British paramedic journal最新文献

The use of pre-hospital blood transfusion by air ambulance crews is increasing. Blood transfusion is traditionally 'authorised' by doctors, not prescribed. However, there is an increasing interest in extending the capability of authorisation to other practitioners - that is, non-medical authorisation (NMA). A UK framework for nurses and midwives has existed since 2007, but training for critical care paramedics (CCPs) has been limited. The Resuscitation with Pre-Hospital Blood Products (RePHILL) trial was launched in 2016, requiring pre-hospital administration of red cells and LyoPlas. Authorisation was initially restricted to doctors, leading to missed recruitment by paramedic-only crews. The trial protocol was amended in 2019 to permit NMA following suitable training and stakeholder consultation. We present a targeted training programme designed to support paramedic-led transfusion within the framework of the pre-hospital trial. We considered the knowledge and skills required for NMA and compared this with baseline knowledge from paramedic training to identify the training gap. We examined examples of existing military and civilian NMA training to develop a targeted programme for a single air ambulance. The four elements of our training programme were pre-course online training, previous trial participation, face-to-face training and competency assessment. Training was delivered to three CCPs, who cascaded the training to 14 colleagues. The training time was one morning, including a face-to-face session and assessment. Novel topics included physiological triggers for transfusion and transfusion risks in the pre-hospital environment. Paramedics were encouraged to recognise and report new patterns of adverse events. Reflective feedback suggests the programme provided CCPs the knowledge to autonomously recruit trial patients and authorise transfusion.

Objectives: Most research investigating staff perceptions of patient safety has been based in primary care or hospitals, with little research on emergency services. Therefore, this study aimed to explore staff perceptions of patient safety in the NHS ambulance services.

Design: A stratified qualitative study using semi-structured interviews.

Setting: Three urban or rural ambulance service NHS trusts in England.

Participants: A total of 44 participants from three organisational levels, including executives, managers and operational staff.

Methods: The semi-structured interviews explored the interpretation and definition of patient safety, perceived risks, incident reporting, communication and organisational culture. The framework method of qualitative data analysis was used to analyse the interviews and NVivo software was used to manage and organise the data.

Results: We identified five dominant themes: varied interpretation of patient safety; significant patient safety risks; reporting culture shift; communication; and organisational culture. The findings demonstrated that staff perceptions of patient safety ranged widely across the three organisational levels, while they remained consistent within those levels across the participating ambulance service NHS trusts in England.

Conclusions: The findings suggest that participants from all organisational levels perceive that the NHS ambulance services have become much safer for patients over recent years, which signifies an awareness of the historical issues and how they have been addressed. The inclusion of three distinct ambulance service NHS trusts and organisational levels provides deepened insight into the perceptions of patient safety by staff. As the responses of participants were consistent across the three NHS trusts, the identified issues may be generic and have application in other ambulance and emergency service settings, with implications for health policy on a national basis.

Background: Older adults with major trauma are frequently under-triaged, increasing the risk of preventable morbidity and mortality. The aim of this systematic review was to identify which individual risk factors and predictors are likely to increase the risk of major trauma in elderly patients presenting to emergency medical services (EMS) following injury, to inform future elderly triage tool development.

Methods: Several electronic databases (including Medline, EMBASE, CINAHL and the Cochrane Library) were searched from inception to February 2021. Prospective or retrospective diagnostic studies were eligible if they examined a prognostic factor (often termed predictor or risk factor) for, or diagnostic test to identify, major trauma. Selection of studies, data extraction and risk of bias assessments using the Quality in Prognostic Studies (QUIPS) tool were undertaken independently by at least two reviewers. Narrative synthesis was used to summarise the findings.

Results: Nine studies, all performed in US trauma networks, met review inclusion criteria. Vital signs (Glasgow Coma Scale (GCS) score, systolic blood pressure, respiratory rate and shock index with specific elderly cut-off points), EMS provider judgement, comorbidities and certain crash scene variables (other occupants injured, occupant not independently mobile and head-on collision) were identified as significant pre-hospital variables associated with major trauma in the elderly in multi-variable analyses. Heart rate and anticoagulant were not significant predictors. Included studies were at moderate or high risk of bias, with applicability concerns secondary to selected study populations.

