Scottish Ambulance Service Research Articles

Re: Analysis of aeromedical retrieval coverage using elliptical isochrones.

Departments of General Surgery and Intensive Care Medicine Aberdeen Royal Infirmary & Health Services Research Unit University of Aberdeen Aberdeen, Scotland Scottish Ambulance Service Glasgow, Scotland Department of Geography and Environment University of Aberdeen Aberdeen, Scotland

A MULTI-MODAL APPROACH TO QUALITY IMPROVEMENT: REDUCING 'DOOR-TO-CT' TIME IN POTENITALLY THOMBOLYSABLE STROKE PATIENTS

Objectives & BackgroundWith 1.9 million neurons lost every minute a stroke is untreated1, rapid assessment and management is a time critical medical emergency, and is reliant on robust Emergency Department...

Evaluating the impact of a national naloxone programme on ambulance attendance at overdose incidents: a controlled time-series analysis.

Background and AimsIt has been suggested that distributing naloxone to people who inject drugs (PWID) will lead to fewer attendances by emergency medical services at opioid‐related overdose incidents if peer administration of naloxone was perceived to have resuscitated the overdose victim successfully. This study evaluated the impact of a national naloxone programme (NNP) on ambulance attendance at opioid‐related overdose incidents throughout Scotland. Specifically, we aimed to answer the following research questions: is there evidence of an association between ambulance call‐outs to opioid‐related overdose incidents and the cumulative number of ‘take‐home naloxone’ (THN) kits in issue; and is there evidence of an association between ambulance call‐outs to opioid‐related overdose incidents in early adopter (pilot) or later adopting (non‐pilot) regions and the cumulative number of THN kits issued in those areas?DesignControlled time–series analysis.SettingScotland, UK, 2008–15.ParticipantsPre‐NNP implementation period for the evaluation was defined as 1 April 2008 to 31 March 2011 and the post‐implementation period as 1 April 2011 to 31 March 2015. In total, 3721 ambulance attendances at opioid‐related overdose were recorded for the pre‐NNP implementation period across 158 weeks (mean 23.6 attendances per week) and 5258 attendances across 212 weeks in the post‐implementation period (mean 24.8 attendances per week).InterventionScotland's NNP; formally implemented on 1 April 2011.MeasurementsPrimary outcome measure was weekly incidence (counts) of call‐outs to opioid‐related overdoses at national and regional Health Board level. Data were acquired from the Scottish Ambulance Service (SAS). Models were adjusted for opioid replacement therapy using data acquired from the Information Services Division on monthly sums of all dispensed methadone and buprenorphine in the study period. Models were adjusted further for a control group: weekly incidence (counts) of call‐outs to heroin‐related overdose in the London Borough area acquired from the London Ambulance Service.FindingsThere was no significant association between SAS call‐outs to opioid‐related overdose incidents and THN kits in issue for Scotland as a whole (coefficient 0.009, 95% confidence intervals = −0.01, 0.03, P = 0.39). In addition, the magnitude of association between THN kits and SAS call‐outs did not differ significantly between pilot and non‐pilot regions (interaction test, P = 0.62).ConclusionsThe supply of take‐home naloxone kits through a National Naloxone Programme in Scotland was not associated clearly with a decrease in ambulance attendance at opioid‐related overdose incidents in the 4‐year period after it was implemented in April 2011.

A collaborative improvement project by an NHS Emergency Department and Scottish Ambulance Paramedics to improve the identification and delivery of sepsis 6.

Early identification of patients with sepsis is key to the delivery of the sepsis 6 bundle including antibiotic therapy within an hour.[1-3] Demand versus capacity challenges in the Emergency Department...

Improving self-referral for diabetes care following hypoglycaemic emergencies: a feasibility study with linked patient data analysis.

