A systematic review of the activity and impact of emergency care practioners in the NHS

Hill, Harry; McMeekin, Peter; Price, Chris

doi:10.1136/emermed-2013-202660

Cited by 13 publications

(26 citation statements)

References 22 publications

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“…We have summarised the characteristics and findings of the seven systematic reviews [146][147][148][149][150][151]173 (Tables 10 and 11). Data on the 12 papers 174-185 not included in the systematic reviews were extracted in to summary tables (Tables 12-14).…”

Section: Resultsmentioning

confidence: 99%

“…Six of the systematic reviews [146][147][148]150,151,187 found evidence that prehospital professionals can successfully reduce the number of patients transported to EDs and provide autonomous care and appropriate referral in the community setting. The evidence is predominated by schemes to provide ambulance paramedics with extended and enhanced clinical skills.…”

Section: Effectivenessmentioning

confidence: 99%

“…NIHR Journals Library www.journalslibrary.nihr.ac.uk 146 Cooper and Grant, 2009 147 Evans, 2014 148 Hill, 2014 149 Mikolaizak, 2013 150 Tohira, 2014 151 Adams, 2005 152 ✓ ✓ …”

Section: Management Of Patients With Urgent Care Problems By Ambulancmentioning

confidence: 99%

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What evidence is there on the effectiveness of different models of delivering urgent care? A rapid review

Turner

Coster

Chambers

et al. 2015

Health Serv Deliv Res

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BackgroundIn 2013 NHS England set out its strategy for the development of an emergency and urgent care system that is more responsive to patients’ needs, improves outcomes and delivers clinically excellent and safe care. Knowledge about the current evidence base on models for provision of safe and effective urgent care, and the gaps in evidence that need to be addressed, can support this process.ObjectiveThe purpose of the evidence synthesis is to assess the nature and quality of the existing evidence base on delivery of emergency and urgent care services and identify gaps that require further primary research or evidence synthesis.Data sourcesMEDLINE, EMBASE, The Cochrane Library, the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and the Web of Science.MethodsWe have conducted a rapid, framework-based, evidence synthesis approach. Five separate reviews linked to themes in the NHS England review were conducted. One general and five theme-specific database searches were conducted for the years 1995–2014. Relevant systematic reviews and additional primary research papers were included and narrative assessment of evidence quality was conducted for each review.ResultsThe review was completed in 6 months. In total, 45 systematic reviews and 102 primary research studies have been included across all five reviews. The key findings for each review are as follows: (1) demand – there is little empirical evidence to explain increases in demand for urgent care; (2) telephone triage – overall, these services provide appropriate and safe decision-making with high patient satisfaction, but the required clinical skill mix and effectiveness in a system is unclear; (3) extended paramedic roles have been implemented in various health settings and appear to be successful at reducing the number of transports to hospital, making safe decisions about the need for transport and delivering acceptable, cost-effective care out of hospital; (4) emergency department (ED) – the evidence on co-location of general practitioner services with EDs indicates that there is potential to improve care. The attempt to summarise the evidence about wider ED operations proved to be too complex and further focused reviews are needed; and (5) there is no empirical evidence to support the design and development of urgent care networks.LimitationsAlthough there is a large body of evidence on relevant interventions, much of it is weak, with only very small numbers of randomised controlled trials identified. Evidence is dominated by single-site studies, many of which were uncontrolled.ConclusionsThe evidence gaps of most relevance to the delivery of services are (1) a requirement for more detailed understanding and mapping of the characteristics of demand to inform service planning; (2) assessment of the current state of urgent care network development and evaluation of the effectiveness of different models; and (3) expanding the current evidence base on existing interventions that are viewed as central to delivery of the NHS England plan by assessing the implications of increasing interventions at scale and measuring costs and system impact. It would be prudent to develop a national picture of existing pilot projects or interventions in development to support decisions about research commissioning.FundingThe National Institute for Health Research Health Services and Delivery Research Programme.

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Section: Resultsmentioning

confidence: 99%

Section: Effectivenessmentioning

confidence: 99%

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What evidence is there on the effectiveness of different models of delivering urgent care? A rapid review

Turner

Coster

Chambers

et al. 2015

Health Serv Deliv Res

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“…The available evidence indicates that specialist roles have reduced conveyance to ED and increased discharge at scene, thus reducing the costs associated with ambulance journeys, ED attendances and hospital admissions. 10,11 However, one of these reviews also concluded that there is a lack of rigorous evidence on the appropriateness of decisions and the safety of patients. 11 The need for a better understanding of influences on the safety of paramedic decision making and potential risk factors (threats) is particularly important in the context of plans to develop emergency ambulances into mobile urgent treatment services capable of dealing with more people at scene, 5 to ensure that such developments do not increase the risk for patients.…”

