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.

PURPOSE:Childhood convulsive status epilepticus (CSE) is a time-critical emergency (incidence 17-23/100,000/yr) requiring prompt treatment to reduce morbidity and mortality. Prehospital midazolam is as safe as diazepam, but more effective. However, legal and logistical barriers limit its use by paramedics. We performed a UK-wide survey of current practice, perceived barriers, and views on intramuscular midazolam (IMMDZ) to inform service development, gauge interest in a potential ambulance-based trial of emergency treatment of childhood CSE and identify opinions to consider in trial study design. METHODS:We conducted a cross-sectional JISC Knowledge-Attitude-Practice survey of personnel across all 13 UK NHS Ambulance Services (21 May-30 June 2025). The survey captured demographics, first-line antiseizure medication (ASM) choices, operational challenges, knowledge of IMMDZ usage, and support for research. RESULTS:153 respondents across all 13 ambulance services (4-26/service) participated; 146 (95%) were paramedics (100 were generalist). Diazepam (by the rectal or intravenous route) was first-line ASM in nine services; buccal midazolam in three, and IMMDZ in one. 89% reported that alternative ASMs should be available to generalist paramedics. 97% supported research on IMMDZ for emergency treatment of childhood CSE. If approved, 85% thought their Trust would likely support its clinical use. Potential barriers to use included dosing uncertainty (53%), risk of respiratory depression (46%), inappropriate use (37%), and reticence of administering intramuscular medication (24%). CONCLUSION:There is a need to standardize paramedic treatment of seizures in children in the UK. NHS Ambulance clinicians are supportive of investigating IMMDZ as prehospital treatment for childhood CSE.

Background:Ambulance clinicians use pre-alert calls to emergency departments to enable them to prepare for the arrival of a patient. This can lead to improved time-critical treatment. However, pre-alerts should be used judiciously, as over-alerting may add pressures on busy emergency departments, while under-alerting may lead to delays in time-critical patient care. We undertook a mixed-methods study to explore how pre-alerts are used and their impact on patients, ambulance and emergency department staff. Method and design:The mixed-methods study integrated data from: (1) linked routine data set of 12 months' (2020-1) electronic patient records (3 ambulance services), clinician information and routine hospital statistics, (2) semistructured interviews with 34 ambulance clinicians and 40 emergency department staff and 162 hours non-participant observation of pre-alerts across 6 emergency departments, (3) national online survey of ambulance clinicians (1298 responses). Multivariate logistic regression was undertaken in R™ (The R Foundation for Statistical Computing, Vienna, Austria) to identify factors associated with pre-alert rates in terms of patient (National Early Warning Score 2, working diagnosis, age, sex), ambulance clinician (experience, role, sex, time to end of shift) and hospital factors (journey time, percentage of ambulances waiting > 30 minutes). Qualitative data were analysed using thematic analysis in NVivo™ (QSR International, Warrington, UK). Findings were integrated using a triangulation protocol. Findings:Pre-alerts are key to enabling emergency department staff to prepare physically and psychologically for critically ill patients, particularly when resources are constrained. We identified significant variation in pre-alert practice and pre-alert rates at both individual and organisational level that was not explained by patient case mix. Pre-alert decisions were based on clinician risk perception, clinical experience (pattern recognition), protocols and anticipated response by emergency department staff, including consideration of different emergency department expectations regarding pre-alerts. Pre-alert calls included advice calls, 'courtesy' or 'heads up' calls where clinicians had no immediate clinical concern, but called due to protocol requirements or concern about the potential for subsequent deterioration during a handover delay. Frustrations arose from different individual expectations of a pre-alert. Inconsistent guidance between ambulance services and emergency departments, and limited clinician knowledge and awareness of guidance, led to uncertainty and misunderstanding regarding who required pre-alerting. Understanding how to pre-alert was based primarily on learning 'on the job' and informal feedback mechanisms rather than formal training and feedback, including emergency department response to previous pre-alerts. Pre-alert calls created interruptions but were valued by emergency department staff. Emergency department response to pre-alert calls was highly variable and dependent principally upon resource availability (staffing, crowding, acuity of other patients) at the time of pre-alert. Variation in individual emergency department's clinician practice and in emergency departments processes for managing pre-alerted patients (particularly for patients not brought into resuscitation bay) contributed to different responses for similar types of pre-alert calls. Different protocols and documentation used by emergency department and ambulance staff to deliver and document the pre-alert created interruptions and frustration during the pre-alert call. Provision of a headline clinical concern to frame the pre-alert was perceived as useful, particularly when observations and clinical concern did not align. Limitations:Despite flexible recruitment procedures, no patients were interviewed. Implications and future work:Pre-alert decision-making and communication may be improved by increased consistency of emergency department and ambulance service pre-alert guidance and training. Improved ambulance service and emergency department communication and co-produced shared documentation may help improve pre-alert clarity and usefulness while reducing tensions. 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 NIHR131293.

