EP13 Perceptions and experiences of residents and relatives of emergencies in care homes: systematic review and meta-synthesis

Background

Medical emergencies in care homes, both residential and nursing care homes, are common and costly, often resulting in calls to an out-of-hours general practitioner (GP) or Emergency Medical Services (EMS). Ambulance attendance frequently results in conveyance to hospital and the concomitant high costs and risks of, often prolonged, hospitalisation. Previous reviews have focussed on various stakeholder perceptions of transfer to hospital. The aim of this systematic review was to provide a comprehensive synthesis of the perceptions and experiences of care home residents and their family members, who have experienced medical emergencies in a care home setting.

Methods

We searched five electronic databases, supplemented with internet searches and forward and backward citation tracking from the included studies and review articles. Data were synthesised thematically following the Thomas and Harden approach. The CASP Qualitative Checklist was used to assess the quality of the included studies of this review.

Results

The search strategy identified 6,140 citations. After removing duplicates and excluding citations based on title and abstract, and full-text screening, ten studies from four countries (Australia, Canada, UK, and US) were included in the review and meta-synthesis. All included studies were considered of acceptable quality. Through an iterative approach, we developed six analytical themes. 1. Infrastructure and process requirements in care homes to prevent and address emergencies; 2. The decision to transfer to hospital – a perfect storm; 3. Challenges of transfer and hospitalisation for older patients; 4. Good communication vital for desirable outcomes; 5. Legal, regulatory and ethical concerns; and 6. Trusting relationships enabled residents to feel safe.

Conclusions

The emergency care experience for care home residents can be enhanced by ensuring resources, staff capacity and processes for high quality care. Building trusting relationships underpinned by good communication and attention to ethical practice were also identified as important factors.

OP07 On the effectiveness and costs of inhaled methoxyflurane versus usual analgesia for prehospital injury and trauma

Background

Acute pain is often inadequately treated in adults with traumatic injury. Inhaled methoxyflurane, newly licensed in Europe for this indication, has limited evidence of clinical effectiveness in the prehospital setting. We aimed to investigate clinical effectiveness and costs of methoxyflurane administered by ambulance staff compared with usual analgesic practice (UAP) for patients with trauma.

Methods

We used a non-randomised control group pragmatic design comparing methoxyflurane versus Entonox® and parenteral analgesics. Verbal numerical pain scores (VNPS) were gathered over time in adults with moderate to severe trauma pain attended by ambulance staff trained in administering and supplied with methoxyflurane. Comparator VNPS were obtained from database records of UAP in similar patients. Clinical efficacy was tested using an Ordered Probit panel regression model of pain linked by observational rules to VNPS. Scenario analyses were used to compare durations under analgesia spent in severe pain, and costs.

Results

Over 12 months, 96 trained paramedics and technicians prepared 510 doses of methoxyflurane for administration to 483 patients. 32 patients reported side-effects, 19 of whom discontinued early. 13 patients, 10 aged over 75 years, were nonadherent to inhaler use instructions.

Modelling results showed statistically significant clinical effectiveness of methoxyflurane over each comparator (all p-values<0.001). Methoxyflurane’s time to achieve maximum pain relief was significantly faster (all p-values<0.001): 26.4 mins (95%CI 25.0-27.8) versus Entonox® 44.4 (39.5-49.3); 26.5 (25.0-27.9) versus IV morphine sulfate 41.8 (38.9-44.7); 26.5 (25.1-28.0) versus IV paracetamol 40.8 (34.7-46.9).

Scenario analyses of durations spent in severe pain were significantly less for methoxyflurane to comparators. Benefits of methoxyflurane were achieved at higher cost to comparators.

Conclusions

Methoxyflurane reduced pain more rapidly and to a greater extent than Entonox® and more quickly than parenteral analgesics in adults with moderate or severe pain due to trauma attended by ambulance clinicians. Methoxyflurane provides a useful addition to prehospital analgesia.

PP18 Is there provider induced demand at emergency departments with primary care services? Patient, local and wider system factors described to influence demand for primary care in emergency departments: realist evaluation

Background

Evidence from evaluations of emergency departments (EDs) with co-located primary care services suggests that they influence additional demand for non-urgent care (provider-induced demand). In a realist review of the literature on the effects of primary care services in EDs we proposed a theory that when primary care services are distinct at an ED they may encourage additional primary care demand and when primary care clinicians work indistinctly in the ED there is no additional demand. We aimed to explore evidence for this theory and explain contexts, mechanisms and outcomes that influence such demand.

Methods

We used realist evaluation methodology and carried out observations of key processes. We interviewed 23 patients, 21 ED clinical directors, 26 other ED staff members and 26 GPs at 13 EDs (England & Wales). Field notes and audio-recorded interviews were transcribed and analysed by creating context, mechanism and outcome configurations to refine and develop theories relating to provider induced demand.