Section: Introductionmentioning

confidence: 99%

A qualitative study of systemic influences on paramedic decision making: care transitions and patient safety

O’Hara

Johnson

Siriwardena

et al. 2014

J Health Serv Res Policy

114

152

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Objectives: Paramedics routinely make critical decisions about the most appropriate care to deliver in a complex system characterized by significant variation in patient case-mix, care pathways and linked service providers. There has been little research carried out in the ambulance service to identify areas of risk associated with decisions about patient care. The aim of this study was to explore systemic influences on decision making by paramedics relating to care transitions to identify potential risk factors. Methods: An exploratory multi-method qualitative study was conducted in three English National Health Service (NHS) Ambulance Service Trusts, focusing on decision making by paramedic and specialist paramedic staff. Researchers observed 57 staff across 34 shifts. Ten staff completed digital diaries and three focus groups were conducted with 21 staff. Results: Nine types of decision were identified, ranging from emergency department conveyance and specialist emergency pathways to non-conveyance. Seven overarching systemic influences and risk factors potentially influencing decision making were identified: demand; performance priorities; access to care options; risk tolerance; training and development; communication and feedback and resources. Conclusions: Use of multiple methods provided a consistent picture of key systemic influences and potential risk factors. The study highlighted the increased complexity of paramedic decisions and multi-level system influences that may exacerbate risk. The findings have implications at the level of individual NHS Ambulance Service Trusts (e.g. ensuring an appropriately skilled workforce to manage diverse patient needs and reduce emergency department conveyance) and at the wider prehospital emergency care system level (e.g. ensuring access to appropriate patient care options as alternatives to the emergency department).

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“…However, this higher level of education and training represents a minority of paramedics. There is some evidence that ECPs can deliver quality care safely 75 and are having an impact on non-conveyance rates, with discharge rates upward of 20% greater than those for usual care, 6,76,77 although the evidence for subsequent readmission or appropriateness of care is generally lacking.…”

Section: Staff Roles Skills and Developmentmentioning

confidence: 99%

A qualitative study of decision-making and safety in ambulance service transitions

O’Hara

Johnson

Hirst³

et al. 2014

Health Services and Delivery Research

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Background: Decisions made by front-line ambulance staff are often time critical and based on limited information, but wrong decisions in this context could have serious consequences for patients. There has been little research carried out in the ambulance service setting to identify areas of risk associated with decisions about patient care.\ud Aim: The aim of this study was to qualitatively examine potential system-wide influences on decision-making in the ambulance service setting and to identify useful areas for future research and intervention.\ud Methods: We used a multisite, multimethod qualitative approach across three ambulance service trusts. In phase 1 we carried out 16 interviews to contextualise the study and provide discussion points for phase 2. For phase 2, university and ambulance service researchers observed paramedics on 34 shifts and 10 paramedics completed ‘digital diaries’ that reported challenges to decision-making or to patient safety. Six focus groups were held, three with staff (n = 21) and three with service users (n = 23). From observation and diary data we developed a typology of decisions made at the scene. Data from these and other sources were also coded within a human factors framework and then thematically analysed to identify influences on those decisions. In phase 3, workshops were held at each site to allow participants and stakeholders (n = 45) to comment on the study findings. Participants were asked to rank influences on decisions using a ‘paired comparison’ method.\ud Results: Interviews provided the context for further qualitative exploration. Nine types of decision were identified from observations and digital diaries, ranging from emergency department conveyance and specialist emergency pathways to non-conveyance. A synthesis of findings from the observations, diaries and staff focus groups revealed seven overarching system influences on decision-making and potential risk factors: meeting increasing demand for emergency care; impacts of performance regime and priorities on service delivery; access to appropriate care options; disproportionate risk aversion; education, training and professional development for crews; communication and feedback to crews; and ambulance service resources. Safety culture issues were also identified. Data from the service user focus groups reflected similar issues to those identified from the staff focus groups. Service user concerns included call handling and communication, triage, patient involvement in decisions, balancing demand, resources, access to care, risk aversion, geographical location and vulnerable patients. Group discussions highlighted a lack of awareness by the public of how best to use emergency and urgent care services. Workshop attendees were satisfied that the findings reflected relevant issues. The two issues ranked highest for warranting attention were staff training and development and access to alternative care.\ud Conclusions: Multiple qualitative methods allowed a range of perspectives to be accessed and validation o...

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A systematic review of the activity and impact of emergency care practioners in the NHS

Abstract: 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.

Cited by 13 publications

References 22 publications

What evidence is there on the effectiveness of different models of delivering urgent care? A rapid review

What evidence is there on the effectiveness of different models of delivering urgent care? A rapid review

A qualitative study of systemic influences on paramedic decision making: care transitions and patient safety

A qualitative study of decision-making and safety in ambulance service transitions

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