bluuebunny/crossref_metadata_2025 huggingface dataset:
Association between human resources and risk of hospitalisation in end-stage renal disease outpatients receiving haemodialysis: a longitudinal cohort study using claim data during 2013–2014
Authors: Choi Hoon-Hee , Han Kyu-Tae , Nam Chung Mo , Moon Ki Tae , Kim Woorim , Park Eun-Cheol
Published: August 2016

Objective

The number of patients requiring haemodialysis has gradually increased in South Korea. Owing to this growth, concerns have been raised regarding haemodialysis quality of care, and healthcare professionals must consider alternatives for appropriate management of patients with chronic kidney disease (CKD). Therefore, we investigated the association between risk of hospitalisation of outpatients who received haemodialysis due to end-stage renal disease (ESRD) and the human resources of the haemodialysis unit.

Setting

We used data from National Health Insurance (NHI) claims during October 2013 to September 2014.

Participants

These data comprised 40 543 outpatients with ESRD (4 751 047 outpatient cases) who received haemodialysis.

Interventions

No interventions were made.

Outcome measure

We performed Poisson regression analysis using a generalised estimating equation that included both patient and haemodialysis unit characteristics to examine the factors associated with hospitalisation of outpatients with ESRD.

Results

Among 4 751 047 outpatient cases, 27 997 (0.59%) were hospitalised during the study period. A higher proportion of haemodialysis patient care specialists and a higher number of nurses experienced in haemodialysis were inversely associated with the risk of hospitalisation (per 10% increase in haemodialysis patient care specialists: relative risk (RR)=0.987, 95% CI 0.981 to 0.993; per 10-person increase in nurses who provided haemodialysis: RR=0.876, 95% CI 0.833 to 0.921). In addition, such associations were greater in severe patients.

Conclusions

Our findings suggest that haemodialysis units with high-quality, haemodialysis-specialised human resources could positively affect the outcomes of outpatients with ESRD. Based on our findings, health policymakers and professionals should implement strategies for the optimal management of patients with CKD.
“What makes it worth the investment to say it?” – Care experiences of lesbian, gay, bisexual and/or trans* people facing life-limiting illness: a qualitative interview study
Authors: Bristowe Katherine , Hodson Matthew , Wee Bee , Almack Kathryn , Daveson Barbara , Koffman Jonathan , McEnhill Linda , Johnson Katherine , Harding Richard
Published: August 2016

Introduction

People who identify as lesbian, gay, bisexual and/or trans* (LGBT) have increased risk of certain life-limiting illnesses. Evidence suggests they may not receive the care and support they need towards the end of life and into bereavement.1,2

Aim

To inform training and resources to improve care, this original study aimed to explore care experiences of LGBT people facing life-limiting illness, by eliciting experiences of: sharing identity (sexual identity/gender history) in healthcare settings; accessing services; discrimination/exclusion; and examples of good practice.

Methods

In-depth qualitative interview study. Participants were recruited across the UK (England, Wales, Scotland) via clinical teams, social media and community networks. Interviews were transcribed verbatim and analysed using thematic analysis.

Results

40 LGBT people were interviewed: 20 patients, 6 informal carers, 14 bereaved informal carers; 21 described cancer experiences, 16 non-cancer, 3 co-morbid cancer/non-cancer; and mean age was 60 (range 27–94).

Five main themes emerged: 1) palliative care needs that may require additional or different consideration for LGBT people; 2) communicative or service level barriers and stressors, including heteronormative assumptions, and homophobic/transphobic behaviours; 3) internalised or invisible barriers and stressors, including fears, or experiences, of discrimination, 4) which shape individuals’ preferences for disclosure and exploration of identity; and 5) communicative or service level facilitators to accessing care and support.

Conclusions

Despite recent legislative change for LGBT people, experiences of discrimination and exclusion in advanced disease and palliative care are still evident. A resource, co-designed with the LGBT community, is being piloted, and learning events being delivered nationally.

References

Harding R, Epiphaniou E, Chidgey-Clark J. Needs, experiences and preferences of sexual minorities for end-of-life care and palliative care: a systematic review.J Palliat Med2012;15:602–611

Bristowe K, Marshall S, Harding R. The bereavement experiences of lesbian, gay, bisexual and/or trans* people who have lost a partner: a systematic review, thematic synthesis and modelling of the literature.Palliat Med2016
UK consensus project on quality in palliative day services: developing a quality indicator set using the RAND/UCLA appropriateness method
Authors: Dempster Martin , McCorry Noleen , O’Connor Sean , Armour Kathy , Coast Joanna , Cohen Joachim , Donnelly Michael , Finucane Anne , Fyvie Joan , Jones Louise , Kernohan George , Leemans Kathleen , Oxenham David , Perkins Paul
Published: August 2016

Introduction

Evaluating quality of palliative day services is essential for assessing care across diverse settings, and for monitoring quality improvement approaches.

Aim

To develop a set of quality indicators for assessment of all aspects (structure, process and outcome) of care in palliative day services.

