<sec id="s1">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. </sec> <sec id="s2">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 free-text responses, explored attitudes towards performing this role. </sec> <sec id="s3">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. </sec> <sec id="s4">Conclusions: Provision of EoLC assessment training and dedicated EoLC referral pathways should facilitate ambulance paramedics’ roles in the timely recognition of EoLC patients, potentially addressing current inequalities in access to EoLC. </sec>
Introduction: 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.Methods: Registered and non-registered clinical staff in one ambulance trust completed an online questionnaire utilising five-point Likert scales to collect data about their experiences of using electronic incident summary notifications to report back to the patient’s GP, and on direct patient referrals to community teams for falls and hypoglycaemic episodes. Participants only completed questions relevant to the process they had experienced.Results: From approximately 2115 members of staff eligible to participate, there were 201 respondents (9.50%) who provided information concerning GP summary notifications, fall referrals or hypoglycaemia referrals (n = 154, 76.62%; n = 178, 88.56%; n = 101, 50.25%, respectively).Overall, staff perceived the electronic communication of patient information as useful, but not essential, to their practice. The applications were seen as easy to use and a safer way to handle patient data. Though their use was felt to prolong the time spent on scene, this was regarded as an efficient use of a clinician’s time.Many staff would prefer to talk directly to a patient’s GP, but fewer felt that this was required for community referrals. While most participants did not feel obliged to send a GP summary notification of every encounter, the majority believed that the rates of appropriate falls and hypoglycaemia referrals would be improved with direct electronic communication.Respondents felt that recording and sharing patient information electronically improved collaborative working with other healthcare professionals, and they preferred having this ability.Conclusion: NHS ambulance trusts are transitioning to electronic patient records and this article suggests that ambulance staff are in favour of this transition when the technology is readily accessible and easy to use. Staff believe this approach is a safer way to store and share patient data and that collaborative working is enhanced. However, many clinicians would still prefer to discuss some incidents directly with a GP rather than sending a summary, highlighting the value staff place on real-time professional interaction when managing a patient.
Introduction Pre-hospital emergency medical teams can transfuse blood products to patients with suspected major traumatic haemorrhage. Common transfusion triggers based on physiological parameters have several disadvantages and are largely unvalidated in guiding pre-hospital transfusion. The addition of pre-hospital lactate (P-LACT) may overcome these challenges. To date, the clinical utility of P-LACT to guide pre-hospital blood transfusion is unclear. Methods A retrospective analysis of patients with suspected major traumatic haemorrhage attended by Air Ambulance Charity Kent Surrey Sussex (KSS) between 8 July 2017 and 31 December 2019. The primary endpoint was the accuracy of P-LACT to predict the requirement for any in-hospital (continued) transfusion of blood product. Results During the study period, 306 patients with suspected major traumatic haemorrhage were attended by KSS. P-LACT was obtained in 194 patients. In the cohort 103 (34%) patients were declared Code Red. A pre-hospital transfusion was commenced in 124 patients (41%) and in-hospital transfusion was continued in 100 (81%) of these patients, in 24 (19%) patients it was ceased. Predictive probabilities of various lactate cut-off points for requirement of in-hospital transfusion are documented. The highest overall proportion correctly classified patients were found for a P-LACT cut-point of 5.4 mmol/L (76.50% correctly classified). Based on the calculated predictive probabilities, optimal cut-off points were derived for both the exclusion- and inclusion of the need for in-hospital transfusion. A P-LACT < 2.5 mmol/L had a sensitivity of 80.28% and a negative likelihood ratio [LR−] of 0.37 for the prediction of in-hospital transfusion requirement, whereas a P-LACT of 6.0 mmol/L had a specificity of 99.22%, [LR−] = 0.78. Conclusion Pre-hospital lactate measurements can be used to predict the need for (continued) in-hospital blood products in addition to current physiological parameters. A simple decision support tool derived in this study can help the clinician interpret pre-hospital lactate results and guide pre-hospital interventions in the major trauma patient.
