1
|
Runacres J, Harvey H, O'Brien S, Halck A. Paramedics as Researchers: A Systematic Review of Paramedic Perspectives of Engaging in Research Activity From Training to Practice. J Emerg Med 2024; 66:e680-e689. [PMID: 38734546 DOI: 10.1016/j.jemermed.2024.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 12/18/2023] [Accepted: 01/06/2024] [Indexed: 05/13/2024]
Abstract
BACKGROUND The need for a stronger evidence-base in paramedicine has precipitated a rapid development of prehospital research agendas. Paramedics are increasingly involved in research, leading to changes in their role. Yet, the integration of research responsibilities has proven to be challenging, resulting in varying attitudes and levels of engagement. OBJECTIVE This systematic review aimed to explore paramedics' views and experiences of research as researchers during training and within practice. METHODS A systematic search was performed across six databases. Qualitative empirical peer-reviewed articles that discussed paramedic perspectives on engaging with research activity were included. Of 10,594 articles identified initially, 11 were included in the final synthesis after quality appraisal. Data were extracted and subjected to narrative synthesis. RESULTS The following four themes were identified: motivation to engage, moral dilemmas, structural issues within the profession, and reflections on trial involvement. Attitudes toward research, understanding of related concepts, and the drive for patient benefit were interwoven core issues. CONCLUSIONS Research was highly valued when links to patient benefit were obvious, however, this review highlights some cultural resistance to research, particularly regarding informed consent and changes to standard practice. Paramedic research methods training should provide structured opportunities to explore concerns and emphasize the role of research in developing a high-quality evidence base to underpin safe practice. Currently, there is inadequate organizational support for paramedics to engage effectively in research activity, with minimal allocations of time, training, and remuneration. Without properly integrating research activity into the paramedic role, their capacity to engage with research activity is limited.
Collapse
Affiliation(s)
- Jessica Runacres
- Midwifery and Allied Health, Staffordshire University, Stafford, Staffordshire, UK
| | - Hannah Harvey
- Nursing and Midwifery, Birmingham City University, Birmingham, West Midlands, UK
| | - Sam O'Brien
- Midwifery and Allied Health, Staffordshire University, Stafford, Staffordshire, UK
| | - Amy Halck
- Midwifery and Allied Health, Staffordshire University, Stafford, Staffordshire, UK
| |
Collapse
|
2
|
Dixon M, Appleton JP, Siriwardena AN, Williams J, Bath PM. A systematic review of ambulance service-based randomised controlled trials in stroke. Neurol Sci 2023; 44:4363-4378. [PMID: 37405524 PMCID: PMC10641071 DOI: 10.1007/s10072-023-06910-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Accepted: 06/12/2023] [Indexed: 07/06/2023]
Abstract
BACKGROUND Treatment for stroke is time-dependent, and ambulance services play a vital role in the early recognition, assessment and transportation of stroke patients. Innovations which begin in ambulance services to expedite delivery of treatments for stroke are developing. However, research delivery in ambulance services is novel, developing and not fully understood. AIMS To synthesise literature encompassing ambulance service-based randomised controlled interventions for acute stroke with consideration to the characteristics of the type of intervention, consent modality, time intervals and issues unique to research delivery in ambulance services. Online searches of MEDLINE, EMBASE, Web of Science, CENTRAL and WHO IRCTP databases and hand searches identified 15 eligible studies from 538. Articles were heterogeneous in nature and meta-analysis was partially available as 13 studies reported key time intervals, but terminology varied. Randomised interventions were evident across all points of contact with ambulance services: identification of stroke during the call for help, higher dispatch priority assigned to stroke, on-scene assessment and clinical interventions, direct referral to comprehensive stroke centres and definitive care delivery at scene. Consent methods ranged between informed patient, waiver and proxy modalities with country-specific variation. Challenges unique to the prehospital setting comprise the geographical distribution of ambulance resources, low recruitment rates, prolonged recruitment phases, management of investigational medicinal product and incomplete datasets. CONCLUSION Research opportunities exist across all points of contact between stroke patients and ambulance services, but randomisation and consent remain novel. Early collaboration and engagement between trialists and ambulance services will alleviate some of the complexities reported. REGISTRATION NUMBER PROSPERO 2018CRD42018075803.
