* Prehospital care pathway
* Paramedics' skills
* Resource implications
There is debate as to whether all patients suffering from hypoglycaemia need to be taken to hospital. Several studies suggest that rapid transfer to hospital may not be appropriate or cost-effective, and that these patients could potentially be managed in the primary care environment. One way to achieve greater efficiencies within ambulance services could be through the adoption of an integrated care pathway as an alternative to secondary care. A prehospital care pathway is suggested for dealing with patients who present with hypoglycaemia.
Patients suffering from hypoglycaemia who present to the ambulance service through the '999' system usually find themselves being transferred to accident and emergency departments because of a lack of alternatives. Several studies suggest that rapid transfer to hospital may not be appropriate, and that these patients could potentially be managed in the primary care environment (Billittier et al, 1996; Weston, 1990; Snooks, 1998).
This article suggests that the development of care pathways which integrate the ambulance service may provide a solution to the problems with current practice.
It has become increasingly clear over recent years that the standard treatment response by the ambulance service is inappropriate for many patients for whom a '999' call is made (Snooks, 1998).
Traditionally, ambulance services have been regarded mainly as transporters of ill or injured people to hospital. Ambulance crews have, of course, always provided essential and often life-saving interventions at the scene and during the journey to hospital. The focus, nevertheless, has been on their function to deliver patients to hospital, with response standards being the only measure of effectiveness.
Recent technological advances and improvements in paramedics' skills raise the question of whether such a focus is still appropriate (Snooks, 1998; Nicholl, 2000).
More seriously, it has been suggested by Nicholl (1996) that the current system of automatic dispatch of an ambulance to every emergency call, followed by the mandatory transfer of the ill or injured patient to hospital, regardless of his/her condition, is directly contributing to inefficiencies in service delivery through the wasteful use of scarce resources.
It is important to note that although it is mandatory for every emergency call to receive a response, the transfer of patients to hospital is only mandatory by virtue of the fact that no alternative means of accessing a more appropriate aspect of the healthcare system is available to crews.
Many callers to the '999' system do not require the 'lights and sirens' response of a paramedic-staffed ambulance, which can result in some patients being taken to an accident and emergency department unnecessarily (Brown, 1993; Billittier et al, 1996).
Research elsewhere is challenging the automatic dispatch rule by examining the effects of introducing systems of triage, in which ambulance control staff categorise calls according to predetermined criteria, and then ensure that an appropriate resource is dispatched (Nicholl, 1996).
There is increasing recognition of the professionalism of paramedics as prehospital care providers, and this is reflected in the increase in the intersectorial collaboration developing with secondary care clinicians, and more recently with primary care providers. This suggests that alternatives to existing models of care can be found that will not only benefit patients, but may also free resources. This would keep pace with the shifting notion that health care should be delivered in the community. The drive for greater efficiency in the face of rising demand has resulted in increasing pressure on healthcare providers to target resources across a limited front in all aspects of healthcare delivery.
Integrated prehospital care pathways
One way of achieving greater efficiencies within ambulance services could be through the adoption of the care pathway process which is currently spreading through hospitals and primary care throughout the UK.
An integrated care pathway defines the optimum care process, sequence and timing of interventions by doctors, nurses and other healthcare professionals for a particular diagnosis or procedure. Although integrated care pathways are a relatively new clinical process improvement tool, they are currently being used in hospitals in the USA, Australia and the UK (Cheah, 1998); however, they have yet to be introduced into prehospital care.
The development of integrated care pathways is dependent on the collaborative efforts of all those involved in the care of the patient. This can include clinicians, nurses, pharmacists, physiotherapists, paramedics and any other allied healthcare professionals. The common aim is to improve the quality of patient care.
The methodology and objectives of integrated care pathways are consistent with those of total quality management and continuous quality improvement. Quality in the context of effective health care can be a confusing concept; the most widely known framework for assessing quality in health services is Donabedian's model of structure, process and outcome (Donabedian, 1980).
In this model:
* Structure refers to the physical and organisational setting and available resources for providing health care
* Process refers to what is done to the patient in terms of advice, diagnosis, treatment and aftercare
* Outcome relates to the change in the health of the patient.
Patients who become hypoglycaemic are arguably ideally suited to prehospital care pathways. Whether all patients suffering from hypoglycaemia need to be taken to hospital or to be admitted after examination is currently debated.
Studies of the treatment of hypoglycaemia by Weston (1990), Yaxley (1991) and Steel (1992) have demonstrated that glucagon or glucose administered by ambulance staff resulted in a significant improvement in the patient's condition. This adds weight to the argument that there may be alternatives to accident and emergency departments for these patients. There have also been several studies which suggest that patients, particularly those suffering from hypoglycaemia, can be adequately managed either in the home or in a community setting (Weston, 1990; Yaxley, 1991; Nicholl, 2000).
Already, several services are developing local protocols for dealing with patients with hypoglycaemia. However, among ambulance service protocols in the UK, it is still more typical for patients who have experienced a severe hypoglycaemic event to be transported to hospital for supervision or further treatment. It could be argued that this is because of a lack of alternatives rather than because it is the best course of action for the patient. For rural services with turn-around times in excess of three hours, this has serious resource implications.
Services that have developed protocols that allow for the fact that some patients may choose to stay away from hospital have developed a 'discharged from care protocol that is dependent on the paramedics receiving answers to a number of pre-defined questions (Snooks, 1998).
