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H Snooks

Publications and source records attributed to H Snooks.

12 recordsLinked to original sources
PubMed2005

Hearing half the message? A re-audit of the care of patients with acute asthma by emergency ambulance crews in London.

PROBLEM: An initial audit of the care provided to emergency asthma patients by the ambulance service was carried out in 1996. Some under-recognition and under-treatment of severe asthma was found as well as a lack of documentation of patient condition on scene. A re-audit was undertaken in 1999. DESIGN: A multidisciplinary advisory group was reconvened. The same method was adopted as for the first audit. Patients included were those administered nebulised salbutamol by crews in the catchment areas of four hospitals and those diagnosed with asthma at the Accident & Emergency (A&E) departments of those hospitals between January and March 1999. SETTING: London Ambulance Service. KEY MEASURES FOR IMPROVEMENT: (1) Accuracy of diagnosis and appropriateness of treatment, and (2) adherence to protocol. STRATEGIES FOR CHANGE: Following the first audit, treatment protocols were widened and brought into line with the British Thoracic Society guidelines for care of acute asthma patients. The results were widely disseminated within the service and training was initiated for all operational staff. EFFECTS OF CHANGE: The number of patients included in the re-audit more than doubled (audit 1: n = 252, audit 2: n = 532). The increase occurred exclusively in those administered nebulised salbutamol by ambulance crews but diagnosed with conditions other than asthma in A&E (audit 1: n = 15, audit 2: n = 161). The proportion of patients diagnosed with asthma in A&E who were administered nebulised salbutamol by their attending crew rose from 58% to 75%. However, 43 asthma patients were not treated; several of these were not recognised as suffering from asthma and others fell within the changed protocols for treatment. Adherence to protocol for administration of salbutamol remained high. Pre-hospital documentation of key observations did not improve. LESSONS LEARNT: Messages from the first audit seem to have been acted upon selectively. Implementing change is complex, and re-audit is necessary to understand the effects of the changes made.

Acute Disease↗
PubMed2004

Results of an evaluation of the effectiveness of triage and direct transportation to minor injuries units by ambulance crews.

OBJECTIVE: To evaluate triage and transportation to a minor injury unit (MIU) by emergency ambulance crews. METHODS: Ambulance crews in two services were asked to transport appropriate patients to MIU during randomly selected weeks of one year. During all other weeks they were to treat such patients according to normal practice. Patients were followed up through ambulance service, hospital and/or MIU records, and by postal questionnaire. Semi-structured interviews were undertaken with crews (n = 15). Cases transferred from MIU to accident and emergency (A&E) were reviewed. RESULTS: 41 intervention cluster patients attended MIU, 303 attended A&E, 65 were not conveyed. Thirty seven control cluster patients attended MIU, 327 attended A&E, 61 stayed at scene. Because of low study design compliance, outcomes of patients taken to MIU were compared with those taken to A&E, adjusted for case mix. MIU patients were 7.2 times as likely to rate their care as excellent (95% CI 1.99 to 25.8). Ambulance service job-cycle time and time in unit were shorter for MIU patients (-7.8, 95% CI -11.5 to -4.1); (-222.7, 95%CI -331.9 to -123.5). Crews cited patient and operational factors as inhibiting MIU use; and location, service, patient choice, job-cycle time, and handover as encouraging their use. Of seven patients transferred by ambulance from MIU to A&E, medical reviewers judged that three had not met the protocol for conveyance to MIU. No patients were judged to have suffered adverse consequences. CONCLUSIONS: MIUs were only used for a small proportion of eligible patients. When they were used, patients and the ambulance service benefited.

Accidents↗
PubMed2004

Safety of telephone consultation for "non-serious" emergency ambulance service patients.

