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Introduction: Bystanders’ interventions improve chances of survival from out-of-hospital cardiac arrest (OHCA) before Emergency Medical Services arrive. Some areas in England are of concern. These high-risk areas have a higher incidence of cardiac arrest combined with lower-than-average bystander CPR rates and are characterised by higher proportions of minority ethnic group residents and deprivation.Collaborating with people from the Black African and Caribbean and South Asian minority communities in deprived areas of England, we aim to develop and evaluate the implementation of theoretically informed intervention(s) to address factors contributing to lower bystander intervention rates. Methods: The study is a collaborative realist enquiry, informed by the Theoretical Domains Framework and associated Behaviour Change Wheel. It consists of 1) a realist evidence synthesis to produce initial program theories developed from primary workshop data and published evidence. It will include identifying factors contributing to the issue and potential interventions to address them; 2) theoretically informed intervention development, using the initial program theories and behaviour change theory and 3) a realist mixed methods implementation evaluation with embedded feasibility.Public involvement (PPI) as study team and public advisory group members is key to this study.We will conduct realist evidence synthesis, qualitative and statistical analyses appropriate to the various methods used. Dissemination: We will develop a dissemination plan and materials targeted to members of the public in high-risk areas as well as academic outputs. We will hold an event for participating community groups and stakeholders to share findings and seek advice on next steps. Study registration: ISRCTN90350842. Registration date 28.03.2023. The study was registered after its start date.

Background: Do not attempt cardiopulmonary resuscitation decisions have been widely criticised. The Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) process was developed to facilitate shared decisions between patients and clinicians in relation to emergency treatments, including cardiopulmonary resuscitation. Objective: To explore how, when and why ReSPECT plans are made and what effects the plans have on patient outcomes. Design: A mixed-methods evaluation, comprising (1) a qualitative study of ReSPECT decision-making processes, (2) an interrupted time series examining process and survival outcomes following in-hospital cardiac arrest and (3) a retrospective observational study examining factors associated with ReSPECT recommendations and patient outcomes. Setting: NHS acute hospitals and primary care and community services in England (2017–2020). Participants: Hospital doctors, general practitioners, nurses, patients and families. Data sources: The following sources were used: (1) observations of ReSPECT conversations at six hospitals and conversations with clinicians, patient, families and general practitioners, (2) survey and freedom of information data from hospitals participating in the National Cardiac Arrest Audit and (3) a review of inpatient medical records, ReSPECT forms and NHS Safety Thermometer data. Results: By December 2019, the ReSPECT process was being used in 40 of 186 (22%) acute hospitals. In total, 792 of 3439 (23%) inpatients, usually those identified at risk of deterioration, had a ReSPECT form. Involvement of the patient and/or family was recorded on 513 of 706 (73%) ReSPECT forms reviewed. Clinicians said that lack of time prevented more conversations. Observed conversations focused on resuscitation, but also included other treatments and the patient’s values and preferences. Conversation types included open-ended conversations, with clinicians actively eliciting the patients’ wishes and preferences, a persuasive approach, swaying the conversation towards a decision aligned with medical opinion, and simply informing the patient/relative about a medical decision that had already been made. The frequency of harms reported on the NHS Safety Thermometer was similar among patients with or without a ReSPECT form. Hospital doctors and general practitioners gave different views on the purpose of the ReSPECT process and the type of recommendations they would record. Limitations: The research was undertaken within the first 2 years following the implementation of ReSPECT. Local policies meant that doctors led these conversations. Most patients were seriously ill, which limited opportunities for interviews. Incomplete adoption of the ReSPECT process and problems associated with the NHS Safety Thermometer tool affected the evaluation on clinical outcomes. Conclusions: Patients and families were involved in most ReSPECT conversations. Conversations focused on resuscitation, but also included other emergency treatments. Respect for patient autonomy and duty to protect from harm informed clinicians’ approach to varying degrees, depending on the clinical situation and their views of ReSPECT as a shared decision-making process. The complexity of these conversations and the clinical, emotional and organisational barriers observed suggest that a nuanced and multifaceted approach will be necessary to support good ReSPECT processes. Future work: Further research is needed to understand the advantages and disadvantages to the adoption of a national emergency care and treatment plan system, the most effective national and local implementation approaches, and whether or not shared decision-making approaches in the context of emergency care and treatment plans could further enhance patient and family engagement. Study registration: This study is registered as ISRCTN11112933. Funding: This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme and will be published in full in Health and Social Care Delivery Research; Vol. 10, No. 40. See the NIHR Journals Library website for further project information.

