Background As part of a study examining systemic influences on conveyance decisions by paramedics... more Background As part of a study examining systemic influences on conveyance decisions by paramedics and potential threats to patient safety, stakeholder workshops were conducted with three Ambulance Service Trusts in England. The study identified seven overarching systemic influences: demand; priorities; access to care; risk tolerance; training, communication and resources. The aim of the workshops was to elicit feedback on the findings and identify perceived areas for future intervention and research. Attendees were also asked to rank the seven threats to patient safety in terms of their perceived importance for future attention. Methods A total of 45 individuals attended across all the workshops, 28 ambulance service staff and 17 service user representatives. Discussions were audio-recorded, transcribed and thematically analysed. A paper based paired comparison approach was used to produce an ordinal ranking to illustrate the relative prioritisation of issues. Analysis included testing for internal consistency and between-rater agreement for this relatively small sample. Findings The two highest ranking priorities were training and development, as well as access to care. The areas for intervention identified represent what attendees perceived as feasible to undertake and relate to: care options; cross boundary working; managing demand; staff development; information and feedback; and commissioning decisions. Perceived areas for research specifically address conveyance decisions and potential threats to patient safety. 17 areas for research were proposed that directly relate to six of the systemic threats to patient safety. Conclusions Feedback workshops were effective in the validation of findings as well as providing an opportunity to identify priorities for future interventions and research. They also facilitated discussion between a variety of Ambulance Service staff and service user representatives. Ongoing collaboration between members of the research team has enabled some of the research recommendations to be explored as part of a mutually agreed research agenda.
Measuring the effects of a national quality improvement collaborative in ambulance services Conte... more Measuring the effects of a national quality improvement collaborative in ambulance services Context We undertook a national collaborative project to improve cardiovascular care for heart attack and stroke by frontline clinicians in 12 English Ambulance Services. Problem Cardiovascular disease is the commonest cause of death in the UK. Early, effective treatment reduces death rates, improves long-term outcomes and reduces future disability. Ambulance clinicians, working to national evidence-based guidelines for Acute Myocardial Infarction(AMI) and stroke, should deliver specific aspects of care but are unreliable at delivering whole bundles of care 1
The contribution of service users to identifying and prioritising research issues is vital to mak... more The contribution of service users to identifying and prioritising research issues is vital to make practice and policy more relevant to their needs. Their experiences and knowledge can complement those of clinicians, health professionals and researchers. The aim of this research was to explore service-user perceptions of ambulance service care and patient safety. Three service-users focus groups (n=23) were conducted in three different Ambulance Service Trust regions and enabled participants to discuss their respective perceptions, experiences and concerns. Discussions were audio-recorded, transcribed and thematically analysed. Service-users identified a number of concerns. The skills of call handlers in managing two-way communication at the initial call stage was perceived as critical to informing appropriate triage decisions; the risk at this stage was considered to be higher where callers have communication difficulties. Participants emphasised the importance of patient involveme...
Journal of health services research & policy, 2015
Paramedics routinely make critical decisions about the most appropriate care to deliver in a comp... more 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 ove...
Refusal by the patient to travel after calling an emergency ambulance may lead to a preventable w... more Refusal by the patient to travel after calling an emergency ambulance may lead to a preventable waste of scarce resources if it can be shown that an alternative more appropriate response could be employed. A greater understanding is required of the reasons behind 'refusal to travel' (RTT) in order to find appropriate solutions to address this issue. We sought to investigate the reasons why patients refuse to travel following emergency call-out in a rural county.
