Setting the scene for the paramedic in primary care: a review of the literature

Understanding paramedic work in general practice in the UK: a rapid realist synthesis

BACKGROUND

General practice in the UK is under substantial pressure and practices are increasingly including paramedics as part of their workforce. Little is known about how different models of paramedic working may affect successful implementation of the role, as viewed from patient, clinician and system perspectives. This realist synthesis developed theories about 'models of paramedic working in general practice' in different UK contexts to understand their impact.

METHODS

The rapid realist synthesis comprised data from: (1) empirical and grey literature searches; (2) semi-structured realist interviews with system leaders involved with the implementation of the role; and (3) a stakeholder event with healthcare professionals and the public, to develop initial programme theories that can be tested in future work. Sources were analysed using a realist approach that explored the data for novel or causal insights to generate initial programme theories.

RESULTS

Empirical sources (n = 32), grey sources (n = 95), transcripts from system leader interviews (n = 7) and audio summaries from the stakeholder event (n = 22 participants) were synthesised into a single narrative document. The findings confirmed the presence of a wide variety of models of paramedic working in UK general practice. The perceived success of models was influenced by the extent to which the paramedic service was mature and embedded in practice, and according to four theory areas: (1) Primary care staff understanding and acceptance of the paramedic role; (2) Paramedic induction process, including access to training, supervision and development opportunities; (3) Patient understanding and acceptance of the role; (4) Variations in paramedic employment models.

CONCLUSIONS

Variability in how the paramedic role is operating and embedding into general practice across the UK affects the success of the role. These findings provide a theoretical foundation for future research to investigate various 'models of paramedic working' in different contexts.

Paramedic management of back pain: a scoping review

BACKGROUND

Research examining paramedic care of back pain is limited.

OBJECTIVE

To 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.

METHODS

We 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.

RESULTS

From 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.

CONCLUSION

Paramedics 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.

A review of the effects of head-worn displays on teamwork for emergency response

Head-Worn Displays (HWD) can potentially support the mobile work of emergency responders, but it remains unclear whether teamwork is affected when emergency responders use HWDs. We reviewed studies that examined HWDs in emergency response contexts to evaluate the impact of HWDs on team performance and on team processes of situation awareness, communication, and coordination. Sixteen studies were identified through manual and systematic literature searches. HWDs appeared to improve the quality of team performance but they increased time to perform under some conditions; effects on team processes were mixed. We identify five challenges to explain the mixed results. We discuss four theoretical perspectives that might address the challenges and guide research needs-joint cognitive systems, distributed cognition, common ground, and dynamical systems. Researchers and designers should use process-based measures and apply greater theoretical guidance to uncover mechanisms by which HWDs shape team processes, and to understand the impact on team performance. Practitioner Summary: This review examines the effects of head-worn displays on teamwork performance and team processes for emergency response. Results are mixed, but study diversity challenges the search for underlying mechanisms. Guidance from perspectives such as joint cognitive systems, distributed cognition, common ground, and dynamical systems may advance knowledge in the area. Abbreviations: HWD: head-worn display; RC: remote collaboration; DD: data display; ARC: augmented remote collaboration; ACC: augmented collocated collaboration; SA: situation awareness; TSA: team situation awareness; CPR: cardiopulmonary resuscitation; SAGAT: situation awareness global assessment technique; SART: situation awareness rating technique.

Paramedics working in general practice: a scoping review

Background: The term ‘paramedic’ has traditionally related to a healthcare professional trained to provide pre-hospital emergency care; however, paramedics are increasingly taking on novel additional non-emergency roles. General practice is facing unprecedented demand for its services related to rising expectations, an aging society and increased prevalence of chronic disease. Paramedics may be recruited to work in general practice to meet some of these demands. We undertook a scoping review to map the current literature considering paramedics working in general practice and inform follow-on research. Methods: We employed the six-stage scoping review framework developed by Arksey and O’Malley. Our research question was ‘to identify the scope of practice, nature of training/qualifications, challenges faced, and impacts of paramedics working in general practice’. Results: After searching PUBMED (Medline, n = 487), EMBASE (n = 536) and the Cochrane Library (n = 0) in June 2020, we identified eleven full-text articles that met our inclusion criteria. The literature suggests that paramedics have diverse skills that enable roles within general practice, some of which are context specific. Additional training is considered necessary to facilitate the transition from emergency care to general practice. We found no research that quantitatively assessed the impact of paramedics working in general practice on healthcare expenditure or patient health outcomes. Conclusions: There is a paucity of empiric scientific literature considering paramedic working in general practice. Further research is needed to inform training pathways, the structure of clinical practice and to measure outcomes.

