David Fitzpatrick

Improving post-hypoglycaemic patient safety in the prehospital environment: a systematic review

To determine the extent to which post-hypoglycaemic patients with diabetes, who are prescribed oral hypoglycaemic agents (OHA) are at risk of repeat hypoglycaemic events (RHE) after being treated in the prehospital environment and whether they should be transported to hospital regardless of their post-treatment response, a systematic literature review was carried out using an overlapping retrieval strategy that included both published and unpublished literature. Retrieved papers were reviewed by each author for inclusion. Disagreements regarding inclusion were resolved through discussion. Ninety-eight papers and other relevant material were retrieved using the developed search strategy. Twenty-three papers and other relevant material were included in the final review. A narrative synthesis of the findings is presented. Although several case reports demonstrate the risks associated with repeat or prolonged hypoglycaemia, the review was unable to locate any specific high quality research in this area. Consequently, caution is required in interpreting the findings of the studies. Post-hypoglycaemic patients treated in the prehospital environment have a 2–7% risk of experiencing a RHE within 48 h. The literature retrieved in this study recognises the potential for OHA to cause RHE. However, the extent to which this occurs in practice remains unknown. This lack of evidence has led to the recommendation that conservative management, through admission to hospital, is appropriate. The review concludes with recommendations for both practice and research.

Improving the management and care of people with sepsis

Many hospitals struggle to implement the full sepsis care bundle, but research suggests that many patients with sepsis are transported to hospital by ambulance. In 2011, the Scottish Ambulance Service introduced a pre-hospital sepsis screening tool (PSST) to expedite sepsis identification and care delivery. However, ambulance clinicians have reported varying degrees of interest and enthusiasm from hospital staff during handover. Therefore, an online survey was set up to investigate medical and nursing staff perceptions and experiences of the introduction of a PSST. This article discusses the results, which show that participants perceive the PSST reduces time to treatment, improves continuity of care, benefits patients and is accurately applied by ambulance clinicians, but which also highlight problems with communication. The delivery of in-hospital and pre-hospital sepsis care is challenging, but simple measures such as improving and standardising communication and alert systems between ambulance services and receiving hospitals could improve the clinical effects of a PSST.

Role and prevalence of impaired awareness of hypoglycaemia in ambulance service attendances to people who have had a severe hypoglycaemic emergency: a mixed-methods study

Objectives (1) To compare the experiences of people who are affected by diabetes-related hypoglycaemia and either do or do not require an emergency attendance and (2) to measure the prevalence of impaired awareness of hypoglycaemia in patients who are attended by an ambulance service due to a severe hypoglycaemic event. Design A sequential mixed-methods study. Setting A qualitative interview study was undertaken with 31 people with diabetes (types 1 and 2) resident in the central belt of Scotland. A national prevalence survey of 590 Scottish Ambulance Service patients who had recently experienced a severe hypoglycaemic emergency requiring ambulance clinicians attendance. Impaired awareness of hypoglycaemia was measured using two standardised measures. Results Considerable differences in impaired awareness of hypoglycaemia were found in the experiences of participants who did or did not require the ambulance service to treat their severe hypoglycaemic events. Those who required an ambulance reported fewer warning signs and symptoms. The prevalence of impaired awareness of hypoglycaemia in ambulance service call-outs as assessed by two standardised measures was 53% and 60%, respectively. Conclusions The prevalence of impaired awareness of hypoglycaemia among those who require an ambulance following a hypoglycaemic event is more than twice that found in the general population of people with diabetes. This may be because the experiences of impaired awareness in people who require an ambulance following a severe hypoglycaemic event differ to those who do not. This study provides important information to guide future prehospital clinical practice, and to develop and evaluate theoretically informed interventions. Improvements in prehospital care for this patient population could lead to global improvements in health outcomes and decreased service costs.

