Original Research

Paramedic and physician perspectives on the potential use of remotely supported prehospital ultrasound

AUTHORS

Genevieve Marsh-Feiley1 BMedSci, Medical Student *

Leila Eadie2 PhD, Research Fellow

Philip Wilson3 DPhil, Professor of Primary Care and Rural Health Director of the Centre for Rural Health

CORRESPONDENCE

*Ms Genevieve Marsh-Feiley

AFFILIATIONS

1, 2, 3 Centre for Rural Health, University of Aberdeen, Centre for Health Science, Inverness, Scotland, IV2 3JH, UK.

PUBLISHED

13 September 2018 Volume 18 Issue 3

HISTORY

RECEIVED: 3 September 2017

REVISED: 8 March 2018

ACCEPTED: 26 April 2018

CITATION

Marsh-Feiley G, Eadie L, Wilson P.  Paramedic and physician perspectives on the potential use of remotely supported prehospital ultrasound . Rural and Remote Health 2018; 18: 4574. https://doi.org/10.22605/RRH4574

AUTHOR CONTRIBUTIONS

Except where otherwise noted, this work is licensed under a Creative Commons Attribution 4.0 International Licence


abstract:

Introduction:  During remotely supported prehospital ultrasound (RSPU), an ultrasound operator performs a scan and sends images to a remote expert for interpretation. This novel technology has been undergoing investigation in the randomised controlled SatCare trial, which seeks to assess the capability of RSPU to improve patient outcomes and standard of prehospital care in the Highlands of Scotland. This study aimed to explore the views of emergency medicine physicians and paramedics prior to starting the trial.
Methods:  An interview schedule was prepared a priori and was based upon normalisation process theory (NPT), which can be used to assess ways in which practitioners work to embed novel technologies in clinical practice. Semi-structured interviews were conducted with four consultant physicians and eight paramedics, who were recruited using purposive sampling until theoretical saturation. Analysis used open and hierarchical axial coding, and NPT as a framework to assist in the management and analysis of codes.
Results:  The prospect of RSPU evoked significantly different responses from emergency care physicians and paramedics. Paramedics thought of RSPU as a logical progression of prehospital care, which addresses core prehospital challenges such as lack of decision-making support and a limited ability to identify life-threatening occult conditions. Paramedics saw RSPU as part of a trend to increase their skills and responsibilities, and viewed ultrasound as a validated tool within emergency medicine. Paramedics felt that ultrasound was simple to learn and would be practical for use within the prehospital arena. In contrast, physicians expressed a greater spectrum of views; most saw limited value to prehospital diagnosis and were concerned that RSPU would distract both paramedics and physicians from their existing roles (particularly in the context of the increasing demand and workload within Scotland’s publicly funded National Health Service). Physicians were also concerned that ultrasound skills were poorly incorporated into training and practice in the British emergency medicine system. Furthermore, they believed that ultrasound was difficult to learn, prone to misinterpretation and easy to become deskilled in. Both sets of participants believed that the relational skills required between the two groups and the practical complexities of RSPU may pose challenges in its implementation. In particular, concerns were raised regarding the time that would be required to conduct the ultrasound scans and difficulties with transmission and communication in the Highlands. Both groups questioned the likelihood of measurable benefits from RSPU for patients. Furthermore, both groups were unsure how the technology would benefit those patients in urban areas close to the emergency department or whether RSPU would be effectively utilised in rural areas where serious emergencies are infrequent.
Conclusion:  There are substantial differences in emergency physician and paramedic perspectives on RSPU; however, both parties were willing to engage with the research process. Both groups have reservations, especially the emergency physicians who perceive significant barriers to the acquisition of skills, as well as the relational and contextual integration of RSPU. This study demonstrates the importance of conversations with physicians and paramedics throughout the research process, particularly as the role of prehospital care remains controversial.

Keywords:

allied health personnel, ambulances, diagnosis, emergency medical services, qualitative research, Scotland.

full article:

Introduction

During remotely supported prehospital ultrasound (RSPU), an ultrasound operator performs a scan and sends images to a remote expert for interpretation1. This technology aims to broaden access to ultrasound by overcoming the need for experts to perform and interpret scans on site. This concept has been tested in a number of settings, including merchant ships, mountainsides and on the International Space Station2,3. RSPU is currently being investigated in remotely located ambulances in Scotland within the SatCare trial. This trial hypothesises that RSPU may improve triage and prehospital interventions and might expedite the treatment of patients. The aim of this study was to assess perspectives on RSPU amongst acute care providers prior to the start of the SatCare trial.

The SatCare trial involves situating ultrasound devices aboard five emergency ambulances serving remote Scottish Highland communities. Satellite communication with the hospital in Inverness, on the north-east coast of Scotland, will allow images collected by paramedics to be viewed by emergency physicians. Patients will be randomised to receive remotely supported ultrasound or standard care. It is hoped that this trial will demonstrate the feasibility and effectiveness of RSPU in rural Scotland. It aims to build on the success of prehospital ECGs in reducing mortality rates following myocardial infarction4, as well as the success of trials of doctor-administered point-of-care ultrasound (POCUS) in the prehospital environment5,6. It also seeks to explore the potential for telemedicine to provide alternative solutions to the challenges of healthcare provision in remote and rural areas7,8.

This is an original application of telesonography, therefore qualitative or quantitative literature are limited. This is in part due to the novelty of the technology but it also reflects the relative paucity of prehospital research9-11. As a result it is recognised that greater participation in research will be essential to improve patient outcomes12,13. To achieve this there must be collaboration between researchers and practitioners, including paramedics and emergency/prehospital physicians14. However, prehospital and emergency research poses unique challenges. Although physicians often have substantial exposure to hospital-based research during their undergraduate and postgraduate training15, clinicians in emergency departments often lack knowledge of the prehospital environment16, have insufficient time for research and may find aspects of communication and implementation of prehospital research difficult11,17-19. Furthermore, participation in research is less widespread in paramedic services11,20,21. Previous studies have found that paramedics describe multiple barriers to research participation including concern for patient safety, perceived lack of clear benefit, too much paperwork, too little time and an agency culture not receptive to change20,22,23. It has been reported that paramedic concerns over participant consent24,25, training requirements26 and noncompliance with protocols posed significant challenges in several large prehospital trials27-29.

Recent achievements have shown that these problems are not insurmountable30. Opportunities include increasing paramedic motivation to participate in research24,26, increasing acceptance of the need for evidence-based practice and a desire to professionalise the paramedic role23,27,31. It is hoped that exploration of the views of physicians and paramedics can overcome human barriers to research success (such as poor adherence to trial protocols) and technical barriers (such as development of procedures appropriate to the prehospital environment)11,14,32.

