Clinical update - London Ambulance Service

Clinical update
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Pelvic injuries
XAddison’s disease
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Issue 27
update
Have You Seen?
Medical Director’s Bulletin
Change of adult defibrillation
electrodes for the FR2
(No.98) 27/09/2011
As the weather changes,
crews are reminded of the
increased incidence of CO
poisoning.
Chronic
exposure
associated with faulty boilers
often presents with vague
symptoms
such
as
headaches
and
flu-like
illness, and should be
considered as part of the
differential diagnosis in this
group of patients, especially
where there is more than
one person affected. HART
are able to measure CO
levels on scene and give
advice on diagnosis and the
importance
of
formal
assessment.
Service meets nonconveyed CPI target!
We all know the increased
risks associated with leaving
a
patient
at
home.
Therefore, this year there
has been a real focus on
ensuring this is being done
safely and documentation
for
these
patients
is
complete. For the first time
ever, the Service has met
the targets agreed with the
commissioners for the nonconveyed CPI.
Well done to everybody who
fully completed their PRF,
safely leaving a patient at
home. Keep up the good
work!
Dec 2011
Clinical
Primacy of care
Carbon monoxide (CO)
O
Clinical quality indicators In April 2011, the Department of Health (DH) introduced 11 new Clinical Quality Indicators (CQIs)
for ambulance services, which replaced the Category B 19 minute response time target for nonlife threatening 999 calls. The Category B response time target had no clinical justification and
now calls will not only be measured simply on response times alone, but on the quality of clinical
care provided and patient outcome. Timeliness of care will still be an important factor and Red 1
and Red 2 calls will continue to be measured against the DH time target of eight minutes.
The 11 Ambulance Service Clinical Quality Indicators:
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Outcome from ST Elevation Myocardial Infarction (STEMI)
Outcome from stroke for ambulance patients
Outcome from cardiac arrest – return of spontaneous circulation (ROSC)
Outcome from cardiac arrest – survival to discharge
Time to answer 999 calls
Ambulance calls closed with telephone advice or managed without transport to A&E
(where clinically appropriate)
999 Call abandonment rate
Re-contact rate within 24 hours of discharge from care (i.e. calls closed with telephone
advice or patients treated and discharged on scene, where re-contact with the
ambulance service via 999 occurs for the same patient within 24 hours from time of
discharge)
•
Time to treatment (time to arrival on scene of a qualified health professional dispatched
by the ambulance service for immediately life-threatening, Category A calls)
•
Service experience
•
Category A 8 minute response
(Technical Guidance for the 2011/12 Operating Framework, DH)
Examples of how clinical indicators are evidenced
The stroke indicator has two component parts:
1.
2.
The percentage of FAST + stroke patients (assessed face-to-face) potentially eligible for
thrombolysis, who arrive at a hyper-acute stroke unit with 60 minutes of call
The percentage of suspected stroke patients (assessed face-to-face) who receive an
appropriate care bundle.
Clinical update
The STEMI indicator has three component parts:
1.
2.
3.
The percentage of patients suffering a ST elevation
myocardial infarction (STEMI) receiving thrombolysis
within 60 minutes of call (NICE national quality standard).
The percentage of patients suffering a STEMI who are
directly transferred to a centre capable of delivering
primary angioplasty and receive this within 150 minutes
of call.
The percentage of patients with STEMI diagnosed that
receive an appropriate care bundle.
See ASCQI article on page six for details of ‘care bundle’
components.
Key data to enable reporting against CQIs is obtained from
PRFs via the clinical performance indicator (CPI) audit
process. High CPI compliance will enable the Service to
accurately report the high standard of clinical care that is
provided to patients and contribute to achieving CQI targets.
Performance against each of the indicators is reported by all
UK ambulance trusts to the DH and the figures published. All
the Information is public and allows comparisons between
one ambulance service and another.
CQI performance data can be found at the following
locations:
LAS CQI data
Decision tree: third stage
management and the considered use
of fundal/uterine massage
Correct management of the third stage following the birth of the
baby is important for safety and wellbeing of the mother. Fundal
or uterine massage must never be used to help deliver the
placenta in the absence of uterine bleeding as it can cause
complications. The aim of the below flowchart is to clarify the
role of the appropriate use of fundal massage in the third stage
of labour. Fundal massage is appropriate if bleeding is
significant and a post partum haemorrhage (PPH) diagnosed.
If unable to give syntometrine then fundal massage alone is
appropriate. Ensure no second baby (twin or more) before
administration of Syntometrine. NB: If the placenta remains in
situ but no significant bleeding occurs, treat as retained
placenta. A midwife on scene may decide to manage the third
stage differently.
Andrew Lingen-Stallard, Consultant Midwife
Flow chart to illustrate management of third stage of labour
http://www.londonambulance.nhs.uk/about_us/how_we_are_doing/cli
nical_quality_indicators/clinical_dashboard.aspx
National CQI data published by DH, for all UK ambulance
trusts
Birth of baby
http://www.dh.gov.uk/en/Publicationsandstatistics/Statistics/Performa
ncedataandstatistics/AmbulanceQualityIndicators/index.htm
rd
Peter Dalton, Staff Officer to the Medical Director
Natural 3 stage
Benzylpenicillin
There have recently been questions raised by staff
regarding whether it is appropriate to administer
benzylpenicillin to a patient with suspected meningitis but
without the presence of a non blanching rash. There has
been much discussion regarding this within the JRCALC
Guideline Development Group and essentially, the
consensus agreement is that UK ambulance services
should be following the NICE guideline which states ‘no
non blanching rash - no antibiotic’. However, the need
for continued observation, to look for a developing rash,
and rapid conveyance to the nearest emergency
department is stressed.
Unmanageable airway and the
importance of prompt transport to
hospital
Where a patient’s airway is considered ‘unmanageable’
and further resources such as HEMS/BASICS doctors
are not available crews should not delay on scene, but
transport the patient rapidly to the nearest hospital. Such
examples may include:
• Severe maxillofacial or neck trauma preventing
effective ventilation
• Excessive regurgitation (or massive
haemorrhage from the airway) where it has not
been possible to successfully place a
supraglottic airway or endo tracheal tube.
