By Lyle Brewster, Amanda Hlushak and Martin Nichols
This literature review wasconducted to critically compare community paramedic programs used worldwide in order to propose a credible model appropriate for Australia.A comparison is presented on the role of a contemporary paramedic in Australia to a newer role for paramedics, with a direct focus on community paramedicine.This role diversification is in direct correlation to an aging population in most first world countries and their effects, which are called the Grey Tsunami.
Online bibliographic databases with no limited date range, including MEDLINE, Primo Search and Google Scholar were searched systematically. Search terms of ‘community paramedic’(CP), ‘paramedic practitioner’ (PP), ‘extended care paramedic’ (ECP) and scope of practice were used.After filtering the results, a total of 17 articles were selected for review and discussion.
There is valuable evidence for using paramedics in a non-traditional role with an expanded scope.The papers reviewed showed collectively an increase in patient centred care, a decrease in non-emergent transportsand better alignment with other health services,with increased patient satisfaction.
Meeting the needs of an aging population is a multifaceted problem with many aspects to consider.Implementing a national community paramedic model in Australia would see benefits in patientcentred care, healthcare costs reduction, better external healthcare relationships and overall better management of the aging population in an out of hospital environment.
Key words:community paramedic, extended care paramedic, paramedic practitioner, non-traditional roles, Grey Tsunami.
Over the past ten years, there has been a significant increase in the use of ambulance services and hospital emergency departments for non-emergency care(1). Growth in the use of non-emergency care has increased by 13.1 per cent in NSW alone over the past FIVE years (1). This in turn has led to emergency department (ED) overcrowding (2).The result of ED overcrowding is a global problem leading to associated mortality, morbidity, bed blockand patient dissatisfaction (3).
While the overuse of non-emergency hospital presentations are acutely increasing, the additional pressure brought on by medical visits from the aging population cannot be ignored.Thus theconcept of a Grey Tsunami is not a new one.It aptly describes the effect that 5.5 million baby boomers will place on the current health care system and aged care facilities. It is estimated that the number of people aged 80 years or older will increase by 49 per cent in 2021(1) and this impending crisis is a critical reason for an emergency medical services (EMS)re-evaluation (4).
Additionally, it is not surprising that a new clinical term involving paramedics, called ‘community paramedic’, is emerging.This term, while still in its infancy, has been popping up in Australia and other countries such as the UK, Canada and USA(5-7).These community paramedics are being called upon to deal with non-emergent care in the health continuum.
Community paramedic models are being used to decrease the pressure on hospital systems and to dealmore effectively with the tsunami effect of the aging population.To this end, many authors argue paramedics are a valuable resource being underutilized in current EMS systems (6).
This article proposes a clearer definition of a community paramedic, a pragmatic model design in Australia and highlights the benefits of such a design.The proposed community paramedic model will be extracted from the current literature of community paramedic models taken from the international literaturein an effort to determine the design of a model suitable to be implemented within Australia.
We conducted a systematic review of the literature to identify existing evidence forthe community paramedic scope of practice. To ensure the most comprehensive search, we identified that the term‘community paramedic’ is not recognized internationally. As such, we then added the words ‘paramedic practitioner’ and ‘extended care paramedic’ to our search field to capture the use of these words in any substantive research. We searched for these termson MEDLINE and Google Scholar for all relevant articles. We further searched using the PRIMO database from the Charles Sturt University library website.
A Google Scholar search resulted in 25,800 results under the term ‘community paramedic’, while ‘paramedic practitioner’and ‘extended care paramedic’ received 8,190 and 807 hits respectively.Abroad MEDLINE search of ‘community paramedic’found ,6975 articles,while a PRIMOsearch garnered 950 results for ‘community paramedic’, 266 results for ‘paramedic practitioner’ and 44 results for ‘extended care paramedic’.
We included all research articles that contributed information on the topic of ‘community paramedic’ scope of practice. We included articles from reputable research journals, nursing journals, prehospital emergency care journals, conference presentations, rural and remote health journals with links to community paramedicine and EMS websites. The data was collected from Australia, Canada, United Kingdom and the United States of America.
