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BackgroundTRIM is an evaluation of the models used to triage and manage emergency ambulance service care for patients with suspected Covid-19 during the first wave of the pandemic in 2020. We aimed to understand experiences and concerns of clinical and managerial staff about implementation of triage protocols in call centre and on-scene.MethodsResearch paramedics in four study sites across England interviewed purposively selected stakeholders from ambulance services (call handlers, clinical advisors in call centres, clinicians providing emergency response, managers) and ED clinical staff from one hospital per site. Interviews (n=23) were conducted remotely using MS Teams, recorded, and transcribed in full. Analysis generated themes from the implicit and explicit ideas within participants’ accounts, following the six stages of analysis described by Braun and Clarke, conducted by a group of researchers and PPI partners working together.ResultsWe identified the following themes:Constantly changing guidelines– at some points, updates several times a dayThe ambulance service as part of the wider healthcare system- changes in other parts of the healthcare system left ambulance services as the default optionPeaks and troughs of demand- demand fluctuated greatly over time, with workload varying across the ambulance service, including an increased role for clinical advisorsA stretched system -resources to respond to patient demand were stretched thinner by staff sickness and isolation, longer job times, and increased handover delays at EDEmotional load of responding to the pandemic -particularly for call centre staffDoing the best they can in the face of uncertainty -in the face of a rapidly evolving situation unlike any which ambulance services had faced beforeDiscussionImplementing triage protocols in response to the Covid-19 pandemic was a complex and process which had to be actively managed by a range of front line staff, dealing with external pressures and a heavy emotional load.

BackgroundPressures of patient demand and GP shortages have prompted a major workforce shift in primary care. Increasingly, paramedics are joining the primary care team but with wide variation in how they are employed, managed and supported. With numbers of paramedics in primary care rapidly increasing, evidence is needed to understand how PPC can be successfully implemented.MethodsWe evaluated two collaborative health board/ambulance service initiatives. Each featured advanced paramedics (APs) – paramedics with additional education - rotating between their usual role and the new primary care role. In site A, the service of 9 APs spanned 5 general practice clusters. Site B featured 1 general practice with 8 APs. We completed 28 qualitative interviews with APs, managers, practice staff, and patients to understand implementation at both sites. We used the iPARIHS implementation framework (Harvey and Kitson 2015) as a conceptual lens to analyse transcripts, applying its interrelated domains of context, innovation, recipients and facilitation.ResultsSite A was introduced as part of an innovation project, with external funding, a focus on training and personal development, and a structured lead in time. In site B paramedics were rapidly introduced to address an acute GP shortage, without formal training and support. The innovations were similar – home-visits and in-practice clinics undertaken by the practitioners. Interviewees (recipients) at both sites reported that the services helped to increase capacity, and were well received by patients and most staff. At site A: facilitation (by dedicated project workers) and training helped to shape the culture and preparedness. Site B APs and practice staff reported less readiness, impacting on morale, interprofessional working, and sustainability.ConclusionsParamedics increasingly feature in primary care, but there is great variation in service models and implementation. Our comparative approach, informed by iPARIHS, illustrates the importance of understanding implementation - alongside or in addition to effectiveness.

AimWe evaluated the introduction of a predictive risk stratification model (PRISM) into primary care. Contemporaneously National Health Service (NHS) Wales introduced Quality and Outcomes Framework payments to general practices to focus care on those at highest risk of emergency admission to hospital. The aim of this study was to evaluate the costs and effects of introducing PRISM into primary care.MethodsRandomised stepped wedge trial with 32 general practices in one Welsh health board. The intervention comprised: PRISM software; practice-based training; clinical support through two ‘general practitioner (GP) champions’ and technical support. The primary outcome was emergency hospital admissions.ResultsAcross 230 099 participants, PRISM implementation increased use of health services: emergency hospital admission rates by 1 % when untransformed (while change in log-transformed rate ΔL=0.011, 95% CI 0.010 to 0.013); emergency department (ED) attendance rates by untransformed 3 % (while ΔL=0.030, 95% CI 0.028 to 0.032); outpatient visit rates by untransformed 5 % (while ΔL=0.055, 95% CI 0.051 to 0.058); the proportion of days with recorded GP activity by untransformed 1 % (while ΔL=0.011, 95% CI 0.007 to 0.014) and time in hospital by untransformed 3 % (while ΔL=0.029, 95% CI 0.026 to 0.031). Thus NHS costs per participant increased by £76 (95% CI £46 to £106).ConclusionsIntroduction of PRISM resulted in a statistically significant increase in emergency hospital admissions and use of other NHS services without evidence of benefits to patients or the NHS.

