ObjectiveTo evaluate effectiveness, safety and cost-effectiveness of Computerised Clinical Decision Support (CCDS) for paramedics attending older people who fall.DesignCluster trial randomised by paramedic; modelling.Setting13 ambulance stations in two UK emergency ambulance services.Participants42 of 409 eligible paramedics, who attended 779 older patients for a reported fall.InterventionsIntervention paramedics received CCDS on Tablet computers to guide patient care. Control paramedics provided care as usual. One service had already installed electronic data capture.Main Outcome MeasuresEffectiveness: patients referred to falls service, patient reported quality of life and satisfaction, processes of care.SafetyFurther emergency contacts or death within one month.Cost-EffectivenessCosts and quality of life. We used findings from published Community Falls Prevention Trial to model cost-effectiveness.Results17 intervention paramedics used CCDS for 54 (12.4%) of 436 participants. They referred 42 (9.6%) to falls services, compared with 17 (5.0%) of 343 participants seen by 19 control paramedics [Odds ratio (OR) 2.04, 95% CI 1.12 to 3.72]. No adverse events were related to the intervention. Non-significant differences between groups included: subsequent emergency contacts (34.6% versus 29.1%; OR 1.27, 95% CI 0.93 to 1.72); quality of life (mean SF12 differences: MCS −0.74, 95% CI −2.83 to +1.28; PCS −0.13, 95% CI −1.65 to +1.39) and non-conveyance (42.0% versus 36.7%; OR 1.13, 95% CI 0.84 to 1.52). However ambulance job cycle time was 8.9 minutes longer for intervention patients (95% CI 2.3 to 15.3). Average net cost of implementing CCDS was £208 per patient with existing electronic data capture, and £308 without. Modelling estimated cost per quality-adjusted life-year at £15,000 with existing electronic data capture; and £22,200 without.ConclusionsIntervention paramedics referred twice as many participants to falls services with no difference in safety. CCDS is potentially cost-effective, especially with existing electronic data capture.Trial Registration ISRCTN Register ISRCTN10538608

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BackgroundMany emergency ambulance calls are for older people who have fallen. As half of them are left at home, a community-based response may often be more appropriate than hospital attendance. The SAFER 1 trial will assess the costs and benefits of a new healthcare technology - hand-held computers with computerised clinical decision support (CCDS) software - to help paramedics decide who needs hospital attendance, and who can be safely left at home with referral to community falls services.Methods/DesignPragmatic cluster randomised trial with a qualitative component. We shall allocate 72 paramedics ('clusters') at random between receiving the intervention and a control group delivering care as usual, of whom we expect 60 to complete the trial.Patients are eligible if they are aged 65 or older, live in the study area but not in residential care, and are attended by a study paramedic following an emergency call for a fall. Seven to 10 days after the index fall we shall offer patients the opportunity to opt out of further follow up. Continuing participants will receive questionnaires after one and 6 months, and we shall monitor their routine clinical data for 6 months. We shall interview 20 of these patients in depth. We shall conduct focus groups or semi-structured interviews with paramedics and other stakeholders.The primary outcome is the interval to the first subsequent reported fall (or death). We shall analyse this and other measures of outcome, process and cost by 'intention to treat'. We shall analyse qualitative data thematically.DiscussionSince the SAFER 1 trial received funding in August 2006, implementation has come to terms with ambulance service reorganisation and a new national electronic patient record in England. In response to these hurdles the research team has adapted the research design, including aspects of the intervention, to meet the needs of the ambulance services.In conclusion this complex emergency care trial will provide rigorous evidence on the clinical and cost effectiveness of CCDS for paramedics in the care of older people who have fallen.Trial RegistrationISRCTN10538608

