Complexity of the decision-making process of ambulance staff for assessment and referral of older people who have fallen: a qualitative study
ABSTRACT Older people who fall commonly present to the emergency ambulance service, and approximately 40% are not conveyed to the emergency department (ED), despite an historic lack of formal training for such decisions. This study aimed to understand the decision-making processes of emergency ambulance staff with older people who have fallen.
During 2005 ambulance staff in London tested a clinical assessment tool for use with the older person who had fallen. Documented use of the tool was low. Following the trial, 12 staff participated in semistructured interviews. Interviews were recorded and transcribed. Thematic analysis was carried out.
The interviews revealed a similar assessment and decision-making process among participants: Prearrival: forming an early opinion from information from the emergency call. Initial contact: assessing the need for any immediate action and establishing a rapport. Continuing assessment: gathering and assimilating medical and social information. Making a conveyance decision: negotiation, referral and professional defence, using professional experience and instinct.
An assessment process was described that highlights the complexity of making decisions about whether or not to convey older people who fall and present to the emergency ambulance service, and a predominance of informal decision-making processes. The need for support for ambulance staff in this area was highlighted, generating a significant challenge to those with education roles in the ambulance service. Further research is needed to look at how new care pathways, which offer an alternative to the ED may influence decision making around non-conveyance.
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ABSTRACT: Background. Achieving knowledge translation in healthcare is growing in importance but methods to capture impact of research are not well developed. We present an attempt to capture impact of a programme of research in prehospital emergency care, aiming to inform the development of EMS models of care that avoid, when appropriate, conveyance of patients to hospital for immediate care. Methods. We describe the programme and its dissemination, present examples of its influence on policy and practice, internationally, and analyse routine UK statistics to determine whether conveyance practice has changed. Results. The programme comprises eight research studies, to a value of > £ 4 m. Findings have been disseminated through 18 published papers, cited 274 times in academic journals. We describe examples of how evidence has been put into practice, including new models of care in Canada and Australia. Routine statistics in England show that, alongside rising demand, conveyance rates have fallen from 90% to 58% over a 12-year period, 2,721 million fewer journeys, with publication of key studies 2003-2008. Comment. We have set out the rationale, key features, and impact on practice of a programme of publicly funded research. We describe evidence of knowledge translation, whilst recognising limitations in methods for capturing impact.The Scientific World Journal 06/2013; 2013:182102. DOI:10.1155/2013/182102 · 1.73 Impact Factor
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ABSTRACT: The Albanian medical system and Albanian health legislation have adopted a paternalistic position with regard to individual decision making. This reflects the practices of a not-so-remote past when state-run facilities and a totalitarian philosophy of medical care were politically imposed. Because of this history, advance directives concerning treatment refusal and do-not-resuscitate decisions are still extremely uncommon in Albania. Medical teams cannot abstain from intervening even when the patient explicitly and repeatedly solicits therapeutic abstinence. The Albanian law on health care has no provisions regarding limits or withdrawal of treatment. This restricts the individual's healthcare choices. The question of 'medically futile' interventions and pointless life-prolonging treatment has been discussed by several authors. Dutch physicians call such interventions 'medisch zinloos' (senseless), and the Netherlands, as one of the first states to legislate on end-of-life situations, actually regulates such issues through appropriate laws. In contrast, leaving an 'advance directive' is not a viable option for Albanian ailing individuals of advanced age. Verbal requests are provided during periods of mental competence, but unfortunately such instructions are rarely taken seriously, and none of them has ever been upheld in a legal or other official forum. End-of-life decisions, treatment refusal and do-not-resuscitate policies are hazardous options in Albania, from the legal point of view. Complying with them involves significant risk on the part of the physician. Culturally, the application of such instructions is influenced from a mixture of religious beliefs, death coping-behaviors and an immense confusion concerning the role of proxies as decision-makers. Nevertheless, Albanian tradition is familiar with the notion of 'amanet', a sort of living will that mainly deals the property and inheritance issues. Such living wills, verbally transmitted, may in certain cases include advance directives regarding end-of-life decisions of the patient including refusal or termination of futile medical treatments. Since these living wills are never formally and legally validated, their application is impossible and treatment refusal remains still non practicable. Tricks to avoid institutional treatment under desperate conditions are used, aiming to provide legal coverage for medical teams and relatives that in extreme situations comply with the advice of withholding senseless treatment.BMC Medical Ethics 06/2011; 12:12. DOI:10.1186/1472-6939-12-12 · 1.60 Impact Factor
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ABSTRACT: Paramedics routinely make critical decisions about the most appropriate care to deliver in a complex system characterized by significant variation in patient case-mix, care pathways and linked service providers. There has been little research carried out in the ambulance service to identify areas of risk associated with decisions about patient care. The aim of this study was to explore systemic influences on decision making by paramedics relating to care transitions to identify potential risk factors. An exploratory multi-method qualitative study was conducted in three English National Health Service (NHS) Ambulance Service Trusts, focusing on decision making by paramedic and specialist paramedic staff. Researchers observed 57 staff across 34 shifts. Ten staff completed digital diaries and three focus groups were conducted with 21 staff. Nine types of decision were identified, ranging from emergency department conveyance and specialist emergency pathways to non-conveyance. Seven overarching systemic influences and risk factors potentially influencing decision making were identified: demand; performance priorities; access to care options; risk tolerance; training and development; communication and feedback and resources. Use of multiple methods provided a consistent picture of key systemic influences and potential risk factors. The study highlighted the increased complexity of paramedic decisions and multi-level system influences that may exacerbate risk. The findings have implications at the level of individual NHS Ambulance Service Trusts (e.g. ensuring an appropriately skilled workforce to manage diverse patient needs and reduce emergency department conveyance) and at the wider prehospital emergency care system level (e.g. ensuring access to appropriate patient care options as alternatives to the emergency department). © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.Journal of Health Services Research & Policy 01/2015; 20(1):45-53. DOI:10.1177/1355819614558472 · 1.73 Impact Factor