The acceptability and safety of video triage for ambulance service patients and clinicians during the COVID-19 pandemic

Introduction

In response to anticipated challenges with urgent and emergency healthcare delivery during the early part of the COVID-19 pandemic, Yorkshire Ambulance Service NHS Trust introduced video technology to supplement remote triage and 'hear and treat' consultations as a pilot project in the EOC. We conducted a service evaluation with the aim of investigating patient and staff acceptability of video triage, and the safety of the decision-making process.

Methods

This service evaluation utilised a mixture of routine and bespoke data collection. We sent postal surveys to patients who were recipients of a video triage, and clinicians who were involved in the video triage pilot logged calls they attempted and undertook.

Results

Between 27 March and 25 August 2020, clinicians documented 1073 triage calls. A successful video triage call was achieved in 641 (59.7%) cases. Clinical staff reported that video triage improved clinical assessment and decision making compared to telephone alone, and found the technology accessible for patients. Patients who received a video triage call and responded to the survey (40/201, 19.9%) were also satisfied with the technology and with the care they received. Callers receiving video triage that ended with a disposition of 'hear and treat' had a lower rate of re-contacting the service within 24 hours compared to callers that received clinical hub telephone triage alone (16/212, 7.5% vs. 2508/14349, 17.5% respectively).

Conclusion

In this single NHS Ambulance Trust evaluation, the use of video triage for low-acuity calls appeared to be safe, with low rates of re-contact and high levels of patient and clinician satisfaction compared to standard telephone triage. However, video triage is not always appropriate for or acceptable to patients and technical issues were not uncommon.

PP31 Patterns of use of ambulance senior support during the COVID-19 pandemic: a service evaluation

Background

In early March 2020, a senior clinical support cell (SCSC) was established within Yorkshire Ambulance Service NHS Trust (YAS). The SCSC aimed to provide an additional layer of clinical leadership within the Emergency Operations Centre to support call centre and decision support for on-scene ambulance staff working in challenging circumstances. It was staffed by advanced practitioners, doctors and other senior paramedics with range of diverse skills from critical to urgent care. We aimed to understand the patterns of use of a SCSC for emergency 999 calls during the COVID-19 pandemic.

Methods

Routinely collected call data was retrospectively analysed to understand the patterns of use in the first three months of the service. The reason for the call, patient demographic and any regional differences were described. An anonymous survey was distributed to frontline ambulance crews to understand the reasons for contacting the SCSC, or not, and the outcomes of that contact for patient care.

Results

7296 patient care episodes received either a telephone triage by SCSC for 999 calls or 111 calls transferred for an emergency ambulance response (3160) or had telephone support provided to crews on scene (4136). Telephone triage accounted for 3160 calls where 642 cases (20.3%) resulted in a hear-and-treat outcome, and the findings suggest a low re-contact rate within 24 hours at 2.4%.

The primary reasons for crews seeking support/advice from the SCSC were discharge advice or permission (37%); support for pathways in their area (25%); or for cases where patients refused care or conveyance (11%).

Conclusions

SCSC was developed in response to the COVID-19 pandemic, and lessons can be learned to prepare for any future significant service challenges as a result of the rapid implementation of the SCSC and the clinical leadership required to support the pace of change and emerging clinical knowledge and practice.

PP35 The acceptability and safety of video triage for ambulance service patients and clinicians during the covid-19 pandemic: a service evaluation

Introduction

In response to anticipated challenges with urgent and emergency healthcare delivery during the early part of the COVID-19 pandemic, Yorkshire Ambulance Service NHS Trust (YAS) introduced video call technology to supplement remote triage and ‘hear and treat’ consultations as a pilot project in the Emergency Operations Centre (EOC). We aimed to investigate patient and staff acceptability of video triage, and the safety of the decision-making process.

Methods

This service evaluation utilised a mixture of routine 999 call and bespoke data collection from participating clinicians who logged calls they both attempted and undertook. We sent postal surveys to a group of patients who were recipients of a video triage.

