Paramedics--is there a place for them in hospitals?
The New Zealand health system faces myriad challenges. These include, but are not limited to: a growing population; increasing life expectancy; increasing rates of chronic disease; an ageing nursing workforce; and a projected future nursing shortage. (1)
There is no one solution to these challenges, but a partial solution may the introduction of "non-traditional" and/ or new providers of health care in our hospitals. It has been suggested a total registered nurse (RN) workforce model is not sustainable, and RNs must work at the top of their scope of practice as part of a multidisciplinary team. (2)
I have been involved in pre-hospital emergency care for 25 years. In that time, I have seen progression and change in the ambulance industry, particularly in the education of paramedics. I use the term "paramedics" to encompass both paramedics and intensive care paramedics.
One of the biggest advances for paramedics has been the transition from industry-based training to university-based training, not dissimilar to the nursing profession's change from hospital-based nursing schools to the tertiary-education sector.
Most paramedics are now degree-qualified, and most intensive care paramedics hold postgraduate qualifications. I say "most", as there are a few older staff who do not hold degrees but continue to practise under their original non-degree paramedic qualification. Additionally, paramedics are on the cusp of becoming registered health professionals and being accountable under the Health Practitioners Competence Assurance Act 2003.
The role of the paramedic is to provide safe transport to hospital along with some pre-hospital emergency care. And, indeed, this is what distinguishes it from other health professionals.
As well as working as a front-line ambulance officer in New Zealand, I have undertaken contracts overseas with a private Australian company in the Solomon Islands and Western Australia. On both those projects, I was employed as an intensive-care paramedic with a response role. However, when not responding to emergencies, the paramedics on those projects worked in clinics, and on a ward, alongside the nurses and doctors. Within those projects, there were many similarities, and some overlap, between the nursing and paramedic roles.
It was partly that experience that provoked in me an interest in whether paramedics could be used in hospital-based roles in the New Zealand health system. In mid-2018, I travelled to Canada and the United Kingdom (UK) on a Winston Churchill Memorial Trust fellowship to research paramedic roles in hospitals.
The Canadian experience
Paramedics have been used in hospital-based roles in Halifax since the mid1980s. A shortage of RNs at that time prompted a trial in which the triage nurse was replaced by a paramedic, so the RN could be better used elsewhere within the emergency department (ED). Evaluation of this programme concluded that paramedics could triage patients as effectively as nurses.
A dedicated ED paramedic was introduced in the late 1990s. The role of this paramedic includes, but is not limited to:
* Responding to cardiac arrests within the hospital.
* Working as part of the trauma team in the resuscitation room.
* Escorting critical care patients within the hospital.
* Undertaking procedural sedation on behalf of medical staff. This includes medications such as propofol, which is not usually part of the paramedic scope of practice.
* Airway management. This includes managing the resuscitation room airway trolley, assisting the medical staff in managing the patient's airway and maintaining an airway registry.
Paramedics undertake about 15 per cent of the intubations within the ED, but are involved in almost all of them, and actively teach airway management to some medical and nursing staff.
* Venepuncture, and inserting intravenous cannulas.
* Applying plaster of Paris casts.
* Suturing minor wounds.
The Halifax ED paramedics are not assigned specific patients; they are task-orientated, and float and assist as required.
In addition to the ED paramedics, there is a separate area of the ED known as Pod 5, which is designed for assessing and treating ambulatory and low-acuity patients. These patients are managed solely by an additional paramedic, because, when Pod 5 opened, there was no budget to support extra emergency RN positions and paramedic wages were cheaper. It was felt this subset of patients would not benefit from the care of emergency nurses.
Without Pod 5, these low-acuity patients would be triaged to wait the longest in ED, because they are less likely to deteriorate and die. A shortage of GPs also adds to the number of low-acuity patients in ED waiting rooms.
A viable alternative
Paramedics, with their core paramedical skills, and some additional training, have proven to offer a viable alternative to the traditional nurse- or doctor-centred treatment of low-acuity patients. Data analysis has shown that patients triaged to Pod 5 spend, on average, half the time in ED, compared to patients streamed to other ED areas. (3)
This is not to say these two groups are similar and Pod 5 is more efficient. But it demonstrates that low-acuity patients can be treated more quickly than high-acuity patients, without affecting the care and treatment of the latter group.
Would it work in New Zealand?
The Canadian and English experiences show paramedics can be used effectively in hospitals. Would the role work in New Zealand? I believe so. Do New Zealand paramedics have the skills and knowledge to work in hospital-based roles? Again, I believe the answer is yes. The Auckland University of Technology (AUT) paramedic degree and the AUT nursing degree share about a third of their content in common. Both degrees have a similar level of clinical hours: nursing, 1200 hours, and paramedicine, 1000 hours.
New Zealand paramedics' level of education, training, and knowledge is comparable--in some cases superior--to our international colleagues.
There are two barriers to paramedics being used in New Zealand hospitals. The first is that paramedics are not currently registered health professionals. But this may well change, as the Government is currently considering registration of paramedics.
The second barrier could potentially come from the nursing profession. There will be some who will still think of paramedics as "ambulance drivers", and that the introduction of paramedic roles in hospitals will be "taking nurses' jobs".
These attitudes have been experienced overseas but, with time, have faded. Paramedics are now an integral part of hospital systems in Canada and the UK. Nurses and paramedics working side-by-side have grown to mutually respect each other's role and their respective professions' strengths and limitations.
I envisage the hospital-based paramedic as a collaborative role that will add value to the departments in which they will work. There are merits in both the Halifax and Croydon systems of using paramedics in ED.
The current structure of our health system is unsustainable--change is inevitable and should not be feared.
We have already seen the introduction of new roles within nursing. Once, the idea of nurse practitioners or roles such as nurse endoscopist would have raised scepticism or derision, yet their value is now proven. Overseas experience has shown hospital-based paramedics can add value to a multi-disciplinary team. Time will tell whether New Zealand will take up this initiative.
Croydon University Hospital, London, UK
The ED at Croydon Hospital has employed its own paramedics since 2014. It was one of the first hospitals in London to do so.
Under the United Kingdom pay system, a standard staff nurse is a band 5. Croydon Hospital has a position called an emergency care nurse/paramedic (ECNP) who works predominantly in the resuscitation room--about 90 per cent of the time. This is a band 6 position, which means greater experience and a leadership/coordination role. As the ECNP title suggests, the role can be filled by either a nurse or a paramedic. In the UK, both nurses and paramedics hold a degree and are registered health professionals. The role is competency-based and all ECNPs are orientated to the role, irrespective of their background. The ECNPs have some features of expanded scope compared to band 5 staff nurses, such as taking arterial blood gas samples and gaining intraosseous access.
Andrew Prescott, MEmergHlth (Paramedic), MEmergMgt, is an intensive care paramedic in Whanganui. In 2018, he travelled to the United States, Canada, and England on a fellowship from the Winston Churchill Memorial Trust looking at models of care using paramedics in hospital-based roles.
(1) Nursing Council of New Zealand. (2013). The Future Nursing Workforce--Supply Projections 2010-2035. Wellington: Author.
(2) Manchester, A. (2013). Envisioning nursing's future. Kai Tiaki Nursing New Zealand, (19)9, p26-28.
(3) Campbell, S., Janes, S., MacKinley, R., Froese, P., Harris, S, Etsell, G., Warren, D., ... Urquhart, D. (2012) Patient management in the emergency department by advanced care paramedics. Health Management Forum, (25) 1, 26-31.
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|Publication:||Kai Tiaki: Nursing New Zealand|
|Date:||Dec 1, 2018|
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