East Midlands Ambulance Service NHS Trust

Major trauma is a leading cause of death and disability. Specialised care in major trauma centres has been associated with improved outcomes and prehospital triage tools are used to ensure injured patients are treated in the right place and the right time. However, there is a trade-off between under- and over-triage, and this study aimed to externally validate current and newly developed major trauma triage tools. A diagnostic case-cohort study was performed between November 2019 and February 2020 in 4 English regional trauma networks as part of the Major Trauma Triage Study (MATTS). The accuracy of 22 adult major trauma triage tools, including 3 newly developed MATTS tools was evaluated. Consecutive patients with acute non-trivial injury presenting to participating ambulance services were included and matched to data from the English national major trauma database. Theoretical accuracy was examined, with index tests assessed according to objective ambulance service data, regardless of the final triage decision or hospital destination. The primary reference standard was a consensus definition of serious injury that would benefit from expedited major trauma centre care. The case-cohort sample consisted of 2,607 patients, including 928 primary reference standard positive patients. The population weighted prevalence of major trauma meeting the primary reference standard definition was 3.1% (95% CI 2.3-4.0). Four optimally performing triage tools were identified with Pareto decision analysis: the Trauma score (sensitivity 0.1, specificity 0.99), MATTS specific tool (sensitivity 0.37, specificity 0.95), MATTS balanced tool (sensitivity 0.58, specificity 0.87), and the MATTS sensitive tool (sensitivity 0.72, specificity 0.76). This finding was unchanged in subgroup analyses of different age-groups and injury mechanisms; secondary analyses examining alternative reference standards (ISS ≥ 16, US consensus definition); and sensitivity analyses exploring missing data. Four optimal triage tools, demonstrating a trade-off between sensitivity and specificity, were identified by this validation study. The choice of ideal tool will depend on prevalence of major trauma, and valuation of false positive and false negative cases. Further prospective investigation of real-life triage tool performance, including compliance and clinical judgment, is necessary.

Paramedic education is underpinned by multiple pedagogical approaches, of which simulation-based learning, case-based learning and problem-based learning are pivotal. These methods support the development of clinical reasoning and enhance learner progression. However, access to high-fidelity simulation and pressures on placement capacity create inconsistent opportunities for self-directed study. Generative artificial intelligence (Gen AI) offers a potential supplement, enabling interactive and adaptable learning experiences. This continuing professional development (CPD) article presents a case study of a final-year paramedic student who engaged with a Gen AI tool to practise complex case-based and problem-based learning. The learner used prompt engineering to frame the tool as a ‘medical expert’, generating scenarios with evolving information. The Gen AI provided feedback, branching pathways and quizzes. Analysis of this interaction is aligned with key educational frameworks and demonstrates how Gen AI supported active learning. While promising, the approach highlights the need for critical appraisal of outputs, awareness of ethical and equity considerations, and alignment with CPD standards to ensure safe and effective application in paramedic education.

Importance/background The 12-lead ECG is recommended in clinical guidelines for prehospital assessment of patients with suspected acute coronary syndrome (ACS) presenting to Emergency Medical Services (EMS). Objectives To determine prehospital ECG (PHECG) utilisation since UK national rollout of primary percutaneous coronary intervention, and whether this is associated with clinical outcomes in patients with ACS. Design Population-based, linked cohort study using Myocardial Ischaemia National Audit Project data from 1 January 2010 to 31 December 2017, related to patients with ACS conveyed by the EMS to hospital in England and Wales. Exposure PHECG administration. Outcomes Proportion of patients where PHECG was recorded, 30-day and 1 year all-cause mortality, use of reperfusion. Results Of 330 713 eligible patients transferred by EMS, 263 420 patients (79.7%) had PHECG recorded, steadily increasing from 74.2% in 2010 to 85.0% in 2017. Patients who received PHECG were generally younger than those who did not (median age: 70 years vs 75 years), less likely to be female (32.8% vs 41.9%) or to have comorbidities such as diabetes (20.8% vs 24.7%) or peripheral vascular disease (4.1% vs 4.8%). Patients who received PHECG had lower mortality at 30 days (7.1% vs 10.9%), with adjusted OR 0.77 (95% CI 0.75 to 0.80), and at 1 year (14.2% vs 23.2%), with adjusted OR 0.69 (95% CI 0.68 to 0.71). Adjustment accommodated demographic characteristics, comorbidities and medical history. Reperfusion was more frequent in patients with ST-elevation myocardial infarction (STEMI) receiving PHECG (84.5% vs 54.7%) with adjusted OR 4.37 (95% CI 4.20 to 4.54), with similar adjustment. Conclusions Use of PHECG by EMS for patients with ACS is associated with lower short-term mortality and higher odds of receiving reperfusion for STEMI patients. Administration of PHECG increased steadily over time, but at the end of the study, still 15% of eligible patients did not receive a PHECG.

