Community emergency medicine: a service review of patients that sustain head injuries in the community—can early intervention by a senior clinical decision maker provide care closer to home?

The Aneurin Bevan University Health Board’s Physician Response Unit (PRU) comprises a physician-paramedic team that brings senior emergency medicine physician (EMP) (consultant/senior registrar) decision-making to patients’ homes.1 It covers 1533 km2 of rural and urban areas in Southeast Wales, serving a population of 600 000, operating 09:00–17:00 5 days a week with cover on alternate weekends. The team either self-tasks based on call handler information available on the list of waiting 999 calls or responds to requests from ambulance crews. The team seeks to identify patients requiring clinical care beyond the scope of paramedics, who can safely remain in the community, avoiding an emergency department (ED) attendance for appropriate patients.2 Patients with head injuries, often older and anticoagulated, are frequently attended. EMPs were empowered to manage anticoagulated patients at home within updated (May 2023) National Institute for Health and Care Excellence guidelines,3 which state ‘consider’ rather than ‘complete’ a CT head in this cohort. Until July 2024, however, under Joint Royal Colleges Ambulance Liaison Committee (JRCALC) guidelines, these patients attended by paramedics were likely to be conveyed to an ED; at this time, paramedics were allowed to take a more flexible and holistic approach.4 This review aims to evaluate the safety of head injury assessments by the PRU in adult patients (18+ years) prior to the changes in the JRCALC guidelines. All adults were included to represent a realistic case load, but the expectation was that older patients would comprise the significant majority.