Background and aims In recent years, the increased prevalence of youth vaping in the United Kingdom (UK) may have coincided with a proliferation in the use of 'illicit' (unregulated) vapes. Media or educational content about illicit vaping aimed at young people is scarce and poorly understood. This study aimed to systematically assess the content of both TikTok videos and educational resources relating to illicit vaping.Methods A systematically conducted analysis of educational and social media resources. Manual searches were conducted in the UK to collect URLs and metadata for publicly available TikTok videos using eight illicit vaping-related hashtags. Video content was coded across inductively derived thematic domains. Educational resources were collected via relevant search terms on Google; illicit vape content was appraised across five domains and the quality of each resource was assessed.Results A total of 58 TikTok videos were categorised across nine thematic domains. The most prevalent themes were 'Apathy Towards Law' (57%), 'Entertain/Humour' (50%) and 'Sub-culture and Shared Experience' (50%), generating a combined total of 21 million likes. Educational resources were rated as 'good' quality overall (56%) but underperformed in domains related to 'Illicit Vapes Health Risk Depiction' and 'Relevance and Appeal to Youth'. In contrast to the 'homemade', 'entertaining' and sometimes 'glamourising' presentation of the TikTok videos, educational resources adopted a serious tone and were often disengaging.Conclusions Illicit vaping content differs between TikTok videos and educational resources, exhibiting differences in sentiment, information and youth appeal. TikTok videos typically receive high engagement and frequently depict themes of apathy towards the law, entertainment and shared experience. Educational resources are generally of good quality but contain limited information on illicit vape health risks and lack youth relevance.

Background:Smoking rates are up to four times higher among people experiencing homelessness compared to the housed population and how to support them to quit is unclear. Objectives:To test the effectiveness and cost-effectiveness of providing e-cigarettes to people accessing homeless support services to stop smoking. To explore implementation fidelity, contextual influences and mechanisms of change. Trial design:A two-arm cluster randomised controlled trial with cost-effectiveness and mixed-methods process evaluation. Methods:Setting and participants: Thirty-two homeless centres (clusters) across Great Britain. Participants were aged 18+ years and known by centre staff to smoke. Sixteen staff and 31 participants in electronic cigarette centres completed qualitative interviews. Interventions:Clusters were randomised (1 : 1) to electronic cigarettes or usual care prior to staff training. Electronic cigarette participants received a refillable electronic cigarette, 4 weeks' supply of e-liquid and a fact sheet. Usual care participants received very brief advice on smoking, a support leaflet and signposting to Stop Smoking Service. Main outcome measures:Primary outcome: Carbon-monoxide-verified sustained smoking abstinence from 2 weeks post baseline to 24 weeks. Secondary outcomes: Carbon-monoxide-verified 7-day point prevalence abstinence, < 50% smoking reduction, intervention costs, quality-adjusted life-years, implementation fidelity and mechanisms of change. Results:Sixteen centres were randomised to electronic cigarettes (n = 239 participants) and 16 to usual care (n = 238 participants). In usual care, one participant died, and one withdrew consent. Final sample analysed: n = 239 (electronic cigarette); n = 236 (usual care). Sustained 24-week carbon-monoxide-verified smoking cessation rates were 5/239 (2.1%) with electronic cigarettes versus 2/236 (0.8%) with usual care (adjusted risk ratio 2.43, 95% confidence interval 0.51 to 11.64); 7-day point prevalence abstinence at 24 weeks was 15/239 (6.3%) with electronic cigarettes versus 5/236 (2.1%) with usual care (adjusted risk ratio 2.95, 95% confidence interval 1.05 to 8.29). Smoking reduction (< 50%) at 24 weeks was 83/239 (34.7%) with electronic cigarettes versus 40/236 (17%) with usual care (adjusted risk ratio 2.02, 95% confidence interval 1.44 to 2.84). Four adverse events were reported in the electronic cigarette arm; three electronic cigarette-related and not serious; one serious and not electronic cigarette-related. Mean per participant intervention costs were £92 (standard error £0) for electronic cigarettes and £50 (standard error £0) for usual care. Mean total costs were £3859 (standard error £441) versus £2716 (standard error £386) in electronic cigarette and usual care groups, respectively. Quality-adjusted life-years were estimated at 0.303 (standard error 0.008) for electronic cigarettes and 0.295 (standard error 0.010) for usual care. From National Health Service and Personal Social Services perspective, the electronic cigarette arm was £1267 (95% confidence interval £219 to £2347) more costly and yielded 0.007 (95% confidence interval -0.016 to 0.033) more quality-adjusted life-years than usual care. The incremental cost-effectiveness ratio was £181,000 per quality-adjusted life-year gain. Electronic cigarette intervention was delivered with high fidelity with no variation by centre size or location, although staff capacity and resourcing were barriers to implementation. Quit enablers included high capability to use electronic cigarettes, support from friends/family and increased motivation following smoking reduction. Barriers included lack of satisfaction with electronic cigarettes compared with smoking, a strong smoking culture at centres and staff deprioritising tobacco-related harm. Limitations:Low quit rates resulted in insufficient power to detect an effect on the primary effectiveness and cost-effectiveness outcomes, leading to uncertainty. Conclusions and future work:Electronic cigarettes showed no effectiveness for 24 weeks' sustained smoking abstinence; 7-day point prevalence abstinence and smoking reduction were possible, and staff can support the intervention. Longer-term and potentially different types of support and systems change are needed to support sustained abstinence. Funding:This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme as award number NIHR132158.

