• Implementation of a prealert to improve in-hospital treatment of anticoagulant-associated strokes: analysis of a prehospital pathway change in a large UK centralised acute stroke system

      Ashton, Christopher; Sammut-Powell, Camilla; Birleson, Emily; Mayoh, Duncan; Sperrin, Matthew; Parry-Jones, Adrian (2020-05-17)
      Intracerebral haemorrhage (ICH) has the worst outcomes of all stroke subtypes, with a case fatality at 1 month of 30%–40% and only 20% regaining independence.1 Improving the implementation of existing evidence-based and guideline-recommended interventions may lead to improved outcomes.2 10%–20% of acute ICH occurs in patients taking oral anticoagulants and this is associated with a high risk of early haematoma expansion.3 4 Rapid treatment to normalise coagulation reduces this risk and may improve outcomes.4 5 The first critical step in achieving this is for suspected stroke patients on anticoagulants to undergo immediate brain imaging, allowing ICH to be identified quickly and anticoagulant reversal therapy initiated. Our regional centralised acute stroke system within Greater Manchester and Eastern Cheshire serves a population of 2.85 million and although suspected stroke patients collected by ambulance <48 hours post onset are transported to a hyperacute stroke unit (HASU), only those within 4 hours of onset are prealerted. We conducted a service evaluation to determine whether an additional prealert and emergency transport for suspected stroke on anticoagulants 4–48 hours post onset facilitated rapid imaging and hence reversal of anticoagulation after ICH on HASU arrival. A proposed prealert for anticoagulant-associated suspected strokes was agreed by the Greater Manchester Stroke Operational Delivery Network and introduced on 13 March 2018. The change in practice was disseminated by the North West Ambulance Service (NWAS) to all prehospital clinicians. https://bmjopenquality.bmj.com/content/9/2/e000883. 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/bmjoq-2019-000883
    • 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.
    • Infections of the heart and how they relate to the ambulance service

      Savage, Leon (2015-08)
      Abstract published with permission. Background: In the pre-hospital environment, the treatment of acute coronary syndrome (ACS) is at the forefront of most clinicians’ priorities when symptoms include non-traumatic chest pain. As ACS is a leading cause of preventable deaths, less emphasis is placed on other potentially life-changing conditions that are associated with non-traumatic chest pain. Objectives: This article discusses the three main groups of cardiac infections (pericarditis, myocarditis, and endocarditis). It then discusses how they can be identified in the pre-hospital setting and how the ambulance service can contribute to the subsequent diagnosis of patients presenting with these conditions. Discussion: Pericarditis is a relatively common cause of non-traumatic chest pain. It has symptoms that can be found in the pre-hospital environment such as specific ECG changes and symptoms that can be identified during an initial consultation. Myocarditis has a low incidence rate as well as a wide variety of symptoms that can be associated with other common ailments. It is a very hard condition to determine in the pre-hospital environment. Endocarditis in the intravenous drug user population is a significant condition and has a high mortality rate.
    • 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.
    • 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
    • Just don't call me sir!

      Smith, Daniel (2019-06-08)
    • 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.
    • Knowing our specialist roles

      Smith, Daniel (2019-08-07)
    • Managing neck breathing patients in the prehospital setting: review of best practice

      Brooke, Mike; Brown, Andrea (2010-11)
      An increasing number of patients with long-term tracheostomies or laryngectomies are being managed in the community. However, recent evidence suggests that many clinicians from both the hospital and prehospital setting lack sufficient skills and knowledge to safely manage them in emergency situations. This article describes the anatomical and pathophysiological variations that may be encountered in tracheostomy and laryngectomy patients, and relates them to the adaptations that may be required when managing this group of patients in the prehospital setting. Abstract published with permission.
    • Medical pharmacology at a glance

      Armitage, Ewan (2016-11)
    • NWAS Library and Information Service

      Holland, Matt (2009-12-18)
      Matt Holland is Outreach Librarian in the North West Ambulance Service. Here he explains his unique role, and the steps involved in the development of a Library Information Service. Abstract published with permission.
    • Packing an academic punch

      Romano, Vincent (2018-06)
    • Paramedic administration of glycoprotein inhibitors for ST elevation myocardial infarction

      Dykes, Simon (2012-08-16)
      Abstract published with permission. Until recently, paramedics were routinely delivering out-of-hospital thrombolysis for ST segment elevation myocardial infarction (STEMI). Now that primary percutaneous coronary intervention (PPCI) is the favoured reperfusion strategy, STEMI patients are by-passing the local emergency department and taken directly to the catheterisation laboratory via ambulance. STEMI patients within a rural setting are facing the prospect of extended transfer times for reperfusion of an already ischaemic myocardium, a potentially perilous strategy. Empirical research conducted outside the UK has identified that the pre-hospital administration of a glycoprotein inhibitor improves clinical outcome for STEMI patients. Glycoprotein naturally helps to build the fibrin mesh essential within the clotting process. Inhibition of this process by glycoprotein inhibitors IIb/IIIa (GPI IIb/IIIa) prevents aggregation at receptor sites on platelets. Original research supports the notion that GPI IIb/IIIa involvement improves patient clinical outcome for STEMI in the out-of-hospital phase. Paramedics are typically the first contact for the STEMI patient and it is tangible that paramedics have the appropriate skill and knowledge to diagnose the out-of-hospital STEMI. With this in mind, it is the purpose of this article to discuss the use of pre-hospital GPI IIb/IIIa administration and to argue that this intervention should be administered by paramedic personnel.
    • 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