Electrification and specialist training associated with decreased neonatal mortality and increased admissions in Sierra Leone.

AIM: The aim of this study was to describe the evolution of a regional neonatal service in Sierra Leone and changes in mortality and service use as it transitioned from a non-specialist service to a dedicated special care baby unit (SCBU). METHODS: This was a retrospective observational study. Anonymised data were taken from the ward admissions books at Bo Government Hospital, and trends in admissions and mortality within the neonatal service were examined for each stage of the department's evolution. RESULTS: Four phases of the service's development were identified between November 2015 and October 2019. Records of 2377 admissions and 333 deaths were identified. The average number of admissions per month and deaths per month varied by service development phase. There was a trend towards reduced death rates and increased numbers of admissions as the unit evolved into a dedicated neonatal unit with a reliable electricity supply. CONCLUSIONS: The development of an adequately sized SCBU with a reliable electricity supply and specially trained staff was associated with a reduction in the death rate and an increase in admissions.

Bystander defibrillation for out-of-hospital cardiac arrest in Ireland.

Aims: To describe and explore predictors of bystander defibrillation in Ireland during the period 2012 to 2020. To examine the relationship between bystander defibrillation and health system developments. Methods: National level Out of Hospital Cardiac Arrest (OHCA) registry data were interrogated, focusing on patients who had defibrillation performed. Bystander defibrillation (as compared to EMS initiated defibrillation) was the key outcome of concern. Logistic regression models were built and refined by fitting predictors, performing stepwise variable selection and by adding pairwise interactions that improved fit. Results: The data included 5,751 cases of OHCA where defibrillation was performed. Increasing year over time (OR 1.17, 95% CI 1.13, 1.21) was associated with increased adjusted odds of bystander defibrillation. Non-cardiac aetiology was associated with reduced adjusted odds of bystander defibrillation (OR 0.30, 95% CI 0.21, 0.42), as were increasing age in years (OR 0.99, 95% CI 0.987, 0.996) and night-time occurrence of OHCA (OR 0.67, 95% CI 0.53, 0.83). Six further variables in the final model (sex, call response interval, incident location (home or other), who witnessed collapse (bystander or not witnessed), urban or rural location, and the COVID period) were involved in significant interactions. Bystander defibrillation was in general less likely in urban settings and at home locations. Whilst women were less likely to receive bystander defibrillation overall, in witnessed OHCAs, occurring outside the home, in urban areas and outside of the COVID-19 period women were more likely, to receive bystander defibrillation. Conclusions: Defibrillation by bystanders has increased incrementally over time in Ireland. Interventions to address sex and age-based disparities, alongside interventions to increase bystander defibrillation at night, in urban settings and at home locations are required.

Health systems developments and predictors of bystander CPR in Ireland.

Aims: To explore predictors of bystander CPR (i.e. any CPR performed prior to EMS arrival) in Ireland over the period 2012-2020. To examine the relationship between bystander CPR and key health system developments during this period. Methods: National level out-of-hospital cardiac arrest (OHCA) registry data relating to unwitnessed, and bystander witnessed OHCA were interrogated. Logistic regression models were built, then refined by fitting predictors, performing stepwise variable selection and by adding pairwise interactions that improved fit. Missing data sensitivity analyses were conducted using multiple imputation. Results: The data included 18,177 OHCA resuscitation attempts of whom 77% had bystander CPR. The final model included ten variables. Four variables (aetiology, incident location, time of day, and who witnessed collapse) were involved in interactions. The COVID-19 period was associated with reduced adjusted odds of bystander CPR (OR 0.77, 95% CI 0.65, 0.92), as were increasing age in years (OR 0.992, 95% CI 0.989, 0.994) and urban location (OR 0.52, 95% CI 0.47, 0.57). Increasing year over time (OR 1.23, 95% CI 1.16, 1.29), and an increased call response interval in minutes (OR 1.017, 95% CI 1.012, 1.022) were associated with increased adjusted odds of bystander CPR. Conclusions: Bystander CPR increased over the study period, and it is likely that health system developments contributed to the yearly increases observed. However, COVID-19 appeared to disrupt this positive trend. Urban OHCA location was associated with markedly decreased odds of bystander CPR compared to rural location. Given its importance bystander CPR in urban areas should be an immediate target for intervention.

Resuscitation for out-of-hospital cardiac arrest in Ireland 2012-2020: Modelling national temporal developments and survival predictors.

