bluuebunny/crossref_metadata_2025 huggingface dataset:
Late Cenozoic paleogeographic reconstruction of the San Francisco Bay area from analysis of stratigraphy, tectonics, and tephrochronology
Authors: Sarna-Wojcicki Andrei M.
Published: August 2021

The Neogene stratigraphic and tectonic history of the Mount Diablo area is a consequence of the passage of the Mendocino triple junction by the San Francisco Bay area between 12 and 6 Ma, volcanism above a slab window trailing the Mendocino triple junction, and crustal transpression beginning ca. 8–6 Ma, when the Pacific plate and Sierra Nevada microplate began to converge obliquely. Between ca. 12 and 6 Ma, parts of the Sierra Nevada microplate were displaced by faults splaying from the main trace of the San Andreas fault and incorporated into the Pacific plate. The Mount Diablo anticlinorium was formed by crustal compression within a left-stepping, restraining bend of the eastern San Andreas fault system, with southwest-verging thrusting beneath, and with possible clockwise rotation between faults on its southeast and northwest sides. At ca. 10.5 Ma, a drainage divide formed between the northern Central Valley and the ocean. Regional uplift accelerated at ca. 6 Ma with onset of transpression between the Pacific and North America plates. Marine deposition ceased in the eastern Coast Range basins as a consequence of the regional uplift accompanying passage of the Mendocino triple junction, and trailing slab-window volcanism. From ca. 11 to ca. 5 Ma, andesitic volcanic intrusive rocks and lavas were erupted along the northwest crest of the central to northern Sierra Nevada and deposited on its western slope, providing abundant sediment to the northern Central Valley and the northeastern Coast Ranges. Sediment filled the Central Valley and overtopped the Stockton fault and arch, forming one large, south-draining system that flowed into a marine embayment at its southwestern end, the ancestral San Joaquin Sea. This marine embayment shrunk with time, and by ca. 2.3 Ma, it was eventually cut off from the ocean. Fluvial drainage continued southwest in the Central Valley until it was cut off in turn, probably by some combination of sea-level fluctuations and transpression along the San Andreas fault that uplifted, lengthened, and narrowed the outlet channel. As a consequence, a great lake, Lake Clyde, formed in the Central Valley at ca. 1.4 Ma, occupying all of the ancestral San Joaquin Valley and part of the ancestral Sacramento Valley. The lake rose and fell with global glacial and interglacial cycles. After a long, extreme glacial period, marine oxygen isotope stage (MIS) 16, it overtopped the Carquinez sill at 0.63 Ma and drained via San Francisco valley (now San Francisco Bay) and the Colma gap into the Merced marine embayment of the Pacific Ocean. Later, a new outlet for Central Valley drainage formed between ca. 130 and ca. 75 ka, when the Colma gap closed due to transpression and right-slip motion on the San Andreas fault, and Duxbury Point at the south end of the Point Reyes Peninsula moved sufficiently northwest along the San Andreas fault to unblock a bedrock notch, the feature we now call the Golden Gate.
Fifteen-minute consultation: Intubation of the critically ill child presenting to the emergency department
Authors: Kanaris Constantinos , Murphy Peter Croston
Published: August 2021

Intubation of critically ill children presenting to the emergency department is a high-risk procedure. Our article aims to offer a step-by-step guide as to how to plan and execute a rapid, successful intubation in a way that minimises risk of adverse events and patient harm. We address considerations such as the need for adequate resuscitation before intubation and selection of equipment and personnel. We also discuss drug choice for induction and peri-intubation instability, difficult airway considerations as well as postintubation care. Focus is also given on the value of preintubation checklists, both in terms of equipment selection and in the context of staff role designation and intubation plan clarity. Finally, in cases of failed intubation, we recommend the application of the Vortex approach, highlighting, thus, the importance of avoiding task fixation and maintaining our focus on what matters most: adequate oxygenation.
Fatal tuberculous meningitis in an infant presenting with seizures in the UK
Authors: Khambati Nisreen , Hou Mimi , Kelly Dominic , Song Rinn
Published: August 2021

A 5-month-old male child of European background presented with sudden onset of prolonged afebrile seizures. He was intubated and transferred to the paediatric intensive care unit where he displayed abnormal neurology and remained ventilated. Brain MRI showed basal leptomeningeal enhancement suggesting malignancy or infection. Subsequent cerebrospinal fluid results of lymphocytic pleocytosis and raised protein were suggestive of tuberculous (TB) meningitis and anti-TB treatment was commenced empirically. Positive TB microbiology was eventually confirmed on respiratory secretions. The infant continued to show abnormal neurologic findings and repeated neuroimaging showed a new extensive cerebral infarct. The infant was compassionately extubated and passed away. The father was later found to have pulmonary TB. This case is an important reminder of TB meningitis for countries where TB is uncommon. The importance of considering TB in any child with abnormal neurology and of taking prompt family histories to identify children at risk is highlighted.
A case of Bartonellosis presenting as a puzzling multisystem disorder complicated by nosocomial COVID-19 infection
Authors: Garland Huw , Stoll Sarah , Patel Shalinee , Mogal Rahul
Published: August 2021

