Urgent care: why joint decision making is so important for paramedics

Published: 11th May 2021
Guest article by Jonathon Will, Clinical Effectiveness Lead, Specialist Paramedic & Tayside Mountain Rescue Officer, Scottish Ambulance Service.
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Paramedicine means ‘alongside medicine’ and ironically, we’re amongst the only clinicians that rarely work alongside our medical colleagues.

If you’re a Nurse or a Junior Doctor, you work alongside experienced doctors and they advise you, supervise you, and mentor you. They often start with lower acuity patients, and as they work towards advanced practice, they become more autonomous and get involved with more complex and higher acuity patients.

With paramedics it’s almost the complete opposite, once qualified you’re sent out on the road with the skills you need to stabilise people in the worst situations from day one but working autonomously and with just a single crew-mate as your support.

To put this into greater context, after six years on the road with the London Ambulance service, I felt like I’d developed a wealth of experience and that I was a very competent clinician, I accepted a new job within an accident and emergency department as an Emergency Care Paramedic. I quickly realised how little I knew and how little I’d been supported as a paramedic. That is not to say that my colleagues aren’t incredible at what they do, just that medicine is so vast, and that our remote and nomadic work makes ongoing supervision very challenging.

I found it amazing in hospital to have a team of people around me every shift, from Nurses and Healthcare Assistants to Phlebotomists, and from Junior Doctors, to Consultants, and every specialist you can think of at the end of a phone. You realise that even the Emergency Medicine Consultant sometimes needs to pick up the phone and speak to a specialist! Why shouldn’t paramedics be able to do the same?

This is particularly true when we realise that much of the work is actually lower acuity ‘Urgent Care’ patients which actually isn’t our area of expertise until more Advanced Practice. These patients often have complex multiple co-morbidities, long term conditions, frailty, cognitive challenges, or other mental, health, or social care needs. All ambulance services ask their crews to be there on the frontline and independently find a solution for patients whether it’s an adult or paediatric presentation, whether its mental health, maternity, medical, surgical, or trauma, and whether its primary, urgent or emergency type care, and we ask them to do it with limited clinical support.

Using a prof-to-prof phone system paramedics can sense-check care plans with a senior or specialist, gain a second opinion, and check that they are not missing anything obvious, and receive feedback and confirmation of their clinical reasoning; it’s more than shared decision support, it’s remote mentorship from a very senior clinician as well.

Crews can ascertain the benefits of conveying a patient and understand what’s truly needed in terms of investigation or treatment, they can ask what the best care option is, and the timescale that it is needed in, which is the best care venue, and then we can get the patient to the ‘Right Care’ first time.

I feel this can really enable better patient centred care through better-informed decision-making.

In Tayside I have also seen how prof-to-prof has helped relationships between our crews and the hospital clinicians and it feels like we’re becoming a much more integrated team.

When to call 

In Tayside, we now ask paramedics to ‘phone first’ via the prof-to-prof service every time (emergencies are still pre-alerted via radio, so this is for Urgent Care presentations only). There have definitely been huge amounts of debate over this, and it splits crew opinion almost 50/50. Many are asking for a list of barn-door ‘no need to call’, but as the test of change progressed, and we’ve done more staff engagement, many paramedics are seeing the wider benefits of calling every time.

Originally the request to ‘phone first’ was about reducing the inter-hospital transfers but we are now realising that it also gives the hospital a good understanding of what’s arriving. This was particularly useful during the height of COVID where the hospital could stream patients and prepare for their arrival. We are even getting to the stage where a senior doctor can review patient notes, take a handover from the paramedic from scene, agree the best care venue, and then order the appropriate investigations (e.g. blood tests / chest x-ray etc) before the patient has even arrived.

The prof-to-prof conversation is front-loading the senior decision making, but it’s also about enabling Ninewells to have multiple doors that stream people into hospital directly to the best place of care, whether it be the ED, specific ward, or assessment unit. Without funnelling all patients through a single front door, it has the potential to avoid ambulance ‘stacking’ outside A&E.

Having these conversations with senior hospital clinicians also enables something of a gap analysis which we hope can help guide and inform the development of further alternative pathways. I’d like to see a point where health boards reallocate money and resources away from discharge teams and focus more upstream, helping support our crews avoid non-essential conveyance to hospital wherever safe and possible.

In Tayside they are reporting that prof to prof clinical decisions can reduce what’s coming into the hospital by up to 20%, which more than justifies them being off the shop floor in terms of their impact on demand. Crucially though, by keeping non-essential presentations down, they allow the rest of the ED team to concentrate on the patients who really need to be there.

For me, that is key, this is not about reducing conveyance to hospital for the sake of performance targets. It’s about streamlining care and managing demand intelligently. In that way, as many people as possible can access care closer to home, and patients that really need our hospitals are received in departments that are not overrun and are cared for by staff who have the time and capacity to provide optimal care.

Useful additional information

Jonathon Will was a speaker at our recent webinar:

How Scottish Health Boards embrace prof-to-prof advice to reduce unnecessary attendances – you can get a copy of the recording here. 

Jonathon was joined by the following speakers:

  • Dr Gordon McNeish, Consultant, Emergency Medicine, University Hospital Hairmyres, NHS Lanarkshire
  • Dr Ron Cook, Clinical Director, Ninewells Hospital, NHS Tayside
  • Susan Bean, Clinical Care Group Manager, Ninewells Hospital, NHS Tayside
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