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BackgroundHandover of care is one of the most perilous procedures in medicine.1The unique shift-based work in the ED, where there is a high degree of patient turnover, unpredictability and patient volume can create challenges to good quality clinician and nursing handover.The above highlights a need for an improved and standardised patient bedside handover tool for both clinicians and nurses involving and empowering patients and families. Both handover tools will cement safe continuity of information between shift changes and improved communication with patients and families.Method and resultsA standard operating procedure, flowchart and clinician’s handover tool was designed to maximise safe handover as illustrated in figure 1. The tool has been introduced into the department since June 2017. After the introduction of the tool, an evaluation survey of 30 participants across various grades of clinicians was performed.Abstract 001 Figure 1Clinicians handover toolBuilding on the success of the clinician’s handover tool; a standard operating procedure, flowchart and the first standardised nurse’s handover tool was designed as illustrated in figure 2.Abstract 001 Figure 2Nurses handover toolConclusionsFor the month of September 2017, 30 completed surveys evaluating the clinician’s handover tool was collected. 100% positive responses were received stating they found it useful. The handing over clinicians commented feeling more satisfied that ‘their patient was appropriately and safely handed over at the bed side in front of the family’.The nurse’s handover over tool was praised as nurses felt ‘happier’ with handover and more satisfied to leave shift ‘without forgetting significant patient information’.Both tools have become routine practice within the ED and are very useful adjuncts to improve patient safety within the department.Multidisciplinary handover post-shift work at the bedside has become standardised practice and improved patient safety with continuity of care with these tools. Regular ongoing audit have demonstrated that the tools are routinely used by both clinicians and nurses.ReferenceBritish Medical Association. Safe handover: safe patients. Guidance on clinical handover for clinicans and managers. London: BMA, 2004.

ObjectiveTo explore how and why self-monitoring of blood glucose (SMBG) is carried out in a real-world context.Research design and methodsWe conducted a multicase study among ten people with type 1 and insulin-treated type 2 diabetes mellitus in Scotland, alongside seven nominated support people and four healthcare professionals. All participants were interviewed in depth and six participants provided SMBG diaries. Stones’ version of structuration theory informed the analysis.ResultsPeople with diabetes were able to provide immediate motives for SMBG at particular times, often having different motives on different occasions. We identified six such motives, including routine, in response to symptoms, associated with a diabetes review, to facilitate lifestyle, when a ‘good’ result was expected, and higher level motives for longer term glycemic control. These motives were influenced by underlying attitudes toward diabetes that included level of engagement and responsibility for diabetes, a desire not to be controlled by diabetes, resistance to diabetes, diabetes education and relationship with the health service, fear of hypoglycemia, and prevention of diabetes complications. Five responses to test results were identified, depending on the immediate motive and underlying attitudes.ConclusionsPeople with insulin-treated diabetes do not necessarily self-monitor with an explicit goal of improving long-term glycemic control, but may have other motives that are important to them. An individualized understanding is therefore needed to advise people with diabetes how SMBG can be optimized for them.

Objectives: (1) To compare the experiences of people who are affected by diabetes-related hypoglycaemia and either do or do not require an emergency attendance and (2) to measure the prevalence of impaired awareness of hypoglycaemia in patients who are attended by an ambulance service due to a severe hypoglycaemic event.\ud \ud Design: A sequential mixed-methods study.\ud \ud Setting: A qualitative interview study was undertaken with 31 people with diabetes (types 1 and 2) resident in the central belt of Scotland. A national prevalence survey of 590 Scottish Ambulance Service patients who had recently experienced a severe hypoglycaemic emergency requiring ambulance clinicians attendance. Impaired awareness of hypoglycaemia was measured using two standardised measures.\ud \ud Results: Considerable differences in impaired awareness of hypoglycaemia were found in the experiences of participants who did or did not require the ambulance service to treat their severe hypoglycaemic events. Those who required an ambulance reported fewer warning signs and symptoms. The prevalence of impaired awareness of hypoglycaemia in ambulance service call-outs as assessed by two standardised measures was 53% and 60%, respectively.\ud \ud Conclusions: The prevalence of impaired awareness of hypoglycaemia among those who require an ambulance following a hypoglycaemic event is more than twice that found in the general population of people with diabetes. This may be because the experiences of impaired awareness in people who require an ambulance following a severe hypoglycaemic event differ to those who do not. This study provides important information to guide future prehospital clinical practice, and to develop and evaluate theoretically informed interventions. Improvements in prehospital care for this patient population could lead to global improvements in health outcomes and decreased service costs.

