The emergence of more complex professional paramedic roles such as community paramedicine raises a host of questions related to expectations, roles, and the extent to which the outcomes justify the investment in these innovations. In Canada, the United States, the United Kingdom, Australia, and New Zealand, pilot programmes and trials of different community paramedic-type models are being undertaken to test the concept, and to determine the safety and impact of these innovations (Mason et al, 2008; Blacker et al, 2009; Martin-Misener et al, 2009; Swain et al, 2010; Montera and Robinson, 2011).
These innovations in paramedic practice have often emerged organically from existing structures and local needs. There has been limited reference to developments elsewhere and they have rarely been based on empirical evidence of positive outcomes. While it can be argued that this is the result of there being a dearth of evidence (Patterson and Skillman, 2013), there may be significant work published throughout the world that is published in refereed journals and conference proceedings that are not routinely accessed by service providers or paramedics.
Community paramedicine programmes have generally been built on strong partnerships between paramedic services and other health and social services, and in that sense are distinctive from traditional paramedic emergency response models and the related emergence of extended care paramedic (ECP) roles. This concept of a mobile, community-based health provider shares some characteristics with those community nursing models that are filling service gaps in places without a medical workforce (Greene and Burley, 2006; Fitzgerald, 2008). In 2005, the first International Roundtable on Community Paramedicine was held in Nova Scotia, Canada. This loosely-bound group has since developed a definition of community paramedicine that is gaining currency around the world. To reduce the potential for confusion around the various models of expanded or extended scopes of practice that often overlap with the concept of a community paramedicine their definition was adopted for this scoping review:
‘Community paramedicine is a model of care whereby paramedics apply their training and skills in “non-traditional” community-based environments, often outside the usual emergency response and transportation model. The community paramedic practices within an “expanded scope”, which includes the application of specialised skills and protocols beyond the base paramedic training. The community paramedic engages in an “expanded role” working in non-traditional roles using existing skills’
Given this varied and ‘non-evidence-based’ approach, it is not surprising that the professional growth and development of paramedics’ professional identity as community paramedics has resulted in internal and external tensions emerging between the traditional paramedics and those in these emerging roles, and between community paramedics and other health professionals as occupational boundaries are challenged and breached (Petrie, 2000; Wanger, 2000; Joyce et al, 2009; Mulholland et al, 2009a; Sheather, 2009; Coleman et al, 2011).
For all of these reasons and more, it is important to undertake a review of the existing literature that addresses this new health provider role (White and Wingrove, 2012). There are a number of approaches that can be taken to reviewing the literature (Grant and Booth, 2009). In this case, it was decided to undertake a scoping review as an alternative to a systematic review. The reason for this approach was to gain the benefit from a scoping review's ability to capture studies and papers reporting on a broad range of methodologies and research questions. The aim is to enable the mapping of key conceptual underpinnings of the community paramedic role, where the evidence exists and what form it takes (Arksey and O'Malley, 2005). There have been a number of recent reviews of expanded scope of practice paramedics (Ball, 2005; Cooper and Grant, 2009), advanced life support (Isenberg and Bisell, 2005), and the economic value of out-of-hospital emergency care (Lerner et al, 2006). Specific reviews of community paramedic roles are much rarer (Jensen and Bigham, 2009).
There have been a number of descriptive accounts of emerging paramedic roles in rural and remote settings that broadly equate to the community paramedic role (O'Meara, 2003; Stirling et al, 2007; Reeve et al, 2008; Wingrove and Laine, 2008), with a small number having measured the impact of paramedics on the health and well-being of communities (Fry, 2009; Martin-Misener et al, 2009). Very few have applied or developed a theoretical framework to analyse emerging models of practice, such as community paramedicine (O'Meara et al, 2012).
This paper reports on the extent of the community paramedicine peer-reviewed literature in academic and professional journals, and those peer-reviewed papers presented at conferences since the Inaugural International Roundtable on Community Paramedicine in 2005. Before this time, the concept of a community paramedic was restricted to local applications and there was no consensus on their potential domains of practice. The reasons for this scoping review were to (Arksey and O'Malley, 2005):
Methods
Scoping reviews are a technique for exploring the breadth and extent of research being conducted in a particular field with similar rigor and transparency to systematic reviews (Arksey and O'Malley, 2005), and are being used increasingly in health and the social sciences (Mitton et al, 2009; Kenny et al, 2013; Trede et al, 2014).
