The COVID-19 ambulance response assessment (CARA) study: a national survey of ambulance service healthcare professionals' preparedness and response to the COVID-19 pandemic.

Background: The COVID-19 pandemic placed significant demand on the NHS, including ambulance services, but it is unclear how this affected ambulance service staff and paramedics in other clinical settings (e.g. urgent and primary care, armed services, prisons). This study aimed to measure the self-perceived preparedness and impact of the first wave of the pandemic on paramedics' psychological stress and perceived ability to deliver care. Methods: Ambulance clinicians and paramedics working in other healthcare settings were invited to participate in a three-phase sequential online survey during the acceleration (April 2020), peak (May 2020) and deceleration (September/October 2020) phases of the first wave of COVID-19 in the United Kingdom. Recruitment used social media, Trust internal bulletins and the College of Paramedics' communication channels, employing a convenience sampling strategy. Data were collected using purposively developed open- and closed-ended questions and the validated general health questionnaire-12 (GHQ-12). Data were analysed using multi-level linear and logistic regression models. Results: Phase 1 recruited 3717 participants, reducing to 2709 (73%) by phase 2 and 2159 (58%) by phase 3. Participants were mostly male (58%, n = 2148) and registered paramedics (n = 1992, 54%). Mean (standard deviation) GHQ-12 scores were 16.5 (5.2) during phase 1, reducing to 15.2 (6.7) by phase 3. A total of 84% of participants (n = 3112) had a GHQ-12 score ≥ 12 during the first phase, indicating psychological distress. Participants that had higher GHQ-12 scores were feeling unprepared for the pandemic, and reported a lack of confidence in using personal protective equipment and managing cardiac arrests in confirmed or suspected COVID-19 patients. Conclusions: Most participants reported psychological distress, the reasons for which are multi-factorial. Ambulance managers need to be aware of the risks to staff mental health and take action to mitigate these, to support staff in the delivery of unscheduled, emergency and urgent care under these additional pressures.

A comparison of daytime and out of hour mental health presentations to Beaumont Hospital Emergency Department between 2018 and 2020.

BACKGROUND: In 2018, there were more than 12,000 self-harm presentations to emergency departments (EDs) in Ireland with 50% occurring between 7p.m. and 3a.m. There is evidence that the assessment quality and follow-up is variable across clinicians. To address this, The National Clinical Programme for the Management of Self-Harm in the ED (NCPSH 2016) was developed to set clear standards. AIM: Our aim was to compare diagnosis and management of patients presenting to Beaumont Hospital (BH) ED, across a 3-year period, by the on-site Liaison Psychiatry Service, during normal working hours, to the off-site on call service outside of normal working hours (OOH). METHODS: This is a retrospective audit of BH ED patients referred for psychiatric assessment between 2018 and 2020, using patient electronic records for data collection, and Pearson's chi square testing for group differences. Post hoc analysis was performed using adjusted residuals and Bonferroni correction. RESULTS: Of 3659 psychiatric referrals to Beaumont ED from 2018 to 2020, alcohol-related disorders were the most common diagnosis and were diagnosed more frequently during normal working hours (n = 592, 16.2%; 22.9% normal hours vs 8.5% OOH, p < 0.001), while personality disorder was diagnosed more frequently out of hours. (n = 432, 11.8%; 9.6% normal hours vs 14.4% out of hours, p < 0.001). There was a statistically significant difference in referral to voluntary services out of hours (7.2% normal hours vs 0.3% OOH). CONCLUSION: In contrast to previous findings, our study found higher rates of alcohol-related disorders diagnosed during normal hours vs OOH. Furthermore, voluntary and addiction services were under-utilised OOH and this presents an important teaching opportunity.

What are the demographic and clinical differences between those older adults with traumatic brain injury who receive a neurosurgical intervention to those that do not? A systematic literature review with narrative synthesis.

OBJECTIVES: This review aimed to identify the demographic and clinical differences between those older adults admitted directly under neurosurgical care and those that were not, and whether EMS clinicians could use these differences to improve patient triage. METHODS: The authors searched for papers that included older adults who had suffered a TBI and were either admitted directly under neurosurgical care or were not. Titles and abstracts were screened, shortlisting potentially eligible papers before performing a full-text review. The Newcastle-Ottawa Scale was used to assess the risk of bias. RESULTS: A total of nine studies were eligible for inclusion. A high abbreviated injury score head, Marshall score or subdural hematoma greater than 10 mm were associated with neurosurgical care. There were few differences between those patients who did and did not receive neurosurgical intervention. CONCLUSIONS: Absence of guidelines and clinician bias means that differences between those treated aggressively and conservatively observed in the literature are fraught with bias. Further work is required to understand which patients would benefit from an escalation of care and whether EMS can identify these patients so they are transported directly to a hospital with the appropriate services on-site.

