• ‘They are not silly people – they know the difference’: clinician focus group views on a pilot randomised controlled trial of prehospital continuous positive airway pressure (CPAP)

      Miller, Joshua; Keating, Samuel; Scott, Alex; Fuller, Gordon W.; Goodacre, Steve (2019-09-24)
      Background Continuous positive airway pressure (CPAP) is not in widespread use in UK ambulance services, but could benefit patients with acute respiratory failure (ARF). As a new treatment in this context, clinician acceptability is an important factor in the feasibility of conducting definitive research in the prehospital arena. Methods As part of a pilot randomised controlled trial (the ACUTE study), nine trial-trained paramedics took part in three semi-structured focus groups. 204 trained staff had been given the opportunity to take part. The sample included six staff who had recruited to the trial, one who had not, and two who had withdrawn from it. Audio-recordings were transcribed and analysed thematically. Results Participants described facilitators to trial participation including: clear eligibility criteria and patient documentation, access to demonstration equipment, training away from the work environment, and repeated patient recruitment. Barriers to taking part included: the lack of protected time for training, inadequate workplace facilities for the electronic learning package used, adverse responses by receiving hospital staff, and infrequent patient exposure. Both paramedics who withdrew cited the inconvenience of carrying packs each shift. Some participants described anxiety and distress when opening packs to find a standard-care mask, and reported patients having similar reactions. Conclusions Future researchers could promote improved workplace computing facilities and increased provision of face-to-face training days, which were praised by participants in these focus groups, but limited to a single event distant from some staff. Greater stakeholder engagement by researchers could reduce the difficulties at hospital handover reported by some ambulance staff. Where blinding is not possible, the perceptions of clinicians and patients should be considered carefully, as this study shows both may have adverse emotional responses to being treated with standard care, particularly when prospective consent discussions describe the trial intervention as potentially beneficial., https://emj.bmj.com/content/36/10/e12.2 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/ DOI http://dx.doi.org/10.1136/emermed-2019-999abs.28
    • Tia prehospital referral feasibility trial (TIER): recruitment and intervention usage

      Rees, Nigel; Hampton, C.; Bulger, Jenna; Ali, K.; Quinn, Tom; Ford, Gary A.; Akbari, Ashley; Ward, Matthew; Porter, Alison; Jones, Colin; et al. (2018-04)
      Aim Early specialist assessment of Transient Ischaemic Attack (TIA) can reduce the risk of stroke and death. We assessed feasibility of undertaking a multi-centre cluster randomised trial to evaluate clinical and cost effectiveness of referral of patients attended by emergency ambulance paramedic with low-risk TIA directly to specialist TIA clinic for early review. Method We randomly allocated volunteer paramedics to intervention or control group. Intervention paramedics were trained to deliver the intervention during the patient recruitment period. Control paramedics continued to deliver care as usual. Patients with TIA were identified from hospital records. Results Development and recruitment phases are complete, with outcome follow up ongoing. Eighty nine of 134 (66%) paramedics participated in TIER. Of 1377 patients attended by trial paramedics during the patient recruitment period, 53 (3.8%) were identified as eligible for trial inclusion. Three of 36 (8%) patients attended by intervention paramedics were referred to the TIA clinic. Of the others, only one appeared to be a missed referral; in one case there was no prehospital record of TIA; one was attended by a paramedic who was not TIER trained; one patient record was missing; all others were recorded with contraindications: FAST positive (n=13); ABCD2 score >3 (n=5); already taking warfarin (n=2); crescendo TIA (n=1) other clinical factors (n=8). Conclusion Preliminary results indicate challenges in recruitment and low referral rates. Further analyses will focus on whether progression criteria for a definitive trial were met, and clinical outcomes from this feasibility trial. https://bmjopen.bmj.com/content/8/Suppl_1/A28.1 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/ http://dx.doi.org/10.1136/bmjopen-2018-EMS.73
    • Tourniquets in the treatment of prehospital haemorrhage