This scoping study aims to systematically search and locate literature on community paramedics from 2005 until 2012, and to map the evolution of the role (Arksey and O'Malley, 2005; O'Malley and Croucher, 2005; Grant and Booth, 2009. The intention is to provide a reliable, replicable and unbiased picture of the existing research irrespective of study design. It maps the key concepts underpinning the emergence of community paramedics and the main sources and types of evidence available which can provide researchers, paramedics, and paramedic service providers with an understanding of the current state of knowledge.
For this scoping review, a framework consisting of six distinct stages was used (Arksey and O'Malley, 2005):
Identifying the research question
The starting point for the scoping review was to clearly identify the research question in terms of study population, interventions, or outcomes. This informed the search strategy.
Question: What is known from the existing literature about community paramedics, their boundaries, and health impact?
Identifying relevant studies
The aim of this scoping study was to identify as many published studies as possible within the parameters of the search. Unpublished studies, Government reports and newspaper reports were excluded. The strategy to identify papers was to search electronic databases and reference lists. In addition, Stage 5 of the process involved consultations with expert informants from the International Roundtable on Community Paramedicine who identified additional literature from journals and refereed conference proceedings.
Online searches were carried out using CINHAL and Medline, as the experience of the researcher and a consultant librarian was that most paramedicine-related studies were closely aligned to either medicine or nursing. A selective citation search was conducted using Google Scholar. The search was restricted to English-language journals from 2005 until 2012, chosen because the earlier date coincided with the formation of the International Roundtable on Community Paramedicine. The search strategy for electronic databases was developed from the research question and definition of key concepts. Search terms used are listed in Table 1.
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A specific search was undertaken of the reference list of one related literature review published in 2009 (Cooper and Grant, 2009). Hand searching was not undertaken as it was unlikely to yield further results due to the short timeframe of the overall search and the preponderance of emergency medicine and paramedic-related journals that are published online.
Study selection
Articles that were clearly irrelevant to community paramedicine were excluded, while short reports, commentaries and editorials of relevance were put aside for separate consideration. The inclusion criteria was that new paramedic roles extended beyond traditional emergency medical responses and focused on the provision of care or advice to a specific population group on either demographic or geographic grounds. Examples of these criteria included the elderly, homeless, high-risk population groups, small rural or isolated towns, and native communities. Exclusion criteria included cases where the initiative was clearly a component of a mainstream change in paramedic services, such as those related to cardiac and stroke patient responses. Even though there are similarities with community paramedics, specific studies of extended care practitioners were excluded on the basis that the philosophical rationale of this role differs from that of community paramedics.
All articles were obtainable through online portals, inter-library loans or professional networks. Having read the available articles in full, 82 articles were selected for inclusion in the review.
Charting the data
The studies that met the inclusion criteria were charted in terms of study population, the type of intervention, outcome measures employed and the study design when appropriate (Arksey and O'Malley, 2005). This allowed a wide diversity of papers to be synthesised and interpreted so that outcomes are contextualised and understandable.
Consultation exercise
In order to inform and validate the findings from the scoping review, key members of the International Roundtable on Community Paramedicine were consulted to confirm whether the process had captured all significant peer-reviewed studies related to community paramedics.
Collating, summarising and reporting the results
An overview of all those studies published in peer-reviewed journals that are included in Ulrichsweb database (http://www.ulrichsweb.com/ulrichsweb/analysis/) or published in peer-reviewed conference proceedings related to the evolution and implementation of community paramedics since the Inaugural International Roundtable on Community Paramedicine in 2005 is provided. Unlike in a systematic review, the evidence is neither synthesised nor critiqued in regard to its weight or quality.
Results
Question: What is known from the existing literature about community paramedics, their boundaries and health impact?
The results of the scoping review initially produced 82 articles, with expert informants adding another four. Figure 1 illustrates the process of discovery, sifting and categorisation. Following application of the exclusion criteria, 23 peer-reviewed articles were categorised into source country and three domains related to the type of article. Table 2 summarises these findings. Summaries of the selected articles are provided in Tables 3 and 4 using the domains of Reviews, Qualitative/Theoretical Studies and Empirical Studies.