While this seems like an extraordinary number of articles, this number was reduced significantly by the inclusions of a few rules, which follow.Only full text articles or articles which were peer reviewed were included in the review.Studies for inclusion needed to address the practice of community paramedic models, frameworks or concepts which discussed health care delivery in an out of hospital environment and ‘scope of practice’. These were reviewed independently by tworeviewers and 80 relevant studies were read in full. The quality of included studieswas assessed and a pro forma was used to record detailed data. Initially this minimized to 40 articles that were relevant to an Australian context of health care delivery.From this decision,16 articles in total were identified for the literature review.
Number of hits
Actual relevant articles reviewed
Articles used for review
Articles taken from the bibliographic list
There is an abundance of literature about community paramedics, or the commonly used UK term ‘paramedic practitioner’. Within Australia, the term ‘extended care paramedic’ is also often referred to, especially within Queensland and NSW. As with other areas of paramedicine though, finding a common word for naming this occupation or a common role descriptor on exactly what these paramedics do, is not so evident. This is a major issue with paramedicine across not just Australia, but also the world. After exploring Australian emergency service providers (state/territory) and the New Zealand paramedic providers of St John New Zealand and Wellington Free Ambulance, there is a notable lack of common terminology used in describing current paramedic roles.It is this lack of consistency and common terminology that contributes to the difficulty in researching the non-traditional role of paramedics when compared to researching more common terminology in the discipline of nursing, community nurses and/or nurse practitioners.
The term ‘community paramedic’ is still very new to paramedicine.According to Ludwig (8), the American EMS system is still trying to establish a common term when referring to a community paramedic.Henceforth, for the purpose of this literature review, the authors will use the term ‘community paramedic’ as an overarching umbrella encompassing other commonly observed terms such as paramedic practitioner, expanded scope paramedic, and extended care paramedic.
As previously stated, there is a large variation in the literature in its attempt to define a current scope of practice for community paramedics. The models from the UK for example, have been born from trials of community paramedics. The trials for community paramedics were born out of the need to deal with the number of medical admissions faced by the National Health Trust (NHS) (9). Within these trials, the community paramedic practitioner scope of practice focussed more on the assessment side of paramedic care than the initiating treatment side. The paramedics taking part were trained in:
- Assessment and treatment of minor injuries
- Assessment of minor head injury
- Assessment of mental function
- Assessment of elderly falls
- Social care assessment of the older patient
In assisting them with their role, senior emergency department medical staff were available via telephone to offer advice and support to the paramedics.The scope outlined in this early definition of community paramedics in 2003 was not highly varied from the role of a normal paramedic. In contrast, in an article by Mason, Knowles (10), the scope that the community paramedics were utilizing was very extensive. They had moved from an extension of their assessment capabilities, to a system that had community paramedics applying practical skills such as:
- Suturing and local anaesthetic techniques
- Full examination of major body systems
- Requests for X-rays
- Referrals to other services such as emergency department and community social services (10)
In an article by Blacker(11), they define the 2009 Australian community paramedic scope of practice from seven of the eight state and territory services, and the outstanding feature is the variance between the ambulance services. The scope of practice is variable based on the actual jurisdiction in which the paramedic is located. The vast difference between each service ranges from ‘providing health “cover” in a location when local doctors and nurses are unavailable’ to ‘providing assessment which is “beyond the current level of skill”’. From the literature it is evident that the scope of practice for community paramedics isdiverse, and therefore a focussed approach to better understanding this new level of practice is warranted.
Much of the current research in Australia on community paramedics and scope of practice has had a rural focus.This expanded scope, in rural and remote areas, evolved out of necessity in order to service communities whose health services are limited due to geographic position (12).The models adopted in the remote areas are those fitting to the area and the health care needs of the community, but lack a consistent national scope.The scope of practice is at the discretion of the service and lacks consistency among other states in Australia (11).According to Martin-Misener, Downe-Wamboldt (5), many of these rural community paramedic models were initiated out of necessity.Rural communities tend to be without adequate health facilities, general physicians (GPs) and/orprimary care practitioners(PCPs) in an accessible area.Because of these less than ideal conditions, the support for a community paramedic model is well supported (5, 7, 12).
The literature often states that the need for community paramedics in rural areas is obvious; they can fill a void left by the exodus of rural general practitioners (13) and help to carry the burden of any current community nurse for under-served rural communities (7). After examiningthe differences in paramedic services and employer beliefs, it is realized that identifying a single scope of practice, even for just the Australian paramedic, is very difficult. The difficulty lies in identifying what the expanded scope should look like.Should it include such conceptsas a wider range of assessment and referral skills (10) including direct referral from the patient’s home or public health and community education or should the current scope be maintained such astraditional treat and/or transport? (14).
