doi: 10.1111/j.1742-6723.2011.01525.

x Emergency Medicine Australasia (2012) 24, 175–180

ORIGINAL RESEARCH

Patient satisfaction and outcome using

emergency care practitioners in New Zealand emm_1525 175..180

Andrew H Swain,1 Manar Al-Salami,1 Sarah R Hoyle2 and Peter D Larsen1

1
Department of Surgery, Anaesthesia, and Emergency Medicine, University of Otago, and 2Clinical
Services, Wellington Free Ambulance, Wellington, New Zealand

Abstract
Objective: A patient satisfaction survey was undertaken in the Kapiti District of the Wellington
Region to ascertain patients’ experience and opinions of New Zealand’s first extended care
paramedic (ECP) service before consideration is given to extending it to other locations
within the region. Patient outcomes were also analysed for 1 week following ECP care.
Methods: One hundred patients, 50 attended by ECPs and 50 by standard emergency ambulance
service paramedics, were interviewed by an independent assessor, either in person or by
phone according to patient preference. The questionnaire was aimed at comparing the
experience of both groups of patients, dividing them into those treated at home and those
transferred to the ED. ED and general practice records were then reviewed to determine
whether the ECP-treated patients attended either facility within 7 days and why.
Results: Patients were very satisfied with their experience of both groups of paramedics but
expressed a clear desire to be treated at home if possible. Of the 50 ECP-treated patients, 11
were transferred directly to the ED. Only one clinical complication arose over the next
7 days in those treated in the community: a seizure in a patient with refractory epilepsy.
Conclusion: The avoidance of unnecessary transfers to hospital is beneficial to patients, the ambulance
service and the ED. This study demonstrates that patients are very satisfied with their
assessment and treatment by ECPs, endorsing the proposal that the scheme should be
extended across the Wellington Region, and perhaps New Zealand.
Key words: ambulatory care, patient care, patient satisfaction, prehospital emergency care, standard of care.

Introduction and avoid unnecessary transfer of these patients to the

In 2009, the New Zealand Ministry of Health funded a
2 year Urgent Community Care (UCC) pilot scheme pro-
posed by Wellington Free Ambulance.1 This involved
the use of selected and more highly trained paramedics,
referred to locally as extended care paramedics (ECPs), to
provide a range of medical and nursing skills to patients
in the Kapiti District (population 46 200, 2006 census)
ED of Wellington Hospital. The initiative was based on
Emergency Care Practitioner schemes established in the
UK.2 Wellington ECPs are trained to have a greater range
of diagnostic and treatment skills than standard para-
medics, allowing more patients to be treated at home or
referred to community health services.
The UCC pilot is the first of its kind in New Zealand.
The service attended 1351 patients in its first year when

Correspondence: Dr Andrew H Swain, Department of Surgery, Anaesthesia, and Emergency Medicine, University of Otago, PO Box
7343, Wellington 6242, New Zealand. Email: andrew.swain@otago.ac.nz
Andrew H Swain, BSc, PhD, FRCS, FCEM, FACEM, Senior Lecturer; Manar Al-Salami, Pharmacy Student; Sarah R Hoyle, MHSc, Executive
Clinical Manager; Peter D Larsen, PhD, Associate Professor of Resuscitation Medicine.