Methods

Using a modified version of the RAND/UCLA appropriateness method (Fitchet al.,2001), a multidisciplinary panel of 16 experts independently completed a survey rating the appropriateness of 182 potential quality indicators previously identified during a systematic evidence review. Panel members then attended a one day, face-to-face meeting where indicators were discussed and subsequently re-rated. Panel members were also asked to rate the feasibility and necessity of measuring each indicator.

Results

71 indicators classified as inappropriate during the survey were removed based on median appropriateness ratings and level of agreement. Following the panel discussions, a further 60 were removed based on appropriateness and feasibility ratings, level of agreement and assessment of necessity. Themes identified during the panel discussion and findings of the evidence review were used to translate the remaining 51 indicators into a final set of 27.

Conclusion

The final indicator set included information on rationale and supporting evidence, methods of assessment, risk adjustment, and recommended performance levels. Further implementation work will test the suitability of this ‘toolkit’ for measurement and benchmarking. The final indicator set provides the basis for standardised assessment of quality across services, including care delivered in community and primary care settings.

Reference

Fitch K, Bernstein SJ, Aguilar MD,et al.The RAND/UCLA Appropriateness Method User’s Manual. Santa Monica, CA: RAND Corporation; 2001.http://www.rand.org/pubs/monograph_reports/MR1269
The chemical compatibility and stability of drug combinations administered by continuous subcutaneous infusions used in end of life care
Authors: Dickman Andrew , Roberts Ellen , Weir Phil , Mason Stephen , Ellershaw John
Published: August 2016

Introduction

In 2007, the National Patient Safety Agency recommended that healthcare staff need to have full technical information about compatibility of commonly used mixtures used in specialist areas only (National Patient Safety Agency 2007). In 2008, the Commission on Human Medicine (CHM) recommended that research should be commissioned to develop authoritative national advice on mixing of medicines to encompass compatibility and stability data (Commission on Human Medicines, 2008).

In the UK, a continuous subcutaneous infusion (CSCI) is considered to be the preferred method of drug administration to maintain symptom management at the end of life. Despite this common practice, compatibility data are lacking. Analysis of national practice identified commonly used drug combinations administered by CSCI that were included in this study.

Aims/objectives

To determine the chemical compatibility/stability of a total of 40 commonly encountered drug combinations. A CME T34 syringe pump was used to simulate infusion of the syringe preparation over a 24 hour period. The combinations were analysed by High Performance Liquid Chromatography-Diode Array Detection (HPLC-DAD).

Results

Thirty combinations were identified as compatible by HPLC-DAD. These combinations also remained clear and free from visible particulate matter and the pH remained constant over the monitored period. Four combinations will require additional analysis as variances were detected during the testing procedure.

Conclusion

This research is the first step towards providing technical information required by healthcare staff for the mixing of injectable medicines in the same syringe.

References

Commission on Human Medicines.Outcome of the consultation exercise on proposals for regularising the position of those mixing and administering medicines in palliative care. London: MHRA; 2008.http://webarchive.nationalarchives.gov.uk/20141205150130/http://mhra.gov.uk/publications/consultations/medicinesconsultations/mlxs/con033523. Accessed June 3, 2016.

National Patient Safety Agency. Promoting safer use of injectable medicines; 2007.http://www.nrls.npsa.nhs.uk/resources/?entryid45=59812. Accessed June 3, 2016.
The influence of organisational context and practitioner attitudes on implementation of the carer support needs assessment tool (CSNAT) intervention
Authors: Diffin Janet , Ewing Gail , Grande Gunn
Published: August 2016

Background

The Carer Support Needs Assessment Tool (CSNAT) intervention identifies and addresses family carer support needs towards end of life.1–3A paucity of studies has investigated how to successfully implement evidence based interventions within palliative care.

Aim

Investigate how staff attitudes and organisational context affect implementation of the CSNAT intervention in palliative care.

Methods

36 UK palliative care services participated. Staff surveys measured attitudes and context prior to, and six months after the implementation began including (i) a questionnaire assessing staff attitudes to the CSNAT; (ii) The Alberta Context Tool (ACT) assessing organisational context. Data on use of the CSNAT intervention were collected over six months; services were classified as ‘high’ or ‘low’ adopters on this basis. Relationships between service characteristics, aggregate data on staff attitudes and organisational context, and level of adoption were analysed.

Results

157/462 surveys were returned at baseline and 69/462 at six months. Level of adoption depended on service type. ‘High’ adopters had a higher ratio of intervention ‘champions’ to total staff numbers and higher scores for ACT ‘informal interactions’ (e.g. more discussions with colleagues about patient care), compared to ‘low’ adopters. Both groups had similarly positive attitudes to the CSNAT intervention pre-implementation. By six months attitudes for ‘low’ adopters were significantly more negative, but remained similar or improved for ‘high’ adopters.

Conclusions

Ensuring successful implementation of complex interventions within palliative care requires consideration of the organisational context, service type, strategies for maintaining positive staff attitudes over time, and the use of intervention ‘champions’.