Nicotine pouch use is rapidly increasing, yet evidence on their smoking and vaping cessation potential remains limited. Social‑media discourse provides early insight into real‑world experiences, perceptions and emerging norms. This study explored discourse within comments on nicotine‑pouch‑related YouTube videos relating to smoking and vaping cessation. Using AI-assisted ‘Big Qual’ methods, we analysed 20,182 publicly available YouTube comments responding to ten videos. Comments were screened for relevance (relating to smoking or vaping cessation, perceived health impacts, or usage patterns), and 5,499 comments were retained for Machine Assisted Topic Analysis (MATA). MATA combines Latent Dirichlet Allocation topic modelling and researcher-led qualitative interpretation. Two researchers independently reviewed topic modelling outputs, supported by an additional researcher and a Patient and Public Involvement representative with lived experience of nicotine pouch use, to collaboratively develop thematic interpretations and reach consensus of meaning. Five themes were identified: First, quitting smoking or vaping using nicotine pouches and experiences of quitting pouches themselves. Second, oral-health impacts, particularly gum irritation. Third, contradictory evaluations of health risks. Fourth, contradictory evaluations of addictiveness. Fifth, cynicism of pouch use, including moral judgements about addiction, user-identity comparisons, and distrust of the tobacco industry. Comments often adopted either pseudo-scientific or dismissive tones. Findings suggest that nicotine pouches may support vaping and smoking cessation as a harm reduction tool, although oral health harms, public suspicion, and mixed messages about health risks and addictiveness may affect their acceptability. This study demonstrates a transparent, scalable Big Qual approach integrating machine learning with human interpretation to analyse online discourse.

