Bridie Angela Evans

It could be a ‘Golden Goose’: a qualitative study of views in primary care on an emergency admission risk prediction tool prior to implementation

BackgroundRising demand for health care has prompted interest in new technologies to support a shift of care from hospital to community and primary care, which may require clinicians to undertake new working practices. A predictive risk stratification tool (Prism) was developed for use in primary care to estimate patients’ risk of an emergency hospital admission. As part of an evaluation of Prism, we aimed to understand what might be needed to bring Prism into effective use by exploring clinicians and practice managers’ attitudes and expectations about using it. We were informed by Normalisation Process Theory (NPT) which examines the work needed to bring an innovation into use.MethodsWe conducted 4 focus groups and 10 interviews with a total of 43 primary care doctors and colleagues from 32 general practices. All were recorded and transcribed. Analysis focussed in particular on the construct of ‘coherence’ within NPT, which examines how people understand an innovation and its purpose.ResultsRespondents were in agreement that Prism was a technological formalisation of existing practice, and that it would function as a support to clinical judgment, rather than replacing it. There was broad consensus about the role it might have in delivering new models of care based on active management, but there were doubts about the scope for making a difference to some patients and about whether Prism could identify at-risk patients not already known to the clinical team. Respondents did not expect using the tool to be onerous, but were concerned about the work which might follow in delivering care. Any potential value would not be of the tool in isolation, but would depend on the availability of support services.ConclusionsPolicy imperatives and the pressure of rising demand meant respondents were open to trying out Prism, despite underlying uncertainty about what difference it could make.Trial registrationControlled Clinical Trials no. ISRCTN55538212.

How hard can it be to include research evidence and evaluation in local health policy implementation? Results from a mixed methods study

BackgroundAlthough an evidence-based approach is the ideal model for planning and delivering healthcare, barriers exist to using research evidence to implement and evaluate service change. This paper aims to inform policy implementation and evaluation by understanding the role of research evidence at the local level through implementation of a national chronic conditions management policy.MethodsWe conducted a national email survey of health service commissioners at the most devolved level of decision-making in Wales (Local Health Boards – LHBs) followed by in-depth interviews with representatives of LHBs, purposively selecting five to reflect geographic and economic characteristics. Survey data were analysed descriptively; we used thematic analysis for interview data.ResultsAll LHBs (n = 22) completed questionnaires. All reported they routinely assessed the research literature before implementing interventions, but free-text answers revealed wide variation in approach. Most commonly reported information sources included personal contacts, needs assessments, information or research databases. No consistent approach to evaluation was reported. Frequently reported challenges were: insufficient staff capacity (17/22); limited skills, cost, limited time, competing priorities (16/22); availability and quality of routine data (15/22). Respondents reported they would value central guidance on evaluation.Five interviews were held with managers from the five LHBs contacted. Service delivery decisions were informed by Welsh Government initiatives and priorities, budgets, perceived good practice, personal knowledge, and local needs, but did not include formal research evidence, they reported. Decision making was a collaborative process including clinical staff, patient representatives, and partner organization managers with varying levels of research experience. Robust evaluation data were required, but they were constrained by a lack of skills, time, and resources. They viewed evaluation as a means of demonstrating that targets had been met.ConclusionsThere is a gap between evidence-based aims of national health policy and how health services are commissioned, implemented, and evaluated at local level. Commissioners and managers are unable to routinely incorporate research evidence. If health services research is to identify most effective ways to implement high quality care, it should be incorporated into commissioning and service delivery. Local commissioners and managers need to build the critical use of research evidence and evaluation into health policy implementation at local level in order to provide consistent and effective healthcare services.

Involving service users in trials: developing a standard operating procedure

BackgroundMany funding bodies require researchers to actively involve service users in research to improve relevance, accountability and quality. Current guidance to researchers mainly discusses general principles. Formal guidance about how to involve service users operationally in the conduct of trials is lacking. We aimed to develop a standard operating procedure (SOP) to support researchers to involve service users in trials and rigorous studies.MethodsResearchers with experience of involving service users and service users who were contributing to trials collaborated with the West Wales Organisation for Rigorous Trials in Health, a registered clinical trials unit, to develop the SOP. Drafts were prepared in a Task and Finish Group, reviewed by all co-authors and amendments made.ResultsWe articulated core principles, which defined equality of service users with all other research team members and collaborative processes underpinning the SOP, plus guidance on how to achieve these. We developed a framework for involving service users in research that defined minimum levels of collaboration plus additional consultation and decision-making opportunities. We recommended service users be involved throughout the life of a trial, including planning and development, data collection, analysis and dissemination, and listed tasks for collaboration. We listed people responsible for involving service users in studies and promoting an inclusive culture. We advocate actively involving service users as early as possible in the research process, with a minimum of two on all formal trial groups and committees. We propose that researchers protect at least 1% of their total research budget as a minimum resource to involve service users and allow enough time to facilitate active involvement.ConclusionsThis SOP provides guidance to researchers to involve service users successfully in developing and conducting clinical trials and creating a culture of actively involving service users in research at all stages. The UK Clinical Research Collaboration should encourage clinical trials units actively to involve service users and research funders should provide sufficient funds and time for this in research grants.

