title: Complexity of the decision-making process of ambulance staff for assessment and referral of older people who have fallen: a qualitative study.
abstract: BACKGROUND
  Older people who fall commonly present to the emergency ambulance service, and approximately 40% are not conveyed to the emergency department (ED), despite an historic lack of formal training for such decisions. This study aimed to understand the decision-making processes of emergency ambulance staff with older people who have fallen.
  
  
  METHODS
  During 2005 ambulance staff in London tested a clinical assessment tool for use with the older person who had fallen. Documented use of the tool was low. Following the trial, 12 staff participated in semistructured interviews. Interviews were recorded and transcribed. Thematic analysis was carried out.
  
  
  RESULTS
  The interviews revealed a similar assessment and decision-making process among participants: Prearrival: forming an early opinion from information from the emergency call. Initial contact: assessing the need for any immediate action and establishing a rapport. Continuing assessment: gathering and assimilating medical and social information. Making a conveyance decision: negotiation, referral and professional defence, using professional experience and instinct.
  
  
  CONCLUSIONS
  An assessment process was described that highlights the complexity of making decisions about whether or not to convey older people who fall and present to the emergency ambulance service, and a predominance of informal decision-making processes. The need for support for ambulance staff in this area was highlighted, generating a significant challenge to those with education roles in the ambulance service. Further research is needed to look at how new care pathways, which offer an alternative to the ED may influence decision making around non-conveyance.
authors.affiliation: Faculty of Health and Social Care Sciences, Kingston University and St George's, University of London, London, UK. m.halter@sgul.kingston.ac.uk
authors.forename: Mary
authors.initials: M
authors.lastname: Halter
authors.forename: Susan
authors.initials: S
authors.lastname: Vernon
authors.forename: Helen
authors.initials: H
authors.lastname: Snooks
authors.forename: Alison
authors.initials: A
authors.lastname: Porter
authors.forename: Jacqueline
authors.initials: J
authors.lastname: Close
authors.forename: Fionna
authors.initials: F
authors.lastname: Moore
authors.forename: Simon
authors.initials: S
authors.lastname: Porsz
mesh_terms: D000058:Accidental Falls / Q000706:statistics & numerical data*; D000368:Aged; D000369:Aged, 80 and over; D000552:Ambulances / Q000706:statistics & numerical data*; D003657:Decision Making; D004632:Emergency Medical Services / Q000379:methods*; D004634:Emergency Medical Technicians; D005260:Female; D016330:Frail Elderly; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D008131:London; D008297:Male; D017064:Process Assessment, Health Care; D036301:Qualitative Research; D012017:Referral and Consultation / Q000706:statistics & numerical data*