Ambulance Services In England Research Articles

Increased survival for resuscitated Utstein-comparator group patients conveyed directly to cardiac arrest centres in a large rural and suburban population in England

AimThe cohort of patients in which cardiac arrest centres (CAC) in rural and suburban populations confer the greatest survival benefit remains unclear. The aim of this study was to assess whether the transfer of resuscitated Utstein-comparator out-of-hospital cardiac arrest (OHCA) patients direct to a CAC was associated with improved survival to hospital discharge compared to patients conveyed to non-specialist centres. MethodsA consecutive sample of adult (≥18 years old) Utstein-comparator patients (witnessed collapse and initial shockable rhythm) were included from the East of England Ambulance Service NHS Trust Utstein resuscitation registry; 2018–2022. Logistic regression was used to compare survival-to-discharge in patients transported to CACs compared with patients transported to non-specialist centres. ResultsDuring the study period, resuscitation was attempted in 18,276 OHCA patients. N = 2448 (13.4%) met the Utstein comparator definition and 1151 patients were included in the final analysis; per protocol. Survival was greater for patients conveyed to a CAC (n = 768, 60.7%) compared to non-specialist centres (n = 383, 47.3%); adjusted OR 1.44 (95%CI 1.07–1.94),p = 0.017. Amongst the centres analysed in this study, there was significant inter-hospital variability in survival between CACs (p = 0.017). There was no association between patient volume and survival (p = 0.850). ConclusionDirect transport to a cardiac arrest centre was associated with a 44% increase in the odds of survival compared to conveyance to a non-specialist centre for resuscitated adult patients presenting with witnessed collapse and initial shockable OHCA rhythm.

Variation in patient gender and sexual identity recording within ambulance records

Background: Health inequality among lesbian, gay, bisexual and transgender people has been highlighted in several reports. Ambulance services have been advised to record the gender identity and sexuality of all patients treated to support monitoring of health equity. Method: Four NHS ambulance services in England were asked for their data showing whether the completed patient record for each incident included gender identity and sexuality. Results: All services responded; data from three were used in the analysis. Only one service had the means to record a patient's sexual orientation. Gender identity was recorded by all services but the rate of data capture as well as potential responses varied between organisations. Discussion: There was little consistency between the three services regarding rates of data being captured, responses and potential answers. These variations could not be explained, although introduction of electronic patient records may impact data capture and quality.

Opportunistic identification of atrial fibrillation during unscheduled contact with emergency ambulance services in England: a qualitative exploration

Abstract Background Atrial fibrillation (AF) is an important risk factor for stroke which commonly affects people attended by Emergency Medical Services (EMS). There may be an opportunity for. EMS clinicians to find new incidental cases of AF suitable for oral anticoagulation (OAC) amongst the population who do not require conveyance to hospital following urgent ambulance review. Purpose This study explored whether it was acceptable to propose a formal pathway for identification and subsequent referral of non-conveyed EMS patients with incidental AF to their general practitioner (GP) for consideration of OAC prescription. The perspectives of patients, paramedics, and field experts were included. Methods This qualitative study included four online focus groups involving 18 members of the public and one-to-one online interviews in England with 11 health care and service providers (6 paramedics, 5 field experts providing multiple expertise in cardiology, general practice, public health, academic research, healthcare policy, and primary care commissioning) between June and September 2022. A semi-structured topic guide was used, with purposive sampling to maximise the diversity of perspective and experience in all participant groups. Data were audio-recorded, transcribed anonymously and analysed thematically. Results All participant groups supported formalising the opportunistic detection of AF during EMS review, but each had concerns and caveats. Of paramount concern to all groups was that any change in practice must not create delays in the emergency response system since incidental AF is non-urgent and other community pathways are in place for detection and management. Public participants were also concerned about how the diagnosis would be communicated to the patient, and opinion was split between whether this should be ‘on the scene’ or in a subsequent GP appointment. Paramedics reported that they frequently identify incidental AF, but that there is variation in practice regarding whether (and how) this is communicated to the GP. There was a concern that the finding of AF was not easily visible within the existing EMS report and may be missed. Paramedics also focussed on safety-netting of patients not being conveyed to hospital and of a need for an ‘active’ reporting process to ensure that the finding of AF was acted upon. In general, field experts felt that a formal pathway would be useful but relatively low impact, and favoured a simple intervention that did not overly complicate existing AF pathways. Conclusions There is support amongst the public and professionals for the development of a formal pathway to ensure ongoing follow-up and care for people with AF incidentally detected in the community by EMS. This novel case finding opportunity has the potential to improve AF detection, oral anticoagulation rates, and reduce the risk of stroke.

