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Community Paramedicine through Multiple Stakeholder Lenses Using a Modified Soft Systems Methodology
Abstract
p> Introduction
Community paramedicine (CP) is an emerging model of care which expands paramedic scopes of practice to collaboratively support primary healthcare delivery in underserviced and disadvantaged communities. CP is a patient-centred holistic approach focussed on improving health outcomes, with success heavily reliant on integrative partnerships. This research aimed to identify key stakeholder perspectives about the value of CP in rural Australia.
Methods
A workshop was conducted using a modified soft system methodology (SSM) that asked participants to consider the value of CP from the perspective of five key stakeholder groups. The 50 participants consisted of paramedics and volunteer ambulance officers, paramedic service executives, paramedic educators, Medicare Local representatives and a general practitioner. Participants were randomly allocated to five stakeholder groups: paramedic profession; Minister for Health and Ageing; consumers, chief executive and executive management team of an ambulance service; and healthcare professionals. The application of SSM placed the five groups into three broad categories of stakeholders: customers, actors, and owners.
‘Customers’ in this context are patients, families and carers. ‘Actors’ are paramedics and volunteer ambulance officers, and ambulance service executives. The ‘owners’ are the Office of the Minister and those with the power to facilitate or block initiatives. Participants were allocated 15 minutes to brainstorm the question: “What can a community paramedic do for you to improve rural health provision?” Group views were verbally shared with all workshop participants and video recorded for analysis.
Results
The ‘customers’ asked about CP from patient, family and carer perspectives, and were highly engaged with questions about how, when and where CP could operate. The paramedic and volunteer ambulance officer group of ‘actors’ battled to move beyond their emergency response mindset to articulate a clear CP vision. The executive management team responded from a strategic and risk management perspective focussing on patient safety and corporate image. They identified the need to form stakeholder partnerships. The ‘owners’ representing the Office of the Minister focussed on the holistic and wellness benefits of CP. The health professional group anticipated the CP role could provide collaborative care and support doctors.
Conclusions
The findings suggest many participants had a limited understanding of CP, which creates a barrier for implementation. Key benefits identified included a reduction in financial and physical burdens on the rural healthcare sector and improved outcomes for consumers. Active participation of stakeholders in the process of introducing CP programs, where people are comfortable questioning current practices and encouraged to explore new concepts and innovations, would enable a shared understanding of program aims and expectations. For paramedic services to expand service delivery models in rural Australia community participation and engagement with stakeholders is essential. They and paramedics must be willing to embrace meaningful and collaborative partnerships with patients, broader health networks, social services, politicians and researchers, and be prepared to step away from their traditional ‘command and control’ culture to co-design innovative paramedic models. SSM was a worthwhile approach to stakeholder engagement that has the potential to improve implementation of community paramedic programs through improved inclusion and the valuing of stakeholder perspectives.
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... The first principle of SSM involves gaining a deep understanding of the institutional arrangements by engaging with stakeholders and exploring their perspectives. This helps to identify different worldviews, assumptions, and tensions existing within the system, allowing for a comprehensive understanding of the context of a problem (Martin and O'Meara, 2020). In addition, SSM emphasizes the importance of defining relevant systems bearing multiple relationships. ...
... Lastly, SSM places significant importance on collaboration and participation throughout the problem-solving process. By involving diverse stakeholders with different expertise, experiences, and perspectives, SSM seeks to create a shared understanding of the wide range of options and pathways while ensuring collective ownership of proposed solutions (Martin et al., 2020;Kutty et al., 2020). ...
Soft Systems Methodology (SSM) and institutional factors offer a complex approach that might be helpful in achieving the sustainable development goals (SDGs) and are therefore gaining an increasing popularity in the research literature. By embracing the principles of SSM within the realm of institutional economics, academics and decision-makers can navigate through the complexities of real-world problems and devise effective strategies for addressing them. Understanding the intricate relationship between SSM and institutional economics offers a unique lens through which organizational performance and sustainability can be enhanced.
... Eaton et al. [42] point out that only limited information is available regarding the competencies needed to work within SRUs. SRU's function which rather aims at patient assessment more than treatment means, from an international perspective, that the ambulance nurse's needs, in addition advanced clinical skills, be adept at assessing and managing chronic diseases, mental illness and mapping social needs [42][43][44]. Competencies that achieved consensus and are considered as important ones in this study are similar with the staff in the similar units than SRU needs to have in other countries, for example in United Kingdom [42], in Finland [14] and in Australia [44]. A standardisation of the function and competence requirements of SRUs in Sweden is needed. ...
... SRU's function which rather aims at patient assessment more than treatment means, from an international perspective, that the ambulance nurse's needs, in addition advanced clinical skills, be adept at assessing and managing chronic diseases, mental illness and mapping social needs [42][43][44]. Competencies that achieved consensus and are considered as important ones in this study are similar with the staff in the similar units than SRU needs to have in other countries, for example in United Kingdom [42], in Finland [14] and in Australia [44]. A standardisation of the function and competence requirements of SRUs in Sweden is needed. ...
Aim
The aim of this study was to describe the general attributes and competence that nurses in the ambulance’s single responder units are considered to need.
Background
The development of ambulance care has led to an increased need for new units and working methods. Single responder unit is a single crewed unit that often uses for the patient assessments, to refer patients to the right level of care and to release regular ambulances. There is a lack of description of the needed competence for the nurses within single responder unit.
Methods
Modified Delphi with three rounds was used. The first round was conducted with focus group interviews and analysed with content analysis. Five competence categories and 19 subcategories were identified. The second and third rounds were conducted through surveys using a 4-point Likert scale and analysed with descriptive statistics.
Results
The ability to communicate with other healthcare providers to achieve one’s goal, the ability to create a good encounter alone and to have appropriate professional experience were identified as the most important general attributes and competencies.
Conclusions
A central competence in prehospital emergency care is the ability to independently assess and treat patients with varying care needs in complex environments. To be able to work in SRU requires good communication and collaborations skills with other healthcare providers but it is also a prerequisite for creating a good patient relationship. Work experience of taking care of varying patients and situations is also needed in SRU.
... There is a perception that research access to JAS is not equitable across HE institutions or for researchers using qualitative or novel research methodologies. 31,32 This concern was reinforced in a recent international study that found that while Australia is strongly represented in the paramedicine research literature, many of the authors were nonparamedics. 5 It is possible that the establishment of a more open access system or readily accessible data warehouse might better support the profession and arguably enhance the value of independent paramedicine research. ...
