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003 OPERATIONALISING AND EVALUATING THE EMERGING ROLE OF THE PARAMEDIC PRACTITIONER
S. Cooper, B. Barrett, S. Black, C. Evans, C. Real, S. Williams, B. Wright, B. Barrett, C. Real, S. Williams, B. Wright.Westcountry Ambulance Services NHS Trust (WAST), Morlaix Drive, Derriford, Plymouth PL6 5AB, UK
Please note: The results shown below are based on an initial analysis of data from a study funded by the Changing Workforce Programme. Definitive confirmed results will not be available until the end of May 2003.
Objectives: The emerging role of the Paramedic Practitioner (PP) (sometimes referred to as Emergency Care Practitioner (ECP) or Practitioner in Emergency Care (PEC)) was the key focus of this study. Using both qualitative and quantitative approaches the objective was to undertake a scoping exercise to identify the key activities and core competencies of the day to day practice of four newly appointed PPs (all of whom had recently graduated from a 2 year part time BSc in Emergency Care). A specific focus related to the impact that PPs had on the patient’s emergency care experience, for example, treat and referral practice and non-conveyance issues.
Method: A constructivist methodology taking account of stakeholder inputs (claims, concerns and issues) as organizational and development foci for the evaluation drawing upon the constant comparisons of different groups constructs of realities. The first stage of data collection was based upon PPs reflective reports and adapted patient report forms. This first case group was compared to paramedics’ reports (second case group) using the same adapted patient report form. Stage two involved data collection from other stakeholders, for example, Health Authority representatives, Minor Injury Unit (MIU) staff, operational managers and General Practitioners.
Results: Four PPs and nine paramedics participated in data collection from October 2002 to March 2003. PPs were resourced via ambulance control, ambulance crews, and multi-professional agencies. PPs spent a proportion of the trail period based in MIUs. Paramedics reported on 331 incidents which were compared to 361 PP incident reports. PPs had a greater exposure to children (<16 years) 64% to the 35% seen by paramedics (p = <0.001). PPs treated 41% of patients on scene compared with 23% by paramedics (p = <0.002). 16% of PPs patients were conveyed by A&E ambulance compared to 57% of paramedics (p = <0.000). PPs stated that 61% of the backup they were sent was not required compared to 21% from paramedics (p = 0.000). (The reader should note that the above results will have been influenced by the different resourcing methods) Qualitative analysis of the 170 reflective reports revealed four key themes. Firstly PPs have an impact on the deployment of resources. Secondly their training and education enhanced their decision making repertoire and developed their confidence for a leadership role. Thirdly inter-agency collaboration and co-operation was improved and finally care benefits were increased especially relating to immediacy of treatment, referral mechanisms and non conveyance.
Conclusions: Further work is required to verify this role, ideally this should be an independent observation of practice. However, these results suggest that a pre-hospital emergency practitioner is likely to have a significant impact on practice.
004 DOES THE USE OF DEDICATED TASKING STAFF INCREASE THE UTILISATION OF AN AIR AMBULANCE?
M. Lindley, A. Walker.West Yorkshire Metropolitan Ambulance Service, WYMAS, Threelands, Bradford Road, Birkinshaw, Bradford BD11 2AH, UK
Introduction: Tasking of air ambulances in the UK has often presented problems for ambulance services, as highlighted by a recent assessment of national dispatch methods. Ambulance communication room staff may be unfamiliar with the criteria for effective dispatch of an air ambulance and are under considerable pressure in the deployment of more familiar resources. The Yorkshire Air Ambulance is dispatched by three different ambulance services, a study was undertaken to assess the impact of dedicated dispatch staff.
Methods: An six week audit was undertaken of Yorkshire Air Ambulance (YAA) dispatch. During weeks 1, 2, 5 and 6 normal dispatch systems were used. During the intervention fortnight (weeks 3 and 4) YAA volunteer aircrew monitored calls and influenced dispatch in the three communication centres.
Results: During the two week intervention period the tasking of the YAA increased by 42% in comparison with the same period the previous year. Tasking also increased by 40% compared with the two weeks prior to the intervention period, and decreased by 25% in the two weeks after. In the intervention fortnight the percentage of stand downs decreased by 12%, but rose to the original levels again in the final two weeks.
During the intervention period the aircraft was off-line for 14 hours due to technical difficulties compared with 7 hours in the period prior to the intervention and none in the period following the intervention.
Conclusion: The current system of dispatch under utilises the Yorkshire Air Ambulance. Given the flexibility, speed and costs of the service every attempt should be made to improve tasking. We have shown that dedicated dispatchers improve the level of tasking with fewer stand-downs. One solution may be a dedicated combined services air desk and dispatchers, to co-ordinate air ambulance activity.
