Background Half a million people live in UK care homes. General practices struggle to deliver primary care for residents due to high demand and staff shortages. Meanwhile, ambulance services are seeing an increase in 999 calls from care homes. In response, some areas are involving paramedics in proactive support to care homes, part of a shift towards paramedics undertaking non-emergency community care. Yet such workforce changes require urgent evaluation to understand implications for residents, staff and health services. We aimed to explore the role of non-emergency paramedics in care homes to support the design of portfolio research. Methods We convened a Research Development Group of care home, ambulance service, health board, primary care, public and academic representatives. We: Conducted fact-finding visits to sites Analysed 999 call data from care homes Surveyed ENRICH (Enabling Research in Care Homes) care home managers in England and Wales Held a stakeholder workshop to explore the issues Results We identified sites in England and Wales where paramedics provide non-emergency care in care homes. Operating models varied with paramedics employed by ambulance services, health boards and practices. Monthly 999 data from 300 homes confirmed high call and hospital conveyance rates. Survey respondents thought paramedics were well suited to assessing residents, identifying issues, improving care and avoiding admissions. They foresaw benefits to inter-professional working, clinical support and person-centred care, but raised concerns over professional boundaries and role clarity. These messages were reinforced in our workshop, where the value of timely assessment was highlighted, alongside challenges of funding and governance. Conclusions The role of paramedics is shifting into dedicated primary and community work, including care homes. It is imperative that research is aligned and informs evidence based practice. We are developing PERCH2, a feasibility study evaluating the impact of paramedics working in this way.
Objectives To explore paramedics’ experience of delivering fascia iliaca compartment block ( FICB) to patients with suspected hip fracture at the scene of injury. Design Focus groups within a randomised controlled trial. Setting Paramedics based at ambulance stations in the catchment area of one Emergency Department in South Wales, recruited and trained in a feasibility study about an alternative to routine prehospital pain management for patients with suspected hip fracture. Participants 11 paramedics. Intervention Paramedic-administered FICB to patients with suspected hip fracture. We randomly allocated eligible patients to FICB, a local anaesthetic injection directly into the hip region—or usual care, most commonly morphine - using audited scratch cards. Outcomes Paramedics’ experiences of administering FICB gathered through thematic analysis of interview transcripts by two researchers, one paramedic and one lay member. Results Respondents believed that FICB was a suitable intervention for paramedics to deliver. It aligned with routine practice and was within people’s capabilities. They said it took up to 10 minutes longer than usual care to prepare and deliver, in part due to nervousness and unfamiliarity with a new procedure. They praised the training provided but said they were anxious about causing harm by injecting into the wrong location. Confidence increased after one paramedic team successfully treated a patient for local anaesthetic toxicity. Reported challenges related to the emergency context: patients often waited many hours for ambulance arrival; moving patients exacerbated their pain; family and neighbours were present as paramedics administered treatment. Conclusions Paramedics are willing and able to administer FICB to patients with suspected hip fracture before ambulance transport to hospital. Feasibility study findings will inform further research. Trial registration number ISRCTN60065373 ; Pre results.
Background NIHR funding is provided to studies which will produce evidence to inform policy and practice in healthcare. Exploratory or feasibility work can be difficult to find funding for. We present the timeline and steps in the process from first having an idea for research through to gaining funding for a definitive trial. Objective To determine costs and effects of Fascia Iliaca Compartment Block delivered by paramedics at the scene of injury for suspected hip fracture. Methods Literature review Development and testing of tool to support identification of hip fracture by paramedics Feasibility trial (RAPID 1) Proposal for definitive trial (RAPID 2) Results Funding was gained from local NHS ‘Pathway to Portfolio’ resources to carry out the first stages of the programme; then a grant was won through the Welsh ‘Research for Patient and Public Benefit’ scheme to undertake a feasibility study. Finally, NIHR HTA funding was awarded to carry out a definitive trial, in five ambulance services. 2015 – 16: A systematic review of the literature found that the effectiveness of FICB carried out by paramedics at the scene of injury is unknown, although nurse practitioners have been found to deliver this intervention safely in the Emergency Department. 2015 – 16: A tool for identifying hip fracture at the scene of injury was developed by orthopaedic clinicians and tested by ambulance service staff. Sensitivity and positive predictive value were high. 2015 – 18: Feasibility trial progression criteria related to methods and intervention safety and acceptability were met. 2019 – 20: A full trial proposal was submitted, shortlisted, rejected, amended, resubmitted and funded. 2020 – 2025: The RAPID 2 trial is now underway, with paramedic training and patient recruitment due to start in June 2021. Conclusions Research funding systems can work to help to progress from idea to full trial, although timescales can be lengthy.
Adequate pain relief at the point of injury and during transport to hospital is a major challenge in all acute traumas, especially for those with hip fractures, whose injuries are difficult to immobilise and whose long-term outcomes may be adversely affected by administration of opiate analgesics. Fascia iliaca compartment block (FICB) is a procedure routinely undertaken by doctors and nurses in the emergency department for patients with hip fracture but not yet evaluated for use by paramedics at the scene of emergency calls. In this feasibility study, we aim to test whether FICB administered by paramedics at the scene of participants' hip fractures is feasible, safe and acceptable. This will enable us to decide whether to proceed to a fully powered, multi-centre pragmatic randomised trial to evaluate whether the procedure is effective for patients and worthwhile for the NHS. In this study, we propose to recruit ten paramedics in an urban area of South Wales. We will train them to carry out FICB when they attend patients with hip fracture. We will randomly allocate eligible patients to FICB or usual care using audited scratch cards. We will follow up participants to assess measurability of key outcomes including quality of life, pain scores, adverse events, length of stay in hospital, acceptability to patients and compliance of paramedics. We will assess whether the findings meet specified feasibility criteria and, if so, plan a full trial. This study will enable us to recommend whether to undertake a definitive trial of FICB by paramedics for hip fracture. ISRCTN60065373
Background Up to 40% of patients with suspected hip fracture report inadequate or no pre-hospital pain management. Morphine may raise risk of complications and may be avoided by paramedics. Fascia Iliaca Compartment Block (FICB) is used in Emergency Department and orthopaedic wards. The RAPID trial tested feasibility of paramedics administering FICB to patients with suspected hip fracture. Objective To explore patients’ views and experience of care received for suspected hip fracture and in particular FICB before ambulance transport to hospital. Method We interviewed six patients and the daughter of a patient who received FICB to manage their suspected hip fracture. Interviews, by telephone or face-to-face, were audio-recorded with consent. We conducted thematic analysis of transcripts. Two researchers, one paramedic and one lay member were in the analysis team Results Respondents’ memory of prehospital care was dominated by their experience of extreme pain. While they recalled events before falling, they only had partial memory of care prior to hip surgery. Although they recalled paramedics’ arrival, which they reported was up to six hours after their injury, respondents said they remembered little else. Just one recalled consenting to receiving FICB and could describe the process. Other respondents said they were in too much pain to comprehend what occurred or respond coherently. They explained their priority was to receive pain management and they expected the paramedics to treat them safely and effectively. Respondents appeared to be a stoical and trusting group who accepted the treatment they were offered. They did recall high quality of care and praised paramedics for their reassuring and calm manner. Conclusions Hip fracture patients’ overwhelming memory of injury and treatment was of pain and their priority was to receive pain relief. The quality of care, reassurance and administration of pain management was more important to patients than the mechanism of delivering the intervention.
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