HEALTH SERVICES AND DELIVERY RESEARCH

HEALTH SERVICES AND DELIVERY RESEARCH VOLUME 2 ISSUE 56 DECEMBER 2014 ISSN 2050-4349 A quaitative study of decision-making and safety in ambuance service transitions Rache 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 quaitative study of decision-making and safety in ambuance service transitions Rache 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 Shewan 5 and A Niroshan Siriwardena 4,9 1 Pubic Heath Section, Schoo of Heath and Reated Research (ScHARR), University of Sheffied, Sheffied, UK 2 Sheffied Emergency Care Forum, Sheffied, UK 3 Department of Psychoogy, University of Bath, Bath, UK 4 East Midands Ambuance Service NHS Trust, Nottingham, UK 5 Yorkshire Ambuance Service NHS Trust, Wakefied, UK 6 South East Coast Ambuance Service NHS Trust, Guidford, UK 7 Heath Services Research Section, Schoo of Heath and Reated Research (ScHARR), University of Sheffied, Sheffied, UK 8 Facuty of Heath and Medica Sciences, University of Surrey, Guidford, UK 9 Community and Heath Research Unit, Coege of Socia Science, University of Lincon, Lincon, UK *Corresponding author Decared competing interests of authors: none Pubished December 2014 DOI: 10.3310/hsdr02560 This report shoud be referenced as foows: O Hara R, Johnson M, Hirst E, Weyman A, Shaw D, Mortimer P, et a. A quaitative study of decision-making and safety in ambuance service transitions. Heath Serv Deiv Res 2014;2(56).

Heath Services and Deivery Research ISSN 2050-4349 (Print) ISSN 2050-4357 (Onine) This journa is a member of and subscribes to the principes of the Committee on Pubication Ethics (COPE) (www.pubicationethics.org/). Editoria contact: nihredit@southampton.ac.uk The fu HS&DR archive is freey avaiabe to view onine at www.journasibrary.nihr.ac.uk/hsdr. Print-on-demand copies can be purchased from the report pages of the NIHR Journas Library website: www.journasibrary.nihr.ac.uk Criteria for incusion in the Heath Services and Deivery Research journa Reports are pubished in Heath Services and Deivery Research (HS&DR) if (1) they have resuted from work for the HS&DR programme or programmes which preceded the HS&DR programme, and (2) they are of a sufficienty high scientific quaity as assessed by the reviewers and editors. HS&DR programme The Heath Services and Deivery Research (HS&DR) programme, part of the Nationa Institute for Heath Research (NIHR), was estabished to fund a broad range of research. It combines the strengths and contributions of two previous NIHR research programmes: the Heath Services Research (HSR) programme and the Service Deivery and Organisation (SDO) programme, which were merged in January 2012. The HS&DR programme aims to produce rigorous and reevant evidence on the quaity, access and organisation of heath services incuding costs and outcomes, as we as research on impementation. The programme wi enhance the strategic focus on research that matters to the NHS and is keen to support ambitious evauative research to improve heath services. For more information about the HS&DR programme pease visit the website: http://www.nets.nihr.ac.uk/programmes/hsdr This report The research reported in this issue of the journa was funded by the HS&DR programme or one of its proceeding programmes as project number 10/1007/53. The contractua start date was in May 2012. The fina report began editoria review in November 2013 and was accepted for pubication in May 2014. The authors have been whoy responsibe for a data coection, anaysis and interpretation, and for writing up their work. The HS&DR editors and production house have tried to ensure the accuracy of the authors report and woud ike to thank the reviewers for their constructive comments on the fina report document. However, they do not accept iabiity for damages or osses arising from materia pubished in this report. This report presents independent research funded by the Nationa Institute for Heath Research (NIHR). The views and opinions expressed by authors in this pubication are those of the authors and do not necessariy refect those of the NHS, the NIHR, NETSCC, the HS&DR programme or the Department of Heath. If there are verbatim quotations incuded in this pubication the views and opinions expressed by the interviewees are those of the interviewees and do not necessariy refect those of the authors, those of the NHS, the NIHR, NETSCC, the HS&DR programme or the Department of Heath. Queen s Printer and Controer of HMSO 2014. This work was produced by O Hara et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. Pubished by the NIHR Journas Library (www.journasibrary.nihr.ac.uk), produced by Prepress Projects Ltd, Perth, Scotand (www.prepress-projects.co.uk).

