The Recognition of STEMI by Paramedics and the Effect of Computer inTerpretation (RESPECT): a randomised crossover feasibility study

Background : The appropriate management of patients with ST-segment elevation myocardial infarction (STEMI) depends on accurate interpretation of the 12-lead ECG by paramedics. Computer interpretation messages on ECGs are often provided, but the effect they exert on paramedics’ decision-making is not known. The objective of this study was to assess the feasibility of using an online assessment tool, and collect pilot data, for a definitive trial to determine the effect of computer interpretation messages on paramedics’ diagnosis of STEMI. Methods : The Recognition of STEMI by Paramedics and the Effect of Computer inTerpretation (RESPECT) feasibility study was a randomised crossover trial using a bespoke, web-based assessment tool. Participants were randomly allocated 12 of 48 ECGs, with an equal mix of correct and incorrect computer interpretation messages, and STEMI and STEMI-mimics. The nature of the responses required a cross-classified multi-level model. Results : 254 paramedics consented into the study, 205 completing the first phase and 150 completing phase two. The adjusted OR for a correct paramedic interpretation, when the computer interpretation was correct (true positive for STEMI or true negative for STEMI-mimic), was 1.80 (95% CI 0.84 to 4.91) and 0.58 (95% CI 0.41 to 0.81) when the computer interpretation was incorrect (false positive for STEMI or false negative for STEMI-mimic). The intraclass correlation coefficient for correct computer interpretations was 0.33 for participants and 0.17 for ECGs, and for incorrect computer interpretations, 0.06 for participants and 0.01 for ECGs. Conclusions : Determining the effect of computer interpretation messages using a web-based assessment tool is feasible, but the design needs to take clustered data into account. Pilot data suggest that computer messages influence paramedic interpretation, improving accuracy when correct and worsening accuracy when incorrect

Do RATs save lives? A retrospective analysis of out-of-hospital cardiac arrest in an English Ambulance Service

Study aimThis study aims to determine the impact of the red arrest teams (RATs) on survival to 30 days and return of spontaneous circulation (ROSC) at hospital.MethodsA retrospective cohort study analysing routinely collected data was undertaken. All adult (≥18 years) OHCAs entered onto the YAS computer aided dispatch (CAD) system between the 1st October, 2015 and 30th September, 2017 were included if the patient was resuscitated, and the cause of the arrest was considered to be medical in origin. Multivariable logistic regression models were created to enable adjustment for common predictors of survival and ROSC.ResultsDuring the 2-year data collection period, 15,151 cardiac arrests that were attended by Yorkshire Ambulance Service. After removing ineligible cases, 5,868 cardiac arrests remained. RATs attended 2,000/5,868 (34.1%) incidents, with each RAT attending a median of 13 cardiac arrests (IQR 7–23, minimum 1, maximum 78).The adjusted odds ratios suggest that a RAT on scene is associated with a slight increase in the odds of survival to 30 days (OR 1.01, 95%CI 0.74–1.38) and odds of ROSC on arrival at hospital (OR 1.13, 95%CI 0.99–1.29), compared to the odds of not having a RAT present, although neither results are statistically significant.ConclusionThe presence of a RAT paramedic was associated with a small increase in survival to 30 days and ROSC on arrival at hospital, although neither were statistically significant. Larger prospective studies are required to determine the effect of roles such as RAT on outcomes from OHC

Soiled airway tracheal intubation and the effectiveness of decontamination by paramedics (SATIATED): a randomised controlled manikin study.

Introduction: Vomiting and regurgitation are commonly encountered in out-of-hospital cardiac arrest (OHCA), with a reported incidence of 20-30%. This is of concern since patients who have suffered an OHCA are already in extremis. If standard suctioning techniques are not sufficient to maintain a clear airway and provide ventilation, then these patients will die, irrespective of the quality of chest compressions and the timeliness of defibrillation. This study aimed to determine whether a short teaching session of the suction assisted laryngoscopy and airway decontamination (SALAD) technique improved paramedics' ability to successfully intubate a contaminated airway. Methods: A modified airway manikin with the oesophagus connected to a reservoir of 'vomit', and a bilge pump capable of propelling the vomit up into the oropharynx, was used to simulate a soiled airway. The intervention consisted of a brief SALAD training session with a demonstration and opportunity to practice. Participants were randomly allocated into two groups: AAB, who made two pre-training intubation attempts and one post-training attempt, and ABB, who made one pre-training and two post-training attempts, to adjust for improvement in performance due to repetition. Results: In this manikin study, following a brief SALAD training session, more paramedics were able to intubate a soiled airway on their first attempt, compared to those without training (90.2% vs. 53.7%, difference of 36.6%, 95% CI 24-49.1%, p < 0.001). In addition, the mean difference in time taken to perform a successful intubation between groups was statistically significant for attempts 1 and 2 (mean difference 11.71 seconds, 95% CI 1.95-21.47 seconds, p = 0.02), but not attempts 1 and 3 (mean difference -2.52 seconds, 95% CI -11.64-6.61 seconds, p = 0.58). This result is likely to be confounded by the use of tracheal suction, which only occurred in the post-training attempts and added additional time to the intubation attempts. There was no statistically significant difference in success rates on the third attempt between AAB and ABB (89.0% vs. 86.6%, difference 2.4%, 95% CI 7.6-12.4%, p = 0.63). Conclusion: In this study, the use of the SALAD technique significantly improved first attempt success rates when paramedics were intubating a simulated soiled airway

