A qualitative study of systemic influences on paramedic decision making: care transitions and patient safety

Abstract

Objectives: Paramedics routinely make critical decisions about the most appropriate care to deliver in a complex system characterized by significant variation in patient case-mix, care pathways and linked service providers. There has been little research carried out in the ambulance service to identify areas of risk associated with decisions about patient care. The aim of this study was to explore systemic influences on decision making by paramedics relating to care transitions to identify potential risk factors. Methods: An exploratory multi-method qualitative study was conducted in three English National Health Service (NHS) Ambulance Service Trusts, focusing on decision making by paramedic and specialist paramedic staff. Researchers observed 57 staff across 34 shifts. Ten staff completed digital diaries and three focus groups were conducted with 21 staff. Results: Nine types of decision were identified, ranging from emergency department conveyance and specialist emergency pathways to non-conveyance. Seven overarching systemic influences and risk factors potentially influencing decision making were identified: demand; performance priorities; access to care options; risk tolerance; training and development; communication and feedback and resources. Conclusions: Use of multiple methods provided a consistent picture of key systemic influences and potential risk factors. The study highlighted the increased complexity of paramedic decisions and multi-level system influences that may exacerbate risk. The findings have implications at the level of individual NHS Ambulance Service Trusts (e.g. ensuring an appropriately skilled workforce to manage diverse patient needs and reduce emergency department conveyance) and at the wider prehospital emergency care system level (e.g. ensuring access to appropriate patient care options as alternatives to the emergency department).

Factors influencing the decision to convey or not to convey elderly people to the emergency department after emergency ambulance attendance: a systematic mixed studies review

“…Another factor found within this theme was making use of a ‘feedback loop’. When EMS staff were provided with objective feedback information on non-conveyance responses, their self-motivation to improve care increased,48 63 and this led to individual and organisational learning 63. Under the workload theme, two studies found that attending incidents during difficult or busy shifts, or at the end of a shift, led to taking the easy option of conveying the patient to hospital 61 62…”

Safety lessons: shifting paradigms and new directions for patient safety research

“…38 The focus on urgent care in this and in Sujan and colleagues' study is welcome as an example of a complex system or web of systems, providing an antidote to the dominance in previous research of studies within hospitals or single organisations. O'Hara and colleagues' study of decision making on ambulances, using immersive ethnographic methods, from observation of ambulance shifts to digital diaries held by paramedics, provides important insights into the complexity of decisions made by frontline staff.…”

Paramedics' views on their seizure management learning needs: a qualitative study in England

“…The Consolidating Framework for Implementation Research24 offers insights into the conditions under which new interventions are and are not likely to be successfully implemented. It highlights that a ‘tension for change’ is one condition that facilitates successful uptake and implementation, that is, stakeholders need to perceive the current situation as needing to change and so be receptive to arrival of the new intervention 24.…”

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