Back in 2013 I wrote the post Transport everyone or act as a professional? A question for paramedics (May 6, 2013).  The most recent issue of the journal Paramedicine contains details of research that looked into the factors that influence decisions to transport a patient to hospital, or not; see:

Based on their research the authors developed a ‘theoretical framework [which] illustrates how the organisational culture of blame culture contradicts the evolving professionalisation of paramedicine, and this contradiction is causing tension for paramedics’.  This framework:

… details how paramedics make conveyance decisions by navigating the tensions between fears of individual blame posed by existing organisational culture and the evolving professionalisation of paramedics. Paramedics were found likely to forego responsibility for making alternative or non-conveyance decisions when working in a culture of blame, resulting in transporting patients to an emergency department when this may not be clinically required. When working in an organisation with an existing blame culture, paramedics forgo clinical decision-making. Paramedics must be educated and supported to make quality, patient-focused conveyance decisions. The theoretical framework explains how paramedics navigate conveyance decisions.

The authors recognise that the increased professional status of paramedics.  They say (emphasis added):

Many participants voiced their frustration about not being able to act differently because of feeling bound to abide by both organisation and community expectations. The cultural expectation – that all patients should be transported to a hospital – has been perpetuated either through paramedics’ education or experiences within the ambulance service, an example of tacit knowledge. It could be surmised that paramedics are demonstrating risk mitigation strategies because of the heavily protocolised organisation in which they are employed, contributing to their feeling constrained. The resultant behaviour of paramedics is not demonstrative of professional clinical reasoning; rather, it is the application of tacit knowledge born out of fear of reprisal should a paramedic not obey the organisational expectations or directions. This may be a result of paramedics feeling a low level of trust from the employing organisation and the personal risk associated with making their own decisions, rather than following a direction provided by the employing organisation. Paramedics must acknowledge that with autonomous practice, they must accept the responsibility aligned with autonomy, which, in this case, has some risk of organisational ramifications. For paramedics to achieve autonomous practice, an attitudinal shift and demonstration that they can be accountable for their clinical decisions are required. This acceptance of personal accountability challenges an organisational culture based on fear.

For a similar discussion see Paramedics becoming autonomous practitioners (September 3, 2020).

In the debates about ambulance ramping many see it as a problem with the hospitals and in particular the ED.  The ED is however just the ‘choke point’ with too many people coming in and not enough people being fed through and into the wards or out of hospital.  If paramedics feel they have to transport everyone then that is clearly part of the problem; more ambulances on the road will mean more people at the door of the hospital rather than more people receiving expert out of hospital care and therefore avoiding the need to present to the ED.  As the authors say ‘When patients are transported to an ED in the absence of the clinical need, this may limit the accountability of the paramedic, impact hospital ramping, delay in assessment times, and place undue strain on the ED’.

The authors conclude that:

… paramedics must be appropriately educated and supported by the organisation to make safe, patient-focused decisions. Further research is needed to examine how organisations can support paramedic decision-making to refer patients to alternative care pathways or be discharged at the scene. This will further promote the professionalisation of paramedicine.

For another related discussion see Do paramedics have to transport everyone? (February 3, 2014) and in particular the various comments that appear after that post.

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