Gaps between policy, protocols and practice: a qualitative study of the views and practice of emergency ambulance staff concerning the care of patients with non-urgent needs

Snooks, Helen; Kearsley, N; Dale, Jeremy; Halter, Mary; Redhead, Julian; Foster, James

doi:10.1136/qshc.2004.012195

Cited by 55 publications

(95 citation statements)

References 10 publications

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“…[6,12] Care providers treat more diverse patient populations than ever, and to be able to manage well, they must possess a wide range of skills. [2] Especially paramedic field managers, who also participate in patient care, require situational awareness.…”

Section: Introductionmentioning

confidence: 99%

“…[1,2] It has been proposed that instead of narrowly focusing on patient care procedures, researchers should develop more comprehensive theories of the whole paramedic practice. [1] Research evidence can be used to promote emergency care providers' professional identity and competence, increase patient safety and bring out the role of the paramedic practice as a source of research topics for nursing science.…”

Section: Introductionmentioning

confidence: 99%

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Non-conveyance of patients: Challenges to decision-making in emergency care

Leikkola¹,

Mikkola²,

Salminen‐Tuomaala

et al. 2016

Clinical Nursing Studies

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Background: It has been suggested that emergency care providers' decision-making competence should be strengthened regarding whether or not to transport the patient. This qualitative study describes challenges related to non-conveyance situations from emergency care providers' perspective. Methods: Data were collected by a questionnaire from emergency care providers of a hospital district in Finland in 2014. Responses to open questions were analyzed using inductive content analysis to examine the difficulty of non-conveyance decisions, reasons for non-conveyance and challenges related to the non-conveyance decision after immediate care. Results: The majority (70%) of care providers did not experienced difficulty in making non-conveyance decisions, although those working in basic emergence care found decision-making slightly more challenging than workers in advanced emergency care. Care providers' reasons for not transporting patients were most commonly connected with their assessment of care needs and the conclusion that no hospital care was required. Other reasons involved treating the patient on site, psychosocial reasons and not seeing the patient as an emergency care client. Difficulty of reaching mutual understanding with patients was considered the greatest challenge. Other challenges included worrying about the patient's coping at home and problems in inter-professional co-operation, related to hurry and the concern that doctors did not always document requests for care instructions. Conclusions: The results suggest that care providers' skills in assessing care needs and making decisions based on assessments are a decisive factor in non-conveyance situations. Reaching a mutual understanding with the patient is the greatest challenge.

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Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Non-conveyance of patients: Challenges to decision-making in emergency care

Leikkola¹,

Mikkola²,

Salminen‐Tuomaala

et al. 2016

Clinical Nursing Studies

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“…Appropriate non-conveyance appears to be based on adequate training as well as confidence. Formal decision-making techniques can be taught to paramedics, but there is also evidence that experience and intuition come into play when first assessing patients, 72 which despite being efficient can sometimes lead to errors because of cognitive bias. 73,74 A major issue for crews, identified as a priority in phase 3, was education and training.…”

Section: Staff Roles Skills and Developmentmentioning

confidence: 99%

A qualitative study of decision-making and safety in ambulance service transitions

O’Hara

Johnson

Hirst³

et al. 2014

Health Services and Delivery Research

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Background: Decisions made by front-line ambulance staff are often time critical and based on limited information, but wrong decisions in this context could have serious consequences for patients. There has been little research carried out in the ambulance service setting to identify areas of risk associated with decisions about patient care.\ud Aim: The aim of this study was to qualitatively examine potential system-wide influences on decision-making in the ambulance service setting and to identify useful areas for future research and intervention.\ud Methods: We used a multisite, multimethod qualitative approach across three ambulance service trusts. In phase 1 we carried out 16 interviews to contextualise the study and provide discussion points for phase 2. For phase 2, university and ambulance service researchers observed paramedics on 34 shifts and 10 paramedics completed ‘digital diaries’ that reported challenges to decision-making or to patient safety. Six focus groups were held, three with staff (n = 21) and three with service users (n = 23). From observation and diary data we developed a typology of decisions made at the scene. Data from these and other sources were also coded within a human factors framework and then thematically analysed to identify influences on those decisions. In phase 3, workshops were held at each site to allow participants and stakeholders (n = 45) to comment on the study findings. Participants were asked to rank influences on decisions using a ‘paired comparison’ method.\ud Results: Interviews provided the context for further qualitative exploration. Nine types of decision were identified from observations and digital diaries, ranging from emergency department conveyance and specialist emergency pathways to non-conveyance. A synthesis of findings from the observations, diaries and staff focus groups revealed seven overarching system influences on decision-making and potential risk factors: meeting increasing demand for emergency care; impacts of performance regime and priorities on service delivery; access to appropriate care options; disproportionate risk aversion; education, training and professional development for crews; communication and feedback to crews; and ambulance service resources. Safety culture issues were also identified. Data from the service user focus groups reflected similar issues to those identified from the staff focus groups. Service user concerns included call handling and communication, triage, patient involvement in decisions, balancing demand, resources, access to care, risk aversion, geographical location and vulnerable patients. Group discussions highlighted a lack of awareness by the public of how best to use emergency and urgent care services. Workshop attendees were satisfied that the findings reflected relevant issues. The two issues ranked highest for warranting attention were staff training and development and access to alternative care.\ud Conclusions: Multiple qualitative methods allowed a range of perspectives to be accessed and validation o...

