• Bypassing nearest hospital for more distant neuroscience care in head-injured adults with suspected traumatic brain injury: findings of the head injury transportation straight to neurosurgery (HITS-NS) pilot cluster randomised trial

      Lecky, Fiona E.; Russell, Wanda; McClelland, Graham; Pennington, Elspeth; Fuller, Gordon W.; Goodacre, Steve; Han, Kyee; Curran, Andrew; Holliman, Damian; Chapman, Nathan; et al. (2017-10)
      Objective Reconfiguration of trauma services, with direct transport of patients with traumatic brain injury (TBI) to specialist neuroscience centres (SNCs)— bypassing non-specialist acute hospitals (NSAHs), could improve outcomes. However, delays in stabilisation of airway, breathing and circulation (ABC) may worsen outcomes when compared with selective secondary transfer from nearest NSAH to SNC. We conducted a pilot cluster randomised controlled trial to determine the feasibility and plausibility of bypassing suspected patients with TBI —directly into SNCs—producing a measurable effect. Setting Two English Ambulance Services. Participants 74 clusters (ambulance stations) were randomised within pairs after matching for important characteristics. Clusters enrolled head-injured adults— injured nearest to an NSAH—with internationally accepted TBI risk factors and stable ABC. We excluded participants attended by Helicopter Emergency Medical Services or who were injured more than 1 hour by road from nearest SNC. Interventions Intervention cluster participants were transported directly to an SNC bypassing nearest NSAH; control cluster participants were transported to nearest NSAH with selective secondary transfer to SNC. Outcomes Trial recruitment rate (target n=700 per annum) and percentage with TBI on CT scan (target 80%) were the primary feasibility outcomes. 30-day mortality, 6-month Extended Glasgow Outcome Scale and quality of life were secondary outcomes. Results 56 ambulance station clusters recruited 293 patients in 12 months. The trial arms were similar in terms of age, conscious level and injury severity. Less than 25% of recruited patients had TBI on CT (n=70) with 7% (n=20) requiring neurosurgery. Complete case analysis showed similar 30-day mortality in the two trial arms (control=8.8 (2.7–14.0)% vs intervention=9.4(2.3–14.0)%). Conclusion Bypassing patients with suspected TBI to SNCs gives an overtriage (false positive) ratio of 13:1 for neurosurgical intervention and 4:1 for TBI. A measurable effect from a full trial of early neuroscience care following bypass is therefore unlikely https://bmjopen.bmj.com/content/bmjopen/7/10/e016355.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-2017-016355
    • The challenges of conducting prehospital research: successes and lessons learnt from the Head Injury Transportation Straight to Neurosurgery (HITS-NS) trial

      McClelland, Graham; Pennington, Elspeth; Byers, Sonia; Russell, Wanda; Lecky, Fiona (2015-08)
      Head Injury Transportation Straight to Neurosurgery was a cluster randomised trial studying suspected severe head injury treatment pathways conducted in the North East Ambulance Service NHS Foundation Trust and North West Ambulance Service NHS Trust between January 2012 and March 2013. This was the world's first large scale trial of any trauma bypass and was conducted as a feasibility study. This short report will describe some of the lessons learnt during this ground breaking and complex trial. https://emj.bmj.com/content/32/8/663.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/emermed-2014-203870
    • Comparison of manual and mechanical cardiopulmonary resuscitation on the move using a manikin: a service evaluation

      Blair, Laura; Kendal, Simon Peter; Shaw, Gary; Byers, Sonia; Dew, Rosie; Norton, Michael; Wilkes, Scott; Wright, John (2017-12)
      Abstract published with permission. Aim: The aim of this study was to assess the effect that transporting a patient has on the quality of cardiopulmonary resuscitation (CPR) provided during pre-hospital resuscitation. Utilising the 2010 European Resuscitation Council (ERC) guidelines as a framework, one- and two-person manual CPR (SCPR) and mechanical CPR (MCPR) were directly compared in a simulated pre-hospital transport setting. Methods: Ten practising paramedics each volunteered to participate in four pre-hospital CPR scenarios. The MCPR device used for this study was the LUCASTM2. Data were captured electronically using QCPRTM wireless technology (Resusci Anne® Wireless SkillReporterTM manikin and software by Laerdal Medical©). Results: A reduction in the rate, depth and percentage of correct compressions was noted when the paramedics were moving the patient. In relation to the 2010 ERC guidelines, the SCPR did not meet current guidelines and was of more variable quality than MCPR. MCPR was consistent and conformed to the guidelines. However, the application of the LUCASTM2 when only one paramedic was present resulted in a significant delay in commencing chest compressions. Conclusion: In the pre-hospital setting, transporting a patient during a cardiac arrest can have a deleterious effect on the quality of chest compressions being provided. When provided by a mechanical device rather than manually, the quality of chest compressions produced is closer to that currently recommended, but two persons would be required for timely deployment of the device and to maximise the chest compression fraction. This could suggest a potential use for pre-hospital MCPR even in the absence of recommendation for routine use.
    • A comparison of manual and mechanical cardiopulmonary resuscitation on the move using a manikin: single-person and two-person emergency medical service crews

