CHRONIC CARE NURSING

IN PREHOSPITAL
SETTINGS
Ns. Suryanto, S.Kep., M.Nurs, PhD.
Content
• Global causes of death
• Key facts of chronic diseases
• Prehospital care providers VS chronic ill patients
• Community paramedicine
• Indonesia, where are you?
Key facts of chronic diseases
• Chronic diseases also known as non-communicable diseases (NCDs)
• The main types of NCDs are
• Cardiovascular diseases (i.e heart attacks, hypertension, stroke)
• Cancers
• Chronic respiratory diseases (i.e COPD, asthma)
• Diabetes

• NCDs kill 41 million people each year, equivalent to 71% of all deaths globally
• Each year, 15 million people die from a NCD between ages of 30 and 69 years; over
85% of these “premature” deaths occur in low and middle income countries
WHO (2018)
Key facts of chronic diseases (2)
• Most NCD deaths (WHO, 2018)
LMIC and NCDs
• Poverty is closely linked with NCDs.
• The rapid rise in NCDs is predicted to impede poverty reduction initiatives in low-
middle income countries (LMICs).
• Vulnerable and socially disadvantaged people get sicker and die sooner than
people of higher social positions, especially because they are at greater risk of
being exposed to harmful products, such as:
• Tobacco
• Unhealthy dietary practices, and
• Have limited access to health services
(WHO, 2014)
Non-communicable Diseases Progress Monitor (WHO, 2017)
 WHO Global NCD Action Plan 2013 – 2020

Voluntary Global Targets:

Prehospital care providers VS chronic ill
patients
• American context (Dainty, 2018)
• Patients with chronic illnesses have an array of complex needs but they don’t always
require hospital visits or emergency care
• Most chronically ill patients surveyed did not want to end up in emergency rooms, where
they can experience long wait times and end up exposed to illnesses that can complicate
their own conditions further
• But there is often no other way for them to get the care they need, and they are forced
to call an ambulance
Prehospital care providers VS chronic ill
patients (2)
• American context (Dainty, 2018)
• The three most common chronic diseases in Canada:
• Diabetes mellitus (DM),
• Congestive heart failure (CHF), and
• Chronic obstructive pulmonary disease (COPD)
are on the rise and cost the Canadian health care system billions of dollars every year, including:
• The cost of 911 system utilization
• Emergency department (ED) visits, and
• hospitalizations
• One strategy is the development of community-based paramedic outreach programs in
partnership with primary care, hospital emergency, and long-term homes, and
integrated with community resources
Community paramedicine
• 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
(Institute of Health Economics Alberta Canada, 2017)
Community paramedicine (2)
• It has been implemented in:
• Australia
• Canada
• the United Kingdom, and
• the United States
The Focus of Community Paramedicine
• Community paramedics generally focus on:
• Providing and connecting patients to primary care services
• Completing post hospital follow-up care
• Integration with local public health agencies, home health agencies, health systems, and
other providers
• Providing education and health promotion programs
• Not duplicating available services in the community
(Garza, 2018)
Benefits of Community Paramedicine
• Benefits:
• Reducing 9-1-1 requests for non-urgent and non-transport services
• Decreasing the down time between calls, exercising medical skills, and improving access
to health providers

• In Milwaukee, State of Winconsin, USA

• Prior the implementation of CP: 4,288 out of 62,763 calls (7%) from chronically ill
patients
• From October – December 2015, the calls decreased 26%
• 2016, the calls decreased 56%
• 2017, the calls decreased 62%
(Garza, 2018)
Services provided by community
paramedics
• Level One
• Assistance with mobility and activity
• Assistance with oxygen equipment
• Assistance with administration of inhaled respiratory devices
• Measure vitals against set criteria
• High-level medications compliance
• Fall assessment
• Support for group medical assessment and/or education
• Support discharge planning from hospital care
• Infection prevention and control
• Health system navigation
Services provided by community
paramedics (2)
• Level Two:
• Chronic disease monitoring:
• Oxygen administration
• IV therapy
• Blood glucose monitoring
• Advanced monitoring methods (i.e spirometer)
• Immunization
• Antibiotic administration
• Lab specimen collection
• Suture removal
• Health and safety teaching
Services provided by community
paramedics (3)
• Level Three:
• Chronic disease management:
• Post-stroke assessment
• Post-discharge monitoring
• Monitoring patient condition
• Assessing pain level
• Catheter and colostomy care
Services provided by community
paramedics (4)

(Catalyst Research and Development Inc., 2017)

Indonesia, where are you?
• Permenkes (Ministry of Health Regulation) no 19/2016 regarding Sistem
Penanggulangan Gawat Darurat Terpadu/SPGDT (Comprehensive System of
Emergency Management) on April 2016
• For the implementation of the SPGDT, it needs:
• National Command Centre (Jakarta, Ministry of Health)
• Public Safety Center in each city of Indonesia
NCC and PSCs

22
Indonesia, where are you? (2)
• The PSCs must be established within 2 years after the launch of the regulation
• There were 124 PSCs out of 514 cities in Indonesia by December 2017
• Malang City? Launched PSC 119 end of last year. Well-implemented?
• What about other cities?
Indonesia, where are you? (3)
• Most prehospital patients are transported to hospital using public transport or
private car without sufficient care during transportation
• Other patients are retrieved by ambulances provided by hospitals or puskesmas
(Community Health Centres), and staffed by a driver and an ambulance nurse
Indonesia, where are you? (4)
• There is no paramedic profession in Indonesia
• Currently, emergency nurses are responsible for providing the majority of
prehospital care
• However, there is no formal education or course for those emergency nurses who
staff an ambulance
Indonesia, where are you? (5)
• Nurses at puskesmas has an important roles in
managing patients with chronic diseases at the
community level
• If developed countries have Community
Paramedics, Indonesia has community nurses
• Empowering community nurses in managing
chronic ill patients in regular basis and emergency
situation is essential for Indonesia
Universitas Brawijaya, what about you?
• Developing a paramedic nurse course for Indonesia, 2015 (funded by DFAT Australia)
• Piloting the ambulance nurse course in Indonesia, 2016 (funded by DFAT, Australia)
• Resuscitation Academy (RA) 10-Step Implementations in the PAROS Group, 2018 (funded
by PAROS Singapore)
Indonesia, what next? Take your turn, now!
References
• BC Emergency Health Services. 2017. Community Paramedicine in British Columbia: Improving health care in rural and
remote communities
• Catalyst Research and Development Inc. 2017. BC Emergency Health Services Community Paramedicine Initiative:
Interim Evaluation Report.
• Dainty, KN., Seaton, MB., Drennan, IR. Morrison, L. 2018. Home Visit-Based Community Paramedicine and Its Potential
Role in Improving Patient-Centered Primary Care: A Grounded Theory Study and Framework. Health Services Research.
On Press. First published 15 march 2018
• Garza. J. 2018. 911 calls from the chronically ill drop after Milwaukee launches community paramedic initiative.
• Institute of Health Economics Alberta Canada. 2017. Community Paramedicine: program characteristics and evaluation.
• World Health Organization. 2017. NonCommunicable Diseases: Progress Monitor 2017.
• World Health Organization. 2014. Global Status Report on Noncommunicable Diseases.
• World Health Organization. 2013. Global Action Plan for the prevention and control of noncommunicable diseases 2013-
2020