• 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)
    • 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 qualitative investigation into paramedics' thoughts about the introduction of the National Early Warning Score

      McClelland, Graham; Haworth, Daniel (2016-05)
      Abstract published with permission. Introduction – The National Early Warning Score is a simple, rapid assessment tool developed by the Royal College of Physicians to standardise the assessment and monitoring of acutely ill patients. The North East Ambulance Service NHS Foundation Trust introduced the National Early Warning Score in 2013/2014 to improve communication between the pre-hospital and hospital setting; however, there was and remains a lack of pre-hospital evidence that supports the value of the National Early Warning Score. A previous study showed that the utilisation of the National Early Warning Score by North East Ambulance Service NHS Foundation Trust paramedics was low. Objective – To investigate what North East Ambulance Service NHS Foundation Trust paramedics think about the National Early Warning Score and its use in practice. Design – Qualitative study using a pragmatic approach with recorded and transcribed semistructured interviews. Framework analysis commenced in parallel with data collection. Participants – A purposive volunteer sample of eight paramedics with a range of roles, locations, educational backgrounds and lengths of service. Results – Three major themes emerged from the data: applying the National Early Warning Score in practice, how the National Early Warning Score was used in decision making and how paramedic practice was subject to external influences. Conclusions – This study gives some insight into how paramedics use the National Early Warning Score in pre-hospital care and how they integrate it into their decision making. The findings also demonstrate the influence that external agencies, primarily the receiving acute hospitals, can have on pre-hospital practice.
    • A randomized trial of epinephrine in out-of-hospital cardiac arrest

      Perkins, Gavin D.; Ji, Chen; Deakin, Charles D.; Quinn, Tom; Nolan, Jerry P.; Scomparin, Charlotte; Regan, Scott; Long, John; Slowther, Anne-Marie; Pocock, Helen; et al. (2018-08)
    • 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
    • Regionalised cardiac arrest centres as a means to improve outcomes from out-of-hospital cardiac arrest in the UK: a literature review

      Miles, Steven (2016-12)
      Abstract published with permission. Introduction ‐ Sudden (out-of-hospital) cardiac arrest (OHCA) is recognised as a leading cause of death in the UK; however, survival rates remain significantly lower in the UK than in other developed countries such as Norway and Holland, which have specialised regional cardiac arrest systems and centres. Aims ‐ This review aims to look at the concept and potential benefits of specialised regional cardiac arrest centres, and to consider whether development of such centres, with bypass protocols to enable transportation of OHCA patients directly to these centres, could improve survival rates and patient outcomes in the UK. Methods ‐ Literature was identified through searching MEDLINE, ProQuest Central, CINAHL and PubMed Central databases, as well as relevant national websites, with the search terms ‘cardiac arrest’, ‘regionalised care’ and ‘out-of-hospital cardiac arrest’. Further screening used the inclusion criteria of publication within the previous 10 years (2006‐2016), English language and peer reviewed journals. Exclusion criteria included duplicated articles, articles with a primary focus on in-hospital arrests and focus on causes and prevention of cardiac arrest. Forty-three records resulted and their full texts were considered and reviewed individually to identify those supported by other sources and containing information to add to understanding of the topic Results ‐ A range of evidence is found to support the development of specialised regional cardiac arrest centres, with bypass protocols to enable ambulance staff to transport directly to these centres. Essential facilities for cardiac arrest centres are identified and potential barriers to development of these centres are discussed. Utilisation of paramedics with additional equipment and skills is considered to enable direct admissions to regional cardiac arrest centres to be effective. Conclusions ‐ Cardiac arrest centres, alongside bypass protocols to enable direct admission, could improve patient outcomes and survival rates for OHCA in the UK. For these measures to be effective some barriers to change need to be addressed and paramedics with additional skills and equipment used. Evidence from within the UK itself appears limited. Further research is needed within the UK, involving a multidisciplinary approach, with close working partnership between hospitals and the ambulance service in relation to development of regional cardiac arrest centres.
    • 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)
    • A Retrospective Analysis of the Nature, Extent and Cost of Alcohol-Related Emergency Calls to the Ambulance Service in an English Region

      Martin, N; Newbury-Birch, Dorothy; Duckett, Jay; Mason, H; Shen, J; Shevills, C; Kaner, E (2012-01-18)
    • A retrospective observational study to explore the introduction of the National Early Warning Score in NEAS