The rationale for the use of telesonography in this setting is based on existing research in the classroom and hospital setting. Within the prehospital arena, ultrasound has been found to have improved sensitivity compared to physical examination by paramedic alone33-35. Furthermore, it has been found to be feasible to perform in various locations, quick36, easy to teach in a classroom setting37 and possible to employ during transit38. Also, it can be used concurrently with critical interventions33,39, and can facilitate more rapid patient assessment and disposition40. However, some are concerned that the adverse consequences of ultrasound use in prehospital and emergency medicine have been insufficiently explored and that the total benefit to patients is as yet unclear41,42. Similar controversies exist regarding the use of both in-hospital and prehospital RSPU. Proponents argue that RSPU has been shown to have a similar error rate when compared to in-person examinations by ultrasound experts43,44. However, critics argue that there are risks posed by poor transmission reliability45-47 and poor image quality48,49.

Given the complexity of this intervention and the number of stakeholders involved, it is necessary to gauge the attitudes of trial participants towards RSPU50-52. An exploration of these issues will aid the understanding of the conditions that may contribute to the success or failure of this and similar trials53. Therefore, the objectives of this study are to answer the following questions:

  1. Do acute care providers understand RSPU and think it is a legitimate addition to their practice?
  2. Is RSPU likely to be supported by acute care providers if it were introduced?
  3. What are the potential practical challenges or difficulties involved in RSPU and how might these be anticipated?

Theoretical framework

Normalisation process theory (NPT) provides the theoretical framework for this investigation. NPT has been developed as a tool for understanding the ways in which novel practices are integrated into day-to-day work54. It has been used extensively in the qualitative evaluation of healthcare interventions, particularly within the field of telehealth and complex, multidisciplinary interventions55. It was selected for use within this study as it focuses on the legitimacy of the intervention and the work that is done by groups of practitioners to embed a new technology. It also considers the trust required between groups, the role of opinion leaders, and of contextual and organisational factors. Therefore, NPT is well suited to the fields of emergency and prehospital medicine, which depend on successful teamwork, involve a diverse array of practitioners, and are influenced by challenging and diverse contextual conditions. NPT describes four key questions that should be considered; three of these are relevant to this study. The constructs and their translation into this setting are described in Table 156,57.

The fourth domain of NPT, which addresses how an issue might arise and be countered (reflexive appraisal), will not be considered given that the intervention has not yet been implemented. The NPT structure was used throughout this study including during the development of the interview schedule and as a framework for analysis.

Table 1:  Summary of the concepts of normalisation process theory and application to the present study.

Study design

This was a cross-sectional study conducted between February and March 2017 using semi-structured interviews with paramedics and consultant physicians involved in the SatCare trial. The interview schedule was developed through use of the NPT constructs, and thought was also given to relevant concerns regarding the effect of RSPU on workflow, diagnosis, treatment, relationships and training. Pilot interviews were conducted with two paramedics and one physician not involved in the SatCare study. This facilitated refinement of the phrasing and sequence of questions.

Purposive sampling was used to identify participants to take part in interviews; participants were recruited until theoretical saturation was reached. Interviews occurred either face-to-face or over the telephone, and were audio-recorded. Data were processed immediately after collection and were managed using the NPT framework combining both case- and theme-based approaches. The data were externally transcribed and transcriptions checked by one of the authors (GMF). The data were coded by GMF with discussion and supervision from two other authors (LE and PW). Coding was carried out through systematic reading of the transcripts, supplemented by a review of the recorded audio files and field notes taken during the original interview. Open coding took place initially, then discussions between investigators facilitated the development of a coding frame. This allowed disagreements concerning codes to be explored and resolved. Following this initial stage, hierarchical axial coding was conducted, using NPT in the management and analysis of codes. Constant comparison was used to ensure consistency of coding throughout the process and to refine the themes uncovered. Memos were used to explore emerging themes, facilitate comparison and to support the development of the final analysis. NVivo software was used in the processing and analysis stage. A flow diagram is shown in Figure 1.

Figure 1:  Flow diagram of the study process.

Ethics approval

This study was granted ethics approval by the University of Aberdeen’s College of Life Sciences and Medicine Ethics Review Board (CERB/2016/12/1408), and NHS Highland research management approval was obtained.

Results

Twelve respondents participated, four of whom were consultant emergency physicians and eight were paramedics. All paramedics had participated in a short familiarisation course involving didactic teaching by an emergency physician and a session of hands-on practice with the ultrasound machines. A summary of participant characteristics is shown in Table 2. The key themes identified and mapped within the NPT framework are summarised in Table 3. More details of comments are included in Table 4.

Table 2:  Participant characteristics and their experience of ultrasound and prehospital telemedicine.

Table 3:  Summary of study findings according to themes identified and concepts from normalisation process theory.

Table 4:  Summary of the views of doctors and paramedics concerning remotely supported ultrasound.

Theme 1: Making sense of ultrasound as a diagnostic tool within emergency medicine

In general, paramedics were extremely enthusiastic about the potential of ultrasound and frequently made statements such as Ultrasound is the future. In prehospital care anyway …’ and believed that it ‘is proven technology’. Paramedics’ understanding of ultrasound was based on personal experience as patients, enthusiasm of colleagues who had been part of a previous prehospital ultrasound trial, and the SatCare ultrasound familiarisation course. Following their experiences in this familiarisation course, paramedics saw ultrasound as quick, simple and were ‘quite surprised that it is not really that difficult to use’. They were also impressed at how ultrasound enabled them to visualise structures and felt the technology was a great improvement from just ‘the intuition of a paramedic’. Some remarked that outside the classroom (especially on an obese or sick patient) ultrasound use might be more challenging. Overall, paramedics believed ultrasound was a ‘fantastic piece of kit’ that could give them, at best, ‘definitive answers’ or at least support their clinical evaluation and ‘confirm what I am already thinking’.

It is not a case of a palpating a belly and hoping that nothing has changed, or not being sure. You have got a definitive answer then and I think that is what ultrasound would give us. Peace of mind. (paramedic 5)

The physicians were more reserved and only one used diagnostic ultrasound in routine clinical practice. Most believed that the role for ultrasound in emergency medicine was in a discrete number of clinical scenarios, including the diagnosis of patients with pneumothorax or undifferentiated shock. In this context, they saw increased ultrasound use as able to ‘give us a wider breadth of diagnostic ability’. Moreover, they believed ultrasound to be a complex tool, difficult to master and easy to become deskilled in. They were also concerned regarding the potential for misinterpretation, especially if ultrasound was understood as ‘being overly reassuring or excluding of a condition’. Therefore, most physicians viewed ultrasound as an adjunct, or an ‘extension of the clinical examination’ and were unconvinced of its benefit in most clinical scenarios.

