London Ambulance Service Research Articles

Blood, Sweat and Tea - Real-Life Adventures in an Inner-City AmbulanceBlood, Sweat and Tea - Real-Life Adventures in an Inner-City Ambulance

Blood, Sweat and Tea reveals the life of an emergency medical technician in the London Ambulance Service. Written initially as a regular website blog, this book retains the diary-entry format to portray the reality of days and nights spent responding to 999 calls.

Appropriateness of intravenous cannulation by paramedics: A london study

Introduction. The number of patients undergoing intravenous (IV) cannulation by paramedics has increased dramatically over recent years in the UK. Treatment protocols for cannulation in the field are loosely defined. Variation in practice may lead to patients' receiving differential treatment according to customary practice, rather than according to their clinical conditions. Objectives. To explore variations in practice and assess level of appropriatenesss of IV cannulation by London Ambulance Service (LAS) paramedics; to revise treatment protocols and work toward clinical guidelines, if indicated by study findings. Methods. Skill usage data were analyzed for all LAS paramedics for 1995-96. All patients who were IV-cannulated and transported to three hospitals by LAS during March 1996 were identified. A panel of accident and emergency (A&E) and prehospital specialists judged each case for appropriateness. Results. Variation during the year was wide, with a range of 1 to 221 (mean 47) patients cannulated per paramedic, although the majority showed some consistency in frequency of skill usage. A sample of 183 cases was reviewed. The majority judged 149 (81.4%) to be appropriate, although there was considerable disagreement between reviewers (κ = 0.43, p < 0.001). Data suggested that those paramedics who cannulate more frequently cannulated less appropriately during the study period (lowest 30%: 73.9% appropriate; highest 30%: 45.8% appropriate, p = 0.05). Conclusion. Despite wide variation between paramedics, the panel judged overall appropriateness of cannulation to be high. The audit advisory group judged that new clinical guidelines might not achieve an improvement in practice and were not supported by study findings. It was recommended that variations be addressed through individual practice review. PREHOSPITAL EMERGENCY CARE 2000;4:156-163

External disturbance control for software project management

Software project management processes are examined using the Law of Requisite variety to illustrate that a different control approach is required to prevent failures. Causes (disturbances) of project failures in the literature are identified to illustrate how a control system might be designed. A more inclusive use of project personnel and a much more proactive role by buyer executives to provide observers and control solutions is needed. Failure of the London Ambulance Service computerisation is used as an example. Software failures can only be reduced if these disturbances are observed and controlled as early as possible in the project formation.

The turnaround of the London Ambulance Service Computer-Aided Despatch system (LASCAD)

The implementation of the Computer-Aided Despatch system at the London Ambulance Service has been one of the most notorious cases of failure within the information systems (IS) literature. What is less well known is that there followed, some time later, a much more successful implementation, described as a turnaround. This paper, based on a case study approach, describes the context and detail of that implementation. A framework from the literature, used in an analysis of the initial failure, is used to analyse and compare the similarities and differences in the development of the two systems. The framework provides four interacting elements and relationships for analysis. These elements are Supporters, Project Organisation, Information System, and the Environment in which they operate. The turnaround system was found to address directly almost all the issues identified as problematic in the failure. These included the approach taken by management to understand the needs of users, including issues unrelated to the system itself, their involvement in the development process, an improvement in the availability of resources (brought about in some part because of the previous failure), the ability to follow a relaxed timeline driven by users' acceptance levels, the preparation of infrastructure projects to develop confidence, participation and prototyping, thorough testing, phased and simple implementation, and trust building. Certain environmental factors could not be so directly addressed but nevertheless were overcome by attention to detail and internal needs. Conclusions indicate that the factors addressed are not new and are to be found in the success literature. What is unusual is that they were implemented in this case in such unlikely circumstances.

