Appropriateness of intravenous cannulation by paramedics: a London study.

INTRODUCTION: The number of patients undergoing intravenous (IV) cannulation by paramedics has increased dramatically over recent years in the UK. Treatment protocols for cannulation in the field are loosely defined. Variation in practice may lead to patients' receiving differential treatment according to customary practice, rather than according to their clinical conditions. OBJECTIVES: To explore variations in practice and assess level of appropriatenesss of IV cannulation by London Ambulance Service (LAS) paramedics; to revise treatment protocols and work toward clinical guidelines, if indicated by study findings. METHODS: Skill usage data were analyzed for all LAS paramedics for 1995-96. All patients who were IV-cannulated and transported to three hospitals by LAS during March 1996 were identified. A panel of accident and emergency (A&E) and prehospital specialists judged each case for appropriateness. RESULTS: Variation during the year was wide, with a range of 1 to 221 (mean 47) patients cannulated per paramedic, although the majority showed some consistency in frequency of skill usage. A sample of 183 cases was reviewed. The majority judged 149 (81.4%) to be appropriate, although there was considerable disagreement between reviewers (kappa = 0.43, p < 0.001). Data suggested that those paramedics who cannulate more frequently cannulated less appropriately during the study period (lowest 30%: 73.9% appropriate; highest 30%: 45.8% appropriate, p = 0.05). CONCLUSION: Despite wide variation between paramedics, the panel judged overall appropriateness of cannulation to be high. The audit advisory group judged that new clinical guidelines might not achieve an improvement in practice and were not supported by study findings. It was recommended that variations be addressed through individual practice review.

Out-of-hospital intravenous cannulation: the perspective of patients treated by London Ambulance Service paramedics.

OBJECTIVES: Previous research has highlighted concern about infection rates in field-placed intravenous (IV) cannulae. In a study of IV placement by London Ambulance Service (LAS) paramedics, 17% of placements were judged to be inappropriate. Large variations in rates of IV placement between LAS paramedics were found. The authors' hypothesis was that placement of an IV carries disadvantages-pain, discomfort, distress, and infection-which may be unacceptable to patients. METHODS: This was a survey of all patients having an IV placed by LAS paramedics and transported to one of three London emergency departments (EDs) over a three-week period in December 1996. Patients were excluded if they had a self-inflicted injury/illness, were less than 14 years old, had no known address, or were visitors to the UK, or if their family doctor suggested it was not appropriate to contact the patient. Pain, discomfort, and distress; infection; satisfaction; understanding of the reason for cannulation; and out-of-hospital cannula use were all ascertained and analyzed with chi-square analysis. RESULTS: Thirty-nine percent of the respondents experienced some discomfort, 39% some pain, and 17% some distress. No patient reported an infection. Distress was more likely to be reported if there was no understanding of why the IV cannula was placed (chi2 [1] 6.1; p < 0.05). Further unstructured information revealed satisfaction with the IV cannulation and with general care. CONCLUSIONS: Despite the disadvantages of IV placement being reported by some respondents, overall levels of satisfaction were high, suggesting that these disadvantages were not unacceptable to patients. However, in the context of the 24,000 patients cannulated each year by LAS paramedics, "costs" to the patient are considerable.

The costs and benefits of helicopter emergency ambulance services in England and Wales.

BACKGROUND: Following the introduction of Helicopter Emergency Ambulance Services (HEAS) in the United Kingdom in the last ten years this paper examines the costs and benefits of three contrasting services in Cornwall, London and Sussex. METHODS: Pre-hospital processes of care were compared between helicopter attended patients and land ambulance patients in all three studies, and health outcomes were compared between helicopter and land ambulance patients in the Cornwall and London studies. A review of the literature on the benefits of HEAS has also been undertaken. RESULTS: There were no improvements in response times and the time on scene was longer for helicopter attended patients. Survival of trauma or cardiac patients attended by helicopter was not improved. In London there was some evidence of worse residual disability in helicopter attended survivors, but in Cornwall residual disability was better in helicopter attended patients. There was no improvement in general health status or aspects of daily living in the helicopter attended patients. The overall total operational costs for these services were [symbol: see text] 55 000 p.a. in Sussex, [symbol: see text] 600 000 in Cornwall and [symbol: see text] 1.2 million in London. CONCLUSION: The analysis suggests that Helicopter Emergency Ambulance Services are costly, the health benefits are small, and there are limited circumstances in which the pre-hospital performance of an ambulance service in England and Wales can be improved.