Exclusion of context knowledge in the development of prehospital guidelines: results produced by realistic evaluation

Abstract

BackgroundPrehospital work is accomplished using guidelines and protocols, but there is evidence suggesting that compliance with guidelines is sometimes low in the prehospital setting. The reason for the poor compliance is not known. The objective of this study was to describe how guidelines and protocols are used in the prehospital context.MethodsThis was a single-case study with realistic evaluation as a methodological framework. The study took place in an ambulance organization in Sweden. The data collection was divided into four phases, where phase one consisted of a literature screening and selection of a theoretical framework. In phase two, semi-structured interviews with the ambulance organization's stakeholders, responsible for the development and implementation of guidelines, were performed. The third phase, observations, comprised 30 participants from both a rural and an urban ambulance station. In the last phase, two focus group interviews were performed. A template analysis style of documents, interviews and observation protocols was used.ResultsThe development of guidelines took place using an informal consensus approach, where no party from the end users was represented. The development process resulted in guidelines with an insufficiently adapted format for the prehospital context. At local level, there was a conscious implementation strategy with lectures and manikin simulation. The physical format of the guidelines was the main obstacle to explicit use. Due to the format, the ambulance personnel feel they have to learn the content of the guidelines by heart. Explicit use of the guidelines in the assessment of patients was uncommon. Many ambulance personnel developed homemade guidelines in both electronic and paper format. The ambulance personnel in the study generally took a positive view of working with guidelines and protocols and they regarded them as indispensable in prehospital care, but an improved format was requested by both representatives of the organization and the ambulance personnel.ConclusionsThe personnel take a positive view of the use of guidelines and protocols in prehospital work. The main obstacle to the use of guidelines and protocols in this organization is the format, due to the exclusion of context knowledge in the development process.

Ambulance nurses' experiences of deciding a patient does not require ambulance care

“…In the field of ambulance nursing, the primary responsibility of the nurse is to care for patients who need ambulance care (Holmberg & Fagerberg, 2010;Sandman & Nordmark, 2006). Andersson Hagiwara, Suserud, Jonsson, and Henricson (2013) describe that there are times when ambulance staff have to deal with situations that do not belong to their actual duties. Ambulance staff can sometimes meet patients with other needs, such as social needs (Holmberg & Fagerberg, 2010).…”

“…This is because the emergency room is open 24 hr, even though it is not the best solution for the patient, instead the patient might would have felt better if he or she could have stayed at home with support (Holmberg & Fagerberg, 2010). In order to cope with this kind of situation, a great ability to be humble, creative and flexible is required (Ahl et al, 2005;Andersson Hagiwara, Suserud et al, 2013).…”

Technology for trauma: testing the validity of a smartphone app for pre-hospital clinicians

“…A Scandinavian study (Hagiwara et al, 2013) identified that the physical format of pre-hospital guidelines was the main barrier to usage and compliance in ambulance staff, with many clinicians constructing their own paper and electronic versions to improve ease of use. The development of well-designed, stable, rapid and accessible smartphone apps has the potential to improve concordance with guideline usage and associated improvements in patient safety.…”

The Effects of Integrated IT Support on the Prehospital Stroke Process: Results from a Realistic Experiment

“…A typical ambulance mission can be divided into a number of defined phases [12,29,30]. Earlier simulation studies of ICT technology for prehospital care [20,22,31] have only focused on one specific phase of the prehospital process, such as on-scene assessment and treatment.…”

“…Today, the support provided to EMS clinicians to manage patients usually consists of a combination of cognitive tools or expert systems such as paperbased protocols or guidelines, and phone consultations with attending ER physicians or (for stroke symptoms) neurologists. As discussed by Andersson Hagiwara et al [12] and Söderholm [13], there are however problems with these tools and practices, in the sense that they are not always suitable for the task or compatible with the EMS work process. As an example, EMS clinicians have to use several different paper-based protocols, guidelines, triage systems and medical record documentation sheets or systems, when managing a patient.…”