Conclusions: Existing pre-hospital major trauma triage tools could be optimised for elderly patients by including elderly-specific physiology thresholds. Future work should focus on more relevant reference standards and further evaluation of novel elderly relevant triage tool variables and thresholds.

Introduction: Emergency medical services (EMS) use a combination of policy, clinical practice guidelines and protocols to set out their expectations for service delivery and to inform patient care. While these are integral to how EMS now operate, relatively little is known about how they are developed, or the processes involved. Therefore, the aim of this scoping review is to understand what is known in the literature about the development of policy, guidelines and protocols within EMS.

Methods: This scoping review will follow the Arksey and O'Malley (2005) methodological framework for scoping reviews. A search strategy has been developed using index term definitions, building from authors' knowledge of the field. The following electronic databases will be searched from 2002 to 2021 for all types of publication: CINAHL, Medline, Academic Search Complete and PsycINFO, EMBASE, Nursing and Allied Health, the Cochrane library, NICE Evidence, Scopus, OpenGrey, EThOS, Google Scholar, Google search and key EMS journal websites. The results will be downloaded using EndNote^X9 reference management software and duplicates will be removed. Titles and abstracts of the results will be independently screened for their relevance to the research question, and the full text of each selected publication will be assessed against pre-determined inclusion and exclusion criteria to determine its eligibility. The reference list and forward citations will be searched for articles meeting the eligibility criteria. A second researcher will independently assess a 10% sample of results to allow for validation of this assessment. Data will be extracted and charted on the characteristics of the publications and the knowledge they contribute on the development of policy, guidelines or protocols. Accompanying narratives will be presented to identify themes and gaps in the available evidence. A critical appraisal will be undertaken of the included publications, where empirical research is presented.

Background: Lower back pain (LBP) is the leading cause of disability globally and can be distressing for patients. It is commonly reported that serious pathologies underlying LBP are rare and most patients would be more appropriately managed in primary care. However, recent literature suggests patients accessing emergency care may differ from those accessing primary care. Currently, little is known about the use of ambulance services by people with LBP. The aim of this study was to investigate the extent and nature of ambulance services utilisation by patients presenting with LBP.

Methods: This observational study is a retrospective analysis of ambulance service calls in the North East of England presenting with LBP from 1 August 2016 to 31 July 2017 (Health Research Authority registration 17/WS/0216).

Results: Of 484,495 answered calls, 3315 (0.7%) calls were categorised as initially presenting with LBP. Women represented 59% of callers. Most calls were from those aged 41-50 and 71-80 years old. Almost half of patients (48%) initially presenting with LBP were later categorised with a problem elsewhere. Of the patients, 49% received analgesia, including Entonox (24%) and morphine (13%). Most patients (69%) were transported to an emergency department while 28% remained at home.

Conclusion: LBP is a relatively common reason to call the ambulance service. Contrary to data from primary care, non-spinal causes, which include medical emergencies, make up a significant proportion of this. Current guidance on back pain focuses on primary care and specialist settings. Future updates may need to consider emergency care as a distinct setting with a potentially different patient population.

Introduction: Falls are a significant cause of morbidity and mortality in older adults. Orthostatic hypotension (OH) is very common in this cohort of patients and is a significant risk for falls and associated injuries. We present the case of an 89-year-old female who fell at home, witnessed by her husband. OH was identified during the clinical assessment and considered to be the predominant contributing factor, although the clinical presentation was not associated with classical symptoms.

