• Breaking bad news and managing family during an out-of-hospital cardiac arrest

      Mainds, Matthew D.; Jones, Colin (2018-07)
      Abstract published with permission. The management of family during out-of-hospital cardiac arrests and death notification to the family of the deceased in the out-of-hospital setting are topics that are poorly evidenced. Two focus groups consisting of six participants in each were conducted, discussing the two subjects. The results suggest that paramedics prefer family not to be present in the room for a number of reasons and that they don’t feel sufficiently trained by their paramedic courses in order to manage family during resuscitation or breaking bad news. The study highlighted a need for more research on both subjects.
    • Building up a positive culture

      Smith, Daniel (2019-01-12)
    • Bypassing nearest hospital for more distant neuroscience care in head-injured adults with suspected traumatic brain injury: findings of the head injury transportation straight to neurosurgery (HITS-NS) pilot cluster randomised trial

      Lecky, Fiona E.; Russell, Wanda; McClelland, Graham; Pennington, Elspeth; Fuller, Gordon W.; Goodacre, Steve; Han, Kyee; Curran, Andrew; Holliman, Damian; Chapman, Nathan; et al. (2017-10)
      Objective Reconfiguration of trauma services, with direct transport of patients with traumatic brain injury (TBI) to specialist neuroscience centres (SNCs)— bypassing non-specialist acute hospitals (NSAHs), could improve outcomes. However, delays in stabilisation of airway, breathing and circulation (ABC) may worsen outcomes when compared with selective secondary transfer from nearest NSAH to SNC. We conducted a pilot cluster randomised controlled trial to determine the feasibility and plausibility of bypassing suspected patients with TBI —directly into SNCs—producing a measurable effect. Setting Two English Ambulance Services. Participants 74 clusters (ambulance stations) were randomised within pairs after matching for important characteristics. Clusters enrolled head-injured adults— injured nearest to an NSAH—with internationally accepted TBI risk factors and stable ABC. We excluded participants attended by Helicopter Emergency Medical Services or who were injured more than 1 hour by road from nearest SNC. Interventions Intervention cluster participants were transported directly to an SNC bypassing nearest NSAH; control cluster participants were transported to nearest NSAH with selective secondary transfer to SNC. Outcomes Trial recruitment rate (target n=700 per annum) and percentage with TBI on CT scan (target 80%) were the primary feasibility outcomes. 30-day mortality, 6-month Extended Glasgow Outcome Scale and quality of life were secondary outcomes. Results 56 ambulance station clusters recruited 293 patients in 12 months. The trial arms were similar in terms of age, conscious level and injury severity. Less than 25% of recruited patients had TBI on CT (n=70) with 7% (n=20) requiring neurosurgery. Complete case analysis showed similar 30-day mortality in the two trial arms (control=8.8 (2.7–14.0)% vs intervention=9.4(2.3–14.0)%). Conclusion Bypassing patients with suspected TBI to SNCs gives an overtriage (false positive) ratio of 13:1 for neurosurgical intervention and 4:1 for TBI. A measurable effect from a full trial of early neuroscience care following bypass is therefore unlikely https://bmjopen.bmj.com/content/bmjopen/7/10/e016355.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-2017-016355
    • 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.
    • The challenges of conducting prehospital research: successes and lessons learnt from the Head Injury Transportation Straight to Neurosurgery (HITS-NS) trial

      McClelland, Graham; Pennington, Elspeth; Byers, Sonia; Russell, Wanda; Lecky, Fiona (2015-08)
      Head Injury Transportation Straight to Neurosurgery was a cluster randomised trial studying suspected severe head injury treatment pathways conducted in the North East Ambulance Service NHS Foundation Trust and North West Ambulance Service NHS Trust between January 2012 and March 2013. This was the world's first large scale trial of any trauma bypass and was conducted as a feasibility study. This short report will describe some of the lessons learnt during this ground breaking and complex trial. https://emj.bmj.com/content/32/8/663.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/ http://dx.doi.org/10.1136/emermed-2014-203870
    • Challenges of SARS-CoV-2 and conflicting PPE guidelines

      Master, Shamima; Gerrard, Mark (2020-11-09)
      During the coronavirus disease 2019 (COVID-19) pandemic, personal protective equipment (PPE) has become a contentious issue in healthcare settings, no more so than in the prehospital environment. The current severe acute respiratory syndrome 2 virus (SARS-CoV-2) has pathogenic and transmission similarities to previous coronaviruses, severe acute respiratory syndrome (SARS-CoV) and Middle Eastern respiratory syndrome (MERS-CoV). There are differences in global and domestic PPE guidelines concerning SARS-CoV-2. Abstract published with permission.
    • Clinical care in the warm zone: a responder’s perspective upon clinical practice in support of UK tactical medical operations

