The effect of a heart failure training intervention assessed via clinical simulation

Prehospital differential diagnosis of heart failure (HF) by paramedics is sometimes unreliable (Schaider et al, 1995) and may lead to therapeutic interventions being withheld (Jenkinson et al, 2008) or the initiation of inappropriate and potentially harmful treatment (Wuerz and Meador, 1992). To date, no studies have evaluated the effect of participation in a HF training intervention on diagnostic accuracy among undergraduate UK paramedics assessed through clinical simulation. In this study, 17 paramedics were exposed to three mannequin based scenarios designed to simulate HF, pneumonia and chronic obstructive pulmonary disease (COPD). Participants were given up to 10 minutes to examine each mannequin and scrutinize clinical data before recording a diagnosis. Participant demographics and self reported confidence relating to assessment and management of HF were collected via a questionnaire. Two weeks later, participants attended a 90 minute targeted HF training intervention. Two weeks post training, the paramedics repeated the clinical simulation exercise and questionnaire. Initial diagnostic sensitivity and specificity for HF were higher than that reported in a previous UK clinical study, and improved following participation in a training intervention, although this failed to reach significance (83% vs 100% and 91.67 vs 100%, P>0.05). A significant improvement in self reported confidence relating to use of ECG findings in assessment of HF patients was noted (z=-2.309, P=0.021). In this study, paramedic differential diagnosis of HF assessed through clinical simulation demonstrated a non-significant trend towards improved sensitivity and specificity following participation in a targeted training intervention.

Book Review

This book provides a refreshing alternative to teaching patient assessment and is effective as a teaching aid due to the dynamic approach adopted by the authors.

Simulation in prehospital care: teaching, testing and fidelity

This article explores imperative issues related to the use of simulation in the education of prehospital care personnel. While the literature shows a growing interest in the effectiveness of the use of simulation in medicine and healthcare (McGaghie, 2010), the authors wished to review those areas especially pertinent to higher education institutions (HEIs) with an emphasis on maximizing learning opportunities and the process of learning in prehospital care programmes. The contention of this article is that the use of simulation can become assessment-driven and may overlook the equally important process issues involved.

Using simulation to enhance safety, quality and education

The practice of simulation continues to grow nationally and globally as one aspect of education among a wide variety of health and social care providers, and paramedics are no exception.

Legislation surrounding the administration of medicines by paramedics

Paramedics routinely administer medicines that are otherwise restricted by law. The aim of this article is to provide an awareness of the legal classification of some of the drugs that you commonly use, provide an overview of the legal framework that allows you to administer medicines to patients, explain the meaning of the ‘marketing authorisation’ (product licence) and highlight the possibility of paramedic prescribing in the future.

Diagnosis and management of minor head injury in the UK

Head injury accounts for a large amount of emergency services work in the UK. We performed a review of current practice in the management of minor head injured patients (GCS 13-15) by way of a survey of UK emergency departments. Nearly all departments (∼95%) reported unrestricted access to computer tomography (CT) scans. Admission rates for minor head injured patients were 18% for adults and 9% for children. From our systematic review, we identified the most accurate clinical decision rule for adults (Canadian CT Head Rule) and children (Pediatric Emergency Care and Research Network) and commented on the applicability of these in the UK population. We also identified the most significant clinical findings that increase the likelihood of intracranial and neurosurgical injury, following minor head injury in adults, children and infants. Finally, we have highlighted where these findings may be relevant to UK paramedic practice, in particular in influencing the decision to transfer patients to the emergency department. This article summarizes the findings of studies undertaken for the National Institute for Health Research (NIHR) Health Technology Assessment (HTA) programme examining the available evidence regarding the diagnostic management of minor head injuries. It will be published in a number of articles and a full report for the HTA programme.

