Factors that influence paramedic decision-making about resuscitation for treatment of out of hospital cardiac arrest: Results of a discrete choice experiment in National Health Service ambulance trusts in England and Wales.

Background: During out of hospital cardiac arrest (OHCA) paramedics must make decisions to commence, continue, terminate or withhold resuscitation. These decisions are known to be complex, subject to variability and often dependent on provider preference. This study aimed to understand paramedic decision-making regarding the commencement of resuscitation using a discrete choice experiment. Methods: A discrete choice experiment between October-December 2022 surveying paramedics from ten National Health Service ambulance trusts in England and Wales. Respondents were presented with fourteen vignettes, each comprising thirteen attributes, and asked to decide if they would provide resuscitation or not. Results: Eight hundred and sixty-four paramedics completed the survey (61.8% male, median age 36 years (IQR 17.1)) and half had < 5 years clinical experience (n = 443 (51.2%). Respondents expressed a general preference to offer resuscitation (p = <0.01). All attributes except patient gender were statistically significant and important regarding an offer of resuscitation. Cut-offs where an offer of resuscitation was less likely were patient age of 73 years (p=>0.05), mild dementia (p = >0.05) and moderate frailty (p = <0.01). Paramedic characteristics of female gender, longest (>10 years) and shortest (<5 years) period qualified, lower academic qualification, lower skill level and attending fewer OHCA's were more likely to result in an offer of resuscitation. Conclusion: During OHCA paramedics use objective and non-objective factors to make pragmatic decisions regarding an offer of resuscitation. Future research should focus on how best to support paramedics to make decisions during OHCA, how variability in decision-making impacts patient outcomes and how this relates to patient and public expectations.

Identifying high cholesterol in the ambulance setting: a mixed-methods cohort study to tackle health inequality.

BACKGROUND: Individuals with low socio-economic status (SES) have disproportionate rates of cardio- vascular disease (CVD) but poorer engagement with preventative health. This study aimed to compare characteristics of individuals with and without hyperlipidaemia and describe their health behaviours. METHODS: A mixed-methods study between January and December 2022. Patients aged ≥40 years using the ambulance service with blood pressure of ≥140/90 had their total cholesterol measured using a point of care device. Data including blood pressure, smoking status, National Early Warning Score 2 and clinical frailty scale (CFS) were analysed. RESULTS: Of 203 patients (59% female, mean age 65.7 years), 115 (56.7%) had total cholesterol ≥5.1 mmol/L. Thirty patients (14.8%) sought treatment and received either statins (n = 9; 4.4%), dietary modification (n = 7; 3.4%) or no further intervention (n = 14; 6.9%), whilst 85 patients (41.9%) took no further action. Lower CFS (OR 0.53 [0.31-0.93]) and higher total cholesterol (OR 2.07 [1.03-2.76]) predicted seeking further management. SES was not associated with hyperlipidaemia or likelihood of seeking further management, rather this was dictated by competing co-morbidity, poor health literacy and digital divide. CONCLUSIONS: Undiagnosed hyperlipidaemia exists in patients using the ambulance service, irrespective of SES. Individual and healthcare system factors prevent engagement in cholesterol lowering behaviours.

Route of drug administration in out-of-hospital cardiac arrest: A protocol for a randomised controlled trial (PARAMEDIC-3).

Aims: The PARAMEDIC-3 trial evaluates the clinical and cost-effectiveness of an intraosseous first strategy, compared with an intravenous first strategy, for drug administration in adults who have sustained an out-of-hospital cardiac arrest. Methods: PARAMEDIC-3 is a pragmatic, allocation concealed, open-label, multi-centre, superiority randomised controlled trial. It will recruit 15,000 patients across English and Welsh ambulance services. Adults who have sustained an out-of-hospital cardiac arrest are individually randomised to an intraosseous access first strategy or intravenous access first strategy in a 1:1 ratio through an opaque, sealed envelope system. The randomised allocation determines the route used for the first two attempts at vascular access. Participants are initially enrolled under a deferred consent model.The primary clinical-effectiveness outcome is survival at 30-days. Secondary outcomes include return of spontaneous circulation, neurological functional outcome, and health-related quality of life. Participants are followed-up to six-months following cardiac arrest. The primary health economic outcome is incremental cost per quality-adjusted life year gained. Conclusion: The PARAMEDIC-3 trial will provide key information on the clinical and cost-effectiveness of drug route in out-of-hospital cardiac arrest.Trial registration: ISRCTN14223494, registered 16/08/2021, prospectively registered.

