Joint Royal Colleges Ambulance Liaison Research Articles

Ambulance clinicians implementing evidence-based practice: mind the gap! Attitudes, perceptions and experiences of student paramedics.

Evidence-based practice (EBP) represents the conscientious and judicious use of the best contemporaneous evidence in partnership with patient values and clinical expertise to guide healthcare professionals. As a result, EBP is a recommended component of undergraduate education and considered fundamental for improving patient outcomes. EBP principles have thus become deeply rooted in higher education curricula, but only in recent years has this begun to permeate the world of paramedic practice. Despite this paradigm, the impact of EBP may be limited because ambulance clinicians may struggle with implementation, as a variety of barriers influence translation and application. A survey study aimed to gain insight into the epistemological and metacognitive barriers impacting student experience in order to help improve teaching and learning practices. A sample of 64 students, across two different undergraduate paramedic science programmes, were recruited. Of these, 70% of BSc (Hons) students versus 33% of DipHE students agreed to some extent or greater that EBP represented minimal benefit in real-world practice due to Trust policy and the guidelines set out by the Joint Royal Colleges Ambulance Liaison Committee (Welch's t = 2.571, df = 26, p = 0.016 two-sided). Furthermore, 25% felt standard operating procedures negatively impacted their ability to implement EBP, and 39% reported their EBP learning had improved their ability to implement improved levels of patient care. A disparity between theoretical learning and EBP implementation was identified. EBP may not dovetail with standard operating procedure within UK ambulance Trusts, resulting in confusion among student paramedics as to the true worth of EBP.

Low-voltage electrical injuries and the electrocardiogram: is a 'normal' electrocardiogram sufficient for safe discharge from care? A systematic review.

The current Joint Royal Colleges Ambulance Liaison Committee guidelines in the United Kingdom provide clear national guidance for low-voltage electrical injury patients. While patients can be considered safe to discharge with an apparently 'normal' initial electrocardiogram (ECG), some evidence questions the safety profile of these patients with a risk of a 'delayed arrhythmia'. This review aims to examine this as well as identifying the frequency and common arrhythmias that require patients to be conveyed to hospital for further monitoring post electrical injury. It will also aim to improve the understanding of potentially clinically significant arrhythmias that may require clinical intervention or even admission within an in-hospital environment. A systematic review using three electronic databases (CINAHL, MEDLINE, AMED) was conducted in January 2022. A preferred reporting items for systematic reviews and meta-analyses (PRISMA) approach was used to identify relevant studies with a suitable quality to support a critical review of the topic. A modified Critical Appraisal Skills Programme quality assessment checklist was used across suitable studies and a descriptive statistics approach was adopted to present the findings. Seven studies, largely retrospective reviews, met the inclusion criteria. The findings showed 26% of patients had an arrhythmia on initial presentation (n = 364/1234) with incidences of sinus tachycardia, sinus bradycardia and premature ventricular contractions. However, making definitive statements is challenging due to the lack of access to individual patients' past ECGs. Within these arrhythmias' ST segment changes, atrial fibrillation and long QT syndrome could be considered potentially significant, however associated prognosis with these and electrical injuries is unknown. Only six (0.5%) patients required treatment by drug therapy, and a further three died from associated complications. Most patients with a normal ECG were discharged immediately with only a limited follow-up. No presentation of a 'delayed arrhythmia' was identified throughout the studies. The data for low-voltage electrical injuries are limited, but the potential arrhythmias for this patient group seldom require intervention. The entity of the 'delayed arrhythmia' may not be a reason to admit or monitor patients for prolonged periods. Further studies should consider the safety profile of discharging a patient with a normal ECG.

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.

Survival in Seattle: the Cardiac Arrest Survival Summit

Survival in Seattle: the Cardiac Arrest Survival Summit

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.

