EMS working in small hospitals, long term care

[tniuqs]

As some of you are aware, the province has taken over ambulance services in Alberta.

The EMS staff are also to work in the ER, under the supervision of the charge nurse in the ER, which right now means that medics cannot work to the full scope of their education, as here, a medic has a bigger scope of practice than a nurse does. Usually, there is not a doctor in the ER, as the doc is at the clinic, or just on call.

Annie: I have to know ... is their any updates with the ACP or EMT/PCP working to full scope of practice in the ER ?

Has HSAA or anyone filed a grievance about the RN coping an attitude in this turf war vs what is best for the patients needs ?

[zippyRN]

Can anyone confirm or deny if this is just in Canadian areas, or if this is more international in scope?

occasionally floated in the UK but never seems to happen, sometimes Hospital Resuscitation ( training and audit) Officers are Paramedics and they will come to crash call in the hospital or trauma calls in the ED and work as part of the team if needed

other ROs are Nurses or ODPs and do exactly the same.

some ECP schemes rotated ECPs of whatever background through Comms, on the road and ED / minor injuries units

[HERBIE1]

I realize this is an older thread, but I do have something to add. First, in my area, we do not have hospital based EMS service- it's either private or municipal/ fire based.

When paramedics started working in ER's as techs here, there happened to be a severe nursing shortage(a cyclic thing around here). Nurses welcomed the help for 2 reasons- first, we were paid far less than an RN so we were not initially perceived as a threat, and because they simply needed another warm body. The skills we were allowed to use varied wildly- depending on the hospital, the charge nurse and/or doctors. The usual rancor between the groups was generally not an issue because we were in their domain, and under their control.

Ironically, at the same time, the turf wars between prehospital EMS and RN's was in full blown crisis mode. Open hostility often existed, but I think the fact that so many ER's employed medics and EMTB's, the barriers eventually began to break down. The nurses began to see and really understand who and what EMS folks are, what they can do, and that we are not the enemy. Nurses are finally understanding that as a side job, working in an ER is fine, but not many EMS folks want to switch roles and become a nurse. Now, for career longevity and physical well being, more EMS folks ARE switching to a hospital based setting, but that's a relatively new trend.

Is it perfect now- hardly, but it is MUCH better. Yes, there are still a few miserable, old-timer RNs who will not give up the "war" but they are few and far between.

An example of how far we have come in this area:

Recently we learned about a personnel change in a local ER, which is well known for it's hostility towards prehospital EMS folks. The ER received a new director- who was basically a private sector efficiency manager with no medical experience. He was initially hired to streamline the hospital as a whole,. but decided to fill the open spot in the ER. On his to-do list- getting rid of or demoting many of the RNs with attitude problems, and hire younger, eager nurses with good attitudes. Another shocker- he promoted an ER tech- a paramedic- to EMS manager. I asked about the reaction from the staff- he said overwhelmingly positive. He's a sharp guy, a hard worker, good skills, and well respected by the staff so everyone apparently supports the decision. Incredible, and certainly good news for our profession.

To sum up-

Not sure what will happen in your case- especially since health care is in flux right now, but you never know how things may turn out.

Edited December 28, 2010 by HERBIE1

[rock_shoes]

It's cheaper to pay a medic than it is to pay a nurse.

This used to be true, however the new Union Provincial agreement has medic wages starting at $29/hr to $40/hr with 2X overtime, and shift differentials up to $5/hr.

Just to re-iterate a particularly important point within this thread. Canadian Advanced Care Paramedics (ACPs) are no less educated than RN’s with regard to emergency care of the sick and injured. In some respects they are better educated and in fact able to perform a greater number of advanced procedures with less direct oversight.

I have a great deal of respect for what many nurses do but starting a pissing match with their emergency service colleagues is poor judgement on their part. There is a lot both sides could be doing to help round out the other. Paramedic knowledge of long-term and continuing care is minimal at best in most cases, while (with the exception of nurse practitioners) nurses have very little in terms of independent care ability (almost nothing for independent scope of practice (SOP)). It is possible for the two to work together in the best interest of patients as a whole.

[HERBIE1]

Just to re-iterate a particularly important point within this thread. Canadian Advanced Care Paramedics (ACPs) are no less educated than RN's with regard to emergency care of the sick and injured. In some respects they are better educated and in fact able to perform a greater number of advanced procedures with less direct oversight.

I have a great deal of respect for what many nurses do but starting a pissing match with their emergency service colleagues is poor judgement on their part. There is a lot both sides could be doing to help round out the other. Paramedic knowledge of long-term and continuing care is minimal at best in most cases, while (with the exception of nurse practitioners) nurses have very little in terms of independent care ability (almost nothing for independent scope of practice (SOP)). It is possible for the two to work together in the best interest of patients as a whole.

