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Title: To convey, or not convey ...? : the effect and usefulness of the National Early Warning Score to support paramedics' decisions to convey patients to hospital or treat closer to home
Author: Essam, Nadya
ISNI:       0000 0004 8501 542X
Awarding Body: University of Lincoln
Current Institution: University of Lincoln
Date of Award: 2019
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Background: The ambulance service studied introduced the National Early Warning Score (NEWS) to help paramedics decide whether patients could be appropriately treated closer to home, via an alternative non-emergency care pathway, or needed conveying to hospital. I investigated the effectiveness and usefulness of the NEWS to support paramedics' decisions to appropriately treat patients closer to home. Methods: I adopted a pragmatic approach and used mixed methods. I used an interrupted time-series design and autoregressive integrated moving average (ARIMA) methods to analyse ambulance data. My analysis focused on the change in outcome and trend in outcome, before and after NEWS was introduced. Primary outcomes measured were numbers and proportions of patients not conveyed to the emergency department (i.e. treated closer to home), which included those treated and left at scene and those conveyed to a minor injury unit or similar. Secondary outcomes measured were numbers and proportions treated and left at scene who recontacted the ambulance service within 24-hours. Numbers of 999-calls attended, patients treated and left at scene and life-threatening calls were also analysed to provide a baseline measure and enhance understanding about primary and secondary outcomes. A self-selected sample of paramedics participated in semi-structured interviews and a non-participant observation study. Semi-structured interviews were conducted to gain insight of perceived effectiveness and usefulness of the NEWS to support decision-making. Non-participant observations were conducted to observe how the NEWS was used in context. Results: Baseline measures showed no significant difference in the numbers of emergency calls attended to by ambulance, although numbers of life-threatening calls increased significantly. Despite the increase in life-threatening calls, the numbers and proportion of patients being treated closer to home remained constant. While a significant decline was found in the numbers of patients left at scene, the numbers and ii proportions of patients who recontacted within 24-hours did not differ significantly. Sixteen paramedics were interviewed. Those interviewed did not perceive the NEWS to have affected their decision-making or clinical practice. Other factors influenced their decision to convey or treat closer to home more than NEWS. They would use the NEWS to inform a decision only at times of uncertainty. NEWS was considered ineffective and not useful when assessing patients with complex conditions. NEWS was more readily adopted in localities where other healthcare providers were familiar and were using the NEWS. Eight paramedics were observed as they worked in the clinical setting. Those observed rarely calculated, documented or verbalised a NEWS. Half the NEWS documented, were calculated or documented incorrectly. There was no visible evidence of the NEWS tool being used; any scores documented were calculated from memory. Conclusions: The effectiveness and usefulness of the NEWS to support paramedics' decision-making to appropriately treat patients closer to home was compromised by a lack of coherence between service providers and practitioners, and lack of accessibility to alternative care pathways. My findings will be of value to service providers seeking to achieve NHS England's ambition to increase the uptake of the NEWS to 100%, and those responsible for redesigning and commissioning integrated care services.
Supervisor: Not available Sponsor: Not available
Qualification Name: Thesis (Ph.D.) Qualification Level: Doctoral
EThOS ID:  DOI: Not available