Explore the vast range of titles available.

It is well recognised that hip fracture surgery is associated with a negative impact on short and long-term post-operative physical health and emotional well-being for patients. Furthermore, these patients are known to be frail with multiple co-morbidities. This study explores how frailty shapes the lived experiences of rehabilitation and recovery for patients who have undergone hip fracture surgery. Semi-structured interviews were conducted with sixteen participants, recently discharged from hospital following hip fracture surgery. Interpretative phenomenological analysis was applied to explore the lived experiences of frail patients and ascertain important themes. Patient experiences were captured in seven overarching themes: 1) the hospital as a place of “safety”, 2) placing trust in others, 3) the slow recovery journey impeded by attitude and support, 4) maintaining autonomy and dignity whilst feeling vulnerable, 5) seeking a new normal, 6) loneliness and social isolation and 7) the ageing body. Based on our study findings, we have been able to suggest a number of opportunities to improve support for frailer patients in finding a new routine to their everyday lives, these include on-going physical and psychological support, information and education and a robust pathway for transition of care into the community. A conceptual thematic diagram is presented which helps to understand the experience and the complex needs of frail older people undergoing hip fracture surgery.

In cardiac arrest, high quality cardiopulmonary resuscitation (CPR) is a key determinant of patient survival. However, delivery of effective chest compressions is often inconsistent, subject to fatigue and practically challenging. Mechanical CPR devices provide an automated way to deliver high-quality CPR. However, large randomised controlled trials of the routine use of mechanical devices in the out-of-hospital setting have found no evidence of improved patient outcome in patients treated with mechanical CPR, compared with manual CPR. The limited data on use during in-hospital cardiac arrest provides preliminary data supporting use of mechanical devices, but this needs to be robustly tested in randomised controlled trials. In situations where high-quality manual chest compressions cannot be safely delivered, the use of a mechanical device may be a reasonable clinical approach. Examples of such situations include ambulance transportation, primary percutaneous coronary intervention, as a bridge to extracorporeal CPR and to facilitate uncontrolled organ donation after circulatory death. The precise time point during a cardiac arrest at which to deploy a mechanical device is uncertain, particularly in patients presenting in a shockable rhythm. The deployment process requires interruptions in chest compression, which may be harmful if the pause is prolonged. It is recommended that use of mechanical devices should occur only in systems where quality assurance mechanisms are in place to monitor and manage pauses associated with deployment. In summary, mechanical CPR devices may provide a useful adjunct to standard treatment in specific situations, but current evidence does not support their routine use.

ObjectiveTo assess the experience of moral distress among intensive care unit (ICU) professionals in the UK.DesignMixed methods: validated quantitative measure of moral distress followed by purposive sample of respondents who underwent semistructured interviews.SettingFour ICUs of varying sizes and specialty facilities.ParticipantsHealthcare professionals working in ICU.Results227 questionnaires were returned and 15 interviews performed. Moral distress occurred across all ICUs and professional demographics. It was most commonly related to providing care perceived as futile or against the patient’s wishes/interests, followed by resource constraints compromising care. Moral distress score was independently influenced by profession (p=0.02) (nurses 117.0 vs doctors 78.0). A lack of agency was central to moral distress and its negative experience could lead to withdrawal from engaging with patients/families. One-third indicated their intention to leave their current post due to moral distress and this was greater among nurses than doctors (37.0% vs 15.0%). Moral distress was independently associated with an intention to leave their current post (p<0.0001) and a previous post (p=0.001). Participants described a range of individualised coping strategies tailored to the situations faced. The most common and highly valued strategies were informal and relied on working within a supportive environment along with a close-knit team, although participants acknowledged there was a role for structured and formalised intervention.ConclusionsMoral distress is widespread among UK ICU professionals and can have an important negative impact on patient care, professional wellbeing and staff retention, a particularly concerning finding as this study was performed prior to the COVID-19 pandemic. Moral distress due to resource-related issues is more severe than comparable studies in North America. Interventions to support professionals should recognise the individualistic nature of coping with moral distress. The value of close-knit teams and supportive environments has implications for how intensive care services are organised.