© 2012 The Authors

EMA © 2012 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
 AH Swain et al.
51% were successfully treated at home. This compares
with a treat-at-home rate of 26% for standard emer-
gency ambulance service (EAS) paramedics (S. Hoyle,
unpubl. data, 2009). Although the service has been wel-
comed by the Kapiti community, the experience of
patients had not been formally assessed. The interna-
tional literature contains limited reports of patient sat-
isfaction with similar services.3,4 Only one study
comparing patient satisfaction with the service pro-
vided by standard paramedics has been found.5
The purpose of this study was to determine whether
patients found the UCC model of service both acceptable
and effective, and to ascertain whether there was any
difference in satisfaction with the care provided by the
two groups of paramedics, EAS or ECP. For the group
of patients treated at home by ECPs, unexpected clinical
interventions occurring within 1 week were identified
by reviewing ED and general practice records for this
period.
Methods
The patient satisfaction survey was undertaken
between 8 November and 13 December 2010 to compare
the experience of patients assessed by paramedics and
either treated at home or transferred to hospital. Fifty
UCC and 50 EAS patients from the Kapiti District were
randomized by blind selection from a pool of numbers.
These patients were surveyed retrospectively by phone
or home visit (according to patient preference)
3–10 days after being attended by paramedics. The
patient was phoned first to obtain consent. The patient
satisfaction questionnaire was then completed on behalf
of the patient by an independent surveyor who had no
links with the ambulance service. All patients were
informed of the purpose of the study by means of an
explanatory handout provided by paramedics and
announcements in local newspapers.
Some questions were common to both the ECP and
EAS groups, whereas others were directed specifically
to those who were transported to hospital or those who
were not.
The minimum age encountered was 14, so patients
could complete the survey themselves. Between the ages
of 82 and 95, eight patients (five EAS-treated and three
ECP-treated) were unwilling to participate as they were
satisfied with the service provided and did not see the
need for a survey. Four patients were intellectually dis-
abled and were excluded as they could not understand
the questions. There remained 50 patients in each group.
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EMA © 2012 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
Referrals and outcome for the 50 ECP-treated patients
were studied by examining electronic ED and general
practice records for 7 days following the assessment to
determine whether the patient sought unscheduled care
and to establish the nature of that care.
During the study period, the ambulance service
deployment plan required ECPs and EAS paramedics to
respond to the full range of clinical emergencies as
either resource could be unavailable for an immediate
response. A selective call system was not operated by
the communications centre at that time. The spectrum
of acuity in ECP-treated patients was therefore similar
to that in the group of patients attended by EAS
paramedics.
Answers were recorded electronically on an Excel
database (Microsoft, Redmond, WA, USA) and analysed
using PASW 18.0 (IBM, New York, NY, USA). Discrete
variables are presented as counts (percentages),
whereas continuous variables are presented as mean
(standard deviation). Comparison of discrete variables
was conducted using c2-test and continual variables
were compared using an unpaired t-test. The study was
designed to have an 80% chance of detecting a differ-
ence at P = 0.05 in the continuous variables between the
two groups of patients of 0.5 or greater.
This study was approved by the Central Regional
Ethics Committee of New Zealand (reference CEN/10/
07/027).
Results
The EAS group was 62% female, with a mean age of 55
(⫾21) years, whereas the ECP group was 56% female
and trended toward being older at a mean age of 68
(⫾17), although this did not reach statistical signifi-
cance (P = 0.07). There was no difference in ethnicity
between the two groups (the New Zealand European to
Maori ratio was 40:3 in the EAS-treated group and 41:4
in the ECP-treated group).
The responses to questions are summarized in
Tables 1–3. From questions put to all patients, it was
determined that both paramedic groups arrived in a
timely manner and that their clinical assessments were
deemed to be appropriate. Satisfaction with the care
provided was rated very highly (greater than 9/10).
However, ECP assessments and treatment took on
average 20 min longer than those of EAS crews (P <
0.0001).
Only eight EAS patients were treated at home and
not transported, rendering analysis of this group more
© 2012 The Authors
 Emergency care practitioners in New Zealand

Table 1. All patients

EAS ECP
1. How long did you wait after you had phoned 111 for the ambulance to arrive?
Too long 4/49 (8.2%) 2/50 (4%)
About right 39/49 (79.6%) 39/50 (78%) NS
Too fast 6/49 (12.2%) 9/50 (18%)
2. Approximately how long did the paramedic spend with you at your house?
Average time (min) 25 45 P < 0.0001
3. While you were being assessed at home, did you think that the paramedic was treating you in an appropriate way?
Yes 50/50 (100%) 50/50 (100%)
No 0/50 (0%) 0/50 (0%)
4. On a scale of 1 to 10, with 1 being completely unsatisfied and 10 being completely satisfied, how satisfied were you with the way
you were assessed in your home?
Average 9.7 ⫾ 1.4 9.4 ⫾ 0.7 NS
5. Did the paramedic(s) treat you at home or transport you?
Home 8/50 (16%) 38/50 (76%) P < 0.0001
EAS, emergency ambulance service paramedic; ECP, extended care paramedic; NS, not significant.

