Sore throat, fever, and pancytopenia during winter.

Care must be taken to mitigate the effect of cognitive bias in times of frequent common presentations. The etiology of bicytopenias and pancytopenias must always be carefully investigated. Blast cells in low count B ALL may not be seen on a peripheral smear and diagnosis often requires confirmational bone marrow aspirate with flow cytometry and molecular typing.

The COVID-19 ambulance response assessment (CARA) study: a national survey of ambulance service healthcare professionals' preparedness and response to the COVID-19 pandemic.

Background: The COVID-19 pandemic placed significant demand on the NHS, including ambulance services, but it is unclear how this affected ambulance service staff and paramedics in other clinical settings (e.g. urgent and primary care, armed services, prisons). This study aimed to measure the self-perceived preparedness and impact of the first wave of the pandemic on paramedics' psychological stress and perceived ability to deliver care. Methods: Ambulance clinicians and paramedics working in other healthcare settings were invited to participate in a three-phase sequential online survey during the acceleration (April 2020), peak (May 2020) and deceleration (September/October 2020) phases of the first wave of COVID-19 in the United Kingdom. Recruitment used social media, Trust internal bulletins and the College of Paramedics' communication channels, employing a convenience sampling strategy. Data were collected using purposively developed open- and closed-ended questions and the validated general health questionnaire-12 (GHQ-12). Data were analysed using multi-level linear and logistic regression models. Results: Phase 1 recruited 3717 participants, reducing to 2709 (73%) by phase 2 and 2159 (58%) by phase 3. Participants were mostly male (58%, n = 2148) and registered paramedics (n = 1992, 54%). Mean (standard deviation) GHQ-12 scores were 16.5 (5.2) during phase 1, reducing to 15.2 (6.7) by phase 3. A total of 84% of participants (n = 3112) had a GHQ-12 score ≥ 12 during the first phase, indicating psychological distress. Participants that had higher GHQ-12 scores were feeling unprepared for the pandemic, and reported a lack of confidence in using personal protective equipment and managing cardiac arrests in confirmed or suspected COVID-19 patients. Conclusions: Most participants reported psychological distress, the reasons for which are multi-factorial. Ambulance managers need to be aware of the risks to staff mental health and take action to mitigate these, to support staff in the delivery of unscheduled, emergency and urgent care under these additional pressures.

How consistent are pre-alert guidelines? A review of UK ambulance service guidelines.

Aims: Ambulance pre-alerts are used to inform receiving emergency departments (EDs) of the arrival of critically unwell or rapidly deteriorating patients who need time-critical assessment or treatment immediately upon arrival. Inappropriate use of pre-alerts can lead to EDs diverting resources from other critically ill patients. However, there is limited guidance about how pre-alerts should be undertaken, delivered or communicated. We aimed to map existing pre-alert guidance from UK NHS ambulance services to explore consistency and accessibility of existing guidance. Methods: We contacted all UK ambulance services to request documentation containing guidance about pre-alerts. We reviewed and mapped all guidance to understand which conditions were recommended for a pre-alert and alignment with Association of Ambulance Chief Executives (AACE) and Royal College of Emergency Medicine (RCEM) pre-alert guidance. We reviewed the language and accessibility of guidance using the AGREE II tool. Results: We received responses from 15/19 UK ambulance services and 10 stated that they had specific pre-alert guidance. We identified noticeable variations in conditions declared suitable for pre-alerts in each service, with a lack of consistency within each ambulance service's own guidance, and a lack of alignment with the AACE/RCEM pre-alert guidance. Services listed between four and 45 different conditions suitable for pre-alert. There were differences in physiological thresholds and terminology, even for conditions with established care pathways (e.g. hyperacute stroke, ST segment elevation myocardial infarction). Pre-alert criteria were typically listed in several short sections in lengthy handover procedure policy documents. Documents appraised were of poor quality with low scores below 35% for applicability and overall. Implications: There is a clear need for ambulance services to have both policies and tools that complement each other and incorporate the same list of pre-alertable conditions. Clinicians need a single, easily accessible document to refer to in a time-critical situation to reduce the risk of making an incorrect pre-alert decision.

'Knowledge exchange' workshops to optimise development of a risk prediction tool to assist conveyance decisions for suspected seizures - Part of the Risk of ADverse Outcomes after a Suspected Seizure (RADOSS) project.

