• The A2Z of Immediate Care

      Walker, Alison (2011-08)
    • Addressing the challenges of paramedic recruitment and engagement in AIRWAYS-2

      Pilbery, Richard; Green, Jonathan; Hall, Helen; Whitley, Gregory Adam (2016-09)
      AIRWAYS-2 is an NIHR-funded study to determine the best initial approach to advanced airway management during out of hospital cardiac arrest (OHCA). Four NHS ambulance trusts are taking part in AIRWAYS-2: East Midlands, South Western, Yorkshire and East of England. One of the key challenges has been the need to recruit approximately 1300 study paramedics for the trial. The three main challenges in engaging and recruiting paramedics to participate in AIRWAYS-2 have been: ▸ Concerns relating to the potential results of the trial and what this will mean for the continuation of intubation for paramedics ▸ Concerns relating to the restriction on paramedic choice of advanced airway in OHCA and potential skill erosion ▸ Provision of training over large geographical areas at a time when morale is low and many ambulance trusts have recruitment and retention issues. How have these challenges been overcome? ▸ Communication: Identifying the most appropriate communication methods in each Trust e.g. face to face, email, internal trust operational updates ▸ Delivery of key messages: Emphasising why the trial is important and needed, and that its goal is not to remove intubation from paramedic practice. Obtaining the engagement of senior operational management to allay fears over impacts on service performance ▸ Valuing study paramedics: Paying clinicians overtime to attend training sessions, which contributes to their own continuing professional development ▸ Equity and opportunity: Delivery of multiple training sessions throughout each of the four ambulance trusts. Key achievements By November 2015, research paramedics had delivered nearly 350 training sessions and recruited in excess of 1300 paramedics to AIRWAYS-2. Conclusion The research paramedics leading AIRWAYS-2 have collaboratively, and successfully, overcome the main challenges relating to recruiting and engaging the paramedics in their Trusts. This should contribute to achieving the target patient sample size for the trial. https://emj.bmj.com/content/emermed/33/9/e12.1.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/emermed-2016-206139.38
    • An alternative care pathway for suspected seizures in pre-hospital care: a service evaluation

      Dickson, Jon M.; Rawlings, Gregg H.; Grünewald, Richard A.; Miles, Kate; Mack, Carina; Heywood, Thomas; Reuber, Markus (2017-09)
      Abstract published with permission. Introduction ‐ An uncomplicated, self-limiting epileptic seizure in a patient with an established diagnosis of epilepsy usually requires only first aid, but in the UK it is estimated that 75% of these patients are transported to hospital and many are discharged without review or follow-up with an epilepsy specialist. Alternative care pathways have the potential to reduce unnecessary conveyance to hospital and to improve rates of epilepsy specialist follow-up, and thereby increase the quality and cost effectiveness of care. Methods ‐ A service evaluation of a new alternative care pathway in a regional ambulance service in the UK. The alternative care pathway allowed paramedics to refer eligible patients to an epilepsy specialist nurse service. Results ‐ The ambulance service managed 3964 suspected seizure incidents in the study period (1 July 2015‐31 May 2016), of which 22.5% (891/3964) were potentially eligible for the alternative care pathway. Of the potentially eligible incidents, 9.8% (87/891) were referred. The 87 incidents were generated by 74 individual patients. A total of 97.3% (71/73) patients were contacted within the target time of five days, the average time taken for each phone call was 10 minutes and the average additional work load generated by each call was 10 minutes. There was a positive outcome in 55% (48/87) of incidents. Conclusions ‐ An alternative care pathway for people after a suspected seizure has the potential to safely reduce rates of transport to hospital and to improve care for people with epilepsy. However, paramedics in our study used the alternative care pathway for only a small proportion of those patients who were potentially eligible. Further research is required to develop tools to support paramedics to confidently identify patients that are suitable for management without transport to hospital.
    • Ambulance over-conveyance to the emergency department: a large data analysis of ambulance journeys