There has been exponential growth in paramedicine research activity and capacity over the last decade. With a strong academic culture emerging from its tertiary-based paramedicine education pathways, Australasia sits comfortably amongst the leading regions for paramedicine research. In the absence of clear paramedicine research priorities, there is concern that inadequate support infrastructure is in place to guide researchers, academics, paramedics, and policymakers within the profession to produce meaningful research capable of triggering change and advancement. The identification of paramedicine research priorities in Australasia, along with the barriers and enablers to research in this field, will prove invaluable to support the paramedicine profession, and improve healthcare systems, and patient outcomes in Australia and New Zealand. The study used a cross-sectional survey design which aimed to identify perceived barriers and enablers to the conduct of paramedicine research in Australasia and describe the demographic profiles and characteristics of respondents across professional, academic and research themes. Of the 341 respondents, 223 (65.4%) were male, 114 (33.4%) were female, and all geographical areas were represented. Approximately 60% of participants worked for a jurisdictional ambulance service in a clinical role. The median number of years of experience in paramedicine was 13 (IQR: 6, 24), with 52.8% having less than 15 years of experience. The analysis resulted in the identification of three themes for research barriers (system, process and human) and enablers, (work conditions, worker profile, and workplace). This study identifies the disconnect between stakeholders and the provision of resources such as funding, time, training, roles and data as major barriers to conducting paramedicine research. The ability or capacity of paramedics, as health professionals, to lead and undertake their own research was not questioned. The value of evidence-based research and autonomous paramedic-led research was identified as likely to empower future capacity within the profession.
... As in this study, previous research has identi ed that broad professional experience and social competence are necessary competencies within the SRU [11,14,37]. The nurses need, in addition to advanced clinical competence, skills in assessing and managing chronic diseases and mental illness and in mapping social needs [38, 39,40] ...
Aim
The aim of this study was to describe the general attributes and competence that nurses in the ambulance's single responder units are considered to need.
Background
The development of ambulance care has led to an increased need for new units and working methods. Single responder unit is a single crewed unit that often uses for the patient assessments, to refer patients to the right level of care and to release regular ambulances. There is a lack of description of the needed competence for the nurses within single responder unit.
Methods
Modified Delphi with three rounds was used. The first round was conducted with focus group interviews and analysed with content analysis. The second and third rounds were conducted through surveys using a 4-point Likert scale and analysed with descriptive statistics.
Results
Five competence categories were identified. 39 of 80 statements reached consensus. The ability to communicate with other actors to achieve one’s goal, the ability to create a good encounter alone and to have appropriate professional experience were identified as the most important general attributes and competencies.
Conclusions
Increased understanding of the needed competence within single responder unit can be implemented in prehospital recruitment and education. Further research on the function of single responder unit and the most appropriate formal competence of the emergency nurses in single responder units is needed.
... (32) Community paramedics, while not referred to in the report on government services, are paramedics employed to provide primary care and public health services -such as immunisation and chronic disease management -to rural and remote communities. (20,25,33) While not all ambulance services recruit for all of these positions, and roles and terminology differ between services both nationally and internationally, these are commonly understood definitions of these roles. The implementation of many of these roles has been effected to address the health disparities and challenges noted in regional, rural and remote communities due to limited access to both primary and emergency healthcare. ...
Introduction
Access to emergency healthcare services and specialist care – particularly paramedic services – is more restricted in the rural and remote areas of Australia, and this disparity is amplified further as remoteness increases. This review aims to investigate the availability of current research regarding both the expanding nature of paramedicine roles in rural environments, and the impacts of rurality on the quality of out-of-hospital care provided to patients.
Methods
Arksey and O'Malley's six-step methodological approach was used to perform a scoping review to assess the availability of literature. Key words including paramedic*, regional, rural, remote and role were inputted into the search engines Scopus, CINAHL and PubMed. Titles and abstracts of the 864 results were screened by all authors and inclusion/exclusion criteria applied, resulting in 13 remaining articles.
Results
The final 13 articles comprised differing data collection types and methodologies from nine separate studies conducted in either Canada, Australia, the United Kingdom, the United States, Saudi Arabia or Qatar. Approximately 2.5 million patients, 534 paramedics, 331 other healthcare professionals and 35 case studies were included in the total combined results of these studies.
Conclusion
Rural communities demonstrated increased mortality rates in out-of-hospital patients due to several factors including rostering, specialist service locations and limited resource availability. Factors which were beneficial to the outcomes of patients in rural settings included enhanced paramedic scopes of practice, the implementation of community paramedicine programmes and wider roles within the community for paramedics. A lack of research on the exact nature of these changing roles in rural paramedicine is evident.
Objective
To evaluate the alignment of undergraduate paramedicine curricula in Australia with the RESPIGHT model, focusing on diverse aspects such as emergency response, community engagement and governance.
Design
Deductive thematic analysis was conducted to assess the alignment of curricula from 16 Australian universities with the RESPIGHT framework.
Setting
The study reviewed undergraduate pre‐registration paramedicine programmes across Australian universities.
Participants
The study included a comprehensive analysis of curricula from 16 universities offering undergraduate paramedicine programmes.
Main Outcome Measure
The degree of alignment of paramedicine curricula with the RESPIGHT categories: emergency response, community engagement, situated practice, primary healthcare, integration with health services, governance, leadership and treatment and transport.
Results
The analysis revealed varying degrees of alignment across the RESPIGHT categories, with notable discrepancies in areas such as community engagement and governance. Some universities demonstrated strong alignment in emergency response and treatment, while others showed weaker integration with primary healthcare and community engagement.
Conclusion
The study highlights significant disparities in the preparedness of paramedicine students for the broad scope of practice required in modern healthcare. The findings underscore the need for curriculum reform to better prepare students for community care models and the evolving healthcare landscape, ensuring a more comprehensive and integrated approach to paramedicine education in Australia.
The field of Soft Operational Research (Soft OR) has emerged from the attempt to address contextually rich, multi-actor ‘wicked’ problems that are not amenable to traditional ‘hard’ operational research techniques, which often rely on mathematical modelling. This study assesses the use of Soft OR techniques in climate change policymaking. Since climate change problems are classical wicked problems, many assume that Soft OR would be in high demand in developing climate change policy. And the review of the use of these techniques conducted here does find that in the cases where Soft OR methods have been used by academics and other non-governmental actors, they have consistently provided useful results for policymaking. It is puzzling therefore that there is little evidence of governments using Soft OR application in this area. We study two cases of explicit (in Bristol UK) and implicit use (Rhode Island, US) of such techniques by governments to explain why this is so. We argue that notwithstanding the challenges the two cases reveal in their application, Soft OR nevertheless has much to offer policymakers in the arena of climate change policymaking and deserve more attention and use.
Background:
Despite health care advances, artificial intelligence and government interventions aiming to improve the health and wellbeing of citizens, huge disparities and failures in care provision exist. This is demonstrated by the rising number of medical errors, increase in readmission rates and mortality rates, and the failure of many health systems to successfully cope with events, such as pandemics and natural disasters. This shortfall is in part because of the complexity of the health care system, the interconnectedness of various parts of service, funding models, the complexity of patients' conditions, patient and carer needs, and the clinical processes needed for patients via multiple providers.
Objective:
The objective of this paper is to describe the use of system thinking methodologies to address complex problems such as those in the public health and health services domains.
