Paramedic Care Research Articles

Clinical reasoning amongst paramedics using nebulised β₂ agonists to treat acute asthma exacerbations: a qualitative study

The heterogeneous nature of asthma results in a wide range of presentations during exacerbation. Despite UK pre-hospital management guidelines focusing on β₂ agonists, variables such as cause, severity, underlying health, comorbidities, and drug side effects can often make emergency treatment optimisation difficult. This article examines paramedics’ methods of observing, perceiving, interpreting, and treating asthma with β₂ agonists, often acting on limited information in rapidly evolving situations. We recruited paramedics from a single UK National Health Service ambulance Trust for qualitative semi-structured interviews. Responses underwent framework analysis to identify data similarities and differences. Fifteen qualitative interviews with paramedics revealed three main themes affecting patient management: clinician experience of presentation, adaptation of patient management approaches, and severity of side effects. Paramedics felt their ability to manage various asthma presentations was enhanced through guideline adaptation based on their own clinical experience and understanding of β₂ agonist side effects, allowing tailored responses based on a set of reinforcing factors. Inductive analysis revealed additional complexities within these themes, such as anxiety and diabetes, which may influence β₂ agonist administration and result in multiple care pathways being initiated during exacerbation. Paramedic care mirrors asthma’s complexity, accounting for a range of characteristics. A dynamic, critically thought approach enables patient management to be based on the presenting conditions rather than strict adherence to a single algorithm. Comprehending the complexities and variables in treatment can be crucial to how paramedics rationalise their treatment and optimise the care provided.

Qualitative Research of Nursing Services

A higher percentage of First Nations patients compared to non-First Nations patients come by ambulance to Saudi emergency rooms, according to previous research. The researchers set out to learn how First Nations people saw paramedic transitions in care and how paramedics see serving First Nations communities. Researchers used purposive sampling techniques based on author connections, preexisting ties, and familiarity with the Saudi paramedicine system to recruit participants for this qualitative participatory research. In order to find and invite First Nations participants, members of the study team reached out to First Nations community organisations. In July 2023, the Saudi First Nations Information Governance Centre used Zoom to host four virtual sharing circles. The information gathered from the sharing circles was subjected to a Western thematic analysis. Indigenous scholars examined the data. Each of the four sharing circles, which lasted between sixty-seven and eighty-eight minutes, drew 48 people. Each circle had eight to fourteen members. Racism, system impediments, and potential remedies were the three main topics that emerged. Participants from First Nations communities experienced racial prejudice and stereotyping from paramedics and emergency department workers due to their perceived drug abuse and misuse of paramedic services. Paramedic care was often necessary for First Nations patients because they did not have other treatment alternatives or because they were afraid of discrimination or did not know how they would go home after receiving treatment.

Paramedics Providing Palliative Care at Home: A Retrospective Cohort Study Comparing Symptom Management of Breathlessness and Pain in Cancer Versus Non-Cancer Conditions.

Background Palliative care aims to alleviate pain and distressing symptoms, affirm life, and offer support to patients and their caregivers. For many, the expressed preference is to die at home. As a result, there is growing recognition that paramedics can play an integral role at the end of life for symptom relief. Paramedic comfort with symptom management in the palliative care context is suspected, based on past work, to be higher for cancer as opposed to non-cancer life advanced disease. The objective of this study was to explore the paramedic management of patients with cancer and non-cancer advanced disease, using pain and breathlessness as key symptoms. Methods A retrospective cohort study was conducted. Paramedic electronic patient care records were queried for calls with palliative goals of care between July 1, 2015, and June 30, 2016, in Nova Scotia, Canada, which was the first year of the Paramedics Providing Palliative Care program. A manual chart review of a subgroup of 100 consecutive charts was completed to gain deeper insight. A descriptive analysis was conducted to understand practice variation within this population. Results The electronic query returned 1909 calls with a palliative approach. A total of 765 (40.1%) had cancer. The most common non-cancer disease category was respiratory. The top chief complaint was respiratory distress in both cancer and non-cancer populations. Medication was administered more often for pain (80%) compared to breathlessness (46.5%). Paramedics were more likely to call Medical Oversight Physicians for pain control advice. Post-treatment pain scores were documented infrequently. In the chart review, symptom management using the patient's own medications occurred in 17% of cases while an additional 5% of cases involved a combination of the patient's medications and paramedic service formulary. Conclusion The non-cancer population was less likely to have a non-transport outcome. Opportunities for improvement of symptom management were noted for pain and particularly so for breathlessness. Increased comfort with a palliative approach in the non-cancer disease cohort as well as with this key symptom will be a key to the success of the program.

