Identifying Features of a System of Practice to Inform a Contemporary Competency Framework for Paramedics in Canada.

INTRODUCTION: Paramedic practice is highly variable, occurs in diverse contexts, and involves the assessment and management of a range of presentations of varying acuity across the lifespan. As a result, attempts to define paramedic practice have been challenging and incomplete. This has led to inaccurate or under-representations of practice that can ultimately affect education, assessment, and the delivery of care. In this study, we outline our efforts to better identify, explore, and represent professional practice when developing a national competency framework for paramedics in Canada. METHODS: We used a systems-thinking approach to identify the settings, contexts, features, and influences on paramedic practice in Canada. This approach makes use of the role and influence of system features at the microsystem, mesosystem, exosystem, macrosystem, supra-macrosystem, and chronosystem levels in ways that can provide new insights. We used methods such as rich pictures, diagramming, and systems mapping to explore relationships between these contexts and features. FINDINGS: When we examine the system of practice in paramedicine, multiple layers become evident and within them we start to see details of features that ought to be considered in any future competency development work. Our exploration of the system highlights that paramedic practice considers the person receiving care, caregivers, and paramedics. It involves collaboration within co-located and dispersed teams that are composed of other health and social care professionals, public safety personnel, and others. Practice is enacted across varying geographical, cultural, social, and technical contexts and is subject to multiple levels of policy, regulatory, and legislative influence. CONCLUSION: Using a systems-thinking approach, we developed a detailed systems map of paramedic practice in Canada. This map can be used to inform the initial stages of a more representative, comprehensive, and contemporary national competency framework for paramedics in Canada.

Impact of a COVID-19 code blue protocol on resuscitation care and CPR quality during in-hospital cardiac arrest.

OBJECTIVE: We sought to evaluate the impact of a COVID-19 Code Blue policy on in-hospital cardiac arrest (IHCA) processes of care, cardiopulmonary resuscitation (CPR) quality metrics, and survival to hospital discharge. METHODS: We completed a health record review of consecutive IHCA for which resuscitation was attempted. We report Utstein outcomes and CPR quality metrics 33 months before (July,2017-March,2020) and after (April,2020-December,2022) the implementation of a COVID-19 Code Blue policy requiring all team members to don personal protective equipment including gown, gloves, mask, and eye protection for all IHCA. RESULTS: There were 800 IHCA with the following characteristics (Before n = 396; After n = 404): mean age 66, 62.9% male, 81.3% witnessed, 31.3% in the emergency department, 25.6% cardiac cause, and initial shockable rhythm in 16.7%. Among all 404 patients screened for COVID-19, 25 of 288 available test results before IHCA occurred were positive. Comparing the before and after periods: there were relevant time delays (min:sec) in start of chest compressions (0:17vs.0:37;p = 0.005), team arrival (0:43vs.1:21;p = 0.002), 1st rhythm analysis (1:15vs.3:16;p < 0.0001), 1st epinephrine (3:44vs.4:34;p = 0.02), and airway insertion (8:38vs. 10:18;p = 0.02). Resuscitation duration was similar (18:28vs.19:35;p = 0.34). Exception of peri-shock pause which appeared longer (0:06vs.0:14;p = 0.07), chest compression fraction, rate and depth were identical and good. Factors independently associated with survival were age (adjOR 0.98;p < 0.001), male sex (adjOR 1.51;p = 0.048), witnessed (adjOR 2.35;p = 0.02), shockable rhythm (adjOR 3.31;p < 0.0001), hospital location (p = 0.0002), and COVID-19 period (adjOR 0.68;p = 0.052). CONCLUSIONS: The COVID-19 Code Blue policy was associated with delayed processes of care but similarly good CPR quality. The COVID-19 period appeared associated with decreased survival.

Multi-phase implementation of automated external defibrillator use by nurses during in-hospital cardiac arrest and its impact on survival.