PURPOSE: Suspected seizures present challenges for ambulance services, with paramedics reporting uncertainty over whether or not to convey individuals to emergency departments. The Risk of ADverse Outcomes after a Suspected Seizure (RADOSS) project aims to address this by developing a risk assessment tool utilizing structured patient care record and dispatch data. It proposes a tool that would provide estimates of an individual's likelihood of death and/or recontact with emergency care within 3 days if conveyed compared to not conveyed, and the likelihood of an 'avoidable attendance' occurring if conveyed. Knowledge Exchange workshops engaged stakeholders to resolve key design uncertainties before model derivation. METHOD: Six workshops involved 26 service users and their significant others (epilepsy or nonepileptic attack disorder), and 25 urgent and emergency care clinicians from different English ambulance regions. Utilizing Nominal Group Techniques, participants shared views of the proposed tool, benefits and concerns, suggested predictors, critiqued outcome measures, and expressed functionality preferences. Data were analysed using Hamilton's Rapid Analysis. RESULTS: Stakeholders supported tool development, proposing 10 structured variables for predictive testing. Emphasis was placed on the tool supporting, not dictating, care decisions. Participants highlighted some reasons why RADOSS might struggle to derive a predictive model based on structured data alone and suggested some non-structured variables for future testing. Feedback on prediction timeframes for service recontact was received, along with advice on amending the 'avoidable attendance' definition to prevent the tool's predictions being undermined by potential overuse of certain investigations in hospital. CONCLUSION: Collaborative stakeholder engagement provided crucial insights that can guide RADOSS to develop a user-aligned, optimized tool.

Delivery of public health interventions by the ambulance sector: a scoping review.

BACKGROUND: With millions of unscheduled patient contacts every year and increasing call outs clustered around the most deprived communities, it is clear the ambulance sector could have a role to play in improving population health. However, the application and value of a public health approach within the ambulance sector has not been comprehensively explored. A scoping review was undertaken to explore the role of the ambulance sector in the delivery of public health interventions and what impact this has on population health and ambulance sector outcomes. METHODS: A search strategy was developed on MEDLINE and translated to other major medical and health related bibliographic databases (Embase; CINAHL; HMIC; Science and Social Sciences Citation Index; Cochrane Library) to identify literature published since 2000 in OECD countries. Targeted grey literature, reference list, and citation searching was also carried out. Search results were downloaded to Microsoft Excel and screened by three reviewers according to pre-determined inclusion / exclusion criteria. Data from included studies, such as the type of activity noted within the paper, the population involved and the public health approach that was utilised, was extracted from within the paper using a data extraction form and narratively synthesised. RESULTS: Fifty-two references were included in the final review (37 database searching; 9 reference list searching; 6 grey literature). Included articles were categorised according to the relevant public health domains and subdomains as articulated by the UK Faculty of Public Health: 1. Health improvement domain: Public health education and advice (Health promotion sub-domain) (n=13) Emergency Services personnel providing vaccines (Disease prevention sub-domain) (n=1) 2. Health care public health domain Paramedicine (Service delivery sub-domain) (n=30) Screening tools and referral pathways used by the ambulance sector (Service delivery sub-domain) (n=28) Health intelligence using ambulance sector data (population health management sub-domain) (n=26) Of note, some domains (e.g. health protection) returned nil results. DISCUSSION: The scoping review demonstrates the breadth of public health related activities in which the ambulance sector is involved. However, an overemphasis on demand management outcomes precludes definitive conclusions on the impact of ambulance sector-led public health initiatives on public health outcomes. Future evaluations of public health initiatives should incorporate wider health system perspectives beyond the immediately apparent remit of the ambulance sector.

Venous blood point-of-care testing (POCT) for paramedics in urgent and emergency care: protocol for a single-site feasibility study (POCTPara).