Out-of-hospital cardiac arrest survival in international airports

BACKGROUND The highest achievable survival rate following out-of-hospital cardiac arrest is unknown. Data from airports serving international destinations (international airports) provide the opportunity to evaluate the success of pre-hospital resuscitation in a relatively controlled but real-life environment. METHODS This retrospective cohort study included all cases of out-of-hospital cardiac arrest at international airports with resuscitation attempted between January 1st, 2013 and December 31st, 2015. Crude incidence, patient, event characteristics and survival to hospital discharge/survival to 30 days (survival) were calculated. Mixed effect logistic regression analyses were performed to identify predictors of survival. Variability in survival between airports/countries was quantified using the median odds ratio. RESULTS There were 800 cases identified, with an average of 40 per airport. Incidence was 0.024/100,000 passengers per year. Percentage survival for all patients was 32%, and 58% for patients with an initial shockable heart rhythm. In adjusted analyses, initial shockable heart rhythm was the strongest predictor of survival (odds ratio, 36.7; 95% confidence interval [CI], 15.5-87.0). In the bystander-witnessed subgroup, delivery of a defibrillation shock by a bystander was a strong predictor of survival (odds ratio 4.8; 95% CI, 3.0-7.8). Grouping of cases was significant at country level and survival varied between countries. CONCLUSIONS In international airports, 32% of patients survived an out-of-hospital cardiac arrest, substantially more than in the general population. Our analysis suggested similarity between airports within countries, but differences between countries. Systematic data collection and reporting are essential to ensure international airports continually maximise activities to increase survival.

The feasibility, acceptability and preliminary testing of a novel, low-tech intervention to improve pre-hospital data recording for pre-alert and handover to the Emergency Department

BackgroundPoor communication during patient handover is recognised internationally as a root cause of a significant proportion of preventable deaths. Data used in handover is not always easily recorded using ambulance based tablets, particularly in time-critical cases. Paramedics have therefore developed pragmatic workarounds (writing on gloves or scrap paper) to record these data. However, such practices can conflict with policy, data recorded can be variable, easily lost and negatively impact on handover quality.MethodsThis study aimed to measure the feasibility and acceptability of a novel, low tech intervention, designed to support clinical information recording and delivery during pre-alert and handover within the pre-hospital and ED setting. A simple pre and post-test design was used with a historical control. Eligible participants included all ambulance clinicians based at one large city Ambulance Station (n = 69) and all nursing and physician staff (n = 99) based in a city Emergency Department.ResultsTwenty five (36%) ambulance clinicians responded to the follow-up survey. Most felt both the pre-alert and handover components of the card were either ‘useful-very useful’ (n = 23 (92%); and n = 18 (72%) respectively. Nineteen (76%) used the card to record clinical information and almost all (n = 23 (92%) felt it ‘useful’ to ‘very useful’ in supporting pre-alert. Similarly, 65% (n = 16) stated they ‘often’ or ‘always’ used the card to support handover. For pre-alert information there were improvements in the provision of 8/11 (72.7%) clinical variables. ​ Results from the post-test survey measuring ED staff (n = 37) perceptions of handover demonstrated small (p < 0.05) improvements in handover in 3/5 domains measured.ConclusionThis novel low-tech intervention was highly acceptable to ambulance clinician participants, improving their data recording and information exchange processes. However, further well conducted studies are required to test the impact of this intervention on information exchange during pre-alert and handover.

VP205 Implementing Electronic Records In Ambulances

INTRODUCTION: Increasingly, ambulance services offer alternatives to transfer to the emergency department (ED), when this is better for patients. The introduction of electronic health records (EHR) in ambulance services is encouraged by national policy across the United Kingdom (UK) but roll-out has been variable and complex. Electronic Records in Ambulances (ERA) is a two-year study which aims to investigate and describe the opportunities and challenges of implementing EHR and associated technology in ambulances to support a safe and effective shift to out of hospital care, including the implications for workforce in terms of training, role and clinical decision-making skills. METHODS: Our study includes a scoping review of relevant issues and a baseline assessment of progress in all UK ambulance services in implementing EHR. These will inform four in-depth case studies of services at different stages of implementation, assessing current usage, and examining context. RESULTS: The scoping review identified themes including: there are many perceived potential benefits of EHR, such as improved safety and remote diagnostics, but as yet little evidence of them; technical challenges to implementation may inhibit uptake and lead to increased workload in the short term; staff implementing EHR may do so selectively or devise workarounds; and EHR may be perceived as a tool of staff surveillance. CONCLUSIONS: Our scoping review identified some complex issues around the implementation of EHR and the relevant challenges, opportunities and workforce implications. These will help to inform our fieldwork and subsequent data analysis in the case study sites, to begin early in 2017. Lessons learned from the experience of implementing EHR so far should inform future development of information technology in ambulance services, and help service providers to understand how best to maximize the opportunities offered by EHR to redesign care.