Aim: To explore potential predictors of national out-of-hospital cardiac arrest (OHCA) survival, including health system developments and the COVID pandemic in Ireland. Methods: National level OHCA registry data from 2012 through to 2020, relating to unwitnessed, and bystander witnessed OHCA were interrogated. Logistic regression models were built by including predictors through stepwise variable selection and enhancing the models by adding pairwise interactions that improved fit. Missing data sensitivity analyses were conducted using multiple imputation. Results: The data included 18,177 cases. The final model included seventeen variables. Of these nine variables were involved in pairwise interactions. The COVID-19 period was associated with reduced survival (OR 0.61, 95%CI 0.43, 0.87), as were increasing age in years (OR 0.96, 95% CI 0.96, 0.97) and call response interval in minutes (OR 0.97, 95% CI 0.96, 0.99). Amiodarone administration (OR 3.91, 95% CI 2.80, 5.48), urban location (OR 1.40, 95% CI 1.12, 1.77), and chronological year over time (OR 1.14, 95% CI 1.08, 1.20) were associated with increased survival. Conclusions: National survival from OHCA has significantly increased incrementally over time in Ireland. The COVID-19 pandemic was associated with decreased survival even after accounting for potential disruption to key elements of bystander and EMS care. Further research is needed to understand and address the discrepancy between urban and rural OHCA survival. Information concerning pre-event patient health status and inpatient care process may yield important additional insights in future.

Teamwork and its impact on chronic disease clinical outcomes in primary care: a systematic review and meta-analysis.

OBJECTIVE: Teamwork positively affects staff performance and patient outcomes in chronic disease management. However, there is limited research on the impact of specific team components on clinical outcomes. This review aims to explore the impact of teamwork components on key clinical outcomes of chronic diseases in primary care. STUDY DESIGN: Systematic review and meta-analysis. METHODS: This systematic review and meta-analysis conducted searching EMBASE, PubMed, Cochrane Central Register of Controlled Trials. Studies included must have at least one teamwork component, conducted in primary care for selected chronic diseases, and report an impact of teamwork on clinical outcomes. Mean differences and 95% confidence intervals were used to determine pooled effects of intervention. RESULTS: A total of 54 studies from 1988 to 2021 were reviewed. Shared decision-making, roles sharing, and leadership were missing in most studies. Team-based intervention showed a reduction in mean systolic blood pressure (MD = 5.88, 95% CI 3.29-8.46, P= <0.001, I2 = 95%), diastolic blood pressure (MD = 3.23, 95% CI 1.53 to 4.92, P = <0.001, I2 = 94%), and HbA1C (MD = 0.38, 95% CI 0.21 to 0.54, P = <0.001, I2 = 58%). More team components led to better SBP and DBP outcomes, while individual team components have no impact on HbA1C. Fewer studies limit analysis of cholesterol levels, hospitalizations, emergency visits and chronic obstructive pulmonary disease-related outcomes. CONCLUSION: Team-based interventions improve outcomes for chronic diseases, but more research is needed on managing cholesterol, hospitalizations, and chronic obstructive pulmonary disease. Studies with 4-5 team components were more effective in reducing systolic blood pressure and diastolic blood pressure. Heterogeneity should be considered, and additional research is needed to optimize interventions for specific patient populations.

Ukraine Trauma Project: the feasibility of introducing advanced trauma-care skills to frontline emergency medical services responders.

OBJECTIVES: To design, develop, deliver and assess a training initiative on haemorrhage control for emergency medical services (EMS) staff in Ukraine, in an active wartime setting. DESIGN: Using the Medical Research Council framework for complex interventions, a training programme was designed and developed in a collaboration between Irish and Ukrainian colleagues and delivered by experienced prehospital clinicians/educators. Feedback was gathered from participants. SETTING: The Russian invasion of Ukraine has caused large numbers of trauma patients with limited access to advanced prehospital emergency care. Ukrainian authorities requested support in delivering such care. PARTICIPANTS: Ukrainian EMS nominated clinical staff as trainees, in partnership with an educational institution in Kyiv. INTERVENTION: One day provider and train-the-trainer courses were developed and delivered, focused on early delivery of tranexamic acid (TXA), using intraosseous access (IO) in victims of wartime trauma. OUTCOME MEASURES: Safe organisation and delivery of courses, assessed knowledge and skills competence and self-reported satisfaction and pre/post confidence/competence. RESULTS: Two provider and one train-the-trainer courses and four equipment supply exercises were delivered for 89 EMS staff (doctors, nurses, paramedics); none had prior experience of IO or prehospital delivery of TXA. All participants were assessed as competent as providers and/or trainers. High levels of satisfaction and significantly improved self-assessed confidence and competence were reported. CONCLUSION: Rapid design and delivery of a training programme focused on an identified need for advanced care of trauma patients in a wartime setting has been possible. Training and immediate access to appropriate equipment was demonstrated. Evidence of frequency of use and safe, effective interventions has not been collected; such data are important for evaluation but difficult to collect in this setting. A high level of demand for this training now exists.

