Summary of findings
Statements appraising feasibility of a direct patient redirection from EMS to ambulatory care practices positively were mainly about technical realizability, e. g. linkage of software platforms, and a few interviewees expected only little effort required to implement a working infrastructure. Potential prerequisite conditions mentioned included an extension of EMS capacities or a comprehensive accessibility of suitable practices. However, the majority of interviewees rather assessed patient redirection as organizationally impossible. It was prevalently expected that the potentially increasing workload could not be managed with the present resources regarding staff and ambulance vehicles. Participants even feared that “real emergencies” may be put at risk if EMS personnel would be tied up in transporting cases not really needing emergency care. Interviewees did prevailingly advocate the integration of other transport options for less urgent cases. Another patient safety concern voiced was that some cases with unrecognized serious conditions may be wrongly relocated to practices, due to limited diagnostic options in the EMS environment.
Many participants welcomed the notion to relieve EDs and their staff and to free ED resources for “real emergencies”. However, they conversely expected undesirable effects for EMS and thus voiced potential low acceptance, both from a personal viewpoint and with regard to paramedic personnel in general. Negative consequences feared were mainly increased workload and associated dissatisfaction among the staff. The sentiment of EMS potentially being used as a taxi service by having to provide “unnecessary” transport to outpatients was prominently raised. Concerning the presumed perspective of patients, interviewees expected a high level of acceptance if informed properly. Advantages like available transport and shorter waiting times would also serve to boost patients’ openness to redirection, while also entailing a danger of misuse for pure convenience reasons.
Results in context
For the interviewed EMS staff, the attractiveness of patient redirection concepts is mainly rooted in a potential relief of ED workload by shifting patients to ambulatory structures. From the hospital perspective, this is frequently considered an important and necessary step towards ensuring appropriate care for “real emergencies” in the ED setting [22]. Some have argued in this context that this patient group uses only small proportions of ED resources [23] and that their impact on waiting times is limited [24]. However, this is discussed controversially and may depend on specifics of the setting studied. As less urgent patients constitute a large proportion of ED consulters [25, 26], it appears very plausible that redirection schemes would serve to diminish pressure.
It was suggested in the interviews that use of non-EMS ambulance transports for redirection would be a far better option for less urgent cases, as resources of both EDs and EMS would be freed. However, while this would ostensibly relieve workload of emergency care providers, the safety of such notions depends on the quality and reliability of the alternative service in question. Non-emergency patient transports have been described as potentially prone to insufficient standardisation and poor communication processes [27]. The topic of “patient safety” also became apparent in the context of time resources and diagnostic options of the EMS. Interviewed staff expressed concerns about the care for time-critical patients, which could be endangered due to resources tied up by redirection, and also about potential misclassification of cases as non-urgent. As urgency categorization has been described as potentially unreliable even in the context of usual hospital-based triage [28], it appears reasonable that this would also – or even more – apply to prehospital care. Research in this context however has shown heterogeneous results. Several studies indicated that the urgency of prehospital patients may be underestimated [12, 29], and that ambulance staff lack confidence in determining patients’ care needs [30, 31]. In contrast, in a UK study from 2008 [32], EMS staff were able to estimate the likelihood of patients’ admission with an adequate accuracy. Some participants of the interviews also talked positively about their ability for decision-making. One participant expressed the view that implementation would be possible with the development of an appropriate SOP. Results of a prospective study by Pointer et al. [33] however showed that EMS staff using written guidelines do not achieve an acceptable level of triage accuracy to determine disposition of patients in the field. This question thus remains altogether unresolved scientifically, and as paramedics’ qualifications and professional training vary internationally, the setting may play an important role here, too.
In the interviews, lack of resources in the EMS and outpatient sector was frequently criticised, and arguments related to resource scarcity prominently feature in the statements on both doubtable feasibility and low acceptance of redirection. Even participants principally acceding to a potential feasibility of the scheme stressed the importance of a prerequisite expansion of personnel and structural capacities (such as nationwide availability of large medical practices). Considering the literature, interviewees’ appraisal of resource availability as a core problem area seems accurate: the logistical effort involved in implementing patients’ redirection and the potentially high investment costs, e. g. for additional staff or training, have been likewise described by others [3, 12]. An additional factor potentially boosting expenditure was also raised in the interviews: prevalent use of EMS as a convenient taxi service (termed “a wrong incentive”) would certainly constitute an economically wasteful situation.