Method:
A description of the system thinking methodology and its associated methods including causal loop diagrams, social network analysis and soft system methodology are described with examples in the health care setting.
Results:
There are various models of knowledge translation that have been employed including the Joanna Briggs Institute model of implementation of evidence into practice, the triple C, and the Promoting Action on Research Implementation in Health Services. However, many of these models are neither scalable nor sustainable, and are most effective for localized projects implemented by trained clinicians and champions in relevant settings.System thinking is essentially a modelling process, which aims to create opportunities for change via an appreciation of perspective, and recognition that complex problems are a result of interconnected factors. The article argues that systems thinking applications need to move beyond that of addressing complex health issues pertaining to a population, and rather consider complex problems surrounding the delivery of high-quality health care.
Conclusion:
It is important that methods to implement systems thinking methodologies in health care settings are developed and tested.
Introduction: This article aimed to evaluate pilot community paramedicine (CP) programs in northern Ontario from the perspectives of paramedics to gain program recommendations related to both rural and urban settings.
Methods: An online questionnaire was created and distributed to 879 paramedics with and without CP experience employed at eight emergency medical services providers in northern Ontario. An explanatory sequential design was used to analyze and synthesize the results from the quantitative survey items and the open-ended responses.
Results: Seventy-five (40.5%) respondents participated in a CP program, and the majority of 75 paramedics who indicated they participated in CP (n=41, 54.4%) were from rural areas. CP was generally well received by both paramedics currently practicing CP and those who were not practicing CP. The majority (86.3%) of paramedics stated paramedics should be practicing CP in the future. Paramedics identified developing professional relationships and improving health promotion as positive aspects of CP. Areas for CP program improvement included better organization and scheduling, improved training and a need for better patient tracking software.
Conclusion: Engaging and consulting paramedics in the ongoing process of CP development and implementation is important to ensure they feel valued and are part of the change process.
Background:
Updating, improving and spreading the evidence base for healthcare practices has proven to be a challenge of considerable magnitude - a wicked, multi-dimensional problem. There are many interlinked factors which determine how, why and whether any particular implementation effort or intervention succeeds. Soft Systems Methodology (SSM), strongly grounded in systems ideas and complexity science, offers a structured, yet flexible process for dealing with situations that are perceived as problematical and in need of improvement. The aim of this paper is to propose the use of SSM for managing change in healthcare by way of addressing some of the complexities. The aim is further to illustrate examples of how SSM has been used in healthcare and discuss the features of the methodology that we believe can be harnessed to improve healthcare.
Discussion:
SSM is particularly suited for tackling real world problems that are difficult to define and where stakeholders may have divergent views on the situation and the objectives of change. SSM engages stakeholders in a learning cycle including: finding out about the problematical situation, i.e. the context in which the problem exists, by developing a rich picture of the situation; defining it by developing conceptual models and comparing these with the real world; taking action to improve it by deciding on desirable and feasible improvements; and implementing these in an iterative manner. Although SSM has been widely used in other sectors, it has not been extensively used in healthcare. We make the case for applying SSM to implementation and improvement endeavours in healthcare using the example of getting clinicians at the hospital level to use evidence-based guidelines.
Conclusion:
Applying SSM means taking account of the multi-dimensional nature of care settings, and dealing with entrenched and unique contexts, cultures and socio-political ecosystems - precisely those that manifest in healthcare. There are gains to be made in appreciating complexity and facilitating contextualization of interventions, and by approaching improvements in an iterative learning cycle.
INTRODUCTION: Community paramedicine is one emerging model filling gaps in rural healthcare delivery. It can expand the reach of primary care and public health service provision in underserviced rural communities through proactive engagement of paramedics in preventative care and chronic disease management. This study addressed key research priorities identified at the National Agenda for Community Paramedicine Research conference in Atlanta, USA in 2012. The motivations, job satisfaction and challenges from the perspectives of community paramedics and their managers pioneering two independent programs in rural North America were identified. METHODS: An observational ethnographic approach was used to acquire qualitative data from participants, through informal discussions, semi-structured interviews, focus groups and direct observation of practice. During field trips over two summers, researchers purposively recruited participants from Ontario, Canada and Colorado, USA. These sites were selected on the basis of uncomplicated facilitation of ethics and institutional approval, the diversity of the programs and willingness of service managers to welcome researchers. Thematic analysis techniques were adopted for transcribing, de-identifying and coding data that allowed identification of common themes. RESULTS: This study highlighted that the innovative nature of the community paramedic role can leave practitioners feeling misunderstood and unsupported by their peers. Three themes emerged: the motivators driving participation, the transitional challenges facing practitioners and the characteristics of paramedics engaged in these roles. A major motivator is the growing use of ambulances for non-emergency calls and the associated need to develop strategies to combat this phenomenon. This has prompted paramedic service managers to engage stakeholders to explore ways they could be more proactive in health promotion and hospital avoidance. Community paramedicine programs are fostering collaborative partnerships between disciplines, while the positive outcomes for patients and health cost savings are tangible motivators for paramedic services and funders. Paramedics were motivated by a genuine desire to make a difference and attracted to the innovative nature of a role delivering preventative care options for patients. Transitional challenges included lack of self-regulation, navigating untraditional roles and managing role boundary tensions between disciplines. Community paramedics in this study were largely self-selected, genuinely interested in the concept and proactively engaged in the grassroots development of these programs. These paramedics were comfortable integrating and operating within multidisciplinary teams. CONCLUSIONS: Improved education and communication from paramedic service management with staff and external stakeholders might improve transitional processes and better support a culture of inclusivity for community paramedicine programs. Experienced and highly motivated paramedics with excellent communication and interpersonal skills should be considered for community paramedic roles. Practitioners who are proactive about community paramedicine and self-nominate for positions transition more easily into the role: they tend to see the 'bigger picture', have broader insight into public health issues and the benefits of integrative health care. They are more likely to achieve higher job satisfaction, remain in the role longer, and contribute to better long-term program outcomes. Paramedic services and policymakers can use these findings to incentivize career pathways in community paramedicine and understand those changes that might better support this innovative model.
Introduction:
For the past 50 years paramedic services and paramedic roles in high-income nations have evolved in response to changes in community needs and expectations. The aim of this article is to review paramedic models of service delivery, with an emphasis on models that have the potential to improve the health and wellbeing of frontier and remote populations.
Methods:
Paramedic models of relevance to rural and frontier settings were identified from searches of CINHAL and Medline, while key paramedic-specific journals were individualy searched in the event that they were not indexed. Search terms were ambulance, paramedic and EMS. These were then combined with model* and rural, remote and frontier. These findings were then synthesised.
Results:
During the 1950s and 1960s the volunteer transport model, based on the values of community informed self-determination, developed to meet local needs for transport to local hospitals and medical services. Somewhat later, the technological model, characterised by professionally staffed and managed paramedic systems providing prehospital using advanced technology and technically skilled staff, became the dominant model in metropolitan and regional settings. Paramedic practitioner models are now emerging that are part of integrated prehospital systems. These provide a range of services to prevent injury and illness, respond to emergencies and facilitate recovery, and contribute to efforts to produce a healthy community.