No routine fundal/
uterine massage
Placenta
expelled
Placenta
expelled
Placenta
remains in situ
No
significant
bleeding
Bleeding
significant
PPH
Bleeding
significant
PPH
No further
action
Fundal massage,
syntometrine
and transfer
Fundal massage,
syntometrine and
transfer
Clinical update
Pelvic injuries
End of life care: important
messages
Pelvic injuries are relatively common in major trauma.
Typical mechanisms include motorcycle collisions and Tbone / side impact road traffic collisions with significant
passenger cell intrusion. It is a reasonably common injury in
pedestrians hit by vehicles, and may occur with relatively
minor impact in older people.
Gross clinical signs include abduction and external rotation /
splaying of the legs; urinary and / or faecal incontinence, and
rectal, urethral or vaginal bleeding. Bruising and swelling
over the iliac crests, pubis, perineum or scrotum may occur,
but this may be a relatively late sign.
Do I need to see a DNA-CPR for it to be valid?
Do I need to involve the police / HM Coroner in end of life
care patients on whom the LAS have performed
recognition of life extinct (ROLE)?
There have unfortunately been a number of recent instances
where Service staff have carried out resuscitative efforts in
entirely inappropriate circumstances. This has then been
compounded by staff then seeking police / HM Coroner
involvement, which in three instances was despite the
palliative care team being in direct contact with the crew(s)
concerned and trying to ensure a dignified end to their
patient’s life. The following paragraphs cover the main
questions that arise when dealing with end of life care
patients and resuscitation / ROLE. Staff are reminded that
this topic was more fully covered in Clinical Update 23
October 2010, available at:
http://thepulse/uploaded_files/Clinical%20Update/ClinicalUpdate23Oct10.pdf
Service staff should be certain beyond reasonable doubt that
a DNA-CPR exists. This does not necessarily mean that
staff need to have seen the physical DNA-CPR. For example
a growing number of resuscitation decisions are sent to the
Service and are logged on the locality information database.
Thus where a crew have been notified by EOC and / or
clinical coordination desk (CCD) that a DNA-CPR exists, it is
NOT necessary for the crew to then physically see the
DNACPR. Equally, if ambulance staff have been informed
by a registered health care professional (HCP) that a DNACPR exists it is reasonable for the crew to record the
name of the HCP who has given them this information
and abide by the decision. It is not necessary for them to
see the physical DNA-CPR form. (This may apply when
phoning a GP or palliative care provider for additional
information. If assistance is needed with this staff should
speak with the CCD). Staff should seek more evidence that a
DNA-CPR
exists
when
potentially
unsubstantiated
statements regarding DNA-CPR are made by the patient’s
relatives. This situation should, wherever possible, prompt a
conversation with the patient’s health care team to clarify this
issue or, at the very least a conversation with staff on CCD.
Some GPs may issue an ‘allow natural death form’ which is
similar to a DNA-CPR order and should be adhered to.
Although patients with pelvic fractures may well be
profoundly shocked on initial assessment, it is important to
remember that this is not always the case, especially since
the majority of trauma victims are young and healthy, and
able to compensate very well for severe blood loss. A pelvic
fracture must be considered in the patient with multiple limb
fractures, or in patients who have a reduced level of
consciousness following trauma.
Subtle symptoms include pain over the sacrum or groin, or
neurological abnormalities in the legs. In the presence of
concerning mechanism, these are highly significant.
In addition to ensuring airway patency and effective
ventilation, and managing other sources of blood loss, crews
should attempt to splint the pelvis, using either frac-straps or
triangular bandages. DO NOT stress or spring the pelvis,
and minimise log-rolling and other movement.
All patients with a possible fracture of the pelvis must be
conveyed to a major trauma centre.
How do I ensure a DNA-CPR is valid?
If ambulance staff are presented with a DNA-CPR it is
reasonable to check the following.
•
Dr Neil Thomson, Assistant Medical Director East
•
Penetrating injuries
Staff are reminded that for patients with central
penetrating trauma (neck to groin) the priority is to move
the patient to hospital. BMs and temperature reading
remain important but should not delay conveyance; nor
should filling in the paperwork on scene. The absolute
necessity is to avoid a lengthy on scene time (aim for < 5
mins); assessment should include a rapid check of the
patient to ensure there are no other wounds (e.g. in groin,
between buttocks or armpits), and then to move to
hospital. Additional clinical observations can be completed
en route.
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•
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The DNA-CPR is for the correct patient. In essence is the
patient for whom they have been called, the same patient
named on the DNA-CPR?
The DNACPR should be signed by the clinician making
the DNA-CPR.
Many DNA-CPR forms will not have a stated review date;
this is acceptable and indicates that the patient’s
condition is not expected to improve. A review date
indicates that the decision needs to be reconsidered in
the light of all available information and the circumstances
you are faced with.
Are there any exceptions to the DNA-CPR? Some DNACPRs will not apply in specific circumstances, such as the
patient having a cardiac arrest when undergoing a clinical
procedure.
Clinical update
Should we still resuscitate a patient who is clearly in the
the patient’s notes. If you cannot find any information at all
regarding such contact numbers then call the CCD for
assistance. CCD can then seek assistance from the out-ofhours GP service, or in extreme cases inform the HM
Coroner’s Officer for the area via the police.
terminal phase of an illness and resuscitation does not seem
appropriate - but there is no DNA-CPR?
The JRCALC National Clinical Guidelines (2006) states
“resuscitation can be discontinued where the patient’s death is
expected due to terminal illness”. There should be clear
evidence of terminal illness and this should be detailed
on the PRF. Terminal illness does not just include advanced
malignancy, but also includes conditions such as end stage
cardiac and respiratory illnesses. Remember that the CCD
can often assist in getting contact details of care teams /
hospice teams etc. Discussion with the HCP/GP involved
in the patient’s care can be very helpful. CCD also have
access to the on call clinical adviser who can give further
advice / guidance to help you.
David Whitmore, Senior Clinical Advisor to the Medical Director
Pyrexia in children
The average body temperature for a child is between 36.5°C
and 37.2°C. Even if temperature is normal, take parental
reports of fever seriously.
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o
Examples of such evidence include.
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Temperature ≥ 38°C in an infant aged 0-3 months is a red flag
Temperature ≥ 39°C in a child aged 3-6 months is a red flag
Most fevers in children are not serious and are due to
common infections of childhood such as coughs, colds and
other viral infections. However, sometimes a fever is a
symptom of a serious infection and these should be
considered. Infections that may cause fever in children can be
broken down into three categories:
Documentation in the patient’s district nursing notes that
confirms terminal illness.