Background:While smoking is common among those experiencing homelessness, the effectiveness of an e-cigarette intervention to reduce smoking in this population is unclear. Objective:To determine the cost-effectiveness of providing an e-cigarette for smoking cessation in homeless support centres compared to usual care. Design and methods:A multicentre two-arm cluster randomised controlled trial, with data collection time points at baseline, 4, 12 and 24 weeks post baseline. Setting and participants:Adults (aged 18+) who smoked daily and accessed 32 homeless support centres across six areas of Great Britain received either e-cigarette intervention (n = 239 in 16 centres) or usual care (n = 236 in 16 centres) by centre (cluster) randomisation. Intervention:The intervention was the provision of an e-cigarette starter kit plus 4 weeks' supply of e-liquids. The usual care comprised very brief advice for smoking cessation and signposting to local Stop Smoking Services. Main outcome measures:The total costs included costs of intervention/usual care, costs of smoking cessation outside of the trial and costs of general healthcare services use over 24 weeks. Quality-adjusted life-years were derived from EuroQol-5 Dimensions, five-level version administered at each data collection point. An incremental cost-effectiveness ratio was calculated for 24 weeks using the difference between groups in total costs and quality-adjusted life-years, with cost-effectiveness acceptability curve constructed based on bootstrap to examine uncertainty. A long-term model was employed to project a lifetime incremental cost-effectiveness ratio with probabilistic sensitivity analysis to examine uncertainty. Data sources:The analysis over 24 weeks was based on research team records and data collected via self-reported questionnaires. Unit costs for valuation were extracted from published secondary sources. The parameters of the long-term model were based on the 24-week results and published secondary sources. Results:Mean intervention costs were estimated at £92 [standard error (SE) £0] per participant and mean usual care costs at £50 (SE £0) per participant. Mean total costs per participant were estimated at £3859 (SE £441) in the e-cigarette group and £2716 (SE £386) in the usual care group. Mean quality-adjusted life-years were estimated at 0.303 (SE 0.008) in the e-cigarette group and 0.295 (SE 0.010) in the usual care group. Adjusting for baseline covariates and respective baseline values, e-cigarette group were £1267 (95% confidence interval £600 to £1938) more costly and yielded 0.007 (95% confidence interval -0.017 to 0.027) more quality-adjusted life-years than usual care. The incremental cost-effectiveness ratio was calculated at £181,000 per quality-adjusted life-year gain, with probability of intervention being cost-effective between the incremental cost-effectiveness ratio thresholds of £20,000-30,000 per quality-adjusted life-year gain at 0.9-3.5%. The lifetime model projected the incremental cost-effectiveness ratio at £38,360 per quality-adjusted life-year gained, with the probability of intervention being cost-effective between £20,000 and £30,000 from 47.6% to 49.6%. Limitations:The imbalance in missing data led to some uncertainty in the results, and healthcare costs recorded in the trial may not reflect the health needs of this population. Conclusions:Providing e-cigarettes for smoking cessation in homeless support centres was more costly than usual care, but the small increase in quality-adjusted life-years was not significant. Future work:Future work should aim to maximise quit rates while being cost-effective and therefore implementable. Funding:This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme as award number NIHR132158.

BACKGROUND:Smoking prevalence among people experiencing homelessness is high. This study explored the factors which influenced potential smoking abstinence among participants receiving an e-cigarette (EC) intervention within the Smoking Cessation Trial in Centres for Homelessness (SCeTCH) across Great Britian. METHODS:Using the Capability Opportunity Motivation - Behaviour (COM-B) model, hypothesised and emerging mediators were explored quantitatively via measures in baseline and follow-up questionnaires (n=239) and qualitatively via interviews with homelessness centre staff (n=16) and participants (n=31) who received an EC starter pack and 4-week e-liquid supply. We purposively sampled 8 centres for interviews, representing varied regions and participant vaping/smoking and sociodemographic status. Quantitative measures were analysed descriptively. Qualitative data were analysed thematically. Data from the two approaches were mapped onto the COM-B for combined analysis and reporting. RESULTS:After receiving the intervention, participants demonstrated high capability to use EC and appreciation of EC for harm reduction. Some participants reported dissatisfaction with vaping. Opportunity for behaviour change was strengthened by perceived acceptability to vape and social support beyond the centre but hindered by a smoking culture and perceived lack of staff support. Motivation was enhanced by EC efficacy belief, pride from cutting down, and financial benefits of vaping, but negatively impacted by challenging personal circumstances. CONCLUSION:For people accessing homelessness support centres, smoking abstinence remains challenging. More intensive support and a variety of approaches to support smoking cessation, particularly those which address the psychosocial factors which hinder smoking abstinence, may be required. Future research should focus on how this can be achieved.

Smoking rates are exceptionally high among people experiencing homelessness. We aimed to test the effectiveness of an e-cigarette (EC) intervention designed to help people accessing homeless support services to stop smoking. A two-arm cluster randomised controlled trial. We recruited 32 homeless centres (clusters) across Great Britain. Participants were aged 18 + and known by centre staff to smoke. Randomisation of clusters (1:1; using various block sizes) to EC or usual care (UC) was generated in Stata by the trial statistician, concealed from researchers. Participants in EC clusters received a refillable EC, 4-week supply of e-liquid, and a fact sheet. UC participants received very brief advice on smoking, a support leaflet, and signposting to the stop smoking service. Interventions were delivered by centre staff. The primary outcome was sustained abstinence from smoking from 2 weeks post-baseline through to 24 weeks, verified by carbon monoxide (CO) measurements below 8 ppm. Secondary outcomes included CO-verified 7-day point prevalence abstinence. Analysis was intention-to-treat. Between February 22, 2022, and June 22, 2023, 16 centres were randomised to EC (n = 239 participants) and 16 to UC (n = 238 participants). In UC, one participant died, and one withdrew consent. Final sample analysed: n = 239 (EC); n = 236 (UC). Sustained 24-week CO-validated smoking cessation rates were 5/239 (2.1

