Graham McClelland

The diagnostic accuracy of the HITSNS prehospital triage rule for identifying patients with significant traumatic brain injury: a cohort study.

Diversion of suspected traumatic brain injury (TBI) patients to trauma centres may improve outcomes by expediting access to specialist neurosurgical care. This study aimed to determine the accuracy of the Head Injury Straight to Neurosurgery (HITSNS) triage rule for identifying patients with significant TBI. A diagnostic cohort study was performed using data from the HITSNS trial, the Trauma Audit and Research Network registry and the North East Ambulance service database. Sensitivity and specificity of the HITSNS triage rule were calculated against a reference standard of significant TBI, defined by a cranial Abbreviated Injury Scale score of at least 3 or by the performance of a neurosurgical procedure. A total of 3628 patients were included in the complete case analyses. The HITSNS triage tool demonstrated a sensitivity of 28.3% (95% confidence interval 21.8–35.4) and a specificity of 94.4% (95% confidence interval 93.6–95.2). The low sensitivity of the HITSNS triage rule suggests that a considerable proportion of patients with significant TBI may not be triaged directly to trauma centres, and further research is needed to improve the accuracy of bypass protocols.

The challenges of conducting prehospital research: successes and lessons learnt from the Head Injury Transportation Straight to Neurosurgery (HITS-NS) trial

Head Injury Transportation Straight to Neurosurgery was a cluster randomised trial studying suspected severe head injury treatment pathways conducted in the North East Ambulance Service NHS Foundation Trust and North West Ambulance Service NHS Trust between January 2012 and March 2013. This was the worlds first large scale trial of any trauma bypass and was conducted as a feasibility study. This short report will describe some of the lessons learnt during this ground breaking and complex trial.

A survey of UK paramedics’ views about their stroke training, current practice and the identification of stroke mimics

Aims – Paramedics play a crucial role in identifying patients with suspected stroke and transporting them to appropriate acute care. Between 25% and 50% of suspected stroke patients are later diagnosed with a condition other than stroke known as a ‘stroke mimic’. If stroke mimics could be identified in the pre-hospital setting, unnecessary admissions to stroke units could potentially be avoided. This survey describes UK paramedics’ stroke training and practice, their knowledge about stroke mimic conditions and their thoughts about pre-hospital identification of these patients. Methods – An online survey invitation was circulated to members within the UK College of Paramedics and promoted through social media (8 September 2016 and 23 October 2016). Topics included: stroke training; assessment of patients with suspected stroke; local practice; and knowledge about and identification of stroke mimics. Results – There were 271 responses. Blank responses (39) and non-paramedic (1) responses were removed, leaving 231 responses from paramedics which equates to 2% of College of Paramedics membership and 1% of Health and Care Professions Council registered paramedics. The majority of respondents (78%) thought that they would benefit from more training on pre-hospital stroke care. Narrative comments focused on a desire to improve the assessment of suspected stroke patients and increase respondents’ knowledge about atypical stroke presentations and current stroke research. The Face Arm Speech Test was used by 97% of respondents to assess suspected stroke patients, although other tools such as Recognition of Stroke in the * Corresponding author: Graham McClelland, Stroke Research Group, Newcastle University, 3–4 Claremont Terrace, Newcastle upon Tyne NE2 4AE, UK. 2_OR_McClelland.indd 4 17/05/2017 14:26 McClelland, G, Flynn, D, Rodgers, H and Price, C, British Paramedic Journal 2017, vol. 2(1) 4–15 McClelland et al. 5 identification instruments tend to over-diagnose stroke (Rudd, Buck, Ford, & Price, 2016). Consequently, their specificity is relatively low. Stroke mimic conditions, such as seizures, infections and migraine, account for 25%–50% of emergency admissions to HASUs (Gibson & Whiteley, 2013; Whiteley, Wardlaw, Dennis, & Sandercock, 2011). While many patients with stroke mimic conditions still require urgent medical care, their status as false positive cases of stroke can lead to unnecessary transportation to distant stroke centres and inefficient use of ambulance and stroke service resources, as well as incurring substantial inconvenience for patients and families. Stroke care is changing, with fewer hospitals providing acute stroke services (Morris et al., 2014), which means that it is more important than ever that paramedics direct stroke patients to the appropriate hospital. In light of this there is a pressing need to understand paramedics’ knowledge and views about stroke, and stroke mimic conditions, to inform future research and practice. A previous US survey reported on basic pre-hospital stroke knowledge and treatment in the US (Crocco, Kothari, Sayre, & Liu, 1999), but this is not directly relevant to current UK practice due to healthcare system and temporal differences. The current survey describes UK paramedics’ views about their stroke training and practice, their knowledge about stroke mimic conditions and their thoughts about pre-hospital identification of these patients.

