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Alqurashi N, Bell S, Carley SD, Lecky F, Body R. Head Injury Evaluation and Ambulance Diagnosis (HOME) Study protocol: a feasibility study assessing the implementation of the Canadian CT Head Rule in the prehospital setting. BMJ Open 2024; 14:e077191. [PMID: 38862222 PMCID: PMC11168128 DOI: 10.1136/bmjopen-2023-077191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 05/21/2024] [Indexed: 06/13/2024] Open
Abstract
INTRODUCTION Traumatic brain injury (TBI) is a common presentation in the prehospital environment. At present, paramedics do not routinely use tools to identify low-risk patients who could be left at scene or taken to a local hospital rather than a major trauma centre. The Canadian CT Head Rule (CCHR) was developed to guide the use of CT imaging in hospital. It has not been evaluated in the prehospital setting. We aim to address this gap by evaluating the feasibility and acceptability of implementing the CCHR to patients and paramedics, and the feasibility of conducting a full-scale clinical trial of its use. METHODS AND ANALYSIS We will recruit adult patients who are being transported to an emergency department (ED) by ambulance after suffering a mild TBI. Paramedics will prospectively collect data for the CCHR. All patients will be transported to the ED, where deferred consent will be taken and the treating clinician will reassess the CCHR, blinded to paramedic interpretation. The primary clinical outcome will be neurosurgically significant TBI. Feasibility outcomes include recruitment and attrition rates. We will assess acceptability of the CCHR to paramedics using the Ottawa Acceptability of Decision Rules Instrument. Interobserver reliability of the CCHR will be assessed between paramedics and the treating clinician in the ED. Participating paramedics and patients will be invited to participate in semistructured interviews to explore the acceptability of trial processes and facilitators and barriers to the use of the CCHR in practice. Data will be analysed thematically. We anticipate recruiting approximately 100 patients over 6 months. ETHICS AND DISSEMINATION This study was approved by the Health Research Authority and the Research Ethics Committee (REC reference: 22/NW/0358). The results will be published in a peer-reviewed journal, presented at conferences and will be incorporated into a doctoral thesis. TRIAL REGISTRATION NUMBER ISRCTN92566288.
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Affiliation(s)
- Naif Alqurashi
- Division of Cardiovascular Sciences, The University of Manchester, Manchester, UK
- Department of Accidents and Trauma, Prince Sultan bin Abdelaziz College for Emergency Medical Services, King Saud University, Riyadh, Saudi Arabia
| | - Steve Bell
- Medical Directorate, North West Ambulance Service NHS Trust, Bolton, UK
| | - Simon D Carley
- Emergency Department, Manchester University NHS Foundation Trust, Manchester, UK
| | - Fiona Lecky
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Richard Body
- Division of Cardiovascular Sciences, The University of Manchester, Manchester, UK
- Emergency Department, Manchester University NHS Foundation Trust, Manchester, UK
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Bell F, Crabtree R, Wilson C, Miller E, Byrne R. Ambulance service recognition of health inequalities and activities for reduction: An evidence and gap map of the published literature. Br Paramed J 2024; 9:47-57. [PMID: 38946737 PMCID: PMC11210581 DOI: 10.29045/14784726.2024.6.9.1.47] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/02/2024] Open
Abstract
Background Emergency medical services (EMS) are often patients' first point of contact for urgent and emergency care needs. Patients are triaged over the phone and may receive an ambulance response, with potential conveyance to the hospital. A recent scoping review suggested disparities in EMS patient care in the United States. However, it is unknown how health inequalities impact EMS care in other developed countries and how inequalities are being addressed. Objectives This rapid evidence map of published literature aims to map known health inequalities in EMS patients and describe interventions reducing health inequalities in EMS patient care. Methods The search strategy consisted of EMS synonyms and health inequality synonyms. The MEDLINE/PubMed database was searched from 1 January 2010 to 26 July 2022. Studies were included if they described empirical research exploring health inequalities within ambulance service patient care. Studies were mapped on to the EMS care interventions framework and Core20PLUS5 framework. Studies evaluating interventions were synthesised using the United Kingdom Allied Health Professions Public Health Strategic Framework. Results The search strategy yielded 771 articles, excluding duplicates, with two more studies added from hand searches. One hundred studies met the inclusion criteria after full-text review. Inequalities in EMS patient care were predominantly situated in assessment, treatment and conveyance, although triage and response performance were also represented. Studies mostly explored EMS health inequalities within ethnic minority populations, populations with protected characteristics and the core issue of social deprivation. Studies evaluating interventions reducing health inequalities (n = 5) were from outside the United Kingdom and focused on older patients, ethnic minorities and those with limited English proficiency. Interventions included community paramedics, awareness campaigns, dedicated language lines and changes to EMS protocols. Conclusions Further UK-based research exploring health inequalities of EMS patients would support ambulance service policy and intervention development to reduce health inequality in urgent and emergency care delivery.
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Affiliation(s)
- Fiona Bell
- Yorkshire Ambulance Service NHS Trust ORCID iD: https://orcid.org/0000-0003-4503-1903
| | | | - Caitlin Wilson
- Yorkshire Ambulance Service NHS Trust ORCID iD: https://orcid.org/0000-0002-9854-4289
| | - Elisha Miller
- NIHR Coordinating Centre ORCID iD: https://orcid.org/0000-0003-4729-8572
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Hastings C. Is the Calgary-Cambridge Model of consultation a suitable communication tool for students and newly qualified paramedics? A qualitative study. Br Paramed J 2024; 9:23-33. [PMID: 38946736 PMCID: PMC11210582 DOI: 10.29045/14784726.2024.6.9.1.23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/02/2024] Open
Abstract
Introduction The Calgary-Cambridge Model (C-CM), developed by Kurtz and Silverman in 1996, is a communication tool developed for doctors. Since its publication, it has been adopted by various healthcare professionals; however, no previous research has been identified that evaluates its use in paramedic practice. This study aims to explore the experience of students and newly qualified paramedics (NQPs) applying the C-CM in practice, and establish their experiences and perceptions of its suitability as a communication tool in the pre-hospital environment. Methods This MSc research project, conducted in April-May 2021, applied qualitative methods with thematic analysis to written reflections and semi-structured interview transcripts discussing the implementation of C-CM in paramedic practice. A convenience-quota sample of 11 participants, consisting of third-year paramedic students and recent NQPs, were recruited. This research is reported using Consolidated Criteria for Reporting Qualitative Research (COREQ) reporting guidelines. Results Eleven participants were recruited in total; nine consented to reflective writing analysis and interviews, two consented to writing analysis only. Analysis of the writing samples allowed for a deductive approach to the interview plan. Participants consisted of seven males and four females. All eleven participants (ten British and one Indian) spoke English as a first language. Ages ranged from 18 to 59 years. Career status was 46.2% third-year students and 53.8% NQPs. Four major themes were identified: barriers to implementation of the C-CM in practice; impact of C-CM on paramedic practice; C-CM as a teaching and learning tool in paramedic practice; and adaptation of C-CM for paramedic practice. Conclusions Participants suggested that implementation of C-CM leads to improved structure and shared decision-making; however, adaptions to make it more paramedic-focused would be welcomed. The diversity of patients and their preferences can make its implementation challenging, and the negative feedback received from experienced ambulance staff was a significant concern to participants.
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Affiliation(s)
- Claire Hastings
- Sheffield Hallam University ORCID iD: https://orcid.org/0009-0003-4139-0981
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Noble AJ, Morris B, Dixon P, Mathieson A, Ridsdale L, Morgan M, Dickson J, Goodacre S, Jackson M, Hughes D, Marson A, Holmes E. Service users' preferences and feasibility - which alternative care pathway for adult ambulance users achieves the optimal balance? Workshops for the COLLABORATE project. Seizure 2024; 118:17-27. [PMID: 38613878 DOI: 10.1016/j.seizure.2024.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 04/08/2024] [Accepted: 04/10/2024] [Indexed: 04/15/2024] Open
Abstract
INTRODUCTION Adults presenting to the ambulance service for diagnosed epilepsy are often transported to emergency departments (EDs) despite no clinical need. An alternative care pathway (CP) could allow paramedics to divert them from ED and instigate ambulatory care improvements. To identify the most promising CP configuration for subsequent testing, the COLLABORATE project surveyed people with epilepsy and family/friends who had recently used the English ambulance service to elicit preferences for 288 CP configurations for different seizures. This allowed CPs to be ranked according to alignment with service users' preferences. However, as well as being acceptable to users, a CP must be feasible. We thus engaged with paramedics, epilepsy specialists and commissioners to identify the optimal configuration. METHODS Three Knowledge Exchange workshops completed. Participants considered COLLABORATE's evidence on service users' preferences for the different configurations. Nominal group techniques elicited views on the feasibility of users' preferences according to APEASE criteria. Workshop groups specified the configuration/s considered optimum. Qualitative data was analysed thematically. Utility to users of the specified CP configurations estimated using the COLLABORATE preference survey data. RESULTS Twenty-seven participants found service users' preferences broadly feasible and outlined delivery recommendations. They identified enough commonality in preferences for different seizures to propose a single CP. Its configuration comprised: 1) patients staying where they were; 2) paramedics having access to medical records; 3) care episodes lasting <6 h; 4) paramedics receiving specialist advice on the day; 5) patient's GP being notified; and 6) a follow-up appointment being arranged with an epilepsy specialist. Preference data indicated higher utility for this configuration compared to current care. DISCUSSION Stakeholders are of the view that the CP configuration favoured by service users could be NHS feasible. It should be developed and evaluated.
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Affiliation(s)
- Adam J Noble
- Department of Public Health, Policy and Systems, University of Liverpool, Liverpool, UK.