I suppose I am a bit more sceptical than some. That is probably a reflection that it has not been something that has been part of my training so I start from a different position from most other people who have been exposed to that through their training … I suppose generally speaking I am thinking of trauma and CT, whereas I don’t know if ultrasound adds so much to the diagnostic process. (physician 3)

Theme 2: Legitimacy of remote support and diagnosis in the prehospital setting

Many paramedics saw RSPU as useful in increasing the ability of paramedics to triage patients confidently, leave patients with minor problems at home, prioritise patients for air transport or admit directly to a ward. Some paramedics thought that RSPU might enable them to alleviate the burden on busy emergency departments by taking on tasks such as venepuncture and the siting of a cannula. However, many paramedics did not believe that RSPU would significantly alter treatment or patient outcomes in a way that could be shown ‘on a piece of paper to show an accountant’ – particularly as some paramedics believed ‘my treatment is managing rather than curing’. Instead, paramedics valued RSPU for enabling them to ‘know what was going on’ with their patients and receive advice or support (especially during long journeys within the Highlands). Paramedics often referenced anecdotes where they had witnessed patients with occult injuries deteriorating unexpectedly and thus viewed an ability to recognise serious pathology as ‘an advancement that is needed’.

On your own in the back of an ambulance with somebody that is not as qualified as you are, but still you are only at paramedic level, it can be a lonely place sometimes. (paramedic 5)

Some paramedics and physicians felt there might be risks associated with increased knowledge, which could overstretch or distract from core roles. Consultants believed the primary role of the ambulance service should remain ‘ABC [first aid] management’ and rapid transport to secondary care. Both groups believed RSPU might result in delays to transport through, as one paramedic described ‘faffing about trying to get a better view’ or by encouraging paramedics to carry out tasks that would be more appropriately carried out in hospital.

I think that the more you train a paramedic to do, the more you increase their skill set, the more they feel they will have to do and there might then be some discrepancies where they are spending time on trying to get an ultrasound when in reality we could probably have had the patient at resus … (paramedic 6)

Although paramedics frequently cited trauma as a good indication for ultrasound, they recognised that in some cases it would be more appropriate to just ‘get to hospital’. In the view of the physicians, early diagnosis might hold limited value in the ‘vast majority’ of patients. They also believed that a change in management would be ‘very rare’, mainly because in a prehospital situation there is often a limited amount that can be done’. Furthermore, most physicians viewed early diagnosis as unhelpful because there were limited alternatives to hospital admission through the emergency department.

I don’t see how the ultrasound interpretation is going to influence the specific management in the field, or certainly in this situation where it is going to influence where the patient might be taken. You might argue otherwise geographically in other places where it might influence that. There is only one place they are going to come; they are going to come to the emergency department of [hospital] because there is nowhere else for them to go. They are not going to go straight to theatre or whatever … (physician 3)

However, another clinician was more optimistic:

I think it will end up turning around that relationship for these patients, such as we are asking the ambulance service to do things that they wouldn’t otherwise be asked to do. And even if that is just to the point of ‘can you sit the patient up, take them off oxygen, could you try and site a cannula …’ that is quite a lot of stuff being pushed back into the ambulance by us. (physician 4)

The variation in perception of the potential RSPU amongst physicians in part resulted from unfamiliarity with prehospital medicine (‘I haven’t been on any prehospital courses, let alone worked in a prehospital environment’) and a feeling that telehealth was out of the comfort zone of the physicians. The paramedics had a generally optimistic view of what they could achieve, expressing a belief that their ‘job has evolved’ and would include more remote telemetry and telehealth in the future.

Theme 3: Engagement and participation in training

Collectively, the paramedics and physicians had great confidence in the engagement of the paramedic team, describing the ambulance service as having ‘good, really motivated staff’ with a number of team leaders looking to drive the process forward. When asked who might be sceptical of the intervention, most paramedics referred to paramedics who were trained in the ‘scoop and run’ culture, were ‘technophobes’ or had less free time for training. Furthermore, paramedics felt that if this system were to become more widely adopted, this increase in responsibility should be recognised with investment in training, higher salaries and the development of a more supportive relationship with management. However, most paramedics described enthusiasm about learning new skills within the trial.

The majority of crews really crave further training and further knowledge, it is just a bit inconvenient that you have to do it on your own time. (paramedic 7)

Physicians were willing to engage with training opportunities and had already attended and enjoyed ultrasound courses in their own time. Nonetheless, they saw the burden of the training on rota commitments as significant and a concern ‘because all extra training is an issue’, especially as they believed existing ultrasound training in postgraduate medicine was insufficiently supported and substantial training commitment would be needed for confidence in interpreting RSPU images.

Theme 4: Anticipating pitfalls and identifying solutions

Paramedics talked about potential teething problems; for example, some thought that the novelty of RSPU might lead to overuse early in the trial. Participants thought most patients would be willing to be scanned. However, they considered that there may be some distrust of paramedics amongst the older generation, or anger in retrospect if harm was thought to have resulted from a change to standard care. Paramedics often noted that RSPU might provoke a similar reaction to the that for the introduction of prehospital ECG, when ‘people were very sceptical about what paramedics could do’. Both physicians and paramedics believed that such mistrust might result in duplication of effort and delays due to the performance of repeat scans. Equally, some paramedics saw that trust could easily be eroded by instances of poor communication with the emergency department.

I think it needs the buy in from both sides. I think we have got a good working relationship with A&E [accident and emergency department] but I think the scepticism will come the first time it is used, and the person that is answering the phone or the radio, or whatever device it is going to be, has to go looking for somebody or isn’t overly interested because they haven’t been trained in it. That is the fall down … It will only take a few fall downs before people start getting a bit sceptical. (paramedic 5)

Physicians also described difficulties in achieving a level of trust and skill where ‘the paramedics feel competent to do the scan and then for us, do we feel competent to interpret it’ especially as there is a tendency for ‘new users to over-report’. Furthermore, there was concern that ‘patient context and removal of their care context can influence the decision making’ and increase the risk of errors, especially where interpreter experience, environmental and patient factors could preclude obtaining clinically useful images. Furthermore, both physicians and paramedics were concerned that while in an urban setting a high volume of patients would facilitate frequent use, there may be limited utility of RSPU as patients would be at the hospital in ‘30 minutes anyway’. Conversely, they believed that prehospital intervention could be more significant in a rural setting with long journey times, but due to the low caseload RSPU may be cost-ineffective with a high risk of skills atrophy.

