Qualitative interview study of patients', ambulance practitioners' and emergency department clinicians' perceptions of prehospital pain management

Introduction Pre-hospital pain management is increasingly important with most patients (80%) presenting to UK ambulance services in pain and 20% of patients reporting inadequate pain relief. Improving prehospital pain management is important for service quality. Our aim was to investigate perceptions of pain management from patients, ambulance and emergency care staff. Methods Qualitative data were gathered through focus group (5) and interviews (28). Participants were purposively sampled from patients recently transported to hospital in pain, ambulance staff and emergency department clinicians. Interviews were audiotaped and transcribed using thematic analysis to iteratively develop themes supported by data analysis software, MAXQDA. Results Themes emerging from the data included: (a) expectations and beliefs (b) assessment methods (c) drug treatment (d) non-drug treatment and (f) improvement strategies for pain. Patients and staff expected pain to be relieved in the ambulance; instances of refusal of or inadequate analgesia were not uncommon because patients were concerned about drug side effects or, did not want to be transported. Pain was commonly assessed using a verbal pain score; clinical observation was often discordant with subjective experience. Communication difficulties, non-cooperation or influence of alcohol or drugs were found as barriers to pain assessment. Morphine and Entonox were commonly used to treat pain. Reassurance, positioning and immobilisation were used as alternatives to drugs. Suggestions to improve prehospital pain management included addressing barriers, modifying the available drugs and developing agreed multi-organisational pain management protocols supported by training for staff. Discussion Patients and practitioners expected pain to be relieved in the ambulance. Suggestions to improve prehospital pain management included addressing identified barriers, modifying the available drugs, using non-drug measures and developing agreed multi-organisational pain management protocols supported by appropriate training for staff. Our findings will inform development of protocols and quality improvement programmes along the pathway of prehospital pain management

Reliability and validity of an Ambulance Patient Reported Experience Measure (A-PREM): pilot study

Background There are no prehospital ambulance Patient Reported Experience Measures (A-PREMs) routinely used to support service comparisons and improvement. We developed an A-PREM, generating items through secondary analysis of ambulance patient interview data, and refining the instrument using expert assessment and cognitive interviews of service users. We aimed to pilot the A-PREM (48 experience and 12 attribute items) investigating user acceptability, reliability and construct validity. Methods Ambulance users attended by a UK regional ambulance service within the previous six months, excluding those suffering cardiac arrest, were sent a self-administered A-PREM. Returned questionnaires were entered into Microsoft Excel and imported into SPSS v22 for analysis. Experience items were recoded to range from 0 (don’t know/can’t remember) to 3 (best recorded experience). Descriptive analysis for item frequencies and missing values, reliability analyses for potential scales and tests of correlation and association were conducted. Results In all, 111 A-PREMs (22.2%) were returned. Missing data were highest for call-taking items. There was a significant association with a shorter wait for first response for four items measuring overall experience of call-taking (χ, p=0.05), ambulance staff (p<0.001), ambulance overall (p=0.001) and A&E (p=0.023). Four separate experience scales encompassing call taking (AmbCallScore, α=0.91), care at scene (AmbCareScore, α=0.90), care on leaving the patient (AmbLeaveScore, α=0.69), and care on transport (AmbTranScore α=0.71), showed satisfactory to high internal consistencies and distributions indicating generally positive experiences. AmbCallScore, AmbCareScore and AmbLeaveScore showed significantly higher scores (ANOVA) with shorter wait to first response. There were no significant differences for overall measures or scales by sex or age of participant, whether they were transported to hospital or not and whether it was their first experience of the ambulance service. Conclusion Our findings show that the A-PREM should be tested more widely for evidence of reliability, validity and sensitivity to different care and settings

Primary care treatment of insomnia: study protocol for a pragmatic, multicentre, randomised controlled trial comparing nurse-delivered sleep restriction therapy to sleep hygiene (the HABIT trial).

