Towards primary care for non-serious 999 callers: results of a controlled study of "Treat and Refer" protocols for ambulance crews

Non-Conveyance Due to Patient-Initiated Refusal in Emergency Medical Services: A Retrospective Population-Based Registry Analysis Study in Riyadh Province, Saudi Arabia

This research study aimed to investigate the association between demographic and operational factors and emergency medical services (EMS) missions ending in non-conveyance (NC) due to patient-initiated refusal (PIR). We conducted a retrospective population-based registry study by analyzing 67,620 EMS missions dispatched to the scene during 2018 in the Riyadh province. First, the number and percentages of conveyances statuses were calculated. Then, using crude and adjusted linear and logistic regression analysis, we determined which characteristics were predictors of NC due to PIR. We found that 23,991 (34.4%) of missions ended in NC due to PIR, and 5969 ended in EMS-initiated refusal (8.6%). NC rates due to PIR were higher for women, adults, for missions in Riyadh city, during nighttime, for medical emergencies, and for advanced life support (ALS) crews. We also found the following additional predictors significantly associated with the odds of NC due to PIR in crude regression analyses: age category, geographical location, EMS-shift, time of call, emergency type, and response time. We conclude that the NC rate represents half of all missions for patients requesting EMS, and the rate in Riyadh city has increased compared to previous studies. Most NC cases occur for the highest urgency level of medical emergency type in Riyadh city during the nighttime with ALS crews. NC due to PIR involves younger patients more than elderly, and females more than males. This study’s findings have provided empirical evidence that indicate that conducting further studies involving EMS providers, patients, and the public to identify precise and detailed reasons is required.

A retrospective cross-sectional analysis of re-contact rates and clinical characteristics in diabetic patients referred by paramedics to a community diabetes service following a hypoglycaemic episode

Aims

To report the re-contact rates and clinical characteristics of individuals referred to community diabetic teams following non-conveyance by HCPC paramedics.

Methods

A retrospective cross-sectional study of routinely collected data by the Northern Ireland Ambulance Service HSC Trust of individuals referred to a community diabetic service following ambulance attendance and non-conveyance. Data were collected over a 3-month period with ambulance service re-contact and clinical data analysed.

Results

418 emergency calls were identified as relating to hypoglycaemia with 169 referrals being made, a referral rate of 40.4%. Patients treated with insulin represented the majority of calls and tended to have a lower Glasgow Coma Scale score, but demonstrated many successful referrals. Increased age and multimorbidity were associated with repeat hypoglycaemic episodes and EMS attendance while other subgroups traditionally considered higher risk, such as patients with infections or under the influence of alcohol, showed potential for safe community management.

Conclusion

The majority of paramedic referrals to community diabetic teams were successful, with less than 5% re-contacting the ambulance service within 3 days. This study, although demonstrating a lower referral rate than previous research, reinforces the safety of paramedic management and community referral for hypoglycaemia.

Time consumption for non-conveyed patients within emergency medical services (EMS): A one-year prospective descriptive and comparative study in a region of Sweden

INTRODUCTION

Over time, ambulance assignments have increased in number both nationally and internationally, and a substantial proportion of patients encountered by emergency medical services are assessed as not being in need of services. Non-conveying patients has become a way for emergency medical services clinicians to meet this increasing workload. It has been shown that ambulances can be made available sooner if patients are non-conveyed, but there is no previous research describing the factors that influence the non-conveyance time.

STUDY OBJECTIVE

To describe ambulance time consumption and the factors that influence time consumption when patients are non-conveyed.

METHODS

A prospective observational review of 2615 non-conveyed patients' ambulance and hospital medical records was conducted using a consecutive sample. Data were analysed with the Kruskal-Wallis test, Mann-Whitney U test and Spearman's rank correlation (rho) for linear correlations.

RESULTS

The mean NC time for all ambulance assignments during the study period was 26 minutes, with a median of 25 minutes. The shortest NC time was 4 minutes, and the longest NC time was 73 minutes. NC times were significantly faster during the day than at night.

CONCLUSIONS

This study provides new knowledge about time consumption when patients are non-conveyed. Although there are time differences when patients are non-conveyed, the differences observed in this study are small and not of clinical value. Ambulances will most often become available sooner if patients are non-conveyed. Although patients might be eligible for non-conveyance, policy-makers might have to decide when it is appropriate to non-convey patients from time, resource, patient safety and patient-centred care perspectives.

Outpatient care in acute and prehospital emergency medicine by emergency medical and patient transport service over a 10-year period: a retrospective study based on dispatch data from a German emergency medical dispatch centre (OFF-RESCUE)

BACKGROUND

The number of operations by the German emergency medical service almost doubled between 1994 and 2016. The associated expenses increased by 380% in a similar period. Operations with treatment on-site, which retrospectively proved to be misallocated (OFF-Missions), have a substantial proportion of the assignment of the emergency medical service (EMS). Besides OFF-Missions, operations with patient transport play a dominant role (named as ON-Missions). The aim of this study is to work out the medical and economic relevance of both operation types.

