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Critical Care Paramedics Delivering Enhanced Pre-Hospital Trauma and Resuscitation Care: a Cost-Effective Approach

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Critical Care Paramedics Delivering Enhanced Pre-Hospital Trauma and Resuscitation Care: a Cost-Effective Approach SDO Network Critical care paramedics Delivering enhanced pre-hospital trauma and resuscitation care: a cost-effective approach The SDO Network is funded by the National Institute for Health Research Service Delivery and Organisation research programme (NIHR SDO) The voice of NHS leadership The NHS Confederation is the only independent All of our work is underpinned by our core values: membership body for the full range of organisations that make up today’s NHS. • ensuring we are member driven • putting patients and the public first We represent over 95 per cent of NHS organisations as well as a growing number of independent • providing independent challenge healthcare providers. • creating dialogue and consensus. Our ambition is a health system that delivers first- class services and improved health for all. We work with our members to ensure that we are an independent driving force for positive change by: • influencing policy, implementation and the public debate • supporting leaders through networking, sharing information and learning • promoting excellence in employment. For more information on our work, please contact: The NHS Confederation 29 Bressenden Place London SW1E 5DD Tel 020 7074 3200 Fax 0844 774 4319 Email [email protected] www.nhsconfed.org Registered Charity no. 1090329 Published by the NHS Confederation © The NHS Confederation 2011 This document may not be reproduced in whole or in part without permission. ISBN: 978-1-85947-191-3 BOK60042 This publication has been manufactured using paper produced under the FSC Chain of Custody. It is printed using vegetable-based inks and low VOC processes by a printer employing the ISO14001 environmental accreditation. Contents Executive summary 2 Background 3 The study 5 Conclusion 10 References 13 0402 Critical care paramedics Executive summary A number of national reports have raised to CCP level in order to treat high-risk patients concerns about pre-hospital care for seriously in the pre-hospital environment more ill and injured patients and recognised that effectively. more lives could be saved. South East Coast Ambulance Service NHS Trust (SECAmb) has CCPs have developed a higher-level clinical responded to this challenge by developing knowledge base with an emphasis upon ‘critical care paramedics’ (CCPs) with enhanced patient assessment together with some clinical clinical capabilities. This report outlines the skills relating to airways and cardiovascular key findings and lessons from an evaluation management. of the CCP programme carried out by Dr Ashok Jashapara, senior lecturer in knowledge CCPs are currently being under-utilised in the management at Royal Holloway, University critical care transfers role, and opportunities of London. It looks at the achievements exist to work more closely with secondary care and challenges of this clinical innovation at (hospital) providers to make this service more SECAmb to treat high-risk patients. widely available. Numerous national reports have International evidence is inconclusive as to acknowledged the need to improve the quality whether doctors save more lives or achieve of hospital and pre-hospital care for high- better clinical outcomes than paramedics risk patients and to reduce the 450–770 operating at CCP level in pre-hospital care, preventable deaths in England each year. but such medically-based systems, which substitute doctors in the paramedic role, are The US emergency medical system delivers 20 per cent lower mortality rates than the substantially more expensive to operate. UK for trauma patients and is based on using paramedics rather than doctors in pre-hospital Cost-benefit analysis shows ‘value of life saved’ care; these systems sometimes include a 24/7 is £34,000 for paramedics operating as CCPs, telemetric online ‘virtual’ medical presence compared to £252,000 for doctors providing at scene when required. This technology may the same provision in the field. have wider application in the UK. Medical input, while important to ambulance The concept of operation used in this CCP services, is likely to be most economically study is based on the ‘Anglo-American’ model effective when focused upon ‘high-level’ of ambulance service delivery, specifically the clinical governance and education input, rather Melbourne, Australia variant which SECAmb is than duplicating what could be accomplished still developing towards, training paramedics by paramedics at a much lower cost. Critical care paramedics 0503 Background A number of reports have been critical of clinical practice, including advanced airway sub-standard hospital and pre-hospital care management with endotracheal intubation for seriously ill and injured patients, and and the use of a wide range of drugs, including recognised that more lives could be saved. those for drug assisted airways management, One common thread throughout these reports such as rapid sequence induction and is the need to reduce between 450 and 770 intubation.4,5 preventable