This study was undertaken to investigate perceptions and experiences of ambulance service personnel who are involved in the inter-hospital transfer (IHT) process. The IHTs that were examined involved non-critical and immediate care transfers. From the literature it is clear that this is an under-researched area of ambulance service work. The study presented here adds to our understanding of the issues and barriers that ambulance service personnel experience when undertaking their role within the IHT process.
Literature search strategy
The literature review focused solely on works related to the purpose of the study outlined in the previous paragraph. MEDLINE, EMBASE and COCHRANE were the databases used for the four literature searches undertaken; a total of 28 articles were identified as relevant to this study.
Literature review
Barratt (2012) undertook a systematic review of IHTs that focused on UK-based intensive care patients. Although Barratt examined a different patient transfer cohort from the one assessed for this article, some key areas of crossover have been identified, such as failure of IHT ‘co-ordination’ and ‘education’, due to limited knowledge surrounding transfers decisions and the ‘haphazard’ approach to education. Another systematic review, undertaken by Hains et al (2010), identified 12 papers across seven countries that demonstrated how little attention has been paid to immediate transfers of non-emergency patients. The review determined patient safety can become compromised due to poor IHT standardisation and failures of the overall communication processes.
As early as 1991, Hickey and Savage identified suboptimal communication, inappropriate transfers and poor use of clinical escorts as common issues in IHTs. Various qualitative studies between 2007 and 2012 conducted by the Victorian Quality Council (VQC) in Australia have also found issues in the areas of communication, documentation, and safety. Its data were collected from several healthcare sources, one of which included ambulance service personnel (VQC, 2007; 2008a; 2008b; 2009; 2012). It is evident that 20 years after Hickey and Savage's publication, the same IHT processes are still regarded by many in the UK as suboptimal (Stevenson et al, 2005; Hains et al, 2010; Bosk et al, 2011; Iwashyna, 2012; London Health Programmes, 2014).
Bosk et al (2011) used content analysis to describe what the IHT process entailed. They uncovered key components to the transfer process at hospital level. These are listed in Box 1. All participants within the study were hospital-based staff, and all identified conflict with emergency medical services (EMS) transportation teams. The study found issues with EMS availability, timeliness, inadequate skill levels, and obstructiveness of IHT policies. Although the study provides insight into the hospitals' perspective, it did not take into account the perceptions of EMS personnel.
Craig (2005) undertook a prospective observational study reporting on the number of phone calls required to facilitate negotiating a transfer. Eighty-one separate patient transfers were included in the study with a mean value of 4.7 (95% CI 3.96–5.43) telephone calls needed to facilitate each transfer. Wong and Levy (2005) found an increase in mortality caused by long delays during IHTs. The findings of these two studies suggest there may be a link between the number of telephone calls made, time delays and an increase in mortality. Confounding factors such as patient's age (mean age 77 years), out-of-hours transfers, and the absence of a clinical escort travelling with the patient were all present and unaccounted for in this study.
It is evident within the literature that IHT policies are not well understood (Hickey and Savage, 1991; Lee et al, 1996; Beckmann et al, 2004; Craig, 2005; Haji-Michael, 2005; Ligtenberg et al, 2005; Antwi et al, 2006; Bosk et al, 2006; VQC, 2008a; Hains et al, 2010; Frendya et al, 2011). Craig (2005) highlights the absence of a state-wide approach to transfer policy development in Australia. In some cases there was an absence of IHT policy altogether (Antwi et al 2006; Hains et al 2010). Ligtenberg et al (2005) identified there were safety and quality issues concerning the use of standard ambulances for IHTs, and concluded that better adherence to published policies and protocols were needed to reduce adverse events. Patient safety issues were also identified by Frendya et al (2011) and Beckmann et al (2003), both of which found suboptimal patient care, equipment failure and human error all increased in IHT systems that did not have clear and explicit transfer policies. The only study that explored EMS policies was by Bosk et al (2011), who identified difficulties with EMS services accepting transfers for unstable patients.
