Publications by authors named "Aloysius Niroshan Siriwardena"

34 Publications

Identifying safe care processes when GPs work in or alongside emergency departments: realist evaluation.

Br J Gen Pract 2021 May 27. Epub 2021 May 27.

Cardiff University School of Medicine, Cardiff, United Kingdom.

Background: Increasing pressure on emergency services has led to the development of different models of care delivery including GPs working in or alongside emergency departments (EDs), but with a lack of evidence for patient safety outcomes.

Aim: We aimed to explore how care processes work and how patient safety incidents associated with GPs working in ED settings may be mitigated.

Design And Setting: We used realist methodology with a purposive sample of 13 EDs with different GP service models. We sought to understand the relationship between contexts, mechanisms and outcomes to develop theories about how and why patient safety incidents may occur, and how safe care was perceived to be delivered.

Method: We collected qualitative data (observations, semi-structured audio-recorded staff interviews and local patient safety incident reports). We coded data using 'if, then, because' statements to refine initial theories developed from an earlier rapid realist literature review and analysis of a sample of national patient safety incident reports.

Results: We developed a programme theory to describe how safe patient care was perceived to be delivered in these service models including: an experienced streaming nurse using local guidance and early warning scores; support for GPs' clinical decision-making with clear governance processes relevant to the intended role (traditional GP approach or emergency medicine approach); and strong clinical leadership to promote teamwork and improve communication between services.

Conclusion: Our findings can be used as a focus for more in-depth human factors investigations to optimise work conditions in this complex care delivery setting.
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http://dx.doi.org/10.3399/BJGP.2021.0090DOI Listing
May 2021

A classification of primary care streaming pathways in UK emergency departments: Findings from a multi-methods study comprising cross-sectional survey; site visits with observations, semi-structured and informal interviews.

Int Emerg Nurs 2021 May 17;56:101000. Epub 2021 Apr 17.

Division of Population Medicine, Cardiff University, Heath Park, Cardiff, UK.

Background: Variation in initial assessment methods at emergency departments in with primary care service models and a conflated terminology causes difficulties in assessing relative performance, improving quality or gathering evidence about safety and clinical effectiveness. We aim to describe and classify streaming pathways in emergency departments in different models of emergency department primary care services in England and Wales.

Methods: We used a multi-stage method, including an online survey completed by 77 emergency departments across England & Wales, interviews with 21 clinical leads, and in-depth case studies of 13 emergency departments. All qualitative data were triangulated and analysed using a framework approach.

Results: Common emergency department pathways to primary care services were: front door streaming; streaming inside the emergency department; or primary care staff selecting patients. Pathways were also in place to redirect patients with non-urgent primary care problems to community primary care services. Streaming and redirection pathways were often adapted, with variation in protocols based on local circumstances.

Conclusion: Clinical leads should consider which pathway(s) best suit their local context. Consistency of terminology used to describe pathways between emergency departments and primary care services is necessary for performance measurement, quality improvement and rigorous future multi-site evaluative and descriptive research.
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http://dx.doi.org/10.1016/j.ienj.2021.101000DOI Listing
May 2021

Ambulance clinician perspectives of disparity in prehospital child pain management: A mixed methods study.

Health Sci Rep 2021 Jun 9;4(2):e261. Epub 2021 Apr 9.

Community and Health Research Unit, School of Health and Social Care University of Lincoln Lincoln UK.

Background: When children suffer acute pain, the ambulance service is often involved to provide initial assessment, treatment, and transport. Several predictors of effective pain management have been identified, including children who are younger (0-5 years), administered analgesics, and living in homes from more affluent areas.

Objective: To explain previously identified predictors of effective prehospital pain management in children.

Design: Mixed methods sequential explanatory study.

Setting And Participants: East Midlands Ambulance Service National Health Service Trust paramedics and emergency medical technicians (EMTs) participated in face-to-face semi-structured interviews. These were audio recorded, transcribed verbatim, and coded using thematic analysis. Meta-inferences were generated and illustrated within a joint display.

Results: Twelve clinicians (9 paramedics and 3 EMTs) were interviewed. Median (interquartile range) age was 43.5 years (41.5, 45.75), 58% were male (n = 7) and 58% were parents (n = 7). Possible explanations were provided for all predictors. Younger children were perceived to express more emotion, were easier to distract, and lived more in the moment than their older counterparts, which explained why younger children were more likely to achieve effective pain management. Analgesics were perceived to have a psychosocial benefit in addition to the pharmacological action. Ambulance clinicians felt that children living in more affluent areas were more likely to achieve effective pain management because the kempt environment facilitated assessment and management and clinicians spent more time on scene; this allowed more time for analgesics to take effect. Participants perceived paramedics to be more confident, and it was found that paramedics were older, more experienced, had a greater scope of practice, and spent more time on scene than EMTs.

Conclusion: Prehospital pain management in children could be improved by facilitating and prioritizing analgesic administration and by ambulance services ensuring a paramedic, or highly trained clinician, is present on each vehicle, necessitating long-term commitment to staff development.
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http://dx.doi.org/10.1002/hsr2.261DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8033633PMC
June 2021

Senior clinical and business managers' perspectives on the influence of different funding mechanisms, and barriers and enablers to implementing models of employing General Practitioners in or alongside emergency departments: Qualitative study.

Health Policy 2021 Apr 22;125(4):482-488. Epub 2021 Jan 22.

PRIME Centre Wales, Division of Population Medicine, 8(th) Floor Neuadd Meirionnydd, Heath Park, Cardiff, UK. Electronic address:

Purpose: Health policy in England has advocated the use of primary care clinicians at emergency departments to address pressures from rising attendances. This study explored senior managers' perspective son funding mechanisms used to implement the policy and experiences of success or challenges in introducing GPs in or alongside emergency departments.

Methods: The perspectives of senior clinical, business and finance managers with responsibility for emergency department services and on-site primary care service implementation were investigated in semi-structured interviews with 31 managers at 12 type-1 emergency departments in England and Wales (February 2018 - September 2019). Emergency departments operated one of three GP models or had prior experience of implementing a GP model. Interviews were thematically analysed.

Results: Perceived successful GPs models in emergency departments were reliant on well-organised and unified funding mechanisms, appropriate staffing and governance, and consideration of population demands and needs. Funding mechanisms and the flow of funds were reported as complex, especially in Inside-parallel GP models. The most efficient mechanisms were described at departments where funding was unified, in collaboration with health and community care services. Staffing with local, experienced GPs was important. There were cautions from experiences with private locum providers.

