The safety of referral

The past decade has seen the introduction of emergency care practitioners, critical care paramedics and an assortment of extended skills have been added to ambulance clinicans’ repertoire. These developments have often evolved from a change in government policy and the subsequent drivers that influence the way we deliver our care. The most significant, over recent years, has been the need to treat more patients at home in an attempt to prevent an unnecessary journey to the emergency department (ED). Such a shift in the balance of care means that the traditional ‘default’ position of transportation to the ED is often no longer justifiable. In its place, where patients and circumstances permit, an alternative pathway of care may be offered through referral to other more appropriate services.

An example of this occurred in Scotland during 2005 following a change in government policy that aimed to provide the ‘hospital at home’ and reduce unnecessary ED attendances (Scottish Executive, 2005). The Scottish Ambulance Service (SAS) responded via the introduction of ‘Treat and Refer’ (T&R) Guidelines. These guidelines were designed to enable ambulance clinicians to attend, treat, discharge or refer patients with a defined list of conditions as appropriate. Four T&R conditions were selected and, subsequently, guidelines were introduced to assist ambulance clinicians with their decision to either leave the patient at home or transport to the ED. It was quickly discovered that ambulance clinicians understandably lacked confidence in their application, insisting they needed additional education, training and support (Colver et al, 2008). These factors, along with a reported fear of litigation, resulted in many ambulance clinicians resorting to transporting patients to the ED or having refusal forms signed instead of T&R forms. This was precisely what the new system had been designed to prevent.