Temporal trends of ambulance time intervals for suspected stroke/transient ischaemic attack (TIA) before and during the COVID-19 pandemic in Ireland: a quasi-experimental study.

OBJECTIVES: Time is a fundamental component of acute stroke and transient ischaemic attack (TIA) care, thus minimising prehospital delays is a crucial part of the stroke chain of survival. COVID-19 restrictions were introduced in Ireland in response to the pandemic, which resulted in major societal changes. However, current research on the effects of the COVID-19 pandemic on prehospital care for stroke/TIA is limited to early COVID-19 waves. Thus, we aimed to investigate the effect of the COVID-19 pandemic on ambulance time intervals and suspected stroke/TIA call volume for adults with suspected stroke and TIA in Ireland, from 2018 to 2021. DESIGN: We conducted a secondary data analysis with a quasi-experimental design. SETTING: We used data from the National Ambulance Service in Ireland. We defined the COVID-19 period as '1 March 2020-31 December 2021' and the pre-COVID-19 period '1 January 2018-29 February 2020'. PRIMARY AND SECONDARY OUTCOME MEASURES: We compared five ambulance time intervals: 'allocation performance', 'mobilisation performance', 'response time', 'on scene time' and 'conveyance time' between the two periods using descriptive and regression analyses. We also compared call volume for suspected stroke/TIA between the pre-COVID-19 and COVID-19 periods using interrupted time series analysis. PARTICIPANTS: We included all suspected stroke/TIA cases ≥18 years who called the National Ambulance Service from 2018 to 2021. RESULTS: 40 004 cases were included: 19 826 in the pre-COVID-19 period and 19 731 in the COVID-19 period. All ambulance time intervals increased during the pandemic period compared with pre-COVID-19 (p<0.001). Call volume increased during the COVID-19-period compared with the pre-COVID-19 period (p<0.001). CONCLUSIONS: A 'shock' like a pandemic has a negative impact on the prehospital phase of care for time-sensitive conditions like stroke/TIA. System evaluation and public awareness campaigns are required to ensure maintenance of prehospital stroke pathways amidst future healthcare crises. Thus, this research is relevant to routine and extraordinary prehospital service planning.

New care pathway to enable ambulances transfer patients to a model 2 hospital medical assessment unit.

BACKGROUND: Reconfiguration of the Irish acute hospital sector resulted in the establishment of a Medical Assessment Unit (MAU) in Mallow General Hospital (MGH). We developed a protocol whereby certain patients deemed to be low risk for clinical deterioration could be brought by the National Ambulance Service (NAS) to the MAU following a 999 or 112 call. AIMS: The aim of this paper is to report on the initial experience of this quality improvement initiative. METHODS: The Plan-Do-Study-Act (PDSA) Cycle for quality improvement was implemented when undertaking this project. A pathway was established whereby, following discussion between paramedic and physician, patients for whom a 999 or 112 call had been made could be brought directly to the MAU in MGH. Strict inclusion and exclusion criteria were agreed. The protocol was implemented from the 1st of September 2022 for a 3-month pilot period. RESULTS: Of 39 patients discussed, 29 were accepted for review in the MAU. One of the 29 accepted patients declined transfer to MAU. Of 28 patients reviewed in the MAU, 7 were discharged home. One patient required same day transfer to a model 4 centre. Twenty patients were admitted to MGH with an average length of stay of 8 days. Frailty and falls accounted for 7 of the admissions and the mean length of stay for these patients was 12 days. CONCLUSIONS: Our results have demonstrated the safety, feasibility and effectiveness of this pathway. With increased resourcing, upscaling of this initiative is possible and should be considered.

Tools and methods for evaluating the change to health service delivery due to pandemics or other similar emergencies: A rapid evidence review.

