The introduction of advanced paramedics into primary care in Northern Ireland: a qualitative descriptive study of the experiences of general practitioners

Background: Primary care is dealing with an ever-increasing workload. The causes are multi-factorial but include a decreasing number of General Practitioners (GPs), combined with increased numbers of patients with multiple co-morbidities and an ageing population. As a result of these pressures, nursing and allied health professionals are now working within a growing number of advanced practice roles delivering community-based care. One such example is paramedics taking up advanced roles within General Practice settings in Northern Ireland. What is not known, however, is what GPs’ experiences are of these developments.Aims: To examine the experiences of GPs who have introduced an advanced paramedic into their primary care team in Northern Ireland.Design: A qualitative descriptive design was chosen as the most suitable approach to allow participants to relay their experiences in their own words within the loose confines of a semi-structured interview.Methods: Semi-structured interviews were conducted with a group of four purposively selected GPs who had direct experience of the phenomena of interest. These interviews were transcribed verbatim, anonymised and then analysed thematically.Results: The thematic analysis produced three superordinate themes of alleviating pressure, acceptance and psychological well-being. These were underpinned by seven ordinate themes that were supported using verbatim quotes. These were then discussed and contextualised with themes from existing literature.Conclusion: Generally, there was widespread support from the GPs for the introduction of advanced paramedics into primary care teams. The reasons were multi-factorial but the reduction in GP workload featured prominently. The participants reported benefits in terms of increased resilience and work‐life balance. The capacity to provide a clinician with experience of dealing with acute and emergency presentations, in combination with managing routine procedures, was also reported to be of great importance.

Structured evaluation of stress triggers in prehospital emergency medical care

Background Emergency medical services work in the environment of high responsibility teams and have to act under unpredictable working conditions. Stress occurs and has potential of negative effects on tasks, teamwork, prioritization processes and cognitive control. Stress is not exclusively dictated by the situation—the individuals rate the situation of having the necessary skills that a particular situation demands. There are different occupational groups in the emergency medical services in Germany. Training, tasks and legal framework of these groups vary. Objective The aim of this study was to identify professional group-specific stressors for emergency medical services. These stress situations can be used to design skills building tools to enable individuals to cope with these stressors. Material and methods The participants were invited to the study via posters and social media. An expert group (minimum 6 months of experience) developed a set of items via a two-step online Delphi survey. The experts were recruited from all professional groups represented in the German emergency medical service. We evaluated the resulting parameters for relevance and validity in a larger collective. Lastly, we identified stress factors that could be grouped in relevant scales. In total 1017 participants (paramedics, physicians) took part in the final validation survey. Results After validation, we identified a catalogue of stressors with 7 scales and 25 items for EMT (Emergency Medical Technician) paramedics (KMO [Kayser-Meyer-Olkin criterion] 0.81), 6 scales and 24 items for advanced paramedics (KMO 0.82) and 6 scales and 24 items for EMS (Emergency Medical Service) physicians (KMO 0.82). For the professional group of EMT basic, the quality parameters did not allow further processing of the items. Professional group-specific scales for EMT paramedics are “professional limitations”, “organizational framework”, “expectations” and “questions of meaning”. For advanced paramedics “appreciation”, “exceptional circumstances” and “legal certainty” were identified. The EMT physicians named “handling third parties”, “tolerance to ambiguity”, “task management” and “pressure to act”. A scale that is representative for all professional groups is “teamwork”. Organizational circumstances occur in all groups. The item “unnecessary missions” for EMT paramedics and “legal concerns with the application of methods” for advanced paramedics are examples. Discussion Different stressors are relevant for the individual professional groups in the German emergency medical service. The developed catalogue can be used in the future to evaluate the subjective stress load of emergency service professionals. There are stressors that are inherent in the working environment (e.g. pressure to act) and others that can be improved through training (teamwork). We recommend training of general resistance as well as training of specific items (e.g., technical, nontechnical skills). All professionals mentioned items with respect to organizational factors. The responsible persons can identify potential for improvement based on the legal and organizational items. The EMT basic requires further subdivision according to task areas due to its variable applicability.

