bluuebunny/crossref_metadata_2025 huggingface dataset:
UNPLANNED, URGENT AND EMERGENCY CARE: WHAT ARE THE ROLES EMS PROVIDE FOR OLDER PEOPLE WITH DEMENTIA? A LITERATURE REVIEW AND NARRATIVE SYNTHESIS
Authors: Buswell Marina , Martin Steven , Lee Caroline , Lumbard Phillip , Prothero Larissa
Published: April 2015

Background

Anecdotally emergency ambulance crews say they frequently encounter older people with dementia (OPWD) and it can be difficult to take history, assess pain and access suitable alternatives to the emergency department especially out of hours. With the current policy landscape of the NHS England Emergency & Urgent Care Review and the high profile of dementia care it is pertinent to ask what role emergency medical services (EMS) have in the urgent and emergency care of OPWD.

Methods

Aware that the research literature in this area was likely to be sparse we used systematic and iterative search techniques to identify relevant studies and documents. All databases available via NHS Evidence were searched and grey literature was included. Articles which made any reference to the pre-hospital role of EMS ambulance services/personnel in the urgent or emergency care of OPWD were included. Discharge roles were excluded.

Results

Nineteen relevant documents were included for review and synthesis, over half from the grey literature. Eight were specifically about EMS treating OPWD, six of those from the grey literature. The other documents, though mentioning the role, were not researching or evaluating that role.

We identified three roles described in the literature; emergency transport, assess and manage, and a last resort/safety net role. This final role is alluded to in over one third of the documents but is not investigated.

Conclusions and recommendations

This review highlights a gap in our understanding and in the research literature about the role EMS play in the care of OPWD, particularly around the last resort/safety net role. We hope it will encourage researchers from EMS and dementia care disciplines to come together, particularly to look at:

▸ Better understanding the last resort/safety net role.

▸ Evaluating AND reporting in the research literature initiatives that are happening in EMS around caring for OPWD.
TRIALS AND TRIBULATIONS: THE STORY OF THE SAFER 2 STUDY
Authors: Chatters Robin , Snooks Helen , Gaze Sarah , Koniotou Marina
Published: April 2015

Background

The SAFER 2 study is an RCT looking to improve the care provided by ambulance service to elderly patients who fall, by providing paramedics with a complex intervention consisting of a paramedic training programme, referral pathway to Falls Prevention Services, clinical support, a clinical decision flowchart and referral feedback. The study received confirmation of funding in December 2008; originally, patient recruitment was scheduled to finish in December 2011.

Methods

Information regarding the progress of the study was sought from study staff, study timelines and quarterly reports sent to the study funders (HTA). General information regarding study progress, as well as events that caused unforeseen set-backs to the study timetable were extracted from these sources and the “story” of the study written in chronological order.

Results

Progress was delayed by a decision by the NIGB to reject an application to access patient's records without consent; we therefore required written consent from patients that would be particularly difficult to obtain. Following ethical approval in February 2010 (11 months behind schedule), the study team worked to confirm participating sites—two falls services within Nottingham had to decline participation, as well as a Health Board within Wales. In early 2010 participating services were confirmed, allowing R&D approvals to be gained for 26 participating trusts. Patient recruitment started in early 2011. Due to issues with patient throughput and retrieval of patient demographics to assess eligibility, a funded extension was granted by the HTA in order to extend recruitment until June 2012.

Discussion

Evaluation of the study was delayed due to issues with ethical approval, site participation and patient eligibility screening and recruitment. Other studies, in other areas of research, have had similar issues, including the COnStRUCT and Family Links studies, which were set-back due to issues with NHS R&D approvals and attribution of costs.
STOCKLIST—A STUDY OF CLINICAL SKILLS OF CRITICAL CARE PARAMEDICS IN THE UK
Authors: Walmsley Jim , Turner Janette
Published: April 2015

Introduction

The Critical Care Paramedic (CCP) is a relatively new advanced practitioner. CCPs provide advanced clinical skills, knowledge and expertise for primary response and critical care retrieval and transfer. In the UK it is currently an undefined role with no common code of practice, clinical governance or national guidance. The aim of this study was to explore the current use of CCPs and assess the views of a range of stakeholders on the required skills and role development within a British context.

How important are the following generic standards?Yes n (%)No n (%)Don't Know n (%)Non Response n (%)Core Competencies95 (68.3)1 (0.7)2 (1.4)41 (29.5)Clinical Governance95 (68.3)1 (0.7)2 (1.4)41 (29.5)Minimum educational standards90 (64.7)4 (2.9)4 (2.9)41 (29.5)National CCP Qualification91 (65.5)1 (0.7)6 (4.3)41 (29.5)Continuous Professional Development93 (66.9)1 (0.7)2 (1.4)43 (30.9)Views about the CCP roleAgree n (%)Disagree n (%)Unsure n (%)Non Response n (%)Can learn from other ‘practitioner’ roles88 (63.3)0 (0)3 (2.2)48 (34.5)Is of limited benefit16 (11.5)69 (49.7)6 (4.3)48 (34.5)Provides an economic advantage55 (39.5)12 (8.7)24 (17.3)48 (34.5)Can't be cost effective.64 (46.1)5 (3.6)22 (15.8)48 (34.5)Fulfills a clinical need82 (59)5 (3.6)4 (2.9)48 (34.5)Should deliver pre-hospital critical care80 (57.6)6 (4.3)5 (3.6)48 (34.5)Should lead pre-hospital critical care51 (36.7)18 (12.9)22 (15.8)48 (34.5)Has the potential to have an impact81 (58.2)1 (0.7)9 (6.5)48 (34.5)Can keep up with rising demand62 (44.6)5 (3.6)24 (17.3)48 (34.5)Is an expensive luxury6 (4.3)66 (47.4)19 (13.7)48 (34.5)Needs opportunities to be effective87 (62.5)0 (0)4 (2.9)48 (34.5)Is not relevant to the provision of care3 (2.1)78 (56.1)10 (7.2)48 (34.5)

