Title: A Mixed Methods Investigation of Paramedic Independent Prescribing by Advanced Paramedics in Emergency and Urgent Care.
Funder: Health Education England

Abstract: Background Paramedic independent prescribing (PIP) is currently practised by advanced paramedics (APs). However, further research is required to evaluate the benefits and limitations within emergency and urgent care. Research Question:What are the benefits and the limitations of paramedic independent prescribing in emergency and urgent care? Research Objectives: 1) To evaluate the scope and scale of PIP in emergency and urgent care, including the range and frequency prescriptions and conditions treated. 2) To explore key stakeholder and AP views of the benefits and limitations of PIP in emergency and urgent care, alongside if/how it is contributing to patient care and service delivery. 3) To explore key stakeholder and AP views on training and education to support PIP4) To investigate if and how PIP has changed practice, confidence and autonomy. 5) To examine whether APs working in emergency and urgent care can access support for their prescribing decisions.Methods A mixed methods exploratory sequential design will be used.Work Package (WP) 1- Systematic Literature search and narrative review A systematic literature search will be undertaken, to identify, critically appraise and synthesise relevant independent prescribing (IP) research. This will inform data collection and analysis in WPs 2-4. A narrative review will be written, to evaluate the evidence base surrounding key areas of IP. These include any benefits and limitations of IP in emergency and urgent care, controlled drug restrictions, prescriber training and in accessing medical support.WP 2 - Semi structured interviews with key stakeholders A sample of key stakeholders will be interviewed to obtain insights into emerging key issues associated with PIP (Objectives 2 and 3). A framework approach to data analysis will be used.WP 3 - Case StudiesCase studies of PIP within an emergency department, an urgent care service and an ambulance Trust will be conducted. Data triangulation and cross case analysis will be undertaken to compare data within and across sites. Within each site: 3.1 PIP prescribing data from electronic databases such as the ePACT2 system for the previous twelve months will be analysed to address objective 1.3.2. To obtain data to address objectives 1-5, the practice of 2-4 APs will be observed at each site using non-participant observation over 4-6 shifts. The views of APs and other site-based health professionals regarding PIP will also be explored. Field notes will be generated, coded and categorised during analysis.WP 4 - Online questionnaire. Building on key issues from WPs 1-3, and to provide generalisable data on objectives 1-5, an online questionnaire will be administered to all APs using PIP in emergency departments, ambulance Trusts and urgent care settings.Timelines for delivery- Please also refer to research timetable. WP 1 -h; 04/2022- 08/2022 WP 2- 09/2022-12/2022 WP 3- 01/2023-05/2024WP 4 -h; 06/2024 - 12/2024 Anticipated impact and dissemination Through ongoing collaboration with the PIP key stakeholders, the research findings will inform future PIP policy and guidance. Dissemination will be achieved by publications in BMC Emergency Medicine, conference presentations and a study website.

Lay abstract: Background and AimsParamedics can now complete significant extra training to develop into advanced paramedics. This enables them to diagnose and treat a wide range of conditions. They provide care to patients in a range of NHS settings, such as ambulance services, out of hours urgent care settings and emergency departments.Following changes to the law in 2019, advanced paramedics can now prescribe medication to patients, once they have completed an independent prescribing course. It is hoped that this training will enable them to deliver better care to patients and manage a wider range of conditions.However, very little research has been carried out to investigate current paramedic prescribing work and practices and to establish if there are problems with this. For example, not all advanced paramedics are completing the recommended level of training before becoming prescribers. They are also not currently allowed to prescribe certain medications (known as controlled drugs), which include strong pain killers and sedatives. These are often needed in emergency and urgent care.This study will investigate how paramedic prescribing is currently being used in ambulance services, urgent care settings and emergency departments. This will evaluate if and how it enables advanced paramedics to provide better patient care and improve NHS services. Design and methodsI will use a range of research methods in this study. Following a review of relevant literature, experts and NHS leaders will be interviewed to explore their views about paramedic prescribing. Case studies (a detailed study) will then be undertaken in an emergency department, an out of hours urgent care setting and an ambulance service in the South West of England. At each site, data will be collected about the range of medications prescribed and the types of conditions treated. Advanced paramedics will be observed as they see patients and prescribe medication. An online questionnaire will then be sent to all advanced paramedics who are prescribing in urgent and emergency settings across the UK. This will capture the views and experiences of a much larger number of advanced paramedics.DisseminationThe findings of this research will be published in journals and presented at national research conferences. They will also be made available on a study website and social media. A summary will be written for the College of Paramedics to inform policies, guidelines and further research regarding paramedic prescribing. This will enable improvements to be made which in turn will benefit patient care.Patient and Public Engagement and Involvement (PPEI)Regular advice has been sought during the development of this application from a group of representatives who have experience in ambulance research PPEI. I have also sought advice from PPEI experts from the Research Design Service.I will continue to work with this PPEI group but also recruit additional members who have experience in receiving care from a prescribing advanced paramedic. To ensure an inclusive approach to PPEI, I will use translation and sign language services if required, plan events around participants preferences and schedules, utilise wheelchair accessible venues, use video calling where preferred and will offer re-imbursement for time and expenses.I will meet regularly with PPEI members, to ask for their advice and feedback on important aspects of the research. This includes seeking their advice on explaining the study and the reason for my observations with patients during the observation work. Input from PPEI members will be important when designing a study website and sharing the research findings with patients and the public. An experienced patient representative has also agreed to participate in the study management meetings to provide advice and feedback

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: GENERIC HEALTH RELEVANCE