Gaps between policy, protocols and practice: a qualitative study of the views and practice of emergency ambulance staff concerning the care of patients with non-urgent needs

AIM

To describe emergency ambulance crews' views about (1) how they make decisions on whether to convey patients to hospital; (2) an intervention enabling them to triage patients to non-conveyance; and (3) their experience of using new protocols for undertaking such triage.

METHODS

Two focus groups were held at the outset of an evaluation of Treat and Refer (T&R) protocols: one with staff based at an ambulance station who were to implement the new service (intervention station), and the other with staff from a neighbouring station who would be continuing their normal practice during the study (control station). A third session was held with staff from the intervention station following training and 3 months' experience of protocol usage.

RESULTS

Before the introduction of the T&R protocols, crews reported experience, intuition, training, time of call during shift, patient preference, and home situation as influencing their decisions concerning conveyance. Crews were positive about changing practice but foresaw difficulties with advising patients who wanted to go to hospital, and with referral to other agencies. Following experience of T&R protocol use, crews felt they had needed more training than had been provided. Some felt their practice and job satisfaction had improved. Problems with referral and with persuading some patients that they did not need to go to hospital were discussed. There was consensus that the initiative should be introduced across the service.

CONCLUSIONS

With crews generally positive about this intervention, an opportunity to tackle this difficult area of emergency care now exists. This study has, however, highlighted the complexity of the change in practice and service delivery, and professional and organisational constraints that need to be considered.

Towards primary care for non-serious 999 callers: results of a controlled study of "Treat and Refer" protocols for ambulance crews

OBJECTIVE

To develop and evaluate "Treat and Refer" protocols for ambulance crews, allowing them to leave patients at the scene with onward referral or self-care advice as appropriate.

METHODS

Crew members from one ambulance station were trained to use the treatment protocols. Processes and outcomes of care for patients attended by trained crews were compared with similar patients attended by crews from a neighbouring station. Pre-hospital records were collected for all patients. Records of any emergency department and primary care contacts during the 14 days following the call were collected for non-conveyed patients who were also followed up by postal questionnaire.

RESULTS

Twenty three protocols were developed which were expected to cover over 75% of patients left at the scene by the attending crew. There were 251 patients in the intervention arm and 537 in the control arm. The two groups were similar in terms of age, sex and condition category but intervention cases were more likely to have been attended during daytime hours than at night. There was no difference in the proportion of patients left at the scene in the intervention and control arms; the median job cycle time was longer for intervention group patients. Protocols were reported as having been used in 101 patients (40.2%) in the intervention group; 17 of the protocols were recorded as having been used at least once during the study. Clinical documentation was generally higher in the intervention group, although a similar proportion of patients in both groups had no clinical assessments recorded. 288 patients were left at the scene (93 in the intervention group, 195 in the control group). After excluding those who refused to travel, there were three non-conveyed patients in each group who were admitted to hospital within 14 days of the call who were judged to have been left at home inappropriately. A higher proportion of patients in the intervention arm reported satisfaction with the service and advice provided.

CONCLUSIONS

"Treat and Refer" protocols did not increase the number of patients left at home but were used by crews and were acceptable to patients. The protocols increased job cycle time and some safety issues were identified. Their introduction is complex, and the extent to which the content of the protocols, decision support and training can be refined needs further study.

Towards primary care for non-serious 999 callers: results of a controlled study of "Treat and Refer" protocols for ambulance crews

OBJECTIVE

To develop and evaluate "Treat and Refer" protocols for ambulance crews, allowing them to leave patients at the scene with onward referral or self-care advice as appropriate.

METHODS

Crew members from one ambulance station were trained to use the treatment protocols. Processes and outcomes of care for patients attended by trained crews were compared with similar patients attended by crews from a neighbouring station. Pre-hospital records were collected for all patients. Records of any emergency department and primary care contacts during the 14 days following the call were collected for non-conveyed patients who were also followed up by postal questionnaire.

RESULTS

Twenty three protocols were developed which were expected to cover over 75% of patients left at the scene by the attending crew. There were 251 patients in the intervention arm and 537 in the control arm. The two groups were similar in terms of age, sex and condition category but intervention cases were more likely to have been attended during daytime hours than at night. There was no difference in the proportion of patients left at the scene in the intervention and control arms; the median job cycle time was longer for intervention group patients. Protocols were reported as having been used in 101 patients (40.2%) in the intervention group; 17 of the protocols were recorded as having been used at least once during the study. Clinical documentation was generally higher in the intervention group, although a similar proportion of patients in both groups had no clinical assessments recorded. 288 patients were left at the scene (93 in the intervention group, 195 in the control group). After excluding those who refused to travel, there were three non-conveyed patients in each group who were admitted to hospital within 14 days of the call who were judged to have been left at home inappropriately. A higher proportion of patients in the intervention arm reported satisfaction with the service and advice provided.

