Rachael Fothergill

Background: The PROTECTeD study sought to develop an evidence-based termination of resuscitation guideline for use within United Kingdom ambulance services. Methods: This mixed-methods study comprised several work packages: Work package 1 – diagnostic test accuracy meta-analysis of termination of resuscitation rules Work package 2 – modelling performance of termination of resuscitation rules using data from the Out of Hospital Cardiac Arrest Outcomes registry Work package 3 – review of ambulance service practices Work package 4 – qualitative interviews with ambulance clinicians, emergency department clinicians and relatives of non-survivors Work package 5 – stakeholder consensus conference to develop a new termination of resuscitation guideline. Results: We described the performance of 42 different termination of resuscitation rules. Our meta-analysis suggests the best performing termination of resuscitation rule is the Universal termination of resuscitation. We modelled the performance of 29 termination of resuscitation rules and found that none would be suitable for implementation within a United Kingdom context. We identified significant variation in how the termination of resuscitation guideline was implemented across the United Kingdom (UK) ambulance services. Ambulance clinicians experience conflict between what the guideline permits them to do and being able to act in the patient’s best interest. They felt obliged to follow the guideline. Most emergency department staff believed that paramedics should be empowered to stop resuscitation where appropriate. However, some felt that more senior emergency department clinicians should make these decisions. Relatives needed to be informed about the resuscitation attempt and must feel confident that every effort had been made to save their relative. They also believed that they were able to provide useful information to inform paramedic decision-making. We drafted a new termination of resuscitation guideline in conjunction with clinical experts and multiple stakeholders at a consensus conference. We employed nominal group techniques to determine content and formulate treatment recommendations. Discussion: Termination of resuscitation decisions are complex, requiring consideration of several important aspects, including what is in the patient’s best interest. Our work suggests that the current ambulance guideline may restrict the paramedics ability to act in the patient’s best interest, increasing the potential for moral injury. Conclusion: Paramedic decision-making is informed by both clinical and best interest considerations. Relatives are confident that paramedics do everything possible to save their loved one, and they are able to provide paramedics with information to guide decision-making. We developed a new evidence-based termination of resuscitation guideline, employing nominal group techniques, in collaboration with multiple stakeholders. Limitations: The evidence comprises observational studies that must be interpreted with caution. We captured the views of multiple stakeholders and patients with personal experience of cardiac arrest. Their insights may not be representative of the wider population who have not had the same experience. Future work: Future research should encompass alternative predictors of poor outcome (e.g. clinical frailty) as well as technology (e.g. ultrasound) to enhance decision-making. Better understanding of how cardiac arrest transport decisions impact system performance and crew safety would be helpful. Little is known about paramedic decision-making in relation to unfavourable neurological outcome rather than fatal outcome. Paramedics may benefit from a decision-making framework. Funding: This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme as award number 17/99/34.

Objectives The complex and dynamic care context of terror attacks must be better understood to reduce deaths. This study was designed to understand the tension between saving lives and maximising safety for emergency responders attending active terror incidents. Design, setting and participants Qualitative study exploring the experience of survivors and emergency responders (armed and unarmed police, paramedics, doctors and fire officers) present in the hot (unsafe) zone of five major terror attacks in the UK since 2000. We used reflexive thematic data analysis to build qualitative case studies, comparing similarities and tensions between perspectives of different participant groups. Results In our analysis of over 2000 min of interview data from 26 participants, we found a common view that the priority during a terror-related mass casualty event was to save lives. However, responder groups maintained distinct mental models that shaped their operational priorities regarding treatment for those injured within the hot zone. All responders expressed willingness to take self-assessed risks to save lives, but better interagency communication was noted to be required to achieve this safely. All responders felt it was vital to have experienced health professionals present to triage and facilitate urgent treatment and extraction decisions. Armed police commanders had dual responsibilities to achieve rapid care delivery while preventing further terrorist-inflicted injuries. Operationally, this was perceived as leading to a lack of shared mental models between responders regarding what is ‘unsafe’ due to zoning, rather than communication of risk, potentially delaying vital care delivery. There were mixed survivor perspectives regarding the risks that responders should be exposed to, but broad agreement that there was a notable absence of health professionals present in the hot zone during the immediate aftermath of attacks. Conclusion There is strong professional and public support for improving care delivery, including potential hot zone working, to minimise the therapeutic vacuum in active terrorist attacks. Better risk communication and better shared mental models are necessary to balance responder risk with care delivery to maximise lives saved as safely as possible.

