Following completion of transcript coding, themes were identified and grouped under five primary central themes. A further twelves secondary themes were identified demonstrated in Fig. 1
During both focus groups participants commented on the guidance used when caring for OHCA patients with ROSC. This guidance ranged from national and local publications to information received from face-to-face training. In addition to this, the usefulness of local ambulance service guidance was emphasised in comments made from multiple participants in both groups. In particular, participants felt that the local ambulance service’s own guidance was useful whilst delivering care for patients with ROSC.
“The guidance is very clear, very simple and very easy to remember” – FG2P1
In addition to local guidance, participants described some of the national publications which were considered when selecting a conveyance destination for OHCA patients, in particular, comments relating to guidelines from RCUK were found in the transcripts. Face-to-face training was felt by multiple participants to have been the most valuable in helping them manage patients with ROSC. However, despite recent improvements in the training provided to local paramedics, participants noted that additional guidance could be made available to support their decision-making, in particular patient selection for immediate transfer to a specialist centre.
“There isn’t any guidance that’s clear on determining a cardiac cause” – FG2P3
The characteristics of the receiving hospitals selected by paramedics to receive OHCA patients were discussed widely in both focus groups. Comments relating to the hospital’s distance and access to specialist services were identified from the transcripts from both groups. In addition to describing the physical distance to the hospital, comments were made regarding the time taken to reach receiving centres.
I figure out the quickest route to get to a hospital that’s able to receive the patient” – FG1P1
The operating hours and availability of specialist services, in particular PCI, was also discussed by participants as a factor influencing the selection of a conveyance destination. However, the groups elicited more nuanced factors including access to pre-alert telephone numbers and equipment compatibility which were also considered in their destination selection.
“When you’re trying to find the phone number for a hospital you don’t know - it’s stressful – FG1P3
The concept of a hospital’s catchment area or “patch” was also widely discussed by participants, in particular when attending cases crossing usual operational boundaries. The conversation in focus group one continued to explore the issue further with participants suggesting conveyance was more likely to occur when a receiving facility is more familiar with an individual clinician.
“I know it’s out of the < Hospital > catchment area, but I’m comfortable there” – FG1P1
Conversation relating to the impact of non-technical skills during the decision making process was discussed by participants with codes triangulated from both groups. Non-technical skills are commonly defined as cognitive and interpersonal aspects of delivering a safe service . In the context of healthcare, this can range from social skills (e.g. communication and teamwork) to abilities such as inter-professional behaviours . Notably, the concept of conflict was frequently mentioned by participants from both groups; the source of this conflict varied and included interactions with both in-hospital and pre-hospital colleagues.
“I did a case where neither hospital wanted the patient, hospital politics I think is definitely a factor” – FG2P1
“There would be quite a backlash if you turn up at < Hospital > instead of < Hospital>” – FG1P2
The professional identity of the pre-hospital clinician providing the pre-alert message to hospitals was discussed by participants as one potential barrier which impacted on their ability to access specialist care.
“It’s often difficult as paramedics to make that call and for the PPCI unit to accept it” – FG1P2
In addition, participants reflected on their own previous experiences of managing OHCA patients. Comments were made relating to the knowledge gained through previous experience and how this heavily influenced an individual’s ability to make future conveyance decisions.
Comments relating to a patient’s condition were triangulated from both focus groups; in particular managing agitation was discussed. Participants often referred to a patient’s agitated state as a key factor impacting on their destination selection. Patient irritability and agitation is a well-documented sequelae following ROSC and should be managed to promote cardiovascular stability and improved oxygenation and ventilation  In addition to agitation, both groups included discussion on broader topics including considering a patient’s overall level of consciousness as a factor which impacts hospital selection.
With agitated patients, they can pull out IV lines, you can’t look after them if you’re trying to keep them still” – FG1P4
Finally, establishing and promoting haemodynamic stability was a concept discussed during the project as a key factor considered by paramedics when considering the distance or time they would be willing to travel to reach specialist care.
“I think the more deeply unconscious they are, the easier they are to handle” FG1P1
“As long as they’re stable, I’d much rather go to the most suitable hospital” – FG1P4
This theme related to comments made by participants regarding the technical or clinical skills required to manage patient in the immediate phase of care following a ROSC. Participants often linked the clinical skills required to the condition of the patient they were treating, for instance, participants commented on how the presence of teams with the ability to sedate or anaesthetise could positively influence their choice of destination. Finally, in addition to agitation, multiple participants discussed the clinical skills required to achieve airway protection or cardiovascular stability as one indicator for deciding which hospital to convey a patients
“Will they need a sedation or anaesthetic beforehand?” – FG1P2
“The anaesthetic was a godsend, just settled him down so he could be managed” – FG2P1