Outpatient care in acute and prehospital emergency medicine by emergency medical and patient transport service over a 10-year period: a retrospective study based on dispatch data from a German emergency medical dispatch centre (OFF-RESCUE)

The utilization of the resources of the emergency medical service (EMS) and patient transport service (PTS) in the public healthcare system has become increasingly important in recent years [1‐3]; while in Germany in 1994 about 9.5 million operations were performed, in 2016 there were already 16.4 million missions [4]. In retrospect, most missions (70%) were non-urgent and mainly took place in cities [5‐8]. In particular, the number of outpatient medical contacts in emergency medicine accounted for a significant proportion; this was rated as 16–41.7% [9‐13]. Here, patients often misjudged the urgency of their complaints [14]. This mainly concerned vulnerable patient groups such as elders, children, young adults and homeless people; neurological and traumatological indications were frequent reasons for emergency calls; in this context, the information in the relevant literature for neurological (1–29%) and traumatological complaints such as injuries caused by falls (9–56%) vary [15‐18].

A distinction is made between assistance services, where a medical service is performed on-site, and operations, where no patient is present at the emergency location [19]. Statistically, spurious trips are recorded as a quota by the German Federal Health Monitoring; in 2013, a proportion of 7.4% of all operations of the public EMS was documented [19]. In contrast to patient transportations, assistance services and spurious trips are not remunerated in Rhineland-Palatinate; these costs must be cross-financed by the organizations that run the EMS; they are included in the operating expenses [20]. Assistant services are not officially recorded by statistics. In order to reduce these non-life-threatening operations in favour of efficient patient management, various solution approaches have been applied in the past; processes of the emergency medical dispatch centre (EMDC) were improved in respect of emergency call handling, which, however, led to an over-prioritization (false positive assignment of a higher priority level) of many patients [21‐23]. In addition, protocols for handling low-priority patients have been successfully implemented, which lead either to the outpatient usage of a nurse or to telephone consultation [24, 25]. In general, the decision on whether a patient should be conveyed at all is made by the team on scene depending on the paramedic’s qualification which is different in EMS and PTS; lower qualified paramedics mainly work in PTS, while higher qualified paramedics work in EMS. The reason is that in the rescue service area studied, the PTS is almost used exclusively for so-called appointment trips (e.g., trips to medical specialists), in which there has already been contact with a physician (e.g., general practitioner) and it was not an emergency call. The EMS mainly provides assistance for so-called primary missions, in which no physician was on the scene and assessed the patient’s condition. So far, several studies have shown inconsistent findings that the paramedic on site is able to decide due to a lack of patient safety whether a patient should be conveyed [26‐28]. Participation of general practitioners in prehospital emergency care would help [29]. During non-indicated operations, emergency devices are not available for life-threatening patients, which delays the ambulance response time. As a result, the outcome of patients with time-critical emergency gets worse [30‐32].

A similar development of overuse is also apparent in the emergency departments [33]. Important reasons are on the one hand the lack of awareness of medical necessity and on the other hand the fact that young people in particular see the emergency department as a contact point outside the opening hours of general practitioners as a substitute service [34‐36]. For most patients (66%), outpatient medical care is sufficient, but it still caused an immense effort [37]. From an economic point of view, healthcare costs in Germany increased by 236% from about € 159 to € 375 billion between 1992 and 2017. The EMS even registered a rise of 380%, the share of healthcare costs rose from 0.8 to 1.3% [38].

In the following, the term OFF-Mission will describe all operations that did not prehospitally result in a patient transportation, while ON-Missions describe completed transports. The aim of this retrospective, explorative study is to compare ON- and OFF-Missions in terms of urban-rural distribution, job cycle time and economic relevance.

This study highlights in particular the increasing use of emergency devices, which is also associated with a progressive misappropriation of these vehicles; especially in the case of OFF-Missions, the EMS records a higher number of operations than PTS; the reasons are a combination of the fact, that emergency operations and their course are not plannable or predictable. From an economic point of view, OFF-Missions are a non-profit business for the service providers; immensely high revenues are missing, but in the present work these are only calculated in a simplified way and thus presented to a lesser extent than it is actually the case. Therefore, better patient management appears to make sense from both sides - the medical and the economic point of view. Practical experience has shown that simple assistance is more time-consuming than normal emergency events, on the one hand because of legal uncertainty in the case of trivial indications and on the other hand because of complex medical care (e.g. unsuccessful resuscitation). In order to be able to make statements about the increased effort of simple assistance, the effective treatment time (= on-site time) between ON- and OFF-Missions should be compared in future studies.

Future studies should also investigate whether and how the generously defined indications of EMS and PTS may have led to higher-quality care for patients. This could be measured by a decrease in hospital admissions that could be avoided by EMS and PTS, shorter hospital stays and better patient outcomes. For specific emergency diseases such as acute stroke and out-of-hospital cardiac arrest, previous studies have shown that a better functional outcome could be achieved by reducing treatment-free time with the help of additional resources [52, 53]. Currently, due to legal uncertainties towards dispatchers and paramedics on the scene, transports to inpatient institutions are increasingly performed after alerting EMS and PTS, which could have been avoided; outpatient, primary care treatment would have been sufficient [54, 55]. Practical experience teaches that such admissions often lead to associated disorders such as nosocomial infections, which increase both hospitalization time and mortality. The legal uncertainty results from German law, which defines EMS and PTS according to its role as a transport company and not as a provider of prehospital emergency medicine, so that remuneration is only paid in case of transport, which creates misaligned incentives in terms of such avoidable admissions [56]. From a socioeconomic point of view, a political rethinking could strengthen and appreciate the position and work of EMS and PTS (remuneration of outpatient missions), provide patients with more goal-oriented care and protect them from overuse, save hospital resources, and thus reduce health care costs.