bluuebunny/crossref_metadata_2025_split huggingface dataset:
PP32 Pathway to portfolio: from idea to full trial funding
Authors: Snooks Helen , Jones Jenna , Watkins Alan , Keen Leigh 
Published: August 2021

BackgroundNIHR 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.ObjectiveTo determine costs and effects of Fascia Iliaca Compartment Block delivered by paramedics at the scene of injury for suspected hip fracture.MethodsLiterature reviewDevelopment and testing of tool to support identification of hip fracture by paramedicsFeasibility trial (RAPID 1)Proposal for definitive trial (RAPID 2)ResultsFunding 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.ConclusionsResearch 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

BackgroundDiabetic 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.MethodsDuring 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.ResultsInformation 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.ConclusionsStudy 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.
PP39 What is the risk of major trauma following a fall down stairs? – A systematic review
Authors: Holt Christopher , Keating Samuel , Tonkins Michael , Bradbury Daniel , Fuller Gordon 
Published: August 2021

BackgroundSpecific mechanisms of injury are stated in pre-hospital triage tools to identify suspected cases of major trauma. Falls down stairs are common presentations in UK emergency departments, yet are frequently overlooked as a causative mechanism of major trauma. No prior systematic review has examined this association.MethodsSeven internationally recognised literature databases and seven grey literature databases were screened utilising a common search strategy from inception until 31 December 2019. Abstracts were screened for relevance by a single reviewer. Full texts were screened and subsequently extracted by 3 separate reviewers against strict inclusion/exclusion criteria. A risk of bias assessment based on GRADE recommendations was performed. In the absence of study heterogeneity, a narrative synthesis was planned. The reporting of this systematic review followed PRISMA 2009 statement guidelines.Results5240 articles were identified from database searching, 89 articles had their full texts assessed for eligibility and 6 articles were included for qualitative synthesis. All studies were retrospective in nature and originated from more economically developed countries. 7431 patients who fell down stairs were analysed, of which, 707 (9.5%) met major trauma definitions. Falls down stairs resulted in a significantly increased risk of serious injury compared to other fall mechanisms (OR: 1.621, 95% CI: 1.381 – 1.902, p<0.0005). Analysis of confounding factors demonstrated age (OR: 2.59, 95% CI: 1.57 – 4.28, p<0.001) and alcohol intoxication (OR: 2.6, 95% CI: 1.4 – 4.7, p=0.001) to be significantly associated with major trauma. Risk of bias was moderate to high across all 6 studies.ConclusionThis systematic review highlighted the paucity of literature surrounding the incidence of major trauma following falls down stairs.A retrospective cohort study is currently being undertaken to analyse the risk of major trauma following falls down stairs. On completion, the results will be incorporated with the results of this systematic review.
04 Improving the prehospital identification and management of people presenting to the ambulance service with COVID 19 symptoms
Authors: Fitzpatrick David , Moore Matthew , Best Catherine , Andreis Federico , Duncan Edward , Esposito Martin , Corfield Alasdair , Dcobbie Richard , Lowe David 
Published: August 2021

BackgroundLittle is known about how patients with COVID-19 present to ambulance services or their outcomes. Between 1st March and 31st August 2020 we investigated individuals who called the Scottish Ambulance Service (SAS) with COVID-19 symptoms and those that were later tested COVID-19 positive. We analysed i) their demographic and clinical characteristics; ii) their disposal; and iii) their admission and mortality outcomes.MethodsSAS and NHS Scotland Health Board data are routinely linked in a national database. These data evidence a patients journey from ambulance call to hospital attendance and subsequent outcome. Evidence of COVID-19 testing was identified 10 days either side of the call.Results171,169 patients made 257,207 calls during the study period. Of these, 2.8% (n=7,305) were categorised as possible COVID-19 patients during telephone triage. From the flagged +ve patient calls 6% had a COVID-19 positive result, 29% had a negative COVID-19 result and the other 65% had no evidence of being tested. The majority (54%) were taken to the Emergency Department; 73% received further hospital care. The proportion of patient calls admitted within 10 days of the call was 31% for those not conveyed against 82% for conveyed. Final prehospital physiology for COVID-19 positive patients demonstrated lower oxygen saturations, higher respiratory rates and temperatures. 4.9% and 11.7% of patients conveyed to hospital died within 3 and 30 days vs 5.2% and 19.6% of patients not conveyed respectively.ConclusionsThis study suggests telephone triage is not a reliable identifier of COVID-19 patients reinforcing existing requirements for Personal Protective Equipment. 30-day mortality rates differed between those patients initially conveyed vs not conveyed. Clinical characteristics of COVID-19 positive patients suggest they were clinically less well than other patients.
PP41 British columbia emergency health services assess, see treat and refer palliative clinical pathway
Authors: Helmer Jennie , Baranowski Leon , Armour Richard , Tallon John , Williscroft David , Brittain Michelle 
Published: August 2021

