Background:Domestic abuse and suicidal ideation are highly prevalent in the United Kingdom, often co-occurring. Numerous practical and psychosocial barriers inhibit help-seeking. This study explored whether community pharmacy could offer an accessible setting for a domestic abuse and suicidal ideation response service. Methods:The design was a randomised cluster feasibility trial. Twelve pharmacies were recruited from one pharmacy organisation, randomised into eight intervention pharmacies and four controls. Thirty-seven pharmacy staff were trained to deliver the Lifeguard Pharmacy intervention, which involved providing a consultation and structured referral or signposting to customers identified as experiencing domestic abuse and/or suicidal ideation. Staff learning from the training was evaluated using the validated Continuing Professional Development reaction questionnaire, analysed using a paired t-test. The intervention ran from January to July 2023 and was accompanied by a nested process evaluation consisting of staff focus groups and a multistakeholder final evaluation workshop with a mix of lay, pharmacy staff and representatives from referral organisations. Data were collected on number and category of client contacts from intervention and control pharmacies; descriptive analyses were performed. Results:After intervention training, pharmacy staff showed statistically significant improvements in their levels of perceived ability, ease and confidence in responding to and referring people in need of help for domestic abuse and suicidal ideation with increased confidence in the ability of other pharmacy staff to support domestic abuse and suicidal ideation. During the intervention period, staff responded to 24 cases in intervention pharmacies: 8 for suicidal ideation, 9 for domestic abuse and 7 for both domestic abuse and suicidal ideation. Of these, 22 were staff-initiated and 2 were client-initiated. Two cases (one suicidal ideation and one domestic abuse) were identified in control pharmacies. Staff participants had a positive perception of the service and its impact on them and their clients. The multistakeholder workshop findings confirmed the feasibility of a staff-initiated response service for both domestic abuse and suicidal ideation in a community pharmacy setting. However, there were challenges marketing and delivering a client-initiated service, and the study was not able to collect all of the information required to inform a future trial. Limitations:There were challenges to collecting data and obtaining informed consent from Lifeguard Pharmacy clients, especially when distressed or time-pressured. Consequently, full data sets were only collected from 4 of the 24 people who used the service. All 12 participating pharmacies were located in 1 region of England, hence a future study would need to test implementation across a broader range of settings. Conclusions:It is feasible to implement a staff-initiated response service for domestic abuse and/or suicidal ideation in selected pharmacies. The combination of staff training, consultation guide, referral tool and client support resources and organisational support empowered staff to proactively identify people experiencing domestic abuse and/or suicidal ideation. Future work:Further development work would be needed before a client-initiated service could be delivered, and a future implementation study is contingent on finding ways to safely consent and collect data from clients. Some preliminary health economic work was conducted but a full health economic analysis would be needed as part of a future study. Funding:This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme as award number NIHR133132.

Background: Cognitive difficulties are common in multiple sclerosis (MS) and are associated with poorer quality of life, reduced independence, and lower employment. Despite growing interest in cognitive rehabilitation, existing interventions often lack generalisability and accessibility. Strengthening Mental Abilities with Relational Training (SMART) is a digital intervention targeting relational skills, which are theorised to underpin broader cognitive functioning. This trial evaluated the feasibility, acceptability, and preliminary signals of efficacy of SMART for people with MS experiencing cognitive difficulties. Methods: We conducted a three-arm parallel-group feasibility randomised controlled trial. Participants with a diagnosis of MS and self-reported cognitive problems were recruited from three NHS sites and randomised (1:1:1) to SMART plus treatment-as-usual (TAU), Active control (Sudoku) plus TAU, or TAU alone. Primary feasibility outcomes included recruitment, retention, intervention adherence, and data completeness. Acceptability was assessed using intervention-usage data and participant feedback. Candidate outcome measures included the Perceived Deficits Questionnaire (PDQ), Symbol Digit Modalities Test (SDMT), Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), EQ-5D-5L, and ICECAP-A. Assessments took place at baseline, 3 months, and 6 months. The study was co-developed with people living with MS and their families through embedded patient and public involvement and engagement processes. Results: A total of 43 participants were randomised (72% of target). Retention was 84% at 3-month follow-up and 77% at 6 months. SMART adherence was high, with 93% of participants meeting the predefined criterion for training adherence. Acceptability feedback was consistently positive across arms. Data completeness for self-report and performance outcomes was acceptable (typically 60–80% across measures), though return rates for RBANS were lower due to postal logistics. Exploratory analysis suggested a moderate effect of SMART on perceived cognitive difficulties (PDQ, Cohen’s d = 0.85 vs Active control; 0.69 vs TAU), with confidence intervals supporting the possibility of a clinically meaningful benefit. No clear between-group signal was observed on the SDMT. Conclusions: Trial procedures were feasible, and the SMART intervention was acceptable to people with MS. Findings support progression to a fully powered trial, with minor refinements to recruitment and assessment processes. Trial Registration: Registration ID: ClinicalTrials.gov: NCT04975685 – registered on July 23rd, 2021