Several studies (Beach et al, 2003; Craig, 2005; VQC, 2008a; Bosk et al, 2011; Iwashyna, 2012) identified poor communication having a negative impact within IHT processes. Insufficient, poorly structured and false information were identified as contributing to the breakdown of information sharing (Matthews et al, 2002; Donchin et al, 2003). As previously identified, these studies did not include data collected from ambulance service personnel.
Various studies have highlighted the organisational difficulties and strain that clinical escorts (i.e. the nurses or doctors who accompany patients during IHT) can place on hospitals (Stevenson et al, 2005; Fried et al, 2010). Fried et al (2010) found that a clinical escort accompanied 825 transfers with staff journeys taking a median of 2 hours (1:24–3:30). Delays were experienced in 60 transfers with the median delayed time of 45 minutes (00:30–01:02). Fried et al and Stevenson et al both found that ambulance services did not always return staff back to their originating hospital after a transfer, which presents significant problems for busy or under staffed hospitals.
Identifying appropriately trained staff to travel with patients emerged as another challenge to IHTs. Deane et al (1990) noted that out of 47 patient transfers, an inappropriately skilled clinical escort was present on 15 occasions. However, Fried et al (2010) noted an increasing clinical seniority of clinical escorts accompanying transfers within NHS Scotland.
Increasing IHT demand has had a negative impact on already stretched emergency care systems, particularly within certain specialties, such as critical care, emergency medicine and NHS ambulance services. Similar issues are reported by the VQC (2008b), citing IHT resourcing issues such as, misunderstanding of resourcing availability and capacity, underestimating distance and response times, issues relating to timeliness of transfers, and inadequate IHT funding as some of the causes hindering the IHT process.
Few studies identified the need for better education of staff involved in the IHT process (Lee et al, 1996; Spencer et al, 2004; Craig, 2005; Stevenson et al, 2005; Cook and Allan, 2008; Hallas et al, 2009. Hallas et al (2009) did recognise issues relating to knowledge, skills and performance gaps between IHT standards and current practice. Cook and Allan (2008) did mention the lack of IHT education of various medical staff, describing the process as haphazard and dependent on local initiatives (Spencer et al, 2004; Stevenson et al, 2005). Lee et al (1996) published an evaluation of scenario-based education where clinical staff (i.e. physicians, nurses and paramedics) put IHT guidelines into practice. The evaluation found that error rates for inappropriate escorts decreased from 35% to 10% when an educational programme was introduced, suggesting that an educational programme was useful and effective in improving informed decision-making when transferring patients.
The study
The aim of the study was to explore what ambulance service personnel perceive to be the issues and barriers surrounding the inter-hospital transfer process.
The study took place at one UK ambulance Service NHS Trust, which between 2013/14 performed a total of 11 542 IHTs, comprising of 1% of all ambulance attendances (Cannon and Shaw, 2015). The study included staff from a number of roles that worked predominantly within the emergency operations centre (EOC) of the ambulance service (see Table 1).
| Participant | Experience (years) | Job descriptions | |||
|---|---|---|---|---|---|
| NCCT | Dispatcher/allocator | CHub paramedic | Clinical manager | ||
| 1 | 4.5 | ✓ | |||
| 2 | 3 | ✓ | ✓ | ||
| 3 | 7 | ✓ | |||
| 4 | 7 | ✓ | |||
| 5 | 7 | ✓ | |||
| 6 | 6 | ✓ | |||
| 7 | 6 | ✓ | |||
| 8 | 18 | ✓ | ✓ | ||
NCCT: non-clinical call takers; CHub paramedics: clinical hub paramedics
Purposive sampling was used to recruit participants who undertook specific roles within the ambulance service. This method was chosen as not all staff would have had the exposure or experiences that were needed to holistically answer the research question. All clinical hub (CHub) paramedics also held front-line clinical paramedic responsibilities. The experience of participants within these roles ranged from 3–18 years in an ambulance service setting.
