Due to the fact that emergency situations can lead to substantial losses, both financial and in terms of human lives, it is essential that texts used in a crisis situation be clearly understandable. This thesis is concerned with the study of the complexity of the crisis management sub-language and with methods to produce new, clear texts and to rewrite pre-existing crisis management documents which are too complex to be understood. By doing this, this interdisciplinary study makes several contributions to the crisis management field. First, it contributes to the knowledge of the complexity of the texts used in the domain, by analysing the presence of a set of written language complexity issues derived from the psycholinguistic literature in a novel corpus of crisis management documents. Second, since the text complexity analysis shows that crisis management documents indeed exhibit high numbers of text complexity issues, the thesis adapts to the English language controlled language writing guidelines which, when applied to the crisis management language, reduce its complexity and ambiguity, leading to clear text documents. Third, since low quality of communication can have fatal consequences in emergency situations, the proposed controlled language guidelines and a set of texts which were re-written according to them are evaluated from multiple points of view. In order to achieve that, the thesis both applies existing evaluation approaches and develops new methods which are more appropriate for the task. These are used in two evaluation experiments – evaluation on extrinsic tasks and evaluation of users’ acceptability. The evaluations on extrinsic tasks (evaluating the impact of the controlled language on text complexity, reading comprehension under stress, manual translation, and machine translation tasks) Text Complexity and Text Simplification in the Crisis Management domain 4 show a positive impact of the controlled language on simplified documents and thus ensure the quality of the resource. The evaluation of users’ acceptability contributes additional findings about manual simplification and helps to determine directions for future implementation. The thesis also gives insight into reading comprehension, machine translation, and cross-language adaptability, and provides original contributions to machine translation, controlled languages, and natural language generation evaluation techniques, which make it valuable for several scientific fields, including Linguistics, Psycholinguistics, and a number of different sub-fields of NLP.

Aim: Using a mixed methods approach, this thesis seeks to explore the attitudes of emergency care staff towards young people (aged 12− 18 years) who self-harm and to gain an understanding of the basis of attitudes that exist. Background: This thesis has drawn on Strauss et al’s (1964), concept of the hospital as a negotiated order, a perspective that has latterly been applied to the organisation of hospital A&E services (Sbaih1997a&b 1998a&b, 2001, 2002). As the fundamental premise of emergency care work is the rapid assessment of patients’ needs, categorisation is an essential element of this work. This thesis therefore also draws on the sociological theories which have examined the categorisation of patients as ‘good’ or ‘bad’, as earlier sociological work has clearly demonstrated that practitioners working in emergency services judge patients based on their reasons for accessing the service (Roth 1972, Jeffery 1979, Dingwall & Murray 1983); patients who self-harm are amongst those adversely judged. However the extent to which these categorisations extend to young people was not wholly clear. Findings from earlier research that had considered this were inconclusive and inconsistent (Dingwall & Murray 1983, White 2002). Methods: A mixed methods approach, using a triangulation convergent design was employed. Staff employed in four emergency departments in South East London and five London Ambulance complexes that served these departments were surveyed; data from 143 questionnaires were analysed using SPSS. Qualitative data were obtained through semi-structured interviews with 12 practitioners, seven nurses and five paramedics, with thematic analysis undertaken. The two data sets were integrated and analysed to identify where the two data sets were consistent and whether/where discrepancies existed. Results: Findings from this study indicate that age, i.e. being a young person, does influence attitudes towards self-harm. Young people are less adversely judged as their self-harm is seen as symptom of distress, a coping mechanism or response to a stressor out with a young person’s control, thus as a consequence, attitudes towards young people who self-harm are benign. The findings lend support to previous research which has indicated that as an occupation, nurses have less positive attitudes than their peers working in emergency services. Although not statistically