Pre-hospital ambulance care of patients following a suspected seizure: A cross sectional study

Purpose We aimed to investigate the characteristics of patients presenting to the ambulance service with suspected seizures, the costs of managing these patients and the factors which predicted transport to hospital. Methods We employed a cross-sectional design using routine clinical data from a UK regional ambulance service. Logistic regression was used to identify predictors of transport to hospital from ambulance response times, demographics, clinical (physiological) findings and treatments. Results There were 177,715 emergency incidents recorded in 2011/12 of which 2.9% (5,139/177,715) were classified as seizures by ambulance call handlers and 2.7% (4,884/177,715) by paramedics on the scene. Suspected seizures were the seventh most common call type. The annual cost of managing these incidents was £890,148. Clinical and physiological variables were normal for most patients. 59.3% (2,894/4,884) of patients were transported to hospital. 1/4,884 (0.02%) patient died. Administration of diazepam, insertion of an airway and pyrexia perfectly predicted transport to hospital, tachycardia had a modest association, but other variables were only weak predictors of transport to hospital. Conclusions This study shows that most patients after a suspected seizure are not acutely unwell but nevertheless most patients are transported to hospital. Further research is required to determine which factors are important in decisions to transport to hospital and to create evidence-based tools to help paramedics identify patients who could be safely managed without transport to hospital

Cancer risk assessment tools for symptomatic individuals presenting to primary care: a systematic scoping review

Cancer risk assessment tools for symptomatic individuals presenting to primary care: a systematic scoping review ABSTRACT CANCER RISK ASSESSMENT TOOLS FOR SYMPTOMATIC INDIVIDUALS PRESENTING TO PRIAMRY CARE: A SYSTEMATIC SCOPING REVIEW Background: Novel cancer risk assessment tools, designed to predict cancer risk in symptomatic individuals in primary care settings, are being advocated to address the problem of late diagnosis of cancer in the UK. Despite this, little is known about the use and implementation of cancer risk assessment tools to aid early detection of cancer risk in general practice. We aimed to scope the evidence on the type of cancer risk assessment tools available for symptomatic individuals, and the current use of the tools including the benefits and barriers to their use. Methods: Using Arksey and O’Malley’s framework, we conducted a systematic scoping review of published literature in the English language from 2004 to 2017. We searched six electronic databases (Medline, CINAHL, Scopus, Cochrane, Science Direct and Psych-INFO) using specific search terms. A narrative synthesis was used to summarise the findings from the studies identified. Results: We retrieved a total of 471 papers from the electronic databases and 43 matched the inclusion criteria. Novel cancer risk assessment tools for symptomatic individuals in primary care identified from the review included the QCancer and RAT series. While there was some evidence supporting use of some of the tools, there was limited evidence on the current use and the impact of using the tools on patient outcomes such as rates of cancer diagnosis and survival. There was also some evidence on potential benefits (potential aid for clinicians to confirm investigations and referral decisions, for reassurance of patients when investigation not needed, helping GPs to recognise symptoms of some cancers and useful for detecting cancer risk in patients with complex histories) and barriers to using the tools in primary care consultations. As the review found, the following barriers to use of the tools would need to be addressed for effective implementation of the tools in primary care: how to make the tools available to clinicians, how best to communicate cancer risk information to patients, uncertainty about the threshold for action to be taken, extra consultation time requirement, potential for causing alarm to patients, potential burden on resources, a challenge about integrating the tools into general practice workflow and a potential for ‘prompt fatigue. Conclusion: The review revealed evidence of novel cancer risk assessment tools designed for symptomatic individuals in primary care. There was also evidence on potential benefits and barriers relating to the use of the tools. There is a need to address the barriers identified when implementing the tools in general consultations

A coproduced patient and public event: An approach to developing and prioritizing ambulance performance measures

