This article reviews evidence relating to paramedics using an extended scope of practice, specifically those providing urgent care or signposting to alternative care provision setting; including paramedics with additional education (paramedic practitioners (PPs)) and those with additional training, for example using guidelines to determine patient care provider/ location.With strategic healthcare direction advocating outcome measurements to appraise the effectiveness of healthcare services, ambulance service NHS Trusts are mandated to provide effective and efficient patient care.
Developing an extended scope of practice provides benefits for the individual practitioner and patients they manage.The attributes and characteristics such paramedics’ possess are identified as desirable in robust clinical leadership provision by ambulance service personnel (CEG,2009).In a challenging healthcare setting these may provide additional flexibility and innovation for ambulance services to continue with their evolving and improving service delivery.
This article will explore political drivers for change, national experiences of paramedics with an extended scope of practice and the experience within the London Ambulance Service (LAS) NHS Trust, a busy urban service.At the time the LAS, similarly to ambulance services across England faces challenges from the response time pressures originating from call connect (Department of Health,2008), challenging their strategic provision of PPs.
Drivers for change in paramedic practice
The suggestion that paramedics could manage their caseload differently, through referral to other healthcare providers or using alternative care destinations other than an emergency department (ED), has been discussed since the late 1990’s (Audit Commission,1998).Acknowledging paramedic training historically centres upon life-threatening emergencies, which form an important but small proportion of their total workload, development of alternative practice preparation routes was suggested as a strategy to equip paramedics in delivering innovative healthcare (Audit Commission,1998).
This background precipitated the Joint Royal Colleges Ambulance Liaison Committee (JRCALC) (Baskett et al,2000) to propose development of a practitioner in emergency care (PEC) role for paramedics; developing paramedical specialism to appropriately manage major and minor emergencies.The proposed role refected changing emergency call case-mix received by ambulance trusts, with less life-threatening emergency requests and an increasing number of undifferentiated cases.Paramedics performing the PEC role were proposed to form 30 % of the total workforce, providing expertise in various care settings including emergency departments (EDs) and Ambulance Service NHS Trusts.The authors draw attention to a requirement for change in the education and continuing development of these practitioners, suggesting it should be from external sources of expertise, thereby preventing knowledge dilution, which could occur during traditional training models within Ambulance Service NHS Trusts.
Extending paramedics’ scope of practice has been facilitated by strategic visions (Ambulance Services Association (ASA),2000; DH,2005; College of Paramedics (CoP),2008; Ambulance Chief Executives Group,2011) of healthcare delivery by Ambulance Service NHS Trusts; viewing them as a mobile healthcare provider to the increasing numbers of undifferentiated cases requiring advanced, innovative and complex management they received.With changes to healthcare delivery and access, Ambulance Service NHS Trusts have faced an increasing number of emergency calls and numbers of patients with complex undifferentiated complaints which challenge their healthcare provision.As healthcare commissioners question the numbers of patients who attend EDs, proposing alternative healthcare provision may be more economically effective and provide increasing service user satisfaction, Ambulance Service NHS Trusts are required to respond to these demands (Office of Strategic Health Authorities (OSHA),2009).
Competence development
The CoP (2008) published a curriculum and competence framework, outlining a five stage career pathway of paramedic progression (Figure 1), encompassing development stages of student paramedic, paramedic, paramedic PP, advanced paramedic and consultant paramedic roles.Each stage is outlined with an expected scope of practice and associated competences.Paramedic development requirements are intended to deliver a workforce for the ambulance service who can provide appropriate healthcare for the variety of patients requesting an ambulance service response.This model is designed to provide a flexible workforce allowing Ambulance Service NHS Trust to truly deliver mobile healthcare.
The CoP career pathway refects the Skills for Healthcare career framework (S4H,2009); allowing comparative career progression with other allied healthcare professionals (AHPs).Paramedics are among the newer registered healthcare professionals, their pathways towards practice preparation and continuing professional development (CPD) opportunities differ from other AHPs.This structure facilitates an assessment of equivalency with other AHPs.
Paramedic practitioner development
The role of a paramedic as an AHP was defined as one who could treat patients or direct them to an appropriate source of healthcare.This was viewed as a strategy to widen patient access to healthcare, improve the cost-effectiveness of service delivery and provide AHPs with professional development opportunities.Early success of paramedics, using an extended scope of practice, came from their work with general practitioners (GPs) managing home visit requests alongside emergency calls.Benefits were reported by patients, GPs and the participating Ambulance NHS Trust (DH,2004) including; reduced emergency department attendances, early referral to specialist in-patient teams and improved ORCON performance, outcomes that resonate with current Ambulance Service NHS Trust priorities.
Development of a cohesive strategy within Ambulance Service NHS Trusts to support an extended scope of practice model for paramedics has been confused; S4H/the Modernisation agency attempted to lead on this but were unable to construct a viable model for national implementation.National educational standards remain varied; courses typically include autonomous practice, but not at the recommended degree level, ranging from Higher Education diplomas to post-praduate qualifications (Cooper et al,2007b).Roles of paramedics with an extended scope of practice also varies from practitioners targeted towards specific patient groups such as older people who have fallen, to requests for undifferentiated healthcare assessments or minor injury presentations.
