Aims: There is a lack of consensus regarding the role for critical care in the prehospital environment in the UK. It was hypothesised that this related to differences in views and understanding among opinion leaders within influential prehospital care organisations.
Methods: A 38-item survey was developed by an established paramedic-physician prehospital critical care service. The survey was distributed to individuals in senior positions within seven organisations that have a major influence on UK prehospital services. Analysis comprised a description of the distribution of results, assessment of the level of agreement with each statement by professional background and current involvement in prehospital critical care and evaluation of the overall consistency of responses. Free-text comments were invited to illustrate the reasoning behind each response.
Results: There were 32 respondents. The estimated response rate was 40%. The consistency of the questionnaire responses was very high. Overall, all individuals agreed with most of the statements. Paramedic respondents were more likely to disagree with statements that suggested that critical care involved interventions that exceed the current capability of the NHS ambulance service (p<0.05). Free-text comments revealed wide differences of opinion.
Conclusion: Although there appears to be broad agreement among opinion leaders regarding the concepts underpinning existing prehospital critical care services, areas of contention are highlighted that may help explain the current lack of consensus. Cooperative efforts to assess the current demand and clinical evidence would assist in the creation of a joint consensus and allow effective future planning for the provision of prehospital critical care throughout the UK.
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The critical care element of prehospital care in the UK is ill defined and variably delivered. Some ambulance services utilise dedicated specialist paramedic–physician prehospital critical care teams to enhance existing ambulance service capability, but the majority rely on a more diverse range of services with varying composition, capabilities and governance arrangements.1 2 The resulting variations in quality and the need for a reliable prehospital critical care component have recently been highlighted.3 Although clinical trials are still underway,4 a consistent survival advantage has been demonstrated for selected patients in systems in which properly targeted specialist prehospital critical care teams are used.4–14
Despite the existence of some successful prehospital critical care systems in the UK, there continues to be a lack of consensus about their role within the health system. We hypothesised that this related to differences among opinion leaders within key organisations responsible for the shaping of prehospital care. We sought to identify these differences. We surveyed opinion leaders within the stakeholding organisations and measured the level of agreement with a range of statements that we believed to reflect accurately the premises underpinning existing services.
Eighteen paramedics and physicians working within an established prehospital critical care and retrieval service (www.magpas.org.uk) articulated a series of 38 statements that represented the rationale for the service concept of operations. Once consensus was reached, the statements were listed on a web-based questionnaire (www.thesistools.com) and all contributing paramedics and physicians were asked to comment on the technical ease of use of the website and the clarity and terminology of the questionnaire. Once this development phase was completed, a five-point Likert scale15 was added to measure the level of agreement or disagreement with each statement and the questionnaire was finalised for distribution. The Local Research Ethics Committee confirmed that this survey constituted a service evaluation, which did not require formal ethical approval.
In order to ensure anonymity, the chairpersons of seven groups who currently play a major role in prehospital care were asked to distribute the survey invitation on our behalf to individuals in key posts within their organisation (table 1). Respondents were asked to state their affiliated organisations, their professional background and their personal involvement in the actual delivery of prehospital critical care. When considering their level of agreement or disagreement with the statements, participants were asked to respond as an individual rather than on behalf of the organisation. Although a web-based response was encouraged, the option of printing out the survey and responding by mail was offered. Comments were also invited and anonymity was guaranteed.
Reminders were sent to the chairpersons at 4 and 6 weeks and the survey was closed at 8 weeks. Analysis involved description of the distribution of results, assessment of the level of agreement or disagreement with each statement and evaluation of the overall consistency of responses.
Responses and free-text comments were grouped by five main themes (terminology, epidemiology and rationale, governance and training, clinical interventions and service operations). When comparing responses by professional background and current critical care activity, the null hypothesis was that there would be no difference. As the data are non-parametric, the Mann–Whitney test was used to determine the probability of any observed differences in the responses for each individual statement having occurred by chance alone.16 A threshold probability of 0.05 was chosen to reject the null hypothesis for an individual statement.
The statements and responses are given in table 2, grouped according to theme and overall agreement or disagreement. Additional free-text comments are given in table 3. Thirty-two opinion leaders responded (30 via the web-based survey, one by e-mail and one by mail). A number of individuals (respondents and non-respondents) reported problems such as error messages and connections timing out without saving responses. Respondents included one nurse, seven paramedics (22%) and 24 physicians (75%). Many respondents reported being concurrent members of two or more of the organisations and occupied 57 of the 142 positions in table 1. If the same proportion of non-respondents held similar multiple positions then the denominator for the response rate could have been as low as 80 individuals and the actual response rate as high as 40%.
