PP23 Improving CPR quality by the innovative use of a CPR quality officer: a simulation randomised control trial

Background

Ambulance services around the world play a pivotal role in the delivery of advanced life support (ALS) in an out of hospital setting. The European Resuscitation Council guidelines highlight the importance of high-quality cardiopulmonary resuscitation (CPR) and early defibrillation for out-of-hospital advanced life support, with the quality of CPR associated with patient outcomes. Despite this importance, research suggests that there is variable quality of ALS in out of hospital settings.

Methods

A multicentre simulation randomised controlled trial was conducted to measure the effectiveness of introducing a CPR quality officer role in supervising and maintaining the quality of CPR in ALS. The data was collected by a research team that undertook training from the principal researcher.

The participants were ALS trained paramedic students who had experience responding to out of hospital cardiac arrests. The participants were randomised into an intervention and control group and asked to undertake two simulated scenarios, one employing the CPR quality officer, the other without.

The primary outcome measure was the compression score calculated by Laerdal QCPR® software. The score was represented as an overall percentage, illustrating the quality of performed chest compressions, interruptions, and chest recoil.

Results

This is a work in progress, with full data collection now completed. The trial pilot results produced reported an increased overall QCPR score, reduced interruptions, improved chest recoil and an improved chest compression fraction.

Qualitative data from focus groups identified that participants were supportive of the inclusion of the CPR quality officer and did not feel the role interfered with their ALS efforts.

Conclusions

The addition of a designated CPR quality officer addresses a fundamental component within the chain of survival. High-quality sustained CPR positively correlates with patient outcomes. Furthermore, assigning a designated CPR officer affords other team members to focus on their tasks. This inclusion is simple, cost-effective and can be utilised in an array of healthcare settings.

PP33 Use of point of care ultrasound in prehospital care: an interview study

Background

Point of Care Ultrasound (PoCUS) is a currently available and rapidly developing technology but still not widely used in the UK. Prehospital PoCUS could help to prioritise initial treatment, procedures and appropriate patient conveyance.

A recent literature review suggests that the image quality, portability and cost of ultrasound devices are improving with widening indications for prehospital PoCUS but evidence of prehospital use and impact is needed in the UK. We aimed to explore the views of practitioners (who use ultrasound in practice) on the potential role of PoCUS and the facilitators associated with its use in prehospital care.

Methods

We conducted a qualitative interview study using purposive sampling through social media and a snowballing technique to recruit eligible participants. Individual interviews were conducted online via Microsoft Teams. The interviews were recorded, transcribed and analysed using a Thematic Framework approach assisted by NVivo 12 software until data saturation.

Results

In total, 16 practitioners aged between 36 and 62 years, with a range of professional backgrounds including paramedics and prehospital emergency physicians, participated in interviews. Participants identified several facilitators to support a widespread implementation of PoCUS in prehospital care: resource requirements for purchase and deployment of devices, sufficient time and a skilled workforce; paying special attention to training, education and support needs; ensuring there is proper organisational governance, guidelines and quality assurance; and including supportive staff, champions and leadership in workforce considerations. Enabling ease of use in aiding decision making and taking unintended consequences or incidental findings into consideration; and more robust evidence to support perceptions of improved patient outcomes and experience, were also identified as facilitators.

Conclusions

Prehospital PoCUS could be a useful intervention for improving care processes and patient health outcomes. However, the facilitators identified should be considered for a widespread implementation of prehospital PoCUS.

EP10 Community first responders‘ contribution to rural emergency medical service provision in the UK

Background

Community First Responders (CFRs) are volunteers dispatched by Emergency Medical Services (EMS) to potentially life-threatening emergencies to provide care until the ambulance staff arrive. Previous qualitative research described CFRs’ role, perceptions, and motivations, but quantitative evidence on their contribution to rural healthcare provision is lacking. We aimed to investigate the number, types, and location of calls (rural or urban), and characteristics of patients attended.

Methods

We used a retrospective observational design analysing routine data from six of ten ambulance services in England during 2019. Descriptive statistics were used to directly compare incidents where CFRs attended first with attendances from ambulance staff. A multiple logistic regression model was used to identify the main predictors of CFR attendance.