Background: Previous studies have shown wide variations in prehospital ambulance care for acute m... more Background: Previous studies have shown wide variations in prehospital ambulance care for acute myocardial infarction (AMI) and stroke. We aimed to evaluate the effectiveness of implementing a Quality Improvement Collaborative (QIC) for improving ambulance care for AMI and stroke. Methods: We used an interrupted time series design to investigate the effect of a national QIC on change in delivery of care bundles for AMI (aspirin, glyceryl trinitrate [GTN], pain assessment and analgesia) and stroke (face-arm-speech test, blood pressure and blood glucose recording) in all English ambulance services between January 2010 and February 2012. Key strategies for change included local quality improvement (QI) teams in each ambulance service supported by a national coordinating expert group that conducted workshops educating staff in QI methods to improve AMI and stroke care. Expertise and ideas were shared between QI teams who met together at three national workshops, between QI leads through monthly teleconferences, and between the expert group and participants. Feedback was provided to services using annotated control charts. Results: We analyzed change over time using logistic regression with three predictor variables: time, gender, and age. There were statistically significant improvements in care bundles in nine (of 12) participating trusts for AMI (OR 1.04, 95% CI 1.04, 1.04), nine for stroke (OR 1.06, 95% CI 1.05, 1.07), 11 for either AMI or stroke, and seven for both conditions. Overall care bundle performance for AMI increased in England from 43 to 79% and for stroke from 83 to 96%. Successful services all introduced provider prompts and individualized or team feedback. Other determinants of success included engagement with front-line clinicians, feedback using annotated control charts, expert support, and shared learning between participants and organizations. Conclusions: This first national prehospital QIC led to significant improvements in ambulance care for AMI and stroke in England. The use of care bundles as measures, clinical engagement, application of quality improvement methods, provider prompts, individualized feedback and opportunities for learning and interaction within and across organizations helped the collaborative to achieve its aims.
Introduction There is a compelling need to develop clinical performance indicators for ambulance ... more Introduction There is a compelling need to develop clinical performance indicators for ambulance services in order to move from indicators based primarily on response times and in light of the changing clinical demands on services. We report on progress on the national pilot of clinical performance indicators for English ambulance services. Method Clinical performance indicators were developed in five clinical areas: acute myocardial infarction, cardiac arrest, stroke (including transient ischaemic attack), asthma and hypoglycaemia. These were determined on the basis of common acute conditions presenting to ambulance services and in line with a previously published framework. Indicators were piloted by ambulance services in England and results were presented in tables and graphically using funnel (statistical process control) plots. Results Progress for developing, agreeing and piloting of indicators has been rapid, from initial agreement in May 2007 to completion of the pilot phase by the end of March 2008. The results of benchmarking of indicators are shown. The pilot has informed services in deciding the focus of their improvement programme in 2008e2009 and indicators have been adopted for national performance assessment of standards of prehospital care. Conclusion The pilot will provide the basis for further development of clinical indicators, benchmarking of performance and implementation of specific evidencebased interventions to improve care in areas identified for improvement. A national performance improvement registry will enable evaluation and sharing of effective improvement methods as well as increasing stakeholder and public access to information on the quality of care provided by ambulance services.
Decisions made by ambulance staff are often time-critical and based on limited information. Wrong... more Decisions made by ambulance staff are often time-critical and based on limited information. Wrong decisions could have serious consequences for patients but little is known about areas of risk associated with decisions about patient care. We aimed to examine system influences on decision making in the ambulance service setting focusing on paramedic roles. An exploratory mixed methods qualitative study was conducted in three Ambulance Service Trusts. A document search and 16 interviews were conducted to understand service delivery in each Trust, how they link with other services and potential influences on decisions about patient care. Researchers observed ambulance crews on 34 shifts and 10 paramedics completed 'digital diaries' to report challenges for decision making or patient safety. Three focus groups with staff (N=21) and three with service users (N=23) were held to explore their views on decision making and patient safety. Data were charted to produce a typology of de...
Context: The National Ambulance Services Clinical Quality Group is responsible for benchmarking a... more Context: The National Ambulance Services Clinical Quality Group is responsible for benchmarking and driving improvement in the quality of clinical care provided by front line ambulance staff (paramedics and ambulance clinicians) across all twelve ambulance services in England. ...
Context: The National Ambulance Services Clinical Quality Group is responsible for benchmarking a... more Context: The National Ambulance Services Clinical Quality Group is responsible for benchmarking and driving improvement in the quality of clinical care provided by front line ambulance staff (paramedics and ambulance clinicians) across all twelve ambulance services in England. ...
... were developed according to the principles set out above and through discussion at two meetin... more ... were developed according to the principles set out above and through discussion at two meetings held in May and October 2007 by two working groups of the National Ambulance Audit Steering Group including the following members; John Appleby-Fleming, Steve Barnard ...
