In his letter of response published in last month's Journal of Paramedic Practice (JPP), Goulding (2014) raises several concerns regarding the validity and necessity for a recently implemented Paramedic Pathfinder (Newton et al, 2013), while attempting to develop an argument against its wider application to UK EMS practice. His reasoning is broadly underpinned by three key assertions:
These concerns essentially mirror those raised in his co-authored e-Letter submitted to the Emergency Medicine Journal in June 2014 (Goulding and Plummer, 2014). Given that I was not involved in the design or expert peer review of the protocol, I do not feel appropriately positioned to comment in any detail on the latter of these three elements. I do, however, feel compelled to comment on the former two.
At first sight, Goulding's letter appears to uncover several interesting findings in relation to the published evaluation of the Paramedic Pathfinder from Newton et al. However, careful examination of Goulding's comments suggest he fails to demonstrate the same academic rigour he accuses Newton et al of omitting from their own study. Indeed, his contribution is biased, inaccurate, and quite frankly does not provide any credible evidence to answer the question he postulates in the title ‘Paramedic Pathfinder: is it really better than current practice?’ I would further suggest that if submitted to the JPP in any other format, it would have been rejected through the robust peerreview process.
Goulding (2014) opens by suggesting that a number of key references that justify the need for a clinical decision support tool are based on American EMS, and therefore should be disregarded due to poor transferability. In actual fact, only one of the three primary references used is from a US system, and (as clearly stated by Newton et al) this examines paramedic referrals to a primary care facility. There is indeed no ‘justification’ for referencing this paper, as none is required; to suggest that data from the US should be essentially disregarded is somewhat unrealistic, especially when considering that the US and UK share a common ‘Anglo- American’ approach to pre-hospital care (Dick, 2003). UK pre-hospital clinicians possess an entire spectrum of education and training, ranging from Level 3 BTEC (IHCD ambulance technician, or equivalent); traditional IHCD paramedic training; more recently, a 2 year Diploma of Higher Education; and up to (and on occasion beyond) BSc and MSc level academic attainment. This entire spectrum of underpinning education is equally replicated across most Anglo-American EMS systems, suggesting even at worst, there is some degree of validity in considering clinical decisions and referral outcomes from both settings. Interestingly, it would appear this is an opinion held by a variety of eminent academics, up to and including those contracted to create policy which is duly published by the Department of Health (2010).
In both submissions (Newton et al, 2013; Goulding, 2014), the authors accurately state that there are a number of UKgenerated studies which demonstrate appropriately educated paramedics can provide safe alternative referral to the ED, and cite some excellent work by Mason et al (2007), and Gray and Walker (2008). However, they also refer to another study by Clesham et al (2008) to support the ability of UK EMS providers in accurately determining the need for ED attendance. Not only is this study of limited relevance to the debate (as the pathfinder is designed to predominantly support alternative referral, rather than non conveyance), closer inspection demonstrates that although Clesham et al did examine whether clinicians felt that ED attendance was required, the outcome of this element were simply reported in a binary format, with no evidence to suggest their correlation with the opinion of senior medical practitioners. Essentially, we have no idea whether the clinicians were accurate in this element of their decision making. As a point of reference, however, the authors did measure the accuracy of clinicians in predicting which patients would be a) admitted to the hospital from the ED; and b) discharged from the ED. Clearly, this research offers limited evidence to suggest paramedics can safely identify alternative pathways, and certainly does not support Goulding's conclusion that ‘the original reasoning for the [Newton et al] study is flawed…[sic].’ The study from Clesham et al is a proxy measure of referral decision accuracy, but demonstrates only modest agreement in clinical decisionmaking between ambulance staff and ED doctors. Of the small (n=396) sample size, EMS clinicians felt that 214 patients would be discharged; in actual fact, 24.8% (n=53) of these needed admission. Even acknowledging the numerous limitations in trying to generalise this data to support or refute the need for a Pathfinder, this still suggests accurate prediction for discharge on 75.2% of occasions (specificity 77.0% (161/209); 95% CI 71% to 82%). In short, roughly ¼ of patients would have been denied a required hospital admission had the decision been made by EMS clinicians alone.
Nonetheless, as both authors accurately state (Newton et al, 2013; Goulding, 2014), there is sufficient evidence to demonstrate that clinicians with extended education (beyond that of the basic IHCD paramedic qualification) make more appropriate clinical decisions. Indeed, this ethos has been embraced by the wider paramedic profession, with a move towards all paramedic registrants being educated to Diploma level (as a minimum) by 2015, and a move towards an all graduate entry profession by 2019 (Lovegrove, 2013). It is currently unclear just how many of the UK's 20 000 registered paramedics have an academic qualification of Diploma or beyond; however, given the relatively recent transition towards higher education, it seems likely that this will be a gradual process. In the interim, it is important to remember that we need to strike a fine balance between developing and maintaining safe patient encounters, while reducing the burden of unnecessary patient journeys; which is a key driver behind the creation of the Pathfinder.
Finally, and in direct address of the somewhat inflammatory statement that labelled NWAS as ‘the poorest ambulance service in the country…’ due to the comparatively low number of patients discharged at scene, I would suggest both authors take a moment to consider the National Ambulance Non-ConveyanceAudit Report (Barnard et al, 2014), published by the National Ambulance Service Clinical Quality Group. In essence, this audit was undertaken to provide a deeper understanding of the relationship between ambulance non-conveyance and subsequent patient re-contact within 24 hours (SQU03_2_2_1: Patients treated and discharged on scene where re-contact occurs within 24 hours). The audit is a snapshot of all ambulance service nonconveyed 999 calls over two 24 hour periods across England; it demonstrated an average non conveyance rate of 29.8%, with a national re-contact figure of 5%. All English ambulance services participated, but provided data to varying degrees, depending upon the sophistication of their data-collection capabilities. During those two periods, a total of 42 298 999 calls were received, and 30 872 (72.9%) were attended by an ambulance resource; 30% of the incidents attended were not conveyed that day, with 477 (5%) recontacting the same ambulance service within 24 hours. Crucially, a severity grading matrix was developed to assess the consequence of the need for recontact, and subsequent analysis by the 5 Trusts able to participate in this element of the audit (patient number = 74) demonstrated 35 instances graded as ‘moderately severe’; 5 instances graded as ‘severe’; and 2 instances of unexpected deaths. In summary, the audit demonstrated a positive relationship between non-conveyance and subsequent re-contact (correlation co-efficient: 0.73 for 2011 and 0.64 for 2012), suggesting that in general, those Trusts which see the greatest proportion of patients not conveyed, can equally expect to see the greatest proportion of re-contact patients over the following 24 hours. It also demonstrated that there currently appears to be elements of risk associated with the non conveyance of patients within the UK
Ambulance clinicians are highly-trained practitioners, with a wide gamut of skills enabling effective management of many life-threatening illnesses or injuries; and it is these skills that have been the focus of education throughout the history of paramedicine. However, the entire landscape of modern health care is experiencing unprecedented change, and we are being called upon to expand and develop our role, to include extended assessment, diagnosis and management or referral. Appropriate education is quite clearly essential to these developments; yet to suggest that a critical mass of EMS clinicians currently possess this specialised knowledge is simply not supported by current and robust clinical evidence. The paramedic profession is committed to developing this knowledge, yet it is an inevitably long process. In the interim period, and in the interest of patient wellbeing, we cannot permit mechanisms of decision support to be undermined by tenuous argument and disingenuous citation. Finally, while it is extremely reassuring to see ambulance clinicians taking a more critical approach in their analysis of research data, any concerns need to be shared in an unbiased, supportive and professional manner.