111 First—slowing the flow?
Everybody has an opinion on NHS 111, especially those working in ambulance services. Following piloting, the system was formally launched in 2014 to alleviate the burden on emergency departments and ensure patients with urgent care needs accessed the right care. In 2020, 111 First was introduced to triage patients before entry to the emergency department (ED) and offer direct booking for patients needing ED or urgent care into same-day arrival timed slots. 111 First continues to be used but concerns have been raised.
This study used semi-structured telephone interviews to capture the views of staff from EDs and urgent care centres across England. An interview topic guide was developed and piloted to explore the impact of NHS 111 on workloads and arrangements of urgent and emergency care services. Data were collected through single-episode, one-to-one interviews, conducted online or by telephone between October 2020 and July 2021. Purposive sampling was employed to recruit from areas with high need and demand so were likely to be using NHS 111 services, and recruitment continued until the research team agreed that data saturation had been reached.
Twenty-seven participants were recruited (10 nurses, nine doctors and eight administrators/managers) working in ED/urgent care services serving areas with a variety of sociodemographic profiles and high levels of deprivation. Two themes emerged:
Remote preassessment of patients before ED arrival appears attractive but effective use of 111 First will be hindered while ED acuity-based triage systems and staff views on the superiority of clinical acumen and face-to-face triage remain.
Time to tighten up on tourniquet use?
The use of extremity tourniquets (ETs) in UK civilian paramedic practice has been controversial for several years. However, their successful use in the military arena has led to a reappraisal of their potential in civilian practice. Survival benefit has been established in civilian studies and has led to their widespread use. However, with the increased use of ETs comes the risk of improper use and improper placement, both of which could harm the patient.
This American study reports a retrospective review of a prospectively collected cohort of 211 adult patients who underwent prehospital placement of an ET over a 3½–year period. Data were collected before and after arrival at hospital, and analysed to assess adherence to the tourniquet protocols in place at the time, and to compare the application by different types of responder.
When actually documented, 161 (76.3%) of ETs were of the combat application tourniquet style with the remaining being either not documented or non-commercial tourniquets, such as shirts, towels or belts. The majority were placed by emergency medical services (EMS) staff, with 67 placed before EMS arrival by police, and 22 by lay people or other medical personnel.
Encouragingly, 97.3% of tourniquets were placed above the location of the injury; only five patients presented with one placed below or at the site of injury, one by EMS and four by police.
Assessment of appropriate need for tourniquet revealed that only 75 (35.6%) patients had an appropriate indication for tourniquet placement. Of those who arrived at hospital with a tourniquet in situ, 59 (35.8%) still had palpable distal pulses and one-third had well-perfused extremities along with present distal pulses.
Most patients (92.8%) had bleeding controlled at arrival to the emergency department but fewer than half had arterial bleeding described by the emergency department providers when the tourniquet was released. Only 77 (36.8%) had undergone packing before ET placement. This study shows that there are still training needs around the use of tourniquets.