A patient survey of out-of-hours care provided by Emergency Care Practitioners

Contribution of paramedics in primary and urgent care: a systematic review

Background

Within the UK, there are now opportunities for paramedics to work across a variety of healthcare settings away from their traditional ambulance service employer, with many opting to move into primary care.

Aim

To provide an overview of the types of clinical roles paramedics are undertaking in primary and urgent care settings within the UK.

Design and setting

A systematic review.

Method

Searches were conducted of MEDLINE, CINAHL, Embase, the National Institute for Health and Care Excellence, the Journal of Paramedic Practice, and the Cochrane Database from January 2004 to March 2019 for papers detailing the role, scope of practice, clinician and patient satisfaction, and costs of paramedics in primary and urgent care settings. Free-text keywords and subject headings focused on two key concepts: paramedic and general practice/primary care.

Results

In total, 6765 references were screened by title and/or abstract. After full-text review, 24 studies were included. Key findings focused on the description of the clinical role, the clinical work environment, the contribution of paramedics to the primary care workforce, the clinical activities they undertook, patient satisfaction, and education and training for paramedics moving from the ambulance service into primary care.

Conclusion

Current published research identifies that the role of the paramedic working in primary and urgent care is being advocated and implemented across the UK; however, there is insufficient detail regarding the clinical contribution of paramedics in these clinical settings. More research needs to be done to determine how, why, and in what context paramedics are now working in primary and urgent care, and what their overall contribution is to the primary care workforce.

Understanding the impact of delegated home visiting services accessed via general practice by community-dwelling patients: a realist review protocol

INTRODUCTION

In western countries, early visiting services (EVS) have been proposed as a recent intervention to reduce both general practitioner workload and hospital admissions among housebound individuals experiencing a healthcare need within the community. EVS involves the delegation of the patient home visits to other staff groups such as paramedics or nursing staff. However, the principles of organising this care are unknown and it remains unclear how different contexts, such as patient conditions and the processes of organising EVS influence care outcomes. A review has been designed to understand how EVS are enacted and, specifically, who benefits, why, how and when in order to provide further insight into the design and delivery of EVS.

METHODS AND ANALYSIS

The purpose of this review is to produce findings that provide explanations of how and why EVS contexts influence their associated outcomes. Evidence on EVS will be consolidated through realist review-a theory-driven approach to evidence synthesis. A realist approach is needed as EVS is a complex intervention. What EVS achieve is likely to vary for different individuals and contexts. We expect to synthesise a range of relevant data such as qualitative, quantitative and mixed-method research in the following stages: devising an initial programme theory, searching evidence, selecting appropriate documents, extracting data, synthesising and refining the programme theory.

ETHICS AND DISSEMINATION

A formal ethics review is not required as this study is secondary research. Findings will be disseminated in a peer-reviewed journal, at national and international conferences and to relevant professional associations.

PROSPERO REGISTRATION NUMBER

CRD42018096518.

What evidence is there on the effectiveness of different models of delivering urgent care? A rapid review

Background

In 2013 NHS England set out its strategy for the development of an emergency and urgent care system that is more responsive to patients’ needs, improves outcomes and delivers clinically excellent and safe care. Knowledge about the current evidence base on models for provision of safe and effective urgent care, and the gaps in evidence that need to be addressed, can support this process.

Objective

The purpose of the evidence synthesis is to assess the nature and quality of the existing evidence base on delivery of emergency and urgent care services and identify gaps that require further primary research or evidence synthesis.

Data sources

MEDLINE, EMBASE, The Cochrane Library, the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and the Web of Science.

Methods

We have conducted a rapid, framework-based, evidence synthesis approach. Five separate reviews linked to themes in the NHS England review were conducted. One general and five theme-specific database searches were conducted for the years 1995–2014. Relevant systematic reviews and additional primary research papers were included and narrative assessment of evidence quality was conducted for each review.

