Pathway enhancement for the referral of non-conveyed patients with incidental findings encountered by ambulance clinicians

Research question: How can ambulance clinicians improve the identification, referral and management of incidental findings in non-conveyed patients to enhance early detection and intervention for serious health conditions? Background: In 2023/24, nearly one-third of emergency ambulance calls in England did not result in hospital conveyance. Approximately half of these patients had incidental findings, such as hypertension, atrial fibrillation or hyperglycaemia, which were unrelated to the initial emergency call but are likely to benefit from investigation or treatment. However, the current approach to these findings is inconsistent, with limited communication between paramedics and GPs. This means that opportunities for early intervention and prevention of conditions like strokes or heart attacks are missed, so there is a clear need for standardised referral processes to improve patient outcomes and reduce healthcare system strain. Aims and objectives: The PERIFERAL study aims to understand how incidental findings identified by ambulance clinicians should be optimally managed. The specific objectives are: To define and identify incidental findings during ambulance attendance, describe the characteristics of affected patients, and explore whether patient characteristics are associated with identifying and acting upon these findings. To evaluate current incidental findings referral practices across UK ambulance services. To identify barriers and facilitators to effective management through stakeholder interviews. To develop and refine a standardised referral pathway for incidental findings in ambulance services. Methods: This 24-month mixed-methods study consists of four work packages, aligned with the development phase of the MRC complex development intervention framework: WP1: Understand the characteristics and referral patterns of non-conveyed ambulance service patients with incidental findings using linked ambulance service and primary and secondary care data. WP2: Telephone survey of all 13 UK ambulance services to map existing referral pathways and understand their effectiveness. WP3: Qualitative interviews with 40-60 patients, paramedics and primary care staff across four case study ambulance services to explore barriers and facilitators to managing incidental findings. WP4: Development and iterative refinement of a referral pathway, with feedback from four stakeholder focus groups, each with up to 8 participants, to assess feasibility and acceptability. Timelines for delivery: Months 0–4: Ethics and governance approvals, dataset access. Months 5–7: Quantitative data analysis (WP1) and telephone survey (WP2). Months 8–14: Data analysis (WP1) and stakeholder interviews (WP3). Months 15–20: Pathway development, focus groups and final refinement (WP4). Months 21-24: Dissemination. Anticipated impact and dissemination: This study will produce a standardised referral pathway for ambulance clinicians to manage incidental findings, improving early detection and intervention for conditions like hypertension, atrial fibrillation, diabetes and chronic obstructive pulmonary disease. Enhanced referral processes will reduce missed diagnoses, prevent long-term health complications and align with public health priorities. Findings will be disseminated through academic publications, social media, conferences, and collaborations with key healthcare organisations, such as the College of Paramedics, Association of Ambulance Chief Executives, the Royal College of General Practitioners and NHS England. The project s outputs will contribute to more efficient healthcare resource utilisation, benefiting patients and the wider healthcare system.

Background: When ambulance crews respond to emergencies, unexpected health problems are found in 1 in 6 patients. These problems are not related to the emergency that the patient called about and are called "incidental findings". These might include an irregular heartbeat, diabetes or high blood pressure. Patients may not know that they have these conditions and so they remain untreated. These conditions particularly affect people from disadvantaged backgrounds. Finding unexpected health problems early helps people get treatment to prevent serious illnesses, like strokes and heart attacks. Ambulance services and ambulance clinicians across the UK vary in how they manage incidental findings. Some take patients to the emergency department, others recommend that patients see their GP - but we do not know if patients follow this advice. Aim: The PERIFERAL project aims to improve care for patients with incidental findings. We intend to: Describe the patients that have incidental findings and what happens to them. Report how UK ambulance services manage incidental findings. Identify what aspects of current processes work (and what does not) for staff and patients. Use what we have learned to improve the management of incidental findings and talk to patients, carers, ambulance and GP staff to see whether they agree with our ideas. Design and Methods: Our study has four steps: Understanding what happens now: We will analyse data from Yorkshire Ambulance Service and GP practices. We will see what happens when ambulance crews find incidental findings, how often they reported them to the GP and how much extra time this adds to their visit with the patient. Comparing approaches: We will explore how other UK ambulance services deal with incidental findings. Identifying what is likely to work: We will interview 40–60 patients, carers, ambulance staff and GPs across four ambulance services. We will ask them what ways of managing incidental findings are likely to work well, and what may cause problems. Develop a new way of managing incidental findings: We will use what we learn from the first three steps to find better ways to handle incidental findings. We will present our ideas to 32 focus group participants for feedback. Patient and Public Involvement: The project s patient panel includes people with experience of ambulance calls. They have diabetes, stroke and heart problems. We have also asked existing patient panels for input. The project and existing patient panels will help by revising research materials, shaping solutions and sharing findings. Dissemination: We will share our new referral pathway and other findings in easy-to-understand formats with the people who take part in the study. We will share findings widely using our website, peer-reviewed publications, reports and presentations to healthcare professionals, researchers and the public.