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Paramedics working in a traditional ambulance service role infrequently see patients who are critically ill or injured; in addition, pressures on hospitals have caused long waiting times, further lowering exposure to all patient groups and reducing how often paramedics use their clinical skills, potentially negatively impacting performance in practice. This study sought to establish the competence of paramedics in a set of skills that included frequent and infrequent as well as simple and complex procedures. They took part in a scored clinical scenario in which they used these skills. The study also sought to explore paramedics' perception of how difficult these skills were. Participants generally scored well; however, in some instances, elements of skills were missed or performed out of sequence. The pressure created by the scenario appeared to negatively impact performance.

BackgroundTranexamic acid (TXA) is an antifibrinolytic drug used to prevent bleeding. It was introduced as an intervention for post-traumatic haemorrhage across emergency medical services (EMS) in the UK during 2012. However, despite strong evidence of effectiveness, prehospital TXA administration rates are low. This study used the theoretical domains framework (TDF) to identify barriers and facilitators to the administration of TXA to trauma patients by EMS providers (paramedics) in the UK.MethodsInterviews were completed with 18 UK paramedics from a single EMS provider organisation. A convenience sampling approach was used, and interviews continued until thematic saturation was reached. Semistructured telephone interviews explored paramedics’ experiences of administering TXA to trauma patients, including identifying whether or not patients were at risk of bleeding. Data were analysed inductively using thematic analysis (stage 1). Themes were mapped to the theoretical domains of the TDF to identify behavioural theory-derived barriers and facilitators to the administration of TXA to trauma patients (stage 2). Belief statements were identified and assessed for importance according to prevalence, discordance and evidence base (stage 3).ResultsBarriers and facilitators to paramedics’ administration of TXA to trauma patients were represented by 11 of the 14 domains of the TDF. Important barriers included a lack of knowledge and experience with TXA (Domain: Knowledge and Skills), confusion and restrictions relating to the guidelines for TXA administration (Domain: Social/professional role and identity), a lack of resources (Domain: Environmental context and resources) and difficulty in identifying patients at risk of bleeding (Domain: Memory, attention and decision processes).ConclusionsThis study presents a behavioural theory-based approach to identifying barriers and facilitators to the prehospital administration of TXA to trauma patients in the UK. It identifies multiple influencing factors that may serve as a basis for developing an intervention to increase prehospital administration of TXA.

BackgroundBirth before arrival at hospital (BBA) is associated with unfavourable perinatal outcomes and increased mortality. An important risk factor for mortality following BBA is hypothermia, and emergency medical services (EMS) providers are well placed to provide warming strategies. However, research from the UK suggests that EMS providers (paramedics) do not routinely record neonatal temperature following BBA. This study aimed to determine the proportion of cases in which neonatal temperature is documented by paramedics attending BBAs in the South West of England and to explore the barriers to temperature measurement by paramedics.MethodsA two-phase multi-method study. Phase I involved an analysis of anonymised data from electronic patient care records between 1 February 2017 and 31 January 2020 in a single UK ambulance service, to determine 1) the frequency of BBAs attended and 2) the percentage of these births where a neonatal temperature was recorded, and what proportion of these were hypothermic. Phase II involved interviews with 20 operational paramedics from the same ambulance service, to explore their experiences of, and barriers and facilitators to, neonatal temperature measurement and management following BBA.ResultsThere were 1582 ‘normal deliveries’ attended by paramedics within the date range. Neonatal temperatures were recorded in 43/1582 (2.7%) instances, of which 72% were below 36.5°C. Data from interviews suggested several barriers and potential facilitators to paramedic measurement of neonatal temperature. Barriers included unavailable or unsuitable equipment, prioritisation of other care activities, lack of exposure to births, and uncertainty regarding responsibilities and roles. Possible facilitators included better equipment, physical prompts, and training and awareness-raising around the importance of temperature measurement.ConclusionsThis study demonstrates a lack of neonatal temperature measurement by paramedics in the South West following BBA, and highlights barriers and facilitators that could serve as a basis for developing an intervention to improve neonatal temperature measurement.