A review of enhanced paramedic roles during and after hospital handover of stroke, myocardial infarction and trauma patients

BackgroundAmbulance 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).MethodsWe 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.ResultsWe 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.ConclusionsThere 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.

PP14 Development of a prehospital assessment to identify stroke mimic conditions

Background Despite routine use of pre-hospital identification instruments, approximately 30% of suspected stroke admissions are stroke mimics (SM). Early identification may allow “false positive” SM patients to be directed to appropriate care and improve healthcare resource utilisation. Methods A retrospective database of ambulance records containing a paramedic impression of stroke was linked to hospital specialist diagnosis data from 01/06/13 to 31/05/16. Logistic regression identified clinical features predictive of SM. An assessment score was constructed prioritising specificity over sensitivity. Results 1650 patients (mean age 75.3, 47% male, 40% SM) were included. 1520 (92%) were Face Arm Speech Test (FAST) positive. Table 1 describes the characteristics in the SM assessment. Each characteristic scores 1 point if present. Table 1 Stroke mimic characteristics Characteristic Stroke patients(n=982) Mimic patients (n=668) Diagnostic Odds Ratio(95% CI) Systolic blood pressure<95 mmHg 3 13 6 (2–13) Temperature>38.0°C AND heart rate>90bpm 2 18 14 (3–59) History of epilepsy AND seizures 0 11 18 (2–138)* Age<40 years 4 24 9 (3–26) History of migraine AND headache 2 12 9 (2–40) *Approximated 86% (66/77) of suspected stroke patients scoring 1 were SM. 100% (6/6) of patients scoring >1 characteristic were SM. A score ≥1 identified SM with 11% (95% CI, 8–13) sensitivity, 99% (95% CI, 98–99) specificity, positive predictive value of 87% (95% CI, 79–94), negative predictive value of 62% (95% CI, 60–64) and a diagnostic odds ratio of 11 (95% CI, 6–20, p<0.0001). Conclusions Amongst ambulance patients with suspected stroke, a small number of SM can be identified with a high degree of certainty. This simple tool needs further validation, prospective testing in the pre-hospital environment with characteristics systematically recorded and consideration of potential clinical impact.

Bypassing nearest hospital for more distant neuroscience care in head-injured adults with suspected traumatic brain injury: findings of the head injury transportation straight to neurosurgery (HITS-NS) pilot cluster randomised trial

Objective Reconfiguration of trauma services, with direct transport of patients with traumatic brain injury (TBI) to specialist neuroscience centres (SNCs)—bypassing non-specialist acute hospitals (NSAHs), could improve outcomes. However, delays in stabilisation of airway, breathing and circulation (ABC) may worsen outcomes when compared with selective secondary transfer from nearest NSAH to SNC. We conducted a pilot cluster randomised controlled trial to determine the feasibility and plausibility of bypassing suspected patients with TBI —directly into SNCs—producing a measurable effect. Setting Two English Ambulance Services. Participants 74 clusters (ambulance stations) were randomised within pairs after matching for important characteristics. Clusters enrolled head-injured adults—injured nearest to an NSAH—with internationally accepted TBI risk factors and stable ABC. We excluded participants attended by Helicopter Emergency Medical Services or who were injured more than 1 hour by road from nearest SNC. Interventions Intervention cluster participants were transported directly to an SNC bypassing nearest NSAH; control cluster participants were transported to nearest NSAH with selective secondary transfer to SNC. Outcomes Trial recruitment rate (target n=700 per annum) and percentage with TBI on CT scan (target 80%) were the primary feasibility outcomes. 30-day mortality, 6-month Extended Glasgow Outcome Scale and quality of life were secondary outcomes. Results 56 ambulance station clusters recruited 293 patients in 12 months. The trial arms were similar in terms of age, conscious level and injury severity. Less than 25% of recruited patients had TBI on CT (n=70) with 7% (n=20) requiring neurosurgery. Complete case analysis showed similar 30-day mortality in the two trial arms (control=8.8 (2.7–14.0)% vs intervention=9.4(2.3–14.0)%). Conclusion Bypassing patients with suspected TBI to SNCs gives an overtriage (false positive) ratio of 13:1 for neurosurgical intervention and 4:1 for TBI. A measurable effect from a full trial of early neuroscience care following bypass is therefore unlikely. Trial registration number ISRCTN68087745.

