The incorporation of deprescribing into structured medication reviews (SMR) is a patient-centred and cost-effective practice in primary care settings. Pharmacists have a key role in deprescribing among older people to improve quality of life and reduce adverse events, but patients and healthcare professionals may be resistant to reducing their medication, and evidence around how deprescribing happens in practice is currently lacking. This study explores the implementation of a co-designed intervention in a single English General Practice (UK). To explore key stakeholders’ perceptions of a co-designed primary care intervention to involve patients and their families in deprescribing and its broader intervention context, guided by the Consolidated Framework for Implementation Research (CIFR). Qualitative semi-structured interview study with a purposive sample of staff, and patients with frailty, to explore perceptions of the deprescribing initiative. Data were analysed using an a priori framework structured by the domains of the CIFR. Interviews (24 in total) were conducted with 13 staff involved in delivering the intervention and 5 patients living with frailty who completed a structured medication review with recommended medication changes. Key factors (mapped to CFIR domains) included: an imperative for formal training around the intervention delivery (Inner setting), engagement with SMR delivery linked to payment through national agendas (Outer setting); the importance of the fit of the intervention with existing processes around prescribing practice and infrastructure (Inner setting); increased understanding of the aims of deprescribing among patients and recognition of the extended pharmacist role in primary care deprescribing (Individuals); recognition that the successful delivery of the intervention was a team effort (Implementation process). Structured medication reviews are a suitable mechanism to discuss and make deprescribing decisions as part of a shared consultation. Resources which support the patient through the deprescribing process can engage patients and promote greater satisfaction with service delivery. Operationally, staff can also benefit from tools which facilitate greater understanding of the process and fit within their usual practice plus improving patient care and saving medication costs. Barriers and facilitators to implementation success should be noted and addressed for upscaling and process sustainability.

Abstract Background The incidence of post-operative periprosthetic femoral fractures (POPFFs) is increasing. However, specific clinical guidance relating to patient management does not exist, resulting in variations in care and outcomes. This study aimed to elicit and synthesise expert knowledge in POPFF service delivery and explore views on variations in service provision and the factors influencing these. Methods Semi-structured interviews were undertaken with healthcare professionals with expertise in POPFF care from England and Wales to explore current practices, challenges, service variations and perceived future opportunities. Participants were identified through specialist research and clinical networks for POPFF and hip fracture care, authors of key publications on the subject, national leads for POPFF/hip fracture networks, and research team contacts. Interviews were analysed using thematic analysis. Results Ten interviews were undertaken with experts in POPFF services across a range of professional roles. Four themes were identified: conceptualisation of POPFF (by different professional groups and in different service settings) and understanding of POPFF patient needs; sources of variation in management and care of POPFF patients; service model rationales, advantages and disadvantages; and potential strategies to improve POPFF care. Conclusion When designing POPFF services, we suggest that four key areas need consideration: the extent to which POPFF patients are a distinct group with particular care needs; the necessity for and consequences of patient transfer between wards and hospitals; the resourcing of extensive multidisciplinary support for POPFF patients; and the need for national initiatives to encourage service developments. These findings should form the basis of future clinical guidance. Sensitivity to contextual factors driving variation in services is needed to ultimately improve care for POPFF patients.

Introduction: Providing feedback to emergency ambulance staff on performance or patient outcomes may improve care quality and professional development. Current feedback provision in ambulance services is limited and staff desire more feedback; however, we do not know what feedback would be most useful. This study aimed to determine the quality of feedback received by emergency ambulance staff, describe self-directed learning activities performed after receiving feedback (e.g. ‘reflected on what exactly I did right/wrong’) and identify situations where ambulance staff desired enhanced feedback. Methods: An observational mixed-methods study was used. Emergency ambulance staff delivering face-to-face patient care in the United Kingdom’s National Health Service completed a baseline survey and diary entries between March and August 2022. Diary entries were event contingent and were collected when a participant identified that they had received feedback or desired feedback but had not received it. Free-text qualitative responses were categorised using content analysis before being included in the quantitative analyses. Quantitative data were analysed using descriptive and inferential statistics. Results: Baseline surveys were completed by 299 participants; 100 participants submitted 374 feedback-desired diary entries and 105 participants submitted 538 feedback-received diary entries. Ambulance staff expressed a statistically significant preference for patient-outcome feedback (77.8% [95% CI 74.0, 82.1]), provided by non-ambulance healthcare professionals (70.7% [66.2, 75.3]) and delivered electronically (54.0% [48.9, 59.4]). Feedback was particularly desired for cases involving neurological (17.1%) and cardiovascular (16.6%) conditions and non-conveyed patients (11.5%). Self-directed learning activities post feedback included reflection (61.5%), considering alignment with own judgement (41.1%) and discussions with colleagues (37.0%). Conclusion: The study identifies critical gaps in current feedback practices within ambulance services and provides directions for feedback designs that would enhance existing systems and approaches. Training programmes should educate ambulance staff on effective feedback utilisation and management of both positive and negative feedback. Cultivating a supportive feedback culture within ambulance services is crucial for fostering continuous professional growth and improving patient care outcomes.