Documentation in patient held palliative care notes that
confirm a terminal diagnosis.
Documentation that the patient is on the “Liverpool Care
Pathway” (LCP) a commonly used care plan for the last
days of a patient’s life, and / or documentation relating to
the “Gold Standards Framework” (GSF). LCP and GSF
can be used independently, but increasingly the use of the
GSF leads to a patient having an LCP plan.
A ‘Preferred Priorities of Care Document’ which sets out
the patient’s choice around their care when they reach the
terminal phase of their condition.
Evidence of injectable palliative care medication such as:
o opioid analgesia
o anti anxiety medications such as midazolam or
haloperidol
o anti secretion medications such as glycopyrronium
and hyoscine butylbromide
(there is also likely to be supporting documentation within
the house regarding these drugs and the doses and route
of administration which will most likely be subcutaneous).
The presence of a subcutaneous syringe driver containing
the above medications (again there is likely to be
supporting documentation in the house). Although the
presence of a subcutaneous syringe driver does not in
itself indicate terminal illness as they are used now for
insulin therapy and anti emetics.
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Viral infections cause many common illnesses such as
colds, coughs, flu, and diarrhoea (norovirus for example).
Sometimes viral infections cause more serious illnesses.
Bacterial infections are less common than viral, and also
cause fevers. Bacteria are more likely to cause serious
illness such as pneumonia, urine and kidney infections,
septicaemia (infection in blood) and meningitis.
Other types of infection are uncommon causes of a high
temperature in the UK. However, don’t forget malaria can
occur up to one year after returning from a malarious
country.
Patient assessment should include consideration/
documentation of:
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Are there circumstances where a patient who has a DNA-
CPR should still be resuscitated?
Appearance: Tone, Interacting, Consolable, Looking around/
making eye contact, Speech/ babbling (TICLS)
Respiratory rate (RR) and any effort (nasal flaring, recession –
suprasternal, intercostal {between ribs}, subcostal {indrawing
along margins rib cage})
Colour/ skin rash
Capillary refill and warmth of hands and feet (assessing
circulation)
Pulse/heart rate – heart rate can be elicited by auscultating the
apex beat
Warning symptoms/signs for early meningitis or septicaemia:
•
Leg pains - which can become severe and make it hurt to
stand or walk.
•
Cold hands or feet - even if there is a fever.
•
Pale or mottled skin. In particular, pale, dusky or blue skin
colour around the lips
•
Purpuric rash, photophobia and neck stiffness are quite rare.
Occasionally a patient who has a DNA-CPR may suffer from a
cardiac arrest from a clearly reversible cause such as
choking. In these very rare occasions it may be entirely
reasonable to consider resuscitation.
Should a patient with a DNA-CPR still be treated for other
conditions?
Yes. A DNA-CPR purely relates to CPR and the patient
should still receive treatment for any other condition.
Therefore, it would be reasonable to discuss the most
appropriate treatment with the patient and medical team/GP
prior to conveying to the emergency department. If further
advice is needed the CCD can be contacted.
Note: Have a very low threshold for undertaking a BM on a sick child.
Capillary refill, respiration rate and heart rate are the most
important signs in determining how unwell a child is.
Remember:
Children under two years of age must be transported to the
emergency department. Children aged two to five years must
be referred to a GP.
Think about safeguarding; document whether you do or do not
have any child protection concerns.
Two sets of observations must be taken (at least 20 minutes
apart, especially if not conveying the patient). Clear advice
must be given to the child’s parents/carers including use of
anti-pyretics.
Recognition of Life Extinct (ROLE)
Once ROLE has been performed the default position
should then be to contact either the GP, the palliative
care team, hospice team or district nursing team.
In the vast majority of cases there will be contact details left in
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Clinical update
Signs and symptoms of Addisonian crisis
Addison’s disease
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What is Addison’s disease?
Addison’s disease is caused by the destruction of the cortex of
the adrenal glands. The adrenals are located on top of each
kidney and the cortices produce hormones including:
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Aldosterone
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Cortisol
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Adrenal androgens
•
•
•
•
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Patients with Addison’s disease have a deficiency of
adrenocorticol secretions (Fitzgerald, 1992).
Management
Addison’s disease can also be known as primary adrenal
insufficiency or hypoadrenalinism.
•
•
•
•
•
Information about Addisonian Crisis can be found at:
http://www.addisons.org.uk/info/addisons/page1.html
Information relating to adrenal insufficiency in children can be found at:
http://www.gosh.nhs.uk/gosh_families/information_sheets/cortisol_defic
iency/cortisol_deficiency_families.html
References:
nd
Fitzgerald, A. (1992). Handbook of clinical endocrinology. (2 Ed.).
Prentice International: London.
Greenspan, F. and Gardner, D. (2001). Basic and clinical
th
endocrinology. (7 Ed.). McGraw Hill: USA.
National Health Service, (2011). Addison’s disease. Symptoms.
Accessed from http://www.nhs.uk/Conditions/Addisonsdisease/Pages/Symptoms.aspx on 12th October, 2011.
Nussey, S. and Whitehead, S.A. (2001). Endocrinology: an integrated
approach. BIOS Scientific Publishers Ltd: Oxford.
Written by Alex Ulrich, Paramedic.
The new PRF code card
A new PRF code card was published in October 2011, to
incorporate a new, simpler, destination suffix coding system.
The suffix system was introduced as it was acknowledged that
the existing list of destination codes was complicated and in a
significant number of cases, accurate codes were not recorded
on PRFs. For example, King’s College Hospital had seven
different PRF codes. It is anticipated that the new suffix system
will more accurately record appropriate care pathway (ACP)
use. Reducing conveyance to emergency departments and
increasing ACP use is an important target that has been set
with NHS London Commissioners.
The letter suffix should be written next to the numerical
destination code as shown below.
produce the hormones.
Addisonian crisis:
Both paramedics and EMTs / SP3s can give
Hydrocortisone
Indicated for ADDISONIAN PATIENTS THAT
BECOME UNWELL
Adult dose of 100mg IV (or IM when IV access can not
be obtained)
Slow IV administration over two minutes
Paediatric doses can be found in the ‘age per page’
section of JRCALC guidelines.
