PP45 ‘Every day was a learning curve’: the experience of implementing COVID-19 triage protocols in UK ambulance services – a qualitative study

Background

TRIM is an evaluation of the models used to triage and manage emergency ambulance service care for patients with suspected Covid-19 during the first wave of the pandemic in 2020. We aimed to understand experiences and concerns of clinical and managerial staff about implementation of triage protocols in call centre and on-scene.

Methods

Research paramedics in four study sites across England interviewed purposively selected stakeholders from ambulance services (call handlers, clinical advisors in call centres, clinicians providing emergency response, managers) and ED clinical staff from one hospital per site. Interviews (n=23) were conducted remotely using MS Teams, recorded, and transcribed in full. Analysis generated themes from the implicit and explicit ideas within participants’ accounts, following the six stages of analysis described by Braun and Clarke, conducted by a group of researchers and PPI partners working together.

Results

We identified the following themes:

Constantly changing guidelines – at some points, updates several times a day

The ambulance service as part of the wider healthcare system - changes in other parts of the healthcare system left ambulance services as the default option

Peaks and troughs of demand - demand fluctuated greatly over time, with workload varying across the ambulance service, including an increased role for clinical advisors

A stretched system - resources to respond to patient demand were stretched thinner by staff sickness and isolation, longer job times, and increased handover delays at ED

Emotional load of responding to the pandemic - particularly for call centre staff

Doing the best they can in the face of uncertainty - in the face of a rapidly evolving situation unlike any which ambulance services had faced before

Discussion

Implementing triage protocols in response to the Covid-19 pandemic was a complex and process which had to be actively managed by a range of front line staff, dealing with external pressures and a heavy emotional load.

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.

Erratum to: 36th International Symposium on Intensive Care and Emergency Medicine: Brussels, Belgium. 15-18 March 2016

[This corrects the article DOI: 10.1186/s13054-016-1208-6.].

Identification of the platelet ADP receptor targeted by antithrombotic drugs

Platelets have a crucial role in the maintenance of normal haemostasis, and perturbations of this system can lead to pathological thrombus formation and vascular occlusion, resulting in stroke, myocardial infarction and unstable angina. ADP released from damaged vessels and red blood cells induces platelet aggregation through activation of the integrin GPIIb-IIIa and subsequent binding of fibrinogen. ADP is also secreted from platelets on activation, providing positive feedback that potentiates the actions of many platelet activators. ADP mediates platelet aggregation through its action on two G-protein-coupled receptor subtypes. The P2Y1 receptor couples to Gq and mobilizes intracellular calcium ions to mediate platelet shape change and aggregation. The second ADP receptor required for aggregation (variously called P2Y(ADP), P2Y(AC), P2Ycyc or P2T(AC)) is coupled to the inhibition of adenylyl cyclase through Gi. The molecular identity of the Gi-linked receptor is still elusive, even though it is the target of efficacious antithrombotic agents, such as ticlopidine and clopidogrel and AR-C66096 (ref. 9). Here we describe the cloning of this receptor, designated P2Y12, and provide evidence that a patient with a bleeding disorder has a defect in this gene. Cloning of the P2Y12 receptor should facilitate the development of better antiplatelet agents to treat cardiovascular diseases.

Comparative effects of a genetically engineered insect virus and a growth-regulating insecticide on microbial communities in aquatic microcosms

The effects of a genetically engineered insect baculovirus on indigenous aquatic microbial communities were determined in closed, recirculating aquatic microcosms, and compared with the effects of a natural strain of the virus and of a growth-regulating insecticide, Dimilin. The recombinant virus was a nuclear polyhedrosis virus (NPV) of the spruce budworm (Choristoneura fumiferana (Cf)) with a lacZ marker gene inserted into the egt region of the CfNPV. The natural virus was Ireland strain CfNPV. Microbial measurement endpoints included decomposition activity (mass loss of organic material), respiration on two different substrates (O2 consumption), heterotrophic bacterial abundance (plate counts), and microbial community metabolic profiles (carbon source utilization patterns in Biolog GN microplates). Viral DNA of both the natural strain and the recombinant viruses, detected by polymerase chain reaction techniques, settled out of the microcosm water and accumulated on bottom substrates within 3 days of the microcosm inoculations. The viral DNA persisted in bottom substrates for the duration of the 21-day experimental period, although there was some evidence that the recombinant virus was less stable than the natural strain in particulate organic matter. No significant changes in microbial decomposition or respiration activity, bacterial abundance, or average metabolic responses were detected by a time trend analysis in microcosms inoculated with either the lacZ recombinant virus or the natural Ireland strain CfNPV. Significant effects on microbial decomposition and respiration activity were detected in microcosms treated with the growth-regulating insecticide at, and above, the expected environmental concentrations. Despite significant effects on microbial community functional attributes in Dimilin-treated microcosms, there were no detectable changes in community structure in terms of metabolic profiles or bacterial abundance.

