A retrospective cross-sectional analysis of re-contact rates and clinical characteristics in diabetic patients referred by paramedics to a community diabetes service following a hypoglycaemic episode

Aims: To report the re-contact rates and clinical characteristics of individuals referred to community diabetic teams following non-conveyance by HCPC paramedics.Methods: A retrospective cross-sectional study of routinely collected data by the Northern Ireland Ambulance Service HSC Trust of individuals referred to a community diabetic service following ambulance attendance and non-conveyance. Data were collected over a 3-month period with ambulance service re-contact and clinical data analysed.Results: 418 emergency calls were identified as relating to hypoglycaemia with 169 referrals being made, a referral rate of 40.4%. Patients treated with insulin represented the majority of calls and tended to have a lower Glasgow Coma Scale score, but demonstrated many successful referrals. Increased age and multimorbidity were associated with repeat hypoglycaemic episodes and EMS attendance while other subgroups traditionally considered higher risk, such as patients with infections or under the influence of alcohol, showed potential for safe community management.Conclusion: The majority of paramedic referrals to community diabetic teams were successful, with less than 5% re-contacting the ambulance service within 3 days. This study, although demonstrating a lower referral rate than previous research, reinforces the safety of paramedic management and community referral for hypoglycaemia.

Psychiatric liaison referrals and the 4PM Rush

AimsReferrals to the psychiatric Liaison team in A&E seem to come in the afternoon in kismet as the day shift is ending. This study looked at the timing distribution of referrals to try improve amount of jobs being handed over to the evening shifts.MethodReferrals made to Homerton University Hospital (HUH) psychiatric liaison was parsed into 1 hour bins and plotted as a histogram (data between August 2016–October 2019. N = 14182). The data were compared to diurnal human body temperature variation, as well as data published on Hospital Accident & Emergency Activity 2019–20 (digital.nhs.uk) for Ambulance attendances.ResultReferrals to HUH liaison team appear to closely follow the average human body temperature variations per hour (Pearson Correlation coefficient = 0.90). A peak appears to occur around 4 PM, and a low at 7AM. The referrals data also mirrored timings of official Hospital Episode Statistics (HES) reports 2019–2020 for ambulance attendance in England (Pearson Correlation coefficient = 0.94).ConclusionAttendance to A&E and referrals to psychiatric liaison appear correlated to a circadian bound rhythm. “The 4PM referrals rush” appears to be a genuine phenomenon replicated in not only HUH mental health referrals, but general ambulance attendance throughout all of England. The body temperature analogue for circadian rhythm may be humorously applied here to correlate with the increased referral rates to A&E; the emergency department could be said to be truly heating up in the afternoon. Indeed temperature and activity has already been shown to link strongly via the Arrhenius equation in cricket activity such as chirps per minute. The conclusions drawn here are that acute mental health attendances, like general health attendances as a whole follow underlying but powerful patterns, and provisions might best be allocated to address this rather than thinking of fixed 9-5 working schedules.

PP18 Ambulance attendance at diabetes or diabetes-related emergencies in care homes – cross sectional database study

BackgroundDiabetes, which affects over 1 in 5 nursing or care home residents, may lead to diabetes-related emergencies with ambulance call-outs and hospitalisation. Our aim was to investigate the epidemiology of diabetes-related emergencies in care home residents which involved an ambulance attendance.MethodsWe used a cross-sectional design to investigate emergency ambulance attendances to people in nursing and residential care homes presenting with diabetes-related emergencies across the East Midlands between January 2012 and December 2017. We used clinical and dispatch data from East Midlands Ambulance Service NHS Trust (EMAS) and care home data from the Care Quality Commission, including call category, timing, location, place of residence, clinical or physiological status, treatments, outcome (conveyance) and costs in the analysis.ResultsOverall 219722 (6.7% of 3.3 million) attendances were to care home residents of which 12080 were for diabetes-related emergencies. Of 3152 care home patients categorised as having a ‘diabetic problem’ 1,957 (62.1%) were conveyed to hospital. This was not significantly different to the rate for other patients, taking into account other factors, despite access to trained staff in care homes. Statistically significant factors associated with conveyance included reduced consciousness level (OR 0.91, 95% CI 0.87–0.95), elevated heart (1.01, 1.01–1.02) or respiratory rate (1.08, 1.06–1.10), no treatment for hypoglycaemia (0.54, 0.34–0.86) or additional co-morbid medical (but not psychiatric) problems. Cost to EMAS was significantly lower when a patient was conveyed, by some £18 (95% CI £11.94–£24.12), but this would not outweigh downstream NHS costs arising from hospital care. For the simulation in which all trusts mean NHS Reference Costs were used, conveyance was no longer significant in the cost model.ConclusionConveyance to hospital was common for care home patients with diabetes-related emergencies and more likely when conscious level was impaired, certain physiological measures abnormal or treatment for hypoglycaemia was not given.

Factors influencing the decision to convey or not to convey elderly people to the emergency department after emergency ambulance attendance: a systematic mixed studies review

BackgroundThe decision over whether to convey after emergency ambulance attendance plays a vital role in preventing avoidable admissions to a hospital’s emergency department (ED). This is especially important with the elderly, for whom the likelihood and frequency of adverse events are greatest.ObjectiveTo provide a structured overview of factors influencing the conveyance decision of elderly people to the ED after emergency ambulance attendance, and the outcomes of these decisions.Data sourcesA mixed studies review of empirical studies was performed based on systematic searches, without date restrictions, in PubMed, CINAHL and Embase (April 2018). Twenty-nine studies were included.Study eligibility criteriaOnly studies with evidence gathered after an emergency medical service (EMS) response in a prehospital setting that focused on factors that influence the decision whether to convey an elderly patient were included.SettingPrehospital, EMS setting; participants to include EMS staff and/or elderly patients after emergency ambulance attendance.Study appraisal and synthesis methodsThe Mixed Methods Appraisal Tool was used in appraising the included articles. Data were assessed using a ‘best fit’ framework synthesis approach.ResultsED referral by EMS staff is determined by many factors, and not only the acuteness of the medical emergency. Factors that increase the likelihood of non-conveyance are: non-conveyance guidelines, use of feedback loop, the experience, confidence, educational background and composition (male–female) of the EMS staff attending and consulting a physician, EMS colleague or other healthcare provider. Factors that boost the likelihood of conveyance are: being held liable, a lack of organisational support, of confidence and/or of baseline health information, and situational circumstances. Findings are presented in an overarching framework that includes the impact of these factors on the decision’s outcomes.ConclusionMany non-medical factors influence the ED conveyance decision after emergency ambulance attendance, and this makes it a complex issue to manage.