review article new models of emergency prehospital care that...

Hindawi Publishing CorporationThe Scientific World JournalVolume 2013, Article ID 182102, 6 pageshttp://dx.doi.org/10.1155/2013/182102

Review ArticleNew Models of Emergency Prehospital Care ThatAvoid Unnecessary Conveyance to Emergency Department:Translation of Research Evidence into Practice?

Helen Anne Snooks, Mark Rhys Kingston,Rebecca Elizabeth Anthony, and Ian Trevor Russell

Centre for Health Information Research and Evaluation (CHIRAL), Institute of Life Science, College of Medicine, Swansea University,Singleton Park, Swansea SA2 8PP, UK

Correspondence should be addressed to Helen Anne Snooks; [email protected]

Received 21 December 2012; Accepted 15 April 2013

Academic Editors: S. Huckson, E. Lang, and B. Rowe

Copyright © 2013 Helen Anne Snooks et al. This is an open access article distributed under the Creative Commons AttributionLicense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properlycited.

Background. Achieving knowledge translation in healthcare is growing in importance butmethods to capture impact of research arenot well developed. We present an attempt to capture impact of a programme of research in prehospital emergency care, aiming toinform the development of EMSmodels of care that avoid, when appropriate, conveyance of patients to hospital for immediate care.Methods.Wedescribe the programme and its dissemination, present examples of its influence onpolicy andpractice, internationally,and analyse routine UK statistics to determine whether conveyance practice has changed. Results. The programme comprises eightresearch studies, to a value of >£4m. Findings have been disseminated through 18 published papers, cited 274 times in academicjournals. We describe examples of how evidence has been put into practice, including newmodels of care in Canada and Australia.Routine statistics in England show that, alongside rising demand, conveyance rates have fallen from 90% to 58% over a 12-yearperiod, 2,721 million fewer journeys, with publication of key studies 2003–2008. Comment. We have set out the rationale, keyfeatures, and impact on practice of a programme of publicly funded research. We describe evidence of knowledge translation,whilst recognising limitations in methods for capturing impact.

1. Background

The gap between the production of research evidence andimplementation into routine clinical practice has been wellacknowledged and has been referred to as the second transla-tional gap; the first gap is that between laboratory scienceand clinical research [1]. With increasing recognition of theimportance of not only carrying out research but also ofensuring that research findings are taken up and used bythose making health care policy and providing health care,researchers and research funders are now paying more atten-tion to dissemination, particularly active forms which havethe ability to influence care delivery, and also to capturing theimpact of research [2–4].

In the field of emergency care, research evidence tounderpin care has been criticised both for its scarcity and

quality [5]. In the prehospital setting these concerns areeven more acute [6–8]. Emergency prehospital care is a fieldwithout a strong academic tradition, but patient volume ishigh and outcomes are linked to responses provided by emer-gency medical systems (EMS). In this growing field, demon-strating impact in practice is fundamental to the continuedattraction of research funding, building of research skills andculture, and thus a high-quality evidence based to informfuture policy and practice.

With sustained increases in demand for emergency pre-hospital care across the developed world, current systems areunable to maintain services that traditionally respond to allemergency calls to the ambulance service with a paramedicstaffed patient carrying vehicle travelling on lights and sirens,andwith a default of conveyance to an emergency department(ED) for medical care unless the patient refused to travel.

2 The Scientific World Journal

Researches focussing on the needs and outcomes of patientsfor whom emergency (999) calls to the ambulance serviceare made have shown that a substantial proportion of thesepatients (up to 52%) [11, 12, 15, 28] do not need immediatemedical care, but that triage systems at the despatch centreand on scene that identify patients for self- or community-based care carry significant safety risks [15–17, 22]. Unneces-sary transportation can also be an issue for patients who havelittle or no chance of survival [29].

In this paper we describe a programme of research relatedto the development and implementation of new models ofcare that allow ambulance services to offer alternatives tothe traditional response and to safely reduce conveyance ofpatients to ED and present data that demonstrate the impactof this research.

