More advanced paramedics needed if A&E pressure is to be eased

Adobe Spark (1)The NHS must introduce more advanced paramedics if emergency departments are to meet growing patient demand. The NHS is reaching a crisis point—annual rises in emergency admissions and insufficient resources mean patients aren’t receiving the necessary levels of care. Traditionally, care provided by paramedics has focused on the immediate assessment and management of potentially life-threatening emergencies. This is then followed by transfer to an appropriate receiving unit. However, increasingly, evidence suggests that patients who present to ambulance services with lower acuity presentations could alleviate the need for hospital admission by undergoing assessment and management in the community.

This is highlighted in new draft guidance published by NICE (2017), which should fall on welcome ears to ambulance services. It recommends that the NHS provides more advanced paramedic practitioners (APPs), who have extended training in assessing and treating people with medical emergencies, to relieve pressure on emergency departments.

Evaluating the evidence

In order to make these recommendations, the guideline committee investigated whether enhancing the competencies of paramedics resulted in a reduction in hospital admissions and demand for emergency department services. When considering clinical evidence, three studies were included in the review. Two studies, which came from the same cluster-randomised controlled trial, looked at a paramedic practitioner service in the UK, which gave enhanced training to paramedics.

The first study comprised 3018 people and evaluated the benefits of paramedic practitioners who have been trained with extended skills to assess, treat, and discharge older patients with minor acute conditions in the community (Mason et al. 2007). The evidence suggested that enhanced competencies of paramedics may provide benefit for reducing the number of hospital admissions (0–28 days), emergency department attendance (0–28 days), and patient and/or carer satisfaction. There was no effect on mortality.

The second study comprised 2025 people and evaluated the safety of clinical decisions made by paramedic practitioners of older patients contacting the emergency medical services with a minor injury or illness (Mason et al. 2008). Of the 3018 patients recruited into the randomised-controlled trial, 993 were admitted to the hospital at the index episode, which explains why they were excluded from the analysis in this study. The evidence suggested that there was no effect of paramedics’ enhanced competencies on unplanned emergency department attendance.

The final study was a non-randomised (quasi-experimental) study of emergency care practitioners who worked as single responders to ambulance service 999 calls, compared with standard paramedic or technician ambulance responding to ambulance service 999 calls. The study comprised 1107 people and aimed to evaluate the impact of emergency care practitioners on patient pathways and care indifferent emergency care settings.
(Mason et al. 2012). The evidence suggested that enhanced competencies of paramedics may provide a benefit from reduced numbers of patients referred to hospital (emergency department or direct admission to a hospital ward), and increased number referred to primary care.

Additionally, one cost-utility analysis was assessed to consider the economic implications of providing additional advanced paramedics within ambulance services, and found that the paramedic practitioner scheme was cost-effective compared with the standard 999 service (Dixon et al. 2009). This study was assessed as partially applicable with minor limitations.

Points for concern

There are a number of considerations when looking at the evidence in question that could be cause for concern. While evidence exists, it is minimal, with only one
randomised-controlled trial and one non-randomised study evaluated by NICE. Though results from the studies are positive, it would be difficult to generalise them beyond the services assessed. Additionally, the quality of evidence is generally of a low GRADE (Grading of Recommendations, Assessment, Development and Evaluations). The randomised-controlled trial evidence has a moderate-to-low GRADE rating overall, mainly owing to risk of bias and imprecision (NICE 2017). The non-randomised study, although it had large effect sizes, has a very low GRADE rating as a result of high risk of bias and indirectness of the outcomes to the protocol (NICE 2017). The economic evidence was considered high-quality but only partially applicable because the costs were quite dated. Some social care costs were also included, which means that the perspective is not strictly NHS and personal social services (NICE 2017).

There are notable concerns over the definition of an APP, as there is a national lack of consensus over paramedic roles and scope of practice. This was a contributing factor to why independent prescribing by APPs was not recommended by the CHM and MHRA (Allied Health Professions Medicines Project Team 2016).

