BACKGROUND:Head-injured children are commonly transported to the Emergency Department (ED) by ambulance. However, most of those conveyed are deemed non-serious and are discharged at triage. Hospital clinicians use clinical decision tools to support their assessment of head-injured children; however, this is generally to determine whether a computed tomography (CT) scan is indicated. Currently, there is no pre-hospital clinical decision tool designed to support paramedics when assessing and managing head-injured children at scene. The aim of this study was to determine consensus amongst experts and stakeholders to inform the development of a new tool to support paramedics in safely assessing and managing children with minor head injury. METHODS:A consultation process using a modified online Delphi technique comprising two rounds and a consensus meeting was completed between September 2023 and January 2024. A 5-point Likert scale was used to assess consensus, set a-priori at 67%. Free text survey responses arising from the Delphi were studied and concepts were developed. Data were analysed anonymously, and feedback was given after each round. RESULTS:An expert stakeholder group comprising 36 participants took part in Round One, and 34 participants in Round Two of the online Delphi. The participants included parents/grandparents/caregivers, paramedics, primary care clinicians, ED doctors, ED nurses and Paediatricians. Consensus was reached in 36 statements following Rounds One and Two. The remaining eight statements were discussed at a consensus meeting, which was attended by 12 stakeholders. Seven of the eight statements reached agreement. CONCLUSION:This Delphi study has established consensus amongst a group of experts and stakeholders on the content and format of a pre-hospital paediatric head injury clinical decision tool, designed for use by paramedics: PATCH (Pre-hospital Assessment Tool for Children with Head injury). Future research should include an evaluation of the acceptability and usability of PATCH by paramedics. CLINICAL TRIAL NUMBER:Not applicable.

INTRODUCTION:Children with head injury are commonly transported to the ED by ambulance. However, most of those conveyed are deemed non-serious and are discharged at triage. Research is needed to explore the factors that influence paramedics when deciding to convey children with minor head injury to the ED, and to establish whether a clinical decision tool designed to support them would be beneficial. METHODS:A generic qualitative approach, comprising semistructured interviews with front-line ambulance paramedics working in the UK. Interviews were audio-recorded and transcribed. Data were analysed using reflexive thematic analysis. Interviews aimed to explore the factors that influence paramedics when deciding to convey children with minor head injury to the ED. RESULTS:A total of 20 paramedics from several ambulance services participated in interviews. Three overarching themes were identified: 'we just take them in'; 'there are too many hurdles'; 'creating the right tool'. These were further categorised into subthemes. Paramedics do not feel confident when assessing and managing children with head injury, and convey children to hospital due to fear of consequences, despite knowing there will be no intervention in the ED. Further education, a prehospital paediatric clinical decision tool and greater support from Ambulance Trusts would be welcomed by paramedics. Criteria such as: parental anxiety; time; wound closure; policy and non-accidental injury need to be considered in a clinical decision tool designed to support paramedics' management of children with head injury. CONCLUSION:Paramedics generally feel a lack of confidence in assessing and managing children with head injury. A decision tool, coupled with training and useful feedback from EDs following conveyance, would be useful to help improve decision-making.

Due to the worldwide pressures on Emergency Departments (EDs), there is a focus on ED interventions to alleviate pressure. Ensuring interventions do not inadvertently impact upon other healthcare sectors is an important outcome. This overview of systematic reviews aimed to evaluate the impact of ED based interventions on subsequent healthcare resource use after ED discharge. An overview of systematic reviews was conducted in accordance with the Cochrane Collaboration. Search criteria were devised using the PRESS standard and duplicate screening and extraction conducted for one third of systematic reviews. A primary study matrix was designed to reduce the impact of duplicate primary studies. Data was extracted in the form presented in the underlying review. After removal of overlapping primary studies, 38 systematic reviews and 213 primary studies were included. Overall confidence in the reviews was high in 12, moderate in seven, low in nine and critically low in 10 reviews. In the 38 reviews, 30 different intervention-population-resource use combinations were analysed. ED based interventions decreased subsequent healthcare resource use in 23.3