Organisational priorities for health care focus on efficiency as the health and care needs of populations increase. But evidence suggests that excessive planning can be counterproductive, leading to resistance from staff and patients, particularly those living with cognitive impairment. The current paper adds to this debate reporting an Institutional Ethnography of staff delivering care for older patients with cognitive impairment on acute orthopaedic wards in three National Health Service hospitals in the United Kingdom. A key problematic identified in this study is the point of disjuncture seen between the actualities of staff experience and intentions of protocols and policies. We identified three forms of disjuncture typified as: ‘disruptions’, where sequenced care was interrupted by patient events; ‘discontinuities’, where divisions in professional culture, space or time interrupted sequenced tasks; and ‘dispersions’, where displaced objects or people interrupted sequenced care flow. Arguably disruption is an integral characteristic of care work; it follows that to enable staff to flourish, organisations need to confer staff the autonomy to address systemic disruptions rather than attempt to eradicate them. Ultimately, organisational representations of ‘good practice’ as readily joined up, impose a care standard ‘stereotype’ that obscures rather than clarifies the interactional problems encountered by staff.

BACKGROUND AND AIMS:Youth use of disposable vapes has increased markedly in the United Kingdom in recent years, yet little is known about the motivations, experiences and perceptions of young people themselves. This study aimed to explore young people's experiences and use of disposable vapes. METHODS:This was a qualitative study recruiting young people reporting regularly vaping disposables, collecting data via dyad guided, individual and group interviews. Data analysis was theoretically informed by the Social Ecological Model. Inductive and deductive coding approaches were used, with resolution of coded interpretations by consensus. RESULTS:Twenty-nine young people aged 16-20 years participated in qualitative interviews. At the individual level, participants discussed how characteristics of disposable vapes were important to them-particularly price, accessibility and the attractive designs, colours, names and flavours. Young people frequently engaged in both vaping and tobacco smoking, seeing the behaviours as interchangeable dependent on context, and having inaccurate relative harm perceptions of vaping compared with smoking. Experimentation was widespread and many used vapes as a way of managing stress and anxiety. Vaping was positioned as a social behaviour, common among peers. Parental influence on vaping behaviour was minimal, although vaping initiation could be influenced by family vaping norms. Culturally, vaping was a widespread normalized behaviour. Young people were aware of media reports and potential harms, but were less aware of smoking related harms as a consequence. CONCLUSIONS:Disposable vapes appear to be attractive and accessible to young people in the United Kingdom. Vaping is normalized in this population, despite being seen as potentially damaging to health, and vaping and smoking are engaged in interchangeably. Underage sales of vapes are reportedly widespread. Strict regulation, such as banning products or increasing prices, may prompt UK youth to switch from vaping to smoking.

IntroductionPeople living in coastal communities have some of the worst health outcomes in the UK, driven in part by high smoking rates. Deprived coastal communities include socially disadvantaged groups that struggle to access traditional stop smoking services. The study aimed to seek the views of people who smoke living in coastal communities, to assess the optimal smoking cessation intervention for this population. In addition, the Template for Intervention Description Replication (TIDieR) checklist was adapted as an analytical framework for qualitative data to inform intervention design.MethodsCurrent or recent ex-smokers (n = 25) were recruited to participate in qualitative interviews from a range of community locations in a deprived English seaside town. A thematic analysis of the interview data was undertaken adapting the TIDieR framework. This analysis was triangulated with relevant literature and notes from stakeholder meetings and observations to map onto the TIDieR checklist to describe the optimal intervention.ResultsBarriers to quitting smoking in the target population included low motivation to quit, high anxiety/boredom, normalisation of smoking and widespread illicit tobacco use. There was broad support for combining behavioural support, e-cigarettes and financial incentives, with a strong preference for the intervention to be delivered opportunistically and locally within (non-healthcare) community settings, in a non-pressurising manner, ideally by a community worker specially trained to give stop smoking support.ConclusionsAn intensive community-based smoking cessation intervention was acceptable to the target population. Adapting the TIDieR checklist as a deductive qualitative analytical framework offered a systematic approach to intervention development. Combined with other intervention development activities, this ensured that the intervention design process was transparent and the proposed intervention was well defined. It is recommended that prior to intervention development researchers speak to members of the target population who may give valuable insight into the optimal intervention.