The need for unanimity across all ambulance services is a concern the College of Paramedics emphasised inits response to the guidance:

‘There has previously been insufficient attention given to career development and career opportunities and there is currently significant variation across the ambulance services in the definitions, titles, education, and training of specialist and advanced paramedics. To ensure consistency of education, training and qualification, the UK ambulance services would need to adopt the frameworks developed by the College of Paramedics, which provide detailed guidance on education, competencies, and career development’ (College of Paramedics 2017).

The College of Paramedics has a clear definition of the APP role in terms of competencies and education:

‘Advanced paramedics are experienced autonomous paramedics who have undertaken further study and skill acquisition to enable them to be able to deliver a more appropriate level of assessment and indeed care to patients in the community and access many more referral pathways.’

It is essential that this becomes the accepted definition across the NHS, and the private health sector. This will ensure that all advanced paramedics are clinically competent and that patient safety is not at risk. More advanced paramedic practitioners with extended training could alleviate current pressures on A&E services.

From guidance to practice

Consulting on the guidance closed on 14 August, with an expected publication of 20 December. If the guidance is to be put into practice, the most important step is to introduce additional funding for NHS ambulance services to educate their clinicians through advanced practice programmes. NHS England and clinical commissioning groups would then have to provide funding to deliver specialist and advanced paramedics as part of the core workforce. Additionally, regulation is essential to ensure clinical competency and patient safety.

There is no denying that acute and emergency care is a challenge for all health services. This is largely owing to the fact that as populations age, costs rise, and technological developments extend the limits of health care. However, providing acute and medical care in the community can reduce the need for hospital admissions.

The introduction of more advanced paramedics will meet the increasing and changing needs of patients who access 999 emergency ambulance services. Having a higher proportion of emergency patients assessed and treated in the community will cause a reduction in the number of attendances at emergency departments.

References

Allied Health Professions Medicines Project Team. 2016. Summary of the responses to the public consultation on proposals to introduce independent prescribing by paramedics across the United Kingdom. Leeds: NHS England.

College of Paramedics. 2017. College of Paramedics respond to NICE Consultation [Internet]. Bridgwater: College of Paramedics; [cited 2017 29 August]. Available from https://www.collegeofparamedics.co.uk/news/college-of-paramedics-responds-tonice-consultation.

Dixon S, Mason S, Knowles E. 2009. Is it cost effective to introduce paramedic practitioners for older people to the ambulance service? Results of a cluster randomised controlled trial. Emerg Med J. 26(6):446-51. http://doi.org/ 10.1136/emj.2008.061424.

Mason S, Knowles E, Colwell B et al. 2007. Effectiveness of paramedic practitioners in attending 999 calls from elderly people in the community: cluster randomised controlled trial. BMJ. 335(7626):919. http://doi.org/10.1136/bmj.39343.649097.55

Mason S, Knowles E, Freeman J, Snooks H. 2008. Safety of paramedics with extended skills. Acad Emerg Med. 15(7):607–12. http://doi.org/10.1111/j.1553-2712.2008.00156.x.

Mason S, O’Keeffe C, Knowles E. 2012. A pragmatic quasi-experimental multi-site community intervention trial evaluating the impact of Emergency Care Practitioners in different UK health settings on patient pathways (NEECaP Trial). Emerg MedJ. 29(1):47-53. http://doi.org/10.1136/emj.2010.103572.

National Institute for Health and CareExcellence. 2017. Emergency and acute medical care in over 16s: service delivery and organisation: Draft guidance consultation [GID-CGWAVE0734] [Internet]. London: NICE; [cited 2017 29 August]. Available from https://www.nice.org.uk/guidance/indevelopment/gid-cgwave0734/consultation/html-content.

Taken from Journal of Paramedic Practice, published 8 September 2017.