006 IS REFERRAL OF ELDERLY FALLERS FROM AN AMBULANCE SERVICE TO A SPECIALIST NURSE TEAM APPROPRIATE?
C. James, A. Walker, H. Hart, L. Longfield.West Yorkshire Metropolitan Ambulance Service, WYMAS, Threelands, Bradford Road, Birkinshaw, Bradford BD11 2AH, UK
Introduction: The ambulance service often receive calls to elderly patients, who have had an apparently simple trip or fall and remain at home following a physiological assessment by the crew. Some of these patients are at risk of further falls. A pilot study was introduced by the West Yorkshire Metropolitan Ambulance Service (WYMAS) to liaise with a specialist assessment team for further review of these patients. One of the aims of the NSF for older people is; ‘to reduce the number of falls which result in serious injury and ensure effective treatment and rehabilitation for those who have fallen.’ One of the standards is; “older people who have fallen (should) receive effective treatment and rehabilitation and with their carers, receive advice on prevention through a specialist falls service.”
Method: Over a 6 month period in one area of West Yorkshire all patients who had fallen, were over 65, and were assessed as suitable to stay at home by the crew, were referred by telephone to a 24 hour specialist assessment team. The team undertook a further assessment within 2 hours, and arranged appropriate packages of care if necessary. Decisions were recorded and patients were sent a satisfaction questionnaire.
Results: A total of 90 patients were referred, 68% were female, and 81% were over the age of 80.
Following discussions with the nurse, 8 patients were transferred to A&E immediately, 79 patients had a risk assessment by the nurse at home, 3 were ineligible for this service. 16 patients were admitted to hospital in the 9 days after nurse assessment (5 to respite care). 35 patients had 10 or more risks for falling identified. 8 patients had incomplete data.
Services arranged included physiotherapy (57%), district nurse (47%), homecare (42%), GP visit (32%). 97% of patients were either very satisfied or satisfied with the ambulance crew/nurse liaison service.
Conclusions: A significant percentage of patients required interventions from the specialist team to improve their safety. An ambulance service assessment alone may not be adequate for elderly people who have fallen at home.
Recommendations: Referral of elderly patients who have fallen at home, by ambulance services, to an appropriately funded specialist nurse teams should be considered for the identification of those at risk of further falls.
007 IS A REFERRAL SYSTEM FROM THE AMBULANCE SERVICE TO SPECIALIST DIABETES NURSES FOR PATIENTS WITH HYPOGLYCAEMIC DIABETIC EPISODES APPROPRIATE?
C. James, A. Walker, M. Bannister, E. Davey.West Yorkshire Metropolitan Ambulance Service, WYMAS, Threelands, Bradford Road, Birkinshaw, Bradford BD11 2AH, UK
Introduction: Patients with diabetes, experiencing acute hypoglycaemia, are a common reason for emergency calls to the ambulance service. Most of these patients are treated effectively by crews, without transfer to A&E. The National Service Framework for Diabetes has stated; “The NHS will develop, implement and monitor agreed protocols for rapid and effective treatment of diabetic emergencies by appropriately trained health care professionals. Protocols will include the management of acute complications and procedures to minimise the risk of recurrence.” This pilot study assessed the effectiveness of ambulance crew referral for diabetic patients who had treatment for acute hypoglycaemia, to a dedicated specialist nurse led team. These patients were assessed by the ambulance service and did not attend A&E. Patients’ satisfaction with the service was also examined.
Methods: For a 3 month period, patients within the criteria, were referred from two areas of West Yorkshire. A diabetes nurse specialist contacted the patient within seven days, and arranged review. Satisfaction questionnaires were sent to patients.
Results: 38 patients were referred and reviewed. Warning signs of hypoglycaemia were identified by 19 patients but 17 had none, 2 had incomplete data.
12 patients had a self-treated episode in the last 6 months, 9 patients had three or more. 15 patients had called a emergency ambulance for similar reasons in the previous 6 months (twenty-seven “999” calls). 20 patients had their treatment altered, 14 patients required ongoing review. 26 patients returned the satisfaction questionnaire, 88% agreed or strongly agreed that they had improved their understanding of hypoglycaemia and 73% felt more able to treat a hypoglycaemic episode in the future.
Conclusions: The ambulance service can coordinate successful referral of patients with episodes of hypoglycaemia to a specialist nurse led diabetes service. Patients valued this service and felt more confident managing their diabetes.
Recommendations: A funded ambulance service/specialist diabetes nurse liaison referral service should be considered by those co-ordinating the management of diabetes patients in primary and pre-hospital care.
009 WYMAS HEALTHCARE RESPONSE PILOT—A MOBILE DIAGNOSTIC AND TREATMENT SERVICE
S. Hessey, A. Walker, P. Ferguson, S. Holmes, T. Baldwin, G. Laycock, G. Johnson.West Yorkshire Metropolitan Ambulance Service, WYMAS, Threelands, Bradford Road, Birkinshaw, Bradford BD11 2AH, UK
Introduction: In an attempt to provide alternatives to standard ambulance dispatch and transfer to hospital various models have been tried, particularly to address those 999 calls which do not require immediate transfer to hospital, but may require early medical input.
Methods: The WYMAS healthcare response (HCR) pilot scheme was conducted to determine whether a dedicated treatment and diagnostic unit, staffed by a suitably qualified doctor, and paramedic or technician, would be effective in reducing accident and emergency transfers of 999 patients by treating selected patients in their own homes. Patients were identified by one of four methods: AMPDS code identification of call priority, referrals to the HCR doctor by ambulance crews on scene with 999 patients, direct referral by the Intermediate Care team and by call screening to identify potentially appropriate calls.
