Volume 7 Issue 2

Continuing Professional Development: Paracetamol overdose

This Continuing Professional Development (CPD) module considers paracetamol overdose—both accidental and deliberate—in the pre-hospital setting, and presents an update on current practices that paramedics need to be conversant with in responding to what is a dangerous and potentially fatal situation.

The perceived concerns of newly qualified paramedics commencing their careers: a pilot study

Objective:To identify the perceived concerns of newly qualified paramedics commencing their careers and how they may be subsequently supported both in university and practice.Methods:A pilot study using a focus group approach to collect qualitative data from a selection of newly qualified paramedics regarding their perceived concerns when first becoming clinical lead. Transcripts were analysed and themes generated.Results:Four paramedics attended the session. Themes emerged around confidence, defensive practice and theory to practice application. Confidence appeared to be a key topic and linked into all the other themes.Conclusions:Newly qualified paramedics have the clinical knowledge and application but lack confidence in their own abilities due to lack of exposure and experience. They rely on support given to them by colleagues, peers and preceptors in the early stage of their careers.

Falls assessment and prevention in older people: an evaluation of the Crisis Response Service

The elderly population of the world is growing, with increasing trends of older people falling and accessing emergency services. The Crisis Response Falls Service in Northamptonshire (UK) was designed to identify health and social care needs, promote independence and limit the impact of falls. This paper presents the findings of an evaluation of the service. A mixed-method approach was applied, drawing on the views of service users (via a survey and telephone interviews) and reviewing existing East Midlands Ambulance Service NHS Trust (EMAS) data with routinely collected data from the service.A decrease in the numbers of patients conveyed to hospital following a fall was observed. Best estimates of financial calculations suggest savings. High levels of patient satisfaction were achieved; patients felt treated with dignity and staff were considered friendly, approachable and well-informed. First responder services can provide positive impacts for those who fall in the community. The development and impact of the CRS shows the importance of evidence-based client centred training to inform the approaches taken to supporting those who fall, and the impact of a strong values based approach on the experiences of patients.

The decision is yours

The paramedic role requires countless sound, logical and sensible decisions to be made. Sometimes paramedics may be faced with decisions that they feel less confident about making. This paper will discuss the types of clinical decision-making approaches. The majority of everyday decisions are made intuitively. The brain uses its experience to match decisions that it has made, observed or contributed. This may not be a reliable method of decision making, especially if you have been unable to gather sufficient information. Pattern recognition is a skill-based activity. Unlike intuition, which can support near-instant decision making, it is done when time permits and there is no need to rush. Under the hypothetico-deductive model of clinical decision making, the clinician sorts the clues and findings into logical groups using previous knowledge of symptoms and anatomical locations and landmarks. Then a hypothesis is formulated based on experience and knowledge of pathological, physiological and psychological conditions. Generally, clinicians need to improve their awareness of clinical decision making: using intuition might well have a role to play coupled with heuristics and bias, but it has its limitations and risks. However, hypothetico-deductive reasoning has a prominent place and should be embedded into education and everyday use.

The NHS oil tanker: heading towards a new horizon for urgent and emergency care

Paramedics have a key role to play in reducing current pressures on NHS services and providing patients with better care within a more sustainable NHS system. Hilary Pillin looks at some of the current transformations in urgent and emergency care delivery and illustrates how these new initiatives highlight a slowly changing culture in the NHS.

Dwindling staff numbers leads to healthcare rationing at its lowest form

The introduction of a policy by the East of England Ambulance Service NHS Trust to downgrade 999 calls and not send paramedics to terminally ill patients has led to allegations of unacceptable patient care. Ian Peate argues that a review of paramedic staffing levels is urgently needed to help identify paramedic staff requirements in order to achieve patient safety outcomes.

Book Review

Achieving High Quality Care: Practical Experience from NICEIt is about this time of year that any New Year's resolutions are firmly relegated to the ‘must try harder’ list or ‘better luck next year’ category. I would suggest, however, that the importance of achieving high-quality care is an annual inclusion on any clinician's list of priorities.The twin bed fellows of evidence-based medicine and high-quality patient care are unlikely to command any literary niche, but what gives this book a particular ‘angle’ is that it offers practical guidance for the delivery of both. As well as touting the sterling role played by the National Institute for Health and Care Excellence (NICE) in all of this, a number of case studies are presented which outline the steps involved. Not specific to paramedic practice, but many of the principles are transferable nonetheless. And while not of any great depth, the examples from practice are well chosen and provide some perspective on the theory.As with any balanced publication, the authors have identified some challenges in achieving quality improvement. Perhaps I am being a little harsh here but I didn't consider this to be particularly insightful, citing, among other things, a lack of money and other resources as key barriers to overcome. It is still too process-orientated for me, whereas I would like to have read a bit more about cultural issues and nail down further the very raison d'être for us doing what we do. Maybe a touch fanciful given the current age of austerity we currently find ourselves in?‘This couldn't be a more timely publication’All in all, though, this couldn't be a more timely publication. As we creep ever closer to a general election (I'm not standing) and the health care system undoubtedly resumes its customary metaphorical position of a round leather thing kicked between politicians of all parties, allow me to quote directly from the text: ‘Our patients need and deserve the best care.’Now that's one resolution we should all be keeping.

