Ethical considerations in prehospital ambulance based research: an interview study of expert informants
Ambulance services conducted 6.3 million face-to-face contacts in 2013-14 of which an estimated 80 percent were for primary care related problems. Prehospital research, needed to inform evidence based ambulance care, has unique ethical considerations due to urgency, time-limitations and the locations (home, ambulance) involved. Despite clinical research based in the ambulance setting increasing, there has been limited work assessing the impact of ethical considerations on this research. We sought to explore these issues through interviews with experts in this field of research.
We employed a qualitative design using semi-structured interviews with a range of expert informants seeking their views and experiences of ethics in ambulance based clinical trials. Participants were chosen because they were actively involved, or had expressed an interest in, ambulance based research. Participants were asked a series of questions regarding their experiences in ambulance trials, their opinions on current regulations and guidelines and their views on ethical considerations more generally. The interview transcripts were digitally recorded, transcribed verbatim, coded by two researchers (SA and AL) and analysed thematically.
We interviewed 14 participants including principal investigators, researchers, ethicists and medical lawyers. Six themes were identified: Capacity, Consent, Complexity, Clinical, Consultation and Regulation. Issues regarding consent and capacity in the ambulance setting were foremost in the discussion as all participants highlighted this as an area for concern. The challenges of the ambulance setting and use of multiple consent models spoke to the complexity of research in this environment. The clinical theme referred to the use of paramedics in research and how research involving ambulance services is increasingly informing improvements to patient care and outcomes or reducing the burden on primary care and hospital services. Most participants felt that current regulations were fit for purpose (Regulation theme) however, more specific guidance regarding the implementation of the regulations in the ambulance setting would be beneficial for researchers, paramedics and ethics committees. This related closely to the theme of consultation, which examined the key role of ethics committees and other advisory groups such as the Confidentiality Advisory Group (CAG) when dealing specifically with ambulance based research.
Research in any setting may be complex but the ambulance context has unique issues due to its time pressured, emergency and remote environment. By interviewing experts in research or ethics in this setting we were able to identify some key issues and highlight areas such as improved guidance that can be developed in the future.