Risk assessment reasoning and decision-making by ambulance professionals in patients with a transient loss of consciousness: a qualitative study.

backgroundPatients with a transient loss of consciousness (T-LOC) present a complex clinical situation for ambulance professionals. The challenge arises from the complexity of the diverse aetiologies associated with T-LOC and the demanding nature of the pre-hospital work environment. Insights into the experiences, dilemmas, and challenges faced by ambulance professionals in the risk assessment and decision-making in this patient category could help to understand the support they need. Our study aimed to explore the risk assessment reasoning and decision-making process of ambulance professionals in patients with a T-LOC in current practice.

methodsWe conducted a qualitative study with focus group interviews in an emergency medical services (EMS) organisation in the Netherlands. Through purposive sampling, ambulance professionals were recruited for two online focus group interviews. An interview guide, based on literature and preliminary individual interviews, was used. The focus group interviews were transcribed verbatim and analysed using thematic analysis.

resultsA total of eleven participants participated in two focus group interviews. Three main themes emerged: (1) Clinical reasoning covering the (initial) approach of ambulance professionals on scene, the T-LOC specific assessment, complexity of the aetiology of T-LOC, and the medical conveyance decision, (2) Collaboration describing the difficulties and facilitating factors in the interprofessional collaboration with other healthcare professionals in the chain of emergency care (e.g., general practitioners, emergency physicians, etc.) and the involvement of patients and relatives, (3) Professionalism describing the influence of professionals' experiences (e.g. professional maturity), the sense of responsibility and accountability of the ambulance professional, and their subsequent need for reflection.

conclusionAmbulance professionals follow a structured approach for the clinical assessment of a patient with a T-LOC. In addition to their professional experience, the complexity of the symptom and the patient's context play a crucial role in the risk assessment reasoning and decision-making process. Ambulance professionals collaborate with other healthcare professionals to enhance their process, with varying experiences. There is a delicate balance between professionals' sense of responsibility and accountability. A non-conveyance decision is considered precarious by professionals, and adequate support from management, education and interprofessional collaboration is required to feel confident in their decision-making.