Results

EDs with distinct primary care services were perceived to attract more demand for primary care than EDs where primary care clinicians worked indistinctly because the primary care service was visible, widely known about, enabled direct access, and received NHS 111 referrals. Other influences on demand were patients’ experiences of accessing primary care, the capacity for urgent care in the community, location of the ED and public transport links, service design and developments (new buildings, renovations) and population characteristics (unfamiliarity with local healthcare services, not registered with a GP or different cultural perceptions of seeking health care).

Conclusions

A range of patient, local-system and wider-system factors contribute to additional demand at an ED with co-located primary care services. Our findings can inform providers and policymakers in developing strategies to limit the effect of these influences on additional demand.

01 The effects of a leaflet-based intervention, ‘hypos can strike twice’, on recurrent hypoglycaemic attendances by ambulance services: a non-randomised stepped wedge study

Background

Hypoglycaemia is a common complication of diabetes therapy needing prompt recognition and treatment. It often results in ambulance attendance incurring health services costs and patient morbidity. Patient education is important for maintaining glycaemic control and preventing recurrent hypoglycaemia. We aimed to investigate the effect of an intervention in which ambulance staff were trained to provide advice supported by a booklet – ‘Hypos can strike twice’- issued following a hypoglycaemic event to prevent future attendances.

Methods

We used a non-randomised stepped wedge-controlled design. The intervention was introduced at different times (steps) in different areas (clusters) of operation of East Midlands Ambulance Service NHS Trust (EMAS). During the first step (T0) no clusters were exposed to the intervention and during the last step (T3) all clusters were exposed. The main outcome was the number of unsuccessful ambulance attendances (i.e. attendances followed by a repeat attendance). Data were analysed using a general linear mixed model (GLMM) and an interrupted-time series analysis (ITSA).

Results

The study included 4825 patients (mean age= 65.42, SD=19.42; 2166 females) experiencing hypoglycaemic events attended by EMAS. GLMM indicated a reduction in the number of unsuccessful attendances in the final step of the intervention when compared to the first (OR: 0.50, 95%CI: 0.33-0.76, p=0.001). ITSA indicated a significant decrease in repeat ambulance attendances for hypoglycaemia – relative to the pre-intervention trend (p=0.008). The hypoglycaemia care bundle (i.e. blood glucose recorded before and after treatment for hypoglycaemia) was delivered in 66% of attendances during the intervention period, demonstrating a significant level of practice change (χ2=30.16, p<0.001).

Conclusions

The ‘Hypos can strike twice’ intervention had a positive effect on reducing numbers of repeat attendances for hypoglycaemia and in achieving the care bundle. The study supports the use of informative booklets by ambulance clinicians to prevent future attendances for recurrent hypoglycaemic events.

PP19 Primary care streaming in emergency departments- contexts and mechanisms associated with perceived effectiveness outcomes: a realist evaluation

Background

Recent policy has encouraged emergency departments (EDs) to deploy nurses to stream patients from the ED front door to GPs working in a separate GP service operating within or alongside an ED. We aimed to describe mechanisms relating to effectiveness of streaming in different primary care service models identified in EDs. We explored perceptions of whether patients were perceived to be appropriately streamed to emergency care, primary care, other hospital services or community primary care services; and effects on patient flow (waiting times and length of stay in the ED); and safe streaming outcomes.

Methods

We used realist evaluation methodology to explore perceived streaming effectiveness. We visited 13 EDs with different primary care service models (purposively selected across England & Wales; 8 streamed primary care patients to a primary care clinician) and carried out observations of triage/streaming and patient flow and interviews with key members of staff (consultants, GPs, nurses). Field notes and audio-recorded interviews were transcribed and analysed by creating context, mechanism and outcome configurations to refine and develop theories relating to streaming effectiveness.

Results

We identified five contexts (nurses’ knowledge and experience, streaming guidance, teamwork and communication, operational management and strategic management) that facilitated mechanisms that influenced the effectiveness of streaming (streaming to an appropriate service, patient flow, delivering safe care). We integrated a middle range psychological theory (cognitive continuum theory) with our findings to recommend a focus for training nurses in streaming and service improvements.

Conclusions

We identified key mechanisms relating to the effectiveness of primary care streaming in different models of service. We recommend a collaborative approach to service development, guidance and training (including input from ED clinicians and primary care clinicians) and a range of training strategies that are suitable for less experienced junior nurses and more experienced senior nurses and nurse practitioners.