‘Event tree’ analysis of out-of-hospital cardiac arrest data: confirming the importance of bystander CPR

Objective: The British National Service Framework (NSF) for heart disease commended the ‘Utstein style’ for auditing out-of-hospital cardiac arrests. The NSF also set standards for pre-hospital treatment and response times. To increase the flexibility of Utstein, an ‘event tree’ technique is proposed as an audit tool. Event trees consist of nodes and branches on which numbers, percentages or probability values are entered. Methods: Using the London Ambulance Service's (LAS) 1997 database on 3759 out-of-hospital cardiac arrests, 2772 arrests witnessed by lay bystanders or unwitnessed were analysed focusing on bystander cardiopulmonary resuscitation (BCPR) and response times. Results: The Utstein template showed that witnessed arrests in ventricular fibrillation (VF) or ventricular tachycardia (VT) who had received BCPR achieved a return of spontaneous circulation (ROSC) in the field significantly more often than non-BCPR recipients—26 versus 16% ( P=0.006). But the likelihood of being admitted to a hospital bed, and discharged alive, was only marginally better for BCPR recipients. To examine the influence of BCPR on the presenting rhythm an event tree showed that in 48% of witnessed BCPR cases the presenting rhythm was VF/VT, whereas, for witnessed non-BCPR cases, 27% were in VF/VT ( P<0.0001). With unwitnessed arrests, 31% of BCPR cases were in VF/VT compared with 18% for non-BCPR cases ( P<0.0001). Call to scene time was less than 8 min for 66% of all VF/VT arrests. Conclusion: The event trees, when combined with the Utstein template, demonstrated the importance of examining comprehensively datasets for both witnessed and unwitnessed cardiac arrests when monitoring performance standards. The analyses also emphasised the relevance of community programmes in Greater London for teaching basic life saving skills.

The Golden Circle: a way of arguing and acting about technology in the London Ambulance Service

This paper analyses the way in which the London Ambulance Service recovered from the events of October 1992, when it implemented a computer-aided despatch system (LASCAD) that remained in service for less than 2 weeks. It examines the enactment of a programme of long-term organizational change, focusing on the implementation of an alternative computer system in 1996. The analysis in this paper is informed by actor-network theory, both by an early statement of this approach developed by Callon in the sociology of translation, and also by concepts and ideas from Latour's more recent restatement of his own position. The paper examines how alternative interests emerged and were stabilized over time, in a way of arguing and acting among key players in the change programme, christened the Golden Circle. The story traces 4 years in the history of the London Ambulance Service, from the aftermath of October 1992 through the birth of the Golden Circle to the achievement of National Health Service (NHS) trust status. LASCAD was the beginning of the story, this is the middle, an end lies in the future, when the remaining elements of the change programme are enacted beyond the Golden Circle.

Dispatcher-assisted cardiopulmonary resuscitation and survival in cardiac arrest

In England, fewer than 1 in 10 out-of-hospital cardiac arrest victims survive to hospital discharge. This could be substantially improved by increasing bystander cardiopulmonary resuscitation and Automated External Defibrillator use.GoodSAM is a mobile-phone, app-based system alerting trained individuals to nearby cardiac arrests. ‘Responders’ can be notified by bystanders using the GoodSAM ‘Alerter’ function. In London, when a 999 call-handler identifies cardiac arrest, in addition to dispatching the usual professional resources, London Ambulance Service automatically activates nearby GoodSAM responders.This article discusses the development of GoodSAM, its integration with London Ambulance Service, and the plans for future expansion.

“AND THAT’S MAGIC!”—MAKING PUBLIC BODIES LIABLE FOR FAILURE TO CONFER BENEFITS

THE facts of Kent v. Giffiths [2000] W.L.R. 1158 were that the claimant had suffered an asthma attack and was attended by a doctor at her home. At 4.25 p.m. the doctor called an ambulance, gave the patient’s name, address, age and condition, and requested that she be transferred immediately to casualty where she was expected. Ambulance control replied “Okay doctor”. At 4.35 p.m. the claimant’s husband was assured, on making a second call, that the ambulance was on its way. He was told to hang on for another seven or eight minutes. A similar response was given to a third call made sixteen minutes later. The ambulance finally arrived forty minutes after the initial call was made. The claimant suffered respiratory arrest resulting in brain damage and a miscarriage. At trial Turner J. held that the London Ambulance Service (LAS) was liable for breach of a duty of care. He found not only that there was no reasonable explanation for the delay, but also that the ambulance crew had falsified their records ([1999] Lloyds Rep. Med. 424). Had the ambulance arrived when it should, there was a high probability that the respiratory arrest would have been averted.

