Community First Responders' Contribution to Emergency Medical Service Provision in the United Kingdom.

STUDY OBJECTIVE: We aimed to investigate community first responders' contribution to emergency care provision in terms of number, rate, type, and location of calls and characteristics of patients attended. METHODS: We used a retrospective observational design analyzing routine data from electronic clinical records from 6 of 10 ambulance services in the United Kingdom during 2019. Descriptive statistics, including numbers and frequencies, were used to illustrate characteristics of incidents and patients that the community first responders attended first in both rural and urban areas. RESULTS: The data included 4.5 million incidents during 1 year. The community first responders first attended a higher proportion of calls in rural areas compared with those in urban areas (3.90% versus 1.48 %). In rural areas, the community first responders also first attended a higher percentage of the most urgent call categories, 1 and 2. The community first responders first attended more than 9% of the total number of category 1 calls and almost 5% of category 2 calls. The community first responders also attended a higher percentage of the total number of cardiorespiratory and neurological/endocrine conditions. They first attended 6.5% of the total number of neurological/endocrine conditions and 5.9% of the total number of cardiorespiratory conditions. Regarding arrival times in rural areas, the community first responders attended higher percentages (more than 6%) of the total number of calls that had arrival times of less than 7 minutes or more than 60 minutes. CONCLUSION: In the United Kingdom, community first responders contribute to the delivery of emergency medical services, particularly in rural areas and especially for more urgent calls. The work of community first responders has expanded from their original purpose-to attend to out-of-hospital cardiac arrests. The future development of community first responders' schemes should prioritize training for a range of conditions, and further research is needed to explore the contribution and potential future role of the community first responders from the perspective of service users, community first responders' schemes, ambulance services, and commissioners.

Patient-reported symptoms and experience following Guillain-Barré syndrome and related conditions: Questionnaire development and validation.

BACKGROUND: Guillain-Barré syndrome (GBS) is a rare inflammatory peripheral nerve disorder with variable recovery. Evidence is lacking on experiences of people with GBS and measurement of these experiences. OBJECTIVE: We aimed to develop and validate an instrument to measure experiences of people with GBS. DESIGN: We used a cross-sectional design and online self-administered questionnaire survey. Question domains, based on a previous systematic review and qualitative study, covered experiences of GBS, symptom severity at each stage, healthcare and factors supporting or hindering recovery. Descriptive, exploratory factor and reliability analyses and multivariable regression analysis were used to investigate the relationships between variables of interest, explore questionnaire reliability and validity and identify factors predicting recovery. SETTING AND PARTICIPANTS: People with a previous diagnosis of GBS were recruited through a social media advert. RESULTS: A total of 291 responders, of different sexes, and marital statuses, were included, with most diagnosed between 2015 and 2019. Factor analysis showed four scales: symptoms, information provided, factors affecting recovery and care received. Positive social interactions, physical activity including physiotherapy and movement, changes made at home and immunoglobulin treatment were important for recovery. Multivariable models showed that immunoglobulin and/or plasma exchange were significant predictors of recovery. Employment and recovery factors (positive interactions, work support and changes at work or home, physical activity and therapy), though associated with recovery, did not reach statistical significance. CONCLUSION: The questionnaire demonstrated good internal reliability of scales and subscales and construct validity for people following GBS. PATIENT CONTRIBUTION: Patients were involved in developing and piloting the questionnaire.

The experiences and perceptions of wellbeing provision among English ambulance services staff: a multi-method qualitative study.

