Birth before arrival at hospital (BBA) is associated with unfavourable perinatal outcomes and increased mortality. An important risk factor for mortality following BBA is hypothermia, and emergency medical services (EMS) providers are well placed to provide warming strategies. However, research from the UK suggests that EMS providers (paramedics) do not routinely record neonatal temperature following BBA. This study aimed to determine the proportion of cases in which neonatal temperature is documented by paramedics attending BBAs in the South West of England and to explore the barriers to temperature measurement by paramedics.A two-phase multi-method study. Phase I involved an analysis of anonymised data from electronic patient care records between 1 February 2017 and 31 January 2020 in a single UK ambulance service, to determine 1) the frequency of BBAs attended and 2) the percentage of these births where a neonatal temperature was recorded, and what proportion of these were hypothermic. Phase II involved interviews with 20 operational paramedics from the same ambulance service, to explore their experiences of, and barriers and facilitators to, neonatal temperature measurement and management following BBA.There were 1582 'normal deliveries' attended by paramedics within the date range. Neonatal temperatures were recorded in 43/1582 (2.7%) instances, of which 72% were below 36.5°C. Data from interviews suggested several barriers and potential facilitators to paramedic measurement of neonatal temperature. Barriers included unavailable or unsuitable equipment, prioritisation of other care activities, lack of exposure to births, and uncertainty regarding responsibilities and roles. Possible facilitators included better equipment, physical prompts, and training and awareness-raising around the importance of temperature measurement.This study demonstrates a lack of neonatal temperature measurement by paramedics in the South West following BBA, and highlights barriers and facilitators that could serve as a basis for developing an intervention to improve neonatal temperature measurement.
The perspective of patients is increasingly recognised as important to care improvement and innovation. Patient questionnaires such as patient-reported outcome measures may often require cross-cultural adaptation (CCA) to gather their intended information most effectively when used in cultures and languages different to those in which they were developed. The use of CCA could be seen as a practical step in addressing the known problems of inclusion, diversity and access in medical research.An example of the recent adaptation of a patient-reported outcome measure for use with ED patients is used to explore some key features of CCA, introduce the importance of CCA to emergency care practitioners and highlight the limitations of CCA.
Memory clinics are specialist outpatient services offering assessment and evaluation in clinical practice. Memory clinics have been criticized for being preoccupied with research. We analysed the outcomes of 405 referrals to a memory clinic, providing a framework for discussion of the contributions of research to clinical practice. Of the 80% of referrals receiving a formal diagnosis, one-third were recruited on to treatment studies, contributing to clinical research. The remaining two-thirds of patients referred were followed up by specialized care services, and findings from assessment procedures were used to contribute towards academic research. These findings are discussed with reference to the role of research for a memory clinic in clinical practice. The benefits of clinical research are noted, in relation to the percentage of patients involved. The nature of academic research is clarified; it is a dual process, with findings both aiding clinical research and contributing to the body of knowledge about dementia as a possible disease process. It is concluded that memory clinics, as specialized outpatient services, are concerned with research as well as clinical practice, and it is essentially this research which enables clinical practice to develop.
The optimal airway management strategy for in-hospital cardiac arrest is unknown.An online survey and telephone interviews with anaesthetic and intensive care trainee doctors identified by the United Kingdom Research and Audit Federation of Trainees. Questions explored in-hospital cardiac arrest frequency, grade and specialty of those attending, proportion of patients receiving advanced airway management, airway strategies immediately available, and views on a randomised trial of airway management strategies during in-hospital cardiac arrest.Completed surveys were received from 128 hospital sites (76% response rate). Adult in-hospital cardiac arrests were attended by anaesthesia staff at 40 sites (31%), intensive care staff at 37 sites (29%) and a combination of specialties at 51 sites (40%). The majority (123/128, 96%) of respondents reported immediate access to both tracheal intubation and supraglottic airways. A bag-mask technique was used 'very frequently' or 'frequently' during in-hospital cardiac arrest by 111/128 (87%) of respondents, followed by supraglottic airways (101/128, 79%) and tracheal intubation (69/128, 54%). The majority (60/100, 60%) of respondents estimated that ≤30% of in-hospital cardiac arrest patients undergo tracheal intubation, while 34 (34%) estimated this to be between 31% and 70%. Most respondents (102/128, 80%) would be 'likely' or 'very likely' to recruit future patients to a trial of alternative airway management strategies during in-hospital cardiac arrest. Interview data identified several barriers and facilitators to conducting research on airway management in in-hospital cardiac arrest.There is variation in airway management strategies for adult in-hospital cardiac arrest across the UK. Most respondents would be willing to take part in a randomised trial of airway management during in-hospital cardiac arrest.
