Out-of-Hours Service Models for Acutely Deteriorating Respiratory Patients: A Scoping Review

Out-of-Hours Service Models for Acutely Deteriorating Respiratory Patients: A Scoping Review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Systematic Review Out-of-Hours Service Models for Acutely Deteriorating Respiratory Patients: A Scoping Review Samantha Cook, Amanda Thomas, Sarah Smyth, Dr Rosalind Leslie, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7260098/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Acute respiratory deterioration in hospitalised patients requires timely intervention to prevent further clinical decline. Out-of-hours respiratory care is typically provided through on-call physiotherapy rotas, extended hour cover, or 24/7 on-site services. However, models of care vary widely internationally, and little is known about how these services are structured, delivered, and evaluated for acutely deteriorating respiratory patients. Objectives To map and describe international models of care for out-of-hours services for acutely deteriorating respiratory patients, including key model characteristics, workforce configurations, referral processes, reported barriers and facilitators, and associated outcomes. Methods A scoping review was undertaken following the Joanna Briggs Institute and PRISMA-ScR guidance. This included a comprehensive search of electronic databases and grey literature. Papers were included if they reported models of out-of-hours care relevant to respiratory physiotherapy or multidisciplinary care for patients with acute respiratory deterioration. Data were extracted independently by four reviewers and synthesised descriptively using a narrative approach. Results Thirteen international papers published between 2002 and 2023 were included. The majority (77%) described out-of-hours physiotherapy models; others reported extended hours or multidisciplinary rapid response teams. Operating hours, referral processes, and protocols varied widely, with many services relying on non-specialist physiotherapists for out-of-hours provision. Barriers to service provision included staffing limitations, variability in competence, and organisational challenges. Facilitators included presence of senior support, structured training, protocols, and institution support for extended hours models. Evidence on clinical outcomes was limited and heterogeneous. Conclusions Out-of-hours care for acutely deteriorating respiratory patients is delivered through a range of models internationally, with considerable variation in structure and workforce configuration. Further research is needed to evaluate model effectiveness, impact on staff well-being, and relevance to evolving workforce demands. out-of-hours on-call respiratory physiotherapy service-delivery Figures Figure 1 Introduction Out-of-hours respiratory care involves the delivery of time-sensitive interventions outside routine clinical hours and is typically provided through respiratory physiotherapy-led out-of-hours rota. 1 This model often covers evenings, overnight periods, and occasionally weekends, depending on local service design. Respiratory physiotherapy plays a critical role in supporting patients whose respiratory needs require timely intervention that cannot be safely deferred until standard business working hours. 2 Interventions include chest clearance, positioning, adjuncts to increase lung volumes, non-invasive support, and suctioning. 3 – 4 Interventions are tailored to individual patients to optimise respiratory function and mitigate clinical deterioration. Internationally, out-of-hours respiratory care is delivered through a range of models, including traditional out-of-hours services where physiotherapists are contacted as needed, 1 extended hours service with physiotherapists on-site beyond standard hours, 5 and in some settings multidisciplinary rapid response teams provide respiratory care out-of-hours. 6 Many out-of-hours services rely on specialist and non-specialist physiotherapists, 2 resulting in variation in the quality and confidence of care delivery due to infrequency of out-of-hours shifts and the challenges of working outside of their usual practice areas. While training initiatives including simulation 7 have been developed to address these issues, concerns remain around staff confidence, stress, and model sustainability. Despite the time-sensitive nature of these interventions and the vulnerability of the patient group, there is limited formal guidance outlining how out-of-hours respiratory care should be organised, staffed, or delivered. While the Chartered Society of Physiotherapy (CSP) published a toolkit 8 in 2025 to support the redesign of on-call services, this resource offers principles rather than prescriptive national standards. As a result, services have developed in isolation, leading to wide variation in model structure, workforce configuration, and clinical governance. The lack of national or international consensus on what constitutes safe and effective out-of-hours respiratory physiotherapy further complicates efforts to evaluate impact on clinical outcomes, staff wellbeing, and service sustainability. This scoping review aimed to explore and describe the models of care for out-of-hours services that are currently being implemented internationally for acutely deteriorating respiratory patients. The term “out-of-hours” is used as an umbrella term to describe services delivered outside standard working hours, recognising that definitions and terminology vary. The review sought to identify key model characteristics, including operating hours, referral processes, workforce arrangements, and the use of protocols or guidelines, and to explore how these models may support staff confidence, patient outcomes, and workforce sustainability. Methods Study Design Scoping review methodology was adopted to systematically explore international models for out-of-hours care of acutely deteriorating respiratory patients. This approach was chosen to examine the breadth and nature of evidence available on this topic and to identify key concepts, gaps, and areas for future research. The review followed the methodological framework proposed by Arksey and O’Malley, 9 further refined by Levac et al , 10 and adhered to the updated guidance from the Joanna Briggs Institute (JBI) for conducting scoping reviews. 11 A protocol was developed a priori to guide the review process and ensure methodological transparency. The protocol was prospectively registered on the Open Science Framework and is publicly available at https://osf.io/mbq7j . Eligibility Criteria Papers were included if they reported on models of care, service delivery approaches, or multidisciplinary interventions aimed at managing acutely deteriorating respiratory patients out-of-hours in any healthcare setting. International papers were included regardless of healthcare system structure as there may be adaptations that would be applicable to UK healthcare systems. All study designs, including qualitative, quantitative, and mixed-methods research were included. Only English-language publications were included due to resource constraints. Information Sources and Search Strategy A three-step search strategy was utilised in this review. First, an initial limited search of MEDLINE (via PubMed) and CINAHL (via EBSCO) was undertaken to identify relevant articles and refine the search terms. Keywords and index terms from the titles and abstracts of retrieved papers were analysed to inform the development of a full search strategy. The full strategy was then adapted and applied across all included databases and information sources. Databases and search terms are in Appendix 1. Study Selection All search results were imported into Rayyan, 12 a platform for systematic review management. Duplicates were removed, and titles and abstracts screened independently by two reviewers against the inclusion criteria. Full-text articles were retrieved and assessed for eligibility. Discrepancies were resolved through discussion or consultation with a third reviewer. Data Extraction The data extraction form was developed and piloted prior to full data extraction by all four independent reviewers. Extracted information included author(s), year of publication, country, study design, setting, population, description of the care model, components of multidisciplinary involvement, reported outcomes, key findings, and barriers and facilitators to model implementation. Data Synthesis Extracted data were synthesised descriptively using a narrative summary approach. Findings were grouped thematically by model type, operating hours, professions involved, referral processes, use of protocols or guidelines, and reported service or clinical outcomes. The review aimed to highlight both the diversity and commonalities in international approaches to out-of-hours care for acutely deteriorating respiratory patients, and to identify elements of care models that may be transferable to the UK context. Results Study Selection The results of the search and screening process are presented in the PRISMA flow diagram 13 (Fig. 1 ). Thirteen papers published between 2002 and 2023 were included in this review. Studies were conducted across seven countries and comprised various designs, including trials, observational studies, audits, surveys, reviews, and guidance documents. Most focused on intensive care (ICU) settings, with two examining paediatric populations 2 , 19 . Full study characteristics are presented in Table 1 . Models of Care Out-of-hours respiratory physiotherapy models were the most common, described in 10 of the 13 papers (77%), where physiotherapists were contacted as needed to provide emergency respiratory care. 1 , 2 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 Extended hours physiotherapy services were reported in one study (8%) 5 where physiotherapists were present on-site beyond standard hours to reduce reliance on out-of-hours provision. In addition, a rapid response team (RRT) model was described in one study (8%) 6 where multidisciplinary teams, including medical and nursing staff, responded to acute respiratory deterioration on a 24/7 basis. Guidance documents, such as the Association of Chartered Physiotherapists in Respiratory Care (ACPRC) 1 position statement, recommended out-of-hours respiratory physiotherapy as a minimum standard, with progression towards 24/7 cover where feasible. Hours of Operation Five out of thirteen papers (38.5%) provided detailed information on service operating hours. Where reported these hours varied widely depending on the model. Berney et al 15 defined out-of-hours physiotherapy as care provided between 21:00 and 06:00. Devroey et al 16 described 24/7 on-site cover, with shifts running from 16:00 to 08:00 on weekdays and 12:00–08:00 on weekends and holidays. Lim et al 18 reported out-of-hours shifts starting from 17:00–21:00 daily, and 21:00 to 08:00 overnight, 12:00–17:00 on Saturdays and 08:00–17:00 on Sundays. Thomas et al 20 reported an average out-of-hours shift from 16:30 − 08:00, seven days a week. Gustafson and Grant 5 described an extended hours model with physiotherapists on-site from 08:00-ily20:00 on weekdays. Referral Process Referral processes were described in seven of the thirteen papers (54%), with notable variation in approach. In most physiotherapy-led models, referrals were typically initiated by nursing or medical staff using phone or bleep systems. 