| | - Beth Morris
- Department of Public Health, Policy and Systems, University of Liverpool, Liverpool, UK
| | - Pete Dixon
- Department of Public Health, Policy and Systems, University of Liverpool, Liverpool, UK
| | - Amy Mathieson
- Department of Public Health, Policy and Systems, University of Liverpool, Liverpool, UK; Centre for Primary Care and Health Services Research, University of Manchester, UK
| | - Leone Ridsdale
- Department of Basic and Clinical Neuroscience, King's College London, London, UK
| | - Myfanwy Morgan
- Institute of Pharmaceutical Science, King's College London, UK
| | - Jon Dickson
- Academic Unit of Primary Medical Care, University of Sheffield, UK
| | - Steve Goodacre
- School of Health and Related Research, University of Sheffield, UK
| | - Mike Jackson
- North West Ambulance Service NHS Trust, Bolton, UK
| | - Dyfrig Hughes
- Centre for Health Economics & Medicines Evaluation, North Wales Medical School, Bangor University, UK; Department of Pharmacology and Therapeutics, University of Liverpool, UK
| | - Anthony Marson
- Department of Pharmacology and Therapeutics, University of Liverpool, UK
| | - Emily Holmes
- Centre for Health Economics & Medicines Evaluation, North Wales Medical School, Bangor University, UK; Department of Pharmacology and Therapeutics, University of Liverpool, UK
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Noble AJ, Morris B, Bonnett LJ, Reuber M, Mason S, Wright J, Pilbery R, Bell F, Shillito T, Marson AG, Dickson JM. 'Knowledge exchange' workshops to optimise development of a risk prediction tool to assist conveyance decisions for suspected seizures - Part of the Risk of ADverse Outcomes after a Suspected Seizure (RADOSS) project. Epilepsy Behav 2024; 151:109611. [PMID: 38199055 DOI: 10.1016/j.yebeh.2023.109611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Revised: 12/21/2023] [Accepted: 12/22/2023] [Indexed: 01/12/2024]
Abstract
PURPOSE Suspected seizures present challenges for ambulance services, with paramedics reporting uncertainty over whether or not to convey individuals to emergency departments. The Risk of ADverse Outcomes after a Suspected Seizure (RADOSS) project aims to address this by developing a risk assessment tool utilizing structured patient care record and dispatch data. It proposes a tool that would provide estimates of an individual's likelihood of death and/or recontact with emergency care within 3 days if conveyed compared to not conveyed, and the likelihood of an 'avoidable attendance' occurring if conveyed. Knowledge Exchange workshops engaged stakeholders to resolve key design uncertainties before model derivation. METHOD Six workshops involved 26 service users and their significant others (epilepsy or nonepileptic attack disorder), and 25 urgent and emergency care clinicians from different English ambulance regions. Utilizing Nominal Group Techniques, participants shared views of the proposed tool, benefits and concerns, suggested predictors, critiqued outcome measures, and expressed functionality preferences. Data were analysed using Hamilton's Rapid Analysis. RESULTS Stakeholders supported tool development, proposing 10 structured variables for predictive testing. Emphasis was placed on the tool supporting, not dictating, care decisions. Participants highlighted some reasons why RADOSS might struggle to derive a predictive model based on structured data alone and suggested some non-structured variables for future testing. Feedback on prediction timeframes for service recontact was received, along with advice on amending the 'avoidable attendance' definition to prevent the tool's predictions being undermined by potential overuse of certain investigations in hospital. CONCLUSION Collaborative stakeholder engagement provided crucial insights that can guide RADOSS to develop a user-aligned, optimized tool.
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Affiliation(s)
- Adam J Noble
- Department of Public Health, Policy and Systems, Institute of Population Health, University of Liverpool, Liverpool, UK.
| | - Beth Morris
- Department of Public Health, Policy and Systems, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Laura J Bonnett
- Department of Health Data Science, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Markus Reuber
- Department of Neuroscience, School of Medicine and Population Health, University of Sheffield, Sheffield, UK
| | - Suzanne Mason
- Sheffield Centre for Health and Related Research, School of Medicine and Population Health, University of Sheffield, Sheffield, UK
| | | | | | - Fiona Bell
- Yorkshire Ambulance Service NHS Trust, Wakefield, UK
| | | | - Anthony G Marson
- Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Jon M Dickson
- Population Health, School of Medicine and Population Health, The University of Sheffield, Sheffield, UK
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Agarwal G, Siriwardena AN, McLeod B, Spaight R, Whitley GA, Ferron R, Pirrie M, Angeles R, Moore H, Gussy M. Development of indicators for avoidable emergency medical service calls by mapping paramedic clinical impression codes to ambulatory care sensitive conditions and mental health conditions in the UK and Canada. BMJ Open 2023; 13:e073520. [PMID: 38086589 PMCID: PMC10729076 DOI: 10.1136/bmjopen-2023-073520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 11/19/2023] [Indexed: 12/18/2023] Open
Abstract
OBJECTIVE Paramedic assessment data have not been used for research on avoidable calls. Paramedic impression codes are designated by paramedics on responding to a 911/999 medical emergency after an assessment of the presenting condition. Ambulatory care sensitive conditions (ACSCs) are non-acute health conditions not needing hospital admission when properly managed. This study aimed to map the paramedic impression codes to ACSCs and mental health conditions for use in future research on avoidable 911/999 calls. DESIGN Mapping paramedic impression codes to existing definitions of ACSCs and mental health conditions. SETTING East Midlands Region, UK and Southern Ontario, Canada. PARTICIPANTS Expert panel from the UK-Canada Emergency Calls Data analysis and GEospatial mapping (EDGE) Consortium. RESULTS Mapping was iterative first identifying the common ACSCs shared between the two countries then identifying the respective clinical impression codes for each country that mapped to those shared ACSCs as well as to mental health conditions. Experts from the UK-Canada EDGE Consortium contributed to both phases and were able to independently match the codes and then compare results. Clinical impression codes for paramedics in the UK were more extensive than those in Ontario. The mapping revealed some interesting inconsistencies between paramedic impression codes but also demonstrated that it was possible. CONCLUSION This is an important first step in determining the number of ASCSs and mental health conditions that paramedics attend to, and in examining the clinical pathways of these individuals across the health system. This work lays the foundation for international comparative health services research on integrated pathways in primary care and emergency medical services.
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Affiliation(s)
- Gina Agarwal
- Department of Family Medicine, Hamilton, Hamilton, Ontario, Canada
| | | | - Brent McLeod
- Hamilton Paramedic Service, Hamilton, Ontario, Canada
| | | | | | - Richard Ferron
- Niagara Emergency Medical Services, Niagara, Ontario, Canada
| | - Melissa Pirrie
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Ricardo Angeles
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
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Barrett JW, Williams J, Skene SS, Griggs JE, Bootland D, Leung J, Da Costa A, Ballantyne K, Davies R, Lyon RM. 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. Scand J Trauma Resusc Emerg Med 2023; 31:65. [PMID: 37908011 PMCID: PMC10619243 DOI: 10.1186/s13049-023-01138-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 10/18/2023] [Indexed: 11/02/2023] Open
Abstract
OBJECTIVE Most older adults with traumatic brain injuries (TBI) reach the emergency department via the ambulance service. Older adults, often with mild TBI symptoms, risk being under-triaged and facing poor outcomes. This study aimed to identify whether sufficient information is available on the scene to an ambulance clinician to identify an older adult at risk of an intracranial haemorrhage following a head injury. METHODS This was a retrospective case-control observational study involving one regional ambulance service in the UK and eight emergency departments. 3545 patients aged 60 years and over presented to one regional ambulance service with a head injury between the 1st of January 2020 and the 31st of December 2020. The primary outcome was an acute intracranial haemorrhage on head computed tomography (CT) scan in patients conveyed to the emergency department (ED). A secondary outcome was factors associated with conveyance to the ED by the ambulance clinician. RESULTS In 2020, 2111 patients were conveyed to the ED and 162 patients were found to have an intracranial haemorrhage on their head CT scan. Falls from more than 2 m (adjusted odds ratio (aOR) 3.45, 95% CI 1.78-6.40), chronic kidney disease (CKD) (aOR 2.80, 95% CI 1.25-5.75) and Clopidogrel (aOR 1.98, 95% CI 1.04-3.59) were associated with an intracranial haemorrhage. Conveyance to the ED was associated with patients taking anticoagulant and antiplatelet medication or a visible head injury or head injury symptoms. CONCLUSION This study highlights that while most older adults with a head injury are conveyed to the ED, only a minority will have an intracranial haemorrhage following their head injury. While mechanisms of injury such as falls from more than 2 m remain a predictor, this work highlights that Clopidogrel and CKD are also associated with an increased odds of tICH in older adults following a head injury. These findings may warrant a review of current ambulance head injury guidelines.
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Affiliation(s)
- J W Barrett
- South East Coast Ambulance Service NHS FT, Crawley, UK.
- University of Surrey, Guildford, UK.
| | - J Williams
- South East Coast Ambulance Service NHS FT, Crawley, UK
- Paramedic Clinical Research Unit, University of Hatfield, Hatfield, UK
| | | | - J E Griggs
- University of Surrey, Guildford, UK
- Air Ambulance Charity Kent, Surrey and Sussex, Redhill, UK
| | - D Bootland
- Air Ambulance Charity Kent, Surrey and Sussex, Redhill, UK
- University Hospitals Sussex NHS Foundation Trust, Worthing, UK
| | - J Leung
- Air Ambulance Charity Kent, Surrey and Sussex, Redhill, UK
- East Kent Hospitals University NHS Foundation Trust, Canterbury, UK
| | - A Da Costa
- Medway Maritime Hospital NHS FT, Gillingham, UK
| | - K Ballantyne
- East Kent Hospitals University NHS Foundation Trust, Canterbury, UK
| | - R Davies
- South East Coast Ambulance Service NHS FT, Crawley, UK
| | - R M Lyon
- University of Surrey, Guildford, UK
- Air Ambulance Charity Kent, Surrey and Sussex, Redhill, UK
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Wolthers SA, Blomberg SNF, Breindahl N, Anjum S, Hägi-Pedersen D, Ersbøll A, Andersen LB, Christensen HC. Association between using a prehospital assessment unit and hospital admission and mortality: a matched cohort study. BMJ Open 2023; 13:e075592. [PMID: 37739475 PMCID: PMC10533654 DOI: 10.1136/bmjopen-2023-075592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 09/04/2023] [Indexed: 09/24/2023] Open
Abstract
OBJECTIVES This study aimed to compare hospital admission and 30-day mortality between patients assessed by the prehospital assessment unit (PAU) and patients not assessed by the PAU. DESIGN This was a matched cohort study. SETTING This study was conducted between November 2021 and October 2022 in Region Zealand, Denmark. PARTICIPANTS 989 patients aged >18, assessed by the PAU, were identified, and 9860 patients not assessed by the PAU were selected from the emergency calls using exposure density sampling. EXPOSURE Patients assessed by the PAU. The PAU is operated by paramedics with access to point-of-care test facilities. The PAU is an alternative response vehicle without the capability of transporting patients. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome was hospital admission within 48 hours after the initial call. The key secondary outcomes were admission within 7 days, 30-day mortality and admission within 6 hours. Descriptive statistical analyses were conducted, and logistic regression models were used to estimate adjusted OR (aOR) and 95% CI. RESULTS Among the PAU assessed, 44.1% were admitted within 48 hours, compared with 72.9% of the non-PAU assessed, p<0.001. The multivariable analysis showed a lower risk of admission within 48 hours and 7 days among the PAU patients, aOR 0.31 (95% CI 0.26 to 0.38) and aOR 0.50 (95% CI 0.38 to 0.64), respectively. The 30-day mortality rate was 3.8% in the PAU-assessed patients vs 5.5% in the non-PAU-assessed patients, p=0.03. In the multivariable analysis, no significant difference was found in mortality aOR 0.99 (95% CI 0.71 to 1.42). No deaths were observed in PAU-assessed patients without subsequent follow-up. CONCLUSION The recently introduced PAU aims for patient-centred emergency care. The PAU-assessed patients had reduced admissions within 48 hours and 7 days after the initial call. Study findings indicate that the PAU is safe since we identified no significant differences in 30-day mortality. TRIAL REGISTRATION NUMBER NCT05654909.
