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Gary A Ford - One of the best experts on this subject based on the ideXlab platform.
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A review of enhanced Paramedic roles during and after hospital handover of stroke, myocardial infarction and trauma patients
BMC Emergency Medicine, 2017Co-Authors: Darren Flynn, Shannon Robalino, Joanne Lally, Helen Snooks, Graham Mcclelland, Helen Rodgers, Gary A Ford, Richard Francis, Christopher PriceAbstract:Ambulance Paramedics play a critical role expediting patient access to emergency treatments. Standardised handover communication frameworks have led to improvements in accuracy and speed of information transfer but their impact upon time-critical scenarios is unclear. Patient outcomes might be improved by Paramedics staying for a limited time after handover to assist with shared patient care. We aimed to categorize and synthesise data from studies describing development/extension of the ambulance-based Paramedic role during and after handover for time-critical conditions (trauma, stroke and myocardial infarction). We conducted an electronic search of published literature (Jan 1990 to Sep 2016) by applying a structured strategy to eight bibliographic databases. Two reviewers independently assessed eligible studies of Paramedics, emergency medical (or ambulance) technicians that reported on the development, evaluation or implementation of (i) generic or specific structured handovers applied to trauma, stroke or myocardial infarction (MI) patients; or (ii) Paramedic-initiated care processes at handover or post-handover clinical activity directly related to patient care in secondary care for trauma, stroke and MI. Eligible studies had to report changes in health outcomes. We did not identify any studies that evaluated the health impact of an emergency ambulance Paramedic intervention following arrival at hospital. A narrative review was undertaken of 36 studies shortlisted at the full text stage which reported data relevant to time-critical clinical scenarios on structured handover tools/protocols; protocols/enhanced Paramedic skills to improve handover; or protocols/enhanced Paramedic skills leading to a change in in-hospital transfer location. These studies reported that (i) enhanced Paramedic skills (diagnosis, clinical decision making and administration of treatment) might supplement handover information; (ii) structured handover tools and feedback on handover performance can impact positively on Paramedic behaviour during clinical communication; and (iii) additional roles of Paramedics after arrival at hospital was limited to ‘direct transportation’ of patients to imaging/specialist care facilities. There is insufficient published evidence to make a recommendation regarding condition-specific handovers or extending the ambulance Paramedic role across the secondary/tertiary care threshold to improve health outcomes. However, previous studies have reported non-clinical outcomes which suggest that structured handovers and enhanced Paramedic actions after hospital arrival might be beneficial for time-critical conditions and further investigation is required.
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Paramedic initiated lisinopril for acute stroke treatment pil fast results from the pilot randomised controlled trial
Emergency Medicine Journal, 2014Co-Authors: Lisa Shaw, Christopher Price, Gary A Ford, Sally Mclure, Denise Howel, Elaine Mccoll, Paul L YoungerAbstract:Background High blood pressure (BP) during acute stroke is associated with poorer stroke outcome. Trials of treatments to lower BP have not resulted in improved outcome, but this may be because treatment commenced too late. Emergency medical service staff (Paramedics) are uniquely placed to administer early treatment; however, experience of prehospital randomised controlled trials (RCTs) is very limited. Methods We conducted a pilot RCT to determine the feasibility of a definitive prehospital BP-lowering RCT in acute stroke. Paramedics were trained to identify, consent and deliver a first dose of lisinopril or placebo to adults with suspected stroke and hypertension while responding to the emergency call. Further treatment continued in hospital. Study eligibility, recruitment rate, completeness of receipt of study medication and clinical data (eg, BP) were collected to inform the design of a definitive RCT. Results In 14 months, 14 participants (median age=73 years, median National Institute of Health Stroke Scale=4) were recruited and received the prehospital dose of medication. Median time from stroke onset (as assessed by Paramedic) to treatment was 70 min. Four participants completed 7 days of study treatment. Of ambulance transported suspected stroke patients, 1% were both study eligible and attended by a PIL-FAST Paramedic. Conclusions It is possible to conduct a Paramedic initiated double-blind RCT of a treatment for acute stroke. However, to perform a definitive RCT in a reasonable timescale, a large number of trained Paramedics across several ambulance services would be needed to recruit the number of patients likely to be required. Clinical trial registration http://www.clinicaltrials.gov. Unique identifier: NCT01066572.
