Kathryn Eastwood
Doctorate
Doctorate Title: Managing the impact of growing low-acuity demand on ambulance services.
Doctorate Description: The demand for emergency ambulances increases annually, placing a substantial burden on ambulance services and emergency departments (EDs). Many cases presenting to ambulance services are low-acuity, having no urgent clinical need and no need for the specific skills that paramedics possess. In an effort to manage increasing demand, some ambulance services have implemented nurse- or paramedic-led secondary telephone triage services for patients identified as low-acuity during the primary triage that occurred in response to a person calling the emergency telephone number. These secondary telephone triage services vary in their structure and operation. The Ambulance Victoria Referral Service (RS), a secondary telephone triage service that has operated in Melbourne, Australia, since 2003, functions by triaging potentially low-acuity cases using a computer-based questioning algorithm. Using a combination of the outcomes of the software-led questioning and paramedic or nurse questioning and clinical judgement, a disposition is assigned allocating a patient to a particular care pathway. This will result in the patient being referred to one of the following:
• emergency ambulance dispatch;
• non-emergency ambulance dispatch;
• referral to an alternative service provider (ASP) , including nursing, home visiting doctor (locum) services, mental health clinicians (crisis assessment and treatment teams (CATT)), and hospital outreach programs; or
• provision of advice allowing the patient to self-manage the condition and/or seek further medical attention independently (including self-presenting at the ED, or arranging an appointment with a doctor).
This thesis presents the first large-scale evaluation of an operational ambulance-based secondary telephone triage service. A large RS dataset spanning 34 months was linked to emergency ambulance paramedic records and ED and hospital admission records to allow for the call-taker triage decisions and patient journey through their care pathway to be examined.
The RS was found to have a substantial impact upon Ambulance Victoria’s operations, with 72.4% of RS-managed cases directed away from emergency ambulance dispatch. The RS also referred 32.2% of its cases to care pathways that did not immediately result in an ED presentation.
The appropriateness of the referral of patients for emergency ambulance dispatch and ED presentation was examined and, overall, these triage decisions were found to be appropriate, however, a large proportion of overtriage remained following secondary telephone triage. Further exploration of the patient and case characteristics identified relationships between these characteristics and emergency ambulance and ED appropriateness highlighting potential avenues for the optimisation of the triage questioning and expansion of alternative care pathways to better service particular case types.
This research shows the RS to be a valuable tool for managing the demand for emergency ambulances in Melbourne through the referral of low-acuity cases away from emergency ambulance dispatch and the identification of cases appropriate for the emergency care pathways. Whilst demand management strategies vary based on the operational structure of the ambulance service within which they are embedded, the analysis described in this thesis represents a powerful and flexible approach for the investigation of the impact and effectiveness of similar services. The knowledge generated in this program of research can be used to inform policymakers and ambulance service managers about the successful operation of secondary telephone triage and be used to guide future research and evaluation of these services.
Details:
Type: PhD
University: Monash University
Primary Supervisor: Professor Just Stoelwinder & Professor Karen Smith
Category: Other
Funding:
Start Date: 2010
End Date: 2017
Status: Complete
Thesis
ThesisResearch Interests
Health Services Research; Mathematics/drug calculation abilities; Pain; Data Linkage; Machine Learning; Artificial Intelligence; Clinical Practice Guidelines.
Publications
PhD Peer reviewed journal publications and conference presentations
Peer Reviewed Journal Articles
1. Eastwood K, Morgans, A, Smith K. Characteristics associated with emergency department
suitability in low-acuity ambulance cases. Australasian Journal of Paramedicine. 2020; 17(1).
2. Eastwood K, Smith K, Morgans, A, Stoelwinder J. The appropriateness of cases referred for emergency ambulance dispatch following an ambulance service secondary telephone triage a retrospective cohort study. PLoS ONE. 2019; 14(8).
3. Eastwood K, Morgans A, Smith K. Patient and case characteristics associated with ‘no paramedic treatment’ for low-acuity cases referred for emergency ambulance dispatch following a secondary telephone triage. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 2018;26(8).
4. Eastwood K, Smith K, Morgans A, Stoelwinder J. Appropriateness of cases presenting in the emergency department following ambulance service secondary telephone triage: a retrospective study. BMJ Open. 2017;7(10).
5. Eastwood K, Morgans, A, Smith K, Hodgkinson, A, Becker, G, Stoelwinder J. A novel approach for managing the growing demand for ambulance services by low-acuity patients: An epidemiological review. Australian Health Review. 2015; 40(4);378-84.
6. Eastwood K, Morgans, A, Smith K, Stoelwinder J. Secondary triage in prehospital emergency ambulance services: A systematic review. Emerg Med J. 2015; Vol 32(6):486-492.
Conference Presentations –Peer Reviewed
1. Eastwood K, Morgans A, Smith K, Stoelwinder J. Characteristics Associated with Emergency Department Suitability in Low-acuity Ambulance Cases. Australasian College of Paramedicine International Conference. October 2020.
2. Eastwood K, Morgans A, Smith K, Stoelwinder J. The appropriateness of cases presenting in the emergency department following ambulance service secondary telephone triage. Paramedics Australasia International Conference. Queensland, Australia. October 2018.
3. Eastwood K, Morgans A, Smith K, Stoelwinder J. Was emergency ambulance dispatch appropriate following secondary telephone triage of low-acuity cases. Paramedics Australasia International Conference. Auckland, New Zealand. November 2016.
4. Eastwood K, Morgans A, Smith K, Stoelwinder J. The Referral Service: Managing growing demand for ambulance services from low-acuity patients with secondary telephone triage. Paramedics Australasia International Conference. Adelaide. October 2015.
5. Eastwood K, Morgans A, Smith K, Stoelwinder J. The Referral Service: Managing growing demand for ambulance services from low-acuity patients with secondary telephone triage. Council of Ambulance Authorities. Melbourne. October 2015.
6. Eastwood K, Morgans A, Smith K, Stoelwinder J. A novel solution for managing the growing demand for ambulance services by low-acuity patients. European Health Management Association Conference. Milan, Italy. 2013.
Paramedic PhD is endorsed by:
