Views regarding the provision of prehospital critical care in the UK

Looking back to inform the future: a review of published paramedicine research

OBJECTIVE

Paramedicine has evolved in ways that may outpace the science informing these changes. Examining the scholarly pursuits of paramedicine may provide insights into the historical academic focus, which may inform future endeavors and evolution of paramedicine. The objective of this study was to explore the existing discourse in paramedicine research to reflect on the academic pursuits of this community.

METHODS

We searched Medline, Embase, CINAHL, Google Scholar and Web of Science from January, 2006 to April, 2019. We further refined the yield using a ranking formula that prioritized journals most relevant to paramedicine, then sampled randomly in two-year clusters for full text review. We extracted literature type, study topic and context, then used elements of qualitative content, thematic, and discourse analysis to further describe the sample.

RESULTS

The initial search yielded 99,124 citations, leaving 54,638 after removing duplicates and 7084 relevant articles from nine journals after ranking. Subsequently, 2058 articles were included for topic categorization, and 241 papers were included for full text analysis after random sampling. Overall, this literature reveals: 1) a relatively narrow topic focus, given the majority of research has concentrated on general operational activities and specific clinical conditions and interventions (e.g., resuscitation, airway management, etc.); 2) a limited methodological (and possibly philosophical) focus, given that most were observational studies (e.g., cohort, case control, and case series) or editorial/commentary; 3) a variety of observed trajectories of academic attention, indicating where the evolution of paramedicine is evident, areas where scope of practice is uncertain, and areas that aim to improve skills historically considered core to paramedic clinical practice.

CONCLUSIONS

Included articles suggest a relatively narrow topic focus, a limited methodological focus, and observed trajectories of academic attention indicating where research pursuits and priorities are shifting. We have highlighted that the academic focus may require an alignment with aspirational and direction setting documents aimed at developing paramedicine. This review may be a snapshot of scholarly activity that reflects a young medically directed profession and systems focusing on a few high acuity conditions, with aspirations of professional autonomy contributing to the health and social well-being of communities.

Prehospital critical care for out-of-hospital cardiac arrest: An observational study examining survival and a stakeholder-focused cost analysis

Background

Survival rates from out-of-hospital cardiac arrest (OHCA) remain low, despite remarkable efforts to improve care. A number of ambulance services in the United Kingdom (UK) have developed prehospital critical care teams (CCTs) which attend critically ill patients, including OHCA. However, current scientific evidence describing CCTs attending OHCA is sparse and research to date has not demonstrated clear benefits from this model of care.

Methods

This prospective, observational study will describe the effect of CCTs on survival from OHCA, when compared to advanced-life-support (ALS), the current standard of prehospital care in the UK. In addition, we will describe the association between individual critical care interventions and survival, and also the costs of CCTs for OHCA.

To examine the effect of CCTs on survival from OHCA, we will use routine Utstein variables data already collected in a number of UK ambulance trusts. We will use propensity score matching to adjust for imbalances between the CCT and ALS groups. The primary outcome will be survival to hospital discharge, with the secondary outcome of survival to hospital admission.

We will record the critical care interventions delivered during CCT attendance at OHCA. We will describe frequencies and aim to use multiple logistic regression to examine possible associations with survival.

Finally, we will undertake a stakeholder-focused cost analysis of CCTs for OHCA. This will utilise a previously published Emergency Medical Services (EMS) cost analysis toolkit and will take into account the costs incurred from use of a helicopter and the proportion of these costs currently covered by charities in the UK.

Discussion

Prehospital critical care for OHCA is not universally available in many EMS. In the UK, it is variable and largely funded through public donations to charities. If this study demonstrates benefit from CCTs at an acceptable cost to the public or EMS commissioners, it will provide a rationale to increase funding and service provision. If no clinical benefit is found, the public and charities providing these services can consider concentrating their efforts on other areas of prehospital care.

Trial registration

ISRCTN registry ID ISRCTN18375201.

Who does what in prehospital critical care? An analysis of competencies of paramedics, critical care paramedics and prehospital physicians

INTRODUCTION

Emergency medical services in the UK are facing the challenge of responding to an increasing number of calls, often for non-emergency care, while also providing critical care to the few severely ill or injured patients. In response, paramedic training in the UK has been extended and there are regional strategies to improve prehospital critical care (PHCC). We describe the clinical competencies of three groups of prehospital providers in the UK with the aim of informing future planning of the delivery of PHCC.

METHODS

We used a data triangulation approach to obtain lists of competencies for paramedics, critical care paramedics (CCPs) and PHCC physicians of the Great Western Ambulance Service. Data sources were professional guidance documents, equipment available to the provider, log sheets of prehospital care episodes, direct observations and a survey of providers.

RESULTS

We identified 389, 441 and 449 competencies for paramedics, CCPs and PHCC physicians, respectively. Competencies of CCPs and PHCC physicians which exceeded those of paramedics can be arranged in four distinct clusters: induction and maintenance of anaesthesia, procedural sedation, advanced cardiovascular management and complex invasive interventions.

DISCUSSION

Paramedics possess a considerable number of competencies which allow them to diagnose and treat a variety of conditions. CCPs and PHCC physicians possess a few additional critical care competencies which are potentially life-saving but are required infrequently and can carry significant risks. Concentration of training and clinical exposure for a small group of providers in critical care teams can help optimising benefits and reducing risks of PHCC.

Availability and utilisation of physician-based pre-hospital critical care support to the NHS ambulance service in England, Wales and Northern Ireland

Background

Every day throughout the UK, ambulance services seek medical assistance in providing critically ill or injured patients with pre-hospital care.

Objective

To identify the current availability and utilisation of physician-based pre-hospital critical care capability across England, Wales and Northern Ireland.

Design

A postal and telephone survey was undertaken between April and December 2009 of all 13 regional NHS ambulance services, 17 air ambulance charities, 34 organisations affiliated to the British Association for Immediate Care and 215 type 1 emergency departments in England, Wales and Northern Ireland. The survey focused on the availability and use of physician-based pre-hospital critical care support.

Results

The response rate was 100%. Although nine NHS ambulance services recorded physician attendance at 6155 incidents, few could quantify doctor availability and utilisation. All but one of the British Association for Immediate Care organisations deployed ‘only when available’ and only 45% of active doctors could provide critical care support. Eleven air ambulance services (65%) operated with a doctor but only 5 (29%) operated 7 days a week. Fifty-nine EDs (27%) had a pre-hospital team but only 5 (2%) had 24 h deployable critical care capability and none were used regularly.

Conclusion

There is wide geographical and diurnal variability in availability and utilisation of physician-based pre-hospital critical care support. Only London ambulance service has access to NHS-commissioned 24 h physician-based pre-hospital critical care support. Throughout the rest of the UK, extensive use is made of volunteer doctors and charity sector providers of varying availability and capability.