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Patients who call emergency ambulances for primary care problems: a qualitative study of the decision-making process
  1. Matthew J Booker,
  2. Rosemary L Simmonds,
  3. Sarah Purdy
  1. Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
  1. Correspondence to Dr Matthew J Booker, Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK; matthew.booker{at}bristol.ac.uk

Abstract

Background Telephone calls for emergency ambulances are rising annually, increasing the pressure on ambulance resources for clinical problems that could often be appropriately managed in primary care.

Objective To explore and understand patient and carer decision making around calling an ambulance for primary care-appropriate health problems.

Methods Semistructured interviews were conducted with patients and carers who had called an ambulance for a primary care-appropriate problem. Participants were identified using a purposive sampling method by a non-participating research clinician attending ‘999’ ambulance calls. A thematic analysis of interview transcripts was undertaken.

Results A superordinate theme, patient and carer anxiety in urgent-care decision making, and four subthemes were explored: perceptions of ambulance-based urgent care; contrasting perceptions of community-based urgent care; influence of previous urgent care experiences in decision making; and interpersonal factors in lay assessment and management of medical risk and subsequent decision making.

Conclusions Many calls are based on fundamental misconceptions about the types of treatment other urgent-care avenues can provide, which may be amenable to educational intervention. This is particularly relevant for patients with chronic conditions with frequent exacerbations. Callers who have care responsibilities often default to the most immediate response available, with decision making driven by a lower tolerance of perceived risk. There may be a greater role for more detailed triage in these cases, and closer working between ambulance responses and urgent primary care, as a perceived or actual distance between these two service sectors may be influencing patient decision making on urgent care.

  • admission aviodance
  • emergency care systems, admission avoidance
  • emergency care systems, primary care
  • primary care
  • systems

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Introduction

Despite recent developments in the breadth of, and access to, unscheduled urgent healthcare services, it appears the public continue to turn increasingly to emergency ambulances to meet these urgent care needs. In the UK emergency ‘999’ ambulance demand has been rising steadily by 6.5% per annum, increasing pressure on ambulance resources when other urgent care channels may be more appropriate.1

A variety of reasons for the increase have been proposed: poor understanding of ‘emergencies’;2 unfamiliarity with urgent care options;3 concerns regarding the priority with which calls to out-of-hours (OOH) providers are handled; and perceived reluctance to offer home visits.4 Some studies indicate only a minority of ambulance callers cite they were actually unable to access timely OOH primary care, suggesting other factors are responsible for their bypassing of it.3 Data gathered soon after NHS Direct was established indicated that there was a reduction in calls to general practitioner (GP) OOH services, but curiously no change in 999 ambulance use.5 It has been suggested that challenges in standardising the patient journey through a variety of urgent care and advice options has resulted in confusion among patients about which service best meets their needs.6

Some qualitative evidence suggests a subset of patients always choose to bypass the GP service, even when aware their problems are ‘primary care’ in nature.7 Other studies suggest that previous experience of being directly referred to the ambulance service or hospital by a GP may make patients more liable to choose this route as a first action in future.3 Perceived waiting times have also been suggested as factors that trigger a 999 call in preference to accessing other services,8 along with transportation9 and convenience factors.10

Providing an appropriate response when a patient calls 999 is further complicated by triaging criteria used by the ambulance service dispatch systems. These are often very sensitive at identifying seriously unwell patients, but may lack the flexibility to identify situations in which alternative responses (such as urgent primary care input) may be more suitable.11–14 Added complexity occurs when the call is not made by the person directly requiring treatment.15 Qualitative work has so far struggled to identify predictors that make a caller more likely to request an ambulance for primary care-appropriate health problems.16

Purpose of study

Of the research that has taken place into patient factors that trigger an ambulance call, much has either been performed outside the UK health infrastructure, or before the current breadth of urgent care options.17 The focus of most of this work was on identification of factors suggesting ‘inappropriate’ use of ambulances (almost all of which are labelled as such retrospectively and from the healthcare professional's perspective).9 ,10 ,18 ,19 Some authors explicitly recognise that many calls are very ‘appropriate’ when viewed from the perspective of a patient in a perceived crisis.20 Increasingly it is recognised that understanding lay decision making is fundamental to reducing the ‘inappropriate’ usage of ambulance services.6 This study aimed to address a gap in understanding the factors that influence patient and carer decision making when deciding to access urgent medical treatment by dialling 999.