Conclusion: Our findings contribute to debates about implementing policy on how primary care clinicians are effectively and safely deployed in emergency departments and how local context should be considered.
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http://dx.doi.org/10.1016/j.healthpol.2020.11.016DOI Listing
April 2021

Mixed methods in pre-hospital research: understanding complex clinical problems.

Br Paramed J 2020 Dec;5(3):44-51

Kingston University & St George's, University of London ORCID iD: https://orcid.org/0000-0002-5116-0034.

Healthcare is becoming increasingly complex. The pre-hospital setting is no exception, especially when considering the unpredictable environment. To address complex clinical problems and improve quality of care for patients, researchers need to use innovative methods to create the necessary depth and breadth of knowledge. Quantitative approaches such as randomised controlled trials and observational (e.g. cross-sectional, case control, cohort) methods, along with qualitative approaches including interviews, focus groups and ethnography, have traditionally been used independently to gain understanding of clinical problems and how to address these. Both approaches, however, have drawbacks: quantitative methods focus on objective, numerical data and provide limited understanding of context, whereas qualitative methods explore more subjective aspects and provide perspective, but can be harder to demonstrate rigour. We argue that mixed methods research, where quantitative and qualitative methods are integrated, is an ideal solution to comprehensively understand complex clinical problems in the pre-hospital setting. The aim of this article is to discuss mixed methods in the field of pre-hospital research, highlight its strengths and limitations and provide examples. This article is tailored to clinicians and early career researchers and covers the basic aspects of mixed methods research. We conclude that mixed methods is a useful research design to help develop our understanding of complex clinical problems in the pre-hospital setting.
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http://dx.doi.org/10.29045/14784726.2020.12.5.3.44DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7783957PMC
December 2020

Predictors of recognition of out of hospital cardiac arrest by emergency medical services call handlers in England: a mixed methods diagnostic accuracy study.

Scand J Trauma Resusc Emerg Med 2021 Jan 6;29(1). Epub 2021 Jan 6.

School of Nursing, University of Central Lancashire, Brook Building, Preston, PR1 2HE, UK.

Background: The aim of this study was to identify key indicator symptoms and patient factors associated with correct out of hospital cardiac arrest (OHCA) dispatch allocation. In previous studies, from 3% to 62% of OHCAs are not recognised by Emergency Medical Service call handlers, resulting in delayed arrival at scene.

Methods: Retrospective, mixed methods study including all suspected or confirmed OHCA patients transferred to one acute hospital from its associated regional Emergency Medical Service in England from 1/7/2013 to 30/6/2014. Emergency Medical Service and hospital data, including voice recordings of EMS calls, were analysed to identify predictors of recognition of OHCA by call handlers. Logistic regression was used to explore the role of the most frequently occurring (key) indicator symptoms and characteristics in predicting a correct dispatch for patients with OHCA.

Results: A total of 39,136 dispatches were made which resulted in transfer to the hospital within the study period, including 184 patients with OHCA. The use of the term 'Unconscious' plus one or more of symptoms 'Not breathing/Ineffective breathing/Noisy breathing' occurred in 79.8% of all OHCAs, but only 72.8% of OHCAs were correctly dispatched as such. 'Not breathing' was associated with recognition of OHCA by call handlers (Odds Ratio (OR) 3.76). The presence of key indicator symptoms 'Breathing' (OR 0.29), 'Reduced or fluctuating level of consciousness' (OR 0.24), abnormal pulse/heart rate (OR 0.26) and the characteristic 'Female patient' (OR 0.40) were associated with lack of recognition of OHCA by call handlers (p-values < 0.05).

Conclusions: There is a small proportion of calls in which cardiac arrest indicators are described but the call is not dispatched as such. Stricter adherence to dispatch protocols may improve call handlers' OHCA recognition. The existing dispatch protocol would not be improved by the addition of further terms as this would be at the expense of dispatch specificity.
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http://dx.doi.org/10.1186/s13049-020-00823-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7789721PMC
January 2021

Do National and International Ethics Documents Accord With the Consent Substitute Model for Emergency Research?

Acad Emerg Med 2021 05 15;28(5):569-577. Epub 2020 Dec 15.

and the Community and Health Research Unit, College of Social Science, University of Lincoln, Lincoln, UK.

In 2010 Largent, Wendler, and Emanuel proposed the "consent substitute model" for emergency research with incapacitated participants. The model provides a means to enroll participants in emergency research without consent, if five conditions are met: 1) the research addresses the patients' urgent medical needs, 2) the risk-benefit ratio is favorable, 3) there are no known conflicts with patients' values or interests, 4) cumulative net risk is minimal, and 5) consent is given as soon as possible. We review national and international ethics laws, regulations, and guidelines to determine 1) whether they accord with the consent substitute model's five conditions and 2) the level of congruence across these documents. We find that only one document meets all five conditions and that there is significant disparity among the documents, particularly between national and international ones. These differences may have stymied international collaboration in emergency research. We recommend that the two international documents used most, the International Council for Harmonization's Guideline for Good Clinical Practice and the World Medical Association's Declaration of Helsinki, are revised to include more specific provisions on emergency medical research.
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http://dx.doi.org/10.1111/acem.14179DOI Listing
May 2021

Factors that motivate individuals to volunteer to be dispatched as first responders in the event of a medical emergency: A systematic review protocol.

HRB Open Res 2019 14;2:34. Epub 2020 Sep 14.

Discipline of General Practice, Clinical Science Institute, School of Medicine, National University of Ireland, Galway, H91 TK33, Ireland.

Voluntary First Response is an important component of prehospital care for medical emergencies, particularly cardiac arrest, in many countries. This intervention entails the mobilisation of volunteers, known as Community First Responders (CFRs), by the Emergency Medical Services to respond to medical emergencies in their locality. They include lay responders and/or professional responders (e.g. police officers, fire fighters, and general practitioners). A wide variety of factors are thought to motivate CFRs to join and remain engaged in Voluntary First Response schemes, such as the availability of learning opportunities, recognition, counselling, and leadership. The aim of this review is to develop an in-depth understanding of CFR motivation, including the factors that influence the initial decision to volunteer as a CFR and the factors that sustain involvement in Voluntary First Response over time. Any factors relevant to CFR de-motivation and turnover will also be examined. This is a protocol for a qualitative systematic review of the factors that influence the motivation of individuals to participate in Voluntary First Response. A systematic search will be carried out on seven electronic databases. Qualitative studies, mixed-methods studies, and any other studies producing data relating to the review question will be eligible for inclusion. Title and abstract screening, as well as full text screening, will be completed independently by two authors. A narrative synthesis, which is an established qualitative synthesis methodology, will be performed. The quality of each of the included studies will be critically appraised. The findings of this review will be used to optimise the intervention of Voluntary First Response. Specifically, the results will inform the design and organisation of Voluntary First Response schemes, including their recruitment, training, and psychological support processes. This could benefit a range of stakeholders, including CFRs, paramedics, emergency physicians, patients, and the public.
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http://dx.doi.org/10.12688/hrbopenres.12969.2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7236422PMC
September 2020

Understanding and remedying the performance of doctors in training.