Background:General practice services are under pressure due increased demand. Alongside substantial national recruitment challenges, there exists a shortage of general practitioners to meet current need. Resultingly, allied healthcare professionals, including paramedics, are being utilised in general practice. Aim:To determine the models of paramedics in general practice settings; the mechanisms that underpin effective paramedics in general practice; and the impact of paramedics in general practice on safety, costs and clinical and patient-reported outcomes and experience. Design:A mixed-methods realist evaluation comprised a rapid realist review followed by an evaluation of paramedics in general practice in general practice case study sites. Patient and public involvement and input was integral, ensuring validity from a patient and carer perspective. Setting:General practices in England. Participants:A total of 34 general practices participated as case study sites, of which 25 were 'paramedics in general practice' sites. Data from qualitative realist interviews (n = 69), quantitative questionnaires (n = 489) and electronic records (n = 22,509 consultations) were collected. Interventions:Paramedics in general practice models were classified according to: (1) level of integration of the paramedic to the general practice team; and (2) complexity of patients seen by paramedics. Main outcome measures:Qualitative interviews investigated initial programme theories with staff and patient participants. Patient participant questionnaires utilised validated measures: the Patient-Reported Experiences and Outcomes of Safety in Primary Care (safety); EuroQol-5 Dimensions, five-level version (health-related quality of life); Primary Care Outcomes Questionnaire; the Modular Resource Use Measure (health and care resource utilisation). Electronic health records provided data on primary care use. Review methods:A rapid realist review of the published and grey literature, supplemented with direct enquiry with system leaders and key stakeholders. Results:The rapid realist review highlighted significant variation in paramedics' roles in general practice. Qualitative interviews identified domains related to access, safety, workforce reconfiguration, infrastructure, patient experience, and outcomes. Lower Patient-Reported Experiences and Outcomes of Safety in Primary Care practice activation scores were found at paramedics in general practice sites (perceived less engaged in promoting safety), in particular those with medium and low levels of paramedics in general practice integration and complexity. There was a small statistically significant difference in the Primary Care Outcomes Questionnaire 'Confidence in Health Plan' by paramedics in general practice complexity, such that confidence had deteriorated slightly more in the high-complexity group compared to non-paramedics in general practice. Paramedics in general practice sites had lower scores at initial visit and 30 days for the Primary Care Outcomes Questionnaire 'Confidence in Health Provision'. We found little evidence that paramedics in general practice care led to substantial spillover effects via increased reconsultations, prescriptions, secondary care referrals or unplanned hospital admission costs. Limitations:The study faced challenges in recruitment. Self-selected participating sites may not be representative of all general practitioners in England, and categorising paramedics in general practice models for analysis was more complex than anticipated. The comparison of costs and outcomes between paramedics in general practice and non-paramedics in general practice sites was based on an observational study design. Conclusions:Paramedics in general practice care improves access to general practice. Safety and acceptability require resources for induction, supervision, training and education. Paramedics in general practice integration affects staff satisfaction and role longevity. Paramedics in general practice allows paramedics to develop and evolve. Future work:Larger studies utilising different study designs with longer follow-up are needed to fully understand the impact of paramedics in general practice on clinical outcomes and episode of care costs. Study registration:This study is registered as ISRCTN56909665 https://doi.org/10.1186/ISRCTN56909665. Funding:This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR132736) and is published in full in Health and Social Care Delivery Research; Vol. 13, No. 6. See the NIHR Funding and Awards website for further award information.

BACKGROUND:Streaming and redirection in the ED involves the assessment, triage and prioritisation of patients. Lower acuity patients can be streamed to alternative services within the hospital or redirected to off-site services with the aim of alleviating ED clinical pressures. This study aimed to understand staff, patient, family members and carers' experiences of streaming and redirection, including patients and staff who used an NHS web-based application. METHODS:A semistructured interview study with staff working in the ED involved in streaming delivery and adult patients and family members who had attended the ED for conditions that could be safely managed in lower acuity settings. Participants were recruited from two NHS Hospital sites in England, one using a web-based NHS urgent care self-service product (digital tool) and one using a nurse-led streaming model. Recruitment took place between August and December 2023. RESULTS:28 interviews were completed. Participants across both sites commented on the challenges of streaming and redirection and confusion around where patients needed to go for what conditions. Patients and staff felt that the lack of capacity in alternative services limited the effectiveness of streaming and redirection. Three themes developed: 'it's too muddy': disruption to the flow of care, balancing privacy and efficiency in streaming and redirection, pressures in the wider healthcare system beyond the ED. CONCLUSIONS:This research has implications for understanding patient and staff experiences of streaming and redirection approaches, and the need for clear communication and navigation when utilising digital technologies in the ED.

