Development of the PriCARE classification for potentially preventable emergency department visits by ambulance: a RAND/UCLA modified Delphi study protocol

Abstract

IntroductionOntario ambulances are restricted from patient transportation to sub-acute levels of care when these facilities may be more suitable than emergency departments for non-emergent conditions. There is no known patient classification specifically constructed to inform ED diversion protocols and guidance for sub-acute centre transportation for primary care–like patient conditions.ObjectiveTo construct a novel patient classification of potentially preventable emergency department visits following transport by ambulance, and analyse patient-level characteristic associations with this classification based in Ontario secondary data.Methods and analysisThe Primary Care–like Ambulance transports following Response for 911-Emergencies (PriCARE) patient classification will be constructed using a two-phase RAND/UCLA modified Delphi design. All experts included are physicians with relevant experience in emergency and/or primary care in Ontario. The first phase of the study will determine consensus of the expert committee on which ED interventions performed on patients with non-emergent acuities could be conducted in sub-acute healthcare centres. The second phase will assess consensus of which patient, hospital and acuity factors are most appropriate to be incorporated into a PriCARE classification. We will also investigate secondary outcomes on consensus of which ED interventions could be transferred to a paramedic context given an expanded scope of practice and patient-level characteristics of PriCARE classified individuals.Ethics and disseminationThis study received a research ethics board exemption waiver from the Hamilton Integrated Research Ethics Board; review reference 2020-11451-GRA. Results will be submitted for publication in a peer-reviewed journal and presented at relevant conferences. The results will be shared with Ontario paramedic services and governing institutions. This study will be used to inform patient classification protocols and clinical decision tools for ambulances to transport to sub-acute healthcare centres.Trial registration numberISRCTN22901977.

Establishing consensus on emergency department interventions that could be conducted in sub-acute care settings for non-emergent paramedic transported visits: A RAND/UCLA modified Delphi study

“…We used purposive sampling to select 25 primary care and emergency physicians who were currently or recently practicing in Ontario, Canada. (3) We sought physicians who had either extensive medical experience, academic experience, or a leadership role in paramedic practice oversight to ensure they could offer high quality comprehension when evaluating ED interventions. All selected experts were sent a study information package (objective, purpose, contribution), and those who participated gave informed consent prior to beginning the modified Delphi.…”

“…Round 1 of the modified Delphi included all ED interventions identified in Stage 1. Interventions were presented in six subsections based on their section of the CCI Tabular List, 2018 Volume 3 categorization: (1) physical/physiological therapeutic interventions; (2) diagnostic interventions; (3) diagnostic imaging interventions, and; (6) cognitive, psychosocial and sensory therapeutic interventions, (7) other healthcare interventions, and (8) therapeutic interventions strengthening the immune system. (23) Section (5) obstetrical and fetal interventions were not included as no interventions assigned in this section was identified in the cohort, and no randomization of questions were used.…”

“…For each intervention, experts were asked to rate whether the intervention should be conducted exclusively in the ED, or alternatively, if could be conducted in a sub-acute healthcare centre. If an expert indicated an intervention suitable for a sub-acute centre, they were asked if it could be conducted in a: (1) urgent care centre, (2) walk-in medical centres, and (3) nurse practitioner led-clinics (multiple selections were permitted). These sub-acute centres were selected as they represented the most feasible centres patients could be redirected to when transported by paramedic services, their services target non-emergent events, are abundant in Ontario, and at present do not receive patients by ambulance.…”

“…We used the RAND/UCLA modified Delphi technique to assess expert consensus through two rounds of ratings over an eight-week timeframe. (3) The modified Delphi method is a strategy that analyzes collective expert judgements to produce superior results than any one expert would, resulting in increased content validity. (22) We used a secure and encrypted CheckMarket software program to develop and administer the study questionnaires to experts.…”

“…(1,2) In Ontario, patients with non-emergent conditions account for 60% of all ambulance transported patients, of which 74% are discharged the same day. (3) Initiatives in health policy and research have not decreased paramedic transports for non-emergent ED visits; from 2014 to 2017 usage has increased by 12% (456 510 / 511 801) in Ontario. (4) Increasing ED visits have outpaced population growth in Ontario by more than double (13.6%, vs. 6.2% respectively)(5), suggesting utilization of ED’s has broadened.…”