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Society faces significant challenges caring for people with urgent mental health needs. General hospitals are well equipped for dealing with medical emergencies, but much less skilled in managing mental health problems. Ambulance and policing staff frequently encounter such individuals, with transport to Emergency Department often the only care pathway. In the UK, no evidence existed on general hospital patterns prior to suicide, or on outcomes for pre-hospital mental health emergencies. This thesis contains five papers, consisting of four research studies and one protocol. Three papers report innovative quantitative approaches using linked datasets. Using 30 years of Scottish hospital data, I showed that 10,907 people who died by suicide with hospital records were 3.1 times more frequently last discharged from general, not psychiatric hospital; 24% within three months of last discharge, of whom 58% were from general hospital. Using national deaths registrations, I reported that cohorts of men born around 1965-70 had been at greater vulnerability to suicide in the 1990s, with stark differences in suicide rates between Scotland, and England & Wales. Analyses of data on unscheduled care revealed that within one year of paramedic attendances for 6,802 people with 'psychiatric emergency', 297 had died, 35% of whom were deaths by suicide. Paramedics were in contact with 8% of people in the year before they died by suicide. Police officers encountering people with mental health concerns have no formal means of vulnerability assessment to support triaging. A review of the evidence found no consensus definition for vulnerability or means of assessing vulnerability, a lack of congruence in terminology across policing and health, and a likely barrier to accessing services. Finally, a protocol was published outlining methods for an analysis of childhood adversity as seen in national hospital datasets. This thesis provides evidence to support redesign of more integrated services, highlights areas for suicide prevention, and closes with an impact generation exemplar.

With an increasing use of health services in England there is a political desire to alter demand patterns and re-design services to reduce spend. With a yearly 4% increase in ambulance service use a variety of generic health education initiatives have been tried to reduce demand with seemingly limited effect. Calling an ambulance when you have a perceived need can be considered a health behaviour and to effectively intervene to alter this behaviour requires an understanding of variation in population use. This study analysed 769,376 emergency calls in the East of England including those not conveyed to hospital by three acuity levels. Population use of the ambulance service was considered in relation to sociodemographic factors derived from the census. A significant regression was found (F(27,3582)=44.81, p < 0.001), with an adjusted R² of 0.2469. Population factors related to higher utilisation included age groups 85-90 and 90 & over, mixed and black ethnicity, and those who had never worked or were long-term unemployed. The study examined, using moderated regression analysis, the influence of self efficacy, access to services, general health status and social networks on the relationship between socio-demographics and ambulance utilisation. The findings suggest that access to services and general health status of the population act as significant moderators, but self efficacy and social networks are not significant moderators. Policy interventions suggested involve targeting specific population types related to higher utilisation to manage demand. The original contribution of this study is the further development of understanding ambulance utilisation through the use of large datasets within the English NHS context.

Introduction: The most appropriate airway management technique for use by paramedics in out-of-hospital cardiac arrest is yet to be determined and evidence relating to the influence of airway management strategy on outcome remains equivocal. In cases where return of spontaneous circulation (ROSC) occurs following out-of-hospital cardiac arrest, patients may undergo direct transfer to a specialist heart attack centre (HAC) where the post resuscitation 12 lead ECG demonstrates evidence of ST elevation myocardial infarction. To date, no studies have investigated the role of airway management strategy on outcomes in this sub-set of patients. The AMICABLE (Airway Management In Cardiac Arrest, Basic, Laryngeal mask airway, Endotracheal intubation) study therefore sought to investigate the influence of prehospital airway management strategy on outcomes in patients transferred by the ambulance service directly to a HAC post ROSC. Methods: Adults with ROSC post out-of-hospital cardiac arrest who met local criteria for transfer to a HAC were identified prospectively. Ambulance records were reviewed to determine prehospital airway management approach and collect physiological and demographic data. HAC notes were obtained to determine in-hospital course and quantify neurological outcome via the Cerebral Performance Category (CPC) scale. Neurologically intact survivors were contacted post discharge to assess quality of life via the SF-36 health survey. Statistical analyses were performed via Chi-square, Mann Whitney U test, odds ratios, and binomial logistic regression. Results: A total of 220 patients were recruited between August 2013 and August 2014, with complete outcome data available for 209. The age of patients ranged from 22-96 years and 71.3% were male (n=149). Airway management was undertaken using a supraglottic airway (SGA) in 72.7% of cases (n=152) with the remainder undergoing endotracheal intubation (ETI). There was no significant difference in the proportion of patients with good neurological outcome (CPC 1&2) between the SGA and ETI groups (p=.286). Similarly, binomial logistic regression incorporating factors known to influence outcome demonstrated no significant difference between the SGA and ETI groups (Adjusted OR 0.725, 95% CI 0.337-1.561). Clinical and demographic variables associated with good neurological outcome included the presence of a shockable rhythm (p < .001), exposure to angiography (p < .001), younger age (p < .001) and shorter time to ROSC (p < .001). Due to an inadequate response rate (25.4%, n=15) analysis of SF36 data was limited to descriptive statistics. Limitations: The study only included patients who achieved ROSC and met the criteria for direct transfer to a HAC. Results are therefore not generalisable to more heterogenous resuscitation populations. Accuracy of clinical decision making and ECG interpretation were not assessed and therefore some patients included in the study may have been inappropriately transferred to a HAC. The low SF-36 survey response rate limited the level of neurological outcome analysis that could be undertaken. Conclusion: In this study, there was no significant difference in the proportion of good neurological outcomes in patients managed with SGA versus ETI during cardiac arrest. Further research incorporating randomised controlled trials is required to provide more definitive evidence in relation to the optimal airway management strategy in out-of-hospital cardiac arrest.