Case presentation: The patient lost balance while turning away from the kitchen sink; she noted some instability due to a complaint of generalised weakness in both of her legs. No acute medical illness or traumatic injury was identified. A comprehensive history was obtained that identified multiple intrinsic and extrinsic risk factors for falling. The cardiovascular examination was unremarkable except for OH, with a pronounced reduction in systolic blood pressure of 34 mmHg at the three-minute interval and which reproduced some generalised weaknesses in the patient's legs and slight instability. Although classical OH symptoms were not identified, this was considered to be the predominant factor contributing to the fall. A series of recommendations was made to primary and community-based care teams based upon a rapid holistic review; this included a recommendation to review the patient's dual antihypertensive therapy.

Conclusion: It is widely known that OH is a significant risk factor for falls, but asymptomatic or atypical presentations can make diagnosis challenging. Using the correct technique to measure a lying and standing blood pressure, as defined by the Royal College of Physicians, is crucial for accurate diagnosis and subsequent management. Ambulance clinicians are ideally placed to undertake this quick and non-invasive assessment to identify OH in patients that have fallen.

Background: Hypoglycaemia is a common and potentially life-threatening condition in people with diabetes, commonly caused by medications such as insulin. Hypoglycaemic events often require in-patient treatment and/or follow-up with a diabetes specialist nurse (DSN) or GP to make adjustments to medication. This referral pathway commonly relies on patient self-referral to primary care, and as a result many patients are not actively followed up and go on to experience repeat hypoglycaemic events.

Methods: Randomised controlled trial in partnership with East Midlands Ambulance Service NHS Trust. People with diabetes calling out an ambulance for a severe hypoglycaemic episode and meeting the eligibility criteria were randomised to either a novel DSN-led pathway or to their general practice for routine follow-up. Primary outcome was proportion of participants with a documented consultation with a healthcare professional to discuss the management of their diabetes within 28 days of call-out.

Results: 162 people were randomised to one of the pathways (73 DSN arm, 89 GP arm) with 81 (50%, 35 DSN, 46 GP) providing full consent to be followed up. Due to lower than anticipated randomisation and consent rates, the recruitment target was not met. In the 81 participants who provided full consent, there were higher rates of consultation following the call-out when referred to a DSN compared to primary care (90% vs. 65%). Of the 81 participants, 26 (32%) had a second call-out within 12 months.

Conclusions: Consultation rates following the call-out were high in the DSN-led arm, but there was insufficient power to complete the planned comparative analysis. The study highlighted the difficulty in recruitment and delivery of research in pre-hospital emergency care. Further work is needed to provide more feasible study designs and consent procedures balancing demands on ambulance staff time with the need for robust well-designed evaluation of referral pathways.

Background: Dementia is common in older adults assessed by ambulance services. However, inconsistent reporting via the patient record may result in this diagnosis being overlooked by healthcare staff further down the care pathway. This can have a deleterious effect on subsequent patient care, increasing morbidity and mortality. We sought to understand how and where ambulance staff would like to record this finding on the electronic patient record (ePR).

Methods: We designed and implemented a survey of ambulance staff in a single service to understand how they identify patients with dementia, how they record dementia on the ePR and how the ePR could be improved to better capture dementia. Scoping questions on frailty were included. The survey was tested using cognitive interviewing. Analysis was conducted using descriptive statistics for closed questions and thematic analysis for open questions as appropriate.

Results: 131 surveys were completed; 60% of participants were paramedics and 40% were other grades of front line staff. Participants reported consulting electronic/paper sources, and individuals such as carers involved in the patients' care, to establish whether dementia had been diagnosed. Frailty assessments were prompted by social context, reduced mobility, a fall or diagnosis of dementia. Staff reported documenting dementia in 20 different areas on the ePR and 46% of participants stated a preference for a designated area to record the information. However, 15% indicated it was not necessary to record dementia or that no ePR changes were required.

Conclusions: We have highlighted the variation in ambulance staff practice in recording of dementia. Alterations to the ePR are required to ensure that dementia is recorded consistently and is easily retrievable. Clearer guidance on when to assess frailty may also enhance information provision to care staff in other sectors, resulting in more appropriate clinical and social care.