Emergency medical service interventions and experiences during pandemics: A scoping review.

BACKGROUND: The global impact of COVID-19 has been profound, with efforts to manage and contain the virus placing increased pressure on healthcare systems and Emergency Medical Services (EMS) in particular. There has been no previous review of studies investigating EMS interventions or experiences during pandemics. The aim of this scoping review was to identify and present published quantitative and qualitative evidence of EMS pandemic interventions, and how this translates into practice. METHODS: Six electronic databases were searched from inception to July 2022, supplemented with internet searches and forward and backward citation tracking from included studies and review articles. A narrative synthesis of all eligible quantitative studies was performed and structured around the aims, key findings, as well as intervention type and content, where appropriate. Data from the qualitative studies were also synthesised narratively and presented thematically, according to their main aims and key findings. RESULTS: The search strategy identified a total of 22,599 citations and after removing duplicates and excluding citations based on title and abstract, and full text screening, 90 studies were included. The quantitative narrative synthesis included seven overarching themes, describing EMS pandemic preparedness plans and interventions implemented in response to pandemics. The qualitative data synthesis included five themes, detailing the EMS workers' experiences of providing care during pandemics, their needs and their suggestions for best practices moving forward. CONCLUSIONS: Despite concerns for their own and their families' safety and the many challenges they are faced with, especially their knowledge, training, lack of appropriate Personal Protective Equipment (PPE) and constant protocol changes, EMS personnel were willing and prepared to report for duty during pandemics. Participants also made recommendations for future outbreak response, which should be taken into consideration in order for EMS to cope with the current pandemic and to better prepare to respond to any future ones. TRIAL REGISTRATION: The review protocol was registered with the Open Science Framework (osf.io/2pcy7).

Community First Responders' role in the current and future rural health and care workforce: a mixed-methods study.

Background: Community First Responders are trained volunteers dispatched by ambulance services to potentially life-threatening emergencies such as cardiac arrest in the first vital minutes to provide care until highly skilled ambulance staff arrive. Community First Responder schemes were first introduced to support ambulance services in rural communities, where access to prehospital emergency care is more likely to be delayed. Evidence is lacking on their contribution to rural healthcare provision, how care is provided and how this might be improved. Objectives: We aimed to describe Community First Responder activities, organisation, costs of provision and outcomes of care together with perceptions and views of patients, public, Community First Responders, ambulance service staff and commissioners of their current and future role including innovations in the rural health and care workforce. Design: We used a mixed-methods design, using a lens of pragmatism and the 'actor', 'behaviour change' and 'causal pathway' framework to integrate quantitative routine and qualitative (policy, guideline and protocol documents with stakeholder interview) data from 6 of 10 English ambulance services. We identified potential innovations in Community First Responder provision and prioritised these using a modified nominal group technique. Patients and public were involved throughout the study. Results: In 4.5 million incidents from six English regional ambulance services during 2019, pre COVID-19 pandemic, Community First Responders attended first a higher proportion of calls in rural areas (almost 4% of calls) than in urban areas (around 1.5%). They were significantly more likely to be called out to rural (vs. urban) areas and to attend older (vs. younger), white (vs. minority ethnic) people in more affluent (vs. deprived) areas with cardiorespiratory and neurological (vs. other emergency) conditions for higher-priority emergency or urgent (category 1 and 2 compared with category 3, 4 or 5) calls but did also attend lower-category calls for conditions such as falls. We examined 10 documents from seven ambulance services. Ambulance policies and protocols integrated Community First Responders into ambulance service structures to achieve the safe and effective operation of volunteers. Costs, mainly for training, equipment and support, varied widely but were not always clearly delineated. Community First Responders enabled a faster prehospital response time. There was no clear benefit in out-of-hospital cardiac arrest outcomes. A specific Community First Responder falls response reduced ambulance attendances and was potentially cost saving. We conducted semistructured interviews with 47 different stakeholders engaged in Community First Responder functions. This showed the trajectory of becoming a Community First Responder, the Community First Responder role, governance and practice, and the positive views of Community First Responders from stakeholders despite public lack of understanding of their role. Community First Responders' scope of practice varied between ambulance services and had developed into new areas. Innovations prioritised at the consensus workshop were changes in processes and structures and an expanded scope of practice supported by training, which included counselling, peer support, better communication with the control room, navigation and communication technology, and specific mandatory and standardised training for Community First Responders. Limitations: Missing data and small numbers of interviews in some stakeholder groups (patients, commissioners) are sources of bias. Future research: Future research should include a robust evaluation of innovations involving Community First Responders. Trial registration: This trial is registered as ClinicalTrials.gov, NCT04279262. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR127920) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 18. See the NIHR Funding and Awards website for further award information.

