ABSTRACT
The COVID-19 pandemic placed the UK healthcare system under unprecedented pressure, and recovery will require whole-system investment in innovative, flexible and pragmatic solutions. Positioned at the heart of the healthcare system, ambulance services have been tasked with addressing avoidable hospital conveyance and reducing unnecessary emergency department and hospital attendances through the delivery of care closer to home. Having begun to implement models of care intended to increase 'see and treat' opportunities through greater numbers of senior clinical decision makers, emphasis has now been placed upon the use of remote clinical diagnostic tools and near-patient or point-of-care testing (POCT) to aid clinical decision making. In terms of POCT of blood samples obtained from patients in the pre-hospital setting, there is a paucity of evidence beyond its utility for measuring lactate and troponin in acute presentations such as sepsis, trauma and myocardial infarction, although potential exists for the analysis of a much wider panel of analytes beyond these isolated biomarkers. In addition, there is a relative dearth of evidence in respect of the practicalities of using POCT analysers in the pre-hospital setting. This single-site feasibility study aims to understand whether it is practical to use POCT for the analysis of patients' blood samples in the urgent and emergency care pre-hospital setting, through descriptive data of POCT application and through qualitative focus group interviews of advanced practitioners (specialist paramedics) to inform the feasibility and design of a larger study. The primary outcome measure is focus group data measuring the experiences and perceived self-reported impact by specialist paramedics. Secondary outcome measures are number and type of cartridges used, number of successful and unsuccessful attempts in using the POCT analyser, length of time on scene, specialist paramedic recruitment and retention, number of patients who receive POCT, descriptive data of safe conveyance, patient demographics and presentations where POCT is applied and data quality. The study results will inform the design of a main trial if indicated.
ABSTRACT
BackgroundOne-fifth of conveyances to the emergency department (ED) are due to acute-on-chronic breathlessness. Paramedic breathlessness management may ease distress quicker and/or reduce ED conveyances. We evaluated the feasibility of a full trial of a paramedic delivered intervention to reduce avoidable conveyances (recruitment, randomisation, consent, training and intervention acceptability, adherence, data quality, best primary outcome, sample size estimation). The intervention comprised evidence-based non-drug techniques and a self-management booklet.MethodsThis mixed-methods feasibility cluster randomised controlled trial (ISRCTN80330546) with embedded qualitative study about trial processes, training and intervention delivery, randomised paramedics to usual care or to intervention+usual care. Retrospective patient consent to use call-out data and prospective patient/carer consent for follow-up was sought. Potential primary outcomes were breathlessness intensity (numerical rating scale) and ED conveyance. Follow-up included an interview for patients/carers and questionnaires at 14 days, 1 and 6 months and paramedic focus groups and survey.ResultsRecruitment was during the COVID-19 pandemic, leading to high demands on paramedics and fewer call-outs by eligible patients. We enrolled 29 paramedics;9 withdrew. Randomisation/trial procedures were acceptable. Paramedics recruited 13 patients;8 were followed up. Data quality was good. The intervention did not extend call-out time, was delivered with fidelity and no contamination and was acceptable to patients, carers, and paramedics. There were no repeat call-outs < 48 hours. Recruitment stop-go criteria were not met. We had insufficient data for sample size estimation.ConclusionsA full trial in the same circumstances is not feasible. However, valuable information was gained on recruitment, attrition, consent, training and intervention acceptability and adherence, and patient-reported data collection.
ABSTRACT
BackgroundIn early March 2020, a senior clinical support cell (SCSC) was established within Yorkshire Ambulance Service NHS Trust (YAS). The SCSC aimed to provide an additional layer of clinical leadership within the Emergency Operations Centre to support call centre and decision support for on-scene ambulance staff working in challenging circumstances. It was staffed by advanced practitioners, doctors and other senior paramedics with range of diverse skills from critical to urgent care. We aimed to understand the patterns of use of a SCSC for emergency 999 calls during the COVID-19 pandemic.MethodsRoutinely collected call data was retrospectively analysed to understand the patterns of use in the first three months of the service. The reason for the call, patient demographic and any regional differences were described. An anonymous survey was distributed to frontline ambulance crews to understand the reasons for contacting the SCSC, or not, and the outcomes of that contact for patient care.Results7296 patient care episodes received either a telephone triage by SCSC for 999 calls or 111 calls transferred for an emergency ambulance response (3160) or had telephone support provided to crews on scene (4136). Telephone triage accounted for 3160 calls where 642 cases (20.3%) resulted in a hear-and-treat outcome, and the findings suggest a low re-contact rate within 24 hours at 2.4%.The primary reasons for crews seeking support/advice from the SCSC were discharge advice or permission (37%);support for pathways in their area (25%);or for cases where patients refused care or conveyance (11%).ConclusionsSCSC was developed in response to the COVID-19 pandemic, and lessons can be learned to prepare for any future significant service challenges as a result of the rapid implementation of the SCSC and the clinical leadership required to support the pace of change and emerging clinical knowledge and practice.