Factors that influence child conveyance decisions made by prehospital clinicians

As the first responders to cases of child trauma or acute illness, prehospital clinicians must have an appropriate knowledge base and the skills and confidence to provide effective and appropriate management (Fowler et al, 2017). Previous studies have noted that ‘management of the prehospital paediatric patient is inherently stressful’ (Fowler et al, 2017), with pre-arrival preparation for such individuals causing ‘extreme anxiety and discomfort for ambulance personnel’ (Houston and Pearson, 2010).

Strict conveyance protocols (Hetherington and Jones, 2021) conflict with both the ambulance services' growing autonomy and the current discourse of hospital avoidance (Hetherington and Jones, 2021), and often result in the unnecessary and avoidable transportation of children.

A cohort study discovered that a significant 15–80% of children visiting accident and emergency departments between 2007 and 2017 presented with conditions that were appropriate for primary care and were discharged with no treatment given (Ruzangi et al, 2020). Nonetheless, it has been recognised that discharging patients at scene is a complex process for prehospital clinicians to undertake and one that is seldom used (O'Hara et al, 2014; O'Cathain et al, 2018).

Therefore, through this rapid review, the authors aimed to identify barriers and enablers to making appropriate decisions on transportation, along with areas of disparity in child conveyance decision-making by prehospital clinicians.

Method

A version of the PICO (population, intervention, control and outcomes) tool for rapid reviews specifically for the formation of clinical questions was used (Curtis et al, 2022). This version, PICo (population, intervention and context), is more appropriate for qualitative reviews such as this (Murdoch University, 2023). This resulted in the specific research question: what factors influence child conveyance decisions made by prehospital clinicians in the prehospital setting?

Preliminary searches of online databases enabled familiarisation with necessary keywords, which aided the final search strategy (Aveyard, 2019) (Table 1). The following databases were searched using a full search strategy from 2012 to 23 July 2023:

• MEDLINE via EBSCOhost
• CINAHL via EBSCOhost
• PubMed.

Supplementary databases were identified through internet searching using the above-mentioned search components. Forward and backward tracking were used (Aveyard, 2019; Curtis et al, 2022). Grey literature and ongoing studies were disregarded in the interests of time and relevance.

Informed by components of the specific research question and Joanna Briggs Institute (2015) methodology (Peters et al, 2020), inclusion criteria were defined and divided according to three factors—population, context, and concept; these can be seen alongside the exclusion criteria in Table 2. These criteria dictated the inclusion of articles within this review and were used to screen titles and abstracts for relevance (Curtis et al, 2022; Mooney, 2012).

The search strategy required a lengthy collection of potentially applicable resources. Duplicates between databases were discounted, after exportation to Microsoft Excel, with all screening documented using the PRISMA flow diagram (PRISMA, 2020) (Appendix 1, online). All studies included specifically review the factors affecting conveyance decisions about children by prehospital clinicians.

While it is recommended that two reviewers independently screen, extract data and risk assess studies to minimise bias and the risk of errors, this was not feasible in this incidence. This created a weakness as some studies may have been missed. 9 Of all articles reviewed, through the exclusion process, it was concluded that three studies were suitable for inclusion (Table 3). These three studies where then critically appraised using the Critical Apraisal Skills Programme (CASP) (2018) systematic review checklist, the results of which can be seen in the next section (Table 4).

A meta-synthesis was used on the evidence gathered (Aveyard, 2019). This was adopted as its purpose of integration and interpretation of similar qualitative studies means it is designed to investigate the occurrence of the same phenomena; it is therefore highly suitable for this study of factors influencing conveyance decisions. A thematic synthesis method was applied to identify recurring themes (Thomas and Harden, 2008), and therefore recurring factors. Five themes were identified using this method of coding (Appendix 2).

Findings

Study population characteristics

The three selected studies investigated the same factors and took similar approaches. They took qualitative approaches through semi-structured interviews of small populations were taken, enabling human factors to be understood.

Critical appraisal showed that all three papers, unusually, fulfilled the following questions:

• Was there a clear statement of the aims of the research?
• Is a qualitative methodology appropriate?
• Was the research design appropriate to address the aims of the research?
• Was the recruitment strategy appropriate to the aims of the research?
• Was the data collected in a way that addressed the research issue?
• Has the relationship between researcher and participants been adequately considered?
• Have ethical issues been taken into consideration?
• Was the data analysis sufficiently rigorous?
• Is there a clear statement of findings?