Background A colorectal resection is standard treatment for patients with colorectal cancer (CRC). However, the procedure results in significant post-operative mortality and reduced quality of life. Maximising pre-operative cardiopulmonary fitness could improve post-surgical outcomes. PREPARE-ABC is a multi-centre, three-armed, randomised controlled trial investigating the effects of exercise interventions, with motivational support on short and longer-term recovery outcomes in CRC patients undergoing major lower-gastrointestinal surgery. The trial included an internal pilot phase with parallel process evaluation. The aim of the process evaluation was to optimise intervention implementation for the main trial. Methods Mixed methods process evaluation conducted in 14 UK hospitals between November 2016 and March 2018. Data included a site profile questionnaire and telephone scoping interview with hospital staff, 34 qualitative observations of standard care and 14 observations of intervention delivery, 13 semi-structured interviews with healthcare professionals (HCPs) and 28 semi-structured interviews with patients. Data analysis focused on describing intervention delivery within each arm, assessing fidelity, acceptability and how variation in delivery was linked to contextual characteristics. Results Standard care exercise advice was typically limited to maintaining current activity levels, and with lead-in time to surgery affecting whether any exercise advice was provided. Variation in HCP capacity affected the ability of colorectal units to deploy staff to deliver the intervention. Patients' exercise history and motivation prior to surgery influenced HCP perceptions and delivery of the motivational components. Observations indicated a high level of fidelity to delivery of the exercise interventions. All but one of the 28 interviewed patients reported increasing exercise levels as a result of receiving the intervention, with most finding them motivational and greatly valuing the enhanced level of social support (versus standard care) provided by staff. Conclusion Hospital-supervised and home-based exercise interventions were highly acceptable for most patients undergoing surgery for CRC. Delivery of pre- and post-operative exercise within the CRC care pathway is feasible but systematic planning of capacity and resources is required to optimise implementation.

Within health and social care, academic attention is increasingly paid to understanding the nature and centrality of body work. Relatively little is known about how and where body work specifically fits into the wider work relations that produce it in healthcare settings. We draw on ethnographic observations of staff practice in three National Health Service acute hospital wards in the United Kingdom to make visible the micro-processes of patient care sequences including both body work and the work contextualising and supporting it. Our data, produced in 2015, show body work interactions in acute care to be critically embedded within a context of initiating, preparing, moving and restoring and proceeding. Shades of privacy and objectification of the body are present throughout these sequences. While accomplishing tasks away from the physical body, staff members must also maintain physical and cognitive work focussed on producing body work. Thus, patient care is necessarily complex, requiring much staff time and energy to deliver it. We argue that by making visible the micro-processes that hospital patient care depends on, including both body work and the work sequences supporting it, the complex physical and cognitive workload required to deliver care can be better recognised. (A virtual version of this abstract is available at: https://www.youtube.com/channel/UC_979cmCmR9rLrKuD7z0ycA).

Background Patient and public involvement (PPI) is a requirement for UK health and social care research funding. Evidence for how best to implement PPI in research programmes, such as National Institute for Health Research (NIHR) Collaborations for Applied Health Research and Care (CLAHRCs), remains limited. This paper reports findings from an action research (AR) project called IMPRESS, which aims to strengthen PPI within CLAHRC East of England (EoE). IMPRESS combines AR with Normalisation Process Theory (NPT) to explore PPI within diverse case study projects, identifying actions to implement, test and refine to further embed PPI. Methods We purposively selected CLAHRC EoE case study projects for in-depth analysis of PPI using NPT. Data were generated from project PPI documentation, semi-structured qualitative interviews with researchers and PPI contributors and focus groups. Transcripts and documents were subjected to abductive thematic analysis and triangulation within case. Systematic across case comparison of themes was undertaken with findings and implications refined through stakeholder consultation. Results We interviewed 24 researchers and 13 PPI contributors and analysed 28 documents from 10 case studies. Three focus groups were held: two with researchers (n = 4 and n = 6) and one with PPI contributors (n = 5). Findings detail to what extent projects made sense of PPI, bought in to PPI, operationalised PPI and appraised it, thus identifying barriers and enablers to fully embedded PPI. Conclusion Combining NPT with AR allows us to assess the embeddedness of PPI within projects and programme, to inform specific local action and report broader conceptual lessons for PPI knowledge and practice informing the development of an action framework for embedding PPI in research programmes. To embed PPI within similar programmes teams, professionals, disciplines and institutions should be recognised as variably networked into existing PPI support. Further focus and research is needed on sharing PPI learning and supporting innovation in PPI.