The novel coronavirus, SARS-CoV-2 and its associated disease COVID-19, were declared a pandemic in March 2020. Countries developed rapid response activities within their health services to prevent spread of the virus and protect their populations. Evaluating health service delivery change is vital to assess how adapted practices worked, particularly during times of crisis. This review examined tools and methods that are used to evaluate health service delivery change during pandemics and similar emergencies. Five databases were searched, including PubMed, CENTRAL, Embase, CINAHL, and PsycINFO. The SPIDER tool informed the inclusion criteria for the articles. Articles in English and published from 2002 to 2020 were included. Risk of bias was assessed using the Mixed-Methods Appraisal Tool (MMAT). A narrative synthesis approach was used to analyse the studies. Eleven articles met the inclusion criteria. Many evaluation tools, methods, and frameworks were identified in the literature. Only one established tool was specific to a particular disease outbreak. Others, including rapid-cycle improvement and PDSA cycles were implemented across various disease outbreaks. Novel evaluation strategies were common across the literature and included checklists, QI frameworks, questionnaires, and surveys. Adherence practices, experience with telehealth, patient/healthcare staff safety, and clinical competencies were some areas evaluated by the tools and methods. Several domains, including patient/practitioner safety and patient/practitioner experience with telemedicine were also identified in the studies.

Effects of the COVID-19 Pandemic on Prehospital Emergency Care for Adults with Stroke and Transient Ischaemic Attack: A Systematic Review and Meta-Analysis.

INTRODUCTION: COVID-19 has challenged global health care systems and resulted in prehospital delays for time-sensitive emergencies, like stroke and transient ischemic attacks (TIA). However, there are conflicting international reports on the level of effect of the pandemic on ambulance response intervals and emergency call volumes for these conditions. OBJECTIVES: The purpose of this study was to synthesize the international evidence on the effect of COVID-19 on ambulance response intervals and emergency call volume for suspected stroke and TIA. METHODS: Following a published protocol, we conducted a systematic search of six databases through May 31, 2022. We re-ran this search on April 14, 2023, to check for any new papers. We considered for inclusion peer-reviewed quantitative studies comparing prehospital emergency care for adults with suspected stroke/TIA before and during the COVID-19 pandemic. Two authors screened title/abstract and full text articles. One author carried out data extraction, with a random selection of articles being checked by another author. We calculated overall pooled estimates of ambulance intervals (activation, response, patient care, and total prehospital intervals) and stroke/TIA emergency call volume. Subgroup and sensitivity analyses included location and stroke/TIA diagnosis. Two authors assessed study quality using the appropriate Joanna Briggs Institute tool. We worked with patient and public involvement contributors and clinical and policy stakeholders throughout the review. RESULTS: Of 4,083 studies identified, 52 unique articles met the inclusion criteria. Mean response interval (-1.29 min [-2.19 to -0.38]) and mean total prehospital interval (-6.42 min [-10.60 to -2.25]) were shorter in the pre-COVID-19 period, compared to the COVID-19 period. Furthermore, there was a higher incidence rate of emergency call volume for suspected stroke/TIA per day pre-COVID-19 compared with the COVID-19 period (log IRR = 0.17 [0.02 to 0.33]). Ambulance response interval definitions and terminology varied between regions and countries. CONCLUSIONS: Our review indicates that prehospital delays for suspected stroke/TIA increased during the COVID-19 pandemic. Furthermore, emergency call volume for suspected stroke/TIA decreased during this period. In order to minimize delays in future pandemics or other health care emergencies future research may involve understanding the potential reasons for these delays.

The Development of Helicopter Emergency Medical Services in the Republic of Ireland.

Helicopter emergency medical services (HEMS) have formed an integral component of the Irish health care system for the past decade; yet, the factors leading their commencement, their evolutions over this time, and the current model of service delivery have not been widely published. Aeromedical service provision may vary significantly from country to country and may also vary regionally within countries. A health system's necessities; capacity and maturity; the level of state, corporate, private, or community investment; and the capacity of the contracted service provider are all factors that influence the service provision. This research article describes the historic factors leading to a military and health system collaboration to HEMS during an era of health care reform. Over the past decade, the Irish health system has undergone significant reconfiguration and centralization of services, leading to increased demands on emergency medical ground and air medical services. Future advancements in aeromedical service provision require an innate understanding of the current model. This article adds to the knowledge base, informs policy makers, and supports decision making surrounding HEMS provision and the potential to explore military and health system collaborations and enhanced overall service provision.

