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Open Access Study protocol

Evidence-based paramedic models of care to reduce unnecessary emergency department attendance – feasibility and safety

Judith C Finn11123, Daniel M Fatovich14, Glenn Arendts14, David Mountain15, Hideo Tohira11, Teresa A Williams1112, Peter Sprivulis16, Antonio Celenza15, Tony Ahern2, Alexandra P Bremner7, Peter Cameron3, Meredith L Borland89, Ian R Rogers10 and Ian G Jacobs1112*

Author Affiliations

1 Discipline of Emergency Medicine (M516), The University of Western Australia, 35 Stirling Highway, Crawley 6009, Western Australia

2 St John Ambulance (Western Australia), 209 Great Eastern Highway, Belmont 6104, Western Australia

3 Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, The Alfred Centre, 99 Commercial Road, Melbourne, Victoria 3004, Australia

4 Department of Emergency Medicine, Royal Perth Hospital, Box X2213 GPO, Perth 6847, Western Australia

5 Emergency Department, Sir Charles Gairdner Hospital, Hospital Ave, Nedlands 6009, Western Australia

6 Emergency Department, Fremantle Hospital, Alma Street, Fremantle 6160, Western Australia

7 School of Population Health, The University of Western Australia, 35 Stirling Highway, Crawley 6009, Western Australia

8 Emergency Department, Princess Margaret Hospital, GPO Box D184, Perth 6840, Western Australia

9 School of Paediatrics and Child Health and School of Primary, Aboriginal and Rural Healthcare, University of Western Australia, Crawley 6009, Western Australia

10 Emergency Department, St John of God Murdoch Hospital, 100 Murdoch Dr, Murdoch 6150, Western Australia

11 Faculty of Health Sciences, Curtin University, GPO Box U1987, Perth 6845, Western Australia

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BMC Emergency Medicine 2013, 13:13  doi:10.1186/1471-227X-13-13

Published: 15 July 2013

Abstract

Background

As demand for Emergency Department (ED) services continues to exceed increases explained by population growth, strategies to reduce ED presentations are being explored. The concept of ambulance paramedics providing an alternative model of care to the current default ‘see and transport to ED’ has intuitive appeal and has been implemented in several locations around the world. The premise is that for certain non-critically ill patients, the Extended Care Paramedic (ECP) can either ‘see and treat’ or ‘see and refer’ to another primary or community care practitioner, rather than transport to hospital. However, there has been little rigorous investigation of which types of patients can be safely identified and managed in the community, or the impact of ECPs on ED attendance.

Methods/Design

St John Ambulance Western Australia paramedics will indicate on the electronic patient care record (e-PCR) of patients attended in the Perth metropolitan area if they consider them to be suitable to be managed in the community. ‘Follow-up’ will examine these patients using ED data to determine the patient’s disposition from the ED. A clinical panel will then develop a protocol to identify those patients who can be safely managed in the community. Paramedics will then assess patients against the derived ECP protocols and identify those deemed suitable to ‘see and treat’ or ‘see and refer’. The ED disposition (and other clinical outcomes) of these ‘ECP protocol identified’ patients will enable us to assess whether it would have been appropriate to manage these patients in the community. We will also ‘track’ re-presentations to EDs within seven days of the initial presentation. This is a ‘virtual experiment’ with no direct involvement of patients or changes in clinical practice. A systems modelling approach will be used to assess the likely impact on ED crowding.

Discussion

To date the efficacy, cost-effectiveness and safety of alternative community-based models of emergency care have not been rigorously investigated. This study will inform the development of ECP protocols through the identification of types of patient presentation that can be considered both safe and appropriate for paramedics to manage in the community.

Keywords:
Pre-hospital; Extended care paramedics; Ambulance; Emergency department demand; Community care; Patient safety; Economic evaluation