Columns, International, Operations

Study Compares Transport and Referral Strategies of International EMS Systems

Issue 7 and Volume 42.

Meeting Needs

Redelsteiner C. Current and future requirements for gatekeeping in the prehospital setting with special consideration of sociodemographic requirements; with a special focus on two rural border regions in the Austrian province of Burgenland. Stumpf + Kossendey: Edewecht, Germany, 2016. [Book in German.]


Many European countries face a reduction of active physicians and health professionals on one side and an increase of older people on the other. Although the ratio of emergency calls to population remains stable, the overall number of calls is rising.

Background: Current data show that in urban areas, 75% of calls to patients under age 20 are minor disturbances that could be taken care of by self-help, general practitioners or outpatient care clinics. Furthermore, 94% of these patients are transported to hospitals for evaluation. In rural settings, 72% of calls for an ALS doctor unit are also non-emergent or could be covered by alternative resources. Prehospital EMS agencies are hence faced with a high volume of requests for “simple” social, nursing and medical interventions that could be served better by other health and social care providers.

Methods: This was a mixed method research study. Quantitative data was researched by retrospective assessment of calls, demand patterns and call severity. Three different statistical prognostic techniques were used to calculate future call demand, combining historic data and demographic scenarios. Qualitative data was collected by field research, responding to calls with different services and creation of case reports. Field providers and managers of different services were given seven hypothetical patient scenarios and outlined their local strategy options to triage and steer patients to different resources.

Results: Depending on the patient scenario, the two rural regions studied will have to handle a call increase of up to 12% by 2020 (34% by 2030) compared to 2013. Currently, the average age of the regions inhabitants is 45 vs. the average age of EMS patients at 72 years. Calls for patients older than 60, representing 27% of the general population, make up for 79% of all calls.

Nearly three-quarters (75%) of the rural family doctors in the region will retire by 2025. This requires steering patients, either by phone or on-scene assessment, to resources that aren’t hospital-based and guiding patients to appropriate community resources. To control this process, a tight logistical connection between general practitioners, home nursing, EMS and hospitals is needed.

The seven hypothetical patient scenarios (simple wound; adult asthma attack, known asthmatic; lumbago; cough and chest pain; fall in nursing home; patient with fever; 75-year-old male urinary catheter change) were compared in the context of provider type and system design for services from 17 European nations and one in the United States. The organizational context of these services is quite different, as are the responding professions, which include basic ambulance attendants, nurses, paramedics, general practitioners and emergency physicians or a combination of multiple tiers.

Three major strategies have been detected:
1) systems that use transport to hospital as a prime strategy, are financed by a “fee for transport” reimbursement, and where a large education gap exists between basic-trained EMS providers and ALS response by physicians; 2) systems that refer patients to alternative resources early on, such as during the 9-1-1 call; and 3) systems that refer systematically to alternative resources or dispatch non-ALS response for evaluation and on-scene treatment (e.g., via community paramedics).

Conclusion: Overall, in the observed services, there’s a tendency to treat and release patients if ambulance providers also have a nursing or community/advanced paramedic background, combined with standardized assessment protocols or if there are general practitioners systematically involved in out-of-hospital care.

On-scene patient assessment requires a systematic, reliable and specific low-threshold mobile resource. General practitioners, nurses, social workers and paramedics could be utilized for this task, following specific interprofessional training and education. A concept for a new interdisciplinary degree program, the community care specialist, could be used-and may be especially helpful in rural regions-that would bridge social and health professions. Training and education for this role would include assessing, clearing and treating non-emergent conditions (e.g., psychosocial and simple medical patients).

The overall goal is to adapt strategies of caller handling in dispatch centers and while on scene and facilitate collaboration and networking between the main primary care medical institutions and related social work, psychosocial and nursing resources to ensure fair, ethical and non-discriminatory distribution of care regardless of age, social level and urban/suburban/rural settings.