Craig Mortimer

Purpose: In 2010, the Global Strategy for Asthma Management and Prevention recommended reducing the reliance on treating acute asthma exacerbations with short-acting β₂ agonists (SABAs) given potential adverse effects. However, more than a decade later, SABAs, particularly nebulised salbutamol, remain at the forefront of acute asthma care. This study examined the physiological effects of nebulised salbutamol in patients experiencing moderate to severe asthma exacerbations. Methods: A six month, prospective and retrospective observational study was undertaken involving prehospital asthma patients treated with nebulised salbutamol. Data were analysed using descriptive and inferential statistics, including paired comparisons and exploratory subgroup analyses, to identify relevant trends and variability. Results: Among 176 eligible patients, reductions were observed in heart rate (mean − 3 beats/min) and respiratory rate (mean − 5 breaths/min), with modest improvement in peripheral oxygen saturation (+2%). Capillary blood glucose (CBG) analysis was conducted on a small prospective subgroup (n=8). A mean increase of +0.375 mmol/L was observed. When one clinically atypical outlier was excluded (n=7), the increase reached statistical significance. Albeit interpretation is limited by the small sample size. Conclusion: Administration of ≥ 5mg nebulised salbutamol in acute asthma exacerbations was transiently associated with improved peripheral oxygen saturation and respiratory parameter changes during the prehospital treatment period. No clinically significant increase in heart rate was observed overall. A small rise in CBG was observed in a small prospectively monitored subgroup. However, the clinical significance of this finding remains uncertain. Larger, adequately powered prospective studies are required to confirm these findings. The present findings are insufficient to recommend changes to current glucose monitoring practices in non-diabetic patients.

Some text in this abstract and article has been reproduced from Taylor et al. (Taylor C, Ollis L, Lyon RM, Williams J, Skene SS, Bennett K, et al.; SEE-IT Trial Group. The SEE-IT Trial: emergency medical services Streaming Enabled Evaluation In Trauma: a feasibility randomised controlled trial. Scand J Trauma Resusc Emerg Med 2024;32:7). This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: https://creativecommons.org/licenses/by/4.0/. The text below includes minor additions and formatting changes to the original text. Background: The use of bystander video livestreaming from scene in emergency medical services is becoming increasingly common to inform decisions about the resources and support required. Possible benefits include clinical and financial gains, but evidence is sparse. We aimed to investigate the feasibility of conducting a definitive randomised controlled trial of its use in major trauma incidents. Objectives: To obtain data required to design a subsequent randomised controlled trial. To test trial processes. To embed a process evaluation. Design: A feasibility randomised controlled trial with embedded process and economic evaluations where working shifts (n = 62) in 6 trial weeks were randomised 1 : 1 to video livestreaming or standard care only; and two observational substudies: (1) assessment of acceptability in a diverse inner-city emergency medical service that routinely uses video livestreaming; and (2) assessment of staff well-being in an emergency medical service that does not use livestreaming (for comparison to the trial site). Qualitative data collection included observations (286 hours) and interviews with staff (n = 25) and bystander callers (n = 2). Setting: A pre-hospital emergency medical service in South-East England, with follow-up in associated major trauma centres and trauma units; substudies in (1) London and (2) East of England emergency medical services. Participants: (1) Patients involved in trauma incidents (n = 269); (2) bystander callers (n = 11); and (3) ambulance service staff (n = 67). Intervention: Video livestreaming using GoodSAM’s Instant-On-Scene. Main outcome measures: Progression to a definitive randomised controlled trial based on four pre-defined criteria and consideration of qualitative data: (1) ≥ 70% bystanders with smartphones agreeing and able to activate livestreaming; (2) ≥ 50% requests to activate livestreaming resulting in footage being viewed; (3) helicopter emergency medical services stand-down rate reducing by ≥ 10% due to livestreaming; and (4) no evidence of psychological harm to bystanders or staff caused by livestreaming. Results: Sixty-two shifts were randomised, contributing 240 eligible incidents (132 control; 108 intervention). In a further three shifts, we randomised by individual call, which contributed four eligible incidents (two control; two intervention), thereby totalling 244 incidents involving 269 patients. Video livestreaming was successful in 53 incidents in the intervention arm. Patient recruitment (to access medical records to assess appropriateness of dispatch) and bystander recruitment (to measure potential harm) were both low (58/269, 22% of patients, 4/244, 2% of bystanders). Two progression criteria were met: (1) 86% of bystanders with smartphones agreed and were able to activate livestreaming; (2) 85% of requests to activate livestreaming resulted in viewed footage; and two were indeterminate due to insufficient data: (3) 2/6 (33%) stand-down due to livestreaming; and (4) no evidence of psychological harm from survey, observations or interviews. In substudy (i), dispatch staff reported that non/limited English language and older age may present barriers to video livestreaming. Limitations: Poor recruitment of patients and bystanders limited assessment of appropriateness of dispatch decisions and potential psychological harm. Conclusions: Video livestreaming is feasible to implement, acceptable to both bystanders and dispatchers, and may aid dispatch decision-making, but further assessment of benefits and harm is required. Future work: Findings support the design and conduct of a future multicentre study taking account of different triage systems and dispatch personnel, potentially using an alternative to a randomised controlled trial due to rapid uptake of video livestreaming in this setting. Funding: This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme as award number NIHR130811.