BackgroundHalf a million people live in UK care homes. General practices struggle to deliver primary care for residents due to high demand and staff shortages. Meanwhile, ambulance services are seeing an increase in 999 calls from care homes. In response, some areas are involving paramedics in proactive support to care homes, part of a shift towards paramedics undertaking non-emergency community care. Yet such workforce changes require urgent evaluation to understand implications for residents, staff and health services. We aimed to explore the role of non-emergency paramedics in care homes to support the design of portfolio research.MethodsWe convened a Research Development Group of care home, ambulance service, health board, primary care, public and academic representatives. We:Conducted fact-finding visits to sitesAnalysed 999 call data from care homesSurveyed ENRICH (Enabling Research in Care Homes) care home managers in England and WalesHeld a stakeholder workshop to explore the issuesResultsWe identified sites in England and Wales where paramedics provide non-emergency care in care homes. Operating models varied with paramedics employed by ambulance services, health boards and practices. Monthly 999 data from 300 homes confirmed high call and hospital conveyance rates. Survey respondents thought paramedics were well suited to assessing residents, identifying issues, improving care and avoiding admissions. They foresaw benefits to inter-professional working, clinical support and person-centred care, but raised concerns over professional boundaries and role clarity. These messages were reinforced in our workshop, where the value of timely assessment was highlighted, alongside challenges of funding and governance.ConclusionsThe role of paramedics is shifting into dedicated primary and community work, including care homes. It is imperative that research is aligned and informs evidence based practice. We are developing PERCH2, a feasibility study evaluating the impact of paramedics working in this way.

BackgroundDue to medical advances, the population of care homes is becoming increasingly frail, often with co-morbidities. Recent innovations have seen paramedics take on non-emergency roles within or supporting care homes. This workforce innovation requires urgent evaluation, taking account of the multiple perspectives at stake. Research is more relevant, feasible and accountable if those who commission, deliver and use healthcare services are able to input their professional and personal insights.MethodWe conducted a stakeholder event as part of research development work for paramedics working in care homes (PERCH: Preliminary Exploration of paramedic Roles in Care Homes). We invited representatives from care homes, including Enabling Research in Care Homes (ENRICH) network members, ambulance services, primary and secondary care, patient/resident and public members, and the research community. To inform discussion, we presented examples of paramedics working in care homes. We then facilitated small-group discussions about how to evaluate such innovations and recorded views on sticky notes and flipcharts.Results23 people attended the event. Clarity of roles and communication processes were considered important to implement the pilot project. Attendees agreed that research outcome measures should include changes in avoidable hospital admissions, emergency department attendances and 999 calls plus staff, patient and family satisfaction. They identified some potential benefits to ambulance services and general practice, such as time saved for other patients, but believed these could be difficult to measure.DiscussionGaining the insights of a wide range of stakeholders prior to research being designed is an important, but under-utilised approach in research development. People who deliver and receive community-based care have insight derived from personal and professional experience which complements research expertise. Research in care home settings is challenging, and insights from stakeholders were significant in the development of a research proposal about the role of paramedics in care homes (PERCH study). We submitted this to the Health and Care Research Wales Research for Public and Patient Benefit funding scheme in 2019.

BackgroundIn response to rising healthcare demand and shortages of general practitioners (GPs), policy across the UK supports paramedics joining the clinical team in primary care. Numbers of paramedics in primary care (PPC) are increasing in England and Wales through a range of local initiatives. As the first stage in the ARRIVE feasibility study evaluating PPC, we conducted preliminary qualitative research to:Understand the key components of the PPC intervention and its potential impactsIdentify sites with PPC and describe the range of existing interventionsDevelop a logic model to describe PPC.MethodsWe interviewed a total of 19 stakeholders from across Wales, including Health Board managers, GPs, practice managers and paramedics. Interviews were recorded and transcribed in full, then analysed thematically. We held a stakeholder event, bringing together 21 people involved in commissioning, planning and delivering PPC to discuss the key components of a logic model, including outcome measures for evaluation.ResultsWe developed a logic model describing how paramedics provide direct clinical contact with patients in a primary care setting. Potential positive impacts include better patient experience, reductions in emergency admissions through better proactive care, increased sustainability of primary care, and increased levels of clinical skills and satisfaction for paramedics. Components of the intervention which varied across sites included type of patient contact (home visit or surgery); approaches to patient selection and triage; employment model; training and induction; and clinical supervision and support from GPs.ImplicationsPPC is a rapidly developing area of provision in primary care, but there is great variation in the nature of models which have been implemented, and there is still uncertainty about the risks and benefits of PPC, and about how best to deliver it. Our logic model underpins the ARRIVE feasibility study, which will help to build the evidence base urgently needed on the PPC innovation.

