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Ambulance ‘Hypos can Strike Twice’ (Ambu-HS2) study

Effect of implementing an ambulance clinician delivered hypoglycaemia intervention (‘Hypos can strike twice’) on repeat ambulance calls, attendances and transportation to hospital: non-randomised stepped wedge and process evaluation 

Why the research is needed? 

The research is needed to find out the effect of ambulance staff delivering the “Hypos can strike twice” intervention on people with diabetes experiencing hypoglycaemia (or “hypo”, meaning low blood sugar) to help prevent further “hypos” and negative impacts on future patient health. The study addresses NHS priorities around diabetes, redesigning urgent and emergency care to improve patient care and strengthen primary and community care. 

What is already known about the subject? 

Hypoglycaemia commonly affects an increasing number of people with diabetes. It is a side effect of treatment with insulin or certain tablets, where blood glucose (sugar) falls causing the brain to malfunction. In mild cases this can lead to sweating, drowsiness and confusion; in more severe cases, coma can occur needing external medical assistance for recovery, and if prolonged can be fatal. It results in 1% of calls to ambulance services. The problem of hypoglycaemia is growing because of the increasing number of people with diabetes and efforts being made to control diabetes more carefully by lowering blood glucose to reduce future problems affecting the heart, eyes, kidneys and feet. 

Who we are working with? 

Academics from the Universities of Lincoln and Leicester are working with East Midlands Ambulance Service NHS Trust and patient groups to develop and conduct this study.  

How are patients and the public involved? 

We have involved patients and the public through two groups, The South Lincolnshire Diabetes Group and the Healthier Ageing Patient and Public Involvement Group.  

What we will do? 

We will analyse routine data from a regional ambulance service before, during and after the introduction of the ‘Hypos can strike twice’ given to patients by ambulance staff with information provided to ambulance staff to improve their care of people with hypoglycaemia. We will also interview and survey ambulance staff who are providing the intervention and patients who receive it to understand how and why it works or does not and how, if it works, this could be spread effectively more widely.    

What the benefits will be? 

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.      

When the findings will be available? 

The findings will be available on completion of the study at the end of one year.  

How we are planning for implementation? 

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, if shown to be effective, could reduce repeat hypoglycaemia, ambulance attendances, hospitalisations and costs. The intervention could easily be scaled up to other ambulance services through existing links between the lead investigator and these national ambulance bodes. We will also work with Diabetes UK to disseminate our findings.  


Professor Niroshan Siriwardena,