Do RATs save lives? A service evaluation of an out-of-hospital cardiac arrest team in an English ambulance service.

Introduction: Out-of-hospital cardiac arrest (OHCA) is a major public health problem, leading to a substantial number of deaths in the UK. In response to this, the Yorkshire Ambulance Service NHS Trust (YAS) has introduced red arrest teams (RATs). RAT members attend a three-day training course, focusing on the technical and non-technical skills that are required to effectively team lead an OHCA and provide high quality post-resuscitation care. This evaluation aims to determine the impact of the RATs on survival to 30 days and return of spontaneous circulation (ROSC) at hospital. Methods: All adult (≥ 18 years) OHCAs entered onto the YAS computer aided dispatch (CAD) system between 1 October 2015 and 30 September 2017 were included if the patient was resuscitated and the cause of the arrest was considered to be medical in origin. Multi-variable logistic regression models were created to enable adjustment for common predictors of survival and ROSC. Results: During the 2-year data collection period, YAS attended 15,151 cardiac arrests. After removing ineligible cases, 5868 cardiac arrests remained. RATs attended 2000/5868 (34.1%) incidents, with each RAT attending a median of 13 cardiac arrests (IQR 7-23, min. 1, max. 78).The adjusted odds ratios suggest that a RAT on scene is associated with a slight increase in the odds of survival to 30 days (OR 1.01, 95% CI 0.74-1.38) and odds of ROSC on arrival at hospital (OR 1.13, 95% CI 0.99-1.29), compared to the odds of not having a RAT present, although neither result is statistically significant. Conclusion: The presence of a RAT paramedic was associated with a small increase in survival to 30 days and ROSC on arrival at hospital, although neither were statistically significant. Larger prospective studies are required to determine the effect of roles such as RAT on outcomes from OHCA

Seven steps for improving influenza vaccination rates in risk-groups: findings from a national cross sectional survey in UK general practice

The problem: Seasonal influenza vaccination rates in at-risk population in the UK are below the national and international target of 75%. Of people aged over 65 years in England 72.8% received influenza (flu) vaccine in 2010/11, just below the target of 75%. However, flu vaccination rates during 2010/11 in the under 65 year old at-risk groups was just 50.4%, which fell far short of 75%; in pregnant women who were not otherwise at risk the vaccination rate was only 36.6%, despite increasing evidence showing the beneficial effects of protection against flu for both mothers and babies. Evidence-based guidance, to advise practices how to optimise all aspects of their flu vaccination campaigns and maximise their likelihood of protecting at-risk patients against flu and its serious sequelae is greatly needed. This study sought to identify which strategies and procedures were associated with higher rates of flu vaccine uptake. The approach: An online questionnaire survey was administered to general practitioners (GPs), nursing staff and practice managers in 795 practices across England. We used logistic regression to analyse data for factors independently associated with higher practice flu vaccination rates in at-risk groups. Findings: The survey was completed by 569 practice managers, 335 nursing staff and 107 GPs. We identified seven independent factors associated with higher flu vaccination rates. Having a lead staff member for planning the flu campaign and producing a written report of practice performance predicted an 8% higher vaccination rate for at-risk patients aged <65 years (OR 1.37; 95% CI 1.10 to 1.71). These strategies, plus sending a personal invitation to all eligible patients and only stopping vaccination when Quality and Outcomes framework (QOF) targets were reached, predicted a 7% higher vaccination rate (OR 1.45; 95% CI 1.10 to 1.92) in patients aged 65 years and over. Using a lead member of staff for identifying eligible patients, with either a modified manufacturer’s or in-house search program for interrogating the practice computer system, independently predicted a 4% higher vaccination rate in patients aged 65 years and over (OR 1.22; 95% CI 1.06 to 1.41 / OR 1.20; 95% CI 1.03 to 1.40). The provision of flu vaccine by midwives was associated with a 4% higher vaccination rate in pregnant women (OR 1.19; 1.02 to 1.40). Consequences: Clear leadership, effective communication with patients, and methods used to identify and contact eligible patients were independently associated with significantly higher rates of flu vaccination. Financial targets appear to incentivise practices to work harder to maximise seasonal influenza vaccine uptake. The strategies identified here could help primary care providers to substantially increase their seasonal flu vaccination rates to meet or even exceed national targets

