Paramedics assessing patients with complex comorbidities in community settings: results from the CARPE study

Identifying Features of a System of Practice to Inform a Contemporary Competency Framework for Paramedics in Canada

INTRODUCTION

Paramedic practice is highly variable, occurs in diverse contexts, and involves the assessment and management of a range of presentations of varying acuity across the lifespan. As a result, attempts to define paramedic practice have been challenging and incomplete. This has led to inaccurate or under-representations of practice that can ultimately affect education, assessment, and the delivery of care. In this study, we outline our efforts to better identify, explore, and represent professional practice when developing a national competency framework for paramedics in Canada.

METHODS

We used a systems-thinking approach to identify the settings, contexts, features, and influences on paramedic practice in Canada. This approach makes use of the role and influence of system features at the microsystem, mesosystem, exosystem, macrosystem, supra-macrosystem, and chronosystem levels in ways that can provide new insights. We used methods such as rich pictures, diagramming, and systems mapping to explore relationships between these contexts and features.

FINDINGS

When we examine the system of practice in paramedicine, multiple layers become evident and within them we start to see details of features that ought to be considered in any future competency development work. Our exploration of the system highlights that paramedic practice considers the person receiving care, caregivers, and paramedics. It involves collaboration within co-located and dispersed teams that are composed of other health and social care professionals, public safety personnel, and others. Practice is enacted across varying geographical, cultural, social, and technical contexts and is subject to multiple levels of policy, regulatory, and legislative influence.

CONCLUSION

Using a systems-thinking approach, we developed a detailed systems map of paramedic practice in Canada. This map can be used to inform the initial stages of a more representative, comprehensive, and contemporary national competency framework for paramedics in Canada.

Does a Community Care programme reach a high health need population and high users of acute care hospital services in Melbourne, Australia? An observational cohort study

OBJECTIVE

The Community Care programme is an initiative aimed at reducing hospitalisations and emergency department (ED) presentations among patients with complex needs. We aimed to describe the characteristics of the programme participants and identify factors associated with enrolment into the programme.

DESIGN

This observational cohort study was conducted using routinely collected data from the National Centre for Healthy Ageing data platform.

SETTING

The study was carried out at Peninsula Health, a health service provider serving a population in Melbourne, Victoria, Australia.

PARTICIPANTS

We included all adults with unplanned ED presentation or hospital admission to Peninsula Health between 1 November 2016 and 31 October 2017, the programme's first operational year.

OUTCOME MEASURES

Community Care programme enrolment was the primary outcome. Participants' demographics, health factors and enrolment influences were analysed using a staged multivariable logistic regression.

RESULTS

We included 47 148 adults, of these, 914 were enrolled in the Community Care programme. Participants were older (median 66 vs 51 years), less likely to have a partner (34% vs 57%) and had more frequent hospitalisations and ED visits. In the multivariable analysis, factors most strongly associated with enrolment included not having a partner (adjusted OR (aOR) 1.83, 95% CI 1.57 to 2.12), increasing age (aOR 1.01, 95% CI 1.01 to 1.02), frequent hospitalisations (aOR 7.32, 95% CI 5.78 to 9.24), frequent ED visits (aOR 2.0, 95% CI 1.37 to 2.85) and having chronic diseases, such as chronic pulmonary disease (aOR 2.48, 95% CI 2.06 to 2.98), obesity (aOR 2.06, 95% CI 1.39 to 2.99) and diabetes mellitus (complicated) (aOR 1.75, 95% CI 1.44 to 2.13). Residing in aged care home and having high socioeconomic status) independently associated with reduced odds of enrolment.

CONCLUSIONS

The Community Care programme targets patients with high-readmission risks under-representation of individuals residing in residential aged care homes warrants further investigation. This study aids service planning and offers valuable feedback to clinicians about programme beneficiaries.

Defining a threshold above which an adult can be considered to frequently use ambulance services: a retrospective cross-sectional study of emergency calls to an ambulance service in England

Objective

There is no empirical definition of adult frequent use of ambulance services. This study aimed to define a threshold, and utilise this to explore characteristics of people frequently using services.

Methods

This was a retrospective cross-sectional study in a single ambulance service in England. Routinely collected, pseudo-anonymised call- and patient-level data were collected for two months (January and June 2019). Incidents, defined as independent episodes of care, were analysed using a zero-truncated Poisson regression model to determine a suitable frequent-use threshold, with comparisons subsequently made between frequent and non-frequent users.

Results

A total of 101,356 incidents involving 83,994 patients were included in the analysis. Two potentially appropriate thresholds were identified: five incidents per month (A); and six incidents per month (B). Threshold A produced 3137 incidents from 205 patients, with five patients likely false-positive identifications. Threshold B produced 2217 incidents from 95 patients, with no false-positive identifications but 100 false-negatives compared to threshold A. Regardless of threshold, frequent users compared to non-frequent users had relatively reduced service use between 08:00 and 15:00, were younger and were more likely to receive lower-priority responses (all p < 0.001). We identified several chief complaints indicative of increased frequent use, including chest pain, psychiatric/suicide attempt and abdominal pains/problems.