14 , 16 , 17 . Lim et al 18 described both pre-planned referrals handed over by daytime physiotherapists, and unplanned/emergency referrals initiated by medical staff. Fernando et al 6 reported that RRTs could be activated by any healthcare provider or family member in response to concerns about acute deterioration. Triggers for referral commonly included clinical indicators including sputum retention, dyspnoea, ineffective cough, or the need for post-extubation support. 6 , 14 , 2 Table 1 Study Characteristics Author Year Country Study Design Setting Model Type Hours of Operation Professions Involved Referral Process Protocols/ Guidelines ACPRC 1 2017 United Kingdom Guidance documentation Acute hospitals On-call Not applicable Physiotherapists Not applicable ACRPC and CSP Standards Babu et al 14 2010 India Single centre randomised controlled trial ICU On-call Not specified Physiotherapists From Nurse/Doctor with specified clinical triggers CSP/ACPRC on-call standards for referral triggers Berney et al 15 2002 Australia Single centre case-control ICU On-call 21:00–06:00 Physiotherapists/ Nurses Not specified Not specified Brusco et al 22 2006 Australia Systematic review Mixed hospital settings On-call, weekend, and extended hours Not specified Physiotherapists Not specified Not specified Devroey et al 16 2016 Belgium Single centre service evaluation Acute hospital On-call Weekday: 16:00–08:00 Weekend: 12:00–08:00 ICU Physiotherapists From Nurse/Doctor with specified clinical triggers Not specified Dixon and Reeve 17 2003 United Kingdom National audit Acute hospitals On-call Not specified Physiotherapists Bleep/Phone ACPRC on-call standards Fernando et al 6 2018 Canada Single centre cohort study Acute hospitals Rapid Response Team 24/7 Medical, nursing, respiratory therapists Referral from staff/ family Not specified Gustafson and Grant 5 2017 United Kingdom Single centre service evaluation ICU Extended Hours 08:00–20:00 Weekdays ICU Physiotherapists Pre-arranged by Physiotherapist No formal protocol Lim et al 18 2008 Singapore Single centre retrospective study Hospital wards On-call Weekdays: 17:00–21:00 Sat: 12:00–17:00 Sun: 08:00–17:00 Overnight: 21:00–08:00 Physiotherapists Physiotherapist and Medical Staff Not specified Shannon et al 2 2015a United Kingdom Single centre randomised crossover trial Paediatric ICU On-call Not specified Respiratory specialist and non-respiratory specialist physiotherapists Not specified Not specified Shannon et al 19 2015 United Kingdom Single centre randomised crossover trial Paediatric ICU On-call Not specified Respiratory specialist and non-respiratory-specialist physiotherapists Not specified Not specified Thomas et al 20 2023 Australia and New Zealand Multicentre cross-sectional survey ICU On-call 16:30 − 08:00, Seven days a week. Physiotherapists Not specified Not specified Van Der Lee et al 21 2018 Australia Multicentre cross-sectional survey ICU On-call Not specified Physiotherapists Initiated by daytime treating physiotherapist Not specified Abbreviations- ACPRC: Association Chartered Physiotherapists in Respiratory Care; CSP: Chartered Society of Physiotherapy; ICU: Intensive Care Unit. Professionals Involved in Out-of-Hours Services Out-of-hours models mostly relied on non-respiratory or general physiotherapists, often supported by senior colleagues by telephone or in-person as well as specialist physiotherapists (n =5 , 38.5%). 2,14,17,19,29 Specialist respiratory or ICU physiotherapists delivered extended hours and 24/7 physiotherapy services. 5,16 Where no physiotherapist was available, basic respiratory care tasks such as suctioning and patient positioning were undertaken by nursing staff. 15,21 In the RRT model, care was delivered by multidisciplinary teams consisting of medical staff, nurses, and respiratory therapists. 6 Protocols and Guidelines Three of the thirteen papers reported the use of protocols (23.1%). Protocols primarily addressed service logistics, including referral method and response time, rather than clinical treatment decision-making. In a UK audit of 20 large NHS trusts in the Trent region, Dixon and Reeve reported that 16 departments had emergency duty protocols in place, 89% of which were documented in written form. 17 These protocols, often based on ACPRC Guidelines, 1 covered aspects such as referral method, expected response time, contact systems, security arrangements, and reimbursement processes. Babu et al 14 reported out-of-hours referrals in an ICU setting in India followed The CSP and ACPRC guidance, although no clinical protocols were described. The ACPRC guidance 1 set out recommendations for service structure and competence requirements but did not provide data on implementation outcomes. Most other papers reported reliance on individual clinical judgement, with no formal physiotherapy protocols described to guide intervention selection or delivery. 2,5,6,15,16,18,19,20,21,22 Outcomes Patient and service outcomes were reported in twelve of the thirteen papers (92.3%). These outcomes were variable and often secondary to descriptions of service models. Some papers reported positive clinical impacts associated with models of care, including reductions in ICU length of stay and ventilation duration, often associated with intensive or out-of-hours physiotherapy provision. 15,23 Babu et al 14 reported improvements in respiratory measures, including peak expiratory flow rate and six-minute walk distance, linked to out-of-hours physiotherapy. Shannon et al 19 found that specialist respiratory physiotherapists more frequently applied effective techniques such as combined chest wall vibration and suction, alongside greater improvements in compliance and tidal volumes, and fewer adverse events (4.8% vs 12.7%) compared to non-respiratory physiotherapists . 2 Service level outcomes included quantifying treatments delivered out-of-hours, 16 reduced out-of-hours burden and cost savings associated with extended hours models. 5 The RRT model highlighted challenges in overnight acute care delivery, reporting higher mortality associated with night-time activations. 6 Overall, while some papers demonstrated positive impacts, formal evaluations of effectiveness, patient centred outcomes, and long-term recovery were limited. Barriers and Facilitators All included papers reported barriers and facilitators to implementing and delivering out-of-hours care for acutely deteriorating respiratory patients (Table 2). Two papers noted the difficulty of maintaining staff competence and confidence, particularly where non-respiratory physiotherapists were involved. 1,19 Staffing limitations were reported as a barrier in both research design 14 and service delivery 5,21 , contributing to concerns about consistency of service delivery and patient safety. Financial and organisational challenges were also identified, highlighting issues related to cost effectiveness and staffing sustainability. 5,16 Brusco et al 23 highlighted barriers, including heterogeneity of study designs and low to medium study quality, which limited conclusions about best practice models. Facilitators of out-of-hours models of care included formal training, access to senior staff, clear protocols, adequate staffing, and organisational commitment to service quality. (Table 2). The ACPRC 1 and the UK audit by Dixon and Reeve 17 highlighted the role of structured training programmes and clear policy frameworks in supporting staff competence and service delivery. Thomas et al 21 similarly identified access to senior ICU physiotherapists support as key enablers of safe and effective service delivery. Van der Lee et al 21 reported that larger ICUs with higher physiotherapy staffing levels facilitated after-hours service provision. Dedicated ICU physiotherapy teams with institutional support were identified as facilitators 16,5 alongside the use of national or professional guidelines to further supported service quality. 1,14,17 Table 2. Barriers and Facilitators Author Year Barriers Facilitators ACPRC 1 2017 Challenges to maintain competency in non-specialist physiotherapists; managing fatigue, securing funding, and ensuring service robustness. Advocates for minimum standards; structured training; clear policies; appropriate staffing and promoting service value. Babu et al 14 2010 Staffing limitations. Use of CSP/ACPRC guidelines for referrals. Berney et al 15 2002 Lack of standardisation of clinical decision making. Dedicated ICU physiotherapy staffing model. Brusco et al 22 2006 Study heterogeneity, low-moderate quality. Demonstrated feasibility in some critical care subgroups (Acute spinal cord injury and high-risk elderly surgical ICU patients). Devroey et al 16 2016 Unable to assess cost effectiveness due to lack of baseline data and ethical constraints. Dedicated ICU physiotherapy team; institutional support and positive staff perception of value. Dixon and Reeve 17 2003 Inconsistent adherence to protocols. Clear protocols, training, and support from senior respiratory physiotherapists. Fernando et al 6 2018 Night-time service challenges; delays in activation, reduced staff experience, shift patterns at risk of impacting cognitive performance. 