Community paramedic hospital reduction and mitigation program: study protocol for a randomized pragmatic clinical trial.

BACKGROUND: New patient-centered models of care are needed to individualize care and reduce high-cost care, including emergency department (ED) visits and hospitalizations for low- and intermediate-acuity conditions that could be managed outside the hospital setting. Community paramedics (CPs) have advanced training in low- and high-acuity care and are equipped to manage a wide range of health conditions, deliver patient education, and address social determinants of health in the home setting. The objective of this trial is to evaluate the effectiveness and implementation of the Care Anywhere with Community Paramedics (CACP) program with respect to shortening and preventing acute care utilization. METHODS: This is a pragmatic, hybrid type 1, two-group, parallel-arm, 1:1 randomized clinical trial of CACP versus usual care that includes formative evaluation methods and assessment of implementation outcomes. It is being conducted in two sites in the US Midwest, which include small metropolitan areas and rural areas. Eligible patients are ≥ 18 years old; referred from an outpatient, ED, or hospital setting; clinically appropriate for ambulatory care with CP support; and residing within CP service areas of the referral sites. Aim 1 uses formative data collection with key clinical stakeholders and rapid qualitative analysis to identify potential facilitators/barriers to implementation and refine workflows in the 3-month period before trial enrollment commences (i.e., pre-implementation). Aim 2 uses mixed methods to evaluate CACP effectiveness, compared to usual care, by the number of days spent alive outside of the ED or hospital during the first 30 days following randomization (primary outcome), as well as self-reported quality of life and treatment burden, emergency medical services use, ED visits, hospitalizations, skilled nursing facility utilization, and adverse events (secondary outcomes). Implementation outcomes will be measured using the RE-AIM framework and include an assessment of perceived sustainability and metrics on equity in implementation. Aim 3 uses qualitative methods to understand patient, CP, and health care team perceptions of the intervention and recommendations for further refinement. In an effort to conduct a rigorous evaluation but also speed translation to practice, the planned duration of the trial is 15 months from the study launch to the end of enrollment. DISCUSSION: This study will provide robust and timely evidence for the effectiveness of the CACP program, which may pave the way for large-scale implementation. Implementation outcomes will inform any needed refinements and best practices for scale-up and sustainability. TRIAL REGISTRATION: ClinicalTrials.gov NCT05232799. Registered on 10 February 2022.

Shifting attention to an undervalued asset; the emergency department technician.

US emergency departments are facing a number of operational challenges related to chronic shortages of registered nurses. Many of the tasks done by registered nurses can be safely and successfully delegated to the emergency department technician (EDT), particularly if a hospital's nursing and administrative leadership are affirmatively engaged in a process to professionalize and train their EDT workforce. This paper examines the state, Joint Commission on Accreditation of Healthcare Organizations, and Centers for Medicare & Medicaid Services regulatory landscape for the EDT, reviews the literature on how hospital's utilize EDT's, discusses approaches to skills training, and examines the need for profession standardization that enables job role expansion.

COVID-19 paraclinical diagnostic tools: Updates and future trends.

MOTIVATION: COVID-19 is one of the most widely affecting pandemics. As for many respiratory viruses-caused diseases, diagnosis of COVID-19 relies on two main compartments: clinical and paraclinical diagnostic criteria. Rapid and accurate diagnosis is vital in such a pandemic. On one side, rapidity may enhance management effectiveness, while on the other, coupling efficiency and less costly procedures may permit more effective community-scale management. METHODOLOGY AND MAIN STRUCTURE: In this review, we shed light on the most used and the most validated diagnostic tools. Furthermore, we intend to include few under-development techniques that may be potentially useful in this context. The practical intent of our work is to provide clinicians with a realistic summarized review of the essential elements in the applied paraclinical diagnosis of COVID-19.

Violence against ambulance personnel: a retrospective cohort study of national data from Safe Work Australia.

