Beyond the Hospital Walls: The Expanding Role of Advanced Practice Providers in Prehospital Acute Care

Description

Background: Emergency Medical Services (EMS) and Hospital Emergency Departments (EDs) across the country, are experiencing an influx of patients presenting with low acuity calls and “frequent flyers” which is contributing to ED overcrowding, high hospital census, and depletion of prehospital resources. Mobile Integrated Health-Community Paramedicine (MIH-CP) programs, traditionally staffed with specially trained EMS paramedics, have recently gained attention due to innovative ways to deliver care outside of the hospital, in turn increasing access to care. Now, some areas of the country have started to utilize advanced practice providers (APP), including Physician Associates (PA) and Nurse Practitioners (NP). However, the effectiveness of APPs serving on these specialized teams has yet to be compared to the traditional standard of care.

Objectives: To evaluate the efficacy of prehospital APPs (PA and NP) compared to the standard level of prehospital care in terms of visits to the ED or hospital transports via ambulance.

Design: Systematic multi-study literature review

Methods: The National Library of Medicine PubMed, Embase, and Scopus were searched using the terms “Advanced Practice Provider” or “Physician Assistant” or “Advanced Practice Nurse” and “Mobile Integrative Health” or “Community Paramedicine” for articles not already included in the previous meta-analysis. Results were then reduced using various inclusion and exclusion criteria for the studies included. All articles were included that reported APPs with ED visits/transports and incorporated MIH-CP-like interventions and outcomes.

Results: The original meta-analysis reviewed 12 traditional MIH-CP programs and found a pooled risk ratio of 0.56 (95% CI 0.42-0.74) for ED visits, which was found to be a consistent 44% reduction in those visits. Study #1 found that PAs referred fewer patients to the general practitioner or ED compared to general ambulance registered nurses (50% vs. 73%, respectively, X2 = 35.5, P < 0.0001). Study #2 found that it was 24 times more likely that a patient’s complaint could be mitigated on scene compared to that of a normal ACLS/BLS response (OR = 24.19, p < 0.001). Study #3 found that of the 792 total patients, 400 (50.5%) were treated and released from the scene or directed to an alternative destination other than the ED. Study #4 found patients had a 65% lower rate of total 30-day readmission compared with patients whose needs were not fully addressed (IRR = 0.35, 95% CI 0.18-0.68, P = 0.002).

Conclusion: The studies reviewed show that advanced practice providers working in prehospital programs such as MIH-CP and other mobile integrative health programs demonstrate the ability to reduce both unnecessary ED visits and hospital admissions while still maintaining safe practices. Evidence from the studies shows that APPs in the field can accurately and effectively treat patients on scene without the need for transport to the hospital, and facilitate alternative transportation destinations, and help coordinate care based on social determinants of health without the need for the patient to be seen or admitted to the hospital. Despite these positive outcomes, limited evidence is available on this topic, leading to a need for further research through the use of randomized controlled studies to better focus on the role of APPs in the prehospital setting.