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Abstract
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.
- emergency ambulance systems
- prehospital care
- training
- extended roles
- paramedics
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Background
Health services in many countries provide some sort of prehospital emergency response service for acute conditions based on the principle that prompt appropriate care can minimise the patient's mortality, morbidity and social consequences.1 ,2 Paramedics perform this function in the UK, together with Emergency Care Assistants. Paramedics respond to emergency (999) calls and evaluate the patient, make necessary (sometimes life-saving) interventions and transfer the patient to hospital (non-transfers can only officially occur if the patient declines). They have a fundamental skill set3 and can use a range of technical equipment and administer a limited list of medicines.
Population growth, epidemiological and demographic transition (the increasing burden of chronic disease and population ageing) and shortage of healthcare workers are affecting healthcare systems in many countries3 compelling them to adapt. For example, demand on UK ambulance services has increased steadily in the last 10 years but only 10% of calls are life-threatening.4
The UK government and health services recognise a need for adaptation to reduce these pressures on Emergency Departments (EDs).3 Ambulance service trusts have begun to respond to the recommendations made in ‘Taking Healthcare to the Patient: Transforming NHS [National Health Service] Ambulance Services (2005)’.4 For example, new dispatcher decision-support software directly transferring between ambulance trusts and telephone health advice had increased the number of ambulance calls in the last 5 years.5 Table 1 details information from Canada, Australia, USA and France. Apart from France, the others have similar structures and problems to the UK.
International drivers of change and responses
Paramedics are many patients’ first contact with the health service and thus have the potential to influence patients’ care pathways. Currently, there is some evidence of allied health professionals with extended skills11 and paramedic skills for decision-making12 or treating minor ailments.13 One relevant systematic review described new roles in emergency medical services (EMS) with some cost-saving,14 but a paucity of studies with sufficient patient follow-up and consideration of training costs means that cost analyses are unreliable.
Service changes are not consistent across countries which risks disadvantaging patients or duplicating research. A systematic, unbiased collation of evidence of paramedics trained with extended skills is essential to ensure a sound evidence base to inform and justify developments to emergency services already strained by financial cuts. This systematic literature review aims to identify international evidence of circumstances in which prehospital emergency care providers—hereafter commonly referred to as ‘paramedics’—have been trained with skills beyond their baseline competencies in new roles or within normal practice, and gauge the effectiveness of these skills in terms of patient care and service use.
Methods
Study design
A comprehensive, sensitive search strategy was devised to include international, relevant studies. Any study design was eligible due to the relative lack of randomised controlled trials in prehospital emergency care. Search terms included the many different prehospital care provider titles used worldwide and synonyms for ‘skill’, ‘extending roles’ and ‘impact’. Systematic reviews were considered for their intrinsic quality and the reviews’ findings, not the findings of individual papers.
Inclusion criteria
Articles were included if they focused on paramedics trained with extra skills to perform tasks beyond their baseline competencies. ‘Skills’ pertains to specific capabilities in history taking, examination, diagnostics, and interventions or less tangible skills such as teamwork or decision-making. Skills may include partnership working with another service or be targeted at a patient group. Single skills acquired incrementally during normal training were excluded. Paramedics of different levels (eg, Paramedic Practitioners) were included, but other roles where skills used were not-comparable (eg, Emergency Care Practitioners (ECPs)) were not.
Procedure
Data sources included both peer-reviewed and non-peer-reviewed information sources: Medline, EMBASE, CINAHL, ProQuest, Scopus, Cochrane Database of Systematic Reviews, York Centre for Reviews and Dissemination, NHS Evidence, the Department of Health website, UK Public Health Observatory, British Library (PhD theses), Web of Science (conference proceedings), Policy Network, Zetoc (conference proceedings) and Newcastle University Library index to theses. Additional papers were identified from reference lists or contacting authors of two or more or the final sample articles.
Databases were searched from 1990 onwards until the end of March 2012. This date was chosen to enable the identification of literature which may have influenced the attention on allied health professionals’ skills in the 2000 UK NHS plan.15 No other filters were applied.