Results

Between 27th March 2020 and 25th August 2020 clinicians documented 1073 video triage calls. A successful video triage call was achieved in 641 (59.7%) of cases. Clinical staff reported that video triage improved clinical assessment and decision making compared to telephone alone, and found the technology accessible for patients. Patients who received a video triage call and responded to the survey (40/201, 19.9%) viewed the technology, the ambulance staff and the care planning favourably.

Callers receiving video triage that ended with a disposition of ‘hear and treat’, had a lower rate of re-contacting the service within 24 hours compared to callers that received clinical support desk telephone triage alone (16/212, 7.5% vs 2508/14349, 17.5% respectively.)

Conclusion

In this single NHS Ambulance Trust evaluation, the use of video triage for low acuity calls appeared to be safe, with low rates of recontact and high levels of patient and clinician satisfaction compared to standard telephone triage. However, video triage is not always appropriate or acceptable to patients and technical issues were not uncommon.

PP40 Pre-hospital and emergency department analgesia for paediatric trauma – a survey of UK trauma centres and ambulance services supports consideration of alternatives such as ketamine

Background

Studies have found that pre-hospital and emergency department (ED) analgesia for children is sub-optimal. In the pre-hospital setting, barriers include limited parenteral routes, education or clinical experience and practice legislation restricting the use of opioids by paramedics. Ketamine is safe and effective with multiple administration routes. It is not bound by the controlled drugs limitations in the pre-hospital setting, and is familiar to pre-hospital and ED practitioners.

Methods

Questionnaires were sent to all UK Ambulance Service Medical Directors and Paediatric Major Trauma Centres to establish current use of parenteral analgesics, and acceptability of alternatives in pre-hospital care such as ketamine. Descriptive analysis was undertaken.

Results

Intranasal opiates were the first line parenteral analgesics in injured children in all EDs. Frequent shortages of IN diamorphine resulted in more variability of second line choices, with 40% opting for another opioid. 96% of EDs would support the use of ketamine by pre-hospital clinicians, although concerns regarding inappropriate (IV) use and use by technician crews were raised. Most ED clinicians were unaware of the limited analgesic choices available to paramedics, with many suggesting alternative opiates as well as ketamine.

All ambulance service directors recognised the need for alternative analgesics being made available. Without legislative changes, inhaled/IN agents or oral opiates were the only current options. All services were supportive of research to explore the use of ketamine by paramedics for injured children.

Conclusions

There is support for the addition of IN ketamine into paramedics’ repertoire of analgesics and recognition of potential benefit. However, there is a lack of experience and evidence around its use, thus warranting research to consider the impact on analgesic timeliness, adequacy and effectiveness. An analgesia ‘system of care’ which integrates pre- and in-hospital practice would be facilitated by the use of medicines effective in managing pain and familiar to practitioners in both settings.

Call volume, triage outcomes, and protocols during the first wave of the COVID-19 pandemic in the United Kingdom: Results of a national survey

OBJECTIVES

During the first wave of the COVID-19 pandemic in the United Kingdom (UK), to describe volume and pattern of calls to emergency ambulance services, proportion of calls where an ambulance was dispatched, proportion conveyed to hospital, and features of triage used.

METHODS

Semistructured electronic survey of all UK ambulance services (n = 13) and a request for routine service data on weekly call volumes for 22 weeks (February 1-July 3, 2020). Questionnaires and data request were emailed to chief executives and research leads followed by email and telephone reminders. The routine data were analyzed using descriptive statistics, and questionnaire data using thematic analysis.

RESULTS

Completed questionnaires were received from 12 services. Call volume varied widely between services, with a UK peak at week 7 at 13.1% above baseline (service range -0.5% to +31.4%). All services ended the study period with a lower call volume than at baseline (service range -3.7% to -25.5%). Suspected COVID-19 calls across the UK totaled 604,146 (13.5% of all calls), with wide variation between services (service range 3.7% to 25.7%), and in service peaks of 11.4% to 44.5%. Ambulances were dispatched to 478,638 (79.2%) of these calls (service range 59.0% to 100.0%), with 262,547 (43.5%) resulting in conveyance to hospital (service range 32.0% to 53.9%). Triage models varied between services and over time. Two primary call triage systems were in use across the UK. There were a large number of products and arrangements used for secondary triage, with services using paramedics, nurses, and doctors to support decision making in the call center and on scene. Frequent changes to triage processes took place.