Background/Research ObjectivesParamedic services have experienced a steadily increasing demand from palliative patients accessing 911 during times of acute crisis, and not wishing subsequent conveyance to ED. Early data indicates that many of these patients are NOT already connected to palliative care teams.To address this demand and to connect patients to care, BCEHS introduced the Assess, See, Treat and Refer (ASTAR)-Palliative Clinical Pathway. Objectives are to reduce patient conveyance to ED, reduce hospitalizations and improve patient care through referral after non-conveyance.InterventionParamedic activation of the ASTaR Palliative Clinical Pathway results in referral of non-conveyed palliative patients to local Home and Community Care teams and BCEHS paramedics. The referral occurs within 1-6 hours of paramedic contact and follow up occurs over the next 24-48 hours by telephone. This referral action provides safe, effective, patient-centred care for non-conveyed patients, and also fills a gap for connecting patients to local palliative care teams.ImpactA retrospective case review of 183 cases was conducted. Symptom improvement was achieved in 70% of cases, the ED non-conveyance rate was 19%, and the time on task when palliative patients were treated at home and not conveyed was 37% less (52 minutes) than if palliative patients were transported (82 minutes). All 183 patients were connected to either the local home and community care team or BCEHS Rural Advanced Care Community Paramedics (RACCP).Lessons LearnedPalliative patients frequently call 911 for help during acute crisis events and many of these patients do not wish conveyance to ED. The introduction of the ASTaR palliative clinical pathway provided safety netting and referral to appropriate care teams.
05 Co-design of a logic model describing components, mechanisms of change and expected impacts of case management for people who frequently call ambulance services
Authors: Aslam Rabeea’h , Cole Robert , Diethart Berni , Edwards Adrian , Edwards Bethan M , Evans Bridie A , Foster Theresa , Fothergill Rachael , Gripper Penny , Hughes Heather , John Ann , Khanom Ashra , Petterson Robin , Phillips Ceri J , Porter Alison , Rees Nigel , Rosser Andy , Scott Jason , Tee Anna , Watkins Alan , Snooks Helen 
Published: August 2021

BackgroundMulti-agency case management is being introduced by ambulance services and their partners in the UK to try to identify and address the needs of those who call 999 ambulance services frequently. However, there is a lack of evidence about what works well in this setting and how. Based on current nationally agreed definitions, calling frequently is defined as 5 or more times in a month, or 12 or more times in a three-month period. The STRETCHED study (STRategies to manageEmergency ambulanceTelephoneCallers with sustainedHigh needs – anEvaluation using linkedData) study seeks to evaluate clinical and cost-effectiveness, safety, and efficiency of case management for people who frequently call the emergency ambulance service.We developed a logic model to describe key components, mechanisms of change and expected impacts of cross-sectoral case management approaches to the management of people who call 999 frequently.MethodWe conducted a stakeholder event with 37 people from Wales, England and Northern Ireland including patient representatives and professional staff involved in commissioning, planning and delivering case management for people who call 999 services frequently. The aggregated responses from the participants was used as the basis for developing a logic model.ResultsComponents:dedicated staff time for case management, availability and knowledge of relevant services for referral, multidisciplinary collaboration, organisational support, and clear information sharing protocolsMechanisms:provision of space for a clear understanding of reasons for calling, tailoring of multi–sectoral management to individual needs, offering therapeutic support and assistance in development of self–efficacyImpacts:improvement in access to appropriate and timely care, increase in efficiency and accessibility of the healthcare system, reduction in emergency calls, costs and mortalityConclusionCase management is a developing area of provision in prehospital emergency care for people who call ambulance services frequently. Our logic model provides a firm foundation for evaluation to build the urgently needed evidence base for case management of people who call ambulance services frequently.
06 Speak to me: a literature review examining the participation of people living with dementia during healthcare interactions
Authors: Lindley Daniel , Baxter John 
Published: August 2021