The ironic situation that I think they are in is I think the ultrasound will probably have the greatest impact in the most remote, rural places but they will probably struggle to get enough jobs to justify it … one of the big problems we have is the paramedics getting deskilled in these areas … (paramedic 6)

Participants agreed that there was ‘a very good relationship at the moment with A&E and the ambulance service’. However, there were mixed views about how RSPU might be contextualised in the existing model of practice: some believed the existing practice of remote ECG telemetry and the extensive use of ambulance pre-alert made ultrasound a logical progression; others believed there was too little experience of ultrasound, prehospital care and telehealth to support the introduction of RSPU. Furthermore, some physicians felt increasingly under pressure at work and saw RSPU as ‘another workload’ that must compete with existing demands on their time and cognitive resources.

… often you are in the face of making multiple decisions about different patients at one time. So to add another potential decision making process or something else you are going to be involved in without it actually generating potentially, in my opinion, much of a benefit could be a significant disadvantage. (physician 3)

Both parties were conscious that RSPU was ‘maybe not the best use of the money’ and recognised that its application was complicated by the need for ‘multi-service, multi-disciplinary engagement’ and were unsure whether nominal support would be translated into ‘clinical commitment’ by management should the trial be successful. Some saw that there was friction between research ‘enthusiasts’ and the clinical ‘pragmatists’, who are more focused on ‘the realities on the ground’. Some believed that there was potential for enthusiasm for the technology to ‘overtake science’ and evidence of benefit.

Maybe we need a bit of technology enthusiasm just to keep us all going. Just to change the flavour of the day, the week, the month, maybe that is a good thing. It becomes an increasingly difficult pill to swallow when you see increasing problems with funding core business, core service, core design activities to say we have got to get patients from one end to the other end of the hospital, efficiently and safely and hopefully as many as possible alive or comfortably dead. (physician 2)

Despite their concerns, both paramedics and physicians felt that there were opportunities to address problems within the trial. For example, physicians were particularly glad of the early trial set-up discussions, which had clarified that if the emergency department was busy then physicians could refuse to interpret images and ask paramedics to limit the conversation to a short pre-alert. There was a need to site the ultrasound viewing area in a convenient location within the emergency department, and to address basic practical challenges in ambulances, such as communication blackspots, difficulty operating the probe with scalloped stretchers, freezing of the batteries and problems with the weight of equipment. Paramedics emphasised the need to maintain the momentum of the learning process; paramedics saw repeated drills and the use of prompt sheets as essential, and many paramedics wanted access to practice on the ultrasound machine in the ambulance station. Although most paramedics felt that training should be kept focused, others wanted a more detailed approach and access to further learning materials such as ultrasound manuals.

Thinking about how ultrasound might be taken forward within prehospital care, some participants suggested ways in which the expense of RSPU could be reduced, for example sharing equipment with general practitioners in rural areas, or limiting ultrasound use to groups of specially trained paramedics. In order to overcome problems with transmission or communication, one paramedic discussed the possibility of having a print-out to hand over to the emergency department should the transmission fail. Both paramedics and physicians were most familiar with the utility of ultrasound for venous access and suggested this as an area for exploration in future trials. While there was optimism and pessimism surrounding many issues within the SatCare trial, participants universally expressed their willingness to engage with the research process.

We don’t jump on all bandwagons with huge enthusiasm but if this has a very definite positive outcome, then it will simply become the responsibility of the organisation to identify how it wants to deliver upon that success. (physician 2)

Discussion

This study aimed to develop an understanding of the potential for RSPU to become normalised within the daily practice of paramedics and doctors working within the SatCare trial. Using the NPT framework it was possible to develop an understanding of staff perceptions of this technology. These results show that while the capacity for normalisation of RSPU amongst paramedics may be strengthened by a strong sense of its value, participating doctors are in general more sceptical of RSPU technology. It is clear that there are substantial risks to the success of this system; a high level of trust between both doctors and paramedics, substantial skill from both parties and a significant amount of effort are required to achieve this type of service. While comparisons to prehospital ECG are useful, RSPU presents distinct challenges that may be difficult to overcome given the increasingly pressured environment into which this technology is being introduced.

There is limited literature with which these findings can be compared as a result a dearth of prehospital research58 and the contingency of these findings upon the precise context and design of the RSPU system involved. Nonetheless, the issues raised by the practitioners included in this study are echoed within related fields. First, physicians had mixed views regarding the use of ultrasound, a modality increasingly incorporated into numerous specialties59,60. Ultrasound is advocated by enthusiasts, who argue that POCUS is versatile, cost-effective, reduces time to diagnosis, and results in no worse mortality than algorithms using CT59,61,62. However, it is seen by others as ‘fraught with scope for diagnostic error’63. In the present study, several physicians expressed concern over the risk of excessive reliance on ultrasound findings. This concern is supported by evidence that overconfidence and insufficient awareness of the limitations of POCUS are significant risk factors for diagnostic error64.

There are widespread disagreements over the role of prehospital care in the UK65. In this study there was some doubt amongst physicians concerning the value of prehospital intervention (the so-called ‘stay and play’ approach) when contrasted with the traditional prioritisation of rapid transport (the so-called ‘scoop and run’ approach)66,67. There is some evidence that prolonged on-scene time is associated with mortality, especially in trauma68,69, and that prehospital intervention does not improve patient outcomes70. This has been contested, as both decreased mortality and no effect on transport times have also been reported71,72. The rapidly evolving professional identity of paramedics is another likely contributor to uncertainty surrounding the role of prehospital medicine. Increased demand on the ambulance service and a rise in non-emergency calls have demanded that modern paramedics have a complex competency range73,74. This has led to the institution of an extended paramedic role, which has in some areas reduced emergency department attendances75,76. Paramedics are enthusiastic over the potential to expand their competencies (although many would also desire more recognition, including financial reward for increased responsibility taken)77. It is unclear which skills might be most appropriate for paramedics to acquire, due to the breadth of the work undertaken. Furthermore, some argue that this expansion may distract from the core purpose of the ambulance service78,79. The desire of paramedics to expand their role is contrasted with the perspective of emergency physicians, who are cautious regarding any increase to existing workload due to issues such as overcrowding, insufficient staffing and lack of flow of patients out of the emergency department80,81.