All individuals agreed or strongly agreed with most of the statements and the internal consistency of the questionnaire responses was very high (Cronbach’s α = 0.92). Only statement 3 had less than 50% agreement. The seven paramedic respondents were significantly less in agreement with 18 of the statements (47%) than the physicians (p<0.05). This statistical finding represented actual disagreement with seven (18%) statements (statements 1, 22, 24, 28, 29, 32 and 34 on table 2).
Thirteen respondents (all of whom were physicians) indicated that they were currently involved in the delivery of prehospital critical care as defined in the survey. With the exception of statement 3 (in which the median response was disagreement) these respondents consistently reported greater agreement than those who were not involved in the actual delivery of prehospital critical care. However, these differences were significant (p<0.05) for statements 13 and 18 only.
Although the clinical service, which forms the basis of the statements, is relatively unusual in the UK, the underlying concept of operations is certainly not unique within international emergency medical systems.17–21 The results show that whereas most opinion leaders agreed with the statements derived from this service, many did not. This provides a possible explanation for the difficulty encountered in reaching the consensus required to move forward. The free-text comments, some of which appear diametrically opposed, illustrate this (table 3).
We were disappointed by the relatively poor response rate, given the role of the individuals invited to participate. We planned to sample 142 individual post-holders within the organisations and institutions in table 1 and did not appreciate how many respondents held dual or triple appointments. However, given that non-respondents are also likely to have held more than one position, the denominator for the response rate may be much less than 142 and the estimate of 40% valid. We also assumed that respondents would be more likely to participate if requested to do so by the chairperson of their organisation rather than an external body. A more direct approach may have clarified and improved the response rate at the expense of honest and open responses. In addition, the questionnaire required some time to complete and some respondents were influenced by technical difficulty with the web-based survey. The future use of similar surveys would require a more robust web model.
The low response rate may have introduced bias as those who chose not to respond may have held very different views. It may also limit the statistical validity of the results, particularly with respect to comparisons between professional groups. This type of survey is prone to bias in other ways. These include acquiescence bias (a tendency to agree with all the questions), end-aversion or central tendency bias related to the Likert scale and organisation bias related to a tendency to reflect organisational perspectives. Nonetheless, the survey appears to show that 32 individuals who are currently involved in the organisation and delivery of services at a very senior level largely agree with most of our arguments and assertions underpinning prehospital critical care. This finding highlights the paradox that such services, in contrast to many European countries, are not widely promoted, developed or utilised across the UK.
We believe the free-text comments provide a powerful insight into the differences in opinion and understanding among opinion leaders (table 3). The statement that appeared to be most contentious was statement 3:
“In most cases, patients who develop prehospital critical care needs can have their needs met (or partially met) by treatment or temporising measures instigated by the current range of NHS ambulance service responses.”
Less than 50% of respondents agreed. One respondent who did strongly agree wrote:
“A statement of the obvious.”
Comments from those who strongly disagreed included:
“There is a mismatch between need and quality provided” and “Patients with critical care needs cannot be adequately treated by the ambulance service alone even simply in terms of airway, breathing or circulatory support.”
Statement 5 related to the specific circumstance of the patient with prehospital critical care needs who cannot immediately be transported to hospital because of entrapment or because of constraints related to physical or functional geography. Historically, these patients are the raison d’être for most prehospital critical care and retrieval services. Only one respondent disagreed with the view that these patients’ critical care needs cannot be met by the current NHS ambulance service range of responses. They wrote:
“In 29 years of service and with a critical care… background, I can think of very few patients who would fall into this category and did not survive.”
We also revealed opposing views with regard to certain clinical interventions (statements 22–34). Comments included:
“…why would anyone do these in the prehospital setting?”
“These are all the things that the modern PHC (doctor) has to bring to the party…”
Paramedic respondents tended to disagree with the idea that certain clinical interventions may be beyond the current range of ambulance service capabilities. There was a sense from some of the free-text comments that this disagreement reflected a response to a perceived challenge to the paramedic role rather than an honest appraisal of the current limitations of the professional paramedic. This view was exemplified by the comment:
“It is clear than many of the interventions listed are not legally allowed under current paramedic practice legislation/guidance. The survey is so far looking like a “we need doctors on ambulances.”
Only three respondents disagreed with the interpretation of the existing literature. Again, a dichotomy of opinion was expressed:
“What is also needed is evidence that these interventions make a difference when applied in the prehospital setting…” compared with “We do know that early and effective interventions make a difference to outcomes.”
