Search

Background. Considerable changes have occurred over the last 5 years in the organization of out-of-hours care in the UK. Users’ experiences of their care are an important part of ‘quality of care’ and are valuable for identifying areas for improvement. \ud Aim. To identify strengths and weaknesses of out-of hours service provision in Wales. The design of the study is a cross-sectional survey. The setting of the study is nine GP services, three Accident and Emergency units and NHS Direct in Wales. \ud Method. Survey using the validated Out-of-Hours questionnaire. We identified the four most and least favourably rated items regarding users’ experience of care. These were analysed by type of care provided, telephone advice, treatment centre and home visit groups. \ud Results. Eight hundred and fifty-five of 3250 users responded (26% response rate). Across providers and types of care, consistent strengths were the ‘manner of treatment by call operator’ and the ‘explanation of the next step by call operator’. Consistent weaknesses were the ‘speed of call back by the clinician’, the ‘information provided by the GP’, ‘getting medication after the consultation’ and ‘when to contact the (in-hours) GP’. \ud Conclusions. Users of out-of-hours care identify clear and consistent strengths and weaknesses of service provision across Wales. Specific areas for improvement concern the interface between in-hours care and out-of-hours care and between out-of-hours care and self-care. GP surgeries need to give better information on how to access the out-of-hours services. Out-of-hours providers should improve their advice on how and when to access in-hours surgeries and also improve the availability of medicines after out-of-hours consultations.

Objective To develop and evaluate a model to involve service users in researching impact of policy. Design (a) a participative approach to develop an involvement model; (b) semi-structured interviews with service users (n=10) and researchers (n=2) to evaluate at 18 months. Setting This project took place across Wales. Research was commissioned to assess impact of the new Chronic Conditions Management (CCM) policy. We wanted service users9 knowledge and understanding to contribute to developing and implementing that research. Participants Patients with chronic conditions and carers of people with chronic conditions. Main Outcome Measure a) Service users participating in CCM research planning and management; b) Impact on research and participants. Results 23 patients and carers were identified through two patient networks. Through workshops and discussions, they agreed an involvement model. This operated through a Steering Group providing support to service users and researchers. A flexible structure reflected unpredictable health status/ability to travel. Members undertook research activities and attended research planning meetings. A structured reporting-back process ensured communication. Over 18 months, activity included: five Strategic research planning meetings with academics and policy makers; five Research management meetings; Research participation (qualitative analysis; data extraction; piloting questionnaires and interview schedules, dissemination); seven Steering Group meetings; and Acting as a forum connecting researchers and service users. Service users said the Steering Group gave them an identity and supported people9s participation. Researchers said it allowed access to motivated service users. Researchers said service users changed their understanding of living with chronic illness. Service users wanted their involvement to have a positive impact on research but longer term participation was needed to enable this, they reported. Some thought they were bringing new perspectives to research. Being involved gave service users new confidence, skills, information and social opportunities. Sometimes it was challenging, tiring or frustrating. Travelling limited some people9s participation. They were helped by feeling they had expertise and gaining a role to engage through. Working with service users gave researchers credibility because it offered insight into the experience of patients and carers. They also gained practice in involving service users in research. Conclusion Patients and carers have experience and knowledge relevant to policy makers and researchers reviewing healthcare services. The model provides a mechanism linking these groups. Service users have fed their views into meetings covering project-specific and strategic topics from an early research stage. Service users and researchers benefited from co-researching. Longer term involvement is needed to identify full impact on research.

Lord Darzi's recent report summarises the challenges for the National Health Service (NHS) in the 21st century: rising expectations, demand driven by demographics, continuing development of the “information society”, advances in treatments, the changing nature of disease, and changing expectations of the workforce.1 These challenges are all relevant to the provision and development of emergency and urgent care services in the future. Perhaps, most acutely, as demand for emergency care in the UK rises, with an increasing proportion of callers with underlying chronic conditions, the challenges become those of meeting demands in a patient-centred way while managing changes to enhance the effectiveness and efficiency of the delivery of services across the spectrum of care. Meeting these challenges requires an increased level of understanding and cooperation among different healthcare professionals, provider organisations and patients. The changes mean reconsidering traditional roles and areas of responsibility and renegotiating the boundaries between acute and community care and between health and social care. Despite the introduction of Minor Injury Units (MIUs), Walk-in Centres (WIC) and NHS Direct, attendances at emergency departments (EDs) continue to rise each year, as can be seen in figure 1, and calls to ambulance services have risen at an even faster rate.2 Figure 1 Changes in attendances at UK emergency departments. Data from http://www.performance.doh.gov.uk/hospitalactivity/data\_requests/download/a\_and\_e\_attendances/ts_ae.xls (accessed 12 Aug 2008). As well as in response to rising demand, change in the UK has been driven by external factors such as the General Medical Services (GMS) contract introduced in April 2004 and the introduction of …