Exploring how paramedics are deployed in general practice and the perceived benefits and drawbacks: a mixed-methods scoping study

Background

General practice in the UK faces continuing challenges to balance a workforce shortage against rising demand. The NHS England GPForward View proposes development of the multidisciplinary, integrated primary care workforce to support frontline service delivery, including the employment of paramedics. However, very little is known about the safety, clinical effectiveness, or cost-effectiveness of paramedics working in general practice. Research is needed to understand the potential benefits and drawbacks of this model of workforce organisation.

Aim

To understand how paramedics are deployed in general practice, and to investigate the theories and drivers that underpin this service development.

Design & setting

A mixed-methods study using a literature review, national survey, and qualitative interviews.

Method

A three-phase study was undertaken that consisted of: a literature review and survey; meetings with key informants (KIs); and direct enquiry with relevant staff stakeholders (SHs).

Results

There is very little evidence on the safety and cost-effectiveness of paramedics working in general practice and significant variation in the ways that paramedics are deployed, particularly in terms of the patients seen and conditions treated. Nonetheless, there is a largely positive view of this development and a perceived reduction in GP workload. However, some concerns centre on the time needed from GPs to train and supervise paramedic staff.

Conclusion

The contribution of paramedics in general practice has not been fully evaluated. There is a need for research that takes account of the substantial variation between service models to fully understand the benefits and consequences for patients, the workforce, and the NHS.

Contribution of paramedics in primary and urgent care: a systematic review

Background

Within the UK, there are now opportunities for paramedics to work across a variety of healthcare settings away from their traditional ambulance service employer, with many opting to move into primary care.

Aim

To provide an overview of the types of clinical roles paramedics are undertaking in primary and urgent care settings within the UK.

Design and setting

A systematic review.

Method

Searches were conducted of MEDLINE, CINAHL, Embase, the National Institute for Health and Care Excellence, the Journal of Paramedic Practice, and the Cochrane Database from January 2004 to March 2019 for papers detailing the role, scope of practice, clinician and patient satisfaction, and costs of paramedics in primary and urgent care settings. Free-text keywords and subject headings focused on two key concepts: paramedic and general practice/primary care.

Results

In total, 6765 references were screened by title and/or abstract. After full-text review, 24 studies were included. Key findings focused on the description of the clinical role, the clinical work environment, the contribution of paramedics to the primary care workforce, the clinical activities they undertook, patient satisfaction, and education and training for paramedics moving from the ambulance service into primary care.

Conclusion

Current published research identifies that the role of the paramedic working in primary and urgent care is being advocated and implemented across the UK; however, there is insufficient detail regarding the clinical contribution of paramedics in these clinical settings. More research needs to be done to determine how, why, and in what context paramedics are now working in primary and urgent care, and what their overall contribution is to the primary care workforce.

Paramedics working in a prison-based healthcare setting: an exploratory mixed methods study

Background:

Prison healthcare departments recently started recruiting paramedics to assist in dealing with a rise in medical emergencies largely attributed to an aging prison population and an increase in novel psychoactive substance misuse. There has been little research investigating the paramedic role in this setting. This study aims to explore the strengths and limitations of employing paramedics within the prison healthcare setting from the perspectives of non-paramedic colleagues.

Methods:

An exploratory mixed methods study was conducted in a UK category B remand prison, focusing on the opinions and observations of current healthcare and custodial staff. Paper questionnaires were completed by 32 members of staff and semi-structured interviews were conducted with two participants.

Results:

Seven global themes were identified within the qualitative data: management of medical responses; effect of a specialist role; effect on ambulance escorts; contribution to professionalism within the department; effect on the role of other healthcare staff; prisoner interaction with paramedics; and difficulties encountered in role implementation. Of the 32 participants, 31 believe paramedics have had an overall positive effect on the provision of healthcare, with a variety of reasons explored.

Conclusion:

In a small exploratory study, it is suggested that paramedics possess the relevant skills and training to offer a meaningful contribution to the provision of prison healthcare; however, further research is required to explore the full scope of their contribution in this setting.

Self-preservation comes at a cost: Why British National Health Service paramedics might be choosing a healthier, but poorer, retirement

Objectives:

To explore and portray the perspectives of National Health Service Ambulance personnel related to the latest rise in the National Health Service occupational pension age.

Methods:

Data gathering took the form of 35 in-depth interviews. A thematic analysis was used to characterise and articulate key concepts and meanings. The analysis applied interpretive techniques, as views expressed were from personal experiences, and allowed for an in-depth analysis of shared meanings.

