'Every day was a learning curve': implementing COVID-19 triage protocols in UK ambulance services-a qualitative study of staff experiences.

Background: TRIM (What TRIage model is safest and most effective for the Management of 999 callers with suspected COVID-19? A linked outcome study) was an evaluation of models used to triage and manage emergency ambulance service care for patients with suspected COVID-19. In an embedded qualitative component, we aimed to understand experiences and concerns of clinical and managerial staff about processes for responding to patients with suspected COVID-19, in the call centre and on scene.

Methods: Research paramedics in four study sites across England interviewed purposively selected stakeholders from ambulance services (call handlers, clinical advisors in call centres, clinicians providing emergency response, managers) and emergency department clinical staff. Interviews (n=25) were conducted remotely, recorded and transcribed. Thematic analysis was conducted by a group of researchers and PPI (patient and public involvement) partners working together.

Results: We present four themes, developed from the data. Services made efforts to target their response to those most in need, while trying to minimise infection risk; they reduced face-to-face contact where possible, dealing with more calls remotely. Adjustments by other providers in the wider healthcare system affected the flow of patients to and from ambulance services. There was substantial work and heavy cognitive load for staff at all levels in updating knowledge and repeatedly implementing changes. Staff working in the range of roles in ambulance services also carried a heavy emotional load.

Conclusions: Services made flexible changes to triage processes using the best level of understanding available at the time, in a healthcare setting which always operates in high levels of uncertainty. Implementing triage protocols in response to the COVID-19 pandemic was a complex and fluid process which had to be actively managed by a range of front-line staff, dealing with external pressures and a heavy emotional load. Increased understanding of the way in which services and staff had to adapt, and the cognitive and emotional burden this entailed, may help in planning for future pandemics.