Patients who call emergency ambulances for primary care problems: a qualitative study of the decision-making process.

BACKGROUND: Telephone calls for emergency ambulances are rising annually, increasing the pressure on ambulance resources for clinical problems that could often be appropriately managed in primary care. OBJECTIVE: To explore and understand patient and carer decision making around calling an ambulance for primary care-appropriate health problems. METHODS: Semistructured interviews were conducted with patients and carers who had called an ambulance for a primary care-appropriate problem. Participants were identified using a purposive sampling method by a non-participating research clinician attending '999' ambulance calls. A thematic analysis of interview transcripts was undertaken. RESULTS: A superordinate theme, patient and carer anxiety in urgent-care decision making, and four subthemes were explored: perceptions of ambulance-based urgent care; contrasting perceptions of community-based urgent care; influence of previous urgent care experiences in decision making; and interpersonal factors in lay assessment and management of medical risk and subsequent decision making. CONCLUSIONS: Many calls are based on fundamental misconceptions about the types of treatment other urgent-care avenues can provide, which may be amenable to educational intervention. This is particularly relevant for patients with chronic conditions with frequent exacerbations. Callers who have care responsibilities often default to the most immediate response available, with decision making driven by a lower tolerance of perceived risk. There may be a greater role for more detailed triage in these cases, and closer working between ambulance responses and urgent primary care, as a perceived or actual distance between these two service sectors may be influencing patient decision making on urgent care.

Seeking ambulance treatment for 'primary care' problems: a qualitative systematic review of patient, carer and professional perspectives.

OBJECTIVES: To understand the reasons behind, and experience of, seeking and receiving emergency ambulance treatment for a 'primary care sensitive' condition. DESIGN: A comprehensive, qualitative systematic review. Medline, Embase, PsychInfo, Cumulative Index of Nursing and Allied Health, Health Management Information Systems, Healthcare Management Information Consortium, OpenSigle, EThOS and Digital Archive of Research Theses databases were systematically searched for studies exploring patient, carer or healthcare professional interactions with ambulance services for 'primary care sensitive' problems. Studies using wholly qualitative approaches or mixed-methods studies with substantial use of qualitative techniques in both the methods and analysis sections were included. An analytical thematic synthesis was undertaken, using a line-by-line qualitative coding method and a hierarchical inductive approach. RESULTS: Of 1458 initial results, 33 studies met the first level (relevance) inclusion criteria, and six studies met the second level (methodology and quality) criteria. The analysis suggests that patients define situations worthy of 'emergency' ambulance use according to complex socioemotional factors, as well as experienced physical symptoms. There can be a mismatch between how patients and professionals define 'emergency' situations. Deciding to call an ambulance is a process shaped by practical considerations and a strong emotional component, which can be influenced by the views of caregivers. Sometimes the value of a contact with the ambulance service is principally in managing this emotional component. Patients often wish to hand over responsibility for decisions when experiencing a perceived emergency. Feeling empowered to take control of a situation is a highly valued aspect of ambulance care. CONCLUSIONS: When responding to a request for 'emergency' help for a low-acuity condition, urgent-care services need to be sensitive to how the patient's emotional and practical perception of the situation may have shaped their decision-making and the influence that carers may have had on the process. There may be novel ways to deliver some of the valued aspects of urgent care, more geared to the resource-limited environment.

Why do patients with 'primary care sensitive' problems access ambulance services? A systematic mapping review of the literature.

OBJECTIVE: Emergency ambulance use for problems that could be managed in primary care continues to rise owing to complex reasons that are poorly understood. The objective of this systematic review is to draw together published evidence across a variety of study methodologies and settings to gain a better understanding of why patients seek help from ambulance services for these problems. DESIGN: Systematic searches were undertaken across the MEDLINE, EMBASE, PsychINFO, CINAHL, Health Management Information Consortium and Health Management Information Service publication databases. Google Scholar, Web of Science, OpenSigle, EThOS and DART databases were also systematically searched for reports, proceedings, book chapters and theses, along with hand-searching of grey literature sources. Studies were included if they reported on findings examining patient, carer, health professional or service management interactions with ambulance services for primary care problems. All study methodologies and perspectives were of interest. Data were extracted, quality assessed and systematically mapped according to key findings through generation of an iterative framework. RESULTS: A total of 31 studies met inclusion criteria. Findings were summarised across 5 broad categories: factors associated with individual patients; actions of care-givers and bystanders; population-level factors; health infrastructure factors; challenges faced by health professionals. A number of subcategories were developed to explore these factors in more detail. CONCLUSIONS: This review reports important factors that may impact on ambulance use for primary care problems across a global setting, including demographic measures associated with deprivation, minority status and individual social circumstances. Categorising ambulance calls for primary care problems as 'inappropriate' is context dependant and may be unhelpful. Potential implications for triage and risk management strategies are discussed.

