Should paramedics undertake an additional scope of practice

Introduction

Ambulance services and the healthcare professionals that provide the support to facilitate this provision are playing an increasingly wide role in the NHS, not just by providing a rapid response to 999 calls and transferring patients to hospital but becoming a portable healthcare service for the NHS. The ambulance service continues to develop and like other clinical specialties within the NHS the practitioners employed within the ambulance service have had to developed knowledge, skills and an understanding of modern technology in an attempt to take healthcare to individuals outside of the hospital environment. It is suggested that ambulance services reach a wide range of patient groups; for example to patients who need an emergency response; to individuals who do not have a life threatening condition but are seeking urgent advice or treatment, and to those whose condition or location prevents them from travelling easily to access healthcare services (Warner, 2005).

Traditionally ambulance services have been primarily perceived as an emergency service where the response is to meet the needs of individuals who may be experiencing life threatening emergencies, with severe breathing difficulties, acute coronary syndrome or suffering major trauma (Lendrum et al,. 2000). Training and service development has been structured to reflect this need for emergency acute care, however a paradigm shift has occurred with focus now being made upon more care and treatment being provided within community settings and within patients homes and the traditional perceptions of the ambulance service are gradually being replaced with the view that it is a mobile health resource, able to provide an increasing range of assessment, treatment and diagnostic services (Department of Health, 2005).

This assignment will aim to explore further these developments in ambulance service provision, emergency care and the developing paramedic professional scope of practice by using the example of an 8 year old boy who had sustained a head wound. The child in question had on initial examination a small laceration above the right eyebrow, his GCS score was 14 and he was able to self report on paediatric pain chart that the wound ‘only hurts a little’. The injury was reported to have been inflicted following a fall whilst ‘play fighting’ with his brother. Historically it would be accepted practice for the ambulance personnel to transfer the child with an appropriate adult to the acute hospital setting for further treatment of the wound, however for the purpose of this assignment and in light of the developing role of the paramedic and ambulance service the focus will be on how the process of home treatment and intervention in a safe and appropriate clinical manner could have been delivered to minimise the use of acute hospital resources and for the patient to receive wound care within their own home and community.

Ambulance Services and Children

It is suggested in the literature that 5 to 10% of calls made to the ambulance service are for children (Jewkes, 2004a, Jewkes, 2004b and Kumar et al,. 1997) and that as this figure is relatively small this may be translated to imply that a paramedics exposure to children who are critically ill or injured would likely to be infrequent (Houston and Pearson, 2010). With this in mind it may be suggested that there is the potential for ongoing difficulties with the implementation of clinical skills in the paramedic’s practice, particularly if those skills are relevant and have been acquired in paediatrics and care of the sick child, if they are not used or practiced often enough.

Houston and Pearson (2010) indicate that ambulance calls that involve children can often be stressful for health care providers such as paramedics and this feeling can often be exacerbated if the individual has not been trained to deal with the needs of a sick or injured child. The result of this is that the anxiety provoked by a call to a paediatric emergency results in the paramedic becoming reluctant to intervene (Roach, 1994; Spaite, 2000 and Dawson 2003) and this may place the child in more danger or alternatively may result in more transfers to the acute hospital environment for cases which could in essence be managed within the pre hospital environment.

A study that was conducted in 2003 by Dawson et al. identified that by evaluating the training and comfort of basic and paramedic skills providers felt overall very well prepared in all areas of emergency care except for paediatrics and childbirth. This study although relevant to the context of this discussion was based on American ambulance workforces who have different qualifications and training approaches therefore can be disregarded as a benchmark for the delivery of care by ambulance service providers to children.

