'Knowledge exchange' workshops to optimise development of a risk prediction tool to assist conveyance decisions for suspected seizures - Part of the Risk of ADverse Outcomes after a Suspected Seizure (RADOSS) project.

PURPOSE: Suspected seizures present challenges for ambulance services, with paramedics reporting uncertainty over whether or not to convey individuals to emergency departments. The Risk of ADverse Outcomes after a Suspected Seizure (RADOSS) project aims to address this by developing a risk assessment tool utilizing structured patient care record and dispatch data. It proposes a tool that would provide estimates of an individual's likelihood of death and/or recontact with emergency care within 3 days if conveyed compared to not conveyed, and the likelihood of an 'avoidable attendance' occurring if conveyed. Knowledge Exchange workshops engaged stakeholders to resolve key design uncertainties before model derivation. METHOD: Six workshops involved 26 service users and their significant others (epilepsy or nonepileptic attack disorder), and 25 urgent and emergency care clinicians from different English ambulance regions. Utilizing Nominal Group Techniques, participants shared views of the proposed tool, benefits and concerns, suggested predictors, critiqued outcome measures, and expressed functionality preferences. Data were analysed using Hamilton's Rapid Analysis. RESULTS: Stakeholders supported tool development, proposing 10 structured variables for predictive testing. Emphasis was placed on the tool supporting, not dictating, care decisions. Participants highlighted some reasons why RADOSS might struggle to derive a predictive model based on structured data alone and suggested some non-structured variables for future testing. Feedback on prediction timeframes for service recontact was received, along with advice on amending the 'avoidable attendance' definition to prevent the tool's predictions being undermined by potential overuse of certain investigations in hospital. CONCLUSION: Collaborative stakeholder engagement provided crucial insights that can guide RADOSS to develop a user-aligned, optimized tool.

Prognostic accuracy of triage tools for adults with suspected COVID-19 in a prehospital setting: an observational cohort study.

BACKGROUND: Tools proposed to triage patient acuity in COVID-19 infection have only been validated in hospital populations. We estimated the accuracy of five risk-stratification tools recommended to predict severe illness and compared accuracy to existing clinical decision making in a prehospital setting. METHODS: An observational cohort study using linked ambulance service data for patients attended by Emergency Medical Service (EMS) crews in the Yorkshire and Humber region of England between 26 March 2020 and 25 June 2020 was conducted to assess performance of the Pandemic Respiratory Infection Emergency System Triage (PRIEST) tool, National Early Warning Score (NEWS2), WHO algorithm, CRB-65 and Pandemic Medical Early Warning Score (PMEWS) in patients with suspected COVID-19 infection. The primary outcome was death or need for organ support. RESULTS: Of the 7549 patients in our cohort, 17.6% (95% CI 16.8% to 18.5%) experienced the primary outcome. The NEWS2 (National Early Warning Score, version 2), PMEWS, PRIEST tool and WHO algorithm identified patients at risk of adverse outcomes with a high sensitivity (>0.95) and specificity ranging from 0.3 (NEWS2) to 0.41 (PRIEST tool). The high sensitivity of NEWS2 and PMEWS was achieved by using lower thresholds than previously recommended. On index assessment, 65% of patients were transported to hospital and EMS decision to transfer patients achieved a sensitivity of 0.84 (95% CI 0.83 to 0.85) and specificity of 0.39 (95% CI 0.39 to 0.40). CONCLUSION: Use of NEWS2, PMEWS, PRIEST tool and WHO algorithm could improve sensitivity of EMS triage of patients with suspected COVID-19 infection. Use of the PRIEST tool would improve sensitivity of triage without increasing the number of patients conveyed to hospital.

The Recognition of STEMI by Paramedics and the Effect of Computer inTerpretation (RESPECT): a randomised crossover feasibility study.

