An examination of the emerging field of community paramedicine: a national cross-sectional survey of community paramedics.

BACKGROUND: Community Paramedicine is an evolving community-based model that expands paramedic roles from emergency and transport care to a focus on non-emergent and preventive health services tailored to local community needs. Though community paramedicine is a growing field and acceptance is gradually increasing, there is limited information on community paramedics (CPs) perceptions of their expanded roles. The study's aim is to assess CPs' perceptions about their training, roles, role clarity, role readiness, role satisfaction, professional identity, interprofessional collaboration, and the future of the community paramedicine care model. METHODS: Using the National Association of Emergency Medical Technicians-mobile integrated health (NAEMT-MIH) listserv, a cross-sectional survey was conducted in July/August 2020 using a 43-item web-based questionnaire. Thirty-nine questions evaluated CPs' training, roles, role clarity, role readiness, role satisfaction, professional identity, interprofessional collaboration, and program/work characteristics. Four open-ended questions examined perceptions of the future of community paramedicine care models and challenges/opportunities encountered during the COVID-19 pandemic. Data was analyzed using Spearman's correlation, Wilcoxon Mann-Whitney U, and Kruskal-Wallis tests. Open-ended questions were analyzed using qualitative content analyses. RESULTS: Responses from fifty-seven CPs were analyzed. Most (80%) completed didactic and/or clinical training. Nearly all respondents (96.5%) performed health assessments; only 38.6% administered vaccines. Overall, participants were neutral about their role readiness with a mean score of 3.3/5.0. The mean role clarity was 15.5 (range 4-29; higher scores = higher clarity), professional identity was 46.8 (range 30-55; higher scores = higher identity), role satisfaction was 4.4/5 with 5 = very satisfied, and interprofessional collaboration was 9.5/10 (10 = very important). Role clarity training (rho = 0.4, p = 0.0013) and higher interprofessional collaboration (rho = 0.4, p = 0.0015) were found to be significantly associated with the enhancement of professional identity. Respondents who completed training showed higher role satisfaction compared to those who did not (p = 0.0114). COVID-19 challenges included keeping up with emerging policies/procedures, CPs' well-being, and inadequate funding to meet service needs; opportunities identified included service delivery expansion and CPs meeting community needs in a flexible manner. Respondents reported that sustainable payment models, expanding services, and geographic reach were important to the future of community paramedicine. CONCLUSIONS: Interprofessional collaboration is important to fulfill CPs roles. Role clarity and readiness could be improved, which aligns with the emerging nature of community paramedicine. The future of the community paramedicine care model is dependent on funding and expanding reach of services.

Implementing a COVID-19 Virtual Observation Unit in Emergency Medicine: Frontline Clinician and Staff Experiences.

The COVID-19 pandemic pushed hospitals to deliver care outside of their four walls. To successfully scale virtual care delivery, it is important to understand how its implementation affects frontline workers, including their teamwork and patient-provider interactions. We conducted in-depth interviews of 17 clinicians and staff involved with the COVID-19 Virtual Observation Unit (CVOU) in the emergency department (ED) of an academic hospital. The program leveraged remote patient monitoring and mobile integrated health care. In the CVOU (vs. the ED), participants observed increases in interactions among clinicians and staff, patient participation in care delivery, attention to nonmedical factors, and involvement of coordinators and paramedics in patient care. These changes were associated with unintended, positive consequences for staff, namely, feeling heard, experience of meaningfulness, and positive attitudes toward virtual care. This study advances research on reconfiguration of roles following implementation of new practices using digital tools, virtual work interactions, and at-home care delivery.

Admission Avoidance for Older Adults Facilitated by Telemedicine during the COVID-19 Pandemic.

INTRODUCTION: The coronavirus pandemic has disproportionately affected older adults and has provided an incentive to find alternatives to emergency department attendance to avoid unnecessary exposure to the SARS-CoV-2 virus. To address this issue, a specialist geriatric multidisciplinary team at Queen Elizabeth Hospital set up a novel telemedicine approach to the ambulance service with the aim of reducing unnecessary emergency department attendance for older adults. This study provides a service evaluation in its first year of use. METHODS: Service evaluation in the first year of the 'Ask OPAL' (older person Assessment and liaison) hotline for ambulance paramedics, run by a multidisciplinary acute geriatrics team at the Queen Elizabeth Hospital, Birmingham. Data on the number, patient demographics, intervention, and outcome of the calls, were recorded. RESULTS: During the study period, 2552 'Ask OPAL' calls were conducted. Of the 2552 calls carried out, 1755 patients (69%) remained at home. Of the patients who remained at home, 76% received verbal advice only, while 24% were referred to community services in addition to receiving verbal advice. CONCLUSION: In conclusion, the use of an integrated multidisciplinary team communicating with paramedics via telemedicine appears to be successful in preventing avoidable hospital admissions in complex patients.

