• 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.
    • An observational study of patient characteristics associated with the mode of admission to acute stroke services in North East, England

      Price, Christopher; Rae, Victoria; Duckett, Jay; Wood, Ruth; Gray, Joanne; McMeekin, Peter; Rodgers, Helen; Portas, Karen; Ford, Gary A. (2013-10)
    • Paramedic acute stroke treatment assessment (PASTA): study protocol for a randomised controlled trial

      Price, Christopher; Shaw, Lisa; Dodd, Peter; Exley, Catherine; Flynn, Darren; Francis, Richard; Islam, Saiful; Javanbakht, Mehdi; Lakey, Rachel; Lally, Joanne; et al. (2019-02)
    • Paramedic consent in the Paramedic Initiated Lisinopril for Acute Stroke Treatment (PIL-FAST) pilot trial

      Shaw, Lisa; Price, Christopher; McLure, Sally; Howel, Denise; McColl, Elaine; Younger, Paul; Ford, Gary A. (2013-05)
    • 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): first results from the pilot randomised controlled trial

      Shaw, L.; Price, Christopher; McLure, Sally; Howel, Denise; McColl, Elaine; Ford, Gary A. (2012-12)
    • 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
    • Paramedic Initiated Lisinopril For Acute Stroke Treatment (PIL-FAST): study protocol for a pilot randomised controlled trial

      Shaw, Lisa; Price, Christopher; McLure, Sally; Howel, Denise; McColl, Elaine; Ford, Gary A. (2011-06)
    • 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.
    • Paramedic training by online video increases the availability of information for hyperacute stroke treatment decisions

      Rudd, M.; Ford, Gary A.; Flynn, Darren; McClelland, Graham; Price, Christopher (2015-12)
    • 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.
    • 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
    • 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.
    • 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/
    • Post-admission outcomes of participants in the PARAMEDIC trial: a cluster randomised trial of mechanical or manual chest compressions

      Ji, Chen; Lall, Ranjit; Quinn, Tom; Kaye, Charlotte; Haywood, K.; Horton, Jessica; Gordon, V.; Deakin, Charles D.; Pocock, Helen; Carson, Andrew; et al. (2017-09)
    • 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.
    • Prehospital adrenaline administration for out-of-hospital cardiac arrest: the picture in England and Wales

      Booth, Scott; Ji, Chen; Soar, Jasmeet; Siriwardena, Aloysius; Fothergill, Rachael; Spaight, Robert; Perkins, Gavin D. (2018-09)
    • Prehospital randomised assessment of a mechanical compression device in out-of-hospital cardiac arrest (PARAMEDIC): a pragmatic, cluster randomised trial and economic evaluation

      Gates, Simon; Lall, Ranjit; Quinn, Tom; Deakin, Charles D.; Cooke, Matthew W.; Horton, Jessica; Lamb, Sarah E.; Slowther, Anne-Marie; Woollard, Malcolm; Carson, Andrew; et al. (2017-04)