Regarding the value of the research, the Hetherington and Jones (2021) study was very valuable as it had very similar aims to the present study. Fratta et al (2021) had very similar aims and most reliable sample size and Ward et al (2022) had very similar aims and large sample.

Themes

Five recurring themes were identified within the synthesis: provision of care; equipment and protocols; exposure, experience and confidence; emotion and social circumstances; and education or skill set (Fratta et al, 2021; Hetherington and Jones, 2021; Ward et al, 2022). Themes are summarised in the current section.

Provision of care

Provision of care by clinicians was a recurring theme in all three studies.

The availability of alternative routes and resources for patients was an important factor in the care and treatment provided (Fratta et al, 2021; Hetherington and Jones, 2021). While Fratta et al (2021) and Ward et al (2022) highlight the impact of time to the nearest facility on decisions, Hetherington and Jones (2021) describes the effect of other clinicians' aversion or lack of support regarding keeping patients at home, even when this is most beneficial for the patient.

One participant described a scenario where they discussed a patient with the GP, highlighting the unpredictability of a decision based on the variability of who is working:

‘We've got two out-of-hours providers. M is compliant and as brilliant as you'd ever want. G—it's like banging your head against a brick wall. It's a postcode lottery.’

(Hetherington and Jones, 2021).

All three articles go on to examine the impact of both the patient's family and the public's assumption that the role of the ambulance service is exclusively patient transportation:

‘I feel that the general public perception is if we turn up for their child, they expect to go to hospital.’

(Hetherington and Jones, 2021)

Ward et al (2022) describe how going against the clinical judgement of the ambulance service is the right of the patient and the caregiver:

‘We take him to the hospital, even if it's against what we feel is necessary.’

(Ward et al, 2022)

Equipment and protocols

Equipment and protocols were investigated by all the included studies.

Restrictions applied within stringent guidelines were discussed.

Fratta et al (2021) found that clinicians followed the protocols:

‘Medical cases have a different protocol. We have to take them to the closest emergency department.’

(Fratta et al, 2021)

However, Hetherington and Jones (2021) found that clinicians used their autonomy in the interest of the patient:

‘We are restricted by MTS [Manchester Triage System] if you follow it to the age limit […] if I am honest, I don't always follow it if I think there is a more sensible route, I will follow what I think. I'll never just leave at home […] I would always refer on.’

(Hetherington and Jones, 2021).

There was a consensus that tools and pathways that were more specific to minor illness and injury should be created (Fratta et al, 2021; Hetherington and Jones, 2021; Ward et al, 2022).

Nonetheless, the presence of pathways did provide relief for the clinician, reducing the pressure of decision-making (Fratta et al, 2021; Hetherington and Jones, 2021).

Exposure, experience and confidence

The theme that recurred the most by far was the effect of exposure, experience and confidence on care. Hetherington and Jones (2021) investigated the effect of having regular contact with children on their management of paediatric patients.

The frequency of exposure affected: advanced skills, such as cannulation; administration of medication, such as that for pain management; and the ability to appropriately assess the patient. This therefore had an impact on the quality of care (Fratta et al, 2021; Hetherington and Jones, 2021; Ward et al, 2022).

Many clinicians said how they had not yet carried out life-saving skills on children during their career, which directly affected their confidence:

‘I've never done that. I wouldn't be confident cannulating a toddler. I've never actually cannulated a child, to be fair.’

(Hetherington and Jones, 2021).

Practitioners said their experience of exposure to children (including their own) or lack thereof affected their approach to the paediatric patient and their family:

‘I have four kids, so I can at least coach [parents] through that process of it's really not a sickness as it is you just freaking out. But you can't really tell them that.’

(Ward et al, 2022).

Emotional and social circumstances

The emotional and social circumstances in which clinicians found themselves greatly affected the clinician's decision to convey (Fratta et al, 2021; Hetherington and Jones, 2021). While interviewees stated the impact of a ‘gut feeling’ (Hetherington and Jones, 2021; Ward et al, 2022), it was clear that across the board clinicians become particularly risk averse when it came to treating children (Fratta et al, 2021; Hetherington and Jones, 2021):

‘Paediatric patients always make me consult more frequently, I'm always a little more nervous about paediatrics than adults.’

(Fratta et al, 2021).