SPECTRa: An Online Tool for Simulating Prehospital Patient Care.

OBJECTIVES: To (1) develop a simulation software environment to conduct prehospital research during the COVID-19 pandemic on paramedics' teamwork and use of mobile computing devices, and (2) establish its feasibility for use as a research and training tool. BACKGROUND: Simulation-based research and training for prehospital environments has typically used live simulation, with highly realistic equipment and technology-enhanced manikins. However, such simulations are expensive, difficult to replicate, and require facilitators and participants to be at the same location. Although virtual simulation tools exist for prehospital care, it is unclear how best to use them for research and training. METHODS: We present SPECTRa-Simulated Prehospital Emergency Care for Team Research-an online simulated prehospital environment that lets participants care concurrently for single or multiple patients remotely. Patient scenarios are designed using Laerdal's SimDesigner. SPECTRa records data about scenario states and participants' virtual interaction with the simulated patients. SPECTRa's supporting environment records participants' verbal communication and their visual and physical interactions with their interface and devices using Zoom conferencing and audiovisual recording. We discuss a pilot research implementation to assess SPECTRa's feasibility. RESULTS: SPECTRa allows researchers to systematically test small-team interaction in single- or multipatient care scenarios and assess the impact of mobile devices on participants' assessment and care of patients. SPECTRa also supports pedagogical features that could allow prehospital educators to provide individual trainees or teams with online simulation training and evaluation. CONCLUSIONS: SPECTRa, an online tool for simulating prehospital patient care, shows potential for remote healthcare research and training.

A Dedicated SARS-CoV-2 Testing Center for Public Service Agency Personnel: Implementation, Results, and Impact on Human Resources.

Objective: A global pandemic due to an emerging infectious disease requires efficient use of resources to ensure continued operation of essential services. To mitigate risk to these services and the population served, there needs to be a rapid identification of infected personnel via screening and testing.Methods: This retrospective study used prospectively collected data from a dedicated SARS-CoV-2 testing center for fire, police, and paramedic personnel in Toronto, Canada to determine the incidence of seropositive personnel and their immediate household, and estimate the days off work saved by timely access to testing and results.Results: In the consecutive 12-month study period, 10624 tests were carried out. Of 7951 personnel tested, 282 (3.55%) were positive, with positivity rates ranging from 2.52% for paramedics, 4.01% for police, and 4.25% for fire personnel. Household members tested positive in 173 of 2592 cases (6.67%), ranging from 5.22% for fire, 6.34% for paramedic, and 7.04% for police households. The median time to obtain test results was 1 day, with 90% available within 2 days. Implementation of the Center is estimated to have saved the Services 7669 person-days off work.Conclusion: A dedicated SARS-CoV-2 testing center for essential personnel can improve access to diagnostic testing and turnaround time for results, and provide a positive impact on human resource availability during a pandemic.

Changes in alcohol intoxication-related ambulance attendances during COVID-19: How have government announcements and policies affected ambulance call outs?

BACKGROUND: In response to COVID-19, government-mandated health directives including widespread lockdowns were implemented. Changes in alcohol purchasing were reported, with growing concern that alcohol may be consumed as a way to cope with pandemic-associated stressors. Hitherto, there have been limited studies examining alcohol-related harms, including acute harms requiring an ambulance, and their relationship to government announcements or policies related to COVID-19. METHODS: Analyses were conducted between January and September 2020, with matched months in 2019, using Victorian data from the National Ambulance Surveillance System in Australia. Interrupted time series (ITS) models with odds ratios (OR) were used to map alcohol-related harms as a function of government policies for both metropolitan and regional areas. FINDINGS: A total of 43,003 alcohol intoxication-related ambulance attendances occurred between January 2019 and September 2020. Attendances in the home increased in 2020 by 9% compared to matched 2019 months. The most socioeconomically advantaged cases showed the highest percentage change. ITS models showed decreased odds of alcohol-related attendances at the beginning of each COVID-19 wave in metropolitan (OR:0•77; 95%CI: 0•71-0•83; p<0•001) and regional Victoria (OR: 0•72; 95%CI: 0•67-0•79, p<0•001) separately, and increased odds following the introduction of harsher restrictions in metropolitan Melbourne (OR:1•07; 95%CI:1•01-1•11, p=0•005). A 19% increase in odds of alcohol-related harms was observed at the end of the second wave lockdown period in regional Victoria (OR:1•19; 95%CI: 1•01-1•41, p=0•004). INTERPRETATION: Alcohol-related attendances during COVID-19 restrictions showed a displacement to home settings. Changes in patterns of harms were evident in specific sociodemographic groups, and geographic regions when mapped to government health directives. This study is one of the first to investigate alcohol-related harms at the population level in response to a global pandemic. FUNDING: Commonwealth Department of Health and Victorian Department of Health.