      Bond, Reiss (2018-11)
      Abstract published with permission. Background: During recent conflicts in Iraq and Afghanistan, tourniquets were a useful tool in the management of non-compressible prehospital catastrophic haemorrhage. Recommendations for use within the civilian setting were then made. However, civilian research supporting this change in practice is limited. Aims: The aim of the research is to evaluate the utility of prehospital tourniquet application through description of the complications associated with use, as well as identification of mortality following prehospital application. Methods: A literature search was completed using PubMed and Embase for research studies on prehospital tourniquet use in extremity trauma. Study relevance was confirmed via their abstracts and final selection was made through reviewing the full publication. Data were extracted on mortality, complications, indication for use, effective application and application duration of tourniquet use. This was tabulated, and a descriptive analysis performed. Results: The research reported a mortality range of 3–14% with an associated complication rate of 2.1–32.4%. The effectiveness of prehospital application was in the 88.8–98.7% range, with tourniquet application durations of 48–103.2 minutes. Conclusions: The tourniquet should continue to be available to UK paramedics for the management of prehospital non-compressible catastrophic haemorrhage. Application is likely to provide a mortality benefit with limited morbidity and associated complications.
    • Traumatic cardiac arrest: what’s HOT and what’s not

      Brown, Aidan (2018-05)
      Abstract published with permission. Traumatic cardiac arrest (TCA) is a rare event in the pre-hospital setting and has a varied aetiology. Paramedic management has changed significantly over the past 5 years. Chest compressions have been de-emphasised in guidelines, and the ‘HOT’ principles have been adopted. This principle stands for hypovolaemia; oxygenation; tension pneumothorax/tamponade. The recommendation is that these should be addressed prior to performing chest compressions. There may however be patient groups in TCA who benefit from chest compressions. A management plan including ‘no chest compressions’ for TCA is not supported in the evidence, and they should be commenced as soon as appropriate reversible causes have been addressed. In addition, chest compressions may take precedence over the administration of fluid if both cannot be performed simultaneously. Ambulance services may improve management of TCA by the introduction of an aide-memoire to support clinicians.
    • UK paramedics can legally withhold resuscitation in defined circumstances

      Bronnert, Rosie; Munday, Daniel; Cole, Robert; Pettifer, Annie (2013-06)
    • Understanding clinical papers

      Armitage, Ewan (2014-03)
    • Use of intranasal drug administration in the pre-hospital setting

      Creed, Chloe (2012-12)
      Abstract published with permission. This article explores the benefits of intranasal as a recommended route for drug delivery in the pre-hospital setting for healthcare professionals. It is currently used in Australia,USA and some UK Ambulance services and remains a preferred route in certain patient groups. Intranasal can lead to a reduction in needle stick injuries for the healthcare professional and allowing immediate drug therapy in a emergency setting for bystanders. Randomised control trial’s and evidencebased practice to discuss the absorption rate and different drugs that could be used through this route. After reading this article paramedics should be more aware of this safe route and its benefits in the emergency setting.
    • Use of the Airtraq laryngoscope in a model of difficult intubation by prehospital providers not previously trained in laryngoscopy

      Woollard, Malcolm; Mannion, W.; Lighton, D.; Johns, I.; O'Meara, P.; Cotton, C.; smyth, mike (2007-10)
    • Utility of ambulance data for real-time syndromic surveillance: a pilot in the West Midlands region, United Kingdom

      Todkill, Dan; Loveridge, Paul; Elliot, Alex J.; Morbey, Roger A.; Edeghere, Obaghe; Rayment-Bishop, Tracy; Rayment-Bishop, Chris; Thornes, John E.; Smith, Gillian; Elliot, Alex J. (2017-12)
    • What are emergency ambulance services doing to meet the needs of people who call frequently? A national survey of current practice in the United Kingdom

