This book may not immediately stand out to the paramedic despite ‘emergency care’ being in the title. To be honest, this wouldn't be a bad assumption to make. That's not to say the book doesn't cover some paramedicine topics—however, it takes some digging to find them.
We are presented with six initial chapters each written by different authors—in fact, there are a total of over 50 authors in this particular book. What becomes apparent is that the vast majority are from the United States (US) and, consequently, the topics are US-centric. The latter section of the book uses 20 case studies to further explore topics in hospital care. However, don't expect these case studies to be clinically focused as we tend to know them. Rather, they are selected to explore topics such as ‘big data’, which addresses the complex world of analytics for operational management within the hospital setting, and ‘high cost users’, which delves into how information technology (IT) can be used to streamline care plans.
Snippets of paramedicine
From this introduction, I am sure you have gathered that this book is aimed at the healthcare manager looking for innovative ways to improve services to make them more efficient and effective. Nevertheless, there are some snippets related to the work of the paramedic and, on rare occasions, the paramedic in the UK.
A victim of its own success
The first chapter takes us on a journey through the past 50 years of the emergency department (ED) across the US. The first thing that stands out is the speed of growth and how much change has been driven by the patient in the first instance, but also by a small number of individual clinicians who refused to accept apathy towards the number of patients dying due to accidents. As the ED developed and the popularity grew, it became a victim of its own success.
Expensive and inefficient
As I was reading, I couldn't help but relate this to the current situation in the UK's ambulance services. There are actually a couple of paragraphs in this section afforded to the UK but the text soon reverts back to US history. The topic of telemedicine is touched upon, using high-fidelity (high-definition or HD to us) video consultation; however, the driver behind this is lower fees for the patient. The chapter concludes that emergency care is expensive and inefficient across both the US and the UK. Is this setting us up for an answer to all of our financial problems?
The following chapters cover such topics as the use of IT and how poor compatibility causes issues, targets and how they can be manipulated and achieved without being patient focused and the obvious problem of long waiting times across all the EDs. With most topics, I found myself drawing parallels with the UK ambulance services and my own experiences of EDs. The areas which I found foreign were the financial phrases such as ‘resource-based relative value scales’, ‘fee-for service’ and ‘value units’.
Conflict of interests
Many of the various options of how health care should be paid for in the US are discussed; however, unsurprisingly, no obvious solution is revealed. A final discussion made me scratch my head a little—a cautionary tale that if the clinician does provide quality holistic care, they may be doing themselves out of future business!
Patient flow
A world of throughput, input and output is then examined at length. Essentially, this chapter delves into patient flow and I found myself a little lost. I did pick up on some interesting discussions around triage and started to visualise some of the EDs I attend.
I have witnessed triage in many forms, often completed by nursing staff; sometimes a consultant is sent at times of increased pressure—with limited success I might add—and on occasions, triage is completely absent. All of these options are discussed and evaluated with a reasonable amount of research presented and an acknowledgement when research is lacking.
Shared decision-making
Before we move towards the case studies, shared decision making (SDM) is looked at and pitfalls are discussed when, for example, difficult clinical decisions need to be made and the patient is unable to understand the complexities associated with this.
Clinical cases
Towards the end of this chapter, three clinical case studies are used; this works well to put some practical focus on the topic.
The 20 case studies which follow are focused on a number of different topics. They begin by giving an in-depth history of the subject matter and then often focus on a specific ED in the US. Topics such as mental health, geriatric care, IT, urgent care centres, ED waiting times and telemedicine are subjects for discussion.
US vs the UK
I felt a mild pang of excitement when I came across case study 16—community paramedics—however, they didn't represent what I recognise here in the UK. They sound more like primary care-based clinicians performing home visits for chronic conditions. Something that seems to be growing in popularity in the UK GP surgeries, and something that prescribing will potentially fuel in the near future.
As I have mentioned, the vast majority of this book is focused on the US, although many of the issues and topics can be related to the UK. The problems they face are mirrored in this country; however, some of the solutions suggested would not be achievable given the unique way the NHS is paid for.
A cuppa and a hand
A final point which I thought worthy of mentioning was one case study suggesting that a conscious effort should be made to follow-up on the patient's experience. Despite the Ipsos MORI's (Thomas and Hills, 2017) survey suggesting that over 40% of the public put a timely response as the most important aspect they expect from an ambulance service.
I would suggest that the softer skills are also important to the patient and their families, making a cup of tea, ensuring the doors are locked and holding someone's hand means a lot—maybe not topics we cover in the university setting to the extent required. It would be interesting to make a conscious effort to find out this information and act on it.