BACKGROUND In the 2004 Healthcare Commission report the majority of patients (4 out of 5) said th... more BACKGROUND In the 2004 Healthcare Commission report the majority of patients (4 out of 5) said they had suffered pain from their presenting conditions while in the ambulance. Although 81% felt that the ambulance crew did everything they could to control pain, 1 in 5 wanted more pain relief: 14% said the crew did this to some extent and 5% that the crew did not do everything they could to control the pain. The management of pain in the pre-hospital environment has been shown to be an important determinant of subsequent pain in the emergency department. How ambulance services manage pain is therefore clinically important and a key indicator of quality of service. Management of pain can be differentiated into a number of essential components. Recording of pain both at the scene (either the patient's home or the scene of an emergency) and on arrival at hospital has been shown to be feasible using numerical, verbal 1 and visual analogue scales 2 . Recording pain scores is valuable, n...
... uk) was launched in summer 2007. ... brought to the Emergency Department (ED) by mountain res... more ... uk) was launched in summer 2007. ... brought to the Emergency Department (ED) by mountain rescue teams or the RAF Search & Rescue helicopter whose ... Method: Between January 2004 and August 2007, 283 patients were brought to the ED by mountain prehospital personnel. ...
Background: Acute asthma is a common reason for patients to seek care from ambulance services. Al... more Background: Acute asthma is a common reason for patients to seek care from ambulance services. Although better care of acute asthma can prevent avoidable morbidity and deaths, there has been little research into ambulance clinicians' adherence to national guidelines for asthma assessment and management and how this might be improved. Our research aim was to explore paramedics' attitudes, perceptions and beliefs about prehospital management of asthma, to identify barriers and facilitators to guideline adherence. Methods: We conducted three focus group interviews of paramedics in a regional UK ambulance trust. We used framework analysis supported by NVivo 8 to code and analyse the data. Results: Seventeen participants, including paramedics, advanced paramedics or paramedic operational managers at three geographical sites, contributed to the interviews. Analysis led to five themes: (1) guidelines should be made more relevant to ambulance service care; (2) there were barriers to assessment; (3) the approach needed to address conflicts between clinicians' and patients' expectations; (4) the complexity of ambulance service processes and equipment needed to be taken into account; (5) and finally there were opportunities for improved prehospital education, information, communication, support and care pathways for asthma. Conclusions: This qualitative study provides insight into paramedics' perceptions of the assessment and management of asthma, including why paramedics may not always follow guidelines for assessment or management of asthma. These findings provide opportunities to strengthen clinical support, patient communication, information transfer between professionals and pathways for prehospital care of patients with asthma.
ABSTRACT Background In 2008/2009 there were nearly 80 000 emergency hospital admissions for asthm... more ABSTRACT Background In 2008/2009 there were nearly 80 000 emergency hospital admissions for asthma. Current UK guidelines emphasise the importance of evidence-based prehospital assessment and treatment of asthma for improving patient outcomes and reducing hospitalisation, morbidity and mortality. National benchmarking of ambulance clinical performance indicators for asthma have revealed important unexplained variations in care across ambulance services. Little research has been undertaken to understand the reasons for poor levels of care. Objective The aim of this study was to gather data on ambulance clinicians' perceptions and beliefs around prevailing and best practice for management of asthma. This was used to identify the factors which prevent or enable better asthma care in ambulance services. Methods We used a phenomenological qualitative approach, which addresses how individuals use their experiences to make sense of their world, focusing on participants' lived experiences of care delivery for asthma. We used focus groups of ambulance clinicians to gather data on barriers and facilitators to better asthma care. Recordings and notes were taken, transcribed and then analysed using QSR NVivo 8. A coding framework was developed based on a priori concepts but with emergent themes added during the analysis. Results Two focus groups were conducted with eight and five participants respectively. A number of preliminary themes and subthemes were identified. The study identified issues relating to clarity of ambulance guidelines, conflicts between training and guidance, misconceptions about the importance of objective assessment and over reliance on non-objective assessment. Some practitioners believed that hospital staff were not interested in prehospital peak flow assessments. Conclusion Our findings will inform improved systems of care for asthma and the effect on indicators will be measured using time series methods. This approach could be used more widely to improve management of specific clinical conditions where quality of care is demonstrated to be suboptimal.
