The contribution of pre-hospital integrated care pathways on improving the clinical effectiveness of emergency ambulance managed care

Abstract

Currently an emergency ambulance staffed by a paramedic and emergency medical technician are responded to every '999' call received regardless of severity or type of call. Evidence has shown this to be necessary and effective for a number of clinical conditions and prioritisation systems have been introduced by every ambulance service in the UK to ensure that those with life threatening conditions have priority above more trivial calls. Once attended by paramedics, unless the patient refuses to travel, they are transferred to hospital due to a lack of alternatives, despite ever increasing demands on both the ambulance service and A&E departments. This study challenges the automatic transfer of patients to accident and emergency departments and suggests an alternative through improved paramedic protocols that would enhance the development of integrated pre-hospital care pathways. The skill levels of paramedics have proven to be effective in the treatment of a number of serious conditions to the extent where the need to transfer the patients can be questioned. However the existing method of measuring performance of ambulance services continues to be speed of response with no measurement of paramedic effectiveness.There have been several studies that debate the appropriateness and inappropriateness of patients being transferred to hospital following an emergency but none could be found that considers how improved paramedic protocols could contribute to the use of integrated care pathways as a means of treating and managing patients in primary care. Government policies dictate that health professionals should work together to both minimise resources and provide clinically effective services and if current arrangements for ambulance services are considered then clearly alternatives must be found that provide a better measure of ambulance service performance.This study suggests that by improving paramedic protocols they can form part of integrated care pathways enabling an alternative to be developed rather than automatic transfer of patients to hospital. Integrated care pathways define the optimal care process, sequencing and timing of interventions and are widely used in hospitals by doctors, nurses and other healthcare professionals for a particular diagnosis or procedure. Although their use is growing in primary care they have yet to be introduced into pre-hospital care. It was felt unlikely that integrated care pathways could be introduced without considering organisational aspects, as ambulance service structures are largely developed to meet response standards. Therefore it was necessary to consider a quality framework that could be used to underpin the development of pre-hospital integrated care pathways that would enable effective audits measuring their effectiveness, to be undertaken. Donabedians framework of structure, process and outcomes was used as a model with review criteria developed enabling the differing aspects of ambulance services performance to be measured.As the ambulance service is driven by clinical protocols developed by clinicians it was recognised that if any change is to happen clinical acceptance must be sought. To ascertain clinical acceptance a workshop was held allowing clinicians to select those clinical conditions that they feh could be appropriately managed by the pre-hospital integrated care pathways with either referral to the GP or primary care team or indeed could be left without referral. Further acceptance was sought through a questionnaire asking paramedics, nurses, GP's and A&E consultants to give their opinions covering a range of issues concerning the development of pre-hospital integrated care pathways.There was a consensus that pre-hospital integrated care pathways could provide an alternative to the automatic transfer of '999' patients to hospital. Clearly there are benefits for the ambulance service in that resources will become available quicker for other emergencies, particularly in rural areas, with demonstrable cost savings. There are also benefits for secondary care in that cases that would be labelled inappropriate for A&E would be managed by primary care where it could be argued the patient is more appropriate for treatment and management. Although there were concerns among some GP's that this concept could increase their workloads as resources are unlikely to be moved from secondary care, however evidence suggests that the increased workloads may not be significant.There are issues such as clinical risk, medico-legal implications and patient acceptance that are beyond the scope of this study and it is accepted that further research may be necessary before any change could be considered.

Date of Award	2004
Original language	English
Supervisor	David Cohen (Supervisor)