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BackgroundThe NIHR HTA funded RAPID2 trial aims to test the safety, clinical and cost-effectiveness of paramedics providing pre-hospital fascia iliaca compartment block (FICB) pain relief for patients with suspected hip fracture. FICB is not routinely available in pre-hospital care but may improve patient outcomes through better pain relief and avoiding morphine side effects. However, training paramedics in FICB is not straightforward. RAPID2 seeks to train 160 paramedics across four sites. This poster will outline some of the strategies employed, challenges encountered, and reflections of research paramedics involved.MethodsChallenges encountered:Co-ordinating hospital and ambulance service staff availability with FICB training opportunities.Increased service demand during the training period, resulting in increased fatigue and reduced morale.Staff withdrawal due to career progression/secondment opportunities.Other commitments competing for staff time.Approaches used:Training was coordinated by RAPID2 site research paramedics and hospital PIs, employing strategies as follows.Increasing training opportunities by recruiting multiple anaesthetists to support trial training.Regular face-to-face contact from RAPID2 Research Paramedics at each site, including ‘drop in’ sessions and refresher training.Promotion of the rationale for the trial and the benefits it may bring to patient care, alongside the opportunity to enhance skill sets.Providing CPD hours and overtime payments for time spent undertaking RAPID2 training.Providing training sessions on different days and at different times to allow hospital and ambulance staff to carry out training at a time that suits them.ResultsThe trial was well received, with 150 expressions of interest gained from paramedics across sites, most of whom have begun training.ConclusionBy adapting to circumstances and employing a range of engagement and promotion strategies, paramedic engagement with training has improved. These strategies could be adopted in other trials.

BackgroundThis project evaluated whether practice change occurred amongst Paramedics directly after the publication of the PARAMEDIC2 trial, regarding adrenaline administration during out-of-hospital cardiac arrest (OHCA) without a change in guidelines. When Paramedics are exposed to a seminal publication there is anecdotal concern their autonomous practice changes, based on comprehension of findings ahead of potential guideline changes, however little evidence appraises whether this really occurs.MethodsA service evaluation to determine any variation in adrenaline administration during OHCA, before and after publication of the PARAMEDIC2 trial.WMAS electronic patient record data that has been collected for use within OHCA ambulance quality indicators was used to evaluate practice variation.Proportion of adult patients receiving adrenaline, number of administrations and time to first administration from EMS arrival (or arrest if EMS witnessed) are reported.This evaluation assesses from the day after recruitment ended on 18th October 2017 until the trial results publication on 19th July 2018, and the same timeframe (273 days) post-publication.Results Proportion receiving adrenaline Pre-publication: 88.7% of 3026 casesPost-publication: 88.0% of 2682 cases Mean number of adrenaline administrations Pre-publication: 4Post-publication: 4 Mean time to adrenaline Pre-publication: 30:02 minutesPost-publication: 30:11 minutesConclusionsIn both datasets, average time to first adrenaline administration and number of administrations were found to be similar. This suggests Paramedic practice adheres to current guidelines when a highly anticipated article is published, however this may vary by intervention so further work is recommended. Limitations of retrospective observational evaluations include uncontrolled treatment variables; however randomised controlled trials cannot assess standard practice. Individuals need continued awareness for implications of changing practice following a trial publication, as patient safety could be breached whilst the wider medical community are scrutinising the trial results. This demonstrates how routine data can be used to evaluate practice and changes within it.

