The experiences of EMS providers taking part in a large randomised trial of airway management during out of hospital cardiac arrest, and the impact on their views and practice. Results of a survey and telephone interviews.

AIMS: To explore EMS experiences of participating in a large trial of airway management during out-of-hospital cardiac arrest (AIRWAYS-2), specifically to explore: 1. Any changes in views and practice as a result of trial participation. 2. Experiences of trial training. 3. Experiences of enrolling critically unwell patients without consent. 4. Barriers and facilitators for out-of-hospital trial participation. METHODS: An online questionnaire was distributed to 1523 EMS providers who participated in the trial. In-depth telephone interviews explored the responses to the online questionnaire. Quantitative data were collated and presented using simple descriptive statistics. Qualitative data collected during the online survey were analysed using content analysis. Interpretive Phenomenological Analysis was used for qualitative interview data. RESULTS: Responses to the online questionnaire were received from 33% of the EMS providers who participated in AIRWAYS-2, and 19 providers were interviewed. EMS providers described barriers and facilitators to trial participation and changes in their views and practice. The results are presented in five distinct themes: research process; changes in airway management views and practice; engagement with research; professional identity; professional competence. CONCLUSIONS: Participation in the AIRWAYS-2 trial was enjoyable and EMS providers valued the study training and support. There was enhanced confidence in airway management as a result of taking part in the trial. EMS providers indicated existing variability in training, experience and confidence in tracheal intubation, and expressed a preference for the method of airway management to which they had been randomised. There was support for the stepwise approach to airway management, but also concern regarding the potential loss of tracheal intubation from 'standard' EMS practice. The views and practices of the EMS providers expressed in this research will usefully inform the design of future similar trials.

Emergency medical service provider decision-making in out of hospital cardiac arrest: an exploratory study.

BACKGROUND: There are approximately 60,000 out-of-hospital cardiac arrests (OHCA) in the United Kingdom (UK) each year. Within the UK there are well-established clinical practice guidelines that define when resuscitation should be commenced in OHCA, and when resuscitation should cease. Background literature indicates that decision-making in the commencement and cessation of resuscitation efforts in OHCA is complex, and not comprehensively understood. No relevant research from the UK has been published to date and this research study seeks to explore the influences on UK Emergency Medical Service (EMS) provider decision-making when commencing and ceasing resuscitation attempts in OHCA. The aim of this research to explore the influences on UK Emergency Medical Services provider decision-making when commencing and ceasing resuscitation attempts in OHCA. METHODS: Four focus groups were convened with 16 clinically active EMS providers. Four case vignettes were discussed to explore decision-making within the focus groups. Thematic analysis was used to analyse transcripts. RESULTS: This research found that there are three stages in the decision-making process when EMS providers consider whether to commence or cease resuscitation attempts in OHCA. These stages are: the call; arrival on scene; the protocol. Influential factors present at each of the three stages can lead to different decisions and variability in practice. These influences are: factual information available to the EMS provider; structural factors such as protocol, guidance and research; cultural beliefs and values; interpersonal factors; risk factors; personal values and beliefs. CONCLUSIONS: An improved understanding of the circumstantial, individual and interpersonal factors that mediate the decision-making process in clinical practice could inform the development of more effective clinical guidelines, education and clinical decision support in OHCA. These changes have the potential to lead to greater consistency. and EMS provider confidence, with the potential for improved patient outcome from OHCA.

Home or hospital for people with dementia and one or more other multimorbidities: What is the potential to reduce avoidable emergency admissions? The HOMEWARD Project Protocol.

INTRODUCTION: Older people with multimorbidities frequently access 999 ambulance services. When multimorbidities include dementia, the risk of ambulance use, accident and emergency (A&E) attendance and hospital admission are all increased, even when a condition is treatable in the community. People with dementia tend to do poorly in the acute hospital setting and hospital admission can result in adverse outcomes. This study aims to provide an evidence-based understanding of how older people living with dementia and other multimorbidities are using emergency ambulance services. It will also provide evidence of how paramedics make decisions about taking this group of patients to hospital, and what resources would allow them to make more person-focused decisions to enable optimal patient care. METHODS AND ANALYSIS: Phase 1: retrospective data analysis: quantitative analysis of ambulance service data will investigate: how often paramedics are called to older people with dementia; the amount of time paramedics spend on scene and the frequency with which these patients are transported to hospital. Phase 2: observational case studies: detailed case studies will be compiled using qualitative methods, including non-participant observation of paramedic decision-making, to understand why older people with multimorbidities including dementia are conveyed to A&E when they could be treated at home or in the community. Phase 3: needs analysis: nominal groups with paramedics will investigate and prioritise the resources that would allow emergency, urgent and out of hours care to be effectively delivered to these patients at home or in a community setting. ETHICS AND DISSEMINATION: Approval for the study has been obtained from the Health Research Authority (HRA) with National Health Service (NHS) Research Ethics Committee approval for phase 2 (16/NW/0803). The dissemination strategy will include publishing findings in appropriate journals, at conferences and in newsletters. We will pay particular attention to dissemination to the public, dementia organisations and ambulance services.

Evaluation of an intervention to reduce tidal volumes in ventilated ICU patients.

BACKGROUND: There is considerable evidence that the use of tidal volumes <6 ml kg(-1) predicted body weight (PBW) reduces mortality in mechanically ventilated patients. We evaluated the effectiveness of using a large screen displaying delivered tidal volume in ml kg(-1) (PBW) for reducing tidal volumes. METHODS: We assessed the intervention in two 6-month periods. A qualitative study was undertaken after the intervention period to examine staff interaction with the intervention. The study was conducted in a mixed medical and surgical intensive care unit at University Hospitals Bristol, UK. Consecutive patients requiring controlled mechanical ventilation for more than 1 h were included. Alerts were triggered when tidal volume breached predetermined targets and these alerts were visible to ICU clinicians in real time. RESULTS: A total of 199 patients with 7640 h of data were observed during the control time period and 249 patients with 10 656 h of data were observed in the intervention period. Time spent with tidal volumes <6 ml kg(-1) PBW increased from 17.5 to 28.6% of the period of controlled mechanical ventilation. Time spent with a tidal volume <8 ml kg(-1) PBW increased from 60.6 to 73.9%. The screens were acceptable to staff and stimulated an increase in attendance of clinicians at the bedside to adjust ventilators. CONCLUSIONS: Changing the format of data and displaying it with real-time alerts reduced delivered tidal volumes. Configuring information in a format more likely to result in desired outcomes has the potential to improve the translation of evidence into practice.