Healthcare professional views about a prehospital redirection pathway for stroke thrombectomy: a multiphase deductive qualitative study.

BACKGROUND: Mechanical thrombectomy for stroke is highly effective but time-critical. Delays are common because many patients require transfer between local hospitals and regional centres. A two-stage prehospital redirection pathway consisting of a simple ambulance screen followed by regional centre assessment to select patients for direct admission could optimise access. However, implementation might be challenged by the limited number of thrombectomy providers, a lack of prehospital diagnostic tests for selecting patients and whether finite resources can accommodate longer ambulance journeys plus greater central admissions. We undertook a three-phase, multiregional, qualitative study to obtain health professional views on the acceptability and feasibility of a new pathway. METHODS: Online focus groups/semistructured interviews were undertaken designed to capture important contextual influences. We purposively sampled NHS staff in four regions of England. Anonymised interview transcripts underwent deductive thematic analysis guided by the NASSS (Non-adoption, Abandonment and Challenges to Scale-up, Spread and Sustainability, Implementation) Implementation Science framework. RESULTS: Twenty-eight staff participated in 4 focus groups, 2 group interviews and 18 individual interviews across 4 Ambulance Trusts, 5 Hospital Trusts and 3 Integrated Stroke Delivery Networks (ISDNs). Five deductive themes were identified: (1) (suspected) stroke as a condition, (2) the pathway change, (3) the value participants placed on the proposed pathway, (4) the possible impact on NHS organisations/adopter systems and (5) the wider healthcare context. Participants perceived suspected stroke as a complex scenario. Most viewed the proposed new thrombectomy pathway as beneficial but potentially challenging to implement. Organisational concerns included staff shortages, increased workflow and bed capacity. Participants also reported wider socioeconomic issues impacting on their services contributing to concerns around the future implementation. CONCLUSIONS: Positive views from health professionals were expressed about the concept of a proposed pathway while raising key content and implementation challenges and useful 'real-world' issues for consideration.

Inequalities in birth before arrival at hospital in South West England: a multimethods study of neonatal hypothermia and emergency medical services call-handler advice.

OBJECTIVES: To examine inequalities in birth before arrival (BBA) at hospitals in South West England, understand which groups are most likely to experience BBA and how this relates to hypothermia and outcomes (phase A). To investigate opportunities to improve temperature management advice given by emergency medical services (EMS) call-handlers during emergency calls regarding BBA in the UK (phase B). DESIGN: A two-phase multimethod study. Phase A analysed anonymised data from hospital neonatal records between January 2018 and January 2021. Phase B analysed anonymised EMS call transcripts, followed by focus groups with National Health Service (NHS) staff and patients. SETTING: Six Hospital Trusts in South West England and two EMS providers (ambulance services) in South West and North East England. PARTICIPANTS: 18 multidisciplinary NHS staff and 22 members of the public who had experienced BBA in the UK. RESULTS: 35% (64/184) of babies conveyed to hospital were hypothermic on arrival. When compared with national data on all births in the South West, we found higher percentages of women with documented safeguarding concerns at booking, previous live births and 'late bookers' (booking their pregnancy >13 weeks gestation). These women may, therefore, be more likely to experience BBA. Preterm babies, babies to first-time mothers and babies born to mothers with disability or safeguarding concerns at booking were more likely to be hypothermic following BBA. Five main themes emerged from qualitative data on call-handler advice: (1) importance placed on neonatal temperature; (2) advice on where the baby should be placed following birth; (3) advice on how to keep the baby warm; (4) timing of temperature management advice and (5) clarity and priority of instructions. CONCLUSIONS: Findings identified factors associated with BBA and neonatal hypothermia following BBA. Improvements to EMS call-handler advice could reduce the number of babies arriving at hospital hypothermic.

The COVID-19 ambulance response assessment (CARA) study: a national survey of ambulance service healthcare professionals' preparedness and response to the COVID-19 pandemic.

