Is anyone afraid that Evidence-Based Medicine will kill EMS?

[Veneficus]

Not sure what you question is?

As far as the FDs, some are taking on the responsibility of EMS for the wrong reasons or without wanting it but find they must in order to keep funds coming in at a minimum to prevent cuts to the FD itself. Health care districts that may operate some hospitals are feeling the pinch as are those who are involved in trauma districts. Combine that with state tax EMS and Fire district reform, you have the public paying an impressive tax bill. The hospitals themselves are lobbying to keep clinics open to relieve their stress of the patients in their ED who would normally go to government funded clinics. We have or had these services already in place and they did work well but with funding cuts, they are vanishishing. Why reinvent something that will take years to come about and has still to prove what differences can be made especially if there are no diagnostic or prescribing privileges associated with it?.

But let me give it a go.

I was not advocating that anyone who doesn't have prescriptive powers would get them.

I do not advocate that medics or RNs run around as an independant provider.

What my point is specifically is that some form of out of the hospital provider needs to be more involved with publichealth, keeping people out of the ED when an ED is not the best resource, and as a consequence of that making sure the patient gets to the proper resource.

I have heard of only a handful of EMS agencies in the US that can make alternative transport decisions. In the past I worked for an EMS agency that could deny transport, but not transport to an urgent care clinic. (personally I think that is madness)

Urgent cares, community clinics, and all the other resources that exist are great. But people need to be directed to the proper ones. Somebody needs to help people navigate the system.

A prehospital provider doesn't have to be an expert at it, all they have to do is know who to call when and for what. A think RNs in particular are well suited for this.

If i could impose my will, I envision a system where a nurse and possibly a driver come in to work in the morning with a schedule of patients to look in on. A few units in reserve to handle emergencies.

Making sure somebody went to a doctors appointment, dialysis, is taking care of themselves, prescriptions refilled, and contacting the resources like "dial a rides," PCP, etc. Interfacility as well as 911 response would be part of the responsibility also.

The educated providers are there. The resources destinations are there. Help navigating the system as well as preventive services are not. It is far cheaper to make sure somebody's furosimide prescription is filled than to treat them in crisis through the ICU stay.

Making sure people understand when and how to take their prescriptions and are doing so, including not taking discontinued ones I don't think is asking a lot. I don't think making sure some elderly person is put in touch with social services to arrange a "meals on wheels" program before a crisis is asking too much of today's providers. Nor is making providing transport to a doctor's office or taking blood at the home and sending to a lab to check warfarin levels on a home bound person outrageous. Considering as you said the "money being spent," and an aging population not familiar with the complexities of the modern healthcare system, I think these types of services are required in order to not have the ED be the primary safety net.

I understand that is a significant change in mentaility as well as shifting of function from primary response to primary prevention. But the system we have now isn't working. There are access problems, tremendous resource waste, and economically cannot continue. Even if congress votes not to cut payments to anyone from current levels healthcare costs even at today's levels are financially unsustainable. How do you plan on addressing that by continuing what is being done now?

I just don't understand the point you are trying to make.

 

[Jon]

The key with OPALS is sperating the trauma portion from the medical portion. Heck, I can post a study that shows that transport by POV saves more lives than BLS ambulance in trauma patients.

Philadelphia PD is part of such a study. Shooting patients that enter the ED via the back of a PD van have a higher survival rate than folks that come in with ALS care.
Philly PD has a habit of scooping and running with the sickest, and anytime they are impatiently waiting for EMS to arrive.

More and more, trauma is being shown to be a BLS or NO LS game.

 

[JPINFV]

How did PD van compare to an EMT-Basic ambulance? That's my contention with the "trauma=BLS" argument. It isn't "trauma=BLS" it's "trauma=time." Just because something doesn't validate paramedics doesn't mean it automatically validates basics. In the case of trauma, it could very well mean that no prehospital care short of transport and bystander first aid matters.

 

[rhan101277]

Maybe EBM will change protocols, but with the 911 system embedded in everyone's mind, it will never go away. Paramedics will always be needed regardless of how dumbed down the protocols get. Many medics go to schools that aren't even accredited, which accreditation isn't required now but will be soon. I think some of these medics makes good medics look bad. Low quality education = low quality medic = maybe everything needs to be EBM.