We piloted an approach to identifying the health and social care needs of people on probation using a survey consisting of validated screening tools and key additional questions. We share findings from our analysis of the sample data, showing that there is a high complexity of needs in this population, with 65.4% of participants reporting at least one unmet need. We also explore the acceptability of this approach to identifying needs being used in routine probation practice and make recommendations about how identification and recording of needs could be approached and further researched in the future.

BackgroundThe COVID-19 pandemic impacted mental health and health care systems worldwide. ObjectiveThis study examined the COVID-19 pandemic’s impact on ambulance attendances for mental health and overdose, comparing similar regions in the United Kingdom and Canada that implemented different public health measures. MethodsAn interrupted time series study of ambulance attendances was conducted for mental health and overdose in the United Kingdom (East Midlands region) and Canada (Hamilton and Niagara regions). Data were obtained from 182,497 ambulance attendance records for the study period of December 29, 2019, to August 1, 2020. Negative binomial regressions modeled the count of attendances per week per 100,000 population in the weeks leading up to the lockdown, the week the lockdown was initiated, and the weeks following the lockdown. Stratified analyses were conducted by sex and age. ResultsAmbulance attendances for mental health and overdose had very small week-over-week increases prior to lockdown (United Kingdom: incidence rate ratio [IRR] 1.002, 95% CI 1.002-1.003 for mental health). However, substantial changes were observed at the time of lockdown; while there was a statistically significant drop in the rate of overdose attendances in the study regions of both countries (United Kingdom: IRR 0.573, 95% CI 0.518-0.635 and Canada: IRR 0.743, 95% CI 0.602-0.917), the rate of mental health attendances increased in the UK region only (United Kingdom: IRR 1.125, 95% CI 1.031-1.227 and Canada: IRR 0.922, 95% CI 0.794-1.071). Different trends were observed based on sex and age categories within and between study regions. ConclusionsThe observed changes in ambulance attendances for mental health and overdose at the time of lockdown differed between the UK and Canada study regions. These results may inform future pandemic planning and further research on the public health measures that may explain observed regional differences.

Aims: The study objective was to compare daily glycemic profiles throughout gestation between the mothers of large-for-gestational-age (LGA) and non-LGA newborns in patients with type 1 diabetes (T1D). Methods: We selected 102 eligible pregnant women who were treated with sensor-augmented pumps in our single-center retrospective cohort study. We used functional data analysis to compare glycemic control across gestation. Results: Median HbA1c values in the first, second, and third trimester were 6.23 %, 5.49 %, and 5.75 % respectively. Median time-in-range (TIR) exceeded 70 % in each trimester (72.4 %, 72.5 %, and 75.9 %, respectively). From 59 % up to 77 % of women met the criteria for well-controlled T1D defined by the mean HbA1c and TIR in each trimester. Despite that, 27 % (28/102) of pregnancies were complicated by LGA. Mothers of LGA infants had significantly increased HbA1c levels and decreased TIR values in the second and third trimesters. The most significant differences in daily mean glucose values between LGA and non-LGA newborns' mothers occurred between 26 and 32 weeks of pregnancy. These discrepancies were noted in daytime glucose values rather than nocturnal and fasting glucose levels. Conclusions: Mothers of LGA newborns present significantly worse glycemic control. Our findings may emphasize the need for more rigorous daytime glycemic control.