The London Ambulance Service PP implementation programme (Williams and Bovill,2008), one of the initial sites trailing paramedics with an extended scope of practice, was based around the concept of one team (of five practitioners) per operational ambulance complex, with one clinical lead supporting three PP teams.The PP team provided individual autonomous practice within the LAS; developed effective relationships with other healthcare professionals and undertook development of, implemented and promoted alternative care pathway use.From allocated time within their rota each practitioner had regular opportunities to undertake CPD opportunities, thereby maintaining competency in less frequently used technical skills, while raising the ambulance service profile with other healthcare professionals.A clinical lead supports three PP teams, proving clinical supervision, practice support, mentorship, appraisal of practice, and ensuring robust development plans exist for each P P.Literature supports this role (Cooper et al,2007a), as a strategy to enhance care provided by PPs and as a mechanism to ensure maintenance of high practice standards by practitioners.
Benefits of paramedics with an extended scope of practice developed through education
PPs role typically involves autonomous practice and cross-boundary practice opportunities; evidence has studied their clinical effectiveness, impact upon healthcare economies and patient perception.PPs have demonstrated enhanced performance working in current healthcare delivery models; reducing the number of diagnostic modalities, are more likely to discharge patients home, complete patient care encounters without further healthcare utilisation and demonstrate increased patient satisfaction compared to traditional ambulance service care delivery (Mason et al,2007).Their additional education provides an extended scope of autonomous practice, allowing paramedics to adequately manage complex undifferentiated or minor presentations.
National data demonstrates 54 % of patients managed by an PP do not require transportation to an ED or referral to another healthcare professional (Mason et al,2007; Dixon 2009).Where patients are referred by a PP to an ED, they experience reduced waiting time before delivery of definitive management (Dixon,2009).The framework transform care delivery and achieve these results requires integrated healthcare provision across a range of provider and services (Mason et al,2006).
Level of education has been linked with leadership and communication ability demonstrated by PPs (Cooper et al,2007b).Increased educational level correlated with enhanced communication and leadership competence—attributes associated with increased collaborative practice.LAS PPs are educated via three pathways,(with 2010 cost in brackets): 18 month diploma in healthcare practice (PP), at St Georges, University of London (£5 600); 16 week post-graduate certificate in patient assessment and management, University of Hertfordshire (£3 500) and 24 month part-time BSc (Hons) paramedic science with emergency care practice, University of Hertfordshire (not funded by PP programme).
Use and dispatch of PPs varies between Ambulance Service NHS Trusts some PPs practice is focused towards specific patient groups (Mason et al,2003; Cooper et al,2004).In the LAS, PPs were dispatched by specific medical priority dispatch system (MPDS) determinant codes and emergency operations centre/clinical telephone advisor identification of appropriate calls.Gray and Walker (2008) demonstrated alternative pathway use, other than ED referral and including case completion by sole PP management, across all MPDS emergency call categories achieving the highest (52 %) in category B.Am LAS trial using PPs to support EOC dispatch (Williams,2009), showed positive trends including; increased call completion (either treat and convey or treat and refer) and less patients being conveyed to an ED in a front line ambulance.This evidence would appear to suggest clinical support of extended scope practitioner dispatch provides an effective solution.This must be tempered by the call connect response time (DH,2008) standards, which to be met frequently required the nearest response to be dispatched.As a result appropriate calls for extended scope of practitioners can be identified, yet it was challenging to ensure the correct resource attends.
PPs have been determined as cost effective practitioners, one estimate provides a mean cost per PP contact of £ 24 (Mason et al,2007).It is difficult to fully evaluate the costs of an PP as they fulfil multiple traditional roles, offsetting some of their lengthened call-cycle times experienced by Ambulance Service NHS Trust.Quality Adjusted Life Year (QALY) measuring quantity and quality of life resulting from healthcare interventions, with PPs demonstrate cost effectiveness (95 % chance of at £20 000 per QALY) (Dixon,2009).PP contact does temporarily increase resource use, refecting alternative patient care provision that is difficult to account (Mason et al,2009).
For comparison within a busy urban ambulance service the LAS PP programme was able to demonstrate (2009–10) the following performance (LAS in brackets for comparison): Category A emergency calls (requiring an eight minute response)=73.9 % (75.4 %); Category B emergency calls (requiring a 19 minute response)=87.0 % (86.6 %); utilisation=56.2 % (Fast Response Unit)=36.2 %, Ambulances=73.3 %); taken to an ED=56.6 % (72.0 %); treat and leave=21.7 % (15.3 %); care pathway referred=9.7 % (1.1 %); care pathway conveyed=2.0 % (2.4 %); and other (for example, patient declined hospital, no trace)=10.1 % (9.4 %).