      Miles, J.; O'Keeffe, C.; Jacques, Richard; Stone, Tony; Mason, Suzanne (2018-04)
      Aim Over-conveyance by the ambulance service is a compounding factor of emergency department (ED) crowding. Previous solutions have focused on specific patient groups which have a limited impact when compared to the whole urgent and emergency care system. This study aims to analyse nonurgent conveyances by the ambulance service that could be suitable for discharge on-scene. Results We analysed a dataset of 1,312,539 patient episodes which linked all pre-hospital emergency and urgent calls to subsequent ED attendance in 2014. The study was set in a large region in England (total population 5.3 million). As well as proportion of avoidable conveyances we also examined the association with patient age, time of arrival, re-attendance and initial triage code from ambulance dispatch. Results There were 4 04 348 (30.8%) patients transported to ED by ambulance and of these 66 220 (16.4%) were considered potentially avoidable. There were significantly increased odds of a non-urgent conveyance out of hours (OR 1.44, 95% CI: 1.41 to 1.46). Patients aged 16–34 had the largest proportion of avoidable conveyances with 24 500 (37%). There were 13 625 (21%) episodes that were received from another healthcare professional or urgent telephone number. When analysing ED diagnosis, the highest proportion were attending with minor injury and illness, and alcohol intoxication. Abstracts A22 BMJ Open 2018;8(Suppl 1):A1–A34 Trust (NHS). Protected by copyright. on 14 August 2019 at Manchester University NHS Foundation http://bmjopen.bmj.com/ BMJ Open: first published as 10.1136/bmjopen-2018-EMS.59 on 16 April 2018. Downloaded from Conclusion One in six ambulance conveyances to ED were deemed non-urgent. The younger population had the largest amount of preventable conveyance by ambulance with diagnoses which could be treated and discharged on-scene. Pathways and interventions would provide a larger patient benefit if they were designed around patient populations as opposed to disease specific https://bmjopen.bmj.com/content/8/Suppl_1/A22.3 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/bmjopen-2018-EMS.59
    • “At the sharp end”: does ambulance dispatch data from south Yorkshire support the picture of increased weapon-related violence in the UK?

      Gray, J.T.; Walker, A. (2009-09-22)
      Objective: To assess whether ambulance responses in South Yorkshire to stabbing, gunshot, penetrating trauma cases have increased over the past few years, supporting the observed increase in media reporting. Methods: A review was undertaken of the frequency with which the ambulance medical priority dispatch system card 27 (stab/gunshot/penetrating trauma) was used, grouped by financial year, and comparison made over time and by patient age group. Results: There is a steady increase in the number of occurrences of these cases and also an increase in the percentage made up by the 10–29 year age group. Conclusions: Ambulance data from South Yorkshire support the media conclusion that there is an increase in stabbing, gunshot and penetrating trauma as well as an increase in the proportion of younger victims. This has wider implications for ambulance staff and the UK as a whole; however, these calls remain a low percentage of overall ambulance service activity. https://emj.bmj.com/content/26/10/741. 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/emj.2008.067298
    • Avoiding admissions from the ambulance service: a review of elderly patients with falls and patients with breathing difficulties seen by emergency care practitioners in South Yorkshire

      Gray, J.T; Walker, A. (2008-02-25)
      To determine the true impact of emergency care practitioners (ECPs) on admissions relative to emergency department (ED) attendance. https://emj.bmj.com/content/25/3/168 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/emj.2007.050732
    • Awareness of CPR-induced consciousness by UK paramedics

      Mays, Ben; Gregory, Pete; Sudron, Ceri; Kilner, Tim (2019-06-01)
    • Bypassing nearest hospital for more distant neuroscience care in head-injured adults with suspected traumatic brain injury: findings of the head injury transportation straight to neurosurgery (HITS-NS) pilot cluster randomised trial