Candidate perceptions of the UK Recorded Consultation Assessment: cross-sectional data linkage study

The Recorded Consultation Assessment (RCA) was rapidly developed to replace the Clinical Skills Assessment (CSA) for UK general practice licencing during COVID-19. We aimed to evaluate candidate perceptions of the RCA and relationships with performance. We conducted a cross-sectional survey of RCA candidates with attitudinal, demographic, and free text response options, undertaking descriptive and factor analysis of quantitative data with qualitative thematic analysis of free text. Binomial regression was used to estimate associations between RCA pass, candidate characteristics and questionnaire responses.645 of 1551 (41.6%) candidates completed a questionnaire; 364 (56.4%) responders permitted linkage with performance and demographic data. Responders and non-responders were similar in exam performance, gender and declared disability but were significantly more likely to be UK graduates (UKG) or white compared with international medical (IMG) or ethnic minority graduates. Responders were positive about the digital platform and support resources. A small overall majority regarded the RCA as a fair assessment; a larger majority reported difficulty collecting, selecting, and submitting cases or felt rushed during recording.Logistic regression showed that ethnicity (white vs minority ethnic: odds ratio [OR] 2.99,95% confidence interval [CI] 1.23, 7.30, p = 0.016), training (UK vs IMG: OR 6.88, 95% CI 2.79, 16.95, p < 0.001), and English as first language (OR 5.11, 0% CI 2.08, 12.56, p < 0.001) were associated with exam success but questionnaire subscales, consultation type submitted, or extent of trainer review were not. The RCA was broadly acceptable but experiences were variable. Candidates experienced challenges and suggested areas for improvement.

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.

Mental health emergencies and COVID-19: the impact of 'lockdown' in the East Midlands of the UK

BACKGROUND

The most immediate response of the research community to COVID-19 has been a focus on understanding the effects, treatment and prevention of infection. Of equal and ongoing importance is elucidating the impact of mitigation measures, such as lockdown, on the well-being of societies. Research about mental health and lockdown in the UK has predominately involved large surveys that are likely to encounter self-selection bias. Further, self-reporting does not constitute a clinical judgement.

AIMS

To (a) compare the age, gender and ethnicity of patients experiencing mental health emergencies prior compared with during lockdown, (b) determine whether the nature of mental health emergencies has changed during compared with before lockdown, (c) explore the utility of emergency medical service data for identifying vulnerability to mental health emergencies in real time during a pandemic.

METHOD

A total of 32 401 clinical records of ambulance paramedics attending mental health emergencies in the East Midlands of the UK between 23 March and 31 July 2020 and the same period in 2019 were analysed using binary logistic regression.

RESULTS

People of younger age, male gender and South Asian and Black ethnicity are particularly vulnerable to acute mental health conditions during lockdown. Patients with acute cases of anxiety have increased during lockdown whereas suicide and intentional drug overdose have decreased.

CONCLUSIONS

Self-reported data may underrepresent the true impact of lockdown on male mental health and ethnic minority groups. Emergency medical data can be used to identify vulnerable communities in the context of the extraordinary circumstances surrounding the current pandemic, as well as under more ordinary circumstances.

Ambulance clinician perspectives of disparity in prehospital child pain management: A mixed methods study

BACKGROUND

When children suffer acute pain, the ambulance service is often involved to provide initial assessment, treatment, and transport. Several predictors of effective pain management have been identified, including children who are younger (0-5 years), administered analgesics, and living in homes from more affluent areas.

OBJECTIVE

To explain previously identified predictors of effective prehospital pain management in children.

DESIGN

Mixed methods sequential explanatory study.

SETTING AND PARTICIPANTS

East Midlands Ambulance Service National Health Service Trust paramedics and emergency medical technicians (EMTs) participated in face-to-face semi-structured interviews. These were audio recorded, transcribed verbatim, and coded using thematic analysis. Meta-inferences were generated and illustrated within a joint display.

RESULTS

Twelve clinicians (9 paramedics and 3 EMTs) were interviewed. Median (interquartile range) age was 43.5 years (41.5, 45.75), 58% were male (n = 7) and 58% were parents (n = 7). Possible explanations were provided for all predictors. Younger children were perceived to express more emotion, were easier to distract, and lived more in the moment than their older counterparts, which explained why younger children were more likely to achieve effective pain management. Analgesics were perceived to have a psychosocial benefit in addition to the pharmacological action. Ambulance clinicians felt that children living in more affluent areas were more likely to achieve effective pain management because the kempt environment facilitated assessment and management and clinicians spent more time on scene; this allowed more time for analgesics to take effect. Participants perceived paramedics to be more confident, and it was found that paramedics were older, more experienced, had a greater scope of practice, and spent more time on scene than EMTs.

CONCLUSION

Prehospital pain management in children could be improved by facilitating and prioritizing analgesic administration and by ambulance services ensuring a paramedic, or highly trained clinician, is present on each vehicle, necessitating long-term commitment to staff development.

Do National and International Ethics Documents Accord With the Consent Substitute Model for Emergency Research?

