• 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.
    • Can paramedics perform and evaluate a focused echocardiogram during a simulated 10-second pulse check, after a one-day training course?

      Younger, Paul; Richards, Simon; Jarman, Robert (2016-12)
      Abstract published with permission. Aim ‐ To assess whether paramedics can be trained to perform basic echocardiograms in the 10-second pulse check window during a simulated advanced life support (ALS) resuscitation. Introduction ‐ Cardiac arrest survival in the UK varies between 2% and 12%. Management of cardiac arrests concentrates on the detection of reversible causes, which is limited pre-hospitally due to a lack of equipment. Ultrasound machines are now small enough for pre-hospital use and may assist in the detection of some of these causes. There is currently no evidence to suggest the best methodology or required course duration to train paramedics to use ultrasound, or to indicate whether ultrasound simulation could be beneficial. Methods ‐ Ten volunteer paramedics were trained to perform focused echocardiograms using handheld ultrasounds and an ultrasound simulator. The training involved six hours of teaching and practical training, at the end of which the participants were assessed using objective structured clinical examinations (OSCEs) on an ultrasound simulator with three different pathologies which were relevant in cardiac arrest management. Results ‐ Paramedics were able to get a view of the heart during the assessments in 96.7% of the OSCEs, but were only able to accurately recognise the pathologies of the condition in 50%. Overall, the participants demonstrated simulated competence in 46.7% of the OSCEs. Conclusion ‐ Paramedics can be trained to gain a view of the heart using focused echocardiograms after a one-day course, but are not consistently able to determine the cardiac activity or pathology from the echocardiogram.
    • 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.
    • Defining major trauma: a literature review

      Thompson, Lee; Hill, Michael; Shaw, Gary (2019-06-01)
      Introduction: Major trauma in the elderly population has been increasingly reported over the past decade. Compared to younger populations, elderly patients may experience major trauma as a result of low mechanisms of injury (MOIs) and as a result, existing definitions for ‘major trauma’ should be challenged. This literature review provides an overview of previous conceptualisations of defining ‘major trauma’ and considers their utility in relation to the pre-hospital phase of care. Methods: A systematic search strategy was performed using CINAHL, Cochrane Library and Web of Science (MEDLINE). Grey literature and key documents from cited references were also examined. Results: A total of 121 articles were included in the final analysis. Predominantly, retrospective scoring systems, such as the Injury Severity Score (ISS), were used to define major trauma. Pre-hospital variables considered indicative of major trauma included: fatal outcomes, injury type/pattern, deranged physiology and perceived need for treatment sequelae such as intensive care unit (ICU) admission, surgical intervention or the administration of blood products. Within the pre-hospital environment, retrospective scoring systems as a means of identifying major trauma are of limited utility and should not detract from the broader clinical picture. Similarly, although MOI is often a useful consideration, it should be used in conjunction with other factors in identifying major trauma patients. Conclusions: In the pre-hospital environment, retrospective scoring systems are not available and other variables must be considered. Based upon this review, a working definition of major trauma is suggested as: ‘A traumatic event resulting in fatal injury or significant injury with accompanying deranged physiology, regardless of MOI, and/or is predicted to require significant treatment sequelae such as ICU admission, surgical intervention, or the administration of blood products’. Abstract published with permission.
    • How do paramedics learn to intubate?

      McClelland, Graham; Younger, Paul; Haworth, Daniel (2016-05)
      Abstract published with permission. A short cut review was carried out to establish what education and training are required for paramedics to gain initial competence in the skill of endotracheal intubation. Nineteen studies were identified with relevance to the question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated. It is difficult to isolate intubation from the wider subject of airway management and the range of skills and techniques necessary to safely secure the airway in the prehospital setting. The evidence presented suggests that at least 25–35 intubations are necessary, as part of a wider programme of training, to gain initial competence in this skill.
    • 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.
    • A qualitative investigation into paramedics' thoughts about the introduction of the National Early Warning Score

      McClelland, Graham; Haworth, Daniel (2016-05)
      Abstract published with permission. Introduction – The National Early Warning Score is a simple, rapid assessment tool developed by the Royal College of Physicians to standardise the assessment and monitoring of acutely ill patients. The North East Ambulance Service NHS Foundation Trust introduced the National Early Warning Score in 2013/2014 to improve communication between the pre-hospital and hospital setting; however, there was and remains a lack of pre-hospital evidence that supports the value of the National Early Warning Score. A previous study showed that the utilisation of the National Early Warning Score by North East Ambulance Service NHS Foundation Trust paramedics was low. Objective – To investigate what North East Ambulance Service NHS Foundation Trust paramedics think about the National Early Warning Score and its use in practice. Design – Qualitative study using a pragmatic approach with recorded and transcribed semistructured interviews. Framework analysis commenced in parallel with data collection. Participants – A purposive volunteer sample of eight paramedics with a range of roles, locations, educational backgrounds and lengths of service. Results – Three major themes emerged from the data: applying the National Early Warning Score in practice, how the National Early Warning Score was used in decision making and how paramedic practice was subject to external influences. Conclusions – This study gives some insight into how paramedics use the National Early Warning Score in pre-hospital care and how they integrate it into their decision making. The findings also demonstrate the influence that external agencies, primarily the receiving acute hospitals, can have on pre-hospital practice.
    • Regionalised cardiac arrest centres as a means to improve outcomes from out-of-hospital cardiac arrest in the UK: a literature review

