Introduction
Methods
Study setting
Phase | Number of participants | Age | Gender | Education | Years in ambulance service |
---|---|---|---|---|---|
Phase 2 Semi- structured interviews
| n = 3 | Male n = 2 | Doctor n = 1 | ||
Female n = 1 | Nurse n = 2 | ||||
Phase 3 Observation rural station
| n = 11 | Mean = 42 | Male n = 7 | Emergency Medical Technicians n = 1 | Mean = 14 |
Range = 32-58 | Female n = 4 | Ambulance nurse n = 10 | Range = 1-34 | ||
Phase 3 Observation urban station
| n = 16 | Mean = 42 | Male n = 13 | Emergency Medical Technicians n = 1 | Mean = 12 |
Range = 32-58 | Female n = 3 | Ambulance nurse n = 15 | Range = 2-32 | ||
Phase 4 Focus group rural station
| n = 8 | Mean = 42 | Male n = 6 | Emergency Medical Technicians n =0 | Mean = 12 |
Range = 33-50 | Female n = 2 | Ambulance nurse n = 8 | Range = 5-28 | ||
Phase 4 Focus group urban station
| n = 5 | Mean = 44 | Male n = 3 | Emergency Medical Technicians n = 0 | Mean = 14 |
Range = 36-54 | Female n = 2 | Ambulance nurse n = 5 | Range = 10-25 |
Name of the guideline/protocol | The main guideline | The pocket guideline | The triage protocol “METTS” | Pathway protocols |
---|---|---|---|---|
Format
| 194 A4 pages in a file. The file did not contain any register. | File in A5 format. Contains no register. | Two formats: the “old” METTS is in an A5 format file and the new METTS in an A4 file. Connected to a patient record file for use as support when handling over the patient. | A4 papers in a file with 5 different pathway protocols. |
Content
| Description of assessment of the medical and trauma patient. Description of different symptoms and conditions and directions for treatment for both adults and children. Description of drugs. Description of some local procedures and routines. | Tables of drug doses, normal values and a few algorithms, such as cardiopulmonary resuscitation. | A mixture of symptoms and diagnoses. The symptoms or diagnoses have their own page with an algorithm which describes a triage grade based on different symptoms. The patient is given a triage color based on symptoms and vital parameters. | Some pathway protocols take the form of checklists with boxes to tick, while others are plain, descriptive text. |
Location
| Between the seats in the front of the ambulance and one copy in the back of the ambulance. | In an ambulance staff member’s leg pocket. | In the back of the ambulance. | In the back of the ambulance. |
Development process
| Informal consensus | Informal consensus | Unknown | Unknown |
Study design
1. | Literature screening and creation of a theory |
2. | Construction of a conjectured Context, Mechanism, Outcome (CMO) configuration |
3. | Test of the conjectured CMO configuration by data collection |
4. | Presentation of a refined CMO configuration (middle range theory) |
Data collection
Analyses
Validity
Ethics
Results
What works
| – Guidelines with a degree of force |
– Guidelines which are connected to patient notes | |
– Guidelines in a format adjusted for use outside the ambulance | |
– Guidelines in a format where it is easy to look up information | |
– Guidelines with a degree of flexibility | |
– Systems which collect all the information in one place | |
– Implementation strategy based on education, simulation and interactive activities | |
– Development of guidelines involving people with context knowledge | |
For whom
| – Both experienced and inexperienced ambulance personnel |
– The team, who can work on a common strategy | |
– The patients, who are treated more equally | |
How
| – The guidelines are mostly used implicitly because of the format |
– Protocols with some form of checklist or algorithm are used more explicitly | |
Under which circumstances
| – On route to the patient as preparation |
– Outside the ambulance to check medical doses | |
– In the ambulance during transport to triage the patient | |
– When the patient is part of a pathway |
Context | Mechanism | Outcome |
---|---|---|
Context 1: The prehospital work is accomplished a long distance from medical support; the personnel handle many different symptoms and conditions in changing environments and they have different levels of education and experience. | Mechanism1: The guidelines are developed in a process in which people with in-depth context knowledge are excluded. | Outcome 1: Guidelines with a format poorly adjusted to the context. |
Outcome 2: Guidelines with limited explicit use. | ||
Outcome 3: Development of homemade guidelines. | ||
Outcome 4: Lack of organizational control. | ||
Outcome 5. Explicit use of guidelines in file format creates a sense of unprofessionalism. | ||
Mechanism 2: Structured implementation strategy of the guidelines at local level. | Outcome 1: The personnel are well informed of the guidelines and their content. | |
Outcome 2: The personnel take a positive view of the guidelines. | ||
Outcome 3: Both inexperienced and experienced personnel use them. | ||
Outcome 4: Improved team function. | ||
Mechanism 3. Difficulty developing guidelines which cover every possible situation. | Outcome 1: Deliberate deviation from guidelines. | |
Outcome 2: Ethical conflicts. | ||
Mechanism 4: The ambulance mission is divided into 5 separate phases. | Outcome 1: Different need for support in the different phases. | |
Outcome 2: Request for a system which covers all phases. |