Paramedic to general practitioner referral pathways within Australian jurisdictional ambulance clinical practice guidelines: a document analysis
Belinda Delardes
A B * , Mostyn Gooley B C , Kelly-Ann Bowles B and Samantha Chakraborty D
A
B
C
D
Abstract
We aimed to compare the prevalence and clarity of paramedic to general practitioner (GP) referral pathways among clinical practice guidelines (CPGs) of Australian jurisdictional ambulance services (JASs).
We completed a document analysis on all publicly available Australian JAS CPGs that were accessed online during 2024. We appraised CPGs according to the AGREE II Domain 4: Clarity of Presentation criteria.
We located 711 CPGs across the eight Australian JASs, of which 109 (15%) referenced a pathway to GP referral. Overall, 5.5% (n = 6/109) of CPGs met all the AGREE II Domain 4 criteria and considerations. The items most frequently satisfied across CPGs were (i) ‘specific recommendations are appropriately selected and reflect the key messages of the guideline’ and (ii) ‘specific recommendations are grouped together in one section’, both of which were met in 96% (105/109) of CPGs. The item least often satisfied was ‘uncertainty in the interpretation and discussion of the evidence is reflected in the recommendations and explicitly stated’, with only 17% (18/109) of CPGs including a discussion of evidence supporting or cautioning referral to GP pathways. Inclusion of a ‘specific and unambiguous statement of the recommended action’ was also consistently lacking from CPGs, with only 23% (25/109) of CPGs with referral pathways giving a specific timeframe within which the patient should be seen by a GP.
A minority of Australian JAS CPGs include a referral to GP pathway, however, these recommendations are generally non-specific and ambiguous, limiting usability for paramedics.
Keywords: ambulance, EMS, general practitioner, low acuity, multidisciplinary, non-conveyance, paramedic, practice guidelines.
References
1 Andrew E, Nehme Z, Cameron P, Smith K. Drivers of Increasing Emergency Ambulance Demand. Prehosp Emerg Care 2020; 24(3): 385.
| Crossref | Google Scholar | PubMed |
2 Delardes B, Nehme E, Bowles K-A, Chakraborty S, Cox S, Smith K. Characteristics and outcomes of patients referred to a general practitioner by Victorian paramedics. Prehosp Emerg Care 2024; 28(8): 1027-36.
| Crossref | Google Scholar | PubMed |
3 Wilkinson-Stokes M, Yap C, Crellin D, Bange R, Braitberg G, Gerdtz M. How should non-emergency EMS presentations be managed? A thematic analysis of politicians’, policymakers’, clinicians’ and consumers’ viewpoints. BMJ Open 2024; 14(7): e083866.
| Crossref | Google Scholar | PubMed |
4 Australian Institute of Health and Welfare. Use of emergency departments for lower urgency care. Canberra: AIHW; 2024. Available at https://www.aihw.gov.au/reports/primary-health-care/use-of-emergency-departments-lower-urgency-care
5 Royal Australian College of General Practitioners. The role of specialist GPs. 2020. Available at https://www.racgp.org.au/advocacy/position-statements/view-all-position-statements/health-systems-and-environmental/the-role-of-specialist-gps
6 Kelly JT, Mitchell N, Campbell KL, Furlong K, Langley M, Clark S, et al. Implementing a virtual emergency department to avoid unnecessary emergency department presentations. Emerg Med Australas 2024; 36(1): 125-32.
| Crossref | Google Scholar | PubMed |
7 Talevski J, Semciw AI, Boyd JH, Jessup RL, Miller SM, Hutton J, et al. From concept to reality: A comprehensive exploration into the development and evolution of a virtual emergency department. J Am Coll Emerg Physicians Open 2024; 5(4): e13231.
| Crossref | Google Scholar | PubMed |
8 Friend TH, Thomas HM, Ordoobadi AJ, Bain PA, Jarman MP. Community emergency medical services approaches to fall prevention: a systematic review. Inj Prev 2024; 30(6): 446.
