Volume 4 Issue 4

Senior Paramedic role at North West Ambulance Service

BackgroundThe service made its vision clear to implement a clinical leadership and supervision structure, some years ago. This process began with the introduction of a consultant paramedic and a team of 36 advanced paramedics. Their role was to focus on clinical care, quality and safety and to provide support and supervision to all frontline clinicians. The trust then developed the model further by conducting a review of clinical band six roles occupied by 256 staff members with a variety of titles; emergency care practitioner, operations supervisor, assistant operations service manager, clinical trainer, team leader and clinical practice supervisor.Research for the review included three methods to scope out the work carried out by band six staff in addition to their ambulance response duties: Line managers were asked to set out the duties of the supervisory and trainer grades;A focus group took place which identifed the actual work carried out;Every band six member of staff was given the opportunity to complete an online questionnaire.The findings of the review raised questions about how effectively these roles were being carried out due to the many aspects required of staff, some with a greater clinical bias and some with a greater bias towards logistical functions.Other conclusions drawn from the review included the lack of strength and status to supervise operational staff groups 24 hours a day seven days a week, across a large geographical footprint, alongside meeting performance targets and keeping up with essential requirements such as infection prevention and control.Feedback from face-to-face staff sessions clearly identifed the need for local supervision. A system where staff could identify a local leader and have access to them in their daily work was needed. The trust’s human resources strategy also set out the ethos for team working in well defned staff groups with identifed leaders.