Community First Responders are volunteers who attend emergencies, particularly in rural areas, and provide help until the ambulance arrives. We aimed to describe Community First Responder activities, costs and effects and get the views of the public, Community First Responders, ambulance staff and commissioners on the current and future role of Community First Responders. Our study design combined different approaches. We examined routine ambulance patient information, reviewed ambulance policies and guidelines, and gathered information from interviews to make sense of our findings. Through interviews we learned about ways that the work of Community First Responders had been enhanced or could be improved. In a 1-day workshop, a group of lay and professional experts ranked in order of importance ideas about future developments involving Community First Responders. Community First Responders arrived before ambulance staff for a higher proportion of calls in rural than in urban areas. They attended people with various conditions, including breathing problems, chest pain, stroke, drowsiness, diabetes and falls, and usually the highest-priority emergencies but also lower-priority calls. Policies aimed to ensure that Community First Responders provided safe, effective care. Costs, mainly used for management, training and equipment, were sometimes incomplete or inaccurate and varied widely between services. Community First Responders attending meant faster responses and positive experiences for those patients and relatives interviewed. A Community First Responder scheme responding to people who had fallen at home led to fewer ambulances attending and possible financial savings. Survival among people attended because their heart had stopped was no better when Community First Responders arrived early. Interviews revealed why and how Community First Responders volunteered and were trained, what they did and how they felt. Interviewees were largely positive about Community First Responders. Improvements suggested included support from colleagues or counsellors, better communication with ambulance services, technology for communication and locating patients, and better training. Community First Responders have benefits in terms of response times and patient care. Future improvements should be evaluated.

Programme theories to describe how different general practitioner service models work in different contexts in or alongside emergency departments (GP-ED): realist evaluation.

BACKGROUND: Addressing increasing patient demand and improving ED patient flow is a key ambition for NHS England. Delivering general practitioner (GP) services in or alongside EDs (GP-ED) was advocated in 2017 for this reason, supported by £100 million (US$130 million) of capital funding. Current evidence shows no overall improvement in addressing demand and reducing waiting times, but considerable variation in how different service models operate, subject to local context. METHODS: We conducted mixed-methods analysis using inductive and deductive approaches for qualitative (observations, interviews) and quantitative data (time series analyses of attendances, reattendances, hospital admissions, length of stay) based on previous research using a purposive sample of 13 GP-ED service models (3 inside-integrated, 4 inside-parallel service, 3 outside-onsite and 3 with no GPs) in England and Wales. We used realist methodology to understand the relationship between contexts, mechanisms and outcomes to develop programme theories about how and why different GP-ED service models work. RESULTS: GP-ED service models are complex, with variation in scope and scale of the service, influenced by individual, departmental and external factors. Quantitative data were of variable quality: overall, no reduction in attendances and waiting times, a mixed picture for hospital admissions and length of hospital stay. Our programme theories describe how the GP-ED service models operate: inside the ED, integrated with patient flow and general ED demand, with a wider GP role than usual primary care; outside the ED, addressing primary care demand with an experienced streaming nurse facilitating the 'right patients' are streamed to the GP; or within the ED as a parallel service with most variability in the level of integration and GP role. CONCLUSION: GP-ED services are complex . Our programme theories inform recommendations on how services could be modified in particular contexts to address local demand, or whether alternative healthcare services should be considered.

Evaluation of different models of general practitioners working in or alongside emergency departments: a mixed-methods realist evaluation.

Background: Emergency healthcare services are under intense pressure to meet increasing patient demands. Many patients presenting to emergency departments could be managed by general practitioners in general practitioner-emergency department service models. Objectives: To evaluate the effectiveness, safety, patient experience and system implications of the different general practitioner-emergency department models. Design: Mixed-methods realist evaluation. Methods: Phase 1 (2017-8), to understand current practice: rapid realist literature review, national survey and follow-up key informant interviews, national stakeholder event and safety data analysis. Phase 2 (2018-21), to collect and analyse qualitative (observations, interviews) and quantitative data (time series analysis); cost-consequences analysis of routine data; and case site data for 'marker condition' analysis from a purposive sample of 13 case sites in England and Wales. Phase 3 (2021-2), to conduct mixed-methods analysis for programme theory and toolkit development. Results: General practitioners commonly work in emergency departments, but delivery models vary widely in terms of the scope of the general practitioner role and the scale of the general practitioner service. We developed a taxonomy to describe general practitioner-emergency department service models (Integrated with the emergency department service, Parallel within the emergency department, Outside the emergency department on the hospital site) and present a programme theory as principal output of the study to describe how these service models were observed to operate. Routine data were of variable quality, limiting our analysis. Time series analysis demonstrated trends across intervention sites for: increased time spent in the emergency department; increased emergency department attendances and reattendances; and mixed results for hospital admissions. Evidence on patient experience was limited but broadly supportive; we identified department-level processes to optimise the safety of general practitioner-emergency department models. Limitations: The quality, heterogeneity and extent of routine emergency department data collection during the study period limited the conclusions. Recruitment was limited by criteria for case sites (time series requirements) and individual patients (with 'marker conditions'). Pandemic and other pressures limited data collection for marker condition analysis. Data collected and analysed were pre pandemic; new approaches such as 'telephone first' and their relevance to our findings remains unexplored. Conclusion: Findings suggest that general practitioner-emergency department service models do not meet the aim of reducing the overall emergency department waiting times and improving patient flow with limited evidence of cost savings. Qualitative data indicated that general practitioners were often valued as members of the wider emergency department team. We have developed a toolkit, based on our findings, to provide guidance for implementing and delivering general practitioner-emergency department services. Future work: The emergency care data set has since been introduced across England to help standardise data collection to facilitate further research. We would advocate the systematic capture of patient experience measures and patient-reported outcome measures as part of routine care. More could be done to support the development of the general practitioner in emergency department role, including a core set of competencies and governance structure, to reflect the different general practitioner-emergency department models and to evaluate the effectiveness and cost effectiveness to guide future policy. Study registration: This study is registered as PROSPERO CRD42017069741. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 15/145/04) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 10. See the NIHR Funding and Awards website for further award information.