Stevens-Johnson Syndrome triggered by chemical hair relaxer: a case report.

This case report describes a 41-year-old Afro-Caribbean lady presenting with a constellation of pyrexia, conjunctivitis, arthralgia, sterile dysuria, apthous ulceration, labial crusting and widespread erythema multiforme. A diagnosis of Stevens-Johnson Syndrome was made. She had taken no medications recently (the most common precipitant of Stevens-Johnson Syndrome) and a full screen for the common and atypical bacterial and viral triggers was negative. The identified trigger was the use of a chemical hair relaxant treatment a few days previously. With supportive measures and a course of oral prednisolone, the patient quickly improved and made a full recovery. This case highlights the importance of considering occupational and recreational precipitants of Stevens-Johnson Syndrome.

Aseptic meningitis in a patient taking etanercept for rheumatoid arthritis: a case report.

BACKGROUND: We report a case of a 53 year old lady recently commenced on etanercept, an anti-TNF (tumour necrosis factor) therapy for rheumatoid arthritis presenting with confusion, pyrexia and an erythematous rash. CASE PRESENTATION: A lumbar puncture was highly suggestive of bacterial meningitis, but CSF cultures produced no growth, and polymerase chain reactions (PCR) for all previously reported bacterial, fungal and viral causes of meningitis were negative. CONCLUSION: This case report describes aseptic meningitis as a previously unreported complication of etanercept therapy, and serves as a reminder of the rare but potentially life-threatening risk of serious infections in patients taking anti-TNF therapy for a variety of conditions.

Neurocysticercosis as a first presentation of tonic-clonic seizures: a case report.

We report the case of a 28 year-old immigrant Asian man from the Punjab region with a first presentation of seizures. This patient had no significant past medical history, but suffered several headaches in the preceding week and was pyrexial on presentation. A CT scan of his head showed a single area of subcortical low attenuation initially suggesting ischaemia. A lumbar puncture and CSF examination was unremarkable. Further investigation revealed discrete calcified gluteal lesions on pelvic X-ray, and serum immunology positive for cysticercosis. The diagnosis of neurocysticercosis was made, and the patient improved on dexamethasone and a short course of vermicide, to be discharged a week later. With increasing global migration, the prevalence of neurological parasitic infections seen in the UK is likely to rise. This case highlights the importance of careful interpretation of non-specific head CTs in the context of first presentation of seizures in a susceptible population.

Pain management in sickle cell disease.

OBJECTIVES: Sickle cell disease (SCD) is an inherited blood disorder characterized by recurrent 'crisis' pain, which is the most common reason for repeated hospital admission. The nature of this pain, however, is poorly understood, and the pain is often sub-optimally managed. METHODS: A focus group format, interpreted using thematic analysis, was used to gain a greater understanding of the barriers that SCD patients face in managing their pain and their perceptions of the treatment that they receive from healthcare professionals. RESULTS: Key issues emerging from the focus groups that adversely affected participants' pain management included: feeling isolated by their experience of 'crisis' pain, not being listened to, and limitations to social support networks. Specific issues relating to seeking medical care included lack of understanding about SCD by nonspecialist clinicians, feelings of being low priority due to the 'invisible' nature of their pain, and feeling mistrusted by medical staff when seeking analgesia. DISCUSSION: Feelings of isolation may drive maladaptive coping strategies and manifest in anger, aggression and active avoidance of service use. Suggested service improvements include the active targeting of isolated individuals in the form of pain discussion groups or self-help groups, and greater provision of specialised services.