Methods

A web based survey design was used to collect information on CCP use and views on skills, role and scope of practice. The survey asked questions on current or intended use of CCPs and skills used. Respondents were asked to rate a list of 23 clinical skills on whether they were essential, desirable or irrelevant; importance of a set of standards and statements about the role of CCPs in the ambulance service. Stakeholders approached included ambulance services, professional bodies, charitable organisations and academic departments.

Results

From 198 invitations there were 141 responses (70%) and 70% were from ambulance trusts. Half of responders said they currently used CCPs. The top 5 essential skills were concerned with airway management. Views on core standards and the CCP role are summarised in the table.

Conclusions

The survey confirmed the CCP role is currently undefined and used variably in practice. There was agreement on the need for core skills and standards but the nature of these is still a matter for debate.
PELVIC FRACTURES IN MOUNTAIN CASUALTIES IN SNOWDONIA: TO STRAP OR NOT TO STRAP?
Authors: Browne Hannah , Dykes Linda
Published: April 2015

Background

Mountain Rescue Teams in Snowdonia endeavour to use pelvic splints as per JRCALC guidelines. However, mountain casualties with major mechanisms of injury are often found in precarious locations where application of splints is challenging. We wondered whether the pelvic fractures seen in mountain casualties are of the type likely to benefit from splintage.

Method

The Bangor Mountain Medicine database (all casualties brought to Ysbyty Gwynedd following contact with MRT and/or RAF SAR helicopter) Jan 2004–October 2012 was interrogated and pelvic fracture cases identified.

Fracture type was analysed from all available imaging using the Tile classification by a Consultant musculoskeletal radiologist. For fatalities, post-mortem reports were examined.

Results

Of 913 casualties in the study period, 730 (80%) were injured rather than ill.

18/730 (2.5%) of trauma casualties had a confirmed pelvic fracture.

14/18 (78%) had fallen from height; 2 were mountain-biking; one crashed his paraglider and one sustained an acetabular fracture in a simple fall.

4.3% of casualties who had fallen from a height greater than standing sustained a pelvic fracture.

2/18 died at scene: post-mortem reports implied severe pelvic disruption but could not be classified further.

In a further 3 cases, imaging was not available, leaving 13 cases for radiological analysis.

13/13 (100%) of fractures could be classified using the Tile system: 61% A1, 31% A2 and 8% C2.

Conclusion

Pelvic fractures are uncommon in Snowdonia mountain casualties, and, in survivors, the vast majority are stable (92%, cf. 55% in urban casualties). Severe pelvic disruption was seen only in casualties declared dead at scene.

Only one casualty in a nine-year period had a pelvic fracture that might benefit from a pelvic splint. Our data suggests that application of pelvic splints need not be considered a high priority in mountain casualties, especially in precarious locations.
PROFESSIONALISM AND CARE: THE DAILY BREAD AND BUTTER OF A PARAMEDIC ATTENDING PATIENTS WHO FALL
Authors: Simmonds Bethany , Clarke Shane , Bradley Rachel , Benger Jonathan , Gooberman-Hill Rachael
Published: April 2015

Falls occur increasingly frequently with age. 35% of people aged over 65 fall each year rising to 50% at age 85. Many patients fall repeatedly. 56% of patients attending an emergency department were recurrent fallers, and 55% of patients presenting with an acute fracture had previously fallen.

Fracturing bones is closely linked to falling and carries great costs both for the NHS and the individual. Paramedics do not routinely assess bone health (fracture risk) in people who fall. This is why a study called ‘The OAK Project’ is being carried out the South West of England to see if it is feasible for paramedics to collect FRAX (The Fracture Risk Assessment Tool) data and whether GPs will put patients with a high risk of fracture on osteoporosis treatment.

A significant element of this feasibility study is a qualitative nested study exploring the acceptability of using FRAX amongst patients and paramedics. When shadowing paramedics (n=6), the level of professionalism and care paramedics gave to patients who fell was striking. Paramedics made clinical assessments, gave personal care, emotional support and provided patients with a high level of dignity.

When questioned about frequent fallers in interviews (n=12), paramedics felt that in many cases everything possible was being done. GPs are quite often aware of their frequent falling patients, home adaptations had been made, often are already taking medications for osteoporosis, they have personal alarms, home carers who visited frequently and fall assessments had been carried out. Additionally, paramedics felt that some patients do not want to be helped and felt there is a limit to what can be done to prevent people from falling in their own homes.