A Systematic Review and Meta-Analysis of the Implementation of High-Performance Cardiopulmonary Resuscitation on Out-of-Hospital Cardiac Arrest Outcomes.

Despite numerous technological and medical advances, out-of-hospital cardiac arrests (OHCAs) still suffer from suboptimal survival rates and poor subsequent neurological and functional outcomes amongst survivors. Multiple studies have investigated the implementation of high-quality prehospital resuscitative efforts, and across these studies, different terms describing high-quality resuscitative efforts have been used, such as high-performance CPR (HP CPR), multi-tiered response (MTR) and minimally interrupted cardiac resuscitation (MICR). There is no universal definition for HP CPR, and dissimilar designs have been employed. This systematic review thus aimed to review current evidence on HP CPR implementation and examine the factors that may influence OHCA outcomes. Eight studies were systematically reviewed, and seven were included in the final meta-analysis. Random-effects meta-analysis found a significantly improved likelihood of prehospital return of spontaneous circulation (pooled odds ratio (OR) = 1.46, 95% CI: 1.16 to 1.82, p < 0.001), survival-to-discharge (pooled OR = 1.32, 95% CI: 1.16 to 1.50, p < 0.001) and favourable neurological outcomes (pooled OR = 1.24, 95% CI: 1.11 to 1.39, p < 0.001) with HP CPR or similar interventions. However, the studies had generally high heterogeneity (I2 greater than 50%) and overall moderate-to-severe risk for bias. Moving forward, a randomised, controlled trial is necessary to shed light on the subject.

Implementation of Drive-Through Testing for COVID-19 With Community Paramedics.

OBJECTIVE: In this manuscript, we discuss the implementation and deployment of mobile integrated health and community paramedicine (MIH/CP) testing sites to provide screening, testing, and community outreach during the first months of the 2019 coronavirus disease (COVID-19) pandemic in the metropolitan region of Charlotte, North Carolina. This program addresses the need for an agile testing strategy during the current pandemic. We disclose the number of patients evaluated as "persons under investigation" and the proportion with positive severe acute respiratory syndrome coronavirus 2 (SARS CoV-2) results from these sites. We describe how the programs were applied to patient care and include considerations on how additional staffing, scalability, and flexibility of these services may be applied to future patient and health care crises. METHODS: This is a descriptive report of the implementation of MIH/CP test sites in our health care system's early response to the COVID-19 pandemic in March 2020. Retrospective data on the number of patients and their associated demographics are reported here as raw data. No statistical analysis was performed. RESULTS: Between March 15, 2020, and April 15, 2020, our 6 MIH/CP test sites evaluated 4342 patients. Of these, 401 patients (9.2%) had positive test results, 62.8% of whom were women. The estimated duration of each patient encounter under investigation was 3 to 5 minutes. The paramedics were able to perform a brief history, specific physical examination, and screening for signs of hypoxemic respiratory failure. There were no cases of accidental exposure or failure of personal protective equipment for the MIH/CP paramedics. CONCLUSIONS: In our health care system, we pivoted the traditional MIH/CP model to rapidly initiate remote drive-through testing for COVID-19 in pre-screened individuals. This model allowed us to test patients with suspected COVID-19 patients away from traditional health care sites and mitigate exposure to health care workers and other patients.

Improving care for residents in long term care facilities experiencing an acute change in health status.

BACKGROUND: Long term care (LTC) facilities provide health services and assist residents with daily care. At times residents may require transfer to emergency departments (ED), depending on the severity of their change in health status, their goals of care, and the ability of the facility to care for medically unstable residents. However, many transfers from LTC to ED are unnecessary, and expose residents to discontinuity in care and iatrogenic harms. This knowledge translation project aims to implement a standardized LTC-ED care and referral pathway for LTC facilities seeking transfer to ED, which optimizes the use of resources both within the LTC facility and surrounding community. METHODS/DESIGN: We will use a quasi-experimental randomized stepped-wedge design in the implementation and evaluation of the pathway within the Calgary zone of Alberta Health Services (AHS), Canada. Specifically, the intervention will be implemented in 38 LTC facilities. The intervention will involve a standardized LTC-ED care and referral pathway, along with targeted INTERACT® tools. The implementation strategies will be adapted to the local context of each facility and to address potential implementation barriers identified through a staff completed barriers assessment tool. The evaluation will use a mixed-methods approach. The primary outcome will be any change in the rate of transfers to ED from LTC facilities adjusted by resident-days. Secondary outcomes will include a post-implementation qualitative assessment of the pathway. Comparative cost-analysis will be undertaken from the perspective of publicly funded health care. DISCUSSION: This study will integrate current resources in the LTC-ED pathway in a manner that will better coordinate and optimize the care for LTC residents experiencing an acute change in health status.