BACKGROUND: NHS ambulance service staff are at risk of poor physical and mental wellbeing because of the likelihood of encountering stressful and traumatic incidents. While reducing sickness absence and improving wellbeing support to ambulance staff is a key NHS priority, few studies have empirically documented a national picture to inform policy and service re-design. The study aimed to understand how ambulance service trusts in England deal with staff health and wellbeing, as well as how the staff perceive and use wellbeing services. METHODS: To achieve our aim, we undertook semi-structured telephone interviews with health and wellbeing leads and patient-facing ambulance staff, as well as undertaking documentary analysis of ambulance trust policies on wellbeing. The study was conducted both before and during the UK first COVID-19 pandemic wave. The University of Lincoln ethics committee and the Health Research Authority (HRA) granted ethical approval. Overall, we analysed 57 staff wellbeing policy documents across all Trusts. Additionally, we interviewed a Health and Wellbeing Lead in eight Trusts as well as 25 ambulance and control room staff across three Trusts. RESULTS: The study highlighted clear variations between organisational and individual actions to support wellbeing across Trust policies. Wellbeing leads acknowledged real 'tensions' between individual and organisational responsibility for wellbeing. Behaviour changes around diet and exercise were perceived to have a positive effect on the overall mental health of their workforce. Wellbeing leads generally agreed that mental health was given primacy over other wellbeing initiatives. Variable experiences of health and wellbeing support were partly contingent on the levels of management support, impacted by organisational culture and service delivery challenges for staff. CONCLUSION: Ambulance service work can impact upon physical and mental health, which necessitates effective support for staff mental health and wellbeing. Increasing the knowledge of line managers around the availability of services could improve engagement.

Perceptions and experiences of medical student first responders: a mixed methods study.

CONTEXT: Medical Student First Responders (MSFRs) are volunteers who respond to emergency calls, managing patients before ambulance staff attend. The MSFR role provides opportunities to manage acutely unwell patients in the prehospital environment, not usually offered as part of formal undergraduate medical education. There are few previous studies describing activities or experiences of MSFRs or exploring the potential educational benefits. We aimed to investigate the activity of MSFRs and explore their experiences, particularly from an educational perspective. METHODS: We used a mixed methods design, combining quantitative analysis of ambulance dispatch data with qualitative semi-structured interviews of MSFRs. Dispatch data were from South Central and East Midlands Ambulance Service NHS Trusts from 1st January to 31st December 2019. Using propensity score matching, we compared incidents attended by MSFRs with those attended by other Community First Responders (CFRs) and ambulance staff. We interviewed MSFRs from five English (UK) medical schools in those regions about their experiences and perceptions and undertook thematic analysis supported by NVivo 12. RESULTS: We included 1,939 patients (median age 58.0 years, 51% female) attended by MSFRs. Incidents attended were more urgent category calls (category 1 n = 299, 14.9% and category 2 n = 1,504, 77.6%), most commonly for chest pain (n = 275, 14.2%) and shortness of breath (n = 273, 14.1%). MSFRs were less likely to attend patients of white ethnicity compared to CFRs and ambulance staff, and more likely to attend incidents in areas of higher socioeconomic deprivation (IMD - index of multiple deprivation) (p < 0.05). Interviewees (n = 16) consistently described positive experiences which improved their clinical and communication skills. CONCLUSION: MSFRs' attendance at serious medical emergencies provide a range of reported educational experiences and benefits. Further studies are needed to explore whether MSFR work confers demonstrable improvements in educational or clinical performance.

Effect of Displacement on Adherence to TB Treatment: An Observational Study in TB Patients from Internally Displaced Persons of Pakistan.

OBJECTIVE: This study was aimed to investigate TB patients adherence and treatment outcomes among internally displaced patients in comparison with adjacent settled areas. METHODS: The study was designed as an observational cross-sectional study among the TB patients of internally displaced populations (IDPs) of North Waziristan Agency (NWA) and adjacent settled areas of Bannu and Lakki Marwat (NIDPs). Based on the study inclusion and exclusion criteria 330 patients fullfilled the inclusion criteria and were assigned equally to both IDPs and NIDPs study groups. Odds ratio (OR) with 95% confidence interval was calculated and p-values, 0.05 were considered statistically significant. RESULTS: The treatment outcomes with the status of "cured" and "completed treatment" were better among NIDPs as compared to IDPs. Patients with treatment outcome status of "defaulted treatment", "without documentary evidence, and "failure" were high in IDPs as compared to NIDPs. Adherence to TB treatment was better among NIDPs (50.9%) as compared to IDPs (39.4%). The patients showing non-adherence to TB treatment were more among IDPS (27.3%) than NIDPs (10.9%). CONCLUSION: Overall results of this study revealed a poor adherence to the TB treatment medications with an odds ratio of 0.286, (p<0.05) among IDPs as compared with NIDPs.

Understanding how Eastern European migrants use and experience UK health services: a systematic scoping review.

