Prearrival: using background information to form an early opinion

The assessment and decision-making process was described as beginning with information received from the ambulance call centre, including, in some cases, the labelling of a patient's need as ‘assist only’. In these cases, many interviewees reported that this formed a picture of a person who had not sustained any injury, but the majority recognised that the person may have experienced an injury or be medically unwell and that care was needed so as to not automatically assume the person was fit to be left at home. Only a minority considered that their assessment or care would differ from any other case:“To me an ‘assist only’ is someone's fallen on the floor, you don't do any obs [vital signs], you put them back to bed and that's it.” (A28)

Decision making also appeared to be influenced by the interviewees' definitions of a ‘fall’. Some conformity with the study's definition of a fall (see table 1) was expressed and there was some agreement that a ‘fall’ was a significant event, usually if associated with a medical cause (such as loss of consciousness) and required assessment in the ED. However, about half of the interviewees also used terms such as a ‘simple fall’ or ‘trip’, and these events were described as less concerning than a ‘fall’, more likely to be attributed to external causes and considered less likely to need treatment in an ED:“my personal understanding would be…hit by something or a medical condition has caused this person to collapse, as opposed to a trip or a stumble or just loss of balance.” (C128)

Initial contact: assessing the situation for any immediate action required and establishing a rapport

The interviewees all articulated their main concern as identifying those older people for whom immediate conveyance to the ED was described as necessitated by one or more of the following: the patient's level of consciousness, pain, injuries associated with the fall or a long lie on the floor, or the patient's medical condition.“‘Do you have pain anywhere?’ Address that first especially chest pain.” (D207)

All interviewees spoke of making an immediate assessment as they entered the premises to establish the details surrounding the fall: what happened, when, and the possible cause for the fall.

Implicit to many of the interviewees' descriptions was the idea of taking care with the way in which questions were phrased, with attempts to establish a rapport being more explicitly described by a small number as a way through which to begin an assessment of the patient and gain accurate information about the circumstances of the fall:“Well you say ‘what are you doing down there?’ Just to break the ice. It usually causes a laugh and then I find out how they managed to get down on the floor.” (C125)

Rapport was also described as serving to gain the older person's trust so that later advice to convey to the ED would not be easily dismissed:“You get a lot of that (refusing to go to hospital) and when they say that straight away we say ‘We're not worrying about that at the moment, let's make sure you're okay, let's find out why you're on the floor’.” (C145)

Continuing assessment: gathering and assimilating medical and social information

In the absence of any clear immediate medical need to convey a patient to the ED, all the interviewees described a further assessment used to make a decision about whether to convey the patient or not. Most interviewees described this assessment as comprising: the patient's medical history, medications, current condition and mobility; and the social and environmental circumstances.“So with an elderly person you check all their medications as well to see if they could lead into what illnesses they do have. So if they've got blood pressure, if they have pleurisy, or heart problems.” (D207)

This information was variously reported as being gained from the older person themselves, from professional and non-professional carers, and from any records kept in the patient's home, although a small number of interviewees considered that the latter were not able to provide the information on medical history, which would have been useful. Some also noted that acquisition of information from patients could be affected by the patient's anxiety regarding the possibility of having to be conveyed to the ED, or by their poor health or cognitive impairment:“…they just don't know because some of them are on so many pills and you say ‘Why are you on these tablets?’ And they say ‘I don't know’ or ‘because the doctor told me to go on them’ and we don't know, unless it's written down.” (A28)

In terms of the patient's current condition, the vast majority of interviewees described their assessment of ‘vital signs’ as that of recording blood pressure, respiratory rate, pulse rate and level of consciousness, and adhering to the standard requirement for ambulance staff of obtaining two readings of ‘vital signs’ while they are with the patient (on arrival and then either before leaving the patient's home or handing over to the ED).“…I used to do just one (set of vital signs) but now I do two, just to see if there's any change since I've been on. Maybe 10 min apart or 5 min apart and their pulse rate and their blood pressure and their sats [oxygen saturation level].” (A22)

The majority of interviewees described such observations as a necessary part of patient care and as providing a baseline in assessing the patient's condition. However, some variation in the types (some performing electrocardiograms (ECGs), while some just pulse and blood pressure checks) and number of observations the interviewees performed was reported. This part of the assessment appeared to be affected by the home circumstances. For the majority this assessment was related to the patient's presenting condition, although two interviewees suggested a reluctance to carry in heavy diagnostic equipment if access to the home was not straightforward.

