• Ambulance documentation of stroke symptoms during the UK COVID-19 ‘Stay at Home’ message

      McClelland, Graham; Wilson, Nina; Shaw, Lisa; Grayling, Michael; Haworth, Daniel; Price, Christopher (2020-11-16)
      On 23 March 2020 the UK government urged the public to ‘Stay Home, Protect the NHS, Save Lives’ in order to reduce consequences from the COVID-19 pandemic.1 Three large National Health Service (NHS) stroke units subsequently reported a 16% (95% CI 27.2 to 3.2) decrease in the weekly trend for stroke admissions during March–April compared with January–February 2020. https://emj.bmj.com/content/early/2020/11/16/emermed-2020-210319 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/emermed-2020-210319
    • 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
    • A comparison of actual versus predicted emergency ambulance journey times using generic Geographic Information System software

      McMeekin, Peter; Gray, Joanne; Ford, Gary A; Duckett, Jay; Price, Christopher (2014-09)
      Study objective The planning of regional emergency medical services is aided by accurate prediction of urgent ambulance journey times, but it is unclear whether it is appropriate to use Geographical Information System (GIS) products designed for general traffic. We examined the accuracy of a commercially available generic GIS package when predicting emergency ambulance journey times under different population and temporal conditions. Methods We undertook a retrospective cohort study of emergency ambulance admissions to three emergency departments (ED) serving differing population distributions in northeast England (urban/suburban/rural). The transport time from scene to ED for all the highest priority dispatches between 1 October 2009 and 30 September 2010 was compared with predictions made by generic GIS software. Results For 10 156 emergency ambulance journeys, the mean prediction discrepancy between actual and predicted journey times across all EDs was an underprediction of 1.6 min (SD 4.9). Underprediction was statistically significant at all population densities, but unlikely to be of clinical significance. Ambulances in urban areas were able to exceed general traffic speed, whereas, the opposite effect was seen in suburban and rural road networks. There were minor effects due to travel outside the busiest traffic times (mean overprediction 0.8 min) and during winter months (mean underprediction 0.4 min). Conclusions It is reasonable to estimate emergency ambulance journey times using generic GIS software, but in order to avoid insufficient regional ambulance provision it would be necessary to make small adjustments because of the tendency towards systematic underprediction. https://emj.bmj.com/content/emermed/31/9/758.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-2012-202246
    • 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
    • The costs of falls in the community to the North East Ambulance Service

      Newton, Julia L.; Kyle, P.; Liversidge, P.; Robinson, G.; Wilton, K.; Reeve, P. (2006-05-19)
      This study set out to quantify the immediate costs to the North East Ambulance Service (NEAS) of attending to fallers. https://emj.bmj.com/content/23/6/479 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/emj.2005.028803
    • Development and impact of a dedicated cardiac arrest response unit in a UK regional ambulance service

      Younger, Paul; McClelland, Graham; Fell, Paul (2015-05-19)
      Background Survival rates from out-of-hospital cardiac arrest (OHCA) vary, with figures from 2% to 12% reported nationally. Our ambulance service introduced a dedicated cardiac arrest response unit (CARU) as a trial in order to improve local patient outcomes by focussing training, extending the scope of practice and increasing exposure to cardiac arrests. CARU launched in January 2014 using a rapid response car staffed by senior paramedics responding to cardiac arrests within a 19 minute radius of their location⇓. VIEW INLINE VIEW POPUP Methods This work describes the development and impact of CARU during the initial six months (10/01/14 to 09/07/2014) of operations using prospectively collected data on all cases attended. Results CARU activated to 165 calls and attended 65% (n=107). 50% (n=54) of the cases attended were cardiac arrests where resuscitation was attempted. Return of Spontaneous Circulation (ROSC) was achieved during pre-hospital resuscitation in 52% (n=28) of cases. Patient outcomes are reported compared with service data for January to June 2014 inclusive and one year of historical data from the regional OHCA registry: Conclusions Based on these figures CARU appears to have a positive impact on ROSC and a significant impact on survival to discharge rates compared with the rest of the service (p<0.01, Fisher's exact test). Further work is needed to explore how CARU delivers this impact and how the CARU model can be implemented beyond the trial setting in a sustainable fashion. https://emj.bmj.com/content/32/6/503.2. 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/ DOI http://dx.doi.org/10.1136/emermed-2015-204979.2
    • Development of a prehospital assessment to identify stroke mimic conditions