BackgroundPeople living with dementia have frequent encounters with ambulance services and have a high risk of mortality when admitted to hospital. The Mental Capacity Act and the National Institute for Health and Care Excellence (NICE) guidance provide a framework for all healthcare practitioners to support the person living with dementia into making their own healthcare decisions and encourages participation regardless of capacity status.The purpose of this study was to understand if people living with dementia are afforded these opportunities to participate in healthcare decisions during interactions with paramedics and what key themes affect participation.MethodsElectronic database search of literature, based on keywords, of EBSCO (searching MEDLINE and CINAHL), hand-sifting, and grey literature.Articles were searched for pre-hospital care, Paramedic, EMS, EMT but yielded few results and the terms Doctor, Nurse, Healthcare Professional were added to search matrix. Included articles focused on decision making, participation, were under 10 years old and UK based. 1 exception was made for a Norwegian study focusing on participation.Articles were reviewed multiple times in a meta-synthesis to find themes within each article. Data was grouped, coded and categorised based on themes.ResultsThe findings illustrate that people living with dementia wish to retain autonomy and should be afforded the opportunity to participate in their own decision making regardless of capacity. Good and bad practice occurs, but many people living with dementia are marginalised, manipulated or have decisions taken from them.ConclusionParamedics need to engage with people living with dementia during all encounters regardless of the severity of the person’s dementia or capacity status. They need to take time to give the person every opportunity to participate, not be influenced by someone who is not the patient and aim to be more inclusive of the patient. Further primary research is required to fully understand the quality of interactions between paramedics and people with dementia.
OP07 On the effectiveness and costs of inhaled methoxyflurane versus usual analgesia for prehospital injury and trauma
Authors: Smith Murray D , Siriwardena Aloysius Niroshan , Spaight Robert , Rowan Elise 
Published: August 2021

BackgroundAcute pain is often inadequately treated in adults with traumatic injury. Inhaled methoxyflurane, newly licensed in Europe for this indication, has limited evidence of clinical effectiveness in the prehospital setting. We aimed to investigate clinical effectiveness and costs of methoxyflurane administered by ambulance staff compared with usual analgesic practice (UAP) for patients with trauma.MethodsWe used a non-randomised control group pragmatic design comparing methoxyflurane versus Entonox® and parenteral analgesics. Verbal numerical pain scores (VNPS) were gathered over time in adults with moderate to severe trauma pain attended by ambulance staff trained in administering and supplied with methoxyflurane. Comparator VNPS were obtained from database records of UAP in similar patients. Clinical efficacy was tested using an Ordered Probit panel regression model of pain linked by observational rules to VNPS. Scenario analyses were used to compare durations under analgesia spent in severe pain, and costs.ResultsOver 12 months, 96 trained paramedics and technicians prepared 510 doses of methoxyflurane for administration to 483 patients. 32 patients reported side-effects, 19 of whom discontinued early. 13 patients, 10 aged over 75 years, were nonadherent to inhaler use instructions.Modelling results showed statistically significant clinical effectiveness of methoxyflurane over each comparator (all p-values<0.001). Methoxyflurane’s time to achieve maximum pain relief was significantly faster (all p-values<0.001): 26.4 mins (95%CI 25.0-27.8) versus Entonox® 44.4 (39.5-49.3); 26.5 (25.0-27.9) versus IV morphine sulfate 41.8 (38.9-44.7); 26.5 (25.1-28.0) versus IV paracetamol 40.8 (34.7-46.9).Scenario analyses of durations spent in severe pain were significantly less for methoxyflurane to comparators. Benefits of methoxyflurane were achieved at higher cost to comparators.ConclusionsMethoxyflurane reduced pain more rapidly and to a greater extent than Entonox® and more quickly than parenteral analgesics in adults with moderate or severe pain due to trauma attended by ambulance clinicians. Methoxyflurane provides a useful addition to prehospital analgesia.
OP08 Levels and sources of stress reported by first year paramedic students associated with their first ambulance placement
Authors: Warren-James Matthew , Hanson Julie , Flanagan Belinda , Katsikitis Mary , Lord Bill 
Published: August 2021