Multinational survey of treatment practices of clinicians managing subclinical hypothyroidism in older people in 2019

Background: International societies have recommended that levothyroxine should not routinely be prescribed in older individuals for the management of mild subclinical hypothyroidism (SCH). However, it is unknown whether clinicians managing people with SCH are either aware of or adhere to these guidelines. Methods: A web-based survey of members of several international thyroid associations and general practitioners in North-East England was conducted. Respondents were presented with a vignette of an 80-year-old gentleman with mild persistent SCH experiencing tiredness. Multivariable logistic regression analyses were performed to evaluate predictors of awareness of guidelines and responses to treatment. Results: The survey response rate was 21.9% (565/2,583). Only 7.6% of clinicians were unaware of guidelines regarding management of SCH in older people. Twenty percent of clinicians stated that they would treat the older patient with mild SCH, whereas 13% were unsure. Clinicians from North America were more likely to treat the older person with mild SCH than clinicians from elsewhere (OR 2.24 [1.25–3.98]). Likewise, non-endocrinologists were also more likely than endocrinologists to treat the older person with mild SCH (OR 3.26 [1.45–6.47]). Conclusion: The majority of clinicians are aware of guidelines regarding management of SCH in older individuals. However, a considerable proportion of clinicians would still treat an older person with non-specific symptoms and mild SCH. These guidelines need to be disseminated more widely and more research is required to understand barriers to adherence to international recommendations

Safety and efficacy of an artificial intelligence-enabled decision tool for treatment decisions in neovascular age-related macular degeneration and an exploration of clinical pathway integration and implementation: protocol for a multi-methods validation study

Introduction Neovascular age-related macular degeneration (nAMD) management is one of the largest single-disease contributors to hospital outpatient appointments. Partial automation of nAMD treatment decisions could reduce demands on clinician time. Established artificial intelligence (AI)-enabled retinal imaging analysis tools, could be applied to this use-case, but are not yet validated for it. A primary qualitative investigation of stakeholder perceptions of such an AI-enabled decision tool is also absent. This multi-methods study aims to establish the safety and efficacy of an AI-enabled decision tool for nAMD treatment decisions and understand where on the clinical pathway it could sit and what factors are likely to influence its implementation. Methods and analysis Single-centre retrospective imaging and clinical data will be collected from nAMD clinic visits at a National Health Service (NHS) teaching hospital ophthalmology service, including judgements of nAMD disease stability or activity made in real-world consultant-led-care. Dataset size will be set by a power calculation using the first 127 randomly sampled eligible clinic visits. An AI-enabled retinal segmentation tool and a rule-based decision tree will independently analyse imaging data to report nAMD stability or activity for each of these clinic visits. Independently, an external reading centre will receive both clinical and imaging data to generate an enhanced reference standard for each clinic visit. The non-inferiority of the relative negative predictive value of AI-enabled reports on disease activity relative to consultant-led-care judgements will then be tested. In parallel, approximately 40 semi-structured interviews will be conducted with key nAMD service stakeholders, including patients. Transcripts will be coded using a theoretical framework and thematic analysis will follow. Ethics and dissemination NHS Research Ethics Committee and UK Health Research Authority approvals are in place (21/NW/0138). Informed consent is planned for interview participants only. Written and oral dissemination is planned to public, clinical, academic and commercial stakeholders

Stakeholder Perspectives on Clinical Decision Support Tools to Inform Clinical Artificial Intelligence Implementation: Protocol for a Framework Synthesis for Qualitative Evidence