References

Ewing G, Brundle C, Payne S, Grande G. The Carer Support Needs Assessment Tool (CSNAT) for use in palliative and end-of-life care at home: A validation study.J Pain Symptom Manage2013;46(3):395–405

Ewing G, Grande G. Development of a Carer Support Needs Assessment Tool (CSNAT) for end-of-life care practice at home: a qualitative study.Palliat Med2013;27(3):244–256

Ewing G, Austin L, Diffin J, Grande G. The Carer Support Needs Assessment Tool: A person centred approach to carer assessment and support.Br J Community Nurs2015;20(12):580–584
Systematic review of prescribing patterns of analgesic medications for older people living in care homes over time
Authors: Frenais Francesca La , Bedder Rachel , Stone Patrick , Sampson Elizabeth L
Published: August 2016

Introduction

Historically care home residents, including people with dementia, have been under-treated for pain (Nygaard and Jarland, 2005). Recent research suggests increased prescriptions within this population but trends are unclear (Sandviket al., 2016, Jensen-Dahmet al., 2015).

Aim

To explore changes in the prescription of analgesic drugs over time; (2) to compare the prescriptions of analgesic medication between the general care home population and cognitively impaired (CI): residents; (3) to carry out subgroup analyses on drug type (opioid; non-opioid; paracetamol) and prescription type (regular vs. regular + ‘as required’).

Method(s)

English-language articles indexed under care homes and analgesic medication; bibliographies of retrieved papers; correspondence. We searched for published and unpublished studies (no restriction on publication year) representative of the care home population that included number of participants, country and year(s) of data collection, and prescription rates of analgesics and/or subtypes. Correlations were generated between the percentage of residents prescribed an analgesic and year of data collection. Studies were rated for quality.

Results

Sixty-two studies met our inclusion criteria. Regular prescription rates for analgesics, including subtypes of opioids and paracetamol, have increased over time for both the general care home population and residents with CI. There were no studies reporting regular prescriptions of analgesics post-2006 for CI residents. There is no trend when also considering PRN medication.

Conclusion(s)

Consistent with recent research, regular prescriptions appear to be increasing. We are unable to comment on whether, currently, residents with CI: receive less analgesic medication.

References

Jensen-Dahm C, Gasse C, Astrup A, Mortensen PB, Waldemar, G. Frequent use of opioids in patients with dementia and nursing home residents: A study of the entire elderly population of Denmark.Alzheimers Dement2015;11:691–699

Nygaard HA, Jarland M. Are nursing home patients with dementia diagnosis at increased risk for inadequate pain treatment?Int J Geriatr Psychiatry2005;20:730–737

Sandvik R, Selbaek G, Kirkevold O, Husebo, BS, Aarsland D. Analgesic prescribing patterns in Norwegian nursing homes from 2000 to 2011: trend analyses of four data samples.Age Ageing2016;45:54–60
One year mortality: recognising the need for urgent or advance care planning in adults aged over 70 years old following emergency admission
Authors: Bielinska A-M , Obanobi A , Riley J , Urch CE
Published: August 2016

Introduction

Approximately 1 in 3 hospital inpatients may be in their last year of life in Scotland (Clark, 2014); however no data exists for England. This study aimed to review outcomes of admissions for patients aged 70 years old and above admitted to a large London hospital Trust during 2014.

Aim

To establish the 1 year mortality of a cohort of admissions in patients aged 70+ years admitted to Imperial College Healthcare NHS Trust.

Methods

Admission data were obtained via the electronic patient record (Cerner) from 1st May-31 October 2014, stratified according to emergency overnight admission and age. Follow-up data on mortality, admission patterns and diagnoses were analysed

Results

During the study period there were 6,701 admissions for patients aged 70+ years, of whom 49.4% were 70–79 years, 38.3% were 80–89 years and 12.3% were 90+years. The 1 year mortality for all age groups combined was 22.4%; 12.7% died within 3 months, 4.8% died between 3–6 months, 3% died between 6–9 months and 1.9% died between 9–12 months. One year mortality rose with age, from 20% in 70–79 year olds, to over 25% in 90+ year olds.

Conclusions

The data from London and Scotland both indicate that a single admission over the age of 70 years old is a significant predictor of death within 1 year. An emergency admission over the age of 70 years could be used to aid recognition of the last years of life and an indicator to initiate care planning. Care planning has been demonstrated to reduce further unscheduled admissions and improve out-of-hours care (Brinkman-Stoppelenburg, 2014).

References

Clark, D.Imminence of death among hospital inpatients: Prevalent cohort study.Palliat Med2014;28(6):474–479

Brinkman-Stoppelenburg A. The effects of advance care planning on end-of-life care: a systematic review.Palliat Med2014;28(8):1000–1025
Co-development strategy for successful recruitment of patients to a qualitative research study on compassion in a UK inpatient hospice
Authors: Armour Kathy , Grubb Rachel , Palfrey Hannah , Ives Jonathan
Published: August 2016

Background

An empirical bioethics analysis exploring what palliative inpatients understand as compassion was planned within an Intercalated BMedSc degree. Limited time was available, so to achieve deadlines, a co-developmental approach was employed maximising clinical/research expertise from hospice and university.

Aim

To study compassion by forming an effective university-hospice research partnership.

