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A systematic review of the activity and impact of emergency care practioners in the NHS
  1. Harry Hill1,
  2. Peter McMeekin1,
  3. Christopher Price2
  1. 1Institute of Health and Society, University of Newcastle, Newcastle, UK
  2. 2Institute for Ageing and Health, Institute of Health and Society, University of Newcastle, Newcastle, UK
  1. Correspondence to Dr Harry Hill, Institute of Health and Society, University of Newcastle, Newcastle upon Tyne NE2 4AX, UK; harry.hill{at}newcastle.ac.uk

Abstract

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.

  • emergency departments
  • nursing
  • nursing, emergency departments
  • practitioners
  • paramedics
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Introduction

The emergency care practitioner (ECP) role was introduced across the NHS in 20031 when emergency services were challenged by waiting time performance measurement in the context of increasing admissions and a reduction in junior doctors’ working hours.1 ,2 ECPs come from nursing and paramedical backgrounds35 and undertake many activities traditionally carried out by doctors.1 These include an initial assessment of patient status and deciding whether to deliver simple treatments or initiate referral to an appropriate clinical team. ECPs were intended to work ‘seamlessly’ across organisational and professional boundaries1 ,6 and thereby increase care quality and service efficiency with an emphasis on avoiding hospital admissions.

There is no national regulation of ECPs as a separate professional group. Instead a national competencies and a curriculum framework was developed that requires an advanced practitioner to obtain a qualification and accumulate relevant evidence of professional development. Competences reflect local service provision and patient need (table 1). The length of core ECP training has typically been 12 months: 6 months taught and 6 months supervised clinical practice.7 This short training period and strong policy support has led to a rapid rise in the number of ECPs employed in NHS emergency departments (EDs) and other urgent care settings.6 Despite this growth, literature describing the impact of the ECP role has not been systematically reviewed in full.

Table 1

Competencies and core skills3

Study aims

The aim of this review was to consider the impact of prehospital and secondary care ECP roles since introduction in the NHS.

Study methods

The historical and policy development of the ECP role over the last decade is well documented.1 ,8 Two previous literature reviews suggest that ECPs improve patient satisfaction9 ,10 and attract high levels of confidence from other emergency healthcare medical professionals.10

Hoskins9 restricted the scope of their review to the acceptability of ECP roles in the workplace and the impact on patient satisfaction. A broader review by Cooper and Grant10 was completed when few empirical studies had investigated ECPs in the UK literature. Since then studies have examined the impact of ECPs in the context of the nationally recognised training criterion that has been developed.3 The previous two reviews included international evidence for ECP-related roles and so presented a synthesis that incorporated settings and practices outside of the NHS. This review summarises all of the empirical evidence that evaluates ECP practices in the UK, which permits a more thorough examination of the impact of their role in the NHS than previous investigations.

The examination of a recently introduced nursing and paramedic role could inform workforce planning and service commissioning in EDs and minor injury settings.

Methods

A search of CINAHL, MEDLINE and EMBASE databases in August 2012 was combined with examinations of the Cochrane library collection and the Journal of Emergency Medicine database. Grey literature was examined via Google, Google Scholar and a search of publicly available resources on the Department of Health website (http://www.dh.gov.uk/en/index.htm). Supplementary studies were identified from reference lists within relevant papers, including organisational website links. No hard copy searching was performed.

Inclusion criteria

In accordance with PRISMA guidelines11 we sought published evidence where ECPs in any UK setting were identified as key components of service operation by the study authors. This included:

  • Any research measuring NHS staff or patients perceptions of the acceptability or performance of the ECP role.

  • Any healthcare cost studies.

  • Any research assessing the clinical working practices of ECPs.

Evidence was included from adult and children emergency care, critical care and minor injury units, and settings outside of hospital (such as home and out-of-hours general practitioner (GP) services). No time or language limitation was applied.

Exclusion criteria

We excluded literature where:

  • The setting was purely a telephone service (such as NHS Direct).

  • The focus was descriptive (eg, legal implications of nursing practice) or no methodological information was provided.

  • Any component of the evidence was from outside the UK.

  • The source was outside of journal, university or government publication.

