British Paramedic Journal

Saving ambulance resources: a service evaluation of the identification of non-viable out-of-hospital cardiac arrest in London by advanced paramedic practitioners in critical care

2023-10-07T13:00:58+01:00

Background: Advanced Paramedic Practitioners in Critical Care (APPCC) are advanced clinical practitioners focused on the delivery of pre-hospital critical care. While working in an ambulance control room setting APPCCs seek to identify emergency calls appropriate for operational APPCCs to attend. These would include out-of-hospital cardiac arrest (OHCA). Through interrogation of incoming emergency calls they are also able to identify OHCA calls where resuscitation may be futile. In these cases and within a governance framework they cancel down multiple ambulance responders leaving only the closest responding resource to attend, thereby ‘saving resources’ that can be re-directed to other waiting emergency calls. It is believed that this is the first initiative of this nature in the United Kingdom.

Methods: A three-year retrospective service evaluation of data was undertaken. The aim was to quantify the number of ‘saved resources’, including both double crew ambulances (DCA) and solo (single person) responders. Furthermore, to equate those savings into potential hours saved using average known job cycle times (JCT). Additionally, we assessed safety by searching all mandated incident reports for occasions where despite cancellation of resources by an APPCC, resuscitation was commenced by the first response to scene.

Results: 13,356 ambulance resources were saved. Of these, 6593 (49.4%) were DCAs and 6763 (50.6%) were solo responders. Using the average JCT for deceased patients of 108.4 minutes, the total time saving equated to 23,328.48 hours of work or 1944.04 12-hour shifts. When considering DCAs alone, the average JCT for obviously deceased patients was 110.9 minutes. This equates to 12,186.1 hours of work or 1015.5 12-hour shifts. 15 incident reports were identified. All had been investigated revealing appropriate decision making in cancelling ambulance resources. No patient harm was identified.

Conclusion: APPCCs working within a governance framework safely saved a significant number of ambulance resources over a three-year period. Perceived benefits include ‘freeing up’ DCA and solo responders allowing them to be redirected to other emergency calls, leading to potential improvement in response times for patients waiting for an ambulance resource.

How consistent are pre-alert guidelines? A review of UK ambulance service guidelines

2023-03-06T10:23:22+00:00

Aims: Ambulance pre-alerts are used to inform receiving emergency departments (EDs) of the arrival of critically unwell or rapidly deteriorating patients who need time-critical assessment or treatment immediately upon arrival. Inappropriate use of pre-alerts can lead to EDs diverting resources from other critically ill patients. However, there is limited guidance about how pre-alerts should be undertaken, delivered or communicated. We aimed to map existing pre-alert guidance from UK NHS ambulance services to explore consistency and accessibility of existing guidance.

Methods: We contacted all UK ambulance services to request documentation containing guidance about pre-alerts. We reviewed and mapped all guidance to understand which conditions were recommended for a pre-alert and alignment with Association of Ambulance Chief Executives (AACE) and Royal College of Emergency Medicine (RCEM) pre-alert guidance. We reviewed the language and accessibility of guidance using the AGREE II tool.

Results: We received responses from 15/19 UK ambulance services. Five had no specific pre-alert guidance. We identified noticeable variations in conditions declared suitable for pre-alerts in each service with a lack of consistency within each ambulance service’s own guidance, and alignment with the AACE/RCEM pre-alert guidance. Services listed between four and 45 different conditions suitable for pre-alert. There were differences in physiological thresholds and terminology, even for conditions with established care pathways (e.g. hyperacute stroke, ST segment elevation myocardial infarction).

Pre-alert criteria were typically a short section in lengthy handover procedure policy documents. Documents appraised were of poor quality with low scores below 35% for applicability and overall.

Implications: There is a clear need for ambulance services to have both policies and tools that complement each other and incorporate the same list of pre-alertable conditions. Clinicians need a single, easily accessible document to refer to in a time critical situation to prevent confusion and reduce risk to clinicians making an incorrect pre-alert decision by not using the policy, tool and guidance.

Sex differences in the pre-hospital ambulance delay, assessment and treatment of patients with acute coronary syndrome: A rapid evidence review

2023-09-18T13:35:27+01:00

Background: Chest pain is a frequent symptom suffered by adult patients attended by ambulance. Evidence suggests female patients may suffer different symptoms to their male counterpart, potentiating differences in pre-hospital time delays, assessment and treatment.

Objective: To explore the sex differences in the pre-hospital ambulance delay, assessment, and treatment of patients with acute coronary syndrome (ACS).