| Crossref | Google Scholar | PubMed |
9 Frith M, Randall S, Savira F, Swann J, White N, Giddy A, et al. Evaluation of the priority primary care centre program to reduce emergency department burden in regional Victoria, Australia: a mixed-method study. BMJ Open 2023; 13(11): e075773.
| Crossref | Google Scholar | PubMed |
10 Coster JE, Turner JK, Bradbury D, Cantrell A. Why Do People Choose Emergency and Urgent Care Services? A Rapid Review Utilizing a Systematic Literature Search and Narrative Synthesis. Acad Emerg Med 2017; 24(9): 1137-49.
| Crossref | Google Scholar | PubMed |
11 Korczak V, Yakubu K, Angell B, Middleton P, Dinh M, Lung T, et al. Understanding patient preferences for emergency care for lower triage acuity presentations during GP hours: a qualitative study in Australia. BMC Health Serv Res 2022; 22(1): 1442.
| Crossref | Google Scholar | PubMed |
12 Knowles E, Bishop-Edwards L, O’Cathain A. Exploring variation in how ambulance services address non-conveyance: a qualitative interview study. BMJ Open 2018; 8(11): e024228.
| Crossref | Google Scholar | PubMed |
13 Delardes B, Powell M, Bowles K-A, Chakraborty S, Smith K, Olaussen A. Paramedic perceptions of conveying patients to an emergency department who were suitable for primary care: a cross-sectional survey. Aust J Prim Health 2024; 30(5):.
| Crossref | Google Scholar | PubMed |
14 Parkinson B, Meacock R, Checkland K, Sutton M. Clarifying the concept of avoidable emergency department attendance. J Health Serv Res Policy 2021; 26(1): 68-73.
| Crossref | Google Scholar | PubMed |
15 Queensland Ambulance Service. CPG: Clinical Practice Guidelines. 2024. Available at https://www.ambulance.qld.gov.au/clinical/cpm/guidelines.
16 New South Wales Ambulance. Guidelines. 2024. Available at https://cpg.ambulance.nsw.gov.au/tabs/guidelines
17 Ambulance Tasmania. Ambulance Tasmania Clinical Practice Guidelines (CPG). 2024. Available at https://www.health.tas.gov.au/hospitals/ambulance/ambulance-information-health-professionals/ambulance-tasmania-clinical-practice-guidelines-cpg
18 South Australia Ambulance Service. SA Ambulance CPG. 2024. Available at https://clinical.saambulance.sa.gov.au/tabs/home
19 St John Ambulance Australia (NT) Inc. Clinical Practice Manual v1.5. 2024. Available at https://stjohnnt.org.au/img/documents/ambulance/St%20John%20Ambulance%20NT_Clinical%20Practice%20Manual_1.5_Final.pdf
20 St John Western Australia. Clinical Practice Guidelines. 2024. Available at https://clinical.stjohnwa.com.au/clinical-practice-guidelines
21 Ambulance Victoria. Clinical Practice Guidelines. 2024. Available at https://www.ambulance.vic.gov.au/paramedics/clinical-practice-guidelines/
22 Clarke SE. Gatekeeping and General Practice in the Australian Health System. 2020. Available at https://ses.library.usyd.edu.au/bitstream/handle/2123/24623/clarke_se_thesis.pdf?sequence=1&isAllowed=y
23 Deloitte Access Economics. General Practitioner Workforce Report 2019. 2019. Available at https://treasury.gov.au/sites/default/files/2020-09/115786_CORNERSTONE_HEALTH_-_SUPPORTING_DOCUMENT.pdf
25 Shannon B, Eaton G, Lanos C, Leyenaar M, Nolan M, Bowles K-A, et al. The development of community paramedicine; a restricted review. Health Soc Care Community 2022; 30(6): e3547-e61.