This presentation will provide an insight into the levels of care and professionalism that paramedics demonstrate when attending people who fall in everyday practice.
SICKER FROM THE START: COPD EXACERBATION AND DISTANCE TO HOSPITAL
Authors: Bassir Leila , Dykes Linda , Perry Rob
Published: April 2015

Introduction

We noticed that COPD patients travelling long distances to our rural ED arrived in a worse condition than those living nearby. We suspected this might be due to oxygen-driven nebulisers en route: high-flow oxygen during transfer is known to increase COPD mortality.

Methods

We conducted a retrospective chart review of ED patients who arrived by ambulance and were admitted with exacerbations of COPD December 2010–March 2011.

▸ 42/114 lacked ambulance records, leaving 72 cases for analysis.

▸ We calculated the NHS Early Warning Score (NEWS) on ambulance arrival at scene (“pickup”), and on arrival in ED (“arrival”), and plotted this against distance to hospital.

Results

Mean NEWS score on pickup and arrival showed a gradual linear increase (6/7 to 8/9) with increasing distance from hospital.

▸ Pickup and arrival scores were similar except for patients travelling >35 miles (n=4) whose NEWS rose from 6–8 to 12.

Discussion

These results support our observation that COPD patients living a long way from hospital are sicker on arrival in ED: but they are sicker to start with. Almost everyone arrives at hospital approximately as sick as they were on ambulance arrival, the exception being a small subgroup living furthest from the hospital (35–40 miles).

Our data are retrospective and preliminary: numbers are too small for statistical analysis. However, they suggest that COPD patients in rural areas are already sicker—possibly seeking help later—than those living nearby. A larger study is needed to confirm these results and investigate why: is it rural GPs, their patients, or both, who have a higher threshold for hospital admission than those living closer?

Rural PHEM service planners should consider that paramedics in rural areas not only have longer transport times to hospital, but may also be caring for sicker patients than their urban counterparts.
INVESTIGATING PATIENTS EXPERIENCES OF HYPOGLYCAEMIC EMERGENCIES
Authors: Fitzpatrick D , Duncan E
Published: April 2015

Background

In Scotland approximately 70% of patients with diabetes treated for a hypoglycaemic event by ambulance clinicians remain at home after treatment. However, many of these individuals experience repeat or subsequent hypoglycaemic events. Current clinical guidance recommends that individuals are advised to follow-up care with their GP, however evidence suggests only a minority make these appointments. The reasons for this are unknown.

Aim

To investigate the experiences of patients who are attended by ambulance clinicians for a hypoglycaemic emergency.

Methods

In depth interviews undertaken with adults with diabetes who have experienced a hypoglycaemic emergency treated by Scottish Ambulance Service ambulance clinicians. Data was analysed thematically.

Findings

Twenty six patients were interviewed. Three key themes were developed. Firstly, an explanation for help seeking behaviour; demonstrating that the patient's misinterpretation or lack of symptoms as well as the inability of friends and relatives to cope can contribute to an ambulance call-out. Secondly, the perceptions of ambulance service care; finding that patients felt care provided was good and dependable and that recovery was predictable. Advice given by ambulance clinicians was found to be inconsistent. Thirdly, the influences on uptake of follow-up care; preferences for follow-up care were influenced by previous experiences of home, hospital and primary care.

Limitations

The study found it hard to recruit younger participants (i.e. 16–25 years). Participants' recollection of events on recovery may have been confused due to problems associated with post hypoglycaemic cognitive impairment.

Conclusion

Many patients do not perceive immediate hospital care or follow-up care with their diabetes care provider post hypoglycaemic event to be beneficial.

Recommendation

Interventions aimed at improving self-referral for follow-up care are required to address these perceptions.
MODIFIED EARLY WARNING SCORES (MEWS) TO SUPPORT AMBULANCE CLINICIANS' DECISIONS TO TRANSPORT OR TREAT AT HOME
Authors: Essam Nadya , Windle Karen , Mullineaux David , Knowles Stacey , Gray James , Siriwardena Niroshan
Published: April 2015

Introduction

Modified Early Warning Scores (MEWS), calculated from patients' vital signs, are used in hospital to identify patients who may benefit from admission or intensive care: higher MEWS indicates greater clinical risk. We aimed to evaluate MEWS to support paramedics' decisions to transport patients to hospital or treat and leave them at home.

Methods

We used an interrupted time series design. We trained 19 volunteer paramedics to use MEWS to support decisions to transport or treat and leave at home. We used linear regression to evaluate differences in weekly transportation rates (percentage of patients attended and transported to hospital) and revisit rates (percentage of patients attended, treated at home and subsequently revisited within 7 days), comparing trends in rates 17 weeks prior (pre-MEWS) and 17 weeks post implementation of MEWS. Auto-calculated scores retrospectively applied to all data provided pre-MEWS and were compared with paramedic calculated scores post-MEWS.

Results

Of the 4140 patients attended, 2208 were excluded owing to missing values (n=1897), recording errors (n=21) or excluded clinical complaints (n=290). From the remaining data (n=1932) there were no significant differences in transportation rates (pre=55±6%; post=63±11%) by catering for the existing increasing trends where the confidence intervals of the regression slopes overlap (pre=0.15; 95%CI −0.51 to 0.80 vs. post=0.54; −0.58 to 1.65). Similarly, there were no significant difference in revisit rates (pre=4±4%; post=2±4%) catering for the similar trends (pre=−0.13; −0.53 to 0.27 vs. post=0.08; −0.33 to 0.49). Paramedic scores were incorrect 39% of the time (n=622).

