Safety of Paramedics with Extended SkillsSuzanne Mason, MBBS, FRCS, FCEM, MD, Emma Knowles, BSc, MA, Jenny Freeman, BSc, MSc,PhD, CStat, Helen Snooks, BSc, PhD

AbstractBackground: The role of paramedics with extended skills is evolving, enabling them to assess and treatpatients in the community. A United Kingdom service led by extended-role paramedic practitioners (PPs)is aimed at managing minor acute illness and injury among older people in the home when appropriate,avoiding unnecessary transfer to the emergency department (ED).

Objectives: The objectives were to evaluate the safety of clinical decisions made by PPs operating withinthe new service.

Methods: As part of a cluster-randomized controlled trial, patients aged >60 years contacting the emer-gency medical services (EMS) with a minor injury or illness were included in the study. The safety of thenew PP intervention was compared with standard practice of EMS transfer and ED treatment. Outcomesincluded unplanned ED attendance within 7 days of the index episode. Clinical records were rated inde-pendently by two senior ED clinicians to identify related episodes, avoidable subsequent episodes, andsuboptimal care.

Results: Of the 2,025 patients included in this analysis, 219 (10.9%) went on to have an unplanned EDattendance within 7 days. Of these, 162 (74.0%) re-presented with a condition related to their index epi-sode. The independent raters agreed on suboptimal care 83.4% of the time. There were 16 agreed uponepisodes related to suboptimal care (0.80%). No significant differences were found between interventionand control groups in relation to re-presentation at hospital within 7 days for a related condition orrates of assessed suboptimal care.

Conclusions: This study suggests that appropriately trained paramedics with extended skills treatingolder people with minor acute conditions in the community are as safe as standard EMS transfer andtreatment within the ED.

ACADEMIC EMERGENCY MEDICINE 2008; 15:607–612 ª 2008 by the Society for Academic EmergencyMedicine

Keywords: paramedics, extended skills, safety

P revious studies have shown that paramedic skillscan be enhanced to assess and treat certain condi-tions in the community, such as wounds,1 cervical

spine injury,2 and stroke.3 One UK study has evaluatedthe use of ‘‘treat and refer’’ protocols for minor condi-tions by ambulance staff.4 This allowed them to leavepatients on-scene with a referral or self-care advice.

In the United Kingdom, the Department of Health’sstrategy has been to encourage the increased use ofnonmedical staff to carry out assessments and treat-ments traditionally carried out by doctors.5 The intro-duction of new models of care, including furtherassessment, triage, and treatment skills for paramedics,has been recommended to help manage ever-increasingdemands for health care and in particular for emer-gency and unscheduled care.5–7 However, currentresearch evidence concerning the safety of thesechanges in practice is lacking.4

Measuring clinical outcomes in emergency medicineis challenging. It is essential that major service changeis accompanied by an evaluation of the quality ofpatient care. As a minimum, care should be as safe asthe previously existing service. This means that somemeasure of the appropriateness and safety of makingclinical decisions is necessary. Despite repeated callsfor developing methods for assessing appropriateness,there is no agreed upon criterion standard. However,studies using inpatient medical record review to detect

ª 2008 by the Society for Academic Emergency Medicine ISSN 1069-6563doi: 10.1111/j.1553-2712.2008.00156.x PII ISSN 1069-6563583 607

From the Section of Health Services Research, School ofHealth and Related Research, University of Sheffield (SM, EK,JF), Sheffield; and the Center for Health Information Researchand Evaluation, School of Medicine, Swansea University (HS),Swansea, UK.Received November 27, 2007; revisions received February 20and March 20, 2008; accepted March 23, 2008.Presented at the Annual Scientific Meeting of the College ofEmergency Medicine, Sheffield, UK, September 2007, and theAnnual Scientific Meeting of the Society for Academic Emer-gency Medicine, Chicago, IL, May 2007.Address for correspondence and reprints: Suzanne Mason,MBBS, FRCS, FCEM, MD; e-mail: s.mason@sheffield.ac.uk.

adverse events have devised a two-step method ofscreening and clinical review of medical records.8,9 Pre-vious studies have shown that this methodology can bemodified to detect adverse events in an emergencydepartment (ED).10 Although it is widely accepted thatdefinitive outcomes such as survival are valuable, whenevaluating non–life-threatening conditions, it is notalways an appropriate measure, nor does it tell us any-thing about the process of care.