      McClelland, Graham; Rodgers, Helen; Flynn, Darren; Price, Christopher (2017-10)
      Background Despite routine use of pre-hospital identification instruments, approximately 30% of suspected stroke admissions are stroke mimics (SM). Early identification may allow “false positive” SM patients to be directed to appropriate care and improve healthcare resource utilisation. Methods A retrospective database of ambulance records containing a paramedic impression of stroke was linked to hospital specialist diagnosis data from 01/06/13 to 31/05/16. Logistic regression identified clinical features predictive of SM. An assessment score was constructed prioritising specificity over sensitivity. Results 1650 patients (mean age 75.3, 47% male, 40% SM) were included. 1520 (92%) were Face Arm Speech Test (FAST) positive. Table 1 describes the characteristics in the SM assessment. Each characteristic scores 1 point if present. Table 1 Stroke mimic characteristics 86% (66/77) of suspected stroke patients scoring 1 were SM. 100% (6/6) of patients scoring >1 characteristic were SM. A score ≥1 identified SM with 11% (95% CI, 8–13) sensitivity, 99% (95% CI, 98–99) specificity, positive predictive value of 87% (95% CI, 79–94), negative predictive value of 62% (95% CI, 60–64) and a diagnostic odds ratio of 11 (95% CI, 6–20, p<0.0001). Conclusions Amongst ambulance patients with suspected stroke, a small number of SM can be identified with a high degree of certainty. This simple tool needs further validation, prospective testing in the pre-hospital environment with characteristics systematically recorded and consideration of potential clinical impact. https://emj.bmj.com/content/34/10/e5.1 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-2017-207114.14
    • Identifying pre-hospital factors which influence outcome for major trauma patients in a regional Trauma Network: an exploratory study

      Thompson, Lee; Hill, Michael; Davies, Caroline; Shaw, Gary (2016-09)
      Background Major trauma is often life threatening or life changing and is the leading cause of death in the United Kingdom for adults aged≤45 years. The aim of this exploratory study was to identify pre-hospital factors influencing patient outcomes for major trauma within the Northern Trauma Network. Method Secondary data analysis of a combined data set of pre-hospital audit data and patient outcome data from the Trauma Audit Research Network (n=1033) was undertaken. Variables included mechanism of injury, age, physiological indices, timings and skill mix. Principle outcome measures included Mortality data and Glasgow Outcome Scales. Results Glasgow Coma Scores proved a significant predictor of mortality in major trauma (p<0.00). Amongst other physiological indices, systolic blood pressure ≤90 mm Hg. was associated with both increased mortality (p≤0.004) and poorer morbidity (p≤0.021). Respiration rate <14/minute was also significantly predictive of morbidity (p≤0.03) and mortality (p<0.00). Prolonged response times to the most critically injured patients (p<0.031), and increasing casualty age were significantly associated with poorer outcomes. The attendance of a Doctor was significantly associated with increased mortality (p≤0.036) perhaps validating existing resource despatching practices. Predictors of positive outcomes included the presence of a Doctor when on-scene time ≤50 minutes (p≤0.015), crew arrival on-scene ≤10 minutes (p<0.046) and on-scene time ≤50 minutes (p<0.015). Conclusion These findings validate GCS, BP and Respiratory Rate values as valid triggers for transport to a Major Trauma Centre. Analysis of the interactions between arrival time, time-on-scene, skill mix and age demand further exploration but tentatively validate the concept of a ‘Golden Hour’ and suggest the potential value of a ‘load and go and play on the way’ approach. https://emj.bmj.com/content/emermed/33/9/e5.1.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/ 10.1136/emermed-2016-206139.18
    • 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
    • Introduction of the I-gel supraglottic airway device for prehospital airway management in a UK ambulance service