Background: Major trauma is a leading cause of death and disability. Specialised care in major trauma centres has been associated with improved outcomes and prehospital triage tools are used to ensure injured patients are treated in the right place and the right time. However, there is a trade-off between under- and over-triage, and this study aimed to externally validate current and newly developed major trauma triage tools. Methods: A diagnostic case-cohort study was performed between November 2019 and February 2020 in 4 English regional trauma networks as part of the Major Trauma Triage Study (MATTS). The accuracy of 22 adult major trauma triage tools, including 3 newly developed MATTS tools was evaluated. Consecutive patients with acute non-trivial injury presenting to participating ambulance services were included and matched to data from the English national major trauma database. Theoretical accuracy was examined, with index tests assessed according to objective ambulance service data, regardless of the final triage decision or hospital destination. The primary reference standard was a consensus definition of serious injury that would benefit from expedited major trauma centre care. Results: The case-cohort sample consisted of 2,607 patients, including 928 primary reference standard positive patients. The population weighted prevalence of major trauma meeting the primary reference standard definition was 3.1% (95% CI 2.3–4.0). Four optimally performing triage tools were identified with Pareto decision analysis: the Trauma score (sensitivity 0.1, specificity 0.99), MATTS specific tool (sensitivity 0.37, specificity 0.95), MATTS balanced tool (sensitivity 0.58, specificity 0.87), and the MATTS sensitive tool (sensitivity 0.72, specificity 0.76). This finding was unchanged in subgroup analyses of different age-groups and injury mechanisms; secondary analyses examining alternative reference standards (ISS ≥ 16, US consensus definition); and sensitivity analyses exploring missing data. Conclusions: Four optimal triage tools, demonstrating a trade-off between sensitivity and specificity, were identified by this validation study. The choice of ideal tool will depend on prevalence of major trauma, and valuation of false positive and false negative cases. Further prospective investigation of real-life triage tool performance, including compliance and clinical judgment, is necessary.

Background: Out-of-hospital cardiac arrest (OHCA) remains a global health burden where neurological injury sustained is a key predictor of mortality but there are challenges in early risk stratification. This study aims to derive the Pre-MIRACLE2 score, which excludes pH as a component from the MIRACLE2 score, as a means of stratifying neurological risk in a pre-hospital setting.Methods: To validate the Pre-MIRACLE2 score, we used (i) the EUCAR Registry retrospectively analysed from 1 May 2012 to 31 December 2021, and (ii) the GLOBAL-MIRACLE Registry, a prospective cohort analysed from 1 January 2022 to 31 May 2023. The primary outcome was poor neurological outcome (defined as Cerebral Performance Category 3-5) at hospital discharge.Results: From 1 May 2012 until 31 May 2023, 2149 patients were resuscitated from OHCA with sustained return of spontaneous circulation. After excluding patients who remained non-comatose following return of spontaneous circulation and those with incomplete scores, 1402 patients from EUCAR and 747 from GLOBAL-MIRACLE were included in the final analysis. The primary endpoint occurred in 54.4% of the study cohort. The performance of the Pre-MIRACLE2 score for the primary endpoint was excellent, with an area under the receiver operating curve (AUROC) of 0.85 (95% CI 0.83, 0.87). From the prospective validation cohort (GLOBAL-MIRACLE), the AUROC was 0.85 (95% CI 0.82-0.88) with a calibration slope of 1.11 (95% CI 0.95-1.29).Conclusion: The Pre-MIRACLE2 score has the potential to be an effective and pragmatic risk stratification tool for prediction of poor neurological outcome in a pre-hospital environment or where the pH cannot be measured.

Background: Emergency ambulance services aim to respond to patients calling with urgent healthcare needs, prioritising the sickest. A small minority make high use of the service, which raises clinical and operational concerns. Multidisciplinary ‘case management’ approaches combining emergency, primary and social care have been introduced in some areas but evidence about effectiveness is lacking. Aim: To evaluate effectiveness, safety and costs of case management for people frequently calling emergency ambulance services. Design: A mixed-methods ‘natural experiment’, evaluating anonymised linked routine outcomes for intervention (‘case management’) and control (‘usual care’) patient cohorts within participating ambulance services, and qualitative data. Cohorts met criteria for ‘Frequent Callers’ designation; we assessed effects of case management within 6 months on processes, outcomes, safety and costs. The primary outcome combined indicators on mortality, emergency hospital admission, emergency department attendance and emergency ambulance call. Focus groups and interviews elicited views of service providers on acceptability, successes and challenges of case management; interviews with service users examined their experiences. Setting: Four United Kingdom ambulance services each with one intervention and one control area. Participants: Natural experiment: adults meeting criteria for ‘frequent caller’ classification by ambulance services during 2018. Service providers: service commissioners; emergency and non-acute health and social care providers. Service users: adults with experience of calling emergency ambulance services frequently. Interventions: Usual care comprised within-service management, typically involving: patient and general practitioner letters; call centre flags invoking care plans; escalation to other services, including police. Intervention care comprised usual care with optional ‘case management’ referral to cross-service multidisciplinary team to review and plan care for selected patients. Results: We found no differences in intervention (n = 550) and control (n = 633) patients in the primary outcome (adjusted odds ratio: 1.159; 95% confidence interval: 0.595 to 2.255) or its components. Nearly all patients recorded at least one outcome (95.6% intervention; 94.9% control). Mortality was high (10.5% intervention; 14.1% control). Less than 25% of calls resulted in conveyance (24.3% intervention; 22.3% control). The most common reasons for calling were ‘fall’ (6.5%), ‘sick person’ (5.2%) and acute coronary syndrome (4.7%). Case management models varied highly in provision, resourcing, leadership and implementation costs. We found no differences in costs per patient of healthcare resource utilisation (adjusted difference: £243.57; 95% confidence interval: −£1972.93 to £1485.79). Service providers (n = 31) recognised a range of drivers for frequent calling, with some categories of need more amenable to case management than others. Some service users (n = 15) reported deep-seated and complex needs for which appropriate support may not have been available when needed. Conclusions: People who called frequently had a high risk of death and emergency healthcare utilisation at 6 months and were a heterogeneous group. Case management may work for some, but we did not find effects on emergency healthcare utilisation or mortality across the population. Limitations: This retrospective study provided limited options in selecting control areas, or in meeting recruitment targets. Data quality was variable. Arranging patient interviews proved challenging. Future research: This should prospectively evaluate different forms of case management; improve data collection; and include patients fully in qualitative components. Study registration: This study is registered as research registry (www.researchregistry.com/) researchregistry7895. Funding statement: This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 18/03/02) and is published in full in Health and Social Care Delivery Research; Vol. 13, No. 37. See the NIHR Funding and Awards website for further award information.

