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

Abstract

Background Head injury (HI) in older adults due to low-energy falls result in a substantial number of emergency department (ED) attendances. However, mortality associated with minor HI is very low. Reducing conveyance to hospital is important for older adults and is a priority for the National Health Service (NHS). Therefore, paramedics are required to make accurate decisions regarding conveyance to the ED. This study used routine data and semi-structured interviews to explore the factors that influence paramedic decision-making when considering whether to convey an adult aged 65 years and over with a minor HI to the ED. Methods Semi-structured telephone interviews were completed with ten UK paramedics from a single EMS (ambulance) provider organisation. Interviews explored the factors influencing the paramedics’ conveyance decision-making in adults aged 65 years and over with a minor HI. Data were initially analysed inductively to develop a thematic framework. A retrospective analysis of ambulance service data was also completed to determine the scope and scale of the issue in Southwest England. An in-depth audit of 100 conveyed patient records was used to determine the proportion of patients conveyed to the ED who met National Institute for Health and Care Excellence (NICE) and Joint Royal Colleges Ambulance Liaison Committee (JRCALC) guidelines. Results In 2019 South Western Ambulance Service NHS Foundation Trust (SWASFT) attended 15,650 emergency calls to patients aged 65 and over with minor HI, with 70.5% conveyed to ED. 81% of conveyed patients met NICE and JRCALC guideline criteria for conveyance, with the remainder conveyed due to wound care or other medical concerns. The framework developed from the interviews comprised four themes: resources; patient factors; consequences; paramedic factors. Important factors included: the patient’s social situation; guidelines; clinical support availability; the history and presentation of the patient; risk. Conclusion This study examined paramedic conveyance decisions for older people with minor HI. It identified multiple influencing factors, highlighting the complex nature of these decisions, and may serve as a basis for developing an intervention to safely decrease ED conveyance in this patient group.

Head injury in older adults presenting to the ambulance service: who do we convey to the emergency department, and what clinical variables are associated with an intracranial bleed? A retrospective case–control study

“…There is limited research on older adults presenting to the ambulance service with head injuries. Nicholson et al [ 9 ] interviewed paramedics (n = 10) on the factors associated with conveyance decision-making; paramedics remarked that the lack of appropriate alternative care pathways, wound management and stringent guidelines make it challenging to non-convey older adults with a head injury. Our study found that older age and cognitive impairment were associated with non-conveyance, perhaps a surrogate marker for frailer older adults where ED services may not be appropriate for these patients.…”

“…While this should be interpreted with caution, there may be a place for ED treatment and review which is beyond the scope of ambulance clinicians. Equally, the literature suggests paramedics would rather access alternative care pathways for their older adult head-injured patients, but these services are unavailable [ 9 ].…”

“…Although ambulance services in England report a non-conveyance rate between 40 and 68% [ 8 ], the conveyance of older adults with a head injury has been reported to be as high as 70% [ 9 ]. Current guidelines available to ambulance clinicians, such as the Joint Royal Colleges' Ambulance Liaison Committee (JRCALC) head injury guidelines, are based on studies conducted in the ED.…”