People living with frailty can experience discrimination, but unlike the characteristics of age and disability, frailty is not protected by law. Frailty is a clinical syndrome associated with ageing in which health deficits increase a person's vulnerability to illness, disability, and death. This scoping review, conducted by a team of methodologists, clinicians, lawyers, and patients, aimed to investigate the extent of discrimination against people living with frailty described in health-care literature. We searched five health-care databases from inception up to June, 2022, and grey literature, to identify 144 texts. The texts were classified by the types of discrimination (direct discrimination, indirect discrimination, harassment, and victimisation) and inductively developed into contextual themes. The median age of the participants was 77 years (IQR 69·9-82·0), and 65·4% were women. The most common types of discrimination were direct (in 90 [63%]), indirect (in 66 [46%]), and harassment (in one [1%]) of the 144 texts, with no instances of victimisation reported. Nine themes of discriminatory actions were developed. Discrimination against people living with frailty overlapped with discrimination based on established protected characteristics, including age, disability, race, and sex. Evidence indicated that frailty discrimination replaces, mediates, masks, and potentiates age discrimination. Discrimination against people with frailty seemed to be both an independent event and one that interacts with established protected characteristics. Future research should focus on preventing frailty-based discrimination and establishing whether frailty should be considered a new protected characteristic by law.

At the start of the COVID-19 pandemic South Western Ambulance Service Foundation Trust (SWASFT) changed its pre-hospital trauma triage tool to include an assessment of frailty, and if scored 5 or more on the Clinical Frailty Scale, the tool instructed the person to be conveyed to a trauma unit and not the major trauma centre. How the use of frailty has been operationalised and effected in daily clinical practice is unknown. There were concerns during the COVID-19 pandemic that care was being rationed by a frailty score alone, without expert oversight or appropriate training. Whether or not care rationing was appropriate at the height of the pandemic remains a philosophical question, however more research is needed into using the CFS for this type of decision making. This is relevant to using frailty scores in trauma triage tools outside of a pandemic situation, particularly when a score may prompt a change in clinical management. This study aims to explore the pathways of care that have been associated with this incorporation of frailty. In addition, it will aim to explore healthcare professionals experience of frailty scoring for trauma patients pre-hospital and at the receiving hospitals. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This study did not receive any funding ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: HRA and Health and Care Research Wales (HCRW) Approval. IRAS project ID: 310646 Protocol number: NBT5146 REC reference: 22/HRA/0950 Sponsor: North Bristol Trust I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data produced in the present study are available upon reasonable request to the authors

Study Aim To understand the survival and emergency medical service call triage and response to patients who suffer an out-of-hospital cardiac arrest after the emergency medical service call is connected. Methods: A descriptive retrospective data analysis of two years’ of out-of-hospital cardiac arrest registry data, 2018-2019, linked to computer aided dispatch data was completed in a single system emergency medical service in the South West of the United Kingdom. Data analysis included descriptive statistics and chi squared analysis for association. Results: There were 4245 out-of-hospital cardiac arrest patients included for analysis. Patients who suffer an out-of-hospital cardiac arrest after the emergency call is connected receive a lower priority response, have a significantly longer response time and where the cardiac arrest is not witnessed by the emergency medical service have poorer outcomes than those patients who have already suffered a cardiac arrest at the time of the emergency call. Conclusion: Emergency medical service response times were significantly shorter for patients who had already suffered a cardiac arrest at the time of the call for help in comparison to those patients who continued to suffer a cardiac arrest after the call for help was connected. Patients who suffer a cardiac arrest after the connection of the emergency call and where the out-of-hospital cardiac arrest is not emergency medical service witnessed have the poorest outcomes.