Introduction Falls are a major public health concern, particularly among older adults. Without life-threatening symptoms, ambulance calls may be triaged as low priority and people may remain on the floor and experience a “long lie”, risking dehydration, pressure injury, muscle damage and psychological distress. However, there is currently limited evidence on the scale, clinical impact and subsequent care trajectory for people who have experienced a long lie. This study aims to address this gap by exploring the characteristics, outcomes, and potential interventions for people who experience a long lie after a fall. Methods This is a comprehensive, 27-month, mixed-methods study structured across seven interlinked work packages (WPs). Quantitative work (WP1 & WP2) will analyse linked ambulance, emergency department, and hospital data from one ambulance service region to characterise individuals who experience long lies, quantify their care trajectories, estimate resource use, and explore and refine the definition of a ‘harmful long lie’ threshold. WP3 involves a detailed review of 200 patient hospital notes to understand the mechanisms by which long lies impact health outcomes and care trajectories. Qualitative work (WP4, WP5, & WP6) includes analysis of surveys and semi-structured interviews with ambulance staff, care home managers, key stakeholders, and, crucially, individuals with lived experience of a long lie and their carers. WP7 will synthesize all findings in workshops with national stakeholders to co-produce clear, evidence-based guidance and policy recommendations for managing long lies. Discussion By integrating quantitative data on scale and cost of long lies with qualitative data on lived experience and professional practice, this study will provide in-depth understanding of the clinical, social, and economic impact of long lies. The findings will inform the development of interventions to mitigate the harmful effects of prolonged time on the floor leading to improved care pathways and better outcomes for individuals who experience a long lie after a fall.

Introduction:People in prison experience substantial health inequalities, including higher prevalence of physical and mental health conditions, substance misuse and mortality. Despite this, ambulance service activity involving the prison population is poorly understood. The aim of this service evaluation was to understand the nature and volume of emergency ambulance calls from prisons in the Yorkshire and Humber region. Methods:This service evaluation used retrospective data from Yorkshire Ambulance Service (YAS) dispatch records for emergency calls for adults (≥18 years) from 13 regional prisons between 1 April 2021 and 31 March 2022. Call details included the call reason, the patient disposition (defined as the plan after assessment and/or treatment, categorised as transported or not transported) and call timings. Publicly available Ministry of Justice statistics on prison populations were also consulted for context. Descriptive analyses were performed using counts, proportions, means, medians and confidence intervals. Conveyance rates (the percentage of calls attended by a YAS vehicle that resulted in patient transport) were calculated and compared to conveyance rates from incidents attended by YAS as a whole. Results:YAS received 1263 calls from prisons, with at least one ambulance dispatched to 1025. These calls accounted for 0.14% of total incidents attended by YAS. Of these, 730 incidents resulted in conveyance, representing a 71.2% conveyance rate, which was approximately one-third higher than the regional average. However, the clinical acuity of patients did not consistently justify this. Considerable variation in call frequency was observed between prisons. Conclusion:Calls to the ambulance service from prisons represent a small proportion of overall YAS workload. Initial call triage placed a greater proportion of calls from prisons in the highest priority category, and both attendance and conveyance rates were higher from prisons compared to the general population.