In 2003, the South Yorkshire Ambulance Service(SYAS), United Kingdom, developed the ParamedicPractitioner Older People’s Support (PPOPS) schemethat set out to deliver patient-centered care to olderpeople calling emergency medical services (EMS) withconditions triaged as not immediately life-threatening.Paramedic practitioners (PPs) were trained in extendedskills to assess and, where possible, treat older peoplein the community. Alternatively, patients were assessedand referred to the ED with a plan for further manage-ment.11 The training program consisted of a 3-week lec-ture-based program, followed by 45 days of supervisedpractice in emergency and unscheduled care settings.Seven PPs were selected after open competition withinthe SYAS to undergo training for this role. Operationalbetween the hours of 08:00 and 20:00 each day, the ser-vice was activated by a call to the EMS or by an ambu-lance crew attending an eligible patient. Ongoingclinical support and continuing professional develop-ment for the PPs was provided by medical staff withinthe ED on both an informal and a formal basis. Thisarticle aims to present results related to an evaluationof the safety of the clinical decisions made and appro-priateness of care provided by the PP working withinthe new service.

METHODS

Study DesignThis study was a part of a cluster-randomized con-trolled trial evaluating a new EMS service.12 Localresearch ethics committee approval was obtained forthe study from the UK North Sheffield Research EthicsCommittee.

Study Setting and PopulationPatients were eligible for inclusion into the trial if theypresented to the EMS with a call originating from a UKSheffield zip code between September 1, 2003, and Sep-tember 26, 2004; the call was made between 08:00 and20:00 hours; the patient was aged 60 years or over; andthey had a presenting complaint that fell within thescope of practice of the PPs working within the scheme.Cluster randomization was used for the main trial toreduce the risk of contamination, because it was con-sidered likely that the presence of a PP would influencepractice in relation to patients who were eligible to beseen. In addition, cluster randomization allowed forevaluation at the service level rather than the individualpatient level. Weeks were randomized using computerrandom number generation before the start of thestudy (to allow for scheduling of the PPs) to the PPscheme either being active (intervention) or being inac-tive (control) when the standard EMS response was

provided (the cluster analysis therefore used ‘‘week’’ asthe unit of analysis). This consisted of EMS crewassessment and transport to the nearest ED, unless thepatient refused to travel. The roster was concealed fromother members of the emergency services. During inac-tive weeks, the PPs were removed from operationalduties within the ambulance service and undertookresearch duties for the trial.

Study ProtocolDuring each week, a PP based in the EMS control roomidentified calls eligible for PP assessment by presentingcomplaint and notified a PP in the community (interven-tion weeks) or in the ED (control weeks). All identifiedpatients were approached face-to-face for written con-sent to follow-up. Patients who had more than one eli-gible episode during the trial period were recruited fortheir first episode only. Subsequent episodes werelogged, but patients were not rerecruited for trial pur-poses.

Data Collection. Clinical data, including investigations,treatment, diagnoses, and outcome, relating to the ini-tial patient episode were collected by the research teamfrom the ED, PP, or EMS records. Information aboutunplanned ED attendances in the 7 days after the indexepisode was collected from hospital records.

Assessment of Safety. The safety of clinical manage-ment was assessed using clinical records available forthe study from the ED. These were the only clinicalrecords that the study had received ethical approval toreview. Retrospective assessment of the records wasundertaken where patients had an unplanned ED atten-dance within 7 days of the index incident. It was feltthat most serious conditions missed at the index epi-sode would have been identified within 7 days. Patientswho were admitted to the hospital during their initialepisode were excluded from the analysis, because itwas not possible to distinguish if any subsequent hospi-tal attendance was related to their initial inpatient stayrather than the clinical decision-making during theirinitial assessment.