Paramedics using guidelines to support alternative access to patient care
Non-conveyance of patients to an ED following paramedic assessment has been subject to global studies.These demonstrate weak underpinning evidence to support paramedics’ accuracy in roles where they actively triage patients to alternative destinations other than EDs without additional educational development.Where evaluation has been conducted concerns have been identified regarding the safety and efficiency of paramedics using alternatives to ED transportation (Snooks et al,2004a).Whereas paramedics who have additional education and practice autonomously frequently use alternative access to healthcare settings, the use of these by paramedics without educational development is generally poor (Snooks et al,2004b; 2005; 2006).From the limited evidence available regarding transportation to minor injuries units paramedics seem to be able to safely make this decision (Snooks et al,2004), although these conclusions are drawn from small numbers of patients.
Introduction of treatment and referral schemes has identified complex issues in their development and implementation, failing to change the number of patients conveyed to an ED (Snooks et al,2004c).While they have been used mainly safely, some emergency calls were found upon review to have mandated transport to an ED rather than community management and some protocols were implemented inappropriately (Snooks et al,2004c).Ambulance staff expressed concerns of inadequate preparation, from limited training time, to deliver a practice change (Snooks et al,2005); patients though remained satisfied with their treatment.Historically, older patients who have fallen and are not conveyed to an ED by ambulance are at risk of further falls and increased mortality (Snooks et al,2006).The decision making process utilised by ambulance staff when managing these patients has been found to be informal despite the complexity of decisions (Halter et al,2010).A randomised-control trial (Logan et al,2010) demonstrated decreased mortality and risk of further falls in patients who had fallen and were referred to a falls service rather than hospital transportation by ambulance.It should be noted 12 out of 252 patients not conveyed to hospital, were either too ill or had died which excluded them from the study; highlighting the risks associated with older people who fall.
A meta-analysis (Brown et al,2009) examined determination of medical necessity decisions by North American paramedics while selecting patients determined not to require ambulance transported to an ED.The rate of under-triage was 9 %, although the authors caution it may be as high as 27 %.Although this figure may seem high, it refects the trend that patients who are not conveyed by ambulance to an ED are at high risk of future adverse events (Snooks et al,2002).Consideration must be given to the difference in training standards of North American paramedics which are generally higher than UK paramedics, alongside widespread availability of medical oversight to enhance and support paramedics’ clinical decisions.
Public perception of treatment by paramedics with an extended scope of practice
While in policy documents the ambulance service has promoted its potential role as a mobile healthcare provider (DH,2005), historically, the ambulance service has been viewed as a transportation provider.Through media portrayal of paramedics they are often viewed as providing lifesaving interventions/treatment environment followed by transportation to an ED.With policy drivers directing paramedics to consider alternative pathways of care provision it is important service users are engaged with and support this practice.
Paramedics with an extended scope of practice are able to demonstrate increased service user satisfaction when they manage patients (Ball 2005; Halter et al,2006; Mason et al,2006; 2007; Cooper et al,2007b).
While service users are generally satisfied with their management by a paramedic, a PP demonstrates increased satisfaction through thoroughness of assessment and clarity of care plan explanation (Halter et al,2006).These qualities refect complex assessment, diagnostic and communication skill originating from PPs additional education attributes historically found in other healthcare professionals, used to support greater case completion and enhanced alternative care destination use.The challenge will be to ensure sufficient development activity supports paramedics clinical reasoning when considering alternative care provision while maintaining high levels of service user satisfaction.
Supporting the provision of clinical leadership in ambulance services
The provision of effective clinical leadership in Ambulance Service NHS Trusts has been identified as an area for development to enhance patient care and healthcare efficiency (DH,2005; Assosication of Ambulance Chief Executives Group,2009).The model in Figure 2, of career progression and development, complements the CoP career structure aiming to enhance ambulance service clinical leadership.This charts the development of practitioners from entry level support staff to consultant paramedics.
The model links increasing professional role with developing clinical leadership attributes.This relationship has been demonstrated as the educational level of PPs increased, those with masters level education possessing greater leadership attributes (Cooper et al,2007a).
Conclusions
Implementing schemes to provide alternatives to ED transport by paramedics have demonstrated safety and use concerns (Brown et al,2009), which may limit benefits to an ambulance service a measured through reductions in total call-cycle time (Snooks et al,2004b).To ensure ambulance services clinical outcome measures are achieved safely and effectively it is essential practice changes are based upon evidence and are appropriate for effective patient care.
Paramedics with an extended scope of practice following additional education demonstrate increased patient satisfaction (Ball,2005; Halter et al,2006; Mason et al,2006; 2007; Cooper et al,2007a) and non-conveyance to ED.This is offset by increased call-cycle time for an PP patient contact, refecting decreased healthcare professional contact time in other settings (Mason et al,2006; Mason et al,2007).Providing education is a strategy to address paramedics’ lack of development in clinical reasoning abilities, such as diagnosis and management plan formation (Kilner,2004).Evidence suggests PPs can contribute to meeting the NHS QIS front loaded model review summary conclusions and assist in meeting current healthcare policy demands upon Ambulance Service NHS Trusts (Quality Improvement Scotland (QIS),2008).
The DH consultation for paramedic prescribing (DH,2010) identifies PP attributes as eligible practitioners to undertake this role.While this does not exclude other paramedics as being suitably qualified, their eligibility is described as requiring careful consideration; as discussed the management strategies currently demonstrated by paramedics’ scope of practice may limit its efficiency.