Emergency departments (EDs) are facing significant and continuous demands on their resources. Affected factors include hospital overcrowding and boarding of inpatients in the ED, increased patient census and acuity, and deficiencies in primary and secondary care availability—all of which are compounded further by a shortage of trained emergency care providers. To meet these demands, numerous strategies have been instituted, from moving boarded patients to alternative hospital space and deflecting patients away from the ED, to the use of mid-level providers with different and specific skills in new and evolving roles. This employment of ‘mid-level care providers’, also called ‘advanced care providers’, is becoming increasingly common (Klauer, 2013; Campbell et al, 2014). The term mid-level provider typically includes nurse practitioners, physician assistants, and paramedics. These health professionals work alongside ED physicians and nurses.
Paramedics are health professionals traditionally known for their work in prehospital care, including the management and transport of acutely ill or injured patients. However, they are being increasingly used in non-traditional settings in countries such as the UK, the United States, and Canada (Oglesby, 2007; Campbell et al, 2008a; 2012; Morrison, 2013; College of Paramedics, 2017a). In these atypical settings, the scope of their practice varies, as does their level of training.
In some centres, EDs have relied solely on the paramedics' prehospital training. For example, in Oklahoma EDs, paramedics administer IVs, draw blood, and provide basic emergency care (Oglesby, 2007). In rural Nova Scotia, Canada, paramedics have been used in centres known as ‘collaborative emergency centres’. These are rural EDs that are staffed solely by paramedics and registered nurses, with online physician oversight (Morrison, 2013). Other centres provide their paramedics with supplemental training. For example, in the American State of North Carolina, paramedics are provided with supplemental training in urinary catheterisation, patient transport, and point-of-care testing (Oglesby, 2007).
At the QEII Health Science Centre, in Halifax—the capital city of the Canadian province of Nova Scotia—the role of ED paramedics has been evolving over the past 30 years. Paramedics are used in triage, in an area for patients with lower acuity complaints (as ‘physician extenders’), and in an area for patients referred to the hospital to be seen directly by a consultant service (Campbell et al, 2008a; 2012).
The most notable role is the ‘department paramedic’ and the purpose of this study was to provide a description of this role. After providing a brief description of traditionally defined paramedic roles in Canada, the authors describe this novel role and, using qualitative methods, explore it from the perspective of paramedics. Specific aims included:
Background: description of role
Paramedicine in Canada
In Canada, four levels of paramedics exist: Emergency Medical Responder (EMR), Primary Care Paramedic (PCP), Advanced Care Paramedic (ACP), and Critical Care Paramedic (CCP) (Paramedic Association of Canada, 2011). The scopes of practice for these titles are described in the ‘National Occupational Competency Profile (NOCP) for Paramedics document’ (Paramedic Association of Canada, 2011).
As described in the document, EMRs typically work as part of volunteer organisations in rural and remote communities; they are trained in the basic skills required for initial assessment, management, and transport of patients. PCPs, who are typically career paramedics, are trained in a number of delegated medical acts, including intravenous cannulation and the administration of certain medications (via oral, sublingual, buccal, inhalation, and intranasal routes) (Paramedic Association of Canada, 2011).
ACPs receive further training after earning their PCP certification. As part of their expanded scope, they have additional skills in the management of life-threatening problems affecting the airway (endotracheal devices, surgical airways, needle thoracostomy); breathing (ventilator set up and use); and circulation (intraosseous needle insertion, manual defibrillation/cardioversion, transcutaneous pacing, maintenance of intra-aortic balloon pump). Additional skills include urinary catheterisation as well as nasogastric and orogastric tube placement (Paramedic Association of Canada, 2011). CCPs receive the highest level of training. Their expanded scope includes the administration of blood products, radial artery puncture, transvenous pacing, invasive patient monitoring (management of patients with an arterial line or pulmonary artery catheter, central venous pressure monitoring) and expanded pharmaceutical therapies (Paramedic Association of Canada, 2011).
Overview of ‘department paramedic’ role
The department paramedic position allows for the presence of a highly trained paramedic in the ED, 24 hours a day. Working 12-hour shifts, the department paramedic carries a specific telephone, providing care on an on-call basis, without a specific patient assignment.