CONCLUSIONS

"Treat and Refer" protocols did not increase the number of patients left at home but were used by crews and were acceptable to patients. The protocols increased job cycle time and some safety issues were identified. Their introduction is complex, and the extent to which the content of the protocols, decision support and training can be refined needs further study.

The efficacy and safety of a new ciprofloxacin suspension compared with co-amoxiclav tablets in the treatment of acute exacerbations of chronic bronchitis

A multinational, multicentre, randomized, prospective, parallel-group study compared treatment with ciprofloxacin administered as an oral suspension (500 mg twice daily for 7 days) with co-amoxiclav tablets (625 mg three times daily for 7 days) in patients suffering from acute exacerbations of chronic bronchitis (AECB). A total of 147 of 165 cases treated with ciprofloxacin (89.1%) and 146 of 162 cases treated with co-amoxiclav (90.1%) were classified as being clinical successes at the primary efficacy assessment 7 days after the end of therapy (assessed as reduced cough, improvement in dyspnoea, reduction in 24-h sputum volume or reduced purulence of sputum). Treatment equivalence was statistically confirmed; treatment difference:--1.0%, 95% CI--6.6% and 4.5%. Before treatment, 128 bacterial strains were isolated from 103 patients (60 ciprofloxacin and 68 co-amoxiclav). The most commonly isolated organism was Haemophilus influenzae (60 isolates), followed by Moraxella catarrhalis (12 isolates), Streptococcus pneumoniae (11 isolates) and Staphylococcus aureus (10 isolates). At day 14, 40 of 46 ciprofloxacin-treated patients (87.0%) and 46 of 55 co-amoxiclav-treated patients (83.6%) who were valid for bacteriological analysis were classified as being bacteriological success (classed as eradication, eradication with colonization or presumed eradication; treatment difference: 3.3%, 95% CI--8.3% and 14.9%). The adverse event profile was comparable between treatment groups. Most adverse events considered possibly or probably related to study drug were related to the gastrointestinal system and were of mild or moderate severity: nausea (13% ciprofloxacin, 10.6% co-amoxiclav), flatulence (10.3% ciprofloxacin, 3.9% co-amoxiclav), abdominal pain (7.6% ciprofloxacin, 7.3% co-amoxiclav) and diarrhoea (4.3% ciprofloxacin, 6.7% co-amoxiclav). We concluded that a 7-day course of ciprofloxacin suspension is equivalent to a 7-day course of co-amoxiclav tablets in terms of clinical and bacteriological efficacy and tolerability for the treatment of AECB. Thus, ciprofloxacin suspension may offer a suitable alternative treatment for AECB patients who have difficulty in swallowing, or who prefer liquid medications to tablets.

Cardiovascular activity during mental stress following vigorous exercise in sportsmen and inactive men

Thirty-six competitive sportsmen and 36 inactive men participated in a two-session experiment. Session 1 involved exercise to exhaustion so as to assess maximal oxygen consumption (VO2 max). In Session 2, both groups were randomized into three experimental conditions: 20 min of exercise at high intensity (70% VO2max) or moderate intensity (50% VO2max) or a light exercise control. Following 30 min of recovery, all subjects performed mental arithmetic and public speech tasks in a counterbalanced order. Cardiovascular, electrodermal, respiratory, and subjective variables were recorded. Sportsmen had higher VO2max, lower body fat, and lower resting heart rate (HR) than inactive men. A postexercise hypotensive response was observed among subjects in the 70% and 50% VO2max conditions, accompanied by baroreceptor reflex inhibition in the 70% condition. Systolic pressure was lower during mental arithmetic and during recovery from the speech task in the high-intensity than in the control group. Diastolic pressure was lower following mental arithmetic in the high-intensity group. No differences in HR reactivity, electrodermal, or respiratory parameters were observed, but baroreceptor reflex sensitivity was inhibited during mental arithmetic. The results are discussed in relation to previous reports of suppressed cardiovascular reactivity to mental stress tests following vigorous exercise and the role of stress-related processes in the antihypertensive response to physical training.

Cognitive and somatic anxiety

Three hundred and forty adults (including sports players, recreational exercisers, mediators and sedentary controls) completed three inventories purporting to measure cognitive and somatic aspects of anxiety. These were the Cognitive-Somatic Anxiety Questionnaire (CSAQ) devised by Schwartz, Davidson & Goleman (Psychosomatic Medicine, 40, 321-328, 1978), the Worry-Emotionality Scale (WES, Morris, Davis & Hutchens, Journal of Educational Psychology, 73, 541-555, 1981) and the Lehrer-Woolfolk (1982) Anxiety Symptom Questionnaire (LWASQ). Factor analysis of the CSAQ and WES identified distinct cognitive and somatic anxiety factors in both inventories. Higher somatic than cognitive ratings were recorded on the CSAQ and WES, while the pattern was reversed on the LWASQ. The CSAQ can tentatively be recommended as a useful measure of these two anxiety components. We were unable to confirm an observation made previously in the literature that practice of meditation is associated with reduced cognitive anxiety, or that exercise is linked with lower somatic anxiety.