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The purpose of this article to review the literature relating to improving paramedic care in an Australian context.

The paper presents changes and challenges that have occurred in the ambulance services in terms of improving care and measuring performance, exploring the literature on quality improvement initiatives and their application to pre‐hospital care.

While hospitals and health services have moved well down the quality improvement pathway, the application of these processes to pre‐hospital care has been a relatively recent phenomenon. Ambulance services have taken a variety of approaches to measuring and improving pre‐hospital care. This article questions the transferability of lessons learned in hospitals to ambulance services. Arguably, the quality improvement approach is dependent upon health control and funding models and where ambulance is categorised in terms of health or emergency services.

The quality improvement approach by Australian paramedics and ambulance services is in its infancy. This article provides insights into the quality improvement approach taken by ambulance staff in Australia compared to other countries, as well as highlighting useful information on the future direction and research into the area.

The uniqueness of the pre-hospital setting and the need for quick decision-making confronts pre-hospital emergency personnel with various moral conflicts that can lead to moral distress (MD) in them. This study aimed to design a valid scale for the assessment of MD in emergency medical service (EMS) staff.

This exploratory mixed-method study was conducted among the EMS provider's community. In the qualitative section, data were gathered and analyzed with semi-structured interviews and conventional content analysis, respectively. The initial pool of items was formed and the primary scale was designed. In the quantitative section, a methodological study was carried out to determine the psychometric properties of the scale including qualitative-quantitative face validity, qualitative-quantitative content validity with content validity ratio and index (CVR/CVI), construct validity by exploratory factor analysis (EFA), and convergent validity, internal consistency (Cronbach's alpha/ Omega McDonald's/ floor and ceiling effect) and stability with intra-class correlation (ICC).

After interviews with 14 emergency technicians, the initial scale was designed with 60 items. Of the total items, 17 poor items were dropped during face and qualitative content validity. In the content validity phase, the items with CVR > 0.62, modified Kappa > 0.74 were retained, which eliminated 23 items. EFA was conducted with 20 items and lead to the 5 factors. The floor and ceiling effect for the whole scale was zero. Finally, the reliability of the scale was confirmed (a = 0.83, O = 0.86, ICC = 0.95).

The developed 20-item scale is a valid and reliable scale for the assessment of the MD in EMS providers.

With the increasing demand on ambulance services, paramedics are tasked to arrange as much out of hospital care as possible, to develop integrated systems of care and work with hundreds of different providers – all in the 15 minutes allocated for assessment. A UK ambulance trust is navigating and leading much of this work as one of the first trusts to implement a general practitioner referral policy as an alternate to direct conveyance. The paper aims to discuss this issue.

Here the authors discuss the referral scheme, examine the limited evidence available and discuss what is needed to influence prospective success of implementing this scheme in other trusts.

Limited evidence for these schemes are described, however there is a clear gap in critical appraisal and methodologically rigorous evidence needed to implement these schemes in other ambulance schemes.

In order to facilitate collaboration of healthcare services and to minimize the burden of increasing numbers of patients, communication and discussion of alternate routes of care is crucial. This viewpoint piece is one of the first to emphasize the potential benefits of such schemes.

Emergency Department (ED) presentations in older people are associated with a wide range of adverse events, which increase the risk of lengthy hospitalisation and poor outcomes. Pathfinder is an inter-organisational initiative delivered in partnership between Beaumont Hospital Occupational Therapy and Physiotherapy departments and the National Ambulance Service. Pathfinder responds to non-serious and non-life-threatening emergency medical service (EMS) calls. This study aims to demonstrate how Pathfinder can safely treat a proportion of older people at home by using alternative care pathways (ACPs), therefore avoiding unnecessary ED presentations. Once a decision has been reached to treat the person at home, the Pathfinder follow-up team delivers functional rehabilitation and case management in the persons’ home over the subsequent days.

This paper outlines the Pathfinder assessment, management and interventions in one clinical case example. Outcome measures include the level of patient satisfaction obtained via routine telephone feedback questionnaire and re-presentation to Beaumont Hospital within 30 days.

This paper illustrates through a case example the benefit of a collaborative multi-disciplinary rapid response team for non-serious and non-life-threatening EMS calls in older adults. The patient in this case example had no further EMS calls or ED presentations for 30 days after Pathfinder intervention and reported a high level of satisfaction with the service.

ED presentation was avoided through comprehensive multi-disciplinary assessment, including immediate access to intensive follow-up support in the person’s own home.

The Pathfinder service is improving access to ACPs for older people in the Beaumont Hospital catchment area. Pathfinder will now be spread nationally, with local adaptation, so that older people in other parts of Ireland will also benefit from this integrated model of care.

Patient feedback surveys confirm older adults want access to alternative care pathways.

This study was designed to examine burnout in US emergency medical services (EMS) providers. It examined burnout scores measured using the Maslach Burnout Inventory (MBI) on a convince sample of US EMS providers as well individual variables associated of burnout in this population.

This study used a convince sample, recruited using social media, of EMTs and paramedics and engaged them in an online survey to obtain information on burnout in this population. The responses were analyzed using stand statistical approached in order to determine MBI burnout scores, as well as which individual variables were influential in contributing to burnout in EMS.

This study found that most EMS providers had high levels of depersonalization and medium levels of personal accomplishment and emotional exhaustion. Gender differences were found as they were differences based on agency type and response area.

The main limitation is the nature of sample recruitment. The use of social media for the recruitment of this type of study has not been done before. Furthermore, it is a convince sample. This issue has limited impact on the results and the ability to apply them more generally because despite the convince nature of this sample, the sample is similar to those used in other studies as well as reflect that national statistics on the make of this population. The second major limitation of this study is that it does not include job specific and organization specific factors that may contribute to burnout. The findings for the variables used in this study suggest that future works should encompass these variables as well.