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Affiliation(s)
- Signe Amalie Wolthers
- Prehospital Center, Region Zealand, Naestved, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | | | - Niklas Breindahl
- Prehospital Center, Region Zealand, Naestved, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Sair Anjum
- Department of Anaesthesiology, Slagelse University Hospital, Slagelse, Denmark
| | | | - Annette Ersbøll
- University of Southern Denmark National Institute of Public Health, Copenhagen, Denmark
| | | | - Helle Collatz Christensen
- Prehospital Center, Region Zealand, Naestved, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Wilson C, Janes G, Lawton R, Benn J. Feedback for Emergency Ambulance Staff: A National Review of Current Practice Informed by Realist Evaluation Methodology. Healthcare (Basel) 2023; 11:2229. [PMID: 37628427 PMCID: PMC10454701 DOI: 10.3390/healthcare11162229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 07/27/2023] [Accepted: 08/07/2023] [Indexed: 08/27/2023] Open
Abstract
Research suggests that feedback in Emergency Medical Services (EMS) positively affects quality of care and professional development. However, the mechanisms by which feedback achieves its effects still need to be better understood across healthcare settings. This study aimed to understand how United Kingdom (UK) ambulance services provide feedback for EMS professionals and develop a programme theory of how feedback works within EMS, using a mixed-methods, realist evaluation framework. A national cross-sectional survey was conducted to identify feedback initiatives in UK ambulance services, followed by four in-depth case studies involving qualitative interviews and documentary analysis. We used qualitative content analysis and descriptive statistics to analyse survey responses from 40 prehospital feedback initiatives, alongside retroductive analysis of 17 interviews and six documents from case study sites. Feedback initiatives mainly provided individual patient outcome feedback through "pull" initiatives triggered by staff requests. Challenges related to information governance were identified. Our programme theory of feedback to EMS professionals encompassed context (healthcare professional and organisational characteristics), mechanisms (feedback and implementation characteristics, psychological reasoning) and outcomes (implementation, staff and service outcomes). This study suggests that most UK ambulance services use a range of feedback initiatives and provides 24 empirically based testable hypotheses for future research.
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Affiliation(s)
- Caitlin Wilson
- School of Psychology, University of Leeds, Leeds LS2 9JT, UK
- Research and Development Department, Yorkshire Ambulance Service NHS Trust, Wakefield WF2 0XQ, UK
- Yorkshire Quality and Safety Research Group, Bradford Institute for Health Research, Bradford BD9 6RJ, UK
| | - Gillian Janes
- Faculty of Health and Education, Manchester Metropolitan University, Manchester M15 6BH, UK
| | - Rebecca Lawton
- School of Psychology, University of Leeds, Leeds LS2 9JT, UK
- Yorkshire Quality and Safety Research Group, Bradford Institute for Health Research, Bradford BD9 6RJ, UK
| | - Jonathan Benn
- School of Psychology, University of Leeds, Leeds LS2 9JT, UK
- Yorkshire Quality and Safety Research Group, Bradford Institute for Health Research, Bradford BD9 6RJ, UK
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Appelboam A, Osborne R, Ukoumunne O, Black S, Boot S, Richards N, Scotney N, Rhodes S, Cranston T, Hawker R, Gillett A, Jones B, Hawton A, Dayer M, Creanor S. Evaluation of the prehospital use of a Valsalva assist device in the emergency treatment of supraventricular tachycardia (EVADE SVT): study protocol for a stepped wedge cluster randomised controlled trial. BMJ Open 2023; 13:e073315. [PMID: 37290949 PMCID: PMC10255124 DOI: 10.1136/bmjopen-2023-073315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 04/21/2023] [Indexed: 06/10/2023] Open
Abstract
INTRODUCTION Patients with episodes of supraventricular tachycardia (SVT), a common heart arrhythmia, are often attended by ambulance services. International guidelines advocate treatment with the Valsalva manoeuvre (VM), but this simple physical treatment has a low success rate, with most patients requiring conveyance to hospital. The Valsalva Assist Device (VAD) is a simple device that might help practitioners and patients perform a more effective VM and reduce the need for patients to be taken to hospital. METHODS AND ANALYSIS This stepped wedge cluster randomised controlled trial, conducted within a UK ambulance service, compares the current standard VM with a VAD-delivered VM in stable adult patients presenting to the ambulance service with SVT. The primary outcome is conveyance to hospital; secondary outcomes measures include cardioversion rates, duration of ambulance care and number of subsequent episodes of SVT requiring ambulance service care. We plan to recruit approximately 800 patients, to have 90% power to detect an absolute reduction in conveyance rate of 10% (from 90% to 80%) between the standard VM (control) and VAD-delivered VM (intervention). Such a reduction in conveyance would benefit patients, the ambulance service and receiving emergency departments. It is estimated potential savings would pay for devices for the entire ambulance trust within 7 months. ETHICS AND DISSEMINATION The study has been approved by the Oxford Research Ethics Committee (reference 22/SC/0032). Dissemination will be through peer-reviewed journal publication, presentation at national and international conferences and by the Arrhythmia Alliance, a patient support charity. TRIAL REGISTRATION NUMBER ISRCTN16145266.
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Affiliation(s)
- Andrew Appelboam
- Medical School, University of Exeter, Exeter, UK
- Academic Department of Emergency Medicine, Royal Devon University Healthcare NHS Foundation Trust, Exeter, Devon, UK
| | - Ria Osborne
- Research, Audit and Improvement, South Western Ambulance Service NHS Foundation Trust, Exeter, UK
| | - Obioha Ukoumunne
- NIHR ARC South West Peninsula (PenARC), University of Exeter, Exeter, UK
| | - Sarah Black
- Research, Audit and Improvement, South Western Ambulance Service NHS Foundation Trust, Exeter, UK
| | - Suzanne Boot
- South Western Ambulance Service NHS Foundation Trust, Exeter, UK
| | | | - Natalie Scotney
- South Western Ambulance Service NHS Foundation Trust, Exeter, UK
| | - Shelley Rhodes
- Exeter Clinical Trials Unit, University of Exeter Medical School, Exeter, UK
| | - Tim Cranston
- Exeter Clinical Trials Unit, University of Exeter Medical School, Exeter, UK
| | - Ruth Hawker
- PPI Representative, honorary SWASFT contract, South Western Ambulance Service NHS Foundation Trust, Exeter, UK
| | - Annette Gillett
- Peninsula Childhood Disability Research Unit (PenCRU), University of Exeter Medical School, Exeter, UK
| | - Ben Jones
- Exeter Clinical Trials Unit, University of Exeter Medical School, Exeter, UK
| | - Annie Hawton
- NIHR ARC South West Peninsula (PenARC), University of Exeter, Exeter, UK
- Health Economics Group, University of Exeter, Exeter, Devon, UK
| | - Mark Dayer
- Cardiology, Taunton and Somerset NHS Foundation Trust, Taunton, UK
- Faculty of Health, University of Plymouth, Plymouth, UK
| | - Siobhan Creanor
- Exeter Clinical Trials Unit, University of Exeter Medical School, Exeter, UK
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11
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Nielsen VML, Lindskou TA, Weinreich UM, Jespersen MS, Christensen EF, Bøggild H. Decision on non-conveyance of patients suspected of COVID-19 in a novel arrangement with assessment visits by paramedics at home. BMC Emerg Med 2023; 23:56. [PMID: 37237344 DOI: 10.1186/s12873-023-00826-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 05/17/2023] [Indexed: 05/28/2023] Open
Abstract
BACKGROUND During the first weeks of the outbreak of the coronavirus disease 2019 (COVID-19), the North Denmark emergency medical services authorised paramedics to assess patients suspected of COVID-19 at home, and then decide if conveyance to a hospital was required. The aim of this study was to describe the cohort of patients who were assessed at home and their outcomes in terms of subsequent hospital visits and short-term mortality. METHODS This was a historical cohort study in the North Denmark Region with consecutive inclusion of patients suspected of COVID-19 who were referred to a paramedic's assessment visit by their general practitioner or an out-of-hours general practitioner. The study was conducted from 16 March to 20 May 2020. The outcomes were the proportion of non-conveyed patients who subsequently visited a hospital within 72 hours of the paramedic's assessment visit and mortality at 3, 7 and 30 days. Mortality was estimated using a Poisson regression model with robust variance estimation. RESULTS During the study period, 587 patients with a median age of 75 (IQR 59-84) years were referred to a paramedic's assessment visit. Three of four patients (76.5%, 95% CI 72.8;79.9) were non-conveyed, and 13.1% (95% CI 10.2;16.6) of the non-conveyed patients were subsequently referred to a hospital within 72 hours of the paramedic's assessment visit. Within 30 days from the paramedic's assessment visit, mortality was 11.1% [95% CI 6.9;17.9] among patients directly conveyed to a hospital and 5.8% [95% CI 4.0;8.5] among non-conveyed patients. Medical record review revealed that deaths in the non-conveyed group had happened among patients with 'do-not-resuscitate' orders, palliative care plans, severe comorbidities, age ≥ 90 years or nursing home residents. CONCLUSIONS The majority (87%) of the non-conveyed patients did not visit a hospital for the following three days after a paramedic's assessment visit. The study implies that this newly established prehospital arrangement served as a kind of gatekeeper for the region's hospitals in regard to patients suspected of COVID-19. The study also demonstrates that implementation of non-conveyance protocols should be accompanied by careful and regular evaluation to ensure patient safety.
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Affiliation(s)
- Vibe Maria Laden Nielsen
- Centre for Prehospital and Emergency Research, Aalborg University Hospital, Aalborg, Denmark.
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
| | - Tim Alex Lindskou
- Centre for Prehospital and Emergency Research, Aalborg University Hospital, Aalborg, Denmark
| | - Ulla Møller Weinreich
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Department of Respiratory Diseases, Aalborg University Hospital, Aalborg, Denmark
| | | | - Erika Frischknecht Christensen
- Centre for Prehospital and Emergency Research, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Prehospital Emergency Services, North Denmark Region, Aalborg, Denmark
| | - Henrik Bøggild
- Public Health and Epidemiology, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
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12
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Greene JA, Goldstein J, Stirling J, Swain JM, Brown R, McVey J, Carter A. Clinical Roles in the Medical Communications Centre: A Rapid Scoping Review. Cureus 2023; 15:e39441. [PMID: 37362545 PMCID: PMC10289204 DOI: 10.7759/cureus.39441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 05/22/2023] [Indexed: 06/28/2023] Open
Abstract
In recent years, 911 call volumes have increased, and emergency medical services (EMS) are routinely stretched beyond capacity. To better match resources with patient needs, some EMS systems have integrated clinician roles into the emergency medical communications centre (MCC). Our objective was to explore the nature and scope of clinical roles in emergency MCCs. Using a rapid scoping review methodology, we searched PubMed for studies related to any clinical role employed within an emergency MCC. We accepted reviews, experimental and observational designs, as well as expert opinions. Studies reporting on dispatcher recognition and pre-arrival instructions were excluded. Title and abstract screening were conducted by a single reviewer, included studies were verified by two reviewers, and data extraction was completed in duplicate, all using Covidence review software. The level of evidence was assessed using the prehospital evidence-based practice (PEP) scale. The protocol was registered in Open Science Framework (10.17605/OSF.IO/NX4T8). Our search yielded 1071 titles, and four were added from other sources; 44 studies were reviewed at the full-text stage and 31 were included. The included studies were published from 2002 to 2022 and represent 17 countries. Studies meeting inclusion criteria consisted of level I (n=4, 11%), II (n=13, 37%), and III (N=6, 17%) methodologies, as well as 12 other studies (34%) with qualitative or other designs. Most of the included studies reported systems that employ nurses in the MCC (n=29, 83%). Twelve (34%) studies reported on the inclusion of paramedics in the MCC, and five (14%) reported physician involvement. The roles of these clinicians chiefly consisted of triage (n=25, 71%), advice (n=20, 57%), referral to non-emergency care (n=14, 40%), and peer-to-peer consulting (n=2, 4%). Alternative dispositions (as opposed to emergency ambulance transport) for low acuity callers included self-care, as well as referral to a general practitioner, pharmacist, or other outreach programs. There is a wide range of literature reporting on clinical roles integrated within MCCs. Our findings revealed that MCC nurses, physicians, and paramedics assist substantively with triage, advice, and referrals to better match resources to patient needs, with or without the requirement for ambulance dispatch.
