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Exclusion of context knowledge in the development of prehospital guidelines: results produced by realistic evaluation
Jönköping University, School of Health Science, HHJ, Quality Improvement and Leadership in Health and Welfare.
Högskolan i Borås, Insitutionen för vårdvetenskap.
Högskolan i Borås, Insitutionen för vårdvetenskap.
Jönköping University, School of Health Science, HHJ, Dep. of Nursing Science. Jönköping University, School of Health Science, HHJ. ADULT.
2013 (English)In: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, ISSN 1757-7241, Vol. 21, no 46Article in journal (Refereed) Published
Abstract [en]

Background

Prehospital work is accomplished using guidelines and protocols, but there is evidence suggesting that compliance with guidelines is sometimes low in the prehospital setting. The reason for the poor compliance is not known. The objective of this study was to describe how guidelines and protocols are used in the prehospital context.

Methods

This was a single-case study with realistic evaluation as a methodological framework. The study took place in an ambulance organization in Sweden. The data collection was divided into four phases, where phase one consisted of a literature screening and selection of a theoretical framework. In phase two, semi-structured interviews with the ambulance organization's stakeholders, responsible for the development and implementation of guidelines, were performed. The third phase, observations, comprised 30 participants from both a rural and an urban ambulance station. In the last phase, two focus group interviews were performed. A template analysis style of documents, interviews and observation protocols was used.

Results

The development of guidelines took place using an informal consensus approach, where no party from the end users was represented. The development process resulted in guidelines with an insufficiently adapted format for the prehospital context. At local level, there was a conscious implementation strategy with lectures and manikin simulation. The physical format of the guidelines was the main obstacle to explicit use. Due to the format, the ambulance personnel feel they have to learn the content of the guidelines by heart. Explicit use of the guidelines in the assessment of patients was uncommon. Many ambulance personnel developed homemade guidelines in both electronic and paper format. The ambulance personnel in the study generally took a positive view of working with guidelines and protocols and they regarded them as indispensable in prehospital care, but an improved format was requested by both representatives of the organization and the ambulance personnel.

Conclusions

The personnel take a positive view of the use of guidelines and protocols in prehospital work. The main obstacle to the use of guidelines and protocols in this organization is the format, due to the exclusion of context knowledge in the development process.

Place, publisher, year, edition, pages
2013. Vol. 21, no 46
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:hj:diva-19950DOI: 10.1186/1757-7241-21-46OAI: oai:DiVA.org:hj-19950DiVA: diva2:573213
Available from: 2012-11-29 Created: 2012-11-29 Last updated: 2014-05-12Bibliographically approved
In thesis
1. Development and Evaluation of a Computerised Decision Support System for use in pre-hospital care
Open this publication in new window or tab >>Development and Evaluation of a Computerised Decision Support System for use in pre-hospital care
2014 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

The aim of the thesis was to develop and evaluate a Computerised Decision Support System (CDSS) for use in pre-hospital care.

The thesis was guided by a theoretical framework for developing and evaluating a complex intervention. The four studies used different designs and methods. The first study was a systematic review of randomised controlled trials. The second and the last studies had experimental and quasi-experimental designs, where the CDSS was evaluated in a simulation setting and in a clinical setting. The third study included in the thesis had a qualitative case study design.

The main findings from the studies in the thesis were that there is a weak evidence base for the use of CDSS in pre-hospital care. No studies have previously evaluated the effect of CDSS in pre-hospital care. Due to the context, pre-hospital care is dependent on protocol-based care to be able to deliver safe, high-quality care. The physical format of the current paper based guidelines and protocols are the main obstacle to their use. There is a request for guidelines and protocols in an electronic format among both clinicians and leaders of the ambulance organisations. The use of CDSS in the pre-hospital setting has a positive effect on compliance with pre-hospital guidelines. The largest effect is in the primary survey and in the anamnesis of the patient. The CDSS also increases the amount of information collected in the basic pre-hospital assessment process. The evaluated CDSS had a limited effect on on-the-scene time.

The developed and evaluated CDSS has the ability to increase pre-hospital patient safety by reducing the risks of cognitive bias. Standardising the assessment process, enabling explicit decision support in the form of checklists, assessment rules, differential diagnosis lists and rule out worst-case scenario strategies, reduces the risk of premature closure in the assessment of the pre-hospital patient.

Place, publisher, year, edition, pages
Jönköping: School of Health Sciences, 2014. 92 p.
Series
Hälsohögskolans avhandlingsserie, ISSN 1654-3602 ; 52
Keyword
prehospital care, patient assessment, clinical judgment, decision making, patient safety, human error, decision support
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:hj:diva-23781 (URN)978-91-85835-51-5 (ISBN)
Public defence
2014-06-05, M 204, Högskolan i Borås, Borås, 13:00
Opponent
Supervisors
Available from: 2014-05-12 Created: 2014-05-12 Last updated: 2014-05-12Bibliographically approved

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