Semi-structured interviews were used for data collection. A pilot interview was conducted to test the topic guide, researcher's interviewing techniques and the recording equipment. The pilot interview was conducted with a participant with a similar role, understanding and characteristics of other participants in the study. Due to the limited number of participants involved in the study it was decided, and agreed with the participant, that the data would be included into the study.
The research took an exploratory approach, using qualitative methods in order to provide a description of the process of transfers as understood by the NHS ambulance service personnel. Data were collected through one-to-one semi-structured interviews, which were conducted and transcribed by the same researcher. Data were analysed using thematic analysis described by Braun and Clarke (2006).
Ethical approval was sought and deemed to be unnecessary by the Health Research Authority (2013). As the research was undertaken on ambulance service NHS Trust premises and included their staff, research and development approval was required and obtained. Participants were invited to participate in the study through email and sent participant information describing and outlining the study. Informed consent was obtained from all participants. Audio recordings of the interviews were stored securely on password-protected devices.
Findings and discussion
The four themes that emerged from the data analysis are listed in Box 2 and described below.
Mixed messages
There seem to be many misconceptions and a lack of knowledge regarding the IHT process. Misunderstandings can send out confusing and contradictory messages, which can be processed differently by all personnel. However, different roles within the transfer process enables staff to understand the IHT process better, which can in effect help to narrow the information and knowledge gap. Subthemes identified were ‘policy, procedure and process clarity’ and ‘experiences from the other side’. Mixed messages can occur at any point throughout the IHT process (see Box 3).
Hospital and ambulance service personnel appear to not fully understand IHT policies, IHT procedures or the entirety of the IHT process. One CHub paramedic used the IHT policy as a guide through the IHT process, but in doing so found that the policy was open to misinterpretation and was not comprehensive enough. There is a lack of clarity around certain IHT procedures, such as the escalation procedure of IHTs. This general lack of clarity and knowledge about IHT policy, procedures and processes may explain why there is inconsistency in the understanding and decision-making process, and why mixed messages are being passed to hospitals and among staff. This causes frustration and anxiety in ambulance service personnel. This is also documented by Bosk et al (2011), who describe frustration among hospital staff towards the interaction with other agencies when using the IHT policy. The findings of this study may go some way in providing an insight into this issue.
Poor understanding of the different roles played among staff in an IHT was also identified as an issue. One participant described how no one person fully understands the role of the other within the process. Each role appears to have different perspectives and understanding from the next, with an agenda that best suits that person/role, and one that may conflict with other roles. This may suggest communication between roles is fractured, which could hinder the fluidity of the IHT process. This is supported by Bosk et al (2011) who described this as a type of intra-organisational friction and an example of a transactional cost, which prevents a fluid IHT process from being achieved. Beach et al (2003), Craig (2005), VQC (2008a), Bosk et al (2011) and Iwashyna (2012) previously described the negative impact of poor communication on the IHT process. However, this has always been from a hospital perspective rather than from an ambulance perspective and is an area that would benefit from further research.
Participants also described that seeing the IHT process from differing roles has helped to ease misunderstanding, as working in different roles allows personnel to gain better knowledge and understanding of the process as a whole, including the interconnectedness of the roles and the impact of the policy on each role. One participant, a front-line paramedic moving from an ambulance environment into the CHub, immediately developed a better understanding and appreciation for IHTs, stating that he did not even know an IHT policy had existed. A transfer of knowledge based on experiences would allow for a better understanding and appreciation of the whole IHT process. It is possible that if staff understood policy, procedures and processes better, and understood other staff members' roles better, it could have a positive impact on the IHT process. This phenomenon has not been described in the literature.
