The Alternative Pre-hospital Pathway team: reducing conveyances to the emergency department through patient centered Community Emergency Medicine

Abstract

Background Internationally increasing demand for emergency care is driving innovation within emergency services. The Alternative Pre-Hospital Pathway (APP) Team is one such Community Emergency Medicine (CEM) initiative developed in Cork, Ireland to target low acuity emergency calls. In this paper the inception of the APP Team is described, and an observational descriptive analysis of the APP Team’s service data presented for the first 12 months of operation. The aim of this study is to describe and analyse the APP team service. Methods The APP Team, consisting of a Specialist Registrar (SpR) in Emergency Medicine (EM) and an Emergency Medical Technician (EMT) based in Cork, covers a mixed urban and rural population of approximately 300,000 people located within a 40-min drive time of Cork University Hospital. The team are dispatched to low acuity 112/999 calls, aiming to provide definitive care or referring patients to the appropriate community or specialist service. A retrospective analysis was performed of the team’s first 12 months of operation using the prospectively maintained service database. Results Two thousand and one patients were attended to with a 67.8% non-conveyance rate. The median age was 62 years, with 33.0% of patients aged over 75 years. For patients over 75 years, the non-conveyance rate was 62.0%. The average number of patients treated per shift was 7. Medical complaints (319), falls (194), drug and alcohol related presentations (193), urological (131), and respiratory complaints (119) were the most common presentations. Conclusion Increased demand for emergency care and an aging population is necessitating a re-design of traditional models of emergency care delivery. We describe the Alternative Pre-Hospital Pathway service, delivered by an EMT and an Emergency Medicine SpR responding to low acuity calls. This service achieved a 68% non-conveyance rate; our data demonstrates that a community emergency medicine outreach team in collaboration with the National Ambulance Service offering Alternative Pre-Hospital Pathways is an effective model for reducing conveyances to hospital.

Impact of the active job openings-to-applicants ratio on the number of ambulance dispatches: a longitudinal ecological study

“…Based on the above considerations, certain measures should be taken to provide means other than calling for an ambulance to address growing health service demands in the future. For example, Patton et al reported that setting up a community emergency medicine outreach team that responds to low-acuity emergency calls successfully achieved a 68% nonconveyance rate [29]. As found by a prior study, ambulances are often called inappropriately due to inaccurate knowledge of diseases [30].…”

Factors associated with pain reporting and severity of pain in the prehospital setting

“…Thirdly the research is descriptive and correlational and does not provide information about causality. Fourthly, data for patients attended by community paramedics or who are managed via alternative care pathways including Pathfinder, 39 or the Alternative Pre-hospital Pathway team, 40 were not available for this study. Fifthly the data for this study was recorded in 2020 during the COVID-19 pandemic.…”

Understanding patient non-transport decision theories in the pre-hospital setting: a narrative review

“…Clinical determinations enacted by the evaluating medical practitioner may occasionally culminate in a non-transport decision for the patient, a scenario commonly referred to as CID. ‘Non-conveyance’ according to clinician discretion is an outcome that has been cited in many studies ( n = 15) [ 18 , 23 – 26 , 28 , 32 – 40 ]. In some instances, non-conveyance represents a clinical verdict enacted by EMS personnel subsequent to their response to an emergency call and the subsequent provision of emergency care to the patient.…”

“…Inferences drawn from a comprehensive examination of prior studies reveal that specific EMS systems have integrated the concept of patient non-conveyance into their guidelines. They deem it a practice with an acceptable level of risk, contingent on initiating a telephonic medical consultation or deploying follow-up units for non-conveyance cases [ 32 , 38 , 49 , 66 ]. Notably, the term ‘acceptable’ risk elicits diverse interpretations across the literature [ 37 , 38 , 50 , 67 ].…”