• Data linkage across ambulance services and acute trusts: assessing the potential for improving patient care

      Clark, Sophie; Porter, Alison; Halter, Mary; Damiani, Mike; Dorning, Holly; McTigue, Martin (2016-09)
      Background Currently, most callers to 999 ambulance services are transported to the hospital emergency department (ED). However, ambulance services receive no further information on those patients, and commissioners do not have the full picture of patient care. The London Ambulance Service have worked with one acute trust to establish the feasibility of data linkage, but questions remain about transferability of the model, and how learning from linked data can bring about changes in patient care and outcomes. Methods PHED Data is our two-year mixed-methods observational study which began in May 2015. We aim to establish the potential for routinely linking data from acute trusts and ambulance services, to allow diagnosis, health care intervention, and mortality outcomes to be tracked, with a range of potential benefits for patient care within ambulance services and across the healthcare economy. We will work with six acute trusts from across London, selected to give a range of performance. The study has six work packages: WP1 examines the technical aspects of the linkage process; WP2-5 each analyse the data to develop one themed indicator set, with qualitative work examining their perceived relevance and viability; WP6 examines how the indicator sets might influence commissioning decisions and service improvements. Results So far, we have engaged with six selected acute trusts; all have shown strong interest in collaborating. We are currently arranging the logistical aspects of data sharing. We aim to respond to trusts' particular interests in our analyses, in addition to developing our common indicator set. Conclusions The proposed work has the potential to bring about quality improvements to current systems and support the development of new pathways and protocols for pre-hospital interventions. Benefits will be felt across the healthcare system. Our findings will be relevant to health service providers across the UK, who all face similar challenges in pre-hospital care. https://emj.bmj.com/content/emermed/33/9/e12.2.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-2016-206139.39
    • Data linkage across ambulance services and acute trusts: challenges and opportunities

      Clark, Sophie; Porter, Alison; Halter, Mary; Dorning, Holly (2017-10)
      Background Most callers to 999 ambulance services are transported to hospital emergency departments (EDs), but ambulance services receive no information on patient outcomes. PHED Data is a two-year mixed-methods observational study of the process and potential benefits of linking data from EDs with ambulance service data to allow analysis of patient outcomes. We report on our first aim, to examine the potential opportunities and challenges to routinely linking these data. Methods We approached six acute trusts, selected to give a range of performance, location and size, from an English metropolitan area. We used a structured learning log to collect data on the process, time input and reflections. We analysed these data with descriptive statistics, and qualitatively for themes. Results All six trusts we approached agreed to participate. Data were linked using an algorithm based on date, time and patient demographics. We achieved a dataset of 7 75 018 records covering 2012–2016, and a linkage rate of 81%. We identified five stages of the process: senior approval; exploring data availability; information governance agreement; data transfer and linking. The most intensive phases were; negotiating senior approval (mean research team input per trust of 8 hours 5 min [SD 8 hours 3 min] plus additional time from acute trusts), and data linkage (mean research team input per trust 12 hours 40 min [SD 7 hours 4 min]). The stage which took the longest was information governance (mean 19 weeks). Key themes included the positive attitudes of trusts to participating, the range of decision-makers involved, and the need for sustained input from the research team. Conclusions We have found the process of data linkage to be feasible, but requires dedicated time from research and trust staff, over a prolonged period, in order to achieve initial set up. Linked data are now being analysed. https://emj.bmj.com/content/34/10/696.1 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-2017-207114.3
    • The decision-making process in an emergency: a reflection on paramedic practice

      Lindsey, Louise (2013-12)
      Abstract published with permission. This article will use a case study to critically reflect and analyse the decisionmaking process used in an emergency situation. It will discuss a range of factors that influenced the clinical decision-making process and how this prompted immediate transport to a local hospital. A wide range of supporting evidence will be explored and the decision-making process will be questioned and challenged. Relevant professional, ethical and legal issues will be considered and discussed. The inclusion of other colleagues, patients, relatives and their involvement, within the decision-making process, will also be deliberated.
    • Descriptive record of the activity of military critical care transfer teams deployed to London in 20 April to undertake transfer of patients with COVID-19