Objectives and importance: Paramedics have high rates of occupational injury and fatality. The objective of this study is to describe their specific risks of violence-related injury. STUDY TYPE: This retrospective cohort study is an examination of retrospective data provided by Safe Work Australia (SWA). METHODS: An examination of the 300 cases of serious claims of injury related to assaults, violence, harassment and bullying that occurred among individuals identified as ambulance officers and paramedics in Australia from 2001 to 2014. Paramedic risks likely vary by exposures such as hours worked and call volume. To examine how those exposures may influence risk, the available data were used to estimate rates based on hours worked and call volume. RESULTS: The data show that, for serious injuries among paramedics in Australia between 2001 and 2014, the total number of violence-related cases increased from 5 to 40 per year; the number of cases of injury secondary to assault tripled from 10 to 30; and the rate of cases by call volume doubled from 6 to 12. The cost of these injuries was approximately AUD$250 000 for the year 2013-14. The median time at work lost per individual case of 'work-related harassment and/or workplace bullying' was 9.6 weeks. Although females comprised 32% of the paramedic workforce, they were the victims in 42% of cases of exposure to violence and 40% of harassment cases. CONCLUSIONS: Although anecdotal reports indicate that some interventions have been attempted, violence against paramedics continues to be a growing problem in Australia. The data presented in this study allow for a better understanding of the problem and can support efforts by ambulance service administrators, physicians, paramedics and university researchers to work together to develop and publish evidence based, cost-effective solutions to reduce the risk of workplace violence. Effective solutions will likely be multifaceted and include training, engineering changes, community education and adjustments to agency policies. Because of the widespread nature of the risks, a national commission should be empowered to address this growing problem.

Mechanical Cardiopulmonary Resuscitation In and On the Way to the Cardiac Catheterization Laboratory.

Cardiac arrest, though not common during coronary angiography, is increasingly occurring in the catheterization laboratory because of the expanding complexity of percutaneous interventions (PCI) and the patient population being treated. Manual chest compression in the cath lab is not easily performed, often interrupted, and can result in the provider experiencing excessive radiation exposure. Mechanical cardiopulmonary resuscitation (CPR) provides unique advantages over manual performance of chest compression for treating cardiac arrest in the cardiac cath lab. Such advantages include the potential for uninterrupted chest compressions, less radiation exposure, better quality chest compressions, and less crowded conditions around the catheterization table, allowing more attention to ongoing PCI efforts during CPR. Out-of-hospital cardiac arrest patients not responding to standard ACLS therapy can be transported to the hospital while mechanical CPR is being performed to provide safe and continuous chest compressions en route. Once at the hospital, advanced circulatory support can be instituted during ongoing mechanical CPR. This article summarizes the epidemiology, pathophysiology and nature of cardiac arrest in the cardiac cath lab and discusses the mechanics of CPR and defibrillation in that setting. It also reviews the various types of mechanical CPR and their potential roles in and on the way to the laboratory. (Circ J 2016; 80: 1292-1299).

Induction of therapeutic hypothermia by paramedics after resuscitation from out-of-hospital ventricular fibrillation cardiac arrest: a randomized controlled trial.

BACKGROUND: Therapeutic hypothermia is recommended for the treatment of neurological injury after resuscitation from out-of-hospital cardiac arrest. Laboratory studies have suggested that earlier cooling may be associated with improved neurological outcomes. We hypothesized that induction of therapeutic hypothermia by paramedics before hospital arrival would improve outcome. METHODS AND RESULTS: In a prospective, randomized controlled trial, we assigned adults who had been resuscitated from out-of-hospital cardiac arrest with an initial cardiac rhythm of ventricular fibrillation to either prehospital cooling with a rapid infusion of 2 L of ice-cold lactated Ringer's solution or cooling after hospital admission. The primary outcome measure was functional status at hospital discharge, with a favorable outcome defined as discharge either to home or to a rehabilitation facility. A total of 234 patients were randomly assigned to either paramedic cooling (118 patients) or hospital cooling (116 patients). Patients allocated to paramedic cooling received a median of 1900 mL (first quartile 1000 mL, third quartile 2000 mL) of ice-cold fluid. This resulted in a mean decrease in core temperature of 0.8 degrees C (P=0.01). In the paramedic-cooled group, 47.5% patients had a favorable outcome at hospital discharge compared with 52.6% in the hospital-cooled group (risk ratio 0.90, 95% confidence interval 0.70 to 1.17, P=0.43). CONCLUSIONS: In adults who have been resuscitated from out-of-hospital cardiac arrest with an initial cardiac rhythm of ventricular fibrillation, paramedic cooling with a rapid infusion of large-volume, ice-cold intravenous fluid decreased core temperature at hospital arrival but was not shown to improve outcome at hospital discharge compared with cooling commenced in the hospital.

Acute pain and availability of analgesia in the prehospital emergency setting in Italy: a problem to be solved.

