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Vaccine hesitancy has been identified as one of the top 10 threats to global health. The causes of low vaccine uptake are many and vary at micro and macro levels. However, rural and remote coastal areas in the UK experience unique vaccine inequalities due to high levels of deprivation and their unique and complex access-related problems. This study aimed to explore community efforts to promote vaccine uptake during the COVID-19 pandemic and understand how the COVID-19 vaccination campaign was experienced by the public. We conducted an exploratory descriptive qualitative study using semi-structured interviews with decision-makers, health professionals and community members in Lincolnshire, a predominantly rural county with a long coastline, a large population of white minority ethnicities, and those living in caravan and temporary housing. Data were analysed using conventional content analysis. Overcoming the various access barriers to vaccination uptake involved working with local media stations, local communities and local community groups, translation of information, bringing vaccines closer to the people through pop-up and mobile clinics and provision of transport and ensuring confidentiality. There is a need to employ inclusive targeted non-conventional care interventions whilst dealing with complex problems as occur in rural and remote coastal regions.

Bringing together a team of leading international experts in the field of research, this book provides an up-to-date and accessible overview of applied research methods in the prehospital environment. Written to support the needs of the paramedicine, emergency medicine and wider healthcare communities in this rapidly advancing research setting, the authors introduce the key areas of research design and methods, evidence-based practice, ethics and quality improvement for both the novice and the more advanced researcher. Relevant examples of prehospital research are also included to fully explain and illustrate the key approaches. High-quality, robust evidence is of the utmost importance to inform prehospital clinical practice and ensure better patient care. This book is essential reading for anyone interested in undertaking research within the prehospital or emergency care setting, including undergraduate and postgraduate students in paramedic science, medicine, nursing and allied health.

Exploring the views of Point of Care Ultrasound practitioners for widespread implementation in community settings in the UK The problem: Point of Care Ultrasound (POCUS) is a currently available and rapidly developing technology but still not widely used in the UK. Community POCUS in prehospital and primary care settings could help to prioritise initial treatment, procedures and appropriate patient referral or conveyance to an appropriate secondary care setting. Recent reviews suggest that image quality, portability and cost of ultrasound devices are improving, that POCUS is increasingly being used by general practitioners and emergency practitioners across the world, and that generalists can safely use ultrasound in a range of clinical settings to aid diagnosis. As further evidence of community POCUS use and impact is needed in the UK, we aimed to explore the views of practitioners who use ultrasound in practice on the role of POCUS and perceived barriers and facilitators for implementation in UK community settings. The approach: We conducted a qualitative interview study with practitioners who use point of care ultrasound in practice. Participants were from community and secondary care settings, and interviews were conducted online via Microsoft Teams. A purposive sampling approach was used to recruit eligible participants through an inclusion criterion. Following ethics approval, participants were recruited by using a flyer advertising the study on social media (Twitter) and websites of relevant research groups. This was enhanced by a snowballing technique, with participants already identified serving as key informants to recruit further eligible and willing participants to the study. Data were collected using individual semi-structured interviews lasting 40 – 60 minutes. Interviews were recorded, transcribed verbatim and analysed using a Framework approach assisted by NVivo 12 software. Findings: In total, 16 practitioners, aged between 40 and 62, with a range o

Background: Point of Care Ultrasound (PoCUS) is a currently available and rapidly developing technology albeit still not widely used in the UK. Prehospital PoCUS could help to prioritise initial treatment, procedures and appropriate patient conveyance. A recent literature review suggests that the image quality, portability and cost of ultrasound devices are improving with widening indications for prehospital PoCUS but evidence of prehospital use and impact is needed. We aimed to explore the views of practitioners (who use ultrasound in practice) on the potential role of PoCUS, the challenges and facilitators associated with its use in prehospital care. Methods: We conducted a qualitative interview study using purposive sampling through social media and a snowballing technique to recruit eligible participants. Individual interviews were conducted online via Microsoft Teams. The interviews were recorded, transcribed and analysed using a Thematic Framework approach assisted by NVivo 12 software until data saturation. Results: In total, 16 practitioners - aged between 36 and 62 years, with a range of professional backgrounds including paramedics and prehospital emergency physicians - participated in interviews. Participants identified several facilitators to support a widespread implementation of PoCUS in prehospital care: resource requirements for purchase and deployment of devices, sufficient time and a skilled workforce; special attention to training, education and support needs; proper organisational governance, guidelines and quality assurance; enabling ease of use in aiding decision making and taking unintended consequences or incidental findings into consideration. In addition, more robust evidence to support perceptions of improved patient outcomes and experience is needed; workforce considerations should include supportive staff, champions and leadership. Conclusions: Prehospital PoCUS could be useful for care processes and pathways. However, the facilitators i