Background Patient and Public Involvement (PPI) is recognised as an important component of high quality health services research. PPI is integral within the Pre-hospital Outcomes for Evidence Based Evaluation (PhOEBE) programme. The PPI event described in detail in this paper focusses on the process of involving patients and public representatives in identifying, prioritising and refining a set of outcome measures that can be used to support ambulance service performance measurement. Objective To obtain public feedback on little known, complex aspects of ambulance service performance measurement. Design The event was co-designed and co-produced with the PhOEBE PPI reference group and PhOEBE research team. The event consisted of: brief researcher-led presentations, group discussions facilitated by the PPI reference group members and electronic voting. Setting and participants Data were collected from eighteen patient and public representatives who attended an event venue in Yorkshire. Results The results of the PPI event showed that this interactive format and mode of delivery was an effective method to obtain public feedback and produced a clear indication of which ambulance performance measures were most highly favoured by event participants. Discussion and Conclusions The event highlighted valuable contributions the PPI reference group made to the design process, supporting participant recruitment and facilitation of group discussions. In addition, the positive team working experience of the event proved a catalyst for further improvements in patient and public involvement within the PhOEBE project

Understanding variation in ambulance service non-conveyance rates: a mixed methods study

Background In England in 2015/16, ambulance services responded to nearly 11 million calls. Ambulance Quality Indicators show that half of the patients receiving a response by telephone or face to face were not conveyed to an emergency department. A total of 11% of patients received telephone advice only. A total of 38% of patients were sent an ambulance but were not conveyed to an emergency department. For the 10 large ambulance services in England, rates of calls ending in telephone advice varied between 5% and 17%. Rates of patients who were sent an ambulance but not conveyed to an emergency department varied between 23% and 51%. Overall non-conveyance rates varied between 40% and 68%. Objective To explain variation in non-conveyance rates between ambulance services. Design A sequential mixed methods study with five work packages. Setting Ten of the 11 ambulance services serving > 99% of the population of England. Methods (1) A qualitative interview study of managers and paramedics from each ambulance service, as well as ambulance commissioners (totalling 49 interviews undertaken in 2015). (2) An analysis of 1 month of routine data from each ambulance service (November 2014). (3) A qualitative study in three ambulance services with different published rates of calls ending in telephone advice (120 hours of observation and 20 interviews undertaken in 2016). (4) An analysis of routine data from one ambulance service linked to emergency department attendance, hospital admission and mortality data (6 months of 2013). (5) A substudy of non-conveyance for people calling 999 with breathing problems. Results Interviewees in the qualitative study identified factors that they perceived to affect non-conveyance rates. Where possible, these perceptions were tested using routine data. Some variation in non-conveyance rates between ambulance services was likely to be due to differences in the way rates were calculated by individual services, particularly in relation to telephone advice. Rates for the number of patients sent an ambulance but not conveyed to an emergency department were associated with patient-level factors: age, sex, deprivation, time of call, reason for call, urgency level and skill level of attending crew. However, variation between ambulance services remained after adjustment for patient-level factors. Variation was explained by ambulance service-level factors after adjustment for patient-level factors: the percentage of calls attended by advanced paramedics [odds ratio 1.05, 95% confidence interval (CI) 1.04 to 1.07], the perception of ambulance service staff and commissioners that advanced paramedics were established and valued within the workforce of an ambulance service (odds ratio 1.84, 95% CI 1.45 to 2.33), and the perception of ambulance service staff and commissioners that senior management was risk averse regarding non-conveyance within an ambulance service (odds ratio 0.78, 95% CI 0.63 to 0.98). Limitations Routine data from ambulance services are complex and not consistently collected or analysed by ambulance services, thus limiting the utility of comparative analyses. Conclusions Variation in non-conveyance rates between ambulance services in England could be reduced by addressing variation in the types of paramedics attending calls, variation in how advanced paramedics are used and variation in perceptions of the risk associated with non-conveyance within ambulance service management. Linking routine ambulance data with emergency department attendance, hospital admission and mortality data for all ambulance services in the UK would allow comparison of the safety and appropriateness of their different non-conveyance rates. Funding The National Institute for Health Research Health Services and Delivery Research programme

Involving older people in a multi-centre randomised trial of a complex intervention in pre-hospital emergency care: implementation of a collaborative model

