Life in the Fast Lane: Collaborating to deliver Research in Ambulance

Services

Nigel ReesAdvanced Paramedic Practitioner Head of Research & Innovation Welsh Ambulance Services NHS Trust

Context

Changing case mix

u Calls to the emergency ambulance service in the UK have been rising over recent years at 7% per annum

u It has also previously been estimated that only 10% of 999 patients have a life threatening condition (Darzi, DOH 2009).

u 8% of emergency ambulance attendances are to older people who have fallen

u In a study conducted by the Welsh Ambulance Services Trust and Swansea University, up to 10.7% of 999 calls to ambulance services were found to relate to mental health problems, and of these 53% related to Self Harm (INVENT 2013).

u Half of patients taken to emergency departments by ambulance have been found to be discharged without being treated or referred (Volans 1998).

Problem/idea

Case for change

Critical incident

Loss of political support

Some evidence against proposed change

Proposed change:

Policy/clinical/model of care

developed and

introduced

Failed to learn lessons or address why needed change or basis of original

problem

Evidence for

change

Positive benefits

observed

Temporary suspension of change

Change abandoned

Scott, J.W (2001) Scott's parabola BMJ 2001; 323:1477 doi: http://dx.doi.org/10.1136/bmj.323.7327.1477

Scott’s Parabola

MAST Garments

Dickinson and Roberts (1999) MAST in patients in patients after trauma: a systematic review of randomised control trials.

u Aim: To identify all relevant randomised or quasi randomised controlled trials available for review in January 1999.

u No evidence to suggest incidence of death, length of stay in hospital or intensive care unit were decreased by MAST

u Pooled relative risk data for mortality suggests MAST group were 1.13 times more likely to die than no MAST.

u Lack of quality trials in humans.

Health Thinkers:Archibald Leman Cochrane (1909–1988)

Man of the Rhondda:

Mechanical Chest Compression Devices

CPAP

HEMS

IV Fluids

Targeted Temperature Management

Airway Management

Role of Drugs in OHCA

Controversies in Ambulance Services care

The ‘research push’ and ‘policy pull’.

This use of evidence is limited by factors such as research production, availability, dissemination and uptake. This has been termed as the ‘research push’ or the ‘policy pull’ (Mitton 2007).

Gap between policy makers researchers and clinicians

Gorissen (et al 2005) explored the gap between doctors and policymakers in the Netherlands,

• the use of knowledge had to ‘compete’ with easily accessible resources, for powerful actors

• using power is easier than arguing it out’.

• powerful actors (a service manager in their case) had little need to use other resources or scientific knowledge, besides the resources of money and formal authority.

The pre-hospital randomised assessment of a mechanical compression device in cardiac arrest (PARAMEDIC)

• Pragmatic, cluster-randomised trial of adults with non-traumatic, out-of-hospital cardiac arrest (OHCA) from four UK Ambulance Services

• Ambulances randomly assigned to LUCAS-2 or manual CPR.• Primary outcome: survival at 30 days• 4471 eligible patients enrolled (1652 LUCAS-2 group, 2819

control group)• Results/Conclusion:No evidence of improvement in 30 day survival with LUCAS-2 compared with manual compressions. On the basis of this and other recent randomised trials, widespread adoption of mechanical CPR devices for routine use does not improve survival.

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Barriers to Researchu Lack of Institutional Support for Research Time

u Consent in the Emergency Out-of-Hospital Setting

u The paramedics have conflicting demands on their time in terms of ensuring that patients received optimum medical care within a limited period

u Difficulty in Maintaining the IMP (Investigtional Mediciinal Product) Log:

u Although a log was maintained at each ambulance station, some envelopes were left in the ambulances and subsequently misplaced or lost when vehicles were moved for servicing or transferred to another ambulance station

u Many eligible patients not approached for the studies. Up to a fifth of eligible patients recruited into studies

u Scattered workforce

u Difficulty in Organizing Face-to-Face Training Sessions

u Paramedics shift-working patterns and the requirement to attend in their personal time are obstacles to attending meetings

u Concerns about ethical and practical challenges

Use established policies and documentation where possible

Push research training

Find paramedics in theirhabitat

Push the incentive button

Engage with R&D office early

Seek out champions

Flag wavers at all levels

Research Paramedic

Policy PullPolicy-making has been argued to be a process of problem solving, constituting rounds in which divergent actors are involved with mutual power-dependency relations, usually having different frames of reference and using different resources, characterized by a sequence of actions with a recognizable course and is a social/political process, than a rational analytical process (dunn1994, gorissen et al 2005).