The most commonly considered infection with aBartonellaspecies is cat-scratch disease caused byBartonella henselae. Here, we discuss a unique case of a 60-year-old man who presented withBartonellainfection complicated by nosocomial COVID-19. He was admitted with a history of chest pain, persistent fever, rash and influenza-like symptoms. PositiveBartonellaserology confirmed diagnosis and the patient developed complications of pericardial effusion in addition to COVID-19 infection, requiring non-invasive ventilation and admission to the intensive care unit. We discuss his symptoms, investigations, treatment and outcomes, while also highlighting the challenges of assessing patients presenting with fever of unknown origin during the COVID-19 pandemic.
Pilot investigation of an activity-based approach to building hardiness
Authors: Judkins Jason , Moore B , Stone E , Welsh A , Carbon G , Rendell B , Peterson A
Published: August 2021

Background

The purpose was to describe an activity-based psychological hardiness training programme delivered by an occupational therapist and examine its acceptability and effectiveness in improving hardiness.

Method

Participants (N=28) completed the 6-hour programme, which included pre/post-programme completion of the Dispositional Resilience Scale-15 (DRS-15) and a Program Evaluation Form. Paired t-tests were used to determine differences between pre-training and post-training scores on the DRS-15.

Results

Results showed a significant increase (p<0.05) in total hardiness, commitment, and control scores on the DRS-15 from pre-training to post-training and good–excellent ratings for all categories on the Program Evaluation Form.

Conclusions

This programme evaluation described an occupational therapist’s role in providing an activity-based psychological hardiness training programme and provided preliminary support for the acceptability of an activity-based approach to training psychological hardiness for service members.
SDG3-related inequalities in women’s, children’s and adolescents’ health: an SDG monitoring baseline for Latin America and the Caribbean using national cross-sectional surveys
Authors: Sanhueza Antonio , Carvajal-Vélez Liliana , Mújica Oscar J , Vidaletti Luis Paulo , Victora Cesar G , Barros Aluisio JD
Published: August 2021

Objectives

Latin America and the Caribbean (LAC) countries have made important progress towards achieving the Sustainable Development Goal (SDG) targets related to health (SDG3) at the national level. However, vast within-country health inequalities remain. We present a baseline of health inequalities in the region, against which progress towards the SDGs can be monitored.

Setting

We studied 21 countries in LAC using data from Demographic and Health Surveys and Multiple Indicator Cluster Survey carried out from 2011 to 2016

Participants

The surveys collect nationally representative data on women and children using multistage sampling. In total, 288 207 women and 195 092 children made part of the surveys in the 21 countries.

Outcome measures

Five health intervention indicators were studied, related to reproductive and maternal health, along with adolescent fertility and neonatal and under-five mortality rates. Inequalities in these indicators were assessed through absolute and relative measures.

Results

In most countries, subnational geographical health gradients were observed for nearly all women, child, and adolescent (WCA) indicators. Coverage of key interventions was higher in urban areas and among the richest, compared with rural areas and poorer quintiles. Analyses by woman’s age showed that coverage was lower in adolescent girls than older women for family planning indicators. Pro-urban and pro-rich inequalities were also seen for mortality in most countries.

Conclusions

Regional averages hide important health inequalities between countries, but national estimates hide still greater inequalities between subgroups of women, children and adolescents. To achieve the SDG3 targets and leave no one behind, it is essential to close health inequality gaps within as well as between countries.
Efficacy of mobilisation with movement in chronic shoulder pain: protocol for a systematic review and meta-analysis of controlled trials
Authors: Storås Arnstein , Lillebostad Fabian , Haslerud Sturla , Joensen Jon , Bjordal Jan Magnus , Stausholm Martin Bjørn
Published: August 2021

Introduction

Shoulder pain affects approximately one in four adults and is thus one of the most common musculoskeletal problems. Only 50% of patients who begin treatment for shoulder pain are cured within 6 months. There is a need for systematic reviews to estimate the effectiveness of shoulder treatments. We decided to evaluate the effect of mobilisation with movement (MWM) on chronic shoulder pain in a systematic review.

Methods and analysis

The review will include controlled trial articles identified via five electronic databases (PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature, Physiotherapy Evidence Database and Cochrane Central Register of Controlled Trials), reference lists, citations searches and experts in the field. Only controlled trials involving participants with a mean duration of pain of ≥3 months, in which the effectiveness of MWM has been compared with non-invasive treatments, sham mobilisation or wait-and-see will be included. The included trials will be synthesised with random effects meta-analyses. Risk-of-bias will be assessed with the Physiotherapy Evidence Database 0–10 point scale.

Ethics and dissemination

The review does not require ethics approval as it is based on anonymised data from trial reports. The results of the review will be disseminated through a peer-reviewed publication.