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Affiliation(s)
| | | | | | - Janel M Swain
- Emergency Health Services, Nova Scotia, Dartmouth, CAN
| | - Ryan Brown
- Interprofessional Practice and Learning, Nova Scotia Health, Sydney, CAN
- Emergency Medicine, Dalhousie University, Halifax, CAN
| | | | - Alix Carter
- Emergency Medicine, Dalhousie University, Halifax, CAN
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13
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Carnicelli A, Edwards DG, Williams AM. Paramedic Education to Support the Use of Low-Acuity Care Pathways: A Scoping Review Protocol. NURSING REPORTS 2023; 13:265-272. [PMID: 36810276 PMCID: PMC9944786 DOI: 10.3390/nursrep13010025] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 02/06/2023] [Accepted: 02/10/2023] [Indexed: 02/16/2023] Open
Abstract
Ambulance services worldwide have transformed over time into health care services that not only attend to life-threatening emergencies, but are also increasingly being utilised for patients with low-acuity or non-urgent illness and injury. As a result, there has been a need to adapt and include mechanisms to assist paramedics in the assessment and management of such patients, including alternative pathways of care. However, it has been identified that education and training for paramedics in the care of low-acuity patients is limited. This study aims to identify potential gaps in the literature and inform further research, paramedic education and training, patient care guidelines, and policy. A scoping review will be conducted utilising the Joanna Briggs Institutes methodology. A range of relevant electronic databases will be searched along with the grey literature, using search terms related to paramedic education for low-acuity patient care pathways. The search results will be screened by two authors and presented in the PRISMA-ScR format, with articles presented in tabular format and analysed thematically. The results of this scoping review will inform further research exploring paramedic education, clinical guidelines, policy and experiences in the management of low-acuity patients.
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Affiliation(s)
- Anthony Carnicelli
- Tasmanian School of Medicine, College of Health and Medicine, University of Tasmania, Hobart, TAS 7000, Australia
- Correspondence:
| | - Dale G. Edwards
- School of Paramedicine, College of Health and Medicine, University of Tasmania, Hobart, TAS 7000, Australia
| | - Anne-Marie Williams
- Tasmanian School of Medicine, College of Health and Medicine, University of Tasmania, Hobart, TAS 7000, Australia
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14
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Noble AJ, Mason SM, Bonnett LJ, Reuber M, Wright J, Pilbery R, Jacques RM, Simpson RM, Campbell R, Fuller A, Marson AG, Dickson JM. Supporting the ambulance service to safely convey fewer patients to hospital by developing a risk prediction tool: Risk of Adverse Outcomes after a Suspected Seizure (RADOSS)-protocol for the mixed-methods observational RADOSS project. BMJ Open 2022; 12:e069156. [PMID: 36375988 PMCID: PMC9668054 DOI: 10.1136/bmjopen-2022-069156] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Ambulances services are asked to further reduce avoidable conveyances to emergency departments (EDs). Risk of Adverse Outcomes after a Suspected Seizure seeks to support this by: (1) clarifying the risks of conveyance and non-conveyance, and (2) developing a risk prediction tool for clinicians to use 'on scene' to estimate the benefits an individual would receive if conveyed to ED and risks if not. METHODS AND ANALYSIS Mixed-methods, multi-work package (WP) project. For WP1 and WP2 we shall use an existing linked data set that tracks urgent and emergency care (UEC) use of persons served by one English regional ambulance service. Risk tools are specific to clinical scenarios. We shall use suspected seizures in adults as an exemplar.WP1: Form a cohort of patients cared for a seizure by the service during 2019/2020. It, and nested Knowledge Exchange workshops with clinicians and service users, will allow us to: determine the proportions following conveyance and non-conveyance that die and/or recontact UEC system within 3 (/30) days; quantify the proportion of conveyed incidents resulting in 'avoidable ED attendances' (AA); optimise risk tool development; and develop statistical models that, using information available 'on scene', predict the risk of death/recontact with the UEC system within 3 (/30) days and the likelihood of an attendance at ED resulting in an AA.WP2: Form a cohort of patients cared for a seizure during 2021/2022 to 'temporally' validate the WP1 predictive models.WP3: Complete the 'next steps' workshops with stakeholders. Using nominal group techniques, finalise plans to develop the risk tool for clinical use and its evaluation. ETHICS AND DISSEMINATION WP1a and WP2 will be conducted under database ethical approval (IRAS 307353) and Confidentiality Advisory Group (22/CAG/0019) approval. WP1b and WP3 have approval from the University of Liverpool Central Research Ethics Committee (11450). We shall engage in proactive dissemination and knowledge mobilisation to share findings with stakeholders and maximise evidence usage.
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Affiliation(s)
- Adam J Noble
- Department of Public Health, Policy and Systems, University of Liverpool, Liverpool, UK
| | - Suzanne M Mason
- School of Health and Related Research, The University of Sheffield, Sheffield, UK
| | - Laura J Bonnett
- Department of Health Data Science, University of Liverpool, Liverpool, UK
| | - Markus Reuber
- Academic Neurology Unit, The University of Sheffield, Sheffield, UK
| | | | - Richard Pilbery
- Research and Development Department, Yorkshire Ambulance Service NHS Trust, Wakefield, UK
| | - Richard M Jacques
- School of Health and Related Research, The University of Sheffield, Sheffield, UK
| | - Rebecca M Simpson
- School of Health and Related Research, The University of Sheffield, Sheffield, UK
| | - Richard Campbell
- School of Health and Related Research, The University of Sheffield, Sheffield, UK
| | | | - Anthony Guy Marson
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Jon Mark Dickson
- Academic Unit of Primary Medical Care, The University of Sheffield, Sheffield, UK
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15
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Green K, Micocci M, Hicks T, Winter A, Martin JE, Shinkins B, Shaw L, Price C, Davies K, Allen JA. Perceived feasibility, facilitators and barriers to incorporating point-of-care testing for SARS-CoV-2 into emergency medical services by ambulance service staff: a survey-based approach. BMJ Open 2022; 12:e064038. [PMID: 36328389 PMCID: PMC9638752 DOI: 10.1136/bmjopen-2022-064038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVES This body of work aimed to elicit ambulance service staff's perceptions on the barriers and facilitators to adoption, and clinical utility of incorporating rapid SARS-CoV-2 testing during ambulance assessments. DESIGN A mixed-methods survey-based project using a framework analysis method to organise qualitative data. SETTING Emergency and non-emergency care ambulatory services in the UK were approached to take part. PARTICIPANTS Current, practising members of the UK ambulance service (paramedics, technicians, assistants and other staff) were included in this body of work. RESULTS Survey 1: 226 responses were collected between 3 December 2020 and 11 January 2021, 179 (79.2%) of which were completed in full. While the majority of respondents indicated that an ambulance-based testing strategy was feasible in concept (143/190, 75.3%), major barriers to adoption were noted. Many open-ended responses cited concerns regarding misuse of the service by the general public and other healthcare services, timing and conveyance issues, and increased workloads, alongside training and safety concerns. Survey 2: 26 responses were received between 8 February 2021 and 22 February 2021 to this follow-up survey. Survey 2 revealed conveyance decision-making, and risk stratification to be the most frequently prioritised use cases among ambulance service staff. Optimal test characteristics for clinical adoption according to respondents were; accuracy (above 90% sensitivity and specificity), rapidity (<30 min time to results) and ease of sample acquisition. CONCLUSIONS The majority of commercially available lateral flow devices are unlikely to be supported by paramedics as their duty of care requires both rapid and accurate results that can inform clinical decision making in an emergency situation. Further investigation is needed to define acceptable test characteristics and criteria required for ambulance service staff to be confident and supportive of deployment of a SARS-CoV-2 test in an emergency care setting.
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Affiliation(s)
- Kile Green
- NIHR Newcastle In Vitro Diagnostics Co-operative, Translational and Clinical Research Institute, Newcastle University, Newcastle Upon Tyne, UK
| | - Massimo Micocci
- NIHR London In Vitro Diagnostics Co-operative, Imperial College London, London, UK
| | - Timothy Hicks
- NIHR Newcastle In Vitro Diagnostics Co-operative, Translational and Clinical Research Institute, Newcastle University, Newcastle Upon Tyne, UK
- NIHR Newcastle In Vitro Diagnostics Co-operative, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Amanda Winter
- NIHR Newcastle In Vitro Diagnostics Co-operative, Translational and Clinical Research Institute, Newcastle University, Newcastle Upon Tyne, UK
- NIHR Newcastle In Vitro Diagnostics Co-operative, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Joanne E Martin
- Centre for Genomics and Child Health, Barts and The London NHS Trust, Blizard Institute, London, UK
| | - Bethany Shinkins
- Academic Unit of Health Economics, University of Leeds, Leeds, UK
| | - Lisa Shaw
- Stroke Research Group, Population Health Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Christopher Price
- Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | - Kerrie Davies
- Healthcare Associated Infections Research Group, University of Leeds, Leeds, UK
| | - Joy A Allen
- NIHR Newcastle In Vitro Diagnostics Co-operative, Translational and Clinical Research Institute, Newcastle University, Newcastle Upon Tyne, UK
- NIHR Newcastle In Vitro Diagnostics Co-operative, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
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16
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Pilbery R, Young T, Hodge A. The effect of a specialist paramedic primary care rotation on appropriate non-conveyance decisions (SPRAINED) study: a controlled interrupted time series analysis. Br Paramed J 2022; 7:9-18. [PMID: 36452026 PMCID: PMC9662143 DOI: 10.29045/14784726.2022.06.7.1.9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2024] Open
Abstract
INTRODUCTION NHS ambulance service non-conveyance rates in the United Kingdom are around 30%, despite an increase in non-emergency cases and a national policy of integrating urgent and emergency care to provide patients with the 'right care, in the right place, at the right time'. Emergency department overcrowding is a significant issue for patients, resulting in poorer quality of care, increased healthcare costs and potentially, increased mortality. It also contributes to increased ambulance turnaround times. Yorkshire Ambulance Service NHS Trust (YAS) introduced a specialist paramedic (SP) to improve the management of lower acuity cases, but non-conveyance rates in this group have not been as high as expected.In 2018, Health Education England funded a pilot scheme to rotate paramedics into a range of healthcare settings and in YAS, 10 SPs undertook a 10-week placement in a GP practice. This study aimed to evaluate whether a primary care placement appropriately increased the level and trend of non-conveyance decisions made by SPs following a 10-week GP placement, in a cost-effective manner. METHODS We conducted a controlled interrupted time series analysis using data from incidents between 1 June 2017 and 31 December 2019, to study appropriate non-conveyance rates before and after a GP placement. A costing analysis, examining the average cost per appropriate non-conveyance achieved for patients receiving care from intervention group SPs pre- and post-placement, was also conducted. RESULTS A total of 7349 incidents attended by intervention group SPs were eligible for inclusion. Following removal of cases with missing data, 5537 (75.3%) cases remained. Post-placement, the intervention group demonstrated an increase in appropriate non-conveyance rate of 35.0% (95% CI 23.8%-46.2%), and a reduction in the trend of appropriate non-conveyance of -1.2% (95% CI -2.8%-0.5%), relative to the control group.Post-placement, the cost per appropriate non-conveyance for intervention group SPs was a mean of £509.41 (95% bootstrapped CI £454.92-£564.26) versus £1257.81 (95% bootstrapped CI £1233.42-£1283.95) for the same group in the pre-placement phase. CONCLUSION In this single UK NHS ambulance service study, we found a clinically important and statistically significant increase in appropriate non-conveyance rates by SPs who had completed a 10-week GP placement. This improvement persisted for the 12-month period following the placement and demonstrated cost savings compared to usual care.
