Hypos can strike twice

Funded by the National Institute for Health Research (NIHR) Applied Research Collaboration East Midlands, awarded £200,000.

Key contact: Professor Niro Siriwardena

This is a non-randomised stepped wedge study with a mixed-methods process evaluation study which aims to evaluate the effect of implementing the ‘Hypo’s can strike twice’ intervention to patients with diabetes and hypoglycaemia attended by East Midlands Ambulance Service NHS Trust in the East Midlands region.

Team	Prof Niro Siriwardena, CaHRU, University of Lincoln Mrs Amanda Brewster, Public and Patient Involvement representative from Healthier Ageing PPI (HAPPI) group Mr Keith Spurr, Public and Patient Involvement Mrs Pauline Mountain, Public and Patient Involvement representative, HAPPI group Mrs Sally Dunmore, East Midlands Ambulance Service NHS Trust (EMAS) Mrs June James, Diabetes Nurse Specialist Rob Spaight, EMAS Dr Leon Roberts, EMAS Dr Murray D. Smith, CaHRU, University of Lincoln Ms Despina Laparidou CaHRU, University of Lincoln Dr Elise Rowan, CaHRU, University of Lincoln Prof Kamlesh Khunti, Leicester Diabetes Centre, University of Leicester Prof Graham Law, CaHRU, University of Lincoln
Team/Consortium	University of Lincoln Healthier Ageing PPI group University of Leicester East Midlands Ambulance Service NHS Trust
Overarching aim	To evaluate the effect of implementing the ‘Hypo’s can strike twice’ intervention to patients with diabetes and hypoglycaemia attended by East Midlands Ambulance Service NHS Trust in the rural East Midlands region.
Objectives	To investigate the effect of implementing the ‘Hypo’s can strike twice’ on: 1. Repeat ambulance calls and attendances for hypoglycaemia; 2. Recorded referrals to an appropriate healthcare professional (e.g. GP, nurse); 3. Completed care bundle for hypoglycaemia (proportion of patients with all of blood glucose recorded before treatment, blood glucose recorded after treatment and treatment given for hypoglycaemia; 4. Costs of implementation ‘Hypo’s can strike twice’ intervention vs costs of health service resource use; 5. To conduct a process evaluation to explore how ‘Hypo’s can strike twice’ exerts its effects and can be scaled up if effective by understanding implementation, mechanisms of impact, and contextual factors using interviews and surveys
Methods	Non-randomised stepped wedge design with mixed-methods process evaluation.
Outcomes	If the new process of care is found to work, this will help prevent recurrence of “hypo”, improve patients’ future health, reduce unnecessary calls to ambulance services or transport of patients to the Emergency Department, and thus reduce pressures and costs for ambulance services and hospitals nationally by over £1 million.
Outputs	Smith MD, Ridyard C, Botan V, Brewster A, Dunmore S, James J Khunti K, Laparidou D,  Law G,  Mountain P, Roberts L, Rowan E, Spaight R, Spurr K, Siriwardena AN. Model-based economic evaluation of the effectiveness of “‘Hypos’ can strike twice”, a leaflet-based ambulance clinician referral intervention to prevent recurrent hypoglycaemia. PLoS One 2023; 18(3): e0282987. Botan V, Law G, Laparidou D, Rowan E, Smith M, Ridyard C, Brewster A, Spaight R, Spurr K, Mountain P, Dunmore S, James J, Roberts L, Khunti K, Siriwardena AN. The effects of a leaflet-based intervention, ‘Hypos can strike twice’, on recurrent hypoglycaemic attendances by ambulance services: a non-randomised stepped wedge study. Diabetic Medicine 2022; 38:e14612. Laparidou D, Botan V, Law G, Rowan E, Smith M, Brewster A, Spaight R, Mountain P, Dunmore S, James J, Roberts L, Khunti K, Siriwardena AN. People with diabetes and ambulance staff perceptions of a booklet-based intervention for diabetic hypoglycaemia, “Hypos can strike twice”: A mixed methods process evaluation. BMC Emergency Medicine 2022; 22:1.
Impact	This study showed that a simple booklet, given along with advice from ambulance crews, reduced the need for further emergency callouts for low blood sugar (hypoglycaemia) in people with diabetes. It helped people recognise early warning signs and manage their own condition. It shows the importance of helping people with diabetes to understand their condition and how to manage hypoglycaemia and the role of the ambulance crew in helping them to do this. Improved ambulance to community hypoglycaemia care pathways for diabetes have been approved nationally by the Association of Ambulance Chief Executives and National Ambulance Services Medical Directors (NASMed), and this intervention has been shown to be effective, reducing repeat ambulance attendances for hypoglycaemia. It has been implemented by East Midlands and other ambulance services through NIHR ARC East Midlands. The team has shared the booklet, which is freely available for services to print and use, with all ambulance services in the UK. More work is being considered to refine the intervention based on the feedback received in this trial. The team are exploring translating the booklet into other languages to make it accessible for community groups and developing an app based on it. The Ambu-HS2 intervention and study has been publicised through an NIHR alert at NHS Evidence and a YouTube animation.