Future of London Ambulance Service under debate

Three Court of Appeal judges ruled this month that ambulance services can be liable to pay compensation for injuries resulting from failure to respond to 999 calls within a reasonable time. This test case ruling could leave ambulance services open to a huge increase in costly litigation. Tracey Kent, a 35 year old asthma sufferer, was awarded more than £360 000 when she claimed that she had suffered …

Out-of-hospital intravenous cannulation: the perspective of patients treated by London Ambulance Service paramedics.

Previous research has highlighted concern about infection rates in field-placed intravenous (IV) cannulae. In a study of IV placement by London Ambulance Service (LAS) paramedics, 17% of placements were judged to be inappropriate. Large variations in rates of IV placement between LAS paramedics were found. The authors' hypothesis was that placement of an IV carries disadvantages-pain, discomfort, distress, and infection-which may be unacceptable to patients. This was a survey of all patients having an IV placed by LAS paramedics and transported to one of three London emergency departments (EDs) over a three-week period in December 1996. Patients were excluded if they had a self-inflicted injury/illness, were less than 14 years old, had no known address, or were visitors to the UK, or if their family doctor suggested it was not appropriate to contact the patient. Pain, discomfort, and distress; infection; satisfaction; understanding of the reason for cannulation; and out-of-hospital cannula use were all ascertained and analyzed with chi-square analysis. Thirty-nine percent of the respondents experienced some discomfort, 39% some pain, and 17% some distress. No patient reported an infection. Distress was more likely to be reported if there was no understanding of why the IV cannula was placed (chi2 [1] 6.1; p < 0.05). Further unstructured information revealed satisfaction with the IV cannulation and with general care. Despite the disadvantages of IV placement being reported by some respondents, overall levels of satisfaction were high, suggesting that these disadvantages were not unacceptable to patients. However, in the context of the 24,000 patients cannulated each year by LAS paramedics, "costs" to the patient are considerable.

A PPROPRIATENESS OF I NTRAVENOUS C ANNULATION BY P ARAMEDICS : A L ONDON S TUDY

Introduction. The number of patients undergoing intravenous (IV) cannulation by paramedics has increased dramatically over recent years in the UK. Treatment protocols for cannulation in the field are loosely defined. Variation in practice may lead to patients' receiving differential treatment according to customary practice, rather than according to their clinical conditions. Objectives. To explore variations in practice and assess level of appropriatenesss of IV cannulation by London Ambulance Service (LAS) paramedics; to revise treatment protocols and work toward clinical guidelines, if indicated by study findings. Methods. Skill usage data were analyzed for all LAS paramedics for 1995–96. All patients who were IV-cannulated and transported to three hospitals by LAS during March 1996 were identified. A panel of accident and emergency (A&E) and prehospital specialists judged each case for appropriateness. Results. Variation during the year was wide, with a range of 1 to 221 (mean 47) patients cannulated per paramedic, although the majority showed some consistency in frequency of skill usage. A sample of 183 cases was reviewed. The majority judged 149 (81.4%) to be appropriate, although there was considerable disagreement between reviewers (κ = 0.43, p < 0.001). Data suggested that those paramedics who cannulate more frequently cannulated less appropriately during the study period (lowest 30%: 73.9% appropriate; highest 30%: 45.8% appropriate, p = 0.05). Conclusion. Despite wide variation between paramedics, the panel judged overall appropriateness of cannulation to be high. The audit advisory group judged that new clinical guidelines might not achieve an improvement in practice and were not supported by study findings. It was recommended that variations be addressed through individual practice review.

The world’s a stage: a survey on requirements engineering using a real-life case study

In this article we present a survey on the area of Requirements Engineering anchored on the analysis of a real life case study, the London Ambulance Service [56]. We aim at bringing to context new methods, techniques and tools that should be of help to both reaserchers and practitioners. The case study in question is of special interest in that it is available to the public and deals with a very large system, of which the software system is only a part of. The survey is divided into four topics of interest: viewpoints, social aspects, evolution and non-functional requirements. This division resulted from the work method adopted by the authors. Our main goal is to bridge recent findings in Requirements Engineering research to a real world problem. In this light, we believe this article to be an important educational device.