Background: Ambulance services treat over 32,000 patients sustaining an out-of-hospital cardiac arrest annually, receiving over 90,000 calls. The definitive treatment for out-of-hospital cardiac arrest is defibrillation. Prompt treatment with an automated external defibrillator can improve survival significantly. However, their location in the community limits opportunity for their use. There is a requirement to identify the optimal location for an automated external defibrillator to improve out-of-hospital cardiac arrest coverage, to improve the chances of survival. Methods: This was a secondary analysis of data collected by the Out-of-Hospital Cardiac Arrest Outcomes registry on historical out-of-hospital cardiac arrests, data held on the location of automated external defibrillators registered with ambulance services, and locations of points of interest. Walking distance was calculated between out-of-hospital cardiac arrests, registered automated external defibrillators and points of interest designated as potential sites for an automated external defibrillator. An out-of-hospital cardiac arrest was deemed to be covered if it occurred within 500 m of a registered automated external defibrillator or points of interest. For the optimisation analysis, mathematical models focused on the maximal covering location problem were adapted. A de novo decision-analytic model was developed for the cost-effectiveness analysis and used as a vehicle for assessing the costs and benefits (in terms of quality-adjusted life-years) of deployment strategies. A meeting of stakeholders was held to discuss and review the results of the study. Results: Historical out-of-hospital cardiac arrests occurred in more deprived areas and automated external defibrillators were placed in more affluent areas. The median out-of-hospital cardiac arrest – automated external defibrillator distance was 638 m and 38.9% of out-of-hospital cardiac arrests occurred within 500 m of an automated external defibrillator. If an automated external defibrillator was placed in all points of interests, the proportion of out-of-hospital cardiac arrests covered varied greatly. The greatest coverage was achieved with cash machines. Coverage loss, assuming an automated external defibrillator was not available outside working hours, varied between points of interest and was greatest for schools. Dividing the country up into 1 km² grids and placing an automated external defibrillator in the centre increased coverage significantly to 78.8%. The optimisation model showed that if automated external defibrillators were placed in each points-of-interest location out-of-hospital cardiac arrest coverage levels would improve above the current situation significantly, but it would not reach that of optimisation-based placement (based on grids). The coverage efficiency provided by the optimised grid points was unmatched by any points of interest in any region. An economic evaluation determined that all alternative placements were associated with higher quality-adjusted life-years and costs compared to current placement, resulting in incremental cost-effectiveness ratios over £30,000 per additional quality-adjusted life-year. The most appealing strategy was automated external defibrillator placement in halls and community centres, resulting in an additional 0.007 quality-adjusted life-year (non-parametric 95% confidence interval 0.004 to 0.011), an additional expected cost of £223 (non-parametric 95% confidence interval £148 to £330) and an incremental cost-effectiveness ratio of £32,418 per quality-adjusted life-year. The stakeholder meeting agreed that the current distribution of registered publicly accessible automated external defibrillators was suboptimal, and that there was a disparity in their location in respect of deprivation and other health inequalities. Conclusions: We have developed a data-driven framework to support decisions about public-access automated external defibrillator locations, using optimisation and statistical models. Optimising automated external defibrillator locations can result in substantial improvement in coverage. Comparison between placement based on points of interest and current placement showed that the former improves coverage but is associated with higher costs and incremental cost-effectiveness ratio values over £30,000 per additional quality-adjusted life-year. Study registration: This study is registered as researchregistry5121. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR127368) and is published in full in Health and Social Care Delivery Research; Vol. 13, No. 5. See the NIHR Funding and Awards website for further award information.