CONCLUSIONS

Call volumes were highly variable. Case mix and workload changed significantly as COVID-19 calls displaced other calls. Triage models and prehospital outcomes varied between services. We urgently need to understand safety and effectiveness of triage models to inform care during further waves and pandemics.

Accuracy of the Mologic COVID-19 rapid antigen test: a prospective multi-centre analytical and clinical evaluation

Background: The coronavirus disease 2019 (COVID-19) pandemic has highlighted the reliance on antigen detection rapid diagnostic tests (Ag-RDTs). Their evaluation at point of use is a priority. Methods: Here, we report a multi-centre evaluation of the analytical sensitivity, specificity, and clinical accuracy of the Mologic COVID-19 Ag-RDT by comparing to reverse transcriptase polymerase chain reaction (RT-qPCR) results from individuals with and without COVID-19 symptoms. Participants had attended hospitals in Merseyside, hospital and ambulance services in Yorkshire, and drive-through testing facilities in Northumberland, UK. Results: The limit of detection of the Mologic COVID-19 Ag-RDT was 5.0 x 102 pfu/ml in swab matrix with no cross-reactivity and interference for any other pathogens tested. A total of 347 participants were enrolled from 26th of November 2020 to 15th of February 2021 with 39.2% (CI 34.0-44.6) testing RT-qPCR positive for SARS-CoV-2. The overall sensitivity and specificity of the Mologic Ag-RDT compared to the reference SARS-CoV-2 RT-qPCR were 85.0% (95% CI 78.3-90.2) and 97.8% (95.0-99.3), respectively. Sensitivity was stratified by RT-qPCR cycle threshold (Ct) and 98.4% (91.3-100) of samples with a Ct less than 20 and 93.2% (86.5-97.2) of samples with a Ct less than 25 were detected using the Ag-RDT. Clinical accuracy was stratified by sampling strategy, swab type and clinical presentation. Mologic COVID-19 Ag-RDT demonstrated highest sensitivity with nose/throat swabs compared with throat or nose swabs alone; however, the differences were not statistically significant. Conclusions: Overall, the Mologic test had high diagnostic accuracy across multiple different settings, different demographics, and on self-collected swab specimens. These findings suggest the Mologic rapid antigen test may be deployed effectively across a range of use settings.

Suicide among ambulance service staff: a review of coroner and employment records

Background:

There is growing evidence to suggest that ambulance service staff may be at increased risk for suicide; however, few studies have explored risk factors within this occupational group.

Aim:

To investigate factors commonly associated with ambulance staff suicides.

Method:

Eleven ambulance service trusts across the United Kingdom were asked to return details of staff suicides occurring between January 2014 and December 2015. Coroners were then contacted to request permission to review the records of the deceased.

Results:

Fifteen suicides were identified (73% male, mean age 42 years). Inquest data were available on 12 deaths. The most common method used was hanging. Possible risk factors identified included recent return to work following a period of sickness absence, poor mental health, relationship and debt problems, history of self-harm and the loss of a driving licence/change in job role.

Conclusion:

Identifying characteristics of suicide among this high-risk group is important to inform the development of suicide prevention initiatives. Additional research is needed with an adequate control group to further explore the risk factors identified in this study.

A service evaluation of paediatric pain management in an English ambulance service

Introduction:

Evidence from the past 20 years has highlighted that acute pain is not managed well in the emergency setting, in particular with children. Inadequate management of pain can result in long-term changes in both physical and mental health. This service evaluation aimed to determine how paediatric pain is assessed and managed by ambulance clinicians in a large region in England.

Methods:

This retrospective service evaluation analysed electronic patient record (ePR) data routinely collected between September and December 2018. All paediatric patients (< 18 years of age) with pain documented narratively, or a pain score of ≥ 1/10, were included. The primary outcome measure was the proportion of patients with severe pain (defined as a pain score of ≥ 7/10) who achieve effective pain management (reduction in pain score of ≥ 2/10).