Collapse
Affiliation(s)
- Mark Dixon
- Stroke Trials Unit, Mental Health & Clinical Neuroscience, University of Nottingham, Queens Medical Centre Campus, Nottingham, NG7 2UH, UK
- East Midlands Ambulance Service NHS Trust, Nottingham, UK
| | - Jason P Appleton
- Stroke Trials Unit, Mental Health & Clinical Neuroscience, University of Nottingham, Queens Medical Centre Campus, Nottingham, NG7 2UH, UK
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | | | - Julia Williams
- Department of Paramedic Science, School of Health and Social Work, University of Hertfordshire, Hatfield, UK
| | - Philip M Bath
- Stroke Trials Unit, Mental Health & Clinical Neuroscience, University of Nottingham, Queens Medical Centre Campus, Nottingham, NG7 2UH, UK.
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK.
| |
Collapse
|
3
|
Dixon M, Williams J, Bath PM. Challenges and Experiences in Multicenter Prehospital Stroke Research: Narrative Data from the Rapid Intervention with Glyceryl Trinitrate in Hypertensive Stroke Trial-2 (RIGHT-2). PREHOSP EMERG CARE 2023:1-9. [PMID: 38019218 DOI: 10.1080/10903127.2023.2287171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 11/20/2023] [Indexed: 11/30/2023]
Abstract
BACKGROUND Ambulance services are increasingly research active and the Rapid Intervention with Glyceryl trinitrate in Hypertensive stroke Trial-2 (RIGHT-2) is the largest United Kingdom (UK) ambulance-based randomized controlled trial in stroke. We explore the complexities and challenges encountered during RIGHT-2. METHODS Five hundred and sixteen of 1487 paramedics from eight UK ambulance services serving 54 comprehensive or primary stroke care centers screened and consented 1149 patients presenting within 4 h of FAST-positive stroke and with systolic blood pressure >120 mmHg; participants were randomized to treatment with transdermal glyceryl trinitrate versus sham patch in the ambulance. KEY FINDINGS Working with multiple ambulance services demanded flexibility in the trial protocol to overcome variation in operating procedures to ensure deliverability. Many paramedics are novice researchers, and research concepts and practices are emerging including consent strategies in emergency stroke care. Regional variation in hospital participation and hours/days of operation presented paramedics with additional considerations prior to patient recruitment. The working hours of hospital research staff often do not reflect the 24/7 nature of ambulance work, which challenged deliverability until trial processes became fully embedded. Management of investigational medicinal product between ambulance stations, in-transit when on ambulance vehicles and on handover at hospital, necessitated an in-depth review to maintain accountability. CONCLUSION RIGHT-2 demonstrated that although there are significant practical challenges to conducting multicenter ambulance-based research in a time-dependent environment, careful planning and management facilitated delivery. Lessons learned here will help inform the design and conduct of future ambulance-based trials.
Collapse
Affiliation(s)
- Mark Dixon
- Stroke Trials Unit, Mental Health & Clinical Neuroscience, University of Nottingham, Queens Medical Centre, Nottingham, UK
- East Midlands Ambulance Service NHS Trust, Nottingham, UK
| | - Julia Williams
- Department of Paramedic Science, School of Health and Social Work, University of Hertfordshire, Hatfield, UK
| | - Philip M Bath
- Stroke Trials Unit, Mental Health & Clinical Neuroscience, University of Nottingham, Queens Medical Centre, Nottingham, UK
- Stroke, Acute Medicine, Nottingham University Hospitals NHS Trust, Nottingham, UK
| |
Collapse
|
4
|
Fladt J, Ospel JM, Singh N, Saver JL, Fisher M, Goyal M. Optimizing Patient-Centered Stroke Care and Research in the Prehospital Setting. Stroke 2023; 54:2453-2460. [PMID: 37548010 DOI: 10.1161/strokeaha.123.044169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
Over the past decades, continuous technological advances and the availability of novel therapies have enabled treatment of more acute medical conditions than ever before. Many of these treatments, such as intravenous thrombolysis and mechanical thrombectomy for acute ischemic stroke, are highly time sensitive. This has raised interest in shifting advanced acute care from hospitals to the prehospital setting. Key objectives of advanced prehospital stroke care may include (1) early targeted treatments in the prehospital setting, for example, intravenous thrombolysis for acute stroke, and (2) advanced prehospital diagnostics such as prehospital large vessel occlusion and intracranial hemorrhage detection, to help inform patient triage and potentially reduce subsequent workload in emergency departments. Major challenges that may hamper a swift transition to more advanced prehospital care are related to conducting clinical trials in the prehospital setting to provide sufficient evidence for emergency interventions, as well as ambulance design, infrastructure, emergency medical service personnel training and workload, and cost barriers. Utilizing new technologies such as telemedicine, mobile stroke units and portable diagnostic devices, customized software applications, and smart storage space management may help surmount these challenges and establish efficient, targeted care strategies that are achievable in the prehospital setting. In this article, we delineate the paradigm of shifting advanced stroke care to the prehospital setting and outline future directions in providing evidence-based, patient-centered prehospital care. While we use acute stroke as an illustrative example, these principles are not limited to stroke patients and can be applied to prehospital triage for any time-critical disease.