Hospital admissions for patients close to the end of life are considered ‘inappropriate’ in contemporary English health policy. Hospitals are supposedly unable to offer a ‘good’ death for patients, and dying there is thought to contradict patient choice, since patients are assumed to want to die at home. However, almost half of all deaths in England in 2015 occurred in hospital, and of these, nearly a third died within three days of admission. This thesis seeks to explore why these admissions are considered to be a problem and how they occur. Through a systematic review of UK literature I found that it cannot be stated that most patients want to die at home, because of the extent of missing data (preferences not asked, expressed, reported or absent). This finding challenges the justification that admissions are inappropriate because they contravene patient choice. Similarly inconclusive evidence about the undesirability, cost, and lack of need for patients to be in hospital were also found in a review of policy. Together with analysis of historical trends in hospital and hospice provision, it is apparent that attitudes towards end-of-life admissions reflect existing tensions about the role of hospital as an acute provider, and as a place of death. An analysis of interviews conducted with healthcare staff and next-of-kin involved in the admission of patients (case-patients) who died shortly after being admitted to Meadowbridge, a large English hospital explored these tensions further. I found that whilst hospital was not recognised as a place where ‘good’ deaths typically occurred, it was acknowledged as an emergency place of care. In this context, patients without obvious need for hospital care were nevertheless admitted to the hospital and the environment was subsequently recognised to offer distinct benefits. The need for emergency care reflected the difficulties of providing end-of-life care in the community. For dying to occur appropriately, home had to be adapted and care organised by healthcare staff. Both tasks were complicated by the unpredictability of dying, and family carers helped to absorb much of the uncertainty and support patients to die at home. Ambulance staff became involved when patients had care needs that exceeded care quickly and easily available in the community. When called to the case-patients, ambulance staff instituted familiar practices in transferring them to hospital. Hospital was recognised as a default place of care because ambulance staff struggled to facilitate alternative care and lacked sufficient professional authority to keep patients at home. The admissions of the case-patients represent the best attempts of staff to navigate the tangled practices of end-of-life care. These practices are the result of the actions of the staff, which in turn both constrained and enabled their action in providing care to patients. The term ‘inappropriate’ to describe admissions does not encompass these attempts, and moreover, devalued the significant care provided by healthcare staff in the community and hospital.

This study has used a mixed methodology to explore the impact of geographic, temporal and ambulance crew skill factors on ambulance clinicians’ decisions to leave a patient on scene after attending a 999 call. Four phases of work were undertaken using both qualitative and quantitative methods to build an understanding of the complex nature of pre-hospital clinical reasoning. A novel scale, the DMASC survey was developed, which indicated four factors influence decision-making in this context. More experienced staff scored significantly differently to other staff groups on the ‘Experience’ and ‘Patient characteristic’ subscales of the tool. Qualitative work explored these findings in more detail and five inter-related themes were identified, namely, ‘Communication’, ‘The three ‘E’s’, education, experience and exposure’, ‘System influences’, ‘Professionalism’ and ‘Patient characteristics’. The final phase of the study undertook to analyse retrospective call data from one large ambulance service over a one-year period. All of the five predictor variables, rurality, time of day, day of the week, patient condition and crew skill level, influenced the likelihood of conveyance. Of these the level of clinical skill of the first crew at scene was independently significant. The results of this work are discussed in relation to the strategic and operational context of NHS ambulance services. The thesis is structured as a series of papers yet to be submitted for publication. Although this confers a degree of repetition, it provides a logical analysis of the methods used to explore factors that may influence paramedic’s clinical decision making when deciding to leave patients at home following a 999-call attendance.

