Prehospital care - a UK perspective

Prehospital care - a UK perspective C J Carney Bedfordshire & Hertfordshire Ambulance and Paramedic Service NHS Trust, Bedford, UK In the UK, emergency ambulances are responding to astonishing increases in levels of emergency calls, in the order of a 40% increase nationally in the last 5 years. Pressures in primary care service out-of-hours provision, and increasing community-based care of elderly patients, as well as increased expectation by the public are contributory causes. Services are also being pressed to improve response times, particularly to life-threatening cases. These various aspects are discussed below Correspondence to Dr C J Carney, Bedfordshire <S Hertfordshire Ambulance and Paramedic Service NHS Trust Hammond Rd, Bedford MK41 ORG, UK In the UK, prehospital care is provided primarily by the ambulance service. Ambulance services are provided by over 30 NHS Ambulance Service Trusts which exclusively supply paramedic level emergency ambulance services and provide many non-emergency patient transport services to hospitals and clinics. A number of these Trusts also provide other services, such as professional ambulance training, and more recently nurse-based advice telephone lines accessible to the public, as part of the NHS Direct service. Emergency services are provided by paramedic staffed emergency ambulances, and single staffed fast paramedic response units either in the form of estate car vehicles or motor cycles in more urban areas. Helicopter and fixed-wing air ambulances are operated by a number of ambulance services. Scotland has had a dedicated air ambulance system for many years, utilising both rotary and fixed-wing aircraft in more remote areas. Helicopters operated as a primary response staffed by paramedics are also operated by a number of services. These have, in some areas, had their operational use refined to bypass smaller acute hospitals, and fly major and multiple injury cases direct to nearby major hospitals with neurosurgery and cardiothoracic specialties on site. The NHS response to major incidents is led by the NHS ambulance services. It is the responsibility of ambulance services to hold up-to-date plans to respond to large incidents. They must provide ambulance staff, vehicle, equipment and communication resources sufficient to manage a major incident. There are collaborative agreements between neighbouring ambulance services to provide mutual assistance in these cases, and the British Medical Bulletin 1999, 55 (No 4) 757-766 O The British Council 1999

Trauma service must arrange for and transport medical teams and the Medical Incident Officer to the scene. Emergency ambulance dispatch Emergency calls are received via the 999 emergency telephone system or from primary care physicians to request urgent admission for their patients. These calls are directed to the nearest ambulance service Dispatch Centre, where they are received, an ambulance response dispatched and first aid advice given over the telephone where appropriate whilst the ambulance is en route. All ambulances are equipped with VHF radio systems for rapid contact and communications. Mobile data terminals, pagers and portable radios are used by many services to expedite activation, and provide flexible communications between the Dispatch Centre, ambulance vehicles and receiving hospitals. Ambulances are equipped with satellite or land-based automatic vehicle location systems, which are used to display the vehicle's location relative to the location of the incident on computerised mapping systems in the Dispatch Centre. Ambulance response times and call prioritisation All the above mentioned technology and operating systems contribute to speedy location and dispatch of ambulances to incidents to ensure response time targets are met. Call prioritisation was suggested in 1996 as a method of selectively deploying ambulance resources to life threatening emergency cases. This would involve the utilisation of either the Advanced Medical Priority Dispatch system or the Criteria Based Dispatch system by trained call takers to triage calls into Category A (life threatening), B (not immediately life threatening), and C (non-emergency) categories. Category A calls must, by 2001, receive a response at the scene within 8 min, category B receiving a response to over 95% of cases within 14 min or 19 min depending on it being a rural or urban-based service. Category C, it was suggested, may not always require an ambulance response. The anxieties surrounding Category C calls and the potential for error based on initial telephone-received information led to this category being dropped from the eventual recommendations. However, ambulances are deployed they must be at the scene more rapidly than is currently the case in most areas. Techniques have been 758 British Medical Bulletin 1999, 55 (No 4)

