Title: Safety INdEx of Prehospital On-Scene Triage (SINEPOST)
Funder: Health Education England

Abstract: Background The majority of ambulance service patients require less critical interventions and more community based care. In response to this, policy has been driving paramedics to make dynamic decisions about their patient care before transporting them to the ED. Demand for the urgent and emergency care system is increasing (~5.2% annually). Ambulance services in England sent 753 emergency ambulances an hour to assess patients in 2015/16. This demand is mirrored in ED, which results in delays when the ambulance service is trying to hand the patient over. In a 3 month winter period in 2017/18 in England, there were 41,879 patient episodes where an ambulance took over an hour to handover to the emergency department. Furthermore, the decision to convey a patient to the ED is not always accurate. A 2018 study in Yorkshire found that up to 16.9% of ambulance conveyances to the ED are potentially avoidable.Aim The aim of this study is to develop and validate a tool for assessing the likelihood of an avoidable conveyance to the ED, which can be used by paramedics on scene. Research Questions Can ambulance service clinical assessment data identify an avoidable attendance at the Emergency Department in adults? Can a clinically useful tool be developed that will predict the likelihood of an avoidable ED attendance in adults before transportation to hospital? How do stakeholders approach conveyance decisions on-scene and what would the risk threshold need to be for them to change a decision? Plan This prognostic study has a sequential transformative design. This allows qualitative methodology to steer the tools usability. Phase 1 will start with a systematic review and meta-analysis. This is important as it will direct the research into using the most accurate and feasible models within the same care setting. This will inform the development of a risk prediction model which will be internally validated with discrimination and calibration. Phase 2 will then present the model to clinicians to establish at what point they would change their clinical decision. It will also be presented to the public to establish how the tool can be used to manage expectation on-scene. This will be used to steer clinical guidance which will appear under the tool so the clinician and patient feel supported with a decision not to transport. Phase 3 will use two different cohorts of patients for external validation of the model. Potential Benefits It is anticipated this project will lead to a significant number of patients having care that is more appropriate, closer to home.Patients accessing any part of the urgent and emergency care system would benefit from this research. If paramedics can make safe non-transport decisions it frees their capacity to assess patients still waiting for help. With less patients being transported to ED with low acuity problems, it minimises delays in caring for those who do need specialist ED interventions. For community care it will identify patients that require out of hospital services so that they can get the right level of care promptly.

Lay abstract: Paramedics have specialist knowledge and skills in helping people in emergencies. For example, if you are involved in a road traffic collision, house fire or if your heart stops. These events are quite rare, and the bulk of ambulance service patients who call have problems that are described as 'urgent'. These cases are where you may need access to healthcare and medical help, but there is only a very small chance your problem is life threatening.The care of urgent patients is complex and trying to find the right place for their care can be hard. In 2014 in Yorkshire, up to 16.9% of patients could have avoided being taken by ambulance to the Emergency Department (ED). This group of patients had no special tests or treatments and were sent home. This means they had a minor problem that could have been managed elsewhere. When the ED is busy, ambulances have to wait a long time to handover the care of their patients. In the winter of 2017 in England, 41,879 ambulance handovers took more than one hour. This delay stops ambulances being free to respond to the next emergency. These problems mean paramedics need to make sure the ED is the right place for their patient before they take them there. This project aims to develop a tool to help with that decision. It is designed to show the paramedic the likelihood of ED benefiting the patient if they were transported. They can apply this tool to all their patients. The first step will link data from the ambulance service with that from a large hospital. This data will show us the complete patient journey from their call for help through to leaving the ED. The dataset will be anonymised so we will only be able to see what happened in a journey, not who's journey it was. This information will help create a tool that identifies patients who may not need to be taken to the ED. The public will be invited to face-to-face meetings to help the researcher produce a lay summary of this phase. The second step will be trying to understand what patients and clinical staff think of the using the tool.Focus groups with clinical staff such as paramedics and doctors will be used to explore how they would interpret the outcome of the tool. Rather than a focus group, members of the public will be invited to a forum theatre. This is where the audience is shown a scene with a paramedic actor and a patient actor. They will act out a patient assessment which ends with a decision to leave the patient at home. The audience can then change the parts of the scene they didn't like and adjust how the paramedic plays out the scene. This public involvement will help to influence how to use the tool in practice. In particular, how to work with the patient to manage their expectation of what will happen if they are not taken to the ED.The final step will test the tool in a data set similar to before but using a different destination hospital to make sure it can work in different settings. The dissemination would involve the public and there will be a range of ways they will be invited to participate. This includes being in a video which will be created by the public; for the public. This will introduce the tool to the wider public and patient audience. We plan for members who were involved in earlier stages to co-author and present publications relating to their involvement.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: GENERIC HEALTH RELEVANCE