Background Many emergency ambulance calls are for older people who have fallen. As half of them are left at home, a community-based response may often be more appropriate than hospital attendance. The SAFER 1 trial will assess the costs and benefits of a new healthcare technology - hand-held computers with computerised clinical decision support (CCDS) software - to help paramedics decide who needs hospital attendance, and who can be safely left at home with referral to community falls services. Methods/Design Pragmatic cluster randomised trial with a qualitative component. We shall allocate 72 paramedics ('clusters') at random between receiving the intervention and a control group delivering care as usual, of whom we expect 60 to complete the trial. Patients are eligible if they are aged 65 or older, live in the study area but not in residential care, and are attended by a study paramedic following an emergency call for a fall. Seven to 10 days after the index fall we shall offer patients the opportunity to opt out of further follow up. Continuing participants will receive questionnaires after one and 6 months, and we shall monitor their routine clinical data for 6 months. We shall interview 20 of these patients in depth. We shall conduct focus groups or semi-structured interviews with paramedics and other stakeholders. The primary outcome is the interval to the first subsequent reported fall (or death). We shall analyse this and other measures of outcome, process and cost by 'intention to treat'. We shall analyse qualitative data thematically. Discussion Since the SAFER 1 trial received funding in August 2006, implementation has come to terms with ambulance service reorganisation and a new national electronic patient record in England. In response to these hurdles the research team has adapted the research design, including aspects of the intervention, to meet the needs of the ambulance services. In conclusion this complex emergency care trial will provide rigorous evidence on the clinical and cost effectiveness of CCDS for paramedics in the care of older people who have fallen. Trial Registration ISRCTN10538608

Background: Several models of GP out-of-hours provision exist in the UK but there is little detail about their effectiveness to meet users' needs and expectations. Aim: To explore users' needs, expectations, and experiences of out-of-hours care, and to identify proposals for service redesign. Setting: Service providers in urban (GP cooperative), mixed (hospital based), rural (private) locations in Wales. Participants: Sixty recent service users or carers (20 in each location). Method: Semi-structured telephone interviews; thematic analysis. Results: Users' concerns were generally consistent across the three different services. Efficiency was a major concern, with repetitive triage procedures and long time delays at various stages in the process being problematic. Access to a doctor when required was also important to users, who perceived an obstructive gatekeeping function of preliminary contacts. Expectations moderated the relationship between user concerns and satisfaction. Where expectations of outcome were unfulfilled, participants reported greater likelihood of reconsulting with the same or alternative services for the same illness episode. Accurate expectations concerning contacts with the next administrative, nursing, or medical staff professional were managed by appropriate information provision. Conclusion: Users require more streamlined and flexible triage systems. Their expectations need to be understood and incorporated into how services advise and provide services for users, and actively managed to meet the aims of both enhancing satisfaction and enabling users to cope with their condition. Better information and education about services are needed if users are to derive the greatest benefit and satisfaction. This may influence choices about using the most appropriate forms of care.

Background. Several different models of out-of-hours primary care now exist in the UK. Important outcomes of care include users’ satisfaction and enablement to manage their illness or condition, but the determinants of these outcomes in the unscheduled care domain are poorly understood. Aim. To identify predictors of user satisfaction and enablement across unscheduled care or GP out-of-hours service providers in Wales. The design of the study is a cross-sectional survey. The setting of the study is nine GP out-of-hours services, three Accident and Emergency units and an all Wales telephone advice service in Wales. Methods. Postal survey using the Out-of-hours Patient Questionnaire. Logistic regression was used to fit both satisfaction and enablement models, based on demographic variables, service provider and treatment received and perceptions or ratings of the care process. Results. Eight hundred and fifty-five of 3250 users responded (26% response rate, range across providers 14–41%, no evidence of non-response bias for age or gender). Treatment centre consultations were significantly associated with decreased patient satisfaction and decreased enablement compared with telephone advice. Delays in call answering or callback for triage and shorter consultations were significantly associated with lower satisfaction. Waiting more than a minute for initial call answering was associated with lower enablement. Conclusions. Giving users more time to discuss their illness in consultations may enhance satisfaction and enablement but this may be resource intensive. More simple interventions to improve access by quicker response and triage, and keeping users informed of waiting times, could also serve to increase satisfaction and ultimately impact on their enablement.