The aim of this paper was to describe the characteristics of paediatric patients who underwent an aeromedical retrieval within Australia (gender and Indigenous status) for suspected appendicitis between 1 July 2014 and 30 June 2018 (4 years). By understanding these trends, we hope to further justify the need for point‐of‐care ultrasound training for clinicians working in rural and remote Australia. Participants included Royal Flying Doctor Service (RFDS) patients aged 0–18 years (inclusive) who underwent an aeromedical retrieval for suspected appendicitis within Australia. Data were collected and coded on each patient’s inflight working diagnosis, using the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification (ICD‐10‐AM) coding method. A combination of descriptive statistics and chi‐square analyses was used in data analysis, with significance considered at <0.05. There were 384 children with a working diagnosis of suspected appendicitis, including 191 (49.7%) males and 193 (50.3%) females, with 133 (34.6%) patients identifying as Aboriginal and/or Torres Strait Islander (hereafter referred to as Indigenous) Australians. The aeromedical retrievals were from rural and remote locations to inner‐regional or metropolitan hospitals, with an average distance flown of 339.0 (SD = 206.4) kilometres. The RFDS most frequently retrieved for acute appendicitis (n = 159; 41.4%), acute abdominal pain (n = 127; 33.1%), and unspecified appendicitis (n = 84; 21.9%). There were non‐significant (P = 0.9) diagnostic differences between genders. Non‐Indigenous patients were overrepresented, compared with Indigenous patients, in relation to a transfer with a diagnosis of acute appendicitis (P = <0.01), whereas Indigenous patients were overrepresented, compared with non‐Indigenous patients, in relation to transfers with diagnoses of acute abdomen pain and unspecified appendicitis (P = <0.01). A significant number of paediatric patients are aeromedically retrieved from rural and remote locations with a diagnosis of appendicitis or acute abdominal pain. Future research should consider whether training in abdominal point‐of‐care ultrasound reduces retrievals.

Various factors have widened the variety of incidents that UK paramedics, practising in a non-specialist role, may be required to attend. This study set out to identify the type and frequency of incidents attended by paramedics, as well as establishing whether geographical location and time of year bear any influence. The study involved a quantitative retrospective review of paramedic-completed patient clinical records, across two locations and the span of 1 year. Results demonstrated the infrequent exposure of paramedics to serious illness/trauma, as well as limited associations of significance in relation to location and time of year. The infrequent nature of certain incidents raises potential issues of skill decay for paramedics; closely aligned to this is their ongoing education, and how learning is best balanced between the infrequent, serious presentations, and those that are frequent but less serious.

ABSTRACTRates of treatment utilization decline as adolescents make the transition to adulthood even though young adults are particularly vulnerable to the negative outcomes of untreated mental illness. Although a variety of factors have been explored to explain decreased treatment utilization in this age group, previous research has almost exclusively employed cross-sectional methods rather than following a group of youth as they enter adulthood. The current study aims to address this methodological limitation by assessing treatment utilization in emerging adults who began participating in a longitudinal study during childhood. One hundred and thirty seven youth who turned 18 during the 96-month follow-up period were included in the current analyses. Demographic and socioeconomic variables such as sex, race, and insurance status and clinical variables such as psychiatric diagnoses and perceptions of treatment effectiveness were investigated as factors potentially associated with outpatient treatment use before and after age 18. Prior to age 18, youth reported using outpatient services at 75% of their visits, but after age 18, outpatient treatment utilization dropped to around 50%. White race, increased parental stress, and increased parental perception of treatment usefulness were associated with greater treatment use prior to age 18, whereas only increased youth perception of symptom-related dysfunction were associated with increased treatment use after age 18. Findings point to the importance of including youth preferences and perceptions of dysfunction in treatment decisions across adolescence in order to optimize treatment use following the transition to adulthood.

Common variable immunodeficiency (CVID) and IgG deficiency are 2 of the more prevalent primary humoral immune defects. The former is defined by consensus with criteria for quantitative and qualitative antibody defects, whereas the latter is used to describe patients with reduced IgG, who commonly have recurrent sinopulmonary infections but do not fulfill CVID criteria. However, these patients are often given this diagnosis.

Background: Pediatric sports specialization, defined as intense year-round training in a single sport as a result of excluding other sports for more than 8 months per year, is common in the United States. There are demonstrated physical and social risks to early pediatric sports specialization (defined as before age 12 years). While thought to be needed to acquire appropriate experience and excel in a given sport, there remains little information on when athletes at the highest levels of their sport specialized. This study aimed to define when professional and collegiate ice hockey players specialized.Hypothesis: Early sports specialization before age 12 years will not be common among elite-level (professional and collegiate) ice hockey players.Study Design: Retrospective cross-sectional survey study.Level of Evidence: Level 3.Methods: Male professional and collegiate ice hockey players within 1 National Hockey League organization and 2 National Collegiate Athletic Association (NCAA) organizations who were 18 years of age or older completed a survey at training camp detailing their history of sports participation and specialization.Results: A total of 91 athletes participated in the study (mean age, 22.8 years; range, 18-39 years). The mean age at the start of any sports participation was 4.5 years, and the mean age of sports specialization was 14.3 years. The mean age of specialization in the professional group, the NCAA Division I group, and the NCAA Division III group was 14.1, 14.5, and 14.6 years, respectively.Conclusion: Early pediatric sports specialization is not common in elite-level (professional and collegiate) ice hockey players.Clinical Relevance: Early pediatric sports specialization before age 12 years is not necessary for athletic success in professional and collegiate ice hockey. This study provides further evidence supporting the recommendations of the American Medical Society for Sports Medicine, American Academy of Pediatrics, and American Orthopaedic Society for Sports Medicine against early sports specialization.