Raising educational standards for the paramedic profession

Making the case for raising the educational qualification for entry to the paramedic professionThe traditional entry routeThe first concerted attempt at regulation of ambulance service training was prompted by the Millar Report of 1966/67 (Ministry of Health, 1996) but it was not until the middle of the 1980s that the Department of Health (DH) requested that the then NHS training directorate develop a training package for the introduction of paramedics into the ambulance service (Kilner, 2004). In 1996 a company by the name of Edexcel was formed and in 1998 it acquired the Institute of Health Care and Development (IHCD). For the best part of a decade, the IHCD was the primary provider for paramedic training in the UK (Edexcel, 2010). Now operating as Pearson Work Based Learning, the paramedic curriculum offered by the IHCD continues to focus on a task-orientated skills approach.Vocational LimitationsAs a high percentage of the UK’s current paramedics have qualified through a vocational route, it is easy to adopt a nostalgic view of this approach to training. Many paramedics will have refected, with varying degrees of affection, on their own experiences in gaining entry onto the Health Professions Council (HPC) register, via this route. However, as reported by Morrow et al, 2011), the inadequacies of this vocational approach to paramedic training were highlighted by the HPC validation of IHCD courses and by recent research on professionalisation (Morrow et al, 2011). As the paramedics, and the ambulance services in particular, continue to evolve from the traditional model of a transport organisation to the concept of a mobile healthcare provider, paramedics are now required to develop a skill and mind set supporting a different method of work.This was initially identified by the Director of UK ambulance services, Peter Bradley, in his now landmark strategic review of the ambulance service in England in 2004, which formed the basis of the DH report Taking Healthcare to the Patient: Transforming NHS Ambulance Services (DH, 2005). No longer was paramedic training to be the sole domain of the ambulance service (under the verification of the IHCD), and the DH also recommended that: ‘Ambulance clinicians should be equipped with a greater range of competencies that enable them to assess, treat, refer, or discharge an increasing number of patients and meet quality requirements for urgent care’ (DH, 2005).Why raise the standard of entry?There has been a fundamental shift in the paramedic skill set now required by changing service demands, increased expectations from the general public and the needs of the health economy in general. It is therefore difficult to see how the vocational approach to paramedic training, which does not emphasise the underlying cognitive elements of practice, nor the attitudes and values to support the new care paradigm, can continue to be ft for purpose.Despite the need for paramedics to become more critically enquiring and acquire a greater spectrum of skills, HPC Standards of Education and Training still regards paramedics as the only allied health profession requiring a registration threshold entry at ‘equivalent to a certificate of higher education’ (HPC, 2009), equating to a level 4 academic award. The College understands that the HPC places more emphasis on the criteria set out in its Standards of Education and Training (HPC, 2009) and Standards of Proficiency (HPC, 2007) than academic levels, but this has resulted in a perverse incentive for some training providers to design and offer courses at a minimal standard, almost mirroring the previous vocational pathway and providing a perpetual alternative entry route into the paramedic profession, effectively creating a ‘two-tier’ competence system.The case for hgher educationThe promotion of public sector higher education (HE) is not new, as the Dearing Report of 1997 advocated active partnerships between HE and industry, commerce and public service (HMSO, 1997). Both the DH and the College of Paramedics have acknowledged the need for HE as a way of to underpinning safe practice (DH, 2005). The concept of paramedics having a broader range of clinical skills was also reinforced by the DH in 2008 where the High Quality Care For All report submitted by Lord Darzi called for a change in focus in the NHS from building capacity to an emphasis on quality of care (DH, 2008). The current government recently proposed new criteria for assessing the quality and performance of ambulance trusts and introduced, for the first time, indicators to look at the actual clinical care given to patients, not simply operational response times (DH, 2010a).A paramedic’s clinical knowledge needs to be more detailed than ever before and with this, enhanced clinical reasoning skills can develop. More informed decision-making abilities allow for appropriate identification of alternative care pathways, affording patients more effective treatment. A wider use of autonomous pharmacological interventions can be supported and though independent prescribing remains a more distant development, it should be recognized that such developments rely on clinicians able to function as autonomous evidence-based practitioners at degree or postgraduate level (Donaghy, 2008). In addition, HE educated paramedics are in a far stronger position to contribute to more generic ideals of health promotion, and, on an individual level, have a greater array of development opportunities available post registration.The College of paramedics influence on professional standardsEarlier this year, the College of Paramedics launched its new HE approvals process (which I am privileged to have been asked to lead). Any HE institution wishing to have its paramedic science course approved will need to satisfy robust criteria for quality. Central to this is the core principle that any course which is designed at a lower academic level than HE Diploma (level 5) will not be approved, as recommended by the College’s Curriculum Guidance and Competency Framework (2008).The reality is that despite the few education providers at level 4, the majority of UK paramedics now graduate from HE programmes at levels 5 or 6 (diploma or degree) despite the minimum standard (level 4) accepted by the HPC, a trend for some years, and confirmed by the recent College of Paramedics and Centre for Workforce Intelligence (CfWI) findings. There are currently 25 universities in the UK offering 46 paramedic science programmes at level 5 , and nine offering programmes at level 6. There are eight training providers producing registrants at the HPC minimum, though these are reducing in favour of the HE route, and almost all these providers are ambulance trusts developing existing technicians staff, an important point, as there should be a pathway for current ambulance technicians to a paramedic level, but it must be through a conversion pathway to a HE qualification.ConclusionsA move away from the traditional vocational approach to paramedic training currently offered by the IHCD is both logical and necessary, but it must be accompanied by a more holistic development of a student paramedic’s clinical knowledge and skills. It must also be done with the benefit of learning from the nursing profession’s experience, where a similar move away from a skills-based approach attracted some criticism (Grundy, 2001). That cautionary note accepted, with greater involvement of HEs prompting change in focus from ‘training’ to ‘educating’ paramedic students, raising the entry threshold into the profession to diploma level is the natural progression in the development of a comparatively young profession.It is incumbent on the College of Paramedics to exert a professional influence on the quality of this process. While the College recognizes that such influence can generate anxiety amongst some of those affected by raising the minimum standard, we are passionate about driving forward the standards that will underpin the move to diploma level entry into the profession as a positive step to underpin further academic progression in the future.

‘Hands-off’ during handover!

Spotlight on Research is edited by Julia Williams, Principal Lecturer, Paramedic Science, University of Hertfordshire, HatfIeld, Hertfordshire UK. To fnd out how you can contribute tfutureissues, please email her at j.williams@herts.ac.uk (to avoid disappointment or duplication we recommend an initial email before beginning any writing).