Aim We aimed to explore service users’ and primary care practitioners’ perspectives on the barriers and facilitators to implementing a cancer risk assessment tool, QCancer, in general practice consultations. Background Cancer risk assessment tools, including QCancer, are designed to estimate the chances of previously undiagnosed cancer in symptomatic individuals. Little is known about the barriers and facilitators to implementing cancer risk assessment tools in primary care consultations. Methods We used a qualitative design, conducting semi-structured individual interviews and focus groups with a convenience sample of service users and primary care practitioners. Findings In all, 36 participants (19 service users, 17 practitioners) living in Lincolnshire, were included in the interviews and focus groups. Before asking for their views, participants were introduced to QCancer and shown an example of how it estimated cancer risk. Participants identified barriers to implementing the tool namely: additional consultation time; unnecessary worry; potential for over-referral; practitioner scepticism; need for training on use of the tool; need for evidence of effectiveness; and need to integrate the tool in general practice systems. Participants also identified facilitators to implementing the tool as: supporting decision making; modifying health behaviours; improving speed of referral; and personalising care. Conclusion The barriers and facilitators identified should be considered when seeking to implement QCancer in primary care. In addition, further evidence is needed that the use of this tool improves diagnosis rates without an unacceptable increase in harm from unnecessary investigation.

Objectives Our aim was to measure ambulance sickness absence rates over time, comparing ambulance services and investigate the predictability of rates for future forecasting. Setting All English Ambulance Services, UK. Design We used a time series design analysing published monthly NHS staff sickness rates by gender, age, job role and region, comparing the ten regional ambulance services in England between 2009 and 2018. Autoregressive Integrated Moving Average (ARIMA) and Seasonal Autoregressive Integrated Moving Average (SARIMA) models were developed using Stata v14.2 and trends displayed graphically. Participants Individual participant data was not available. The total number of Full Time Equivalent (FTE) days lost due to sickness absence (including non-working days) and total number of days available for work for each staff group and level were available. In line with The Data Protection Act, if the organization had less than 330 FTE days available during the study period it was censored for analysis. Results A total of 1117 months of sickness absence rate data for all English ambulance services were included in the analysis. We found considerable variation in annual sickness absence rates between ambulance services and over the 10-year duration of the study in England. Across all the ambulance services the median days available were 1,336,888 with inter quartile range (IQR) of 54,8796 and 73,346 median days lost due to sickness absence, with IQR of 30,551 days. Amongst clinical staff sickness absence varied seasonally with peaks in winter and falls over summer. The winter increases in sickness absence were largely predictable using seasonally adjusted (SARIMA) time series models. Conclusion Sickness rates for clinical staff were found to vary considerably over time and by ambulance trust. Statistical models had sufficient predictive capability to help forecast sickness absence, enabling services to

A scoping review following the framework suggested by Arksey and O’Malley (2005) will be used to gather information on patient pathways for people who present to NHS emergency services (e.g., ambulance, accident and emergency departments/minor injuries units, out of hours services, mental health related crisis or liaison teams) with conditions or issues relating to substance and/or alcohol use. A scoping study aims to address a broad topic and retrieve relevant information from publications varying in design and context, rather than answering a specific well-defined question as would be expected with a systematic review (Arksey and O’Malley, 2005). This design was deemed as appropriate in order to gather information that had been published on patient pathways for substance and/or alcohol related issues. The scoping review aims to summarise information on what is known, draw conclusions and make recommendations based on the information retrieved. However, quality assessment of the publications is not within the remit of this type of review (Arksey and O’Malley, 2005). The information and outcome of this scoping review will be utilised to recommend patient pathways that can be implemented in emergency ambulance care, acute hospital accident and emergency departments, and mental health NHS Trust settings. This will inform the submission of a research bid for a feasibility study to test the patient pathway(s). The results from this scoping review will be written for publication.