Introduction Urgent and emergency care (UEC) systems in England face unprecedented pressures, with record accident and emergency attendances, persistent breaches of ambulance response targets and poorer outcomes for time-sensitive conditions. National UEC recovery plans have introduced multiple innovations—such as same-day emergency care, virtual wards and specialty hubs—to manage these pressures and improve patient flow. Rural coastal areas are particularly vulnerable to excessive demand due to higher levels of deprivation, older populations with complex health needs, seasonal surges that generate unpredictable demand and challenges in attracting and retaining staff. Following the Chief Medical Officer’s 2021 Annual Report, funding research and developing bespoke solutions to manage UEC demand and address geographical disparities has been recognised as a national priority. The Elevate study responds to this priority by identifying and evaluating innovative models of UEC in rural coastal communities in England.Methods and analysis The Elevate study is a 30-month, mixed-methods evaluation that comprises three interlinked work packages: (1) National service mapping—outlining provision of innovative models of UEC in rural coastal areas of England. This will be developed through document review and interviews with regional and national service leaders. (2) Quantitative analysis—quasiexperimental and longitudinal approaches will use National Health Service (NHS) England’s Emergency Care Data Set and linked routine NHS datasets to evaluate the impact of UEC models on health and process outcomes. Standard and bespoke metrics will be developed and used to assess performance. (3) Qualitative case studies—up to 12 case studies of UEC models in rural coastal communities. Interviews with patients and staff and non-participant observation will explore how and why different UEC models influence patient experience, clinical outcomes, resource use and the workforce. Findings will be integrated using the Consolidated Framework for Implementation Research to identify components of UEC models that are effective, scalable and sensitive to local context,Ethics and dissemination Ethical approval for qualitative components was granted by the North of Scotland Research Ethics Committee (25/NS/0099). Dissemination will include peer-reviewed publications, policy briefs, creative media and community engagement activities to ensure findings are communicated inclusively and effectively to policymakers, health and social care practitioners and the public.Trial registration number Research Registry (researchregistry11126).

Introduction The Major Trauma Triage Study (‘MATTS’) triage tool was designed to identify patients with major trauma who could benefit from expedited care in specialist major trauma centres (MTCs). We aimed to investigate the impact of the MATTS tool on major trauma triage decisions after implementation. Methods Consecutive patients were included in a multicentre, prospective cohort study conducted between 1 November 2021 and 15 May 2022 in six trauma networks served by West Midlands and Yorkshire Ambulance Services. Electronic data from ambulance service patient report forms were linked to data from the Trauma Audit and Research Network trauma registry. The accuracy of prehospital triage decisions (conveyance to an MTC with pre-alert) against a bespoke MATTS reference standard to define major trauma was calculated. This was compared with optimal undertriage/overtriage trade-off indicated by previous economic modelling. Additional analyses investigated theoretical triage tool accuracy based on recorded data irrespective of hospital destination, examined important injury subgroups, evaluated alternative reference standards and described triage tool use. Results In total, 38 010 injured patients were included, with 2.2% prevalence of major trauma. The MATTS triage tool demonstrated 55.3% sensitivity (95% CI 51.8% to 58.7%) and 94.3% specificity (95% CI 94.1% to 94.6%). There was evidence of triage tool use in a minority of patients (6.3%), with senior clinical advice sought in 9.3% of patients. Theoretical triage tool sensitivity was 51.1% (95% CI 47.6% to 54.5%) with specificity 93.6% (95% CI 92.7% to 94.4%). Agreement between the theoretical triage tool result and the observed triage decision was good (absolute agreement 90.4%, Gwet’s agreement coefficient 1 (AC1) statistic 0.89, 95% CI 0.89 to 0.89). Accuracy varied across different ages, mechanisms of injury subgroups and alternative reference standards for major trauma. Conclusions The MATTS triage tool achieved an appropriate undertriage/overtriage trade-off compared with previously established targets. However, documented adherence to MATTS was low. Dedicated training and further evaluation are necessary prior to national wider implementation.

Introduction: Paramedics play an important role in addressing the growing demands in urgent and emergency care. Point-of-care testing (POCT) devices are increasingly portable and may assist with appropriate non-conveyance, but limited research exists to support this. This feasibility study aimed to inform the design of a larger study to determine whether it is practical for paramedics to use blood analysis POCT. Methods: An eight-month single-site feasibility sequential explanatory mixed-method study was conducted between April and December 2023, with a team of specialist paramedics who were provided with Abbott® i-STAT Alinity ™ POCT devices with CHEM8+ and CG4+ cartridges. Using a qualitative evaluation of paramedic participants’ experience with a POCT device and a descriptive analysis of case report forms and routine ambulance service data collection. Results: Seven specialist paramedics were recruited; 287 patients were screened, of which 252 (88%) were excluded and 35 (12%) were recruited. Lack of mental capacity excluded 76% of cases. The mean age was 82 years; 40% of participants were female and 60% were male. Hospital conveyance rates were four (11%) of the recruited patients. In those recruited and not conveyed, the median time on scene was 120 minutes. The success rate to obtain a test result at the first attempt was 81% (CHEM8+) and 84% (CG4+). Test result failure rates were 13% (CHEM8+) and 3% (CG4+). Focus group data revealed that paramedic participants considered POCT useful for decision making and the device procedures to be acceptable. Paramedics reported that extended time on scene was related to trial procedures and waiting times to discuss test results with healthcare professionals. Conclusion: The POCT devices were acceptable and practical for use by our specialist paramedic participants. The results of this feasibility study should inform the design of a larger study to test the impact of using POCT, to understand challenges in recruitment and retention where POCT is utilised and to determine the clinical presentations where POCT can be applied.

