New Models of Emergency Prehospital Care That Avoid Unnecessary Conveyance to Emergency Department: Translation of Research Evidence into Practice?

Table 1

Summary of studies and outputs included in research programme.

Study and; funding	Research focus	Research sites,; patient population	Research design	Key messages and references
Epidemiology of emergency ambulance calls; South West Regional Health Authority R&D; 1996–1999	To increase the knowledge base regarding demand for emergency medical services and the factors influencing demand	Wiltshire; All 999 callers	Observational study and review of evidence	(i) Demand for emergency ambulances rose by 72% in Wiltshire between 1988 and 1996 with no evidence of an increase in GP placed calls [9]; (ii) Calls to emergency ambulance service rising (1993–5 England 8% increase, varying from <1% in Durham to 20% in West Country) [10]; (iii) Determinants of ambulance usage little researched [10]; (iv) Although rates vary (from 19–52%), inappropriate use of emergency ambulances found consistently [11, 12]; (v) Research to developand evaluate alternatives to current 999 system urgently needed
Telephone Advice Study; NHS Primary and Secondary Care Interface R&D programme; 1996–1999	To assess the safety of nurses and paramedics offering telephone assessment, triage, and advice as an alternative to immediate ambulance despatch for emergency ambulance service callers classified by non-clinical call takers as presenting with “non-serious” problems	London, West Midlands; 999 callers triaged in ambulance call centre as low priority	Quasi experimental, shadow trial	(i) 999 alternatives that leave patients at home instead of taking them to hospital carry safety risks [13]; (ii) Telephone assessment in the ambulance call centre can identify patients who may not need to be attended by emergency ambulance [14]; (iii) No serious safety issues were found in this shadow trial [15]; (iv) Full randomised trial of clinical and cost effectiveness of telephone advice for non-urgent 999 callers warranted [13–15]
Minor Injuries Units study; NHS North Thames Regional Health Authority R&D programme; 1999–2002	To evaluate triage and transportation to a minor injury unit (MIU) by paramedics	London, Surrey; Patients with minor injuries attended by 999 ambulance	Randomised controlled trial	(i) Trial results reported by treatment received due to low study compliance [16]; (ii) MIU usage was low (10% of eligible patients) [16]; (ii) Patients taken to MIU were more likely to rate their care as excellent, with emergency ambulance episode and total emergency episodes considerably shorter for these patients [16]
Treat and Refer study; NHS North Thames Regional Health Authority R&D programme; 1999–2002	To develop and evaluate “Treat and Refer” protocols for paramedics, allowing them to leave patients at the scene with onward referral or self-care advice as appropriate	London; Patients who may not need to be taken to Emergency Department (ED) for immediate care	Quasi experimental	(i) With interest in developing alternatives high, few services (2/42) had formally audited non-conveyance or (9/42) put new models of care into practice. Only 3 services had carried out any evaluation of these initiatives [17]; (ii) 23 protocols were developed for the face to face assessment and care of 999 patients who may not need to be taken to ED for treatment [18]; (iii) 17 were used, for 40% of intervention group patients (𝑛=101/251), with falls protocol used much more frequently than any other (𝑛=57) [18]; (iv) Conveyance rates were unaffected, but protocols were found to be safe and patient satisfaction was high [18]; (v) There was consensus at the end of the project that Treat and Refer protocols should be introduced across the service, but crews reported feeling unsupported to change practice [19]; (vi) Further research needed at multiple sites barriers to implementation need to be addressed [17–19]
Fit to be Left; NSF for Older people R&D programme; 2003–2006	To design, develop, implement and evaluate a tool designed to support ambulance staff to make consistent and formalised decisions concerning the conveyance of older people who have fallen	London; Patients aged 65+ attended by a 999 ambulance following a fall	Observational, quasi experimental	(i) Patients left at home by their attending crew following a fall were at high risk of a further fall, 999 attendance, ED contact and death within 2 weeks [20]; (ii) Decisions to leave older people at home following a fall were complex and multi factorial [21]
Non serious 999 calls managed by nurse advisers by telephone; NHS Service Delivery and Organisation R&D programme, 2002–2005	An evaluation of the costs and benefits of transferring some low priority 999 calls to NHS Direct nurse advisers for further assessment and advice	South Wales, Thames Valley Greater Manchester; 999 callers with problems assessed in ambulance call centre as non-urgent	Randomised controlled trial	(i) Transferring non-urgent 999 calls for further advice and assessment provides a safe and cost-effective service for some calls [22]; (ii) Almost half of calls transferred were returned to the ambulance service for an ambulance response indicating that, although non-urgent, many of these calls are for patients who need transport or some form of face to face assessment [22]; (iii) Further research required todevelop and evaluate models of care that suit the range of 999 callers [22]
Non conveyance; Wales Office of R&D,; 2004–2006	Exploration of ambulance crew members' attitudes towards clinical documentation and non-conveyed patients	South Wales; Patients left at home following an attendance by emergency ambulance	Qualitative study, focus groups	(i) Decision making complex for two reasons: capacity of patients to make decisions and input of patients, friends, family and ambulance crew [23]; (ii) Mismatch between policy and practice needs to be addressed through research [23]; (iii) Low rates of clinical documentation for 999 patients not taken to ED pose a litigation risk but the process is not valued by clinical staff or adequately audited by managers [24]
Paramedic Practitioner Older People Study; The Health Foundation; 2003–2006	To evaluate the safety, effectiveness and cost effectiveness of clinical decisions made by Paramedic Practitioners operating within the new service compared with standard practice of EMS transfer and ED treatment	Sheffield; 999 patients aged 65+	Randomised controlled trial	(i) Patients in the intervention group were less likely to attend ED, require hospital admission within 28 days, experienced a shorter episode of care time, and were more likely to report being highly satisfied with their care, with no difference in 28 day mortality [25]; (ii) 219/2025 patients attended ED within 7 days of their index call, in which 16 (0.8%) were judged to have received suboptimal care. No difference was found in rate between intervention and control arms [26] Paramedics with extended skills can provide a safe, clinically and cost effective alternative to standard ambulance transfer and treatment in an ED for elderly patients with acute minor conditions [25–27]