• Clinically unnecessary and avoidable emergency health service use for epilepsy: A survey of what English services are doing to reduce it

      Mathieson, Amy; Marson, Anthony G.; Jackson, Mike; Ridsdale, Leone; Goodacre, Steve; Dickson, Jon M.; Noble, Adam J. (2020-02-19)
    • Derivation of a Termination of Resuscitation Clinical Decision Rule in the UK

      Jackson, Mike; House, Matthew; McMeekin, Peter; Dinning, Joanne (2017-08)
    • Developing patient-centred, feasible alternative care for adult emergency department users with epilepsy: protocol for the mixed-methods observational ‘Collaborate’ project

      Noble, Adam J.; Mathieson, Amy; Ridsdale, Leone; Holmes, E.A.; Morgan, Myfanwy; McKinlay, Alison; Dickson, Jon M.; Jackson, Mike; Hughes, Dyfrig A.; Goodacre, Steve; et al. (2019-11-02)
      INTRODUCTION: Emergency department (ED) visits for epilepsy are common, costly, often clinically unnecessary and typically lead to little benefit for epilepsy management. An 'Alternative Care Pathway' (ACP) for epilepsy, which diverts people with epilepsy (PWE) away from ED when '999' is called and leads to care elsewhere, might generate savings and facilitate improved ambulatory care. It is unknown though what features it should incorporate to make it acceptable to persons from this particularly vulnerable target population. It also needs to be National Health Service (NHS) feasible. This project seeks to identify the optimal ACP configuration. METHODS AND ANALYSIS: Mixed-methods project comprising three-linked stages. In Stage 1, NHS bodies will be surveyed on ACPs they are considering and semi-structured interviews with PWE and their carers will explore attributes of care important to them and their concerns and expectations regarding ACPs. In Stage 2, Discrete Choice Experiments (DCE) will be completed with PWE and carers to identify the relative importance placed on different care attributes under common seizure scenarios and the trade-offs people are willing to make. The uptake of different ACP configurations will be estimated. In Stage 3, two Knowledge Exchange workshops using a nominal group technique will be run. NHS managers, health professionals, commissioners and patient and carer representatives will discuss DCE results and form a consensus on which ACP configuration best meets users' needs and is NHS feasible. ETHICS AND DISSEMINATION: Ethical approval: NRES Committee (19/WM/0012) and King's College London ethics Committee (LRS-18/19-10353). Primary output will be identification of optimal ACP configuration which should be prioritised for implementation and evaluation. A pro-active dissemination strategy will make those considering developing or supporting an epilepsy ACP aware of the project and opportunities to take part in it. It will also ensure they are informed of its findings.Abstract, URL 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: 10.1136/bmjopen-2019-031696
    • Joint Royal College Ambulance Liaison Committee Airway Working Group commentary