Defining a threshold above which an adult can be considered to frequently use ambulance services: a retrospective cross-sectional study of emergency calls to an ambulance service in England.

There is no empirical definition of adult frequent use of ambulance services. This study aimed to define a threshold, and utilise this to explore characteristics of people frequently using services. This was a retrospective cross-sectional study in a single ambulance service in England. Routinely collected, pseudo-anonymised call- and patient-level data were collected for two months (January and June 2019). Incidents, defined as independent episodes of care, were analysed using a zero-truncated Poisson regression model to determine a suitable frequent-use threshold, with comparisons subsequently made between frequent and non-frequent users. A total of 101,356 incidents involving 83,994 patients were included in the analysis. Two potentially appropriate thresholds were identified: five incidents per month (A); and six incidents per month (B). Threshold A produced 3137 incidents from 205 patients, with five patients likely false-positive identifications. Threshold B produced 2217 incidents from 95 patients, with no false-positive identifications but 100 false-negatives compared to threshold A. Regardless of threshold, frequent users compared to non-frequent users had relatively reduced service use between 08:00 and 15:00, were younger and were more likely to receive lower-priority responses (all p < 0.001). We identified several chief complaints indicative of increased frequent use, including chest pain, psychiatric/suicide attempt and abdominal pains/problems. We suggest a threshold of five incidents per month, with recognition that a small number of patients may be incorrectly identified as using ambulance services frequently. The rationale for this choice is discussed. This threshold may be applicable in wider UK settings and could be used for the routine automated identification of people using ambulance services frequently. The identified characteristics can help inform interventions. Future research should examine applicability of this threshold in other UK ambulance services and countries where patterns and determinants of frequent ambulance use may differ.

Research protocol for delivering on the front line: a qualitative exploration of paramedics' experiences of providing pre-hospital maternity care in the United Kingdom.

Maternity patients form a small but significant portion of paramedical workload and this research aims to pragmatically explore East of England Ambulance Service paramedics' experiences of providing pre-hospital maternity care. Through semi-structured individual interviews, participants' thoughts and feelings regarding obstetric confidence and competence will be explored. It will be investigated whether they think their training and equipment is adequate and what they would change about maternity patient management. Data will be thematically analysed and the findings used to improve paramedic training, with a view to improving their confidence and competence. In turn, this should improve patient experiences and outcomes.

Time intervals and distances travelled for prehospital ambulance stroke care: data from the randomised-controlled ambulance-based Rapid Intervention with Glyceryl trinitrate in Hypertensive stroke Trial-2 (RIGHT-2)

ObjectivesAmbulances offer the first opportunity to evaluate hyperacute stroke treatments. In this study, we investigated the conduct of a hyperacute stroke study in the ambulance-based setting with a particular focus...

Supraglottic airway device versus tracheal intubation in the initial airway management of out-of-hospital cardiac arrest: the AIRWAYS-2 cluster RCT.