Outcomes of out-of-hospital cardiac arrest in Ireland 2012-2020: Protocol for an observational study.

Background: Out-of-hospital cardiac arrest (OHCA) is a leading cause of preventable mortality that now affects almost 3,000 people each year in Ireland. Survival is low at 6-7%, compared to a European average of 8%. The Irish Out-of-Hospital Cardiac Registry (OHCAR) prospectively gathers data on all OHCA in Ireland where emergency medical services attempted resuscitation.The Irish health system has undergone several developments that are relevant to OHCA care in the period 2012-2020. OHCAR data provides a means of exploring temporal trends in OHCA incidence, care, and outcomes over time. It also provides a means of exploring whether system developments were associated with a change in key outcomes.This research aims to summarise key trends in available OHCAR data from the period 2012 - 2020, to explore and model predictors of bystander CPR, bystander defibrillation, and survival, and to explore the hypothesis that significant system level temporal developments were associated with improvements in these outcomes. Methods: The following protocol sets out the relevant background and research approach for an observational study that will address the above aims. Key trends in available OHCAR data (2012 - 2020) will be described and evaluated using descriptive summaries and graphical displays. Multivariable logistic regression will be used to model predictors of 'bystander CPR', 'bystander defibrillation' and 'survival to hospital discharge' and to explore the effects (if any) of system level developments in 2015/2016 and the COVID-19 pandemic (2020) on these outcomes. Discussion: The findings of this research will be used to understand temporal trends in the care processes and outcomes for OHCA in Ireland over the period 2012-2020. The results can further be used to optimise future health system developments for OHCA in both Ireland and internationally.

Paramedic recognition of posterior circulation stroke: a vignette and focus group study.

Introduction: The main pre-hospital screening tool used for stroke in Ireland and the United Kingdom is the FAST (face, arms, speech, time) test. However, posterior circulation stroke (PCS) patients may be FAST negative on exam, presenting with sudden dizziness, headaches, visual problems, nausea and vomiting and balance/co-ordination problems. There is a lack of research into paramedic recognition of PCS, and this study sought to evaluate recognition rates among paramedics (Ps) and advanced paramedics (APs) in Ireland. Methods: A cross-sectional sequential exploratory design was chosen. An anonymous online survey was carried out, which informed focus group discussions. The survey contained six clinical vignettes, two of which were PCS presentations. Correct diagnosis, hospital destination and type of pre-alert were recorded. Focus groups were chaired by an independent moderator via Zoom. Recordings were transcribed and thematic analysis was carried out to create codes and themes. Results: One hundred and fifty-one staff members (91 Ps, 60 APs) completed the survey (response rate 40%). Of these, 67% did not recognise PCS symptoms and 77% did not choose to transport to a stroke unit. For those correctly suspecting PCS, 42% requested resus at the stroke unit and 18% requested resus in the local emergency department (ED). Two focus groups of four practitioners (n = 8) took place. Three main themes were created: (1) comfort levels with posterior stroke, with subthemes of recognition and personal experiences; (2) education, with subthemes of clinical practice guideline (CPG) issues and training issues; and (3) hospital factors, with subthemes of pre-alerting and disconnect between hospital and emergency medical services. Participants were uncomfortable with PCS recognition and bypassing their local ED. More training was called for, with a dedicated CPG. Relationships with hospital staff affected willingness to pre-alert. Conclusions: In this sample group, recognition of PCS and onward transfer to a stroke unit was low. Focus groups showed that practitioners were uncomfortable recognising PCS and bypassing a local ED without adequate training and a dedicated CPG. Relationships with hospital staff also affected pre-alert decisions.

Factors that affect GP referral of a child with intellectual disability for a mild illness: A discrete choice experiment.

