# Paramedic Utilization In-Hospital



## disassociative (Nov 18, 2007)

Ok, as you guys know this has been a hectic week, and I thank you for your support. However, it is important for me to stay productive. 

Therefore, I am inclined to share with you an article from the Journal of Emergency Nursing entitled _Recruitment and Retention Benefits of EMT—Paramedic Utilization During ED Nursing Shortages_.

This article speaks with regard to the implementation of paramedics into ICU programs, ED medicine(reformation), and other hospital roles by utilizing a team approach with clearly defined scope of practice and the use of paramedics as supplements to nursing rather than a high paid Nurse Aide with extra skill. 

You can access this article here:
http://www.sciencedirect.com/scienc...d=590719&md5=1234ab78620c1e906739ad90e81deb9b


*Works Cited:*
Ryan Oglesby MSN, RN, CEN, NREMT-P, MHA. Journal of Emergency Nursing. 2007. Sciencedirect.com: Journal of Emergency Nursing.. Volume 33, Issue 1, February 2007, Pages 21-25 <http://www.sciencedirect.com>.


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## firecoins (Nov 18, 2007)

The print is too small on my computer to read it properly.  

The Nurse's union in NY would never allow it.  In NJ, all critical care transports get a nurse and a paramedic.  I don't think the medic will ever go inside the ED in NJ either for the same reason.


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## Chimpie (Nov 18, 2007)

I don't really feel like reading the whole article.

Are they saying they want to take medics off the streets to work in ICUs?


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## Asclepius (Nov 18, 2007)

Our hospitals and some of the ones that are in the Cincinnati area, where I used to live, employ paramedics. The problem is, in my experience, is that they amount to little more than a nursing assistant except for in the ED and in Triage. I specifically did not go into nursing, because I did not want to change people's diapers and such. If I could work in a hospital setting and actually practice emergency medicine and my skills then I would give it some consideration.


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## VentMedic (Nov 18, 2007)

I always chuckle when I see these threads start.

The paramedic is still considered a "tech" inside the hospital due to the lack of uniform education and standards. It would be a slap in the face of other healthcare professionals such as the LVN and Respiratory Tech (CRTT) who have gone by the wayside when they did not advance their measly 1 year education.   I would find it hard to believe that the hospitals would go backward in their education standards now.  Yes, a paramedic can "supplement" nursing care in the hospital. 


Quote from article: 


> In the emergency department, EMT-Ps with supplemental training can provide interventions such as urinary catheterization, *patient transport*, point-of-care testing, and *activities of daily living * and contribute significantly to the provision of emergency care. These activities, in addition to the advanced life support skills that EMT-Ps perform routinely in a prehospital environment, can *supplement nursing care *in the emergency department *above and beyond that of traditional unlicensed *support personnel.



For those of you not familiar with *activities of daily living *, it is a required duty for the tech in the ED to clean up the patients. 

All professions supplement "nursing care" in some way.  

"above and beyond that of traditional unlicensed support professional"; There are very, very few unlicensed personnel left in the hospital. The CNA, PCT, phlebotomist, and patient transporter are unlicensed and the first 3 are certified.  So yes, it is possible to for the paramedic to do some of their skills as mentioned in the article. 

Again, most of the duties being performed by the paramedic are SKILLS.  Nurses will still keep the nursing process going for the whole hospital continuation of care.



> To employ EMS personnel in a nontraditional setting, institutions must submit an application to the NCOEMS that clearly documents a joint effort between the institution and the county EMS system to plan for their appropriate utilization.



This is just the tip of the iceberg. Competencies on a regular basis inside the hospital must also be done to satisfy hospital accrediting agencies. 

HEMS and other transport crews are also utilitzed between calls inside the hospital but the standards and documentation criteria are high.  

Now if they are already an EMS crew awaiting a call, why not use them? It can also keep their skills sharp. However, I've also heard a lot of griping from EMTs and EMT-Ps in these situations.  It may interfere with their TV or nap time.  They might even accidentially learn something from hanging out in the ED. 



> One of the proponent articles from the United States, Getting More out of EMTs in Oklahoma,3 details how a job-sharing arrangement has helped a rural hospital and surrounding community. In Stroud, Oklahoma, EMTs are utilizing their “down time” while not on patient transports by working in Stroud Hospital's emergency room. “They do not require any extra training for the work they do in the hospital. Anything they are trained to do in the field they can perform in the hospital—this includes *administering IVs, drawing blood, and providing basic emergency care,*” says Scott Devers, the hospital's EMS manager.3



95% of the patients in many EDs are clinic and/or med-surg patients. So you may be changing alot of foleys, wiping noses and butts.  So yes, I'm sure there is a place in the ED to "supplement" nursing. 