2. Summary of Research Programme

Supported by over £4m in research grants, the programmeof work includes studies that have followed the UK’s MedicalResearch Council’s Framework for the Development andEvaluation of Complex Interventions [30, 31] and comprisesreviews of existing research and practice and experimentalresearch, including randomised controlled trials (Table 1).Research findings indicate and describe the problem [9–13]and then the costs and effectiveness of alternatives to currentpractice [14–19, 22]. Study findings have been widely dissem-inated to generic and specialist audiences through publica-tion in peer reviewed and practitioner journals, as well as atconferences at local, national, and international levels. Theresearch team works closely with prehospital care providersand policy makers in the UK but does not follow a formalknowledge transfer strategic approach.

3. Impact on Policy and Practice:Knowledge Transfer

3.1. Methods. We tracked citations using Google Scholar,undertook extensive electronic searching of policy docu-ments, and gathered ad hoc information related to servicedevelopments in which studies from this programme of workwere cited. We analysed routine national data provided by allindividual services as part of their required performancestatistics for the period before and since publication of find-ings from studies within the programme.

3.2. Results. Papers reported in Table 1 have been cited inacademic journals 274 times to date. An influential systematicreview of 999 alternatives for the UK Department of Health(2005) draws heavily upon the work of the research team andhas gone on to influence guidance emanating from statutoryUK bodies [32–34]. Nontransport (to ED) guidelines fromthe Ambulance Service Association and Department ofHealth, which cite elements of this work, have been widelyadopted, as have “Treat and Refer” protocols.

Enhanced telephone triage has been adopted across theUK ambulance service providers, in line with the recommen-dations of the Department of Health and the Ambulance

Service Association—both of which respond to work pub-lished within this programme. Through correspondence anddesktop reviewswe are aware of similar servicemodels havingbeen adopted internationally, in Canada, for example, and inSouth Australia, where the Ambulance Service was able toreport financial savings following implementation across thestate of Victoria, having cited findings from the TelephoneAdvice Study [13–15], in their business case.

“Prior to 2003 we sent an ambulance to all callsreceived via the “000” ambulance emergency callcentre. Professor Snooks work, including the evi-dence of very high caller satisfaction and very fewadverse events from referrals instead of con-veyance, was used to show the need for a referralservice at point of call. In the year following imple-mentation we were able to show cost savings andhave now fully implemented the service, and themodel is being rolled out across Australia.” SeniorResearch Fellow, Ambulance Victoria, Australia.

“We have used Professor Snooks published work[on pre hospital clinical decision making tools] toinform policies in Nova Scotia and Alberta. Thereare similar challenges being faced in the UK andCanada.” Senior Performance Strategist, AlbertaHealth Services Emergency Medical Services.

Evidence of the impact of the work in prehospital carecan be seen in conveyance rates—90% of emergency calls inEngland resulted in hospital conveyance in 2000 compared to58% in 2012 (see Figures 1 and 2)—equivalent to 2,721 millionfewer journeys.

4. Discussion

4.1. Key Points. Findings from this programme of work haveconsistently highlighted the need for alternatives to routineconveyance of 999 patients to ED and the team have devel-oped, implemented, and tested a range of approaches toimproving and providing evidence about the quality, safety,and cost effectiveness of care.

Working collaborativelywith theNHS and policymakers,lessons from the programme of work have been disseminatedwidely in peer-reviewed articles, policy literature, interna-tional conferences, and through personal invitations to visitservice providers.

Nationally and internationally, evidence from this pro-gramme of work has been cited in policy documents and inservice developments, including the provision of telephoneadvice and Treat and Refer protocols.

In the face of consistent increases in demand for the 999emergency ambulance service in the UK and internationally,we have demonstrated evidence of falling conveyance ratesand an increasing proportion of patients treated at scene inEngland since the publication of our findings.

4.2. Strengths and Limitations. Methods for capturing impactof research are not well developed and include a variety of

The Scientific World Journal 3

Table1:Summaryof

studies

andou

tputsincludedin

research

programme.