A self-completed questionnaire study of attitudes and perceptions of paramedic and prehospital practitioners towards acute seizure care in Northern Ireland

IntroductionParamedics are increasingly expected to take on wider roles in the management of epilepsy in the community by making nonconveyance decisions after patients have had seizures. Studies have identified barriers to the successful implementation of this clinical role. We sought to determine levels of confidence, training, perceived barriers, and self-identified learning needs and methods to address these needs regarding seizure management. Methods and materialsA questionnaire was developed by consensus and administered to 63 paramedic and prehospital clinicians at various mandatory training days occurring at the central headquarters of the regional ambulance service in Northern Ireland. Participants had no foreknowledge of the questionnaire, which was self-completed and returned immediately. ResultsA 75% return rate was obtained after 63 questionnaires were distributed. Paramedics had a mean of 11.5years of experiences, and 49% had treated 1–10 seizures in the last year. The Joint Royal Colleges Ambulance Liaison Committee guideline on seizure management is the most commonly utilized clinical guideline (100%). All could recall formal training on seizures in their qualification course. They identified a need to develop their knowledge in certain aspects of drug management and seizure subtype identification, including nonepileptic attack disorder (NEAD). Seventy percent of paramedics had a limited understanding of NEAD.Overall, paramedics rated their confidence as higher in drug treatment and the process of managing a seizure but rated their confidence lower in recognizing different seizure types as well as making nonconveyance decisions. The two factors which were cited as instilling high confidence included clinical experience and good use of provided protocols. Other barriers identified included lack of access to intramuscular midazolam, poor information availability in the prehospital setting, and a lack of a feedback mechanism to ensure follow-up. The methods by which learning needs would be addressed included tutorials, e-Learning, and simulation, with 30% preferring a combination of these methods. ConclusionsWe identified that the paramedic workforce feels a reasonable to high level of confidence in the management of acute seizures. However, there are areas where they experience less confidence including making nonconveyance decisions and the identification of nontonic–clonic seizure subtypes.

Preclinical calculation of burn size: a method of estimation for pre-hospital use

Journal of Paramedic PracticeVol. 8, No. 11 Spotlight on ResearchPreclinical calculation of burn size: a method of estimation for pre-hospital useTeresa GrovesTeresa GrovesSearch for more papers by this authorTeresa GrovesPublished Online:16 Nov 2016https://doi.org/10.12968/jpar.2016.8.11.560AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References Thom, D. (2016) Appraising current methods for preclinical calculation of burn size – a pre-hospital perspective. http://dx.doi.org/10.1016/j.burns.2016.07.0003 Google ScholarAssociation of Ambulance Chief Executives and the Joint Royal Colleges Ambulance Liaison Committee (2016) UK ambulance services clinical practice guidelines. Class Professional Publishing: Bridgwater Google Scholar FiguresReferencesRelatedDetails 2 November 2016Volume 8Issue 11ISSN (print): 1759-1376ISSN (online): 2041-9457 Metrics History Published online 16 November 2016 Published in print 2 November 2016 Information© MA Healthcare LimitedPDF download

Pre-hospital care after a seizure: Evidence base and United Kingdom management guidelines

PurposeSeizures are a common presentation to pre-hospital emergency services and they generate significant healthcare costs. This article summarises the United Kingdom (UK) Ambulance Service guidelines for the management of seizures and explores the extent to which these guidelines are evidence-based. MethodsSummary of the Clinical Practice Guidelines of the UK Joint Royal Colleges Ambulance Liaison Committee relating to the management of seizures. Review of the literature relating to pre-hospital management of seizure emergencies. ResultsMuch standard practice relating to the emergency out of hospital management of patients with seizures is drawn from generic Advanced Life Support (ALS) guidelines although many patients do not need ALS during or after a seizure and the benefit of many ALS interventions in seizure patients remains to be established. The majority of studies identified pertain to medical treatment of status epilepticus. These papers show that benzodiazepines are safe and effective but it is not possible to draw definitive conclusions about the best medication or the optimal route of administration. ConclusionThe evidence base for current pre-hospital guidelines for seizure emergencies is incomplete. A large proportion of patients are transported to hospital after a seizure but many of these may be suitable for home management. However, there is very little research into alternative care pathways or criteria that could be used to help paramedics avoid transport to hospital. More research is needed to improve care for people after a seizure and to improve the cost-effectiveness of the healthcare systems within which they are treated.