Most interviewees spoke of the importance they assigned to an assessment of the patient's mobility in establishing if the patient was safe to be left at home, in particular attempting to ascertain if any change in mobility or pain had resulted from the fall. However, difficulties were again noted in assessment in this group of frail patients, for whom no baseline information was available:“So you're asking them does it hurt anyway. ‘Yes my knees really hurt’. ‘Is that how they are normally?’ ‘Yes’ ‘So there's nothing new?” (C119)“You would always test mobility. You always say to them ‘If you can't walk then we'll take you in because you can't get around your own flat’. So we always make sure that they can walk around the flat.” (D203)

Finally in this stage of assessment, eight of the interviewees spoke explicitly of the need to assess the patient's social and environmental situation given the complexity of factors they recognised as potentially causing a fall. These interviewees generally stated that they assessed the patient's living conditions to provide an indication as to how the patient was being cared for either by themselves or others. This could include checking who might be visiting the patient next and when, as well as assessing food, heating and environmental hazards:“Sometimes you go into just death traps basically, and they have rolls of carpet everywhere and boxes lying about which obviously for an unstable old person is not that helpful. So you might move a few of them out of the way and say to them ‘Have you had an assessment of your living circumstances?’ sort of thing.” (D207)

It was recognised that poor social and environmental circumstances did not necessarily indicate a need for conveyance to the ED:“There may not be anything like illness or injury wrong with them in that way, so A&Es [the ED] pointless. They're just going to sit there for 4 h and be sent home because as far as I know, it's the GP that refers them to the social services, and not really the A&E department.” (C145)

For half of those interviewed the presence of carers was an important factor in the decision whether to convey or not, with the absence of carers given as a reason in itself to convey the patient in some cases.

Making a conveyance decision: a process of negotiation, referral and professional defence

Interviewees were asked about their use of the CAT, which had been evaluated in the quantitative stage of the study. All bar one of those who reported having completed the CAT stated this to have been performed retrospectively, after a decision about conveyance had been made and the patient care episode completed. The participants appeared to be mostly ambivalent about the value of the standardised assessment tool as a decision-making instrument, all stating that they considered that it documented an assessment process that they already followed. In fact the interviewees described their knowledge from prior work experience as being most influential in the decisions they made, with ‘instinct’ named as a factor that was given credence in the assessment process.”It's a job you learn through experience and not by knowledge on paper really I feel.” (A22)“You walk in and you get that feeling. I don't like the look of this.” (D203)

That said, nine of the interviewees made positive statements about the tool in terms of the extra information provided by themselves for the patient's GP as part of the CAT.

Interviewees' responses suggested that there are some situations where they felt it was clear what decision needed to be made, while in others, where the patient's needs were complex or where the patient refused, the decision was more anxiety provoking. Clear decisions to leave a patient at home were described as usually indicated when the fall was assessed to have been an explainable accidental slip or trip and all concerned agreed that there was no reason for conveyance:“They've just clipped the door frame or just tripped over a bit of carpet. We just put the carpet back where it's supposed, tell them it's an easy thing to get sorted out with the warden, and then that's it. There's no need for the GP to go round, they've only tripped on a bit of carpet.” (D203)

That said, three participants suggested that they always try to convey the patient to the ED whatever the perceived cause of the fall due to concern about what will happen next for the older person. This approach was reflected for a larger number of interviewees in situations where the complexity of the patient's health and social care situation meant that the only solution to addressing some of the patient's perceived needs was seen to be conveyance to the ED. This was described by half the interviewees as facilitating further assessment of the patient with a view to implementing increased community care support.

All interviewees reported that the process of gaining a patient's agreement to go to the ED was not always straightforward, with some patients reluctant to go in:“You've just got to be a bit careful with elderly people, as I say they don't like going into hospital much. So they'll try and do everything to get out of it.” (D207)

Interviewees reported a range of reasons why older people, in their experience, refuse to go to the ED following a fall. Most of the interviewees reported sympathy with the older person's concerns and respect for their right to decide not to go to the ED, but all participants described their attempts to counter the older person's fears, using words such as ‘negotiate’, ‘cajole’, ‘bribe’, or ‘coax’ to describe the process they entered into. If this period of negotiation failed then firmer tactics were described:“And then I feel like I've got to bully them into going, and it is a horrible situation to be in because sometimes there's nothing wrong with them. They've accidentally tripped over their carpet, they've not actually injured themselves. They've got an underlying illness but I don't know their history. So because of that I have to take them in, because I have to cover myself…” (A22)

This quote also highlights another issue that was clearly of importance to the interviewees, that is, ‘covering your back’. The vast majority of interviewees spoke of anxiety associated with decisions, particularly concerns about potential repercussions arising from the risk associated with non-conveyance to the ED and strategies to mitigate this perceived risk:“Everyone has got the right to refuse to go to hospital….So in that circumstance I would try contacting either a relative or doctor to come round and see them and use their persuasion as well. If that failed, then the only thing we could do is to advise the patient or relatives if they get any worse we will call back. And to record what we've done…and contact a doctor in some way.” (A8)

However, the experiences participants recounted in contacting GPs were varied, with access difficulties predominant (all bar one reported issues at times) and a lack of feedback on the outcome of their referrals explicitly reported as frustrating by three participants. Referral to other services, such as district nursing or social services was also mentioned by a small number of participants. Although these referrals could be problematic, one example of a positive conclusion was also given:“She was being left at home. We found a GP, he came out and visited her…the GP was fuming that she'd been sent home, and we were here, so I got him to ‘phone Social Services as well. And the GP's driver, he fixed her burner so she then had heating and hot water.” (A22)

Another method that a smaller number of interviewees described to ‘cover their backs’ was asking the patient to sign to say they had refused conveyance, although there was doubt expressed whether this would be a defence should there be any future medical issue. Three participants also described the CAT as a way to mitigate risk, although one other suggested that the CAT (and the research project) were in fact another form of scrutiny causing concern about repercussions and therefore encouraging conveyance to the ED.