The clinical effectiveness of a falls rapid response service, and sex differences of patients using the service: a cross-sectional study in an English ambulance trust.

Background: Falls in older adults are an important issue internationally. They occur from complex interactions between biological, environmental and activity-related factors. As the sexes age differently, there may be sex differences regarding falls. This study aimed to determine the clinical effectiveness of a falls rapid response service (FRRS) in an English ambulance trust and to identify sex differences between patients using the service. Methods: A cross-sectional study between December 2018 and September 2020. Patients aged ≥ 60 years who had fallen within the study area were included. The FRRS comprised a paramedic and occupational therapist and responded 07:00-19:00, 7 days per week. Anonymised data regarding age, sex and conveyance were collected for all patients attended by the FRRS and standard ambulance crews. Clinical data regarding fall events were collected from consenting patients attended by the FRRS only. Results: There were 1091 patients attended by the FRRS versus 4269 by standard ambulance crews. Patient characteristics were similar regarding age and sex. The FRRS consistently conveyed fewer patients versus standard ambulance crews (467/1091 (42.8%) v. 3294/4269 (77.1%), p = < 0.01). Clinical data were collected from 426/1091 patients attended by the FRRS. In these patients, women were more likely to reside alone than men (181/259 (69.8%) v. 86/167 (51.4%), p = < 0.01), and less likely to experience a witnessed fall (16.2% v. 26.3%, p = 0.01). Women had a higher degree of comorbidity specific to osteoarthritis and osteoporosis, while men were more likely to report a fear of falling score of 0 (35.3% v. 22.7%, p = < 0.01). Conclusion: The FRRS is clinically effective regarding falls compared to standard ambulance crews. Sex differences existed between men and women using the FRRS, indicating women are further along the falls trajectory than men. Future research should focus on demonstrating the cost effectiveness of the FRRS and how to better meet the needs of older women who fall.

The RESearch PARamedic Experience (RESPARE) study: a qualitative study exploring the experiences of research paramedics working in the United Kingdom.

Background: The research paramedic position is a relatively niche role undertaken by a small number of paramedics who support, deliver and promote research. Research paramedic roles provide opportunities to develop talented researchers who are recognised as vital elements of developing a research culture within ambulance services. The benefits of research-active clinicians have been recognised at a national level. The aim of this study was to explore the experience of people who work, or have worked, as research paramedics. Methods: A generic qualitative approach underpinned by phenomenological concepts was used. Volunteers were recruited via ambulance research leads and social media. Online focus groups allowed participants to discuss their roles with peers who may be geographically distant. Semi-structured interviews expanded on the focus group findings. Data were recorded, transcribed verbatim and analysed using framework analysis. Results: Eighteen paramedics (66% female, median involvement in research six (interquartile range 2-7) years) representing eight English NHS ambulance trusts participated in three focus groups and five interviews lasting around one hour, in November and December 2021.Six key themes were identified: starting as a research paramedic; barriers and facilitators to working as a research paramedic; research careers; opportunities; the community (support and networking); and the value of a clinical identity. Conclusions: Many research paramedics had similar experiences in terms of starting their career by delivering research for large studies, then building on this experience and the networks they create to develop their own research. There are common organisational and financial barriers to working as a research paramedic. Career progression in research beyond the research paramedic role is not well defined, but often involves building links outside of the ambulance service.

Care Home Residency and Its Association with Ambulance Service Workload.

OBJECTIVES: Care home residents comprise a significant minority of ambulance patients, but little is known about how care homes impact ambulance service workload. This study aims to quantify differences in the workload of ambulance paramedics associated with patient residence (care home vs private). DESIGN: This was an observational study using routine ambulance service data and Clinical Frailty Scale scores from patients attended by 112 study paramedics between January 1, 2021, and June 30, 2021. SETTING AND PARTICIPANTS: 3056 patients (459 in care homes) aged ≥50 attended by the North East Ambulance Service NHS Foundation Trust, England. METHODS: This study used 2 outcome measures of treatment: time spent at scene and conveyance to hospital. Anonymized patient data and incident time logs were collected from ambulance electronic patient care records. The relationships between care home residency, conveyance to hospital, and time spent at scene were investigated using ordinal logistic regression and quantile regression. Models were weighted to address potential sampling imbalance using anonymised call logs containing all eligible ambulance callouts. RESULTS: Care home residents were less likely to be conveyed to hospital [odds ratio: 0.75 (0.59-0.96)] and received shorter treatment time than community residents [median -7.0 (-12.0, -1.9) minutes for patients conveyed to hospital, -2.8 (-5.4, -0.3) minutes for patients discharged at scene]. CONCLUSIONS AND IMPLICATIONS: Our results suggest that care homes provide support that reduces demand on the ambulance service and other "downstream" services in secondary care. This study also points to a need to enhance care for older people in private households to contain the demands on ambulance services. These findings have implications for countries like England, where ambulance services struggle to meet target response times, which may affect patient outcomes.