All resultant articles were sifted in two stages by two researchers, independently and blinded to one another's response. Quality assessment was performed using study design-appropriate Critical Appraisal Skills Programme (CASP) tools.16 A good/moderate/poor grade was allocated according to the quantity of positively marked CASP criteria. Grades were used not for exclusion but weighting of study findings. Data extraction forms using Microsoft Excel were piloted with three articles and amended accordingly. Quality assessment and data extraction were also performed by two independent and blinded researchers. Disagreements were resolved either by discussion or in consultation with another author.
Results
A total of 8724 articles were identified during the search. Following removal of duplicates and sifting, the final sample for analysis contained 19 articles that met the inclusion criteria (figure 1).
Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement of the progression of articles through the review.
In all, 19 articles described 15 original trials of varying methodology (tables 2⇓–4).
Study characteristics
Interventions and measures of included studies
Findings from studies
Comparison of studies is problematic due to the wide variety of methodologies and paramedic skills focused upon. Studies are classified by the type of skill to the British Paramedic Association's core paramedic competences.17 Evidence was found for five of the nine categories.
‘Assessment and investigation of health’ and ‘planning/preparation for and addressing of health requirements’
These two categories are considered together because of the cross-over in skills.
Nine articles considered enhancing paramedics’ normal EMS care skills relating to a variety of patient groups.
Paramedics in the UK can be trained with more sophisticated skills for assessing and managing patients aged over 60.1 ,18 ,19 This is satisfactory to patients20 and carers1 but evidence for beneficial resource use difference compared with routine (control) care is lacking.18 Patients receiving care from trained paramedics are less likely to go to the ED or be admitted to hospital but had more secondary care contacts within 28 days.8 ,18 This may have been a result of more appropriate referrals, but jeopardises the safety of the model. There was no difference in mortality between intervention and control groups at 28 days and economic data were lacking.8 One single review article corroborated this benefit14 but their early searches miss the qualitative1 and economic evaluation8 published later.
Evidence for skills focusing on other patient groups is weaker; for instance, paramedics trained with enhanced skills for managing children with special healthcare needs made more appropriate interventions compared with untrained paramedics. This may be due to the training being taken up by more motivated practitioners who may have performed better anyway.21 This intervention had no effect on resource use: the proportion of patients transported or admitted through the ED remained similar to pretraining levels.22 It is questionable why two articles on the same study used different comparison groups.
Paramedic training placements in UK general practices were acceptable to trainers and paramedics but not tested in practice.23 They aimed to enhance the autonomy of normal EMS care. Paramedics working with UK General Practitioners (GPs) in a new ‘appropriate care at point of need’ (ACAPON) system were trained to treat minor injuries and make home visits alongside EMS care.24 ‘Just under half’ of treated patients remained in the community and others were admitted by ‘the most appropriate pathway’, generating an estimated saving of £28 279 per annum (compared with routine GP and EMS care). Paramedics trained to assess and manage heat-injury patients at a mass event (450 000people) in urban Canada managed 126 patients who would have otherwise burdened another site care facility.25 Evaluations by the same author team of screening by paramedics initially focused on patients aged over 6526 but later those over 6027 which makes interpretation in relation to older patients difficult. We found that authors used different age cut-offs to identify patients as ‘elderly’. Studies showed that paramedics could correctly identify the relevant features in patients, but they did not achieve sufficient coverage or follow-up intervention to constitute a ‘screening programme’.28
Development and sharing of information and knowledge of health
Skills training described by Riley et al29 aimed to enhance Canadian paramedics’ documentation of patients’ ability to understand and decide (capacity) to decline ambulance transport showed no effect compared with pretraining records. It is important to ascertain if the 1.5 h of training did not work or was not enough.
‘Safeguard and protect individuals’
Two safety studies in the USA showed that paramedics can accurately identify risks in homes, although not consistently and evidence of long-term benefit is lacking.30 ,31 Paramedics in one health department inspected 257 households for medication storage and 49 for gun storage (no reasons given),30 and paramedics from two ambulances tested carbon monoxide levels in 340 homes (out of up to 2637; not clear how many were indoors).31
This may result from families self-selecting for inspections30 or practical barriers in that paramedics took carbon monoxide measurements when clinical need allowed.31 This risks disadvantaging patients and limits the generalisability of the findings.