Effects of the COVID-19 pandemic on prehospital emergency care for adults with stroke and transient ischaemic attack: A protocol for a systematic review and meta-analysis.

Background: The COVID-19 pandemic impacted on health service provision worldwide, including care for acute time sensitive conditions. Stroke and transient ischaemic attacks (TIA) are particularly vulnerable to pressures on healthcare delivery as they require immediate diagnosis and treatment. The global impact of the COVID-19 pandemic on prehospital emergency care for stroke/TIA is still largely unknown. Thus, the aim of this study is to conduct a systematic review and meta-analysis to investigate the impact of the COVID-19 pandemic on prehospital emergency care for stroke and TIA. Methods: Following the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) guidelines, the review is registered on PROSPERO (registration number CRD42022315260). Peer-reviewed quantitative studies comparing prehospital emergency care for adults with stroke/TIA before and during the COVID-19 pandemic will be considered for inclusion. The outcomes of interest are ambulance times and emergency call volumes for stroke/TIA. A systematic search of databases including PubMed, Embase and Scopus will be conducted. Two authors will independently screen studies for inclusion based on predetermined inclusion and exclusion criteria. Data extraction and quality assessment will be conducted by two authors. Meta-analysis will be performed to calculate overall pooled estimates of ambulance times (primary outcome) and stroke/TIA call volumes (secondary outcome), where appropriate.  Where heterogeneity is low a fixed-effects model will be used and where heterogeneity is high a random-effects model will be used. Subgroup and sensitivity analyses will include location, stroke/TIA diagnosis and COVID-19 case numbers. Results: Data on primary and secondary outcomes will be provided. Results of subgroup/sensitivity analyses and quality assessment will also be presented. Conclusions: This review will identify existing evidence reporting the impact of the COVID-19 pandemic on prehospital emergency care for adult patients with stroke/TIA and provide summary estimates of effects on ambulance response times.

Quality improvement in a crisis: a qualitative study of experiences and lessons learned from the Irish National Ambulance Service response to the COVID-19 pandemic.

OBJECTIVES: The COVID-19 pandemic has produced radical changes in international health services. In Ireland, the National Ambulance Service established a novel home and community testing service that was central to the national COVID-19 screening programme. This service was overseen by a multidisciplinary response room. This research examined the response room service, particularly areas that performed well and areas requiring improvement, using a quality improvement (QI) framework. DESIGN: This was a qualitative study comprising semi-structured, individual interviews. Maximum variation sampling was used. The data were analysed using an established thematic analysis procedure. The analysis was guided by the framework, which comprised six QI drivers. SETTING: Response room employees, including clinicians, dispatchers and administrators, were interviewed via telephone. RESULTS: Leadership for quality: participants valued person-oriented leadership, including regular, open communication and consultation with staff. Person/family engagement: participants endeavoured to provide patient-centred care. Formal patient feedback mechanisms and shared decision-making could be beneficial in the future. Staff engagement: working in a response room could affect well-being, though it also provided networking and learning opportunities. Staff require support and teambuilding. Use of improvement methods: improvements were made in a relatively informal, ad hoc manner. The use of robust methods based on improvement science was not reported. Measurement for quality: data were collected to improve efficiency and accuracy. More rigorous measurement would be beneficial, especially formally collecting stakeholder feedback. Governance for quality: close alignment with collaborators and clear communication with staff are essential. Information and communications technology for quality: this seventh driver was added because the importance of information technology specially designed for pandemics was frequently highlighted. CONCLUSIONS: The study provides insights on what worked well and what required improvement in a pandemic response room. It can inform health services, particularly emergency services, in their preparation for additional COVID-19 waves, as well as future crises.

Community first response and out-of-hospital cardiac arrest: Identifying priorities for data collection, analysis, and use via the nominal group technique.