METHODS

This analysis examined N = 819,780 missions of the EMS and patient transport service (PTS) in the catchment area of the emergency medical dispatch centre (EMDC) Bad Kreuznach over the period from 01/01/2007 to 12/31/2016 in terms of triage and disposition, urban-rural distribution, duration of operations and economic relevance (p < .01).

RESULTS

53.4% of ON-Missions are triaged with the indication non-life-threatening patient transport; however, 63.7% are processed by the devices of the EMS. Within the OFF-Mission cohort, 78.2 and 85.8% are triaged or dispatched for the EMS. 74% of all ON-Missions are located in urban areas, 26% in rural areas; 81.3% of rural operations are performed by the EMS. 66% of OFF-Missions are in cities. 93.2% of the remaining 34% of operations in rural locations are also performed by the EMS. The odds for both ON- and OFF-Missions in rural areas are significantly higher than for PTS (ORON 3.6, 95% CI 3.21-3.30; OROFF 3.18, 95% CI 3.04-3.32). OFF-Missions last 47.2 min (SD 42.3; CI 46.9-47.4), while ON-Missions are processed after 79.7 min on average (SD 47.6; CI 79.6-79.9). ON-Missions generated a turnover of more than € 114 million, while OFF-Missions made a loss of almost € 13 million.

CONCLUSIONS

This study particularly highlights the increasing utilization of emergency devices; especially in OFF-Missions, the resources of the EMS have a higher number of operations than PTS. OFF-Missions cause immensely high costs due to misallocations from an economic point of view. Appropriate patient management appears necessary from both medical and economic perspective, which requires multiple solution approaches.

Alternatives to direct emergency department conveyance of ambulance patients: a scoping review of the evidence

Background

The role of ambulance services is shifting, due in part to more intermediate, non-urgent patients who do not require direct emergency department conveyance, yet who cannot be safely left at home alone. Evidence surrounding the safety, effectiveness and efficiency of alternate care routes is not well known.

Methods

This scoping review sought to identify all studies that examined alternate routes of care for the non-urgent “intermediate” patient, as triaged on scene. Search terms for the sample (ambulances, paramedics, etc.) and intervention (e.g. referrals, alternate care route, non-conveyance) were combined. Articles were systematically searched using four databases and grey literature sources (February 2020). Independent researchers screened title-abstract and full text stages.

Results

Of 16,037 records, 41 examined alternate routes of care after triage by the on-scene paramedic. Eighteen articles considered quantitative patient data, 12 studies provided qualitative perspectives while 11 were consensus or opinion-based articles. The benefits of alternative schemes are well-recognised by patients, paramedics and stakeholders and there is supporting evidence for a positive impact on patient-centered care and operational efficiency. Challenges to successful use of schemes included: patient safety resulting from incorrect triage decisions, inadequate training, lack of formal partnerships between ambulance and supporting services, and insufficient evidence to support safe implementation or continued use. Studies often inaccurately defined success using proxies for patient safety (e.g. decision comparisons, rates of secondary contact). Finally, patients expressed willingness for such schemes but their preference must be better understood.

Conclusions

This broad summary offers initial support for alternate routes of care for intermediate, non-urgent patients. Even so, most studies lacked methodologically rigorous evidence and failed to evaluate safe patient outcomes. Some remedies appear to be available such as formal triage pathways, targeted training and organisational support, however there is an urgent need for more research and dissemination in this area.

Developing patient-centred, feasible alternative care for adult emergency department users with epilepsy: protocol for the mixed-methods observational 'Collaborate' project

INTRODUCTION

Emergency department (ED) visits for epilepsy are common, costly, often clinically unnecessary and typically lead to little benefit for epilepsy management. An 'Alternative Care Pathway' (ACP) for epilepsy, which diverts people with epilepsy (PWE) away from ED when '999' is called and leads to care elsewhere, might generate savings and facilitate improved ambulatory care. It is unknown though what features it should incorporate to make it acceptable to persons from this particularly vulnerable target population. It also needs to be National Health Service (NHS) feasible. This project seeks to identify the optimal ACP configuration.

METHODS AND ANALYSIS

Mixed-methods project comprising three-linked stages. In Stage 1, NHS bodies will be surveyed on ACPs they are considering and semi-structured interviews with PWE and their carers will explore attributes of care important to them and their concerns and expectations regarding ACPs. In Stage 2, Discrete Choice Experiments (DCE) will be completed with PWE and carers to identify the relative importance placed on different care attributes under common seizure scenarios and the trade-offs people are willing to make. The uptake of different ACP configurations will be estimated. In Stage 3, two Knowledge Exchange workshops using a nominal group technique will be run. NHS managers, health professionals, commissioners and patient and carer representatives will discuss DCE results and form a consensus on which ACP configuration best meets users' needs and is NHS feasible.