On the Origins of Some Spectroscopic Properties of "Purple Iron" (the Tetraoxoferrate(VI) Ion) and Its Pourbaix Safe-Space.

In this work, the authors attempt to interpret the visible, infrared and Raman spectra of ferrate(VI) by means of theoretical physical-inorganic chemistry and historical highlights in this field of interest. In addition, the sacrificial decomposition of ferrate(VI) during water treatment will also be discussed together with a brief mention of how Rayleigh scattering caused by the decomposition of FeVIO42- may render absorbance readings erroneous. This work is not a compendium of all the instrumental methods of analysis which have been deployed to identify ferrate(VI) or to study its plethora of reactions, but mention will be made of the relevant techniques (e.g., Mössbauer Spectroscopy amongst others) which support and advance this overall discourse at appropriate junctures, without undue elaboration on the foundational physics of these techniques.

A national survey of ambulance paramedics on the identification of patients with end of life care needs.

AIMS: Developing the proactive identification of patients with end of life care (EoLC) needs within ambulance paramedic clinical practice may improve access to care for patients not benefitting from EoLC services at present. To inform development of this role, this study aims to assess whether ambulance paramedics currently identify EoLC patients, are aware of identification guidance and believe this role is appropriate for their practice. METHODS: Between 4 November 2019 and 5 January 2020, registered paramedics from nine English NHS ambulance service trusts were invited to complete an online questionnaire. The questionnaire initially explored current practice and awareness, employing multiple-choice questions. The Gold Standards Framework Proactive Identification Guidance (GSF PIG) was then presented as an example of EoLC assessment guidance and further questions, permitting free-text responses, explored attitudes towards performing this role. RESULTS: 1643 questionnaires were analysed. Most participants (79.9%; n = 1313) perceived that they attended a patient who was formally unrecognised as within the last year of life on at least a monthly basis. Despite 72.0% (n = 1183) of paramedics indicating that they had previously made an EoLC referral to a General Practitioner (GP), only 30.5% (n = 501) were familiar with the GSF PIG and of those only 25.9% (n = 130) had received training in its use. Participants overwhelmingly believed that they can (94.4%; n = 1551) and should (97.0%; n = 1594) perform this role, yet current barriers were identified as the inaccessibility of a patient's medical records, inadequate EoLC education and communication difficulties. Consequently, facilitators to performing this role were identified as the provision of further training in EoLC assessment guidance and establishing accessible, responsive EoLC referral pathways. CONCLUSION: Ambulance paramedics frequently encounter patients that they perceive are not receiving appropriate EoLC provision, and participants in this study overwhelmingly supported a role in highlighting this to primary care providers. Though many paramedics are already making referrals for these patients, the majority are performed without knowledge of validated EoLC assessment guidance. Provision of EoLC assessment training might therefore be expected to improve the timeliness and sensitivity of referrals, potentially addressing current inequalities in access to EoLC. The communication difficulties currently encountered when making a referral might be addressed by the provision of dedicated EoLC referral pathways. Future qualitative and quantitative evaluation of local initiatives providing both assessment training and referral pathways would be hugely beneficial for revealing the benefits and barriers associated with the development of this role in practice.

A survey of ambulance clinicians' perceptions of recording and communicating patient information electronically.

OBJECTIVE: Ambulance services are evolving from use of paper-based recording of patient information to electronic platforms and the impact of this change has yet to be fully explored. The aim of this study is to explore how the introduction of a system permitting electronic information capture and its subsequent sharing were perceived by the ambulance clinicians using it. METHODS: An online questionnaire was designed based upon the technology acceptance model and distributed throughout one ambulance service in the south east of England. Closed-ended questions with Likert scales were used to collect data from patient-facing staff who use an online community falls and diabetic referral platform or an electronic messaging system to update GPs following a patient encounter. RESULTS: There were 273 responses from ambulance clinicians. Most participants agreed that they used tablet computers and smartphones to make their life easier (85% and 86%, respectively). Most participants felt that referring patients to a community falls or diabetic team electronically was an efficient use of their time (81% and 81%, respectively) and many believed that these systems improved the communication of confidential patient information. GP summaries were perceived as increasing time spent on scene but most participants (89%) believed they enabled collaborative working. Overall, collecting and sharing patient information electronically was perceived by most participants as beneficial to their practice. CONCLUSION: In this study, the ability to electronically refer patients to community services and share patient encounters with the GP was predominantly perceived as both safe for patients and an effective use of the participants' clinical time. However, there is often still a need to communicate to GPs in real time, demonstrating that technology could complement, rather than replace, how clinicians communicate.

A national survey of ambulance paramedics on the identification of patients with end of life care needs.