      Miles, Steven (2016-12)
      Abstract published with permission. Introduction ‐ Sudden (out-of-hospital) cardiac arrest (OHCA) is recognised as a leading cause of death in the UK; however, survival rates remain significantly lower in the UK than in other developed countries such as Norway and Holland, which have specialised regional cardiac arrest systems and centres. Aims ‐ This review aims to look at the concept and potential benefits of specialised regional cardiac arrest centres, and to consider whether development of such centres, with bypass protocols to enable transportation of OHCA patients directly to these centres, could improve survival rates and patient outcomes in the UK. Methods ‐ Literature was identified through searching MEDLINE, ProQuest Central, CINAHL and PubMed Central databases, as well as relevant national websites, with the search terms ‘cardiac arrest’, ‘regionalised care’ and ‘out-of-hospital cardiac arrest’. Further screening used the inclusion criteria of publication within the previous 10 years (2006‐2016), English language and peer reviewed journals. Exclusion criteria included duplicated articles, articles with a primary focus on in-hospital arrests and focus on causes and prevention of cardiac arrest. Forty-three records resulted and their full texts were considered and reviewed individually to identify those supported by other sources and containing information to add to understanding of the topic Results ‐ A range of evidence is found to support the development of specialised regional cardiac arrest centres, with bypass protocols to enable ambulance staff to transport directly to these centres. Essential facilities for cardiac arrest centres are identified and potential barriers to development of these centres are discussed. Utilisation of paramedics with additional equipment and skills is considered to enable direct admissions to regional cardiac arrest centres to be effective. Conclusions ‐ Cardiac arrest centres, alongside bypass protocols to enable direct admission, could improve patient outcomes and survival rates for OHCA in the UK. For these measures to be effective some barriers to change need to be addressed and paramedics with additional skills and equipment used. Evidence from within the UK itself appears limited. Further research is needed within the UK, involving a multidisciplinary approach, with close working partnership between hospitals and the ambulance service in relation to development of regional cardiac arrest centres.
    • A service evaluation of a dedicated pre-hospital cardiac arrest response unit in the North East of England

      McClelland, Graham; Younger, Paul; Haworth, Daniel; Gospel, Amy; Aitken-Fell, Paul (2016-09)
      Abstract published with permission. Aim ‐ This article describes the introduction of a specialist cardiac arrest response unit by the North East Ambulance Service NHS Foundation Trust, with the aim of improving treatment and outcomes of out-of-hospital cardiac arrest patients, in the North East of England. Methods ‐ This study is a retrospective analysis of prospectively collected data, describing all cases where the cardiac arrest response unit was dispatched in the first 12 months of operation (January 2014 to January 2015). Results ‐ The cardiac arrest response unit was activated 333 times during the first year of operation and attended 164 out-of-hospital cardiac arrest patients. The cardiac arrest response unit demonstrated a significant impact on return of spontaneous circulation sustained to hospital (OR 1.74 (95% CI 1.19‐2.54), p = 0.004) and survival to discharge (OR 2.08 (95% CI 1.12‐3.84), p = 0.017) compared with the rest of the North East Ambulance Service NHS Foundation Trust. Conclusion ‐ The cardiac arrest response unit project demonstrated an improvement in return of spontaneous circulation and survival to discharge compared to current standard care. The specific mechanism, or mechanisms, by which the cardiac arrest response unit influences patient outcomes remain to be determined.
    • A service evaluation of the iTClamp™50 in pre-hospital external haemorrhage control

      Shaw, Gary; Thompson, Lee; Davies, Caroline (2016-09)
      Abstract published with permission. It has long been accepted that uncontrolled haemorrhage is a leading cause of early death in trauma patients, with the majority of deaths occurring in the pre-hospital setting. While most cases of haemorrhage can be dealt with using standard dressings, tourniquets and haemostatic agents, some anatomical areas such as the head, neck, axilla and junctional areas continue to be problematic, as it is challenging to apply tourniquets or trauma pressure dressings to these areas effectively. One device designed to overcome this issue is the iTClamp™50, which was the subject of a service evaluation by the North East Ambulance Service NHS Foundation Trust, from July 2014 to February 2016. Experienced paramedics stationed close to the participating major trauma centre were asked to evaluate the device with a view to obtaining a minimum of 20 cases of iTClamp use to determine its suitability. Paramedic participants were trained by the manufacturer before being provided with two iTClamps. After every application, the evaluating paramedic produced an unstructured reflective account and completed an evaluation questionnaire. Paramedics who used the iTClamp™50 found it enhanced their ability to quickly control external haemorrhage in difficult anatomical areas and could be used as part of a major haemorrhage control strategy. Overall, paramedics felt it was quick and easy to use following a short training session.
    • A survey of paramedic advanced airway practice in the UK

