Using realist approaches to explain and understand the optimal use of paramedics in primary care

Paramedics, with their generalist clinical background acquired from ambulance service experience, are increasingly employed in primary care. However, the specific contribution paramedics can offer to the primary care workforce has not been distinctly outlined. This thesis aims to address this uncertainty, employing realist approaches to construct a programme theory. This theory is derived from evidence gathered through five interconnected studies, enriched by active involvement and engagement with stakeholders, patients, and the public. An exploratory systematic review of the literature published in the United Kingdom (UK) identified gaps in the evidence base on the subject and enabled the production of an initial programme theory. This initial programme theory was refined following a broader realist review, which included a range of document sources across a global scale, and integration with key substantive theories. Realist evaluation unfolded in three consecutive phases, each contributing to the refinement of the middle-range program theory: - In Phase I, a mixed-methods cross-sectional survey of paramedics in primary care in the UK was conducted to comprehend the existing practices of paramedics within the NHS. - Phase II involved an analytic auto-netnography, where the DPhil student observed online conversations among paramedics in primary care. This exploration aimed to understand paramedics' perceptions of their role and provided a unique perspective for the student as a practitioner-researcher. - Phase III utilised focused observations and interviews to delve into the impact of paramedics on the primary care workforce. This comparative study collected data from sixty participants across fifteen sites in the UK, and twelve participants across three sites in a specific region in Canada. The culmination of findings from each phase led to the development of a final programme theory, encompassing three conceptual categories: Expectations associated with paramedics in primary care, the transition of paramedics into primary care roles, and the roles and responsibilities of paramedics in primary care. Based on the evidence generated, there are four key recommendations regarding how paramedics work in primary care: 1. A clear strategy for communication of the paramedic’s role in primary care 2. Developing a comprehensive curriculum framework for paramedics in primary care 3. The need for an effective transition support structure 4. Changes to legislation and policy Addressing these recommendations on education, implementation and policy adjustments would likely enable paramedics optimise their contribution to primary care teams

Paramedic practice in low light conditions: a scoping review

Paramedics undertake visually demanding tasks, which may be adversely affected by low lighting conditions. The study aimed to: identify difficulties paramedics experience carrying out tasks in low light; and establish occupational health standards and adjustments that may improve working practices. Abstract published with permission

International Examination and Synthesis of the Primary and Secondary Surveys in Paramedicine

BackgroundTo guide their care paramedics routinely rely upon two assessment and treatment algorithms, known as the primary survey and the secondary survey.  No clear consensus of the concepts (assessments and interventions) that are, or should be, included in these algorithms exist internationally. Methods This paper evaluated Australasian paramedic clinical practice guidelines (CPGs), as well as six other international paramedic CPGs (USA, Ireland, UK, South Africa, Qatar, and the United Arab Emirates) in order to identify which concepts are currently described in best-practice recommendations for paramedics.  The authors also contributed concepts that they felt were important additions based on their experience as veteran paramedics and paramedic educators.Results The resulting amalgamation of concepts identified in each term was then formed into two mnemonics which, together sequentially list approximately 100 specific clinical concepts that paramedics routinely consider in their care of patients. We describe these as the “International Paramedic Primary and Secondary Surveys”.Conclusion The primary and secondary surveys presented in this paper represent an evidence-based guide to the best practice in conducting a primary and secondary survey in the paramedic context.  Findings will be of use to paramedics, paramedic students, and other clinicians working in remote or isolated practices

improving Pain mAnagement for childreN and young people attendeD by Ambulance (PANDA): protocol for a realist review [version 1; peer review: awaiting peer review]

BackgroundEach year in England, 450,000 children and young people (CYP) under 18 years of age are transported by ambulance to emergency departments. Approximately 20% of these suffer acute pain caused by illness or injury. Pain is a highly complex sensory and emotional experience. The intersection between acute pain, unwell CYP and the unpredictable pre-hospital environment is convoluted. Studies have shown that prehospital pain management in CYP is poor, with 61% of those suffering acute pain not achieving effective pain relief (abolition or reduction of pain score by 2 or more out of 10) when attended by ambulance. Consequences of poor acute pain management include altered pain perception, post-traumatic stress disorder and the development of chronic pain. This realist review will aim to understand how ambulance clinicians can provide improved prehospital acute pain management for CYP.MethodsA realist review will be conducted in accordance with the Realist And Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) guidance. A five-stage approach will be adopted; 1) Developing an Initial Programme Theory (IPT) – develop an IPT with key stakeholder input and evidence from informal searching; 2) Searching and screening – conduct a thorough search of relevant research databases and grey literature sources and perform screening in duplicate; 3) Document selection – assess documents for relevance and rigour in duplicate; 4) Extracting and organising data – code relevant data into conceptual “buckets” using qualitative data analysis software; and 5) Synthesis and Programme Theory (PT) refinement – utilise a realist logic of analysis to generate context-mechanism-outcome configurations (CMOCs) within and across conceptual “buckets”, test and refine the IPT into a realist PT.ConclusionThe realist PT will enhance our understanding of what works best to improve acute prehospital pain management in CYP, which will then be tested and refined within a realist evaluation.RegistrationPROSPERO Registration: CRD4202450597

2018 Research & Innovation Day Program

A one day showcase of applied research, social innovation, scholarship projects and activities.https://first.fanshawec.ca/cri_cripublications/1005/thumbnail.jp

Management of an isolated neck-of-femur fracture in an elderly patient

Abstract published with permission. Femoral neck fractures affect up to 75 000 elderly people per year, with up to a third of these patients dying within twelve months. While there is a paucity of research specific to the pre-hospital field, current evidence demonstrates that optimal treatments include appropriate and adequate analgesia, fluid management and correct immobilisation of the injured leg. Analgesia should be considered in a step-wise approach and should be progressive to the patients' needs. Pain relief should be sought through the variety of options open to paramedics and should be initiated immediately. Transfer to the ambulance should be done in a safe manner, ensuring the patient is immobilised and remains pain free. This pre-hospital management of the patient with a femoral neck fracture ensures they receive adequate analgesia and fluid replacement before any definitive treatment at hospital

Advancing practice through the lens of patient care

Just over a decade ago, when I first registered with the Health and Care Professions Council (HCPC) (then the Health Professions Council), I did not picture a career outside of the back of an ambulance—unless I ceased to be a paramedic entirely. Yet, over the last 10 years, one of the main components that has catalysed the development of the profession is the idea that paramedics could capitalise their generalist unique selling point (USP) to work to an enhanced clinical level. The development of the paramedic profession itself is not new—we have continuously developed since our inception from working clinically within the constraints of providing life support under the supervision of cardiologists, to being autonomous clinicians in our own right. However, the progression to working within advanced practice has been something new—and I think we have the changing model of care delivery within the ambulance service to thank for this. Abstract published with permission

Documentation: are we writing it right?

Abstract published with permission. While the need to keep accurate patient records is acknowledged by the bodies that govern healthcare practice, there is currently little evidence to support a specific standard of record keeping, with advice on following one of several recognised models. For many ambulance Trusts, documentation guidelines are based on expert opinion of what should constitute good medical records and documentation, but this can vary from region to region. However, whichever model is used, there are several core principles that should be used when writing medical documentation. This article aims to provide ambulance staff with general information on documentation in an attempt to enable readers to understand why records are kept, the standard to which records should be kept, and the legal and regulatory issues relating to record-keeping for paramedics