Background An evaluation of NHS Direct Wales (NHSDW), a national telephone-based healthcare advice and information service, was undertaken. A key objective was to describe the actions of callers and assess the appropriateness of advice and healthcare contacts made following calls, results of which are reported here. Methods Postal questionnaires were sent to consecutive callers to NHSDW in May 2002 and February 2004 to determine 1) callers' actions following calls and 2) their views about the appropriateness of: advice given; and when to seek further care. An independent clinical panel agreed and applied a set of rules about healthcare sites where examinations, investigations, treatments and referrals could be obtained. The rules were then applied to the subsequent contacts to healthcare services reported by respondents and actions were classified in terms of whether they had been necessary and sufficient for the care received. Results Response rates were similar in each survey: 1033/1897 (54.5%); 606/1204 (50.3%), with 75% reporting contacting NHSDW. In both surveys, nearly half of all callers reported making no further healthcare contact after their call to NHSDW. The most frequent subsequent contacts made were with GPs. More than four fifths of callers rated the advice given - concerning any further care needed and when to seek it - as appropriate (further care needed: survey 1: 673/729, 82.3%; survey 2: 389/421, 92.4%; when to seek further care - survey 1: 462/555, 83.2%; survey 2: n = 295/346, 85.3%). A similar proportion of cases was also rated through the rule set and backed up by the clinical panel as having taken necessary and sufficient actions following their calls to NHSDW (survey 1: 624/729, 80.6%; survey 2: 362/421, 84.4%), with more unnecessary than insufficient actions identified at each survey (survey 1: unnecessary 132/729, 17.1% versus insufficient 11/729, 1.4%; survey 2: unnecessary 47/421, 11.0% versus insufficient 14/421, 3.3%). Conclusion Based on NHSDW caller surveys responses and applying a transparent rule set to caller actions a large majority of subsequent actions were assessed as appropriate, with insufficient contacts particularly infrequent. The challenge for NHSDW is to reduce the number of unnecessary contacts made following calls to the service, whilst maintaining safety.

The recent UK Department of Health publication “ Taking Healthcare to the Patient: Transforming NHS Ambulance Services ”1 recommended that the Department of Health should commission a programme of work to build the evidence base for the delivery of emergency and unscheduled prehospital care. As a starting point, the Department of Health commissioned the 999 EMS Research Forum to review the evidence base for the delivery of emergency prehospital care; to identify gaps in the evidence base; and to prioritise topics for future research. The 999 EMS Research Forum is a partnership of academics, clinicians and prehospital care practitioners and managers formed in 1999, whose aim is to encourage, promote and disseminate research and evidence-based policy and practice in 999 health care. Prioritisation of research topics is a key part of the process of commissioning of research, although methods may differ.2 3 The desirability of including a wide range of stakeholders in a structured approach has been stressed, in order to achieve a credible result that may be more likely to produce research that informs policy and practice.4–6 This emergency prehospital care research prioritisation exercise included …

Background: A scheme to train paramedics to undertake a greater role in the care of older people following a call for an emergency ambulance was developed in a large city in the UK. Objectives: To assess the cost effectiveness of the paramedic practitioner (PP) scheme compared with usual emergency care. Methods: A cluster randomised controlled trial was undertaken of PP compared with usual care. Weeks were allocated to the study group at random to the PP scheme either being active (intervention) or inactive (control). Resource use data were collected from routine sources, and from patient-completed questionnaires for events up to 28 days. EQ-5D data were also collected at 28 days. Results: Whereas the intervention group received more PP contact time, it reduced the proportion of emergency department (ED) attendances (53.3% vs 84.0%) and time in the ED (126.6 vs 211.3 minutes). There was also some evidence of increased use of health services in the days following the incident for patients in the intervention group. Overall, total costs in the intervention group were £140 lower when routine data were considered (p = 0.63). When the costs and QALY were considered simultaneously, PP had a greater than 95% chance of being cost effective at £20 000 per QALY. Conclusion: Several changes in resource use are associated with the use of PP. Given these economic results in tandem with the clinical, operational and patient-related benefits, the wider implementation and evaluation of similar schemes should be considered. The UK Department of Health has developed a strategy to encourage the increased use of nonmedical staff trained with extended skills to assess and treat patients, a role normally undertaken by doctors. 1 The introduction of new models of care, including further assessment, triage and treatment skills for paramedics, has been recommended to help manage ever-increasing demands for healthcare. 2 However, current research evidence concerning safety, effectiveness and costs to support these changes in practice is lacking. 3