Results

The review was completed in 6 months. In total, 45 systematic reviews and 102 primary research studies have been included across all five reviews. The key findings for each review are as follows: (1) demand – there is little empirical evidence to explain increases in demand for urgent care; (2) telephone triage – overall, these services provide appropriate and safe decision-making with high patient satisfaction, but the required clinical skill mix and effectiveness in a system is unclear; (3) extended paramedic roles have been implemented in various health settings and appear to be successful at reducing the number of transports to hospital, making safe decisions about the need for transport and delivering acceptable, cost-effective care out of hospital; (4) emergency department (ED) – the evidence on co-location of general practitioner services with EDs indicates that there is potential to improve care. The attempt to summarise the evidence about wider ED operations proved to be too complex and further focused reviews are needed; and (5) there is no empirical evidence to support the design and development of urgent care networks.

Limitations

Although there is a large body of evidence on relevant interventions, much of it is weak, with only very small numbers of randomised controlled trials identified. Evidence is dominated by single-site studies, many of which were uncontrolled.

Conclusions

The evidence gaps of most relevance to the delivery of services are (1) a requirement for more detailed understanding and mapping of the characteristics of demand to inform service planning; (2) assessment of the current state of urgent care network development and evaluation of the effectiveness of different models; and (3) expanding the current evidence base on existing interventions that are viewed as central to delivery of the NHS England plan by assessing the implications of increasing interventions at scale and measuring costs and system impact. It would be prudent to develop a national picture of existing pilot projects or interventions in development to support decisions about research commissioning.

Funding

The National Institute for Health Research Health Services and Delivery Research Programme.

Alternatives to Traditional EMS Dispatch and Transport: A Scoping Review of Reported Outcomes

Objectives

Emergency medical services (EMS) programs, which provide an alternative to traditional EMS dispatch or transport to the emergency department (ED), are becoming widely implemented. This scoping review identified and catalogued all outcomes used to measure such alternative EMS programs.

Data Source

Broad systematized bibliographic and grey literature searches were conducted.

Study Selection

Inclusion criteria were 911 callers/EMS patients, reported on alternatives to traditional EMS dispatch OR traditional EMS transport to the ED, and reported an outcome measure.

Data Extraction

The reports were categorized as either alternative to dispatch or to EMS transport, and outcome measures were categorized and described.

Data Synthesis

The bibliographic search retrieved 13,215 records, of which 34 articles met the inclusion criteria, with an additional 10 added from reference list hand-searching (n=44 included). In the grey literature search, 31 websites were identified, from which four met criteria and were retrieved (n=4 included). Fifteen reports (16 studies) described alternatives to EMS dispatch, and 33 reports described alternatives to EMS transport. The most common outcomes reported in the alternatives to EMS dispatch reports were service utilization and decision accuracy. Twenty-four different specific outcomes were reported. The most common outcomes reported in the alternatives to EMS transport reports were service utilization and safety, and 50 different specific outcomes were reported.

Conclusions

Numerous outcome measures were identified in reports of alternative EMS programs, which were catalogued and described. Researchers and program leaders should achieve consensus on uniform outcome measures, to allow benchmarking and improve comparison across programs.

A systematic review of the activity and impact of emergency care practitioners in the NHS

BACKGROUND

The NHS has seen a great expansion in the number of emergency care practitioners (ECPs) working in prehospital, primary and acute care settings since the role was introduced in 2003. This paper updates and expands on two previous reviews of ECP roles by identifying and discussing all empirical studies to date that examined the impact of ECP services in the NHS.

OBJECTIVES

To summarise the national evidence-based literature on the impact of ECPs on healthcare delivery, effectiveness of practice and related health service resource use.

METHODS

Searches in MEDLINE, EMBASE and CINAHL databases, and two internet search engines (Google and Google Scholar). Identified publications were screened for relevance and quality before a description and synthesis of their findings. No statistical comparison was undertaken.

RESULTS

Studies from the peer-reviewed literature (n=15) and project reports (n=6) were included. Overall, there was evidence that investment in ECP roles is beneficial for the quality of care reported by patients and cost efficiency savings. There was clear support from staff and patients for ECP services, and a number of studies of high methodological quality described care processes (diagnosis, investigations instigated and treatment initiated) provided by ECPs to be equivalent to or better to that provided by practitioners with traditional roles. Prehospital ECPs provided 'added value' by treating more patients at the scene thereby reducing unnecessary referral to emergency departments. It was often unclear whether the ECP intervention was part of a larger service change and/or new investment.