When a cardiac arrest occurs, cardiopulmonary resuscitation should be started immediately. However, there is limited evidence about the best approach to airway management during cardiac arrest. The objective was to determine whether or not the i-gel® (Intersurgical Ltd, Wokingham, UK) supraglottic airway is superior to tracheal intubation as the initial advanced airway management strategy in adults with non-traumatic out-of-hospital cardiac arrest. This was a pragmatic, open, parallel, two-group, multicentre, cluster randomised controlled trial. A cost-effectiveness analysis accompanied the trial. The setting was four ambulance services in England. Patients aged ≥ 18 years who had a non-traumatic out-of-hospital cardiac arrest and were attended by a participating paramedic were enrolled automatically under a waiver of consent between June 2015 and August 2017. Follow-up ended in February 2018. Paramedics were randomised 1 : 1 to use tracheal intubation (764 paramedics) or i-gel (759 paramedics) for their initial advanced airway management and were unblinded. The primary outcome was modified Rankin Scale score at hospital discharge or 30 days after out-of-hospital cardiac arrest, whichever occurred earlier, collected by assessors blinded to allocation. The modified Rankin Scale, a measure of neurological disability, was dichotomised: a score of 0-3 (good outcome) or 4-6 (poor outcome/death). The primary outcome for the economic evaluation was quality-adjusted life-years, estimated using the EuroQol-5 Dimensions, five-level version. A total of 9296 patients (supraglottic airway group, 4886; tracheal intubation group, 4410) were enrolled [median age 73 years; 3373 (36.3%) women]; modified Rankin Scale score was known for 9289 patients. Characteristics were similar between groups. A total of 6.4% (311/4882) of patients in the supraglottic airway group and 6.8% (300/4407) of patients in the tracheal intubation group had a good outcome (adjusted difference in proportions of patients experiencing a good outcome: -0.6%, 95% confidence interval -1.6% to 0.4%). The supraglottic airway group had a higher initial ventilation success rate than the tracheal intubation group [87.4% (4255/4868) vs. 79.0% (3473/4397), respectively; adjusted difference in proportions of patients: 8.3%, 95% confidence interval 6.3% to 10.2%]; however, patients in the tracheal intubation group were less likely to receive advanced airway management than patients in the supraglottic airway group [77.6% (3419/4404) vs. 85.2% (4161/4883), respectively]. Regurgitation rate was similar between the groups [supraglottic airway group, 26.1% (1268/4865); tracheal intubation group, 24.5% (1072/4372); adjusted difference in proportions of patients: 1.4%, 95% confidence interval -0.6% to 3.4%], as was aspiration rate [supraglottic airway group, 15.1% (729/4824); tracheal intubation group, 14.9% (647/4337); adjusted difference in proportions of patients: 0.1%, 95% confidence interval -1.5% to 1.8%]. The longer-term outcomes were also similar between the groups (modified Rankin Scale: at 3 months, odds ratio 0.89, 95% confidence interval 0.69 to 1.14; at 6 months, odds ratio 0.91, 95% confidence interval 0.71 to 1.16). Sensitivity analyses did not alter the overall findings. There were no unexpected serious adverse events. Mean quality-adjusted life-years to 6 months were 0.03 in both groups (supraglottic airway group minus tracheal intubation group difference -0.0015, 95% confidence interval -0.0059 to 0.0028), and total costs were £157 (95% confidence interval -£270 to £583) lower in the tracheal intubation group. Although the point estimate of the incremental cost-effectiveness ratio suggested that tracheal intubation may be cost-effective, the huge uncertainty around this result indicates no evidence of a difference between groups. Limitations included imbalance in the number of patients in each group, caused by unequal distribution of high-enrolling paramedics; crossover between groups; and the fact that participating paramedics, who were volunteers, might not be representative of all paramedics in the UK. Findings may not be applicable to other countries. Among patients with out-of-hospital cardiac arrest, randomisation to the supraglottic airway group compared with the tracheal intubation group did not result in a difference in outcome at 30 days. There were no notable differences in costs, outcomes and overall cost-effectiveness between the groups. Future work could compare alternative supraglottic airway types with tracheal intubation; include a randomised trial of bag mask ventilation versus supraglottic airways; and involve other patient populations, including children, people with trauma and people in hospital. This trial is registered as ISRCTN08256118. This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and supported by the NIHR Comprehensive Research Networks and will be published in full in Health Technology Assessment; Vol. 26, No. 21. See the NIHR Journals Library website for further project information.