      James, Robert Hywel; Doyle, C.P.; Cooper, D.J. (2020-12-28)
      In the face of the COVID-19 outbreak, military healthcare teams were deployed to London to assist the London Ambulance Service t transfer ventilated patients between medical facilities. This paper describes the preparation and activity of these military teams, records the lessons identified (LI) and reviews the complications encountered’. The teams each had two members. A consultant or registrar in emergency medicine (EM) and pre-hospitalemergency medicine (PHEM)E or anaesthesia and an emergency nurse or paramedic. Following a period of training, the teams undertook 52 transfers over a 14-day period. LI centred around minimising both interruption to ventilation and risk of aerosolisation of infectious particles and thus the risk of transmission of COVID-19 to the treating clinicians. Three patient-related complications (6% of all transfers) were identified. This was the first occasion on which the Defence Medical Services (DMS) were the main focus of a large-scale clinical military aid to the civil authorities. It demonstrated that DMS personnel have the flexibility to deliver a novel effect and the ability to seamlessly and rapidly integrate with a civilian organisation. It highlighted some clinical lessons that may be useful for future prehospital emergency care taskings where patients may have a transmissible respiratory pathogen. It also showed that clinicians from different backgrounds are able to safely undertake secondary transfer of ventilated patients. This approacmay enhance flexibility in future operational patient care pathways. https://militaryhealth.bmj.com/content/early/2020/12/28/bmjmilitary-2020-001619 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/bmjmilitary-2020-001619
    • Developing and introducing a new triage sieve for UK civilian practice

      Stephenson, John; Andrews, Lewis; Moore, Fionna (2015-04)
    • Development and pilot of clinical performance indicators for English ambulance services

      Siriwardena, Aloysius; Shaw, Deborah; Donohoe, Rachel; Black, Sarah; Stephenson, John; National Ambulance Clinical Audit Steering Group (2010-04-12)
      Introduction There is a compelling need to develop clinical performance indicators for ambulance services in order to move from indicators based primarily on response times and in light of the changing clinical demands on services. We report on progress on the national pilot of clinical performance indicators for English ambulance services. Method Clinical performance indicators were developed in five clinical areas: acute myocardial infarction, cardiac arrest, stroke (including transient ischaemic attack), asthma and hypoglycaemia. These were determined on the basis of common acute conditions presenting to ambulance services and in line with a previously published framework. Indicators were piloted by ambulance services in England and results were presented in tables and graphically using funnel (statistical process control) plots. Results Progress for developing, agreeing and piloting of indicators has been rapid, from initial agreement in May 2007 to completion of the pilot phase by the end of March 2008. The results of benchmarking of indicators are shown. The pilot has informed services in deciding the focus of their improvement programme in 2008–2009 and indicators have been adopted for national performance assessment of standards of prehospital care. Conclusion The pilot will provide the basis for further development of clinical indicators, benchmarking of performance and implementation of specific evidence-based interventions to improve care in areas identified for improvement. A national performance improvement registry will enable evaluation and sharing of effective improvement methods as well as increasing stakeholder and public access to information on the quality of care provided by ambulance services. https://emj.bmj.com/content/27/4/327. 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.2009.072397
    • The Development of Swedish Military Healthcare System: Part II-Re-evaluating the Military and Civilian Healthcare Systems in Crises Through a Dialogue and Study Among Practitioners

      Khorram-Manesh, Amir; Burkle, Frederick M.; Phattharapornjaroen, Phatthranit; Ahmadi Marzaleh, Milad; Al Sultan, Mohammed; Mantysaari, Matti; Carlstrom, Eric; Goniewicz, Krzysztof; Santamaria, Emelia; Comandante, John David; et al. (2020-11-02)
    • Direct to CT – Does conveying FAST positive patients direct to the CT scanner improve a thrombolysis service?