Results

The data included 4.5 million incidents over one year. CFRs attended first a significantly higher proportion of calls in rural areas compared to urban areas (3.90% vs 1.48%, p<0.05). The main predictors of CFR presence were rurality (Odds Ratio [OR] 2.05, 95% Confidence Interval [CI] 1.99-2.11, p<0.001), conditions including cardiorespiratory (OR 9.20, 95%CI 5.08-16.64, p<0.001) or neurological/endocrine (OR 9.26, 95%CI 5.12-16.77, p<0.001) and the most urgent call category 1 (OR 5.19, 95%CI 3.86-6.99, p<0.001) and call category 2 (OR 4.44, 95%CI 3.31-5.96 p<0.001). CFRs were also less likely to attend patients from minority ethnic backgrounds, those younger than 39 years, and incidents in more deprived areas.

Conclusions

CFRs play an important role in EMS delivery, supporting the work of ambulance services, especially in rural areas. The work of CFRs has expanded from its original purpose to attend out-of-hospital cardiac arrest to more types of emergencies. Future development of CFR schemes should prioritise training for a range of conditions, and access to more deprived and ethnically diverse areas.

Mental health emergencies attended by ambulances in the United Kingdom and the implications for health service delivery: A cross-sectional study

OBJECTIVE

In the context of increasing demand for ambulance services, emergency mental health cases are among the most difficult for ambulance clinicians to attend, partly because the cases often involve referring patients to other services. We describe the characteristics of mental health emergencies in the East Midlands region of the United Kingdom. We explore the association between 999 (i.e. emergency) call records, the clinical impressions of ambulance clinicians attending emergencies and the outcomes of ambulance attendance. We consider the implications of our results for optimizing patient care and ambulance service delivery.

METHODS

We conducted a retrospective observational study of records of all patients experiencing mental health emergencies attended by ambulances between 1 January 2018 and 31 July 2020. The records comprised details of 103,801 '999' calls (Dispatch), the preliminary diagnoses by ambulance clinicians on-scene (Primary Clinical Impression) and the outcomes of ambulance attendance for patients (Outcome).

RESULTS

A multinomial regression analysis found that model fit with Outcome data was improved with the addition of Dispatch and Primary Clinical Impression categories compared to the fit for the model containing only the intercept and Outcome categories (Chi-square = 18,357.56, df = 180, p < 0.01). Dispatch was a poor predictor of Primary Clinical impression. The most common predictors of Outcome care pathways other than 'Treated and transported' were records of respiratory conditions at Dispatch and anxiety reported by clinicians on-scene.

CONCLUSIONS

Drawing on the expertise of mental health specialists may help '999' dispatchers distinguish between physical and mental health emergencies and refer patients to appropriate services earlier in the response cycle. Further investigation is needed to determine if training Dispatch operatives for early triage and referral can be appropriately managed without compromising patient safety.

Clinical and cost-effectiveness of paramedic administered fascia iliaca compartment block for emergency hip fracture (RAPID 2)-protocol for an individually randomised parallel-group trial

Background

Approximately 75,000 people fracture a hip each year in the UK. This painful injury can be devastating—with a high associated mortality rate—and survivors likely to be more dependent and less mobile. Pain relief at the scene of injury is known to be inadequate. Intravenous morphine is usually given by paramedics, but opioids are less effective for dynamic pain and can cause serious side effects, including nausea, constipation, delirium and respiratory depression. These may delay surgery, require further treatment and worsen patient outcomes. We completed a feasibility study of paramedic-provided fascia iliaca compartment block (FICB), testing the intervention, trial methods and data collection. The study (RAPID) demonstrated that a full trial was feasible. In this subsequent study, we aim to test safety, clinical and cost-effectiveness of paramedic-provided FICB as pain relief to patients with suspected hip fracture in the prehospital environment.

Methods

We will conduct a pragmatic multi-centre individually randomised parallel-group trial, with a 1:1 allocation between usual care (control) and FICB (intervention). Hospital clinicians in five sites (paired ambulance services and receiving hospitals) in England and Wales will train 220 paramedics to administer FICB. The primary outcome is change in pain score from pre-randomisation to arrival at the emergency department. One thousand four hundred patients are required to find a clinically important difference between trial arms in the primary outcome (standardised statistical effect ~ 0.2; 90% power, 5% significance). We will use NHS Digital (England) and the SAIL (Secure Anonymised Information Linkage) databank (Wales) to follow up patient outcomes using routine anonymised linked data in an efficient study design, and questionnaires to capture patient-reported outcomes at 1 and 4 months. Secondary outcomes include mortality, length of hospital stay, job cycle time, prehospital medications including morphine, presence of hip fracture, satisfaction, mobility, and NHS costs. We will assess safety by monitoring serious adverse events (SAEs).

