Evidence
Alert

Paramedics value a structured handover of care for patients with suspected stroke

Stroke is a medical emergency that often results in serious disability. A drug treatment called thrombolysis improves the chance of recovery in some patients but can only be given in hospital in the first few hours after a stroke.

A coordinated emergency response involving ambulance and hospital services is needed to identify the patients who could benefit. In the Paramedic Acute Stroke Treatment Assessment (PASTA) trial, paramedics were briefed to collect extra information from stroke patients and then to follow a structured procedure to smooth the handover of care to hospital doctors who make the decision on thrombolysis.

The current study captured the views of paramedics in the PASTA trial. It found that they viewed the structured handover as the most beneficial part of the PASTA approach. Professional boundaries and expectations made an enhanced role for paramedics in hospital harder to achieve.

What’s the issue?

Each year around 130,000 people in the UK are admitted to hospital due to a stroke. Those whose stroke was caused by a blood clot (ischaemic stroke) can benefit from thrombolysis. But not all stroke patients are suitable and there is a limited time – of four and a half hours – to identify the people who could benefit.

At the scene, paramedics look for symptoms of stroke . They then rapidly transport patients to hospital to be considered for thrombolysis and other specialist treatments by a doctor. A smooth handover of a patient’s care is essential for timely decision-making on thrombolysis treatment. However, the lack of an agreed structure for the information collected by paramedics may hamper the handover to hospital staff.

The PASTA trial aimed to improve the handover and the quality of decisions on thrombolysis for people with a suspected stroke. Paramedics at three NHS ambulance services were trained to collect more information from suspected stroke patients, to follow a structured hospital handover, provide practical assistance in hospital, use a care checklist and note clinician feedback. However, the PASTA approach did not increase the overall numbers of stroke patients who received thrombolysis, although there were local variations.

What’s new?

The current qualitative study explored paramedics’ experiences. 26 paramedics were recruited from 453 in the PASTA trial.

Overall, they thought that conducting a more detailed assessment of the patient at the scene and a structured handover helped with the efficient handover of important clinical information. But they felt that expanding their role to help with practical tasks in hospital was challenging.

  • Assessment at the scene. Paramedics did not think the PASTA approach was significantly different from routine assessment, but it brought together their existing knowlege with new assessment tools. This enabled more standardised and efficient assessment, and gave them confidence in their initial diagnosis: “I liked the structured approach, and I found it easy enough. It’s no different to what we would be doing with the patient. It’s just more structured and more organised, and more reportable.”
  • Ambulance journey and pre-alert to the hospital. There were mixed experiences with the pre-alert phone call but some paramedics reported increased confidence: “I’m more confident when I ring them as well because I know more stuff now so I can answer questions easier.”
  • Handover to the hospital clinical team. On the whole, paramedics appreciated the structured approach and said it increased efficiency: “Just having that in front of you, it’s much easier to fill that in on the way to hospital, and have that ready, then that gives you the structured handover, and everything's there.”
  • Assisting in hospital and getting feedback on their initial diagnosis. This extension of the paramedic’s role was difficult to achieve because of professional boundaries and expectations. Some paramedics did not feel confident asking to be involved in aspects of care that are typically the job of hospital staff: “I felt a bit like I was getting in the way, really, more than anything, what the ED nurse being there, and then the specialist nurse.” In busy emergency departments, paramedics were sometimes unable to see the stoke team: “I never handed over to anybody from the stroke team, even with the appropriate pre-alerts and everything else. That never happened.” And many felt that hospital staff ‘took over’ in these interactions, possibly because of their expectation of the paramedic’s role and time pressure.

Why is this important?

Paramedics who took part in the study felt that there was value in expanding their role. They felt they could help by carrying out a more thorough on-scene assessment. A structured handover of care at hospital would lead to more efficient transfer of relevant clinical information.

Formal symptom checklists have been used for some time in emergency stroke care and continue to evolve. But the information handed from ambulance to hospitals is not presented in a standard format. Standard formats could be particularly helpful for chaotic and noisy A&E departments.

Inter-disciplinary training could help hospital and ambulance staff work together more effectively. Interviewees felt that hospital staff sometimes guarded cultural and professional boundaries. The researchers suggest that the hospital team should be aware of an enhanced role for paramedics and be active participants in their evolving role.

What’s next?

More research is needed to understand how to further improve clinical treatment pathways to improve the effectiveness, cost and efficiency of delivering care for emergency stroke and other common scenarios. These studies should consider whether interdisciplinary training is needed to enable more radical extension of professional boundaries for paramedics.

You may be interested to read

The full paper: Lally J, and others. Paramedic experiences of using an enhanced stroke assessment during a cluster randomised trial: a qualitative thematic analysis. Emerg Med J. 2020;37:480–485

The results of the PASTA trial: Price CI, and others. Effect of an Enhanced Paramedic Acute Stroke Treatment Assessment on Thrombolysis Delivery During Emergency Stroke Care. JAMA Neurol. 2020;77:840–848

Information on using the FAST test to identify symptoms of stroke, by the Stroke Association

Information on thrombolysis, by the Stroke Association

National Clinical Guideline for Stroke (2016), by the Royal College of Physicians

UK Ambulance Services Clinical Practice Guidelines (2019), by the Joint Royal Colleges Ambulance Liaison Committee (JRCLAC)

 

Funding: This work was funded by an NIHR Programme Grant for Applied Research.

Conflicts of Interest: The study authors declare no conflicts of interest.

Disclaimer: NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that views expressed in NIHR Alerts are those of the author(s) and reviewer(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.

Commentaries

Study author

Although the PASTA intervention did not increase thrombolysis rates in hospital, views from paramedics describe that it was valuable to have a clearer structure about the information which was most valuable for hospital staff to make a treatment decision. A structured information handover is an easy and cheap intervention to introduce for many emergency scenarios, whereas further extension of roles will require greater effort from services to integrate professional skills beyond standard operational boundaries.

Christopher Price, Professor of Stroke and Applied Health Research, Newcastle University

Paramedic

The need for better integration between pre-hospital and hospital care is crucial for the development of paramedics’ clinical practice and the continuity of multi-disciplinary and multi-professional care for patients. Integrated training for pre-hospital and hospital staff should be encouraged to ensure the best possible care for people potentially suffering from a stroke. Future guidelines and policies should incorporate the care provided by paramedics into holistic patient care pathways.

Paramedics are educated and trained extensively in the recognition and management of potential stroke patients. It is an expectation of their professional practice. Having said that, algorithmic approaches to clinical diagnosis can aid paramedics and improve their clinical confidence. Clinical assessment, pathways, and handover should be standardised throughout the healthcare system.

Enrico Dippenaar, Senior Lecturer in Emergency Medicine, Faculty of Health, Education, Medicine and Social Care, Anglia Ruskin University, Chelmsford