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The growing demand for prehospital critical care


How are ambulance services in the UK evolving to meet the needs of an NHS under increasing pressure? Michael Smyth, Clinical Research Fellow at WMS, shares his thoughts.

Unlike many other parts of the world, where ambulance services are perceived solely as an emergency service, in the UK, they are recognised as an integral part of the NHS. Despite comprising only a small proportion of the NHS workforce, there are approximately 35,000 registered paramedics in comparison to over 230,000 doctors and 60,0000 nurses. Hardly a day passes without the media reporting on the performance of, or pressures on, NHS Ambulance Services.

In part, this is because demand for ambulance services is growing rapidly. In 2015-16 the number of calls to ambulance services exceeded 10.7 million, up from 7.9 million in 2009-10. Contributing factors include an ageing population, increasing mental health issues, availability of primary care services and alcohol-related concerns. In response to the changing patterns of patient demand, epidemiology and wider social changes, ambulance services are evolving. Rapidly.

Public expectation that ambulance services can respond to an ever-increasing range of clinical presentations of increasing complexity, is forcing ambulance services to recognise that is simply not possible to train all paramedics, to manage the entire range of cases they may encounter, and at the same time ensure their continuing competence. As in other areas of health care practice, this has led to the development of areas of specialist practice.

A clear example of the evolution of specialist paramedic practice within the NHS is the development of critical care paramedics alongside regional trauma networks. Centralising specialist trauma services, to ensure all required specialities are available at a single hospital site, concentrates expertise, leads to improved patient outcomes and is cost effective. However, ensuring victims of major trauma receive optimal prehospital care and are transported to the most appropriate hospital presents unique challenges.

Regionalisation of trauma services means critically injured patients often need to travel extended distances to reach the major trauma centres. The most severely injured patients frequently require advanced treatments, including surgical interventions, administration of blood products or delivery of an anaesthetic, before arriving at hospital. Traditional paramedics cannot provide this level of care at present. Specialist prehospital critical care teams are central to delivering this level of care.

There are several challenges to delivering prehospital critical care. Many might assume the training to undertake such a role focuses on in-depth understanding of pathophysiology and delivery of advanced interventions, however this is not the most important element of such training. Human factors, team working, effective communication and managing a chaotic environment are the key skills to be developed within prehospital critical care teams.

Delivery of prehospital critical care requires a multidisciplinary team, comprising a suitably trained and experienced doctor, a critical care paramedic (or prehospital critical care nurse), ambulance paramedics, ambulance technicians, often police or fire service colleagues and potentially community first responders. Although the doctor leading the critical care team is ultimately responsible for the treatments delivered at the roadside, they depend upon the members of the team to deliver critical care. It is never a one-man-show! The doctor and critical care paramedic co-ordinate the delivery of care, delegating appropriate tasks to other members of the team in line with their respective skill sets. This delegation enables the critical care team to focus on specific interventions, requiring specialist knowledge.

Development of the critical care practitioner to include human factors, team working, and broad knowledge of specialist practice such as acute mental health crises, major incident response ensures that they are able to play a much wider role in supporting areas of specialist ambulance practice, including emergency preparedness, Medical Emergency Response Incident Team (MERIT) functions, Helicopter Emergency Medical Services (HEMS), logistic management and co-ordination of specialist resources, provision of clinical support and advice for non-specialist practitioners as well as potential roles in education.

A well developed, highly skilled and motivated workforce helps to ensure that ambulance services can adapt to future challenges, and are able to meet the needs of the most seriously ill or injured patients. The postgraduate certificate in prehospital critical care offered by Warwick Medical School helps to prepare clinicians from all health care backgrounds to work in this highly-specialised area of practice.