Paramedic perceptions of barriers and facilitators to the use of ambulance service appropriate care-referral pathways in Northern Ireland: a qualitative study.

Introduction: Paramedic clinical practice has seen significant evolution from the traditional role of transporting patients to an emergency department (ED). An evolving and flexible scope of practice, modernisation and healthcare reform has necessitated the development of a range of referral pathways for paramedics, with the aim of ensuring that service users receive the most appropriate care at the point of contact. Ambulance conveyance rates to EDs in Northern Ireland (NI) have only occasionally fallen below 75%. A study examining a Northern Ireland Ambulance Service (NIAS) referral pathway showed a much lower referral rate than those of comparable ambulance services. A similar study found that over 70% of people who experience a fall are not referred to falls prevention services. This study aimed to identify what paramedics perceive are the barriers and facilitators to the use of patient care pathways (PCPs) in NI. Methods: In this single-centre qualitative study, participants were recruited using volunteer sampling. Data were collected through 11 semi-structured interviews until data saturation was reached. Online interviews were recorded, transcribed verbatim and thematically analysed. Results: Five main themes were constructed during analysis. The participants discussed their perceptions of the barriers and facilitators to utilising PCPs in relation to risk, cultural issues, person-centred practice, inter-professional communication and operational infrastructure. Conclusion: The study provides insight into perceived barriers and facilitators to the use of PCPs, while indicating the existence of a paramedic workforce dedicated to achieving the best outcomes for people in their care. The themes identified are consistent with existing literature that calls for standardised pathways across regions. Future research should investigate the link between the NHS 111 service and ambulance demand. In order to facilitate the complex decision making involved in referrals, relevant knowledge and skills should be embedded in paramedic education. Efforts should be made to improve inter-professional communication and awareness of the paramedic scope of practice and knowledge base. An intervention designed to reassure staff who have concerns regarding clinical risk may improve referral rates.