Aims:Postoperative periprosthetic femoral fractures (POPFFs) following hip arthroplasty pose complex challenges, with differences in management and outcomes across healthcare facilities. However, there is limited published literature on such variability to inform improvement initiatives. This study aims to quantify the between-hospital variations in surgical management and short-term outcomes. Methods:Administrative hospitalizations data from all 177 NHS hospital Trusts in England were analyzed for patients aged 18 years and above with a primary diagnosis of POPFF between April 2016 and December 2022. Patient demographic characteristics, comorbidities, procedures, length of stay, in-hospital mortality, 30-day total mortality (in or out of hospital), and emergency 30-day all-cause readmissions were extracted. Multilevel models with random intercepts for hospitals and funnel plots assessed the non-random variations between hospitals in procedures and outcomes. Results:Among 39,035 hospitalized patients, 66% were female (n = 25,720), with a median age of 82 years (IQR 73 to 88). Hospital variation existed in treatment outcomes, with adjusted intraclass correlation coefficients for fixation without revision, revision, and no surgical procedure of 4.0%, 3.8%, and 2.4%, respectively. Funnel plots revealed hospital outliers for procedure choice after adjusting for age, sex, and number of comorbidities - among 177 hospitals, nine (5.1%) exceeded the upper 95% control limit for fixation and 17 (9.6%) did so for revision; outlier proportions were 14.1% for length of stay, 3.9% for emergency 30-day readmission, and 1.1% for mortality. Conclusion:Inter-hospital variation exists for the management and short-term outcomes following POPFFs in England. This warrants further explanation to better understand the reasons for this.

Background and objective Post-operative periprosthetic femoral fractures (POPFF) present a growing challenge for healthcare services, but there are limited national data on patient profiles, short-term outcomes, and post-discharge follow-up. We aimed to fill these gaps. Methods Using Hospital Episode Statistics (HES), we identified POPFF discharges from hospitals in England for patients aged 18 and above between April 2016 and December 2022. We flagged prior admissions for hip fracture and elective hip or knee replacement surgery (primary, revision or re-revision) between April 2000 and the day of the POPFF admission date. We extracted information on patient factors, treatment modes for POPFF (nonoperative, fixation, revision), and outcomes (in-hospital mortality, length of stay, unplanned readmission). We used outpatient data to summarise post-hospitalisation follow-up. Results Of 39,035 cases, 65.9% were female; the median age was 82 years. HES data identified that 34.0% had previously undergone elective hip replacement, 26.2% elective knee replacement, and 22.8% surgery for hip fracture. Those with a prior hip fracture were more likely to have delirium during the index POPFF admission, and, compared with those with a prior elective hip or knee replacement, they faced higher in-hospital mortality (5.1% vs 3.2% and 3.6%, respectively), rates of readmission (15.4% vs 13.1% and 12.8%, respectively), and hip re-fracture after POPFF (2.9% vs 1.2% and 1.6%, respectively). Their median length of stay was longer (16 vs 14 days, p<0.001). The most common reason for hospital readmission following POPFF was another fracture (11.3% of all readmissions). Overall, 74% of patients were discharged from outpatient follow-up within 12 months. Conclusion This is the first national description of the burden of adverse outcomes for people with POPFF in England, of whom a large proportion require ongoing specialist support. Fewer POPFF cases follow prior hip fracture surgery than elective joint replacement, but these patients face higher risks of worse outcomes. With an expected increasing incidence of POPFF, this may have considerable health service implications.