Conclusion

MEWS had a minimal effect on transportation or revisit rates. Scores were frequently not calculated or recorded, or incorrectly calculated. Opportunities for ongoing training, clinical support and feedback were limited. A larger study, ensuring adequate ongoing support, is recommended before implementing MEWS on a wider scale.
HOW DO PEOPLE WITH CHRONIC CONDITIONS EXPERIENCE CARE IN THE HYWEL DDA HEALTH BOARD AREA? FINDINGS FROM INTERVIEWS WITH PATIENTS
Authors: Evans B A , Morrison-Rees S , Harris-Mayes R , Hurlin C
Published: April 2015

Background

The Welsh Government's strategy to improve Chronic Conditions Management includes improving care coordination and patient self-management to reduce unscheduled care use. Welsh health boards have responsibility for implementing the strategy since 2008. In 2011, integrated working between health and social care professionals was piloted in Carmarthenshire, part of Hywel Dda Health Board.

Objective

To describe how people with chronic conditions experience care in Hywel Dda Health Board including changes due to integrated working by professionals.

Method

We conducted semi-structured telephone interviews with chronic conditions patients with multiple and complex conditions. Interviews were recorded, transcribed and analysed using a framework approach. The research team comprised two academic members, two service users and one manager of local health services.

Results

Thirty interviews were undertaken. Experience of care had a big effect on quality of life and helped ability to self-manage, alongside personal outlook, support and information. When missing, patients struggled to manage medication and symptoms. Patients reported variation in coordination between conditions. Respondents with stable or few conditions did not generally identify gaps between different services providing their care. Patients with very poor health appeared to have well integrated care. People with multiple conditions identified lack of communication, slow information exchange and a condition-specific not person-focused approach to care. Difficulties travelling to hospital caused worry and patients missed appointments. It was difficult to discern differences in how care was delivered between Carmarthenshire and other parts of Hywel Dda Health Board.

Conclusion

People with multiple and complex chronic conditions appear confident about self managing their health. Integrated working across providers seems to work best for patients who are least or most ill; otherwise people with multiple conditions complain that care is disease-specific not patient-focused. Accessing treatment should be considered as a component of care because difficult travel arrangements are preventing people attending appointments.
STROKE MIMICS IN THE PRE-HOSPITAL SETTING
Authors: Edwards M J , Fothergill R T , Williams J , Gompertz P
Published: April 2015

Accurate identification of stroke patients is essential to ensure appropriate and timely treatment. Stroke mimics—patients initially suspected to have suffered a stroke who are subsequently diagnosed with a condition other than stroke—are estimated to account for 5–33% of suspected stroke patients conveyed by paramedics to a hospital stroke unit. The prevalence of stroke mimics in London has not been investigated although pan-London hospital data suggests that one quarter of all patients admitted to hyper-acute stroke units (HASUs) are stroke mimics.

Participants were recruited as part of a larger study investigating whether the use of the Recognition of Stroke in the Emergency Room (ROSIER) tool by ambulance crews improved pre-hospital stroke recognition. Only patients indicated by the ROSIER to have potentially suffered a stroke and conveyed to a participating HASU (n=256) were included.

A final diagnosis of stroke was received by 160 patients (“strokes”) while 96 patients received a final diagnosis of non-stroke (“mimics”), resulting in a stroke mimic rate of 38%. Mimics received a wide range of diagnoses, including seizure, syncope, brain tumour, non-organic stroke/symptoms, sepsis, somatisation, and migraine. Compared to strokes, mimics had a lower total ROSIER score, displayed fewer stroke-related symptoms, and presented with more symptoms not indicative of a stroke (e.g. loss of consciousness/syncope, seizure).

The stroke mimic rate is higher than reported by previous studies and pan-London hospital data. It is unlikely this higher rate is due to the use of the ROSIER since the specificity of the ROSIER is equal to the FAST in the pre-hospital setting (Fothergillet al, submitted). Stroke recognition in the pre-hospital setting needs to be improved in order to reduce the number of non-strokes falsely identified as stroke and to ensure these patients are taken to the appropriate facility for treatment.
LEADERSHIP, INNOVATION AND ENGAGEMENT IN QUALITY IMPROVEMENT IN THE AMBULANCE SERVICES CARDIOVASCULAR QUALITY INITIATIVE: CROSS SECTIONAL STUDY
Authors: Essam Nadya , Phung Viet-Hai , Asghar Zahid , Spaight Anne , Siriwardena Aloysius Niroshan
Published: April 2015

Introduction

Clinical leadership and organisational culture are important contextual factors for successful Quality Improvement (QI) programmes. The relationship between these and with organisational performance is complex and poorly understood. We aimed to explore the relationship between leadership, culture of innovation, and clinical engagement in QI for organisations participating in a large-scale national ambulance Quality Improvement Collaborative (QIC).

Methods

We used a cross sectional survey design. An online questionnaire was distributed to 22,117 frontline ambulance staff across all 12 ambulance services in England. Scores (0–100%) were derived for each key aspect: clinical leadership; culture of innovation; use of QI methods; and effectiveness of QI methods. Responses to an open-ended question were analysed and complemented the quantitative findings.

