Out-of-hospital cardiac arrest is a major cause of morbidity and mortality in the UK (Hawkes et al, 2017). In 2019, ambulance services in England resuscitated 31 024 patients in cardiac arrest. Of those, 30.1% sustained return of spontaneous circulation to hospital and, overall, 9.3% survived to discharge (NHS England, 2020).
Survival following out-of-hospital cardiac arrest depends on a swift ‘chain of survival’ (Nolan et al, 2006), which begins with early cardiopulmonary resuscitation (CPR) and defibrillation. High-quality CPR and early defibrillation are simple skills but remain the most important interventions for these patients (Rainer et al, 1997). Survival rates increase when patients receive early bystander CPR and public access defibrillation (Hawkes et al, 2017).
Many UK ambulance service trusts are supported by volunteer community first responders (CFRs) (Perkins et al, 2016). Often responding to emergencies in their local areas, CFRs initiate life-saving interventions before an ambulance resource arrives. The dispatch of CFRs has been shown to increase the rate of defibrillation and survival to admission (Barry et al, 2019).
The London Ambulance Service NHS Trust (LAS) emergency responder (ER) scheme has similar goals to CFR organisations, but with key differences. This review aims to outline the origins, current operations and future goals of the LAS ER scheme.
Development of the service
Scott Bateman, a Royal Air Force pilot, wanted to explore ways of reducing the time taken for life-saving interventions to reach a patient, having experienced the cardiac arrest of a family member. In 2008, he worked with Chris Hartley-Sharpe, head of first responders at the LAS, to establish an initial 6-month trial of a blue-light volunteer responder scheme in London.
A team of 12 volunteers from the police or armed forces began responding from Hillingdon Ambulance Station to the 999 calls with the most life-threatening presentations. The initial 6-month trial was a resounding success, with shorter response times to these emergencies and excellent feedback from ambulance crews, patients and their families. As a result, the scheme was integrated into the LAS permanently, with training, future development and clinical governance managed by the LAS first responder department.
Over the last 13 years, the scheme has grown in both size and scope, particularly during the London 2012 Olympics and, most recently, the COVID-19 pandemic. The scheme now operates across London with more than 120 volunteers, and a fleet of 12 vehicles based at seven ambulance stations. In 2020, many ERs were upskilled to allow them to work alongside regular LAS colleagues on double-crewed ambulances (DCAs).
Operations
ERs respond in pairs, in marked blue-light vehicles under emergency response driving conditions, differing from most volunteer responder schemes where response is under non-emergency driving conditions (Figure 1). They attend a range of medical and trauma presentations (Table 1). ERs aim to be first on scene to provide initial patient assessment, begin life-saving treatment, update the control room and then handover to subsequent resources. Once another clinician arrives, ERs can remain on scene to assist or can become available for any other emergency calls. When required, ERs can accompany the patient in the DCA to hospital.
| Medical | Trauma |
|---|---|
| Cardiac arrest | Traumatic cardiac arrest |
| Difficulty in breathing | Catastrophic haemorrhage |
| Chest pain | Major trauma including penetrating and blunt trauma |
| Seizures | Minor traumatic injuries |
| Anaphylaxis | Hanging |
| Diabetic emergencies | Falls |
| Unconscious | Burns |
| Abdominal pain | Drowning |
| Non-traumatic haemorrhage | |
| Stroke | |
| Sepsis |
The scheme operates 24 hours a day, 365 days a year, and ERs are free to choose their shift times. ERs operate from LAS ambulance stations and wear ambulance service green uniform, differentiated from regular LAS clinicians by unique call signs and by light blue ‘emergency responder’ epaulettes.
All consumables, uniform, personal protective equipment (PPE), training and running costs are paid for by the LAS. However, the scheme remains, at its core, a charitable endeavour. Most notably, emergency response driving courses and the fast response cars are funded through charitable donations to the LAS Volunteer Responder Group charity (registered charity number: 1061191). The charity has been fortunate to receive considerable support from various donors, including the local councils of Hillingdon, Barnet and Croydon, as well as the Freemasons, who have purchased nine vehicles for the scheme.
Recruitment and selection
The ER scheme recruits volunteers from a wide range of clinical and non-clinical backgrounds, but favours those with experience of responding to emergencies and interacting with the public. However, because of the scope for practice conflicts, the scheme does not accept applications from doctors or paramedics.
There is a minimum requirement for prospective candidates to have a pre-existing proficiency in basic life support (BLS). After shortlisting, the interview process includes a panel interview and practical skills assessment. If successful, candidates are enrolled onto an initial course designed to strengthen essential BLS skills, improve existing knowledge and provide familiarisation with operational procedures.
Training, management and CPD
Historically ERs were trained to First Person on Scene intermediate level (Pearson, 2021) with LAS-specific drug and paramedic-assist modules to cover the enhanced ER scope of practice. This qualification was superseded by the FutureQuals level 3 certificate for Ambulance Service First Responders: Co-Responder course (FutureQuals, 2021) in 2018.