Here is MS. paramedics can decide whether or not to spend time at the scene doing cervical spine precautions and backboarding. If its bad just get them in, try to get an IV in 2 minutes or less, if not just go and control what you can.

I can usually start one in 30 seconds with supplies ready.

 

[VentMedic]

But let me give it a go.

I was not advocating that anyone who doesn't have prescriptive powers would get them.

I do not advocate that medics or RNs run around as an independant provider.

What my point is specifically is that some form of out of the hospital provider needs to be more involved with publichealth, keeping people out of the ED when an ED is not the best resource, and as a consequence of that making sure the patient gets to the proper resource.

I have heard of only a handful of EMS agencies in the US that can make alternative transport decisions. In the past I worked for an EMS agency that could deny transport, but not transport to an urgent care clinic. (personally I think that is madness)

Urgent cares, community clinics, and all the other resources that exist are great. But people need to be directed to the proper ones. Somebody needs to help people navigate the system.

A prehospital provider doesn't have to be an expert at it, all they have to do is know who to call when and for what. A think RNs in particular are well suited for this.

If i could impose my will, I envision a system where a nurse and possibly a driver come in to work in the morning with a schedule of patients to look in on. A few units in reserve to handle emergencies.

++++++++++++++++++++++++++++++++++
The educated providers are there. The resources destinations are there. Help navigating the system as well as preventive services are not. It is far cheaper to make sure somebody's furosimide prescription is filled than to treat them in crisis through the ICU stay.

Making sure people understand when and how to take their prescriptions and are doing so, including not taking discontinued ones I don't think is asking a lot. I don't think making sure some elderly person is put in touch with social services to arrange a "meals on wheels" program before a crisis is asking too much of today's providers. Nor is making providing transport to a doctor's office or taking blood at the home and sending to a lab to check warfarin levels on a home bound person outrageous. Considering as you said the "money being spent," and an aging population not familiar with the complexities of the modern healthcare system, I think these types of services are required in order to not have the ED be the primary safety net.

I understand that is a significant change in mentaility as well as shifting of function from primary response to primary prevention. But the system we have now isn't working. There are access problems, tremendous resource waste, and economically cannot continue. Even if congress votes not to cut payments to anyone from current levels healthcare costs even at today's levels are financially unsustainable. How do you plan on addressing that by continuing what is being done now?

I just don't understand the point you are trying to make.

My question was not necessarily addressed at you but rather to point out that home health is complex and if we just add another "provider" to the mix with limited abilities that must still be supported from some funds, then we haven't really found a solution. Even for places like Wake County that have a fly car, they must fund that extra Paramedic and provide the individual cars as well as all the insurance and upkeep. The same for FDs and EMS agencies that do welfare checks with their ambulances and expensive Fire Trucks. The extra mileage and maintenance adds up.

To say the system now isn't working is relative to the magnitude of the problem. For those who are in the system or who had been in the system before the cut backs, it did work or EMS and the EDs would literally be swamped more than they are. You would be amazed at how many people are being taken care of outside of the hospital without requiring any EMS involvement at all.

Making sure somebody went to a doctors appointment, dialysis, is taking care of themselves, prescriptions refilled, and contacting the resources like "dial a rides," PCP, etc. Interfacility as well as 911 response would be part of the responsibility also.

We do have people that see these needs are met in the form of case managers and social workers. To add another provider to the mix who can not really fill out the paper work or spend hours connecting the services may just add confusion and duplication. However that is not to say EMS agencies can not contact Social Services to get people into the system. I approached that subject on another forum and was bashed for even suggesting such a thing because EMS is not in the hand holding or social work business.

Right now Paramedic programs across the country can not even agree on prerequisites like A&P or Pharmacology at a college level. The other things that would have to be included for the Paramedic to be effective in home health would be identifying the patient's ability to care for oneself, support systems, recent lifestyle changes,more indepth geriatric and pediatric medicine, psychosocial issues and long term care. Even some critical care medicine should be involved especially with the technology that is now in the home care situations. We still have members in EMS that have yet to be educated about the many types of venous access devices, IV pumps, pegs, the many different trachs or airway devices and all the technology attached to them.