Results:

A total of 2801 paediatric patients who had documented pain were included in the analysis and the median age of patients was three years (interquartile range, 1–12 years). Most had a medical cause of pain (2387/2801, 85.2%), and analgesia was administered by the ambulance crew in 403/2801 (14.4%) patients. Multiple pain scores were recorded for 667 patients. Effective pain management was achieved in 233/271 (86%) patients in moderate pain and 204/210 (97.1%) patients in severe pain. However, of the 437 children in moderate to severe pain who achieved effective pain management, 381 (87%) received no analgesia.

Conclusion:

Children in severe pain received effective pain management, despite the majority not receiving any analgesia. This should be investigated further since non-pharmacological methods of analgesia are unlikely to explain a reduction of this magnitude. Ambulance staff need to be encouraged to record a pain score promptly after arriving on scene and ensure it is repeated. Pain score should be documented as part of the physiological observations and not in the free text of ePRs to ensure that it is identified during audits.

PP24 Time: take-home naloxone in multicentre emergency settings: protocol for a feasibility study

Background

Opioids such as heroin kill more people worldwide than any other drug. Death rates associated with opioid poisoning in the UK are at record levels. Naloxone is an opioid agonist which can be distributed in take home ‘kits’. This intervention is known as Take Home Naloxone (THN).

Methods

We propose to carry out a randomised controlled feasibility trial (RCT) of THN distributed in emergency settings clustered by Emergency Department (ED) catchment area, and local ambulance service; with anonymised linked data outcomes. This will include distribution of THN by paramedics and ED staff to patients at risk of opioid overdose. Existing linked data will be used to develop a discriminant function to retrospectively identify people at high risk of overdose death based on observable predictors of overdose to include in outcome follow up.

Results

We will gather outcomes up to one year including; deaths (and drug related); emergency admissions; intensive care admissions; ED attendances (and overdose related); 999 attendances (and for overdose); THN kits issued; and NHS resource usage. We will agree progression criteria following consultation with research team members related to sign up of sites; successful identification and provision of THN to eligible participants; successful follow up of eligible participants and opioid decedents; adverse event rate; successful data matching and data linkage; and retrieval of outcomes within three months of projected timeline.

Conclusions

THN programmes are currently run by some drug services in the UK. However, saturation is low. There has been a lack of experimental research in to THN, and so questions remain: Does THN reduce deaths? Are there unforeseen harms associated with THN? Is THN cost effective? This feasibility study will establish whether a fully powered cluster RCT can be used to answer these questions.

OP6 An investigation into suicide amongst ambulance service staff

Background

In 2015, Ambulance Service Medical Directors raised concerns regarding a perceived increase in suicide deaths among ambulance service staff. The Association of Ambulance Chief Executives (AACE) then commissioned a research study to investigate these concerns and provide recommendations towards a suicide prevention strategy. The aim of this study was to determine whether staff who work in the UK ambulance services (AS) are at higher risk of suicide than staff who work in other professions.

Methods

Data was requested from the Office for National Statistics (ONS) regarding AS staff suicide. Eighteen AS were invited to return data on Occupational Health (OH). AS in England and Wales (n=11) were also asked to return data on staff suicides. Coroners were contacted to request permission to review the records of the deaths.

Results

The ONS analysis of occupational suicide risk between 2011 and 2015 indicated that there were 20 suicide deaths amongst paramedics in England during that period. The risk of suicide amongst male paramedics was 75% higher than the national average.

Over a 2 year period, 8 AS trusts identified 15 staff suicides (11 male, 4 female). The mean age of those dying by suicide was 42 years. Findings from coroners’ records indicated that the predominant suicide method used was hanging (66.7%).

Conclusions

The following recommendations have been accepted by the AACE: a) Develop a mental health strategy for all staff which includes specific emphasis on suicide prevention b) Review and assess suicide risk at times of increased vulnerability c) Collect and monitor data on AS suicides d) Review occupational health, counselling and support services e) Training for staff in identifying and responding to a colleague in distress f) Return to work discussions should consider and establish the status of an individual’s mental health and wellbeing.