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Affiliation(s)
- Richard Pilbery
- Yorkshire Ambulance Service NHS Trust ORCID iD: https://orcid.org/0000-0002-5797-9788
| | - Tracey Young
- University of Sheffield ORCID iD: https://orcid.org/0000-0001-8467-0471
| | - Andrew Hodge
- Yorkshire Ambulance Service NHS Trust ORCID iD: https://orcid.org/0000-0002-2632-2249
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17
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Heppenstall E, McClelland G, Price C, Wilkinson C. Documentation of atrial fibrillation among non-conveyed ambulance patients: a new primary prevention opportunity? Br Paramed J 2022; 7:51-57. [DOI: 10.29045/14784726.2022.06.7.1.51] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Introduction: Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and is a significant risk factor for stroke. Prescription of oral anticoagulant (OAC) medication reduces the risk of AF-related stroke by 64% ‐ yet over 400,000 people in England have
undiagnosed (and therefore untreated) AF.Emergency medical services (EMS) encounter a wide range of patients, some of whom may not engage with other healthcare services. AF may be detected by EMS in connection with the cause of the call, or as an incidental finding. While EMS are not traditionally
utilised for public health screening, they may offer an opportunity to identify patients with undiagnosed or untreated AF and refer onward.This study aimed to explore what proportion of patients seen by EMS who were not transported to hospital had AF and to estimate how many would potentially
benefit from OAC.Methods: A retrospective service evaluation was conducted using routinely collected data from a large UK regional ambulance service. The sample included adults attended by EMS on the 15th of each month in 2019, who were not transported to hospital and where an electrocardiogram
was recorded. Of those with AF, we calculated the proportion in whom this was possibly new and report whether OAC was prescribed.Results: There were 859 patients who met the inclusion criteria, of whom 91 (11%) had AF documented. Of the 91 patients with AF, 23 (25%) had no documented
history of AF or OAC prescription, so were potentially new diagnoses of AF, who would benefit from consideration of OAC therapy.Conclusion: The EMS assessment offers an opportunity for AF to be identified in patients who were not transported to hospital. EMS may have a role in primary
prevention of harm, including stroke, by identifying and referring patients with AF for consideration of OAC.
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Affiliation(s)
- Emily Heppenstall
- Newcastle University ORCID iD:, URL: https://orcid.org/0000-0003-2423-6221
| | - Graham McClelland
- Newcastle University; North East Ambulance Service NHS Foundation Trust ORCID iD:, URL: https://orcid.org/0000-0002-4502-5821
| | - Chris Price
- Newcastle University ORCID iD:, URL: https://orcid.org/0000-0003-3566-3157
| | - Chris Wilkinson
- Newcastle University ORCID iD:, URL: https://orcid.org/0000-0003-0748-0150
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18
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Wilson C, Howell AM, Janes G, Benn J. The role of feedback in emergency ambulance services: a qualitative interview study. BMC Health Serv Res 2022; 22:296. [PMID: 35241068 PMCID: PMC8896262 DOI: 10.1186/s12913-022-07676-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 02/23/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Several international studies suggest that the feedback that emergency ambulance service (EMS) personnel receive on the care they have delivered lacks structure, relevance, credibility and routine implementation. Feedback in this context can relate to performance or patient outcomes, can come from a variety of sources and can be sought or imposed. Evidence from health services research and implementation science, suggests that feedback can change professional behavior, improve clinical outcomes and positively influence staff mental health. The current study aimed to explore the experience of EMS professionals regarding current feedback provision and their views on how feedback impacts on patient care, patient safety and staff wellbeing. METHODS This qualitative study was conducted as part of a wider study of work-related wellbeing in EMS professionals. We used purposive sampling to select 24 frontline EMS professionals from one ambulance service in the United Kingdom and conducted semi-structured interviews. The data was analyzed in iterative cycles of inductive and deductive reasoning using Abductive Thematic Network Analysis. The analysis was informed by psychological theory, as well as models from the wider feedback effectiveness and feedback-seeking behavior literature. RESULTS Participants viewed current feedback provision as inadequate and consistently expressed a desire for increased feedback. Reported types of prehospital feedback included patient outcome feedback, patient-experience feedback, peer-to-peer feedback, performance feedback, feedforward: on-scene advice, debriefing and investigations and coroners' reports. Participants raised concerns that inadequate feedback could negatively impact on patient safety by preventing learning from mistakes. Enhancing feedback provision was thought to improve patient care and staff wellbeing by supporting personal and professional development. CONCLUSIONS In line with previous research in this area, this study highlights EMS professionals' strong desire for feedback. The study advances the literature by suggesting a typology of prehospital feedback and presenting a unique insight into the motives for feedback-seeking using psychological theory. A logic model for prehospital feedback interventions was developed to inform future research and development into prehospital feedback.
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Affiliation(s)
- Caitlin Wilson
- School of Psychology, University of Leeds, Leeds, United Kingdom. .,North West Ambulance Service NHS Trust, Bolton, United Kingdom.
| | | | - Gillian Janes
- Faculty of Health, Psychology and Social Care, Manchester Metropolitan University, Manchester, United Kingdom
| | - Jonathan Benn
- School of Psychology, University of Leeds, Leeds, United Kingdom.,Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, United Kingdom
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Shepard K, Spencer S, Kelly C, Wankhade P. Staff perceptions of patient safety in the NHS ambulance services: an exploratory qualitative study. Br Paramed J 2022; 6:18-25. [PMID: 35340577 PMCID: PMC8892446 DOI: 10.29045/14784726.2022.03.6.4.18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Objectives Most research investigating staff perceptions of patient safety has been based in primary care or hospitals, with little research on emergency services. Therefore, this study aimed to explore staff perceptions of patient safety in the NHS ambulance services. Design A stratified qualitative study using semi-structured interviews. Setting Three urban or rural ambulance service NHS trusts in England. Participants A total of 44 participants from three organisational levels, including executives, managers and operational staff. Methods The semi-structured interviews explored the interpretation and definition of patient safety, perceived risks, incident reporting, communication and organisational culture. The framework method of qualitative data analysis was used to analyse the interviews and NVivo software was used to manage and organise the data. Results We identified five dominant themes: varied interpretation of patient safety; significant patient safety risks; reporting culture shift; communication; and organisational culture. The findings demonstrated that staff perceptions of patient safety ranged widely across the three organisational levels, while they remained consistent within those levels across the participating ambulance service NHS trusts in England. Conclusions The findings suggest that participants from all organisational levels perceive that the NHS ambulance services have become much safer for patients over recent years, which signifies an awareness of the historical issues and how they have been addressed. The inclusion of three distinct ambulance service NHS trusts and organisational levels provides deepened insight into the perceptions of patient safety by staff. As the responses of participants were consistent across the three NHS trusts, the identified issues may be generic and have application in other ambulance and emergency service settings, with implications for health policy on a national basis.
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Affiliation(s)
- Keegan Shepard
- University of Oxford ORCID iD: https://orcid.org/0000-0003-3867-9752
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20
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Lederman J, Lindström V, Elmqvist C, Löfvenmark C, Ljunggren G, Djärv T. Non-conveyance of older adult patients and association with subsequent clinical and adverse events after initial assessment by ambulance clinicians: a cohort analysis. BMC Emerg Med 2021; 21:154. [PMID: 34895152 PMCID: PMC8666056 DOI: 10.1186/s12873-021-00548-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Accepted: 11/24/2021] [Indexed: 11/10/2022] Open
Abstract
Background Older adults (age ≥ 65 years) represent a significant proportion of all patients who are not transported to hospital after assessment by ambulance clinicians (non-conveyed patients). This study aimed to fill the knowledge gap in the understanding of the prevalence of older adult non-conveyed patients and investigate their characteristics and risk factors for subsequent and adverse events with those of younger non-conveyed patients comparatively. Methods This population-based retrospective cohort study included all adult non-conveyed patients who availed the ambulance service of Region Stockholm, Sweden in 2015; they were age-stratified into two groups: 18–64 and ≥ 65 years. Inter-group differences in short-term outcomes (i.e. emergency department visits, hospitalisations, and mortality within 7 days following non-conveyance) were assessed using multivariate regression analyses. Results Older adult patients comprised 48% of the 17,809 non-conveyed patients. Dispatch priority levels were generally lower among older non-conveyed patients than among younger patients. Non-conveyance among older patients occurred more often during daytime, and they were more frequently assessed by ambulance clinicians with nonspecific presenting symptoms. Approximately one in five older adults was hospitalised within 7 days following non-conveyance. Patients presenting with infectious symptoms had the highest mortality risk following non-conveyance. Oxygen saturation level < 95% or systolic blood pressure > 160 mmHg had significantly higher associations with hospitalisation within 7 days following non-conveyance in older adult patients. Conclusions Older adult patients have an increased risk for adverse events following non-conveyance. In combination with a complex and variating presentation of symptoms and vital signs proved difficult for dispatch operators and ambulance clinicians to identify and assess, the identified risks raise questions on the patient safety of older adult non-conveyed patients. The results indicate a system failure that need to be managed within the ambulance service organisation to achieve higher levels of patient safety for older non-conveyed patients. Supplementary Information The online version contains supplementary material available at 10.1186/s12873-021-00548-7.