BACKGROUND: General practitioners (GP) report multiple challenges when treating individuals with intellectual disabilities which may influence referral rates. The study aimed to establish factors that influence GP's decision-making when referring a child with intellectual disabilities to the emergency department. METHOD: Discrete choice experiments (DCEs) are increasingly used in health research to further understand complex decision making. A DCE was designed to assess the relative importance of factors that may influence a GP's (N = 157) decision to refer. RESULTS: A random parameters model indicated that perceived limited parental capacity to manage an illness was the most important factor in the decision to refer a child to the ED, followed by a repeat visit, a referral request from the parent, and a Friday afternoon appointment. CONCLUSION: Understanding the factors that influence referral is important for service improvement and to strengthen primary care provision for this population and their families.

Hepatitis C Infection and Treatment among Injecting Drug Users Attending General Practice: A Systematic Review and Meta-Analysis.

BACKGROUND: The care provided in general practice to intravenous drug users (IDUs) with hepatitis C (HCV) extends beyond opioid substitution therapy. An aggregated analysis of HCV service utilization within general practice specifically related to diagnosis and treatment outcomes remains unknown from previous literature. AIMS: This study aims to estimate the prevalence of HCV and analyze data related to the diagnosis and treatment-related outcomes of HCV patients with a history of intravenous drug use in the general practice setting. DESIGN AND SETTING: A systematic review and meta-analysis in general practice. METHODS: This review included studies published in the following databases: EMBASE, PubMed, and Cochrane Central Register of Controlled Trials. Two reviewers independently extracted data in standard forms in Covidence. A meta-analysis was done using a DerSimonian and Laird random-effects model with inverse variance weighting. RESULTS: A total of 20,956 patients from 440 general practices participated in the 18 selected studies. A meta-analysis of 15 studies showed a 46% (95% confidence interval (CI), 26-67%) prevalence rate of hepatitis C amongst IDUs. Genotype information was available in four studies and treatment-related outcomes in 11 studies. Overall, treatment uptake was 9%, with a cure rate of 64% (95% CI, 43-83%). However, relevant information, such as specific treatment regimens, treatment duration and doses, and patient comorbidities, was poorly documented in these studies. CONCLUSION: The prevalence of HCV in IDUs is 46% in general practice. Only ten studies reported HCV-related treatment outcomes; however, the overall uptake rate was below 10%, with a cure rate of 64%. Likewise, the genotypic variants of HCV diagnoses, medication types, and doses were poorly reported, suggesting a need for further research into this aspect of care within this patient group to ensure optimal treatment outcomes.

The role of contextual factors in decision-making by General Practitioners on paediatric referral to the Emergency Department in Ireland: A Discrete Choice Experiment.

A General Practitioner's (GP) decision to refer a patient to the emergency department (ED) requires consideration of a multitude of factors, and significant variation in GP referral patterns to secondary care has been recorded. This study examines the contextual factors that influence GPs when referring a paediatric patient with potentially self-limiting clinical symptoms to the ED. Utilizing a discrete choice experiment, survey data was collected from GPs in Ireland (n = 142) to elicit factors influencing this decision across five attributes: time/day of visit, repeat presentation, parents' capacity to cope, parent requesting a referral, and access to a paediatric outpatient clinic/day unit. Using mixed logit models, all attributes were statistically significant, with repeat presentation and parents lacking the capacity to cope identified as the strongest contextual factors leading to the decision to refer to the ED. There has been limited exploration of this decision-making process and this study uses a robust design to identify and rank contextual attributes. Enhanced awareness of contextual factors on referral decision-making is crucial to understanding patterns of paediatric unscheduled healthcare and to planning services that respond to parent's and children's needs, whilst allowing GPs to make decisions in the best interest of the child.

Impact of malnutrition management e-learning module on GPs' knowledge: a pilot study.

BACKGROUND: Malnutrition is underdiagnosed in primary care. GPs are key healthcare contacts for older adults at risk of protein-energy malnutrition; however, lack of knowledge and confidence in its diagnosis and treatment is often reported. AIM: To evaluate the impact of a bespoke online education module on GP malnutrition knowledge and management. DESIGN & SETTING: A prospective pre-post pilot study with 23 GPs and eight GP trainees in the Republic of Ireland. METHOD: The module included units on the following: 'malnutrition definition, prevalence, and latest evidence'; 'identifying malnutrition in clinical practice'; 'food-first advice'; 'reviewing malnutrition'; and 'oral nutritional supplements'. Participant knowledge was measured using a multiple choice questionnaire (MCQ) before and after the module (n = 31), and 6 weeks following completion (n = 11). Case studies assessing identification and management of malnutrition were evaluated by a clinical specialist dietitian with expertise in managing malnutrition. Changes in assessment performance were calculated using paired t-tests. Acceptability was evaluated using a questionnaire. RESULTS: Post-training, 97% of GPs increased MCQ scores from baseline (+25%, P<0.001), with the greatest improvement in 'identifying malnutrition in clinical practice' (mean increase 47%, P<0.001). Eleven GPs completed the 6-week MCQ with scores remaining significantly higher than baseline (mean increase 15%, P = 0.005); 'identifying malnutrition in clinical practice' remained the most highly scored (mean increase 40%, P<0.001). Seventeen GPs completed the case studies; 76% at baseline and 88% post-module correctly calculated malnutrition risk scores. Appropriate malnutrition management improved for 47% of GPs after module completion. CONCLUSION: This e-learning module improved malnutrition knowledge, with good short-term retention in a small cohort. Development of online evidence-based nutrition education may improve GP nutrition care.