IHT as a business
Findings showed that some participants approached IHTs from a business perspective that can alter the way decisions are made about transfers, and in turn, affect the way IHTs are perceived by all staff involved. Three sub-themes emerging were ‘core business versus IHT business’, ‘good business versus bad business’, and ‘competing priorities’ (see Box 4).
In some instances, IHTs were viewed as a service directly competing against the day-to-day business, or core business, of the ambulance service. CHub paramedics viewed all tasks involved in managing 999 emergency calls as core business, suggesting a shifting away from a patient-centred model to a business model that focuses much more on achieving predetermined targets. Some participants demonstrated internal turmoil with managing IHT as a business model rather than a clinical model.
Certain aspects of IHTs were further broken down by participants into two categories: ‘good business’ or ‘bad business’. One described ‘critical transfers’ as good business and ‘immediate transfers’ as bad business. Yet, it is unclear whether critical transfers are good business because of the ease in process or due to its strong patient focus. The same participant did, however, refer to immediate transfers as bad business, describing them as time consuming and problematic to process, especially when competing against the demands of 999 emergency calls.
Participants had varying opinions on managing IHTs. These perspectives were either business-centred, patient-centred or a combination. Within these was an undercurrent of competing priorities. One participant described being torn between having to make a business decision rather than a patient centred decision. Others suggested that not all paramedics are suited to perform this role, and that a paramedic with a different skillset was needed—one comfortable in balancing business decisions with patient centred decisions. Ambulance service personnel demonstrated an inherent conflict in choosing business over patient care. This conflict can at times mean IHTs are inappropriately accepted, triaged or dispatched, resulting in ambulances being sent to transfers that do not match the paramedics clinical skill set.
IHTs as a business is a new phenomenon not previously described in the literature. This may be because previous literature has rarely sought the perceptions of ambulance service personnel with regards to IHTs. Bosk et al (2011) did not mention this phenomenon, which further surmises that IHT processes were not focused on optimising patient outcomes. However, the research of Bosk et al (2011) was performed within a privatised healthcare system that has more business orientated objectives than that of a public healthcare system.
IHT as a nuisance
There appears to be consensus that IHTs are a nuisance and are perceived as a separate entity to other emergency services—a service that is provided on the periphery of their core business, and one that often hinders their core business. Two sub-themes were identified as ‘transfer burden’ and ‘transfer dumping’ (see Box 5).
IHTs were seen as a burden on the ambulance service, partly because of the volume of IHTs experienced. Although some CHub paramedics attempted to contextualise how many IHTs occur per day, others suggested the true burden of IHTs are the transfers that are inappropriately accepted, which can be the result of the reasons described in ‘mixed messages’. This combined with the other themes demonstrates an underlying tension or frustration surrounding the IHT process. Some participants perceived some transfers as being ‘dumped’ onto the ambulance service (e.g. a transfer that could be appropriately cared for by the hospitals own resources). There is a perception that these transfers are being ‘dumped’ for practical issues rather than clinical issues. This perception only adds to the frustration of ambulance service personnel and provides further resistance to the IHT process. There were examples of how frustration has become too much for both the ambulance service personnel and hospital staff, which resulted in some form of conflict occurring between the hospitals and ambulance service during a transfer negotiation. Bosk et al (2011) also reported this direct conflict phenomenon between the ambulance service staff and hospital staff.
IHTs challenging professional identities
Some participants perceived that their professional identities are being challenged when undertaking IHTs, either within EOC or working on ambulances. This offers an interesting insight into how paramedics currently perceive IHTs. Two subthemes were identified as ‘professional roles’ and ‘professional recognition’ (see Box 6).