BackgroundDrug overdose or self poisoning is an important reason for an ambulance service respons... more BackgroundDrug overdose or self poisoning is an important reason for an ambulance service response. We aimed to undertake a preliminary investigation into the pattern of drug overdose presenting to one ambulance service and factors associated with adverse clinical features and treatment.MethodsWe examined data from clinical records obtained by ambulance crews attending non-fatal overdoses over 3 months. We produced descriptive statistics
To investigate the factors associated with adverse clinical features presented by drug overdose/s... more To investigate the factors associated with adverse clinical features presented by drug overdose/self-poisoning patients and the treatments provided.
Introduction There is a compelling need to develop clinical performance indicators for ambulance ... more Introduction There is a compelling need to develop clinical performance indicators for ambulance services in order to move from indicators based primarily on response times and in light of the changing clinical demands on services. We report on progress on the national pilot of clinical performance indicators for English ambulance services. Method Clinical performance indicators were developed in five clinical areas: acute myocardial infarction, cardiac arrest, stroke (including transient ischaemic attack), asthma and hypoglycaemia. These were determined on the basis of common acute conditions presenting to ambulance services and in line with a previously published framework. Indicators were piloted by ambulance services in England and results were presented in tables and graphically using funnel (statistical process control) plots. Results Progress for developing, agreeing and piloting of indicators has been rapid, from initial agreement in May 2007 to completion of the pilot phase by the end of March 2008. The results of benchmarking of indicators are shown. The pilot has informed services in deciding the focus of their improvement programme in 2008e2009 and indicators have been adopted for national performance assessment of standards of prehospital care. Conclusion The pilot will provide the basis for further development of clinical indicators, benchmarking of performance and implementation of specific evidencebased interventions to improve care in areas identified for improvement. A national performance improvement registry will enable evaluation and sharing of effective improvement methods as well as increasing stakeholder and public access to information on the quality of care provided by ambulance services.
Background As part of a study examining systemic influences on conveyance decisions by paramedics... more Background As part of a study examining systemic influences on conveyance decisions by paramedics and potential threats to patient safety, stakeholder workshops were conducted with three Ambulance Service Trusts in England. The study identified seven overarching systemic influences: demand; priorities; access to care; risk tolerance; training, communication and resources. The aim of the workshops was to elicit feedback on the findings and identify perceived areas for future intervention and research. Attendees were also asked to rank the seven threats to patient safety in terms of their perceived importance for future attention. Methods A total of 45 individuals attended across all the workshops, 28 ambulance service staff and 17 service user representatives. Discussions were audio-recorded, transcribed and thematically analysed. A paper based paired comparison approach was used to produce an ordinal ranking to illustrate the relative prioritisation of issues. Analysis included testing for internal consistency and between-rater agreement for this relatively small sample. Findings The two highest ranking priorities were training and development, as well as access to care. The areas for intervention identified represent what attendees perceived as feasible to undertake and relate to: care options; cross boundary working; managing demand; staff development; information and feedback; and commissioning decisions. Perceived areas for research specifically address conveyance decisions and potential threats to patient safety. 17 areas for research were proposed that directly relate to six of the systemic threats to patient safety. Conclusions Feedback workshops were effective in the validation of findings as well as providing an opportunity to identify priorities for future interventions and research. They also facilitated discussion between a variety of Ambulance Service staff and service user representatives. Ongoing collaboration between members of the research team has enabled some of the research recommendations to be explored as part of a mutually agreed research agenda.
