Review of:Mason S, Knowles E, Colwell B, et al: “Effectiveness of paramedic practitioners in attending 999 calls from elderly people in the community: cluster randomised controlled trial.” BMJ (Clinical research ed.). 11(335):919-925, 2007.
The Science
South Yorkshire is a metropolitan county in the center of England with a busy urban based ambulance service. The goal of this study was to determine whether paramedics trained to evaluate and treat minor complaints of the elderly would have a positive effect on their healthcare utilization of the emergency department (ED).
Paramedics underwent a three-week course of study followed by 45 days of supervised practice. The following table lists their scope of practice.
Scope of practice of paramedic practitioners
Presenting complaint
_ Falls
_ Lacerations
_ Epistaxis
_ Minor burns
_ Foreign body in ear, nose, throat
Practical skills
_ Local anesthetic techniques
_ Wound care and suturing techniques
_ Principles of dressings and splinting
Special skills
_ Joint examination
_ Examination of neurological, cardiovascular, and respiratory system
_ Examination of ear, nose, and throat
_ Protocol led dispensing: simple analgesia, antibiotics, tetanus toxoid
Additional options for referral and investigations
_ Request for x-rays
_ Referral to emergency department, general practitioner, district nurse, community social services
The researchers deployed these paramedic practitioners in a random manner during the day and measured the rates of ED visit, hospitalization and patient satisfaction between those that were cared for by the practitioners (intervention group) and those that were not (control group).
The intervention group had a 25% lower frequency of transport to the hospital and was less likely to require hospitalization within the following 28 days than the control group. No difference was noted in 28 day mortality, and the patients in the intervention group were significantly more satisfied with the services rendered than those in the control group.
The authors conclude, “Paramedics with extended skills can provide a clinically effective alternative to standard ambulance transfer and treatment in an emergency department for elderly patients with acute minor conditions.”
The Street
I believe this was what the authors of the current National Scope of Practice had in mind when they began that project. However, that level of practitioner was dropped from the document and is still just a dream. To be fair though, we have to recognize the difference between EMS in urban areas of England and the U.S. A significant percentage of ambulance responses in England don’t result in transport to the ED. They’ve integrated themselves into public health in such as way as to facilitate home nursing visits and referral to local clinics.
This study examined the particular impact that specialized training could have when treating the elderly. So did it really have an impact? When considering only the abstract, one would say yes. But let’s look more closely at the data.
The most common reason for the calls by the elderly in both groups was for falls (88.4% in the intervention and 89.4% in the control group). The non-transport rate for both was the same. Likewise, 40% of those not transported required hospitalization within 28 days, and 5% died.
Although I commend the authors for attempting to measure the impact of extended cared paramedic practitioners and hope we will someday reach a similar level of public health integration, this study does more to highlight the very significant impact of falls in the elderly. I would be happy to see these authors will return with a follow-up study after they’ve modified their educational program to address this impact.
