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.

General practice and cardiac arrest community first response in Ireland.

BACKGROUND: In Ireland, the MERIT 3 scheme enables doctors to volunteer as cardiac arrest community first responders and receive text message alerts from emergency medical services (EMS) to facilitate early care. AIM: To establish the sustainability, systems and clinical outcomes of a novel, general practice based, cardiac arrest first response initiative over a four-year period. METHODS: Data on alerts, responses, incidents and outcomes were gathered prospectively using EMS control data, incident data reported by responders and corroborative data from the national Out-of-Hospital Cardiac Arrest Registry. RESULTS: Over the period 2016-2019, 196 doctors joined MERIT 3 and 163 (83.2%) were alerted on one or more occasions; 61.3% of those alerted responded to at least one alert. Volunteer doctors attended 300 patients of which 184 (61.3%) had suffered OHCA and had a resuscitation attempt. Responders arrived to OHCA before EMS on 75 occasions (40.8%), initiated chest compressions on seven occasions (3.8%), and brought the first defibrillator on 42 occasions (22.8%). Information on the first monitored rhythm was available for 149/184 (81.0%) patients and was shockable in 30/149 (20.1%); in 9/30 cases, shocks were administered by responders. The overall survival rate was 11.0% (national survival rate 7.3%). Doctors also provided advanced life support and were closely involved in decision making on ceasing resuscitation. CONCLUSION: The MERIT 3 initiative in Ireland has been sustained over a four-year period and has demonstrated the ability of volunteer doctors to provide early care for OHCA patients as well as more complex interventions including end-of-life care. Further development of this strategy is warranted.

COVID-19 community assessment hubs in Ireland-the experience of clinicians.

BACKGROUND: COVID-19 required rapid innovation in health systems, in the context of an infection which placed healthcare professionals at high risk; general practice has been a key component of that innovative response. In Ireland, GPs were asked to work in a network of community assessment hubs. A focused training programme in infection control procedures/clinical use of personal protective equipment (PPE) was rapidly developed in advance. University departments of general practice were asked to develop and deliver that training. AIM: The aim of this article is to describe infection control procedure training in Ireland, the uptake by GPs and the initial experience of GPs working in this unusual environment. DESIGN AND SETTING: Two anonymous cross-sectional online surveys are sent to participants in training courses. METHOD: Survey 1 followed completion of training; survey 2 followed establishment of the hubs. RESULTS: Six hundred seventy-five participants (including 439 GPs, 156 GP registrars) took part in the training. Two hundred thirty-nine (50.3%) out of four hundred seventy-five responded to Survey 1-over 95% reported an increase in confidence in the use of PPE. Two hundred ten (44.2%) out of four hundred seventy-five participants responded to Survey 2; 195 had completed hub shifts. Younger, female GPs predominated. Very high levels of infection control procedures were reported. Participants commented positively on teamworking, environment and systems. However, 'real-time' ambulance service data suggest the peak of the surge may have passed by the time the hubs were established. CONCLUSION: Academic departments, GPs and the Irish health system collaborated effectively to respond to the need for community assessment of COVID-19 patients.

General practice nursing: the views and experience of practice nurses and GPs in one county.

BACKGROUND: Slaintecare, the Irish government's plan for the coming decade, relies heavily on integrated, team-based care in the community to achieve its goals. General practice nursing is a key component of that care, both now and in the future, but little is known about the experience and views of those providing this service. This preliminary study is part of a wider national project on teamworking in primary care. AIM: To document the experiences and views of practice nurses (PNs) and general practices in a single county of Ireland, in relation to current and future roles. METHOD: Confidential questionnaires sent to all practices and all practice nurses in the county. RESULTS: Overall, 28/35 (80%) practices and 36/59 (61%) PNs responded; most PNs work part-time. Almost all practices have PNs; in 93% of practices, patients can see the PN without referral by the GP and there is very good concordance between practices and PNs about the wide range of tasks undertaken. Ninety-four percent of practices and 81% of PNs rated an expanded role for PNs as high or highest priority; barriers identified by both groups were financial and indemnity issues. CONCLUSION: Practice nursing contributes extensively to general practice, and an expansion of the role is advocated by PNs and practices.

Ireland's Assisted Decision Making Capacity Act-the potential for unintended effects in critical emergencies: a cross-sectional study of Advanced Paramedic decision making.