ETHICS AND DISSEMINATION

Ethical approval: NRES Committee (19/WM/0012) and King's College London ethics Committee (LRS-18/19-10353). Primary output will be identification of optimal ACP configuration which should be prioritised for implementation and evaluation. A pro-active dissemination strategy will make those considering developing or supporting an epilepsy ACP aware of the project and opportunities to take part in it. It will also ensure they are informed of its findings.

PROJECT REGISTRATION NUMBER

Researchregistry4723.

Re-contact demographics and clinical characteristics of diabetic patients treated for a hypoglycaemic episode in the pre-hospital environment: a rapid literature review

Introduction:

Diabetes mellitus has been referred to as an ‘epidemic’ and the World Health Organization reported 422 million people with the disease in 2014. Hypoglycaemia is common among emergency presentations, yet understanding around the utilisation of emergency medical services (EMS) for this is incomplete.

Ambulance service referral pathways for those suitable to be treated in the community have been developed as a means of managing this growing demand. However, there is limited evidence to suggest how they should be constructed or implemented.

The aim of this review was to examine patients who re-contacted the health services following EMS non-transport for a hypoglycaemic episode and to determine if risk factors could be identified.

Methods:

Medline/PubMed and CINAHL online databases were searched for papers published between 1998 and 2018 relating to re-contacts following an interaction with EMS. The Cochrane Library online database was also searched, as well as manual searches from key journals. Relevant clinical manuals, guidelines and specific grey literature were also hand searched.

Results:

After duplicates were removed, 260 articles were identified, with 41 selected for full review. These were then reduced by excluding those that did not provide any data on re-contact rates/demographics. The remaining papers were then assessed using the Critical Appraisal Skills Programme (CASP) appraisal tool and those identified as of low quality were removed. This produced 17 papers for final inclusion.

Conclusion:

The literature demonstrates that ambulance clinicians can appropriately treat hypoglycaemia in the community and identify those requiring further assessment at emergency departments. However, due to the very nature of diabetes, repeat episodes will and do occur, regardless of community or emergency department management, but these are rarely in the acute phase. Some groups are higher risk, but thorough holistic assessment is vital for identifying those suitable for community management.

Assessment of Inadequate Use of Pediatric Emergency Medical Transport Services: The Pediatric Emergency and Ambulance Critical Evaluation (PEACE) Study

Aim: To provide data on the inadequate use of emergency medical transports services (EMTS) in children and underlying contributing factors. Methods: This was a prospective single-center cohort study (01/2017-12/2017) performed at the Saarland University Children's Hospital, Homburg, Germany. Patients ≤20 years of age transported by EMTS for suspected acute illness/trauma were included and proportion of inadequate/adequate EMTS use, underlying contributing factors, and additional costs were analyzed. Results: Three hundred seventy-nine patients (mean age: 9.0 ± 6.3 years; 55.7% male, 44.3% female) were included in this study. The three most common reasons for EMTS use were: central nervous system (30.6%), respiratory system affection (14.0%), and traumas (13.2%). ETMS use was categorized as inadequate depending on physician's experience: senior physician (58.8%), pediatrician (54.9%), resident (52.7%). All three physicians considered 127 (33.5%) cases to be medically indicated for transportation by EMTS, and 177 (46.7%) to be medically not indicated. The following parameters were significantly associated with inadequate EMTS use: non-acute onset of symptoms (OR 2.5), parental perception as non-life-threatening (OR 1.7), and subsequent out-patient treatment (OR 4.0). Conversely, transport by an emergency physician (OR 3.5) and first time parental EMTS call (OR 1.7) were associated with adequate use of EMTS. Moreover, a significant relation existed between maternal, respectively, paternal educational status and inadequate EMTS use (each p = 0.01). Using multiple logistic regression analysis, non-acute onset of symptoms (OR 2.2) was associated with inadequate use of EMTS while first time parental EMTS call (OR 1.8), transport by an emergency physician (OR 3.3), and need for in-patient treatment (OR 4.0) were associated with adequate use of EMTS. Conclusion: A substantial number of pediatric EMTS is medically not indicated. Possibly, specific measures including multifaceted educational efforts may be helpful in reducing unnecessary EMTS use.

Factors influencing the decision to convey or not to convey elderly people to the emergency department after emergency ambulance attendance: a systematic mixed studies review

BACKGROUND

The decision over whether to convey after emergency ambulance attendance plays a vital role in preventing avoidable admissions to a hospital's emergency department (ED). This is especially important with the elderly, for whom the likelihood and frequency of adverse events are greatest.

OBJECTIVE

To provide a structured overview of factors influencing the conveyance decision of elderly people to the ED after emergency ambulance attendance, and the outcomes of these decisions.