significant, the nurses surveyed in this study obtained lower scores on the scale used to measure attitudes than their medical and paramedical colleagues. The data from the interviews illustrated the difficulties and frustration the nurses faced in managing the care of young people who self-harm, which centred on the pressure to ‘move young people on’, pressures that were exacerbated by the need to do this within four hours. The paramedics interviewed did not face these challenges. Nurses faced considerable difficulty in securing admission to a children’s ward; the accounts of the nurse interviewees suggested that their ward colleagues expected and anticipated that young people who had self-harmed would be challenging in terms of their behaviours, whereas no such expectation existed with other adolescent patients. To this end the diagnostic label of self-harm had negative connotations Conclusions: The findings from this study have extended existing knowledge in relation to practitioners’ attitudes towards young people who self-harm, providing as they do an insight into how young peoples’ immaturity and diminished agency, contribute to the framing of young people as vulnerable, thus their self-harming behaviour is less adversely judged. A negotiated order perspective remains a relevant lens through which to analyse and explore the organisation of hospital services and specifically the work of the A&E department; the findings of the research presented in this thesis have revealed how young people who self-harm, through both their actual and perceived behaviours, disrupt the organisation of children’s accident and emergency care, thereby distorting its ‘shape’. The ambiguity of adolescence as a life-stage is reflected in the attitudes and perceptions of the study participants and is also reflected in health policy and guidelines, which is particularly exemplified by inconsistency in how the emergency care needs of young people between the ages of 16– 18 years generally, and young people who self-harm specifically, are addressed. This inconsistency and ambiguity in turn serves to impede young people’s progress through emergency services following an episode of self-harm.

This work compares the procedures used in the Emergency Departments in the University of Benin Teaching Hospital (UBTH) in Nigeria and in Manchester Royal Infirmary (MRI) in the UK. It goes on to develop a discrete event model of the latter in Rockwell Arena®.Raw data from UBTH were obtained over a number of visits by interviewing senior administrators, clinicians and nursing staff and by tracking patients over a period of 2 months between 1 July and 29 August, 2011. Information from MRI was supplied through an approved ethical protocol to the National Research Ethics committee (REC Reference 13/NN/0175, IRAS ID 124168, dated March 4, 2013). This embraced patient journeys, locations, investigations and tests for the 98236 patients who attended the ED between April 2012 and March 2013. These (anonymised) data were obtained as spreadsheets from the original Symphony® records, which were then manipulated and analysed using the computer language, R. Anecdotal information on ED operations, patient flow and procedure duration times were also obtained from ED staff. All of this information identified similarities and differences between patient journeys in the two hospitals and were used to generate appropriate process maps. Proposals were made to improve the recoding and maintenance of patients’ records in UBTH. In the case of MRI, each patient’s journey was expressed as a journey-string, which was an ordered list of locations and milestones derived from the time-stamps recorded in the original spreadsheets. A large transition matrix (168 by 168) was generated from the set of journey strings and established the probability of a patient going from one location to any another. This reflects all the decisions which were made at each step of the patient’s journey. The number of destinations from a particular source reflects the options available at a particular instant in time, while the size of each probability reflects the preferred destination. The transition matrix together with the duration and resource requirement of the process associated with the destination is the key to the generation of a process map for each journey through the system. This methodology is original and can be applied generally. This was used as a basis for the journey-path model. In the final MRI model the 4h deadline was not included since the mechanism for its actual implementation was somewhat vague. Instead some isolated models based on patients’ priorities and resource re-allocation were described. From these it was inferred that changing the priority of a patient may not in itself be sufficient to alter the journey profile and in order to do so resources must be re-allocated. The only alternative would appear to be the fast-tracking of patients.

