Clinical reasoning in undergraduate paramedicine: utilisation of a script concordance test.

INTRODUCTION: Clinical reasoning is a complex cognitive and metacognitive process paramount to patient care in paramedic practice. While universally recognised as an essential component of practice, clinical reasoning has been historically difficult to assess in health care professions. Is the Script Concordance Test (SCT) an achievable and reliable option to test clinical reasoning in undergraduate paramedic students? METHODS: This was a single institution observational cohort study designed to use the SCT to measure clinical reasoning in paramedic students. Clinical vignettes were constructed across a range of concepts with varying shades of clinical ambiguity. A reference panel mean scores of the test were compared to that of students. Test responses were graded with the aggregate scoring method with scores awarded for both partially and fully correct responses. RESULTS: Eighty-three student paramedic participants (mean age: 21.8 (3.5) years, 54 (65%) female, 27 (33%) male and 2 (2%) non-binary) completed the SCT. The difference between the reference group mean score of 80 (5) and student mean of score of 65.6 (8.4) was statistically significant (p < 0.001). DISCUSSION: Clinical reasoning skills are not easily acquired as they are a culmination of education, experience and the ability to apply this in the context to a specific patient. The SCT has shown to be reliable and effective in measuring clinical reasoning in undergraduate paramedics as it has in other health professions such as nursing and medicine. More investigation is required to establish effective pedogeological techniques to optimise clinical reasoning in student and novice paramedics who are devoid of experience.

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.

Out-of-hospital or pre-hospital: Is it time to reconsider the language used to describe and define paramedicine?

The professionalisation of paramedicine in Australasia necessitates discussion about how the profession defines and describes itself in the literature and more broadly. This editorial discusses the descriptors pre-hospital care and out-of-hospital care, and the connotations, relevance and implications of their use to describe paramedic roles and practice.

The Evolution of Clinician-Academics in Paramedicine: Completing the Picture of Professionalism.

Paramedicine is an evolving and integral component of the health system, though the profession has historically relied on medicine and nursing to drive a research agenda. Now, with a well-established research presence, still lacking is the formalized role of the clinician-academic. In this opinion piece, the authors detail how paramedic clinician-academics can drive the profession forward, contribute to enhanced patient care, systems design, and staff well-being.

Health professionals' experience of implementing and delivering a 'Community Care' programme in metropolitan Melbourne: a qualitative reflexive thematic analysis.

OBJECTIVES: To explore the experiences of health professionals involved in delivering a multidisciplinary Community Care programme that provides a transitional care coordination service for patients visiting a tertiary hospital service in Melbourne, Australia. DESIGN: Reflexive thematic analysis was used to identify themes from descriptions of delivering the programme, including its perceived strengths and challenges. PARTICIPANTS: 12 healthcare professionals from four disciplines working in the Community Care programme were interviewed. RESULTS: Four themes were identified: (1) 'increasingly complex', depicts the experience of delivering care to patients with increasingly complex health needs; (2) 'plugging unexpected gaps', describes meeting patient's healthcare needs; (3) 'disconnected', explains system-based issues which made participants feel disconnected from the wider health service; (4) 'a misunderstood programme', illustrates that a poor understanding of the programme within the health service is a barrier to patient enrolment which may have been exacerbated by a service name change. CONCLUSIONS: The healthcare professionals involved in this study described the experience of providing care to patients as challenging, but felt they made a positive difference. By unravelling the patients' health problems in context of their surroundings, they were able to recognise the increasingly complex patients' health needs. The disconnection they faced to integrate within the wider healthcare system made their role at times difficult. This disconnection was partly contributed to by the fact that they felt the programme was misunderstood.

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.

Impact of COVID-19 on paramedicine students: A mixed methods study.

BACKGROUND: Viral epidemics have negative and sometimes extreme impacts on psychological well-being, particularly in health care workers. Studies have reported higher levels of depression, anxiety, insomnia, stress, distress, fear, burnout, and post-traumatic symptoms. OBJECTIVE: This research aimed to explore the psychological impacts of COVID 19 on paramedicine students. METHODS: A convergent mixed method design study was undertaken using self-reporting instruments and qualitative interviews. RESULTS: Responses were received from 151 students (38.3% responses rate). Most students experienced some level of anxiety (62%), although severe levels were only reported by 6% of respondents. Students had significantly greater odds (OR = 2.05, p = 0.045, 95% CI: 1.02, 4.12) of higher anxiety levels if they were female. Thematic analysis of the interviews largely supported these results, with themes focused on changing approaches to study, financial situation, social support, University adaptation, acceptance and career pathway choice. CONCLUSIONS: This study identified and explored the anxiety and coping strategies in an undergraduate paramedicine cohort when faced with a viral epidemic. Although most of the responding paramedic students reported above normal levels of anxiety in the initial stages of the COVID-19 outbreak, many students, with the help of learning, financial and social support, and a range of positive coping strategies, have adapted well to the impact of the pandemic and associated lockdown period.

Review article: Paramedic pain management of femur fractures in the prehospital setting: A systematic review.

