International Emergency Nursing (2008) 16, 180–184

www.elsevierhealth.com/journals/aaen

CASE STUDY

Emergency care practitioners (ECP): Practice andperformance in the UK West country – A casestudy

Simon Cooper PhD, MEd, BA, RGN (Senior Lecturer) *,Judith O’Carroll MSc, BA (Research Assistant), Annie Jenkin MSc, RGN,ILTM (Principal Lecturer), Beryl Badger MSc, BA (Principal Lecturer)

Faculty of Health and Social Work, C501 Portland Square, University of Plymouth, Plymouth,Devon PL4 8AA, United Kingdom

Received 19 February 2008; accepted 12 April 2008

Introduction and background

In the UK there is a drive to develop referral path-ways for a ‘seamless service’ which for ambulanceservices has led to a series of reports advising onemergency care networks and collaborative prac-tice (DH, 1997, 2000, 2004) aiming for the ‘right re-sponse, first time, in time’ (DH, 2005). In additionchanges in doctors’ working hours and their outof hours practice have led to the emergence ofthe emergency care practitioner (ECP) role(JRCALC, 2000).

ECPs are defined as an ‘‘advanced practitioner(paramedic or nurse) capable of assessing, treat-ing and discharging/referring patients at thescene’’ (DH, 2005 p. 51). As part of a larger

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* Corresponding author. Present address: Monash University,School of Nursing and Midwifery, Gippsland Campus, Churchill,Victoria, Australia. Tel.: +61 (0) 3 51226627.

E-mail addresses: simon.cooper@med.monash.edu.au(S. Cooper), annie.jenkin@plymouth.ac.uk (A. Jenkin), annie.jenkin@plymouth.ac.uk (B. Jenkin), beryl.badger@plymouth.ac.uk (B. Badger).

study on inter-professional collaboration (Cooperet al., 2007a,b) (which has been granted fullNHS ethics approval) we undertook a review ofWest country ECPs’ practice in a regional patientsurvey.

Of the 25 ECPs that responded the majoritywere paramedics, but 3 were qualified nursesand 2 were dual qualified (paramedic/nurse). Allwere employed by West country Ambulance Ser-vice NHS Trust (WAST) (UK), and were either com-pleting or had completed a full time 3 monthCertificate level programme or a part time Bache-lors level programme in emergency care. ECPsshifts were based in response cars or in treatmentcentres from where they responded to emergencycalls. Our objectives were to identify contempo-rary practice and performance in this unique andemerging role.

Methods

ECPs employed by WAST were asked to complete apatient report form (Appendix A – adapted fromthe 2006 National ECP Audit) for each of their

rved.

Emergency care practitioners (ECP): Practice and performance in the UK West country 181

patients during two 3 week periods in February2006 and April/May 2006. The form included pa-tient demographics, response times, resources,diagnostic, treatment and referral details, andopen questions related to referral and collabora-tive practice.

Data analysis

Analysis was based upon descriptive statistics, cor-relation (Spearman’s rho), binary logistic regres-sion and approximate 95% confidence intervals(CI) for mean and proportion differences. Numeri-cal data was analysed with SPSS version 11.5 andconfidence interval analysis software (SISA, 2006).All tests for statistical significance were two-tailedwith the level of significance at a < 0.05.

Results

Twenty five ECPs (a response rate of 40%; 25/63)completed a total of 611 patient audit forms duringthe survey periods. A significant proportion of pa-tients were over 75 years – 40% (240/605) whilst18% (71/605) were less than 16 years of age. Inthe majority of cases patients accessed ECP caredirectly through the 999 system 458/611 (76%),but they were also seen by ECPs in treatment cen-tres 58/611 (10%) or referred by ambulance crews56/611 (9%).

The mean ECP response time was 16.5 min rang-ing from less than a minute to 13 h (related to nonurgent referrals) (SD 47.6). Only 30% of patients

Table 1 Patient reported condition and diagnosis

Chief complaint Reportedcondition

Rate Mean

1 Respiratory 53 9.22 Cardiac 50 8.73 Gastrointestinal 14 2.44 Neurological 10 1.75 Other medical 128 22.26 Trauma 194 33.67 Burns 2 0.38 Poisoning 1 0.29 Deliberated self harm 2 0.310 Social need 61 10.611 Other unspecified condition 59 10.212 No information 3 0.5

Total 577 100

were seen out of hours (18.30–08.00 and week-ends). Additional responses (e.g., an ambulance)were sent to 38% of patients (90/235) howeverECPs considered 27% (17/63) of these to be inap-propriate and indicated that an alternative re-source should have been used in 40% of cases(127/319), mainly an ambulance 25%, and occa-sionally a GP 5%.

