A qualitative study on conveyance decision-making during emergency call outs to people with dementia: the HOMEWARD project

Abstract

Background: Paramedics are increasingly required to make complex decisions as to whether they should convey a patient to hospital or manage their condition at the scene. Dementia can be a significant barrier to the assessment process. However, to our knowledge no research has specifically examined the process of decision-making by paramedics in relation to people with dementia. This qualitative study was designed to investigate the factors influencing the decision-making process during Emergency Medical Services (EMS) calls to older people with dementia who did not require immediate clinical treatment. Methods: This qualitative study used a combination of observation, interview and document analysis to investigate the factors influencing the decision-making process during EMS calls to older people with dementia. A researcher worked alongside paramedics in the capacity of observer and recruited eligible patients to participate in case studies. Data were collected from observation notes of decision-making during the incident, patient care records and post incident interviews with participants, and analysed thematically. Findings: Four main themes emerged from the data concerning the way that paramedics make conveyance decisions when called to people with dementia: 1) Physical condition; the key factor influencing paramedics' decision-making was the physical condition of the patient. 2) Cognitive capacity; most of the participants preferred not to remove patients with a diagnosis of dementia from surroundings familiar to them, unless they deemed it absolutely essential. 3) Patient circumstances; this included the patient's medical history and the support available to them. 4) Professional influences; participants also drew on other perspectives, such as advice from colleagues or information from the patient's General Practitioner, to inform their decision-making. Conclusion: The preference for avoiding unnecessary conveyance for patients with dementia, combined with difficulties in obtaining an accurate patient medical history and assessment, mean that decision-making can be particularly problematic for paramedics. Further research is needed to find reliable ways of assessing patients and accessing information to support conveyance decisions for EMS calls to people with dementia.

Factors influencing conveyance of older adults with minor head injury by paramedics to the emergency department: a multiple methods study

“…Previous research on paramedic conveyance decisions for persons with dementia found that the person's clinical condition was the key factor [19]. The patient's circumstances, including the support available to them at home, were also recognised as important which reflects the results of this study.…”

“…Participants sometimes found that balancing guidelines and the best interests of the patient could be challenging. This mismatch of guidelines and clinical opinion has been found in previous research on UK paramedic conveyance decisions [19,24]. In particular, some participants reported they felt the NICE HI guidelines were less appropriate for frail patients.…”

Access to Ambulance Services for People with Dementia: A Comprehensive Review of Facts, Challenges, Strategies and Future Scopes

“…This can make it challenging for those individuals to reach a phone to call for an ambulance or to go to the door to let ambulance crews in. Being bedridden or wheelchair-bound in some of these patients can furthermore complicate their ability to access ambulance services [52,53].…”

Advanced paramedics’ restraint decision-making when managing acute behavioural disturbance (ABD) in the UK pre-hospital ambulance setting: A qualitative investigation

“…Research on paramedic decision-making more broadly finds professional vulnerability and a fear of repercussions is a dominant theme with paramedics fearing disciplinary investigation and litigation in relation to managing patients who self-harm [ 14 ]; making non-conveyance decisions [ 18 – 21 ]; and cardiac arrest management [ 22 , 23 ]. More generally, there is anxiety around practice in what has been described as a ‘hostile environment’ of discipline and blame within UK ambulance services [ 24 ].…”