In 2010 Largent, Wendler, and Emanuel proposed the "consent substitute model" for emergency research with incapacitated participants. The model provides a means to enroll participants in emergency research without consent, if five conditions are met: 1) the research addresses the patients' urgent medical needs, 2) the risk-benefit ratio is favorable, 3) there are no known conflicts with patients' values or interests, 4) cumulative net risk is minimal, and 5) consent is given as soon as possible. We review national and international ethics laws, regulations, and guidelines to determine 1) whether they accord with the consent substitute model's five conditions and 2) the level of congruence across these documents. We find that only one document meets all five conditions and that there is significant disparity among the documents, particularly between national and international ones. These differences may have stymied international collaboration in emergency research. We recommend that the two international documents used most, the International Council for Harmonization's Guideline for Good Clinical Practice and the World Medical Association's Declaration of Helsinki, are revised to include more specific provisions on emergency medical research.

Predictors of recognition of out of hospital cardiac arrest by emergency medical services call handlers in England: a mixed methods diagnostic accuracy study

BACKGROUND

The aim of this study was to identify key indicator symptoms and patient factors associated with correct out of hospital cardiac arrest (OHCA) dispatch allocation. In previous studies, from 3% to 62% of OHCAs are not recognised by Emergency Medical Service call handlers, resulting in delayed arrival at scene.

METHODS

Retrospective, mixed methods study including all suspected or confirmed OHCA patients transferred to one acute hospital from its associated regional Emergency Medical Service in England from 1/7/2013 to 30/6/2014. Emergency Medical Service and hospital data, including voice recordings of EMS calls, were analysed to identify predictors of recognition of OHCA by call handlers. Logistic regression was used to explore the role of the most frequently occurring (key) indicator symptoms and characteristics in predicting a correct dispatch for patients with OHCA.

RESULTS

A total of 39,136 dispatches were made which resulted in transfer to the hospital within the study period, including 184 patients with OHCA. The use of the term 'Unconscious' plus one or more of symptoms 'Not breathing/Ineffective breathing/Noisy breathing' occurred in 79.8% of all OHCAs, but only 72.8% of OHCAs were correctly dispatched as such. 'Not breathing' was associated with recognition of OHCA by call handlers (Odds Ratio (OR) 3.76). The presence of key indicator symptoms 'Breathing' (OR 0.29), 'Reduced or fluctuating level of consciousness' (OR 0.24), abnormal pulse/heart rate (OR 0.26) and the characteristic 'Female patient' (OR 0.40) were associated with lack of recognition of OHCA by call handlers (p-values < 0.05).

CONCLUSIONS

There is a small proportion of calls in which cardiac arrest indicators are described but the call is not dispatched as such. Stricter adherence to dispatch protocols may improve call handlers' OHCA recognition. The existing dispatch protocol would not be improved by the addition of further terms as this would be at the expense of dispatch specificity.

Mixed methods in pre-hospital research: understanding complex clinical problems

Healthcare is becoming increasingly complex. The pre-hospital setting is no exception, especially when considering the unpredictable environment. To address complex clinical problems and improve quality of care for patients, researchers need to use innovative methods to create the necessary depth and breadth of knowledge. Quantitative approaches such as randomised controlled trials and observational (e.g. cross-sectional, case control, cohort) methods, along with qualitative approaches including interviews, focus groups and ethnography, have traditionally been used independently to gain understanding of clinical problems and how to address these. Both approaches, however, have drawbacks: quantitative methods focus on objective, numerical data and provide limited understanding of context, whereas qualitative methods explore more subjective aspects and provide perspective, but can be harder to demonstrate rigour. We argue that mixed methods research, where quantitative and qualitative methods are integrated, is an ideal solution to comprehensively understand complex clinical problems in the pre-hospital setting.

The aim of this article is to discuss mixed methods in the field of pre-hospital research, highlight its strengths and limitations and provide examples. This article is tailored to clinicians and early career researchers and covers the basic aspects of mixed methods research. We conclude that mixed methods is a useful research design to help develop our understanding of complex clinical problems in the pre-hospital setting.

Factors that motivate individuals to volunteer to be dispatched as first responders in the event of a medical emergency: A systematic review protocol

Background: Voluntary First Response is an important component of prehospital care for medical emergencies, particularly cardiac arrest, in many countries. This intervention entails the mobilisation of volunteers, known as Community First Responders (CFRs), by the Emergency Medical Services to respond to medical emergencies in their locality. They include lay responders and/or professional responders (e.g. police officers, fire fighters, and general practitioners). A wide variety of factors are thought to motivate CFRs to join and remain engaged in Voluntary First Response schemes, such as the availability of learning opportunities, recognition, counselling, and leadership. The aim of this review is to develop an in-depth understanding of CFR motivation, including the factors that influence the initial decision to volunteer as a CFR and the factors that sustain involvement in Voluntary First Response over time. Any factors relevant to CFR de-motivation and turnover will also be examined. Methods: This is a protocol for a qualitative systematic review of the factors that influence the motivation of individuals to participate in Voluntary First Response. A systematic search will be carried out on seven electronic databases. Qualitative studies, mixed-methods studies, and any other studies producing data relating to the review question will be eligible for inclusion. Title and abstract screening, as well as full text screening, will be completed independently by two authors. A narrative synthesis, which is an established qualitative synthesis methodology, will be performed. The quality of each of the included studies will be critically appraised. Discussion: The findings of this review will be used to optimise the intervention of Voluntary First Response. Specifically, the results will inform the design and organisation of Voluntary First Response schemes, including their recruitment, training, and psychological support processes. This could benefit a range of stakeholders, including CFRs, paramedics, emergency physicians, patients, and the public.

