• Ambulance clinicians’ perspectives of sharing patient information electronically

      Barrett, Jack (2019-12)
      Communication in the NHS is vital to patient care and safety. Government bodies are pushing for the digitisation of patient health records so that access and transfer of information is easier between patient care teams. Many ambulance trusts have issued their clinical staff tablet computers as a step in the transition from paper-based to electronic-based patient health records. This study aims to evaluate whether these ambulance clinicians perceive tangible benefits to digitisation, particularly regarding collaborative working with other healthcare professionals. Abstract published with permission.
    • The ambulance service: what it ought to be

      Chamberlain, Douglas (2016-12)
    • The assessment and management of thermal burn injuries in a UK ambulance service: a clinical audit

      Ashman, Harriet; Rigg, Dean; Moore, Fionna (2020-12-01)
      Background: Although burn emergencies are infrequently encountered, the ambulance service is often the first point of contact for patients in these situations. It is therefore important that these potentially devastating injuries are managed in accordance with the evidence base. Appropriate assessment and management of these patients in the pre-hospital phase will have a significant impact upon their long-term outcomes, such as scarring cosmesis and functionality. Aim and objectives: This audit was conducted to determine if patients presenting to one UK ambulance service with thermal burn injuries were managed safely, effectively and in a timely manner. Areas highlighted for improvement will assist in directing future pre-hospital research and educational requirements. Epidemiological data will also be provided. Results: 278 thermal burn incidents occurring from June 2017 to May 2018 (inclusive) were included in this audit. A larger proportion of burn patients were paediatrics who fell into the 0-10 age category, most burn patients were injured at a home address and only nine of the overall sample were major burns. Only 35% of patients received adequate cooling of their burns, an essential first aid intervention. The assessment of pain (87%) and provision of analgesia (75%) showed a higher compliance rate. However, only 54% had pain reassessed after analgesia. There was a near 100% compliance rate for patients being managed without hydrogel dressings and topical medicines. Conclusion: The results indicate several areas for improvement within the ambulance trust. Of importance is the application of basic first aid, such as cooling. It is important not only to improve education among staff but also to understand non-compliance. It should be acknowledged that assessment of pain and provision of analgesia demonstrated far higher compliance compared to current pre-hospital evidence. Several points for education and research have been identified. Abstract published with permission.
    • Experts' perspectives on professionalism in paramedic practice: findings from a Delphi process

      Gallagher, Ann; Snook, Verity; Horsfield, Claire; Rutland, Stuart; Vyvyan, Emma; Juniper, Joan; Collen, Andy (2016-09)
      Abstract published with permission. This article reports findings from a Delphi process which aimed to enable an expert panel to reach consensus in the following areas: the meaning of ‘professionalism’ in the context of UK paramedic practice; enablers of professionalism in paramedic practice; interventions or approaches likely to promote or sustain paramedic professionalism; and values that underpin paramedic professionalism. The research project was the Consensus towards Understanding and Sustaining Professionalism in Paramedic Practice (CUSPPP) project. The Delphi panel consisted of 12 experts from education, leadership, management and senior clinical roles, as well as a service user. The data from each of the three rounds were distilled to statements using a basic content analysis and subjected to team review. Statements that achieve 75% (where participants agreed or strongly agreed on a Likert scale) were considered to have reached consensus. The data highlight the view that responsibility for paramedic professionalism goes beyond individuals, with organisations having a key role in providing support and debriefing opportunities and demonstrating the value of human rather than material resources. Further research relating to the topic of paramedic professionalism is necessary, and a crucial component of this is to also capture the views and experiences of service users and the general public.
    • Exploring paramedic perceptions of feedback using a phenomenological approach