Bak apoptotic pores involve a flexible C-terminal region and juxtaposition of the C-terminal transmembrane domains

Bak and Bax mediate apoptotic cell death by oligomerizing and forming a pore in the mitochondrial outer membrane. Both proteins anchor to the outer membrane via a C-terminal transmembrane domain, although its topology within the apoptotic pore is not known. Cysteine-scanning mutagenesis and hydrophilic labeling confirmed that in healthy mitochondria the Bak α9 segment traverses the outer membrane, with 11 central residues shielded from labeling. After pore formation those residues remained shielded, indicating that α9 does not line a pore. Bak (and Bax) activation allowed linkage of α9 to neighboring α9 segments, identifying an α9:α9 interface in Bak (and Bax) oligomers. Although the linkage pattern along α9 indicated a preferred packing surface, there was no evidence of a dimerization motif. Rather, the interface was invoked in part by Bak conformation change and in part by BH3:groove dimerization. The α9:α9 interaction may constitute a secondary interface in Bak oligomers, as it could link BH3:groove dimers to high-order oligomers. Moreover, as high-order oligomers were generated when α9:α9 linkage in the membrane was combined with α6:α6 linkage on the membrane surface, the α6-α9 region in oligomerized Bak is flexible. These findings provide the first view of Bak carboxy terminus (C terminus) membrane topology within the apoptotic pore.

Reference intervals for red cell variables and platelet counts in infants at 2, 5 and 13 months of age: a cohort study

AIMS

To derive reference values for red cell variables and platelet counts from a cohort of infants sampled at precise ages during the first 13 months of life.

METHODS

Blood counts, reticulocyte counts and zinc protoporphyrin concentrations were obtained from healthy term infants of North European ancestry at 2, 5 and 13 months of age.

RESULTS

Mean cell volume (MCV) and mean cell haemoglobin (MCH) values did not differ significantly between 5 and 13 months and MCH concentration was unaffected by age. Values of all other variables at any one age differed significantly from those at the other two. Haemoglobin, mean cell haemoglobin, zinc protoporphyrin and platelet values (95% ranges) at 2 (n=119), 5 (n=97) and 13 months (n=42) were, respectively, 91-125, 101-129 and 105-133 g/L; 28.6-33.1, 24.5-28.7 and 24.3-28.7 pg; 36-116, 25-91 and 27-57 micromol/mol haem; and 216-658, 241-591 and 209-455×10(9)/L. At 2 and 5 months, respectively, 26.9% and 10.8% of subjects had platelet counts >500×10(9)/L. Reticulocyte counts at 2 months and MCV and MCH values at 5 months were significantly higher in girls. In boys, red cell distribution width values were significantly higher at 5 months, and zinc protoporphyrin values at both 2 and 5 months.

CONCLUSIONS

These findings indicate the value of obtaining reference data at precise ages during infancy and confirm and extend earlier reports indicating a gender difference in laboratory measures used to assess iron status in early infancy.

Dynamic microRNA gene transcription and processing during T cell development

By disrupting microRNA (miRNA) biogenesis, we previously showed that this pathway is critical for the differentiation and function of T cells. Although various cloning studies have shown that many miRNAs are expressed during T cell development, and in a dynamic manner, it was unclear how comprehensive these earlier analyses were. We therefore decided to profile miRNA expression by next generation sequencing. Furthermore, we profiled miRNA expression starting from the hematopoietic stem cell. This analysis revealed that miRNA expression during T cell development is extremely dynamic, with 645 miRNAs sequenced, and the expression of some varying by as much as 3 orders of magnitude. Furthermore, changes in precursor processing led to altered mature miRNA sequences. We also analyzed the structures of the primary miRNA transcripts expressed in T cells and found that many were extremely long. The longest was pri-mir-29b-1/29a at ∼168 kb. All the long pri-miRNAs also displayed extensive splicing. Our findings indicate that miRNA expression during T cell development is both a highly dynamic and a highly regulated process.