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Affiliation(s)
- Jakob Lederman
- Dept. of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Sjukhusbacken 10, 118 83, Stockholm, Sweden. .,Academic Emergency Medical Services/AISAB Ambulance care in Greater Stockholm Ltd, Region Stockholm, Sweden.
| | - Veronica Lindström
- Samariten Ambulance, Stockholm, Sweden.,Dept. of Neurobiology, Care Sciences and Society, section of nursing, Karolinska Institutet, Stockholm, Sweden
| | - Carina Elmqvist
- Dept. of Health and Caring Sciences, Linnaeus University, Växjö, Sweden.,Centre of Interprofessional Cooperation within Emergency care (CICE), Linnaeus University, Växjö, Sweden
| | - Caroline Löfvenmark
- Dept. of Health promoting science, Sophiahemmet University, Stockholm, Sweden
| | - Gunnar Ljunggren
- Division for Family Medicine, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden.,Academic Primary Health care Centre, Region Stockholm, Stockholm, Sweden
| | - Therese Djärv
- Dept. of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
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21
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Watson A, Clubbs Coldron B, Wingfield B, Ruddell N, Clarke C, Masterson S, McConnell D, Coates V. Exploring variation in ambulance calls and conveyance rates for adults with diabetes mellitus who contact the Northern Ireland Ambulance Service: a retrospective database analysis. Br Paramed J 2021; 6:15-23. [PMID: 34966247 PMCID: PMC8669640 DOI: 10.29045/14784726.2021.12.6.3.15] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Background: People with diabetes frequently contact the ambulance service about acute problems. Overall, treating diabetes and its associated complications costs the NHS 10% of the annual budget. Reducing unnecessary hospital admissions and ambulance attendances is a high priority policy for the NHS across the UK. This study aimed to determine the characteristics of emergency calls for people with diabetes who contact the ambulance service and are subsequently conveyed to hospital by the Northern Ireland Ambulance Service (NIAS). Methods: A retrospective dataset from the NIAS was obtained from the NIAS Trust’s Command and Control system relating to calls where the final complaint group was ‘Diabetes’ for the period 1 January 2017 to 23 November 2019. Results: Of a total 11,396 calls related to diabetes, 63.2% of callers to the NIAS were conveyed to hospital. Over half of the calls related to males, with 35.5% of callers aged 60–79. The more deprived areas had a higher frequency of calls and conveyance to hospital, with this decreasing as deprivation decreased. Calls were evenly distributed across the week, with the majority of calls originating outside of GP working hours, although callers were more likely to be conveyed to hospital during working hours. Calls from healthcare professionals were significantly more likely to be conveyed to hospital, despite accounting for the minority of calls. Conclusion: This research found that older males were more likely to contact the ambulance service but older females were more likely to be conveyed to hospital. The likelihood of conveyance increased if the call originated from an HCP or occurred during GP working hours. The availability of alternative care pathways has the potential to reduce conveyance to hospital, which has been particularly important during the COVID-19 pandemic. Integration of data is vitally important to produce high quality research and improve policy and practice in this area.
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Moafa HN, van Kuijk SMJ, Moukhyer ME, Alqahtani DM, Haak HR. Non-Conveyance Due to Patient-Initiated Refusal in Emergency Medical Services: A Retrospective Population-Based Registry Analysis Study in Riyadh Province, Saudi Arabia. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18179252. [PMID: 34501841 PMCID: PMC8431479 DOI: 10.3390/ijerph18179252] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Revised: 08/25/2021] [Accepted: 08/27/2021] [Indexed: 11/26/2022]
Abstract
This research study aimed to investigate the association between demographic and operational factors and emergency medical services (EMS) missions ending in non-conveyance (NC) due to patient-initiated refusal (PIR). We conducted a retrospective population-based registry study by analyzing 67,620 EMS missions dispatched to the scene during 2018 in the Riyadh province. First, the number and percentages of conveyances statuses were calculated. Then, using crude and adjusted linear and logistic regression analysis, we determined which characteristics were predictors of NC due to PIR. We found that 23,991 (34.4%) of missions ended in NC due to PIR, and 5969 ended in EMS-initiated refusal (8.6%). NC rates due to PIR were higher for women, adults, for missions in Riyadh city, during nighttime, for medical emergencies, and for advanced life support (ALS) crews. We also found the following additional predictors significantly associated with the odds of NC due to PIR in crude regression analyses: age category, geographical location, EMS-shift, time of call, emergency type, and response time. We conclude that the NC rate represents half of all missions for patients requesting EMS, and the rate in Riyadh city has increased compared to previous studies. Most NC cases occur for the highest urgency level of medical emergency type in Riyadh city during the nighttime with ALS crews. NC due to PIR involves younger patients more than elderly, and females more than males. This study’s findings have provided empirical evidence that indicate that conducting further studies involving EMS providers, patients, and the public to identify precise and detailed reasons is required.
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Affiliation(s)
- Hassan N. Moafa
- Department of Health Services Management, Faculty of Public Health and Tropical Medicine, Jazan University, Jazan 82817 2820, Saudi Arabia
- Department of Health Services Research, CAPHRI School for Public Health and Primary Care, Maastricht University, 6229 GT Maastricht, The Netherlands;
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre, 6202 AZ Maastricht, The Netherlands;
- Correspondence: or ; Tel.: +31-615-373-733
| | - Sander M. J. van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre, 6202 AZ Maastricht, The Netherlands;
| | - Mohammed E. Moukhyer
- Department of Academic Development and Quality, Faculty of Applied Medical Sciences, Jazan University, Jazan 82511, Saudi Arabia;
| | - Dhafer M. Alqahtani
- Department of Electronic Transaction Management, Saudi Red Crescent Authority, Ministry of Health, Riyadh 13251-8261, Saudi Arabia;
| | - Harm R. Haak
- Department of Health Services Research, CAPHRI School for Public Health and Primary Care, Maastricht University, 6229 GT Maastricht, The Netherlands;
- Department of Internal Medicine, Maxima Medisch Centre, 5631 BM Eindhoven, The Netherlands
- Department of Internal Medicine, Maastricht University Medical Centre, 6229 HX Maastricht, The Netherlands
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Hetherington J, Jones I. What factors influence clinical decision making for paramedics when attending to paediatric emergencies in the community within one ambulance service trust? Br Paramed J 2021; 6:15-22. [PMID: 34335096 PMCID: PMC8312366 DOI: 10.29045/14784726.2021.6.6.1.15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background: Children’s healthcare needs are complex and diverse. Paramedics are expected to respond to a range of emergency calls across the patient demographic spectrum and to make complex clinical decisions, whilst facing growing pressures to seek provisions of care for their patients within the community. Aim: This study looked to understand the lived experiences of paramedics when attending to paediatric patients, and what factors influenced decision making. Methods: A qualitative study employing semi-structured interviews, to collect and describe the lived experiences of participants. Participants were paramedics working for an ambulance service responding to calls in the community. Participants varied in experience and registrant level of education. Interview data were transcribed verbatim and analysed utilising inductive thematic analysis. Results: Education provoked the most discussion, with a desire for more knowledge and training to improve confidence when attending to patients with low acuity complaints. Confidence was found to be intrinsically linked to experience, with clinicians who were more exposed to paediatrics in their professional or personal life displaying more confidence when attending to this patient group. Emotion of clinicians and/or families contributes to the clinical decision-making process; coupled with a reliance on clinical guidelines, there is a high probability of a paediatric consultation resulting in conveyance to an emergency department. Provision of care was variable geographically, with largely negative experiences observed with attempts for community referrals.
Conclusions: Providing a focus of education more reflective of paramedics’ experiences will address some of the factors discussed by participants. Introducing innovative solutions such as developing guidelines for lower acuity conditions and the introduction of specialist roles could contribute to mitigating the barriers paramedics faced while improving the quality of care provided to paediatric patients. Barriers to confidence existing due to lack of exposure may well still exist, as would options to refer to community services.
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Vicente V, Johansson A, Selling M, Johansson J, Möller S, Todorova L. Experience of using video support by prehospital emergency care physician in ambulance care - an interview study with prehospital emergency nurses in Sweden. BMC Emerg Med 2021; 21:44. [PMID: 33827436 PMCID: PMC8028766 DOI: 10.1186/s12873-021-00435-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 03/12/2021] [Indexed: 12/04/2022] Open
Abstract
Introduction When in need of emergency care and ambulance services, the ambulance nurse is often the first point of contact for the patient with healthcare. This role requires comprehensive knowledge of the ambulance nurse to be able to assign the right level of care and, if necessary, to provide self-care advice for patients with no further conveyance to hospital. Recently, an application was developed for transmitting real-time video to facilitate consultation between ambulance nurses and prehospital physicians in the role of regional medical support (RMS) for ambulance care. The use of video communication as a complement of medical support when referring to self-care is still an unexplored method in a prehospital setting. Our study aimed to elucidate ambulance nurses’ experience of video consultation with RMS physician during the assessment of patients considered to be triaged to self-care. Method We conducted a qualitative design study using semi-structured interviews with open questions. Twelve ambulance nurses were included in the study. To explore the ambulance nurses’ experience of performing video consultation with RMS physician, in cases when a patient was assessed and triaged to self-care, a content analysis was performed. Results A main category emerged from the results: “ Video consultation as decision support in the ambulance care promotes increased patient participation and for the ambulance nurses, it creates a feeling of increased patient safety “. The main category was based and formed on the following categories: “ Simultaneous presence of ambulance nurse and a physician increases patient participation during the assessment resulting in a confident care decision “. “Interprofessional collaboration strengthens the medical assessment”. “Video technology promotes accessibility for patients needs in the ambulance care regardless of emergency level”. Conclusions Ambulance nurses experienced that the use of video consultation increases patient involvement and confidence in healthcare when both the ambulance nurse and the physician were present when deciding on self-care advice. The live imaging allowed the ambulance nurse and prehospital physician to reach a consensus on the patient’s current medical care needs, which in turn led to a feeling of increased patient safety for the ambulance nurses.
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Affiliation(s)
- Veronica Vicente
- The Ambulance Medical Service in Stockholm (AISAB), Lindetorpsvägen 11, SE-121 18 Johanneshov, Stockholm, Sweden. .,Academic EMS, Stockholm, Sweden. .,Karolinska Institute, Department of Clinical Science and Education, Södersjukhuset in Stockholm, Stockholm, Sweden.
| | - Anders Johansson
- Office of Medical Services, Region Skåne, Malmö, Sweden.,Department of Clinical Science, Lund University, Region Skåne, Lund, Sweden
| | - Magnus Selling
- Karolinska Institute, Department of Clinical Science and Education, Södersjukhuset in Stockholm, Stockholm, Sweden
| | - Johnny Johansson
- Karolinska Institute, Department of Clinical Science and Education, Södersjukhuset in Stockholm, Stockholm, Sweden
| | - Sebastian Möller
- Office of Medical Services, Region Skåne, Malmö, Sweden.,Department of Clinical Science, Lund University, Region Skåne, Lund, Sweden
| | - Lizbet Todorova
- Office of Medical Services, Region Skåne, Malmö, Sweden.,Department of Clinical Science, Lund University, Region Skåne, Lund, Sweden
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Todd VF, Swain A, Howie G, Tunnage B, Smith T, Dicker B. Factors Associated with Emergency Medical Service Reattendance in Low Acuity Patients Not Transported by Ambulance. PREHOSP EMERG CARE 2021:1-17. [PMID: 33320722 DOI: 10.1080/10903127.2020.1862943] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 12/03/2020] [Accepted: 12/06/2020] [Indexed: 10/22/2022]
Abstract
Background: The decision for emergency medical services (EMS) personnel not to transport a patient is challenging: there is a risk of subsequent deterioration but transportation of all patients to hospital would overburden emergency departments. The aim of this large-scale EMS study was to identify factors associated with an increased likelihood of ambulance reattendance within 48 hours in low acuity patients who were not transported by ambulance.Methods: We conducted a 2-year retrospective cohort study using data from the St John New Zealand EMS between 1 July 2016 and 30 June 2018 to investigate demographic and clinical associations with ambulance reattendance.Results: In total, 83,171 low acuity patients not transported by ambulance were included, of whom 4,512 (5.4%) had an EMS ambulance reattend within 48 hours. There were significant associations between EMS reattendance and patient age, sex, ethnicity, deprivation, and event location. Patients aged 60-74 years old had the highest likelihood of ambulance recall (OR 2.87, 95% CI: 2.51-3.28). Males were more likely to have an EMS ambulance reattend within 48 hours (OR 1.17, 95% CI: 1.09-1.25). Māori and Pacific Peoples had a similar likelihood of EMS recall to European/Others; however, the Asian cohort showed a reduced likelihood of reattendance (OR 0.76, 95% CI: 0.62-0.93).There were significant associations between EMS reattendance and non-transport reason, time spent on scene, event type, clinical acuity level (status), and pain score. Shorter (<30 minutes) on scene times were associated with a decreased likelihood of ambulance reattendance, whereas longer scene times (>45 minutes) were associated with an increased likelihood. Medical events were more likely to require reattendance than accident-related events (OR 1.22, 95% CI: 1.13-1.32). Non-transported patients with a severe pain score (7-10/10) were at increased likelihood of requiring reattendance (OR 1.60, 95% CI: 1.33-1.92).Discussion: The overall low rate of EMS reattendance is encouraging. Further research is needed into the clinical presentation of patients requiring ambulance reattendance within 48 hours to determine if there are early warning signs indicative of subsequent deterioration.