Conclusions:
Implementation of paramedic practitioner models in frontier and remote settings raises challenging policy and practice issues, including changes in scopes of practice, design of education programs, self-regulation of paramedics, and reimbursement.
Human perceptions under unstructured forms contain valuable information for ecological restoration (ER). To aid in ER, this paper introduces a working process to analyze the unstructured information for the case study of black bear restoration (BBR) in East Texas where understanding of the perceptions of stakeholders at a community level is needed. We identified the current situation, revealed stakeholders and their interactions, and developed actions for change for BBR. Our techniques included recording discussions in meetings, Soft Systems Methodology, and stakeholder analysis. Results indicated the current situation of BBR with human-bear and human-human conflicts. We figured out that information exchange was interrupted in the public, a potential cause for conflicts. Through a systemization, results showed various roles of key stakeholders and constraints for BBR. We found that local state agencies and local residents (particularly landowners) are the key decision-makers for BBR success. Their collaboration can result in a small portion of success (1/9) that can be increased by more cooperation. The SSM framework introduced in this study can be used for modeling community perceptions in ecological restoration.
Background
Expanded roles for paramedics, commonly termed community paramedicine, are becoming increasingly common. Paramedics working in community paramedicine roles represent a distinct departure away from the traditional emergency paradigm of paramedic services. Despite this, little research has addressed how community paramedics are perceived by their clients. Methods
This study took an interpretivist qualitative approach to examine participants’ perceptions of paramedics providing a community paramedicine program, named the Community Health Assessment Program through Emergency Medical Services (CHAP-EMS). Both participant observation and semi-structured interviews conducted with program participants were used to gain insight into the on-the-ground experiences of the program. Thematic analysis was employed to analyze all data. ResultsThree themes emerged: i) Caring and trusting relationships; ii) paramedics as health advocates; iii) the added value of EMS skills. Paramedics were perceived by residents as having dual identities: first in a novel role as health advocates and secondly in a traditional role as emergency experts despite lacking contextual features associated with emergency response. Conclusions
From this exploratory, qualitative study we present an emerging framework in which to conceptualize paramedic roles in community paramedicine settings. Future research should address the saliency of these roles in different contexts and how these roles relate to paramedic practice.
Objectives: This paper reports on the extent of the peer-reviewed literature relating to community paramedics since the inaugural meeting of the International Roundtable on Community Paramedicine in 2005. A scoping review was undertaken to: examine the extent, range and nature of research activity; determine the value of undertaking a full systematic review; summarise and disseminate research findings; and identify research gaps in the existing literature.
Methods: This scoping study systematically searched and located literature on community paramedics from 2005 to 2012 irrespective of study design. It mapped the key concepts underpinning the emergence of community paramedics and the main sources and types of evidence available. In this review the concept of community paramedics as defined by the International Roundtable on Community Paramedicine was used as the key reference point.
Results: The community paramedicine literature fell into three broad categories: theoretical studies; empirical studies measuring outcomes; and reviews. While there are few peer-reviewed articles, a growing number of empirical studies are beginning to emerge as a result of programme evaluations in various regions of the world. At this time there are a handful of relevant reviews in the literature that are focused on innovations in paramedic practice. One Australian research team has published all of the peer-reviewed theoretical papers underpinning this innovation in paramedic practice.
Conclusions: There is growing evidence of community paramedicine research in the literature, including some links with related studies, such as that of the extended care paramedic programmes in the United Kingdom. There remains a strong focus on commentaries and opinion papers in both peer-reviewed and trade publications. Nonetheless, there is an emerging research literature that is contributing to the development of community paramedicine programme models and the evaluation tools that will contribute toward the future evolution of the model.
A significant paradigm shift in the care of non-urgent, low-acuity patients by paramedics has been gathering momentum over the last two decades. However the current nomenclature to define paramedics who specialise in the low-acuity setting is confusing, inconsistent and arguably misrepresentative. This commentary contends that two discernible paradigms lie along the spectra of low-acuity service delivery in paramedicine and argues that the nomenclature should also reflect this difference. Consistency in nomenclature has implications for the evolving professionalism in paramedicine and the movement towards national registration.
p>With evidence based practice now the norm, paramedics today can confidently and easily search for answers to clinical questions. For anyone seeking to better understand the non-clinical aspects of paramedic practice, however; looking to social theory can be a starting point. Understanding social theory gives paramedic researchers a lens through which to closely examine every day events and behaviours that affect paramedic practice within the context of society. Arguably, the move towards professionalisation is one of the most significant events impacting paramedicine today. The process of professionalisation described by Wilensky (1964) is summarised by Williams et al. as involving five steps:
Development of a full-time occupation and formation of occupational territory;
Establishment of training schools or colleges; linkage to university education;
Occupational promotion to national and international parties;
Professional licensing and accreditation;
Code of ethics is implemented.
Australian paramedics have been moving through these steps with support for professional registration heightened in recent months. Alongside this professional evolution, the practitioner identity is gradually being challenged and reshaped, raising a number of important questions. Examples include, do paramedics feel that they are a discipline in transition? Do they see themselves as ‘more professional’ in the current climate? How do paramedics now see their role and how would they define themselves? A starting point to explore these and other non-clinical questions raised by professionalisation begins with appreciating how social theory can both inform the questions and guide the research to answer them. The purpose of this article is to explore how two prominent social theorists, Bourdieu and Goffman, can be used by paramedic researchers to explore inevitable questions related to professions and professional identity. </p
Background
Community paramedicine programs have emerged throughout North America and beyond in response to demographic changes and health system reform. Our aim was to identify and analyse how community paramedics create and maintain new role boundaries and identities in terms of flexibility and permeability and through this develop and frame a coherent community paramedicine model of care that distinguish the model from other innovations in paramedic service delivery.
Methods
Using an observational ethnographic case study approach, we collected data through interviews, focus groups and field observations. We then applied a combination of thematic analysis techniques and boundary theory to develop a community paramedicine model of care.
Results
A model of care that distinguishes community paramedicine from other paramedic service innovations emerged that follows the mnemonic RESPIGHT: Response to emergencies; Engaging with communities; Situated practice; Primary health care; Integration with health, aged care and social services; Governance and leadership; Higher education; Treatment and transport options.
Conclusions
Community engagement and situated practice distinguish community paramedicine models of care from other paramedicine and out-of-hospital health care models. Successful community paramedicine programs are integrated with health, aged care and social services and benefit from strong governance and paramedic leadership.
Objective:
To evaluate a community paramedicine program in rural Ontario, Canada, through the perceptions and experiences of consumers.
Design:
An observational ethnographic approach was used to acquire qualitative data through informal discussions, semi-structured interviews and direct observation of interactions between consumers and community paramedics.
