Venous blood point-of-care testing (POCT) for paramedics in urgent and emergency care: protocol for a single-site feasibility study (POCTPara)

The COVID-19 pandemic placed the UK healthcare system under unprecedented pressure, and recovery will require whole-system investment in innovative, flexible and pragmatic solutions. Positioned at the heart of the healthcare system, ambulance services have been tasked with addressing avoidable hospital conveyance and reducing unnecessary emergency department and hospital attendances through the delivery of care closer to home. Having begun to implement models of care intended to increase 'see and treat' opportunities through greater numbers of senior clinical decision makers, emphasis has now been placed upon the use of remote clinical diagnostic tools and near-patient or point-of-care testing (POCT) to aid clinical decision making. In terms of POCT of blood samples obtained from patients in the pre-hospital setting, there is a paucity of evidence beyond its utility for measuring lactate and troponin in acute presentations such as sepsis, trauma and myocardial infarction, although potential exists for the analysis of a much wider panel of analytes beyond these isolated biomarkers. In addition, there is a relative dearth of evidence in respect of the practicalities of using POCT analysers in the pre-hospital setting. This single-site feasibility study aims to understand whether it is practical to use POCT for the analysis of patients' blood samples in the urgent and emergency care pre-hospital setting, through descriptive data of POCT application and through qualitative focus group interviews of advanced practitioners (specialist paramedics) to inform the feasibility and design of a larger study. The primary outcome measure is focus group data measuring the experiences and perceived self-reported impact by specialist paramedics. Secondary outcome measures are number and type of cartridges used, number of successful and unsuccessful attempts in using the POCT analyser, length of time on scene, specialist paramedic recruitment and retention, number of patients who receive POCT, descriptive data of safe conveyance, patient demographics and presentations where POCT is applied and data quality. The study results will inform the design of a main trial if indicated.

Exploring the experiences of community first responders working in a UK ambulance service

Background

Community first responders (CFRs) work voluntarily to support UK ambulance services by responding to emergencies. They are dispatched via the local 999 call centre and details of incidents in their local area are sent to their mobile phone. They have emergency equipment with them, including a defibrillator and oxygen, and attend a range of incidents, including cardiac arrests. Previous research has looked at the impact the CFR role has had on patient survival, but there is no previous research looking at the experiences of the CFRs while working in a UK ambulance service.

Method

This study involved 10 semi-structured interviews, which took place in November and December 2018. One researcher interviewed all the CFRs using a pre-defined interview schedule. The findings of the study were analysed using thematic analysis.

Results

The main themes from the study are 'relationships' and 'systems'. The sub-themes of relationships are the relationship between CFRs; the relationship between CFRs and ambulance service staff; and the relationship between CFRs and patients. The sub-themes of systems are call allocation; technology; and reflection and support.

Conclusions

CFRs support one another and are encouraging with new starting members. Their relationships with ambulance service staff have improved since CFRs first became active, but there is still room for improvement. The calls that CFRs attend are not always within their scope of practice, but the rate of this occurring is unclear. CFRs are frustrated with the level of technology involved in their role and feel it impacts them attending incidents quickly. CFRs reported attending cardiac arrests on a regular basis and the support that they receive afterwards. Further research should use a survey approach to further explore the experiences of the CFRs based on the themes raised in this study. Using this methodology would identify if these themes are unique to the one ambulance service where this was conducted, or if they are relevant to all UK CFRs.

The experiences and perceptions of wellbeing provision among English ambulance services staff: a multi-method qualitative study

Background

NHS ambulance service staff are at risk of poor physical and mental wellbeing because of the likelihood of encountering stressful and traumatic incidents. While reducing sickness absence and improving wellbeing support to ambulance staff is a key NHS priority, few studies have empirically documented a national picture to inform policy and service re-design. The study aimed to understand how ambulance service trusts in England deal with staff health and wellbeing, as well as how the staff perceive and use wellbeing services.

Methods

To achieve our aim, we undertook semi-structured telephone interviews with health and wellbeing leads and patient-facing ambulance staff, as well as undertaking documentary analysis of ambulance trust policies on wellbeing. The study was conducted both before and during the UK first COVID-19 pandemic wave. The University of Lincoln ethics committee and the Health Research Authority (HRA) granted ethical approval. Overall, we analysed 57 staff wellbeing policy documents across all Trusts. Additionally, we interviewed a Health and Wellbeing Lead in eight Trusts as well as 25 ambulance and control room staff across three Trusts.