BACKGROUND: The UK has experienced significant immigration from Eastern Europe following European Union (EU) expansion in 2004, which raises the importance of equity and equality for the recent immigrants. Previous research on ethnic health inequalities focused on established minority ethnic groups, whereas Eastern European migrants are a growing, but relatively under-researched group. We aimed to conduct a systematic scoping review of published literature on Eastern European migrants' use and experiences of UK health services. METHODS: An initial search of nine databases produced 5997 relevant publications. Removing duplicates reduced the figure to 2198. Title and abstract screening left 73 publications. Full-text screening narrowed this down further to 10 articles, with three more from these publications to leave 13 included publications. We assessed publications for quality, extracted data and undertook a narrative synthesis. RESULTS: The included publications most commonly studied sexual health and family planning services. For Eastern European migrants in the UK, the most commonly cited barriers to accessing and using healthcare were limited understanding of how the system worked and language difficulties. It was also common for migrants to return to their home country to a healthcare system they were familiar with, free from language barriers. Familial and social networks were valuable for patients with a limited command of English in the absence of suitable and available interpreting and translating services. CONCLUSIONS: To address limited understanding of the healthcare system and the English language, the NHS could produce information in all the Eastern European languages about how it operates. Adding nationality to the Electronic Patient Report Form (EPRF) may reveal the demand for interpretation and translation services. Eastern European migrants need to be encouraged to register with GPs to reduce A&E attendance for primary care conditions. Many of the issues raised will be relevant to other European countries since the long-term outcomes from Brexit are likely to influence the level of Eastern European and non-Eastern European migration across the continent, not just the UK.

Performance in candidates declaring versus those not declaring dyslexia in a licensing clinical examination.

CONTEXT: High-stakes medical examinations seek to be fair to all candidates, including an increasing proportion of trainee doctors with specific learning differences. We aimed to investigate the performance of doctors declaring dyslexia in the clinical skills assessment (CSA), an objective structured clinical examination for licensing UK general practitioners. METHODS: We employed a cross-sectional design using performance and attribute data from candidates taking the CSA between 2010 and 2017. We compared candidates who declared dyslexia ('early' before their first attempt or 'late' after failing at least once) with those who did not, using multivariable negative binomial regression investigating the effect of declaring dyslexia on passing the CSA, accounting for relevant factors previously associated with performance, including number of attempts, initial score, sex, place of primary medical qualification and ethnicity. RESULTS: Of 20 879 CSA candidates, 598 (2.9%) declared that they had dyslexia. Candidates declaring dyslexia were more likely to be male (47.3% versus 37.8%; p < 0.001) and to have a non-UK primary medical qualification (26.9% versus 22.4%; p < 0.01), but were no different in ethnicity compared with those who never declared dyslexia. Candidates who declared dyslexia late were significantly more likely to fail compared with those candidates who declared dyslexia early (40.6% versus 9.2%; p < 0.001) and were more likely to have a non-UK medical qualification (79.3% versus 15.6%; p < 0.001) or come from a minority ethnic group (84.9% versus 39.2%; p < 0.001). The chance of passing was lower for candidates declaring dyslexia compared to those who never declared dyslexia and lower in those declaring late (incident rate ratio [IRR], 0.82; 95% confidence interval [CI], 0.70-0.96) compared with those declaring early (IRR, 0.95; 95% CI, 0.93-0.97). CONCLUSIONS: A small proportion of candidates declaring dyslexia were less likely to pass the CSA, particularly if dyslexia was declared late. Further investigation of potential causes and solutions is needed.

Patient and clinician factors associated with prehospital pain treatment and outcomes: cross sectional study.