DATA SOURCES

A mixed studies review of empirical studies was performed based on systematic searches, without date restrictions, in PubMed, CINAHL and Embase (April 2018). Twenty-nine studies were included.

STUDY ELIGIBILITY CRITERIA

Only studies with evidence gathered after an emergency medical service (EMS) response in a prehospital setting that focused on factors that influence the decision whether to convey an elderly patient were included.

SETTING

Prehospital, EMS setting; participants to include EMS staff and/or elderly patients after emergency ambulance attendance.

STUDY APPRAISAL AND SYNTHESIS METHODS

The Mixed Methods Appraisal Tool was used in appraising the included articles. Data were assessed using a 'best fit' framework synthesis approach.

RESULTS

ED referral by EMS staff is determined by many factors, and not only the acuteness of the medical emergency. Factors that increase the likelihood of non-conveyance are: non-conveyance guidelines, use of feedback loop, the experience, confidence, educational background and composition (male-female) of the EMS staff attending and consulting a physician, EMS colleague or other healthcare provider. Factors that boost the likelihood of conveyance are: being held liable, a lack of organisational support, of confidence and/or of baseline health information, and situational circumstances. Findings are presented in an overarching framework that includes the impact of these factors on the decision's outcomes.

CONCLUSION

Many non-medical factors influence the ED conveyance decision after emergency ambulance attendance, and this makes it a complex issue to manage.

The ambulance nurse experiences of non-conveying patients

Aims and objectives

To explore ambulance nurses' (ANs) experiences of non‐conveying patients to alternate levels of care.

Background

Increases in ambulance utilisation and in the number of patients seeking ambulance care who do not require medical supervision or treatment during transport have led to increased nonconveyance (NC) and referral to other levels of care.

Design

A qualitative interview study was conducted using an inductive research approach.

Methods

The study was conducted in a region in the middle of Sweden during 2016–2017. Twenty nurses were recruited from the ambulance departments in the region. A conventional content analysis was used to analyse the interviews. The study followed the COREQ checklist.

Results

The ANs experienced NC as a complex and difficult task that carried a large amount of responsibility. They wanted to be professional, spend time with the patient and find the best solution for him or her. These needs conflicted with the ANs' desire to be available for assignments with a higher priority. The ANs could feel frustrated when they perceived that ambulance resources were being misused and when it was difficult to follow the NC guidelines.

Conclusion

If ANs are expected to nonconvey patients seeking ambulance care, they need a formal mandate, knowledge and access to primary health care.

Relevance to clinical practice

This study provides new knowledge regarding the work situation of ANs in relation to NC. These findings can guide future research and can be used by policymakers and ambulance organisations to highlight areas that need to evolve to improve patient care.

Patient Satisfaction with Pre-Hospital Emergency Services. A Qualitative Study Comparing Professionals' and Patients' Views

Objective: To describe patient satisfaction with pre-hospital emergency knowledge and determine if patients and professionals share a common vision on the satisfaction predictors. Methods: A qualitative study was conducted in two phases. First, a systematic review following the PRISMA protocol was carried out searching publications between January 2000 and July 2016 in Medline, Scopus, and Cochrane. Second, three focus groups involving professionals (advisers and healthcare providers) and a total of 79 semi-structured interviews involving patients were conducted to obtain information about what dimensions of care were a priority for patients. Results: Thirty-three relevant studies were identified, with a majority conducted in Europe using questionnaires. They pointed out a very high level of satisfaction of callers and patients. Delay with the assistance and the ability for resolution of the case are the elements that overlap in fostering satisfaction. The published studies reviewed with satisfaction neither the overall care process nor related the measurement of the real time in responding to an emergency. The patients and professionals concurred in their assessments about the most relevant elements for patient satisfaction, although safety was not a predictive factor for patients. Response capacity and perceived capacity for resolving the situation were crucial factors for satisfaction. Conclusions: Published studies have assessed similar dimensions of satisfaction and have shown high patient satisfaction. Expanded services resolving a wide number of issues that can concern citizens are also positively assessed. Delays and resolution capacity are crucial for satisfaction. Furthermore, despite the fact that few explanations may be given due to a lack of face-to-face attention, finding the patient's location, taking into account the caller's emotional needs, and maintaining phone contact until the emergency services arrive are high predictors of satisfaction.

Trust in the early chain of healthcare: lifeworld hermeneutics from the patient's perspective

PURPOSE

Patients must be able to feel as much trust for caregivers and the healthcare system at the healthcare centre as at the emergency department. The aim of this study is to explain and understand the phenomenon of trust in the early chain of healthcare, when a patient has called an ambulance for a non-urgent condition and been referred to the healthcare centre.

METHOD

A lifeworld hermeneutic approach from the perspective of caring science was used. Ten patients participated: seven female and three male. The setting is the early chain of healthcare in south-western Sweden.

