From the ambulance to the emergency department
Little is known about paramedics who have left the ambulance service to work in specialist or advanced roles within emergency departments (EDs). This qualitative study explored the lived experiences of such paramedics focusing on role transition, influences on effective clinical practice and perceptions of role optimisation. Three emergency care practitioners (ECPs), three student ECPs and two advanced clinical practitioners—all HCPC-registered paramedics—were recruited to the study and interviewed. Role transition to the ED involves significant adjustment to a new clinical environment, responsibilities and decision-making. Prehospital history-taking and physical assessment skills, along with experience of autonomous working were voiced as pertinent enablers of effective ED practice. The paramedics felt supported in their roles and spoke positively about future role expansion into areas such as the resuscitation bay and paediatrics. Difficulties in accessing medication emerged as a significant barrier to daily practice that could affect the patient experience and influenced perceptions of sub-optimal working. Some participants also reported confusion among their ED colleagues regarding paramedic competencies which could make inter-professional working difficult. Independent prescribing for advanced paramedics will address some of these issues, but interim improvements are required to extend existing local arrangements for the supply of medicines by ED staff to include paramedics, improving the quality and safety of care they provide and, ultimately, the patient experience.
Double-sequential defibrillation during cardiac arrest
Cardiac arrests associated with shockable rhythms are associated with improved outcomes from cardiac arrest; however, the more defibrillation attempts required, the lower the survival. Double-sequential defibrillation (DSD) has been used for refractory ventricular fibrillation (VF)/pulseless ventricular tachycardia (pVT) cardiac arrest despite limited evidence examining this practice. This systematic review summarised the evidence related to the use of DSD during cardiac arrest.
The predefined outcomes of interest were termination of VF/pVT (important), return of spontaneous circulation (important), survival-to-hospital admission (important), survival and/or good neurological outcome at hospital discharge, >30 days (critical). Nine studies were included in the final analysis including four cohort studies, three case series, one case-control study and one prospective pilot clinical trial. All studies were considered to have serious or critical risk of bias, which meant that the authors of this paper could not perform a meta-analysis. Overall, the authors found no differences in any of the key measures between DSD and a standard defibrillation strategy.
Although the authors concluded that the use of DSD was not associated with improved outcomes from out-of-hospital cardiac arrest, they did note the limitations of the current literature and the need for further high-quality evidence.
Evaluating respiratory rate measurament periods
In prehospital care, the respiratory rate is often measured over periods shorter than 1 minute and then multiplied to produce a rate per minute. Until now, there has been little evidence of the accuracy of this practice, especially in the presence of abnormal respiratory rates or patterns. This prospective, single-centre observational study aimed to compare performance of respiratory rates calculated between 15 and 30 seconds of observations with measurements over the full minute.
During the study, 770 respiratory rates were recorded on 321 patients while they were in the hospital. The bias (limits of agreement) between the rate derived from 15 seconds of observations and the full minute was −1.22 breaths per minute (bpm) (−7.16 to 4.72 bpm), and between the rate derived from 30 seconds and the full minute was −0.46 bpm (–3.89 to 2.97 bpm). Rates observed over 1 minute that scored 3 National Early Warning Score (NEWS) points were not identified by half the rates derived from 15 seconds and a quarter of the rates derived from 30 seconds.
This study suggests that abnormal respiratory rates are more reliably detected with measurements made over a full minute, and that ‘short-cuts’ often fail to identify sick patients.