Of course, if you want to improve your IV skills, medication knowledge and get an overall patient care education, the ED is an excellent place to work. 

It is also important to remember RNs and RRTs also can get their time on the ambulances, especially in North Carolina, with their skills. But, they have used licensure, documented training, standardized education and license statute amendments to achieve this.


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## reaper (Nov 18, 2007)

Alot of the smaller hospitals around here use Paramedics in the ed. Not as techs, but as substitutes to RN's. They cannot find enough RN's, so they fill the gaps. Smaller ED's may have 1-RN,2-LPN's,2- MEDICs and 1-EMT.

The EMT is used in triage. The medics do almost the same skills and work load of the RN. Alot of the ED DR's actually like having medics in the ED.


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## disassociative (Nov 18, 2007)

Vanderbilt University Medical Center, where I am working has a great outlook on Paramedics in hospital:

http://www.mc.vanderbilt.edu/root/vumc.php?site=adulted&doc=828


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## Asclepius (Nov 18, 2007)

disassociative said:


> Vanderbilt University Medical Center, where I am working has a great outlook on Paramedics in hospital:
> 
> http://www.mc.vanderbilt.edu/root/vumc.php?site=adulted&doc=828


Do they function as clean-up crews or do they actual get to do medicine?


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## disassociative (Nov 18, 2007)

Since TN has special EMS Designations:

 EMT-IV and EMT-P, we have more opportunities within the hospital. Our EMT-B's are EMT-IV and their course hours approach 400 with a 180 hr absolute minimum(they can do IVs, administer some meds, drop airways, and have a more thorough understanding of the overall pathophysiology of various conditions.)

Our Paramedic Program(approaching 2,400 hours the minimum being 1,218 hrs) ensures the appropriate training for this level provider. Tn does not even recognize EMT-B or EMT-I; The requirement for reciprocity from another state is NREMT-B + a transition to EMT-IV course lasting about 3 months.

Vanderbilt University Medical Center
Emergency Department

PARAMEDIC JOB ROLE AND RESPONSIBILITIES

I.	PURPOSE:  To identify paramedic role responsibilities in the Emergency Department

II.	POLICY:  

Paramedic job role and responsibilities are included but not limited to:

Patient Transport
IV starts
Medication administration
Documentation of all medication and treatments given
Take orders from the physicians
Lunch Relief
Equipment
Rhythm Disturbances
Reassess patients
EJ’s
Assist with procedures
Secondary in trauma
Scribe in trauma
Monitor critical patients
Documentation of care delivered
Draw lab (IV, Porta Cath,PIC)
Splinting
Restocking rooms
Phone triage
Triage assignment 7A-11A
Patient report
Preceptor
Decontamination
EKG
POCT
Lift and roll assistance
Administrator Blood
Fast Track
White Board Maintenance
Clothing List
Valuables
Assist getting patients out of cars
Assist with helipad

Here is the EMS Magazine survey of TN EMS for those of you that want to know more:
http://www.emsresponder.com/survey/TN.jsp

There is also another law allowing EMT-IV to act as LPN within a hospital environment.


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## VentMedic (Nov 18, 2007)

> Tennessee EMS Act
> 
> T.C.A. 68-140-509. Duties and authority of EMS personnel and physician on the scene.
> 
> (c)  An EMT or EMT-P may function within hospital emergency services under nursing supervision in accordance with policies and procedures adopted by the hospital.



I think that spells that out.


The skills listed in the TN ED are pretty much what an ER tech does with proper training.  Each ED will be different as to what technology and medications can be administered.  The phone triage is deceiving because it usually means directing calls to the right professional.  "Monitoring critical patients" is also deceiving terminology and can be interpreted in different ways. 



> Alot of the smaller hospitals around here use Paramedics in the ed. Not as techs, but as substitutes to RN's. They cannot find enough RN's, so they fill the gaps. Smaller ED's may have 1-RN,2-LPN's,2- MEDICs and 1-EMT.
> 
> The EMT is used in triage. The medics do almost the *same skills *and work load of the RN. Alot of the ED DR's actually like having medics in the ED.



Skills again being the key word. 

Paramedics and EMTs have always found a place in Florida as ER Technicians with varying skills allowed.  Paramedics are not allowed triage status in the ED in Florida.  EMTLA/COBRA laws also spell that out. LPNs haven't been in EDs or ICUs for years except as a "tech" or aide status. Their nursing responsibilites are very limited now and are now found mostly in the nursing homes.  LPNs do not "assess" by their licensure. An RN supervises and assesses.  For a paramedic to act as an LPN is in the hospital is very limiting now. Many RTs were given the opportunity to be an LPN after their 1 year of RT school and to this day I don't think anyone has ever done that even for the added credential. 