PP19 A study of the prevalence of impaired awareness of hypoglycaemia in people who have had a severe hypoglycaemic emergency and been attended by the ambulance service

Background Severe hypoglycaemia is a serious condition and accounts for 0.6%–1.0% of all UK emergency ambulance calls per annum. Our previous qualitative research suggested that many Diabetes related hypoglycaemia patients attended by the ambulance service experienced impaired awareness of hypoglycaemia (IAH), a treatable condition which reduces patients’ awareness of the signs and symptoms of an impending severe hypoglycaemic emergency. The prevalence of IAH among people with type 1 Diabetes is approximately 25%. In type 2 its prevalence is approximately 10%. However the prevalence of IAH in people who use the ambulance service due to a hypoglycaemic emergency was unknown. Our aim therefore was to investigate the prevalence of IAH in patients who require ambulance service attendance due to severe hypoglycaemia. Methods We undertook a national cross-sectional survey of the prevalence of IAH. An a priori target sample size of 415 was set to allow estimation of proportions of IAH within a 5% margin of error (99% CI). From January–June 2016, patients (>16 years) attended by the Scottish Ambulance Service due a Diabetes related emergency with a blood glucose <4 mmol/L were identified as potential participants. A questionnaire with two standardised IAH measures (Gold et al. and Clarke et al) was posted to potential participants within a month of their severe hypoglycaemic event. Consent to participate was assumed through questionnaire return. Ethical approval was received from the National Research Ethics Service (15/EE/0383). Results Five hundred and ninety-two questionnaires were returned. The prevalence of impaired awareness of hypoglycaemia in among participants as measured using the two standardised measures was 53% and 57% respectively. Conclusion IAH is considerably more prevalent among people who have a severe hypoglycaemic emergency and call the ambulance service than in the general Diabetic population. This knowledge will assist in the development of an intervention to reduce hypoglycaemic emergencies and may lead to improved outcomes and cost savings.

01 Investigating the population characteristics, processes and outcomes of pre-hospital psychiatric and self-harm emergencies in scotland: a national record linkage study

Background Effective management of people who present to ambulance services with a psychiatric or self-harm emergency is essential to ensure positive outcomes. However very little is known about this vulnerable patient population. Therefore, this study aimed to investigate their demographic characteristics, care pathways, and clinical and service outcomes. This information will be valuable for service planning and intervention development. Methods We conducted a retrospective cohort study of patients attended by the Scottish Ambulance Service in 2011 with ambulance clinician attendance codes relating to ‘psychiatric emergency’ or ‘self-harm’. Patients resident in Scotland and>=16 years on first contact were included. We used NHS Scotland’s Unscheduled Care Data Mart to link data from:–the ambulance service; emergency departments (ED); general and psychiatric inpatient hospital admissions episodes; and death records. Results There were 9014 calls from 6802 people. Slightly more males (n=4708, 52%) than females (n=4306, 48%) were attended. Most were discharged from ED with no known follow-up (n=4566; 51%). Some were left at home (n=1003 attendances, 11%). Almost half of the people (n=3238, 48%) made at least one repeat call. People who self-discharge from ED were more likely to have another ambulance attendance for psychiatric emergency/self-harm within the same year (Pearson chi square=5.24, p=0.02). Two hundred and seventy-nine (4%) people died within the study period, 97 (35%) were recorded as suicide. Ethical approval (NRES 15/EM/0260) and other data approvals were received. Conclusion While linked data analysis may not identify all relevant cases, it provides important information to guide the development and evaluation of evidence-based interventions. Ambulance service and ED are missing opportunities to improve outcomes for people who experience a psychiatric emergency or who self-harm. New interventions could lead to decreases in the number of suicides, episodes of self-harm and levels of patient distress; and ambulance and ED service use.