Further Reading
What causes Addison’s disease?
Addison’s disease is caused by the destruction of the adrenal
cortices, which can occur in a variety of ways. Worldwide, the
most common cause is Tuberculosis (TB). TB is a bacterial
infection that can spread to the adrenal glands and destroy
them.
In Europe, however, the disease is most commonly caused by
autoimmune destruction of the adrenal glands. This is known
as Autoimmune Addison’s Disease. Autoimmune destruction
occurs when the body produces antibodies that specifically
attack the adrenals. Patients with the disease are more likely to
have other autoimmune conditions, such as hypothyroidism
and vitiligo (a condition causing white pigmentation of the skin).
Surgical removal of the adrenals or ‘adrenalectomy’ may also
cause the disease as the adrenal glands are simply not there to
History of Addison’s disease accompanied by new
illness or injury
Severe hypotension
Severe dehydration
Vomiting and diarrhoea - only two episodes of vomiting
need to occur before hydrocortisone is given
Fatigue
Coma
Bradycardia / Tachycardia
Confusion
Possible fever
Possible abdominal tenderness
Addisonian patients are managed with steroids in an attempt to
replace the lack of hormones. If they are managed well,
patients can lead a normal life. However, if these patients are
exposed to illness for example; trauma, infection or severe
pain, extra steroid cover is required. Addisonian patients may
carry an alert card or bracelet and may even carry an
emergency steroid injection. If these patients are not managed
with extra steroids, they may develop Addisonian Crisis.
E.g. PRU HASU
-5-
Clinical update
ASCQI - frontline ambulance crews
improving patient care.
Primacy of care
Introducing the Ambulance Service Cardiovascular Quality
Initiative …
The Service has joined a national project to improve care for
stroke and STEMI patients, with a focus on more STEMI patients
receiving analgesia as this is our weakest area of care.
In July 2011, the Health Professions Council (HPC) wrote a
letter to all UK ambulance trusts, outlining the expectations of
paramedics, as registered healthcare professionals, in regards
to primacy of care. The letter was written in response to an
increasing number of fitness to practice allegations against
paramedics, arising from the decision by a paramedic to drive
the ambulance and leave a patient in the care of a less
qualified ambulance clinician.
The letter does not set out to de-value the important role
emergency medical technicians have within the ambulance
service, nor does it imply that paramedics must always attend
during a shift. The HPC and the LAS acknowledge that in the
vast majority of situations, it is entirely appropriate for nonparamedic clinicians to provide patient care.
This is the first time an improvement programme has been led
by frontline clinicians. Crews at Pinner complex have been
identifying areas for improvement, developing ideas and are
soon to be testing them in practice. It is great for us as clinicians
to identify issues and be involved in making the changes that we
want to happen.
We want to ensure that every patient receives optimal care,
these elements are grouped together into ‘care bundles’.
STEMI care bundle
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•
•
•
Aspirin
GTN
Pain scores x2
Analgesia
In a situation where it is reasonably foreseeable that the skills
of a paramedic may be required, the paramedic must assume
primacy of care and travel with the patient. This decision
should be based on sound clinical reasoning and in the case
that a decision is made not to attend, this must be justifiable.
Section 1 of the HPC Standards of Conduct, Performance and
Ethics states:
‘You are responsible for the appropriateness of your decision
to delegate a task. You must be able to justify your decisions if
asked to...’
‘You must not do anything, or allow someone else to do
anything that you have good reason to believe will put the
health or safety of a service user in danger. This includes both
your own actions and those of other people...’
STROKE care bundle
•
•
•
Face-arms-speech
test
BM recorded
Blood pressure
recorded
We are extremely good at providing some of these aspects but it
is important that every patient receives the entire care bundle
as this has been proven to lead to better patient outcomes.
The project launched at Pinner at the end of September
with crews being asked ‘Why don’t we give enough
STEMI patients analgesia?’
The second statement has particular reference to the practice
of paramedics travelling behind an ambulance (crewed by less
clinically qualified staff) in an FRU. A less qualified ambulance
clinician will only be able to call for assistance if they are
aware of the need for such assistance. For example, if the
crew member does not notice that the patient has subtle signs
of deterioration, the paramedic in the following FRU may not
even be alerted. This is also applicable for situations where
the paramedic is driving the ambulance en-route to hospital,
with a less qualified member of staff attending. In these
situations, the paramedic retains clinical responsibility for the
patient. If there is an on-going requirement for paramedic
intervention en route to hospital (i.e. pain management using
IV morphine), the paramedic must attend.
To summarise, a paramedic must always be able to clinically
justify why they did/did not opt to attend.
We have wallpaper sheets full of notes and possible reasons for
this, it is from here where we then get ideas for improvement.
The full letter from the HPC can be accessed via the Pulse;
Operational > HPC letter about primacy of care
The HPC Standards of Conduct, Performance & Ethics can be
accessed at:
http://www.hpc-uk.org/aboutregistration/standards/standardsofconduct
performanceandethics/
Read more about the ideas we are testing and when ASCQI will
be
coming your way on the Pulse>Clinical> Improving stroke
and heart care.
Georgina Jones, Quality Improvement Fellow
Leaving supra glottic airway devices in situ
Where a supraglottic airway device has been successfully
placed by an EMT, providing an ETCO2 ‘box waveform’ is
present and a numerical ETCO2 reading is visible, the
supraglottic airway device should NOT be removed in order
to replace this with an endotracheal tube. However, if there
is considerable difficulty in effectively ventilating the patient
then this may be considered.
Intra aortic balloon pump (IABP) transfers
If allocated an interhospital transfer to convey a patient on
an intra aortic balloon pump you will require specific straps
(Q-straints) which are stored on main station and will need
to be collected prior to arrival at the referring hospital. Not
all vehicles are able to accommodate a balloon pump, only
those with longer ‘trolley bed tracking’ (ie any ‘Sprinter’
vehicle that is not a 53 plate). As a reminder, instructions of
how to secure a balloon pump are described in Medical
Director’s Bulletin no. 18 (Nov 2005).
-6-
Clinical update
Crew action on locality
information from EOC
New A&E Support
Dispatch Model
The high risk register exists to collate evidence in order to
‘Dispatch clinically determined, NOT determinant based’.
