Research

Military and civilian handover communication in emergency care: how does it differ?

February 2019

There is a growing body of literature on handover communication between prehospital and hospital receiving teams in civilian emergency care settings but little is known about how this differs from handover in the UK military medical services. This literature review shows that civilian handover is a complex process conducted in less-than-ideal circumstances, and it is affected by human behaviour and patient factors. There is a debate around standardisation including the use of the Mechanism, Injury or Illness, Signs, Treatment (MIST) mnemonic. There is limited understanding of how this mnemonic was used by the UK military, how it was developed to deal with specific patient characteristics or in the context of military operations in Afghanistan within which it evolved. Advancements in clinical practice made during conflict are ancillary to military objectives and should be supported by an evidence base before being transferred to civilian health care.

$Prehospital care in isolated neck of femur fracture: a literature review$

Prehospital care in isolated neck of femur fracture: a literature review

Around 65 000 people experience a fractured neck of femur (NOF) each year in the UK. It is estimated that one in 10 patients with an NOF fracture will die within 1 month, and one in three will die within 1 year. The bill for NOF fracture, excluding substantial social care costs, is £1 billion per year. Given the exposure that ambulance services have to these patients, several aspects of NOF fracture care could be improved in the prehospital environment, which could also generate significant savings for the NHS. This article reviews the literature regarding NOF fracture care, and highlights aspects that affect ambulance services and prehospital care. A variety of these, including pain management, fast-track systems, fluid therapy and renal impairments, can be improved, but evidence specific to the prehospital environment is lacking.

Examining the benefits of paramedic engagement for the novice researcher

Background:Paramedics new to research need to know how to optimise the quality of proposed research studies. A prehospital mixed-methods study design required guidance, not only from an academic perspective but also from experts within paramedicine. Paramedic engagement was defined as an exercise where paramedic researchers and paramedic clinical academics could be involved as advisory professionals.Aim:The aim of this paramedic engagement was the revision of a proposed research design on how senior clinical advisers determine futility in pulseless electrical activity in out-of-hospital cardiac arrest.Method:Five research paramedics and four clinical academics were interviewed by email using semi-structured questions. A generic qualitative inquiry with inductive content analysis was applied.Results:Paramedic engagement identified five themes: rewording the proposed study title; acknowledging that paramedics withdrew resuscitation; the implications of prolonged futile resuscitation; the need for autonomous paramedic decision-making; and improving research methodology.Conclusions:Professional paramedic engagement meant a number of complexities were identified within prehospital research and and pragmatic solutions were provided to the limitations in the proposed design. Novice researchers within paramedicine would benefit from early paramedic engagement to facilitate the design of research studies, provide guidance on methodology and identify limitations to improve the overall quality of prehospital research proposals.

Cerebral oximetry monitoring in OHCA

Background:Cerebral oximetry allows non-invasive, real-time monitoring information of cerebral blood flow to be carried out. It has recently been used to provide information about cerebral perfusion during resuscitation efforts in cases of cardiac arrest and may give an indication of neurological survival. Most of this information has been obtained during the hospital phase of treatment and little is known about cerebral flow in the prehospital phase.Methods:A systematic review was carried out, with the PubMed and EMBASE databases searched to identify clinical trials where cerebral oximetry monitoring was performed in the prehospital phase of out-of-hospital cardiac arrest. It aimed specifically to answer the following questions: is cerebral oximetry monitoring feasible in the prehospital environment? Can cerebral oximetry be used as a useful marker of the quality of cardiopulmonary resuscitation in the prehospital setting? Can cerebral oximetry be used to assist decisions around prognostication and futility for out-of-hospital cardiac arrest?Results:Five studies were identified for review. Feasibility was demonstrated in four of these. The usefulness of cerebral oximetry in monitoring cardiopulmonary resuscitation has not been well explored in out-of-hospital cardiac arrest. Similarly, data linking intra-arrest cerebral oximetry values and prognosis in out-of-hospital cardiac arrest is sparse.Conclusions:cerebral oximetry is feasible in out-of-hospital cardiac arrest but its usefulness in guiding resuscitation attempts in this environment remains largely unknown.

Rapid recognition tools for subarachnoid haemorrhage

Subarachnoid haemorrhage (SAH) carries a substantial burden of morbidity and mortality—therefore, the development of methods to rapidly detect SAH with high sensitivity is very important. Paramedics are frequently called to patients complaining of headache and the treatment for patients with clinically likely SAH is mostly straightforward for prehospital clinicians. However, a number of patients present with atypical symptoms and 12% of all SAHs are overlooked on initial assessment (Kowalski et al, 2004).

Paramedics' perceptions and experiences of pelvic injuries in prehospital situations

Mortality rates remain high in patients with pelvic injuries despite improvements in trauma care in recent years. Pelvic injuries are associated with patients with a high Injury Severity Score (ISS); it can therefore be difficult to distinguish whether the pelvic injury was a primary causative factor of mortality. ‘Open book’ fractures carry a mortality rate as high as 50% and clinicians should therefore have a low threshold for suspecting a pelvic injury. Paramedics should follow the latest guidance found in the UK Ambulance Service Clinical Practice Guidelines (Joint Royal Colleges Ambulance Liaison Committee (JRCALC), 2016; 2017). Additionally, log rolling and/or ‘springing’ the pelvis of a patient with a pelvic injury will cause pain, disrupt clots and distort a potential fracture. Furthermore, pelvic binders/splints can reduce the area into which a patient can haemorrhage, if they are placed correctly. Lastly, triage of these patients can be difficult and major trauma centres should be considered for definitive care.