BackgroundHypoglycaemia is a common and potentially life threatening consequence of insulin and sulphonylurea treated Diabetes. Some severe hypoglycaemic events result in emergency ambulance attendance. Many of these patients are treated at home and do not require immediate transportation to an Emergency Department. However only 27-37 % of patients then follow up their care with a diabetes specialist. Consequently repeat severe hypoglycaemic events occur.MethodsThe intervention was implemented for 8 months, using a prospective cohort design with a historic control, in one Scottish Health Board in 2012. Data was collected using postal survey questionnaires to patients and ambulance clinicians, telephone survey follow-up questions to patients. Scottish Ambulance Service electronic records were linked with the SCI-Diabetes database of patient records to enable objective measurement of follow-up behaviour.ResultsAmbulance clinicians’ (n = 92) awareness of the intervention was high and both the prompt card and telephone call components of the intervention were delivered to most eligible patients. The intervention was perceived as highly acceptable to patients (n = 37), and very useful by both patients and ambulance clinicians. However, comparison of patient follow-up behaviours using linked-data (n = 205), suggest that the intervention was unsuccessful in improving rates of patients’ following up their care.ConclusionsThis study shows that the intervention is implementable, highly acceptable to patients, and considered very useful by both patients and ambulance clinicians. However, preliminary evidence of effectiveness is not encouraging. The study’s novel use of linking existing clinical data for outcome measurement exposed challenges in the feasibility of using this data for intervention development and evaluation. Future research should examine challenges to the successful testing and effectiveness of the intervention. Revisions are likely to be required, both to study design and the optimisation of the intervention’s content and components.Electronic supplementary materialThe online version of this article (doi:10.1186/s12873-016-0078-1) contains supplementary material, which is available to authorized users.

Access to specialist care: Optimizing the geographic configuration of trauma systems.

BACKGROUNDThe optimal geographic configuration of health care systems is key to maximizing accessibility while promoting the efficient use of resources. This article reports the use of a novel approach to inform the optimal configuration of a national trauma system.METHODSThis is a prospective cohort study of all trauma patients, 15 years and older, attended to by the Scottish Ambulance Service, between July 1, 2013, and June 30, 2014. Patients underwent notional triage to one of three levels of care (major trauma center [MTC], trauma unit, or local emergency hospital). We used geographic information systems software to calculate access times, by road and air, from all incident locations to all candidate hospitals. We then modeled the performance of all mathematically possible network configurations and used multiobjective optimization to determine geospatially optimized configurations.RESULTSA total of 80,391 casualties were included. A network with only high- or moderate-volume MTCs (admitting at least 650 or 400 severely injured patients per year, respectively) would be optimally configured with a single MTC. A network accepting lower-volume MTCs (at least 240 severely injured patients per year) would be optimally configured with two MTCs. Both configurations would necessitate an increase in the number of helicopter retrievals.CONCLUSIONThis study has shown that a novel combination of notional triage, network analysis, and mathematical optimization can be used to inform the planning of a national clinical network. Scotland’s trauma system could be optimized with one or two MTCs.LEVEL OF EVIDENCECare management study, level IV.

An Integrated Community Falls Emergency Pathway

The abstract gives an example of both an innovation to integrated care and an example of good practice: an Integrated Community Falls Emergency Pathway. Most adults fall each year. The consequences of a fall become more serious with both increasing age and the presence of multiple morbities. In Scotland, a fall is the most common reason a person over the age of 65 years contacts the emergency services, resulting in the most frequent reason for a ‘call-out’ by an ambulance from the Scottish Ambulance Service (SAS). Without an appropriate alternative, ‘falls’ become the most common reason for presentation by older adults to Emergency Departments (EDs). However, not all falls result in an injury that requires either conveyance to the ED, or admission into secondary care. Furthermore, evidence suggests admissions to secondary care can be detrimental to the health and well-being of people with multiple morbities, and can result in a reduction in functional ability, social isolation and iatrogenic infection. Thus, alternatives to ED conveyance for treatment of the outcomes of non-injurious falls are urgently sought. The City of Edinburgh worked to develop an Integrated Care Pathway for treatment of noninjurious falls in the community; the Community Emergency Falls Pathway. The pathway links the SAS, Social Care Direct and Intermediate Care with the fallen person in order to provide multifactorial falls assessment and intervention in the most appropriate location, often at home. This includes a full review of falls risk factors, environmental assessment and strength and balance training. Initial outcomes show that as well as reduced presentations to the ED, admissions to secondary care through the ED can be avoided, bed-days saved and future admissions prevented.

Feasibility and utility of population-level geospatial injury profiling: prospective, national cohort study.

Geospatial analysis is increasingly being used to evaluate the design and effectiveness of trauma systems, but there are no metrics to describe the geographic distribution of incidents. The aim of this study, therefore, was to evaluate the feasibility and utility of using spatial analysis to characterize, at scale, the geospatial profile of an injured population. This is a prospective national cohort study of all trauma patients attended to by the Scottish Ambulance Service in a complete year (between July 1, 2013, and June 30, 2014). Incident location and severity were collected at source. Incident distribution was evaluated using geostatistical techniques. There were 80,391 recorded incidents involving traumatic injury. Incident density was highest in the central Southern part of the country and along the East coast, broadly following the population distribution and road network. The overall distribution was highly clustered, and centered on the central Southern and Eastern parts of the country. When analyzed by triage category, the distribution of incidents triaged to major trauma center care was slightly less clustered than that of incidents triaged to trauma unit or local emergency hospital care, but the spread was similar. When analyzed by type of injury, assaults and falls were more clustered than incidents relating to traffic and transportation. This study demonstrates the feasibility and power of describing the geographic distribution of a group of injured patients. The methodology described has potential application for injury surveillance and trauma system design and evaluation.

