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Complexity of the decision-making process of ambulance staff for assessment and referral of older people who have fallen: a qualitative study
  1. Mary Halter1,
  2. Susan Vernon2,
  3. Helen Snooks3,
  4. Alison Porter3,
  5. Jacqueline Close4,
  6. Fionna Moore5,
  7. Simon Porsz6
  1. 1Faculty of Health and Social Care Sciences, Kingston University and St George's, University of London, London, UK
  2. 2Bentleigh Bayside Community Health, Melbourne, Australia
  3. 3Centre for Health Information, Research and Evaluation, Swansea University, Swansea, UK
  4. 4Prince of Wales Hospital and Prince of Wales Medical Research Institute, University of New South Wales, Sydney, Australia
  5. 5London Ambulance Service NHS Trust, London, UK
  6. 6Royal Free Hampstead NHS Trust, London, UK
  1. Correspondence to Mary Halter, Faculty of Health and Social Care Sciences, Kingston University and St George's, University of London, Grosvenor Wing, London SW17 0RE, UK; m.halter{at}


Background Older people who fall commonly present to the emergency ambulance service, and approximately 40% are not conveyed to the emergency department (ED), despite an historic lack of formal training for such decisions. This study aimed to understand the decision-making processes of emergency ambulance staff with older people who have fallen.

Methods During 2005 ambulance staff in London tested a clinical assessment tool for use with the older person who had fallen. Documented use of the tool was low. Following the trial, 12 staff participated in semistructured interviews. Interviews were recorded and transcribed. Thematic analysis was carried out.

Results The interviews revealed a similar assessment and decision-making process among participants:

▶ Prearrival: forming an early opinion from information from the emergency call.

▶ Initial contact: assessing the need for any immediate action and establishing a rapport.

▶ Continuing assessment: gathering and assimilating medical and social information.

▶ Making a conveyance decision: negotiation, referral and professional defence, using professional experience and instinct.

Conclusions An assessment process was described that highlights the complexity of making decisions about whether or not to convey older people who fall and present to the emergency ambulance service, and a predominance of informal decision-making processes. The need for support for ambulance staff in this area was highlighted, generating a significant challenge to those with education roles in the ambulance service. Further research is needed to look at how new care pathways, which offer an alternative to the ED may influence decision making around non-conveyance.

  • Accidental falls
  • emergency medical services–triage
  • emergency medical technicians
  • health services for the aged
  • decision making
  • clinical assessment
  • emergency care systems
  • admission avoidance
  • nursing
  • pre-hospital
  • paramedics
  • guidelines
  • research

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  • Funding The study was funded by the Department of Health Research Programme to Support Implementation of the National Service Framework for Older People. The funding body did not contribute to the study design, to the collection, analysis and interpretation of the data or to the writing of the manuscript.

  • Competing interests None.

  • Ethics approval This study was conducted with the approval of the Metropolitan Multi-Centre Research Ethics Committee.

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

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