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Out-of-hospital or pre-hospital: Is it time to reconsider the language used to describe and define paramedicine?

Published:February 09, 2022DOI:https://doi.org/10.1016/j.auec.2022.01.002

      Abstract

      The professionalisation of paramedicine in Australasia necessitates discussion about how the profession defines and describes itself in the literature and more broadly. This editorial discusses the descriptors pre-hospital care and out-of-hospital care, and the connotations, relevance and implications of their use to describe paramedic roles and practice.

      Keywords

      Introduction

      The professionalisation of paramedicine in Australasia necessitates discussion about how the profession defines and describes itself in the literature and more broadly. Language and descriptors matter, and influence how the profession and the role paramedics play in health care is viewed. Is the term ‘pre-hospital’ limiting, and influencing how the paramedic role and profession is viewed within health systems? Does the term ‘pre-hospital’ unduly imply a simplistic view that paramedics attend patients and transfer them to hospital?
      Paramedicine is moving and evolving at a rapid pace with advances in scope of practice and alternate service delivery models being informed by robust research and contemporary evidence. Models of practice and care are also evolving to meet the needs and demands of growing and aging populations. Paramedicine was recently defined by an expert consensus process as “a domain of practice and health profession that specialises across a range of settings including, but not limited to, emergency and primary care [
      • Williams B.
      • Beovich B.
      • Olaussen A.
      The definition of paramedicine: an international delphi study.
      ]”. The consensus definition went on to say that paramedics work in a variety of roles and possess complex knowledge and skills [
      • Williams B.
      • Beovich B.
      • Olaussen A.
      The definition of paramedicine: an international delphi study.
      ].
      While the term ‘pre-hospital care’ is currently and historically used broadly to describe paramedic practice, in literal terms it means ‘before hospital’ and implies that paramedics attend patients and transport them to hospital. You could be forgiven for aligning this descriptor with the old ‘stretcher bearer’ days where ‘ambulance drivers’ picked patients up and drove them to the hospital to receive definitive care. This underplays the current situation in Australasia were paramedics have evolved well beyond this to highly educated and skilled clinicians who provide advanced care which does not always culminate in transport to hospital. So, is it time language and descriptors also evolve to better reflect what and how paramedics practice?

      Alternatives to pre-hospital care?

      Paramedics assess, treat, refer, and sometimes transport patients. Alternative models of care not culminating in transport include increasing examples of primary and secondary referral or triage programs, and paramedics working in other roles such as extended and community paramedic positions [
      • Bigham B.L.
      • Kennedy S.M.
      • Drennan I.
      • Morrison L.J.
      Expanding paramedic scope of practice in the community: a systematic review of the literature.
      ]. Changing community needs and patient demographics, health sector expectations, increasing workloads and hospital capacity issues have necessitated the evolution of paramedic practice from an emergency care and transport role to a broader role incorporating primary care. Paramedic initiated referral and non-transport to the emergency departments is fast becoming recognised as one of the most important practices in providing an appropriate level of care for the patient’s needs [
      • Blodgett J.M.
      • Robertson D.J.
      • Pennington E.
      • Ratcliffe D.
      • Rockwood K.
      Alternatives to direct emergency department conveyance of ambulance patients: a scoping review of the evidence.
      ]. In an attempt to provide the right care, at the right time and place for patients, paramedics show their worth in working in roles such as extended care and community paramedicine [
      • Wilkinson-Stokes M.
      A taxonomy of Australian and New Zealand paramedic clinical roles.
      ]. These roles can include working outside of traditional employments streams, such as ambulance services, that never involve transport to a hospital.
      Paramedics therefore do not only provide ‘pre-hospital’ care but more broadly ‘out-of-hospital’ care in many settings and for a myriad of employers. These settings include but are not limited to general practice surgeries [
      • Proctor A.
      Home visits from paramedic practitioners in general practice: patient perceptions.
      ], urgent care centres [
      • Whalen S.
      • Goldstein J.
      • Urquhart R.
      • Carter A.J.
      The novel role of paramedics in collaborative emergency centres aligns with their professional identity: a qualitative analysis.
      ] and other community-based employers [
      • Eaton G.
      • Wong G.
      • Williams V.
      • Roberts N.
      • Mahtani K.R.
      Contribution of paramedics in primary and urgent care: a systematic review.
      ] where the intention is not always to provide care before arriving at the hospital, but rather to care for the patient in their own home or another setting without the need for hospital attendance or admission. The current expectation of registered paramedics, as determined by the Paramedicine Board of Australia, does not include transfer of care to a hospital [

      Professional capabilities for registered paramedics: paramedicine board of Australia; 2021. [Available from: 〈https://www.paramedicineboard.gov.au/Professional-standards/Professional-capabilities-for-registered-paramedics.aspx〉.

      ]. It is very clear that paramedics work as part of the broad health care system, and that descriptors for historical models of service delivery are no longer accurate. The modern paramedic is an ‘out-of-hospital’ health care provider, and the transport of patients to hospital is only one avenue of care.
      Only a portion of paramedic practice can now be termed ‘pre-hospital’ care, making ‘out-of-hospital’ care a more inclusive and accurate descriptor. While some may consider this a small and nuanced difference, language and descriptors have impact and influence. As paramedicine strives for professional identity, recognition and inclusion it is imperative that language is aligned with current and future service delivery and models of care.
      So, is ‘out-of-hospital’ care an accurate and inclusive descriptor of paramedic practice? It could exclude paramedics that perform roles and provide care with a hospital setting. As with recent work cited on the definition of paramedicine by consensus, it is now necessary to determine and define accurate language and descriptors of paramedic care and practice to ensure accuracy and inclusivity.

      Acknowledgements

      Nil.

      Disclosures

      The authors received no funding for this article and have no conflicts of interest to declare.

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