In the UK there has been little research to identify the efficacy and skill of ambulance service providers in the delivery of care to children up until the publication of Houston and Pearson’s (2010) exploratory work on ambulance provision for children. The findings of this study identified that although the NHS did not have a specific budget to support ambulance crews and paramedics in training and education in paediatric care in 85% of ambulance service trusts it was reported that there was the opportunity for ‘in house’ clinical training in paediatrics. The study was also able to identify that if the training was not mandatory then double technician ambulance crews would be dispatched to calls involving children and that overall variation in practice is reducing with a more cohesive shift within NHS trusts towards ensuring ambulance service staff are appropriately trained to deliver effective pre hospital care to children.

Wound Care

In the scenario described in the introduction the author referred to the clinical case of an 8 year old boy with a head laceration, the ambulance service had been called to respond and the paramedic in attendance became the lead health practitioner in managing the pre hospital care of the child in question.

Prior to the development of the ambulance services and prior to the shift towards becoming a portable healthcare service for the NHS, ambulance crews would triage the patient on scene, ensure they were physically stable for transfer and the facilitate the patients transition between the community and the acute hospital setting for further assessment and treatment. With the paradigm shift towards ambulance services providing improved and expansive pre hospital care being acknowledged this assignment will now continue by exploring the principles of good practice in wound care which the paramedic on scene could deliver to the 8 year old boy with the head laceration to facilitate care delivery within the home environment and reduce the need for acute hospital care which places a heavier demand on the time of all parties involved in this scenario and on the NHS.

Wound care is an integral part of the role of the paramedic or the emergency care practitioner and is a clinical skill with an evidence based knowledge that is acquired during the training process. The overall aim of managing wounds is to promote the healing process and for many patients and health professionals, for different reasons, they would want wound closure to occur as quickly as possible (Flanagan, 2005). It is well documented that wound care has advanced significantly within recent years and with the development of wound care specialists that are research literate, knowledgeable about policy and practice and are able to effectively bridge the gap across theory and practice (Flanagan, 2005) other health professionals, such as paramedics, have the opportunity to learn skills and techniques in wound management by sharing good practice and being able to access training programmes that are specifically tailored to develop clinical skills in wound care.

In relation to the scenario presented of the 8 year old child with the small head laceration, he was assisted to the local hospital by the ambulance service so that his head laceration could be glued, however utilising the paradigm that the ambulance service is a mobile health resource, able to provide an increasing range of assessment, treatment and diagnostic services (Department of Health, 2005) the focus will now move on to the alternative approach to attending the local acute hospital and will present the argument that pre hospital treatment and wound care would have been more appropriate in this instance.

Pre Hospital Triage

A large number of people sustain head injuries and head wounds each year many of which are sufficiently minor to not require medical attention (National Collaborating Centre for Acute Care, 2007) ; as an alternative to transporting an individual (child or adult) to hospital for the assessment and treatment of a head wound, the health professional from the ambulance service may have been able to deliver care to the patient within their own home, thus supporting the ideology of ambulance services being a mobile health resource.

The paramedic would have to make an assessment of the child to ascertain how the wound was inflicted, assess the child’s neurological status by using the paediatric version of the Glasgow Coma Scale (Jennett and Teasdale, 1974) and make a record of the child’s baseline observations for future reference if there was an acute change to the patient which required further intervention. The assessment and triage of the patient would also provide an opportunity for the health professional to identify any factors that if present would indicate the immediate transfer of the child to the hospital setting. These factors include the presence and reporting of; vomiting, headache, loss of consciousness, amnesia, seizure and neurological change, evidence of skull fracture or head injury, injury that was caused by high impact, drug or alcohol intoxication, irritability or altered behaviour or if the patient has had previous cranial neurosurgery or head injuries (NCCAC, 2007; NICE, 2007).

In the case of the 8 year old child, the only report that may prompt the paramedic to transport the child to hospital may be the GCS (Jennett and Teasdale, 1974) that was recorded as 14/15 and the report of the laceration hurting a little, however with the triage identifying that the child (corroborated by an appropriate adult) had not experienced or reported any of the factors that would indicate evidence of a head injury requiring emergency or even urgent treatment in the acute hospital setting, the triage may indicate that the treatment options may be reduced to being delivered within the home environment.