BackgroundDebriefing post out-of-hospital cardiac arrest (OHCA) is emerging as a strategy to improve patient outcomes and is recommended by JRCALC and Resus Council UK. There is limited research on debriefing post OHCA and no ‘gold standard’ for paramedics to use. A scoping exercise was conducted to gain insight into current practice and to inform the development of a PhD proposal exploring debriefing post OHCA in the prehospital setting.Methods24 paramedics employed by a UK ambulance service were approached by the author and asked to complete a questionnaire. Inclusion criteria: NHS employed paramedics, who had attended at least 1 OHCA over the past 6 months.ResultsPreliminary results showed that mean experience of participants was 4.5 years and median exposure of OHCA over 6 months was 5 (interquartile range 2-7). 55.48% of OHCA were followed by a debrief. When a debrief was not conducted, 58.33% of paramedics felt they did not need one. Debriefs were led by Team Leader (n=16), HEMS personnel (n=10), self-directed (n=8), Paramedic (n=4) and Clinical Team Educator (n=2). Debriefs took place at hospital (n=19), at scene (n=9) and ambulance station (n=4). Further analysis will look at differences between newly-qualified paramedics and experienced paramedics.ConclusionMore needs to be done to improve the debriefing rate for OHCA. A debrief post OHCA was twice as likely to take place at hospital compared to on scene, despite a low conveyance rate for OHCA. A Team Leader was most likely to lead a post OHCA debrief, but staff in this role are not provided formal training. Further research is needed to explore paramedics’ interpretations of debriefs, what paramedics want from debriefs, and the willingness of paramedics to participate in the debriefing process.

BackgroundParamedic engagement is crucial for the success of prehospital research studies. The Head injury evaluatiOn and aMbulancE Diagnosis (HOME) study aims to examine the feasibility of a diagnostic-test accuracy study to assess using the Canadian CT Head Rule in the prehospital setting to improve prehospital triage. However, significant recruitment challenges led to undertaking this qualitative study, aiming to identify barriers and facilitators to paramedic research engagement.MethodsA qualitative study was conducted using semi-structured interviews with 13 paramedics with varying experience, both participants and non-participants in the HOME study, to understand their perspectives. Interviews were recorded, transcribed, and analysed using an accepted thematic analysis approach, with data saturation guiding sample size.ResultsFour themes were identified. The first, Paramedic Perspectives on the HOME study, highlighted potential benefits for practice and patient care and identified recruitment challenges, including the unpredictable nature of paramedic work, geographical restrictions to recruitment, and poor awareness among hospital staff. The second, Personal and Professional Constraints Impacting Engagement, identified barriers such as time constraints due to demanding work schedules, burnout from high-intensity work, and mixed attitudes toward clinical studies, influenced by factors such as generational differences and past research experiences. The third, Considerations for Research Engagement Among Paramedics, explored factors influencing paramedics’ decisions to participate in research, including personal interest in the study topic, its relevance to their practice, flexibility in engagement, and ethical concerns about patient care. The fourth, Strategies for Enhancing Paramedic Research Engagement, suggested offering incentives for participation, enhancing interaction and recognition, and improving communication and organisational support.ConclusionWith unpredictable workloads, a complex prehospital environment and multiple demands on their time, paramedics face substantial barriers to research engagement. This can be mitigated by remunerating and rewarding participation, adopting flexible approaches to training and research design and optimising communication and organisational support.

BackgroundDeciding which medical resources are needed for trauma incidents often results in over- or under-triage. Evaluation of innovations aimed at improving dispatch decision-making (e.g., video livestreaming) requires retrospective assessment of the appropriateness of these decisions, but no tools currently exist.MethodsWe aimed to develop a tool through expert consensus to assess the need for enhanced medical resources (either critical care and/or Helicopter Emergency Medical Services) for trauma incidents. A modified Delphi approach was used, comprising three meetings with an Expert Panel who developed the criteria iteratively. The resulting criteria – the Retrospective Assessment Tool in Emergency Trauma Dispatch (RATED) - were applied to data from a feasibility randomised controlled trial by research paramedics to test reliability: (i) pilot stage: two cases rated independently by two research paramedics; (ii) all cases (n=58) rated independently by two research paramedics (blind to allocation and resource dispatch). A sub-sample (n=30) of cases were rated by the Expert Panel (blind to research paramedic ratings, allocation, and resource dispatch).ResultsCriteria across four areas of decision-making were developed (i) pre-hospital clinical interventions; (ii) injury pattern/physiology/anatomy; (iii) pre-hospital clinical decision making; (iv) patient disposition and geographical considerations. Reliability of ratings between research paramedics was high (2/2 cases, 100% agreement for pilot application; 56/58, 97% agreement for all cases). Expert Panel members agreed with each other in 24/30 cases (80%) and agreed with the research paramedics ratings in 16/30 cases (53%). Expert Panel members discussed cases that lacked agreement (n=14) until consensus was reached. Final agreed ratings were: appropriate (n=40, 70%), over-resourced (n=10, 17.2%) and under-resourced (n=8, 13.8%) dispatches.ConclusionRATED is a novel tool developed to aid evaluation of interventions in the pre-hospital setting. RATED was found to be reliable and easily applied across a range of clinicians. Further evaluation and critique are needed.

