Paramedics working blend hospital/ambulance

[mobey]

Thinking out loud again!

I am in a small community that claims it cannot afford ALS....(don't go there)

I am wondering if any paramedics out there (in AB) have a blend position where the ambulance/hospital share the extra cost?

I am considering drawing up a proposal and would like any info I can get.

Our EMS is town run, our hospital is part of a health region.

How is the wage split? What is the scope of practice in an ER for a medic?What do the nurses think? .....and so on..

[courageheartx]

Alberta?Claiming they have no resources or money for ALS in rural areas? Where is this?Curious

[mobey]

Umm... Red Deer, Rocky area

[rock_shoes]

Bump. I know this is an old thread but the topic in question is particularly near and dear to me. Perhaps 2010 will bring some new and valuable insight to the topic.

[fireflymedic]

Mobey,

I know you are canadian, however, this solution was worked between a hospital not too far from here, and also a larger university that required transport services. Took a bit of fine tuning, but eventually they got it down quite right and it runs fairly well (actually two of the better planned services).

1. The County service - is technically county owned, however the hospital was left with either flying ALL their ALS patients which was absolutely absurd, sending a nurse every time (which wasn't feasible as they were so small it didn't make sense to staff an extra nurse in case something had to go out), or downgrade many of their ALS patients to BLS to allow locals to transport which just wasn't an option many times either. County claimed they couldn't afford to staff trucks ALS, but stated they would on the condition that one of the ER physicians assumed med director (local FP doc wanted nothing to do with ALS which was part of the problem), and that the hospital absorbed part of the cost.

It turned out to be a fantastic marriage - the hospital provided EMS with the ALS supplies needed to go on transfers or function chase. Since they rarely ran more than 2 calls a night (actual 911), but had a great deal of transfers out, this worked quite well. BLS made the initial response for simple patients with medic meeting them enroute to return if requested, or was automatically dispatched on certain priority calls that would likely require ALS interventions (codes, etc). The patient was then (if required flight services) flown directly from scene (was a VERY rural county and local hospital was nothing more than a glorified clinic at best), or transported to ER and transferred via ground to appropriate facility if stable to do so (the more likely scenario). In return, the ALS crew (staffed as medic/medic crew) would be split and the BLS crew would function as two ALS units leaving a medic in county. One going on transfer, the other remaining to serve the area until other crew was returned to base. In the down time, or whoever was left, functioned in the ER - one working in triage, the other functioning as a tech alongside the nurse (place only had four rooms, so that tells ya how small it was). Service ended up with better trucks, funds from both county and hospital for equipment, and much better pay. They always maintained medic rate of pay (which was very close to nursing pay there) and basics were paid basically CNA level pay. Worked well. The medics were able to do all their skill scope and actually had expanded practice in hospital as did basics.

Now service 2. Large University looking to integrate medics into the ER as they were having ER nurse staffing issues and did not care to employ temps any longer. Also, they had purchased a sister hospital across town and were looking to be able to shuttle more minor patients to the sister facility to ease the burden on the trauma center. Here the medics lost skills as both they and basics essentially functioned on a similar level - only the medics were able to give a limited scope of meds. They mainly staffed the fast track area or minor care. They staffed trucks medic/basic and kept two crews on at all times. It was an okay situation, but not the best. Pay was fairly close to street medic pay and basics made better than street basic pay. They functioned so watered down, but the job was easy enough and paid well enough with better working conditions, they stayed well staffed and are still functioning in that capacity.

Hope that helps ya out there !

[rock_shoes]

1. The County service - is technically county owned, however the hospital was left with either flying ALL their ALS patients which was absolutely absurd, sending a nurse every time (which wasn't feasible as they were so small it didn't make sense to staff an extra nurse in case something had to go out), or downgrade many of their ALS patients to BLS to allow locals to transport which just wasn't an option many times either. County claimed they couldn't afford to staff trucks ALS, but stated they would on the condition that one of the ER physicians assumed med director (local FP doc wanted nothing to do with ALS which was part of the problem), and that the hospital absorbed part of the cost.

It turned out to be a fantastic marriage - the hospital provided EMS with the ALS supplies needed to go on transfers or function chase. Since they rarely ran more than 2 calls a night (actual 911), but had a great deal of transfers out, this worked quite well. BLS made the initial response for simple patients with medic meeting them enroute to return if requested, or was automatically dispatched on certain priority calls that would likely require ALS interventions (codes, etc). The patient was then (if required flight services) flown directly from scene (was a VERY rural county and local hospital was nothing more than a glorified clinic at best), or transported to ER and transferred via ground to appropriate facility if stable to do so (the more likely scenario). In return, the ALS crew (staffed as medic/medic crew) would be split and the BLS crew would function as two ALS units leaving a medic in county. One going on transfer, the other remaining to serve the area until other crew was returned to base. In the down time, or whoever was left, functioned in the ER - one working in triage, the other functioning as a tech alongside the nurse (place only had four rooms, so that tells ya how small it was). Service ended up with better trucks, funds from both county and hospital for equipment, and much better pay. They always maintained medic rate of pay (which was very close to nursing pay there) and basics were paid basically CNA level pay. Worked well. The medics were able to do all their skill scope and actually had expanded practice in hospital as did basics.

