Benjamin A Audit: how to do it in practice. BMJ. 2008; 336:(7655)1241-1245

Biau DJ, Kernéis S, Porcher R Statistics in Brief: The Importance of Sample Size in the Planning and Interpretation of Medical Research. Clin Orthopaed Relat Res. 2008; 466:(9)2282-2288

Collicott PE, Hughes I Training in advanced trauma life support. J Am Med Assoc. 1980; 243:(11)1156-1159

Duncan C, Riley B BET 2: Low-dose ketamine for acute pain in the ED. Emerg Med J. 2016; 33:(12)892-893

Grossman MD, Ofurum U, Stehly CD, Stoltzfus J Long-term survival after major trauma in geriatric trauma patients: the glass is half full. J Trauma Acute Care Surg. 2012; 72:(5)1181-1185

Hirota K, Lambert DG Ketamine: New uses for an old drug?. Br J Anaesth. 2011; 107:(2)123-126

Iqbal M, Spaight PA, Siriwardena AN Patients' and emergency clinicians' perceptions of improving pre-hospital pain management: a qualitative study. Emerg Med J. 2012; 30:(3)

Kehoe A, Smith JE, Edwards A, Yates D, Lecky F The changing face of major trauma in the UK. Emerg Med J. 2015; 32:(12)911-915

Kolawole IK Ketamine hydrochloride: A useful but frequently misused drug. Nig J Surg Res. 2001; 3:(3)118-225

Kurdi MS, Theerth KA, Deva RS Ketamine: Current applications in anesthesia, pain, and critical care. Anesth Essays Res. 2014; 8:(3)283-290

Krug EG, Sharma GK, Lozano R The global burden of injuries. Am J Public Health. 2000; 90:(4)523-526

McGuinness SK, Wasiak J, Cleland H A Systematic Review of Ketamine as an Analgesic Agent in Adult Burn Injuries. Pain Med. 2011; 12:(10)1551-1558

Motov S, Rockoff B, Cohen V Intravenous Subdissociative-Dose Ketamine Versus Morphine for Analgesia in the Emergency Department: A Randomized Controlled Trial. Ann Emerg Med. 2015; 66:(3)336-337

National Ambulance Resilience Unit. About NARU. 2017. https// (accessed 25 September 2018)

Principles of Best Practice in Clinical Audit.Abingdon: Radcliffe Medical Press Ltd; 2002

Patient Group Directions.London: NICE; 2017

Perumal DK, Adhimoolam M, Selvaraj N, Lazarus SP, Mohammed MR Midazolam premedication for Ketamine-induced emergence phenomenon: A prospective observational study. J Res Pharm Pract. 2015; 4:(2)89-93

Pfizer. Ketalar 10 mg/ml Injection. 2018. https// (accessed 25 September 2018)

Smith R Audit & Research. Br Med J. 1992; 305:905-906

Trust Clinical Guideline: Patient Group Directive—Ketamine (Analgesia 1).Exeter: NHS Publication; 2015

Svenson J, Biedermann M Ketamine: a unique drug with several potential uses in the prehospital setting. J Para Pract. 2011; 3:(10)552-556

The National Archives. The Misuse of Drugs Regulations. 2001. https// (accessed 25 September 2018)

The National Archives. The Human Medicines Regulations 2012. 2012. https// (accessed 25 September 2018)

Trauma Audit and Research Network. Major Trauma in Older People—2017 Report. 2017. https// (accessed 25 September 2018)

World Health Organization. Using audit and feedback to health professionals to improve the quality and safety of health care. 2010. https// (accessed 25 September 2018)

Ketamine administration by HART paramedics: a clinical audit review

02 October 2018
Volume 10 · Issue 10


Hazardous Area Response Team (HART) paramedics from a single ambulance service Trust were trained to administer ketamine up to 0.5 mg/kg for analgesia in the pre-hospital environment. The Trust's special operations department felt that, in doing so, patient care could be improved in both hazardous areas and regular pre-hospital clinical situations. After completing a written examination and scenario training on the relevant Trust patient group directive (PGD), HART paramedics were authorised from 4 July 2016 to administer ketamine autonomously. HART paramedics then retrospectively self-reported on the details of administration using a computerised auditing application called iAuditor. Data from 1 year of usage were then collated and analysed using Microsoft Excel with the aim of identifying current practice and developing recommendations for the future. Despite encountering complications, safe independent use of ketamine was demonstrated and was shown to be an effective analgesic agent in the majority of incidents. Suggested methods for developing and improving ketamine use by paramedics are discussed. Furthermore, a number of recommendations for optimising the Trust's ketamine PGD and the iAuditor template were identified. This work has provided the foundations for future audit and research.

The Hazardous Area Response Team (HART) consists of specially trained paramedics—and in some trusts, ambulance service technicians—who deliver clinical care in potentially dangerous environments to increase survival rates and improve clinical outcomes. Each of England's ten NHS Ambulance trusts, as well as Wales, Northern Ireland and Scotland, all have at least one HART unit. This allows the team's capabilities to reach the whole of the UK (National Ambulance Resilience Unit (NARU), 2017). South Western Ambulance Service Foundation Trust (SWASFT) has two HART units—one based in Bristol and the other in Exeter.

It was deemed by SWASFT Special Operations that patient care could be improved, in both hazardous areas and regular pre-hospital clinical situations, by training and authorising HART operatives to autonomously administer ketamine up to 0.5 mg/kg for analgesia. The data available from the unit's ketamine usage were systematically audited and analysed with the aim of identifying current practice and developing recommendations for the future.

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