Results

The study highlighted clear variations between organisational and individual actions to support wellbeing across Trust policies. Wellbeing leads acknowledged real ‘tensions’ between individual and organisational responsibility for wellbeing. Behaviour changes around diet and exercise were perceived to have a positive effect on the overall mental health of their workforce. Wellbeing leads generally agreed that mental health was given primacy over other wellbeing initiatives. Variable experiences of health and wellbeing support were partly contingent on the levels of management support, impacted by organisational culture and service delivery challenges for staff.

Conclusion

Ambulance service work can impact upon physical and mental health, which necessitates effective support for staff mental health and wellbeing. Increasing the knowledge of line managers around the availability of services could improve engagement.

PP42 Perceptions and experiences of wellbeing provision for NHS ambulance staff: a qualitative interview study of wellbeing leads and frontline staff

Background

The wellbeing of ambulance staff is critical to their safety and safe care delivery. This study examined the perceptions of English NHS ambulance Trust health and wellbeing leads, and the experiences of UK ambulance staff of workplace wellbeing culture and provision.

Methods

Semi-structured telephone interviews were undertaken with staff wellbeing leads for eight NHS ambulance trusts in England and with ambulance staff from three NHS ambulance trusts in England, selected to represent services with high, medium or low relative sickness absence rates. Interviews were subsequently transcribed, coded and analysed using Framework Analysis (FA).

Results

We interviewed eight wellbeing leads and 25 frontline ambulance staff from April-November 2020. Decisions around what was included in or omitted from wellbeing policies sometimes led to conflict between wellbeing leads and their superiors. Ambulance work was perceived as inherently unhealthy because of work stress and the risk of encountering traumatic incidents. Well-being leads understood the adverse impacts of work on mental health for some staff. Ambulance staff wanted empathy, understanding and practical support from managers, but the reality did not always match these needs, because of variability in provision and experiences of health and wellbeing services, poor behaviours or attitudes from line managers, and a stigmatising rather than open organisational culture. COVID-19 not only impacted significantly on staff health and wellbeing, but also challenged how ambulance trusts support them.

Conclusions

The importance of an open organisational culture and the variable availability and experiences of interventions to support staff to stay well at work means that improvements are needed in both to ensure positive staff mental health and wellbeing. Early interventions, improved training for line managers to support staff at work, bespoke wellbeing services and an open culture are key to delivering effective support to ambulance staff, especially in the light of the COVID-19 pandemic.

Mixed-methods feasibility cluster randomised controlled trial of a paramedic-administered breathlessness management intervention for acute-on-chronic breathlessness (BREATHE): Study findings

Introduction

One-fifth of emergency department presentations by ambulance are due to acute-on-chronic breathlessness. We explored the feasibility of an evaluation-phase, cluster randomised controlled trial (cRCT) of the effectiveness and cost-effectiveness of a paramedic-administered, non-pharmacological breathlessness intervention for people with acute-on-chronic breathlessness at ambulance call-out (BREATHE) regarding breathlessness intensity and conveyance to hospital.

Methods

This mixed-methods, feasibility cRCT (ISRCTN80330546), randomised paramedics to usual care or intervention plus usual care. Retrospective patient consent to use call-out data (primary endpoint) and prospective patient/carer consent for follow-up was sought. Potential primary outcomes included breathlessness intensity (numerical rating scale) and conveyance. Follow-up included: interviews with patients/carers and questionnaires at 14 days, 1 and 6 months; paramedic focus groups and surveys.

Results

Recruitment was during COVID-19, with high demands on paramedics and fewer call-outs by eligible patients. We enrolled 29 paramedics; nine withdrew. Randomisation/trial procedures were acceptable.

Paramedics recruited thirteen patients, not meeting recruitment target (n=36); eight patients and three carers were followed up. Data quality was good but insufficient for future sample size estimation.

The intervention did not extend call-out time, was delivered with fidelity and was acceptable to patients, carers and paramedics. There were no repeat call-outs within 48 h. All trained paramedics strongly recommended BREATHE as a highly relevant, simple intervention.

Conclusion

Patient recruitment to target was not feasible during the pandemic. Training and intervention were acceptable and delivered with fidelity. Results include valuable information on recruitment, consent, attrition, and data collection that will inform the design and delivery of a definitive trial.

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.

PP25 The take home naloxone intervention multicentre emergency setting feasibility (TIME) trial: an early perspective from one UK ambulance service

Background

Drug poisoning deaths in England and Wales have increased by 52% since 2011 with over half involving opioids. Deaths are preventable if naloxone is administered in time. Take Home Naloxone (THN) kits have been distributed through drug services; however, uptake is low and effectiveness unproven. The TIME trial tests the feasibility of conducting a full randomised controlled trial of providing THN administration and basic life support training to high-risk opioid-users in emergency care settings.