Prehospital care - a UK perspective applied both in the US and some areas of the UK to improve response times, particularly to life threatening cases. These methods require better balancing of ambulance resources to demand patterns by hour of the day, and better location of emergency ambulances and fast response units. Much work has been done of late to re-organise paramedics' shift patterns more and more closely related to demand to ensure sufficient ambulances are in the system relative to anticipated call demand. These patterns are derived from statistical analysis of historical call data. Similarly, mapping of 999 call and life threatening calls by map reference over several months can assist in locating ambulance response posts located in or adjacent to high call demand areas. These innovations are providing improvements in response times to emergency calls to ensure prompt arrival of paramedic assistance. Ambulance paramedic clinical training and education Whilst getting the ambulance to the patient quickly may improve patient outcomes, unless the paramedic is optimally trained and practices to the standard laid down by guidelines reflecting current best medical practice, the potential for gaining the best outcomes will never be fully realised. Ambulance paramedics and technicians are trained in the UK to a single national level, denned by the Institute of Health Care and Development. Ambulance technician training was first implemented in the wake of the Millar Report 1 on ambulance training and equipment published in the mid 1960s. In the 1970s, paramedics were being developed in the US, and, in the late 1970s and early 1980s, Douglas Chamberlain devised a pilot scheme in Brighton, utilising 'extended skills' trained ambulance staff to defibrillate and intubate cardiac arrest cases. This built on the pioneering work from Frank Pantridge m Belfast in the 1960s 2, who introduced medically staffed prehospital coronary care ambulances, and demonstrated successful outcomes from cardiac arrest in patients attended by this unit. Many local-based paramedic training schemes slowly evolved over the 1980s, and m 1988, these were brought together when the national Extended Training for ambulance staff training scheme was launched by the then National Health Service Training Authority 3. This was updated in 1991 as the Ambulance Service Paramedic Training Manual, and issued by the National Health Service Training Directorate. This course is now the subject of a review to bring its teachings m line with current medical practice. In the early 1990s, the Government set a target to be achieved by all services, requiring sufficient paramedics to be trained to ensure a paramedic on each emergency ambulance by 1996. This target has been achieved by the majority of services, leading to the UK now having an Advanced Life Support (ALS) based emergency ambulance service. British Medical Bulletin 1999, 55 (No 4) 759

Trauma Additional courses have been adopted by many UK services to supplement basic paramedic training. These largely relate to the management of trauma and paediatric emergencies. Significant changes have occurred in UK hospital practice since 1991 in both these areas, with the introduction of the Advanced Trauma Life Support (ATLS) 4 and the Advanced Paediatric Life Support (APLS) 5 courses for doctors. Prehospital care, as taught on the Ambulance Service Paramedic Training manual, was not integrated with these new more systematic methods of initial assessment and care of trauma and paediatric emergencies. The implementation of Pre Hospital Trauma Life Support (PHTLS) 6 and Pre Hospital Paediatric Life Support (PHPLS) 7 training for paramedics has effectively filled this training void, and improved the chances of the patient experiencing seamless and integrated prehospital and hospital care. Apart from the need to bring together in hospital and prehospital clinical practice, concern has also been raised at the potential for adversely affecting outcomes for certain patient groups by paramedic practices and interventions as taught on the 1991 Paramedic Training course. Those suffering from severe haemorrhage, typically as a result of penetrating injuries, may be a specific case. A study by Nicholl et al from Sheffield 8 demonstrated poorer outcomes with increased mortality when paramedics managed a series of these cases compared to lesser trained ambulance technicians. These poorer results may well be related to increases in time spent on scene, and intravenous fluid administration commenced by paramedics. In response to these findings, revision of treatment guidelines, and improved training of paramedics in trauma assessment and management is needed. This must be combined with ongoing audit of cases to assess the effects of any such change. This need to critically review the clinical effectiveness of prehospital care, with the implementation of comprehensive clinical audit, is a good example of the role to be played by employing capable medical direction in UK ambulance Trusts. So far, few Trusts have full-time medical direction, but many have introduced part-time medical director posts. Traditionally, paramedics have been well trained to acquire and practice certain resuscitation skills. These courses have been high on training in these skill areas, but low on background education content. A number of universities have launched higher education courses at Certificate and Diploma level for existing paramedics to steer them towards an eventual degree path. Sheffield and Hertfordshire Universities have both pioneered the launch of undergraduate degree programmes in Paramedical Sciences to implement degree level education for potential paramedics. Paramedics are likely to become state registered as a profession allied to medicine in 1999. This will necessitate changes to future education 760 British Medical Bulletin 1999, 55 (No 4)