      McClelland, Graham (2015-02)
      Abstract published with permission. Background: The National Early Warning Score (NEWS) is a simple, rapid assessment tool compiled from respiratory rate, oxygen saturations, supplemental oxygen, temperature, systolic blood pressure, heart rate and level of consciousness developed by the Royal College of Physicians. NEWS was introduced into practice at North East Ambulance Service NHS Foundation Trust (NEAS) between April 2013 and March 2014. This paper will examine the use of NEWS in pre-hospital practice and seek to describe the patient population in terms of NEWS. Methods: Cross-sectional samples of patient records from NEAS attendances over two 24-hour periods were examined for NEWS usage, completeness of necessary observations and outcomes that may be linked to NEWS. A primary sample from 8 July 2013 included 100% of patients. A secondary sample of 10% of patients was taken from 1 April 2014. Results: Although 90% of all cases may be suitable for NEWS <1% (n=6) of patients attended had NEWS recorded. Of the NEWS elements only temperature was not consistently recorded. 95% of sets of observations included >4 NEWS elements. A consistent pattern emerged when the sample population was described according to NEWS using three methods of accounting for missing items of data. Pre-alerting based on NEWS was examined with little agreement between NEWS and current practice found, although this does not take into account practical reasons for pre-alerting such as underlying condition or local pathways. Conclusions: NEWS is not being documented by ambulance crews although the majority of the necessary elements are being recorded. This largely descriptive account of the use of NEWS within NEAS indicates that NEWS has not been adopted by ambulance crews.
    • A review of enhanced paramedic roles during and after hospital handover of stroke, myocardial infarction and trauma patients

      Flynn, Darren; Francis, Richard; Robalino, Shannon; Lally, Joanne; Snooks, Helen; Rodgers, Helen; McClelland, Graham; Ford, Gary A.; Price, Christopher (2017-02)
    • A review of the pre-ROSC intranasal cooling effectiveness study

      Glencorse, Mark; Glencorse, Sandra (2011-06)
      Abstract published with permission. With the publication of the 2010 European Resuscitation Council Guidelines, therapeutic hypothermia has been recommended as part of the treatment algorhythm for the management of adult cardiac arrest. As ambulance services around the world struggle to decide on the best method of cooling a patient at the time of the return of spontaneous circulation (ROSC), the ground-breaking ‘PRINCE’ study has been published describing the novel approach of ‘trans-nasal’ evaporative cooling during the peri-arrest period. This study describes a significant difference found on arrival at hospital between the mean tympanic temperatures of the two groups (cooled vs control) following a period of cooling (34.2 °C [SD 1.5 °C] vs 35.5 °C [SD 0.9 °C], P<0.001). In addition, when looking at survival to discharge following out-of-hospital (OOH) cardiac arrest, there was a statistically significant difference in a subgroup of patients where CPR was commenced within 10 minutes of cardiac arrest (56.5% of trans-nasally cooled patients survived to discharge compared with 29.4% of control patients (P=0.04, relative risk =1.9)). This article examines the PRINCE study and considers the implication of this method of inducing therapeutic hypothermia in the out-of-hospital cardiac arrest patient within the UK.
    • A scoping review of pre-hospital technology to assist ambulance personnel with patient diagnosis or stratification during the emergency assessment of suspected stroke

      Lumley, H.A.; Flynn, Darren; Shaw, L.; McClelland, Graham; Ford, Gary A.; White, P.M.; Price, Christopher (2020-04-26)
    • A service evaluation of a dedicated pre-hospital cardiac arrest response unit in the North East of England

      McClelland, Graham; Younger, Paul; Haworth, Daniel; Gospel, Amy; Aitken-Fell, Paul (2016-09)
      Abstract published with permission. Aim ‐ This article describes the introduction of a specialist cardiac arrest response unit by the North East Ambulance Service NHS Foundation Trust, with the aim of improving treatment and outcomes of out-of-hospital cardiac arrest patients, in the North East of England. Methods ‐ This study is a retrospective analysis of prospectively collected data, describing all cases where the cardiac arrest response unit was dispatched in the first 12 months of operation (January 2014 to January 2015). Results ‐ The cardiac arrest response unit was activated 333 times during the first year of operation and attended 164 out-of-hospital cardiac arrest patients. The cardiac arrest response unit demonstrated a significant impact on return of spontaneous circulation sustained to hospital (OR 1.74 (95% CI 1.19‐2.54), p = 0.004) and survival to discharge (OR 2.08 (95% CI 1.12‐3.84), p = 0.017) compared with the rest of the North East Ambulance Service NHS Foundation Trust. Conclusion ‐ The cardiac arrest response unit project demonstrated an improvement in return of spontaneous circulation and survival to discharge compared to current standard care. The specific mechanism, or mechanisms, by which the cardiac arrest response unit influences patient outcomes remain to be determined.