BACKGROUND: The appropriate management of patients with ST-segment elevation myocardial infarction (STEMI) depends on accurate interpretation of the 12-lead ECG by paramedics. Computer interpretation messages on ECGs are often provided, but the effect they exert on paramedics' decision-making is not known. The objective of this study was to assess the feasibility of using an online assessment tool, and collect pilot data, for a definitive trial to determine the effect of computer interpretation messages on paramedics' diagnosis of STEMI. METHODS: The Recognition of STEMI by Paramedics and the Effect of Computer inTerpretation (RESPECT) feasibility study was a randomised crossover trial using a bespoke, web-based assessment tool. Participants were randomly allocated 12 of 48 ECGs, with an equal mix of correct and incorrect computer interpretation messages, and STEMI and STEMI-mimics. The nature of the responses required a cross-classified multi-level model. RESULTS: 254 paramedics consented into the study, 205 completing the first phase and 150 completing phase two. The adjusted OR for a correct paramedic interpretation, when the computer interpretation was correct (true positive for STEMI or true negative for STEMI-mimic), was 1.80 (95% CI 0.84 to 4.91) and 0.58 (95% CI 0.41 to 0.81) when the computer interpretation was incorrect (false positive for STEMI or false negative for STEMI-mimic). The intraclass correlation coefficient for correct computer interpretations was 0.33 for participants and 0.17 for ECGs, and for incorrect computer interpretations, 0.06 for participants and 0.01 for ECGs. CONCLUSIONS: Determining the effect of computer interpretation messages using a web-based assessment tool is feasible, but the design needs to take clustered data into account. Pilot data suggest that computer messages influence paramedic interpretation, improving accuracy when correct and worsening accuracy when incorrect.

An analysis of NHS 111 demand for primary care services: A retrospective cohort study.

The NHS 111 service triages over 16,650,745 calls per year and approximately 48% of callers are triaged to a primary care disposition, such as a telephone appointment with a general practitioner (GP). However, there has been little assessment of the ability of primary care services to meet this demand. If a timely service cannot be provided to patients, it could result in patients calling 999 or attending emergency departments (ED) instead. This study aimed to explore the patient journey for callers who were triaged to a primary care disposition, and the ability of primary care services to meet this demand. We obtained routine, retrospective data from the Connected Yorkshire research database, and identified all 111 calls between the 1st January 2021 and 31st December 2021 for callers registered with a GP in the Bradford or Airedale region of West Yorkshire, who were triaged to a primary care disposition. Subsequent healthcare system access (111, 999, primary and secondary care) in the 72 hours following the index 111 call was identified, and a descriptive analysis of the healthcare trajectory of patients was undertaken. There were 56,102 index 111 calls, and a primary care service was the first interaction in 26,690/56,102 (47.6%) of cases, with 15,470/26,690 (58%) commenced within the specified triage time frame. Calls to 999 were higher in the cohort who had no prior contact with primary care (58% vs 42%) as were ED attendances (58.2% vs 41.8), although the proportion of avoidable ED attendances was similar (10.5% vs 11.8%). Less than half of 111 callers triaged to a primary care disposition make contact with a primary care service, and even when they do, call triage time frames are frequently not met, suggesting that current primary care provision cannot meet the demand from 111.

How consistent are pre-alert guidelines? A review of UK ambulance service guidelines.

Aims: Ambulance pre-alerts are used to inform receiving emergency departments (EDs) of the arrival of critically unwell or rapidly deteriorating patients who need time-critical assessment or treatment immediately upon arrival. Inappropriate use of pre-alerts can lead to EDs diverting resources from other critically ill patients. However, there is limited guidance about how pre-alerts should be undertaken, delivered or communicated. We aimed to map existing pre-alert guidance from UK NHS ambulance services to explore consistency and accessibility of existing guidance. Methods: We contacted all UK ambulance services to request documentation containing guidance about pre-alerts. We reviewed and mapped all guidance to understand which conditions were recommended for a pre-alert and alignment with Association of Ambulance Chief Executives (AACE) and Royal College of Emergency Medicine (RCEM) pre-alert guidance. We reviewed the language and accessibility of guidance using the AGREE II tool. Results: We received responses from 15/19 UK ambulance services and 10 stated that they had specific pre-alert guidance. We identified noticeable variations in conditions declared suitable for pre-alerts in each service, with a lack of consistency within each ambulance service's own guidance, and a lack of alignment with the AACE/RCEM pre-alert guidance. Services listed between four and 45 different conditions suitable for pre-alert. There were differences in physiological thresholds and terminology, even for conditions with established care pathways (e.g. hyperacute stroke, ST segment elevation myocardial infarction). Pre-alert criteria were typically listed in several short sections in lengthy handover procedure policy documents. Documents appraised were of poor quality with low scores below 35% for applicability and overall. Implications: There is a clear need for ambulance services to have both policies and tools that complement each other and incorporate the same list of pre-alertable conditions. Clinicians need a single, easily accessible document to refer to in a time-critical situation to reduce the risk of making an incorrect pre-alert decision.

Modelling NHS England 111 demand for primary care services: a discrete event simulation.