Abstract Background Care home residents are at higher risk compared with community dwelling elders for medical emergencies, often resulting in ambulance attendance and conveyance to hospital. We aimed to determine the factors predicting care home resident conveyance to hospital or referral to community pathways by an ambulance service. Methods We used a retrospective cross-sectional study design analysing routine data from electronic clinical records from East Midlands Ambulance Service NHS Trust (EMAS). Data comprised all patients including care home residents attended by ambulance from 2018 to 2021. A multivariable logistic regression model was used to identify the main predictors of conveyance to hospital or referral to community services. Results Data included 170,612 attendances to care homes representing 7.5% of the total number of EMAS attendances between 2018 and 2021. The main predictors of conveyance to hospital were being male (Relative Risk Ratio [RRR] 1.07, 95% Confidence Interval [CI] 1.03–1.10, p < 0.001), aged 70–79 years (RRR 1.09, 95%CI 1.03–1.17, p < 0.001) or 80–89 years (RRR 1.10, 95%CI 1.03–1.17, p < 0.001), situated in an area of higher deprivation (RRR 1.06, 95%CI 1.03–1.09, p < 0.001), or having dispatch categories which included cardiovascular (RRR 11.29, 95%CI 10.43–12.22, p < 0,001), trauma such as falls (RRR 9.50, 95%CI 8.97–10.05, p < 0,001) or neurological conditions (RRR 9.06, 95%CI 8.42–9.75, p < 0,001). Calls made by health care professionals (HCPs) (RRR 15.37, 95%CI 13.41–17.62, p < 0,001) or where patients had a higher National Early Warning Score (NEWS2) (RRR 1.23, 95%CI 1.22–1.24, p < 0,001) resulted in significantly increased conveyance. Conclusions Various factors significantly predicted conveyance of care home residents to hospital by ambulance. These included HCP referral and a higher NEWS2 score confirming that severity of clinical condition of the patient significantly increased conveyance. Future interventions to prevent or address certain conditions such as falls or provide enhanced care in care homes may prevent some emergencies or reduce the likelihood of conveyance to hospital.

Colorectal cancer is one of the most common malignancies worldwide. Improvements in screening and treatment have allowed for earlier detection and longer survival. However, treatments, which may involve surgery, radiotherapy and/or chemotherapy, often lead to patients developing both gastrointestinal and non-gastrointestinal symptoms that can persist long term. This systematic review aims to understand better the non-gastrointestinal symptoms that patients develop after colorectal cancer treatment and how these are identified and assessed through the use of questionnaires. The review was conducted according to PRISMA guidelines. Scopus, PubMed, Web of Science, PsycINFO and Cochrane Library were searched. Eligible studies evaluated the non-gastrointestinal symptoms that patients had developed and continued to have at 12 months or longer after treatment. Studies that were performed on patients who were within 12 months of treatment, who had a recurrent or a secondary cancer, had stage 4 cancer/were palliative or that looked solely at gastro-intestinal symptoms were excluded. Articles were limited to studies on human subjects written in English published between February 2012 and July 2024. The searches identified 3491 articles. Thirty-seven articles met the inclusion criteria, of which, 33 were quantitative, 2 were qualitative and 2 were mixed methods study designs. Nearly two-thirds (n = 22) were cross-sectional studies, whereas 14 were longitudinal. One study had both a cross-sectional and longitudinal component to it. Most studies were of medium to high quality based on the Newcastle Ottawa Scale (n = 23) and were conducted in 14 countries, the majority of which were performed in the Netherlands (n = 14). The majority of participants in the included studies (n = 30/37) were men. There were also three studies that were performed with only female participants and one study that was performed with male participants only. The age range of research participants across all the studies was 29 to 89 years. Forty-five different validated questionnaires containing 5–125 question items were used to collect information on the side effects and impact of colorectal cancer treatment. Completion rate for questionnaires varied from 30 to 100