Introduction Adequate analgesia is an essential element of patient care. A recent investigation into a UK major incident (MI) highlighted that delivery of analgesia during it was inadequate. A subsequent inquiry suggested that oral transmucosal fentanyl citrate (OTFC) may improve delivery of analgesia in this setting. This systematic review aims to determine the most effective and safest dose of OTFC in the context of a MI for adults, children, the frail and elderly, and the hypovolaemic. Methods A literature search of MEDLINE, CINAHL, and Embase was conducted, searching for articles containing original data in human subjects with no restriction for language. Hand-searching of all articles was also undertaken. Data from included papers were extracted into a template and risk of bias assessment completed using the Cochrane RoB2 tool. A random effects model was planned for meta-analysis. Results 28 papers were included. 13 reported adult data (1227 individuals), one reported on the frail and elderly (five individuals) and 14 reported on children (593 individuals). 18 of the papers were randomised controlled trials; the remainder were observational studies. The heterogeneity of papers precluded meta-analysis. In adults, a dose of 800mcg provided the best balance between effectiveness and safety. For children, 10–15mcg/kg had a similar profile. Effectiveness was good, with most patients showing a clinically significant reduction in pain. Serious adverse events were rare, although minor side effects were more prevalent. Discussion The lack of evidence originating from MIs and in some groups of interest is the greatest limitation of this study. However, we are confident to recommend that in adults 18–65 years of age, who are responsive to voice, 800mcg of OTFC would provide safe and effective analgesia. In children >5 years of age, who are responsive to voice, 10–15mcg/kg of OTFC will provide safe and effective analgesia.

Background: Heart failure (HF) is complex and difficult to diagnose in prehospital settings, leading to potential overuse of treatments such as intravenous (IV) furosemide. This prompted a scoping review to assess its effectiveness in managing acute left ventricular failure (ALVF) in emergency contexts. Aim: This study aims to enhance understanding of IV furosemide use in high-acuity prehospital emergencies and its implications for future diuretic therapies. Methods: A scoping review was conducted on literature exploring the use of IV furosemide in high-acuity emergency settings. Results: Three main themes emerged: the accuracy of ALVF diagnosis and its impact on outcomes; the influence of transport times on furosemide administration; and the potential risks of furosemide outweighing its benefits. Conclusion: IV furosemide can alleviate HF symptoms, but prehospital diagnostic challenges may increase the risk or harm to patients, with alternative treatments offering more benefits and fewer adverse effects.

The prelims comprise: Half-Title Page Title Page Copyright Page Table of Contents About the Contributors About the Editors List of Case Study Authors Foreword Preface

ObjectivesThe purpose of this study was to identify which, and to what extent, demographic and operational factors are indicative of likelihood for a new call handler or paramedic to remain in role within the first two years of employment at an ambulance trust using data held in the trust’s bespoke data warehouse.DesignThe study uses a retrospective observational cohort design using routinely collected data.SettingOne ambulance trust focused on a large, predominantly urban area in the UK.ParticipantsThe study used the data of all employees of the trust who started employment as call handlers (869) or paramedics (1672) between 1 January 2018 and 31 July 2023.Primary and secondary outcome measures‘Time-to-event’ analysis of ‘likelihood to remain in post within the first two years of employment’ as call handlers or paramedics via accelerated failure time regression.ResultsSeveral factors showed a significant contribution to the likelihood of remaining in post within an ambulance National Health Service Trust. Among the findings, short-term sick leave in the first two years of employment was associated with increased retention for paramedics (0.040, 95% CI 0.030, 0.060). In addition, female call handlers were found to have increased retention (0.29, 95% CI 0.043, 0.54), and paramedic retention increased with time outside of ‘job cycle time’ (JCT) activities (ie, activities other than responding to calls) (0.097, 95% CI 0.057, 0.14).ConclusionsThis study presents a method for extracting new insights from routinely collected operational data, identifying common drivers and specific predictors for retention among the ambulance NHS workforce. It emphasises the importance of workforce-centred retention strategies, highlighting the need for non-JCT time, which in turn would allow paramedics to have time to reflect and recuperate to avoid burnout and attrition. The study also suggests that a lack of sick leave might indicate a lack of trust and self-care culture, potentially leading to paramedic staff attrition. Our approach to retention analytics provides a new mechanism for trusts to monitor and respond to their attrition risks in a timely, proactive fashion.

