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Evidence suggests a positive effect, but future programmes need rigorous assessment before being expanded
In this week's BMJ, Mason and colleagues report a cluster randomised controlled trial examining the effects of a “paramedic practitioner” service in a UK urban setting.1 The trial focused on managing older patients without life threatening conditions who accessed the emergency ambulance service. It aimed to increase the proportion receiving care in the community and reduce admissions to the emergency department. It found that people in the intervention group were less likely to attend the emergency department (relative risk 0.72, 95% confidence interval 0.68 to 0.75) or need hospital admission within 28 days (0.87, 0.81 to 0.94). However, use of secondary care services after the initial episode increased (1.21, 1.06 to 1.38).
Paramedic practitioners undertook a three week theory course followed by 45 days of supervised clinical experience. Their scope of practice was restricted to common presentations considered unlikely to result in serious injury, including falls, lacerations, epistaxis, and minor burns. Skills acquired beyond those normally practised by UK paramedics included wound care and suturing; examination of the joints; examination of the neurological, cardiovascular, respiratory, and ear, nose, and throat systems; social needs assessment; administration of antibiotics, simple analgesics, and tetanus toxoid; and referral of patients for radiography or to a general practitioner, district nurse, or social services.
As long ago as 1994, it was reported that services that deputised for general practitioners often could not cope with the demand for out of hours consultations.2 In addition, calls for emergency ambulances have been rising persistently by as much as 8% each year,3 yet half of patients taken to emergency departments by ambulance are discharged without being treated or referred.4 The increased demand for emergency ambulances may have been exacerbated by the introduction of general practitioner contracts that do not require the provision of out of hours services, although this has not been proved. Ambulances often have to queue outside emergency departments because a lack of trolley bays means that patients cannot be admitted. This in turn results in a lack of ambulances to respond to further emergency calls. Similar problems have occurred in Australia, New Zealand, the United States, and Canada. This, along with the need to tackle the challenges of providing health care to remote populations, has led to the formation of the International Roundtable on Community Paramedicine (www.ircp.info).
Emergency care practitioners were introduced with the aim of reducing admissions to the emergency department for a broader range of patients than those discussed by Mason and colleagues.5 A pilot programme began in the Warwickshire Ambulance Service in 2002, with the support of Coventry University and the changing workforce programme. It was subsequently expanded to encompass 17 pilot sites.6 Although this was intended to promote a standardised 15 week university based course, with all practitioners having a similar scope of practice, several centres opted for alternative approaches, including that described by Mason and colleagues.1 Most emergency care practitioners are paramedics working in ambulance services, but some are nurses or physiotherapists, and most work in out of hours and primary care services or emergency departments. Similar paramedic based programmes in other countries include those of the Queensland and New South Wales Ambulance Services in Australia.
Few high quality evaluations of the emergency care practitioner scheme and other extended scope paramedic practitioner schemes have been published to date. A changing workforce programme review reported that emergency care practitioners could reduce admissions to emergency departments by 100 to 358 patients each year in rural and urban settings, respectively. For a training investment of £24250 (€34800; $50000), this would save the National Health Service £62000-£72000 each year for each practitioner.6 In Wales, autonomous “advanced paramedic practitioners,” who are educated to masters degree level, responded to about 25% (n=635) of 999 calls received in one primary care trust area. Of these, 292 (46%) patients were treated and discharged at the scene; 75 (12%) were re-graded to non-emergency transport; and 34 (5%) were admitted to hospital destinations other than the emergency department. Although emergency care practitioners are typically targeted to calls triaged as “low priority” by ambulance dispatchers, the Welsh scheme found that the greatest proportion of patients with altered care pathways fell within high and medium priority categories (24% and 22%, respectively, v 17% in the lowest priority category).7
In a scheme in the west of England, 48/170 (28%) patients were treated “on scene” by emergency care practitioners with a BSc in emergency care, compared with 60/331 (18%) attended by paramedics.8 A more recent evaluation found that 62% of patients seen by emergency care practitioners were not admitted and 38% were referred; practitioners self reported that their intervention prevented an acute admission in 66% of cases.9
The trial by Mason and colleagues is the first adequately powered randomised controlled trial to investigate the effect of an extended scope paramedic programme on admissions to the emergency department.1 Although their results are largely positive, they cannot be generalised beyond the scheme evaluated. Perhaps, most importantly, the trial shows that high quality study designs are feasible in this setting. Such trials should, therefore, be used to evaluate the more widespread emergency care practitioner scheme and other extended scope paramedic programmes before further costly expansions take place.
This article was posted on bmj.com on4 October 2007: http://bmj.com/cgi/doi/10.1136/bmj.39356.700139.BE
Competing interests: None declared.
Provenance and peer review: Commissioned; not externally peer reviewed.