Background: The Chain of Survival identifies the importance of early recognition of patients who are at imminent risk of out-of-hospital cardiac arrest. This research investigated the interaction between callers and call-takers during calls to the Emergency Medical Service; it specifically focussed on patients who were alive at the initiation of the EMS call, but who subsequently deteriorated into out-of-hospital cardiac arrest during the prehospital phase of care (i.e., before arrival at hospital). Methods: Conversation-analytic methods were used to examine the call openings of 38 Emergency Medical Service calls for patients who were at imminent risk of out-of-hospital cardiac arrest. Call openings centred on pre-triage questions designed to rapidly identify patients who are either in out-of-hospital cardiac arrest, or who are at imminent risk of out-of-hospital cardiac arrest. Results: Emergency Medical Service call openings did not facilitate efficient and accurate triage, thus delaying the identification of critically unwell patients by call-takers. In 50% of call openings, the caller wanted to give the reason for the call during the pre-triage questions. The caller and call-takers orientate to different agendas causing delays to call progression and risking information loss that impacts on effective call triage. Conclusions: The design of the Emergency Medical Service call opening can cause interactional trouble, thus impacting on call progression and risking critical information loss. Modifications to the Emergency Medical Service call opening to quickly align the caller and call-taker, communications training for call-takers and public education may support early identification of patients at imminent risk of out-of-hospital cardiac arrest.

Objective Hospital-based clinical decision tools support clinician decision-making when a child presents to the emergency department with a head injury, particularly regarding CT scanning. However, there is no decision tool to support prehospital clinicians in deciding which head-injured children can safely remain at scene. This study aims to identify clinical decision tools, or constituent elements, which may be adapted for use in prehospital care.Design Systematic mapping review and narrative synthesis.Data sources Searches were conducted using MEDLINE, EMBASE, PsycINFO, CINAHL and AMED.Eligibility criteria Quantitative, qualitative, mixed-methods or systematic review research that included a clinical decision support tool for assessing and managing children with head injury.Data extraction and synthesis We systematically identified all in-hospital clinical decision support tools and extracted from these the clinical criteria used in decision-making. We complemented this with a narrative synthesis.Results Following de-duplication, 887 articles were identified. After screening titles and abstracts, 710 articles were excluded, leaving 177 full-text articles. Of these, 95 were excluded, yielding 82 studies. A further 14 studies were identified in the literature after cross-checking, totalling 96 analysed studies. 25 relevant in-hospital clinical decision tools were identified, encompassing 67 different clinical criteria, which were grouped into 18 categories.Conclusion Factors that should be considered for use in a clinical decision tool designed to support paramedics in the assessment and management of children with head injury are: signs of skull fracture; a large, boggy or non-frontal scalp haematoma neurological deficit; Glasgow Coma Score less than 15; prolonged or worsening headache; prolonged loss of consciousness; post-traumatic seizure; amnesia in older children; non-accidental injury; drug or alcohol use; and less than 1 year old. Clinical criteria that require further investigation include mechanism of injury, clotting impairment/anticoagulation, vertigo, length of time of unconsciousness and number of vomits.

Introduction Traumatic pneumothoraces are present in one of five victims of severe trauma. Current guidelines advise chest drain insertion for most traumatic pneumothoraces, although very small pneumothoraces can be managed with observation at the treating clinician’s discretion. There remains a large proportion of patients in whom there is clinical uncertainty as to whether an immediate chest drain is required, with no robust evidence to inform practice. Chest drains carry a high risk of complications such as bleeding and infection. The default to invasive treatment may be causing potentially avoidable pain, distress and complications. We are evaluating the clinical and cost-effectiveness of an initial conservative approach to the management of patients with traumatic pneumothoraces.Methods and analysis The CoMiTED (Conservative Management in Traumatic Pneumothoraces in the Emergency Department) trial is a multicentre, pragmatic parallel group, individually randomised controlled non-inferiority trial to establish whether initial conservative management of significant traumatic pneumothoraces is non-inferior to invasive management in terms of subsequent emergency pleural interventions, complications, pain, breathlessness and quality of life. We aim to recruit 750 patients from at least 40 UK National Health Service hospitals. Patients allocated to the control (invasive management) group will have a chest drain inserted in the emergency department. For those in the intervention (initial conservative management) group, the treating clinician will be advised to manage the participant without chest drain insertion and undertake observation. The primary outcome is a binary measure of the need for one or more subsequent emergency pleural interventions within 30 days of randomisation. Secondary outcomes include complications, cost-effectiveness, patient-reported quality of life and patient and clinician views of the two treatment options; participants are followed up for 6 months.Ethics and dissemination This trial received approval from the Wales Research Ethics Committee 4 (reference: 22/WA/0118) and the Health Research Authority. Results will be submitted for publication in a peer-reviewed journal.Trial registration number ISRCTN35574247.