30 A study of the prevalence of impaired awareness of hypoglycaemia in people who have had a severe hypoglycaemic emergency and been attended by the ambulance service

Aim To investigate the prevalence of Impaired Awareness of Hypoglycaemia in patients who require ambulance service attendance due to severe hypoglycaemia. Methods We undertook a national cross-sectional survey of the prevalence of Impaired Awareness of Hypoglycaemia (IAH). An a priori target sample size of 415 was set to allow estimation of proportions of IAH within a 5% margin of error (99% CI). From January–June 2016, patients (>16 years) attended by the Scottish Ambulance Service due a Diabetes related emergency with a blood glucose <4 mmol/L were identified as potential participants. A questionnaire with two standardised IAH measures1,2 was posted to potential participants within a month of their severe hypoglycaemic event. Consent to participate was assumed through questionnaire return. Ethical approval was received from the National Research Ethics Service (15/EE/0383). Results Five hundred and ninety-two questionnaires were returned. The prevalence of impaired awareness of hypoglycaemia in among participants as measured using the two standardised measures was 53% and 57% respectively. Conclusion IAH is considerably more prevalent among people who have a severe hypoglycaemic emergency and call the ambulance service than in the general Diabetic population, where prevalence is 25%.1 This knowledge will assist in the development of an intervention to reduce hypoglycaemic emergencies and may lead to improved outcomes and cost savings. References Gold AE, Macleod KM, Frier BM. Frequency of severe hypoglycemia in patients with type I diabetes with impaired awareness of hypoglycemia. Diabetes Care 1994;17(7):697–703. Clarke WL, Cox DJ, Gonder-Frederick LA, Julian D, Schlundt D, Polonsky W. Reduced awareness of hypoglycemia in adults with IDDM: a prospective study of hypoglycemic frequency and associated symptoms. Diabetes Care 1995;18(4):517–522. Conflict of interest This study was funded by the Scottish Ambulance Service who employ Dr. D Fitzpatrick. The ambulance service management had no direct involvement in the design, conduct, analysis or output arising from the study. Funding Scottish Ambulance Service

29 Investigating the population characteristics, processes and outcomes of pre-hospital psychiatric and self-harm emergencies in scotland: a national record linkage study

Aim To investigate the demographic characteristics, care pathways, and clinical and service outcomes of people who present to ambulance services with a psychiatric or self-harm emergency Methods We conducted a retrospective cohort study of patients attended by the Scottish Ambulance Service in 2011 with ambulance clinician attendance codes relating to ‘psychiatric emergency’ or ‘self-harm’. Patients resident in Scotland and>=16 years on first contact were included. We used NHS Scotland’s Unscheduled Care Data Mart (1) to link data from: – the ambulance service; emergency departments (ED); general and psychiatric inpatient hospital admissions episodes; and death records. Results There were 9014 calls from 6802 people. Slightly more males (n=4708, 52%) than females (n=4306, 48%) were attended. Most were discharged from ED with no known follow-up (n=4566; 51%). Some were left at home (n=1003 attendances, 11%). Almost half of the people (n=3238, 48%) made at least one repeat call. People who self-discharge from ED were more likely to have another ambulance attendance for psychiatric emergency/self-harm within the same year (Pearson chi square=5.24, p=0.02). Two hundred and seventy-nine (4%) people died within the study period, 97 (35%) were recorded as suicide. Ethical approval (NRES 15/EM/0260) and other data approvals were received. Conclusion While linked data analysis may not identify all relevant cases, it provides important information to guide the development and evaluation of evidence-based interventions. Ambulance service and ED are missing opportunities to improve outcomes for people who experience a psychiatric emergency or who self-harm. New interventions could lead to decreases in the number of suicides, episodes of self-harm and levels of patient distress; and ambulance and ED service use. Reference Information Services Division (NHS Scotland) (2016) Unscheduled Care Datamart Background Paper. Accessible at http://www.isdscotland.org/Health-Topics/Emergency-Care/Patient-Pathways/unscheduledcare_background.pdf Accessed on 13/01/17 Conflict of interest None declared. Funding Scottish Government, Chief Scientists Office