The COVID-19 pandemic placed the UK healthcare system under unprecedented pressure, and recovery will require whole-system investment in innovative, flexible and pragmatic solutions. Positioned at the heart of the healthcare system, ambulance services have been tasked with addressing avoidable hospital conveyance and reducing unnecessary emergency department and hospital attendances through the delivery of care closer to home. Having begun to implement models of care intended to increase 'see and treat' opportunities through greater numbers of senior clinical decision makers, emphasis has now been placed upon the use of remote clinical diagnostic tools and near-patient or point-of-care testing (POCT) to aid clinical decision making. In terms of POCT of blood samples obtained from patients in the pre-hospital setting, there is a paucity of evidence beyond its utility for measuring lactate and troponin in acute presentations such as sepsis, trauma and myocardial infarction, although potential exists for the analysis of a much wider panel of analytes beyond these isolated biomarkers. In addition, there is a relative dearth of evidence in respect of the practicalities of using POCT analysers in the pre-hospital setting. This single-site feasibility study aims to understand whether it is practical to use POCT for the analysis of patients' blood samples in the urgent and emergency care pre-hospital setting, through descriptive data of POCT application and through qualitative focus group interviews of advanced practitioners (specialist paramedics) to inform the feasibility and design of a larger study. The primary outcome measure is focus group data measuring the experiences and perceived self-reported impact by specialist paramedics. Secondary outcome measures are number and type of cartridges used, number of successful and unsuccessful attempts in using the POCT analyser, length of time on scene, specialist paramedic recruitment and retention, number of patients who receive POCT, descriptive data of safe conveyance, patient demographics and presentations where POCT is applied and data quality. The study results will inform the design of a main trial if indicated.

Stakeholder perspectives of piloting pre-hospital COVID-19 lateral flow testing and direct admissions pathway: exploring why well-received ideas have low uptake.

Introduction: In January 2021, Yorkshire Ambulance Service and Hull University Teaching Hospitals implemented a pilot COVID-19 lateral flow testing (LFT) and direct admissions pathway to assess the feasibility of using pre-hospital LFTs to bypass the emergency department. Due to lower than anticipated uptake of the pilot among paramedics, we undertook a process evaluation to assess reasons for low uptake and perceived potential benefits and risks associated with the pilot. Methods: We undertook semi-structured telephone interviews with 12 paramedics and hospital staff. We aimed to interview paramedics who had taken part in the pilot, those who had received the project information but not taken part and ward staff receiving patients from the pilot. We transcribed interviews verbatim and analysed data using thematic analysis. Results: Participation in the pilot appeared to be positively influenced by high personal capacity for undertaking research (being 'research-keen') and negatively influenced by 'COVID-19 exhaustion', electronic information overload and lack of time for training. Barriers to use of the pathway related to 'poor timing' of the pilot, restrictive patient eligibility and inclusion criteria. The rapid rollout meant that paramedics had limited knowledge or awareness of the pilot, and pilot participants reported poor understanding of the pilot criteria or the rationale for the criteria. Participants who were involved in the pilot were overwhelmingly positive about the intervention, which they perceived as having limited risks and high potential benefits to the health service, patients and themselves, and supported future roll-out. Conclusions: Ambulance clinician involvement in rapid research pilots may be improved by using multiple recruitment methods (electronic and other), providing protected time for training and increased direct support for paramedics with lower personal capacity for research. Improved communication (including face-to-face approaches) may help understanding of eligibility criteria and increase appropriate recruitment.

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.

Accuracy of emergency medical service telephone triage of need for an ambulance response in suspected COVID-19: an observational cohort study.

OBJECTIVE: To assess accuracy of emergency medical service (EMS) telephone triage in identifying patients who need an EMS response and identify factors which affect triage accuracy. DESIGN: Observational cohort study. SETTING: Emergency telephone triage provided by Yorkshire Ambulance Service (YAS) National Health Service (NHS) Trust. PARTICIPANTS: 12 653 adults who contacted EMS telephone triage services provided by YAS between 2 April 2020 and 29 June 2020 assessed by COVID-19 telephone triage pathways were included. OUTCOME: Accuracy of call handler decision to dispatch an ambulance was assessed in terms of death or need for organ support at 30 days from first contact with the telephone triage service. RESULTS: Callers contacting EMS dispatch services had an 11.1% (1405/12 653) risk of death or needing organ support. In total, 2000/12 653 (16%) of callers did not receive an emergency response and they had a 70/2000 (3.5%) risk of death or organ support. Ambulances were dispatched to 4230 callers (33.4%) who were not conveyed to hospital and did not deteriorate. Multivariable modelling found variables of older age (1 year increase, OR: 1.05, 95% CI: 1.04 to 1.05) and presence of pre-existing respiratory disease (OR: 1.35, 95% CI: 1.13 to 1.60) to be predictors of false positive triage. CONCLUSION: Telephone triage can reduce ambulance responses but, with low specificity. A small but significant proportion of patients who do not receive an initial emergency response deteriorated. Research to improve accuracy of EMS telephone triage is needed and, due to limitations of routinely collected data, this is likely to require prospective data collection.

Accuracy of telephone triage for predicting adverse outcomes in suspected COVID-19: an observational cohort study.

