Joint Royal Colleges Ambulance Liaison Committee Research Articles

Factors influencing conveyance of older adults with minor head injury by paramedics to the emergency department: a multiple methods study

BackgroundHead injury (HI) in older adults due to low-energy falls result in a substantial number of emergency department (ED) attendances. However, mortality associated with minor HI is very low. Reducing conveyance to hospital is important for older adults and is a priority for the National Health Service (NHS). Therefore, paramedics are required to make accurate decisions regarding conveyance to the ED. This study used routine data and semi-structured interviews to explore the factors that influence paramedic decision-making when considering whether to convey an adult aged 65 years and over with a minor HI to the ED.MethodsSemi-structured telephone interviews were completed with ten UK paramedics from a single EMS (ambulance) provider organisation. Interviews explored the factors influencing the paramedics’ conveyance decision-making in adults aged 65 years and over with a minor HI. Data were initially analysed inductively to develop a thematic framework. A retrospective analysis of ambulance service data was also completed to determine the scope and scale of the issue in Southwest England. An in-depth audit of 100 conveyed patient records was used to determine the proportion of patients conveyed to the ED who met National Institute for Health and Care Excellence (NICE) and Joint Royal Colleges Ambulance Liaison Committee (JRCALC) guidelines.ResultsIn 2019 South Western Ambulance Service NHS Foundation Trust (SWASFT) attended 15,650 emergency calls to patients aged 65 and over with minor HI, with 70.5% conveyed to ED. 81% of conveyed patients met NICE and JRCALC guideline criteria for conveyance, with the remainder conveyed due to wound care or other medical concerns. The framework developed from the interviews comprised four themes: resources; patient factors; consequences; paramedic factors. Important factors included: the patient’s social situation; guidelines; clinical support availability; the history and presentation of the patient; risk.ConclusionThis study examined paramedic conveyance decisions for older people with minor HI. It identified multiple influencing factors, highlighting the complex nature of these decisions, and may serve as a basis for developing an intervention to safely decrease ED conveyance in this patient group.

Paramedics' perceptions and experiences of pelvic injuries in prehospital situations

Mortality rates remain high in patients with pelvic injuries despite improvements in trauma care in recent years. Pelvic injuries are associated with patients with a high Injury Severity Score (ISS); it can therefore be difficult to distinguish whether the pelvic injury was a primary causative factor of mortality. ‘Open book’ fractures carry a mortality rate as high as 50% and clinicians should therefore have a low threshold for suspecting a pelvic injury. Paramedics should follow the latest guidance found in the UK Ambulance Service Clinical Practice Guidelines ( Joint Royal Colleges Ambulance Liaison Committee (JRCALC), 2016 ; 2017 ). Additionally, log rolling and/or ‘springing’ the pelvis of a patient with a pelvic injury will cause pain, disrupt clots and distort a potential fracture. Furthermore, pelvic binders/splints can reduce the area into which a patient can haemorrhage, if they are placed correctly. Lastly, triage of these patients can be difficult and major trauma centres should be considered for definitive care.

Continuing Professional Development: Tension pneumothorax

Overview Tension pneumothorax is a life threatening complication of chest injury. It can cause rapid physiological decompensation, cardiac arrest and death. The Joint Royal Colleges Ambulance Liaison Committee (JRCALC) provide guidelines on the pre-hospital diagnosis and treatment of this condition. This Continuing Professional Development (CPD) module firstly looks at the pathophysiology of the developing tension pneumothorax, discusses the signs and symptoms likely and less likely to be found, looks at the difficulties in recognising these signs and analyses the accepted methods of first line treatment. The module goes on to study alternative pre-hospital management methods and discusses the safety and effectiveness of each. Learning Outcomes After completing this module you will: • Appreciate the need for vigilance in making a diagnosis of tension pneumothorax. • Understand the potential for error and patient harm in treating tension pneumothorax, regardless of clinical skill level. • Have an understanding of the wider breadth of research and evidence surrounding tension pneumothorax which complement UK pre-hospital guidelines. • Have reviewed the techniques advocated for relieving a tension pneumothorax in the pre-hospital field.

Acute exacerbation of COPD: Are we still over-oxygenating?

Chronic obstructive pulmonary disease (COPD) affects thousands of people across the UK. It accounts for a large amount of hospital admissions, which are often seen by the ambulance service during acute exacerbations. Discussion has surrounded the amount of oxygen this type of patient should be receiving during acute exacerbations. Research to provide evidence–based practice for the use of oxygen in the hospital and pre-hospital environment has been ongoing for several years. In 2009 the Joint Royal Colleges Ambulance Liaison Committee (JRCALC) changed their guidance following the British Thoracic Society's (BTS) release of new guidelines in oxygen use in adult patients, thus determining that oxygen should be delivered in a more precise manner. However in light of current evidence could further changes be made in the delivery of oxygen, by using air–driven nebulisation during the delivery of drugs to patients presenting in the pre-hospital environment with an acute exacerbation of chronic obstructive pulmonary disease (AECOPD). This would allow patients to receive an appropriate amount of oxygen during their transfer to hospital, giving improved care and treatment of patients at risk of hypercapnic respiratory failure. This article will discuss the changes to practice which have already been identified and recommended and also discuss the potential implications these changes may have on patient care.