24/7 multidisciplinary team and defined activation criteria. Gustafson and Grant 5 2017 Staffing challenges, burnout risk. Extended hours reduced on-call burden, organisational support Lim et al 18 2008 No evaluation of long-term outcomes or cost effectiveness. Structured after-hours service. Shannon et al 2 2015a Skill level having potential impact on patient outcomes. Use of force-sensing technology for training feedback; potential for targeted education. Shannon et al 19 2015 Confidence gaps between specialist and non-specialist. Highlighted need for targeted training. Thomas et al 20 2023 Lower staffing linked to dissatisfaction, variability in access to senior staff. Access to senior staff. Integrated orientation and educated processes. Van Der Lee et al 21 2018 Staffing limitations, reliance on other health professionals to provide respiratory care. Larger ICUs, more availability for on-call staff. Abbreviations: ACPRC: Association of Chartered Physiotherapists in Respiratory Care; CSP: Chartered Society of Physiotherapy; ICU: Intensive Care Unit Discussion This scoping review highlights considerable variation in how out-of-hours respiratory care is structured and delivered across international healthcare systems. Models ranged from traditional out-of-hours services such as from 16:00-8:00 seven days a week, to extended working hours and 24/7 multidisciplinary teams, with operational hours, staffing configurations, and referral processes differing significantly between settings. Importantly, these models were implemented across a diverse range of hospital types, from specialist ICUs to general wards each with distinct clinical demands and workforce capabilities. Variability is important to note and highlights the challenge of prescribing a single “ideal” model for out-of-hours respiratory care. Rather than advocating for a one-size-fits-all approach, our findings support the need for scalable and contextually adaptable service models that can evolve in response to local population needs, organisational resources, and existing workforce capacity. Future guidance may be more effectively framed around a set of core principles or standards, such as those outlined in the CSP Toolkit 8 which define the function and responsiveness of out-of-hours care, allowing for localised implementation within a flexible framework. Barriers identified suggest a potential need for deliberate and system-level planning in designing sustainable out-of-hours respiratory services. Workforce limitations and inconsistent staff competence, particularly among non-specialist physiotherapists, raise important questions about how services can safely scale or operate in resource-constrained environments. These challenges are unlikely to be addressed through training alone and demand integrated approaches that include role clarity, protected time for skill maintenance, and flexible models of care. Applying implementation science frameworks such as the Consolidated Framework for Implementation Research (CFIR) 23 and Expert Recommendations for Implementing Change (ERIC) 24 may help organisations systematically identify and address context-specific barriers and facilitators to service implementation. Financial and organisational barriers may also suggest that commissioning out-of-hours services should go beyond workforce inputs and consider broader questions of service value, outcome measurement, and long-term sustainability through appropriate data collection and analysis. Health economic evaluation was largely absent in the current literature and could play a critical role in informing decisions around resource allocation and service design. A notable observation across papers was the diversity of professionals delivering out-of-hours respiratory interventions. While physiotherapists were the primary providers, responsibility for managing acute deterioration was sometimes shared with, or transferred to other health professionals, including nurses and medical staff, particularly in RRT models of multidisciplinary nature. These arrangements raise important questions about professional boundaries, role clarity, and the competencies required to deliver safe and effective respiratory care out-of-hours. Rather than focussing on the role of respiratory physiotherapy, it may be more productive to consider who is best equipped to respond to acute respiratory deterioration and under what conditions. Re-framing the issue shifts the lens from profession-specific tasks to the broader issue of system responsiveness, interdisciplinary capability and sustainability, and patient safety. Finally, facilitators such as structured training, senior mentorship, clear protocols, and institutional support offer valuable direction for service development. However, ensuring consistent access to these enablers across diverse settings remains a challenge, particularly where staffing and financial constraints exist. Alignment of governance structures, education pathways, and quality monitoring may help promote consistent, high-quality care delivery. Conclusions This scoping review identified wide variation in out-of-hours respiratory care models internationally, reflecting differences in context, resource availability, and workforce. A single standardised model is unlikely to address the diverse needs and contextual challenges identified across settings. Future research should focus on identifying core components of safe and effective care - including staff competence, timely access, and referral clarity - and on adapting these through flexible, context-sensitive implementation. Collaboration between professional bodies, policymakers, and service leaders- including those in strategic physiotherapy roles, will be critical to enable the development of models that are evidence-informed, equitable, and sustainable in real-world practice. References The Association of Chartered Physiotherapists in Respiratory Care (ACPRC) On-call position statement. London. [online] Available from: https://www.acprc.org.uk/data/Resource_Downloads/ACPRCOn-CallDocument2017.pdf (Accessed 15/05/25) Shannon H, Stocks J, Gregson RK, Dunne C, Peters MJ, Main E. Clinical effects of specialist and on-call respiratory physiotherapy treatments in mechanically ventilated children: a randomised crossover trial. Physiotherapy . 2015;101(4):349–356. https://doi.org/10.1016/j.physio.2014.12.004 Go sselink R, Clerckx B, Robbeets C, Vanhullebusch T, Vanpee G, Segers J. Physiotherapy in the intensive care unit. 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Australian critical care , 2018, 31(6), 349–354. https://doi.org/10.1016/j.aucc.2017.10.001 Brusco, Natasha & Paratz, Jennifer. The effect of additional physiotherapy to hospital inpatients outside of regular business hours: A systematic review. Physiotherapy theory and practice . 2007 22. 291-307. 10.1080/09593980601023754. Damschroder, L.J., Reardon, C.M., Widerquist, M.A.O. et al. The updated Consolidated Framework for Implementation Research based on user feedback. Implementation Sci 17, 75. (2022) https://doi.org/10.1186/s13012-022-01245-0 Powell, B.J., Waltz, T.J., Chinman, M.J. et al. A refined compilation of implementation strategies: results from the Expert Recommendations for Implementing Change (ERIC) project. Implementation Sci 10, 21 (2015). https://doi.org/10.1186/s13012-015-0209-1 Additional Declarations The authors declare no competing interests. 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London","correspondingAuthor":false,"prefix":"","firstName":"Amanda","middleName":"","lastName":"Thomas","suffix":""},{"id":493628233,"identity":"afd0f38e-d6aa-4511-b620-c279e697a6e7","order_by":2,"name":"Sarah Smyth","email":"","orcid":"","institution":"University Hospitals of North Midlands NHS Trust","correspondingAuthor":false,"prefix":"","firstName":"Sarah","middleName":"","lastName":"Smyth","suffix":""},{"id":493628234,"identity":"3e37761b-3318-4c0a-b4b6-1878ed2e4ba4","order_by":3,"name":"Dr Rosalind Leslie","email":"","orcid":"https://orcid.org/0000-0001-7155-5052","institution":"The Royal Wolverhampton NHS Trust","correspondingAuthor":false,"prefix":"Dr","firstName":"Rosalind","middleName":"","lastName":"Leslie","suffix":""},{"id":493628235,"identity":"5a5bce9c-479f-4b85-9a46-73a23b8921f3","order_by":4,"name":"Ceri Sedgley","email":"","orcid":"","institution":"University Hospitals of North Midlands NHS Trust","correspondingAuthor":false,"prefix":"","firstName":"Ceri","middleName":"","lastName":"Sedgley","suffix":""},{"id":493628236,"identity":"fb1eae55-3ed1-432c-9544-a6b503044eb1","order_by":5,"name":"Dr Ema Swingwood","email":"","orcid":"https://orcid.org/0000-0003-1507-6748","institution":"University Hospital Bristol and Weston NHS Foundation Trust","correspondingAuthor":false,"prefix":"Dr","firstName":"Ema","middleName":"","lastName":"Swingwood","suffix":""}],"badges":[],"createdAt":"2025-07-31 08:53:30","currentVersionCode":1,"declarations":{"humanSubjects":false,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":false,"humanSubjectConsent":false,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-7260098/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7260098/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":88118878,"identity":"fe357d79-32de-4e91-8ab3-e07591cb9200","added_by":"auto","created_at":"2025-08-01 15:17:19","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":72258,"visible":true,"origin":"","legend":"\u003cp\u003ePRISMA flow diagram for scoping review process.\u003csup\u003e13\u003c/sup\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7260098/v1/63c06085d8c69d85f8344ee9.png"},{"id":88119956,"identity":"967d8260-ab8c-4297-a870-ebacb7c159bf","added_by":"auto","created_at":"2025-08-01 15:33:19","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":764654,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7260098/v1/d8a319a9-8e12-4584-a3a9-f23eb728c356.pdf"},{"id":88118880,"identity":"229d15b9-e33e-4777-b046-3e2370eaeb98","added_by":"auto","created_at":"2025-08-01 15:17:19","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":14745,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix1.docx","url":"https://assets-eu.researchsquare.com/files/rs-7260098/v1/17513d52411573552d4abf4a.docx"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eOut-of-Hours Service Models for Acutely Deteriorating Respiratory Patients: A Scoping Review\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eOut-of-hours respiratory care involves the delivery of time-sensitive interventions outside routine clinical hours and is typically provided through respiratory physiotherapy-led out-of-hours rota.