Trends in paramedic-to-general practitioner referrals following the COVID-19 pandemic and the introduction of a virtual emergency department: An interrupted time series analysis

Objectives: We aimed to evaluate the impact of the COVID-19 pandemic and subsequent introduction of the Victorian Virtual Emergency Department (VVED) consultation service for paramedics on paramedic-to-general practitioner (GP) referral patterns, case time burden and ambulance reattendance rates. Methods: We conducted interrupted time series regression assessing paramedic-to-GP referrals with the following two interruptions: (1) the COVID-19 pandemic in March 2020 and (2) VVED integration in July 2022. We included ambulance patients between 2018 and 2023 across Victoria, Australia. Results: A total 3 205 562 patients across 65 months were included; 38.7% presented in the 26 months prior to the beginning of the COVID-19 pandemic (n=1 239 975), 43.8% between March 2020 and June 2022 (n=1 403 139) and 17.6% in the 11 months after VVED implementation (n=562 448). There was no step change in paramedic-to-GP referrals associated with the COVID-19 pandemic, although a 3% relative monthly trend increase in referrals to GP occurred (incident rate ratio (IRR) 1.03, 95% CI 1.02 to 1.04). Subsequent VVED integration was associated with a -16% relative step change in referrals to GPs (IRR 0.84, 95% CI 0.74 to 0.96); however, no trend change was observed. Median case time burden increased throughout the study by 0.52 min per month (median difference 0.52 min, 95% CI 0.51 to 0.52). At the study period conclusion, EMS attendances resulting in GP referrals had a 40 min median case cycle duration, compared with 120 min for ED conveyances. Ambulance 7-day reattendance rates were similar between those referred to VVED (8.8%) vs GPs (8.7%). Conclusions: The COVID-19 pandemic was associated with increased paramedic-to-GP referrals in lieu of ambulance conveyances. The VVED was associated with an initial decrease in paramedic-to-GP referrals; however, the trend of increasing GP referrals continued. paramedic-to-GP referrals consumed a third of the time burden associated with ambulance conveyance to ED.