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The role of Advanced Paramedic Practitioner (APP) specialising in Urgent Care is a new and developing role within the London Ambulance Service (LAS). While an APP currently has an undefined role nationally (Walmsley and Turner, 2015) the overarching vision of the programme is to provide advanced clinical assessment for patients with complex health conditions. Ambulance services are seen as pivotal to the wider health system however there is no clear pathway to integration (Committee of Public Accounts, 2017). The APP programme is helping the LAS forge a legitimate pathway through greater inter professional collaboration while promoting professional autonomy. This paper will review the assessment made by an APP in relation to a 72 year old lady who presented with breathlessness secondary to swollen legs.
Background and Rationale
Research has shown that approximately 10% of emergency calls to 999 are for life threatening complaints (Evans et al 2013) and 75% of total patient consultations involve only an assessment (AACE, 2011). Despite these figures only 16.3% are treated via an alternative care pathway (NAO, 2013). The LAS were the worst performing ambulance service in this respect, clearly suggestive of a huge opportunity for an APP to impact on unnecessary conveyance and ease the burden on the emergency department (NAO, 2017).
The APPs are typically tasked to patients with non-specific symptoms where in depth assessment is imperative for a reasoned, but ultimately safe, outcome. Swollen legs, as described by the patient, is the layman term for peripheral oedema and is defined as an increase in the volume of interstitial fluid resulting in palpable swelling (Ely et al, 2006). Peripheral oedema is recognised as a non-specific symptom with multiple etiologies ranging from trivial to life changing (Cho and Atwood, 2012). Venous insufficiency is the most common cause while heart failure is also often responsible (Thaler et al, 2015). Approximately 75% of patients discharged from hospital with a heart failure diagnosis had peripheral oedema, identifying a clear link and important causation (Shoaib et al, 2016). Treatment typically consists of diuretic medication without significant investigation, a twofold problem that leads to missed diagnoses and physical consequences. Sloane (2008) recognises that premature closure is a typical human trait where we ignore non confirmatory facts. Consequently it is easy to presume heart failure is the cause of a patient’s oedema however Wurez and Meador (1992) highlighted an increased mortality rate for patients incorrectly treated for heart failure in the pre hospital setting. While this study is outdated it does underline the detrimental impact of poor assessment and decision making.