Letter by Price et al Regarding Article, “Does Use of the Recognition of Stroke In the Emergency Room Stroke Assessment Tool Enhance Stroke Recognition by Ambulance Clinicians?”

We welcome the comments made by Price et al1 and Brandler and Sharma2 and are grateful for the opportunity to respond to their observations. In our study,3 ambulance clinicians had to suspect a stroke before they used the Recognition of Stroke in the Emergency Room (ROSIER). Our clinicians use a range of factors to suspect that a patient is having a stroke including clinical assessments and observations taken on scene, medical history, history of the current event, medications, and the call determinant allocated during triage of the emergency call for help. Our clinicians practice in line with the Joint Royal Colleges Ambulance Liaison Committee’s UK Ambulance Service Clinical Practice Guidelines.4 The average age of patients in our study was indeed relatively young at 65 years; however, this is representative of suspected stroke patients in the area of London where our study was conducted. Our stroke audit figures from last year (2012/13) show that the average age of suspected stroke patients conveyed by our clinicians to the hospital involved in our study was 67 years, which is consistent with the age reported in our article. Information from the 2011 National Census5 confirms that the …

Response to Letter Regarding Article, “Does Use of the Recognition of Stroke In the Emergency Room Stroke Assessment Tool Enhance Stroke Recognition by Ambulance Clinicians?”

We welcome the comments made by Price et al1 and Brandler and Sharma2 and are grateful for the opportunity to respond to their observations. In our study,3 ambulance clinicians had to suspect a stroke before they used the Recognition of Stroke in the Emergency Room (ROSIER). Our clinicians use a range of factors to suspect that a patient is having a stroke including clinical assessments and observations taken on scene, medical history, history of the current event, medications, and the call determinant allocated during triage of the emergency call for help. Our clinicians practice in line with the Joint Royal Colleges Ambulance Liaison Committee’s UK Ambulance Service Clinical Practice Guidelines.4 The average age of patients in our study was indeed relatively young at 65 years; however, this is representative of suspected stroke patients in the area of London where our study was conducted. Our stroke audit figures from last year (2012/13) show that the average age of suspected stroke patients conveyed by our clinicians to the hospital involved in our study was 67 years, which is consistent with the age reported in our article. Information from the 2011 National Census5 confirms that the …

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.

Randomised comparison of the effectiveness of the laryngeal mask airway supreme, i-gel and current practice in the initial airway management of prehospital cardiac arrest (REVIVE-Airways): a feasibility study research protocol

IntroductionEffective cardiopulmonary resuscitation with appropriate airway management improves outcomes following out-of-hospital cardiac arrest (OHCA). Historically, tracheal intubation has been accepted as the optimal form of OHCA airway management in the...

Raising a profession

Journal of Paramedic PracticeVol. 4, No. 12 Raising a professionRaising a professionJohn MartinJohn MartinSearch for more papers by this authorJohn MartinPublished Online:16 Aug 2013https://doi.org/10.12968/jpar.2012.4.12.735AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References Brandon DJ (2012) Principles of Child Development University of Tennessee Extension Family and Consumer Sciences. http://fcs.tennessee.edu/humandev/kidsmart/ (accessed 29th October 2012) http://cfs.utk.edu/files/2012/06/CV_Stolz.pdf Google Scholar British Paramedic Association (2006) A Curriculum Framework for Ambulance Education. British Paramedic Association, Derby, UK Google Scholar College of Paramedics (2011) Articles of Association. www.collegeofparamedics.co.uk/downloads/Articles_of_Association_JUNE_2011.pdf (accessed 30 November 2012) Google Scholar College of Paramedics (2008) Paramedic Curriculum. College of Paramedics, Bridgwater, UK Google Scholar Guidance & Competence Framework, CoP, Derby Google Scholar College of Paramedics (2008) Guidance & Competence Framework. College of Paramedics, Bridgwater, UK Google Scholar Health Care and Professions Council (2012) Standards of Education and Training. HCPC, London Google Scholar Health Professions Order (2001) Statutory Instruments. www.hpc-uk.org/assets/documents/1000061DThe_Health_Professions_Order.pdf (accessed 30 November) Google Scholar Joint Royal Colleges Ambulance Liaison Committee and Ambulance Service Association (2006) UK Ambulance Service Clinical Practice Guidelines. (2006). The Ambulance Service Association, London Google Scholar FiguresReferencesRelatedDetails 7 December 2012Volume 4Issue 12ISSN (print): 1759-1376ISSN (online): 2041-9457 Metrics History Published online 16 August 2013 Published in print 7 December 2012 Information© MA Healthcare LimitedPDF download

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.