| Category | USA | UK | Canada | Australia | Other |
|---|---|---|---|---|---|
| Reviews | 0 | 4 | 0 | 1 | 0 |
| Qualitative/Theoretical | 0 | 0 | 0 | 4 | 0 |
| Empirical | 4 | 2 | 3 | 4 | 1 |
| Total | 4 | 6 | 3 | 9 | 1 |
| Reviews | |||||
|---|---|---|---|---|---|
| Author/Date | Origin | Type of Review | |||
| Ball, 2005 | UK | Literature review | |||
| Blacker et al, 2006* | Australia | Descriptive review of innovative ambulance service models | |||
| Cooper and Grant, 2009 | UK | Literature review | |||
| Hoskins, 2011 | UK | Literature review | |||
| Hoskins, 2012 | UK | Literature review | |||
| Author/Date | Origin | Pop/Pats | Intervention | Methods | Measure | Outcomes |
|---|---|---|---|---|---|---|
| Reeve et al, 2008 | Australia | Paramedics | Grad cert in rural and remote paramedic practice | Surveys | Attitudes to population health activities | Positive |
| Kue et al, 2009 | USA | Elderly patients | Referral programme | Retrospective case series | Referral rates | Social need referrals high |
| Brice et al, 2009 | USA | Infants | Home visits | Retrospective data analysis | Safe home environment | Failed due to poor design |
| Naved et al, 2009 | Bangladesh | Abused women | Paramedics as mental health counsellors | Qualitative evaluation | Satisfaction of clients | Positive |
| Dixon et al, 2009 | UK | Older people | Paramedic practitioners | Cluster randomised controlled trial | Economic and clinical outcomes | Cost effective Reduced ED load |
| Martin-Misener et al, 2009 | Canada | Island population | Community paramedics and nurse practitioners | Longitudinal study | Cost, access and satisfaction | Decreased cost High satisfaction |
| Neumayer and Malone, 2009 | Australia | Rural communities | Integration pilot | Qualitative project evaluation | Access and satisfaction | Potential for further development |
| Shah et al, 2010 | USA | Older adults | Screening by paramedics | Programme evaluation | Referrals | Feasible Some resistance |
| Knowles et al, 2011 | UK | Carers of the aged | Paramedic practitioner programme | Questionnaire | Level of care | High satisfaction |
| Arendts et al, 2011 | Australia | Low-risk patients | Referral pathway | Randomised controlled trial | Unplanned medical attention | Trial indicated |
| Comans et al, 2011 | Australia | Falls patients >65 years | Referal pathway | Observational cross-sectional study | Future callouts, ED presentations and hospital admissions | No referral reported |
| Weaver et al, 2012 | USA | Unnecessary paramedic service transports | Not relevant | Multi-year cross-sectional study | Percentage of unnecessary transportations | Rising demand nationally |
| Ruest et al, 2012 | Canada | Aged patients at home | Multi-disciplinary team | Retrospective case series | Impact on emergency calls | Reduction in emergency calls |
| Orkin et al, 2012 | Canada | First nations | Wilderness education | Evaluation | Patient outcomes Participant self-confidence Community resilience | Layperson model proposed |
The review found a total of 23 articles, three of which were peer-reviewed conference proceedings that meet the inclusion criteria: five reviews, four theoretical papers and 14 empirical studies. Table 2 provides an overview of the geographic origin and categories of peer-reviewed articles related to community paramedicine models. The more recent empirical studies are mainly reported from North America as a result of an increasing number of community paramedicine programmes being trialled and evaluated in the United States and Canada. In terms of theoretical or conceptual papers, one research team from Australia dominates the field. They have examined the evolution of distinctly rural paramedic roles and proposed a specific set of domains of practice that also characterise many of the emerging community paramedic roles. Even after excluding the literature focusing on ECPs, researchers in the United Kingdom have produced almost all of the reviews related to community paramedics. Table 3 sumarises the reviews and theoretical underpinning of topics closely related to community paramedics since 2005 until 2012.
Table 4 summarises the 14 empirical studies related to community paramedicine. Most studies concentrated on disadvantaged patients or clients, such as the aged, low socio-economic groups and rural populations, who would potentially benefit most from changes in paramedic service delivery models. The types of interventions were clustered around educational programmes, and outreach and referral programmes for these populations, while the methodologies employed varied across the spectrum from service evaluations to a proposed randomised control trial methodology. The outcome measures used included the number of emergency department visits, referral patterns and customer satisfaction. Some of the excluded studies from the United States considered the impact of community paramedicine programmes on response times and the cost-benefit of the interventions (Zavadsky, 2010; Goodwin, 2012).
