A national perspective of ambulance clinicians' perceptions, experiences and decision-making processes when assessing older adults with a head injury: a mixed-methods study.

Introduction: UK ambulance services employ diverse models of care, resulting in 40-60% emergency department (ED) conveyance rates. Head injury conveyance rates for older adults (60 years and over) remain high (60-70%), despite most being mild. This research aimed to explore ambulance clinicians' perceptions, experiences and decision-making processes when assessing older adults with head injuries, considering the various factors influencing their clinical decisions. Methods: This study used a mixed-methods sequential explanatory design comprising an online survey and one-to-one interviews with patient-facing ambulance clinicians in the UK. The survey, distributed through nine ambulance services and via social media, gathered data about clinicians' experiences, confidence levels and perceptions when assessing older adults with head injuries. It focused on exposure frequency, confidence in assessing asymptomatic patients, perceived risks of medications and confidence in available decision tools. The subsequent interviews delved deeper into the survey responses. Results: A total of 385 participants were recruited, predominantly male paramedics (61%), with a median age of 35 years and a median of eight years of ambulance service experience. Participants reported frequent encounters with older adults with head injuries, and expressed high confidence in assessing visible injuries but lower confidence in conducting neurological examinations. Participants found NICE and JRCALC guidelines satisfactory, and reported confidence in conveying patients to the ED but less confidence in alternative referrals or discharges. The interviews revealed two overarching themes: guideline-based care and patient-centred care, with sub-themes emphasising the importance of shared decision making, collaboration with other healthcare professionals and safety-netting strategies. Conclusion: Although clinicians express confidence in using clinical guidelines for ED conveyances, they often find such guidance overly prescriptive and struggle to translate them for individual cases. There is a need for more patient-centred, holistic decision making, especially considering the unique aspects of head injuries in older adults. Challenges include fear of poor outcomes, limited feedback on patient outcomes and low confidence in making referral or discharge decisions. Specific guidelines tailored to this demographic, as well as improved support services, may aid in reducing unnecessary ED conveyances.