Results:

The themes reported captured the desire of many Ambulance personnel to exit their employment well in advance of their retirement age, despite satisfaction gained from patient care. This early exit is being driven by increased worry that the work demands of the job are unsustainable, especially for older workers, as clinical responsibilities increase and their social support diminishes. Also, Ambulance personnel feel betrayed by their employers, because their retirement is being delayed further by another change in their pensionable age.

Conclusion:

There is an increased orientation for ‘living for today’ and indications of a willingness to sacrifice salary and pension income in order to protect their health in older age, which has implications for long-term financial and general well-being in retirement.

Prior Participation in Simulation Events Is Associated With Insimulation Team Performance Among Emergency Medical Services Professionals

INTRODUCTION

Prior evidence has supported the use of high-fidelity simulation in initial emergency medical services (EMS) education, but there is a dearth of research on whether EMS professionals can also benefit from it. We sought to examine simulation use and years of practice as predictors of insimulation team performance among EMS professionals. The hypothesis is that both the prior participation in simulation events and the accumulated years of practice will predict insimulation performance.

METHODS

This cross-sectional study was conducted as part of a simulation-based EMS competition. Paramedic and physician teams were tested. Participants' years of EMS and healthcare practice and their prior participation in simulation events were assessed with a survey and correlated with performance in the competition.

RESULTS

Participants were 120 EMS professionals from 51 teams, which was 75% of all competitors. They had in average 8.03 years of healthcare practice and 5.71 years of EMS practice and had previously participated in 4.34 simulation events. The prior participation in simulation events correlated significantly with EMS insimulation performance at the team level (r = 0.40-0.59). In contrast, neither the years of healthcare practice nor the years of EMS practice significantly predicted insimulation team performance. Furthermore, there was no interaction of simulation use and years of practice.

CONCLUSIONS

The benefits of simulation use are not limited to initial EMS education but spread also to experienced professionals. Even individuals who have been working in the field for many years may benefit from high-fidelity simulation. Future research should examine whether this also translates into better clinical performance.

Paramedics' experiences of administering fascia iliaca compartment block to patients in South Wales with suspected hip fracture at the scene of injury: results of focus groups

OBJECTIVES

To explore paramedics' experience of delivering fascia iliaca compartment block (FICB) to patients with suspected hip fracture at the scene of injury.

DESIGN

Focus groups within a randomised controlled trial.

SETTING

Paramedics based at ambulance stations in the catchment area of one Emergency Department in South Wales, recruited and trained in a feasibility study about an alternative to routine prehospital pain management for patients with suspected hip fracture.

PARTICIPANTS

11 paramedics.

INTERVENTION

Paramedic-administered FICB to patients with suspected hip fracture. We randomly allocated eligible patients to FICB, a local anaesthetic injection directly into the hip region-or usual care, most commonly morphine - using audited scratch cards.

OUTCOMES

Paramedics' experiences of administering FICB gathered through thematic analysis of interview transcripts by two researchers, one paramedic and one lay member.

RESULTS

Respondents believed that FICB was a suitable intervention for paramedics to deliver. It aligned with routine practice and was within people's capabilities. They said it took up to 10 minutes longer than usual care to prepare and deliver, in part due to nervousness and unfamiliarity with a new procedure. They praised the training provided but said they were anxious about causing harm by injecting into the wrong location. Confidence increased after one paramedic team successfully treated a patient for local anaesthetic toxicity. Reported challenges related to the emergency context: patients often waited many hours for ambulance arrival; moving patients exacerbated their pain; family and neighbours were present as paramedics administered treatment.

CONCLUSIONS

Paramedics are willing and able to administer FICB to patients with suspected hip fracture before ambulance transport to hospital. Feasibility study findings will inform further research.

TRIAL REGISTRATION NUMBER

ISRCTN60065373; Pre results.