When they felt their professional roles were being challenged, paramedics felt occasional frustration and negative attitudes towards IHTs. Throughout the interviews CHub paramedics openly discussed some of their frustrations when undertaking IHTs on front-line ambulances. Some suggested that the paramedic skillset is more advanced than what is required for certain IHTs, and it would benefit all involved if the ambulance service sent someone with a more appropriately matched skillset to manage some IHTs. Another suggested that hospital staff do not fully understand what being a paramedic entails. These paramedics may be alluding to how their professional roles are not yet fully understood, accepted among peers, or integrated into the healthcare system. However, these attitudes could easily be the by-product of a poorly managed IHT process. If IHTs are approached as a ‘business’ and undertaken in a process that is littered with ‘mixed messages’, then matching the right skill to the right transfer would prove challenging. What is clear is that paramedics experience frustration and a negative attitude towards IHTs, which may ultimately lead to further resistance to the IHT process. Additionally, professional roles and professional recognition are closely linked and when hospitals provide less qualified personnel as escorts during IHTs, this leads to paramedics feeling that they are not being recognised for the clinical skillset.
The phenomenon of challenging professional identities has not been addressed in the IHT literature. To understand why this phenomenon is occurring requires an examination of the recent history of the paramedic profession. Recently the profession has experienced many changes including professional registration with the Health and Care Professions Council, entry into higher education, and a gradual integration and acceptance into the healthcare system (O'Meara, 2009). It could be argued that it is the latter that has not been the smoothest, and combined with a poorly managed IHT process, paramedics are having negative experiences that are challenging their roles and what their professional identities represent within health care.
Limitations of the study
There are a number of limitations within this study. One was the small sample of ambulance services personnel from one NHS ambulance service Trust within the UK. Consequently, any findings cannot be generalised to the wider ambulance service community. Additional and larger studies would need to be carried out. Secondly, the sample that was selected was heavily weighted with CHub paramedics. It would have been useful to obtain further input from persons in other roles in the ambulance service. Considering additional views would have provided a wider breadth of perceptions and experiences from which to assess IHTs that either supported these findings or provided different insights. This study did not include any hospital-based staff involved in IHTs. In order to gain a full and comprehensive understanding of the whole IHT process, the perceptions and experiences of hospital staff would be required. Furthermore, the researcher's background and role was from the same setting as some of the participants in this study, which could lead to researcher bias. The themes that were illuminated in this study were not validated by an independent person, which would have added rigour to this study.
Conclusions
The aim of this study was to engage ambulance service staff perceptions on the process of IHTs and the issues involved. The overall message that appears to have emerged was how a misunderstood IHT process can impact negatively on the staff involved. Moreover, the notion that IHT policies presented staff with mixed message was ever present in the literature, and this study's findings were consistent with those conclusions on messaging and communication.
Another interesting phenomenon that has not appeared before in the literature but emerged from this study was that ambulance service personnel approached IHTs from a business perspective. This could suggest a shift in the way that CHub paramedics, for example, view the purpose of their work. Rather than a medical model, the staff saw this part of their workload as business. Additional research would be needed to explore this emerging phenomenon and its implications.
The discussions revealed a sense of frustration over the prioritisation of IHTs within the ambulance service, which was insightful, because even when managers within an ambulance service regard transfers as important, it is clear that these opinions are not entirely reflected among their own ambulance service personnel.
In terms of future practice it would be useful to explore changing perceptions of IHTs when ambulance service personnel change roles—for example, from frontline paramedic to CHub paramedic. A change in role provides the opportunity to learn policy through the experience of having to interpret it for others. The ability to successfully interpret and understand IHT policy has the potential to help staff in all areas of ambulance service.
Finally, some of the findings in this study have not been identified previously in the literature. Future research areas such as different phases of the IHT process (from ambulance and hospital perspective), patient outcomes, and patient experiences also require consideration. In an ideal world the transfer process would bind together hospitals into a healthcare network that was fluid, unproblematic and clinically focused. The reality, as described by Bosk et al (2011), and supported by this study is a transfer process that at times is cumbersome and lacks fluidity. Shedding new light onto IHTs by considering ambulance service perspectives has identified problematic areas that require further attention and research.
Key Points
Conflict of interest: none declared