Measuring frailty and its association with key outcomes in the ambulance setting: a cross sectional observational study.

BACKGROUND: Little is known about frailty in the ambulance setting, or its association with outcomes relevant to ambulance services. We sought to measure frailty in people aged ≥ 50 attended by an ambulance, and describe the relationship between frailty, odds of conveyance to hospital, and duration at scene. METHODS: An observational study between 01/01/2021-30/06/2021 in North East Ambulance Service, England. Participants were aged ≥ 50 attended by an ambulance, excluding patients requiring immediate treatment for a life-threatening condition or with Glasgow Coma Scale < 15. Paramedics (n = 112) measured patient frailty using the Clinical Frailty Scale (CFS). Additional information was extracted from ambulance care records. Weighted regression models examined associations between frailty, hospital conveyance, and duration at scene. RESULTS: Three thousand and fifty-six callouts were observed (mean patient age: 78.1 years, 57.2% female). Frailty prevalence (CFS ≥ 5) was 58.7%. Median duration at scene was 47.0 min (interquartile range 34.0-67.0 min). Ambulances spent a median of 8.2 (95%CI:5.4-11.0) minutes longer with frail patients than non-frail patients. Frail patients were less likely to be conveyed to hospital than non-frail patients (OR:0.75, 95%CI:0.60-0.94). CONCLUSION: Frailty is common among people aged ≥ 50 attended by an ambulance and an important influence on workload. Ambulance services need a good understanding of frailty to meet patient needs. As populations age, community support should be prioritised to deliver appropriate frailty care and reduce demands on ambulance services.

Public attitudes towards bystander CPR and their association with social deprivation: Findings from a cross sectional study in North England.

Background: Bystander cardiopulmonary resuscitation (BCPR) is undertaken in only 40% of out of hospital cardiac arrests (OHCAs) in the UK. Lower rates of BCPR and public access defibrillator (PAD) use have been correlated with lower socio-economic status (SES). The aim of this study was to examine knowledge and attitudes towards BCPR and PAD's using a study specific questionnaire, and to understand how these potentially interact with individual characteristics and SES. Methods: Cross-sectional study between July-December 2021 across areas of varying SES in North England. Results: Six hundred and one individuals completed the survey instrument (mean age = 51.9 years, 52.2 % female). Increased age was associated with being less willing to call 999 (p < 0.001) and follow call handler advice (p < 0.001). Female respondents were less comfortable performing BCPR than male respondents (p = 0.006). Individuals from least deprived areas were less likely to report comfort performing CPR, (p = 0.016) and less likely to know what a PAD is for, (p = 0.025). Higher education level was associated with increased ability to recognise OHCA (p = 0.005) and understanding of what a PAD is for (p < 0.001). Individuals with higher income were more likely to state they would follow advice regarding BCPR (p = 0.017) and report comfort using a PAD (p = 0.029). Conclusion: Individual characteristics such as age and ethnicity, rather than SES, are indicators of knowledge, willingness, and perceived competency to perform BCPR. Policy makers should avoid using SES alone to target interventions. Future research should examine how cultural identity and social cohesion intersect with these characteristics to influence willingness to perform BCPR.

The impact of introducing real time feedback on ventilation rate and tidal volume by ambulance clinicians in the North East in cardiac arrest simulations.