Methods

A multi-disciplinary research team (MDRT) was created comprising a student, academic researcher, hospice nurse and hospice facilitator. Introductory meetings in January 2016 developed a research strategy appropriate to a hospice inpatient unit (IPU). Three members of the MDRT attended the IRAS committee and on-going support ensured governance permissions were obtained. Recruitment over 8 weeks (March–May 2016) was designed to be symbiotic with clinical care, promoting a good experience of exploratory qualitative interviewing.

Results and discussion

Intense support of the researcher facilitated timely transition through governance. All IPU patients were screened. Nineteen eligible patients were approached and introduced to the study by the nurse who also communicated with the clinical care teams. Six patients were consented by the student and 15–25 minute semi-structured interviews were conducted. Reasons for non-participation varied from feeling tired or poorly to exclusive interest in interventional research trials.

Conclusion

A MDRT approach can facilitate a qualitative research study in an inpatient hospice. Knowledge of the clinical setting maximised an effective recruitment strategy. Recruitment barriers included time constraints, patient willingness, patient availability, and perceptions of patient capacity and willingness. Ethics and procedural questions around promoting compassion research participation in this potentially vulnerable population can be addressed.

Reference

Byrne A, Upton L, Townsend S. Mind the gap: a step forward in supporting hospice-based research.BMJ Support Palliat Care2014;5(1):4–6. doi:10.1136/bmjspcare-2014-000808
Development of a psychoeducational workshop for patients with cancer cachexia and their carers
Authors: Wheelwright Sally , Hopkinson Jane B , Darlington Anne-Sophie , Fitzsimmons Deborah , Johnson Colin D
Published: August 2016

Introduction

Cancer cachexia has a negative impact on the quality of life (QOL) of patients and their informal caregivers but there are few psychoeducational interventions to address this.

Aim

To develop a brief supportive group-based intervention for patients with cancer cachexia and their carers

Methods

Workshop development followed the Coventry Intervention Development Process.1Reasons why unintentional weight loss is difficult for patients and carers were mapped from interviews with 5 patients, 5 carers and 5 health care professionals (HCPs). A summary map was supplemented with data from systematic reviews of the patient and carer literature and by previously conducted interviews with patients and HCPs about the effect cancer cachexia has on QOL. Project advisory panel members rated the importance and changeability of each reason in the context of a workshop. The highest scoring reasons were grouped to form intervention targets. Reviews of the literature informed the information provided to address the targets and the methods used to do this.

Results

Underpinning the intervention is the Integrated Theory of Health Behaviour.2The workshop has three intervention targets: providing information about eating well with cancer, addressing conflict and addressing negative emotions. Activities were devised to inform how cancer can cause unintentional weight loss, what to eat, strategies to maximise intake and conflict self-management. The underlying assumption is that negative emotions will be alleviated by providing clear information and advice.

Conclusion

We have developed a workshop to educate, aid coping and provide relationship support for patients with cancer cachexia and unintentional weight loss.

References

Martin F, Turner A, Bourne C, Batehup L. Development and qualitative evaluation of a self-management workshop for testicular cancer survivor-initiated follow-Up.Oncol Nurs Forum2013;40:E14–E23

Ryan P. Integrated theory of health behavior change: background and intervention development.Clinl Nurse Spec2009;23:161–170
How accurate are palliative care doctors at recognising dying?
Authors: White Nicola , Harris Adam , Reid Fiona , Harries Priscilla , Minton Ollie , McGowan Catherine , Lodge Philip , Tookman Adrian , Stone Patrick
Published: August 2016

Background

Before being able to plan for end of life care, a doctor must first recognise that a patient is dying. A recent review has highlighted that doctors are not very good at this (Neuberger, 2013).

Aim

We set out to develop a “test” to assess how accurate doctors are at recognising dying. The test will consist of case studies, or “vignettes”, based on real palliative care patients.

Methods

In order to create the vignettes for the test, we undertook a prospective observational study of patients at two sites (a hospice and a hospital palliative care team). Any inpatient, over 18 years old, English speaking, and who was identified by the palliative care team as likely to die within the next two weeks was eligible. The clinical course of each patient was observed and was used to create a vignette, which formed the basis of the prognostic test.

Results

50 participants were recruited and 20 were used to devise a prognostic test. For each vignette, clinicians were asked to assess the likelihood of death in the next 72 hours (scale 0% to 100%) based on the information presented. Illustrative examples of the test questions will be presented at the conference.

Conclusions

We have developed a standardised test to assess clinicians’ abilities to accurately diagnose imminent death. This test may be used to identify doctors who are most accurate at recognising dying. This may lead to an improved understanding of how this clinical skill is acquired and how it can be taught to less expert clinicians.

Reference

Neuberger J. More care, less pathway: a review of the Liverpool Care Pathway; 2013. Available at:https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/212450/Liverpool_Care_Pathway.pdf
Multi-disciplinary research team approach to recruiting patients, close persons and healthcare professionals in hospices
Authors: Armour Kathy , Campbell Cathy L , Bailey Cara , Kinghorn Philip , Orlando Rosanna , Perry Rachel , Jones Louise , Coast Joanna
Published: August 2016

Introduction

There are several well-known barriers to conducting research in hospices. Hospices may lack experience of research and have less developed governance procedures. The vulnerability of patients and the sensitivity of the topic may also form real, or perceived, barriers. Recruitment of participants to end-of-life projects therefore tends to be slow and resource intensive. It requires clear communication between academic researchers and hospice staff.