Background: Changing service demands require United Kingdom ambulance services to redefine their role and response strategies, in order to reduce unnecessary Emergency Department attendances. Treat and Refer guidelines have been developed with this aim in mind. However, these guidelines have been developed in the absence of reliable evidence or guiding mid-range theory. This has resulted in inconsistencies in clinical practice. One condition frequently included in Treat and Refer guidelines is hypoglycaemia. Therefore this thesis aimed to investigate prehospital hypoglycaemic emergencies in order to develop an evidence base for future interventions and guideline development. Research approach: A pragmatic and inductive applied health services research approach was employed. Multiple methods were used in a sequential explanatory design. Three linked studies were undertaken with the results of previous studies informing the development of the next. Study one: A scoping review of prehospital treatment of hypoglycaemic events. Aims: i) To describe the demographics of the patient population requiring ambulance service assistance for hypoglycaemic emergencies; ii) To determine the extent to which post-hypoglycaemic patients with diabetes, who are prescribed oral hypoglycaemic agents (OHA), experience repeat hypoglycaemic events (RHE) after being treated in the prehospital environment. Methods: A scoping literature review was conducted using an overlapping retrieval strategy that included both published and unpublished literature. Findings: Twenty-three papers and other relevant material were included. Hypoglycaemia related ambulance calls account for 1.3% to 5.2% of ambulance calls internationally. Transportation rates varied between studies (25%-73%). Repeat hypoglycaemic emergencies are experienced by 2-7% of patients within 48 hours. There was insufficient detail to determine any relationship between repeat events and OHA. The low quality of included papers means that the results should be cautiously interpreted. The safety of leaving patients on OHA at home post hypoglycaemic emergency is unknown. Consequently patients taking OHAs who experience a hypoglycaemic emergency should be transported to hospital for observation. There was a lack of knowledge about the Scottish demographics of the patient population. Study two: A retrospective cross-sectional observational study of diabetes related emergency calls. Aims: To investigate i) the patient demographics and characteristics of hypoglycaemia related emergency calls; ii) the incidence of repeat hypoglycaemic events; and iii) the factors associated with emergency calls that result in individuals being left at home. Methods: A retrospective observational cross-sectional study conducted using Medical Priority Dispatch System® call data from West of Scotland Ambulance Control Centre over a 12 month period. Data were extracted on age, gender, dispatch code, time of call, deprivation category, and immediate outcome (home or hospital). Multiple regression analysis was used to determine predictors of remaining at home. Findings: 1319 calls for hypoglycaemia were received. Patient demographics were similar to the scoping review findings. Most patients remained at home (N = 916 vs N = 380; p < .001). RHE’s were experience by 3.1% within 48 hours, and 10.6% within two weeks. The most significant independent predictor for patients remaining at home was a prior call to the ambulance service (OR of 2.4 [95%CI 1.5 to 3.7]). Patients’ reasons for remaining at home and the causes of subsequent severe events are unknown. It is likely that non-clinical factors may explain some of this behaviour. Study 3: Investigating patients’ experiences of prehospital hypoglycaemic care. Aim: To investigate the experiences of patients who are attended by ambulance clinicians for a hypoglycaemic emergency. Methods: In-depth interviews with adults with diabetes who had recently experienced a hypoglycaemic emergency treated by ambulance clinicians. Participants were recruited from Greater Glasgow and Clyde and Lanarkshire Health Board areas. Data were analysed using Framework Analysis. Findings: Twenty six patients were interviewed. Three key themes were developed. Firstly, an explanation for help seeking behaviour; patients’ impaired awareness of hypoglycaemia as well as the inability of friends and relatives to cope can contribute to an ambulance call-out. Secondly, the perceptions of ambulance service care; patients felt the service provided was good; however ambulance clinicians’ advice was inconsistent. Thirdly, the influences on uptake of follow-up care; patient preferences for follow-up care were influenced by previous experiences of home, hospital and primary care. Post-hoc analysis identified three psychological theories that may explain these findings and provide a useful basis for intervention development: Common Sense Model (Leventhal et al, 1998); Health Belief Model (Rosenstock, 1966); Ley’s cognitive hypothesis model of communication (Ley and Llewelyn, 1995; 1981). Conclusion: Most people treated for severe hypoglycaemia by ambulance clinicians remain at home and do not follow-up their care. A few experience repeat hypoglycaemic emergencies. Key causal, but modifiable factors, contributing to this include:- impaired awareness of hypoglycaemia; inconsistent delivery of ambulance clinician referral advice; and patients’ perceptions of the costs and benefits of follow-up care. Ambulance services cannot address all these factors in isolation. The studies in this thesis have generated an evidence base and identified plausible candidate theories. This will support the future development of novel interventions to improve severe hypoglycaemic emergency follow-up.