RESULTS

The findings show that the phenomenon of trust does not automatically involve medical care. However, attention to the patient's lifeworld in a professional caring relationship enables the patient to trust the caregiver and the healthcare environment. It is clear that the "voice of the lifeworld" enables the patient to feel trust.

CONCLUSION

Trust in the early chain of healthcare entails caregivers' ability to pay attention to both medical and existential issues in compliance with the patient's information and questions. Thus, the patient must be invited to participate in assessments and decisions concerning his or her own healthcare, in a credible manner and using everyday language.

Paramedic literature search filters: optimised for clinicians and academics

Background

Search filters aid clinicians and academics to accurately locate literature. Despite this, there is no search filter or Medical Subject Headings (MeSH) term pertaining to paramedics. Therefore, the aim of this study was to create two filters to meet to different needs of paramedic clinicians and academics.

Methods

We created a gold standard from a reference set, which we measured against single terms and search filters. The words and phrases used stemmed from selective exclusion of terms from the previously published Prehospital Search Filter 2.0 as well as a Delphi session with an expert panel of paramedic researchers. Independent authors deemed articles paramedic-relevant or not following an agreed definition. We measured sensitivity, specificity, accuracy and number needed to read (NNR).

Results

We located 2102 articles of which 431 (20.5%) related to paramedics. The performance of single terms was on average of high specificity (97.1% (Standard Deviation 7.4%), but of poor sensitivity (12.0%, SD 18.7%). The NNR ranged from 1 to 8.6. The sensitivity-maximising search filter yielded 98.4% sensitivity, with a specificity of 74.3% and a NNR of 2. The specificity-maximising filter achieved 88.3% in specificity, which only lowered the sensitivity to 94.7%, and thus a NNR of 1.48.

Conclusions

We have created the first two paramedic specific search filters, one optimised for sensitivity and one optimised for specificity. The sensitivity-maximising search filter yielded 98.4% sensitivity, and a NNR of 2. The specificity-maximising filter achieved 88.3% in specificity, which only lowered the sensitivity to 94.7%, and a NNR of 1.48. A paramedic MeSH term is needed.

Electronic supplementary material

The online version of this article (10.1186/s12911-017-0544-z) contains supplementary material, which is available to authorized users.

A patient-safety and professional perspective on non-conveyance in ambulance care: a systematic review

BACKGROUND

This systematic review aimed to describe non-conveyance in ambulance care from patient-safety and ambulance professional perspectives. The review specifically focussed at describing (1) ambulance non-conveyance rates, (2) characteristics of non-conveyed patients, (3) follow-up care after non-conveyance, (4) existing guidelines or protocols, and (5) influencing factors during the non-conveyance decision making process.

METHODS

We systematically searched MEDLINE, PubMed, CINAHL, EMBASE, and reference lists of included articles, in June 2016. We included all types of peer-reviewed designs on the five topics. Couples of two independent reviewers performed the selection process, the quality assessment, and data extraction.

RESULTS

We included 67 studies with low to moderate quality. Non-conveyance rates for general patient populations ranged from 3.7%-93.7%. Non-conveyed patients have a variety of initial complaints, common initial complaints are related to trauma and neurology. Furthermore, vulnerable patients groups as children and elderly are more represented in the non-conveyance population. Within 24 h-48 h after non-conveyance, 2.5%-6.1% of the patients have EMS representations, and 4.6-19.0% present themselves at the ED. Mortality rates vary from 0.2%-3.5% after 24 h, up to 0.3%-6.1% after 72 h. Criteria to guide non-conveyance decisions are vital signs, ingestion of drugs/alcohol, and level of consciousness. A limited amount of non-conveyance guidelines or protocols is available for general and specific patient populations. Factors influencing the non-conveyance decision are related to the professional (competencies, experience, intuition), the patient (health status, refusal, wishes and best interest), the healthcare system (access to general practitioner/other healthcare facilities/patient information), and supportive tools (online medical control, high risk card).

CONCLUSIONS

Non-conveyance rates for general and specific patient populations vary. Patients in the non-conveyance population present themselves with a variety of initial complaints and conditions, common initial complaints or conditions are related to trauma and neurology. After non-conveyance, a proportion of patients re-enters the emergency healthcare system within 2 days. For ambulance professionals the non-conveyance decision-making process is complex and multifactorial. Competencies needed to perform non-conveyance are marginally described, and there is a limited amount of supportive tools is available for general and specific non-conveyance populations. This may compromise patient-safety.

'Popping nana back into bed' - a qualitative exploration of paramedic decision making when caring for older people who have fallen

BACKGROUND

Older fallers constitute a large proportion of ambulance work, and as many as 25% are not transported to hospital following paramedic assessment. The objective of this study was to explore the decision making process used by paramedics when caring for older fallers.