Paramedicine research with family and bystanders: A methodological review

The evolving nature of paramedic care has resulted in a growing body of evidence considering service user experience, including the experiences of patients, family members and bystanders. As new areas of research enquiry emerge in paramedicine, it is important to review the methods, methodologies, and quality of evidence in these topic areas. A methodological review was conducted of peer-reviewed empirical studies reporting on family and bystander experiences where emergency ambulance services responded. Descriptive statistics were calculated to describe select study characteristics. Study quality was appraised using the Johanna Briggs Institute Checklist for Qualitative Research and the Mixed Method Appraisal Tool. Service user engagement was evaluated using a newly adapted tool, the Service User Engagement Ladder. After searching five databases, 37 studies of varying research designs were included in this review. While overall study quality was high, there was a notable absence of theoretical discussion, particularly regarding qualitative methodologies. In assessing service user engagement, family and bystanders had very low levels of engagement in the research process. Only one study in this review utilised methods where co-construction of research occurred. Current research is dominated by Western study locations and biomedical paradigms that privilege Westernised populations and ways of considering experience, ignoring the preferences and experiences of Indigenous people and people from minoritised ethnic groups. To further develop paramedicine research involving family and bystanders, transparent reporting around the theoretical underpinnings of research must be strengthened. There is a significant opportunity to increase service user engagement in the research process. Greater attention to cultural and ethnic diversity is needed in researching family and bystander experiences.

Exploring paramedic care for First Nations in Alberta: a qualitative study

Exploring paramedic care for First Nations in Alberta: a qualitative study

The hospital care and outcomes of long-term care patients treated by paramedics during an emergency call: exploring the potential impact of 'treat-and-refer' pathways and community paramedicine.

Adults living in long-term care (LTC) are at increased risk of harm when transferred to the emergency department (ED), and programs targeting treatment on-site are increasing. We examined characteristics, clinical course, and disposition of LTC patients transported to the ED to examine the potential impact of alternative models of paramedic care for LTC patients. We conducted a health records review of paramedic and ED records between April 1, 2016, and March 31, 2017. We included emergency calls originating from LTC centers and patients transported to either ED campus of The Ottawa Hospital. We excluded scheduled or deferrable transfers, and patients with Canadian Triage and Acuity Scale of 1. We categorized patients into groups based on care they received in the ED. We calculated standardized differences to examine differences between groups. We identified four groups: (1) patients requiring no treatment or diagnostics in the ED (7.9%); (2) patients receiving ED treatment within current paramedic directives and no diagnostics (3.2%); (3) patients requiring diagnostics or ED care outside current paramedic directives (54.9%); and (4) patients requiring admission (34.1%). This study found 7.9% of LTC patients transported to the ED did not receive diagnostics, medications, or treatment, and overall 11.1% of patients could have been treated by paramedics within current medical directives using 'treat-and-refer' pathways. This group could potentially expand utilizing community paramedics with expanded scopes of practice.

Ambulance ramping predicts poor mental health of paramedics.