Med Educ 2020 12 20;54(12):1090-1092. Epub 2020 Sep 20.

Community and Health Research Unit, University of Lincoln, Lincoln, UK.

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http://dx.doi.org/10.1111/medu.14370DOI Listing
December 2020

Emergency department clinical leads' experiences of implementing primary care services where GPs work in or alongside emergency departments in the UK: a qualitative study.

BMC Emerg Med 2020 08 14;20(1):62. Epub 2020 Aug 14.

Division of Population Medicine, Cardiff University, Heath Park, Cardiff, UK.

Background: To manage increasing demand for emergency and unscheduled care NHS England policy has promoted services in which patients presenting to Emergency Departments (EDs) with non-urgent problems are directed to general practitioners (GPs) and other primary care clinicians working within or alongside emergency departments. However, the ways that hospitals have implemented primary care services in EDs are varied. The aim of this study was to describe ED clinical leads' experiences of implementing and delivering 'primary care services' and 'emergency medicine services' where GPs were integrated into the ED team.

Methods: We conducted interviews with ED clinical leads in England (n = 19) and Wales (n = 2). We used framework analysis to analyse interview transcripts and explore differences across 'primary care services', 'emergency medicine services' and emergency departments without primary care services.

Results: In EDs with separate primary care services, success was reported when having a distinct workforce of primary care clinicians, who improved waiting times and flow by seeing primary care-type patients in a timely way, using fewer investigations, and enabling ED doctors to focus on more acutely unwell patients. Some challenges were: trying to align their service with the policy guidance, inconsistent demand for primary care, accessible community primary care services, difficulties in recruiting GPs, lack of funding, difficulties in agreeing governance protocols and establishing effective streaming pathways. Where GPs were integrated into an ED workforce success was reported as managing the demand for both emergency and primary care and reducing admissions.

Conclusions: Introducing a policy advocating a preferred model of service to address primary care demand was not useful for all emergency departments. To support successful and sustainable primary care services in or alongside EDs, policy makers and commissioners should consider varied ways that GPs can be employed to manage variation in local demand and also local contextual factors such as the ability to recruit and retain GPs, sustainable funding, clear governance frameworks, training, support and guidance for all staff. Whether or not streaming to a separate primary care service is useful also depended on the level of primary care demand.
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http://dx.doi.org/10.1186/s12873-020-00358-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7429882PMC
August 2020

Exploring the experiences of having Guillain-Barré Syndrome: A qualitative interview study.

Health Expect 2020 10 3;23(5):1338-1349. Epub 2020 Aug 3.

Community and Health Research Unit (CaHRU), School of Health and Social Care, University of Lincoln, Lincoln, UK.

Background: Guillain-Barré syndrome (GBS) is a rare inflammatory disorder affecting the peripheral nerves. Although typically there is full neurological recovery, some people continue to experience residual physical, psychological or social problems longer term. Evidence describing the experiences of people with GBS is limited.

Objective: We aimed to explore the experiences of people with GBS in the UK.

Design: We used qualitative (face-to-face and telephone) interviews to explore experiences of people with GBS. Audio-recorded data were transcribed verbatim and analysed using the Framework Method supported by NVivo 11.

Setting And Participants: We purposively recruited a sample of 16 volunteers with a prior diagnosis of GBS of varying age, sex, ethnicity, location, marital status, time since diagnosis and length of hospital stay to maximize differences in experience. Interviewees were required to have been discharged from hospital, able to give informed consent, able to speak and understand English and currently resident in the United Kingdom.

Results: The key themes arising from the analysis were as follows: the importance of early diagnosis; the experiences of inpatient care; the importance of active support for recovery; the need for communication throughout the course of the illness; the need for greater awareness, knowledge and provision of information by health-care staff; and path to achieving function.

Conclusion: This is the first qualitative study exploring experiences of people with GBS in the UK through their whole illness journey from onset to recovery. The findings contribute to our understanding of the experiences and support needs of people recovering from GBS.
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http://dx.doi.org/10.1111/hex.13116DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7696117PMC
October 2020

Communicating cancer risk in the primary care consultation when using a cancer risk assessment tool: Qualitative study with service users and practitioners.

Health Expect 2020 04 22;23(2):509-518. Epub 2020 Jan 22.

Community and Health Research Unit, School of Health and Social Care, University of Lincoln, Lincoln, UK.

Background: Cancer risk assessment tools are designed to help detect cancer risk in symptomatic individuals presenting to primary care. An early detection of cancer risk could mean early referral for investigations, diagnosis and treatment, helping to address late diagnosis of cancer. It is not clear how best cancer risk may be communicated to patients when using a cancer risk assessment tool to assess their risk of developing cancer.

Objective: We aimed to explore the perspectives of service users and primary care practitioners on communicating cancer risk information to patients, when using QCancer, a cancer risk assessment tool.

Design: A qualitative study involving the use of individual interviews and focus groups.

Setting And Participants: Conducted in primary care settings in Lincolnshire with a convenience sample of 36 participants (19 service users who were members of the public) and 17 primary care practitioners (general practitioners and practice nurses).

Results: Participants suggested ways to improve communication of cancer risk information: personalizing risk information; involving patients in use of the tool; sharing risk information openly; and providing sufficient time when using the tool during consultations.

Conclusion: Communication of cancer risk information is complex and difficult. We identified strategies for improving communication with patients involving cancer risk estimations in primary care consultations.
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http://dx.doi.org/10.1111/hex.13016DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7104630PMC
April 2020

Predictors of effective management of acute pain in children within a UK ambulance service: A cross-sectional study.

Am J Emerg Med 2020 07 9;38(7):1424-1430. Epub 2019 Dec 9.

Community and Health Research Unit, School of Health and Social Care, University of Lincoln, Lincoln, England, United Kingdom.