Heath Services and Deivery Research Editor-in-Chief Professor Ray Fitzpatrick Professor of Pubic Heath and Primary Care, University of Oxford, UK NIHR Journas Library Editor-in-Chief Professor Tom Waey Director, NIHR Evauation, Trias and Studies and Director of the HTA Programme, UK NIHR Journas Library Editors Professor Ken Stein Chair of HTA Editoria Board and Professor of Pubic Heath, University of Exeter Medica Schoo, UK Professor Andree Le May Chair of NIHR Journas Library Editoria Group (EME, HS&DR, PGfAR, PHR journas) Dr Martin Ashton-Key Consutant in Pubic Heath Medicine/Consutant Advisor, NETSCC, UK Professor Matthias Beck Chair in Pubic Sector Management and Subject Leader (Management Group), Queen s University Management Schoo, Queen s University Befast, UK Professor Aieen Carke Professor of Pubic Heath and Heath Services Research, Warwick Medica Schoo, University of Warwick, UK Dr Tessa Criy Director, Crysta Bue Consuting Ltd, UK Dr Peter Davidson Director of NETSCC, HTA, UK Ms Tara Lamont Scientific Advisor, NETSCC, UK Professor Eaine McCo Director, Newcaste Cinica Trias Unit, Institute of Heath and Society, Newcaste University, UK Professor Wiiam McGuire Professor of Chid Heath, Hu York Medica Schoo, University of York, UK Professor Geoffrey Meads Professor of Heath Sciences Research, Facuty of Education, University of Winchester, UK Professor John Powe Consutant Cinica Adviser, Nationa Institute for Heath and Care Exceence (NICE), UK Professor James Raftery Professor of Heath Technoogy Assessment, Wessex Institute, Facuty of Medicine, University of Southampton, UK Dr Rob Riemsma Reviews Manager, Keijnen Systematic Reviews Ltd, UK Professor Heen Roberts Professor of Chid Heath Research, UCL Institute of Chid Heath, UK Professor Heen Snooks Professor of Heath Services Research, Institute of Life Science, Coege of Medicine, Swansea University, UK Pease visit the website for a ist of members of the NIHR Journas Library Board: www.journasibrary.nihr.ac.uk/about/editors Editoria contact: nihredit@southampton.ac.uk NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02560 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 56 Abstract A quaitative study of decision-making and safety in ambuance service transitions Rache 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 Shewan 5 and A Niroshan Siriwardena 4,9 1 Pubic Heath Section, Schoo of Heath and Reated Research (ScHARR), University of Sheffied, Sheffied, UK 2 Sheffied Emergency Care Forum, Sheffied, UK 3 Department of Psychoogy, University of Bath, Bath, UK 4 East Midands Ambuance Service NHS Trust, Nottingham, UK 5 Yorkshire Ambuance Service NHS Trust, Wakefied, UK 6 South East Coast Ambuance Service NHS Trust, Guidford, UK 7 Heath Services Research Section, Schoo of Heath and Reated Research (ScHARR), University of Sheffied, Sheffied, UK 8 Facuty of Heath and Medica Sciences, University of Surrey, Guidford, UK 9 Community and Heath Research Unit, Coege of Socia Science, University of Lincon, Lincon, UK *Corresponding author r.ohara@sheffied.ac.uk Background: Decisions made by front-ine ambuance staff are often time critica and based on imited information, but wrong decisions in this context coud have serious consequences for patients. There has been itte research carried out in the ambuance service setting to identify areas of risk associated with decisions about patient care. Aim: The aim of this study was to quaitativey examine potentia system-wide infuences on decision-making in the ambuance service setting and to identify usefu areas for future research and intervention. Methods: We used a mutisite, mutimethod quaitative approach across three ambuance service trusts. In phase 1 we carried out 16 interviews to contextuaise the study and provide discussion points for phase 2. For phase 2, university and ambuance service researchers observed paramedics on 34 shifts and 10 paramedics competed digita diaries that reported chaenges to decision-making or to patient safety. Six focus groups were hed, three with staff (n = 21) and three with service users (n = 23). From observation and diary data we deveoped a typoogy of decisions made at the scene. Data from these and other sources were aso coded within a human factors framework and then thematicay anaysed to identify infuences on those decisions. In phase 3, workshops were hed at each site to aow participants and stakehoders (n = 45) to comment on the study findings. Participants were asked to rank infuences on decisions using a paired comparison method. Resuts: Interviews provided the context for further quaitative exporation. Nine types of decision were identified from observations and digita diaries, ranging from emergency department conveyance and speciaist emergency pathways to non-conveyance. A synthesis of findings from the observations, diaries Queen s Printer and Controer of HMSO 2014. This work was produced by O Hara et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. v