This article consists of a citation of a published article describing research funded by the Health and Social Care Delivery Research programme under project number NIHR130811, and is provided as as part of the complete record of research outputs for this project. The original publication is available at: https://doi.org/10.1186/s13049-024-01179-0 Background: Use of bystander video livestreaming from scene to Emergency Medical Services (EMS) is becoming increasingly common to aid decision making about the resources required. Possible benefits include earlier, more appropriate dispatch and clinical and financial gains, but evidence is sparse. Methods: A feasibility randomised controlled trial with an embedded process evaluation and exploratory economic evaluation where working shifts during six trial weeks were randomised 1:1 to use video livestreaming during eligible trauma incidents (using GoodSAM Instant-On-Scene) or standard care only. Pre-defined progression criteria were: (1) ≥ 70% callers (bystanders) with smartphones agreeing and able to activate live stream; (2) ≥ 50% requests to activate resulting in footage being viewed; (3) Helicopter Emergency Medical Services (HEMS) stand-down rate reducing by ≥ 10% as a result of live footage; (4) no evidence of psychological harm in callers or staff/dispatchers. Observational sub-studies included (i) an inner-city EMS who routinely use video livestreaming to explore acceptability in a diverse population; and (ii) staff wellbeing in an EMS not using video livestreaming for comparison to the trial site. Results: Sixty-two shifts were randomised, including 240 incidents (132 control; 108 intervention). Livestreaming was successful in 53 incidents in the intervention arm. Patient recruitment (to determine appropriateness of dispatch), and caller recruitment (to measure potential harm) were low (58/269, 22% of patients; 4/244, 2% of callers). Two progression criteria were met: (1) 86% of callers with smartphones agreed and were able to activate livestreaming; (2) 85% of requests to activate livestreaming resulted in footage being obtained; and two were indeterminate due to insufficient data: (3) 2/6 (33%) HEMS stand down due to livestreaming; (4) no evidence of psychological harm from survey, observations or interviews, but insufficient survey data from callers or comparison EMS site to be confident. Language barriers and older age were reported in interviews as potential challenges to video livestreaming by dispatchers in the inner-city EMS. Conclusions: Progression to a definitive RCT is supported by these findings. Bystander video livestreaming from scene is feasible to implement, acceptable to both 999 callers and dispatchers, and may aid dispatch decisionmaking. Further assessment of unintended consequences, benefits and harm is required. Trial registration: ISRCTN 11449333 (22 March 2022). https://www.isrctn.com/ISRCTN11449333 Funding: This publication was funded by the Health and Social Care Delivery Research programme as a part of award number NIHR130811. This article reports on one component of the research award Emergency medical services Streaming Enabled Evaluation In Trauma: The SEE-IT trial. For more information about this research please view the award page [https://fundingawards.nihr.ac.uk/award/NIHR130811] DOI: https://doi.org/10.1186/s13049-024-01179-0