Objective: We aimed to identify predictors of effective management of acute pain in children in the pre-hospital setting.

Methods: A retrospective cross-sectional study using electronic clinical records from one large UK ambulance service during 01-Oct-2017 to 30-Sep-2018 was performed using multivariable logistic regression. We included all children <18 years suffering acute pain. Children with a Glasgow Coma Scale score of <15, no documented pain or without a second pain score were excluded. The outcome measure was effective pain management (abolition or reduction of pain by ≥2 out of 10 using the numeric pain rating scale, Wong-Baker FACES® scale or FLACC [face, legs, activity, crying and consolability] scale).

Results: 2312 patients were included for analysis. Median (IQR) age was 13 (9-16), 54% were male and the cause of pain was trauma in 66% of cases. Predictors of effective pain management include children who were younger (0-5 years) compared to older (12-17 years) (adjusted odds ratio [AOR] 1.53; 95% confidence interval [CI] 1.18-1.97), administered analgesia (AOR 2.26; CI 1.87-2.73), attended by a paramedic (AOR 1.46; CI 1.19-1.79) or living in an area of low deprivation (index of multiple deprivation [IMD] 8-10) compared to children in an area of high deprivation (IMD 1-3) (AOR 1.37; CI 1.04-1.80). Child sex, type of pain, transport time, non-pharmacological treatments and clinician experience were not significant.

Conclusion: These predictors highlight disparity in effective pre-hospital management of acute pain in children. Qualitative research is needed to help explain these findings.
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http://dx.doi.org/10.1016/j.ajem.2019.11.043DOI Listing
July 2020

A tailored e-learning gives long-term changes in determinants of GPs' benzodiazepines prescribing: a pretest-posttest study with self-report assessments.

Scand J Prim Health Care 2019 Dec 18;37(4):418-425. Epub 2019 Sep 18.

Clinical Pharmacology Research Unit, Heymans Institute of Pharmacology, Ghent University, Ghent, Belgium.

Despite guidelines and campaigns, general practitioners (GPs) continue to overprescribe benzodiazepines (BZDs). New approaches to improve prescribing are needed. Using behavior change techniques and tailoring interventions to user characteristics are vital to promote behavior change. This study evaluated the impact of a tailored e-learning module on factors known to determine BZD prescribing within GPs. A pretest-posttest study design with three self-report assessments concerning determinants of BZD prescribing: at baseline, immediately after the module (short term) and six months after completion (long term). Flanders (Belgium) A tailored e-module that focuses on avoiding initial BZD prescriptions and using psychological interventions as an alternative. 244 GPs Assessed determinants include GPs' attitudes concerning treatment options, perceptions of the patient and self-efficacy beliefs. Readiness to adhere to prescribing guidelines was evaluated through assessing motivation, self-efficacy and implementability of non-pharmacological interventions. A significant and durable impact on determinants of BZD prescribing was observed. GPs underwent desirable changes in attitudes, perceptions and self-efficacy beliefs and these changes remained significant six months later. Tailoring an e-intervention to target group characteristics appears to be successful in promoting behavioral change in experienced GPs. Significant and lasting changes were observed in determinants of prescribing BZDs.Key PointsA tailored e-intervention resulted in significant and long term changes in previously identified determinants of prescribing BZDs. The e-module resulted in a positive impact on GPs' readiness to adhere to BZD prescribing guidance and the way they experience psychosocial consultations. Tailoring an e-intervention to target group characteristics appears to be successful in promoting behavioral change in experienced GPs.
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http://dx.doi.org/10.1080/02813432.2019.1663591DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6883414PMC
December 2019

Performance in candidates declaring versus those not declaring dyslexia in a licensing clinical examination.

Med Educ 2019 12 20;53(12):1243-1252. Epub 2019 Aug 20.

Community and Health Research Unit (CaHRU), School of Health and Social Care, University of Lincoln, Lincoln, UK.

Context: High-stakes medical examinations seek to be fair to all candidates, including an increasing proportion of trainee doctors with specific learning differences. We aimed to investigate the performance of doctors declaring dyslexia in the clinical skills assessment (CSA), an objective structured clinical examination for licensing UK general practitioners.

Methods: We employed a cross-sectional design using performance and attribute data from candidates taking the CSA between 2010 and 2017. We compared candidates who declared dyslexia ('early' before their first attempt or 'late' after failing at least once) with those who did not, using multivariable negative binomial regression investigating the effect of declaring dyslexia on passing the CSA, accounting for relevant factors previously associated with performance, including number of attempts, initial score, sex, place of primary medical qualification and ethnicity.

Results: Of 20 879 CSA candidates, 598 (2.9%) declared that they had dyslexia. Candidates declaring dyslexia were more likely to be male (47.3% versus 37.8%; p < 0.001) and to have a non-UK primary medical qualification (26.9% versus 22.4%; p < 0.01), but were no different in ethnicity compared with those who never declared dyslexia. Candidates who declared dyslexia late were significantly more likely to fail compared with those candidates who declared dyslexia early (40.6% versus 9.2%; p < 0.001) and were more likely to have a non-UK medical qualification (79.3% versus 15.6%; p < 0.001) or come from a minority ethnic group (84.9% versus 39.2%; p < 0.001). The chance of passing was lower for candidates declaring dyslexia compared to those who never declared dyslexia and lower in those declaring late (incident rate ratio [IRR], 0.82; 95% confidence interval [CI], 0.70-0.96) compared with those declaring early (IRR, 0.95; 95% CI, 0.93-0.97).

Conclusions: A small proportion of candidates declaring dyslexia were less likely to pass the CSA, particularly if dyslexia was declared late. Further investigation of potential causes and solutions is needed.
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http://dx.doi.org/10.1111/medu.13953DOI Listing
December 2019

Patient and clinician factors associated with prehospital pain treatment and outcomes: cross sectional study.

Am J Emerg Med 2019 02 23;37(2):266-271. Epub 2018 May 23.

Swansea University, Wales, United Kingdom.

Objective: We aimed to identify how patient (age, sex, condition) and paramedic factors (sex, role) affected prehospital analgesic administration and pain alleviation.

Methods: We used a cross-sectional design with a 7-day retrospective sample of adults aged 18 years or over requiring primary emergency transport to hospital, excluding patients with Glasgow Coma Scale below 13, in two UK ambulance services. Multivariate multilevel regression using Stata 14 analysed factors independently associated with analgesic administration and a clinically meaningful reduction in pain (≥2 points on 0-10 numerical verbal pain score [NVPS]).