      Lecky, Fiona E.; Russell, Wanda; McClelland, Graham; Pennington, Elspeth; Fuller, Gordon W.; Goodacre, Steve; Han, Kyee; Curran, Andrew; Holliman, Damian; Chapman, Nathan; et al. (2017-10)
      Objective Reconfiguration of trauma services, with direct transport of patients with traumatic brain injury (TBI) to specialist neuroscience centres (SNCs)— bypassing non-specialist acute hospitals (NSAHs), could improve outcomes. However, delays in stabilisation of airway, breathing and circulation (ABC) may worsen outcomes when compared with selective secondary transfer from nearest NSAH to SNC. We conducted a pilot cluster randomised controlled trial to determine the feasibility and plausibility of bypassing suspected patients with TBI —directly into SNCs—producing a measurable effect. Setting Two English Ambulance Services. Participants 74 clusters (ambulance stations) were randomised within pairs after matching for important characteristics. Clusters enrolled head-injured adults— injured nearest to an NSAH—with internationally accepted TBI risk factors and stable ABC. We excluded participants attended by Helicopter Emergency Medical Services or who were injured more than 1 hour by road from nearest SNC. Interventions Intervention cluster participants were transported directly to an SNC bypassing nearest NSAH; control cluster participants were transported to nearest NSAH with selective secondary transfer to SNC. Outcomes Trial recruitment rate (target n=700 per annum) and percentage with TBI on CT scan (target 80%) were the primary feasibility outcomes. 30-day mortality, 6-month Extended Glasgow Outcome Scale and quality of life were secondary outcomes. Results 56 ambulance station clusters recruited 293 patients in 12 months. The trial arms were similar in terms of age, conscious level and injury severity. Less than 25% of recruited patients had TBI on CT (n=70) with 7% (n=20) requiring neurosurgery. Complete case analysis showed similar 30-day mortality in the two trial arms (control=8.8 (2.7–14.0)% vs intervention=9.4(2.3–14.0)%). Conclusion Bypassing patients with suspected TBI to SNCs gives an overtriage (false positive) ratio of 13:1 for neurosurgical intervention and 4:1 for TBI. A measurable effect from a full trial of early neuroscience care following bypass is therefore unlikely https://bmjopen.bmj.com/content/bmjopen/7/10/e016355.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-2017-016355
    • Bystander cardiopulmonary resuscitation: Impact of training initiatives

      Brown, Terry P.; Booth, Scott; Lockey, Andrew S.; Askew, Sara; Hawkes, Claire A.; Fothergill, Rachael T.; Black, Sarah; Pocock, Helen; Gunson, Imogen; Soar, Jasmeet; et al. (2018-09)
    • Characteristics of neighbourhoods with high incidence of out-of-hospital cardiac arrest and low bystander cardiopulmonary resuscitation rates in England

      Brown, Terry P.; Booth, Scott; Hawkes, Claire A.; Soar, Jasmeet; Mark, Julian; Mapstone, James; Fothergill, Rachael; Black, Sarah; Pocock, Helen; Bichmann, Anna; et al. (2019-01-01)
    • Characteristics of people from Leeds with severe hypoglycaemia requiring emergency services intervention in the home

      james, cathryn; Scott, A. R.; Walker, Alison; Ajjan, Ramzi A.; Clapham, Linda (2010-03)
    • Clinical guidelines — one year on

      Irving, Steve; Millins, Mark (2014-01)
    • Consensus statement: a framework for safe and effective intubation by paramedics

      Gowens, Paul; Aitken-Fell, Paul; Broughton, Will; Harris, Liz; Williams, Julia; Younger, Paul; Bywater, David; Crookston, Colin; Curatolo, Lisa; Edwards, Tim; et al. (2018-06)
      Abstract published with permission. This consensus statement provides profession-specific guidance in relation to tracheal intubation by paramedics ‐ a procedure that the College of Paramedics supports. Tracheal intubation by paramedics has been the subject of professional and legal debate as well as crown investigation. It is therefore timely that the College of Paramedics, through this consensus group, reviews the available evidence and expert opinion in order to prevent patient harm and promote patient safety, clinical effectiveness and professional standards. It is not the purpose of this consensus statement to remove the skill of tracheal intubation from paramedics. Neither is it intended to debate the efficacy of intubation or the effect on mortality or morbidity, as other formal research studies will answer those questions. The consensus of this group is that paramedics can perform tracheal intubation safely and effectively. However, a safe, well-governed system of continual training, education and competency must be in place to serve both patients and the paramedics delivering their care.
    • Cross-sectional study of the hospital management of adult patients with a suspected seizure (EPIC2)