OBJECTIVES: Developing the proactive identification of patients with end of life care (EoLC) needs within ambulance paramedic clinical practice may improve access to care for patients not benefitting from EoLC services at present. To inform development of this role, this study aims to assess whether ambulance paramedics currently identify EoLC patients, are aware of identification guidance and believe this role is appropriate for their practice. METHODS: Between 4 November 2019 and 5 January 2020, registered paramedics from nine English NHS ambulance service trusts were invited to complete an online questionnaire. The questionnaire initially explored current practice and awareness, employing multiple-choice questions. The Gold Standards Framework Proactive Identification Guidance (GSF PIG) was then presented as an example of EoLC assessment guidance, and further questions, permitting free-text responses, explored attitudes towards performing this role. RESULTS: 1643 questionnaires were analysed. Most participants (79.9%; n = 1313) perceived that they attended a patient who was unrecognised as within the last year of life on at least a monthly basis. Despite 72.0% (n = 1183) of paramedics indicating that they had previously made an EoLC referral to a General Practitioner, only 30.5% (n = 501) were familiar with the GSF PIG and of those only 25.9% (n = 130) had received training in its use. Participants overwhelmingly believed that they could (94.4%; n = 1551) and should (97.0%; n = 1594) perform this role, yet current barriers were identified as the inaccessibility of a patient's medical records, inadequate EoLC education and communication difficulties. Consequently, facilitators to performing this role were identified as the provision of training in EoLC assessment guidance and establishing accessible, responsive EoLC referral pathways. CONCLUSIONS: Provision of EoLC assessment training and dedicated EoLC referral pathways should facilitate ambulance paramedics' roles in the timely recognition of EoLC patients, potentially addressing current inequalities in access to EoLC.

Pre-hospital anaesthesia and assessment of head injured patients presenting to a UK Helicopter Emergency Medical Service with a high Glasgow Coma Scale: a cohort study.

OBJECTIVES: Patients who sustain a head injury but maintain a Glasgow Coma Scale (GCS) of 13-15 may still be suffering from a significant brain injury. We aimed to assess the appropriateness of triage and decision to perform prehospital rapid sequence induction (RSI) in patients attended by a UK Helicopter Emergency Medical Service (HEMS) following head injury. DESIGN: A retrospective cohort study of patients attended by Kent Surrey & Sussex Air Ambulance Trust (KSSAAT) HEMS. SETTING: A mixed urban and rural area of 4.5 million people in South East England. PARTICIPANTS: GCS score of 13, 14 or 15 on arrival of the HEMS team and clinical findings suggesting head injury. Patients accompanied by the HEMS team to hospital ('Escorted'), and those that were 'Assisted' but conveyed by the ambulance service were reviewed. No age restrictions to inclusion were set. PRIMARY OUTCOME MEASURE: Significant brain injury. SECONDARY OUTCOME MEASURE: Recognition of patients requiring prehospital anaesthesia for head injury. RESULTS: Of 517 patients, 321 had adequate follow-up, 69% of these were Escorted, 31% Assisted. There was evidence of intracranial injury in 13.7% of patients and clinically important brain injury in 7.8%. There was no difference in the rate of clinically important brain injury between Escorted and Assisted patients (p=0.46). Nineteen patients required an RSI by the HEMS team and this patient group was significantly more likely to have clinically important brain injury (p=0.04). CONCLUSION: In patients attended by a UK HEMS service with a head injury and a GCS of 13-15, a small but significant proportion had a clinically important brain injury and a proportion were appropriately recognised as requiring prehospital RSI. For patients deemed not to need a HEMS intervention, differentiating between those with and without clinically important brain injury appears challenging. LEVEL OF EVIDENCE: V.

A retrospective review of patients with significant traumatic brain injury transported by emergency medical services within the south east of England.