In October 2011, the way EOC dispatches A&E Support crews
changed. Prior to this date, A&E Support had a list of lower
priority MPDS determinants that they were able to respond to.
It was acknowledged that in reality, details provided at call
taking did not always reflect the patient’s actual condition (i.e. a
fall that is in fact a medical collapse, or non traumatic back pain
that is a leaking aortic aneurysm). In these situations, a
resource with an EMT3 or above skill level needed to be sent
to provide additional clinical assistance. Clearly, this had an
impact both clinically and operationally, due to the number of
resources being unavailable.
establish a record of address locations where past experience
suggests that the personal safety of ambulance staff may be
at risk. All LA277 forms submitted by crews following incidents
of verbal abuse or physical aggression are robustly reviewed
by an AOM before entry on to the register, to ensure that any
action as a result, is defensible by the Service.
Category 1
The most serious type of incident where a
member of staff has actually been the subject
of physical violence.
Category 2
An incident where there has been (a) a
specific threat of use of a weapon or (b) where
there has been verbal abuse with intimidation
or (c) where there has been verbal abuse
aggravated by being based on the grounds of
race, religion or sexual orientation.
Category 3
An incident where a member of staff has been
verbally abused.
Category 4
Where a medical condition was a major factor
in the incident
A&E Support are now only dispatched in one of three
ways:
EOC Dispatch
of A&E
Support
Categories 1 and 2 will result in the police being requested to
attend. Category 3 entries on the register will not
automatically result in a police attendance. Category 4 entries
are where violence or abuse occurs as a direct result of a
medical condition (ie history of patient being combative post
epileptic seizure). The police will not routinely attend these
addresses with the Service, however this will be considered
on a case-by-case basis.
Yearly review of every entry on the high risk register ensures
that information is as up-to-date as possible and on-going
assessment of risk is completed.
As the Service has a duty of care to both patients and staff,
clearly all requests to attend high risk addresses will require
operational staff to attend and assess the situation. Staff
should undertake a dynamic risk assessment using the
information provided by EOC to determine if it may be safe to
proceed without the police. To assist this dynamic risk
assessment, further information about the situation can be
gathered by EOC, by calling the origin number back (the
patient may very well not be the person the high risk
information applies to, or may be the person in cardiac arrest).
The complete high risk register policy (O/P 20) can be
accessed on the Pulse under Operational > Operational
Procedures > Operational Policies.
Reducing delays on scene with sick
patients
When managing a critically unwell/sick patient it is vital that
there are no delays incurred due to attempting to complete
paperwork prior to leaving scene. Under no circumstance
should a patient be denied rapid transport from scene to
hospital in order to complete paperwork. If there are any
concerns over a patient’s condition then the PRF should be
filled in either en route or after arrival at hospital.
Solo responder
(EMT/SP3+) on
scene. Patient
assessed as
being
appropriate for
A&E Support
response and
transport.
(‘see and treat’)
Patient has
undergone
clinical review
either by CTA or
CSD and
determined to be
appropriate for
A&E Support
response.
(‘hear and treat’)
Red 1 calls,
responding
alongside
another
resource.
Solo responders are able to request A&E support to respond
on blue lights if required. Where a solo responder
(FRU/MRU/CRU) has assessed a patient and their clinical
condition has required use of interventions or drugs outside the
scope of practice of A&E support the solo responder clinician
must travel with the A&E support crew and accept clinical
responsibility for the patient until they reach definitive care.
Other time-scales for A&E support response are 30 minutes,
<one hour and >one hour (referred to as ‘response profiles’),
explained in Operations bulletin dated 17/11/2011.
The intention of the updated dispatch model is to aid utilisation
and ensure that A&E support crews are only dispatched to
clinically appropriate calls. The updated model now has a list of
exclusion criteria for A&E support crews, developed by the
Medical Directorate and matched to the training and clinical
competencies of A&E support staff. The list outlines the calls
that A&E support crews should not be sent on and includes
major trauma, severe difficulty breathing, RTCs and patients
<five years of age.
Full details of the updated A&E support tasking model are
located on the Pulse; Operational > Urgent care > A&E support
tasking
Peter Dalton, Staff Officer to the Medical Director.
-7-
Clinical update
Wound infection
Demand management plan (DMP)
The demand management plan (DMP) was introduced within
Control Services in November 2010. The purpose of DMP is to
provide the Emergency Operations Centre (EOC) with
structured, risk mitigating options to respond to demand at
times when it exceeds the capacity of the Service to provide a
timely response. It provides a framework in which Control
Services are able to respond to periods of high pressure, due
to unexpected demand or on occasion where capacity to
respond does not exist.
DMP enables the Service to prioritise higher MPDS category
calls and put in place automatic no sends to lower priority
calls, ensuring that those patients with the most serious
conditions or in greatest need continue to receive a response.
Escalating stages of DMP (A-H) decreases the response to
lower call categories. At higher stages of DMP there is
increased clinical involvement in EOC, with clinical ‘floor
walkers’ available to assist call handlers, and by clinicians
ringing calls back to provide advice, to re-triage and on
occasion to negotiate alternative means of transport or follow
up.
The complete DMP is located on the Pulse under Control
Services > Demand Management Plan
A 55-year-old man rang 999 complaining of a swollen arm
following a dog bite (puncture wound) two days earlier. He
reported his arm was swollen to twice its normal size. He
was correctly triaged and referred for clinical telephone
assessment which appropriately identified he needed to seek
medical attention within one to four hours. The patient did
not get medical attention at this stage and he became
increasingly unwell over the next 24 hours before being
admitted to ITU where he was diagnosed as having
Necrotising Fasciitis (NF) from which he sadly died despite
all efforts to treat him.
It is important that when assessing patients with open
wounds, particularly puncture wounds, that have occurred
more than 24 hours prior to assessment, to inspect closely
for signs of infection. Signs may include:
•
Local pain, swelling and erythema (redness)
•
Severe, constant pain, out of proportion to the
physical signs
•
The area may develop tense oedema, extending
beyond the margin of erythema (redness).
•
Systemic signs of infection including fever,
sweating, generally feeling unwell
Adrenaline 1:10,000 syringes breaking off in the
cannula port
Following two incidents paramedic staff are reminded that
whilst relatively robust, adrenaline 1:10,000 syringes are
made of glass and the syringe tip can snap off if subjected
to too much torque in a cannula port. It is appreciated that
adrenaline requires to be administered without delay in
cardiac arrest, but staff are urged to take care when
inserting the syringe into the port, administering the dose
and when removing the syringe from the port (where only a
slight twist is needed).