Setting:
The study was conducted in rural Ontario where a community paramedicine program has been established consisting of four components: ad hoc home visiting, ageing at home, paramedic wellness clinics and community paramedic response unit.
Participants:
Fourteen adult consumers participated, representing all program components.
Main outcome measures:
Consumer satisfaction and perceived benefits.
Results:
Three main interlinked themes were identified: (i) improved health monitoring and primary health care access close to home; (ii) improved sense of security and support for vulnerable residents in the community; and (iii) improved consumer education and empowerment for enhanced health management.
Conclusions:
Consumers' reflections on their experiences and perceptions of a rural community paramedicine program indicate acceptance of paramedics in non-traditional preventative health care roles. This supports the desirability of investigating the potential development of community paramedicine programs in rural Australia to meet identified health service needs.
We used an observational, ethnographic research approach to identify the nature of the relationship between public engagement and the successful integration of a community paramedicine program with local health, aged care and social services in rural Ontario, Canada. Data were collected through a combination of direct observations of practice, informal discussions, interviews and focus groups. We found evidence of public engagement during the planning and implementation stages of the program, with strong participatory processes evident. There was some evidence of a culture of inclusiveness, despite the strength of the command and control heritage in emergency health services. The community paramedicine model is well placed to facilitate greater integration between paramedic services and health, aged and social services. Public engagement incorporating both participation and inclusiveness can lead to a closer alignment and integration between paramedic services and other services. This ‘grass-roots’ approach to interacting with local communities has the potential to better integrate paramedic services as part of a less-fragmented system across the health, aged care and social service sectors.
Objective. The aim of the present study was to describe the Ambulance Victoria (AV) secondary telephone triage service, called the Referral Service (RS), for low-priority patients calling triple zero. This service provides alternatives to ambulance dispatch, such as doctor or nurse home visits. Methods. A descriptive epidemiological review of all the cases managed between 2009 and 2012 was conducted, using data from AV case records, the Victorian Admitted Episodes Dataset and the Australian Bureau of Statistics. Cases were reviewed for patient demographics, condition, final disposition and RS outcome. Results. In all, 107 148 cases were included in the study, accounting for 10.3% of the total calls for ambulance attendance. Median patient age was 54 years and 55% were female. Geographically based socioeconomic status was associated with the rate of calls to the RS (r = -0.72; 95% confidence interval CI -0.104, -0.049; P < 0.001). Abdominal pain and back symptoms were the most common patient problems. Although 68% of patients were referred to the emergency department, only 27.6% of the total cases were by emergency ambulance; the remainder were diverted to non-emergency ambulance or the patient'sownprivate transport. The remaining32%of cases were referred to alternative service providers or given home care advice. Conclusions. This paper describes the use of an ongoing secondary triage service, providing an effective strategy for managing emergency ambulance demand.
This volume provides fresh insights and management understanding of the changing role of the ambulance services against the backdrop of massive cuts in health budgets around the world and the changing context of pre-hospital care within the wider healthcare networks. The challenges of funding, training and cultural transformation are now felt globally. The need to learn and adapt from suitable models of ambulance service delivery have never been greater. The book offers critical insights into the theory and practice of strategic and operational management of ambulance services and the leadership needs for the service. One of the highlight of this volume is to bring together scholarship using experts- academics, practitioners and professionals in the field, to each of the chosen topics. The chapters are based in the practical experiences of the authors and are written in a way that is accessible and suitable for a range of audiences. We are confident that this book will cater to a wider audience to inform policy and practice, both in the UK and internationally.
This chapter considers the impact of both new forms of police governance and the impact of cuts in funding to the police service in England and Wales. It assesses the implications of the 2012 Winsor Independent Review and the HR implications of the recommendations made within it for police officers. It evaluates the potential implications of outsourcing and future internal police management structures. It argues that much more positive workforce modernisation proposals which are evidence based have been sidelined in the movement towards private sector provision to police forces. Finally it explores the potential and real benefits arising from closer collaborative arrangements between both police forces and police and local authorities.
This paper presents a systemic methodology for identifying and analysing the stakeholders of an organisation at many different levels. The methodology is based on soft systems methodology and is applicable to all types of organisation, both for profit and non-profit. The methodology begins with the top-level objectives of the organisation, developed through debate and discussion, and breaks these down into the key activities needed to achieve them. A range of stakeholders are identified for each key activity. At the end, the functions and relationships of all the stakeholder groups can clearly be seen. The methodology is illustrated with an actual case study in Hunan University.
Introduction
Collaboration of emergency medical services and community organisations such as primary health care providers, social service agencies, and public safety groups can enable innovative initiatives that have the potential to improve the level of health care within a community and reduce health care system pressures. The purpose of this research is to evaluate the impact of an ‘aging at home’ program that uses an integrated health care team involving community paramedics on 911 calls.
Methods
This study involved a retrospective case series involving a chart review of clients participating in the ‘Aging at Home’ program located in a rural community in Ontario between January 1 2010 and April 30 2011. Each record was evaluated for the presenting problem and whether transport to a local hospital emergency department was initiated by using 911.
Results
Of the 129 client interactions by community paramedics and personal support workers, 13 chief complaint categories were determined and 15 incidents resulted in emergency department visits by using 911.
Conclusion
The use of community paramedics in an integrated health care team aimed at supporting clients living at home demonstrates a negative correlation in the use of 911 calls.
The incidence of chronic diseases, including diabetes mellitus (DM), heart failure (HF) and chronic obstructive pulmonary disease (COPD) is on the rise. The existing health care system must evolve to meet the growing needs of patients with these chronic diseases and reduce the strain on both acute care and hospital-based health care resources. Paramedics are an allied health care resource consisting of highly-trained practitioners who are comfortable working independently and in collaboration with other resources in the out-of-hospital setting. Expanding the paramedic’s scope of practice to include community-based care may decrease the utilization of acute care and hospital-based health care resources by patients with chronic disease.
This will be a pragmatic, randomized controlled trial comparing a community paramedic intervention to standard of care for patients with one of three chronic diseases. The objective of the trial is to determine whether community paramedics conducting regular home visits, including health assessments and evidence-based treatments, in partnership with primary care physicians and other community based resources, will decrease the rate of hospitalization and emergency department use for patients with DM, HF and COPD. The primary outcome measure will be the rate of hospitalization at one year. Secondary outcomes will include measures of health system utilization, overall health status, and cost-effectiveness of the intervention over the same time period. Outcome measures will be assessed using both Poisson regression and negative binomial regression analyses to assess the primary outcome.
The results of this study will be used to inform decisions around the implementation of community paramedic programs. If successful in preventing hospitalizations, it has the ability to be scaled up to other regions, both nationally and internationally. The methods described in this paper will serve as a basis for future work related to this study.
Trial registration
ClinicalTrials.gov: NCT02034045. Date: 9 January 2014.