      Duckett, Jay; Fell, P.; Han, Kyee; Kimber, C.; Taylor, C. (2014-06)
      Aim To clinically review the use of basic and advanced airway management techniques within the North East Ambulance Service National Health Service Foundation Trust (NEAS) for cardiac arrests following the introduction of the i-gel. Method Two retrospective clinical audits were carried out over a monthly period (May 2011 and January 2012) using electronic and paper NEAS patient records. Results This audit confirmed that a range of basic and/or advanced airway management techniques are being successfully used to manage the airways of cardiac arrest patients. I-gel is emerging as a popular choice for maintaining and securing the airway during prehospital cardiopulmonary resuscitation. Success rates for i-gel insertion are higher (94%, 92%) than endotracheal (ET) tube insertion (90%, 86%). Documentation of the airway management method was poor in 11% of the records. The Quality Improvement Officers addressed this by providing individual feedback. Conclusions I-gel shows a higher success rate in cardiac arrest patients compared to the ET tube. Staff who chose to use methods other than i-gel indicated this was a confidence issue when using new equipment. The re-audit indicated an upward trend in the popularity of i-gel; insertion is faster with a higher success rate, which allows the crew to progress with the other resuscitation measures more promptly. Airway soiling and aspiration beforehand have been reasons staff resort to ET intubation. It is anticipated by the authors that i-gel will emerge as the first choice of airway management device in prehospital cardiac arrests. https://emj.bmj.com/content/emermed/31/6/505.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-2012-202126
    • Is weight just a number? The accuracy of UK ambulance paediatric weight guidance – findings from a cross sectional study

      Charlton, Karl; Capsey, Matt; Moat, Christopher (2020-09-25)
      Background The weight of children is the cornerstone of their clinical management. It determines fluid quantities, drug dosages and defibrillation power, which are administered on a per kilogram basis. Gold standard care for all paediatric patients who attend hospital involves being weighed using scales. This is not possible in the out of hospital setting, where weight derives from a guidance table based upon age. No evidence exists to indicate if the page by age approach indicated in current ambulance guidelines meets the reference standard of 70% of estimations within 10% of actual weight and 95% within 20% of actual weight. Methods We used a cross sectional study design and collected data from a convenience sample of children who attended the outpatient’s department of a major hospital in England between July and September 2019. All children aged between one and eleven years who were weighed were eligible for inclusion. Outcomes were to determine if the page by age approach meets the reference standard and to determine any implications for care. Results Three hundred and forty-one children were included in this study. Each age group consisted of varying numbers of children. 50.5% (172/341) of the sample were female. Observed weights ranged from 8.28 to 82.70 kg (median 20.60 kg). The mean weight of girls versus boys was 24.69 kg and 23.39 kg respectively (95% CI -4.12–1.32, p=0.3123). Observed weights were greater than the page for age guidance in all age groups and the accuracy of this approach diminishes with age. Conclusion Page by age weight guidance does not meet the reference standard. Most paediatric prehospital care is administered by age and not weight. In the absence of an accurate weight, ambulance clinicians should continue to use the page for age system, although the gold standard remains to use an accurate weight measurement. https://emj.bmj.com/content/37/10/e9.1. 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/ DOI http://dx.doi.org/10.1136/emermed-2020-999abs.17
    • 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; Shaw, Lisa; Ford, Gary A.; Flynn, Darren; Exley, Catherine (2020-06-16)
      Background 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. Methods Interviewees were recruited from 453 trained intervention paramedics across three UK ambulance services hosting the trial: North East, North West and Welsh Ambulance Services. A semistructured interview guide aimed to (1) explore the stroke-specific assessment and handover procedures which were part of the PASTA pathway and (2) enable paramedics to share relevant views about expanding their role and any barriers/enablers they encountered. Interviews were audiorecorded, transcribed verbatim and analysed following the principles of the constant comparative method. Results Twenty-six interviews were conducted (11 North East, 10 North West and 5 Wales). Iterative data analysis identified four key themes, which reflected paramedics’ experiences at different stages of the care pathway: (1) Enhanced assessment at scene: paramedics felt this improved their skillset and confidence. (2) Prealert to hospital: a mixed experience dependent on receiving hospital staff. (3) Handover to hospital team: standardisation of format was viewed as the primary benefit of the PASTA pathway. (4) Assisting in hospital and feedback: due to professional boundaries, paramedics found these aspects harder to achieve, although feedback from the clinical team was valued when available. Conclusion Paramedics believed that the PASTA pathway enhanced their skills and the emergency care of stroke patients, but a continuing clinical role postadmission was challenging. Future studies should consider whether interdisciplinary training is needed to enable more radical extension of professional boundaries for paramedics. https://emj.bmj.com/content/early/2020/06/16/emermed-2019-209392. 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/emermed-2019-209392
    • 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; 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/
    • Paramedic initiated Lisinopril for acute stroke treatment (PIL-FAST): results from the pilot randomised controlled trial