Pre-hospital improvised bronchodilator therapy of a patient on bi-level positive airway pressure therapy

Patients suffering acute breathlessness is a common emergency situation, many patients with airways disease require bronchodilator therapy with (3-agonists. To assist the management of these cases paramedics use guidelines drawn up by the Joint Royal Colleges Ambulance Liaison Committee (JRCALC). They provide guidance on the management of most situations paramedics are likely to encounter. However, there will be occasions when paramedics are called to deal with a situation which is outside of their experience and the JRCALC guidelines do not provide the appropriate guidance required to fully inform clinical decision making. In the UK telephone support from a physician skilled in the specific discipline they require is generally not available, so paramedics have become skilled at improvising. This case study describes such an improvisation, in the management of acute breathlessness in a patient who is on home bi-level positive airway pressure (BiPAP) therapy.

P101 A survey of emergency oxygen guideline implementation among all 15 UK Ambulance Services in early 2011

The British Thoracic Society (BTS), together with 21 other societies published a UK guideline for emergency oxygen use in 2008. This guideline was endorsed by the Joint Royal Colleges Ambulance...

Enlargement of the Inferior Intercavernous Sinus: A New Sign for the Diagnosis of Craniospinal Hypotension

<h3>Background:</h3> Oxygen is widely used but poorly studied in emergency medicine, with a limited evidence base for its use in specific conditions. There are safety concerns about the underuse of oxygen in patients with critical illness and its overuse in conditions such as chronic obstructive pulmonary disease (COPD). A baseline audit was required to assess current practice prior to the introduction of new national emergency oxygen guidelines in late 2008. <h3>Methods:</h3> The use of pulse oximetry and oxygen therapy was audited in patients brought by ambulance to the “majors” section of the emergency department (ED) in a university hospital. Oxygen therapy in the ambulance and the ED was subsequently documented. Oxygen use in ambulances was compared with Joint Royal Colleges Ambulance Liaison Committee (JRCALC) guidance and with subsequent patient management. <h3>Results:</h3> The ambulance and ED records of 1022 patients were audited manually. Oxygen saturation (Spo₂) was recorded for 90% of patients, 17% of whom had Spo₂ &lt;94% at some time and 7% had Spo₂ &lt;90%, including 33% of patients with COPD and 5.5% of patients without COPD. 34% of patients received oxygen in the ambulance and almost half of these had oxygen discontinued in the ED. Only 62% of ambulance oxygen use was in accordance with JRCALC guidance, but most “undertreated” patients were stable normoxaemic patients for whom guidance recommends high-flow oxygen. Only 58% of patients with COPD were correctly identified in the ambulance and 73% of these patients were treated with flow rates &gt;4 l/min (equivalent to &gt;35% oxygen). <h3>Conclusions:</h3> Oxygen use in ambulances is very common, equivalent to 2.2 million episodes annually in the UK. The quality of oxygen use is suboptimal, especially for patients with COPD. Emergency oxygen therapy will become simpler when new evidence-based UK emergency oxygen guidelines are published, and it is hoped that future audits will show better protocol adherence.

JRCALC: advice or requirement?

The Joint Royal Colleges Ambulance Liaison Committee (JRCALC) is the body that develops and reviews clinical guidelines for use by paramedics working in the UK and it has been instrumental in moving ambulance services from locally-derived protocol and guidance to a national, systematically developed set of guidelines based upon current best evidence. The evidence is based upon systematic reviews, meta-analyses and randomized, controlled trials, where available. JRCALC states that its ‘guidance is advisory and has been developed to assist health care professionals, together with patients, to make decisions about the management of the patient's health, including treatments’ (JRCALC, 2006). The guidance is intended to support decisions and sound clinical judgement, not replace it. This begs the common question: what are the consequences for me if I make a clinical decision that deviated from the JRCALC guidance?

Audit of oxygen use in emergency ambulances and in a hospital emergency department

Background:Oxygen is widely used but poorly studied in emergency medicine, with a limited evidence base for its use in specific conditions. There are safety concerns about the underuse of oxygen...