Background Effective management of people who present to ambulance services with a psychiatric or self-harm emergency is essential to ensure positive outcomes. However very little is known about this vulnerable patient population. Therefore, this study aimed to investigate their demographic characteristics, care pathways, and clinical and service outcomes. This information will be valuable for service planning and intervention development. Methods We conducted a retrospective cohort study of patients attended by the Scottish Ambulance Service in 2011 with ambulance clinician attendance codes relating to ‘psychiatric emergency’ or ‘self-harm’. Patients resident in Scotland and>=16 years on first contact were included. We used NHS Scotland’s Unscheduled Care Data Mart to link data from:–the ambulance service; emergency departments (ED); general and psychiatric inpatient hospital admissions episodes; and death records. Results There were 9014 calls from 6802 people. Slightly more males (n=4708, 52%) than females (n=4306, 48%) were attended. Most were discharged from ED with no known follow-up (n=4566; 51%). Some were left at home (n=1003 attendances, 11%). Almost half of the people (n=3238, 48%) made at least one repeat call. People who self-discharge from ED were more likely to have another ambulance attendance for psychiatric emergency/self-harm within the same year (Pearson chi square=5.24, p=0.02). Two hundred and seventy-nine (4%) people died within the study period, 97 (35%) were recorded as suicide. Ethical approval (NRES 15/EM/0260) and other data approvals were received. Conclusion While linked data analysis may not identify all relevant cases, it provides important information to guide the development and evaluation of evidence-based interventions. Ambulance service and ED are missing opportunities to improve outcomes for people who experience a psychiatric emergency or who self-harm. New interventions could lead to decreases in the number of suicides, episodes of self-harm and levels of patient distress; and ambulance and ED service use.

Background Severe hypoglycaemia is a serious condition and accounts for 0.6%–1.0% of all UK emergency ambulance calls per annum. Our previous qualitative research suggested that many Diabetes related hypoglycaemia patients attended by the ambulance service experienced impaired awareness of hypoglycaemia (IAH), a treatable condition which reduces patients’ awareness of the signs and symptoms of an impending severe hypoglycaemic emergency. The prevalence of IAH among people with type 1 Diabetes is approximately 25%. In type 2 its prevalence is approximately 10%. However the prevalence of IAH in people who use the ambulance service due to a hypoglycaemic emergency was unknown. Our aim therefore was to investigate the prevalence of IAH in patients who require ambulance service attendance due to severe hypoglycaemia. Methods We undertook a national cross-sectional survey of the prevalence of IAH. An a priori target sample size of 415 was set to allow estimation of proportions of IAH within a 5% margin of error (99% CI). From January–June 2016, patients (>16 years) attended by the Scottish Ambulance Service due a Diabetes related emergency with a blood glucose Results Five hundred and ninety-two questionnaires were returned. The prevalence of impaired awareness of hypoglycaemia in among participants as measured using the two standardised measures was 53% and 57% respectively. Conclusion IAH is considerably more prevalent among people who have a severe hypoglycaemic emergency and call the ambulance service than in the general Diabetic population. This knowledge will assist in the development of an intervention to reduce hypoglycaemic emergencies and may lead to improved outcomes and cost savings.

Objectives: To investigate patterns of self monitoring of blood glucose concentration in diabetic patients who use insulin and to determine whether frequency of self monitoring is related to glycaemic control. Setting: Diabetes database, Tayside, Scotland. Subjects: Patients resident in Tayside in 1993-5 who were using insulin and were registered on the database and diagnosed with insulin dependent (type 1) or non-insulin dependent (type 2) diabetes before 1993. Main outcome measures: Number of glucose monitoring reagent strips dispensed (reagent strip uptake) derived from records of prescriptions. First recorded haemoglobin A1c concentration in the study period, and reagent strips dispensed in the previous 6 months. Results: Among 807 patients with type 1 diabetes, 128 (16%) did not redeem any prescriptions for glucose monitoring reagent strips in the 3 year study period. Only 161 (20%) redeemed prescriptions for enough reagent strips to test glucose daily. The corresponding figures for the 790 patients with type 2 diabetes who used insulin were 162 (21%; no strips) and 131 (17%; daily tests). Reagent strip uptake was influenced both by age and by deprivation category. There was a direct relation between uptake and glycaemic control for 258 patients (with recorded haemoglobin A1c concentrations) with type 1 diabetes. In a linear regression model the decrease in haemoglobin A1c concentration for every extra 180 reagent strips dispensed was 0.7%. For the 290 patients with type 2 diabetes who used insulin there was no such relation. Conclusions: Self monitoring of blood glucose concentration is associated with improved glycaemic control in patients with type 1 diabetes. Regular self monitoring in patients with type 1 and type 2 diabetes is uncommon. Key messages Several studies have indicated the importance of self monitoring of blood glucose concentration for prevention of complications in patients with diabetes Uptake of reagent strips for self monitoring of blood glucose among diabetic patients who used insulin was low, with only 20% of patients with type 1 diabetes and 17% of those with type 2 diabetes obtaining enough strips to test blood glucose concentration once daily Reagent strip uptake depends on characteristics such as age and social deprivation category, and patient groups with low uptake should be identified and targeted There was a direct association between strip uptake in the previous 6 months and glycaemic control in patients with type 1 diabetes but not in those with type 2 diabetes

