• Building up a positive culture

      Smith, Daniel (2019-01-12)
    • Can paramedics avoid A&E departments with patients complaining of non-traumatic chest pain?

      Best, Pete (2017-04)
      Abstract published with permission. The ‘Paramedic Pathfinder’, a triage tool for paramedics, contains a discriminator for patients complaining of non-traumatic chest pain. The pathfinder advises all patients with non-traumatic chest pain to be taken to hospital. Given a background of large numbers of patients complaining of chest pain and the policy direction of UK ambulance services to treat patients closer to home, the inclusion of discriminator in the pathfinder can be challenged. A greater understanding of ACS, university education for paramedics, bedside troponin measurement, ACS risk scoring, current NICE guidelines and rapid access chest pain clinics have been identified as enablers to remove the discriminator safely and assist paramedics in finding suitable alternatives to Accident and Emergency for certain patients. Risk is an important factor in discussing chest pain and establishing the best pathway for patients. The enablers identified need further testing and development in the pre-hospital environment before they can be utilised.
    • 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.
    • Creating a safety net for patients in crisis: paramedic perspectives towards a GP referral scheme

      Blodgett, Joanna M; Robertson, Duncan; Ratcliffe, David; Rockwood, Kenneth (2017-01)
      Abstract published with permission. An innovative policy implemented by a UK Ambulance Service allows paramedics to refer patients to a GP Acute Visiting Service scheme. Initial evidence suggests that this alternate route of care can decrease hospital admission rates, decrease A&E waiting time and provide substantial savings for the NHS. However, there are many unrecognised barriers to referral that are not captured by the quantitative analysis. The goal of this qualitative-observational study was to gain insight into the GP referral scheme from a paramedic's perspective. All notes were transcribed, coded and analysed using a Grounded Theory approach. Four main themes emerged: 1) barriers to referral including wait time, process, and lack of confidence, experience and training 2) approaching the patient with the GP referral scheme in mind 3) frustrations with GP decision making and 4) awareness/understanding of the scheme's impacts. This study provided valuable insight into the paramedic's perspective of the GP referral scheme. Maximising understanding of the scheme, investigating the GP's perspective in decision making and ensuring knowledge and accountability of paramedics, GPs and the public were identified as solutions to strengthen and increase referral rates and scheme success.
    • Developing and diversifying

      Smith, Daniel (2019-07-10)
    • Frailty as lived, frailty as applied: exploring lived experiences in older patients who have fallen and called 999

      Robertson, Duncan; Cooke, Mary (2016-09)
      Rationale The aim of this pilot study was to explore the personal meanings of frailty within a purposive sample of older patients who had fallen, needed an Emergency Ambulance Service response and were subsequently referred to a falls service. A systematic literature review indicated that no qualitative studies had been carried out within such a sample previously. Methods The qualitative methodology used Interpretative Phenomenological Analysis; which explored the essential nature of frailty as a phenomenon though a series of subjective narrative accounts generated by focused interviews. Employing a reflexive approach to the analysis allowed completion of a participant-centred and ethically sound study. Results Analysis of six focused interviews with older adults provided a thick description which highlighted five themes: Adaptations to frailty, Focus on confidence as psychological frailty, A changing lifeworld-towards social frailty, Reconciling a frail future and Frailty as stigma. These themes were discussed in relation to sociological literature including theories concerning transitions from the third to fourth age, liminality and social death, frailty as stigma and frailty as lived and frailty as applied. Implications This sample of patients represented a group in transition. They occupied a liminal zone situated between the third and fourth age and while acknowledging oldness, they actively challenged biomedical assumptions of frailty through an emphasis on control and individual agency. This study enables paramedics to modulate their communications when encountering elders who reject the notion of frailty as a term applied. For service design, the results allow the voice of the patient group to be heard, so that solutions can be designed in an inclusive, rather than hierarchical fashion. Significantly, this thesis forms part of an emerging body of evidence that questions the usefulness of the term frailty as experienced by this sample of participants. https://emj.bmj.com/content/emermed/33/9/e11.1.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-2016-206139.35
    • Paramedic perspectives towards gp referral schemes in north west England: a qualitative-observational study

      Blodgett, Joanna M; Robertson, Duncan; Ratcliffe, David; Rockwood, Kenneth (2017-10)
      Background An innovative policy developed and implemented by a UK Ambulance Service allows paramedics to refer patients to the GP Acute Visiting Service scheme. Initial evidence suggests that using this alternate route of care can decrease hospital admission rates, increase bed availability, decrease wait time in A and Es and provide substantial savings for the NHS. However, there are many unrecognised barriers to referral that have not been captured by the quantitative analysis. The goal of this qualitative-observational study was to gain insight into the GP referral scheme from a paramedic’s perspective. Methods We observed eight paramedics throughout full shifts of 8–12 hours. Data was collected using participant demographics, researcher observations and informal semi-structured interviews. All notes were transcribed, coded and analysed using a Grounded Theory approach to identify emerging themes. Results Paramedics expressed a wide range of frustrations with the scheme, identifying the waiting time, the process and a lack of confidence, experience and training as the three major barriers to referrals. They described how they approached patients with the GP referral scheme in mind, identified common characteristics of referrals, described how the triage tool shaped their decision making and shared how they involved the patient in the decision making. They shared too their frustrations with some GP decision making, which they admitted then influenced their future decision making. Finally, they described what motivated them to refer and discussed the lack of awareness and understanding of the scheme’s impact and aims. Conclusions This study provided valuable insight into the paramedic’s perspective of the GP referral scheme. Maximising understanding of the scheme, investigating the GP’s perspective in decision making and ensuring knowledge and accountability of paramedics, GPs and the public were identified as solutions to strengthen and increase referral rates and scheme success. https://emj.bmj.com/content/34/10/696.2 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-2017-207114.4
    • 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
    • Why evaluation is important to you, me and everybody

      Simpson, Karen (2014-11)
      Abstract published with permission. The Health and Care Professionals Council (HCPC) suggest that the use of operational evaluation and monitoring contributes to the creation of correct and current assessment standards (HCPC, 2009). This short article is aimed at anyone who attends training courses including mandatory, induction, CPD, management and clinical skills, and explores the theory of evaluation and its benefit in adding depth and value to all training purposes.