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Abstract
Objective To conduct a systematic review and meta-analysis to examine the impact of new prehospital practitioners (NPPs), including emergency care practitioners (EmCPs), paramedic practitioners and extended care paramedics (ECPs), on ambulance transportation to the emergency department (ED).
Methods We searched MEDLINE, Embase, CINAHL and AUSTHealth databases, and hand searched emergency medicine journals and journal reference lists for relevant papers. To be included, studies were required to target one type of NPP and compare outcomes such as the frequencies of conveyance to the ED, discharge at scene, subsequent ED attendance and/or appropriateness of care between NPPs and conventional ambulance crews. Three investigators independently selected relevant studies. The risk of bias in individual studies was assessed using a validated checklist. We conducted meta-analyses for comparisons which had acceptable heterogeneity (I2<75%) and reported pooled estimates of ORs with 95% CIs.
Results 13 studies were identified from 16 584 citation reports. EmCPs were most frequently studied. The majority of studies (77%) did not fully report important potential confounders. NPPs were less likely to convey patients to the ED and more likely to discharge patients at the scene than conventional ambulance crews. Pooled ORs for conveyance to the ED and discharge at the scene by ECPs were 0.09 (95% CI 0.04 to 0.18) and 10.5 (95% CI 5.8 to 19), respectively. The evidence for subsequent ED attendance and appropriateness of care was equivocal.
Conclusions The NPP schemes reduced transport to the ED; however, the appropriateness of the decision of the NPPs and the safety of patients were not well supported by the reported studies.
- emergency ambulance systems
- emergency care systems
- paramedics, extended roles
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Introduction
The Department of Health in the UK reported that emergency department (ED) presentations increased from 14 million in 2001–2002 to 21 million in 2010–2011.1 When the demand for ED services exceeds available resources, ED crowding occurs, which can lead to delay in the delivery of time sensitive care (eg, thrombolysis for acute myocardial infarction).2
One strategy proposed to reduce demand for ED services is to decrease ambulance transportations to the ED by providing care at the scene and/or referring a patient to an alternative healthcare service. New prehospital practitioners (NPPs), including emergency care practitioners (EmCPs) and paramedic practitioners (PPs), were introduced in the UK in the early 2000s to reduce the ED demand.3 ,4 In Canada, New Zealand and Australia, extended care paramedics (ECPs), with a similar role to EmCPs, were introduced in the late 2000s. The aim of NPPs is to provide pathways other than the default transport to the ED for patients who suffer from minor illness or injury.
NPPs are similar to paramedics but their role differs in that they have an expanded scope of clinical practice in patient assessment and treatment options. NPPs (EmCP, PP and ECP) are trained to manage minor illness and injury —for example, perform simple suturing, order investigations such as x-rays, and prescribe medications. They are also trained to decide whether a patient needs care at an ED or could be treated at home or in the community. Although there are some differences in the settings and prerequisite qualifications among NPPs, they are all able to provide care at the scene and discharge patients on site without referral to other clinicians.3
The impact of NPPs on emergency services has been reported in four published reviews,5–8 in which the implementation of EmCP and PP programmes reduced conveyances to the ED. However, these reviews were not conducted in a systematic manner and did not include ECPs. To provide a more robust assessment of the strengths and limitations of the current evidence base and better inform policy decisions about the structure of prehospital emergency services, we have conducted a systematic review and meta-analysis of the impact of NPPs on patient transportation to the ED.