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e This model often covers evenings, overnight periods, and occasionally weekends, depending on local service design. Respiratory physiotherapy plays a critical role in supporting patients whose respiratory needs require timely intervention that cannot be safely deferred until standard business working hours.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e Interventions include chest clearance, positioning, adjuncts to increase lung volumes, non-invasive support, and suctioning. \u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e–\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e Interventions are tailored to individual patients to optimise respiratory function and mitigate clinical deterioration.\u003c/p\u003e\u003cp\u003eInternationally, out-of-hours respiratory care is delivered through a range of models, including traditional out-of-hours services where physiotherapists are contacted as needed,\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e extended hours service with physiotherapists on-site beyond standard hours,\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e and in some settings multidisciplinary rapid response teams provide respiratory care out-of-hours.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e Many out-of-hours services rely on specialist and non-specialist physiotherapists,\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e resulting in variation in the quality and confidence of care delivery due to infrequency of out-of-hours shifts and the challenges of working outside of their usual practice areas. While training initiatives including simulation\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e have been developed to address these issues, concerns remain around staff confidence, stress, and model sustainability.\u003c/p\u003e\u003cp\u003eDespite the time-sensitive nature of these interventions and the vulnerability of the patient group, there is limited formal guidance outlining how out-of-hours respiratory care should be organised, staffed, or delivered. While the Chartered Society of Physiotherapy (CSP) published a toolkit \u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e in 2025 to support the redesign of on-call services, this resource offers principles rather than prescriptive national standards. As a result, services have developed in isolation, leading to wide variation in model structure, workforce configuration, and clinical governance. The lack of national or international consensus on what constitutes safe and effective out-of-hours respiratory physiotherapy further complicates efforts to evaluate impact on clinical outcomes, staff wellbeing, and service sustainability.\u003c/p\u003e\u003cp\u003eThis scoping review aimed to explore and describe the models of care for out-of-hours services that are currently being implemented internationally for acutely deteriorating respiratory patients. The term “out-of-hours” is used as an umbrella term to describe services delivered outside standard working hours, recognising that definitions and terminology vary. The review sought to identify key model characteristics, including operating hours, referral processes, workforce arrangements, and the use of protocols or guidelines, and to explore how these models may support staff confidence, patient outcomes, and workforce sustainability.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cem\u003eStudy Design\u003c/em\u003e\u003c/p\u003e\u003cp\u003eScoping review methodology was adopted to systematically explore international models for out-of-hours care of acutely deteriorating respiratory patients. This approach was chosen to examine the breadth and nature of evidence available on this topic and to identify key concepts, gaps, and areas for future research. The review followed the methodological framework proposed by Arksey and O’Malley,\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e further refined by Levac \u003cem\u003eet al\u003c/em\u003e,\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e and adhered to the updated guidance from the Joanna Briggs Institute (JBI) for conducting scoping reviews.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eA protocol was developed \u003cem\u003ea priori\u003c/em\u003e to guide the review process and ensure methodological transparency. The protocol was prospectively registered on the Open Science Framework and is publicly available at \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://osf.io/mbq7j\u003c/span\u003e\u003cspan address=\"https://osf.io/mbq7j\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cem\u003eEligibility Criteria\u003c/em\u003e\u003c/p\u003e\u003cp\u003ePapers were included if they reported on models of care, service delivery approaches, or multidisciplinary interventions aimed at managing acutely deteriorating respiratory patients out-of-hours in any healthcare setting. International papers were included regardless of healthcare system structure as there may be adaptations that would be applicable to UK healthcare systems. All study designs, including qualitative, quantitative, and mixed-methods research were included. Only English-language publications were included due to resource constraints.\u003c/p\u003e\u003cp\u003e\u003cem\u003eInformation Sources and Search Strategy\u003c/em\u003e\u003c/p\u003e\u003cp\u003eA three-step search strategy was utilised in this review. First, an initial limited search of MEDLINE (via PubMed) and CINAHL (via EBSCO) was undertaken to identify relevant articles and refine the search terms. Keywords and index terms from the titles and abstracts of retrieved papers were analysed to inform the development of a full search strategy. The full strategy was then adapted and applied across all included databases and information sources. Databases and search terms are in Appendix 1.\u003c/p\u003e\u003cp\u003e\u003cem\u003eStudy Selection\u003c/em\u003e\u003c/p\u003e\u003cp\u003eAll search results were imported into Rayyan,\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e a platform for systematic review management. Duplicates were removed, and titles and abstracts screened independently by two reviewers against the inclusion criteria. Full-text articles were retrieved and assessed for eligibility. Discrepancies were resolved through discussion or consultation with a third reviewer.\u003c/p\u003e\u003cp\u003e\u003cem\u003eData Extraction\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThe data extraction form was developed and piloted prior to full data extraction by all four independent reviewers. Extracted information included author(s), year of publication, country, study design, setting, population, description of the care model, components of multidisciplinary involvement, reported outcomes, key findings, and barriers and facilitators to model implementation.\u003c/p\u003e\u003cp\u003e\u003cem\u003eData Synthesis\u003c/em\u003e\u003c/p\u003e\u003cp\u003eExtracted data were synthesised descriptively using a narrative summary approach. Findings were grouped thematically by model type, operating hours, professions involved, referral processes, use of protocols or guidelines, and reported service or clinical outcomes. The review aimed to highlight both the diversity and commonalities in international approaches to out-of-hours care for acutely deteriorating respiratory patients, and to identify elements of care models that may be transferable to the UK context.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cem\u003eStudy Selection\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThe results of the search and screening process are presented in the PRISMA flow diagram\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Thirteen papers published between 2002 and 2023 were included in this review. Studies were conducted across seven countries and comprised various designs, including trials, observational studies, audits, surveys, reviews, and guidance documents. Most focused on intensive care (ICU) settings, with two examining paediatric populations \u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e. Full study characteristics are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eModels of Care\u003c/em\u003e\u003c/p\u003e\u003cp\u003eOut-of-hours respiratory physiotherapy models were the most common, described in 10 of the 13 papers (77%), where physiotherapists were contacted as needed to provide emergency respiratory care.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e,\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e,\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e,\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e,\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e,\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e Extended hours physiotherapy services were reported in one study (8%) \u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e where physiotherapists were present on-site beyond standard hours to reduce reliance on out-of-hours provision. In addition, a rapid response team (RRT) model was described in one study (8%)\u003csup\u003e6\u003c/sup\u003e where multidisciplinary teams, including medical and nursing staff, responded to acute respiratory deterioration on a 24/7 basis. Guidance documents, such as the Association of Chartered Physiotherapists in Respiratory Care (ACPRC)\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e position statement, recommended out-of-hours respiratory physiotherapy as a minimum standard, with progression towards 24/7 cover where feasible.