Reducing 9-1-1 Emergency Medical Service Calls By Implementing A Community Paramedicine Program For Vulnerable Older Adults In Public Housing In Canada: A Multi-Site Cluster Randomized Controlled Trial

Objective: Older adults account for 38-48% of emergency medical service (EMS) calls, have more chronic diseases, and those with low income have lower quality of life. Mobile integrated health and community paramedicine may help address these health inequalities and reduce EMS calls. This study examines the effectiveness of the Community Paramedicine at Clinic (CP@clinic) program in decreasing EMS calls and improving health outcomes in low-income older adults. Methods: This was an open-label, pragmatic, cluster-randomized controlled trial conducted within subsidized public housing buildings for older adults in 5 paramedic services across Ontario, Canada. A total of 30 apartment buildings were eligible (>50 units, >60% of units occupied by older adults, unique postal code, available match for pairing). Paired buildings were randomly allocated to intervention (CP@clinic for one year) or control (usual care) via computer-generated randomization. The CP@clinic intervention is a community-based, paramedic-led, health promotion and disease prevention program held weekly in building common rooms. CP@clinic includes risk assessment with validated tools, decision support, health promotion, referrals to resources, and reports back to family doctors. All residents could participate, but only older adults (55 years and older) were included in analyses. The primary outcome was building-level EMS calls from paramedic service databases. Secondary outcomes were individual-level changes in chronic disease risk factors and quality-adjusted-life-years (QALYs). Data were analyzed using Generalized Estimating Equations to account for clustering by sites. Results: Intention-to-treat analysis showed no significant difference in EMS calls (mean difference = -0.37/100 apartment units/month, 95%CI: -0.98 to 0.24). Sensitivity analysis excluding data from 2 building pairs with eligibility changes after intervention initiation revealed a significant difference in EMS calls in favor of the intervention buildings (mean difference = -0.90/100 apartment units/month, 95%CI: -1.54 to -0.26). At the individual level, there was a significant QALY increase (mean difference = 0.06, 95%CI: 0.02 to 0.10) and blood pressure decrease (systolic mean change = 3.65 mmHg, 95%CI: 2.37 to 4.94; diastolic mean change = 2.03 mmHg, 95%CI: 1.00 to 3.06). Conclusions: CP@clinic showed a significant decrease in EMS calls, decrease in BP, and improvement in QALYs among older adults in subsidizing public housing, suggesting this simple program should be replicated in other communities with public housing. Trial Registration: Clinicaltrials.gov, Registration no. NCT02152891.

The evolving role of paramedics - a NICE problem to have?

This short essay supports the growing role of paramedics in the clinical and academic workforce. We present a commentary of recent draft consultations by the National Institute for Health and Care Excellence in England that set out how the role of paramedics may be evolving to assist with the changing demands on the clinical workforce. Using these consultations as a basis, we extend their recommendations and suggest that the profession should also lead the academically driven evaluation of these new roles.

Paramedics assessing Elders at Risk for Independence Loss (PERIL): Derivation, Reliability and Comparative Effectiveness of a Clinical Prediction Rule

OBJECTIVES

We conducted a program of research to derive and test the reliability of a clinical prediction rule to identify high-risk older adults using paramedics' observations.

METHODS

We developed the Paramedics assessing Elders at Risk of Independence Loss (PERIL) checklist of 43 yes or no questions, including the Identifying Seniors at Risk (ISAR) tool items. We trained 1,185 paramedics from three Ontario services to use this checklist, and assessed inter-observer reliability in a convenience sample. The primary outcome, return to the ED, hospitalization, or death within one month was assessed using provincial databases. We derived a prediction rule using multivariable logistic regression.

RESULTS

We enrolled 1,065 subjects, of which 764 (71.7%) had complete data. Inter-observer reliability was good or excellent for 40/43 questions. We derived a four-item rule: 1) "Problems in the home contributing to adverse outcomes?" (OR 1.43); 2) "Called 911 in the last 30 days?" (OR 1.72); 3) male (OR 1.38) and 4) lacks social support (OR 1.4). The PERIL rule performed better than a proxy measure of clinical judgment (AUC 0.62 vs. 0.56, p=0.02) and adherence was better for PERIL than for ISAR.

CONCLUSIONS

The four-item PERIL rule has good inter-observer reliability and adherence, and had advantages compared to a proxy measure of clinical judgment. The ISAR is an acceptable alternative, but adherence may be lower. If future research validates the PERIL rule, it could be used by emergency physicians and paramedic services to target preventative interventions for seniors identified as high-risk.

