Availability and utilisation of physician-based pre-hospital critical care support to the NHS ambulance service in England, Wales and Northern Ireland

Background: Every day throughout the UK, ambulance services seek medical assistance in providing critically ill or injured patients with pre-hospital care. Objective: To identify the current availability and utilisation of physician-based pre-hospital critical care capability across England, Wales and Northern Ireland. Design: A postal and telephone survey was undertaken between April and December 2009 of all 13 regional NHS ambulance services, 17 air ambulance charities, 34 organisations affiliated to the British Association for Immediate Care and 215 type 1 emergency departments in England, Wales and Northern Ireland. The survey focused on the availability and use of physician-basedpre-hospital critical care support. Results: The response rate was 100%. Although nine NHS ambulance services recorded physician attendance at 6155 incidents, few could quantify doctor availability and utilisation. All but one of the British Association for Immediate Care organisations deployed ‘only when available’ and only 45% of active doctors could provide critical care support. Eleven air ambulance services (65%) operated with a doctor but only 5 (29%) operated 7 days a week. Fifty-nine EDs (27%) had a pre-hospital team but only 5 (2%) had 24 h deployable critical care capability and none were used regularly. Conclusion: There is wide geographical and diurnal variability in availability and utilisation of physician-based pre-hospital critical care support. Only London ambulance service has access to NHS-commissioned 24 h physician-based pre-hospital critical care support. Throughout the rest of the UK, extensive use is made of volunteer doctors and charity sector providers of varying availability and capability

Neuropsychological outcome following minimal access subtemporal selective amygdalohippocampectomy.

PURPOSE: The present study provides a detailed account of neurocognitive outcome following minimal access subtemporal selective amygdalohippocampectomy (SAH) and establishes rates of neurocognitive decline in the largest sample to date. Use of a subtemporal surgical approach to SAH has been proposed to possibly reduce the risk for postoperative neurocognitive decline since lateral neocortical tissues is not resected and the temporal stem is preserved. The current study extends prior research with subtemporal SAH patients to include not only group level analyses but also analyses based on reliable change data. METHODS: Neurocognitive comparisons are made between 47 patients that underwent subtemporal SAH. Statistical comparisons were made between neurocognitive performance at the group level and with use of reliable change scores. RESULTS: Approximately 75% of patients were seizure free postoperatively. At the group level, there were no significant postoperative changes. For the left SAH patients, reliable change scores demonstrated a decline in approximately one third of patients for memory, verbal intellect, and naming. Right SAH patients showed decline primarily in memory. CONCLUSIONS: These results indicated good seizure control following subtemporal SAH with greatest risk for neurocognitive decline following dominant SAH and best cognitive outcome following non-dominant SAH. Findings demonstrated the importance of reliable change analyses that make individual based comparisons and take into account measurement error. Despite preservation of the lateral neocortical tissue and the temporal stem, subtemporal SAH presents a risk for cognitive decline in a notable portion of patients

Community Paramedicine in Rural Areas: State and Local Findings and the Role of the State Flex Program (Policy Brief #35)

This study examined the evidence base for community paramedicine in rural communities, the role of community paramedics in rural healthcare delivery systems, the challenges faced by states in implementing community paramedicine programs, and the role of the state Flex programs in supporting development of community paramedicine programs. Additionally, the study provides a snapshot of community paramedicine programs currently being developed and/or implemented in rural areas. Another FMT briefing paper describes these same findings in detail. Highlights: Many rural community paramedicine programs are in pilot stages. Most community paramedics work within an expanded role rather than an expanded scope of practice, the latter requiring legislative or regulatory change. Funding and reimbursement for community paramedicine services are major challenges for the sustainability of community paramedicine programs. Data collection is vital for community paramedicine programs to be able to show value, including shared saving and patient outcomes. Collaboration at local and state levels is essential for buy-in, and partnering with the State Office of Rural Health is especially helpful in the early development and outreach efforts for rural community paramedicine programs

Exploring State Data Sources to Monitor Rural Emergency Medical Services Performance Improvement