      Hooper, Craig (2016-06)
      Abstract published with permission. Active shooter incidents both nationally and internationally have embedded significant cultural reforms within emergency medical services response frameworks. The deployment of specialist responders within specific preidentified areas or ‘zones’ of an active shooter incident is unprecedented, and reflects the level of public expectation now required of the ambulance service. As seen within the recent 2015 Paris attacks, the delivery of effective clinical practice in tactical medical operations (TMO) facilitates a range of unique challenges for clinical responders. Conflicting priorities between operational tactics and clinical priorities, especially within multiagency working, has historically led to ‘Good medicine becoming bad tactics, and bad tactics leading to further casualties’ (Butler, 2001: 625). Although situational dynamics may make it impossible to ever achieve an absolute equilibrium of safety and tactical efficiency within this sphere of practice, this article intends to contribute toward achieving this ideal by reviewing the Tactical Emergency Casualty Care (TECC) guidelines to establish if this framework would be compatible for use within the UK’s TMO response framework.
    • Clinical navigation for beginners: the clinical utility and safety of the Paramedic Pathfinder

      Newton, Mark; Tunn, Eddie; Moses, Ian; Ratcliffe, David; Mackway-Jones, Kevin C. (2014-10)
      Background English Ambulance Services are faced with annual increases in emergency demand. Addressing the demand for low acuity emergency calls relies upon the ability of ambulance clinicians to accurately identify the most appropriate destination or referral pathway. Given the risk of undertriage, the challenge is to develop processes that can safely determine patient dispositions, thereby increasing the number of patients receiving care closer to home. Aims The aim of the study was to evaluate the clinical utility and safety of triage support tools (Paramedic Pathfinders). Methods Two triage filters (Pathfinders) were developed (one medical, one trauma). These were applied by ambulance clinicians to 481 patients who had been transported to emergency departments (EDs). Preferred (gold standard) patient dispositions were established by senior medical practitioners using both ambulance and ED clinical records. The clinical utility of ambulance clinicians using Pathfinders was evaluated against this gold standard. Results The Medical Pathfinder was applied to 367 patients (76.3%) and the Trauma Pathfinder to 114 (23.7%). Agreement between ambulance clinician and gold standard was achieved in 387 cases (80.5%) giving the tools a combined sensitivity of 94.83% and specificity of 57.9%. 20.9% of medical patients and 30.7% of trauma patients who had been transported to hospital could have been safely cared for elsewhere. Conclusions Ambulance clinicians using Pathfinders have demonstrated acceptable levels of sensitivity in identifying patients who require ED care. The actual impact of the tools in clinical practice will be dependent on the provision of suitable alternatives to ED. https://emj.bmj.com/content/emermed/31/e1/e29.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-2012-202033
    • 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.
    • 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)
    • Community service

      Byrom, Sarah (2013-04)
    • Consensus statement: a framework for safe and effective intubation by paramedics

      Gowens, Paul; Aitken-Fell, Paul; Broughton, Will; 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.
    • COPD: an overview of prehospital care

      Scholes, Steven; Hedges, Nicola (2009-12-18)
      Chronic obstructive pulmonary disease (COPD) is the name for a collection of lung diseases including chronic bronchitis, emphysema and chronic obstructive airways disease. It is a debilitating airways disease which presents to the ambulance service with varying severity and is characterized by airflow obstruction which is usually progressive, not fully reversible and does not change markedly over several months. It may coexist with other comorbidities such as cardiovascular disease, making diagnosis of exacerbations difficult. COPD management in the prehospital environment is focused on effective recognition and the early application of pharmacological intervention to alleviate symptoms using current Joint Royal Colleges Ambulance Liaison Committee Guidelines. Abstract published with permission.
    • Could mindfulness activity improve occupational health in UK paramedics?

      Forster, Christopher (2020-05-05)
      Emerging research is supporting the implementation of mindfulness-based strategies for NHS staff. It has been shown that, by spending 10 minutes daily on the activity, health professionals can improve their emotional and cognitive functioning, while reducing work-related rumination. Through an exploratory multi-methods approach, this study sets out to quantify the occupational health levels of paramedics, and establish their appreciation of both their employer's health and wellbeing policy and mindfulness as a concept, for the overall purpose of gaining a qualitative insight into whether mindfulness activity could improve occupational health. Paramedics reported high levels of occupational stress, coupled with minimal levels of knowledge or experience of mindfulness as a health-promoting concept. Structured application of mindfulness strategies within prehospital care may promote a range of health benefits for paramedics, lead to improved organisational efficiency for trusts and support positive outcomes for patients. Abstract published with permission.
    • Creating a safety net for patients in crisis: paramedic perspectives towards a GP referral scheme

      Blodgett, Joanna; 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.
    • Creating authentic video scenarios for use in prehospital research

      Preston, Christopher; Carter, Bernie; Jack, Barbara; Bray, Lucy (2017-05)