; Gadd, Stephen; Whitbread, Mark; Moore, Fionna (2010-01)
    • Out-of-hospital cardiac arrest in South Asian and white populations in London: database evaluation of characteristics and outcome

      Shah, Anoop S. V.; Bhopal, Raj S.; Gadd, Stephen; Donohoe, Rachel (2009-09-10)
      Objective: To compare out-of-hospital cardiac arrest (OOHCA) characteristics in white and South Asian populations within Greater London. Methods: Data for OOHCAs were extracted from 1 April 2003 to 31 March 2007. Primary study variables included age, gender, ethnicity, response times from 999 call to ambulance arrival, initial cardiac rhythm, whether bystander cardiopulmonary resuscitation was provided before arrival of the London Ambulance Service (LAS) NHS Trust crew, whether the arrest was witnessed (bystander or LAS crew) and hospital outcome, including survival to hospital admission and discharge. Results: Of 13 013 OOHCAs of presumed cardiac cause, 3161 (24.3%) had ethnicity codes assigned. These comprised 63.1% (n = 1995) white and 5.8% (n = 183) South Asian people, with the remainder from other backgrounds. White patients were on average 5 years older than South Asians (69.5 vs 64.6, p<0.005). Response time (7.48 min vs 7.46 min), bystander cardiopulmonary resuscitation (34.4% vs 29.7%), initial cardiac rhythm (29.5% vs 30.4%) and survival to admission (22.2% vs 22.5%) and discharge (8.7% vs 8.9%) were comparable between the two ethnic groups. South Asians were slightly more likely to have a witnessed an OOHCA than their white counterparts (OR = 1.1, 95% CI 1.0 to 1.2). Discussion: The quality of care provided was comparable between white and South Asian populations. The data support the emerging view that South Asians’ high mortality from coronary heart disease reflects higher incidence rather than higher case fatality. South Asians had an OOHCA at a significantly younger age. The study demonstrates the importance of ethnic coding within the emergency services. https://heart.bmj.com/content/96/1/27. 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/hrt.2009.170183
    • 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, Daniel I.; Whitbread, Mark; Archbold, Andrew R.; Jain, Ajay K.; Mathur, Anthony; Wragg, Andrew; Knight, Charles J. (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
    • Outcome of 1051 octogenarians after primary percutaneous coronary intervention for ST elevation myocardial infarction: observational cohort from the London Heart Attack Group

      Bromage, D.I.; Jones, Daniel A.; Rathod, Krishnaraj S.; Lim, Pitt; Virdi, G.; Jain, A.J.; Singh Kalra, S.; Crake, Tom; Meier, Pascal; Astroulakis, Zoe; et al. (2013-05)
      Introduction The use of primary percutaneous coronary intervention (PCI) in octogenarians to treat ST elevation myocardial infarction (STEMI) is less than in other age groups. This is due in part to underrepresentation in clinical trials and perceived increased risk. We present long-term survival of a large cohort of elderly patients following primary PCI in London. Methods This was an observational study of 10 249 consecutive patients undergoing primary PCI for STEMI at eight London heart attack centres between January 2005 and November 2011. Patient’s details were recorded at the time of procedure into the British Cardiac Intervention Society (BCIS) database. Outcome was assessed by all-cause mortality. Anonymous datasets from the eight centres were merged for analysis. The primary end-point was all-cause mortality at a median follow-up of 3.0 years (IQR range 1.2–4.6 years). Results A total of 1051 octogenarians (10.3% of the study population) with an average age of 84.2 years (IQR 80–101) were treated with primary PCI during the study period. Over time, the annual proportion of octogenarians gradually increased from 9.1% in 2005 to 10.5% in 2010. Unsurprisingly, when compared to patients under 80, octogenarian STEMI patients included a higher proportion of women, and had a higher prevalence of hypertension, hypercholesterolaemia, multi-vessel disease, previous infarction and previous CABG (table 1). They additionally were less likely to undergo radial access, receive GPIIb/IIIa inhibitors or a drug-eluting stent. When compared with younger patients, primary PCI in octogenarians was less likely to achieve TIMI flow grade 3. However between 2005 and 2011 the rates of post-procedural TIMI flow grade 3 increased significantly from 80.5% in 2005 to 90% in 2011 (p for trend 0.05). The cumulative incidence of all-cause mortality during follow-up was significantly higher in the octogenarian group compared to the younger subgroup (51.6% vs 12.8%, p<0.0001) (figure 1). As expected, the hazard of death during follow-up increased with age (unadjusted HR 1.069 per year increase (95% CI 1.064 to 1.074), p<0.0001), which persisted after adjustment for other predictors of mortality (HR of 1.059 (95% CI 1.048 to 1.071), p<0.0001). Table 1 Under 80 Over 80 p Value Gender (female) 1800 (19.6%) 474 (45.4%) <0.0001 Hypertension 3692 (42.3%) 501 (51.3%) 0.02 Hypercholesterolaemia 3708 (42.5%) 548 (56.1%) <0.0001 Previous MI 1442 (16.9%) 182 (18.7%) 0.150 Previous CABG 264 (3.0%) 46 (4.6%) 0.010 Multi vessel disease 3821 (41.8%) 562 (54.0%) <0.0001 GPIIb/IIIa 6515 (74.4%) 530 (53.8%) <0.0001 DES use 4058 (45.9%) 311 (30.9%) <0.0001 Access (radial) 2115 (23.4%) 194 (18.8%) 0.001 Procedural success 6932 (88.3%) 736 (84.7%) 0.003 Figure 1 Heart May 2013 Vol 99 Suppl S2 A27 BCS Abstracts 2013 (NHS). Protected by copyright. on January 7, 2020 at Manchester University NHS Foundation Trust http://heart.bmj.com/ Heart: first published as 10.1136/heartjnl-2013-304019.37 on 24 May 2013. Downloaded from Conclusions Octogenarians constitute an important subgroup of STEMI patients. Data from London ’s experience would suggest that primary PCI rates are increasing in this group and that despite the high long term mortality, acute/year one rates survival rates are very encouraging. https://heart.bmj.com/content/heartjnl/99/suppl_2/A27.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/heartjnl-2013-304019.37
    • Oxford Handbook of Pre-Hospital Care