Electronic hospital pharmacy (EHP) systems are ubiquitous in today’s hospitals, with many also implementing electronic prescribing (EP) systems; both contain a potential wealth of medication-related data to support quality improvement. The reasons for reuse and users of this data are generally unknown. Our objectives were to survey secondary use of data (SUD) from EHP and EP systems in UK hospitals, to identify users of and factors influencing SUD.A national postal survey was sent out to all hospital chief pharmacists with pre-notifications and follow-up reminders. Descriptive statistical analysis was performed.Of 187 hospital organisations, 65 (35%) responded. All had EHP systems (for ≥20 years) and all reused data; 50 (77%) had EP systems (established 1–10 years) but only 40 (80%) reused data. Reported facilitators for SUD included medication safety, providing feedback, benchmarking, saving time and patient experience. The purposes of SUD included audits, quality improvement, risk management and general medication-related reporting. Earlier introduction of SUD could provide an opportunity to heighten local improvement initiatives.Data from EHP systems is reused for multiple purposes. Evaluating SUD and sharing experiences could provide richer insight into potential SUD and barriers/factors to consider when implementing or upgrading EP/EHP systems.

Resilience in nursing medication administration practice: a systematic review with narrative synthesis.ObjectiveLittle is known about how nurses adapt medication administration practices to preserve safety. The capacity to adapt and respond before harm occurs has been labelled ‘resilience’. Current evidence examining medication safety largely focuses on errors and what goes wrong. This review aimed to synthesise evidence for the application of resilience principles and practices in nursing medication administration.DesignThe Preferred Reporting Items for Systematic Reviews and Meta-Analyses guided the review, which was registered with PROSPERO.Data sourcesMEDLINE, EMBASE, PsychINFO and CINAHL databases were searched from 14 August 2020 to 1 January 2021 for English-language studies.MethodsA systematic review of empirical studies of any design relating to resilience and safety in nursing medication administration in the inpatient setting was conducted. Methodological quality was appraised using the Mixed Methods Appraisal Tool. Data were synthesised thematically.ResultsThirty-two studies with a range of methodologies of mostly good quality met the inclusion criteria. Eleven interventional studies included two that evaluated the effectiveness of education interventions and nine exploratory studies with outcomes showing the impact of an intervention designed or examined to build resilience. Twenty-one non-interventional studies showed how resilience principles are put into practice. Only three studies explicitly named the concept of resilience. Resilient medication administration strategies result from five triggers.ConclusionsNurses’ resilience practices were found to be responses to identified trigers that threaten safety and productivity. These were often short term, real-time proactive adaptations to preserve safety, compensating for and responding to complexities in the modern healthcare setting.PROSPERO registration numberCRD42018087928.

BackgroundProviding feedback to healthcare professionals and organisations on performance or patient outcomes may improve care quality and professional development, particularly in Emergency Medical Services (EMS) where professionals make autonomous, complex decisions and current feedback provision is limited. This study aimed to determine the content and outcomes of feedback in EMS by measuring feedback prevalence, identifying predictors of receiving feedback, categorising feedback outcomes and determining predictors of feedback efficacy.MethodsAn observational mixed-methods study was used. EMS professionals delivering face-to-face patient care in the United Kingdom's National Health Service completed a baseline survey and diary entries between March-August 2022. Diary entries were event-contingent and collected when a participant identified they had received feedback. Self-reported data were collected on feedback frequency, environment, characteristics and outcomes. Feedback environment was measured using the Feedback Environment Scale. Feedback outcomes were categorised using hierarchical cluster analysis. Multilevel logistic regression was used to assess which variables predicted feedback receipt and efficacy. Qualitative data were analysed using content analysis.Results299 participants completed baseline surveys and 105 submitted 538 diary entries. 215 (71.9%) participants had received feedback in the last 30 days, with patient outcome feedback the most frequent (n = 149, 42.8%). Feedback format was predominantly verbal (n = 157, 73.0%) and informal (n = 189, 80.4%). Significant predictors for receiving feedback were a paramedic role (aOR 3.04 [1.14, 8.00]), a workplace with a positive feedback-seeking culture (aOR 1.07 [1.04, 1.10]) and white ethnicity (aOR 5.68 [1.01, 29.73]). Feedback outcomes included: personal wellbeing (closure, confidence and job satisfaction), professional development (clinical practice and knowledge) and service outcomes (patient care and patient safety). Feedback-seeking behaviour and higher scores on the Feedback Environment Scale were statistically significant predictors of feedback efficacy. Solicited feedback improved wellbeing (aOR 3.35 [1.68, 6.60]) and professional development (aOR 2.58 [1.10, 5.56]) more than unsolicited feedback.ConclusionFeedback for EMS professionals was perceived to improve personal wellbeing, professional development and service outcomes. EMS workplaces need to develop a culture that encourages feedback-seeking to strengthen the impact of feedback for EMS professionals on clinical decision-making and staff wellbeing.