Collapse
Affiliation(s)
- Joachim Fladt
- Departments of Clinical Neurosciences, Radiology, and Community Health Sciences, Calgary Stroke Program, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Canada (J.F., J.M.O., M.G.)
- Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Switzerland (J.F.)
| | - Johanna M Ospel
- Departments of Clinical Neurosciences, Radiology, and Community Health Sciences, Calgary Stroke Program, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Canada (J.F., J.M.O., M.G.)
| | - Nishita Singh
- Department of Neurology, University of Manitoba, Winnipeg, Canada (N.S.)
| | - Jeffrey L Saver
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine, University of California, Los Angeles (J.L.S.)
| | - Marc Fisher
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA (M.F.)
| | - Mayank Goyal
- Departments of Clinical Neurosciences, Radiology, and Community Health Sciences, Calgary Stroke Program, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Canada (J.F., J.M.O., M.G.)
| |
Collapse
|
5
|
Dixon M, Appleton JP, Scutt P, Woodhouse LJ, Haywood LJ, Havard D, Williams J, Siriwardena AN, Bath PM. Time intervals and distances travelled for prehospital ambulance stroke care: data from the randomised-controlled ambulance-based Rapid Intervention with Glyceryl trinitrate in Hypertensive stroke Trial-2 (RIGHT-2). BMJ Open 2022; 12:e060211. [PMID: 36410799 PMCID: PMC9680177 DOI: 10.1136/bmjopen-2021-060211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES Ambulances offer the first opportunity to evaluate hyperacute stroke treatments. In this study, we investigated the conduct of a hyperacute stroke study in the ambulance-based setting with a particular focus on timings and logistics of trial delivery. DESIGN Multicentre prospective, single-blind, parallel group randomised controlled trial. SETTING Eight National Health Service ambulance services in England and Wales; 54 acute stroke centres. PARTICIPANTS Paramedics enrolled 1149 patients assessed as likely to have a stroke, with Face, Arm, Speech and Time score (2 or 3), within 4 hours of symptom onset and systolic blood pressure >120 mm Hg. INTERVENTIONS Paramedics administered randomly assigned active transdermal glyceryl trinitrate or sham. PRIMARY AND SECONDARY OUTCOMES Modified Rankin scale at day 90. This paper focuses on response time intervals, distances travelled and baseline characteristics of patients, compared between ambulance services. RESULTS Paramedics enrolled 1149 patients between September 2015 and May 2018. FINAL DIAGNOSIS intracerebral haemorrhage 13%, ischaemic stroke 52%, transient ischaemic attack 9% and mimic 26%. Timings (min) were (median (25-75 centile)): onset to emergency call 19 (5-64); onset to randomisation 71 (45-116); total time at scene 33 (26-46); depart scene to hospital 15 (10-23); randomisation to hospital 24 (16-34) and onset to hospital 97 (71-141). Ambulances travelled (km) 10 (4-19) from scene to hospital. Timings and distances differed between ambulance service, for example, onset to randomisation (fastest 53 min, slowest 77 min; p<0.001), distance from scene to hospital (least 4 km, most 20 km; p<0.001). CONCLUSION We completed a large prehospital stroke trial involving a simple-to-administer intervention across multiple ambulance services. The time from onset to randomisation and modest distances travelled support the applicability of future large-scale paramedic-delivered ambulance-based stroke trials in urban and rural locations. TRIAL REGISTRATION NUMBER ISRCTN26986053.