      Eaton-Williams, Peter; Mold, Freda; Magnusson, Carin (2020-06-01)
      Abstract published with permission. Objectives: Despite widespread advocacy of a feedback culture in healthcare, paramedics receive little feedback on their clinical performance. Provision of ‘outcome feedback’, or information concerning health-related patient outcomes following incidents that paramedics have attended, is proposed, to provide paramedics with a means of assessing and developing their diagnostic and decision-making skills. To inform the design of feedback mechanisms, this study aimed to explore the perceptions of paramedics concerning current feedback provision and to discover their attitudes towards formal provision of patient outcome feedback. Methods: Convenience sampling from a single ambulance station in the United Kingdom (UK) resulted in eight paramedics participating in semi-structured interviews. Interpretative phenomenological analysis was employed to generate descriptive and interpretative themes related to both current and potential feedback provision. Results: The perception that only exceptional incidents initiate feedback, and that often the required depth of information supplied is lacking, resulted in some participants describing an isolation of their daily practice. Barriers and limitations of the informal processes currently employed to access feedback were also highlighted. Formal provision of outcome feedback was anticipated by participants to benefit the integration and progression of the paramedic profession as a whole, in addition to facilitating the continued development and well-being of the individual clinician. Participants anticipated feedback to be delivered electronically to minimise resource demands, with delivery initiated by the individual clinician. However, a level of support or supervision may also be required to minimise the potential for harmful consequences. Conclusions: Establishing a just feedback culture within paramedic practice may reduce a perceived isolation of clinical practice, enabling both individual development and progression of the profession. Carefully designed formal outcome feedback mechanisms should be initiated and subsequently evaluated to establish resultant benefits and costs.
    • Mixed methods in pre-hospital research: understanding complex clinical problems

      Whitley, Gregory; Munro, Scott; Hemingway, Pippa; Law, Graham Richard; Siriwardena, Aloysius; Cooke, Debbie; Quinn, Tom (2020-12-01)
      Healthcare is becoming increasingly complex. The pre-hospital setting is no exception, especially when considering the unpredictable environment. To address complex clinical problems and improve quality of care for patients, researchers need to use innovative methods to create the necessary depth and breadth of knowledge. Quantitative approaches such as randomised controlled trials and observational (e.g. cross-sectional, case control, cohort) methods, along with qualitative approaches including interviews, focus groups and ethnography, have traditionally been used independently to gain understanding of clinical problems and how to address these. Both approaches, however, have drawbacks: quantitative methods focus on objective, numerical data and provide limited understanding of context, whereas qualitative methods explore more subjective aspects and provide perspective, but can be harder to demonstrate rigour. We argue that mixed methods research, where quantitative and qualitative methods are integrated, is an ideal solution to comprehensively understand complex clinical problems in the pre-hospital setting. The aim of this article is to discuss mixed methods in the field of pre-hospital research, highlight its strengths and limitations and provide examples. This article is tailored to clinicians and early career researchers and covers the basic aspects of mixed methods research. We conclude that mixed methods is a useful research design to help develop our understanding of complex clinical problems in the pre-hospital setting. Abstract published with permission.
    • A national survey of ambulance paramedics on the identification of patients with end of life care needs

      Eaton-Williams, Peter; Barrett, Jack; Mortimer, Craig; Williams, Julia (2020-12-01)
      Objectives: Developing the proactive identification of patients with end of life care (EoLC) needs within ambulance paramedic clinical practice may improve access to care for patients not benefitting from EoLC services at present. To inform development of this role, this study aims to assess whether ambulance paramedics currently identify EoLC patients, are aware of identification guidance and believe this role is appropriate for their practice. Methods: Between 4 November 2019 and 5 January 2020, registered paramedics from nine English NHS ambulance service trusts were invited to complete an online questionnaire. The questionnaire initially explored current practice and awareness, employing multiple-choice questions. The Gold Standards Framework Proactive Identification Guidance (GSF PIG) was then presented as an example of EoLC assessment guidance, and further questions, permitting freetext responses, explored attitudes towards performing this role. Results: 1643 questionnaires were analysed. Most participants (79.9%; n = 1313) perceived that they attended a patient who was unrecognised as within the last year of life on at least a monthly basis. Despite 72.0% (n = 1183) of paramedics indicating that they had previously made an EoLC referral to a General Practitioner, only 30.5% (n = 501) were familiar with the GSF PIG and of those only 25.9% (n = 130) had received training in its use. Participants overwhelmingly believed that they could (94.4%; n = 1551) and should (97.0%; n = 1594) perform this role, yet current barriers were identified as the inaccessibility of a patient’s medical records, inadequate EoLC education and communication difficulties. Consequently, facilitators to performing this role were identified as the provision of training in EoLC assessment guidance and establishing accessible, responsive EoLC referral pathways. Abstract published with permission.
    • Paramedic accuracy and confidence with a trauma triage algorithm: a cross-sectional survey