Emergency Medical Services (EMS) play a pivotal role in any healthcare organisation. Response and turnaround time targets are always of great concern for the Welsh Ambulance NHS Trust (WAST). In particular, the more rural areas in South East Wales consistently perform poorly with respect to Government set response standards, whilst delayed transfer of care to Emergency Departments (EDs) is a problem publicised extensively in recent years. Many Trusts, including WAST, are additionally moving towards clinical outcome based performance measures, allowing an alternative system-evaluation approach to the traditional response threshold led strategies, resulting in a more patient centred system. Three main investigative parts form this thesis, culminating in a suite of operational and strategic decision support tools to aid EMS managers. Firstly, four novel allocation model methods are developed to provide vehicle allocations to existing stations whilst maximising patient survival. A detailed simulation model then evaluates clinical outcomes given a survival based (compared to response target based) allocation, determining also the impact of the fleet, its location and a variety of system changes of interest to WAST (through ‘what-if?’ style experimentation) on entire system performance. Additionally, a developed travel time matrix generator tool, enabling the calculation and/or prediction of journey times between all pairs of locations from route distances is utilised within the aforementioned models. The conclusions of the experimentation and investigative processes suggest system improvements can in fact come from better allocating vehicles across the region, by reducing turnaround times at hospital facilities and, in application to South East Wales, through alternative operational policies without the need to increase resources. As an example, a comparable degree of improvement in patient survival is witnessed for a simulation scenario where the fleet capacity is increased by 10% in contrast to a scenario in which ideal turnaround times (within the target) occur.

Aim and objectives: To describe the ideal doctors' shift handover process in a systematic fashion, and to identify tasks that should be performed, but are not consistently done. To understand the types of communication problems that may occur during the handover process, their causes, their likelihood of occurrence and their effect on patient safety. Method: Three studies were conducted in two, Scottish Acute Medical Units. A Hierarchical Task Analysis was performed and data was collected by means of interviews and focus groups. Observations of doctors' actual shift handover process were compared against the description of doctors' ideal handover process. To examine potential failures modes, a Healthcare Failure Modes and Effects Analysis was performed using focus group interviews. Results: The handover process entailed the pre-handover, the handover, and the post- handover phases. Multiple critical steps in the process were omitted by outgoing shift doctors. The pre-handover was particularly vulnerable to information omission, with over 50% of its critical tasks not being performed across a total of 62 observations. Nonetheless, most of these omissions were typically caught during the handover meeting, especially if incoming doctors participated in pre-handover activities. Post-handover activities involved prioritizing and delegating clinical tasks. However these were observed not to happen consistently due to multiple interruptions. Thirty-four failure modes were identified, with eight of them posing a significant risk to patient safety. The studies found that interruptions, patient workload, and a lack of standardised procedures were the biggest causes for information loss during the handover process. Conclusions: There are key critical tasks necessary for an ideal doctors' shift handover process. A simple, handover process checklist may ensure critical handover tasks have been achieved prior to any shift change. Interruptions, patient workload, peer trust, and a lack of standard operating procedures are areas that future handover research should examine.

Rehabilitation outcomes are an important measurement of trauma system effectiveness. However, currently there is no clinically applicable trauma rehabilitation score or framework available to evaluate health and rehabilitation needs after trauma. The World report on Disability (2011) recommended the application of the World Health Organisation International Classification of Function, Disability and Health (ICF) as a framework for all aspects of rehabilitation. A standardised language, based on coded categories would aid in international efforts to evaluate health and disability globally. The ICF framework has not been applied in trauma rehabilitation or trauma systems to date. The objectives were to investigate rehabilitation needs of trauma patients and evaluate to what extent the ICF can be used as a framework to capture and assess health and rehabilitation outcome of patients following traumatic injuries. Two cohort studies with 103 and 308 patients respectively demonstrated the utility of the Rehabilitation Complexity Scale (RCS) in an acute trauma setting. The RCS outperformed other acute measures and rehabilitation complexity correlated with length of stay and discharge destination. A systematic review of 34 articles confirmed that outcome measures frequently used in trauma outcome studies represent only six percent of health concepts contained in the ICF. A quantitative international on-line questionnaire with expert clinicians working in trauma (n=217), identified 121 ICF categories pertinent to rehabilitation and health outcome of trauma patients. Qualitative patient interviews (n=32) identified nearly double the amount of ICF categories (n=234) compared to clinicians. Combined analysis of qualitative and quantitative data presents 109 ICF categories important for rehabilitation and health outcome assessment of trauma patients, using the ICF as a framework. This thesis describes the need for improved outcome evaluation of trauma patients. It demonstrates the acceptability of the ICF language and framework amongst clinicians and suggests the application of the ICF as a framework for trauma service delivery and outcome assessment.