AIM: Community First Response (CFR) is an important component of Out-of-hospital Cardiac Arrest management in many countries, including Ireland. Reliable, strategic data collection and analysis are required to support the development of CFR. However, data on CFR are currently limited in Ireland and internationally. This research aimed to identify the most important CFR data to record, the most important uses of CFR data, and barriers and facilitators to CFR data collection and use. METHODS: The Nominal Group Technique structured consensus process was used. An expert panel comprising key stakeholders, including volunteers, clinicians, researchers, policy-makers, and a patient, completed a survey to generate lists of the most important CFR data to record and the most important uses of CFR data. Subsequently, they participated in a consensus meeting to agree the top ten priorities from each list. They also identified barriers and facilitators to CFR data collection and use. RESULTS: The top ten CFR data items to record included volunteer response time, interventions/activities completed by volunteers, and the mental/physical impact on volunteers. The top ten most important uses of CFR data included providing feedback to volunteers, improving volunteer training, and measuring CFR effectiveness. Barriers included time constraints and limited training. Facilitators included having appropriate software/equipment and collecting minimal data. CONCLUSION: The results can guide CFR research and inform the development of CFR data collection and analysis policy and practice in Ireland and internationally. Ultimately, improving CFR data collection and use will help to optimise this important intervention and enhance its evidence base.

Ambulance waiting and associated work flow improvement strategies: a pilot study to improve door-in-door-out time for thrombectomy patients in a primary stroke center.

BACKGROUND: Rapid access to thrombectomy for patients with large vessel occlusion (LVO) acute ischemic stroke (AIS) is critical for improving outcome. A major challenge for the 'drip and ship' model is reducing the door-in-door-out time (DIDO). We propose a new protocol with the aim of reducing DIDO, without adversely affecting emergency service usage time. METHODS: Consecutive patients with suspected LVO AIS admitted to a Primary Stroke Center (PSC) from October 2018 to January 2021 were included. On arrival, the ambulance crew remained with the patient. Following immediate clinical and radiological evaluation, patients were transferred to the Comprehensive Stroke Center (CSC) by the same waiting crew. Key time metrics were collected and compared with historical data prior to the new protocol. RESULTS: 27 patients had an LVO amenable for mechanical thrombectomy during the time period. There was a significant reduction in the DIDO times compared with the historical group (median 45 min vs 96 min; p<0.0001). There was no significant difference in ambulance usage time between the two time periods (median 53 min vs 45 min; p=0.530). There was an increase in ambulance usage time in FAST-positive patients not for transfer in the pilot group compared with FAST-positive patients not for transfer in the historical group (27 min vs 58 min; p<0.001). In addition, door-to-needle times (24 min vs 40 min; p=0.018) and door-to-CT times (11 min vs 25 min; p<0.0001) improved between the two groups. CONCLUSION: Our data show a significant reduction in the DIDO for patients transferred for thrombectomy, with no adverse effects on ambulance usage time.

The Alternative Pre-hospital Pathway team: reducing conveyances to the emergency department through patient centered Community Emergency Medicine.

BACKGROUND: Internationally increasing demand for emergency care is driving innovation within emergency services. The Alternative Pre-Hospital Pathway (APP) Team is one such Community Emergency Medicine (CEM) initiative developed in Cork, Ireland to target low acuity emergency calls. In this paper the inception of the APP Team is described, and an observational descriptive analysis of the APP Team's service data presented for the first 12 months of operation. The aim of this study is to describe and analyse the APP team service. METHODS: The APP Team, consisting of a Specialist Registrar (SpR) in Emergency Medicine (EM) and an Emergency Medical Technician (EMT) based in Cork, covers a mixed urban and rural population of approximately 300,000 people located within a 40-min drive time of Cork University Hospital. The team are dispatched to low acuity 112/999 calls, aiming to provide definitive care or referring patients to the appropriate community or specialist service. A retrospective analysis was performed of the team's first 12 months of operation using the prospectively maintained service database. RESULTS: Two thousand and one patients were attended to with a 67.8% non-conveyance rate. The median age was 62 years, with 33.0% of patients aged over 75 years. For patients over 75 years, the non-conveyance rate was 62.0%. The average number of patients treated per shift was 7. Medical complaints (319), falls (194), drug and alcohol related presentations (193), urological (131), and respiratory complaints (119) were the most common presentations. CONCLUSION: Increased demand for emergency care and an aging population is necessitating a re-design of traditional models of emergency care delivery. We describe the Alternative Pre-Hospital Pathway service, delivered by an EMT and an Emergency Medicine SpR responding to low acuity calls. This service achieved a 68% non-conveyance rate; our data demonstrates that a community emergency medicine outreach team in collaboration with the National Ambulance Service offering Alternative Pre-Hospital Pathways is an effective model for reducing conveyances to hospital.