OBJECTIVE: We sought to evaluate the impact of a medical directive allowing nurses to use defibrillators in automated external defibrillator-mode (AED) on in-hospital cardiac arrest (IHCA) outcomes. METHODS: We completed a health record review of consecutive IHCA for which resuscitation was attempted using a pragmatic multi-phase before-after cohort design. We report Utstein outcomes before (Jan.2012-Aug.2013;Control) the implementation of the AED medical directive following usual practice (Sept.2013-Aug.2016;Phase 1), and following the addition of a theory-based educational video (Sept.2016-Dec.2017;Phase 2). RESULTS: There were 753 IHCA with the following characteristics (Before n = 195; Phase 1n = 372; Phase 2n = 186): mean age 66, 60.0% male, 79.3% witnessed, 29.1% noncardiac-monitored medical ward, 23.9% cardiac cause, and initial ventricular fibrillation/tachycardia (VF/VT) 27.2%. Comparing the Before, Phase 1 and 2: an AED was used 0 time (0.0%), 21 times (5.7%), 15 times (8.1%); mean times to 1st analysis were 7 min, 3 min and 1 min (p < 0.0001); mean times to 1st shock were 12 min, 10 min and 8 min (p = 0.32); return of spontaneous circulation (ROSC) was 63.6%, 59.4% and 58.1% (p = 0.77); survival was 24.6%, 21.0% and 25.8% (p = 0.37). Among IHCA in VF/VT (n = 165), time to 1st analysis and 1st shock decreased by 5 min (p = 0.01) and 6 min (p = 0.23), and ROSC and survival increased by 3.0% (p = 0.80) and 15.6% (p = 0.31). There was no survival benefit overall (1.2%; p = 0.37) or within noncardiac-monitored areas (-7.2%; p = 0.24). CONCLUSIONS: The implementation of a medical directive allowing for AED use by nurses successfully improved key outcomes for IHCA victims, particularly following the theory-based education video and among the VF/VT group.

Brain-based arterial pulse pressure threshold for death determination: a systematic review.

PURPOSE: There is lack of consensus regarding the minimum arterial pulse pressure required for confirming permanent cessation of circulation for death determination by circulatory criteria in organ donors. We assessed direct and indirect evidence supporting whether one should use an arterial pulse pressure of 0 mm Hg vs more than 0 (5, 10, 20, 40) mm Hg to confirm permanent cessation of circulation. SOURCE: We conducted this systematic review as part of a larger project to develop a clinical practice guideline for death determination by circulatory or neurologic criteria. We systematically searched Ovid MEDLINE, Ovid Embase, Cochrane Central Register of Controlled Trials (CENTRAL) via the Cochrane Library, and Web of Science for articles published from inception until August 2021. We included all types of peer-reviewed original research publications related to arterial pulse pressure as monitored by an indwelling arterial pressure transducer around circulatory arrest or determination of death with either direct context-specific (organ donation) or indirect (outside of organ donation context) data. PRINCIPAL FINDINGS: A total of 3,289 abstracts were identified and screened for eligibility. Fourteen studies were included; three from personal libraries. Five studies were of sufficient quality for inclusion in the evidence profile for the clinical practice guideline. One study measured cessation of cortical scalp electroencephalogram (EEG) activity after withdrawal of life-sustaining measures and showed that EEG activity fell below 2 µV when the pulse pressure reached 8 mm Hg. This indirect evidence suggests there is a possibility of persistent cerebral activity at arterial pulse pressures > 5 mm Hg. CONCLUSION: Indirect evidence suggests that clinicians may incorrectly diagnose death by circulatory criteria if they apply any arterial pulse pressure threshold of greater than 5 mm Hg. Moreover, there is insufficient evidence to determine that any pulse pressure threshold greater than 0 and less than 5 can safely determine circulatory death. STUDY REGISTRATION: PROSPERO (CRD42021275763); first submitted 28 August 2021.

RéSUMé: OBJECTIF: Il n'y a pas de consensus concernant la pression artérielle minimale requise pour confirmer l'arrêt permanent de la circulation pour la détermination du décès selon des critères circulatoires chez les donneurs d'organes. Nous avons évalué les données probantes directes et indirectes soutenant l'utilisation d'une pression pulsée artérielle de 0 mmHg vs plus de 0 (5, 10, 20, 40) mm Hg pour confirmer l'arrêt définitif de la circulation. SOURCES: Nous avons réalisé cette revue systématique dans le cadre d'un projet plus vaste visant à élaborer des lignes directrices de pratique clinique pour la détermination du décès selon des critères circulatoires ou neurologiques. Nous avons mené des recherches systématiques dans Ovid MEDLINE, Ovid Embase, le registre Cochrane des études contrôlées (CENTRAL) via la Cochrane Library et Web of Science pour trouver des articles publiés depuis leur création jusqu'en août 2021. Nous avons inclus tous les types de publications de recherches originales évaluées par des pairs liées à la pression pulsée artérielle telle que surveillée par un transducteur de pression artérielle à demeure entourant un arrêt circulatoire ou de une détermination de décès avec des données directes spécifiques au contexte (don d'organes) ou indirectes (en dehors d'un contexte du don d'organes). CONSTATATIONS PRINCIPALES: Au total, 3289 résumés ont été identifiés et examinés pour déterminer leur admissibilité. Quatorze études ont été incluses, trois provenant de bibliothèques personnelles. Cinq études étaient de qualité suffisante pour être incluses dans le profil de données probantes des Lignes directrices de pratique clinique. Une étude a mesuré l'arrêt de l'activité de l'électroencéphalogramme (EEG) au niveau du scalp cortical après l'interruption des thérapies de maintien des fonctions vitales et a montré que l'activité EEG tombait en dessous de 2 µV lorsque la pression pulsée atteignait 8 mm Hg. Ces données probantes indirectes suggèrent qu'il existe une possibilité d'activité cérébrale persistante à des pressions pulsées artérielles > 5 mm Hg. CONCLUSION: Des données probantes indirectes suggèrent que les cliniciens pourraient diagnostiquer à tort un décès selon des critères circulatoires s'ils appliquent un seuil de pression pulsée artérielle supérieur à 5 mm Hg. De plus, il n'y a pas suffisamment de données probantes pour déterminer que tout seuil de pression pulsée supérieur à 0 et inférieur à 5 peut permettre de déterminer en toute sécurité un décès cardiocirculatoire. ENREGISTREMENT DE L'éTUDE: PROSPERO (CRD42021275763); soumis pour la première fois le 28 août 2021.