Ambulance ramping involves a patient remaining under paramedic care until a hospital emergency department bed becomes available. This study examined whether negative ramping experiences (verbal abuse, physical abuse, compromised patient care, and patient fatality) contribute to relatively high levels of depression, anxiety, stress, and posttraumatic stress disorder (PTSD) in paramedics. Ninety Australian paramedics (Mage = 37.68, SD = 10.73; 52.2% male) completed an online survey. Path analysis found that negative ramping experiences were positively associated with symptoms of depression, anxiety, stress, and PTSD. Interactions indicated that negative ramping experiences predicted greater depression, stress, and PTSD among paramedics with higher, but not lower, work-related self-efficacy. All interactions with resilience were nonsignificant. These findings suggest that policymakers should aim to reduce ambulance ramping, and that future research could fruitfully investigate the mental health benefits of training programs that include strategies to minimize paramedics' feelings of powerlessness, frustration, and self-blame, during ramping. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Out-of-Hospital emergency airway management practices: A nationwide observational study from Aotearoa New Zealand

Background and ObjectivesAirway management is crucial for emergency care in critically ill patients outside the hospital setting. An Airway Registry is useful in providing essential information for quality improvement purposes. Therefore, this study aimed to develop an out-of-hospital airway registry and describe airway management practices in Aotearoa New Zealand (AoNZ). MethodsData from the Aotearoa New Zealand Paramedic Care Collection (ANZPaCC) database were used in a retrospective cohort study covering July 2020 to June 2021. All patients receiving airway interventions were included. An airway intervention was defined as one or more of the following: non-drug assisted endotracheal intubation (NDA-ETI), drug-assisted endotracheal intubation (DA-ETI; where a combination of paralytic agent and sedative were used to aid in intubation), laryngeal mask airway (LMA), oropharyngeal airway (OPA), nasopharyngeal airway (NPA), surgical airway (cricothyroidotomy), suction, jaw thrust. Descriptive statistics were analysed using Chi-Square and logistic regression modelling investigated the relationship between advanced airway success and patient characteristics. ResultsThe study included 4,529 patients who underwent 7,779 airway interventions. Basic airway interventions were used most frequently: OPA (45.1%), NPA (29.3%), LMA (28.9%), suction (19.9%) and jaw thrust (17.6%). Advanced airway interventions were used less frequently: NDA-ETI (19.8%), DA-ETI (8.7%), and surgical airways (0.2%). The success rate for ETI (including both NDA-ETI and DA-ETI) was 89.4%, with NDA-ETI success at 85.8% and DA-ETI success at 97.7%. ETI first-pass success rates were significantly lower for males (aOR 0.65, 95%CI 0.48–0.87, p < 0.001) and higher for non-cardiac arrest injury patients (aOR 2.94, 95%CI 1.43–6.00, p < 0.001). In this cohort receiving airway interventions the 1-day mortality rate was 41.1%, demonstrating that a high proportion of these patients were severely clinically compromised. ConclusionsOut-of-hospital airway management practices and success rates in AoNZ are comparable to those elsewhere. This research has determined the variables to be used as the AoNZ Paramedic Airway Registry ongoing and has demonstrated baseline outcomes in airway management for ongoing quality improvement using this registry.

The Benefit of YouTube Videos as a Source of Information on Tinnitus for Patients.

Introduction Tinnitus is one of the most common otological complaints encountered. Patients often use the internet, especially YouTube videos, as a source of information regarding their health condition. There is a need to analyze the standard and quality of information in these videos so that the patients receive correct information. Objective The purpose of the present study was to evaluate the reliability and utility of YouTube videos on tinnitus. Methods The first 100 videos on YouTube using the search terms tinnitus and ringing in the ear were identified. Three subject experts assessed the reliability using the modified five-point DISCERN score and utility using a usefulness score. Various indices like view ratio, like ratio, video power index, and interaction index were also calculated. Results Out of the 100 videos selected, 34 were excluded; collectively the remaining 66 videos were viewed 12,797,730 times. The most common upload sources were hospital/physician (39%), paramedic health care providers (19%), and alternative medicine (19%). The discern score was the highest in hospital/physician group (mean 19.3) and lowest in patient experience group (mean 13.4). A negative correlation was observed between the number of views (correlation coefficient -0.214), number of likes (correlation coefficient -0.242), number of comments (correlation coefficient -0.242), and the usefulness score. Conclusion Although there are multiple videos on YouTube regarding tinnitus, the overall educational content and reliability of the videos are poor. Video popularity is not associated with usefulness. Healthcare providers should counsel patients regarding videos on YouTube and try to create more comprehensive videos.