Prehosprtal care - a UK perspective needs and the implementation of professional self-regulation to this group of ambulance staff. Emergency ambulance vehicles and equipment Emergency ambulances are equipped with an extensive range of equipment to provide for immediate resuscitation, an array of medical and trauma emergencies, and the initial management of major incidents. Defibrillators, both manual and automated and pulse oximeters are carried, along with endotracheal intubation and intravenous infusion equipment. An automatic patient ventilator, fixed and portable aspirators and sphygmomanometer are provided along with a full array of drugs including cardiac, analgesic and inhaled bronchodilator medications. Long spinal boards, spinal splints, traction and box splints are carried in the ambulance which are now equipped exclusively with a single easyload stretcher trolley. Vehicles are now far more sophisticated with external mains charging of circuits, mains inverters to power ITU transfer monitors, and some are telemetry equipped to transfer data to receiving hospital units. Medical prehospital support in the UK Medical support is provided in a variety of ways. Immediate care schemes Many areas have an Immediate Care Scheme, comprising volunteer doctors trained and experienced in prehospital care. These schemes provide medical support to mainly entrapment and unusual incidents at the request of the ambulance service, who alert them via the Ambulance Dispatch Centre. They use their own equipment and vehicles and provide this support service voluntarily. These schemes are united nationally under the umbrella of BASICS, the British Association of Immediate Care. Hospital teams In the absence of these schemes, most areas have a facility to respond a 'flying squad' from the receiving acute hospital. These hospital teams are at one extreme, well organised with dedicated vehicles and equipment and only utilise prehospital trained senior medical and nursing staff, or British Medical Bulletin 1999, 55 (No 4) 761

Trauma perhaps more commonly at the other, staffed by more junior staff, with little or no prehospital training. The London Hospital has been the base of a unique medical and paramedic staffed helicopter emergency service (HEMS) serving London and its surrounding areas. This aircraft serves to provide skilled medical assistance at the accident scene, and transportation to a hospital suited to the patients needs, during daylight hours. Medical support is essential in these cases, and others where skilled manipulation of analgesia is needed to extricate the patient. The majority of medical support calls involve patients with major injuries, who are entrapped at the accident scene either in vehicles or machinery. Paramedics are capable of initiating resuscitation but require medical expertise to safely manage the patient over the time scale of extrication. Medical support is essential in these cases, and others where skilled manipulation of analgesia is needed to extricate the patient. More recently, drug assisted endotracheal intubation and elective ventilation by clinicians has become more commonly practiced in managing some of these more complex multiply injured patients in the prehospital phase and en route to hospital. This more aggressive airway and ventilatory management is especially important where serious head trauma is involved to minimise the risks of hypoxia due to airway or ventilatory inadequacies. Providing prehospital care Managing trauma patients The methodology of the ATLS primary and secondary assessment and immediate treatment approaches to trauma patient management, have been extended by the teachings of the PHTLS course. This also includes more full assessment of the mechanism of injury, and the kinematics involved in causing specific injury patterns. The paramedic approaches the scene, ensuring personal and patient safety. The injury mechanics are assessed, and the patient assessed and managed along ATLS principles. Immediate manual spinal immobilisation is applied, and airway and breathing management commenced with the application of high flow oxygen. Initial circulatory management comprises haemorrhage control, followed by assessment of disability, and then evaluation of the patient following primary survey. Significant airway, breathing circulatory or disability deficit on primary survey leads the paramedic to manage the patient as time-critical. This implies a maximum time to be spent at the scene of less than 10 min, with 762 British Medical Bulletin 1999, 55 (No 4)