Objectives To examine inequalities in birth before arrival (BBA) at hospitals in South West England, understand which groups are most likely to experience BBA and how this relates to hypothermia and outcomes (phase A). To investigate opportunities to improve temperature management advice given by emergency medical services (EMS) call-handlers during emergency calls regarding BBA in the UK (phase B).Design A two-phase multimethod study. Phase A analysed anonymised data from hospital neonatal records between January 2018 and January 2021. Phase B analysed anonymised EMS call transcripts, followed by focus groups with National Health Service (NHS) staff and patients.Setting Six Hospital Trusts in South West England and two EMS providers (ambulance services) in South West and North East England.Participants 18 multidisciplinary NHS staff and 22 members of the public who had experienced BBA in the UK.Results 35% (64/184) of babies conveyed to hospital were hypothermic on arrival. When compared with national data on all births in the South West, we found higher percentages of women with documented safeguarding concerns at booking, previous live births and ‘late bookers’ (booking their pregnancy >13 weeks gestation). These women may, therefore, be more likely to experience BBA. Preterm babies, babies to first-time mothers and babies born to mothers with disability or safeguarding concerns at booking were more likely to be hypothermic following BBA. Five main themes emerged from qualitative data on call-handler advice: (1) importance placed on neonatal temperature; (2) advice on where the baby should be placed following birth; (3) advice on how to keep the baby warm; (4) timing of temperature management advice and (5) clarity and priority of instructions.Conclusions Findings identified factors associated with BBA and neonatal hypothermia following BBA. Improvements to EMS call-handler advice could reduce the number of babies arriving at hospital hypothermic.

Background: Emergency department nurses and paramedics have contact with millions of people and could use these contacts as opportunities to help people improve their health. These two professional groups could identify people with modifiable risk factors and provide information, brief interventions, and signposting to locally provided services. This study aimed to investigate if and how health promotion is delivered by emergency department nurses and paramedics, and its acceptability to both the staff and patients in these settings. Methods: A mixed methods study consisting of an online survey with paramedics and emergency department nurses and semi-structured telephone interviews with staff and patients. The setting was the emergency departments in three NHS Hospital Trusts and four Ambulance Service Trusts in England. Results: Three hundred and thirty-one online survey responses, 21 virtual interviews with staff and 14 virtual interviews with patients were analysed. Three main themes emerged from the data: (1) role and relevance of health promotion provision; (2) needs and support for health promotion provision; (3) trust and receptiveness for health promotion provision. Conclusions: The findings of this study indicate that staff often refrain from engaging in health promotion activities due to uncertainty about whether it falls within their job responsibilities and a lack of confidence in their ability to perform these activities. Further research is needed to identify effective strategies to encourage, empower, and support staff in integrating health promotion activities into their daily routines in ways that are acceptable to both patients and staff.

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.

