General practitioner attendance at emergencies notified to ambulance control.

For two years doctors from a small village went to the scene of emergency calls received by ambulance control. On 80% of the occasions when the doctor was called at the same time as the ambulance was dispatched the doctor arrived before the ambulance. There were 24 incidents, 16 of which were road traffic accidents. In two cases the doctor established a clear airway in an unconscious patient before the ambulance arrived. Two patients were trapped in their vehicles and were given parenteral analgesics. Four patients required intravenous fluids. The call out system provided first aid for patients before the ambulance arrived and medical assistance to the emergency services at serious accidents. Patients who did not require hospital attention could be examined and treated at the scene, making the ambulance available for other duties and reducing the number of patients taken to the hospital accident and emergency department.     

Follow-up of emergency ambulance calls in Nottingham: implications for coronary ambulance servie.

Information about patients in ambulance service records has been linked to that in the patients'' hospital records in an attempt to make the most efficient use of a special ambulance service for patients suspected of having heart attacks. During one week 248 emergency (999) calls for an ambulance were made by the public in the city of Nottingham. The quality of information given to the ambulance centre was poor, and all four patients eventually found to have had a myocardial infarction were described as having collapsed. A further study of patients who were also described as having collapsed has led to a system which allows an ambulance controller to send a "coronary ambulance" only in answer to those emergency calls where there is a reasonable possibility that the patient has had a heart attack.     

Resuscitation of patients with cardiac arrest by ambulance staff with extended training in West Yorkshire.

OBJECTIVE--To investigate the results of resuscitation of patients with cardiac arrest by ambulance staff with extended training in West Yorkshire. DESIGN--Study of all such attempts at resuscitation over 32 months, based on the standard report form for each call made by the ambulance staff and the electrocardiogram that showed the initial rhythm in each patient. SETTING--Area covered by West Yorkshire ambulance service. SUBJECTS--1196 Patients with cardiac arrests attended by 29 ambulance staff with extended training. MAIN OUTCOME MEASURE--Result of resuscitation. RESULTS--The initial rhythm was asystole or electromechanical dissociation in 740 patients and ventricular fibrillation in 456 patients; overall 65 patients survived to be discharged from hospital. Sixty four of the 456 patients in whom ventricular fibrillation was the initial rhythm recorded, and 46 in whom ventricular fibrillation persisted after the ambulance staff arrived, survived. Only one of the 740 patients who initially had asystole or electromechanical dissociation survived. Factors associated with a greater chance of ventricular fibrillation occurring were: age less than 71, the arrest being witnessed by a bystander, resuscitation by a bystander, the arrest occurring in a public place, and a response time by the ambulance staff of less than six minutes. For patients found in ventricular fibrillation a shorter response time was associated with improved survival but resuscitation by a bystander was not. Additional skills learnt during extended training were used for 51 of the 65 patients who survived. CONCLUSIONS--Ambulance staff with extended training can save the lives of patients with cardiac arrest due to fibrillation, though asystole and electromechanical dissociation have a poor prognosis and should perhaps receive little attention during extended training.     

Time delays in provision of thrombolytic treatment in six district hospitals. Joint Audit Committee of the British Cardiac Society and a Cardiology Committee of Royal College of Physicians of London.

OBJECTIVE--To measure the delays between onset of symptoms and admission to hospital and provision of thrombolysis in patients with possible acute myocardial infarction. DESIGN--Observational study of patients admitted with suspected myocardial infarction during six months. SETTING--Six district general hospitals in Britain. SUBJECTS--1934 patients admitted with suspected myocardial infarction. MAIN OUTCOME MEASURES--Route of admission to hospital and time to admission and thrombolysis. RESULTS--Patients who made emergency calls did so sooner after onset of symptoms than those who called their doctor (median time 40 (95% confidence interval 30 to 52) minutes v 70 (60 to 90) minutes). General practitioners took a median of 20 (20 to 25) minutes to visit patients, rising to 30 (20 to 30) minutes during 0800-1200. The median time from call to arrival in hospital was 41 (38 to 47) minutes for patients who called an ambulance from home and 90 (90 to 94) minutes for those who contacted their doctor. The median time from arrival at hospital to thrombolysis was 80 (75 to 85) minutes for patients who were treated in the cardiac care unit and 31 (25 to 35) minutes for those treated in the accident and emergency department. CONCLUSION--The time from onset of symptoms to thrombolysis could be reduced substantially by more effective use of emergency services and faster provision of thrombolysis in accident and emergency departments.     

