Public awareness and knowledge of sepsis: a cross-sectional survey of adults in Canada.

BACKGROUND: Sepsis is a life-threatening complication of the body's response to infection. The financial, medical, and psychological costs of sepsis to individuals and to the healthcare system are high. Most sepsis cases originate in the community, making public awareness of sepsis essential to early diagnosis and treatment. There has been no comprehensive examination of adult's sepsis knowledge in Canada. METHODS: We administered an online structured survey to English- or French-literate adults in Canada. The questionnaire comprised 28 questions in three domains: awareness, knowledge, and information access. Sampling was stratified by age, sex, and geography and weighted to 2016 census data. We used descriptive statistics to summarize responses; demographic differences were tested using the Rao-Scott correction for weighted chi-squared tests and associations using multiple variable regression. RESULTS: Sixty-one percent of 3200 adults sampled had heard of sepsis. Awareness differed by respondent's residential region, sex, education, and ethnic group (p < 0.001, all). The odds of having heard of sepsis were higher for females, older adults, respondents with some or completed college/university education, and respondents who self-identified as Black, White, or of mixed ethnicity (p < 0.01, all). Respondent's knowledge of sepsis definitions, symptoms, risk factors, and prevention measures was generally low (53.0%, 31.5%, 16.5%, and 36.3%, respectively). Only 25% of respondents recognized vaccination as a preventive strategy. The strongest predictors of sepsis knowledge were previous exposure to sepsis, healthcare employment, female sex, and a college/university education (p < 0.001, all). Respondents most frequently reported hearing about sepsis through television (27.7%) and preferred to learn about sepsis from healthcare providers (53.1%). CONCLUSIONS: Sepsis can quickly cause life-altering physical and psychological effects and 39% of adults sampled in Canada have not heard of it. Critically, a minority (32%) knew about signs, risk factors, and strategies to lower risk. Education initiatives should focus messaging on infection prevention, employ broad media strategies, and use primary healthcare providers to disseminate evidence-based information. Future work could explore whether efforts to raise public awareness of sepsis might be bolstered or hindered by current discourse around COVID-19, particularly those centered on vaccination.

Providing palliative care at home aligns with the professional identity of paramedics: a qualitative study of paramedics and palliative health care providers.

BACKGROUND: An innovative program, 'Paramedics Providing Palliative Care at Home,' was implemented in Nova Scotia, Canada in 2015. Roles like this are part of an evolving professional identity; role discordance or lack of clarity not only hinders professionalization but may impair the wellbeing, and career longevity of paramedics. This study explored the alignment of providing palliative support at home with paramedic professional identity. METHODS: Qualitative description was employed, with thematic analysis of focus groups with paramedics and palliative health care providers. Recruitment posters were sent through the professional college (paramedics) and program managers (health care providers). Focus groups followed a semi-structured guide, discussing understanding of and experiences with the role and its alignment with professional identity. Challenges to paramedic palliative support and fit with professional identify were explored. Thematic content analysis was ongoing while focus groups were being conducted, until no new codes were found. Codes were combined, sorted into categories, and ultimately, agreed-upon themes. Saturation of themes was reached. RESULTS: Eleven paramedics and twenty palliative health care providers participated. Four themes reflected paramedic's expanded role: (1) patient centeredness and job satisfaction with provision of palliative support, (2) a bridging role, (3) paramedic as advocate and educator, (4) provision of psychosocial support. Four themes reflected paramedic's professional identity: (1) evolution of paramedicine as a skilled clinical profession, (2) helping people and communities, (3) paramedic skill set aligns with work in palliative care, and (4) changing paramedic mindset. CONCLUSION: Paramedics and palliative health care providers highlighted the provision of palliative care as part of a positive growth of paramedicine as a health profession, and a good fit with professional identity. Novel roles like this are important in the evolution of our health care system faced with increasing pressures to get the right care with the right provider at the right time.