There is controversy about the effectiveness of adrenaline in traumatic cardiac arrest. This study reports the patient characteristics and outcomes of adults with trauma-related out of hospital cardiac arrest treated with adrenaline or placebo. This post-hoc, sub-group analysis of the Pre-hospital Randomised Assessment of Adrenaline in Cardiac Arrest-2 (PARAMEDIC-2) trial explored the effect of adrenaline on survival to hospital admission, longer-term survival and neurological outcomes amongst adults with trauma related out of hospital cardiac arrest. Individual patients were randomised through opening a single treatment pack which contained either 10 doses of 1mg adrenaline or 0.9% saline placebo. Treating clinicians, investigators, outcome assessors and patients were blinded to treatment allocation. The primary outcome was survival to 30days post cardiac arrest. 123 of 8,014 enrolled patients (1.5%) sustained a traumatic cardiac arrest (66 in the adrenaline arm and 57 in the placebo arm). Three times as many patients were admitted to hospital alive in the adrenaline arm 16/66 (24.2%) compared to 5/56 (8.9%) in the placebo arm, unadjusted odds ratio 3.3 (95% confidence interval 1.1 to 9.6), p=0.03; adjusted odd ratio 5.6 (95% CI 1.6 to 20.4), p=0.009. A single patient, in the adrenaline arm, survived beyond 30days (1/66 (1.5%) compared to 0/57 (0%)), who also experienced a favourable neurological outcome. Adrenaline was associated with a trebling of the rate of survival to hospital admission. These data support the use of adrenaline in trauma related out of hospital cardiac arrest. ISRCTN73485024.

BackgroundYorkshire Ambulance Service NHS Trust (YAS), West Midlands Ambulance Service University NHS Foundation Trust (WMAS) and The University of Warwick (UoW) collaborated to deliver the first clinical trial of an investigative medicinal product (CTIMP) of controlled drugs in the UK: PACKMaN (paramedic analgesia comparing ketamine and morphine in trauma).YAS Research Institute and collaborators reflected on the lessons learnt delivering this CTIMP across two ambulance services with reference to training, logistics, recruitment, and follow-up processes.Methods489 paramedics were trained and recruited 458 participants between Oct-2021 and May-2023. UoW monitored location and timing of paramedics training and patient recruitment, alongside follow-up rates.Paramedics’ pain score collection data (PACKMaN’s primary outcome) was compared to YAS clinical audit compliance adult pain management.Participants recruited by YAS (n=243) were compared to 2015 census data regarding index of multiple deprivation status.ResultsYAS conducted facilitated training resulting in more paramedics trained faster, resulting in higher recruitment. However, an IMP stock shortage impacted YAS’ recruitment more so than WMAS. Both sites used different consenting and follow up models, WMAS resulted in only 22 lost to follow up compared to YAS’ 63.Pain score collection data was high across both sites: 100% for YAS and 96.9% for WMAS, compared to 71% in the YAS-wide clinical audit for adult pain management, evidencing research involvement can improve routine data collection.Descriptive statistics indicated that YAS’ recruitment sample was similar to the population of Yorkshire regarding index of multiple deprivation scores demonstrating the ambulance services’ ability to conduct research with populations commonly underrepresented in research.ConclusionsThis study highlighted the challenges and opportunities two ambulance services encountered when delivering the first CTIMP with controlled drugs in the UK. Devoting time to specific tasks like facilitated training aided recruitment. These reflections will inform best practice for future research delivery.

BackgroundMulti-agency case management across the UK addresses the needs of those who call 999 ambulance services frequently (≥5 times in a month, or ≥12 times in a three-month period). However, there is little evidence about what works and how. STRETCHED (Strategies to Manage Emergency Ambulance Telephone Callers with Sustained High needs – an Evaluation using Linked Data) evaluated case management using mixed methods. One objective was to develop and refine a logic model to describe cross-sectoral case management and its expected impacts, as a basis for evaluation.MethodsStage 1: We conducted a stakeholder event with 37 people from Wales, England and Northern Ireland including public partners (with lived experience) and relevant staff to develop an initial logic model.Stage 2: Following the main data collection and analysis phases of the study, we reviewed and refined the logic model in the light of findings.ResultsThe logic model summarises in graphic form:Inputs: resources and activitiesMechanisms of change: at organisational and individual levelImpacts: on service users, ambulance services, individual staff, and wider service networks.Study findings showed that: case management initiatives varied considerably between sites; patients had a high level of need with high mortality and rates of hospital admission; the conditions of many patients are not amenable to individual behaviour change.We then revised the logic model to show:the range of contextual/mediating factors shaping local initiativesvariation in case management activities between sitesa reduced emphasis on individual behaviour change.ConclusionIn this challenging and complex area of health care, a logic model can be an essential tool to support evaluation, and refined on the basis of study insights.