\u003c/p\u003e\u003cp\u003e\u003cem\u003eHours of Operation\u003c/em\u003e\u003c/p\u003e\u003cp\u003eFive out of thirteen papers (38.5%) provided detailed information on service operating hours. Where reported these hours varied widely depending on the model. Berney \u003cem\u003eet al\u003c/em\u003e \u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e defined out-of-hours physiotherapy as care provided between 21:00 and 06:00. Devroey \u003cem\u003eet al\u003c/em\u003e \u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e described 24/7 on-site cover, with shifts running from 16:00 to 08:00 on weekdays and 12:00\u0026ndash;08:00 on weekends and holidays. Lim \u003cem\u003eet al\u003c/em\u003e \u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e reported out-of-hours shifts starting from 17:00\u0026ndash;21:00 daily, and 21:00 to 08:00 overnight, 12:00\u0026ndash;17:00 on Saturdays and 08:00\u0026ndash;17:00 on Sundays. Thomas \u003cem\u003eet al\u003c/em\u003e \u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e reported an average out-of-hours shift from 16:30\u0026thinsp;\u0026minus;\u0026thinsp;08:00, seven days a week. Gustafson and Grant \u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e described an extended hours model with physiotherapists on-site from 08:00-ily20:00 on weekdays.\u003c/p\u003e\u003cp\u003e\u003cem\u003eReferral Process\u003c/em\u003e\u003c/p\u003e\u003cp\u003eReferral processes were described in seven of the thirteen papers (54%), with notable variation in approach. In most physiotherapy-led models, referrals were typically initiated by nursing or medical staff using phone or bleep systems.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e,\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e. Lim \u003cem\u003eet al\u003c/em\u003e \u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e described both pre-planned referrals handed over by daytime physiotherapists, and unplanned/emergency referrals initiated by medical staff. Fernando \u003cem\u003eet al\u003c/em\u003e \u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e reported that RRTs could be activated by any healthcare provider or family member in response to concerns about acute deterioration. Triggers for referral commonly included clinical indicators including sputum retention, dyspnoea, ineffective cough, or the need for post-extubation support. \u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eStudy Characteristics\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"10\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAuthor\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYear\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCountry\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eStudy Design\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eSetting\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eModel Type\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eHours of Operation\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eProfessions Involved\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u003cp\u003eReferral Process\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c10\"\u003e\u003cp\u003eProtocols/ Guidelines\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eACPRC \u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2017\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eUnited Kingdom\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eGuidance documentation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eAcute hospitals\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eOn-call\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eNot applicable\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003ePhysiotherapists\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eNot applicable\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003eACRPC and CSP Standards\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBabu \u003cem\u003eet al\u003c/em\u003e \u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2010\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eIndia\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eSingle centre randomised controlled trial\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eICU\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eOn-call\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eNot specified\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003ePhysiotherapists\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eFrom Nurse/Doctor with specified clinical triggers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003eCSP/ACPRC on-call standards for referral triggers\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBerney \u003cem\u003eet al\u003c/em\u003e \u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2002\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAustralia\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eSingle centre case-control\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eICU\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eOn-call\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e21:00\u0026ndash;06:00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003ePhysiotherapists/ Nurses\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eNot specified\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003eNot specified\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBrusco \u003cem\u003eet al\u003c/em\u003e \u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2006\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAustralia\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eSystematic review\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eMixed hospital settings\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eOn-call, weekend, and extended hours\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eNot specified\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003ePhysiotherapists\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eNot specified\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003eNot specified\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDevroey \u003cem\u003eet al\u003c/em\u003e \u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2016\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eBelgium\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eSingle centre service evaluation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eAcute hospital\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eOn-call\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eWeekday: 16:00\u0026ndash;08:00\u003c/p\u003e\u003cp\u003eWeekend: 12:00\u0026ndash;08:00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eICU Physiotherapists\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eFrom Nurse/Doctor with specified clinical triggers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003eNot specified\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDixon and Reeve \u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2003\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eUnited Kingdom\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNational audit\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eAcute hospitals\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eOn-call\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eNot specified\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003ePhysiotherapists\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eBleep/Phone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003eACPRC on-call standards\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFernando \u003cem\u003eet al\u003c/em\u003e \u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2018\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCanada\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eSingle centre cohort study\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eAcute hospitals\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eRapid Response Team\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e24/7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eMedical, nursing, respiratory therapists\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eReferral from staff/ family\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003eNot specified\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGustafson and Grant \u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2017\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eUnited Kingdom\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eSingle centre service evaluation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eICU\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eExtended Hours\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e08:00\u0026ndash;20:00 Weekdays\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eICU Physiotherapists\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003ePre-arranged by Physiotherapist\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003eNo formal protocol\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLim \u003cem\u003eet al\u003c/em\u003e \u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2008\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSingapore\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eSingle centre retrospective study\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eHospital wards\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eOn-call\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eWeekdays: 17:00\u0026ndash;21:00\u003c/p\u003e\u003cp\u003eSat: 12:00\u0026ndash;17:00\u003c/p\u003e\u003cp\u003eSun: 08:00\u0026ndash;17:00\u003c/p\u003e\u003cp\u003eOvernight: 21:00\u0026ndash;08:00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003ePhysiotherapists\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003ePhysiotherapist and Medical Staff\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003eNot specified\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eShannon \u003cem\u003eet al\u003c/em\u003e \u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2015a\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eUnited Kingdom\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eSingle centre