This particular circumstance sounds like it might work extremely well. I think it could be improved even further with the development of a Paramedic Practitioner level. I’m thinking something similar in educational requirements to a Nurse Practitioner or a Physician Assistant but geared specifically towards emergency and transport medicine. This would provide the resources required for CCT’s and save on hospital admissions. When little Johnny cuts his finger sharpening his new pocketknife the availability of a Paramedic Practitioner would likely eliminate the need to transport while still providing a high level of care. When it’s time for the local nursing home to go through flu inoculations that resource will be available on site. Imagine the value in providing such a high level of public exposure control. I’ve always wondered how many elderly patients catch a flu virus when they go to the public flu clinics. In my own little dream world I envision a provider who can put a couple stitches in little Johnny at 0800, give grandma her flu shot at 1200, and take a CCT to the nearest Cardiac Centre at 1700. All without making any “mother may I” phone calls.

[tniuqs]

Alberta?Claiming they have no resources or money for ALS in rural areas? Where is this?Curious

Its the new improved, no loss or down grade in services AHC centralized system of perfection ... WTF ?

ps I have air miles to send Dr. Druckman back to OZ and let ausiephill feed him to a croc.

[JTpaintball70]

This particular circumstance sounds like it might work extremely well. I think it could be improved even further with the development of a Paramedic Practitioner level. I’m thinking something similar in educational requirements to a Nurse Practitioner or a Physician Assistant but geared specifically towards emergency and transport medicine. This would provide the resources required for CCT’s and save on hospital admissions. When little Johnny cuts his finger sharpening his new pocketknife the availability of a Paramedic Practitioner would likely eliminate the need to transport while still providing a high level of care. When it’s time for the local nursing home to go through flu inoculations that resource will be available on site. Imagine the value in providing such a high level of public exposure control. I’ve always wondered how many elderly patients catch a flu virus when they go to the public flu clinics. In my own little dream world I envision a provider who can put a couple stitches in little Johnny at 0800, give grandma her flu shot at 1200, and take a CCT to the nearest Cardiac Centre at 1700. All without making any “mother may I” phone calls.

This sounds a lot like what our EMT-Ps that work for the local trauma center are allowed to do, minus they're not on trucks anymore. While working ED they are allowed to do most suturing, administer a range of meds, start lines (U/S lines as well), splint, etc. Combining that into someone working the street in a rural area or even a smaller metro area would be an incredible idea. But here in the US we run into the problem of needing more education than is the current standard to make it work. I'd be all for it though

[VentMedic]

Mobey,

Now service 2. Large University looking to integrate medics into the ER as they were having ER nurse staffing issues and did not care to employ temps any longer. Also, they had purchased a sister hospital across town and were looking to be able to shuttle more minor patients to the sister facility to ease the burden on the trauma center. Here the medics lost skills as both they and basics essentially functioned on a similar level - only the medics were able to give a limited scope of meds. They mainly staffed the fast track area or minor care. They staffed trucks medic/basic and kept two crews on at all times. It was an okay situation, but not the best. Pay was fairly close to street medic pay and basics made better than street basic pay. They functioned so watered down, but the job was easy enough and paid well enough with better working conditions, they stayed well staffed and are still functioning in that capacity.

Here in the states it is a very different situation due to limited education. Unless the state statute has been changed specificially in the state, Paramedics are limited as to legally doing triage and assessment in the hospital without an RN overseeing and co-signing. It is essentially the same as an LVN in some cases and that is what I would compare the Parmedic's practice to in the ED except for the lack of general nursing care rather than to an RN's. The same goes for medications. The meds that could be given by the Paramedic still had to be witnessed and co-signed by the RN. If the patient was admitted to ICU status or level of care beyond the Paramedic and still held in the ED, assignments would often have to be switched to accomondate the Paramedic. I am also familar with this because of working Flight as a Paramedic while stationed at a hospital. We could only assist with a few things and not assume care for any patient fully since report would have to be given with the patient handed off properly. That can waste time getting into flight. Thus even at Flight Paramedic status in the U.S. the education and training varies greatly to where they are not always allowed to do very much inside the hospital.

In the U.S. we have not evolved to a true critical level even with the "80 hour" CCEMTP course in addition to the Parmedic cert. The Flight and the CCT Paramedic here in the U.S. should have at least an Associates degree with another 6 month (preferably one year hospital critical care experience) before being allowed to work in an ED as something other than an ED Tech. However, I believe the Canadian system in places has gone well beyond this and there should not be any issue with level of care but rather just the hand off of care to get on the street.

[rock_shoes]

But here in the US we run into the problem of needing more education than is the current standard to make it work. I'd be all for it though

Education reform would definitely be a crucial part of implementing any such program. I think educational requirements for a practitioner program should be similar to those of a Nurse Practitioner or Physician Assistant program which would result in 5-6 years of post-secondary education. As a point of reference, In Canada becoming an Advanced Care Paramedic (roughly equivalent in SOP to a US EMT-P) is about a 3 year endeavour going to school full time (not including acquiring experience between provider levels or program pre-requisites). With that in mind a 2-3 year practitioner program for Canadian ACP's isn't as far fetched as it might be in other places. Add to that the ongoing development of Critical Care Paramedic (a step beyond ACP) programs in Canada and it becomes a realistic goal.