Background To identify the benefits of a network in emergency and unscheduled care research, a six week scoping study was undertaken. Objectives were to: draw together stakeholders; identify and prioritise research topics; identify sites for recruitment to studies; and agree a research strategy for a network. Methods A workshop was held to discuss and agree a research strategy based on results from four activities: visits to established research centres in emergency and unscheduled care; a literature overview; interviews with stakeholders in a GP out-of-hours service; and an exploration of the potential for routine data to support research in emergency care. Results Participants attended the workshop from user groups, primary care, the ambulance service, social care, the national telephone based health helpline, the Welsh Assembly Government and the academic sector. Site visits identified opportunities for collaboration. Gaps in knowledge were identified concerning the effectiveness of alternative models of emergency care delivery. Interview data highlighted a lack of evidence related to the quality of out-of-hours provision of primary care. The All Wales Injury Surveillance System (AWISS) was found to offer the potential to use routine data to support quantitative studies in emergency care. Three key issues emerged across all activities: working across boundaries; patient involvement; and triage. Conclusion The study included views from patient, provider, policy and academic perspectives and built the case for a research network in emergency care. Now funded, TRUST (Thematic Research network for emergency and UnScheduled Treatment) will allow the development of research proposals, building of research teams and recruitment of sites and patients both in Wales and across the UK. It aims to address the imbalance between investment and research in this area and help support provision of 'the right care to the right people at the right time'.

Background: Up to 30% of people who call for an emergency ambulance are, for various reasons, not conveyed to hospital. Across the UK, the majority of ambulance services have policies and procedures requiring ambulance crews to complete clinical documentation for these patients, as they do for patients who travel to hospital. However, studies have suggested that documentation does not get completed for a large proportion of non-conveyed patients. Methods: A qualitative study in one large ambulance service trust used focus groups to explore crew members’ attitudes towards clinical documentation and non-conveyed patients. Results: Considerable ambiguity was found: crews were aware of the need to “cover their backs” by completing clinical records, but at the same time expressed doubts about the value of this documentation. There appeared to be two main circumstances in which records were not completed. Firstly, there were the cases where crews may have been unable to obtain necessary information from patients who were intoxicated or otherwise uncooperative. Secondly, there were cases where the crews may not have recognised their encounter with a patient as having a clinical dimension, such as older people who had fallen but were apparently uninjured. These circumstances were combined with a lack of monitoring by managers of whether forms were being completed, and a disinclination on the part of some crew members to do what they regarded as unnecessary work. Conclusion: The low rates of completion of clinical records for non-conveyed patients appeared to result from crew members not believing they were important in every circumstance, combined with a lack of management focus. Low rates of completion may lead in turn to clinical risk and a risk of litigation if things go wrong.

This study compared fixation of simple mandibular angle fractures with a single miniplate either placed from a combined transbuccal and intra-oral approach, or intra-orally alone. 140 consecutive patients were randomly allocated to the two treatment groups. Complications were noted and compared. An email questionnaire to all the participating surgeons examined their personal preferences between the two methods. 20% of plates needed to be removed during the 3 month study period in the combined transbuccal/intra-oral group compared with 36% in the intra-oral alone group (p

Need for an effective triage system in the NHS National Health Service (NHS) policy recognises the importance of providing appropriate care at the right time and in the right place to people who seek emergency medical aid, so that those who can benefit from an immediate response and treatment at the highest level of care are identified, and those who can wait can receive advice or be directed to an appropriate service for further care with less urgency. Department of Health policy documents1–4 have portrayed a vision in which the spectrum of providers, such as emergency departments, general practitioners, the ambulance service, NHS Direct (the UK …

