Question: TMA 03 Literature review relating to project question, ‘For residential settings
requiring emergency or urgent medical assistance, particularly in out of hours situations,
does Telemedicine offer a reduction in 999 calls and unnecessary hospital transfers for
establishments without 24hr nursing provision?’.
K316 Exploring practice
Answer: The writer has ensured anonymity of any people and organisations that may be
referred to in any part of this piece of work.
The aim of TMA03 is to write an account of the mini literature review and the review process
that was undertaken, along with any barriers or issues that were encountered. The literature
sourced related to the project question that has been devised for the purpose of K316,
Exploring Practice, The Open University. The project question is ‘For residential settings
requiring emergency or urgent medical assistance, particularly in out of hours situations,
does Telemedicine offer a reduction in 999 calls and unnecessary hospital transfers for
establishments without 24hr nursing provision?’.
8 articles were sourced using a variety of online resources including Cinahl and Medline,
using key words including ‘residential care’ ‘ambulance service’ ‘ooh care’ and ‘telemeds’ to
form the initial part of the search. After reading and conducting a round-up review of the
articles, 5 were chosen to formulate the mini review. 3 were eliminated on the basis of
relevancy to the project question and content. An inclusion and exclusion criteria were used
to decide what articles to use.
A literature review is an essential skill if considering engaging in a change in practice, as
discussed by Wakefield (2014). Its about examining the worth or credibility and value of the
research evidence (Aveyard, 2010). A literature review should summarise, critically analyse,
evaluate and clarify ideas that the author has presented.
Wakefield (2010) also suggests using a method of PICO (Patient or
Population/Intervention/Comparison/Outcome). In the instance of the project question for
K316, Exploring Practice, the population is clients in residential care, the intervention is 999
calls and unnecessary hospital transfers, the comparison is telemedicine service and the
outcome are a reduction in 999 calls and a reduction in unplanned hospital transfers.
Interestingly, the method of PICO did also assist with the formulation of the project question
Page 1 of 6
as I had found it difficult to get the right approach. This method formulated stage one of the
literature review – Generating a researchable question. I found the PICO method
significantly beneficial as my previous formulated questions appeared weak, and not to the
point. This enabled me to strengthen the question.
Stage 2, as Wakefield (2010) explains is around selecting a database of which the research
itself will take place. This could be one database or consist of several. There are multiple
databases available academic and non-academic. The most popular being CINAHL
(Cumulative index to nursing and allied health literature) and Medline (medicine, dentistry
and nursing related topics). The other research database I used across all of K316 was the
nursing Journal ‘Nursing Standard’. These databases enabled me to access peer-reviewed
journals that was the main source of evidence for the literature review. I have used academic
databases; however, it has been several years, therefore I found it beneficial to refresh my
knowledge base around what is available and brushing up on my skills on how to search
using specific key words and how to drill down the content.
Stage 3 details once you have generated the research question and chosen the database or
databases it is important to think about what terms will be entered to enable a well-organised
literature search (Jones and Smyth, 2004). Searching for what relates to the intervention or
the outcome will assist in finding the best literature. For this step, I felt it necessary to
brainstorm the ‘intervention’ and the ‘outcome’ to help generate a list of search terms relating
to the research question. In the list for the intervention I explored terms such as 999
ambulances, emergency services, out of hours, urgent care, ambulance call rates,
emergency ambulance. For the outcome I listed included unplanned admissions, reduction
of 999 calls, out of hours care, hospital transfers. The search did require some tweaking to
enable the most relevant literature to be found. Using Boolean operators such as AND, OR
or NOT can narrow a search or in the instance of OR can expand the search (Jones and
Smyth, 2004).
Step 4 is about selecting the literature using inclusion and exclusion criteria’s to limit the
number of articles you wish to review (Aveyard, 2010). The inclusion and exclusion criteria’s
need to be unambiguous but sufficiently wide ranged and explicit to ensure that if someone
else were to undertake the review using the same set of articles, they too would select more
or less the same articles (Randolph, 2009). The inclusion criteria I specifically looked for
were care home residents with emergency ambulance involvement and/or out of hours
services. I searched specifically for any literature involving the use of the telemedicine
service in any setting, be it hospitals, prisons, GP surgeries etc. as I wanted to focus on the
Page 2 of 6
abilities of the telemedicine service and what it could potentially offer to a care home setting.
It wasn’t of great importance if the literature found involving telemedicine was in a care home
setting or not, as at this stage the importance was looking at the service and evaluating its
potential impact and whether or not it did assist in the reduction of 999 calls and unplanned
hospital transfers. I did look at the date articles were published – telemedicine in particular is
a fairly new development, and the 999 services 10 years ago were significantly different to
what they are today, therefore I did try to source literature from the last 5 years. I had no
preference on the type of research – be it quantitative or qualitative.
I excluded any literature that focused on people in their own homes and the utilisation of 999
emergency ambulances and transfers to hospital. I did look at any literature that did included
the use of telemedicine by district nursing teams for example to see if it did avoid the use of
an ambulance. I excluded any literature produced by any American or overseas researchers,
based on I was looking at the UK’s health care services, although one article written in
America did give me food for thought in their approach to emergency services, however I did
decide not to include.