Using computer simulation in healthcare is a longstanding endeavor, where alternative scenarios and system configurations can be tested before they are implemented in the real world. One facet of healthcare that has an apparent lack of simulation work is that of emergency transportation, especially that which has a goal to reduce the amount of time a crew works over their designated shift. In collaboration with a Midwest USA Hospital, the researcher sought to model the current system, then experiment by altering crew schedule start times, the number of crews, and policy to reduce the frequency and duration a crew works past their scheduled end time. Therefrom, a framework was developed to help other institutions with similar aims. After the simulation model was verified and validated, experiments varying the start times of the crews, scheduling the crew constituent resources separately, and the number of crews were investigated. With the goal to reduce the time a crew spends working past their scheduled shift without negatively affecting productivity, scenarios that performed similarly in the number of transport requests serviced where there was a decrease in over-shift metrics were identified. The results of the simulation experimentation can be summarized this way: reducing over-shift comes at a cost, likely, either a reduction in productivity or an additional crew. A seven-themed framework for future studies was derived: a sound mission, system understanding, data availability/understanding, respect for process, simulation experience, results analysis and recommendations, and empathy.

In 2019, the Emergency Medical System (EMS) employed over 20,000 personnel in the state of Georgia. EMS personnel were often exposed to unsafe working conditions while caring for injured patients, emphasizing that the workplace served as a potential occupational health intervention site. At the time of this study, there was no surveillance for EMS personnel’s employee wellness or any solutions to improve psychosocial wellness in the workplace in Georgia. The purpose of this quantitative, cross-sectional study was to determine the association of current physical and mental health outcomes in Georgia EMS personnel, as it relates to the presence of workplace wellness strategies and work-related stressors. Our study presented the findings of health help-seeking behaviors and coping skills regarding workplace support by geographic area, gender, age, and license level. The online and paper surveys were distributed to EMS personnel across Georgia’s hospital-based, municipal, and private EMS agencies. The sample included 218 participants who consented to participate in the study. For modeling purposes, the completed sample (114 participants) were included within the full analysis (54.2% completion rate). Descriptive statistics, T-test, F-test, linear, and linear regressions were conducted. During COVID-19, participants reported significant exposure to traumatic incidents at work (N=116, 96%), having low social support (scored 2.93 out of 5 points), and increased use of avoidant coping skills (scored 6.2 out of 8 points). Among all participants, sleep at work was less than 1.7 hours less than when sleep at home (t-test=25.75, p-value

Emergency medical services (EMS) providers have been some of the most exposed healthcare workers during the COVID-19 pandemic even when wearing personal protective equipment. Pre-hospital environments have a high risk of disease transmission exposing EMS providers to bioaerosols and droplets from infectious patients. Field intubation procedures may be performed causing the generation of bioaerosols, thereby increasing the exposure of EMS workers to pathogens. Additionally, ambulances have a reduced volume compared to a hospital treatment space, often without an air filtration system and no control mechanism to reduce exposure. The present study evaluated two different filtration concepts for reducing aerosol concentrations in the patient module of the ambulance. Concentration measurements were done in an unoccupied research ambulance at NIOSH Cincinnati using a tracer aerosol and optical particle counters. The first filtration concept evaluated small portable HEPA filter units within the ambulance compartment after the aerosol generation had occurred. The second concept was a containment pod with a HEPA-filtered evacuation system that was developed and tested based on its ability to contain, capture, and remove aerosols during the intubation procedure. The portable HEPA units reduced aerosol concentration by about 1/3rd within the initial 10 minutes of testing, when compared to the natural decay. The containment pod with HEPA-filtered evacuation showed instantaneous containment of generated particle concentrations followed by rapid air cleaning within the containment pod. Both filtration concepts can help reduce aerosol concentrations within the ambulance patient module.

Traumatic injury is a major burden in global healthcare systems, ranking among the leading causes of morbidity and mortality worldwide.1 Patients are first encountered at the pre-hospital scene by providers of varying levels of expertise, such as emergency medical technicians (EMTs) and paramedics, who provide temporizing measures while patients are transported to receiving hospitals to receive definitive care.2 Ultrasound is an ever-improving medical imaging modality which is increasingly portable, low cost, and provides diagnostic imaging rapidly without the harmful effects of radiation. The objective of this study is to determine whether introduction of prehospital ultrasound (PHUS) for use on ground ambulances by prehospital providers in order to improve choice of destination hospital and aid in needle thoracostomy for tension pneumothorax will have a positive impact on mortality rate of trauma patients in an urban EMS environment. In the proposed study, trauma patients in the city of Boston, Massachusetts receiving care from Boston Emergency Medical Services (EMS) prehospital providers will be recruited over a 12-month period with a minimum goal of 2,500 patients in total. Emergency responses coded as trauma by EMS dispatch will be randomized at a 1:1 ratio to either utilize PHUS or to refrain from utilizing PHUS. A z-test will be used to analyze primary outcome of 30-day mortality rate in patients who receive PHUS care as needed compared with patients who do not receive PHUS care. Study data will be collected directly from Boston EMS Electronic Medical Record (EMR). This study will be the first of its kind to randomize at the patient level, and the first to investigate a major clinical outcome of ultrasound in prehospital medical care: 30-day mortality. Point-of-care Ultrasound is an intriguing diagnostic modality that is becoming increasingly feasible in the prehospital environment, and may improve outcomes in trauma patients. Current studies provide convincing evidence for the diagnostic accuracy of these devices, especially in evaluating hemoperitoneum and pneumothorax. If an improvement in mortality rate of patients treated with prehospital ultrasound (PHUS) is demonstrated, this will be convincing evidence for the implementation of PHUS in ground ambulances and air medical services across the United States and worldwide.