Defining the paramedic process

The use of a ‘process of care’ is well established in several health professions, most evidently within the field of nursing. Now ingrained within methods of care delivery, it offers a logical approach to problem solving and ensures an appropriate delivery of interventions that are specifically suited to the individual patient. Paramedicine is a rapidly advancing profession despite a wide acknowledgement of limited research provisions. This frequently results in the borrowing of evidence from other disciplines. While this has often been useful, there are many concerns relating to the acceptable limit of evidence transcription between professions. To date, there is no formally recognised ‘process of care’-defining activity within the pre-hospital arena. With much current focus on the professional classification of paramedic work, it is considered timely to formally define a formula that underpins other professional roles such as nursing. It is hypothesised that defined processes of care, particularly the nursing process, may have features that would readily translate to pre-hospital practice. The literature analysed was obtained through systematic searches of a range of databases, including Ovid MEDLINE, Cumulative Index to Nursing and Allied Health. The results demonstrated that the defined process of care provides nursing with more than just a structure for practice, but also has implications for education, clinical governance and professional standing. The current nursing process does not directly articulate to the complex and often unstructured role of the paramedic; however, it has many principles that offer value to the paramedic in their practice. Expanding the nursing process model to include the stages of Dispatch Considerations, Scene Assessment, First Impressions, Patient History, Physical Examination, Clinical Decision-Making, Interventions, Re-evaluation, Transport Decisions, Handover and Reflection would provide an appropriate model for pre-hospital practices.

Are paramedic students ready to be professional? An international comparison study

INTRODUCTION

The last decade has seen rapid advancement in Australasian paramedic education, clinical practice, and research. Coupled with the movements towards national registration in Australia and New Zealand, these advancements contribute to the paramedic discipline gaining recognition as a health profession.

AIM

The aim of this paper was to explore paramedic students' views on paramedic professionalism in Australia and New Zealand.

METHODS

Using a convenience sample of paramedic students from Whitireia New Zealand, Charles Sturt University and Monash University, attitudes towards paramedic professionalism were measured using the Professionalism at Work Questionnaire. The 77 item questionnaire uses a combination of binary and unipolar Likert scales (1 = Strongly disagree/5 = Strongly agree; Never = 1/Always = 5).

RESULTS

There were 479 students who participated in the study from Charles Sturt University n = 272 (56.8%), Monash University n = 145 (30.3%) and Whitireia New Zealand n = 62 (12.9%). A number of items produced statistically significant differences P < 0.05 between universities, year levels and course type. These included: 'Allow my liking or dislike for patients to affect the way I approach them' and 'Discuss a bad job with family or friends outside work as a way of coping'.

CONCLUSIONS

These results suggest that paramedic students are strong advocates of paramedic professionalism and support the need for regulation. Data also suggest that the next generation of paramedics can be the agents of change for the paramedic discipline as it attempts to achieve full professional status.

Next generation paramedics, agents of change, or time for curricula renewal?

BACKGROUND

Knowledge translation involves the dissemination and application of scientific research findings into clinical practice. In the health care arena, uptake of evidence-based assessment and intervention strategies is aimed at reducing inefficiencies and ultimately improving patient outcomes. However, numerous studies have purported gaps in knowledge translation in the health care professions. The objective of this study was to classify the traits of undergraduate paramedic students from Monash Univeristy, Australia, using the practice style inventory (PSI).

METHODS

A cross-sectional study of students across all undergraduate years from Emergency Health and Emergency Health/Nursing was completed. Student knowledge translation levels were measured using the 17-item paper-based PSI.

RESULTS

A total of 266 students participated in the study, of which 68.4% were females. The majority of participants were <26 years of age (n=228) and just over half enrolled in second year studies (n=134). Two subscales produced statistically significant differences: evidence versus experience (extent to which scientific evidence rather than authority is perceived as the best source of knowledge) and nonconformity (degree of comfort with clinical practices that are out of step with recommendations of leaders). There was a statistically significant difference between sex on the evidence versus experience subscale (P<0.0001, d =0.51), and between year levels on the nonconformity subscale (P<0.007, d =0.63).

CONCLUSION

This study identified several differences in knowledge translation subscales in the undergraduate paramedic cohorts. Further investigation is warranted in order to better understand barriers and facilitate improved uptake of evidence-based research into clinical practice and, ultimately, improve patient outcomes. Future research using a longitudinal study design to capture changing attitudes to knowledge translation in the postgraduate population may also prove valuable in curricula renewal.

Examining the measurement properties of the Interdisciplinary Education Perception Scale (IEPS) in paramedic education

BACKGROUND

Healthcare systems are continuing searching for alternative service delivery models while at the same time also promoting interprofessional practice and cooperation among workers. One scale that aims to measure interprofessional cooperation is the Interdisciplinary Education Perception Scale (IEPS), although limited psychometric testing on its validity and reliability has been carried out. Therefore the aim of this study was to investigate the dimensionality and internal consistency of the IEPS (suggested by McFadyen and colleagues) when completed by a group of paramedic undergraduates.

METHODS

Data from the IEPS were analysed with a factor analysis using a Principal Axis Factoring (PAF) with Oblique Oblimin rotation.