Spotlight on Research

Hip hip hooray! Transferable methods in hip pain managementUsing a qualitative research approach involving Flanagan's Critical Incident Technique (Flanagan, 1954), this paper reports on ambulance staff's experiences of managing pain in people with a suspected hip fracture. Notably the study was undertaken in Sweden where an ambulance crew comprises a pre-hospital emergency care nurse and an emergency medical technician (EMT), both of whom have to recertify every other year.Despite the differences in health care system, there appear to be some transferable elements in the findings, which should be of interest to UK paramedics, as treating elderly people who have sustained a hip fracture as a result of falling is a regular phenomenon.In total, 22 people participated (18 pre-hospital emergency care nurses, 4 EMTs) in individual, face-to-face interviews. Eligibility criteria included having worked for more than three years in the ambulance service, and participants must have had experience of managing patients with suspected hip fracture.During the interview, participants had to reflect on previous incidents where they were involved in the care and management of these patients and, in line with the approach used in Flanagan's Critical Incident Technique, they were required to discuss both the strengths and limitations of what happened during these encounters, in this case with a particular focus on management of the patients' pain.Although the introductory phase of the interviews was not recorded (presumably to help relax the participant), audio recording was undertaken from the point where the aim of the study was explained to the ambulance staff.Interviews were transcribed verbatim and data analysis was conducted using a variant of qualitative content analysis. In total, 51 incidents emerged from the 22 interviews.The authors give a good account of processes involved in their analysis, illustrating how they moved from a coding stage, through to the development of five sub-categories and, finally, to the identification of the following two main categories: i) care based on the individual patient's needs; ii) empowering the patient.‘Care based on the individual patient's needs’ reflects how ambulance staff, through clinical reasoning, tailored the management of pain relief to each individual patient and, perhaps unsurprisingly, this involved the following three sub-categories: ‘strategies of selecting pharmacological analgesia’, ‘strategies when moving the injured patient’, and, ‘choice of positioning of the patient on the stretcher’.There were many similarities to UK practice identified in these sub-categories, although the choice and available selection of analgesic agents reveals some differences. However, principles of pain assessment, management and consideration of the patients' needs during transportation appear to be similar between the two health care systems.The second main category that emerged in this study—‘empowering the patient’—included two sub-categories: ‘create conditions for patient participation’, and, ‘adaptation to the patient’. The first sub-category focuses on effective communication, emphasising the importance of keeping the patient informed as to what was happening and why, and engaging them in decisions around pain management, movement and positioning.‘Adaptation to the patient’ happened in different ways. In some cases it centred on assessment of their non-verbal communication, or listening to the patient's relatives or caregivers if the patient was incapable of verbal communication. Other examples given within this sub-category included giving patients the time they needed either to get maximum benefit from any administered analgesia, or to feel ready and safe to leave home.The authors identify some methodological limitations such as the use of reflection on past events during interviews, as participants may suffer from lack of recall of specific detail. Interestingly they identify that the two interviewers were also pre-hospital emergency care nurses and that this can be seen either as a strength as they had relevant, contextual knowledge about the ambulance service, or a limitation, in that there was the potential that their own experiences could bias their interpretation of the participants' narratives.Overall, the study's findings illustrate that participants attempted to individualise care based on patients' needs but that this was also influenced by the practitioners' own knowledge base and skills. So no different to UK practice in that sense—the main differences emerged in relation to choice of pharmacological interventions, and variations in moving and handling equipment. However, the principle of engagement of the patient, where possible, in decision-making about their care and management, is relevant for all ambulance staff. This study usefully highlights a need for further research to examine the issues and complexities surrounding the concept of patient empowerment within ambulance service settings.

A retrospective observational study to explore the introduction of the National Early Warning Score in NEAS

Background:The National Early Warning Score (NEWS) is a simple, rapid assessment tool compiled from respiratory rate, oxygen saturations, supplemental oxygen, temperature, systolic blood pressure, heart rate and level of consciousness developed by the Royal College of Physicians. NEWS was introduced into practice at North East Ambulance Service NHS Foundation Trust (NEAS) between April 2013 and March 2014. This paper will examine the use of NEWS in pre-hospital practice and seek to describe the patient population in terms of NEWS.Methods:Cross-sectional samples of patient records from NEAS attendances over two 24-hour periods were examined for NEWS usage, completeness of necessary observations and outcomes that may be linked to NEWS. A primary sample from 8 July 2013 included 100% of patients. A secondary sample of 10% of patients was taken from 1 April 2014.Results:Although 90% of all cases may be suitable for NEWS <1% (n=6) of patients attended had NEWS recorded. Of the NEWS elements only temperature was not consistently recorded. 95% of sets of observations included >4 NEWS elements. A consistent pattern emerged when the sample population was described according to NEWS using three methods of accounting for missing items of data. Pre-alerting based on NEWS was examined with little agreement between NEWS and current practice found, although this does not take into account practical reasons for pre-alerting such as underlying condition or local pathways.Conclusions:NEWS is not being documented by ambulance crews although the majority of the necessary elements are being recorded. This largely descriptive account of the use of NEWS within NEAS indicates that NEWS has not been adopted by ambulance crews.

Exercising the right to be heard

Throughout history whistleblowers have been viewed in one of two ways: as honest and brave individuals carrying out their moral responsibility, or as traitors to the organisation and people they work for. However, for health professionals, including paramedics, the act of whistleblowing should be seen as an obligation rather than a choice.

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