Purpose There are increasing numbers of patients who have been treated for colorectal cancer (CRC) who struggle with ongoing physical and psychological symptoms. ‘Cancer survivor’ is often used to describe these patients but this terminology remains controversial. This study sought to understand the follow-up experience of CRC patients in the UK and identify the terminology they prefer following diagnosis and treatment. Methods Purposeful sampling of patients from specialist CRC follow-up clinics was performed until data saturation was achieved. Two 1:1 semi-structured qualitative interviews were performed for each participant. Data were analysed thematically. Results Seventeen participants, median age = 62, 53% male were interviewed. Several themes were identified. Of note, fear of cancer recurrence dominates patients’ agendas at follow-up appointments. There are also clinical and administrative barriers to discussing symptoms including being embarrassed, feeling that their symptoms were not relevant or not having enough time to discuss issues. However, there are several methods which may improve this, such as through the use of video consultations and questionnaires. In addition, patients identified inadequate holistic support despite significant psychological and social distress. Our data suggest that labelling a diverse group of patients as ‘cancer survivors’ can be problematic. Conclusion It is important that clinicians systematically screen patients for symptoms that are known to occur following treatment. Clinicians and patients should have routine access to pathways and programmes that can support patients in navigating their life after cancer therapy.

Background Residents of care homes may be affected by medical emergencies, resulting in ambulance attendance and conveyance to hospital which add extra pressure and costs on an already strained emergency and healthcare system. The aim of this study was to determine the factors predicting conveyance to hospital of care home residents by ambulance services. Methods We used a cross-sectional study design analysing routine data from electronic clinical records from East Midlands Ambulance Service NHS Trust (EMAS) from 2018 to 2021. A multivariable multinominal regression model was used to identify the main predictors of conveyance to hospital or referral to community services. Results The data included 170,612 attendances to care homes representing 7.5% of the total number of EMAS attendances between 2018-2021. The main predictors of conveyance to hospital were being male (Relative Risk Ratio [RRR] 1.07, 95% Confidence Interval [CI] 1.03-1.10, p<0.001), aged 70-79 years (RRR 1.09, 95%CI 1.03-1.17, p<0.001) or 80-89 years (RRR 1.10, 95%CI 1.03-1.17, p<0.001), situated in an area of higher deprivation (RRR 1.06, 95%CI 1.03-1.09, p<0.001), or having dispatch categories which included cardiovascular (RRR 11.29, 95%CI 10.43-12.22, p<0,001), trauma including falls (RRR 9.50, 95%CI 8.97-10.05, p<0,001) or neurological (RRR 9.06, 95%CI 8.42-9.75, p<0,001) conditions. Calls made by health care professionals (HCPs) (RRR 15.37, 95%CI 13.41-17.62, p<0,001) or where patients had a higher National Early Warning Score (NEWS2) (RRR 1.23, 95%CI 1.22-1.24, p<0,001) resulted in significantly increased conveyance. Conclusion A series of factors significantly predict conveyance to hospital by ambulance of home care residents. These include HCP referral or NEWS2 confirming that the severity of clinical condition of the patient was associated with significantly increased conveyance. Future interventions to prevent or address certain conditions such as falls or provide enhanced care in care homes may prevent some emergencies or reduce the risk of conveyance to hospital.