OBJECTIVE: We aimed to identify how patient (age, sex, condition) and paramedic factors (sex, role) affected prehospital analgesic administration and pain alleviation. METHODS: We used a cross-sectional design with a 7-day retrospective sample of adults aged 18 years or over requiring primary emergency transport to hospital, excluding patients with Glasgow Coma Scale below 13, in two UK ambulance services. Multivariate multilevel regression using Stata 14 analysed factors independently associated with analgesic administration and a clinically meaningful reduction in pain (≥2 points on 0-10 numerical verbal pain score [NVPS]). RESULTS: We included data on 9574 patients. At least two pain scores were recorded in 4773 (49.9%) patients. For all models fitted there was no significant relationship between analgesic administration or pain reduction and sex of the patient or ambulance staff. Reduction in pain (NVPS ≥2) was associated with ambulance crews including at least one paramedic (odds ratio [OR] 1.52, 95% confidence interval [CI] 1.14 to 2.04, p < 0.01), with any recorded pain score and suspected cardiac pain (OR 2.2, 95% CI 1.02 to 4.75). Intravenous morphine administration was also more likely where crews included a paramedic (OR 2.82, 95% CI 1.93 to 4.13, P < 0.01), attending patients aged 51 to 64 years (OR 2.04, 95% CI 1.21 to 3.45, p = 0.01), in moderate to severe (NVPS 4-10) compared with lower levels of pain for any clinical condition group compared with the reference condition. CONCLUSION: There was no association between patient sex or ambulance staff sex or grade and analgesic administration or pain reduction.

Performance of candidates disclosing dyslexia with other candidates in a UK medical licensing examination: cross-sectional study.

PURPOSE OF THE STUDY: The aim of this study was to compare performance of candidates who declared an expert-confirmed diagnosis of dyslexia with all other candidates in the Applied Knowledge Test (AKT) of the Membership of the Royal College of General Practitioners licensing examination. STUDY DESIGN: We used routinely collected data from candidates who took the AKT on one or more occasions between 2010 and 2015. Multivariate logistic regression was used to analyse performance of candidates who declared dyslexia with all other candidates, adjusting for candidate characteristics known to be associated with examination success including age, sex, ethnicity, country of primary medical qualification, stage of training, number of attempts and time spent completing the test. RESULTS: The analysis included data from 14 examinations involving 14 801 candidates of which 2.6% (379/14 801) declared dyslexia. The pass rate for candidates who declared dyslexia was 83.6% compared with 95.0% for other candidates. After adjusting for covariates linked to examination success including age, sex, ethnicity, country of primary medical qualification, stage of training, number of attempts and time spent completing the test dyslexia was not significantly associated with pass rates in the AKT. Candidates declaring dyslexia after initially failing the AKT were more likely to have a primary medical qualification outside the UK. CONCLUSIONS: Performance was similar in AKT candidates disclosing dyslexia with other candidates once covariates associated with examination success were adjusted for. Candidates declaring dyslexia after initially failing the AKT were more likely to have a primary medical qualification outside the UK.

Consensus on innovations and future directions of community first responder schemes in United Kingdom: a national nominal group technique study.

AIM: We aimed to achieve consensus among NHS and community stakeholders to identify and prioritise innovations in Community First Responder (CFR) schemes. METHODS: We conducted a mixed-methods study, adopting a modified nominal group technique with participants from ambulance services, CFR schemes and community stakeholders. The 1-day consensus workshop consisted of four sessions: introduction of innovations derived from primary research; round-robin discussions to generate new ideas; discussion and ranking of innovations; feedback of ranking, re-ranking and concluding statements. Innovations were ranked on a 5-point Likert scale and descriptive statistics of median and interquartile range calculated. Discussions were recorded, transcribed, and analysed thematically. RESULTS: The innovations found were classified into two categories: process innovations and technological innovations. The process innovations included six types of innovations: roles, governance, training, policies and protocols, recruitment, and awareness. The technological innovations included three aspects: information and communication; transport; and health technology. The descriptive statistics revealed that innovations such as counselling and support for CFRs (median: 5 IQR 5,5), peer support [5 (4,5)], and enhanced communication with control room [5 (4,5)] were essential priorities. Contrastingly, innovations such as the provision of dual CFR crew [1.5 (1,3)], CFR responsibilities in patient transport to hospital [1 (1,2)], and CFR access to emergency blue light [1 (1,1.5)] were deemed non-priorities. CONCLUSIONS: This article established consensus on innovations in the CFR schemes and their ranking for improving the provision of care delivered by CFRs in communities. The consensus-building process also informed policy- and decision-makers on the potential future change agenda for CFR schemes.

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.

Dynamics of social influence on consumption choices: A social network representation.