Discussion

The trial will help to determine whether paramedic administered FICB is a safe, clinically and cost-effective treatment for suspected hip fracture in the pre-hospital setting. Impact will be shown if and when clinical guidelines either recommend or reject the use of FICB in routine practice in this context.

Trial registration

ISRCTN15831813. Registered on 22 September 2021.

Improving ambulance care for children suffering acute pain: a qualitative interview study

Background

Pain is a highly complex sensory and emotional experience. When a child suffers acute pain through illness or injury, they are often transported to hospital by ambulance. Pre-hospital pain management in children is poor, with 61% of children receiving suboptimal pain management. Consequences of poor pain management include the risk of developing post-traumatic stress disorder and altered pain perception. We aimed to identify clinicians’ perceptions of barriers, facilitators and potential improvements for the management of pre-hospital acute pain in children.

Methods

Qualitative face to face semi-structured recorded interviews were performed in one large UK ambulance service. Audio files were transcribed verbatim with thematic analysis used to generate themes. NVivo 12 was used to support data analysis. Findings were combined with existing evidence to generate a driver diagram.

Results

Twelve ambulance clinicians participated, including 9 registered paramedics and 3 emergency medical technicians. Median (IQR) age was 43.50 (41.50, 45.75) years, 58% were male, median (IQR) experience was 12 (4.25, 15.50) years and 58% were parents. Several themes relating to barriers and facilitators were identified, including physical, emotional, social, organisational, environmental, management, knowledge and experience. Improvement themes were identified relating to management, organisation and education. These data were combined to create a driver diagram; the three primary drivers were 1) explore methods to increase rates of analgesic administration, including utilising intranasal or inhaled routes; 2) reduce fear and anxiety in children, by using child friendly uniform, additional non-pharmacological techniques and more public interaction and 3) reduce fear and anxiety in clinicians, by enhancing training and optimising crew mix.

Conclusions

The quality of care that children receive for acute pain in the ambulance service may be improved by increasing rates of analgesic administration and reducing the fear and anxiety experienced by children and clinicians. Future research involving children and parents would be useful to determine the most important outcome measures and facilitate intervention development.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-022-00648-y.

Characterizing Unusual Spatial Clusters of Male Mental Health Emergencies Occurring During the First National COVID-19 "Lockdown" in the East Midlands Region, UK: A Geospatial Analysis of Ambulance 999 Data

The widespread psychological effects of contagion mitigation measures associated with the novel coronavirus disease 2019 (COVID-19) are well known. Phases of “lockdown” have increased levels of anxiety and depression globally. Most research uses methods such as self-reporting that highlight the greater impact of the pandemic on the mental health of females. Emergency medical data from ambulance services may be a better reflection of male mental health. We use ambulance data to identify unusual clusters of high rates of male mental health emergencies occurring in the East Midlands of the United Kingdom during the first national “lockdown” and to explore factors that may explain clusters. Analysis of more than 5,000 cases of male mental health emergencies revealed 19 unusual spatial clusters. Binary logistic regression analysis (χ² = 787.22, df = 20, p ≤ .001) identified 16 factors that explained clusters, including proximity to “healthy” features of the physical landscape, urban and rural dynamics, and socioeconomic condition. Our findings suggest that the factors underlying vulnerability of males to severe mental health conditions during “lockdown” vary within and between rural and urban spaces, and that the wider “hinterland” surrounding clusters influences the social and physical access of males to services that facilitate mental health support. Limitations on social engagement to mitigate effects of the pandemic are likely to continue. Our approach could inform delivery of emergency services and the development of community-level services to support vulnerable males during periods of social isolation.

Ambulance attendance for substance and/or alcohol use in a pandemic: Interrupted time series analysis of incidents

INTRODUCTION

The ambulance attendance for substance and/or alcohol use in a pandemic (ASAP) study explores incidents during the COVID-19 lockdown in the East Midlands region of the United Kingdom (23 March-4 July 2020).

METHOD

Retrospective cross-sectional count per day of ambulance attendances from the East Midlands Ambulance Service Trust. Ambulance attendances relating to alcohol or other drug use in the year prior, during lockdown and weeks following, were examined using interrupted time series analysis by patient demographics and geographical location.

RESULTS

A total of 36 104 records were identified (53.7% male, 84.5% ethnicity classified as White, mean age 38.4 years). A significant drop in the number of attendances per day at the start of lockdown (-25.24, confidence interval - 38.16, -12.32) was observed, followed by a gradual increase during the ongoing lockdown period (0.36, confidence interval 0.23, 0.46). Similar patterns were found across genders, age groups 16-64 and urban/rural locations.

