Decision-making by ambulance clinicians in London when managing patients with epilepsy: a qualitative study

Burrell, Lisa; Noble, Adam; Ridsdale, Leone

doi:10.1136/emermed-2011-200388

Cited by 61 publications

(98 citation statements)

References 14 publications

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“…A UK-based qualitative study of decision-making in emergency ambulance clinicians identified themes such as lack of experience, patient views, insufficient information, anxiety over litigation, lack of access to the patients' medical records and bystander expectation as factors influencing the rate of transfer to hospital in this group of patients (Burrell et al, 2013). Many paramedics feel transport to hospital is both clinically safer and a lower risk medico-legally.…”

Section: Author Contributionsmentioning

confidence: 99%

“…In the UK, nearly all emergency calls for seizures lead to the dispatch of an ambulance, and a recent study in one UK ambulance study showed that 75% of these patients are transported to hospital (Dickson et al, 2015). Most suspected seizures have stopped by the time the ambulance or paramedics arrive on the scene (Burrell, Noble, & Ridsdale, 2013;Dickson et al, 2017;O'Hara et al, 2015) and many of these patients do not require transport to hospital. 'Reducing the rate of ambulance 999 calls that result in transportation to A&E' is an NHS Commissioning for Quality and Innovation (CQUIN) indicator (NHS England, 2016) and the ambulance service has tried to develop guidelines to support this aim.…”

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confidence: 99%

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An alternative care pathway for suspected seizures in pre-hospital care: a service evaluation

Dickson¹,

Rawlings²,

Grünewald³

et al. 2017

BPJ

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Introduction -An uncomplicated, self-limiting epileptic seizure in a patient with an established diagnosis of epilepsy usually requires only first aid, but in the UK it is estimated that 75% of these patients are transported to hospital and many are discharged without review or follow-up with an epilepsy specialist. Alternative care pathways have the potential to reduce unnecessary conveyance to hospital and to improve rates of epilepsy specialist follow-up, and thereby increase the quality and cost effectiveness of care.Methods -A service evaluation of a new alternative care pathway in a regional ambulance service in the UK. The alternative care pathway allowed paramedics to refer eligible patients to an epilepsy specialist nurse service.

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Section: Author Contributionsmentioning

confidence: 99%

mentioning

confidence: 99%

An alternative care pathway for suspected seizures in pre-hospital care: a service evaluation

Dickson¹,

Rawlings²,

Grünewald³

et al. 2017

BPJ

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“…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 …”

Section: Safety and Decision-makingmentioning

confidence: 99%

“…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 …”

Section: Implementation Of Initiativesmentioning

confidence: 99%

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

Turner

Coster

Chambers

et al. 2015

Health Serv Deliv Res

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BackgroundIn 2013 NHS England set out its strategy for the development of an emergency and urgent care system that is more responsive to patients’ needs, improves outcomes and delivers clinically excellent and safe care. Knowledge about the current evidence base on models for provision of safe and effective urgent care, and the gaps in evidence that need to be addressed, can support this process.ObjectiveThe purpose of the evidence synthesis is to assess the nature and quality of the existing evidence base on delivery of emergency and urgent care services and identify gaps that require further primary research or evidence synthesis.Data sourcesMEDLINE, EMBASE, The Cochrane Library, the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and the Web of Science.MethodsWe have conducted a rapid, framework-based, evidence synthesis approach. Five separate reviews linked to themes in the NHS England review were conducted. One general and five theme-specific database searches were conducted for the years 1995–2014. Relevant systematic reviews and additional primary research papers were included and narrative assessment of evidence quality was conducted for each review.ResultsThe review was completed in 6 months. In total, 45 systematic reviews and 102 primary research studies have been included across all five reviews. The key findings for each review are as follows: (1) demand – there is little empirical evidence to explain increases in demand for urgent care; (2) telephone triage – overall, these services provide appropriate and safe decision-making with high patient satisfaction, but the required clinical skill mix and effectiveness in a system is unclear; (3) extended paramedic roles have been implemented in various health settings and appear to be successful at reducing the number of transports to hospital, making safe decisions about the need for transport and delivering acceptable, cost-effective care out of hospital; (4) emergency department (ED) – the evidence on co-location of general practitioner services with EDs indicates that there is potential to improve care. The attempt to summarise the evidence about wider ED operations proved to be too complex and further focused reviews are needed; and (5) there is no empirical evidence to support the design and development of urgent care networks.LimitationsAlthough there is a large body of evidence on relevant interventions, much of it is weak, with only very small numbers of randomised controlled trials identified. Evidence is dominated by single-site studies, many of which were uncontrolled.ConclusionsThe evidence gaps of most relevance to the delivery of services are (1) a requirement for more detailed understanding and mapping of the characteristics of demand to inform service planning; (2) assessment of the current state of urgent care network development and evaluation of the effectiveness of different models; and (3) expanding the current evidence base on existing interventions that are viewed as central to delivery of the NHS England plan by assessing the implications of increasing interventions at scale and measuring costs and system impact. It would be prudent to develop a national picture of existing pilot projects or interventions in development to support decisions about research commissioning.FundingThe National Institute for Health Research Health Services and Delivery Research Programme.