This study aimed to assess perspectives and approaches of paramedics in the Saudi Red Crescent Authority regarding spine trauma management. Given the high prevalence of spinal injuries in Saudi Arabia, particularly from traffic incidents. A descriptive, cross-sectional survey was conducted among 236 Saudi red crescent authority paramedics. A structured questionnaire measured participants' perspectives and approaches on spine trauma management. The findings indicated that paramedics demonstrated adequate foundational knowledge, particularly regarding the mechanisms of spinal injury and basic immobilization techniques, with an average knowledge score of 4.01 out of 5. However, gaps were observed in familiarity with advanced protocols, such as ATLS, where responses were neutral. Attitudes toward evidence-based guidelines were generally positive, with a mean attitude score of 3.57, though confidence in handling complex spine trauma cases was lower. Practice scores revealed consistent application of basic immobilization techniques, yet documentation and reassessment practices were less rigorously applied. The study highlights a solid knowledge base among Saudi Red Crescent Authority paramedics but identifies specific areas for improvement, particularly in advanced protocol training, practical skills reinforcement, and documentation practices. Targeted training programs, scenario-based simulations, and feedback mechanisms are recommended to enhance paramedics' confidence, skills, and consistency in managing spine trauma.

Background There have been major developments in healthcare services as well as changes in demographics in recent years, and this has, among other things, led to increased demand for ambulance services. In general, this has also led to calls for more highly educated paramedics. Main body Erasmus + provided a grant for three universities and one public service provider in four Nordic countries to work on a harmonised model curriculum for a bachelor’s degree in paramedic education. The project group has now completed the first phase of the project, which was to examine what paramedic education is available in the participating countries and what laws and regulations affect both the operation of ambulance services and the education of paramedics. At the end of the project, a harmonised exemplary curriculum will be available to anyone interested in educating paramedics at the university level. Conclusions The growing need for highly educated paramedics should be addressed by offering a bachelor’s degree university education with an exemplary curriculum and coordinating it within Europe. The added value of a harmonised education programme within Europe would thus enable further and deeper collaboration.

Background Since 2002, paramedics have been working in primary care within the United Kingdom (UK), a transition also mirrored within Australia, Canada and the USA. Recent recommendations to improve UK NHS workforce capacities have led to a major push to increase the numbers of paramedics recruited into primary care. However, gaps exist in the evidence base regarding how and why these changes would work, for whom, in what context and to what extent. To understand the ways in which paramedics impact (or not) the primary care workforce, we conducted a realist review. Methods A realist approach aims to provide causal explanations through the generation and articulation of contexts, mechanisms and outcomes. Our search of electronic databases was supplemented with Google and citation checking to locate grey literature including news items and workforce reports. Included documents were from the UK, Australia, Canada and the Americas—countries within which the paramedic role within primary care is well established. Results Our searches resulted in 205 included documents, from which data were extracted to produce context-mechanism-outcome configurations (CMOCs) within a final programme theory. Our results outline that paramedics are more likely to be effective in contributing to primary care workforces when they are supported to expand their existing role through formal education and clinical supervision. We also found that unless paramedics were fully integrated into primary care services, they did not experience the socialisation needed to build trusting relationships with patients or physicians. Indeed, for patients to accept paramedics in primary care, their role and its implications for their care should be outlined by a trusted source. Conclusions Our realist review highlights the complexity surrounding the introduction of paramedics into primary care roles. As well as offering an insight into understanding the paramedic professional identity, we also discuss the range of expectations this professional group will face in the transition to primary care. These expectations come from patients, general practitioners (family physicians) and paramedics themselves. This review is the first to offer insight into understanding the impact paramedics may have on the international primary care workforce and shaping how they might be optimally deployed.