Background:Hospital 'command centres' use digital technologies to collect, analyse and present real-time information that may improve patient flow and patient safety. Bradford Royal Infirmary has trialled this approach and presents an opportunity to evaluate effectiveness to inform future adoption in the United Kingdom. Objective:To evaluate the impact of the Bradford Command Centre on patient care and organisational processes. Design:A comparative mixed-methods study. Operational data from a study and control site were collected and analysed. The intervention was observed, and staff at both sites were interviewed. Analysis was grounded in a literature review and the results were synthesised to form conclusions about the intervention. Setting:The study site was Bradford Royal Infirmary, a large teaching hospital in the city of Bradford, United Kingdom. The control site was Huddersfield Royal Infirmary in the nearby city of Huddersfield. Participants:Thirty-six staff members were interviewed and/or observed. Intervention:The implementation of a digitally enabled hospital command centre. Main outcome measures:Qualitative perspectives on hospital management. Quantitative metrics on patient flow, patient safety, data quality. Data sources:Anonymised electronic health record data. Ethnographic observations including interviews with hospital staff. Cross-industry review including relevant literature and expert panel interviews. Results:The Command Centre was implemented successfully and has improved staff confidence of better operational control. Unintended consequences included tensions between localised and centralised decision-making and variable confidence in the quality of data available. The Command Centre supported the hospital through the COVID-19 pandemic, but the direct impact of the Command Centre was difficult to measure as the pandemic forced all hospitals, including the study and control sites, to innovate rapidly. Late in the study we learnt that the control site had visited the study site and replicated some aspects of the command centre themselves; we were unable to explore this in detail. There was no significant difference between pre- and post-intervention periods for the quantitative outcome measures and no conclusive impact on patient flow and data quality. Staff and patients supported the command-centre approaches but patients expressed concern that individual needs might get lost to 'the system'. Conclusions:Qualitative evidence suggests the Command Centre implementation was successful, but it proved challenging to link quantitative evidence to specific technology interventions. Staff were positive about the benefits and emphasised that these came from the way they adapted to and used the new technology rather than the technology per se. Limitations:The COVID-19 pandemic disrupted care patterns and forced rapid innovation which reduced our ability to compare study and control sites and data before, during and after the intervention. Future work:We plan to follow developments at Bradford and in command centres in the National Health Service in order to share learning. Our mixed-methods approach should be of interest to future studies attempting similar evaluation of complex digitally enabled whole-system changes. Study registration:The study is registered as IRAS No.: 285933. 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: NIHR129483) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 41. See the NIHR Funding and Awards website for further award information.