      Shaw, Lisa; Price, Christopher; McLure, Sally; Howel, Denise; McColl, Elaine; Younger, Paul; Ford, Gary A. (2014-12)
      Background High blood pressure (BP) during acute stroke is associated with poorer stroke outcome. Trials of treatments to lower BP have not resulted in improved outcome, but this may be because treatment commenced too late. Emergency medical service staff (paramedics) are uniquely placed to administer early treatment; however, experience of prehospital randomised controlled trials (RCTs) is very limited. Methods We conducted a pilot RCT to determine the feasibility of a definitive prehospital BP-lowering RCT in acute stroke. Paramedics were trained to identify, consent and deliver a first dose of lisinopril or placebo to adults with suspected stroke and hypertension while responding to the emergency call. Further treatment continued in hospital. Study eligibility, recruitment rate, completeness of receipt of study medication and clinical data (eg, BP) were collected to inform the design of a definitive RCT. Results In 14 months, 14 participants (median age=73 years, median National Institute of Health Stroke Scale=4) were recruited and received the prehospital dose of medication. Median time from stroke onset (as assessed by paramedic) to treatment was 70 min. Four participants completed 7 days of study treatment. Of ambulance transported suspected stroke patients, 1% were both study eligible and attended by a PIL-FAST paramedic. Conclusions It is possible to conduct a paramedic initiated double-blind RCT of a treatment for acute stroke. However, to perform a definitive RCT in a reasonable timescale, a large number of trained paramedics across several ambulance services would be needed to recruit the number of patients likely to be required. https://emj.bmj.com/content/emermed/31/12/994.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-2013-202536
    • Phenomenological study exploring ethics in prehospital research from the paramedic's perspective: experiences from the Paramedic-2 trial in a UK ambulance service

      Charlton, Karl; Franklin, John; McNaughton, Rebekah (2019-09)
      Objectives We set out to investigate paramedics’ views of ethics and research, drawing on experiences from Paramedic-2, a randomised controlled trial comparing epinephrine and placebo in out-of-hospital cardiac arrest (OHCA). Methods An interpretative phenomenological approach was adopted. A purposive sample of paramedics (n=6) from North East Ambulance Service NHS Foundation Trust were invited to a semi-structured, in-depth interview. Results Three superordinate themes emerged: (1) morality, (2) emotion and (3) equipoise. Some viewed Paramedic-2 as an opportunity to improve OHCA outcomes for the many, viewing participation as a moral obligation; others viewed the study as unethical, equating participation with immoral behaviour. Morality was a motivator to drive individual action. Positive and negative emotions were exhibited by the paramedics involved reflecting the wider view each paramedic held about trial participation. Those morally driven to participate in Paramedic-2 discussed their pride in being associated with the trial, while those who found participation unethical, discussed feelings of guilt and regret. Individual experience and perceptions of epinephrine guided each paramedic’s willingness to accept or reject equipoise. Some questioned the role of epinephrine in OHCA; others believed withholding epinephrine was synonymous to denying patient care. Conclusion A paucity of evidence exists to support any beneficial role of epinephrine in OHCA. Despite this, some paramedics were reluctant to participate in Paramedic-2 and relied on their personal perceptions and experiences of epinephrine to guide their decision regarding participation. Failure to acknowledge the importance of individual perspectives may jeopardise the success of future out-of-hospital trials. https://emj.bmj.com/content/36/9/535.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/ DOI eg http://dx.doi.org/10.1136/emermed-2019-208556
    • 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
    • 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/
    • A qualitative investigation into paramedics' thoughts about the introduction of national early warning scores

