Ambulance Service Treat and Refer Guidelines: A Qualitaive Investigation Into the Use of Treat and Refer Guidelines by Ambulance Clinicians

Abstract

BackgroundOver the last decade there has been a steadily increasing demand for unscheduled healthcare services, including the ambulance services. To address this demand, various projects have been developed to reduce admissions to the emergency department. One of these was the introduction of Treat and Refer (T&R) guidelines, to allow ambulance clinicians to treat certain groups of patients in the community without the need to convey them to hospital. Aims: This study aims to explore the challenges and barriers faced by ambulance clinicians in the use of T&R guidelines, to inform the future development and governance of non-conveyance guidelines and interventions.MethodsSemi-structured interviews were conducted with 18 ambulance clinicians. Data were analysed using framework analysis. Setting: A national UK NHS ambulance service.ResultsThere was a broad support for the concept and policy of T&R; however the participants had mixed views with respect to the actual practice of treating and referring patients. Participants acknowledged the potential benefits of T&R for patients and the NHS, but identified several risks in using T&R in routine practice. Their perceptions of risk seemed to determine whether and how the guidelines were used. Challenges in the use of T&R included: lack of training and knowledge, fear of litigation, a lack of support from the management and difficulties in decision-making.ConclusionsThis study and the supporting literature do not support the use of T&R guidelines in their current format by traditionally trained ambulance clinicians. Ambulance clinicians have identified the need for further education and support. The conceptual support for T&R may provide a foundation to develop and improve the education and support for ambulance clinicians. This should be combined with implementation/review strategies, clinician-led decision support and management support which can provide the ambulance clinician with the skills and confidence to take responsibility for non-conveyance.

Understanding variation in ambulance service non-conveyance rates: a mixed methods study

“…12 Paramedics work with the fear of litigation and can perceive a lack of support from management for their non-conveyance decisions if adverse events occur. 15 Negotiating the balance between patient safety and patient choice, together with paramedics' own fears of litigation, can result in conveyance to an emergency department as a precaution. 16 In the past, crew members have not always completed documentation around non-conveyance because they did not perceive it to be important.…”

Paramedic Education to Support the Use of Low-Acuity Care Pathways: A Scoping Review Protocol

“…To further assist non-specialist or general paramedics with the increasing need to manage low-acuity conditions in the field, often until the patient can access their primary care practitioner, ambulance services around the world have implemented several strategies for providing alternative care pathways. These pathways include various options to guide low-acuity treatment and referral (T&R), including on-scene triage and assessment tools, flowcharts, guidelines, protocols, and policy [ 26 , 27 , 28 , 29 ]. The range of low-acuity conditions they address and provide guidance on varies.…”

“…The range of low-acuity conditions they address and provide guidance on varies. Some focus on only one or a limited number of issues, whilst others have developed protocols for a multitude of conditions [ 26 , 28 , 29 , 30 , 31 , 32 , 33 ].…”

“…Several challenges have been identified with the implementation and use of T&R pathways into general paramedic practice, with deficiencies in training notably highlighted [ 24 , 28 , 29 , 34 , 35 ]. It has been reported that inadequate training is a barrier to their use in the field, with paramedics citing a lack of confidence and thus hesitancy to use them even for appropriately identified patients [ 15 , 28 , 36 ].…”

Supporting the ambulance service to safely convey fewer patients to hospital by developing a risk prediction tool: Risk of Adverse Outcomes after a Suspected Seizure (RADOSS)—protocol for the mixed-methods observational RADOSS project

“…One factor which has yet to be addressed is that ambulance clinicians can find it difficult to confidently identify cases suitable for non-conveyance. Some report uncertainty regarding the accuracy of their assessments for non-conveyance, and express concern for patient safety and their liability if an incorrect decision is made 10 27–37…”