Results: The unit attended 181 patients over 116 days. Overall 82.1% of patients were treated at home, and of the four methods, patients identified by ambulance crews on scene were most likely to be treated at home and avoid hospital transfer (92%). The AMPDS system was not found to be a reliable predictor of need for hospital admission. 29.3% of patients identified by a designated “category C” AMPDS code were referred to hospital following HCR doctor assessment. 60% of patients were over 65 years old, and one sixth were referred to the intermediate care team for follow-up. 53.6% of patients required planned follow-up by an agency other than A&E, most frequently the patients own General Practitioner. Apart from dispensing or prescription of medication, the commonest treatment intervention was wound closure with tissue adhesive or steri-strips. Point of care testing of blood was performed on 15 occasions, an abnormality requiring immediate attention was identified on only one occasion. The facility for onboard radiology was developed during the pilot period, but not implemented owing to the short time-scale, 11 patients would have potentially benefited from this investigation. Patient satisfaction with the service was high. However, job satisfaction of the HCR team was hampered by the low caseload during the pilot, and the relatively minor nature of the majority of calls.
Conclusions: Future service development should look at ways of increasing call uptake without compromising patient safety, and review of both case mix and staff skill mix. One way of achieving this would be to integrate the service with other emergency care work streams.
011 AMBULANCE CREW DIAGNOSIS—DO THEY GET IT RIGHT?
A. Walker, S. Coleman, J. Brenchley.West Yorkshire Metropolitan Ambulance Service, WYMAS, Threelands, Bradford Road, Birkinshaw, Bradford BD11 2AH, UK
Introduction: Paramedics institute initial emergency treatment for patients during transfer to the A&E department. Although not formally asked for a definitive diagnosis, the treatment option chosen is clearly made on a provisional diagnosis by the paramedics. To date no study has examined the accuracy in terms of system diagnosis by paramedics and therefore the appropriateness of treatment given. We have compared the accuracy of ambulance personnel diagnosis with A&E diagnosis for patients admitted to the ‘major side’ or resus areas of A&E.
Methods: A single investigator interviewed paramedic crews on arrival at the A&E department of a large teaching hospital and completed a standard proforma. The crews were asked for their provisional diagnosis and ‘illness severity score’. This was a Likert style question based on a nine point scale from not ill (1) or life threatening (9). Obvious multiply injured patients were excluded. The crews’ provisional diagnosis was compared with the A&E diagnosis where appropriate. The triage nurse was also asked for an assessment of illness severity based on the same scale.
Results: Fifty one patients were entered into the study. Twenty five were treated by paramedics and twenty six by EMT in each crew. Triage categories on arrival ranged from 1–4 (median 3). There was complete agreement between ambulance crew diagnosis and final A&E diagnosis in 36 patients and partial agreement (same system, not exact diagnosis—e.g. angina and myocardial infarction) in 12 patients. No agreement was seen in 3 patients. Complete or partial agreement was thus seen in 94% of patients. Illness severity score varied from 1 to 9. In 84% of cases the illness severity score was in agreement ± two points.
Conclusions: Ambulance crews in this small study correctly classified the diagnosis in the majority of cases.
014 FINDING A MEASURE OF ‘RURALITY’ THAT HELPS EXPLAIN EMERGENCY SERVICE RESOURCING DIFFERENCES BETWEEN AMBULANCE SERVICES
M. Vicary, P. Murray.Operational Research in Health Ltd, 60–62 Kings Road, Reading RG1 3AA, UK
Background: Emergency service costs vary between Ambulance Services for various reasons. One uncontrollable variable is the relative level of rurality between Services. Population density is most often used to distinguish ‘urban’ from ‘rural’ Services, but this simple measure does not reflect the incident distribution profile. A better measure of rurality could be used in national benchmarking.
Objective: To find a measure of rurality that helps explain the emergency service resourcing differences between Ambulance Trusts.
Methodology: The study used available data for Ambulance Trusts to allow analysis of resourcing differences in relation to demand levels and rurality. A literature search was undertaken to identify potential rurality measures which were then appraised. A shortlist of measures was applied to a sample of Services and a preferred measure then selected.
Results: Measures were tested for their ability to explain deployed hours per case differences between Services. The most appropriate measure found was the geometric mean of ward-weighted population density (TWGM):
Where Pi = Population of Ward i; Ai = Area of Ward i.
The table shows the TWGM value and rank for the 32 English Trusts alongside population density.
Discussion: The R2 values of regressing deployed hours per case against TWGM rank and population density rank are 0.6 and 0.1 respectively. TWGM is a better discriminator than population density as it reflects incident clustering and density.
Conclusion: The TWGM rank gives a more appropriate measure of ambulance service rurality than population density and could be used to group Services into families for benchmarking purposes.