Objectives
This paper examines the issues that affect the quality of paramedic student clinical placements. Participants included paramedics, paramedic educators, paramedic students and ambulance service managers who had gathered for an Australian conference in Bendigo in central Victoria. The aim of this paper is to highlight issues identified by the participants and to start a conversation about the importance of clinical placement for paramedic students.
Methods
This was a qualitative study utilising ‘Community conversations’ as a research methodology. ‘Community conversations’ is an action research approach. This study had 53 participants, who spent around 5 hours in conversation throughout a 3-day conference. The conversation initiated was to discuss and raise issues that related to paramedic student clinical placements, and identify creative and innovative solutions.
Results
In this paper, we focus on three themes that emerged from the conversations: planning and preparation of the placement; continuity of placement experience; and diversity of placements. We argue that better communication is required between the university, the ambulance service, the paramedic educator/clinical instructor and the student.
Conclusions
Clinical education is an essential element of student learning and skill development, yet in Australia there are no mandatory requirements in relation to duration, content or measurement of quality in student clinical placements. We strongly recommend that continuity is an essential element of a quality clinical placement and argue that students should be allocated to work in one location for 1–2 week blocks.
Serious long-term recruitment and retention problems among rural health workers in Australia have contributed to inequitable health service access for rural Australians. In response new health care models with flexible workforce roles are emerging, including expanded-scope paramedic roles. Objective This research project addressed the need to develop more flexible and integrated services to improve rural Australians' health outcomes with a primary focus on the role of ambulance service personnel. The principal objective was to identify Australian and international trends in the evolving role of ambulance paramedics and to determine the key characteristics, roles and expected outcomes for an Expanded Scope of Practice (ESP) that are desirable, feasible and acceptable to key stakeholders.
Background. Paramedics are an important health human resource and are uniquely mobile in most communities across Canada. In the last dozen years, challenges in the delivery of health care have prompted governments from around the globe to consider expanding the role paramedics play in health systems. Utilizing paramedics for the management of urgent, low-acuity illnesses and injuries has been coined "community paramedicine," but the role, safety, and effectiveness of this concept are poorly understood. Objective. We undertook a systematic review of the international literature to describe existing community paramedic programs. Method. We used the Cochrane methodology for systematic reviews. An international group of experts developed a search strategy and a health information specialist executed this search in Medline, Embase, and CINAHL starting January 1, 2000. We included all research articles in the English language that reported a research methodology. We excluded commentaries and letters to the editor. Two investigators independently screened citations in a hierarchical manner and abstracted data. Results. Of 3,089 titles, 10 articles were included in the systematic review and one additional paper was author-nominated. The nature of the 11 articles was heterogeneous, and only one randomized controlled trial (RCT) was found. This trial showed community paramedicine to be beneficial to patients and health systems. The other articles drew conclusions favoring community paramedicine. Conclusion. Community paramedicine research to date is lacking, but programs in the United Kingdom, Australia, and Canada are perceived to be promising, and one RCT shows that paramedics can safely practice with an expanded scope and improve system performance and patient outcomes. Further research is required to fully understand how expanding paramedic roles affect patients, communities, and health systems.
Major health inequities between urban and rural populations have resulted in rural health as a reform priority across a number of countries. However, while there is some commonality between rural areas, there is increasing recognition that a one size fits all approach to rural health is ineffective as it fails to align healthcare with local population need. Community participation is proposed as a strategy to engage communities in developing locally responsive healthcare. Current policy in several countries reflects a desire for meaningful, high level community participation, similar to Arnstein's definition of citizen power. There is a significant gap in understanding how higher level community participation is best enacted in the rural context. The aim of our study was to identify examples, in the international literature, of higher level community participation in rural healthcare.
A scoping review was designed to map the existing evidence base on higher level community participation in rural healthcare planning, design, management and evaluation. Key search terms were developed and mapped. Selected databases and internet search engines were used that identified 99 relevant studies.
We identified six articles that most closely demonstrated higher level community participation; Arnstein's notion of citizen power. While the identified studies reflected key elements for effective higher level participation, little detail was provided about how groups were established and how the community was represented. The need for strong partnerships was reiterated, with some studies identifying the impact of relational interactions and social ties. In all studies, outcomes from community participation were not rigorously measured.
In an environment characterised by increasing interest in community participation in healthcare, greater understanding of the purpose, process and outcomes is a priority for research, policy and practice.
This paper examines the SSM technique CATWOE, which focuses on defining necessary elements that together constitute a human activity system from a certain perspective. Despite its recognition within the literature and its numerous uses, there are few studies on how the technique can be improved. This research reflects on each of the elements both from a theoretical and a practical perspective. Findings point to the fact that some of the terms have a meaning in everyday language that differs from its definition within CATWOE. Other concepts are not well-defined. This is unfortunate and may both lead to misunderstandings and limit analysis. The paper points to a number of ways in which the use of CATWOE can be developed in order to further support the process of eliciting novel ideas for future actions. Hence, the overall conclusion is that the elements need to be rethought and some of them renamed.
Existing rural prehospital models have been criticised for being isolated from the healthcare system, and for following inflexible clinical protocols. Greater reliance on clinical judgement and informed decision making in the prehospital setting offer the potential to improve patient care.
Soft systems methodology was used to develop and critically appraise the prehospital practitioner model as an alternative to existing models. This approach started from the philosophical viewpoint that prehospital services should be patient centred. Soft systems methodology was used to structure the elements of prehospital systems and the relations between them into metaphors and pictures that could be analysed.
This analysis showed that the most powerful reason for advocating the prehospital practitioner model is that it places prehospital systems within a symbiotic relationship with the healthcare system. Unlike the existing emergency service models or the "chain of survival" model, it is an integrated system that provides a range of services at multiple points during the patient care cycle. Thus, the prehospital practitioner would have roles in the prevention of injury and illness, responding to emergencies, facilitating recovery, and planning future strategies for a healthy community.
Implementing this new model would see the prehospital system using its available capacity more effectively to fulfill broader public health and primary care outreach roles than is currently the case. Patients would be referred or transported to the most appropriate and cost effective facility as part of a seamless system that provides patients with well organised and high quality care.
A small, isolated community in the south east of Australia, Malacoota, had a long-standing concern about the adequacy of their emergency medical systems. There was no hospital, the local medical practitioners were under stress and their ambulance services were limited. Following an approach through the local Division of General Practice in August 2002, the School of Rural Health at Monash University was invited to assist.
A policy development toolkit was used to improve the rural urgent care systems through engagement with community members. The process involved community consultation, a meeting of key stakeholders, and the formation of a representative Steering Committee to oversee the local management of the project. Project officers worked with a university facilitator and other stakeholders to implement the Transforming Rural Urgent Care Systems (TrUCs) process from August 2002 to June 2003. A proposal of recommendations was put to the Victorian State Minister of Health and this was accompanied by a degree of political action. The submission raised the issues of poor interstate communications, ambulance staffing, support for medical practitioners, facilities for the stabilisation of patients, and access to air ambulance services. Funding was obtained for the implementation of a community paramedic model. Ambulance service communications systems improved and an innovative model of ambulance service delivery for isolated communities was implemented.