DISCUSSION AND CONCLUSION

The pattern of ambulance attendances for alcohol or other drug use changed during the COVID-19 lockdown period. Lockdown significantly affected the use of ambulances for incidents involving alcohol or other drug use, impacting on health-care services. Further research into hazardous use of alcohol or other drugs during the lockdown periods is needed to inform policy, planning and public health initiatives.

The effectiveness of primary care streaming in emergency departments on decision-making and patient flow and safety - A realist evaluation

Primary care streaming was implemented in UK Emergency Departments (EDs) to manage an increasing demand for urgent care. We aimed to explore its effectiveness in EDs with different primary care models and identify contexts and mechanisms that influenced outcomes: streaming patients to the most appropriate clinician or service, ED flow and patient safety.

METHOD

We observed streaming and interviewed ED and primary care staff during case study visits to 10 EDs in England. We used realist methodology, synthesising a middle-range theory with our qualitative data to refine and create a set of theories that explain relationships between contexts, mechanisms and outcomes.

RESULTS

Mechanisms contributing to the effectiveness of primary care streaming were: quality of decision-making, patient flow, redeploying staff, managing patients across streams, the implementation of governance protocols, guidance, training, service evaluation and quality improvement efforts. Experienced nurses and good teamworking and strategic and operational management were key contextual factors.

CONCLUSION

We recommend service improvement strategies, operational management, monitoring, evaluation and training to ensure that ED nurses stream patients presenting at an ED seeking urgent care to the most appropriate clinicians for their needs in a safe and efficient manner.

Exploring the Impact of the COVID-19 Pandemic on Male Mental Health Emergencies Attended by Ambulances During the First National "Lockdown" in the East Midlands of the United Kingdom

The novel coronavirus disease 2019 (COVID-19) pandemic and associated mitigation strategies such as “lockdown” are having widespread adverse psychological effects, including increased levels of anxiety and depression. Most research using self-reported data highlights the pandemic’s impact on the psychological well-being of females, whereas data for mental health emergency presentations may reflect the impact on male mental health more accurately. We analyzed records of male mental health emergencies occurring in the East Midlands of the United Kingdom during the first national “lockdown.” We computed two binary logistic regression models to (a) compare male mental health emergencies occurring during “lockdown,” 2020 (5,779) with those occurring in the same period in 2019 (N = 4,744) and (b) compare male (N = 5,779) and female (N = 7,695) mental health emergencies occurring during “lockdown.” Comparisons considered the characteristics of mental health emergencies recorded by ambulance clinicians (Primary Impressions), and the socioeconomic characteristics of communities where emergencies use the Index of Multiple Deprivation. We found that during “lockdown,” male emergencies were more likely to involve acute anxiety (odds ratio [OR]: 1.42) and less likely to involve intentional drug overdose (OR: 0.86) or attempted suicide (OR: 0.71) compared with 2019. Compared with females, male emergencies were more likely to involve acute behavioral disturbance (OR: 1.99) and less likely to involve anxiety (OR: 0.67), attempted suicide (OR: 0.83), or intentional drug overdose (OR: 0.76). Compared with 2019, and compared with females, males experiencing mental health emergencies during “lockdown” were more likely to present in areas of high deprivation. Understanding the presentation of male mental health emergencies could inform improved patient care pathways.

Patients’ experiences of attending emergency departments where primary care services are located: qualitative findings from patient and clinician interviews from a realist evaluation

Background

Patient experience is an important outcome and indicator of healthcare quality, and patient reported experiences are key to improving quality of care. While patient experience in emergency departments (EDs) has been reported in research, there is limited evidence about patients’ specific experiences with primary care services located in or alongside EDs. We aim to identify theories about patient experience and acceptability of being streamed to a primary care clinician in an ED.

Methods

Using theories from a rapid realist review as a basis, we interviewed 24 patients and 106 staff members to generate updated theories about patient experience and acceptability of streaming to primary care services in EDs. Feedback from 56 stakeholders, including clinicians, policymakers and patient and public members, as well as observations at 13 EDs, also contributed to the development of these theories, which we present as a programme theory.

Results

We found that patients had no expectations or preferences for which type of clinician they were seen by, and generally found being streamed to a primary care clinician in the ED acceptable. Clinicians and patients reported that patients generally found primary care streaming acceptable if they felt their complaint was dealt with suitably, in a timely manner, and when clinicians clearly communicated the need for investigations, and how these contributed to decision-making and treatment plans.

