What are emergency ambulance services doing to meet the needs of people who call frequently? A national survey of current practice in the United Kingdom.

BACKGROUND: Emergency ambulance services are integral to providing a service for those with unplanned urgent and life-threatening health conditions. However, high use of the service by a small minority of patients is a concern. Our objectives were to describe: service-wide and local policies or pathways for people classified as Frequent Caller; call volume; and results of any audit or evaluation. METHOD: We conducted a national survey of current practice in ambulance services in relation to the management of people who call the emergency ambulance service frequently using a structured questionnaire for completion by email and telephone interview. We analysed responses using a descriptive and thematic approach. RESULTS: Twelve of 13 UK ambulance services responded. Most services used nationally agreed definitions for 'Frequent Caller', with 600-900 people meeting this classification each month. Service-wide policies were in place, with local variations. Models of care varied from within-service care where calls are flagged in the call centre; contact made with callers; and their General Practitioner (GP) with an aim of discouraging further calls, to case management through cross-service, multi-disciplinary team meetings aiming to resolve callers' needs. Although data were available related to volume of calls and number of callers meeting the threshold for definition as Frequent Caller, no formal audits or evaluations were reported. CONCLUSIONS: Ambulance services are under pressure to meet challenging response times for high acuity patients. Tensions are apparent in the provision of care to patients who have complex needs and call frequently. Multi-disciplinary case management approaches may help to provide appropriate care, and reduce demand on emergency services. However, there is currently inadequate evidence to inform commissioning, policy or practice development.

Use and impact of the prehospital 12-lead ECG in the primary PCI era (PHECG2): protocol for a mixed-method study.

Introduction: Use of the prehospital 12-lead ECG (PHECG) is recommended in patients presenting to emergency medical services (EMS) with suspected acute coronary syndrome (ACS). Prior research found that although PHECG use was associated with improved 30-day survival, a third of patients (typically women, the elderly and those with comorbidities) under EMS care did not receive a PHECG.The overall aim of the PHECG2 study is to update evidence on care and outcomes for patients eligible for PHECG, specifically addressing the following research questions: (1) Is there a difference in 30-day mortality, and in reperfusion rate, between those who do and those who do not receive PHECG? (2) Has the proportion of eligible patients who receive PHECG changed since the introduction of primary percutaneous coronary intervention networks? (3) Are patients that receive PHECG different from those that do not in terms of social and demographic factors, or prehospital clinical presentation? (4) What factors influence EMS clinicians' decisions to perform PHECG? Methods and analysis: This is an explanatory, mixed-method study comprising four work packages (WPs). WP1 is a population-based, linked-data analysis of a national ACS registry (Myocardial Ischaemia National Audit Project). WP2 is a retrospective chart review of patient records from three large regional EMS. WP3 comprises focus groups of EMS personnel. WP4 will synthesise findings from WP1-3 to inform the development of an intervention to increase PHECG uptake. Ethics and dissemination: The study has been approved by the London-Hampstead Research Ethics Committee (ref: 18LO1679). Findings will be disseminated through feedback to participating EMS, conference presentations and publication in peer-reviewed journals. Trial registration number: NCT03699137.

Transient ischaemic attack pre-hospital referral feasibility trial (TIER): recruitment and intervention usage.

AIMS: Early specialist assessment of transient ischaemic attack (TIA) can reduce the risk of stroke and death. This study assessed the feasibility of undertaking a multi-centre randomised trial to evaluate clinical and cost effectiveness of referral of patients attended by emergency ambulance paramedics with low-risk TIA directly to specialist TIA clinics for early review. METHODS: We developed a protocol and referral pathway for paramedics to assess and refer patients directly to a TIA clinic, and administer aspirin. We randomly allocated volunteer paramedics to intervention or control groups. Intervention paramedics were trained to deliver the intervention during the patient recruitment period. Control paramedics continued to deliver care as usual. Patients with TIA were identified from hospital records. We aimed to recruit 86 patients and pre-defined progression criteria related to feasibility of intervention delivery and trial methods. RESULTS: Development and recruitment phases are complete, with outcome follow-up ongoing. Of 134 (66%) paramedics, 89 participated in TIER. Of 1377 patients attended by trial paramedics during the patient recruitment period, 53 (3.8%) were identified as eligible for trial inclusion. Of 36 (8%) patients attended by intervention paramedics, three were referred to the TIA clinic. Of the others, only one appeared to be a missed referral; in one case there was no pre-hospital record of TIA; one was attended by a paramedic who was not TIER trained; one patient record was missing; and all others were recorded with contra-indications: FAST positive (n = 13); ABCD2 score > 3 (n = 5); already taking warfarin (n = 2); crescendo TIA (n = 1); and other clinical factors (n = 8). CONCLUSIONS: Preliminary results indicate challenges in recruitment and low referral rates. The low-risk 999 TIA population suitable for emergency department avoidance may be smaller than previously thought. Further analyses will focus on whether progression criteria for a definitive trial were met, and clinical outcomes from this feasibility trial.