Introduction: Many clinical trials within ambulance services require trained frontline paramedics to directly recruit or enrol eligible patients. Research paramedics may then review study documents and often contact recruiting paramedics to provide feedback or obtain missing data. Using the example of the Paramedic Analgesia Comparing Ketamine and MorphiNe in trauma (PACKMaN) study, we aimed to evaluate the provision of feedback by the Yorkshire Ambulance Service (YAS) research team to recruiting paramedics. Methods: This was a service evaluation using a qualitative design. Data collection was conducted in January 2023 and consisted of a focus group and document analysis. The focus group lasted one hour and involved nine YAS research staff involved in feedback provision. Preliminary results were presented to focus group members to facilitate member checking. Reviewed documents included written feedback sent by the local research team and a standard operating procedure on incidental clinical errors. Data were analysed using the framework method. Results: Research paramedics provided recruiting paramedics with feedback on ‘research study activities’, such as missing data, (in) eligible patients (not) enrolled or study protocol (not) followed. Feedback on ‘clinical practice’ not related to research activities, but incidentally discovered, was not considered within the remit of research paramedics. Barriers to effective feedback provision were the lack of awareness in recruiting paramedics that feedback would be provided and a perception that unsolicited feedback is mostly negative. Using different formats to provide feedback and engaging in a dialogue with recruiting paramedics was seen to facilitate more meaningful feedback. Conclusion: Training for recruiting paramedics should highlight that performance and documentation will be scrutinised as part of their involvement in the clinical trial. Although flexibility of local teams regarding feedback format and delivery was important, researchers planning interventional studies in ambulance services may wish to consider the impact of different ways of working with frontline clinicians in their protocol development and study evaluation.

Objectives Ambulance clinicians use prealert calls to advise emergency departments (ED) of the arrival of patients requiring immediate review or intervention. Consistency of prealert practice is important in ensuring appropriate ED response to prealert calls. We used routine data to describe prealert practice and explore factors affecting variation in practice.Design and setting We undertook a retrospective observational study in three UK ambulance services using a linked dataset incorporating 12 months’ ambulance patient records, ambulance clinician data and emergency call data.Outcome measures We used least absolute shrinkage and selection operator regression to identify candidate variables for multivariate logistic regression models to predict variation in prealert use, analysing clinician factors (role, experience, qualification, time of prealert during shift), patient factors (National Early Warning Score version 2, clinical working impression, age, sex) and hospital factors (receiving ED, ED handover delay status).Results From the dataset of 1 363 274 patients conveyed to ED, 142 795 (10.5%) were prealerted, of whom 42 362 (30%) were for conditions with clear prealert pathways (eg, sepsis, stroke, ST-elevation myocardial infarction, major trauma). Prealert rates varied across and within different ambulance services. Casemix (illness acuity score, clinical diagnostic impression) was the strongest predictor of prealert use, but male patient sex, clinician role, receiving hospital and hospital turnaround delay at receiving hospitals were also statistically significant predictors, after adjusting for casemix. There was no evidence that prealert rates are higher during the final hour of shift.Conclusions Prealert decisions are influenced by factors other than illness acuity and clinical diagnostic impression alone. Variation in prealert practice suggests that procedures and processes for prealerting may lack clarity and improved prealert protocols may be required. Research is required to understand whether our findings are reproducible elsewhere and why non-clinical factors (eg, patient gender) may influence prealert practice.