Introduction Insomnia is a prevalent sleep disorder that negatively affects quality of life. Multicomponent cognitive-behavioural therapy (CBT) is the recommended treatment but access remains limited, particularly in primary care. Sleep restriction therapy (SRT) is one of the principal active components of CBT and could be delivered by generalist staff in primary care. The aim of this randomised controlled trial is to establish whether nurse-delivered SRT for insomnia disorder is clinically and cost-effective compared with sleep hygiene advice. Methods and analysis In the HABIT (Health-professional Administered Brief Insomnia Therapy) trial, 588 participants meeting criteria for insomnia disorder will be recruited from primary care in England and randomised (1:1) to either nurse-delivered SRT (plus sleep hygiene booklet) or sleep hygiene booklet on its own. SRT will be delivered over 4 weekly sessions; total therapy time is approximately 1 hour. Outcomes will be collected at baseline, 3, 6 and 12 months post-randomisation. The primary outcome is self-reported insomnia severity using the Insomnia Severity Index at 6 months. Secondary outcomes include health-related and sleep-related quality of life, depressive symptoms, use of prescribed sleep medication, diary and actigraphy-recorded sleep parameters, and work productivity. Analyses will be intention-to-treat. Moderation and mediation analyses will be conducted and a cost-utility analysis and process evaluation will be performed. Ethics and dissemination Ethical approval was granted by the Yorkshire and the Humber - Bradford Leeds Research Ethics Committee (reference: 18/YH/0153). We will publish our primary findings in high-impact, peer-reviewed journals. There will be further outputs in relation to process evaluation and secondary analyses focussed on moderation and mediation. Trial results could make the case for the introduction of nurse-delivered sleep therapy in primary care, increasing access to evidence-based treatment for people with insomnia disorder

Impact of the British Lung Foundation Active Steps service on patient reported outcomes: (i) concurrent cohort study, (ii) process evaluation, (iii) economic evaluation. Presentations at European Respiratory Society International Congress 2021

Background: Active Steps is a remote behaviour change service supporting inactive adults with a lung condition to become physically active. Aim: To determine the efficacy of Active Steps in improving physical activity and quality life

Clinical and cost-effectiveness of nurse-delivered sleep restriction therapy for insomnia in primary care (HABIT): a pragmatic, superiority, open-label, randomised controlled trial.

Background Insomnia is prevalent and distressing but access to the first-line treatment, cognitive behavioural therapy (CBT), is extremely limited. We aimed to assess the clinical and cost-effectiveness of sleep restriction therapy, a key component of CBT, which has the potential to be widely implemented. Methods We did a pragmatic, superiority, open-label, randomised controlled trial of sleep restriction therapy versus sleep hygiene. Adults with insomnia disorder were recruited from 35 general practices across England and randomly assigned (1:1) using a web-based randomisation programme to either four sessions of nurse-delivered sleep restriction therapy plus a sleep hygiene booklet or a sleep hygiene booklet only. There was no restriction on usual care for either group. Outcomes were assessed at 3 months, 6 months, and 12 months. The primary endpoint was self-reported insomnia severity at 6 months measured with the insomnia severity index (ISI). The primary analysis included participants according to their allocated group and who contributed at least one outcome measurement. Cost-effectiveness was evaluated from the UK National Health Service and personal social services perspective and expressed in terms of incremental cost per quality-adjusted life year (QALY) gained. The trial was prospectively registered (ISRCTN42499563). Findings Between Aug 29, 2018, and March 23, 2020 we randomly assigned 642 participants to sleep restriction therapy (n=321) or sleep hygiene (n=321). Mean age was 55·4 years (range 19–88), with 489 (76·2%) participants being female and 153 (23·8%) being male. 580 (90·3%) participants provided data for at least one outcome measurement. At 6 months, mean ISI score was 10·9 (SD 5·5) for sleep restriction therapy and 13·9 (5·2) for sleep hygiene (adjusted mean difference –3·05, 95% CI –3·83 to –2·28; p<0·0001; Cohen's d –0·74), indicating that participants in the sleep restriction therapy group reported lower insomnia severity than the sleep hygiene group. The incremental cost per QALY gained was £2076, giving a 95·3% probability that treatment was cost-effective at a cost-effectiveness threshold of £20 000. Eight participants in each group had serious adverse events, none of which were judged to be related to intervention. Interpretation Brief nurse-delivered sleep restriction therapy in primary care reduces insomnia symptoms, is likely to be cost-effective, and has the potential to be widely implemented as a first-line treatment for insomnia disorder

Response to letter to the editor by Nicholas S. Kelley, Michael T. Osterholm, and Edward A. Belongia, M.D.