Methods
This systematic review was registered with PROSPERO (CRD42012003142) before commencing the literature search.9
Eligibility criteria
To be included in our review, studies were required to meet four criteria: (1) the paper must report an original comparative study; (2) study participants must be those who sought an ambulance service; (3) the study must target one type of NPP; and (4) the study must report one or more of the following outcome measures: the number of patients discharged at the scene, the number of patients conveyed to the ED, subsequent ED attendance and appropriateness of care provided/decisions made. We only included articles published in 2002 or later because NPP programmes started after 2002. We did not set any language restriction for the literature search and intended to seek a translation service if required. Conference abstracts were included, but letters and commentaries were excluded.10
Information source
Databases searched for relevant studies were: Ovid MEDLINE (to 2012 October week 3), Ovid Embase (to 2012 week 43), EBSCO CINAHL (2002 to current) and Informit AUSTHealth (2002 to current). We also hand searched emergency medicine journals (2002–2013) for relevant papers and journal reference lists.
Search strategy
We used the following text words and relevant subject headings in our search strategy: (‘emergency care practitioner’ or ‘paramedic practitioner’ or ‘extended care paramedic’) or ((‘provider’ or ‘practitioner’ or ‘paramedic’ or ‘new role’ or ‘Emergency Medical Technician’) and (‘ambulance’ or ‘emergency medical service’ or ‘prehospital’ or ‘pre-hospital’)). Subject headings were expanded if available. The detailed search strategies are available in the online supplementary appendix 1.
Study selection
Three reviewers (HT, TAW and JF) screened titles and abstracts of all retrieved studies for potentially relevant studies. Full text articles of these studies were reviewed by the same three reviewers. Disagreements in study eligibility were resolved by consensus. If multiple papers were generated from one study, we cited all papers but used the data from the most comprehensive paper and supplementary information from the other paper. We planned to contact corresponding authors if information was insufficient to determine eligibility for inclusion.
Data abstraction
We created a data extraction form based on a Cochrane data extraction template.11 We piloted and refined the form before the formal data extraction process began, and then used it to record the following information about each study: author(s), study year, study location, study period, study design, participants, type of NPP, outcome measures and results. If a study reported information related to non-prehospital settings (eg, ED), only data pertaining to a prehospital ambulance setting were collected. One reviewer (HT) extracted information and double checked the accuracy and details of the extracted data.
Assessment of risk of bias in individual studies
We critically appraised relevant studies using a tool developed by Downs and Black.12 The checklist consisted of 27 questions: 25 with yes/no answers, scored 1 for ‘yes’ and 0 for ‘no’; one question about confounders, scored 0–2; and another about sample size, scored 0–5. The maximum score was 32, with a higher score indicating lower risk of bias. The tool has been reported to perform well for both randomised and non-randomised studies.12
Summary measures
Outcomes were summarised using ORs that compared the odds for NPPs with those for conventional ambulance crews. If there was not enough information to compute an OR, we presented other relevant information (eg, percentages of events).
Synthesis of results
We used RevMan software V.5.1 to perform meta-analyses that employed the Mantel–Haenszel method in random effects models, which is the preferred approach when there is heterogeneity among studies.13 ,14 We first performed analyses for each outcome measure, including all types of NPPs, and then conducted subgroup analyses for each type of NPP.
Heterogeneity was quantified using the I2 statistic.15 An I2 statistic >75% implies that there is high heterogeneity15; therefore, we decided not to report pooled results when the I2 statistic was >75%.
Risk of bias across studies
Risk of bias across studies was determined using the method proposed by Harbord et al.16 We used the 5% significance level for this test.
Results
Study selection
We retrieved a total of 16 584 citations from the database searches. After excluding duplicate citations, 12 547 remained. We screened titles and abstracts and excluded 12 492 that clearly did not meet the selection criteria. In addition to the 55 potentially relevant papers, we identified one paper from hand searching relevant journals and four papers from reference lists. Of the 60 papers eligible for full text review, 20 papers described the 13 studies that met our selection criteria and were included in this systematic review (figure 1).
Flow diagram of study selection process.