Dear Editor, We read with interest the systematic review and meta-analysis by Lavery et al. examining physician-led interprofessional pre-hospital teams for critically ill and injured patients [1]. Prehospital critical care beyond advanced life support for out-of-hospital cardiac arrest: a systematic review. [DOI: https://dx.doi.org/10.1016/j.resplu.2024.100803] [PubMed: https://www.ncbi.nlm.nih.gov/pubmed/39807287] 3. von Vopelius-Feldt, J; Morris, RW; Benger, J. The effect of prehospital critical care on survival following out-of-hospital cardiac arrest: a prospective observational study.

IntroductionMultimorbidity or the presence of two or more long-term conditions is now common in people undergoing surgery. However, current care pathways often miss these healthcare encounters to support long-term health promotion. Therefore, there is a need for practical, scalable approaches that can be integrated into routine surgical care, for which limited solutions exist at present. We have co-designed a structured preoperative checklist to help identify and manage long-term conditions in patients listed for elective surgery. This study aims to evaluate the feasibility and acceptability of this preoperative checklist in patients undergoing elective surgery.Methods and analysisThis is a mixed-methods feasibility study in one National Health Service trust in the UK. We will recruit up to 50 adults scheduled for elective surgery and use the checklist during initial surgical clinic appointments. Quantitative data will include recruitment and retention rates, completion of the checklist and baseline clinical characteristics, analysed using descriptive statistics. Qualitative data will be collected through semistructured interviews with up to 16 patients and clinicians. These interviews will be analysed thematically, guided by the Consolidated Framework for Implementation Research. Triangulation of quantitative and qualitative data will allow us to explore fidelity, acceptability, barriers and facilitators to implementation and refine the intervention ahead of a future pilot cluster randomised trial.Ethics and disseminationThis study has received approval from the Yorkshire & The Humber - Sheffield Research Ethics Committee (approval number: 25/YH/0045). All participants will give written informed consent. Results will be published in peer-reviewed journals and shared with participants, the public and policy stakeholders.

Summary Background The increasing prevalence of multiple long-term conditions (MLTC) presents significant challenges to healthcare delivery globally. Although interventions for long-term conditions have predominantly been designed and evaluated in primary care settings, there is a growing recognition of the need to address the management of MLTC within secondary care. This scoping review aims to comprehensively evaluate hospital-initiated complex interventions for people with MLTC. Methods We searched MEDLINE, Embase, PsycINFO, CINAHL Plus and Cochrane Library to identify published studies from Jan 1, 2010, evaluating hospital-initiated interventions initiated for adults (aged ≥ 18 years) with MLTC (PROSPERO: CRD42024498448). Studies reporting patients with frailty only, one long-term condition or orthogeriatric studies that did not focus solely on people with MLTC were excluded. The primary outcome measures were the characteristics of these complex interventions measured as: (i) intervention components, (ii) stakeholders involved; and (iii) implementation strategies, reported according to a theoretical framework (Expert Recommendations for Implementing Change). Secondary outcome measures were clinical and cost implications of these complex interventions, feasibility and sustainability, defined according to the World Health Organisation implementation framework. Findings This scoping review identified 70 studies (56,111 participants). Twelve intervention components were identified in 52 combinations; the most common were medication review and optimisation ( n  = 39), chronic disease management ( n  = 34) and providing detailed care plans ( n  = 23). Majority of studies included two or more interventions components ( n  = 49) delivered by multiple stakeholders ( n  = 38). Of eleven implementation strategies reported, training and educating stakeholders, establishing integrated wards or clinics and regular multidisciplinary team meetings were the most common. Majority of combinations of intervention groups were associated with improved clinical outcomes for patients with MLTC ( n  = 43/70, 61.4%), yet eight studies reported on costs. However, embedding training and education or integrated clinics in delivering these intervention groups were associated with improved clinical outcomes, irrespective of the number of healthcare professionals involved. Majority of studies were evaluated in single centre settings, with limited evaluation of broader implementation measures. Interpretation Hospital-initiated complex interventions that involve multiple stakeholders may be feasible and appear to be clinically useful for people with MLTC. To strengthen impact and support wider scale-up across health systems, closing knowledge gaps around cost-implications and strategies to improve implementation of these complex interventions through training and education or integrated clinics will be crucial.