      Jackson, Mike (2010-03)
      The publication of the paper by the Joint Royal College Ambulance Liaison Committee Airway Working Group (JRCALC AWG) will no doubt start a fierce debate among the paramedic and medical professions about prehospital intubation. Prehospital intubation performed by paramedics is a profession-defining skill, has been practised by paramedics in the UK for over 20 years, and has been a mainstay of prehospital airway management. In a survey of paramedics in the USA, prehospital intubation was ranked as a more important skill than defibrillation and patient assessment.1 Most of the literature reviewed by the JRCALC AWG was from the USA and included studies of drug-assisted intubation. Wang and associates2 examined 592 attempts at intubation in one year and found 536 of these to be successful (90.5%); another study of 264 paediatric prehospital intubations reported a much higher success rate of 99%,3 Bulger and colleagues4 in Seattle reported a success rate of 98.4% and in Bellingham, Washington, Wayne and Friedland5 reported a 95.5% success rate. It must be said that there are significant differences in the training and education of paramedics between the USA and the UK. The national standard curriculum for emergency medical technicians in the USA6 states that paramedics require only five successful intubations before graduation, whereas in the UK until recently paramedics needed to achieve 25 successful intubations. It is recognised that achieving intubation of the trachea does not necessarily mean the individual is proficient or competent in the skill of intubation. However, it must also be noted that achieving 25 intubations provides the paramedic with a higher degree of proficiency and competency than those achieving five. Limited capacity in the clinical placement circuit and the increased use of supraglottic devices for anaesthetic procedures in hospital means that paramedics are having difficulty in achieving the target of 25; as a result the accreditation bodies no longer demand that the 25 target is met, although there is still a need to learn the skill. In the future it is likely that training opportunities will be even more difficult to secure, and so the profession now finds itself at a crossroads. We need to look at what is right and what is safe for the patient, and importantly what is achievable by the profession. This will mean looking for alternative ways of achieving competence, for example, human simulation laboratories or looking at alternative airways. Recent evidence suggests that increasing the intubation experience of paramedics leads to better prehospital outcomes.7 Further evidence suggests there is no difference between experienced paramedics and doctors in performing successful intubation in prehospital cardiac arrest.8 Therefore, rather than removing the skill of intubation for all paramedics the focus should be on ensuring a proportion, for example, those in senior or advanced roles, are given the opportunity to acquire the necessary experience. If we adopt this approach the more exposure these clinicians will have the more proficient they will become, and this will result in improved outcomes. The JRCALC AWG has recognised this as a possible solution to the current problem. Ambulance services would be able to structure their response model to reflect this clinical provision and use these senior clinicians appropriately, not only to provide the expertise but also to supervise and lead on patient care at critical incidents. By using these senior clinicians the impact upon operational performance and resources will be minimised. With the training and revalidation problems we face the time is right for newly qualified paramedics and existing ones unable to maintain their intubation skills to adopt an alternative to intubation. Supraglottic airway devices are an alternative to intubation, but the suggestion by the JRCALC AWG that we should simply replace prehospital intubation by paramedics with supraglottic devices needs to be debated and researched. There is little evidence to support the effectiveness of supraglottic devices in prehospital non-fasted patients. Research to date has focussed primarily on the use of these devices in hospitals. We have no evidence to suggest that these devices are safe outside of hospitals; thus we need further research about their effectiveness. It is a gold standard in trauma that drug-assisted intubation is the best way to intubate the patient, and it is accepted that this should only be done by skilled operatives who perform the procedure regularly. However, although the JRCALC AWG agrees there is little evidence that prehospital intubation without anaesthetic drugs improves patient outcomes, there is also little evidence (especially from the UK) that prehospital intubation in patients in cardiac arrest is harmful. There are many examples in medicine in which treatment is given when it has not been proved to be effective, but the treatment continues as there is no evidence it is harmful. As there is no UK evidence that prehospital intubation by paramedics is harmful, the profession needs to continue this practice for patients in cardiac arrest—but with the skill performed by experienced senior and advanced paramedics working in a robust governance framework to ensure revalidation and maintenance of these skills. In the meantime, we need to explore the use of alternative devices including supraglottic devices, to decide if they are safe as an alternative to prehospital intubation especially for cardiac arrest, and to see if they will improve patient outcomes., https://emj.bmj.com/content/27/3/171.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 http://dx.doi.org/10.1136/emj.2009.090381
    • Kerbside consultations: advice from the advanced paramedic to the frontline

      Jackson, Mike; Jones, Colin (2012-09)
      Abstract published with permission. Aim To observe the issues, benefits and challenges of providing dynamic telephone clinical advice to frontline clinicians by advanced paramedics of the North West Ambulance Service NHS Trust. Method In order to focus on the key issues the study used a mixed method approach. A group of 11 advanced paramedics took part in two focus groups which was then followed up with a questionnaire to frontline clinicians. Using focus groups in the research not only allows for the possibility of multiple realities but also for participant validation. Using a qualitative approach allowed theory to develop and emerge which was then codified into themes and the data was then used to develop a questionnaire for frontline clinicians who had received clinical advice in the past in order to provide an element of quantitative data. Findings Five themes emerged from the stud: function, responsibility, barriers, education and support. Conclusion The study finds that clarity is required in relation to responsibilities and clinicians would benefit from a structured model to communicate information over the telephone—we believe the introduction of remote advice has improved patient safety and support to staff and has created opportunity for additional learning.
    • Paramedics' views on their seizure management learning needs: a qualitative study in England