Measuring the effects of a national quality improvement collaborative in ambulance services Conte... more Measuring the effects of a national quality improvement collaborative in ambulance services Context We undertook a national collaborative project to improve cardiovascular care for heart attack and stroke by frontline clinicians in 12 English Ambulance Services. Problem Cardiovascular disease is the commonest cause of death in the UK. Early, effective treatment reduces death rates, improves long-term outcomes and reduces future disability. Ambulance clinicians, working to national evidence-based guidelines for Acute Myocardial Infarction(AMI) and stroke, should deliver specific aspects of care but are unreliable at delivering whole bundles of care 1
The contribution of service users to identifying and prioritising research issues is vital to mak... more The contribution of service users to identifying and prioritising research issues is vital to make practice and policy more relevant to their needs. Their experiences and knowledge can complement those of clinicians, health professionals and researchers. The aim of this research was to explore service-user perceptions of ambulance service care and patient safety. Three service-users focus groups (n=23) were conducted in three different Ambulance Service Trust regions and enabled participants to discuss their respective perceptions, experiences and concerns. Discussions were audio-recorded, transcribed and thematically analysed. Service-users identified a number of concerns. The skills of call handlers in managing two-way communication at the initial call stage was perceived as critical to informing appropriate triage decisions; the risk at this stage was considered to be higher where callers have communication difficulties. Participants emphasised the importance of patient involveme...
Journal of health services research & policy, 2015
Paramedics routinely make critical decisions about the most appropriate care to deliver in a comp... more 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 ove...
Refusal by the patient to travel after calling an emergency ambulance may lead to a preventable w... more Refusal by the patient to travel after calling an emergency ambulance may lead to a preventable waste of scarce resources if it can be shown that an alternative more appropriate response could be employed. A greater understanding is required of the reasons behind 'refusal to travel' (RTT) in order to find appropriate solutions to address this issue. We sought to investigate the reasons why patients refuse to travel following emergency call-out in a rural county.
Background: Previous studies have shown wide variations in prehospital ambulance care for acute m... more Background: Previous studies have shown wide variations in prehospital ambulance care for acute myocardial infarction (AMI) and stroke. We aimed to evaluate the effectiveness of implementing a Quality Improvement Collaborative (QIC) for improving ambulance care for AMI and stroke. Methods: We used an interrupted time series design to investigate the effect of a national QIC on change in delivery of care bundles for AMI (aspirin, glyceryl trinitrate [GTN], pain assessment and analgesia) and stroke (face-arm-speech test, blood pressure and blood glucose recording) in all English ambulance services between January 2010 and February 2012. Key strategies for change included local quality improvement (QI) teams in each ambulance service supported by a national coordinating expert group that conducted workshops educating staff in QI methods to improve AMI and stroke care. Expertise and ideas were shared between QI teams who met together at three national workshops, between QI leads through monthly teleconferences, and between the expert group and participants. Feedback was provided to services using annotated control charts. Results: We analyzed change over time using logistic regression with three predictor variables: time, gender, and age. There were statistically significant improvements in care bundles in nine (of 12) participating trusts for AMI (OR 1.04, 95% CI 1.04, 1.04), nine for stroke (OR 1.06, 95% CI 1.05, 1.07), 11 for either AMI or stroke, and seven for both conditions. Overall care bundle performance for AMI increased in England from 43 to 79% and for stroke from 83 to 96%. Successful services all introduced provider prompts and individualized or team feedback. Other determinants of success included engagement with front-line clinicians, feedback using annotated control charts, expert support, and shared learning between participants and organizations. Conclusions: This first national prehospital QIC led to significant improvements in ambulance care for AMI and stroke in England. The use of care bundles as measures, clinical engagement, application of quality improvement methods, provider prompts, individualized feedback and opportunities for learning and interaction within and across organizations helped the collaborative to achieve its aims.
Introduction There is a compelling need to develop clinical performance indicators for ambulance ... more Introduction There is a compelling need to develop clinical performance indicators for ambulance services in order to move from indicators based primarily on response times and in light of the changing clinical demands on services. We report on progress on the national pilot of clinical performance indicators for English ambulance services. Method Clinical performance indicators were developed in five clinical areas: acute myocardial infarction, cardiac arrest, stroke (including transient ischaemic attack), asthma and hypoglycaemia. These were determined on the basis of common acute conditions presenting to ambulance services and in line with a previously published framework. Indicators were piloted by ambulance services in England and results were presented in tables and graphically using funnel (statistical process control) plots. Results Progress for developing, agreeing and piloting of indicators has been rapid, from initial agreement in May 2007 to completion of the pilot phase by the end of March 2008. The results of benchmarking of indicators are shown. The pilot has informed services in deciding the focus of their improvement programme in 2008e2009 and indicators have been adopted for national performance assessment of standards of prehospital care. Conclusion The pilot will provide the basis for further development of clinical indicators, benchmarking of performance and implementation of specific evidencebased interventions to improve care in areas identified for improvement. A national performance improvement registry will enable evaluation and sharing of effective improvement methods as well as increasing stakeholder and public access to information on the quality of care provided by ambulance services.