ObjectiveTo summarise studies describing incidence of sudden cardiac death in a general population of young individuals to inform screening policy.DesignSystematic review.Data sourcesDatabase searches of MEDLINE, EMBASE and the Cochrane library (all inception to current) on 29 April 2019 (updated 16 November 2019), and forward/backward citation tracking of eligible studies.Study eligibility criteriaAll studies that reported incidence of sudden cardiac death in young individuals (12–39 years) in a general population, with no restriction on language or date. Planned subgroups were incidence by age, sex, race and athletic status (including military personnel).Data extractionTwo reviewers independently assessed study eligibility, extracted study data and assessed risk of bias using the Joanna Briggs Institute critical appraisal checklist for prevalence studies.AnalysisReported incidence of sudden cardiac death in the young per 100 000 person-years.Results38 studies that reported incidence across five continents. We identified substantial heterogeneity in population, sudden cardiac death definition, and case ascertainment methods, precluding meta-analysis. Median reported follow-up years was 6.97 million (IQR 2.34 million–23.70 million) and number of sudden cardiac death cases was 64 (IQR 40–251). In the general population, the median of reported incidence was 1.7 sudden cardiac death per 100 000 person-years (IQR 1.3–2.6, range 0.75–11.9). Most studies (n=14, 54%) reported an incidence between one and two cases per 100 000 person-years. Incidence was higher in males and older individuals.ConclusionsThis systematic review identified variability in the reported incidence of sudden cardiac death in the young across studies. Most studies reported an incidence between one and two cases per 100 000 person-years.PROSPERO registration numberCRD42019120563.

Objective The trial objective is to determine if Continuous Positive Airway Pressure (CPAP) or High-Flow Nasal Oxygen (HFNO) is clinically effective compared to standard oxygen therapy in patients with confirmed or suspected COVID-19. Trial design Adaptive (group-sequential), parallel group, pragmatic, superiority randomised controlled, open-label, multi-centre, effectiveness trial. Participants The trial is being conducted across approximately 60 hospitals across England, Wales, Scotland, and Northern Ireland. Inpatients at participating hospitals are eligible to participate if they have respiratory failure with suspected or proven COVID-19, and meet all of the inclusion criteria and none of the exclusion criteria. Inclusion criteria: 1) Adults ≥ 18 years; 2) Admitted to hospital with suspected or proven COVID-19; 3) Receiving oxygen with fraction of inspired oxygen (FiO 2 ) ≥0.4 and peripheral oxygen saturation (SpO 2 ) ≤94%; and 4) Plan for escalation to tracheal intubation if needed. Exclusion criteria: 1) Planned tracheal intubation and mechanical ventilation imminent within 1 hour; 2) Known or clinically apparent pregnancy; 3) Any absolute contraindication to CPAP or HFNO; 4) Decision not to intubate due to ceiling of treatment or withdrawal of treatment anticipated; and 5) Equipment for both CPAP and HFNO not available. Intervention and comparator Intervention one: Continuous positive airway pressure delivered by any device. Set-up and therapy titration is not protocolised and is delivered in accordance with clinical discretion. Intervention two: High-flow nasal oxygen delivered by any device. Set-up and therapy titration is not protocolised and is delivered in accordance with clinical discretion. Comparator group: Standard care- oxygen delivered by face mask or nasal cannula (excluding the use of continuous positive airway pressure or high-flow nasal oxygen). Set-up and therapy titration is not protocolised and is delivered in accordance with clinical discretion. Intervention delivery continues up to the point of death, tracheal intubation, or clinical determination that there is no ongoing need (palliation or improvement). Main outcomes The primary outcome is a composite outcome comprising tracheal intubation or mortality within 30 days following randomisation. Secondary outcomes include tracheal intubation rate, time to tracheal intubation, duration of invasive ventilation, mortality rate, time to mortality, length of hospital stay, and length of critical care stay. Randomisation Participants are randomised in a 1:1:1 ratio to receive either continuous positive airway pressure, high-flow nasal oxygen or standard care. Due to the challenging environment of study delivery, a specific intervention may not always be available at the hospital site. The study uses two integrated randomisation systems to allow, where required, the site to randomise between all three interventions, between CPAP and standard care, and between HFNO and standard care. System integration ensures maintenance of balance between interventions. Randomisation is performed using a telephone-based interactive voice response system to maintain allocation concealment. The randomisation sequence was computer-generated using the minimisation method. Participant randomisation is stratified by site, gender (M/F), and age (<50, >=50 years). Blinding (masking) The nature of the trial interventions precludes blinding of the researcher, patient and clinical team. Primary and secondary outcomes are all objective outcomes, thereby minimising the risk of detection bias. Numbers to be randomised (sample size) 4002 participants (1334 to be randomized to each of the three study arms) Trial Status Current protocol: Version 4.0, 29 th May 2020. Recruitment began on April 6, 2020 and is anticipated to be complete by April 5, 2021. The trial has been awarded Urgent Public Health status by the National Institute of Health Research on 13 th April 2020. Trial registration ISRCTN, ISRCTN16912075. Registered 6 th April 2020, http://www.isrctn.com/ISRCTN16912075 Full protocol The full protocol (version 4.0, 29 th May 2020) is attached as an additional file, accessible from the Trials website (Additional file 1 ). In the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this Letter serves as a summary of the key elements of the full protocol. The study protocol has been reported in accordance with the Standard Protocol Items: Recommendations for Clinical Interventional Trials (SPIRIT) guidelines (Additional file 2 ).