PROSPERO registration number

CRD42018109380.
Protocol for the National Nurse Health Study (NNHS): a web-based ambispective cohort study
Authors: Zhuo Lin , Zhang Heli , Geng Rongmei , Wang Panfeng , Zeng Lin , Che Ying , Wang Peng , Li Pengfei , Huang Tao , Li Baohua , Zhan Siyan
Published: August 2021

Introduction

The physical and mental health of nurses may significantly impact the entire medical care group and directly affect the quality of medical services. Due to the intense emotional involvement and often problematic working conditions that characterise their profession, nurses appear to be especially susceptible to a complex set of stressors with repercussions to their health. Several landmark studies of nurses have provided an abundance of evidence on risk factors that influence the health status of nurses. However, few studies have investigated the health status of nurses who work in high-intensity work environments in China. The National Nurse Health Study (NNHS) objective is to build an ambispective cohort to gather web-based information on early-life events, daily habits, occupational and environmental risk factors, and health outcomes of a specific subset of healthcare professionals of Chinese nurses.

Methods and analysis

NNHS, which was developed at a tertiary hospital in Beijing, China, is a research initiative that enrolls registered nurses working at Peking University Third Hospital. A web-based self-administered system was designed to collect health-related data and link them with previous physical examination data. During the study period, participants with signed informed consent will be invited to annually repeat a similar procedure.

Ethics and dissemination

The NNHS research protocol was approved by the Institutional Ethics Committee and provides promising data that contribute to the understanding of pathophysiological links between early-life events, body composition, gut microbiota, and inflammatory and metabolic risk profiles. Moreover, the combination of a user-friendly tool with the innovative purposes of the NNHS offers a remarkable resource to test hypotheses about mechanisms of diseases, including work stress, and further plan preventive programmes in public health.

Trial registration number

The study was registered on Clinicaltrials.gov (https://clinicaltrials.gov/ct2/show/NCT04572347) and the China Cohort Consortium (http://chinacohort.bjmu.edu.cn/project/102/).
Health care utilisation preceding relapse or second malignant neoplasm after childhood acute lymphoblastic leukaemia: a population-based matched cohort study
Authors: Jensen Karen Schow , Klug Albertsen Birgitte , Schrøder Henrik , Zalounina Falborg Alina , Schmiegelow Kjeld , Rosthøj Steen , Callesen Michael Thude , Vedsted Peter
Published: August 2021

Objectives

To investigate health care utilisation including both primary and secondary health care 6 months before the diagnosis of a relapse or a second malignant neoplasm (SMN) in survivors of childhood acute lymphoblastic leukaemia (ALL).

Design and setting

A Danish population-based matched cohort study linking multiple nationwide registries.

Participants

Participants were recruited from a total of 622 childhood ALL 2.5-year event-free survivors diagnosed between 1994 and 2015. Cases were survivors developing a relapse or an SMN and references were survivors still in first remission. Each case was matched with five references on age, sex, treatment protocol and risk group.

Primary outcome measures

Consultations in general practice and hospital the last 6 months before relapse or SMN. Cases and references were compared with monthly incidence rate ratios (IRRs) from negative binomial regression models.

Results

Of the 622 childhood ALL survivors, 60 (9.6%) developed a relapse (49) or an SMN (11) and 295 matched references were identified. Health care utilisation in general practice increased among cases the last month before the event compared with references with an IRR of 2.71 (95% CI 1.71 to 4.28). Data showed a bimodal structure with a significantly increased number of visits 4, 5 and 6 months before the event. Hospital health care utilisation increased 2 months before the event in cases with an IRR of 5.01 (3.78 to 6.63) the last month before the event and an IRR of 1.94 (1.32 to 2.85) the second-last month comparing cases and references.

Conclusions

Survivors of childhood ALL developing a relapse or an SMN have a short period of increased health care utilisation before diagnosis. At hospital, this might be explained by pre-diagnostic examinations. In general practice, data suggest a bimodal structure with children later developing a relapse having more contacts also half a year before the relapse, suggesting that there could be early warnings.
Observational study of the implementation of telephone advice nursing in Sweden: did callers follow recommendations and did the rate of healthcare visits change?
Authors: Sundberg Amanda , Wahlberg Anna Carin , Zethraeus Niklas , Karampampa Korinna
Published: August 2021

Objectives

Telephone advice nursing is introduced in many countries with one key aim being a reduction of avoidable healthcare visits. The aim of this study was to explore whether callers to a telephone advice nursing service followed the telenurses’ recommendations, and whether there was a change in the level and trend of the rate of healthcare visits after the introduction of telephone advice nursing.

Design

Observational study.

Setting

Primary and secondary care in Jönköping Region, Sweden.

Participants

Telephone advice nursing calls, 6:00–23:00, 2014–2015 (n=185 994) and outpatient healthcare visits 2012–2015 (n=6 877 266).

Primary outcome

Proportion of callers who visited healthcare within the time period advised by the telenurse.

Secondary outcome

Change in level or trend of the overall rate of healthcare visits per 1000 persons and 4-week period after the introduction of telephone advice nursing, with subgroup analysis for primary and secondary care.

