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.

Global variation in the incidence and outcome of emergency medical services witnessed out-of-hospital cardiac arrest: A systematic review and meta-analysis.

AIM OF THE REVIEW: To examine global variation in the incidence and outcomes of emergency medical services (EMS) witnessed out-of-hospital cardiac arrest (OHCA). DATA SOURCES: We systematically reviewed four electronic databases for studies between 1990 and 5th April 2021 reporting EMS-witnessed OHCA populations. Studies were included if they reported sufficient data to calculate the primary outcome of survival to hospital discharge or 30-day survival. Random-effects models were used to pool incidence and survival outcomes, and meta-regression was used to examine sources of heterogeneity. Study quality was appraised using the Joanna Briggs Institute critical appraisal tools. RESULTS: The search returned 1178 non-duplicate titles of which 66 articles comprising 133,981 EMS-witnessed patients treated by EMS across 33 countries were included. All but one study was observational and only 12 studies (18%) were deemed to be at low risk of bias. The pooled incidence of EMS-treated cases was 4.1 per 100,000 person-years (95% CI: 3.5, 4.7), varying almost 4-fold across continents. The pooled proportion of survivors to hospital discharge or 30-days was 20% overall (95% CI: 18%, 22%; I2 = 98%), 43% (95% CI: 37%, 49%; I2 = 94%) for initial shockable rhythms and 6% (95% CI: 5%, 8%; I2 = 79%) for initial non-shockable rhythms. In the meta-regression analysis, only region and aetiology were significantly associated with survival. When compared to studies from North America, pooled survival was significantly higher in studies from Europe (14% vs. 26%; p = 0.04) and Australasia (14% vs. 31%, p < 0.001). CONCLUSION: We identified significant global variation in the incidence and survival outcome of EMS-witnessed OHCA. Further research is needed to understand the factors contributing to these variations.

Consensus statement: a framework for safe and effective intubation by paramedics.

This consensus statement provides profession-specific guidance in relation to tracheal intubation by paramedics - a procedure that the College of Paramedics supports. Tracheal intubation by paramedics has been the subject of professional and legal debate as well as crown investigation. It is therefore timely that the College of Paramedics, through this consensus group, reviews the available evidence and expert opinion in order to prevent patient harm and promote patient safety, clinical effectiveness and professional standards. It is not the purpose of this consensus statement to remove the skill of tracheal intubation from paramedics. Neither is it intended to debate the efficacy of intubation or the effect on mortality or morbidity, as other formal research studies will answer those questions. The consensus of this group is that paramedics can perform tracheal intubation safely and effectively. However, a safe, well-governed system of continual training, education and competency must be in place to serve both patients and the paramedics delivering their care.

How to implement live video recording in the clinical environment: A practical guide for clinical services.

BACKGROUND: The use of video in healthcare is becoming more common, particularly in simulation and educational settings. However, video recording live episodes of clinical care is far less routine. AIM: To provide a practical guide for clinical services to embed live video recording. MATERIALS AND METHODS: Using Kotter's 8-step process for leading change, we provide a 'how to' guide to navigate the challenges required to implement a continuous video-audit system based on our experience of video recording in our emergency department resuscitation rooms. RESULTS: The most significant hurdles in installing continuous video audit in a busy clinical area involve change management rather than equipment. Clinicians are faced with considerable ethical, legal and data protection challenges which are the primary barriers for services that pursue video recording of patient care. DISCUSSION: Existing accounts of video use rarely acknowledge the organisational and cultural dimensions that are key to the success of establishing a video system. This article outlines core implementation issues that need to be addressed if video is to become part of routine care delivery. CONCLUSION: By focussing on issues such as staff acceptability, departmental culture and organisational readiness, we provide a roadmap that can be pragmatically adapted by all clinical environments, locally and internationally, that seek to utilise video recording as an approach to improving clinical care.

Validation of the National Early Warning Score in the prehospital setting.

BACKGROUND: Early intervention and response to deranged physiological parameters in the critically ill patient improves outcomes. A National Early Warning Score (NEWS) based on physiological observations has been developed for use throughout the National Health Service (NHS) in the UK. Although a good predictor of mortality and deterioration in inpatients, its performance in the prehospital setting is largely untested. This study aimed to assess the validity of the NEWS in unselected prehospital patients. METHODS: All clinical observations taken by emergency ambulance crews transporting patients to a single hospital were collated along with information relating to hospital outcome over a two month period. The performance of the NEWS in identifying the endpoints of 48h and 30 day mortality, intensive care unit (ICU) admission, and a combined endpoint of 48h mortality or ICU admission was analysed. RESULTS: 1684 patients were analysed. All three of the primary endpoints and the combined endpoint were associated with higher NEWS scores (p<0.01 for each). The medium-risk NEWS group was associated with a statistically significant increase in ICU admission (RR=2.466, 95% CI 1.0-6.09), but not in-hospital mortality relative to the low risk group. The high risk NEWS group had significant increases in 48h mortality (RR 35.32 [10.08-123.7]), 30 day mortality (RR 6.7 [3.79-11.88]), and ICU admission (5.43 [2.29-12.89]). Similar results were noted when trauma and non-trauma patients were analysed separately. CONCLUSIONS: Elevated NEWS among unselected prehospital patients is associated with a higher incidence of adverse outcomes. Calculation of prehospital NEWS may facilitate earlier recognition of deteriorating patients, early involvement of senior Emergency Department staff and appropriate critical care.

Capability of Scottish emergency departments to provide physician-based prehospital critical care teams: a national survey.

OBJECTIVE: The aim of this study was to establish the current capabilities of emergency departments in Scotland to provide a prehospital medical team at the request of the ambulance service. METHODS: A prospective telephone survey of all major emergency departments in Scotland was conducted, requesting information on their ability to provide a prehospital team, the configuration of the team and the equipment, transport, training and governance arrangements for this service. RESULTS: All 25 major emergency departments in Scotland responded to the survey (100% response). Eighteen departments (72%) were able to provide a prehospital team, with 15 (60%) able to provide a team 24 h/day. Team composition was variable and only one-third of teams were able to deploy within 15 min. In total, 50% of departments able to respond had received no requests in the preceding 12 months and only two departments had each received more than 50 requests. Less than half of the departments checked prehospital equipment on a weekly or a more frequent basis and only three departments provided ongoing training in prehospital care. CONCLUSION: The majority of emergency departments in Scotland are able to provide a prehospital team on the request of the ambulance service. There is high variability in the composition and seniority of the team, with less ability to provide a team out of hours. With two notable exceptions, the overall activation of these prehospital teams is infrequent, and there are significant improvements required with regard to the clinical governance surrounding the provision of these teams.

Issues around conducting prehospital research on out-of-hospital cardiac arrest: lessons from the TOPCAT study.

Outcome from OHCA is primarily determined by prehospital events and meaningful clinical OHCA research must include data recorded in this setting. There is little evidence on which to base the practice of prehospital resuscitation and research in this area presents huge challenges but is required if survival from OHCA is to improve. This short report aims to provide a practical guide to performing prehospital research on OHCA, based on lessons learned from the Temperature Post Cardiac Arrest (TOPCAT) research; an observational study into OHCA.