Background Pain after traumatic injury is common, yet few patients receive adequate pain relief. NHS paramedics have a limited formulary to treat severe pain. Objectives To estimate the cost-effectiveness of ketamine versus morphine for severe pain in acute traumatic injury. Methods A cost-utility analysis was conducted based on data from a pragmatic, multicentre, randomised controlled trial (PACKMAN). The base-case analysis took the form of an intention-to-treat analysis conducted from a UK National Health Service (NHS) and personal social services (PSS) perspective and separately from a societal perspective. Costs (£ 2021–2022 prices) were collected prospectively over a 6-month follow-up period. A bivariate regression of costs and quality-adjusted life-years (QALYs), with multiple imputation of missing data, was conducted to estimate the incremental cost per QALY gained and the incremental net monetary benefit (INMB) of ketamine in comparison to morphine. Sensitivity and pre-specified subgroup analyses explored uncertainty and heterogeneity in cost-effectiveness estimates. Results Participants ( n  = 416) were randomised to ketamine ( n  = 206) or morphine ( n  = 210) amongst whom complete data for the economic evaluation was available for 189 (45.4%) participants. Mean (standard deviation [SD]) observed NHS and PSS costs over 6 months were £5,191 (£3,155) in the ketamine arm versus £5,143 (£3,897) in the morphine arm (mean difference [MD]: £47). Mean (SD) observed QALY estimates were 0.309 (0.10) versus 0.293 (0.010), respectively (MD: 0.016). The base case (imputed) analysis generated an incremental cost of -£117 (95%CI: -£849 to £597) and incremental QALYs of 0.025 (95%CI: 0.010 to 0.041), indicating a 92%-96% probability of cost-effectiveness at cost-effectiveness thresholds of £20,000 and £30,000 per QALY. A sensitivity analysis, using observed data only (without imputation) generated an incremental cost of £233 (95%CI: -£783 to £1216) and incremental QALYs of 0.016 (95%CI: -0.013 to 0.044), indicating a lower 54%-62% probability of cost-effectiveness. The base-case cost-effectiveness results remained robust to other sensitivity analyses. Conclusions This economic evaluation found that ketamine administered by paramedics to adults with severe pain following traumatic injuries is cost-effective compared to morphine. However, our results are subject to high levels of missing data, which were handled through recommended multiple imputation techniques. Trial registration The trial was registered with the International Standard Randomised Controlled Trial Number (ISRCTN) registry (ISRCTN14124474) on 22 October 2020.

Background Improving outcomes after surgery is a major public health research priority for patients, clinicians and the NHS. The greatest burden of perioperative complications, mortality and healthcare costs lies amongst the population of patients aged over 50 years who undergo major non-cardiac surgery. The Volatile vs Total Intravenous Anaesthesia for major non-cardiac surgery (VITAL) trial specifically examines the effect of anaesthetic technique on key patient outcomes: quality of recovery after surgery (quality of recovery after anaesthesia, patient satisfaction and major post-operative complications), survival and patient safety. Methods A multi-centre pragmatic efficient randomised trial with health economic evaluation comparing total intravenous anaesthesia with volatile-based anaesthesia in adults (aged 50 and over) undergoing elective major non-cardiac surgery under general anaesthesia. Discussion Given the very large number of patients exposed to general anaesthesia every year, even small differences in outcome between the two techniques could result in substantial excess harm. Results from the VITAL trial will ensure patients can benefit from the very safest anaesthesia care, promoting an early return home, reducing healthcare costs and maximising the health benefits of surgical treatments. Trial registration ISRCTN62903453. September 09, 2021.