ABSTRACT
BACKGROUND: In response to COVID-19, alongside other service changes, North Central London and East Kent implemented prehospital video triage: this involved stroke and ambulance clinicians communicating over FaceTime (Apple Inc., Cupertino, CA, USA) to assess suspected stroke patients while still on scene. OBJECTIVE: To evaluate the implementation, experience and impact of prehospital video triage in North Central London and East Kent. DESIGN: A rapid mixed-methods service evaluation (July 2020 to September 2021) using the following methods. (1) Evidence reviews: scoping review (15 reviews included) and rapid systematic review (47 papers included) on prehospital video triage for stroke, covering usability (audio-visual and signal quality);acceptability (whether or not clinicians want to use it);impact (on outcomes, safety, experience and cost-effectiveness);and factors influencing implementation. (2) Clinician views of prehospital video triage in North Central London and East Kent, covering usability, acceptability, patient safety and implementation: qualitative analysis of interviews with ambulance and stroke clinicians (n = 27), observations (n = 12) and documents (n = 23);a survey of ambulance clinicians (n = 233). (3) Impact on safety and quality: analysis of local ambulance conveyance times (n = 1400;April to September 2020). Analysis of national stroke audit data on ambulance conveyance and stroke unit delivery of clinical interventions in North Central London, East Kent and the rest of England (n = 137,650;July 2018 to December 2020). RESULTS: (1) Evidence: limited but growing, and sparse in UK settings. Prehospital video triage can be usable and acceptable, requiring clear network connection and audio-visual signal, clinician training and communication. Key knowledge gaps included impact on patient conveyance, patient outcomes and cost-effectiveness. (2) Clinician views. Usability - relied on stable Wi-Fi and audio-visual signals, and back-up processes for when signals failed. Clinicians described training as important for confidence in using prehospital video triage services, noting potential for 'refresher' courses and joint training events. Ambulance clinicians preferred more active training, as used in North Central London. Acceptability - most clinicians felt that prehospital video triage improved on previous processes and wanted it to continue or expand. Ambulance clinicians reported increased confidence in decisions. Stroke clinicians found doing assessments alongside their standard duties a source of pressure. Safety - clinical leaders monitored and managed potential patient safety issues;clinicians felt strongly that services were safe. Implementation - several factors enabled prehospital video triage at a system level (e.g. COVID-19) and more locally (e.g. facilitative governance, receptive clinicians). Clinical leaders reached across and beyond their organisations to engage clinicians, senior managers and the wider system. (3) Impact on safety and quality: we found no evidence of increased times from symptom onset to arrival at services or of stroke clinical interventions reducing in studied areas. We found several significant improvements relative to the rest of England (possibly resulting from other service changes). LIMITATIONS: We could not interview patients and carers. Ambulance data had no historic or regional comparators. Stroke audit data were not at patient level. Several safety issues were not collected routinely. Our survey used a convenience sample. CONCLUSIONS: Prehospital video triage was perceived as usable, acceptable and safe in both areas. FUTURE RESEARCH: Qualitative research with patients, carers and other stakeholders and quantitative analysis of patient-level data on care delivery, outcomes and cost-effectiveness, using national controls. Focus on sustainability and roll-out of services. STUDY REGISTRATION: This study is registered as PROSPERO CRD42021254209. FUNDING: This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme and will be published in full in Health and Social Care Delivery Research;Vol. 10, No. 26. See the NIHR Journals Library website for further project information.
ABSTRACT
Background: In 2020, North Central (NC) London and East Kent introduced prehospital video triage, where stroke and ambulance clinicians used videoconferencing to assess suspected stroke patients on scene. The aim was to reduce conveyance of non-stroke patients to stroke services and reduce transmission of Covid-19. Methods: Rapid, mixed-method evaluation of prehospital video triage in NC London and East Kent (July 2020-September 2021), drawing on: • Interviews with ambulance and stroke clinicians (n=27);observations (n=12);documents (n=23);• Survey of ambulance clinicians (n=233) in NC London and East Kent. • Descriptive statistical analysis of local ambulance conveyance data (n=1,400;April-September 2020). • Difference-in-differences regression analysis of team-level national audit data, to understand changes in delivery of clinical interventions in NC London and East Kent relative to the rest of England (n=137,650;2018-2020). Results: Interview and survey data suggested clinicians perceived prehospital video triage as usable, safe, and preferable to 'business-as-usual'. Several interrelated factors influenced implementation, including impetus of Covid-19, facilitative local governance, receptive professional values, engaging clinical leadership, active training approaches, and stable audiovisual signal;stroke clinician capacity was a potential risk to sustainability. Neither area saw increased time from symptom onset to arrival at services, while delivery of clinical interventions either remained unchanged or improved significantly, relative to the rest of England. Conclusions: Prehospital video triage in NC London and East Kent was perceived as usable, acceptable, and safe;it was associated with some significant improvements in secondary care processes. Key influences included national and local context, characteristics of triage services, and implementation approaches.
ABSTRACT
BACKGROUND: The implementation of change in health and care services is often complicated by the 'micropolitics' of the care system. There is growing recognition that health and care leaders need to develop and use types of 'political skill' or 'political astuteness' to understand and manage the micropolitics of change. AIM: The aim of this study was to produce a new empirical and theoretical understanding of the acquisition, use and contribution of leadership with 'political astuteness', especially in the implementation of major system change, from which to inform the co-design of training, development and recruitment resources. METHODS: The qualitative study comprised four work packages. Work package 1 involved two systematic literature reviews: one 'review of reviews' on the concept of political astuteness and another applying the learning from this to the health services research literature. Work package 2 involved biographical narrative interviews with 66 health and care leaders to investigate their experiences of acquiring and using political skills in the implementation of change. Work package 3 involved in-depth qualitative case study research with nine project teams drawn from three regional Sustainability and Transformation Partnerships operating in different English regions. Work package 4 involved a series of co-design workshops to develop learning materials and resources to support service leaders' acquisition and use of political skills and astuteness. RESULTS: The concepts of political skills and astuteness have had growing influence on health services research, yet these have tended to emphasise a relatively individualised and behavioural view of change leadership. The interview study suggests that, although leaders certainly use individual skills and behaviours when implementing change, change processes are contingent on local contextual factors and the patterns of collective action in the forms of interlocking constellations of political interactions. The in-depth case study research further shows these interactive, contingent and collective processes in the implementation of major system change. The study finds that major system change occurs over several linked stages, each involving particular controversies for which skills, strategies and actions are needed. Informed by these findings, and through a series of co-design workshops, the study has produced a set of resources and materials and a workbook to support individuals and project teams to acquire and develop political skill. LIMITATIONS: The study was complicated by the COVID-19 pandemic and there were difficulties in recruiting in-depth cases for observational research, and also recruiting patient and community groups. CONCLUSIONS: Health and care leaders can develop and use a range of skills, strategies and actions to understand and navigate the diverse interests that complicate change. Building on the literature, the study presents a novel empirical framework of these skills, strategies and behaviours, and shows how they are used in the implementation of major system change. This study concludes with a set of co-designed learning resources and materials to support future leaders to develop similar skills and strategies. Further evidence is needed on the contribution of the learning resources on leadership activities and to understand the contribution of political skills to other areas of service governance. STUDY REGISTRATION: This study is registered as researchregistery4020. FUNDING: This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme and will be published in full in Health and Social Care Delivery Research;Vol. 10, No. 11. See the NIHR Journals Library website for further project information.