OBJECTIVE: Irish legislation on Advance Healthcare Directives (Assisted Decision Making Capacity Act 2015, ADMC) proposes to change the basis of decision making from acting in the patient's best interests to following the expressed will and intentions of the patient. Refusal of life-saving care can occur, without sound reasons. The implications for care in life-threatening emergencies have not been explored among clinicians. DESIGN: An anonymous questionnaire survey of Advanced Paramedics (AP) covering awareness of the legislation, attitudes to and experience of refusal of care and potential actions in emergency scenarios now and if the legislation were in force. The scenarios covered end-of-life and deliberate self-harm situations potentially requiring resuscitation. SETTING: All 482 graduates of the Advanced Paramedic Training Programme were invited to take part. RESULTS: Overall, 85/389 (21.9%) valid contacts responded, with demographic characteristics similar to the overall population. Attitudes ranged from highly positive to highly negative in relation to the potential impact of the legislation on professional and operational responsibilities. Respondents described marked changes in whether they would offer resuscitation if the ADMC were in place. CONCLUSION: Irish legislation which changes the traditional basis of medical practice away from the best interests of the patient may affect the resuscitation practices of Advanced Paramedics in life-threatening situations. It has significant implications for medical education, professional practice and clinician-patient interactions. This legislation and similar planned legislation may have implications for other EU jurisdictions.

Ten years of cardiac arrest resuscitation in Irish general practice.

AIM: The aim of this study is to establish the role and outcome of general practitioner (GP) involvement in out of hospital cardiac arrest (OHCA) resuscitation in the Republic of Ireland. METHODS: A ten year prospective observational study involving a cohort of Irish general practices. SETTING: 521 general practice settings distributed throughout the Republic of Ireland, representing approximately one quarter of all practices and a third of Irish GPs. PARTICIPANTS: 534 patients suffering cardiac arrest in the community for whom resuscitation was attempted. INTERVENTIONS: Cardiac arrest with resuscitation attempted (CARA) in which a GP played a role. RESULTS: Over a ten year period almost half of participating practices reported one or more CARAs. A total of 534 CARAs were reported at a variety of locations; 161 (30%) had ROSC (return of spontaneous circulation) at some point, with outcome data available for 147/161; 90 patients survived to hospital discharge. Most survivors for whom follow up data are available were discharged home and were completely independent. The highest rate of survival was achieved when CARAs occurred at a GP practice premises (47.4%). CONCLUSIONS: Resuscitation following OHCA is a key task in general practice. Over time a significant number of GPs encounter OHCA, attempt resuscitation and achieve higher survival to hospital discharge rates than occur nationally among OHCAs in Ireland. We conclude that a defibrillator should be routinely available at all general practices and staff should have appropriate resuscitation skills.

Opiate addiction and overdose: experiences, attitudes, and appetite for community naloxone provision.

BACKGROUND: More than 200 opiate overdose deaths occur annually in Ireland. Overdose prevention and management, including naloxone prescription, should be a priority for healthcare services. Naloxone is an effective overdose treatment and is now being considered for wider lay use. AIM: To establish GPs' views and experiences of opiate addiction, overdose care, and naloxone provision. DESIGN AND SETTING: An anonymous postal survey to GPs affiliated with the Department of Academic General Practice, University College Dublin, Ireland. METHOD: A total of 714 GPs were invited to complete an anonymous postal survey. Results were compared with a parallel GP trainee survey. RESULTS: A total of 448/714 (62.7%) GPs responded. Approximately one-third of GPs were based in urban, rural, and mixed areas. Over 75% of GPs who responded had patients who used illicit opiates, and 25% prescribed methadone. Two-thirds of GPs were in favour of increased naloxone availability in the community; almost one-third would take part in such a scheme. A higher proportion of GP trainees had used naloxone to treat opiate overdose than qualified GPs. In addition, a higher proportion of GP trainees were willing to be involved in naloxone distribution than qualified GPs. Intranasal naloxone was much preferred to single (P<0.001) or multiple dose (P<0.001) intramuscular naloxone. Few GPs objected to wider naloxone availability, with 66.1% (n = 292) being in favour. CONCLUSION: GPs report extensive contact with people who have opiate use disorders but provide limited opiate agonist treatment. They support wider availability of naloxone and would participate in its expansion. Development and evaluation of an implementation strategy to support GP-based distribution is urgently needed.

Development and process evaluation of an educational intervention for overdose prevention and naloxone distribution by general practice trainees.

BACKGROUND: Overdose is the most common cause of fatalities among opioid users. Naloxone is a life-saving medication for reversing opioid overdose. In Ireland, it is currently available to ambulance and emergency care services, but General Practitioners (GP) are in regular contact with opioid users and their families. This positions them to provide naloxone themselves or to instruct patients how to use it. The new Clinical Practice Guidelines of the Pre-hospital Emergency Care Council of Ireland allows trained bystanders to administer intranasal naloxone. We describe the development and process evaluation of an educational intervention, designed to help GP trainees identify and manage opioid overdose with intranasal naloxone. METHODS: Participants (N = 23) from one postgraduate training scheme in Ireland participated in a one-hour training session. The repeated-measures design, using the validated Opioid Overdose Knowledge (OOKS) and Attitudes (OOAS) Scales, examined changes immediately after training. Acceptability and satisfaction with training were measured with a self-administered questionnaire. RESULTS: Knowledge of the risks of overdose and appropriate actions to be taken increased significantly post-training [OOKS mean difference, 3.52 (standard deviation 4.45); P < 0.001]; attitudes improved too [OOAS mean difference, 11.13 (SD 6.38); P < 0.001]. The most and least useful delivery methods were simulation and video, respectively. CONCLUSION: Appropriate training is a key requirement for the distribution of naloxone through general practice. In future studies, the knowledge from this pilot will be used to inform a train-the-trainer model, whereby healthcare professionals and other front-line service providers will be trained to instruct opioid users and their families in overdose prevention and naloxone use.