Hospital emergency departments are under huge pressure. Patients are waiting many hours to be seen, some with problems that general practitioners could deal with. To reduce waiting times and improve patient care, arrangements have been put in place for general practitioners to work in or alongside emergency departments (general practitioner­emergency department models). We studied the different ways of working to find out what works well, how and for whom. We brought together a lot of information. We reviewed existing evidence, sent out surveys to 184 emergency departments, spent time in the emergency departments observing how they operated and interviewing 106 staff in 13 hospitals and 24 patients who visited those emergency departments. We also looked at statistical information recorded by hospitals. Two public contributors were involved from the beginning, and we held two stakeholder events to ensure the relevance of our research to professionals and patients. Getting reliable figures to compare the various general practitioner­emergency department set-ups (inside, parallel to or outside the emergency department) was difficult. Our findings suggest that over time more people are coming to emergency departments and overall waiting times did not generally improve due to general practitioner­emergency department models. Evidence that general practitioners might admit fewer patients to hospital was mixed, with limited findings of cost savings. Patients were generally supportive of the care they received, although we could not speak to as many patients as we planned. The skills and experience of general practitioners were often valued as members of the wider emergency department team. We identified how the care provided was kept safe with: strong leaders, good communication between different types of staff, highly trained and experienced nurses responsible for streaming and specific training for general practitioners on how they were expected to work. We have produced a guide to help professionals develop and improve general practitioner­emergency department services and we have written easy-to-read summaries of all the articles we published.

An exploration of the experiences and self-generated strategies used when navigating everyday life with Long Covid.

BACKGROUND: Around one in ten people who contract Covid-19 report ongoing symptoms or 'Long Covid'. Without any known interventions to cure the condition, forms of self-management are routinely prescribed by healthcare professionals and described by people with the condition. However, there is limited research exploring what strategies are used to navigate everyday life with Long Covid, and experiences that initiate development of these strategies. Our study aimed to explore the range and influence of self-generated strategies used by people with Long Covid to navigate everyday life within the context of their own condition. METHODS: Forming part of the Long Covid Personalised Self-managemenT support co-design and EvaluatioN (LISTEN) project, we conducted a qualitative study using narrative interviews with adults who were not hospitalised with Covid-19. Participants aged over 18 years, who self-identified with Long Covid, were recruited from England and Wales. Data were analysed with patient contributors using a reflexive thematic analysis. RESULTS: Eighteen participants (mean age = 44 years, SD = 13 years) took part in interviews held between December 2021 and February 2022. Themes were constructed which depicted 1) the landscape behind the Long Covid experience and 2) the everyday experience of participants' Long Covid. The everyday experience comprised a combination of physical, emotional, and social factors, forming three sub-themes: centrality of physical symptoms, navigating 'experts' and the 'true colour' of personal communities, and a rollercoaster of psychological ambiguity). The third theme, personal strategies to manage everyday life was constructed from participants' unique presentations and self-generated solutions to manage everyday life. This comprised five sub-themes: seeking reassurance and knowledge, developing greater self-awareness through monitoring, trial and error of 'safe' ideas, building in pleasure and comfort, and prioritising 'me'. CONCLUSIONS: Among this sample of adults with Long Covid, their experiences highlighted the unpredictable nature of the condition but also the use of creative and wide ranging self-generated strategies. The results offer people with Long Covid, and healthcare professionals supporting them, an overview of the collective evidence relating to individuals' self-management which can enable ways to live 'better' and regain some sense of identity whilst facing the impact of a debilitating, episodic condition. TRIAL REGISTRATION: LISTEN ISRCTN36407216.

Prehospital transdermal glyceryl trinitrate for ultra-acute ischaemic stroke: data from the RIGHT-2 randomised sham-controlled ambulance trial.