Ambulance infection prevention and control for patient and staff safety: an analysis of current Australian policy, practice and governance. Background: The most common preventable adverse events in Australian healthcare are healthcare acquired infections (HAI), consuming 850,000 bed days annually, costing $950 million. HAI in the ambulance setting pose significant risks to patients and healthcare workers (HCW). Infection prevention and control programs (IPCP) significantly reduce the risks of HAI, yet few ambulance services have such programs, posing the question: are ambulance services required to have an IPCP? Methods: A literature review and analysis of HAI prevalence data in the ambulance setting; analysis of SA Health policy and legislation related to the prevention and control of HAI; and a corporate risk assessment and evaluation of the ambulance setting to establish whether standard hospital-based IPCP are transferable to this setting. Results: Literature addressing these issues is limited. Paramedics have a high risk of unprotected exposure to HAI, and an increasing rate of blood and body fluid exposure. SA Health policy was generally well developed, but poorly implemented. Legislation, SA Health policy and risk management principles require ambulance services within South Australia to have an IPCP. They also place personal responsibilities upon individual HCW. Important differences between the ambulance and hospital settings mean that hospital-based IPCP are not directly transferable to the ambulance sector. Conclusions: Patients and HCW in the ambulance setting are at risk of acquiring HAI. SA ambulance services are required to have an IPCP. Failure to comply with these requirements could be considered a crime. Ambulance services lack comprehensive procedures, education and surveillance for preventing HAI. Ambulance HCW require access to 24/7 post-exposure management and surveillance systems. When faced with limited resources, HCW will employ workarounds to bypass IPCP requirements. Specific programs must be developed to accommodate the requirements of ambulance clinical practice and environment. These programs should be designed and led by practitioners from the paramedicine field. Recommendations: Ambulance services should implement an IPCP that has been developed specifically by, and for, the ambulance setting. Further national research is recommended to identify and develop the requirements for such a program.

What is the role of the 911 ambulance in the American city? The prevailing narrative provides a rather simple answer: to save and transport the critically ill and injured. This is not an incorrect description, but it is incomplete. The ambulance plays another role, one that is less known. Along with other frontline institutions like the prison and welfare office, I argue the ambulance is part of a poverty regulating regime that is focused less on the eradication of material suffering and more on the day-to-day management of its symptoms. I draw on nearly two years of fieldwork (including 9 months working as a novice emergency medical technician) and over 100,000 medical records to reimagine the ambulance as an institution of poverty governance. Against somewhat common assumptions that this vehicle is absent or tardy in poor neighborhoods, my research demonstrates that the ambulance is actually a prevalent and busy institution in these areas. Not only are the poor more likely to experience life threatening crises, they are also more likely to summon the ambulance for so-called non-emergencies. Whether by compressing lifeless chests on the streets or by transporting the publicly intoxicated into the hospital, ambulance crews daily transform the bodies and spaces of urban poverty. This work brings them in recurrent contact with the emergency department nurses and police officers who share their clientele. I show how these different workers often conflict over the management of subjects they generally see as burdensome. With “legit” ambulance calls being relatively rare, crews frequently struggle with police and nurses over “bullshit” work. These street-level relations, however, cannot be understood without considering the forces that control and coordinate labor from above. Neoliberal principles of organizational efficiency and flexibility have flooded poverty governing institutions throughout the American city, and the ambulance is no exception. The state often delegates paramedical operations to for-profit agencies that run on a fee-for-service model. This intensifies the exploitation of labor and exacerbates tense relations between crews and their clientele on the one hand and crews and their nurse and police counterparts on the other. My research advances a new framework for understanding the management of marginality: the labor theory of poverty governance. This model insists that we cannot understand how the poor are governed without understanding the labor process that generates and re-generates the poverty regulating state. This means accounting not only for the interactions between laborers and the subjects of their labor, but also the horizontal interactions amongst laborers and the vertical interactions between laborers and those who control and coordinate their work. This framework is novel in that it integrates three crucial dimensions of poverty regulation: the frontlines of governance, the horizontality of governance, and the verticality of governance.