Hospital records were checked for subsequentunplanned ED attendance. A hospital attendance wasidentified as unplanned when patients did not have aplanned review indicated in their index incident recordsor did not have a subsequent ‘‘booked’’ attendance.Records were sought for the first subsequent atten-dance in the ED after the index incident and examinedto determine if the subsequent unplanned attendancewas clinically related to the original episode or the sub-sequent unplanned attendance could have been avoided(i.e., there was suboptimal care provided on the indexday).

Records from the index incident and subsequentattendance were first examined by a nonclinical mem-ber of the research team to elicit if the subsequent visitto hospital was related to the initial visit. A randomsample of these records was checked for agreement byan ED clinician. In cases where it was unclear if the epi-sodes were related, these were passed to the ED clini-cian for clarification and a final decision.

608 Mason et al. • SAFETY OF PARAMEDICS WITH EXTENDED SKILLS

Notes that indicated an episode was related to theindex incident were then checked to assess if the sub-sequent episode could have been avoided. This wasundertaken by two senior ED clinicians (each withmore than 10 years’ experience working in the ED);the ED clinician leading the research (RC) and an EDclinician independent from the study (IC). Notes werereviewed by both ED clinicians independently todetermine if there had been suboptimal care duringclinical management at the index incident. As far aspossible, the two reviewers were blinded to whichservice the patients had received during their indexassessment by deidentification of patient records. Cli-nicians reviewing the records were asked to completea proforma indicating if there had been suboptimalcare during the clinical assessment at the index inci-dent and, if so, to provide their reasons for reachingthat decision.

Data AnalysisThe level of agreement of RC and IC wasassessed using Cohen’s kappa statistic. Differencesbetween the intervention and control groups in thepercentage of patients reattending the ED (in totaland for a condition related to their indexincident) and the percentage assessed as a failure ofcare were compared using a cluster-adjustedchi-square test using ‘‘week’’ as the unit of clusteranalysis. The main trial recruited patients over56 weeks, and therefore the analysis was based on 56clusters.13

RESULTS

Main Trial Results12

A total of 3,018 older patients calling EMS wereincluded in the trial over a 56-week period (n = 1,549intervention, n = 1,469 control). Table 1 providesdemographic and incident details of the recruited trialpatients. There were no differences between recruitedpatients in the intervention and control groups interms of patient demographics or presenting com-plaint. Overall, patients in the intervention groupwere less likely to attend the ED (relative risk [RR]0.72, 95% CI = 0.68 to 0.75) or require hospital admis-

sion within 28 days (RR 0.87, 95% CI = 0.81 to 0.94)and experienced a shorter total episode time(235.07 min vs. 277.8 min, 95% CI of difference )59.5to )25.0). Patients in the intervention groupwere more likely to report being highly satisfiedwith their health care episode (RR 1.16, 95% CI = 1.09to 1.23). There was no statistically significantdifference in 28-day mortality (RR 0.87, 95% CI = 0.63to 1.21).

Selection of Patients for Safety StudyOf the 3,018 patients recruited into the trial, 993 (32.9%)were admitted to the hospital at the index episode andtherefore excluded from this analysis. Of the remaining2,025 patients, 219 (10.8%) went on to have anunplanned ED attendance in the 7 days after dischargefrom care at the index episode (Figure 1). Of these, 162(74.0%) presented with a clinical condition that relatedto their index episode. For the intervention group, 100(75.2%) unplanned admissions were related to the indexepisode, whereas for the control groups the numberwas 62 (72.1%). The clinical notes were not available for5 patients; therefore, 157 cases (7.8%) were analyzed.Figure 1 shows the trial profile and distribution ofpatients for the safety study between intervention andcontrol groups.14

A significant difference was found in the proportionof patients returning as an unplanned ED visit betweenthe intervention and control groups (11.9 and 9.5%,respectively; cluster-adjusted v2(1) = 3.89, p = 0.049).However, there was no significant difference in the pro-portion returning with a related condition, either as aproportion of the total included (intervention 8.9% vs.control 6.8%; cluster-adjusted v2(1) = 3.76, p = 0.052) oras a proportion of returning patients (intervention75.2% vs. control 72.1%; cluster-adjusted v2(1) = 0.21,p = 0.64).