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London Trauma Conference addresses key questions in emergency medicine

The ninth London Trauma Conference took place at the Royal Geographical Society, Kensington Gore, between 8 December and 11 December 2015. A main programme of presentations, where speakers addressed a number of topical questions in trauma and emergency medicine, was supplemented by breakaway sessions held parallel to the main conference. The concurrent London Cardiac Arrest Symposium also returned for another year. The Journal of Paramedic Practice once again attended the Air Ambulance and Pre-hospital Care Day held on 10 December, which focused on trauma issues directly relevant to professionals working in the pre-hospital setting.

Proceedings began with Prof Pierre Carli discussing pre-hospital extracorporeal membrane oxygenation (ECMO). Carli gave an overview of how the treatment works in Paris, providing results and considering its role in the future. Interestingly, it was found in France that transferring into hospital for ECMO with ongoing cardiopulmonary resuscitation (CPR) had very poor results, and so the need for earlier intervention and pre-hospital ECMO became apparent.

Dr Thomas Lindner then spoke on CPR in helicopter emergency medical services (HEMS) and the new European Resuscitation Council Guidelines. He explained how the key message in cardiac arrest remains minimal interruption of high-quality chest compressions. He also emphasised how an automated external defibrillator takes 20 seconds to shock, and so clinicians should use that time to decide if a patient needs shocking so they can continue compressions.

Dr Marius Rehn then gave a talk on rapid response cars (RRCs) and whether they are more dangerous than aircraft. Rehn highlighted how London’s Air Ambulance attends around five jobs a day, 32% by aircraft and 68% by RRC. He pointed out that while aviation is heavily regulated, RRCs are not. He noted that one of the easiest ways to improve safety in RRCs is to strap the equipment and ensure passengers are restrained and seated.

Assoc Prof Andrew Pearce followed with a talk on making the best of long distance critical care. Pearce explained how the remoteness of much of Australia makes the provision of pre-hospital care challenging. However, he emphasised that as pre-hospital practitioners you are ‘never alone’, as there is always someone you can call for help and advice. He went on to say that the need for a retrieval service is not just about transport, but about being able to bring critical and definitive care to patients.

After coffee, Mr Andy Thurgood gave an engaging talk on the agitated trauma patient, considering causes, rules and practicalities. He explained how agitation is a feeling of aggravation or restlessness brought on by provocation or a medical condition. Thurgood suggested it is important as a health professional to consider what may cause the provocation of a patient. For example, an agitated patient could be ‘a dying patient that is trying really hard to stay alive.’ One of the most interesting take home points from Thurgood’s talk was that there is not always a medical cause for agitation in the trauma patient. He suggested that trapped agitated patients may have nothing wrong with them and simply want to be talked to and reassured.

Dr Leif Rognas discussed setting up a national retrieval service in Denmark, where the brief was to set up a state-of-the-art pre-hospital care service, with rapid access to highly specialised hospital treatment, to the entire Danish population. This was followed by Dr Rhys Thomas, who discussed setting up a retrieval service in Wales. Thomas explained that starting a national retrieval service takes a good story, organisation collaboration, hard work and persistence. The clinical model of the Welsh national retrieval service consists of pre-hospital critical care, adult and paediatric time-critical stabilisation and transfer, neonatal and maternal support to free-standing midwifery-led units and home births, and major incident and mass-casualty support. An interesting comparison: governmental funding for the retrieval service in Denmark means the service is more dependent on government, but acquiring funding is easier and it offers a higher degree of political awareness.

Dr Per Kristian Hyldmo gave the final pre-lunch talk on a reconsideration of spinal immobilisation, including when it may be appropriate. The discussion surrounding immobilisation remains ambivalent; however, Hyldmo closed with the amusing question: ‘When there is little evidence what are your options: Cochrane? Or GOBSATT (good old boys sitting around the table talking)?’

Mr Tom Judge gave the first talk after lunch on US air ambulances. Judge explained how in the US, if ambulance services transport the patient you get paid, whereas if you do not, you get no money. As a result, this has led to unhealthy competition, where contemporary HEMS in the US is driven by demand. But, with a market-driven system medical necessity often goes down and costs go up. This sparks the question as to whether this is an aviation business or a medical service? However, Judge presented evidence to suggest there is reasonable cost benefit in having air ambulances. He also argued that helicopters should be seen as instruments of time: time to team, time to tertiary centre, and total time.