      Durham, Mark (2017-03)
      Abstract published with permission. Introduction – Since 2008, the UK has been developing trauma networks, with ambulance services adopting triage tools to support these. So far there has been no published work on how UK paramedics use these algorithms. This study aims to evaluate factors affecting the accuracy and self-perceived confidence of paramedics from one UK Ambulance Trust when applying the Major Trauma Decision Tree. Methods – A quantitative cross-sectional survey was e-mailed to every paramedic within the participating Ambulance Trust, asking for basic demographic data and presenting four case studies. Respondents applied the Major Trauma Decision Tree to the case studies, stating which algorithm steps (if any) they triggered, and their appropriate destination. A Likert scale was utilised to explore respondent views on the Major Trauma Decision Tree. Descriptive and inferential statistics were used to identify linked factors affecting accuracy/confidence. Results – Of the 1132 paramedics employed by the Trust, 178 completed the survey (16% response rate). Sensitivity with the Major Trauma Decision Tree was 77% (95% CI 72–81%) and specificity, 61% (95% CI 56–66%). The trigger most commonly missed was patient age of greater than 55 years. Respondents reported that transport time to a major trauma centre/trauma unit influenced compliance with the algorithm. Self-perceived confidence was low overall, but correlated positively with frequency of exposure to trauma (rs [178] = 0.323, p < 0.0005). Respondents’ concerns about the reception they would encounter from hospital staff correlated negatively with confidence (rs [178] = –0.459, p < 0.0005). Conclusion – Respondent sensitivity when using the Major Trauma Decision Tree was low, which may be due to paramedic concerns about transport time. The most commonly missed trigger was patient age. Future training may benefit from addressing these points. In addition, respondents’ confidence with the Major Trauma Decision Tree was also low and closely linked with exposure to trauma, and the reception anticipated from hospital staff.
    • Patient positioning and airway management in the pre-hospital setting: an observational study

      Plumbley, Stuart; Parkhe, Emma; Lambert, Ruth (2017-03)
      Abstract published with permission. Background – Pre-hospital airway management is often carried out in unconventional and challenging settings. The position of the patient requires the clinician to adjust the working position in order to get optimal visualisation. Aim and objective – This study aims to determine whether patient positioning affects the time to ventilation by tracheal intubation and the insertion of a supraglottic device in order to optimise airway management and reduce the period of hypoxia. The objective is also to compare the results of paramedics with the results of specialised critical care paramedics in order to ascertain whether additional training affects the time to ventilation in different positions. Methods – A sample of seven paramedics and seven critical care paramedics was recruited on a voluntary basis. The paramedics were timed while intubating with an endotracheal tube and inserting a supraglottic device, i-gel, from three different positions: lying down on the floor, kneeling in front of an ambulance trolley and standing with the trolley adjusted to the paramedic’s preferred height. Results – On average, both paramedics and critical care paramedics intubated from a lying down position in 26 seconds. The critical care paramedics were on average quicker than the paramedics from the kneeling and standing positions. The quickest paramedic intubation attempt was from a lying down position in 26 seconds, whereas the quickest critical care paramedic intubation attempt from a standing position by a height-adjusted trolley took 20 seconds. Conclusion – Both paramedics and critical care paramedics intubate from a lying down position in the same time. The critical care paramedics were on average quicker than the paramedics from the kneeling and standing positions. The critical care paramedics were more consistent in all their attempts, with less of a performance gap among themselves. The variation in time to ventilate among paramedics showed huge differences in the paramedics’ overall performance.
    • Professionalism in paramedic practice: the views of paramedics and paramedic students