Each ER is allocated a home station for administrative purposes; however, they may respond from any of the seven stations. Each station has a volunteer team leader (TL) and deputy team leader (DTL), who are the initial point of contact for ERs for operational issues or queries. They also provide pastoral support to their team members, particularly after they have attended stressful or traumatic incidents. Beyond overseeing their team members, all TLs/DTLs attend monthly team leader meetings to manage, govern and discuss the future directions of the scheme. TL/DTLs may also opt to take on additional responsibilities such as fleet management, communications, research and training.
After their initial course, all ERs must complete training shifts where they join a mentor and another ER as part of a three-person crew. These consolidation shifts are a mixture of shadowing and supervised practice, with the ultimate aim of the ER responding to calls with minimal supervision and input from their mentor. After completing these mentored shifts and demonstrating the required competency, they can progress to a standard two-person crew.
Further progression includes mentoring others, blue-light driving and additional responsibilities such as becoming a TL or DTL. At each stage of progression, ERs must demonstrate: commitment to minimum hours; completion of continuing professional development (CPD) and mandatory training; and good performance during audit of their patient report forms against key clinical performance indicators. To progress, they must also be recommended by their team leader.
To maintain clinical and operational competencies, ERs complete at least 16 hours of clinical shifts per month but many ERs volunteer well beyond this minimum. All ERs must also pass an annual mandatory intermediate life support assessment. Monthly CPD sessions are run for ERs, and cover core topics such as resuscitation, medical and traumatic emergencies, as well as other clinical and non-clinical subjects.
Content during these sessions is predominantly delivered as lectures; however, practical skills training and simulated scenarios are often used to consolidate knowledge. Since 2017, because it was recognised that ERs were exposed to high-acuity incidents only infrequently, two large-scale ‘moulage’ training days have been held for ERs, focusing on high-fidelity simulation using actors, make-up and real equipment (Figure 2). However, since the COVID-19 pandemic, CPD has largely been delivered online in the form of webinars.
Scope of practice and dispatch
The ER scope of practice is detailed in Table 2. ERs are sent to all category 1 (immediately life-threatening) and category 2 (emergency) calls (NHS England, 2018), with the exception of maternity, paediatric patients under the age of 8 years, psychiatric emergencies and violent incidents. ERs may also respond to crew requests; for example, to assist in extricating a patient. ERs are dispatched as a supplementary resource to emergency calls, meaning that a DCA is always dispatched to the call when one becomes available.
| Observations and assessment | Interventions | Drugs | |
|---|---|---|---|
| Airway |
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| Breathing |
|
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| Circulation |
|
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| Disability |
|
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| Exposure |
|
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The ER scope focuses on skills required by clinicians arriving first on scene to incidents, including rapid assessment of patients (including history-taking, examination and observations), identification and initial treatment of life-threatening pathologies, and subsequent handover to other ambulance service clinicians.
If an ER crew finds that a patient has greater clinical need than initially anticipated, they can escalate the call through the control room to expedite the arrival of further LAS resources. Examples include when patients are in confirmed cardiac arrest or are presenting with red-flag symptoms (e.g. cardiac chest pain or stroke symptoms) or physiology (e.g. significant derangement in observations).
There are specific circumstances where an ER crew may recognise that a patient does not require an emergency DCA response. Such patients must have stable observations and meet specific criteria. For example, ERs can independently arrange a taxi to convey patients with isolated below-knee or belowelbow injures in the absence of any concerning symptoms (e.g. loss of consciousness, gross deformity, severe pain or serious bleeding).
For any other patients if, after assessment, the ER crew and the patient agree that an alternative transport option is suitable or that hospital attendance is not required, they must liaise with senior clinicians in the control room to arrange a suitable plan. This acts as an additional safeguard and, if there are any concerns, the DCA will still attend the call.
In some circumstances where it is felt that hospital attendance is not required, a solo paramedic vehicle may be dispatched instead of a DCA to assess the patient and arrange alternative care pathways or discharge the patient on scene. This pragmatic approach enables ERs to protect precious DCA resources, allowing them to attend higher-acuity calls that require DCA conveyance to hospital.
Future directions
The ER scheme has grown considerably in the last decade, resulting in a steady increase in the number of patients attended by ERs (Figure 3). In the 2020–2021 financial year, ERs responded to 8941 emergencies, and were the first ambulance resource on scene in the majority (63.4%) of cases. This growth in capacity is projected to increase further, especially as there are plans to double the number of ERs by 2023 as part of the LAS' strategy to improve care and outcomes for patients (LAS, 2018).
Compared to traditional volunteer first responder schemes, the LAS ER scheme has significant differences, most notably its enhanced skillset, dispatch to medical and traumatic emergencies in addition to cardiac arrest and use of blue-light vehicles to reduce response times.
Research into benefits of volunteer first responder schemes in the UK is limited and focuses on cardiac arrest. Further research is planned to investigate patient-centred outcomes, exploring the benefits of training volunteers to an extended skillset.