Results

There were 2,743 (12%) responses from 11 of 12 participating ambulance services. Despite only a small proportion of responders (3%) being directly involved with ASCQI, leadership behaviour was significantly higher for ASCQI members than for non-ASCQI members. Involvement in ASCQI was not significantly associated with responders' perceptions of the culture of innovation of their organisation, which was generally considered to be poor. ASCQI members were significantly more likely to use QI methods but overall uptake of QI methods was low. The use of QI methods was also significantly associated with leadership behaviour and service tenure.

Limitations

There was a low response rate, although sufficient responses to enable comparison of those who participated in ASCQI with those who did not.

Conclusion and recommendations

Although participants reported a lack of organisational culture of innovation, considered a prerequisite for QI, the collaborative achieved significant wide-scale improvements in prehospital care for myocardial infarction and stroke. We postulate that improvement was mediated through a ‘QI subculture’ developed from ASCQI's distributed leadership and network. Further research is needed to understand success factors for QI in different complex healthcare environments.
AMBULANCE SERVICE TREAT AND REFER GUIDELINES: A QUALITAIVE INVESTIGATION INTO THE USE OF TREAT AND REFER GUIDELINES BY AMBULANCE CLINICIANS
Authors: Colver Keith , Abhyankar Purva , Niven Catherine
Published: April 2015

Background

Over the last decade there has been a steadily increasing demand for unscheduled healthcare services, including the ambulance services. To address this demand, various projects have been developed to reduce admissions to the emergency department. One of these was the introduction of Treat and Refer (T&R) guidelines, to allow ambulance clinicians to treat certain groups of patients in the community without the need to convey them to hospital. Aims: This study aims to explore the challenges and barriers faced by ambulance clinicians in the use of T&R guidelines, to inform the future development and governance of non-conveyance guidelines and interventions.

Methods

Semi-structured interviews were conducted with 18 ambulance clinicians. Data were analysed using framework analysis. Setting: A national UK NHS ambulance service.

Results

There was a broad support for the concept and policy of T&R; however the participants had mixed views with respect to the actual practice of treating and referring patients. Participants acknowledged the potential benefits of T&R for patients and the NHS, but identified several risks in using T&R in routine practice. Their perceptions of risk seemed to determine whether and how the guidelines were used. Challenges in the use of T&R included: lack of training and knowledge, fear of litigation, a lack of support from the management and difficulties in decision-making.

Conclusions

This study and the supporting literature do not support the use of T&R guidelines in their current format by traditionally trained ambulance clinicians. Ambulance clinicians have identified the need for further education and support. The conceptual support for T&R may provide a foundation to develop and improve the education and support for ambulance clinicians. This should be combined with implementation/review strategies, clinician-led decision support and management support which can provide the ambulance clinician with the skills and confidence to take responsibility for non-conveyance.
PREHOSPITAL OUTCOMES FOR AMBULANCE SERVICE CARE: SYSTEMATIC REVIEW
Authors: Phung Viet-Hai , Booth Andrew , Coster Joanne , Turner Janette , Wilson Richard , Niroshan Siriwardena A.
Published: April 2015

Background

Ambulance service performance measurement has previously focused on response times and survival. We conducted a systematic review of the international literature on quality measures and outcomes relating to pre-hospital ambulance service care, aiming to identify a broad range of outcome measures to provide a more meaningful assessment of ambulance service care.

Methods

We searched a number of electronic databases including CINAHL, the Cochrane Library, EMBASE, Medline, and Web of Science. For inclusion, studies had to report either research or evaluation conducted in a pre-hospital setting, published in the English language from 1982 to 2011, and reporting either outcome measures or specific outcome instruments.

Results

Overall, 181 full-text articles were included: 83 (46%) studies from North America, 50 (28%) from Europe and 21 (12%) from the UK. A total of 176 articles were obtained after examining 257 full-text articles in detail from 5,088 abstracts screened. A further five papers were subsequently identified from references of the articles examined and studies known to the authors. There were 140 articles (77%) which contained at least one survival-related measure, 47 (34%) which included information about length of stay and 87 (48%) which identified at least one place of discharge as an outcome.

Limitations

We encountered the problem of incomplete information, for instance studies not specifying which pain scales when these had been used or using survival without a specific time period.

Conclusion and recommendations

In addition to measures relating to survival, length of stay and place of discharge, we identified 247 additional outcome measures. Few studies included patient reported or cost outcomes. By identifying a wide range of outcome measures this review will inform further research looking at the feasibility of using a wider range of outcome measures and developing new outcome measures in prehospital research and quality improvement.
BARRIERS AND FACILITATORS FOR PEOPLE IN BME GROUPS ACCESSING PRE-HOSPITAL CARE AND CAUSES AND CONSEQUENCES OF ANY DIFFERENCES IN DELIVERY: SYSTEMATIC REVIEW AND NARRATIVE SYNTHESIS
Authors: Windle Karen , Niroshan Siriwardena A , Barot Mukesh , Essam Nadya , Johnson Mark , Kai Joe , Ortega Marishona
Published: April 2015

Introduction

Research addressing inequalities has focused predominantly on primary and community care; few initiatives relate to the pre-hospital environment. We aimed to identify in the literature barriers or facilitators experienced by patients from BME communities in accessing pre-hospital care and to explore the causes and consequences of any differences in delivery.