The physicians in this study felt that there was a conflict between the allocation of financial and cognitive resources to research of unknown benefit in the face of tangible needs to improve patient care. This conflict is exacerbated by the problem of waste in clinical research82, and difficulties in quantifying the value of research compared to the application of existing knowledge within any given field83,84. Therefore, although the technology may be ready for application, it is unclear that the potential benefits of research in this area outweigh the benefit of optimising current practice85,86.

This study has a number of weaknesses. Due to the qualitative nature of this study, it is not appropriate to generalise these findings, and this study will primarily be used to supplement the process analysis of the SatCare trial. Nonetheless, the use of the NPT framework may facilitate understanding of a number of issues raised in this study in a wider context, and it is likely that some themes uncovered in this investigation may be relevant within other settings. This is particularly true of the questions of professional identity, and the value of integration of prehospital and emergency medicine. This study reiterated controversies within this field regarding the future role of ultrasound diagnostics and prehospital medicine within the modern healthcare landscape, issues that merit further investigation. This is an example of how in-depth qualitative exploration may be useful in understanding the research–practice gap, which hinders the application of new health technologies. These findings also illustrate the importance of consultation with staff within trials of complex interventions.

Conclusion

The potential for the normalisation of RPSU within the Highlands is unclear, and views regarding this technology differ substantially between the two professional groups involved. Paramedics are enthusiastic and keen to engage with the RSPU technology, which aligns well with their experience of ECGs as well as their beliefs regarding progression of the paramedic role. However, emergency care physicians expressed a wider spectrum of views. Some physicians were particularly concerned about further extension of their duties in light of existing strains on their time and resources. They were more sceptical that RSPU, and more broadly prehospital intervention, can improve outcomes. Although these differences in opinion pose risks to the successful normalisation of RSPU, both groups also described factors that may aid in its success, including the existence of a strong working relationship between the two groups, and a willingness to engage in the research process. Nonetheless, the success of RSPU will be contingent on numerous factors – patient, operator, contextual and interactional issues – and therefore substantial work and effective communication will be needed to overcome these challenges.

Acknowledgements

The authors thank the doctors and paramedics who gave up their time to take part in this study. This includes those who participated in the pilot phase of the interviews, who were instrumental in the formation and refinement of the interview schedule. They also thank the members of the Scottish Ambulance Service (SAS) for their assistance, particularly Dr Jim Ward, Dr David Fitzpatrick and Mr Robbie Farquhar, who provided invaluable advice and guidance in the submission of the proposal to the SAS.

references:

1 Eadie L, Mort A, Regan L, MacAden AS, Wilson P. Remotely supported prehospital ultrasound: real-time communication for diagnosis in remote and rural communities. In: G Cumming, T French, H Gilstad, MG Jaatun, EAA Jaatun (Eds). Proceedings of the 3rd European Workshop on Practical Aspects of Health Informatics. October 2016 . Elgin, United Kingdom: CEUR Workshop Proceedings. 1574: 53-60.
2 Pian L, Gillman LM, McBeth PB, Xiao Z, Ball CG, Blaivas M, et al. Potential use of remote telesonography as a transformational technology in underresourced and/or remote settings. Emergency Medicine International 2013; 28: 986160. https://doi.org/10.1155/2013/986160
3 Sutherland JE, Sutphin D, Redican K, Rawlins F. Telesonography: foundations and future directions. Journal of Ultrasound in Medicine 2011; 30(4): 517-522. https://doi.org/10.7863/jum.2011.30.4.517 PMid:21460152
4 Quinn T, Johnsen S, Gale CP, Snooks H, McLean S, Woollard M, et al. Effects of prehospital 12-lead ECG on processes of care and mortality in acute coronary syndrome: a linked cohort study from the Myocardial Ischaemia National Audit Project. Heart 2014; 100: 944-950. https://doi.org/10.1136/heartjnl-2013-304599 PMid:24732676
5 El Sayed MJ, Zaghrini E. Prehospital emergency ultrasound: a review of current clinical applications, challenges, and future implications. Emergency Medicine International 2013; 2013: e531674.
6 Strode CA. Satellite and mobile wireless transmission of focused assessment with sonography in trauma. Academic Emergency Medicine 2003; 10(12): 1411-1414. https://doi.org/10.1197/S1069-6563(03)00547-5
7 Gray LC, Fatehi F, Martin-Khan M, Peel NM, Smith AC. Telemedicine for specialist geriatric care in small rural hospitals: preliminary data. Journal of the American Geriatrics Society 2016; 64(6): 1347-1351. https://doi.org/10.1111/jgs.14139 PMid:27321617
8 Itrat A, Taqui A, Cerejo R, Briggs F, Cho S-M, Organek N, et al. Telemedicine in prehospital stroke evaluation and thrombolysis: taking stroke treatment to the doorstep. JAMA Neurology 2016; 73(2): 162-168. https://doi.org/10.1001/jamaneurol.2015.3849 PMid:26641366
9 Fishe JN, Crowe RP, Cash RE, Nudell NG, Martin-Gill C, Richards CT. Implementing prehospital evidence-based guidelines: a systematic literature review. Prehospital Emergency Care 2018; 22(4): 511-519. https://doi.org/10.1080/10903127.2017.1413466 PMid:29351495
10 University of Sheffield Medical Care Research Unit. Building the evidence base in pre-hospital urgent and emergency care: a review of research evidence and priorities for future research. Available: https://www.gov.uk/government/publications/building-the-evidence-base-in-pre-hospital-urgent-and-emergency-care-a-review-of-research-evidence-and-priorities-for-future-research (Accessed 7 March 2018).
11 Pepe PE, Copass MK, Sopko G. Clinical trials in the out-of-hospital setting: Rationale and strategies for successful implementation. Critical Care Medicine 2009; 37(1): S91. https://doi.org/10.1097/CCM.0b013e318192154d PMid:19104231
12 Rehn M, Krüger AJ. Quality improvement in pre-hospital critical care: increased value through research and publication. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2014; 22: 34. https://doi.org/10.1186/1757-7241-22-34 PMid:24887186
13 Wilson MH, Habig K, Wright C, Hughes A, Davies G, Imray CHE. Pre-hospital emergency medicine. The Lancet 2015; 386(10012): 2526-2534. https://doi.org/10.1016/S0140-6736(15)00985-X
14 Lerner EB, Weik T, Edgerton EA. Research in prehospital care: overcoming the barriers to success. Prehospital Emergency Care 2016; 20(4): 448-453. PMid:25985185
15 General Medical Council. Domain 9: capabilities in research and scholarship. Available: https://www.gmc-uk.org/education/postgraduate/30986.asp (Accessed 7 March 2018).
16 Waldron R, Sixsmith DM. Emergency physician awareness of prehospital procedures and medications. Western Journal of Emergency Medicine 2014; 15(4): 504-510. https://doi.org/10.5811/westjem.2014.2.18651 PMid:25035759
17 Good AMT, Driscoll P. Clinical research in emergency medicine: putting it together. Emergency Medicine Journal 2002; 19(3): 242-246. https://doi.org/10.1136/emj.19.3.242
18 Sonnenwald DH, Söderholm HM, Welch GF, Cairns BA, Manning JE, Fuchs H. Illuminating collaboration in emergency health care situations: paramedic-physician collaboration and 3D telepresence technology. Information Research 2014; 19(2): 618. Available: http://InformationR.net/ir/19-2/paper618.html (Accessed 7 March 2018).
19 Siemsen IM, Madsen MD, Pedersen LF, Michaelsen L, Pedersen AV, Andersen HB, Østergaard D. Scandinavian Journal of Public Health. 2012; 40(5): 439-448. https://doi.org/10.1177/1403494812453889 PMid:22798283
20 Hargreaves K, Goodacre S, Mortimer P. Paramedic perceptions of the feasibility and practicalities of prehospital clinical trials: a questionnaire survey. Emergency Medicine Journal 2014; 31(6): 499-504. https://doi.org/10.1136/emermed-2013-202346 PMid:23513236
21 Lockey DJ. Research questions in pre-hospital trauma care. PLOS Medicine 2017; 14(7): e1002345. https://doi.org/10.1371/journal.pmed.1002345 PMid:28719604
22 Watson DLB, Sanoff R, Mackintosh JE, Saver JL, Ford GA, Price C, et al. Evidence from the scene: paramedic perspectives on involvement in out-of-hospital research. Annals of Emergency Medicine 2012; 60(5): 641-650. https://doi.org/10.1016/j.annemergmed.2011.12.002 PMid:22387089
23 Leonard JC, Scharff DP, Koors V, Brooke Lerner E, Adelgais KM, Anders J, et al. A qualitative assessment of factors that influence emergency medical services partnerships in prehospital research. Academic Emergency Medicine 2012; 19(2): 161-173.
24 Schmidt TA, Nelson M, Daya M, DeIorio NM, Griffiths D, Rosteck P. Emergency medical service providers' attitudes and experiences regarding enrolling patients in clinical research trials. Prehospital Emergency Care 2009; 13(2): 160-168. https://doi.org/10.1080/10903120802708852 PMid:19291551
25 Kim DT, Spivey WH. A retrospective analysis of institutional review board and informed consent practices in EMS research. Annals of Emergency Medicine 1994; 23(1): 70-74. https://doi.org/10.1016/S0196-0644(94)70011-7
26 Ankolekar S, Parry R, Sprigg N, Siriwardena AN, Bath PMW. Views of paramedics on their role in an out-of-hospital ambulance-based trial in ultra-acute stroke: qualitative data from the Rapid Intervention with Glyceryl Trinitrate in Hypertensive Stroke Trial (RIGHT). Annals of Emergency Medicine 2014; 64(6): 640-648. https://doi.org/10.1016/j.annemergmed.2014.03.016 PMid:24746844
27 Gates S, Lall R, Quinn T, Deakin CD, Cooke MW, Horton J, et al. Prehospital randomised assessment of a mechanical compression device in out-of-hospital cardiac arrest (PARAMEDIC): a pragmatic, cluster randomised trial and economic evaluation. Health Technology Assessment 2017; 21(11): 170-176. https://doi.org/10.3310/hta21110 PMid:28393757
28 Garner AA, Mann KP, Fearnside M, Poynter E, Gebski V. The Head Injury Retrieval Trial (HIRT): a single-centre randomised controlled trial of physician prehospital management of severe blunt head injury compared with management by paramedics only. Emergency Medicine Journal 2015; 32: 869-875. https://doi.org/10.1136/emermed-2014-204390 PMid:25795741