Objectives: To assess whether different cervical spine immobilisation strategies (full immobilisation, movement minimisation or no immobilisation), impact neurological and/or other outcomes for patients with suspected cervical spinal injury in the pre-hospital and emergency department setting. Design: Systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Data sources: MEDLINE, EMBASE, CINAHL, Cochrane Library and two research registers were searched until September 2023. Eligibility criteria: All comparative studies (prospective or retrospective) that examined the potential benefits and/or harms of immobilisation practices during pre-hospital and emergency care of patients with a potential cervical spine injury (pre-imaging) following blunt trauma. Data extraction and synthesis: Two authors independently selected and extracted data. Risk of bias was appraised using the Cochrane ROBINS-I tool for non-randomised studies. Data were synthesised without meta-analysis. Results: Six observational studies met the inclusion criteria. The methodological quality was variable, with most studies having serious or critical risk of bias. The effect of cervical spine immobilisation practices such as full immobilisation or movement minimisation during pre-hospital and emergency care did not show clear evidence of benefit for the prevention of neurological deterioration, spinal injuries and death compared with no immobilisation. However, increased pain, discomfort and anatomical complications were associated with collar application during immobilisation. Conclusions: Despite the limited evidence, weak designs and limited generalisability, the available data suggest that pre-hospital cervical spine immobilisation (full immobilisation or movement minimisation) was of uncertain value due to the lack of demonstrable benefit and may lead to potential complications and adverse outcomes. High-quality randomised comparative studies are required to address this important question. Trial registration: PROSPERO REGISTRATION Fiona Lecky, Abdullah Pandor, Munira Essat, Anthea Sutton, Carl Marincowitz, Gordon Fuller, Stuart Reid, Jason Smith. A systematic review of cervical spine immobilisation following blunt trauma in pre-hospital and emergency care. PROSPERO 2022 CRD42022349600 Available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022349600.

Objectives The ambulance service plays a pivotal role in the provision of care in out-of-hospital maternity emergencies. Telephone triage of this patient group is complex and must be sensitive to an emergency situation to prevent unnecessary delays in treatment. This study aimed to explore emergency medical dispatchers’ (EMDs) perceptions of the structured protocol they use. Design Voluntary participation in semistructured phenomenological focus groups. The participants were asked to discuss their experiences of using Medical Priority Dispatch System Protocol 24 (pregnancy, childbirth and miscarriage). Thematic analysis was applied to code and group topics. Discussion between the EMDs is presented for each theme and their experiences, including quotes, are presented to offer an overview of the maternity protocol and its use. Setting A large urban UK ambulance service. Participants 23 control room staff. Results Perceptions of maternity emergencies, challenges with key questions, the need for sensitivity surrounding miscarriage, using prearrival instructions and postdispatch instructions to help patients and ideas for additional ProQA functionality emerged as the five overarching themes. Protocol 24 was considered to reflect many of the clinical factors EMDs associate with maternity emergencies although further factors, including some non-clinical, were suggested for inclusion. Miscarriage and termination-related calls were thought to be challenging as the language of the protocol is designed for pregnancy. However, instructions were generally considered well written and user-friendly, although some were thought to be unnecessary. EMDs were largely positive regarding the ProQA software, but felt backward navigation was difficult if a situation changed. Conclusions Maternity calls were considered rewarding but complex by EMDs. We suggest changes including the use of more sensitive language in response to miscarriage and termination and make recommendations for the omission and inclusion of specific instructions, as well as enhancements to key questions and functionality. Further research is needed to ensure focus group findings are generalisable to other services, particularly in other countries.