Conclusions

We suggest a threshold of five incidents per month, with recognition that a small number of patients may be incorrectly identified as using ambulance services frequently. The rationale for this choice is discussed. This threshold may be applicable in wider UK settings and could be used for the routine automated identification of people using ambulance services frequently. The identified characteristics can help inform interventions. Future research should examine applicability of this threshold in other UK ambulance services and countries where patterns and determinants of frequent ambulance use may differ.

The development of community paramedicine; a restricted review

Community paramedic roles are expanding internationally, and no review of the literature could be found to guide services in the formation of community paramedicine programmes. For this reason, the aim of this restricted review was to explore and better understand the successes and learnings of community paramedic programmes across five domains being; education requirements, models of delivery, clinical governance and supervision, scope of roles and outcomes. This restricted review was conducted by searching four databases (CENTRAL, ERIC, EMBASE, MEDLINE and Google Scholar) as well as grey literature search from 2001 until 28/12/2021. After screening, 98 articles were included in the narrative synthesis. Most studies were from the USA (n = 37), followed by Canada (n = 29). Most studies reported on outcomes of community paramedicine programmes (n = 50), followed by models of delivery (n = 28). The findings of this review demonstrate a lack of research and understanding in the areas of education and scope of the role for community paramedics. The findings highlight a need to develop common approaches to education and scope of role while maintaining flexibility in addressing community needs. There was an observable lack of standardisation in the implementation of governance and supervision models, which may prevent community paramedicine from realising its full potential. The outcome measures reported show that there is evidence to support the implementation of community paramedicine into healthcare system design. Community paramedicine programmes result in a net reduction in acute healthcare utilisation, appear to be economically viable and result in positive patient outcomes with high patient satisfaction with care. There is a developing pool of evidence to many aspects of community paramedicine programmes. However, at this time, gaps in the literature prevent a definitive recommendation on the impact of community paramedicine programmes on healthcare system functionality.

Palliative care models for patients living with advanced cancer: a narrative review for the emergency department clinician

Eighty-one percent of persons living with cancer have an emergency department (ED) visit within the last 6 months of life. Many cancer patients in the ED are at an advanced stage with high symptom burden and complex needs, and over half is admitted to an inpatient setting. Innovative models of care have been developed to provide high quality, ambulatory, and home-based care to persons living with serious, life-limiting illness, such as advanced cancer. New care models can be divided into a number of categories based on either prognosis (e.g., greater than or less than 6 months), or level of care (e.g., lower versus higher intensity needs, such as intravenous pain/nausea medication or frequent monitoring), and goals of care (e.g., cancer-directed treatment versus symptom-focused care only). We performed a narrative review to (1) compare models of care for seriously ill cancer patients in the ED and (2) examine factors that may hasten or impede wider dissemination of these models.

Relevance of assessment items in community paramedicine home visit programmes: results of a modified Delphi study

OBJECTIVE

Guidelines for a structured assessment in community paramedicine home visit programmes have not been established and evidence to inform their creation is lacking. We sought to investigate the relevance of assessment items to the practice of community paramedics according to a pre-established clarity-utility matrix.

DESIGN

We designed a modified-Delphi study consisting of predetermined thresholds for achieving consensus, number of rounds of for scoring items, a defined meeting and discussion process, and a sample of participants that was purposefully representative.

SETTING AND PARTICIPANTS

We established a panel of 26 community paramedics representing 20 municipal paramedic services in Ontario, Canada. The sample represented a majority of paramedic services within the province that were operating a community paramedicine home visit programme.

MEASURES

Drawing from a bank of standardised assessment items grouped according to domains aligned with the International Classification on Functioning, Disability, and Health taxonomy, 64 previously pilot-tested assessment items were scored according to their clarity (being free from ambiguity and easy to understand) and utility (being valued in care planning or case management activities). Assessment items covered a broad range of health, social and environmental domains. To conclude scoring rounds, assessment items that did not achieve consensus for relevance to assessment practices were discussed among participants with opportunities to modify assessment items for subsequent rounds of scoring.

RESULTS

Resulting from the first round of scoring, 54 assessment items were identified as being relevant to assessment practices and 3 assessment items were removed from subsequent rounds. The remaining 7 assessment items were modified, with some parts removed from the final items that achieved consensus in the final rounds of scoring.

CONCLUSION

A broadly representative panel of community paramedics identified consensus for 61 assessment items that could be included in a structured, multidomain, assessment instrument for guiding practice in community paramedicine home visit programmes.

TRAIL REGISTRATION NUMBER

ISRCTN58273216.