There are small hospitals like Lake Butler that also use expanded skills for the paramedic but they still must obey State and Federal regulations.  Triage is one such function that is closely regulated.  A higher license will have to monitor a Paramedic in triage.  There are also regulations as to what providers insurance and medicare will reimburse. If they are reimbursing for the services of an RN and someone that is not recognized by their system is actually providing the care, that can result in legal problems other than just medical issues. This has already been discussed at great length. 

Some hospitals such as Baptist and Orlando have Flight and CCT specialty teams which include Paramedics attached so they will do the advanced skills in the ED. 




> Our Paramedic Program(approaching 2,400 hours the minimum being *1,218 hrs*) ensures the appropriate training for this level provider.


  1218 hours is just over the minimum required to take the NREMT-P.  If you were to add on a few college classes similar to a 2 year degree, that would bring this closer to the upper end of hours.  This is not unique to any state. The hours is all about the ambition of the student. 

Again, the paramedic's educational focus on "skills" and "what I can do" is what is keeping the paramedic out of a lot of opportunities due to the lack of educational foundation to back up the skills. 

There is a Bachelors EMS program in Georgia that is attempting to get Critical Care Transport Paramedics more hours in the ICU since the CCEMT-P is barely an introductory class when it comes to critical patients in the ICU. This is still in the works with lots of legislative hoops to jump and they will still be working under nursing supervision as a "tech" in many ways. If the paramedics are stationed at the hospital they may pull it off. Now that program sounds impressive so far. 


These are ads we have now for Paramedics and ER techs in Miami:
*I don't want everybody coming down here to apply for these well paying jobs until you check out our rent and over all cost of living here in paradise. *
http://www.baptisthealth.net/bhs/en/emp/openings/0,2301,3372_10696_101,00.html
Position 
*Ed Technician/Paramedic*
Location:    South Miami Hospital 

Department:    Chest Pain Unit 

Pay Rate:    $11.77 min 

Description:    High School diploma or equivalent. Graduate from a certified EMT School. Current EMT License and BLS certification. One year EMT experience desired. 

*Emergency Room Tech*
Location:    BMP at Westchester 

Department:    BMP - Westchester Urgent Care 

Pay Rate:    Commensurate with experience 

Description:    High school diploma or equivalent. Good interpersonal skills and BLS certified required. Previous experience in emergency room setting, ortho splinting, EKG's and phlebotomy preferred. 

*Emergency Room Tech*Location:    Baptist Hospital 

Department:    Emergency Department 

Pay Rate:    $10.48 min 

Description:    FL Paramedic certification required. BLS certification required. Computer skills required. Patient care experience preferred. 

This ad is from a trauma center in Orlando:
*Orlando Regional Medical Ctr
Paramedic*
Req: 056325

Position No: 01018408

Job Code: 1239

Title: Paramedic

Status: Pool

Shift: Varies

Department: ORMC Emergency Services

Location: Orlando Regional Medical Ctr

Posted Date: 06-28-2007

Duties / Requirements: 
Works in collaboration with RNs and MD's to provide patient care to adult medical and trauma patients utilizing advanced skills and judgment. Paramedics will be responsible for assessment/reassessment, ECG interpretation, IV therapy, airway patency, and initiation of protocol orders and guidelines of adult patients in the ED setting. Current certification as a Paramedic in the state of Florida. Minimum one year of clinical experience in a Hospital ED or as a Paramedic in a pre-hospital environment. BLS/ACLS/PALS required. Excellent customer service. Computer skills required.


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## Ridryder911 (Nov 19, 2007)

> _One of the proponent articles from the United States, Getting More out of EMTs in Oklahoma,3 details how a job-sharing arrangement has helped a rural hospital and surrounding community. In Stroud, Oklahoma, EMTs are utilizing their “down time” while not on patient transports by working in Stroud Hospital's emergency room. “They do not require any extra training for the work they do in the hospital. Anything they are trained to do in the field they can perform in the hospital—this includes administering IVs, drawing blood, and providing basic emergency care,” says Scott Devers, the hospital's EMS manager_





Ironically, some of my partners have worked there and one of my best friend is a P.A. at this ER. What they do not tell you is that it is a 2 bed ER, and about 14 bed hospital. As well, the medics also did patient care (total) and R.T. treatments, etc... Basically, cheap labor for nursing care

Now, they have a private EMS (for the time being), which I believe no longer works in ER, other than to assist when needed. The P.A. is a former fire fighter, RN/Flight Nurse Paramedic, with 25+ years in EMS, and is big supporter of EMS.