Their role includes critical care transport of unstable patients throughout the hospital, assisting in the resuscitation and airway management of critically ill patients, and provision of procedural sedation to patients who require short and unpleasant emergency procedures. Their practice is guided by standard operating procedures, but they do have significant autonomy, especially with regards to procedural sedation. Additionally, they manage and maintain an advanced airway cart, as well as the department's procedural sedation and airway registries. They are also a part of the hospital trauma team and code blue team.
Education and training
Advanced care paramedics with a minimum of 3 years of prehospital experience are accepted into the programme. Upon acceptance, there is a comprehensive orientation. This includes the Airway Intervention and Management in Emergencies (AIME) course, cadaveric workshops, high-fidelity simulations, and 20 supervised shifts. They also received additional training in procedural sedation.
Procedural sedation
Department paramedics at this centre independently perform procedural sedation for a variety of indications, including cardioversion, chest tube placement, endoscopy, imaging, incision and drainage, lumbar puncture, wound care, and orthopaedic reductions (Campbell et al, 2006; 2008b; 2016; Butler et al, 2017). Prior to administering the procedural sedation agent, paramedics are responsible for performing an airway assessment, and gaining consent for the sedation. In collaboration with the emergency physician, paramedics select and administer medications used for the sedation, and monitor the patient throughout the procedure until full recovery. Agents commonly selected by paramedics include fentanyl, midazolam, propofol, and ketamine; the most common combination being fentanyl and propofol (Campbell et al, 2008b).
Paramedics in this role are totally focused on the process of sedation and at no time do they assist the operator with the procedure. After recovery, they assist with the provision of discharge information and follow-up arrangement.
Procedural sedation training for paramedics includes both didactic and applied learning. Initial reading assignments and lectures on the basic pharmacology and risk factors associated with procedural sedation and analgesia (PSA) agents, and how they interact with different patient scenarios, are followed by high-fidelity simulation training. These simulations test the ability to manage adverse events, including anaphylaxis, pulmonary aspiration, cardiac infarction, decompensation during sedation, and the unanticipated loss of an airway. Evaluation of competency involves a multiple-choice examination (with a required pass rate of 80%) and a competency-based peer assessment, where PSA trainees perform PSA under supervision of a senior paramedic. Trainees must perform a minimum of 50 witnessed PSAs before working independently. If after 50 witnessed sedations, the senior paramedic does not feel confident in the trainee's abilities, they may be asked to continue with supervised PSAs, until such time as the senior paramedic feels confident in the trainee's abilities.
Paramedic expertise with procedural sedation and the procedural sedation registry has stimulated significant paramedic-driven research in the field, including both randomised trials (Campbell, 2016) and retrospective registry exploration (Campbell, 2006; 2008b; 2015; Wiemer et al, 2016).
Methods
Ethics approval
This study was approved by the institutional ethics review board (Nova Scotia Health Authority Research Ethics Board File number 1021292).
Setting
This study was conducted in the Charles V Keating Emergency and Trauma Centre. This is a 38-bed ED in a busy tertiary care teaching hospital. The ED has an annual census of about 75 000 patients over the age of 16. Interviews were held in private rooms within the department.
Participants
The authors interviewed paramedics who had been employed at the Charles V. Keating Emergency and Trauma Centre for at least 1 year at the time of the study. There were no exclusion criteria. Recruitment was conducted via email, with permission from the site director. The authors interviewed the first six paramedics who expressed interest in participating in the study, at which point saturation was reached; this represented 75% of the full-time paramedic staff (eight full-time paramedics are employed in this position). Formal consent for these interviews was obtained at the time of the interview. Participants did not receive any monetary incentive for their participation.
Data collection strategies
IInterviews, which took place in June and July of 2016, were semi-structured, and lasted about 15–20 minutes. They were recorded using an Olympus WS-852 Digital Voice Recorder. All interviews were transcribed for further analysis.
Data analysis
The interview transcripts were read by the lead author (BC) who developed an initial coding structure, using the interview as a template. This was discussed with the second (SC) and fourth authors (KM) and an agreed-upon coding structure was applied to all of the interviews. Following this, the authors examined the data for emerging themes and concepts with respect to the paramedics' views, as well as patterns of themes among the interviews, according to King and Horrocks (2010). Quotations supporting these themes were also identified.
Results
Demographics
The participants in this study consisted of one female and five males. Their years of experience as paramedics ranged from 12–27 years, with an average of 19.2 years.