Table 2. Treated at home

EAS ECP
6. Was your treatment explained to you clearly?
Yes 8/8 (100%) 35/38 (92%)
No 0/8 0/38 NS
Don’t know 0/8 3/38 (8%)
7. Would you have preferred to be taken to hospital?
Yes 0/8 5/38 (13%)
NS
No 8/8 (100%) 33/38 (87%)
8. Had the paramedic explained to you what to do if you continued to feel unwell or got worse?
Yes 7/8 (88%) 32/38 (84%)
No 0/8 (0%) 1/38 (3%) NS
Don’t know 1/8 (13%) 5/38 (13%)
9. Did you need to go and see your GP or any other health professional about your condition within 1 week of your ambulance visit?
Yes 6/8 (75%) 9/38 (24%) P = 0.01
No 2/8 (25%) 29/38 (76%)
Don’t know 0/8 0/38
10. On a scale of 1 to 10, with 1 being completely unsatisfied and 10 being completely satisfied, how satisfied were you with the
standard of care you received from the paramedic(s)?
Average 9.5 ⫾ 0.9 9.6 ⫾ 0.5 P = 0.07
EAS, emergency ambulance service paramedic; ECP, extended care paramedic; GP, general practitioner; NS, not significant.

difficult. However, no patient managed at home thought
that their care had been inadequately explained by
either EAS or ECP staff.
Five of the 38 ECP patients treated at home would
have preferred to be taken to hospital, but the ECPs
determined that hospital admission was not required.
None of the eight EAS patients treated at home would
have preferred to be taken to the ED.
Of the patients left at home, more than 80% consid-
ered that they had been adequately advised regarding
the action to be taken if their condition failed to improve
(84% ECP, 88% EAS), and only one patient felt that
such advice was deficient. Twenty-four per cent (9/38)
of ECP-treated patients needed to see their general prac-
titioner (GP) within 1 week compared with the majority
(6/8) of the EAS patients. However, advice to see a GP
for review would be standard practice for both groups
of paramedics.
Only 11 ECP-treated patients were transferred to hos-
pital, and one was transported directly to the GP. Of

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EMA © 2012 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
 AH Swain et al.

Table 3. Transported to hospital

EAS ECP
11. Would you have preferred to be treated at home without having to go to hospital, if it was a possibility?
Yes 31/42 (73.8%) 5/11
No 7/42 (16.7%) 4/11 NS
Don’t know 4/42 (9.5%) 2/11
12. Did the paramedic clearly explain to you why you were being taken to hospital?
Yes 40/42 (95%) 11/11 (100%)
No 0/42 0/11 NS
Don’t know 2/42 (5%) 0/11
13. How comfortable were you during the ambulance journey to hospital (for those transferred by ambulance vehicle)?
Not comfortable 4/41 (10%) 0/8
Comfortable 3/41 (7%) 0/8 NS
Very comfortable 34/41 (83%) 8/8 (100%)
14. On a scale of 1 to 10, with 1 being completely unsatisfied and 10 being completely satisfied, how satisfied were you with the
standard of care you received from the paramedic(s)?
Average 9.8 ⫾ 0.7 9.8 ⫾ 0.7 NS
15. Approximately how long did you have to wait to be seen by a doctor at the hospital?
Average 1.6 h 1.25 h NS
16. How did you get home from the hospital?
Family member 31/42 (74%) 7/11
Friend 6/42 (14%) 3/11
Taxi 3/42 (7%) 1/11
Public transport 2/42 (5%) 0/11
17. On a scale of 1 to 10, with 1 being completely unsatisfied and 10 being completely satisfied, how satisfied were you with the
standard of care you received from the hospital?
Average 9.0 ⫾ 1.1 9.4 ⫾ 1.2 NS
EAS, emergency ambulance service paramedic; ECP, extended care paramedic; NS, not significant.