Prehospital care - a UK perspective rapid airway, breathing and haemorrhage control, and immobilisation on a long spinal board. The patient must then be loaded, treatment, including obtaining intravenous access, continued en route to hospital, and a hospital pre-alert message passed to the receiving hospital. If no significant problem is detected at primary survey, the patient is treated as non time-critical, and a brief secondary survey, with appropriate initial management of isolated injuries undertaken. The patient is re-assessed regularly to monitor for signs of deterioration and transported with minimal delay to a suitable hospital. Entrapped patients are managed as above, but intravenous access obtained early to allow fluid replacement and analgesia to be given as required. Close working with Fire and Rescue services is essential to ensure the most rapid extrication in line with the patient's condition. Medical support is an essential requirement for the management of trapped patients, where injury severity is frequently high, in association with the high speed, rapid deceleration mechanisms associated with these incidents. Spmal board extrication is used to remove these patients by sliding them along the smooth surface of the board, with in line spinal immobilisation continued until all straps and head immobilisation blocks are in place. Trauma patients should ideally be removed from the scene directly to the hospital most appropriate to their needs. In the case of multi-system trauma patients, this will often require neurosurgery, and ideally cardiothoracic specialties to be on site. These specialties are rarely found in the majority of district general hospitals (DGH), and, except in areas where direct admission to such units are possible, the Accident and Emergency department of the DGH is the most likely initial unit to receive all trauma cases. Trauma teams have been formed to receive major trauma cases at many DGHs, and effective handover of the patient to the team leader by the paramedic is critically important. In areas where a major hospital with all key specialties on site is present and accessible, bypass procedures and transportation protocols should be agreed by the ambulance service and all hospitals, on the types of case that should be best admitted directly to the accident and emergency department of the major hospital, by land or air ambulance. Managing medical emergencies The majority of 999 calls attended are related to medical rather than trauma emergencies. Cardiovascular and respiratory crises are responsible for most life-threatening emergencies, and paramedics are trained and equipped to initially assess and manage most of these problems effectively. British Medical Bulletin 1999, 55 (No 4) 763

Trauma Initial assessment follows the primary survey approach whilst obtaining immediate history details. Immediate airway and breathing management with use of high flow oxygen, and any specific drug therapy is then provided prior to removal to hospital. Monitoring with electrocardiographic rhythm assessment and pulse oximetry is applied, and peak flow and blood glucose monitoring used where indicated. Specific drug therapy in persistent epileptic fitting with diazepam, bronchospasm with salbutamol, and hypoglycaemia with intravenous glucose or intramuscular glucagon may be administered by paramedics. Analgesia using inhaled entonox or intravenous nalbuphine can also be administered as required. Anaphylaxis can be specifically treated with appropriate doses of intramuscular 1 in 1000 adrenaline, and fluid replacement administered where appropriate to assist with the management of haemorrhageor dehydration. Managing out-of-hospital cardiac arrest Improving the outcome from sudden cardiac death m the prehospital setting has been the subject of extensive research and development of improved prehospital resuscitation procedures for over 20 years. The value of early 'citizen CPR', telephone CPR advice, prehospital defibrillation, and advanced life support techniques have all been subject to scrutiny 9. Two overriding features emerge in common linked to increased survival: (i) the early provision of basic life support; and (ii) the speed with which the first defibnllatory shock is applied 10. This has lead to efforts to audit cardiac arrest cases in the UK, and, in particular, the geographic locations and case profiles. In a recent audit of 1200 cases, 80% occurred in a private residence, only 20% occurring in the street or other public place 11. This impacts on the number of cases where CPR is attempted in the prehospital phase, with 20% of cases in the home receiving CPR against 50% of cases in public places. The implication of this is a clear need to target CPR training to spouses and relatives of those at additional risk of sudden cardiac death, namely patients after myocardial infarction, or those with angina. The need to speed defibrillation demands a more aggressive deployment of automated defibrillators, and emphasis during paramedic training of the need to initially manage cardiac arrest with immediate basic life support and defibrillation, rather than more elaborate and timeconsuming advanced life support techniques. Some services provide two defibrillators in a vehicle, an AED in the immediate response bag, and a larger more fixed monitor defibrillator mounted in the vehicle. This helps the crew to be constantly ready to provide rapid defibnllation, even on occasions where initial call information does not lead them to suspect the patient may be in cardiac arrest. 764 British Medical Bulletin 1999. 55 (No 4)