BACKGROUND: The effect of transdermal glyceryl trinitrate (GTN, a nitrovasodilator) on clinical outcome when administered before hospital admission in suspected stroke patients is unclear. Here, we assess the safety and efficacy of GTN in the prespecified subgroup of patients who had an ischaemic stroke within the Rapid Intervention with Glyceryl trinitrate in Hypertensive stroke Trial-2 (RIGHT-2). METHODS: RIGHT-2 was an ambulance-based multicentre sham-controlled blinded-endpoint study with patients randomised within 4 hours of onset. The primary outcome was a shift in scores on the modified Rankin scale (mRS) at day 90. Secondary outcomes included death; a global analysis (Wei-Lachin test) containing Barthel Index, EuroQol-5D, mRS, telephone interview for cognitive status-modified and Zung depression scale; and neuroimaging-determined 'brain frailty' markers. Data were reported as n (%), mean (SD), median [IQR], adjusted common OR (acOR), mean difference or Mann-Whitney difference (MWD) with 95% CI. RESULTS: 597 of 1149 (52%) patients had a final diagnosis of ischaemic stroke; age 75 (12) years, premorbid mRS>2 107 (18%), Glasgow Coma Scale 14 (2) and time from onset to randomisation 67 [45, 108] min. Neuroimaging 'brain frailty' was common: median score 2 [2, 3] (range 0-3). At day 90, GTN did not influence the primary outcome (acOR for increased disability 1.15, 95% CI 0.85 to 1.54), death or global analysis (MWD 0.00, 95% CI -0.10 to 0.09). In subgroup analyses, there were non-significant interactions suggesting GTN may be associated with more death and dependency in participants randomised within 1 hour of symptom onset and in those with more severe stroke. CONCLUSIONS: In patients who had an ischaemic stroke, ultra-acute administration of transdermal GTN in the ambulance did not improve clinical outcomes in a population with more clinical and radiological frailty than seen in previous in-hospital trials.

Nurse-delivered sleep restriction therapy in primary care for adults with insomnia disorder: a mixed-methods process evaluation.

BACKGROUND: Sleep restriction therapy (SRT) is a behavioural therapy for insomnia. AIM: To conduct a process evaluation of a randomised controlled trial comparing SRT delivered by primary care nurses plus a sleep hygiene booklet with the sleep hygiene booklet only for adults with insomnia disorder. DESIGN AND SETTING: A mixed-methods process evaluation in a general practice setting. METHOD: Semi-structured interviews were conducted in a purposive sample of patients receiving SRT, the practice nurses who delivered the therapy, and also GPs or practice managers at the participating practices. Qualitative data were explored using framework analysis, and integrated with nurse comments and quantitative data, including baseline Insomnia Severity Index score and serial sleep efficiency outcomes to investigate the relationships between these. RESULTS: In total, 16 patients, 13 nurses, six practice managers, and one GP were interviewed. Patients had no previous experience of behavioural therapy, needed flexible appointment times, and preferred face-to-face consultations; nurses felt prepared to deliver SRT, accommodating patient concerns, tailoring therapy, and negotiating sleep timings despite treatment complexity and delays between training and intervention delivery. How the intervention produced change was explored, including patient and nurse interactions and patient responses to SRT. Difficulties maintaining SRT, negative attitudes towards treatment, and low self-efficacy were highlighted. Contextual factors, including freeing GP time, time constraints, and conflicting priorities for nurses, with suggestions for alternative delivery options, were raised. Participants who found SRT a positive process showed improvements in sleep efficiency, whereas those who struggled did not. CONCLUSION: SRT was successfully delivered by practice nurses and was generally well received by patients, despite some difficulties delivering and applying the intervention in practice.

Development of indicators for avoidable emergency medical service calls by mapping paramedic clinical impression codes to ambulatory care sensitive conditions and mental health conditions in the UK and Canada.

OBJECTIVE: Paramedic assessment data have not been used for research on avoidable calls. Paramedic impression codes are designated by paramedics on responding to a 911/999 medical emergency after an assessment of the presenting condition. Ambulatory care sensitive conditions (ACSCs) are non-acute health conditions not needing hospital admission when properly managed. This study aimed to map the paramedic impression codes to ACSCs and mental health conditions for use in future research on avoidable 911/999 calls. DESIGN: Mapping paramedic impression codes to existing definitions of ACSCs and mental health conditions. SETTING: East Midlands Region, UK and Southern Ontario, Canada. PARTICIPANTS: Expert panel from the UK-Canada Emergency Calls Data analysis and GEospatial mapping (EDGE) Consortium. RESULTS: Mapping was iterative first identifying the common ACSCs shared between the two countries then identifying the respective clinical impression codes for each country that mapped to those shared ACSCs as well as to mental health conditions. Experts from the UK-Canada EDGE Consortium contributed to both phases and were able to independently match the codes and then compare results. Clinical impression codes for paramedics in the UK were more extensive than those in Ontario. The mapping revealed some interesting inconsistencies between paramedic impression codes but also demonstrated that it was possible. CONCLUSION: This is an important first step in determining the number of ASCSs and mental health conditions that paramedics attend to, and in examining the clinical pathways of these individuals across the health system. This work lays the foundation for international comparative health services research on integrated pathways in primary care and emergency medical services.

An early warning precision public health approach for assessing COVID-19 vulnerability in the UK: the Moore-Hill Vulnerability Index (MHVI).