OBJECTIVES: This feasibility study aimed to model in silico the current healthcare system for patients triaged to a primary care disposition following a call to National Health Service (NHS) 111 and determine the effect of reconfiguring the healthcare system to ensure a timely primary care service contact. DESIGN: Discrete event simulation. SETTING: Single English NHS 111 call centre in Yorkshire. PARTICIPANTS: Callers registered with a Bradford general practitioner who contacted the NHS 111 service in 2021 and were triaged to a primary care disposition. PRIMARY AND SECONDARY OUTCOME MEASURES: Face validity of conceptual model. Comparison between real and simulated data for quarterly counts (and 95% CIs) for patient contact with emergency ambulance (999), 111, and primary and secondary care services. Mean difference and 95% CIs in healthcare system usage between simulations and difference in mean proportion of avoidable admissions for callers who presented to an emergency department (ED). RESULTS: The simulation of the current system estimated that there would be 39 283 (95% CI 39 237 to 39 328) primary care contacts, 2042 (95% CI 2032 to 2051) 999 calls and 1120 (95% CI 1114 to 1127) avoidable ED attendances. Modifying the model to ensure a timely primary care response resulted in a mean percentage increase of 196.1% (95% CI 192.2% to 199.9%) in primary care contacts, and a mean percentage decrease of 78.0% (95% CI 69.8% to 86.2%) in 999 calls and 88.1% (95% CI 81.7% to 94.5%) in ED attendances. Avoidable ED attendances reduced by a mean of -26 (95% CI -35 to -17). CONCLUSION: In this simulated study, ensuring timely contact with a primary care service would lead to a significant reduction in 999 and 111 calls, and ED attendances (although not avoidable ED attendance). However, this is likely to be impractical given the need to almost double current primary care service provision. Further economic and qualitative research is needed to determine whether this intervention would be cost-effective and acceptable to both patients and primary care clinicians.

Venous blood point-of-care testing (POCT) for paramedics in urgent and emergency care: protocol for a single-site feasibility study (POCTPara).

The COVID-19 pandemic placed the UK healthcare system under unprecedented pressure, and recovery will require whole-system investment in innovative, flexible and pragmatic solutions. Positioned at the heart of the healthcare system, ambulance services have been tasked with addressing avoidable hospital conveyance and reducing unnecessary emergency department and hospital attendances through the delivery of care closer to home. Having begun to implement models of care intended to increase 'see and treat' opportunities through greater numbers of senior clinical decision makers, emphasis has now been placed upon the use of remote clinical diagnostic tools and near-patient or point-of-care testing (POCT) to aid clinical decision making. In terms of POCT of blood samples obtained from patients in the pre-hospital setting, there is a paucity of evidence beyond its utility for measuring lactate and troponin in acute presentations such as sepsis, trauma and myocardial infarction, although potential exists for the analysis of a much wider panel of analytes beyond these isolated biomarkers. In addition, there is a relative dearth of evidence in respect of the practicalities of using POCT analysers in the pre-hospital setting. This single-site feasibility study aims to understand whether it is practical to use POCT for the analysis of patients' blood samples in the urgent and emergency care pre-hospital setting, through descriptive data of POCT application and through qualitative focus group interviews of advanced practitioners (specialist paramedics) to inform the feasibility and design of a larger study. The primary outcome measure is focus group data measuring the experiences and perceived self-reported impact by specialist paramedics. Secondary outcome measures are number and type of cartridges used, number of successful and unsuccessful attempts in using the POCT analyser, length of time on scene, specialist paramedic recruitment and retention, number of patients who receive POCT, descriptive data of safe conveyance, patient demographics and presentations where POCT is applied and data quality. The study results will inform the design of a main trial if indicated.

The effect of a specialist paramedic primary care rotation on appropriate non-conveyance decisions (SPRAINED) study: a controlled interrupted time series analysis.