Collapse
Affiliation(s)
- Mark Dixon
- Division of Mental Health and Clinical Neuroscience, University of Nottingham Faculty of Medicine and Health Sciences, Nottingham, UK
- Leicester, Leicestershire & Rutland Division, East Midlands Ambulance Service NHS Trust, Nottingham, UK
| | - Jason P Appleton
- Stroke, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Polly Scutt
- Division of Mental Health and Clinical Neuroscience, University of Nottingham Faculty of Medicine and Health Sciences, Nottingham, UK
| | - Lisa J Woodhouse
- Division of Mental Health and Clinical Neuroscience, University of Nottingham Faculty of Medicine and Health Sciences, Nottingham, UK
| | - Lee J Haywood
- Division of Mental Health and Clinical Neuroscience, University of Nottingham Faculty of Medicine and Health Sciences, Nottingham, UK
| | - Diane Havard
- Division of Mental Health and Clinical Neuroscience, University of Nottingham Faculty of Medicine and Health Sciences, Nottingham, UK
| | - Julia Williams
- Division of Paramedic Science, School of Health and Social Work, University of Hertfordshire, Hatfield, Hertfordshire, UK
| | | | - Philip M Bath
- Division of Mental Health and Clinical Neuroscience, University of Nottingham Faculty of Medicine and Health Sciences, Nottingham, UK
| |
Collapse
|
6
|
Blair L, Duffy R. What are ambulance crews' experiences of using a mechanical chest compression device for out-of-hospital resuscitation? A constructivist qualitative study utilising online focus groups. Br Paramed J 2022; 7:24-30. [PMID: 36451709 PMCID: PMC9662154 DOI: 10.29045/14784726.2022.09.7.2.24] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/03/2023] Open
Abstract
Introduction Mechanical chest compression devices (MCCDs) provide chest compressions mechanically to a person in cardiac arrest. Those chest compressions would usually be provided manually. Previous studies into the use of MCCDs have focused on the quantitative outcomes, with little emphasis on the qualitative experiences of those using MCCDs. Purpose To collect and report ambulance crews' experiences of using MCCDs for out-of-hospital resuscitation attempts. Methods The philosophical approach was constructivist, the methodology qualitative and the data collection method online focus groups. Convenience sampling was used to recruit participants who met the inclusion criteria, which broadly were to have experience of using MCCDs for out-of-hospital resuscitation. There have been two types of MCCD used locally. Participants were included regardless of which type of device they had experience of. Similarly, participants were included whether they had active or passive experience of the devices. The focus groups were recorded, fully transcribed and then analysed using constant comparison. Results Four selective codes emerged. These were factors directly affecting ambulance crew members; practicalities of a resuscitation attempt; ambulance crew members' perceptions, experiences and thoughts; negatives of MCCDs. Conclusion The main perceptions arising from the participants' discussion in this work were that MCCD use could potentially provide psychological protection to ambulance crew members when reflecting on resuscitation attempts, and participants felt there is an overall reduction of cognitive load for ambulance crew members when using MCCDs for resuscitation attempts. There were particularly timely benefits expressed of MCCDs easing the physical fatigue of a resuscitation attempt when responding wearing personal protective equipment, as has been required during the COVID-19 pandemic. MCCDs were felt to be of benefit when transporting a patient in cardiac arrest but differences were expressed as to whether the LUCAS-2 in particular helps or hinders extrication of a patient.
Collapse
Affiliation(s)
- Laura Blair
- North East Ambulance Service NHS Foundation Trust ORCID iD: https://orcid.org/0000-0001-9846-9429
| | - Richelle Duffy
- Northumbria University ORCID iD: https://orcid.org/0000-0002-7180-8707
| |
Collapse
|
7
|
Paratz E, Semsarian C, La Gerche A. Mind the gap: Knowledge deficits in evaluating young sudden cardiac death. Heart Rhythm 2020; 17:2208-2214. [PMID: 32721478 DOI: 10.1016/j.hrthm.2020.07.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 07/19/2020] [Accepted: 07/20/2020] [Indexed: 12/17/2022]
Abstract
Sudden cardiac arrest affects around half a million people aged under 50 years old annually, with a 90% mortality rate. Despite high patient numbers and clear clinical need to improve outcomes, many gaps exist in the evidence underpinning patients' management. Domains identifying the greatest barriers to conducting trials are the prehospital and forensic settings, which also provide care to the majority of patients. Addressing gaps in evidence along each point of the cardiac arrest trajectory is a key clinical priority.