INVESTIGATING PATIENTS EXPERIENCES OF HYPOGLYCAEMIC EMERGENCIES

BackgroundIn Scotland approximately 70% of patients with diabetes treated for a hypoglycaemic event by ambulance clinicians remain at home after treatment. However, many of these individuals experience repeat or subsequent...

Pre-hospital technology research: reflecting on a collaborative project between ambulance service and academia

The University of Aberdeen MIME project (Managing Information in Medical Emergencies) aimed to develop technology to support volunteer rural community first responders when managing patients. This can be a particularly stressful activity with many challenges to overcome while waiting for ambulance clinicians to arrive. The MIME system employed lightweight medical sensors streaming data (heart and respiratory rate, and blood oxygen saturation) wirelessly to a tablet computer. Novel software was developed to present these data on-screen in a simple way and facilitate the quick digital capture of first responder actions and observations. MIME also applied the technique of Natural Language Generation, which interrogated sensor data, user-inputted actions and observations to automatically generate a handover report in English. This paper describes the MIME system, and then focuses on our collaboration journey between academia and the Scottish Ambulance Service. We illustrate the challenges encountered during our research and development, and describe the academia-ambulance service collaboration model that was developed to deliver success. We also discuss the Knowledge Exchange sub-context to our research activities, which coincided with the early development of research capacity within the ambulance service.

Using Technology to Enhance Rural Resilience in Pre-Hospital Emergencies

This paper contributes to understanding of the geography of emergency pre-hospital care in rural Scotland and explores the role technology can play in improving the resilience of rural communities. In rural areas worldwide, it can be difficult to access appropriate health services locally and long journeys present challenges to the delivery of care. Poor mobile network coverage, remote locations with poor transport networks and inclement weather can all delay the arrival of help. The Scottish Ambulance Service operates a Community First Responder (CFR) scheme to care for patients in mainly rural areas while an ambulance is on its way. Community First Responders are volunteers trained in the basics of life-support but may have to care for patients with life-threatening illness (and sometimes injury) for a considerable period of time. Our paper showcases the Managing Information in Medical Emergencies project, which aims to support CFRs. We have developed novel technology to enable CFRs to capture a greater volume of patient data (including physiological parameters), provide them with an enhanced awareness of a patient's medical status and automatically generate handover reports for them. It is hoped that the handover reports improve the chain of communication from first person on scene to definitive care.

Co-designing a Digital Directory of Services

Abstract The Digital Health and Care Institute is a new innovation centre in Scotland which aims to transform health and social care delivery using a dynamic model of innovation ( www.dhi-scotland.com ). Experience Laboratories are at the core of this model and are led and developed by the Institute of Design Innovation at The Glasgow School of Art. Experience Labs provide a new way of working collaboratively within health and social care contexts in Scotland through a process of exploration, co-design and co-creation, and rapid prototyping of ideas. Bring together academic, business and civic partners, Experience Labs provide the opportunity for extreme collaboration in a safe and realistic environment. Through a series of design-led activities, which position the user at the centre of the design process, the Labs enable the trialing of ideas and co-design of sustainable health and social care solutions, together with end-users. This paper presents the findings of a design-led project to co-design a new directory of services application for the Scottish Ambulance Service. The Experience Lab aimed to explore and develop a basic prototype of a Directory App to support ambulance clinicians to consider alternatives to Accident and Emergency where appropriate, and support initial small scale testing. The Experience Labs provided the opportunity to co-design, develop and test a solution with users. The design-led approach enabled the delivery of a set of user-driven requirements for the development of the Directory App. The safe space for trialling and testing provided by the Labs together with the design-led approach allowed users to share their ideas and experience, contributing to the design of the ideal Directory App.