OBJECTIVE: To assess accuracy of telephone triage in identifying need for emergency care among those with suspected COVID-19 infection and identify factors which affect triage accuracy. DESIGN: Observational cohort study. SETTING: Community telephone triage provided in the UK by Yorkshire Ambulance Service NHS Trust (YAS). PARTICIPANTS: 40 261 adults who contacted National Health Service (NHS) 111 telephone triage services provided by YAS between 18 March 2020 and 29 June 2020 with symptoms indicating COVID-19 infection were linked to Office for National Statistics death registrations and healthcare data collected by NHS Digital. OUTCOME: Accuracy of triage disposition was assessed in terms of death or need for organ support up to 30 days from first contact. RESULTS: Callers had a 3% (1200/40 261) risk of serious adverse outcomes (death or organ support). Telephone triage recommended self-care or non-urgent assessment for 60% (24 335/40 261), with a 1.3% (310/24 335) risk of adverse outcomes. Telephone triage had 74.2% sensitivity (95% CI: 71.6 to 76.6%) and 61.5% specificity (95% CI: 61% to 62%) for the primary outcome. Multivariable analysis suggested respiratory comorbidities may be overappreciated, and diabetes underappreciated as predictors of deterioration. Repeat contact with triage service appears to be an important under-recognised predictor of deterioration with 2 contacts (OR 1.77, 95% CI: 1.14 to 2.75) and 3 or more contacts (OR 4.02, 95% CI: 1.68 to 9.65) associated with false negative triage. CONCLUSION: Patients advised to self-care or receive non-urgent clinical assessment had a small but non-negligible risk of serious clinical deterioration. Repeat contact with telephone services needs recognition as an important predictor of subsequent adverse outcomes.

Prognostic accuracy of triage tools for adults with suspected COVID-19 in a prehospital setting: an observational cohort study.

BACKGROUND: Tools proposed to triage patient acuity in COVID-19 infection have only been validated in hospital populations. We estimated the accuracy of five risk-stratification tools recommended to predict severe illness and compared accuracy to existing clinical decision making in a prehospital setting. METHODS: An observational cohort study using linked ambulance service data for patients attended by Emergency Medical Service (EMS) crews in the Yorkshire and Humber region of England between 26 March 2020 and 25 June 2020 was conducted to assess performance of the Pandemic Respiratory Infection Emergency System Triage (PRIEST) tool, National Early Warning Score (NEWS2), WHO algorithm, CRB-65 and Pandemic Medical Early Warning Score (PMEWS) in patients with suspected COVID-19 infection. The primary outcome was death or need for organ support. RESULTS: Of the 7549 patients in our cohort, 17.6% (95% CI 16.8% to 18.5%) experienced the primary outcome. The NEWS2 (National Early Warning Score, version 2), PMEWS, PRIEST tool and WHO algorithm identified patients at risk of adverse outcomes with a high sensitivity (>0.95) and specificity ranging from 0.3 (NEWS2) to 0.41 (PRIEST tool). The high sensitivity of NEWS2 and PMEWS was achieved by using lower thresholds than previously recommended. On index assessment, 65% of patients were transported to hospital and EMS decision to transfer patients achieved a sensitivity of 0.84 (95% CI 0.83 to 0.85) and specificity of 0.39 (95% CI 0.39 to 0.40). CONCLUSION: Use of NEWS2, PMEWS, PRIEST tool and WHO algorithm could improve sensitivity of EMS triage of patients with suspected COVID-19 infection. Use of the PRIEST tool would improve sensitivity of triage without increasing the number of patients conveyed to hospital.

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.

The acceptability and safety of video triage for ambulance service patients and clinicians during the COVID-19 pandemic.

INTRODUCTION: In response to anticipated challenges with urgent and emergency healthcare delivery during the early part of the COVID-19 pandemic, Yorkshire Ambulance Service NHS Trust introduced video technology to supplement remote triage and 'hear and treat' consultations as a pilot project in the EOC. We conducted a service evaluation with the aim of investigating patient and staff acceptability of video triage, and the safety of the decision-making process. METHODS: This service evaluation utilised a mixture of routine and bespoke data collection. We sent postal surveys to patients who were recipients of a video triage, and clinicians who were involved in the video triage pilot logged calls they attempted and undertook. RESULTS: Between 27 March and 25 August 2020, clinicians documented 1073 triage calls. A successful video triage call was achieved in 641 (59.7%) cases. Clinical staff reported that video triage improved clinical assessment and decision making compared to telephone alone, and found the technology accessible for patients. Patients who received a video triage call and responded to the survey (40/201, 19.9%) were also satisfied with the technology and with the care they received. Callers receiving video triage that ended with a disposition of 'hear and treat' had a lower rate of re-contacting the service within 24 hours compared to callers that received clinical hub telephone triage alone (16/212, 7.5% vs. 2508/14349, 17.5% respectively). CONCLUSION: In this single NHS Ambulance Trust evaluation, the use of video triage for low-acuity calls appeared to be safe, with low rates of re-contact and high levels of patient and clinician satisfaction compared to standard telephone triage. However, video triage is not always appropriate for or acceptable to patients and technical issues were not uncommon.