      Snooks, Helen; Khanom, Ashrafunnesa; Cole, Robert; Edwards, Adrian; Edwards, Bethan Mair; Evans, Bridie A.; Foster, Theresa; Fothergill, Rachael; Gripper, Carol P.; Hampton, Chelsey; et al. (2019-12-28)
    • What fluids are given during air ambulance treatment of patients with trauma in the UK, and what might this mean for the future? Results from the RESCUER observational cohort study

      Naumann, David N.; Hancox, James M.; Raitt, James; Smith, Iain M.; Crombie, Nicholas; Doughty, Heidi; Perkins, Gavin D.; Midwinter, Mark J.; RESCUER Collaborators (2018-01)
      Objectives We investigated how often intravenous fluids have been delivered during physician-led prehospital treatment of patients with hypotensive trauma in the UK and which fluids were given. These data were used to estimate the potential national requirement for prehospital blood products (PHBP) if evidence from ongoing trials were to report clinical superiority. Setting The Regional Exploration of Standard Care during Evacuation Resuscitation (RESCUER) retrospective observational study was a collaboration between 11 UK air ambulance services. Each was invited to provide up to 5 years of data and total number of taskings during the same period. Participants Patients with hypotensive trauma (systolic blood pressure <90mm Hg or absent radial pulse) attended by a doctor. Primary and secondary outcome measures The primary outcome was the number of patients with hypotensive trauma given prehospital fluids. Secondary outcomes were types and volumes of fluids. These data were combined with published data to estimate potential national eligibility for PHBP. Results Of 29037 taskings, 729 (2.5%) were for patients with hypotensive trauma attended by a physician. Half were aged 21–50 years; 73.4% were male. A total of 537 out of 729 (73.7%) were given fluids. Five hundred and ten patients were given a single type of fluid; 27 received >1type. The most common fluid was 0.9% saline, given to 486/537 (90.5%) of patients who received fluids, at a median volume of 750 (IQR 300–1500)mL. Three per cent of patients received PHBP. Estimated projections for patients eligible for PHBP at these 11 services and in the whole UK were 313 and 794 patients per year, respectively. Conclusions One in 40 air ambulance taskings were manned by physicians to retrievepatients with hypotensive trauma. The most common fluid delivered was 0.9% saline. If evidence justifies universal provision of PHBP, approximately 800 patients/year would be eligible in the UK, based on our data combined with others published. Prospective investigations are required to confirm or adjust these estimations. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5786144/pdf/bmjopen-2017-019627.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-2017-019627
    • What happened on Restart a Heart Day 2017 in England?

      Brown, Terry P.; Perkins, Gavin D.; Lockey, Andrew S.; Soar, Jasmeet; Askew, Sara; Mersom, Frank; Fothergill, Rachael; Cox, Emma; Black, Sarah; Lumley-Holmes, Jenny (2018-09)
    • ‘What is the rate of general practitioner registration amongst homeless patients who present to an English ambulance service?’

      Miller, Joshua; McBride, Shaun (2020-10)
      Marginalised groups such as homeless people and migrants experience barriers to registration with a general practitioner (GP). While various interventions have been trialed to improve registration rates, the potential for opportunistic interventions through the ambulance service has not yet been considered. The aim of this study was to determine the scope for these interventions by researching the prevalence of GP registration amongst the homeless population that present to a regional English ambulance service that covers both rural and urban areas. https://emj.bmj.com/content/37/10/e3.2 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. http://creativecommons.org/licenses/by-nc/4.0/ DOI http://dx.doi.org/10.1136/emermed-2020-999abs.4
    • Who receives bystander CPR in a witnessed out-of-hospital cardiac arrest in England

      Brown, Terry P.; Booth, Scott; Hawkes, Claire A.; Fothergill, Rachael; Black, Sarah; Pocock, Helen; Gunson, Imogen; Soar, Jasmeet; Mark, Julian; Perkins, Gavin D. (2018-09)