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We lead multidisciplinary applied research and training to rethink the way health care is delivered in general practice and across the community.
Bronchial obstruction due to respiratory mucosal sloughing in toxic epidermal necrolysis
A 17 year old woman is described who nearly asphyxiated because of sloughing of the bronchial mucosa as a result of toxic epidermal necrolysis. Bronchoscopic aspiration of bronchial slough proved life saving.
Randomised cross-over comparison of five inhaler systems for bronchodilator therapy
The pharmacological efficacy of β-2 agonists such as bronchodilators is well established, yet many patients fail to obtain optimum benefit from conventional metered-dose inhalers. This is usually because of difficulty in achieving adequate co-ordination between activation of the aerosol and inhalation. To some extent this problem can be alleviated by detailed personal instruction and re-instruction, but the medical or paramedical staff needed to do this may be unavailable and in any case their time is expensive. To increase the benefit obtained from bronchodilators, therefore, pharmaceutical companies have produced a variety of devices, eg, large-volume (750 ml) spacers (Nebuhaler, Volumatic) which enclose a cloud of aerosol, obviating the need for actuation-inhalation co-ordination, and breath actuated dry-power inhalers with (Rotahaler, Diskhaler) or without (Turbohaler) carrier powders. Subsequent compliance with treatment is dependent upon the acceptability of the inhaler device to the patient.
Collecting, communicating and using information: the educational issues. A report from the Royal College of Physicians Committee on Medical Information Technology.
Few of the major advances in information science and technology have yet been successfully introduced in health care. Their implementation could improve both quality of care and the working environment of clinicians, but this will not be achieved by investing in hardware and software alone. Investment in education is also required.
Effect of intermaxillary fixation on pulmonary function
A study to measure the pulmonary effects of intermaxillary fixation (IMF) demonstrated that this technique produces a significant degree of airway obstruction. This may be dangerous to patients with limited respiratory reserve due to chronic obstructive airways disease. The impairment of pulmonary function can be assessed pre-operatively and should be estimated in high risk patients. Alternative management of stabilization of jaw fractures that avoid IMF should be considered in such patients. © 1990 Munksgaard International Publishers Ltd.
A realist review of acute pain management in children and young people attended by ambulance
Acute pain management in children and young people (CYP) attended by ambulance services is a significant challenge due to the complex nature of pain, the variation of approach needed across the age range, and the unpredictability of the environment. We aimed to understand how ambulance clinicians can provide improved prehospital acute pain management for CYP. A realist review was conducted and reported in accordance with the Realist And Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) guidance. We developed an initial programme theory (PT) using key stakeholder input, searched the major bibliographic databases MEDLINE, CINAHL Complete and PsycINFO, and other sources from January 2000 to February 2024, screened and assessed relevance and rigour in duplicate, and performed synthesis and programme theory refinement. We developed an initial PT that focussed on the preparedness of staff and the expectations of CYP and parents/carers, along with key outcomes such as pain score severity, fear and anxiety. The subsequent search strategy yielded 1503 documents, of which 95 were included, representing empirical research articles, reviews, theses, book chapters and clinical guidelines. The initial PT was tested and refined throughout the synthesis to produce a PT underpinned by 34 context-mechanism-outcome configurations. The PT portrayed positive (e.g. presence of parents, focussed education and training, building trust) and negative (e.g. misinformation, fear and anxiety, long-term consequences) effects on prehospital acute pain management for CYP. This PT was mapped to the Behaviour Change Wheel to provide a clinically relevant behaviour change model for improvement. This realist review has provided a clinically focussed model to guide the improvement of prehospital acute pain management in children and young people attended by ambulance. The programme theory lays a foundation on which future empirical testing can be conducted to effect behaviour change in practice. Registration: CRD42024505978.