BACKGROUND: Research suggests rescuers deliver ventilations outside of recommendations during out of hospital cardiac arrest (OHCA), which can be deleterious to survival. We aimed to determine if ambulance clinician compliance with ventilation recommendations could be improved using the Zoll Accuvent real time ventilation feedback device (VFD). METHODS: Participants simulated a two-minute cardiac arrest scenario using a mannequin and defibrillator without ventilation feedback. Eligible for inclusion were all clinicians aged ≥18 years who perform cardiopulmonary resuscitation (CPR) as part of their role, who had completed an internal advanced life support (ALS) refresher. Following familiarisation of a few minutes with the VFD, participants repeated the two-minute scenario with ventilation feedback. Ventilation rate and volume and CPR quality were recorded. Primary outcome was % difference in ventilation compliance with and without feedback. Secondary outcomes were differences between paramedic and non-paramedic clinicians and compliance with chest compression guidelines. RESULTS: One hundred and six participants completed the study. Median ventilation rate without feedback was 10 (IQR 8-14, range 4-30) compared to 9 (IQR 9-9, range 6-17) with feedback; median tidal volume without feedback was 630 mls (IQR 518-725, range 201-1114) compared to 546 mls (IQR 531-560, range 490-750) with feedback. Proportion of clinicians ≥50% compliant with European Resuscitation Council ventilation recommendations were significantly greater with ventilation feedback compared to without, 91% vs. 9%, (McNemars test p = <0.0001). Paramedics out performed non-paramedic clinicians with and without feedback and compression quality was not compromised by using the VFD. CONCLUSIONS: Ambulance clinician baseline ventilation quality was frequently outside of recommendations, but a VFD can ensure treatment is within evidence-based recommendations. Further research is required to validate the use of the VFD in true clinical practice and to evaluate the relationship between improved ventilation quality during OHCA and patient outcomes.

Adrenaline to improve survival in out-of-hospital cardiac arrest: the PARAMEDIC2 RCT.

BACKGROUND: Adrenaline has been used as a treatment for cardiac arrest for many years, despite uncertainty about its effects on long-term outcomes and concerns that it may cause worse neurological outcomes. OBJECTIVES: The objectives were to evaluate the effects of adrenaline on survival and neurological outcomes, and to assess the cost-effectiveness of adrenaline use. DESIGN: This was a pragmatic, randomised, allocation-concealed, placebo-controlled, parallel-group superiority trial and economic evaluation. Costs are expressed in Great British pounds and reported in 2016/17 prices. SETTING: This trial was set in five NHS ambulance services in England and Wales. PARTICIPANTS: Adults treated for an out-of-hospital cardiac arrest were included. Patients were ineligible if they were pregnant, if they were aged < 16 years, if the cardiac arrest had been caused by anaphylaxis or life-threatening asthma, or if adrenaline had already been given. INTERVENTIONS: Participants were randomised to either adrenaline (1 mg) or placebo in a 1 : 1 allocation ratio by the opening of allocation-concealed treatment packs. MAIN OUTCOME MEASURES: The primary outcome was survival to 30 days. The secondary outcomes were survival to hospital admission, survival to hospital discharge, survival at 3, 6 and 12 months, neurological outcomes and health-related quality of life through to 6 months. The economic evaluation assessed the incremental cost per quality-adjusted life-year gained from the perspective of the NHS and Personal Social Services. Participants, clinical teams and those assessing patient outcomes were masked to the treatment allocation. RESULTS: From December 2014 to October 2017, 8014 participants were assigned to the adrenaline (n = 4015) or to the placebo (n = 3999) arm. At 30 days, 130 out of 4012 participants (3.2%) in the adrenaline arm and 94 out of 3995 (2.4%) in the placebo arm were alive (adjusted odds ratio for survival 1.47, 95% confidence interval 1.09 to 1.97). For secondary outcomes, survival to hospital admission was higher for those receiving adrenaline than for those receiving placebo (23.6% vs. 8.0%; adjusted odds ratio 3.83, 95% confidence interval 3.30 to 4.43). The rate of favourable neurological outcome at hospital discharge was not significantly different between the arms (2.2% vs. 1.9%; adjusted odds ratio 1.19, 95% confidence interval 0.85 to 1.68). The pattern of improved survival but no significant improvement in neurological outcomes continued through to 6 months. By 12 months, survival in the adrenaline arm was 2.7%, compared with 2.0% in the placebo arm (adjusted odds ratio 1.38, 95% confidence interval 1.00 to 1.92). An adjusted subgroup analysis did not identify significant interactions. The incremental cost-effectiveness ratio for adrenaline was estimated at £1,693,003 per quality-adjusted life-year gained over the first 6 months after the cardiac arrest event and £81,070 per quality-adjusted life-year gained over the lifetime of survivors. Additional economic analyses estimated incremental cost-effectiveness ratios for adrenaline at £982,880 per percentage point increase in overall survival and £377,232 per percentage point increase in neurological outcomes over the first 6 months after the cardiac arrest. LIMITATIONS: The estimate for survival with a favourable neurological outcome is imprecise because of the small numbers of patients surviving with a good outcome. CONCLUSIONS: Adrenaline improved long-term survival, but there was no evidence that it significantly improved neurological outcomes. The incremental cost-effectiveness ratio per quality-adjusted life-year exceeds the threshold of £20,000-30,000 per quality-adjusted life-year usually supported by the NHS. FUTURE WORK: Further research is required to better understand patients' preferences in relation to survival and neurological outcomes after out-of-hospital cardiac arrest and to aid interpretation of the trial findings from a patient and public perspective. TRIAL REGISTRATION: Current Controlled Trials ISRCTN73485024 and EudraCT 2014-000792-11. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 25. See the NIHR Journals Library website for further project information.