RESULTS

A total of (n=303) undergraduate paramedic students participated in the study who reported having positive attitudes towards interprofessional cooperation. Factor analysis of the 12-items revealed two factors with eigenvalues above 1, accounting for 53.85% of the total variance. Items with loadings greater than ±.30, with the factor in question were used to describe the two factors: Cooperation and Teamwork, and Positivity.

CONCLUSION

While data from this study produced a multi-dimensional scale with adequate eigenvalues and communalities, improvements to the scales internal consistency can be made with future data sets. The results from the IEPS suggest that undergraduate paramedics have positive regard towards interprofessional cooperation.

Performance of experienced versus less experienced paramedics in managing challenging scenarios: a cognitive task analysis study

STUDY OBJECTIVE

Out-of-hospital care is becoming more complex, thus placing greater reliance on the cognitive abilities of paramedics to manage difficult situations. In adapting to the challenges in their work, paramedics develop expertise. We study the cognitive strategies used by expert paramedics to contribute to understanding how paramedics and the EMS system can adapt to new challenges.

METHODS

We conducted a "staged-world" cognitive task analysis to explore paramedics' handling of cognitive challenges related to sense-making and to resource and task management. A mixed-fidelity simulation was used to present paramedics with 2 challenging scenarios: a pulmonary embolism initially presenting as a myocardial infarction and a 2-person shooting with limited resources available.

RESULTS

Participants were 10 paramedics, 6 more experienced and 4 less experienced. Analysis involved comparing the performance of the 2 groups to identify strategies associated with expertise. The more experienced paramedics made more assessments, explored a wider variety of presumptive diagnoses, and identified the pulmonary embolism earlier. They switched attention between the 2 shooting victims more, used their emergency medical technician-basic level partners more, and provided more advanced level care for both patients. Their patients arrived at the emergency department more prepared for specialized emergency care.

CONCLUSION

Our findings correspond to general cognitive attributes of expertise: greater cue gathering and inferential reasoning, and more functional and strategic thinking. These results suggest potential areas and methods to facilitate development of expertise, as well as ways to better support use of expertise. Future studies should expand on these findings through larger sample sizes and more complex scenarios.

The public's perception of prehospital emergency care in the County of Skane, southern Sweden

INTRODUCTION

The prehospital emergency care has had a rapid progress in Sweden in terms of technology, treatments and personnel education demands. In the County of Skane there is at least one specialized nurse in every ambulance. Possible misuses of the resources by the public have been acknowledged.

AIM

To investigate the public's use, knowledge and expectations of the prehospital emergency care in Skane, southern Sweden.

METHOD

A cross sectional descriptive survey, using a stratified sampling. Inclusion criteria were: 18 year or older and currently living in Skane.

RESULTS

Of 735 people who were asked 54.4% (n=400) chose to participate in the study. 44.0% of the respondents had been transported with ambulance. 34.5% of the respondents believed that the lowest educated personnel responsible for the patient was the paramedic. The results show that the respondents trust the personnel's knowledge and work skills. Older informants expected faster treatment by a physician when arriving by ambulance to the hospital, regardless of medical condition.

CONCLUSION

The public had confidence in the ambulance personnel's knowledge, ability to make assessment and give treatment despite not being updated on the current competence of the personnel. A positive experience of contact with the ambulance service was distinct.

Which extended paramedic skills are making an impact in emergency care and can be related to the UK paramedic system? A systematic review of the literature

Background

Increasing demand on the UK emergency services is creating interest in reviewing the structure and content of ambulance services. Only 10% of emergency calls have been seen to be life-threatening and, thus, paramedics, as many patients’ first contact with the health service, have the potential to use their skills to reduce the demand on Emergency Departments. This systematic literature review aimed to identify evidence of paramedics trained with extra skills and the impact of this on patient care and interrelating services such as General Practices or Emergency Departments.

Methods

International literature from Medline, Embase, Cumulative Index of Nursing and Allied Health Literature (CINAHL), ProQuest, Scopus and grey literature from 1990 were included. Articles about any prehospital emergency care provider trained with extra skill(s) beyond their baseline competencies and evaluated in practice were included. Specific procedures for certain conditions and the extensively evaluated UK Emergency Care Practitioner role were excluded.

Results

8724 articles were identified, of which 19 met the inclusion criteria. 14 articles considered paramedic patient assessment and management skills, two articles considered paramedic safeguarding skills, two health education and learning sharing and one health information. There is valuable evidence for paramedic assessing and managing patients autonomously to reduce Emergency Department conveyance which is acceptable to patients and carers. Evidence for other paramedic skills is less robust, reflecting a difficulty with rigorous research in prehospital emergency care.

