Recent Submissions

  • Improving systems for research management and governance

    McLure, Sally; Dorgan, Sharon; Smith, Justine (2010-02)
    The North East Ambulance Service NHS Trust (NEAS) is committed to the implementation of a number of nationally proposed initiatives following the introduction of the research strategy Best Research for Best Health (Department of Health, 2006). The ambitious strategy introduces several measures to improve the research environment and ensure that studies commence more efficiently. This article provides an overview of the national initiatives, i.e. the Research Passport Scheme and the National Institute for Health Research Coordinated System for gaining NHS Permissions. These initiatives aim to strengthen and streamline research management and governance across England, which NEAS are actively embracing. Abstract published with permission.
  • A scoping review of pre-hospital technology to assist ambulance personnel with patient diagnosis or stratification during the emergency assessment of suspected stroke

    Lumley, H.A.; Flynn, Darren; Shaw, L.; McClelland, Graham; Ford, Gary A.; White, P.M.; Price, Christopher I. (2020-04-26)
  • Call to hospital times for suspected stroke patients in the North East of England: a service evaluation

    Haworth, Daniel; McClelland, Graham (2019-09-01)
    Introduction: Stroke is a leading cause of mortality and morbidity. The role of the ambulance service in acute stroke care focuses on recognition followed by rapid transport to specialist care. The treatment options for acute ischaemic strokes are time dependent, so minimising the prehospital phase of care is important. The aim of this service evaluation was to report historical pre-hospital times for suspected stroke patients transported by the North East Ambulance Service NHS Foundation Trust (NEAS) and identify areas for improvement. Methods: This was a retrospective service evaluation using routinely collected data. Data on overall call to hospital times, call to arrival times, on scene times and leave scene to hospital are reported. Results: Data on 24,070 patients with an impression of stroke transported by NEAS between 1 April 2011 and 31 May 2018 are reported. The median call to hospital time increased from 41 to 68 minutes, call to arrival from 7 to 17 minutes, on scene from 20 to 30 minutes and leave to hospital from 12 to 15 minutes. Conclusion: The pre-hospital call to hospital time for stroke patients increased between 2011 and 2018. The call to arrival phase saw a sharp increase between 2015 and 2017, whereas on scene and leave scene to hospital saw steadier increases. Increasing demand on the ambulance service, reorganisation of regional stroke services and other factors may have contributed to the increase in times. Reducing the on scene phase of pre-hospital stroke care would lead to patient benefits and is the area where ambulance clinicians have the most influence. Abstract published with permission.
  • Paramedic experiences of using an enhanced stroke assessment during a cluster randomised trial: a qualitative thematic analysis

    Lally, Joanne; Vaittinen, Anu; McClelland, Graham; Price, Christopher I.; Shaw, Lisa; Ford, Gary A.; Flynn, Darren; Exley, Catherine (2020-06-16)
    Intravenous thrombolysis is a key element of emergency treatment for acute ischaemic stroke, but hospital service delivery is variable. The Paramedic Acute Stroke Treatment Assessment (PASTA) multicentre cluster randomised controlled trial evaluated whether an enhanced paramedic-initiated stroke assessment pathway could improve thrombolysis volume. This paper reports the findings of a parallel process evaluation which explored intervention paramedics' experience of delivering the enhanced assessment. https://emj.bmj.com/content/37/8/480. 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/
  • Positive Predictive Value of Stroke Identification by Ambulance Clinicians in North East England: A Service Evaluation

    McClelland, Graham; Flynn, Darren; Rodgers, Helen; Price, Christopher (2020-05-08)
    Introduction/background Accurate prehospital identification of patients who had an acute stroke enables rapid conveyance to specialist units for time-dependent treatments such as thrombolysis and thrombectomy. Misidentification leads to patients who had a ‘stroke mimic’ (SM) being inappropriately triaged to specialist units. We evaluated the positive predictive value (PPV) of prehospital stroke identification by ambulance clinicians in the North East of England. Methods This service evaluation linked routinely collected records from a UK regional ambulance service identifying adults with any clinical impression of suspected stroke to diagnostic data from four National Health Service hospital trusts between 1 June 2013 and 31 May 2016. The reference standard for a confirmed stroke diagnosis was inclusion in Sentinel Stroke National Audit Programme data or a hospital diagnosis of stroke or transient ischaemic attack in Hospital Episode Statistics. PPV was calculated as a measure of diagnostic accuracy. Results Ambulance clinicians in North East England identified 5645 patients who had a suspected stroke (mean age 73.2 years, 48% male). At least one Face Arm Speech Test (FAST) symptom was documented for 93% of patients who had a suspected stroke but a positive FAST was only documented for 51%. Stroke, or transient ischaemic attack, was the final diagnosis for 3483 (62%) patients. SM (false positives) accounted for 38% of suspected strokes identified by ambulance clinicians and included a wide range of non-stroke diagnoses including infections, seizures and migraine. Discussion In this large multisite data set, identification of patients who had a stroke by ambulance clinicians had a PPV rate of 62% (95% CI 61 to 63). Most patients who had a suspected stroke had at least one FAST symptom, but failure to document a complete test was common. Training for stroke identification and SM rates need to be considered when planning service provision and capacity. http://dx.doi.org/10.1136/emermed-2019-208902. 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/
  • Positive predictive value of stroke identification by ambulance clinicians in North East England: a service evaluation