Prehospital care pathway design
Figure / outlines a suggested design of a pre-hospital care pathway. This considers issues such as clinical risk, the role of paramedics and factors that are deemed appropriate to the ambulance service, such as:
* Receipt of call and pre-arrival advice
* Dispatch criteria in accordance with new response standards
* On-scene management treatment in accordance with both nationally accepted protocols and those determined locally be paramedic steering committees
* Clinical criteria, such as:
- Is this the first episode?
- Is there a predisposing medical condition?
- Is the blood glucose reading outside the range 4-l0 mmol?
- Is the Glasgow Coma Score <15?
- Has the patient been drinking alcohol or taking drugs?
- Are there abnormal electrocardiogram (ECG) rhythms (using a 12-lead ECG)?
- Is the patient under 16 years of age?
- Non-clinical criteria, such as:
- Does the patient live with a competent adult, or can someone be contacted easily to stay with the patient?
- Does the patient have the capacity to understand?
The introduction of integrated care pathways will clearly have resource implications. Although it has the potential to save the ambulance service unnecessary journeys to hospitals, there is the possibility of an increase in primary care workload. The introduction of prehospital care pathways for several clinical conditions would require an extensive examination of how resources are used and distributed in the prehospital environment, which may well impact on existing contractual arrangements.
However, a greater awareness of ambulance service potential, together with the development of partnerships with other health professionals and commissioners, will ensure that the component parts required to measure effectiveness can be developed into an acceptable framework. This would enable the development of cohesive care pathways that are both clinically and cost-effective.
Particularly relevant is the setting of explicit objectives between managers and other healthcare professionals regarding what needs to be achieved, while ensuring an explicit quality definition. Together these components will form the basis for ensuring the effectiveness of care pathways, which can be evaluated against set clinical and non-clinical criteria.
It is recognised that there are several unanswered questions, such as resourcing, medical and legal implications and training. However, it is suggested that care pathways developed through a multidisciplinary approach involving all healthcare professionals will provide ambulance services with alternatives to transferring patients to accident and emergency departments, and will better serve our patients.
Figure 1. Example of a '999' diabetes care pathway.
999 Call dispatch criteria
Ask caller if patient is/has (been):
* Unconscious or not breathing
* Severe difficulty in breathing
If any of the above exist:
Respond crew priority A (life threatening)
* Decreased level of consciousness
* Chest pain
* Unusual behaviour/acting strange
If any of the above exist:
Respond crew priority B (serious)
* If possible, establish whether patient is diabetic If patient is unconscious and breathing normally:
* Instruct caller to lay patient on side
* Continue to check for normal breathing until help arrives
* Watch for the rise and fall of the chest
* Place your cheek next to the nose and mouth and listen and feel
* If the patient stops breathing and vomits, call back immediately
* If patient is responsive and able to accept fluid, give juice with sugar (2-3 tablespoons)
* Gather the patient's medication
Can someone meet the ambulance?
On-scene treatment protocol
On arrival at the scene:
* Assess the patient (check for Meditag identification)
* Position the patient to protect airway
* Administer oxygen
* Measure blood glucose level
If the blood glucose level is below 4 mmol/l:
* Give oral glucose if the patient's level of consciousness is such that the patient is able to swallow
* Administer glucagon if the patient is unconscious or very aggressive because of the hypoglycaemia; alternatively, 50% glucose may be given intravenously
* Reassess the patient
* Retake the blood glucose level
Treatment time should not exceed potential time to hospital
If you can answer 'yes' to any of the following, consider transportation to hospital or treatment centre:
* Is this a first episode?
* Is there a predisposing medical condition?
* Is the blood glucose reading outside the range 4-10 mmol?
* Is the Glasgow Coma Score <15?
* Has the patient been drinking alcohol or taking drugs?
* Are there abnormal electrocardiogram (ECG) rhythms (taking 12-lead ECGs)?
* Is the patient <16 years of age?
If answers are negative, consider non-clinical criteria
Does the patient live with a competent adult or can someone be contacted easily to stay with the patient?
If 'yes,' explain to the patient and relatives that transfer to hospital is not necessary, contact GP/diabetic nurse or community nurse and arrange for them to call within an agreed time. Advise patient and leave in care of competent adult. Advise patient to contact NHS Direct for further advice
If 'no', transfer to hospital or treatment centre Brown E (1993) The emergent problem of ambulance misuse. Annals of Emergency Medicine 22: 646-9
Billittier AJ, Moscati R et al (1996) A multisite survey of factors contributing to medically unnecessary ambulance transports. Academic Emergency Medicine 3(11:
Cheah TS (1998) Clinical pathways--the new paradigm in healthcare? Medical Journal of Malaysia 53(1): 87-96
Donabedian A (1980) The Definition of Quality and Approaches to its Health Assessment. Health Administration Press, Michigan
Nicholl J (1996) The Safety and Reliability of Priority Dispatch Systems: Report to Department of Health. Sheffield University, Sheffield
Nicholl J (2000) The Future of Ambulance Services in the UK Draft Report to Department of Health. Sheffield University, Sheffield
Snooks H (1998) Appropriateness of use of emergency ambulances. Journal of Emergency Medicine IS: 212-18
Steel J (1992) Use of Lucozade and glucagon by ambulance staff for treating hypoglycaemia. British Medical Journal 304: 1282-3
Weston C (1990) Hypoglycaemic attacks treated by ambulance personnel with extended training. British Medical Journal 300: 908-9
Yaxley L (1991) Ambulance personnel can successfully treat severe hypoglycaemia. Practical Diabetes 10(2): 67-8
David Ellis is Regional
Ambulance Officer, Central and West Region, Welsh Ambulance Services NHS Trust, Swansea, South Wales.
COPYRIGHT 2002 S.B. Communications
COPYRIGHT 2003 Gale Group