The Alternative Pre-hospital Pathway team: reducing conveyances to the emergency department through patient centered Community Emergency Medicine

Patton, Andrew; O’Donnell, Cathal; Keane, Owen; Henry, Kieran; Crowley, Donal; Collins, A; Redmond, Eoghan; Glynn, Nicky; Dunne, Martin; Deasy, Conor

doi:10.1186/s12873-021-00536-x

Cited by 10 publications

(10 citation statements)

References 26 publications

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“…Among the patients assessed by the PAU, those non-conveyed were younger, and all survived at 30 days after the initial call; otherwise, no apparent differences were found. These findings are consistent with previous studies 24 29 and indicate that PAUs are safe and that dispatch of the PAU in those patients was appropriate. The PAU dispatch criteria were relatively broad.…”

Section: Discussionsupporting

confidence: 92%

Association between using a prehospital assessment unit and hospital admission and mortality: a matched cohort study

Wolthers,

Blomberg,

Breindahl

et al. 2023

BMJ Open

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ObjectivesThis study aimed to compare hospital admission and 30-day mortality between patients assessed by the prehospital assessment unit (PAU) and patients not assessed by the PAU.DesignThis was a matched cohort study.SettingThis study was conducted between November 2021 and October 2022 in Region Zealand, Denmark.Participants989 patients aged >18, assessed by the PAU, were identified, and 9860 patients not assessed by the PAU were selected from the emergency calls using exposure density sampling.ExposurePatients assessed by the PAU. The PAU is operated by paramedics with access to point-of-care test facilities. The PAU is an alternative response vehicle without the capability of transporting patients.Primary and secondary outcome measuresThe primary outcome was hospital admission within 48 hours after the initial call. The key secondary outcomes were admission within 7 days, 30-day mortality and admission within 6 hours. Descriptive statistical analyses were conducted, and logistic regression models were used to estimate adjusted OR (aOR) and 95% CI.ResultsAmong the PAU assessed, 44.1% were admitted within 48 hours, compared with 72.9% of the non-PAU assessed, p<0.001. The multivariable analysis showed a lower risk of admission within 48 hours and 7 days among the PAU patients, aOR 0.31 (95% CI 0.26 to 0.38) and aOR 0.50 (95% CI 0.38 to 0.64), respectively. The 30-day mortality rate was 3.8% in the PAU-assessed patients vs 5.5% in the non-PAU-assessed patients, p=0.03. In the multivariable analysis, no significant difference was found in mortality aOR 0.99 (95% CI 0.71 to 1.42). No deaths were observed in PAU-assessed patients without subsequent follow-up.ConclusionThe recently introduced PAU aims for patient-centred emergency care. The PAU-assessed patients had reduced admissions within 48 hours and 7 days after the initial call. Study findings indicate that the PAU is safe since we identified no significant differences in 30-day mortality.Trial registration numberNCT05654909.

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Section: Discussionsupporting

confidence: 92%

Association between using a prehospital assessment unit and hospital admission and mortality: a matched cohort study

Wolthers,

Blomberg,

Breindahl

et al. 2023

BMJ Open

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“…Thirdly the research is descriptive and correlational and does not provide information about causality. Fourthly, data for patients attended by community paramedics or who are managed via alternative care pathways including Pathfinder, 39 or the Alternative Pre-hospital Pathway team, 40 were not available for this study. Fifthly the data for this study was recorded in 2020 during the COVID-19 pandemic.…”

Section: Discussionmentioning

confidence: 99%

Factors associated with pain reporting and severity of pain in the prehospital setting

et al. 2023

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An effective pain management strategy requires understanding of the epidemiology of pain in the population of interest and accurate measurement upon which to base quality improvement plans. The aims of this study were to estimate the incidence of pain in the prehospital setting and to explore features that impact on (1) documentation of pain; (2) severity of pain reported by patients. This retrospective cohort study included 212,401 care episodes attended by National Ambulance Service practitioners during 2020. Descriptive analysis of patient and care episode characteristics and regression analyses for the outcomes pain recorded and severity of pain were performed. We also used text pattern-matching of the notes field to estimate the proportion of patients in pain for whom a pain score assessment had not been documented. Sixty-five percent of all patients had a pain score documented and 29.5% were in pain (11% in severe pain). Likelihood of pain being recorded was most strongly associated with: Glasgow Coma Scale (GCS) Score, working diagnosis of the patient, location of the incident, and patient age. Likelihood of pain severity was most strongly associated with: transport status of patient, GCS score, and patient age. We treated missing data as a separate category and found consistent associations between the outcomes and missing data. We also found that pain was a symptom in approximately 15% of cases where no formal pain score assessment was documented. The data showed associations between routinely collected variables and the likelihood of pain recording and pain severity. Our findings also demonstrate the impact of missing data. To mitigate missing data impact, we suggest that EMS agencies consider making pain score assessment a mandatory requirement of their reporting for every patient. We also recommend that services report the extent and impact of missing data when measuring clinical performance.