Abstract Introduction Problematic polypharmacy in older people living with frailty can cause harm due to adverse drug events and deprescribing (withdrawing inappropriate medication to manage polypharmacy and improve outcomes (1)) is one solution to mitigate this. Structured Medication Reviews (SMRs) have been commissioned in England to be conducted by Primary Care Network (PCN) pharmacists for which older people living with frailty are a priority group. SMRs are an ideal opportunity to deprescribe for this high-risk population and a person-centred approach is required to ensure deprescribing is safe, effective and acceptable to patients. However, the optimal deprescribing process has not been developed and tested in this context. Aim To develop a person-centred process for deprescribing for older people living with frailty which could potentially be implemented within SMRs in primary care. Methods We conducted qualitative research with older people living with frailty, carers and primary healthcare professionals to identify barriers and facilitators to deprescribing in this context in the North of England (2). We then used these findings and a “trigger film” of patients’ experiences to conduct Experience-based Co-design (EBCD), a multi-event process where older people living with frailty, informal carers and primary healthcare professionals came together to determine the key features of an ideal deprescribing process and identify priorities for a complex intervention to support the process. Following this, we presented the process model for feedback at the training day of a large multi-site primary care practice based (involving pharmacists, GPs and administrative practice staff) in the North of England and subsequently refined the model to integrate within their evolving SMR programme. Results The co-designed deprescribing process consisted of 3 phases: 1. Prior to the SMR consultation which involved case-finding of high-risk patients, case-note review for deprescribing eligibility and clinician planning for the consultation, inviting and preparing the patient for the consultation with written information (including what to expect during the medication review, and questions for patients about their medicines to reflect upon); 2. The consultation which included shared decision-making, agreement of plans to stop medicines, recording of decisions in the electronic health record, providing written information for patients on how to safely stop their medicines, safety netting and signposting to post-deprescribing support; 3. Post-consultation which involved evaluating patient experiences and organising follow-up and further review as needed. Key elements of the optimal process to ensure it was person-centred, were effective written and verbal communication for patients (during the entire process), shared decision-making and tailored support post-consultation. Conclusion We have developed a person-centred process for deprescribing for older people living with frailty and adapted it for implementation within nationally commissioned SMRs in England. Although the model is grounded in the requirements of multiple stakeholders, the final version requires evaluation. The next steps are to design and develop tools which can support our deprescribing process and to undertake feasibility testing in primary care. References 1. Reeve E, Gnjidic D, Long J, Hilmer S. A systematic review of the emerging definition of 'deprescribing' with network analysis: implications for future research and clinical practice. Br J Clin Pharmacol. 2015;80(6):1254-1268. 2. Peat G, Fylan B, Marques I, Raynor DK, Breen L, Olaniyan J, Alldred DP. Barriers and enablers of successful deprescribing as described by older patients with frailty, supporting peers and clinicians: A qualitative interview study. BMJ Open 2022. 12:e054279.

ObjectivesThe Computer-Aided Risk Score for Mortality (CARM) estimates the risk of in-hospital mortality following acute admission to the hospital by automatically amalgamating physiological measures, blood tests, gender, age and COVID-19 status. Our aims were to implement the score with a small group of practitioners and understand their first-hand experience of interacting with the score in situ.DesignPilot implementation evaluation study involving qualitative interviews.SettingThis study was conducted in one of the two National Health Service hospital trusts in the North of England in which the score was developed.ParticipantsMedical, older person and ICU/anaesthetic consultants and specialist grade registrars (n=116) and critical outreach nurses (n=7) were given access to CARM. Nine interviews were conducted in total, with eight doctors and one critical care outreach nurse.InterventionsParticipants were given access to the CARM score, visible after login to the patients' electronic record, along with information about the development and intended use of the score.ResultsFour themes and 14 subthemes emerged from reflexive thematic analysis: (1) current use (including support or challenge clinical judgement and decision making, communicating risk of mortality and professional curiosity); (2) barriers and facilitators to use (including litigation, resource needs, perception of the evidence base, strengths and limitations), (3) implementation support needs (including roll-out and integration, access, training and education); and (4) recommendations for development (including presentation and functionality and potential additional data). Barriers and facilitators to use, and recommendations for development featured highly across most interviews.ConclusionOur in situ evaluation of the pilot implementation of CARM demonstrated its scope in supporting clinical decision making and communicating risk of mortality between clinical colleagues and with service users. It suggested to us barriers to implementation of the score. Our findings may support those seeking to develop, implement or improve the adoption of risk scores.

