• Clinical decision-making and its place in paramedic practice

      Murdoch, Samantha (2019-05-07)
      In the pre-hospital environment, paramedics are required to make clinical decisions, often rapidly to ensure correct treatment and care is provided. Decisions made by paramedics majorly impacts on the life, clinical outcome, safety, health and wellbeing of their patients. With the introduction of the Newly Qualified Paramedic Framework, it potentially has never been more pertinent to examine the decision-making process-an integral part of paramedicine. The implementation of the NQP framework has prompted an exploration into clinical decision making and its place in an ever-evolving profession. Through examination of theories and frameworks, this article aims to identify the underpinning evidence that enables a paramedic to reach a competent decision and the barriers experienced in the process. Abstract published with permission.
    • 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.
    • Evaluation of pre-hospital point-of-care testing for lactate in sepsis and trauma patients

      Younger, Paul; McClelland, Graham (2014-10)
      Abstract published with permission. Objective: Lactate is a significant marker of critical illness and mortality in sepsis and trauma patients. The purpose of this study is to evaluate point-of-care lactate testing by paramedics in a UK ambulance service. Methods: Selected enhanced care paramedics were trained to use the lactate meter in patients with suspected sepsis and patients who trigger the major trauma bypass protocol. Feedback was collected on the practicalities of using the meter and the potential impact on the diagnosis of sepsis. Results: Data were collected on 114 patients, 96% had suspected sepsis (n=109) and 4% (n=5) were patients who had sustained trauma. The participants found that the ability to take lactate readings was useful and increased their confidence in their clinical decision making. Conclusions: Point-of-care lactate measurement is feasible in pre-hospital care and appears to support paramedics in their decision making.
    • Feasibility of phenytoin as a paramedic-led second-line anti-epileptic drug

      Morrison, Luke (2020-09-07)
      Background: Convulsive status epilepticus (CSE) is a medical emergency that is commonly encountered in the prehospital setting. In almost all prehospital settings, treatment is limited to benzodiazepines even though the standard of care in emergency departments includes second-line agents such as phenytoin. Methods: A literature search was conducted using PubMed and Google Scholar using the search terms ‘phenytoin’, ‘seizure’ or ‘convulsive’ and ‘prehospital’, ‘EMS’ or ‘ambulance’ or ‘emergency department’. Five articles were analysed and a narrative review formed. Results: Phenytoin is an effective and commonly used second-line anti-epileptic agent but there is a distinct lack of evidence on prehospital phenytoin. Phasing the introduction of phenytoin into practice while simultaneously running a well-designed research trial could provide data for prehospital providers and the wider health community. Conclusion: Management of CSE will continue to present challenges to prehospital providers. Promoting the introduction of phenytoin to select patients, administered by advanced clinicians, could be an excellent opportunity to generate much-needed clinical data and potentially reduce morbidity and mortality in CSE. Abstract published with permission.
    • 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.
    • 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.
    • 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.
    • Moving sepsis care to the front line: knowledge and views of pre-hospital clinicians

      Roebuck, Elizabeth (2015-09)
      Abstract published with permission. Background: Previous in-hospital studies have highlighted the opportunity pre-hospital clinicians have to recognise sepsis at an early stage. Left untreated, mortality in septic shock increases rapidly. Sepsis screening tools have been developed to assist recognition; however, current knowledge of sepsis, effectiveness of previous training and attitudes towards implementation of a screening tool is unknown. Methods: A survey was emailed to 529 paramedics and 131 advanced technicians in the North of England to determine their current knowledge of sepsis, views around previous training and the use of a screening tool. Case studies were included to investigate current management of patients with history of infection. Results: 144 clinicians completed the survey, gaining a 21.8% response rate. 54% (95% CI 46%, 62%) of clinicians felt like they had good knowledge, leaving 46% of clinicians feeling a lack of knowledge. 94% (95% CI 89%, 97%) thought emergency departments should treat sepsis immediately or within the first hour. Case studies highlighted variability in the management pathways chosen and 98% (95% CI 94%, 99%) of clinicians required further training. 97% (95% CI 92%, 99%) agreed a screening tool would assist in the identification of septic patients and 98% (95% CI 95%, 99%) would use the tool. Conclusions: Severity level and importance of quick recognition and management are acknowledged among clinicians. Although response rate is a limitation of this study, knowledge levels differentiate greatly among the cohort and nearly all state they require further education. Clinicians agreed a screening tool would help identify septic patients and would use it alongside clinical acumen.
    • 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.
    • Paramedic perceptions and attitudes to working with patients with alcohol related injury or illness