A number of lessons have been identified, including the crucial role of the project officers, and communication within the community and among specific stakeholders. The approach used could be adopted in other rural locations hoping to improve their emergency health services.
p> Background
Professionalisation was cited as one of the key drivers for the recent addition of paramedics to the National Accreditation and Regulation Scheme (NRAS) making paramedics the fifteenth health profession in the NRAS. Self-regulation inherently shifts the basis of establishing professional identity and the formal authority for determining professional standards. This has increased discussion of professionalism in paramedicine, however, professionalisation and professionalism are often poorly defined concepts with a myriad of interpretations.
Method
A scoping review was conducted to determine the available literature about professionalism and professionalisation in paramedicine. The review utilised 10 academic databases augmented with Google and Google Scholar to capture grey literature; 2740 results were refined to 53 sources for review.
Results
Several works on paramedic professionalisation explore elements such as autonomy and occupational characteristics. Others consider the process of professionalisation for United Kingdom (UK) and Australian paramedics. Education is discussed as a key factor in professionalism, while the increasing scope and diversity of roles in paramedicine is explored as indicative of professionalisation. Several UK papers relate professionalisation and culture to change processes within paramedicine and paramedic organisations.
Discussion
Academic work on professionalisation and professionalism in paramedicine appears sporadic and may benefit from explorations of a wider range of theories. Paramedicine has been described as constantly and rapidly developing around its practitioners rather than being a stable profession where practitioners enter with clear expectations of their ongoing identity. Further work is needed to understand the process of professionalisation that paramedicine is undergoing within its cultural and professional context.</p
Background
Community paramedicine (CP) leverages trained emergency medical services personnel outside of emergency response as an innovative model of health care delivery. Often used to bridge local gaps in healthcare delivery, the CP model has existed for decades. Recently, the number of programs has increased. However, the level of robust data to support this model is less well known.
Objective
To describe the evidence supporting community paramedicine practice.
Data sources
OVID, PubMed, SCOPUS, EMBASE, Google Scholar-WorldCat, OpenGrey.
Study appraisal and synthesis methods
Three people independently reviewed each abstract and subsequently eligible manuscript using prespecified criteria. A narrative synthesis of the findings from the included studies, structured around the type of intervention, target population characteristics, type of outcome and intervention content is presented.
Results
A total of 1098 titles/abstracts were identified. Of these 21 manuscripts met our eligibility criteria for full manuscript review. After full manuscript review, only 6 ultimately met all eligibility criteria. Given the heterogeneity of study design and outcomes, we report a description of each study. Overall, this review suggests CP is effective at reducing acute care utilization.
Limitations
The small number of available manuscripts, combined with the lack of robust study designs (only one randomized controlled trial) limits our findings.
Conclusions
Initial studies suggest benefits of the CP model; however, notable evidence gaps remain.
Background
Since the beginning of 2000, the primary healthcare services around the globe are challenged between demands of home care and number of staff delivering it. The delivery of healthcare needs new models to reduce the costs, patient's readmission and increase their possibilities to stay at home. Several paramedicine programmes have been developed to deliver home care as an integral part of the local healthcare system. The programmes varied in nature and the concept of Community Paramedicine (CP) has not been established, demanding clarity. The aim of this review was to identify and describe the core components of CP, and identify research gaps for the further study.
Method
A scoping review was performed using five electronic databases: Medline; CINAHL; Academic Search Premier; PubMed and the Cochrane Library for the period 2005 – June 2018. The references of articles were checked, and papers were assessed against inclusion criteria and appraised for quality.
Results
From 803 initial articles, 21 met the criteria and were included. Inductive content analysis was carried out. The four core components of Community Paramedicine emerged (a) Community engagement, (b) Multi‐agency collaboration, (c) Patient‐centred prevention and (d) Outcomes of programme: cost‐effectiveness and patients’ experiences.
Conclusion
The Community Paramedicine programmes are perceived to be promising. However, Community Paramedicine research data are lacking. Further research is required to understand whether this novel model of healthcare is reducing costs, improving health and enhancing people's experiences.
As health care systems in the United States have become pressured to provide greater value, they have embraced the adoption of innovative population health solutions. One of these initiatives utilizes prehospital personnel in the community as an extension of the traditional health care system. These programs have been labeled as Community Paramedicine (CP) and Mobile Integrated Health (MIH). While variation exists amongst these programs, generally efforts are targeted at individuals with high rates of health care utilization. By assisting with chronic disease management and addressing the social determinants of health care, these programs have been effective in decreasing Emergency Medical Services (EMS) utilization, emergency department visits, and hospital admissions for enrolled patients.
The actual training, roles, and structure of these programs vary according to state oversight and community needs, and while numerous reports describe the novel role these teams play in population health, their utilization during a disaster response has not been previously described. This report describes a major flooding event in October 2015 in Columbia, South Carolina (USA). While typical disaster mitigation and response efforts were employed, it became clear during the response that the MIH providers were well-equipped to assist with unique patient and public health needs. Given their already well-established connections with various community health providers and social assistance resources, the MIH team was able to reconnect patients with lost medications and durable medical equipment, connect patients with alternative housing options, and arrange access to outpatient resources for management of chronic illness.
Mobile integrated health teams are a potentially effective resource in a disaster response, given their connections with a variety of community resources along with a unique combination of training in both disease management and social determinants of health. As roles for these providers are more clearly defined and training curricula become more developed, there appears to be a unique role for these providers in mitigating morbidity and decreasing costs in the post-disaster response. Training in basic disaster response needs should be incorporated into the curricula and community disaster planning should identify how these providers may be able to benefit their local communities.
Gainey CE, Brown HA, Gerard WC. Utilization of mobile integrated health providers during a flood disaster in South Carolina (USA). Prehosp Disaster Med.
Purpose
There is a growing academic interest in the examination and exploration of work intensification in a wide range of healthcare settings. The purpose of this paper is to explore the differing staff perceptions in emergency ambulance services in the UK. It provides evidence on the challenges for the paramedic professionalisation agenda and managing operational demands and work intensity in emotionally challenging circumstances, with significant implications for patient safety.
Design/methodology/approach
Drawing on the evidence from an empirical study in a large National Health Service ambulance trust in England, this paper examines the challenges and differing staff perceptions of the changing scope and practice of ambulance personnel in the UK. Amidst the progress on the professionalisation of the paramedic agenda, individual trusts are facing challenges in form of staff attitudes towards meeting performance targets, coupled with rising demand, fear of loss of contracts and private competition.
Findings
Research findings highlight differing perceptions from various sub-cultural groups and lack of clarity over the core values which are reinforced by cultural and management differences. Need for greater management to explore the relationship between high sickness levels and implications for patient safety including the need for policy and research attention follows from this study. The implications of work intensity on gender equality within the ambulance settings are also discussed.