deaths in England each year and to improve patient survival rates, which are 20 per Many national reports have focused on cent higher in the United States.1,2,3 improving the quality of trauma care. They suggest the need for greater quality assurance Higher patient survival rates in the United mechanisms to monitor standards of States occur in a paramedic-led system patient care and better clinical governance where organisational arrangements to bypass arrangements between pre-hospital and hospitals for trauma and other specialist hospital care.6 They acknowledge that greater centres are common. Medical input in these patient assessment skills, greater advanced ambulance services focuses upon high-level airway management skills and the increased leadership and management functions, such use of doctors may enhance the quality of as clinical quality improvement, through care. Whether doctors are best suited for a audit, research, procedure development and clinical role in the field or whether paramedics, the education and training of paramedics especially those with specialist training, can be who deliver the care. The 24/7 availability of equally effective is contentious. consultant-level advice to paramedics using telemetry avoids the need to place doctors in Evidence from Germany’s doctor-based the field and subsequently avoids low levels emergency medical services (EMS) shows that of medical productivity. This system design their provisions are 42 per cent more expensive is often referred to as the ‘Anglo-American than in the UK.7 Doctor-based EMS does not Model,’ as opposed to the ‘Franco-German necessarily lead to greater patient survival rates Model’ which substitutes doctors in the and can sometimes lead to higher mortality paramedic role. rates.8 The death of Princess Diana in Paris in 1997 is at the heart of this controversy. The CCP system at SECAmb is based on Some argue that she would have survived in a the highly successful Mobile Intensive Care paramedic-based EMS in America compared Paramedic (MICA) system in Melbourne, to a doctor-based system in France.9 Lessons Australia. Launched in 1971 to tackle avoidable from the Purley and Cannon Street rail crashes deaths of high-risk patients, the paramedics’ in 1989 and 1991 suggested that paramedics advanced clinical skill set meant they were could conduct many of the advanced able to replace registrars on MICA ambulances. capabilities currently in the domain of medical Successful pre-hospital systems of this kind are doctors.10 common in many Commonwealth countries, the United States, parts of the EU and in In order to tackle the issue of preventable many military systems, even though they deaths, the UK Government’s strategy recently have been absent from the UK until recently. has been to develop trauma systems and MICA paramedics have a broader scope of networks. Trauma systems in the United 0604 Critical care paramedics States, Canada, Australia and other countries who would enhance their everyday learning have shown to reduce in-hospital mortality by from continuous exposure to seriously ill and 15 to 20 per cent, and there is every reason to injured patients. believe the same can be accomplished in the UK.11 Efforts are underway to improve trauma It was recognised that the move to systems based on the recommendations of the undergraduate preparation and the NHS Clinical Advisory Group on Trauma.12 development of foundation and BSc degrees for all new paramedics would be valuable but In its own analysis, SECAmb recognised the would be only one part of a solution. It was need for specialised paramedics to better assumed that greater familiarity with high-risk manage the 600–700 cases of major trauma but low-volume patients would enhance the and to improve the survival rates of the 185 paramedic’s learning curve and lead to better expected deaths each year. In addition, the CCP clinical outcomes. The rationale was to provide business case showed that there were 5,784 a small pool of highly-motivated, experienced annual cases of high-risk but low-volume paramedics with concentrated experience in patients, over and above trauma patients, who high-risk patients and supported by regular could benefit from advanced CCP capabilities. coaching and clinical supervision. This is in Life-threatening calls represent 5 to 8 per contrast to traditional paramedics who may cent of ambulance staff workloads, and the manage trauma patients very occasionally rationale was to develop highly-skilled CCPs during their normal workloads. Critical care paramedics 0705 The study Approach ‘The development of ‘specialist The aim of this study conducted by Dr Ashok practice’ also helps ensure a clear Jashapara was to evaluate the introduction of professional development career CCPs at SECAmb, developed to meet the needs pathway, which maximises the accrued of high-risk patients, save more lives and treat clinical experience of paramedics and a wider range of conditions, and to do so in the helps recruitment and retention within most cost-effective manner. The development of ‘specialist practice’ also helps ensure a clear the paramedic profession’ professional development career pathway, which maximises the accrued clinical experience of September 2007.
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