Call volume, triage outcomes, and protocols during the first wave of the COVID-19 pandemic in the United Kingdom: Results of a national survey.

OBJECTIVES: During the first wave of the COVID-19 pandemic in the United Kingdom (UK), to describe volume and pattern of calls to emergency ambulance services, proportion of calls where an ambulance was dispatched, proportion conveyed to hospital, and features of triage used. METHODS: Semistructured electronic survey of all UK ambulance services (n = 13) and a request for routine service data on weekly call volumes for 22 weeks (February 1-July 3, 2020). Questionnaires and data request were emailed to chief executives and research leads followed by email and telephone reminders. The routine data were analyzed using descriptive statistics, and questionnaire data using thematic analysis. RESULTS: Completed questionnaires were received from 12 services. Call volume varied widely between services, with a UK peak at week 7 at 13.1% above baseline (service range -0.5% to +31.4%). All services ended the study period with a lower call volume than at baseline (service range -3.7% to -25.5%). Suspected COVID-19 calls across the UK totaled 604,146 (13.5% of all calls), with wide variation between services (service range 3.7% to 25.7%), and in service peaks of 11.4% to 44.5%. Ambulances were dispatched to 478,638 (79.2%) of these calls (service range 59.0% to 100.0%), with 262,547 (43.5%) resulting in conveyance to hospital (service range 32.0% to 53.9%). Triage models varied between services and over time. Two primary call triage systems were in use across the UK. There were a large number of products and arrangements used for secondary triage, with services using paramedics, nurses, and doctors to support decision making in the call center and on scene. Frequent changes to triage processes took place. CONCLUSIONS: Call volumes were highly variable. Case mix and workload changed significantly as COVID-19 calls displaced other calls. Triage models and prehospital outcomes varied between services. We urgently need to understand safety and effectiveness of triage models to inform care during further waves and pandemics.

Cost comparison of different models of palliative care delivery.

OBJECTIVE: The aim of this project was to assess the value for money of a modified unit within a residential aged care facility (RACF) for people requiring palliative care at the end of life. METHODS: A three-way comparison using a mixed-method costing was used to estimate the per day cost of the unit compared to care in a palliative care unit within a hospital and a standard RACF bed. RESULTS: The cost of the unit was estimated at $242 per day (2015 Australian dollars). The palliative care hospital bed cost $1,664 per day. The cost of a standard RACF bed was $123 per day, indicating that an additional $120 per day is required to provide the higher level of care required by people with complex palliative care needs. CONCLUSION: A modified RACF unit could provide substantial cost savings to the health budget for selected complex palliative care patients.

Protocol for Take-home naloxone In Multicentre Emergency (TIME) settings: feasibility study.

