• Ambulance clinicians' perceptions, assessment and management of frailty: thematic analysis of focus groups

      Green, Jonathan; Kirby, Kim; Hope, Suzy (2018-12-01)
      Introduction: More than half of all patients attended by the South Western Ambulance Service NHS Foundation Trust are over the age of 65. In 2017, 62% of older patients who were the subject of a frailty assessment were believed to have at least mild frailty (1/5 of all patients). Frailty is an increasingly relevant concept/diagnosis and ambulance services are well positioned to identify frailty and influence the 'care pathways' through which patients are directed (thereby influencing health outcomes). Throughout the South Western Ambulance Service NHS Foundation Trust, a mandatory training session regarding frailty was delivered to clinical personnel in 2017 and frailty assessment tools are available on the electronic Patient Clinical Record. Aim: To explore and gain insight into the current knowledge, practice and attitudes of ambulance clinicians regarding frailty and patients with frailty. Methods: Two focus groups of ambulance clinicians (n = 8; n = 9) recruited from across the South Western Ambulance Service NHS Foundation Trust were held in October 2017. Focus group discussions were analysed thematically. Results: Knowledge of conceptual models of frailty, appropriate assessment of patients with frailty and appropriate care pathways varied substantially among focus group participants. Completion of the 'Rockwood' Clinical Frailty Scale for relevant patients has become routine. However, conflicting opinions were expressed regarding the context and purpose of this. The Timed-Up-and-Go mobility assessment tool is also on the electronic Patient Clinical Record, but difficulties regarding its completion were expressed.Patient management strategies ranged from treatment options which the ambulance service can provide, to referrals to primary/community care which can support the management of patients in their homes, and options to refer patients directly to hospital units or specialists with the aim of facilitating appropriate assessment, treatment and discharge. Perceptions of limited availability and geographical variability regarding these referral pathways was a major feature of the discussions, raising questions regarding awareness, capacity, inter-professional relationships and patient choice. Conclusion: Knowledge, practice and attitudes of ambulance staff, with regard to frailty, varied widely. This reflected the emerging nature of the condition, both academically and clinically, within the ambulance profession and the wider healthcare system. Abstract published with permission.
    • Effect of a Strategy of a Supraglottic Airway Device vs Tracheal Intubation During Out-of-Hospital Cardiac Arrest on Functional Outcome: The AIRWAYS-2 Randomized Clinical Trial

      Benger, Jonathan; Kirby, Kim; Black, Sarah; Brett, Stephen; Clout, Madeleine; Lazaroo, Michelle; Nolan, Jerry; Reeves, Barnaby; Robinson, Maria; Scott, Lauren; et al. (2018-08-28)
    • An exploration of the experiences of paramedics taking part in a large randomised trial of airway management, and the impact on their views and practice

      Kirby, Kim; Brandling, Janet; Robinson, Maria; Voss, Sarah; Benger, Jonathan (2019-09-24)
      Background The participation of over 1500 study paramedics in AIRWAYS-2 provides a unique opportunity for an in depth exploration of how the views and practice of study paramedics, in advanced airway management, may have developed as a result of their participation in AIRWAYS-2, and how their experiences can inform future trials in out-of-hospital cardiac arrest (OHCA). Future prehospital guidelines and practice will not only be shaped by the results of large trials such as AIRWAYS-2, but also by the views and attitudes of UK paramedics towards OHCA, airway management and research. This study allows an opportunity to add depth and understanding to the results of AIRWAYS-2. Study aims To explore paramedics’ experiences of participating in a large cluster randomized trial of airway management during OHCA, specifically: The challenges of enrolling patients who are critically unwell and unable to consent; Barriers and facilitators to successful research in OHCA patients; The impact on paramedics’ clinical practice and airway management during and after the trial; The role of advanced airway management during OHCA. Methods Content analysis of an online survey of 1500 study paramedics to assess their experiences of participating in the trial and to establish any changes in their views and practice. Thematic analysis of telephone interviews with study paramedic to explore the findings of the online questionnaire. Exploring any changes in views and practice around advanced airway management as a result of participating in the trial; assessing experiences of trial training and enrolling critically unwell patients without consent, and exploring the barriers and facilitators for trial participation and the views of paramedics on the future role of advanced airway management during OHCA. Results and conclusions The study is in the analysis phase and is due to complete and report by the 31st January 2019. https://emj.bmj.com/content/36/10/e12.1. 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/emermed-2019-999abs.27
    • Home or hospital for people with dementia and one or more other multimorbidities: What is the potential to reduce avoidable emergency admissions? The HOMEWARD Project Protocol

