Editor’s Note: California has approved a large community paramedicine pilot project that begins in June 2015, and the report that recommended it identified the many barriers it would face, before it could be legally or practically implemented. See my comments below — Dwight G. Jones/Elevaed Consultants
EMS Regulations, Statutes, and Other Barriers to CP Program Implementation (from the report)
Three aspects of California’s current EMS statutes and regulations preclude the development and implementation of CP programs:
1. The requirement that callers to 911 must be taken to an acute care hospital having a basic or comprehensive ED.
2. The locations where paramedics can practice — i.e., at the scene of a medical emergency, during transport to an acute care hospital with a basic or comprehensive emergency department, during interfacility transfer, while in the ED of an acute care hospital until responsibility is assumed by hospital staff, or while working in a small and rural hospital.
3. The specification of the paramedic scope of practice.
It is important to note that the paramedic scope of practice in California is explicitly defined in both statute and regulation as referring to a set of authorized skills and activities that emergency medical personnel may perform and the places in which those skills and activities may be performed. This is unusual in that most scope of practice definitions specify skills and activities but not location. California’s dual definition means that any of the potential CP scenarios described in this report would require a statutory change to one or more aspects of the paramedic scope of practice.
For 1) and 2) the transport and location requirements can and must be removed to allow emergency services to expand outside the 911-ambulance-hospital axis. But there are legitimate concerns about the quality or lack of care that might result, from both the patient’s and the medical control perspectives, and those caveats must be dealt with separately and satisfactorily.
A more difficult matter will be 3) the paramedic scope of practice, and this need not change, but will require an altered safety architecture for California EMS.
The central issue is that vehicular EMS (fire, ambulance) is central, being a hub and spoke model feeding hospitals. As such it is one-dimensional, bringing patients from one point to another point, and that strategy is overloading ED targets.
Motorized emergency vehicles have been used for these responses since 1915, as has the telephone, and hospitals do offer excellent after care, but first care depends on early intervention, and that’s not being reliably achieved, if at all for acute incidents.
If early intervention is economical and practical, all other quality care issues and policies become secondary to it. That is what we shall briefly consider here.
Deploy Field Paramedics
Large, densely populated cities can economically support a two-dimensional grid layout that brings (some) EMTs out of their passive stations and into the field, within walking distance of their patients, meeting and registering them. Utilizing this block EMS model, a small team of 3 EMTs can protect up to nine contiguous blocks economically, when they have a population totalling 1000+ occupants. The response time could be a full ten minutes earlier than at present – and reliably so.
My current estimate is that the gross cost would be about $15US per resident each month, and from that figure we can deduct a variety of revenues that a trained human attendant onsite can generate, looking at telehealth and digital medicine’s imminence. Much of EMS funding could then be consolidated into the property tax base, a needed upgrade, and block EMS might also become a viable independent business model for veteran paramedics.
Given that California has an estimated 60,000 EMTs and almost 20,000 paramedics, there obviously are considerable human resources to redeploy within this state’s densely populated cities.
EMTs as EMTs
There is one important point I want to make about the scope problem mentioned above, because it addresses how these deployed paramedics are going to be trained, and to what level.
The short answer is they don’t have to be retrained beyond Advanced Emergency Medical Technician (AEMT) because they continue answering to 9-1-1 dispatchers or patients when called, using the same skills set and scope.
The scope conundrum arises when we picture these EMT’s heading out to visit ill patients in their homes, whether to change their dressings, check their vital signs, make sure their meds are being taken, start an IV, etc. That description is of a community health aide, not an EMT.
An EMT is an Emergency Medical Technician., and he or she has 1000+ people in those home blocks that they are responsible for safeguarding against medical life threats. If they have to treat-and-release a patient, they can be supervised by an emergency physician in real time, if need be with cellular video conferencing. Or, they can direct a patient to a local clinic for routine procedures – a valuable function in paramedicine that builds out diversified community health.
Physicians and Field Paramedics are Professional Allies
Telemedicine and especially its DTC (Direct To Consumer) variants are a deep and legitimate threat to the western medical tradition. From self-diagnosis on the Web to Skype sessions with offshore “physicians”, the intrusion is unprecedented; both for the profession and as a risk for patients. Yet the existing hegemony and quality of care can be preserved with one simple provision: that telemedicine be conducted over an EMS network, in recognition of this legitimate danger to patient safety.
When a field paramedic connects his cellphone to the EMS medical network, with access to emergency physicians in real time, and then conducts a telemedicine session, he is enabling enhanced clinical decision making within the shortest possible time, without transporting the patient. All are invaluable features that must accompany telehealth sessions, lest they become tragic parodies of healthcare conducted by amateurs. Physicians must understand this and wholeheartedly and pre-emptively back the right horse – field EMS.
In this way the EMT works at a specialized high level, and does not need wider scope to do so. Their patients come to trust them and the medical services they enable, acknowleging that the 911-ambulance-hospital option will be reserved for acute events. Indeed, the legacy word “ambulance” is replaced by “medical services” to reflect the expanded capabilities inherent in field EMS.
By moving EMS out to the people, with clear communications boundaries and related support services identified, a city can be woven into a safe fabric not chronically dependent on lights, sirens and fire crews for medical calls. The deep value of block security lies in delivering early intervention where it has never been reliable before, introducing a level of care that will always be the gold standard for life and injury safety. Health admins can easily add cellular infrastructure to consistently bring response times down inside five minutes, and promote telemedicine – but they themselves need to grasp that vision before patients will see the results.
Distributed and diversified EMS will indeed deliver patient satisfaction, improved care and cost savings, but until field personnel are in place, cities will continue to endure the ad hoc, noisy, expensive and injurious model of a century ago.