Non-medical prescribing by paramedics in emergency, urgent and critical care

This article considers some of the unique considerations and challenges that are associated with non-medical prescribing in the context of paramedic emergency care. In contrast to primary care, advanced paramedics practicing in emergency settings are more likely to encounter patients who require an immediate supply or administration of medication and access to a range of controlled drugs. Furthermore, access to medical support for prescribing decision-making, restrictions on the prescribing of controlled drugs and potential challenges in obtaining access to patient records, may also impact non-medical prescribing in these settings. Currently, very little empirical evidence has been published on the topic of non-medical prescribing in paramedic practice. Further research is required to understand whether the anticipated benefits are being realised for patients and NHS services. This is particularly the case in the context of prehospital emergency, urgent and critical care settings.

Paramedic-delivered teleconsultations: A scoping review

Introduction Progression in the field of paramedicine has resulted in the development of novel roles within the profession, including the role of advanced paramedics providing teleconsultations for frontline paramedics. Little is known about the experience of paramedics providing or receiving teleconsultations. This scoping review aimed to investigate paramedic perceptions of physician and paramedic-delivered teleconsultations. Methods A scoping review of MEDLINE, CINAHL and EBM Reviews as well as paramedic-specific journals and the grey literature was conducted. Articles were included if they examined advanced paramedics, paramedics, emergency ambulance crew or emergency medical technicians receiving teleconsultations, or physicians and advanced paramedics providing teleconsultations. Results A total of 7461 unique citations were identified. Two citations were ultimately included in the review. One study examined the delivery of teleconsultations by advanced paramedics and one by physicians, both from the perspective of paramedics. Paramedics delivering teleconsultations generally considered the experience to be positive, while those receiving paramedic-delivered teleconsultations felt the level of advice was appropriate and assisted in expanding their own knowledge base. Paramedics receiving physician-delivered teleconsultations reported variable understanding of the unique challenges of out-of-hospital care and tension in the relationship between paramedics and physicians. Conclusion Little literature was identified examining the perceptions of paramedics delivering or receiving physician-delivered or paramedic-delivered teleconsultations. Given the continuing expansion of teleconsultation programs for out-of-hospital staff, this represents a significantly understudied area.

Clinical presentations and practitioner levels appropriate for the introduction of ‘Treat and Referral’ into the Irish Emergency Medical Service: A survey of Consultants in emergency medicine.

<p>Objectives: Overcrowding in emergency departments (EDs) is an international issue and ambulance bypass is seen as one element of the solution to a complex problem. Irish EDs are not immune to this healthcare crisis, which, together with increased off-load delays for ambulances, is one catalyst for the introduction of Treat and Referral (paramedic non-ED disposition decision). The confidence of consultants in emergency medicine in paramedics and advanced paramedics offering Treat and Referral to patients presenting with hypoglycaemia or seizure was explored. Other specific clinical presentations were also investigated for suitability for Treat and Referral and a consensus was sought on an upper age limit for such patients. </p><p> </p><p>Methods: Public-sector consultants in emergency medicine in Ireland at the time of the study, were invited to complete an online survey. A 62% response was received from the targeted population.</p><p> </p><p>Results: Confidence was expressed in advanced paramedics offering Treat and Referral to patients with hypoglycaemia or seizure by the majority (78%) of respondents. However, confidence was reduced for paramedics (53%). Six of the twelve specific clinical presentations received clear support as suitable for Treat and Referral, with the remaining receiving reducing support and ‘falls in the elderly (without injury)’ was opposed. There was no consensus on an upper age limit for patients being offered Treat and Referral.</p><p> </p><p>Conclusions: Support for the highest level of EMS practitioner in Ireland, advanced paramedic, to expand their scope of practice to include Treat and Referral was identified. Clinical presentations have been identified that would be conducive to a Treat and Referral clinical care pathway. A trial implementation period may be essential to build confidence in the programme before a universal roll out.</p>

What are the clinical practice experiences of specialist and advanced paramedics working in emergency department roles? A qualitative study