Background Clinical performance feedback has been demonstrated to have positive effects on patient care in hospital and primary care settings (Ivers et al., 2012). Emerging evidence suggests that providing prehospital clinicians with feedback on their performance and patient outcomes may similarly improve patient care, patient safety and staff wellbeing (Wilson et al., 2022). The aim of this study was to describe the predictors and outcomes of feedback received by prehospital clinicians in the UK, and to identify situations where prehospital clinicians desired enhanced feedback. Methods This was an observational mixed-methods study involving online diary entries between March - August 2022. Eligible participants were emergency ambulance staff delivering face-to-face patient care, employed by NHS ambulance trusts in the UK. Baseline survey data was analysed using logistic regression and diary entries were analysed using multilevel modelling and content analysis. Feedback effects were categorised using hierarchical cluster analysis. Results The baseline survey was completed by n=299 participants, a third of which (n=101) went on to submit n=956 diary entries. Patient outcome feedback was the most frequently received feedback type (n=226). Significant predictors for receiving feedback were paramedic role (p=0.024), workplace with good feedback-seeking culture (p=0.001) and white ethnicity (p=0.024). Categories of feedback effects were personal development (closure, confidence, job satisfaction), professional development (clinical practice, knowledge) and service outcomes (patient care, patient safety). Feedback on patient satisfaction was associated with positive effects on service outcomes (p=0.017), whilst patient outcome feedback was associated with positive effects on professional development (p=0.056). Feedback was most frequently desired for non-conveyed patients and those with neurological or cardiovascular conditions. Conclusion Feedback and follow-up to prehospital clinicians improves personal development, professional development and service outcomes. The results of this study highlight subsets of patients and staff that prehospital feedback should be enhanced for to improve clinical decision-making and staff wellbeing.

In the last 6 years, hospitals in developed countries have been trialling the use of command centres for improving organizational efficiency and patient care. However, the impact of these command centres has not been systematically studied in the past. It is a retrospective population-based study. Participants were patients who visited the Bradford Royal Infirmary hospital, Accident and Emergency (A&E) Department, between 1 January 2018 and 31 August 2021. Outcomes were patient flow (measured as A&E waiting time, length of stay, and clinician seen time) and data quality (measured by the proportion of missing treatment and assessment dates and valid transition between A&E care stages). Interrupted time-series segmented regression and process mining were used for analysis. A&E transition time from patient arrival to assessment by a clinician marginally improved during the intervention period; there was a decrease of 0.9 min [95% confidence interval (CI): 0.35-1.4], 3 min (95% CI: 2.4-3.5), 9.7 min (95% CI: 8.4-11.0), and 3.1 min (95% CI: 2.7-3.5) during 'patient flow program', 'command centre display roll-in', 'command centre activation', and 'hospital wide training program', respectively. However, the transition time from patient treatment until the conclusion of consultation showed an increase of 11.5 min (95% CI: 9.2-13.9), 12.3 min (95% CI: 8.7-15.9), 53.4 min (95% CI: 48.1-58.7), and 50.2 min (95% CI: 47.5-52.9) for the respective four post-intervention periods. Furthermore, the length of stay was not significantly impacted; the change was -8.8 h (95% CI: -17.6 to 0.08), -8.9 h (95% CI: -18.6 to 0.65), -1.67 h (95% CI: -10.3 to 6.9), and -0.54 h (95% CI: -13.9 to 12.8) during the four respective post-intervention periods. It was a similar pattern for the waiting and clinician seen times. Data quality as measured by the proportion of missing dates of records was generally poor (treatment date = 42.7% and clinician seen date = 23.4%) and did not significantly improve during the intervention periods. The findings of the study suggest that a command centre package that includes process change and software technology does not appear to have a consistent positive impact on patient safety and data quality based on the indicators and data we used. Therefore, hospitals considering introducing a command centre should not assume there will be benefits in patient flow and data quality.

Research suggests that feedback in Emergency Medical Services (EMS) positively affects quality of care and professional development. However, the mechanisms by which feedback achieves its effects still need to be better understood across healthcare settings. This study aimed to understand how United Kingdom (UK) ambulance services provide feedback for EMS professionals and develop a programme theory of how feedback works within EMS, using a mixed-methods, realist evaluation framework. A national cross-sectional survey was conducted to identify feedback initiatives in UK ambulance services, followed by four in-depth case studies involving qualitative interviews and documentary analysis. We used qualitative content analysis and descriptive statistics to analyse survey responses from 40 prehospital feedback initiatives, alongside retroductive analysis of 17 interviews and six documents from case study sites. Feedback initiatives mainly provided individual patient outcome feedback through "pull" initiatives triggered by staff requests. Challenges related to information governance were identified. Our programme theory of feedback to EMS professionals encompassed context (healthcare professional and organisational characteristics), mechanisms (feedback and implementation characteristics, psychological reasoning) and outcomes (implementation, staff and service outcomes). This study suggests that most UK ambulance services use a range of feedback initiatives and provides 24 empirically based testable hypotheses for future research.