This study sets a clear foundation for further examination of US EMS providers and burnout. It helps to establish key ideas that can be followed up. Difference and key issues among US EMS providers need to be understood on a more comprehensive level before the assertion that they are similar to EMS providers worldwide. Ultimately, there is a need to develop better screening tools to assess burnout in EMS as well as to develop prevention and intervention programs based on clear empirical data.

Burnout EMS provides are a harm to themselves as well as the organization that employ them. The cost of burnout EMS provider crosses over to patient care and provision of care.

This study is one of the first to examine such a large US-based sample of EMS providers using the MBI. Other studies have used smaller sample or other tools to assess burnout in providers

The traditional principles of the ambulance service have served to underpin developments in pre‐hospital care, which together with increasing skills of paramedics and technology have both raised the profile of the service and arguably contributed to improvements in patient care. However despite these advances patients are still transferred to hospital following treatments from paramedic responses to ‘999’ emergencies. Evidence from the on‐scene treatment of diabetics suggests that certain patient groups can be appropriately managed in the community without recourse to either secondary or primary care through increasing paramedic judgement skills. Although this alone may not be enough to encourage support from health care professionals, the development of pre‐hospital care pathways with strict clinical and non‐clinical criteria may provide the answer. Increasing demands on all disciplines of the health service are to some extent determining the pace at which professionals work in finding solutions to more clinically effective care. The following paper offers a hypothesis that could potentially integrate paramedics more fully into the health care system.

Paramedics increasingly attend to mental health-related emergencies; however, there has been little evaluation of the mental health training for paramedics. This study aims to analyze the fit between paramedicine pedagogy, patient needs and the conditions for paramedics’ skill development.

Data were collected in a single, qualitative, critical ethnographic case study of pre-hospital mental health and psychosocial care in paramedicine in Ontario, Canada. Transcripts from interviews (n = 46), observation (n ∼ 90h) and document analysis were thematically analyzed using a constant comparative method. The study is theoretically grounded in a feminist political economy framework.

Tensions are explored in relation to the pedagogy of paramedicine and the conditions of work faced by paramedics. The paper presents challenges and insufficiencies with existing training, the ways in which certain work and training are valued and prioritized, increased emergency care and training needs and the limitations of training to improving care.

Recommendations include more comprehensive didactic training, including the social determinants of health; scenario training; practicum placements in mental health or social services; collaboration with mental health and social services to further develop relevant curriculum and potential inclusion of service users.

This paper addresses the lack of mental health pedagogy in Ontario and internationally and the need for further training pre-certification and while in the workforce. It presents promising practices to ameliorate mental health training and education for paramedics.

The purpose of this paper is to study the links between contextual changes, contract arrangements and resultant problems when changes in outsourcing regulatory requirements are applied to complex pre-hospital services previously characterized by relational contracting.

The study deployed a qualitative design based on interviews with key informants and extensive studies of documents. It is a longitudinal study of a procurement process taking place in a regional health authority covering the period 2006 to 2017.

A complex and longitudinal public procurement process where pre-hospital (ambulance) services are transformed from relational and outsourced governance to more formal arrangements based on legal and transactional controls, is described in detail. After several years, the process collapsed due to challenges following public scrutiny, legal actions and administrative staff resignations. The public body lacked procurement competencies and the learning process following the regulations was lengthy. In the end, the services were in-sourced.

This study is based on one case and it should, therefore, not be generalized without limitations.

One practical implication of this study is that transactional contracts are not optimal when core and complex services are produced in inter-organizational settings. In public sector health-care contexts, the role of informal and social controls based on relational exchanges are particularly applicable.

Acute health-care services essential to citizens’ security and health imply high asset specificity, frequency and uncertainty. Such transactions should according to theory be produced in-house because of high agency costs in the procurement process.

The paper contributes to the understanding of how the public procurement process can itself be complex, as managerial challenges and solutions vary along several dimensions and are contingent upon external factors. In particular, the study increases knowledge of why the design and implementation of outsourcing models may create problems that impede and obstruct control in a particular public sector context.

Ambulance services staff worldwide have long been at risk of encountering violence and aggression directed towards them during their work. Verbal forms of violence and aggression are the most prevalent form, but sometimes incidents involve physical injury, and on rare occasions homicides do occur. Exposure to such violence and aggression can have a lasting negative impact upon ambulance staff and has been associated with increased levels of stress, fear, anxiety, emotional exhaustion, depersonalisation and burnout syndrome. Despite the significance of this issue, little progress has been made to tackle it. The purpose of this paper is to describe this multi-agency approach being taken in Wales (UK) to reduce such harms from violence and aggression directed towards ambulance services staff.

An interpretative post-positivist narrative methodology and policy analysis approach was followed. Snowball methods of gathering data were used to construct this narrative involving meetings, telephone calls, review of policy documents, legislation and academic literature.

The authors report how tackling violence and aggression directed towards emergency workers has become a priority within Wales (UK), resulting in policy developments and initiatives from groups such as the UK and Welsh Government, the Welsh Ambulance Services National Health Services (NHS) Trust, Health Boards, the NHS Wales Anti-Violence Collaborative and the Joint Emergency Services Group (JESG) in Wales. This has included changes in legislation such as the Assaults on Emergency Workers (Offences) Act 2018 that came into force on 13th November 2018 and policy changes such as the obligatory responses to violence in health care and the JESG #WithUsNotAgainst Us campaign. Our study however reflects the complexity of this issue and the need for further high-quality research.

The experiences and activities of Wales (UK) reported in this paper adds to the international body of knowledge and literature on violence and aggression directed towards ambulance services staff.