The aim of this study was to explore the range and nature of influences on safety in decision-making by ambulance service staff (paramedics). A qualitative approach was adopted using a range of complementary methods. The study has provided insights on the types of decisions that staff engage in on a day-to-day basis. It has also identified a range of system risk factors influencing decisions about patient care. Although this was a relatively small-scale exploratory study, confidence in the generalisability of the headline findings is enhanced by the high level of consistency in the findings, obtained using multiple methods, and the notable consensus among participants.
The seven predominant system influences identified should not be considered discrete but as overlapping and complementary issues. They also embody a range of subthemes that represent topics for future research and/or intervention.
The apparently high level of consistency across the participating trusts suggests that the issues identified may be generic and relevant to other ambulance service trusts.
In view of the remit of this study, aspects relating to system weaknesses and potential threats to patient safety dominate in the account of findings. However, it should be noted that respondent accounts also provided examples of systems that were said to be working well, for example specific care management pathways, local roles and ways of working and technological initiatives such as IBIS and the ePRF.
Implications for health care
The NHS system within which the ambulance service operates is characterised in our study as fragmented and inconsistent. For ambulance service staff the extent of variation across the geographical areas in which they work is problematic in terms of knowing what services are available and being able to access them. The lack of standardisation in practice guidelines, pathways and protocols across services and between areas makes it particularly challenging for staff to keep up to date with requirements in different parts of their own trust locations and when crossing trust boundaries. Although a degree of consistency across the network is likely to improve the situation, it is also desirable to have sufficient flexibility to accommodate the needs of specific local populations. There was some concern over the potential for further fragmentation with the increased number of CCGs.
Ambulance services are increasingly under pressure to focus on reducing conveyance rates to A&E; this arguably intensifies the need to ensure that crews are appropriately skilled to be able to make effective decisions over the need to convey or not to convey if associated risks to patients are to be minimised. Our findings highlight the challenges of developing staff and ensuring that their skills are utilised where they are most needed within the context of organisational resource constraints and operational demands. Decisions over non-conveyance to A&E are moderated by the availability of alternative care pathways and providers. There were widespread claims of local variability in this respect. Staff training and development, and access to alternatives to A&E, were identified as priorities for attention by workshop attendees.
One of the difficulties for ambulance services is that they operate as a 24/7 service within a wider urgent and emergency care network that, beyond A&E, operates a more restricted working day. The study findings identify this as problematic for two reasons. First, it fuels demand for ambulance service care as a route to timely treatment, when alternatives may involve delay. Second, it contributes to inappropriate conveyance to A&E because more appropriate options are unavailable or limited during out-of-hours periods. Ultimately, this restricts the scope for ensuring that patients are getting the right level of care at the right time and place. Study participants identified some patient populations as particularly poorly served in terms of alternatives to A&E (e.g. those with mental health issues, those at the end of life, older patients and those with chronic conditions).
The effectiveness of the paramedic role in facilitating access to appropriate care pathways hinges on relationships with other care providers (e.g. primary care, acute care, mental health care, community health care). An important element relates to the cultural profile of paramedics in the NHS, specifically, the extent to which other health professionals and care providers consider the clinical judgements/decisions made by paramedics as credible and actionable. Staff identified this as a barrier to access where the ambulance service is still viewed primarily as a transport service. Consideration could be given to ways of improving effective teamworking and communication across service and professional boundaries.
Although paramedics acknowledged the difficulties of telephone triage, they also identified how the limitations of this system impact on them. Over-triage at the initial call-handling stage places considerable demands on both staff and vehicle resources. A related concern is the limited information conveyed to crews following triage. Initial triage was suggested as an area that warrants attention to improve resource allocation.
The findings highlight the challenges faced by front-line ambulance service staff. It was apparent that the extent and nature of the demand for ambulance conveyance represents a notable source of strain and tension for individuals and at an organisational level. For example, there were widespread claims that meeting operational demands for ambulance services limits the time available for training and professional development, with this potentially representing a risk for patients and for staff. Staff perceptions of risk relating to patient safety extend to issues of secondary risk management, that is, personal and institutional liabilities, in particular risks associated with loss of professional registration. The belief that they are more likely to be blamed than supported by their organisation in the event of an incident was cited by staff as a source of additional anxiety when making more complex decisions. This perceived vulnerability can provoke excessively risk-averse decisions. These issues merit further attention to examine the workforce implication of service delivery changes, including how to ensure that staff are appropriately equipped and supported to deal effectively with the demands of their role.
Paramedics identified a degree of progress in relation to the profile of patient safety within their organisations but the apparent desire within trusts to prioritise safety improvement was felt to be constrained by service demands and available resources. Attempts to prioritise patient safety appear to focus on ensuring that formal systems are in place (e.g. reporting and communication). Concerns were expressed over how well these systems function to support improvement, for example how incident reports are responded to and whether lessons learned are communicated to ambulance staff within and between trusts. Consideration could be given to identifying ways of supporting ambulance service trusts to develop the safety culture within their organisation.
Service users attributed the increased demand for ambulance services to difficulties in identifying and accessing alternatives. They were receptive to non-conveyance options but felt that lack of awareness of staff roles and skills may cause concern when patients expect conveyance to A&E.