Lost in translation? Information quality in pediatric pre-hospital medical emergencies with a language barrier in Germany

BackgroundIn pediatric medical emergencies, paramedics and emergency physicians must often rely on the information of third parties, often caregivers, to gather information. Failing to obtain relevant information may lead to misinterpretation of symptoms and subsequent errors in decision making and clinical treatment. Thus, children and/or caregivers with limited proficiency of the locally spoken language may be at risk for medical errors. This study analyzes logs of rescue missions to determine whether paramedics could obtain essential information from German-speaking and foreign-language children and their caregivers.MethodsWe conducted a secondary data analysis based on retrospective data on pediatric patients of four emergency medical services (EMS) stations in Northern Germany. We defined language discordance with communication difficulties as main exposure. We used documentation quality as outcome defined as existing information on (a) pre-existing conditions, (b) current medication, and (c) events prior to the medical emergency. Statistical analyses include descriptive statistics, simple regression and multivariable regression. As multivariable regression model, a logistic regression was applied with documentation quality as dependent variable and language discordance with communication difficulties as independent variable adjusted for age, sex and Glasgow Coma Scale (GCS).ResultsData from 1,430 pediatric rescue missions were analyzed with 3.1% (n = 45) having a language discordance with communication difficulties. Patients in the pediatric foreign-language group were younger compared to German-speaking patients. Thorough documentation was more frequent in German-speaking patients than in patients in the foreign-language group. Pre-existing conditions and events prior to the medical emergency were considerably more often documented in German-speaking than for foreign-language patients. Documentation of medication did not differ between these groups. The adjustment of sex, age and GCS in the multivariable analysis did not change the results.ConclusionLanguage barriers are hindering paramedics to obtain relevant information in pediatric pre-hospital emergencies. This jeopardizes the safe provision of paramedic care to children who themselves or their caregivers are not fluent in German language. Further research should focus on feasible ways to overcome language barriers in pre-hospital emergencies.Trial registrationThis is a retrospective secondary data analysis of a study that was registered at the German Clinical Trials Register (No. DRKS00016719), 08/02/2019.

Overcoming Language Barriers in Paramedic Care With an App Designed to Improve Communication With Foreign-Language Patients: Nonrandomized Controlled Pilot Study

Communication across language barriers is a particular challenge for health care providers. In emergency medical services, interpreters are mostly not available on rescue scenes, which jeopardizes safe and high-quality medical care. In a cocreative process together with paramedics and software designers, we developed a fixed-phrase translation app with 600 phrases and 18 supported languages that supports paramedics when providing care to foreign-language patients. This paper reports on the results of a pilot study to evaluate the app's effect on paramedic-patient communication. This study aims to gain insights into the efficacy and feasibility of a multilingual app that helps paramedics to communicate with patients who are not proficient in the local language. A 3-armed nonrandomized interventional pilot study was conducted in 4 rescue stations in the German Federal State of Lower Saxony: 3 rural areas and 1 in urban environment. The intervention group comprised rescue missions with patients with limited German language proficiency (LGP) with whom the app was used; control group 1 comprised LGP patients without app usage; and control group 2 consisted of rescue missions with German-speaking patients. For each rescue operation with LGP patients, paramedics filled out questionnaires about the communications with patients. From standardized Rescue Service Case Protocols, we extracted information on patient demographics (age and sex), clinical aspects (preliminary diagnosis and Glasgow Coma Scale), and rescue operation characteristics (time spent on emergency scene and additional dispatch of emergency physicians). The primary outcome was the paramedics' perceived quality of communication with LGP patients. The secondary outcome was the ability to obtain necessary information from patients and the ability to provide important information to patients. A linear regression model was applied to assess the impact of the app on perceived communication, controlling demographic factors, and severity of illness. A total of 22 LGP patients were recruited into the intervention group and 122 into control group 1. The control group 2 included 27,212 German-speaking patients. LGP patients were more than 2 decades younger than German-speaking patients. App usage among LGP patients was associated with higher perceived overall quality of communication (0.7 points on a 5-point Likert scale, P=.03). Applying a linear regression model controlling for age, sex, and Glasgow Coma Scale, the quality of communication was associated with an increase of 0.9 points (95% CI 0.2-1.6, P=.01). Compared to either German-speaking patients or LGP patients, paramedics spent 6-7 minutes longer on an emergency scene when the app was used (P=.24). The use of the app suggests a relevant improvement in communication with patients with limited proficiency in the locally spoken language in paramedic care. The small sample size and the lack of randomization reduce the generalizability of the findings. German Clinical Trials Register DRKS00016719; https://drks.de/search/de/trial/DRKS00016719.