Introduction: NHS ambulance service non-conveyance rates in the United Kingdom are around 30%, despite an increase in non-emergency cases and a national policy of integrating urgent and emergency care to provide patients with the 'right care, in the right place, at the right time'. Emergency department overcrowding is a significant issue for patients, resulting in poorer quality of care, increased healthcare costs and potentially, increased mortality. It also contributes to increased ambulance turnaround times. Yorkshire Ambulance Service NHS Trust (YAS) introduced a specialist paramedic (SP) to improve the management of lower acuity cases, but non-conveyance rates in this group have not been as high as expected.In 2018, Health Education England funded a pilot scheme to rotate paramedics into a range of healthcare settings and in YAS, 10 SPs undertook a 10-week placement in a GP practice. This study aimed to evaluate whether a primary care placement appropriately increased the level and trend of non-conveyance decisions made by SPs following a 10-week GP placement, in a cost-effective manner. Methods: We conducted a controlled interrupted time series analysis using data from incidents between 1 June 2017 and 31 December 2019, to study appropriate non-conveyance rates before and after a GP placement. A costing analysis, examining the average cost per appropriate non-conveyance achieved for patients receiving care from intervention group SPs pre- and post-placement, was also conducted. Results: A total of 7349 incidents attended by intervention group SPs were eligible for inclusion. Following removal of cases with missing data, 5537 (75.3%) cases remained. Post-placement, the intervention group demonstrated an increase in appropriate non-conveyance rate of 35.0% (95% CI 23.8%-46.2%), and a reduction in the trend of appropriate non-conveyance of -1.2% (95% CI -2.8%-0.5%), relative to the control group.Post-placement, the cost per appropriate non-conveyance for intervention group SPs was a mean of £509.41 (95% bootstrapped CI £454.92-£564.26) versus £1257.81 (95% bootstrapped CI £1233.42-£1283.95) for the same group in the pre-placement phase. Conclusion: In this single UK NHS ambulance service study, we found a clinically important and statistically significant increase in appropriate non-conveyance rates by SPs who had completed a 10-week GP placement. This improvement persisted for the 12-month period following the placement and demonstrated cost savings compared to usual care.

Accuracy of emergency medical service telephone triage of need for an ambulance response in suspected COVID-19: an observational cohort study.

OBJECTIVE: To assess accuracy of emergency medical service (EMS) telephone triage in identifying patients who need an EMS response and identify factors which affect triage accuracy. DESIGN: Observational cohort study. SETTING: Emergency telephone triage provided by Yorkshire Ambulance Service (YAS) National Health Service (NHS) Trust. PARTICIPANTS: 12 653 adults who contacted EMS telephone triage services provided by YAS between 2 April 2020 and 29 June 2020 assessed by COVID-19 telephone triage pathways were included. OUTCOME: Accuracy of call handler decision to dispatch an ambulance was assessed in terms of death or need for organ support at 30 days from first contact with the telephone triage service. RESULTS: Callers contacting EMS dispatch services had an 11.1% (1405/12 653) risk of death or needing organ support. In total, 2000/12 653 (16%) of callers did not receive an emergency response and they had a 70/2000 (3.5%) risk of death or organ support. Ambulances were dispatched to 4230 callers (33.4%) who were not conveyed to hospital and did not deteriorate. Multivariable modelling found variables of older age (1 year increase, OR: 1.05, 95% CI: 1.04 to 1.05) and presence of pre-existing respiratory disease (OR: 1.35, 95% CI: 1.13 to 1.60) to be predictors of false positive triage. CONCLUSION: Telephone triage can reduce ambulance responses but, with low specificity. A small but significant proportion of patients who do not receive an initial emergency response deteriorated. Research to improve accuracy of EMS telephone triage is needed and, due to limitations of routinely collected data, this is likely to require prospective data collection.

Accuracy of telephone triage for predicting adverse outcomes in suspected COVID-19: an observational cohort study.

OBJECTIVE: To assess accuracy of telephone triage in identifying need for emergency care among those with suspected COVID-19 infection and identify factors which affect triage accuracy. DESIGN: Observational cohort study. SETTING: Community telephone triage provided in the UK by Yorkshire Ambulance Service NHS Trust (YAS). PARTICIPANTS: 40 261 adults who contacted National Health Service (NHS) 111 telephone triage services provided by YAS between 18 March 2020 and 29 June 2020 with symptoms indicating COVID-19 infection were linked to Office for National Statistics death registrations and healthcare data collected by NHS Digital. OUTCOME: Accuracy of triage disposition was assessed in terms of death or need for organ support up to 30 days from first contact. RESULTS: Callers had a 3% (1200/40 261) risk of serious adverse outcomes (death or organ support). Telephone triage recommended self-care or non-urgent assessment for 60% (24 335/40 261), with a 1.3% (310/24 335) risk of adverse outcomes. Telephone triage had 74.2% sensitivity (95% CI: 71.6 to 76.6%) and 61.5% specificity (95% CI: 61% to 62%) for the primary outcome. Multivariable analysis suggested respiratory comorbidities may be overappreciated, and diabetes underappreciated as predictors of deterioration. Repeat contact with triage service appears to be an important under-recognised predictor of deterioration with 2 contacts (OR 1.77, 95% CI: 1.14 to 2.75) and 3 or more contacts (OR 4.02, 95% CI: 1.68 to 9.65) associated with false negative triage. CONCLUSION: Patients advised to self-care or receive non-urgent clinical assessment had a small but non-negligible risk of serious clinical deterioration. Repeat contact with telephone services needs recognition as an important predictor of subsequent adverse outcomes.