Recommendations for research
The workshop attendees identified a range of areas for attention in relation to intervention and research, which are provided in Chapter 6 (see Suggestions for potential interventions and research). The following recommendations for research are based on the study findings:
Limited and variable access to services in the wider health and social care system is a significant barrier to reducing inappropriate conveyance to A&E. More research is needed to identify effective ways of improving the delivery of care across service boundaries, particularly for patients with limited options at present (e.g. those with mental health issues, those at the end of life and older patients). Research should address structural and attitudinal barriers and how these might be overcome.
Ambulance services are increasingly focused on reducing conveyance to A&E and they need to ensure that there is an appropriately skilled workforce to minimise the potential risk. The evidence points to at least two issues: (1) training and skills and (2) the cultural profile of paramedics in the NHS, that is, whether others view their decisions as credible. Research could explore the impact of enhanced skills on patient care and on staff, for example the impact of increased training in urgent rather than emergency care. This would also need to address potential cultural barriers to the effective use of new skills.
Research to explore the impact of different aspects of safety culture on ambulance service staff and the delivery of patient care (e.g. incident reporting, communication, teamworking, and training) could include comparisons across different staff groups and the identification of areas for improvement, as well as interventions that could potentially be tested.
The increased breadth of decision-making by ambulance service crews with advanced skills includes more diagnostics; therefore, there is a need to look at the diagnostic process and potential causes of error in this environment.
There is a need to explore whether there are efficient and safe ways of improving telephone triage decisions to reduce over-triage, particularly in relation to calls requiring an 8-minute response. This could include examining training and staffing levels, a higher level of clinician involvement or other forms of decision support.
There is a need to explore public awareness of, attitudes towards, beliefs about and expectations of the ambulance service and the wider urgent and emergency care network and the scope for behaviour change interventions, for example communication of information about access to and use of services; empowering the public through equipping them with the skills to directly access the services that best meet their needs; and informing the public about the self-management of chronic conditions.
A number of performance measures were identified engendering perverse motivations leading to suboptimal resource utilisation. An ongoing NIHR Programme Grant for Applied Research (RP-PG-0609–10195; ‘Pre-hospital Outcomes for Evidence-Based Evaluation’) aims to develop new ways of measuring ambulance service performance. It is important that evaluations of new performance metrics or other innovations (e.g. Make Ready ambulances, potential telehealth technologies or decision-support tools) address their potential impact on patient safety.
is composed of many small companies loosely connected to integrated circuit manufacturers. In Japan, on the other hand, equipment vendors and device manufacturers are tightly linked and are often parts of the same company.
Plasma processes used today in fabricating microelectronic devices have been developed largely by time-consuming, costly, empirical exploration. The chemical and physical complexity of plasma-surface interactions has so far eluded the accurate numerical simulation that would enable process design. Similarly, plasma reactors have also been developed by trial and error. This is due, in part, to the fact that reactor design is intimately intertwined with the materials process for which it will be used. Nonetheless, fundamental studies of surface processes and plasma phenomena—both experimental and numerical—have contributed to process development by providing key insights that enable limitation of the broad process-variable operating space. The state of the science that underpins plasma processing technology in the United States is outlined in Chapter 4. Although an impressive arsenal of both experimental and numerical tools has been developed, significant gaps in understanding and lack of instrumentation limit progress.
The broad interdisciplinary nature of plasma processing is highlighted in the discussion of education issues outlined in Chapter 5, which addresses the challenges and opportunities associated with providing a science education in the area of plasma processing. For example, graduate programs specifically focused on plasma processing are rare because of insufficient funding of university research programs in this field. By contrast, both Japan and France have national initiatives that support education and research in plasma processing.
FINDINGS, CONCLUSIONS, AND RECOMMENDATIONS
Finding and Conclusion: In recent years, the number of applications requiring plasmas in the processing of materials has increased dramatically. Plasma processing is now indispensable to the fabrication of electronic components and is widely used in the aerospace industry and other industries. However, the United States is seeing a serious decline in plasma reactor development that is critical to plasma processing steps in the manufacture of VLSI microelectronic circuits. In the interest of the U.S. economy and national defense, renewed support for low-energy plasma science is imperative.
Finding and Conclusion: The demand for technology development is outstripping scientific understanding of many low-energy plasma processes. The central scientific problem underlying plasma processing concerns the interaction of low-energy collisional plasmas with solid surfaces. Understanding this problem requires knowledge and expertise drawn from plasma physics, atomic physics, condensed matter physics, chemistry, chemical engineering, electrical engineering, materials science, computer science, and computer engineering. In the absence of a coordinated approach, the diversity of the applications and of the science tends to diffuse the focus of both.
Finding: Technically, U.S. laboratories have made many excellent contributions to plasma processing research—making fundamental discoveries, developing numerical algorithms, and inventing new diagnostic techniques. However, poor coordination and inefficient transfer of insights gained from this research have inhibited its use in the design of new plasma reactors and processes.
Finding: The Panel on Plasma Processing of Materials finds that plasma processing of materials is a critical technology that is necessary to implement key recommendations contained in the National Research Council report Materials Science and Engineering for the 1990s (National Academy Press, Washington, D.C., 1989) and to enhance the health of technologies as identified in Report of the National Critical Technologies Panel (U.S. Government Printing Office, Washington, D.C., 1991). Specifically, plasma processing is an essential element in the synthesis and processing arsenal for manufacturing electronic, photonic, ceramic, composite, high-performance metal, and alloy materials.