Methods

Study design

This was a qualitative study using semistructured interviews and thematic analysis.

Setting

MJB, a primary care doctor, accompanied ambulance crews responding to 999 calls in the Great West Ambulance Service NHS Trust catchment area across an equal spread of daytime, night time, weekday and weekend shifts. This trust serves approximately 2.4 million people over 3000 square miles, and handles in excess of 270 000 emergency calls annually.

Selection of participants

Patient participants were selected according to a condition-specific purposive sampling method to reflect conditions commonly managed in primary care. If the patient receiving treatment was not the person who made the decision to dial 999, then the caller was recruited, with the consent of the patient. Consensus between MJB and the ambulance crews, including ambulance paramedics, rapid response vehicle paramedics and emergency care practitioners verified the selected patient sample as those likely to have been managed successfully in primary care.

Procedure

Once suitable cases were identified, the recruitment process involved providing the patient or caller with a study information sheet together with the researcher's contact details and a verbal invitation to contact the researcher if willing to take part. Written informed consent was obtained from those who responded. Interviews were arranged within 2 weeks of contacting the researcher (with the majority, n=14, completed within 7 days of the ambulance attendance) and were conducted at the participant's home.

Data collection

A topic guide was developed and refined after a pilot of four interviews with respondents. Box 1 summarises the key topic areas forming the basis for the semistructured interview. Interviews were conducted with 16 adult participants. Interviews lasted an average of 60 min, were digitally audio recorded and transcribed verbatim, removing potentially identifying information. Half of participants responded to an invitation to verify that the transcripts accurately reflected the interview content.

Box 1

Key interview topic areas

  • Contextualising the call: narrative account of background leading up to the ‘999’ call

  • Events immediately before the ambulance call: final precipitating and triggering factors

  • Sources of advice

  • Background awareness and perceptions of alternative avenues of urgent care

  • Previous personal experiences of ambulance care and urgent primary care

  • Reflections after the treatment episode: thoughts about future care

Data analysis

Transcripts were analysed thematically using a constant comparative methodology21 ,22 and with the aid of Atlas-ti (V.6) qualitative analysis software for the management and coding of data. Analysis began alongside data collection, with ideas from early analysis informing later data collection in an iterative process. Thematic saturation was achieved after 16 interviews. Analysis of individual transcripts commenced with open coding21 generating an initial coding framework, which was added to and refined, with material regrouped and recoded as new data were gathered. The codes were gradually built into broader categories and through comparison across transcripts higher-level recurring themes were developed. Data were scrutinised for disconfirming and confirming views across the range of participants. Discrepancies were resolved by discussion at regular research meetings to ensure consistency. Findings were verified with representatives of the relevant health and social care sectors who formed our study advisory group.

Results

Table 1 summarises the characteristics of the participants in the study, and describes the category of clinical problem triggering the ambulance call.

Patient and carer anxiety in urgent care decision making was identified as a superordinate theme. This key theme, together with four related subthemes, identified participant decision-making processes in the context of navigating urgent care infrastructures. The four subthemes relate to perceptions of ambulance-based urgent care (and particularly the perceived competency of the service to deal with ‘anything’); the contrasting perceptions of the capacity of community-based urgent care; influences of previous urgent care experiences in decision making; and interpersonal factors in assessing risk. Figure 1 summarises how these themes are related.

Table 1

Summary of characteristics of participants

Figure 1

Relationship between themes.

Perceptions of community-based urgent care

Patient and carer decision making on who to contact for urgent healthcare was influenced by perceptions of community-based services. In the following extract a participant reflects on the rationale for his decision to call an ambulance, for a urinary tract infection: The doctor would find it very difficult to do anything useful I think, just with me describing the symptoms of a water infection over the telephone. (Urinary tract infection, 6)

This participant thought a community-based doctor would not be able to help him because he would only be able to talk on the phone. Being able to talk to someone face to face about their condition may be a factor influencing some patients and carers in their decision to call an ambulance.

OOH primary healthcare services were perceived as limited and disconnected from other necessary services, such as pharmacists: Well, the visiting doctor has his bag, but he doesn't have any medicine like a chemist does, so if you needed something you would have to wait until the morning anyway! (Viral illness, 3).

Participants were unsure about the services that could be provided by an OOH GP and may decide that a delay in accessing other services, such as a pharmacy, may present too much of a risk.

The perceived limitations of OOH primary care services were more common in participants with limited experience of OOH providers. These perceptions may be based on participants’ own experiences of GP practice care where home visits from a GP are difficult to access.