The family also played a significant role in clinicians' decisions, through both consideration of the parent's anxiety and feelings (Hetherington and Jones, 2021; Fratta et al, 2021) and the involvement of the caregiver in the history of the patient (Hetherington and Jones, 2021; Ward et al, 2022). One practitioner highlighted the impact of appearing confident on new parents:

‘The new parents are nervous. You know, the child spikes a little fever and they kind of go into freak-out mode.’

(Ward et al, 2022).

Education or skill set

A consensus was reached between papers that education about children was lacking (Fratta et al, 2021; Hetherington and Jones, 2021; Ward et al, 2022). The training provided was exclusively on cardiac arrest and resuscitation (Fratta et al, 2021; Hetherington and Jones, 2021) and was devoid of content on communication techniques and how to approach family members as well as on minor illness and injuries.

Training was also found to be aimed at adult patients:

‘We treat adults and the elderly all the time and I don't feel like we get enough paediatric education to know to be prepared to take care of them.’

(Fratta et al, 2021)

Professionals were aware that, while their exposure to adult patients was high, child exposure was infrequent so there was a risk of skill fade (Fratta et al, 2021; Hetherington and Jones, 2021; Ward et al, 2022).

Self-reflection and responsibility were discussed regarding keeping professional practice current:

‘It's very much up to you to go and keep yourself current.’

(Hetherington and Jones, 2021).

Discussion

The subject and overall ambition of this rapid review were to determine the factors that influence child conveyance decisions made by prehospital clinicians in the prehospital setting. The three included studies investigated the factors that influence child conveyance decisions and synthesis of these studies generated five themes.

It is evident that, despite expansion of skill sets, expectations and consequently scope of practice (Association of Ambulance Chief Executives (AACE), 2011), historical perceptions of the prehospital clinician's ability undermine the reality of the contemporary professional (Hetherington and Jones, 2021). Families, the public and longstanding members of the service were found to be barriers for the provision of care and using alternative routes (Hetherington and Jones, 2021; Ward et al, 2022), with the UK-based papers showing the public expected transportation rather than an educated clinician.

In addition, access to alternative routes was impeded by their availability (Houston and Pearson, 2010; Fratta et al, 2021). Limitations because of reduced out-of-hour provision, geographic restrictions and even the lack of agreement between other services and health professionals often resulted in avoidable conveyance (Fratta et al, 2021; Hetherington and Jones, 2021; Ward et al, 2022).

Roland and Matheson (2012) identified that specialist clinicians or those with substantial experience in the assessment and treatment of children relied more on their intuition and knowledge rather than guidelines or protocols. Conversely, most participants in the reviewed studies not only relied on the protocols, regardless of experience, but also suggested there should be further protocols and guidelines for less severe illness and injury (Fratta et al, 2021; Hetherington and Jones, 2021; Ward et al, 2022), underlining the fact that guidelines for children existed only for severe illness and cardiac arrest (Brown et al, 2021). Additionally, clinicians felt supported by the existence of strict protocols such as those on conveyance, which reduced the pressure and possible vulnerability to criticism that decision-making creates (Whitley et al, 2020; Ward et al, 2022).

Exposure to children in a professional, prehospital environment is difficult to control, with most prehospital clinicians unable to choose which incidents they respond to (AACE, 2011).

Although research into the effect of clinician confidence on clinical practice is limited (Brady, 2018), a lack of exposure and confidence were found, through Brady's (2018) focus groups, to be directly linked. Experience was a key and recurring factor across two of the three studies (Fratta et al, 2021; Hetherington and Jones, 2021). O'Connor and Leonard (2014) recognised that this link was an evident and important factor when working within children's healthcare, with participants of both their study and Hetherington and Jones' (2021) observing that confidence could impact on quality of care and patient outcome.

A strong consideration and appreciation of emotional and social circumstances were also identified. Children tended to increase apprehension and often caused the largest amount of distress for the clinician after a negative outcome (Houston and Pearson, 2010). The child who is in distress discomforts not only the inexperienced clinician, increasing apprehension and clouding judgment (Houston and Pearson, 2010; Ward et al, 2022) but also the family (Hetherington and Jones, 2021). While a parent or caregiver's presence on scene can be beneficial because of their knowledge of the child and comforting presence (Hetherington and Jones, 2021), some clinicians have found that parents' situational ‘hysteria’ and possible confrontational nature can exacerbate the state of the child (Williams et al, 2012; Gunnvall et al, 2018).