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Affiliation(s)
- Verity F Todd
- Received November 25, 2019 from Clinical Audit and Research Team, St John New Zealand, Auckland, New Zealand (VFT, GH, BT, TS, BD); Paramedicine Department, Auckland University of Technology, Auckland, New Zealand (VFT, AS, GH, BT, BD); Wellington Free Ambulance, Wellington, New Zealand (AS). Revision received December 3, 2020; accepted for publication December 6, 2020
| | - Andy Swain
- Received November 25, 2019 from Clinical Audit and Research Team, St John New Zealand, Auckland, New Zealand (VFT, GH, BT, TS, BD); Paramedicine Department, Auckland University of Technology, Auckland, New Zealand (VFT, AS, GH, BT, BD); Wellington Free Ambulance, Wellington, New Zealand (AS). Revision received December 3, 2020; accepted for publication December 6, 2020
| | - Graham Howie
- Received November 25, 2019 from Clinical Audit and Research Team, St John New Zealand, Auckland, New Zealand (VFT, GH, BT, TS, BD); Paramedicine Department, Auckland University of Technology, Auckland, New Zealand (VFT, AS, GH, BT, BD); Wellington Free Ambulance, Wellington, New Zealand (AS). Revision received December 3, 2020; accepted for publication December 6, 2020
| | - Bronwyn Tunnage
- Received November 25, 2019 from Clinical Audit and Research Team, St John New Zealand, Auckland, New Zealand (VFT, GH, BT, TS, BD); Paramedicine Department, Auckland University of Technology, Auckland, New Zealand (VFT, AS, GH, BT, BD); Wellington Free Ambulance, Wellington, New Zealand (AS). Revision received December 3, 2020; accepted for publication December 6, 2020
| | - Tony Smith
- Received November 25, 2019 from Clinical Audit and Research Team, St John New Zealand, Auckland, New Zealand (VFT, GH, BT, TS, BD); Paramedicine Department, Auckland University of Technology, Auckland, New Zealand (VFT, AS, GH, BT, BD); Wellington Free Ambulance, Wellington, New Zealand (AS). Revision received December 3, 2020; accepted for publication December 6, 2020
| | - Bridget Dicker
- Received November 25, 2019 from Clinical Audit and Research Team, St John New Zealand, Auckland, New Zealand (VFT, GH, BT, TS, BD); Paramedicine Department, Auckland University of Technology, Auckland, New Zealand (VFT, AS, GH, BT, BD); Wellington Free Ambulance, Wellington, New Zealand (AS). Revision received December 3, 2020; accepted for publication December 6, 2020
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Alternatives to direct emergency department conveyance of ambulance patients: a scoping review of the evidence. Scand J Trauma Resusc Emerg Med 2021; 29:4. [PMID: 33407771 PMCID: PMC7789540 DOI: 10.1186/s13049-020-00821-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 12/02/2020] [Indexed: 12/02/2022] Open
Abstract
Background The role of ambulance services is shifting, due in part to more intermediate, non-urgent patients who do not require direct emergency department conveyance, yet who cannot be safely left at home alone. Evidence surrounding the safety, effectiveness and efficiency of alternate care routes is not well known. Methods This scoping review sought to identify all studies that examined alternate routes of care for the non-urgent “intermediate” patient, as triaged on scene. Search terms for the sample (ambulances, paramedics, etc.) and intervention (e.g. referrals, alternate care route, non-conveyance) were combined. Articles were systematically searched using four databases and grey literature sources (February 2020). Independent researchers screened title-abstract and full text stages. Results Of 16,037 records, 41 examined alternate routes of care after triage by the on-scene paramedic. Eighteen articles considered quantitative patient data, 12 studies provided qualitative perspectives while 11 were consensus or opinion-based articles. The benefits of alternative schemes are well-recognised by patients, paramedics and stakeholders and there is supporting evidence for a positive impact on patient-centered care and operational efficiency. Challenges to successful use of schemes included: patient safety resulting from incorrect triage decisions, inadequate training, lack of formal partnerships between ambulance and supporting services, and insufficient evidence to support safe implementation or continued use. Studies often inaccurately defined success using proxies for patient safety (e.g. decision comparisons, rates of secondary contact). Finally, patients expressed willingness for such schemes but their preference must be better understood. Conclusions This broad summary offers initial support for alternate routes of care for intermediate, non-urgent patients. Even so, most studies lacked methodologically rigorous evidence and failed to evaluate safe patient outcomes. Some remedies appear to be available such as formal triage pathways, targeted training and organisational support, however there is an urgent need for more research and dissemination in this area.
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Höglund E, Andersson-Hagiwara M, Schröder A, Möller M, Ohlsson-Nevo E. Characteristics of non-conveyed patients in emergency medical services (EMS): a one-year prospective descriptive and comparative study in a region of Sweden. BMC Emerg Med 2020; 20:61. [PMID: 32778074 PMCID: PMC7418316 DOI: 10.1186/s12873-020-00353-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 07/21/2020] [Indexed: 01/10/2023] Open
Abstract
Background There has been an increasing demand for emergency medical services (EMS), and a growing number of patients are not conveyed; i.e., they are referred to levels of care other than ambulance conveyance to the emergency department. Patient safety issues have been raised regarding the ability of EMS to decide not to convey patients. To improve non-conveyance guidelines, information is needed about patients who are not conveyed by EMS. Therefore, the purpose of this study was to describe and compare the proportion and characteristics of non-conveyed EMS patients, together with assignment data. Methods A descriptive and comparative consecutive cohort design was undertaken. The decision of whether to convey patients was made by EMS according to a region-specific non-conveyance guideline. Non-conveyed patients’ medical record data were prospectively gathered from February 2016 to January 2017. Analyses was conducted using the chi-squared test, two-sample t test, proportion test and Mann-Whitneys U-test. Results Out of the 23,250 patients served during the study period, 2691 (12%) were not conveyed. For non-conveyed adults, the most commonly used Emergency Signs and Symptoms (ESS) codes were unspecific symptoms/malaise, abdomen/flank/groin pain, and breathing difficulties. For non-conveyed children, the most common ESS codes were breathing difficulties and fever of unclear origin. Most of the non-conveyed patients had normal vital signs. Half of all patients with a designated non-conveyance level of care were referred to self-care. There were statistically significant differences between men and women. Conclusions Fewer patients were non-conveyed in the studied region compared to national and international non-conveyance rates. The differences seen between men and women were not of clinical significance. Follow-up studies are needed to understand what effect patient outcome so that guidelines might improve.
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Affiliation(s)
- Erik Höglund
- University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Box 1613, 701 16, Örebro, Sweden.
| | - Magnus Andersson-Hagiwara
- Centre for Prehospital Research, Faculty of Caring Science, Work Life and Social Welfare, University of Borås, Borås, Sweden
| | - Agneta Schröder
- University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Box 1613, 701 16, Örebro, Sweden.,Department of Health Sciences in Gjøvik, Faculty of Medicine and Health Sciences, NTNU - Norwegian University of Science and Technology, Gjøvik, Norway
| | - Margareta Möller
- University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Box 1613, 701 16, Örebro, Sweden
| | - Emma Ohlsson-Nevo
- University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Box 1613, 701 16, Örebro, Sweden.,Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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Lederman J, Lindström V, Elmqvist C, Löfvenmark C, Djärv T. Non-conveyance in the ambulance service: a population-based cohort study in Stockholm, Sweden. BMJ Open 2020; 10:e036659. [PMID: 32665389 PMCID: PMC7365423 DOI: 10.1136/bmjopen-2019-036659] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES Non-conveyed patients represent a significant proportion of all patients cared for by ambulance services in the western world. However, scientific knowledge on non-conveyance is sparse. Therefore, the aim of this study was to describe the prevalence of non-conveyance, investigate associations and compare patients' characteristics, drug administration, initial problems and vital signs between non-conveyed and conveyed patients. DESIGN A population-based retrospective cohort study. SETTING The study setting area, Stockholm, Sweden, has a population of 2.3 million inhabitants, with seven emergency hospitals. Annually, approximately 210 000 assignments are performed by 73 ambulances. All ambulance assignments performed from 1 January to 31 December 2015 were included. RESULTS In total, 23 603 ambulance assignments ended in non-conveyance-13.8% of all ambulance assignments performed in 2015. Compared with conveyed patients, non-conveyed patients were younger and more often female (median age 50.1 years for non-conveyed vs 61.7 years for conveyed; female=52 %, both p values <0.001). Approximately half of all ambulance assignments ending in non-conveyance were initially prioritised and dispatched as the highest priority. Non-conveyed patients were more often assessed by ambulance clinicians as presenting non-specific symptoms or symptoms related to psychiatric problems. Low blood glucose levels were highly associated with non-conveyance (adjusted OR (AOR): 15; 95 % CI 11.18 to 20.13), although non-conveyed patients presented abnormal vital signs across all categories of vital signs. Moreover, drugs were more often administered to younger non-conveyed patients. Older patients were more often conveyed and administered drugs once conveyed (AOR: 1.29; 95 % CI 1.07 to 1.56). CONCLUSIONS This study shows that non-conveyed patients represent a non-negligible proportion of all patients in contact with ambulance services. In general, most cases of non-conveyance occur at the highest dispatch level, to a large extent involve younger patients, and features problems assessed by ambulance clinicians as non-specific or related to psychiatric symptoms.