Stud

yand

fund

ing

Research

focus

Research

sites,

patie

ntpo

pulatio

nRe

search

desig

nKe

ymessagesa

ndreferences

Epidem

iology

ofem

ergencyam

bulancec

alls

SouthWestR

egional

Health

Authority

R&D

1996–1999

Toincrease

the

know

ledgeb

ase

regardingdemandfor

emergencymedical

services

andthefactors

influ

encing

demand

Wiltshire

All999callers

Observatio

nal

study

and

review

ofevidence

(i)Dem

andfore

mergencyam

bulances

rose

by72%in

Wiltshire

between1988

and1996

with

noevidence

ofan

increase

inGPplaced

calls

[9]

(ii)C

allsto

emergencyam

bulances

ervice

rising(19

93–5

England8%

increase,

varyingfro

m<1%

inDurham

to20%in

WestC

ountry)[10]

(iii)Determinantsof

ambu

lanceu

sage

little

researched

[10]

(iv)A

lthou

ghratesv

ary(fr

om19–52%

),inapprop

riateuseo

femergency

ambu

lances

foun

dconsistently

[11,12]

(v)R

esearchto

developand

evaluatealternatives

tocurrent9

99syste

murgently

needed

Teleph

oneA

dviceS

tudy

NHSPrim

aryand

Second

aryCa

reInterfa

ceR&

Dprogramme

1996–1999

Toassessthes

afetyof

nurses

andparamedics

offeringtelep

hone

assessment,triage,and

advice

asan

alternative

toim

mediate

ambu

lanced

espatchfor

emergencyam

bulance

servicec

allerscla

ssified

byno

n-clinicalcall

takersas

presentin

gwith

“non

-serious”

prob

lems

Lond

on,W

est

Midland

s999callerstriaged

inam

bulancec

all

centre

aslow

priority

Quasi

experim

ental,

shadow

trial

(i)999alternatives

thatleavep

atientsa

thom

einstead

oftaking

them

toho

spita

lcarry

safetyris

ks[13]

(ii)T

eleph

onea

ssessm

entinthea

mbu

lancec

allcentre

canidentifypatie

nts

who

may

notn

eedto

beattend

edby

emergencyam

bulance[14]

(iii)Noserio

ussafetyissuesw

erefou

ndin

thisshadow

trial[15]

(iv)F

ullrando

mise

dtrialofclin

icalandcosteffectiv

enesso

ftelepho

neadvice

forn

on-urgent9

99callerswarranted

[13–15]

Minor

Injurie

sUnitsstu

dyNHSNorth

Tham

esRe

gion

alHealth

Authority

R&Dprogramme

1999–2002

Toevaluatetriage

and

transportatio

nto

aminor

injury

unit

(MIU

)byparamedics

Lond

on,Surrey

Patie

ntsw

ithminor

injurie

sattend

edby

999

ambu

lance

Rand

omise

dcontrolledtrial

(i)Trialresultsrepo

rted

bytre

atmentreceiveddu

etolowstu

dycompliance[16]

(ii)M

IUusagew

aslow(10%

ofeligiblep

atients)[16]

(ii)P

atientstaken

toMIU

werem

orelikely

toratetheirc

area

sexcellent,w

ithem

ergencyam

bulancee

pisode

andtotalemergencyepiso

desc

onsid

erably

shorterfor

thesep

atients[16]

Treatand

Referstudy

NHSNorth

Tham

esRe

gion

alHealth

Authority

R&Dprogramme

1999–2002

Todevelopand

evaluate“Treatand

Refer”protocolsfor

paramedics,allowing

them

toleavep

atients

atthes

cene

with

onwardreferralor

self-care

advice

asapprop

riate

Lond

onPatie

ntsw

homay

notn

eedto

betakento

Emergency

Departm

ent(ED

)forimmediate

care

Quasi

experim

ental

(i)With

interestin

developing

alternatives

high

,few

services

(2/42)

had

form

allyauditedno

n-conveyance

or(9/42)

putn

ewmod

elsof

care

into

practic

e.Only3services

hadcarriedou

tany

evaluatio

nof

theseinitia

tives

[17]

(ii)2

3protocolsw

ered

evelop

edforthe

face

toface

assessmentand

care

of999

patie

ntsw

homay

notn

eedto

betakento

EDfortreatment[18]

(iii)17

wereu

sed,for4

0%of

interventio

ngrou

ppatie

nts(𝑛=101/251),with

falls

protocolused

muchmorefrequ

ently

than

anyother(𝑛=57)[18]

(iv)C

onveyancer

ates

wereu

naffected,but

protocolsw

erefou

ndto

besafeand

patie

ntsatisfactionwas

high

[18]

(v)Th

erew

asconsensusa

tthe

endof

thep

rojectthatTreatand

Referp

rotocols

shou

ldbe

intro

ducedacrossthes

ervice,but

crew

sreportedfeeling

unsupp

ortedto

change

practice[

19]

(vi)Fu

rtherresearchneeded

atmultip

lesites

barriersto

implem

entatio

nneed

tobe

addressed[17–19]


Table1:Con

tinued.