Background: The COVID-19 pandemic placed significant demand on the NHS, including ambulance services, but it is unclear how this affected ambulance service staff and paramedics in other clinical settings (e.g. urgent and primary care, armed services, prisons). This study aimed to measure the self-perceived preparedness and impact of the first wave of the pandemic on paramedics' psychological stress and perceived ability to deliver care. Methods: Ambulance clinicians and paramedics working in other healthcare settings were invited to participate in a three-phase sequential online survey during the acceleration (April 2020), peak (May 2020) and deceleration (September/October 2020) phases of the first wave of COVID-19 in the United Kingdom. Recruitment used social media, Trust internal bulletins and the College of Paramedics' communication channels, employing a convenience sampling strategy. Data were collected using purposively developed open- and closed-ended questions and the validated general health questionnaire-12 (GHQ-12). Data were analysed using multi-level linear and logistic regression models. Results: Phase 1 recruited 3717 participants, reducing to 2709 (73%) by phase 2 and 2159 (58%) by phase 3. Participants were mostly male (58%, n = 2148) and registered paramedics (n = 1992, 54%). Mean (standard deviation) GHQ-12 scores were 16.5 (5.2) during phase 1, reducing to 15.2 (6.7) by phase 3. A total of 84% of participants (n = 3112) had a GHQ-12 score ≥ 12 during the first phase, indicating psychological distress. Participants that had higher GHQ-12 scores were feeling unprepared for the pandemic, and reported a lack of confidence in using personal protective equipment and managing cardiac arrests in confirmed or suspected COVID-19 patients. Conclusions: Most participants reported psychological distress, the reasons for which are multi-factorial. Ambulance managers need to be aware of the risks to staff mental health and take action to mitigate these, to support staff in the delivery of unscheduled, emergency and urgent care under these additional pressures.

A qualitative exploration of ambulance clinician behaviour and decision making to identify factors influencing on-scene times for suspected stroke patients in North East England.

Aims/objectives: Ambulance clinician assessment of suspected stroke patients aims to provide rapid access to specialist care, however regional and national data show increasing pre-hospital times. This study explored paramedic views about factors contributing to on-scene time (OST) for suspected stroke patients, with a view to identifying opportunities for future interventions, to reduce OST. Methods: Views of paramedics from one regional service on factors influencing OST were explored using a qualitative approach. Semi-structured interviews with volunteers were recorded, transcribed and analysed using thematic analysis. Results: Interviews were conducted with 13 paramedics between August and November 2021. Five interlinked themes were identified and described a range of factors influencing OST: 'Initial assessment and sources of information' describes how clinicians make assessments based on initial presentation, influenced by pre-arrival information from ambulance control and family members / bystanders at the scene, and how this influences OST.'Suitability for treatment and interventions' describes how paramedics consider actions such as the face, arms, speech test, cannulation, electrocardiograms and neurological assessments while recognising that pre-hospital interventions for suspected stroke are limited.'The environment' describes the influence of incident setting on OST, including the overall process needed to transport the patient to appropriate care.'Hospital interactions' describes how interactions with hospital staff influenced paramedic actions and OST.'Changing practice' describes the influence of experience and interaction with hospital staff leading to changes in paramedic practice over time. Conclusion: This study provides insight into how UK paramedics spend time on scene with stroke patients. Multiple factors influencing OST were identified which signpost opportunities for interventions designed to reduce OST. Standardising on-scene assessments for stroke patients, refining communication processes between ambulance services and hospital stroke services and increasing availability of stroke continuing professional development for paramedics were all identified as potential targets for improving OST.

What factors contribute towards ambulance on-scene times for suspected stroke patients? An observational study.