RéSUMé: CONTEXTE: Un programme innovant, " Programme de soins palliatifs paramédicaux à domicile ", a été mis en œuvre en Nouvelle-Écosse, au Canada, en 2015. Les rôles de ce type font partie d'une identité professionnelle en évolution ; la discordance ou le manque de clarté des rôles non seulement entrave la professionnalisation, mais peut aussi nuire au bien-être et à la longévité de la carrière des ambulanciers paramédicaux. Cette étude a exploré l'alignement de la prestation de soutien palliatifs à domicile avec l'identité professionnelle des ambulanciers paramédicaux. MéTHODES: Une description qualitative a été employée, avec une analyse thématique de groupes de discussion avec des ambulanciers paramédicaux et des prestataires de soins palliatifs. Des affiches de recrutement ont été envoyées par le biais du collège professionnel (paramédicaux) et des gestionnaires de programmes (prestataires de soins de santé). Les groupes de discussion ont suivi un guide semi-structuré, discutant de la compréhension et des expériences du rôle et de son alignement avec l'identité professionnelle. Les défis du soutien palliatif paramédical et son adéquation avec l'identité professionnelle ont été explorés. L'analyse du contenu thématique s'est poursuivie pendant la tenue des groupes de discussion, jusqu'à ce qu'aucun nouveau code ne soit trouvé. Les codes ont été combinés, triés en catégories et, finalement, en thèmes convenus. La saturation des thèmes a été atteinte. RéSULTATS: Onze ambulanciers paramédicaux et vingt prestataires de soins palliatifs ont participé. Quatre thèmes reflétaient le rôle élargi des ambulanciers paramédicaux : 1) l'orientation vers le patient et la satisfaction professionnelle à l'égard de la prestation de soutien palliatifs, 2) un rôle de transition, 3) les ambulanciers paramédicaux à titre de défenseurs et d'éducateurs, 4) un soutien psychosocial. Quatre thèmes reflétaient l'identité professionnelle des ambulanciers paramédicaux : 1) l'évolution de la profession paramédicale en tant que profession clinique qualifiée, 2) l'aide aux personnes et aux collectivités, 3) l'ensemble des compétences des ambulanciers paramédicaux s'harmonise avec le travail en soins palliatifs, et 4) l'évolution de l'état d'esprit des ambulanciers paramédicaux. CONCLUSION: Les ambulanciers paramédicaux et les prestataires de soins palliatifs ont souligné que la prestation de soins palliatifs faisait partie d'une croissance positive de la profession paramédicale en tant que profession de la santé et correspondait bien à l'identité professionnelle. Des rôles novateurs comme celui-ci sont importants dans l'évolution de notre système de soins de santé, confronté à des pressions croissantes pour obtenir les bons soins auprès du bon prestataire au bon moment.

Essential Elements to Implementing a Paramedic Palliative Model of Care: An Application of the Consolidated Framework for Implementation Research.

Background: Comfort care without transport to hospital was not traditionally a paramedic practice. The novel Paramedics Providing Palliative Care at Home Program includes a new clinical practice guideline, medications, a database to manage and share goals of care, and palliative care training. This study determined essential elements for implementation, scale, and spread of this Program. Methods: Deliberative dialogs, a qualitative method, were held with diverse stakeholders/experts in one province with the Program (Nova Scotia, March 2018) and one without (British Columbia, July 2018). The Consolidated Framework for Implementation Research (CFIR) informed the discussion guide and was used in a framework analysis. Four team members analyzed the data independently; themes were derived by consensus with the broader research team. Results: CFIR constructs framed several key elements. Inter-sectoral communication is critical but challenged by privacy concerns and the siloed structure of the health system. Locally adapted training is an essential characteristic of the intervention; cost is a factor. A shift in mindset away from traditional paramedic roles is required; this can be facilitated by paramedic champions and a positive implementation climate. Early engagement of diverse stakeholders and planning for sustainability is key. Conclusion: This framework analysis using CFIR constructs can guide successful scale and spread of the program. The constructs of Outer setting: Cosmopolitanism; Characteristics of the intervention: Adaptability; Inner Setting: Implementation climate; and Processes: Engagement, and Planning, emerged as essential.

Urban-Rural Differences in Cardiac Arrest Outcomes: A Retrospective Population-Based Cohort Study.

