decision making and safety in ambulance service transitions

170 Pages·2014·1.57 MB·English

HEALTH SERVICES AND DELIVERY RESEARCH
VOLUME 2 ISSUE 56 DECEMBER 2014
ISSN 2050-4349
A qualitative study of decision-making and safety in
ambulance service transitions
Rachel O’Hara, Maxine Johnson, Enid Hirst, Andrew Weyman, Deborah Shaw,
Peter Mortimer, Chris Newman, Matthew Storey, Janette Turner, Suzanne Mason,
Tom Quinn, Jane Shewan and A Niroshan Siriwardena
DOI 10.3310/hsdr02560

A qualitative study of decision-making and
safety in ambulance service transitions
’
Rachel O Hara,1* Maxine Johnson,1 Enid Hirst,2
Andrew Weyman,3 Deborah Shaw,4 Peter Mortimer,5
Chris Newman,6 Matthew Storey,5 Janette Turner,7
Suzanne Mason,7 Tom Quinn,8 Jane Shewan5
and A Niroshan Siriwardena4,9
1Public Health Section, School of Health and Related Research (ScHARR),
University of Sheffield, Sheffield, UK
2Sheffield Emergency Care Forum, Sheffield, UK
3Department of Psychology, University of Bath, Bath, UK
4East Midlands Ambulance Service NHS Trust, Nottingham, UK
5Yorkshire Ambulance Service NHS Trust, Wakefield, UK
6South East Coast Ambulance Service NHS Trust, Guildford, UK
7Health Services Research Section, School of Health and Related Research
(ScHARR), University of Sheffield, Sheffield, UK
8Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
9Community and Health Research Unit, College of Social Science,
University of Lincoln, Lincoln, UK
*Corresponding author
Declared competing interests of authors: none
Published December 2014
DOI: 10.3310/hsdr02560
This reportshould be referenced as follows:
O’Hara R, Johnson M, Hirst E, Weyman A, Shaw D, Mortimer P,et al. Aqualitativestudyof
decision-makingandsafetyinambulanceservicetransitions.HealthServDelivRes2014;2(56).

