RESEARCH
Effectiveness of paramedic practitioners in attending 999
calls from elderly people in the community: cluster
randomised controlled trial
Suzanne Mason, reader in emergency medicine,1 Emma Knowles, research fellow,1 Brigitte
Colwell, research associate,1 Simon Dixon, senior lecturer,3 Jim Wardrope, consultant in emergency
medicine,2 Robert Gorringe, lead emergency care practitioner,4 Helen Snooks, professor of health services
research,5 Julie Perrin, nurse consultant in emergency medicine,2 Jon Nicholl, professor1
ABSTRACT
Objective To evaluate the benefits of paramedic
practitioners assessing and, when possible, treating
older people in the community after minor injury or
illness. Paramedic practitioners have been trained with
extended skills to assess, treat, and discharge older
patients with minor acute conditions in the community.
Design Cluster randomised controlled trial involving 56
clusters. Weeks were randomised to the paramedic
practitioner service being active (intervention) or inactive
(control) when the standard 999 service was available.
Setting A large urban area in England.
Participants 3018 patients aged over 60 who called the
emergency services (n=1549 intervention, n=1469
control).
Main outcome measures Emergency department
attendance or hospital admission between 0 and
28 days; interval from time of call to time of discharge;
patients’ satisfaction with the service received.
Results Overall, patients in the intervention group were
less likely to attend an emergency department (relative
risk 0.72, 95%confidence interval 0.68 to 0.75) or require
hospital admission within 28 days (0.87, 0.81 to 0.94)
and experienced a shorter total episode time (235 v
278 minutes, 95% confidence interval for difference −
60 minutes to −25 minutes). Patients in the intervention
group were more likely to report being highly satisfied
with their healthcare episode (relative risk 1.16, 1.09 to
1.23). There was no significant difference in 28 day
mortality (0.87, 0.63 to 1.21).
Conclusions Paramedics with extended skills can provide
a clinically effective alternative to standard ambulance
transfer and treatment in an emergency department for
elderly patients with acute minor conditions.
Trial registration ISRCTN27796329.
INTRODUCTION
The UK Department of Health’s strategy has been
to encourage the increased use of non-medical staff to
carry out assessments and treatments traditionally car-
ried out by doctors.1 The introduction of new models
of care, including further assessment, triage, and
treatment skills for paramedics, has been recom-
mended to help manage ever increasing demands for
health care.2 Current evidence concerning safety,
effectiveness, and costs to support these changes in
practice, however, is lacking.3
Paramedics can be trained to assess and treat or refer
patients with a range of conditions such as wounds,4
hypoglycaemia,5 falls, and epistaxis.6 The merits of a
pre-hospital practitioner working in certain geographi-
cal areas such as rural locations in fulfilling a broader
public health and primary care outreach role in the
local community have also been discussed.7 Other
authors, however, have cast doubt on the safety, feasi-
bility, and cost effectiveness of paramedics assessing
and treating apparently minor problems in the
community.8 9
Elderly people make 12-21% of visits to emergency
departments. Many of them attend after an accident or
fall.10 11 Recently completed studies suggest that an
alternative approach to an emergency ambulance
response would have the greatest chance of improving
patients’ experience, as well as potentially helping to
reduce demand, if it was targeted at elderly patients
with minor complaints.12 13
The SouthYorkshireAmbulance Service developed
the paramedic practitioner in older people’s support
(PPOPS) scheme to deliver patient centred care to
elderly people who call the emergency services with
conditions triaged as not immediately life threatening.
Practitioners underwent a three week full time theory
based course with lectures from specialists in emer-
gency medicine or care of the elderly. They spent a
period of 45 days in supervised practice.
Seven experienced paramedics were selected
through open competition and completed the training
course to enable them to provide community based
clinical assessment for patients aged over 60 who con-
tacted the emergency ambulance service with minor
acute conditions. Initial assessment and, when appro-
priate, treatment was delivered within the patient’s
residence by an individual paramedic practitioner
who responded to emergency calls. When the
1Health Services Research, School
of Health and Related Research,
University of Sheffield,
Sheffield S1 4DA
2Department of Emergency
Medicine, Sheffield Teaching
Hospitals Trust, Sheffield S5 7AU
3Health Economics and Decision
Science, School of Health and
Related Research, University of
Sheffield, Sheffield
4South Yorkshire Ambulance
Service, Rotherham S60 2BQ
5Centre for Health Information
Research and Evaluation, School
of Medicine, Swansea University,
Swansea SA2 8PP
Correspondence to: S Mason
s.mason@sheffield.ac.uk
doi:10.1136/bmj.39343.649097.55
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paramedic practitioner deemed it necessary, patients