Perceptions of ambulance-based urgent care

Participants who were not sure about the most appropriate course of action to take for an urgent health problem reported looking to the ambulance service as a decision-making and signposting service: Sometimes you feel like the ambulance is a half way between your doctor and the hospital, you know, and can make sure you go the right way to one or the other, as sometimes you simply don't know which is for the best? (Chronic respiratory infection, 12)

A perception that the ambulance service could rapidly assess or ‘triage’ the patient's condition and direct them to the ‘right care’ was a common theme across patient and carer interviews: I just needed someone there quickly, to tell me what was going on, to tell me whether it was something serious? (Urinary tract infection, 5)

In contrast, for participants with a chronic condition and frequent exacerbations the rationale for calling an ambulance can be based on the desire to avoid hospital admission: I knew my own doctor would probably send me back to hospital, and I hate it there. I thought maybe the ambulance people... they have more equipment [than the GP]... might be able to treat me at home? (Chronic respiratory exacerbation, 9)

In wanting to avoid an admission some patients may hope the ambulance service can provide a ‘hospital at home’ approach to the treatment of their condition as they believe the ambulance service is equipped to deal with anything.

Influences of previous urgent care experiences in decision making

In flare-ups of chronic conditions, patient and carer decision making was often influenced by previous negative experiences of seeking urgent care: The district nurse said she couldn't help. The doctor's surgery couldn't help. The hospital clinic couldn't help. After that many calls, you just snap? (Chronic pain exacerbation, 14)

When discussing their decision to call an ambulance some participants thought a request for help from other care providers would result in time wasting or meet with barriers to accessing care.

For patients with previous experiences of attending a walk-in centre for urgent care, spending hours waiting to be seen and then being referred to hospital were factors that influenced their decision to call an ambulance: The walk-in centre just sends you up the hospital if they can't do anything. So you end up, like, waiting 3 hours twice. And 3 hours to be phoned back before you can even get an appointment. So it's a whole day. At least the ambulance service comes when called! (Abdominal pain, 15)

Participants knew they could rely on the ambulance service for a quick response. However, it was not just the OOH setting that motivated participants to call an ambulance, several participants also reported a difficulty in accessing their regular primary care provider as the trigger for their ambulance call: I was feeling so rotten, and to have to make several calls to the surgery... then I had to try and get a lift, and to be honest I felt it was such a battle I couldn't deal with it. (Soft tissue infection, 8)

Participants spoke of ‘battling’ or ‘struggling’ to access urgent care in the community. Finding transport to a community health service or GP practice can be perceived as an additional barrier in a situation of perceived urgency. Immediacy of provider response was seen as one of the key factors in participant decision making when calling an ambulance, regardless of the eventual management or clinical outcome.

Patient and carer anxiety and decision making

Patient or carer anxiety may be a common factor underpinning many emergency service calls. One participant cited anxiety and feeling out of control as a reason for calling an ambulance. This participant felt she needed urgent reassurance that her symptoms were not the sign of serious illness: I just knew I needed someone there right then to help me get control... and make sure something very serious wasn't happening. (Anxiety, 10).

Paradoxically, health professional advice can augment patient or carer anxiety: The doctor on the phone said [it may be] early appendicitis. You are bound to need blood tests and scans and stuff... he can't do that in the doctor's office, so I just called the ambulance to get straight up to hospital. (Abdominal pain, 15)

If a tentative diagnosis is suggested over the phone some patients and carers may become extremely anxious, and without clinical assessment the responsibility for making a decision on who to contact next is placed with the patient or carer.

Interpersonal factors and the assessment of risk in decision making

The process of deciding on an appropriate course of action for urgent health problems often involves carers and significant others. Participants reflected on how interpersonal factors affected their decision making as well as perceptions of medical risk: With his history it was a no brainer to be honest. There is nothing a doctor can do so straight to the ambulance really! (Chronic respiratory exacerbation, 2)

Carers may feel a responsibility to take an optimal and least risky course of action for their cared for in a perceived health emergency. Informal carers reported feelings of helplessness and wanting to avoid a situation of feeling guilty for not doing enough: Well I was out at work. So I said, “look dad, just call the ambulance”. That was the most straightforward thing to tell him, to make sure he was seen and was OK before I could get there. (Minor trauma, 4)

In addition, some participants were influenced in their decision making by what they thought their nearest and dearest might say after the event, even if they personally thought an ambulance was not needed: I could just hear my daughter saying “oh mum, why didn't you get the ambulance out?” even though I didn't think I needed it. (Soft tissue infection, 8)

Participants generally reported examples of occasions when their assessment of medical urgency was at odds with those of their significant others. These types of interpersonal factors can result in a decreased tolerance of medical risk, driving a decision to call an ambulance.

