Stakeholder opinion on the proposal to introduce 'treat and referral' into the Irish emergency medical service

Paramedic Education and Training for the Management of Patients Presenting with Low-Acuity Clinical Conditions: A Scoping Review

Ambulance services around the world are increasingly attending to calls for non-emergency conditions. These lower-acuity conditions do not always require patients to be transported to the emergency department. Consequently, over the past two decades, ambulance services have implemented strategies to support paramedics in diverting non-urgent patients to alternative care pathways. However, assessing and managing low-acuity conditions can be challenging for paramedics, especially when education and training has traditionally focussed on emergency care. This scoping review explores the education and training provided to paramedics on low-acuity clinical conditions and the use of alternative care pathways. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews was applied. The databases searched included Scopus, CINAHL, Embase, Emcare, and MEDLINE (PubMed). The search identified one-hundred sixty-six records, with a total of nine articles reviewed after the removal of duplicates and the screening process. The articles were diverse, with education and training ranging from university degrees for extended care practitioners to short in-service-based training for a suite of protocols or assessment tools. However, the literature addressing education and training on low-acuity conditions and alternative care pathways is limited, with the type and length of education programs appearing to influence practice. There is a need for further research to establish a low acuity education model.

Clinician and Caregiver Determinations of Acuity for Children Transported by Emergency Medical Services: A Prospective Observational Study

STUDY OBJECTIVE

Many Emergency Medical Services (EMS) agencies have developed alternative disposition processes for patients with nonemergency problems, but there is a lack of evidence demonstrating EMS clinicians can accurately determine acuity in pediatric patients. Our study objective was to determine EMS and other stakeholders' ability to identify low acuity pediatric EMS patients.

METHODS

We conducted a prospective, observational study of children transported to a pediatric emergency department (ED) by EMS. Acuity was defined using a composite measure that included data from the patient's vital signs and examination, resources used (laboratory results, radiographs, etc), and disposition. For each patient, an EMS clinician, patient caregiver, ED nurse, and ED provider completed a survey as soon as possible after the patient's arrival at the ED. The survey asked respondents 2 questions: to state their level of agreement that a patient was low acuity and could the patient have been managed by various alternative dispositions. For each respondent group, we calculated the sensitivity, specificity, and positive and negative predictive values for low acuity versus the composite measure.

RESULTS

From August 2020 through September 2021, we approached 1,015 caregivers, of whom 996 (99.8%) agreed to participate and completed the survey. Survey completion varied between 78.7% and 84.1% for EMS and ED nurses and providers. The mean patient age was 7 years, 62.6% were non-Hispanic Black, and 60% were enrolled in public insurance programs. Of the 996 patient encounters, 33% were determined to be low acuity by the composite measure. The positive predictive value for EMS clinicians when identifying low acuity children was 0.60 (95% confidence intervals [CI], 0.58 to 0.67). The positive predictive value for ED nurses and providers was 0.67 (95% CI, 0.61 to 0.72) and 0.68 (95% CI, 0.63 to 0.74) respectively. The negative predictive value for EMS clinicians when identifying not low acuity children was 0.62 (95% CI, 0.58 to 0.67). The negative predictive value for ED nurses and providers was 0.72 (95% CI, 0.68 to 0.76) and 0.73 (95% CI, 0.70 to 0.77) respectively. Caregivers had the lowest positive predictive value 0.34 (95% CI, 0.30 to 0.40) but the highest negative predictive value 0.82 (95% CI, 0.79 to 0.85). The EMS clinicians, ED nurses and providers were more likely than caregivers to think that a child with a low acuity complaint could have been safely managed by alternative disposition.

CONCLUSION

All 4 groups studied had a limited ability to identify which children transported by EMS would have no emergency resource needs, and support for alternative disposition was limited. For children to be included in alternative disposition processes, novel triage tools, training, and oversight will be required to prevent undertriage.