Improving UK trauma care: the NCEPOD trauma report

As representatives of the Royal College of Anaesthetists on the Joint Royal Colleges Ambulance Liaison Committee (JRCALC), we read with interest David Lockey’s sensible Editorial ‘Improving UK trauma care: the NCEPOD trauma report’ [1] and would like to take the opportunity to respond to some of the shortcomings highlighted. Since 1989, the Joint Royal Colleges Ambulance Service Liaison Committee, has provided a national forum to support the UK Ambulance Service with a particular focus on its interactions with other professional healthcare groups. The committee has widespread representation including the Ambulance Service, the Royal Medical Colleges including that of Physicians, Surgeons, Anaesthetists, Obstetricians & Gynaecologists, General Practitioners, Nursing, Paediatric and Child Health, Emergency Medicine and observers from the Department of Health, The Scottish Ambulance Service, the Health Professions Council and the Institute of Healthcare Development. The Editorial underlined a number of valid points concerning the prehospital phase of trauma care such as excessive on-scene time (though rightly acknowledged as often being circumstance driven), the recording of an inappropriate prehospital secondary survey, the failure to give oxygen (though in our experience this is much more likely to be a failure to record the fact on the ambulance crew Patient Record Form) and omitting to provide a pre-alert to the hospital. These are fortunately, all factors that can be speedily resolved by educational reinforcement and without the need for significant extra resources. However, whilst there may be reservations over the robustness of the data used to support some of the prehospital findings of the report, the clear recognition of the suboptimal level of airway management should concern us all whether as anaesthetists or prehospital care providers. To address this shortcoming is indeed a challenge and an expert group recently formed at the request of JRCALC has already looked in detail at possible contributory factors. The summary of its findings, though not yet formally published, is already provoking widespread and far-ranging discussion. In his penultimate paragraph Dr Lockey suggests that an examination of the entire patient journey from roadside to rehabilitation may meet some resistance ‘particularly from ambulance services’, but we would strongly disagree that the latter are reluctant to pursue any achievable means to ensure optimum patient care. The way forward is to make certain that ambulance services are an integral part of the discussions to determine how we all address the persistent inadequacies of UK trauma care as presented in this salutary report.

The gum elastic bougie: One of anaesthesia's best-kept secrets

Recent guidelines for paramedic intubation have been published by the Joint Royal Colleges Ambulance Liaison Committee (JRCALC) (2008). One important recommendation for paramedic intubation is that: ‘When prehospital tracheal intubation is undertaken, a gum elastic bougie should be available routinely’. Despite this, the bougie has not been universally available among ambulance services in the UK—up to a third do not include the bougie as part of their airway management strategy. We aim to introduce the bougie, provide information on its use, advantages and pitfalls, and provide some tips as to how to get the most out of this invaluable device in clinical practice.

CT scan findings in oesophagogastric perforation after out of hospital cardiopulmonary resuscitation

Rupture of the oesophagus or stomach at the time of cardiopulmonary resuscitation can occur with accidental oesophageal intubation. The common site of rupture is the lesser curvature of the stomach,...

Is there still a place for emergency department thrombolysis following the introduction of the amended Joint Royal Colleges Ambulance Liaison Committee criteria for thrombolysis?

Objective:To apply the current (2004) and the amended (2006) Joint Royal Colleges Ambulance Liaison Committee (JRCALC) criteria for paramedic initiated thrombolysis to all patients who received thrombolytic treatment in an...

Emergency management of arrhythmias and/or shocks in patients with implantable cardioverter defibrillators (ICDs): A statement on behalf of the Resuscitation Council (UK), Heart Rhythm UK (formerly The British Pacing and Electrophysiology Group, BPEG), The Joint Royal Colleges Ambulance Liaison Committee (JRCALC) and the Ambulance Services Association (ASA)

a Wales College of Medicine, Cardiff University, Cardiff CF14 4XN, UK b St George’s Hospital, Blackshaw Road, London SW17 0QT, UK c Newcastle General Hospital, Westgate Road, Newcastle upon Tyne NE4 6BE, UK d Ambulance Services Association, Friars House, 157—168 Blackfriars Road, London SE1 8EZ, UK e Royal Berkshire Ambulance NHS Trust, 44 Finchampstead Road, Wokingham, Berkshire RG40 2NN, UK f Freeman Hospital, High Heaton, Newcastle upon Tyne NE7 7DN, UK

Training for Emergency Care Practitioners: Bsc Degree

Demands for ambulance services rose by nearly 50% in the ten years from 1989, which catalyzed a rethink in the way ambulance services delivered their care. In November 1999, the Ambulance Service Association (ASA) outlined possible models for future ambulance services, and included a model that would see ambulance services providing a wide range of community health care services through the development of practitioners in emergency care (PEC). This concept was supported by the Joint Royal Colleges Ambulance Liaison Committee (JRCALC) who advocated the development of PEC’s and foresaw the movement of ambulance education towards Higher Education Institutions (HEI). Subsequent papers acknowledged the requirement to change the way ambulance services worked and recognised the need to develop the education and role of the paramedic. Other catalysts included the four hour A&E waiting targets and reforms in out-of-hours care set out in the NHS plan, and the conclusions from the Carson report, which advocated that all those involved in the delivery of out-of-hours care should work collaboratively, and that the NHS should be striving to ensure the appropriateness of response to a call.