Aim

To establish a multi-disciplinary team (MDT) approach to enhance research in a voluntary-sector hospice incorporating day services, outpatient clinical services and inpatient unit.

Method

An integrated multi-disciplinary research team (MDRT) was created comprising four sub-teams: the hospice team including a dedicated research lead, the university team, a wider project group and an external advisory group. Seventy-two participants: 33 patients, 21 close persons and 17 healthcare professionals were recruited to a semi-qualitative research study between October 2012 and February 2014. Challenges to recruitment were identified and solutions applied during the course of the study by the MDRT.

Results

Key members of the MDRT, identified early in the research process, enabled recruitment difficulties to be overcome. Approaches included increasing the visibility of researcher, increasing and regularising communication between core MDRT team members and maintaining ongoing dialogue with potential participants to reduce staff gatekeeping.

Conclusion

Simulating a clinical MDT-style working approach can facilitate palliative care research activity. Creating a research-supportive environment identifies problems and creates solutions. The MDRT model is offered to researchers and hospice staff to develop and enact effective participant recruitment to build end-of-life research.

Reference

Bailey C, Kinghorn P, Orlando R,et al. The ICECAP-SCM tells you more about what I am going through: A think-aloud study measuring quality of life among: patients receiving supportive and palliative care.Palliat Med2016;30(7):642–652
JOINT RESPONSE UNIT: IMPROVING PATIENT CARE AND SAFETY THROUGH COLLABORATIVE WORKING BETWEEN AMBULANCE AND POLICE SERVICES
Authors: Zipfel Rebecca , McIlwaine Scott
Published: August 2016

Background

The London Ambulance Service NHS Trust receives more than one million calls every year, with roughly 10% of these coming from the Metropolitan Police Service. The majority of calls from the police are for patients with non-life-threatening symptoms, to which a clinical response is aimed to be dispatched within 30 minutes. When demand is high, however, ambulances get re-directed to more severely ill patients and police officers end up waiting on-scene for prolonged periods. This has a detrimental impact on the police services' response to calls.

Methods

The Joint Response Unit is an initiative designed to address the above problem. It consists of a solo clinician providing a dedicated response to police requests within an assigned borough. Initiated in 2011, it now covers 12 London boroughs, with the hope of further expansion within and outside of London. This evaluation is assessing the necessity and clinical safety of this initiative.

Findings

An on-scene clinical response was required for 95% of patients, highlighting the need for the Joint Response Unit. Arrival time to life-threatening calls is improved and conveyance to hospital decreased due to the clinician's ability to appropriately assess, treat and discharge on-scene. Since its implementation in 2012, the Joint Response Unit has reduced police on-scene waiting times from an average of 36 minutes to 7 minutes. Over the course of just one weekend, the faster clinical response equates to a total of 13 hours of officer-time saved.

Conclusions

The Joint Response Unit is a unique and successful model of collaborative working between emergency services, with benefits to both the ambulance and police services. Other services should look at replicating this model to enable effective collaboration nationally.
PAST, PRESENT, AND FUTURE OF EMERGENCY DISPATCH RESEARCH: A SYSTEMATIC LITERATURE REVIEW
Authors: Gardett Isabel , Clawson Jeff , Scott Greg , Barron Tracey , Patterson Brett , Olola Christopher
Published: August 2016

Abstract previously published in Annals of Emergency Dispatch and Response.
A STUDY TO DETERMINE THE EZ-IO® INTRAOSSEOUS INFUSION SYSTEM SUCCESS RATE, INCLUDING IMPACT ON RETURN OF SPONTANEOUS CIRCULATION
Authors: Woodhart Ben , Shaw Joanna
Published: August 2016

Background

In the UK the EZ-IO® Intraosseous Infusion System is a paramedic delivered technique involving the placement of the Intraosseous (IO) needle into the patient's bone marrow via an EZ-IO driver. The primary use for EZ-IO is when intravenous (IV) access is not possible, mainly for patients in cardiac arrest but may include severely unwell/injured patients. This study aimed to determine EZ-IO success rate, including impact on return of spontaneous circulation (ROSC).

Methods

One hundred and ninety-five cardiac arrest patient records where EZ-IO placement was attempted were retrospectively examined to determine whether ROSC was achieved at any point. Findings were compared to records where resuscitation was attempted and patients were administered drugs IV and tested for association using Pearson's Chi-Square Test.

In addition, patients' records were assessed for their compliance to best practice guidance issued by the Joint Royal Colleges Ambulance Liaison Committee for use in UK Ambulance Services and manufacturer's guidelines.

Results

ROSC was achieved for 29% of the patients who had an EZ-IO inserted (n=57), therefore for 71% (n=138) ROSC was not achieved. This compares to 46% (n=338) and 54% (n=399) retrospectively for patients administered drugs IV.We observed a strong association between method of access and patient's outcome (χ2(1)=17.465, p=.000).

