Patients' experiences of care provided by emergency care practitioners and traditional ambulance practitioners: a survey from the London Ambulance Service

Abstract

Patients' experiences after receiving care from emergency care practitioners (ECPs) were compared with those after receiving care from traditional ambulance practitioners using a postal questionnaire distributed to 1658 patients in London; 888 responses were received. The responses of patients receiving care from both groups were similar and largely positive. But in two areas (“thoroughness of assessment” and “explaining what would happen next”), the care provided by ECPs was experienced as considerably better. These differences were partly explained by considerably fewer patients from ECPs being conveyed to the emergency department, suggesting that empowering ECPs to explore and explain alternatives to the emergency department improves patient satisfaction.

Patient satisfaction with emergency care tends to be high,¹,²,³,⁴,⁵,⁶ particularly among patients not conveyed to the emergency department⁴,⁵,⁶—a common feature of care provided by emergency care practitioners (ECPs).⁷

ECPs are autonomous, and flexible practitioners who can respond to emergency calls, work in treatment centres and provide out‐of‐hours primary care.⁸ The UK policy supports the development of ECPs among recommendations to make ambulance services the ”mobile healthcare arm” of the NHS.⁹ In London, ECPs undertake diploma‐level or degree‐level training and became operational in 2003. During this study, 21 ECPs worked in three primary care trusts, dispatched centrally to any emergency call.

This study aimed to compare patients' experiences of ECP care with that from traditional ambulance practitioners (state‐registered paramedic (SRPara) or emergency medical technician (EMT)).

Methods

Between October and December 2004, all ECP‐attended calls and a stratified random sample of calls attended by SRParas or EMTs (matched by postcode and emergency call category) were identified. After piloting, a postal questionnaire containing 13 research‐based items⁵,⁶,¹⁰ was sent to these patients 2–6 weeks after their emergency call. The responses of patients attended by ECPs and by SRPara or EMTs were dichotomised (additional data are available online at http://emj.bmjjournals.com/supplemental) and compared using χ² and logistic regression. The Lewisham Local Research Ethics Committee approved the study.

Results

The questionnaire was sent to 1658 patients. Responses were received from 888 (53.6%), 481 patients were attended by SRPara or EMTs and 407 by ECPs. This exceeds the 580 respondents required to detect a 10% difference from a baseline of 80% “very” positive,⁵ at 80% power.

Respondents were older than non‐respondents (χ² 69.53, df = 3, p<0.001), but there were no significant differences in sex, ethnicity, call category, conveyance or the interval between care and questionnaire. Respondents attended by SRPara or EMTs or by ECPs were also similar, except that 80.2% of those attended by SRPara or EMTs were conveyed to the emergency department compared with 58.0% of those attended by ECPs (χ² = 52.08, df = 1, p<0.001).

For most aspects of care, most respondents gave “very” positive ratings, but fewer than half did so for “explanations”, “information provided” or for being “comfortable with what happened” (table 1). Additional data are available online at http://emj.bmjjournals.com/supplemental.

Table 1 Respondents' views of care received from state‐registered paramedic or emergency medical technician and emergency care practitioners.

Item	Percentage giving “very” positive ratings
	SRPara or EMT	ECP
Overall care	79.2	79.1
Response time	63.8	61.3
Friendliness or courtesy	78.8	78.7
Showing concern	74.8	73.0
Listening	73.4	70.3
Answering questions	70.2	68.0
Examination quality	68.3	68.2
Explaining condition	63.9	64.7
Suitability of treatment or advice	88.9	88.1
Thoroughness of assessment or examination*	55.8	64.6
Explaining what happens next*	35.2	44.5
Relevant information provided	38.0	44.8
Patient comfortable with what happened	40.6	45.1

*p<0.05.

ECP, emergency care practitioner; EMT, emergency medical technician; SRPara, state‐registered paramedic.

Compared with respondents attended by SRPara or EMTs, ECP‐attended respondents were significantly more likely to rank “thoroughness of assessment” (odds ratio (OR) 1.4; 95% confidence interval (CI) 1.0 to 1.9) and “staff explaining what would happen” (OR 1.5; 95% CI 1.1 to 2.1) “very” positively. However, though the difference in “explaining what would happen next” was unchanged after controlling for variation in conveyance, the difference in “thoroughness of assessment” was no longer significant (OR 1.3; 95% CI 1.0 to 1.8).

Conclusion

The experiences of patients cared for by ECPs and those cared for by SRPara or EMTs were similar and largely positive. However, in two areas, the care provided by ECPs was believed to be better. Probably this reflects how the education and practice of ECPs focuses on structured assessment, autonomous decision making and negotiating an appropriate pathway of care. Indeed, the differential satisfaction was partly explained by ECPs' reduced conveyance to the emergency department because ECPs are empowered to offer alternative care outcomes.⁷ As previous research has associated non‐conveyance to the emergency department with higher patient satisfaction,⁴,⁵,⁶ our findings are not entirely unexpected. Nonetheless, our findings suggest that ECPs elicit higher patient satisfaction not simply because they convey fewer patients to the emergency department but also because they explain alternative care better. This lends support to developing the role of an ECP, although it is also clear that further research is required to deal with this study's limitations: a modest response rate, some delay between care and survey, and limited data on differences in care and clinical outcomes.

Additional table is available at http://emj.bmjjournals.com/supplemental

Abbreviations

ECP - emergency care practitioner

EMT - emergency medical technician

SRPara - state‐registered paramedic