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evidence from the scene Paramedic perspectives on involvement in out of hospital research
Annals of Emergency Medicine, 2012Co-Authors: Christopher Price, Gary A Ford, Duika Burges L Watson, Randy Sanoff, Joan Mackintosh, Jeffrey L Saver, Sidney Starkman, Marc Eckstein, Robin ConwitAbstract:Study objective In the context of calls to develop better systems for out-of-hospital clinical research, we seek to understand Paramedics' perceptions of involvement in research and the barriers and facilitators to that involvement. Methods This was a qualitative study using semistructured focus groups with 58 United Kingdom Paramedics and interviews with 30 US firefighter-Paramedics. The study focused on out-of-hospital research (trials of out-of-hospital treatment for stroke), whereby Paramedics identified potential study subjects or obtained consent and administered study treatment in the field. Data were analyzed with a thematic and discourse approach. Results Three key themes emerged as significant facilitators and barriers to Paramedic involvement in research: patient benefit, professional identity and responsibility, and time. Paramedics showed willingness and capacity to engage in research but also some reticence because of the perceived sacrifice of autonomy and challenge to their identity. Paramedics work in a time-sensitive environment and were concerned that research would increase time taken in the field. Conclusion Awareness of these perspectives will help with development of out-of-hospital research protocols and potentially facilitate greater participation.
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agreement between ambulance Paramedic and physician recorded neurological signs with face arm speech test fast in acute stroke patients
Stroke, 2004Co-Authors: Mohd A Nor, C Mcallister, Stephen J Louw, Alexander G Dyker, Michelle Davis, Damian Jenkinson, Gary A FordAbstract:Background and Purpose— Patients with suspected stroke first assessed by ambulance Paramedics require early recognition to facilitate appropriate triage and early treatment. We determined Paramedic...
Christopher Price - One of the best experts on this subject based on the ideXlab platform.
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effect of an enhanced Paramedic acute stroke treatment assessment on thrombolysis delivery during emergency stroke care a cluster randomized clinical trial
JAMA Neurology, 2020Co-Authors: Christopher Price, Helen Snooks, Darren Flynn, Richard Francis, Lisa Shaw, Saiful Islam, Mehdi Javanbakht, Alan Watkins, Peter Mcmeekin, Rachel L LakeyAbstract:Importance Rapid thrombolysis treatment for acute ischemic stroke reduces disability among patients who are carefully selected, but service delivery is challenging. Objective To determine whether an enhanced Paramedic Acute Stroke Treatment Assessment (PASTA) intervention increased hospital thrombolysis rates. Design, Setting, and Participants This multicenter, cluster randomized clinical trial took place between December 2015 and July 2018 in 3 ambulance services and 15 hospitals. Clusters were Paramedics based within ambulance stations prerandomized to PASTA or standard care. Patients attended by study Paramedics were enrolled after admission if a hospital specialist confirmed a stroke and Paramedic assessment started within 4 hours of onset. Allocation to PASTA or standard care reflected the attending Paramedic’s randomization status. Interventions The PASTA intervention included additional prehospital information collection, a structured hospital handover, practical assistance up to 15 minutes after handover, a predeparture care checklist, and clinician feedback. Standard care reflected national guidelines. Main Outcomes and Measures Primary outcome was the proportion of patients receiving thrombolysis. Secondary outcomes included time intervals and day 90 health (with poor status defined as a modified Rankin Score >2, to represent dependency or death). Results A total of 11 478 patients were screened following ambulance transportation; 1391 were eligible and approached, but 177 did not consent. Of 1214 patients enrolled (mean [SD] age, 74.7 [13.2] years; 590 women [48.6%]), 500 were assessed by 242 Paramedics trained in the PASTA intervention and 714 were assessed by 355 Paramedics continuing with standard care. The Paramedics trained in the PASTA intervention took a mean of 13.4 (95% CI, 9.4-17.4) minutes longer (P Conclusions and Relevance An enhanced Paramedic assessment did not facilitate thrombolysis delivery. The unexpected combination of thrombolysis and health outcomes suggests possible alternative influences on treatment decisions by the intervention, requiring further evaluation. Trial Registration ISRCTN Registry Identifier:ISRCTN12418919
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A review of enhanced Paramedic roles during and after hospital handover of stroke, myocardial infarction and trauma patients