Education and learning around health
Two studies highlight a community engagement aspect to the paramedic role in rural Australia. Paramedics trained with skills to provide health education alongside patient management, screening, a ‘first-point-of-contact’ function, integration with voluntary services and increased community health capacity.32 Training paramedics alongside other individuals to increase community resilience to road trauma produced favourable results.33 ‘Professionals’ (mainly health workers, which would include paramedics, although the number is not clear) found practicing practical skills beneficial.
Quality of this evidence and its meaning
This review identified four ‘good’,1 ,19 ,25 ,34 eight ‘moderate’5 ,8 ,10 ,23 ,24 ,27 ,28 ,30 and two ‘poor’ quality articles.15 ,25 All studies, except one,35 address a clearly focused question using an adequate, if not always ideal methodology. For example, although a randomised controlled trial could more rigorously evaluate the paramedic skill, controlling the patient group allocation is difficult and quasi-experimental design may be more appropriate.
The main weaknesses of the above studies are inadequate follow-up or accounting for patients not assessed by paramedics; a lack of controlling for confounding factors, such as patient characteristics or paramedics previous experience; and lack of control group or comparison data. These factors limit the reliability and attributability of outcomes.
Discussion
There is some evidence from developed countries that paramedics can accurately identify health and social problems in patients and, in particular, those aged over 60.5 ,8 ,11 ,14 ,15 ,18 ,24 ,25 Paramedics can be successfully trained to autonomously assess and manage these patients with acute minor conditions, benefitting patients, carers and (probably) resource use more widely. Evidence of cost–benefit is however lacking. Evidence for paramedic care of other patient groups carries less weight but is valuable for informing future developments.
Paramedics working with enhanced skills are acceptable to service users and in the main reduced the burden on other care providers. Mason et al (2007) undertook the longest follow-up of 28 days, but longer follow-up may be required to assess the impact of extended paramedic care on patients’ long-term health consequences.19 However, if services are aiming to reduce the burden on EDs, then this review corroborates that paramedics with extended skills may be a viable means for this, provided referral services have the capacity for the extra referrals from paramedics. Protocols for paramedics to ‘treat and refer’ have been trialled in the UK but have not altered the number of patients left at home,36 suggesting that protocol-based procedures are not sufficient and successful paramedic referrals need improved paramedic skills. Paramedic difficulty with destination decision-making has been highlighted in other studies: paramedics transport patients ‘just in case’ and rely more on intuition than formal decision-making procedures.36 ,37
There is no evidence for paramedics providing screening programmes, which must be comprehensive and provide accessible, effective interventions.28 This review suggests that paramedics can accurately but not comprehensively assess; evidence for the success of subsequent interventions is weak because it is based on case studies and inadequate sample sizes and follow-up. There is a risk to the safety of patients who screen positive (ie, are in need) and do not achieve contact with an appropriate service. Krumperman35 describes some potential barriers to paramedic referrals from the receiving services, including being already overburdened and a lack of resources or patient concordance with existing services.
Paramedics may have a valuable role in rural community health capacity and health promotion (including, interestingly, first aid teaching) but this requires further investigation to identify the exact characteristics and benefits of such roles. Evidence for home safety roles was inadequate. All paramedic skill changes required some sort of support from the wider ambulance service, such as call-handling and engagement with trainers and patients. There may be person factors limiting the success of paramedic skill extensions in some circumstances, which have not been explored in this review.