015 MODELLING ASSESSORS IN THE LONDON AMBULANCE SERVICE (LAS)
A. Greenwood, M. Vicary.Operational Research in Health Ltd, 60–62 Kings Road, Reading RG1 3AA, UK
Background: The LAS categorises emergency calls into Category A (40%), Category B (38%) and Category C (22%). Category C calls potentially do not need a full A&E ambulance response. A two-tier operational régime is being considered for the future: Tier II meeting non-urgent work and the bulk of Category C calls; and Tier I meeting Category A, Category B, doctor’s urgent and the residual Category C calls. Some Category C calls are ‘triaged out’ through clinical telephone advice; the remainder join a queue for an assessor response. An assessor is a single-manned (paramedic/technician) car. This study modelled this system using data from a trial area.
Objective: To model the impact of ‘assessors’ within the LAS operational tiering plans.
Methodology: Modelling parameters were derived from an analysis of Category C workload data and from the outcomes of the trial. A model simulated the assessors in different sectors and shifts. The relationship between the number of Category C calls that the assessors ‘save’ and the reduction in the number of Tier II ambulances was then determined.
Results: The assumptions are shown below:
49 Category C calls during day/evening shift
80% of Category C calls are suitable for an assessor (39 calls during day/evening shift)
Assessors work 16 hours/day
60 minute assessor job cycle time
60 minute maximum wait for assessor
60% of assessed patients are not conveyed to hospital by ambulance
The results are shown in the table.
Discussion: The sensitivity of the input parameters was modelled. With two assessors working, the percentage of Category C calls saved is sensitive to the assessor job cycle time, but less sensitive to the maximum wait for an assessor.
Conclusion: It is not cost-effective to assess all Category C calls from a dedicated assessor tier, nor is it efficient to deploy assessors at night. Assessors work better in urban services than rural services. A balance must be sought between assessor utilisation, Category C calls saved and reduction in ambulances.
016 APPRAISING THE RANGE OF AMBULANCE SERVICES’ FRV OPERATIONAL REGIMEN WITH A VIEW TO IDENTIFYING BEST PRACTICE
P. Murray, M. Vicary.ORH (Operational Research in Health), 60–62 Kings Road, Reading RG1 3AA, UK
Background: Fast Response Vehicles (FRVs) have been gradually introduced into Ambulance Services in England since 1996. FRVs now account for around 12 per cent of resources and about 9 per cent of Category A 8-minute (A8) performance. Services are using FRVs, alongside other resources, in a variety of ways to help meet the new performance targets.
Objective: To investigate the range in operational regimens for FRVs with a view to identifying best practice.
Methodology: Information regarding 12 representative Services was collected, allowing analytical and modelling techniques to be used to identify key factors for achieving optimum FRV usage.
Results: The results are shown in the table.
Optimum FRV usage in relation to the A8 target is achieved around the following key factors which are listed in a rough priority order:
1. Quick activation times (30 to 60 seconds on average);
2. Focussing on Category A cases (minimum of about 60% of workload);
3. Short on scene times (15 minutes);
4.; Minimal journeys to hospital (max 10 per cent);
5. Working within optimum catchments (10 minutes from best locations).
Discussion: Optimum FRV usage also depends on whether FRVs are ‘counted’ against the other targets (i.e. A14, A19, B14 and B19) or used in an ‘assessment’ role, and on acceptable utilisation levels. Whilst most FRV deployments are best made across the 16-hour day/evening period, night deployments can make a significant contribution in urban areas. The proportion of Category A cases in a Service is also a key factor.
Conclusions: There is a wide range in FRV operational régimes in use. Best practice in optimising A8 performance has been linked to five key factors. However, optimum FRV usage will depend on whether FRVs are ‘counted’ against the other targets and/or usage in an assessment role.
017 IS NAPPY RASH A LIFE THREATENING EVENT?
A. Heward, C. Hartley-Sharpe.London Ambulance Service NHS Trust, 220 Waterloo Road, London SE1 8SD, UK
Introduction: Since the implementation of Call Prioritisation in the United Kingdom, children under the age of two years have been required by the Department of Health to receive the highest level of response that ambulance services can provide; Category A. This means children under the age of two receive the same response as a patient in cardiac arrest regardless of actual clinical need. This study aimed to identify the level of risk that existed if this requirement did not exist.
Methods: A retrospective, quantitative study of secondary data sources was undertaken using data from a three-month period. The data was studied for inclusion criteria.
1. The patient was under the age of two
2. The patient required a “priority call” to hospital
3. The patient hadn’t been allocated a AMPDS determinant that would have elicited a Category A response.
The Patient Report Forms (PRF) of the patients fitting the inclusion criteria were subjected to a blinded peer review process to identify if there were clinical factors that presented an immediate threat to the patients life either prior to the arrival of the ambulance at the incident or during the transfer to hospital.
Findings: Of the 4359 calls over the three-month period, 158 generated a “priority call” to the receiving hospital (3.6%). Of these 38 (0.87%) would not have been allocated a “Category A” level response if the special requirement of allocating every patient under two years of age a Category A response was removed. Blinded peer review identified that there was no clinical need for some patients to have a “priority call” placed and review of the calls identified that remedial action could be taken in a number of cases to avoid under-triage. Overall the risk of under-triage was reduced to 0.09%. This could be further improved through the revision of a statement within one AMPDS protocol which would then lower the risk to 0.04% or 1 in 2500 calls.