Characteristics of included studies
The characteristics of the included studies are summarised in table 1. The majority of studies (n=9) were conducted in the UK,17–32 three studies were conducted in New Zealand33–35 and one in Canada.36 EmCPs were most frequently studied.17–20 22–24 28–32 The most frequently reported outcome measure was conveyance to the ED,18 ,21–29 33–36 followed by discharge at the scene18–22 25–30 ,33 ,34 ,36 and subsequent attendance at a health service.18 ,21 ,22 ,25–34 There were no individual patient randomised controlled trials, but there was one cluster randomised controlled trial, which generated four papers.21 ,25–27
Characteristics of the included studies
Risk of bias in individual studies
The median score using the Downs and Black's checklist12 was 21 (range 7–28). The majority of studies did not report important potential confounding factors or adjust outcome measures for these. Detailed results are available in the online supplementary appendix 2.
Results of individual studies
Conveyance to the ED
NPPs were 1.6–50 times less likely to convey patients to the ED than conventional ambulance crews (figure 2A).18 ,23 ,24 ,27 ,28 ,34 ,36 In a meta-analysis of the ECP subgroup, ECPs were 11.1 times less likely to convey patients to the ED (pooled OR (95% CI)=0.09 (0.04 to 0.18), I2=40%) (figure 2B). We did not perform meta-analyses for conveyance to the ED for other NPP types because of high heterogeneity. Three studies22 ,33 ,35 reported the proportion of patients who were transported to the ED by NPPs and conventional ambulance crews without sufficient information to compute ORs. One22 of the three studies used two specific subcohorts (patients with breathlessness and patients who had fallen). All three studies reported that smaller proportions of patients were transported to the ED by NPPs than conventional ambulance crews (40% vs 74%33; 38% vs 63%35; 36% vs 76% for the breathlessness cohort; and 27% vs 51% for the falls cohort22).
Forest plots for conveyance to the emergency department. ED, emergency department; EmCP, emergency care paramedic; PP, prehospital practitioner; ECP, extended care paramedic.
Discharge at the scene
NPPs were 1.6–26 times more likely to discharge patients at the scene than conventional ambulance crews (figure 3A).18 ,27 ,28 ,30 ,34 ,36 A meta-analysis of the ECP subgroup revealed that ECPs were 10.5 times more likely to discharge patients than conventional ambulance crews (pooled OR (95% CI)=10.5 (5.8–19), I2=20%) (figure 3B). Overall meta-analysis and other subgroup meta-analyses for this outcome were not performed because of high heterogeneity. Two studies19 ,22 reported proportions of patients who were discharged at the scene without enough information to compute ORs. As in the previous section, one study22 used the two subcohorts (breathlessness and falls cohorts). Both studies reported greater proportions of discharges at the scene for NPPs than conventional ambulance crews (48% vs 32%19; 64% vs 24% for the breathlessness cohort; and 73% vs 49% for the falls cohort22).
Forest plots for discharge at the scene. ED, emergency department; EmCP, emergency care paramedic; PP, prehospital practitioner; ECP, extended care paramedic.
Subsequent ED attendance
There was no conclusive evidence about the impact of NPPs on subsequent ED attendance. Two studies (three comparisons) reported ORs for subsequent ED attendance (figure 4).26 ,27 ,30 Mason et al26 reported ORs for two different follow-up periods: 7 and 28 days.27 One study reported a 26% increase in ED attendance while two did not show a difference (figure 4).26 Cooper et al18 reported that there was no subsequent ED attendance within 24 h after the first contact with NPPs or conventional ambulance crews. Mason et al28 reported a 41% increase in subsequent health service contact after being seen by EmCPs compared with conventional ambulance crews (unadjusted OR=1.41, 95% CI not available). There were variations in the follow-up period to study subsequent ED attendance. Three studies26 ,28 ,30 followed-up patient outcome after contact by NPPs for 28 days, one study27 followed-up patients for 7 days and one18 for 24 h.
Forest plot for subsequent emergency department attendance. *7 day follow-up; **28 day follow-up.