Background Health services research is expected to involve service users as active partners in the research process, but few examples report how this has been achieved in practice in trials. We implemented a model to involve service users in a multi-centre randomised controlled trial in pre-hospital emergency care. We used the generic Standard Operating Procedure (SOP) from our Clinical Trials Unit (CTU) as the basis for creating a model to fit the context and population of the SAFER 2 trial. Methods In our model, we planned to involve service users at all stages in the trial through decision-making forums at 3 levels: 1) strategic; 2) site (e.g. Wales; London; East Midlands); 3) local. We linked with charities and community groups to recruit people with experience of our study population. We collected notes of meetings alongside other documentary evidence such as attendance records and study documentation to track how we implemented our model. Results We involved service users at strategic, site and local level. We also added additional strategic level forums (Task and Finish Groups and Writing Days) where we included service users. Service user involvement varied in frequency and type across meetings, research stages and locations but stabilised and increased as the trial progressed. Conclusion Involving service users in the SAFER 2 trial showed how it is feasible and achievable for patients, carers and potential patients sharing the demographic characteristics of our study population to collaborate in a multi-centre trial at the level which suited their health, location, skills and expertise. A standard model of involvement can be tailored by adopting a flexible approach to take account of the context and complexities of a multi-site trial

Realist analysis of whether emergency departments with primary care services generate ‘provider-induced demand’

Background: It is not known whether emergency departments (EDs) with primary care services influence demand for non-urgent care (‘provider-induced demand’). We proposed that distinct primary care services in EDs encourages primary care demand, whereas primary care integrated within EDs may be less likely to cause additional demand. We aimed to explore this and explain contexts (C), mechanisms (M) and outcomes (O) influencing demand. Methods: We used realist evaluation methodology and observed ED service delivery. Twenty-four patients and 106 staff members (including Clinical Directors and General Practitioners) were interviewed at 13 EDs in England and Wales (240 hours of observations across 30 days). Field notes from observations and interviews were analysed by creating ‘CMO’ configurations to develop and refine theories relating to drivers of demand. Results: EDs with distinct primary care services were perceived to attract demand for primary care because services were visible, known or enabled direct access to health care services. Other influencing factors included patients’ experiences of accessing primary care, community care capacity, service design and population characteristics. Conclusions: Patient, local-system and wider-system factors can contribute to additional demand at EDs that include primary care services. Our findings can inform service providers and policymakers in developing strategies to limit the effect of potential influences on additional demand when demand exceeds capacity

Involve the patient and pass the MRCGP: investigating shared decision making in a consulting skills examination using a validated instrument.

Contains fulltext : 50788.pdf (publisher's version ) (Closed access)BACKGROUND: Shared decision making is an important aspect of patient centredness. Lack of this consulting behaviour is a common reason for failure in the Membership of the Royal College of General Practitioners (MRCGP) consulting skills examination. AIM: To investigate candidates' performance in shared decision making and overall performance in the MRCGP consulting skills assessment compared with an independently validated measure, the OPTION ('observing patient involvement') scale. DESIGN: Cross-sectional study. SETTING: MRCGP examination, UK. PARTICIPANTS: Two hundred and fifty-two consultations submitted by 36 GPs submitting seven consultations per videotape. METHOD: A stratified sample of 63 candidates, 21 each from fail, pass and merit selected from candidates in the MRCGP consulting skills examination, were approached for participation. Participants' examination videotapes were independently assessed for shared decision making using the OPTION scale by two non-clinical raters. RESULTS: Thirty-six candidates (of 63; 57%) who participated were no different from non-participants. Candidates who passed the 'sharing management options' in the MRCGP had significantly higher OPTION scores than those who did not (35.4 versus 27.3; mean difference = 8.1, P = 0.044). There was a significant difference between OPTION scores of MRCGP candidates with 'fail' and 'pass' (including pass with merit): 28.6 versus 36.1, 95% confidence interval CI = 1.13 to 13.87. Scores decreased as clinician age increased but were not significantly associated with sex of GP, age or sex of patient or consultation duration. The probability of passing the MRGCP increased as OPTION scores increased. CONCLUSION: This study demonstrated concurrent validity of the MRCGP consulting skills assessment of sharing management options against an independent validated instrument for shared decision making, the OPTION scale. Candidates who performed best in the MRCGP exhibited high scores with OPTION. This study provides the basis for further work to demonstrate evidence for the potential of training for professional assessment to improve consulting competence

Migrant GPs and patients: a cross-sectional study of practice characteristics, patient experiences and migration concordance.