Paramedic Education to Support the Use of Low-Acuity Care Pathways: A Scoping Review Protocol

Ambulance services worldwide have transformed over time into health care services that not only attend to life-threatening emergencies, but are also increasingly being utilised for patients with low-acuity or non-urgent illness and injury. As a result, there has been a need to adapt and include mechanisms to assist paramedics in the assessment and management of such patients, including alternative pathways of care. However, it has been identified that education and training for paramedics in the care of low-acuity patients is limited. This study aims to identify potential gaps in the literature and inform further research, paramedic education and training, patient care guidelines, and policy. A scoping review will be conducted utilising the Joanna Briggs Institutes methodology. A range of relevant electronic databases will be searched along with the grey literature, using search terms related to paramedic education for low-acuity patient care pathways. The search results will be screened by two authors and presented in the PRISMA-ScR format, with articles presented in tabular format and analysed thematically. The results of this scoping review will inform further research exploring paramedic education, clinical guidelines, policy and experiences in the management of low-acuity patients.

Introducing Advanced Paramedics into the rural general practice team in Ireland – general practitioners attitudes

Introduction

As Ireland's population increases and chronic disease becomes more prevalent, demand on limited general practice services will increase. Nursing roles within general practice are now considered to be standard, yet alternative allied health professional roles are under explored within an Irish context. Allied health personnel such as Advanced Paramedics (APs) may have the capability to provide support to general practice.

Aim

To explore General Practitioners’ (GPs) attitudes and opinions of integrating Advanced Paramedics (APs) into rural general practice in Ireland.

Methods

A sequential explanatory mixed methodology was adopted. A questionnaire was designed and distributed to a purposeful sample of GPs attending a rural conference followed by semi-structured interviews. Data was recorded and transcribed verbatim and thematically analysed.

Results

In total n = 27 GPs responded to the survey and n = 13 GPs were interviewed. The majority of GPs were familiar with APs and were receptive to the concept of closely collaborating with APs within a variety of settings including out-of-hours services, home visits, nursing homes and even roles within the general practice surgery.

Conclusion

General Practitioner and Advanced Paramedic clinical practice dovetail within many facets of primary care and emergency care. GPs recognise that current rural models are unsustainable and realise the potential of integrating APs into the general practice team to help support and sustain the future of rural general practice services in Ireland. These interviews provided an exclusive, detailed insight into the world of general practice in Ireland that has not been previously documented in this way.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-022-01740-9.

Supporting the ambulance service to safely convey fewer patients to hospital by developing a risk prediction tool: Risk of Adverse Outcomes after a Suspected Seizure (RADOSS)-protocol for the mixed-methods observational RADOSS project

INTRODUCTION

Ambulances services are asked to further reduce avoidable conveyances to emergency departments (EDs). Risk of Adverse Outcomes after a Suspected Seizure seeks to support this by: (1) clarifying the risks of conveyance and non-conveyance, and (2) developing a risk prediction tool for clinicians to use 'on scene' to estimate the benefits an individual would receive if conveyed to ED and risks if not.

METHODS AND ANALYSIS

Mixed-methods, multi-work package (WP) project. For WP1 and WP2 we shall use an existing linked data set that tracks urgent and emergency care (UEC) use of persons served by one English regional ambulance service. Risk tools are specific to clinical scenarios. We shall use suspected seizures in adults as an exemplar.WP1: Form a cohort of patients cared for a seizure by the service during 2019/2020. It, and nested Knowledge Exchange workshops with clinicians and service users, will allow us to: determine the proportions following conveyance and non-conveyance that die and/or recontact UEC system within 3 (/30) days; quantify the proportion of conveyed incidents resulting in 'avoidable ED attendances' (AA); optimise risk tool development; and develop statistical models that, using information available 'on scene', predict the risk of death/recontact with the UEC system within 3 (/30) days and the likelihood of an attendance at ED resulting in an AA.WP2: Form a cohort of patients cared for a seizure during 2021/2022 to 'temporally' validate the WP1 predictive models.WP3: Complete the 'next steps' workshops with stakeholders. Using nominal group techniques, finalise plans to develop the risk tool for clinical use and its evaluation.

ETHICS AND DISSEMINATION

WP1a and WP2 will be conducted under database ethical approval (IRAS 307353) and Confidentiality Advisory Group (22/CAG/0019) approval. WP1b and WP3 have approval from the University of Liverpool Central Research Ethics Committee (11450). We shall engage in proactive dissemination and knowledge mobilisation to share findings with stakeholders and maximise evidence usage.

