Improved quality of pre-hospital resuscitation in out-of-hospital cardiac arrest (OHCA) in Edinburgh, Scotland has been accomplished, in part, through the introduction of resuscitation team leadership supported by a programme of audit, feedback and training for ambulance crews (Lyon et al, 2012).
Building on previous work, the TOPCAT2 study aimed to demonstrate the feasibility of establishing a second tier, expert paramedic response to support crews in managing OHCAs in Edinburgh.
Identified as a service improvement evaluation, TOPCAT2 provided an unspecified length of training for eight paramedics in both technical (cardiopulmonary resuscitation and defibrillation skills) and non-technical skills, including teamwork and communication. Training sessions incorporated refreshers in advanced life support skills, as well as seminar sessions combined with simulation and video recording to facilitate debriefing and subsequent development of non-technical skills.
The participating paramedics were selected based on their regular attendance at voluntary OHCA education sessions and performance during simulated OHCA, but there is no reference in this paper to their length of service, training or experience. The paramedics worked on Rapid Response Units, one for each shift during the three month pilot, and were preferentially tasked to suspected OHCA calls.
Standard operating procedures were developed for the Emergency Medical Dispatch Centre to ensure that TOPCAT2 paramedics were dispatched in addition to the nearest available resource, that they could leave non urgent jobs for an OHCA, and could be requested by ambulance crews when required.
To enable audit and analysis of resuscitation attempts during TOPCAT2, paramedics completed an ambulance service electronic patient record and submitted a defibrillator download. The authors report that an OHCA audit form was additionally completed but limited information on the methodology of data collection and analysis is provided.
During the three months of the evaluation, TOPCAT2 paramedics attended 40 cases of OHCA where resuscitation attempts were made. Results demonstrated that this model of expert paramedic response had no specific impact on overall emergency medical services performance in the area and no significant difference was observed in response times to Category A calls. However with a median time of 3.2 minutes from call to dispatch for TOPCAT2 paramedics, the authors note improvements could be made to shorten activation times.
OHCAs attended by TOPCAT2 paramedics had a return of spontaneous circulation (ROSC) rate of 22.5%, compared to a national average of 16%. When interpreting these results other influencing variables should be considered, such as the previous TOPCAT study and additional OHCA training for the ambulance crews in Edinburgh.
The authors acknowledge that the TOPCAT2 study was limited by the small sample size; as a feasibility pilot it was not designed to establish the impact of the model on patient outcome. Future work is planned to focus on the impact of these developments on patient outcome but no further detail is given in this paper.
Whilst no formal evaluation of paramedics’ perceptions of the TOPCAT model is described, the authors note that TOPCAT2 paramedics reported an initial reluctance from ambulance crews to accept guidance.
A move towards a formalised approach to out-of-hospital resuscitation team leadership may present a challenge to ambulance crews, but there is growing evidence that such non-technical skills improve quality of care and have the potential to save lives.