Discussion

These data suggest that perceived or actual barriers encountered when attempting to access urgent care via a channel other than the ambulance service is a factor shaping patients’ decision-making processes. Previous authors have discussed how the assumptions of infrastructure complexity may be generating obstacles6 and may even be fuelling the default to the ambulance service. Although all except one of the participants had previous experience of calling an ambulance, none could recall being diverted to another provider on this occasion, so at an organisational level these patients were ‘allowed’ to bypass community-based urgent care options.

The perception that serious illness could not be excluded by anyone other than a hospital doctor was shared across a number of clinical presentations, even when it was recognised that the chance of such illness was very small. In addition, the perceived value of clinical assessment and examination by a GP in excluding serious illness was downplayed in favour of hospital-based specialist investigations. Some participants actually perceived clinical assessment in the community as a delay or a hurdle to accessing the ‘right’ urgent specialist care. The ambulance service was seen as a means to ‘bypass’ these hurdles.

There was a view among many participants that the ambulance service is competent to deal with any and every urgent care need, and an interesting perception of the service in a ‘triage and signposting’ role, bypassing alternative established decision-aiding services (notably NHS Direct). This can be compared to other researchers’ findings of minor illness help-seeking behaviour in the emergency department, as patients’ perceptions of the capacity of alternative providers to manage their treatment needs are often inaccurate.23 There appears a perception that a primary care response would be either too slow or ill equipped to exclude serious illness. While this study supports previous indications that previous experience of referral elsewhere by primary care can shape subsequent health-seeking patterns,3 these data add to this evidence by highlighting the internal dilemma and conflict many callers undergo when assessing medical risk and choosing a response. Previous studies suggest a confusion between the need for urgent medical assessment and the need for an ambulance response.16 If this misconception persists the service is likely to face serious capacity issues.

The interpersonal factors in the assessment and management of risk demonstrate how both patients and informal carers feel a responsibility to access urgent care in the most ‘risk minimising’ way possible, which they frequently perceive to be via an ambulance attendance. Previous studies have highlighted how the disparity between clinical and lay assessment of urgency is linked with emergency department attendances for non-urgent treatment.24 This study supports a similar link with emergency ambulance usage, and importantly highlights the significance of the role of friends and family members in shaping urgent care choices. Indeed, even when the family member was not directly present or consulted, their perceived viewpoints were often very important in shaping urgent help-seeking choices. Educating patients and their carers about the capacity and scope of the urgent care response options available is likely to be fundamental in tackling this, via such initiatives as the ‘Choosewell’ and ‘GP 24/7’ national and regional campaigns.25 However, these data suggest that in isolation this may not be sufficient, as the anxiety surrounding a ‘perceived’ medical emergency may be as pertinent as that in a ‘genuine’ one in shaping the decision-making process.

Limitations

This study only included adult callers and adult patients in one geographical region, and as such it is not possible to comment on whether these findings are generalisable to conditions affecting children or to other regions of the UK. Although the participants were unaware of the observing clinician's professional background until after the interviews, it is important to recognise how this primary care perspective may have shaped the analysis.

Conclusions

There is a perception of a dichotomous infrastructure that delivers either routine or emergency care, with little middle ground. Individuals’ risk management strategy often defaults to the most immediate response, especially if acting in the capacity of a formal carer. When chronic conditions exist, there may be a role for more detailed triage and pre-emptive exacerbation planning, focussing on empowerment to choose the most appropriate provider. A public perception of closer working between urgent primary care and ambulance services might help to address the perceived fragmentation.

References

Footnotes

  • Contributors MJB: design and methodology, data collection, data analysis, full checking of final draft. RLS: data anlaysis, full checking of final draft. SP: design and methodology, data analysis, full checking of final draft.

  • Funding MJB is funded by an academic clinical fellowship from the National Institute for Health Research. Funding support was received from the Severn Faculty of the Royal College of General Practitioners.

  • Competing interests None.

  • Ethics approval The study protocol received a favourable opinion from the South West 4 Research Ethics Committee.

  • Patient consent Obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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