Agreement in Assessment of CareRecords of those patients where the subsequent reat-tendance was related to the clinical condition on theindex attendance were reviewed by the two ED clini-cians. Agreement between the two ED clinicians, as towhether or not there was suboptimal care, was foundin 131 ⁄ 157 (83.4%) cases (see Table 2). The kappa

Table 1Baseline Characteristics of Patients Recruited for Main Trial12

Arm of Trial

Total(N = 3,018)

Intervention(n = 1,549)

Control(n = 1,469)

Female (%) 1,115 (72.0) 1,077 (73.3) 2,192 (72.6)Mean age (yr) (±SD) 82.6 (8.3) 82.5 (8.3) 82.6 (8.3)Living in own home (%) 1,209 (78.1) 1,139 (77.5) 2,348 (77.8)Incident occurred at usual residence (%) 1,336 (88.4) 1,234 (88.1) 2,579 (88.3)Presenting complaint

Fall (%) 1,369 (88.4) 1,313 (89.4) 2,682 (88.9)Hemorrhage (%) 93 (6.0) 78 (5.3) 171 (5.7)

Acute medical condition (%) 86 (5.6) 78 (5.3) 164 (5.4)

SD = standard deviation.

ACAD EMERG MED • July 2008, Vol. 15, No. 7 • www.aemj.org 609

statistic for these data was 0.46, indicating moderateagreement.15

In the majority of cases, both clinicians felt thatthere had not been suboptimal care during the indexepisode (n = 115). Of the patients included in thisanalysis, both clinicians agreed that 16 ⁄ 2,025 (0.80%)experienced suboptimal care during their index epi-sode.

Assessed Suboptimal CareAs evident in Table 2, there was a difference in judg-ment of suboptimal care between RC and IC, with theRC judging more cases to have had suboptimal care

during the initial episode, 35 cases versus 22 cases. Theassessors were only asked to record the reason formaking their decision when they judged care to be sub-optimal. Thus, it was not possible to compare reasonsfor their decisions for all cases, but only for thosewhere both RC and IC concluded there had been sub-optimal care.

In total, there were 42 cases where at least one clini-cian felt there had been suboptimal care. Table 3 showsthese by trial arm. There were no significant differencesin suboptimal care between intervention and controlgroups (26.5% vs. 27.1%, respectively; cluster-adjustedv2(1) = 0.006, p = 0.94).

Figure 1. Trial profile, presented according to CONSORT flow diagram guidelines.14

610 Mason et al. • SAFETY OF PARAMEDICS WITH EXTENDED SKILLS

DISCUSSION

This trial evaluated the management of older peoplecalling EMS with minor acute conditions. It comparedassessment and treatment by paramedics with extendedskills (PPs) with the standard UK EMS response ofassessment and transfer to the local ED. The resultspresented here were for patients who were not admit-ted to the hospital at their index episode. Of these,there was an overall 10.8% return visit rate at the EDwithin 7 days of the index episode. Although therewere more return visits to the ED in the interventiongroup patients, the proportion returning with a relatedcondition in both groups was not found to be signifi-cantly different. The main trial also found no differ-ences between the two groups in relation to mortalityat 28 days.12

Two ED clinicians independently reviewed therecords of patients returning to the ED with relatedconditions to assess for suboptimal care at the indexepisode. Their level of agreement on suboptimal carewas moderate. Suboptimal care was judged by eitheror both clinicians to have occurred for 2.1% of thepatients not admitted after their index episode. Therewere no significant differences between interventionand control groups with respect to suboptimal care.

Although more unplanned return visits were identi-fied in the intervention group (see Figure 1), this didnot translate into an increased number of cases identi-fied as having received suboptimal care at the indexepisode. It may be that more reattendances in thisgroup are to be expected, because the main trial foundthat there were fewer ED attendances and hospitaladmissions after the index episode than in the controlgroup (Table 4).