BACKGROUND:TRIM (What TRIage model is safest and most effective for the Management of 999 callers with suspected COVID-19? A linked outcome study) was an evaluation of models used to triage and manage emergency ambulance service care for patients with suspected COVID-19. In an embedded qualitative component, we aimed to understand experiences and concerns of clinical and managerial staff about processes for responding to patients with suspected COVID-19, in the call centre and on scene. METHODS:Research paramedics in four study sites across England interviewed purposively selected stakeholders from ambulance services (call handlers, clinical advisors in call centres, clinicians providing emergency response, managers) and emergency department clinical staff. Interviews (n=25) were conducted remotely, recorded and transcribed. Thematic analysis was conducted by a group of researchers and PPI (patient and public involvement) partners working together. RESULTS:We present four themes, developed from the data. Services made efforts to target their response to those most in need, while trying to minimise infection risk; they reduced face-to-face contact where possible, dealing with more calls remotely. Adjustments by other providers in the wider healthcare system affected the flow of patients to and from ambulance services. There was substantial work and heavy cognitive load for staff at all levels in updating knowledge and repeatedly implementing changes. Staff working in the range of roles in ambulance services also carried a heavy emotional load. CONCLUSIONS:Services made flexible changes to triage processes using the best level of understanding available at the time, in a healthcare setting which always operates in high levels of uncertainty. Implementing triage protocols in response to the COVID-19 pandemic was a complex and fluid process which had to be actively managed by a range of front-line staff, dealing with external pressures and a heavy emotional load. Increased understanding of the way in which services and staff had to adapt, and the cognitive and emotional burden this entailed, may help in planning for future pandemics.

BACKGROUND:Occupational burnout affects between 11 % and 30 % of healthcare professionals and is associated with staff sickness, job turnover, increased costs and poorer quality of care. This study aimed to compare the effects of two theoretically distinctive interventions for burnout in healthcare professionals. METHODS:This multi-site randomised non-inferiority trial recruited 465 healthcare professionals working across 20 National Health Service (NHS) providers in England. Recruitment took place between October 1, 2020 and June 30, 2021. Participants were randomly assigned to digital health interventions based on cognitive behavioural therapy (CBT; n = 227) or job crafting (JC; n = 238), each of which lasted 6-weeks and involved participation in weekly webinars (1hr) supplemented by online coping skills modules. The primary outcome (Oldenburg Burnout Inventory) was measured at baseline, after 6 weeks, and after 6 months. Between-group differences were compared using analysis of covariance adjusting for baseline measures, testing a non-inferiority hypothesis. RESULTS:At 6 weeks, the adjusted mean difference of 0.47 (95 % CI: -0.25 to 1.20; p = .197) in the OLBI favoured CBT. Although this difference was not statistically significant, the non-inferiority hypothesis was not supported based on a pre-specified minimum clinically important difference. At 6 months, the adjusted mean difference favoured CBT indicating superiority; 0.80 (95 % CI: 0.05 to 1.54; p = .036). CONCLUSIONS:Brief digital health interventions can help to improve occupational burnout and well-being in healthcare professionals. CBT was more effective than JC.

Background: Falls in older adults are a leading cause of morbidity, particularly when compounded by polypharmacy. There is mixed evidence of the efficacy of medicine reviews, but there is little work exploring this in the ambulance setting. A new referral pathway enabling ambulance staff to connect patients to primary care pharmacists aimed to address this. This study explored staff and patient experiences with the pathway and its potential to improve medication safety after a fall. Methods: A mixed-method service evaluation was conducted to assess the implementation and impact of this pathway. Routine data from an ambulance trust and pharmacist proformas were used to address objectives relating to referral rates, clinical appropriateness, and fall recurrence. Patient and staff stakeholder perspectives were gathered through two cross-sectional surveys designed to explore emotional, behavioral, and practical responses to the intervention. Quantitative data were analyzed descriptively and using ordinal logistic regression where appropriate. Free-text responses were analyzed thematically. Results: Between May 2019 and March 2020, referrals were initiated for 775 older adults after ambulance attendance for a fall, with pharmacists completing medicine reviews on 340 patients. Survey data revealed improvements in patients’ emotional responses to their medicines. Ambulance clinicians identified patient disclosure, stockpiling, and the presence of expired medicines as key indicators of poor medicines management and valued the ability to refer patients. Conclusions: Overall, referral to the pathway demonstrates a marginal improvement in recontact rates in the short-term but does not necessarily represent an improvement in overall patient safety. The cost of such an intervention and patient expectations need further exploration to prove efficacy and patient satisfaction.