      Younger, Paul; Pilbery, Richard; Lethbridge, Kris (2016-12)
      Abstract published with permission. Introduction ‐ Although there are published studies examining UK paramedic airway management in the out-of-hospital setting, there has been no sizeable survey of practicing UK paramedics that examines their advanced airway management practice, training and confidence. Therefore, the Airway Management Group of the College of Paramedics commissioned a survey to gain an up to date snapshot of advanced airway management practice across the UK among paramedics. Methods ‐ An online questionnaire was created, and a convenience sample of Health and Care Professions Council (HCPC) registered paramedics was invited to participate in the survey. Invitations were made using the College of Paramedics e-mail mailing list, the College website, as well as social media services such as Twitter and Facebook. The survey ran online for 28 days from 21 October to 18 November 2014 to allow as many paramedics to participate as possible. The survey questions considered a range of topics including which supraglottic airway devices are most commonly available in practice and whether or not tracheal intubation also formed a part of individual skillsets. In relation to intubation, respondents were asked a range of questions including which education programmes had been used for original skill acquisition, how skills were maintained, what techniques and equipment were available for intubation attempts, individual practitioner confidence in intubation and how intubation attempts were documented. Results ‐ A total of 1658 responses to the survey were received. Following data cleansing, 152 respondents were removed from the survey, leaving a total of 1506. This represented 7.3% of paramedics registered with the HCPC (20,565) at the time the survey was conducted. The majority of respondents were employed within NHS ambulance services. Summary ‐ This is the largest survey of UK paramedics conducted to date, in relation to advanced airway management. It provides an overview of advanced airway management, with a particular focus on intubation, being conducted by UK paramedics.
    • A survey of UK paramedics' views about their stroke training, current practice and the identification of stroke mimics

      McClelland, Graham; Flynn, Darren; Rodgers, Helen; Price, Christopher (2017-06)
      Abstract published with permission. Aims ‐ Paramedics play a crucial role in identifying patients with suspected stroke and transporting them to appropriate acute care. Between 25% and 50% of suspected stroke patients are later diagnosed with a condition other than stroke known as a ‘stroke mimic’. If stroke mimics could be identified in the pre-hospital setting, unnecessary admissions to stroke units could potentially be avoided. This survey describes UK paramedics’ stroke training and practice, their knowledge about stroke mimic conditions and their thoughts about pre-hospital identification of these patients. Methods ‐ An online survey invitation was circulated to members within the UK College of Paramedics and promoted through social media (8 September 2016 and 23 October 2016). Topics included: stroke training; assessment of patients with suspected stroke; local practice; and knowledge about and identification of stroke mimics. Results ‐ There were 271 responses. Blank responses (39) and non-paramedic (1) responses were removed, leaving 231 responses from paramedics which equates to 2% of College of Paramedics membership and 1% of Health and Care Professions Council registered paramedics. The majority of respondents (78%) thought that they would benefit from more training on pre-hospital stroke care. Narrative comments focused on a desire to improve the assessment of suspected stroke patients and increase respondents’ knowledge about atypical stroke presentations and current stroke research. The Face Arm Speech Test was used by 97% of respondents to assess suspected stroke patients, although other tools such as Recognition of Stroke in the Emergency Room (17%) and Miami Emergency Neurological Deficit (11%) were also used. According to those responding, 50% of stroke patients were taken to emergency departments, 35% went straight to a stroke ward and 8% were taken directly to CT scan. Most respondents (65%) were aware of the term ‘stroke mimic’. Two-thirds of respondents (65%) thought a tool that predicted the likelihood of a suspected stroke being a stroke mimic would be useful in pre-hospital care. Conclusion ‐ This study reports a survey of UK paramedics’ views about the stroke care they provide. Conclusions are limited by the low number of responses. Assessment of suspected stroke patients was recognised as an important skill by paramedics and an area where many would like further training. Respondents’ current practice varied in terms of the stroke assessment tools used and whether suspected stroke patients were taken to the emergency department or direct to a stroke ward. A stroke mimic identification tool would be useful if it allowed stroke mimic patients to be directed to appropriate care, but it would need to have a high level of specificity and not adversely impact on time to treatment for true stroke patients.