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.
The concept of non-conveyance or T&R of patients was found to be a little more complicated than it was first appreciated (Snooks et al, 2004a-b). The introduction of T&R guidelines had in reality represented a significant change in practice for ambulance clinicians but this fact had somehow gone unrecognized by many. Ambulance clinicians were being asked to make clinical decisions in areas in which they had no specific formal education or training. Although T&R education is now an integrated component of the newly developed SAS Paramedic Diploma, even when advanced education and training is provided, determining who can be suitably left at home can be challenging. So how can ambulance clinicians avoid making a wrong decision and exposing the patient to any associated risk? Well, sometimes they can't. As Gray and Walker (2008) demonstrated, the patient's condition can evolve over time with the ‘big sick’ becoming ‘little sick’ and, more worryingly, the ‘little sick’ becoming ‘big sick’. Before leaving a patient at home, consider again the differential diagnosis, look for the ‘big sick’ clues during your assessment and in the history. Apply the appropriate guidelines to the appropriate condition. Basic rules to apply to your decision-making when considering leaving a patient at home include: a) admit to yourself when ‘you don't know’ and don't take risks based on a ‘hunch’. Perceived ‘minor’ illness and injury is an incredibly complex area and requires specific advanced skills and knowledge to manage cases. b) if and when you get to the point that ‘you know that you don't know’ always seek advice from more experienced and qualified colleagues, if available use professional to professional lines i.e. NHS24/NHS Direct. In doing so, you will ensure that the patient receives the most appropriate and safest care.