OBJECTIVE: To assess the safety of nurses and paramedics offering telephone assessment, triage, and advice as an alternative to immediate ambulance dispatch for emergency ambulance service callers classified by lay call takers as presenting with "non-serious" problems (category C calls). DESIGN: Data for this study were collected as part of a pragmatic randomised controlled trial reported elsewhere. The intervention arm of the trial comprised nurse or paramedic telephone consultation using a computerised decision support system to assess, triage, and advise patients whose calls to the emergency ambulance service had been classified as "non-serious" by call takers applying standard priority dispatch criteria. A multidisciplinary expert clinical panel reviewed data from ambulance service, accident and emergency department, hospital inpatient and general practice records, and call transcripts for patients triaged by nurses and paramedics into categories that indicated that dispatch of an emergency ambulance was unnecessary. All cases for which one or more members of the panel rated that an emergency ambulance should have been dispatched were re-reviewed by the entire panel for an assessment of the "life risk" that might have resulted. SETTING: Ambulance services in London and the West Midlands, UK. STUDY POPULATION: Of 635 category C patients assessed by nurses and paramedics, 330 (52%) cases that had been triaged as not requiring an emergency ambulance were identified. MAIN OUTCOME MEASURES: Assessment of safety of triage decisions. RESULTS: Sufficient data were available from the routine clinical records of 239 (72%) subjects to allow review by the specialist panel. For 231 (96.7%) sets of case notes reviewed, the majority of the panel concurred with the nurses' or paramedics' triage decision. Following secondary review of the records of the remaining eight patients, only two were rated by the majority as having required an emergency ambulance within 14 minutes. For neither of these did a majority of the panel consider that the patient would have been at "life risk" without an emergency ambulance being immediately dispatched. However, the transcripts of these two calls indicated that the correct triage decision had been communicated to the patient, which suggests that the triage decision had been incorrectly entered into the decision support system. CONCLUSIONS: Telephone advice may be a safe method of managing many category C callers to 999 ambulance services. A clinical trial of the full implementation of this intervention is needed, large enough to exclude the possibility of rare adverse events.

Ambulances↗
PubMed2004

Towards primary care for non-serious 999 callers: results of a controlled study of "Treat and Refer" protocols for ambulance crews.

OBJECTIVE: To develop and evaluate "Treat and Refer" protocols for ambulance crews, allowing them to leave patients at the scene with onward referral or self-care advice as appropriate. METHODS: Crew members from one ambulance station were trained to use the treatment protocols. Processes and outcomes of care for patients attended by trained crews were compared with similar patients attended by crews from a neighbouring station. Pre-hospital records were collected for all patients. Records of any emergency department and primary care contacts during the 14 days following the call were collected for non-conveyed patients who were also followed up by postal questionnaire. RESULTS: Twenty three protocols were developed which were expected to cover over 75% of patients left at the scene by the attending crew. There were 251 patients in the intervention arm and 537 in the control arm. The two groups were similar in terms of age, sex and condition category but intervention cases were more likely to have been attended during daytime hours than at night. There was no difference in the proportion of patients left at the scene in the intervention and control arms; the median job cycle time was longer for intervention group patients. Protocols were reported as having been used in 101 patients (40.2%) in the intervention group; 17 of the protocols were recorded as having been used at least once during the study. Clinical documentation was generally higher in the intervention group, although a similar proportion of patients in both groups had no clinical assessments recorded. 288 patients were left at the scene (93 in the intervention group, 195 in the control group). After excluding those who refused to travel, there were three non-conveyed patients in each group who were admitted to hospital within 14 days of the call who were judged to have been left at home inappropriately. A higher proportion of patients in the intervention arm reported satisfaction with the service and advice provided. CONCLUSIONS: "Treat and Refer" protocols did not increase the number of patients left at home but were used by crews and were acceptable to patients. The protocols increased job cycle time and some safety issues were identified. Their introduction is complex, and the extent to which the content of the protocols, decision support and training can be refined needs further study.

Ambulances↗
PubMed2003

Computer assisted assessment and advice for "non-serious" 999 ambulance service callers: the potential impact on ambulance despatch.

