The capabilities and scope-of-practice requirements of advanced life support practitioners undertaking critical care transfers: A Delphi study

Abstract

Background. Critical care transfers (CCT) refer to the high level of care given during transport (via ambulance, helicopter or fixed-wing aircraft) of patients who are of high acuity. In South Africa (SA), advanced life support (ALS) paramedics undertake CCTs. The scope of ALS in SA has no extended protocol regarding procedures or medications in terms of dealing with these CCTs. Aim. The aim of this study was to obtain the opinions of several experts in fields pertaining to critical care and transport and to gain consensus on the skills and scope-of-practice requirements of paramedics undertaking CCTs in the SA setting. Methods. A modified Delphi study consisting of three rounds was undertaken using an online survey platform. A heterogeneous sample (n=7), consisting of specialists in the fields of anaesthesiology, emergency medicine, internal medicine, critical care, critical care transport and paediatrics, was asked to indicate whether, in their opinion, selected procedures and medications were needed within the scope of practice of paramedics undertaking CCTs. Results. After three rounds, consensus was obtained in 70% (57/81) of procedures and medications. Many of these items are not currently within the scope of paramedics' training. The panel felt that paramedics undertaking these transfers should have additional postgraduate training that is specific to critical care. Conclusion. Major discrepancies exist between the current scope of paramedic practice and the suggested required scope of practice for CCTs. An extended scope of practice and additional training should be considered for these practitioners. There is currently a critical shortage of intensive and specialist care in South Africa (SA). [1] In fact, 77% of state healthcare facilities and 16% of private healthcare facilities do not have intensive or high-care capacity.[1] Owing to this shortage, adequate district and provincial healthcare might not be available in many areas, [2] necessitating frequent transfer of patients to urban tertiary centres for specialist care.Internationally, paramedics undertaking critical care transfers (CCTs) have extended scope of practice when compared with standard emergency paramedics in order to be equipped for these high-acuity patients.[3] Locally, however, all paramedics registered as advanced life support (ALS) practitioners may undertake CCTs. [4] No extended training or additional scope of practice is given to these paramedics who might need to intervene to stabilise patients for transfer.[4] Studies have shown that adverse events (AEs) during CCTs are significant and proportionate to the level of training and experience of the transferring practitioner. [5,6] A prospective 1-year audit conducted in SA in 2001 focused on CCTs of paediatric patients in a low-resource setting.[7] The study found that the transfers were predominantly undertaken by paramedics (82%) via road ambulance (76%). [7] It was found that a number of technical AEs such as inadequate monitoring, absent venous access, and malpositioning of e...

A national retrospective review of neonatal critical care transfers in dedicated critical care transport services in the private sector

“…The exact format of such a qualification, however, is yet to be determined. A previous study [18] has also suggested that an additional scope of practice is required to support the CCT of a neonate, and this suggestion is in line with the patient demographic and attachment and medication requirements of the patients described in this study.…”

Experiences of emergency care providers conducting critical care transfers in Gauteng Province, South Africa

“…The lack of a contextually relevant and universally accepted definition of a CCT results in a lack of standardisation of local CCT practices and support for the ambulance crews. [7,8] There seems to be ongoing confusion and debate as to whether the patient requiring transfer indeed warrants a CCT team, and if the team has the required qualifications, competencies, equipment and experience for the transfer. Internationally, CCT is usually reserved for high-acuity patients transferred between ICUs and is performed by specialist CCT teams.…”

“…In SA, CCTs of high-acuity patients are commonly conducted by advanced life support (ALS) providers. [7] The professional registering body in SA, the Health Professions Council of South Africa (HPCSA), further distinguishes between different ALS providers, allowing for registration on one of two registers (paramedic and emergency care practitioner (ECP)). Therefore, to perform CCTs, an ALS provider can either be qualified as a paramedic or an ECP.…”

“…ALS providers with limited training conduct CCTs of high-acuity patients in SA. [2,7] The aforementioned necessitated making use of purposeful sampling to ensure sources of rich and meaningful data. Limited healthcare resources solely aimed at CCTs further supported the sampling method and identification of participants for the focus group discussions.…”

“…[5,6] While CCTs comprise a significant part of the work of South African (SA) ambulance services, purpose-built ICU ambulances are not available in all areas, and the majority of local paramedic education and training programmes do not focus extensively on equipping their graduates to conduct CCTs. [7,8] This situation may explain anecdotal reports from EC graduates indicating that they feel less comfortable in undertaking CCTs than they do performing mainstream primary response duties. Despite these reports, no local or international literature could be found describing the experiences of EC providers involved in CCTs.…”