Results

77% of callers who were recommended either to visit healthcare within 24 hours or to ‘wait and see’ followed the recommendations. There was no significant change in level (−5.15; 95% CI −15.80 to 5.50; p=0.349) or trend (−0.24; 95% CI −0.86 to 0.38; p=0.448) of the overall rate of visits per 1000 persons and 4-week period after the introduction of telephone advice nursing. For the rate of primary care visits, an increase in level (8.01; 95% CI 6.36 to 9.66; p<0.001) and trend (1.28; 95% CI 1.17 to 1.39; p<0.001) were observed. For the rate of secondary care visits, a decrease in level (−8.77, 95% CI −14.41 to −3.13; p=0.004) and trend (−1.03, 95% CI −1.35 to −0.71; p<0.001) were observed.

Conclusions

The introduction of telephone advice nursing may have contributed to a shift in the rate of healthcare visits from secondary to primary care.
Abstracts from international emergency medicine journals
Authors: Production EMJ
Published: August 2021

Editor’s note: EMJ has partnered with the journals of multiple international emergency medicine societies to share from each a highlighted research study, as selected by their editors. This edition will feature an abstract from each publication.
EP10 The impact of introducing real time feedback on ventilation rate and volume by ambulance clinicians in the North East in a simulated cardiac arrest scenario: the VANZ study
Authors: McClelland Graham , Charlton Karl , Millican Karen , Haworth Daniel , Aitken-Fell Paul , Norton Michael
Published: August 2021

Background

Adequate ventilation is an important aspect of cardiopulmonary resuscitation (CPR). Research suggests 80% of caregivers hyperventilate during CPR and that feedback improves compliance with ventilation guidelines. Hyperventilation is associated with increased intrathoracic pressure, impaired haemodynamics and cerebral vasoconstriction and therefore can be deleterious to survival. VANZ aimed to determine if compliance with European Resuscitation Council (ERC) ventilation guidelines could be improved using a real time ventilation feedback device

Methods

Participants simulated a two-minute cardiac arrest scenario using a manikin and defibrillator without ventilation feedback. Researchers demonstrated the ventilation feedback device and participants practiced using it. The two-minute scenario was then repeated with ventilation feedback. The ventilation rate, volume and CPR quality were recorded during each scenario. The primary outcome was based on achieving ≥50% compliance with ERC ventilation guidelines of ventilating at 8-12 breaths per minute and 500-600ml per breath. Following the study participants were asked to complete a short survey on the ventilation feedback device

Results

During September 2020 106 participants (58% male, mean age 42, 74% paramedics) completed the study. The primary outcome showed a significant improvement from 9% of participants achieving ≥50% compliance without feedback to 91% of participants achieving ≥50% compliance with feedback (McNemars test p<0.0001). Survey data from participants was overwhelmingly positive about the ventilation feedback device.

Conclusions

Use of real time ventilation feedback during CPR significantly improved participants ability to deliver ventilations compliant with ERC guidelines in a simulated scenario. The fact that this was a manikin study is a limitation but the low rate of compliance with ventilation guidelines without feedback raises questions about ventilation quality when CPR is performed on patients. Future research should examine the quality of ventilations performed on patients, the ability of feedback to improve compliance with guidelines and the impact this has on patient outcomes.
EP11 Using machine learning to recover unrecorded prehospital data
Authors: Reich Thilo , Bancroft Adam , Budka Marcin
Published: August 2021

Background

The recording practices, of electronic patient records for ambulance crews, are continuously developing. South Central Ambulance Service (SCAS) adapted the common AVPU-scale (Alert, Voice, Pain, Unresponsive) in 2019 to include an option for ‘New Confusion’. Progressing to this new AVCPU-scale made comparisons with older data impossible. We demonstrate a method to retrospectively classify patients into the alertness levels most influenced by this update.

Methods

SCAS provided ~1.6 million Electronic Patient Records, including vital signs, demographics, and presenting complaint free-text, these were split into training, validation, and testing datasets (80%, 10%, 10% respectively), and under sampled to the minority class. These data were used to train and validate predictions of the classes most affected by the modification of the scale (Alert, New Confusion, Voice).

A transfer-learning natural language processing (NLP) classifier was used, using a language model described by Smerity et al. (2017) to classify the presenting complaint free-text.

A second approach used vital signs, demographics, conveyance, and assessments (30 metrics) for classification. Categorical data were binary encoded and continuous variables were normalised. 20 machine learning algorithms were empirically tested and the best 3 combined into a voting ensemble combining three vital-sign based algorithms (Random Forest, Extra Tree Classifier, Decision Tree) with the NLP classifier using a Random Forest output layer.

Results

The ensemble method resulted in a weighted F1 of 0.78 for the test set. The sensitivities/specificities for each of the classes are: 84%/ 90% (Alert), 73%/ 89% (Newly Confused) and 68%/ 93% (Voice).