Where an EZ-IO was attempted 100% (n=195) were identified as having a successful IO placement, although certain areas of documentation were highlighted as requiring improvement, specifically: insertion site (recorded for 26%, n=51); needle size (74%, n=145), and saline flush (93%, n=182).

Conclusions

Although, this shows that the practice of pre-hospital EZ-IO insertion is successful, it compares less favourably to administering resuscitation drugs IV. However, there may be other factors associated with achieving ROSC that have not been taken into account, including the reasons IV access was not possible and whether this was an influencing factor.
PRE-HOSPITAL ANALGESIA FOR PATIENTS WITH FEMORAL FRACTURE: A SYSTEMATIC REVIEW OF THE LITERATURE
Authors: Bulger Jenna , Ford Simon , Pallister Ian , Rees Nigel , Russell Daphne , Russell Ian , Snooks Helen
Published: August 2016

Objective

To identify and estimate the effectiveness of interventions to provide analgesia for patients with femoral fracture in the emergency pre-hospital setting.

Methods

We searched the Cochrane Library, CINAHL, HMIC, Medline, PubMed, Scopus, Web of Science, grey literature and citations of included studies. We included randomised trials and observational studies that included pain score measurements. We carried out a meta-analysis using Review Manager.

Results

We identified 858 studies and assessed 36 full articles for eligibility. Ten studies met the inclusion criteria, including 478 patients. Five studies were randomised controlled trials, comparing outcomes between: fascia iliaca compartment block (FICB) with standard care; femoral nerve block with standard care; Transcutaneous Electrical Nerve Stimulation (TENS) with placebo; auricular acupressure with sham acupressure; and simple splints with traction splints. Two cohort studies included comparisons of pain scores with and without FICB. Three uncontrolled observational studies reported effects of FICB. Meta-analysis of four randomised studies with 227 patients showed that, compared with control, proactive interventions reduced pain scores by 1.9 standard deviations (95% CI from 1.1 to 2.7; p<0.0001); but these trials were clinically and statistically heterogeneous.

Conclusions

Current published research suggests that interventions to enhance the provision of analgesia for femoral fracture in emergency pre-hospital care reduce pain scores significantly more than standard care. However, as only five randomised studies are available with a range of diverse interventions, further research is warranted.
OVERCOMING CHALLENGES OF SETTING-UP A LARGE AND COMPLEX PRE-HOSPITAL TRIAL: AIRWAYS-2
Authors: Robinson Maria , Taylor Jodi , Voss Sarah , Rogers C , Brett S , Benger Jonathan
Published: August 2016

Background

AIRWAYS-2 is an NIHR-funded study to determine the best initial approach to advanced airway management during out of hospital cardiac arrest (OHCA). The trial will enrol more than 9,000 patients and 1,500 paramedics. To achieve this, collaboration between four Ambulance Trusts and every hospital served by these was required. Patients receive the trial intervention pre-hospital, and the primary outcome and other data are collected in-hospital. We describe the set-up process for this large, complex, pre-hospital trial.

Methods

Pre-hospital research presents unique challenges. Obtaining approvals and set-up can be complex, time consuming and expensive. A strategy to engage with all stakeholders was developed, ensuring that they were well informed during the planning and set-up phases. Specifically, this included: establishing R&D and Clinical Research Network contacts; involving critical care leads; consultation with ambulance trusts; utilisation of network support; implementation of a wide-reaching communications plan. All hospitals were contacted to identify local collaborators prior to SSI submission, and were provided with FAQs and study information. The approval process was streamlined. The SSI was generic and did not require input from local teams. A one page statement of responsibilities replaced review of contracts for sites. Comprehensive review by REC & CAG meant that full consideration was given to the ethical challenges during planning and set-up phases.

Results

Trust permission was obtained from all acute hospitals (95 in total), served by participating ambulance trusts. All set-up milestones were achieved and the first patient was enrolled on time.

Conclusions

Ambulance services are increasingly research active. Incidents attended can be life-threatening emergencies but good quality pre-hospital trials are possible. Early and comprehensive engagement assists with sites' participation and enables successful set-up of collaborative trials.
LEVEL OF SEPSIS KNOWLEDGE IN UK AMBULANCE SERVICES
Authors: Murphy-Jones Barry , Shaw Joanna
Published: August 2016

Background

Sepsis is responsible for over 37,000 deaths a year in the UK, with long term morbidity consequences for survivors. More than 40% of cases develop within the community, making the ambulance service vitally important. This project sought to ascertain the current level of sepsis knowledge in UK ambulance services to better understand potential knowledge gaps.

Methods

This observational study used an online questionnaire to describe the level of knowledge of sepsis and how it is recognised and managed in the pre-hospital setting. A convenience sample of clinicians at one ambulance service was invited to complete a questionnaire which consisted of ten questions and was hosted on the web-based tool SurveyMonkey®. One hundred and seventy-one complete responses were received from ambulance staff (response rate 5.4%) and data were entered into Microsoft Excel and analysed using descriptive statistics.