Helicopter Emergency Medical Services Out-of-Hospital Cardiac Arrests During the Initial COVID-19 Lockdown Versus Nonpandemic: A Comparison

ObjectiveCOVID-19 may have contributed to an excess of out-of-hospital cardiac arrests (OOHCAs). This observational study identified changes in OOHCA epidemiology pre– and post–COVID-19 lockdown in a single UK helicopter emergency medical service (HEMS). MethodsA retrospective, single-center (Essex & Herts Air Ambulance), observational study was undertaken with anonymized OOHCA data (demographics, etiology, and outcomes) from March 23, 2020, to June 23, 2020, and comparative data from March 23, 2019, to June 23, 2019. Supplementary data (total OOHCAs and patient outcomes) were provided by the East of England Ambulance Service National Health Service Trust. Data were analyzed using the Mann-Whitney U test and chi-square test; P < .05 was statistically significant.Results: Of the HEMS activations during national lockdown, 33.6% were for OOHCAs compared with 25.8% during the reference time frame. The frequency of young and female OOHCAs demonstrated a statistically significant increase. Statistically significant variations in medical etiology and initial cardiac rhythm were identified. ConclusionDuring the initial UK-wide lockdown, the OOHCA characteristics attended by 1 HEMS team were altered. The changes seen may be due to the pathophysiology of COVID-19 or an alteration in dispatch due to the demand placed on the wider ambulance service; this may require further consideration for any future lockdowns or pandemics.

Trends, variations and prediction of staff sickness absence rates among NHS ambulance services in England: a time series study

ObjectivesOur aim was to measure ambulance sickness absence rates over time, comparing ambulance services and investigate the predictability of rates for future forecasting.SettingAll English ambulance services, UK.DesignWe used a time...

Winning in winter with marginal gains: enhancing welfare on the frontline

Winter pressures on the NHS challenge every one of us. Patients may experience delays waiting for emergency ambulances and face extended waiting times at hospital emergency departments (ED). During this season, GPs, hospitals, NHS organisations and staff will face increased demand for services; yet are still required to deliver on agreed performance targets with only a finite availability of resources. Add Brexit and the second wave of COVID-19 wave into the mix and it might appear difficult to make improvements in any of these areas. During the winter of 2019–2020, a large ambulance service in England introduced a ‘welfare van’ to support busy emergency ambulance crews in one of its busy urban areas. It was tasked to see if it could make a positive difference to staff welfare and uphold or improve on ambulance service performance during a period of expected increased demand.

Adrenaline to improve survival in out-of-hospital cardiac arrest: the PARAMEDIC2 RCT.