Air Medical Support for a Peripheral Hospital in Southern Israel: An Evolving Role for the Air Ambulance and Emergency Department Clinicians

The early use of helicopters on the battlefields of Korea and Vietnam led to the introduction of “air ambulances” into civilian practice. Initially, these aircraft were tasked to retrieve casualties and provide conventional paramedic care at the scene and en route to the hospital. The introduction of advanced medical teams on helicopters led to the evolution of helicopter emergency medical service units. Yoseftal Hospital is a 65-bed hospital serving the town of Eilat in southern Israel. It does not offer full intensive care or specialist services but does provide general surgical, medical, pediatric, and psychiatric services. The hospital is 100 km from the nearest tertiary center in Be'er Sheva, an ambulance journey of 2 hours across desert. The hospital serves a population of 70,000 residents and up to 500,000 tourists. Recognizing the need to provide a facility to transfer critical or complex patients, in August 2021, the Israeli Ministry of Health provided a dedicated helicopter to Yoseftal Hospital. The first 100 missions are presented. Forty-four missions were for cardiac presentations. For patients with ST-segment elevation myocardial infarction, the median time from the initial medical contact at Yoseftal to reception at the tertiary center was 141 minutes. Other transfers were for ear, nose, and throat (2); neurosurgical (14); trauma (9); respiratory (6); obstetrics and gynecology (3); and pediatric services (14) and nontraumatic surgical emergencies (15). Our experience validates the need for this resource and highlights the importance of robust clinical, operational, and transfer protocols between Yoseftal and the receiving specialist units. The challenging and diverse clinical activity requires additional skills and competencies for the critical care paramedics on the aircraft. Integrating the flight crew into the emergency department team facilitated early activation of the aircraft and expedited patient preparation for flight. Our experience describes an evolving new role for the helicopter—support for a remote peripheral hospital.

Mobile Integrated Health Interventions for Older Adults: A Systematic Review.

Mobile integrated health (MIH) interventions have not been well described in older adult populations. The objective of this systematic review was to evaluate the characteristics and effectiveness of MIH programs on health-related outcomes among older adults. We searched Ovid MEDLINE, Ovid EMBASE, CINAHL, AgeLine, Social Work Abstracts, and The Cochrane Library through June 2021 for randomized controlled trials or cohort studies evaluating MIH among adults aged 65 and older in the general community. Studies were screened for eligibility against predefined inclusion/exclusion criteria. Using at least 2 independent reviewers, quality was appraised using the Downs and Black checklist and study characteristics and findings were synthesized and evaluated for potential bias. Screening of 2,160 records identified 15 studies. The mean age of participants was 67 years. The MIH interventions varied in their focus, community paramedic training, types of assessments and interventions delivered, physician oversight, use of telemedicine, and post-visit follow-up. Studies reported significant reductions in emergency call volume (5 studies) and immediate emergency department (ED) transports (3 studies). The 3 studies examining subsequent ED visits and 4 studies examining readmission rates reported mixed results. Studies reported low adverse event rates (5 studies), high patient and provider satisfaction (5 studies), and costs equivalent to or less than usual paramedic care (3 studies). There is wide variability in MIH provider training, program coordination, and quality-based metrics, creating heterogeneity that make definitive conclusions challenging. Nonetheless, studies suggest MIH reduces emergency call volume and ED transport rates while improving patient experience and reducing overall health care costs.