Thus, it will take years of preparation to get the Paramedic to assume an extensive role in something other than an emergency medicine focus which still has to be perfected as well.

 

[lsetzer]

EMS will always exist in one form or another regardless. I think the question you need to ask is: Will evidence based medicine kill EMS as we know it?

And I think the answer to that question is: yes, absolutly.

 

[Veneficus]

Thus, it will take years of preparation to get the Paramedic to assume an extensive role in something other than an emergency medicine focus which still has to be perfected as well.

Which is exactly why as more and more time passes with the lack on EMS interest, I think the ole best filled by a nurse.

With a BSN many already have the education and qualities you cited.

there is a limited amount of physician house calls, and I understand that it is slowly growing. But I do not see house calls becoming wide spread.

I understand the amount of people being taken care of outside the hospital. I also understand how the care of indigent populations work. (or doesn't rather)

I am not particularly worried about the people with outstanding insurance or the ability to pay, I am cocerned with the 25-60% of the population (depending on whose numbers you like) that the system doesn't work for. It is those people that are in need of the safety net that the ED has become. As the population ages, that need by anyones account will only grow.

I don't think you would doubt that the ED is not capable of handling chronically ill patients as a primary provider.

Maybe down in Florida the demands are met by the resources, but across the nation particularly in "old world" economy states. The system is woefully inadequete. It is absolutely outrageous that things like this need to be provided across the country.

http://www.ramusa.org/projects/reach.html

 

[VentMedic]

Philadelphia PD is part of such a study. Shooting patients that enter the ED via the back of a PD van have a higher survival rate than folks that come in with ALS care.
Philly PD has a habit of scooping and running with the sickest, and anytime they are impatiently waiting for EMS to arrive.

More and more, trauma is being shown to be a BLS or NO LS game.

So do we cater EMS to only those who are going to be shot? The majority of EMS calls still involve the medical side. BLS education in the U.S. does not prepare one for to adequately decide how serious or o treat the emergent medial patient. It doesn't really qualify them to do routine ITF transports.

The OPALS study for trauma is difficult to use as a comparison in the U.S. since the length of education for the BLS providers in that part of Canada is longer than the U.S. Paramedic. Thus, what other countries may term as "BLS" may actually surpass ALS in the U.S.

 

[triemal04]

What my point is specifically is that some form of out of the hospital provider needs to be more involved with publichealth, keeping people out of the ED when an ED is not the best resource, and as a consequence of that making sure the patient gets to the proper resource.

<snip>

Urgent cares, community clinics, and all the other resources that exist are great. But people need to be directed to the proper ones. Somebody needs to help people navigate the system.

A prehospital provider doesn't have to be an expert at it, all they have to do is know who to call when and for what. A think RNs in particular are well suited for this.

If i could impose my will, I envision a system where a nurse and possibly a driver come in to work in the morning with a schedule of patients to look in on. A few units in reserve to handle emergencies.

Making sure somebody went to a doctors appointment, dialysis, is taking care of themselves, prescriptions refilled, and contacting the resources like "dial a rides," PCP, etc. Interfacility as well as 911 response would be part of the responsibility also.

<snip>

Making sure people understand when and how to take their prescriptions and are doing so, including not taking discontinued ones I don't think is asking a lot. I don't think making sure some elderly person is put in touch with social services to arrange a "meals on wheels" program before a crisis is asking too much of today's providers. Nor is making providing transport to a doctor's office or taking blood at the home and sending to a lab to check warfarin levels on a home bound person outrageous. Considering as you said the "money being spent," and an aging population not familiar with the complexities of the modern healthcare system, I think these types of services are required in order to not have the ED be the primary safety net.

I don't disagree with any of that, it'd be a good program and it has been done before, and I think is still being done in some areas; DC of all places had something similar for a time, and San Francisco had a similar program that focused on the homeless, though I think that was a privately funded deal.

