Transition in care from paramedics to emergency department nurses: a systematic review protocol

The objectives of this systematic review are to assess factors that mitigate or improve transitions in care from EMS practitioners to ED nurses and to identify effective interventional strategies that lead to improvements in communication and a reduction in adverse events.

Our review question goes beyond what works to understand the perceptions, attitudes, and beliefs of those directly involved in transitions in care. Based on a preliminary scoping search, we expect diverse observational and qualitative studies of transitions in care. As such, we will conduct a mixed systematic review (i.e., mixed studies or mixed methods review) [24, 25] by combining the findings of diverse primary studies within a single review to address overlapping review questions. This protocol adheres to the PRISMA-P statement [26] and has been registered with PROSPERO CRD42017068844.

The questions of relevance are as follows:

We will search DARE, MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, CINAHL, and Joanna Briggs Institute EBP electronic databases from database inception for English-language publications. Gray literature will be searched for in databases (Proquest Dissertation and Theses Global, Web of Science Conference Proceedings Citation Index, OAIster, OpenGrey, Canadian Health Research Collection), relevant organizational websites (e.g., National Emergency Nurses Association, Paramedic Association of Canada, National Association of EMS Physicians), and consultations with clinicians. We will visually search the electronically available table of contents of key emergency nursing and EMS journals that are not indexed in two of the identified databases. The search strategy was developed by an information scientist (KAH). Table 1 provides the provisional search strategy for MEDLINE. We will search the reference lists and cited bys of included studies and will provide our final list of included studies to EMS and nursing experts in emergency medicine to identify any further studies for inclusions. Records will be exported to EndNote X8 to facilitate data management, removal of duplicates, and finding full texts.

Prior to screening, we will conduct training and a calibration exercise with the review team to pilot and refine the screening tool in Excel. Titles/abstracts (level 1) will be independently screened by pairs of two reviewers. Disagreements will be resolved by a third reviewer. Full texts of potential studies (Level 2) will then be obtained and screening will be conducted in the same manner as level 1 screening.

The methodological quality of quantitative studies will be assessed using the Effective Public Health Practice Project Quality Assessment Tool [EPHPP; 29], which can be used to assess multiple study designs and has evidence of validity and reliability. [27] Each of six domains—selection bias, study design, confounders, blinding, data collection methods, and withdrawals and drop-outs—are rated as strong, moderate, weak, or not applicable. For qualitative studies, we will use the Joanna Briggs Institute Critical Appraisal Checklist for Qualitative Research. [28] This coherent tool performs well in assessing intrinsic methodological quality. [29] Ten domains are assessed as yes, not, unclear, or not applicable: philosophy, objective, data collection, data analysis, interpretation of results, theory or cultural location, researcher reflexivity, participant representation, ethical considerations, conclusion. For mixed methods studies, we will use both appraisal tools. All studies will be independently assessed for quality by two reviewers, and disagreements will be resolved through discussion; if consensus cannot be reached, a third reviewer will break the tie. While we will report on the results of this quality assessment, studies will not be excluded on the basis of quality alone.

To assess confidence in the evidence in the syntheses, we will use the GRADE [30] (each quantitative outcome) and CERQual [31] (each qualitative review finding). GRADE and CERQual findings will be presented in a summary of findings table.

Table 2 details the data items to be extracted from the full texts. We will use a template data extraction tool in Excel. After the review team conducts a calibration exercise with the extraction tool, one reviewer will extract study data; a second reviewer will verify the extracted data for accuracy. We will discuss discrepancies and consult a third reviewer if a discrepancy cannot be resolved through consensus. Studies that have been published in duplicate will be retained and assessed in full text; we will combine related papers from the same study and treat them as one study.

Should the quantitative data permit, a meta-analysis will be conducted using a random effects model in RevMan (standardized mean differences for continuous outcomes; odds ratios for categorical outcomes; 95% confidence intervals). We expect considerable heterogeneity between studies; thus, meta-analysis may not be appropriate. In this case, we will aggregate the quantitative findings with the qualitative findings using data-based convergent synthesis [24], whereby one synthesis will be conducted with all studies after we transform the quantitative findings into textual categories or themes. Study characteristics will be tabulated (frequency, proportion), and narrative synthesis [32] will be used to integrate and explore relationships within the data. Where studies have substantial conceptual overlap, we will apply thematic analysis [33] in three stages to translate and integrate findings. Studies will be imported into NVivo 11 for coding. [34] First, two reviewers will inductively code first-order (verbatim participant accounts) and second-order interpretations (author observations) from the extracted data. Next, the initial codes will be compared between studies and grouped to generate initial descriptive themes. Finally, we will generate analytical themes by considering how the descriptive themes relate. Revisions to the coding framework will be recorded to provide an audit trail.

Providing that there is sufficient information, we will consider comparisons of several subgroups: (1) study types, (2) paramedics and nurses, (3) different countries, (4) transitions in care at triage and bedside, and (5) barriers and facilitators. We will also conduct a sensitivity analysis to examine the influence of studies with a low quality rating on the robustness of review findings. [35, 36] To do this, our synthesis (with all studies) will be compared post hoc to a synthesis without the methodologically weak studies within NVivo 11 using source classifications/attributes. The criteria or threshold for low quality (e.g., data collection method, sampling) will be established a priori. This comparison can provide insight into whether the low quality studies contribute unique information and how they may impact the generalizability of the findings. [35]

We are using an integrated knowledge translation [37] approach for this review. Our multidisciplinary team includes representative knowledge users who are frontline healthcare professionals, health system decision-makers, knowledge synthesis methodologist, information scientist, researchers (nursing, emergency medicine, EMS, health science), and trainees. Our team co-developed the review question and protocol and will continue to be involved throughout the entire process, including developing a knowledge translation plan to accelerate the uptake of the findings of the review. This strategy will detail the audiences, strategies with anticipated timing, key messages and activities, targeted venues, and measures of success. The findings of this review will be disseminated through multiple mechanisms: (1) open access publication; (2) presentations at targeted scientific conferences (e.g., Western Emergency Department Operations Conference); (3) presentations to provincial decision-makers and healthcare professionals through the Emergency Strategic Clinical Network; (4) meetings with EMS, manager, and nurse educators in local EDs; and (5) infographic representing meaningful information about transition in care. If indicated by the findings, this review will also inform the development of a communication transition tool to facilitate transfer of essential patient information in a consistent manner.