Qualitative interview study of clinicians’ opinions of which intubation aids to use following a CBRN incident

Aim: to ascertain what intubation aids clinicians believed should be consideredfor further evaluation for use while wearing CBRN-PPEIntroduction: Intubation remains a key treatment option for the managementof casualties with respiratory failure following a chemical biological radiationnuclear (CBRN) incident. However, CBRN personnel protective equipment (CBRN-PPE) adversely affects intubation performance. To date, only the IntubatingLaryngeal Mask airway has been evaluated as an intubation aid for use whilewearing CBRN-PPE within a randomized control study.Methods: This is a qualitative, interview based study involving 25 clinicians fromvarious backgrounds. All interviewees had previously been involved in a numberof manikin based CBRN-PPE research studies involving airway managementincluding intubation.Results: Five different intubation aids were identified by the interviewees, including the gum elastic bougie, Airtraq™, stylet, Intubating Laryngeal MaskAirway and the McCoy laryngoscope as well as non intubation aids such aspractising intubation techniques while wearing CBRN-PPE, training with regardsto optimal techniques for intubation/airway management while wearing CBRN-PPE, correct/optimal patient position as well as the availability of a skilledassistant.Conclusion: This interviewed opinion based study involving UK clinicianswith experience of performing intubation and other related resuscitationtechniques while wearing CBRN-PPE has identified a number of intubation aidsthat clinicians believe may assist with intubation performance by potentiallyimproving speed and/or intubation success within the CBRN environment.However, the loss of fine motor movement and tactile sensation has beenidentified as a possible limitation of the devices and therefore these intubationaids warrant further evaluation. The role of training in skill performance andsimulation based practise, while wearing CBRN-PPE, also requires furtherinvestigation.

Guideline alert: British thoracic society emergency oxygen use in adult patients

In 2008 the British Thoracic Society produced the first guideline on the emergency use of oxygen. The main focus of the guideline is attempting to debunk the myth that where oxygen is concerned ‘more is better’ introducing the concept of target oxygen saturations, with target saturations of 94–98 % being recommended for most patients and 88–92 % in those at risk of type 2 respiratory failure. The guideline acknowledges that high concentration oxygen is likely to be beneficial in critical illness and cardiopulmonary resuscitation. The aim of this article is to draw further attention to this guideline in the hope that compliance with its recommendations can be further improved.

Pre-hospital improvised bronchodilator therapy of a patient on bi-level positive airway pressure therapy

Patients suffering acute breathlessness is a common emergency situation, many patients with airways disease require bronchodilator therapy with (3-agonists. To assist the management of these cases paramedics use guidelines drawn up by the Joint Royal Colleges Ambulance Liaison Committee (JRCALC). They provide guidance on the management of most situations paramedics are likely to encounter. However, there will be occasions when paramedics are called to deal with a situation which is outside of their experience and the JRCALC guidelines do not provide the appropriate guidance required to fully inform clinical decision making. In the UK telephone support from a physician skilled in the specific discipline they require is generally not available, so paramedics have become skilled at improvising. This case study describes such an improvisation, in the management of acute breathlessness in a patient who is on home bi-level positive airway pressure (BiPAP) therapy.

Wound ballistics: exploring the wounding potential of penetrating projectile injury

Within the civilian pre-hospital environment, penetrating projectile injury may be caused by an extremely broad range of firearms and explosive propellants. Despite a great variance in the potential for injury however, a basic knowledge of how penetrating projectiles behave and interact with living tissues is likely to assist emergency healthcare professionals with making informed decisions, as well as establishing priorities for treatment and transportation. Amoung such important considerations is the transference of kinetic energy from a projectile to the tissues, itself influenced by factors such as the area of presentation, deformation, fragmentation, mass and velocity. Projectile retardation, along with correlating levels of energy transference, will also be influenced by the density of the affected tissues, and the permanent disruption caused by the stretching and shearing forces of temporary cavitation will be largely dictated by the elastic tolerance of the tissues and their capacity to expand. The presence and location of entrance and exit wounds, if they exist, can offer some clue to the nature of the projectile/tissue interaction, though caution is required when interpreting such signs. Focussing upon the civilian pre-hospital environment, this article will seek to highlight some of the key features of wound ballistics, and explore some of the misconceptions that can exist concerning the impoprtance of projectile velocity, as well as the dangers of drawing potentially erroneous clinical conclusions based solely upon the nature of the firearm involved, or visible signs of injury.

They think it’s all over-managing post cardiac arrest syndrome

Return of spontaneous circulation (ROSC) is the first stage in the successful management of the cardiac arrest patient. The care that the patient receives during the immediate post-ROSC period, has a major impact on subsequent survival from out of hospital cardiac arrest (OHCA), particularly in terms of surviving to hospital discharge neurologically intact. For the first time, the 2010 Resuscitation Council (UK) (Nolan, 2010) guidelines incorporates a section specifically relating to the mangement of OHCA.This review will outline the guidance from the Resuscitation Council (UK) and the International Liaison Committee On Resuscitation (ILCOR) on the management of post cardiac arrest syndrome (PCAS) and how this can be practically implemented in the pre-hospital environment. interventions directly applicable to the pre-hospital phase until handover at the emergency department (ED) will be considered. In addition, specific guidance relating to the management of the ROSC patient in the pre-hospital phase of their care will be provided.