Emergency department clinical leads' experiences of implementing primary care services where GPs work in or alongside emergency departments in the UK: a qualitative study

BACKGROUND

To manage increasing demand for emergency and unscheduled care NHS England policy has promoted services in which patients presenting to Emergency Departments (EDs) with non-urgent problems are directed to general practitioners (GPs) and other primary care clinicians working within or alongside emergency departments. However, the ways that hospitals have implemented primary care services in EDs are varied. The aim of this study was to describe ED clinical leads' experiences of implementing and delivering 'primary care services' and 'emergency medicine services' where GPs were integrated into the ED team.

METHODS

We conducted interviews with ED clinical leads in England (n = 19) and Wales (n = 2). We used framework analysis to analyse interview transcripts and explore differences across 'primary care services', 'emergency medicine services' and emergency departments without primary care services.

RESULTS

In EDs with separate primary care services, success was reported when having a distinct workforce of primary care clinicians, who improved waiting times and flow by seeing primary care-type patients in a timely way, using fewer investigations, and enabling ED doctors to focus on more acutely unwell patients. Some challenges were: trying to align their service with the policy guidance, inconsistent demand for primary care, accessible community primary care services, difficulties in recruiting GPs, lack of funding, difficulties in agreeing governance protocols and establishing effective streaming pathways. Where GPs were integrated into an ED workforce success was reported as managing the demand for both emergency and primary care and reducing admissions.

CONCLUSIONS

Introducing a policy advocating a preferred model of service to address primary care demand was not useful for all emergency departments. To support successful and sustainable primary care services in or alongside EDs, policy makers and commissioners should consider varied ways that GPs can be employed to manage variation in local demand and also local contextual factors such as the ability to recruit and retain GPs, sustainable funding, clear governance frameworks, training, support and guidance for all staff. Whether or not streaming to a separate primary care service is useful also depended on the level of primary care demand.

Exploring the experiences of having Guillain-Barré Syndrome: A qualitative interview study

Background

Guillain‐Barré syndrome (GBS) is a rare inflammatory disorder affecting the peripheral nerves. Although typically there is full neurological recovery, some people continue to experience residual physical, psychological or social problems longer term. Evidence describing the experiences of people with GBS is limited.

Objective

We aimed to explore the experiences of people with GBS in the UK.

Design

We used qualitative (face‐to‐face and telephone) interviews to explore experiences of people with GBS. Audio‐recorded data were transcribed verbatim and analysed using the Framework Method supported by NVivo 11.

Setting and Participants

We purposively recruited a sample of 16 volunteers with a prior diagnosis of GBS of varying age, sex, ethnicity, location, marital status, time since diagnosis and length of hospital stay to maximize differences in experience. Interviewees were required to have been discharged from hospital, able to give informed consent, able to speak and understand English and currently resident in the United Kingdom.

Results

The key themes arising from the analysis were as follows: the importance of early diagnosis; the experiences of inpatient care; the importance of active support for recovery; the need for communication throughout the course of the illness; the need for greater awareness, knowledge and provision of information by health‐care staff; and path to achieving function.

Conclusion

This is the first qualitative study exploring experiences of people with GBS in the UK through their whole illness journey from onset to recovery. The findings contribute to our understanding of the experiences and support needs of people recovering from GBS.

Communicating cancer risk in the primary care consultation when using a cancer risk assessment tool: Qualitative study with service users and practitioners

Background

Cancer risk assessment tools are designed to help detect cancer risk in symptomatic individuals presenting to primary care. An early detection of cancer risk could mean early referral for investigations, diagnosis and treatment, helping to address late diagnosis of cancer. It is not clear how best cancer risk may be communicated to patients when using a cancer risk assessment tool to assess their risk of developing cancer.

Objective

We aimed to explore the perspectives of service users and primary care practitioners on communicating cancer risk information to patients, when using QCancer, a cancer risk assessment tool.

Design

A qualitative study involving the use of individual interviews and focus groups.

Setting and participants

Conducted in primary care settings in Lincolnshire with a convenience sample of 36 participants (19 service users who were members of the public) and 17 primary care practitioners (general practitioners and practice nurses).

Results

Participants suggested ways to improve communication of cancer risk information: personalizing risk information; involving patients in use of the tool; sharing risk information openly; and providing sufficient time when using the tool during consultations.

Conclusion

Communication of cancer risk information is complex and difficult. We identified strategies for improving communication with patients involving cancer risk estimations in primary care consultations.