    McClelland, Graham; Flynn, Darren; Rodgers, Helen; Price, Christopher (2020-05-08)
    Accurate prehospital identification of patients who had an acute stroke enables rapid conveyance to specialist units for time-dependent treatments such as thrombolysis and thrombectomy. Misidentification leads to patients who had a ‘stroke mimic’ (SM) being inappropriately triaged to specialist units. We evaluated the positive predictive value (PPV) of prehospital stroke identification by ambulance clinicians in the North East of England. https://emj.bmj.com/content/37/8/474. 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/ https://https://emj.bmj.com/content/37/8/474
  • Views of ambulance paramedics on involvement in stroke research

    Mackintosh, J. E.; Burges Watson, D.; Cessford, C.; Ford, Gary A.; Murtagh, M. J.; Price, C. (2009-12-01)
  • National research guidance and support for Trusts

    McLure, Sally; McColl, Elaine; Mason, James (2009-12-18)
    The Research Design Service (RDS) is one of the key components of the National Institute for Health Research (NIHR) which aims to position, manage and maintain world-class research in the National Health Service (NHS). Formed in 2008 as a component of the Department of Health's Research and Development (R&D) Strategy, Best Research for Best Health (Department of Health, 2006), the NIHR RDS is a major new initiative in which the NIHR will be investing around £50 million over 5 years. This article provides an overview of the RDS and highlights some of the major developments and consequential opportunities for Ambulance Trusts in England. Abstract published with permission.
  • People in rubber suits and how to treat them: decompression injuries in divers

    McClelland, Graham (2013-09-29)
    The majority of our planet is covered in water and millions of people around the world enjoy exploring what lies beneath the surface of our seas and lakes. Diving is a popular activity, with a long history, that allows people to visit—for pleasure or for business—a different world. Diving is a sport with inherent risks. The hazards and potential for injuries, ranging from the minor to the life-threatening, are an unavoidable part of the activity. The factors involved in diving injuries and the signs and symptoms divers may present with, are many and varied. Decompression injuries are one of the potential injuries that will respond to appropriate treatment and may have the longest lasting effects. Confident treatment of decompression injuries is made easier by understanding the physics involved in breathing gases underwater. The definitive treatment involves recompression that should be provided at a specialist hyperbaric facility. Abstract published with permission.
  • Intravenous versus oral paracetamol in a UK ambulance service: a case control study

    Charlton, Karl; Limmer, Matthew; Moore, Hayley (2020-06-01)
    Abstract published with permission Objectives: To determine the effectiveness of intravenous versus oral paracetamol (acetaminophen) in the management of acute pain in the out-of-hospital setting. Methods: We extracted ambulance electronic patient care records for all patients who received 1 g intravenous paracetamol throughout January 2019, and case matched these by sex and age with consecutive patients who received 1 g oral paracetamol over the same time period. Eligible for inclusion were all patients aged ≥ 18 who received 1 g paracetamol for acute pain and who were transported to the emergency department (ED). The primary outcome was the mean reduction in pain score using the numeric rating scale (NRS), with a reduction of 2 or more accepted as clinically significant. Results: 80 care records were eligible for analysis; 40 patients received intravenous and 40 patients received oral paracetamol. The mean age of both groups was 54 years (± 3 years) and 67.5% (n = 54) were female. Patients receiving intravenous paracetamol had a clinically significant mean (SD) improved pain score compared to those receiving oral paracetamol, 2.02 (1.64) versus 0.75 (1.76), respectively [p = 0.0013]. 13/40 (32.5%) patients who received intravenous paracetamol saw an improved pain score of ≥ 2 compared to 8/40 (20%) who received oral paracetamol. No patients received additional analgesia or reported any adverse symptoms. Abdominal pain, infection and trauma were the most common causes of pain in both groups. Conclusion: Our study suggests that intravenous paracetamol is more effective than oral paracetamol when managing acute pain in the out-of-hospital setting. Our findings support further investigation of the role of paracetamol in paramedic practice using more robust methods.
  • Improving pressure ulcer risk identification: a pilot project by ambulance staff