Results

The questionnaire identified 59% of respondents (n=100) had heard of the terms sepsis and systemic inflammatory response syndrome, with 23% (n=40) identifying all three stages of sepsis. Sixty-nine per cent of respondents (n=118) identified the correct definition of sepsis, and 23% (n=39) believed this definition was used in the pre-hospital setting.

Four per cent of respondents (n=7) identified all of the common signs and symptoms and 22% (n=37) knew all of the pre-hospital interventions for severe sepsis and septic shock. Finally, 71% (n=121) agreed paramedics could identify patients at high risk of sepsis, with 94% (n=161) agreeing pre-hospital recognition and interventions may improve outcomes for sepsis.

Conclusions

Findings showed poor knowledge of sepsis, its recognition and pre-hospital management which is supported by other literature. As a result, a mandatory training programme has been delivered and a sepsis screening tool, including prompts for appropriate management, has been produced. A continuous clinical audit will also be introduced to understand how this knowledge is applied in practice.
PARAMEDIC RESUSCITATION DECISION-MAKING IN OUT OF HOSPITAL CARDIAC ARREST: AN EXPLORATORY STUDY
Authors: Brandling Janet , Kirby Kim , Black Sarah , Voss Sarah , Benger Jonathan
Published: August 2016

Background

There are approximately 60,000 out-of-hospital cardiac arrests (OHCA) in the United Kingdom (UK) each year. Within the UK there are well-established clinical practice guidelines that define when resuscitation should be commenced in OHCA, and when resuscitation should cease. This study explored the influences on paramedic decision-making when commencing and ceasing resuscitation attempts in OHCA.

Methods

Four focus groups were convened with 16 clinically active paramedics from emergency response vehicles and specialist teams as well as teaching and management staff. Four case vignettes were discussed in these focus groups to explore paramedic decision-making. The initial three focus groups were formulated to test and refine the research methodology and consisted of non-standard paramedics (i.e. those in management, teaching or specialist paramedic roles). The final focus group consisted of ‘standard’ paramedics. The focus group discussions were audio recorded and transcribed in full. Thematic analysis was used after the focus groups had taken place and for final reporting.

Results

There are three stages in the paramedic decision-making process when deciding whether to commence or cease resuscitation attempts in OHCA. These stages are: the call; arrival on scene; the protocol. Influential factors present at each of the three stages can lead to different decisions and variability in practice. These are: factual information available to the paramedic; structural factors such as protocol, guidance and research; cultural beliefs and values; interpersonal factors; risk factors; personal values and beliefs. Variations in context and circumstance are vast, and therefore simple guidance cannot suit every case.

Conclusions

An improved understanding of the circumstantial, individual and interpersonal factors that mediate the decision-making process in practice could inform the development of more effective guidelines, leading to greater consistency and paramedic confidence, with the potential for improved patient outcome.
TIMELY SOCIAL CARE AND EMERGENCY HOSPITAL ADMISSIONS
Authors: Porter Alison , Bardsley Martin , Ford David , Grenfell John , Heaven Martin , Morrison-Rees Sian , Oades Judith , Sewell Bernadette , Tingay Karen , Watkins Alan
Published: August 2016

Background

Appropriate and timely social care can potentially delay or avoid the need for interventions such as emergency hospitalisation. Routine data provides scope to examine the relationship between emergency hospital admissions in Wales and local authority-supported social care for people aged 65 and over.

Methods

This observational study employed mixed methods for data collection and analysis covering the period January 2006 to December 2012. We used interrupted time series analyses to study overall trends in the use of social care and unplanned use of secondary care across Wales. Within one case study area, we used the SAIL database to link health and social care data anonymously, to examine service use at an individual level.

Results

At an all-Wales level, we observed no relationship between trends in health care and social care for older people.

In our case study area, we examined data on ‘qualifying emergency admissions’ (QEAs), that is, the first emergency admission to hospital in the study period for a person aged 65 or over. Over the study period, about four-fifths of all the people receiving social care (n=10,864) also had a QEA.

We compared those receiving social care before the QEA (n=3362) with those who received social care only after their QEA (n=7478). Those receiving social care before the QEA were likely to:

▸ have fewer subsequent admissions (1.4 v 2.9, p<0.01).

▸ have a shorter length of stay for all subsequent admissions (41.5 v 66.4 days, p<0.01)

Conclusions

Anonymously linking health and social care data for research is feasible and has potential for being taken further. Linked data reveals more about the relationship between health and social care use than unlinked data sets.