Introduction Drug overdose is the most frequent cause of death among people who misuse illegal drugs. People who inject these drugs are 14–17 times more likely to die than their non-drug using peers. Various strategies to reduce drug-related deaths have failed to meet target reductions. Research into community-based interventions for preventing drug overdose deaths is promising. This review seeks to identify published studies describing community-based interventions and to evaluate their effectiveness at reducing drug overdose deaths. Methods and analysis We will systematically search key electronic databases using a search strategy which groups terms into four facets: (1) Overdose event, (2) Drug classification, (3) Intervention and (4) Setting. Searches will be limited where possible to international literature published in English between 1998 and 2014. Data will be extracted by two independent reviewers using a predefined table adapted from the Cochrane Collaboration handbook. The quality of included studies will be evaluated using the Cochrane Collaboration9s tool for assessing risk of bias. We will conduct a meta-analysis for variables which can be compared across studies, using statistical methods to control for heterogeneity where appropriate. Where clinical or statistical heterogeneity prevents a valid numerical synthesis, we will employ a narrative synthesis to describe community-based interventions, their delivery and use and how effectively they prevent fatal overdoses. Ethics and dissemination We will publish findings from this systematic review in a peer-reviewed scientific journal and present results at national and international conferences. It will be disseminated electronically and in print. Trial registration number PROSPERO CRD42015017833.

Background Delays to the handover of patients from ambulances to the emergency department (ED) cause operational challenges for hospitals and the ambulance service, and have attracted considerable public and policy concern. As part of a wider study of handover delays, we sought to understand the perspective of health service staff on their impact and causes, in the ED of a large teaching hospital. Methods We conducted semi-structured interviews with a stratified sample of key staff from the hospital and the ambulance service, including doctors (n=5); nurses (n=7); hospital based support staff (n=2); paramedics and ambulance technicians (n=12); and other ambulance service staff (n=8). All interviews were recorded and transcribed in full, then analysed using the framework approach. Results All staff groups expressed concerns about the impact of crowding and handover delays on the quality of patient care, with a minority of respondents identifying clinical risk to patients. Handover delays were associated with high levels of stress for all staff groups, and in particular frustration for ambulance clinicians tied up waiting with patients outside the hospital. Delays were felt to have an impact on the relationship between professional groups. The negative impact on ambulance service performance measures was felt to be substantial. There was a high level of consensus that problems of crowding in the ED were complex, with issues right through the system. Almost all respondents identified lack of capacity elsewhere in the hospital as an immediate cause, and reflected positively on the impact of recent initiatives to improve patient flow. Batched arrival of ambulances, associated in part with shift patterns, was reported as causing knock-on delays from which it was hard to recover. Conclusions Handover delays at the ED have a negative impact on patients, staff and health service organisations. System-wide impacts suggest that system-wide approaches to resolving delays are required.

Background The Medical Research Council (MRC) guidance for the development and evaluation of complex interventions describes such an intervention as one which has several interacting components; the MRC recommends that complex interventions are developed through literature identification, modelling of processes and theory development. We describe the utilisation of this guidance to develop the SAFER 2 (Support and Assessment for Fall Emergency Referrals) study intervention—a multi-centre randomised controlled trial (RCT) looking to improve the care Ambulance Services provide to elderly patients who fall. Methods Literature was identified using MedLine and through applicant9s previous work in this field. Two pilot studies were undertaken in two UK ambulance services; an economic evaluation was identified. A workshop, incorporating stakeholders from ambulance services, acute trusts and primary care, allowed further development and finalisation of the intervention. Specialist sub-groups were set-up to develop specific components of the intervention Results Literature review identified previous RCTs and a recent systematic review, highlighting the need for a comprehensive evaluation of the ability of paramedics to safely make decisions to not convey elderly patients who fall to hospital and the effect of direct referral to multi-factorial community interventions on such patients. Pilot studies reinforced the need for an intervention that improves paramedic9s decision making. The workshop resulted in the amalgamation of all evidence and agreement of the final intervention by all stakeholders. The final definition of the intervention comprised of paramedic training, patient assessment tool, referral tool, process of referral, clinical support and Falls Prevention Service make-up and response. Discussion Thorough intervention development and effective implementation are vital to the success of SAFER 2 and other studies in this field. In order to produce generalisable evidence about clinical and cost effectiveness that is reproducible, the intervention needs to be clearly defined with input and agreement from study stakeholders.