Background: Approximately 10% of people who suffer an out-of-hospital cardiac arrest (OHCA) treated by paramedics survive to hospital discharge. Survival differs by up to 19.2% between urban centres and rural areas. Our goal was to investigate the differences in OHCA survival between urban centres and rural areas. Methods: This was a retrospective cohort study of OHCA patients treated by Nova Scotia Emergency Medical Services (EMS) in 2017. Cases of traumatic, expected, and noncardiac OHCA were excluded. Data were collected from the Emergency Health Service electronic patient care record system and the discharge abstract database. Geographic information system analysis classified cases as being in urban centres (population > 1000 people) or rural areas, using 2016 Canadian Census boundaries. The primary outcome was survival to hospital discharge. Multivariable logistic regression covariates were age, sex, bystander resuscitation, whether the arrest was witnessed, public location, and preceding symptoms. Results: A total of 510 OHCAs treated by Nova Scotia Emergency Medical Services were included for analysis. A total of 12% (n = 62) survived to discharge. Patients with OHCAs in urban centres were 107% more likely to survive than those with OHCAs in rural areas (adjusted odds ratio = 2.1; 95% confidence interval = 1.1 to 3.8; P = 0.028). OHCAs in urban centres had a significantly shorter mean time to defibrillation of shockable rhythm (11.2 minutes ± 6.2) vs those in rural areas (17.5 minutes ± 17.3). Conclusions: Nova Scotia has an urban vs rural disparity in OHCA care that is also seen in densely populated OHCA centres. Survival is improved in urban centres. Further improvements in overall survival, especially in rural areas, may arise from community engagement in OHCA recognition and optimized healthcare delivery.

Contexte: Environ 10 % des personnes qui subissent un arrêt cardiaque en milieu extrahospitalier (ACEH), traité par des intervenants paramédicaux, survivent jusqu'à leur congé de l'hôpital. Le taux de survie peut différer de 19,2 % entre les centres urbains et les régions rurales. Notre étude visait à étudier les différences en matière de survie après un ACEH entre les centres urbains et les régions rurales. Méthodologie: Il s'agissait d'une étude de cohorte rétrospective portant sur des patients ayant subi un ACEH traité par les services médicaux d'urgence de la Nouvelle-Écosse en 2017. Les cas d'ACEH traumatique, prévu et non cardiaque ont été exclus. Les données ont été recueillies à partir du système de dossiers électroniques de soins aux patients des services médicaux d'urgence et de la Base de données sur les congés des patients. L'analyse du système d'information géographique a classé les cas selon qu'ils sont survenus dans un centre urbain (population de plus de 1 000 personnes) ou dans une région rurale, en utilisant les limites du recensement canadien de 2016. Le principal paramètre d'évaluation était la survie à la sortie de l'hôpital. Les covariables utilisées dans la régression logistique multivariée étaient l'âge, le sexe, la réanimation effectuée par des témoins si présents lors de l'arrêt cardiaque, l'emplacement public et les symptômes précédents. Résultats: Au total, 510 ACEH traités par les services médicaux d'urgence de la Nouvelle-Écosse ont été inclus aux fins de l'analyse. En tout, 12 % (n = 62) des sujets ont survécu jusqu'à leur congé hospitalier. Les patients ayant subi un ACEH dans un centre urbain étaient 107 % plus susceptibles de survivre que ceux ayant subi un ACEH dans une région rurale (rapport de cotes ajusté : 2,1; intervalle de confiance à 95 % : 1,1 ­ 3,8; p = 0,028). Le temps moyen de délivrance d'un choc lors d'un ACEH avec rythme défibrillable est significativement plus court (11,2 ± 6,2 minutes) dans un centre urbain que dans une région rurale (17,5 ± 17,3 minutes). Conclusions: La Nouvelle-Écosse fait état d'une disparité dans les soins de l'ACEH entre les régions urbaines et les régions rurales, que l'on observe également dans les villes densément peuplées. La survie est plus longue dans les centres urbains. Il est possible de prolonger davantage la survie globale, en particulier dans les régions rurales, en sensibilisant la communauté à l'ACEH et en optimisant la prestation des soins de santé.