INTRODUCTION: Pre-hospital stroke care focusses on rapid access to specialist stroke units, but UK ambulance data shows increasing pre-hospital times. This study aimed to describe factors contributing towards ambulance on-scene times (OST) for suspected stroke patients and identify targets for a future intervention. PATIENTS AND METHODS: Ambulance clinicians in North East Ambulance Service were asked to complete a survey after transporting any suspected stroke patients to describe the patient encounter, interventions and timings. Completed surveys were linked with electronic patient care records. Potentially modifiable factors were identified by the study team. Poisson regression analysis quantified the association of selected potentially modifiable factors with OST. RESULTS: About 2037 suspected stroke patients were conveyed between July and December 2021, resulting in 581 fully completed surveys by 359 different clinicians. The median age of patients was 75 years (interquartile range (IQR) 66-83) and 52% of patients were male. Median OST was 33 min (IQR 26-41). Three potentially modifiable factors were identified as contributors to extended OST. Performing additional advanced neurological assessments added 10% to OST (34 vs 31 min, p = 0.008); intravenous cannulation added 13% (35 vs 31 min, p = <0.001) and ECGs added 22% (35 vs 28 min, p = <0.001). CONCLUSIONS: This study identified three potentially modifiable factors that increased pre-hospital OST with suspected stroke patients. This type of data can be used to target interventions at behaviours that extend pre-hospital OST but which have questionable patient benefit. This approach will be evaluated in a follow up study in the North East of England.

The RESearch PARamedic Experience (RESPARE) study: a qualitative study exploring the experiences of research paramedics working in the United Kingdom.

Background: The research paramedic position is a relatively niche role undertaken by a small number of paramedics who support, deliver and promote research. Research paramedic roles provide opportunities to develop talented researchers who are recognised as vital elements of developing a research culture within ambulance services. The benefits of research-active clinicians have been recognised at a national level. The aim of this study was to explore the experience of people who work, or have worked, as research paramedics. Methods: A generic qualitative approach underpinned by phenomenological concepts was used. Volunteers were recruited via ambulance research leads and social media. Online focus groups allowed participants to discuss their roles with peers who may be geographically distant. Semi-structured interviews expanded on the focus group findings. Data were recorded, transcribed verbatim and analysed using framework analysis. Results: Eighteen paramedics (66% female, median involvement in research six (interquartile range 2-7) years) representing eight English NHS ambulance trusts participated in three focus groups and five interviews lasting around one hour, in November and December 2021.Six key themes were identified: starting as a research paramedic; barriers and facilitators to working as a research paramedic; research careers; opportunities; the community (support and networking); and the value of a clinical identity. Conclusions: Many research paramedics had similar experiences in terms of starting their career by delivering research for large studies, then building on this experience and the networks they create to develop their own research. There are common organisational and financial barriers to working as a research paramedic. Career progression in research beyond the research paramedic role is not well defined, but often involves building links outside of the ambulance service.

Documentation of atrial fibrillation among non-conveyed ambulance patients: a new primary prevention opportunity?

Introduction: Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and is a significant risk factor for stroke. Prescription of oral anticoagulant (OAC) medication reduces the risk of AF-related stroke by 64% - yet over 400,000 people in England have undiagnosed (and therefore untreated) AF.Emergency medical services (EMS) encounter a wide range of patients, some of whom may not engage with other healthcare services. AF may be detected by EMS in connection with the cause of the call, or as an incidental finding. While EMS are not traditionally utilised for public health screening, they may offer an opportunity to identify patients with undiagnosed or untreated AF and refer onward.This study aimed to explore what proportion of patients seen by EMS who were not transported to hospital had AF and to estimate how many would potentially benefit from OAC. Methods: A retrospective service evaluation was conducted using routinely collected data from a large UK regional ambulance service. The sample included adults attended by EMS on the 15th of each month in 2019, who were not transported to hospital and where an electrocardiogram was recorded. Of those with AF, we calculated the proportion in whom this was possibly new and report whether OAC was prescribed. Results: There were 859 patients who met the inclusion criteria, of whom 91 (11%) had AF documented. Of the 91 patients with AF, 23 (25%) had no documented history of AF or OAC prescription, so were potentially new diagnoses of AF, who would benefit from consideration of OAC therapy. Conclusion: The EMS assessment offers an opportunity for AF to be identified in patients who were not transported to hospital. EMS may have a role in primary prevention of harm, including stroke, by identifying and referring patients with AF for consideration of OAC.