Cardiac arrest is a medical emergency that happens when the heart suddenly stops pumping effectively. When cardiac arrest happens, awareness is lost within seconds. If emergency treatment is not started quickly, the person will die. The first treatments of cardiac arrest involve pressing on the chest, giving rescue breaths and defibrillation (electric shocks applied to the heart). If these treatments do not work, ambulance paramedics use a drug called adrenaline to try to restart the heart. Although this treatment has been used for many years, some recent research suggests that it may cause more harm than good. In this research study, we compared the effects of giving adrenaline with the effects of not giving adrenaline to people who had a cardiac arrest in the community. The research showed that adrenaline was effective at restarting the heart, so more people survived long enough to be admitted to hospital. Thirty days later, 130 out of 4012 patients (3.2%) who received adrenaline and 94 out of 3995 (2.4%) who did not receive adrenaline were alive. However, adrenaline did not improve the number of patients who went home from hospital having made a good recovery and were able to care for themselves. The evidence suggests that adrenaline represents a poor use of NHS funds on cost-effectiveness grounds. In a community survey, 95% of people who responded thought that long-term survival with good brain function was more important than just being alive. Further research exploring the opinions of patients and the public will help to understand the results of this research for the NHS.

Incidence of emergency calls and out-of-hospital cardiac arrest deaths during the COVID-19 pandemic: findings from a cross-sectional study in a UK ambulance service.

BACKGROUND: In response to the COVID-19 pandemic, a national lockdown was introduced on 23 March 2020. In the following weeks, emergency departments in the UK reported a reduction in attendances. We aimed to explore the incidence of emergency calls across North East England, as well as the number of out-of-hospital cardiac arrest (OHCA) deaths. METHODS: Data were collected for all patients who contacted North East Ambulance Service between 4 March 2019-2 June 2019 and 2 March 2020-31 May 2020 suffering stroke, ST elevation myocardial infarction, allergy, asthma, chronic obstructive pulmonary disease, falls, intoxication, seizure, sepsis, acute coronary syndrome and OHCA. RESULTS: There were a reduction in incidence of calls, excluding OHCA, resulting in ambulance activation during the pandemic compared with same period in 2019, 16 743 versus 19 639, respectively (-14.74%). The decline in calls was partially reversed by the end of May 2020. Incidence of OHCA at the time of the national lockdown had increased by 13.79% with a peak increase of 73.56% in the second week in April 2020. OHCA deaths peaked in the first 2 weeks in April 2020, 95.65% and 90.07%, respectively, but by the end May 2020, incidence of OHCA and OHCA deaths had returned to prelockdown levels. CONCLUSION: Incidence of emergency calls were reduced during the pandemic compared with 2019. There was a rise in incidence of OHCA and OHCA deaths during the same period; however, these changes appear transient. Further research is required to understand patient behaviour towards seeking help during the pandemic and the long-term consequences of not doing so.

Intravenous versus oral paracetamol in a UK ambulance service: a case control study.