In this work, through employing Friedkin Johnsen's model, we provide a valuable tool for understanding the complex dynamics of social influence and informational inducements in shaping consumption behaviour and highlight the need for governments, businesses, and individuals to address environmental concerns proactively. People mostly derive anticipation utility from consuming commodities through online shopping. Results suggest that in an information-loving society, people tend to follow the opinion of their groups, which can lead to inefficient choices. On the other hand, in a completely information-averse society, people tend to make inconsistent choices, leading to a lack of consensus. However, in a responsible society, individuals prioritise their own opinions and preferences while still taking into account the information and opinions of others. This results in a slow convergence of opinions, which can lead to responsible consumption and decision-making. People should be encouraged to form their own opinions based on their own experiences and preferences while still considering the information and opinions of others. It can lead to a more efficient and responsible society. Individuals with high self-confidence and self-control are more likely to resist peer pressure and make decisions that align with their values and goals. So, it is essential to consider the context and nature of the social influence when evaluating its impact on people's decision-making. Consumers are not the only players who can shape the world's future. Consumers, governments, corporations, and the media all have important roles to play, and their efforts must be coordinated and complementary to create a more sustainable future.

Improving early infant diagnosis for HIV-exposed infants using unmanned aerial vehicles for blood sample transportation in Conakry, Guinea: a comparative cost-effectiveness analysis.

BACKGROUND: Early infant diagnosis (EID) for HIV-exposed infants is essential due to high mortality during the first months of their lives. In Conakry (Guinea), timely EID is difficult as traffic congestion prevents the rapid transport of blood samples to the central laboratory. We investigated the cost-effectiveness of transporting EID blood samples by unmanned aerial vehicles (UAV), also known as drones. METHODS AND FINDINGS: Using Monte Carlo simulations, we conducted a cost-effectiveness comparative analysis between EID blood samples transportation by on-demand UAV transportation versus the baseline scenario (ie, van with irregular collection schedules) and compared with a hypothetic on-demand motorcycle transportation system. Incremental cost-effectiveness ratio (ICER) per life-year gained was computed. Simulation models included parameters such as consultation timing (eg, time of arrival), motorcycle and UAV characteristics, weather and traffic conditions. Over the 5-year period programme, the UAV and motorcycle strategies were able to save a cumulative additional 834.8 life-years (585.1-1084.5) and 794.7 life-years (550.3-1039.0), respectively, compared with the baseline scenario. The ICER per life-year gained found were US$535 for the UAV strategy versus baseline scenario, US$504 for the motorcycle strategy versus baseline scenario and US$1137 per additional life-year gained for the UAV versus motorcycle strategy. Respectively, those ICERs represented 44.8%, 42.2% and 95.2% of the national gross domestic product (GDP) per capita in Guinea-that is, US$1194. CONCLUSION: Compared with the baseline strategy, both transportation of EID blood samples by UAVs or motorcycles had a cost per additional life-year gained below half of the national GDP per capita and could be seen as cost-effective in Conakry. A UAV strategy can save more lives than a motorcycle one although the cost needed per additional life-year gained might need to consider alongside budget impact and feasibility considerations.

"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.

Ethnicity and risk for SARS-CoV-2 infection among the healthcare workforce: Results of a retrospective cohort study in rural United Kingdom.

BACKGROUND: The reason why Black and South Asian healthcare workers are at a higher risk for SARS-CoV-2 infection remain unclear. We aimed to quantify the risk for SARS-CoV-2 infection among healthcare staff who belong to the ethnic minority and elucidate pathways of infection. METHODS: A one-year follow-up retrospective cohort study has been conducted among National Health Service employees who were working at 123 facilities in Lincolnshire, UK. RESULTS: Overall, 13,366 professionals were included. SARS-CoV-2 incidence per person-year was 5.2% (95% CI: 3.6-7.6%) during the first COVID-19 wave (January-August 2020) and 17.2% (13.5-22.0%) during the second wave (September 2020-February 2021). Compared with White staff, Black and South Asian employees were at higher risk for SARS-CoV-2 infection during both the first wave (hazard ratio, HR 1.58 [0.91-2.75] and 1.69 [1.07-2.66], respectively) and the second wave (HR 2.09 [1.57-2.76] and 1.46 [1.24-1.71]). Higher risk for SARS-CoV-2 infection persisted even after controlling for age, sex, pay grade, residence environment, type of work, and time exposure at work. Higher adjusted risk for SARS-CoV-2 infection were also found among lower-paid health professionals. CONCLUSION: Black and South Asian health workers continue to be at higher risk for SARS-CoV-2 infection than their White counterparts. Urgent interventions are required to reduce SARS-CoV-2 infection in these ethnic groups.