BackgroundCommand centres have been piloted in some hospitals across the developed world in the last few years. Their impact on patient safety, however, has not been systematically studied. Hence, we aimed to investigate this.MethodsThis is a retrospective population-based cohort study. Participants were patients who visited Bradford Royal Infirmary Hospital and Calderdale & Huddersfield hospitals between 1 January 2018 and 31 August 2021. A five-phase, interrupted time series, linear regression analysis was used.ResultsAfter introduction of a Command Centre, while mortality and readmissions marginally improved, there was no statistically significant impact on postoperative sepsis. In the intervention hospital, when compared with the preintervention period, mortality decreased by 1.4% (95% CI 0.8% to 1.9%), 1.5% (95% CI 0.9% to 2.1%), 1.3% (95% CI 0.7% to 1.8%) and 2.5% (95% CI 1.7% to 3.4%) during successive phases of the command centre programme, including roll-in and activation of the technology and preparatory quality improvement work. However, in the control site, compared with the baseline, the weekly mortality also decreased by 2.0% (95% CI 0.9 to 3.1), 2.3% (95% CI 1.1 to 3.5), 1.3% (95% CI 0.2 to 2.4), 3.1% (95% CI 1.4 to 4.8) for the respective intervention phases. No impact on any of the indicators was observed when only the software technology part of the Command Centre was considered.ConclusionImplementation of a hospital Command Centre may have a marginal positive impact on patient safety when implemented as part of a broader hospital-wide improvement programme including colocation of operations and clinical leads in a central location. However, improvement in patient safety indicators was also observed for a comparable period in the control site. Further evaluative research into the impact of hospital command centres on a broader range of patient safety and other outcomes is warranted.

INTRODUCTION:This paper presents a mixed-methods study protocol that will be used to evaluate a recent implementation of a real-time, centralised hospital command centre in the UK. The command centre represents a complex intervention within a complex adaptive system. It could support better operational decision-making and facilitate identification and mitigation of threats to patient safety. There is, however, limited research on the impact of such complex health information technology on patient safety, reliability and operational efficiency of healthcare delivery and this study aims to help address that gap.METHODS AND ANALYSIS:We will conduct a longitudinal mixed-method evaluation that will be informed by public-and-patient involvement and engagement. Interviews and ethnographic observations will inform iterations with quantitative analysis that will sensitise further qualitative work. Quantitative work will take an iterative approach to identify relevant outcome measures from both the literature and pragmatically from datasets of routinely collected electronic health records.ETHICS AND DISSEMINATION:This protocol has been approved by the University of Leeds Engineering and Physical Sciences Research Ethics Committee (#MEEC 20-016) and the National Health Service Health Research Authority (IRAS No.: 285933). Our results will be communicated through peer-reviewed publications in international journals and conferences. We will provide ongoing feedback as part of our engagement work with local trust stakeholders.

BACKGROUND:In older people living with frailty, polypharmacy can lead to preventable harm like adverse drug reactions and hospitalization. Deprescribing is a strategy to reduce problematic polypharmacy. All stakeholders should be actively involved in developing a person-centred deprescribing process that involves shared decision-making.OBJECTIVE:To co-design an intervention, supported by a logic model, to increase the engagement of older people living with frailty in the process of deprescribing.DESIGN:Experience-based co-design is an approach to service improvement, which uses service users and providers to identify problems and design solutions. This was used to create a person-centred intervention with the potential to improve the quality and outcomes of the deprescribing process. A 'trigger film' showing older people talking about their healthcare experiences was created and facilitated discussions about current problems in the deprescribing process. Problems were then prioritized and appropriate solutions were developed. The review located the solutions in the context of current processes and procedures. An ideal care pathway and a complex intervention to deliver better care were developed.SETTING AND PARTICIPANTS:Older people living with frailty, their informal carers and professionals living and/or working in West Yorkshire, England, UK. Deprescribing was considered in the context of primary care.RESULTS:The current deprescribing process differed from an ideal pathway. A complex intervention containing seven elements was required to move towards the ideal pathway. Three of these elements were prototyped and four still need development. The complex intervention responded to priorities about (a) clarity for older people about what was happening at all stages in the deprescribing process and (b) the quality of one-to-one consultations.CONCLUSIONS:Priorities for improving the current deprescribing process were successfully identified. Solutions were developed and structured as a complex intervention. Further work is underway to (a) complete the prototyping of the intervention and (b) conduct feasibility testing.PATIENT OR PUBLIC CONTRIBUTION:Older people living with frailty (and their informal carers) have made a central contribution, as collaborators, to ensure that a complex intervention has the greatest possible potential to enhance the experience of deprescribing medicines.