Stud

yand

fund

ing

Research

focus

Research

sites,

patie

ntpo

pulatio

nRe

search

desig

nKe

ymessagesa

ndreferences

Fittobe

Left

NSF

forO

lder

peop

leR&

Dprogramme

2003–2006

Todesig

n,develop,

implem

entand

evaluateatoo

ldesigned

tosupp

ortambu

lance

staff

tomakec

onsistent

andform

alise

ddecisio

nsconcerning

thec

onveyanceo

folder

peop

lewho

have

fallen

Lond

onPatie

ntsa

ged65+

attend

edby

a999

ambu

lance

follo

wingafall

Observatio

nal,

quasi

experim

ental

(i)Patie

ntsleft

atho

meb

ytheira

ttend

ingcrew

follo

wingafallw

erea

thighris

kof

afurther

fall,999attend

ance,E

Dcontactand

deathwith

in2weeks

[20]

(ii)D

ecision

stoleaveo

lder

peop

leatho

mefollowingafallw

erec

omplex

and

multifactorial[21]

Non

serio

us999calls

managed

bynu

rsea

dvise

rsby

teleph

one

NHSServiceD

eliveryand

Organisa

tionR&

Dprogramme,2002–2005

Anevaluatio

nof

the

costs

andbenefitso

ftransfe

rringsomelow

priority999calls

toNHSDire

ctnu

rse

advisersforfurther

assessmentand

advice

SouthWales,

Tham

esVa

lley

Greater

Manchester

999callerswith

prob

lemsa

ssessed

inam

bulancec

all

centre

asno

n-urgent

Rand

omise

dcontrolledtrial

(i)Transfe

rringno

n-urgent

999calls

forfurther

advice

andassessment

provides

asafea

ndcost-

effectiv

eservice

forsom

ecalls[22]

(ii)A

lmosth

alfo

fcallstransfe

rred

werer

eturnedto

thea

mbu

lances

ervice

for

anam

bulancer

espo

nseind

icatingthat,alth

ough

non-urgent,m

anyof

these

calls

arefor

patie

ntsw

honeed

transporto

rsom

eform

offace

toface

assessment[22]

(iii)Fu

rtherresearchrequ

iredtodevelopandevaluatemod

elso

fcarethatsuit

ther

ange

of999callers[22]

Non

conveyance

Wales

Office

ofR&

D,

2004–2006

Explorationof

ambu

lancec

rew

mem

bers’attitudes

towards

clinical

documentatio

nand

non-conveyed

patie

nts

SouthWales

Patie

ntsleft

atho

mefollowingan

attend

ance

byem

ergency

ambu

lance

Qualitative

study,focus

grou

ps

(i)Decision

makingcomplex

fortworeason

s:capacityof

patie

ntstomake

decisio

nsandinpu

tofp

atients,friend

s,family

andam

bulancec

rew[23]

(ii)M

ismatch

betweenpo

licyandpractic

eneeds

tobe

addressedthroug

hresearch

[23]

(iii)Lo

wrateso

fclin

icaldo

cumentatio

nfor9

99patie

ntsn

ottakento

EDpo

sealitigatio

nris

kbu

tthe

processisn

otvalued

byclinicalstaffor

adequately

auditedby

managers[24]

