Extended Care Paramedic Program

Better meeting the emergency needs of the NSW community : Ambulance Service of NSW Extended Care Paramedic program

Ambulance Service of NSW

Abstract

Modern ambulance services, emergency departments (ED) and health services face many challenges including managing increases in service demand.  Ambulance services have traditionally provided limited options for patients other than transport to an ED. 

Our Extended Care Paramedic (ECP) program promotes the broad philosophy of "the right care at the right place and at the right time".  The ECP program aims to either provide on-the-spot treatment or referral to patients with sub or non-acute health care needs that have sought help through triple zero that do not necessarily require presentation to an ED.

Twelve ECPs were recruited and trained with a locally developed 9 week education program in collaboration with local partners.  The ECP program has been associated with a significant reduction in emergency department presentations and is providing a career opportunity for paramedics whilst simultaneously increasing choices available to patients that is associated with high levels of satisfaction.

Aim

The aim of the ECP program was to establish a new role for paramedics that better meets the needs of patients with health care needs that does not necessarily require attendance at an Emergency Department (ED) through formal training and equipping specialist paramedics extended assessment and clinical skills to work across traditional boundaries in emergency and unplanned care.

Nature of the Problem

Patients who access healthcare via triple zero (000) have had few options other than to be transported to an ED or refuse or decline the offer of transport.  Triple zero (000) is commonly used to access health care even when the unplanned health care need may not necessarily be a true emergency.  Presently, one in four ‘000’ contacts with paramedics results in non-transport to an ED.  Ambulance is experiencing increases in demand for service with calls increasing by 5% annually with Emergency Departments being under simultaneous pressures to provide emergency and non-emergency care.  Paramedics, whilst experts in providing emergency care, have traditionally had little to offer patients with sub and non-acute health care needs other than transport to an ED.  The need to better meet the needs of patients was established from feedback from patients, paramedics and the knowledge of emerging alternate models of care overseas.

Extent of the Problem

The demand for Ambulance services has been steadily increasing by approximately 5% annually.  Paramedics have been increasingly reporting that they are attending many cases where the patient who called triple zero does not necessarily need either emergency care or transport to an emergency department.  EDs are well aware of access block and ambulance jurisdictions are well aware of the impact on access block on case cycle times and operational performance.  Ambulance services traditionally offer patients limited choices regarding access to health care, the choice to decline or refuse the service/s or to accept transport to an ED. 

Access for patients to other parts of the health system has traditionally been unavailable to patients until they arrive at the ED or are admitted to hospital.  Analysis of local workload patterns identified a range of possible presentations where paramedics could provide extended care to meet the health care needs of patients with sub or non-acute health care needs.  Discussions with a local area health service and a local ED established some common problems amenable to provision of high quality care without the need to unnecessarily present to an ED. 

Strategic Importance

The Extended Care Paramedic program fulfils Strategic Direction 7 – "Be ready for new risks and opportunities".  The ECP program is an example of the Ambulance Service of NSW being aware of international trends and being responsive to the best available evidence.  International models have been adapted to meet the needs of our local needs and health system and the scope of practice has been flexible to adapt to further increase the program impact. 

Consumer expectations for ambulance are changing and Ambulance faces an increased diversity of calls for assistance for emergency and sub and non-acute health care needs.  The ECP program has developed and implemented an education program and that has fulfilled its objectives.  The ECP program has increased significantly choices available to patients following an encounter with an ECP allowing for patients to make informed choices about their health care. 

The ECP program has responded to unanticipated opportunities with one recent example being deployment to the World Youth Day health effort presenting an opportunity for ECPs to play a role in the response to major incidents.  A further program benefit is the creation of a new role and career path for paramedics thereby also fulfilling Strategic Direction 6 “Build a sustainable health workforce” where ECPs may become a permanent part of the health workforce contributing to meeting patient needs in various locations.

Planning and Implementing Solutions

There has been emerging evidence from the United Kingdom that providers of Ambulance services can be part of the solution for current challenges faced by health care providers and systems.  In the United Kingdom, a generic practitioner called an Emergency Care Practitioner (drawn from paramedic and nursing communities) who receive formal training and extended clinical skills to equip them to work across traditional boundaries in emergency and unplanned care have been established (Mason et al., 2006). 

