RSS 1.0Publications - South Central Ambulance Service
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Validation of oxygen saturations measured in the community by emergency medical services as a marker of clinical deterioration in patients with confirmed COVID-19: a retrospective cohort studyObjectives To evaluate oxygen saturation and vital signs measured in the community by emergency medical services (EMS) as clinical markers of COVID-19-positive patient deterioration. Design A retrospective data analysis. Setting Patients were conveyed by EMS to two hospitals in Hampshire, UK, between 1 March 2020 and 31 July 2020. Participants A total of 1080 patients aged ≥18 years with a COVID-19 diagnosis were conveyed by EMS to the hospital. Primary and secondary outcome measures The primary study outcome was admission to the intensive care unit (ICU) within 30 days of conveyance, with a secondary outcome representing mortality within 30 days of conveyance. Receiver operating characteristic (ROC) analysis was performed to evaluate, in a retrospective fashion, the efficacy of different variables in predicting patient outcomes. Results Vital signs measured by EMS staff at the first point of contact in the community correlated with patient 30-day ICU admission and mortality. Oxygen saturation was comparably predictive of 30-day ICU admission (area under ROC (AUROC) 0.753; 95% CI 0.668 to 0.826) to the National Early Warning Score 2 (AUROC 0.731; 95% CI 0.655 to 0.800), followed by temperature (AUROC 0.720; 95% CI 0.640 to 0.793) and respiration rate (AUROC 0.672; 95% CI 0.586 to 0.756). Conclusions Initial oxygen saturation measurements (on air) for confirmed COVID-19 patients conveyed by EMS correlated with short-term patient outcomes, demonstrating an AUROC of 0.753 (95% CI 0.668 to 0.826) in predicting 30-day ICU admission. We found that the threshold of 93% oxygen saturation is prognostic of adverse events and of value for clinician decision-making with sensitivity (74.2% CI 0.642 to 0.840) and specificity (70.6% CI 0.678 to 0.734). https://bmjopen.bmj.com/content/14/1/e067378 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/
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‘Call before convey’ – delivering urgent care for patients in the right place with the right clinician, first timeAims and Objectives Aim: Ensure patients have timely access to the right urgent care, in the right place with the right clinician. Many people access urgent care via the emergency department (ED) resulting in poor patient experience, delays to care and duplication, also causing overcrowding, leading to harm. Method and Design Using the model for improvement we defined aims and set measures, including number of patients offered alternatives to ED or admission, with balancing measures of patient reattendance/readmission. The data identified pathways with largest impact potential - chest pain, dyspnoea and falls/frailty/head injury. Working with our trust clinical communication centre (CCC) as single point of access, ambulances called before conveying patients in these pathways. We worked with specialty consultants from Cardiology, Respiratory, Frailty, Emergency Medicine and Acute Medicine to offer senior decision maker input to pre-hospital conversations to define the best urgent care pathways. We engaged with community falls car, urgent care response team and GPs along with hospital SDECs and virtual wards as well as providing specialty ‘hot clinic’ appointments where appropriate, to provide alternatives to ED and admission. In addition these pathways could be utilised by GPs referring via CCC, and ED where a patient could be given an alternative to admission. We used daily huddles to enact rapid cycle PDSA changes. After a first pilot we added additional pathways for a second pilot, converting to business as usual within 6 months. Results and Conclusion Across the pilots, 32-38% were given an alternative to ED attendance or admission. 24% avoided hospital entirely. We reduced ambulance lost minutes by 84-87 hours compared to the previous 3 week average. Streamlining access to urgent care pathways with a single point of access benefits these patients but also those who do attend by reducing harm from overcrowding through better ED and hospital flow by offering alternatives to ED attendance and admission. https://emj.bmj.com/content/40/12/871.2 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/
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Point-of-care blood testing with secondary care decision support for frail patientsAim: A service evaluation was conducted to assess the feasibility and impact of a pilot service to facilitate alternatives to hospital admission for frail patients in supportive care settings. Paramedic assessments were enhanced by point-of-care testing and telephone support from senior physicians. Method: A rapid response vehicle, staffed by a specialist paramedic and equipped with the Abbott i-STAT Wireless 1 point-of-care testing platform that could transmit results to hospital electronic patient record (EPR) systems, was dispatched to frail, non-injured patients over a 3-month period. Results were obtained on scene and transmitted to Oxford University Hospitals EPR system. The patient was then discussed over the telephone with a senior acute medical assessment physician at the Trust for advice and decision support and to coordinate referral to secondary care or other services. Results: The analysis included 56 patients, 21 men and 35 women, with a median age of 86 years. Seventeen patients who had significantly deranged blood test results were transferred to hospital, as were another 10 who did not have such results; 27 patients were admitted in total. Twenty-nine patients remained in their usual environment; of these, four presented to hospital within the next 30 days, and no deaths or adverse events were reported. Conclusion: Point-of-care testing by the ambulance services is feasible and, when combined with telephone advice and decision support from secondary care physicians, may be effective in reducing hospital admission for frail patients in supportive care environments. Larger systematic evaluations are warranted to establish the utility and cost-effectiveness of point-of-care testing by ambulance services. Abstract published with permission