Results: We included data on 9574 patients. At least two pain scores were recorded in 4773 (49.9%) patients. For all models fitted there was no significant relationship between analgesic administration or pain reduction and sex of the patient or ambulance staff. Reduction in pain (NVPS ≥2) was associated with ambulance crews including at least one paramedic (odds ratio [OR] 1.52, 95% confidence interval [CI] 1.14 to 2.04, p < 0.01), with any recorded pain score and suspected cardiac pain (OR 2.2, 95% CI 1.02 to 4.75). Intravenous morphine administration was also more likely where crews included a paramedic (OR 2.82, 95% CI 1.93 to 4.13, P < 0.01), attending patients aged 51 to 64 years (OR 2.04, 95% CI 1.21 to 3.45, p = 0.01), in moderate to severe (NVPS 4-10) compared with lower levels of pain for any clinical condition group compared with the reference condition.

Conclusion: There was no association between patient sex or ambulance staff sex or grade and analgesic administration or pain reduction.
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http://dx.doi.org/10.1016/j.ajem.2018.05.041DOI Listing
February 2019

Has there been a change in the knowledge of GP registrars between 2011 and 2016 as measured by performance on common items in the Applied Knowledge Test?

Educ Prim Care 2018 07 8;29(4):215-221. Epub 2018 May 8.

d Primary and Prehospital Health Care, Community and Health Research Unit, Brayford Campus , University of Lincoln , Lincoln , UK.

The aim of this study was to assess whether the absolute standard of candidates sitting the MRCGP Applied Knowledge Test (AKT) between 2011 and 2016 had changed. It is a descriptive study comparing the performance on marker questions of a reference group of UK graduates taking the AKT for the first time between 2011 and 2016. Using aggregated examination data, the performance of individual 'marker' questions was compared using Pearson's chi-squared tests and trend-line analysis. Binary logistic regression was used to analyse changes in performance over the study period. Changes in performance of individual marker questions using Pearson's chi-squared test showed statistically significant differences in 32 of the 49 questions included in the study. Trend line analysis showed a positive trend in 29 questions and a negative trend in the remaining 23. The magnitude of change was small. Logistic regression did not demonstrate any evidence for a change in the performance of the question set over the study period. However, candidates were more likely to get items on administration wrong compared with clinical medicine or research. There was no evidence of a change in performance of the question set as a whole.
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http://dx.doi.org/10.1080/14739879.2018.1467737DOI Listing
July 2018

Perceptions and experiences of community first responders on their role and relationships: qualitative interview study.

Scand J Trauma Resusc Emerg Med 2018 Feb 5;26(1):13. Epub 2018 Feb 5.

Community and Health Research Unit (CaHRU), School of Health & Social Care, University of Lincoln, Lincoln, LN5 7AY, UK.

Background: Community First Responders (CFRs) are lay volunteers who respond to medical emergencies. We aimed to explore perceptions and experiences of CFRs in one scheme about their role.

Methods: We conducted semi-structured interviews with a purposive sample of CFRs during June and July 2016 in a predominantly rural UK county. Interviews were transcribed verbatim and analysed using the Framework method, supported by NVivo 10.

Results: We interviewed four female and 12 male adult CFRs aged 18-65+ years with different levels of expertise and tenures. Five main themes were identified: motivation and ongoing commitment; learning to be a CFR; the reality of being a CFR; relationships with statutory ambulance services and the public; and the way forward for CFRs and the scheme. Participants became CFRs mainly for altruistic reasons, to help others and put something back into their community, which contributed to personal satisfaction and helped maintain their involvement over time. CFRs valued scenario-based training and while some were keen to access additional training to enable them to attend a greater variety of incidents, others stressed the importance of maintaining existing abilities and improving their communication skills. They were often first on scene, which they recognised could take an emotional toll but for which they found informal support mechanisms helpful. Participants felt a lack of public recognition and sometimes were undervalued by ambulance staff, which they thought arose from a lack of clarity over their purpose and responsibilities. Although CFRs perceived their role to be changing, some were fearful of extending the scope of their responsibilities. They welcomed support for volunteers, greater publicity and help with fundraising to enable schemes to remain charities, while complementing the role of ambulance services.

Discussion: CFR schemes should consider the varying training, development and support needs of staff. CFRs wanted schemes to be complementary but distinct from ambulance services. Further information on outcomes and costs of the CFR contribution to prehospital care is needed.

Conclusion: Our findings provide insight into the experiences of CFRs, which can inform how the role might be better supported. Because CFR schemes are voluntary and serve defined localities, decisions about levels of training, priority areas and targets should be locally driven. Further research is required on the effectiveness, outcomes, and costs of CFR schemes and a wider understanding of stakeholder perceptions of CFR and CFR schemes is also needed.
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http://dx.doi.org/10.1186/s13049-018-0482-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5800091PMC
February 2018

Performance of candidates disclosing dyslexia with other candidates in a UK medical licensing examination: cross-sectional study.

Postgrad Med J 2018 Apr 12;94(1110):198-203. Epub 2018 Jan 12.

Stonehaven Medical Practice, Stonehaven, UK.

Purpose Of The Study: The aim of this study was to compare performance of candidates who declared an expert-confirmed diagnosis of dyslexia with all other candidates in the Applied Knowledge Test (AKT) of the Membership of the Royal College of General Practitioners licensing examination.

Study Design: We used routinely collected data from candidates who took the AKT on one or more occasions between 2010 and 2015. Multivariate logistic regression was used to analyse performance of candidates who declared dyslexia with all other candidates, adjusting for candidate characteristics known to be associated with examination success including age, sex, ethnicity, country of primary medical qualification, stage of training, number of attempts and time spent completing the test.

Results: The analysis included data from 14 examinations involving 14 801 candidates of which 2.6% (379/14 801) declared dyslexia. The pass rate for candidates who declared dyslexia was 83.6% compared with 95.0% for other candidates. After adjusting for covariates linked to examination success including age, sex, ethnicity, country of primary medical qualification, stage of training, number of attempts and time spent completing the test dyslexia was not significantly associated with pass rates in the AKT. Candidates declaring dyslexia after initially failing the AKT were more likely to have a primary medical qualification outside the UK.

Conclusions: Performance was similar in AKT candidates disclosing dyslexia with other candidates once covariates associated with examination success were adjusted for. Candidates declaring dyslexia after initially failing the AKT were more likely to have a primary medical qualification outside the UK.
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http://dx.doi.org/10.1136/postgradmedj-2017-135326DOI Listing
April 2018

Teaching young GPs to cope with psychosocial consultations without prescribing: a durable impact of an e-module on determinants of benzodiazepines prescribing.