When Cannabis Use Goes Wrong: Mental Health Side Effects of Cannabis Use That Present to Emergency Services.

Cannabis use is a modifiable risk factor for the development and exacerbation of mental illness. The strongest evidence of risk is for the development of a psychotic disorder, associated with early and consistent use in youth and young adults. Cannabis-related mental health adverse events precipitating Emergency Department (ED) or Emergency Medical Services presentations can include anxiety, suicidal thoughts, psychotic or attenuated psychotic symptoms, and can account for 25-30% of cannabis-related ED visits. Up to 50% of patients with cannabis-related psychotic symptoms presenting to the ED requiring hospitalization will go on to develop schizophrenia. With the legalization of cannabis in various jurisdiction and the subsequent emerging focus of research in this area, our understanding of who (e.g., age groups and risk factors) are presenting with cannabis-related adverse mental health events in an emergency situation is starting to become clearer. However, for years we have heard in popular culture that cannabis use is less harmful or no more harmful than alcohol use; however, this does not appear to be the case for everyone. It is evident that these ED presentations should be considered another aspect of potentially harmful outcomes that need to be included in knowledge mobilization. In the absence of a clear understanding of the risk factors for mental health adverse events with cannabis use it can be instructive to examine what characteristics are seen with new presentations of mental illness both in emergency departments (ED) and early intervention services for mental illness. In this narrative review, we will discuss what is currently known about cannabis-related mental illness presentations to the ED, discussing risk variables and outcomes both prior to and after legalization, including our experiences following cannabis legalization in Canada. We will also discuss what is known about cannabis-related ED adverse events based on gender or biological sex. We also touch on the differences in magnitude between the impact of alcohol and cannabis on emergency mental health services to fairly present the differences in service demand with the understanding that these two recreational substances may impact different populations of individuals at risk for adverse events.

Breaking Down Silos: Consensus-Based Recommendations for Improved Content, Structure, and Accessibility of Advance Directives in Emergency and Out-of-Hospital Settings.

Background: Patients receiving palliative care often interact with a variety of health care providers across various settings. While patients may experience good care from these services, the connection between these can be disjointed as care providers may work siloed from each other. This is particularly true in out-of-hospital and hospital emergency settings, where providers have no prior knowledge of the patient, particularly their advanced directives (ADs) and goals of care. In the Emergency Department or when paramedics respond to the home, ADs are further challenged by issues of clarity of content, contextual relevance, and accessibility. Objectives: (1) What content should be in AD for medical emergencies, and (2) what would ensure the AD is accessible in times of crisis? Design: Phase 1 involved a review of existing AD and published literature to generate a list of candidate elements. Phase 2 presented these in an online survey using modified Delphi method to paramedics, emergency nurses, and physicians. During phase 3, a focus group with palliative and emergency care providers and information technology experts was held regarding current accessibility of AD and a vision for improvement. The detailed focus group notes were coded using inductive analysis. Results: Fifty-five candidate elements were provided for the Delphi. After three rounds, 36 panelists achieved consensus on 46 elements. Participation was greater than 80% in all rounds. From the focus group on access, six themes emerged; (1) imprecise language, (2) mismatch of protocols, (3) lack of understanding by patients/families, (4) lack of AD, (5) difficulty accessing AD, and (6) opportunities: database, education. Conclusion: This project makes recommendations to improve palliative care in emergency or crisis situations and facilitate care consistent with patient's goals: (1) a consensus-based template for AD content; and (2) development of a centralized database. These findings served as the foundation for the "Paramedics Providing Palliative Care at Home" program.

Paramedics providing palliative care at home: A mixed-methods exploration of patient and family satisfaction and paramedic comfort and confidence.