Out-of-hospital cardiac arrests in the young population; a 6-year review of the Irish out-of-hospital cardiac arrest register.

STUDY PURPOSE: Out-of-hospital cardiac arrests (OHCA) in the young population have only been examined in a limited number of regional studies. Hence, we sought to describe OHCA characteristics and predictors of survival to hospital discharge for the young Irish population. STUDY DESIGN: An observational analysis of the national Irish OHCA register for all OHCAs aged ≤35 years between January 2012 and December 2017 was performed. The young population was categorised into three age groups: ≤1 year, 1-15 years and 16-35 years. Multivariable logistic regression was used to determine the independent predictors of survival to hospital discharge. RESULTS: A total of 1295 OHCAs aged ≤35 years (26.9% female, median age 25 (IQR 17-31)) had resuscitation attempted. OHCAs in those aged ≥16 years (n=1005) were more likely to happen outside the home (38.5% vs 22.8%, p<0.001) and be of non-medical aetiology (59% vs 27.6%, p<0.001) compared with those aged <16 years (n=290). Asphyxiation, trauma and drug overdoses accounted for over 90% of the non-medical OHCAs for those 16-35 years. Overall survival to hospital discharge for the cohort was 5.1%; survival was non-significantly higher for those aged 16-35 years compared with those aged 1-15 years (6.0%, vs 2.8% p=0.93). Independent predictors of survival to hospital discharge included bystander witnessed OHCA, a shockable initial rhythm and a bystander defibrillation attempt. CONCLUSIONS: The high prevalence of non-medical OHCAs and the OHCA location need to be considered when developing OHCA care pathways and preventative strategies to reduce the burden of OHCAs in the young population.

Out-of-hospital cardiac arrest quality of life follow-up study of survivors in Munster, Ireland.

Quality of life of out-of-hospital cardiac arrest (OHCA) survivors is believed to be as important as a factor in resuscitation outcome as the survival rate. The aim of this investigation is to assess the quality of life outcomes of survivors of out-of- hospital cardiac arrest in the Munster region. OHCAR was used to identify survivors who were contacted in writing to invite their participation. Internationally standardized phone based questionnaires were utilized to assess quality of life. The mean age of participants was 63.5 years with 85% male and 15% female. Eighty percent (n = 16) had no issues with mobility, 90% (n = 18) had no issues with personal care, 90% could undertake all usual activities, and 90% (n = 18) experienced no anxiety or depression. In conclusion, survivors of OHCA in the Munster area, who participated in this study, survive at a very high functional level.

Rapid response and learning for later: establishing high quality information networks and evaluation frameworks for the National Ambulance Service response to COVID-19 - the ENCORE COVID Project Protocol.

Background: The National Ambulance Service (NAS) is at the forefront of Ireland's response to the COVID-19 pandemic. As directed in Ireland's National Action Plan, NAS significantly expanded prehospital services, including provision of a novel COVID-19 testing service. Additionally, other health services rely on NAS's capacity to assess, transport and/or treat COVID-19 patients. In a climate of innovation and adaptation, NAS needs to learn from international ambulance services and share experience. Evaluation of the NAS response to COVID-19 is required to facilitate evidence-based planning for subsequent waves or future pandemics, and to identify innovative practice for mainstreaming into routine service provision. Aims: This project aims to test the utility of novel information networks and develop a tool that is tailored to evaluating pandemic-imposed change in an emergency medical service. Methods: The first aim will be to introduce and measure the impact of ambulance-specific research and information updates for NAS. Secondly, the usefulness to members of an international network of senior ambulance and research personnel ('AMBULANCE+COVID19' network), and the clarity and feasibility of a short-survey instrument, the Emergency Medical Services Five Question Survey (EMS-5QS), will be assessed. Finally, an evaluation framework for assessing pandemic-imposed change will be developed to enable NAS determine innovations: (1) for reactivation in another wave or new pandemic; (2) to be sustained as part of routine service. The framework will be developed in collaboration with NAS and the National Quality Improvement Team. The Research Team includes expertise from academia, ambulance services and the National Public Health Emergency Team. Conclusions: This project will facilitate the prompt introduction of information sharing processes to an emergency medical service and assess the impact of those processes. By developing a process for evaluating pandemic-imposed change in NAS, this project will add to the toolbox for future pandemic planning in emergency medical services internationally.