The aim of the project was to identify the neighbourhood characteristics of areas in England where out-of-hospital cardiac arrest (OHCA) incidence was high and bystander cardiopulmonary resuscitation (BCPR) was low using registry data.

BackgroundThe role of the Emergency Medical Service (EMS) in End of Life (EOL) is often overlooked. The Gold Standards Framework Proactive Identification Guidance (GSFPIG) is an evidence-based screening tool to identify patients nearing EOL. We conducted a quantitative investigation using the GSFPIG to determine how often paramedics attend EOL patients with and without Advance Care Planning (ACP) in place followed by a qualitative interview study of paramedic perspectives on the usability and acceptability of the GSFPIG.MethodsA mixed methods explanatory sequential design was used. Thirty-five paramedics were recruited from one EMS in England. Paramedics were trained in study procedures and asked to apply the GSFPIG to every patient they attended, aged 65 and over, and to record EOL status and ACP presence. Data was analysed using descriptive statistics.Ten paramedics were purposively selected for an individual interview to explore their experiences of using the GSFPIG and the concept of paramedics referring EOL patients to the GP to implement ACP. Framework analysis was used to analyse interview data.ResultsAlmost half (108/244;44.2%) of patients identified as EOL had no ACP in place. Where ACP was in place 37% of patients had a Do Not Attempt Resuscitation Order only, 50% a Recommended Summary Plan for Emergency Care or Treatment Escalation Plan and 13% unknown ACP type.Analysis of ten paramedic interviews identified three key themes: Participant experiences of using the GSFPIG; Putting a screening and referral tool into practice; Paramedic views on ACPs.ConclusionParamedics are well placed to identify patients who would benefit from an ACP. The GSFPIG has utility in EMS and paramedics found it easy to use. Paramedics report that good quality ACP allows them to provide treatment and care in line with patient preferences.

Trace amine-associated receptor 1 (TAAR1) agonists have been shown to have procognitive, antipsychotic-like, anxiolytic, weight-reducing, glucose-lowering, and wake-promoting activities. We used Taar1 knockout (KO) and overexpressing (OE) mice and TAAR1 agonists to elucidate the role of TAAR1 in sleep/wake. EEG, EMG, body temperature (Tb), and locomotor activity (LMA) were recorded in Taar1 KO, OE, and WT mice. Following a 24 h recording to characterize basal sleep/wake parameters, mice were sleep deprived (SD) for 6 h. In another experiment, mice were given three doses of the TAAR1 partial agonist RO5263397, caffeine, or vehicle p.o. Baseline wakefulness was modestly increased in OE compared with WT mice. Baseline theta (4.5–9 Hz) and low gamma (30–60 Hz) activity was elevated in KO compared with OE mice in NREM and REM sleep. Following SD, both KO and OE mice exhibited a homeostatic sleep rebound. In WT mice, RO5263397 increased waking and reduced NREM and REM sleep, decreased gamma power during wake and NREM, and decreased Tbwithout affecting LMA; these effects were absent in KO mice and potentiated in OE mice. In contrast, caffeine increased wake time, NREM gamma power, and LMA in all strains compared with vehicle; this effect was attenuated in KO and potentiated in OE mice. TAAR1 overexpression modestly increases wakefulness, whereas TAAR1 partial agonism increases wakefulness and also reduces NREM and also REM sleep. These results indicate a modulatory role for TAAR1 in sleep/wake and cortical activity and suggest TAAR1 as a novel target for wake-promoting therapeutics.

Rapid identification of patients with life-threatening conditions is the main priority for any ambulance telephone triage system. Historically there has been a focus on the identification of patients in cardiac arrest; however, the clinical benefits of early recognition of patients in peri-arrest could be considered equally important. An expanded definition of the highest priority response, Red 1, was introduced to identify patients who are critically unwell, at high risk of cardiac arrest, and who would benefit clinically from the fastest level of response from the ambulance service.An evaluation of the impact of the new Red 1 definition was completed in South Western Ambulance Service NHS Foundation Trust during 2013. It demonstrated that the new Red 1 definition was more sensitive than the previous Red 1 definition in identifying patients in cardiac arrest and those at high risk of out-of-hospital cardiac arrest. The total number of patients who required resuscitation decreased by 11.7% under the new Red 1 definition, supporting the hypothesis that more patients are captured by the new Red 1 definition and a more rapid response diminishes their likelihood of experiencing a cardiac arrest.