Social care appears targeted appropriately at the frailest older people, and seems to have a protective effect in reducing emergency admissions and length of stay following an admission.
RAPID INTERVENTION WITH GLYCERYL TRINITRATE IN HYPERTENSIVE STROKE TRIAL-2 (RIGHT-2): SAFETY AND EFFICACY OF TRANSDERMAL GLYCERYL TRINITRATE, A NITRIC OXIDE DONOR
Authors: Bath Philip M W , Dixon Mark , Appleton Jason , Scutt Polly , England Timothy , Foster Hayley , Howard Harriet , Jarvis Malcolm , Montgomery Alan , Pocock Stuart , Potter John , Price Christopher , Robinson Tom , Roffe Christine , Siriwardena A Niro , Sprigg Nikola , Wardlaw Joanna
Published: August 2016

Rationale

High blood pressure (BP) is common in acute stroke and is associated with poor outcome. Previous hospital-based trials testing the effects of BP lowering on functional outcome have been inconclusive. The PIL-FAST and RIGHT pilot trials confirmed the feasibility of performing single-centre ambulance-based stroke trials in the UK. In both RIGHT and a subgroup of patients recruited within 6 hours into the large ENOS trial, transdermal glyceryl trinitrate (GTN), a nitric oxide donor, lowered BP and reduced death or disability. Based on these results, RIGHT-2 aims to test the safety and efficacy of transdermal GTN in the pre-hospital setting.

Methods

Paramedics from 7 UK ambulance services serving 40 comprehensive or primary stroke care centres will screen, consent, randomise and treat 850 patients presenting within 4 hours of FAST-positive stroke and with systolic BP >120 mm Hg. Treatment will comprise GTN or similar sham patch, and will be continued in hospital for 3 days. The primary outcome will be the modified Rankin Scale at day 90. Secondary outcomes include vascular events, disability, quality of life, mood and cognition. Neuroimaging and biomarkers will examine potential mechanisms of action.

Status

Recruitment commenced in October 2015. Challenges with the trial and baseline characteristics of the first recruited patients will be presented.

Funding

British Heart Foundation.
PARAMEDIC SUPPLIED “TAKE HOME” NALOXONE: A RANDOMISED FEASIBILITY STUDY
Authors: Moore Chris , Lloyd Greg , Oretti Rosanna , Russell Ian T , Snooks Helen
Published: August 2016

Introduction

“Take Home” Naloxone (THN) kits for use in the event of an opioid overdose may reduce further overdose and deaths, but distribution through Drugs Services may not reach those at highest risk. Attendance by paramedics at emergency calls for opioid overdose presents an opportunity to distribute THN kits. This feasibility study will assess the acceptability of THN, and gather data to inform definitive trial planning.

Methods and analysis

Cluster randomised trial with staggered allocation of paramedics (clusters) to groups. Paramedics in an urban area of south Wales, UK were invited to take part and randomly allocated to training. Patients attended by trained paramedics and issued THN kits fell into the intervention group. Patients attended by paramedics following usual practice (until they received their training) fell into the control group. We will gather data about processes and outcomes of care: numbers of patients eligible for intervention, offered and accepted THN, attended Emergency Department, suffered further overdose, died within 12 months; and about follow up rates: numbers of patients consented, completed questionnaire (postal or telephone). We will gather qualitative data about acceptability to patients and paramedics through interviews and focus groups.

Preliminary findings (unvalidated data)

85 of 102 eligible paramedics took part. The number of opioid related EMS contacts (n=215), exceeded the number predicted (100–120) for the 12-months period. Of the 182 cases attended by study paramedics, 148 were attended by trained paramedics. 35 of the 55 patients eligible for the intervention were offered it. 25 accepted the intervention, received training and a THN kit. As anticipated, follow-up of participants proved challenging. Of the 215 events for which we have data, 58 were repeat episodes involving 25 individual users. The number of repeat encounters experienced by these individuals ranged from 2 to 5. Six deaths were recorded during the study period.
HOME OR HOSPITAL FOR PEOPLE WITH DEMENTIA AND ONE OR MORE OTHER MULTIMORBIDITIES: WHAT IS THE POTENTIAL TO REDUCE AVOIDABLE EMERGENCY ADMISSIONS?
Authors: Voss Sarah , Benger Jonathan , Black Sarah , Brandling Janet , Buswell Marina , Cheston Richard , Kirby Kim , Purdy Sarah
Published: August 2016

Older people with multiple health problems often call a 999 ambulance. Where one of these health problems is dementia, the risk of ambulance use, A&E attendance and hospital admission are all increased. It is important to try and reduce this, as patients with dementia tend to have poor outcomes when they are taken to A&E or admitted to hospital unnecessarily.

This study aims to find out why older people with multiple health issues including dementia are taken to hospital by ambulance, instead of being treated in the community. This will build on earlier work to find the true burden of dementia on pre-hospital care. It will look at the length of time paramedics spend at the scene, factors guiding the decision to transport and alternatives to A&E visits and hospital admissions.

There will be 3 phases of work:

Phase 1: Analysis of existing ambulance service data from previous 999 calls.

Phase 2: Observations of ambulance call-outs to patients with multiple health problems including dementia.

Phase 3: An assessment of what could be provided in the community to avoid hospital admission.

This proposal is part of an overall research plan, and will inform further investigations and future service delivery. We plan to study issues specific to the ambulance service that reduce or increase the risk of someone with dementia and other long-term health conditions requiring hospital care, rather than being looked after in or close to their own home. It contributes to a larger piece of work developing and evaluating safe and effective alternatives to hospital admission for people with dementia. This will lead to a reduction in the number of avoidable emergency admissions, and better patient outcomes, for example through the introduction of rapid response health and social care teams as described in the NHS Five Year Forward View (2014).