Integer linear programming models that incorporate probabilistic and stochastic components represent one approach for capturing the stochastic nature of emergency medical service ambulance systems. This includes modeling non-deterministic call arrival and servicing rates and congestion in the ambulance network (i.e., ambulance unavailability). These models focus on maximizing the total population that can find an available ambulance within a set service time standard (s) with a probability of at least α%. In MALP the concept of local vehicle busyness estimates is introduced to estimate the availability of service in a neighborhood given the neighborhood’s level of demand and the number of ambulance vehicles located in the neighborhood. QMALP is an extension of MALP where queue-theory derived parameters are implemented in the MALP model framework in order to relax the assumption that the probability of different ambulances being busy are independent. Despite this considerable development, several concerns remained about MALP and QMALP, namely the districting assumption where its assumed that a neighborhood’s calls for service are served only by an ambulance in the area, that ambulances in a neighborhood only serve calls for service originating within the neighborhood, or that at least the flow of ambulance service to and from external neighborhoods was roughly equal. Questions have been raised about the validity of MALP and QMALP’s reliability estimates, that is, whether a neighborhood actually received α-reliable service.To address these issues, we developed the Resource-Constrained Queue-based Maximum Availability Location Problem (RC-QMALP). This model is based on a location-allocation framework that (1) assigns workload from neighborhoods to ambulances located within s and ambulance idle capacity to neighborhoods and (2) includes additional constraints designed to help ensure the validity of the original MALP and QMALP constraints used to establish whether a neighborhood can find an available ambulance with α-reliability. We also implemented a secondary minsum objective that minimizes the average travel distance between ambulances and the neighborhoods they service while maintaining the priority of the MALP and QMALP coverage objective.In this thesis, we validated RC-QMALP by comparing the reliable coverage levels predicted by the RC-QMALP to the ambulance system simulations that used the locational configurations suggested by the RC-QMALP. We found that MALP 2 and QMALP provided higher levels of reliable coverage and that RC-QMALP’s secondary objective has a negligible impact on system performance. However, RC-QMALP-based models provide more accurate estimates of reliable coverage and location solutions whose simulated reliable coverage performance was always within 5% of the optimal solution with the same system parameters (we tested 1,080 different model configurations). Our work suggests that (1) simulation models must be developed to handle the modeling assumptions that underlie location optimization models and that (2) service reliability location models should consider additional factors such as ambulance workloads (and their distribution).

‘Falls’ is the most common incident category to which an emergency ambulance is dispatched in New South Wales (NSW), with approximately 60% of these involving patients aged 65 years or more. This thesis explores the epidemiology of older fallers attended by paramedics, employing a mix of quantitative and qualitative research methods with the aim of providing new information in an area of paramedic practice about which little is known. A retrospective, population-level study (n=42,331), prospective cohort study (n=1,610), and retrospective linked data analysis (n=34,313) form the basis of the epidemiological analyses, reporting operational and clinical outcomes arising from an ambulance response and paramedic intervention. A qualitative investigation, using grounded theory methodology, presents a theoretical model exploring paramedic decision making when providing care to older people who have fallen. Significant findings include: 1. Older fallers constitute 5.1% of the annual emergency ambulance workload in NSW; 28% are not transported to hospital. 2. 1 in 10 older fallers who receive an ambulance response experience a ‘long lie’ (>1 hour on the ground). 3. Prediction of non-transport at time of dispatch is not feasible for cases involving older fallers, making risk management through dispatch of specialised resources unfeasible. 4. Rates of analgesia administration among fallers with suspected hip fracture (67%) has increased compared to earlier research, but almost one third still receive no prehospital pain relief. 5. Non-transported older fallers are at twice the risk of death at 28 days compared to those transported to ED and discharged without admission. Ambulance re-attendance within one month is common. 6. Paramedics do not perceive cases involving older fallers to be ‘real paramedic work’. This arises from confusion around role perception, and impacts negatively on the clinical decision making relating to the treatment of older fallers. The findings of this thesis constitute a comprehensive analysis of an area of paramedicine about which little was previously known in an Australasian context. The results will inform clinical and operational strategy being developed by ambulance services and will make a meaningful contribution to optimising prehospital service delivery to, and improving outcomes of, older people who have fallen.