Background: Changing service demands require United Kingdom ambulance services to redefine their role and response strategies, in order to reduce unnecessary Emergency Department attendances. Treat and Refer guidelines have been developed with this aim in mind. However, these guidelines have been developed in the absence of reliable evidence or guiding mid-range theory. This has resulted in inconsistencies in clinical practice. One condition frequently included in Treat and Refer guidelines is hypoglycaemia. Therefore this thesis aimed to investigate prehospital hypoglycaemic emergencies in order to develop an evidence base for future interventions and guideline development. Research approach: A pragmatic and inductive applied health services research approach was employed. Multiple methods were used in a sequential explanatory design. Three linked studies were undertaken with the results of previous studies informing the development of the next. Study one: A scoping review of prehospital treatment of hypoglycaemic events. Aims: i) To describe the demographics of the patient population requiring ambulance service assistance for hypoglycaemic emergencies; ii) To determine the extent to which post-hypoglycaemic patients with diabetes, who are prescribed oral hypoglycaemic agents (OHA), experience repeat hypoglycaemic events (RHE) after being treated in the prehospital environment. Methods: A scoping literature review was conducted using an overlapping retrieval strategy that included both published and unpublished literature. Findings: Twenty-three papers and other relevant material were included. Hypoglycaemia related ambulance calls account for 1.3% to 5.2% of ambulance calls internationally. Transportation rates varied between studies (25%-73%). Repeat hypoglycaemic emergencies are experienced by 2-7% of patients within 48 hours. There was insufficient detail to determine any relationship between repeat events and OHA. The low quality of included papers means that the results should be cautiously interpreted. The safety of leaving patients on OHA at home post hypoglycaemic emergency is unknown. Consequently patients taking OHAs who experience a hypoglycaemic emergency should be transported to hospital for observation. There was a lack of knowledge about the Scottish demographics of the patient population. Study two: A retrospective cross-sectional observational study of diabetes related emergency calls. Aims: To investigate i) the patient demographics and characteristics of hypoglycaemia related emergency calls; ii) the incidence of repeat hypoglycaemic events; and iii) the factors associated with emergency calls that result in individuals being left at home. Methods: A retrospective observational cross-sectional study conducted using Medical Priority Dispatch System® call data from West of Scotland Ambulance Control Centre over a 12 month period. Data were extracted on age, gender, dispatch code, time of call, deprivation category, and immediate outcome (home or hospital). Multiple regression analysis was used to determine predictors of remaining at home. Findings: 1319 calls for hypoglycaemia were received. Patient demographics were similar to the scoping review findings. Most patients remained at home (N = 916 vs N = 380; p < .001). RHE’s were experience by 3.1% within 48 hours, and 10.6% within two weeks. The most significant independent predictor for patients remaining at home was a prior call to the ambulance service (OR of 2.4 [95%CI 1.5 to 3.7]). Patients’ reasons for remaining at home and the causes of subsequent severe events are unknown. It is likely that non-clinical factors may explain some of this behaviour. Study 3: Investigating patients’ experiences of prehospital hypoglycaemic care. Aim: To investigate the experiences of patients who are attended by ambulance clinicians for a hypoglycaemic emergency. Methods: In-depth interviews with adults with diabetes who had recently experienced a hypoglycaemic emergency treated by ambulance clinicians. Participants were recruited from Greater Glasgow and Clyde and Lanarkshire Health Board areas. Data were analysed using Framework Analysis. Findings: Twenty six patients were interviewed. Three key themes were developed. Firstly, an explanation for help seeking behaviour; patients’ impaired awareness of hypoglycaemia as well as the inability of friends and relatives to cope can contribute to an ambulance call-out. Secondly, the perceptions of ambulance service care; patients felt the service provided was good; however ambulance clinicians’ advice was inconsistent. Thirdly, the influences on uptake of follow-up care; patient preferences for follow-up care were influenced by previous experiences of home, hospital and primary care. Post-hoc analysis identified three psychological theories that may explain these findings and provide a useful basis for intervention development: Common Sense Model (Leventhal et al, 1998); Health Belief Model (Rosenstock, 1966); Ley’s cognitive hypothesis model of communication (Ley and Llewelyn, 1995; 1981). Conclusion: Most people treated for severe hypoglycaemia by ambulance clinicians remain at home and do not follow-up their care. A few experience repeat hypoglycaemic emergencies. Key causal, but modifiable factors, contributing to this include:- impaired awareness of hypoglycaemia; inconsistent delivery of ambulance clinician referral advice; and patients’ perceptions of the costs and benefits of follow-up care. Ambulance services cannot address all these factors in isolation. The studies in this thesis have generated an evidence base and identified plausible candidate theories. This will support the future development of novel interventions to improve severe hypoglycaemic emergency follow-up.