Prehospital care - a UK perspective Managing paediatric emergencies The importance of simultaneous improvement of response times, telephone CPR advice to callers and paramedic training emphasis on immediate defibrdlation, can be seen to be complementary to contributing to improving survival from out-of-hospital cardiac arrest. Education of patients must also cover the early reporting of chest pain persisting more than 15-20 min directly via the 999 emergency call system. The new Emerging Findings from the evidence based Service Framework for Managmg Coronary Heart Disease 12 recommends a defibrillator reaches any suspected myocardial infarction case within 8 min. This clearly has serious implications for ambulance services. Until recently, paramedic training in managing ill and injured children was too brief to provide any real confidence in paramedic management of these cases. The immediate hospital management of these children within the Accident and Emergency departments has been improved since the introduction of the Advanced Paediatric Life Support (APLS) course. Children make up a significant volume of the trauma workload and present periodically in extremis with serious medical illnesses to paramedics. The occasional nature of these presentations, the need to use unfamiliar equipment sizes and drug doses, and the heavy emotional burden associated with caring for the unwell child, all conspires to stress the paramedic on these occasions. This has been addressed with the introduction in 1996 of the Pre Hospital Paediatric Life Support course, allied to the APLS course. It teaches paramedics the primary survey approach of assessment and treatment priorities to both injured and ill children. Trauma management follows basic PHTLS methods, and great emphasis is placed upon the recognition and management of the seriously ill child. Usmg these common approaches, paramedics can manage ill and injured children with more confidence, prioritise interventions on the immediate management requirements to reverse hypoxia, and know far better when a child's care demands rapid removal to hospital for more specialist care. Conclusions Prehospital care is largely provided in the UK by NHS Ambulance Trusts, supported by a variety of medical support mechanisms when medical and paramedical care is needed at the scene of the incident. Technology can be used to activate effective emergency paramedic response to emergency calls more rapidly, assisted by re-engineering of paramedic shift rotas and ambulance deployment to response posts nearer areas of high call density to reduce response times to emergencies. British Medical Bulletin 1999, 55 (No 4) 765

Trauma Call priormsation attempts to deploy ambulances to potentially life threatening calls in preference to less serious calls, and uses medical priority dispatch systems to triage incoming emergency calls providing telephone first aid advice whilst the ambulance is en route. Emergency ambulances are equipped with single cots, ECG and pulse oximetry monitoring and defibrillators. Equipment for ALS procedures is also carried. The content of paramedic training is currently being reviewed nationally, and is already being enhanced by many services by the introduction of PHTLS and PHPLS training to interface with hospital based ATLS and APLS teaching. This common prehospital and in hospital training base is contributing to more harmonious and seamless patient care. Paramedics can provide a wide range of therapeutic interventions, ranging from administering parenteral analgesia to reversal of hypoglycaemia with 50% glucose solution. At the same time, early BLS and defibriuation are being applied in combination with targeted CPR training and telephone CPR advice to improve the clinical effectiveness of cardiac arrest management. This will only improve survival, however, if operational changes occur within ambulance services and communities, to speed response times to reach these patients earlier than is now the case. References 1 Working Party on Ambulance Training and Equipment. Report, Part 1. London: HMSO, 1966 2 Pantndge JF, Gcddes JS. A mobile intensive care unit in the management of myocardial infarction. Lancet 1967; ii: 271 3 National Health Service Training Directorate. Ambulance Service Paramedic Training. Bristol: NHSTD, 1991 4 American College of Surgeons. Advanced Trauma Life Support Program for Doctors, 6rh edn. Chicago: American College of Surgeons, 1997: 633 5 Advanced Life Support Group Advanced Paediatnc Life Support, 1st edn. LondomBMJ Publishing Group,1993 6 National Association of Emergency Medical Technicians in Cooperation with the Committee on Trauma, American College of Surgeons Pre Hospital Trauma Life Support, 4th edn, USA:Mosby, 1999 7 Advanced Life Support Group. Pre Hospital Paediatnc Life Support. 1997 8 Nicholl J, Hughes S, Dixon S, Yates D The costs and benefits of paramedic skills in pre hospital care Sheffield Medical Care Research Unit, University of Sheffield, 1998 9 Weaver WD, Cobb LA, Hallstrom AP et al. Factors influencing outcome after out-of-hospital cardiac arrest. / Am Coll Cardiol 1986, 7: 752-7 10 Newman M. Early access, early CPR, and early defibnllation: cry of the 1988 Conference on Citizen CPR. / Emerg Med Serv 1988; 13: 30-5 11 Bedfordshire and Hertfordshire Ambulance and Paramedic Service Annual Report on Cardiac Arrest Survival, 1997/98. Bedfordshire and Hertfordshire Ambulance and Paramedic Service - internal publication 12 Emerging findings on National Service Framework - Coronary Heart Disease. Nov. 1998, Deparment of Health 766 British Medical Bulletin 1999, 55 (No 4)