Background: Emergency medical services (EMS) are often patients’ first point of contact for urgent and emergency care needs. Patients are triaged over the phone and may receive an ambulance response, with potential conveyance to the hospital. A recent scoping review suggested disparities in EMS patient care in the United States. However, it is unknown how health inequalities impact EMS care in other developed countries and how inequalities are being addressed.Objectives: This rapid evidence map of published literature aims to map known health inequalities in EMS patients and describe interventions reducing health inequalities in EMS patient care.Methods: The search strategy consisted of EMS synonyms and health inequality synonyms. The MEDLINE/PubMed database was searched from 1 January 2010 to 26 July 2022. Studies were included if they described empirical research exploring health inequalities within ambulance service patient care. Studies were mapped on to the EMS care interventions framework and Core20PLUS5 framework. Studies evaluating interventions were synthesised using the United Kingdom Allied Health Professions Public Health Strategic Framework.Results: The search strategy yielded 771 articles, excluding duplicates, with two more studies added from hand searches. One hundred studies met the inclusion criteria after full-text review. Inequalities in EMS patient care were predominantly situated in assessment, treatment and conveyance, although triage and response performance were also represented. Studies mostly explored EMS health inequalities within ethnic minority populations, populations with protected characteristics and the core issue of social deprivation. Studies evaluating interventions reducing health inequalities (n = 5) were from outside the United Kingdom and focused on older patients, ethnic minorities and those with limited English proficiency. Interventions included community paramedics, awareness campaigns, dedicated language lines and changes to EMS protocols.Conclusions: Further UK-based research exploring health inequalities of EMS patients would support ambulance service policy and intervention development to reduce health inequality in urgent and emergency care delivery.

Background Care for injured patients in England is provided by inclusive regional trauma networks. Ambulance services use triage tools to identify patients with major trauma who would benefit from expedited Major Trauma Centre (MTC) care. However, there has been no investigation of triage performance, despite its role in ensuring effective and efficient MTC care. This study aimed to investigate the accuracy of prehospital major trauma triage in representative English trauma networks.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). Consecutive patients with acute injury presenting to participating ambulance services were included, together with all reference standard positive cases, and matched to data from the English national major trauma database. The index test was prehospital provider triage decision making, with a positive result defined as patient transport with a pre-alert call to the MTC. The primary reference standard was a consensus definition of serious injury that would benefit from expedited major trauma centre care. Secondary analyses explored different reference standards and compared theoretical triage tool accuracy to real-life triage decisions.Results The complete-case case-cohort sample consisted of 2,757 patients, including 959 primary reference standard positive patients. The prevalence of major trauma meeting the primary reference standard definition was 3.1% (n=54/1,722, 95% CI 2.3 - 4.0). Observed prehospital provider triage decisions demonstrated overall sensitivity of 46.7% (n=446/959, 95% CI 43.5-49.9) and specificity of 94.5% (n=1,703/1,798, 95% CI 93.4-95.6) for the primary reference standard. There was a clear trend of decreasing sensitivity and increasing specificity from younger to older age groups. Prehospital provider triage decisions commonly differed from the theoretical triage tool result, with ambulance service clinician judgement resulting in higher specificity.Conclusions Prehospital decision making for injured patients in English trauma networks demonstrated high specificity and low sensitivity, consistent with the targets for cost-effective triage defined in previous economic evaluations. Actual triage decisions differed from theoretical triage tool results, with a decreasing sensitivity and increasing specificity from younger to older ages.

Abstract Background Opioids kill more people than any other class of drug. Naloxone is an opioid antagonist which can be distributed in kits for peer administration. We assessed the feasibility of implementing a Take-home Naloxone (THN) intervention in emergency settings, as part of designing a definitive randomised controlled trial (RCT). Methods We undertook a clustered RCT on sites pairing UK Emergency Departments (ED) and ambulance services. At intervention sites, we recruited emergency healthcare practitioners to supply THN to patients presenting with opioid overdose or related condition, with recruitment across 2019–2021. We assessed feasibility of intervention implementation against four predetermined progression criteria covering site sign up and staff training; identification of eligible patients; issue of THN kits and Serious Adverse Events. Results At two intervention sites, randomly selected from 4, 299/687 (43.5%) clinical staff were trained (ED1 = 107, AS1 = 121, ED2 = 25, AS2 = 46). Sixty THN kits were supplied to eligible patients (21.7%) (n: ED1 = 36, AS1 = 4, ED2 = 16, AS2 = 4). Across sites, kits were not issued to eligible patients on a further 164 occasions, with reasons reported including: staff forgot (n = 136), staff too busy (n = 15), and suspected intentional overdose (n = 3), no kit available (n = 2), already given by drugs nurse (n = 4), other (n = 4). Staff recorded 626 other patients as ineligible but considered for inclusion, with reasons listed as: patient admitted to hospital (n = 194), patient absconded (n = 161) already recruited (n = 64), uncooperative or abusive (n = 55), staff not trained (n = 43), reduced consciousness level (n = 41), lack of capacity (n = 35), patient in custody (n = 21), other (n = 12). No adverse events were reported. Conclusion Staff and patient recruitment were low and varied widely by site. This feasibility study did not meet progression criteria; a fully powered RCT is not planned. Trial Registration ISRCTN13232859 (Registered 16/02/2018).