      Gallagher, Ann; Vyvyan, Emma; Juniper, Joan; Snook, Verity; Horsfield, Claire; Collen, Andy; Rutland, Stuart (2016-09)
      Abstract published with permission. Paramedic practice is complex and involves decision-making in situations that are often complex and pressured. A high level of professionalism is required to respond appropriately. There has been little previous research in this area. The aim of the Consensus towards Understanding and Sustaining Professionalism in Paramedic Practice project was to develop an in-depth understanding of professionalism in paramedic practice (CUSPPP). This article reports findings from the qualitative component of the CUSPPP project. Interviews were conducted with clinical managers, specialist paramedics and student paramedics. A favourable ethical opinion was obtained from the University of Surrey Ethics Committee. Data were analysed thematically and three themes identified are discussed in this article: components of paramedic professionalism; professionalism enablers; and professionalism inhibitors. Components of paramedic professionalism include: the conduct of paramedics; the role of regulation; professional education; and values for paramedic practice. Paramedic professionalism enablers and inhibitors relate to three levels: individual, organisational and regulatory/societal levels. On-going education and interventions that promote paramedics’ well-being should be discussed with ambulance trusts and collaboration established to promote the development of educational materials and further research.
    • A retrospective analysis of ketamine administration by critical care paramedics in a pre-hospital care setting

      Cowley, Alan; Williams, Julia; Westhead, Pete; Gray, Nick; Watts, Adam; Moore, Fionna (2018-03)
      Abstract published with permission. Objective: This project aims to describe pre-hospital use of ketamine in trauma by South East Coast Ambulance Service critical care paramedics and evaluate the occurrence of any side effects or adverse events. Methods: A retrospective analysis of patients receiving pre-hospital ketamine for trauma between 16 March 2013 and 30 April 2017. Administrations were identified from Advanced Life Saving Interventions and Procedures reports submitted by the clinician and, later, from an electronic database. Each was scrutinised for patient demographics, doses and reports of side effects or adverse events. Results: A total of 510 unique administrations were identified. Following the exclusion of 61 records, 449 (88.0%) administrations remained. The most common indication for administration of ketamine was lower limb injury, with 228 (50.8%) administrations. Ketamine was only administered intravenously, and the median dose of ketamine for all administrations was 30 mg (interquartile range 20‐40 mg). The gender split was dominated by males who accounted for 302 (67.3%) administrations compared to 147 (32.7%) females. The median age of patients was 44 years (interquartile range 28‐58 years), with women on average being older than men. Telephone calls to a consultant were made for 243/449 (54.1%) of the administrations, reflecting a need for sanctioning of the drug, advice on dosages or indications, for example. Conclusions: Critical care paramedics within a well governed system are able to safely administer ketamine within an approved dosing regimen under a Patient Group Direction. Median doses are in keeping with nationally approved guidelines. Reported side effects were within the described frequencies in the British National Formulary. Prospective studies are now needed in order to confirm the safety and efficacy of ketamine administration among the advanced paramedic population.
    • A retrospective review of patients with significant traumatic brain injury transported by emergency medical services within the south east of England

      Barrett, Jack (2019-03)
      Traumatic brain injury (TBI) will be a leading cause of death and disability within the Western world by 2020. Currently, 80% of all TBI patients in England are transported to hospital by an ambulance service. The aim of this retrospective study is to compare TBI patients transported to a major trauma centre (MTC) against those transported to a trauma unit (TU). Abstract published with permission.