CONCLUSIONS

Successful implementation of the ECP role has been described. Further evaluations should consider whether the beneficial impact of the role transfers equally across all operational settings and patient groups, and is not just a reflection of new investment in clinical services.

To handle the unexpected - the meaning of caring in pre-hospital emergency care

The patient's voice has not been present to the same degree as the professional perspective in caring research in a pre-hospital context. In order to further develop and improve pre-hospital care, it is therefore important to explore patients' situations not only in life threatening but also in non-traumatic situations. This is especially important as these patients might be defined as inappropriate attendees of ambulance services. The aim of this study was to interpret and explain experiences of caring in pre-hospital care situations that are not defined as traumatic or life threatening. Twenty informants aged between 34 and 82 years were interviewed. The design of the study was exploratory, and it used an interpretative approach in order to understand the meaning of pre-hospital caring. The findings show that pre-hospital caring can be understood and explained as a matter of interplay between carer(s) and patient with potentials for positive as well as negative outcomes. Our conclusion is that the initial meeting is of vital importance in how patients experience pre-hospital care. It is suggested that general public information on the development of Swedish pre-hospital care received in turn may facilitate the first encounter between patient and carer(s).

Evaluating new roles within emergency care: a literature review

INTRODUCTION

In recent years economic and political drivers have strongly influenced the development and introduction of new roles such as medical substitution roles within emergency care in the National Health Service (NHS) in the United Kingdom (UK).

AIMS

The aims of this literature review were to establish the national and international evidence available which examine the scope of practice of emergency nurse practitioners, emergency care practitioners and extended scope physiotherapists; to establish the national and international evidence which explores patient satisfaction with non-medical roles in emergency care; to establish the national and international evidence which explores the acceptability of emergency nurse practitioner, emergency care practitioner and extended scope physiotherapists services from a healthcare professional perspective.

METHODS

A search of the literature was undertaken using BNI, CINAHL plus, International Bibliography of the Social Sciences, MEDLINE and SPORTDiscus databases combined with searches of the Cochrane library collection, NICE and the grey literature. Critical assessment of the literature is presented.

RESULTS

A high level of patient satisfaction was found with all the new roles. Interestingly the scope of practice of Emergency nurse practitioners appears to be most limited in the UK. Five major themes were identified from healthcare professionals' perceptions of these new roles.

CONCLUSION

There is general agreement that non-medical roles help to reduce waiting times in emergency departments, as well as attracting a high level of patient satisfaction, confidence and acceptance of these roles. Several issues were identified which warrant further study; including the current UK evidence surrounding the limited scope of practice of these roles.

Nurse practitioner management of acute in-hours home visit or assessment requests: a pilot study

BACKGROUND

GPs often perceive home-visit requests as a time-consuming aspect of general practice. The new general medical services contract provides for practices to be relieved of responsibility for home-visits, although there is no model for the transfer of care. One such model could be to employ nurse practitioners to manage such requests. Nurse practitioners can effectively substitute for GPs in managing same-day in-hours emergency care in the surgery, but their role in managing all such requests, including those requiring home visits, has not been assessed.

AIM

To explore the feasibility and clinical management outcomes of nurse practitioner management of same-day care requests, including those requiring home visits, to inform a proposed randomised controlled trial.

DESIGN OF STUDY

Non-randomised comparative trial.

SETTING

One large general practice (14 600 patients) in south London.

METHOD

Nurse practitioner assessment and management of all same-day care requests for 2 days per week was compared with normal GP management on another 2 days, over a 6-month period. Clinical management outcome data were collected from patient records and from data-collection forms completed by a nurse practitioner and GPs. Patient and staff satisfaction was assessed by questionnaire.

RESULTS

The nurse practitioner was more likely than GPs to assess patients in person, less likely to give advice alone, and more likely to issue a prescription. There was no significant difference between the nurse practitioner and GPs regarding any other clinical management outcomes or patient satisfaction; however, the response rate of the patient satisfaction questionnaire in this pilot study was poor.

CONCLUSION

Nurse practitioner management of acute in-hours care requests, including home visits, appears feasible in practice and merits further assessment.