Supporting the ambulance service to safely convey fewer patients to hospital by developing a risk prediction tool: Risk of Adverse Outcomes after a Suspected Seizure (RADOSS)-protocol for the mixed-methods observational RADOSS project.

INTRODUCTION: Ambulances services are asked to further reduce avoidable conveyances to emergency departments (EDs). Risk of Adverse Outcomes after a Suspected Seizure seeks to support this by: (1) clarifying the risks of conveyance and non-conveyance, and (2) developing a risk prediction tool for clinicians to use 'on scene' to estimate the benefits an individual would receive if conveyed to ED and risks if not. METHODS AND ANALYSIS: Mixed-methods, multi-work package (WP) project. For WP1 and WP2 we shall use an existing linked data set that tracks urgent and emergency care (UEC) use of persons served by one English regional ambulance service. Risk tools are specific to clinical scenarios. We shall use suspected seizures in adults as an exemplar.WP1: Form a cohort of patients cared for a seizure by the service during 2019/2020. It, and nested Knowledge Exchange workshops with clinicians and service users, will allow us to: determine the proportions following conveyance and non-conveyance that die and/or recontact UEC system within 3 (/30) days; quantify the proportion of conveyed incidents resulting in 'avoidable ED attendances' (AA); optimise risk tool development; and develop statistical models that, using information available 'on scene', predict the risk of death/recontact with the UEC system within 3 (/30) days and the likelihood of an attendance at ED resulting in an AA.WP2: Form a cohort of patients cared for a seizure during 2021/2022 to 'temporally' validate the WP1 predictive models.WP3: Complete the 'next steps' workshops with stakeholders. Using nominal group techniques, finalise plans to develop the risk tool for clinical use and its evaluation. ETHICS AND DISSEMINATION: WP1a and WP2 will be conducted under database ethical approval (IRAS 307353) and Confidentiality Advisory Group (22/CAG/0019) approval. WP1b and WP3 have approval from the University of Liverpool Central Research Ethics Committee (11450). We shall engage in proactive dissemination and knowledge mobilisation to share findings with stakeholders and maximise evidence usage.

The acceptability and safety of video triage for ambulance service patients and clinicians during the COVID-19 pandemic.

INTRODUCTION: In response to anticipated challenges with urgent and emergency healthcare delivery during the early part of the COVID-19 pandemic, Yorkshire Ambulance Service NHS Trust introduced video technology to supplement remote triage and 'hear and treat' consultations as a pilot project in the EOC. We conducted a service evaluation with the aim of investigating patient and staff acceptability of video triage, and the safety of the decision-making process. METHODS: This service evaluation utilised a mixture of routine and bespoke data collection. We sent postal surveys to patients who were recipients of a video triage, and clinicians who were involved in the video triage pilot logged calls they attempted and undertook. RESULTS: Between 27 March and 25 August 2020, clinicians documented 1073 triage calls. A successful video triage call was achieved in 641 (59.7%) cases. Clinical staff reported that video triage improved clinical assessment and decision making compared to telephone alone, and found the technology accessible for patients. Patients who received a video triage call and responded to the survey (40/201, 19.9%) were also satisfied with the technology and with the care they received. Callers receiving video triage that ended with a disposition of 'hear and treat' had a lower rate of re-contacting the service within 24 hours compared to callers that received clinical hub telephone triage alone (16/212, 7.5% vs. 2508/14349, 17.5% respectively). CONCLUSION: In this single NHS Ambulance Trust evaluation, the use of video triage for low-acuity calls appeared to be safe, with low rates of re-contact and high levels of patient and clinician satisfaction compared to standard telephone triage. However, video triage is not always appropriate for or acceptable to patients and technical issues were not uncommon.

Research paramedics' observations regarding the challenges and strategies employed in the implementation of a large-scale out-of-hospital randomised trial.