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“…49 A UK study identified that the non-clinical factors affecting these decisions include experience and confidence of ambulance staff, time into the shift, presence of carers, quality of the accommodation, waiting times at the local ED and prior knowledge of the patient. 50 Ambulance services, with key stakeholders, have been required to develop alternative care pathways, some of which involve the direct referral of older patients who have fallen to primary 51 or community services. 52 This is particularly relevant at a time when pressures on EDs give rise to safety concerns and challenges to demand management; 53 general practice and wider community services are being required to support the ED directly in order to avoid secondary care, in a time of major system reorganisation.…”

Section: Conveyance Rate Of Older Adults Who Fallmentioning

confidence: 99%

Support and Assessment for Fall Emergency Referrals (SAFER) 2: a cluster randomised trial and systematic review of clinical effectiveness and cost-effectiveness of new protocols for emergency ambulance paramedics to assess older people following a fall with referral to community-based care when appropriate

Snooks

Anthony

Chatters

et al. 2017

Health Technol Assess

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Background: Emergency calls are frequently made to ambulance services for older people who have fallen, but ambulance crews often leave patients at the scene without any ongoing care. We evaluated a new clinical protocol which allowed paramedics to assess older people who had fallen and, if appropriate, refer them to community-based falls services.\ud Objectives: To compare outcomes, processes and costs of care between intervention and control groups; and to understand factors which facilitate or hinder use.\ud Design: Cluster randomised controlled trial.\ud Participants: Participating paramedics at three ambulance services in England and Wales were based at stations randomised to intervention or control arms. Participants were aged 65 years and over, attended by a study paramedic for a fall-related emergency service call, and resident in the trial catchment areas.\ud Interventions: Intervention paramedics received a clinical protocol with referral pathway, training and support to change practice. Control paramedics continued practice as normal.\ud Outcomes: The primary outcome comprised subsequent emergency health-care contacts (emergency admissions, emergency department attendances, emergency service calls) or death at 1 month and 6 months. Secondary outcomes included pathway of care, ambulance service operational indicators, self-reported outcomes and costs of care. Those assessing outcomes remained blinded to group allocation.\ud Results: Across sites, 3073 eligible patients attended by 105 paramedics from 14 ambulance stations were randomly allocated to the intervention group, and 2841 eligible patients attended by 110 paramedics from 11 stations were randomly allocated to the control group. After excluding dissenting and unmatched patients, 2391 intervention group patients and 2264 control group patients were included in primary outcome analyses. We did not find an effect on our overall primary outcome at 1 month or 6 months. However, further emergency service calls were reduced at both 1 month and 6 months; a smaller proportion of patients had made further emergency service calls at 1 month (18.5% vs. 21.8%) and the rate per patient-day at risk at 6 months was lower in the intervention group (0.013 vs. 0.017). Rate of conveyance to emergency department at index incident was similar between groups. Eight per cent of trial eligible patients in the intervention arm were referred to falls services by attending paramedics, compared with 1% in the control arm. The proportion of patients left at scene without further care was lower in the intervention group than in the control group (22.6% vs. 30.3%). We found no differences in duration of episode of care or job cycle. No adverse events were reported. Mean cost of the intervention was £17.30 per patient. There were no significant differences in mean resource utilisation, utilities at 1 month or 6 months or quality-adjusted life-years. In total, 58 patients, 25 paramedics and 31 stakeholders participated in focus groups or interviews. Patients were very satisfied ...

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Gaps between policy, protocols and practice: a qualitative study of the views and practice of emergency ambulance staff concerning the care of patients with non-urgent needs

Cited by 55 publications

References 10 publications

Non-conveyance of patients: Challenges to decision-making in emergency care

Non-conveyance of patients: Challenges to decision-making in emergency care

A qualitative study of decision-making and safety in ambulance service transitions

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