The problem that comes up though, is where does the money to fund this come from? If it was a municipal service that does it you could argue that various departments (fire, PD, sanitation, etc etc) could cut out the waste from their budgets, but, contrary to what many people think, (and I know there are exceptions on both sides) there isn't that much monetary waste, especially with how many city services are cutting their budgets due to lack of funds. The next logical spot would be from insurance, but I'd bet that the majority of people that this type of program would be targeting would not have insurance, and would be either relying on private pay, or medicare. And given that medicare is cutting reimbursement rates...that's an issue. Of course, higher education should bring about higher rates of return, but again...if payments are cut no matter what, the money just won't be there.

I don't disagree that things need to change and that this wouldn't be a good way to go...but like a lot of the problems we have, the solutions will cost, and that cost has to come from somewhere, AND be factored into making the decision to change.

 

[VentMedic]

and San Francisco had a similar program that focused on the homeless, though I think that was a privately funded deal.

San Francisco has a couple different programs both of which are provided by the city.

One is "Healthy San Francisco" which provides affordable health care to the uninsured who are enrolled in the plan.

The other is for the homeless which is "Care not Cash" which was created out of a Proposition voted in by the citizens of SF a few years ago.

The primary goal of "Care Not Cash" is to reduce homelessness and improve the health and welfare of homeless indigent adults receiving cash assistance through permanent housing opportunities and enhanced services.

The funding for "Care Not Cash" has also allowed for the creation of a Behavioral Health Roving Team. The goal of the Behavioral Health Roving Team is to provide medical and behavioral health services to tenants living in the Single Room Occupancy Housing Program in order to stabilize them in housing and avoid future episodes of homelessness. The case management part of the team is supervised by UCSF/City-Wide Case Management and consists of two Clinical Supervisors, five social workers and a substance abuse specialist. The medical part of the team is comprised of a psychiatrist and two nurse practitioners employed and supervised by the Department of Public Health.

However, the City of SF is in the same financial mess as the State of CA with the future of many programs offered by Human Services Agency of SF in jeopardy.

 

[Veneficus]

There are only two options to fund it.

1. Local Tax
2. increased federal funds (most likely wth a tax increase)

As painful as it is, if you want programs, you have to pay for them.

At one point I suggested that the current local EMS providers be given funds directly from health and human services with an increase in their budget federally. But that solution was not well received. Even if it was there would likely be a tax increase.

Its not that I want a tax increase, but I am a bit of a realist. The entire structure of the US is failing. From bridges to schools, to healthcare. We have the lowest tax rate of any western country. If we want things like roads and services, we will simply have to pay the cost. If not, then we can't have it.

I agree there simply is not that much local waste. I also think that federal waste is exceedingly hard to reduce.

I also understand that many people are opposed to paying more. Especially people who really are just making it now. But particularly in healthcare, if you want it to be a value you'll have to pay.

The US has ong dropped education from its list of values. If you cannot afford it you cannot have it. It hasn't worked out very well.

When a nation becomes if you can't pay you can't have it, what you get is an India or Pakistan. What charming conditions those are.

 

[Veneficus]

Maybe this thread should have been split a few pages back

alas, I do not have the power.

 

[VentMedic]

Maybe this thread should have been split a few pages back

Maybe, maybe not...

As the financial environment changes, EMS agencies both Public and Private may be held more accountable and the need to review EBM for implimentation will become more obvious to meet the needs of the community and the standards of the insurers.

 

[triemal04]

There are only two options to fund it.

1. Local Tax
2. increased federal funds (most likely wth a tax increase)

As painful as it is, if you want programs, you have to pay for them.

At one point I suggested that the current local EMS providers be given funds directly from health and human services with an increase in their budget federally. But that solution was not well received. Even if it was there would likely be a tax increase.

Its not that I want a tax increase, but I am a bit of a realist. The entire structure of the US is failing. From bridges to schools, to healthcare. We have the lowest tax rate of any western country. If we want things like roads and services, we will simply have to pay the cost. If not, then we can't have it.

I agree there simply is not that much local waste. I also think that federal waste is exceedingly hard to reduce.

I also understand that many people are opposed to paying more. Especially people who really are just making it now. But particularly in healthcare, if you want it to be a value you'll have to pay.

The US has ong dropped education from its list of values. If you cannot afford it you cannot have it. It hasn't worked out very well.