      McClelland, Graham; Haworth, Daniel (2016-09)
      Background The National Early Warning Score (NEWS) is a simple, rapid assessment tool developed by the Royal College of Physicians to standardise the assessment and monitoring of acutely ill patients and facilitate communication across settings. Ambulance Service introduced NEWS in 2013/14. Previous work in this area showed that paramedics were not using NEWS in practice so this study explored the reasons why and how paramedics use, or don’t use, NEWS in practice. Methods Qualitative study using a pragmatic approach. Semi-structured interviews were conducted on a purposive volunteer sample of 8 paramedics with a range of roles, locations and lengths of service. Interviews were digitally recorded and transcribed for analysis. Five stage framework analysis commenced in parallel with data collection. Results Two main themes emerged from the data. The first theme was when and how paramedics used NEWS in their decision making. All participants thought that they, and their peers, collected all the observations necessary to calculate a NEWS but that it didn’t enter their thoughts until after decisions had been made and were being documented. Participants saw NEWS as a tool to support their decisions but also thought NEWS may be beneficial for triggering decisions by non-paramedic ambulance staff. The second theme was how interactions with other healthcare professionals impacted on paramedics’ use of NEWS. The reception participants received when handing a NEWS over at hospital had a strong influence on their continuing use of NEWS. The perception that Emergency Department staff weren’t interested in NEWS acted as a negative influence on pre-hospital practice apart from one area where the local hospital encouraged the use of NEWS which had a localised positive reinforcing effect. Conclusions Paramedics use NEWS to support rather than trigger decisions. The perceived importance placed on information handed over at hospital influences paramedics pre-hospital practice. https://emj.bmj.com/content/emermed/33/9/e2.3.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-2016-206139.10
    • A rapid response falls service – a new solution to a growing problem

      Charlton, Karl (2019-09-24)
      Background Falls are frequent in older people and are the primary cause of injury in adults aged 65+. Falls are associated with high mortality, morbidity and immobility. Many people who fall become frequent fallers, increasing the risk of serious injury; subsequently falls prevention is an NHS priority. A new rapid response falls service comprising of a Paramedic and Occupational Therapist was launched on 30th November 2018 but no evidence exists to determine the clinical or cost effectiveness of this intervention. This research aims to: Evaluate the rate of hospital admission for patients who pass through the intervention Evaluate the cost effectiveness of the intervention. Determine the prevalence of risk factors for falling in the study group & determine any differences between those admitted to hospital and those who are not Methods This study is an observational, prospective cohort study and aims to recruit all patients who pass through the intervention who meet the eligibility criteria. Calculations indicate a sample size of 677. With informed consent, we will collect anonymised data relating to each patient, their care episode and ambulance despatch data. These data will answer the aims of this study and provide detail on how various patient groups differ. Research ethics committee and HRA approval has been granted. Results Interim results will be presented in the form of graphs, frequencies, percentages and mean values to demonstrate the rate of hospital admission, cost effectiveness of the intervention and disease prevalence for the study group. A narrative will contextualise findings to date and generate discussion. We will provide the rate of consent, dissent and withdrawal for the cohort. Conclusions A summary of findings to date will be provided as well as implications for patients and the NHS. Limitations of this work will be discussed and opportunities for future research highlighted., https://emj.bmj.com/content/36/10/e5.3 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/emermed-2019-999abs.10
    • Stakeholder engagement in the design of a novel pre-hospital acute stroke assessment

      Lally, Joanne; McClelland, Graham; Exley, Catherine; Ford, Gary A.; Price, Christopher (2016-09)
      Background Outcomes for stroke patients can be improved by rapid identification and assessment, but delays commonly occur due to the availability of clinical information and brain imaging. We sought to develop a novel paramedic-led intervention to reduce scene to needle time for stroke patients suitable for thrombolysis. Methods Over 12 months we undertook group interviews and consultation in North East England, North West England and Wales involving patient representatives (n=20), paramedics, emergency department and stroke service hospital staff (n=100). The primary aim was to understand the impact of organisational boundaries, service pressures and traditional professional roles upon a new paramedic approach to stroke assessment. Secondly, to develop a clinical trial protocol for later evaluation of the proposed new paramedic approach. All interviews were digitally recorded, transcribed and analysed using open then focussed coding. Results Participant feedback supported an intervention which transgressed organisational and professional boundaries. Modifications were made following participant views about logistical, ethical and governance issues: ▸ The protocol was changed to reflect operational barriers restricting paramedics taking patients directly to the CT scan room. ▸ Participants advocated obtaining research consent after admission in order to address concerns over treatment delays, and supported a trial protocol which allowed data collection from patients that died before consent was feasible. ▸ Paramedics would provide additional information at patient handover directly to the stroke team or A&E staff rather than attempt to convey more during pre-notification. Conclusions Following the interviews significant alterations were made to the intervention and protocol in order to improve trial feasibility, acceptability and data quality. This emphasizes the importance of engaging with ambulance services, other clinical teams and patients during the development of pre-hospital research protocols. https://emj.bmj.com/content/emermed/33/9/e9.3.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-2016-206139.31