Immunizing preschool children: beliefs and practices of pediatric residents

Immunization practices and knowledge of vaccine contraindications among pediatric residents were assessed at five pediatric training facilities by surveying 227 pediatric residents. Residents administer vaccines even in the presence of an afebrile minor illness. They are less likely to vaccinate if a fever (< 102 degrees F) is present. Only 57% of residents report administering vaccines at the 15-month well-child checks. Many residents had difficulty recognizing true and false contraindications, though third-year residents did better than first-year residents. Failure during residency to utilize 15-month well visits and ill visits in the presence of a fever and the lack of knowledge of true and false vaccine contraindications may be causes of missed opportunities to vaccinate among residents. Immunization practices resulting in missed opportunities to vaccinate seen during during residency may influence later immunization practices.

Characterization of a HeLa cDNA clone encoding the human SII protein, an elongation factor for RNA polymerase II

We present the cloning and sequence characterization of a HeLa cDNA encoding the SII transcription elongation factor. This cDNA clone is distinct from those previously isolated from a human kidney cDNA library [Yoo et al., Nucleic Acids Res. 19 (1991) 1073-1079]. Southern analysis suggests that more than one gene may exist for SII in the human genome. A comparison of deduced amino acid sequences for SII-related proteins from a variety of eukaryotes demonstrates very high similarity, especially within the C-terminal domain.

Src homology region 2 domains direct protein-protein interactions in signal transduction

Cytoplasmic proteins that regulate signal transduction or induce cellular transformation, including cytoplasmic protein-tyrosine kinases, p21ras GTPase-activating protein (GAP), phospholipase C gamma, and the v-crk oncoprotein, possess one or two copies of a conserved noncatalytic domain, Src homology region 2 (SH2). Here we provide direct evidence that SH2 domains can mediate the interactions of these diverse signaling proteins with a related set of phosphotyrosine ligands, including the epidermal growth factor (EGF) receptor. In src-transformed cells GAP forms heteromeric complexes, notably with a highly tyrosine phosphorylated 62-kDa protein (p62). The stable association between GAP and p62 can be specifically reconstituted in vitro by using a bacterial polypeptide containing only the N-terminal GAP SH2 domain. The efficient phosphorylation of p62 by the v-Src or v-Fps tyrosine kinases depends, in turn, on their SH2 domains and correlates with their transforming activity. In lysates of EGF-stimulated cells, the N-terminal GAP SH2 domain binds to both the EGF receptor and p62. Fusion proteins containing GAP or v-Crk SH2 domains complex with similar phosphotyrosine proteins from src-transformed or EGF-stimulated cells but with different efficiencies. SH2 sequences, therefore, form autonomous domains that direct signaling proteins, such as GAP, to bind specific phosphotyrosine-containing polypeptides. By promoting the formation of these complexes, SH2 domains are ideally suited to regulate the activation of intracellular signaling pathways by growth factors.

Ascorbate: the most effective antioxidant in human blood plasma

Ascorbate is the only endogenous antioxidant in plasma that can completely protect the lipoproteins from detectable peroxidative damage induced by aqueous peroxyl radicals and the oxidants released from activated PMNs. In contrast to aqueous oxidants, lipid-soluble peroxyl radicals unsparingly induce detectable peroxidative damage to plasma lipids. However, under these conditions, too, ascorbate appears to belong to the first line of antioxidant defense. Our findings strongly suggest that pathologically relevant lipid hydroperoxide formation consequent to acute or chronic leukocyte activation can be prevented by ascorbate supplementation, provided no free metal catalysts are present. Ascorbate should prove very helpful in the treatment and prevention of diseases and degenerative processes caused by oxidative stress.

Ascorbate is an outstanding antioxidant in human blood plasma

We have shown recently that the temporal order of antioxidant consumption in human blood plasma exposed to a constant flux of aqueous peroxyl radicals is ascorbate = protein thiols greater than bilirubin greater than urate greater than alpha-tocopherol and that detectable lipid peroxidation starts only after ascorbate has been consumed completely. In this paper, we show that it is indeed ascorbate that completely protects plasma lipids against detectable peroxidative damage induced by aqueous peroxyl radicals and that ascorbate is the only plasma antioxidant that can do so. Plasma devoid of ascorbate, but no other endogenous antioxidant, is extremely vulnerable to oxidant stress and susceptible to peroxidative damage to lipids. The plasma proteins' thiols, although they become oxidized immediately upon exposure to aqueous peroxyl radicals, are inefficient radical scavengers and appear to be consumed mainly by autoxidation. Our data demonstrate that ascorbate is the most effective aqueous-phase antioxidant in human blood plasma and suggest that in humans ascorbate is a physiological antioxidant of major importance for protection against diseases and degenerative processes caused by oxidant stress.