BMC Emergency Medicine, 2017Co-Authors: Darren Flynn, Shannon Robalino, Joanne Lally, Helen Snooks, Graham Mcclelland, Helen Rodgers, Gary A Ford, Richard Francis, Christopher PriceAbstract:Ambulance Paramedics play a critical role expediting patient access to emergency treatments. Standardised handover communication frameworks have led to improvements in accuracy and speed of information transfer but their impact upon time-critical scenarios is unclear. Patient outcomes might be improved by Paramedics staying for a limited time after handover to assist with shared patient care. We aimed to categorize and synthesise data from studies describing development/extension of the ambulance-based Paramedic role during and after handover for time-critical conditions (trauma, stroke and myocardial infarction). We conducted an electronic search of published literature (Jan 1990 to Sep 2016) by applying a structured strategy to eight bibliographic databases. Two reviewers independently assessed eligible studies of Paramedics, emergency medical (or ambulance) technicians that reported on the development, evaluation or implementation of (i) generic or specific structured handovers applied to trauma, stroke or myocardial infarction (MI) patients; or (ii) Paramedic-initiated care processes at handover or post-handover clinical activity directly related to patient care in secondary care for trauma, stroke and MI. Eligible studies had to report changes in health outcomes. We did not identify any studies that evaluated the health impact of an emergency ambulance Paramedic intervention following arrival at hospital. A narrative review was undertaken of 36 studies shortlisted at the full text stage which reported data relevant to time-critical clinical scenarios on structured handover tools/protocols; protocols/enhanced Paramedic skills to improve handover; or protocols/enhanced Paramedic skills leading to a change in in-hospital transfer location. These studies reported that (i) enhanced Paramedic skills (diagnosis, clinical decision making and administration of treatment) might supplement handover information; (ii) structured handover tools and feedback on handover performance can impact positively on Paramedic behaviour during clinical communication; and (iii) additional roles of Paramedics after arrival at hospital was limited to ‘direct transportation’ of patients to imaging/specialist care facilities. There is insufficient published evidence to make a recommendation regarding condition-specific handovers or extending the ambulance Paramedic role across the secondary/tertiary care threshold to improve health outcomes. However, previous studies have reported non-clinical outcomes which suggest that structured handovers and enhanced Paramedic actions after hospital arrival might be beneficial for time-critical conditions and further investigation is required.
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Paramedic initiated lisinopril for acute stroke treatment pil fast results from the pilot randomised controlled trial
Emergency Medicine Journal, 2014Co-Authors: Lisa Shaw, Christopher Price, Gary A Ford, Sally Mclure, Denise Howel, Elaine Mccoll, Paul L YoungerAbstract:Background High blood pressure (BP) during acute stroke is associated with poorer stroke outcome. Trials of treatments to lower BP have not resulted in improved outcome, but this may be because treatment commenced too late. Emergency medical service staff (Paramedics) are uniquely placed to administer early treatment; however, experience of prehospital randomised controlled trials (RCTs) is very limited. Methods We conducted a pilot RCT to determine the feasibility of a definitive prehospital BP-lowering RCT in acute stroke. Paramedics were trained to identify, consent and deliver a first dose of lisinopril or placebo to adults with suspected stroke and hypertension while responding to the emergency call. Further treatment continued in hospital. Study eligibility, recruitment rate, completeness of receipt of study medication and clinical data (eg, BP) were collected to inform the design of a definitive RCT. Results In 14 months, 14 participants (median age=73 years, median National Institute of Health Stroke Scale=4) were recruited and received the prehospital dose of medication. Median time from stroke onset (as assessed by Paramedic) to treatment was 70 min. Four participants completed 7 days of study treatment. Of ambulance transported suspected stroke patients, 1% were both study eligible and attended by a PIL-FAST Paramedic. Conclusions It is possible to conduct a Paramedic initiated double-blind RCT of a treatment for acute stroke. However, to perform a definitive RCT in a reasonable timescale, a large number of trained Paramedics across several ambulance services would be needed to recruit the number of patients likely to be required. Clinical trial registration http://www.clinicaltrials.gov. Unique identifier: NCT01066572.