Conclusions

From our findings, we have developed a programme theory to demonstrate that service providers can expect that patients will be generally satisfied with their experience of being streamed to, and seen by, primary care clinicians working in these services. Service providers should consider the potential advantages and disadvantages of implementing primary care services at their ED. If primary care services are implemented, clear communication is needed between staff and patients, and patient feedback should be sought.

Rethinking the health implications of society-environment relationships in built areas: An assessment of the access to healthy and hazards index in the context of COVID-19

Urban environments have been evolving to mitigate threats to the health and wellbeing of societies for thousands of years, including establishing open spaces to combat bubonic plague, improving waste management in the 20th century, and more recently retrofitting urban landscapes with green space to promote physical exercise. In the context of the current COVID-19 pandemic there is a need to rethink how societies interact with space in built environments to prevent contagion at the same time as facilitating health behaviours, such as exercise. Previously, we examined the spatial relationship between features of urban landscapes that are commonly considered to be 'hazardous' and 'healthy' and unusual clusters of COVID-19 cases in the East Midlands of the UK using ambulance data. Here, we consider the nature of social engagement that these features of urban landscapes facilitate and identify society-environment interactions that may increase risk of exposure to the virus. In some cases, spaces that are commonly thought to promote health behaviour may increase exposure. Contagion hot-spots occur at the nexus of exposure and underlying susceptibility. The viral-host dynamics of infectious disease are changing. Now, as in past eras, societies are required to evolve and adapt to the new challenges presented by emerging infectious diseases in the modern world.

Alcohol and other substance use during the COVID-19 pandemic: A systematic review

BACKGROUND

Although evidence suggests substance and alcohol use may change during the Covid-19 pandemic there has been no full review of the evidence around this.

METHODS

A systematic review of all available evidence was carried out to document and interpret the frequency and severity of alcohol and other substance use during the Covid-19 pandemic and their relationship to demographic and mental health variables that may suggest further clinical implications. Peer reviewed articles in MEDLINE, Embase, PsycINFO, CINAHL complete and Sociological Abstracts were searched from December 2019 until November 2020.

RESULTS

The search and screening identified 45 articles from 513 deduplicated records. The evidence suggests a mixed picture for alcohol use. Overall, there was a trend towards increased alcohol consumption. The proportion of people consuming alcohol during the pandemic ranged from 21.7% to 72.9% in general population samples. Unlike alcohol use, there was a clear trend towards increased use of other substances use during the COVID-19 pandemic. The proportion of people consuming other substances during the pandemic ranged from 3.6% to 17.5% in the general population. Mental health factors were the most common correlates or triggers for increased use of both alcohol and other substances.

CONCLUSION

There is an increased need for treatment for alcohol and other substance use related problems during the pandemic. Increased targeting and evidence-based interventions will also be important in the period which follows this pandemic, to improve the quality of life for individuals and families, but also to prevent additional costs to society and health systems.

Identifying safe care processes when GPs work in or alongside emergency departments: a realist evaluation

BACKGROUND

Increasing pressure on emergency services has led to the development of different models of care delivery including GPs working in or alongside emergency departments (EDs), but with a lack of evidence for patient safety outcomes.

AIM

This study aimed to explore how care processes work and how patient safety incidents associated with GPs working in ED settings may be mitigated.

DESIGN AND SETTING

Realist methodology with a purposive sample of 13 EDs in England and Wales with different GP service models. The study sought to understand the relationship between contexts, mechanisms, and outcomes to develop theories about how and why patient safety incidents may occur, and how safe care was perceived to be delivered.

METHOD

Qualitative data were collected (observations, semi-structured audio-recorded staff interviews, and local patient safety incident reports). Data were coded using 'if, then, because' statements to refine initial theories developed from an earlier rapid realist literature review and analysis of a sample of national patient safety incident reports.

RESULTS

The authors developed a programme theory to describe how safe patient care was perceived to be delivered in these service models, including: an experienced streaming nurse using local guidance and early warning scores; support for GPs' clinical decision making, with clear governance processes relevant to the intended role (traditional GP approach or emergency medicine approach); and strong clinical leadership to promote teamwork and improve communication between services.

CONCLUSION

The findings of this study can be used as a focus for more in-depth human factors investigations to optimise work conditions in this complex care delivery setting.