OBJECTIVES: To determine the effectiveness of intravenous versus oral paracetamol (acetaminophen) in the management of acute pain in the out-of-hospital setting. METHODS: We extracted ambulance electronic patient care records for all patients who received 1 g intravenous paracetamol throughout January 2019, and case matched these by sex and age with consecutive patients who received 1 g oral paracetamol over the same time period. Eligible for inclusion were all patients aged ≥ 18 who received 1 g paracetamol for acute pain and who were transported to the emergency department (ED). The primary outcome was the mean reduction in pain score using the numeric rating scale (NRS), with a reduction of 2 or more accepted as clinically significant. RESULTS: 80 care records were eligible for analysis; 40 patients received intravenous and 40 patients received oral paracetamol. The mean age of both groups was 54 years (± 3 years) and 67.5% (n = 54) were female. Patients receiving intravenous paracetamol had a clinically significant mean (SD) improved pain score compared to those receiving oral paracetamol, 2.02 (1.64) versus 0.75 (1.76), respectively [p = 0.0013]. 13/40 (32.5%) patients who received intravenous paracetamol saw an improved pain score of ≥ 2 compared to 8/40 (20%) who received oral paracetamol. No patients received additional analgesia or reported any adverse symptoms. Abdominal pain, infection and trauma were the most common causes of pain in both groups. CONCLUSION: Our study suggests that intravenous paracetamol is more effective than oral paracetamol when managing acute pain in the out-of-hospital setting. Our findings support further investigation of the role of paracetamol in paramedic practice using more robust methods.

A two-armed, randomised, controlled exploratory study of adding the AmbuGard cleaning system to normal deep-cleaning procedures in a regional ambulance service.

BACKGROUND: Ambulance services transport patients with infections and diseases, and could pose a cross-transmission risk to patients and staff through environmental contamination. The literature suggests that environmental pathogens are present in ambulances, cleaning is inconsistent and patient/staff impact is difficult to quantify. Eco-Mist developed a dry misting decontamination system for ambulance use called AmbuGard, which works in < 30 minutes and is 99.9999% effective against common pathogens. The research question is: 'What pathogens are present in North East Ambulance Service ambulances and what impact does adding AmbuGard to the deep-cleaning process make?'. METHODS: A two-armed, randomised controlled trial enrolled 14 ambulances during their regular 24-week deep clean, which were 1:1 randomised to deep cleaning (control arm) or deep cleaning plus AmbuGard (intervention arm). Polywipe swabs were taken before and after cleaning from five locations selected for high rates of contact (steering wheel, shelf, side-door grab rail, patient seat armrest, rear door handle/grab rail). Microbiology culture methods identified the presence and amount of bacterial organisms present, including the selected pathogens: Enterococcus spp.; Enterobacter spp.; Klebsiella spp.; Staphylococcus aureus; Acinetobacter spp.; Pseudomonas spp.; Clostridium difficile; coagulase-negative staphylococci (CoNS). The researcher taking the swabs and the laboratory were blinded to the trial arm. RESULTS: Pathogens of interest were found in 10 (71%) vehicles. CoNS were found in all vehicles. Pathogens were found on all locations swabbed. Normal deep cleaning was effective at eliminating pathogens and the addition of AmbuGard showed no obvious improvement in effectiveness. CONCLUSION: Pathogens associated with healthcare-acquired infections were found throughout all ambulances. Normal deep cleaning was effective, and adding AmbuGard showed no obvious improvement. This was a small study at a single point in time. Further research is needed into temporal trends, how to reduce pathogens during normal clinical duties and patient/staff impact.

Is weight just a number? The accuracy of UK ambulance paediatric weight guidance - findings from a cross-sectional study.

BACKGROUND: The weight of children provides the cornerstone of their clinical management, as many drug dosages, equipment sizes, fluid boluses, as well as DC shock energy, are administered on a per kilogram basis. Children who attend hospital are weighed using scales prior to receiving these interventions. This is not possible in the pre-hospital environment. A paucity of evidence exists to support the page for age weight guidance indicated by JRCALC, and it remains unknown if this approach meets the reference standard of 70% of estimations within 10% of actual weight and 95% within 20% of actual weight. METHODS: We used a cross-sectional study design and collected data from a convenience sample of children who attended the outpatients department of a major hospital in England between July and September 2019. All children aged between 1 and 11 years who were weighed were eligible for inclusion. Outcomes were to determine if the page for age approach meets the reference standard and to determine any implications for care. RESULTS: 341 children were included in this study. Each age group consisted of varying numbers of children. 50.5% (172/341) of the sample were female. Observed weights ranged from 8.28 to 82.70 kg (median 20.60 kg). The mean weight of girls versus boys was 24.69 kg and 23.39 kg respectively (95% CI -4.12-1.32, p = 0.3123). Observed weights were greater than the page for age guidance weight in all age groups, and the accuracy of page for age weight guidance diminished with age. Adrenaline 1:10,000 doses and defibrillation energy levels guided by page for age differ from those guided by weight, but are not deleterious to care. CONCLUSION: Page for age weight guidance does not meet the reference standard. Most paediatric pre-hospital care is administered by age and not weight. In the absence of an accurate weight, ambulance clinicians should continue to use the page for age system, although the gold standard remains to use an accurate weight measurement. While there are no facilities to weigh children in ambulances, if an accurate weight is available then consideration should be given to using this rather than age.

