One of the measurements that many EMS systems use to determine if they are “doing it right” is their survival rate for cardiac arrest patients. These numbers are broken down in many different ways but the accepted “standard” seems to be witnessed arrest with a shockable rhythm (ventricular fibrillation or ventricular tachycardia). In other words, the patients with the best possible chance at survival.
One of my current tasks in my system is entering all of our data into the CARES registry so that our patients can be matched with their hospital outcome and our system performance can be tracked for cardiac arrests. Typical of most quality improvement projects, part of this one involves figuring out how to do what we do better.
Over at MedicSBK, there’s a post entitled “Doing it Better” that looks at precisely this idea. In this post, Scott contrasts his system with that of Wake County in North Carolina. I have been lucky enough to hear Brett Myers speak about cardiac arrest care and the approach that his system takes is revolutionary and it works. By performing CPR only on scene and packaging a patient for transport only after sustained return of circulation, they are locking their crews into focusing on high quality chest compressions. This, along with defibrillation, is the only treatment that has been PROVEN to help cardiac arrest victims. I say good for them!
I recently began analyzing the quality of compressions that our crews perform in conjunction with our first response agencies. A quick Twitter poll leads me to believe that many EMS systems are not performing detailed analysis of this important component of care. Our findings have mirrored Dr. Myers views on when and where to treat these patients: despite the best efforts of everyone involved, CPR quality suffers during transport and lengthy pauses in CPR are not uncommon. The conclusion? We should not be transporting under CPR! Treat these patient where they drop.
I’m lucky in that my crews have the latitude to remain on scene during resuscitation. We transport very few of our cardiac arrest patients and usually only after regaining pulses. Thanks to Scott for bringing this up about his system. I hope that we can all move towards treatment algorithms that closely mimic Wake County and that allow us to provide optimal care in the optimal setting.
What about your system? Do you routinely transport during CPR? Do you wait for a certain length of ROSC before transporting? Let me know in the comments.
In the kitchen that is. Over at JEMS, Guy Haskell has an article about a patient with suicidal ideation who evidently requires no less than 10 fire, police and EMS employees to treat her. The article brings up an interesting question: How many providers do you REALLY need on scene?
Having gone from a system that had up to 6 medics on every medical call (and more on traumas) to a system that only has two from the ambulance (and many calls get no first responders), I’m not sure that there is an easy answer. Predictably, the comments section of article devolves into an argument for or against ALS fire/ALS first response/public vs. private EMS/whatever else we want to argue about. That’s unfortunate because I think Haskell raises a legitimate concern. Driving emergency vehicles is dangerous. Driving them with lights and sirens is more dangerous. And not just to us but to the public as a whole. Putting everyone at risk under the guise of “first doing no harm” is ridiculous. We owe it to ourselves and our public to find a better way.
Medical priority dispatching does go a long way towards reducing the number of vehicles running code around the city, but I don’t think it goes far enough. Why not have units (first response or transport, I don’t think it matters) treat and release more patients? Why not only call a transport unit if the patient actually NEEDS transport? What about alternate destinations by alternate means? Say, for instance, your patient has suicidal ideations but has not made an attempt and is cooperative? Couldn’t you use a single responder to take that patient directly to the psychiatric facility? The vehicle would, of course, have to have a screen and door handles removed and what not, but I don’t see a reason why that couldn’t work. Suddenly, Haskell’s patient has one, maybe two, personnel on scene rather than 10. Cost savings and improved safety, all in one package.
Obviously this is the ideal. Some areas are moving towards such a model, but there is a long way to go. What about you? What do your ideal system look like? Totally ignore tradition for a moment and forget the way things have always been done. Design the perfect medical response and share it with the rest of us.
One of the hallmarks of advanced paramedic programs and really the future of EMS in general is the ability of providers to determine if a patient NEEDS to go to the emergency department. If the goal of such programs is to reduce the utilization of ED resources, field practitioners must be able to safely determine if alternate transport or non transport is appropriate.