Collapse
Affiliation(s)
- Elizabeth Paratz
- Clinical Research Domain, Baker Heart & Diabetes Institute, Melbourne, Australia; National Centre for Sports Cardiology, St Vincent's Hospital Melbourne, Fitzroy, Australia.
| | - Christopher Semsarian
- Agnes Ginges Centre for Molecular Cardiology at Centenary Institute, The University of Sydney, Sydney, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Andre La Gerche
- Clinical Research Domain, Baker Heart & Diabetes Institute, Melbourne, Australia; National Centre for Sports Cardiology, St Vincent's Hospital Melbourne, Fitzroy, Australia
| |
Collapse
|
8
|
Green J, Robinson M, Pilbery R, Whitley G, Hall H, Clout M, Reeves B, Kirby K, Benger J. Research paramedics' observations regarding the challenges and strategies employed in the implementation of a large-scale out-of-hospital randomised trial. Br Paramed J 2020; 5:26-31. [PMID: 33456383 PMCID: PMC7783908 DOI: 10.29045/14784726.2020.06.5.1.26] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Introduction: AIRWAYS-2 was a cluster randomised controlled trial (RCT) comparing the clinical and cost effectiveness of the i-gel supraglottic airway device with tracheal intubation in the initial airway management of out-of-hospital cardiac arrest (OHCA). In order to successfully conduct this clinical trial, it was necessary for research paramedics to overcome multiple challenges, many of which will be relevant to future emergency medical service (EMS) research. This article aims to describe a number of the challenges that were encountered during the out-of-hospital phase of the AIRWAYS-2 trial and how these were overcome. Methods: The research paramedics responsible for conducting the pre-hospital phase of the trial were asked to reflect on their experience of facilitating the AIRWAYS-2 trial. Responses were then collated by the lead author. A process of iterative revision and review was undertaken by the research paramedics to produce a consensus of opinion. Results: The main challenges identified by the trial research paramedics related to the recruitment and training of paramedics, screening of eligible patients and investigation of protocol deviations / reporting errors. Even though a feasibility study was conducted prior to the commencement of AIRWAYS-2, the scale of these challenges was underestimated. Conclusion: Large-scale pragmatic cluster randomised trials are being successfully undertaken in out-of-hospital care. However, they require intensive engagement with EMS clinicians and local research paramedics, particularly when the intervention is contentious. Feasibility studies are an important part of research but may fail to identify all potential challenges. Therefore, flexibility is required to manage unforeseen difficulties.
Collapse
Affiliation(s)
- Jonathan Green
- University of Plymouth; South Western Ambulance Service NHS Foundation Trust
| | | | | | - Gregory Whitley
- East Midlands Ambulance Service NHS Trust; University of Lincoln
| | - Helen Hall
- East of England Ambulance Service NHS Trust; James Paget University Hospitals NHS Foundation Trust
| | | | | | - Kim Kirby
- South Western Ambulance Service NHS Foundation Trust; University of the West of England
| | | |
Collapse
|
9
|
Pocock H, Thomson M, Taylor S, Deakin CD, England E. Optimising ambulance service contribution to clinical trials: a phenomenological exploration using focus groups. Br Paramed J 2019; 4:8-15. [PMID: 33447146 PMCID: PMC7783917 DOI: 10.29045/14784726.2019.12.4.3.8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Introduction: Out-of-hospital cardiac arrest trials can prove challenging and there is a need to share learning from those that have recruited successfully. We have just completed three years of recruitment to PARAMEDIC2, a placebo-controlled trial of adrenaline in out-of-hospital cardiac arrest. This study was designed to describe the experience of operational ambulance staff involved in recruiting patients into PARAMEDIC2. Methods: Four focus groups involving trial paramedics and supporting members of the emergency care team were conducted across different geographical regions of a single UK ambulance service participating in the PARAMEDIC2 study. Data analysis was supported by NVivo 12 and themes were identified using a thematic analysis approach. Results: Forty-four participants contributed to the focus groups. Four overarching themes were identified: context for the research, ethical concerns, concerns at the patient’s side and ongoing trial support. Participants felt that research such as PARAMEDIC2 is important and necessary to drive medical progress. They valued the opportunity to be part of a large project. Due to the deferred consent model employed, public awareness of the trial was felt to be important. Most expressed equipoise regarding adrenaline, but some felt concerned about enrolling younger patients and there was discussion around what constitutes a successful outcome. Struggles with ethical concerns were overcome through training and one-to-one discussion with research paramedics. Participants valued feedback on their performance of trial tasks, but also wanted feedback on their resuscitation skills. Cardiac arrest places a high cognitive demand on paramedics; simplicity and reinforcement of trial processes were key to facilitating recruitment. Caring for relatives was a high priority for paramedics and some felt conflicted about not discussing the trial with them. Conclusions: This study has provided insights into paramedic experience of a large-scale pre-hospital trial. Investment in time and resource to provide face-to-face training and personalised feedback to paramedics can foster engagement and optimise performance.
