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Clinical presentations and practitioner levels appropriate for the introduction of ‘Treat and Referral’ into the Irish Emergency Medical Service: a survey of consultants in emergency medicine.
DOI: http://dx.doi.org/10.32378/ijp.v5i1.233
Abstract
Objectives: Overcrowding in emergency departments (EDs) is an international issue and ambulance bypass is seen as one element of the solution to a complex problem. Irish EDs are not immune to this healthcare crisis, which, together with increased off-load delays for ambulances, is one catalyst for the introduction of Treat and Referral (paramedic non-ED disposition decision). The confidence of consultants in emergency medicine in paramedics and advanced paramedics offering Treat and Referral to patients presenting with hypoglycaemia or seizure was explored. Other specific clinical presentations were also investigated for suitability for Treat and Referral and a consensus was sought on an upper age limit for such patients.
Methods: Public-sector consultants in emergency medicine in Ireland at the time of the study, were invited to complete an online survey. A 62% response was received from the targeted population.
Results: Confidence was expressed in advanced paramedics offering Treat and Referral to patients with hypoglycaemia or seizure by the majority (78%) of respondents. However, confidence was reduced for paramedics (53%). Six of the twelve specific clinical presentations received clear support as suitable for Treat and Referral, with the remaining receiving reducing support and ‘falls in the elderly (without injury)’ was opposed. There was no consensus on an upper age limit for patients being offered Treat and Referral.
Conclusions: Support for the highest level of EMS practitioner in Ireland, advanced paramedic, to expand their scope of practice to include Treat and Referral was identified. Clinical presentations have been identified that would be conducive to a Treat and Referral clinical care pathway. A trial implementation period may be essential to build confidence in the programme before a universal roll out.
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Boyle A, Abel G, Raut P, et al. Comparison of the International Crowding Measure in Emergency Departments (ICMED) and the National Emergency Department Overcrowding Score (NEDOCS) to measure emergency department crowding: pilot study. Emergency medicine journal : EMJ 2016;33(5):307-12. doi: 10.1136/emermed-2014-203616
Hickey F. IAEM slams official responses to worsening Emergency Department crowding crisis: Irish Association for Emergency Medicine, 2016.
Wenman K. Review of pre-hospital emergency care services to ensure high quality in the assessment, diagnosis, clinical management and transporting of acutely ill patients to appropriate healthcare facilities: Health Information and Quality Authority, 2014.
Billings J, Parikh, Nina, Mijanovich, Tod. Emergency Department Use: The New York Story. Issue Brief 2000. www.cmwf.org.
Schaefer RA, Rea TD, Plorde M, et al. An emergency medical services program of alternate destination of patient care. Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors 2002;6(3):309-14. [published Online First: 2002/07/12]
Gratton MC, Ellison SR, Hunt J, et al. Prospective determination of medical necessity for ambulance transport by paramedics. Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors 2003;7(4):466-9.
Patton GG, Thakore S. Reducing inappropriate emergency department attendances--a review of ambulance service attendances at a regional teaching hospital in Scotland. Emergency medicine journal : EMJ 2013;30(6):459-61. doi: 10.1136/emermed-2012-201116
Snooks H, Foster T, Nicholl J. Results of an evaluation of the effectiveness of triage and direct transportation to minor injuries units by ambulance crews. Emergency medicine journal : EMJ 2004;21(1):105-11.