Methods

We conducted a systematic literature review and narrative synthesis. Electronic and journal hand searches from 2003 through 2013 identified relevant evaluative studies (systematic reviews, randomised controlled trials, quasi-experimental, case and observational studies). A researcher extracted data to determine characteristics, results and quality, each checked by a second reviewer. The main outcome measures were delays in patient calls, mortality rates and 30-days survival post discharge.

Results

Eighteen studies met criteria for the review: two concerned services in England and Wales and 15 were United States based. Reported barriers to accessing care were generic (and well-known) given the heterogeneity of BME groups: difficulties in communication where English was the patient's second language; new migrants' lack of knowledge of the health care system leading to inappropriate emergency calls; and cultural assumptions among clinical staff resulting in inappropriate diagnoses and treatment. There were limited reported facilitators to improvement, such as the need for translation services and staff education, but the latter were poorly described or developed. Where outcomes were discussed, there was evidence for race-related disparity in mortality and survival rates. This could reflect differences in condition severity, delays between onset and initiation of calls, or the scope of response and assistance.

Conclusion

The paucity of literature and difficulties of transferring findings from US to UK context identified an important research gap. Further studies should be undertaken to investigate UK differences in prehospital care and outcomes for BME groups, followed by qualitative approaches to understand barriers and enablers to equitable access.
INTRODUCTION OF A PREDICTIVE RISK TOOL IN PRIMARY CARE: CONTEXT AND EXPECTATIONS
Authors: Kingston Mark Rhys , Evans Bridie Angela
Published: April 2015

Introduction

Patients with chronic conditions account for a third of emergency hospital admissions, many of which are not life-threatening and result in unnecessary hospital stays. Focussed primary and community care could prevent one-in-five emergency admissions, improving health outcomes and saving money. Predictive risk models which use routine data to identify at risk populations for targeted care aim to reduce emergency admissions but we do not know how GPs react to their introduction.

The Prism tool predicts likelihood of patient's emergency admission to hospital and divides the entire practice population into risk categories low to high. Swansea University is leading the PRISMATIC trial, evaluating the introduction of Prism into 32 Welsh GP practices.

Prism, and other similar tools, effectively predict admissions but questions remain over their adoption. We asked potential users of Prism how they expect its introduction to affect patient care and emergency admissions.

Methods

43 GPs, practice managers and nurses from 32 general practices participated in one of four focus groups or an interview before receiving Prism. We recorded the groups and interviews, with participants' consent, and carried out thematic analysis of transcripts.

Results

We found that respondents supported the principle of proactively identifying at risk patients and were willing to trial Prism. It appealed to their desire to improve care through targeting patients who could become emergencies. Perceived challenges included: integrating Prism with existing practice; limited time and community staff to follow up identified patients.

Risk predictions tools like Prism effectively predict hospital emergency admissions and are increasingly being introduced. Without sufficient evidence about how practitioners perceive and use these tools, their introduction is unlikely to make a difference to patients—nor have the desired effect on resources. PRISMATIC will provide evidence about how context and expectations can affect implementation.
INVESTIGATING THE VOLUME OF MENTAL HEALTH EMERGENCY CALLS IN THE WELSH AMBULANCE SERVICE TRUST (WAST) AND DEVELOPING A PRE-HOSPITAL MENTAL HEALTH MODEL OF CARE FOR APPLICATION AND TESTING
Authors: Morisson-Rees Sian , Whitfield Richard , Evans Sherrill , Snooks Helen , Huxley Peter , John Ann , Baker Chris , Engamba Serge , Rees Nigel
Published: April 2015

Background

Limited published evidence indicates a significant impact from mental health related calls on ambulance services (AS), however available routine data appear to underestimate the amount of these calls and the resources spent in response.

Paramedics have reported feeling ill-equipped for informed clinical decision-making in mental health cases: leaving at home can risk self harm, but conveying to an emergency departments is often not the most appropriate place for patients with mental distress and unnecessarily ties up resources.

Objective

To investigate mental health 999 calls in WAST and design a relevant model-of-care for testing.

Method

We examined the Patient Clinical Records (PCR) completed by paramedics on scene for all calls handled by WAST in April 2012. We extracted an electronically generated 10% random sample and coded the narrative section based upon ICD 10 codes.

We mapped statutory mental health services in three different ambulance trusts. A panel of experts identified the critical factors and devised a generic model of care based upon an ideal model to support paramedics and the pragmatics of existing services.

Results

In April 2012 WAST handled 28,328 999 calls, with 1642 (5.8%) recorded with a mental health condition code. In the random sample we found 164 (10.5%) calls related to mental health problems and estimate the volume to be 2974 per month. Each category of mental health problem had a conveyance rate of over 80%, with the exception of anxiety (61.6%)

The alternative statutory services available varies by AS area, however enough commonality existed to reach consensus and design a generic mental health model of care.