Background The SAFER 2 study is an RCT looking to improve the care provided by ambulance service to elderly patients who fall, by providing paramedics with a complex intervention consisting of a paramedic training programme, referral pathway to Falls Prevention Services, clinical support, a clinical decision flowchart and referral feedback. The study received confirmation of funding in December 2008; originally, patient recruitment was scheduled to finish in December 2011. Methods Information regarding the progress of the study was sought from study staff, study timelines and quarterly reports sent to the study funders (HTA). General information regarding study progress, as well as events that caused unforeseen set-backs to the study timetable were extracted from these sources and the “story” of the study written in chronological order. Results Progress was delayed by a decision by the NIGB to reject an application to access patient9s records without consent; we therefore required written consent from patients that would be particularly difficult to obtain. Following ethical approval in February 2010 (11 months behind schedule), the study team worked to confirm participating sites—two falls services within Nottingham had to decline participation, as well as a Health Board within Wales. In early 2010 participating services were confirmed, allowing R&D approvals to be gained for 26 participating trusts. Patient recruitment started in early 2011. Due to issues with patient throughput and retrieval of patient demographics to assess eligibility, a funded extension was granted by the HTA in order to extend recruitment until June 2012. Discussion Evaluation of the study was delayed due to issues with ethical approval, site participation and patient eligibility screening and recruitment. Other studies, in other areas of research, have had similar issues, including the COnStRUCT and Family Links studies, which were set-back due to issues with NHS R&D approvals and attribution of costs.

Introduction: A high number of emergency (999) calls are made for older people who fall, with many patients not subsequently conveyed to hospital. Ambulance crews do not generally have protocols or training to leave people at home, and systems for referral are rare. The quality and safety of current practice is explored in this study, in which for the first time, the short-term outcomes of older people left at home by emergency ambulance crews after a fall are described. Results will inform the development of care for this population. Methods: Emergency ambulance data in London were analysed for patterns of attendance and call outcomes in 2003–4. All older people who were attended by emergency ambulance staff after a fall in September and October 2003, within three London areas, were identified. Those who were not conveyed to hospital were followed up; healthcare contacts and deaths within the following 2 weeks were identified. Results: During 2003–4, 8% of all 999 calls in London were for older people who had fallen (n = 60 064), with 40% not then conveyed to hospital. Of 2151 emergency calls attended in the study areas during September and October 2003, 534 were for people aged ⩾65 who had fallen. Of these, 194 (36.3%) were left at home. 86 (49%) people made healthcare contacts within the 2-week follow-up period, with 83 (47%) people calling 999 again at least once. There was an increased risk of death (standard mortality ratio 5.4) and of hospital admission (4.7) compared with the general population of the same age in London. Comment: The rate of subsequent emergency healthcare contacts and increased risk of death and hospitalisation for older people who fall and who are left at home after a 999 call are alarming. Further research is needed to explore appropriate models for delivery of care for this vulnerable group.

Aim: To describe emergency ambulance crews' views about (1) how they make decisions on whether to convey patients to hospital; (2) an intervention enabling them to triage patients to non-conveyance; and (3) their experience of using new protocols for undertaking such triage. Methods: Two focus groups were held at the outset of an evaluation of Treat and Refer (T&R) protocols: one with staff based at an ambulance station who were to implement the new service (intervention station), and the other with staff from a neighbouring station who would be continuing their normal practice during the study (control station). A third session was held with staff from the intervention station following training and 3 months' experience of protocol usage. Results: Before the introduction of the T&R protocols, crews reported experience, intuition, training, time of call during shift, patient preference, and home situation as influencing their decisions concerning conveyance. Crews were positive about changing practice but foresaw difficulties with advising patients who wanted to go to hospital, and with referral to other agencies. Following experience of T&R protocol use, crews felt they had needed more training than had been provided. Some felt their practice and job satisfaction had improved. Problems with referral and with persuading some patients that they did not need to go to hospital were discussed. There was consensus that the initiative should be introduced across the service. Conclusions: With crews generally positive about this intervention, an opportunity to tackle this difficult area of emergency care now exists. This study has, however, highlighted the complexity of the change in practice and service delivery, and professional and organisational constraints that need to be considered.

With rising demand and recognition of the variety of cases attended by emergency ambulance crews, services have been considering alternative ways of providing non-urgent care. This paper describes and appraises the research literature concerning on-scene alternatives to conveyance to an emergency department, focusing on the: (1) profile and outcomes of patients attended but not conveyed by emergency crews; (2) triage ability of crews; (3) effectiveness and safety of protocols that allow crews to convey patients to alternative receiving units or to self care. The literature search was conducted through standard medical databases, supplemented with manual searches. Very few "live" studies were identified, and fewer still that included a control group. Findings indicated a complex area, with the introduction of protocols allowing crews to leave patients at scene carrying clinical risk. Robust research evidence concerning alternatives to current emergency care models is needed urgently to inform service and practice development.