randomised crossover trial\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ePaediatric ICU\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eOn-call\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eNot specified\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eRespiratory specialist and non-respiratory specialist physiotherapists\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eNot specified\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003eNot specified\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eShannon \u003cem\u003eet al\u003c/em\u003e \u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2015\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eUnited Kingdom\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eSingle centre randomised crossover trial\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ePaediatric ICU\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eOn-call\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eNot specified\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eRespiratory specialist and non-respiratory-specialist physiotherapists\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eNot specified\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003eNot specified\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eThomas \u003cem\u003eet al\u003c/em\u003e \u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2023\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAustralia and New Zealand\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMulticentre cross-sectional survey\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eICU\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eOn-call\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e16:30\u0026thinsp;\u0026minus;\u0026thinsp;08:00, Seven days a week.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003ePhysiotherapists\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eNot specified\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003eNot specified\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVan Der Lee \u003cem\u003eet al\u003c/em\u003e \u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2018\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAustralia\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMulticentre cross-sectional survey\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eICU\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eOn-call\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eNot specified\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003ePhysiotherapists\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eInitiated by daytime treating physiotherapist\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003eNot specified\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eAbbreviations- ACPRC: Association Chartered Physiotherapists in Respiratory Care; CSP: Chartered Society of Physiotherapy; ICU: Intensive Care Unit.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e\u0026nbsp;\u003c/sup\u003e\u003cem\u003eProfessionals Involved in Out-of-Hours Services\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eOut-of-hours models mostly relied on non-respiratory or general physiotherapists, often supported by senior colleagues by telephone or in-person as well as specialist physiotherapists \u003cem\u003e(n\u003c/em\u003e=5\u003cem\u003e,\u003c/em\u003e 38.5%). \u003csup\u003e2,14,17,19,29\u003c/sup\u003e Specialist respiratory or ICU physiotherapists delivered extended hours and 24/7 physiotherapy services. \u003csup\u003e5,16\u003c/sup\u003e Where no physiotherapist was available, basic respiratory care tasks such as suctioning and patient positioning were undertaken by nursing staff. \u003csup\u003e15,21\u003c/sup\u003e In the RRT model, care was delivered by multidisciplinary teams consisting of medical staff, nurses, and respiratory therapists.\u003csup\u003e6\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eProtocols and Guidelines\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThree of the thirteen papers reported the use of protocols (23.1%). Protocols primarily addressed service logistics, including referral method and response time, rather than clinical treatment decision-making. In a UK audit of 20 large NHS trusts in the Trent region, Dixon and Reeve reported that 16 departments had emergency duty protocols in place, 89% of which were documented in written form.\u003csup\u003e17\u003c/sup\u003e These protocols, often based on ACPRC Guidelines,\u003csup\u003e1\u003c/sup\u003e covered aspects such as referral method, expected response time, contact systems, security arrangements, and reimbursement processes. Babu \u003cem\u003eet al\u003c/em\u003e \u003csup\u003e14\u003c/sup\u003e reported out-of-hours referrals in an ICU setting in India followed The CSP and ACPRC guidance, although no clinical protocols were described. The ACPRC guidance \u003csup\u003e1\u003c/sup\u003e set out recommendations for service structure and competence requirements but did not provide data on implementation outcomes. Most other papers reported reliance on individual clinical judgement, with no formal physiotherapy protocols described to guide intervention selection or delivery. \u003csup\u003e2,5,6,15,16,18,19,20,21,22\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cem\u003eOutcomes\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003ePatient and service outcomes were reported in twelve of the thirteen papers (92.3%). These outcomes were variable and often secondary to descriptions of service models. Some papers reported positive clinical impacts associated with models of care, including reductions in ICU length of stay and ventilation duration, often associated with intensive or out-of-hours physiotherapy provision. \u003csup\u003e15,23\u003c/sup\u003e Babu \u003cem\u003eet al\u003c/em\u003e \u003csup\u003e14\u0026nbsp;\u003c/sup\u003ereported improvements in respiratory measures, including peak expiratory flow rate and six-minute walk distance, linked to out-of-hours physiotherapy. Shannon \u003cem\u003eet al\u003c/em\u003e \u003csup\u003e19\u003c/sup\u003e found that specialist respiratory physiotherapists more frequently applied effective techniques such as combined chest wall vibration and suction, alongside greater improvements in compliance and tidal volumes, and fewer adverse events (4.8% vs 12.7%) compared to non-respiratory physiotherapists .\u003csup\u003e2\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Service level outcomes included quantifying treatments delivered out-of-hours,\u003csup\u003e16\u003c/sup\u003e reduced out-of-hours burden and cost savings associated with extended hours models.\u003csup\u003e5\u003c/sup\u003e The RRT model highlighted challenges in overnight acute care delivery, reporting higher mortality associated with night-time activations.\u003csup\u003e6\u0026nbsp;\u003c/sup\u003eOverall, while some papers demonstrated positive impacts, formal evaluations of effectiveness, patient centred outcomes, and long-term recovery were limited.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cem\u003eBarriers and Facilitators\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAll included papers reported barriers and facilitators to implementing and delivering out-of-hours care for acutely deteriorating respiratory patients (Table 2). Two papers noted the difficulty of maintaining staff competence and confidence, particularly where non-respiratory physiotherapists were involved.\u003csup\u003e1,19\u003c/sup\u003e Staffing limitations were reported as a barrier in both research design \u003csup\u003e14\u0026nbsp;\u003c/sup\u003eand service delivery \u003csup\u003e5,21\u003c/sup\u003e, contributing to concerns about consistency of service delivery and patient safety. Financial and organisational challenges were also identified, highlighting issues related to cost effectiveness and staffing sustainability.\u003csup\u003e5,16\u003c/sup\u003e Brusco \u003cem\u003eet al\u003c/em\u003e \u003csup\u003e23\u003c/sup\u003e highlighted barriers, including heterogeneity of study designs and low to medium study quality, which limited conclusions about best practice models.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003eFacilitators of out-of-hours models of care included formal training, access to senior staff, clear protocols, adequate staffing, and organisational commitment to service quality. (Table 2). The ACPRC \u003csup\u003e1\u0026nbsp;\u003c/sup\u003eand the UK audit by Dixon and Reeve \u003csup\u003e17\u003c/sup\u003e highlighted the role of structured training programmes and clear policy frameworks in supporting staff competence and service delivery. Thomas \u003cem\u003eet al\u003c/em\u003e \u003csup\u003e21\u003c/sup\u003e similarly identified access to senior ICU physiotherapists support as key enablers of safe and effective service delivery. Van der Lee \u003cem\u003eet al\u003c/em\u003e \u003csup\u003e21\u003c/sup\u003e reported that larger ICUs with higher physiotherapy staffing levels facilitated after-hours service provision. Dedicated ICU physiotherapy teams with institutional support were identified as facilitators \u003csup\u003e16,5\u003c/sup\u003e alongside the use of national or professional guidelines to further supported service quality. \u003csup\u003e1,14,17\u003c/sup\u003e \u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"614\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 2. Barriers and Facilitators\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16.9381%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAuthor\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.7492%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eYear\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36.9707%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBarriers\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 35.342%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFacilitators\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16.9381%;\"\u003e\n \u003cp\u003eACPRC\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.7492%;\"\u003e\n \u003cp\u003e2017\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36.9707%;\"\u003e\n \u003cp\u003eChallenges to maintain competency in non-specialist physiotherapists; managing fatigue, securing funding, and ensuring service robustness.