Pelvic binder placement in a regional trauma centre

Background:Pelvic circumferential compression devices (PCCDs) are a life-saving prehospital adjunct to trauma care. Correct positioning at the level of the trochanters maximises their efficacy.Methods:To examine the positioning of PCCDs in a regional trauma centre in England, a retrospective analysis of patients who had experienced major trauma was carried out over a 6-month period. The primary outcome of PCCD position was assessed using computerised tomography imaging and recorded as ‘high’, ‘centred’ or ‘low’ (depending on trochanter level). Secondary outcomes, including patient demographics, mechanism, pattern, number and types of injury were also collected.Results:Eighty-nine patients were identified with a PCCD in situ, in whom 28 (31%) devices were positioned too high and eight (10%) too low. There was no correlation between mechanism, pattern, number or type of injury and PCCD position.Conclusions:Despite published evidence on PCCD position and training for personnel, many PCCDs are still poorly placed. Further education for professionals involved in PCCD application is recommended.

Ketamine administration by HART paramedics: a clinical audit review

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.

Adult intraosseous access: a comparison of devices

Background:Evidence to support device choice in intraosseous access is lacking in UK paramedic practice. Being unable to access the sternum with devices may result in under-treatment because of the inability to gain timely vascular access. This represents a shortcoming in current practice and a need for further research.Method:A literature review was conducted to find suitable studies and these were critically appraised. The data were synthesised to draw conclusions that could either influence practice or inform research. Study results were analysed in order to examine the following outcomes for devices most successful in terms of insertion rates; insertion times; ease of use; and flow rates. Cost-efficacy was also taken into consideration.Results:Forty-eight relevant articles were identified in the search and 18 were analysed. Of the 18 articles, 7 were randomised controlled trials and 11 were observational studies. Results varied widely with differences in reporting making the synthesis of data problematic. However, there was sufficient evidence to conclude that semi-automatic devices are superior to manual ones.Conclusion:Weaknesses in the evidence and inconsistencies between studies limited the conclusions that could be drawn. There is a strong mandate here for further research.

A qualitative exploration of current paramedic cardiac auscultation practices

This exploratory study addresses the current paucity of knowledge available in UK paramedic practice in relation to cardiac auscultation. There is a recognised lack of data surrounding the efficacy, safety and relevance of patient assessment skills in the pre-hospital setting in general, and cardiac auscultation specifically. This study provides information about current paramedic practice, and provides a basis for further research in this area. An online survey was distributed using convenience and snowball sampling, receiving 328 responses within a 31-day period. The results show that many paramedics rarely, or indeed never, undertake cardiac auscultation and that many lack confidence in recognising normal and abnormal heart sounds. There is also a divided opinion among respondents who provided free-text answers, with some feeling that the skill of cardiac auscultation is vital in pre-hospital care and others firmly disagreeing. This research lays the groundwork for further developments in training, education and continuing professional development for paramedics.

Secondary traumatic stress and resilience among EMS

Aim:The current study investigated the positive and negative psychological adaptations that are a result of secondary traumatic stress, and the role of resilience among paramedics and emergency medical technicians (EMTs).Methods:Emergency medical service (EMS) providers anonymously completed four validated questionnaires on: secondary traumatic stress, post-traumatic growth, resilience, and changes in outlook. Relationships between these constructs and demographics were explored.Findings:Overall, EMS participants reported a higher-than-average positive change in outlook. Resilience (p<0.001) was significantly inversely related to secondary traumatic stress and negative change in outlook. EMS working part-time demonstrated a significantly higher level of resilience (p=0.005) compared with full-time. Post-traumatic growth was significantly higher (p=0.03) in EMTs compared with paramedics. No significant differences (p>0.05) were detected between years of experience for any attributes analysed.Conclusion:Findings demonstrated significant correlations between secondary traumatic stress, resilience, post-traumatic growth, and changes in outlook in EMTs and paramedics.

Paramedic views on clinical research in cardiac arrest

Background:The success of pre-hospital research relies on positive engagement from paramedics. Without adequate participation and protocol compliance, trials will not succeed.Aims:The aims of the current research were to seek feedback from paramedics about trial participation and determine their views and preferences regarding a large-scale research study in future.Methods:Paramedics participating in REVIVE-Airways, a trial of airway management in out-of-hospital cardiac arrest, were sent a feedback questionnaire according to their study allocation.Findings:Of the total respondents, 99% were willing to participate in a further large-scale trial. Participants offered recommendations for future pre-hospital trials.Conclusion:There was strong support for further clinical trials of alternative airway management strategies during out-of-hospital cardiac arrest. Paramedics welcome opportunities to participate in research and receive feedback about trial progress and patient outcomes.

Cooling of thermal burn injuries: a literature review

Correct initial management of thermal burns is key in promoting patient outcomes. Cooling burns with cool running water (CRW) for 20 minutes has been shown to accelerate the wound healing process, improve cosmetic outcomes and prevent burn progression. This literature review aims to increase understanding of this simple first aid (FA) intervention, help inform paramedic practice, and determine areas for further research. Three themes came to light following systematic searching of the available literature. As a result of a paucity in evidence, a wide range of topics relating to cooling burns have been explored. The topics look at how patients and carers may approach FA in burns, how pre-hospital practitioners currently manage burns patients, and the best methods to use for cooling burns. Findings suggest that there is need for improved education for the lay public and pre-hospital providers in order to improve burn outcomes through FA interventions. While CRW is supported as a beneficial intervention, further research is required into alternative cooling methods to enhance care and evidence-based practice.

View all Research

Research

Keep up to date with Journal of Paramedic Practice!