Background Several international studies suggest that the feedback that emergency ambulance service (EMS) personnel receive on the care they have delivered lacks structure, relevance, credibility and routine implementation. Feedback in this context can relate to performance or patient outcomes, can come from a variety of sources and can be sought or imposed. Evidence from health services research and implementation science, suggests that feedback can change professional behavior, improve clinical outcomes and positively influence staff mental health. The current study aimed to explore the experience of EMS professionals regarding current feedback provision and their views on how feedback impacts on patient care, patient safety and staff wellbeing. Methods This qualitative study was conducted as part of a wider study of work-related wellbeing in EMS professionals. We used purposive sampling to select 24 frontline EMS professionals from one ambulance service in the United Kingdom and conducted semi-structured interviews. The data was analyzed in iterative cycles of inductive and deductive reasoning using Abductive Thematic Network Analysis. The analysis was informed by psychological theory, as well as models from the wider feedback effectiveness and feedback-seeking behavior literature. Results Participants viewed current feedback provision as inadequate and consistently expressed a desire for increased feedback. Reported types of prehospital feedback included patient outcome feedback, patient-experience feedback, peer-to-peer feedback, performance feedback, feedforward: on-scene advice, debriefing and investigations and coroners' reports. Participants raised concerns that inadequate feedback could negatively impact on patient safety by preventing learning from mistakes. Enhancing feedback provision was thought to improve patient care and staff wellbeing by supporting personal and professional development. Conclusions In line with previous research in this area, this study highlights EMS professionals' strong desire for feedback. The study advances the literature by suggesting a typology of prehospital feedback and presenting a unique insight into the motives for feedback-seeking using psychological theory. A logic model for prehospital feedback interventions was developed to inform future research and development into prehospital feedback.

BackgroundPrehospital feedback is increasingly receiving attention from clinicians, managers and researchers. The effectiveness of feedback in changing professional behaviour and improving clinical performance is strongly evidenced across a range of healthcare settings, but this has not yet been replicated within the prehospital context. Without a firmer evidence base, development in practice relies on isolated initiatives with no clear intervention model or evaluative framework. The aim of this study was to understand how UK ambulance services are currently meeting the challenge of providing prehospital feedback.MethodsThis was a national survey, which formed the first part of a realist evaluation of prehospital feedback. The survey used purposive and snowball sampling. It was advertised on social media and sent to prehospital feedback initiative leads identified through grey literature and networking (n=35). In addition n=8 NHS Ambulance Trusts formally supported this study and identified further initiatives (n=17). Data was analysed using content analysis.ResultsWe received responses from n=41 unique prehospital feedback initiatives, equating to a response rate of 79%. Of these n=27 were currently active. Responses were received from within 10 of the 13 NHS Ambulance Trusts in the UK. Initiatives most commonly provided individual patient outcome feedback to individual frontline ambulance staff members using email format, triggered by a request for feedback (i.e. a pull initiative). Common facilitators were engaged and responsive collaborators, with barriers being information governance and the time and resources involved.ConclusionsThis study suggests that the majority of UK Ambulance Trusts currently have examples of prehospital feedback initiatives within their footprint. In contrast with findings from a recent systematic review, there appear to be more initiatives providing individual patient outcome feedback than performance feedback. To further understand how prehospital feedback initiatives work, we will conduct in-depth case studies of 4 initiatives and develop a programme theory as part of our ongoing realist evaluation.