• Intravenous versus oral paracetamol in a UK ambulance service: a case control study

      Charlton, Karl; Limmer, Matthew; Moore, Hayley (2020-06-01)
      Abstract published with permission Objectives: To determine the effectiveness of intravenous versus oral paracetamol (acetaminophen) in the management of acute pain in the out-of-hospital setting. Methods: We extracted ambulance electronic patient care records for all patients who received 1 g intravenous paracetamol throughout January 2019, and case matched these by sex and age with consecutive patients who received 1 g oral paracetamol over the same time period. Eligible for inclusion were all patients aged ≥ 18 who received 1 g paracetamol for acute pain and who were transported to the emergency department (ED). The primary outcome was the mean reduction in pain score using the numeric rating scale (NRS), with a reduction of 2 or more accepted as clinically significant. Results: 80 care records were eligible for analysis; 40 patients received intravenous and 40 patients received oral paracetamol. The mean age of both groups was 54 years (± 3 years) and 67.5% (n = 54) were female. Patients receiving intravenous paracetamol had a clinically significant mean (SD) improved pain score compared to those receiving oral paracetamol, 2.02 (1.64) versus 0.75 (1.76), respectively [p = 0.0013]. 13/40 (32.5%) patients who received intravenous paracetamol saw an improved pain score of ≥ 2 compared to 8/40 (20%) who received oral paracetamol. No patients received additional analgesia or reported any adverse symptoms. Abdominal pain, infection and trauma were the most common causes of pain in both groups. Conclusion: Our study suggests that intravenous paracetamol is more effective than oral paracetamol when managing acute pain in the out-of-hospital setting. Our findings support further investigation of the role of paracetamol in paramedic practice using more robust methods.
    • 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
    • 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.
    • Mapping midwifery and obstetric units in England

      Walsh, Denis; Spiby, Helen; Grigg, Celia P.; Dodwell, Miranda; McCourt, Christine; Culley, Lorraine; Bishop, Simon; Wilkinson, Jane; Coleby, Dawn; Pacanowski, Lynne; et al. (2018-01)
    • Mechanical chest compression for out of hospital cardiac arrest: Systematic review and meta-analysis.

      Gates, Simon; Quinn, Tom; Deakin, Charles D.; Blair, Laura; Couper, Keith; Perkins, Gavin D. (2015-09)
    • Mechanical versus manual chest compression for out-of-hospital cardiac arrest (PARAMEDIC) : a pragmatic, cluster randomised controlled trial

      Perkins, Gavin D.; Lall, Ranjit; Quinn, Tom; Deakin, Charles D.; Cooke, Matthew W.; Horton, Jessica; Lamb, Sarah E.; Slowther, Anne-Marie; Woollard, Malcolm; Carson, Andy; et al. (2015-03)
    • Modeling outcomes following redirection of emergency stroke admissions from ten local stroke units to two neuroscience centres

      McMeekin, Peter; Gray, J.; Price, Christopher; Rae, Victoria; Duckett, Jay; Wood, R.; Rodgers, H.; Ford, A. (2012-12-06)
    • 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.
    • 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)