Decisions made by ambulance staff are often time-critical and based on limited information. Wrong... more Decisions made by ambulance staff are often time-critical and based on limited information. Wrong decisions could have serious consequences for patients but little is known about areas of risk associated with decisions about patient care. We aimed to examine system influences on decision making in the ambulance service setting focusing on paramedic roles. An exploratory mixed methods qualitative study was conducted in three Ambulance Service Trusts. A document search and 16 interviews were conducted to understand service delivery in each Trust, how they link with other services and potential influences on decisions about patient care. Researchers observed ambulance crews on 34 shifts and 10 paramedics completed 'digital diaries' to report challenges for decision making or patient safety. Three focus groups with staff (N=21) and three with service users (N=23) were held to explore their views on decision making and patient safety. Data were charted to produce a typology of de...
Context: The National Ambulance Services Clinical Quality Group is responsible for benchmarking a... more Context: The National Ambulance Services Clinical Quality Group is responsible for benchmarking and driving improvement in the quality of clinical care provided by front line ambulance staff (paramedics and ambulance clinicians) across all twelve ambulance services in England. ...
Context: The National Ambulance Services Clinical Quality Group is responsible for benchmarking a... more Context: The National Ambulance Services Clinical Quality Group is responsible for benchmarking and driving improvement in the quality of clinical care provided by front line ambulance staff (paramedics and ambulance clinicians) across all twelve ambulance services in England. ...
... were developed according to the principles set out above and through discussion at two meetin... more ... were developed according to the principles set out above and through discussion at two meetings held in May and October 2007 by two working groups of the National Ambulance Audit Steering Group including the following members; John Appleby-Fleming, Steve Barnard ...
BACKGROUND In the 2004 Healthcare Commission report the majority of patients (4 out of 5) said th... more BACKGROUND In the 2004 Healthcare Commission report the majority of patients (4 out of 5) said they had suffered pain from their presenting conditions while in the ambulance. Although 81% felt that the ambulance crew did everything they could to control pain, 1 in 5 wanted more pain relief: 14% said the crew did this to some extent and 5% that the crew did not do everything they could to control the pain. The management of pain in the pre-hospital environment has been shown to be an important determinant of subsequent pain in the emergency department. How ambulance services manage pain is therefore clinically important and a key indicator of quality of service. Management of pain can be differentiated into a number of essential components. Recording of pain both at the scene (either the patient's home or the scene of an emergency) and on arrival at hospital has been shown to be feasible using numerical, verbal 1 and visual analogue scales 2 . Recording pain scores is valuable, n...
... uk) was launched in summer 2007. ... brought to the Emergency Department (ED) by mountain res... more ... uk) was launched in summer 2007. ... brought to the Emergency Department (ED) by mountain rescue teams or the RAF Search & Rescue helicopter whose ... Method: Between January 2004 and August 2007, 283 patients were brought to the ED by mountain prehospital personnel. ...
Background: Acute asthma is a common reason for patients to seek care from ambulance services. Al... more Background: Acute asthma is a common reason for patients to seek care from ambulance services. Although better care of acute asthma can prevent avoidable morbidity and deaths, there has been little research into ambulance clinicians' adherence to national guidelines for asthma assessment and management and how this might be improved. Our research aim was to explore paramedics' attitudes, perceptions and beliefs about prehospital management of asthma, to identify barriers and facilitators to guideline adherence. Methods: We conducted three focus group interviews of paramedics in a regional UK ambulance trust. We used framework analysis supported by NVivo 8 to code and analyse the data. Results: Seventeen participants, including paramedics, advanced paramedics or paramedic operational managers at three geographical sites, contributed to the interviews. Analysis led to five themes: (1) guidelines should be made more relevant to ambulance service care; (2) there were barriers to assessment; (3) the approach needed to address conflicts between clinicians' and patients' expectations; (4) the complexity of ambulance service processes and equipment needed to be taken into account; (5) and finally there were opportunities for improved prehospital education, information, communication, support and care pathways for asthma. Conclusions: This qualitative study provides insight into paramedics' perceptions of the assessment and management of asthma, including why paramedics may not always follow guidelines for assessment or management of asthma. These findings provide opportunities to strengthen clinical support, patient communication, information transfer between professionals and pathways for prehospital care of patients with asthma.