What you say is true, but even in Canada, don't paramedics still need to operate under a physician's license?

EMS is evolving, and when started, EMS was about PREHOSPITAL care, and very few of us worked inside a traditional hospital setting. Now, with changes in scope of practice and staffing shortages, our paths are indeed crossing.

Here's a question for our resident MD's and DO's here- do they really feel threatened with the advent of PA's or advanced nurse practitioners? Seems to me it's simply another allied/adjunct health provider that helps a doctor, and ultimately the patient.

[chbare]

To go off on a tangent, I would say there is a big difference between the physician assistant and many nurse practitioners. There exists a large movement among nurse practitioners advocating complete independence of practice. In essence, you have a provider working without any physician input or collaboration and basically taking on the role of the physician. Arizona, for example does not require any agreement of collaboration between a NP or a physician. Basically, I can open a clinic and set up shop like any other physician. Clearly, this is much different than simple skills or knowledge overlap of a nurse and a paramedic.

Another movement that has a significant amount of momentum is the concept of a "Doctor nurse practitioner." Basically, NP's go back to school for a while, do a few hundred hours of clinicals and come out with a clinical doctoral degree in nursing. A massive push is in effect and presumably, by around 2015 all new NP's must have this "doctor" degree. While I am not against education, this degree is catalysing some people to push for sweeping doctor nurse privileges.

Obviously, I think this differs from the situation involving a PA where the PA has a physician relationship and is ultimately accountable to a board of medicine.

My opinion for what it's worth, and not a particularly popular opinion among some nursing circles.

Take care,

chbare.

[mobey]

What you say is true, but even in Canada, don't paramedics still need to operate under a physician's license?

No we do not.

I would even challenge that you do?

We practice under protocols/guidelines written by physicians. We are audited by a medical director. However, we practice under our own license. If I screw up and kill someone, it is MY license that action is taken against, NOT my medical directors.

[HERBIE1]

No we do not.

I would even challenge that you do?

We practice under protocols/guidelines written by physicians. We are audited by a medical director. However, we practice under our own license. If I screw up and kill someone, it is MY license that action is taken against, NOT my medical directors.

We have our own license, but we still must work under our medical director's license as well, who is the one that sets up the protocols we follow. We cannot set up shop somewhere and work on our own.

[mobey]

We have our own license, but we still must work under our medical director's license as well, who is the one that sets up the protocols we follow. We cannot set up shop somewhere and work on our own.

I think this may be a little like semantics.

We (ems) do work within protocols as set out by our medical director, however we do so as an individual.

That is to say; If we were working under our Med Directors license, and we mistreated, that Med Director would be up for review and his license could be frozen during that period. This can be seen in the ER with Nurses. If a nurse mistreats a pt (medicaly), all eyes go onto the responsible physician.

If we mistreat a pt, all eyes are on us, and our licence is on the table.

We have been given a scope of practice, standard of care, protocols, and a license. Although we work with medical oversight, we do not work under thier license.

[HERBIE1]

I think this may be a little like semantics.

We (ems) do work within protocols as set out by our medical director, however we do so as an individual.

That is to say; If we were working under our Med Directors license, and we mistreated, that Med Director would be up for review and his license could be frozen during that period. This can be seen in the ER with Nurses. If a nurse mistreats a pt (medicaly), all eyes go onto the responsible physician.

If we mistreat a pt, all eyes are on us, and our licence is on the table.

We have been given a scope of practice, standard of care, protocols, and a license. Although we work with medical oversight, we do not work under thier license.

Well, I guess this is about semantics but the question is what untoward event happened. Was it negligence, working outside scope of practice, failure to follow protocols, etc? Does this involve a civil suit, is it an internal investigation/complaint, a criminal charge, etc? Certain rules and legal standards apply based on the situation, and accountability/liability depends on specifics of the case. Certain standards need to be met to prove things like negligence, and as such, various folks would be held complicit. Other standards are system specific and involve specific internal rules- above and beyond legal statutes. Respondeat superior is a legal standard that holds the employer accountable for the actions of a worker- unsatisfactory training./oversight, etc. Depending on the outcome, the medical director, employer, AND the employee can be charged.

If a medical director received evidence- either direct, a 3rd party complaint, or an internal investigation- that a provider is incompetent, that director can suspend the license, pending the outcome of some established review board. As such, we DO work under their license- or at the very least their authority- if they are able to initiate such proceedings against us.

We cannot finish paramedic school, set up a jump bag and start free lancing. We need to work within the confines of some established medical control- whether it be in a hospital setting, or withing the rules of some municipality. Our ability to practice is not autonomous.