East of England Ambulance Service NHS Trust

Abstract Background: Mobile stroke units (MSUs) are specialist ambulances equipped with scanning and point of care testing that can identify patients eligible for intravenous thrombolysis – medication to dissolve a clot used in ischaemic strokes – and provide this on location. While benefits of MSUs have been demonstrated, this has been highly context dependent. Routine use of MSUs across the English and Welsh National Health Service (NHS) has not yet been considered, with only one MSU currently deployed as part of a research project, and as such no pathway for their operation exists. This study aimed to co-design a viable pathway for MSUs within the NHS context. Methods: The study used interdisciplinary co-design alongside Nominal Group Technique (NGT) to generate consensus. Participants were recruited using a combination of purposive, opportunistic and snowball sampling. Data collection took place in online workshops, across three rounds, with supplemental interviews conducted where required. Data were analysed as an ongoing process, with participants checking interpretations after each round, and then further analysed deductively to identify key uncertainties following all the rounds. The consensus threshold for the NGT was set a priori at ≥80%. Results: The study resulted in a developed MSU pathway that reached consensus for being viable within the NHS, with consideration for current systems and pressures. In developing the pathway key uncertainties were identified such as where to base the MSU. We also identified where participants had to make trade-offs in the co-designed pathway, such as staffing considerations. Together, the identified uncertainties and trade-offs represent challenges to MSU implementation and are presented alongside the process to reach the finalised pathway. Future developments which may have implications for the implementation of MSUs were also explored. Conclusions: The co-designed MSU pathway provides a foundation for MSU implementation in the English and Welsh NHS and can be subjected to local and regional modifications required for implementation. However, optimal implementation is likely hindered by several uncertainties and trade-offs that represent challenges to implementation of MSUs at scale, though future developments in acute stroke care may help to mitigate these challenges.

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.

BackgroundVitamin D deficiency can significantly impact health and wellbeing and may affect workplace performance. Evidence shows that shift, indoor and night working are risk factors for vitamin D deficiency; furthermore, awareness of vitamin D is variable amongst ambulance service staff, putting them at increased risk of deficiency. Screening in one ambulance service identified 46% of staff had insufficient or deficient vitamin D levels (i.e., 50.0nmol/L or less, as defined by National Institute for Health and Care Excellence).MethodsA purposive sample of 40 ambulance staff were recruited over seven months and invited to a one-hour, online, semi-structured interview. Interviews explored behaviours and lifestyle factors of those above and below the recommended adequate vitamin D levels and included questions about the impacts of vitamin D level on personal and professional wellbeing, and the opportunity to suggest possible improvements. Interview transcription analysis consisted of both descriptive and inductive thematic methods.ResultsParticipants were aged between 21 and 61 years and worked in varying roles, including control room (n=9), operational (n=20) and support staff (n=11) and included those from diverse ethnic backgrounds, to represent Trust demographics. 6 themes were identified: working environment; supplements; activity levels; outside spaces; impact of deficiency symptoms; and diet. A lack of awareness of vitamin D related issues was identified, despite participants emphasising the importance of awareness to allow staff to take responsibility to promote their own health and wellbeing.ConclusionSeveral improvement suggestions were made including improved access to and maintenance of outside spaces at work, annual well-being checks and improved breaks. Strategies to promote awareness of vitamin D should be considered to improve staff wellbeing in this area. Participants positively perceived research exploring staff health and wellbeing, highlighting this as an area for future research.

