Quality, Patient Safety & Risk Reduction in Community Paramedicine

The current healthcare system in Canada and many other nations are experiencing an increased demand (CHCA, 2011).  As a result, there is a significant transition underway to deliver care in alternative settings.  We are well aware that many hospital stays have been shortened with the advancement of medicine, technology and techniques (Vincent, 2016). This has resulted in many patients with complex conditions and multiple comorbidities being cared for at home (CPSI, 2014).

Modern patient safety practices are often targeted at hospital-based care with emphasis on high risk areas of practice such as surgery and transfusion services. Many safety solutions are discipline specific and do not translate to other clinical environments, even within hospital (Vincent, 2016). As care is shifting to a home-based model, many of the hospital based patient safety solutions do not directly translate to the home environment (CPSI, 2014).  Family members in many cases are replacing registered professionals in this setting.  Understanding this new landscape is important, family members without formalized healthcare education are at the forefront of patient safety.  Areas of risks of home-based care include coordination of care, falls, medication errors, social integration, and infection control and prevention. (Blais, 2013). 

Community Paramedicine (CP) is an emerging field of practice within Paramedic Services (PS). The paramedics’ role is evolving as a distinct medical profession (Nolan, 2018).  CP programs are roughly described as, a care model that deploys existing skilled paramedics in a non-traditional manner to expand their scope to care for patients in a community or home care setting as part of an integrated healthcare team.  The progress of CP programs has been particularly progressive in nations with public healthcare systems such as Canada, Australia and the United Kingdom (Agarwal, 2017).  

This literature review is important as it takes a novel perspective, looking to understand and conceptualize how CP programs are currently, or could potentially; increase patient safety, reduce risk and improve quality of care. Benchmarking of CP programs is particularly difficult as there are few common indicators for outcomes, quality of care; or patient safety (Leyenaar, 2019).

Methods

The approach used to consider this objective, is an integrated literature review of ten selected papers on CP using a PICO framework to define the question for this review.  The population is patients receiving care at home, the intervention is community paramedicine programs, the comparison is across published works of CP programs, and the outcome is patient safety, risk reduction and quality of care. The resulting question formed the lens for conceptualizing this review: Do community paramedic programs currently, or could they potentially; improve patient safety, quality of care and reduce risk for patients in a homecare-based setting?

In order to identify what would be considered patient safety, quality and risk in the out-of-hospital/home care setting, the Canadian Patient Safety Institute (CPSI) – Home Care Safety Roundtable Action Plan (CPSI, 2014) themes are used. The CPSI roundtable process identified the following themes as priorities to improve homecare based patient safety, quality and risk reduction. (1) System Level Communication; (2) Collaborative Care; (3) Client’s Right to live at risk and partnering with client’s families; (4) Advanced knowledge of measurement for improvement; (5) Leading practices in Medication safety, Falls Prevention, and Infection Prevention and control.  Therefore, these five themes are used to analyze the selected papers.

A search of the literature was undertaken using MedLine (OVID) using an initial MeSH search followed by keywords, the same search terminology was applied to EMBASE (OVID) with similar results.  Papers were retrieved through MedLine and papers were retrieved through EMBASE. There were no exclusions applied to the search.  A combination of MeSH was applied and linked using ‘AND’ with Keywords applied and linked using the ‘OR’ qualifier. The term mobile integrated healthcare was considered as an equivalent to community paramedicine (APPENDIX A).

The selection criteria eliminated any editorials, presentations, opinions, new articles and conference proceedings. This retained papers through Medline and papers through EMBASE. The primary pass for inclusion scanned the article titles for reference to a Community Paramedic or Mobile Integrated Healthcare program. The secondary review entailed reading the abstract for relevance to a community paramedic program and preference given for those that discussed the CPSI themes, those with no abstract in the search database were immediately excluded. This resulted in 16 papers for complete review with a full read. In addition, the references of each of these papers were reviewed for common citations that may also meet the thematic criteria. Finally, a full review of ten articles was conducted resulting in the synthesis.

Discussion

Despite documentation indicating that there have been CP programs in one format or another since the early 2000’s, there remains very little formalized research on the topic. In review of the literature an overarching focus appears in the CP research, many have been looking to understand if CP programs can safely and effectively reduce ambulance transports to emergency departments (ED). The main outcome measurements in this case are transport deferral rates and adverse events.  As a program delivery perspective there is interest in tracking adverse events for patient safety, resulting from the CP program transport diversion. This is an important aspect that appears to show good results overall with minimal adverse events as a result of the CP program. The interest of this review is to look more holistically beyond the transport deferral question and consider the community paramedics as part of an integrated primary healthcare team with a patient centred focus on care in the home.  