Tense oedema of an infected limb
The presence of severe swelling after a puncture wound,
from an animal bite for example, may be due to a very
serious local infection caused by anaerobic organisms which
may cause the likelihood of systemic effects such as
septicaemia.
If any of the signs above are detected, patients should be
conveyed to the nearest appropriate hospital or urgent care
centre for a clinical assessment as to whether antibiotics are
needed.
Courtesy calls
Staff are reminded that the term ‘courtesy call’ should no
longer be used as this causes confusion both at the
receiving hospital and in EOC. If there is concern over a
patient’s clinical condition and it is felt necessary to pre alert
the hospital then either the term ‘blue’ or ‘pre alert’ call
should be used.
Trauma reminders:
•
Trauma patients who do not trigger the major trauma
decision tree should go to the nearest emergency
department and not be diverted to a major trauma
centre (MTC). If a crew feel their patient needs a MTC
and doesn’t trigger the tree, they should discuss this
with the Clinical Coordination Desk before conveying.
•
When diverting to a MTC it should be clear from the
PRF why the patient is being conveyed to a MTC.
•
IV fluids should not routinely be administered to trauma
patients, only when clinically indicated (see JRCALC
guidance).
•
When treating paediatric patients, it is best practice to
document if you DO or DO NOT have any safeguarding
concerns. Please remember to indicate on the LA4
when you have completed a safeguarding referral form.
In very rare instances a severe deep infection may cause NF
which carries high mortality and complication rates. Early
treatment of wound infections reduces the chances of
developing NF. The below are signs of necrotising fasciitis, a
rare infection which typically develops over a few days and
may be fatal if left untreated:
•
•
•
Skin becomes discoloured, progressing to grey
necrosed (dead) skin which breaks down.
The tissues underlying the skin have a woodenhard feel (unlike cellulitis).
Pain sensation may progress from severe pain to
loss of feeling / sensation as the nerves are
destroyed.
Urgent surgical debridement is the key factor in treatment
and improved survival of NF. Even a few hours delay
increases mortality. If NF is suspected then patients should
be transported to hospital without delay.
-8-
Clinical update
Pain management
Control of pain is important not only for humanitarian reasons,
but also because it may prevent deterioration of the patient
and allow better assessment. Analgesia should be
administered, where appropriate, as soon as clinically
possible after arriving on scene, although this can be done en
route so as not to delay time-critical patients.
It is important to remember that the pain a patient
experiences cannot be objectively validated in the same way
as other vital signs. Clinicians should therefore seek and
accept the patient’s self-report of their pain.
All patients with pain should have a pain severity score
undertaken and repeated after each intervention (the timing
of the repeat score depends on the expected time for the
analgesic to have an effect). The Service recommends that a
simple 0-10 point verbal scale is used (where 0= ‘no pain’ and
10= ‘the worst pain imaginable’). These scores must be
recorded on the patient report form (PRF) before and after
analgesia. ‘Wong and Baker faces’ are recommended for pain
scoring in paediatric patients. It must not be assumed that a
blank box indicates no pain. If it is not possible to administer
pain relief, the reason for this must be documented.
The College of Emergency Medicine recommends that the
following definitions are used for assessment of acute pain:
•
0
No pain
•
1-3
Mild pain
•
4-6
Moderate pain
•
7-10
severe pain
Documenting acronyms on the Patient
Report Form (PRF)
The PRF is a medico-legal document and is used by other
professionals when continuing care. It may also be used in
Coroners Court and by support service departments (who do
not have clinical knowledge) in the Service. It is therefore
crucial that not only is the PRF fully completed and legible,
but it is written in a format that everyone can understand.
Only acronyms that are established should be used when
completing your PRF.
Would you know what all of the following meant (these have
appeared recently on PRFs)?
•
•
•
•
•
•
A&O AB B/A CAM CCP GA
•
•
•
•
•
•
GSD MSC NFAW URQ Vt W/P There is a list of accepted acronyms that can be found in the
glossary on the Pulse under Home>Operational>Glossary
Use of acronyms in the times sections for observations are
also inappropriate and documenting time in this way, and not
HH:MM, will unfortunately score a ‘no’ under the Clinical
Performance Indicators (CPIs).
Remember, entonox is a good analgesic for adults and
children who are able to self-administer. It can be used as the
first analgesic whilst other pain relief is instituted.
A balanced analgesic approach to pain management consists
of treating the cause wherever possible, and analgesia
involving psychological, physical (eg splinting)
and
pharmacological interventions (more than one agent, when
possible, in smaller and titrated doses to achieve better
analgesia with less side-effects by acting at different involving
the pain pathways). Don’t forget, fear and anxiety worsen
pain, reassurance and explanation can alleviate pain
considerably.
Work is currently being undertaken covering all aspects of
pain management and further guidance will soon be available.
Stroke care
Obtaining a 12 lead ECG has been removed from the
Clinical Performance Indicators (CPI) for FAST positive
patients.
Where the diagnosis of stroke is clear and the decision has
been made to transport a patient to a HASU, a 12 lead ECG
adds little to the diagnosis and is not considered an
essential part of the assessment of the patient. Obtaining
one could potentially delay transport. The average on scene
time for FAST+ patients is 34 minutes, and only 64 per cent
of patients get to hospital within an hour of the 999 call. It is
estimated that for every minute of delay to definitive
treatment, two million neurones are lost. Remember
that ‘time is brain!’
Aspirin
Staff are reminded that if a patient is taking warfarin/other
anticoagulants that this is NOT A CONTRAINDICATION regarding
aspirin administration for ACS. Although JRCALC states that
aspirin is contraindicated, since 2007 the Service’s guidance
states that anticoagulant therapy is only a ‘caution’. Service
paramedics and EMTs may therefore administer aspirin to
such patients. (See Medical Director’s Bulletin dated January 9
2007 for further details).
Crews are reminded that, in line with JRCALC guidance, aspirin
may be administered to patients with ECG evidence of myocardial
infarction or ischaemia (even if they are pain free).