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 35.342%;\"\u003e\n \u003cp\u003eAdvocates for minimum standards; structured training; clear policies; appropriate staffing and promoting service value.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16.9381%;\"\u003e\n \u003cp\u003eBabu \u003cem\u003eet al\u003c/em\u003e\u003csup\u003e14\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.7492%;\"\u003e\n \u003cp\u003e2010\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36.9707%;\"\u003e\n \u003cp\u003eStaffing limitations.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 35.342%;\"\u003e\n \u003cp\u003eUse of CSP/ACPRC guidelines for referrals.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16.9381%;\"\u003e\n \u003cp\u003eBerney \u003cem\u003eet al\u003c/em\u003e\u003csup\u003e15\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.7492%;\"\u003e\n \u003cp\u003e2002\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36.9707%;\"\u003e\n \u003cp\u003eLack of standardisation of clinical decision making.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 35.342%;\"\u003e\n \u003cp\u003eDedicated ICU physiotherapy staffing model.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16.9381%;\"\u003e\n \u003cp\u003eBrusco \u003cem\u003eet al\u003c/em\u003e\u003csup\u003e22\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.7492%;\"\u003e\n \u003cp\u003e2006\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36.9707%;\"\u003e\n \u003cp\u003eStudy heterogeneity, low-moderate quality.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 35.342%;\"\u003e\n \u003cp\u003eDemonstrated feasibility in some critical care subgroups (Acute spinal cord injury and high-risk elderly surgical ICU patients).\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16.9381%;\"\u003e\n \u003cp\u003eDevroey \u003cem\u003eet al\u003c/em\u003e\u003csup\u003e16\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.7492%;\"\u003e\n \u003cp\u003e2016\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36.9707%;\"\u003e\n \u003cp\u003eUnable to assess cost effectiveness due to lack of baseline data and ethical constraints.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 35.342%;\"\u003e\n \u003cp\u003eDedicated ICU physiotherapy team; institutional support and positive staff perception of value.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16.9381%;\"\u003e\n \u003cp\u003eDixon and Reeve\u003csup\u003e17\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.7492%;\"\u003e\n \u003cp\u003e2003\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36.9707%;\"\u003e\n \u003cp\u003eInconsistent adherence to protocols.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 35.342%;\"\u003e\n \u003cp\u003eClear protocols, training, and support from senior respiratory physiotherapists.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16.9381%;\"\u003e\n \u003cp\u003eFernando \u003cem\u003eet al\u003c/em\u003e\u003csup\u003e6\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.7492%;\"\u003e\n \u003cp\u003e2018\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36.9707%;\"\u003e\n \u003cp\u003eNight-time service challenges; delays in activation, reduced staff experience, shift patterns at risk of impacting cognitive performance.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 35.342%;\"\u003e\n \u003cp\u003e24/7 multidisciplinary team and defined activation criteria.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16.9381%;\"\u003e\n \u003cp\u003eGustafson and Grant\u003csup\u003e5\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.7492%;\"\u003e\n \u003cp\u003e2017\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36.9707%;\"\u003e\n \u003cp\u003eStaffing challenges, burnout risk.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 35.342%;\"\u003e\n \u003cp\u003eExtended hours reduced on-call burden, organisational support\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16.9381%;\"\u003e\n \u003cp\u003eLim \u003cem\u003eet al\u003c/em\u003e\u003csup\u003e18\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.7492%;\"\u003e\n \u003cp\u003e2008\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36.9707%;\"\u003e\n \u003cp\u003eNo evaluation of long-term outcomes or cost effectiveness.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 35.342%;\"\u003e\n \u003cp\u003eStructured after-hours service.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16.9381%;\"\u003e\n \u003cp\u003eShannon \u003cem\u003eet al\u003c/em\u003e\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.7492%;\"\u003e\n \u003cp\u003e2015a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36.9707%;\"\u003e\n \u003cp\u003eSkill level having potential impact on patient outcomes.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 35.342%;\"\u003e\n \u003cp\u003eUse of force-sensing technology for training feedback; potential for targeted education.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16.9381%;\"\u003e\n \u003cp\u003eShannon \u003cem\u003eet al\u003c/em\u003e\u003csup\u003e19\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.7492%;\"\u003e\n \u003cp\u003e2015\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36.9707%;\"\u003e\n \u003cp\u003eConfidence gaps between specialist and non-specialist.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 35.342%;\"\u003e\n \u003cp\u003eHighlighted need for targeted training.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16.9381%;\"\u003e\n \u003cp\u003eThomas \u003cem\u003eet al\u003c/em\u003e\u003csup\u003e20\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.7492%;\"\u003e\n \u003cp\u003e2023\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36.9707%;\"\u003e\n \u003cp\u003eLower staffing linked to dissatisfaction, variability in access to senior staff.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 35.342%;\"\u003e\n \u003cp\u003eAccess to senior staff. Integrated orientation and educated processes.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16.9381%;\"\u003e\n \u003cp\u003eVan Der Lee \u003cem\u003eet al\u003c/em\u003e\u003csup\u003e21\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.7492%;\"\u003e\n \u003cp\u003e2018\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36.9707%;\"\u003e\n \u003cp\u003eStaffing limitations, reliance on other health professionals to provide respiratory care.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 35.342%;\"\u003e\n \u003cp\u003eLarger ICUs, more availability for on-call staff.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eAbbreviations: ACPRC: Association of Chartered Physiotherapists in Respiratory Care; CSP: Chartered Society of Physiotherapy; ICU: Intensive Care Unit\u003c/em\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis scoping review highlights considerable variation in how out-of-hours respiratory care is structured and delivered across international healthcare systems. Models ranged from traditional out-of-hours services such as from 16:00-8:00 seven days a week, to extended working hours and 24/7 multidisciplinary teams, with operational hours, staffing configurations, and referral processes differing significantly between settings. Importantly, these models were implemented across a diverse range of hospital types, from specialist ICUs to general wards each with distinct clinical demands and workforce capabilities.\u003c/p\u003e\n\n\u003cp\u003eVariability is important to note and highlights the challenge of prescribing a single \u0026ldquo;ideal\u0026rdquo; model for out-of-hours respiratory care. Rather than advocating for a one-size-fits-all approach, our findings support the need for scalable and contextually adaptable service models that can evolve in response to local population needs, organisational resources, and existing workforce capacity. Future guidance may be more effectively framed around a set of core principles or standards, such as those outlined in the CSP Toolkit \u003csup\u003e8 \u003c/sup\u003ewhich define the function and responsiveness of out-of-hours care, allowing for localised implementation within a flexible framework. \u003c/p\u003e\n\n\u003cp\u003eBarriers identified suggest a potential need for deliberate and system-level planning in designing sustainable out-of-hours respiratory services. Workforce limitations and inconsistent staff competence, particularly among non-specialist physiotherapists, raise important questions about how services can safely scale or operate in resource-constrained environments. These challenges are unlikely to be addressed through training alone and demand integrated approaches that include role clarity, protected time for skill maintenance, and flexible models of care. Applying implementation science frameworks such as the Consolidated Framework for Implementation Research (CFIR)\u003csup\u003e23\u003c/sup\u003e and Expert Recommendations for Implementing Change (ERIC)\u003csup\u003e24\u003c/sup\u003e may help organisations systematically identify and address context-specific barriers and facilitators to service implementation.\u003c/p\u003e\n\n\u003cp\u003eFinancial and organisational barriers may also suggest that commissioning out-of-hours services should go beyond workforce inputs and consider broader questions of service value, outcome measurement, and long-term sustainability through appropriate data collection and analysis. Health economic evaluation was largely absent in the current literature and could play a critical role in informing decisions around resource allocation and service design.\u003c/p\u003e\n\n\u003cp\u003eA notable observation across papers was the diversity of professionals delivering out-of-hours respiratory interventions. While physiotherapists were the primary providers, responsibility for managing acute deterioration was sometimes shared with, or transferred to other health professionals, including nurses and medical staff, particularly in RRT models of multidisciplinary nature. These arrangements raise important questions about professional boundaries, role clarity, and the competencies required to deliver safe and effective respiratory care out-of-hours. Rather than focussing on the role of respiratory physiotherapy, it may be more productive to consider who is best equipped to respond to acute respiratory deterioration and under what conditions. Re-framing the issue shifts the lens from profession-specific tasks to the broader issue of system responsiveness, interdisciplinary capability and sustainability, and patient safety.