The literature that looks at ED deferrals are generally favourable to the concept and safety of such programs.  A more rigorous systematic review was conducted by Pang (2019) and presents the most current and critical analysis. Limited manuscripts meet the inclusion criteria of the systematic review mainly due to a lack of quality research and presents a substantial limitation. The results are that little evidence exists to support CP deferral programs and an urgent call for more research.  The lack of peer-reviewed and robust research into CP programs is a recurring theme amongst all the current literature. Due to this paucity of literature and absence of specific papers on patient safety, risk reduction and quality improvement in CP programs, let’s consider the CPSI roundtable themes.

System level communication for the purpose of this review is interpreted as coordination of care. Coordination of care is important for ensuring quality of care, as well as reducing risk and patient safety. Many of the populations served by CP programs are those that are considered to “fall through the cracks” of the system. Many are low socioeconomic status, have little ability to care for themselves and often do not have a home support network (Vincent, 2016). The issue of having a primary care physician and being able to travel to appointments often plays into this as well. 

The most robust example of coordination of care by Community Paramedics is presented by Dainty (2018) in their grounded theory study of the Expanding Paramedics In the Community (EPIC) study.  This study partners paramedics with primary care health teams to delivery in-hope scheduled and unscheduled care to enrolled patients.  The EPIC study provides chronic disease management and regular communication with the patient’s primary health care provider. The communication is through shared electronic health records as well as direct conversation when needed.  They showed a robust communication system amongst care givers provided increased patient satisfaction and sense of a “safety net”.

A Grounded theory study is a challenging approach to summarize the findings.  This particular paper did a quality job synthesizing the information and have an excellent participation rate, although low numbers enrolled overall. The particularly interesting part is that this was the first study to include quotes from patient’s and their families. Patient’s identified that CP’s maintained continuity of care often acting as patient advocates and ensuring coordination of other health care practitioners and services in a patient navigator type role.

Hand in hand with communication is a collaborative care model.  This review considers mobile integrated health (MIH) performed by paramedic services as an equivalent to community paramedicine.  MIH as a program name implies that the paramedics are integrating and collaborating with the patient’s health care team. Each of the programs describes in some way shows collaboration and communication with other primary healthcare providers.

Several examples of collaboration with CP programs are shown across the literature. Ranran (2018) in their single-blinded control trial hypothesized and showed a CP discharge follow-up program in coordination with the ED providers could safely reduce ED readmissions.  This is one of the better designed and controlled studies with adequate power to make conclusions. However, it was lacking precise outcomes to achieve other than readmission and it was unclear using retrospective data if readmissions were directly related to the prior admission.

On a more positive note a scoping review from Scandinavia looking at multiple CP sites came to the conclusion that a core component of CP programs included multi-agency collaboration (Rasku, 2019). In this paper their review showed consistency across multiple articles with phrases identifies such as partnership, multidisciplinary, collaboration and integrated care. This is only a scoping review, and these are observations, not giving us a depth of effectiveness, but clearly an area that CP programs a consistently focused.

The theme of a client’s right to live at risk and partnering with client’s families is focused on building communication and rapport with the patient and their families. The ability to share information and educate on safety and risk is at the core of this theme for informed decision making and care planning (CPSI, 2014). 

As an example of CP programs assessing the support network and ability to interact with the patient and family Lee (2016) conducted a study on the reliability and effectiveness of a clinical prediction rule.  The prediction rule known as Paramedics assessing Elders at Risk for Independence Loss (PERIL) looks at validating a tool to refer patients to CP programs. The PERIL assessment includes an assessment of home-based risks and social interactions support from family and friends to determine patient needs. This is an excellent example of a quality study that seeks to identify patients at risk in their home and open the system level communication and collaboration on a proactive prevention basis.

This particular study presents a valuable perspective in finding that a reproducible and validated assessment tool is superior to paramedic judgement alone in assessing risk in the elderly at home.  This study finding presents a substantial case for a robust quality assurance and quality improvement program in CP programs that can enhance the quality of care, safety and reduce risk for patients.

Patient outcome and quality measures are scarce in CP programs.  There needs to be a coordination of effort to determine a best approach to ensure quality of care and outcomes in a measurable fashion.  CPSI identifies the need for more advanced measurements for quality and safety improvement in home healthcare.  What do community paramedics asses? An environmental scan and content analysis of patient assessment in community paramedicine (Leyenaar, 2019), gives us a direct summary of what assessment are currently employed in CP programs and may contribute to patient safety, risk reduction and quality of care.

A very positive element of this papers approach is the use of the International Classification of Functioning, Disability and Health (ICF); as well as the International Classification of Diseases (ICD) to better understand how community paramedicine patients directly relate within the overall healthcare system.  The review methodology and coding appear to be strong with excellent depiction of methodology but is also geographically limited to one Province of Canada.