Keywords

The keywords we developed were designed to capture national literature about ECPs and included ‘Care practitioner’ and ‘ECP’. A separate broad search was also carried out using keyword search terms ‘Nurse practitioner’ and ‘Nursing’ combined with keyword terms describing emergency settings and ECP roles within emergency care. All searches including mappings to a large number of MeSH such as: Nursing; Nurse's Role; Nurse's Practice Patterns; Nursing Staff; Nursing Staff, Hospital; Professional Competence; Patient Care; Quality of Health Care; Outcome Assessment (Health Care). The full search strategy for each database is available as a supplementary file on the publisher's website.

Data extraction

We used a structured form for data extraction from quantitative studies that included: recruitment/sampling; method of data collection; method of data analysis; key ideas, models, concepts, arguments and assumptions; authors’ conclusions; and the likely generalisability of findings. This quality appraisal tool was constructed from published guidance on the quality appraisal of cohort studies.12–15 No additional analysis was performed on quantitative data. We added to the quality appraisal tool a key set of conditions independently designed for the appraisal of qualitative studies16 and mixed-method studies.17 Differences in appraisal outcomes found between the two researchers were resolved in a scheduled meeting.

Search results

A diagram of the study selection process is in figure 1. The initial screening of title and abstracts (247 studies) was by one researcher (HH). Two hundred and twelve articles were excluded for evaluating different aspects of nursing to ECP roles, leaving 35 articles. Fourteen were excluded because they did not contain original evidence: 11 were not empirical evaluations; one was not a full text and judged by two researchers (HH and PM) independently to contain too little methodological information for inclusion; two studies had little relevance despite including ECP participants as there was no evaluative or descriptive component. The remaining 21 studies were quality appraised. All of the studies that were identified from the grey literature were project reports and it was unclear whether they had been subjected to external peer review.

Figure 1

Flow diagram of the study selection process.

Summary of identified papers

The agreed quality of the final set of studies is summarised in table 2.

Table 2

Summary of quality assessment

The design and results of studies that meet the inclusion criteria are summarised in tables 37.

Table 3

Summary of patient care and processes of care studies

Table 4

Summary of workplace behaviour studies

Table 5

Summary of patient referral studies

Table 6

Summary of avoided admission studies

Table 7

Summary of cost-effectiveness studies

Patient care and processes of care

Ten studies examined the care provided by ECPs.18–27 Three were qualitative interviews with ECPs and stakeholders18–20 which found a range of benefits to patient care from nursing and paramedic based ECPs particularly during patient assessment, for example, in information provision. Halter et al26 found high levels of patient support for the care provided by care-home based ECPs, and patient compliance with their treatment advice.

Five studies212,5 were of high quality with large samples (>600 participants) and observational controls of usual practitioners in emergency services, although they did not identify whether observed ECPs were nursing or paramedic based. Five high quality studies found either greater overall patient satisfaction in patients seen by an ECP23 ,26 or better processes of care associated with ECP decision-making.23 ,25 ,27

The trend for a positive impact on patient care specifically linked to the ECP role was not supported by one comprehensive study24 which used matched controls in five different settings and applied additional controls for possible confounding factors (age, sex and presenting complaint). The service setting was the main determinant of whether ECPs or traditional practitioners were more likely to spend time with a patient, undertake investigations, provide treatment and offer advice. There were statistically significant (p<0.05) differences in care detected between ECP and usual practitioners, although these were small and may not reflect a clinical difference to the patient or have a useful service implication.

Workplace behaviour

Five studies19 ,23 ,28–30 examined workplace decision-making and collaborative practices of ECPs. In an analysis of 269 practitioners’ reflective reports and 14 stakeholder interviews, Cooper et al19 found that ECPs from a paramedical background worked closely with other healthcare professionals to resolve communication problems and identify patients that matched their skills. Cooper et al28 ,29 reported a similar finding from ECPs with nursing and paramedic backgrounds in a 12 month clinical case study with mixed methods design. On direct observational ratings, ECPs scored highly on communication skills, teamwork rating and leadership behaviour.28 In interviews with ECPs and stakeholders, they found collaborative practices between ECPs and other health professions were present and had a beneficial impact on developmental links in clinical areas and teamwork.29 Evidence of ECPs working successfully with a range of other professionals including GPs, paramedics and technicians is also present in other studies.23 ,28

Three studies found opportunities to improve ECPs’ decision making processes through experience, training and support. More experienced ECPs from a nursing or paramedic background achieved higher scores on tools measuring workplace collaborative practices.28 ECPs from a paramedic background reported scope to further develop their decision-making through improvements in baseline clinical knowledge, greater support from traditional healthcare practitioners and direct feedback.30 Paramedic ECPs also reported that appropriate training strongly influenced their strategic use of clinical resources.29

Patient referrals

A large number of studies report conveyance as an outcome,19 ,23 ,24 ,26 ,28 ,29 ,31–33 that is, ECPs referred to another stage of healthcare (usually EDs). There was a wide variation in methodological quality, with studies published earlier more likely to have design limitations.