Is the emergency ambulance service abused?

Analysis of 1000 consecutive patients brought to the accident and emergency department of a busy district general hospital by ambulance after emergency "999" telephone calls showed that 51.7% of these journeys were unnecessary. Medical cases accounted for a greater percentage of necessary calls than did trauma and surgical cases. Medical education of the public is essential if the number of these calls is to be cut.     

An Observational Study of Patient Characteristics Associated with the Mode of Admission to Acute Stroke Services in North East,England

Objective

Effective provision of urgent stroke care relies upon admission to hospital by emergency ambulance and may involve pre-hospital redirection. The proportion and characteristics of patients who do not arrive by emergency ambulance and their impact on service efficiency is unclear. To assist in the planning of regional stroke services we examined the volume, characteristics and prognosis of patients according to the mode of presentation to local services.

Study design and setting

A prospective regional database of consecutive acute stroke admissions was conducted in North East, England between 01/09/10-30/09/11. Case ascertainment and transport mode were checked against hospital coding and ambulance dispatch databases.

Results

Twelve acute stroke units contributed data for a mean of 10.7 months. 2792/3131 (89%) patients received a diagnosis of stroke within 24 hours of admission: 2002 arrivals by emergency ambulance; 538 by private transport or non-emergency ambulance; 252 unknown mode. Emergency ambulance patients were older (76 vs 69 years), more likely to be from institutional care (10% vs 1%) and experiencing total anterior circulation symptoms (27% vs 6%). Thrombolysis treatment was commoner following emergency admission (11% vs 4%). However patients attending without emergency ambulance had lower inpatient mortality (2% vs 18%), a lower rate of institutionalisation (1% vs 6%) and less need for daily carers (7% vs 16%). 149/155 (96%) of highly dependent patients were admitted by emergency ambulance, but none received thrombolysis.

Conclusion

Presentations of new stroke without emergency ambulance involvement were not unusual but were associated with a better outcome due to younger age, milder neurological impairment and lower levels of pre-stroke dependency. Most patients with a high level of pre-stroke dependency arrived by emergency ambulance but did not receive thrombolysis. It is important to be aware of easily identifiable demographic groups that differ in their potential to gain from different service configurations.     

Importance of patient selection in evaluating a cardiac ambulance service.

All patients brought to hospital by a special cardiac ambulance were followed up and compared with patients carried by routine ambulances to assess the effectiveness of a cardiac ambulance service. The overall mortality of patients with heart attacks was 51% among those carried by an ordinary ambulance and 40% among those carried by the cardiac ambulance. The apparently low mortality in the latter group was balanced, however, by a high mortality (68%) among patients carried by ordinary ambulances when the cardiac ambulance was available but not used; these patients tended to have a short duration of symptoms and heart attacks away from home, and their ambulance was more often called by a member of the public than a general practitioner. It seems therefore that low-risk cases were inadvertently selected for transport by the cardiac ambulance; such unintentional selection makes it difficult to evaluate a cardiac ambulance service.     

Obstetric flying squad service-a defence.

Eighty-one calls made by the obstetric flying squad in West Berkshire were assessed on the basis of a suggestion that patients would do as well, if not better, if they were brought straight to hospital by ambulance rather than await the arrival of the flying squad. Of the 81 calls, 36 were made to general-practitioner maternity units and 45 were made to patients'' homes. In both groups, the flying squad service was considered to be still of great value. Though slightly slower than an emergency ambulance call, it represents a much safer method of transporting an obstetric patient in an emergency.     

Deputising services: the portsmouth experience.

An analysis of the deputising service in the city of Portsmouth showed that the workload of doctors was not excessive and there was no evidence that the number of calls was higher than in areas where no deputising service exists. Sixty seven per cent of patients were seen within one hour of requesting a call and 93% within two hours. Seven per cent of patients were admitted to hospital and 88% of these were seen within one hour of requesting medical care. Drugs were prescribed at 65% of all contacts between doctor and patient which compares favourably with prescribing rates for consultations in general practice. A notable feature of the Portsmouth scheme is that all subscribers who use the deputising service have to agree to participate as a deputy, with 90% of deputies being practising general practitioners or eligible to be principals in general practice. This has probably conserved costs and hospital resources.     