Emergency Care Practitioners working within Ambulance jurisdictions had a reported non-transport rate of approximately 40% (Mason et al., 2006).  More recently, a prospective (cluster) randomised trial demonstrated that ‘Paramedic Practitioners’ attending elderly patients reduced presentations to emergency departments, reduce admissions to hospital, resulted in shorter care episode times and were associated with increased patient satisfaction (Mason et al., 2007).

Based on this evidence, Ambulance commenced planning to establish an Extended Care Paramedic program.  A project team was established a project manager and a clinical educator reporting to a project director.  Our program was based largely on the UK's Emergency Care Practitioner program however there was obviously a need to modify the program to fit with the NSW and Australian health care system. 

A partnership was established with the University of Sydney Nepean Clinical School as it was clear that Ambulance, whilst able to plan and coordinate the education program, would not have the capacity to cover the required breadth of the proposed ECP course curriculum.  Further assistance was obtained from Nepean Hospital and Sydney West Area Health Service (SWAHS) staff. 

A local management group was established with representatives from Ambulance, SWAHS, Nepean Hospital and the Nepean Division of General Practice.  The program was also supported by a high level steering committee comprised Ambulance executive and NSW Health representatives. 

The proposed clinical scope of ECPs was approved by the Senior Medical Advisor and the Ambulance Clinical Advisory Committee.  As the role was new within Ambulance, there was significant consultation with industry and the Health Services Union. 

Program information was distributed to ambulance staff through internal publications, administrative bulletins, information papers and information sessions.  The clinical operations of the program was monitored via a robust clinical governance process that included the formation of a monitoring and safety committee and follow-up of consenting patients by telephone 72 hours following an encounter with an ECP.  Prior to commencing clinical operations, peak bodies and stakeholders were informed of the program and the commitment to measure meaningful operational, health economic and clinical outcomes.

Outcomes and Evaluation

Feedback on the initial course was very positive and ECP satisfaction following implementation of the program.  In the first 162 days of clinical operations, the ECP program significantly reduced presentation to EDs by 11.6% equating to 224 fewer ambulance transports (63.3% versus 74.9% p < 0.0001).  The impact of ECPs was greatest for ‘000’ calls triaged to a non-emergency response reducing presentations to ED by 21.3% (59.1% versus 81.2% p < 0.0001) when compared to standard care. 

The locally developed 9 week course successfully prepared ECPs for this new role with the curriculum supporting the clinical practice of ECPs.  There is clinical and statistical evidence that ECPs have the greatest impact on common ‘000’ problems including back pain, haemorrhage/lacerations, person-ill, falls, traumatic injuries and abdominal pain/Problems. 

Modelling indicates that attendance at a greater proportion of these conditions will further increase the program’s impact.  Satisfaction of patients attended by an ECP was very high.  No significant adverse events were identified through patient follow-up activities and the program’s clinical governance processes. 

The program, if more widely implemented is likely to reduce pressures on EDs, free up front-line ambulance resources to attend emergency cases, improve operational performance and reduce the time for certain patients to access the care.  The program is maintaining patient satisfaction and providing safe and appropriate care that benefits patients.  Outcomes to date suggest that our impact is consistent with published international experiences.

Sustaining Change

A second ECP course has commenced to establish a program in two large regional centres and to provide future capacity to establish ECPs in other areas.  The ECP course has been modified to incorporate student feedback and program experience.  The ECP curriculum has been refined and published and instructors / coordinators have been trained.  A recent analysis of ECP impact has enabled a more strategic approach to dispatch of ECPs.  Modelling suggests that the overall impact can be increased from 11.6% to 18.0% if this strategy is implemented.  Planning has commenced to further evaluate relevant patient outcomes and implement the program more broadly.

Future Scope

The Extended Care Paramedic program is an example of successfully translating emerging evidence from overseas into practice to better meet the needs of patients.  The program was implemented with the cooperation of key stakeholders who were all committed to solving the identified problem.  The program has obvious benefits for patients, Ambulance, Emergency Departments and Area Health Services.  Simultaneously, the program has established a possible career path for not only paramedics but also for other health care professionals including nurses.  The program may be the first important step in creating a role for a generic Emergency Care Practitioner like in the United Kingdom.

References

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