Conclusion

Both dispatch and on-scene condition codes underestimate the volume of mental health related emergency calls by nearly half. Our model of care provides considerable potential to support paramedics to assess and reduce transfers to emergency departments through access to pre-existing community care provision.
SINGLE DOSE ACTIVATED CHARCOAL FOR PRE-HOSPITAL USE, A FEASIBILITY STUDY BY SOUTH WESTERN AMBULANCE SERVICE NHS FOUNDATION TRUST
Authors: Walker Richard , Black Sarah
Published: April 2015

In 2004 The National Institute for Health and Care Excellence (NICE) recommended in that ambulance services should carry Single Dose Activated Charcoal (SDAC) as an antidote to self-poisoning.

A survey of ambulance services conducted a year later found a strong reluctance by services to carry the medication.

As a result of a research project supporting the recommendation of NICE the South Western Ambulance Service conducted a six month trial of SDAC in two of its zones.

A Patient Group Directive was produced and an education programme put in place.

Patient Report Forms coded for overdose or where SDAC had been used were retrieved and examined for data. An on-line survey was completed by staff who had been involved in the trial.

Paramedic crews attending cases of self-poisoning within one hour of ingestion offered SDAC to those patients.

Of 69 occasions on which the medication was offered the uptake rate was 94%.

54% of administrations (n=38) were for hepatotoxic overdoses of paracetamol with a further 3 administrations for lethal doses of other types of drug.

Crews used Toxbase on 13 occasions finding their advice extremely clear and helpful. This resulted in SDAC administration on all 13 occasions where crews were uncertain about its suitability on grounds of type of toxin ingested or because the one hour window had been exceeded..

Average time from ingestion to SDAC administration was 23 minutes and 26 seconds.

Time on scene where SDAC was offered was 20 minutes and 24 seconds compared with 23 minutes and 26 seconds where SDAC was not offered.

Vomiting post administration occurred in only 11% of cases and crews reported no problems encountered in managing patients.

Concerns of ambulance services in 2005 of prolonged on-scene times, poor take-up and time required to clean ambulances appear unfounded.
Safe sedation practices among gastroenterology registrars: do we need more training?
Authors: Mohanaruban Aruchuna , Bryce Kathleen , Radhakrishnan Archchana , Gallaher Joseph , Johnson Gavin
Published: April 2015

Endoscopy training is a central component of gastroenterology training for the vast majority of UK trainees, and integral to this is the practice of safe sedation. The majority of endoscopic procedures are performed with the patient under conscious sedation with a benzodiazepine, often combined with an opioid. Little data exists on the practice of sedation among gastroenterology trainees, including their degree of knowledge of the common sedation agents used and their actions. Using both an online and paper-based questionnaire, we surveyed current gastroenterology speciality trainees (ST) in the UK and received 78 responses giving a response rate of 10%. Fifty-one per cent of the trainees did not receive structured training in safe sedation, despite national guidelines advising this to be an essential part of the training programme, and 92% felt a structured sedation course would be beneficial. We also identified some gaps in trainees’ knowledge of the action of sedation agents. We propose that a formal training session in sedation or an e-learning module could be incorporated as part of a deanery or trust induction for gastroenterology trainees and kept under regular review.
Women's economic activity trajectories over the life course: implications for the self-rated health of women aged 64+ in England
Authors: Stone Juliet , Evandrou Maria , Falkingham Jane , Vlachantoni Athina
Published: April 2015

Background

Previous research has highlighted the importance of accumulated life-course labour market status and the balancing of multiple roles for understanding inequalities in health in later life. This may be particularly important for women, who are increasingly required to balance work and family life in liberal welfare contexts, such as in Britain.

Methods

This study analyses retrospective life history data for 2160 women aged 64+ years (born 1909–1943) from the English Longitudinal Study of Ageing, collected in 2006–2007 as part of an ongoing panel study. Optimal matching and cluster analyses are used to produce a taxonomy of women's life-course economic activity trajectories based on their experiences between ages 16 and 64 years. This classification is then used in logistic regression analysis to investigate associations with self-rated health in later life.

Results

A set of five trajectories emerge as the dominant patterns of women's economic activity over the life course for those cohorts of English women born prior to 1943: (1) full-time workers; (2) family carers; (3) full-time returners; (4) part-time returners; (5) atypical/inactive. Regression analyses show that women who experience defined periods of full-time work both before and after focusing on family life appear to have the most favourable later life health outcomes.

Conclusions

The findings are discussed with reference to the accumulation of social and economic resources over the life course and the balancing of multiple roles in work and family domains. In conclusion, the development of policies that facilitate women, if they wish, to successfully combine paid employment with family life could have a positive impact on their health in later life.
Effect of a community intervention programme promoting social interactions on functional disability prevention for older adults: propensity score matching and instrumental variable analyses, JAGES Taketoyo study
Authors: Hikichi Hiroyuki , Kondo Naoki , Kondo Katsunori , Aida Jun , Takeda Tokunori , Kawachi Ichiro
Published: April 2015

Background

The efficacy of promoting social interactions to improve the health of older adults is not fully established due to residual confounding and selection bias.

Methods

The government of Taketoyo town, Aichi Prefecture, Japan, developed a resident-centred community intervention programme called ‘community salons’, providing opportunities for social interactions among local older residents. To evaluate the impact of the programme, we conducted questionnaire surveys for all older residents of Taketoyo. We carried out a baseline survey in July 2006 (prior to the introduction of the programme) and assessed the onset of functional disability during March 2012. We analysed the data of 2421 older people. In addition to the standard Cox proportional hazard regression, we conducted Cox regression with propensity score matching (PSM) and an instrumental variable (IV) analysis, using the number of community salons within a radius of 350 m from the participant's home as an instrument.

