Emergency Department (ED) crowding (and access block) has been described as the most serious issue currently confronting EDs [1–3]. The demand for ED services exceeds any growth that can be explained by population increase . A recent Australian Institute of Health and Welfare (AIHW) report identified that “between 2009–10 and 2010–11, ED presentations increased in all states and territories, with increases ranging from 1.6% in Tasmania to 8.1% in Western Australia” , p vii. ED crowding has been linked to a range of adverse outcomes for patients and staff, including increased medical errors, increased patient mortality, patient dissatisfaction, high levels of work-related stress, decreased morale among ED staff and decreased capacity of EDs to respond to mass casualty incidents [2, 3, 6, 7].
Ambulance usage is also increasing annually. In Western Australia (WA), St John Ambulance Western Australia (SJA-WA) activity in the Perth metropolitan area increased by 23% to 171,462 cases attended in the 2010/11 financial year from138,996 cases in 2006/07 . For the year 2012, SJA-WA paramedic crews in metropolitan Perth attended a total of 132,862 cases and 105,327 (79.3%) were transported to ED. (“unpublished data” provided to Prof I. Jacobs by SJA-WA.) Increasing numbers of ambulance arrivals are one of the key drivers of ED demand and also increased episodes of ramping . There is growing recognition that not all patients attended by paramedics actually need to be transported to ED. As part of a major overhaul of emergency services in the UK , the concept of ‘emergency care practitioners’ (EmCPs) emerged as an alternative model of ambulance paramedic response [10–12]. Initial reports showed that EmCPs were dealing with “54% of patients without the need for an immediate referral to another healthcare professional or emergency transportation to ED” . A cluster randomised trial in the UK reported reduced ED attendance associated with Paramedic Practitioner (a similar role to EmCP) attendance, whilst maintaining patient satisfaction and safety .
Notwithstanding reports of the apparent success of the EmCP role in the UK, the structure of the health system, both in relation to primary care and emergency services, is different to that in both Australia and New Zealand. Extended care paramedics (ECPs) have been introduced in New Zealand , NSW  and SA . In 2009 the Wellington (New Zealand) Ambulance service initiated a new model of care for a rural district with approximately 50,000 residents and a high proportion of over 65 year olds. Ambulance staff, trained in additional clinical skills, are sent to patients with conditions considered amenable to treatment in their own homes or local communities . As explained, “this has shifted the focus of the ambulance service towards taking healthcare to the patient and away from automatically transporting the majority of patients to hospital” [14, p11]. A recent paper  reports favourable results for the first 1,000 patients attended by ECPs, with 40% of patients transported to the ED when compared to 74% of patients attended by conventional ambulance crews. Moreover, only 5% of patients who had been managed in the community by an ECP had an acute ED presentation within 7 days of that ECP attendance; although no comparison data were provided for conventional ambulance crews.
In the Sydney West-Nepean catchment area, the ECP program commenced operations in December 2007. By October 2009, a total of 22 ECPs had responded to over 10,000 cases, with a non-transport rate of 38% - 45% depending on area . The South Australian Ambulance Service (SAAS) introduced an ECP programme in the metropolitan area in December 2008 . A conference abstract reported that in the first 7 months “ECPs attended 1123 patients, of those 555 interventions (49.4%) were considered to have prevented an ED presentation and 60 (5.3%), were considered to have prevented a hospital admission; and no adverse events were recorded” .
ECPs provide alternative care pathways for patients who call for an ambulance and meet certain pre-defined criteria, such as the patient having a minor illness or injury, or only requiring basic medical advice or reassurance . Through a ‘see and treat’ or a ‘see and refer’ strategy it is suggested that they can assist in reducing ambulance transport to hospital . Whilst there is clear enthusiasm about the concept of ECPs as an alternative community-based model of emergency/primary health care, there is no good quality research data in Australia to support the efficacy, safety or cost-effectiveness of an ECP programme. It needs to be established that patients seen by ECPs do not end up presenting to ED within hours/days of the initial ECP attendance – possibly in a worse clinical condition than their initial presentation – or come to harm or die because of an unrecognised life-threatening condition.
Our project will develop and test (through simulation) the feasibility and safety of empirically derived clinical protocols for an extended care paramedic (ECP) role for the Perth metropolitan area. We are aware of the fact that paramedics do not have the same repertoire of clinical assessment skills as emergency physicians, nor do they have access to the same array of diagnostic tests. Of concern to all clinicians is the risk of failing to identify potentially catastrophic events, such as sepsis, stroke or myocardial infarction. Thus, while we are interested in modelling the impact of the introduction of ECPs on ED demand and ED crowding, our primary concern will be patient safety.