Pre-hospital mixed methods research: An updated methodological review
Mixed methods research, a methodology that integrates both qualitative and quantitative data in order to gain a more comprehensive understanding through drawing upon the strengths of each method, is increasingly used in the pre-hospital context. Despite its growing prevalence, little is known about how mixed methods research is conducted and reported in this unique setting. This methodological review builds on our prior systematic review and examines mixed methods studies in the pre-hospital context, mapping and describing how mixed methods research is conducted and reported. We searched MEDLINE, CINAHL Complete, Embase and Scopus bibliographic databases from 1 January 2012 to 3 June 2025, using an updated pre-hospital search strategy. Study screening was undertaken in duplicate. Articles reported in English, explicitly stating the use of ‘mixed methods’ in the pre-hospital ambulance setting were included, Data related to underpinning philosophical or theoretical framework, rationale for utilising mixed methods, background of the corresponding author, mode of data integration, model of publication and adherence to reporting standards, utilising the good reporting of a mixed methods study (GRAMMS) guidelines, was extracted and analysed. A range of pre-hospital mixed methods research was identified (n = 110). Reporting standards varied, with some studies demonstrating strong integration of qualitative and quantitative data, while others lacked clarity in methodological rationale. Diversity in subject and design reflects the need for flexibility in dynamic pre-hospital environments. This methodological review highlights opportunities for improvement in mixed methods research in pre-hospital care. While the approach supports comprehensive inquiry, it is largely not underpinned by philosophical frameworks which may support methodological rigour. In many cases, mixed methods research in the pre-hospital context is used for practical reasons, and the influence of the pre-hospital setting is observed in adaptable methodologies and a diverse range of subject matter. Our findings offer new insights and guidance for future research design and reporting in this field.
Using realist approaches to explain and understand the optimal use of paramedics in primary care
Paramedics, with their generalist clinical background acquired from ambulance service experience, are increasingly employed in primary care. However, the specific contribution paramedics can offer to the primary care workforce has not been distinctly outlined. This thesis aims to address this uncertainty, employing realist approaches to construct a programme theory. This theory is derived from evidence gathered through five interconnected studies, enriched by active involvement and engagement with stakeholders, patients, and the public. An exploratory systematic review of the literature published in the United Kingdom (UK) identified gaps in the evidence base on the subject and enabled the production of an initial programme theory. This initial programme theory was refined following a broader realist review, which included a range of document sources across a global scale, and integration with key substantive theories. Realist evaluation unfolded in three consecutive phases, each contributing to the refinement of the middle-range program theory: - In Phase I, a mixed-methods cross-sectional survey of paramedics in primary care in the UK was conducted to comprehend the existing practices of paramedics within the NHS. - Phase II involved an analytic auto-netnography, where the DPhil student observed online conversations among paramedics in primary care. This exploration aimed to understand paramedics' perceptions of their role and provided a unique perspective for the student as a practitioner-researcher. - Phase III utilised focused observations and interviews to delve into the impact of paramedics on the primary care workforce. This comparative study collected data from sixty participants across fifteen sites in the UK, and twelve participants across three sites in a specific region in Canada. The culmination of findings from each phase led to the development of a final programme theory, encompassing three conceptual categories: Expectations associated with paramedics in primary care, the transition of paramedics into primary care roles, and the roles and responsibilities of paramedics in primary care. Based on the evidence generated, there are four key recommendations regarding how paramedics work in primary care: 1. A clear strategy for communication of the paramedic’s role in primary care 2. Developing a comprehensive curriculum framework for paramedics in primary care 3. The need for an effective transition support structure 4. Changes to legislation and policy Addressing these recommendations on education, implementation and policy adjustments would likely enable paramedics optimise their contribution to primary care teams.
improving Pain mAnagement for childreN and young people attendeD by Ambulance (PANDA): protocol for a realist review.