Including service users in trials and rigorous studies in health and social care: developing a standard operating procedure for researchers

Background Involving service users in research is encouraged as a way to improve research quality, relevance and accountability and is a pre-requisite for many funding bodies. Existing guidance for researchers on how to do this mainly discusses general principles. Some researchers may question the value, feasibility and impact of including service users and limit the scope of involvement. We defined service users as patients, carers, people eligible for a service or anyone relevant to the trial inclusion criteria.

Effects of an air pollution personal alert system on health service usage in a high-risk general population: a quasi-experimental study using linked data

Background There is no evidence to date on whether an intervention alerting people to high levels of pollution is effective in reducing health service utilisation. We evaluated alert accuracy and the effect of a targeted personal air pollution alert system, airAware, on emergency hospital admissions, emergency department attendances, general practitioner contacts and prescribed medications. Methods Quasi-experimental study describing accuracy of alerts compared with pollution triggers; and comparing relative changes in healthcare utilisation in the intervention group to those who did not sign-up. Participants were people diagnosed with asthma, chronic obstructive pulmonary disease (COPD) or coronary heart disease, resident in an industrial area of south Wales and registered patients at 1 of 4 general practices. Longitudinal anonymised record linked data were modelled for participants and non-participants, adjusting for differences between groups. Results During the 2-year intervention period alerts were correctly issued on 208 of 248 occasions; sensitivity was 83.9% (95% CI 78.8% to 87.9%) and specificity 99.5% (95% CI 99.3% to 99.6%). The intervention was associated with a 4-fold increase in admissions for respiratory conditions (incidence rate ratio (IRR) 3.97; 95% CI 1.59 to 9.93) and a near doubling of emergency department attendance (IRR=1.89; 95% CI 1.34 to 2.68). Conclusions The intervention was associated with increased emergency admissions for respiratory conditions. While findings may be context specific, evidence from this evaluation questions the benefits of implementing near real-time personal pollution alert systems for high-risk individuals.

Involving older people in a multi-centre randomised trial of a complex intervention in pre-hospital emergency care: implementation of a collaborative model

BackgroundHealth services research is expected to involve service users as active partners in the research process, but few examples report how this has been achieved in practice in trials. We implemented a model to involve service users in a multi-centre randomised controlled trial in pre-hospital emergency care. We used the generic Standard Operating Procedure (SOP) from our Clinical Trials Unit (CTU) as the basis for creating a model to fit the context and population of the SAFER 2 trial.MethodsIn our model, we planned to involve service users at all stages in the trial through decision-making forums at 3 levels: 1) strategic; 2) site (e.g. Wales; London; East Midlands); 3) local. We linked with charities and community groups to recruit people with experience of our study population. We collected notes of meetings alongside other documentary evidence such as attendance records and study documentation to track how we implemented our model.ResultsWe involved service users at strategic, site and local level. We also added additional strategic level forums (Task and Finish Groups and Writing Days) where we included service users. Service user involvement varied in frequency and type across meetings, research stages and locations but stabilised and increased as the trial progressed.ConclusionInvolving service users in the SAFER 2 trial showed how it is feasible and achievable for patients, carers and potential patients sharing the demographic characteristics of our study population to collaborate in a multi-centre trial at the level which suited their health, location, skills and expertise. A standard model of involvement can be tailored by adopting a flexible approach to take account of the context and complexities of a multi-site trial.Trial registrationCurrent Controlled Trials ISRCTN60481756. Registered: 13 March 2009

Rapid analgesia for prehospital hip disruption (RAPID): protocol for feasibility study of randomised controlled trial