Out-of-hospital cardiac arrests in the older population in Ireland.

INTRODUCTION: Age influences survival from an out-of-hospital cardiac arrest (OHCA) but it is unclear to what extent. Improved understanding of the impact of increasing age may be helpful in improving decision making on who should receive attempted resuscitation to optimise outcomes and minimise inappropriate end-of-life management. Our aim is to describe the demographics, characteristics and outcomes following resuscitation attempts in OHCA patients aged 70 years and older in Ireland. METHODS: Data were extracted from the national OHCA Register. Patient and event characteristics were compared across three age categories (70-79; 80-89; ≥90 years). Multivariable logistic regression was used to determine the predictors of the primary outcome (survival to hospital discharge). RESULTS: A total of 2281 patients aged 70 years and older were attended by emergency medical services and had resuscitation attempted between 2012 and 2014. Overall survival to hospital discharge was 2.9%. For those aged 70-79 years, 80-89 years, 90 years and older survival to hospital discharge in each age group was 4.0%, 1.8% and 1.4%, respectively. Older age (adjusted OR (AOR) 0.95 95% CI 0.90 to 0.99) and having an arrest in the subjects own home (AOR 0.14 95% CI 0.07 to 0.28) were independent predictor associated with reduced odds of survival to hospital discharge. An initial shockable rhythm (AOR 17.9. 95% CI 8.19 to 39.2) and having a bystander witnessed OHCA (AOR 3.98. 95% CI 1.38 to 11.50) were independent predictors associated with increased odds of survival to hospital discharge. CONCLUSION: In those aged 70 years and older, the rate of survival to hospital discharge declined with increasing age group. Younger age, an initial shockable rhythm and witnessed arrest were independent predictors of survival to hospital discharge.

Telemedicine in pre-hospital care: a review of telemedicine applications in the pre-hospital environment.

The right person in the right place and at the right time is not always possible; telemedicine offers the potential to give audio and visual access to the appropriate clinician for patients. Advances in information and communication technology (ICT) in the area of video-to-video communication have led to growth in telemedicine applications in recent years. For these advances to be properly integrated into healthcare delivery, a regulatory framework, supported by definitive high-quality research, should be developed. Telemedicine is well suited to extending the reach of specialist services particularly in the pre-hospital care of acute emergencies where treatment delays may affect clinical outcome. The exponential growth in research and development in telemedicine has led to improvements in clinical outcomes in emergency medical care. This review is part of the LiveCity project to examine the history and existing applications of telemedicine in the pre-hospital environment. A search of electronic databases including Medline, Excerpta Medica Database (EMBASE), Cochrane, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) for relevant papers was performed. All studies addressing the use of telemedicine in emergency medical or pre-hospital care setting were included. Out of a total of 1,279 articles reviewed, 39 met the inclusion criteria and were critically analysed. A majority of the studies were on stroke management. The studies suggested that overall, telemedicine had a positive impact on emergency medical care. It improved the pre-hospital diagnosis of stroke and myocardial infarction and enhanced the supervision of delivery of tissue thromboplasminogen activator in acute ischaemic stroke. Telemedicine presents an opportunity to enhance patient management. There are as yet few definitive studies that have demonstrated whether it had an effect on clinical outcome.

Can advanced paramedics in the field diagnose patients and predict hospital admission?