Background Helicopter Emergency Medical Services (HEMS) respond to serious trauma and medical emergencies. Geographical disparity and the regionalisation of trauma systems can complicate accurate HEMS dispatch. We sought to evaluate HEMS dispatch sensitivity in older trauma patients by analysing critical care interventions and conveyance in a well-established trauma system. Methods All trauma patients aged ≥65 years that were attended by the Air Ambulance Kent Surrey Sussex over a 6-year period from 1 July 2013 to 30 June 2019 were included. Patient characteristics, critical care interventions and hospital disposition were stratified by dispatch type (immediate, interrogate and crew request). Results 1321 trauma patients aged ≥65 were included. Median age was 75 years [IQR 69–89]. HEMS dispatch was by immediate (32.0%), interrogation (43.5%) and at the request of ambulance clinicians (24.5%). Older age was associated with a longer dispatch interval and was significantly longer in the crew request category (37 min [34–39]) compared to immediate dispatch (6 min [5–6] (p = .001). Dispatch by crew request was common in patients with falls < 2 m, whereas pedestrian road traffic collisions and falls > 2 m more often resulted in immediate dispatch (p = .001). Immediate dispatch to isolated head injured patients often resulted in pre-hospital emergency anaesthesia (PHEA) (39%). However, over a third of head injured patients attended after dispatch by crew request received PHEA (36%) and a large proportion were triaged to major trauma centres (69%). Conclusions Many patients who do not fulfil the criteria for immediate HEMS dispatch need advanced clinical interventions and subsequent tertiary level care at a major trauma centre. Further studies should evaluate if HEMS activation criteria, nuanced by age-dependant triggers for mechanism and physiological parameters, optimise dispatch sensitivity and HEMS utilisation.
ObjectivesPatients who sustain a head injury but maintain a Glasgow Coma Scale (GCS) of 13–15 may still be suffering from a significant brain injury. We aimed to assess the appropriateness of triage and decision to perform prehospital rapid sequence induction (RSI) in patients attended by a UK Helicopter Emergency Medical Service (HEMS) following head injury.DesignA retrospective cohort study of patients attended by Kent Surrey & Sussex Air Ambulance Trust (KSSAAT) HEMS.SettingA mixed urban and rural area of 4.5 million people in South East England.ParticipantsGCS score of 13, 14 or 15 on arrival of the HEMS team and clinical findings suggesting head injury. Patients accompanied by the HEMS team to hospital (‘Escorted’), and those that were ‘Assisted’ but conveyed by the ambulance service were reviewed. No age restrictions to inclusion were set.Primary outcome measureSignificant brain injury.Secondary outcome measureRecognition of patients requiring prehospital anaesthesia for head injury.ResultsOf 517 patients, 321 had adequate follow-up, 69% of these were Escorted, 31% Assisted. There was evidence of intracranial injury in 13.7% of patients and clinically important brain injury in 7.8%. There was no difference in the rate of clinically important brain injury between Escorted and Assisted patients (p=0.46). Nineteen patients required an RSI by the HEMS team and this patient group was significantly more likely to have clinically important brain injury (p=0.04).ConclusionIn patients attended by a UK HEMS service with a head injury and a GCS of 13–15, a small but significant proportion had a clinically important brain injury and a proportion were appropriately recognised as requiring prehospital RSI. For patients deemed not to need a HEMS intervention, differentiating between those with and without clinically important brain injury appears challenging.Level of evidenceV.
Paramedics are exposed to both physiological and psychological stressors that the general population does not typically face. Although there is evidence to show that paramedics can be resilient to these, cardiovascular disease, mental health problems and musculoskeletal injuries are still prevalent among paramedics. Exercise has been shown to reduce the physical demands of lifting for paramedics, but data on the effects in other areas of paramedic life are limited. In the general population, exercise is becoming a popular treatment option for mental health problems. However, the methodologies used are inconsistent and it is difficult to draw definitive conclusions from the data available. A more thorough examination of how regular exercise could positively impact the health and well-being of paramedics, who are key, front-line personnel in the medical services, is an area that requires crucial further research.
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