Responding to the rising trend of ambulance use for non-emergency calls, the National Ambulance Service (NAS) is moving from an Emergency Medical Service (EMS) to a Mobile Medical Service (MMS) which aims to deliver the right patient care in the right setting. This re-design of emergency care delivery has inspired the development of numerous hospital avoidance initiatives including the introduction of a telemedical clinical hub, a mental health signposting desk and Community Paramedics amongst others. At Cork University Hospital (CUH), the Alternative Pre-hospital Pathway (APP) Team is a bespoke model of pre-hospital healthcare delivery which complements the national shift toward integrated community care.
Founded in November 2019, the APP Team is a Community Emergency Medicine collaboration between CUH and the NAS. The team responds to low acuity 112/999 emergency calls in the Cork area and aims to provide definitive patient care in the community or to refer patients to the appropriate community or specialist service. This precludes the need for ambulance conveyance to the Emergency Department (ED) and frees up emergency ambulance resources for critically ill or injured patients.
The APP Team is comprised of a Registrar in Emergency Medicine (EM) and an Emergency Medical Technician (EMT) in a NAS response vehicle. Running 7 days a week from 10am to 8pm, the team operates out of CUH ED and covers a mixed urban and rural population of approximately 300,000 people within a 40 minute drive time of CUH. The team is tasked to calls considered low acuity by the ambulance dispatcher. Calls may also be generated by Paramedics and Advanced Paramedics (APs) who have assessed patients and deemed them amenable to definitive treatment by the APP Team in the community. Real-time clinical oversight for the APP Team is provided by a Consultant in EM via tele-medicine. The team meets monthly to facilitate detailed discussions regarding cases and operational issues.
The APP Team provided 2,200 episodes of patient care in 2021, with a median of 6 patients treated per shift and a median age of 61 years. The overall non-conveyance rate was 70%. 715 (32%) of patients attended were aged over 75 years, with a non-conveyance rate of 66%. There were no reported complaints or un-expected re-presentations.
The most common presentations seen by the APP Team were general medical, low falls, drug and alcohol related presentations, urological complaints and respiratory complaints. Where follow-up was arranged the majority was organised with the patient’s GP but could involve referral to Outpatient Clinics, review by Clinical Nurse Specialists (e.g. Epilepsy and Diabetes), home visits by the Integrated Care Team or Public Health Nurse, scheduled appointments with the Acute Medical Unit or Psychiatric Community Assessment Hub, or referral to St Finbarr’s Assessment and Treatment Centre for the elderly. Having been assessed by an Emergency Doctor on the APP Team, patients requiring hospital transport were often able to bypass the ED process and be seen directly by the specialty team.
Providing definitive care to patients at the first point of contact is a key aim of Irish healthcare delivery as described in the Sláintecare report. “Increasing demand for emergency care and an aging population is necessitating a re-design of traditional models of emergency care delivery and the Alternative Pre-Hospital Pathway (APP) Team is one such response, “ said Professor Conor Deasy, Consultant in Emergency Medicine at CUH. Professor Deasy has said that the data generated by the APP Team demonstrates that in a cohort of patients with low acuity complaints for whom an emergency ambulance was called, 70% of them were suitable for management in the community, avoiding the need for conveyance to an emergency department. ‘This is good for service providers as resources are finite, and great for the patient’ according to Professor Deasy.
The APP Team at CUH ED is just one example of how novel collaborative initiatives between community, pre-hospital and hospital services are driving the health service towards delivery of patient-centred integrated community care.