Older people and their families consistently place high value on hospital care that promotes personalised relationships between staff and patients, often termed Person-Centred Care (PCC). PCC features in care guidelines from across Europe, North America and the Asia-Pacific region, demonstrating the value increasingly placed by policymakers on methods emphasising ‘personhood’-in care practices. However, as many secondary care settings such as acute trauma wards become highly rationalised and task driven, PCC orientations can be given less priority. This paper reports on an ethnographic study undertaken within an international research programme exploring ways of delivering care to people living with dementia and admitted to secondary care with hip fracture. Observations were undertaken by five academic and three trained ‘lay’ researchers in Emergency Departments and Trauma wards in three hospitals from across the United Kingdom, generating a data set of 192 hours of observations (48 observations, approximately 4 hours each). Fieldnotes collected from the differing spaces were thematically analysed and further analysed applying Kitwood's (1997) person centred care framework. Data illuminated staff creativity in identifying and responding to opportunities to maintain patient personhood while performing the routine care tasks prioritised within settings. Staff in acute care environments can bring an integrated awareness both of policies prioritising PCC opportunities and policies prioritising task performance, to moderate their practice in creative ways. We conclude that skilled practice responses can ensure task-orientated routines and providing PPC need not be mutually exclusive.

Patients who have fractured their hip and have a cognitive impairment have poorer outcomes compared to those with full cognition. We aimed to determine whether a novel multi-component intervention developed to enhance the recovery of hip fracture patients with cognitive impairment could be implemented in acute trauma wards. A Plan, Do, Study, Act model for service improvement was used in 4 cycles to change practice in 3 acute orthopaedic trauma wards in England. The PERFECT-ER intervention was used to assess care, inform action planning and as a catalyst for service improvement. A Service Improvement Lead (SIL) facilitated implementation at each site. Intervention scores, implementation process reports and observational fieldwork data were collected. Thematic analysis was conducted by case. All sites implemented multiple aspects of the PERFECT-ER, with Service Improvement Leads (SIL) using different implementation styles. All SILs tackled easier changes first. More complex and organisational changes occurred when SILs had gained working knowledge and confidence. Results show some implementation reflected changes in documentation or wording to make existing practices visible rather than actual changes in practice although numerous changes in practice were made. The PERFECT-ER intervention was collaboratively refined and an implementation manual created. Barriers and facilitators to implementation were identified. This study demonstrated the novel multi-component PERFECT-ER intervention can be implemented in acute orthopaedic trauma wards and practice can change to facilitate care of hip fracture patients with cognitive impairment. Further testing is needed to identify if practice changes influence patient outcomes.

BACKGROUND:Health and social care provision for an ageing population is a global priority. Provision for those with dementia and hip fracture has specific and growing importance. Older people who break their hip are recognised as exceptionally vulnerable to experiencing confusion (including but not exclusively, dementia and/or delirium and/or cognitive impairment(s)) before, during or after acute admissions. Older people experiencing hip fracture and confusion risk serious complications, linked to delayed recovery and higher mortality post-operatively. Specific care pathways acknowledging the differences in patient presentation and care needs are proposed to improve clinical and process outcomes. METHODS:This protocol describes a multi-centre, feasibility, cluster-randomised, controlled trial (CRCT) to be undertaken across ten National Health Service hospital trusts in the UK. The trial will explore the feasibility of undertaking a CRCT comparing the multicomponent PERFECTED enhanced recovery intervention (PERFECT-ER), which acknowledges the differences in care needs of confused older patients experiencing hip fracture, with standard care. The trial will also have an integrated process evaluation to explore how PERFECT-ER is implemented and interacts with the local context. The study will recruit 400 hip fracture patients identified as experiencing confusion and will also recruit "suitable informants" (individuals in regular contact with participants who will complete proxy measures). We will also recruit NHS professionals for the process evaluation. This mixed methods design will produce data to inform a definitive evaluation of the intervention via a large-scale pragmatic randomised controlled trial (RCT). DISCUSSION:The trial will provide a preliminary estimate of potential efficacy of PERFECT-ER versus standard care; assess service delivery variation, inform primary and secondary outcome selection, generate estimates of recruitment and retention rates, data collection difficulties, and completeness of outcome data and provide an indication of potential economic benefits. The process evaluation will enhance knowledge of implementation delivery and receipt. TRIAL REGISTRATION:ISRCTN, 99336264 . Registered on 5 September 2016.