Background Heightened pressures on hospitals and Emergency Medical Services (EMS) due to growing demand and staff shortages have led to prolonged ambulance response times and delays in handing over the care of EMS patients on arrival at an Emergency Department. These delays jeopardise patient safety and staff wellbeing. Point of care (POC) tests in EMS have been proposed to facilitate effective on-scene decision-making, reduced conveyance, improved clinical outcomes, enhanced system efficiency and patient experience. Despite an acceleration in POC testing during the Covid-19 pandemic, limited evidence exists for integrating POC tests into routine EMS practice. The aim of this research was to explore the impact, benefits, barriers, and facilitators of POC testing in United Kingdom (UK) EMS, alongside factors influencing future research on POC testing implementation. Methods Convenience and snowballing sample techniques were used to recruit a diverse stakeholder group, including patient and public participants, for online semi-structured interviews between June and July 2023. Interviews were recorded, transcribed verbatim and thematically analysed using the framework method. The codes were pre-selected using the outcomes of a prior stakeholder event and double coded by the research team. Results A total of 25 participants took part in semi-structured interviews. Whilst most participants identified clear potential benefits associated with the implementation of further POC tests within UK EMS, barriers that need to be considered in future research were also highlighted. Three themes were identified: enhancing patient care and system efficiency through POC testing; navigating implementation challenges: balancing barriers and facilitators for successful implementation; building the foundations: key considerations for future research. Conclusions Our study indicates that although the adoption of further POC testing was viewed positively, with substantial potential for impact, it will be essential to carefully address the barriers identified, along with insights from prior research, to overcome the associated challenges effectively.

Background There are increasing demands on Emergency Medical Services. More efficient treatment pathways are required to support conveyance decision making and patient referral in prehospital care. Point of Care testing is increasingly available and utilised across the NHS to support optimal ways of working. We aimed to design and conduct a Multiple Criteria Decision Analysis to prioritise in vitro point of care tests and use cases for inclusion in a platform trial of in vitro point of care testing in UK Emergency Medical Services. Methods We designed a Multiple Criteria Decision Analysis that included systematic scoping reviews stakeholder recruitment, two stakeholder surveys and two stakeholder workshops to scope the use cases, explore criteria and map use cases, evaluate the criteria and measure the use cases against the criteria. Results We recruited 32 stakeholders. We developed a scoring matrix with 4 criteria for scoring the use cases and 8 criteria for scoring the point of care tests and applied weighting determined from survey results. Use cases were scored by the stakeholders against 4 criteria. The 3 highest scoring use cases were point of care troponin testing in: possible Acute Myocardial Infarction, lactate testing in suspected sepsis and in trauma. We developed the process for scoring the point of care tests to be completed close to a proposed trial to allow for a changes in technology. Conclusions We successfully designed a Multiple Criteria Decision Analysis to identify use cases and candidate tests for inclusion in a future platform trial of in vitro point of care testing in UK Emergency Medical Services. We identified 3 use cases for evaluation in a platform trial of in vitro point of care testing: troponin testing in possible acute myocardial infarction, lactate testing in suspected sepsis and lactate testing to identify occult haemorrhage in trauma.

Background:Traumatic haemorrhage is common after severe injury, leading to disability and death. Cryoprecipitate, a source of fibrinogen, may improve outcomes for patients with traumatic haemorrhage. Objective:To investigate the effects of early fibrinogen supplementation in the form of 3 pools (15 units, approximately 6 g of fibrinogen) of cryoprecipitate on 28-day mortality. Design:A randomised, parallel-group, unblinded, multicentre, international trial and economic evaluation. Patients were randomised to either the intervention (early cryoprecipitate) or the comparator (standard major haemorrhage protocol) arm via opaque, sealed envelopes in the emergency department or the transfusion laboratory/blood bank. All analyses were performed on an intention-to-treat basis. A cost-effectiveness analysis was undertaken. Setting:Twenty-five major trauma centres in the UK and one level 1 trauma centre in the USA. Participants:Adults who had traumatic haemorrhage following severe injury requiring activation of the major haemorrhage protocol and had received a blood transfusion. Intervention:Early cryoprecipitate - 3 pools (equivalent to 15 single units of cryoprecipitate or 6 g of fibrinogen supplementation), infused as rapidly as possible, within 90 minutes of arrival at hospital in addition to standard major haemorrhage protocol or standard major haemorrhage protocol only. Main outcome measures:The primary outcome was all-cause mortality at 28 days. The secondary outcomes were all-cause mortality at 6 hours, 24 hours, 6 months and 12 months from admission; death from bleeding at 6 hours and 24 hours; transfusion requirements at 24 hours from admission; destination of participant at discharge; quality-of-life measurements (EuroQol-5 Dimensions, five-level version and Glasgow Outcome Scale) at discharge/day 28 and 6 months after injury; and hospital resource use up to discharge or day 28 (including ventilator-days, hours spent in critical care and inpatient stays). Results:Eight hundred and five patients were randomised to receive the standard major haemorrhage protocol (control arm). Seven hundred and ninety-nine patients were randomised to receive an additional three pools of cryoprecipitate in addition to standard care (intervention arm). Baseline characteristics appeared well matched. Patients had a median age of 39 (interquartile range 26-55) years, and the majority (79%) were male. All-cause 28-day mortality (n = 1531 patients; intention to treat) was 25.3% in the intervention arm compared with 26.1% in the control arm (odds ratio 0.96; p = 0.74). Limitations:There was variability in the timing of cryoprecipitate administration, with overlap between the treatment arms, limiting the degree of intervention separation. Conclusions:There was no evidence that early empiric administration of high-dose cryoprecipitate reduced the risk of death in unselected patients with traumatic haemorrhage. There was also no difference in adverse events. The cost-effectiveness of the intervention was similar to that of standard care. Future work:Research to evaluate if fibrinogen replacement is more beneficial for selected patients, for example those with low fibrinogen blood levels, is needed, as is further exploration of whether there is a difference in outcome according to mechanism of injury. Trial registration:This trial is registered as ISRCTN14998314. Funding:This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 15/57/02) and is published in full in Health Technology Assessment; Vol. 28, No. 76. See the NIHR Funding and Awards website for further award information.