Accident Flying Squad

This paper describes the organization, evaluation, and costing of an independently financed and operated accident flying squad. 132 accidents involving 302 casualties were attended, six deaths were prevented, medical treatment contributed to the survival of a further four, and the condition or comfort of many other casualties was improved. The calls in which survival was influenced were evenly distributed throughout the three-and-a-half-year survey and seven of the 10 so aided were over 16 and under 30 years of age, all 10 being in the working age group.The time taken to provide the service was not excessive and the expense when compared with the overall saving was very small. The scheme was seen to be equally suitable for basing on hospital or general practice or both, and working as an integrated team with the ambulance service. The use of specialized transport was found to be unnecessary. Other benefits of the scheme included use of the experience of attending accidents to ensure relevant and realistic training for emergency service personnel, and an appreciation of the effect of ambulance design on the patient.     

B.M.A. Deputizing Service in Sheffield, 1970

Seventy-four per cent. of Sheffield general practitioners and 78% of those in Nottingham used a deputizing service in 1970. In each city the deputizing service was used by about 80% of single-handed general practitioners, 90% of doctors in two-doctor practices, and 60% of those in partnerships of three or more.The Sheffield deputizing service handled 15,988 new calls in the year, an average of 106 per subscribing doctor, and in addition made 339 revisits. The median number of calls handled for single-handed doctors was 98, for those in two-doctor practices 95, and for those in partnerships of three or more 75. The growth of group practice has not eliminated the demand for deputizing services.Sixty-six per cent. of consultations were with deputies who were primarily hospital doctors, 20% with a full-time deputy, 11% with deputies who were primarily general practitioners, and 3% with the switchboard staff, who were also trained nurses. The deputies had been qualified, on average, for eight years. Seventy-two per cent. of patients attended were seen within one hour of receipt of the call.Calls handled by the deputizing service represented approximately 1% of all the subscribers'' consultations, 5% of their home visits, and half their calls between midnight and 07.00 hours. At this level of activity the concept of “personal doctoring” was not threatened.     

Confirmation of death.

A working party set up to study the problems surrounding the confirmation of death investigated current practice by means of a questionnaire sent to a random sample of accident and emergency departments in district general hospitals. Of the 38 replying, 24 said that bodies were examined in the ambulance, four in the accident and emergency department, and 10 in both. Answers to the other questions also suggest that the present procedures are in general unsatisfactory, and some dissatisfaction was expressed by departments. The individuals and organisations consulted were unanimous that confirmation of death should not be carried out in the ambulance. A change of practice would, however, create practical problems. The working party recommends therefore that the standard practice should be for all bodies to be properly examined by a doctor in the accident and emergency department, and that funds should be made available for any building alterations and increase in staff made necessary by such changes.     

Management of HIV infected health care workers: lessons from three cases.

Three cases in which doctors in Glasgow were diagnosed as having HIV infection were all handled differently in relation to telling patients and the media. In the first patients were not told because the doctor had been doing administrative work and there was thought to be no risk to patients; although the media did report the case, it accepted the assurances given. In the second case, where a doctor had done many jobs in different specialties and places, the media identified the doctor before most patients had been informed: most calls to the helpline subsequently set up by the health authority were from patients who had not been treated by this doctor. This episode, however, allowed the incident team to be prepared for the next case, enabling the helpline to be established swiftly. In this case the doctor voluntarily identified himself, and this served to allay public fears and reduce the number of inappropriate calls to the helpline.     

Pre-hospital Coronary Care Service

The Dublin cardiac ambulance service operates two specially-equipped ambulances from a private ambulance station; five metropolitan hospitals provide coronary care beds on a rota system. The service covers an area of 450 square miles (1,165 sq km) and a population of 800,000. The ambulances are staffed solely by trained ambulance personnel. During the first three years 1,973 patients were transported to hospital. Primary ventricular fibrillation was encountered in 20 patients and successfully treated in 17. No deaths occurred in the ambulance.Over 98% of the patients were transferred uneventfully to hospital, so a medical team from the hospital on duty was called on 30 occasions only. A feature of the Dublin service is the low cost of a standard ambulance call, at about £7·50.     

Profile of an Accident Flying Squad

An analysis of 184 accident flying squad calls and of 280 patients injured in road accidents and treated by a flying squad based on an accident department inclusive from 1967 to 1971 has shown that such a service can provide an efficient system without disrupting the routine work of the hospital.     