ABSTRACT and staff focus groups reveaed seven overarching system infuences on decision-making and potentia risk factors: meeting increasing demand for emergency care; impacts of performance regime and priorities on service deivery; access to appropriate care options; disproportionate risk aversion; education, training and professiona deveopment for crews; communication and feedback to crews; and ambuance service resources. Safety cuture issues were aso identified. Data from the service user focus groups refected simiar issues to those identified from the staff focus groups. Service user concerns incuded ca handing and communication, triage, patient invovement in decisions, baancing demand, resources, access to care, risk aversion, geographica ocation and vunerabe patients. Group discussions highighted a ack of awareness by the pubic of how best to use emergency and urgent care services. Workshop attendees were satisfied that the findings refected reevant issues. The two issues ranked highest for warranting attention were staff training and deveopment and access to aternative care. Concusions: Mutipe quaitative methods aowed a range of perspectives to be accessed and vaidation of issues across perspectives. Recommendations for future research incude exporing effective ways of providing access to aternative care pathways to accident and emergency, assessing pubic awareness and expectations of ambuance and reated services, exporing safe ways of improving teephone triage decisions and assessing the effects of different staff ski eves on patient safety. Funding: The Nationa Institute for Heath Research Heath Services and Deivery Research programme. vi NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02560 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 56 Contents List of tabes List of figures List of boxes Gossary List of abbreviations Pain Engish summary Scientific summary xi xiii xv xvii xix xxi xxiii Chapter 1 Introduction 1 Background 1 The ambuance service system and decision-making 1 Patient safety modes 2 Patient safety in an evoving system 3 Aim and objectives 4 Aim 4 Objectives 4 Chapter 2 Methods 5 Justification for the study design 5 Methodoogica approaches 5 The systems approach 5 The mutisource approach 5 Study setting 5 Components of the study 6 Phase 1: mapping the system 6 Phase 2: exporing infuences on decision-making and safety 7 Phase 2: service user focus groups 11 Phase 3: feedback workshops 13 Ethica and research governance approva 14 Chapter 3 Phase 1 findings: mapping the system 15 Institutiona and organisationa context 15 Funding and commissioning 15 Care quaity and performance measurement 16 Reorganisation and restructuring 17 Foundation trust status 17 Poicies, procedures and guideines 18 Incident reporting 18 Compaints procedures 19 Queen s Printer and Controer of HMSO 2014. This work was produced by O Hara et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. vii

CONTENTS Professiona roes and responsibiities 19 Emergency operations centre staff 19 Operationa staff 20 Other supportive roes 22 Documentation and communication 22 Patient record forms 22 Eectronic patient record forms 23 Computerised databases 23 Characteristics of participating sites 23 Site 1 23 Site 2 25 Site 3 26 Themes from phase 1 interviews 27 Increasing demand 27 Prioritisation 27 Communication: information accuracy 28 Time for assessment: appropriate decisions 28 Staff roes: skis and training 28 Protocos compared with fexibiity over decisions 29 Ambuance service resources 29 Avaiabiity of oca community pathways and out-of-hours care 30 Deays in response and handover 30 Targets 31 Transfers/handover to other services 31 Communication between staff and services 32 Feedback on decisions 32 Geography/distance: time 32 NHS changes: Cinica Commissioning Groups 32 Specific patient groups 33 Pubic awareness and understanding of the service 33 Comparisons across sites 34 Chapter 4 Phase 2 findings: observations and digita diaries 35 Ethnographic observations and interviews 35 Digita diaries 35 Decision-making typoogy 36 Emergency conveyance: condition-specific pathway 37 Emergency/urgent conveyance: accident and emergency 37 Conveyance to maternity, oncoogy or another hospita unit 38 Decision to convey to hospita aready made by another cinician 38 Non-urgent conveyance/referra 38 Conveyance of patients to accident and emergency as a pace of safety 39 Conveyance rather than referra to a community practitioner 40 Decision based on the preference of the patient or famiy 40 Non-conveyance: treat and eave at scene (residentia care/sef-care) regarded as safe options or safer options than conveyance 41 Infuences on decision-making 42 Communication from emergency operations centres 42 Patient assessment 42 Decision support systems 49 Aternatives to accident and emergency 50 Summary 51 viii NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02560 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 56 Phase 2 findings: staff focus groups 51 Contro room: triage and dispatch information 51 Changing service demands 52 Service deivery priorities and pressures 53 Aternative care options for patients 55 Risk perception and avoidance 57 Staff training and skis 58 Staff roes 59 Information and support 60 Access to feedback 61 Ambuance service resources: equipment, vehices and staff 62 Ambuance service patient safety cuture 62 Patient safety as a priority 63 Organisationa earning from patient safety incidents 64 Staff support and deveopment 66 Areas of reative strength and weakness 67 Synthesis of the findings 67 Chapter 5 Phase 2 findings: service user focus groups 69 Ca handing: communication and triage 69 Invovement in decisions 70 Baancing demand and resources 71 Demand 71 Resources 72 Access to care 73 Risk aversion 75 Geographica ocation 75 Vunerabe patients 76 Chapter 6 Phase 3 findings: workshops and prioritisation 77 Feedback from attendees: comments on findings 77 Prioritisation task 77 Findings 77 Suggestions for potentia interventions and research 79 Interventions 79 Research 80 Chapter 7 Discussion 81 Introduction 81 Principa findings 81 Typoogy of decisions and system infuences 81 The changing nature of ambuance service care and decisions 82 Staff roes, skis and deveopment 83 The interface with other heath and socia care services 83 Communication and feedback to support decision-making 84 Risk perception and management 85 The service user perspective 86 Strengths of the study 86 Limitations of the study 87 Chaenges 88 Queen s Printer and Controer of HMSO 2014. This work was produced by O Hara et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. ix

