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Information on the readiness of Irish general practice to participate in structured chronic disease management (CDM) care is limited. This study explores the logistic, staffing, and organizational preparedness of Irish general practice to do so, stratified by their size, location, and training status; implementation challenges were also explored. An anonymous, paper-based random survey was performed. A chi-square test was applied to compare practices by location (urban/rural), post-graduate training status (with/without), and numbers of GMS patient (≥1500/>1500 patients) and prevalence ratio and Poisson regression analysis to examine the relationship of staffing with key variables. Overall, 125/243 practices participated, 22% were rural, 56.6% were post-graduate training practices, and 53.9% had ≥1500 GMS patients. The rural, non-training practices and those with

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

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

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

Introduction Opiate use disorder is a common condition in healthcare services in Ireland, where over 200 opiate overdose deaths occur annually. There is limited addiction medicine education at undergraduate level and medical graduates may not be adequately prepared to diagnose and manage opioid use disorders and emergency drug overdose presentations. Therefore, we examined final-year medical students' learning experiences and attitudes toward opioid use disorder, overdose and community naloxone provision as an emerging overdose treatment. Methods We administered an anonymous paper-based survey to 243 undergraduate medical students undertaking their final professional completion module prior to graduation from University College Dublin, Ireland. Results were compared with parallel surveys of General Practitioners (GPs) and GP trainees. Results A total of 197 (82.1%) completed the survey. Just under half were male, and most were aged under 25 (63.3%) and of Irish nationality (76.7%). The students felt moderately prepared to recognise opioid use disorder, but felt less prepared to manage other aspects of its care. Most had taken a history from a patient with an opioid use disorder (82.8%), and a third had witnessed at least one opioid overdose. Although 10.3% had seen naloxone administered, most had never administered naloxone themselves (98.5%). Half supported wider naloxone availability; this was lower than support rates among GPs (63.6%) and GP trainees (66.1%). Conclusions Our findings suggest an unmet learning need in undergraduate training on opioid use disorder, with potential consequences for patient care.

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

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

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

Background The work context of the general practitioner (GP) potentially lends itself to the provision of early community based, cardiac arrest care. GPs have traditionally encountered out of hospital cardiac arrest (OHCA) as a component of routine patient care but have not been formally linked with the statutory ambulance service. Computer aided dispatch technology now allows real time GP text message alert to nearby cardiac arrest events. Aim To examine the feasibility, uptake and outcome of a novel scheme to alert GPs to nearby OHCA events in their communities. Methods GPs are recruited to voluntarily participate in a cardiac arrest text alert initiative called the ‘MERIT 3′ project. GPs indicate the hours during which they wish to receive OHCA text alerts, and also specify a geo-location from which they will receive alerts to OHCA events occurring within a specified radius. Data on alerts, responses, OHCA incidents and outcomes are gathered prospectively, using ambulance control and GP data and with corroborative data from the national OHCA registry. Results 423 general practices throughout Ireland were invited to participate. In the initial 12 months, 100 GPs from 85 individual practices have enrolled, 74 GPs have received alerts and 26 GPs have responded to incidents. Only 222/781 (28.4%) text alerts issued by ambulance control have proven to be recognised as cardiac arrests with resuscitation attempts. GPs have attended 51/776 (6.6%) OHCA incidents to which they have been alerted, with resuscitation undertaken in 34 cases with three survivors. Conclusion Text alert activation of GPs to nearby OHCA events has proven feasible, with significant activity during the establishment period, but a low survival rate which is similar to the overall national OHCA survival rate. A high proportion of alerts do not involve resuscitation opportunities.

Heroin use continues to drive opioid-related overdoses and mortality globally (Degenhardt & Hall, 2012). Not-as-prescribed use of prescription opioids increases the number of victims of this epidemic (Logan, Liu, Paulozzi, Zhang, & Jones, 2013). Naloxone has been shown to reduce mortality in overdose among people who use heroin and other opioids; however, its administration in a number of countries, including Ireland, is limited to paramedics and health professionals (Bury, 2015), despite proven effectiveness of overdose education and naloxone distribution (OEND) programmes by trained lay-people worldwide (McAuley, Aucott, & Matheson, 2015). The effectiveness of these programmes has been demonstrated around outcomes such as knowledge, skills, attitudes and reduced overdose deaths (Coffin & Sullivan, 2013), and involved groups including social workers and needle-exchange staff as well as family and friends of people who use opioids (Walley et al., 2013). While recent systematic reviews have demonstrated the efficacy and feasibility of training diverse groups in OEND (Behar, Santos, Wheeler, Rowe, & Coffin, 2015), the potential and capacity of general practice (GP), to contribute in this area have not been fully characterised (Nielsen & Van Hout, 2016). A naloxone demonstration project is underway in Ireland at the moment and aims to reduce Ireland’s high number of opioid-related deaths (Department of Health, 2015). European Commission Irish Research Council ELEVATE Marie Curie Actions

