Safety, Appropriateness and Acceptability of Ambulance Telephone Advice: A mixed methods study

Background
High demand for ambulance care has led to changes in service provision, with calls identified as low urgency increasingly being dealt with by telephone advice. This study uses linked routine health data and interviews with ambulance service staff to explore the safety, appropriateness and acceptability of telephone advice.
Methods
A mixed-method approach comprising of systematic reviews, analysis of routine linked data and qualitative interviews was used. Definitions of safety, appropriateness and acceptability were developed from a narrative review of concepts and definitions, and evidence around telephone advice was synthesised using a systematic review. Ambulance service call and telephone advice data for 2521 patients was linked with other health-service data and subsequent health contacts and outcomes were identified within 3 days of the ambulance call. Semi-structured interviews were undertaken with staff involved in the telephone advice process.
Results
Linked data analysis identified no subsequent health contacts (Emergency department/Hospital admission/death) for 60% (n=1485/2521) of patients. Sensitivity analyses identified low subsequent event rates for hospital admissions (2.5%–10.5%) and deaths (0.06%–0.24%), and higher rates for ambulance recontacts (7.6%–32.2%) and emergency department attendances (6.2%–26.4%). Service provider interviews identified safety mechanisms at service, team and individual levels that enhance safety, but described potential gaps in service safety relating to under-triage, long waits for a clinical call back and concerns about the triage Concerns Process. Interviewees perceived telephone advice as mostly appropriate but identified mental health calls as particularly challenging. Interviewees described mixed service user reactions to telephone advice and perceived user acceptability was linked to expectations around receiving an ambulance, whether the caller is reassured and length of time to receive a clinical call back.
Conclusion
Telephone advice in EMAS is likely to be safe and appropriate; most patients do not have subsequent health events, multiple methods are used by ambulance services to ensure safety at a service, team and individual level and staff perceive telephone advice was mostly a safe and appropriate way of handling lower urgency calls. However, mental health calls were perceived as challenging and best handled by specialist mental health clinicians. Service providers perceived mixed service user reactions to telephone advice and linked user acceptability to expectations around receiving an ambulance, the caller’s need for reassurance, and the length of time to receive telephone advice.