**Community Paramedicine Restricted/Rapid Review Protocol** ------------------------------------------------------- Community paramedic roles have evolved over the last twenty years across the globe. Within the United Kingdom, paramedics with extended skills within ambulance services sought to treat more patients in the community from 2002 (1) At a similar time in Nova Scotia, community paramedics worked alongside nurses and family physicians in a home-visiting model (2), and evidence of rural paramedics adopting a community approach has been present in Australia for at least a decade (3). Now, such programmes are widely implemented across Australasia, Canada, United Kingdom and the United States of America. The main drivers for the community paramedicine model have been the changing paramedic service caseloads that reflect aging populations, declining access to other health services and an increasing recognition of paramedic capabilities. These developments provide an opportunity for community paramedics to be more widely employed across the health system in ‘non-traditional’ roles. These non-traditional roles aim to meet the needs of disadvantaged communities who often lack access to high-quality emergency health services or primary health care. For health services looking to implement community paramedicine programs there can be many factors to navigate, and the siloed nature of healthcare means many programs are built without consultation with the wider experience base both domestically and internationally. This leads to difficulties for regulatory bodies when looking to define scope of role, educational entrance requirements and clinical governance and supervision requirements for community paramedicine programmes. This restricted review will provide a collation of evidence to support the introduction of community paramedicine into any jurisdiction with evidence to support decision making for any governing bodies. **Condition or domain being studied** Community paramedicine programs as well as community paramedicine training and education programs. **Comparator(s)/control** There is no comparator. **Main outcome(s)** The primary outcomes of this review are to classify past and current community paramedicine programs. We will conduct a restricted review of the literature using the methodology recommended by the Cochrane Rapid Reviews Methods Group (4). The review will focus on community paramedicine literature published from 2001* through to the present, and will review evidence on the following topics: ● Education including entry-level requirements ● Models of delivery to include clinical governance, supervision, and other structural supports ● Outcomes from community paramedicine programs ● Scope of role *The timeframe limit for included studies is utilised as relevant literature pertaining to community paramedicine does not predate the roles inception which is at earliest 2001 **Review question** What is the international evidence for community paramedicine: ● Education including entry-level requirements ● Models of delivery to include clinical governance, supervision, and other structural supports ● Appropriate outcomes from community paramedicine programs (such as quality of life, patient satisfaction, and economic impact) ● Scope of role **Searches** We will search the following electronic bibliographic databases: • CENTRAL • ERIC • EMBASE • MEDLINE • The CADTH Grey Matters toolkit (5) will be used to guide grey literature searches for agency reports, international organisation reports, and Google Scholar searches ***Search strategy*** This search strategy is a piloted and validated existing search strategy from Eaton et.al (6, 7), which has been modified to suit the requirements of this study. Medline (Ovidsp) example- (search strategy will be adapted to suit each database): 1. Allied Health Personnel/ and emergenc*.mp. 2. Emergency Medical Technicians/ 3. (paramedic* or ((emergency or ambulance) adj3 (technician? or practitioner? or staff* or personnel or workforce))).tw. 4. 1 or 2 or 3 5. exp General Practice/ 6. general practitioners/ or physicians, family/ or physicians, primary care/ 7. Primary Health Care/ 8. Community Medicine/ or Community Health Services/ or Rural Health Services/ 9. After-Hours Care/ 10. Ambulatory Care Facilities/ 11. Office Visits/ 12. ((family or general) adj3 (practi* or doctor? or physician?)).tw. 13. (primary adj (care or healthcare or "health care")).tw. 14. (community adj2 (care or medicine or service?)).tw. 15. ("out of hours" or ooh or walk in or walk-in).tw. 16. ((health* or medical or ambulatory) adj2 (centre? or center? or clinic?)).tw. 17. *Triage/ 18. triage.ti. 19. (Remote Consultation/ or Triage/) and Telephone/ 20. exp Call Centers/ 21. (helpline? or help line? or hotline? or hot line? or call centre? or call center?).tw. 22. (telephone? adj3 (service? or centre? or center? or triage)).tw. 23. ((enhanc* or expand*) adj3 role?).tw. 24. 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15 or 16 or 17 or 18 or 19 or 20 or 21 or 22 or 23 25. 4 and 24 26. ((community or primary care or primary health care or primary healthcare) adj3 paramedic*).tw. 27. 