In three studies19 ,23 ,32 conveyance was a binary outcome measured as ‘conveyed/not conveyed to the ED’. The studies7 ,24 ,26 ,28 ,31–33 that captured referrals to other agencies (eg, community care or inpatient services) produced more relevant findings when considering the broader societal perspective preferred by NHS policy makers.34 Only a small number of studies24 ,28 ,31 provided separate information on the discharge of patients by ECPs which would be required to determine whether an ECP service has simply added another stage in the patient pathway.

A problem in two studies28 ,31 was the comparison of the conveyance rate of ECPs to an approximate measure of the historical average across a whole organisation (including ECP-attended cases). Others referenced the conveyance of patients from traditional practitioners.19 ,23 ,31–33 The unreported regional prevalence of treatment profiles (illnesses, accidents, morbidities) and demographic factors was a confounding influence in the studies that compare conveyance rate figures from ECP services across different trusts and healthcare settings.24 ,32 ,33

A small number of high quality studies24 ,32 ,33 recently found mixed results after attempting to adjust for demographic and clinical confounders in conveyance rates by matching ECPs to usual healthcare providers across multiple sites. Halter and Ellison32 found that after adjustment, a lower conveyance rate was observed among ECP-attended cases (p<0.05). Whereas Mason et al24 found that in static settings (GP out-of-hours and urgent-care centres) ECPs were less likely to discharge patients (p<0.05) than usual providers and were more likely to refer to hospitals or EDs (p<0.05). In children's services O'Keefee et al33 reported that in all settings (minor injury unit, urgent-care centre and GP out-of-hours) ECP input was associated with higher rates of conveyance and lower rates of discharge which reached statistical significance (p<0.05). The two sets of ECPs may operate very differently and be assigned different tasks and/or to different operational settings.

Avoided admissions further along in the patients care pathway

Three studies directly investigated avoidance of admissions to hospital or primary care following the introduction of ECPs.35–37 The measures varied widely, each assuming a different method of identifying a causal influence in the context of possible confounding variables. Gray and Walker35 defined avoided attendance as occasions when an ECP provided an intervention that would prevent a GP from doing so in primary care. This restricted the generalisation of their findings, as they tried to ascertain any added value over a GP from commissioning GP referrals inhours to ECPs. This led to a 9.5% avoided attendance rate compared with the trust's standard workload of 60% for an ECP service responding to 999 calls, crew referrals and direct care-home referrals.

Gray and Walker36 avoided case-mix confounding factors by investigating two defined patient groups (elderly patients with breathing difficulties or a fall) at a single ED and also considered the effect of reinitiation of contact with patients after 28 days. By comparing historical attendances data for patients seen by non-ECP ambulance service personnel to those seen by an ECP service, they found ECPs decreased rates of admission to EDs at initial and follow-up contact in both patient groups.

Coates et al37 employed a method of having an ED consultant and GP independently review medical records to assess whether the actions of ECPs resulted in an avoided attendance. ECPs considered that 11.6% of patients treated at the scene avoided hospital admission as a result of their input while the ED consultant reported an admission avoidance rate of 15.1% and the GP 9.9%.

Cost-effectiveness

There is a paucity of evidence available for a comparison of ECP cost-effectiveness.1. 7 ,23 ,35 The three studies which specifically investigated the cost of introducing an ECP service found a saving1 ,7 ,23 although they did not state whether the service was paramedic or nursing based. Mason et al23 approximate this saving to be £291 per patient compared with usual care providers when operational in a single ambulance trust setting. They reported this to be a consequence of lower staff costs at incidents, a reduction in ED and hospital admissions in patients seen by ECPs and lower use of non-inpatient follow-up services from patients seen by ECPs.

A much smaller cost saving (£26–£31 per patient visit) was found in Mason et al7 from an analysis of descriptive survey data of project leaders in an ECP service. This is less reliable data to that of routinely collected site records although the survey reflected a large number and broad range of operational settings: 14 sites including ambulance services, EDs and minor injury units.