METHODS

A qualitative study was conducted using constructivist grounded theory methodology. Purposive sampling was used to recruit paramedics to participate in semi-structured interviews and focus groups. Data analysis commenced with line-by-line coding, developing into formation of theoretical categories. Theoretical sampling was then used to clarify emerging theoretical concepts, with data collection and analysis continuing until theoretical saturation was achieved.

RESULTS

A total of 33 paramedics participated in 13 interviews and 4 focus groups. When caring for older fallers, paramedic decision making is profoundly affected by 'role perception', in which the individual paramedic's perception of what the role of a paramedic is determines the nature of the decision making process. Transport decisions are heavily influenced by a sense of 'personal protection', or their confidence in the ambulance service supporting their decisions. 'Education and training' impacts on decision making capacity, and the nature of that training subliminally contributes to role perception. Role perception influences the sense of legitimacy a paramedic attaches to cases involving older fallers, impacting on patient assessment routines and the quality of subsequent decisions.

CONCLUSIONS

Paramedic decision making processes when caring for older people who have fallen appear to be strongly influenced by their perception of what their role should be, and the perceived legitimacy of incidents involving older fallers as constituting 'real' paramedic work.

Referral pathways for patients with TIA avoiding hospital admission: a scoping review

OBJECTIVE

To identify the features and effects of a pathway for emergency assessment and referral of patients with suspected transient ischaemic attack (TIA) in order to avoid admission to hospital.

DESIGN

Scoping review.

DATA SOURCES

PubMed, CINAHL Web of Science, Scopus.

STUDY SELECTION

Reports of primary research on referral of patients with suspected TIA directly to specialist outpatient services.

DATA EXTRACTION

We screened studies for eligibility and extracted data from relevant studies. Data were analysed to describe setting, assessment and referral processes, treatment, implementation and outcomes.

RESULTS

8 international studies were identified, mostly cohort designs. 4 pathways were used by family doctors and 3 pathways by emergency department physicians. No pathways used by paramedics were found. Referrals were made to specialist clinic either directly or via a 24-hour helpline. Practitioners identified TIA symptoms and risk of further events using a checklist including the ABCD2 tool or clinical assessment. Antiplatelet medication was often given, usually aspirin unless contraindicated. Some patients underwent tests before referral and discharge. 5 studies reported reduced incident of stroke at 90 days, from 6-10% predicted rate to 1.3-2.1% actual rate. Between 44% and 83% of suspected TIA cases in these studies were referred through the pathways.

CONCLUSIONS

Research literature has focused on assessment and referral by family doctors and ED physicians to reduce hospitalisation of patients with TIA. No pathways for paramedical use were reported. We will use results of this scoping review to inform development of a paramedical referral pathway to be tested in a feasibility trial.

TRIAL REGISTRATION NUMBER

ISRCTN85516498. Stage: pre-results.

Support and Assessment for Fall Emergency Referrals (SAFER 1): cluster randomised trial of computerised clinical decision support for paramedics

Objective

To evaluate effectiveness, safety and cost-effectiveness of Computerised Clinical Decision Support (CCDS) for paramedics attending older people who fall.

Design

Cluster trial randomised by paramedic; modelling.

Setting

13 ambulance stations in two UK emergency ambulance services.

Participants

42 of 409 eligible paramedics, who attended 779 older patients for a reported fall.

Interventions

Intervention paramedics received CCDS on Tablet computers to guide patient care. Control paramedics provided care as usual. One service had already installed electronic data capture.

Main Outcome Measures

Effectiveness: patients referred to falls service, patient reported quality of life and satisfaction, processes of care.

Safety

Further emergency contacts or death within one month.

Cost-Effectiveness

Costs and quality of life. We used findings from published Community Falls Prevention Trial to model cost-effectiveness.

Results

17 intervention paramedics used CCDS for 54 (12.4%) of 436 participants. They referred 42 (9.6%) to falls services, compared with 17 (5.0%) of 343 participants seen by 19 control paramedics [Odds ratio (OR) 2.04, 95% CI 1.12 to 3.72]. No adverse events were related to the intervention. Non-significant differences between groups included: subsequent emergency contacts (34.6% versus 29.1%; OR 1.27, 95% CI 0.93 to 1.72); quality of life (mean SF12 differences: MCS −0.74, 95% CI −2.83 to +1.28; PCS −0.13, 95% CI −1.65 to +1.39) and non-conveyance (42.0% versus 36.7%; OR 1.13, 95% CI 0.84 to 1.52). However ambulance job cycle time was 8.9 minutes longer for intervention patients (95% CI 2.3 to 15.3). Average net cost of implementing CCDS was £208 per patient with existing electronic data capture, and £308 without. Modelling estimated cost per quality-adjusted life-year at £15,000 with existing electronic data capture; and £22,200 without.

Conclusions

Intervention paramedics referred twice as many participants to falls services with no difference in safety. CCDS is potentially cost-effective, especially with existing electronic data capture.