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“…This is supported by a study of non-conveyance in the ambulance service for epilepsy, where ambulance crew were concerned about litigation and therefore transported people to hospitals. 69 Additionally, hospital admission has been seen as the only option for ED management of people with mental health problems in rural areas in Australia. 70 …”

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confidence: 99%

Explaining variation in emergency admissions: a mixed-methods study of emergency and urgent care systems

O’Cathain

Knowles

Turner

et al. 2014

Health Services and Delivery Research

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BackgroundRecent increases in emergency admission rates have caused concern. Some emergency admissions may be avoidable if services in the emergency and urgent care system are available and accessible. A set of 14 conditions, likely to be rich in avoidable emergency admissions, was identified by expert consensus.ObjectiveWe aimed to understand variation in avoidable emergency admissions between different emergency and urgent care systems in England.MethodsThe design was a sequential mixed-methods study in three phases. In phase 1 we calculated an age- and sex-adjusted avoidable admission rate for 2008–11. We located routine data on characteristics of emergency and urgent care systems and used linear regression to explain variation in avoidable admissions rates in 150 systems. In phase 2 we undertook in-depth case studies in six systems to identify further factors. A key part of these case studies was interviews with commissioners, service providers and patient representatives, totalling 82 interviews. In phase 3 we returned to the linear regression to test further factors identified in the case studies.ResultsThe 14 conditions accounted for 3,273,395 admissions in 2008–11 (22% of all emergency admissions). The mean age- and sex-adjusted admission rate was 2258 per year per 100,000 population, with a 3.4-fold variation between systems (1268–4359). Characteristics of the population explained the majority of variation: deprivation explained 72% of variation, with urban/rural status explaining 3% more. Systems serving populations with high levels of deprivation and in urban areas had high rates of potentially avoidable admissions. Interviewees described the complexity of deprivation, representing high levels of morbidity, low awareness of alternative services to emergency departments and high expressed need for immediate access to urgent care. Factors related to emergency departments (EDs), hospitals, emergency ambulance services and general practice explained a further 10% of variation in avoidable admissions. Systems with high, potentially avoidable, admission rates had high rates of acute beds (suggesting supply-induced demand), high rates of attendance at EDs (which have been associated with poor perceived access to general practice), high rates of conversion from ED attendances to admissions, and low rates of non-transport to emergency departments by emergency ambulances. The six case studies revealed further possible explanations of variation: there was variation in how hospitals coded admissions; some systems focused proactively on admission avoidance whereas others were more interested in hospital discharge, for example use of multidisciplinary teams based at acute trusts; there were different levels of integration between different services such as health and social care, and acute and community trusts; and some systems faced more challenging problems around geographical boundaries operating for different services in the system. Interviewees often described admission as the easy or safe option.ConclusionsDeprivation explained most of the variation in avoidable admission rates. Research is needed to understand the complex relationship between deprivation and avoidable admission, and to develop interventions tailored to avoid admissions from deprived communities. Standardisation of coding of admissions would reduce variation.FundingThe National Institute for Health Research Health Service and Research Delivery programme.

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Decision-making by ambulance clinicians in London when managing patients with epilepsy: a qualitative study

Cited by 61 publications

References 14 publications

An alternative care pathway for suspected seizures in pre-hospital care: a service evaluation

An alternative care pathway for suspected seizures in pre-hospital care: a service evaluation

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

Explaining variation in emergency admissions: a mixed-methods study of emergency and urgent care systems

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