Early prehospital assessment of non-urgent patients and outcomes at the appropriate level of care: A prospective exploratory study

https://doi.org/10.1016/j.ienj.2017.02.003Get rights and content

Highlights

  • Early prehospital assessment affects the appropriate level of care.

  • Ambulance and primary care collaborates in a effective way.

  • Patients with non-urgent medical conditions remain at home.

  • Decrease in ambulance transports to accident and emergency department.

  • Decrease in admission to hospital ward.

Abstract

Introduction

The Ambulance Organization of Sweden provides qualified medical assessment and treatment by ambulance nurses based on patient needs regarding appropriate levels of care. A new model for patients with non-urgent medical conditions has been introduced. The main objective of this study was to examine early prehospital assessment of non-urgent patients, and its impact on the choice of the appropriate level of care.

Methods

The study design was a 1-year, prospective study, involving an ambulance district in southwestern Sweden with a population of 78,000. Eligible patients were from18 years of age, assessed as priority GREEN by Rapid Emergency Triage and Treatment System (RETTS). Ambulance nurses contacted primary care physicians on decisions on whether a patient should be transported to a primary healthcare unit or an A&E. Data was collected from electronic health records from April 2014 to July 2015. A comparison was made with a retrospective control group without consulting a physician concerning the appropriate level of care.

Results

394 patients were included, 184 in the intervention group, and 210 in the control group. There were statistically significant differences in favor of the study group (p < 0.001) regarding no transport, or transport and admission to an A&E. The groups did not differ significantly regarding transport to a primary care unit.

Conclusion

This prehospital assessment model indicates a decrease in ambulance transports to an A&E and admissions to a hospital ward. Collaboration between ambulance nurses and primary physicians affects the decision for the appropriate level of care for patients with a non-urgent condition.

Introduction

The Ambulance Organization of Sweden provides qualified medical assessment and treatment by ambulance nurses [1]. Standard procedure for a mission is transport to an Accident and Emergency Ward (A&E), regardless of the patient’s medical condition [2]. However, patients with non-urgent medical conditions constitute both a significant proportion of ambulance transports to an A&E, and a significant challenge to the healthcare system, regarding the appropriate level of care. [3].

Several studies describe the factors influencing patients to call an ambulance in non-emergency situations, resulting in unnecessary ambulance transports to the A&E [4], [5]. Studies in Sweden and England, however, have reported positive experiences of ambulance nurses capable of assessing patients for alternative levels of care instead of transporting them directly to an A&E [6], [7], [8]. Nevertheless, there is another study from England describing uncertainty in elderly patients not granted ambulance transport to the A&E [9].

A majority of Swedish ambulance and A&E organizations have implemented the RETTS, Rapid Emergency Triage and Treatment System [10]. The RETTS is a triage and priority instrument for the assessment of a patient’s medical condition. This implies that ambulance nurses assess the patient’s medical priorities according to vital signs and reasons for calling an ambulance, then transporting them to the A&E for further assessment of the appropriate level of care.

The Ambulance organization of southwestern Sweden has introduced a model of prehospital care for all adult patients with varying non-urgent medical problems. Ambulance nurses in collaboration with primary healthcare physicians assess patients at the scene to choose the appropriate level of care. A decision is made as to whether a patient should be transported by ambulance either to a primary healthcare unit, an A&E, or remain at home.

Prehospital measures are governed by clinical guidelines, and are carried out by registered nurses [1], [11]. However, very little is known about structured assessments and outcomes involving collaboration between ambulance nurses and physicians in primary care, when managing patients with non-urgent medical conditions.

The main objective of this study was, therefore, to examine early prehospital assessment of non-urgent patients, and investigate outcomes on the appropriate level of care with collaboration between ambulance personnel and physicians in primary health care.

Section snippets

Methods

The design was a quantitative exploratory study based on a consecutive and retrospective review of patient records. The study was conducted from April 2014 to July 2015 involving one ambulance district in southwestern Sweden, with a population of 78,000 inhabitants. The ambulance organization in the district includes four units, and provides prehospital emergency care with transport to the emergency hospital within 50 km of ten primary care units in this district.

Results

During the study period, 394 patients assessed as GREEN by the RETTS were included, 184 to the intervention group, and 210 to the control group. The intervention and control groups did not differ significantly for gender, age, time of day, reason for calling an ambulance, and accommodation (Table 1). Regarding staying at home, transport to an emergency ward, and admission to a hospital ward, there was a significant difference in favor of the intervention group (p < 0.001 and p < 0.001,

Discussion

The main findings of this prospective exploratory study indicate fewer ambulance transports to an A&E, and more patients staying at home when using the model of early prehospital assessment. There was a significant difference between groups for transport to an A&E and patients who remained at home. It is fair to assume that the difference depended on early dialogue between the ambulance nurse and primary care physician concerning a decision on the appropriate level of care. Our findings showed

Conclusion

This prehospital model indicates a decrease in the number of ambulance transports to the A&E and admissions to a hospital ward. Collaboration between ambulance nurses and primary care physicians facilitates correct decisions on the appropriate level of care for patients with non-urgent medical conditions. Early assessment of a patient’s current medical condition is important for determining the most appropriate level of care, and to avoid unnecessary ambulance transports to the A&E. We need to

Acknowledgement

Founding source are Department of Prehospital Care and Scientific Council of Region Halland.

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