    Mains, Jacqueline; Graham, Yitka; Hayes, Catherine (2020-03-10)
    Background: A quality improvement initiative was designed to identify patients at risk of compromised tissue viability before they were admitted to hospital. Paramedics were educated to better identify patients with pressure ulcers or pressure damage, or those at risk of compromised tissue viability, and these patients were fitted with a pressure ulcer alert bracelet so that emergency department staff could identify them. Aims: The aims of the current initiative were to educate paramedics to better identify patients with pressure ulcers or those at risk of compromised tissue viability to emergency department staff, and fit them with a pressure ulcer alert bracelet to highlight them to emergency department staff so they would receive prompt intervention. Methods: A plan, do, study, act improvement methodology was used, and data from a 3-month period were retrospectively analysed. Patients identified as being at risk of compromised tissue viability were flagged as requiring assessment via a pressure ulcer risk assessment tool to enable prevention. Results: Paramedics identified 130 at-risk patients (aged 23–100 years), and data from 127 patients were analysed. Most at-risk patients fitted with pressure ulcer alert bracelets were aged 70 years or over, and there was an even female/male division. More than half (53%) of patients were found to have a pressure ulcer and alerted to emergency department staff. More than one in four (27%) patients who were identified as being at risk of pressure ulcers lived in nursing or residential homes, and 43% lived alone or in warden-controlled accommodation. Conclusions: Paramedics effectively identified potential risk factors for pressure ulcer development, indicating a need for immediate intervention. This study gives insight into how pressure ulcer risk assessment using an alert bracelet may be used in paramedic practice in emergency department handovers. Success depends on hospital staff acting upon paramedic recommendation. Abstract published with permission.
  • Incidence of peri-opiate nausea and vomiting in the pre-hospital setting: an intermediate analysis

    Campbell, Gareth; Woollard, Malcolm; McLure, Sally; Duckett, Jay; Newcombe, Robert; Clarke, Tom (2011-03)
    Background Intravenous morphine is the preferred drug for the treatment of moderate to severe pain by paramedics. Nausea and vomiting are believed to be frequent side-effects and routine co-administration of metoclopramide is common. In the absence of pre-hospital data to support this practice, we sought to determine the incidence of peri-opiate nausea and vomiting in an ambulance service which does not administer anti-emetics. Methods This prospective observational study is currently assessing the incidence of emesis in 400 patients attended by the North East Ambulance Service, aged above 17 years and receiving morphine, using a patient-scored Nausea and Vomiting Score (NVS: 0=no nausea or vomiting, 1=slight nausea, 2=moderate nausea, 3=severe nausea, 4=vomited once, 5=vomited twice or more). Results To date 145 patients have been recruited. Median NVS before morphine was 0 (range 0 to 6, inter-quartile range (IQR) 0 to 1): 54/141 (38%) of patients had some degree of nausea or vomiting. Median NVS on hospital arrival (after morphine) was 0 (range of 0 to 6, IQR 0 to 1): 54/130 (42%) patients had some degree of nausea or vomiting. The differences pre- vs. post-morphine in median NVS (p=0.98) and proportion of patients suffering nausea and vomiting are not statistically significant (p=0.98 and p=0.54 respectively). There were no significant correlations between pre-morphine pain score and pre-morphine NVS; post-morphine pain score and post-morphine NVS; pre-morphine NVS and total morphine dose; and post-morphine NVS and total morphine dose (Spearman's rank correlation 0.09, p=0.274; 0.07, p=0.44; 0.10, p=0.25; and 0.10, p=0.24 respectively). Conclusion and recommendations To date this study has found no evidence that pre-hospital administration of morphine is associated with an increased incidence or severity of nausea and vomiting and therefore does not appear to support the routine co-administration of metoclopramide. https://emj.bmj.com/content/emermed/28/3/237.2.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/emj.2010.108597.2
  • A review of the pre-ROSC intranasal cooling effectiveness study

