Effectiveness of Emergency Physicians in changing disposition of lower-acuity ambulance patients in the community

Andy Quin, Clinical Fellow in EM with PHEM & MedEd

Linda Dykes, Consultant in Emergency Medicine

Ysbyty Gwynedd, Bangor, North Wales

Do I have to go to hospital, doc? IntroductionTo most people, “PHEM doctor” means helicopters & critical-care interventions. There is, however, emerging interest in the utility of doctors embedded in ambulance services (on the road or in the control room) in the assessment and treatment of more minor injuries/illnesses. We present an evaluation of the influence of three post-ACCS EM Clinical Fellows, whose job plan includes time with Welsh Ambulance (WAST), on the disposition of patients they saw whilst working alongside WAST paramedics.

MethodsLogbooks of three Clinical Fellows were examined. Cases were deemed “doctor changed disposition” if the doctor and/or attending paramedic considered that patient disposition differed from usual paramedic practice based on utilisation of other services, provision of treatment outside paramedic scope of practice, or use of pathways outwith ambulance service guidelines. Patients who refused conveyance to ED were excluded. The addition of a Clinical Fellow to the WAST crew did not influence dispatching decisions. Where possible, cases were clarified with the attending paramedic regarding whether they would have conveyed the patient.

Results• Of 110 individual patient cases, it was deemed that the presence of the doctor had changed

the disposition in 31 case (28%).• Examples of “doctor changed disposition” included additional discharges from scene (e.g.

discharging paediatric patients or cases requiring only oral POM treatment, neither of which are within WAST paramedic scope of practice), diversion to more appropriate facilities (e.g. community mental health teams), preventing futile resuscitation efforts in obviously end-of-life patients, and liaison for future outpatient management such as with the patient’s GP.

• In addition, some patients were still conveyed to hospital, with the presence of a doctor enabling the bypassing of ED direct to inpatient specialties (often with established plans and initial investigations ordered), but unfortunately this was not reliably recorded.

Discussion• Physicians embedded with Welsh Ambulance ground assets are exposed to a range of cases.

Our data confirms that in almost one third of cases they can streamline the patient journey, improving both patient experience and asset availability for WAST, as well as reducing pressure on receiving EDs.

• This evaluation took place during a period when Welsh Ambulance Service trust were introducing patient disposition decision support protocols (Paramedic Pathfinder) which also has scope to recommend diversion of care to other facilities or self treatment. However, this is not yet universally in use, and there are currently few alternatives to ED or GP/GPOOH care in our rural part of North Wales.

• Many of these patients could have been treated by Advanced Paramedic Practitioners (Band 7, MSc qualified) but these are currently scarce in North Wales. Appropriate attendance to a patient’s own GP might also achieve similar outcomes, but if patients choose to access care via the 999 system, it is more efficient to get them out of that system again at the first possible opportunity. Also, many GPs are less comfortable dealing with trauma than Emergency Physicians.

• Improving the triage of incoming 999 calls may reduce the number of ambulance responses to lower-acuity patients, but in the meantime, this data suggests there is significant scope for middle-grade Emergency Physicians to streamline the handling of these patients.

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