Adrenaline has been used as a treatment for cardiac arrest for many years, despite uncertainty about its effects on long-term outcomes and concerns that it may cause worse neurological outcomes. The objectives were to evaluate the effects of adrenaline on survival and neurological outcomes, and to assess the cost-effectiveness of adrenaline use. This was a pragmatic, randomised, allocation-concealed, placebo-controlled, parallel-group superiority trial and economic evaluation. Costs are expressed in Great British pounds and reported in 2016/17 prices. This trial was set in five NHS ambulance services in England and Wales. Adults treated for an out-of-hospital cardiac arrest were included. Patients were ineligible if they were pregnant, if they were aged < 16 years, if the cardiac arrest had been caused by anaphylaxis or life-threatening asthma, or if adrenaline had already been given. Participants were randomised to either adrenaline (1 mg) or placebo in a 1 : 1 allocation ratio by the opening of allocation-concealed treatment packs. The primary outcome was survival to 30 days. The secondary outcomes were survival to hospital admission, survival to hospital discharge, survival at 3, 6 and 12 months, neurological outcomes and health-related quality of life through to 6 months. The economic evaluation assessed the incremental cost per quality-adjusted life-year gained from the perspective of the NHS and Personal Social Services. Participants, clinical teams and those assessing patient outcomes were masked to the treatment allocation. From December 2014 to October 2017, 8014 participants were assigned to the adrenaline (n = 4015) or to the placebo (n = 3999) arm. At 30 days, 130 out of 4012 participants (3.2%) in the adrenaline arm and 94 out of 3995 (2.4%) in the placebo arm were alive (adjusted odds ratio for survival 1.47, 95% confidence interval 1.09 to 1.97). For secondary outcomes, survival to hospital admission was higher for those receiving adrenaline than for those receiving placebo (23.6% vs. 8.0%; adjusted odds ratio 3.83, 95% confidence interval 3.30 to 4.43). The rate of favourable neurological outcome at hospital discharge was not significantly different between the arms (2.2% vs. 1.9%; adjusted odds ratio 1.19, 95% confidence interval 0.85 to 1.68). The pattern of improved survival but no significant improvement in neurological outcomes continued through to 6 months. By 12 months, survival in the adrenaline arm was 2.7%, compared with 2.0% in the placebo arm (adjusted odds ratio 1.38, 95% confidence interval 1.00 to 1.92). An adjusted subgroup analysis did not identify significant interactions. The incremental cost-effectiveness ratio for adrenaline was estimated at £1,693,003 per quality-adjusted life-year gained over the first 6 months after the cardiac arrest event and £81,070 per quality-adjusted life-year gained over the lifetime of survivors. Additional economic analyses estimated incremental cost-effectiveness ratios for adrenaline at £982,880 per percentage point increase in overall survival and £377,232 per percentage point increase in neurological outcomes over the first 6 months after the cardiac arrest. The estimate for survival with a favourable neurological outcome is imprecise because of the small numbers of patients surviving with a good outcome. Adrenaline improved long-term survival, but there was no evidence that it significantly improved neurological outcomes. The incremental cost-effectiveness ratio per quality-adjusted life-year exceeds the threshold of £20,000-30,000 per quality-adjusted life-year usually supported by the NHS. Further research is required to better understand patients' preferences in relation to survival and neurological outcomes after out-of-hospital cardiac arrest and to aid interpretation of the trial findings from a patient and public perspective. Current Controlled Trials ISRCTN73485024 and EudraCT 2014-000792-11. This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 25. See the NIHR Journals Library website for further project information.

Hangings attended by emergency medical services: a scoping review.

Background:In the United Kingdom (UK) there were 6507 deaths by suicide in 2018, with hanging being the most common method. Hanging will normally result in emergency medical services (EMS) being called and may result in resuscitation being attempted. Trauma audits conducted by North East Ambulance Service NHS Foundation Trust have identified an increased trend in hanging cases, which were also reported in national data. The aim of this scoping review was to explore the literature around EMS attendance at hangings to inform further research and clinical practice.Methods:A five-stage scoping review method was used. Relevant studies were identified by searching MEDLINE, CINAHL, EMBASE and EMCARE with the help of the Library and Knowledge Service for NHS Ambulance Services in England. Grey literature and reference lists were also searched. Studies were included based on relevance to hangings attended by EMS. Data were tabulated and narratively synthesised.Results:Sixteen papers were included in the review. Australia was the most frequent source of studies (n = 5, 31%). Most studies (n = 11, 69%) were published in the past 10 years. The median sample size was 53 (IQR 41–988, range 10–3981). All papers included varying levels of patient characteristics, EMS input and patient outcomes.Conclusion:Hanging is a highly lethal method of suicide that is increasingly used in the UK. This scoping review found that there is scarce literature focused on hangings attended by EMS. Treatment of the hanging patient in cardiac arrest is described in many of the papers included. Hanging patients may benefit from the presence of specialist resources who can deliver interventions such as sedation and advanced airway management. The psychological impact of attending, or witnessing, hanging patients is an area that needs further consideration. Further research is needed to describe and improve EMS treatment of hangings.

Mobile stroke unit in the UK healthcare system: avoidance of unnecessary accident and emergency admissions.