\u003c/p\u003e\n\n\u003cp\u003eFinally, facilitators such as structured training, senior mentorship, clear protocols, and institutional support offer valuable direction for service development. However, ensuring consistent access to these enablers across diverse settings remains a challenge, particularly where staffing and financial constraints exist. Alignment of governance structures, education pathways, and quality monitoring may help promote consistent, high-quality care delivery.\u003c/p\u003e\n"},{"header":"Conclusions","content":"\u003cp\u003eThis scoping review identified wide variation in out-of-hours respiratory care models internationally, reflecting differences in context, resource availability, and workforce. A single standardised model is unlikely to address the diverse needs and contextual challenges identified across settings. Future research should focus on identifying core components of safe and effective care -\u0026nbsp;including staff competence, timely access, and referral clarity - and on adapting these through flexible, context-sensitive implementation. Collaboration between professional bodies, policymakers, and service leaders- including those in strategic physiotherapy roles, will be critical to enable the development of models that are evidence-informed, equitable, and sustainable in real-world practice.\u003c/p\u003e\n"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eThe Association of Chartered Physiotherapists in Respiratory Care (ACPRC) \u003cem\u003eOn-call position statement.\u003c/em\u003e London. [online] Available from: https://www.acprc.org.uk/data/Resource_Downloads/ACPRCOn-CallDocument2017.pdf\u003cstrong\u003e (Accessed 15/05/25)\u003c/strong\u003e\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eShannon H, Stocks J, Gregson RK, Dunne C, Peters MJ, Main E.\u003c/strong\u003e Clinical effects of specialist and on-call respiratory physiotherapy treatments in mechanically ventilated children: a randomised crossover trial. \u003cem\u003ePhysiotherapy\u003c/em\u003e. 2015;101(4):349\u0026ndash;356. https://doi.org/10.1016/j.physio.2014.12.004\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eGo\u003c/strong\u003e\u003cstrong\u003esselink R, Clerckx B, Robbeets C, Vanhullebusch T, Vanpee G, Segers J.\u003c/strong\u003e Physiotherapy in the intensive care unit. \u003cem\u003eNeth J Crit Care\u003c/em\u003e. 2011;15:1\u0026ndash;10\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eBritish Thoracic Society and Association of Chartered Physiotherapists in Respiratory Care.\u003c/strong\u003e Concise BTS/ACPRC guidelines: physiotherapy management of the adult, medical, spontaneously breathing patient. 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The effects of \u0026apos;on-call/out of hours\u0026apos; physical therapy in acute exacerbations of chronic obstructive pulmonary disease: a randomized controlled trial. \u003cem\u003eClinical rehabilitation\u003c/em\u003e, 2010 24(9), 802\u0026ndash;809. https://doi.org/10.1177/0269215510367558\u003c/li\u003e\n\u003cli\u003eBerney, S., Stockton, K., Berlowitz, D., \u0026amp; Denehy, L. Can early extubation and intensive physiotherapy decrease length of stay of acute quadriplegic patients in intensive care? A retrospective case control study. \u003cem\u003ePhysiotherapy research international : the journal for researchers and clinicians in physical therapy\u003c/em\u003e, 2002 7(1), 14\u0026ndash;22. https://doi.org/10.1002/pri.237\u003c/li\u003e\n\u003cli\u003eDevroey, M., Buyse, C., Norrenberg, M., Ros, A. M., \u0026amp; Vincent, J. L. Cardiorespiratory Physiotherapy around the Clock: Experience at a University Hospital. \u003cem\u003ePhysiotherapy Canada\u003c/em\u003e, 2016 68(3), 254\u0026ndash;258. https://doi.org/10.3138/ptc.2015-40\u003c/li\u003e\n\u003cli\u003eDixon, T and Reeve, Emergency on-call duties: Audit of support, education and training provision in NHSE region. \u003cem\u003ePhysiotherapy, \u003c/em\u003e2003. 89:2, 104-113. https://doi.org/10.1016/S0031-9406(05)60581-0\u003cem\u003e \u003c/em\u003e\u003c/li\u003e\n\u003cli\u003eLim, E. C., Liu, J., Yeung, M. T., \u0026amp; Wong, W. P. After-hour physiotherapy services in a tertiary general hospital. \u003cem\u003ePhysiotherapy theory and practice\u003c/em\u003e, 2008 24(6), 423\u0026ndash;429. https://doi.org/10.1080/09593980802511821\u003c/li\u003e\n\u003cli\u003eShannon, H., Stocks, J., Gregson, R. K., Hines, S., Peters, M. J., \u0026amp; Main, E. Differences in delivery of respiratory treatments by on-call physiotherapists in mechanically ventilated children: a randomised crossover trial. P\u003cem\u003ehysiotherapy\u003c/em\u003e, 2015 101(4), 357\u0026ndash;363. https://doi.org/10.1016/j.physio.2014.12.001\u003c/li\u003e\n\u003cli\u003eThomas, P., Chaseling, W., Marais, L., Matheson, C., Paton, M., \u0026amp; Swanepoel, N. Physiotherapy services in intensive care. A workforce survey of Australia and New Zealand. \u003cem\u003eAustralian critical care\u003c/em\u003e 2023, 36(5), 806\u0026ndash;812. https://doi.org/10.1016/j.aucc.2022.11.004\u003c/li\u003e\n\u003cli\u003evan der Lee, L., Hill, A. M., \u0026amp; Patman, S. After-hours respiratory physiotherapy for intubated and mechanically ventilated patients with community-acquired pneumonia: An Australian perspective. \u003cem\u003eAustralian critical care\u003c/em\u003e, 2018, 31(6), 349\u0026ndash;354. https://doi.org/10.1016/j.aucc.2017.10.001\u003c/li\u003e\n\u003cli\u003eBrusco, Natasha \u0026amp; Paratz, Jennifer. The effect of additional physiotherapy to hospital inpatients outside of regular business hours: A systematic review. \u003cem\u003ePhysiotherapy theory and practice\u003c/em\u003e. 2007 22. 291-307. 10.1080/09593980601023754.\u003c/li\u003e\n\u003cli\u003eDamschroder, L.J., Reardon, C.M., Widerquist, M.A.O. et al. The updated Consolidated Framework for Implementation Research based on user feedback. \u003cem\u003eImplementation Sci\u003c/em\u003e 17, 75. (2022) https://doi.org/10.1186/s13012-022-01245-0\u003c/li\u003e\n\u003cli\u003ePowell, B.J., Waltz, T.J., Chinman, M.J. et al. A refined compilation of implementation strategies: results from the Expert Recommendations for Implementing Change (ERIC) project. \u003cem\u003eImplementation Sci\u003c/em\u003e 10, 21 (2015). https://doi.org/10.1186/s13012-015-0209-1\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"The Royal Wolverhampton NHS Trust","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"out-of-hours, on-call, respiratory, physiotherapy, service-delivery","lastPublishedDoi":"10.21203/rs.3.rs-7260098/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7260098/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eAcute respiratory deterioration in hospitalised patients requires timely intervention to prevent further clinical decline. Out-of-hours respiratory care is typically provided through on-call physiotherapy rotas, extended hour cover, or 24/7 on-site services. However, models of care vary widely internationally, and little is known about how these services are structured, delivered, and evaluated for acutely deteriorating respiratory patients.\u003c/p\u003e\u003ch2\u003eObjectives\u003c/h2\u003e\u003cp\u003eTo map and describe international models of care for out-of-hours services for acutely deteriorating respiratory patients, including key model characteristics, workforce configurations, referral processes, reported barriers and facilitators, and associated outcomes.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA scoping review was undertaken following the Joanna Briggs Institute and PRISMA-ScR guidance. This included a comprehensive search of electronic databases and grey literature. Papers were included if they reported models of out-of-hours care relevant to respiratory physiotherapy or multidisciplinary care for patients with acute respiratory deterioration. Data were extracted independently by four reviewers and synthesised descriptively using a narrative approach.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThirteen international papers published between 2002 and 2023 were included. The majority (77%) described out-of-hours physiotherapy models; others reported extended hours or multidisciplinary rapid response teams. Operating hours, referral processes, and protocols varied widely, with many services relying on non-specialist physiotherapists for out-of-hours provision. Barriers to service provision included staffing limitations, variability in competence, and organisational challenges. Facilitators included presence of senior support, structured training, protocols, and institution support for extended hours models. Evidence on clinical outcomes was limited and heterogeneous.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eOut-of-hours care for acutely deteriorating respiratory patients is delivered through a range of models internationally, with considerable variation in structure and workforce configuration. Further research is needed to evaluate model effectiveness, impact on staff well-being, and relevance to evolving workforce demands.\u003c/p\u003e","manuscriptTitle":"Out-of-Hours Service Models for Acutely Deteriorating Respiratory Patients: A Scoping Review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-01 15:17:14","doi":"10.21203/rs.3.rs-7260098/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"15f1d373-2ca7-4014-8936-b9d8019efc74","owner":[],"postedDate":"August 1st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-08-01T15:17:14+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-01 15:17:14","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7260098","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7260098","identity":"rs-7260098","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}