Appropriateness of care/decision
Four studies17 ,23 ,27 ,30 assessed the appropriateness of care provided or decisions made by NPPs with a ‘review by experts’, but each study used a different measure: a scale measure of appropriateness,30 a dichotomous measure (yes/no) of appropriateness,23 avoidance of ED attendance for those discharged at the scene17 and proportion of suboptimal care (table 2).27 As such, data synthesis was impossible. Coates et al reported that the agreement between EmCPs and senior health care professionals on the avoidance of ED attendance was fair (κ=0.39).37 Halter and Ellison23 reported that EmCPs were significantly more likely to make appropriate decisions about patient disposition than conventional ambulance crews.23 Mason et al27 reported no significant difference in the appropriateness of care and the rate of suboptimal care between NPPs and conventional ambulance crews. 30
Summary of findings: appropriateness of care/decision
We examined publication bias across studies that reported discharge at the scene and conveyance to the ED. There was no significant publication bias detected among the studies (p>0.1).
Discussion
Summary of evidence
Our systematic review of the effect of NPPs on emergency services included 13 studies that met predetermined criteria. We identified one cluster randomised controlled trial which generated four papers21 ,25–27 and two quasi-experimental studies.22 ,30 The other 10 studies17–20 22–24 ,28 ,29 ,31–36 were observational studies. Differences in baseline characteristics were common, and there was infrequent adjustment for potential confounders. Despite these limitations in study quality, we found that NPPs were more likely to discharge patients at the scene and less likely to convey patients to the ED than conventional ambulance crews. The evidence for subsequent ED attendances and appropriateness of care/decision remains equivocal.
Although we could not perform meta-analyses for all outcome measures due to heterogeneity, there was evidence that the NPP programme could reduce conveyances to the ED and increase discharges at the scene. All ORs for conveyance to the ED and discharge at the scene were statistically significant. Further, these favourable results for NPPs were consistent across the three types of NPP. The majority of studies have been conducted in the UK. More studies from countries where the NPP programme has been implemented will supplement this evidence.
Patient safety has to be assured for the successful implementation of the NPP programme. In this review, we considered two patient safety measures: appropriateness of care provided/decision made and subsequent ED attendance/hospital admission. The former is commonly used when assessing the appropriateness of decisions made by paramedics.38–40 The latter is a relative measure which addresses the quality of the NPP's initial decision. For instance, if subsequent ED visits occur more often when patients are seen by NPPs than when seen by conventional paramedics, the initial NPP decision might not be adequate. We could not draw conclusions about patient safety using the measures. Subsequent ED attendances/hospital admissions were not able to be assessed due to variable inclusion criteria: for instance, Mason et al27 included unplanned subsequent ED attendances only, while two other studies28 ,30 identified both planned and unplanned subsequent ED attendances. The former criterion may be a better measure than the latter but determination of what constitutes a planned versus unplanned ED attendance is somewhat subjective. Follow-up periods to determine patient outcomes were also different across the studies: 24 h, 7 days and 28 days. Mason et al27 noted that most serious adverse results would have occurred within 7 days after the initial contact. If subsequent unplanned ED attendance occurred a ‘prolonged’ period after the initial episode (and ‘prolonged’ was not defined), such a late re-presentation may be more related to chronic aetiology rather than acute illness.
There was considerable variation in the methods used to review appropriateness of care and decisions made by NPPs. Consistent use of the same method may facilitate evidence generation.
Limitations
This review has several limitations at study and review level. Observational studies were included; therefore, differences in potential confounders between the NPP group and conventional ambulance crew group are likely to exist, and the majority of studies did not adjust for potential confounders (eg, age and/or patient clinical presentation). If characteristics of groups are different, their study results may be misleading and cannot be generalised.