Conclusions

This review identifies many viable extra skills for paramedics but the evidence is not strong enough to guide policy. The findings should be used to guide future research, particularly into paramedic care for elderly people.

High school allied health students and their exposure to the profession of EMS

INTRODUCTION

Ensuring a stable Emergency Medical Services (EMS) workforce is a growing concern, and effective recruiting strategies are needed to expose young adults to the EMS profession. The objective of this study was to assess the exposure of high school allied health students to EMS as a career option, as well as measure their attitudes and beliefs about the EMS profession. Hypothesis Few high school allied health students are exposed to EMS educational and career opportunities.

METHODS

A convenience sample of allied health students in a rural high school system was surveyed about exposure to EMS, career intentions, factors impacting career decisions, and attitudes and beliefs about EMS. Descriptive statistics were calculated, and intention to pursue an EMS career was modeled using logistic regression.

RESULTS

Of 171 students enrolled in allied health courses across six high schools, 135 (78.9%) agreed to participate; 85.2% were female. Almost all (92.6%) respondents intended to pursue a health career, but only 43.0% reported that their allied health course exposed them to EMS as a profession. Few participants (37.7%) were knowledgeable about EMS associate degree or baccalaureate degree (27.4%) programs. Only 20.7% of the respondents intended to pursue EMS as a career, although 46.0% wanted to learn more about the profession. Most (68.2%) students expressed interest in an emergency medical technician (EMT) course if one were offered, and 80.0% were interested in a ride-along program. Independent predictors of pursuing an EMS career included exposure to EMS outside of high school (OR = 7.4, 95% CI = 1.7-30.4); media influence on career choice (OR = 9.6, 95% CI = 1.8-50.1); and the belief that EMS was mentally challenging (OR = 15.9, 95% CI = 1.1-216.6). Negative predictors included the beliefs that an EMS career was stimulating (OR = 0.05, 95% CI = 0.00-0.53) and physically challenging (OR = 0.06, 95% CI = 0.00-0.63); as well as prior exposure to an EMS job advertisement (OR = 0.14, 0.03-0.53).

CONCLUSIONS

Overall, there was a lack of exposure to career and educational options in EMS among allied health students in the school system studied, and few students intended to pursue an EMS career after graduation. However, the majority of students indicated they would like to learn more about EMS, and would enroll in an EMT course and ride-along program if available. These findings suggest that, with exposure to the profession, more allied health students could choose EMS as a career.

One model of healthcare provision lessons learnt through clinical governance

AIM

Clinical Governance describes a systematic approach to maintaining and improving the quality of patient care. Risk management includes a themes analysis of clinical incidents and positive interventions with the resulting information disseminated to staff through personal performance plans, and publication and development training workshops. Our model of healthcare provision utilises doctors, nurses and paramedics to assess individuals in custody and this paper discusses the implementation of clinical risk management within this setting.

METHOD

A description of the model of healthcare provision, together with a themes analysis was undertaken for all clinical incidents received by the clinical team. Each incident receives an individual response and is discussed within the clinical risk management committee. From the review of each event, learning outcomes are identified and the information captured on a database. The information is analysed for reoccurring themes and further measures are introduced to ensure a high standard of healthcare provision to all counties.

FINDINGS

Of the 86,184 patient/detainee episodes from 11 county forces, from January 2009-December 2009, 159 clinical incidents and positive interventions were generated. These were categorised into Clinical Near Misses--39, Prescribing issues--38, Health and Safety matters--13, Organisational matters--23, Positive Interventions--21 and Professional issues--25.

CONCLUSION

Risk management, with a regular review of clinical incidents is an essential part of clinical governance especially when working in a multidisciplinary team providing safe and effective custody healthcare. This analysis contributes to the knowledge base in clinical forensic medicine and supports the importance of identifying educational requirements for staff, working in a multiagency partnership and continuous monitoring of the quality of care for detainees.

[Cooperation between ambulance personnel and regular general practitioners]

BACKGROUND

The ambulance service in Norway has gone through a pronounced upgrading of skills and professionalization during the last 10 years. The purpose of this survey was to obtain knowledge on how the ambulance personnel perceive their own professional competence and their relationship to other occupational groups with whom they cooperate.

MATERIAL AND METHOD

A questionnaire was sent to 300 persons who received authorization as ambulance personnel between 2002 - 2005. Questions were included on evaluation of inter-professional cooperation, professional appreciation and competence in practical handling of patients.