OBJECTIVE: Paramedics Providing Palliative Care at Home was launched in two provinces, including a new clinical practice guideline, database, and paramedic training. The aim of this study was to evaluate patient/family satisfaction and paramedic comfort and confidence. METHODS: In Part A, we gathered perspectives of patients/families via surveys mailed at enrolment and telephone interviews after an encounter. Responses were reported descriptively and by thematic analysis. In Part B, we surveyed paramedics online pre- and 18 months post-launch. Comfort and confidence were scored on a 4-point Likert scale, and attitudes on a 7-point Likert scale, reported as the median (interquartile range [IQR]); analysis with Wilcoxon ranked sum/thematic analysis of free text. RESULTS: In Part A, 67/255 (30%) enrolment surveys were returned. Three themes emerged: fulfilling wishes, peace of mind, and feeling prepared for emergencies. In 18 post-encounter interviews, four themes emerged: 24/7 availability, paramedic professionalism and compassion, symptom relief, and a plea for program continuation. Thematic saturation was reached with little divergence. In Part B, 235/1255 (18.9%) pre- and 267 (21.3%) post-surveys were completed. Comfort with providing palliative care without transport improved post launch (p = < 0.001) as did confidence in palliative care without transport (p = < 0.001). Respondents strongly agreed that all paramedics should be able to provide basic palliative care. CONCLUSIONS: After implementation of the multifaceted Paramedics Providing Palliative Care at Home Program, paramedics describe palliative care as important and rewarding. The program resulted in high patient/family satisfaction; simply registering provides peace of mind. After an encounter, families particularly noted the compassion and professionalism of the paramedics.

CONTEXTE: Un programme de prestation de soins palliatifs à domicile par des ambulanciers paramédicaux a été lancé dans deux provinces, précédé de l'extension d'un guide de pratique clinique, de la mise à jour d'une base de données et de l'élaboration d'une formation particulière à l'intention des ambulanciers paramédicaux. Ont été évalués le degré de satisfaction des patients et des familles ainsi que le degré d'aisance et de confiance des ambulanciers paramédicaux. MÉTHODE: Dans la partie A, il y a eu collecte de données sur le point de vue des patients et des familles à l'aide d'un questionnaire d'enquête envoyé par la poste au moment de la sélection et d'entrevues téléphoniques après les rencontres. Les réponses ont été présentées en style descriptif et sous forme d'analyse thématique. Dans la partie B, une enquête en ligne a été menée parmi les ambulanciers paramédicaux avant le lancement du programme et 18 mois après celui-ci. Le degré d'aisance et de confiance a été évalué sur une échelle de Likert de 4 points, et les attitudes, sur une échelle de Likert de 7 points; les résultats ont été exprimés sous forme d'intervalles interquartiles (IQ) médians; l'analyse des données, calculée à l'aide du test de Wilcoxon, et les textes libres, présentés sous forme d'analyse thématique. RÉSULTATS: Dans la partie A, 67 questionnaires sur 255 (30%) ont été remis. Trois thèmes importants se sont dégagés des réponses : la satisfaction des désirs, la tranquillité d'esprit et le sentiment de préparation à toute éventualité. Par ailleurs, il y a eu 18 entrevues après les rencontres, desquelles se sont dégagés quatre grands thèmes : la disponibilité des soins 24 h sur 24, 7 jours sur 7; le professionnalisme et la compassion des ambulanciers paramédicaux; le soulagement des symptômes et un appel pressant en faveur de la poursuite du programme. La saturation thématique s'est obtenue avec un faible degré de divergence. Dans la partie B, 235 questionnaires sur 1255 (18,9%) ont été remplis avant le lancement du programme, et 267 sur 1255 (21,3%), après la mise en œuvre. Le degré d'aisance et la prestation de soins palliatifs, dans le contexte d'absence de transport des malades, se sont améliorés après le lancement (p ( 0,001); il en allait de même pour le degré de confiance dans la prestation de soins palliatifs, dans le même contexte (p ( 0,001). Les répondants étaient fortement d'avis que tous les ambulanciers paramédicaux devraient être en mesure de fournir des soins palliatifs de base. CONCLUSION: Après la mise en œuvre de ce programme à volets multiple, les ambulanciers paramédicaux considéraient la prestation de soins palliatifs comme un geste important et gratifiant. Le programme a donné lieu à un degré élevé de satisfaction tant des patients que des familles, et la facilité d'inscription a procuré la tranquillité d'esprit. Enfin, après une rencontre, les familles ont souligné tout particulièrement le professionnalisme et la compassion des ambulanciers paramédicaux.