BMC Med Educ 2017 Dec 19;17(1):259. Epub 2017 Dec 19.

Clinical Pharmacology Research Unit, Ghent University, Heymans Institute of Pharmacology, Ghent, Belgium.

Background: Despite guidelines and campaigns to change prescribing behavior, General Practitioners (GPs) continue to overprescribe benzodiazepines (BZDs). New approaches to improve prescribing are needed. Using behavior change techniques and tailoring interventions to user characteristics are vital to promote behavior change. This study evaluated the impact of an e-module on factors known to determine BZD prescribing practice.

Methods: A tailored e-module that focuses on avoiding initial BZD prescriptions (and using psychological interventions as an alternative) was developed and offered to GPs in vocational training. Three self-report assessments took place: at baseline, immediately after the module (short term) and at least six months after completion (long term). Assessed determinants include GPs' attitudes concerning treatment options, perceptions of the patient and self-efficacy beliefs. Readiness to adhere to prescribing guidelines was evaluated through assessing motivation, self-efficacy and implementability of non-pharmacological interventions. Changes in determinants were analyzed using the Wilcoxon signed-rank test. Changes in readiness to adhere to guidelines was analyzed using the nonparametric McNemar Bowker test.

Results: A desirable, significant and durable impact on determinants of BZD prescribing was observed. GPs (n = 121) underwent desirable changes in their attitudes, perceptions and self-efficacy beliefs and these changes remained significant months after the intervention. Barriers to using a non-pharmacological approach often cited in literature remained absent and were not highlighted by the intervention. Furthermore a significant impact on GPs' readiness to adhere to guidelines was observed. Participants reported change in their ability to cope with psychosocial consultations and to have tried using non-pharmacological interventions.

Conclusions: Tailoring an e-intervention to target group (GPs) characteristics appears to be successful in promoting behavioral change in GPs undertaking vocational training. Significant and lasting changes were observed in determinants of prescribing BZDs. The e-intervention resulted in a positive impact on participants' readiness to adhere to BZD prescribing guidance and their coping with psychosocial consultations. Investigating which mechanisms of change are responsible for the observed effectiveness could help to refine and improve future interventions.
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http://dx.doi.org/10.1186/s12909-017-1100-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5735912PMC
December 2017

Digital technology to facilitate Proactive Assessment of Obesity Risk during Infancy (ProAsk): a feasibility study.

BMJ Open 2017 Sep 6;7(9):e017694. Epub 2017 Sep 6.

Professor of Health Psychology, Institute of Mental Health, University of Nottingham Innovation Park, Nottingham, UK.

Objective: To assess the feasibility and acceptability of using digital technology for Proactive Assessment of Obesity Risk during Infancy (ProAsk) with the UK health visitors (HVs) and parents.

Design: Multicentre, pre- and post-intervention feasibility study with process evaluation.

Setting: Rural and urban deprived settings, UK community care.

Participants: 66 parents of infants and 22 HVs.

Intervention: ProAsk was delivered on a tablet device. It comprises a validated risk prediction tool to quantify overweight risk status and a therapeutic wheel detailing motivational strategies for preventive parental behaviour. Parents were encouraged to agree goals for behaviour change with HVs who received motivational interviewing training.

Outcome Measures: We assessed recruitment, response and attrition rates. Demographic details were collected, and overweight risk status. The proposed primary outcome measure was weight-for-age z-score. The proposed secondary outcomes were parenting self-efficacy, maternal feeding style, infant diet and exposure to physical activity/sedentary behaviour. Qualitative interviews ascertained the acceptability of study processes and intervention fidelity.

Results: HVs screened 324/589 infants for inclusion in the study and 66/226 (29%) eligible infants were recruited. Assessment of overweight risk was completed on 53 infants and 40% of these were identified as above population risk. Weight-for-age z-score (SD) between the infants at population risk and those above population risk differed significantly at baseline (-0.67 SD vs 0.32 SD). HVs were able to collect data and calculate overweight risk for the infants. Protocol adherence and intervention fidelity was a challenge. HVs and parents found the information provided in the therapeutic wheel appropriate and acceptable.

Conclusion: Study recruitment and protocol adherence were problematic. ProAsk was acceptable to most parents and HVs, but intervention fidelity was low. There was limited evidence to support the feasibility of implementing ProAsk without significant additional resources. A future study could evaluate ProAsk as a HV-supported, parent-led intervention.

Trial Registration Number: NCT02314494 (Feasibility Study Results).
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http://dx.doi.org/10.1136/bmjopen-2017-017694DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5588959PMC
September 2017

Paramedic Assessment of Older Adults After Falls, Including Community Care Referral Pathway: Cluster Randomized Trial.

Ann Emerg Med 2017 Oct 13;70(4):495-505.e28. Epub 2017 Mar 13.

Swansea University Medical School, Swansea, Wales, United Kingdom.

Study Objective: We aim to determine clinical and cost-effectiveness of a paramedic protocol for the care of older people who fall.

Methods: We undertook a cluster randomized trial in 3 UK ambulance services between March 2011 and June 2012. We included patients aged 65 years or older after an emergency call for a fall, attended by paramedics based at trial stations. Intervention paramedics could refer the patient to a community-based falls service instead of transporting the patient to the emergency department. Control paramedics provided care as usual. The primary outcome was subsequent emergency contacts or death.

Results: One hundred five paramedics based at 14 intervention stations attended 3,073 eligible patients; 110 paramedics based at 11 control stations attended 2,841 eligible patients. We analyzed primary outcomes for 2,391 intervention and 2,264 control patients. One third of patients made further emergency contacts or died within 1 month, and two thirds within 6 months, with no difference between groups. Subsequent 999 call rates within 6 months were lower in the intervention arm (0.0125 versus 0.0172; adjusted difference -0.0045; 95% confidence interval -0.0073 to -0.0017). Intervention paramedics referred 8% of patients (204/2,420) to falls services and left fewer patients at the scene without any ongoing care. Intervention patients reported higher satisfaction with interpersonal aspects of care. There were no other differences between groups. Mean intervention cost was $23 per patient, with no difference in overall resource use between groups at 1 or 6 months.

