A retrospective cohort study of pre-hospital agitation management by advanced paramedic practitioners in critical care

Abstract

Introduction: Pre-hospital clinicians can expect to encounter patients with agitation, including acute behavioural disturbance (ABD). These situations carry significant risk for patients and emergency medical services. Advanced paramedics within the London Ambulance Service (LAS) are frequently tasked to these incidents. At present, little evidence exists regarding clinical decision-making and management of this patient group. We sought to explore the demographics of patients presenting with potential ABD and quantify the degree of agitation, physical restraint, effectiveness of chemical sedation and any associated complications.Methods: A retrospective analysis of pre-hospital clinical records for patients coded with ABD and attended by LAS advanced paramedics between 1 October 2019 and 30 September 2020. Sedation assessment tool (SAT) scores were used as the primary outcome measure.Results: A total of 237 patient records were identified. Of the patients, 147 (62%) were physically restrained and 104 (44%) were chemically sedated. Sedation was more commonly administered where patients were exposed to physical restraint. High SAT scores were associated with the administration of sedative agents and at higher doses. Of patients undergoing sedation, 89 (85%) had a SAT score reduction of 2 points or a final score ≤ 0. The mean SAT score reduction was 2.72. Three cases of minor injury were reported following physical restraint.Conclusion: Advanced paramedics undertook sedation in less than half the cohort, suggesting that other strategies such as communication and positioning were utilised. Most patients were managed into a state between being restless and rousable, largely negating the need for ongoing physical restraint during hospital transfer. Appropriately trained advanced paramedics can utilise sedation safely and effectively in selected cases.

Advanced paramedics’ restraint decision-making when managing acute behavioural disturbance (ABD) in the UK pre-hospital ambulance setting: A qualitative investigation

“…The typical response to a high-acuity emergency is the attendance of an emergency ambulance, staffed by a paramedic and emergency medical technician, with or without the additional attendance of a solo paramedic attending by car or motorcycle. LAS has a well-established critical care advanced practice service, and additionally deploys APs to suspected cases of ABD, with a recent study identifying that 237 patients were coded as presenting with ABD by APs in a 12-month period [ 13 ]. APs are permitted to administer chemical sedation to patients using Patient Group Directions (PGDs), a legal framework which enables registered health care professionals to administer parenteral medicines without a prescription in the UK.…”

“…This study took place in a single setting, which is described here to enhance transferability and is not intended to be generalisable to every ambulance service. The LAS employs a small group of around 40 APs who staff four response cars on a 24/7 basis with targeted deployment to suspected ABD incidents, seeing 237 in a year according to one study [ 13 ]. The exposure of ambulance clinicians to suspected ABD cases may vary between different ambulance services.…”

“…APs usually attend later, often at the request of the police themselves. APs may arrive at a chaotic scene [ 13 ] and make restraint decisions, although they will not normally be responsible for carrying out physical restraint. Little is known about how APs make restraint decisions.…”