Aims:The aim of the study was to explore the benefit of a mobile stroke unit (MSU) in the UK National Health Service (NHS) for reduction of hospital admissions.Methods:Prospective cohort audit observation with dispatch of the MSU in the East of England Ambulance Service was conducted. Emergency patients categorised as code stroke and headache were included from 5 June to 18 December 2018. Rate of avoided admission to the accident and emergency (A&E) department, rate of admission directly to target ward and stroke management metrics were assessed.Results:In 116 MSU-treated patients, the following diagnoses were made: acute stroke, n = 33 (28.4%); transient ischaemic attacks, n = 13 (11.2%); stroke mimics, n = 32 (27.6%); and other conditions, n = 38 (32.8%). Pre-hospital thrombolysis was administered to eight of 28 (28.6%) ischaemic stroke patients. Pre-hospital diagnosis avoided hospital admission for 29 (25.0%) patients. As hospital treatment was indicated, 35 (30.2%) patients were directly triaged to the stroke unit, one patient (0.9%) even directly to the catheter laboratory. Thus, only 50 (43.1%) patients required transfer to the A&E department. Moreover, the MSU enabled thrombolysis with a median dispatch-to-needle time of 42 mins (interquartile range, 40–60).Conclusion:This first deployment of an MSU in the UK NHS demonstrated improved triage decision-making for or against hospital admission and admission to the appropriate target ward, thereby reducing pressure on strained A&E departments.

Association between admission to a cardiac arrest centre and survival to hospital discharge for adults following out-of-hospital cardiac arrest: A multi-centre observational study

AimThis study examined the association between admission to a cardiac arrest centre and survival to hospital discharge for adults following out-of-hospital cardiac arrest (OHCA). MethodsWe undertook a multicentre retrospective observational study of patients transferred to hospital after OHCA of presumed cardiac aetiology in three ambulance services in England. We used propensity score matching to compare rates of survival to hospital discharge in patients admitted to OHCA centres (defined as either 24/7 PPCI availability or >100 OHCA admissions per year) to rates of survival of patients admitted to non-centres. ResultsBetween January 2017 and December 2018, 10,650 patients with OHCA were included in the analysis. After propensity score matching, admission to a hospital with 24/7 PPCI availability or a high volume centre was associated with an absolute improvement in survival to hospital discharge of 2.5% and 2.8%, respectively. The corresponding odds ratios and 95% confidence intervals were 1.69 (1.28–2.23) and 1.41 (1.14–1.75), respectively. The results were similar when missing values were imputed. In subgroup analyses, the association between admission to an OHCA centre and improved rates of survival was mainly seen in patients with OHCA due to shockable rhythms, with no or minimal potential benefit for patients with OHCA and asystole as first presenting rhythm. ConclusionFollowing OHCA, admission to a cardiac arrest centre is associated with a moderate improvement in survival to hospital discharge. A corresponding bypass policy would need to consider the resulting increased workload for OHCA centres.

Randomized trial of the i-gel supraglottic airway device versus tracheal intubation during out of hospital cardiac arrest (AIRWAYS-2): Patient outcomes at three and six months

AimThe AIRWAYS-2 cluster randomised controlled trial compared the i-gel supraglottic airway device (SGA) with tracheal intubation (TI) as the first advanced airway management (AAM) strategy used by Emergency Medical Service clinicians (paramedics) treating adult patients with non-traumatic out-of-hospital cardiac arrest (OHCA). It showed no difference between the two groups in the primary outcome of modified Rankin Scale (mRS) score at 30 days/hospital discharge. This paper reports outcomes to 6 months. MethodsParamedics from four ambulance services in England were randomised 1:1 to use an i-gel SGA (759 paramedics) or TI (764 paramedics) as their initial approach to AAM. Adults who had a non-traumatic OHCA and were attended by a participating paramedic were enrolled automatically under a waiver of consent. Survivors were invited to complete questionnaires at three and six months after OHCA. Outcomes were analysed using regression methods. Results767/9296 (8.3%) enrolled patients survived to 30 days/hospital discharge and 317/767 survivors (41.3%) consented and were followed-up to six months. No significant differences were found between the two treatment groups in the primary outcome measure (mRS score: 3 months: odds ratio (OR) for good recovery (i-gel/TI, OR) 0.89, 95% CI 0.69–1.14; 6 months OR 0.91, 95% CI 0.71–1.16). EQ-5D-5L scores were also similar between groups and sensitivity analyses did not alter the findings. ConclusionThere were no statistically significant differences between the TI and i-gel groups at three and six months. We therefore conclude that the initially reported finding of no significant difference between groups at 30 days/hospital discharge was sustained when the period of follow-up was extended to six months.