If the patient has chest pain, a history of collapse or
transient loss of consciousness, or where the diagnosis is
unclear, a 12 lead ECG may help clarify the diagnosis and
should be obtained as normal.
Changes to MPDS instructions
The MPDS aspirin diagnostic tool used by EOC is no longer in
use. Therefore 999 callers stating they have/the patient has chest
pain will not be instructed to administer aspirin (both by EMDs and
CTA staff). This change has been implemented due to the fact that
too many patients received aspirin inappropriately (due to lack of
specificity of the MPDS algorithm). We would like to thank crew
staff for their feedback relating to this practice.
Blood glucose levels should be measured in all patients
with a positive FAST as hypoglycaemic patients may
present with stroke like symptoms.
Time of onset of symptoms should be documented for
stroke patients. If not known, this should also be
documented.
-9-
Clinical update
SAFER 2
It is important to document each individual aspect of the
FAST test in the boxes provided on the PRF (as below).
Older people who experience a fall and dial 999 are currently
attended by a paramedic or EMT who will assess whether to
convey the patient to hospital or leave them at home.
Evidence shows that when left at home with no further
support older people often experience a further fall, which
may result in injury, a visit to the emergency department and
potentially a stay in hospital. Health related costs of a fall in
the elderly are high, both personally and to the NHS. It is
known that older people who fall have a high risk of injury
due to subsequent falls, loss of independence, disability and
even death.
Support and Assessment for Fall Emergency Referrals 2
(SAFER 2) study is a research study led by Swansea
University aimed at evaluating the clinical and cost
effectiveness of training paramedics in the use of a tool to
support their decision whether to transfer the patient to the
hospital or to safely leave them at home with a referral to a
community based falls team.
Clinical Audit and Research
Unit (CARU): reminders
•
•
•
•
•
•
•
•
•
•
•
•
To ensure that there is an ongoing child protection safety
net, all emergency services have a legal requirement to
document the name of the primary carer / health visitor
and the name of the school/nursery attended by the
patient. It is important to document these details on your
PRF.
A complete set of journey details relevant to the incident
must be recorded. This includes the following: left scene
time; pre alert time (where required); arrive hospital,
clinical handover and patient handover times and
handover signature (if conveying).
Remember to record a blood glucose level after
treatment of hypoglycaemic patients.
When recording drug administration on the PRF,
remember to document in full; the drug code, name, dose,
route, time and by whom.
For acute asthma, oxygen saturations should be
measured before treatment where pulse oximetry is
immediately available. Moderate levels of supplemental
oxygen are indicated if the patient is hypoxaemic (sats
<94% for non COPD patients and sats <92% for COPD
patients). If oxygen is given, the dose administered must
be documented in the drug administration section on the
PRF.
For patients with ‘difficulty in breathing’ a peak flow
reading should be documented both before and after
treatment, or there must be a clear documentation of the
reason why it could not be obtained. It is not acceptable to
simply note ‘unable to do’.
It is vital that end tidal CO2 is measured for all patients
where an endotracheal tube or supraglottic airway is
placed and a corresponding numerical reading recorded.
It is important to document whether or not a cardiac arrest
was witnessed and who by. If this is not recorded it may
not be possible to use the patient outcome data to
contribute towards the Service’s Utstein survival rates.
Documenting if ROSC is achieved or not is an important
patient outcome. ROSC is now accepted as a return of
circulation that is sustained for 30 seconds or longer.
Unless contraindicated, GTN should be administered to all
STEMI patients.
Analgesia (IV morphine and/or entonox) should be
administered to any STEMI patient in pain (unless
contraindicated).
All patients with suspected cardiac chest pain should be
conveyed to hospital with a pre alert call (even if the ECG
is normal).
Research method
SAFER 2 is a cluster Randomised Control Trial (RCT), where
24 ambulance stations have been randomly selected as
either intervention group stations or control group stations
among the three trial sites: London Ambulance Service,
Welsh Ambulance Service and East Midlands Ambulance
Service.
Within the Service, three control stations and four
intervention stations have been selected through this method.
Nearly all of the intervention paramedics have been trained
and have received a new protocol for assessment and
referral to falls services, which they can make via the
Emergency Bed Service - whilst the control group crew
continue to deliver care as usual.
For every elderly (>65 years) falls patient a study paramedic
attends, an invitation pack is sent to the patient to ask for
permission to look at their NHS records. For those that say
‘yes’, their hospital attendances will be looked at for the six
months after their fall. This will enable the study to compare
outcomes of the long-term effect of the new referral pathway
with current practice. All eligible patients must be aged 65 or
over and attended by control or intervention paramedics and
they need to live within the falls service catchment areas,
which are Camden, Islington, City and Hackney and Tower
Hamlets.
What we’ve seen so far…..
By mid October 2011, 369 eligible patients were invited to
participate in the study, of whom 27 per cent consented for
their patient records to be followed up. This took the Service
firmly ahead of the other trial sites who have only received a
ten percent consent rate. However, overall patient
recruitment figures in London are a little lower than expected.
What will we do with the research findings?
The Service will contribute to ‘first of its kind research’ looking
at the primary outcome of further falls for which emergency
health care contact is made or if death occurs. The
secondary outcomes will assess quality of life of patients,
self-reported falls, fear of falling, quality of care monitor,
costs, pathways of care and job cycle times.
Finally, a health economics evaluation will be undertaken
alongside the trial to look at the accurate estimation of
resources used in both groups and an estimation of the
different costs between the two groups from the perspective
of the UK NHS.
Clinical Audit and Research unit
The outcome of this research may make a real difference to
- 10 -
Clinical update
patient care and inform
development across the UK.
policy,
practice
and
service
For more information, please contact:
[email protected] Tel: 0207 783 2557
SAFER 2 Project Researcher
The below link relates to a report recently released by the
Patient’s Association. The patient stories relayed are a reminder
of the huge importance of maintaining dignity and respect and
how patients often see this as a real measure of the quality of
care that we provide:
http://www.networks.nhs.uk/networks/news/report-highlightslapses-in-patient-care
‘Bumper’ fracture
Definition:
A break of the tibial plateau or fibular head or both. The
reference to bumper is the bumper of a motor vehicle, the
fracture being caused by the impact of the bumper. This
happens in patients old enough or tall enough for their knee to
be on a level with the bumper (generally over the age of 12-14
years).