      Blair, Laura; Kendal, Simon P.; Shaw, Gary; Byers, Sonia; Wright, John (2016-09)
      Background Delivery of good quality cardiopulmonary resuscitation (CPR) is essential for survival from cardiac arrest but manual CPR has its limitations, especially in the pre-hospital environment and situations which demand transportation. Our aim was to examine the effect that transporting a patient during Advanced Life Support (ALS) has on the quality of CPR being provided. In the same simulated pre-hospital scenario we directly compared manual (standard) CPR (SCPR) and mechanical CPR (MCPR), as well as comparing both against the 2010 European Resuscitation Council guidelines. The quality of CPR provided by one and two person crews was also compared. Methods Ten experienced paramedics volunteered to take part in four pre-hospital observational manikin CPR scenarios each. The mechanical CPR device chosen was the LUCASTM2. Data were captured electronically using QCPRTM with the core values being minute-by-minute mean compression rate and depth, as well as variations within, hands off ratios and the average time to CPR commencement. Results A marked reduction in the rate, depth and percentage of correct compressions was noted when the paramedics started to move the patient. When compared against the 2010 ERC guidelines, SCPR was more variable than MCPR and not delivered in a way that conforms to the guidelines. MCPR was consistent and conformed to the guidelines. There was significant time required for a single paramedic to start CPR with a mechanical device. Conclusion In the pre-hospital setting having to transport a patient during ALS can have a negative impact on the quality of CPR being provided. The quality of CPR is closer to that currently recommended when provided by a mechanical device rather than manually, but two persons would be required for rapid deployment of the device. This could suggest a potential role for pre-hospital MCPR even in the absence of recommendation for routine use. https://emj.bmj.com/content/emermed/33/9/e9.2.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-2016-206139.30
    • Development of research governance awareness to support pre-hospital studies

      Lawrence, Janet; Byers, Sonia; McClelland, Graham; Price, Christopher (2016-03)
      Abstract published with permission. Background: Development of new evidence to support pre-hospital emergency care benefits both patients and practitioners. Clinical research must be conducted within a formal governance framework but it is challenging for paramedics to access traditional good clinical practice (GCP) training due to high service demands and some content is of little relevance to the prehospital setting. Objective: To establish the content and format of easily accessible research governance awareness training for use by paramedics and other members of the ambulance service as and when appropriate. Methods: A systematic literature review identified descriptions of pre-hospital research training. An online survey sought views about the formal research training undertaken by NHS paramedics and an expert consensus process confirmed the content of training materials. Results: Research governance training was rarely acknowledged in pre-hospital clinical trial literature and was recalled by only one in eight respondents who had assisted with clinical research. A pre-hospital orientated slide set and matching assessment questions were reviewed in two cycles by an expert panel to achieve a consensus on the content and format. Conclusions: Through a structured process of literature review, stakeholder engagement and expert consensus we have developed training and assessment materials which can be used flexibly to prepare paramedics and the wider ambulance workforce for safe hosting of low-risk research activities.
    • The head injury transportation straight to neurosurgery (HITS-NS) randomised trial: a feasibility study

      Lecky, Fiona; Russell, Wanda; Fuller, Gordon W.; McClelland, Graham; Pennington, Elspeth; Goodacre, Steve; Han, Kyee; Curran, Andrew; Holliman, Damian; Freeman, Jennifer; et al. (2016-01)
    • 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.
    • Mapping midwifery and obstetric units in England

      Walsh, Denis; Spiby, Helen; Grigg, Celia P.; Dodwell, Miranda; McCourt, Christine; Culley, Lorraine; Bishop, Simon; Wilkinson, Jane; Coleby, Dawn; Pacanowski, Lynne; et al. (2018-01)
    • Post-admission outcomes of participants in the PARAMEDIC trial: a cluster randomised trial of mechanical or manual chest compressions

      Ji, Chen; Lall, Ranjit; Quinn, Tom; Kaye, Charlotte; Haywood, K.; Horton, Jessica; Gordon, V.; Deakin, Charles D.; Pocock, Helen; Carson, Andrew; et al. (2017-09)