Problem: Guillain-Barré Syndrome (GBS) is a rare inflammatory peripheral nerves disorder with variable recovery and variant or chronic forms. Previous qualitative studies have been published of GBS sufferers’ experiences but survey evidence on the experiences and needs of people with GBS or its variants particularly in a UK context is limited. We aimed to develop and validate a survey to quantify the experiences and health and social care needs of people with GBS and its variants in the UK. Approach: We developed a self-administered anonymous online questionnaire survey to explore patients’ experiences of care and recovery from GBS. Questionnaire items were based on a systematic review and metasynthesis of qualitative studies and an interview study of people with the condition. After gaining ethical approval, the survey was publicised via a national GBS charity website and social media. Participants with a diagnosis of GBS consented and completed the questionnaire online. Question domains included experiences of the GBS and its care, symptom severity at various stages, and factors that supported or hindered recovery. We conducted descriptive statistical analyses and developed a multiple regression model exploring the relationship between experiences, demographic and disease factors. Findings: Of 291 responders who completed the survey within 6 weeks of its launch, 140 (51.9%) were male, 130 (48.1%) female; 178 (65.9%) married or in civil partnership whereas 57 (21.1%) were single; 252 (86.6%) were from the UK. Most participants (116; 43%) were diagnosed between 2015 and 2019. Time to diagnosis was usually 1-7 days (161, 61.7%). First medical help was sought more often from a general practitioner (163; 62.2%) than from the Emergency Department (67; 25.6%). Improvement in symptoms was associated with younger age (≤ 39 years vs older), patients who were married (vs civil partnership or single), and those who presented to medical care early within the first 4 weeks comp

This comment aims to illustrate and discuss the complexity of the pain management process for children in the pre-hospital setting. We have developed a process map illustrating the four facets of pre-hospital pain management in children; the illness / injury causing the pain, the child’s perception of the pain, the ambulance clinician’s assessment of the pain and the ambulance clinician’s management of the pain. These four facets are influenced by a number of factors and informed by an overarching theory of pain: gate control theory. Pre-hospital pain management in children is extremely complex. Further research is required to explore the associations and influencing factors within this process map.

Introduction There are increasing numbers of doctors with dyslexia undertaking the MRCGP licensing exam for general practice. Exam bodies seek to be fair to candidates with disabilities such as dyslexia as part of their Public Sector Equality Duty under the Equality Act 2010. We aimed to investigate performance of doctors declaring dyslexia in the Clinical Skills Assessment (CSA) component of the MRCGP. Methods We used a cross-sectional design, analysing routine candidate performance and demographic data from the MRCGP CSA between 2010 and 2017. We used multivariable logistic regression to compare candidates who declared dyslexia (either ‘early’ before their first attempt, or ‘late’ after failing at least once) with candidates who did not declare dyslexia to investigate the effect of declaring dyslexia on passing the CSA taking into account number of attempts, sex, place of primary medical qualification and ethnicity. Results Overall, 20879 candidates took the CSA between 2010 and 2017 of which 598 (2.9%) declared dyslexia. Candidates declaring dyslexia were no different in ethnicity compared with those who did not declare dyslexia but were significantly more likely to be male (47.3 vs 37.8; p<0.001) and to have a non-UK primary medical qualification (27.0% vs 22.4%; p=0.001). Candidates who declared dyslexia late were significantly more likely to fail the CSA compared with those candidates who declared early (40.6% vs 9.2%; p<0.001). They were also more likely to have a non-UK medical qualification (79.3% vs 15.7%; p<0.001) or come from a minority ethnic group (84.9% vs 39.2%; p<0.001). Candidates who declared dyslexia were significantly less likely to pass the CSA compared to candidates who did not declare dyslexia, particularly when this was declared late (Incident Rate Ratio [IRR] 0.78, 95%; confidence interval [CI] 0.67 to 0.91) but also when declared early (IRR 0.94 95%; CI] 0.92 to 0.97). Conclusion Trainees declaring dyslexia, and particularly declared late