Background: Proximal femoral fracture is a major health problem in old age, with annual UK health and social care costs of £2.3B. Rehabilitation has the potential to maximise functional recovery and maintain independent living, but evidence of clinical effectiveness and cost-effectiveness is lacking. Objectives: To develop an enhanced community-based rehabilitation package following surgical treatment for proximal femoral fracture and to assess acceptability and feasibility for a future definitive randomised controlled trial (RCT) and economic evaluation. Design: Phase I – realist review, survey and focus groups to develop the rehabilitation package. Phase II – parallel-group, randomised (using a dynamic adaptive algorithm) feasibility study with focus groups and an anonymised cohort study. Setting: Recruitment was from orthopaedic wards of three acute hospitals in the Betsi Cadwaladr University Health Board, North Wales. The intervention was delivered in the community following hospital discharge. Participants: Older adults (aged ≥ 65 years) who had received surgical treatment for hip fracture, lived independently prior to fracture, had mental capacity (assessed by the clinical team) and received rehabilitation in the North Wales area. Interventions: Participants received usual care (control) or usual care plus an enhanced rehabilitation package (intervention). Usual care was variable and consisted of multidisciplinary rehabilitation delivered by the acute hospital, community hospital and community services depending on need and availability. The intervention was designed to enhance rehabilitation by improving patients’ self-efficacy and increasing the amount and quality of patients’ practice of physical exercise and activities of daily living. It consisted of a patient-held information workbook, a goal-setting diary and six additional therapy sessions. Main outcome measures: The primary outcome measure was the Barthel Activities of Daily Living (BADL) index. The secondary outcome measures included the Nottingham Extended Activities of Daily Living (NEADL) scale, EuroQol-5 Dimensions, ICEpop CAPability measure for Older people, General Self-Efficacy Scale, Falls Efficacy Scale – International (FES-I), Self-Efficacy for Exercise scale, Hospital Anxiety and Depression Scale (HADS) and service use measures. Outcome measures were assessed at baseline and at 3-month follow-up by blinded researchers. Results: Sixty-two participants were recruited (23% of those who were eligible), 61 were randomised (control, n = 32; intervention, n = 29) and 49 (79%) were followed up at 3 months. Compared with the cohort study, a younger, healthier subpopulation was recruited. There were minimal differences in most outcomes between the two groups, including the BADL index, with an adjusted mean difference of 0.5 (Cohen’s d = 0.29). The intervention group showed a medium-sized improvement on the NEADL scale relative to the control group, with an adjusted mean difference between groups of 3.0 (Cohen’s d = 0.63). There was a trend for greater improvement in FES-I and HADS in the intervention group, but with small effect sizes, with an adjusted mean difference of 4.2 (Cohen’s d = 0.31) and 1.3 (Cohen’s d = 0.20), respectively. The cost of delivering the intervention was £231 per patient. There was a possible small relative increase in quality-adjusted life-years in the intervention group. No serious adverse events relating to the intervention were reported. Conclusions: Trial methods were feasible in terms of eligibility, recruitment and retention, although recruitment was challenging. The NEADL scale was more responsive than the BADL index, suggesting that the intervention could enable participants to regain better levels of independence compared with usual care. This should be tested in a definitive Phase III RCT. There were two main limitations of the study: the feasibility study lacked power to test for differences between the groups and a ceiling effect was observed in the primary measure. Trial registration: Current Controlled Trials ISRCTN22464643. Funding: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 44. See the NIHR Journals Library for further project information.

Background: The Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) includes agreed clinical recommendations for a person’s care in a future emergency which have been informed by discussion of the person’s preferences. Previous evaluation of ReSPECT plans in acute NHS hospitals found inconsistencies in recording patient’s preferences and involvement in the plan, and infrequent justification for recommendations. Aim: To explore to what extent ReSPECT recommendations reflect individual preferences, as documented in the plan. Methods: ReSPECT plans of adults were collected from 11 General Practices in England. We adapted an evaluation tool used previously to analyse ReSPECT plans in acute settings. Free text sections for individual values/preferences and clinical recommendations were examined for clarity, consistency and congruency between them. Results: We retrieved 141 ReSPECT plans. Patients or those close to the patient were recorded as being consulted in most plans (94%). Individual preferences were completed in 57% of plans. Clinical recommendations reflected individual preferences by directly referencing the person and their preferences (31%), by being consistent with the documented preferences (30%), or by using the same wording as the preferences (6%). Conclusion: While many clinical recommendations reflect individual preferences, the preferences themselves are only recorded in just over half of ReSPECT plans. This is problematic, because the recording of individual preferences facilitates person-centred care, both directly by informing recommendations and indirectly when used to guide decision-making in situations not anticipated in the plan. Future training for clinicians should emphasize the need to document the personal values section of the plan.

Background: As an emergency care and treatment planning process (ECTP), a key feature of the Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) is the engagement of patients and/or their representatives in conversations about treatment options including, but not limited to, cardiopulmonary resuscitation (CPR). However, qualitative research suggests that some ReSPECT conversations lead to partial or no decision-making about treatment recommendations. This paper explores why some ReSPECT conversations are left incomplete. Methods: Drawing on observation and interview data collected in four National Health Service (NHS) hospital sites in England, this paper offers an in-depth exploration of six case studies in which ReSPECT conversations were incomplete. Using thematic analysis, we triangulate fieldnote data documenting these conversations with interview data in which the doctors who conducted these conversations shared their perceptions and reflected on their decision-making processes. Results: We identified two themes, both focused on ‘mismatch’: (1) Mismatch between the doctor’s clinical priorities and the patient’s/family’s immediate needs; and (2) mismatch between the doctor’s conversation scripts, which included patient autonomy, the feasibility of CPR, and what medicine can and should do to prolong a patient’s life, and the patient’s/family’s understandings of these concepts. Conclusions: This case study analysis of six ReSPECT conversations found that mismatch between doctors’ priorities and understandings and those of patients and/or their relatives led to incomplete ReSPECT conversations. Future research should explore methods to overcome these mismatches.