"'Hypos' can strike twice" (HS2) is a pragmatic, leaflet-based referral intervention designed for administration by clinicians of the emergency medical services (EMS) to people they have attended and successfully treated for hypoglycaemia. Its main purpose is to encourage the recipient to engage with their general practitioner or diabetic nurse in order that improvements in medical management of their diabetes may be made, thereby reducing their risk of recurrent hypoglycaemia. Herein we build a de novo economic model for purposes of incremental analyses to compare, in 2018-19 prices, HS2 against standard care for recurrent hypoglycaemia in the fortnight following the initial attack from the perspective of the UK National Health Service (NHS). We found that per patient NHS costs incurred by people receiving the HS2 intervention over the fortnight following an initial hypoglycaemia average £49.79, and under standard care costs average £40.50. Target patient benefit assessed over that same period finds the probability of no recurrence of hypoglycaemia averaging 42.4% under HS2 and 39.4% under standard care, a 7.6% reduction in relative risk. We find that implementing HS2 will cost the NHS an additional £309.36 per episode of recurrent hypoglycaemia avoided. Contrary to the favourable support offered in Botan et al., we conclude that in its current form the HS2 intervention is not a cost-effective use of NHS resources when compared to standard NHS care in reducing the risk of hypoglycaemia recurring within a fortnight of an initial attack that was resolved at-scene by EMS ambulance clinicians.

BackgroundAnnualized relapse rate (ARR) is used as an outcome measure in multiple sclerosis (MS) clinical trials. Previous studies demonstrated that ARR has reduced in placebo groups between 1990 and 2012. This study aimed to estimate real-world ARRs from contemporary MS clinics in the UK, in order to improve the feasibility estimations for clinical trials and facilitate MS service planning.MethodsA multicentre observational, retrospective study of patients with MS from 5 tertiary neuroscience centres in the UK. We included all adult patients with a diagnosis of MS that had a relapse between 01/04/2020 and 30/06/2020.ResultsOne hundred thirteen out of 8783 patients had a relapse during the 3-month study period. Seventy-nine percent of the patients with a relapse were female, the mean age was 39 years, and the median disease duration was 4.5 years; 36% of the patients that had a relapse were on disease-modifying treatment. The ARR from all study sites was estimated at 0.05. The ARR for relapsing remitting MS (RRMS) was estimated at 0.08, while the ARR for secondary progressive MS (SPMS) was 0.01.ConclusionsWe report a lower ARR compared to previously reported rates in MS.

BackgroundThe Recorded Consultation Assessment (RCA) was developed rapidly during the COVID-19 pandemic to replace the Clinical Skills Assessment (CSA) for UK general practice licensing. Our aim was to evaluate examiner perceptions of the RCA.MethodsWe employed a cross-sectional design using a questionnaire survey of RCA examiners with attitudinal (relating to examiners thoughts and perceptions of the RCA) and free text response options. We conducted statistical descriptive and factor analysis of quantitative data with qualitative thematic analysis of free text responses.ResultsOverall, 182 of 260 (70%) examiners completed the questionnaire. Responders felt that consultations submitted were representative of the work of a typical GP during the pandemic and provided a good sample across the curriculum. They were also generally positive about the logistic, advisory and other support provided as well as the digital platform. Despite responders generally agreeing there was sufficient information available in video or audio consultations to judge candidates' data gathering, clinical management, and interpersonal skills, they were less confident about their ability to make judgments of candidates' performance compared with the CSA. The qualitative analysis of free text responses detailed the problems of case selection and content, explained examiners' difficulties when making judgments, and detailed the generally positive views about support, training and information technology. Responders also provided helpful recommendations for improving the assessment.ConclusionThe RCA was considered by examiners to be feasible and broadly acceptable, although they experienced challenges from candidate case selection, case content and judgments leading to suggested areas for improvement.