Limitations: This study did not look at the hospital records of the patients, although it is felt that any immediate life threat would be picked up by the responding ambulance crew.
Discussion: The current requirement of every emergency call for a patient under the age of two years, regardless of clinical need, creates substantial over-triaged. This presents a multitude of complications for ambulance services including:
Inappropriately use of resources.
Negative staff perception issues with the process of triage
Inappropriate care for the patient
019 NHS DIRECT—IS AN AMBULANCE REQUIRED?
A. Heward, C. Hartley-Sharpe.London Ambulance Service NHS Trust, 220 Waterloo Road, London SE1 8SD, UK
Introduction: NHS Direct has become an integral part of accessing the NHS, attempting to direct the many people who require medical advice and assistance towards the most appropriate care pathway. Seen initially as a resource that met the needs of the many non-emergency calls received by the UK’s ambulance services, NHS Direct has recently been perceived to direct many calls that do not require a lights and sirens response to the ambulance service.
Objective: To determine what happens to calls that NHS Direct refer to the ambulance service for an emergency response?
Methods: One year’s data comprising all calls referred directly by NHS Direct to the London Ambulance Service NHS Trust (LAS) were examined. Each call was studied and the priority level assigned documented along with the illness or injury code used by the responding crew to summarise the patient’s condition and details about whether the patient was conveyed to hospital. These details were entered into an Excel spreadsheet and analysed. This study does not include calls where the caller has been told to call for an ambulance, or investigate the issues that may arise from this practice.
Findings: Over a one year period 5567 calls were refer to the LAS from NHSD. Of these:
54% were triaged as immediately life threatening (Category A)
30% were triaged as serious in need of urgent assessment (Category B)
16% were considered as neither life threatening nor serious and suitable for a Category C response.
From the 5039 cases that had an illness/injury code assigned by the responding crew:
16% of referrals from NHSD were not conveyed to hospital
2% of all calls were documented as having no injury or illness
2% were suffering from a Cardiac Arrest.
Discussion: A significant number of patients referred to the LAS by NHSD are not conveyed to hospital, with a considerable number documented as having no injury or illness. This is surprising as NHSD should be identifying those patients who require non-emergent treatment. Further analysis is needed to identify those patients who are referred to the LAS and transported to A&E, to establish if those patients actually required a frontline, lights and sirens response.
020 ASSAULTS ON AMBULANCE CREWS: CAN RISK FACTORS BE IDENTIFIED?
K. Nanuwa1, C. Hartley-Sharpe2, E. Glucksman3.1Guy’s, King’s & St. Thomas’ School of Medicine, Flat 1 Tayet Towers, 3 Rothsay Street, London SE1 4UH, UK; 2London Ambulance Service, UK; 3King’s College Hospital, UK
Background: In 1998–1999 a survey carried out by the NHS Executive found that approximately 65,000 violent incidents occurred against Trust staff each year, (84,273 by 2000–2001) and that the average number of incidents in ambulance Trusts was over twice the average for acute trusts. In 1999–2000 there were 526 cases of physical violence and a further 924 incidents of verbal abuse and anti-social behaviour reported by the London Ambulance Service (LAS). The LAS have undertaken a number of initiatives to decrease the risk of violence to front line staff. This has included a publicity campaign, a vehicle location system and a database containing details of locations where crews have previously been exposed to physical or verbal abuse.
Objective: To attempt to identify pre-disposing risk factors with respect to 999 calls where emergency ambulance crews have been physically assaulted.
Methods: The sample was obtained from all incidents of physical assault formally reported within the LAS which could be successfully matched with the record of the relevant 999 call between April and September 2002 (n = 90). All 999 call information collected systematically, by the LAS control room computer, was analysed.
Results: The following information from the 999 call report suggests incident characteristics with a higher or lower than average risk of assault. The percentage of assault incidents with each characteristic is given compared with the mean for all emergency responses (in brackets). Age: 44% between 26–45 years (26%). Sex: 69% male (50%). Time of day: 39% between 1900–2300 hrs (21%). AMPDS chief complaint: disproportionately high for ‘Unconscious/Passing out’ 11% (5%) ‘Overdose/ingestion/poisoning’ 9% (3%) ‘Convulsions/fitting’ 9% (3%) ‘Psychiatric/suicide attempt’ 4% (2%). Disproportionately low for ‘Traumatic injuries’ 3% (11%) ‘Falls/back injuries’ 3% (9%) ‘Traffic accidents’ 1% (5%) ‘Breathing problems’ 6% (10%) ‘Haemorrhage/lacerations’ 2% (5%). Calls received from the police: 13% (7%). Priority category: Approximately twice as likely to get assaulted if a delayed response is Category A at 21% than a lower priority call at 11%.
Limitations: The study was not designed to produce statistically significant results, but to highlight areas where future research may be worthwhile.
