• Assessment of Nutrition and Supplementation in Patients With Hip Fractures

      Arkley, James; Dixon, Jan; Wilson, Faye; Charlton, Karl; Ollivere, Benjamin John; Eardley, William (2019-10-17)
    • 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
    • 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.
    • 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
    • Characteristics of patients according to the mode of admission to regional stroke services

      Price, C.; Rae, V.; Duckett, Jay; Wood, R.; McMeekin, Peter; Gray, J.; Rodgers, Helen; Ford, Gary A. (2012-12)
    • The clinical characteristics of false negative stroke patients: a systematic review

      Jones, S.; Price, C.; McClelland, Graham; Gibson, J.; Watkins, C. (2019-05-22)
    • 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.
    • 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 I.M. (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
    • Comparison of manual and mechanical cardiopulmonary resuscitation on the move using a manikin: a service evaluation

      Blair, Laura; Kendal, Simon Peter; Shaw, Gary Richard; 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 R.; 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
    • 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.
    • Development and validation of a pragmatic prehospital tool to identify stroke mimic patients

      McClelland, Graham; Rodgers, Helen; Flynn, Darren; Price, Christopher I.M. (2018-04)
      Aim Stroke mimics (SM) are non-stroke conditions producing stroke-like symptoms. Prehospital stroke identification tools prioritise sensitivity over specificity.1 It is estimated that >25% of prehospital suspected stroke patients are SM.2 Failure to identify SM creates inefficient use of ambulances and specialist stroke services. We developed a pragmatic tool to identify SM amongst suspected prehospital stroke patients. Method The tool was developed using regression analysis of clinical variables documented in ambulance records of suspected stroke patients linked to primary hospital diagnoses (derivation dataset, n=1,650, 40% SM).3 It was refined using feedback from paramedics (n=3) and hospital clinicians (n=9), and analysis of an expanded prehospital derivation dataset (n=3,797, 41% SM (original 1650 patients included)). Results The STEAM tool combines six variables: 1 point for Systolic blood pressure <90 mmHg; 1 point for Temperature >38.5°C with Abstracts A2 BMJ Open 2018;8(Suppl 1):A1–A34 (NHS). Protected by copyright. on 14 August 2019 at Manchester University NHS Foundation Trust http://bmjopen.bmj.com/ BMJ Open: first published as 10.1136/bmjopen-2018-EMS.6 on 16 April 2018. Downloaded from heart rate >90 bpm; 1 point for seizures or 2 points for seizures with known diagnosis of Epilepsy; 1 point for Age <40 years or 2 points for age <30 years; 1 point for headache with known diagnosis of Migraine; 1 point for FAST-ve. A score of 2 on STEAM predicted SM diagnosis in the derivation dataset with 5.5% sensitivity, 99.6% specificity and positive predictive value (PPV) of 91.4%. External validation (n=1,848, 33% SM) showed 5.5% sensitivity, 99.4% specificity and a PPV of 82.5%. Conclusion STEAM uses common clinical characteristics to identify SM patients with high certainty. The benefits of using STEAM to reduce SM admissions to stroke services need to be weighed up against delayed admissions for stroke patients wrongly identified as SM. https://bmjopen.bmj.com/content/8/Suppl_1/A2.3 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/ http://dx.doi.org/10.1136/bmjopen-2018-EMS.6
    • Development of a prehospital assessment to identify stroke mimic conditions

      McClelland, Graham; Rodgers, Helen; Flynn, Darren; Price, Christopher I.M. (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
    • Development of a prehospital stroke mimic identification tool: a focus group study with healthcare professionals

      McClelland, Graham; Flynn, Darren; Rodgers, Helen; Price, Christopher I.M. (2017-11)
    • 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.