BackgroundIn response to rising demand for health care and limited availability of GPs, paramedics are increasingly working in general practices, most commonly to carry out home visits. UK policy supports this change which involves role substitution across professional groups and sectors of care. In Wales, schemes have recently been introduced with various configuration, employment and governance arrangements, but we do not know the risks and benefits of Paramedics working in Primary Care (PPC), or which model works best. As well as effects at individual patient level (safety, acceptability, and quality of care), this interface-crossing innovation may have an impact on service and workforce issues including efficiency, costs, professional role development, emergency ambulance availability and 999 response. There is an urgent need to better understand the PPC innovation. We aim to describe the evidence base, theoretical underpinning and current initiatives; and determine the feasibility of undertaking a definitive evaluation of PPC in order to produce generalisable evidence to inform policy and practice.MethodA survey of Welsh Health boards has been undertaken to identify sites and stakeholders to take part in qualitative interviews. We will conduct a feasibility study using a controlled before and after natural experiment design with three GP practice sites: one with a directly-employed paramedic; one with a Welsh Ambulance Service-employed paramedic; and a control site. We will collect the following outcomes:Number of home visits requestedHome visit outcomes – the proportion resolved; further home visit required; emergency admission; 999 call placedPrescribing patternsSubsequent health care contactsPatient satisfactionSerious Adverse EventsCost profileConclusionWe will submit an application for a fully powered application to NIHR HS&DR if indicated by our progression criteria.ResultsWelsh Health board survey and qualitative findings will be available at the time of the conference.

BackgroundNumbers of asylum seekers and refugees living in Wales have increased sharply. Many are liable to have unmet health needs and difficulty accessing services. We investigated the experience of, and access to, unplanned and emergency health services by asylum seekers, refugees and those refused asylum living in Wales.MethodWe surveyed 210 asylum seekers, refused asylum seekers and refugees and conducted eight focus groups with 57 participants (with interpreters present when necessary) to explore experiences. We used descriptive statistics to analyse survey data and framework analyses to analyse interview data.ResultsSurvey data showed awareness of unscheduled health services was mixed. Best known was the 999 ambulance service (72% reportedly had heard of and could contact this outside daytime hours). NHS111 was familiar to 36% but just a quarter (26%) had heard of and could contact GP out-of-hours services. Fewer than half of respondents (44%) knew of the Emergency Department. 26% reported using a health service out-of-hours. Focus group respondents with little English reported difficulty explaining their health needs, particularly in emergencies and when seeking telephone help through 999 and 111 calls. Others said they used emergency services if they did not know how to access routine and out-of-hours care or if they felt their efforts to see a GP did not resolve their problem.ConclusionLanguage barriers and poor knowledge of UK health systems mean asylum seekers, refused asylum seekers and refugees use emergency health services to meet needs which could be seen and treated in routine primary services. Language barriers using phone lines may also result in paramedic attendance or conveyance to Emergency Departments because health needs are not clearly identified. Better information and support may help this population access services which match their needs and support their health more effectively.

Introduction Emergency admission risk prediction models are increasingly used to identify patients, typically with one or more chronic conditions, for proactive management in primary care to avoid admissions, save costs and improve patient experience. Aim To identify and review the published evidence on the costs, effects and implementation of emergency admission risk prediction models in primary care for patients with, or at risk of, chronic conditions. Methods We shall search for studies of healthcare interventions using routine data-generated emergency admission risk models. We shall report: the effects on emergency admissions and health costs; clinician and patient views; and implementation findings. We shall search ASSIA, CINAHL, the Cochrane Library, HMIC, ISI Web of Science, MEDLINE and Scopus from 2005, review references in and citations of included articles, search key journals and contact experts. Study selection, data extraction and quality assessment will be performed by two independent reviewers. Ethics and dissemination No ethical permissions are required for this study using published data. Findings will be disseminated widely, including publication in a peer-reviewed journal and through conferences in primary and emergency care and chronic conditions. We judge our results will help a wide audience including primary care practitioners and commissioners, and policymakers. Trial registration number CRD42015016874; Pre-results.