BACKGROUND: Most COVID-19 vulnerability indices rely on measures that are biased by rates of exposure or are retrospective like mortality rates that offer little opportunity for intervention. The Moore-Hill Vulnerability Index (MHVI) is a precision public health early warning alternative to traditional infection fatality rates that presents avenues for mortality prevention. METHODS: We produced an infection-severity vulnerability index by calculating the proportion of all recorded positive cases that were severe and attended by ambulances at small area scale for the East Midlands of the UK between May 2020 and April 2022. We produced maps identifying regions with high and low vulnerability, investigated the accuracy of the index over shorter and longer time periods, and explored the utility of the MHVI compared to other common proxy measures and indices. Analysis included exploring the correlation between our novel index and the Index of Multiple Deprivation (IMD). RESULTS: The MHVI captures geospatial dynamics that single metrics alone often overlook, including the compound health challenges associated with disadvantaged and declining coastal towns inhabited by communities with post-industrial health legacies. A moderate negative correlation between MHVI and IMD reflects spatial analysis which suggests that high vulnerability occurs in affluent rural as well as deprived coastal and urban communities. Further, the MHVI estimates of severity rates are comparable to infection fatality rates for COVID-19. CONCLUSIONS: The MHVI identifies regions with known high rates of poor health outcomes prior to the pandemic that case rates or mortality rates alone fail to identify. Pre-hospital early warning measures could be utilised to prevent mortality during a novel pandemic.

Understanding colorectal cancer patient follow-up: a qualitative interview study.

PURPOSE: There are increasing numbers of patients who have been treated for colorectal cancer (CRC) who struggle with ongoing physical and psychological symptoms. 'Cancer survivor' is often used to describe these patients but this terminology remains controversial. This study sought to understand the follow-up experience of CRC patients in the UK and identify the terminology they prefer following diagnosis and treatment. METHODS: Purposeful sampling of patients from specialist CRC follow-up clinics was performed until data saturation was achieved. Two 1:1 semi-structured qualitative interviews were performed for each participant. Data were analysed thematically. RESULTS: Seventeen participants, median age = 62, 53% male were interviewed. Several themes were identified. Of note, fear of cancer recurrence dominates patients' agendas at follow-up appointments. There are also clinical and administrative barriers to discussing symptoms including being embarrassed, feeling that their symptoms were not relevant or not having enough time to discuss issues. However, there are several methods which may improve this, such as through the use of video consultations and questionnaires. In addition, patients identified inadequate holistic support despite significant psychological and social distress. Our data suggest that labelling a diverse group of patients as 'cancer survivors' can be problematic. CONCLUSION: It is important that clinicians systematically screen patients for symptoms that are known to occur following treatment. Clinicians and patients should have routine access to pathways and programmes that can support patients in navigating their life after cancer therapy.

Prehospital transdermal glyceryl trinitrate in patients with ultra-acute presumed stroke (RIGHT-2): effects on outcomes at day 365 in a randomised, sham-controlled, blinded, phase III, superiority ambulance-based trial.

Background: The Rapid Intervention with Glyceryl Trinitrate in Hypertensive Stroke Trial-2 (RIGHT-2) reported no overall treatment difference between glyceryl trinitrate (GTN) and sham at day 90. Here we assess participants' outcomes 1 year after randomisation. Methods: RIGHT-2 was an ambulance-based prospective randomised controlled trial where patients with presumed stroke and systolic blood pressure (BP) of >120 mm Hg received either GTN (5 mg/day) or sham patch. Centralised blinded telephone follow-up was performed at days 90 (primary endpoint) and 365 (secondary endpoint). The lead outcome was dependency assessed with the modified Rankin Scale (mRS). Results: 1149 patients were recruited to RIGHT-2 between October 2015 and May 2018, and 1097 (95.5%) had outcome data recorded at day 365. At baseline, the patients were; female (48%), had a mean age of 73 (15) years, BP of 162 (25)/92 (18) mm Hg, onset to randomisation of 70 (45-115) min, diagnosis of ischaemic stroke (52%), intracerebral haemorrhage (ICH) (13%), transient ischaemic attack (TIA) (9%) and mimics (26%). There was no effect of GTN on mRS score at day 365 in participants with confirmed stroke/TIA (adjusted common odds ratio (acOR) 1.10, 95% CI 0.86 to 1.42) or in all patients. In patients randomised to GTN, mRS at day 365 tended to be worse in those with ICH (acOR 1.65, 95% CI 0.84 to 3.25) and better in those with a mimic diagnosis (acOR 0.53, 95% CI 0.33 to 0.84). Conclusion: At 1 year post randomisation, dependency did not differ between GTN and sham treatment in either the target population or overall. In prespecified subgroup analyses, GTN was associated with reduced dependency in participants with a final diagnosis of mimic and a non-significant worse outcome in participants with ICH. Trial registration number: ISRCTN26986053.

Building an understanding of Ethnic minority people's Service Use Relating to Emergency care for injuries: the BE SURE study protocol.