Approximately a year ago, the National Association of EMS Physicians (NAEMSP) issued a position statement on this topic and determined that:
• There may be potential for EMS providers to avert unnecessary emergency department
visits by providing a medical assessment to determine whether patients can safely be
managed without emergency transport to an acute care facility.
• While evidence supports determination of necessity of transport to acute care facilities
by EMS providers in certain select situations, in general evidence is currently lacking to
establish that EMS providers can universally make determinations about necessity of
• Prior to adoption of EMS provider initiated non-transport programs, there should be
evidence in the peer-reviewed literature that demonstrates that EMS initiated nontransport for the specific situation is a safe practice.
• A prerequisite to EMS provider decision to not transport requires at minimum:
additional education for the providers, a quality improvement process, and stringent
The entire document can be viewed here (PDF).
I appreciate a few aspect of this position statement. First, the NAEMSP acknowledges that EMS plays a pivotal role in the reduction of utilization of ED resources for non-acute patients. Second, the position paper calls for evidence-based standards and adequate training and oversight when developing such programs. In the current state of EMS, however, there is little incentive to develop non-transport guidelines as there is no reimbursement for patients that are not transported.
In another position paper published at the same time, the NAEMSP addresses issues surrounding reimbursement:
• When callers access 9-1-1 (or a similar emergency call center) requesting emergency
medical response, third party payers—including federal and state programs, their agents,
and private insurers—should provide fair and reasonable reimbursement for those
• Retrospective determination that a transport was not medically necessary should not
result in denial of payment. Payment for 9-1-1 emergency response should be based on
the prudent layperson standard.
• When EMS systems that possess adequate educational, medical direction and quality
improvement resources choose to implement EMS-initiated non-transport policies
(including, but not limited to, treat and release protocols, termination of resuscitation or
on-site care for mass gatherings), third party payers should consider the relative cost
savings associated with providing on-scene care without subsequent transport, and
provide fair and reasonable reimbursement for those services
The entire document can be viewed here (PDF).
Note, in particular, the last bullet point. A system that takes the effort to building an appropriate non-transport program should be reimbursed fairly. Makes good sense to me.
The resource document for both of these position statements can be found here (PDF).
So what do you think? How close are we to researching the ability of paramedics to make a determination not to transport? Are there cases where we can do this already? Does your system get reimbursed for non-transports? Let me know in the comments.
Community health departments have a variety of resources for patients suffering from chronic disease. It may be that you know about some of these resources in your own community. If not, I recommend that you reach out to the Department of Public Health so that you or your agency can compile a list for patients. Doing so can increase the general health of the community but can also connect patients to these resources before they suffer lasting consequences. Often, patient who do not utilize their primary care physician are not adequately screened for diseases like hypertension or diabetes. If these patient utilize the 911 system, EMS practitioners have an opportunity to perform these screenings.
A study out of King County in Washington published earlier this year looked at the ability of EMS to identify patients at risk for uncontrolled hypertension. The study can be found here (PDF).
It is important to note that this was a feasibility study only. The researchers were looking at whether it was possible to develop a program in which first responders identified at risk patients. This study did not look at outcomes or improvement in health. That said, the results were interesting. Survey respondents seemed interested in the program with 82% stating that they would be comfortable having their blood pressure screened at a local fire station. The next obvious step is to implement a program and track a population for changes. Compliance with medication, reduced ED visits and improved overall blood pressure could be outcomes to consider.
Does your agency perform health screenings outside of calls? Do you have a list of health and social resources you can provide on scene? What has the response from patients been? Let me know in the comments.
I recently had the opportunity to attend the Michigan Community Paramedicine Summit in Mt. Pleasant. As I’ve written previously, the idea of community paramedics has received increasing traction of late. More and more states around the country are looking at adopting these types of programs as healthcare costs increase and funding and federal reimbursement falls. There is no question that EMS can help to play a role in remedying this situation.
The Paramedic Summit was sponsored by the Michigan Association of Ambulance Services. Presenting were Gary Wingrove, Chris Montera and Anne Robinson. Attendees were provided background on various community paramedic programs around the country by Wingrove while Montera and Robinson presented the Eagle County, Colorado model and how their program was developed.