In context of the acceptance of patient redirection, interviewed EMS staff tried to put themselves into different stakeholders’ position and related their views regarding respective benefits and drawbacks, based on their professional and personal experiences with a high number of patients. In the interviews, both individual acceptance of the interviewee and presumed acceptance by other EMS colleagues were described or assessed as rather low. In this context, the unwanted situation of an “unnecessary” transport of outpatients was mentioned very prominently. Participants clearly felt that being used as a mere ambulance transport or even a taxi would equal a vilification of their job and qualification, and the notion that non-emergency patients should go and seek appropriate outpatient care on their own was raised. However, a survey of walk-in ED patients showed that patients sometimes do not know alternative care options for acute problems [34]. In line with this, a qualitative investigation of ED outpatients conducted in our network suggested limited health competencies regarding self-assessment of complaints and the associated urgency, with resulting decision-making difficulties in acute situations [35]. It is difficult to judge whether the prominently raised apprehensions regarding potential misuse of EMS constitutes an adequate assessment or rather an indication of a prevalent general resistance to change and expansion of the profession’s scope, and views speculatively may change in the wake of establishing new care pathways and paramedics’ functions [36]. A stronger interlocking of primary care and EMS care may both shift part of the care burden from hospital structures to the ambulatory sector and altogether increase low-acuity utilization by supply-induced demand if the new care pathways are attractive to patients [37].
In this context, most of the interviewed personnel supposed that patients would accept the redirection to other care facilities if provided an appropriate elucidation. Validity of this expectation is difficult to judge, as the pertinent literature is comparably scarce and controversial. In line with our participants’ valuation, a study by Jones et al. [38] suggested that patients find alternative destinations and transport for acute care acceptable. Willingness to consider such alternatives however is difficult to predict and potentially depends on the perceived individual benefits. Contrarily to the results of this study and the expectations in our interviews however, others have reported negative attitudes of ED patients towards possible redirections [39, 40]. Interestingly, interviewees in our study clearly described potential benefits to patients (e.g. shorter waiting times) as well as EDs, but nevertheless were prevailingly aversive to redirection concepts as to the potential negative consequences to their own workload, work environment, and professional mission. Such priority setting however should not be interpreted as self-centeredness, but as an indication of a profession frequently feeling strained [41,42,43] – as formidably illustrated by the statement “we are [ …] already at the limit. Beyond the limit.” (R19). Correspondingly, paramedics have scored significantly lower than the mixed-profession reference group in a recent nationwide job satisfaction survey [44]. It thus appears reasonable that readiness for change is limited as to apprehension towards potential new burdens.
Strengths and limitations
To our knowledge, this study constitutes the first qualitative investigation of paramedics’ perspectives on potential EMS patient redirection to ambulatory care. The qualitative interviews with EMS personnel add a new perspective to the discussion about alternative pathways for patients with non-hospital care needs and allow a more comprehensive assessment of the redirection potential. Studies purely looking at EMS patients’ medical case characteristics and labelling medically less urgent cases as “actually eligible for primary care” fall short of considering the implications of changing care pathways, of associated facilitators and barriers, and of potential consequences for the stakeholders involved.
As to limitations, we must stress that a convenience sampling was chosen due to the initially expected limited interest in participation, which could have biased the spectrum of views captured due to self-selection. The sample is balanced in regard to age groups; however, men are clearly over-represented, reflecting the gender imbalance in EMS staff. Nevertheless, we did not get the impression of female participants’ views tendentially differing from the male majority when performing our analysis.
Participant statements on the acceptance by EMS staff, and even more so by patients, may be associated with assumptions and presumptions of the interviewees and therefore must be regarded with a considerable degree of caution, as they constitute a second-hand view. Nevertheless, valuations of potential acceptance voiced by the EMS staff members are valuable, as these are not ungrounded utterances, but insights rooted in many years of professional experience and permanent contact with the colleagues, as well as numerous patients.
As to the study objective focused on the current political discussion, we did only present the redirection model proposed by the Advisory Council to the participants for consideration, and – while being more speculative – an inclusion of variants or alternative models in the interview guide could potentially have generated further insights and increased generalizability.
Lastly, the interviews contain specific details of the German health care system that may not be transferable to other health care systems.