When a nation becomes if you can't pay you can't have it, what you get is an India or Pakistan. What charming conditions those are.

That's true, but good luck getting the masses to actually believe that. (and good luck cutting out enough gov't monetary waste which should really be done first)

Unfortunately, the system that has been in place for...well...the majority of the time this country has been a country is what people are used to. Getting people to change an ingrained behavior, especially if it's something they think is one of their "rights" would be a battle of epic proportions.

 

[Outbac1]

To raise taxes to pay for things is not always the solution. We pay more taxes here (both income and sales tax) and still gripe about our roads, services and healthcare.

However taxes pay for our provincial healthcare which includes Emergency Health Services. Our EHS bill is about $85 million per year. This includes all ground ambulances, a dispatch center and a helicopter. We have a little under a million people in an area about the size of West Virginia. This works out to under a $100.00 per person per year.

I'm curious, does anyone know how much is spent in your state per person per year for similar services? This may be a hard figure to get as you need to include both government spending and the cost of privately operated services. Any thoughts as to how our model would translate to a larger geographical area and larger population? One of us is getting a better deal for our money, but which one??

 

[EMTinNEPA]

I got into this conversation a little late, so forgive me if I'm rehashing anything...

First off, why is there a separation between BLS and ALS? Medicine is medicine is medicine. Any EMT who thinks that ALS is useless or that "EMTs save paramedics" need to be put in their place, and any medic that forgets the basics needs to go to EMT school again.

Second off, as has already been stated, the are situations where pre-hospital ALS can have a dramatic effect on patient outcome... STEMIs, CHF, flash pulmonary edema, SVT, rapid a-fib, sepsis, significant trauma, stroke, GI bleeds, and so on and so forth. Any study advocating "Scoop and run", especially in rural systems where you may be 30 minutes from the closest hospital or even 45 minutes from the closest appropriately equipped hospital isn't worth the paper it's printed on or the ink used to print fallacy after misleading statement.

Third off, protocols are meant to be a guideline, not a cookbook. It's up to you whether you treat the patient based on the protocol or treat the patient based on their presentation while keeping the protocol buried in the back of your mind. Do you want to be a robot or a healthcare professional?

I fully advocate evidence-based medicine. Change is definitely needed in EMS in the US... screw MAST trousers, give me blood or something...

 

[Jeffrey_169]

I got into this conversation a little late, so forgive me if I'm rehashing anything...

First off, why is there a separation between BLS and ALS? Medicine is medicine is medicine. Any EMT who thinks that ALS is useless or that "EMTs save paramedics" need to be put in their place, and any medic that forgets the basics needs to go to EMT school again.

Second off, as has already been stated, the are situations where pre-hospital ALS can have a dramatic effect on patient outcome... STEMIs, CHF, flash pulmonary edema, SVT, rapid a-fib, sepsis, significant trauma, stroke, GI bleeds, and so on and so forth. Any study advocating "Scoop and run", especially in rural systems where you may be 30 minutes from the closest hospital or even 45 minutes from the closest appropriately equipped hospital isn't worth the paper it's printed on or the ink used to print fallacy after misleading statement.

Third off, protocols are meant to be a guideline, not a cookbook. It's up to you whether you treat the patient based on the protocol or treat the patient based on their presentation while keeping the protocol buried in the back of your mind. Do you want to be a robot or a healthcare professional?

I fully advocate evidence-based medicine. Change is definitely needed in EMS in the US... screw MAST trousers, give me blood or something...

I agree. As a rural volunteer IO know all too the well the value of ALS and BLS. We don't need to revert, but we do need more education.

Alos, I agree we should treat the pt., not the machines, the textbooks, or the protocols.

 

[Veneficus]

That's true, but good luck getting the masses to actually believe that. (and good luck cutting out enough gov't monetary waste which should really be done first)

Unfortunately, the system that has been in place for...well...the majority of the time this country has been a country is what people are used to. Getting people to change an ingrained behavior, especially if it's something they think is one of their "rights" would be a battle of epic proportions.

That is exactly why I am glad I don't have to be the one to fight that battle.

I think basic economics will bring about the change irregardless of how people feel, what they are used to, or what they believe they are entitled to.