ABSTRACT Background In 2008/2009 there were nearly 80 000 emergency hospital admissions for asthm... more ABSTRACT Background In 2008/2009 there were nearly 80 000 emergency hospital admissions for asthma. Current UK guidelines emphasise the importance of evidence-based prehospital assessment and treatment of asthma for improving patient outcomes and reducing hospitalisation, morbidity and mortality. National benchmarking of ambulance clinical performance indicators for asthma have revealed important unexplained variations in care across ambulance services. Little research has been undertaken to understand the reasons for poor levels of care. Objective The aim of this study was to gather data on ambulance clinicians' perceptions and beliefs around prevailing and best practice for management of asthma. This was used to identify the factors which prevent or enable better asthma care in ambulance services. Methods We used a phenomenological qualitative approach, which addresses how individuals use their experiences to make sense of their world, focusing on participants' lived experiences of care delivery for asthma. We used focus groups of ambulance clinicians to gather data on barriers and facilitators to better asthma care. Recordings and notes were taken, transcribed and then analysed using QSR NVivo 8. A coding framework was developed based on a priori concepts but with emergent themes added during the analysis. Results Two focus groups were conducted with eight and five participants respectively. A number of preliminary themes and subthemes were identified. The study identified issues relating to clarity of ambulance guidelines, conflicts between training and guidance, misconceptions about the importance of objective assessment and over reliance on non-objective assessment. Some practitioners believed that hospital staff were not interested in prehospital peak flow assessments. Conclusion Our findings will inform improved systems of care for asthma and the effect on indicators will be measured using time series methods. This approach could be used more widely to improve management of specific clinical conditions where quality of care is demonstrated to be suboptimal.
BackgroundDrug overdose or self poisoning is an important reason for an ambulance service respons... more BackgroundDrug overdose or self poisoning is an important reason for an ambulance service response. We aimed to undertake a preliminary investigation into the pattern of drug overdose presenting to one ambulance service and factors associated with adverse clinical features and treatment.MethodsWe examined data from clinical records obtained by ambulance crews attending non-fatal overdoses over 3 months. We produced descriptive statistics
To investigate the factors associated with adverse clinical features presented by drug overdose/s... more To investigate the factors associated with adverse clinical features presented by drug overdose/self-poisoning patients and the treatments provided.
Introduction There is a compelling need to develop clinical performance indicators for ambulance ... more Introduction There is a compelling need to develop clinical performance indicators for ambulance services in order to move from indicators based primarily on response times and in light of the changing clinical demands on services. We report on progress on the national pilot of clinical performance indicators for English ambulance services. Method Clinical performance indicators were developed in five clinical areas: acute myocardial infarction, cardiac arrest, stroke (including transient ischaemic attack), asthma and hypoglycaemia. These were determined on the basis of common acute conditions presenting to ambulance services and in line with a previously published framework. Indicators were piloted by ambulance services in England and results were presented in tables and graphically using funnel (statistical process control) plots. Results Progress for developing, agreeing and piloting of indicators has been rapid, from initial agreement in May 2007 to completion of the pilot phase by the end of March 2008. The results of benchmarking of indicators are shown. The pilot has informed services in deciding the focus of their improvement programme in 2008e2009 and indicators have been adopted for national performance assessment of standards of prehospital care. Conclusion The pilot will provide the basis for further development of clinical indicators, benchmarking of performance and implementation of specific evidencebased interventions to improve care in areas identified for improvement. A national performance improvement registry will enable evaluation and sharing of effective improvement methods as well as increasing stakeholder and public access to information on the quality of care provided by ambulance services.
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Papers by Debbie Shaw