The impact of new prehospital practitioners on ambulance transportation to the emergency department: a systematic review and meta-analysis

Abstract

Objective To conduct a systematic review and metaanalysis to examine the impact of new prehospital practitioners (NPPs), including emergency care practitioners (EmCPs), paramedic practitioners and extended care paramedics (ECPs), on ambulance transportation to the emergency department (ED). Methods We searched MEDLINE, Embase, CINAHL and AUSTHealth databases, and hand searched emergency medicine journals and journal reference lists for relevant papers. To be included, studies were required to target one type of NPP and compare outcomes such as the frequencies of conveyance to the ED, discharge at scene, subsequent ED attendance and/ or appropriateness of care between NPPs and conventional ambulance crews. Three investigators independently selected relevant studies. The risk of bias in individual studies was assessed using a validated checklist. We conducted meta-analyses for comparisons which had acceptable heterogeneity (I2<75%) and reported pooled estimates of ORs with 95% CIs. Results 13 studies were identified from 16 584 citation reports. EmCPs were most frequently studied. The majority of studies (77%) did not fully report important potential confounders. NPPs were less likely to convey patients to the ED and more likely to discharge patients at the scene than conventional ambulance crews. Pooled ORs for conveyance to the ED and discharge at the scene by ECPs were 0.09 (95% CI 0.04 to 0.18) and 10.5 (95% CI 5.8 to 19), respectively. The evidence for subsequent ED attendance and appropriateness of care was equivocal. Conclusions The NPP schemes reduced transport to the ED; however, the appropriateness of the decision of the NPPs and the safety of patients were not well supported by the reported studies.