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Affiliation(s)
- Jakob Lederman
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
- Academic Emergency Medical Services, Stockholm, Sweden
| | - Veronica Lindström
- Department of Neurobiology, Care Sciences and Society, Section of Nursing, Karolinska Institutet, Stockholm, Sweden
- Samariten Ambulance, Stockholm, Sweden
| | - Carina Elmqvist
- Department of Health and Caring Sciences, Faculty of Health and Life Sciences, Linnaeus University, Växjö, Sweden
- Centre of Interprofessional Cooperation within Emergency care, Faculty of Health and Life Sciences, Linnaeus University, Växjö, Sweden
| | - Caroline Löfvenmark
- Department of Health Promoting Science, Sophiahemmet University College, Stockholm, Sweden
| | - Therese Djärv
- Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
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Porter A, Badshah A, Black S, Fitzpatrick D, Harris-Mayes R, Islam S, Jones M, Kingston M, LaFlamme-Williams Y, Mason S, McNee K, Morgan H, Morrison Z, Mountain P, Potts H, Rees N, Shaw D, Siriwardena N, Snooks H, Spaight R, Williams V. Electronic health records in ambulances: the ERA multiple-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2020. [DOI: 10.3310/hsdr08100] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background
Ambulance services have a vital role in the shift towards the delivery of health care outside hospitals, when this is better for patients, by offering alternatives to transfer to the emergency department. The introduction of information technology in ambulance services to electronically capture, interpret, store and transfer patient data can support out-of-hospital care.
Objective
We aimed to understand how electronic health records can be most effectively implemented in a pre-hospital context in order to support a safe and effective shift from acute to community-based care, and how their potential benefits can be maximised.
Design and setting
We carried out a study using multiple methods and with four work packages: (1) a rapid literature review; (2) a telephone survey of all 13 freestanding UK ambulance services; (3) detailed case studies examining electronic health record use through qualitative methods and analysis of routine data in four selected sites consisting of UK ambulance services and their associated health economies; and (4) a knowledge-sharing workshop.
Results
We found limited literature on electronic health records. Only half of the UK ambulance services had electronic health records in use at the time of data collection, with considerable variation in hardware and software and some reversion to use of paper records as services transitioned between systems. The case studies found that the ambulance services’ electronic health records were in a state of change. Not all patient contacts resulted in the generation of electronic health records. Ambulance clinicians were dealing with partial or unclear information, which may not fit comfortably with the electronic health records. Ambulance clinicians continued to use indirect data input approaches (such as first writing on a glove) even when using electronic health records. The primary function of electronic health records in all services seemed to be as a store for patient data. There was, as yet, limited evidence of electronic health records’ full potential being realised to transfer information, support decision-making or change patient care.
Limitations
Limitations included the difficulty of obtaining sets of matching routine data for analysis, difficulties of attributing any change in practice to electronic health records within a complex system and the rapidly changing environment, which means that some of our observations may no longer reflect reality.
Conclusions
Realising all the benefits of electronic health records requires engagement with other parts of the local health economy and dealing with variations between providers and the challenges of interoperability. Clinicians and data managers, and those working in different parts of the health economy, are likely to want very different things from a data set and need to be presented with only the information that they need.
Future work
There is scope for future work analysing ambulance service routine data sets, qualitative work to examine transfer of information at the emergency department and patients’ perspectives on record-keeping, and to develop and evaluate feedback to clinicians based on patient records.
Study registration
This study is registered as Health and Care Research Wales Clinical Research Portfolio 34166.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 10. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Alison Porter
- Swansea University Medical School, Swansea University, Swansea, UK
| | - Anisha Badshah
- Department of Human Resources and Organisational Behaviour, University of Greenwich, London, UK
| | - Sarah Black
- South Western Ambulance Service NHS Foundation Trust, Exeter, UK
| | - David Fitzpatrick
- Faculty of Health Sciences and Sport, University of Stirling, Stirling, UK
| | | | - Saiful Islam
- Swansea University Medical School, Swansea University, Swansea, UK
| | - Matthew Jones
- Swansea University Medical School, Swansea University, Swansea, UK
| | - Mark Kingston
- Swansea University Medical School, Swansea University, Swansea, UK
| | | | - Suzanne Mason
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Katherine McNee
- South Western Ambulance Service NHS Foundation Trust, Exeter, UK
| | - Heather Morgan
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Zoe Morrison
- Aberdeen Business School, Robert Gordon University, Aberdeen, UK
| | | | - Henry Potts
- Centre for Health Informatics and Multiprofessional Education, University College London, London, UK
| | - Nigel Rees
- Pre-Hospital Emergency Research Unit, Welsh Ambulance Service NHS Trust, Swansea, UK
| | - Debbie Shaw
- East Midlands Ambulance Service NHS Trust, Lincoln, UK
| | - Niro Siriwardena
- School of Health and Social Care, University of Lincoln, Lincoln, UK
| | - Helen Snooks
- Swansea University Medical School, Swansea University, Swansea, UK
| | - Rob Spaight
- East Midlands Ambulance Service NHS Trust, Lincoln, UK
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Lederman J, Löfvenmark C, Djärv T, Lindström V, Elmqvist C. Assessing non-conveyed patients in the ambulance service: a phenomenological interview study with Swedish ambulance clinicians. BMJ Open 2019; 9:e030203. [PMID: 31551383 PMCID: PMC6773311 DOI: 10.1136/bmjopen-2019-030203] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVES To combat overcrowding in emergency departments, ambulance clinicians (ACs) are being encouraged to make on-site assessments regarding patients' need for conveyance to hospital, and this is creating new and challenging demands for ACs. This study aimed to describe ACs' experiences of assessing non-conveyed patients. DESIGN A phenomenological interview study based on a reflective lifeworld research approach. SETTING The target area for the study was Stockholm, Sweden, which has a population of approximately 2.3 million inhabitants. In this area, 73 ambulances perform approximately just over 200 000 ambulance assignments annually, and approximately 25 000 patients are non-conveyed each year. INFORMANTS 11 ACs. METHODS In-depth open-ended interviews. RESULTS ACs experience uncertainty regarding the accuracy of their assessments of non-conveyed patients. In particular, they fear conducting erroneous assessments that could harm patients. Avoiding hasty decisions is important for conducting safe patient assessments. Several challenging paradoxes were identified that complicate the non-conveyance situation, namely; responsibility, education and feedback paradoxes. The core of the responsibility paradox is that the increased responsibility associated with non-conveyance assessments is not accompanied with appropriate organisational support. Thus, frustration is experienced. The education paradox involves limited and inadequate non-conveyance education. This, in combination with limited support from non-conveyance guidelines, causes the clinical reality to be perceived as challenging and problematic. Finally, the feedback paradox relates to the obstruction of professional development as a result of an absence of learning possibilities after assessments. Additionally, ACs also described loneliness during non-conveyance situations. CONCLUSIONS This study suggests that, for ACs, performing non-conveyance assessments means experiencing a paradoxical professional existence. Despite these aggravating paradoxes, however, complex non-conveyance assessments continue to be performed and accompanied with limited organisational support. To create more favourable circumstances and, hopefully, safer assessments, further studies that focus on these paradoxes and non-conveyance are needed.
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Affiliation(s)
- Jakob Lederman
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
- Academic Emergency Medical Service, Region Stockholm, Stockholm, Sweden
| | - Caroline Löfvenmark
- Division of Cardiovascular Medicine, Danderyds Hospital, Karolinska Institutet, Stockholm, Sweden
- Sophiahemmet University College, Stockholm, Sweden
| | - Therese Djärv
- Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Veronica Lindström
- Academic Emergency Medical Service, Region Stockholm, Stockholm, Sweden
- Department of Neurobiology, Care Sciences and Society, Section of Nursing, Karolinska Institutet, Stockholm, Sweden
| | - Carina Elmqvist
- Department of Health and Caring Sciences, Faculty of Health and Life Sciences, Linnaeus University, Växjö, Sweden
- Centre of Interprofessional Cooperation within Emergency care (CICE), Linnaeus University Faculty of Health and Life Sciences, Växjö, Sweden
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Zhan Y, Etter JF, Leischow S, Zeng D. Electronic cigarette usage patterns: a case study combining survey and social media data. J Am Med Inform Assoc 2019; 26:9-18. [PMID: 30544163 PMCID: PMC6308011 DOI: 10.1093/jamia/ocy140] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 08/13/2018] [Accepted: 10/09/2018] [Indexed: 11/14/2022] Open
Abstract
Objective To identify who were social media active e-cigarette users, to compare the use patterns from both survey and social media data for data triangulation, and to jointly use both datasets to conduct a comprehensive analysis on e-cigarette future use intentions. Materials and Methods We jointly used an e-cigarette use online survey (n = 5132) and a social media dataset. We conducted analysis from 3 different perspectives. We analyzed online forum participation patterns using survey data. We compared e-cigarette use patterns, including brand and flavor types, ratings, and purchase approaches, between the 2 datasets. We used logistic regression to study intentions to use e-cigarettes using both datasets. Results Male and younger e-cigarette users were the most likely to participate in e-cigarette-related discussion forums. Forum active survey participants were hardcore vapers. The e-cigarette use patterns were similar in the online survey data and the social media data. Intention to use e-cigarettes was positively related to e-liquid ratings and flavor ratings. Social media provided a valuable source of information on users' ratings of e-cigarette refill liquids. Discussion For hardcore vapers, social media data were consistent with online survey data, which suggests that social media may be useful to study e-cigarette use behaviors and can serve as a useful complement to online survey research. We proposed an innovative framework for social media data triangulation in public health studies. Conclusion We illustrated how social media data, combined with online survey data, can serve as a new and rich information source for public health research.
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Affiliation(s)
- Yongcheng Zhan
- Department of Management Information Systems, University of Arizona, Tucson, Arizona, USA
| | - Jean-François Etter
- Institute of Global Health, Faculty of Medicine, University of Geneva, Switzerland
| | - Scott Leischow
- College of Health Solutions, Arizona State University, Phoenix, Arizona, USA
| | - Daniel Zeng
- Department of Management Information Systems, University of Arizona, Tucson, Arizona, USA
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Knowles E, Bishop-Edwards L, O'Cathain A. Exploring variation in how ambulance services address non-conveyance: a qualitative interview study. BMJ Open 2018; 8:e024228. [PMID: 30498049 PMCID: PMC6278803 DOI: 10.1136/bmjopen-2018-024228] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVES There is considerable variation in non-conveyance rates between ambulance services in England. The aim was to explore variation in how each ambulance service addressed non-conveyance for calls ending in telephone advice and discharge at scene. DESIGN A qualitative interview study. SETTING Ten large regional ambulance services covering 99% of the population in England. PARTICIPANTS Between four and seven interviewees from each ambulance service including managers, paramedics and healthcare commissioners, totalling 49 interviews. METHODS Telephone semistructured interviews. RESULTS The way interviewees in each ambulance service discussed non-conveyance within their organisation varied for three broad themes. First, ambulance service senior management appeared to set the culture around non-conveyance within an organisation, viewing it either as an opportunity or as a risky endeavour. Although motivation levels to undertake non-conveyance did not appear to be directly affected by the stability of an ambulance service in terms of continuity of leadership and externally assessed quality, this stability could affect the ability of the organisation to innovate to increase non-conveyance rates. Second, descriptions of workforce configuration differed between ambulance services, as well as how this workforce was used, trained and valued. Third, interviewees in each ambulance service described health and social care in the wider emergency and urgent care system differently in terms of availability of services that could facilitate non-conveyance, the amount of collaborative working between health and social care services and the ambulance service and complexity related to the numbers of services and healthcare commissioners with whom they had to work. CONCLUSIONS This study suggests that factors within and outside the control of ambulance services may contribute to variation in non-conveyance rates. These findings can be tested in a quantitative analysis of factors affecting variation in non-conveyance rates between ambulance services in England.
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Affiliation(s)
- Emma Knowles
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | | | - Alicia O'Cathain
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
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