Broad scope of practice is well matched to a dynamic workplace
Paramedics in the study identified their broad scope of practice as being key to the success of their role in the ED. They explained that it allows them to provide care anywhere in the department, according to its constantly changing needs. Paramedics also highlighted that they do not carry a specific patient assignment, allowing them to easily transition from the care of one patient to another. This facilitates their role on the trauma team and code blue team, as they are easily able to leave a stable patient to go see a patient who is critically ill. One paramedic shared the following:
‘…It's kind of a jack of all trades position… we have a very broad scope of practice. That combined with not being tied to a specific care area, we are able to flow through and jump in wherever and whenever is needed. If someone unexpectedly crashes, we are able to drop everything and go.’
The participants also noted that, while they do have a broad scope, they also have areas of expertise for which they are relied upon by other health professionals within the ED. Areas emphasised were procedural sedation, airway management, and difficult venous access. Paramedics explained that they are often paged to assist in the intubation or IV placement of anatomically challenging patients.
Procedural sedations improve ED flow
The majority of the paramedics in the study identified PSA as being the aspect of their role that has had the greatest impact on the ED. Paramedics cited the effect that their role in PSA has had on department flow. Freeing up a physician that would have administered the sedation and only requiring the operator to be present for the procedure allows physicians to see other patients. Paramedics shared the following:
‘…sedation is a very big part of what we do… and that itself may be the thing that is our greatest influence within our department, is the impact that we have on flow….’
‘we do a ton of procedural sedations which in a lot of cases would impact the hospital… traditionally these procedures would have to be done in the OR…’
Paramedics reported PSA as being the part of their role that consumes most of their time; although a common qualifier was that it depended on the day.
Interactions with other health professionals
The interactions between paramedics and other health professionals in the ED were central to the discussion of the paramedic role. According to participants, the role of a hospital-based paramedic has a significant inter-professional component, especially when compared with their previous experience as paramedics in the field. Unlike their prehospital counterparts, these hospital-based paramedics work alongside many other health professionals, including nurses, physicians, and respiratory therapists. They describe their role as one that supports physicians and nurses, pointing out that the overlap between the paramedic scope of practice with the scopes of physicians and nurses, makes them ideal for this role.
Paramedics in the study noted that there was initially some resistance to their presence in the ED from other health professionals within the department. They attributed this to the overlap in their roles. There was an apparent concern that other members of the ED would be replaced by paramedics. One paramedic commented:
‘…when you introduce a new position within an organization, you get pushback and you get resistance. People are worried about their jobs; is this going to take away their job? How is this going to affect what they do? Are they going to lose something, for this new thing to happen?’
According to participants, conflicts of this nature have become very rare as the programme has progressed.
Overcoming interprofessional conflict
Time and familiarity were reportedly large factors in overcoming initial conflicts. Educating members of the ED on the role of the paramedic was also essential. Other health professionals in the department now appreciate their presence, and recognise that they improve patient care and the flow of the department. One paramedic explained:
‘…with us coming in to a traditional nursing (environment), there is kind of a give and take…ultimately when you sit down and you think of the end result, are we giving better care?, it's easier to accept those different roles.’
Continually expanding scope of practice
All paramedics felt that their role could be expanded further. In the case of some of the paramedics in the study, they had already been practising a wider scope of practice when they had worked in an air ambulance setting. These paramedics noted however that many of these skills are not in high demand in the ED or are already covered by other healthcare providers. All participants expressed interest in further expanding their scope of practice if it could improve department flow and patient care.
Discussion and conclusions
Paramedics are clearly well suited for employment in the ED. The role offers a novel way to improve patient care in a system that has been hamstrung by tradition, challenging the belief that emergency physicians or anaesthesiologists need to be providing components of care such as procedural sedation and advanced airway management. Paramedics are fundamentally generalists, which is a chief requirement of an ED healthcare provider, and their versatility and mobility within the ED fills a specific niche in emergency care. Paramedics are also well trained in managing critically ill patients, making them an asset to any ED.
Furthermore, their broad knowledge base makes them excellent candidates for further training. The paramedics at this centre have demonstrated success in this regard and are eager to expand their scope further. A recent example of a newly expanded role is the provision of procedural sedation for patients undergoing gastro-esophageal endoscopy—a role previously filled by members of the gastroenterology team (Wiemer et al, 2016).
