bluuebunny/crossref_metadata_2025_split huggingface dataset:
EP11 Using machine learning to recover unrecorded prehospital data
Authors: Reich Thilo , Bancroft Adam , Budka Marcin 
Published: August 2021

BackgroundThe 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.MethodsSCAS 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.ResultsThe 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).ConclusionsThe 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

BackgroundTimely 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.MethodsWe 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.Results783186 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.ConclusionsUsing 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

BackgroundSurvival 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.MethodsWe 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.ResultsBetween 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.ConclusionsFollowing 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

BackgroundThe 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.MethodsA 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.Results522 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).ConclusionsThe 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

BackgroundFollowing 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.MethodsData selected were representative of high or low clinical risk, and reliably recorded. The following ‘risk factors’ were chosen:Call outcomeEmergency conditionsClinical interventionsMedications administeredWith 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 policyAssessing risk of code downgrades in the pandemic responseIdentifying codes suitable for automatic specialist clinician allocationsSupplementing analysis of harm caused by long response delaysIdentifying codes for protection within End of Shift protocolsProviding intelligence to aid national decisions on code categorisationNext steps:The Tool continues to assist in decision-making locally. Future ambitions include:Validation of the scoring algorithmsProcess automation to ensure more timely data is availableCollaboration 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

BackgroundIn 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.MethodsA 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.ResultsSixteen 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.ConclusionHanging 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

BackgroundPrehospital 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.MethodsThis 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 ConclusionThe 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

BackgroundDrug 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.MethodsA 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.ResultsThe 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).ConclusionsThe 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

BackgroundDuring 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.MethodsTen 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.ResultsThe 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.ConclusionsParticipants 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

BackgroundUse of the Pre-Hospital 12-lead Electrocardiogram (PHECG) is recommended in patients presenting to emergency medical services (EMS) with suspected acute coronary syndrome (ACS).ObjectivesTo investigate differences in mortality between those who did/did not receive PHECG.MethodsPopulation-based, linked cohort study using Myocardial Ischaemia National Audit Project (MINAP) data from 2010-2017.ResultsOf 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).ConclusionPHECG was associated with lower mortality at 30 days and 1 year in both STEMI and non-STEMI patients.