Developing Cultural Competence In Paramedic Education: An Analysis of Culturally Diverse Training Equipment Amongst Universities In Australia And New Zealand

Aim: This study aims to identify the availability of culturally diverse training equipment across approved paramedicine undergraduate degrees in Australia and New Zealand and explore its impact on a university’s ability to teach paramedic care that is culturally safe and competent. Methodology: Academic staff from 16 university accredited paramedicine programs across Australia and New Zealand were invited to complete an online survey about their access to culturally diverse training equipment and their ability to teach culturally competent paramedic care. Responses were then summarised in tables. Results: There were a total of 14 responses. The total number of students enrolled in each program ranged from &lt;100 - &gt;500. There are a total of at least 140 ALS manikin, only twelve (n=12) identified as reflecting people of colour. In addition to this, there were 145 cannulation arms, 27 (n=27) were identified as being of colour. Most respondents believed that their university developed emerging skills in culturally competent paramedic care. Conclusion: Access to culturally diverse training equipment across Australian and New Zealand universities is limited. Access to culturally diverse training equipment impacts a university’s ability to teach paramedicine students culturally safe practice through simulation-based learning. Greater access to culturally diverse equipment plays an important role in a university’s ability to make students more culturally aware. It was concluded that acquiring more culturally diverse training equipment will lead to greater levels of cultural competence amongst paramedicine students.

Health service utilization by people experiencing homelessness and engaging with community paramedics: a pre-post study.

To compare health service utilization of patients interacting with a mobile integrated health care program consisting of advanced care paramedics delivering community paramedic care to people experiencing homelessness before and after their initial visit. ED visits, physician claims, and pharmaceutical dispensations were compared in the year prior to and in the year following the initial community paramedic visit. Administrative databases were linked and utilization rates were calculated and analyzed between periods in this pre-post cohort study. The 1360 community paramedic patients included in this study had no significant change in ED visits (IRR: 1.02) following their initial visit. There were 17,699 ED visits in the pre-period and 18,398 visits in the post-period. There was an observed increase in rates of primary care physician claims (IRR 1.22) and pharmaceutical dispensations from community pharmacies (IRR 1.04). Patients who did not have pharmaceutical dispensations and those without physician claims in the pre-period were significantly less likely to not access these services in the post-period. In the year following the initial community paramedic visit there were small but significant increases in community-based care utilization of people experiencing homelessness. These data suggest that the continued development and implementation of paramedics as part of an interdisciplinary care team can increase access to care for a traditionally underserved population with complex health needs. Patients would likely benefit from the integration of community paramedics in community-based management that aim to improve access to care following ED visits.

Paramedic management of back pain: a scoping review

BackgroundResearch examining paramedic care of back pain is limited.ObjectiveTo describe ambulance service use and usual paramedic care for back pain, the effectiveness and safety of paramedic care of back pain, and the characteristics of people with back pain who seek care from paramedics.MethodsWe included published peer-reviewed studies of people with back pain who received any type of paramedic care on-scene and/or during transport to hospital. We searched MEDLINE, EMBASE, CINAHL, Web of Science and SciELO from inception to July 2022. Two authors independently screened and selected the studies, performed data extraction, and assessed the methodological quality using the PEDro, AMSTAR 2 and Hawker tools. This review followed the JBI methodological guidance for scoping reviews and PRISMA extension for scoping reviews.ResultsFrom 1987 articles we included 26 articles (25 unique studies) consisting of 22 observational studies, three randomised controlled trials and one review. Back pain is frequently in the top 3 reasons for calls to an ambulance service with more than two thirds of cases receiving ambulance dispatch. It takes ~ 8 min from time of call to an ambulance being dispatched and 16% of calls for back pain receive transport to hospital. Pharmacological management of back pain includes benzodiazepines, NSAIDs, opioids, nitrous oxide, and paracetamol. Non-pharmacological care is poorly reported and includes referral to alternate health service, counselling and behavioural interventions and self-care advice. Only three trials have evaluated effectiveness of paramedic treatments (TENS, active warming, and administration of opioids) and no studies provided safety or costing data.ConclusionParamedics are frequently responding to people with back pain. Use of pain medicines is common but varies according to the type of back pain and setting, while non-pharmacological care is poorly reported. There is a lack of research evaluating the effectiveness and safety of paramedic care for back pain.