Health Services and Delivery Research
ISSN2050-4349(Print)
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DOI:10.3310/hsdr02560 HEALTHSERVICESANDDELIVERYRESEARCH2014 VOL.2 NO.56
Abstract
A qualitative study of decision-making and safety in
ambulance service transitions
Rachel O’Hara,1* Maxine Johnson,1 Enid Hirst,2 Andrew Weyman,3
Deborah Shaw,4 Peter Mortimer,5 Chris Newman,6 Matthew Storey,5
Janette Turner,7 Suzanne Mason,7 Tom Quinn,8 Jane Shewan5
and A Niroshan Siriwardena4,9
1Public Health Section, School of Healthand Related Research (ScHARR), University of Sheffield,
Sheffield, UK
2Sheffield EmergencyCare Forum, Sheffield, UK
3Department of Psychology, University ofBath, Bath, UK
4East Midlands Ambulance Service NHS Trust,Nottingham, UK
5Yorkshire Ambulance Service NHSTrust, Wakefield, UK
6South East CoastAmbulance Service NHS Trust, Guildford, UK
7Health Services Research Section, Schoolof Health andRelated Research (ScHARR),
University ofSheffield, Sheffield, UK
8Faculty of Health andMedical Sciences, University of Surrey, Guildford, UK
9Community andHealth Research Unit, College ofSocial Science, University of Lincoln,
Lincoln, UK
*Corresponding author [email protected]
Background: Decisions made byfront-line ambulancestaff areoften time critical and based on limited
information, butwrong decisions in this context could haveserious consequences for patients. There has
been little research carried out in theambulance service setting to identify areasof risk associated with
decisions about patient care.
Aim: Theaim of this study was to qualitatively examine potential system-wide influences on
decision-making inthe ambulanceservice setting and to identify useful areasfor future research
and intervention.
Methods: We used amultisite, multimethod qualitative approach across threeambulance service trusts.
In phase 1we carried out16 interviews to contextualise the study andprovide discussion points for
phase 2. For phase 2, university and ambulance service researchers observedparamedics on 34 shifts
and 10 paramedics completed ‘digital diaries’ that reported challenges to decision-making or to patient
safety. Six focus groups were held, threewith staff (n=21) and threewith service users (n=23). From
observation and diary datawe developed atypology of decisions made at the scene.Data from theseand
other sources were also coded withina humanfactors framework and then thematically analysed to
identify influences on those decisions. In phase 3, workshops were heldat each site to allowparticipants
and stakeholders (n=45)to comment onthe studyfindings. Participants were asked to rankinfluences on
decisions usinga‘paired comparison’ method.
Results: Interviews provided thecontext for further qualitative exploration. Nine typesof decision
were identified from observations and digital diaries, ranging from emergency department conveyance and
specialist emergencypathways to non-conveyance. A synthesis of findings from the observations, diaries
©Queen’sPrinterandControllerofHMSO2014.ThisworkwasproducedbyO’Haraetal.underthetermsofacommissioningcontractissuedbytheSecretaryofStatefor
Health.Thisissuemaybefreelyreproducedforthepurposesofprivateresearchandstudyandextracts(orindeed,thefullreport)maybeincludedinprofessionaljournals v
providedthatsuitableacknowledgementismadeandthereproductionisnotassociatedwithanyformofadvertising.Applicationsforcommercialreproductionshouldbe
addressedto:NIHRJournalsLibrary,NationalInstituteforHealthResearch,Evaluation,TrialsandStudiesCoordinatingCentre,AlphaHouse,UniversityofSouthamptonScience
Park,SouthamptonSO167NS,UK.
ABSTRACT
and staff focus groups revealed seven overarching system influences ondecision-making and potential risk
factors: meetingincreasing demand for emergency care; impacts of performance regime andpriorities
on service delivery; access to appropriate care options; disproportionate riskaversion; education, training
and professional development for crews; communication and feedbackto crews; andambulance service
resources. Safety culture issues were also identified. Datafrom theservice user focus groups reflected
similar issues to thoseidentified from thestaff focus groups. Service userconcerns included callhandling
and communication, triage, patient involvement in decisions, balancing demand, resources, access to care,
risk aversion, geographical location and vulnerable patients. Group discussions highlighted a lack of
awareness by thepublic of howbest to use emergencyand urgent care services. Workshop attendees
were satisfied that thefindings reflected relevant issues. Thetwo issues ranked highestfor warranting
attention were staff training and developmentand access to alternative care.
Conclusions: Multiple qualitative methods allowed arange of perspectives to beaccessed and validation
of issues acrossperspectives. Recommendations for future research includeexploring effective ways of
providing access to alternative carepathways to accident and emergency, assessingpublic awareness and
expectations of ambulance andrelated services, exploring safe ways of improving telephone triage
decisions and assessingthe effects of different staff skill levelson patient safety.
Funding: TheNational Institute for Health Research HealthServices and Delivery Research programme.
vi
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DOI:10.3310/hsdr02560 HEALTHSERVICESANDDELIVERYRESEARCH2014 VOL.2 NO.56
Contents
List oftables xi
List offigures xiii
List ofboxes xv
Glossary xvii
List ofabbreviations xix
PlainEnglish summary xxi
Scientific summary xxiii
Chapter 1Introduction 1
Background 1
The ambulanceservice system and decision-making 1
Patient safety models 2
Patient safety in anevolving system 3
Aim and objectives 4
Aim 4
Objectives 4
Chapter 2Methods 5
Justification for thestudy design 5
Methodological approaches 5
The systems approach 5
The multisource approach 5
Study setting 5
Components of the study 6
Phase 1: mapping the system 6
Phase 2: exploring influences ondecision-making and safety 7
Phase 2: service user focusgroups 11
Phase 3: feedback workshops 13
Ethical and research governance approval 14
Chapter 3Phase 1findings: mappingthe system 15
Institutional and organisational context 15
Funding and commissioning 15
Care quality and performance measurement 16
Reorganisation and restructuring 17
Foundation trust status 17
Policies, proceduresand guidelines 18
Incident reporting 18
Complaints procedures 19
©Queen’sPrinterandControllerofHMSO2014.ThisworkwasproducedbyO’Haraetal.underthetermsofacommissioningcontractissuedbytheSecretaryofStatefor
Health.Thisissuemaybefreelyreproducedforthepurposesofprivateresearchandstudyandextracts(orindeed,thefullreport)maybeincludedinprofessionaljournals vii
providedthatsuitableacknowledgementismadeandthereproductionisnotassociatedwithanyformofadvertising.Applicationsforcommercialreproductionshouldbe
addressedto:NIHRJournalsLibrary,NationalInstituteforHealthResearch,Evaluation,TrialsandStudiesCoordinatingCentre,AlphaHouse,UniversityofSouthamptonScience
Park,SouthamptonSO167NS,UK.
CONTENTS
Professional roles and responsibilities 19
Emergency operations centre staff 19
Operational staff 20
Other supportive roles 22
Documentation and communication 22
Patient record forms 22
Electronic patient record forms 23
Computerised databases 23
Characteristics of participating sites 23
Site 1 23
Site 2 25
Site 3 26
Themes from phase 1interviews 27
Increasing demand 27
Prioritisation 27
Communication: information accuracy 28
Time for assessment: appropriate decisions 28
Staff roles: skills and training 28
Protocols compared with flexibility over decisions 29
Ambulance service resources 29
Availability of local community pathways and out-of-hours care 30
Delays in response and handover 30
Targets 31
Transfers/handover to other services 31
Communication between staff andservices 32
Feedback on decisions 32
Geography/distance: time 32
NHS changes: Clinical Commissioning Groups 32
Specific patient groups 33
Public awareness and understanding of theservice 33
Comparisons acrosssites 34
Chapter 4Phase 2findings: observationsand digital diaries 35
Ethnographic observations and interviews 35
Digitaldiaries 35
Decision-making typology 36
Emergency conveyance: condition-specific pathway 37
Emergency/urgent conveyance: accident and emergency 37
Conveyance to maternity, oncology or another hospital unit 38
Decision to convey to hospital already made byanother clinician 38
Non-urgent conveyance/referral 38
Conveyance of patients to accident and emergency as aplaceof safety 39
Conveyance rather thanreferral to acommunity practitioner 40
Decision based on thepreference of thepatient or family 40
Non-conveyance: ‘treat and leave’ at scene(residential care/self-care) regarded as safe
options or safer options thanconveyance 41
Influences on decision-making 42
Communication from emergency operations centres 42
Patient assessment 42
Decision support systems 49
Alternatives to accident and emergency 50
Summary 51
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