Policymakers to prevent Europe from suffocating

Workshop 1: Prevention and diagnosis of COPDThe first workshop was hosted by Sean Kelly MEP (Member of European Parliament) and supported by MEPs Eva-Britt Svensson, Catherine Stihler and Francoise Grossetête. Professor Ronald Dahl, former President of the European Respiratory Society, informed participants of the medical impact of COPD and the available treatment options available. Depending on the severity of the disease, the international GOLD (Global Initiative for Chronic Obstructive Lung Disease) guidelines suggest cumulative measures such as the ‘exclusion of risk factors such as smoking’ and vaccination against influenza, pharmacological treatment, rehabilitation, long-term oxygen and transplantation (GOLD, 2010). Generally, earlier diagnosis of the disease reduces costly treatments and can improve the quality of life for the patient. For instance, participant Michael Wilken, a COPD patient and in dependent coach and management consultant from Hannover, Germany, was diagnosed with COPD in 2004, developing the first symptoms of the disease more than 10 years before his diagnosis. Wilkin’s life is severely impacted by the disease, as he cannot walk fast, use stairs, or walk for more than 100 m if the temperature is below 5 degrees Celsius.Monica Fletcher, Chair of the European Lung Foundation, highlighted the severe repercussions of COPD for the patient’s family, their working environment and society overall. Addressing the myth that COPD only affected elderly men of a low socioeconomic status, she noted that equal numbers of women are now being diagnosed due to an increasing prevalence of the disease in female smokers. In fact, COPD affects just as many people between 40 – 65 years old, an age group that is otherwise at the peak of its economic and social productivity. COPD severely hampers this productivity—quantifable as €32.8 billion work days lost across Europe, it is even more alarming therefore, that so many patients live in complete ignorance of their condition. In England, for example, 900 000 people are known to have COPD but the estimated prevalence is 3.7 million, implying more than 75% remain undiagnosed (Shahab, 2006).‘In England, for example, 900,000 people are known to have COPD but the estimated prevalence is 3.7 million, implying more than 75% remain undiagnosed’Smoking cessation was identified as the most effective treatment in many patients and the best means for prevention of COPD prevalence within society. However, regret was expressed by participants that smoking cessation programmes remained inadequately supported along with the absence of support and reimbursement for healthcare professionals who had helped smokers fight their addiction. Ronald Slootweg, Director of Health Services of Dow Benelux, illustrated his company’s efforts to prevent smoking prevalence within its workforce. Among the measures suggested by the company was the implementation of a non-tobacco day in all of its plants around the world, and rewards for employees who refrained from smoking. Furthermore, as of 1 January 2010, the Dow’s Dutch factory is smoke-free, meaning that employees are required to leave the plant’s site if they wish to smoke. In addition, participants specifically recommended mentioning COPD as a fatal and debilitating condition directly linked to tobacco smoke as one possible means for increasing public awareness. Low diagnosis of COPD has also been linked to general practitioners, who can misdiagnose a COPD patient with asthma or other respiratory conditions.

Cup of tea and a chat? Get the kettle on…

Do you remember a time when after a ‘bad’ job control would return you to base to ‘re-stock’, have a cup of tea, and give you and your crew mate the opportunity to chat. Academic research has indicated that emergency workers have an increased risk of experiencing psychologically traumatic situations due to their profession, and that peer support following a traumatic call (and socialization into the role through our training and our culture) provides a ‘protective-like’ mechanism against chronic stress and/or stressful symptoms such as re-experiencing the incident through ‘fashbacks’, nightmares, and intense distress (Regher and Bober, 2005). Though occupational stress exposure has been found to be beneficial in enhancing wellbeing of ambulance staff, building up a level of resilience to stress via professional socialization, social support from peers, humour, and other personal factors, has been proven to enhance ambulance workers emotional and psychological mental state (Regehr and Millar, 2007; Alexander and Klein, 2001).

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