• Consensus statement: a framework for safe and effective intubation by paramedics

      Gowens, Paul; Aitken-Fell, Paul; Broughton, William; Harris, Liz; Williams, Julia; Younger, Paul; Bywater, David; Crookston, Colin; Curatolo, Lisa; Edwards, Tim; et al. (2018-06)
      Abstract published with permission. This consensus statement provides profession-specific guidance in relation to tracheal intubation by paramedics ‐ a procedure that the College of Paramedics supports. Tracheal intubation by paramedics has been the subject of professional and legal debate as well as crown investigation. It is therefore timely that the College of Paramedics, through this consensus group, reviews the available evidence and expert opinion in order to prevent patient harm and promote patient safety, clinical effectiveness and professional standards. It is not the purpose of this consensus statement to remove the skill of tracheal intubation from paramedics. Neither is it intended to debate the efficacy of intubation or the effect on mortality or morbidity, as other formal research studies will answer those questions. The consensus of this group is that paramedics can perform tracheal intubation safely and effectively. However, a safe, well-governed system of continual training, education and competency must be in place to serve both patients and the paramedics delivering their care.
    • Implementing a paediatric early warning score into pre-hospital practice

      Rolls, Martin (2019-06-01)
      Aim: This study addressed a desire by ambulance clinicians for additional education in the examination and assessment of the unwell child; it also explored whether ambulance clinicians could use a paediatric early warning score (PEWS) safely and effectively in the pre-hospital arena. Methods: A small-scale study introduced a validated PEWS into pre-hospital practice. The paediatric observations priority score (POPS) combines physiological observations with clinicians’ review. POPS uses a range of proxy measures such as work of breathing, alertness, gut feeling and known high-risk factors, to further refine the scoring. Based on a sample of over 24,000 patients, POPS has been validated for use in emergency departments (EDs). POPS can identify potentially critically unwell children as well as those fit for discharge without hospital admission, the fundamental purpose of an ED. Study participants were surveyed before and after the trial period in order to examine self-reported scores in confidence and competence levels for the child in pain, the breathless child, the child with a decreased level of consciousness, the febrile child and the seriously injured child. Completed patient report forms (PRFs) were returned to the principal investigator for further analysis. PRFs were re-distributed among participants for rescoring. Once rescoring was completed, the PRFs were returned to the principal investigator for calculation of interrater reliability. Participants remained anonymous for the survey. Results: Interrater reliability (Kappa coefficient) was calculated as 0.401, which is considered moderate agreement. As POPS rose, variance decreased. Lower POPS had variance, but these patients were lower acuity. Equal scoring in the main was reliable. Conclusion: For a cohort of ambulance clinicians, POPS was found to be safe and effective. Self-reported levels in confidence and competence improved in all patient presentations when comparing before and after the trial period (Table 1). Table 1. Comparison of mean scores for confidence and competence before and after trial period, stratified by patient presentation. Comparison of mean scores Confidence Competence Before After Diff (+/-) Before After Diff (+/-) Pain 5.01 6.34 1.33 4.17 7.49 3.32 Breathless 5.13 6.52 1.39 6.54 7.62 1.08 Decreased level of consciousness 5.93 6.47 0.54 6.04 7.58 1.54 Febrile 6.92 7.06 0.14 6.85 8.20 1.35 Seriously injured 5.95 6.44 0.49 5.99 7.60 1.61 Abstract published with permission.
    • Pre-hospital surgical cricothyroidotomy by advanced paramedics within a UK regional ambulance service: a service evaluation