Table 1 indicates patients reported condition(by Ambulance Control), ECPs diagnosis andthe diagnosis at 24 h. One hundred and sixty-three conditions were recoded to 12 chief com-plaints in line with previous re-coding of ECPdata (Cooper et al., 2004). There was a weakcorrelation between reported condition andECP diagnosis (q = 0.475, p = 0.01) and a highcorrelation between ECP diagnosis and diagnosisafter 24 h (q = 0.731, p = 0.01). Put another wayinitial patient condition reports are poorly re-lated to ECPs diagnosis, but the ECPs diagnosisis closely related to the medical diagnosis after24 h.

The mean time on scene was 46.5 min (range<1 min – 4.5 h; SD 28.5). From our interviewand observational data (Cooper et al., 2007a, b)the longer times on scene appear to be relatedto transport delays and delays in referralprocesses.

ECPs non-conveyance rate was 62% (336/539)(95% CI 58–66). Reports from the same period(Wenman, 2006) indicate that the average Trustnon-conveyance rate was 32% and compare wellwith previously reported rates of 50% for ECPsand 36% for paramedics (Cooper et al., 2004).

ECP diagnosis 24 h diagnosis

Rate Mean Rate Mean

44 8.1 11 8.018 3.3 2 1.522 4.1 1 0.749 9.1 6 4.494 17.4 15 10.968 12.6 19 13.93 0.6 3 2.21 0.2 0 01 0.2 0 060 11.1 22 16.1181 33.5 58 42.30 0 0 0

541 100 137 100

Table 2 Significant diagnostic predictors oftransportation

Chief complaint Significance Odds ratio

Respiratory 0.007 2.88Cardiac 0.001 10.81Neurological 0.000 5.67Trauma 0.005 2.48Social need 0.032 0.34

182 S. Cooper et al.

Multivariate associations with dichotomous out-comes (patient transported or not) were assessed,using forward stepwise binary logistic regression,for the following independent variables: ECPgrade, patient age, response time, time on scene,and ECPs diagnostic category. All except ‘diagno-sis’ were rejected from the equation making itthe key predictor of transportation. The odds ratiois significantly higher for some conditions, forexample you are 11 times more likely to requiretransport if you are a cardiac patient and 6 times,if you are have a neurological condition (Table 2).

Where patients were referred by ECPs, mostwere sent to ED 46% (139/302) (95% CI 41–52),but patients were also referred to GPs (13%), MinorInjury Units (MIUs) (7%), district nurses (2%), andFalls groups (1%).

In a few cases (5% (29/582) (95% CI 4–7)) ECPsreported outcomes to be unsatisfactory, suggestingfor example that a patient group directive wouldhave been beneficial. ECPs reported working witha range of other professionals (e.g., GPs, paramed-ics, technicians, first responders). They claimedthat they had made the referral decision in 87%of cases (136/156) (95% CI 81–92) and that thereferral had been successful in 96% of cases(238/249) (95% CI 92–98). Finally, in response tothe question ‘did you perform an ECP-specificintervention, which avoided acute trust admis-sion’, 66% (396/600) (95% CI 62–70) responded inthe affirmative.

Discussion

A significant number of ECPs patients (40%) wereover 75 years which suggests that future educationshould include a distinct focus on elderly care. Therole emerged in part due to the reduction in out ofhours medical cover, so it was surprising that ECPssaw the majority of their patients during the day-

time. A review of manning and shift patterns couldimprove cover out of hours.

There were reported inappropriate primaryreferrals and secondary responses, and the low cor-relation between reported condition and ECP diag-nosis suggest that an increase in paramedics andECPs in Ambulance Control (replacing non para-medic call takers), and use of models such as thetransport decision model (Table 2), may aid appli-cable patient referral.