Abstract Background Emergency Care and Treatment Plans are recommended for all primary care patients in the United Kingdom who are expected to experience deterioration of their health. The Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) was developed to integrate resuscitation decisions with discussions about wider goals of care. It summarises treatment recommendations discussed and agreed between patients and their clinicians for a future emergency situation and was designed to meet the needs of different care settings. Our aim is to explore GPs’ experiences of using ReSPECT and how it transfers across the primary care and secondary care interface. Methods We conducted five focus groups with GPs in areas being served by hospitals in England that have implemented ReSPECT. Participants were asked about their experience of ReSPECT, how they initiate ReSPECT-type conversations, and their experiences of ReSPECT-type recommendations being communicated across primary and secondary care. Focus groups were transcribed and analysed using Thematic Analysis. Results GPs conceptualise ReSPECT as an end of life planning document, which is best completed in primary care. As an end of life care document, completing ReSPECT is an emotional process and conversations are shaped by what a ‘good death’ is thought to be. ReSPECT recommendations are not always communicated or transferable across care settings. A focus on the patient’s preferences around death, and GPs’ lack of specialist knowledge, could be a barrier to completion of ReSPECT that is transferable to acute settings. Conclusion Conceptualising ReSPECT as an end of life care document suggests a difference in how general practitioners understand ReSPECT from its designers. This impacts on the transferability of ReSPECT recommendations to the hospital setting.

Background: The Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) form, which supports the ReSPECT process, is designed to prompt clinicians to discuss wider emergency treatment options with patients and to structure the documentation of decision-making for greater transparency. Methods: Following an accountability for reasonableness framework (AFR), we analysed 141 completed ReSPECT forms (versions 1.0 and 2.0), collected from six National Health Service (NHS) hospitals in England during the early adoption of ReSPECT. Structured through an evaluation tool developed for this study, the analysis assessed the extent to which the records reflected consistency, transparency, and ethical justification of decision-making. Results: Recommendations relating to CPR were consistently recorded on all forms and were contextualised within other treatment recommendations in most forms. The level of detail provided about treatment recommendations varied widely and reasons for treatment recommendations were rarely documented. Patient capacity, patient priorities and preferences, and the involvement of patients/relatives in ReSPECT conversations were recorded in some, but not all, forms. Clinicians almost never documented their weighing of potential burdens and benefits of treatments on the ReSPECT forms. Conclusion: In most ReSPECT forms, CPR recommendations were captured alongside other treatment recommendations. However, ReSPECT form design and associated training should be modified to address inconsistencies in form completion. These modifications should emphasise the recording of patient values and preferences, assessment of patient capacity, and clinical reasoning processes, thereby putting patient/family involvement at the core of good clinical practice. Version 3.0 of ReSPECT responds to these issues.

Aim: Bystander CPR rates have steadily increased in England between 2014 and 2018. In West Yorkshire, there have been two important developments during this time. We aimed to describe whether postcode districts (PCDs) with more cumulative annual ‘Restart a Heart’ (RSAH) and/or Community First Responder (CFR) scheme activity between 2014 and 2018 were associated with greater improvements in non-EMS bystander CPR rates for out-of-hospital cardiac arrest (OHCA) when compared with PCDs in the same region with lesser or no such historic activity during the same time period. Method: We collated data from the OHCA Outcomes Registry for all non-EMS witnessed OHCA in West Yorkshire treated by Yorkshire Ambulance Service. We analysed clusters of PCDs with high and low levels of RSAH and CFR activity between 2014 and 2018 using descriptive statistics, and comparisons were made between groups using chi-square and t-test. Results: The reported bystander CPR rate for non-EMS witnessed OHCA cases for West Yorkshire rose from 38.4% in 2014 to 69.7% in 2018. The largest increases were seen in PCDs with high RSAH activity (+34.3%) and in the combination of high RSAH and low CFR activity (+38.5%). There was no significant difference when considering the interaction between RSAH and CFR groups. Conclusion: The data infers the possibility of a non-significant association between improved non-EMS bystander CPR rates and RSAH training and CFR scheme activity. We recommend coordinated mass training, in particular for children in regions where CPR is not a mandatory part of the school curriculum.

Background Bystander cardiopulmonary resuscitation (CPR) and public access defibrillator (PAD) use can save the lives of people who experience out‐of‐hospital cardiac arrest. Little is known about the proportions of UK adults trained, their characteristics and willingness to act if witnessing an out‐of‐hospital cardiac arrest, or the public's knowledge regarding where the nearest PAD is located. Methods and Results An online survey was administered by YouGov to a nonprobabilistic purposive sample of UK adults, achieving 2084 participants, from a panel that was matched to be representative of the population. We used descriptive statistics and multivariate logistic regression modeling for analysis. Almost 52% were women, 61% were aged