Conclusions

The ensemble combining free text and vital signs resulted in high sensitivity and specificity when reclassifying the alertness levels of prehospital patients. This study demonstrates the capabilities of machine learning classifiers to recover missing data, allowing the comparison of data collected with different recording standards.
EP12 Using electronic patient record (EPR) routine data to inform decisions about which ambulance stations should participate in randomised controlled trials
Authors: Miller Joshua , Lumley-Holmes Jenny
Published: August 2021

Background

Timely recruitment of patients to randomised controlled trials (RCTs) is vital to delivering high-quality, cost-effective research, but RCTs often fail to meet recruitment targets, or meet them more slowly than planned. Ambulance services using electronic patient records (EPR) may be able to use this data to better inform decisions about which sites should participate in future RCTs.

Methods

We used off-the-shelf business intelligence software to examine electronic patient records for all emergency and urgent cases within one English ambulance service for the 287 days 1st January 2020 to 13th October 2020. We adapted inclusion criteria from an upcoming RCT and applied it to this dataset: patient age; trauma mechanism; IV morphine administered. These potentially eligible cases were then displayed by ambulance station, an approximate daily rate per station calculated, and this rate applied to the RCT recruitment period of 304 days. This gave a potentially eligible patient population per station. Finally, we applied a patient conversion rate of 20% to estimate how many participants would be recruited from each station, basing this on recent experience of recruitment to another RCT. The RCT target is 111 patients per station.

Results

783186 records were reviewed, with 7667 of them potentially eligible for the study. When applied to the proposed study period, there is a potential population of 8121 across the 14 stations. Estimated recruitment per station varied (median 100, range 60-209) and with a 20% conversion rate, 9/14 stations would under-recruit.

Conclusions

Using retrospective data from electronic patient records could be a simple, low-cost way to optimise patient recruitment. Other study criteria could be applied easily, as well as differing conversion rates. We identified ambulance stations where patient recruitment would not be likely to reach study targets, helping inform our decisions around stations as potential study settings.
PP15 Association between admission to a cardiac centre and survival to hospital discharge for adults following out-of-hospital cardiac arrest
Authors: Vopelius-Feldt Johannes von , Perkins Gavin , Benger Jonathan
Published: August 2021

Background

Survival following out-of-hospital cardiac arrest (OHCA) depends on the Chain of Survival, which spans from bystander cardio-pulmonary resuscitation to in-hospital treatment. There is an increased interest in regionalisation of post-OHCA care, which includes ambulances bypassing the nearest hospital in favour of OHCA centres. This study examined the association between admission to OHCA centres and survival to hospital discharge for adults following OHCA of presumed cardiac aetiology.

Methods

We undertook a multicentre retrospective observational study of patients transferred to hospital after OHCA of presumed cardiac aetiology in three ambulance services in England. We used propensity score matching to compare rates of survival to hospital discharge in patients admitted to OHCA centres (defined as either 24/7 PPCI availability or >100 OHCA admissions per year) to rates of survival of patients admitted to non-centres.

Results

Between January 2017 and December 2018, 10,650 patients with OHCA were included in the analysis. After propensity score matching, admission to a hospital with 24/7 PPCI availability or a high-volume centre was associated with an absolute improvement in survival to hospital discharge of 2.5% and 2.8%, respectively. The corresponding odds ratios and 95% confidence intervals were 1.69 (1.28 to 2.23) and 1.41 (1.14 to 1.75), respectively. The results were similar when missing values were imputed. In subgroup analyses, the association between admission to an OHCA centre and improved rates of survival was mainly seen in patients with OHCA due to shockable rhythms, with no or minimal potential benefit for patients with asystole as first presenting rhythm.

Conclusions

Following OHCA, admission to an OHCA centre is associated with a moderate improvement in survival to hospital discharge. A corresponding bypass policy would need to consider the resulting increased workload for OHCA centres and longer ambulance transfer times.
PP16 A whole health care system review of the effects from changes to pre-hospital emergency care pathways during the COVID-19 pandemic
Authors: Tankel Jeremy W , Ratcliffe David , Smith Martin , Mullarkey Andrew , Pover Jennifer , Marsden Zoe , Bennett Paula , Green Darren
Published: August 2021

Background

The United Kingdom COVID-19 pandemic response included large scale changes to emergency healthcare delivery across primary care, secondary care and ambulance services without fully understanding potential unintended effects. Our aim was to ascertain themes within the emergency response that could be modified to mitigate against future excess deaths.

Methods

A structured judgement review of the entire care pathway (primary care, secondary care, 111 and 999 calls) for deaths registered in Salford during weeks 12-19 of 2020, creating a single integrated record of all Healthcare interactions and outcomes between 1stMarch 2020 and death for all patients. An expert panel judged avoidability of death against the National Mortality Case Record Review Programme scale, and themes associated with potential harm.

Results

522 deaths (197 hospital, 190 care homes): 51% female, 81% Caucasian, 35% dementia, age 79±9 years, 44% COVID-19 cause of death.

18% of deaths contained avoidability themes. In people aged ≥75 years who lived at home this was 53%, in care home residents 29%, in learning disability patients 44%. For COVID-19 and non-COVID-19 deaths the figures were 49% and 23%. 15 deaths were judged more than 50:50 avoidable. For higher avoidability (score 2 or 3), 44% had >2 themes.

