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Authors conducted a before and after, retrospective, observational study using anonymised, routinely collected, patient-level data from a single English NHS ED between April 2018 and December 2019. The primary outcomes of interest were the proportion of admitted patients, that is, the admission rate, the length of stay in the ED and ambulance handover times. They used interrupted time series models to study and estimate the impact of removing the 4-hour access standard.

A casually centred proposal identifying how Fire and Rescue Services can improve pre-hospital care and quality of life outcomes for burn survivors.  David Wales and Kristina Stiles have released this report looking at the burn survivor experience in the pre-hospital environment. The work makes ten operational recommendations and also two 'lessons learned' recommendations exploring strategic partnership working and the resulting fragmented services.

NHS England commissioned a limited scope independent review into patient safety concerns and governance processes related to the North East Ambulance Service. Chaired by Dame Marianne Griffiths DBE, the review considered the facts surrounding a number of individual cases, reviewed the processes surrounding coronial investigations and reviewed the seven previous investigations and reviews undertaken by the ambulance service to determine if they were sufficient to fully understand and resolve issues. On 22 May 2022, media coverage in the Sunday Times alleged that the North East Ambulance Service NHS Foundation Trust (NEAS) was covering up evidence in relation to patient deaths and withholding key evidence from Her Majesty’s Coroners (HMC) linked to service failures. The news article made reference to seven incidents and the names of five individuals were included. The report said that families were not always told the full facts of the circumstances surrounding the death of their relatives. In addition, the whistle-blower who reported these concerns to the Sunday Times also alleged that he had raised concerns about patient safety in NEAS a number of times and that he was bullied and victimised as a result of his actions. Some of the concerns raised by the whistle-blower were known in NEAS and the wider NHS system particularly in relation to some specific complaints from families and the robustness of coronial processes and reporting. The alleged incidents took place between December 2018 to December 2019

This interview is part of the hub's 'Frontline insights during the pandemic' series where Martin Hogan interviews healthcare professionals from various specialties to capture their experience and insights during the coronavirus pandemic. Here Martin interviews an advanced specialist paramedic working in central London with four years' experience of working on the frontline. 

Human factors is a scientific discipline which is used to understand the interacting elements and design of a complex system, aimed at improving system performance and optimising human well-being. This book brings together a range of specialist authors to explore some of the key concepts of human factors related to the field of paramedic practice. The system elements of paramedic practice can include the patient, the paramedic and their colleagues, the environment, the equipment, the tasks, and the processes and procedures of the organisation. The relationships between these components are explored in detail through chapters which cover ‘human error’, systems thinking, human-centred design, interaction with the patient, non-technical skills of individuals and teams, well-being of the paramedic, safety culture and learning from events. This helpful and informative guide provides frontline paramedics and ambulance clinicians with practical advice and knowledge of human factors that will be helpful in supporting safe and effective practice for all involved. It will also be of interest to pre-hospital care professionals who are involved in education, learning from events, procurement and influencing safety culture. Above all, it shows how an understanding and application of human factors principles can enhance system performance and well-being, and ultimately lead to safer patient care.

A memoir of the chaos, intensity and occasional beauty of life as a paramedic. Jake Jones has worked in the UK ambulance service for 10 years: every day, he sees a dozen of the scenes we hope to see only once in a lifetime. Can You Hear Me? - the first thing he says when he arrives on the scene - is a memoir of the chaos, intensity and occasional beauty of life on the front-lines of medicine in the UK. As well as a look into dozens of extraordinary scenes - the hoarder who won't move his collection to let his ailing father leave the house, the blood-soaked man who tries to escape from the ambulance, the life saved by a lucky crew who had been called to see someone else entirely - Can You Hear Me? is an honest examination of the strains and challenges of one of the most demanding and important jobs anyone can do.

Coroners have a statutory duty to issue a Prevention of Further Deaths report to any person or organisation where, in the opinion of the coroner, action should be taken to prevent future deaths.  This coroners report relates to the death of 15 year-old Najeeb Katende and the delay in defibrillation due to the equipment being set to manual mode and not detecting his shockable rhythm. The coroner found that the delay in defibrillating Najeeb significantly reduced his chances of survival.

This US-focused article looks at the evolution of the ambulance service and the methods used to try to ensure that supply meets demand.