Objective: Mortality among adults of all ages diagnosed with impaired glucose regulation (IGR) in Tayside, Scotland, UK, was evaluated using routinely collected healthcare data sets. Research design and methods: Using recordlinked data in 2003–2008, all instances of blood glucose testing in the population defined 2 cohorts of patients aged 18+years: those with IGR (whether impaired fasting glucose or impaired glucose tolerance (IGT)) according to the WHO criteria, and those who were normoglycemic. They were followed in survival analyses for mortality or cardiovascular mortality (censoring deaths that occurred within a 30-day period of testing), to derive HRs (with 95% CI) for IGR status using Cox regression, adjusted for age, sex, and an area measure of deprivation. Results: There were 2 372 712 tests for 214 094 patients, with 196 799 patients in the non-IGR cohort and 50 080 in the IGR cohort. During follow-up, 19 147 (9.7%) and 8397 (16.8%) patients died in 2 cohorts, respectively, with mortality rates of 33.2/1000 patient-years and 70.7/1000 patient-years. In multivariable analyses, the overall adjusted risk of mortality for IGR was 1.16 (95% CI 1.13 to 1.20). However, it was 2.59 (95% CI 2.17 to 3.10) for people aged

Problem Antibiotic administration to inpatients developing sepsis in general hospital wards was frequently delayed. We aimed to reproduce improvements in sepsis management reported in other settings. Context Ninewells Hospital, an 860-bed teaching hospital with quality improvement (QI) experience, in Scotland, UK. The intervention wards were 22 medical, surgical and orthopaedic inpatient wards. Design A multifaceted intervention, informed by baseline process data and questionnaires and interviews with junior doctors, evaluated using segmented regression analysis of interrupted time series (ITS) data. Measures for improvement Primary outcome measure: antibiotic administration within 4 hours of sepsis onset. Secondary measures: antibiotics within 8 hours; mean and median time to antibiotics; medical review within 30 min for patients with a standardised early warning system score ≥4; blood cultures taken before antibiotic administration; blood lactate level measured. Strategies for change The intervention included printed and electronic clinical guidance, educational clinical team meetings including baseline performance data, audit and monthly feedback on performance. Effects of change Performance against all study outcome measures improved postintervention but differences were small and ITS analysis did not attribute the observed changes to the intervention. Lessons learnt Rigorous analysis of this carefully designed improvement intervention could not confirm significant effects. Statistical analysis of many such studies is inadequate, and there is insufficient reporting of negative studies. In light of recent evidence, involving senior clinical team members in verbal feedback and action planning may have made the intervention more effective. Our focus on rigorous intervention design and evaluation was at the expense of iterative refinement, which likely reduced the effect. This highlights the necessary, but challenging, requirement to invest in all three components for effective QI.

Many health promotion programmes for physical activity are targeted during childhood and adolescence, as these life stages are seen to be important for the development of health behaviours. The underlying assumption is that physical activity will become habitual or “track” (ie will be a stable aspect of behaviour between different ages). Given the considerable variation between studies in the extent to which physical activity demonstrates tracking, this systematic review examined studies that provided data on the tracking of physical …

To compare risks of cardiovascular outcomes between patients with type 2 diabetes and patients with established coronary heart disease.Cross sectional study and cohort study using routinely collected datasets.Tayside, Scotland (population 400 000) during 1988-95.In the cross sectional study, among patients aged 45-64, 1155 with type 2 diabetes were compared with 1347 who had had a myocardial infarction in the preceding 8 years. In the cohort study 3477 patients of all ages with newly diagnosed type 2 diabetes were compared with 7414 patients who had just had a myocardial infarction.Risk ratios for death from all causes, cardiovascular death, and hospital admission for myocardial infarction were calculated by Cox proportional hazards analysis and adjusted for age and sex.In the cross sectional study the adjusted risk ratio for death from all causes for patients who had myocardial infarction compared with those with diabetes was 1.33 (95% confidence interval 1.14 to 1.55) [corrected], and the risk ratio for hospital admission for myocardial infarction was 2.27 (1.82 to 2.83) [corrected]. In the cohort study, patients who had just had a myocardial infarction had a higher risk of death from all causes (adjusted risk ratio 1.35 (1.25 to 1.44)), cardiovascular death (2.93 (2.54 to 3.41)), and hospital admission for myocardial infarction (3.10 (2.57 to 3.73)).Patients with type 2 diabetes were at lower risk of cardiovascular outcomes than patients with established coronary heart disease.