OBJECTIVE: To investigate the potential impact for ambulance services of telephone assessment and triage for callers who present with non-serious problems (Category C calls) as classified by ambulance service call takers. DESIGN: Pragmatic controlled trial. Calls identified using priority dispatch protocols as non-serious were allocated to intervention and control groups according to time of call. Ambulance dispatch occurred according to existing procedures. During intervention sessions, nurses or paramedics within the control room used a computerised decision support system to provide telephone assessment, triage and, if appropriate, offer advice to permit estimation of the potential impact on ambulance dispatch. SETTING: Ambulance services in London and the West Midlands. SUBJECTS: Patients for whom emergency calls were made to the ambulance services between April 1998 and May 1999 during four hour sessions sampled across all days of the week between 0700 and 2300. MAIN OUTCOME MEASURES: Triage decision, ambulance cancellation, attendance at an emergency department. RESULTS: In total, there were 635 intervention calls and 611 controls. Of those in the intervention group, 330 (52.0%) were triaged as not requiring an emergency ambulance, and 119 (36.6%) of these did not attend an emergency department. This compares with 55 (18.1%) of those triaged by a nurse or paramedic as requiring an ambulance (odds ratio 2.62; 95% CI 1.78 to 3.85). Patients triaged as not requiring an emergency ambulance were less likely to be admitted to an inpatient bed (odds ratio 0.55; 95% CI 0.33 to 0.93), but even so 30 (9.2%) were admitted. Nurses were more likely than paramedics to triage calls into the groups classified as not requiring an ambulance. After controlling for age, case mix, time of day, day of week, season, and ambulance service, the results of a logistic regression analysis revealed that this difference was significant with an odds ratio for nurses:paramedics of 1.28 (95% CI 1.12 to 1.47). CONCLUSIONS: The findings indicate that telephone assessment of Category C calls identifies patients who are less likely to require emergency department care and that this could have a significant impact on emergency ambulance dispatch rates. Nurses were more likely than paramedics to assess calls as requiring an alternative response to emergency ambulance despatch, but the extent to which this relates to aspects of training and professional perspective is unclear. However, consideration should be given to the acceptability, reliability, and cost consequences of this intervention before it can be recommended for full evaluation.

Adolescent↗
PubMed2002

Can warfarin be continued during dental extraction? Results of a randomized controlled trial.

A randomized controlled trial was set up to investigate whether patients who were taking warfarin and had an International Normalised Ratio (INR) within the normal therapeutic range require cessation of their anticoagulation drugs before dental extractions. Of 109 patients who completed the trial, 52 were allocated to the control group (warfarin stopped 2 days before extraction) and 57 patients were allocated to the intervention group (warfarin continued). The incidence of bleeding complications in the intervention group was higher (15/57, 26%) than in the control group (7/52, 14%) but this difference was not significant. Two patients in the study required hospital review for bleeding and all other episodes of bleeding were controlled by patients at home. Continuing warfarin when the INR is < 4.1 may lead to an increase in minor post-extraction bleeding after dental extractions but we found no evidence of an increase in clinically important bleeding. As there are risks associated with stopping warfarin, the practice of routinely discontinuing it before dental extractions should be reconsidered.

Acetaminophen↗
PubMed2000

Out-of-hospital intravenous cannulation: the perspective of patients treated by London Ambulance Service paramedics.