A review on ambulance offload delay literature.

Ambulance offload delay (AOD) occurs when care of incoming ambulance patients cannot be transferred immediately from paramedics to staff in a hospital emergency department (ED). This is typically due to emergency department congestion. This problem has become a significant concern for many health care providers and has attracted the attention of many researchers and practitioners. This article reviews literature which addresses the ambulance offload delay problem. The review is organized by the following topics: improved understanding and assessment of the problem, analysis of the root causes and impacts of the problem, and development and evaluation of interventions. The review found that many researchers have investigated areas of emergency department crowding and ambulance diversion; however, research focused solely on the ambulance offload delay problem is limited. Of the 137 articles reviewed, 28 articles were identified which studied the causes of ambulance offload delay, 14 articles studied its effects, and 89 articles studied proposed solutions (of which, 58 articles studied ambulance diversion and 31 articles studied other interventions). A common theme found throughout the reviewed articles was that this problem includes clinical, operational, and administrative perspectives, and therefore must be addressed in a system-wide manner to be mitigated. The most common intervention type was ambulance diversion. Yet, it yields controversial results. A number of recommendations are made with respect to future research in this area. These include conducting system-wide mitigation intervention, addressing root causes of ED crowding and access block, and providing more operations research models to evaluate AOD mitigation interventions prior implementations. In addition, measurements of AOD should be improved to assess the size and magnitude of this problem more accurately.

State of the Evidence for Emergency Medical Services (EMS) Care: The Evolution and Current Methodology of the Prehospital Evidence-Based Practice (PEP) Program.

Background: Emergency medical services (EMS) leaders and clinicians need to incorporate evidence into safe and effective clinical practice. Access to high-quality evidence, and the time to synthesize it, can be barriers to evidence-based practice. The Prehospital Evidence-Based Practice (PEP) program is an online, freely accessible, repository of critically appraised evidence specific to EMS. This paper describes the evolution and current methodology of the PEP program. Methods|design: The purpose of PEP is to identify, catalog and critically appraise relevant studies. Following regular systematic searches, two trained appraisers critically appraise included studies and assign a score on three-point level of evidence (LOE) and direction of evidence (DOE) scales. Each clinical intervention is plotted on a 3 × 3 (LOE × DOE) evidence matrix, which provides a summary recommendation. Discussion: The PEP program is a unique knowledge translation tool, specific to EMS. End-users can easily identify which clinical interventions are, or are not, supported by evidence.

The novel role of paramedics in collaborative emergency centres aligns with their professional identity: A qualitative analysis.

OBJECTIVE: The Collaborative Emergency Centre (CEC) model of care was implemented in Nova Scotia without an identifiable, directly comparable precedent. It features interprofessional teams working towards the goal of providing improved access to primary health care, and appropriate access to 24/7 emergency care. One important component of CEC functioning is overnight staffing by a paramedic and registered nurse (RN) team consulting with an off-site physician. Our objective was to ascertain the attitudes, feelings and experiences of paramedics working within Nova Scotia's CECs. METHODS: We conducted a qualitative study informed by the principles of grounded theory. Semi-structured telephone interviews were conducted with paramedics with experience working in a CEC. Analysis involved an inductive grounded approach using constant comparative analysis. Data collection and analysis continued until thematic saturation was reached. RESULTS: Fourteen paramedics participated in the study. The majority were male (n=10, 71%) with a mean age of 44 years and mean paramedic experience of 14 years. Four major themes were identified: 1) interprofessional relationships, 2) leadership support, 3) value to community and 4) paramedic identity. CONCLUSIONS: Paramedics report largely positive interprofessional relationships in Nova Scotia's CECs. They expressed enjoyment working in these centres and believe this work aligns with their professional identity. High levels of patient and community satisfaction were reported. Paramedics believe future expansion of the model would benefit from development of continuing education and improved communication between leadership and front-line workers.

Correlation of age and rurality with low-urgency use of emergency medical services (LUEMS): A geographic analysis.