A qualitative exploration of the views of paramedics regarding the identification of cardiovascular risk factors in the pre-hospital environment.

Background: Cardiovascular disease remains the most prominent cause of death in England. Healthcare professionals have been encouraged to identify cardiovascular risk factors (CVRFs). The aim of this study was to explore how paramedics contribute to the identification of CVRFs in the pre-hospital setting, through their role, behaviours and practice. Methods: The study took place within the North East Ambulance Service NHS Foundation Trust supported by a National Institute for Health Research clinical research internship. A qualitative approach was used, and a single focus group was conducted. The study recruited participants through advertising for volunteers and purposive sampling. The themes that arose from the focus group allowed the initial exploration of the views of paramedics in relation to role, behaviour and practice in identifying CVRFs. Results: A single focus group with five paramedics was conducted in June 2021. Two central themes emerged: education/health promotion and fear/anxiety. Participants agreed that their role in this area centred around patient education. Participants' behaviours and practice were adversely affected through fear of complaints, fear of hypocrisy and feeling a lack of support from the ambulance service. Participants felt that further training and subsequent indemnity from complaints would improve the likelihood of more direct patient education. Support from the ambulance service to improve employees' own health and well-being was also a key topic of discussion. Conclusion: The study explored the views of a small sample of paramedics on this topic. Patient education was felt to be part of a paramedic's role; however, barriers were identified that prevent paramedics from carrying out this role. Further research is needed to explore these barriers further.

Public attitudes towards bystander CPR and their association with social deprivation: Findings from a cross sectional study in North England.

Background: Bystander cardiopulmonary resuscitation (BCPR) is undertaken in only 40% of out of hospital cardiac arrests (OHCAs) in the UK. Lower rates of BCPR and public access defibrillator (PAD) use have been correlated with lower socio-economic status (SES). The aim of this study was to examine knowledge and attitudes towards BCPR and PAD's using a study specific questionnaire, and to understand how these potentially interact with individual characteristics and SES. Methods: Cross-sectional study between July-December 2021 across areas of varying SES in North England. Results: Six hundred and one individuals completed the survey instrument (mean age = 51.9 years, 52.2 % female). Increased age was associated with being less willing to call 999 (p < 0.001) and follow call handler advice (p < 0.001). Female respondents were less comfortable performing BCPR than male respondents (p = 0.006). Individuals from least deprived areas were less likely to report comfort performing CPR, (p = 0.016) and less likely to know what a PAD is for, (p = 0.025). Higher education level was associated with increased ability to recognise OHCA (p = 0.005) and understanding of what a PAD is for (p < 0.001). Individuals with higher income were more likely to state they would follow advice regarding BCPR (p = 0.017) and report comfort using a PAD (p = 0.029). Conclusion: Individual characteristics such as age and ethnicity, rather than SES, are indicators of knowledge, willingness, and perceived competency to perform BCPR. Policy makers should avoid using SES alone to target interventions. Future research should examine how cultural identity and social cohesion intersect with these characteristics to influence willingness to perform BCPR.

How do interventions to improve the efficiency of acute stroke care affect prehospital times? A systematic review and narrative synthesis.