Discussion: Identification of a significant risk factor, or combination of risk factors, could enable ambulance services to take pre-emptive action to reduce assaults on staff.
021 THE EFFECT OF THE WORDING OF TELEPHONE CPR INSTRUCTIONS ON THE DEPTH OF CHEST COMPRESSIONS GIVEN BY LAY RESCUERS. A RANDOMISED CONTROLLED TRIAL
K. Drysdale, M. Woollard.Pre-hospital Emergency Research Unit, Pre-hospital Emergency Research Unit, Finance Building, Lansdowne Hospital, Sanatorium Road, Canton, Cardiff CF11 8PL, UK
There is much evidence that the provision of early CPR improves survival rates from out-of-hospital cardiac arrest. Dispatcher-assisted CPR has been shown to increase both the proportion of cardiac arrests which receive early CPR and the quality of the CPR given. However several simulation studies have shown that during CPR lay people and healthcare professionals frequently fail to compress the chest to the recommended depth regardless of previous training or the provision of telephone instructions.
A randomised controlled trial was carried out. 60 volunteers from Heartstart training programmes were randomly allocated on an individual basis to receive either standard (control group) or modified (intervention group) telephone CPR instructions. They carried out seven minutes of CPR on a Laerdal Recording Manikin. The data from the manikin were analysed using SPSS and Statsdirect.
Paired data analysis comparing first and last full minutes of CPR failed to show evidence of fatigue.
How well this manikin simulation reflects a real emergency is unknown. The participants were all taking part in CPR training so may not be representative of those who follow telephone CPR instructions.
There were no significant demographic differences between the two study groups. Less than a third of participants compressed the chest to the recommended depth in this study. Changing the wording of the instruction for the depth of chest compressions did not result in significantly deeper chest compressions being given. Widening use of telephone CPR means further research to ascertain the most effective phrasing for each part of the protocol should be prioritised.
023 HOW EFFECTIVE WAS THE ‘ONLY ONE OF THESE IS A TAXI SERVICE’ INAPPROPRIATE USE ADVERTISING CAMPAIGN IN REDUCING INAPPROPRIATE 999 CALLS TO THE LONDON AMBULANCE SERVICE?
M. F. Bossy.Guy’s King’s and St Thomas’ Medical School, University of London, 16 Telford House, Tiverton Street, Southwark, London SE1 6NY, UK
Background: The level of unnecessary ambulance response is estimated to be 16%–52%. Coupled with increasing annual workloads, this has obvious implications for wasted resources and delayed provision of care to patients with more life-threatening needs. Consequently, an inappropriate use advertising campaign was conducted by the London Ambulance Service in December 2001 to reduce non-serious (category C) calls.
Objectives: To assess whether the campaign was effective in its aim of reducing workload attributable to inappropriate calls.
Methods: Total emergency responses during three weeks in November 2001 and in January 2002 were compared to a control year (2000/2001). Monthly emergency responses since January 1993 were used to indicate seasonal fluctuations in response and gross differences resulting from the campaign.
Results: There was an overall reduction in workload spread across all levels. Category A responses fell by 1.5%, category B by 19.2% and C by 1.5% after the campaign (compared with 9.6%, 6.4%, and a 4.0% rise respectively during the control year). Individual chief complaints and determinants increased or decreased according to no apparent pattern.
Limitations: Use of other data, such as caller demographics or larger time periods may have detected more subtle effects from campaign
Conclusion: This campaign was not as effective as anticipated; any reduction occurred across all levels of clinical severity. This may be due to confusion of clinical needs and patient perceptions and beliefs. It has been shown that laypersons lack medical knowledge and the ability to assess the seriousness of their own condition. Interaction between many different factors is likely to influence any decision to involve the ambulance service.
Recommendations for change: Further research into why people call 999 and how their behaviour may be influenced effectively to involve other more appropriate services would help development of prioritisation systems to free ambulance services from 999 callers that do not need urgent care.
024 AUDIT OF ACUTE STROKE ADMISSIONS AND FAST TEST EFFICIENCY
T. K. Khoo, G. Skinner, E. Turner, C. McAllister, T. Clarke.North East Ambulance Service, Ambulance HQ, Amethyst Road, Newcastle Business Park, Newcastle upon Tyne NE4 7YL, UK
Introduction: Implementation of new acute therapies for stroke patients requires the rapid and direct referral to specialist stroke units. Ambulance teams must therefore rapidly assess patients, with a high degree of accuracy.
Aims and objectives: We examined the pattern of queried stroke admissions to both the Acute stroke unit (ASU) at the Freeman hospital and to the Accident and emergency department at Newcastle general hospital (NGH), following concerns the number of stroke admissions to the ASU were decreasing. The Face Arms and Speech Test (FAST) was recently introduced by NEAS over the last few years. We set out to assess its efficiency in correctly diagnosing patients, and gathered other possible reasons for the pattern of stroke admissions to the two hospitals.
Methods: FAST test results of all queried stroke patients, and their admission hospitals were determined over a 2 year period. FAST test efficiency was measured by combining all test results with all ASU confirmed strokes over this period. A survey was conducted on ambulance personnel for confidence in the test and other reasons of admitting to both hospitals.