Trial Registration

ISRCTN Register ISRCTN10538608

New models of emergency prehospital care that avoid unnecessary conveyance to emergency department: translation of research evidence into practice?

Background. Achieving knowledge translation in healthcare is growing in importance but methods to capture impact of research are not well developed. We present an attempt to capture impact of a programme of research in prehospital emergency care, aiming to inform the development of EMS models of care that avoid, when appropriate, conveyance of patients to hospital for immediate care. Methods. We describe the programme and its dissemination, present examples of its influence on policy and practice, internationally, and analyse routine UK statistics to determine whether conveyance practice has changed. Results. The programme comprises eight research studies, to a value of >£4 m. Findings have been disseminated through 18 published papers, cited 274 times in academic journals. We describe examples of how evidence has been put into practice, including new models of care in Canada and Australia. Routine statistics in England show that, alongside rising demand, conveyance rates have fallen from 90% to 58% over a 12-year period, 2,721 million fewer journeys, with publication of key studies 2003–2008. Comment. We have set out the rationale, key features, and impact on practice of a programme of publicly funded research. We describe evidence of knowledge translation, whilst recognising limitations in methods for capturing impact.

Which extended paramedic skills are making an impact in emergency care and can be related to the UK paramedic system? A systematic review of the literature

Background

Increasing demand on the UK emergency services is creating interest in reviewing the structure and content of ambulance services. Only 10% of emergency calls have been seen to be life-threatening and, thus, paramedics, as many patients’ first contact with the health service, have the potential to use their skills to reduce the demand on Emergency Departments. This systematic literature review aimed to identify evidence of paramedics trained with extra skills and the impact of this on patient care and interrelating services such as General Practices or Emergency Departments.

Methods

International literature from Medline, Embase, Cumulative Index of Nursing and Allied Health Literature (CINAHL), ProQuest, Scopus and grey literature from 1990 were included. Articles about any prehospital emergency care provider trained with extra skill(s) beyond their baseline competencies and evaluated in practice were included. Specific procedures for certain conditions and the extensively evaluated UK Emergency Care Practitioner role were excluded.

Results

8724 articles were identified, of which 19 met the inclusion criteria. 14 articles considered paramedic patient assessment and management skills, two articles considered paramedic safeguarding skills, two health education and learning sharing and one health information. There is valuable evidence for paramedic assessing and managing patients autonomously to reduce Emergency Department conveyance which is acceptable to patients and carers. Evidence for other paramedic skills is less robust, reflecting a difficulty with rigorous research in prehospital emergency care.

Conclusions

This review identifies many viable extra skills for paramedics but the evidence is not strong enough to guide policy. The findings should be used to guide future research, particularly into paramedic care for elderly people.

Support and assessment for fall emergency referrals (SAFER 2) research protocol: cluster randomised trial of the clinical and cost effectiveness of new protocols for emergency ambulance paramedics to assess and refer to appropriate community-based care

INTRODUCTION

Emergency calls to ambulance services are frequent for older people who have fallen, but ambulance crews often leave patients at the scene without ongoing care. Evidence shows that when left at home with no further support older people often experience subsequent falls which result in injury and emergency-department attendances. SAFER 2 is an evaluation of a new clinical protocol which allows paramedics to assess and refer older people who have fallen, and do not need hospital care, to community-based falls services. In this protocol paper, we report methods and progress during trial implementation. SAFER 2 is recruiting patients through three ambulance services. A successful trial will provide robust evidence about the value of this new model of care, and enable ambulance services to use resources efficiently.

DESIGN

Pragmatic cluster randomised trial.

METHODS AND ANALYSIS

We randomly allocated 25 participating ambulance stations (clusters) in three services to intervention or control group. Intervention paramedics received training and clinical protocols for assessing and referring older people who have fallen to community-based falls services when appropriate, while control paramedics deliver care as usual. Patients are eligible for the trial if they are aged 65 or over; resident in a participating falls service catchment area; and attended by a trial paramedic following an emergency call coded as a fall without priority symptoms. The principal outcome is the rate of further emergency contacts (or death), for any cause and for falls. Secondary outcomes include further falls, health-related quality of life, 'fear of falling', patient satisfaction reported by participants through postal questionnaires at 1 and 6 months, and quality and pathways of care at the index incident. We shall compare National Health Service (NHS) and patient/carer costs between intervention and control groups and estimate quality-adjusted life years (QALYs) gained from the intervention and thus incremental cost per QALY. We shall estimate wider system effects on key-performance indicators. We shall interview 60 intervention patients, and conduct focus groups with contributing NHS staff to explore their experiences of the assessment and referral service. We shall analyse quantitative trial data by 'treatment allocated'; and qualitative data using content analysis.

ETHICS AND DISSEMINATION

The Research Ethics Committee for Wales gave ethical approval and each participating centre gave NHS Research and Development approval. We shall disseminate study findings through peer-reviewed publications and conference presentations.