Predictors of effective management of acute pain in children within a UK ambulance service: A cross-sectional study

OBJECTIVE

We aimed to identify predictors of effective management of acute pain in children in the pre-hospital setting.

METHODS

A retrospective cross-sectional study using electronic clinical records from one large UK ambulance service during 01-Oct-2017 to 30-Sep-2018 was performed using multivariable logistic regression. We included all children <18 years suffering acute pain. Children with a Glasgow Coma Scale score of <15, no documented pain or without a second pain score were excluded. The outcome measure was effective pain management (abolition or reduction of pain by ≥2 out of 10 using the numeric pain rating scale, Wong-Baker FACES® scale or FLACC [face, legs, activity, crying and consolability] scale).

RESULTS

2312 patients were included for analysis. Median (IQR) age was 13 (9-16), 54% were male and the cause of pain was trauma in 66% of cases. Predictors of effective pain management include children who were younger (0-5 years) compared to older (12-17 years) (adjusted odds ratio [AOR] 1.53; 95% confidence interval [CI] 1.18-1.97), administered analgesia (AOR 2.26; CI 1.87-2.73), attended by a paramedic (AOR 1.46; CI 1.19-1.79) or living in an area of low deprivation (index of multiple deprivation [IMD] 8-10) compared to children in an area of high deprivation (IMD 1-3) (AOR 1.37; CI 1.04-1.80). Child sex, type of pain, transport time, non-pharmacological treatments and clinician experience were not significant.

CONCLUSION

These predictors highlight disparity in effective pre-hospital management of acute pain in children. Qualitative research is needed to help explain these findings.

Factors that motivate individuals to volunteer to be dispatched as first responders in the event of a medical emergency: A systematic review protocol

Background: Voluntary First Response is an important component of prehospital care for medical emergencies, particularly cardiac arrest, in many countries. This intervention entails the mobilisation of volunteers, known as Community First Responders (CFRs), by the Emergency Medical Services to respond to medical emergencies in their locality. They include lay responders and/or professional responders (e.g. police officers, fire fighters, and general practitioners). A wide variety of factors are thought to motivate CFRs to join and remain engaged in Voluntary First Response schemes, such as the availability of learning opportunities, recognition, counselling, and leadership. The aim of this review is to develop an in-depth understanding of CFR motivation, including the factors that influence the initial decision to volunteer as a CFR and the factors that sustain involvement in Voluntary First Response over time. Any factors relevant to CFR de-motivation and turnover will also be examined. Methods: This is a protocol for a qualitative systematic review of the factors that influence the motivation of individuals to participate in Voluntary First Response. A systematic search will be carried out on seven electronic databases. Qualitative studies, mixed-methods studies, and any other studies producing data relating to the review question will be eligible for inclusion. Title and abstract screening, as well as full text screening, will be completed independently by two authors. A narrative synthesis, which is an established qualitative synthesis methodology, will be performed. The quality of each of the included studies will be critically appraised. Discussion: The findings of this review will be used to optimise the intervention of Voluntary First Response. Specifically, the results will inform the design and organisation of Voluntary First Response schemes, including their recruitment, training, and psychological support processes. This could benefit a range of stakeholders, including CFRs, paramedics, emergency physicians, patients, and the public.

A tailored e-learning gives long-term changes in determinants of GPs' benzodiazepines prescribing: a pretest-posttest study with self-report assessments

Objective: Despite guidelines and campaigns, general practitioners (GPs) continue to overprescribe benzodiazepines (BZDs). New approaches to improve prescribing are needed. Using behavior change techniques and tailoring interventions to user characteristics are vital to promote behavior change. This study evaluated the impact of a tailored e-learning module on factors known to determine BZD prescribing within GPs.Design: A pretest-posttest study design with three self-report assessments concerning determinants of BZD prescribing: at baseline, immediately after the module (short term) and six months after completion (long term).Setting: Flanders (Belgium)Intervention: A tailored e-module that focuses on avoiding initial BZD prescriptions and using psychological interventions as an alternative.Subjects: 244 GPsMain outcome measures: Assessed determinants include GPs' attitudes concerning treatment options, perceptions of the patient and self-efficacy beliefs. Readiness to adhere to prescribing guidelines was evaluated through assessing motivation, self-efficacy and implementability of non-pharmacological interventions.Results: A significant and durable impact on determinants of BZD prescribing was observed. GPs underwent desirable changes in attitudes, perceptions and self-efficacy beliefs and these changes remained significant six months later.Conclusion: Tailoring an e-intervention to target group characteristics appears to be successful in promoting behavioral change in experienced GPs. Significant and lasting changes were observed in determinants of prescribing BZDs.Key PointsA tailored e-intervention resulted in significant and long term changes in previously identified determinants of prescribing BZDs. The e-module resulted in a positive impact on GPs' readiness to adhere to BZD prescribing guidance and the way they experience psychosocial consultations. Tailoring an e-intervention to target group characteristics appears to be successful in promoting behavioral change in experienced GPs.