25 or 26 28. limit 27 to yr="2001 -Current" **Types of study to be included** Articles of all types that discuss community paramedicine will be included from the peer-reviewed and grey literature*. Only studies published in English will be included. **this does not include conference abstracts or magazine articles* **Definitions and screening criteria** Studies will be selected for inclusion against strict eligibility criteria. Justification for the eligibility criteria is set out below: **Population** This restricted review will focus on paramedics working within community paramedicine programs or equivalent only. The definition for community paramedicine, to be used in the absence of a global consensus, is that provided by the International Roundtable on Community Paramedicine which defines community paramedicine as: “Community paramedicine is a model of care whereby paramedics apply their training and skills in ‘non-traditional’ community-based environments, often outside the usual emergency response and transportation model. The community paramedic practices within an ‘expanded scope’, which includes the application of specialized skills and protocols beyond the base paramedic training. The community paramedic engages in an ‘expanded role’ working in non-traditional roles using existing skills.” (8) *Country of Origin* There is no global regulation, or definition, of a paramedic. However, similarities exist for paramedics working in Australia, Canada, Finland, the Republic of Ireland, the United Kingdom, and the United States of America. Therefore, papers exploring community paramedicine from these countries will be included. Inclusion/exclusion criteria **Inclusion:** community paramedicine programs that have been previously, or are currently, in operation (this includes mixed-response models whereby paramedics collaborate with or work alongside other healthcare professionals). **Exclusion:** programs that are not community paramedicine (i.e., ambulance-based retrieval services, home visit by nursing or general practitioners). **Study design** No limits to study design have been included in this restricted review. **Screening and data extraction** The search strategy will be conducted through the databases previously described above. Results will be uploaded into Covidence screening software and duplicates will be removed. Title and abstract screening will then be conducted by two research team members independently with conflicts resolved by a third. Full-text screening of the remaining studies will the occur independently by one author with a random 20% sample to be audited for verification by a second author. Searching of reference lists and forwards reference chaining of final included studies will then be conducted via the use of “citationchaser” software (9) as a final step. Data from each included study will then be extracted independently by one author. As has been deemed acceptable for restricted reviews (10), a random 20% sample will be audited for verification by a second author. A data extraction form created by the authors, informed by the Cochrane handbook for systematic reviews (11) will be utilised for this restricted review. Data extracted will include study design information such as: ● Study type ● Setting ● Duration ● Sample size ● Scope of role ● Education including entry-level requirements ● Models of clinical governance ● Models of clinical supervision ● Outcome data **Risk of bias (quality) assessment** One reviewer will independently assess the risk of bias in included studies, this will be verified by a a random 20% sample audit by a second author. The Mixed Methods Appraisal Tool (MMAT) (12) will be utilised to assess the risk of bias. **Strategy for data synthesis** A narrative synthesis of findings from the included studies will be completed. The narrative synthesis of the included studies will be presented in text and table form. **References** 1. College of Paramedics. Journey of the College. 2021. 2. Martin-Misener R, Downe-Wamboldt B, Cain E, Girouard M. Cost effectiveness and outcomes of a nurse practitioner-paramedic-family physician model of care: The Long and Brier Islands study. Primary Health Care Research & Development. 2009;10:14-25. 3. Mulholland P, Stirling C, Walker J, editors. Roles of the rural paramedic-much more than clinical expertise. 10th national rural health conference; 2009: Citeseer. 4. Garritty C, Gartlehner G, Nussbaumer-Streit B, King VJ, Hamel C, Kamel C, et al. Cochrane Rapid Reviews Methods Group offers evidence-informed guidance to conduct rapid reviews. Journal of clinical epidemiology. 2021;130:13-22. 5. Drugs CAf, Health Ti. Grey matters: a practical tool for searching health-related grey literature. Ottawa, ON. 2015. 6. Eaton G, Wong G, Tierney S, Roberts N, Williams V, Mahtani KR. Understanding the role of the paramedic in primary care: a realist review. BMC medicine. 2021;19(1):1-14. 7. Eaton G, Wong G, Williams V, Roberts N, Mahtani KR. Contribution of paramedics in primary and urgent care: a systematic review. British Journal of General Practice. 2020;70(695):e421-e6. 8. Wingrove G. International roundtable on community paramedicine. Australasian Journal of Paramedicine. 2011;9(1). 9. Haddaway N, Grainger M, Gray C. citationchaser: An R package and Shiny app for forward and backward citations chasing in academic searching. 2021. 10. Plüddemann A, Aronson JK, Onakpoya I, Heneghan C, Mahtani KR. Redefining rapid reviews: a flexible framework for restricted systematic reviews. BMJ evidence-based medicine. 2018;23(6):201-3. 11. Higgins JP, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, et al. Cochrane handbook for systematic reviews of interventions: John Wiley & Sons; 2019. 12. Hong QN, Fàbregues S, Bartlett G, Boardman F, Cargo M, Dagenais P, et al. The Mixed Methods Appraisal Tool (MMAT) version 2018 for information professionals and researchers. Education for Information. 2018;34(4):285-91.