TRIAL REGISTRATION

ISRCTN 60481756.

Introduction of non-transport guidelines into an ambulance service: a retrospective review

BACKGROUND

Recent government policy has looked at improving the role of ambulance services in delivering alternative care models for patients.

OBJECTIVE

To review the outcomes of the introduction of some specific non-transport guidelines into an ambulance service.

METHODS

A retrospective review was undertaken of the documentation produced from the use of these protocols in the first 4 months following introduction for appropriateness of use, and potential for risk of adverse outcome.

RESULTS

Of 354 uses of the guidelines, 140 (39.5%) were considered inappropriate. A large number of these were cases where the issue was refusal of transport rather than a use of the guideline. Of the rest the more focused guidelines showed better adherence (hypoglycaemia 2/69 inappropriate, epilepsy 1/23 inappropriate) than the more non-specific guidelines (no apparent injury 17/84 inappropriate, minor limb injury 28/58 inappropriate).

CONCLUSIONS

This short study suggests that focused guidelines can help support ambulance staff decision making; however, care must be taken to ensure safe practice and that these guidelines are not used to add legitimacy to poor practice.

Effectiveness of paramedic practitioners in attending 999 calls from elderly people in the community: cluster randomised controlled trial

OBJECTIVE

To evaluate the benefits of paramedic practitioners assessing and, when possible, treating older people in the community after minor injury or illness. Paramedic practitioners have been trained with extended skills to assess, treat, and discharge older patients with minor acute conditions in the community.

DESIGN

Cluster randomised controlled trial involving 56 clusters. Weeks were randomised to the paramedic practitioner service being active (intervention) or inactive (control) when the standard 999 service was available.

SETTING

A large urban area in England.

PARTICIPANTS

3018 patients aged over 60 who called the emergency services (n=1549 intervention, n=1469 control).

MAIN OUTCOME MEASURES

Emergency department attendance or hospital admission between 0 and 28 days; interval from time of call to time of discharge; patients' satisfaction with the service received.

RESULTS

Overall, patients in the intervention group were less likely to attend an emergency department (relative risk 0.72, 95% confidence interval 0.68 to 0.75) or require hospital admission within 28 days (0.87, 0.81 to 0.94) and experienced a shorter total episode time (235 v 278 minutes, 95% confidence interval for difference -60 minutes to -25 minutes). Patients in the intervention group were more likely to report being highly satisfied with their healthcare episode (relative risk 1.16, 1.09 to 1.23). There was no significant difference in 28 day mortality (0.87, 0.63 to 1.21).

CONCLUSIONS

Paramedics with extended skills can provide a clinically effective alternative to standard ambulance transfer and treatment in an emergency department for elderly patients with acute minor conditions.

TRIAL REGISTRATION

ISRCTN27796329 [controlled-trials.com].

Patients' experiences of care provided by emergency care practitioners and traditional ambulance practitioners: a survey from the London Ambulance Service

Patients' experiences after receiving care from emergency care practitioners (ECPs) were compared with those after receiving care from traditional ambulance practitioners using a postal questionnaire distributed to 1658 patients in London; 888 responses were received. The responses of patients receiving care from both groups were similar and largely positive. But in two areas ("thoroughness of assessment" and "explaining what would happen next"), the care provided by ECPs was experienced as considerably better. These differences were partly explained by considerably fewer patients from ECPs being conveyed to the emergency department, suggesting that empowering ECPs to explore and explain alternatives to the emergency department improves patient satisfaction.

Gaps between policy, protocols and practice: a qualitative study of the views and practice of emergency ambulance staff concerning the care of patients with non-urgent needs

AIM

To describe emergency ambulance crews' views about (1) how they make decisions on whether to convey patients to hospital; (2) an intervention enabling them to triage patients to non-conveyance; and (3) their experience of using new protocols for undertaking such triage.

METHODS

Two focus groups were held at the outset of an evaluation of Treat and Refer (T&R) protocols: one with staff based at an ambulance station who were to implement the new service (intervention station), and the other with staff from a neighbouring station who would be continuing their normal practice during the study (control station). A third session was held with staff from the intervention station following training and 3 months' experience of protocol usage.

RESULTS

Before the introduction of the T&R protocols, crews reported experience, intuition, training, time of call during shift, patient preference, and home situation as influencing their decisions concerning conveyance. Crews were positive about changing practice but foresaw difficulties with advising patients who wanted to go to hospital, and with referral to other agencies. Following experience of T&R protocol use, crews felt they had needed more training than had been provided. Some felt their practice and job satisfaction had improved. Problems with referral and with persuading some patients that they did not need to go to hospital were discussed. There was consensus that the initiative should be introduced across the service.

CONCLUSIONS

With crews generally positive about this intervention, an opportunity to tackle this difficult area of emergency care now exists. This study has, however, highlighted the complexity of the change in practice and service delivery, and professional and organisational constraints that need to be considered.