INTRODUCTION: Injuries are a major public health problem which can lead to disability or death. However, little is known about the incidence, presentation, management and outcomes of emergency care for patients with injuries among people from ethnic minorities in the UK. The aim of this study is to investigate what may differ for people from ethnic minorities compared with white British people when presenting with injury to ambulance and Emergency Departments (EDs). METHODS AND ANALYSIS: This mixed methods study covers eight services, four ambulance services (three in England and one in Scotland) and four hospital EDs, located within each ambulance service. The study has five Work Packages (WP): (WP1) scoping review comparing mortality by ethnicity of people presenting with injury to emergency services; (WP2) retrospective analysis of linked NHS routine data from patients who present to ambulances or EDs with injury over 5 years (2016-2021); (WP3) postal questionnaire survey of 2000 patients (1000 patients from ethnic minorities and 1000 white British patients) who present with injury to ambulances or EDs including self-reported outcomes (measured by Quality of Care Monitor and Health Related Quality of Life measured by SF-12); (WP4) qualitative interviews with patients from ethnic minorities (n=40) and focus groups-four with asylum seekers and refugees and four with care providers and (WP5) a synthesis of quantitative and qualitative findings. ETHICS AND DISSEMINATION: This study received a favourable opinion by the Wales Research Ethics Committee (305391). The Health Research Authority has approved the study and, on advice from the Confidentiality Advisory Group, has supported the use of confidential patient information without consent for anonymised data. Results will be shared with ambulance and ED services, government bodies and third-sector organisations through direct communications summarising scientific conference proceedings and publications.

External validation of the Manchester Acute Coronary Syndromes ECG risk model within a pre-hospital setting.

OBJECTIVES: The Manchester Acute Coronary Syndromes ECG (MACS-ECG) prediction model calculates a score based on objective ECG measurements to give the probability of a non-ST elevation myocardial infarction (NSTEMI). The model showed good performance in the emergency department (ED), but its accuracy in the pre-hospital setting is unknown. We aimed to externally validate MACS-ECG in the pre-hospital environment. METHODS: We undertook a secondary analysis from the Pre-hospital Evaluation of Sensitive Troponin (PRESTO) study, a multi-centre prospective study to validate decision aids in the pre-hospital setting (26 February 2019 to 23 March 2020). Patients with chest pain where the treating paramedic suspected acute coronary syndrome were included. Paramedics collected demographic and historical data and interpreted ECGs contemporaneously (as 'normal' or 'abnormal'). After completing recruitment, we analysed ECGs to calculate the MACS-ECG score, using both a pre-defined threshold and a novel threshold that optimises sensitivity to differentiate AMI from non-AMI. This was compared with subjective ECG interpretation by paramedics. The diagnosis of AMI was adjudicated by two investigators based on serial troponin testing in hospital. RESULTS: Of 691 participants, 87 had type 1 AMI and 687 had complete data for paramedic ECG interpretation. The MACS-ECG model had a C-index of 0.68 (95% CI: 0.61 to 0.75). At the pre-determined cut-off, MACS-ECG had 2.3% (95% CI: 0.3% to 8.1%) sensitivity, 99.5% (95% CI: 98.6% to 99.9%) specificity, 40.0% (95% CI: 10.2% to 79.3%) positive predictive value (PPV) and 87.6% (87.3% to 88.0%) negative predictive value (NPV). At the optimal threshold for sensitivity, MACS-ECG had 50.6% sensitivity (39.6% to 61.5%), 83.1% specificity (79.9% to 86.0%), 30.1% PPV (24.7% to 36.2%) and 92.1% NPV (90.4% to 93.5%). In comparison, paramedics had a sensitivity of 71.3% (95% CI: 60.8% to 80.5%) with 53.8% (95% CI: 53.8% to 61.8%) specificity, 19.7% (17.2% to 22.45%) PPV and 93.3% (90.8% to 95.1%) NPV. CONCLUSION: Neither MACS-ECG nor paramedic ECG interpretation had a sufficiently high PPV or NPV to 'rule in' or 'rule out' NSTEMI alone.

Patient, family member, and ambulance staff experiences of prehospital acute pain management in adults: A systematic review and meta-synthesis.

Background: We aimed to synthesize the qualitative experiences of patients, their family members, and ambulance staff involved in the prehospital management of acute pain in adults and generate recommendations to improve the quality of care. Methods: A systematic review was conducted following the enhancing transparency in reporting the synthesis of qualitative research (ENTREQ) guidelines. We searched from inception to June 2021: MEDLINE, CINAHL Complete, PsycINFO and Web of Science (search alerts were screened up to December 2021). Articles were eligible for inclusion if they reported qualitative data and were published in the English language. The Critical Appraisal Skills Program for qualitative studies checklist was used to assess risk of bias, thematic synthesis was performed on included studies and recommendations for clinical practice improvement were generated. Results: Twenty-five articles were included in the review, representing over 464 patients, family members, and ambulance staff from 8 countries. Six analytical themes and several recommendations to improve clinical practice were generated. Strengthening the patient-clinician relationship by building trust, promoting patient empowerment, addressing patient needs and expectations, and providing a holistic approach to pain treatment is key to improving prehospital pain management in adults. Shared pain management guidelines and training across the prehospital and emergency department intersection should improve the patient journey. Conclusion: Interventions and guidelines that strengthen the patient-clinician relationship and span the prehospital and emergency department phase of care are likely to improve the quality of care for adults suffering acute pain in the prehospital setting.

Performance of ethnic minority versus White doctors in the MRCGP assessment 2016-2021: a cross-sectional study.