    Glencorse, Mark; Glencorse, Sandra (2011-06)
    Abstract published with permission. With the publication of the 2010 European Resuscitation Council Guidelines, therapeutic hypothermia has been recommended as part of the treatment algorhythm for the management of adult cardiac arrest. As ambulance services around the world struggle to decide on the best method of cooling a patient at the time of the return of spontaneous circulation (ROSC), the ground-breaking ‘PRINCE’ study has been published describing the novel approach of ‘trans-nasal’ evaporative cooling during the peri-arrest period. This study describes a significant difference found on arrival at hospital between the mean tympanic temperatures of the two groups (cooled vs control) following a period of cooling (34.2 °C [SD 1.5 °C] vs 35.5 °C [SD 0.9 °C], P<0.001). In addition, when looking at survival to discharge following out-of-hospital (OOH) cardiac arrest, there was a statistically significant difference in a subgroup of patients where CPR was commenced within 10 minutes of cardiac arrest (56.5% of trans-nasally cooled patients survived to discharge compared with 29.4% of control patients (P=0.04, relative risk =1.9)). This article examines the PRINCE study and considers the implication of this method of inducing therapeutic hypothermia in the out-of-hospital cardiac arrest patient within the UK.
  • Smallpox and the origins of vaccination

    McClelland, Graham (2011-05)
    Abstract published with permission. Smallpox is a highly infectious virus with a high mortality rate. Until the 19th century, smallpox epidemics regularly swept the UK. In some areas of the world, smallpox epidemics continued well into the 20th century. Smallpox has now been eradicated by an international effort led by the World Health Organisation (WHO). The eradication of smallpox was achieved by vaccination, and the history of vaccination is closely linked to the treatment of this disease. Despite being eradicated in the natural environment, there are still stocks of smallpox kept by two governments which are the cause of ongoing debate. Today, biological weapons are considered part of the threat posed by terrorist organizations and a deliberate smallpox release is a conceivable scenario. This article will describe smallpox, its connection with vaccination and why knowledge of diseases such as smallpox can be valuable to paramedics.
  • Lactate measurement in pre-hospital care: a review of the literature

    McClelland, Graham; Younger, Paul; Byers, Sonia (2012-06)
    Abstract published with permission. Background: Lactate has been identified as a useful marker of shock. Lactate can be measured in the pre-hospital environment rapidly and accurately. Method: A comprehensive literature search was conducted using a targeted search strategy. Additional literature was located through reference list searching and prior awareness by the authors. This identified a number of papers which were appraised for relevance. This appraisal identified 29 papers which were included in the review. Conclusion: Lactate has been shown to be measurable in the pre-hospital environment and to be prognostic of mortality. Lactate measurement needs to be linked to specific treatment algorithms with improved outcomes for patients in order to justify inclusion in pre-hospital practice.
  • Paramedic Initiated Lisinopril For Acute Stroke Treatment (PIL-FAST): study protocol for a pilot randomised controlled trial

    Shaw, Lisa; Price, Christopher I.M.; McLure, Sally; Howel, Denise; McColl, Elaine; Ford, Gary A. (2011-06)
  • Trauma systems: the anticipated impact of trauma divert in the North East

    Moy, R.; Denning, J.; Han, Kyee (2011-11)
    Introduction The advent of the new Trauma Network system will drive significant changes in the transport of trauma patients. We aimed to find out what the impact of the new trauma network would be on the two prospective trauma centres in the Northern region, in terms of increased workload. This could allow the centres to gain additional resources to provide care for these patients. Methods We conducted a retrospective audit of all trauma patients conveyed by North East Ambulance service during the month of October 2009. These patients were then assessed by the London Ambulance Service Trauma Divert Criteria. Any patients who would have bypassed their local hospital, and been taken to the nearest trauma centre were identified. Also identified were any patients at risk of airway compromise, who would have been transported to the nearest ED for stabilisation and secondary transfer. Patients transported by air ambulance were excluded, as they are already taken to the Trauma Centres. Results 3500 patients were identified during the initial search. Of these, 70 met the criteria for bypass, although 16 were transported to trauma centres as the nearest hospitals. 54 were transported to their nearest hospital, although under the criteria used, would have been taken to a trauma centre. 8 met the criteria for transfer to the nearest hospital, for airway protection. Based on geography of receiving hospital, we estimate that an additional 17 patients would have gone to James Cook University Hospital, and 29 to Newcastle General Hospital. Conclusion We conclude that introduction of the bypass guidelines would lead to an additional 46 patients being taken to a trauma centre in that month. This suggests that specific arrangements may need to be made to deal with the extra workload, and further investment may be required. https://emj.bmj.com/content/emermed/28/11/e2.15.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-2011-200645.8
  • The clinical characteristics of false negative stroke patients: a systematic review

    Jones, S.; Price, C.; McClelland, Graham; Gibson, J.; Watkins, C. (2019-05-22)

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