Behind the trauma tree: influences on paramedic trauma triage decisions in a UK ambulance service, a qualitative study.

Abstract

Background
Bypassing local hospitals by ambulance clinicians to take severely injured patients to specialist trauma hospitals has been shown to reduce morbidity and mortality in multiple healthcare systems. There is a lack of evidence as to how pre-hospital providers make these decisions and what else influences the decision-making process outside of triage guidelines. Studies have shown that triage tools in the form of a decision-making algorithm are not consistently used in practice and that the process of decision-making in clinical practice may be more complex and heuristic. Some US-based studies have attempted to capture this decision-making process in the field, but there remains a lack of research into understanding the practice, routines and behaviour that underpin this decision-making process and the social and organisational context in which it occurs. While outcome data- driven changes to the criteria of the decision-tool based on retrospective studies may improve outcomes, there is also a need to understand the way in such tools are actually used and interpreted in practice to better understand the challenges around adoption and implementation, as well as the other factors that may influence decisions.

Methods
A qualitative approach was taken using a critical realism informed reflexive thematic analysis. In-depth semi-structured interviews of 18 paramedics were completed. Participants were selected using convenience sampling from within a single UK ambulance service and trauma network. The interviews explored each paramedic’s approach to trauma triage decisions and the influences that affected how and why they decided to transport patients to a given hospital. Questions focussed on the use of a triage tool, the decision process, supported decision-making and participant beliefs about their capability, consequences and any other influences on decisions they chose to identify. Interviews were conducted remotely, audio recorded and transcribed.

Data Generation
Transcribed interviews were analysed using a critical-realist informed approach to thematic analysis using QSR NVivo. Following a data familiarisation phase, initial codes were developed using an iterative approach. Descriptive codes were initially applied which were then consolidated and refined into general and theoretical terms that informed theme development and the identification of causal mechanisms.

Analysis
Five explanatory themes were developed that suggested a range of causal mechanisms that underpin the way in which trauma triage decisions are made by participant in this study. Theme 1: Paramedic triage practice is variable between care episodes according to clinical context, provider judgement, education and experience. Theme 2: Triage decisions by paramedics may be augmented by remote support and constrained by the professional and hierarchical dynamics of hospital interactions, which can involve negotiation and challenge during and after the care episode. Theme 3: Paramedics can be affected by both personal and professional responsibility for triage decisions often made in an absence of feedback and learning from previous decisions. Theme 4: Paramedics consider wider social and personal determinants of triage decisions for patients, families and caregivers that impact holistic care considerations. Theme 5: Triage decisions by paramedics are situated within a wider context of system awareness, resource availability, personal capability and environmental challenges.

Contribution to knowledge
This research has contributed to existing research in this area by showing that paramedics do not rely only on triage tools to make decisions, and the way in which guidelines are followed vary between individuals and in different situations. Some issues such as hospital interactions have been described elsewhere but not within the context of the impact on future triage decision-making. Novel insights were identified with respect to personal, professional, social and organisational influences on paramedic trauma-triage decision-making that appear to affect patient transfer outcomes but are not documented in the wider literature, including challenging moral and ethical decisions. The need for better education and feedback to support decision-making has been suggested, as has a need for further research into the impact this potentially challenging clinical decision has on patients and families, as well as paramedic welfare and professional identity.

Date of Award	13 Nov 2024
Original language	English
Awarding Institution	University of Bath
Supervisor	Charlotte Dack (Supervisor) & Ben Ainsworth (Supervisor)