Background Internationally, Emergency Medical Service (EMS) triage emergency calls so that healthcare resources can be allocated appropriately. Studies have indicated that call triage in EMS may trigger a suboptimal response to some patients with life threatening conditions. The triage of emergency calls is an important element of the 'Chain of Survival' in OHCA and in the recognition of deteriorating patients. The aim of this study was to investigate Emergency Operation Centre (EOC) staff views on the barriers to identification, and how to improve the early identification of patients contacting EMS who are at imminent risk of cardiac arrest. Methods This was a qualitative study using interviews and focus groups with EOC employees. Two UK EMS participated in the research. We aimed to recruit 20 participants to the study using purposive sampling. Reflexive thematic analysis (RTA) was used to analyse the data using a combined inductive and deductive approach. The deductive and inductive analyses were combined into the final overarching themes and sub themes. Themes were identified where there was a central organising concept. Results Twelve semi-structured interviews were completed between July and September 2021. Four participants also took part in a focus group in September 2021. Three main themes were identified The dispatch protocol and EMD audit; Identifying and responding to deteriorating patients; Education, knowledge and skills. Each of these main themes were broken into sub-themes. Conclusion Participants identified several barriers to recognizing patients at imminent risk of OHCA, including the restrictive dispatch protocol, lack of opportunity to monitor a patient, compliance auditing and inadequate clinical and communication education. Participants reported that clinician support for the EMD role was not always adequate. Callers are unaware of the structure of the EMS call which leads to initial confusion and a lack of patient outcome feedback restricts EMD learning and development.

Survival from in-hospital cardiac arrest is approximately 18%, but for patients who require advanced airway management survival is lower. Those who do survive are often left with significant disability. Traditionally, resuscitation of cardiac arrest patients has included tracheal intubation, however insertion of a supraglottic airway has gained popularity as an alternative approach to advanced airway management. Evidence from out-of-hospital cardiac arrest suggests no significant differences in mortality or morbidity between these two approaches, but there is no randomised evidence for airway management during in-hospital cardiac arrest.The aim of the AIRWAYS-3 randomised trial, described in this protocol paper, is to determine the clinical , cost effectiveness of a supraglottic airway versus tracheal intubation during in-hospital cardiac arrest. Patients will be allocated randomly to receive either a supraglottic airway or tra-cheal intubation as the initial advanced airway management. We will also estimate the relative cost-effectiveness of these two approaches. The pri-mary outcome is functional status, measured using the modified Rankin Scale at hospital discharge or 30 days post-randomisation, whichever occurs first.AIRWAYS-3 presents ethical challenges regarding patient consent and data collection. These include the enrolment of unconscious patients without prior consent in a way that avoids methodological bias. Other complexities include the requirement to randomise patients efficiently during a time -critical cardiac arrest. Many of these challenges are encountered in other emergency care research; we discuss our approaches to addressing them.