Studies in the United States that have evaluated tri-age decisions have mainly involved the utilization of

protocols or guidelines. Silvestri et al.16 also previouslyconcluded that paramedics could not safely determinewhich patients could be left at home without additionaltraining. They found that subsequent ED attendanceand hospital admission rates were unacceptably high inthose patients triaged to be left at home. Pointer et al.17

found that after a brief training session and review of astudy workbook, ambulance crews were not able to tri-age patients accurately, with a 9.6% undertriage rate.Schmidt et al.18 found a similar 9% undertriage rate.Other U.S. studies have discussed the difficulties inidentification by ambulance crews of cases eligible forcommunity treatment.19,20 In addition, the relative mer-its of an out-of-hospital practitioner have been dis-cussed with respect to certain geographic areas such asrural locations, in fulfilling a broader public health andprimary care outreach role in the local community.21

In the United Kingdom, significant changes haveoccurred with guidance from the National Health Ser-vice (NHS) Plan, which outlined greater opportunitiesfor NHS staff to extend their roles.5–7 It has been sug-gested that the development of out-of-hospital carepathways may represent a way in which the increasingskills of paramedics could contribute to the ever-increasing demands for emergency health care.

LIMITATIONS

The approach taken here to evaluate rates of subopti-mal care is simple. A more robust approach could havetaken the opinion of an expert panel in deciding on fail-ures of care. However, there is growing evidence that arecords-review approach is sufficiently accurate inidentifying events.22 Equally, a more thorough investi-gation of all possible sources of care that patients couldaccess following their initial health care episode (suchas primary care services) may have revealed differencesbetween the two groups. However, we have no reason

Table 2Agreement between Research Clinician (RC) and Independent

Clinician (IC) about Suboptimal Care

RC

IC

TotalSuboptimal

CareNo Suboptimal

Care

Suboptimal care 16 19 35No suboptimal care 7 115 122Total 23 134 157*

*Five incomplete records.

Table 3Suboptimal Care Identified by either Research Clinician (RC) or

Independent Clinician (IC) by Trial Arm

Intervention Control Total

Any suboptimal care 26 (26.5) 16 (27.1) 42 (26.8)No suboptimal care 72 (73.5) 43 (72.9) 115 (73.2)Total 98 (100.0) 58 (100.0) 157 (100.0)

Data are reported as n (%).

Table 4Paramedic Practitioner Scope of Practice

Presenting complaint• Falls• Lacerations• Epistaxis• Minor burns• Foreign body–ENTPractical skills• Local anesthetic techniques• Wound care and suturing techniques• Principles of dressings and splintingSpecial skills• Joint examination• Neurologic, cardiovascular, and respiratory system

examination• ENT examination• Protocol led dispensing: simple analgesia, antibiotics,

tetanus toxoid• Mobility and social needs assessmentAdditional referral and investigation request options• Radiograph requests• Referral processes: ED, general practitioner, district nurse,

community social services

ED = emergency department; ENT = ear, nose, or throat.

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to suspect that the patients in the two groups wouldaccess services differently, and the resources availableto the trial and ethical approval received would notallow for clinical records from other services to be sub-ject to this safety review.

This study also only evaluated unplanned return visitswithin a 7-day period after the initial episode for thosepatients not initially admitted to the hospital. This cutoffpoint was felt to be reasonable to capture most of the sig-nificant related conditions representing due to possiblefailures in care. However, it is possible that the resultswould be altered if a longer time period was assessed.

This trial evaluated the delivery of a community-based service to older people by seven paramedics whohave received extended skills training. The paramedicswere experienced in their existing role and wereselected for extended training through a robust applica-tion and interview process. In that sense, they werehighly motivated and enthusiastic about the new servicethey were delivering. The trial was undertaken after thePPs had been operational for about 12 months. The tim-ing of the trial coincided with the availability of fund-ing. The trial was not focused on long-term viability ofthe service. However, it is possible that patient caremay be compromised over time, which could affect theoutcomes measured.

CONCLUSIONS

These findings indicate that paramedics trained withthe appropriate skills working in the community assess-ing and treating older people with minor acute condi-tions are doing so in a manner that is at least as safe asthe standard care provided by EMS and the ED. Theirdecisions to treat patients and leave them at home ortransfer them to the ED appeared to be, in the mostpart, safe and did not lead to a significant increase inreattendance rates or death of these patients, repre-senting a very important clinical finding.

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