Introduction:Menopause is a key workplace issue. Many women will experience symptoms through their later working life. The ambulance service constitutes an employment setting that, dependent on the roles of female staff, can impact on the severity of menopause symptoms and experiences (Prothero et al., 2021). This study aimed to explore female ambulance staff experiences of the menopause transition and suggest ways to improve support offerings.Methods:A qualitative interpretive approach was adopted, involving 12 UK ambulance services. Participants were identified via purposive sampling, and semi-structured interviews were conducted from February to July 2022 via an online platform or telephone. Recordings were transcribed verbatim and analysed using an inductive thematic approach.Results:Twenty-two female participants, aged between 42 and 62 years, were interviewed, and represented all phases of the menopause: peri-menopause (n = 9); menopause (n = 5); post-menopause (n = 3); and unsure (n = 5). Fourteen participants had front-line (patient-facing) or emergency operation centre-based roles, while seven were employed in service support roles. Ten themes were identified: impact on work role; awareness and preparedness for menopause transition; personal impact of symptoms; desired support; appropriate sickness and menopause policy; managerial development; compassion and dignity; impact of working environment; impact on safety; and lack of choice. Lack of understanding and support from colleagues and line managers were identified as the key issues. This is included under the managerial development and compassion and dignity themes.Conclusions:The varying range of menopausal symptoms and their severity impacted on women’s performance at work. The experience of working while going through the menopause could be challenging. Employers should adopt a menopause policy which includes training and awareness for all staff, and suitable for front-line as well as service support staff. There is a need to create a culture where the menopause is not taboo, and women feel able to talk about their symptoms.

Although prehospital stroke management is challenging, it is a crucial part of the acute stroke chain to enable equal access to highly specialised stroke care. It involves a critical understanding of players usually not specialized in acute stroke treatments. There is contradictory information about gender inequity in prehospital stroke detection, dispatch, and delivery to hospital stroke centers. The aim of this narrative review is to summarize the knowledge of gender differences in the first three stages of acute stroke management. Information on the detection of acute stroke symptoms by patients, their relatives, and bystanders is discussed. Women seem to have a better overall knowledge about stroke, although general understanding needs to be improved. However, older age and different social situations of women could be identified as reasons for reduced and delayed help-seeking. Dispatch and delivery lie within the responsibility of the emergency medical service. Differences in clinical presentation with symptoms mainly affecting general conditions could be identified as a crucial challenge leading to gender inequity in these stages. Improvement of stroke education has to be applied to tackle this inequal management. However, specifically designed projects and analyses are needed to understand more details of sex differences in prehospital stroke management, which is a necessary first step for the potential development of substantially improving strategies.

Acute mountain sickness (AMS) is a common illness affecting people ascending to high altitudes. AMS may progress rapidly, and can be fatal if symptoms are neglected, acclimatisation processes fail or if the ascent continues. For many patients with AMS or AMS symptoms, medical assistance is given by mountain rescue and allied health professionals. Currently, the prediction of AMS in the high-altitude environment relies upon recognising and tracking subjective symptoms. However, owing to psychophysical factors commonly associated with high-altitude travel, such as stress and fatigue, subjective symptom recall is innately at risk of bias. There is no objective method for predicting AMS. This scoping literature review analyses the accuracy of pulse oximetry as a tool for predicting the onset of AMS.

Objectives:Patients who frequently call ambulance services are a vulnerable yet heterogeneous population with unmet multiple and complex physical health, mental health and/or social care needs. In this article, we report the challenges that the COVID-19 pandemic has introduced for ambulance services across the UK when managing frequent callers, and reflect on how existing systems and practices are adapting to support changing patient needs.Methods:Data reported in this article comprise reflections from the frequent caller leads in each ambulance service in the UK. All data were provided between 23 April 2020 and 1 May 2020, shortly after the peak of the outbreak in the UK. A single anonymised case study is also reported to illustrate how the pandemic is affecting people’s circumstances and contributing to frequent caller behaviour.Results:Ambulance services are observing changes to the frequent caller population, with many new frequent callers due to health anxiety caused or exacerbated by the pandemic. Management of frequent callers is also changing, with multidisciplinary and multi-agency working becoming more challenging due to decreased access to external services, whether in social care or the community and voluntary sector, and the redeployment of ambulance service staff. There is also decreased face-to-face contact with frequent callers, meaning that opportunities to deliver person-centred care are reduced. However, the introduction or increased use of tele/video conferencing with other organisations has mitigated some of these challenges, and in some cases has improved engagement among external organisations.Conclusions:Health anxieties, lack of access to other health, social and community and voluntary sector services and exacerbations of social isolation and/or loneliness have reportedly contributed to changing behaviour among frequent callers. The COVID-19 pandemic has also affected how ambulance services have been able to manage frequent callers. Ambulance services should continue to engage with external organisations to aid the delivery of person-centred care, particularly organisations with experience in multiple complex needs such as mental health, social isolation and/or loneliness. Future research should examine the consequences of the pandemic for frequent users of ambulance services, and how these impact on the wider health and care community.