Screening for atrial fibrillation in general practice: a national, cross-sectional study of an innovative technology.

BACKGROUND: To test the use of three lead monitoring as a screening tool for atrial fibrillation (AF) in general practice. AF is responsible for up to a quarter of all strokes and is often asymptomatic until a stroke occurs. METHODS: 26 randomly selected general practices identified 80 randomly selected patients aged 70 or older from their database and excluded those known to have AF, those with clinical issues or who had not attended for three years. Up to 40 eligible patients/practice were invited to attend for screening. A 2min three-lead ECG was recorded and collected centrally for expert cardiology assessment. Risk factor data was gathered. OUTCOMES: (i) point prevalence of AF, (ii) proportion of ECG tracings which were adequate for interpretation, (iii) uptake rate by patients and (iv) acceptability of the screening process to patients and staff (reported separately). RESULTS: Of 1447 current patients, 1003 were eligible for inclusion, 639 (64%) agreed to take part in screening and 566 (56%) completed screening. The point prevalence rate for AF was 10.3%-2.1% new cases (12 of 566 who were screened) and 9.5% existing cases (137 of 1447 eligible patients). Only four of 570 (0.7%) screening visits did not record a usable ECG and 11 (2.6%) three lead ECGs required a clarifying 12 lead ECG. CONCLUSIONS: Three lead screening for AF is feasible, effective and offers an alternative to pulse taking or 12 lead ECGs. The availability of this technology may facilitate more effective screening, leading to reduced stroke incidence.

Urban overdose hotspots: a 12-month prospective study in Dublin ambulance services.

BACKGROUND: Opioid overdose (OD) is the primary cause of death among drug users globally. Personal and social determinants of overdose have been studied before, but the environmental factors lacked research attention. Area deprivation or presence of addiction clinics may contribute to overdose. OBJECTIVES: The objective of the study is to examine the baseline incidence of all new ODs in an ambulance service and their relationship with urban deprivation and presence of addiction services. METHODS: A prospective chart review of prehospital advanced life support patients was performed on confirmed OD calls. Demographic, geographic, and clinical information, that is, presentation, treatment, and outcomes, was collected for each call. The census data were used to calculate deprivation. Geographical information software mapped the urban deprivation and addiction services against the overdose locations. RESULTS: There were 469 overdoses, 13 of which were fatal; most were male (80%), of a young age (32 years), with a high rate of repeated overdoses (26%) and common polydrug use (9.6%). Most occurred in daytime (275) and on the streets (212). Overdoses were more likely in more affluent areas (r = .15; P < .05) and in a 1000-m radius of addiction services. Residential overdoses were in more deprived areas than street overdoses (mean difference, 7.8; t170 = 3.99; P < .001). Street overdoses were more common in the city center than suburbs (χ(2)(1) = 33.04; P < .001). CONCLUSIONS: The identified clusters of increased incidence-urban overdose hotspots-suggest a link between environment characteristics and overdoses. This highlights a need to establish overdose education and naloxone distribution in the overdose hotspots.

Cardiac arrest in Irish general practice: an observational study from 426 general practices.

SETTING: Sudden Cardiac Death accounts for approximately 5000 deaths in Ireland each year. Nationally, out-of-hospital cardiac arrest has a very low resuscitation rate, reported at less than 5%. Ireland has a well developed general practice network which routinely manages emergencies arising in the community setting. However, little is known about its potential impact on Sudden Cardiac Death. This study reports on the incidence and management of cardiac arrest in Irish general practice. METHOD: A national training/equipment project in defibrillation in general practice (MERIT) has established a network to prospectively report all cardiac arrests with a resuscitation attempt in general practice. Three monthly surveys of the network record events; structured debriefing uses a modified Utstein template to detail events and their outcomes. RESULTS: 426 practices reported data during a 36-month period (85-97% response rate to surveys), reporting 144 events, of which data are available on 136 events. 88.4% of events were witnessed, 31.6% by general practice staff. 58.2% of events occurred in the general practice or in the patient's home. The general practitioner (GP) was on scene before the ambulance in 72.6% of cases and 52.3% of the patients involved were patients of the GP attending. 52.3% of patients were defibrillated, 32.6% had return of spontaneous circulation at some point and 26 patients (19.5%) were discharged from hospital. CONCLUSIONS: Cardiac arrest in general practice is compatible with structured, effective interventions and significant rates of successful resuscitation. All general practices should be capable of providing this care.