Introduction: The most appropriate airway management technique for use by paramedics in out-of-hospital cardiac arrest is yet to be determined and evidence relating to the influence of airway management strategy on outcome remains equivocal. In cases where return of spontaneous circulation (ROSC) occurs following out-of-hospital cardiac arrest, patients may undergo direct transfer to a specialist heart attack centre (HAC) where the post resuscitation 12 lead ECG demonstrates evidence of ST elevation myocardial infarction. To date, no studies have investigated the role of airway management strategy on outcomes in this sub-set of patients. The AMICABLE (Airway Management In Cardiac Arrest, Basic, Laryngeal mask airway, Endotracheal intubation) study therefore sought to investigate the influence of prehospital airway management strategy on outcomes in patients transferred by the ambulance service directly to a HAC post ROSC. Methods: Adults with ROSC post out-of-hospital cardiac arrest who met local criteria for transfer to a HAC were identified prospectively. Ambulance records were reviewed to determine prehospital airway management approach and collect physiological and demographic data. HAC notes were obtained to determine in-hospital course and quantify neurological outcome via the Cerebral Performance Category (CPC) scale. Neurologically intact survivors were contacted post discharge to assess quality of life via the SF-36 health survey. Statistical analyses were performed via Chi-square, Mann Whitney U test, odds ratios, and binomial logistic regression. Results: A total of 220 patients were recruited between August 2013 and August 2014, with complete outcome data available for 209. The age of patients ranged from 22-96 years and 71.3% were male (n=149). Airway management was undertaken using a supraglottic airway (SGA) in 72.7% of cases (n=152) with the remainder undergoing endotracheal intubation (ETI). There was no significant difference in the proportion of patients with good neurological outcome (CPC 1&2) between the SGA and ETI groups (p=.286). Similarly, binomial logistic regression incorporating factors known to influence outcome demonstrated no significant difference between the SGA and ETI groups (Adjusted OR 0.725, 95% CI 0.337-1.561). Clinical and demographic variables associated with good neurological outcome included the presence of a shockable rhythm (p < .001), exposure to angiography (p < .001), younger age (p < .001) and shorter time to ROSC (p < .001). Due to an inadequate response rate (25.4%, n=15) analysis of SF36 data was limited to descriptive statistics. Limitations: The study only included patients who achieved ROSC and met the criteria for direct transfer to a HAC. Results are therefore not generalisable to more heterogenous resuscitation populations. Accuracy of clinical decision making and ECG interpretation were not assessed and therefore some patients included in the study may have been inappropriately transferred to a HAC. The low SF-36 survey response rate limited the level of neurological outcome analysis that could be undertaken. Conclusion: In this study, there was no significant difference in the proportion of good neurological outcomes in patients managed with SGA versus ETI during cardiac arrest. Further research incorporating randomised controlled trials is required to provide more definitive evidence in relation to the optimal airway management strategy in out-of-hospital cardiac arrest.