We could not conduct meta-analyses for all outcome measures due to heterogeneity among studies, even though we performed subgroup analyses, which is a technique to reduce heterogeneity by grouping similar studies.41 The small number of studies did not facilitate further subgroup analysis to examine the reason for the heterogeneity. A potential source of heterogeneity was the variability in casemix between the NPPs and conventional ambulance crews.23 ,33 For example, patients with cardiac aetiology were more likely to be conveyed to the ED while those with minor cuts were more likely to be discharged at the scene. The distribution of clinical presentations in each group should be reported.
Other sources of heterogeneity include the inconsistency of education programmes and the mode of deployment across the regions studied. The duration of education programmes ranges from 1 month35 to 2 years.19 ,42 Master level NPPs might be more likely to make appropriate decisions than those who completed 1 month training programmes. The mode of deployment of NPPs might also affect patient disposition. Patients seen by paramedics who call NPPs are unlikely to be conveyed to the ED because the paramedics have already decided that the patient could be treated by NPPs.
Only two studies27 ,28 reported patient destinations other than the ED or discharge at the scene and compared them between NPPs and conventional ambulance crews. This information might be important for those who educate NPPs and policy makers. Both studies reported NPPs were more likely to refer patients to other health services (eg, community social service). This implies that NPPs may require skills to determine whether a given patient may be more appropriately treated at another health service. Educational programmes for NPPs may need to include information about community health services. Further, if the NPP programme is implemented, the number of attendances at other health services may increase, and policy makers may need to plan to improve the accessibility and availability of these health services.
Although we conducted an extensive literature search, we could only identify 13 studies and all were conducted in the UK, Canada and New Zealand. In the USA, emergency medical technician-paramedics can perform similar or even advanced skills compared with new prehospital healthcare providers. However, in the 200 largest US cities, discharge at the scene without medical oversight was sanctioned in only five cities.43
Future directions
Future research should focus on the safety of patients attended by NPPs. Six studies17 ,18 ,23 ,27 ,28 ,30 assessed patient safety using subsequent ED attendance after being seen by NPPs and/or appropriateness of care/decision made by NPPs. However, we could not draw generalised evidence regarding patient safety because the methods employed varied between studies. Policy makers may be reluctant to embrace the concept of NPPs without evidence of patient safety. Studies that use consistent and/or standardised methods are required.
Future research should also focus on the impact of the NPP schemes on ED crowding. Although the NPP schemes have the potential to reduce the demand for ED services, it is still uncertain whether the NPP schemes can mitigate ED crowding. Several studies reported that diversion of non-urgent patients had little effect on ED crowding.44–46 The NPP schemes are similar to this divert non-urgent patients strategy in terms of the reduction of input to EDs. Thus the NPP schemes may not alleviate ED crowding.
Conclusion
The implementation of NPP schemes reduced patient conveyance to the ED and may reduce unnecessary transportation of patients by providing care at the place where a patient resides. However, rigorous evidence about the appropriateness of decisions made by NPPs and the safety of patients is lacking. This information is crucial for policy makers and other stakeholders to inform decision making and ensure patient safety. Standardisation of methods to evaluate the appropriateness of decisions is needed.
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Files in this Data Supplement:
- Data supplement 1 - Online appendix 1
- Data supplement 2 - Online appendix 2
Footnotes
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Contributors HT, IJ, JF, TAW and AB conceived the study. HT, TAW and JF conducted the search of relevant articles. HT abstracted relevant information and drafted the manuscript. TAW and AB provided statistical advice. All authors contributed to the analysis and interpretation of the data and revision of the article. HT analysed the data, drafted the article and takes responsibility for this paper as a whole. All authors gave approval to submit this article.
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Funding This review was funded by the Targeted Research Fund, Western Australia Department of Health (reference number: F-AA-00788).
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Competing interests IJ is the Clinical Services Director at St John Ambulance Western Australia (SJA-WA), JF receives partial salary support from SJA-WA for her role as Adjunct Professorial Research Fellow and TAW is a non-compensated Adjunct Senior Research Fellow at SJA-WA.
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Provenance and peer review Not commissioned; externally peer reviewed.