| Crossref | Google Scholar | PubMed |
26 Maria S, Colbeck M, Wilkinson-Stokes M, Moon A, Thomson M, Ballard J, et al. Paramedic clinical practice guideline development in Australia and New Zealand: A qualitative descriptive analysis. Australas Emerg Care 2024; 27(4): 259-67.
| Crossref | Google Scholar | PubMed |
27 Brouwers MC, Kho ME, Browman GP, Burgers JS, Cluzeau F, Feder G, et al. AGREE II: advancing guideline development, reporting and evaluation in health care. CMAJ 2010; 182(18): E839--E42.
| Crossref | Google Scholar | PubMed |
28 Morley C, Unwin M, Peterson GM, Stankovich J, Kinsman L. Emergency department crowding: A systematic review of causes, consequences and solutions. PLoS One 2018; 13(8): e0203316.
| Crossref | Google Scholar | PubMed |
29 Whyatt D, Tuson M, Haynes E, Mountain D, Nagree Y, Vickery AW. Burden of primary care-type emergency department presentations using clinical assessment by general practitioners: A cross-sectional study. Emerg Med Australas 2019; 31(5): 780-6.
| Crossref | Google Scholar | PubMed |
30 O’Cathain A, Knowles E, Bishop-Edwards L, Coster J, Crum A, Jacques R, et al. Understanding variation in ambulance service non-conveyance rates: a mixed methods study. Health Serv Res 2018; 6(19): 1-244.
| Crossref | Google Scholar |
31 Green L, Selleck L, Gibbons M, Klim S, Ritchie P, Patel R, et al. Does the evidence justify routine transfer of residents of aged care facilities for CT scan after minor head trauma? Intern Med J 2020; 50(9): 1048-52.
| Crossref | Google Scholar | PubMed |
32 Tulchinsky I, Buckley R, Meek R, Lim JJY. Potentially avoidable emergency department transfers from residential aged care facilities for possible post-fall intracranial injury. Emerg Med Australas 2023; 35(1): 41-7.
| Crossref | Google Scholar | PubMed |
33 Venaglia K, Fox A, MacAndrew M. Post-fall outcomes of aged care residents that did not transfer to hospital following referral to a specialised hospital outreach service: A retrospective cohort study. Collegian 2024; 31(3): 165-72.
| Crossref | Google Scholar |
34 O’Hara R, Johnson M, Siriwardena AN, Weyman A, Turner J, Shaw D, et al. A qualitative study of systemic influences on paramedic decision making: care transitions and patient safety. J Health Serv Res Policy 2014; 20(1_suppl): 45-53.
| Crossref | Google Scholar |
35 Petschack S, Lasslett R, Ross L. The paramedic–general practitioner relationship: a scoping review. Aust J Prim Health 2023; 29(6): 547-57.
| Crossref | Google Scholar | PubMed |
36 Delardes B, Prakash S, Smith K, Chakraborty S, Bowles K-A. Rates of general practitioner attendance following paramedic-to-general practitioner referral in Victoria, Australia. Paramedicine 2023; 20(3): 79-88.
| Crossref | Google Scholar |
37 Blodgett J, Robertson D, Ratcliffe D, Rockwood K. Creating a safety net for patients in crisis: paramedic perspectives towards a GP referral scheme. J Paramed Sci 2017; 9(1): 11-7.
| Crossref | Google Scholar |
38 Miles J, Jacques R, Campbell R, Turner J, Mason S. The Safety INdEx of Prehospital On Scene Triage (SINEPOST) study: The development and validation of a risk prediction model to support ambulance clinical transport decisions on-scene. PLoS One 2022; 17(11): e0276515.
| Crossref | Google Scholar | PubMed |
39 Newton M, Tunn E, Moses I, Ratcliffe D, Mackway-Jones K. Clinical navigation for beginners: the clinical utility and safety of the Paramedic Pathfinder. Emerg Med J 2014; 31(e1): e29-34.
| Crossref | Google Scholar | PubMed |