After attending the summit, I have a few thoughts. First, I absolutely feel that EMS has a role in the future of preventative/primary care. EMS practitioners are well positioned to have resources available 24 hours a day and have been raised around the idea of standing orders and autonomy. Second, I support the idea of a college-based training program. There is a healthy debate on the social media forums about whether EMS providers “need” a college degree. This debate goes hand-in-hand with the notion that we need to move EMS towards an actual career rather than a job stop on the way to a fire or nursing career. Go get education, seriously.
While I like the idea of a standardized educational curriculum, I hesitate at the idea of tying such a curriculum to the term “community paramedic” in a mandatory sense. I maintain that there are many systems around the country in which paramedics are filling the needs of their population outside of standard transport to the emergency room. To me, those programs accomplish the spirit of a “community paramedic”. All that said, the IRCP is willing to provide its curriculum free-of-charge and from what they showed us, that curriculum does an excellent job of incorporating experience from public health, social services and EMS into one clearing house.
During the talk, I found myself thinking of ways to implement a version of this program in my own community. Both Chris and Gary preached about finding a need. I can think of a few needs my community has, but there have to be others I haven’t even imagined. Perhaps the first step is reaching outside of my normal EMS-centered circle to find partners in the community. At any rate, this is an exciting possibility that I look forward to exploring. In the spirit of informing myself and then my readers, over the next several weeks I will be reviewing some of the currently implemented community paramedic programs and brainstorming ways that these models can be incorporated in my largely urban system.
What are the needs in your community? Does your system address those needs? Do you provide any sort of preventative care when you run 911 calls? What about connecting patients to services outside of medicine? Let me know in the comments.
At my real job the other day, I was offered a chance to participate in a state-wide summit on community paramedicine. Our state ambulance leadership is interested in understanding how other community paramedic programs are operating and whether this model is appropriate for Michigan.
This got us talking around the office about what, exactly, a community paramedicine program is. Community paramedicine has been in the news lately as state after state (most recently Maine) looks at the usefulness of developing such a program. Issues with funding and reimbursement as well as educational standards not withstanding, let’s look at what a community paramedic was intended to be. According to communityparamedic.org:
The Community Healthcare and Emergency Cooperative (CHEC) formed in July 2007 to address critical health care shortages in rural and remote areas—specifically by developing a new community health provider model.
Now this is all well and good, but I work in a largely urban/suburban system. What if I want a community paramedic program? A search for the term “urban” on the CHEC site turns up:
Now the International Roundtable on Community Paramedicine site states:
While its focus is on rural and remote medicine, the lessons learned may prove beneficial to the better provision of urban health care.
And I couldn’t agree more. The goal of a community paramedic program seems to be providing care to fill a gap in a particular community. While many of the existing and proposed programs are focused on the rural environment, why can’t we do the same in urban systems? In fact, what if we’re already doing this in an urban system?
When I worked in Alameda County, my manager Mike Taigman developed a program to send EMTs and paramedics into the homes of chronic adult asthma patients to work on educating them in “asthma-proofing” their homes. The county offered a similar program for children, but nothing for adults. Find a need and fill it.
Here in Grand Rapids, crews are able to take indigent and intoxicated patients to a sobering center staffed by nurses and EMTs to reduce load on the local emergency rooms. The hospitals subsidize the cost of the program because it provides a direct benefit to the community. Find a need and fill it.
At the end of the day, the term “community paramedic” is more of a buzz word than anything else. With state legislators becoming involved we are at an increased risk of building a “one size fits none” program by blindly patterning it off of existing programs. Each community needs to define what they need from their EMS practitioners both for emergency and non-emergency care. If we rush into implementing community paramedicine before we establish a usefulness and a need, then all we will do is prove that a system which worked in rural Minnesota doesn’t work in metro New York City. We are so interested in changing what we do now that we haven’t looked carefully at what we ARE doing that takes us outside traditional 911 response.
What about your system? Do you function outside of the traditional EMS realm already? Are you considering a community paramedic program? Who is guiding that process? Let me know in the comments.