ParamedicPractitioner

Older

Peop

leStud

yTh

eHealth

Foun

datio

n2003–2006

Toevaluatethes

afety,

effectiv

enessa

ndcost

effectiv

enesso

fclin

ical

decisio

nsmadeb

yParamedic

Practitionersop

erating

with

inthen

ewservice

comparedwith

standard

practic

eof

EMStransfe

rand

EDtre

atment

Sheffi

eld999patie

ntsa

ged

65+

Rand

omise

dcontrolledtrial

(i)Patie

ntsintheinterventiongrou

pwerelesslikely

toattend

ED,require

hospita

ladm

issionwith

in28

days,exp

erienced

asho

rter

episo

deof

care

time,

andwerem

orelikely

torepo

rtbeinghigh

lysatisfiedwith

theirc

are,with

nodifferencein28

daymortality[25]

(ii)2

19/2025patie

ntsa

ttend

edED

with

in7days

oftheirind

excall,in

which

16(0.8%)w

erejud

gedto

have

received

subo

ptim

alcare.N

odifferencew

asfoun

din

ratebetweeninterventio

nandcontrolarm

s[26]P

aram

edicsw

ithextend

edskillsc

anprovidea

safe,clin

icallyandcosteffectiv

ealternativetostandard

ambu

lancetransfera

ndtre

atmentinan

EDfore

lderlypatientsw

ithacute

minor

cond

ition

s[25–27]

The Scientific World Journal 5

0

1

2

3

4

5

6

7

8

920

00-0

1

2001

-02

2002

-03

2003

-04

2004

-05

2005

-06

2006

-07

2007

-08

2008

-09

2009

-10

2010

-11

2011

-12

Mil

lio

ns

Total emergency callsEmergency attendances Treated at scene only

Period of publication of

evaluative reports from

work programme

Patient journeys (conveyed)

Figure 1: Ambulance Service Summary Statistics (a), England,2000–2012.

0

10

20

30

40

50

60

70

80

90

100

2000

-01

2001

-02

2002

-03

2003

-04

2004

-05

2005

-06

2006

-07

2007

-08

2008

-09

2009

-10

2010

-11

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-12

Total emergency callsconveyed (%)

Period of publication of

evaluative reports from

work programme

Total emergency calls resulting in emergency attendances (%)

Figure 2: Ambulance Service Summary Statistics (b), England,2000–2012.

approaches [35, 36]. In this under researched area, policy doc-uments are often consensual rather than based on evidenceand citation of underpinning research is rare.

In this paper we have described the scope, characteristics,and impact of a research programme in emergency prehospi-tal care. For inferences about impact on practice we have hadto rely on citations and ad hoc reports of service innovationalongside routine statistics related to emergency demand andtreatment. Citations are recognised as a weak indicator of realimpact [36]. Routine data are reliable but observational.

We are conscious that there are other potential causesfor these changes. In an ideal or planned world with multi-ple indicators and well-defined interventions, the statisticaltechnique of interrupted time series can draw stronger con-clusions about cause and impact, as in the Respect trial [37,38]. In the real world inferences about causation are moredifficult.

4.3. Implications. Demonstration of impact of research isincreasingly important in times when resources are scarceand competition is heavy. Research funders and researchersare under pressure to report impact but methods are under-developed. Policy and treatment guidelines often lack trans-parent underpinning research evidence. Measuring impact isour only way of capturing knowledge transfer from researchevidence to patient care.

Against this setting we have attempted to set out therationale, key features, and resulting impact on practice ofa programme of research funded through the public pursein the UK. We argue that findings have been influential atnational and international levels although we recognise thatthe rigour of methods for identifying and attributing impactis not as high as in the traditional “gold standard” RCT.

References

[1] D. Cooksey, A Review of UK Health Research Funding, HMTreasury, London, UK, 2006.

[2] L. A. Bero, R. Grilli, J. M. Grimshaw, E. Harvey, A. D. Oxman,and M. A. Thomson, “Getting research findings into practice.Closing the gap between research and practice: an overview ofsystematic reviews of interventions to promote the implemen-tation of research findings,” British Medical Journal, vol. 317, no.7156, pp. 465–468, 1998.

[3] WorldHealthOrganization,World Report onKnowledge for Bet-ter Health: Strengthening Health Systems, World Health Organi-zation, Geneva, Switzerland, 2004.

[4] S. R. Hanney, M. A. Gonzalez-Block, M. J. Buxton, and M.Kogan, “The utilisation of health research in policy-making:concepts, examples andmethod of assessment,”Health ResearchPolicy and Systems, vol. 1, no. 1, article 2, 2003.