In addition to benefiting the healthcare system through their versatility and adaptability, the presence of paramedics in the ED also benefits the discipline of paramedicine. The role provides paramedics with an opportunity to become players in the integrated network of care, where their prior contribution stopped at the hospital door. This exposure to a more varied clinical experience better positions paramedics for academic and leadership roles in our evolving healthcare system. The robust research and quality assurance infrastructure, in conjunction with a high volume setting and diverse patient population, also provides the ideal set of conditions for the further expansion of the paramedic scope.
An added benefit of the hospital-based role is the improvement of relations and understanding between paramedics and these other health professionals. Much of this benefit is achieved through involvement in non-traditional roles, such as teaching or mentoring medical students and residents, which improves professional exposure and understanding on both sides. The effects of this are difficult to measure; at the authors' centre, this insight has been passed along to local ground-based paramedics by hospital-based paramedics, through both formal and informal means of communication.
Additionally, it is hoped that the medical students and residents, who come to the centre from all over the country, have a positive experience with a hospital-based paramedic, which may influence how they perceive and interact with paramedics in their future practice.
Paramedics are especially well suited to perform procedural sedation. The Practice Guidelines for Sedation and Analgesia by Non-Anesthesiologists (American Society of Anesthesiologists, 2002) state that healthcare providers caring for patients who require PSA should have an understanding of the pharmacological agents being used in the sedation and should be able to recognise the associated complications. While paramedics are not initially trained in the use of all PSA agents, their previous training in pharmacology makes learning the pharmacology of PSA a natural extension of their skills. The guidelines also state that an individual with advanced life support skills be immediately available. Paramedics also meet this requirement and are experienced in recognising potential instability, as well as managing unstable patients—a critical requirement for anyone using agents with cardiorespiratory side effects.
In terms of the initial resistance met with the introduction of this paramedic role, managing change is a challenge for any leaders in healthcare. Introduction of a new position to a department, or expansion of the scope of an existing position, should be expected to stimulate uncertainty and resistance. Often these conflicts stem from a misunderstanding of the objectives of the new role. Clear communication and education are essential to mitigate and minimise conflicts.
Parallels can be drawn between this role and expanded paramedic scopes elsewhere. In the UK, the College of Paramedics has similarly recognised the versatility of paramedics, stating, ‘the College of Paramedics supports further opportunities for paramedics to develop and expand their scope and area of practice, both of which are anticipated to increase in future in order to respond to changes in patient demand and workforce planning’ (College of Paramedics, 2017a). In support of this, the College has published two documents outlining postgraduate training for paramedics including ‘Post Registration Paramedic Career Framework’ (College of Paramedics, 2018) and the Paramedic Post-Graduate Curriculum Guidance’ (College of Paramedics, 2017b). As part of this framework, the College has recognised ‘four pillars’: clinical practice, research, leadership/management and education (College of Paramedics, 2018). Though the paramedic role described in this paper exists in Canada, it is an excellent demonstration of these four pillars. In addition to clinical practice, paramedics in this centre have taken on academic roles, with several paramedic-driven research initiatives (Campbell, 2006; 2008a; 2016; Wiemer et al, 2016) and publications. Department paramedics at this centre have also taken on teaching roles (education pillar); this includes teaching medical students, paramedicine students, and medical residents. Lastly, several paramedics have taken on administrative, quality improvement and managerial roles in the department (leadership/management pillar).
This paper ultimately describes the success of a novel paramedic role, with an expanded scope, in meeting the needs of a Canadian ED. While the authors recognise that the role described here may not meet the needs of EDs everywhere, it is felt that this is a useful demonstration of the versatility and adaptability of paramedics to meet the needs of a healthcare system with increasing and evolving demands.
Limitations
The present study describes the role of a paramedic within a busy tertiary care trauma centre. Therefore, these findings may not be applicable to all EDs. Furthermore, the role of the paramedic in Halifax has evolved slowly over time and has been tailored to fit the needs of this department. The authors believe that the principles of ED paramedicine will benefit most busy departments, but realise that the ‘finished product’ will vary according to the specific needs of each ED.
A notable limitation of the study is that none of the paramedics who were interviewed were present when the paramedic role was originally introduced, so opinions on the process of introduction of the programme are from newer generations of ED paramedics and not direct reports from pioneers in the programme. The study also investigated the role of the paramedic from only the paramedic's perspective. Further research may explore the views of nurses and physicians within the department.