Results: Of 1163 total admissions of queried strokes between Jan 2001 and Dec 2002, 632 were admitted to the ASU and 531 to NGH. The difference in numbers of admissions to each has remained steady throughout. Of these numbers, ASU were mostly FAST suspected stroke patients (71%), and NGH admissions mostly non suspected strokes (63%). It was found via the study on stroke admissions and survey of ambulance crew that the FAST test contributed towards the diagnosis of stroke.
Conclusions: The pattern of admission has remained constant, most suspected strokes being referred to ASU and most not suspected, to NGH. There are several unmodifiable reasons why suspected stroke patients still are not taken to the ASU.
027 PREDICTING THE WORKLOAD OF A DOCTOR/PARAMEDIC EMERGENCY MEDICAL RESPONSE TEAM IN AN ENGLISH COUNTY
D. Beaven, R. Mackenzie.MAGPAS (Mid Anglia General Practitioner Accident Service), MAGPAS, 105 Needingworth Road, St Ives, Cambridgeshire PE27 5WF, UK
“The current provision of advanced pre-hospital skills by immediate care doctors is sporadic. The interventions performed are dependent on the skill level of the individual doctor and the area and time they operate in. The concept of a duty doctor scheme has been developed to address this by providing a doctor/paramedic response team with a defined operational area and duty hours. The duty medics will have a common skill base, including advanced drug regimes, drug assisted intubation, thoracotomy and advanced extrication training (including amputation, ketamine etc.). However, there is currently little available data to estimate how many times these interventions could potentially be performed in the geographical area covered. The immediate care scheme has therefore sponsored a trauma audit facility (TARN) in the three receiving hospitals of the county. Summary data for 2001/2002 was used to estimate the number of patients that have suffered serious trauma (ISS>15), prolonged vehicle entrapment at the scene, or significantly reduced level of consciousness. This data was combined with the immediate care scheme activity records, and a five-year retrospective study of road traffic related deaths in the county, to produce an estimate of the predicted number of seriously injured patients that may benefit from advanced medical intervention. For example of the first 215 patients entered into TARN during the seven month period, 32 had an ISS>15. There were 14 casualties identified as trapped following traffic incidents, with an average on scene time of 42 minutes. On arrival at hospital, 12 patients had a recorded GCS of 12 or less. During the previous 17 months the immediate care scheme doctors performed 9 drug assisted intubations. The implications of this potential workload on training and skill retention are discussed, together with the ongoing audit support of the scheme.”
029 INCIDENCE AND PREDICTIVE FACTORS OF POST-TRAUMATIC STRESS DISORDER, DEPRESSION, AND ANXIETY IN EMERGENCY AMBULANCE PERSONNEL
Y. LaFlamme-Williams, M. Woollard, P. Bennett, N. Page, K. Hood.Pre-hospital Emergency Research Unit, Welsh Ambulance Services NHS Trust/University of Wales College of Medicine, Pre-hospital Emergency Research Unit, Finance Building, Lansdowne Hospital, Sanatorium Road, Cardiff CF11 8PL, UK
Introduction: This first large-scale study in emergency ambulance staff measured the incidence of PTSD, anxiety, and depression and their associations with work and incident related factors, basic demographic variables, and personality traits.
Methods: Anonymised questionnaires were sent to all 1,029 EMTs and Paramedics in a single UK ambulance service. A reminder was sent three weeks later.
Those staff reporting intrusive work related memories (present or past) persisting for 1 month or more completed the Posttraumatic Diagnostic Scale; Hospital Anxiety and Depression Scale; Positive and Negative Affect Scale; and an adapted Ambulance Work Stressors Questionnaire. All participants were asked to describe their job type, gender and years in post.
Results: A 60% (n = 617) response rate was achieved. The prevalence rate for diagnosable PTSD was 22% (95% CI 19–26%), comparable with other similar populations. Clinical levels of depression and anxiety were present in 9% and 22% of respondents respectively. Women showed lower PTSD prevalence rates than men (15 versus 23%), but there were no gender differences for anxiety and depression. Surprisingly, the intrinsic factors associated with emergency work were not strongly correlated with stress. However, significant correlations were found between PTSD and organisational stress and trait negative affect (P⩽0.001). Length of service, background organisational stress (P<0.01) and trait negative affect (P<0.001) were also predictive of anxiety and depression.
Limitations: A higher questionnaire response rate would have increased the reliability of our findings. The relatively small number of women participating in the trial suggests that the apparent gender difference in PTSD incidence between should be interpreted with caution.
Conclusion and recommendations: Background organisational stress and, particularly, trait negative affect were found to be predictors of both PTSD and anxiety and depression in ambulance staff. Research is required to evaluate interventions that may reduce the troubling incidence of these illnesses.