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.

COVID-19 Assessment and Testing in Rural Communities During the Pandemic: Cross-sectional Analysis.

BACKGROUND: The COVID-19 pandemic exacerbated the need for urgent improvements in access to health care for rural, remote, and underserviced communities. The Renfrew County Virtual Triage and Assessment Centre (VTAC) was designed to provide access to COVID-19 testing and assessment with a family physician. The goal was to protect emergency departments and 911 paramedics while ensuring that nobody was left at home, suffering in silence. Residents were encouraged to call their own family physician for any urgent health needs. If they did not have a family physician or could not access their usual primary care provider, then they could call VTAC. This study reports on the output of a service model offering access to assessment and COVID-19 testing through a blend of virtual and in-person care options by a multidisciplinary team. OBJECTIVE: The purpose of this study was to assess the ability of VTAC to provide access to COVID-19 assessment and testing across rural, remote, and underserviced communities. METHODS: We conducted a cross-sectional analysis of the data derived from the cases handled by VTAC between March 27, 2020 (launch day), and September 30, 2020. RESULTS: Residents from all 19 census subdivisions and municipalities of Renfrew County accessed VTAC. A total of 10,086 family physician assessments were completed (average 64 per day). Of these, 8535 (84.6%) assessments were to unique patient users. Thirty physicians provided care. Using digital equipment setup in the patients' home, 31 patients were monitored remotely. VTAC community paramedics completed 14,378 COVID-19 tests and 3875 home visits. CONCLUSIONS: Renfrew County's experience suggests that there is tremendous synergy between family physicians and community paramedics in providing access to COVID-19 assessment and COVID-19 testing. The blended model of virtual and in-person care is well suited to provide improved access to other aspects of health care post pandemic, particularly for patients without a family physician.

Out-of-hospital cardiac arrest in countries of the Gulf Cooperation Council: a scoping review.

BACKGROUND: Published data are lacking on response to and outcomes of out-of-hospital cardiac arrest in the Middle East. What data there are have not been comprehensively analysed. AIMS: This study aimed to assess the characteristics of people with out-of-hospital cardiac arrest in Gulf Cooperation Council (GCC) countries (Bahrain, Kuwait, Oman, Qatar, Saudi Arabia and United Arab Emirates) and the response to and outcomes of such incidents. METHODS: This was a scoping review of published and grey literature on out-of-hospital cardiac arrest in GCC countries from 1990 to June 2019. Studies in English and Arabic were eligible for inclusion. MEDLINE, CINAHL, Web of Science and EMBASE were searched as well as relevant non-indexed journals. Google searches were also done. References of included studies were scanned for relevant articles. Experts on the subject in the region were consulted. RESULTS: Of 647 citations retrieved, 24 studies were included for data extraction and analysis. No literature was identified for Bahrain. People with out-of-hospital cardiac arrest in the region were younger, predominantly male and had more comorbidity than reported in other regions of the world. Use of emergency medical services was low across the GCC countries, as was bystander cardiopulmonary resuscitation, return of spontaneous circulation and survival to discharge. CONCLUSIONS: A coordinated effort to address out-of-hospital cardiac arrest, including the generation of research, is lacking within and among GCC countries. Establishment of lead agencies responsible for developing and coordinating strategies to address out-of-hospital cardiac arrest, such as community response, public education and reporting databases, is recommended.