I did find searching for the articles a difficult task and found it necessary to expand my
search terms or try to be more specific. Despite the significant overuse of the ambulance
service, there is surprisingly not a lot of literature available. I did however, review NHS
England’s Ambulance Quality Indicators that provided a vast amount of data broken down
into ambulance NHS trust’s. I was also able to compare this to the quality indicators from
2012 and found it interesting how vastly different the data is.
Other searches did point me in the direction of documents issued by the department of
health including ‘Taking Healthcare to the Patient, Transforming NHS Ambulance Services’
and one search did direct me to a NHS trust in England that did have some important to my
research question – ‘Telemedicine in care homes in **, ** and **’, written by a Doctor of
Emergency Medicine. This data collection report showed a significant reduction in
Emergency Department (ED) attendances from care homes with telemedicine. The data also
highlighted a breakdown of virtual consultations including advice only, medication advice,
referral to Out of hours (OOH) GP or referral to a 999 ambulance. The data showed only
11% of telemedicine consultations resulted in a 999 emergency ambulance. This document
was paramount to my project question and provide an important answer.
Step 5, continued further by Wakefield (2014) describes that you need to take a much more
detailed look at the articles to see if they address exactly what you are looking for. Once you
Page 3 of 6
have devised your list of articles, you need to filter them further and decide which are
relevant. I found 8 articles that had some form of relevancy to the project question after
following steps 1 to 4. Step 5 enabled me to eliminate 3 of the articles I had shortlisted for
the literature review. I had to adopt an additional strategy to decide which ones I wanted to
keep and which to discard. I read the abstracts of each article to capture a detailed overview
and to decide if it was relevant to the topic. This was easy to conduct due to only having 8
articles to explore. The next step was to examine the literature and ask more detailed
questions to see if it is what you are looking for. Wakefield (2014) advises to read the full
article and ask questions such as looking at the title – does it address the subject matter you
are exploring? Abstract – read it in full and compare its content with the inclusion and
exclusion criteria and see if the article addresses these. Full text – read it and compare the
content with the topic, purpose of the study and the criteria to see if it meets all of the
requirements. Type of article – you need to decide if this article is what you want.
This 4-step filtering process enabled me to review all 8 articles and decide on the 5 to use
for my literature review. It was an interesting approach to adopt and not one I have used
before.
Step 6 included identifying the main themes explored in the articles selected for inclusion in
the review (Cronin et al, 2008). Summarising the information enabled me to not only see
how the research relates, but also how the articles relate to each other in terms of content
and findings. When re-reading the articles again, I was able to search for words of phrases
that could be used for a collection of similar ideas or thoughts. A critical analysis and
critically thinking about the articles and what is presented in the literature enabled me to
draw a conclusion about what has been written. This step made me view one of the articles
differently and consider its relevancy to the research project. However, I decided to keep it
as a wild card and a basis for significant comparison.
Step 7, the final step for Wakefield, Searching and critiquing the research literature (2014), is
about presenting the findings, putting the ideas together and writing up the literature review
in a logically structured way. A literature review has enabled me to critically analyse the
research papers to see what others have to say on the same or similar topic. This final step
enabled a clear and logical link and highlighted gaps in the research evidence.
The literature review has been that of a ‘mini’ nature, therefore the review itself has not been
as in depth or as widely explored as one might expect from a literature review. However, the
Page 4 of 6
article from Wakefield (2014) gave me significant background knowledge and guidance I
very much needed in order to complete this part of K316, Exploring Practice.
The literature review has been a challenge, personally, professionally and academically
simply due to the lack of research into alternative practices for emergency or urgent care. I
find this alarming, considering the data produced by NHS England on the amount of
unnecessary 999 ambulance calls, the significant increase on demand and lack of front line
staff. It begs the question of why hasn’t alternative approaches been explored or devised?
Reference List
Aveyard H (2010) Doing A Literature Review in Health and Social Care: A Practical Guide.
Second Edition. McGraw Hill International. Maidenhead.
Cronin P, Ryan F, Coughlan M (2008) Undertaking a Literature Review: a step-by-step
approach. British Journal of Nursing. 17, 1, 38-43.
Jones LV, Smyth RL (2004) How to perform a literature search. Current Paediatrics. 14, 6,
482-488.
Randolph JJ (2009) A Guide to Writing the Dissertation Literature Review.
http://writingcenter.gmu.edu/?p=307.
Wakefield A (2014) Searching and Critiquing the research literature. Nursing Standard, 28,
39, 49-57.
Additional Resources Used
K316, Exploring Practice, The Open University.
Department of Health, Taking Healthcare to the Patient. Transforming NHS Ambulance
Services (2005), www.dh.gov.uk/publications.
Telemedicine in Care Homes in Airdale, Wharfedale and Craven (2015), Dr Justin Tuggey,
Airdale NHS Foundation Trust.
Page 5 of 6
https://www.kingsfund.org.uk/sites/default/files/media/Justin%20Tuggey%20Airedale%20tele
medicine%20KF%20presentation%2021%2005%2015%20V4%20JT.pdf
NHS England, Ambulance Quality Indicators.
https://www.england.nhs.uk/statistics/statistical-work-areas/ambulance-quality-indicators/
Page 6 of 6