those transported by the EAS, 73.8% (31/42) would Table 4. Outcomes for 50 extended care paramedic-treated
have preferred to be treated at home. All transported patients
patients with the exception of two in the EAS group Group n Breakdown
thought that the reasons for transferring them to hospi-
tal had been clearly explained. The journey was com- Transported to 11 Hospital admissions = 4
the ED ED treatment and discharge = 6
fortable for all patients with the exception of four in the
ED assessment and discharge = 1
EAS category. Although it appears that UCC patients Transported to 1
were seen by a doctor slightly earlier in the ED and the GP
spent less time there, the differences did not reach sta- Treated at home 38 GP review = 8
tistical significance. GP attendance for different condition = 2
Transported patients scored the standard of care pro- GP phone consultation = 2
vided by both paramedic groups very highly at 9.8/10, Midwife review = 1
and there was no significant difference in the satisfaction GP, general practitioner.
levels of patients treated at home or in hospital. Those
who were treated at home were equally well satisfied
with the standard of care provided by both UCC and EAS
paramedics (who scored 9.6/10 and 9.5/10, respectively). original condition, and one was seen by a midwife.
Perusal of the general practice records for 1 week after
the paramedic assessment revealed no complication or
Outcome morbidity arising from ECP care during this period.
There was only one unscheduled ED attendance
This is summarized in Table 4. Of the 38 patients treated within 7 days for a patient treated at home. This occurred
at home by ECPs, eight were reviewed by the GP for their 4 days after the ECP documented that the patient was

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EMA © 2012 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
 Emergency care practitioners in New Zealand

Table 5. Provisional diagnoses for extended care paramedic- Discussion

managed patients
Treated at home It is gratifying that patients in the Kapiti District were
Mechanical fall – no injury ¥4 equally satisfied with the care provided by either ECP
Low back injury ¥4 or EAS paramedics. Both groups of ambulance staff
Soft tissue injuries ¥3 arrived in a timely manner, undertook appropriate clini-
Mild allergic reaction ¥2 cal assessments and generated high satisfaction ratings
Hyperventilation, anxiety ¥2 for the care they administered. No patient felt that their
Gastroenteritis ¥2 care had been inadequately explained and only one of
Postural hypotension ¥2
the total of 100 patients considered that clinical advice
Migraine ¥2
Epistaxis ¥2
given by any paramedic was deficient.
Mild dehydration Extended care paramedics spent on average an extra
Acute asthma 20 min with each patient. This can be attributed to the
Air in i.v. line more comprehensive clinical assessment they are
Hypotension – other trained to apply, which is based on a medical model.
Hypertension Although longer paramedic assessments can tie up
Accidental overdose, non-toxic ambulance resources, they generate benefit by reducing
Neck spasm the number of patient transfers to the ED 55 km (34
Minor injury – assault miles) distant, a transfer time by road of 45–60 min.
Alcohol intoxication Overall, the duration of paramedic contact time with
Elbow bursitis
each patient is reduced.
Pleuritic chest pain
Syncope – vasovagal
In the first 6 months of operation, 38 % of patients
Viral infection – sinusitis seen by ECPs required transfer to hospital from the
Side-effect of drugs – lethargy Kapiti District compared with 63% of those seen by
Nausea standard paramedics.1 Similar results have been
Transported to the ED reported from the UK.6 A reduction in hospital transfers
Abdominal pain ¥4 is not only beneficial for ED and ambulance service
Chest pain ¥2 workloads; it would also have been the preference of
Cellulitis of hand secondary to cat bite 74% of patients transported to hospital by standard
Bowel obstruction EAS paramedics in this study.
Urinary retention and faecal incontinence Although the average waiting time to be seen by a
TIA secondary to AF doctor in the ED was significant, patients were not
Ectopic pregnancy dissatisfied with that service overall, scoring it at 9 to
AF, atrial fibrillation; TIA, transient ischaemic attack. 9.4/10. However, free-text questions indicated that there
were frustrations arranging private transport back to
Kapiti District, and some patients felt that the ED
anxious and hyperventilating following a possible nurses they encountered were impolite or dismissive.
seizure. Hospital records indicate that the patient had The latter has been attributed to work pressures in
been an unstable epileptic since May 2010, was under the the ED which, together with the discomfort of the ambu-
care of a neurologist, and was having complex partial lance journey described by 10% of EAS patients,
seizures every 1–2 weeks. Following her transfer to the reinforces the argument in favour of providing good
ED, she was not admitted to hospital and was discharged local ECP care to reduce unnecessary transfers to
to be reviewed in the neurology clinic. hospital.
All direct ED referrals made by the ECPs were con- Of the patients left at home by both groups of para-
sidered appropriate by an emergency medicine special- medics, significantly fewer of those treated by ECPs
ist. Four of these patients were admitted to hospital, six needed to consult their GP within 7 days. However, 16%
required ED treatment before discharge, and one needed (6/38) of ECP-treated patients were uncertain or
ED assessment only. unaware of what to do if their condition worsened.
The range of clinical presentations encountered by Although ECP records invariably document such
ECPs and the disposition of their patients is summa- advice, it is clear that verbal advice is either not being
rized in Table 5. conveyed effectively or recalled by the patient. This is