Continuous glucose monitoring (CGM) provides the most objective method of assessing glucose in daily life. Although there have been small, short-term physiologic studies of glucose metabolism in ‘healthy’ pregnant women a comprehensive, longitudinal description of changes in glucose over the course of pregnancy and how glucose dysregulation earlier in pregnancy relates to traditional third trimester screening for gestational diabetes, fetal growth and pregnancy outcomes is lacking. This study aims to characterise longitudinal changes in glycemia across gestation using CGM, in order to understand the evolution of dysglycemia and its relationship to fetal growth. A multi-centre, prospective, observational, cohort study of 500 healthy pregnant women, recruited in the first trimester of pregnancy. Masked CGM will be performed for a 14-day period on five occasions across pregnancy at 10–12, 18–20, 26–28, 34–36 weeks gestation and postnatally. Routinely collected anthropometric and sociodemographic information will be recorded at each visit including: weight, height, blood pressure, current medication. Age, parity, ethnicity, smoking will be recorded. Blood samples will be taken at each visit for HbA1c and a sample stored. Details on fetal growth from ultrasound scans and the OGTT results will be recorded. Maternal and neonatal outcomes will be collected. CGM glucose profiling is the exposure of interest, and will be performed using standard summary statistics, functional data analysis and glucotyping. The primary maternal outcome is clinical diagnosis of GDM. The primary neonatal outcome is large for gestational age (LGA) (> 90th centile defined by customised birthweight centile). The relationship of glucose to key secondary maternal and neonatal outcomes will be explored. This study will ascertain the relationship of maternal dysglycemia to fetal growth and outcomes. It will explore whether CGM glucose profiling can detect GDM before the OGTT; or indeed whether CGM glucose profiling may be more useful than the OGTT at detecting LGA and other perinatal outcomes. ISRCTN 15,706,303 https://www.isrctn.com/ISRCTN15706303 Registration date: 13th March 2023.

BackgroundSubstantial numbers of medical students and doctors have specific learning difficulties (SpLDs) and failure to accommodate their needs can disadvantage them academically. Evidence about how SpLDs affect performance during postgraduate general practice (GP) specialty training across the different licencing assessments is lacking. We aimed to investigate the performance of doctors with SpLDs across the range of licencing assessments. MethodsWe adopted the social model of disability as a conceptual framework arguing that problems of disability are societal and that barriers that restrict life choices for people with disabilities need to be addressed. We used a longitudinal design linking Multi-Specialty Assessment (MSRA) records from 2016 and 2017 with their Applied Knowledge Test (AKT), Clinical Skills Assessment (CSA), Recorded Consultation Assessment (RCA) and Workplace Based Assessment (WPBA) outcomes up to 2021. Multivariable logistic regression models accounting for prior attainment and demographics were used to determine the SpLD doctors' likelihood of passing licencing assessments. ResultsThe sample included 2070 doctors, with 214 (10.34%) declaring a SpLD. Candidates declaring a SpLD were significantly less likely to pass the CSA (OR 0.43, 95% CI 0.26, 0.71, p = 0.001) but not the AKT (OR 0.96, 95% CI 0.44, 2.09, p = 0.913) or RCA (OR 0.81, 95% CI 0.35, 1.85, p = 0.615). Importantly, they were significantly more likely to have difficulties with WPBA (OR 0.28, 95% CI 0.20, 0.40, p < 0.001). When looking at licencing tests subdomains, doctors with SpLD performed significantly less well on the CSA Interpersonal Skills (B = -0.70, 95% CI -1.2, -0.19, p = 0.007) and the RCA Clinical Management Skills (B = -1.68, 95% CI -3.24, -0.13, p = 0.034). ConclusionsCandidates with SpLDs encounter difficulties in multiple domains of the licencing tests and during their training. More adjustments tailored to their needs should be put in place for the applied clinical skills tests and during their training.