Risk Perception Mental Health Impact and Coping Strategies during Covid 19 Pandemic among Health Care Workers

Objective: To assess the risk perception mental health impact and coping strategies during Covid-19 pandemic among health care workers. Study Design: Cross-sectional study. Place and Duration of Study: Department of Community Dentistry, Frontier Medical &amp; Dental College, Abbottabad from 1st January 2021 to 31st December 2021. Methodology: Two hundred health care workers were given questionnaire for complete detailing their information regarding demographic, occupational, anxiety scoring and depression state. Results: The age of the health care workers was mostly within 26-40 years followed by greater than 18 years. It was observed that anxiety was presented at a mild score within doctors and other health care worker staff while it was seen to a moderate level within the nursing health care workers. Furthermore, the gender distribution of anxiety showed higher level of anxiety among females than males. Within genders a low risk perception was seen within males than females. Among the health care workers, the risk perception was highest in nurses followed by paramedic and other health care staff. Conclusion: Covid-19 has caused devastating effects on the psychological stability of the health care workers which needs to be properly assessed and addressed. Keywords: Covid-19, Health care workers, Anxiety, Risk perception

Multimethod Process Evaluation of a Community Paramedic Delivered Care Transitions Intervention for Older Emergency Department Patients

Objective We assessed fidelity of delivery and participant engagement in the implementation of a community paramedic coach-led Care Transitions Intervention (CTI) program adapted for use following emergency department (ED) visits. Methods The adapted CTI for ED-to-home transitions was implemented at three university-affiliated hospitals in two cities from 2016 to 2019. Participants were aged ≥60 years old and discharged from the ED within 24 hours of arrival. In the current analysis, participants had to have received the CTI. Community paramedic coaches collected data on program delivery and participant characteristics at each transition contact via inventories and assessments. Participants provided commentary on the acceptability of the adapted CTI. Using a multimethod approach, the CTI implementation was assessed quantitatively for site- and coach-level differences. Qualitatively, barriers to implementation and participant satisfaction with the CTI were thematically analyzed. Results Of the 863 patient participants, 726 (84.1%) completed their home visits. Cancellations were usually patient-generated (94.9%). Most planned follow-up visits were successfully completed (94.6%). Content on the planning for red flags and post-discharge goal setting was discussed with high rates of fidelity overall (95% and greater), while content on outpatient follow-up was lower overall (75%). Differences in service delivery between the two sites existed for the in-person visit and the first phone follow-up, but the differences narrowed as the study progressed. Participants showed a 24.6% increase in patient activation (i.e., behavioral adoption) over the 30-day study period (p < 0.001). Overall, participants reported that the program was beneficial for managing their health, the quality of coaching was high, and that the program should continue. Not all participants felt that they needed the program. Community paramedic coaches reported barriers to CTI delivery due to patient medical problems and difficulties with phone visit coordination. Coaches also noted refusal to communicate or engage with the intervention as an implementation barrier. Conclusions Community paramedic coaches delivered the adapted CTI with high fidelity across geographically distant sites and successfully facilitated participant engagement, highlighting community paramedics as an effective resource for implementing such patient-centered interventions.

The effect of a specialist paramedic primary care rotation on appropriate non-conveyance decisions (SPRAINED) study: a controlled interrupted time series analysis.