29 Rådestad M, Lennquist Montán K, Rüter A, Castrén M, Svensson L, Gryth D, et al. Attitudes towards and experience of the use of triage tags in major incidents: a mixed method study. Prehospital Disaster Medicine 2016; 31(4): 376-385. https://doi.org/10.1017/S1049023X16000480 PMid:27212424
30 Mausz J, Cheskes S. The impact of prehospital resuscitation research on in-hospital care. Canadian Journal of Emergency Medicine 2015; 17(5): 551-557. https://doi.org/10.1017/cem.2015.84
31 Brandling J, Rhys M, Thomas M, Voss S, Davies SE, Benger J. An exploration of the views of paramedics regarding airway management. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2016; 24: 56. https://doi.org/10.1186/s13049-016-0243-2 PMid:27121111
32 Pocock H, Deakin CD, Quinn T, Perkins GD, Horton J, Gates S. Human factors in prehospital research: lessons from the PARAMEDIC trial. Emergency Medicine Journal 2016; 33(8): 562-568. https://doi.org/10.1136/emermed-2015-204916 PMid:26917497
33 Walcher F, Weinlich M, Conrad G, Schweigkofler U, Breitkreutz R, Kirschning T, et al. Prehospital ultrasound imaging improves management of abdominal trauma. British Journal of Surgery 2006 1; 93(2): 238-242.
34 Blaivas M, Lyon M, Duggal S. Ultrasound image transmission via camera phones for overreading. American Journal of Emergency Medicine 2005; 23(4): 433-438. https://doi.org/10.1016/j.ajem.2004.09.037 PMid:16032606
35 Breitkreutz R, Price S, Steiger HV, Seeger FH, Ilper H, Ackermann H, et al. Focused echocardiographic evaluation in life support and peri-resuscitation of emergency patients: a prospective trial. Resuscitation 2010; 81(11): 1527-1533. https://doi.org/10.1016/j.resuscitation.2010.07.013 PMid:20801576
36 Prosen G, Klemen P, Štrnad M, Grmec S. Combination of lung ultrasound (a comet-tail sign) and N-terminal pro-brain natriuretic peptide in differentiating acute heart failure from chronic obstructive pulmonary disease and asthma as cause of acute dyspnea in prehospital emergency setting. Critical Care 2011; 15(2): R114. https://doi.org/10.1186/cc10140 PMid:21492424
37 Brooke M, Walton J, Scutt D. Paramedic application of ultrasound in the management of patients in the prehospital setting: a review of the literature. Emergency Medicine Journal 2010; 27(9): 702-707. https://doi.org/10.1136/emj.2010.094219 PMid:20668110
38 Snaith B, Hardy M, Walker A. Emergency ultrasound in the prehospital setting: the impact of environment on examination outcomes. Emergency Medicine Journal 2011 1; 28(12): 1063-1065.
39 Mazur SM, Pearce A, Alfred S, Goudie A, Sharley P. The F.A.S.T.E.R. trial. Injury 2008 May 1; 39(5): 512-518. https://doi.org/10.1016/j.injury.2007.11.010 PMid:18339389
40 Melniker LA, Leibner E, McKenney MG, Lopez P, Briggs WM, Mancuso CA. Randomized controlled clinical trial of point-of-care, limited ultrasonography for trauma in the emergency department: the first sonography outcomes assessment program trial. Annals of Emergency Medicine 2006; 48(3): 227-235. https://doi.org/10.1016/j.annemergmed.2006.01.008 PMid:16934640
41 Salustri A, Trambaiolo P. The 'ultrasonic stethoscope': is it of clinical value? Heart 2003 Jul; 89(7): 704-706. https://doi.org/10.1136/heart.89.7.704 PMid:12807833
42 Jørgensen H, Jensen CH, Dirks J. Does prehospital ultrasound improve treatment of the trauma patient? A systematic review. European Journal of Emergency Medicine 2010 Oct; 17(5): 249-253. https://doi.org/10.1097/MEJ.0b013e328336adce PMid:20124905
43 Zennaro F, Neri E, Nappi F, Grosso D, Triunfo R, Cabras F, et al. Real-time tele-mentored low cost 'point-of-care US' in the hands of paediatricians in the emergency department: diagnostic accuracy compared to expert radiologists. PLOS One 2016; 11(10): e0164539. https://doi.org/10.1371/journal.pone.0164539 PMid:27749905
44 Kim C, Cha H, Kang BS, Choi HJ, Lim TH, Oh J. A feasibility study of smartphone-based telesonography for evaluating cardiac dynamic function and diagnosing acute appendicitis with control of the image quality of the transmitted videos. Journal of Digital Imaging 2016; 29(3): 347-356. https://doi.org/10.1007/s10278-015-9849-6 PMid:26620200
45 Strode CA. Satellite and mobile wireless transmission of focused assessment with sonography in trauma. Academic Emergency Medicine 2003; 10(12): 1411-1414. https://doi.org/10.1197/S1069-6563(03)00547-5
46 Courreges F, Vieyres P, Istepanian RSH, Arbeille P, Bru C. Clinical trials and evaluation of a mobile, robotic tele-ultrasound system. Journal of Telemedicine and Telecare 2005; 11(S1): 46-49. https://doi.org/10.1258/1357633054461552 PMid:16035992
47 Liteplo AS, Noble VE, Attwood BHC. Real-time video streaming of sonographic clips using domestic internet networks and free videoconferencing software. Journal of Ultrasound Medicine 2011; 30(11): 1459-1466. https://doi.org/10.7863/jum.2011.30.11.1459
48 Sibert K, Ricci MA, Caputo M, Callas PW, Rogers FB, Charash W, et al. The feasibility of using ultrasound and video laryngoscopy in a mobile telemedicine consult. Telemedicine and e-Health 2008; 14(3): 266-272. https://doi.org/10.1089/tmj.2007.0050 PMid:18570551
49 Song KJ, Shin SD, Hong KJ, Cheon KW, Shin I, Song S-W, et al. Clinical applicability of real-time, prehospital image transmission for FAST (Focused Assessment with Sonography for Trauma). Journal of Telemedicine and Telecare 2013; 19(8): 450-455. https://doi.org/10.1177/1357633X13512068 PMid:24197401
50 Moore GF, Audrey S, Barker M, Bond L, Bonell C, Hardeman W, et al. Process evaluation of complex interventions: Medical Research Council guidance. British Medical Journal 2015; 350: h1258. https://doi.org/10.1136/bmj.h1258 PMid:25791983
51 Williams T, May C, Mair F, Mort M, Gask L. Normative models of health technology assessment and the social production of evidence about telehealth care. Health Policy 2003; 64(1): 39-54. https://doi.org/10.1016/S0168-8510(02)00179-3
52 King G, Richards H, Godden D. Adoption of telemedicine in Scottish remote and rural general practices: a qualitative study. Journal of Telemedicine and Telecare 2007; 13(8): 382-386. https://doi.org/10.1258/135763307783064430 PMid:18078547
53 Gagnon M-P, Duplantie J, Fortin J-P, Landry R. Implementing telehealth to support medical practice in rural/remote regions: what are the conditions for success? Implementation Science 2006; 1: 18. https://doi.org/10.1186/1748-5908-1-18 PMid:16930484
54 May C, Finch T. Implementing, embedding, and integrating practices: an outline of normalization process theory. Sociology 2009; 43(3): 535-554. https://doi.org/10.1177/0038038509103208
55 McEvoy R, Ballini L, Maltoni S, O'Donnell CA, Mair FS, MacFarlane A. A qualitative systematic review of studies using the normalization process theory to research implementation processes. Implementation Science 2014; 9: 2. https://doi.org/10.1186/1748-5908-9-2 PMid:24383661
56 Finch TL, Mair FS, O'Donnell C, Murray E, May CR. From theory to 'measurement' in complex interventions: methodological lessons from the development of an e-health normalisation instrument. BMC Medical Research Methodology 2012; 12: 69. https://doi.org/10.1186/1471-2288-12-69 PMid:22594537