Conclusion: A clinical protocol for paramedics reduced emergency ambulance calls for patients attended for a fall safely and at modest cost.
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http://dx.doi.org/10.1016/j.annemergmed.2017.01.006DOI Listing
October 2017

A Systematic Review and Meta-Synthesis of Patients' Experiences and Perceptions of Seeking and Using Benzodiazepines and Z-Drugs: Towards Safer Prescribing.

Patient 2017 02;10(1):1-15

Community and Health Research Unit, School of Health and Social Care, Bridge House, Brayford Campus, University of Lincoln, Lincoln, LN6 7TS, UK.

Background: Benzodiazepines and Z-drugs are used to treat complaints like insomnia, anxiety and pain. These drugs are recommended for short-term use only, but many studies report long-term use, particularly in older people.

Objective: The aim of this study was to identify and synthesise qualitative studies exploring patients' experiences and perceptions of receiving benzodiazepines and Z-drugs, and through this identify factors which perpetuate use of these drugs, and strategies for achieving safer prescribing.

Methods: A systematic search of six databases for qualitative studies exploring patients' experiences and perceptions of primary care benzodiazepine and z-drug prescribing published between January 2000 and April 2014 in a European language, and conducted in Europe, the United States, Australia or New Zealand. Reference lists of included papers were also searched. Study quality was assessed using the Critical Appraisal Skills Programme qualitative checklist. Findings were synthesised using thematic synthesis.

Results: Nine papers were included and seven analytical themes were identified relating to patients' experiences and perceptions and, within that, strategies for safer prescribing of benzodiazepines and Z-drugs: (1) patients' negative perceptions of insomnia and its impact, (2) failed self-care strategies, (3) triggers to medical help-seeking, (4) attitudes towards treatment options and service provision, (5) varying patterns of use, (6) withdrawal, (7) reasons for initial or ongoing use.

Conclusions: Inappropriate use and prescribing of benzodiazepines and Z-drugs is perpetuated by psychological dependence, absence of support and patients' denial/lack of knowledge of side effects. Education strategies, increased availability of alternatives, and targeted extended dialogue with patients could support safer prescribing.
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http://dx.doi.org/10.1007/s40271-016-0182-zDOI Listing
February 2017

Ethnicity and pre-hospital care for people with suspected cardiac pain: cross-sectional study.

J Eval Clin Pract 2016 Oct 10;22(5):721-5. Epub 2016 Mar 10.

Community and Health Research Unit, School of Health and Social Care, University of Lincoln, Lincoln, LN6 7TS, UK.

Objectives: Few studies have investigated the quality of pre-hospital care by ethnicity. We aimed to investigate ethnic differences in pre-hospital ambulance care of patients with suspected cardiac pain.

Methods: We conducted a cross-sectional analysis of retrospective electronic clinical data for patients with suspected cardiac pain over one year (August 2011 to July 2012) extracted from a single regional ambulance service. This included patient demographic data, clinical measurements, drugs administered and outcomes, such as transportation to hospital or referral to primary care. We used multivariate regression to investigate differences in care by ethnicity comparing non-White with White patients.

Results: There were 7046 patients with suspected cardiac pain, with 4825 who had ethnicity recorded including 4661 (96.6%) White and 164 (3.4%) non-White. After correcting for age, sex, socio-economic status and whether transported to hospital, non-White patients were significantly more likely to have temperature [odds ratio (OR) 2.96, P = 0.007], blood glucose (OR 3.95, P = 0.003), respiratory rate (OR 4.94, P = 0.03) and oxygen saturation (OR 2.43, P = 0.006) recorded. Non-White patients were significantly less likely to be transported to hospital (OR 0.43, P = 0.03).

Conclusion: There were significant differences in pre-hospital ambulance care for non-White compared with White patients with suspected cardiac pain. These differences could be due to differences in clinical condition or case-mix, language and cultural barriers, limited understanding of appropriate use of health care services, recording bias or true differences in provider management. Further analysis should involve larger and more complete data sets to explore ethnic differences in greater detail.
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http://dx.doi.org/10.1111/jep.12523DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5069611PMC
October 2016

Systematic review of randomised controlled trials of interventions that aim to reduce the risk, either directly or indirectly, of overweight and obesity in infancy and early childhood.

Matern Child Nutr 2016 Jan 20;12(1):24-38. Epub 2015 Apr 20.

Institute of Mental Health, University of Nottingham Innovation Park, Nottingham, UK.

The risk factors for childhood overweight and obesity are known and can be identified antenatally or during infancy, however, the majority of effective interventions are designed for older children. This review identified interventions designed to reduce the risk of overweight/obesity that were delivered antenatally or during the first 2 years of life, with outcomes reported from birth to 7 years of age. Six electronic databases were searched for papers reporting randomised controlled trials of interventions published from January 1990 to September 2013. A total of 35 eligible studies were identified, describing 27 unique trials of which 24 were behavioural and three were non-behavioural. The 24 behavioural trials were categorised by type of intervention: (1) nutritional and/or responsive feeding interventions targeted at parents of infants, which improved feeding practices and had some impact on child weight (n = 12); (2) breastfeeding promotion and lactation support for mothers, which had a positive effect on breastfeeding but not child weight (n = 5); (3) parenting and family lifestyle (n = 4); and (4) maternal health (n = 3) interventions that had some impact on feeding practices but not child weight. The non-behavioural trials comprised interventions manipulating formula milk composition (n = 3). Of these, lower/hydrolysed protein formula milk had a positive effect on weight outcomes. Interventions that aim to improve diet and parental responsiveness to infant cues showed most promise in terms of self-reported behavioural change. Despite the known risk factors, there were very few intervention studies for pregnant women that continue during infancy which should be a priority for future research.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5029770PMC
http://dx.doi.org/10.1111/mcn.12184DOI Listing
January 2016

Reassurance as a key outcome valued by emergency ambulance service users: a qualitative interview study.

Health Expect 2015 Dec 10;18(6):2951-61. Epub 2014 Oct 10.

Community and Health Research Unit, University of Lincoln, Lincoln, UK.

Background: There is an increasing need to assess the performance of emergency ambulance services using measures other than the time taken for an ambulance to arrive on scene. In line with government policy, patients and carers can help to shape new measures of ambulance service performance.

Objective: To investigate the aspects of emergency ambulance service care valued by users.

Design: Qualitative interview study.

Setting: One of 11 ambulance services in England.

Participants: Twenty-two users and eight of their spouses (n = 30).