Aims/Objectives/Background One approach to addressing increasing demand in emergency departments (EDs) has been the co-location of general practitioners (GPs) in or alongside the emergency department (ED), known as GPED. This approach was both advocated by the National Health Service (NHS) and supported by capital funding in 2017. However, little is known about the models of GPED that have been implemented as a result. Methods/Design We collected data on the model of GPED in use (if any) at 163/177 (92%) of type one EDs in England at two time points: September 2017 and December 2019. Multiple data sources were used including: on-line surveys; interviews; case study data; publicly available information. Models were classified according to an iteratively developed taxonomy as Inside/integrated, Inside/parallel, Outside/onsite, Outside/offsite. Results/Conclusions The proportion of EDs using GPED increased from 81% to 95% over the study period. The most common model was ‘Inside/parallel’ to the ED: 30% (44/149) in 2017, rising to 49% (78/159) in 2019. The number of Inside/integrated models dropped from 26% (38/149) to 9% (15/159). 23 sites commenced and four sites ceased GPED provision. 87% (142/163) of the EDs sampled were awarded capital funding. We identified no association between the type of GPED model adopted and the observable characteristics of EDs such as annual attendance, rurality of location and deprivation within the population served. The majority of EDs in England have now adopted GPED. The increase in Inside/parallel models and the reduction in Inside/integrated models is likely to be related to the availability of capital funding to finance structural changes to EDs so that separate GP services could be provided. Further research is required to understand the relative effectiveness of the various models of GPED identified.
There are potential health gains such as reducing early deaths, years spent in ill-health and costs to society and the health and care system by encouraging NHS staff to use encounters with patients to help individuals significantly reduce their risk of disease. Emergency department staff and paramedics are in a unique position to engage with a wide range of the population and to use these contacts as opportunities to help people improve their health. The aim of this research was to examine barriers and facilitators to effective health promotion by urgent and emergency care staff.A systematic search of the literature was performed to review and synthesise published evidence relating to barriers and facilitators to effective health promotion by urgent and emergency care staff. Medical and social science databases were searched for articles published between January 2000 and December 2021 and the reference lists of included articles were hand searched. Two reviewers independently screened the studies and assessed risk of bias. Data was extracted using a bespoke form created for the study.A total of 19 papers were included in the study. Four themes capture the narratives of the included research papers: 1) should it be part of our job?; 2) staff comfort in broaching the topic; 3) format of health education; 4) competency and training needs. Whilst urgent and emergency care staff view health promotion as part of their job, time restraints and a lack of knowledge and experience are identified as barriers to undertaking health promotion interventions. Staff and patients have different priorities in terms of the health topics they feel should be addressed. Patients reported receiving books and leaflets as well as speaking with a knowledgeable person as their preferred health promotion approach. Staff often stated the need for more training.Few studies have investigated the barriers to health promotion interventions in urgent and emergency care settings and there is a lack of evidence about the acceptability of health promotion activity. Additional research is needed to determine whether extending the role of paramedics and emergency nurses to include health promotion interventions will be acceptable to staff and patients.
Following prehospital birth, babies can become hypothermic within minutes, sometimes before paramedics arrive. The risk of the baby dying increases by at least 28% for every degree that their temperature drops below <36.5°C. The earlier we can provide effective warming interventions, the lower the risk of poor outcomes. The aim of this project was to 1), examine the neonatal temperature management advice given to people calling 999 about a prehospital birth in the UK and 2), explore NHS staff and patient views about the content and accessibility of advice given.
Methods
All 999 calls between January 2021-January 2022 were searched by the Clinical Information and Records teams at two ambulance services using the two different triage systems (AMPDS and NHS Pathways). Thirty eligible calls were selected from postcodes with varying levels of deprivation and passed to the study team for content analysis. Nine focus groups were held with 18 NHS staff (paramedics, midwives, neonatal nurses/doctors, call-handlers), and 22 members of the public who had experienced prehospital birth, to discuss the content and accessibility of the advice given.
Results
Five themes were identified as potential barriers to good quality neonatal temperature management: confusing or conflicting advice on where the baby should be placed following birth, vague or unclear instructions on warming the baby, the timing of temperature management advice, the priority given to other instructions, and a lack of importance placed on neonatal temperature. Participants suggested a number of simple changes to advice, including increased focus on the importance of neonatal temperature, encouraging skin-to-skin contact, and providing specific advice on warming the baby.
Conclusions
There is an opportunity to improve the neonatal temperature management advice given by 999 call-handlers during calls related to prehospital birth. This could reduce the number of babies arriving at hospital hypothermic, therefore improving outcomes.
Background: Fluid therapy is a controversial topic in both human and veterinary medicine. While it is appreciated that fluid therapy can be immediately life‐saving, particularly in animals suffering from hypovolaemic shock, it is increasingly recognised that inappropriate fluid therapy can lead to significant morbidity. Aim of the article: This article, the second in a two‐part series, considers some clinical aspects of fluid therapy in adult horses with colic and some of the controversies surrounding fluid rates, fluid types and the management of metabolic acidosis. The first part, published in last month's issue of In Practice , discussed basic physiological concepts of body fluids, available fluid types and the practicalities of administration in the adult horse.
The Chain of Survival identifies the importance of early recognition of patients who are at imminent risk of out-of-hospital cardiac arrest. This research investigated the interaction between callers and call-takers during calls to the Emergency Medical Service; it specifically focussed on patients who were alive at the initiation of the EMS call, but who subsequently deteriorated into out-of-hospital cardiac arrest during the prehospital phase of care (i.e., before arrival at hospital).
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