Assessment of Nutrition and Supplementation in Patients With Hip Fractures.

INTRODUCTION: Malnutrition is common in older people, is known to interact with frailty, and is a risk factor for wound complications and poor functional outcomes postoperatively. Sustaining a hip fracture is a significant life event, often resulting in a decline in mobility and functional ability. A poor nutritional state may further impede recovery and rehabilitation, so strategies to improve perioperative nutrition are of considerable importance. We provide a review of nutritional supplement practices in this vulnerable and growing population. METHOD: Systematic review of preoperative oral nutritional supplementation (ONS) in hip fracture patients. RESULTS: We identified 12 articles pertaining to this important area of perioperative care. The findings suggest postoperative ONS can improve postoperative outcomes in hip fracture patients, especially in terms of increasing total serum protein, improving nutritional status to near-optimum levels, and decreasing postoperative complications. DISCUSSION: There is an absence of evidence specific to preoperative ONS in patients admitted following hip fracture. Literature relating to other populations is encouraging but is yet to be robustly studied. It is unclear whether these results are generalizable to the frailer hip fracture population. There is a need for studies clearly defining outcome measurement and complication assessment pertaining to preoperative ONS. The potential benefit is considerable, and this review will provide a means to inform the construction of meaningful trials in preoperative ONS of patients sustaining hip fracture. CONCLUSION: Oral nutritional supplementation in hip fracture patients may decrease postoperative complications while increasing elderly patient's nutritional state to a near-optimum level. This is extrapolated from postoperative literature, however with a clear gap in research pertaining specifically to preoperative care. The need for well-constructed studies focused on the impact and assessment of early ONS in this population is transparent.

Phenomenological study exploring ethics in prehospital research from the paramedic's perspective: experiences from the Paramedic-2 trial in a UK ambulance service.

OBJECTIVES: We set out to investigate paramedics' views of ethics and research, drawing on experiences from Paramedic-2, a randomised controlled trial comparing epinephrine and placebo in out-of-hospital cardiac arrest (OHCA). METHODS: An interpretative phenomenological approach was adopted. A purposive sample of paramedics (n=6) from North East Ambulance Service NHS Foundation Trust were invited to a semi-structured, in-depth interview. RESULTS: Three superordinate themes emerged: (1) morality, (2) emotion and (3) equipoise. Some viewed Paramedic-2 as an opportunity to improve OHCA outcomes for the many, viewing participation as a moral obligation; others viewed the study as unethical, equating participation with immoral behaviour. Morality was a motivator to drive individual action. Positive and negative emotions were exhibited by the paramedics involved reflecting the wider view each paramedic held about trial participation. Those morally driven to participate in Paramedic-2 discussed their pride in being associated with the trial, while those who found participation unethical, discussed feelings of guilt and regret. Individual experience and perceptions of epinephrine guided each paramedic's willingness to accept or reject equipoise. Some questioned the role of epinephrine in OHCA; others believed withholding epinephrine was synonymous to denying patient care. CONCLUSION: A paucity of evidence exists to support any beneficial role of epinephrine in OHCA. Despite this, some paramedics were reluctant to participate in Paramedic-2 and relied on their personal perceptions and experiences of epinephrine to guide their decision regarding participation. Failure to acknowledge the importance of individual perspectives may jeopardise the success of future out-of-hospital trials.

The effects of adrenaline in out of hospital cardiac arrest with shockable and non-shockable rhythms: Findings from the PACA and PARAMEDIC-2 randomised controlled trials.