Collapse
Affiliation(s)
- Helen Pocock
- South Central Ambulance Service NHS Foundation Trust: ORCID iD: http://orcid.org/0000-0001-7648-5313
| | | | - Sarah Taylor
- South Central Ambulance Service NHS Foundation Trust
| | - Charles D Deakin
- South Central Ambulance Service NHS Foundation Trust: ORCID ID: https://orcid.org/0000-0002-2565-9771
| | - Ed England
- South Central Ambulance Service NHS Foundation Trust: ORCID iD: https://orcid.org/0000-0002-8009-2843
| |
Collapse
|
10
|
Stassen W, Wallis L, Castren M, Vincent-Lambert C, Kurland L. A prehospital randomised controlled trial in South Africa: Challenges and lessons learnt. Afr J Emerg Med 2019; 9:145-149. [PMID: 31528533 PMCID: PMC6742591 DOI: 10.1016/j.afjem.2019.02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 12/01/2018] [Accepted: 02/03/2019] [Indexed: 11/02/2022] Open
Abstract
The incidence of cardiovascular disease and STEMI is on the rise in sub-Saharan Africa. Timely treatment is essential to reduce mortality. Internationally, prehospital 12 lead ECG telemetry has been proposed to reduce time to reperfusion. Its value in South Africa has not been established. The aim of this study was to determine the effect of prehospital 12 lead ECG telemetry on the PCI-times of STEMI patients in South Africa. A multicentre randomised controlled trial was attempted among adult patients with prehospital 12 lead ECG evidence of STEMI. Due to poor enrolment and small sample sizes, meaningful analyses could not be made. The challenges and lessons learnt from this attempt at Africa's first prehospital RCT are discussed. Challenges associated with conducting this RCT related to the healthcare landscape, resources, training of paramedics, rollout and randomisation, technology, consent and research culture. High quality evidence to guide prehospital emergency care practice is lacking both in Africa and the rest of the world. This is likely due to the difficulties with performing prehospital clinical trials. Every trial will be unique to the test intervention and setting of each study, but by considering some of the challenges and lessons learnt in the attempt at this trial, future studies might experience less difficulty. This may lead to a stronger evidence-base for prehospital emergency care.
Collapse
|
11
|
Charlton K, Franklin J, McNaughton R. Phenomenological study exploring ethics in prehospital research from the paramedic's perspective: experiences from the Paramedic-2 trial in a UK ambulance service. Emerg Med J 2019; 36:535-540. [PMID: 31427472 DOI: 10.1136/emermed-2019-208556] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 07/05/2019] [Accepted: 07/08/2019] [Indexed: 11/03/2022]
Abstract
OBJECTIVES We set out to investigate paramedics' views of ethics and research, drawing on experiences from Paramedic-2, a randomised controlled trial comparing epinephrine and placebo in out-of-hospital cardiac arrest (OHCA). METHODS An interpretative phenomenological approach was adopted. A purposive sample of paramedics (n=6) from North East Ambulance Service NHS Foundation Trust were invited to a semi-structured, in-depth interview. RESULTS Three superordinate themes emerged: (1) morality, (2) emotion and (3) equipoise. Some viewed Paramedic-2 as an opportunity to improve OHCA outcomes for the many, viewing participation as a moral obligation; others viewed the study as unethical, equating participation with immoral behaviour. Morality was a motivator to drive individual action. Positive and negative emotions were exhibited by the paramedics involved reflecting the wider view each paramedic held about trial participation. Those morally driven to participate in Paramedic-2 discussed their pride in being associated with the trial, while those who found participation unethical, discussed feelings of guilt and regret. Individual experience and perceptions of epinephrine guided each paramedic's willingness to accept or reject equipoise. Some questioned the role of epinephrine in OHCA; others believed withholding epinephrine was synonymous to denying patient care. CONCLUSION A paucity of evidence exists to support any beneficial role of epinephrine in OHCA. Despite this, some paramedics were reluctant to participate in Paramedic-2 and relied on their personal perceptions and experiences of epinephrine to guide their decision regarding participation. Failure to acknowledge the importance of individual perspectives may jeopardise the success of future out-of-hospital trials.