Reflections on recruiting healthcare professionals as research participants: Learning from the ONSPres Study.

The involvement of healthcare professionals (HCPs) as research participants is essential to generate high quality evidence for enhancing health services and practice.  Research teams face many challenges in recruiting HCPs for research, and barriers and enablers for interdisciplinary research are not well described in the literature.  The Oral Nutritional Supplement Prescribing Malnutrition Research Study (ONSPres Study) examined malnutrition identification, management, and appropriate oral nutritional supplement prescribing in primary care in Ireland.  The ONSPres Study offers a unique view of recruiting HCPs for research because a range of disciplines were sought for participation in a mixed methods study.  The purpose of this open letter is to describe the experiences of recruitment and participation.  Sixteen general practitioners (GPs) were recruited to participate in one-to-one interviews, eighty health and social care professionals working in community care (including nurses, pharmacists, dietitians, physiotherapists, speech and language therapists, and occupational therapists) were recruited to take part in 12 focus groups, and 31 GPs and trainee GPs were recruited to participate in an education programme developed by the study team.   Strategies required to gain access and reach HCPs differed between disciplines.   Professional networks enhanced access to HCPs working in practice and recruitment was slower and more tailored when those networks were less available to the team.  An interest in malnutrition, to assist in research, to advance patient care, and the opportunity for learning were incentives for the participating HCPs.  Limitations in the diversity of the sample arose, with a bias towards female participants and GPs motivated by an interest in the topic.  It is recommended that study teams collaborate early with relevant HCP disciplines so they can contribute to recruitment planning at project concept and design stages.  To enhance and incentivise HCP participation in research, dedicated time and acknowledgement of participation as continuous professional development is proposed.

National Chronic Disease Management Programmes in Irish General Practice-Preparedness and Challenges.

Information on the readiness of Irish general practice to participate in structured chronic disease management (CDM) care is limited. This study explores the logistic, staffing, and organizational preparedness of Irish general practice to do so, stratified by their size, location, and training status; implementation challenges were also explored. An anonymous, paper-based random survey was performed. A chi-square test was applied to compare practices by location (urban/rural), post-graduate training status (with/without), and numbers of GMS patient (≥1500/>1500 patients) and prevalence ratio and Poisson regression analysis to examine the relationship of staffing with key variables. Overall, 125/243 practices participated, 22% were rural, 56.6% were post-graduate training practices, and 53.9% had ≥1500 GMS patients. The rural, non-training practices and those with <1500 GMS patients had substantially lower staffing levels. The average number of GPs was significantly less in rural practices; however, the difference was insignificant for nurses. Salary costs for practice nurses in all practices and staff IT training and clinical equipment in smaller practices were important barriers. Most practices reported 'inadequate' waiting times for access to almost all referral and paramedical services. The study recommends addressing the staffing, funding, and training challenges within Irish general practice to effectively implement a structured CDM program.

Policy of free GP care for children under 6 years: The impact on daytime and out-of-hours general practice.

Ireland does not yet have a comprehensive system of universal access to primary care. In 2015, access to general practitioner (GP) care at no charge was introduced for the 70% of children aged under six who previously paid out-of-pocket fees. This study uses data from 16 practices and a regional out-of-hours (OOH) GP service to assess the impact of this policy on attendance. A difference-in-difference (DiD) analysis was applied to visit records of paediatric patients over a period of five years, two years of which were pre-policy, with treatment and control differentiated by age. Attendance at daytime GP by children aged under-six increased by 20%-21% in the three years following the introduction of the policy, largely explained by an increase in the number of patients attending (17.4%-18.6%). Of children aged under-six attending pre-policy, 14.9%-15.8% had >6 visits annually, increasing to 18.5%-20.3% post-policy. OOH GP attendance also increased by 20.5%-29.4% over the same period. Findings are consistent with international literature on the provision of financially accessible healthcare. Prior unmet need, the provision of additional assessments to children aged under six, parental response to a service at no charge, and rerouting of access to the ED through GP, are all possible contributors to this increased demand. A more integrated policy of boosting supply as well as demand is desirable, particularly in the context of future expansion plans, to ensure the health benefits anticipated from the introduction of this policy have every opportunity to be realised.