57 May C, Rapley T, Mair FS, Treweek S, Murray E, Ballini L, et al. Normalization process theory on-line users' manual, toolkit and NoMAD instrument. 2015. Available: http://www.normalizationprocess.org (Accessed September 2017).
58 Fevang E, Lockey D, Thompson J, Lossius HM. The top five research priorities in physician-provided pre-hospital critical care: a consensus report from a European research collaboration. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2011; 19: 57. https://doi.org/10.1186/1757-7241-19-57 PMid:21996444
59 Brenchley J, Sloan JP, Thompson PK. Echoes of things to come. Ultrasound in UK emergency medicine practice. Emergency Medicine Journal 2000; 17(3): 170-175. https://doi.org/10.1136/emj.17.3.170
60 Wittenberg M. Will ultrasound scanners replace the stethoscope? British Medical Journal 2014; 348: g3463. https://doi.org/10.1136/bmj.g3463 PMid:24875141
61 Boulanger BR, McLellan BA, Brenneman FD, Ochoa J, Kirkpatrick AW. Prospective evidence of the superiority of a sonography-based algorithm in the assessment of blunt abdominal injury. Journal of Trauma 1999; 47(4): 632-637. https://doi.org/10.1097/00005373-199910000-00005 PMid:10528595
62 Campana B. The ultrasound controversy. Canadian Journal of Emergency Medicine 1999; 1(2): 122. https://doi.org/10.1017/S1481803500003870
63 Education and Practical Standards Committee, European Federation of Societies for Ultrasound in Medicine and Biology. Minimum training recommendations for the practice of medical ultrasound. Ultraschall in der Medzin 2006; 27(1): 79-105. https://doi.org/10.1055/s-2006-933605 PMid:16508866
64 Pinto A, Pinto F, Faggian A, Rubini G, Caranci F, Macarini L, et al. Sources of error in emergency ultrasonography. Critical Ultrasound Journal 2013; 5(1): S1. PMid:23902656
65 Mackenzie R, Steel A, French J, Wharton R, Lewis S, Bates A, et al. Views regarding the provision of prehospital critical care in the UK. Emergency Medicine Journal 2009; 26(5): 365-370. https://doi.org/10.1136/emj.2008.062588 PMid:19386879
66 Liberman M, Branas C, Mulder DS, Lavoie A, Sampalis JS. Advanced versus basic life support in the pre‐hospital setting – the controversy between the 'scoop and run' and the 'stay and play' approach to the care of the injured patient. International Journal of Disaster Medicine 2004; 2(1-2): 9-17. https://doi.org/10.1080/15031430410025515
67 Isenberg DL, Bissell R. Does advanced life support provide benefits to patients? A literature review. Prehospital Disaster Medicine 2005; 20(4): 265-270. https://doi.org/10.1017/S1049023X0000265X
68 Seamon MJ, Fisher CA, Gaughan J, Lloyd M, Bradley KM, Santora TA, et al. Prehospital procedures before emergency department thoracotomy: 'scoop and run' saves lives. Journal of Trauma – Injury, Infection and Critical Care 2007; 63(1): 113-120. https://doi.org/10.1097/TA.0b013e31806842a1 PMid:17622878
69 Brown JB, Rosengart MR, Forsythe RM, Reynolds BR, Gestring ML, Hallinan WM, et al. Not all prehospital time is equal: influence of scene time on mortality. Journal of Trauma and Acute Care Surgery 2016; 81(1): 93-100. https://doi.org/10.1097/TA.0000000000000999 PMid:26886000
70 Osterwalder JJ. Insufficient quality of research on prehospital medical emergency care – where are the major problems and solutions? Swiss Medical Weekly 2004; 134(27-28): 389-394. PMid:15389355
71 Meizoso JP, Valle EJ, Allen CJ, Ray JJ, Jouria JM, Teisch LF, et al. Decreased mortality after prehospital interventions in severely injured trauma patients. Journal of Trauma and Acute Care Surgery 2015; 79(2): 227-231. https://doi.org/10.1097/TA.0000000000000748 PMid:26218690
72 Garner AA, Mann KP, Fearnside M, Poynter E, Gebski V. The Head Injury Retrieval Trial (HIRT): a single-centre randomised controlled trial of physician prehospital management of severe blunt head injury compared with management by paramedics only. Emergency Medicine Journal 2015; 32(11): 869-875. https://doi.org/10.1136/emermed-2014-204390 PMid:25795741
73 Department of Health. Taking healthcare to the patient: transforming NHS ambulance services. Report on the outcome of a strategic review of NHS ambulance services. London: Department of Health, 2005.
74 von Vopelius-Feldt J, Benger J. Who does what in prehospital critical care? An analysis of competencies of paramedics, critical care paramedics and prehospital physicians. Emergency Medicine Journal 2014; 31(12): 1009-1013. https://doi.org/10.1136/emermed-2013-202895 PMid:23965274
75 Mason S, Knowles E, Freeman J, Snooks H. Safety of paramedics with extended skills. Academic Emergency Medicine 2008; 15(7): 607-612. https://doi.org/10.1111/j.1553-2712.2008.00156.x PMid:18691211
76 Flynn D, Francis R, Robalino S, Lally J, Snooks H, Rodgers H, et al. A review of enhanced paramedic roles during and after hospital handover of stroke, myocardial infarction and trauma patients. BMC Emergency Medicine 2017; 17: 5. https://doi.org/10.1186/s12873-017-0118-5 PMid:28228127
77 Cox H, Albarran JW, Quinn T, Shears K. Paramedics' perceptions of their role in providing pre-hospital thrombolytic treatment: qualitative study. Accident and Emergency Nursing 2006; 14(4): 237-244. https://doi.org/10.1016/j.aaen.2006.08.002 PMid:17055274
78 Bissell RA, Seaman KG, Bass RR, Racht E, Gilbert C, Weltge AF, et al. A medically wise approach to expanding the role of paramedics as physician extenders. Prehospital Emergency Care 1999; 3(2): 170-173. https://doi.org/10.1080/10903129908958928 PMid:10225653
79 Evans R, McGovern R, Birch J, Newbury-Birch D. Which extended paramedic skills are making an impact in emergency care and can be related to the UK paramedic system? A systematic review of the literature. Emergency Medicine Journal 2013; 31: 594-603. https://doi.org/10.1136/emermed-2012-202129 PMid:23576227
80 Forero R, McCarthy S, Hillman K. Access block and emergency department overcrowding. Critical Care 2011; 15: 216. https://doi.org/10.1186/cc9998 PMid:21457507
81 House of Commons Health Committee. Winter pressure in accident and emergency departments. Third report of Session 2016-2017. HC 2777. London: House of Commons, 2016.
82 Ioannidis JPA. Why most published research findings are false. PLOS Medicine 2005; 2(8). https://doi.org/10.1371/journal.pmed.0020124
83 Yazdizadeh B, Majdzadeh R, Salmasian H. Systematic review of methods for evaluating healthcare research economic impact. Health Research Policy and Systems 2010; 8: 6. https://doi.org/10.1186/1478-4505-8-6 PMid:20196839
84 Minelli C, Baio G. Value of information: a tool to improve research prioritization and reduce waste. PLOS Medicine 2015; 12(9). https://doi.org/10.1371/journal.pmed.1001882 PMid:26418866
85 Ginexi EM, Hilton TF. What's next for translation research? Evaluation and the health professions 2006; 29(3): 334-347. https://doi.org/10.1177/0163278706290409 PMid:16868341
86 Le May A, Mulhall A, Alexander C. Bridging the research–practice gap: exploring the research cultures of practitioners and managers. Journal of Advanced Nursing 1998; 28(2): 428-437. https://doi.org/10.1046/j.1365-2648.1998.00634.x PMid:9725742
This PDF has been produced for your convenience. Always refer to the live site https://www.rrh.org.au/journal/article/4574 for the Version of Record.