Introducing International Paramedic Practice

Recent developmentsRefective learning logRegular JPP readers will have noticed that we recently introduced a fold-out reflective practice learning log. This allows subscribers to quickly record their learning outcomes gained from reading the issue. It is a simple way to regularly update any CPD portfolio.Bigger issuesStarting in May 2011, JPP increased the size of each issue, allowing us to give readers at least three more articles each month.New international editionSince its launch, JPP's editorial content and approach have attracted considerable interest from overseas. However, although many of our articles can benefit emergency care professionals wherever they practice, the journal as a whole is published specifically with reference to the needs of UK paramedics.To alter the character of the journal to accommodate an international favour makes no sense. Therefore, the JPP team are happy to announce that we shall be launching a new quarterly title, International Paramedic Practice (IPP). IPP will be produced quarterly and online on account of its global reach—www.internationaljpp.comIPP will share the publishing style and quality thresholds of the JPP you are currently reading, but the content will be unique to the new title. The first issue will be available from 5 September 2011. Scheduled content is outlined in Box 1.Box 1.Issue 1 contentsMeet the international editorial board membersManagement of heat emergencies in the military settingMental health legislation: an era of change in paramedic clinical practice and responsibilityResusciation from out-of-hospital cardiac arrest in an under-resourced environmentPrehospital care data for traffic injury prevention: what Pakistani research tells usOrganizational models of prehospital emergency medicineParamedics in prehospital emergency medical systems across EuropeAssessment and treatment of trauma: an international courseInternational conference listingsBespoke editorial boardAs a separate publication to JPP, the international edition benefits from its own editorial board comprising: Guillaume Alinier (UK/Qatar); Stephen Burgess (Australia); Peter O’Meera (Australia); Stew Stancil (USA); Geoff Miller (USA); and Tim Essington (Canada). Their experience and enthusiasm for developing standards and themes that apply to dedicated professionals, whatever their national jurisdiction, will ensure the title is interesting and useful.Free with your JPP renewalIPP will help substantially as an evidence-based resource for UK paramedics. A subscription to IPP will cost US$75. However, the JPP team feel it is right to reward the readers who have supported the UK title through its early years. Therefore, current subscribers to JPP will receive access to IPP for free when they renew their subscription. A subscription may be extended at any stage of its lifecycle.

The safety of referral

The past decade has seen the introduction of emergency care practitioners, critical care paramedics and an assortment of extended skills have been added to ambulance clinicans’ repertoire. These developments have often evolved from a change in government policy and the subsequent drivers that influence the way we deliver our care. The most significant, over recent years, has been the need to treat more patients at home in an attempt to prevent an unnecessary journey to the emergency department (ED). Such a shift in the balance of care means that the traditional ‘default’ position of transportation to the ED is often no longer justifiable. In its place, where patients and circumstances permit, an alternative pathway of care may be offered through referral to other more appropriate services.

A mannequin study comparing suitability of the i-gelTM with a laryngeal mask airway device

Objectives: To compare the suitability of the i-gelTM (Intersurgical Ltd, UK) supraglottic airway device with a single-use laryngeal mask airway (LMA) in the hazardous area response team (HART) environment and the urban search and rescue (USAR) environment. Method: five chemical, biological, radiological and nuclear trained urban search and rescue paramedics attempted five insertions of each supraglottic airway device into a Laerdal® ALS mannequin (Laerdal, Norway) in three separate environments: normal (supine, waist high), HART (wearing gas-tight suits and respirators) and USAR (in a simulated confined space). As a control group, five anaesthetists also attempted five insertions of each supraglottic airway device into a Laerdal® Airway Trainer (Laerdal, Norway) under normal conditions. Time from first touching the device to successful inflation of the mannequin's lungs’ using a self-inflating bag-valve device was recorded and operator opinion was captured using a four-point Likert scale. Results: insertion of the i-gel airway was significantly faster than insertion of the LMA in simulated USAR conditions (P<0.001), there was no significant difference in control conditions or when wearing gas-tight personal protective equipment. There was no difference in the number of attempts required to achieve correct placement of either supraglottic airway device in any situation. Conclusions: this study has demonstrated that, in simulated USAR conditions, the i-gel supraglottic airway device performs at least as well as the LMA and is significantly quicker to insert. The authors therefore recommend that the i-gel is introduced into the USAR HART environment with further clinical evaluation in this and other prehospital settings.

Enhancing the student learning experience through interactive virtual reality simulation

A virtual simulation workshop took place at the University of Hertfordshire (UH) in 2010 as part of a small project funded by the UH Learning and Teaching Institute. The project saw the development and implementation of an innovative virtual simulation package (virtual paramedic scene management software). The project was a joint venture combining teams from the School of Health and Emergency Professions (paramedic science) and the School of Computer Science (real-time 3D team). Learning from simulation is already well established at UH through the Hertfordshire Intensive Care and Emergency Simulation Centre (Alinier, 2007). Together with existing education and training for clinical skills and patient assessment and management, it was envisaged that introducing virtual e-learning might complement those approaches. This brief report serves to share our experience with those who may be considering using virtual reality scenarios as a teaching/learning approach in the future.