      Voss, Sarah; Black, Sarah; Brandling, Janet; Buswell, Marina; Cheston, Richard; Cullum, Sarah; Kirby, Kim; Purdy, Sarah; Solway, Chris; Taylor, Hazel; et al. (2017-04-03)
      Introduction Older people with multimorbidities frequently access 999 ambulance services. When multimorbidities include dementia, the risk of ambulance use, accident and emergency (A&E) attendance and hospital admission are all increased, even when a condition is treatable in the community. People with dementia tend to do poorly in the acute hospital setting and hospital admission can result in adverse outcomes. This study aims to provide an evidence-based understanding of how older people living with dementia and other multimorbidities are using emergency ambulance services. It will also provide evidence of how paramedics make decisions about taking this group of patients to hospital, and what resources would allow them to make more person-focused decisions to enable optimal patient care. Methods and analysis Phase 1: retrospective data analysis: quantitative analysis of ambulance service data will investigate: how often paramedics are called to older people with dementia; the amount of time paramedics spend on scene and the frequency with which these patients are transported to hospital. Phase 2: observational case studies: detailed case studies will be compiled using qualitative methods, including non-participant observation of paramedic decision-making, to understand why older people with multimorbidities including dementia are conveyed to A&E when they could be treated at home or in the community. Phase 3: needs analysis: nominal groups with paramedics will investigate and prioritise the resources that would allow emergency, urgent and out of hours care to be effectively delivered to these patients at home or in a community setting. Ethics and dissemination Approval for the study has been obtained from the Health Research Authority (HRA) with National Health Service (NHS) Research Ethics Committee approval for phase 2 (16/NW/0803). The dissemination strategy will include publishing findings in appropriate journals, at conferences and in newsletters. We will pay particular attention to dissemination to the public, dementia organisations and ambulance services. https://bmjopen.bmj.com/content/7/4/e016651. 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/bmjopen-2017-016651
    • The impact of working shifts: exploring the views of UK paramedics

      Kirby, Kim; Moreland, Stephanie; Pollard, John (2016-05-11)
      There is limited research within the UK investigating the effects of shift work on paramedics. Paramedics have relatively high rates of sickness levels and there are links between shift work and health. This study explores UK paramedics’ perceptions of the impact of working shifts. Methods: Exploratory qualitative research was utilised to investigate the perceptions of UK paramedics on the impacts of working shifts. Two focus groups were completed involving 11 paramedics. The transcriptions were analysed using thematic analysis. Results: Paramedics described factors associated with working shifts that mirror research already completed within different occupations: effects on physical health, fatigue, family life, safety and performance; but paramedics additionally described factors that are more limited to working in the paramedic profession such as a broader range of psychological stressors and organisational factors. The theme of psychological health was a wider theme that went beyond shift work and encompassed the overall paramedic role and the unique and stressful nature of the work. Conclusions: This research has allowed an insight into the perceived effects of shift work on UK paramedics and exposes the challenges paramedics face in their working environment. There is a suggested link between the relatively high rates of sickness and the effects of shift work and paramedics’ overall working environment. Further exploration and recognition of the effects of shift work on UK paramedics is recommended. Abstract published with permission.
    • 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 lactate testing in the identification of patients with sepsis: a review of the literature

      Kirby, Kim (2014-04-16)
      Sepsis is increasingly common and has a high mortality rate. Sepsis can be difficult to identify and patients with severe sepsis often initially present to the ambulance service. Lactate testing has been utilised successfully in other healthcare settings to assist with the identification of septic patients and stratification of illness severity. A focused literature review has revealed that pre-hospital lactate testing has shown benefits to clinicians pre-hospitally in the identification of septic patients presenting to the ambulance service. Only four pieces of primary research were identified and small sample sizes and variability of lactate testing limit the generalisation of the findings. Further research is required to fully investigate the potential benefits of using pre-hospital lactate testing to identify those patients with sepsis, severe sepsis and septic shock presenting to the ambulance service. Abstract published with permission.
    • A qualitative study on conveyance decision-making during emergency call outs to people with dementia: the HOMEWARD project

      Voss, Sarah; Brandling, Janet; Pollard, Katherine; Taylor, Hazel; Black, Sarah; Buswell, Marina; Cheston, Richard; Cullum, Sarah; Foster, Theresa; Kirby, Kim; et al. (2020-01-29)
    • Research paramedics’ observations regarding the challenges and strategies employed in the implementation of a large-scale out-of-hospital randomised trial

      Green, Jonathan; Robinson, Maria; Pilbery, Richard; Whitley, Gregory; Hall, Helen; Clout, Madeleine; Reeves, Barnaby; Kirby, Kim; Benger, Jonathan (2020-06-01)
      Introduction: AIRWAYS-2 was a cluster randomised controlled trial (RCT) comparing the clinical and cost effectiveness of the i-gel supraglottic airway device with tracheal intubation in the initial airway management of out-of-hospital cardiac arrest (OHCA). In order to successfully conduct this clinical trial, it was necessary for research paramedics to overcome multiple challenges, many of which will be relevant to future emergency medical service (EMS) research. This article aims to describe a number of the challenges that were encountered during the out-of-hospital phase of the AIRWAYS-2 trial and how these were overcome. Methods: The research paramedics responsible for conducting the pre-hospital phase of the trial were asked to reflect on their experience of facilitating the AIRWAYS-2 trial. Responses were then collated by the lead author. A process of iterative revision and review was undertaken by the research paramedics to produce a consensus of opinion. Results: The main challenges identified by the trial research paramedics related to the recruitment and training of paramedics, screening of eligible patients and investigation of protocol deviations / reporting errors. Even though a feasibility study was conducted prior to the commencement of AIRWAYS-2, the scale of these challenges was underestimated. Conclusion: Large-scale pragmatic cluster randomised trials are being successfully undertaken in out-of-hospital care. However, they require intensive engagement with EMS clinicians and local research paramedics, particularly when the intervention is contentious. Feasibility studies are an important part of research but may fail to identify all potential challenges. Therefore, flexibility is required to manage unforeseen difficulties. Abstract published with permission.