An insight into the demands and stressors experienced by Community First Responders

Background: Community First Responders (CFR) are volunteers who respond to appropriate medical emergencies while an ambulance is en route. The emergencies that CFRs attend are situations where stress is inherent, yet little is known of which stressors and demands are present and which are considered to be the greatest attributer to stress experienced. Objective: This survey aims to gain further understanding of the demands and stressors experienced by CFRs. Design: An online survey using a modified NASA-TLX scoring system was distributed to CFRs throughout Scotland (n=535). CFRs were asked to gauge the demands and stressors experienced during a ‘typical’ and their ‘most stressful’ callout, what would be the biggest cause of stress if present and the most stressful time-period during callouts. Results: 88 CFRs started the survey with 40 continuing to completion. Frustration that the CFR could not help the patient more was considered to be the biggest stressor for both a typical and most the stressful callout. Emotional demand was the most present demand in a typical callout and mental demand in the most stressful callout. If present, loneliness and isolation was deemed to be the biggest cause of stress for CFRs. Prior to arrival at scene was the most stressful time. Conclusions: This insight provides a valuable appraisal for the Scottish Ambulance Service of the CFR scheme and the concerns and demands experienced by its volunteers. The results also act as a cross-sectional study for research investigating stress alleviation through human-computer interaction in the pre-hospital care domain.

Improving the management and care of people with sepsis

Many hospitals struggle to implement the full sepsis care bundle, but research suggests that many patients with sepsis are transported to hospital by ambulance. In 2011, the Scottish Ambulance Service introduced a pre-hospital sepsis screening tool (PSST) to expedite sepsis identification and care delivery. However, ambulance clinicians have reported varying degrees of interest and enthusiasm from hospital staff during handover. Therefore, an online survey was set up to investigate medical and nursing staff perceptions and experiences of the introduction of a PSST. This article discusses the results, which show that participants perceive the PSST reduces time to treatment, improves continuity of care, benefits patients and is accurately applied by ambulance clinicians, but which also highlight problems with communication. The delivery of in-hospital and pre-hospital sepsis care is challenging, but simple measures such as improving and standardising communication and alert systems between ambulance services and receiving hospitals could improve the clinical effects of a PSST.

Trauma care in Scotland: effect of rurality on ambulance travel times and level of destination healthcare facility.

The aim of this study was to determine the effect of rurality on the level of destination healthcare facility and ambulance response times for trauma patients in Scotland. We used a retrospective analysis of pre-hospital data routinely collected by the Scottish Ambulance Service from 2009-2010. Incident locations were categorised by rurality, using the Scottish urban/rural classification. The level of destination healthcare facility was coded as either a teaching hospital, large general hospital, general hospital, or other type of facility. A total of 64,377 incidents met the inclusion criteria. The majority of incidents occurred in urban areas, which mostly resulted in admission to teaching hospitals. Incidents from other areas resulted in admission to a lower-level facility. The majority of incidents originating in very remote small towns and very remote rural areas were treated in a general hospital. Median call-out times and travel times increased with the degree of rurality, although with some exceptions. Trauma is relatively rare in rural areas, but patients injured in remote locations are doubly disadvantaged by prolonged pre-hospital times and admission to a hospital that may not be adequately equipped to deal with their injuries. These problems may be overcome by the regionalisation of trauma care, and enhanced retrieval capability.

Pre-Hospital ECG E-Transmission for Patients with Suspected Myocardial Infarction in the Highlands of Scotland

Patients with ST elevation myocardial infarction (STEMI) require prompt treatment, best done by primary percutaneous coronary intervention (PPCI). However, for patients unable to receive PPCI, immediate pre-hospital thrombolysis (PHT) is the best alternative. Evidence indicates that diagnostic and management support for staff increases the use of PHT. This study aimed to describe the patient demographics and management of patients, to determine any potential inter-area differences in referral rates to the ECG e-transmission service and to explore the views and experiences of key staff involved in ECG e-transmission within NHS Highland. Data from 2,025 patient episodes of ECG e-transmission identified a statistically significant geographical variation in ECG e-transmission and PHT delivery. Scottish Ambulance Service (SAS) staff were more likely than GPs to deliver PHT overall, however, GPs were more likely to deliver in remote areas. Interviews with six Cardiac Care Unit (CCU) nurses and six SAS staff highlighted their positive views of ECG e-transmission, citing perceived benefits to patients and interprofessional relationships. Poor access to network signal was noted to be a barrier to engaging in the system. This study has demonstrated that a specialist triage service based on e-transmission of ECGs in patients with suspected STEMI can be implemented in a diverse geographical setting. Work is needed to ensure equity of the service for all patients.