STAKEHOLDER ENGAGEMENT IN THE DESIGN OF A NOVEL PRE-HOSPITAL ACUTE STROKE ASSESSMENT

Background Outcomes for stroke patients can be improved by rapid identification and assessment, but delays commonly occur due to the availability of clinical information and brain imaging. We sought to develop a novel paramedic-led intervention to reduce scene to needle time for stroke patients suitable for thrombolysis. Methods Over 12 months we undertook group interviews and consultation in North East England, North West England and Wales involving patient representatives (n=20), paramedics, emergency department and stroke service hospital staff (n=100). The primary aim was to understand the impact of organisational boundaries, service pressures and traditional professional roles upon a new paramedic approach to stroke assessment. Secondly, to develop a clinical trial protocol for later evaluation of the proposed new paramedic approach. All interviews were digitally recorded, transcribed and analysed using open then focussed coding. Results Participant feedback supported an intervention which transgressed organisational and professional boundaries. Modifications were made following participant views about logistical, ethical and governance issues: ▸ The protocol was changed to reflect operational barriers restricting paramedics taking patients directly to the CT scan room. ▸ Participants advocated obtaining research consent after admission in order to address concerns over treatment delays, and supported a trial protocol which allowed data collection from patients that died before consent was feasible. ▸ Paramedics would provide additional information at patient handover directly to the stroke team or A&E staff rather than attempt to convey more during pre-notification. Conclusions Following the interviews significant alterations were made to the intervention and protocol in order to improve trial feasibility, acceptability and data quality. This emphasizes the importance of engaging with ambulance services, other clinical teams and patients during the development of pre-hospital research protocols.

DEVELOPMENT AND IMPACT OF A DEDICATED CARDIAC ARREST RESPONSE UNIT IN A UK REGIONAL AMBULANCE SERVICE

Background Survival rates from out-of-hospital cardiac arrest (OHCA) vary, with figures from 2% to 12% reported nationally. Our ambulance service introduced a dedicated cardiac arrest response unit (CARU) as a trial in order to improve local patient outcomes by focussing training, extending the scope of practice and increasing exposure to cardiac arrests. CARU launched in January 2014 using a rapid response car staffed by senior paramedics responding to cardiac arrests within a 19 minute radius of their location. CARU Service (CARU removed) 2012 OHCA Registry Cardiac arrests where resuscitation was attempted 54 705 1,853 ROSC (Sustained to hospital) 35.2% 25.8% 23.0% Survival to discharge (Based on latest available data) 13.0% 3.3% 7.0% Methods This work describes the development and impact of CARU during the initial six months (10/01/14 to 09/07/2014) of operations using prospectively collected data on all cases attended. Results CARU activated to 165 calls and attended 65% (n=107). 50% (n=54) of the cases attended were cardiac arrests where resuscitation was attempted. Return of Spontaneous Circulation (ROSC) was achieved during pre-hospital resuscitation in 52% (n=28) of cases. Patient outcomes are reported compared with service data for January to June 2014 inclusive and one year of historical data from the regional OHCA registry: Conclusions Based on these figures CARU appears to have a positive impact on ROSC and a significant impact on survival to discharge rates compared with the rest of the service (p<0.01, Fishers exact test). Further work is needed to explore how CARU delivers this impact and how the CARU model can be implemented beyond the trial setting in a sustainable fashion.