OBJECTIVES: Studies suggest that addressing the needs of the older population in rural areas may substantially reduce their low-urgency use of emergency medical services (LUEMS). It may ultimately also help improve the efficiency in our health system. There is, however, a dearth of evidence substantiating geographic patterns in LUEMS by different age cohorts. This exploratory study was aimed to clarify the understanding of emergency medical services (EMS) use in Nova Scotia through a geographic analysis. METHODS: Records with Canadian Triage and Acuity Scale of 4 and 5 were considered as LUEMS. We assessed the distribution of LUEMS incidence rates (proportion of LUEMS out of all EMS uses) by age and rurality, using descriptive statistics and Geographic Information Systems mapping. RESULTS: Nearly half of all EMS transports were individuals of 65+ years of age; 35% of those were LUEMS. The rates increased along with the level of rurality, and the older cohort had the highest incidence rates in non-metro communities. High rates were seen primarily in some rural communities farthest away from the capital/tertiary care centre. CONCLUSION: High LUEMS incidence rates are rural phenomena but not specific to the older population. However, the absolute number of LUEMS by the older cohort is significant, and elder-specific interventions in rural regions could still lead to effective cost savings. Further investigation of other factors, such as distance to the emergency department, availability of public transportation, and socioeconomic conditions of EMS users, is needed.

Impact of a Novel Collaborative Long-Term Care -EMS Model: A Before-and-After Cohort Analysis of an Extended Care Paramedic Program.

To compare system and clinical outcomes before and after an extended care paramedic (ECP) program was implemented to better address the emergency needs of long-term care (LTC) residents. Data were collected from emergency medical services (EMS), hospital, and ten LTC facility charts for two five-month time periods, before and after ECP implementation. Outcomes include: number of EMS patients transported to emergency department (ED) and several clinical, safety, and system secondary outcomes. Statistics included descriptive, chi-squared, t-tests, and ANOVA; α = <0.05. 413 cases were included (before: n = 136, 33%; after n = 277, 67%). Median patient age was 85 years (IQR 77-91 years) and 292/413 (70.7%) were female. The number of transports to ED before implementation was 129/136 (94.9%), with 147/224 (65.6%) after, p < 0.001. In the after period, fewer patients seen by ECP were transported: 58/128 (45.3%) vs. 89/96 (92.7%) of those not seen by ECP, p < 0.001. Hospital admissions were similar between phases: 39/120 (32.5%) vs. 56/213 (29.4%), p = NS, but in the after phase, fewer ECP patients were admitted vs. non-ECP: 21/125 (16.8%) vs. 35/88 (39.8%), p < 0.001. Mean EMS call time (dispatch to arrive ED or clear scene) was shorter before than after: 25 minutes vs. 57 minutes, p < 0.001. In the after period, calls with ECP were longer than without ECP: 1 hour, 35 minutes vs. 30 minutes, p < 0.001. The mean patient ED length-of-stay was similar before and after: 7 hours, 29 minutes compared to 8 hours, 11 minutes; p = NS. In the after phase, ED length-of-stay was somewhat shorter with ECPs vs. no ECPs: 7 hours, 5 minutes vs. 9 hours, p = NS. There were zero relapses after no-transport in the before phase and three relapses from 77 calls not transported in the after phase (3/77, 3.9%); two involved ECP (2/70, 2.8%). Reductions were observed in the number of LTC patients transported to the ED when the ECP program was introduced, with fewer patients admitted to the hospital. EMS calls take longer with ECP involved. The addition of ECP to the LTC model of care appears to be beneficial and safe, with few relapse calls identified.

Alternatives to Traditional EMS Dispatch and Transport: A Scoping Review of Reported Outcomes.