BACKGROUND: Opioids, such as heroin, kill more people worldwide by overdose than any other type of drug, and death rates associated with opioid poisoning in the UK are at record levels (World Drug Report 2018 [Internet]. [cited 2019 Nov 19]. Available from: http://www.unodc.org/wdr2018/; Deaths related to drug poisoning in England and Wales - Office for National Statistics [Internet]. [cited 2019 Nov 19]. Available from: https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/deathsrelatedtodrugpoisoninginenglandandwales/2018registrations). Naloxone is an opioid antagonist which can be distributed in 'kits' for administration by witnesses in an overdose emergency. This intervention is known as take-home naloxone (THN). We know that THN can save lives on an individual level, but there is currently limited evidence about the effectiveness of THN distribution on an aggregate level, in specialist drug service settings or in emergency service settings. Notably, we do not know whether THN kits reduce deaths from opioid overdose in at-risk populations, if there are unforeseen harms associated with THN distribution or if THN is cost-effective. In order to address this research gap, we aim to determine the feasibility of a fully powered cluster randomised controlled trial (RCT) of THN distribution in emergency settings. METHODS: We will carry out a feasibility study for a RCT of THN distributed in emergency settings at four sites, clustered by Emergency Department (ED) and catchment area within its associated ambulance service. THN is a peer-administered intervention. At two intervention sites, emergency ambulance paramedics and ED clinical staff will distribute THN to adult patients who are at risk of opioid overdose. At two control sites, practice will carry on as usual. We will develop a method of identifying a population to include in an evaluation, comprising people at risk of fatal opioid overdose, who may potentially receive naloxone included in a THN kit.We will gather anonymised outcomes up to 1 year following a 12-month 'live' trial period for patients at risk of death from opioid poisoning. We expect approximately 100 patients at risk of opioid overdose to be in contact with each service during the 1-year recruitment period. Our outcomes will include deaths, emergency admissions, intensive care admissions, and ED attendances. We will collect numbers of eligible patients attended by participating in emergency ambulance paramedics and attending ED, THN kits issued, and NHS resource usage. We will determine whether to progress to a fully powered trial based on pre-specified progression criteria: sign-up of sites (n = 4), staff trained (≥ 50%), eligible participants identified (≥ 50%), THN provided to eligible participants (≥ 50%), people at risk of death from opioid overdose identified for inclusion in follow-up (≥ 75% of overdose deaths), outcomes retrieved for high-risk individuals (≥ 75%), and adverse event rate (< 10% difference between study arms). DISCUSSION: This feasibility study is the first randomised, methodologically robust investigation of THN distribution in emergency settings. The study addresses an evidence gap related to the effectiveness of THN distribution in emergency settings. As this study is being carried out in emergency settings, obtaining informed consent on behalf of participants is not feasible. We therefore employ novel methods for identifying participants and capturing follow-up data, with effectiveness dependent on the quality of the available routine data. TRIAL REGISTRATION: ISRCTN13232859 (Registered 16/02/2018).

Suicide among ambulance service staff: a review of coroner and employment records.

BACKGROUND: There is growing evidence to suggest that ambulance service staff may be at increased risk for suicide; however, few studies have explored risk factors within this occupational group. AIM: To investigate factors commonly associated with ambulance staff suicides. METHOD: Eleven ambulance service trusts across the United Kingdom were asked to return details of staff suicides occurring between January 2014 and December 2015. Coroners were then contacted to request permission to review the records of the deceased. RESULTS: Fifteen suicides were identified (73% male, mean age 42 years). Inquest data were available on 12 deaths. The most common method used was hanging. Possible risk factors identified included recent return to work following a period of sickness absence, poor mental health, relationship and debt problems, history of self-harm and the loss of a driving licence/change in job role. CONCLUSION: Identifying characteristics of suicide among this high-risk group is important to inform the development of suicide prevention initiatives. Additional research is needed with an adequate control group to further explore the risk factors identified in this study.

A service evaluation of paediatric pain management in an English ambulance service.

INTRODUCTION: Evidence from the past 20 years has highlighted that acute pain is not managed well in the emergency setting, in particular with children. Inadequate management of pain can result in long-term changes in both physical and mental health. This service evaluation aimed to determine how paediatric pain is assessed and managed by ambulance clinicians in a large region in England. METHODS: This retrospective service evaluation analysed electronic patient record (ePR) data routinely collected between September and December 2018. All paediatric patients (< 18 years of age) with pain documented narratively, or a pain score of ≥ 1/10, were included. The primary outcome measure was the proportion of patients with severe pain (defined as a pain score of ≥ 7/10) who achieve effective pain management (reduction in pain score of ≥ 2/10). RESULTS: A total of 2801 paediatric patients who had documented pain were included in the analysis and the median age of patients was three years (interquartile range, 1-12 years). Most had a medical cause of pain (2387/2801, 85.2%), and analgesia was administered by the ambulance crew in 403/2801 (14.4%) patients. Multiple pain scores were recorded for 667 patients. Effective pain management was achieved in 233/271 (86%) patients in moderate pain and 204/210 (97.1%) patients in severe pain. However, of the 437 children in moderate to severe pain who achieved effective pain management, 381 (87%) received no analgesia. CONCLUSION: Children in severe pain received effective pain management, despite the majority not receiving any analgesia. This should be investigated further since non-pharmacological methods of analgesia are unlikely to explain a reduction of this magnitude. Ambulance staff need to be encouraged to record a pain score promptly after arriving on scene and ensure it is repeated. Pain score should be documented as part of the physiological observations and not in the free text of ePRs to ensure that it is identified during audits.