There is a clear need to develop a better understanding of existing evidence and ensure that this is widely disseminated. We noted that a greater proportion of respondents chose a neutral response to statements 7 (32%) and 9 (25%) when compared with other statements regarding epidemiology and rationale. This may reflect poorly constructed statements or genuine uncertainty. Statement 7 articulated the view that the current UK NHS ambulance service may be unable to meet the critical care needs of up to 0.5% of patients. The figure of 0.5% of 999 calls may seem very small until the fact that ambulance services in the UK deal with almost 6 million emergency calls a year is considered. There may be as many as five of these cases a day in each of the regional ambulance services—a figure consistent with the operational activity of existing prehospital services.
Some respondents appeared to have a limited understanding of the practical reality faced by prehospital services across the UK on a daily basis. One respondent commented:
“There are few places in the UK where it is not better to take the patient to an appropriate A&E (sic) ASAP. There are very few entrapments that cannot be immediately expedited on medical authority.”
There were also opposing views relating to the historical use of a largely volunteer workforce to provide current services:
“Over the years the volunteer workforce has been highly predictable and very reliable.”
“Our continued reliance on volunteers to provide prehospital care is bizarre and archaic…”
With regard to the development of healthcare professionals into these roles, one respondent commented:
“I know of no evidence to support the use of paramedics of any background in the circumstances you describe.”
However, two respondents specifically mentioned the need to include appropriately trained nursing staff in this role.
Finally, a number of respondents challenged the use of the terms “critical care” and “retrieval”. Critical care reflects a process, not a place, and it is not defined by physical location or professional background.22 For example, paramedic–physician teams regularly undertake prehospital emergency anaesthesia and transfer patients by land and/or air ambulance while maintaining organ and system support. Use of the term “prehospital critical care” therefore accurately reflects the care provided during this phase of the patient journey.
The term “retrieval” refers to the process of transporting a patient while maintaining in-transit critical care. We recognise that an arbitrary distinction is often made between retrieval and transport (or transfer) on the basis of the location of the patient (eg, scene or hospital), the type of patient (eg, paediatric or adult) and the origins of the retrieval or transfer team (eg, retrieval teams from tertiary centres or transport teams from peripheral hospitals). Given the confusing terminology, we chose the word “retrieval” to encompass the movement of all patients while delivering critical care. These distinctions are not just semantics, some prehospital opinion leaders clearly do not recognise that current prehospital clinical activity involves the delivery of critical care.
CONCLUSIONS AND RECOMMENDATIONS
High quality, effective and timely prehospital critical care has been emphasised as an essential component in the effective management of seriously ill or injured patients.23 Our survey of opinion among 32 individuals who are influential in shaping the face of prehospital care has revealed broad agreement regarding many of the concepts and arguments underpinning services that provide prehospital critical care. However, some of the survey responses also imply confusion and uncertainty regarding the current need and future role of these services. Until all stakeholders agree on the fundamental principles underpinning the provision of prehospital critical care, plans for its nationwide provision and the development of specialist services and practitioners cannot develop in a structured and equitable way. We would urge stakeholder groups to reflect on these results and jointly commission: an analysis of current prehospital critical care activity across the UK; a systematic review of prehospital critical care systems; a formal joint consensus position statement that addresses areas of both concordance and contention.
We believe that by doing so, current inadequacies in the provision of critical care to the seriously ill and injured within the UK can be more effectively addressed.
The authors would like to thank all the Magpas volunteer paramedics and physicians for helping to develop the survey. They also thank all those who freely participated in the survey. The authors are particularly grateful to Dr T Clarke and Ms L Large of Joint Royal Colleges Ambulance Liaison Committee, Mr R Furber of the British Paramedic Association, Dr J Stephenson for the Ambulance Service Directors of Clinical Care Group, Professor K Porter and Ms L Millar of the Faculty of Prehospital Care of the Royal College of Surgeons of Edinburgh, Dr J Nolan and Ms S Mitchell of the Resuscitation Council, Mr D Philpott of the Association of Air Ambulance Charities and Dr D Zideman and Ms J Clarke of the British Association for Immediate Care for supporting our project and forwarding our invitation to participate. Dr C Notley provided valuable advice regarding how to handle the free-text commentary.
Competing interests: Declared. All of the authors are active members of the prehospital critical care and retrieval service used to derive the original statements used in the survey.
Funding: This research was supported by the Magpas Research Programme, which is funded by the people of Cambridgeshire.