BackgroundCalls to emergency departments (EDs) from ambulances to alert them to a critical case being transported to that facility that requires a special response (‘pre-alerts’) have been shown to improve outcomes for patients requiring immediate time-critical treatment (eg, stroke). However, little is known about their usefulness for other patients and the processes involved in ED responses to them. This study aimed to understand how pre-alerts influence patient care in the ED.MethodsWe undertook non-participant observation (162 hours, 143 pre-alerts) and semi-structured interviews with staff (n=40) in six UK EDs between August 2022 and April 2023 focusing on how ED staff respond to pre-alert calls and what influences their response. Observation notes and interview transcripts were imported into NVivo and analysed using a thematic approach.ResultsPre-alert calls involved significant time and resources for ED staff but they were valued as they enabled staff to prepare for a patient’s arrival (practically and psychologically). High demand and handover delays at ED created additional pre-alerts due to ambulance clinician concerns about the impact of long waits on patients.Despite the risk of pre-alert fatigue from calls for patients considered not to require a special response, ED clinicians appreciated timely pre-alert information, perceiving a higher risk from underalerting than overalerting. Variation in ED response was influenced by individual and organisational factors, particularly the resources available at the time of pre-alert. Unclear ED processes for receiving, documenting and sharing information about pre-alerts increased the risk of information loss.ConclusionImproving processes for receiving and sharing pre-alert information may help ED clinicians prepare appropriately for incoming patients. Alternative routes for ambulance clinicians to seek advice on borderline pre-alert patients may help to improve the appropriateness of pre-alerts.

Background Opioids kill more people than any other class of drug. Naloxone is an opioid antagonist which can be distributed in kits for peer administration. We aimed to determine feasibility of undertaking a definitive randomised controlled trial (RCT) of Take-home Naloxone (THN) in emergency settings. Methods Using individual-level-routine health records (2015-21) we tested feasibility of developing a discriminant function to identify people at high-risk of fatal opioid poisoning for outcome comparisons. We undertook a clustered RCT on paired UK Emergency Department (ED) and ambulance service sites. At intervention sites, we recruited practitioners to administer THN to patients presenting with opioid overdose or related condition during ta 1year recruitment period, 2019 – 21. We assessed feasibility of intervention and trial methods against predetermined progression criteria. Results Within routine health records on the population of Wales (~3,200,000), we identified 1,105 adult deaths from opioid poisoning, of whom 307 (27.8%) had no ED or drugs service contacts in the year before death. At a predicted probability threshold of 0.0003, a discriminant function based on demographics and recent healthcare contacts identified 809 opioid related deaths within 1 year (sensitivity 74.7%) in 989,151 people, missing 274 cases. Lowering the threshold to 0.0002 increased sensitivity to 86.1% but included a further 608,191 non-cases; raising it to 0.0004 reduced sensitivity to 65.4% and inclusion of non-cases to 646,750. At two intervention sites, randomly selected from 4: 299/687 (43.5%) clinical staff were trained; 60/277 eligible patients (21.7%) were supplied with a THN kit and no adverse events were reported. Conclusion With a low incidence of opioid-related death and significant proportion with no contact with ED or drug services in the year before death, the numbers needed to reach a reasonable sensitivity was very high. This study did not meet progression criteria, a fully powered trial is not planned. Trial Registration ISRCTN13232859 (Registered 16/02/2018)