Lord Carter's report into NHS ambulance service efficiency; will its findings make a difference and stimulate the service to escape “the mediocrity trap?”

PurposeReview of major policy paper in relation to the ambulance service [in England] efficiency and productivity with reference to observed “unacceptable variation”.Design/methodology/approachCritical review of ambulance service/EMS policy approach in England.FindingsLord Carter’s review describes failings in performance of UK ambulance service/EMS. However, the identified failings are essentially a repetition of many almost identical similar findings. There is a tendency of policy in respect of the ambulance service in England, as exemplified by Lord Carter’s report to consider analysis of the problem a more significant task that actually addressing the shortcoming defined.Research limitations/implicationsThis viewpoint comment piece is produced as a viewpoint with all the attendant limitations implied in this approach. However, it has been produced from an informed position.Practical implicationsChallenge to current UK ambulance policy. Previous repetitious finding need to be addressed definitively.Social implicationsThe efficiency of UK ambulance services/EMS is seriously impaired, and indeed these findings have been acknowledge previously. However, little by way of active remediation has been attempted. The current approach as exemplified in Lord Carter's recent review appears to ensure that analysis of the long- standing problems that exist is sufficient and possible preferable to active remediation and improvement.Originality/valueNo previous critical review of this type has been attempted (as it would be career-limiting).

The Cardiac Arrest Support Tier: a service evaluation.

Aim:This service evaluation seeks to determine whether the pre-hospital Cardiac Arrest Support Tier (CAST), implemented by a Hazardous Area Response Team (HART), was clinically effective, feasible and acceptable during its pilot year.Methods:Chest compression feedback, provision of Return of Spontaneous Circulation (ROSC) care and CAST paramedic exposure to Out-of-Hospital Cardiac Arrest (OHCA) were audited. The number of incidents that CAST responded to and the number of staff it committed were also assessed. An online questionnaire was used to gauge acceptability of the project among frontline Ambulance Service Trust staff.Results:CAST attended 178 OHCAs and committed a median of three (IQR 2–3) paramedics to each incident. In comparison to data from both South Western Ambulance Service Foundation Trust (SWASFT) and the National Ambulance Service in England, CAST delivered the full complement of post-ROSC care more frequently during the same period (CAST = 80% vs SWASFT = 68.5% vs England = 77.46%). CAST paramedics had a median exposure to 15.5 (IQR 12–19) OHCAs during the pilot year. Unfortunately, chest compression feedback was unavailable due to ongoing equipment inaccuracies and failure.Additionally 64.6% (n = 42/65) of SWASFT respondents believed CAST to be beneficial to resuscitation attempts, 63.1% (n = 41/65) would like CAST to continue to support resuscitation attempts in the future and 55.6% (n = 35/63) felt supported by CAST staff on scene.Conclusion:CAST is logistically feasible, is acceptable to the majority of SWASFT staff and demonstrated the successful delivery of evidence-based practice (EBP) to OHCA incidents.

Mobile Stroke Unit in the UK Healthcare System: Avoidance of Unnecessary Accident and Emergency Admissions

Background: Acute stroke patients are usually transported to the nearest hospital regardless of their required level of care. This can lead to increased pressure on emergency departments and treatment delay. Objective: The aim of the study was to explore the benefit of a mobile stroke unit (MSU) in the UK National Health Service (NHS) for reduction of hospital admissions. Methods: Prospective cohort audit observation with dispatch of the MSU in the East of England Ambulance Service area in Southend-on-Sea was conducted. Emergency patients categorized as code stroke and headache were included from June 5, 2018, to December 18, 2018. Rate of avoided admission to the accident and emergency (A&E) department, rate of admission directly to target ward, and stroke management metrics were assessed. Results: In 116 MSU-treated patients, the following diagnoses were made: acute stroke, n = 33 (28.4%); transient ischaemic attacks, n = 13 (11.2%); stroke mimics, n = 32 (27.6%); and other conditions, n = 38 (32.8%). Pre-hospital thrombolysis was administered to 8 of 28 (28.6%) ischaemic stroke patients. Pre-hospital diagnosis avoided hospital admission for 29 (25.0%) patients. As hospital treatment was indicated, 35 (30.2%) patients were directly triaged to the stroke unit, 1 patient (0.9%) even directly to the catheter laboratory. Thus, only 50 (43.1%) patients required transfer to the A&E department. Moreover, the MSU enabled thrombolysis with a median dispatch-to-needle time of 42 min (interquartile range, 40–60). Conclusion: This first deployment of an MSU in the UK NHS demonstrated improved triage decision-making for or against hospital admission and admission to the appropriate target ward, thereby reducing pressure on strained A&E departments.