• Shift away from the dichotomous culture of producers and users of research evidence; ‘knowledge translation’, ‘transfer’ and mobilisation being imbedded in ‘learning’, ‘contribution’, and co-production (jasanoff 2013).

• Frames the relationship between research and policy as a two-way negotiation, in which both partners learn from the other – pragmatically and politically a step towards an equality of prioritisation and experience.

Delivering Research in Ambulance Services is bridging the gap between the Service and a Knowledge economy

NASMED

• Despite the increase of academia and policy-making roles in medicine and other professions, there are few examples of formal brokerage roles of individuals (Ettelt & Mayes 2011),

Health & Care Research Wales performance matrix

u Number of patients recruited into Health and Care Research Wales Clinical Research Portfolio (CRP) studies

u Number of patients recruited into commercially sponsored studies

u Percentage of commercially sponsored and CRP studies:u receiving NHS research permission within 40 calendar

days u recruiting the first patient within 30 calendar days of

approval/ site initiationu recruiting to time and target u Percentage of non-recruiting studies

Pull

Policy pull

u Integrated Medium Term Plan

u Local Delivery Plans

u R & D key target for Health Minister PDR with Chairman

u Performance matrix reported to CEO and board

0

1

2

3

4

5

6

Q1 Q2 Q3 Q4

2014/15

2015/16

2016/17 Q3

C1. Number of Health and Care Research Wales

0

100

200

300

400

500

600

Q1 Q2 Q3 Q4

2014/15

2015/16

2016/17 Q3

D1. Number of Patients recruited into

WAST Research

Streamlining in ED

INVENT

Paramedics perceptions of caring for people who self harm

PEARS & PASTA

Take home Naloxone

Ethnographic study of emotion work

Transient Ischaemic attack 999 Emergency Referral (TIER): feasibility trial

Ethnography of 'Primary Care Sensitive' Ambulance Contacts".

Public and clinicians views of Prudent Healthcare

Evaluating the Diversion of Alcohol-Related Attendances

Your ViewsTo help improve our services we value

your feedback:www.healthandcareresearch.gov.wales/your-views/

Publicationsu National Institute of Health Research (2016) Dissemination centre themed review Care at the Scene: Research for ambulance

services. Available from: http://www.dc.nihr.ac.uk/themed-reviews/care-at-the-scene.htm. Accessed on 12/02/2017

u National Institute of Health Research (2017) Roads to Recovery: organisation and quality of stroke services. Available from: http://www.dc.nihr.ac.uk/themed-reviews/roads-to-recovery.htm. [Accessed 24/04/2017]

u Jenna K. Bulger, Alan Brown, Bridie A. Evans, Greg Fegan, Simon Ford, Katy Guy, Sian Jones, Leigh Keen, Ashrafunnesa Khanom, Ian Pallister, Nigel Rees, Ian T. Russell, Anne C. Seagrove, Helen A. Snooks (2017) Rapid analgesia for prehospital hip disruption (RAPID): protocol for feasibility study of randomised controlled trial. Pilot Feasibility Stud. 2017 Jan 23;3:8. doi: 10.1186/s40814-016-0115-6. eCollection 2017.

u Evans BA, Ali K, Bulger J, Ford GA, Jones M, Moore C, Porter A, Pryce AD, Quinn T, Seagrove AC, Snooks H, Whitman S, Rees N, on behalf of the TIER Trial Research Management Group. 'Referral pathways for patients with TIA avoiding hospital admission: a scoping review'. BMJ Open 2017;7:e013443. doi:10.1136/bmjopen-2016-013443

u Claire Hawkesa, Scott Bootha, Chen Ji a, Samantha J. Brace-McDonnella,b, Andrew Whittingtona, James Mapstonej, Matthew W. Cookea, Charles D. Deakinc, Chris P. Galed, Rachael Fothergill e, Jerry P. Nolanf, Nigel Rees g, Jasmeet Soarh, A. NiroshanSiriwardenai, Terry P. Browna, Gavin D. Perkinsa,b,∗, on behalf of OHCAO collaborators1 Epidemiology and outcomes from out-of-hospital cardiac arrests in England. Resuscitation 110 (2017) 133–140

u Rajagopal S1, Kaye CR2, Lall R2, Deakin CD3, Gates S2, Pocock H4, Quinn T5, Rees N6, Smyth M7, Perkins GD8.Characteristics of patients who are not resuscitated in out of hospital cardiac arrests and opportunities to improve community response to cardiac arrest. Resuscitation 110 (2017) 133–140

u Rees, N. Rapport, F. Snooks H. John, A. Patel, C. (2016) How do emergency ambulance paramedics view the care they provide to people who self harm?: Ways and means. International Journal of Law and Psychiatry