What impact does working on the frontline in healthcare have on your own mental health? How do you cope with the daily traumatic events you see at work and then go home and care for your family? What happens when you start to feel out of control?  In this blog, a paramedic recounts their feelings and fear when things started to get out of control at work and at home, describing the symptoms of 'moral injury', and how talking openly to colleagues, their line-manager and to a counsellor helped them to recover.   I don’t ‘do’ mental health. Growing up, my family always had a stiff upper lip, told me to "take a breath and get on with it". It was seen very much as a weakness. If I was ever feeling upset about something that had happened at work, they would always retort back with a story far more gruesome and awful than mine. My family are all healthcare professionals. Dinner table talk usually turned to horror stories of car crashes, attempted murders, limbs falling off, wounds and cardiac arrests. Very interesting and often led to great discussions, but didn’t explore how we felt about being involved in the worst days of other peoples' lives. My family spoke of these incidents as if they were viewing through glass, an invisible wall. They distanced themselves. This is how they dealt with the horror of healthcare. From their behaviour and how they dealt with ‘work’, I followed suit. It seemed to work. Something bad would happen – a traumatic cardiac arrest at the roadside, a stabbing of a young man, a four car pile up with three dead at the scene, a murdered child – I would then go back to my family home on days off, have dinner and we would swap stories. We would all try and out do each other, a bit like a game of gruesome top trumps. But I could not brush off what I had seen. I saw the trauma that was inflicted on survivors, the pain people had been through, the raw emotions from other during the worst day of their lives, the conditions people lived in. I was seeing this daily, not once a month or once a year, daily. It was bound to take its toll. All was going well, or so I thought. Until my life got in the way. I have two boys: 13 and 11 years old. Starting out in the world. I have been able to keep them safe; I keep them away from these horrors I see. I have protected them from the society we live in. The knife crime, the drugs, the violence, but as they grow up they have become more independent. They want to go out alone, they mix with other groups of kids I don’t know. No longer can I call the parents of a child I deem ‘suitable’ for a play date. I am relying on my children to make the right choices. I felt out of control. Whereas at work, I am in control. I may not have control about which job I go to, but I have control on how I manage the patient, I have drugs to ease pain and can give immediate treatment. I feel as if I am in a ‘bubble of professionalism’. What happens at work, stays at work (or my parent's dinner table). But here in the real world, there is no bubble. I tried bringing my feelings about the loss of control and fear around bringing up boys in 2020 at the dinner table. "That’s life," announced my dad. "We got through it and you're OK," said mum. And that was that. My feelings were deemed as mundane, not good enough to discuss. Before I knew it, the conversation had moved on to a patient who needed helicoptering off a rugby field with a broken leg. I wasn’t sleeping. I couldn’t concentrate. I had this weird pain in my chest. All I could think of was the safety of my boys. I replayed scenarios of them getting run over, getting into a fight and getting stabbed, being involved in a car crash. I wouldn’t go on unnecessary journeys in case we crashed and they died. I was just about coping with work. I did not have the capacity to take stress from any other angle. So, when I needed to step up to the plate at home, bringing up kids, it was all too much. Getting help I made an appointment with a GP. I’m never ill, so don’t see a regular one. Any GP would do. I wanted some help, but wasn’t sure what help was available. I felt embarrassed about going. I didn’t tell anyone. Once I was in there, I just burst into tears. I’ve seen GPs behind closed doors, people do it all the time. I bet they get sick of it. I was now one ‘of those’ people. She heard my symptoms; she heard the causes. With that she wrote a prescription for Sertraline (a drug for anxiety) and an offer to sign me off sick for 2 weeks and I was out the door with a follow up in 3 weeks. Looks like I am labelled now, and it took less than 10 minutes. Were pills the answer? Surely there are other therapies I could try? I don’t want time off. It won't make it better. After opening up to a colleague at work, it seems myself and my family are suffering with moral injury. The term ‘moral injury’ has been used to describe the psychological effects of ‘bearing witness to the aftermath of violence and human carnage’ (Litz et al., 2009[1]). Carnage sounds like a normal shift to me. The symptoms of moral injury are strongly linked to feelings of guilt and shame and can manifest as social isolation and emotional numbing. This was my mechanism for coping with the stress at work. Numbing the emotions, not allowing my emotions to show themselves in fear that I would not be able to do my job. I’m no good to anyone being a blubbering wreck am I, everyone else is OK, so I must hold it together. Binned the pills I was told about ‘talking therapies’ that my employer can refer me to – for free. I went to my line manager. We spoke at length about how I felt, and she referred me to the talking therapy provided by my Trust. While I waited for the appointment date, I opened up to friends. Found out I am not alone. Seems we are all struggling in different ways. Being able to speak freely with a trained counsellor has really helped. I have strategies to help me with anxiety and stress, I have started the NHS couch to 5K and have started to feel so much better. I have not taken the pills offered by the GP. I’m sure some people need them; I feel I don’t need them at the moment. We know that we need to have more and better conversations about our mental wellbeing, and it is worth thinking about what kinds of conversations might be useful; certainly a game of top trauma trumps isn’t a good idea while eating sausage and mash. It is true what the literature suggests, that paramedics are suffering from increasing rates of post-traumatic stress disorder (PTSD) (Regehr et al., 2002[2]), but it is also true that not all those who are psychologically affected by their work, even in lasting ways, will reach the threshold for a diagnosis of PTSD. Some people will become ill as a result of their work, and some will become distressed; moral injury offers a different way of thinking about the psychological harms that may result from the practice of prehospital and emergency medicine (Murray, 2019[3]). This may give paramedics and other ambulance staff the opportunity to think about the impacts of their work in ways which do not threaten their ability to do it. Ensuring there are opportunities to sit down and talk through their jobs in the course of a working day, or night, could be the best place to start (Murray, 2019[3]). References 1. Litz BT, Stain N, Delaney E et al. Moral injury and moral repair in war veterans: a preliminary model and intervention strategy. Clin Psychol Rev 2009;29(8):695–706. 2. Regehr C, Goldberg G, Hughes J. Exposure to human tragedy, empathy and trauma in ambulance paramedics. Am J Orthopsychiatr 2002;72(4):505–13 3. Murray E . Moral injury and paramedic practice. Journal of Paramedic Practice 2019;1(10).