Rachel O'Hara1, Maxine Johnson2, A Niroshan Siriwardena3, Andrew Weyman4, Janette Turner5, Deborah Shaw6, Peter Mortimer7, Chris Newman8, Enid Hirst9, Matthew Storey10, Suzanne Mason11, Tom Quinn12, Jane Shewan13. 1. Lecturer in Public Health, Public Health Section, ScHARR, University of Sheffield, UK r.ohara@sheffield.ac.uk. 2. Research Fellow, Public Health Section, ScHARR, University of Sheffield, UK. 3. Professor of Primary and Prehospital Health Care, Community and Health Research Unit, College of Social Science, University of Lincoln, UK. 4. Senior Lecturer in Psychology, Department of Psychology, University of Bath, UK. 5. Senior Research Fellow, Health Services Research Section, ScHARR, University of Sheffield, UK. 6. Research Manager, East Midlands Ambulance Service NHS Trust, UK. 7. Research & Development Manager, Yorkshire Ambulance Service NHS Trust, UK. 8. Paramedic, South East Coast Ambulance Service NHS Trust, UK. 9. PPI/Service User Representative, Sheffield Emergency Care Forum, UK. 10. Paramedic, Yorkshire Ambulance Service NHS Trust, UK. 11. Professor of Emergency Medicine, Health Services Research Section, ScHARR, University of Sheffield, UK. 12. Professor of Clinical Practice, Faculty of Health and Medical Sciences, University of Surrey, UK. 13. Head of Research & Development, Yorkshire Ambulance Service NHS Trust, UK.
Abstract
OBJECTIVES: Paramedics routinely make critical decisions about the most appropriate care to deliver in a complex system characterized by significant variation in patient case-mix, care pathways and linked service providers. There has been little research carried out in the ambulance service to identify areas of risk associated with decisions about patient care. The aim of this study was to explore systemic influences on decision making by paramedics relating to care transitions to identify potential risk factors. METHODS: An exploratory multi-method qualitative study was conducted in three English National Health Service (NHS) Ambulance Service Trusts, focusing on decision making by paramedic and specialist paramedic staff. Researchers observed 57 staff across 34 shifts. Ten staff completed digital diaries and three focus groups were conducted with 21 staff. RESULTS: Nine types of decision were identified, ranging from emergency department conveyance and specialist emergency pathways to non-conveyance. Seven overarching systemic influences and risk factors potentially influencing decision making were identified: demand; performance priorities; access to care options; risk tolerance; training and development; communication and feedback and resources. CONCLUSIONS: Use of multiple methods provided a consistent picture of key systemic influences and potential risk factors. The study highlighted the increased complexity of paramedic decisions and multi-level system influences that may exacerbate risk. The findings have implications at the level of individual NHS Ambulance Service Trusts (e.g. ensuring an appropriately skilled workforce to manage diverse patient needs and reduce emergency department conveyance) and at the wider prehospital emergency care system level (e.g. ensuring access to appropriate patient care options as alternatives to the emergency department).
OBJECTIVES: Paramedics routinely make critical decisions about the most appropriate care to deliver in a complex system characterized by significant variation in patient case-mix, care pathways and linked service providers. There has been little research carried out in the ambulance service to identify areas of risk associated with decisions about patient care. The aim of this study was to explore systemic influences on decision making by paramedics relating to care transitions to identify potential risk factors. METHODS: An exploratory multi-method qualitative study was conducted in three English National Health Service (NHS) Ambulance Service Trusts, focusing on decision making by paramedic and specialist paramedic staff. Researchers observed 57 staff across 34 shifts. Ten staff completed digital diaries and three focus groups were conducted with 21 staff. RESULTS: Nine types of decision were identified, ranging from emergency department conveyance and specialist emergency pathways to non-conveyance. Seven overarching systemic influences and risk factors potentially influencing decision making were identified: demand; performance priorities; access to care options; risk tolerance; training and development; communication and feedback and resources. CONCLUSIONS: Use of multiple methods provided a consistent picture of key systemic influences and potential risk factors. The study highlighted the increased complexity of paramedic decisions and multi-level system influences that may exacerbate risk. The findings have implications at the level of individual NHS Ambulance Service Trusts (e.g. ensuring an appropriately skilled workforce to manage diverse patient needs and reduce emergency department conveyance) and at the wider prehospital emergency care system level (e.g. ensuring access to appropriate patient care options as alternatives to the emergency department).
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