CONTENTS Chapter 8 Concusions and recommendations 89 Impications for heath care 89 Recommendations for research 91 Acknowedgements 93 References 95 Appendix 1 Phase 1 information sheet 101 Appendix 2 Phase 1 interview topic guide 103 Appendix 3 Phase 2 staff information sheet 105 Appendix 4 Phase 2 staff observation guide 109 Appendix 5 Phase 2 staff observation participants 111 Appendix 6 Phase 2 digita diary guidance 113 Appendix 7 Manchester Patient Safety Framework: ambuance 115 Appendix 8 Phase 2 staff focus group topic guide 117 Appendix 9 Phase 2 service user information sheet 119 Appendix 10 Phase 2 service user focus group topic guide 121 Appendix 11 Phase 3 workshop invitation etter 123 Appendix 12 Phase 3 workshop attendees 125 Appendix 13 Phase 3 prioritisation booket 127 Appendix 14 Phase 1 participants 129 Appendix 15 Phase 2 observation data anaysis matrix 131 Appendix 16 System infuences on decision-making: human factors framework 133 Appendix 17 Areas for future research identified by workshop participants 137 x NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02560 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 56 List of tabes TABLE 1 Staff roes for digita diary participants across sites 9 TABLE 2 Staff roes for staff focus group participants across sites 10 TABLE 3 Characteristics of service user focus group participants 12 TABLE 4 Detais of workshop attendees 13 TABLE 5 Typoogy of operationa/cinica decision-making 36 TABLE 6 Comparison of ambuance staff and service user future rankings of priorities for emergency care patient safety 78 TABLE 7 Characteristics of staff observation participants 111 TABLE 8 Site 1 workshop attendees 125 TABLE 9 Site 2 workshop attendees 125 TABLE 10 Site 3 workshop attendees 125 TABLE 11 Cassification of risk factors potentiay infuencing paramedic decisions using a human factors framework based on interviews, observations, digita diaries and focus groups 133 Queen s Printer and Controer of HMSO 2014. This work was produced by O Hara et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. xi

DOI: 10.3310/hsdr02560 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 56 List of figures FIGURE 1 Reative importance/saience by potting the distance between the entities on a singe continuum 78 Queen s Printer and Controer of HMSO 2014. This work was produced by O Hara et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. xiii

DOI: 10.3310/hsdr02560 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 56 List of boxes BOX 1 Summary of study findings: types of paramedic decisions 81 BOX 2 Summary of study findings: system infuences on decisions 82 Queen s Printer and Controer of HMSO 2014. This work was produced by O Hara et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. xv

DOI: 10.3310/hsdr02560 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 56 Gossary Aternative pathways Pathways that provide an aternative to accident and emergency, for exampe minor injuries unit, out-of-hours services, wak-in centre, emergency care practitioner or paramedic practitioner. Ambuance service crew When references to ambuance service crew or crew members are used they refer to staff in response vehices (e.g. ambuances, cars), incuding soo (singe) responders. Cadicott review Guideines on the storage of, maintenance of and access to patient information. Digita diary Digita recording of events and experiences whist in the natura setting. Dispatch Aocation of ambuance service resources to cover demands paced on the service. FAST Stroke assessment too: face, arms, speech, time. Hear and treat Cinician gives advice to a patient/carer over the teephone. Make Ready ambuances Make Ready is a vehice preparation system that empoys speciaist teams of staff to cean, restock and maintain vehices, to aow cinica staff more time to treat patients. Monitor Reguator for the protection of patient interests. NHS 111 Resource for medica hep (non-emergency). NHS Direct Digita heath and advice service. NHS Pathways Computerised triage system. Non-conveyance A decision is made not to convey a patient to accident and emergency or another heath-care faciity. Pre-aert Ca made to a heath-care unit to advise about a patient transfer. See and treat Practitioner provides treatment at the scene. Toxbase Guide to deaing with the effects of toxic substances. Trauma tree Agorithm to aid decision-making when assessing trauma patients. Treat and eave Patient is assessed and treated at the scene and a decision is made not to convey him or her to accident and emergency or another heath-care faciity. Triage Prioritisation for treatment according to the seriousness of the condition. Typoogy Cassification of types. Queen s Printer and Controer of HMSO 2014. This work was produced by O Hara et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. xvii

