Background and objectivesInternational and national health policies advocate greater integration of emergency and community care. The Physician Response Unit (PRU) responds to 999 calls ‘taking the Emergency Department to the patient’. Operational since 2001, the service was reconfigured in September 2017. This article presents service activity data and implications for the local health economy from the first year since remodelling.MethodsA retrospective descriptive analysis of a prospectively maintained database was undertaken. Data collected included dispatch information, diagnostics and treatments undertaken, diagnosis and disposition. Treating clinical teams recorded judgments whether patients managed in the community would have been (1) conveyed to an emergency department (ED)and (2) admitted to hospital, in the absence of the PRU. Hospital Episode Statistics data and NHS referencing costs were used to estimate the monetary value of PRU activity.Results1924 patients were attended, averaging 5.3 per day. 1289 (67.0%) patients were managed in the community. Based on the opinion of the treating team, 945 (73.3%) would otherwise have been conveyed to hospital, and 126 (9.7%) would subsequently have been admitted. The service was estimated to deliver a reduction of 868 inpatient bed days and generate a net economic benefit of £530 107.ConclusionsThe PRU model provides community emergency medical care and early patient contact with a senior clinical decision-maker. It engages with community providers in order to manage 67.0% of patients in the community. We believe the PRU offers an effective model of community emergency medicine and helps to integrate local emergency and community providers.

ObjectivesPrehospital rapid sequence induction (RSI) of anaesthesia is an intervention with significant associated risk. In this study, we aimed to investigate the haemodynamic response over time of a prehospital RSI protocol of fentanyl, ketamine and rocuronium in a heterogeneous population of trauma patients.Design, setting and participantWe performed a retrospective study of all trauma patients who received a prehospital RSI for trauma by a physician staffed Helicopter Emergency Medical Service in the UK between 1 June 2018 and 1 February 2020.Primary outcome measurePrimary outcome was defined as the incidence of clinically relevant hypotensive (systolic blood pressure (SBP) or mean arterial pressure (MAP) >20% below baseline, with an absolute SBP <90 mm Hg or MAP <65 mm Hg) or hypertensive (SBP or MAP >20% above baseline) episodes in the first 10 minutes post-RSI.ResultsIn total, 322 patients were included. 204 patients (63%) received a full-dose induction of 3 μg/kg fentanyl, 2 mg/kg ketamine and 1 mg/kg rocuronium, whereas 128 patients (37%) received a reduced-dose induction. Blood pressures decreased on average 12 mm Hg (95% CI 7 to 16) in the full-dose group and 6 mm Hg (95% CI 1 to 11) in the reduced-dose group, p=0.10). A hypotensive episode (mean SBP drop 53 mm Hg) was noted in 29 patients: 17 (8.3%) receiving a full dose and 12 (10.2%) receiving a reduced-dose induction, p=0.69. The blood pressure nadir was recorded on average 6–8 min after RSI. A hypertensive episode was present in 22 patients (6.8%). The highest blood pressures were recorded in the first 3 min after RSI.ConclusionPrehospital induction of anaesthesia for trauma with fentanyl, ketamine and rocuronium is not related to a significant change in haemodynamics in most patients. However, a (delayed) hypotensive response with a significant drop in SBP should be anticipated in a minority of patients irrespective of the dose regimen chosen.

Prehospital rapid sequence intubation (RSI) is an important aspect of prehospital care for helicopter emergency medical services (HEMS). This study examines the feasibility of in-aircraft (aircraft on the ground) RSI in different simulated settings. Methods: Using an AW169 aircraft cabin simulator at Air Ambulance Kent Surrey Sussex, 3 clinical scenarios were devised. All required RSI in a "can intubate, can ventilate" (easy variant) and a "can't intubate, can't ventilate" scenario (difficult variant). Doctor-paramedic HEMS teams were video recorded, and elapsed times for prespecified end points were analyzed. Results: Endotracheal intubation (ETI) was achieved fastest outside the simulator for the easy variant (median = 231 seconds, interquartile range = 28 seconds). Time to ETI was not significantly longer for in-aircraft RSI compared with RSI outside the aircraft, both in the easy (p = .14) and difficult variant (p = .50). Wearing helmets with noise distraction did not impact the time to intubation when compared with standard inaircraft RSI, both in the easy (p = .28) and difficult variant (p = .24). Conclusion: In-aircraft, on-the-ground RSI had no significant impact on the time to successful completion of ETI. Future studies should prospectively examine in-cabin RSI and explore the possibilities of in-flight RSI in civilian HEMS services.

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BackgroundPre-hospital blood component transfusion poses logistical challenges. Current patterns of pre-hospital blood use across the UK are not known. A potential benefit of providing a single combined component of whole blood is reduced need for multiple steps of administering separate components and more efficient use of time and resources by medical staff. .Objectivesto undertake a detailed time-analysis of the steps of pre-hospital combined component transfusion against separate blood component transfusion, and to determine current UK pre-hospital transfusion practice and users’ optimal pre-hospital transfusion strategyMethodsA three-arm cross-over major haemorrhage simulation study compared: flow-time (time from decision-to-transfuse [DTT] to complete transfusion); touch-time (direct team ’hands on’ contact time with transfusion process); and number of steps, people and equipment required for transfusion of 2 units of RCP [arm-A], 2 RBC + 2 TP [arm-B] or RBC + 2 Lyoplas [arm-C]). A national survey of current and optimal pre-hospital transfusion strategies was sent to 22 UK Air Ambulance Services (AAS) and 27 Major Trauma Centres (MTC) in December 2019. ResultsThe simulation demonstrated that arm-A had a shorter flow-time (median 6min 31sec vs. 12min 20 sec, vs 16min 29 sec) and touch-time (median 2min 31 seconds vs. 5min 21sec vs. 15min 3sec) than arm-B and arm-C respectively, and required fewer steps, equipment and checks. 18 MTCs and 18 AAS responded to the national survey (response rates of 67 and 82%). 10 transfused RBC/plasma (5 TP/5 Lyoplas), 4 RBC only, 2 Lyoplas only, 1 RBC/Lyoplas/Fibrinogen, and 1 ’red cell and plasma’ (only available at one hospital site). 89% replied that a combined component transfusion would be desirable, as it would reduce patient mortality (83%) and tasks on scene (75%). ConclusionThe time-analysis established the benefits for combined pre-hospital component transfusion in trauma patients. The national survey demonstrates the variation in current pre-hospital transfusion practice and reiterates that combined component transfusion pre-hospital may have logistical advantages over separate components.