Methods

A multi-site feasibility trial commenced in June 2019 with two hospitals and their surrounding ambulance services (Bristol Royal Infirmary (BRI) with South Western Ambulance NHS Foundation Trust (SWASFT) and Hull Royal Infirmary with Yorkshire Ambulance Service) randomly allocated to intervention arms; and sites in Wrexham and Sheffield allocated as ‘usual care’ controls. SWASFT began recruiting in October 2019 with the aim of recruiting and training 50% (n=111) of paramedics working within the BRI’s catchment area, to supply THN to at least 100 eligible patients during a 12-month period.

Results

The trial was suspended between 17.03.2020-06.08.2020 and extended to 01.03.2021 (COVID-19). Despite this, 121 SWASFT paramedics undertook TIME training. TIME trained paramedics attended 30% (n=57) of the n=190 opioid-related emergency calls requiring naloxone administration during the study period. A total of n=29 potentially eligible patients were identified before and n=28 after the COVID-19 suspension. Two patients were supplied with THN during each period. During the COVID-19 suspension, twenty-two potentially eligible patients were missed. The majority of eligible patients presented with a reduced consciousness level, preventing recruitment (73%; n=42/48). These patients were transported to hospital for further treatment (n=39) or died on scene following advanced life support (n=3).

Conclusions

The lowered consciousness levels of prehospital emergency ambulance patients who present with opioid poisoning, often prevent the delivery of training required to enable the supply of THN.

A feasibility cluster randomised controlled trial of a paramedic-administered breathlessness management intervention for acute-on-chronic breathlessness (BREATHE)

Chronic breathlessness, persistent and disabling despite optimal treatment of underlying causes, is a prevalent and frightening symptom and is associated with many emergency presentations and admission to hospital. Breathlessness management techniques used by paramedics may reduce the need for conveyance to hospital. The Breathlessness RElief AT HomE study (BREATHE) aims to explore the feasibility of conducting a definitive cluster randomised controlled trial (cRCT) for people with acute-on-chronic breathlessness who have called an ambulance, to evaluate the effectiveness and cost-effectiveness of a paramedic-administered non-pharmacological breathlessness intervention.

The trial is a mixed-methods feasibility cRCT. Eight paramedics will be randomised 1:1 to deliver either the BREATHE intervention in addition to usual care or usual care alone at call-outs for acute-on-chronic breathlessness. Sixty participants will be recruited to provide access to routine data relating to the index call-out with optional follow-up questionnaires at 14 days, 1 month and 6 months. An in-depth interview will be conducted with a subgroup. Feasibility outcomes relating to recruitment, data quality (especially candidate primary outcomes), and intervention acceptability and fidelity will be collected as well as providing data to estimate a sample size for a definitive trial.

Yorkshire and The Humber–Sheffield Research Ethics Committee approved the trial protocol (19/YH/0314). The study results will inform progression to, or not, and design of a main trial according to predetermined stop-go criteria. Findings will be disseminated to relevant stakeholders and submitted for publication in a peer-reviewed journal.

Acute-on-chronic breathlessness initiates many emergency presentations. The BREATHE protocol describes a feasibility, cluster randomised controlled trial of a paramedic breathlessness management intervention.https://bit.ly/2LZg72w

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

Background:

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

Aim:

To investigate factors commonly associated with ambulance staff suicides.

Method:

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

Results:

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

Conclusion:

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

OP6 An investigation into suicide amongst ambulance service staff

Background

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

Methods

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

Results

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

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

Conclusions

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

Dysprosody following acquired neurogenic impairment

Dysprosody is typically associated with the dysarthrias following acquired neurogenic disturbance but it has also been associated with impairment to the cortex of the right cerebral hemisphere (Behrens, 1985). Currently there is little agreement in the clinical literature as to the locus or nature of processes involved in production and reception of prosody. This paper investigates the usefulness of two psycholinguistic models of prosody--involving "abstract" and "concrete" processes (Ladd & Cutler, 1983)--in accounting for dysprosody following motor pathway as well as cortical lesions. Four groups of 10 adult patients each participated in the study; the first group had sustained a right cerebral hemisphere cortical stroke, the second group had hypokinetic dysarthria, the third group had ataxic dysarthria, and the fourth group was normal controls. Acoustic analysis using the Kay VisiPitch/PC was conducted on pairs of matched noun phrase and noun compounds (e.g., greenhouse, green house), interrogative and declarative versions of sentences, and sentences spoken in each of four different emotional tones. Right cerebral hemisphere damaged subjects produced shorter durations than the other groups for each stimulus class. However, all of the subjects were able to use duration to signal temporal information for the lexical distinction between noun compounds and noun phrases. The results are consistent with a model of prosodic control which involves both cortical as well as physiological control processes. Current treatment for dysprosody is discussed in light of this new emphasis on cognitive control processes.