Study objective: Prehospital ambulance based research has unique ethical considerations due to urgency, time-limitations and the locations (home, ambulance) involved. We sought to explore these issues through interviews with paramedics that have research experience. Methods: We undertook semi-structured interviews with paramedics, seeking their views and experiences of undertaking research in ambulance based clinical trials. Participants were purposively chosen because they were actively involved research and had enrolled one or more patients into a clinical trial. Participants were questioned regarding their experiences of the enrolment and consent process, and their opinions regarding the facilitators and barriers to ambulance based research. Transcripts were digitally recorded, transcribed verbatim, and analysed thematically. Results: We interviewed 15 paramedics. They ranged from newly qualified to experienced advanced paramedics. Mental capacity and consent were discussed and the time and complexity for undertaking these processes were highlighted. Participants discussed problems with completing paperwork due to the complexity of recording systems. Most highlighted paramedic training and experience as a potential barrier to research, stating that those that had gone through a university education in general seemed more open to research than those that had ‘learnt on the job’. It was also felt that more information on the benefits of a trial to both patients and practice were needed from the outset to allow paramedics to make an informed decision about whether to take part in research or not. Several stated that they did additional reading around the subject before signing up. All stated that the training given prior to commencing the research was good and appropriate to each trial. Conclusions: We identified patient capacity and consent, paramedic training and experience and complexity of processes as important potential barriers to prehospital research. There

Title Preventable mortality in patients at low risk of death requiring prehospital ambulance care: structured judgment case note review Siriwardena AN, Akanuwe J, Crum A, Coster J, Jacques R, Turner J. Background Reviewing patient records for quality of care can help to identify deaths that could have been avoided. Any failures identified can inform measures to improve the quality of patient care. Mortality reviews are increasingly being conducted in hospitals but the evidence for their validity in pre-hospital ambulance settings is limited. We aimed to review the records for avoidable deaths relating to care provided by emergency ambulance services. Methods Ethical approval was sought and gained to link ambulance call, dispatch and clinical data with hospital and mortality data from patients attended by one UK ambulance service for records over a period of 6 months in 2015. The anonymised dataset was used for analysis. Patients who died within 3 days of the initial ambulance call were selected for case review. Cases were stratified according to age group (age 0-2, 3-10, 11-20, 21-30, 31-40, 41-50, 51-60, 61-70, 71-80, 81-90, and 91-120 years), dispatch code classification and urgency (Red1 - Green4) to ensure maximum variation. The number of calls within each group, and the number of deaths (within 3 days of a call) within each group was calculated. The death rate for each group was determined and groups were sorted by this rate (lowest first), selecting 6 patients from those with the lowest mortality rate in each group. A structured judgement case note review method with 5 reviewers (GP, nurse, 2 paramedics and a medically qualified health service manager) was used to assess in detail anonymised patient records for quality of care and avoidable mortality relating to the care provided by one ambulance trust. Results In total, 153 records were selected from 150037 where the patient had been subsequently transported to hospital or died. These represented patients fro

