04 Relational factors that influence paramedic decision-making with families of acutely unwell children: a qualitative case-study

<h3>Background</h3> Paramedics encounter young children as part of their workload on ambulances. Discerning a self-limiting acutely unwell child from a deteriorating one remains a challenge to paramedic practice. How paramedics formulate decisions and families relate to the proposed outcome (conveyance, referral, or discharge) is poorly understood. Moreso is the child’s involvement in the decision-making process. The study explores the decision-making of paramedics with families of acutely unwell children, seeking to understand factors that influence the decisional outcome. <h3>Methods</h3> A qualitative case study of an ambulance service, analysing policy documents, and interviewing paramedics and families respectively following an ambulance encounter, children were encouraged to talk and draw about their experience. Initially, participating paramedics recruited families after a callout by directing them to an online website detailing the purpose of the study. Families then consented to enrol. The paramedic-family encounter constituted a case encounter. Only one case was acquired with this strategy. Cases were then dissociated to comprise the family view, the child narrative, and the paramedic view. Ethics was approved for both strategy and revision. The documents, single case-study and three separate groups, paramedic (n=10), family (n=10), and child narrative (n=2), were analysed consisting of <i>in vivo,</i> theming, belief analysis and for the child, narrative analysis using schema where drawing was included. Concept meta-matrices then melded themes amongst the groups, formulating assertions on key factors in decision-making. <h3>Results</h3> Paramedics follow a distinctive decision-making process: 1) Initial intuition 2) deliberation excluding sinister causes 3) dichotomy (uncertainty) 4) abductive logic. Exposure and confidence reduced doubts about risk of child deterioration, resulting in non-conveyance strategies, instilling parental confidence if expectations were met. Utilising guidelines aided the transition from dichotomy to abductive logic, but consisted of a confirmation bias. Families were provided options at the end-point of the encounter in the absence of critical illness. Whilst parents perceived themselves to wield the final decision, paramedic authority strongly influenced the outcome. The mandatory conveyance policy of children under one yielded no clinical benefit when decisions were purely age-based, disempowering paramedics and causing unnecessary inconvenience to families. Child personality affected their response to the presence of paramedics. Failure to establish child rapport resulted in conveyance. The two four-year-olds perceived the paramedic role to ‘tell’ or ‘take’ people to hospital. <h3>Conclusion</h3> Children should be the focal point of the encounter, where rapport is essential in determining an appropriate outcome. Paramedics can exclude sinister causes in acutely unwell children, and guidelines can assist in discerning a safe outcome irrespective of age. Future policy ought to empower paramedics to provide alternative pathways that are less inconvenient to the family.