Research limitations/implications
Ambulance services around the world are witnessing a strain on their operational budgets with increasing demand for their services. Study evidence support inconclusive evidence for patent safety despite the growing specialist paramedic roles. Organisational implications of high staff sickness rates have been largely overlooked in the management literature. This study makes an original contribution while building upon the earlier conceptions of work intensification.
Practical implications
The study findings have significant implications for the ambulance services for better understanding of the staff perceptions on work intensity and implications for patient safety, high sickness absence rates amidst increasing ambulance demand. Study findings will help prepare the organisational policies and design appropriate response.
Social implications
Societal understanding about the organisational implications of the work intensity in an important emergency response service will encourage further debate and discussion.
Originality/value
This study makes an original contribution by providing insights into the intra-organisational dynamics in an unusual organisational setting of the emergency ambulance services. Study findings have implications for further research inquiry into staff illness, patient safety and gender issues in ambulance services. Evidence cited in the paper has further relevance to ambulance services globally.
One of the intellectual legacies of the 50s and 60s was the approach to tackling real-world problems embodied in such methodologies as Systems Engineering and RAND Corporation Systems Analysis. Such methodology entails a search for the best means to achieve an end defined as desirable. In a programme of collaborative research undertaken in real problem situations, such an approach was found inadequate when faced with obscure objectives and multiple legitimate viewpoints. The alternative which emerged, Soft Systems Methodology, SSM, uses models of purposeful activity systems to set up a debate about change and learns its way to changes which would be both (systematically) desirable and (culturally) feasible. The shift from a paradigm of optimizing to one of learning marks the new systems thinking of the 70s and 80s the emergence and nature of SSM as described.
Various initiatives are using emergency medical service personnel to address critical problems in local U.S. delivery systems, such as insufficient primary and chronic care resources, overburdened EDs, and costly, fragmented emergency and urgent care networks.
Objectives:
Long-term care (LTC) patients are often sent to emergency departments (EDs) by ambulance. In this novel extended care paramedic (ECP) program, specially trained paramedics manage LTC patients on site. The objective of this pilot study was to describe the dispatch and disposition of LTC patients treated by ECPs and emergency paramedics.
Methods:
Data were collected from consecutive calls to 15 participating LTC facilities for 3 months. Dispatch determinants, transport rates, and relapse rates were described for LTC patients attended by ECPs or emergency paramedics. ECP involvement in end-of-life care was identified.
Results:
Of 238 eligible calls, 140 (59%) were attended by an ECP and 98 (41%) by emergency paramedics. Although the top three determinants were the same in each group, the overall distribution of dispatch determinants and acuity differed. In the ECP cohort, 98 of 140 (70%) were treated and released, 33 of 140 (24%) had "facilitated transfer" arranged by an ECP, and 9 of 140 (6%) were immediately transported to the ED by ambulance. In the emergency paramedic cohort, 77 of 98 (79%) were immediately transported to the ED and 21 of 98 (21%) were not transported. In the ECP group, 6 of 98 (6%) patients not transported triggered a 911 call within 48 hours for a related clinical reason, although none of the patients not transported by emergency paramedics relapsed.
Conclusion:
ECP involvement in LTC calls was found to reduce transports to the ED with a low rate of relapse. These pilot data generated hypotheses for future study, including determination of appropriate populations for ECP care and analysis of appropriate and safe nontransport.
Abstract Objective. An extended-care paramedic (ECP) program was implemented to provide emergency assessment and care on site to long-term care (LTC) residents suffering acute illness or injury. A single paramedic works collaboratively with physicians, LTC staff, patient, and family to develop care plans to address acute situations, often avoiding the need to transport the resident to hospital. We sought to identify insights gained and lessons learned during implementation and operation of this novel program. Methods. The perceptions and experiences of various stakeholders were explored in focus groups, using a semi-structured interview guide. Two investigators independently conducted thematic analysis and identified emerging themes and related codes. Congruence and differences were discussed to achieve consensus. Results. Twenty-one participants took part in four homogeneous focus groups: paramedics and dispatchers, ECPs, ECP oversight physicians, and decision-makers. The key themes identified were (1) program implementation, (2) ECP process of care, (3) communications, and (4) end-of-life care. Conclusion. The ECP program has positive implications for the relationship between EMS and LTC, requires additional paramedic training, and can positively affect LTC patient experiences during acute medical events. ECPs have a novel role to play in end-of-life care and find this new role rewarding.
Aim This longitudinal study was designed to address four research questions and the hypothesis; that adults living in a rural community receiving primary health care and emergency services from a team that included an on-site nurse practitioner (NP) and paramedics and an off-site family physician would, over time, demonstrate evidence of improved psychosocial adjustment and less expenditure of health care resources.Background In Canada, there is a growing awareness and commitment to addressing the challenges of providing primary health care services in rural areas. A literature review supported the role of NPs in primary health care and a potential role for paramedics. No studies were found that evaluated the combination of NPs, paramedics and physicians as providers of primary health care.Methods Structured questionnaires, individual and group interviews with patients, health and social service care providers and administrators and community members were used to describe and evaluate the impact of the model of care over the three years of the study.Findings The innovative model of care resulted in decreased cost, increased access, a high level of acceptance and satisfaction and effective collaboration among care providers. Organizational structures to support the innovative model of primary health care were identified.
There are many complicated and seemingly intractable problems in the health care sector. Past ways to address them have involved political responses, economic restructuring, biomedical and scientific studies, and managerialist or business-oriented tools. Few methods have enabled us to develop a systematic response to problems. Our version of soft systems methodology, SSM+, seems to improve problem solving processes by providing an iterative, staged framework that emphasises collaborative learning and systems redesign involving both technical and cultural fixes.
Community paramedicine: a promising model for integrating emergency and primary care
- K Kizer
- K Shore
- A Moulin
Kizer K, Shore K, Moulin A. Community paramedicine: a
promising model for integrating emergency and primary
care. California report 2013;1-24. Available at: https://
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Community paramedicine in Canada
- M Nolan
- T Hillier
- D' Angelo
Nolan M, Hillier T, D'Angelo C. Community paramedicine in
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Community paramedicine: a historical review of policy development
- K Krumperman
Krumperman K. Community paramedicine: a historical
review of policy development. EMS Insider 2010;37:3-6.
A framework for implementing community paramedic programs in British Columbia
- M Ivashkevich
- M Fitzgerald
Ivashkevich M, Fitzgerald M. A framework for implementing
community paramedic programs in British Columbia.
Ambulance Paramedics of British Columbia
- B C Richmond
Richmond, BC, Ambulance Paramedics of British
Columbia. CUPE 873;2014. Available at: www.apbc.ca/
files/3814/0916/4457/APBC_Community_Paramedicine_
Framework.pdf
Healthcare transformation: action research linking local practices to national scale
- H Bradbury
- W Allen
- J M Apgar
Bradbury H, Allen W, Apgar JM, et al. Healthcare
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