BackgroundParamedics work in a highly complex and unpredictable environment which is characterized by ongoing decision-making. Decisions made by paramedics in the prehospital setting have implications for patient safety, transport, treatment, and health resource utilization. The objective of this study was; a) to understand how paramedics conduct decision-making in the field, and b) to develop a grounded theory of paramedic decision-making in the prehospital setting.MethodThis study was conducted using classical grounded theory. Paramedics (n = 13) with five or more years’ experience, who worked in a large urban center in Western Canada were interviewed. Field observations were conducted, each lasting 12 h, with five different ambulance crews. The data were analyzed and coded using the constant comparative method.ResultsThe resultant theory, Creative Adapting in a Fluid Environment, indicates paramedic decision-making is a fluid iterative process. Unpredictable and dynamic features of the prehospital environment require paramedics to use a flexible and creative approach to decision-making. The model consists of the three categories constructing a malleable model, revising the model, and situation-specific action. Two additional components, safety and extrication, are considered at each stage of the call. These two components in conjunction with the three categories influence how decisions are made and enacted.ConclusionParamedic decision-making is highly contextual and requires accurate interpretation and flexible cognitive constructs that are rapidly adaptable. Evaluation of paramedic decision-making needs to account for the complex and dynamic interaction between the environment, patient characteristics, available resources, and provider experience and knowledge.

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Triage RNs require appropriately designed triage environments and computer technology that enable them to secure real time knowledge of the ED to maintain situation awareness.

BackgroundEffective and efficient transitions in care between emergency medical services (EMS) practitioners and emergency department (ED) nurses is vital as poor clinical transitions in care may place patients at increased risk for adverse events such as delay in treatment for time sensitive conditions (e.g., myocardial infarction) or worsening of status (e.g., sepsis). Such transitions in care are complex and prone to communication errors primarily caused by misunderstanding related to divergent professional perspectives leading to misunderstandings that are further susceptible to contextual factors and divergent professional lenses. In this systematic review, we aim to examine (1) factors that mitigate or improve transitions in care specifically from EMS practitioners to ED nurses, and (2) effectiveness of interventional strategies that lead to improvements in communication and fewer adverse events.MethodsWe will search electronic databases (DARE, MEDLINE, EMBASE, Cochrane, CINAHL, Joanna Briggs Institute EBP; Communication Abstracts); gray literature (gray literature databases, organization websites, querying experts in emergency medicine); and reference lists and conduct forward citation searches of included studies. All English-language primary studies will be eligible for inclusion if the study includes (1) EMS practitioners or ED nurses involved in transitions for arriving EMS patients; and (2) an intervention to improve transitions in care or description of factors that influence transitions in care (barriers/facilitators, perceptions, experiences, quality of information exchange). Two reviewers will independently screen titles/abstracts and full texts for inclusion and methodological quality. We will use narrative and thematic synthesis to integrate and explore relationships within the data. Should the data permit, a meta-analysis will be conducted.DiscussionThis systematic review will help identify factors that influence communication between EMS and ED nurses during transitions in care, and identify interventional strategies that lead to improved communication and decrease in adverse events. The findings can be used to develop an evidence-informed transitions in care tool that ensures efficient transfer of accurate patient information, continuity of care, enhances patient safety, and avoids duplication of services. This review will also identify gaps in the existing literature to inform future research efforts.Trial registrationPROSPERO CRD42017068844

Creating evidence that is both scientifically rigorous and patient oriented in addressing patients' needs is essential to informing health-care professionals' practice and meeting patient needs. Patient-oriented research (POR) aims to address this 2-fold mandate by engaging and incorporating patients' voices throughout the research process through a variety of techniques. Currently, there is little methodological rigor or guidance to help qualitative patient-oriented researchers design, collect, and analyze patient data. Classical grounded theory (GT) is arguably one of the most rigorous qualitative research methods, focusing on the development of theory from data grounded in participants' voices. As such, classical GT is an ideal methodological approach for conducting POR due to its rigor, patient-oriented focus, and generation of an empirical model focused on the topic of interest. The purpose of this article is to describe the convergence and divergence between classical GT and POR, based on the current literature and pragmatically through an ongoing classical GT study focused on combat veterans' perspective on Operational Stress Injuries (OSIs). By describing the methodological principles and their implementation in a POR study, we provide readers with both substantive and practical knowledge to utilize classical GT in POR studies, particularly within study populations that may be averse to or experience challenges in participating in research. Classical GT therefore provides patient-oriented researchers with a pragmatic methodological framework for engaging patients and generating rigorous evidence.