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Prehospital management of sepsis with IV antibiotics: a UK literature reviewBackground: Sepsis mortality rates increase if prompt treatment is not administered. The Sepsis Six care bundle advocates the early administration of broad-spectrum intravenous antibiotics to reduce mortality and morbidity but this is not routinely practised nationally in UK prehospital settings, although UK ambulance services regularly attend septic patients. Aims: A literature review was conducted to investigate knowledge around paramedics' ability to recognise and treat prehospital sepsis with intravenous antibiotics in the UK and the impact of this on patient outcomes. Methods: A search was conducted and the three eligible studies included underwent a structured critical appraisal and thematic analysis. Findings: Three themes emerged: diagnostic accuracy; administration of prehospital antibiotics; and impact on patient outcomes. Conclusion: There is a significant gap in evidence in this field in the UK, and it was difficult to make generalised recommendations from the studies. Paramedics have the potential to be highly accurate in the recognition of sepsis and administer intravenous antibiotics when following a protocol. No major studies measure patient outcomes following prehospital intravenous antibiotics administration by paramedics in the UK and large empirical studies should be conducted to assess the effectiveness of this. Abstract published with permission
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Febrile seizure management and effectiveness of prevention with antipyreticsBackground: Before reaching the age of 5, 2–5% of children will have had a febrile seizure. Most are categorised as simple but they can be complex and carry the risk of complications. They can be frightening for parents. UK guidelines advise against the use of antipyretic drugs to prevent febrile seizure recurrence while being mindful of parental sensitivities. Aim: This systematised literature review aimed to appraise the global body of evidence in relation to current guidelines on using conventional antipyretics for the prevention of febrile seizures and explore factors that influence their management. Method: A research question was developed using the PICO (population/participant(s); intervention(s); comparison/control; outcome) framework and two databases were searched for primary research, and abstracts were screened for relevance. Results: Thirty-four articles were identified, or which three were relevant to the research aim. These were critically appraised using the Mixed Methods Appraisal Tool and five themes were identified. Conclusion: One study found that paracetamol may prevent recurrent febrile seizures, one found a small reduction in febrile seizure recurrence when treated with an antipyretic and one found antipyretics ineffective at reducing febrile seizure recurrence. Similar contemporary studies conducted in the UK population may help to improve understanding of the factors influencing febrile seizure management and the effectiveness of antipyretics. Abstract published with permission
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Quantifying the impact of environment factors on the risk of medical responders’ stress‐related absenteeismMedical emergency response staff are exposed to incidents which may involve high-acuity patients or some intractable or traumatic situations. Previous studies on emergency response staff stress-related absence have focused on perceived factors and their impacts on absence leave. To date, analytical models on absenteeism risk prediction use past absenteeism to predict risk of future absenteeism. We show that these approaches ignore environment data, such as stress factors. The increased use of digital systems in emergency services allows us to gather data that were not available in the past and to apply a data-driven approach to quantify the effect of environment variables on the risk of stress-related absenteeism. We propose a two-stage data-driven framework to identify the variables of importance and to quantify their impact on medical staff stress-related risk of absenteeism. First, machine learning techniques are applied to identify the importance of different stressors on staff stress-related risk of absenteeism. Second, the Cox proportional-hazards model is applied to estimate the relative risk of each stressor. Four significant stressors are identified, these are the average night shift, past stress leave, the squared term of death confirmed by the Emergency Services and completion of the safeguarding form. We discuss counterintuitive results and implications to policy