Common themes were delays in patients presenting to care providers (10%, n=53), delays in testing (27%, 139), avoidable exposure to COVID-19 (29%, 149), delays in provider response (6%, 32), and sub-optimal care (34%, 177).

Pre-hospital healthcare contact frequently was primary care 81%, 999 56%, NHS 111 11%. The most common outcome of 111 calls was advice to contact GP (34%). 46 patients (9%) had healthcare appointments cancelled (median 1 cancellation, range 1-9).

Conclusions

The initial emergency response to COVID-19 was associated with late presentation, sub-optimal assessments, and delays in receiving care. The effects had multifaceted impacts and will require complex remedy.
PP17 Development and application of a clinical risk stratification tool using routine data from electronic patient clinical records
Authors: Lynde Jessica , Black Sarah
Published: August 2021

Background

Following the introduction of electronic patient clinical records, ambulance service managers wished to combine clinical and operational data to devise a method of risk stratifying 999 calls by the MPDS disposition code assigned at call triage. Initial aims were to establish the risk threshold if an ambulance was no longer routinely dispatched.

Methods

Data selected were representative of high or low clinical risk, and reliably recorded. The following ‘risk factors’ were chosen:

Call outcome

Emergency conditions

Clinical interventions

Medications administered

With expert local opinion, a scoring algorithm was created using weighted factor scores to create an aggregate risk score for each MPDS code. It was also designed to distribute codes along a ‘risk range’, allowing for thresholds setting suitable to the specific purpose of individual projects. These factors and their scores were captured alongside contextual information and to date contains over 1.4 million records over 3 years.

In collaboration with academic colleagues, we also developed an AI model to refine the algorithm used to reflect acuity. With one year of data the tool did not demonstrate the sensitivity or specificity to reliably contribute to prediction, however this exercise may be repeated now there is a greater volume of data.

Applications:This Tool has been successfully used for a variety of purposes:

Developing the Enhanced Hear and Treat policy

Assessing risk of code downgrades in the pandemic response

Identifying codes suitable for automatic specialist clinician allocations

Supplementing analysis of harm caused by long response delays

Identifying codes for protection within End of Shift protocols

Providing intelligence to aid national decisions on code categorisation

Next steps:The Tool continues to assist in decision-making locally. Future ambitions include:

Validation of the scoring algorithms

Process automation to ensure more timely data is available

Collaboration to improve the variety and volume of data
PP21 Hangings attended by emergency medical services: a scoping review
Authors: Shaw Gary , Thompson Lee , McClelland Graham
Published: August 2021

Background

In the United Kingdom (UK) there were 6,507 deaths by suicide in 2018 with hanging being the most common method. Hanging will normally result in emergency medical services (EMS) being called and may result in resuscitation being attempted.

The lead author identified an increasing trend in hanging cases in the NHS Ambulance service trauma audit, which were also reported in national data. The aim of this scoping review was to explore the literature around EMS attendance at hangings to inform further research and clinical practice.

Methods

A five-stage scoping review method was used. Relevant studies were identified by searching MEDLINE, CINAHL, EMBASE and EMCARE with the help of the Library and Knowledge Service for NHS Ambulance Services in England (LKS). Grey literature and reference lists were also searched. Studies were included based on relevance to hangings attended by EMS. Data were tabulated and narratively synthesised.

Results

Sixteen papers were included in the review. Australia was the most frequent source of studies (n=5, 31%). Most studies (n=11, 69%) were published in the past ten years. The median sample size was 53 (IQR 41-988, range 10-3981). All papers included varying levels of patient characteristics, EMS input and patient outcomes.

Conclusion

Hanging is a highly lethal method of suicide that is increasingly used in the UK. This scoping review found that there is scarce literature focussed on hangings attended by EMS. Treatment of the hanging patient in cardiac arrest is described in many of the papers included. Hanging patients may benefit from the presence of specialist resources who can deliver interventions such as sedation and advanced airway management. The psychological impact of attending, or witnessing, hanging patients is an area that needs further consideration. Further research is needed to describe and improve EMS treatment of hangings.
PP24 Prehospital feedback in the United Kingdom: protocol for a review of current practice using a realist approach
Authors: Wilson Caitlin , Janes Gillian , Lawton Rebecca , Benn Jonathan
Published: August 2021

Background

Prehospital feedback is increasingly receiving attention from clinicians, managers and researchers. The effectiveness of feedback in changing professional behaviour and improving clinical performance is strongly evidenced across a range of healthcare settings, but this has not yet been replicated within the prehospital context. Without a firmer evidence base, development in practice relies on isolated initiatives with no clear intervention model or evaluative framework. The aim of this study is to understand how UK ambulance services are currently meeting the challenge of providing prehospital feedback and generate an explanatory programme theory.