      Fellows, Bob (2008-10)
      This is a small pocket guide written by a pair of eminent doctors with a clear market for other doctors who want to be more involved in the ‘sexy’ world of pre- and out-of-hospital care. Abstract published with permission.
    • Paramedic assessment of older adults after falls, including community care referral pathway: cluster randomized trial

      Snooks, Helen A.; Anthony, Rebecca; Chatters, Robin; Dale, Jeremy; Fothergill, Rachael T.; Gaze, Sarah; Halter, Mary; Humphreys, Ioan; Koniotou, Marina; Logan, Phillipa; et al. (2017-10)
    • 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
    • Paramedic delivery of bad news: a novel dilemma during the COVID-19 crisis

      Campbell, Iain (2020-10-30)
      As a result of the COVID-19 global pandemic, paramedics in the UK face unprecedented challenges in the care of acutely unwell patients and their family members. This article will describe and discuss a new ethical dilemma faced by clinicians in the out-of-hospital environment during this time, namely the delivery of bad news to family members who are required to remain at home and self-isolate while the critically unwell patient is transported to hospital. I will discuss some failings of current practice and reflect on some of the ethical and practical challenges confronting paramedics in these circumstances. I conclude by making three recommendations: first, that dedicated pastoral outreach teams ought to be set up during pandemics to assist family members of patients transported to hospital; second, I offer a framework for how bad news can be delivered during a lockdown in a less damaging way; and finally, that a new model of bad news delivery more suited for unplanned, time-pressured care should be developed. https://jme.bmj.com/content/early/2020/10/30/medethics-2020-106710 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/medethics-2020-106710
    • Paramedics' experiences of end-of-life care decision making with regard to nursing home residents: an exploration of influential issues and factors

      Murphy-Jones, Georgina; Timmons, Stephen (2016-10)
      Introduction For a patient nearing the end of his or her life, transfer from a nursing home to the ED can be inappropriate, with potentially negative consequences, but transfer in these circumstances is, regrettably, all too common. There is a lack of published literature exploring how paramedics make decisions in end-of-life care situations. This study aims to explore how paramedics make decisions when asked to transport nursing home residents nearing the end of their lives. Methods Phenomenological influenced design with a pragmatic approach. Semi-structured face-to-face interviews were conducted with six paramedics in an English NHS Ambulance Trust and subsequent data collected by text message. Audio-recorded interviews were transcribed verbatim and analysed using a thematic approach. Results Three themes emerged in relation to the decision to transport patients from nursing homes to EDs in end-of-life care situations. Paramedics identified difficulties in understanding nursing home residents’ wishes. When a patient no longer had the capacity for decision making, paramedics’ reasoning processes were aligned to best interest decision making, weighing the risks and benefits of hospitalisation. Paramedics found it challenging to balance patients’ best interests with pressure from others: nursing staff, patients’ relatives and colleagues. Conclusions A range of factors influence paramedics’ decisions to transport nursing home residents to EDs in end-of-life care situations. Decision making became a process of negotiation when the patient’s perceived best interests conflicted with that of others, resulting in contrasting approaches by paramedics. This paper considers how paramedics might be better trained and supported in dealing with these situations, with the aim of providing dignified and appropriate care to patients as they reach the end of their lives. https://emj.bmj.com/content/emermed/33/10/722.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-2015-205405
    • A pilot study of pre-hospital initiation of therapeutic hypothermia using intra-nasal cooling

      Lyon, Richard; Henderson, Charles; Van Antwerp, Jerry; Weaver, Anne; Davies, Gareth; Lockey, David (2012-10-15)
    • The potential for bystander automated external defibrillator deployment in London, UK

      Smith, Christopher M.; Lall, Ranjit; Hartley-Sharpe, Christopher; Perkins, Gavin D. (2018-09)
    • A practical risk score for early prediction of neurological outcome after out-of-hospital cardiac arrest: MIRACLE2

      Pareek, Nilesh; Kordis, Peter; Beckley-Hoelscher, Nicholas; Pimenta, Dominic; Kocjancic, Spela Tadel; Jazbec, Anja; Nevett, Joanne; Fothergill, Rachael; Kalra, Sandeep; Lockie, Tim; et al. (2020-12)