BACKGROUND: Emergency medical services (EMS) are the first point of contact for most acute stroke patients. EMS call to hospital times have increased in recent years for stroke patients in the UK which is undesirable due to the relationship between time and effectiveness of reperfusion treatment. This review aimed to identify and describe interventions devised to improve the efficiency of acute stroke care which reported an impact on ground-based EMS call to hospital times. METHODS: A systematic review of published literature identified from five databases (Medline, EMBASE, CINAHL, the Cochrane library and the Database of Research in Stroke (DORIS)) from January 2000 to December 2020 with narrative synthesis was conducted. Inclusion criteria were primary studies of ground-based EMS, focused on stroke and aiming to improve EMS times. Papers published before 2000, focussing on mobile stroke units or in languages other than English were excluded. Two reviewers independently screened prospective titles. Cochrane ROB2 and ROBINS-I tools were used to assess for risk of bias. This review was funded by a Stroke Association fellowship. RESULTS: From 3767 initial records, 11 studies were included in the review. Included studies were categorised into three groups: studies targeting EMS dispatch and EMS clinicians (n = 4); studies targeting EMS clinicians only (n = 4); and studies targeting whole system change (n = 3). Suspected stroke patients were the primary population studied and most (n = 10) interventions involved clinician education. Only one study (9%) reported a significant decrease in call to hospital time in one subgroup whereas two studies (18%) reported a significant increase in call to hospital time and all other studies (73%) reported no significant change. CONCLUSIONS: Based on the included studies, interventions intended to improve the efficiency of the acute stroke pathway rarely improved EMS call to hospital times. Included studies were heterogenous and rarely focussed on the review topic which limits the usability of the findings. Further research is needed to explore the trade-off between changes to EMS stroke care and call to hospital times and subsequent impacts on in-hospital care and patient outcomes.

Temperature measurement of babies born in the pre-hospital setting: analysis of ambulance service data and qualitative interviews with paramedics.

BACKGROUND: Birth before arrival at hospital (BBA) is associated with unfavourable perinatal outcomes and increased mortality. An important risk factor for mortality following BBA is hypothermia, and emergency medical services (EMS) providers are well placed to provide warming strategies. However, research from the UK suggests that EMS providers (paramedics) do not routinely record neonatal temperature following BBA. This study aimed to determine the proportion of cases in which neonatal temperature is documented by paramedics attending BBAs in the South West of England and to explore the barriers to temperature measurement by paramedics. METHODS: A two-phase multi-method study. Phase I involved an analysis of anonymised data from electronic patient care records between 1 February 2017 and 31 January 2020 in a single UK ambulance service, to determine 1) the frequency of BBAs attended and 2) the percentage of these births where a neonatal temperature was recorded, and what proportion of these were hypothermic. Phase II involved interviews with 20 operational paramedics from the same ambulance service, to explore their experiences of, and barriers and facilitators to, neonatal temperature measurement and management following BBA. RESULTS: There were 1582 'normal deliveries' attended by paramedics within the date range. Neonatal temperatures were recorded in 43/1582 (2.7%) instances, of which 72% were below 36.5°C. Data from interviews suggested several barriers and potential facilitators to paramedic measurement of neonatal temperature. Barriers included unavailable or unsuitable equipment, prioritisation of other care activities, lack of exposure to births, and uncertainty regarding responsibilities and roles. Possible facilitators included better equipment, physical prompts, and training and awareness-raising around the importance of temperature measurement. CONCLUSIONS: This study demonstrates a lack of neonatal temperature measurement by paramedics in the South West following BBA, and highlights barriers and facilitators that could serve as a basis for developing an intervention to improve neonatal temperature measurement.

Novel Technologies and Techniques for Prehospital Airway Management: An NAEMSP Position Statement and Resource Document.