Methods

This mixed methods study will follow a realist evaluation methodology framework with an explanatory case study research design. A realist approach was selected as it will facilitate development of programme theory by exploring context, mechanisms and outcomes. The study will consist of three phases: a pilot case study, a national survey and three in-depth case studies. Phase 1 and 3 of the study will involve semi-structured qualitative interviews and site visits, whilst phase 2 will consist of a cross-sectional survey sent out to leads of UK prehospital feedback initiatives. This study will draw upon a range of existing theories to aid understanding such as the Consolidated Framework for Implementation Research, Normalisation Process Theory and Clinical Performance Feedback Intervention Theory.

Results and Conclusion

The three phases of this study will allow for cyclical development, testing and refinement of programme theory by describing existing prehospital feedback intervention types and variations in implementation, as well as evaluating their causal mechanisms and outcomes. Study findings will facilitate an understanding of the extent and limitations of current initiatives, with a view towards identifying opportunities for intervention.
PP25 The take home naloxone intervention multicentre emergency setting feasibility (TIME) trial: an early perspective from one UK ambulance service
Authors: Johnston Sasha , Snooks Helen , Jones Jenna , Bell Fiona , Benger Jonathan , Black Sarah , Dixon Simon , Edwards Adrian , Evans Bridie , Fuller Gordon , Goodacre Steve , Hoskins Rebecca , John Ann , Lawrence Barbara , Moore Chris , Parry Emma , Hird Kelly , Wait Sarah , Watkins Alan
Published: August 2021

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.
PP26 Stepping up: interviews with student paramedics and lecturers about a scheme to increase workforce capacity within an English ambulance service during the first wave of the COVID-19 pandemic
Authors: Miller Joshua
Published: August 2021

Background

During the UK’s first wave of the COVID-19 pandemic in early 2020, ambulance services acted to increase capacity rapidly. One English ambulance service recruited existing supernumerary student paramedics into a new, paid, hybrid role, working as one half of a double-crewed ambulance team.

Methods

Ten student paramedics and two university lecturers were interviewed remotely in one-to-one sessions with a single interviewer. Students participated from 3 of 4 partner universities, and lecturers from 2 of the 4. Their responses were transcribed and coded into a framework of the four processes of organisational entry: analysis, recruitment, selection, and induction.

Results

The participants described barriers and facilitators to the success of the scheme in all four processes. Analysis: job descriptions and working conditions were not always clear to interviewees. Recruitment: some students described feeling under pressure to take part. Lecturers criticised communications, particularly around some of their student paramedics who had withdrawn from study. Selection: students were critical of some aspects of physical assessment being omitted for this new role, but later reinstated for subsequent paramedic recruitment events. Induction: most students praised the initial training and their induction onto ambulance stations, but many felt they should have been given driver training. Lecturers raised concerns that students at risk of failing in placement may not be supported adequately in this new role. Almost all participants praised the scheme’s intentions and overall delivery, and some suggested a similar role bears consideration for future business-as-usual university placements.

Conclusions

Participants were broadly positive about this scheme, with some suggesting that elements of this hybrid role could feature in a post-pandemic student paramedic programme. Limitations include recall bias and response bias, particularly in that students who declined to take part in the scheme also declined to take part in this interview study.
03 The prehospital 12 lead electrocardiogram is associated with improved outcomes in patients with acute coronary syndromes presenting to emergency medical services: a nationwide linked cohort study
Authors: Quinn Tom , Driscoll Timothy , Gavalova Lucia , Halter Mary , Gale Chris P , Weston Clive FM , Watkins Alan , Munro Scott , Davies Glenn , Hampton Chelsey , Rosser Andy , Rees Nigel , Black Sarah , Snooks Helen A
Published: August 2021

Background

Use of the Pre-Hospital 12-lead Electrocardiogram (PHECG) is recommended in patients presenting to emergency medical services (EMS) with suspected acute coronary syndrome (ACS).

Objectives

To investigate differences in mortality between those who did/did not receive PHECG.

Methods

Population-based, linked cohort study using Myocardial Ischaemia National Audit Project (MINAP) data from 2010-2017.

Results

Of 330,713 patients, 263,420 (79.6%) had PHECG, 67,293 (20.3%) did not. 30-day mortality was 7.8% overall, 7.1% with PHECG vs 10.9% without PHECG (adjusted Odds Ratio [aOR] 0.772, 95% confidence interval [CI] 0.748-0.795, p<0.001). 1 year mortality was 16.1% overall, 14.2% with PHECG vs 23.2% without (aOR 0.692, 95% CI 0.676-0.708, p<0.001). 144,254 patients had ST segment elevation myocardial infarction (STEMI); 130,240 (90.2%) had PHECG, 30 day mortality 8.8% overall, 8.0% with PHECG vs 15.9% without (aOR 0.588, 95% CI 0.557-0.622, p<0.001), 1 year mortality 13.1% overall, 12.1% with PHECG vs 22.8% without (aOR 0.585, 95% CI 0.557-0.614, p<0.001). 186,459 patients had non-STEMI; 133,180 (71.4%) had PHECG. 30-day mortality 7.1% overall, 6.1% with PHECG vs 9.6% without (aOR 0.677, 95%CI 0.652-0.704, p<0.001), 1 year mortality 18.3% overall, 16.3% with PHECG vs 23.3% without (aOR 0.694, 95% CI 0.676-0.713, p<0.001). 110,571 STEMI patients received primary PCI, 103,741 (93.8%) had PHECG. 30 day mortality 5.4% overall, 5.3% with PHECG vs 7.0% without (aOR 0.739, 95% CI 0.667-0.829, p<0.001). 1 year mortality 8.5% overall, 8.4% with PHECG vs 9.8% without (aOR 0.833, 95% CI 0.762-0.911, p<0.001). 26,127 (18.1%) STEMI patients received no reperfusion; 19,873 (76%) had PHECG. Mortality at 30 days 22.1% overall, 21.3% with PHECG vs 24.7% without (aOR 0.911, 95% CI 0.847-0.980, p=0.013), 1 year mortality 32.2% overall, 30.9% with PHECG, 36.4% without (aOR 0.865, 95% CI 0.810-0.925, p<0.001).

