Overcoming barriers to implementing community paramedicine programs

By Robert J. Steeps, MHS, RN, CEN, NRP, I/C

The number of patients presenting to emergency departments in the United States has been on the rise over the past three decades [1]. According to the Centers for Disease Control and Prevention, there was a 16.5-percent increase in total ED visits from 2007 to 2009, with 116.8 million to 136.1 million respectively [1].

This increase in annual ED visits has subsequently led to a 25-percent increase in the amount of time a patient has to wait to see a provider; 46.5 minutes to 58.1 minutes between 2003 and 2009 [2]. These increased wait times can also hinder ambulance crews from returning to service.

Emergency medical services professionals have begun to assuage this increased use of emergency services by developing a new model of care provided by community paramedics.

As the EMS profession begins to transition from a primarily reactive role toward one of prevention in the EMS 3.0 model, many services are beginning the process of developing and implementing their own CP programs. As EMS leaders begin this process, identification of barriers to successful implementation, such as acceptance from EMS professionals, can impact their success. A recent project conducted by a group of EMS researchers sought to examine EMS professionals’ attitudes about – and willingness to participate in – CP programs [3].

Community paramedicine survey results

Results from the survey of EMS professionals indicated that female participants were nearly five times as likely to express a willingness to participate in CP programs than their male counterparts [3]. Their willingness may be influenced, in part, by the empathy levels of the participants. Several authors reported similar results when investigating the empathy levels of healthcare students queried about different medical conditions [4-8].

One barrier discovered during the survey was the concern about time commitment for additional duties. The results indicated that EMS professionals might be more willing to participate in a CP program if specific shifts or positions are developed for that purpose [3]. EMS leaders might have more success with implementation if their staff members are directly committed to CP duties instead of dual responsibilities.

While evaluating EMS professionals’ willingness to perform CP duties, survey results found no statistically significant differences with provider level, age, education or rural versus urban practice setting [3].

Attitudinal community paramedicine implementation barriers

While there is a paucity of research evaluating EMS professionals’ attitudes toward CP program participation, researchers have explored parallels with other public safety professions. Several published studies evaluating law enforcement officers’ and firefighters’ acceptance of the non-traditional role of providing patient care in the prehospital environment have been found in the literature. These reports can provide insight to EMS leaders implementing/expanding a CP program within their agencies.

A study investigating a LEO naloxone administration program found officers were concerned with the added responsibilities of the new program [9]. EMS professionals may also have concerns with the added responsibilities of CP programs with the new focus of assessing and managing chronic medical conditions in the patient’s community instead of routine transports to the ED. Over one-fourth of our survey respondents felt that they became EMS professionals to respond to emergency calls and not to participate in a CP program [3]. These new responsibilities might be a participation barrier for some participants.

LEOs expressing a lack of comfort with the role change in a study of a law enforcement automated external defibrillator (AED) programs created an implementation challenge for their leaders [10,11]. It might also prove to be difficult for EMS leaders to recruit willing participants for their CP programs if their EMS professionals do not see these new duties as part of their role. Forty percent of the respondents to our survey did not think that their co-workers would be interested in performing CP duties [3]. A lack of co-worker willingness to participate in this new role change is a barrier to successful program implementation.

Other studies of LEO and firefighter AED programs found impediments to their implementation when participants were hesitant to participate related to a perception of new liabilities [12,13]. As CP programs focus on providing and arranging care in the community verses routinely transporting patients to the ED, barriers to successful program implementation may be created by EMS professionals’ concerns for new liabilities.

Thankfully, a majority of our participants (74%) indicated that a CP program should be a significant responsibility for EMS in their communities [3]. This may be an indication that liability concerns were not an issue for these professionals.

Serving the underserved and vulnerable

While several barriers have been found to the enactment of new programs in public safety professions, several items have been discovered in the literature to assist with implementation. LEOs and firefighters were more likely to express positive attitudes when they felt their new roles would benefit those they served in their community [10,12,14-16].

Eighty-four percent of our survey respondents felt that CP programs will help those with the greatest needs in their respective communities [3]. EMS professionals might be willing to participate in CP programs when they understand the benefits received by the underserved and vulnerable members of their response areas.

Another study found that chief officers who showed support for a LEO AED program had a majority of officers that also believed the program would be valuable to their community [12]. When EMS leaders express a high level of support of their CP programs, this may translate to the frontline providers as well. Three-fourths of our survey respondents felt that their leaders would support a CP program [3].

A majority of public safety professionals participating in a research study agreed that providing EMS-related activities improved the public’s perception of their respective law enforcement agency or fire department and their members [12-14]. The additional services CP programs will provide to the community may also improve the public’s perception of participating EMS agencies. In times of tighter budgets, community support is paramount to funding. Three-fourths of those responding to our survey believe that the community they serve would be in favor of having a CP program delivered by their agency [3].

Embracing new patient care opportunities in community paramedicine

LEOs and firefighters that personally experienced on-the-job impacts of EMS-related activities had positive attitudes toward new patient care roles [9,14,17]. Another study found that LEOs with less experience or no recent experience with overdose cases were resistant even toward naloxone training programs [17]. When EMS professionals can see the tangible benefits that CP programs can provide for their community, they may have a more positive attitude toward implementation. Participants of our survey felt that nearly half of the patients they currently contact in the field could benefit from a CP program [3].

Another barrier found to implementing AED programs for public safety professionals has been negative attitudes that stemmed from a lack of education about the programs and their benefits [18]. Education provided about public health programs has shown an increase in LEOs’ and firefighters’ willingness to participate [12-14,17,18].

EMS professionals that are given education about the benefits of CP programs may also be more willing to participate in them. The majority of our survey respondents perceived that they currently have a good understanding of CP programs and that they would volunteer for additional education in order to become a CP [3].

Leaders of EMS agencies can use this information when making strategic plans for the implementation of a new CP program or the growth of a current one.

Acknowledgements

Special thanks to the coauthors of the CP attitudinal research project: Micheal W. Hubble, PhD, MBA, NRP; Denise A. Wilfong, PhD, NRP; and Daniel L. Bercher, PhD, NRP.

About the author
Robert J. Steeps has been in the emergency field for over two decades. While his career has spanned a Level I trauma center, fire-based EMS, helicopter EMS, hospital education and postsecondary education, his professional passion remains with prehospital care, education, research and the continued development of professionalism in EMS.

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