• A clinical review of the indications for, and subsequent implementation of, a pilot pre-hospital sepsis pathway within NWAS

      Butterworth, Daniel (2015-10)
      Abstract published with permission. Aim: Review the clinical evidence for, and introduce a modified ‘Red Flag’ sepsis screening tool, treatment pathway and associated education package into a pilot site within the North West Ambulance Service NHS Trust (NWAS) and evaluate its impact. Methods: Retrospective application of a modified ‘Red Flag’ sepsis screening tool to 259 hospital confirmed cases of sepsis to evaluate the current identification and treatment of sepsis within NWAS.A subsequent prospective pilot launch of the tool within central Manchester in collaboration with Salford Royal Foundation Trust and Central Manchester Foundation Trust hospital emergency departments,collecting and analysing 100 cases of suspected sepsis in which the screening tool has been utilised. Results: The modified ‘Red Flag’ sepsis tool was found to be highly sensitive when applied retrospectively. Only 46% of confirmed severe sepsis cases were found to show hypotension (systolic BP <90 mmHg) pre-hospital. In the pilot,complete analysis of Systemic Inflammatory Response Syndrome (SIRS) criteria and a suspicion and documentation of sepsis increased from 15% to 94%. Compliance with a bundle of care in suspected severe sepsis cases increased from 10% to 90%. Conclusions: The introduction of a modified ‘Red Flag’ screening tool significantly improved pre-hospital sepsis identification and treatment within the pilot site. Paramedics were able to give fluid boluses to normotensive patients in suspected severe sepsis safely without adverse incident.
    • How accurate is the prehospital diagnosis of hyperventilation syndrome?

      Wilson, Caitlin; Harley, Clare; Steels, Stephanie (2020-11-09)
      Background: The literature suggests that hyperventilation syndrome (HVS) should be diagnosed and treated prehospitally. Aim: To determine diagnostic accuracy of HVS by paramedics and emergency medical technicians using hospital doctors' diagnosis as the reference standard. Methods: A retrospective audit was carried out of routine data using linked prehospital and in-hospital patient records of adult patients (≥18 years) transported via emergency ambulance to two emergency departments in the UK from 1 January 2012–31 December 2013. Accuracy was measured using sensitivity, specificity, positive and negative predictive values (NPV/PPVs) and likelihood ratios (LRs) with 95% confidence intervals. Results: A total of 19 386 records were included in the analysis. Prehospital clinicians had a sensitivity of 88% (95% CI [82–92%]) and a specificity of 99% (95% CI [99–99%]) for diagnosing HVS, with PPV 0.42 (0.37, 0.47), NPV 1.00 (1.00, 1.00), LR+ 75.2 (65.3, 86.5) and LR− 0.12 (0.08, 0.18). Conclusions: Paramedics and emergency medical technicians are able to diagnose HVS prehospitally with almost perfect specificity and good sensitivity. Abstract published with permission.
    • Is paramedic practice ready to adopt the NICE Transient Loss of Consciousness Guideline?

      Thoburn, Steve (2013-10)
      Abstract published with permission. In 2010 the National Institute for Health and Care Excellence (NICE) published a guideline to assist clinicians, across various healthcare settings, to diagnose and subsequently manage patients experiencing a transient loss of consciousness (TLoC). The guideline emphasises that patients who are diagnosed as having had an ‘uncomplicated faint’ or ‘situational syncope’, from the initial assessment process, may not require conveyance to the nearest emergency department. JRCALC have included these recommendations within the latest published guidelines. Evidently, this may reduce inappropriate admissions and reduce unnecessary NHS expenditure. In addition it enables clinicians to provide care to patients within their home environment thus improving their experience and outcome as a service user. Furthermore, non-conveyance may reduce ambulance turn-around times enabling clinicians to become available to respond to life-threatening emergencies sooner. However, to utilise the guideline, clinicians are expected to be proficient in aspects of history taking, physical examination and 12-lead ECG interpretation. The current paucity of pre-hospital evidence base provides no support for use of the guideline by paramedics. It is questionable as to whether further education and training are required, before paramedics can utilise the guideline, to diagnose and discharge patients at scene without causing any detriment to patient outcome.
    • Paramedic application of ultrasound in the management of patients in the prehospital setting: a review of the literature

      Brooke, Mike; Walton, Julie; Scutt, Diane (2010-07-28)
      ABSTRACT Objectives Recently, attempts have been made to identify the utility of ultrasound in the management of patients in the prehospital setting. However, in the UK there is no directly relevant supporting evidence that prehospital ultrasound may reduce patient mortality and morbidity. The evidence available to inform this debate is almost entirely obtained from outside the UK, where emergency medical services (EMS) routinely use doctors as part of their model of service delivery. Using a structured review of the literature available, this paper examines the evidence to determine ‘Is there a place for paramedic ultrasound in the management of patients in the prehospital setting?’ Method A structured review of the literature to identify clinical trials which examined the use of ultrasound by non-physicians in the prehospital setting. Results Four resources were identified with sufficient methodological rigour to accurately inform the research question. Conclusion The theoretical concept that paramedicinitiated prehospital ultrasound may be of benefit in the management of critically ill patients is not without logical conceptual reason. Studies to date have demonstrated that with the right education and mentorship, some paramedic groups are able to obtain ultrasound images of sufficient quality to positively identify catastrophic pathologies found in critically ill patients. More research is required to demonstrate that these findings are transferable to the infrastructure of the UK EMS, and in what capacity they may be used to help facilitate optimal patient outcomes. https://emj.bmj.com/content/27/9/702.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: 10.1136/bmj.h535
    • Paramedic application of ultrasound in the management of patients in the prehospital setting: a review of the literature