RESULTS

The response rate was 52 %. The ambulance personnel regarded the most problematic relationships and situations to be with nurses and regular general practioners in the out-of-hours services and with doctors in connection with emergencies at accident sites. 78 % of the ambulance personnel claimed that their own occupational group has the highest competence in the practical handling of patients with acute illness and injuries outside of hospitals. Nevertheless, only 19 % of them felt that occupational groups with who they cooperate appreciate their competence.

INTERPRETATION

Ambulance personnel have strong confidence in their own occupational group's competence in practical handling of patients. Strengthened formal competence combined with increased possibilities for initial medical treatment in the ambulances, may have contributed to an expanded role for ambulance personnel within pre-hospital emergency care. Smooth cooperation between regular general practitioners and ambulance personnel requires that both parties increase their understanding of the other group's procedures and roles.

An investigation of theory-practice gap in undergraduate paramedic education

BACKGROUND

Bachelor of Emergency Health (Paramedic) (BEH) students at Monash University undertake clinical placements to assist with the transition from student to novice paramedic. Anecdotally, students report a lack of opportunity to practise their clinical skills whilst on placements. The barriers to participation and the theory-practice gap have not been previously documented in Australian paramedic literature. The purpose of this study was to investigate the theory-practice gap for paramedic students by linking education and skill level to case exposure and skills praxis during clinical placements.

METHODS

A cross-sectional retrospective study using a convenience sample of second and third year BEH undergraduate students. Ethics approval was granted.

RESULTS

Eighty four second and third year BEH students participated. 59.5% were female (n = 50), 40.5% were male (n = 34). Overall, students most commonly reported exposure to cardiac and respiratory cases and were satisfied with the number of cases encountered during placement. However, over half (n = 46) reported being exposed to < 50% of cases that allowed skills praxis. The most common barrier to participation (34.5%) was the opportunity to participate in patient care and 68% of student's were unsure if paramedics understood their role during clinical placements.

CONCLUSION

This study demonstrates that the majority of students were satisfied with their clinical placement experience; even though they were exposed to < 50% of cases that allowed skills practice. Identifying these educational barriers will assist in improving the quality and theory-practice gap of paramedic clinical education.

The evolution of trauma services at Beaumont Hospital

OBJECTIVE

To review and examine the epidemiology, severity and management of trauma admissions at the national neurosurgical teaching hospital.

METHODS

An extensive audit of volume, type and severity of injury and the management requirements of the trauma population admitted to the hospital.

RESULTS

The vast majority of severely injured patients were referred from outside the catchment area of the hospital with only 26% being admitted directly through the Emergency Department. As a consequence, 73% of patients arrived out of normal working hours, which posed problems in providing skilled trauma specialists.

CONCLUSIONS

The management of patients with serious injury is complex. The large proportion of patients with critical injuries, some of whom were paediatric, highlighted the need for 24 h cover by senior trauma personnel and the provision of radiology and operating facilities to meet their needs. The inclusion of indicators of alterations in innate or adaptive immune responses may improve the predictive power of severity of injury scores.

The advanced paramedic internship: an important clinical learning opportunity

INTRODUCTION

Ireland introduced paramedic services to its ambulance services in 2005 and an accredited training programme has begun to train candidates. The training programme is 11 months long and includes distance learning, taught and internship phases. The internship involves six weeks of supervised paramedic practice in the setting of a rapid response vehicle crewed by two candidates, principally in urban and suburban settings. Internationally, little information has been published on the educational opportunities or impact of paramedic training and particularly on the clinical practice components of that training.

METHODS

A detailed audit was carried out of clinical care activity completed by the initial 30 candidates to undertake the internship. Data were collected on patient descriptors, types of clinical problem, basic and advanced interventions undertaken and the Clinical Practice Guideline-Advanced (CPG-A) under which the advanced intervention was undertaken. Data were compiled using SPSS V11.

RESULTS

Thirty candidates completed the 6-week internship, caring for a total of 1237 patients, of whom 46.3% had an advanced intervention. Intravenous cannulation was the most common advanced procedure undertaken, in one fifth of all patients seen. Twenty-two candidates inserted a total of 42 tracheal tubes or laryngeal mask airways and 55 cardiac arrests were managed. Smaller numbers of glycaemic, epilepsy and fluid resuscitation cases were dealt with.

DISCUSSION

Well supervised clinical training facilitates the transition from student to autonomous practitioner. Candidates in this programme accomplished a range of clinical assessments, decisions and interventions with the support of a senior supervisor, but in a situation where they carried responsibility for safe practice.