Performance in candidates declaring versus those not declaring dyslexia in a licensing clinical examination

CONTEXT

High-stakes medical examinations seek to be fair to all candidates, including an increasing proportion of trainee doctors with specific learning differences. We aimed to investigate the performance of doctors declaring dyslexia in the clinical skills assessment (CSA), an objective structured clinical examination for licensing UK general practitioners.

METHODS

We employed a cross-sectional design using performance and attribute data from candidates taking the CSA between 2010 and 2017. We compared candidates who declared dyslexia ('early' before their first attempt or 'late' after failing at least once) with those who did not, using multivariable negative binomial regression investigating the effect of declaring dyslexia on passing the CSA, accounting for relevant factors previously associated with performance, including number of attempts, initial score, sex, place of primary medical qualification and ethnicity.

RESULTS

Of 20 879 CSA candidates, 598 (2.9%) declared that they had dyslexia. Candidates declaring dyslexia were more likely to be male (47.3% versus 37.8%; p < 0.001) and to have a non-UK primary medical qualification (26.9% versus 22.4%; p < 0.01), but were no different in ethnicity compared with those who never declared dyslexia. Candidates who declared dyslexia late were significantly more likely to fail compared with those candidates who declared dyslexia early (40.6% versus 9.2%; p < 0.001) and were more likely to have a non-UK medical qualification (79.3% versus 15.6%; p < 0.001) or come from a minority ethnic group (84.9% versus 39.2%; p < 0.001). The chance of passing was lower for candidates declaring dyslexia compared to those who never declared dyslexia and lower in those declaring late (incident rate ratio [IRR], 0.82; 95% confidence interval [CI], 0.70-0.96) compared with those declaring early (IRR, 0.95; 95% CI, 0.93-0.97).

CONCLUSIONS

A small proportion of candidates declaring dyslexia were less likely to pass the CSA, particularly if dyslexia was declared late. Further investigation of potential causes and solutions is needed.

Out-of-hospital cardiac arrest termination of resuscitation with ongoing CPR: An observational study

INTRODUCTION

Termination of resuscitation guidelines for out-of-hospital cardiac arrest can identify patients in whom continuing resuscitation has little chance of success. This study examined the outcomes of patients transferred to hospital with ongoing CPR. It assessed outcomes for those who would have met the universal prehospital termination of resuscitation criteria (no shocks administered, unwitnessed by emergency medical services, no return of spontaneous circulation).

METHODS

A retrospective cohort study of consecutive adult patients who were transported to hospital with ongoing CPR was conducted at three hospitals in the West Midlands, UK between September 2016 and November 2017. Patient characteristics, interventions and response to treatment (ROSC, survival to discharge) were identified.

RESULTS

227 (median age 69 years, 67.8% male) patients were identified. 89 (39.2%) met the universal prehospital termination of resuscitation criteria. Seven (3.1%) were identified with a potentially reversible cause of cardiac arrest. After hospital arrival, patients received few specialist interventions that were not available in the prehospital setting. Most (n = 210, 92.5%) died in the emergency department. 17 were admitted (14 to intensive care), of which 3 (1.3%) survived to hospital discharge. There were no survivors (0%) in those who met the criteria for universal prehospital termination of resuscitation.

CONCLUSION

Overall survival amongst patients transported to hospital with ongoing CPR was very poor. Application of the universal prehospital termination of resuscitation rule, in patients without obvious reversible causes of cardiac arrest, would have allowed resuscitation to have been discontinued at the scene for 39.2% of patients who did not survive.

Has there been a change in the knowledge of GP registrars between 2011 and 2016 as measured by performance on common items in the Applied Knowledge Test?

The aim of this study was to assess whether the absolute standard of candidates sitting the MRCGP Applied Knowledge Test (AKT) between 2011 and 2016 had changed. It is a descriptive study comparing the performance on marker questions of a reference group of UK graduates taking the AKT for the first time between 2011 and 2016. Using aggregated examination data, the performance of individual 'marker' questions was compared using Pearson's chi-squared tests and trend-line analysis. Binary logistic regression was used to analyse changes in performance over the study period. Changes in performance of individual marker questions using Pearson's chi-squared test showed statistically significant differences in 32 of the 49 questions included in the study. Trend line analysis showed a positive trend in 29 questions and a negative trend in the remaining 23. The magnitude of change was small. Logistic regression did not demonstrate any evidence for a change in the performance of the question set over the study period. However, candidates were more likely to get items on administration wrong compared with clinical medicine or research. There was no evidence of a change in performance of the question set as a whole.