BackgroundWhilst there is evidence to suggest paramedics experience significant stress when working in the ambulance setting little is known about the experiences of first year paramedic students. This research aimed to: (i) identify whether levels of stress, anxiety and depression experienced by first year paramedic students changed after ambulance placement compared to a control group, and (ii) identify the main perceived and actual sources of stress around ambulance placement.MethodsA before-and-after quasi-experimental design was used to compare whether the experience of ambulance placement altered the levels of stress, anxiety and depression in an experimental group that attended an ambulance placement (n = 20) and the control group who did not (n = 10). Online surveys encompassing the Depression, Anxiety and Stress Scale (DASS-21) and qualitative questions about sources of stress were concurrently deployed to both the experimental and control groups before and after the ambulance placement. Participants were first year paramedic students working in Queensland Ambulance Service, Australia.ResultsThere was a significant reduction in levels of stress in participants after undertaking their first ambulance placement (Mdn = -4.00) when compared to a control group (Mdn = 0.00),U= 52.5,p= .035,n2= 0.15. Responses to survey questions suggest anticipation about experiencing death and dying of patients was the most frequently reported stressor of student paramedics before undertaking ambulance placements, however insecurity about knowledge, competence and fear of failure was the most frequently experienced stressor reported after completing ambulance placements.ConclusionsThe findings from this study suggest that the fear of the unknown may be worse than the reality. Anticipatory stress is the foremost problem for first year paramedic students attending their first ambulance placement. Placement pre-briefing should focus on educational interventions to build knowledge and skills competency to reduce stress levels and fear of failure.
OP09 An investigation of the clinical decision-making challenges experienced by ambulance clinicians during the management of patients presenting with COVID-19 symptoms
Authors: Fitzpatrick David , Ikegwuonu Theresa , Duncan Edward , Esposito Martin , Moore Matthew , Corfield Alasdair , Best Catherine , Andreis Federico , Dobbie Richard , Lowe David 
Published: August 2021

BackgroundAs well as patient impact, COVID-19 also considerably impacts on staff who have been required to make challenging patient care decisions in uncertain circumstances. This study investigated ambulance clinicians’ experiences and use of decision support strategies during the COVID-19 pandemic.MethodsForty-eight percent (16/33) of paramedics invited agreed to be interviewed. Telephone/video interviews were undertaken between September and December 2020. Framework analysis was undertaken. Data were indexed and charted by one researcher. A sample was then checked by two other researchers. Analytical interpretation was collectively undertaken by all three researchers to identify a higher-level conceptual understanding.ResultsFour key themes were identified:Impact on clinical decision making– Deciding whether to take a patient to an Emergency Department is often challenging. Paramedics reported that COVID-19 increased the complexity of this process.Decision Support– Enhanced decision support was perceived as unequally available across the ambulance service. Where present, several paramedics reported that it was highly valuable.Use of Personal Protective Equipment (PPE)– Routine use of extensive PPE was a very new experience for all participants. Some reported that the number of calls initially exceeded PPE availability.Personal impact of dealing with COVID-19– Several paramedics stated that media reports combined with paramedics appearing in full PPE increased levels of anxiety among many patients they attended. Some participants were worried about catching COVID-19 and the possibility of taking the virus home to their families.ConclusionsOur findings suggest that COVID-19 has placed considerable stress on the ambulance service at both organisational and individual levels. These findings could inform implementation processes surrounding rapid clinical guideline development and communication.*This abstract was presented by Edward Duncan