Pathology:
A bumper fracture is a compression fracture of the lateral tibial
condyle due to a forceful valgus stress applied to the knee.
The name is derived from the fact that a car bumper hitting the
lateral aspect of the knee when the leg is firmly planted on the
ground is one of the most common causes of this type of
injury. If the medial collateral ligament remains intact, the
lateral femoral condyle is forced down on the lateral tibial
condyle and this causes a compression fracture. Older
patients with osteoporosis are the most prone to this type of
injury. There may be a haemarthrosis (blood in the joint,
evidenced by swelling) and the lateral tibial plateau will be
tender. Note that the swelling will take time to develop, a
bruise in that area in the early stages is a warning sign.
Treatment:
A patient with a painful knee and evidence of direct impact
from a car should be conveyed to hospital in order to exclude
a diagnosis of tibial plateau fracture (even if partially weight
bearing – be aware that symptoms may be relatively mild).
Dr Peta Longstaff, Assistant Medical Director West.
Capacity guidance
The capacity tool (LA5) is used to establish if the patient has
capacity to consent to a particular intervention or treatment. It
helps establish a course of action should a patient’s condition
not be life threatening but they are refusing treatment and do
not have capacity.
Circumstances in which staff might find it appropriate to use
the capacity tool include:
•
•
Radiographic appearance:
An X-ray will show compression fracture of the lateral tibial
plateau, resulting in separation at the margin of the plateau or
depression of the central portion of the articular surface. A
valgus (knee forced inwards) injury can result in a fracture of
the lateral tibial plateau. At times these fractures are difficult to
identify and are obvious only on oblique X-rays. The fractures
consist of either a vertical split through, or a depression of, a
portion of the joint surface. There may be an associated
fracture of the neck of the fibula.
If a patient’s condition is potentially life threatening
but they are refusing certain treatment, for example a
patient who has ECG changes and chest pain and is
refusing to go to hospital.
If a patient is presenting with psychological problems
and is refusing assessment or conveyance.
Before making a judgement that a patient lacks capacity, all
reasonable steps in the circumstances must be taken by staff
to ensure the patient is assisted in making their own decisions.
This may involve explaining what is involved in very simple
language, using pictures and communication and decision
aids as appropriate. A pre-hospital communication guide is
available to help communicate with people with a range of
different needs, including people with a learning disability,
people with a hearing impairment, people for whom English is
not their first language and people who have acquired
communication difficulty through injury.
Staff should attempt to involve people close to the patient
(spouse/partner, family and friends, carer, supporter, advocate
or specialist colleagues) in the decision-making process as
they may be able to provide valuable information about the
patient’s wishes and values.
Remember:
•
Capacity is ‘decision-specific’ and while the patient
may lack capacity to take a particular complex
decision, they may be quite able to make other more
straight forward decisions or parts of decisions.
•
Every adult patient has the right to make his or her
own decisions and must be assumed to have
capacity to do so unless it is proved otherwise
•
If it is deemed that a patient has capacity, they are
within their rights to refuse treatment.
- 11 -
Clinical update
A patient is deemed to lack capacity to consent if he or she is:
•
unable to understand or retain key information relating
to the decision they are being asked to make,
especially information relating to the consequences of
accepting, or refusing, a treatment or intervention
AND/OR
•
or Treatment and form LA5b; Parental Agreement to
Investigation or Treatment for a child or young person.
Further information on the law on consent can be found in the
Department of Health’s reference guide to consent for
examination or treatment.
Left bundle branch block: important reminder
unable to use and weigh this information in the
decision-making process
LBBB can cause confusion in suspected myocardial
infarction as a decision will need to be made as to
whether the patient previously had LBBB, or whether the
LBBB pattern is new as a result of the infarct. If the
patient has a copy of a previous ECG showing LBBB, or
informs the crew that they have LBBB then, even in the
presence of cardiac chest pain, they should NOT be
taken direct to a catheter lab. If it is suspected that the
patient is suffering from new onset LBBB and is
suffering from classic cardiac chest pain and they
‘look like they’re having an MI’ then they should be
taken direct to the nearest catheter lab for expert
assessment.
If it is found that a patient lacks capacity, then part two of the
capacity tool will require completion and in life threatening
situations removal against the patient’s wishes may be
appropriate. You must however ensure that all other less
restrictive avenues have been explored and that the proposed
plan seems a reasonable and balanced way of ensuring the
right treatment of the patient. If the patient’s condition is not life
threatening forced removal is not an option. In such cases,
continue to use your best efforts to persuade the patient to
accept your advice and document the steps you have taken.
For further information about issues around patient consent,
please refer to form LA5a; Patient Agreement to Investigation
ECG questions and answers
ECG of the month
This ECG belongs to an 80-year-old female who
suffered a brief loss of consciousness whilst out
shopping. On arrival of the crew the patient
complained of feeling dizzy, was slightly
confused and appeared a little pale.
The patient had a history of ischaemic heart
disease, hypertension and numerous previous
‘falls’ during the last two weeks.
What abnormalities does the ECG show?
Where would you convey this patient?
ECG of the month
Last issue’s ECG
This ECG belongs to a 30-year-old male
who had a four day history of progressively
worsening shortness of breath. On arrival of
the crew he was conscious, alert but
severely breathless. Initial observations
were: GCS 15, HR 130 reg, RR 28, sats
80% (rising to 100% on O2), temp 37.0°C,
BP 130/75.
The patient complained of intermittent,
pleuritic chest pains, dull in nature and non
radiating. On auscultation his chest was
clear bilaterally and he had no peripheral
oedema. He had no lower limb swelling or
tenderness and no recent travel history.
Last issue’s ECG (thanks to Steve Gosnell, Deptford complex, for sending in this case study)
What abnormalities does the ECG show?
What do you think the diagnosis may be?
Where would you convey this patient?
This ECG shows sinus tachycardia with the
‘S1, Q3, T3’ pattern sometimes seen with
pulmonary embolism (PE). So called as it
is abnormal to have a deep S wave in lead I,
a Q wave in lead III and an inverted T wave
in lead III. The crew placed a pre alert call
to the nearest ED where a ‘massive PE’
was diagnosed.
In addition, ECGs of those suffering from PE
sometimes show RBBB.
Edited by Jo Smith and Peter Dalton, Medical Directorate
- 12 -