Background:Although concept mapping was created in the early 1980s, research in nursing education first appeared in 1992. This literature review analyzes the impact of concept mapping in nursing education.Method:A total of 221 articles, books, and book chapters were reviewed on the topic of concept mapping in nursing education.Results:Results indicate that concept-mapping research progressed from the emergence state, to an expansion and adaptation stage, to an established stage.Conclusion:Nursing education could benefit from further research on applying concept map scoring formulas, using concept maps with simulation, developing knowledge models, and creating concept map–centered learning environments. [Nursing education could benefit from further research on applying concept map scoring formulas, using concept maps with simulation, developing knowledge models, and creating concept map–centered learning environments. [J Nurs Educ.2016;55(11):631–639.]

Ambulance demand in South West England is increasing year-on-year, but the driving forces behind such increases are poorly understood. We developed a system dynamics model to simulate the factors that influence a call being made for an ambulance. We used data from the South West Ambulance Service NHS Foundation Trust (SWAST), the Office of National Statistics (ONS) and quantitative relationship data in both national and international literature to parameterise the model. We compared predicted ambulance demand over 12 months in the base case model with scenarios in which each influencing factor was removed in turn.The model predicts that the prevalence of regular falls among older people most influences the level of demand for ambulances. The model also predicts that the number of users of adult mental health services could be a significant contributor to ambulance demand.Additional focus on, and investment in, falls prevention strategies could help to significantly alleviate increasing levels of demand for ambulance services in South West England. Additionally, efforts to understand why those with mental health needs tend to use ambulances more than those without such needs could also be beneficial.

The article focuses on the services of the financial services companies of UBS AG (UBS) and DB Group Services (UK) Ltd (DB) and the approach to statutory construction in tax avoidance cases of the Great Britain's Supreme Court decision in the case Murray Group Holdings Ltd v HMRC.

Patients with Huntington's disease (HD) show a high prevalence of sleep disorders that typically occur prior to the onset of motoric symptoms and neurodegeneration. Our understanding of the pathophysiological alterations in premanifest HD is limited, hindering the ability to measure disease modification in response to treatment. We used a full-length knock-in HD model to determine early changes in the electroencephalogram (EEG) and sleep that may predict the onset and progression of the disease.

Following a previous article published in the Journal of Paramedic Practice (Walker, 2013) this article summarises the findings of a study conducted by South Western Ambulance Service NHS Foundation Trust (SWASFT). As a result of the literature review detailed in the previous article, approval was given to run a 6-month study examining the feasibility of paramedic crews carrying and administering single-dose activated charcoal (SDAC) to patients of self-poisoning attended within 1 hour of ingestion of a suitable toxin. Sixty nine patients were offered SDAC, with an acceptance rate of 94%. Fears of adverse incidents such as vomiting, aspiration and increased time on scene appeared almost entirely unfounded and crews found the medication easy to use and popular with patients. Paracetamol, usually at hepatotoxic levels accounted for 57% of all overdoses encountered, most of these receiving SDAC within 1 hour, with 81.5% of all patients receiving the medication in that time frame. SWASFT has now adopted SDAC as a treatment for patients of overdose.

INTRODUCTION: There is a compelling need to develop clinical performance indicators for ambulance services in order to move from indicators based primarily on response times and in light of the changing clinical demands on services. We report on progress on the national pilot of clinical performance indicators for English ambulance services. METHOD: Clinical performance indicators were developed in five clinical areas: acute myocardial infarction, cardiac arrest, stroke (including transient ischaemic attack), asthma and hypoglycaemia. These were determined on the basis of common acute conditions presenting to ambulance services and in line with a previously published framework. Indicators were piloted by ambulance services in England and results were presented in tables and graphically using funnel (statistical process control) plots. RESULTS: Progress for developing, agreeing and piloting of indicators has been rapid, from initial agreement in May 2007 to completion of the pilot phase by the end of March 2008. The results of benchmarking of indicators are shown. The pilot has informed services in deciding the focus of their improvement programme in 2008–2009 and indicators have been adopted for national performance assessment of standards of prehospital care. CONCLUSION: The pilot will provide the basis for further development of clinical indicators, benchmarking of performance and implementation of specific evidence-based interventions to improve care in areas identified for improvement. A national performance improvement registry will enable evaluation and sharing of effective improvement methods as well as increasing stakeholder and public access to information on the quality of care provided by ambulance services.