Religion and culture can impact profoundly on healthcare practices and health outcomes. The Australian community is rich and diverse in differing cultures and religions, and at times of medical emergency the paramedic increasingly will be required to respond to healthcare needs of this diverse community. This study is designed to investigate current paramedic practices as they relate to an awareness of the cultural and religious needs of community groups as a holistic approach. It also incorporates the voices of these community groups from their experiences with emergency paramedics during pre‐hospital health care for those living in Melbourne, Australia.

We propose new approaches to tackle the problems of static and dynamic ambulance fleet allocation. Static ambulance fleet allocation refers to deciding on home bases for ambulances, to which they return after serving calls. The number and location of bases are given. The goal is to keep response times to calls as small as possible. The first part introduces two models for this problem. Both of them are based on the Erlang loss formula. The first model is stylized and serves to illustrate that allocating ambulances to bases in proportion to base offered load is often non-optimal. The second model is similar in spirit to queueing theoretical models developed in the past but uses the but uses the Erlang loss function as a key ingredient. A careful computational comparison shows that the predictions obtained from our model are often more accurate than those produced by previous models, especially in low utilization regimes. This model can be used as a prescreening tool to find promising candidate allocations to be further evaluated through detailed simulation. Dynamic redeployment concerns the real-time relocation of idle ambulances so as to ensure better preparedness. The second part of this dissertation formulates this problem as a dynamic program in a high-dimensional and uncountable state space, and then resorts to approximate dynamic programing (ADP) techniques to obtain approximate solutions. To this end, a specially tailored approximation architecture for the problem is developed. The architecture depends on a small number of free parameters which are tuned using simulated cost trajectories of the system and linear regression. Computational experiments show that the relocation policies obtained from this approach offer significant performance improvements relative to benchmark static-relocation policies. In the third part we use the linear programming approach to ADP on the dynamic-redeployment problem, using the previously developed approximation architecture. We conclude that, although the policies obtained are comparable in quality to those obtained using regression, there are serious issues related to numerical stability. Furthermore, the amount of computation required makes this approach less practical than the regression-based one.

The primary aim of the research project was to develop conceptual models of rural ambulance service delivery based on different worldviews or philosophical positions, and then to compare and contrast these new and emerging models with existing organisational policy and practice. Four research aims were explored: community expectations of pre-hospital care, the existing organization of rural ambulance services, the measurement of ambulance service performance, and the comparative suitability of different pre-hospital models of service delivery. A unique feature was the use of soft systems methodology to develop the models of service delivery. It is one of the major non-traditional systems approaches to organisational research and lends itself to problem solving in the real world. The classic literature-hypothesis-experiment-results-conclusion model of research was not followed. Instead, policy and political analysis techniques were used as counter-points to the systems approach. The program of research employed a triangulation technique to adduce evidence from various sources in order to analyse ambulance services in rural Victoria. In particular, information from questionnaires, a focus group, interviews and performance data from the ambulance services themselves were used. These formed a rich dataset that provided new insight into rural ambulance services. Five service delivery models based on different worldviews were developed, each with its own characteristics, transformation processes and performance criteria. The models developed are titled: competitive; sufficing; community; expert; and practitioner. These conceptual models are presented as metaphors and in the form of holons and rich pictures, and then transformed into patient pathways for operational implementation. All five conceptual models meet the criteria for systemic desirability and were assessed for their political and cultural feasibility in a range of different rural communities. They provide a solid foundation for future discourse, debate and discussion about possible changes to the way pre-hospital services are delivered in rural Victoria.

With decreased revenues and increased or constant demands for services state and local government units have examined a wide range of privatization alternatives. The most common of these alternatives has been the use of contracting for services. Contracting of services has been an alternative that has been utilized by an increasing percentage of municipalities as revenues have decreased. Data obtained from the City of Flint and various other sources were compared to illustrate implications that must be considered if a privatization effort of the municipal ambulance service was to be pursued. Implications that were examined concern economic factors, quality of service issues, social concerns, union and labor implications, legal issues, and political effects. The results of the examination indicate that 1) wage and fringe benefit packages offered to private sector employees were generally less than those received by comparable public employees; 2) competition would increase efficiency in the ambulance service; 3) the impact on minority individuals would be proportionate to the impact on the total work force; 4) labor and union negotiation is mandatory for an effort to succeed; 5) legal issues must be explored thoroughly as they pertain to the situation; and 6) political factors have an immense impact on the structure of the EMS service.