Multidisciplinary heath care teams including the use of community paramedics in a case based patient care approach can be found in the literature.Many of the models trialled and evaluated have documented a positive increase in exposure and acceptance within the health care continuum when paramedics are working in a team approach (5, 7).This team approach ultimately benefits the patient.However, caution must be exercised when overtaking of roles and role replacement such as the personal view ofEisenman (15), in which retired paramedics can assert their skills in the ED to assist physicians, similarly to the roles and responsibilities of nurses.As such, the potential for job creep and dissatisfaction among health care professionals is potentially significant and can translate to poorer outcomes in patient care management.
The literature suggests there is a growing need for an augmentation of the roles and responsibilitiesof paramedics in their current scope and skills set to that of an expanded scope and an expanded role. O’Meara (7) articulates the necessity of using paramedic practitioners in rural Australia to enhance patient centred care,therebyfunctioning in a health continuum rather than in an independent allied health role.This enriched scope is not only a necessity in Australia due to the impending Grey Tsunami, but also to reduce the strain on the health care resources available.
Given the literature on non-traditional roles, the authors have proposed a model for Australia.This community paramedicmodel encompasses four key strategies based on the current literature:
- That the community paramedic model in Australia would be focused on the community regardless of remoteness;
- Community paramedics would be trained to have expanded scopes of practice with emphasis on patient centred care.This would include patient safety, patient education, referrals, treatment, injury prevention and health promotion;
- Research would be the foundation for the education provided to staff, patients, scope and policies and procedures.
- Community paramedics would be a part of the health continuum model in which the community paramedic engages with the heath community as a larger part of the health care system.
The theoretical strengths of this Australian model include a focus on patients and their care in a non-acute setting.It aims to reduce the strains and stresses in the hospital department, reduce health care costs and increase patient satisfaction in relation to their perceived health concerns.
A change to a new model of paramedic practice is not without its challenges.These challenges and limitationsfor the model are related to the challenges of any project involving a national scope.Incorporating a community paramedic model in Australia would involve considerable resources and changes in the areas of education, equipment, technology, scope, policies, legislation and organisation(7).The acceptance of a model such as the one proposed above would require stakeholder buy-in across many disciplines of health care.This type of national project would therefore be best undertaken after the introduction of a national registration. Recently Australian paramedics are one step closer to national registration following the announcement of support from the Council of Australian Governments (COAG) meeting held on November 2015(16).
It is the current authors’ opinions that this model be examinedin a comparison study between community paramedics working in rural and urban Australia.It is hypothesized the outcomes, including patient benefits, would be similar despite the location of the community paramedics.
This article has summarized the use of paramedics in non-traditional roles with varying scopes of practice. A national model of community paramedicine in Australia would be a huge undertaking, but one that needs consideration.The Grey Tsunami is not just a figment of our imagination but a close future reality. If EMS systems are not prepared for the impending boom in retired Australians the national health care system will be under even more pressure than it is currently. The Australian population is growing older by the day, and the predicted population by 2020 will be in a reverse pyramid. With more people aged 65 than those age one (17).The use of community paramedics to manage patient centred care within the heath continuum is a vital cog in the wheel of home-based health care.The ability to vastly improve patient care and drastically reduce the non-emergency burden on our health care facilities is within reach.Community paramedics have an opportunity to relieve some of the strain on local Emergency departments, general physician and/or primary care physician services and assist in boosting the numbers of nurse practitioners currently working in Australia. Emergency medical services in Australia need to sit up and take notice of this relevant future role paramedics can play. It is timely for the current services to hold a symposium on how we can create a functional, adaptive and responsive community paramedic model for all of Australia.
About The Authors
Amanda Hlushak, email@example.com
Associate Lecturer in Paramedic Practice
Lyle Brewster, firstname.lastname@example.org
Lecturer in Paramedic Practice
Martin Nichols, email@example.com
Lecturer in Paramedic Practice
Associate Lecturer Bachelor of Clinical Practice
School of Biomedical Sciences
Charles Sturt University
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