Perceptions and experiences of residents and relatives of emergencies in care homes: a systematic review and metasynthesis of qualitative research

Background

the perceptions and experiences of care home residents and their families are important for understanding and improving the quality of emergency care.

Methods

we conducted a systematic review and metasynthesis to understand the perceptions and experiences of care home residents and their family members who experienced medical emergencies in a care home setting. The review protocol was registered in PROSPERO (CRD42020167018). We searched five electronic databases, MEDLINE, CINAHL, PubMed, Cochrane Library and PsycINFO, supplemented with internet searches and forward and backward citation tracking from included studies and review articles. Data were synthesised thematically following the Thomas and Harden approach. The Critical Appraisal Skills Programme qualitative checklist was used to assess the quality of studies included in this review.

Results

of the 6,140 references retrieved, 10 studies from four countries (Australia, Canada, UK and USA) were included in the review and metasynthesis. All the included studies were assessed as being of good quality. Through an iterative approach, we developed six analytical themes: (i) infrastructure and process requirements in care homes to prevent and address emergencies; (ii) the decision to transfer to hospital; (iii) experiences of transfer and hospitalisation for older patients; (iv) good communication is vital for desirable outcomes; (v) legal, regulatory and ethical concerns and (vi) 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 and trusting relationships between staff, patients and relatives, underpinned by good communication and attention to ethical practice.

Patient-reported symptoms and experience following Guillain-Barré syndrome and related conditions: Questionnaire development and validation

Background

Guillain‐Barré syndrome (GBS) is a rare inflammatory peripheral nerve disorder with variable recovery. Evidence is lacking on experiences of people with GBS and measurement of these experiences.

Objective

We aimed to develop and validate an instrument to measure experiences of people with GBS.

Design

We used a cross‐sectional design and online self‐administered questionnaire survey. Question domains, based on a previous systematic review and qualitative study, covered experiences of GBS, symptom severity at each stage, healthcare and factors supporting or hindering recovery. Descriptive, exploratory factor and reliability analyses and multivariable regression analysis were used to investigate the relationships between variables of interest, explore questionnaire reliability and validity and identify factors predicting recovery.

Setting and Participants

People with a previous diagnosis of GBS were recruited through a social media advert.

Results

A total of 291 responders, of different sexes, and marital statuses, were included, with most diagnosed between 2015 and 2019. Factor analysis showed four scales: symptoms, information provided, factors affecting recovery and care received. Positive social interactions, physical activity including physiotherapy and movement, changes made at home and immunoglobulin treatment were important for recovery. Multivariable models showed that immunoglobulin and/or plasma exchange were significant predictors of recovery. Employment and recovery factors (positive interactions, work support and changes at work or home, physical activity and therapy), though associated with recovery, did not reach statistical significance.

Conclusion

The questionnaire demonstrated good internal reliability of scales and subscales and construct validity for people following GBS.

Patient Contribution

Patients were involved in developing and piloting the questionnaire.

Trends, variations and prediction of staff sickness absence rates among NHS ambulance services in England: a time series study

OBJECTIVES

Our aim was to measure ambulance sickness absence rates over time, comparing ambulance services and investigate the predictability of rates for future forecasting.

SETTING

All English ambulance services, UK.

DESIGN

We used a time series design analysing published monthly National Health Service staff sickness rates by gender, age, job role and region, comparing the 10 regional ambulance services in England between 2009 and 2018. Autoregressive Integrated Moving Average (ARIMA) and Seasonal ARIMA (SARIMA) models were developed using Stata V.14.2 and trends displayed graphically.

PARTICIPANTS

Individual participant data were not available. The total number of full-time equivalent (FTE) days lost due to sickness absence (including non-working days) and total number of days available for work for each staff group and level were available. In line with The Data Protection Act, if the organisation had less than 330 FTE days available during the study period it was censored for analysis.

RESULTS

A total of 1117 months of sickness absence rate data for all English ambulance services were included in the analysis. We found considerable variation in annual sickness absence rates between ambulance services and over the 10-year duration of the study in England. Across all the ambulance services the median days available were 1 336 888 with IQR of 548 796 and 73 346 median days lost due to sickness absence, with IQR of 30 551 days. Among clinical staff sickness absence varied seasonally with peaks in winter and falls over summer. The winter increases in sickness absence were largely predictable using seasonally adjusted (SARIMA) time series models.

CONCLUSION

Sickness rates for clinical staff were found to vary considerably over time and by ambulance trust. Statistical models had sufficient predictive capability to help forecast sickness absence, enabling services to plan human resources more effectively at times of increased demand.

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.