BACKGROUND:Telephone triage is an increasingly common means of handling requests for same-day appointments in general practice. AIM:To determine whether telephone triage (GP-led or nurse-led) reduces clinician-patient contact time on the day of the request (the index day), compared with usual care. DESIGN AND SETTING:A total of 42 practices in England recruited to the ESTEEM trial. METHOD:Duration of initial contact (following the appointment request) was measured for all ESTEEM trial patients consenting to case notes review, and that of a sample of subsequent face-to-face consultations, to produce composite estimates of overall clinician time during the index day. RESULTS:Data were available from 16,711 initial clinician-patient contacts, plus 1290 GP, and 176 nurse face-to-face consultations. The mean (standard deviation) duration of initial contacts in each arm was: GP triage 4.0 (2.8) minutes; nurse triage 6.6 (3.8) minutes; and usual care 9.5 (5.0) minutes. Estimated overall contact duration (including subsequent contacts on the same day) was 10.3 minutes for GP triage, 14.8 minutes for nurse triage, and 9.6 minutes for usual care. In nurse triage, more than half the duration of clinician contact (7.7 minutes) was with a GP. This was less than the 9.0 minutes of GP time used in GP triage. CONCLUSION:Telephone triage is not associated with a reduction in overall clinician contact time during the index day. Nurse-led triage is associated with a reduction in GP contact time but with an overall increase in clinician contact time. Individual practices may wish to interpret the findings in the context of the available skill mix of clinicians.

Background: Nurse-led telephone triage is increasingly used to manage demand for general practitioner consultations in UK general practice. Previous studies are equivocal about the relationship between clinical experience and the call outcomes of nurse triage. Most research is limited to investigating nurse telephone triage in out-of-hours settings.Objective: To investigate whether the professional characteristics of primary care nurses undertaking computer decision supported software telephone triage are related to call disposition.Design: Questionnaire survey of nurses delivering the nurse intervention arm of the ESTEEM trial, to capture role type (practice nurse or nurse practitioner), prescriber status, number of years' nursing experience, graduate status, previous experience of triage, and perceived preparedness for triage.Our main outcome was the proportion of triaged patients recommended for follow-up within the practice (call disposition), including all contact types (face-to-face, telephone or home visit), by a general practitioner or nurse.Settings: 15 general practices and 7012 patients receiving the nurse triage intervention in four regions of the UK.Participants: 45 nurse practitioners and practice nurse trained in the use of clinical decision support software.Methods: We investigated the associations between nursing characteristics and triage call disposition for patient 'same-day' appointment requests in general practice using multivariable logistic regression modelling.Results: Valid responses from 35 nurses (78%) from 14 practices: 31/35 (89%) had >= 10 years' experience with 24/35 (69%) having >= 20 years. Most patient contacts (3842/4605; 86%) were recommended for follow-up within the practice. Nurse practitioners were less likely to recommend patients for follow-up odds ratio 0.19, 95% confidence interval 0.07; 0.49 than practice nurses. Nurses who reported that their previous experience had prepared them less well for triage were more likely to recommend patients for follow-up (OR 3.17, 95% CI 1.18-5.55).Conclusion: Nurse characteristics were associated with disposition of triage calls to within practice follow-up. Nurse practitioners or those who reported feeling 'more prepared' for the role were more likely to manage the call definitively. Practices considering nurse triage should ensure that nurses transitioning into new roles feel adequately prepared. While standardised training is necessary, it may not be sufficient to ensure successful implementation. (C) 2016 The Authors. Published by Elsevier Ltd.