• Pre-hospital coronary heart disease: analysing performance indicators

      Fletcher, David (2013-01)
      Abstract published with permission. The prevalence of coronary heart disease is massive within the UK and is the leading cause of myocardial infarction. Between a third and two thirds of associated deaths occur in the pre hospital setting, many within the first few minutes of symptom onset. Immediate quality treatment is proven to improve patient survival however recent evidence suggests patients are not receiving all the elements of a quality care bundle. Pain management has been identified as one area which requires national improvement to meet standards directed by the National Service Framework for Coronary Heart Disease. In response, Ambulance services nationally have used clinical performance indicators to address quality issues in order to enhance practice and achieve target. This article reviews the importance of pain relief in the treatment of acute coronary syndrome and analyses the use of clinical performance indicators in the pursuit of best practice within the North West.
    • Pre-hospital detection of post-stroke visual impairment

      Rowe, F.J.; Hepworth, L.R.; Dent, J. (2017-11)
    • 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
    • PRe-hospital Evaluation of Sensitive TrOponin (PRESTO) Study: multicentre prospective diagnostic accuracy study protocol

      Alghamdi, Abdulrhman; Cook, Eloïse; Carlton, Edward; Siriwardena, Aloysius; Hann, Mark; Thompson, Alexander; Foulkes, Angela; Phillips, John; Cooper, Jamie; Steve, Bell; et al. (2019-10-07)
      Introduction Within the UK, chest pain is one of the most common reasons for emergency (999) ambulance calls and the most common reason for emergency hospital admission. Diagnosing acute coronary syndromes (ACS) in a patient with chest pain in the prehospital setting by a paramedic is challenging. The Troponin-only Manchester Acute Coronary Syndromes (T-MACS) decision rule is a validated tool used in the emergency department (ED) to stratify patients with suspected ACS following a single blood test. We are seeking to evaluate the diagnostic accuracy of the T-MACS decision aid algorithm to ‘rule out’ ACS when used in the prehospital environment with point-of-care troponin assays. If successful, this could allow paramedics to immediately rule out ACS for patients in the ‘very low risk’ group and avoid the need for transport to the ED, while also risk stratifying other patients using a single blood sample taken in the prehospital setting. Methods and analysis We will recruit patients who call emergency (999) ambulance services where the responding paramedic suspects cardiac chest pain. The data required to apply T-MACS will be prospectively recorded by paramedics who are responding to each patient. Paramedics will be required to draw a venous blood sample at the time of arrival to the patient. Blood samples will later be tested in batches for cardiac troponin, using commercially available troponin assays. The primary outcome will be a diagnosis of acute myocardial infarction, established at the time of initial hospital admission. The secondary outcomes will include any major adverse cardiac events within 30 days of enrolment. Ethics and dissemination The study obtained approval from the National Research Ethics Service (reference: 18/ES/0101) and the Health Research Authority. We will publish our findings in a high impact general medical journal.Abstract, URL 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/bmjopen-2019-032834
    • 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.
    • Predictors of effective management of acute pain in children within a UK ambulance service: A cross-sectional study

      Whitley, Gregory; Hemingway, Pippa; Law, Graham Richard; Wilson, Caitlin; Siriwardena, Aloysius (2020-07)
    • The prehospital early warning triage tool

      Earley, Darren (2010-12)
      The purpose of this article is to provide background information and guidance in the use of the prehospital early warning triage tool (PHEWT); and completion of the PHEWT documentation. The system is intended to provide an aid to prehospital care clinicians in ensuring all patients (ages 16 years and above) are triaged and conveyed to the department or unit best suited to their needs. In order to bring this triage system to fruition, a forward thinking ambulance service could take this on as a well constructed, multi-centre validation study. The article itself is simply the generation of that idea. Abstract published with permission.
    • Qualitative study of paramedics' experiences of managing seizures: a national perspective from England.