Results: Users of the emergency ambulance service, experiencing different types of ambulance service response, valued similar aspects of their pre-hospital care. Users were often extremely anxious about their health, and the outcome they valued was reassurance provided by ambulance service staff that they were receiving appropriate advice, treatment and care. This sense of being reassured was enhanced by the professional behaviour of staff, which instilled confidence in their care; communication; a short wait for help; and continuity during transfers. A timely response was valued in terms of allaying anxiety quickly.

Discussion And Conclusions: The ability of the emergency ambulance service to allay the high levels of fear and anxiety felt by users is crucial to the delivery of a high quality service. Measures developed to assess and monitor the performance of emergency ambulance services should include the proportion of users reporting feeling reassured by the response they obtained.
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http://dx.doi.org/10.1111/hex.12279DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5810705PMC
December 2015

Identifying barriers and facilitators to ambulance service assessment and treatment of acute asthma: a focus group study.

BMC Emerg Med 2014 Aug 3;14:18. Epub 2014 Aug 3.

Clinical Audit and Research Department, East Midlands Ambulance Service NHS Trust, East Division Headquarters, Cross O'Cliff Court, Lincoln LN4 2HL, England.

Background: Acute asthma is a common reason for patients to seek care from ambulance services. Although better care of acute asthma can prevent avoidable morbidity and deaths, there has been little research into ambulance clinicians' adherence to national guidelines for asthma assessment and management and how this might be improved. Our research aim was to explore paramedics' attitudes, perceptions and beliefs about prehospital management of asthma, to identify barriers and facilitators to guideline adherence.

Methods: We conducted three focus group interviews of paramedics in a regional UK ambulance trust. We used framework analysis supported by NVivo 8 to code and analyse the data.

Results: Seventeen participants, including paramedics, advanced paramedics or paramedic operational managers at three geographical sites, contributed to the interviews. Analysis led to five themes: (1) guidelines should be made more relevant to ambulance service care; (2) there were barriers to assessment; (3) the approach needed to address conflicts between clinicians' and patients' expectations; (4) the complexity of ambulance service processes and equipment needed to be taken into account; (5) and finally there were opportunities for improved prehospital education, information, communication, support and care pathways for asthma.

Conclusions: This qualitative study provides insight into paramedics' perceptions of the assessment and management of asthma, including why paramedics may not always follow guidelines for assessment or management of asthma. These findings provide opportunities to strengthen clinical support, patient communication, information transfer between professionals and pathways for prehospital care of patients with asthma.
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http://dx.doi.org/10.1186/1471-227X-14-18DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4125344PMC
August 2014

The effect of a national quality improvement collaborative on prehospital care for acute myocardial infarction and stroke in England.

Implement Sci 2014 Jan 23;9:17. Epub 2014 Jan 23.

East Midlands Ambulance Service NHS Trust (EMAS), Cross O'Cliff Court, Lincoln LN4 2HN, England.

Background: Previous studies have shown wide variations in prehospital ambulance care for acute myocardial infarction (AMI) and stroke. We aimed to evaluate the effectiveness of implementing a Quality Improvement Collaborative (QIC) for improving ambulance care for AMI and stroke.

Methods: We used an interrupted time series design to investigate the effect of a national QIC on change in delivery of care bundles for AMI (aspirin, glyceryl trinitrate [GTN], pain assessment and analgesia) and stroke (face-arm-speech test, blood pressure and blood glucose recording) in all English ambulance services between January 2010 and February 2012. Key strategies for change included local quality improvement (QI) teams in each ambulance service supported by a national coordinating expert group that conducted workshops educating staff in QI methods to improve AMI and stroke care. Expertise and ideas were shared between QI teams who met together at three national workshops, between QI leads through monthly teleconferences, and between the expert group and participants. Feedback was provided to services using annotated control charts.

Results: We analyzed change over time using logistic regression with three predictor variables: time, gender, and age. There were statistically significant improvements in care bundles in nine (of 12) participating trusts for AMI (OR 1.04, 95% CI 1.04, 1.04), nine for stroke (OR 1.06, 95% CI 1.05, 1.07), 11 for either AMI or stroke, and seven for both conditions. Overall care bundle performance for AMI increased in England from 43 to 79% and for stroke from 83 to 96%. Successful services all introduced provider prompts and individualized or team feedback. Other determinants of success included engagement with front-line clinicians, feedback using annotated control charts, expert support, and shared learning between participants and organizations.

Conclusions: This first national prehospital QIC led to significant improvements in ambulance care for AMI and stroke in England. The use of care bundles as measures, clinical engagement, application of quality improvement methods, provider prompts, individualized feedback and opportunities for learning and interaction within and across organizations helped the collaborative to achieve its aims.
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http://dx.doi.org/10.1186/1748-5908-9-17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3904412PMC
January 2014

General practitioners' experiences and perceptions of benzodiazepine prescribing: systematic review and meta-synthesis.

BMC Fam Pract 2013 Dec 13;14:191. Epub 2013 Dec 13.

Community and Health Research Unit, School of Health and Social Care, University of Lincoln, Lincoln, UK.

Background: Benzodiazepines are often prescribed long-term inappropriately. We aimed to systematically review and meta-synthesise qualitative studies exploring clinicians' experiences and perceptions of benzodiazepine prescribing to build an explanatory model of processes underlying current prescribing practices.

Methods: We searched seven electronic databases for qualitative studies in Western primary care settings published in a European language between January 1990 and August 2011 analysing GP or practice nurse experiences of benzodiazepine prescribing. We assessed study quality using the Critical Appraisal Skills Programme Checklist. We analysed findings using thematic synthesis.

Results: We included eight studies from seven countries published between 1993 and 2010. Benzodiazepine prescribing decisions are complex, uncomfortable, and demanding, taken within the constraints of daily general practice. Different GPs varied in the extent to which they were willing to prescribe benzodiazepines, and individual GPs' approaches also varied. GPs were ambivalent in their attitude towards prescribing benzodiazepines and inconsistently applied management strategies for their use. This was due to the changing context of prescribing, differing perceptions of the role and responsibility of the GP, variation in GPs' attitudes to benzodiazepines, perceived lack of alternative treatment options, GPs' perception of patient expectations and the doctor-patient relationship. GPs faced different challenges in managing initiation, continuation and withdrawal of benzodiazepines.

Conclusion: We have developed a model which could be used to inform future interventions to improve adherence to benzodiazepine prescribing guidance and improve prescribing through education and training of professionals on benzodiazepine use and withdrawal, greater provision of alternatives to drugs, reflective practice, and better communication with patients.
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http://dx.doi.org/10.1186/1471-2296-14-191DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4028802PMC
December 2013