Barriers and opportunities of establishing an integrated prehospital emergency response system in North West Ethiopia: a qualitative study

Background

Prehospital emergency care helps to reduce mortality and morbidity from time-sensitive conditions. In this study, we summarised the perspectives of various stakeholders on the establishment of a prehospital integrated emergency response system.

Methods

We conducted a qualitative study using a key informant interview. We used a purposive sampling technique to select participants from the sector offices based on their proximity to the problem under consideration. We took verbal informed consent from each participant before the interviews. We conducted a thematic content analysis.

Results

Twenty-three study participants, working at six sector offices (the zonal health office, University of Gondar, traffic office, fire extinguisher office, the Amhara regional health bureau and the Ethiopian red cross association), were included in this study. Five major themes have emerged. The themes that emerged include participants’ views on the importance of prehospital service, barriers and opportunities for establishing the system, and how to start and sustain the system.

Conclusion and recommendation

Lack of resources is not the main reason for the lack of prehospital emergency care in the study area rather; lack of commitment, ownership and high turnover of decision-makers were the main reasons for the absence of prehospital care, as viewed by respondents. On the other side, the availability of professionals, training institutions and the fact that emergency care is a shared agenda by different stakeholders were stated as an opportunity to establish the system. With the growing number of injuries and non-communicable diseases, emergency management should get due attention.

Identification of new demands regarding prehospital care based on 35,188 missions in 2018

BACKGROUND

Population ageing and increased prevalence of chronic diseases result in the emergence of new demands in prehospital care. The prehospital system is facing an increase of cases without acute threat to life (so-called "non-urgent"), which generates tension due to a higher number of admissions to emergency departments and a greater use of prehospital resources. Our aim is to understand this transition in prehospital activities and to delineate the primary missions performed by paramedics in 2018 with a focus on the population concerned, the severity of cases encountered and the typology of health issues.

METHOD

The study is retrospective, and descriptive, using a statistical description of 35,188 primary missions realized in 2018 in the State of Vaud (Switzerland). The characteristics taken into consideration are the age and gender of patients, as well as the health issue, the severity of cases based on National Advisory Committee for Aeronautics score (NACA score), and the time and place of intervention.

RESULTS

The results describe the primary missions in the State of Vaud in 2018 and show that 87% of missions concern "non-urgent" situations (without acute threat to life). Over half of patients are 65 or older, the highest proportion of health issues, 49%, are medical and only 23% of missions are for traumas. Mission related to mental health issues reach 7% and those for intoxication 6%. Most missions take place between 7:00 am and 6:00 pm (67%), and around 12% of missions lead to the non-transport of the patient.

CONCLUSION

The prehospital sector is confronted with a major transition in terms of patient care. An increase of non-urgent cases is observed, associated with the care of persons aged 65 or more. Our results question the adequacy between the needs in terms of prehospital care and the paramedic profession as it is currently defined, as well as the place of this profession within the health network. Reflecting upon the role of paramedics with respect to the socio-demographic evolution of populations appears necessary, to analyse the adequacy of the paramedics' skills to respond to the current needs.

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.

Patient experience of non-conveyance following emergency ambulance service response: A scoping review of the literature

INTRODUCTION

Evolution of ambulance service response models has resulted in significant numbers of patients not being conveyed to Emergency Departments. Prior research has attempted to measure patient-safety aspects of non- conveyance with inconclusive results. Several authors have recommended investigation of patient experience as an alternative metric. Understanding patient experience is acknowledged as a core requirement for design and evaluation of changes to healthcare delivery. However, it is unclear to what extent patient experience of non-conveyance is described in academic literature.

AIMS

To map scholarly literature that describes patient experience of non-conveyance and identify knowledge gaps that guide future research.

METHODS

Scoping review guided by the Joanna Briggs Institute (JBI) framework.

RESULTS

Ten studies of heterogenous methodology were included. Commonly, high levels of satisfaction with paramedic care were reported, yet contributing factors to satisfaction were generally not described. Qualitative studies provided deeper insight into experience. Value was attributed to reassurance and being empowered in the decision-making process. Not having concerns validated by paramedics led to negative experiences.

CONCLUSION

There is a scarcity of quality research that has investigated patient experience of non-conveyance following emergency ambulance service response. Methods used by existing research is of low-quality. Patient experience of non-conveyance is not fully known.