DOI: 10.3310/hsdr02560 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 56 List of abbreviations A&E accident and emergency HCPC Heath Care Professionas Counci AMPDS Advanced Medica Priority Dispatch System IBIS Inteigence Based Information System BASICS CCG British Association for Immediate Care Cinica Commissioning Group IR1 JRCALC incident report form Joint Roya Coeges Ambuance Liaison Committee CCP CFR COPD critica care paramedic community first responder chronic obstructive pumonary disease MaPSaF NPSA PCT Manchester Patient Safety Framework Nationa Patient Safety Agency primary care trust CQC Care Quaity Commission PP paramedic practitioner DMA ECA ECG ECP EMT EOC eprf FAST FT dua manned ambuance emergency care assistant eectrocardiogram emergency care practitioner emergency medica technician emergency operations centre eectronic patient record form face, arms, speech, time foundation trust PPCI PPI PRF RRV SBAR SDO STEMI primary percutaneous coronary intervention patient and pubic invovement patient record form rapid response vehice situation, background, assessment, recommendation Service Deivery and Organisation ST segment eevation myocardia infarction GP genera practitioner STFG staff focus group HART hazardous area response team SUFG service user focus group Queen s Printer and Controer of HMSO 2014. This work was produced by O Hara et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. xix

DOI: 10.3310/hsdr02560 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 56 Pain Engish summary In this study we aimed to ook at infuences on decisions made about patients by front-ine ambuance service staff (paramedics). We were particuary interested in whether and where patients were transported and the impact of decisions on patient safety. We were aso interested in safety cuture within the organisation and how this might infuence staff. We used a number of research methods incuding interviews, observations, digita diaries and focus groups with staff and service users to coect data at three ambuance service trust sites. This aowed us to gather information that represented a wide range of views and experiences. We fed back the study findings to ambuance service staff and service user participants at three workshops. Data were anaysed to identify the main issues of importance in reation to infuences on staff decision-making. A number of different types of decisions that paramedics make on scene were identified aong with a number of infuences on decision-making. The main infuences were demand, access to care services, performance targets, fear of risk, training and education, communication and resources (staff and equipment). The workshop attendees fet that these findings refected their experiences and concerns. Recommendations for future research incude exporing effective ways of providing access to care for peope who do not need to attend the accident and emergency department, assessing the effects of different staff ski eves on patient safety, exporing safe ways of improving initia teephone assessments and exporing pubic awareness and expectations of the ambuance service. Queen s Printer and Controer of HMSO 2014. This work was produced by O Hara et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. xxi

DOI: 10.3310/hsdr02560 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 56 Scientific summary Background The deivery of emergency heath care within the NHS embodies chaenges for risk management and patient safety. Circumstances can be demanding for patients and staff, with mutipe decisions being made that often invove crossing professiona and organisationa boundaries. Front-ine ambuance service staff routiney make critica decisions about the most appropriate care to deiver in a compex system characterised by significant variation in patient case mix, care pathways and inked service providers. Before the commissioning of this research very itte research had been carried out within ambuance service settings to identify areas of high risk associated with decision-making about patient care options. The increase in demand for emergency care over the ast decade has ed to significant changes in the way pre-hospita emergency care is deivered. These changes have increased the compexity of the system, with the introduction of new services, staff roes and associated patient care pathways, aong with increasing demands to meet operationa standards and performance targets. To address the patient safety issues associated with decisions around transitions in patient care, it is therefore necessary to examine the infuence of the wider system in which these decisions are made. This study examined system infuences on decision-making by ambuance service staff around transitions in patient care. Aim To expore the various infuences on safe decision-making by ambuance service staff to identify areas in which interventions are needed to improve patient safety during transitions and areas in which further research is needed. Objectives 1. To map the ambuance service system, care pathways, inked services and decisions that are critica for safe care in a sampe of ambuance services in Engand. 2. To conduct an ethnographic investigation of factors infuencing decision-making by ambuance service staff directy invoved in patient care to identify threats to patient safety (risk factors) and how these threats are managed. 3. To feed back the study findings to participating ambuance services and oca stakehoders to eicit their views and identify areas in which strategies are needed to improve patient safety and areas in which further research is needed. Study setting Seection of three ambuance service trusts sought to ensure that the study represented the variety of contextua factors in the pre-hospita emergency care system (e.g. care pathways, staff roes, service configuration) and that the issues identified had reevance to the other ambuance service trusts in Engand. Three case study organisations enabed the examination of variations in system characteristics and how these reate to deivering safe care. The participating trusts operate across diverse geographica areas, incuding densey popuated urban areas and sparsey popuated rura areas. They aso serve Queen s Printer and Controer of HMSO 2014. This work was produced by O Hara et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. xxiii