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evidence from the scene Paramedic perspectives on involvement in out of hospital research
Annals of Emergency Medicine, 2012Co-Authors: Christopher Price, Gary A Ford, Duika Burges L Watson, Randy Sanoff, Joan Mackintosh, Jeffrey L Saver, Sidney Starkman, Marc Eckstein, Robin ConwitAbstract:Study objective In the context of calls to develop better systems for out-of-hospital clinical research, we seek to understand Paramedics' perceptions of involvement in research and the barriers and facilitators to that involvement. Methods This was a qualitative study using semistructured focus groups with 58 United Kingdom Paramedics and interviews with 30 US firefighter-Paramedics. The study focused on out-of-hospital research (trials of out-of-hospital treatment for stroke), whereby Paramedics identified potential study subjects or obtained consent and administered study treatment in the field. Data were analyzed with a thematic and discourse approach. Results Three key themes emerged as significant facilitators and barriers to Paramedic involvement in research: patient benefit, professional identity and responsibility, and time. Paramedics showed willingness and capacity to engage in research but also some reticence because of the perceived sacrifice of autonomy and challenge to their identity. Paramedics work in a time-sensitive environment and were concerned that research would increase time taken in the field. Conclusion Awareness of these perspectives will help with development of out-of-hospital research protocols and potentially facilitate greater participation.
Christopher F Bladin - One of the best experts on this subject based on the ideXlab platform.
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Paramedic diagnosis of stroke examining long term use of the melbourne ambulance stroke screen mass in the field
Stroke, 2010Co-Authors: Janet Bray, Bill Barger, Kelly Coughlan, Christopher F BladinAbstract:Background and Purpose— Recent evidence suggests the Cincinnati Prehospital Stroke Scale is ineffectively used and lacks sensitivity and specificity. Melbourne (Australia) Paramedics have been using the Melbourne Ambulance Stroke Screen (MASS) since 2005. The aim of this study was to review the real-world use of MASS 3 years after citywide implementation. Methods— Two groups of consecutively admitted patients to an Australian hospital between January and May 2008 were used: (1) patients for whom Paramedics performed MASS; and (2) patients with a discharge diagnosis of stroke or transient ischemic attack. Use of MASS was examined for all transports and for patients diagnosed with stroke or transient ischemic attack. The sensitivity and specificity of Paramedic diagnosis, MASS, and Cincinnati Prehospital Stroke Scale were calculated. Paramedic diagnosis of stroke among patients with stroke was statistically compared with those obtained immediately post-MASS implementation in 2002. Results— For the study per...
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Success With Paramedic Diagnosis of Stroke
Stroke, 2009Co-Authors: Janet Bray, Christopher F BladinAbstract:To the Editor: We read with interest the recent article by Frendle et al,1 the first study to demonstrate a lack of improvement in Paramedic stroke diagnosis after training and implementation of a prehospital stroke scale. Having implemented a similar program to Australian Paramedics with success (stroke detection …
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an interventional study to improve Paramedic diagnosis of stroke
Prehospital Emergency Care, 2005Co-Authors: Janet Bray, Stephen Bernard, Jenepher Martin, Greg Cooper, Bill Barger, Christopher F BladinAbstract:Objective. The aim of the Faster Access to Stroke Therapy (FAST) study was to determine the effect of educational intervention andthe use of a prehospital stroke tool on the Paramedic diagnosis of stroke. Methods. Paramedics in emergency medical service units servicing a university teaching hospital were divided into two groups: FAST study Paramedics (n = 18) andnon-FAST study Paramedics (n = 43). The FAST study Paramedics received stroke education andinstruction in the use of a prehospital stroke assessment tool [Melbourne Ambulance Stroke Screen (MASS)] to assist in stroke diagnosis. Based on final hospital diagnosis, the sensitivities of Paramedic stroke diagnosis in the two groups were compared for a 12-month period before andafter the intervention. Results. The sensitivity for the FAST study Paramedics in identifying stroke improved from 78% (95% confidence interval [CI]: 63% to 88%) to 94% (95% CI: 86% to 98%) (p = 0.006) after receiving the stroke education session andwith use of the MASS tool. The...
Janet Bray - One of the best experts on this subject based on the ideXlab platform.
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Paramedic exposure to out of hospital cardiac arrest resuscitation is associated with patient survival
Circulation-cardiovascular Quality and Outcomes, 2016Co-Authors: Kylie Dyson, Janet Bray, Karen Smith, Stephen Bernard, Lahn Straney, Judith FinnAbstract:Background—Although out-of-hospital cardiac arrest (OHCA) is a major public health problem, individual Paramedics are rarely exposed to these cases. In this study, we examined whether previous Paramedic exposure to OHCA resuscitation is associated with patient survival. Methods and Results—For the period 2003 to 2012, we linked data from the Victorian Ambulance Cardiac Arrest Registry to Ambulance Victoria’s employment data set. We defined exposure as the number of times a Paramedic attended an OHCA where resuscitation was attempted in the 3 years preceding each case. Using a multivariable model adjusting for known predictors of survival, we measured the association between Paramedic OHCA exposure and patient survival to hospital discharge. During the study period, there were 4151 Paramedics employed and 48 291 OHCAs (44% with resuscitation attempted). The median exposure of all Paramedics was 2 (interquartile range 1–3) OHCAs/year. Eleven percent of Paramedics were not exposed to any OHCA cases. Increase...