[No abstract available

Preventable mortality in patients at low risk of death requiring prehospital ambulance care: structured judgment case note review

Title Preventable mortality in patients at low risk of death requiring prehospital ambulance care: structured judgment case note review Siriwardena AN, Akanuwe J, Crum A, Coster J, Jacques R, Turner J. Background Reviewing patient records for quality of care can help to identify deaths that could have been avoided. Any failures identified can inform measures to improve the quality of patient care. Mortality reviews are increasingly being conducted in hospitals but the evidence for their validity in pre-hospital ambulance settings is limited. We aimed to review the records for avoidable deaths relating to care provided by emergency ambulance services. Methods Ethical approval was sought and gained to link ambulance call, dispatch and clinical data with hospital and mortality data from patients attended by one UK ambulance service for records over a period of 6 months in 2015. The anonymised dataset was used for analysis. Patients who died within 3 days of the initial ambulance call were selected for case review. Cases were stratified according to age group (age 0-2, 3-10, 11-20, 21-30, 31-40, 41-50, 51-60, 61-70, 71-80, 81-90, and 91-120 years), dispatch code classification and urgency (Red1 - Green4) to ensure maximum variation. The number of calls within each group, and the number of deaths (within 3 days of a call) within each group was calculated. The death rate for each group was determined and groups were sorted by this rate (lowest first), selecting 6 patients from those with the lowest mortality rate in each group. A structured judgement case note review method with 5 reviewers (GP, nurse, 2 paramedics and a medically qualified health service manager) was used to assess in detail anonymised patient records for quality of care and avoidable mortality relating to the care provided by one ambulance trust. Results In total, 153 records were selected from 150037 where the patient had been subsequently transported to hospital or died. These represented patients from different age, condition and urgency groups with the lowest risk of death. Most patients selected for review (81%; 124/153) were transported to hospital. At initial assessment 10% (16/153) of cases showed strong or probable evidence of avoidability and 2% (3/153) possible evidence of avoidability based on lack of care provision according to current national UK guidance. Evidence of avoidability was more likely in those patients that were not transported to hospital (38%; 11/29). A further assessment was made in light of the diagnosis of death which reduced the number of cases showing strong or probably evidence of avoidability to 7% (11/153). Conclusion Structured judgment cases reviews can be used to assess avoidable mortality in prehospital ambulance care and to inform deficiencies and improvements in care processes. This requires access to ambulance records linked to hospital and mortality data to ensure that accurate assessments are made in light of the final diagnosis and cause of death

Early years' prevention of childhood obesity: the challenges facing UK health visitors

Objectives A number of modifiable risk factors are associated with the development of childhood obesity. These are lower breast feeding duration, early weaning onto solid foods, parental response to infant temperament and parental control over food intake. This study explored parents’ beliefs concerning their infant’s size and growth and their receptiveness to intervention aimed at reducing the risk of childhood obesity. Method Six focus groups were undertaken in a range of different demographic areas, with parents of infants less than one year old. The focus groups were audio-recorded, transcribed verbatim and subjected to thematic analysis using an interpretative, inductive approach. Results 38 parents (n=36 female, n=2 male), age range 19-45 years (mean 30.1 years, SD 6.28) participated in the focus groups. Half the sample were overweight (n=12) or obese (n=8). Five main themes were identified. These were a) rationalisation for infant’s larger size, b) parents’ understanding of breastfed infants’ growth and age-related behaviour; c) parents’ understanding of infant growth, developmental norms and feeding practices, d) belief that nothing can be done about overweight/obese infants and e) intentions and behaviour in relation to a healthy diet.Conclusions Some risk factors for childhood obesity are potentially modifiable. Parents are receptive to prevention prior to weaning and need better support with best practice in infant feeding. This should focus on helping them understand the physiology of breast feeding, the rationale around weaning at 6 months and how to recognise that hunger is only one explanation for infant distress and behaviour change.</p

RAPID INTERVENTION WITH GLYCERYL TRINITRATE IN HYPERTENSIVE STROKE TRIAL-2 (RIGHT-2): SAFETY AND EFFICACY OF TRANSDERMAL GLYCERYL TRINITRATE, A NITRIC OXIDE DONOR

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