Funding body European Commission and Euratom Treaties funded under the 7th Framework Programmes (FP7-HEALTH-2012-INNOVATION-1) Project number 306093 Total funding €2,563,530.75 Team/consortium •TESAN S.P.A., Italy •Restech SRL – Del Politcnico Di Milano, Italy •The University of Liverpool, United Kingdom •Tallina Tehnikaulikool, Estonia •Universitat De Barcelona, Spain •Uppsala Universitet, Sweden •Universitetssykehuset Nord-Norge HF, Norway •Community and Health Research Unit (CaHRU), University of Lincoln, United Kingdom (Professor Niro Siriwardena and Dr Jo Middlemass). Also involved will be colleagues from Lincolnshire Community Health Services. •Bolnisnica Sezana Zavod, Slovenia. Overarching aim The aim of the CHROMED project was to evaluate the impact of adopting an electronic monitoring system to support elderly patients with a combination of chronic diseases including respiratory and cardiovascular systems, in their own homes. Objectives To develop and evaluate clinical protocols and organisational models based on the new telemonitoring technologies in order to improve both quality of life and healthcare costs associated with elderly patients with multiple diseases. Methods Feasibility study leading to a full scale study which included: •Customisation and adaptation of the technological infrastructure in patients’ own homes. •Conducting a feasibility study on 20 patients in 3 centres of which 5 patients will be recruited from Lincolnshire. The purpose of the feasibility study is to test the systems and the protocol for the main study. •Qualitative feedback from users to inform possible enhancement of the system. Full randomised controlled trial with 300 patients, of which 32 were to be recruited from Lincolnshire. •Utility measure (EQ-5D3L) administered before and after the study. •Measures throughout the study included, service use, symptoms checklist, hospital admissions, length of stay and readmissions. Outcomes •An increased knowledge of chronic obstruct

Introduction: The health and social care environment is being transformed by the needs of the aging population, higher levels of multimorbidity, and shifts in the care landscape, such as specialisation, ‘privatisation’ and fragmentation. Health and social care systems were not designed to appropriately support individuals with multimorbidities; primarily evolving to cater for single diseases and acute events. Nevertheless, there is now an urgent need to redesign existing structures and care delivery to address the needs of the population, ensuring individuals can access the right care at the right time and in the right place. If patients or users are unable to adequately navigate health, social and third sector care, there is likely to be an increase in expenditure through use of non-appropriate services and a reduction in patient satisfaction and well-being. Multimorbidity requires patients to seek care from different clinicians and professionals, within and beyond primary care. However, little is known about how these patients interact with the complex health and social care systems, and particularly how this impacts on effective care navigation. This study aimed to scope the literature on how older people (aged 55 years and over) with multimorbidities effectively navigate the care system. Methods: A scoping review was conducted to address the research question: ‘What information is available in the literature regarding care system navigation in the setting of older people with multimorbidity?’. A detailed search strategy was developed, including the following inclusion criteria: literature published between 2003-2014 in English, Dutch, French or German, holding the key terms of navigat* AND multi*morbid*. Papers were initially selected based on title from five electronic databases together with a review of ten grey literature sources. The selection was further refined through abstract reading. The final selection of full text papers was analysed through the use o

The problem: The health and social care environment is being transformed by the needs of the aging population, higher levels of multimorbidity, and shifts in the care landscape, e.g., specialisation and fragmentation. Health and social care systems were not designed to appropriately support individuals with multimorbidities; evolving to cater for single diseases and acute events. There is now an urgent need to redesign care structures and delivery to ensure individuals can access the right care at the right time and in the right place. If users are unable to adequately navigate health, social and third sector care, there is likely to be an increase in expenditure (use of non-appropriate services) and reduction in patient satisfaction and well-being. Multimorbidity requires patients to seek care from different practitioners, within and beyond primary care. Little is known about how users interact with care systems, and particularly how this impacts on effective care navigation. This study aimed to scope the literature on how older people (aged 55 years and over) with multimorbidities effectively navigate the care system. The approach: A systematic scoping review addressed the research question: ‘What evidence is available in the literature regarding care system navigation in the setting of older people with multimorbidity?’ Papers were drawn from five databases and ten grey literature sources using the following inclusion criteria: literature published between 2003-2014 in English, Dutch, French or German and included key terms of navigat* AND multi*morbid*. The selection was refined through reading abstracts or full papers. Final papers were extracted into a data extraction table for analysis. Findings: From 3,171 papers in the initial search, 367 papers were identified through reviewing title and abstract. Further in-depth review of abstracts and full texts resulted in a final 12 papers. These studies demonstrated that patients perceived they were expected to find