[5] V. Bounes, E. Dehours, V. Houze-Cerfon, B. Valle, R. Lipton,and J. L. Ducasse, “Quality of publications in emergency medi-cine,”American Journal of EmergencyMedicine, vol. 31, no. 2, pp.297–301, 2013.

[6] D.W. Spaite, E. A. Criss, T. D. Valenzuela, and J. Guisto, “Emer-gency medical service systems research: problems of the past,challenges of the future,”Annals of EmergencyMedicine, vol. 26,no. 2, pp. 146–152, 1995.

[7] Sheffield University, “Building the evidence base in pre hospitalurgent and emergency care: a review of research evidence andpriorities for future research,” 2010.

[8] S. Brace and M. Cooke, “What are the priorities for prehospitalresearch?” Journal of Paramedic Practice, vol. 2, no. 11, pp. 502–504, 2010.

[9] H. Wrigley, S. George, H. Smith, H. Snooks, A. Glasper, and E.Thomas, “Trends in demand for emergency ambulance servicesinwiltshire over nine years: observational study,”BritishMedicalJournal, vol. 324, no. 7338, pp. 646–647, 2002.


[10] H. Wrigley, H. Snooks, E. Thomas, H. Smith, A. Glasper, andS. George, “Epidemiology and demography of 999 ambulancecalls: a review,” Pre-Hospital Immediate Care, vol. 3, pp. 94–98,1999.

[11] H. Snooks, H. Wrigley, S. George, E. Thomas, H. Smith, andA. Glasper, “Appropriateness of use of emergency ambulances,”Journal of Accident and Emergency Medicine, vol. 15, no. 4, pp.212–215, 1998.

[12] H. Snooks, S.Williams, R. Crouch, T. Foster, C. Hartley-Sharpe,and J. Dale, “NHS emergency response to 999 calls: alternativesfor cases that are neither life threatening nor serious,” BritishMedical Journal, vol. 325, no. 7359, pp. 330–333, 2002.

[13] H. A. Snooks, J. Dale, C. Hartley-Sharpe, and M. Halter, “On-scene alternatives for emergency ambulance crews attendingpatients who do not need to travel to the accident and emer-gency department: a review of the literature,” Emergency Medi-cine Journal, vol. 21, no. 2, pp. 212–215, 2004.

[14] J. Dale, J. Higgins, S. Williams et al., “Computer assisted assess-ment and advice for “non-serious” 999 ambulance servicecallers: the potential impact on ambulance despatch,” Emer-gency Medicine Journal, vol. 20, no. 2, pp. 178–183, 2003.

[15] J. Dale, S. Williams, T. Foster et al., “Safety of telephone con-sultation for “non-serious” emergency ambulance servicepatients,” Quality and Safety in Health Care, vol. 13, no. 5, pp.363–373, 2004.

[16] H. Snooks, T. Foster, and J. Nicholl, “Results of an evaluationof the effectiveness of triage and direct transportation tominor injuries units by ambulance crews,” Emergency MedicineJournal, vol. 21, no. 1, pp. 105–111, 2004.

[17] H. Snooks, N. Kearsley, J. Dale, and M. Halter, “New modelsof care for 999 callers with conditions that are neither life-threatening nor serious: results of a national survey,” Pre-Hos-pital Immediate Care, vol. 4, pp. 180–182, 2000.

[18] H. Snooks, N. Kearsley, J. Dale, M. Halter, J. Redhead, and W.Y. Cheung, “Towards primary care for non-serious 999 callers:results of a controlled study of “Treat and Refer” for ambulancecrews,”Quality and Safety in Health Care, vol. 13, no. 6, pp. 435–443, 2004.

[19] H. A. Snooks, N. Kearsley, J. Dale, M. Halter, J. Redhead, and J.Foster, “Gaps between policy, protocols and practice: a qualita-tive study of the views and practice of emergency ambulancestaff concerning the care of patients with non-urgent needs,”Quality and Safety in Health Care, vol. 14, no. 4, pp. 251–257,2005.