u Perkins, D.G. Brace-McDonnell, S.J. On behalf of the OHCAO Project Group (2015) The UK Out of Hospital Cardiac Arrest Outcome (OHCAO) project BMJ Open 2015;5:e008736doi:10.1136/bmjopen-2015-008736

u Pre-hospital Assessment of the Role of Adrenaline: Measuring the Effectiveness of Drug administration In Cardiac arrest (PARAMEDIC-2): Trial protocol Sep 2016 · Resuscitation

u Perkins, G.D. Lall, R. Quinn, T. Deakin, C.D. Cooke, M.W. Horton, J. Lamb, S.E. Slowther, A. Woollard, M. Carson, A. Smyth, M. Whitfield, R. Williams, A. Pocock, H. Black, J.J.M. Wright, J. Han, Kee. Gates, S (2015) Mechanical versus manual chest compression for out-of-hospital cardiac arrest (PARAMEDIC): a pragmatic, cluster randomised controlled trial PARAMEDIC trial collaborators* Lancet 2015; 385: 947–55

u Rees, N. Rapport, F. Snooks, H. (2015) Perceptions of paramedics and emergency staff about the care they provide to people who Self Harm: Constructivist Metasynthesis of the qualitative literature. Journal of Psychosomatic Research. doi: 10.1016/j.jpsychores.2015.03.007

u John, A. Okolie, C. Porter, A. Moore, C. Thomas, G. Whitfeild, R. Oretti, R. Snooks, H. (2016) Non-accidental non-fatal poisonings attended by emergency ambulance crews: an observational study of data sources and epidemiology BMJ Open 6:e011049(8) · August 2016 DOI: 10.1136/bmjopen-2016-011049

u Morisson-Rees, S. Whitfield, R. Evans, S. Snooks, H. Huxley, P. John, A. Baker, S. Engamba, S. Rees, N. (2015) Investigating the volume of mental health emergency calls in the welsh ambulance service trust (WAST) and developing a pre-hospital mental health model of care for application and testing. Emergency Medicine Journal. July 2015

u Rees, N, Rapport, F, Thomas, G. John, A, Snooks,H. (2014) Perceptions of Paramedic and Emergency Care Workers of those who Self Harm: A Systematic Review of the Quantitative Literature. Journal of Psychosomatic Research. 77 (2014) 449–456

u Porter, A. Evans, B.A. Gammon, B. Mayes, R.H. Poulden, M. Rees, N. Snooks, H. Toghill, A. Wells,B. Whitfield, R. (2015) The jam in the sandwich, down here in A&E’: staff perspectives on the impact and causes of handover delays between the ambulance service and the emergency department. Emerg med j 2015;32(6):e12–e18

u Perkins, D.G. Brace-McDonnell, S.J. On behalf of the OHCAO Project Group (2015) The UK Out of Hospital Cardiac Arrest Outcome (OHCAO) project BMJ Open 2015;5:e008736doi:10.1136/bmjopen-2015-008736

u Moore, C. Lloyd, G. Oretti, R. Russell, I. Snooks, H (2014) Paramedic-supplied ‘Take Home’ Naloxone: protocol for cluster randomised feasibility study. BMJ Open 2014;4:e004712doi:10.1136/bmjopen-2013-00471

u Wells, B. Evans, B.A. Gammon, B. Mayes, R.H. Poulden, M. Rees, N. Snooks, H. Toghill, A. (2015) Snapshot of initiatives to support timely patient handover from ambulances to the emergency department. Emergency Medicine Journal. June 16, 2015

u Evans, B. Porter, A. Gammon, B. Mayes, R.H. Poulden, M. Rees, N. Snooks, H. Toghill, A. Wells, B. Whitfield, R. A systematic review of rapid access models of care and their effects on delays in emergency departments. Emergency Medicine Journal 32(6), e15.3-e16.

u Morisson-Rees, S. Whitfield, R. Evans, S. Snooks, H. Huxley, P. John, A. Baker, S. Engamba, S. Rees, N. (2015) Investigating the volume of mental health emergency calls in the welsh ambulance service trust (WAST) and developing a pre-hospital mental health model of care for application and testing. Emergency Medicine Journal. July 2015

u Article review: Julia Williams (2015) Managing people who self-harm: what does the qualitative literature say Spotlight on Research: Journal of Paramedic Practice,Vol. 7, Iss. 9, 04 Sep 2015, pp 466 - 467

u Rees, N. Whitfield, R. (2015) Smartphone Use in Out-of-Hospital Cardiac Arrest. Journal of Emergency medical Services (JEMS)November 20, 2015 available from: http://www.jems.com/articles/print/volume-40/issue-12/features/smartphone-use-in-out-of-hospital-cardiac-arrest.html