INTRODUCTION: Previous research suggests there may be differences in the effects of adrenaline related to the initial cardiac arrest rhythm. The aim of this study was to assess the effect of adrenaline compared with placebo according to whether the initial cardiac arrest rhythm was shockable or non-shockable. METHODS: Return of spontaneous circulation (ROSC), survival and neurological outcomes according to the initial arrest rhythm were compared amongst patients enrolled in the PARAMEDIC-2 randomised, placebo controlled trial. The results of the PARAMEDIC-2 and PACA out of hospital cardiac arrest trials were combined and meta-analysed. RESULTS: The initial rhythm was known for 3929 (98.2%) in the placebo arm and 3919 (97.6%) in the adrenaline arm. The effect on the rate of ROSC of adrenaline relative to placebo was greater in patients with non-shockable cardiac rhythms (1002/3003 (33.4%) versus 222/3005 (7.4%), adjusted OR: 6.5, (95% CI 5.6-7.6)) compared with shockable rhythms 349/716 (48.7%) versus (208/702 (29.6%), adjusted OR: 2.3, 95%CI: 1.9-2.9)). The adjusted odds ratio for survival at discharge for non-shockable rhythms was 2.5 (1.3, 4.8) and 1.3 (0.9, 1.8) for shockable rhythms (P value for interaction 0.065) and 1.8 (0.8-4.1) and 1.1 (0.8-1.6) respectively for neurological outcome at discharge (P value for interaction 0.295). Meta-analysis found similar results. CONCLUSION: Relative to placebo, the effects of adrenaline ROSC are greater for patients with an initially non-shockable rhythm than those with a shockable rhythms. Similar patterns are observed for longer term survival outcomes and favourable neurological outcomes, although the differences in effects are less pronounced. ISRCTN73485024.

Assessment and Early Management of Pain in Hip Fractures: The Impact of Paracetamol.

INTRODUCTION: As the number of patients sustaining hip fractures increases, interventions aimed at improving patient comfort and reducing complication burden acquire increased importance. Frailty, cognitive impairment, and difficulty in assessing pain control characterize this population. In order to inform future care, a review of pain assessment and the use of preoperative intravenous paracetamol (IVP) is presented. MATERIALS AND METHODS: Systematic review of preoperative IVP administration in patients presenting with a hip fracture. RESULTS: Intravenous paracetamol is effective in the early management of pain control in the hip fracture population. There is a considerable decrease in use of breakthrough pain medications when compared with other pain relief modalities. Additionally, IVP reduces the incidence of opioid-induced complications, reduces length of stay, and lowers mean pain scores. Another significant finding of this study is the poor administration of all analgesics to patients with hip fracture with up to 72% receiving no prehospital analgesia. DISCUSSION: The potential benefits of IVP as routine in the early management of hip fracture-related pain are clear. Studies of direct comparison between analgesia regimes to inform optimum bundles of analgesic care are sparse. This study highlights the need for properly constructed pathway-driven comparator studies of contemporary analgesia regimes, with IVP as a central feature to optimize pain control and minimize analgesia-related morbidity in this vulnerable population.

A Randomized Trial of Epinephrine in Out-of-Hospital Cardiac Arrest.

BACKGROUND: Concern about the use of epinephrine as a treatment for out-of-hospital cardiac arrest led the International Liaison Committee on Resuscitation to call for a placebo-controlled trial to determine whether the use of epinephrine is safe and effective in such patients. METHODS: In a randomized, double-blind trial involving 8014 patients with out-of-hospital cardiac arrest in the United Kingdom, paramedics at five National Health Service ambulance services administered either parenteral epinephrine (4015 patients) or saline placebo (3999 patients), along with standard care. The primary outcome was the rate of survival at 30 days. Secondary outcomes included the rate of survival until hospital discharge with a favorable neurologic outcome, as indicated by a score of 3 or less on the modified Rankin scale (which ranges from 0 [no symptoms] to 6 [death]). RESULTS: At 30 days, 130 patients (3.2%) in the epinephrine group and 94 (2.4%) in the placebo group were alive (unadjusted odds ratio for survival, 1.39; 95% confidence interval [CI], 1.06 to 1.82; P=0.02). There was no evidence of a significant difference in the proportion of patients who survived until hospital discharge with a favorable neurologic outcome (87 of 4007 patients [2.2%] vs. 74 of 3994 patients [1.9%]; unadjusted odds ratio, 1.18; 95% CI, 0.86 to 1.61). At the time of hospital discharge, severe neurologic impairment (a score of 4 or 5 on the modified Rankin scale) had occurred in more of the survivors in the epinephrine group than in the placebo group (39 of 126 patients [31.0%] vs. 16 of 90 patients [17.8%]). CONCLUSIONS: In adults with out-of-hospital cardiac arrest, the use of epinephrine resulted in a significantly higher rate of 30-day survival than the use of placebo, but there was no significant between-group difference in the rate of a favorable neurologic outcome because more survivors had severe neurologic impairment in the epinephrine group. (Funded by the U.K. National Institute for Health Research and others; Current Controlled Trials number, ISRCTN73485024 .).