      Bathula, R.; Moynihan, Barry; Simister, R.; Pereira, Anthony C.; Khan, U.; Cloud, Geoffrey; Garcia-Reitboeck, P.; Edwards, S.; Browning, S.; Murphy-Jones, Georgina; et al. (2014-11)
    • Do paediatric early warning score relate to emergency department outcomes for children aged 0–2 years brought in by ambulance?

      Broughton, William (2017-10)
      Background Current ambulance service policy requires paramedics in certain parts of the UK to transport children aged 0–2 years to hospital, regardless of their presenting complaint. A number of Paediatric Early Warning Scores (PEWS) exist to detect deterioration in the hospitalised child. This study aims to evaluate and understand the potential utility of PEWS in an ambulance service setting. Method This study is a retrospective analysis of patient reports over a 12 month period (June 2013–June 2014). PEWS are calculated using ambulance vital signs and compared against the following ED discharge outcomes: admission to hospital, GP referral and discharge home. Data analysis consisted of the variables of sensitivity; specificity; positive and negative predictive values; positive and negative likelihood ratios; and ROC curve for the PEWS values against the three main outcomes. Results From a randomised sample of 300 patient records, 131 were excluded based on the exclusion criteria listed above, leaving 169 complete data sets that were included for analysis. Of the 169 record analysed, 100 (59.2%) were discharged to home, 30 (17.8%) referred to their GP, and 18 (10.7%) were admitted following assessment in the ED. PEWS for admission showed low sensitivity (6.8%–10.12%). PEWS for GP referral also demonstrated low sensitivity (15.53%–18.12%). PEWS for discharge to home showed higher sensitivity and specificity than other outcomes. Discussion Overall, PEWS has some degree of high specificity in all outcome measures, but often with wide confidence intervals. PEWS is weakly sensitive across all outcomes, and this is demonstrated in the AUCs for each outcome measure. As a potential diagnostic test to predict ED outcome, in this study PEWS is shown to perform poorly. Further work is therefore required to determine the utility of PEWS, or other early warning scores, for use in an out-of-hospital setting. https://emj.bmj.com/content/34/10/e3.2 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/emermed-2017-207114.11
    • Does obesity affect defibrillation parameters or outcomes among out-of-hospital cardiac arrest patients presenting in ventricular fibrillation?

      Freese, John P.; Jorgenson, Dawn B.; Liu, Ping-Yu; Innes, Jennifer; Matallana, Luis; Nammi, Krishnakant; Donohoe, Rachael T.; Whitbread, Mark; Silverman, Robert A.; Kaufman, B. J.; et al. (2010-12-01)
    • Does prehospital intubation affect outcomes among cardiac arrest patients presenting in ventricular fibrillation?

      Donohoe, Rachael T.; Liu, Ping-Yu; Jorgenson, Dawn B.; Nammi, Krishnakant; Matallana, Luis; Innes, Jennifer; Whitbread, Mark; Kaufman, B. J.; Prezant, David J.; Silverman, Robert A.; et al. (2010-12-01)
    • Does triage of patients diagnosed by paramedics with ventricular tachycardia directly to arrhythmia centres improve patient care?

      Cooklin, Michael; Sporton, S.; Lovell, M.; Kanagaratnam, P.; Lowe, M.; Markides, V.; Mason, Mark; Whitbread, Mark (2014-10)
    • Does use of the recognition of stroke in the emergency room stroke assessment tool enhance stroke recognition by ambulance clinicians?

