**7. Providing access to effective emergency care**

"Access" is a multifaceted term. From the patient's perspective it may start by picking up the phone to either call an emergency number, a healthcare advice number, or a clinic to book a primary care appointment. Each country, state, or community operates slightly differently but some of the possible decision pathways from call takers in the case of a potential medical emergency are illustrated in **Figure 2**. It may range from the call taker simply providing advice to a patient over the phone regarding a minor ailment, to dispatching an ambulance crew, sometimes with a rapid response vehicle if a higher level of response is required. Call takers may also advise the caller to either call another healthcare assistance number or to call their primary healthcare clinic [15]. Call takers may either be clinicians (nurse, physician…), Emergency Medical Dispatchers (EMDs) with or without clinical training, or even clerical staff [16, 17]. Advice they provide and decisions they make are often based on a scripted series of questions aimed at getting information from the caller to eventually select the most appropriate protocol to follow and potentially dispatch an ambulance or determine that no face to face help was needed [18].

Once an ambulance crew reaches the patient and the assessment is performed. The paramedics can decide of the most appropriate patient disposition which may be one of four possibilities as illustrated in **Figure 3**. Such practice varies vastly between ambulance service providers and from country to country [15, 19]. Many factors may impact on the patient transport decisions made by ambulance crews, such as

**Figure 2.** *Proposed call taker decision tree when communicating with a patient or caller.*

**Figure 3.** *Possible ambulance crew decisions after assessing a patient face to face.*

operating procedures, patient triage algorithms, healthcare policies, relationships with other healthcare entities, staff training, but also the pressure of the call volume the ambulance service is experiencing at the time. In some cases the patient may be provided with reassurance, treated on scene, and discharged by the ambulance crew [10]. The paramedics may advise the patient to seek further medical help if needed, but there are potential negative implications such as subsequent emergency call, delayed care, or even mortality [20]. Another possibility is that the ambulance crew might not be the best suited clinical team to address the patient's needs so they may be offered transportation to their local PHC or advised to report there by their own means of transportation so the crew can instead deal with more critical cases. Then comes what should be the most common scenario, corresponding to a real emergency call, whereby the ambulance crew needs to provide immediate care and transport the patient to an ED. There are also highly critical cases which require the prehospital intervention of additional clinicians with a wider scope of practice before the patient can be safely transported to an ED or other highly specialized facility. Some specific triage or scoring system based on physiological, motor, and mental status parameters if often used to identify the level of severity of the patient condition [21]. For such cases and depending on the country's prehospital response model adopted, the call taker may dispatch a prehospital emergency physician with a nurse anesthetist or a critical care paramedic who will help stabilize the patient or perform other lifesaving procedures before urgent transportation to a more specialized facility such as a high level trauma centre, cardiac centre, or severe burns unit.

PHC services in general can play a big role in reducing the number of ED visits [10, 22]. Whether a patient has been referred over the phone to report to a PHC Urgent Care Clinic (UCC) by a call taker (**Figure 2**) or by an ambulance crew advising them to self-transport there (**Figure 3**), or a patient is directly self-reporting there, the triage nurse will first assess them. The possible outcomes of a visit to the PHC UCC are illustrated in **Figure 4**. The patient may be immediately treated (depending on how busy the UCC is) and discharged. If the case is a more complex, treatment may be initiated and the patient will be reassessed after a short period of time (e.g. 2 hours). Depending on the evolution of the patient's condition, they may either be discharged or an ambulance transfer may be arranged to the nearest ED. If from the

#### **Figure 4.**

*Disposition of patients reporting to a primary healthcare center urgent care clinic.*

#### **Figure 5.**

*Emergency Department triage algorithm incorporating the recommendation for low acuity patients to report to a Primary Healthcare Center Urgent Care Clinic.*

initial assessment, the patient is determined to have deteriorated from the previous interaction with the call taker or ambulance crew, only stabilization measures will be performed and arrangements will be made to transfer the patient to ED without delay. Lastly, if the patient requires special emergency care (e.g. myocardial infarction), an emergency call will be made so they will be transported by ambulance to a specialized facility as a high priority case, possibly with a more medically advanced team (e.g. accompanied by a critical care paramedic). The presence of an ambulance on standby near the PHC is an important element for the rapid transfer of such cases.

Lastly, the case when a patient reports directly to an ED needs to be considered. Again some form of triage needs to be implemented to determine if the patient is trying to make use of the most appropriate service. There are several triage systems, for example the Canadian Triage and Acuity Scale (CTAS) and many other validated triage systems are commonly used in emergency departments worldwide [23, 24]. Most systems result in EDs seeing all patients, even those with a very low acuity level, but their non-urgent triage level often results in them experiencing a potentially very long wait time before being seen after their initial assessment. This is usually not a pleasant experience for patients and will affect their satisfaction level with the overall care experience eventually received [25]. **Figure 5** proposes an ED triage algorithm incorporating a pathway whereby low acuity patients are asked to report to a Primary Healthcare Center Urgent Care Clinic or to book a primary care appointment. Probably not the desired outcome of a patient's visit to the ED, this approach would be expected to significantly relieve the pressure on EDs and contribute to a better use of the ED resources and expertise. Higher acuity patients will however be treated more rapidly, according to the severity of their health condition, and reassessed to determine if they should be discharged with or without a referral for a follow up outpatient consultation, or be admitted into hospital for definitive care. In some particular cases, if the patient walked-in, was wrongly transported to hospital by ambulance, or their condition changed, they may need to be urgently transferred to a specialized emergency facility (e.g. trauma, cardiac, burns unit) after having been stabilized.