BACKGROUND: Differential attainment has previously been suggested as being due to subjective bias because of racial discrimination in clinical skills assessments. AIM: To investigate differential attainment in all UK general practice licensing tests comparing ethnic minority with White doctors. DESIGN AND SETTING: Observational study of doctors in GP specialty training in the UK. METHOD: Data were analysed from doctors' selection in 2016 to the end of GP training, linking selection, licensing, and demographic data to develop multivariable logistic regression models. Predictors of pass rates were identified for each assessment. RESULTS: A total of 3429 doctors entering GP specialty training in 2016 were included, with doctors of different sex (female 63.81% versus male 36.19%), ethnic group (White British 53.95%, minority ethnic 43.04%, and mixed 3.01%), country of primary medical qualification (UK 76.76% versus non-UK 23.24%), and declared disability (disability declared 11.98% versus not declared 88.02%). Multi-Specialty Recruitment Assessment (MSRA) scores were highly predictive for GP training end-point assessments, including the Applied Knowledge Test (AKT), Clinical Skills Assessment (CSA), Recorded Consultation Assessment (RCA), and Workplace-Based Assessment (WPBA) and Annual Review of Competency Progression (ARCP). Ethnic minority doctors did significantly better compared with White British doctors in the AKT (odds ratio [OR] 2.05, 95% confidence interval [CI] = 1.03 to 4.10, P = 0.042). There were no significant differences on other assessments: CSA (OR 0.72, 95% CI = 0.43 to 1.20, P = 0.201), RCA (OR 0.48, 95% CI = 0.18 to 1.32, P = 0.156), or WPBA-ARCP (OR 0.70, 95% CI = 0.49 to 1.01, P = 0.057). CONCLUSION: Ethnic background did not reduce the chance of passing GP licensing tests once sex, place of primary medical qualification, declared disability, and MSRA scores were accounted for.

Effectiveness and cost-effectiveness of a personalised self-management intervention for living with long COVID: protocol for the LISTEN randomised controlled trial.

BACKGROUND: Individuals living with long COVID experience multiple, interacting and fluctuating symptoms which can have a dramatic impact on daily living. The aim of the Long Covid Personalised Self-managemenT support EvaluatioN (LISTEN) trial is to evaluate effects of the LISTEN co-designed self-management support intervention for non-hospitalised people living with long COVID on participation in routine activities, social participation, emotional well-being, quality of life, fatigue, and self-efficacy. Cost-effectiveness will also be evaluated, and a detailed process evaluation carried out to understand how LISTEN is implemented. METHODS: The study is a pragmatic randomised effectiveness and cost-effectiveness trial in which a total of 558 non-hospitalised people with long COVID will be randomised to either the LISTEN intervention or usual care. Recruitment strategies have been developed with input from the LISTEN Patient and Public Involvement and Engagement (PPIE) advisory group and a social enterprise, Diversity and Ability, to ensure inclusivity. Eligible participants can self-refer into the trial via a website or be referred by long COVID services. All participants complete a range of self-reported outcome measures, online, at baseline, 6 weeks, and 3 months post randomisation (the trial primary end point). Those randomised to the LISTEN intervention are offered up to six one-to-one sessions with LISTEN-trained intervention practitioners and given a co-designed digital resource and paper-based book. A detailed process evaluation will be conducted alongside the trial to inform implementation approaches should the LISTEN intervention be found effective and cost-effective. DISCUSSION: The LISTEN trial is evaluating a co-designed, personalised self-management support intervention (the LISTEN intervention) for non-hospitalised people living with long COVID. The design has incorporated extensive strategies to minimise participant burden and maximise access. Whilst the duration of follow-up is limited, all participants are approached to consent for long-term follow-up (subject to additional funding being secured). TRIAL REGISTRATION: LISTEN ISRCTN36407216. Registered on 27/01/2022.

"It's like a swan, all nice and serene on top, and paddling like hell underneath": community first responders' practices in attending patients and contributions to rapid emergency response in rural England, United Kingdom-a qualitative interview study.

BACKGROUND: Community First Responder (CFR) schemes are a long-established service supplementing ambulance trusts in their local community in the United Kingdom. CFRs are community members who volunteer to respond to people with life-threatening conditions. Previous studies highlighted the motivations for becoming CFRs, their training, community (un)awareness and implications of their work on themselves and others. The practices of CFRs in prehospital care remain underexplored. Therefore, we aimed to explore real-world practice of Community First Responders and their contribution to prehospital emergency care. METHODS: We conducted 47 interviews with CFRs (21), CFR leads (15), ambulance clinicians (4), commissioners (2) and patients and relatives (5) from six ambulance services and regions of England, United Kingdom. Thematic analysis enabled identification of themes and subthemes, with subsequent interpretation built on the theory of practice wisdom. RESULTS: Our analysis revealed the embeddedness of the concept of doing the right thing at the right time in CFR practice. CFRs' work consisted of a series of sequential and interconnected activities which included: identifying patients' signs, symptoms and problems; information sharing with the ambulance control room on the patient's condition; providing a rapid emergency response including assessment and care; and engaging with ambulance clinicians for patient transfer. The patient care sequence began with recognising patients' signs and symptoms, and validation of patient information provided by the ambulance control room. The CFRs shared patient information with ambulance control who in turn notified the ambulance crew en-route. The practices of CFRs also included delivery of emergency care before ambulance clinicians arrived. Following the delivery of a rapid emergency response, CFRs engaged with the ambulance crew to facilitate patient transfer to the nearest medical facility. CONCLUSION: The sequential CFR practices supported ambulance services in delivering prehospital and emergency care in rural areas. CFR practices were founded on the principle of practice wisdom where CFRs constructed their practice decisions based on the patient's condition, their training, availability of equipment and medications and their scope of practice.