In 1981, responsibility for overseeing emergency medical services (EMS) largely shifted to states and localities, contributing to the creation of a fragmented national picture of the state of EMS that is most evident in the resultant data collection and reporting issues that curb the availability of EMS data. These patchwork systems of care disproportionately affect rural areas, where myriad challenges – from a high reliance on a volunteer workforce to low call volumes and inadequate reimbursement – hinder performance. Previous studies by the Flex Monitoring Team (FMT) highlighted how little is known about the administrative, operational, and clinical capacity of rural EMS, which are key to investigate further before considering traditional EMS outcome measures. In this study, the FMT convened an expert panel comprised of representatives from a variety of stakeholders to highlight existing data challenges EMS face, identify data to support rural EMS performance measurement, as well as reassess the FMT’s 2017 rural-relevant EMS performance measures. Among the themes raised by the panel, experts suggested that improved engagement in oversight by state EMS agencies would increase accountability by local EMS; however, they cited a lack of staff capacity and expertise to analyze data in states, as well as disagreement between states on relevant measures. The FMT created EMS capacity measures to monitor and improve rural EMS capacity, along with the National Highway Traffic Safety Administration’s EMS Compass outcome measures to monitor performance. Potential opportunities identified by the panel to source standardized data for those measures include an assessment tool developed through the Joint Committee of Rural Emergency Care, or for the relevant data to be collected by state EMS agencies through their existing EMS service licensure process, many of which already collect some of the relevant data. Electronic patient care records, the typical source of data to calculate EMS clinical and non-clinical performance measures, can be collected and reported to states through the National EMS Information System (NEMSIS). Though not perfect, targeted efforts to improve the collection of local EMS data provides an opportunity for state EMS agencies and State Flex Programs (SFPs) to train local services in data collection, in addition to educating them on how to access and use their own data for performance improvement. This collaboration can also play a role in supporting improved health information exchange between EMS, hospitals, and other providers, which help improve the quality of pre-hospital care and assist in monitoring the quality and outcomes of care across the system of care. The importance of reliable, standardized, and timely data from local and state EMS is underscored by the recently launched Medicare Ground Ambulance Data Collection System, a Centers for Medicare and Medicaid Services study that will collect information to evaluate how ground ambulance costs relate to current payment policies. In turn, this will be used to formulate a report to Congress assessing the adequacy of Medicare ground ambulance payment rates and geographic variations in cost. As the data will be used to assess reimbursement rates across urban, rural, and super rural areas, accurate data collection and reporting is vital. The expert panel also reaffirmed the validity of FMT’s rural-relevant measures and raised questions about monitoring the measures longitudinally or developing measures to assess financial performance and sustainability. Additional work is needed to understand how to best use these measures to track rural EMS capacity over time, as well as identify the relevant financial measures

Aluminium electrodes effect the operation of titanium oxide sol-gel memristors

By a comparison between memristors made with aluminium and gold electrodes, this letter demonstrates that aluminium electrodes are an essential component of the TiO$_2$ sol-gel flexible memristor . Both slow varying `analogue' and sudden switching `digital' memristor devices have been observed. Limiting the oxygen exposure of the bottom aluminium electrode favours the creation of digital memristors over analogue ones. A straight-forward fabrication of drop-coated memristors based on sol-gel chemistry is also presented and these show similar behaviour and dependence on electrode material, making them useful as test memristors for experimentation

Addressing Opioid Use in Rural Communities: Examples from Critical Access Hospitals

The opioid epidemic continues to have a devastating impact in rural areas disproportionately affected by a lack of infrastructure to provide treatment for opioid use disorders (OUDs). Critical Access Hospitals (CAHs), often the hubs of local systems of care, can play an important role in addressing OUDs. Using a substance use framework developed for the Flex Monitoring Team’s earlier study of CAH substance use strategies, this brief highlights strategies adopted by CAHs to combat opioid use in their communities. It also identifies resources that State Flex Programs can use to support CAHs with this challenging population health issue

The co-evolutionary relationship between energy service companies and the UK energy system: Implications for a low-carbon transition

The Energy Service Company (ESCo) business model is designed to reward businesses by satisfying consumers' energy needs at less cost and with fewer carbon emissions via energy demand management and/or sustainable supply measures. In contrast, the revenue of the incumbent Energy Utility Company (EUCo) model is coupled with the sale of units of energy, which are predominantly sourced from fossil fuels. The latter is currently dominant in the UK. This paper addresses two questions. First, why has the ESCo model traditionally been confined to niche applications? Second, what role is the ESCo model likely to play in the transition to a low-carbon UK energy system? To answer these, the paper examines the core characteristics of the ESCo model, relative to the EUCo model. The paper then examines how ESCos have co-evolved with the various dimensions of the energy system (i.e. ecosystems, institutions, user practices, technologies and business models) to provide insight into how ESCos might help to shape the future UK energy system. We suggest that institutional and technological changes within the UK energy system could result in a more favourable selection environment for ESCos, consequently enabling the ESCo model to proliferate at the expense of the EUCo model. © 2013 Elsevier Ltd

Fragment Flow and the Nuclear Equation of State

We use the Boltzmann-Uehling-Uhlenbeck model with a momentum-dependent nuclear mean field to simulate the dynamical evolution of heavy ion collisions. We re-examine the azimuthal anisotropy observable, proposed as sensitive to the equation of state of nuclear matter. We obtain that this sensitivity is maximal when the azimuthal anisotropy is calculated for nuclear composite fragments, in agreement with some previous calculations. As a test case we concentrate on semi-central $^{197}{\rm Au}\ +\ ^{197}{\rm Au}$ collisions at 400 $A$ MeV.Comment: 12 pages, ReVTeX 3.0. 12 Postscript figures, uuencoded and appende