Novel technologies and techniques can influence airway management execution as well as procedural and clinical outcomes. While conventional wisdom underscores the need for rigorous scientific data as a foundation before implementation, high-quality supporting evidence is frequently not available for the prehospital setting. Therefore, implementation decisions are often based upon preliminary or evolving data, or pragmatic information from clinical use. When considering novel technologies and techniques. NAEMSP recommends:Prior to implementing a novel technology or technique, a thorough assessment using the best available scientific data should be conducted on the technical details of the novel approach, as well as the potential effects on operations and outcomes.The decision and degree of effort to adopt, implement, and monitor a novel technology or technique in the prehospital setting will vary by the quality of the best available scientific and clinical information:• Routine use - Technologies and techniques with ample observational but limited or no interventional clinical trial data, or with strong supporting in-hospital data. These techniques may be reasonably adopted in the prehospital setting. This includes video laryngoscopy and bougie-assisted intubation. • Limited use - Technologies and techniques with ample pragmatic clinical use information but limited supporting scientific data. These techniques may be considered in the prehospital setting. This includes suction-assisted laryngoscopy and airway decontamination and cognitive aids. • Rare use - Technologies and techniques with minimal clinical use information. Use of these techniques should be limited in the prehospital setting until evidence exists from more stable clinical environments. This includes intubation boxes.The use of novel technologies and techniques must be accompanied by systematic collection and assessment of data for the purposes of quality improvement, including linkages to patient clinical outcomes.EMS leaders should clearly identify the pathways needed to generate high-quality supporting scientific evidence for novel technologies and techniques.

Hangings attended by ambulance clinicians in the North East of England.

INTRODUCTION: Suicide rates have risen in England over the last decade and hanging, a highly lethal method of suicide, has been the most common method. Previous work in this area identified a lack of literature discussing emergency medical services (EMS) attendance at hangings. This article aims to describe hangings attended by EMS in the North East of England in order to inform future work in this area. METHODS: A retrospective service evaluation was conducted using existing data from a comprehensive pre-hospital trauma audit database to describe patients with hanging documented in their records who were attended by ambulance clinicians between 1 December 2018 and 31 November 2020. RESULTS: Hanging was recorded in 604 incidents. Most cases (n = 579/604) involved adults (aged 18 years or older) with a median age of 35 years (IQR 27-45 years), who were male (n = 410/579, 71%). Just over half (n = 341/579, 59%) of adult hangings resulted in cardiac arrest and of these, 10% (n = 33/341) were resuscitated and survived to hospital admission. Threatened and non-fatal hangings appear to have increased dramatically in the latter half of 2020. Previous suicide attempts and mental health issues were frequently reported across this population. CONCLUSION: Hangings are a method of suicide which frequently result in a cardiac arrest. In the North East of England the ambulance service attends approximately one hanging per day and one fatal hanging every two days. When fatal hangings were resuscitated, pre-hospital outcomes were similar to other causes of cardiac arrest, highlighting that despite the traumatic nature of these cases resuscitation is not futile. In order to better understand this patient group and improve care, pre-hospital data need to be linked to data from other services such as mental health services and acute hospitals.

Ambulance service call handler and clinician identification of stroke in North East Ambulance Service.

INTRODUCTION: Emergency medical services (EMS) are the first point of contact for most acute stroke patients. The EMS response is triggered by ambulance call handlers who triage calls and then an appropriate response is allocated. Early recognition of stroke is vital to minimise the call to hospital time as the availability and effectiveness of reperfusion therapies are time dependent. Minimising the pre-hospital phase by accurate call handler stroke identification, short EMS on-scene times and rapid access to specialist stroke care is vital. The aims of this study were to evaluate stroke identification by call handlers and clinicians in North East Ambulance Service (NEAS) and report on-scene times for suspected stroke patients. METHODS: A retrospective service evaluation was conducted linking routinely collected data between 1 and 30 November 2019 from three sources: NEAS Emergency Operations Centre; NEAS clinicians; and hospital stroke diagnoses. RESULTS: The datasets were linked resulting in 2214 individual cases. Call handler identification of acute stroke was 51.5% (95% CI 45.3-57.8) sensitive with a positive predictive value (PPV) of 12.8% (95% CI 11.4-14.4). Face-to-face clinician identification of stroke was 76.1% (95% CI 70.4-81.1) sensitive with a PPV of 27.4% (95% CI 25.3-29.7). The median on-scene time was 33 (IQR 25-43) minutes, with call handler and clinician identification of stroke resulting in shorter times. CONCLUSION: This service evaluation using ambulance data linked with national audit data showed that the sensitivity of NEAS call handler and clinician identification of stroke are similar to figures published on other systems but the PPV of call handler and clinician identification stroke could be improved. However, sensitivity is paramount while timely identification of suspected stroke patients and rapid transport to definitive care are the primary functions of EMS. Call handler identification of stroke appears to affect the time that clinicians spend at scene with suspected stroke patients.