Introduction: Prehospital sepsis alerts assist paramedics in identifying patients with sepsis and in communicating this diagnosis to receiving facilities. Following the prospective implementation study of our regional systemic inflammatory response syndrome-based alert criteria (Alert), the purpose of this sub-study was to determine the cause of Alert false negatives (patients without an Alert that subsequently met sepsis criteria in the Emergency Department (ED)). Additionally, the sensitivity of the Alert for detecting sepsis was compared to the Quick Sequential Organ Failure Assessment (qSOFA) and Hamilton Early Warning Score (HEWS). Methods: This study was an additional analysis of the prospective Alert implementation study. Included patients were ≥ 18 years old, transported by a regional Emergency Medical Service and met severe sepsis or septic shock criteria (SS/SS, 2012 Surviving Sepsis Guidelines) in regional EDs in 2013. False negative patients were identified prospectively and reviewed by comparing paramedic determined Alert status to the retrospective application of the Alert criteria to Paramedic Call Report (PCR) data. The Alert sensitivity was first calculated from prospective data, then retrospective sensitivities of the Alert, qSOFA and HEWS were calculated by retrospectively applying these tools to PCRs, using ED diagnosis of SS/SS as reference standard. Results: In 2013, 229 patients met SS/SS criteria in the ED and had PCRs available; 115 (50.2%) were male and median age [interquartile range] was 76.0 [63.0-84.0]. Of 229, 149 (65.0%) arrived in the ED without an Alert (false negatives) and 46 (30.9%) of these met Alert criteria retrospectively and were therefore missed by paramedics. Sensitivity of the Alert was 34.9% when applied by paramedics and 41.5% when applied retrospectively to PCRs. The retrospective sensitivities of the qSOFA and HEWS were 37.6% and 67.7%, respectively. Conclusion: In ED patients diagnosed with SS/SS who arrived with no Alert, the majority (69.1%) were missed by the Alert criteria, rather than by paramedic application of the tool. The Alert had a sensitivity of 34.9%. When applied retrospectively and compared to the Alert, qSOFA had similar sensitivity and HEWS had increased sensitivity. Future research should focus on deriving improved alerts or implementing those with higher accuracy, such as HEWS.

Background Paramedicine is a rapidly evolving health profession with increasing responsibilities and contributions to healthcare. This rapid growth has left the profession with unclear professional and clinical boundaries. Existing defining frameworks may no longer align with the practice of paramedicine or expectations of the public. The purpose of this study was to explore the roles paramedics in Canada are to embody and that align with or support the rapid and ongoing evolution of the profession. Methods We used a concurrent mixed methods study design involving a focused discourse analysis (i.e., analysis of language used to describe paramedics and paramedicine) of peer reviewed and grey literature (Phase 1) and in-depth one-on-one semi-structured interviews with key informants in Canadian paramedicine (Phase 2). Data from both methods were analyzed simultaneously throughout and after being merged using inductive thematic analysis. Results Saturation was reached after 99 national and international grey and peer reviewed publications and 20 in depth interviews with stakeholders representing six provinces, seven different service/agency types, 11 operational roles and seven provider roles. After merging both data sets three framing concepts, six roles and four crosscutting themes emerged that may be significant to both present-day practice and aspirational. Framing concepts, which provide context, include variable contexts or practice, embedded relationships and a health and social continuum. Roles include clinician, health and social advocate, team member, educator, professional and reflective practitioner. Crosscutting themes including patient safety, adaptability, compassion and communication appear to exist in all roles. Conclusions The paramedic profession is experiencing a shift that appears to deviate or at least place a tension on traditional views or models of practice. Underlying and evolving notions of practice are resulting in intended or actual clinical and professional boundaries that may require the profession to re-think how it is defined and/or shaped. Until these framing concepts, roles and crosscutting themes are fully understood, tested and operationalized, tensions between guiding frameworks and actual or intended practice may persist.