BackgroundAdequate pain relief at the point of injury and during transport to hospital is a major challenge in all acute traumas, especially for those with hip fractures, whose injuries are difficult to immobilise and whose long-term outcomes may be adversely affected by administration of opiate analgesics. Fascia iliaca compartment block (FICB) is a procedure routinely undertaken by doctors and nurses in the emergency department for patients with hip fracture but not yet evaluated for use by paramedics at the scene of emergency calls.In this feasibility study, we aim to test whether FICB administered by paramedics at the scene of participants’ hip fractures is feasible, safe and acceptable. This will enable us to decide whether to proceed to a fully powered, multi-centre pragmatic randomised trial to evaluate whether the procedure is effective for patients and worthwhile for the NHS.Methods/designIn this study, we propose to recruit ten paramedics in an urban area of South Wales. We will train them to carry out FICB when they attend patients with hip fracture. We will randomly allocate eligible patients to FICB or usual care using audited scratch cards. We will follow up participants to assess measurability of key outcomes including quality of life, pain scores, adverse events, length of stay in hospital, acceptability to patients and compliance of paramedics. We will assess whether the findings meet specified feasibility criteria and, if so, plan a full trial.DiscussionThis study will enable us to recommend whether to undertake a definitive trial of FICB by paramedics for hip fracture.Trial registrationISRCTN60065373

Referral pathways for patients with TIA avoiding hospital admission: a scoping review

Objective To identify the features and effects of a pathway for emergency assessment and referral of patients with suspected transient ischaemic attack (TIA) in order to avoid admission to hospital. Design Scoping review. Data sources PubMed, CINAHL Web of Science, Scopus. Study selection Reports of primary research on referral of patients with suspected TIA directly to specialist outpatient services. Data extraction We screened studies for eligibility and extracted data from relevant studies. Data were analysed to describe setting, assessment and referral processes, treatment, implementation and outcomes. Results 8 international studies were identified, mostly cohort designs. 4 pathways were used by family doctors and 3 pathways by emergency department physicians. No pathways used by paramedics were found. Referrals were made to specialist clinic either directly or via a 24-hour helpline. Practitioners identified TIA symptoms and risk of further events using a checklist including the ABCD2 tool or clinical assessment. Antiplatelet medication was often given, usually aspirin unless contraindicated. Some patients underwent tests before referral and discharge. 5 studies reported reduced incident of stroke at 90 days, from 6–10% predicted rate to 1.3–2.1% actual rate. Between 44% and 83% of suspected TIA cases in these studies were referred through the pathways. Conclusions Research literature has focused on assessment and referral by family doctors and ED physicians to reduce hospitalisation of patients with TIA. No pathways for paramedical use were reported. We will use results of this scoping review to inform development of a paramedical referral pathway to be tested in a feasibility trial. Trial registration number ISRCTN85516498. Stage: pre-results.

SNAPSHOT OF INITIATIVES TO SUPPORT TIMELY PATIENT HANDOVER FROM AMBULANCES TO THE EMERGENCY DEPARTMENT

Background Increasing pressure on the emergency care system contributes to delays in patient handover from ambulances to emergency departments. The impact of these delays includes ambulance queues, sub-optimal care for patients, staffing and operational challenges, and (in England) financial penalties. New models of care have the potential to reduce handover delay. We surveyed ambulance services across England and Wales to produce a snapshot of initiatives under development or being trialled in order to address problems associated with handover delay. Methods During 2014, we carried out semi-structured telephone interviews with R&D leads in all 11 independent ambulance service trusts in England and Wales. We asked respondents about initiatives taking place within their area, what evaluation was taking place, and what they believed to be the challenges to evaluation. Interviews were recorded and transcribed, and analysed using the Framework approach. Results Initiatives fell into three groups: prehospital; at the ED; and whole system. Prehospital initiatives comprised clinical decision support tools (n=6); alternative pathways (n=6); hospital capacity monitoring (n=3); automated data transfer (n=3). Initiatives at ED included handover screens (n=8); rapid access models (n=7); hospital ambulance liaison officers (n=6); corridor care (n=3). Whole system approaches included new models of collaborative working (n=2); service review (n=2). Challenges to implementing and evaluating change included the lack of standardised approaches to handover across multiple hospital trusts within an ambulance service area; many of the reported initiatives took place only in a small part of the ambulance services operational area. Only five respondents reported evaluation of handover initiatives, and of these two were described as informal evaluation only. The need to report and comply with performance targets was reported as a more immediate pressure than evaluation of new developments. Conclusions While there is a range of activity taking place across England and Wales to address handover delays, there is little formal evaluation and there are missed opportunities for transferable learning.

Community-based interventions to prevent fatal overdose from illegal drugs: a systematic review protocol.

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 Collaborations 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.