Upcoming Randomized Trial of Assessment and Referral by Paramedics

Posted by Patrick Lickiss on Aug 17, 2011 in Assessment, EMS 2.0, General, Research, Treatment | 2 comments

By far, one of the possibilities for the future of EMS which excites me the most is generally characterized as “community paramedicine”. The idea that paramedics will be placed in a position to treat and release and treat and refer in the field, diverting patients from the local emergency rooms is an exciting one to be sure. The first step in rolling out a system like that, however, is determining whether or not paramedics can safely determine which patients don’t actually need an ambulance transport. Published recently in BMC Emergency Medicine (PDF link) was the study protocol for just such an experiment in Perth, Western Australia ^[1].

INCLUSION/EXCLUSION CRITERIA
Patients will be considered for the trial if they are suffering from the following conditions:

Isolated minor injury
Simple infection
Hardware problem (like issues with a urinary catheter)

The exclusion criteria are:

Younger than 16
Third trimester pregnancy
Not in the patient’s residence
Residence is unsafe
GCS < 15
SpO2 < 95% on room air
Heart rate > 100
Systolic BP < 100
Pain requiring narcotics
Patient unable to wait four hours for further treatment

STUDY DESIGN
For patients meeting the eligibility criteria, the paramedics will call in, provide enrollment information and be told if the patient is randomized into the control arm (transport by ambulance to the ED) or the intervention arm (referral to the in-home hospital service). Within four hours, a home hospital service nurse or nurse practitioner will respond to the patient’s residence for evaluation and treatment. The patient might be treated and then released from the service, enrolled into ongoing care or referred to the ED. As a side note for US readers, check out the website for Silver Chain, the home hospital service. This is an amazing concept.

OUTCOMES
The primary outcome focus of the researchers is the proportion of patients needing unplanned medical care within 48 hours of enrollment. The secondary outcome focuses include a variety of clinical, operational and investigatory measures. Additionally, cost benefit and patient satisfaction data will be collected and analyzed.

ESTIMATED OUTCOMES
With an annual transport volume of approximately 100,000, researchers estimate that they can enroll roughly 10% of their total patient base in the study. With a goal of 940 patients in both the control and intervention arms, it is estimated that patient enrollment will be completed within a year.

DISCUSSION
As I mentioned earlier, this is a truly exciting possibility. If paramedics can be shown to safely determine whether or not a patient can be treated at home, it opens the door to diverting at least a portion of patients from overwhelmed Emergency Departments. As the researchers note, there have been mixed messages in the literature about the ability of paramedics to safely evaluate patients for non-transport. This study seems well designed and isn’t biting off too much at once. By focusing on one piece at a time, the researchers appear to be approaching this type of program the right way. I’ll keep an eye out for the completed study and will let you know the results when it is published, likely next year.

CITED ARTICLES
[1]- Arendts G, et al.: “ParaMED Home: A protocol for a randomised controlled trial of paramedic assessment and referral to access medical care at home”. BMC Emergency Medicine 2011; 11:7.

Image via Flickr

http://twitter.com/insomniacmedic1 InsomniacMedic

We’ve been doing this London for some time. The problem with the system isn’t only the paramedics involved, but also patients understanding that not every single ailment means that they need a visit to hospital, much less an ambulance.
It will take a lot more time for decades of traditional treatment, the “you call, we haul” mentality of both staff and patients to change for the better, but it’s starting to move in the right direction.
Paramedics here are increasingly competent of recommending and aware of more appropriate referral pathways for a wide variety of illnesses and injuries. However, the systems that are supposedly in place, on all fronts – ambulance staff, minor injury units, GP (MD) surgeries, etc still have this fear of the unknown, the fear of “what if something goes wrong”, and eventually still far too many people are ending up in the ED departments.
It will take confidence and trust of management in their staff, staff in their skills, external agencies in the ambulance service, and above all patients in those who they call to treat them.
There’s a very very long way to go…..

http://510medic.com 510medic

Well said! I think that management support and necessary training for these types of programs is the first step. Those two tools can give the providers the confidence to explain to a patient why an ambulance transport isn’t warranted. There’s no perfect system, but it’s exciting to see more systems moving in a positive direction.