Hangings attended by emergency medical services: a scoping review.

BACKGROUND: In the United Kingdom (UK) there were 6507 deaths by suicide in 2018, with hanging being the most common method. Hanging will normally result in emergency medical services (EMS) being called and may result in resuscitation being attempted. Trauma audits conducted by North East Ambulance Service NHS Foundation Trust have identified an increased trend in hanging cases, which were also reported in national data. The aim of this scoping review was to explore the literature around EMS attendance at hangings to inform further research and clinical practice. METHODS: A five-stage scoping review method was used. Relevant studies were identified by searching MEDLINE, CINAHL, EMBASE and EMCARE with the help of the Library and Knowledge Service for NHS Ambulance Services in England. Grey literature and reference lists were also searched. Studies were included based on relevance to hangings attended by EMS. Data were tabulated and narratively synthesised. RESULTS: Sixteen papers were included in the review. Australia was the most frequent source of studies (n = 5, 31%). Most studies (n = 11, 69%) were published in the past 10 years. The median sample size was 53 (IQR 41-988, range 10-3981). All papers included varying levels of patient characteristics, EMS input and patient outcomes. CONCLUSION: Hanging is a highly lethal method of suicide that is increasingly used in the UK. This scoping review found that there is scarce literature focused on hangings attended by EMS. Treatment of the hanging patient in cardiac arrest is described in many of the papers included. Hanging patients may benefit from the presence of specialist resources who can deliver interventions such as sedation and advanced airway management. The psychological impact of attending, or witnessing, hanging patients is an area that needs further consideration. Further research is needed to describe and improve EMS treatment of hangings.

To collar or not to collar. Views of pre-hospital emergency care providers on immobilisation without cervical collars: a focus group study.

BACKGROUND: Spinal cord injury (SCI) is a rare event, with high numbers of patients unnecessarily immobilised with no potential benefit based on limited evidence from the 1950s and 1960s. Contemporary opinion now challenges the notion that traditional immobilisation prevents movement and protects the spine. Current literature suggests that these methods which include semi-rigid collars can potentially cause more movement of the spine and harm the patient. The purpose of this study was to explore the views and perspectives of pre-hospital care providers on immobilising patients without the use of a semi-rigid collar. METHODS: Focus groups were used to allow individuals to discuss and comment on a new method of immobilisation which omits the semi-rigid collar and to capture the thoughts, feelings and experiences of participants. Thematic analysis of the coded transcriptions was used to identify emerging themes. RESULTS: Three focus groups were conducted with 15 participants in each. Participants were all exposed to patients sustaining trauma within their professional roles. Six intertwined themes emerged from the analysis: communication, conflict, education/training, empowerment, risk and the patient. Woven between these themes are the complex interactions that bring together the inter-professional relationships with other emergency services and hospital staff, the patient, the public and pre-hospital care providers. DISCUSSION: Existing immobilisation practices are being challenged, with clinicians empowered to tailor practice to meet specific patient needs. There is limited empirical evidence to support current immobilisation practices. Contemporary literature suggests current practices may potentially cause harm. New pragmatic immobilisation practices are gradually being adopted by some pre-hospital care providers. CONCLUSION: This study explored the perspectives of pre-hospital care providers on immobilising patients without the use of a semi-rigid collar for potential SCI. The consensus of the participants supports a pragmatic approach to managing potential SCI that provides safe, high-quality patient-centred care.