Caseload of a land-based trauma team

Pre-hospital care is provided by a variety of models worldwide. The Tayside Trauma Team responds from Ninewells Hospital in Dundee to provide a physician-led pre-hospital care service targeted primarily at trauma patients. We present a description of the functions of the team, and data detailing the clinical work of the Team over a six-month period. The Team was called out 35 times in six months and attended 22 incidents, some involving multiple casualties. 34 patients received treatment at the scene of an incident. Most incidents were road traffic collisions, although the team also attended falls from height, an assault and a vascular injury. Eight patients (24%) met Injury Severity Score criteria for major trauma (ISS>15). Mean time from 999 calls to Team activation was 20 (range 4-79) min; and mean time from Team dispatch to 'Team mobile' was 4.6 (2-21) min. The Tayside Trauma Team provides a physician-led pre-hospital care response on demand from the Scottish Ambulance Service. It provides critical care interventions at the scene of various incidents (primarily traumatic) to attempt to improve patient outcome. Response times are favourable.

The high cost to health and social care of managing falls in older adults living in the community in Scotland

Estimate costs for health and social care services in managing older people in the community who fall. Analyses of predominantly national databases using cost of illness methodologies. In Scotland, 294,000 (34%) of people over 65 years and living in the community fall at least once a year. Of these 20%, almost 60,000 people contacted a medical service for assistance. There were almost 30,000 attendances at GP practices, over 36,100 calls to the Scottish Ambulance Service and 46,816 people presenting at A&E, with 16,549 admitted, 30% with a hip fracture. Mortality was high, 7% during the hospital stay, rising to over 12% at 1 year. Over 20% of patients were unable to return to their homes. Associated costs were over £470 million, with 60% incurred by social services, mainly providing long-term care. Cost per person falling was over £1720, rising to over £8600 for those seeking medical assistance. A hip fracture admission cost £39,490, compared with £21,960 for other falls-related admissions. Transparent, robust cost information demonstrates the substantial burden of falls for health and social care services and should be a driver for implementing evidence-based interventions to reduce falls.

Demographic and geographical characteristics of pediatric trauma in Scotland

BackgroundTrauma systems reduce mortality and improve functional outcomes. The aim of this study was to analyse the demographic and geospatial characteristics of pediatric trauma patients in Scotland, and determine the level of destination healthcare facility which injured children are taken to, to determine the need for, and general feasibility, of developing a pediatric trauma system for Scotland. MethodsRetrospective analysis of incidents involving children aged 1–14 attended to by the Scottish Ambulance Service between 1 November 2008 and 31 October 2010. A subgroup with physiological derangement was defined. Incident location postcode was used to determine incident location by health board region, rurality and social deprivation. Destination healthcare facility was classified into one of six categories. ResultsOf 10,759 incidents, 72.3% occurred in urban areas and 5.8% in remote areas. Incident location was associated with socioeconomic deprivation. Of the patients, 11.6% were taken to a pediatric hospital with pediatric intensive care facilities, 21.8% to a pediatric hospital without pediatric intensive care service, and 50.2% to an adult large general hospital without pediatric surgical service. ConclusionsThe majority of incidents involving children with injuries occurred in urban areas. Half were taken to a hospital without pediatric surgical service. There was no difference between children with normal and deranged physiology.

Destination healthcare facility of shocked trauma patients in Scotland: Analysis of transfusion and surgical capability of receiving hospitals

AimsHaemorrhage is a leading cause of death from trauma. Management requires a combination of haemorrhage control and resuscitation which may incur significant surgical and transfusion utilisation. The aim of this study is to evaluate the resource provision of the destination hospital of Scottish trauma patients exhibiting evidence of pre-hospital shock. MethodsPatients who sustained a traumatic injury between November 2008 and October 2010 were retrospectively identified from the Scottish Ambulance Service electronic patients record system. Patients with a systolic blood pressure less than 110 mmHg or if missing, a heart rate greater than 120 bpm, were considered in shock. The level of the destination healthcare facility was classified in terms of surgical and transfusion capability. Patients with and without shock were compared. ResultsThere were 135 004 patients identified, 133 651 (99.0%) of whom had sustained blunt trauma, 68 411 (50.7%) were male and the median (IQR) age was 59 (46). There were 6721 (5.0%) patients with shock, with a similar age and gender distribution to non-shocked patients. Only 1332 (19.8%) of shocked patients were taken to facilities with full surgical capability, 5137 (76.4%) to hospitals with limited (general and orthopaedic surgery only) and 252 (3.7%) to hospitals with no surgical services. In terms of transfusion capability, 5556 (82.7%) shocked patients were admitted to facilities with full capability and 1165 (17.3%) to a hospital with minimal or no capability. ConclusionsThe majority of Scottish trauma patients are transported to a hospital with full transfusion capability, although the majority lack surgical sub-specialty representation.