The out-of-hospital cardiac arrest (OHCA) outcomes project is a national research registry. One of its aims is to explore sources of variation in OHCA survival outcomes. This study reports the development and validation of risk prediction models for return of spontaneous circulation (ROSC) at hospital handover and survival to hospital discharge. The study included OHCA patients who were treated during 2014 and 2015 by emergency medical services (EMS) from seven English National Health Service ambulance services. The 2014 data were used to identify important variables and to develop the risk prediction models, which were validated using the 2015 data. Model prediction was measured by area under the curve (AUC), Hosmer-Lemeshow test, Cox calibration regression, and Brier score. All analyses were conducted using mixed-effects logistic regression models. Important factors included age, gender, witness/bystander cardiopulmonary resuscitation (CPR) combined, aetiology, and initial rhythm. Interaction effects between witness/bystander CPR with gender, aetiology and initial rhythm and between aetiology and initial rhythm were significant in both models. The survival model achieved better discrimination and overall accuracy compared with the ROSC model (AUC = 0.86 vs. 0.67, Brier score = 0.072 vs. 0.194, respectively). Calibration tests showed over- and under-estimation for the ROSC and survival models, respectively. A sensitivity analysis individually assessing Index of Multiple Deprivation scores and location in the final models substantially improved overall accuracy with inconsistent impact on discrimination. Our risk prediction models identified and quantified important pre-EMS intervention factors determining survival outcomes in England. The survival model had excellent discrimination.

BackgroundTwo-thirds of severe sepsis patients are initially seen in the emergency department, with the majority arriving via ambulance. Since early sepsis recognition, diagnosis and clinical management are considered key for optimal patient outcomes, ambulance clinicians are well placed to have a key role in sepsis care. This study aims to identify key patient, clinician and organisation-derived factors which lead to missed sepsis recognition and delayed access to definitive care in the ambulance setting.MethodsThe East of England Ambulance Service NHS Trust declares any missed cases of sepsis as a Serious Incident (SI; NHS England Serious Incident Framework 2015) to support clinician and service learning and prevent reoccurrence. A qualitative thematic review, based on the Yorkshire Contributory Factors Framework, has being conducted using seventeen sepsis-related SI reports generated between March 2014 and March 2016.ResultsSIs were usually associated with emergency/999 calls resulting in non-conveyance. Breathing/respiratory problems were the most prevalent chief complaint. Perceived contributory factors to these incidences were:‘Patient-derived’: unwell patients with capacity choosing to remain at home, despite advice to attend hospital; presence of co-morbidities and other medical conditions.‘Clinician-derived’: inadequate patient assessment and triage; failure to recognise sepsis markers and use screening tools; low index of suspicion for sepsis and rapid patient deterioration; insufficient safety-netting and documentation; communication errors.‘Organisation-derived’: increasing service demands; mismatch between clinician and vehicle response allocation; lower acuity calls receiving delayed responses at peak demand; variable provision of staff training; lack of clinical practice monitoring; lack of safety culture; promotion of alternative care pathways.ConclusionsErrors in pre-hospital sepsis care occur at all service levels. SI reports provide invaluable systems-based analyses of healthcare episodes and offer concise guidance to prevent error reoccurrence and improve future care. The study findings will inform the development of a prospective sepsis risk assessment tool using prospective hazards analysis methodologies.