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

Background: Although widely acknowledged, few data exist on the scope of general practice involvement in the management of prehospital emergencies. A study was undertaken to explore the frequency and types of emergencies dealt with and the interventions undertaken by GPs who had completed Immediate Care training. Methods: All participants in Immediate Care courses in Ireland in 2002, 2003 and 2004 were invited to complete an anonymised questionnaire in which they estimated their experience of emergencies since completing a course. Sections dealt with personal/practice information, types of emergencies, interventions used and follow-up training. Results: 448 participants completed courses, 408 were available to participate in the study and 259 (63.5%) responded; 66.6% of GPs responded. The mean reporting period was 29.4 months (range 18–53). Participants included many younger female GPs at the start of their general practice careers. Although most emergencies dealt with were medical, few other patterns emerged in the timing or setting of emergencies. 88% of GPs had called an ambulance in an emergency at least once in the preceding year. 84% of GPs had managed a suspected acute myocardial infarction at least once during the reporting period; seizures, serious injuries, paediatric emergencies and hypoglycaemia were dealt with by up to half of all GPs. Interventions used included intravenous access in a medical emergency (69%), intravenous fluid administration (51%), intravenous morphine (54%), cardiopulmonary resuscitation (37%), defibrillation (21%), use of airway adjuncts (28%) and use of advanced life support drugs in cardiac arrest (24%). Conclusions: GPs make frequent use of a wide range of interventions in prehospital emergencies. Issues relating to tailored training, adequate equipment, collaboration with the emergency services and skills maintenance are highlighted by these data.

Background Overdose is the most common cause of fatalities among opioid users. Naloxone is a life-saving medication for reversing opioid overdose. In Ireland, it is currently available to ambulance and emergency care services, but General Practitioners (GP) are in regular contact with opioid users and their families. This positions them to provide naloxone themselves or to instruct patients how to use it. The new Clinical Practice Guidelines of the Pre-hospital Emergency Care Council of Ireland allows trained bystanders to administer intranasal naloxone. We describe the development and process evaluation of an educational intervention, designed to help GP trainees identify and manage opioid overdose with intranasal naloxone. Methods Participants (N = 23) from one postgraduate training scheme in Ireland participated in a one-hour training session. The repeated-measures design, using the validated Opioid Overdose Knowledge (OOKS) and Attitudes (OOAS) Scales, examined changes immediately after training. Acceptability and satisfaction with training were measured with a self-administered questionnaire. Results Knowledge of the risks of overdose and appropriate actions to be taken increased significantly post-training [OOKS mean difference, 3.52 (standard deviation 4.45); P

Recent data suggest GPs contribute to successful resuscitation of cardiac arrests in the community. This paper examines uptake of Immediate Care training by GPs over a 12 year period. Data was collated on all courses and attenders (2002-2013). 244 cardiac, trauma and paediatric courses were held with 4247 attendances by 2069 individuals, including 1790 (86.5%) doctors. Of these 1648 (92.1% of all doctors) were GPs or GP registrars who generated 3585 days of attendance (84.4% of the total); 1270 attended more than one course. Between 2006 and 2013, an average of 219 (range 186-261) GPs/GP registrars attended at least one course each year, representing around 8% of all GPs in Ireland. A subset of these GPs has been shown to have a significant success rate in cardiac arrest care; there may be links between uptake of training and the clinical effectiveness of care provided.

Background: Opioid overdose is the primary cause of death among drug users globally. Personal and social determinants of overdose have been studied before, but the environmental factors lacked research attention. Area deprivation or presence of addiction clinics may contribute to overdose. Objectives: To examine the baseline incidence of all new opioid overdoses in an ambulance service, and their relationship with urban deprivation and presence of addiction services. Methods: A prospective chart review of pre-hospital advanced life support patients was performed on confirmed opioid overdose calls. Demographic, geographic, and clinical information, i.e. presentation, treatment, outcomes, was collected for each call. The Census data were used to calculate deprivation. Geographical information software mapped the urban deprivation and addiction services against the overdose locations. Results: There were 469 overdoses, 13 of which were fatal; most were male (80%), of a young age (32 years), with a high rate of repeated overdoses (26%), and common poly-drug use (9.6%). Majority occurred in daytime (275), on the streets (212). Overdoses were more likely in more affluent areas (r = .15, P < .05), and in a 1000 m radius of addiction services. Residential overdoses were in more deprived areas than street overdoses (mean difference 7.8, t(170) = 3.99, P < .001). Street overdoses were more common in the city centre than suburbs (χ2(1) = 33.04, P < 0.001). Conclusions: the identified clusters of increased incidence – urban overdose hotspots - suggest a link between environment characteristics and overdoses. This highlights a need to establish overdose education and naloxone distribution in the overdose hotspots. MERIT

