Evidence matters

Emergency care without the emergency department: Treat and release programs

By Sarah Garland

Hospital emergency rooms are overcrowded, and ambulance services are stretched thin. Recent news articles have raised the issue that some cities or regions have gone for periods of time without any ambulances available, as paramedics must stay with patients as they are transferred to emergency departments. An aging population, increase in chronic and complex illnesses, high volumes of minor issues, along with health care worker shortages have led to a problem with emergency room overcrowding. While this was a problem before COVID, the pandemic has only exacerbated this.

Emergency room overcrowding is difficult for both health care workers and for patients. For staff it can mean increased stress, but it can also increase rates of violence towards health care workers. For people requiring care, it can mean increased length of stay, risk of medication errors, return trips to the hospital, decreased satisfaction with care, and an increased risk of poor health outcomes or death.

One proposed solution to help address overcrowded emergency rooms and ambulance shortages is “treat and release” programs. This is when a person receives emergency medical services at the scene and is not transferred to a hospital emergency room.

But do treat and release programs work? Are they safe? What kinds of injury and illness can be treated this way? CADTH – an independent agency that finds, assesses, and summarizes the research on drugs, medical devices, tests, and procedures – looked into what evidence there is about treat and release programs.

CADTH looked for studies that explored the use of treat and release programs for non-urgent or semi-urgent conditions. One health technology assessment (HTA) (which included 1 randomized controlled trial and economic evaluation) and 2 non-randomized studies were found. These studies included people who had a low blood sugar event (hypoglycemia), heat stroke, or experienced a fall.

For those with low blood sugar, with or without diabetes, people who were treated by paramedics but were not transported to hospital were compared with those who went to hospital after their initial treatment by paramedics. The researchers looked at how many people accessed health care services after their initial paramedic call. There was no difference, after 3 days, between those who were not transported to hospital, and those who were.

For those who had heat stroke – while running a half-marathon – the people treated onsite were compared with those who were immediately transported to hospital. The researchers for this study looked at mortality (no one from either group died) and hospital admissions. They reported that 60 per cent of people who were transported immediately to hospital ultimately had to be admitted to hospital, while 41 per cent of people treated onsite ultimately had to be admitted.

CADTH also found a study that looked at treat and release programs for older people who have experienced a fall. People who were cared for under the treat and release program, when compared with those transferred to emergency departments, were often more satisfied with their care and were less likely to be at risk for future falls or fractures. They also had fewer repeat calls to emergency services, compared with those taken to the emergency department.

The study that looked at treat and release programs for people who experienced a fall, also considered the cost-effectiveness of these programs. While it’s hard to know how applicable the findings are to a Canadian context (the study was out of the UK), the study authors found the cost-effectiveness analysis of the treat and release program to be inconclusive, as the costs and benefits of the program and usual care were similar.

Overall, according to the studies CADTH found, treat and release programs appear to be as good as, or better than, usual care. However, CADTH only found studies that looked at treat and release programs for people who had experienced a fall, heat stroke, or hypoglycemia – it’s not certain how safe and effective treat and release programs are for other conditions. More research on this topic could help improve our understanding of the effectiveness of these programs and how they can best be used.

CADTH’s review of treat and release programs is freely available on the CADTH website at https:// www.cadth.ca/treat-and-release-patients-requiring-emergency-medical-services. To learn more about CADTH, you can visit our website, or follow us on Twitter @CADTH_ACMTS, or speak to a Liaison Officer in your region: cadth.ca/contact-us/liaison-officers. ■ H

DO TREAT AND RELEASE PROGRAMS WORK? ARE THEY SAFE? WHAT KINDS OF INJURY AND ILLNESS CAN BE TREATED THIS WAY?