AimTo model optimum proportions of dual-crewed ambulances (DCAs) and rapid-response vehicles (RRVs) in Ambulance Trusts with a view to generating a policy brief for one Ambulance Trust and a modelling tool for other Trusts on the strategic procurement and allocation of emergency vehicle (EV) resources. MethodsHistorical EV assignments for 12 months of emergency calls in 2019 were provided by an NHS Ambulance Trust and analysed for backup, see and treat, and patient to hospital conveyance. Unit costs were derived for paramedics and technicians using Agenda for Change pay rates. Time cycles were assigned for RRV and DCA attendances and unit costs assigned to these. Information was put into a decision analytical model to estimate the costs and numbers of vehicles attending incidents based on relative proportions of available RRVs and DCAs. ResultsOf 711 992 calls attended by 837 107 EVs, 514 766 (72.3%) required at least one emergency department conveyance. The rate of conveyance was significantly lower when RRVs arrived first on the scene. 27 883 out of 529 693 (5.3%) DCAs first arriving at an incident required some backup, and this was also factored into the model. Modelling demonstrated high conveyance rates were counterproductive when increasing the relative proportions of RRVs to DCAs. For example, with conveyance rates of 65%, increasing the RRVs increased the cost and numbers of vehicles attending per incident. At lower conveyance rates, however, there was a levelling around 30% where it could become cost-effective to increase the relative proportions of RRVs to DCAs. ConclusionAt current overall conveyance rates, there is no benefit in increasing the relative proportions of RRVs to DCAs unless additional benefits can be realised that bring the conveyance rates down.

Background Medical emergencies in residential or nursing care homes are common and costly, resulting in ambulance attendance and hospitalisation, with extra pressure on an emergency system severely impacted by the Covid-19 pandemic. The aim of this study was to explore how the number of ambulance attendances to care homes varied before and during Covid-19 pandemic whilst considering the UK national lockdowns. Methods We used a cross-sectional study design analysing routine data from electronic clinical records from East Midlands Ambulance Service NHS Trust (EMAS) from 2018 to 2021. An interrupted-time series analysis (ITSA) was used to compare the total number of ambulance attendances to care homes per week before and during the pandemic whilst considering the three UK national lockdown periods. Seasonality (i.e., month of the year), call category, deprivation, and rurality were included as covariates in the model. Results The interrupted time series analysis indicated a significant decrease of 9.9 ambulance attendances to 1956 East Midlands care homes per week during the first lockdown relative to the pre-pandemic period (CI: -19.1, -0.8, p=0.034). This was followed by a significant increase of 13.7 attendances per week in the period between the first two lockdowns (CI: 4.0, 23.5, p=0.006) relative to the first lockdown period. There was no significant change during the second lockdown but there was a significant decrease of 19.7 attendances per week in the third lockdown (CI: -30.5, -9.0, p<0.001) compared to the non-lockdown period preceding it. Conclusion Ambulance attendances to care homes decreased during the Covid-19 pandemic, were significantly reduced in the first and third lockdowns, and remained lower during the pandemic compared to pre-pandemic levels. Further research is needed to investigate the factors that might have influenced this trend including changes in ambulance service policies, ambulance and care home personnel, and increased death rates in care homes.

Background Medical emergencies in care homes are common and costly, often resulting in calls to emergency services, ambulance attendance, conveyance, and hospital admissions. Over half of emergency transfers to hospital could be prevented with better ongoing care, access to primary care and training of staff. Our aim was to explore ambulance staff experiences of emergencies in care homes. Methods We employed a qualitative design. The study involved semi-structured interviews with ambulance staff working at the East Midlands Ambulance Service NHS Trust. Data were analysed thematically using a framework approach. Results We interviewed 15 ambulance staff (including paramedics, technicians, urgent care assistants). Preliminary analysis showed that although good communication with care home staff was considered important, experiences were varied. The importance of good, adequate resident information ready for ambulance staff upon arrival was highlighted. Regarding the decision-making process, participants reported consulting with everyone involved (care home staff, residents, relatives) and making final decisions based on various factors, including the resident/their family's wishes, medical history, ReSPECT forms, alternative pathways to A&E, and what they considered the most appropriate course of action for the resident. Care home-related factors (access/egress issues; staff training; policies and procedures; and overall quality of care) and Emergency Medical Services-related factors (current pressures on the service; better training needed on working with people with dementia, end-of-life care, etc.; having access to an on-call geriatrician), which impact those who experience emergencies in care homes, were also discussed. Conclusion This study highlights the main challenges and facilitators that ambulance staff are faced with when dealing with emergencies in care homes. These data present findings of one staff group and triangulation with care home staff, resident and family perspectives would generate further insights. The findings will inform the development of interventions to improve outcomes and experiences of emergencies in care homes.