Continuing Professional Development: Epinephrine and its use in acute life-threatening asthma in adults

Overview This CPD module, will act as revision of existing treatments for acute asthma exacerbations, as well as discussing the indications for use of epinephrine in asthma and the potential problems you may encounter with its use. Although epinephrine has been used for many years in other medical emergencies, such as anaphylaxis, is not widely used for asthma exacerbations. This module will discuss a number of different methods for the delivery of epinephrine; however it should be appreciated that not all of these routes are suitable for use in asthma. You will also have the opportunity to reflect and consolidate your existing clinical knowledge of epinephrine, as well as providing a basis for further learning about the pre-hospital management of acute asthma exacerbations. There are a number of resources available through the ‘Journal of Paramedic Practice’, and other guidelines and information available to supplement your learning; in particular from the British Thoracic Society, Scottish Intercollegiate Guidelines Network and Joint Royal Colleges Ambulance Liaison Committee. Learning Outcomes After completing this module you will: • Describe and use the clinical findings with which to determine the severity of an asthma exacerbation. • Understand that asthma is a condition with a significant mortality rate, and patients can rapidly deteriorate without appropriate resuscitation. • Understand the different pharmacological treatments in acute asthma, and their uses in current guidelines and protocols. • Appreciate the emerging role of epinephrine in pre-hospital practice and the different routes by which it can be given. • Identity and reflect upon personal areas of concerns in the pre-hospital management of acute asthma exacerbations.

Exertional heat stroke: a rapidly progressive pre-hospital presentation

Journal of Paramedic PracticeVol. 4, No. 9 College of ParamedicsExertional heat stroke: a rapidly progressive pre-hospital presentationNick BrownNick BrownSearch for more papers by this authorNick BrownPublished Online:16 Aug 2013https://doi.org/10.12968/jpar.2012.4.9.549AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References Caroline N (2008) Emergency Care on the Streets (6th Ed). Jones and Bartlet, London Google ScholarHelman R (2009) Heatstroke. emedicine. medscape.com/article/166320-overview (accessed 14 August) Google ScholarJoint Royal Colleges Ambulance Liaison Committee (2006) UK Ambulance Service Clinical Practice Guidelines 2006. Joint Royal Colleges Ambulance Liaison Committee/Ambulance Service Association, London. www2.warwick.ac.uk/ fac/med/research/hsri/emergencycare/ prehospitalcare/jrcalcstakeholderwebsite/ guidelines/clinical_guidelines_2006.pdf (accessed 14 August 2012) Google ScholarMarieb E (1992) Human Anatomy and Physiology. Benjamin/Cummings, California Google ScholarNHS Choices (2011) Heat Exhaustion and Heat Stroke. www.nhs.uk/conditions/heat-exhaustion-and-heatstroke/pages/ introduction.aspx (accessed 1 March 2011) Google ScholarPanté M, Pollak M (2010) Advanced Assessment and Treatment of Trauma. Jones and Bartlett, London Google ScholarWillacy H (2010) Heat-related Illness. www. patient.co.uk/doctor/Heat-Related-Illness. htm (accessed 14 August 2012) Google Scholar FiguresReferencesRelatedDetails 9 September 2012Volume 4Issue 9ISSN (print): 1759-1376ISSN (online): 2041-9457 Metrics History Published online 16 August 2013 Published in print 9 September 2012 Information© MA Healthcare LimitedPDF download

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.

A critical reassessment of ambulance service airway management in prehospital care: Joint Royal Colleges Ambulance Liaison Committee Airway Working Group, June 2008

Paramedic tracheal intubation has been practised in the UK for more than 20 years and is currently a core skill for paramedics. Growing evidence suggests that tracheal intubation is not...