บุคลากรที่ปฏิบัติงานในรถพยาบาลฉุกเฉินอาจได้รับภาวะเสี่ยงจากการออกแบบภายในรถที่ไม่เหมาะสมและความไม่พร้อมของอุปกรณ์ การศึกษานี้ได้ประเมินความเหมาะสมของการออกแบบภายในรถและความพร้อมของอุปกรณ์ที่จำเป็นในการป้องกันความเสี่ยงจากการปฏิบัติงาน ตามแนวทางของสมาคมเวชศาสตร์ฉุกเฉิน ประเทศสหรัฐอเมริกา (2008) จำนวน 47 คัน ของโรงพยาบาลประจำจังหวัดแห่งหนึ่งและโรงพยาบาลเครือข่าย และสัมภาษณ์บุคลากรที่ปฏิบัติงานจำนวน 35 คน ถึงความเห็นเกี่ยวกับความเหมาะสมของการออกแบบภายในรถ นอกจากนี้ได้ติตตามสังเกตในขณะที่มีการปฏิบัติการจริงจำนวน 30 คันๆ ละ 1 เที่ยวรอบวิ่ง ผลการศึกาพบว่าร้อยละ 74.5 เป็นรถพยาบาลฉุกเฉินรุ่นใหม่ มีส่วนกั้นแยกช่วงหน้าห้องคนขับรถออกจากช่วงหลังซึ่งจัดเป็นห้องพยาบาลรวมทั้งหน้าต่างที่เปิดเลื่อนได้เพื่อใช้ในการติดต่อสื่อสาร ร้อยละ 83 มีระบบระบายอากาศไฟฟ้า ร้อยละ 93.6 มีตุ้เก็บอุปกรณ์และเวชภัณฑ์ที่มิดชิด ร้อยละ 97.9 มีเจียงผู้ป่วยแบบมีล้อเลื่อน ร้อยละ 91.5 มีเวชภัณฑ์ยาอย่างพอเพียงแต่มากกว่าร้อยละ 50 ยังขาดอุปกรณ์กู้ภัยฉุกเฉินประจำในรถ เพื่อพิจารณาถึงอุปกรณ์มาตรฐานเพื่อการป้องกันการติดเชื้อและการบาดเจ็บในขณะปฏิบัติงาน พบว่า ร้อยละ 25.5 มีอุปกรณ์ป้องกันตา ร้อยละ 53.2 มีอุปกรณ์สำหรับรัดเพื่อความปลอดภัยขณะรถวิ่งหรือหยุดกระทันหัน ข้อมูลจากการสัมภาษณ์บุคลากรที่ปฏิบัติงาน พบว่า ร้อยละ 80 มีความเห็นด้วยการมีส่วนกั้นแยกระหว่างคนขับกับส่วนผู้ป่วย ร้อยละ 91.4 มีความเห็นว่าในส่วนผู้ป่วยควรสามรถรองรับผู้ป่วยและบุคลากรได้อย่างน้อย 3 คน เป็นต้น ข้อมูลจากการสังเกตขณะปฏิบัติงาน พบว่ารถพยาบาลฉุกเฉินเกือบทุกคัน (27/30 คัน) ภาชนะใส่ของมีคมและถังขยะติดเชื้อไม่มีการติดตั้งที่มั่งคง อาจทำให้เกิดอันตรายได้รถทุกคันผู้ปฏิบัติงานไม่มีการเปิดระบบระบายอากาศและไม่ได้รับปรับอุณหภูมิในรถตามเกณฑ์ ผลการศึกษาโดยสรุปแสดงให้เห็นว่า ควรมีการปรับปรุงการออกแบบภายในรถพยาบาลฉุกเฉินให้มีความเหมาะสมกับการปฏิบัติงาน นอกจากนี้ต้องมีการดูแลและเตรียมความพร้อมการช้รถเพื่อความปลอดภัยและการลดความเสี่ยงจากการปฏิบัติงานด้วย Personnel working in an ambulance may be at risk from the inappropriate interior design in ambulance. This study attempts to assess the appropriate interior design and standard supplies of an ambulance for safety work followed a guideline of The American College of Emergency Physicians (2008) in a provincial hospital network. Forty-seven ambulances were assessed and 35 personnel were interviewed by voluntary participation. Additionally, 30 ambulances were observed the real practice. Results reveal that 74.5% of studied ambulances are new model designs and have the driver and the patient compartments. Approximately, 83% have an electrical air ventilation system, and 93.6% have enclosed storage cabinet. About 97.9% have standard stretcher, and 91% have an appropriate medication. Standard supplies for infection control and injury prevention showed that 25.5% have eye protection equipments, and 53.2% have appropriate seat belts. Data from interviews showed that 80% agreed with having the driver and patient compartments and 91.4% agreed that the patient compartment should be accommodated to transport with at least 3 persons. For observation, it was found that 90% of observed ambulances (27/30) have a sharp disposal container placed on the floor which may slip or spill out of disposal when the ambulance stops immediately. All observed ambulances, the air ventilation systems were not opened, and the temperature was not adjusted in standard level. In conclusion, the study revealed, not only the interior ambulance design should be improved, but also, the routine care of ambulance should be emphasized for work safety.