Collapse
Affiliation(s)
- Karl Charlton
- R&D Department, North East Ambulance Service NHS Trust, Newcastle Upon Tyne, UK
| | - John Franklin
- School of Health & Social Care, Teesside University, Middlesbrough, UK
| | | |
Collapse
|
12
|
Glasheen J, Wall B, Keogh S. A BRILL idea? The benefits, risks, insights, learning and limitations of an emergency airway registry in pre-hospital and retrieval medicine. Emerg Med Australas 2019; 31:483-486. [PMID: 30924314 DOI: 10.1111/1742-6723.13283] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 02/04/2019] [Accepted: 02/24/2019] [Indexed: 12/31/2022]
Abstract
Airway management is a cornerstone of emergency care. Development of a robust evidence base to support the practice of pre-hospital emergency anaesthesia is key to the safety and evolution of this common but high-risk procedure. This paper discusses the benefits, risks, insights, learning and limitations of the use of an airway registry in pre-hospital and retrieval medicine, for both research and quality improvement purposes.
Collapse
Affiliation(s)
- John Glasheen
- LifeFlight Retrieval Medicine, Brisbane, Queensland, Australia.,Anaesthesia Trauma and Critical Care, Lancashire, UK
| | - Brigid Wall
- Anaesthesia Trauma and Critical Care, Lancashire, UK.,Queensland Ambulance Service, Brisbane, Queensland, Australia
| | - Sean Keogh
- Faculty of Science, Health, Education and Engineering, University of the Sunshine Coast, Sunshine Coast, Queensland, Australia
| |
Collapse
|
13
|
Couper K, Quinn T, Lall R, Devrell A, Orriss B, Seers K, Yeung J, Perkins GD. Mechanical versus manual chest compressions in the treatment of in-hospital cardiac arrest patients in a non-shockable rhythm: a randomised controlled feasibility trial (COMPRESS-RCT). Scand J Trauma Resusc Emerg Med 2018; 26:70. [PMID: 30165909 PMCID: PMC6117876 DOI: 10.1186/s13049-018-0538-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 08/20/2018] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Mechanical chest compression devices consistently deliver high-quality chest compressions. Small very low-quality studies suggest mechanical devices may be effective as an alternative to manual chest compressions in the treatment of adult in-hospital cardiac arrest patients. The aim of this feasibility trial is to assess the feasibility of conducting an effectiveness trial in this patient population. METHODS COMPRESS-RCT is a multi-centre parallel group feasibility randomised controlled trial, designed to assess the feasibility of undertaking an effectiveness to compare the effect of mechanical chest compressions with manual chest compressions on 30-day survival following in-hospital cardiac arrest. Over approximately two years, 330 adult patients who sustain an in-hospital cardiac arrest and are in a non-shockable rhythm will be randomised in a 3:1 ratio to receive ongoing treatment with a mechanical chest compression device (LUCAS 2/3, Jolife AB/Stryker, Lund, Sweden) or continued manual chest compressions. It is intended that recruitment will occur on a 24/7 basis by the clinical cardiac arrest team. The primary study outcome is the proportion of eligible participants randomised in the study during site operational recruitment hours. Participants will be enrolled using a model of deferred consent, with consent for follow-up sought from patients or their consultee in those that survive the cardiac arrest event. The trial will have an embedded qualitative study, in which we will conduct semi-structured interviews with hospital staff to explore facilitators and barriers to study recruitment. DISCUSSION The findings of COMPRESS-RCT will provide important information about the deliverability of an effectiveness trial to evaluate the effect on 30-day mortality of routine use of mechanical chest compression devices in adult in-hospital cardiac arrest patients. TRIAL REGISTRATION ISRCTN38139840 , date of registration 9th January 2017.