Disparities in Oral Nutritional Supplement Usage and Dispensing Patterns across Primary Care in Ireland: ONSPres Project.

When treating malnutrition, oral nutritional supplements (ONSs) are advised when optimising the diet is insufficient; however, ONS usage and user characteristics have not been previously analysed. A retrospective secondary analysis was performed on dispensed pharmacy claim data for 14,282 anonymised adult patients in primary care in Ireland in 2018. Patient sex, age, residential status, ONS volume (units) and ONS cost (EUR) were analysed. The categories of 'Moderate' (<75th centile), 'High' (75th-89th centile) and 'Very High' ONS users (≥90th centile) were created. The analyses among groups utilised t-tests, Mann-Whitney U tests and chi-squared tests. This cohort was 58.2% female, median age was 76 years, with 18.7% in residential care. The most frequently dispensed ONS type was very-high-energy sip feeds (45% of cohort). Younger males were dispensed more ONSs than females (<65 years: median units, 136 vs. 90; p < 0.01). Patients living independently were dispensed half the volume of those in residential care (112 vs. 240 units; p < 0.01). 'Moderate' ONS users were dispensed a yearly median of 84 ONS units (median cost, EUR 153), 'High' users were dispensed 420 units (EUR 806) and 'Very High' users 892 yearly units (EUR 2402; p < 0.01). Further analyses should focus on elucidating the reasons for high ONS usage in residential care patients and younger males.

Is it feasible to learn research skills in addition to audit skills through clinical audit? A mixed methods study in general practice.

BACKGROUND: Involving medical students in research in their undergraduate careers may increase the likelihood that they will be research active after graduation. To date, there has been a paucity of published research of students doing research in general practice. AIM: The study aims to evaluate the impact of general practice clinical audits on early-stage graduate entry students' audit and research self-efficacy and explore feasibility issues from the student and GP perspective. METHODS: Two student questionnaires (pre- and post-intervention), a qualitative GP survey of the 25 participating GPs and semi-structured interviews of a purposeful sample of GPs were conducted. RESULTS: Participating students who completed the follow-up survey found that it had a positive educational impact (55%), increased their understanding of the audit cycle (72%) and real-world prescribing (77%). Research confidence wise, there was a statistically significant difference in the student group who completed the audit project compared to those students who did not in knowledge of the audit cycle and the difference between research and audit (p = 0.001) but not in other research skills. Ninety-six percent of responding GPs would be happy for students to do future audits in their practice but some feasibility issues similar to other research initiatives in general practice were identified. CONCLUSION: We found this audit initiative feasible and useful in helping students learn about audit skills, patient safety and real-world prescribing. GPs and students would benefit more if it were linked to a substantial clinical placement, focussed on a topic of interest and given protected time. Separate research projects may be needed to develop research skills confidence.

Pitch-side Acute Severe Pain Management Decisions in European Elite Football.

This is the first study on acute severe pain management involving sport and exercise medicine Doctors who are leaders in football medicine in their respective countries. An online survey was designed describing the management of acute severe pain in this expert cohort. The survey captured participant sex, age, years working in sports medicine, core specialty and use of clinical practice guidelines (CPGs). Finally, three clinical vignettes exploring the management of acute pain were presented. Forty-four senior team doctors across 55 European countries completed the survey. There were no consistent guidelines proposed, with 33 (75%) participants indicating they did not use any. Methoxyflurane was proposed by 14 (32%) and 13 (30%) participants for female anterior cruciate ligament rupture and male ankle fracture, respectively. Strong opioids were not used in 17 (39%) and 6 (14%) participants regarding female cruciate injuries and male fractures, respectively. Despite 75% of participants having paediatric life support training, eight (18%) participants expressed uncertainty administering medications in this population, and 15 (34%) would avoid using strong opioids altogether. There is a tendency to undertreat pain and avoid strong opioids for reasons including lack of monitoring equipment, anti-doping concerns and lack of comfort treating paediatric patients with opioids.