      Dickson, Jon M.; Dudhill, Hannah; Shewan, Jane; Mason, Suzanne; Grünewald, Richard A.; Reuber, Markus (2017-07)
      Objective To determine the clinical characteristics, management and outcomes of patients taken to hospital by emergency ambulance after a suspected seizure. Design Quantitative cross-sectional retrospective study of a consecutive series of patients. Setting An acute hospital trust in a large city in England. Participants In 2012–2013, the regions’ ambulance service managed 605 481 emergency incidents, 74 141/605 481 originated from Sheffield (a large city in the region), 2121/74 141 (2.9%) were suspected seizures and 178/2121 occurred in May 2012. We undertook detailed analysis of the medical records of the 91/178 patients who were transported to the city’s acute hospital. After undertaking a retrospective review of the medical records, the best available aetiological explanation for the seizures was determined. Results The best available aetiological explanation for 74.7% (68/91) of the incidents was an epileptic seizure, 11.0% (10/91) were psychogenic non-epileptic seizures and 9.9% (9/91) were cardiogenic events. The epileptic seizures fall into the following four categories: first epileptic seizure (13.2%, 12/91), epileptic seizure with a historical diagnosis of epilepsy (30.8%, 28/91), recurrent epileptic seizures without a historical diagnosis of epilepsy (20.9%, 19/91) and acute symptomatic seizures (9.9%, 9/91). Of those with seizures (excluding cardiogenic events), 2.4% (2/82) of patients were seizing on arrival in the Emergency Department (ED), 19.5% (16/82) were postictal and 69.5% (57/82) were alert. 63.4% (52/82) were discharged at the end of their ED attendance and 36.5% (19/52) of these had no referral or follow-up. Conclusions Most suspected seizures are epileptic seizures but this is a diagnostically heterogeneous group. Only a small minority of patients require emergency medical care but most are transported to hospital. Few patients receive expert review and many are discharged home without referral to a specialist leaving them at risk of further seizures and the associated morbidity, mortality and health services costs of poorly controlled epilepsy https://bmjopen.bmj.com/content/bmjopen/7/7/e015696.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-2016-015696
    • Cross-sectional study of the prehospital management of adult patients with a suspected seizure (EPIC1)

      Dickson, Jon M.; Taylor, Louise H.; Shewan, Jane; Baldwin, Trevor; Grünewald, Richard A.; Reuber, Markus (2016-02)
      Objectives: Suspected seizures are a common reason for emergency calls to ambulance services. Prehospital management of these patients is an important element of good quality care. The aim of this study, conducted in a regional ambulance service in the UK, was to quantify the number of emergency telephone calls for suspected seizures in adults, the associated costs, and to describe the patients’ characteristics, their prehospital management and their immediate outcomes. Design: Quantitative cross-sectional study using routinely collected data and a detailed review of the clinical records of a consecutive series of adult patients (≥16 years). Setting: A regional ambulance service within the National Health Service in England. Participants: Cross-sectional data from all 605 481 adult emergency incidents managed by the ambulance service from 1 April 2012 to 31 March 2013. We selected a consecutive series of 178 individual incidents from May 2012 for more detailed analysis (132 after exclusions and removal of non-seizure cases). Results: Suspected seizures made up 3.3% of all emergency incidents. True medical emergencies were uncommon but 3.3% had partially occluded airways, 6.8% had ongoing seizure activity and 59.1% had clinical problems in addition to the seizure (29.1% involving injury). Emergency vehicles were dispatched for 97.2% of suspected seizures, the seizure had terminated on arrival in 93.2% of incidents, 75% of these patients were transported to hospital. The estimated emergency management cost per annum of suspected seizures in the English ambulance services is £45.2 million (€64.0 million, $68.6 million). Conclusions: Many patients with suspected seizures could potentially be treated more effectively and at lower cost by modifying ambulance call handling protocols. The development of innovative care pathways could give call handlers and paramedics alternatives to hospital transportation. Increased adoption of care plans could reduce 999 calls and could increase the rates of successful home or community treatment. https://bmjopen.bmj.com/content/bmjopen/6/2/e010573.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-2015-010573
    • Decision making and safety in ambulance service transitions