INTRODUCTION: AIRWAYS-2 was a cluster randomised controlled trial (RCT) comparing the clinical and cost effectiveness of the i-gel supraglottic airway device with tracheal intubation in the initial airway management of out-of-hospital cardiac arrest (OHCA). In order to successfully conduct this clinical trial, it was necessary for research paramedics to overcome multiple challenges, many of which will be relevant to future emergency medical service (EMS) research. This article aims to describe a number of the challenges that were encountered during the out-of-hospital phase of the AIRWAYS-2 trial and how these were overcome. METHODS: The research paramedics responsible for conducting the pre-hospital phase of the trial were asked to reflect on their experience of facilitating the AIRWAYS-2 trial. Responses were then collated by the lead author. A process of iterative revision and review was undertaken by the research paramedics to produce a consensus of opinion. RESULTS: The main challenges identified by the trial research paramedics related to the recruitment and training of paramedics, screening of eligible patients and investigation of protocol deviations / reporting errors. Even though a feasibility study was conducted prior to the commencement of AIRWAYS-2, the scale of these challenges was underestimated. CONCLUSION: Large-scale pragmatic cluster randomised trials are being successfully undertaken in out-of-hospital care. However, they require intensive engagement with EMS clinicians and local research paramedics, particularly when the intervention is contentious. Feasibility studies are an important part of research but may fail to identify all potential challenges. Therefore, flexibility is required to manage unforeseen difficulties.

The impact of an ambulance vehicle preparation service on the presence of bacteria: a service evaluation.

INTRODUCTION: Around 300,000 patients a year in England acquire a healthcare-associated infection (HAI) while being cared for by the NHS. The contribution from NHS Ambulance Services is not known, but previous studies have identified the presence of pathogenic bacteria such as Methicillin-resistant Staphylococcus aureus (MRSA) and Enterococcus, including resistant strains in some cases, inside ambulances. To improve ambulance cleanliness, Yorkshire Ambulance Service NHS Trust (YAS) piloted an Ambulance Vehicle Preparation Service (AVPS) at two ambulance stations, where staff were tasked with ensuring every ambulance at these stations was cleaned every 24 hours. METHODS: Adenosine triphosphate (ATP) bioluminescence testing was conducted on 16 ambulances at the two pilot AVPS stations and on 18 ambulances at four 'business as usual' (BAU) ambulance stations using a Hygiena SystemSURE luminometer. Swabs were obtained from 10 pre-selected locations inside each ambulance. RESULTS: Between November 2016 and August 2018, a total of 690 swabs were obtained and recorded from 34 ambulances. Overall, median relative light unit (RLU) values for both groups were < 100, with only the BAU group having an upper quartile value > 100. However, when stratified by swabbing area, three areas had a median RLU of > 100 in the BAU group: suction unit handle, steering wheel and airway seat shelf. In addition, the upper quartile RLU values for the grab rail above the stretcher and the passenger seat in the BAU group were also > 100. No swab areas had a median RLU > 100 in the AVPS group. CONCLUSION: A dedicated AVPS results in better cleaning of ambulance vehicles than the existing cleaning system utilising operational crews. The areas most likely to be contaminated are the suction unit handle, steering wheel, airway seat shelf and grab rails. The position of equipment and the materials that equipment are constructed from should have infection prevention and control (IPC) as a consideration.

Soiled airway tracheal intubation and the effectiveness of decontamination by paramedics (SATIATED): a randomised controlled manikin study.

INTRODUCTION: Vomiting and regurgitation are commonly encountered in out-of-hospital cardiac arrest (OHCA), with a reported incidence of 20-30%. This is of concern since patients who have suffered an OHCA are already in extremis. If standard suctioning techniques are not sufficient to maintain a clear airway and provide ventilation, then these patients will die, irrespective of the quality of chest compressions and the timeliness of defibrillation. This study aimed to determine whether a short teaching session of the suction assisted laryngoscopy and airway decontamination (SALAD) technique improved paramedics' ability to successfully intubate a contaminated airway. METHODS: A modified airway manikin with the oesophagus connected to a reservoir of 'vomit', and a bilge pump capable of propelling the vomit up into the oropharynx, was used to simulate a soiled airway. The intervention consisted of a brief SALAD training session with a demonstration and opportunity to practice. Participants were randomly allocated into two groups: AAB, who made two pre-training intubation attempts and one post-training attempt, and ABB, who made one pre-training and two post-training attempts, to adjust for improvement in performance due to repetition. RESULTS: In this manikin study, following a brief SALAD training session, more paramedics were able to intubate a soiled airway on their first attempt, compared to those without training (90.2% vs. 53.7%, difference of 36.6%, 95% CI 24-49.1%, p < 0.001). In addition, the mean difference in time taken to perform a successful intubation between groups was statistically significant for attempts 1 and 2 (mean difference 11.71 seconds, 95% CI 1.95-21.47 seconds, p = 0.02), but not attempts 1 and 3 (mean difference -2.52 seconds, 95% CI -11.64-6.61 seconds, p = 0.58). This result is likely to be confounded by the use of tracheal suction, which only occurred in the post-training attempts and added additional time to the intubation attempts. There was no statistically significant difference in success rates on the third attempt between AAB and ABB (89.0% vs. 86.6%, difference 2.4%, 95% CI 7.6-12.4%, p = 0.63). CONCLUSION: In this study, the use of the SALAD technique significantly improved first attempt success rates when paramedics were intubating a simulated soiled airway.