OBJECTIVES: Emergency medical services (EMS) programs, which provide an alternative to traditional EMS dispatch or transport to the emergency department (ED), are becoming widely implemented. This scoping review identified and catalogued all outcomes used to measure such alternative EMS programs. Data Source Broad systematized bibliographic and grey literature searches were conducted. Study Selection Inclusion criteria were 911 callers/EMS patients, reported on alternatives to traditional EMS dispatch OR traditional EMS transport to the ED, and reported an outcome measure. Data Extraction The reports were categorized as either alternative to dispatch or to EMS transport, and outcome measures were categorized and described. Data Synthesis The bibliographic search retrieved 13,215 records, of which 34 articles met the inclusion criteria, with an additional 10 added from reference list hand-searching (n=44 included). In the grey literature search, 31 websites were identified, from which four met criteria and were retrieved (n=4 included). Fifteen reports (16 studies) described alternatives to EMS dispatch, and 33 reports described alternatives to EMS transport. The most common outcomes reported in the alternatives to EMS dispatch reports were service utilization and decision accuracy. Twenty-four different specific outcomes were reported. The most common outcomes reported in the alternatives to EMS transport reports were service utilization and safety, and 50 different specific outcomes were reported. CONCLUSIONS: Numerous outcome measures were identified in reports of alternative EMS programs, which were catalogued and described. Researchers and program leaders should achieve consensus on uniform outcome measures, to allow benchmarking and improve comparison across programs.

Offload zones to mitigate emergency medical services (EMS) offload delay in the emergency department: a process map and hazard analysis.

UNLABELLED: Introduction Offload delay is a prolonged interval between ambulance arrival in the emergency department (ED) and transfer of patient care, typically occurring when EDs are crowded. The offload zone (OZ), which manages ambulance patients waiting for an ED bed, has been implemented to mitigate the impact of ED crowding on ambulance availability. Little is known about the safety or efficiency. The study objectives were to process map the OZ and conduct a hazard analysis to identify steps that could compromise patient safety or process efficiency. METHODS: A Health Care Failure Mode and Effect Analysis was conducted. Failure modes (FM) were identified. For each FM, a probability to occur and severity of impact on patient safety and process efficiency was determined, and a hazard score (probability X severity) was calculated. For any hazard score considered high risk, root causes were identified, and mitigations were sought. RESULTS: The OZ consists of six major processes: 1) patient transported by ambulance, 2) arrival to the ED, 3) transfer of patient care, 4) patient assessment in OZ, 5) patient care in OZ, and 6) patient transfer out of OZ; 78 FM were identified, of which 28 (35.9%) were deemed high risk and classified as impact on patient safety (n=7/28, 25.0%), process efficiency (n=10/28, 35.7%), or both (n=11/28, 39.3%). Seventeen mitigations were suggested. CONCLUSION: This process map and hazard analysis is a first step in understanding the safety and efficiency of the OZ. The results from this study will inform current policy and practice, and future work to reduce offload delay.

The Epidemiology of Prehospital Emergency Responses for Older Adults in a Provincial EMS System.

OBJECTIVES: Societal aging is expected to impact the use of emergency medical services (EMS). Older adults are known as high users of EMS. Our primary objective was to quantify the rate of EMS use by older adults in a Canadian provincial EMS system. Our secondary objective was to compare those transported to those not transported. METHODS: We analysed data from a provincial EMS database for emergency responses between January 1, 2010 and December 31, 2010 and included all older adults (≥65 years) requesting EMS for an emergency call. We described EMS use in relation to age, sex, and resources. RESULTS: There were 30,653 emergency responses for older adults in 2010, representing close to 50% of the emergency call volume and an overall response rate of 202.8 responses per 1,000 population 65 years and older. The mean age was 79.9±8.5 years for those 57.3% who were female. The median paramedic-determined Canadian Triage and Acuity Scale (CTAS) score was 3 and the mean on-scene time was 24.2 minutes. Non-transported calls (12.3%) for the elderly involved predominantly (54.9%) female patients of similar mean age (78.3 years) but lower acuity (CTAS 5) and longer average on-scene times (32.6 minutes). CONCLUSIONS: We confirmed the increasingly high rate of EMS use with age to be consistent with other industrialized populations. The low-priority and non-transport calls by older adults consumed considerable resources in this provincial system and might be the areas most malleable to meet the challenges facing EMS systems.

Insights into the implementation and operation of a novel paramedic long-term care program.

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.