The presence of a gut feeling, whether in family or clinician, was also a key factor and, though its accuracy varies depending on experience, the concept shows potential for the identification of illness in children (Van den Bruel et al, 2010). It was suggested that the age of the child had a direct impact on the clinician's gut feeling and apprehension (Fratta et al, 2021; Ward et al, 2022). Whitley et al (2020) highlighted barriers when managing younger children that render them more difficult to assess and treat.

Prehospital clinicians with additional, specific training have higher rates of non-conveyance, and those who engaged in such training were more likely to refer to a community service, such as the patient's GP (O'Cathain et al, 2018; Ward et al, 2022).

The three articles showed that clinicians desired more education that covered a larger range of child patients, specifically on primary care presentations and age-based conditions (Fratta et al, 2021; Hetherington and Jones, 2021; Ward et al, 2022). However, other studies have concluded that the desired duration and level of training ranges greatly (Fowler et al, 2017), with some suggesting limiting the depth delivered.

Hetherington and Jones (2021) noted that training after registration relies on the professional themselves, so there is no prescribed topic choice and skill fade could easily occur (O'Hara et al, 2014; Ward et al, 2022). Additionally, mandatory and preregistration training currently focuses on resuscitation, leaving the clinician devoid of specific techniques in communication and handling families or knowledge of minor illness and injuries specific to children (Houston and Pearson, 2010; Hetherington and Jones, 2021).

Limitations

Only three papers were included in this review, limiting the strength of recommendations.

Additional consideration has been given to the considerable lack of UK-based research and consequent requirement to use research based in the United States. It is therefore important to consider the differences in the healthcare services between the two countries, accepting that this may directly impact the results. Because of the specific natures of the research question and the setting, the available evidence was limited.

Given the methodological rigour applied, the authors feel this review has generated unique insights and will be useful as a foundation for future research.

Implications for practice and research

There is an urgent need to develop and broaden the depth of prehospital child education to improve decision making and confidence levels, because current education is considered suboptimal because of limited training and placement exposure (O'Cathain et al, 2018). The Health and Care Professions Council requirement of an honours degree has offered an opportunity for implementation of an in-depth paediatric module. However, this does not benefit those who are already registered; it could be suggested that the paediatric module on the yearly mandatory training is expanded to encompass a larger range of conditions and alternative resources.

To complement this increase in education, national protocols and guidelines for children with lower acuity complaints should be developed and this should be combined with an extensive list of alternative resources.

The increased scope of practice should be made widely known, developing both clinician and public confidence in the role.

Further research should be developed to investigate the prospect and benefits of prehospital paediatric specialist roles on appropriate and effective patient care. The creation of such a role, responding primarily to the 5–10% of call volumes that are about children, would negate concerns of confidence, exposure and experience. While it is accepted that their presence may not be possible for all ambulance attendances, support from their specialist skill set could be accessed through alternative methods, empowering other clinicians. The research should take a mixed-methods approach, identifying successful and appropriate decision-making through an analysis of clinical record data, while involving interviews or collation of qualitative feedback from the specialist, the patient and family to review confidence and patient-centred care.

Conclusion

This review identified several key barriers and facilitators to the prehospital clinicians' paediatric conveyance decision-making process, including educational, experiential, physical and social factors.

The findings of this review provide a basis for discussion and clinical practice improvement.

Enhanced paediatric training is needed for prehospital clinicians before and after registration to help increase confidence in conveyance decision-making on scene.

Specialist prehospital paediatric roles should be explored further, with empirical methods used to assess clinical and cost effectiveness.

Key Points

• Children can evoke discomfort, resulting in reluctance to start treatment or immediate and often avoidable hospital conveyance
• Public and professional perception of a paramedic's ability undermines the scope of the contemporary professional, with many expecting transfer to hospital rather than treatment
• Limited access to alternative routes and facilities results in avoidable conveyances
• Specialist clinicians or those with experience of paediatrics rely more on intuition and knowledge than guidelines or protocols; such practitioners have higher rates of non-conveyance
• Inexperienced clinicians relied on protocols and guidelines for support and felt additional ones were required for less severe illness
• Increased exposure to paediatrics directly increases clinicians' confidence, which affects quality of care and patient outcome

CPD Reflection Questions

• Has there a time when you've taken in a low-acuity paediatric patient ‘just in case’?
• What tools and processes do you use to assist your decision making? What factors affect your conveyance decision?
• Do you have enough education in specialist areas such as paediatrics? How could you be further supported?