      O'Hara, Rachel; Johnson, Maxine; Hirst, Enid; Weyman, Andrew; Shaw, Deborah; Mortimer, Peter; Newman, Chris; Storey, Matthew; Turner, Janette; Mason, Suzanne; et al. (2015-05)
      Introduction Decisions made by ambulance staff are often timecritical and based on limited information. Wrong decisions could have serious consequences for patients but little is known about areas of risk associated with decisions about patient care. We aimed to examine system in fluences on decision making in the ambulance service setting focusing on paramedic roles. Method An exploratory mixed methods qualitative study was conducted in three Ambulance Service Trusts. A document search and 16 interviews were conducted to understand service delivery in each Trust, how they link with other services and potential influences on decisions about patient care. Researchers observed ambulance crews on 34 shifts and 10 paramedics completed ‘digital diaries’ to report challenges for decision making or patient safety. Three focus groups with staff (N=21) and three with service users (N=23) were held to explore their views on decision making and patient safety. Data were charted to produce a typology of decisions then coded and thematically analysed to identify in fluences on those decisions. Findings Nine types of decision were identi fied, ranging from specialist emergency pathways to non-conveyance. In fluences on these decisions included communication with Control Room staff; patient assessment, decision support and alternative options to ED conveyance. Seven main issues in fluencing patient safety in decision making were identi fied: meeting demand; performance and priorities; access to care options; risk aversion; education, training and professional development for crews; communication and feedback to crews; resources and safety culture. Conclusions A range of decisions are made by ambulance staff in complex, time bound changing conditions. Training and development and access to alternative options to ED conveyance were identi fied as particularly important issues. https://emj.bmj.com/content/emermed/32/5/e2.1.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/emermed-2015-204880.4
    • Describing and predicting frequent callers to an ambulance service: analysis of 1 year call data

      Scott, Jason; Strickland, Annette Patricia; Warner, Karen; Dawson, Pamela (2014-05)
      Aims Ambulance services in England receive around 8 million calls a year, and no known studies have explored characteristics of frequent callers. This study aimed to identify the characteristics of the most frequent callers to Yorkshire Ambulance Service (YAS) between April 2010 and March 2011. Methods Top 100 frequent callers to YAS were analysed using population comparison, case control and multiple regression methods. 7808 calls were made by the frequent callers, and data were analysed to predict total number of calls made, and explore characteristics of frequent callers. Results Six call codes were associated with a higher number of calls. Frequent callers were assigned slower response levels, or often no call code. Calls increased during the times of 4:00–9:00, 16:00–20:00 and 22:00–2:00, and in the months of December, January and February. Men and patients with all but the very highest conveyance rates had a higher number of different reasons for calling. Patients with a medical diagnosis were more likely to be conveyed, while patients with a psychiatric classification had a higher number of different reasons for calling, were older and were more likely to call for ‘assault/sexual assault’ or ‘haemorrhage/laceration’. Conclusions Frequent callers to YAS were a heterogeneous group that differed from the overall population served, resulting in numerous implications for the delivery of services for this group of patients. Further research is required to determine if and how frequent callers differ from frequent attenders at emergency departments. https://emj.bmj.com/content/emermed/31/5/408.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/emermed-2012-202146
    • Developing leadership in the UK’s ambulance service: a review of the consultant paramedic role

      Hodge, Andrew (2014-03)
      Abstract published with permission. Background: This study seeks to understand part of the emerging clinical leadership framework implemented in the UK’s NHS ambulance services in recent years. The aim is to explore the relatively new role of consultant paramedics and understand their leadership activities in relationship to nationally determined requirements, and the challenges they face performing this crucial leadership role. Methods: Semi-structured interviews were conducted with all consultant paramedics in the UK in 2013. Thematic analysis and coding were used to analyse the data and identify emergent themes. Additionally, basic demographic data was collected for comparison against national requirements. Findings: The findings illustrated three key themes: credible clinical leadership, an emerging empowered profession, and role expectations. There is a clear indication that consultant paramedics are a key part of clinical leadership for the paramedic profession. However, they are challenged to remain clinically competent by undertaking regular clinical practice and providing visible leadership on the ground, while strategically taking the profession forward. Operational resistance and power issues were highlighted as some of the problems faced by these clinical leaders. Implications: The findings may prove useful for employers in reviewing their clinical leadership structures, and in workforce planning for future consultant paramedics. The paramedic profession and its professional body may equally find this study useful for informing future strategic planning.