      Glencorse, Mark; Wilson, Graeme; Newbury Birch, Dorothy (2014-06)
      Abstract published with permission. Aims: To ascertain views, perceptions and attitudes of paramedics when working with patients presenting with alcohol-related injury or illness, and to explore perceived barriers and facilitators for the introduction of alcohol interventions to the NHS ambulance services. Methods: A total of 142 (24%) from 589 paramedics from the North East Ambulance Service NHS Foundation Trust returned completed surveys between January 2013 to April 2013, which included measures of current perceptions and attitudes of working with patients with alcohol-related injury or illness, and the Shortened Alcohol and Alcohol Problems Perception Questionnaire (SAAPPQ). Results: Paramedics reported little to no formal training on working with patients with alcohol-related injury or illness (77%). Paramedics scored low across all domains of the SAAPPQ for working with both problem and dependent drinkers. Not having suitable counseling materials (77%), not enough training (72%) and no facilities or time to deal with prevention (69%) were key barriers. Conclusions: At this present time, levels of commitment, motivation, satisfaction, legitimacy and adequacy are low in front-line paramedics when working with patients with alcohol-related injury and illness. However, they are open to finding ways to provide interventions if they are adequately trained and have appropriate referral pathways open to them.
    • 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.
    • A pilot study exploring the accuracy of pre-hospital sepsis recognition in the North East Ambulance Service

      McClelland, Graham; Jones, Jacqui (2015-09)
      Abstract published with permission. Background: Over the past decade there has been a focus on improving pre-hospital recognition and treatment of patients with sepsis. This pilot study investigates pre-hospital sepsis recognition, including the use of a Sepsis Screening Tool (SST), treatment and whether timely identification influenced the time to treatment and outcome at the receiving unit. Methods: A cross-sectional sample of patients with a documented suspicion of sepsis by North East Ambulance Service NHS Foundation Trust (NEAS) was combined and cross referenced with patients coded for sepsis at The James Cook University Hospital (JCUH) to generate a sample of sepsis patients seen within January 2014. NEAS sepsis recognition was compared with SST identification by retrospectively examining patients’ medical records. Sensitivity and specificity for NEAS diagnosis were calculated by comparing NEAS identification with JCUH diagnosis using the hospital SST. Results: The sample included 49 patients from January 2014. NEAS correctly identified 18/42 patients with sepsis (43% sensitivity, 14% specificity). NEAS correctly identified 8/27 patients with severe sepsis (30% sensitivity, 77% specificity). Conclusions: It is evident that NEAS clinicians diagnose sepsis without consistently using the SST. Use of the SST would improve the ability of NEAS clinicians to identify patients with sepsis.
    • Pre-hospital lactate monitoring for adults with sepsis

      Charlton, Karl (2014-09)
      Abstract published with permission. Background: Sepsis is a life-threatening condition that claims 37 000 lives in the UK. The sepsis six care bundle was developed by the surviving sepsis campaign in 2002 to address this high mortality rate. Part of this care bundle involves measuring blood lactate which is prognostic of mortality. Lactate can be measured by paramedics in the pre-hospital setting using hand held monitors similar to blood glucose machines, with accuracy that is comparable to laboratory measured lactate. Method: A focused electronic literature search was carried out on a number of different databases as well as a hand search of specific relevant journals. Data was also obtained from reference harvesting, although the limitations of this was appreciated. Experts in the field were also contacted with relevant data obtained. An ongoing pre-hospital trial monitoring lactate was also identified and these researchers were contacted with relevant data obtained. Conclusions: Pre-hospital lactate monitoring would promote better recognition of sepsis in adults and improve the quality of care. It could be used to initiate a specific treatment regime such as intravenous antibiotics. This would reduce the numbers of patients admitted to intensive care, helping to reduce mortality and costs for the NHS.
    • Report from the first pre-hospital sepsis conference

      McClelland, Graham; Younger, Paul (2014-07)
    • Research developments within the Allied Health Professions Research Network (AHPRN)

      Williams, Julia; Robinson, Maria; McClelland, Graham (2014-01)
    • The research paramedic: a new role

      McClelland, Graham (2013-10)