      Noble, Adam J.; Snape, Darlene; Goodacre, Steve; Jackson, Mike; Sherratt, Frances C.; Pearson, Mike; Marson, Anthony G. (2016-11)
      Objectives: The UK ambulance service is expected to now manage more patients in the community and avoid unnecessary transportations to hospital emergency departments (ED). Most people it attends who have experienced seizures have established epilepsy, have experienced uncomplicated seizures and so do not require the full facilities of an ED. Despite this, most are transported there. To understand why, we explored paramedics’ experiences of managing seizures. Design and setting: Semistructured interviews were conducted with a purposive sample of paramedics from the English ambulance service. Interviews were transcribed and thematically analysed. Participants: A diverse sample of 19 professionals was recruited from 5 different ambulance NHS trusts and the College of Paramedics. Results: Participants’ confirmed how most seizure patients attended to do not clinically require an ED. They explained, however, that a number of factors influence their care decisions and create a momentum for these patients to still be taken. Of particular importance was the lack of access paramedics have to background medical information on patients. This, and the limited seizure training paramedics receive, meant paramedics often cannot interpret with confidence the normality of a seizure presentation and so transport patients out of precaution. The restricted time paramedics are expected to spend ‘on scene’ due to the way the ambulance services’ performance is measured and that are few alternative care pathways which can be used for seizure patients also made conveyance likely. Conclusions: Paramedics are working within a system that does not currently facilitate nonconveyance of seizure patients. Organisational, structural, professional and educational factors impact care decisions and means transportation to ED remains the default option. Improving paramedics access to medical histories, their seizure management training and developing performance measures for the service that incentivise care that is cost-effective for all of the health service might reduce unnecessary conveyances to ED. https://bmjopen.bmj.com/content/bmjopen/6/11/e014022.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-2016-014022
    • The reality of role play

      Smith, Daniel (2019-04-08)
    • 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 secrets of success

      First, Sue; McGregor, Erica (2006-12-01)
    • Sharing data from the Ambulance Service to avoid admission for hypoglycaemia

      Dermott, S.; Byrne, J.; McCrory, S.; Rajbhandari, S. (2016-03)
    • Social prescribing: surely, we are not just going to prescribe tea and biscuits

      Tang, Sammer; McBride, Shaun; Potts, Kieran (2019-07-10)
    • Stay on the ambulance long enough and you’ll go full circle: an evaluation of the clinical safety and effectiveness of non-emergency and multi-occupancy ambulance conveyance in non-emergency percutaneous coronary intervention patients

      Scholes, Steven; Tunn, Eddie; Newton, Mark; Ratcliffe, David (2016-12)
      Abstract published with permission. Mechanisms to facilitate rapid ambulance transport of diagnosed STEMI patients from the community and emergency departments (ED) settings directly to primary percutaneous coronary intervention (PPCI) facilities are well established within NHS Ambulance Services. Direct challenge of inter-hospital transfer requests for non-emergency percutaneous coronary intervention (PCI) patients by a regional NHS Ambulance Service identified disagreement between peripheral feeder hospitals and the NHS Ambulance Service on what level of ambulance transport is most appropriate. To reduce unnecessary peripheral feeder hospital requests for paramedic emergency service transfer and resource utilisation in non-emergency PCI patients and to assess the clinical safety of both non-emergency transport and multi-occupancy conveyance for this patient group. A process was established with a regional cardiothoracic centre to support pre-screening of non-emergency PCI patients for conveyance via non-emergency ambulance resources and multi-occupancy. This included centralisation of all non-emergency PCI ambulance transport booking practices and dissemination of learning materials on the process to all stakeholders. During the three-year period 3172 patients were identified as suitable for conveyance by both non-emergency ambulance transports. Of this, 36% (n=1767) were conveyed as part of a multi-occupancy journey and 56% (n=782) were conveyed by non-emergency resources. Overall, 69% (n=782) of all multi-occupancy conveyances were undertaken by non-emergency resources. Two clinical incidents were noted during this period, both of which were managed via clinical telephone advice. Non-emergency ambulances can be safely used to transport non-emergency PCI patients via multi-occupancy, following appropriate pre-screening by the receiving PCI unit. Further work is needed to understand the feasibility of this across other patient groups in the inter-hospital transfer scenario and its transferability to other NHS Ambulance Services.
    • Storytelling via social media in the ambulance services

      Cotton, Mark; MacGregor, Murray; Warner, Claire; Bateson, Fiona (2019-09-11)