SCIENTIFIC SUMMARY socioeconomicay diverse popuations and provide a variety of emergency care responses (e.g. paramedics or paramedics with advanced training and skis). Methods The study adopted a mutisite design using mutipe quaitative methods to examine the various infuences on decision-making by ambuance service staff, particuary concerning transitions in the care process and the safety impications for patient care. Phase 1: mapping the system Phase 1 aimed to provide some contextua understanding of the three sites by mapping the emergency care system, care pathways, inked services, safety critica decisions and organisationa characteristics that coud affect patient safety in the participating ambuance services. This invoved conducting semistructured interviews with a sma number of key informants (n = 16) across the three sites and consuting documentation to deveop a representation of the oca system and eicit informants perceptions of infuences on staff decisions, care transitions and threats to patient safety. Phase 1 highighted a number of issues reevant to phase 2 that heped to trigger discussion in the focus groups. Phase 2: exporing infuences on decision-making and safety Phase 2 examined decision-making practices and infuences around care transitions across the three ambuance services and their inked urgent and emergency care network. It addressed how the emergency care system infuenced decision-making and identified the key issues for staff and service users. Phase 2 incuded an ethnographic study in which ambuance service staff at each site were observed over a fu shift period (10 12 hours) by either a university researcher or an ambuance service researcher. In tota, 34 shifts were observed across the three trusts, incuding at east two different operationa areas per site and invoving a range of staff (n = 57) and patient cas (n = 155). Digita diaries were competed by paramedics across the three sites (n = 10), recording issues in reation to a range of patient cas (n = 141). Three staff focus groups were conducted across the three ambuance service trusts (n = 21). Participants had experience with the service ranging from < 1 year to 20 years. Roes incuded soo rapid response, dua crew member, emergency care practitioner (ECP), paramedic practitioner (PP) and critica care paramedic (CCP). In addition, three focus groups were carried out invoving service users (n = 23). Phase 3: feedback workshops Phase 3 invoved workshops at each site to feed back research findings. The aim was to feed back the study findings and eicit suggestions on potentia areas for intervention to improve patient safety and areas in which further research is needed. Across the three sites, a tota of 45 staff and service users attended the workshops aong with members of the study team. Data anaysis For interviews, focus groups, digita diaries and workshops, data were audio recorded. Data from observations were coected using a mix of audio recorder and written notes. Audio recordings were transcribed verbatim for anaysis. Data anaysis invoved coding and categorisation of data, using a human factors framework. From the framework, an iterative process of coding and categorisation identified themes reevant to the research question. Observation data from each shift attended were charted and coded to produce a typoogy of different types of decisions that paramedics make when attending patients. Infuences on those decisions from observation, digita diary and focus group data were coded within the human factors framework and then thematicay anaysed. The categories were fed back to participants at the three workshops. xxiv NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02560 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 56 Findings In phase 1 the changing poitica and financia context of the ambuance service was acknowedged and interview data identified a range of institutiona and organisationa issues that potentiay impact on operationa decision-making. Nine types of decision were identified, from speciaist emergency pathways to non-conveyance. The nine decision types iustrate the escaation in compexity and the potentia risk invoved in decision-making for urgent and more compicated cases compared with emergency and protoco-driven pathways for conditions such as trauma, cerebrovascuar accident (stroke) and heart attack (ST segment eevation myocardia infarction). Whereas emergency cases are more straightforward in terms of whether to convey a patient to hospita or not, non-emergency patients and potentia non-conveyance invoke compex decisions about socia and psychoogica care as we as attending to comorbidities. Whereas the typoogy iustrated the kinds of decisions made by ambuance crews, focus group, observation and digita diary data aso provided information about factors that impact on decisions. The rea-time data gathered during observations aowed the process of decision-making on scene to be observed as we as some of the infuences on those decisions. Digita diary and focus group data provided accounts from paramedics about decision-making and infuences on decisions in the context of patient safety. Coping with increasing demand, particuary in urgent care, infuenced decisions as accident and emergency (A&E) departments are becoming overoaded and there was acknowedgement that one way to improve the situation for staff and patients is, as far as possibe, to support patients to remain at the scene rather than conveying them to hospita. Observations and digita diaries showed that this option was considered in cases in which hospita admission was not stricty necessary. However, a data methods used highighted the compexity of this option in practice. For exampe, to aow patients to be treated and remain on scene paramedics needed the confidence to make this decision safey, which required an appropriate eve of skis and knowedge. Patients and/or carers needed to understand the impications of treatment and foow-up care and/or sef-care. Foow-up often required referra to other professionas outside the ambuance service, which was dependent on those services being avaiabe at that time and in that setting. The process of decision-making began with information retrieved from the contro room and was foowed by patient assessment. Assessment incuded ooking for cues about what was norma or abnorma for the patient, what was needed in that situation and whether this perceived need coud be reconcied with what the patient wanted. Externa cues about best practice and aternative options to A&E conveyance were retrieved from the avaiabe ambuance decision support mechanisms. Staff focus group data highighted 10 main issues infuencing patient safety in decision-making. These overapped with findings from observations and digita diaries and gave a degree of confidence to the vaidity of the findings. However, focus groups provided a different perspective because they were retrospective and group based. Groups spoke about the changing nature of demand for ambuance service care, incuding the increased scope and compexity of decisions that encompass emergency care, primary care and psychosocia decisions. Time and resource pressures were fet to be exacerbated by the current ambuance service performance regime and targets designed to improve emergency care outcomes. Operationa demands and performance targets aso impacted on opportunities for training and education, which was regarded as a risk to patient safety. A ack of standardised access to appropriate care options for a range of conditions and situations was a major issue, especiay as crews were working across numerous boundaries, geographica and organisationa. Some patient popuations were fet to be at greater risk because of imited and inconsistent service provision across the urgent and emergency care system (e.g. menta heath, end-of-ife and edery patients), particuary out of hours. This ed to situations, Queen s Printer and Controer of HMSO 2014. This work was produced by O Hara et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. xxv