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EMA © 2012 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
 AH Swain et al.
an important learning point indicating that advice given
to some patients needs to be reinforced.
Telephone surveys of ambulance patients7 are rarely
reported, but this study achieved a very high response
rate. Postal questionnaires have generated response
rates of 37–40%8 and 54%,5 but telephone surveys have
also been associated with a response rate of only 50%.7
We are grateful to the patients of the Kapiti District for
their willingness to answer the questions put to them.
A comparable study of patient satisfaction with EAS
and ECP crews in London5 reported overall satisfaction
of 79% with both groups, but less than half rated expla-
nations or the information provided by EAS or ECP
staff as ‘very positive’. The thoroughness of examina-
tion was also ‘very positive’ for only 65% of the ECP-
treated patients. These authors commented on their
modest response rate and some delay between para-
medic care and the postal survey, a problem that our
local and more contained study avoided.
Only one patient made an unscheduled visit to the ED
following treatment by an ECP. She suffered from
refractory complex partial epilepsy and was discharged
to her GP without treatment. Review of the ED and
general practice records for the 50 ECP-treated patients
revealed no other complication or morbidity arising
within 1 week of the ECP’s visit.
Paramedic practitioner initiatives similar to that in
Kapiti have been introduced in some parts of Australia,
but not necessarily sustained.9 Concerns have been
expressed regarding clinical safety, but in 2.5 years of
the UCC service, there have been only three reportable
events: a case of compartment syndrome diagnosed by
the ECP but discharged by the orthopaedic doctor, a
head injury without loss of consciousness or impair-
ment that produced bloody otorrhoea 5 days later, and a
case of vertigo with delayed onset of central symptoms.
Safety nets include options to revisit the patient at home
and direct communication with the ED or GP to whom
the clinical records are automatically transmitted.
Although our study examined a small sample of
patients, no clinical deficiencies could be identified in
the ECP-managed cohort, and the study of patient out-
comes will be repeated in a larger sample.
Conclusion
This study confirms that patients are very satisfied
with the care provided by ECPs in our region. A review
of ED and general practice records for 50 ECP-treated
patients confirmed that no adverse outcomes arose
180
EMA © 2012 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
during the first week following patient assessment. In
the light of the other benefits of this model of care, we
would encourage funders to develop, trial and evaluate
such models throughout New Zealand.
Acknowledgements
MAS thanks the Wellington Medical Research Founda-
tion for sponsorship of her summer studentship. The
authors acknowledge the assistance of Hayley Cameron,
Clinical Administrator at Wellington Free Ambulance,
who provided data on Kapiti patients. They also thank
Paul Fake, UCC Manager, and all patients who were
kind enough to contribute to the study.
Competing interests
None declared.
Accepted 30 November 2011
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