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Paramedic diagnosis of stroke examining long term use of the melbourne ambulance stroke screen mass in the field
Stroke, 2010Co-Authors: Janet Bray, Bill Barger, Kelly Coughlan, Christopher F BladinAbstract:Background and Purpose— Recent evidence suggests the Cincinnati Prehospital Stroke Scale is ineffectively used and lacks sensitivity and specificity. Melbourne (Australia) Paramedics have been using the Melbourne Ambulance Stroke Screen (MASS) since 2005. The aim of this study was to review the real-world use of MASS 3 years after citywide implementation. Methods— Two groups of consecutively admitted patients to an Australian hospital between January and May 2008 were used: (1) patients for whom Paramedics performed MASS; and (2) patients with a discharge diagnosis of stroke or transient ischemic attack. Use of MASS was examined for all transports and for patients diagnosed with stroke or transient ischemic attack. The sensitivity and specificity of Paramedic diagnosis, MASS, and Cincinnati Prehospital Stroke Scale were calculated. Paramedic diagnosis of stroke among patients with stroke was statistically compared with those obtained immediately post-MASS implementation in 2002. Results— For the study per...
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Success With Paramedic Diagnosis of Stroke
Stroke, 2009Co-Authors: Janet Bray, Christopher F BladinAbstract:To the Editor: We read with interest the recent article by Frendle et al,1 the first study to demonstrate a lack of improvement in Paramedic stroke diagnosis after training and implementation of a prehospital stroke scale. Having implemented a similar program to Australian Paramedics with success (stroke detection …
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an interventional study to improve Paramedic diagnosis of stroke
Prehospital Emergency Care, 2005Co-Authors: Janet Bray, Stephen Bernard, Jenepher Martin, Greg Cooper, Bill Barger, Christopher F BladinAbstract:Objective. The aim of the Faster Access to Stroke Therapy (FAST) study was to determine the effect of educational intervention andthe use of a prehospital stroke tool on the Paramedic diagnosis of stroke. Methods. Paramedics in emergency medical service units servicing a university teaching hospital were divided into two groups: FAST study Paramedics (n = 18) andnon-FAST study Paramedics (n = 43). The FAST study Paramedics received stroke education andinstruction in the use of a prehospital stroke assessment tool [Melbourne Ambulance Stroke Screen (MASS)] to assist in stroke diagnosis. Based on final hospital diagnosis, the sensitivities of Paramedic stroke diagnosis in the two groups were compared for a 12-month period before andafter the intervention. Results. The sensitivity for the FAST study Paramedics in identifying stroke improved from 78% (95% confidence interval [CI]: 63% to 88%) to 94% (95% CI: 86% to 98%) (p = 0.006) after receiving the stroke education session andwith use of the MASS tool. The...
Peter Cameron - One of the best experts on this subject based on the ideXlab platform.
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is Paramedic judgement useful in prehospital trauma triage
Injury-international Journal of The Care of The Injured, 2005Co-Authors: Stephen Andrew Mulholland, Belinda J Gabbe, Peter CameronAbstract:Precise prehospital trauma triage criteria are critical for ensuring patients with severe injuries are transported to trauma centres. Most prehospital trauma triage criteria adopt a combination of physiological, anatomic and mechanism of injury components, but this approach still fails to identify a number of patients with severe injuries and often burdens trauma centres with patients suffering minor injuries. Paramedic judgement has been identified as an alternative method for the triage of trauma patients. This study critically reviewed the literature regarding the ability of Paramedics to predict injury severity, and found there is no clear evidence supporting Paramedic judgement as an accurate triage method. However, the studies were limited due to significant data losses, variable definitions of major trauma, differences across EMS and trauma care systems, variable Paramedic experience levels and incomparable methods of data collection. The role of Paramedic judgement in identifying patients with severe blunt anatomic injuries requires further investigation.