Pre-hospital intranasal analgesia for children suffering pain: a rapid evidence review.

INTRODUCTION: Pre-hospital analgesic treatment of injured children is suboptimal, with very few children in pain receiving analgesia. Studies have identified a number of barriers to pre-hospital pain management in children which include the route of analgesia administration. The aim of this review is to critically evaluate the pre-hospital literature, exploring the safety and efficacy of intranasal (IN) analgesics for children suffering pain. METHODS: We performed a rapid evidence review, searching from inception to 17 December 2018, CINAHL, MEDLINE and Google Scholar. We included studies of children < 18 years suffering pain who were administered any IN analgesic in the pre-hospital setting. Our outcomes were effective pain management, defined as a pain score reduction of ≥ 2 out of 10, safety and rates of analgesia administration. Screening and risk of bias assessments were performed in duplicate. We performed a narrative synthesis. RESULTS: From 310 articles screened, 23 received a full-text review resulting in 10 articles included. No interventional studies were found. Most papers reported on the use of intranasal fentanyl (INF) (n = 8) with one reporting IN ketamine and the other IN S-ketamine. Narrative synthesis showed that INF appeared safe and effective at reducing pain; however, its ability to increase analgesia administration rates was unclear. The effectiveness, safety and ability of IN ketamine and S-ketamine to increase analgesia administration rates were unclear. There was no evidence for IN diamorphine for children in this setting. CONCLUSION: Interventional studies are needed to determine with a higher confidence the effectiveness and safety of IN analgesics (fentanyl, ketamine, S-ketamine, diamorphine) for children in the pre-hospital setting.

Do RATs save lives? A service evaluation of an out-of-hospital cardiac arrest team in an English ambulance service.

INTRODUCTION: Out-of-hospital cardiac arrest (OHCA) is a major public health problem, leading to a substantial number of deaths in the UK. In response to this, the Yorkshire Ambulance Service NHS Trust (YAS) has introduced red arrest teams (RATs). RAT members attend a three-day training course, focusing on the technical and non-technical skills that are required to effectively team lead an OHCA and provide high quality post-resuscitation care. This evaluation aims to determine the impact of the RATs on survival to 30 days and return of spontaneous circulation (ROSC) at hospital. METHODS: All adult (≥ 18 years) OHCAs entered onto the YAS computer aided dispatch (CAD) system between 1 October 2015 and 30 September 2017 were included if the patient was resuscitated and the cause of the arrest was considered to be medical in origin. Multi-variable logistic regression models were created to enable adjustment for common predictors of survival and ROSC. RESULTS: During the 2-year data collection period, YAS attended 15,151 cardiac arrests. After removing ineligible cases, 5868 cardiac arrests remained. RATs attended 2000/5868 (34.1%) incidents, with each RAT attending a median of 13 cardiac arrests (IQR 7-23, min. 1, max. 78).The adjusted odds ratios suggest that a RAT on scene is associated with a slight increase in the odds of survival to 30 days (OR 1.01, 95% CI 0.74-1.38) and odds of ROSC on arrival at hospital (OR 1.13, 95% CI 0.99-1.29), compared to the odds of not having a RAT present, although neither result is statistically significant. CONCLUSION: The presence of a RAT paramedic was associated with a small increase in survival to 30 days and ROSC on arrival at hospital, although neither were statistically significant. Larger prospective studies are required to determine the effect of roles such as RAT on outcomes from OHCA.

A service evaluation of paediatric pain management in an English ambulance service.