As expected, this paper found few clinical guidelines informing practice or consistency across programs.  Also, of significance is a lack of documentation standards and quality assurance and improvement process formalization.

This paper identifies the need for a minimum threshold and consolidation of assessment practices to create a standard of care for community paramedic programs.  Additional training and clinical guidelines are needed.  This identifies a need for improved quality assurance and improvement practices for community paramedicine, centred around patient outcomes and identifying evidence-based assessment tool. These would help improve the ability to measure both locally and across regional programs.

CP programs across the literature appear to also have a common interest in in-home safety, fall prevention and health prevention.  Many of the programs address the fifth theme of the leading practices in medication safety, falls prevention; but not infection prevention and control.  Ontengco (2019) describes a quality improvement process within a hospital to increase enrollment in an ED discharge falls prevention program. This article is not a specific description of a CP program but was chosen due to its clear demonstration of quality improvement (QI) in patient care using QI and process improvement methods with collaboration of a CP program despite the small sample size.

The PERIL assessment tool (Lee, 2016) also looks at a broad assessment and referral of patients to a CP program with a significant range of questions pertaining to fall and injury prevention in patients’ homes. Designed to be used by all standard paramedic crews as a referral tool for follow-up by CP programs, this approach has potentially large benefits to improving patient safety and risk through prevention. This tool includes fall, mobility, fire, sanitation, medication, social and medical assessments to predict risk and recommend intervention.  Clearly a shining example as an approach to deploying CP’s to enhance quality of care, safety and reduce risk.

Dainty (2018) considers and describes the social, family and patient perspective to this approach in their review of EPIC.  A particularly compelling element described by the patient’s and family’s is the willingness to participate and compliance for prevention, risk reduction and disease management as a result of the relationships built with the community paramedics.  While the broader outcome being studied elsewhere has been the deferral of ED visits.  This study shows some compelling evidence towards improved quality of care and patient safety that is mainly qualitative and difficult to directly compare or quantify, but arguably more important.

Conclusion

This literature review has confirmed that there remains a paucity of research with few of significant quality or power to make definitive conclusions. CP programs in the literature appear to have poorly defined or consistent problem coding, interventions; or outcome, quality and safety measures.  CP programs have much more to offer patient’s receiving care at home than deferred visits to the ED.  There is evidence to show that CP’s can be an integral part of a primary healthcare team but the lack of defined education standards, validated assessment tools and standards, clear collaborative relationship goals and lack of measurable performance indicators makes the cost benefit analysis extremely difficult to demonstrate. More work needs to be completed to define all of these elements and consider broad and consistent adoption to benchmark programs. In order to further these goals, additional rigorous research should be conducted in Community Paramedicine to show that these described areas are measurable, reproducible and correlate with patient’s primary healthcare goals.

The answer to the question at hand within this review, appears to be that CP programs are currently contributing to improved quality of care, patient safety and risk reduction. There are further identified areas where CP programs describe opportunities to further these goals. Ultimately, CP programs as part of an integrated primary healthcare team can provide a significant contribution to the patient’s lived experience resulting in improved overall quality of care, patient safety and risk reduction as part of a system that communicates well, collaborates, provides client and family interaction, measures quality for improvement and actively participates in prevention programs.

As a path forward from this literature review, it is recommended that consideration be given to a proposed framework for Community Paramedic – Quality Improvement, Patient Safety and Risk Reduction program to be adopted as part of any CP program.

Community Paramedicine – Quality, Patient Safety & Risk Reduction Framework

The proposed framework is based around patient centred care, the hallmark of modern and current patient safety and quality improvement programs. This is particularly fitting in the primary healthcare setting with an integrated team model.  Expansion of the basic framework should include breaking down the categories to include defined outcomes, performance indicators and specific services delivered by CP programs. The use of process flow charts, checklist and closed loop communication systems should be implemented as part of the framework to reduce gaps and ensure each element of the CP program has been implemented.

Communication & CollaborationHealth & Risk PreventionPatient SafetyQA/QI 
Electronic Health RecordsFallsBest Medication HistoryOutcome Measures
Direct CommunicationMedicationLiving conditionsPt Problem Coding
Multidisciplinary CareInfection PreventionFamily EducationDischarge Follow-up
Family ConferencesInfection ControlPatient EducationStandardized Education
Patient AdvocacyFire PreventionInfection ControlStandardized Assessments
System NavigationMedication ComplianceMedication RemindersProgram Benchmarking
Patient EducationCP/Primary ReferralsMedication TrackingCare Transition Tracking
Family EducationWound/Ulcer MgmtCare Transition ProcessesEHR Audits
PharmacistChronic Disease MgmtEHR FlaggingHospital Admis. Tracking

References

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