Objective To investigate practice type and location of native and immigrant general practitioners (GPs); effects of migration status concordance between GPs and patients on experiences of patients in key areas of primary care quality and discrimination. Design and setting Secondary analysis of GP and patient survey data from QUALICOPC (Quality and Costs of Primary Care), a cross-sectional study of GPs and their patients in 34 countries, performed between 2011 and 2013. Main outcome measures We explored practice type and location of native and immigrant GPs and the experiences of native patients and patients with a migration background of communication, continuity, comprehensiveness, accessibility, and discrimination, using multilevel analysis. Concordance was modelled as a cross-level interaction between migration status of GPs and patients. Results Percentages of immigrant GPs varied widely. In Europe, this was highest in England and Luxemburg (40% of GPs born abroad) and lowest in Bulgaria and Romania (1%). The practice population of immigrant GPs more often included an above average proportion of people from ethnic minorities. There were no differences in main effects of patient experiences following a visit to an immigrant or native GP, in four core areas of primary care or in discrimination. However, people from first-generation migrant background more often experienced discrimination, in particular when visiting a native GP. Conclusion Patient experiences did not vary with GPs' migration status. Although experience of discrimination was uncommon, first-generation migrant patients experienced more discrimination. Primary care should provide non-discriminatory care, through GP awareness of unconscious bias and training to address this. Key messagesThere were large differences in percentage of migrant GPs between countries.Migrant GPs' practices had an above average proportion of people from ethnic minorities.In general, patients' experienced discrimination from GPs and practice staff was low, but first-generation migrant patients more often experienced discrimination.First-generation migrant patients more often experienced discrimination when they visited a native GP

20 Preventable mortality in patients at low risk of death requiring prehospital ambulance care: retrospective case record review study

Aim: Retrospective case record reviews (RCRR) have been widely used to assess quality of care but evidence for their use in prehospital ambulance settings is limited. We aimed to review case records of potentially avoidable deaths related to ambulance care. Method: We identified patients who were transported to hospital or died using linked ambulance-hospital-mortality data from one UK ambulance service over 6 months in 2013. Death rates (within 3 days) for patient groups (based on age, dispatch code and urgency) were determined; 3 patients calling in-hours and 3 out-of-hours were selected from categories with the lowest death rates. Five reviewers (GP, nurse, 2 paramedics and medical health service manager) assessed anonymised patient records for quality of care and avoidable mortality. Results: We selected 29 linked records from 1 50 003 focussing on patients not transported to distinguish pre-hospital from hospital causes. Overall 8 cases out of 29 (27.6%) scored between 2.4 and 2.8 (1=Definitely avoidable, 2=Strong evidence of avoidability), 8 cases (27.6%) scored between 3.0 and 4.6 (3=Probably avoidable, 4=Possibly avoidable), and the remaining 13 cases (44.8%) between 4.0 and 5.8 (5=Slightly avoidable or 6=Definitely not avoidable). Variation between raters was satisfactory with ICC 0.84 (95% CI: 0.73 to 0.92). Common themes among cases with strong evidence of avoidability were symptoms or physical findings indicating a potentially serious condition and refusal by patients or their carers to be transported to hospital. RCRRs require linked ambulance, hospital and mortality data to ensure accurate assessment in light of the diagnosis and cause of death. Conclusion: Retrospective case record reviews (RCRR) have been widely used to assess quality of care but evidence for their use in prehospital ambulance settings is limited. We aimed to review case records of potentially avoidable deaths related to ambulance care