Patient safety incidents and medication errors during a clinical trial: experience from a pre-hospital randomized controlled trial of emergency medication administration

To assess and evaluate patient safety incidents and in particular, medication errors, during a large multi-center pre-hospital trial of emergency therapy (PARAMEDIC2), in order to inform and improve future pre-hospital medicines trials. The PARAMEDIC2 trial was undertaken across five NHS Ambulance Services in England and Wales with randomisation between December 2014 and October 2017. Patients with an out -of-hospital cardiac arrest unresponsive to initial resuscitation were randomly assigned to 1mg intravenous adrenaline or matching placebo. Records were reviewed to identify trial medication errors involving documentation and/or clinical protocol errors occurring in trial participants. Causes of medication errors, including root cause analysis where available, were reviewed to identify patterns and themes contributing to these errors. Eight thousand sixteen patients were enrolled, of whom 4902 received trial medication. A total of 331 patient safety incidents was reported, involving 295 patients, representing an overall rate of 3.6% of these, 166 (50.2%) were documentation errors while 165 (49.8%) were clinical protocol/medication errors. An overall rate of 0-4.5% was reported across all five ambulance services, with a mean of 2.0%. These errors had no impact on patient care or the trial and were all resolved CONCLUSION: The overall medication error rate of 1.8% primarily consisted of administration of open-label adrenaline and confusion with trial medication packs. A similar number of patients had documentation errors. This study is the first to provide data on patient safety incidents relating to medication errors encountered during a pre-hospital trial of emergency medication administration and will provide supporting data for planning future trials in this area.

'We're the First Port of Call' - Perspectives of Ambulance Staff on Responding to Deaths by Suicide: A Qualitative Study.

IntroductionExposure to suicide is a known risk factor for suicide. Ambulance staff are exposed to work-related stressors including attending suicides, which may elevate their risk for mental health problems/suicide. Little is known about ambulance staff’s perspectives on how they experience these events and whether they feel equipped to respond to bereaved families at the scene of death. This study explores the perspectives of ambulance staff about responding to deaths by suicide.Materials and MethodsA convenience sample of ambulance staff recruited from one ambulance service in England. In-depth, qualitative, semi-structured face-to-face interviews conducted with nine ambulance staff (six male, three female) to explore experiences of responding to suicide. Data analyzed using thematic analysis.ResultsParticipants reported the experience of job-related strain including exposure to the suicide/suicidal ideation of colleagues; they described suppressing their distress despite significant emotional impact. All participants had been personally bereaved by suicide and responding to suicide was a common part of their job. They were often the first professionals at the scene, and undertook varied and often conflicting roles: negotiating with patients in crisis; informing individuals of the death of a loved one; preserving the body/potential crime scene; dealing with the intense emotional reactions of bereaved individuals. Participants reported long-term, salient memories of these events; however, there was a reported lack of acknowledgment in the workplace that suicides may be traumatic and no guidance for staff on how to cope. Opportunities to debrief were reportedly rare, and there was reluctance to access work-based liaison services. Training in how to respond to individuals bereaved by suicide was also lacking.DiscussionThe study is the first to reveal the complex challenges faced by ambulance staff in responding to suicide without adequate training and support. It demonstrates the potential impact that responding to suicide can have personally and professionally on staff, and emphasizes the need for employers to support staff wellbeing in better ways. Training and postvention support could enable better coping among staff, more effective support for bereaved individuals and reduce the risk of death by suicide both in those bereaved by suicide and in ambulance staff.