Trends, variations and prediction of staff sickness absence rates among NHS ambulance services in England: a time series study.

OBJECTIVES: Our aim was to measure ambulance sickness absence rates over time, comparing ambulance services and investigate the predictability of rates for future forecasting. SETTING: All English ambulance services, UK. DESIGN: We used a time series design analysing published monthly National Health Service staff sickness rates by gender, age, job role and region, comparing the 10 regional ambulance services in England between 2009 and 2018. Autoregressive Integrated Moving Average (ARIMA) and Seasonal ARIMA (SARIMA) models were developed using Stata V.14.2 and trends displayed graphically. PARTICIPANTS: Individual participant data were not available. The total number of full-time equivalent (FTE) days lost due to sickness absence (including non-working days) and total number of days available for work for each staff group and level were available. In line with The Data Protection Act, if the organisation had less than 330 FTE days available during the study period it was censored for analysis. RESULTS: A total of 1117 months of sickness absence rate data for all English ambulance services were included in the analysis. We found considerable variation in annual sickness absence rates between ambulance services and over the 10-year duration of the study in England. Across all the ambulance services the median days available were 1 336 888 with IQR of 548 796 and 73 346 median days lost due to sickness absence, with IQR of 30 551 days. Among clinical staff sickness absence varied seasonally with peaks in winter and falls over summer. The winter increases in sickness absence were largely predictable using seasonally adjusted (SARIMA) time series models. CONCLUSION: Sickness rates for clinical staff were found to vary considerably over time and by ambulance trust. Statistical models had sufficient predictive capability to help forecast sickness absence, enabling services to plan human resources more effectively at times of increased demand.

A new generator for proposing flexible lifetime distributions and its properties.

In this paper, we develop a generator to propose new continuous lifetime distributions. Thanks to a simple transformation involving one additional parameter, every existing lifetime distribution can be rendered more flexible with our construction. We derive stochastic properties of our models, and explain how to estimate their parameters by means of maximum likelihood for complete and censored data, where we focus, in particular, on Type-II, Type-I and random censoring. A Monte Carlo simulation study reveals that the estimators are consistent. To emphasize the suitability of the proposed generator in practice, the two-parameter Fréchet distribution is taken as baseline distribution. Three real life applications are carried out to check the suitability of our new approach, and it is shown that our extension of the Fréchet distribution outperforms existing extensions available in the literature.

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% (5139/177,715) were classified as seizures by ambulance call handlers and 2.7% (4884/177,715) 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% (2894/4884) of patients were transported to hospital. 1/4884 (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.

Ethnicity and pre-hospital care for people with suspected cardiac pain: cross-sectional study.

OBJECTIVES: Few studies have investigated the quality of pre-hospital care by ethnicity. We aimed to investigate ethnic differences in pre-hospital ambulance care of patients with suspected cardiac pain. METHODS: We conducted a cross-sectional analysis of retrospective electronic clinical data for patients with suspected cardiac pain over one year (August 2011 to July 2012) extracted from a single regional ambulance service. This included patient demographic data, clinical measurements, drugs administered and outcomes, such as transportation to hospital or referral to primary care. We used multivariate regression to investigate differences in care by ethnicity comparing non-White with White patients. RESULTS: There were 7046 patients with suspected cardiac pain, with 4825 who had ethnicity recorded including 4661 (96.6%) White and 164 (3.4%) non-White. After correcting for age, sex, socio-economic status and whether transported to hospital, non-White patients were significantly more likely to have temperature [odds ratio (OR) 2.96, P = 0.007], blood glucose (OR 3.95, P = 0.003), respiratory rate (OR 4.94, P = 0.03) and oxygen saturation (OR 2.43, P = 0.006) recorded. Non-White patients were significantly less likely to be transported to hospital (OR 0.43, P = 0.03). CONCLUSION: There were significant differences in pre-hospital ambulance care for non-White compared with White patients with suspected cardiac pain. These differences could be due to differences in clinical condition or case-mix, language and cultural barriers, limited understanding of appropriate use of health care services, recording bias or true differences in provider management. Further analysis should involve larger and more complete data sets to explore ethnic differences in greater detail.