Background: Each year in England, 450,000 children and young people (CYP) under 18 years of age are transported by ambulance to emergency departments. Approximately 20% of these suffer acute pain caused by illness or injury. Pain is a highly complex sensory and emotional experience. The intersection between acute pain, unwell CYP and the unpredictable pre-hospital environment is convoluted. Studies have shown that prehospital pain management in CYP is poor, with 61% of those suffering acute pain not achieving effective pain relief (abolition or reduction of pain score by 2 or more out of 10) when attended by ambulance. Consequences of poor acute pain management include altered pain perception, post-traumatic stress disorder and the development of chronic pain. This realist review will aim to understand how ambulance clinicians can provide improved prehospital acute pain management for CYP. Methods: A realist review will be conducted in accordance with the Realist And Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) guidance. A five-stage approach will be adopted; 1) Developing an Initial Programme Theory (IPT): develop an IPT with key stakeholder input and evidence from informal searching; 2) Searching and screening: conduct a thorough search of relevant research databases and other literature sources and perform screening in duplicate; 3) Relevance and rigour assessment: assess documents for relevance and rigour in duplicate; 4) Extracting and organising data: code relevant data into conceptual “buckets” using qualitative data analysis software; and 5) Synthesis and Programme Theory (PT) refinement: utilise a realist logic of analysis to generate context-mechanism-outcome configurations (CMOCs) within and across conceptual “buckets”, test and refine the IPT into a realist PT. Conclusion: The realist PT will enhance our understanding of what works best to improve acute prehospital pain management in CYP, which will then be tested and refined within a realist evaluation. Registration: PROSPERO Registration: CRD42024505978
The need for translational bioethics within perinatal healthcare and policy making: A COVID-19 case study
The COVID-19 pandemic highlighted many issues that can occur due to lack of translation between the spheres of bioethics and clinical practice. In this paper, we examine how mothers and newborn infants were inappropriately separated during the initial stages of the pandemic due to inconsistent application of ethical principles in determining policy. One of the significant challenges that translational bioethics face is the complexity regarding its implementation into the health service environment. As outlined in the literature, it may be postulated that responsibility for translating bioethics from philosophical concepts into practice is the duty of those training in philosophical theory and reasoning. However, the use of bioethics in informing clinical practice is not just the case of needing a translator but rather requires an interpreter in the widest sense: professionals attuned to both bioethics and clinical practice, who can communicate with both groups effectively. A two-way dialogue needs to be more cohesively established to ensure clinical practice is guided by ethical principles and to focus academic debate towards the pragmatic issues that require ethical exploration. Utilising the translational bioethics model described by Bærøe and applying it to our perinatal COVID case study, we examine how an integrated translational bioethics approach could have prevented the harm and disruption to mother–infant dyads during the initial phase of the pandemic in 2020.
Addressing the challenges facing the paramedic profession in the United Kingdom
Background: The paramedic profession within the United Kingdom has been evolving at pace over the last 20 years. While they are most associated with their work in ambulance services, paramedics are now found throughout a range of clinical and academic settings. Sources of data: Literature Review. Areas of agreement: Despite emergence of the paramedic across the healthcare workforce, the understanding and awareness of the professional role and capabilities is poor. This could be due to a lack of representation within senior leadership roles and within health and social care policy. Areas of controversy: Understanding of the paramedic professional identity, from a philosophical and sociological perspective, remains incomplete. Growing points: A challenge for the future is to explore how the paramedic role can continue to develop across a range of clinical settings, while retaining its sui generis professional identity. Areas timely for developing research: Research to establish perspectives of and about the paramedic profession may assist in developing an understanding of identity and its place within the wider healthcare workforce.