      Bell, Steve (2017-09)
      Abstract published with permission. Introduction ‐ Surgical cricothyroidotomy, the insertion of a tracheal tube through an incision in the cricothyroid membrane, is a life-saving intervention utilised when other methods of airway management are ineffective. This evaluation aims to examine the procedural success of the intervention when performed by advanced paramedics within the North West Ambulance Service over a 4-year period. Methods ‐ A retrospective database and patient record evaluation were used, utilising internal data from the North West Ambulance Service. Patients who underwent pre-hospital surgical cricothyroidotomy performed by a North West Ambulance Service advanced paramedic between November 2012 and April 2017 were included. Indications for use, patient demographics, time to insertion and overall success rate data were collected. Results ‐ Pre-hospital surgical cricothyroidotomy was performed on a total of 36 occasions. Medical cardiac arrest accounted for 18 (50%) and traumatic cardiac arrest for 12 (33%) of the interventions. The remaining interventions were performed on patients with cardiac output at the time of the intervention: five (14%) traumatic aetiology and one (3%) medical aetiology. Of the patients, 31 (86%) were male and five (14%) female. The median age was 44.5 years old; ages ranged from 9 years to 88 years old (IQR 29.75). Median time from first cut to insertion of the tracheal tube was 1 minute (range < 30 secs‐5 mins; IQR 75 secs). The overall success rate for pre-hospital surgical cricothyroidotomy was 97% (n = 35). An inability to locate anatomical landmarks was attributed to the only unsuccessful attempt secondary to foreign body airway obstruction. Discussion ‐ Surgical cricothyroidotomy was successfully performed autonomously for a variety of pre-hospital emergency aetiologies across a variety of patient demographics. The success rate (97%) of the intervention, defined as successful ventilation via a surgically inserted tracheal tube, when performed by this cohort of North West Ambulance Service advanced paramedics is highly favourable when compared with other professional groups undertaking the intervention in the pre-hospital environment.
    • Reducing the futile transportation of out-of-hospital cardiac arrests: a retrospective validation

      House, Matthew; Gray, Joanne; McMeekin, Peter (2018-09)
      Abstract published with permission. Objectives: The primary aim was to measure the predictive value of a termination of resuscitation guideline that allows for pre-hospital termination of adult cardiac arrests of presumed cardiac aetiology where the patient did not present in a shockable cardiac rhythm and did not achieve return of spontaneous circulation on-scene. The secondary objective was to compare the effectiveness of that guideline with existing basic life support and advanced life support guidelines. Methods: A retrospective review of 2139 adult out-of-hospital primary cardiac arrest patients transported to hospital by a single ambulance trust during a 12-month period between 1 April 2014 and 31 March 2015. Results: Application of the new guideline identified 832 for termination, from which three (0.4%) survived, resulting in a specificity of 99.1% (95% CI: 97.4% to 99.8%), PPV of 99.6% (95% CI: 99% to 99.9%), sensitivity of 46.5% (95% CI: 44.1% to 48.8%) and NPV of 25.6% (95% CI: 23.2% to 28.1%). The transport rate was 60.7%, compared to 72.8% for the basic life support guideline and 95.2% for the advanced life support guideline. Conclusions: Within the tested cohort, a reduction of 39.3% in transport of adult out-of-hospital primary cardiac arrest of presumed cardiac aetiology could have been achieved if using a termination of resuscitation guideline that allows for termination on-scene when the patient presented in a non-shockable rhythm and there has been no return of spontaneous circulation. These guidelines require prospective validation, but may identify more futile transportations than other previously validated guidelines.
    • The utilisation of a structured debriefing framework within the pre-hospital environment: a service evaluation

      Tierney, Shaun (2018-06)
      Abstract published with permission. Background: Debriefing improves care and reduces error. To be effective, debriefs should be facilitated by trained individuals utilising structured and validated tools. Currently, in UK ambulance services there is no published evidence that structured processes utilising validated tools are being consistently delivered by trained facilitators, potentially impacting clinical practice. Methods: A pre-intervention survey related to debriefing was sent to 1000 clinicians within a specific geographical area of the trust via e-mail. In addition, 12 senior or advanced paramedics were recruited from the same area to participate in a training day and 12-week trial, utilising the Debrief Diamond as part of post-event debriefing. Following the trial period, all facilitators and participants of any recorded debriefs were invited to complete a post-intervention survey. Results: A total of 130 staff responded to the pre-intervention survey, with 22% reporting that previous debriefs had not identified areas for learning, and 13% reporting that previous debriefs had not identified good practice, learning opportunities or near misses. Post-intervention, 89% believed the process of debriefing was improved utilising a structured framework, 85% stated trained individuals improved the process, 93% reported the identification of good practice, 70% identified team level learning and 100% of facilitators reported improvements in identifying and supporting learning. Conclusion: Improvements in identifying good practice and learning opportunities were reported by both clinicians and facilitators in this evaluation, reflecting current evidence that structured and facilitated debriefs support safer care through the identification and subsequent reduction of human error. Consequently, the evaluation of appropriate debrief frameworks to provide consistency and validity to clinical debriefs in the pre-hospital environment should be considered to support safer clinical care.