      Brooke, Mike; Walton, Julie; Scutt, Diane (2010-07-28)
      Objectives Recently, attempts have been made to identify the utility of ultrasound in the management of patients in the prehospital setting. However, in the UK there is no directly relevant supporting evidence that prehospital ultrasound may reduce patient mortality and morbidity. The evidence available to inform this debate is almost entirely obtained from outside the UK, where emergency medical services (EMS) routinely use doctors as part of their model of service delivery. Using a structured review of the literature available, this paper examines the evidence to determine ‘Is there a place for paramedic ultrasound in the management of patients in the prehospital setting?’ Method A structured review of the literature to identify clinical trials which examined the use of ultrasound by non-physicians in the prehospital setting. Results Four resources were identified with sufficient methodological rigour to accurately inform the research question. Conclusion The theoretical concept that paramedic-initiated prehospital ultrasound may be of benefit in the management of critically ill patients is not without logical conceptual reason. Studies to date have demonstrated that with the right education and mentorship, some paramedic groups are able to obtain ultrasound images of sufficient quality to positively identify catastrophic pathologies found in critically ill patients. More research is required to demonstrate that these findings are transferable to the infrastructure of the UK EMS, and in what capacity they may be used to help facilitate optimal patient outcomes. https://emj.bmj.com/content/27/9/702. 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.2010.094219
    • Pre-hospital diagnostic accuracy for hyperventilation syndrome

      Wilson, Caitlin; Harley, Clare; Steels, Stephanie (2017-10)
      Background Hyperventilation syndrome (HVS) encompasses a wide variety of symptoms and is diagnosed by excluding organic causes for patients’ symptoms. Literature suggests that HVS should be diagnosed and treated pre-hospitally to avoid costly attendances at Accident and Emergency departments. The study aim was to determine diagnostic accuracy for HVS of paramedics and emergency medical technicians (index test) in comparison to hospital doctors (reference standard). Methods A retrospective cross-sectional audit of routine data utilising linked pre-hospital and in-hospital patient records of adult patients (age ≥18 years) transported via emergency ambulance to two Accident and Emergency departments in the United Kingdom from January 2012 – December 2013. Agreement between pre-hospital and in-hospital HVS diagnoses was calculated using percent agreement, Cohen’s kappa and prevalence-adjusted bias-adjusted kappa. Accuracy was measured using sensitivity, specificity, predictive values and likelihood ratios with 95% confidence intervals. Results A total of 19 386 records were included in the analysis. Percent agreement between pre-hospital clinicians and hospital doctors was 98.73%, producing kappa of κ=0.57 and adjusted kappa of PABAK=0.97. Pre-hospital clinicians had a sensitivity 0.88 (0.82, 0.92) and specificity 0.99 (0.99, 0.99) for diagnosing HVS, with PPV 0.42 (0.37, 0.47), NPV 1.00 (1.00, 1.00), LR +75.2 (65.3, 86.5) and LR- 0.12 (0.08, 0.18). Subgroup analyses for sensitivity were statistically non-significant but for positive predictive values were statistically significant (p<0.001) for the number of pre-hospital diagnoses and patient age. Conclusions Paramedics and emergency medical technicians were able to diagnose HVS pre-hospitally with almost perfect specificity and good sensitivity. Pre-hospital diagnostic accuracy was highest for patients less than 30 years of age and if HVS was the sole diagnosis documented. Following this study, a review of the local ambulance service policy excluding adult HVS patients from referrals to Primary Care Services is anticipated. https://emj.bmj.com/content/34/10/e3.3 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/ http://dx.doi.org/10.1136/emermed-2017-207114.9
    • Systematic review and meta-analysis of pre-hospital diagnostic accuracy studies

      Wilson, Caitlin; Harley, Clare; Steels, Stephanie (2018-12)
      https://emj.bmj.com/content/35/12/757.long. Introduction Paramedics are involved in examining, treating and diagnosing patients. The accuracy of these diagnoses is evaluated using diagnostic accuracy studies. We undertook a systematic review of published literature to provide an overview of how accurately paramedics diagnose patients compared with hospital doctors. A bivariate meta-analysis was incorporated to examine the range of diagnostic sensitivity and specificity. Methods We searched MEDLINE, CINAHL, Embase, AMED and the Cochrane Database from 1946 to 7 May 2016 for studies where patients had been given a diagnosis by paramedics and hospital doctors. Keywords focused on study type (’diagnostic accuracy’), outcomes (sensitivity, specificity, likelihood ratio?, predictive value?) and setting (paramedic*, pre-hospital, ambulance, ’emergency service?’, ’emergency medical service?’, ’emergency technician?’). Results 2941 references were screened by title and/ or abstract. Eleven studies encompassing 384 985 patients were included after full-text review. The types of diagnoses in one of the studies encompassed all possible diagnoses and in the other studies focused on sepsis, stroke and myocardial infarction. Sensitivity estimates ranged from 32% to 100%and specificity estimates from 14% to 100%. Eight of the studies were deemed to have a low risk of bias and were incorporated into a metaanalysis which showed a pooled sensitivity of 0.74 (0.62 to 0.82) and a pooled specificity of 0.94 (0.87 to 0.97). Discussion Current published research suggests that diagnoses made by paramedics have high sensitivity and even higher specificity. However, the paucity and varying quality of studies indicates that further prehospital diagnostic accuracy studies are warranted especially in the field of non-life-threatening conditions. https://emj.bmj.com/content/emermed/35/12/757.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-2018-207588