The advantages and challenges experienced with the implementation and delivery of community paramedicine programmes: A qualitative reflexive thematic analysis
Objective: This study aims to investigate the experiences of individuals involved in implementing and delivering community paramedicine programmes across several different regions internationally, in order to identify key themes that can inform ongoing development and introduction of community paramedicine programmes. Methods: In this study, participants were enlisted through convenience sampling and a snowballing method. They responded to a custom survey emphasising open-ended responses. We employed a qualitative reflexive thematic analysis, utilising an inductive coding technique at the semantic/explicit level. This approach allowed us to discern themes from the participants’ accounts of the programme's implementation and delivery, along with their perceptions of its strengths and challenges. Results: Data was collected from 29 participants engaged in the development or delivery of community paramedicine programmes spanning seven countries. Five themes were created: (1) community drives the need, which emphasises the importance of community engagement and flexible response to health needs; (2) working with others, which underscores the necessity of collaboration with stakeholders for integration and relationship maintenance; (3) promotion and communication, focusing on clarifying roles and countering misconceptions; (4) recruitment and support of community paramedics, highlighting the significance of experienced paramedic recruitment and providing support for staff retention; and (5) research and evaluation, stressing the importance of data sharing for patient care and programme evaluation. These themes demonstrate the significance of community-centred approaches, interprofessional practice, and programme evaluation in community paramedicine. Conclusion: This study highlights the significance of community-centred approaches, interprofessional practice, and programme evaluation in community paramedicine. These findings can inform policymakers and practitioners in the development and implementation of community paramedicine programmes, ultimately improving the health and well-being of communities across different regions internationally.
The development of community paramedicine; a restricted review
Community paramedic roles are expanding internationally, and no review of the literature could be found to guide services in the formation of community paramedicine programmes. For this reason, the aim of this restricted review was to explore and better understand the successes and learnings of community paramedic programmes across five domains being; education requirements, models of delivery, clinical governance and supervision, scope of roles and outcomes. This restricted review was conducted by searching four databases (CENTRAL, ERIC, EMBASE, MEDLINE and Google Scholar) as well as grey literature search from 2001 until 28/12/2021. After screening, 98 articles were included in the narrative synthesis. Most studies were from the USA (n = 37), followed by Canada (n = 29). Most studies reported on outcomes of community paramedicine programmes (n = 50), followed by models of delivery (n = 28). The findings of this review demonstrate a lack of research and understanding in the areas of education and scope of the role for community paramedics. The findings highlight a need to develop common approaches to education and scope of role while maintaining flexibility in addressing community needs. There was an observable lack of standardisation in the implementation of governance and supervision models, which may prevent community paramedicine from realising its full potential. The outcome measures reported show that there is evidence to support the implementation of community paramedicine into healthcare system design. Community paramedicine programmes result in a net reduction in acute healthcare utilisation, appear to be economically viable and result in positive patient outcomes with high patient satisfaction with care. There is a developing pool of evidence to many aspects of community paramedicine programmes. However, at this time, gaps in the literature prevent a definitive recommendation on the impact of community paramedicine programmes on healthcare system functionality.
Designing and implementing an educational framework for advanced paramedic practitioners rotating into primary care in North Wales
Background: Rotational working has been offered as a solution to bridge the retention crises faced by ambulance services in the United Kingdom due to the inception of paramedics working in primary care. One project in North Wales examines the viability of rotating Advanced Paramedic Practitioners employed by Welsh Ambulance Services NHS Trust into primary care. As part of this project, an educational framework was developed to prepare and support Advanced Paramedic Practitioners in the provision of clinical care in primary care settings. This educational framework was evaluated to determine how it supported the development of Advanced Paramedic Practitioners in the primary care setting. Methods: Semi-structured focus groups were undertaken with Advanced Paramedic Practitioners (n = 7) and GP trainers (n = 4). Outcome: A narrative analysis of the information collected highlighted three overarching themes concerning the need for clinical supervision and feedback in primary care, and the usefulness of the education framework in regard to a tailored curriculum and recording progression. Discussion: Despite the upcoming workforce changes, there is currently no standard education framework to support the development of Advanced Paramedic Practitioners in primary care. This evaluation offers insight into the educational needs of Advanced Paramedic Practitioners working in this setting and suggests an education structure that can best support their learning, whilst meeting regulatory requirements for paramedic professional development. Formal research is required to determine any link between provision of education for Advanced Paramedic Practitioners in primary care and patient outcome and safety.