      Fothergill, Rachael; Williams, Julia; Edwards, Melanie J.; Russell, Ian T.; Gompertz, Patrick (2013-11)
    • Ecstasy toxicity and the cooling factor

      Archer, Tom (2008-07-25)
      A rapid response unit (RRU) and ambulance were dispatched to a young adult reported to be fitting at the site of a “rave”. On arrival, the patient was being treated by a medical team who were providing cover at the event and the RRU paramedic. The patient was reported to have taken eight ecstasy tablets and had been fitting for approximately 10 min, but this had been terminated with 10 mg diazepam (Diazemuls) given intravenously. He had also been given 800 μg naloxone and 50 ml 0.9% normal saline had also been administered. https://emj.bmj.com/content/25/8/534 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/emj.2007.054783
    • Effect of a centralised transfer service on characteristics of inter-hospital neonatal transfers

      Kempley, S. T.; Baki, Y.; Hayter, G.; Ratnavel, Nandiran; Cavazzoni, E.; Reyes, T. (2007-05)
      To determine the effect of a centralised neonatal transfer service on numbers of neonatal transfers and the time taken for teams to reach the baby. https://fn.bmj.com/content/92/3/F185 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/adc.2006.106047
    • The effect of a heart failure training intervention assessed via clinical simulation

      Edwards, Timothy (2011-08)
      Abstract published with permission. Prehospital differential diagnosis of heart failure (HF) by paramedics is sometimes unreliable (Schaider et al, 1995) and may lead to therapeutic interventions being withheld (Jenkinson et al, 2008) or the initiation of inappropriate and potentially harmful treatment (Wuerz and Meador, 1992). To date, no studies have evaluated the effect of participation in a HF training intervention on diagnostic accuracy among undergraduate UK paramedics assessed through clinical simulation. In this study, 17 paramedics were exposed to three mannequin based scenarios designed to simulate HF, pneumonia and chronic obstructive pulmonary disease (COPD). Participants were given up to 10 minutes to examine each mannequin and scrutinize clinical data before recording a diagnosis. Participant demographics and self reported confidence relating to assessment and management of HF were collected via a questionnaire. Two weeks later, participants attended a 90 minute targeted HF training intervention. Two weeks post training, the paramedics repeated the clinical simulation exercise and questionnaire. Initial diagnostic sensitivity and specificity for HF were higher than that reported in a previous UK clinical study, and improved following participation in a training intervention, although this failed to reach significance (83% vs 100% and 91.67 vs 100%, P>0.05). A significant improvement in self reported confidence relating to use of ECG findings in assessment of HF patients was noted (z=-2.309, P=0.021). In this study, paramedic differential diagnosis of HF assessed through clinical simulation demonstrated a non-significant trend towards improved sensitivity and specificity following participation in a targeted training intervention.
    • The effect of airway management on CPR quality in the PARAMEDIC2 randomised controlled trial

      Deakin, Charles; Nolan, Jerry P.; Ji, Chen; Fothergill, Rachael; Quinn, Tom; Rosser, Andy; Lall, Ranjit; Perkins`, Gavin (2020-11-12)
    • The effects of adrenaline in out of hospital cardiac arrest with shockable and non-shockable rhythms: Findings from the PACA and PARAMEDIC-2 randomised controlled trials

      Perkins, Gavin D.; Kenna, Claire; Ji, Chen; Deakin, Charles D.; Nolan, Jerry P.; Quinn, Tom; Fothergill, Rachael; Gunson, Imogen; Pocock, Helen; Rees, Nigel; et al. (2019-07)
    • Emergency care of older people who fall: a missed opportunity

      Snooks, Helen; Halter, Mary; Close, Jacqueline; Cheung, Wai Yee; Moore, Fionna; Roberts, Stephen E. (2006-12-01)
      A high number of emergency (999) calls are made for older people who fall, with many patients not subsequently conveyed to hospital. Ambulance crews do not generally have protocols or training to leave people at home, and systems for referral are rare. The quality and safety of current practice is explored in this study, in which for the first time, the short-term outcomes of older people left at home by emergency ambulance crews after a fall are described. Results will inform the development of care for this population. https://qualitysafety.bmj.com/content/15/6/390 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 10.1136/qshc.2006.018697