were transported to an emergency department for
further assessment or treatment such as radiological
investigation.14 The box outlines the scope of practice.
Operational between the hours of 8am and 8pm
each day, the service was activated by a 999 call or an
urgent call from a general practitioner to the ambu-
lance control roomor from an ambulance crew attend-
ing an eligible patient.
We conducted a cluster randomised controlled trial
to evaluate the effectiveness and safety of this new ser-
vice.
METHODS
Patients were recruited from 1 September 2003 to 26
September 2004. Patients aged 60 and above were eli-
gible for inclusion when the call to the ambulance ser-
vice originated froma Sheffield postcode between 8am
and 8pm, with a presenting complaint that fell within
the scope of practice of the paramedic practitioners.
We used cluster randomisation to reduce the risk of
contamination (practice in the control group being
influenced by the presence of the paramedic practi-
tioner in the community) and to allow service level,
rather than individual patient level, evaluation of the
intervention. Weeks were randomised before the start
of the study (to allow for rostering of the paramedic
practitioners) to the paramedic practitioner service
being active (intervention) or inactive (control), when
the standard 999 service was available. The forward
roster was concealed from othermembers of the emer-
gency services. During inactive weeks, the paramedic
practitioners were removed from operational duties
within the ambulance service, and undertook research
duties including obtaining patients’ consent and fol-
low-up. Randomisation of weeks was undertaken by
computer random number generation.
Before the trial we carried out a fourweek pilot study
to establish the number of weeks needed to complete
recruitment and to test data collection methods.
Principal outcomes in the study protocol were atten-
dance at emergency department and hospital admis-
sion between 0 and 28 days, interval from time of call
to time of discharge, and patients’ satisfaction with the
service received. Secondary outcomes were investiga-
tions and treatments prescribed, subsequent use of
health services within 28 days, and health status and
mortality at 28 days.
Recruitment of patients
During each week, a paramedic practitioner based in
the ambulance control room identified eligible calls by
the presenting complaint and notified a paramedic
practitioner in the community (during intervention
weeks) or in the emergency department (during con-
trol weeks). All identified patients were approached
face to face either in the community or in the emer-
gency department for written consent to follow-up.
To avoid unnecessary burden on participants, patients
who hadmore than one eligible episodewere recruited
only for their first episode.
If patients were unable to complete questionnaires—
for example, because of cognitive impairment or who
were unable to read English—we obtained consent for
follow-up by review of clinical records only.
The research team independently checked the
ambulance service call database at the end of each
month for any additional eligible calls not identified
by the paramedic practitioners at the time of the inci-
dent. We noted patients identified retrospectively to
check for selection bias but did not follow them up.
Data collection
Routine data
The research team used the emergency department or
ambulance service records to collect clinical data,
including investigations, treatment, diagnoses, and dis-
charge from the service, relating to the initial patient
episode. Total episode time was derived by calculating
the interval between the time the initial call was
received in the ambulance control room to the time
that the patient left the emergency department, was
admitted to hospital, or, if the patient was discharged
in to the community, the time that the paramedic prac-
titioner or ambulance crew left the scene. These times
therefore included any time spent waiting for assess-
ment in the emergency department.
We used hospital records to collect information
about unplanned hospital attendances or admissions
within Sheffield in the 28 days after the initial episode
and mortality at 28 days. Information relating to sub-
sequent ambulance requests was collected from the
local ambulance service. Attendance at an emergency
department or hospital admission on day 0 was
Scope of practice of paramedic practitioners
Presenting complaint

Falls

Lacerations

Epistaxis

Minor burns

Foreign body in ear, nose, or throat
Practical skills

Local anaesthetic techniques

Wound care and suturing techniques

Principles of dressings and splintage
Special skills

Joint examination

Examination of neurological, cardiovascular, and
respiratory system

Examination of ear, nose, and throat

Protocol led dispensing: simple analgesia,
antibiotics, tetanus toxoid

Assessment of mobility and social needs
Additional options for referral and requesting
investigations

Requests for radiography

Referral processes: emergency department, general
practitioner, district nurse, community social services
RESEARCH
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