Adolescent self harm patients: audit of assessment in an accident and emergency department.

OBJECTIVE--To examine the assessment of adolescent self harm patients attending an accident and emergency department. DESIGN--Retrospective assessment of case notes. SETTING--Accident and emergency department, Leicester Royal Infirmary. PATIENTS--210 adolescent patients (aged 9-19 years) attending the department during 1 January 1989-31 December 1989 after deliberate self poisoning; records were available for 200. MAIN OUTCOME MEASURES--Numbers of admissions, discharges from department without either a psychiatric consultation or some form of follow up, and discharges with either of these; scoring of adequacy of psychiatric and social assessment by accident and emergency doctor. RESULTS--89 patients were admitted (mean score 5.1, excluding 22 patients too drowsy or unforthcoming for proper assessment), 80 were discharged without specific psychiatric consultation or other follow up (mean score 5.4), and 31 were discharged with psychiatric consultation or other follow up (mean score 9.1). The percentage of patients in each group whose assessment by the accident and emergency doctor was considered to be adequate or better than adequate over 10 headings ranged from 0%-40% for admitted patients, 0%-50% for those discharged without psychiatric assessment, and 0%-61% in the remaining group. Overall, in almost half (49%, 54/111) of all of those discharged documentation of the suicidal state was inadequate. CONCLUSION--The assessment of many adolescent self harm patients in this clinic was unsatisfactory. IMPLICATIONS--Doctors working in accident and emergency departments should be encouraged to liaise with child psychiatrists before discharging such patients.     

Simple training programme for ambulance personnel in the management of cardiac arrest in the community.

The extended training for ambulance personnel in Nottinghamshire includes a period of training in cardiac resuscitation by defibrillation, and defibrillators are now part of the standard equipment of vehicles used on the accident and emergency service. Comparison of recent results with previous attempts in the City of Nottingham to provide a service for out of hospital cardiac arrest has shown that an elementary training course and the provision of defibrillators on emergency vehicles enables the ambulance service to save the lives of a reasonable proportion of those who suffer sudden death in the community. The extended training programme as a whole has proved acceptable to ambulance personnel and we believe that this programme could be the basis for a more widespread introduction of post basic training.     

The Brighton resuscitation ambulances: a continuing experiment in prehospital care by ambulance staff.

Two ambulances from the existing fleet in Brighton and one in Hove are equipped with portable defibrillator-oscilloscope units. Selected attendants have been trained not only to defibrillate patients but also to perform endotracheal intubation and administer intravenous atropine and lignocaine for carefully defined indications. In the two years up to December 1975 the ambulances responded to 2253 calls which were considered possible emergencies. Retrospective analysis showed that half of these had been for patients with myocardial infarction, coronary insufficiency, or angina. The ambulances took a median time of five minutes to reach a patient. Attempts at resuscitation were made in 207 patients with circulatory arrest, of whom 160 had ventricular fibrillation. Coordinated rhythm was restored at least transiently in 66 patients, and 27 of them survived to leave hospital. Sixteen of the survivors had been in ventricular fibrillation before the arrival of the ambulance. The delay before admission to hospital was reduced: over 50% of patients carried in the ambulances were admitted within two hours of the onset of major symptoms. No extra ambulance staff have been employed for the scheme. The increased load on hospital services has been limited by encouraging a rational admission policy and also by early discharge.     

Randomised trial of a mobile coronary care unit for emergency calls.

A randomised trial was conducted to assess the value of sending a mobile coronary care unit (MCCU) to all emergency calls other than those for children or for patients injured in road-traffic accidents or brawls. Over 15 months 6223 calls for emergency ambulances were considered for the study, but a routine ambulance had to be dispatched on 2583 occasions because the MCCU was not available. A group of 1664 patients was randomly allocated to transport by the MCCU and 1676 patients to routine transport. In these groups the prehospital mortality among patients with heart attacks was 45% and 47%, and no patient survived resuscitation attempts long enough to leave hospital. During the same period general practitioners sent 190 patients with heart attacks to hospital in routine ambulances and none of them died during the interval between the call for the ambulance and arrival at hospital. Although it may be worth equipping all emergency ambulances with a defibrillator, MCCUs as at present envisaged will not appreciably affect mortality from heart attacks.