INTRODUCTION: Evidence from the past 20 years has highlighted that acute pain is not managed well in the emergency setting, in particular with children. Inadequate management of pain can result in long-term changes in both physical and mental health. This service evaluation aimed to determine how paediatric pain is assessed and managed by ambulance clinicians in a large region in England. METHODS: This retrospective service evaluation analysed electronic patient record (ePR) data routinely collected between September and December 2018. All paediatric patients (< 18 years of age) with pain documented narratively, or a pain score of ≥ 1/10, were included. The primary outcome measure was the proportion of patients with severe pain (defined as a pain score of ≥ 7/10) who achieve effective pain management (reduction in pain score of ≥ 2/10). RESULTS: A total of 2801 paediatric patients who had documented pain were included in the analysis and the median age of patients was three years (interquartile range, 1-12 years). Most had a medical cause of pain (2387/2801, 85.2%), and analgesia was administered by the ambulance crew in 403/2801 (14.4%) patients. Multiple pain scores were recorded for 667 patients. Effective pain management was achieved in 233/271 (86%) patients in moderate pain and 204/210 (97.1%) patients in severe pain. However, of the 437 children in moderate to severe pain who achieved effective pain management, 381 (87%) received no analgesia. CONCLUSION: Children in severe pain received effective pain management, despite the majority not receiving any analgesia. This should be investigated further since non-pharmacological methods of analgesia are unlikely to explain a reduction of this magnitude. Ambulance staff need to be encouraged to record a pain score promptly after arriving on scene and ensure it is repeated. Pain score should be documented as part of the physiological observations and not in the free text of ePRs to ensure that it is identified during audits.

How do paramedics learn and maintain the skill of tracheal intubation? A rapid evidence review.

INTRODUCTION: Endotracheal intubation has been considered a core skill for all paramedics since the inception of the profession in the 1970s, and continues to be taught within the majority of pre-registration paramedic training programmes. However, the standards of both training and assessment of competence in intubation vary considerably between institutions; this has been compounded by reduced opportunities for supervised clinical practice within the operating theatre environment.The College of Paramedics' Airway Working Group commissioned a rapid evidence review, to inform a consensus statement on paramedic intubation, with the research question: How do paramedics learn and maintain the skill of tracheal intubation? METHODS: Rapid evidence reviews are literature reviews that use methods to accelerate or streamline the traditional systematic review process. Randomised controlled trials, quasi-randomised controlled trials, prospective and retrospective observational studies, systematic reviews and qualitative studies, published from 1970 onwards, were all eligible for inclusion. The search was restricted to paramedics/paramedic students and learning/maintaining the skill of tracheal intubation. RESULTS: A comprehensive search of CINAHL, MEDLINE and Google Scholar was undertaken. Ten papers were classed as sufficiently relevant for inclusion. They identified that there is no clear definition of a paramedic having 'learnt' the skill of intubation. Suggested measures include first-pass success of 90% for pre-hospital intubation, or a range of measures, such as intubation success and complication rates, laryngoscopy technique and decision-making. Intubation training should use a range of modalities, including didactic lectures, videos and practical sessions on multiple types of airway manikins. Supervision by experienced faculty is required.Little is known about how paramedics maintain their skill in intubation, given the lack of clinical opportunity. Yearly skills retraining can help, and can be enhanced by demonstrations/lectures from experienced faculty. CONCLUSION: Further research is needed to understand how paramedics maintain their skill in intubation, given the limited opportunities to use the skill in a clinical setting and lack of opportunities with UK ambulance services for retraining.

Soiled airway tracheal intubation and the effectiveness of decontamination by paramedics: a randomised controlled manikin study protocol.

Vomiting and regurgitation are commonly encountered in out-of-hospital cardiac arrest with a reported incidence of 20-30%. Arguably, tracheal intubation is the preferred airway management technique in patients with ongoing airway contamination, but there is evidence that this is difficult to achieve when the airway is soiled. In addition, traditional suctioning techniques have been criticised, and training in the management of contaminated airways is limited. If standard suctioning techniques are not sufficient to maintain a clear airway and provide ventilation, then these patients will die, irrespective of the quality of chest compressions and the timeliness of defibrillation. This has led to the development of a combined suction/laryngoscopy technique to facilitate intubation, known as Suction Assisted Laryngoscopy and Airway Decontamination, and the creation of modified airway manikins to allow for practice in these techniques. However, to date there has only been one study specifically looking at the Suction Assisted Laryngoscopy and Airway Decontamination technique, and the outcomes were self-reported confidence measures of trainees in using the technique. The primary objective of Soiled Airway Tracheal Intubation and the Effectiveness of Decontamination is to determine the difference between paramedic first-pass intubation success, before and after Suction Assisted Laryngoscopy and Airway Decontamination training, in a simulated soiled airway. The primary outcome is the difference in proportions of paramedic first-pass intubation success, before and after Suction Assisted Laryngoscopy and Airway Decontamination training. Paramedic recruitment commenced in July 2018 and the study will enrol 154 paramedics by the end of 2018. The results of this study will contribute to the evidence relating to the Suction Assisted Laryngoscopy and Airway Decontamination technique.