SCIENTIFIC SUMMARY which were aso reported in digita diaries and interviews, in which paramedics made difficut decisions without speciaist support. There was a sense that communication between crews and their organisation was opportunistic and somewhat distant. A particuar issue was the ack of usefu feedback to crews about the appropriateness of the decisions they had made. This hampered earning for use in simiar future cases. Disproportionate risk aversion was associated with a combination of imited confidence, imited care options and a cuture in which paramedics fet at risk professionay shoud they make a mistake. Service user focus groups across the three sites refected on simiar issues. The accuracy of information being accessed during the initia process was a concern. Service users aso emphasised the importance of patient invovement in decisions made on scene. Service users were aware of the demands facing staff and the impact of being accessibe 24/7, whereas other services are more difficut to access. Risk aversion among the pubic and heath professionas was reported to be a potentia reason for increased demand, particuary in reation to patients with primary care and psychosocia needs. The study findings resonated with workshop participants. The prioritisation exercise to rank issues for attention identified the two highest ranking issues as training and deveopment and access to aternative care options. A range of potentia topics for future research as we as interventions was suggested at the workshops. The seven overarching issues identified are not mutuay excusive and they encompass an array of underying subthemes that might be more fruitfu to target for research or intervention. The eve of consistency across the participating trusts suggests that the issues identified are possiby reevant to other ambuance service trusts. Athough the findings argey focus on perceived weaknesses in the system and potentia threats to patient safety, it is fair to say that there were parts of the system within each of the trusts that were working we, for exampe specific pathways, oca roes and ways of working and technoogica initiatives that address information needs [Inteigence Based Information System (IBIS) and eectronic patient record form (eprf)]. Concusions and research recommendations The study expored infuences on safe decision-making and provided insights on the types of decisions that staff make as we as a range of system infuences. The use of mutipe methods provided consistent evidence around key issues. The NHS system within which the ambuance service operates is characterised in our study as fragmented and inconsistent. For ambuance service staff the extent of variation across the geographica areas in which they work is probematic in terms of knowing what services are avaiabe and being abe to access them. The ack of standardisation in practice guideines, pathways and protocos across services and between areas makes it particuary chaenging for staff to keep up to date with requirements. As ambuance services are increasingy under pressure to focus on reducing conveyance rates to A&E, this intensifies the need to ensure that crews are appropriatey skied to make effective decisions over the need to convey or not. However, there were widespread caims that meeting ambuance service operationa demands and performance targets imits the time avaiabe for training and professiona deveopment. The effectiveness of the paramedic roe in faciitating access to appropriate care pathways aso hinges on reationships with other care providers but staff fet that perceptions of the ambuance service as primariy a transport service pose a barrier to working across these professiona and service boundaries. Service users were receptive to non-conveyance options but fet that ack of awareness of staff roes and skis may cause concern when patients expect conveyance to A&E. xxvi NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02560 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 56 The foowing research recommendations are based on the study findings: identify effective ways of improving the deivery of care across service boundaries, particuary for patients with imited options at present (e.g. menta heath, end-of-ife care, oder patients) expore the impact of enhanced skis on patient care and on staff, for exampe the impact of increased training for urgent rather than emergency care expore the impact of different aspects of safety cuture on ambuance service staff and the deivery of patient care given the increased breadth of paramedic decision-making, there is a need to ook at the diagnostic process and potentia causes of error expore whether there are efficient and safe ways of improving teephone triage decisions to reduce over-triage expore pubic awareness of, attitudes towards, beiefs about and expectations of the ambuance service and the wider urgent and emergency care network and the scope for behaviour change interventions ensure that evauations of new ambuance service performance metrics or other innovations address their potentia impact on patient safety. Funding Funding for this study was provided by the Heath Services and Deivery Research programme of the Nationa Institute for Heath Research. Queen s Printer and Controer of HMSO 2014. This work was produced by O Hara et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. xxvii

