Optimising road-based Intensive Care Paramedic crewing configurations: A conceptual framework

Background Prehospital intensive care is commonly delivered within tiered service delivery models. Road-based Intensive Care Paramedic (ICP) crewing varies across international contexts and national jurisdictions, yet the way these models are evaluated is often inconsistent and incomplete. The literature is narrowly focused on out of hospital cardiac arrest (OHCA), frequently infers efficiency from tiered models without rigorous evaluation, and rarely incorporates provider perspectives. Together, these limitations make it difficult for Emergency Medical Services (EMS) leaders to compare crewing models in a meaningful way. Objectives To present a theory-informed conceptual framework for the comparative evaluation of ICP crewing configurations using multidimensional outcome measures. Methods Framework development drew on a scoping review with systematic searching and screening and was theoretically grounded in aspects of the Quadruple Aim, labour economics, and institutional theory. It is intended for application to Australian road-based ICP crewing while remaining adaptable across EMS systems. Results The framework specifies four outcome domains: (a) patient outcomes (e.g. survival), (b) provider experience (e.g. workload, burnout, safety climate), (c) operational efficiency (e.g. response/scene times paired with meaningful outcomes), and (d) economic sustainability (e.g. cost, productivity, overtime/backfill). Each domain is supported by theory that helps explain why these outcomes matter and how they may interact. Conclusion The framework provides a structured approach to comparing road-based ICP crewing configurations across patient, provider, operational, and economic domains. Future research should test and refine the framework within the Australian EMS context.