Aim: Little is known about paramedics who have left the ambulance service to work in emergency departments (EDs). This study sought to explore the lived experiences of paramedics working in specialist/advanced ED roles, focusing on role transition, influences on effective clinical practice and perceptions of role optimisation. A secondary aim of the study was to make recommendations on the future development of specialist/advanced ED roles for paramedics.Methods: This was a qualitative study utilising descriptive phenomenology to collect and describe the lived experiences of participants via semi-structured interviews. The final sample comprised three emergency care practitioners (ECPs), three student ECPs and two advanced clinical practitioners (ACPs), all Health and Care Professions Council registered paramedics. Interview data were transcribed verbatim and analysed using inductive thematic analysis.Results: <list id="list1" list-type="bullet"> <list-item>Transition to the ED involves significant adjustment to a new clinical environment, responsibilities and decision making.</list-item> <list-item>Pre-hospital physical assessment and history taking skills, and experience of autonomous working are pertinent enablers to effective practice within the ED.</list-item> <list-item>Difficulties in accessing medication in the ED emerged as a significant barrier to daily practice that could affect the patient experience and influence perceptions of sub-optimal working.</list-item> <list-item>Misconceptions by ED staff regarding paramedic competencies could lead to role confusion and make inter-professional working difficult.</list-item> <list-item>Opportunities exist for future role expansion into areas such as resus, majors and paediatrics within the ED environment.</list-item> </list>Conclusions: While role transition to the ED represents a turbulent period for paramedics, elements of pre-hospital paramedic practice transfer directly into ED roles and contribute to effective practice. Participants found that they were accepted and supported to work in the ED setting and spoke positively of future role expansion. A lack of access to medicines presents a significant barrier to current clinical practice and a disparity in practice between paramedics and their nursing counterparts. The change in legislation to allow independent prescribing for advanced paramedics will address some of these issues, but interim improvements are required to extend existing arrangements to paramedics, improving the quality and safety of care they provide and ultimately the patient experience.

Stakeholder opinion on the proposal to introduce ‘treat and referral’ into the Irish emergency medical service

Background The Irish ambulance services have traditionally transported all patients following an emergency (112/999) call, regardless of acuity, to an emergency department (ED). A proposal to introduce Treat and Referral, an established care pathway in some jurisdictions, is under active consideration in Ireland. This will present a significant change. Stakeholder engagement is recognised as an essential component of management of such change. This study has conducted a multicentre, cross-sectional survey exploring opinions on the introduction of Treat and Referral among key Irish stakeholders; consultants in emergency medicine, paramedics and advanced paramedics. Methods Public-sector consultants in emergency medicine (EM), registered paramedics and advanced paramedics, in Ireland at the time of the study, were invited to complete an on-line survey. Results A significant finding was that 90% of both cohorts (EM consultants and registered paramedic practitioners) support written after-care instructions being given to referred patients, that > 83% agree that Treat and Referral will reduce unnecessary ambulance journeys and that 70% are in favour of their own family member being offered Treat and Referral. Consensus was reached between respondents that Treat and Referral would improve care and increase clinical judgement of practitioners. Differences were identified in relation to the increased availability of ambulances locally, that only adults should be included, and that research was required to extend Treat and Referral beyond the index conditions. There was no consensus on whether general practitioners (GPs) should be directly informed. Conclusions This study identified that the Irish healthcare practitioners surveyed are supportive of the introduction of Treat and Referral into Ireland. It also affords healthcare policymakers the opportunity to address the concerns raised, in particular the clinical level which will be targeted for inclusion in this extended scope of practice.

Stakeholder Opinion on the proposal to introduce ‘Treat and Referral’ into the Irish Emergency Medical Service.

Background: The Irish ambulance services have traditionally transported all patients following an emergency (112/999) call, regardless of acuity, to an ED. A proposal to introduce Treat and Referral, an established care pathway in some jurisdictions, is under active consideration in Ireland. This will present a significant change. Stakeholder engagement is recognised as an essential component of management of such change. This study has conducted a multicentre, cross-sectional survey exploring opinions on the introduction of Treat and Referral among key Irish stakeholders; consultants in emergency medicine, paramedics and advanced paramedics. Methods: Public-sector consultants in emergency medicine, registered paramedics and advanced paramedics, in Ireland at the time of the study, were invited to complete an on-line survey. Results: A significant finding was that 90% of both cohorts (EM consultants and PHECC practitioners) support written after-care instructions being given to referred patients, that > 83% agree that Treat and Referral will reduce unnecessary ambulance journeys and that 70% are in favour of their own family member being offered Treat and Referral. Consensus was reached between respondents that Treat and Referral would improve care and increase clinical judgement of practitioners. Differences were identified in relation to the increased availability of ambulances locally, that only adults should be included, and that research was required to extend Treat and Referral beyond the index conditions. There was no consensus on whether GPs should be directly informed. Conclusions: This study identified that the Irish healthcare practitioners surveyed are supportive of the introduction of Treat and Referral into Ireland. It also affords healthcare policymakers the opportunity to address the concerns raised, in particular the clinical level which will be targeted for inclusion in this extended scope of practice.