INTRODUCTION: Traumatic brain injury (TBI) will be a leading cause of death and disability within the Western world by 2020. Currently, 80% of all TBI patients in England are transported to hospital by an ambulance service. The aim of this retrospective study is to compare TBI patients transported to a major trauma centre (MTC) against those transported to a trauma unit (TU). METHOD: All patients with a primary injury of TBI who were transported to hospital by South East Coast Ambulance Service NHS Foundation Trust (SECAmb) from 1 January 2016 to 31 December 2016 and entered into the Trauma Audit & Research Network (TARN) registry were reviewed. Patients were stratified by hospital designation (MTC or TU). Severity of TBI was categorised using the patients' pre-hospital Glasgow Coma Scale (GCS) and Abbreviated Injury Score (AIS) Head. The outcomes of interest were 30-day mortality and Glasgow Outcome Score (GOS) at discharge. RESULTS: Between 1 January and 31 December 2016, 549 TBI patients were identified in the TARN database as being transported by SECAmb to either an MTC or a TU. The majority of patients were transported to a TU (77.96%), and the median age of the TU cohort was older than the MTC group (TU 82.15 IQR 16.73 vs. MTC 62.1 IQR 42.6). The median Injury Severity Score (ISS) was greater in the MTC cohort (22 IQR 10 vs. 17 IQR 9), where falls from height and road traffic collisions (RTCs) contributed to 50.51% of all injuries. Within the TU cohort, falls from less than 2 metres (standing height) were the main mechanism of injury (MOI) (77.62%). The median length of hospital stay (LOS) was longer in the MTC cohort compared to the TU cohort (10 IQR 13.25 vs. 8 IQR 14). CONCLUSION: The high proportion of mild TBI and absence of reliable triage guidelines make it difficult for ambulance clinicians to identify patients who will benefit from transport to an MTC. Future research should focus on how TBI triage influences outcomes and how ambulance services can better identify patients with a TBI and who would benefit from specialist care.

Ambulance clinicians' perspectives of sharing patient information electronically.

INTRODUCTION: Communication in the NHS is vital to patient care and safety. Government bodies are pushing for the digitisation of patient health records so that access and transfer of information is easier between patient care teams. Many ambulance trusts have issued their clinical staff tablet computers as a step in the transition from paper-based to electronic-based patient health records. This study aims to evaluate whether these ambulance clinicians perceive tangible benefits to digitisation, particularly regarding collaborative working with other healthcare professionals. METHODS: Registered and non-registered clinical staff in one ambulance trust completed an online questionnaire utilising five-point Likert scales to collect data about their experiences of using electronic incident summary notifications to report back to the patient's GP, and on direct patient referrals to community teams for falls and hypoglycaemic episodes. Participants only completed questions relevant to the process they had experienced. RESULTS: From approximately 2115 members of staff eligible to participate, there were 201 respondents (9.50%) who provided information concerning GP summary notifications, fall referrals or hypoglycaemia referrals (n = 154, 76.62%; n = 178, 88.56%; n = 101, 50.25%, respectively).Overall, staff perceived the electronic communication of patient information as useful, but not essential, to their practice. The applications were seen as easy to use and a safer way to handle patient data. Though their use was felt to prolong the time spent on scene, this was regarded as an efficient use of a clinician's time.Many staff would prefer to talk directly to a patient's GP, but fewer felt that this was required for community referrals. While most participants did not feel obliged to send a GP summary notification of every encounter, the majority believed that the rates of appropriate falls and hypoglycaemia referrals would be improved with direct electronic communication.Respondents felt that recording and sharing patient information electronically improved collaborative working with other healthcare professionals, and they preferred having this ability. CONCLUSION: NHS ambulance trusts are transitioning to electronic patient records and this article suggests that ambulance staff are in favour of this transition when the technology is readily accessible and easy to use. Staff believe this approach is a safer way to store and share patient data and that collaborative working is enhanced. However, many clinicians would still prefer to discuss some incidents directly with a GP rather than sending a summary, highlighting the value staff place on real-time professional interaction when managing a patient.

A description of the spread of injectate after psoas compartment block using magnetic resonance imaging.

BACKGROUND AND OBJECTIVES: Magnetic resonance imaging (MRI) provides for excellent visualization of spread of solution after peripheral nerve block. The aim of this observational study was to utilize MRI to describe the distribution of injectate (gadopentetate dimeglumine) administered for continuous psoas compartment block (PCB) performed by use of two approaches (Capdevila and modified Winnie) and to describe the spread of injectate to the lumbar plexus. METHODS: Four volunteers were enrolled in a prospective crossover study. Each volunteer underwent PCB with catheter placement performed by use of Capdevila's approach followed 1 week later by PCB, with catheter placement performed by use of a modified Winnie approach. MRI of injectate distribution was performed after each PCB. RESULTS: The catheter was unable to be inserted in 1 volunteer undergoing Winnie's approach; therefore, 7 sets of MR images were analyzed. In 6 of 7 cases (4 Capdevila and 2 Winnie) spread was primarily within the psoas muscle. Contrast surrounded the L2-3 lumbar branch of the femoral nerve at L4 and cleaved the fascial plane within the psoas muscle and spread cephalad to reach the lumbar nerve roots. In 1 case (Winnie approach) contrast spread between the psoas and quadratus lumborum muscles. Contrast surrounded the femoral and obturator nerves where they lie outside the psoas muscle at L5. CONCLUSION: The most common pattern of injectate spread seen on MRI with both approaches to PCB was spread within the body of the psoas muscle around the lumbar branches (L2-4), with cephalad spread to the lumbar nerve roots. One catheter resulted in injectate between the psoas and quadratus lumborum muscles.