Discussion
The objective of this scoping review was to explore the breadth and extent of the research being undertaken in the field of community paramedicine since the formation of the International Roundtable on Community Paramedicine in 2005. This undertaking found 23 peer-reviewed papers over a seven-year period when reviews and all study designs were included. There was evidence of an increase in research and evaluation of community paramedicine programmes in a small number of countries, along with some links emerging between this research and the extended care paramedic research literature in the United Kingdom. A strong focus on commentaries and opinion papers was evident in trade publications and some peer-reviewed journals. This was particularly noticeable in the United States, where refereed paramedicine-orientated journals are rare and those that exist tend to focus on emergency medicine topics.
Theoretical studies are uncommon and remain largely restricted to Australia where a conceptual model incorporating community engagement, primary health care and an appreciation of place and other contextual factors has been developed (O'Meara et al, 2012). The number of empirical publications is increasing as community paramedicine programmes become more widespread, with studies in Canada and the United Kingdom concentrating on workforce issues (Martin-Misener et al, 2009; Knowles et al, 2011), while innovations addressing the needs of disadvantaged patients or clients such as the aged and native populations are widespread (Dixon et al, 2009; Orkin et al, 2012). The types of interventions reported mainly clustered around outreach and referral programmes (Brice et al, 2009; Comans et al, 2011; Ruest et al, 2012), with a variety of outcome measures employed such as the number of emergency department visits, referral patterns and customer satisfaction.
The major shortcoming of the community paramedicine literature is its absence from peer-reviewed journals, where other health care innovations jostle with each other for credibility and acceptance. While opinion papers and commentaries are useful contributions to the debate about the future utility of community paramedicine programmes, funders and policy makers demand evidence of the conceptual relevance of new programmes and of cost-effective outcomes.
Limitations
There are limitations to this scoping review. First, the search may not have been exhaustive, despite the search of two large databases using comprehensive search strategies with the assistance of a librarian. It is possible that the search missed broad categories of important papers. Second, only English-language sources were retrieved and reviewed. No doubt there is literature on community paramedicine that has been produced in other languages. At the same time, there were few non-English-language sources cited in the reviewed papers. This suggests that the most important sources may be available in English. Third, non-refereed articles were excluded, which excluded a number of potentially valuable contributions from the United States where non-refereed paramedicine journals are common.
Conclusions
The volume of the literature related to emerging models of paramedic practice is slowly growing, with two overlapping bodies of work developing. Broadly speaking, the United Kingdom literature focuses on extended care paramedics (ECP), their deployment, and safety, while the North American literature is explicitly focused on community paramedics. The literature from Australia and New Zealand draws inspiration from both approaches and is much more theoretically orientated.
In this scoping review most of the UK literature was excluded because of its focus on ECPs who are operating in highly reactive domains with limited levels of community engagement that tends to distinguish the community paramedic innovation (Mulholland et al, 2009a). However different the roles may be in some ways, it is acknowledged that there is considerable overlap between ECPs and community paramedic clinical competencies, with much of the UK work being of great value to the community paramedic discipline as researchers and providers work toward the development of appropriate approaches to the measurement of quality and safety. Measuring the non-traditional outcomes of community paramedicine programmes, such as community engagement and intergration with other health disciplines remain major challenges, with the answers more likely to come from the public health and community development literature (Milton et al, 2011).
Early work on community paramedics largely consisted of advocacy and editorial comment with few empirical studies. However, this is changing as more community paramedicine programmes are implemented and evaluated for their appropriateness, effectivenes, and cost-benefit throughout the world. We are seeing a growing number of descriptive studies that clearly articulate the roles of community paramedics and a smaller number of empirical studies that seek to measure the outcomes of these innovations in practice. Despite the growing number of community paramedic programme evaluations taking place throughout the world, few are published in peer-reviewed journals or are widely disseminated. There is a strong need for the many evaluations and studies in the United States and Canada to be published in the peer-reviewed literature. Without this final step in the innovation process being completed, the impact, reach, and sustainability of community paramedicine programmes is diminished. ECP researchers in the United Kingdom have established useful templates for the future analysis of out-of-hospital innovations, such as community paramedics, in other parts of the world (Mason et al, 2008; Dixon et al, 2009; Knowles et al, 2011).
Apart from one Australian research article, there remain few published studies that analyse the theoretical underpinnings of the community paramedicine model or consider where it fits into the wider health care system. Without a theoretical basis, the empirical studies of community paramedicine models will tend to remain descriptive and ambiguous in nature.