To evaluate triage and transportation to a minor injury unit (MIU) by emergency ambulance crews.Ambulance crews in two services were asked to transport appropriate patients to MIU during randomly selected weeks of one year. During all other weeks they were to treat such patients according to normal practice. Patients were followed up through ambulance service, hospital and/or MIU records, and by postal questionnaire. Semi-structured interviews were undertaken with crews (n = 15). Cases transferred from MIU to accident and emergency (AE) were reviewed.41 intervention cluster patients attended MIU, 303 attended AE, 65 were not conveyed. Thirty seven control cluster patients attended MIU, 327 attended AE, 61 stayed at scene. Because of low study design compliance, outcomes of patients taken to MIU were compared with those taken to AE, adjusted for case mix. MIU patients were 7.2 times as likely to rate their care as excellent (95% CI 1.99 to 25.8). Ambulance service job-cycle time and time in unit were shorter for MIU patients (-7.8, 95% CI -11.5 to -4.1); (-222.7, 95%CI -331.9 to -123.5). Crews cited patient and operational factors as inhibiting MIU use; and location, service, patient choice, job-cycle time, and handover as encouraging their use. Of seven patients transferred by ambulance from MIU to AE, medical reviewers judged that three had not met the protocol for conveyance to MIU. No patients were judged to have suffered adverse consequences.MIUs were only used for a small proportion of eligible patients. When they were used, patients and the ambulance service benefited.

Objective: To assess the safety of nurses and paramedics offering telephone assessment, triage, and\ud advice as an alternative to immediate ambulance despatch for emergency ambulance service callers\ud classified by lay call takers as presenting with "non-serious" problems (category C calls).\ud Design: Data for this study were collected as part of a pragmatic randomised controlled trial reported\ud elsewhere. The intervention arm of the trial comprised nurse or paramedic telephone consultation using a\ud computerised decision support system to assess, triage, and advise patients whose calls to the emergency\ud ambulance service had been classified as "non-serious" by call takers applying standard priority despatch\ud criteria. A multidisciplinary expert clinical panel reviewed data from ambulance service, accident and\ud emergency department, hospital inpatient and general practice records, and call transcripts for patients\ud triaged by nurses and paramedics into categories that indicated that despatch of an emergency\ud ambulance was unnecessary. All cases for which one or more members of the panel rated that an\ud emergency ambulance should have been despatched were re-reviewed by the entire panel for an\ud assessment of the "life risk" that might have resulted.\ud Setting: Ambulance services in London and the West Midlands, UK.\ud Study population: Of 635 category C patients assessed by nurses and paramedics, 330 (52%) cases that\ud had been triaged as not requiring an emergency ambulance were identified.\ud Main outcome measures: Assessment of safety of triage decisions.\ud Results: Sufficient data were available from the routine clinical records of 239 (72%) subjects to allow\ud review by the specialist panel. For 231 (96.7%) sets of case notes reviewed, the majority of the panel\ud concurred with the nurses’ or paramedics’ triage decision. Following secondary review of the records of\ud the remaining eight patients, only two were rated by the majority as having required an emergency\ud ambulance within 14 minutes. For neither of these did a majority of the panel consider that the patient\ud would have been at "life risk" without an emergency ambulance being immediately despatched.\ud However, the transcripts of these two calls indicated that the correct triage decision had been\ud communicated to the patient, which suggests that the triage decision had been incorrectly entered into the\ud decision support system.\ud Conclusions: Telephone advice may be a safe method of managing many category C callers to 999\ud ambulance services. A clinical trial of the full implementation of this intervention is needed, large enough to\ud exclude the possibility of rare adverse events.

Objective To provide a detailed description of the current UK ambulance service provision for older people who fall. Method National survey of UK ambulance services. Results 11/13 Ambulance services (84.6%) participated in this national survey. Conclusion This survey has highlighted the need for robust evidence to inform policy, service and practice development to improve the care of this vulnerable population.

A randomized controlled trial was set up to investigate whether patients who were taking warfarin and had an International Normalised Ratio (INR) within the normal therapeutic range require cessation of their anticoagulation drugs before dental extractions. Of 109 patients who completed the trial, 52 were allocated to the control group (warfarin stopped 2 days before extraction) and 57 patients were allocated to the intervention group (warfarin continued). The incidence of bleeding complications in the intervention group was higher (15/57, 26%) than in the control group (7/52, 14%) but this difference was not significant. Two patients in the study required hospital review for bleeding and all other episodes of bleeding were controlled by patients at home. Continuing warfarin when the INR is < 4.1 may lead to an increase in minor post-extraction bleeding after dental extractions but we found no evidence of an increase in clinically important bleeding. As there are risks associated with stopping warfarin, the practice of routinely discontinuing it before dental extractions should be reconsidered.