BackgroundComputerised clinical decision support (CCDS) has been shown to improve processes of care in some healthcare settings, but there is little evidence related to its use or effects in pre-hospital emergency care. CCDS in this setting aligns with policies to increase IT use in ambulance care, enhance paramedic decision-making skills, reduce avoidable emergency department attendances and improve quality of care and patient experience. This qualitative study was conducted alongside a cluster randomised trial in two ambulance services of the costs and effects of web-based CCDS system designed to support paramedic decision-making in the care of older people following a fall. Paramedics were trained to enter observations and history for relevant patients on a tablet, and the CCDS then generated a recommended course of action which could be logged. Our aim was to describe paramedics’ experience of the CCDS intervention and to identify factors affecting its implementation and use.MethodsWe invited all paramedics who had been randomly allocated to the intervention arm of the trial to participate in interviews or focus groups. The study was underpinned by Strong Structuration Theory, a theoretical model for studying innovation based on the relationship between what people do and their context. We used the Framework approach to data analysis.ResultsTwenty out of 22 paramedics agreed to participate. We developed a model of paramedic experience of CCDS with three domains: context, adoption and use, and outcomes. Aspects of context which had an impact included organisational culture and perceived support for non-conveyance decisions. Experience of adoption and use of the CCDS varied between individual paramedics, with some using it with all eligible patients, some only with patients they thought were ‘suitable’ and some never using it. A range of outcomes were reported, some of which were different from the intended role of the technology in decision support.ConclusionImplementation of new technology such as CCDS is not a one-off event, but an ongoing process, which requires support at the organisational level to be effective.Trial registrationISRCTN Registry 10538608. Registered 1 May 2007. Retrospectively registered.Electronic supplementary materialThe online version of this article (10.1186/s13012-018-0786-x) contains supplementary material, which is available to authorized users.

Introduction A recent national review of English ambulance services, Taking Healthcare to the Patient: Transforming NHS Ambulance Services,1 published by the Department of Health, recommended that pre-hospital care research topics should be prioritised to ensure that service provision and development are evidence based wherever possible and that limited available funds are targeted to the most pressing needs. To identify gaps in research evidence related to delivery of pre-hospital care; and to rank topics in order of priority for research. Methods Research priorities were initially identified by delegates at the UK Ambulance Service Association’s annual conference, AMBEX 2006. An examination of research reviews in pre-hospital care identified other research evidence gaps. Relevant websites, databases and review bibliographies were also searched. Management, service delivery and treatment recommendations in UK policy/guidance documents published since 2000 were matched to research evidence. A list of evidence gaps was circulated in a Delphi-style three-round consultation to experts in pre-hospital care, including clinicians, managers and researchers. Round 1 confirmed/identified research gaps; Round 2 focussed on ranking topics; and Round 3 reviewed the scores and provided an option to rescore. Scores were analysed using SPSS. Results Ninety-six research issues were identified for circulation and prioritisation from 52 reviews and expert consultation and these were matched against 30 policy and guidance documents. Forty people participated in the Delphi exercise. The subject receiving highest priority for research was the development of new performance measures other than emergency ambulance response times. Other highly ranked priorities included treatment of stroke, cardiac conditions, children and people who self-harm; alternatives to Accident and Emergency (A&E) treatment; patient information sharing across care providers; access issues; decision support systems; and demand management systems for pre-hospital care. These priorities reflect three key issues: measuring activity to benefit patients; development of safe non-A&E care; and providing appropriate evidence-based clinical care in the pre-hospital environment. Implications There are many evidence gaps related to current pre-hospital policy and practice including management, clinical and service delivery issues. This Delphi consultation combines expertise of clinicians, managers and researchers to generate consensus on future research priorities in pre-hospital care. The need to develop meaningful performance measures plus alternative methods of patient management illustrates the synergistic relationship between service delivery and performance measurement. It suggests an opportunity to identify alternatives to response times as indicators of quality of pre-hospital care. The final results from this study will be useful to commissioners when developing their strategic approach to decision making about which research should be funded to facilitate continued development of quality patient care in the pre-hospital setting.