Treatment

The laceration to the child was originally treated in the emergency department with Dermabond which is a cyanoacrylate tissue adhesive that forms a strong bond across apposed wound edges, allowing normal healing to occur below (Bruns and Worthington, 2000). This treatment could have been delivered efficiently within the patient’s own home by the paramedic and by doing so may have kept health care practitioners and resources from the acute hospital and NHS focused on delivering care to other individuals whose needs had been assessed to be greater.

Legal and Ethical Considerations

The paramedic scope of practice is the documented area or areas of the profession in which the knowledge, skills and experience to practise lawfully, safely and effectively, is structured in a way that meets agreed standards and does not pose any danger to the public or to the paramedic. As long as the paramedic exercises self governance in ensuring they are practising safely and effectively within the given scope of practice and do not practise in the areas where they are not proficient to do so, this is not advocated to be problem in relation to performing within the professional scope of practice (Health Professions Council, 2007).

Legal frameworks are in place for the paramedic to adhere to and understand to ensure their clinical practice is legitimate as patients have the legal right to make their own health care decisions even if the paramedic believes they have the clinical skills and abilities to improve the health of the individual. However, poor health can jeopardize people’s ability to defend their legal rights and this is the reason why legal frameworks, such as the Mental Capacity Act (2005) or the Children’s Act (2004), support individuals to maintain their legal rights and gives direction and a framework for health care professionals to ensure appropriate action is taken to protect both the service provider and the proposed recipient of the service.

Ethics are not part of a legal or legislative framework but are more focused on how, for the purpose of this assignment, the healthcare professional makes clinical decisions and judgements when involved in the process of patient care. Ethics are important for a number of reasons. Firstly, ethics are important because they give us a baseline for understanding the concepts of right and wrong. Ethics help us to have a ready understanding of how to react to a certain situation long before that situation happens and having the ability to provide ethical reasoning in situations which are not straight forward or present as challenging to decision making processes.

Legally, in the situation we have focused on during the course of this essay, it would be unlawful for the paramedic to commence treatment on the child’s head wound without consent. As a child below the age of 16 is legally classed as a minor then consent to treatment should be obtained from the child’s relative or appropriate adult representing the child’s interests. Additionally it would be ethically wrong to use, as an example, a new treatment for the closure of head wounds that was part of a clinical trial without advising the patient and their adult representative of the research process and explain the risk/ benefit issues. If the paramedic attending to the child had not kept up to date with mandatory training on wound care or had not received any training on child and paediatric pre hospital care it would be un-ethical for the paramedic to continue to treat the child, the paramedic would be in breach of their professional scope of practice and there may be legal consequences if any action taken by the paramedic results in further injury or damage to the patients health and welfare.

Conclusion

In order for ambulance services and paramedics to deliver the portable healthcare service for the NHS with service developments including mobile health resources, able to provide an increasing range of assessment, treatment and diagnostic services (Department of Health, 2005), it has become apparent that paramedics have to develop and increase their knowledge and scope of practice to ensure that these changes can be delivered. Evolving service provision must address the training needs of the care providers to ensure that patients continue to receive high quality evidence based health care that is delivered in a variety of settings, from the acute hospital to their own homes.

Wound care is one element of service provision that paramedics and ambulance service personnel are trained in addressing and in the scenario for this assignment the wound care intervention was assessed to be relatively straight forward therefore clinical decision making based on the professionals scope of practice and ethical reasoning supported the decision for the paramedic to treat within the patients home environment.

In more complex situations, where the wound care requires more advanced intervention it is essential for the paramedic to have achieved a level of competence in the management of wounds and injuries for their professional scope of practice to remain relevant. The importance of training and skill development ensures levels of anxiety remain low and clinical competence and decision making remains of the highest quality.