OBJECTIVES: The treatment of acute pain in the prehospital emergency setting remains a significant problem. We evaluated the incidence, site, and possible cause of acute pain in the prehospital period and also the current state of prehospital pain management by evaluating analgesic availability in emergency vehicles in Italy. METHODS: First aid volunteers documented the presence, intensity, and site of acute pain by questionnaire for over 3 months. Emergency service operations completed a questionnaire on analgesic availability in ambulances and helicopters. RESULTS: Pain symptoms were present in two-thirds of the patients (n = 383) and ranked as moderate to unbearable in 41.75%. Results of the analgesic availability survey indicate that 10.6% of the ambulance services carry no pain killers (including non-steroidal anti-inflammatory drugs [NSAIDs] and/or paracetamol) and 11.5% are without an opioid. The emergency helicopter survey showed a significant difference in analgesic availability compared with ambulances, with 97.6% having at least one opioid agent available (weak or strong). A wide geographical variation in the availability of analgesic agents in ambulance and helicopter services was seen. CONCLUSIONS: There is a high prevalence of pain among patients receiving prehospital emergency treatment in Italy and treatment for acute pain during emergency treatment of trauma patients is inadequate. All emergency vehicles, without distinction, should carry opioids and other analgesic drugs (NSAIDs and paracetamol) and there should be no geographic differences in the availability of pain medications.

The evolution of the Rhode Island trauma system: where do we stand?

The Rhode Island Trauma System today has been shown to demonstrate several positive attributes in the delivery of patient care; however, ongoing efforts need to continue in the realms of field and inter-facility communication, efficiency in inter-hospital transfer, and rehabilitation services. Through ongoing dialogue and the fundamental desire to improve, it remains our goal to provide patients the best care possible during one of the most stressful times of their lives.

The evolution of the emergency care practitioner role in England: experiences and impact.

BACKGROUND: The emergency care practitioner (ECP) is a generic practitioner who combines extended nursing and paramedic skills. The "new" role emerged out of changing workforce initiatives intended to improve staff career opportunities in the National Health Service and ensure that patients' health needs are assessed appropriately. OBJECTIVE: To describe the development of ECP Schemes in 17 sites, identify criteria contributing to a successful operational framework, analyse routinely collected data and provide a preliminary estimate of costs. METHODS: There were three methods used: (a) a quantitative survey, comprising a questionnaire to project leaders in 17 sites, and analysis of data collected routinely; (b) qualitative interpretation based on telephone interviews in six sites; and (c) an economic costing study. RESULTS: Of 17 sites, 14 (82.5%) responded to the questionnaire. Most ECPs (77.4%) had trained as paramedics. Skills and competencies have been extended through educational programmes, training, and assessment. Routine data indicate that 54% of patient contacts with the ECP service did not require a referral to another health professional or use of emergency transport. In a subset of six sites, factors contributing to a successful operational framework were strategic visions crossing traditional organisational boundaries and appropriately skilled workforce integrating flexibly with existing services. Issues across all schemes were patient safety, appropriate clinical governance, and supervision and workforce issues. On the data available, the mean cost per ECP patient contact is 24.00 pounds sterling, which is less than an ED contact of 55.00 pounds sterling. CONCLUSION: Indications are that the ECP schemes are moving forward in line with original objectives and could be having a significant impact on the emergency services workload.

The emerging role of the emergency care practitioner.

OBJECTIVES: To examine the emerging role of the emergency care practitioner (ECP) with comparisons to paramedic practice. Key activities were identified of newly appointed ECPs using qualitative methodology and a qualitative and quantitative comparison of patient treatment was made. METHOD: A constructivist methodology taking account of stakeholder input and drawing upon the constant comparisons of different group's construction of reality. Four practitioners completed reflective patient case studies and adapted patient report forms, which were compared with a second case group of 11 paramedics. In addition individual and focus groups interviews were performed with key stakeholders. RESULTS: In the comparison between ECP and paramedic roles, 331 paramedic incidents were compared with 170 ECP reports. ECPs treated 28% of patients on scene compared with 18% by paramedics (p = 0.007). Fifty per cent of ECPs patients were conveyed compared with 64% of paramedics (p = 0.000). Analysis of the 269 reflective reports and 14 stakeholder interviews revealed four key themes. Firstly, ECPs had a beneficial impact on the deployment of resources, especially relating to non-conveyance. Secondly, their training and education improved their decision making repertoire and developed their confidence for a leadership role. Thirdly, inter-agency collaboration and cooperation was improved, and finally, care benefits were increased especially relating to immediacy of treatment and referral mechanisms. CONCLUSIONS: The results indicate that an investment in the ECP role could be beneficial, however, more work is required to evaluate the development of practice, the quality of care, and cost benefits.