Results

In the 5 years after the first salon was launched, the salon participants showed a 6.3% lower incidence of functional disability compared with non-participants. Even adjusting for sex, age, equivalent income, educational attainment, higher level activities of daily living and depression, the Cox adjusted HR for becoming disabled was 0.49 (95% CI 0.33 to 0.72). Similar results were observed using PSM (HR 0.52, 95% CI 0.33 to 0.83) and IV-Cox analysis (HR 0.50, 95% CI 0.34 to 0.74).

Conclusions

A community health promotion programme focused on increasing social interactions among older adults may be effective in preventing the onset of disability.
Alignment of systematic reviews published in the Cochrane Database of Systematic Reviews and the Database of Abstracts and Reviews of Effectiveness with global burden-of-disease data: a bibliographic analysis
Authors: Yoong Sze Lin , Hall Alix , Williams Christopher M , Skelton Eliza , Oldmeadow Christopher , Wiggers John , Karimkhani Chante , Boyers Lindsay N , Dellavalle Robert P , Hilton John , Wolfenden Luke
Published: April 2015

Background

Systematic reviews of high-quality evidence are used to inform policy and practice. To improve community health, the production of such reviews should align with burden of disease. This study aims to assess if the volume of research output from systematic reviews proportionally aligns with burden of disease assessed using percentages of mortality and disability-adjusted life years (DALYs).

Methods

A cross-sectional audit of reviews published between January 2012 and August 2013 in the Cochrane Database of Systematic Reviews (CDSR) and Database of Abstracts of Reviews of Effects (DARE) was undertaken. Percentages of mortality and DALYs were obtained from the 2010 Global Burden of Disease study. Standardised residual differences (SRD) based on percentages of mortality and DALYs were calculated, where conditions with SRD of more than or less than three were considered overstudied or understudied, respectively.

Results

1029 reviews from CDSR and 1928 reviews from DARE were examined. There was a significant correlation between percentage DALYs and systematic reviews published in CDSR and DARE databases (CDSR: r=0.68, p=0.001; DARE: r=0.60, p<0.001). There was no significant correlation between percentage mortality and number of systematic reviews published in either database (CDSR: r=0.34, p=0.14; DARE: r=0.22, p=0.34). Relative to percentage of mortality, mental and behavioural disorders, musculoskeletal conditions and other non-communicable diseases were overstudied. Maternal disorders were overstudied relative to percentages of mortality and DALYs in CDSR.

Conclusions

The focus of systematic reviews is moderately correlated with DALYs. A number of conditions may be overstudied relative to percentage of mortality particularly in the context of health and medical reviews.
The MITOS system predicts long-term survival in amyotrophic lateral sclerosis
Authors: Tramacere Irene , Dalla Bella Eleonora , Chiò Adriano , Mora Gabriele , Filippini Graziella , Lauria Giuseppe
Published: April 2015

Objective

The choice of adequate proxy for long-term survival, the ultimate outcome in randomised clinical trials (RCT) assessing disease-modifying treatments for amyotrophic lateral sclerosis (ALS), is a key issue. The intrinsic limitations of the ALS Functional Rating Scale-Revised (ALSFRS-R), including non-linearity, multidimensionality and floor-effect, have emerged and its usefulness argued. The ALS Milano-Torino staging (ALS-MITOS) system was proposed as a novel tool to measure the progression of ALS and overcome these limitations. This study was performed to validate the ALS-MITOS as a 6-month proxy of survival in 200 ALS patients followed up to 18 months.

Methods

Analyses were performed on data from the recombinant human erythropoietin RCT that failed to demonstrate differences between groups for both primary and secondary outcomes. The ALS-MITOS system is composed of four key domains included in the ALSFRS-R scale (walking/self-care, swallowing, communicating and breathing), each with a threshold reflecting the loss of function in the specific ALSFRS-R subscores. Sensitivity, specificity and the area under the curve of the receiver operating characteristic curves of the ALS-MITOS system stages and ALSFRS-R decline at 6 months were calculated and compared with the primary outcome (survival, tracheotomy or >23-hour non-invasive ventilation) at 12 and 18 months Predicted probabilities of the ALS-MITO system at 6 months for any event at 12 and 18 months were computed through logistic regression models.

Results

Disease progression from baseline to 6 months as defined by the ALS-MITOS system predicted death, tracheotomy or >23-hour non-invasive ventilation at 12 months with 82% sensitivity (95% CI 71% to 93%, n=37/45) and 63% specificity (95% CI 55% to 71%, n=92/146), and at 18 months with 71% sensitivity (95% CI 61% to 82%, n=50/70) and 68% specificity (95% CI 60% to 77%, n=76/111). The analysis of ALS-MITOS and ALSFRS-R progression at 6-month follow-up showed that the best cut-off to predict survival at 12 and 18 months was 1 for the ALS-MITOS (ie, loss of at least one function) and a decline ranging from 6 to 9 points for the ALSFRS-R.

Conclusions

The ALS-MITOS system can reliably predict the course of ALS up to 18 months and can be considered a novel and valid outcome measure in RCTs.