This article consists of a citation of a published article describing research funded by the Health and Social Care Delivery Research programme under project number NIHR130811, and is provided as as part of the complete record of research outputs for this project. The original publication is available at: https://doi.org/10.1186/s12873-024-01015-9 Background: Timely dispatch of appropriate emergency medical services (EMS) resources to the scene of medical incidents, and/or provision of treatment at the scene by bystanders and medical emergency lay callers (referred to as ‘callers’ in this review) can improve patient outcomes. Currently, in dispatch systems worldwide, prioritisation of dispatch relies mostly on verbal telephone information from callers, but advances in mobile phone technology provide means for sharing video footage. This scoping review aimed to map and identify current uses, opportunities, and challenges for using video livestreaming from callers’ smartphones to emergency medical dispatch centres. Methods: A scoping review of relevant published literature between 2007 and 2023 in the English language, searched within MEDLINE; CINAHL and PsycINFO, was descriptively synthesised, adhering to the PRISMA extension for scoping reviews. Results: Twenty-four articles remained from the initial search of 1,565 articles. Most studies were simulation-based and focused on emergency medical dispatchers’ (referred to as ‘dispatcher/s’ in this review) assisted video cardiopulmonary resuscitation (CPR), predominantly concerned with measuring how video impacts CPR performance. Nine studies were based on real-life practice. Few studies specifically explored experiences of dispatchers or callers. Only three articles explored the impact that using video had on the dispatch of resources. Opportunities offered by video livestreaming included it being: perceived to be useful; easy to use; reassuring for both dispatchers and callers; and informing dispatcher decision-making. Challenges included the potential emotional impact for dispatchers and callers. There were also concerns about potential misuse of video, although there was no evidence that this was occurring. Evidence suggests a need for appropriate training of dispatchers and video-specific dispatch protocols. Conclusion: Research is sparse in the context of video livestreaming. Few studies have focussed on the use of video livestreaming outside CPR provision, such as for trauma incidents, which are by their nature time-critical where visual information may offer significant benefit. Further investigation into acceptability and experience of the use of video livestreaming is warranted, to understand the potential psychological impact on dispatchers and callers. Keywords: EMERGENCY MEDICAL DISPATCH, EMERGENCY MEDICAL SERVICES, VIDEO LIVESTREAMING, CALLERS, SMARTPHONE, REVIEW Funding: This publication was funded by the Health and Social Care Delivery Research programme as a part of award number NIHR130811. This article reports on one component of the research award Emergency medical services Streaming Enabled Evaluation In Trauma: The SEE-IT trial. For more information about this research please view the award page [https://fundingawards.nihr.ac.uk/award/NIHR130811] DOI: https://doi.org/10.1186/s12873-024-01015-9

The heterogeneous nature of asthma results in a wide range of presentations during exacerbation. Despite UK pre-hospital management guidelines focusing on β₂ agonists, variables such as cause, severity, underlying health, comorbidities, and drug side effects can often make emergency treatment optimisation difficult. This article examines paramedics’ methods of observing, perceiving, interpreting, and treating asthma with β₂ agonists, often acting on limited information in rapidly evolving situations. We recruited paramedics from a single UK National Health Service ambulance Trust for qualitative semi-structured interviews. Responses underwent framework analysis to identify data similarities and differences. Fifteen qualitative interviews with paramedics revealed three main themes affecting patient management: clinician experience of presentation, adaptation of patient management approaches, and severity of side effects. Paramedics felt their ability to manage various asthma presentations was enhanced through guideline adaptation based on their own clinical experience and understanding of β₂ agonist side effects, allowing tailored responses based on a set of reinforcing factors. Inductive analysis revealed additional complexities within these themes, such as anxiety and diabetes, which may influence β₂ agonist administration and result in multiple care pathways being initiated during exacerbation. Paramedic care mirrors asthma’s complexity, accounting for a range of characteristics. A dynamic, critically thought approach enables patient management to be based on the presenting conditions rather than strict adherence to a single algorithm. Comprehending the complexities and variables in treatment can be crucial to how paramedics rationalise their treatment and optimise the care provided.