      Sherratt, Frances C.; Snape, Darlene; Goodacre, Steve; Jackson, Mike; Pearson, Mike; Marson, Anthony G.; Noble, Adam J. (2017-01)
      Introduction: The UK ambulance service often attends to suspected seizures. Most persons attended to will not require the facilities of a hospital emergency department (ED) and so should be managed at scene or by using alternative care pathways. Most though are transported to ED. One factor that helps explain this is paramedics can have low confidence in managing seizures. Objectives: With a view to ultimately developing additional seizure management training for practicing paramedics, we explored their learning needs, delivery preferences and potential drivers and barriers to uptake and effectiveness. Design and setting: Semistructured interviews were conducted with a purposive sample of paramedics from the English ambulance service. Interviews were transcribed and thematically analysed. Participants: A diverse sample of 19 professionals was recruited from 5 different ambulance NHS trusts and the College of Paramedics. Results: Participants said seizure management was neglected within basic and postregistration paramedic training. Most welcomed additional learning opportunities and identified gaps in knowledge. This included how to differentiate between seizure types and patients that do and do not need ED. Practical, interactive e-learning was deemed the most preferable delivery format. To allow paramedics to fully implement any increase in skill resulting from training, organisational and structural changes were said to be needed. This includes not penalising paramedics for likely spending longer on scene. Conclusions: This study provides the first evidence on the learning needs and preferences of paramedics regarding seizures. It can be used to inform the development of a bespoke training programme for paramedics. Future research should develop and then assess the benefit such training has on paramedic confidence and on the quality of care they offer to seizure patients. https://bmjopen.bmj.com/content/bmjopen/7/1/e014024.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-2016-014024
    • Qualitative study of paramedics' experiences of managing seizures: a national perspective from England.

      Noble, Adam J.; Snape, Darlene; Goodacre, Steve; Jackson, Mike; Sherratt, Frances C.; Pearson, Mike; Marson, Anthony G. (2016-11)
      Objectives: The UK ambulance service is expected to now manage more patients in the community and avoid unnecessary transportations to hospital emergency departments (ED). Most people it attends who have experienced seizures have established epilepsy, have experienced uncomplicated seizures and so do not require the full facilities of an ED. Despite this, most are transported there. To understand why, we explored paramedics’ experiences of managing seizures. Design and setting: Semistructured interviews were conducted with a purposive sample of paramedics from the English ambulance service. Interviews were transcribed and thematically analysed. Participants: A diverse sample of 19 professionals was recruited from 5 different ambulance NHS trusts and the College of Paramedics. Results: Participants’ confirmed how most seizure patients attended to do not clinically require an ED. They explained, however, that a number of factors influence their care decisions and create a momentum for these patients to still be taken. Of particular importance was the lack of access paramedics have to background medical information on patients. This, and the limited seizure training paramedics receive, meant paramedics often cannot interpret with confidence the normality of a seizure presentation and so transport patients out of precaution. The restricted time paramedics are expected to spend ‘on scene’ due to the way the ambulance services’ performance is measured and that are few alternative care pathways which can be used for seizure patients also made conveyance likely. Conclusions: Paramedics are working within a system that does not currently facilitate nonconveyance of seizure patients. Organisational, structural, professional and educational factors impact care decisions and means transportation to ED remains the default option. Improving paramedics access to medical histories, their seizure management training and developing performance measures for the service that incentivise care that is cost-effective for all of the health service might reduce unnecessary conveyances to ED. https://bmjopen.bmj.com/content/bmjopen/6/11/e014022.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-2016-014022