Femur shaft and neck of femur (NOF) fractures are often undertreated in the prehospital setting. These injuries can present unique clinical and logistical concerns in the prehospital setting. This systematic review aimed to investigate paramedic prehospital pain management of patients who had suffered NOF or femur fractures, and to investigate which interventions are effective. A systematic review was conducted in line with Preferred Reporting Item for Systematic Reviews and Meta-Analyses guidelines. Four databases were searched from inception date 23 March 2020. Articles were independently reviewed by two authors and conflicts resolved by a third author, followed by a hand search of the included reference lists. References were included if they addressed paramedic interventions for NOF or femur shaft fractures. Outcomes of interest were the effectiveness and complications of different modalities administered by paramedics. The search yielded 6868 articles, of which 19 met the final inclusion criteria. Studies investigated a variety of interventions including traction splints, intravenous (IV) analgesia and alternative analgesic options. Traction splinting and IV analgesia were consistently reported as underutilised. Alternative analgesics such as auricular acupressure, transcutaneous electrical nerve stimulation (TENS) and fascia iliaca compartment block were found to be effective techniques that could be safely and competently employed by paramedics, reducing pain for patients with limited adverse events. NOF and femur shaft fractures are an undertreated injury in the prehospital setting. Traction splinting and IV analgesia remain the traditional methodologies of treatment for these injuries; however, there are alternatives such as TENS, auricular acupressure and fascia iliaca compartment block that appear to be emerging as safe and effective options for the prehospital setting.

Prehospital paramedic pleural decompression: A systematic review.

BACKGROUND: Tension pneumothorax (TPT) is a frequent life-threat following thoracic injury. Time-critical decompression of the pleural cavity improves survival. However, whilst paramedics utilise needle thoracostomy (NT) and/or finger thoracostomy (FT) in the prehospital setting, the superiority of one technique over the other remains unknown. AIM: To determine and compare procedural success, complications and mortality between NT and FT for treatment of a suspected TPT when performed by paramedics. METHODS: We searched four databases (Ovid Medline, PubMed, CINAHL and Embase) from their commencement until 25th August 2020. Studies were included if they analysed patients suffering from a suspected TPT who were treated in the prehospital setting with a NT or FT by paramedics (or local equivalent nonphysicians). RESULTS: The search yielded 293 articles after duplicates were removed of which 19 were included for final analysis. Seventeen studies were retrospective (8 cohort; 7 case series; 2 case control) and two were prospective cohort studies. Only one study was comparative, and none were randomised controlled trials. Most studies were conducted in the USA (n=13) and the remaining in Australia (n=4), Switzerland (n=1) and Canada (n=1). Mortality ranged from 12.5% to 79% for NT and 64.7% to 92.9% for FT patients. A higher proportion of complications were reported among patients managed with NT (13.7%) compared to FT (4.8%). We extracted three common themes from the papers of what constituted as a successful pleural decompression; vital signs improvement, successful pleural cavity access and absence of TPT at hospital arrival. CONCLUSION: Evidence surrounding prehospital pleural decompression of a TPT by paramedics is limited. Available literature suggests that both FT and NT are safe for pleural decompression, however both procedures have associated complications. Additional high-quality evidence and comparative studies investigating the outcomes of interest is necessary to determine if and which procedure is superior in the prehospital setting.

What is the prevalence of frequent attendance to emergency departments and what is the impact on emergency department utilisation? A systematic review and meta-analysis.

Patients who frequently attend to emergency departments are a varying group and have complex health care needs. This systematic review and meta-analysis aimed to determine the prevalence of patients who have frequent attendance to emergency departments. A systematic review was performed in line with PRISMA guidelines. A database search was conducted, and studies were included in the final review if they analysed a population of frequent attendance. Meta-analysis was performed only on population-based studies to estimate prevalence. The search yielded 2922 nonduplicate publications, of which 27 were included in the meta-analysis. The most common definition used for frequent attendance was greater than three presentations a year. The proportion of people who frequently attended as a percentage of the total study population ranged from 0.01 to 20.9%, with emergency department presentations from frequent attenders ranging from 0.2 to 34%. When limiting the definition of frequent attendance to greater than three visits in a 12-month period, people who frequently attended contributed between 3 and 10% [pooled estimate 6%; CI 4-7%] of emergency department presentations and between 12 and 34% [pooled estimate 21%; CI 15-27%] of total emergency department presentations. Meta-analysis found substantial heterogeneity between estimates [I2 > 50%]. The prevalence of frequent attendance compared to the total population of patients seeking emergency care was small, but the impact on emergency department utilisation is significant. Early identification of people attending for frequent care at an emergency department provides the opportunity to implement alternative models of care.

Review article: Outcomes of patients who are not transported following ambulance attendance: A systematic review and meta-analysis.

The aim of this systematic review and meta-analysis was to evaluate the outcomes of patients who are not transported to hospital following ambulance attendance. A database search was conducted using PubMed, Medline, Embase, CINAHL and Cochrane Library. Studies were included if they analysed the outcomes of patients who were not transported following ambulance attendance. The primary outcome of this review was subsequent presentation to an ED following a non-transport decision. Secondary outcome measures included hospital admission, subsequent presentation to alternative service provider (e.g. private physician), and death at follow up. The search yielded 1953 non-duplicate articles, of which 10 met the inclusion criteria. Three studies specified that the non-transport decision was emergency medical services (EMS)-initiated, seven studies did not specify. Meta-analysis found substantial heterogeneity between estimates (I2 >50%) that was likely because of differences in study design, length of follow up, patient demographic and sample size. Between 5% and 46% (pooled estimate 21%; 95% CI 11-31%) of non-transport patients subsequently presented to ED. Few (pooled estimate 8%; 95% CI 5-12%) EMS-initiated non-transport patients were admitted to hospital compared to the unspecified group (pooled estimate 40%; 95% CI 7-72%). Mortality rates were low across included studies. Studies found varying estimates for the proportion of patients discharged at the scene that subsequently presented to ED. Few patients were admitted to hospital when the non-transport decision was initiated by EMS, indicating EMS triage is a relatively safe practice. More research is needed to elucidate the context of non-transport decisions and improve access to alternative pathways.