Stakeholder perspectives of piloting pre-hospital COVID-19 lateral flow testing and direct admissions pathway: exploring why well-received ideas have low uptake.

Introduction: In January 2021, Yorkshire Ambulance Service and Hull University Teaching Hospitals implemented a pilot COVID-19 lateral flow testing (LFT) and direct admissions pathway to assess the feasibility of using pre-hospital LFTs to bypass the emergency department. Due to lower than anticipated uptake of the pilot among paramedics, we undertook a process evaluation to assess reasons for low uptake and perceived potential benefits and risks associated with the pilot. Methods: We undertook semi-structured telephone interviews with 12 paramedics and hospital staff. We aimed to interview paramedics who had taken part in the pilot, those who had received the project information but not taken part and ward staff receiving patients from the pilot. We transcribed interviews verbatim and analysed data using thematic analysis. Results: Participation in the pilot appeared to be positively influenced by high personal capacity for undertaking research (being 'research-keen') and negatively influenced by 'COVID-19 exhaustion', electronic information overload and lack of time for training. Barriers to use of the pathway related to 'poor timing' of the pilot, restrictive patient eligibility and inclusion criteria. The rapid rollout meant that paramedics had limited knowledge or awareness of the pilot, and pilot participants reported poor understanding of the pilot criteria or the rationale for the criteria. Participants who were involved in the pilot were overwhelmingly positive about the intervention, which they perceived as having limited risks and high potential benefits to the health service, patients and themselves, and supported future roll-out. Conclusions: Ambulance clinician involvement in rapid research pilots may be improved by using multiple recruitment methods (electronic and other), providing protected time for training and increased direct support for paramedics with lower personal capacity for research. Improved communication (including face-to-face approaches) may help understanding of eligibility criteria and increase appropriate recruitment.