DOI: 10.3310/hsdr02560 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 56 Chapter 1 Introduction Background The deivery of emergency heath care within the NHS embodies chaenges for risk management and patient safety. Circumstances can be demanding for patients and staff, with mutipe decisions being made that often invove crossing professiona and organisationa boundaries. Front-ine ambuance service staff routiney make critica decisions about the most appropriate care to deiver in a compex system characterised by significant variation in patient case mix, care pathways and inked service providers. Before the commissioning of this research very itte research had been carried out within ambuance service settings to identify areas of high risk associated with decision-making about patient care options or to examine ways in which working across boundaries can affect patient care. The patient s journey from caing an ambuance to a decision about subsequent discharge by ambuance service staff is compex and can invove being assessed over the teephone by a cinician to having cinica assessment and initia emergency treatment at the scene of an emergency. The Nationa Institute for Heath Research commissioned this primary research to expore safe decision-making by ambuance service staff around transitions through the pre-hospita care system. The ambuance service system and decision-making To address the patient safety issues associated with decisions around transitions in patient care, it is necessary to examine the infuence of the wider system, taking into account ongoing deveopments such as changes to service configurations, patient care options and staff roes. The ambuance service contro room represents the initia point of contact for patients making 999 cas. Critica decisions regarding the prioritisation of cas and the most appropriate responses must be made based on information provided by the caer. Two UK studies that have specificay examined the safety and accuracy of ca prioritisation systems 1,2 found that the risk of serious under-triage (i.e. assigning a ow-priority response to a high-priority ca) is ow, whereas over-triage to high priority eves for ower-eve priority cas is high. Decisions aso need to be made regarding the type of emergency response to send and what information needs to be conveyed to heath-care staff. In recent years the initia ca-handing process has been enhanced to represent an emergency care response in its own right ( hear and treat ), which entais decisions made by quaified cinicians such as nurses and paramedics over whether or not to dispatch other resources to the patient. However, there is itte evidence on patient safety issues and what is needed to ensure safe decision-making by staff deaing with the varied case mix of patients seeking emergency care. 3 Ambuance services have made increasing use of speciaist paramedic roes [variousy termed emergency care practitioners (ECPs), paramedic practitioners (PPs) or community paramedics according to the specific nature of the roe and the training provided], equipped with the enhanced knowedge and skis needed to make compex decisions about patient care. Decisions about patient management wi invove assessment, diagnosis, treatment, incuding medication, and discharge or referra. The avaiabe evidence indicates that these speciaist roes have provided service deivery benefits in terms of enhanced efficiency of patient care, increased patient satisfaction and a reduction in costs associated with ambuance journeys, accident and emergency (A&E) attendances and hospita admissions. 4 7 However, there remains a ack of research examining the safety of these new roes and the care pathways in which they operate, despite the recommendation that the safety of ambuance service staff to discharge patients at scene or decide on appropriate referra shoud be assessed before being widey adopted. 8 Studies empoying expert review of patient care from PPs and ECPs 9 11 suggest that the care provided by staff in these new roes was appropriate. However, these were sma-scae reviews and provide a imited assessment of the care Queen s Printer and Controer of HMSO 2014. This work was produced by O Hara et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. 1