Improving referral mechanisms, to a wider set ofresources, may reduce on scene times and thenumber of admissions to ED. ECPs non-conveyancerate (68%) was significantly higher than the averagein the Trust and suggests that an increase in educa-tion has improved confidence with possible reduc-tions in inappropriate admissions? In fact ECPsgenerally reported satisfactory outcomes afterworking with a range of other professionals leadingto a reduction in hospital admissions.

However, despite a reasonable number andrange of patients (n = 611) the study is limited bythe small number of ECPs included (n = 25) andits lack of regional diversity. We do not knowthe number of returns to patients left at home,which would be one indication of safe ECP prac-tice, and the broad categorisation of patient con-ditions means that subsequent conclusions arelimited. Nevertheless a clearer picture of ECPspractice has emerged with indications of how per-formance can be enhanced. Future researchshould focus on regional variations and models ofpractice and there is a need to measure the safetyand cost effectiveness of out of hospital emer-gency care.

Conflict of Interest Statements

None.

Funding

Burdett Trust for Nursing.

Acknowledgments

The authors would like to offer their sincere thanksto the ambulance service and all those who partic-ipated in the study.

Appendix A.

Form No.

(Last 4 digits of PRF) Patient Age

0-11 Pleasespecify

12-16 17-64 65-74 75+

Patient Gender Male Female

Patient accessed system via: 999 Call A&E Treatment Centre (MIU/PCC/WiC etc) GP Surgery Home Visit Ambulance Referral

Other (please state) ............................. ..............................................................In Hrs Out of Hrs (18:30 –

08:00hrs)

Times: First Contact by Patient

ECP contact with patient / arrival on scene

Patient discharge/ referral

Patient Condition (Code or Text) Patient Transport:

Call given as (ifappropriate.):

ProvisionalDiagnosis:

Diagnosis after 24hr (if poss.):

No Ambulance / Transport In your opinion, what would have been the most suitable INITIAL resource for this patient?

Transported by Emerg Amb Ambulance Emerg Amb stood down RRV Emerg Amb downgraded

(IC/Urgent/STV) ECP

ECP transported Patient GP Y/N Was another resource sent? Other (specify)

If YES what e.g. Amb. RRV. GP (Please specifiy)

Please state why?

N/A

Patient Outcome: Patient Outcome unsatisfactory due to (where appropriate)?

See & Treat (ECP Discharge) Hear & Treat See & Treat with assistance from other clinician (eg GP) Other clinician attended / discharged Refer A&E Other ...............................................................................

Drugs Administered: ……………………………………………… Notes: ………………………………………………………………….

Lack of Equipment Lack of PGD ................................... Social Reasons Pain Control

Access to Services Unable to refer appropriately Pathway refused patient

Patient refusal Other ...............................................

Was anyone else on scene? NO Paramedic GP Other(specify)

Referral Pathways: Who made referral decision? Yourself Paramedic GP Other(specify)

Pathway Successful Pathway tried but failed Outcome unknown

A&E Treatment Centre (MIU/PCC/WiC etc)

Elderly Care Team

Medical Admissions (MAU)

GP Surgery Appointment Falls Team

Surgical Admissions (SAU) GP home visit In-Hrs Urgent Home Assessment Team Outpatients Clinic GP home visit In-Hrs Non-Urgent Intermediate Care Team Fracture Clinic GP home visit OoHs Mental Health Team Gynaecology District Nurse Social Services Orthopaedics Nurse Specialist Other Care Pathway:

Site ID:

Appendix 1: Emergency Care Practitioner Impact Measures

National Audit Data Sheet

Paediatrics Practice Nurse …………………………........ Other Speciality:………………………………

Physiotherapy ECP Follow-up X-Ray

Notes / Referral Reason: …………………………………………………………………………………………………

Did you perform an ECP-specific intervention, which avoided Acute Trust involvement? Yes No

Details: ............................................................................................ Trust Avoided:

Emergency care practitioners (ECP): Practice and performance in the UK West country 183

184 S. Cooper et al.

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Cooper, S., O’Carroll, J., Jenkin, A., Badger, B., 2007b.Collaborative practices in unscheduled emergency care.The role and impact of the emergency care practitioner(ECP): qualitative and summative findings. Emergency Med-ical Journal 24, 625–629.

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