• Rachel O'Hara, Maxine Johnson, A Niroshan Siriwardena, Andrew Weyman, Janette Turner, Deborah Shaw, Peter Mortimer, Chris Newman, Enid Hirst, Matthew Storey, Suzanne Mason, Tom Quinn, and Jane Shewan.
• Lecturer in Public Health, Public Health Section, ScHARR, University of Sheffield, UK r.ohara@sheffield.ac.uk.
• J Health Serv Res Policy. 2015 Jan 1; 20 (1 Suppl): 45-53.

ObjectivesParamedics routinely make critical decisions about the most appropriate care to deliver in a complex system characterized by significant variation in patient case-mix, care pathways and linked service providers. There has been little research carried out in the ambulance service to identify areas of risk associated with decisions about patient care. The aim of this study was to explore systemic influences on decision making by paramedics relating to care transitions to identify potential risk factors.MethodsAn exploratory multi-method qualitative study was conducted in three English National Health Service (NHS) Ambulance Service Trusts, focusing on decision making by paramedic and specialist paramedic staff. Researchers observed 57 staff across 34 shifts. Ten staff completed digital diaries and three focus groups were conducted with 21 staff.ResultsNine types of decision were identified, ranging from emergency department conveyance and specialist emergency pathways to non-conveyance. Seven overarching systemic influences and risk factors potentially influencing decision making were identified: demand; performance priorities; access to care options; risk tolerance; training and development; communication and feedback and resources.ConclusionsUse of multiple methods provided a consistent picture of key systemic influences and potential risk factors. The study highlighted the increased complexity of paramedic decisions and multi-level system influences that may exacerbate risk. The findings have implications at the level of individual NHS Ambulance Service Trusts (e.g. ensuring an appropriately skilled workforce to manage diverse patient needs and reduce emergency department conveyance) and at the wider prehospital emergency care system level (e.g. ensuring access to appropriate patient care options as alternatives to the emergency department).© The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.

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