Practitioners' views on community implementation of point-of-care ultrasound (POCUS) in the UK: a qualitative interview study.

BACKGROUND: Implementing Point-of-care ultrasound (POCUS) in community practice could help to decide upon and prioritise initial treatment, procedures and appropriate specialist referral or conveyance to hospital. A recent literature review suggests that image quality, portability and cost of ultrasound devices are all improving with widening indications for community POCUS, but evidence about community POCUS use is needed in the UK. We aimed to explore views of clinical practitioners, actively using ultrasound, on their experiences of using POCUS and potential facilitators and barriers to its wider implementation in community settings in the UK. METHODS: We conducted a qualitative interview study with practitioners from community and secondary care settings actively using POCUS in practice. A convenience sample of eligible participants from different clinical specialties and settings was recruited using social media adverts, through websites of relevant research groups and snowball sampling. Individual semi-structured interviews were conducted online using Microsoft Teams. These were recorded, transcribed verbatim, and analysed using a Framework approach supported by NVivo 12. RESULTS: We interviewed 16 practitioners aged between 40 and 62 years from different professional backgrounds, including paramedics, emergency physicians, general practitioners, and allied health professionals. Participants identified key considerations and facilitators for wider implementation of POCUS in community settings in the UK: resource requirements for deployment and support of working devices; sufficient time and a skilled workforce; attention to training, education and support needs; ensuring proper governance, guidelines and quality assurance; workforce considerations; enabling ease of use in assisting decision making with consideration of unintended consequences; and more robust evidence to support perceptions of improved patient outcomes and experience. CONCLUSIONS: POCUS could be useful for improving patient journey and health outcomes in community care, but this requires further research to evaluate outcomes. The facilitators identified could help make community POCUS a reality.

Examiner perceptions of the MRCGP recorded consultation assessment for general practice licensing during COVID-19: cross-sectional study.

BACKGROUND: The Recorded Consultation Assessment (RCA) was developed rapidly during the COVID-19 pandemic to replace the Clinical Skills Assessment (CSA) for UK general practice licensing. Our aim was to evaluate examiner perceptions of the RCA. METHODS: We employed a cross-sectional design using a questionnaire survey of RCA examiners with attitudinal (relating to examiners thoughts and perceptions of the RCA) and free text response options. We conducted statistical descriptive and factor analysis of quantitative data with qualitative thematic analysis of free text responses. RESULTS: Overall, 182 of 260 (70%) examiners completed the questionnaire. Responders felt that consultations submitted were representative of the work of a typical GP during the pandemic and provided a good sample across the curriculum. They were also generally positive about the logistic, advisory and other support provided as well as the digital platform. Despite responders generally agreeing there was sufficient information available in video or audio consultations to judge candidates' data gathering, clinical management, and interpersonal skills, they were less confident about their ability to make judgments of candidates' performance compared with the CSA. The qualitative analysis of free text responses detailed the problems of case selection and content, explained examiners' difficulties when making judgments, and detailed the generally positive views about support, training and information technology. Responders also provided helpful recommendations for improving the assessment. CONCLUSION: The RCA was considered by examiners to be feasible and broadly acceptable, although they experienced challenges from candidate case selection, case content and judgments leading to suggested areas for improvement.

Common hierarchies, varied rules - the problem of governing community first responders in prehospital care for quality standards: documentary discourse analysis.

A key focus is placed on engaging communities to become involved in making decisions to support health and care services in healthcare policies in England, UK. An example is the deployment of volunteers such as community first responders (CFRs), who are members of the public with basic life support skills, trained to intervene in emergency situations prior to the arrival of ambulance services. CFR policies have been devised by National Health Service (NHS) Trusts as a way of governing these and related activities. This paper critically examines the discourse around CFR policies to understand how CFR roles are organised and monitoring governance mechanisms are delineated in ensuring quality care delivery. We collected ten CFR policies from six ambulance services. Inductive analysis, guided by Foucault's theory, enabled the identification of themes and subthemes. We found that Trusts have a common goal to make care quality assurances to regulatory bodies on CFR roles, and this is depicted in common hierarchies of individual responsibilities across Trusts. However, policies that govern approaches to CFRs activity vary. Firstly, the paper highlights institutional approaches to ensuring public safety through the application of organised surveillance systems to monitor CFR activities, and draws parallels between such surveillance and Foucault's docile bodies. Secondly, the paper discusses how varying rules in the surveillance system compromises safety by decentralising knowledge to regulatory bodies to whom NHS Trusts must make safety assurances. We suggest that stronger interrelationships between Trusts in considering the CFR role has potential to increase public safety and outline a clearer direction for CFRs.