Collapse
Affiliation(s)
- Keith Couper
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, CV4 7AL UK
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Tom Quinn
- Emergency, Cardiovascular and Critical Care Research Group, Faculty of Health, Social Care and Education, Kingston University, London and St George’s, University of London, London, UK
| | - Ranjit Lall
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, CV4 7AL UK
| | | | | | - Kate Seers
- Warwick Research in Nursing, Warwick Medical School, University of Warwick, Coventry, UK
| | - Joyce Yeung
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, CV4 7AL UK
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Gavin D. Perkins
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, CV4 7AL UK
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| |
Collapse
|
14
|
Naumann DN, Hancox JM, Raitt J, Smith IM, Crombie N, Doughty H, Perkins GD, Midwinter MJ. What fluids are given during air ambulance treatment of patients with trauma in the UK, and what might this mean for the future? Results from the RESCUER observational cohort study. BMJ Open 2018; 8:e019627. [PMID: 29362272 PMCID: PMC5786144 DOI: 10.1136/bmjopen-2017-019627] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVES We investigated how often intravenous fluids have been delivered during physician-led prehospital treatment of patients with hypotensive trauma in the UK and which fluids were given. These data were used to estimate the potential national requirement for prehospital blood products (PHBP) if evidence from ongoing trials were to report clinical superiority. SETTING The Regional Exploration of Standard Care during Evacuation Resuscitation (RESCUER) retrospective observational study was a collaboration between 11 UK air ambulance services. Each was invited to provide up to 5 years of data and total number of taskings during the same period. PARTICIPANTS Patients with hypotensive trauma (systolic blood pressure <90 mm Hg or absent radial pulse) attended by a doctor. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome was the number of patients with hypotensive trauma given prehospital fluids. Secondary outcomes were types and volumes of fluids. These data were combined with published data to estimate potential national eligibility for PHBP. RESULTS Of 29 037 taskings, 729 (2.5%) were for patients with hypotensive trauma attended by a physician. Half were aged 21-50 years; 73.4% were male. A total of 537 out of 729 (73.7%) were given fluids. Five hundred and ten patients were given a single type of fluid; 27 received >1 type. The most common fluid was 0.9% saline, given to 486/537 (90.5%) of patients who received fluids, at a median volume of 750 (IQR 300-1500) mL. Three per cent of patients received PHBP. Estimated projections for patients eligible for PHBP at these 11 services and in the whole UK were 313 and 794 patients per year, respectively. CONCLUSIONS One in 40 air ambulance taskings were manned by physicians to retrievepatients with hypotensive trauma. The most common fluid delivered was 0.9% saline. If evidence justifies universal provision of PHBP, approximately 800 patients/year would be eligible in the UK, based on our data combined with others published. Prospective investigations are required to confirm or adjust these estimations.
Collapse
Affiliation(s)
- David N Naumann
- NIHR Surgical Reconstruction and Microbiology Research Centre, Queen Elizabeth Hospital, Birmingham, UK
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - James M Hancox
- NIHR Surgical Reconstruction and Microbiology Research Centre, Queen Elizabeth Hospital, Birmingham, UK
- West Midlands Ambulance Service NHS Foundation Trust, Brierley Hill, UK
- Midlands Air Ambulance Charity, Stourbridge, West Midlands, UK
| | - James Raitt
- Thames Valley Air Ambulance, RAF Benson, Oxfordshire, UK
| | - Iain M Smith
- NIHR Surgical Reconstruction and Microbiology Research Centre, Queen Elizabeth Hospital, Birmingham, UK
| | - Nicholas Crombie
- NIHR Surgical Reconstruction and Microbiology Research Centre, Queen Elizabeth Hospital, Birmingham, UK
| | | | | | - Mark J Midwinter
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- School of Biomedical Sciences, Faculty of Medicine, University of Queensland, Brisbane, Australia
| |
Collapse
|