Quantitative systematic reviews have identified clinical artificial intelligence (AI)-enabled tools with adequate performance for real-world implementation. To our knowledge, no published report or protocol synthesizes the full breadth of stakeholder perspectives. The absence of such a rigorous foundation perpetuates the "AI chasm," which continues to delay patient benefit. The aim of this research is to synthesize stakeholder perspectives of computerized clinical decision support tools in any health care setting. Synthesized findings will inform future research and the implementation of AI into health care services. The search strategy will use MEDLINE (Ovid), Scopus, CINAHL (EBSCO), ACM Digital Library, and Science Citation Index (Web of Science). Following deduplication, title, abstract, and full text screening will be performed by 2 independent reviewers with a third topic expert arbitrating. The quality of included studies will be appraised to support interpretation. Best-fit framework synthesis will be performed, with line-by-line coding completed by 2 independent reviewers. Where appropriate, these findings will be assigned to 1 of 22 a priori themes defined by the Nonadoption, Abandonment, Scale-up, Spread, and Sustainability framework. New domains will be inductively generated for outlying findings. The placement of findings within themes will be reviewed iteratively by a study advisory group including patient and lay representatives. Study registration was obtained from PROSPERO (CRD42021256005) in May 2021. Final searches were executed in April, and screening is ongoing at the time of writing. Full text data analysis is due to be completed in October 2021. We anticipate that the study will be submitted for open-access publication in late 2021. This paper describes the protocol for a qualitative evidence synthesis aiming to define barriers and facilitators to the implementation of computerized clinical decision support tools from all relevant stakeholders. The results of this study are intended to expedite the delivery of patient benefit from AI-enabled clinical tools. PROSPERO CRD42021256005; https://tinyurl.com/r4x3thvp. DERR1-10.2196/33145. [Abstract copyright: ©Mohaimen Al-Zubaidy, HD Jeffry Hogg, Gregory Maniatopoulos, James Talks, Marion Dawn Teare, Pearse A Keane, Fiona R Beyer. Originally published in JMIR Research Protocols (https://www.researchprotocols.org), 01.04.2022.

Precision medicine in laryngeal cancer: protocol of the laryngeal cancer cohort (LARCH).

IntroductionLaryngeal cancer disproportionately affects socioeconomically disadvantaged patients. Treatment can render a patient nil by mouth or in need of a permanent tracheostomy. In the past 30 years, survival has remained at best static and at worst it has declined. Currently, there is no method of prognosticating how a patient will respond to treatment.The LARyngeal Cancer coHort (LARCH) aims to establish how survival and quality-of-life outcomes compare between surgery and (chemo)radiotherapy in early and advanced laryngeal cancer and how the presenting features of laryngeal cancer influence oncological, functional and quality-of-life outcome.Methods and analysisThis study is the first enhanced laryngeal cancer disease cohort. In the initial phase, we aim to deliver a prospective cohort study of 150 patients in 8 centres over a 3-year period.Patient, tumour, quality-of-life and laryngeal functional data will be collected from patients with squamous cell carcinoma of the larynx at baseline, 6, 12 and 24 months. Multiple logistic regression analyses will be used to quantify locoregional control and identify factors associated with control overall and by treatment modality and identify factors associated with quality of life overall and by treatment modality.Ethics and disseminationMost interventions take place as part of routine care, with LARCH providing a mechanism for recording this data centrally. When successfully recruiting in the North of England, we plan to roll out LARCH nationwide; in the future, LARCH can be used as a trial platform in the disease. The results will be submitted for publication in high-impact international peer-reviewed journals and presented to scientific meetings. Access to the anonymised LARCH dataset by other researchers will be publicised and promoted.Trial registration numberISRCTN27819867

Development and validation of a novel risk score for primary percutaneous coronary intervention for ST elevation myocardial infarction

Background Primary percutaneous coronary intervention (PPCI) is the default treatment for patients with ST elevation myocardial infarction (STEMI) and carries a higher risk of adverse outcomes when compared with elective and urgent PCI. Conventional PCI risk scores tend to be complex and may underestimate the risk associated with PPCI due to under-representation of patients with STEMI in their datasets. This study aimed to develop a simple, practical and contemporary risk model to provide risk stratification in PPCI. Methods Demographic, clinical and outcome data were collected for all patients who underwent PPCI between January 2009 and October 2013 at the Northern General Hospital, Sheffield. Multiple regression analysis was used to identify independent predictors of mortality and to construct a risk model. This model was then separately validated on an internal and external dataset. Results The derivation cohort included 2870 patients with a 30-day mortality of 5.1% (145 patients). Only four variables were required to predict 30-day mortality: age [OR:1.047, 95% CI:1.031–1.063], call-to-balloon (CTB) time [OR:1.829, 95% CI:1.198–2.791], cardiogenic shock [OR:13.886, 95% CI:8.284–23.275] and congestive heart failure [OR:3.169, 95% CI:1.420–7.072]. Internal validation was performed in 693 patients and external validation in 660 patients undergoing PPCI. Our model showed excellent discrimination on ROC-curve analysis (C-Stat = 0.87 internal and 0.86, external), and excellent calibration on Hosmer-Lemeshow testing (p = 0.37 internal, 0.55 external). Conclusions We have developed a bedside risk model which can predict 30-day mortality after PPCI using only four variables: age, CTB time, congestive heart failure and shock