A new study focusing on decision making by paramedic and specialist paramedic staff and conducted in three English National Health Service (NHS) Ambulance Service Trusts was published this month. The study, entitled ‘A qualitative study of systemic influences on paramedic decision making: care transitions and patient safety‘ published in the Journal of Health Services Research and Policy was led by Dr Rachel O’Hara from ScHARR at the University of Sheffield and included Professor Niro Siriwardena, director of CaHRU, and Debbie Shaw, visiting fellow at CaHRU, and both members of the East Midlands Ambulance Research Alliance at East Midlands Ambulance Service NHS Trust.
The study involved observation and interviews, analysis of digital diaries and focus groups with paramedic staff. Different types of decision were identified, ranging from the decision to convey a patient to the emergency department, use of specialist emergency pathways or the decision to treat and leave a patient at home. Systemic influences and risk factors affecting decision making included demand, performance priorities, access to care options, risk tolerance, training, communication, feedback and resources.
The study highlighted the complexity of paramedic decision making and system factors which could worsen risk. Decision making has been studied in other settings but rarely in the prehospital environment, and the uncertainty which paramedics have to face when making decisions needs further work. The study forms part of the Prehospital Emergencies Quality and Outcomes programme at CaHRU.
Researchers from CaHRU with colleagues from the School of Health and Related Research (ScHARR) at the University of Sheffield have published a new study: “Reassurance as a key outcome valued by emergency ambulance service users: a qualitative interview study” in the journal Health Expectations. The study’s lead author was Fiona Togher, PhD student and Graduate Research Assistant in CaHRU. She was supported in the work by Alicia O’Cathain, Professor of Health Services Research at the University of Sheffield, Viet-Hai Phung, Research Assistant in CaHRU, Janette Turner, Research Fellow at the University of Sheffield and Professor Niro Siriwardena, director of CaHRU. The study is part of a five year NIHR Programme for Applied Health Research, Prehospital Outcomes for Evidence Based Evaluation (PhOEBE).
The authors aimed to investigate the aspects of emergency ambulance care that were most valued by users of the service. Fiona and Viet-Hai interviewed people (patients and carers) that had used the ambulance service for a range of different conditions such as diabetes, suspected stroke, breathing difficulties and falls. The participants had also received various types of ambulance service response i.e. ‘hear and treat’ in which the participants received enhanced clinical assessment and advice over the telephone only, ‘see and treat’ in which the participants were treated on-scene by appropriately skilled clinicians without the need for hospital admission and the more familiar, ‘see and convey’ in which the participants received pre-hospital assessment and treatment before transportation to acute care.
The authors found that regardless of their specific clinical problem people valued similar aspects of their emergency ambulance service experience. Participants had often been extremely anxious about their health, and they most valued the reassurance they felt from receiving appropriate advice, treatment and care from ambulance service staff. It was found that the ability of the emergency ambulance service to allay the high levels of fear and anxiety felt by users is crucial to the delivery of a high quality service.
The qualitative interview data collected from this research is now being re-analysed as part of Fiona’s doctoral studies to develop a Patient Reported Experience Measure (PREM) for use in UK ambulance services.
A new book, ‘Quality Improvement in Primary Care: the essential guide‘ has recently been published by Radcliffe. The book is co-authored by Dr Steve Gillam (Cambridge University) and Professor Niro Siriwardena (Director of CaHRU, University of Lincoln). The content was developed from the authors’ work on quality improvement over many years and on quality improvement and implementation science research conducted by CaHRU. The text provides the foundations of knowledge for health and social care practitioners and students to improve the quality of care they provide.
The first section of the book ‘Managing for quality’ leads readers though fundamentals of improvement including patient perspectives, leadership and management, regulation and commissioning. The middle section focuses on quality improvement tool and techniques covering topics such as improvement frameworks, processes, measurement, systems, safety, spreading improvement and financial incentives. The final part of the book covers evaluating improvement, understanding evidence and applying this learning to individual and group quality improvement projects.
Quality is a watchword across the health and social care sector. Quality Improvement in Primary Care will be a text for students embarking on the new course module, ‘Quality Improvement, Implementation and Safety Science’ which forms part of the new Master’s in Social Research at the University of Lincoln. It will provide readers with the tools to convert challenges and opportunities for improvement into meaningful and useful change.[su_document url=”https://communityandhealth.dev.lincoln.ac.uk/files/2014/10/Quality-improvement-in-primary-care.pdf” height=”1600″ responsive=”no”]Multi-morbidity, goal-oriented care, the community and equity[/su_document]
Researchers in CaHRU and East Midlands Ambulance Service NHS Trust (EMAS) have published a new study: “Identifying barriers and facilitators to ambulance service assessment and treatment of acute asthma: a focus group study” in BMC Emergency Medicine. The study’s lead author was Deborah Shaw of the Clinical Audit and Research Department at EMAS and visiting fellow at CaHRU. She was supported in the work by Prof Niro Siriwardena, director of CaHRU and associate clinical director at EMAS.
The authors aimed to explore paramedics’ attitudes, perceptions and beliefs about prehospital management of asthma, to identify barriers and facilitators to guideline adherence, acknowledging variations in prehospital care for asthma. The investigators interviewed paramedics and managers and their analysis identified that guidelines should be made more relevant to ambulance service care; barriers to assessment; conflicts between clinicians’ and patients’ expectations; complex ambulance service processes and equipment; and opportunities for improved prehospital education, information, communication, support and care pathways for asthma.
The service has already used these findings to improve prehospital care for people with asthma and other chronic respiratory conditions.
Novel treatments for stroke are increasingly being tested and delivered in the ultra-acute period during initial presentation to ambulance services. In the first feasibility trial of nitroglycerin (glyceryl trinitrate) in ultra-acute stroke (RIGHT) there were early indications of improvements in outcomes and disability at three months. The research team was led by Prof Philip Bath and his team at Nottingham University, together with Sandeep Ankolekar, Prof Niro Siriwardena from CaHRU and researchers at East Midlands Ambulance Service NHS Trust.
A nested qualitative study entitled ‘Views of paramedics on their role in an out-of-hospital ambulance-based trial in ultra-acute stroke: qualitative data from the Rapid Intervention with Glyceryl Trinitrate in Hypertensive Stroke Trial (RIGHT)‘ explored facilitators and barriers to paramedic involvement in clinical trials. The fieldwork was conducted by Dr Sandeep Ankolekar and the team. Barriers to participation included the pressure of the emergency setting, difficulties obtaining informed consent, institutional support for research, the steep learning curve for research naive staff and relative rarity for individual paramedics of clinical conditions seen, and difficulty in attending training sessions.
Suggestions for improvement included a simple diagnostic tool for stroke, use of assent and proxy consent on behalf of patients (as in the trial), and simpler trial processes.Recruitment became easier with each new randomisation attempt. Paramedics in the study were motivated to participate in research. Treatment of acute stroke in the out-of-hospital environment was feasible, but important barriers needed to be addressed.