Conclusion

PHECG was associated with lower mortality at 30 days and 1 year in both STEMI and non-STEMI patients.
PP32 Pathway to portfolio: from idea to full trial funding
Authors: Snooks Helen , Jones Jenna , Watkins Alan , Keen Leigh
Published: August 2021

Background

NIHR funding is provided to studies which will produce evidence to inform policy and practice in healthcare. Exploratory or feasibility work can be difficult to find funding for. We present the timeline and steps in the process from first having an idea for research through to gaining funding for a definitive trial.

Objective

To determine costs and effects of Fascia Iliaca Compartment Block delivered by paramedics at the scene of injury for suspected hip fracture.

Methods

Literature review

Development and testing of tool to support identification of hip fracture by paramedics

Feasibility trial (RAPID 1)

Proposal for definitive trial (RAPID 2)

Results

Funding was gained from local NHS ‘Pathway to Portfolio’ resources to carry out the first stages of the programme; then a grant was won through the Welsh ‘Research for Patient and Public Benefit’ scheme to undertake a feasibility study. Finally, NIHR HTA funding was awarded to carry out a definitive trial, in five ambulance services.

2015 – 16: A systematic review of the literature found that the effectiveness of FICB carried out by paramedics at the scene of injury is unknown, although nurse practitioners have been found to deliver this intervention safely in the Emergency Department.

2015 – 16: A tool for identifying hip fracture at the scene of injury was developed by orthopaedic clinicians and tested by ambulance service staff. Sensitivity and positive predictive value were high.

2015 – 18: Feasibility trial progression criteria related to methods and intervention safety and acceptability were met.

2019 – 20: A full trial proposal was submitted, shortlisted, rejected, amended, resubmitted and funded.

2020 – 2025: The RAPID 2 trial is now underway, with paramedic training and patient recruitment due to start in June 2021.

Conclusions

Research funding systems can work to help to progress from idea to full trial, although timescales can be lengthy.
PP37 Use of capillary blood ketone meters to improve ambulance service care of hyperglycaemic patients: protocol for a stepped-wedge, controlled feasibility study (KARMA2)
Authors: Prothero Larissa , Foster Theresa , Dhatariya Ketan , Lake Andrea , Boyle Adrian , Rayman Gerry , Williams Julia , Sampson Mike
Published: August 2021

Background

Diabetic ketoacidosis (DKA) is a potentially life-threatening condition associated with diabetes (Type 1 and Type 2), certain medications (i.e. SGLT2 inhibitors), and other health conditions. Hospital-based guidelines advocate immediate start of intravenous fluid therapy upon DKA diagnosis, which does not reliably happen in the pre-hospital setting. Ambulance clinicians do not routinely have access to ketone meters to determine presence of ketones; they rely on non-specific clinical signs and symptoms for care strategies. The aims of this feasibility study are to determine whether ambulance clinicians can reliably and safely identify patients with DKA using capillary blood ketone meters, commence fluid therapy, and gather necessary study data.

Methods

During an 8-month period (4-month control: 4-month intervention), 120 ambulance clinicians from one UK ambulance service will receive training to determine presence of ketones using capillary blood testing from 800 consenting patients with hyperglycaemia and unwell patients with diabetes. Subsequent patient care will depend on the ketone value obtained: high-risk DKA patients will receive fluid therapy. Twenty ambulance and hospital clinicians will be invited to an interview to share their views of DKA care and the impact of capillary blood ketone meters.

Results

Information collated will include completion of study training, patient recruitment, intervention adherence, service call activity, and ambulance and hospital patient clinical data. Prevalence and severity of hyperglycaemia, incidence of DKA and ability of paramedics to commence fluid therapy for DKA will be explored. Quantitative findings will be analysed using descriptive statistics, whilst the qualitative study interviews will be thematically analysed.

Conclusions

Study findings will be used to inform the need and feasibility to proceed to a full stepped-wedge, controlled trial. If warranted, we will develop a research funding proposal evaluating the clinical and cost-effectiveness of ambulance ketone meters and further explore meter provision for improved ambulance patient care.