Trauma centres: a British perspective.

Trauma centres: a British perspective.

Human error and information systems failure: the case of the London ambulance service computer-aided despatch system project

Human error and systems failure have been two constructs that have become linked in many contexts. In this paper we particularly focus on the issue of failure in relation to that group of software systems known as information systems. We first review the extant theoretical and empirical work on this topic. Then we discuss one particular well-known case — that of the London ambulance service computer-aided despatch system (L ascad) project — and use it as a particularly cogent example of the features of information systems failure. We maintain that the tendency to analyse information systems failure solely from a technological standpoint is limiting, that the nature of information systems failure is multi-faceted, and hence cannot be adequately understood purely in terms of the immediate problems of systems construction. Our purpose is also to use the generic material on IS failure and the specific details of this particular case study to critique the issues of safety, criticality, human error and risk in relation to systems not currently well considered in relation to these areas.

Who calls 999 and why? A survey of the emergency workload of the London Ambulance Service.

BACKGROUND: In 1996-97 there were 623,000 emergency (999) calls made to the London Ambulance Service (LAS) and this represents a 30% increase over the previous five years. The reasons for...

Misuse of the London ambulance service: How much and why?

OBJECTIVES: To assess the degree of inappropriate use of the London Ambulance Service and analyse the reasons for misuse. DESIGN: An immediate assessment of the appropriateness of the "999" call...

Scenario-based requirements analysis

A method for scenario-based requirements engineering is described. The method uses two types of scenario: structure models of the system context and scripts of system usage. A modelling language is reported for describing scenarios, and heuristics are given to cross-check dependencies between scenario models and the requirements specification. Heuristics are grouped into several analytic treatments that investigate correspondences between users’ goals and system functions; input events and system processes to deal with them; system output and its destination in the scenario model, and acceptability analysis of system output for different stakeholders. The method is illustrated with a case study taken from the London Ambulance Service report. The prospects for scenario-based requirements engineering and related work are discussed.

London Ambulance Service: on call to technology

London Ambulance Service: on call to technology

Succeedings of the 8th international workshop on software specification and design

The 8th International Workshop on Software Specification and Design (IWSSD-8) was held at Schloss Velen, Germany, in March 1996. In order to foster informed and fruitful discussions, the workshop was an invitation-only event of limited size. Based on formal submissions, approximately 60 people were selected and invited. Like its predecessors, IWSSD-8 maintained the principle that the accepted papers should serve as background material for the workshop. Therefore, the workshop did not include formal paper presentations, but rather provided an opportunity to engage in real work, with intensive discussions focussed around major themes. Each theme was discussed in a separate working group directed by a Working Group Chair who organized their group members so as to discuss the research issues of that particular theme. This year the themes selected were Requirements Engineering, Design Engineering, Software Architecture, and Concurrency/Distribution.IWSSD has established a tradition of using "case studies" as a focus for individual working groups. These case studies, supplied in advance to participants, have proved to be a fruitful way of working. Evidence of this can be seen most clearly in the "succeedings" or workshop reports which have followed previous workshops. It was decided that for IWSSD-8, in order to provide common ground between the themes, a single common case study should be used. The "Report on the Inquiry into the London Ambulance Service" was selected, with each theme drawing on it in a manner appropriate to their own interests and concerns.The London Ambulance Service (LAS) is briefly summarized below and discussed in the first paper appearing in the proceedings. The case study was presented in a plenary session at the beginning of the workshop and the findings of the different working groups presented and discussed at the end of the workshop, again in a plenary session. In order to make best use of the time available, working group members were asked to prepare for the workshop by familiarizing themselves with the case study and the major issues in their area relevant to that case study. We believe that this format made it both attractive and rewarding for people to attend, and was a major reason for the success of this workshop.

London Ambulance Service computer-aided despatch system

This paper illustrates the dangers of trying to implement high technology projects, without sufficient technical research and development, adequate management organisation and due regard to social factors. The London Ambulance Service is the largest in the world. During the early 1990s, it attempted to introduce a computer-aided despatch system. This system was finally commissioned in October 1992, about 9 months late and failed within 2 weeks. This case study traces the history of the project and identifies the flaws that led to its failure.