Methods: A rapid evidence review was conducted following the Cochrane rapid review guidelines. MEDLINE and CINAHL Complete were searched via EBSCOhost on 2 February 2023 and reference lists of included studies and reviews were screened. The Joanna Briggs Institute checklist for analytical cross-sectional studies was used to perform critical appraisal and a narrative synthesis was conducted.

Results: From 216 articles screened, nine were included representing over 3.1 million patients from five different countries. Female patients were more likely to suffer delays in time to first electrocardiogram (ECG) and delays in transport time to the emergency department by ambulance. Female patients were also less likely to receive an ECG, aspirin, glyceryl trinitrate and other analgesics.

Conclusion: There are sex disparities in the pre-hospital ambulance delay, assessment, and treatment of patients with ACS. Future research is urgently needed to fully understand the reasons for these observations.

A qualitative exploration of ambulance clinician behaviour and decision making to identify factors influencing on-scene times for suspected stroke patients in North East England

2023-05-03T19:12:09+01:00

Aims/objectives: Ambulance clinician assessment of suspected stroke patients aims to provide rapid access to specialist care, however regional and national data show increasing pre-hospital times. This study explored paramedic views about factors contributing to on-scene times (OST) for suspected stroke patients, with a view to identifying opportunities for future interventions to reduce OST.

Methods: Views of paramedics from one regional service on factors influencing OST were explored using a qualitative approach. Semi structured interviews with volunteers were recorded, transcribed, and analysed using thematic analysis.

Results: Interviews were conducted with 13 paramedics between August and November 2021. Five interlinked themes were identified and described a range of factors influencing OST:

‘Initial assessment and sources of information’ describes how clinicians make assessments based on initial presentation, influenced by pre-arrival information from ambulance control and family members/bystanders at the scene, and how this influences OST.
‘Suitability for treatment and interventions’ describes how paramedics consider actions such as the FAST test, cannulation, ECGs, and neurological assessments while recognising that pre-hospital interventions for suspected stroke are limited.
‘The environment’ describes the influence of incident setting on OST, including the overall process needed to transport the patient to appropriate care.
‘Hospital interactions’ describes how interactions with hospital staff influenced paramedic actions and OST.
‘Changing practice’ describes the influence of experience and interaction with hospital staff leading to changes in paramedic practice over time.

Conclusion: This study provides insight into how UK paramedics spend time on-scene with stroke patients. Multiple factors influencing OST were identified which signpost opportunities for interventions designed to reduce OST. Standardising on-scene assessments for stroke patients, refining communication processes between ambulance services and hospital stroke services, and increasing availability of stroke CPD for paramedics were all identified as potential targets for improving OST.

The COVID-19 ambulance response assessment (CARA) study: a national survey of ambulance service healthcare professionals’ preparedness and response to the COVID-19 pandemic

2022-10-28T15:44:00+01:00

Background: The coronavirus (COVID-19) pandemic placed significant demand on the National Health Service (NHS), including ambulance services, but it is unclear how this affected ambulance service staff and paramedics in other clinical settings (e.g. urgent and primary care, armed services, prisons). This study aimed to measure the self-perceived preparedness and impact of the first wave of the pandemic on paramedics’ psychological stress and perceived ability to deliver care.

Methods: Ambulance clinicians and paramedics working in other healthcare settings were invited to participate in a three-phase sequential online survey during the acceleration (April 2020), peak (May 2020) and deceleration (September/October 2020) phases of the first wave of COVID-19 in the United Kingdom. Recruitment used social media, trust internal bulletins and the College of Paramedics communication channels employing a convenience sampling strategy. Data were collected using purposively developed open- and closed-ended questions and the validated General Health Questionnaire-12 (GHQ-12) . Data were analysed using multi-level linear and logistic regression models.

Results: Phase one recruited 3717 participants, reducing to 2709 (73%) by phase two and 2159 (58%) by phase three. Participants were mostly male (58%, n = 2148) and registered paramedics (n = 1992, 54%). Mean (standard deviation) GHQ-12 scores were 16.5 (5.2) during phase one, reducing to 15.2 (6.7) by phase three. 84% of participants (n = 3112) had a GHQ-12 score ≥ 12 during the first phase, indicating psychological distress. Participants that had higher GHQ-12 scores were feeling unprepared for the pandemic, reported a lack of confidence in using personal protective equipment and managing cardiac arrests in confirmed or suspected COVID-19 patients.

Conclusions: Most participants reported psychological distress, the reasons for which are multi-factorial. Ambulance managers need to be aware of the risks to staff mental health and take action to mitigate these, to support staff in the delivery of unscheduled, emergency and urgent care under these additional pressures.