There is no conclusive evidence to recommend one training method over another in this review. Most studies incorporated a combination of theory and practical training which reflects current UK paramedic training, but a vast range of methods were identified. Even similar methods were not similarly effective; a 90 min case-based discussion did not change practice29 but a 90 min case-based ‘instruction’ resulted in accurate screening but no effect on vaccine rates.25
Everden et al24 note that although ‘some GPs may be wary of something which appears to give them more work’, paramedics may be effectively trained in primary care; many GPs already have training qualifications and are familiar with the assessments and clinic experience fosters autonomous practice.23 The development of confident autonomous practice is essential if paramedics are to make referrals or decide to leave patients at home, as has been shown to be effective.20 The experiential learning may help paramedics to rely less upon protocols and hospital transfer as fall-back options.
Claims of cost-effectiveness were based on missing data,24 were not statistically significant8 or subject to outcome bias. For example, Paramedic Practitioners were £92 less costly if the equivalent care is fast-response vehicle staffed by ECPs,18 which is credible because ECPs also undertake extensive training. However, were the comparison group relatively less-skilled Emergency Medical Technicians, the saving would be substantially less, if any. ACAPON saves an estimated annual £28 729,24 but this may be susceptible to case study outcome bias.38
Although no system of grading by quality currently exists, the use of validated measures from the CASP tools made this review's crude grades objective and reliable. It was also sensitive enough to identify differences in quality within the same study design.
Recommendations
Further research is required in order to develop some of the findings of this review. These may differ between geographical regions, as different communities have distinct needs. Suggestions for the UK include:
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An EMS trial register is reinstated to improve the accessibility, quality and quantity of emergency research.
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A centralised database for ambulance and emergency patient data and a common reporting template for research and innovation 39 is designed and shared to improve the quality and accessibility of informal research (‘grey’ literature).
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Future adaptations to emergency care to address current pressures adopt a systems perspective in order to comprehensively assess the impact on all the relevant actors. Evidence for changes must include qualitative, quantitative and economic evaluations to ensure the quality and reproducibility of research.
This review identified the interaction of paramedics with other community services as the most promising means of reducing demand on EDs. Therefore, further investigation is needed in these areas:
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Paramedics working with GPs. This has the potential to save costs and resources and is beneficial and acceptable to paramedics and GPs.23 ,24 Specifically, ‘ACAPON’ should be trialled further in the UK.
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Paramedic referrals to non-EDs. Specifically, which patients and conditions benefit from paramedic referrals and which require hospital management and the current barriers to paramedic referral.
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Paramedics assessing and managing acute minor conditions in elderly patients. There is the strongest evidence base for this skill development. Good practice models, such as that by Mason et al (2007),19 should be taken up where trusts have the capacity to train a paramedic and these outcomes should be tightly monitored and shared.
In order to develop the features identified in this review, it is essential to ascertain which patients and conditions are suitable for autonomous paramedic care in order to protect patient safety. Where paramedic referral schemes already exist, barriers to their success should be investigated, including how many referral services are actually available for the demand. Furthermore, to facilitate the translation of such research, a systems perspective should be employed to identify the wider logistical, financial and other implications of changes to ambulance services; for example, extra training or capacity required for call-handlers to improve the appropriateness, acceptability and success of paramedic skill innovations.
Limitations
Identified articles used assorted methodologies and focused on varied skills and patient groups, meaning meta-analyses could not be performed and therefore deductions are only based on narrative syntheses. It is also important to note that qualifications may differ across different countries and that for instance an ECP in one country may have different roles in another and this could have affected the findings. Finally, it could be that a one-sided focus on adapting services to increasing demand ignores patients’ responsibility to access the correct service.
Conclusions
This review identifies many viable extra skills for paramedics but the evidence is not strong enough to guide policy. Instead, its findings should be used to guide future research, particularly into paramedic care for elderly people.
Acknowledgments
James Petter, College of Paramedics, UK and Dahrlene Tough, Scottish Ambulance Service, UK.
References
Footnotes
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Contributors RE, DNB and RM were involved in the design of the research. RE and JB carried out the systematic review under the supervision of DNB and RM. RE drafted the article with all authors contributing to the writing of the article.
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Collaborators None.
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Funding None.
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Disclaimer None.
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Competing interests None.
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Provenance and peer review Not commissioned; externally peer reviewed.
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Data sharing statement Not obtained.