The keynote talk for the day was delivered by Prof Sir Simon Wessely on the myth of panic. Wessely’s entertaining talk highlighted how approximately 10% of the population think their health is at risk no matter what is going on at the time. Considering associations of distress, Wessely emphasised how people who cannot reach friends or family following major incidents find themselves more affected than those who can. Debriefing has been used whenever something bad happens; however, it does not always work. Not everyone wants or needs to talk re-traumatisation, it interferes with the recovery process, and it impedes people talking to who they want, when they want. Wessely also argued that debriefing increases post-traumatic stress disorder. He said that only 1% of Londoners thought they needed professional help after the 7/7 bombings. The immediate mental health measures that are needed after mass-casualty incidents, such as bombings, are accurate and timely, practical information; communication; security, food, warmth, shelter and transport; and practical assistance with the legal system, employers, authorities etc. And if people want to talk it should be when they want to, and to who they want to. Wessely noted that less than 10% of soldiers want to talk to medical professionals or welfare services about traumatic incidents. Most want to talk to friends and family.

Prof Kai Zacharowski then spoke on pre-hospital sepsis, considering how to make a diagnosis, what interventions count, and whether biomarkers are the future. Zacharowski emphasised that sepsis should be a serious consideration among ambulance services, as care can begin pre-hospital. By raising suspicions of possible sepsis to hospital staff, the patient can be prioritised correctly.

Prof Zacharowski followed with a quick fire session on point-of-care testing in pre-hospital haemorrhage.

Dr Julian Thompson then questioned if pre-hospital crew resource management (CRM) and standard operating procedures (SOPs) can be implemented in the hospital. Defective judgement and poor teamwork affects ability to provide successful airway management, so can pre-hospital CRM and SOPs be implemented in hospital? Thompson concluded that it is probably not possible across an institution, it is highly applicable to high-risk situations, and that clinicians should select a small well-governed team and aspire to excellence at the point of greatest need.

Dr Samy Sadek then looked at pre-hospital resuscitative endovascular balloon occlusion of the aorta (REBOA) a year on, considering whether or not it works. Sadek presented results of REBOA by London’s Air Ambulance since being introduced 2 years ago. He reported seven cases of successful placement and four deaths (none due to exsanguination). The lack of REBOA cases illustrates how it is only considered in the sickest patients. A year on from last year’s talk that Sadek gave, a number of questions can be answered. In terms of potential complications, London’s Air Ambulance have reported one dissection, no ruptures, a thrombus, and no cases of displacement. Tolerance remains unknown—the maximum length of time undertaken by London’s Air Ambulance was 2 hours and 47 minutes. Diagnostic certainty is still unclear as there have been a few cases that were missed. While the definite benefit of REBOA is still unclear, Sadek offered a very sincere reflection of his own REBOA experience, where he feels he has definitely saved the lives of people who would otherwise have died.

Dr Matt Thomas then spoke on pharmacologically assisted laryngeal mask insertion (PALM), considering whether it was an elegant rescue technique or a dangerous compromise. Thomas concluded that it is a rescue technique rather than a primary technique, and should be considered as a plan B. However, if you are considering PALM then the patient probably needs a rapid sequence induction.

Mr Tom Judge closed the day with a talk on videolaryngoscopy, asking whether it is the standard of pre-hospital airway care. Judge highlighted that use of videolaryngoscopes increased first tube and overall intubation success rate. However, it remains expensive and in-hospital clinicians are already good at endotracheal intubation, with a 95% success rate.

The Air Ambulance and Pre-hospital Care Day represented a fraction of the packed programme of presentations on offer at this year’s London Trauma Conference. The invited speakers had a truly international breadth, offering an unparalleled excellence in the level of learning on offer. It is therefore with great anticipation that we look forward to the London Trauma Conference 2016.

Taken from Journal of Paramedic Practice, published 8 January 2016.