Demand for emergency medical services in the United Kingdom is rising.1 Research into the type of patients transported by emergency ambulances and the severity of their illness has tended to focus on identifying people who use the service inappropriately rather than factors influencing demand, and our understanding of the increase in demand is poor. 2 3\ud \ud In Wiltshire, a largely rural county in the south west of England, the number of emergency transports of patients increased from 11 268 in 1988 to 16 814 in 1996, a crude increase of 49%.4 This increase is often attributed to general practitioners redirecting patients with urgent problems to the ambulance service, particularly out of surgery hours. Over the same period, however, urgent transports booked by general practitioners rather than in response to a 999 call rose from 9982 to 13 951 (40%). We examined the reasons for this rise.

Background Only 10% of 999 calls are for people with life-threatening emergencies; up to 1/3 callers have needs that could be met by community based care. CCDS supports paramedics to assess patients and make decisions about onward care, aligning with policies to standardise patient care, promote community based care pathways, enhance paramedic decision making skills, reduce emergency admissions to hospital, and improve quality of care. CCDS has been shown to improve processes of care in other settings however there is little evidence in the emergency care setting. The aim of this research was to study the adoption of CCDS by paramedics and its impact on their role and practice. Methods This qualitative study was conducted alongside a cluster randomised trial of the costs and effects of CCDS in two ambulance services (AS). We invited all intervention group paramedics to participate in interviews or focus groups to explore their use of CCDS and their views on its impact on role and practice. We used the ‘Framework’ approach to data analysis, underpinned by Strong Structuration Theory, a theoretical framework for studying innovation based on the relationship between what people do and their context. Results 20/22 (17 male and 5 female) paramedics participated, with an average age of 39, and paramedic experience of 3 to 20 years. Paramedics reported low CCDS usage, particularly at one AS where problems with implementation persisted. Higher usage was reported at the AS where systems existed to support technology implementation. Use of CCDS was influenced by policy context (e.g. time-based performance pressures), organisational context (e.g. technological readiness), the paramedics’ own skills and attitudes (e.g. towards non-conveyance/use of technology) and the technology itself (e.g. usability). Paramedics reported that CCDS generally supported their decision making, provided documented evidence of their patient assessment, prompted them to do all the necessary checks and honed their skills with this patient group. However, they raised doubts about its usefulness and the time required to use it. In principle there was support for the potential of CCDS, it was not seen as a threat to paramedic autonomy but as another tool in the kit bag. Conclusion Although paramedics felt that CCDS could support their decision making role in the future, across a range of patient conditions, in this trial usage was low. Organisational readiness and support for implementation is critical.

The number of patients undergoing intravenous (IV) cannulation by paramedics has increased dramatically over recent years in the UK. Treatment protocols for cannulation in the field are loosely defined. Variation in practice may lead to patients' receiving differential treatment according to customary practice, rather than according to their clinical conditions.To explore variations in practice and assess level of appropriatenesss of IV cannulation by London Ambulance Service (LAS) paramedics; to revise treatment protocols and work toward clinical guidelines, if indicated by study findings.Skill usage data were analyzed for all LAS paramedics for 1995-96. All patients who were IV-cannulated and transported to three hospitals by LAS during March 1996 were identified. A panel of accident and emergency (AE) and prehospital specialists judged each case for appropriateness.Variation during the year was wide, with a range of 1 to 221 (mean 47) patients cannulated per paramedic, although the majority showed some consistency in frequency of skill usage. A sample of 183 cases was reviewed. The majority judged 149 (81.4%) to be appropriate, although there was considerable disagreement between reviewers (kappa = 0.43, p0.001). Data suggested that those paramedics who cannulate more frequently cannulated less appropriately during the study period (lowest 30%: 73.9% appropriate; highest 30%: 45.8% appropriate, p = 0.05).Despite wide variation between paramedics, the panel judged overall appropriateness of cannulation to be high. The audit advisory group judged that new clinical guidelines might not achieve an improvement in practice and were not supported by study findings. It was recommended that variations be addressed through individual practice review.