Understanding variation in ambulance service non-conveyance rates: a mixed methods study

Background

In England in 2015/16, ambulance services responded to nearly 11 million calls. Ambulance Quality Indicators show that half of the patients receiving a response by telephone or face to face were not conveyed to an emergency department. A total of 11% of patients received telephone advice only. A total of 38% of patients were sent an ambulance but were not conveyed to an emergency department. For the 10 large ambulance services in England, rates of calls ending in telephone advice varied between 5% and 17%. Rates of patients who were sent an ambulance but not conveyed to an emergency department varied between 23% and 51%. Overall non-conveyance rates varied between 40% and 68%.

Objective

To explain variation in non-conveyance rates between ambulance services.

Design

A sequential mixed methods study with five work packages.

Setting

Ten of the 11 ambulance services serving > 99% of the population of England.

Methods

(1) A qualitative interview study of managers and paramedics from each ambulance service, as well as ambulance commissioners (totalling 49 interviews undertaken in 2015). (2) An analysis of 1 month of routine data from each ambulance service (November 2014). (3) A qualitative study in three ambulance services with different published rates of calls ending in telephone advice (120 hours of observation and 20 interviews undertaken in 2016). (4) An analysis of routine data from one ambulance service linked to emergency department attendance, hospital admission and mortality data (6 months of 2013). (5) A substudy of non-conveyance for people calling 999 with breathing problems.

Results

Interviewees in the qualitative study identified factors that they perceived to affect non-conveyance rates. Where possible, these perceptions were tested using routine data. Some variation in non-conveyance rates between ambulance services was likely to be due to differences in the way rates were calculated by individual services, particularly in relation to telephone advice. Rates for the number of patients sent an ambulance but not conveyed to an emergency department were associated with patient-level factors: age, sex, deprivation, time of call, reason for call, urgency level and skill level of attending crew. However, variation between ambulance services remained after adjustment for patient-level factors. Variation was explained by ambulance service-level factors after adjustment for patient-level factors: the percentage of calls attended by advanced paramedics [odds ratio 1.05, 95% confidence interval (CI) 1.04 to 1.07], the perception of ambulance service staff and commissioners that advanced paramedics were established and valued within the workforce of an ambulance service (odds ratio 1.84, 95% CI 1.45 to 2.33), and the perception of ambulance service staff and commissioners that senior management was risk averse regarding non-conveyance within an ambulance service (odds ratio 0.78, 95% CI 0.63 to 0.98).

Limitations

Routine data from ambulance services are complex and not consistently collected or analysed by ambulance services, thus limiting the utility of comparative analyses.

Conclusions

Variation in non-conveyance rates between ambulance services in England could be reduced by addressing variation in the types of paramedics attending calls, variation in how advanced paramedics are used and variation in perceptions of the risk associated with non-conveyance within ambulance service management. Linking routine ambulance data with emergency department attendance, hospital admission and mortality data for all ambulance services in the UK would allow comparison of the safety and appropriateness of their different non-conveyance rates.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Perceptions and experiences of community first responders on their role and relationships: qualitative interview study

BACKGROUND

Community First Responders (CFRs) are lay volunteers who respond to medical emergencies. We aimed to explore perceptions and experiences of CFRs in one scheme about their role.

METHODS

We conducted semi-structured interviews with a purposive sample of CFRs during June and July 2016 in a predominantly rural UK county. Interviews were transcribed verbatim and analysed using the Framework method, supported by NVivo 10.

RESULTS

We interviewed four female and 12 male adult CFRs aged 18-65+ years with different levels of expertise and tenures. Five main themes were identified: motivation and ongoing commitment; learning to be a CFR; the reality of being a CFR; relationships with statutory ambulance services and the public; and the way forward for CFRs and the scheme. Participants became CFRs mainly for altruistic reasons, to help others and put something back into their community, which contributed to personal satisfaction and helped maintain their involvement over time. CFRs valued scenario-based training and while some were keen to access additional training to enable them to attend a greater variety of incidents, others stressed the importance of maintaining existing abilities and improving their communication skills. They were often first on scene, which they recognised could take an emotional toll but for which they found informal support mechanisms helpful. Participants felt a lack of public recognition and sometimes were undervalued by ambulance staff, which they thought arose from a lack of clarity over their purpose and responsibilities. Although CFRs perceived their role to be changing, some were fearful of extending the scope of their responsibilities. They welcomed support for volunteers, greater publicity and help with fundraising to enable schemes to remain charities, while complementing the role of ambulance services.

DISCUSSION

CFR schemes should consider the varying training, development and support needs of staff. CFRs wanted schemes to be complementary but distinct from ambulance services. Further information on outcomes and costs of the CFR contribution to prehospital care is needed.

CONCLUSION

Our findings provide insight into the experiences of CFRs, which can inform how the role might be better supported. Because CFR schemes are voluntary and serve defined localities, decisions about levels of training, priority areas and targets should be locally driven. Further research is required on the effectiveness, outcomes, and costs of CFR schemes and a wider understanding of stakeholder perceptions of CFR and CFR schemes is also needed.