Determining the paediatric educational needs of prehospital providers: part 1

Caring for paediatric patients presents unique challenges to prehospital personnel who may have limited training, experience and confidence caring for children. The State of Oregon recently increased its paediatric training requirements for prehospital providers; however, little is known about the specific educational needs, barriers, and preferences of providers in this largely rural state. Objectives: the purpose of this study was to characterize the paediatric educational needs, barriers, and preferences of prehospital providers in Oregon. Methods: this was a qualitative analysis of 9 focus group discussions with a total of 64 prehospital providers from the State of Oregon. An iterative process of theme identification was used to generate themes, and then inter-rater checking was applied to confirm themes and assure inter-rater reliability. Results: participants identified a need for more paediatric training. They described knowledge gaps in assessing medically ill children, working with children with long-term medical conditions, and dealing with issues related to communication and the emotional difficulty of caring for children. Distance and cost were identified as barriers to attaining paediatric education, especially for rural providers. Other barriers included finding time for training and courses that are not designed specifically for the prehospital provider. Providers recommended increasing time spent with children during training by involving local schools and paediatricians. They recommended expanding the courses to include the areas where they felt less comfortable and increasing hands-on training opportunities. Simulation and online training were suggested as effective modalities to augment their trainings. Conclusion: our findings support previous studies that show prehospital providers feel less comfortable providing care to children.The specific barriers that our respondents identified can be related to the demographics of Oregon.To address the needs of prehospital providers in caring for children, we recommend: 1) expanding the curriculum to involve more time with children and an increased emphasis on assessing medically complicated children; 2) take measures to assure that the training is affordable and accessible to providers in different practice settings, and does not require long distance travel to attend; and 3) use online training modules and simulation to bring flexible ‘hands-on’ training to providers.

Prehospital Troponin T testing in patients with suspected acute myocardial infarction

This study set out to examine both the feasibility of point-of-care biomarker testing by paramedics -specifically prehospital Troponin T (TnT), and its diagnostic value in prehospital patients with suspected AMI.

Continuing Professional Development: Ethical issues in paramedic practice

OverviewThis CPD module will focus on some of the key ethical issues in relation to paramedic practice and prehospital care. Currently, few published research or evidence-based texts exist, specifically in relation to prehospital care. There are a numbers of texts in other areas, such as nursing and medicine, but not exclusively in relation to paramedics. This situation will hopefully alter over time, so this module attempts to present the four ethical contexts common in other health disciplines and discuss them in relation to paramedic practice.Learning OutcomesAfter completing this module you will be able:• To provide an overview of the four key ethical principles that underpin current clinical practice in the UK• To explore these four ethical principles in relation to specific prehospital and clinical issues• To encourage the practitioner to reflect on their own ethical practice• To begin to develop the ability to share, discuss and debate the four ethical principles with colleagues and friends, in relation to your own clinical practice

London Ambulance Service: practice education course

Certificate in practice educationThe London Ambulance Service certificate in practice education course is designed to support the mentors by giving them the tools to effectively mentor and support students in practice placements, which includes understanding the role of the practice placement educator, providing feedback and the standards required in completing the practice assessment document.The development of practice educators in other health disciplines is predominantly aimed at developing the registered health professional. It was recognised that there was a wealth of knowledge and expertise with the development of emergency medical technicians (EMTs) and their skills. As a result, this course was developed to include EMTs as well as paramedics, to provide student placement support and mentorship within the scope of their practice and in relation to the students’ developmental needs.Staff wishing to become practice educators must have completed one year post qualification and be supported in their application by their area management team when applying for the course.The certificate in practice education has been designed to attract a higher education credit rating. The University of Greenwich, School of Health and Social Care (credits for learning) offer practice educators who successfully complete the programme, 15 credits at level 5 or 6. The programme consists of three taught modules, totalling 30 hours of study and 120 hours of student placement development. After completing this, practice educators have to submit a specific portfolio that demonstrates their continued professional development. Modules 1 and 2 are taught consecutively and students then consolidate this theory during subsequent student placements.

What factors influence decisions to transfer elderly patients?

This qualitative study, undertaken in Western Australia, explores factors that influence decision-making as to whether to transfer elderly people in residential care homes to the emergency department (ED) for acute medical problems. A total of 33 stakeholders participated in three focus groups: family members (n=5), GPs (n=4), carers (n=7), care-home managers (n=5), nurses working in the care home (n=5); and ED staff (n=7). In addition, semi-structured interviews were carried out with nine residents who had previous experience of being transferred to the ED for an acute medical problem.