Research Highlight: NHS Ambulance trusts

The experience of implementing alternative transport protocols in the UK can be instructive, particularly for US EMS services rooted in a similar tradition of care. Indeed, the highest-quality evidence for the effectiveness of such protocols has come out of interventional studies performed in the UK. Below are a few studies representing a cross section of relevant articles investigating non-traditional EMS processes in use by the NHS.

(Open access)
Transforming NHS ambulance services. National Audit Office. 2011.

This widely-cited report describes the state of NHS Ambulance services and lays out a roadmap for widening the scope of ambulance services in the UK. Focus is placed on the integration of ambulance services with other NHS services, broadening the scope of performance measurement, and reducing variability across trusts.

(Closed access)
Radcliffe J, Heath G. Ambulance calls and cancellations: policy and implementation issues. Intl Jnl Public Sec Management. 2009 Jul 10;22(5):410–22.

A Mixed-methods analysis of an NHS Ambulance trust performed 1999-2001. This study outlines the circumstances at an English Ambulance trust prior to the recent efforts at standardizing expanded scope paramedicine – the similarities to US practice are striking, with rising ambulance demand and high levels of ambulance cancellations. This is a great example of how data can be used to gain insights into the structure of an organization even without the employment of sophisticated analytical techniques.

(Closed access)
Widiatmoko D, Machen I, Dickinson A, Williams J, Kendall S. Developing a new response to non-urgent emergency calls: evaluation of a nurse and paramedic partnership intervention. Primary Health Care Research & Development. 2008 Jul;9(03):183–90.

Assessment of an intervention whereby a paramedic and nurse or nurse practitioner were dispatched to low-priority calls along with the standard ambulance response. This team was able to significantly reduce transport rates as compared to low-priority patients recieving only an ambulance (46% v. 82.5% transported). In an economic model of the impacted healtcare systems, this was shown to produce an overall cost saving, though decision accuracy was not investigated. Placing hospital staff in the field represents one method for effectively identifying and treating patients for whom ED care is not indicated.

(Open access)
Snooks H, Kearsley N, Dale J, Halter M, Redhead J, Cheung W. Towards primary care for non-serious 999 callers: results of a controlled study of “Treat and Refer” protocols for ambulance crews. Qual Saf Health Care. 2004 Dec;13(6):435–43.

Assessment of an intervention whereby paramedics were trained in the application of “treat and release” protocols. This study found no statistically significant decrease in transport rates, though on-scene time and patient satisfaction with some aspects of care did increase. While the protocols used appear to be safe and acceptable to patients, it is striking that training and explicit protocols were not able to produce an increase in non-transport rates above those found in controls utilizing only informal processes. Training of existing EMS staff and rigorous protocols are another plausible method for implementing non-transport protocols. Further studies investivating this topic can be found in this literature review.

(Open access)
Hyde P, Mackenzie R, Ng G, Reid C, Pearson G. Availability and utilisation of physician-based pre-hospital critical care support to the NHS ambulance service in England, Wales and Northern Ireland. Emerg Med J. 2012 Mar 1;29(3):177–81.

This study highlights the variability among NHS Ambulance trusts in the use of physicians in the field. Gauging the effectiveness of pre-hospital physicians in emergent cases is another under-studied care delivery mechanism which warrants further investigation.

(Open access)
Dale J, Williams S, Foster T, Higgins J, Snooks H, Crouch R, et al. Safety of telephone consultation for “non-serious” emergency ambulance service patients. Qual Saf Health Care. 2004 Oct 1;13(5):363–73.

This non-interventional study assesses the safety of a telephone-based triage system to identify patients not in need of immediate ambulance response. There was good agreement between the dispatcher and an expert panel as to the need for an emergency ambulance (96.7%), but it was found that about 10% of patients determined by dispatchers to be non-emergent were subsequently admitted to a hospital ward, raising concerns about the reliability of such systems.

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