OBJECTIVES: Previous research has highlighted concern about infection rates in field-placed intravenous (IV) cannulae. In a study of IV placement by London Ambulance Service (LAS) paramedics, 17% of placements were judged to be inappropriate. Large variations in rates of IV placement between LAS paramedics were found. The authors' hypothesis was that placement of an IV carries disadvantages-pain, discomfort, distress, and infection-which may be unacceptable to patients. METHODS: This was a survey of all patients having an IV placed by LAS paramedics and transported to one of three London emergency departments (EDs) over a three-week period in December 1996. Patients were excluded if they had a self-inflicted injury/illness, were less than 14 years old, had no known address, or were visitors to the UK, or if their family doctor suggested it was not appropriate to contact the patient. Pain, discomfort, and distress; infection; satisfaction; understanding of the reason for cannulation; and out-of-hospital cannula use were all ascertained and analyzed with chi-square analysis. RESULTS: Thirty-nine percent of the respondents experienced some discomfort, 39% some pain, and 17% some distress. No patient reported an infection. Distress was more likely to be reported if there was no understanding of why the IV cannula was placed (chi2 [1] 6.1; p < 0.05). Further unstructured information revealed satisfaction with the IV cannulation and with general care. CONCLUSIONS: Despite the disadvantages of IV placement being reported by some respondents, overall levels of satisfaction were high, suggesting that these disadvantages were not unacceptable to patients. However, in the context of the 24,000 patients cannulated each year by LAS paramedics, "costs" to the patient are considerable.

Adolescent↗
PubMed1996

The cost and effectiveness of the London Helicopter Emergency Medical Service.

OBJECTIVES: To assess the incremental consequences of the London Helicopter Emergency Medical Service (HEMS) for the outcomes of survivors in terms of disability and health status, and cost. METHODS: Prospective comparison of outcomes in cohorts of seriously injured patients attended either by the HEMS or by paramedically crewed land ambulances. In survivors, disability was assessed using an 11-point disability scale, and general health status was measured by the six dimensions of the 100-point Nottingham Health Profile (NHP) assessed 6 months after the injury. Costs were estimated for the HEMS and associated facilities at the Royal London Hospital, and the extra admissions attributable to the HEMS. RESULTS: There was no evidence of reduced disability in HEMS survivors (estimate: +0.8 disability grades worse; 95% CI: 0, 1.6), and no evidence of improvement in the six NHP dimensions scores or in the mean number of problems with seven aspects of daily living (estimated difference: +0.5; 95% CI: -0.2, 1.2). The incremental costs of HEMS were estimated to be 2.0 Pounds million a year. CONCLUSION: As there is no evidence of any improvement in outcomes overall for the extra cost, the HEMS has not been found to be a cost-effective service.

Adolescent↗
PubMedDate not supplied

Appropriateness of intravenous cannulation by paramedics: a London study.

INTRODUCTION: The number of patients undergoing intravenous (IV) cannulation by paramedics has increased dramatically over recent years in the UK. Treatment protocols for cannulation in the field are loosely defined. Variation in practice may lead to patients' receiving differential treatment according to customary practice, rather than according to their clinical conditions. OBJECTIVES: To explore variations in practice and assess level of appropriatenesss of IV cannulation by London Ambulance Service (LAS) paramedics; to revise treatment protocols and work toward clinical guidelines, if indicated by study findings. METHODS: Skill usage data were analyzed for all LAS paramedics for 1995-96. All patients who were IV-cannulated and transported to three hospitals by LAS during March 1996 were identified. A panel of accident and emergency (A&E) and prehospital specialists judged each case for appropriateness. RESULTS: Variation during the year was wide, with a range of 1 to 221 (mean 47) patients cannulated per paramedic, although the majority showed some consistency in frequency of skill usage. A sample of 183 cases was reviewed. The majority judged 149 (81.4%) to be appropriate, although there was considerable disagreement between reviewers (kappa = 0.43, p < 0.001). Data suggested that those paramedics who cannulate more frequently cannulated less appropriately during the study period (lowest 30%: 73.9% appropriate; highest 30%: 45.8% appropriate, p = 0.05). CONCLUSION: Despite wide variation between paramedics, the panel judged overall appropriateness of cannulation to be high. The audit advisory group judged that new clinical guidelines might not achieve an improvement in practice and were not supported by study findings. It was recommended that variations be addressed through individual practice review.

Catheterization↗