030 PROTECTING AMBULANCE STAFF: AN EVALUATION OF A TRAINING COURSE IN THE PREVENTION AND MANAGEMENT OF VIOLENCE AND AGGRESSION
G. Smart.Avon Ambulance Service NHS Trust, 12, Chesterfield Road, Downend, Bristol BS16 5RQ, UK
Objective: These are violent times; as we enter the 21st century comprehensive studies have shown that violence towards ambulance staff, previously considered neutrals even on the field of battle, is widespread and increasing. In reaction to this, many ambulance services have introduced training in the management of violence and aggression. Against this background, this study presents an evaluation of the real effectiveness of a 2-day course in the prevention and management of aggression and violence for emergency ambulance personnel.
Methods: This enquiry has used a case study approach; making use of multiple sources of data collection to obtain substantially qualitative data. Set within a cross sectional design, a combination of individual interviews, focus group interviews and service documents were used, in combination with the existing literature, to investigate the impact and real effects of the training. Participants in the study included ambulance staff, course designers and managers; the main focus being on emergency ambulance staff prior to the training, immediately post-training and within a three month follow-up group.
Results: Results are discussed and include reduced incidence of assault and reported improvements in knowledge, understanding and confidence; resulting in improvements to individual practice when approaching and managing violent incidents. Of concern is the reported lack of retention of the physical skills associated with breakaway techniques, although staff felt they retained a knowledge of what was ‘acceptable’ in self-defence. Ambulance staffs experience of violence is also discussed along with their perceptions of the reasons for widespread under-reporting of violent incidents.
Conclusion: Training for ambulance staff dealing with potentially violent people is frequently advocated, increasingly implemented, but rarely if ever evaluated. Their experience and accounts of violence both pre and post training is disturbing. This study shows ambulance staffs’ perception and experience of a 2-day course. Results in most areas show positive and significant improvements have been engendered.
031 A REVIEW OF THE FINDINGS FROM AN ONGOING AUDIT DESIGNED TO EXAMINE AND EVALUATE THE NATURE AND EXTENT OF CALLS TRANSFERRED TO NHS DIRECT (AVON, GLOUCESTERSHIRE AND WILTSHIRE) FROM AVON AMBULANCE SERVICE NHS TRUST
C. Johnson, C. Cook.NHS Direct (Avon, Gloucestershire and Wiltshire) & Avon Ambulance, Acuma House, Axis 4/5, Woodlands, Almonsbury, Bristol BS32 4JT, UK
Objective: To examine data collected during 2002 from Category ‘C’ (non-life threatening) calls passed to NHS Direct.
Introduction: Over the past 10 years the number of emergency incidents resulting in ambulance journeys has increased by over 60%.
NHS Ambulance Trusts’ were encouraged to set up pilot studies looking at alternative responses to minor Category C calls.
Methods: A working group of Avon Ambulance and NHS Direct staff determined the ‘Advanced Medical Priority Dispatch System’ (AMPDS) Codes that would be chosen for transfer to NHS Direct within the predetermined Category C range. Category C calls were transferred to NHS Direct (Avon, Gloucester and Wiltshire) from Avon Ambulance from November 2001. Monthly audit implementation identifyed all CategoryC calls received by NHS Direct.
The process: Callers phoning 999, with recognised Category C codes are passed to NHS Direct for further assessment by a registered nurse.
Results: The report gives a monthly breakdown of calls taken during the year. The dispositions of all calls are displayed together with a breakdown of the most frequent dispositions used for Category C calls. Calls returned to Avon ambulance are shown, each having been subject to monthly reviews.
Summary: From the 393 calls that were taken by NHS Direct from Avon Ambulance during the year:
61 calls were advised to contact their GP for an appointment within 4 hours
33 callers were given advice to manage their condition at home.
All calls requiring transfer back to Emergency Medical Dispatch Centre (EMDC) were reviewed regularly and learning outcomes cascaded to all call taking staff.
Conclusions: Category C calls taken in the first year has been small but the process manageable.
Any call problems have been reviewed and lessons learnt.
Issues of safety have been an on-going priority.
The Organisational Review in April 2003, called on NHS Direct sites to take low priority ambulance calls.
032 SPEED HUMP RESEARCH AND EMERGENCY AMBULANCE RESPONSES
M. Belchamber.London Ambulance Service NHS Trust, London, UK
A study of paramedics’ attitudes to the effects of speed humps on resuscitation of patients en route to hospital, including general patient care and ambulance response times. Thank you for your interest in my research, which was undertaken in 2002 to May 2003. It concerns the way that Paramedics actually think about and respond to the presence of speed humps - and involved Paramedics from many southern ambulance services (although I know that many respondents worked in London). This research was disseminated in June 2003 in Harrogate at Ambex 2003. It has also been submitted in evidence at a meeting with the Greater London Authority in December 2003. The Microsoft PowerPoint presentation from Ambex 2003 can be downloaded from http://www.belchamber.org/speedhumps/SpeedHumpsAmbex03.ppt or you can view it online http://www.belchamber.org/speedhumps/presentation/index.htm. If you want a copy of the full research document in Microsoft Word (85 pages) you can find it http://www.belchamber.org/speedhumps/ResearchProject.doc. Clearly this is a highly emotive and controversial subject but there is almost no research in the way that Paramedics are affected in their day to day job by speed humps. Hopefully I have begun to address this with this study which needs to be built upon and expanded!