NHS ambulance service non-conveyance rates in the United Kingdom are around 30%, despite an increase in non-emergency cases and a national policy of integrating urgent and emergency care to provide patients with the 'right care, in the right place, at the right time'. Emergency department overcrowding is a significant issue for patients, resulting in poorer quality of care, increased healthcare costs and potentially, increased mortality. It also contributes to increased ambulance turnaround times. Yorkshire Ambulance Service NHS Trust (YAS) introduced a specialist paramedic (SP) to improve the management of lower acuity cases, but non-conveyance rates in this group have not been as high as expected.In 2018, Health Education England funded a pilot scheme to rotate paramedics into a range of healthcare settings and in YAS, 10 SPs undertook a 10-week placement in a GP practice. This study aimed to evaluate whether a primary care placement appropriately increased the level and trend of non-conveyance decisions made by SPs following a 10-week GP placement, in a cost-effective manner. We conducted a controlled interrupted time series analysis using data from incidents between 1 June 2017 and 31 December 2019, to study appropriate non-conveyance rates before and after a GP placement. A costing analysis, examining the average cost per appropriate non-conveyance achieved for patients receiving care from intervention group SPs pre- and post-placement, was also conducted. A total of 7349 incidents attended by intervention group SPs were eligible for inclusion. Following removal of cases with missing data, 5537 (75.3%) cases remained. Post-placement, the intervention group demonstrated an increase in appropriate non-conveyance rate of 35.0% (95% CI 23.8%-46.2%), and a reduction in the trend of appropriate non-conveyance of -1.2% (95% CI -2.8%-0.5%), relative to the control group.Post-placement, the cost per appropriate non-conveyance for intervention group SPs was a mean of £509.41 (95% bootstrapped CI £454.92-£564.26) versus £1257.81 (95% bootstrapped CI £1233.42-£1283.95) for the same group in the pre-placement phase. In this single UK NHS ambulance service study, we found a clinically important and statistically significant increase in appropriate non-conveyance rates by SPs who had completed a 10-week GP placement. This improvement persisted for the 12-month period following the placement and demonstrated cost savings compared to usual care.

Building integrated, adaptive and responsive healthcare systems \u2013 lessons from paramedicine in Ontario, Canada

BackgroundBeing responsive and adaptive to local population needs is a key principle of integrated care, and traditional top-down approaches to health system governance are considered to be ineffective. There is need for more guidance on taking flexible, complexity-aware approaches to governance that foster integration and adaptability in the health system. Over the past two decades, paramedics in Ontario, Canada have been filling gaps in health and social services beyond their traditional mandate of emergency transport. Studying these grassroots, local programs can provide insight into how health systems can be more integrated, adaptive and responsive.MethodsSemi-structured interviews were conducted with people involved in new, integrated models of paramedic care in Ontario. Audio recordings of interviews were transcribed and coded inductively for participants’ experiences, including drivers, enablers and barriers to implementation. Thematic analysis was done to ascertain key concepts from across the dataset.ResultsTwenty-six participants from across Ontario’s five administrative health regions participated in the study. Participants described a range of programs that included acute, urgent and preventative care driven by local relationship networks of paramedics, hospitals, primary care, social services and home care. Three themes were developed that represent participants’ experiences implementing these programs in the Ontario context. The first theme, adapting and being nimble in tension with system structures, related to distributed versus central control of programs, a desire to be nimble and skepticism towards prohibitive legal and regulatory systems. The second theme, evolving and flexible professional role identity, highlighted the value and challenges of a functionally flexible workforce and interest in new roles amongst the paramedic profession. The third theme, unpredictable influences on program implementation, identified events such as the COVID-19 pandemic and changing government priorities as accelerating, redirecting or inhibiting local program development.ConclusionsThe findings of this study add to the discourse on governing health systems towards being more integrated, adaptive and responsive to population needs. Governance strategies include: supporting networks of local organizational relationships; considering the role of a functionally flexible health workforce; promoting a shared vision and framework for collaboration; and enabling distributed, local control and experimentation.