The impact of introducing real time feedback on ventilation rate and tidal volume by ambulance clinicians in the North East in cardiac arrest simulations.

BACKGROUND: Research suggests rescuers deliver ventilations outside of recommendations during out of hospital cardiac arrest (OHCA), which can be deleterious to survival. We aimed to determine if ambulance clinician compliance with ventilation recommendations could be improved using the Zoll Accuvent real time ventilation feedback device (VFD). METHODS: Participants simulated a two-minute cardiac arrest scenario using a mannequin and defibrillator without ventilation feedback. Eligible for inclusion were all clinicians aged ≥18 years who perform cardiopulmonary resuscitation (CPR) as part of their role, who had completed an internal advanced life support (ALS) refresher. Following familiarisation of a few minutes with the VFD, participants repeated the two-minute scenario with ventilation feedback. Ventilation rate and volume and CPR quality were recorded. Primary outcome was % difference in ventilation compliance with and without feedback. Secondary outcomes were differences between paramedic and non-paramedic clinicians and compliance with chest compression guidelines. RESULTS: One hundred and six participants completed the study. Median ventilation rate without feedback was 10 (IQR 8-14, range 4-30) compared to 9 (IQR 9-9, range 6-17) with feedback; median tidal volume without feedback was 630 mls (IQR 518-725, range 201-1114) compared to 546 mls (IQR 531-560, range 490-750) with feedback. Proportion of clinicians ≥50% compliant with European Resuscitation Council ventilation recommendations were significantly greater with ventilation feedback compared to without, 91% vs. 9%, (McNemars test p = <0.0001). Paramedics out performed non-paramedic clinicians with and without feedback and compression quality was not compromised by using the VFD. CONCLUSIONS: Ambulance clinician baseline ventilation quality was frequently outside of recommendations, but a VFD can ensure treatment is within evidence-based recommendations. Further research is required to validate the use of the VFD in true clinical practice and to evaluate the relationship between improved ventilation quality during OHCA and patient outcomes.

Characteristics of patients who had a stroke not initially identified during emergency prehospital assessment: a systematic review.

BACKGROUND: Around 25% of patients who had a stroke do not present with typical 'face, arm, speech' symptoms at onset, and are challenging for emergency medical services (EMS) to identify. The aim of this systematic review was to identify the characteristics of acute stroke presentations associated with inaccurate EMS identification (false negatives). METHOD: We performed a systematic search of MEDLINE, EMBASE, CINAHL and PubMed from 1995 to August 2020 using key terms: stroke, EMS, paramedics, identification and assessment. Studies included: patients who had a stroke or patient records; ≥18 years; any stroke type; prehospital assessment undertaken by health professionals including paramedics or technicians; data reported on prehospital diagnostic accuracy and/or presenting symptoms. Data were extracted and study quality assessed by two researchers using the Quality Assessment of Diagnostic Accuracy Studies V.2 tool. RESULTS: Of 845 studies initially identified, 21 observational studies met the inclusion criteria. Of the 6934 stroke and Transient Ischaemic Attack patients included, there were 1774 (26%) false negative patients (range from 4 (2%) to 247 (52%)). Commonly documented symptoms in false negative cases were speech problems (n=107; 13%-28%), nausea/vomiting (n=94; 8%-38%), dizziness (n=86; 23%-27%), changes in mental status (n=51; 8%-25%) and visual disturbance/impairment (n=43; 13%-28%). CONCLUSION: Speech problems and posterior circulation symptoms were the most commonly documented symptoms among stroke presentations that were not correctly identified by EMS (false negatives). However, the addition of further symptoms to stroke screening tools requires valuation of subsequent sensitivity and specificity, training needs and possible overuse of high priority resources.