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“…Clinical determinations enacted by the evaluating medical practitioner may occasionally culminate in a non-transport decision for the patient, a scenario commonly referred to as CID. ‘Non-conveyance’ according to clinician discretion is an outcome that has been cited in many studies ( n = 15) [ 18 , 23 – 26 , 28 , 32 – 40 ]. In some instances, non-conveyance represents a clinical verdict enacted by EMS personnel subsequent to their response to an emergency call and the subsequent provision of emergency care to the patient.…”

Section: Discussionmentioning

confidence: 99%

“…Inferences drawn from a comprehensive examination of prior studies reveal that specific EMS systems have integrated the concept of patient non-conveyance into their guidelines. They deem it a practice with an acceptable level of risk, contingent on initiating a telephonic medical consultation or deploying follow-up units for non-conveyance cases [ 32 , 38 , 49 , 66 ]. Notably, the term ‘acceptable’ risk elicits diverse interpretations across the literature [ 37 , 38 , 50 , 67 ].…”

Section: Discussionmentioning

confidence: 99%

Understanding patient non-transport decision theories in the pre-hospital setting: a narrative review

Farhat,

Aifa,

Alinier

et al. 2023

Int J Emerg Med

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Background In pre-hospital emergency care, decisions regarding patient non-conveyance emerged as significant determinants of healthcare outcomes and resource utilization. These complex decisions became integral to the progress of emergency medical services, thus warranting an evolving exploration within the medical discourse. Objectives and methods This narrative review aimed to synthesize and critically evaluate various theoretical stances on patient non-conveyance in the pre-hospital emergency. The focus on studies published between January 2012 and August 2022 was intentional to capture contemporary practices and insights. PubMed and Google Scholar served as the primary databases for the investigation, while the AL-Rayyan® software facilitated a thorough screening process. Results and discussion Twenty-nine studies—encompassing articles, books, and theses—were discovered through our search, each presenting unique perspectives on patient non-transport, thus highlighting its criticality as a healthcare concern. Predominant factors influencing non-transport decisions were classified into patient-initiated refusals (PIR), clinician-initiated decisions (CID), and dispatcher-initiated decisions (DID). Conclusions The issue of patient non-conveyance to hospitals continues to pose a crucial challenge to the seamless operation of emergency healthcare systems, warranting increased attention from various healthcare entities. To comprehend and pinpoint potential areas of improvement, a comprehensive analysis of pre-hospital non-transport events is imperative. A well-informed, strategic approach could prevent resource waste while ensuring patients receive the required and definitive care. Key messages Why is this topic important? Some studies have suggested that non-transport to hospitals following emergency calls is safe. However, it is a concerning issue for health systems. It is also considered a key performance metric for health systems. What does this review attempt to show? This review aimed to map the various factors discussed in the literature regarding the decisions not to transport patients following emergency calls in a pre-hospital setting. What are the key findings? The existing theories regarding non-transport to hospitals after the provision of emergency care in the pre-hospital setting were identified. Non-transport due to non-clinical decisions jeopardizes emergency care outcomes for paediatric and elderly patients in particular. Hence, further research is required to identify and control the factors governing these decisions. How is patient care impacted? The decisions regarding patient transport following emergency calls in a pre-hospital setting are crucial for patient outcomes. They could impact the pre-hospital emergency care outcomes as well as patient safety. They can also affect the emergency services resources’ ability to respond to other critical emergencies.

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The Alternative Pre-hospital Pathway team: reducing conveyances to the emergency department through patient centered Community Emergency Medicine

Cited by 10 publications

References 26 publications

Association between using a prehospital assessment unit and hospital admission and mortality: a matched cohort study

Association between using a prehospital assessment unit and hospital admission and mortality: a matched cohort study

Factors associated with pain reporting and severity of pain in the prehospital setting

Understanding patient non-transport decision theories in the pre-hospital setting: a narrative review

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