Objective To document the involvement of general practitioners (GPs) in cardiac arrests with resuscitation attempts (CARAs) and to describe the outcomes. Design A 5-year prospective cross-sectional study of GPs in Ireland equipped with automated external defibrillators (AEDs) and immediate care training by the MERIT Project, with data collection every 3 months over the 5-year period. Practices reported CARAs by quarterly survey with an 89% mean response rate (81–97% for the period). Setting General practices throughout Ireland. Participants 495 GP participated: 168 (33.9%) urban, 163 (32.9%) rural and 164 (33.1%) mixed. Interventions All participating practices received a standard AED and basic life support kit. Training in immediate care was provided for at least one GP in the practice. Main outcome measures Incidence of CARA in participating practices. Return of spontaneous circulation (ROSC) and discharge alive from hospital. Results 36% of practices were involved in a CARA during the 5-year period and 13% were involved in more than one CARA. Of the 272 CARAs reported, ROSC occurred in 32% (87/272) and discharge from hospital in 18.7% (49/262). In 45% of cases, the first AED was brought by the GP and in 65%, the GP arrived before the ambulance service. More cases occurred in rural and mixed settings than urban ones, but the survival rates did not differ between areas. In 65% of cases, the GP was on duty at the time of the incident and 47% of cases occurred in the patient9s home. Conclusions These outcomes are comparable with more highly structured components of the emergency response system and indicate that GPs have an important role to play in the care of patients in their own communities. GPs experience cardiac arrest cases during the course of their daily work and provide prompt care which results in successful outcomes in urban, mixed and rural settings.

Background: Ireland’s health services are undergoing dramatic reorganisation. The establishment of general practitioner (GP) out of hours cooperatives and the integration of current ambulance services into a national ambulance service are among the issues that will impact on prehospital care of emergencies. The study aimed to explore the perceptions of GPs and emergency medical technicians (EMTs) of their own and each other’s roles in the context of such reforms. Methods: A census of all GPs (511) and EMTs (301) in three of Ireland’s eight health board regions was undertaken. A questionnaire containing 31 statements asked respondents to indicate their agreement (or lack of it) in areas such as general relationships, care, and training, roles in emergencies and future developments. Results: Of the personnel contacted, 72% of GPs and 75% of EMTs responded. They report excellent working relationships, agree that the ambulance service is of high quality, and that GPs are willing to provide care in emergencies. However, working links are less satisfactory for EMTs, who report a far higher perception of GP use of emergency ambulances than reported by GPs. Both groups are interested in innovative future links. Discussion: Convergence between the professional groups in different geographic areas and between the disciplines across the areas is striking. They include areas of satisfaction and dissatisfaction. The need for improved liaison between the disciplines is clear.

PURPOSE OF STUDY Confidence levels in junior doctors are improved by pre-graduation courses that focus on clinical skills.1,2. The Professional Completion Module (PCM) in the final year of medicine at University College Dublin (UCD) includes an intensive 2-day scenario-based clinical skills course that focuses on initial emergency care of common problems. The course comprises certified BLS/AED, 2 core lectures, 15 x 30 minute small group skills and scenario stations. Core content is based on PHECC Clinical Practice Guidelines3. Multidisciplinary faculty includes senior medical, nursing and paramedic staff. We report the effect of emergency care clinical skills training on the confidence levels of senior medical students prior to graduation. METHODS Data were collected for 3 consecutive years. Pre and post-course questionnaires were completed by 447 of 540 students (response rate 83%) RESULTS Mean confidence levels significantly increased for all parameters related to the clinical skills taught. Students rated this course as a highlight of their final year. CONCLUSIONS Self-assessed confidence is improved by a short, intensive scenario-based course in emergency care. Competency-based training has been shown to translate to improved performance and better patient care on graduation. Assessment of competence as opposed to confidence could be monitored in the future.