No cost saving was demonstrated by Gray and Walker35 when ECPs were commissioned to see referrals from primary care within usual working hours. The scope of their investigation was the narrowest of the four ECP cost-effectiveness studies: a single ambulance service setting with a single patient group (elderly patients). Using routinely collected data from 2005, approximately the same study period as Mason et al,7 ,23 they estimated a cost of £130 per case for an ECP response compared with a historical figure of £115 for an ambulatory response in the same trust. The evaluation with the largest scope was reported by the Department of Health,1 collecting data from 17 health communities in two waves during the first ECP schemes. A cost efficiency saving of £8817—£31 700 per ECP (2004 prices) was found but the validity of the findings is uncertain because the methodological approach was not fully reported.

Discussion

After a wide search, the available literature described that the workplace performance of ECPs and care quality delivered (from a patient's perspective) was as good as existing services. The studies that specifically investigated the costs of introducing an ECP service found a cost saving, which varied widely according to the clinical context. The literature finds that some patients attended by ECPs are less likely to be referred to other services. Although this may result from improved decision-making skills it is also possible that the patients selected for review by ECPs are less likely to be conveyed by the nature and severity of their condition. The literature suggested that the effectiveness of ECPs in reducing attendances did depend upon the operational setting. Almost all studies considered only a single clinical patient encounter. Without data about reattendance, it cannot be assumed that over a long period of time a patient reviewed by ECPs would be admitted less frequently than if they were seen by other practitioners. Nonetheless, the studies which have directly examined ‘admission avoidance’ presented findings which support that aspect of the ECPs’ role.

Few studies describe the ECPs’ professional background. When this information is not present, inferring a firm conclusion from common findings across studies is problematic. This is because the training and qualifications of participants will substantially differ between groups that are nursing and paramedic based. Future research should provide descriptive information on the qualifications, training and the career pathway through which the study participants achieved formal ECP status.

The majority of studies that examined health service costs retrospectively compared emergency services to when ECPs were not operational. They did not investigate whether patients selected for ECP visits were broadly representative of the general population or of patients receiving care from ECPs in other settings. Further research is therefore warranted to establish whether this cost saving would be possible across ambulatory services and EDs in general, and the main resource benefit.

Policy implications

Pressure on emergency medical systems has meant a particular focus on the development and reorganisation of services. This review has identified methodologically robust evaluations which allow managers and clinicians to apply the conclusions to local context. We found the ECP role has had advantages for NHS service delivery, particularly high satisfaction scores from patients and colleagues. However, caution should be exercised before drawing inferences that the commissioning of an ECP service is a more productive option than GP visits or paramedic treatment on scene. Patient care pathways are complex and it should be considered that the service improvement evidence is from ECPs’ supporting staff in existing services rather than a performance improvement over existing roles. For example, ECPs could be using NHS resources more efficiently (preventing avoidable ambulance and ED admittances) and impacting emergency services workloads (releasing time other health professionals spend on delivering routine treatments). A comprehensive judgment on the commissioning of ECP services cannot yet be made in absence of evidence of delivery of care across the whole patient episode. Ongoing evidence is also needed to understand if ECPs are meeting the original objectives of the role1 and whether acquisition of these skills by more nurses and paramedics might improve care and performance. Although caution should be exercised in such comparisons as the deployment and service duties of ECPs are often different to that of paramedics and nurses.

Conclusion

ECPs are an established part of emergency medical services in the NHS. This is the first review to evaluate all aspects of their impact in UK health services by drawing together findings from all health service research designs (quantitative, qualitative and mixed-methods). We have identified a distinct variation in the practice of ECPs and diverse benefits from the extra skills they possess. Differences in the study populations and research methods employed mean that a firm conclusion about cost-effectiveness is not possible.

References

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Footnotes

  • Contributors HH is the contributor responsible for the overall content as guarantor. HH constructed search terms and conducted database and grey literature searchers. He also identified the final set of studies against the inclusion and exclusion criteria. HH and PM quality appraised the studies. HH, PM and CP constructed the inclusion and exclusion criteria and wrote the text.

  • Funding NIHR Research Capability Funding, NHS Foundation Trust.

  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement None of the authors have access to additional unpublished data.

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