Raatiniemi L, Brattebo G. The challenge of ambulance missions to patients not in need of emergency medical care. Acta anaesthesiologica Scandinavica 2018;62(5):584-87. doi: 10.1111/aas.13103
Beillon LM, Suserud BO, Karlberg I, et al. Does ambulance use differ between geographic areas? A survey of ambulance use in sparsely and densely populated areas. The American journal of emergency medicine 2009;27(2):202-11. doi: 10.1016/j.ajem.2008.01.012
Alpert A, Morganti KG, Margolis GS, et al. Giving EMS flexibility in transporting low-acuity patients could generate substantial Medicare savings. Health Aff (Millwood) 2013;32(12):2142-8. doi: 10.1377/hlthaff.2013.0741
Booker MJ, Shaw AR, Purdy S. Why do patients with 'primary care sensitive' problems access ambulance services? A systematic mapping review of the literature. BMJ open 2015;5(5):e007726. doi: 10.1136/bmjopen-2015-007726
Khunti K, Fisher H, Paul S, et al. Severe hypoglycaemia requiring emergency medical assistance by ambulance services in the East Midlands: A retrospective study. Primary care diabetes 2013;7(2):159-65. doi: 10.1016/j.pcd.2013.01.001 [published Online First: 2013/02/05]
Osborne A, Taylor L, Reuber M, et al. Pre-hospital care after a seizure: Evidence base and United Kingdom management guidelines. Seizure : the journal of the British Epilepsy Association 2015;24:82-7. doi: 10.1016/j.seizure.2014.09.002
Dickson JM, Taylor LH, Shewan J, et al. Cross-sectional study of the prehospital management of adult patients with a suspected seizure (EPIC1). BMJ open 2016;6(2):e010573. doi: 10.1136/bmjopen-2015-010573
Villani M, Nanayakkara N, Ranasinha S, et al. Utilisation of emergency medical services for severe hypoglycaemia: An unrecognised health care burden. Journal of diabetes and its complications 2016 doi: 10.1016/j.jdiacomp.2016.04.015
Cain E, Ackroyd-Stolarz S, Alexiadis P, et al. Prehospital hypoglycemia: the safety of not transporting treated patients. Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors 2003;7(4):458-65. [published Online First: 2003/10/29]
Neeki MM, Dong F, Avera L, et al. Alternative Destination Transport? The Role of Paramedics in Optimal Use of the Emergency Department. The western journal of emergency medicine 2016;17(6):690-97. doi: 10.5811/westjem.2016.9.31384
Gray JT, Wardrope J. Introduction of non-transport guidelines into an ambulance service: a retrospective review. Emergency medicine journal : EMJ 2007;24(10):727-9. doi: 10.1136/emj.2007.048850 [published Online First: 2007/09/29]
Snooks HA, Kingston MR, Anthony RE, et al. New models of emergency prehospital care that avoid unnecessary conveyance to emergency department: translation of research evidence into practice? TheScientificWorldJournal 2013;2013:182102. doi: 10.1155/2013/182102
Tohira H, Fatovich D, Williams TA, et al. Is it Appropriate for Patients to be Discharged at the Scene by Paramedics? Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors 2016;20(4):539-49. doi: 10.3109/10903127.2015.1128028
Pre-Hospital Emergency Care Council. Clinical Practice Guidelines, 2017 Edition - Advanced Paramedic. Naas: Pre-Hospital Emergency Care Council, 2017.
O'Meara P. The rural and regional ambulance paramedic: moving beyond emergency response. Australia: School of Public Health, Charles Sturt University, Bathurst, 2006.
Raven S, Tippett, V., Ferguson, J., Smith, S. An exploration of expanded paramedic healthcare roles for Queensland. Queensland: Australian Centre for Prehospital Research James Cook University, 2006.
Kizer K, Shore, K., Moulin, A. Community Paramedicine: A Promising Model for Integrating Emergency and Primary Care. USA: Institute for Population Health Improvement, UC Davis Health System, 2013.
National Institute for Health and Care Excellence (UK). Paramedics with enhanced competencies. London: National Institute for Health and Care Excellence, 2017.
Millin MG, Brown LH, Schwartz B. EMS provider determinations of necessity for transport and reimbursement for EMS response, medical care, and transport: combined resource document for the National Association of EMS Physicians position statements. Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors 2011;15(4):562-9. doi: 10.3109/10903127.2011.598625
Zachariah BS, Bryant D, Pepe P, et al. Follow-up and Outcome of Patients who Decline or are Denied Transport by EMS. Prehosp Disaster Medicine 1992;7(4):359 - 63.
Norberg G, Wireklint Sundstrom B, Christensson L, et al. Swedish emergency medical services' identification of potential candidates for primary healthcare: Retrospective patient record study. Scandinavian journal of primary health care 2015;33(4):311-7. doi: 10.3109/02813432.2015.1114347
Snooks H, Kearsley N, Dale J, et al. Towards primary care for non-serious 999 callers: results of a controlled study of “Treat and Refer” protocols for ambulance crews. Quality and Safety in Health Care 2004;13(6):435-43.