[20] H. A. Snooks, M. Halter, J. C. T. Close, W. Cheung, F. Moore,and S. E. Roberts, “Emergency care of older people who fall: amissed opportunity,” Quality and Safety in Health Care, vol. 15,no. 6, pp. 390–392, 2006.

[21] M. Halter, S. Vernon, H. Snooks et al., “Complexity of thedecision-making process of ambulance staff for assessment andreferral of older people who have fallen: a qualitative study,”Emergency Medicine Journal, vol. 28, no. 1, pp. 44–50, 2011.

[22] J. Turner, H. Snooks, A. Youren et al., “The costs and benefitsof managing some low-priority 999 ambulance calls by NHSDirect nurse advisers,” Report for National Co-OrdinatingCentre for NHS Service Delivery and Organisation R&D,NCCSDO, 2006.

[23] A. Porter, H. Snooks, A. Youren et al., “‘Should I stay or should Igo?’ Deciding whether to go to hospital after a 999 call,” Journalof Health Services Research and Policy, vol. 12, supplement 1, pp.S1–S1, 2007.

[24] A. Porter, H. Shooks, A. Youren et al., ““Covering our backs”:ambulance crews’ attitudes towards clinical documentationwhen emergency (999) patients are not conveyed to hospital,”Emergency Medicine Journal, vol. 25, no. 5, pp. 292–295, 2008.

[25] S. Mason, E. Knowles, B. Colwell et al., “Effectiveness of para-medic practitioners in attending 999 calls from elderly peoplein the community: cluster randomised controlled trial,” BritishMedical Journal, vol. 335, no. 7626, pp. 919–922, 2007.

[26] S. Mason, E. Knowles, J. Freeman, and H. Snooks, “Safety ofparamedics with extended skills,” Academic Emergency Medi-cine, vol. 15, no. 7, pp. 607–612, 2008.

[27] S. Dixon, S. Mason, E. Knowles et al., “Is it cost effective tointroduce paramedic practitioners for older people to the ambu-lance service? Results of a cluster randomised controlled trial,”Emergency Medicine Journal, vol. 26, no. 6, pp. 446–451, 2009.

[28] S. Thakore, E. A. McGugan, and W. Morrison, “Emergencyambulance dispatch: is there a case for triage?” Journal of theRoyal Society of Medicine, vol. 95, no. 3, pp. 126–129, 2002.

[29] L. J. Morrison, L. M. Visentin, A. Kiss et al., “Validation of arule for termination of resuscitation in out-of-hospital cardiacarrest,”NewEngland Journal ofMedicine, vol. 355, no. 5, pp. 478–487, 2006.

[30] Medical Research Council, “A Framework for developmentand evaluation of RCTs for Complex Interventions to ImproveHealth,” 2000.

[31] P. Craig, P. Dieppe, S. Macintyre, S. Michie, I. Nazareth, and M.Petticrew, “Developing and evaluating complex interventions:the new Medical Research Council guidance,” British MedicalJournal, vol. 337, article a1655, 2008.

[32] Department of Health, Taking Healthcare To the Patient, Trans-forming NHS Ambulance Services, 2005.

[33] Welsh Assembly Government, A Guide to Good Practice: Emer-gency Care: Tools and Techniques to Enable the NHS and SocialServices to Improve the Delivery of Health and Social Care, 2004.

[34] HealthWorkforce Australia,National HealthWorkforce Innova-tion and Reform Strategic Framework for Action 2011–2015, 2011.

[35] P. Davis and P. Howden-Chapman, “Translating research find-ings into health policy,” Social Science and Medicine, vol. 43, no.5, pp. 865–872, 1996.

[36] J. Lavis, S. Ross, C. McLeod, and A. Gildiner, “Measuring theimpact of health research,” Journal of Health Services Researchand Policy, vol. 8, no. 3, pp. 165–170, 2003.

[37] RESPECT trial team, “Effectiveness of shared pharmaceuticalcare for older patients: RESPECT trial findings,” British Journalof General Practice, vol. 60, no. 570, pp. e10–e19, 2010.

[38] RESPECT trial team, “Cost-effectiveness of shared pharmaceu-tical care for older patients: RESPECT trial findings,” BritishJournal of General Practice, vol. 60, no. 570, pp. e20–e27, 2010.

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