Table 5.

Themes within participant interviews and quotes illustrating them

Theme	Subtheme	Illustrative quotes
Need for relevant historical information to guide care and conveyance decisions	Information gaps about patients prior history	The biggest challenge begins with seizures themselves because more often than not when a crew arrives the seizure has ceased so you're relying entirely on individuals present to describe things to you… If you've only got the individual that suffered the seizure present while they're in the recovery phase it's very difficult to establish a full history. You've got to think about whats caused it … it might be epilepsy, but you've got to think about hypoxia, hyperglycaemia, is there any sort of toxic issues going on. (p. 4) While they're postictal we don't know if it's a normal fit for them, we don't know when they last had one, we don't know if they've had a history of repeated ones. We don't even know if they are epileptic or not half the time. (p. 3)
	Obtaining information is challenging	Finding a patient with medical alert band on them to say that they've got epilepsy or carrying a seizure diary is like ‘striking gold’…most of the time you're guessing really what's normal for the patient. You are trying to pick it up and work it out as you go along and you reach a sort of limit of what you can access, especially if the patient remains postictal while they're in your care… (p. 1) You can try to ring a patient's GP for further information, but I'll tell you now that doesn't help…Just to get to speak to a GP is nigh on impossible. They're extremely busy. (p. 8) You can have to wait for GPs or out of hours doctors to phone you back…we can wait an hour and half. (p. 13)
Perverse incentives to convey to ED caused by time pressure/performance requirements	Times pressure can impact care decisions	There's an expectation that we will turn a job around you know…if they've been on scene for 20/30 min crews start to feel almost panicky that they're taking up time and that they need to get on with it. (p. 4) If someone has a seizure outside of the home, we wouldn't really take them home… It's not necessarily the right option for that patient… But by taking them home, which is further away, we will be tied up for longer. (p. 6) If I've been on scene a while I'll get messages sent down the mobile data terminal saying ‘Are you ok?’ which is a euphemism for ‘why is it taking you so long?’ So again it's that idea of we'll just put them in the back of the ambulance while their postictal and start driving to hospital rather than waiting to see if they recover… (p. 3)
	Time pressures operate differently in rural areas	Large urban areas are saturated with hospitals and if I'm getting monitored and measured on time performance well I might as well just take all my epileptic patients to hospital because I'm only 4 min away…I've done my job, the patient's safe and I've hit my time targets, I'm not going to be criticised by anybody. Whereas where we work in a more rural setting…that's not the case. (p. 8)
Knowledge gaps and uncertainty about postictal care	Limited training on seizures for paramedics	Epilepsy and convulsions don't come into any post-registration training… I have not had a single days training in managing convulsions since I was first trained in 1987. (p. 8) Paramedic training is geared towards critical illness, critical injury but we're seeing less and less of that and we're seeing more and more of chronic illness. (p. 12)
	Knowledge and confidence in seizure management low	There certainly needs to be more training on epilepsy because hand on heart I think if you took most ambulance crews today and said tell me about epilepsy, tell me what's going on, tell me about serial convulsions, tell me about status epilepticus, tell me about eclampsia and how would you recognise that from somebody having an epileptic convulsion, I think you would start hitting boundaries, I really do. (p. 8)
Limitations in care pathways and need for patient centred care	Pathfinder offers some reassurance and structured decision-making	If we follow that (Paramedic Pathfinder), the Trust will support us in our decision-making… so if something were to go wrong and we've used Pathfinder, that supports us. (p. 6)
	For most JRALC and pathfinder are unhelpful	There's] only one paragraph in JRCALC that relates to patients who've had a seizure…it's very vague, it's definitely left to your own clinical interpretation about what you feel is safe. (p. 1) We have got the Pathways flowcharts. But if you do too much of that it becomes ambulance service by numbers. Indeed some of the statements are quite vague, such as the one about whether the patient has a history of unconsciousness. You might say well ‘look a person's who's had a seizure will have had a history of unconsciousness and therefore now I'm going to transport because that's what the pathway dictates’… I've found this. (p. 7)
	Fear of adverse events if patient is not conveyed	They worry the patient is going to have another convulsion. How do they differentiate between the patients that need to go to hospital vs the patients that don't?…I think the service would support you [if an adverse event occurred] but I think over half of staff think they won't be… its of a lack of information about what actually happens the vast majority of times. (p. 3) ‘the paramedics will think in the back of their mind if I discharge this person on scene and allow them to continue their journey to work or wherever and they suffer another seizure and fall under a train, I will be responsible for that as the last practitioner to have seen that patient’…so some staff might well ask, ‘Non-conveyance of patients, what's really in it for me?’ (p. 9) A lot of clinicians and it's a historical thing have this perception that if they leave a patient and something then goes wrong erm that that the ‘book will be thrown at them’, that you know it will be it will be deemed to be their fault… (p. 4)
	Lack of alternative care pathways	We struggle for alternative pathways and so while we might be directed towards primary care, when we actually try and put some of those pathways into actual practice, they do seem to be lacking. (p. 7) So we have a self-care pathway option for epileptics. The patient must be over the age of 16, be an known epileptic and there are a number of criteria. One is that there must be a competent carer or individual who can accept responsibility of care for the patient…that's one that we quite often fail on especially within a public place. (p. 5) I think it just comes back to those challenges of I'm worried I might make mistake, I'm worried that they might get worse, I'm I haven't got anyone to look after them especially because they're at work and I just need to do something with them erm and I'm going to go with the easier option of just conveying them and let the A&E sort it out. (p. 3) There was a big investment in a new urgent care centre locally but they won't take people who've had a seizure. I've had patients…in a postictal state who need maybe half an hour until they come round…but there's this crazy idea that if somebody's had a seizure then they need to have a CT scan…Sometimes there is no alternative but to take them to ED. (p. 8)

P, participant number.