Aims:Ambulance pre-alerts are used to inform receiving emergency departments (EDs) of the arrival of critically unwell or rapidly deteriorating patients who need time-critical assessment or treatment immediately upon arrival. Inappropriate use of pre-alerts can lead to EDs diverting resources from other critically ill patients. However, there is limited guidance about how pre-alerts should be undertaken, delivered or communicated. We aimed to map existing pre-alert guidance from UK NHS ambulance services to explore consistency and accessibility of existing guidance.Methods:We contacted all UK ambulance services to request documentation containing guidance about pre-alerts. We reviewed and mapped all guidance to understand which conditions were recommended for a pre-alert and alignment with Association of Ambulance Chief Executives (AACE) and Royal College of Emergency Medicine (RCEM) pre-alert guidance. We reviewed the language and accessibility of guidance using the AGREE II tool.Results:We received responses from 15/19 UK ambulance services and 10 stated that they had specific pre-alert guidance. We identified noticeable variations in conditions declared suitable for pre-alerts in each service, with a lack of consistency within each ambulance service's own guidance, and a lack of alignment with the AACE/RCEM pre-alert guidance. Services listed between four and 45 different conditions suitable for pre-alert. There were differences in physiological thresholds and terminology, even for conditions with established care pathways (e.g. hyperacute stroke, ST segment elevation myocardial infarction). Pre-alert criteria were typically listed in several short sections in lengthy handover procedure policy documents. Documents appraised were of poor quality with low scores below 35% for applicability and overall.Implications:There is a clear need for ambulance services to have both policies and tools that complement each other and incorporate the same list of pre-alertable conditions. Clinicians need a single, easily accessible document to refer to in a time-critical situation to reduce the risk of making an incorrect pre-alert decision.

Background:Opioids kill more people than any other drug. Naloxone is an opioid antagonist which can be distributed in take-home 'kits' for peer administration (take-home naloxone). Aim:To determine the feasibility of carrying out a definitive randomised controlled trial of take-home naloxone in emergency settings. Design:We used Welsh routine data (2015-21) to test the feasibility of developing a discriminant function to identify people at high risk of fatal opioid overdose. We carried out a cluster randomised controlled trial and qualitative study to examine experiences of service users and providers. We assessed feasibility of intervention and trial methods against predetermined progression criteria related to: site sign-up, staff trained, identification of eligible patients, proportion given kits, identification of people who died of opioid poisoning, data linkage and retrieval of outcomes. Setting:This study was carried out in the emergency environment; sites comprised an emergency department and associated ambulance service catchment area. Participants:At intervention sites, we invited emergency department clinicians and paramedics to participate. We recruited adult patients who arrived at the emergency department or were attended to by ambulance paramedics for a problem related to opioid use with capacity to consent to receiving the take-home naloxone and related training. Interventions:Usual care comprised basic life support plus naloxone by paramedics or emergency department staff. The take-home naloxone intervention was offered in addition to usual care, with guidance for recipients on basic life support, the importance of calling the emergency services, duration of effect, safety and legality of naloxone administration. Discriminant function:With low numbers of opioid-related deaths (1105/3,227,396) and a high proportion having no contact with health services in the year before death, the predictive link between death and opioid-related healthcare events was weak. Logistic regression models indicated we would need to monitor one-third of the population to capture 75% of the decedents from opioid overdose in 1-year follow-up. Randomised controlled trial:Four sites participated in the trial and 299 of 687 (44%) eligible clinical staff were trained. Sixty take-home naloxone kits were supplied to patients during 1-year recruitment. Eligible patients were not offered take-home naloxone kits 164 times: 'forgot' (n = 136); 'too busy' (n = 15); suspected intentional overdose (n = 3). Qualitative interviews:Service users had high levels of knowledge about take-home naloxone. They were supportive of the intervention but noted concerns about opioid withdrawal and resistance to attending hospital for an overdose. Service providers were positive about the intervention but reported barriers including difficulty with consenting and training high-risk opioid users. Health economics:We were able to calculate costs to train staff at three sites (£40 per AS and £17 in Site 1 ED). No adverse events were reported. Progression criteria were not met - fewer than 50% of eligible staff were trained, fewer than 50% of eligible patients received the intervention and outcomes were not retrieved within reasonable timescales. Future work:The take-home naloxone intervention needs to be developed and evaluated in emergency care settings, with appropriate methods. Limitations:The Take-home naloxone Intervention Multicentre Emergency setting study was interrupted by coronavirus disease. Conclusions:This study did not meet progression criteria for intervention or trial methods feasibility, so outcomes were not followed up and a fully powered trial is not planned. Trial registration:This trial is registered as ISRCTN13232859. Funding:This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 16/91/04) and is published in full in Health Technology Assessment; Vol. 28, No. 74. See the NIHR Funding and Awards website for further award information.