Bridget Wells

What are the highest priorities for research in emergency prehospital care

The recent UK Department of Health publication “ Taking Healthcare to the Patient: Transforming NHS Ambulance Services ”1 recommended that the Department of Health should commission a programme of work to build the evidence base for the delivery of emergency and unscheduled prehospital care. As a starting point, the Department of Health commissioned the 999 EMS Research Forum to review the evidence base for the delivery of emergency prehospital care; to identify gaps in the evidence base; and to prioritise topics for future research. The 999 EMS Research Forum is a partnership of academics, clinicians and prehospital care practitioners and managers formed in 1999, whose aim is to encourage, promote and disseminate research and evidence-based policy and practice in 999 health care. Prioritisation of research topics is a key part of the process of commissioning of research, although methods may differ.2 3 The desirability of including a wide range of stakeholders in a structured approach has been stressed, in order to achieve a credible result that may be more likely to produce research that informs policy and practice.4–6 This emergency prehospital care research prioritisation exercise included …

Support and assessment for fall emergency referrals (SAFER 1) : cluster randomised trial of computerised clinical decision support for paramedics

Objective To evaluate effectiveness, safety and cost-effectiveness of Computerised Clinical Decision Support (CCDS) for paramedics attending older people who fall. Design Cluster trial randomised by paramedic; modelling. Setting 13 ambulance stations in two UK emergency ambulance services. Participants 42 of 409 eligible paramedics, who attended 779 older patients for a reported fall. Interventions Intervention paramedics received CCDS on Tablet computers to guide patient care. Control paramedics provided care as usual. One service had already installed electronic data capture. Main Outcome Measures Effectiveness: patients referred to falls service, patient reported quality of life and satisfaction, processes of care. Safety Further emergency contacts or death within one month. Cost-Effectiveness Costs and quality of life. We used findings from published Community Falls Prevention Trial to model cost-effectiveness. Results 17 intervention paramedics used CCDS for 54 (12.4%) of 436 participants. They referred 42 (9.6%) to falls services, compared with 17 (5.0%) of 343 participants seen by 19 control paramedics [Odds ratio (OR) 2.04, 95% CI 1.12 to 3.72]. No adverse events were related to the intervention. Non-significant differences between groups included: subsequent emergency contacts (34.6% versus 29.1%; OR 1.27, 95% CI 0.93 to 1.72); quality of life (mean SF12 differences: MCS −0.74, 95% CI −2.83 to +1.28; PCS −0.13, 95% CI −1.65 to +1.39) and non-conveyance (42.0% versus 36.7%; OR 1.13, 95% CI 0.84 to 1.52). However ambulance job cycle time was 8.9 minutes longer for intervention patients (95% CI 2.3 to 15.3). Average net cost of implementing CCDS was £208 per patient with existing electronic data capture, and £308 without. Modelling estimated cost per quality-adjusted life-year at £15,000 with existing electronic data capture; and £22,200 without. Conclusions Intervention paramedics referred twice as many participants to falls services with no difference in safety. CCDS is potentially cost-effective, especially with existing electronic data capture. Trial Registration ISRCTN Register ISRCTN10538608

SNAPSHOT OF INITIATIVES TO SUPPORT TIMELY PATIENT HANDOVER FROM AMBULANCES TO THE EMERGENCY DEPARTMENT

Background Increasing pressure on the emergency care system contributes to delays in patient handover from ambulances to emergency departments. The impact of these delays includes ambulance queues, sub-optimal care for patients, staffing and operational challenges, and (in England) financial penalties. New models of care have the potential to reduce handover delay. We surveyed ambulance services across England and Wales to produce a snapshot of initiatives under development or being trialled in order to address problems associated with handover delay. Methods During 2014, we carried out semi-structured telephone interviews with R&D leads in all 11 independent ambulance service trusts in England and Wales. We asked respondents about initiatives taking place within their area, what evaluation was taking place, and what they believed to be the challenges to evaluation. Interviews were recorded and transcribed, and analysed using the Framework approach. Results Initiatives fell into three groups: prehospital; at the ED; and whole system. Prehospital initiatives comprised clinical decision support tools (n=6); alternative pathways (n=6); hospital capacity monitoring (n=3); automated data transfer (n=3). Initiatives at ED included handover screens (n=8); rapid access models (n=7); hospital ambulance liaison officers (n=6); corridor care (n=3). Whole system approaches included new models of collaborative working (n=2); service review (n=2). Challenges to implementing and evaluating change included the lack of standardised approaches to handover across multiple hospital trusts within an ambulance service area; many of the reported initiatives took place only in a small part of the ambulance services operational area. Only five respondents reported evaluation of handover initiatives, and of these two were described as informal evaluation only. The need to report and comply with performance targets was reported as a more immediate pressure than evaluation of new developments. Conclusions While there is a range of activity taking place across England and Wales to address handover delays, there is little formal evaluation and there are missed opportunities for transferable learning.

Implementation and use of computerised clinical decision support (CCDS) in emergency pre-hospital care: a qualitative study of paramedic views and experience using Strong Structuration Theory

BackgroundComputerised clinical decision support (CCDS) has been shown to improve processes of care in some healthcare settings, but there is little evidence related to its use or effects in pre-hospital emergency care. CCDS in this setting aligns with policies to increase IT use in ambulance care, enhance paramedic decision-making skills, reduce avoidable emergency department attendances and improve quality of care and patient experience. This qualitative study was conducted alongside a cluster randomised trial in two ambulance services of the costs and effects of web-based CCDS system designed to support paramedic decision-making in the care of older people following a fall. Paramedics were trained to enter observations and history for relevant patients on a tablet, and the CCDS then generated a recommended course of action which could be logged. Our aim was to describe paramedics’ experience of the CCDS intervention and to identify factors affecting its implementation and use.MethodsWe invited all paramedics who had been randomly allocated to the intervention arm of the trial to participate in interviews or focus groups. The study was underpinned by Strong Structuration Theory, a theoretical model for studying innovation based on the relationship between what people do and their context. We used the Framework approach to data analysis.ResultsTwenty out of 22 paramedics agreed to participate. We developed a model of paramedic experience of CCDS with three domains: context, adoption and use, and outcomes. Aspects of context which had an impact included organisational culture and perceived support for non-conveyance decisions. Experience of adoption and use of the CCDS varied between individual paramedics, with some using it with all eligible patients, some only with patients they thought were ‘suitable’ and some never using it. A range of outcomes were reported, some of which were different from the intended role of the technology in decision support.ConclusionImplementation of new technology such as CCDS is not a one-off event, but an ongoing process, which requires support at the organisational level to be effective.Trial registrationISRCTN Registry 10538608. Registered 1 May 2007. Retrospectively registered.