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

Abstract

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...

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

“…Patients and their families also expressed concerns that the risks of telephone triage should be addressed by training staff in communication, and that a lack of awareness of the range of options used by ambulance services might lead to patients expecting conveyance to emergency departments. 12 Within this research there was a sense that patients and their families were happy to have non-conveyance as an option and even preferred it in some situations. This preference for non-conveyance was also found in a qualitative study of patients who called the ambulance service for primary care conditions because they wanted to be treated at home; this was in contrast to calling their general practitioner (GP), who they felt would be likely to send them to hospital.…”

“…The decision to discharge a patient at scene is complex and can be affected by a range of factors, including the high demand for ambulance services, priorities around performance management, access to care options as an alternative to the emergency department, risk tolerance when the least risky option is conveyance to an emergency department, the level of training paramedics receive, and the quality of communication and feedback for paramedics who often make non-conveyance decisions in isolation. 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.…”

What evidence is there on the effectiveness of different models of delivering urgent care? A rapid review

“…The qualitative research studies that have explored in more depth the barriers and facilitators to developing management of patients in the community have highlighted the need to develop robust clinical care and referral pathways for a range of different conditions as alternatives to transport to hospital. Without these pathways and confidence that onward referrals will be actioned, 176 efforts to manage more people at home will be thwarted. Development of pathways is linked to development of robust guidelines and tools to support clinical decision-making at-scene.…”

“…A detailed study on safety and decision-making by ambulance staff highlighted that, as the need to reduce transports to hospital increases, the requirement for appropriate training and education to equip ambulance clinicians for this role also increases. 176 Two studies on decision-making by ambulance staff for patients with epilepsy 174 and elderly fallers 175 both identified a need for additional training and support to aid safe decision-making, as did one Canadian study that focused on out-of-hospital management of patients with long-term conditions. 182 …”

“…Issues about effects of integration with the wider urgent and emergency care system on successful implementation and, in particular, the need to have clear information about patients and about access to alternative care pathways for patients have also been raised. 150,174,176 Other relevant issues identified which impede patient management out of hospital include the conflicting demands of maintaining operational performance and meeting response-time targets (which reduces opportunities for training), barriers between professional groups, a continuing perception that the ambulance service is still primarily a transport service and fear of litigation which is associated with complex decision-making. 174,176 …”