BACKGROUND: Accurate patient diagnosis in the prehospital environment is essential to initiate suitable care pathways. The advanced paramedic (AP) is a relatively recent role in Ireland, and refers to a prehospital practitioner with advanced life-support skills and training. OBJECTIVES: The objectives of this study were to compare the diagnostic decisions of APs with emergency medicine (EM) physicians, and to investigate if APs, as currently trained, can predict the requirement for hospital admission. METHODS: A prospective study was initiated, whereby each emergency ambulance call received via the statutory 999 system was recorded by the attending AP. The AP was asked to provide a clinical diagnosis for each patient, and to predict if hospital admission was required. The data was then cross-referenced with the working diagnosis of the receiving emergency physician and the hospital admission records. RESULTS: A total of 17 APs participated in the study, and 1369 emergency calls were recorded over a 6-month period. Cases where a general practitioner attended the scene were excluded from the concordance analysis. Concordance with the receiving emergency physician represents 70% (525/748) for all cases of AP diagnosis, and is mirrored with 70% (604/859) correct hospital admission predictions. CONCLUSIONS: AP diagnosis and admission prediction for emergency calls is similar to other emergency medical services systems despite the relative recency of the AP programme in Ireland. Recognition of non-concordance case types may identify priorities for AP education, and drive future AP practice in areas such as 'treat and refer'.

The advanced paramedic internship: an important clinical learning opportunity.

INTRODUCTION: Ireland introduced paramedic services to its ambulance services in 2005 and an accredited training programme has begun to train candidates. The training programme is 11 months long and includes distance learning, taught and internship phases. The internship involves six weeks of supervised paramedic practice in the setting of a rapid response vehicle crewed by two candidates, principally in urban and suburban settings. Internationally, little information has been published on the educational opportunities or impact of paramedic training and particularly on the clinical practice components of that training. METHODS: A detailed audit was carried out of clinical care activity completed by the initial 30 candidates to undertake the internship. Data were collected on patient descriptors, types of clinical problem, basic and advanced interventions undertaken and the Clinical Practice Guideline-Advanced (CPG-A) under which the advanced intervention was undertaken. Data were compiled using SPSS V11. RESULTS: Thirty candidates completed the 6-week internship, caring for a total of 1237 patients, of whom 46.3% had an advanced intervention. Intravenous cannulation was the most common advanced procedure undertaken, in one fifth of all patients seen. Twenty-two candidates inserted a total of 42 tracheal tubes or laryngeal mask airways and 55 cardiac arrests were managed. Smaller numbers of glycaemic, epilepsy and fluid resuscitation cases were dealt with. DISCUSSION: Well supervised clinical training facilitates the transition from student to autonomous practitioner. Candidates in this programme accomplished a range of clinical assessments, decisions and interventions with the support of a senior supervisor, but in a situation where they carried responsibility for safe practice.

Interfacility transport of patients with decompression illness: literature review and consensus statement.

OBJECTIVE: Decompression illness (DCI) is a potentially lethal complication of diving and may occur far from hyperbaric facilities. The need for prompt transport to a hyperbaric facility often involves air medical transport, but this may exacerbate DCI. The authors reviewed available literature to establish evidence-based transport strategies utilizing safe altitudes for patients, with DCI. METHODS: MEDLINE, EMBASE, and materials from organizations with expertise in diving medicine were searched for the following terms: decompression sickness, caisson disease, hyperbaric oxygenation, depth intoxication, or diving. Two reviewers independently selected relevant citations involving patients with DCI and air medical transport for review and consensus statement development by an expert working group. RESULTS: A total of 341 citations were identified, and 53 unique citations were reviewed. Nine relevant citations were selected for consensus statement development. There were no clinical trials or prospective cohort studies. Only two retrospective case series, including nine patients, specifically examined the effect of altitude on patients with DCI during transport. No symptom recurrence occurred when the cabin altitude remained within 500 feet of ground level. Seven citations were either letters or statements of expert opinion, recommending a maximum cabin altitude of 500-1000 feet (152-305 meters). CONCLUSIONS: The working group identified the paucity of clinical studies and evidence-based recommendations for air medical transport of patients with DCI. Transport selection should be based on minimizing total transport time and, when transporting by air, ensuring that a cabin altitude of the transporting vehicle does not exceed 500 feet (152 meters) above the departure point.