O'Hara R, Johnson M, Siriwardena AN, et al. A qualitative study of systemic influences on paramedic decision making: care transitions and patient safety. J Health Serv Res Policy 2015;20(1 Suppl):45-53. doi: 10.1177/1355819614558472
Barry S, Dalton, R. and Eustace-Cook, J. Understanding Change in Complex Health Systems. Trinity College Dublin: Trinity College, 2018.
Minhas R. A prehospital treat-and-release protocol for supraventricular tachycardia. Canadian Journal of Emergency Medicine 2014;15
Coates D, Rawstorne S, Benger J. Can emergency care practitioners differentiate between an avoided emergency department attendance and an avoided admission? Emergency medicine journal : EMJ 2012;29(10):838-41. doi: 10.1136/emermed-2011-200484 [published Online First: 2012/02/16]
Cummins NMD, M. Garavan, C. Landymore, E. Mulligan, N. O'Donnell, C. Can advanced paramedics in the field diagnose patients and predict hospital admission? Emergency medicine journal : EMJ 2013;30(12):1043-7. doi: 10.1136/emermed-2012-201899
Snooks HA, Dale J, Hartley-Sharpe C, et al. On-scene alternatives for emergency ambulance crews attending patients who do not need to travel to the accident and emergency department: a review of the literature. Emergency medicine journal : EMJ 2004;21(2):212-5. [published Online First: 2004/02/28]
Ambulance Service of New South Wales. Clinical Assessment & Referral (CARE). CARE Clinical Pathways. Sydney: Ambulance Service of New South Wales, 2008.
O'Brien BC, Harris IB, Beckman TJ, et al. Standards for reporting qualitative research: a synthesis of recommendations. Acad Med 2014;89(9):1245-51. doi: 10.1097/ACM.0000000000000388
Guéret M. Irish Medical Directory 2012 - 2013. Dublin: Irish Medical Directory 2012.
Jeong HJ LW. The level of collapse we are allowed: Comparison of different response scales in Safety Attitudes Questionnaires. Biometrics & Biostatistics International Journal 2016;4(4): 00100. doi: 10.15406/bbij.2016.04.00100
MaCorr Research Solutions. Sample size calculator Toronto, Ontario Canada: MaCorr Research; 2018 [Available from: http://www.macorr.com/sample-size-calculator.htm2018.
Lerner EB, Billittier AJt, Lance DR, et al. Can paramedics safely treat and discharge hypoglycemic patients in the field? The American journal of emergency medicine 2003;21(2):115-20. doi: 10.1053/ajem.2003.50014 [published Online First: 2003/04/03]
Cone DC, Schmidt TA, Mann NC, et al. Developing research criteria to define medical necessity in emergency medical services. Prehospital Emergency Care 2004;8(2):116-25.
Strote J, Simons R, Eisenberg M. Emergency medical technician treatment of hypoglycemia without transport. The American journal of emergency medicine 2008;26(3):291-5. doi: 10.1016/j.ajem.2007.05.030 [published Online First: 2008/03/25]
Leikkola P, Mikkola R, Salminen-Tuomaala M, et al. Non-conveyance of patients: Challenges to decision-making in emergency care. BMC Nurs 2016;4:9. doi: 10.5430/cns.v4n4p31
Fealy GM, Treacy M, Drennan J, et al. A profile of older emergency department attendees: findings from an Irish study. Journal of advanced nursing 2012;68(5):1003-13. doi: 10.1111/j.1365-2648.2011.05800.x [published Online First: 2011/08/13]
Tiedemann A, Mikolaizak AS, Sherrington C, et al. Older fallers attended to by an ambulance but not transported to hospital: a vulnerable population at high risk of future falls. Australian and New Zealand journal of public health 2013;37(2):179-85. doi: 10.1111/1753-6405.12037
Barnard S, Appleby-Flemming, J., Black, B., Peters, M., Robinson, C. National Ambulance Non-Conveyance Audit (NANA) Report. London: National Ambulance Service Clinical Quality Group (NASCQG), 2014.
Deasy Cea. MAJOR TRAUMA AUDIT National Report 2016. Dublin: Health Service Executive, 2018.
DOI: http://dx.doi.org/10.32378/ijp.v5i1.233
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