What factors are associated with ambulance use for non-emergency problems in children?:A systematic mapping review and qualitative synthesis

Objective To explore what factors are associated with ambulance use for non-emergency problems in children. Methods This study is a systematic mapping review and qualitative synthesis of published journal articles and grey literature. Searches were conducted on the following databases, for articles published between January 1980 and July 2020: MEDLINE, EMBASE, PsycINFO, CINAHL and AMED. A Google Scholar and a Web of Science search were undertaken to identify reports or proceedings not indexed in the above. Book chapters and theses were searched via the OpenSigle, EThOS and DART databases. A literature advisory group, including experts in the field, were contacted for relevant grey literature and unpublished reports. The inclusion criteria incorporated articles published in the English language reporting findings for the reasons behind why there are so many calls to the ambulance service for non-urgent problems in children. Data extraction was divided into two stages: extraction of data to generate a broad systematic literature € map', and extraction of data from highly relevant papers using qualitative methods to undertake a focused qualitative synthesis. An initial table of themes associated with reasons for non-emergency calls to the ambulance for children formed the € thematic map' element. The uniting feature running through all of the identified themes was the determination of € inappropriateness' or € appropriateness' of an ambulance call out, which was then adopted as the concept of focus for our qualitative synthesis. Results There were 27 articles used in the systematic mapping review and 17 in the qualitative synthesis stage of the review. Four themes were developed in the systematic mapping stage: socioeconomic status/geographical location, practical reasons, fear of consequences and parental education. Three analytical themes were developed in the qualitative synthesis stage including practicalities and logistics of obtaining care, arbitrary scoring system and retrospection. Conclusions There is a lack of public and caregiver understanding about the use of ambulances for paediatrics. There are factors that appear specific to choosing ambulance care for children that are not so prominent in adults (fever, reassurance, fear of consequences). Future areas for attention to decrease ambulance activation for paediatric low-acuity reports were highlighted as: identifying strategies for helping caregivers to mitigate perceived risk, increasing availability of primary care, targeted education to particular geographical areas, education to first-time parents with infants and providing alternate means of transportation. PROSPERO registration number CRD42019160395

Exploring how paramedics are deployed in general practice and the perceived benefits and drawbacks: a mixed-methods scoping study

Background: General practice in the UK faces continuing challenges to balance a workforce shortage against rising demand. The NHS England GP Forward View proposes development of the multidisciplinary, integrated primary care workforce to support frontline service delivery, including the employment of paramedics. However, very little is known about the safety, clinical effectiveness, or cost-effectiveness of paramedics working in general practice. Research is needed to understand the potential benefits and drawbacks of this model of workforce organisation. Aim: To understand how paramedics are deployed in general practice, and to investigate the theories and drivers that underpin this service development. Design & setting: A mixed-methods study using a literature review, national survey, and qualitative interviews. Method: A three-phase study was undertaken that consisted of: a literature review and survey; meetings with key informants (KIs); and direct enquiry with relevant staff stakeholders (SHs). Results: There is very little evidence on the safety and cost-effectiveness of paramedics working in general practice and significant variation in the ways that paramedics are deployed, particularly in terms of the patients seen and conditions treated. Nonetheless, there is a largely positive view of this development and a perceived reduction in GP workload. However, some concerns centre on the time needed from GPs to train and supervise paramedic staff. Conclusion: The contribution of paramedics in general practice has not been fully evaluated. There is a need for research that takes account of the substantial variation between service models to fully understand the benefits and consequences for patients, the workforce, and the NHS

Which elements of hospital-based clinical decision support tools for the assessment and management of children with head injury can be adapted for use by paramedics in prehospital care? A systematic mapping review and narrative synthesis

Objective Hospital-based clinical decision tools support clinician decision-making when a child presents to the emergency department with a head injury, particularly regarding CT scanning. However, there is no decision tool to support prehospital clinicians in deciding which head-injured children can safely remain at scene. This study aims to identify clinical decision tools, or constituent elements, which may be adapted for use in prehospital care. Design Systematic mapping review and narrative synthesis. Data sources Searches were conducted using MEDLINE, EMBASE, PsycINFO, CINAHL and AMED. Eligibility criteria Quantitative, qualitative, mixed-methods or systematic review research that included a clinical decision support tool for assessing and managing children with head injury. Data extraction and synthesis We systematically identified all in-hospital clinical decision support tools and extracted from these the clinical criteria used in decision-making. We complemented this with a narrative synthesis. Results Following de-duplication, 887 articles were identified. After screening titles and abstracts, 710 articles were excluded, leaving 177 full-text articles. Of these, 95 were excluded, yielding 82 studies. A further 14 studies were identified in the literature after cross-checking, totalling 96 analysed studies. 25 relevant in-hospital clinical decision tools were identified, encompassing 67 different clinical criteria, which were grouped into 18 categories. Conclusion Factors that should be considered for use in a clinical decision tool designed to support paramedics in the assessment and management of children with head injury are: signs of skull fracture; a large, boggy or non-frontal scalp haematoma neurological deficit; Glasgow Coma Score less than 15; prolonged or worsening headache; prolonged loss of consciousness; post-traumatic seizure; amnesia in older children; non-accidental injury; drug or alcohol use; and less than 1 year old. Clinical criteria that require further investigation include mechanism of injury, clotting impairment/anticoagulation, vertigo, length of time of unconsciousness and number of vomits

Staff stakeholder views on the role of UK paramedics in advance care planning for patients in their last year of life

Background: Early advance care planning has clear benefits for patients approaching the end of their life, yet many of those attended by UK paramedics do not have this planning in place.Aims: To explore staff stakeholder views on the role of UK paramedics in advance care planning, including the use of the Gold Standards Framework Proactive Identification Guidance for screening and referral of patients.Methods: In-depth semi-structured telephone interviews with paramedics, general practitioners, Emergency Department and community doctors and nurses in the South West of England.Results: Seventeen staff stakeholders participated. Four main themes were identified: a lack of advance care planning; variation across health conditions; a lack of joined-up care; poor-quality end of life conversations. Paramedic use of the Gold Standards Framework Proactive Identification Guidance to screen and refer patients for advance care planning was seen as feasible and acceptable, with perceived benefits such as identifying patients not accessing primary care, and the potential to reduce avoidable hospital admissions.Conclusions: UK paramedics are well-placed to screen and refer patients for advance care planning. Further research is needed to explore how this type of intervention might be developed to fit into a community-centred approach aimed at improving advance care planning

Assessment and management of children with head injury: Practice and opinion

Background: Head injury is common in children with approximately 700 000 attendances at emergency departments annually; one-third are conveyed by ambulance. However, 75% of them are discharged with no treatment. Most head-injured children could be managed on scene. Aim: This study aimed to investigate paramedic assessment and management of children with minor head injury. Methods: A web-based survey of paramedics at one trust was carried out, and simple descriptive analysis was completed. Findings: Fifty-nine paramedics took part. Parental anxiety, mechanism of injury, presence of red flags, fear of consequences and safeguarding concerns were the most common reasons that paramedics convey children with head injury to the emergency department. Paramedics employ a variety of non-validated tools to help them assess and manage children with head injury, with the head injury guidance by the National Institute for Health and Care Excellence most used. A lack of confidence in wound closure was a key barrier to managing patients on scene, along with a perceived inability to manage children in general, limited GP availability, a lack of training in paediatrics and risk avoidance. Conclusions: Several factors inhibit the ability of paramedics to manage children with minor head injury on scene, leading to avoidable hospital conveyance. Three-quarters of paramedics said they would benefit from a clinical decision tool to support them in the assessment and management of children with minor head injury