Introduction: Physiological changes experienced by asthma patients receiving nebulised salbutamol in the acute setting primarily offers therapeutic effects. However, the potential for blood glucose levels to increase in some patients could cause metabolic effects that prolong exacerbations. Could using blood glucose levels as a marker assist in maximising the therapeutic effects of salbutamol, whilst reducing the adverse effects? Method: All pre-coded asthma calls were collated over a year from one UK ambulance service and filtered to identify those where at least two concurrent doses of nebulised salbutamol were administered. Patients that also received hydrocortisone or adrenaline as part of their treatment were removed, along with those that did not have pulse rate, respiratory rate, blood oxygenation (SpO2) and blood glucose levels recorded pre and post nebulisation. Results: Over the timeframe 281 asthma patients who received nebulised salbutamol from ambulance crews also had pre and post nebulisation observations recorded. Eighty patients received concurrent doses without the addition of adrenaline or hydrocortisone. Of these 80 patients; 38 (48%) showed an increase in blood glucose levels, with 17 (21%) also showing an increase in Pulse Rate, 7 (9%) an increase in respiratory rate and 6 (8%) a decrease in SpO2. Conclusion: Although full parameters were not set, the potential for some asthmatics to have an underlying susceptibility to beta-2 agonists such as salbutamol is shown by the number of patients that demonstrated an increased blood glucose level and other undesirable effects following nebulisation.

Introduction: Nebulised beta-2 agonists are often used in asthma patients experiencing an exacerbation, but the adverse physiological effects from their use are unclear. This review sets out to identify these effects and determine their potential impact on the patient’s presenting condition and any underlying conditions they may have. Methods: A systematic search of literature published between 2010 to 2020 and focusing on asthmatic patients receiving nebulised beta-2 agonists during an acute exacerbation was undertaken. Databases searched: PubMed, MEDLINE, CINAHL, EMBASE, Cochrane Library, Web of Science, TRIP and EThOS, using key words: ‘asthma’ with albuterol, salbutamol, Ventolin, or beta2. Results: Following review, eight studies out of 897 met the inclusion criteria. The studies used a range of methodologies and outcomes resulting in heterogeneous data that prevented a meta-analysis being undertaken. Synthesis showed evidence of therapeutic bronchodilator action of beta-2 agonists throughout most studies. Reduction in potassium levels and cardiovascular changes such as increased heart rate, were reported in several studies. Clinical significance between age, dosage regimens, clinical observations, and comorbidity were not reported. Conclusions: The therapeutic effects demonstrated within the presented data support the use of nebulised beta-2 agonists in the treatment of asthma exacerbations. Adverse effects are frequently seen in the cardiovascular and endocrine systems although the level of impact on the patient’s overall condition is unclear. Equally, it is unclear how these changes may interact with any underlying conditions and this requires further research.

Introduction: The commonality of shared comorbidities and potential predisposition for those patients suffering from asthma or diabetes to develop the other provides an opportunity to maximise early detection and increase the effectiveness of current treatment. Early detection of both is essential in allowing vital interventions to take place that can improve health outcomes. Aim: Ascertain whether the prehospital treatment of acute asthma exacerbation with nebulised Salbutamol results in increased blood glucose levels that may be used as treatment markers. Method: All pre-coded asthma calls were collated over a 12-month period from one UK ambulance service. These calls were filtered to identify those where nebulised Salbutamol was used as part of their treatment, with a particular focus on those patients that demonstrated a post nebulisation blood glucose level of above 5.5 mmol/L, or any increase between pre and post levels. Results: Over the timeframe ambulance clinicians administered nebulised Salbutamol to a total of 1,465 asthma patients. Of these 1,134 (77%) had their blood glucose recorded at least once, with 241 (13%) demonstrating a post nebulisation level in excess of 5.5 mmol/l. Where a pre and post blood glucose measurement was taken 92 (8%) patients showed a rise in their levels. In total where a post nebulisation measurement was taken 106 (9%) patients demonstrated a level of 10 mmol/l or above. Conclusion: The potential for asthmatics to have an underlying predisposition for diabetes and need for further development is highlighted by the number of patients that demonstrated a high or increase in blood glucose levels following nebulisation.