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## BossyCow (Nov 19, 2007)

We were just discussing this topic the other day.  Apparently in our state, an RN won't cover you for field work and Paramedic, EMT won't cover you for facility care.  

If an EMT or Paramedic wants to work in an ER they have to have additional licensure, either CNA, LPN or RN.  If  nurses wish to work in an ambulance they have to obtain additional EMS certification.  

The airlift nurses do that through flight nurse certs.  Our state doesn't recognize MICU cert for nurses so nurses wishing to work on ambulances must either have a paramedic on board or they have to have their EMT or Paramedic cert in addition to their RN.


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## Medic8388 (Dec 10, 2007)

I work part time at a small rural hospital.  My title is 'er tech' but I function like a nurse.  The only things I am not allowed to do (per my job description) is administer blood products and take phone orders from a physician.  All the skills I routinely use in the field I perform in the hospital (such as medication administration). I think using medics in the hospital is a two sided issue... On one hand its a good opportunity for the medics ( I know I've learned quite a bit), on the other hand hasn't nursing taken enough good paramedics?

Andrew Woodard


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## VentMedic (Dec 10, 2007)

reaper said:


> Alot of the smaller hospitals around here use Paramedics in the ed. Not as techs, but as substitutes to RN's. They cannot find enough RN's, so they fill the gaps. Smaller ED's may have 1-RN,2-LPN's,2- MEDICs and 1-EMT.



Being a substitute can have its drawbacks. They are not permanent.  

http://www.heraldtribune.com/article/20070706/BUSINESS/707060338/0/COLUMNIST06

*Sarasota hospital lays off 7, shifting nurses into the jobs*By DAVID GULLIVER

SARASOTA -- Sarasota Memorial Hospital is laying off seven people from its emergency room as it restructures to find more work for nurses.

Seven employees -- two paramedics, four technicians and a materials specialist -- will lose their jobs.

Hospital officials said the moves will not hurt patient care, as nurses are shifting into those roles.

The layoffs are part of a larger effort to staff units primarily with nurses.

When the expanded emergency care center opened in late 2005, it had 19 nursing vacancies. The paramedic and tech positions covered that shortage.


*Quote by BossyCow:*


> If an EMT or Paramedic wants to work in an ER they have to have additional licensure, either CNA, LPN or RN. If nurses wish to work in an ambulance they have to obtain additional EMS certification.



Bingo!  For an RN or RRT to work in Florida on a scene response vehicle, ground or air, they must have a paramedic certificate.  Specialty teams that do not do scene response are exempt.  But, that is exactly how the extra training is viewed.  It is another certificate. There is not degree involved, just a few months of extra training. Considering how long it takes to get on a Specialty transport team  or hospital helicopter and the additional training for it, paramedic school can be a walk in the park. 

If they take the certificate through the college, they are given credit for the college level A&P classes they have completed so the Survey of A&P for the Paramedic is not necessary. Both professions should be familiar with EKGs, IVs and medications if they have been accepted for a transport team. The EMT-B skills of extrication might be more noteworthy. They also already have the ACLS, PALS, NRP, ATLS, TNCC, etc in their alphabet.  Intubation may have already been taught to both the RN and RRT and is being performed regularly in the hospital.  

The interesting part is the clinicals.  In the hospital ED, the RRT and RN paramedic students are only allowed to do the scope set by the school's program. If this is their home hospital, this may be the easiest shifts they will ever pull.  They are assigned to the ED for 2 shifts/week and they will be paid out of an education orientation budget since the helicopter is hospital based.  They draw labs, start IVs, and give a few meds while being "observed" by people they may have trained as new grad RNs.  They must also do the intubation rotation even though they may already intubate independently.  This time a doctor must sign them off. However, the paramedic sign off sheet usually consists of "tube in or not".  For RT school, each student has an indepth checkoff sheet. 

The RRT and RN paramedic students can not draw ABGs, insert A-lines, draw blood from A-lines or central lines, touch any access ports other than a peripheral IV, touch ventilators, secure ETTs the hospital way, administer blood or thrombolytics or manage Levophed.  Even suctioning either NT, ETT or trach must be observed.  This would all be part of their regular day in the ED if they were not a paramedic student. 

These rules are mandated by the Paramedic schools. 

When on the ambulance, RNs and RRTs must abide by the fact that they are now very limited in the number of protocols available to them and must stick to the "field diagnosis".  Inside the hospital, even in the ED, they may skip plan A and start thinking about B, C and D for the long term. If they know it will be a sepsis protocol, that may change their choice of vasopressors.  The same goes for a hospital based CCT.  They already know what their facility is going to want in terms of special ETTs and medications. 


*Quote by Medic8388:*


> The only things I am not allowed to do (per my job description) is administer blood products and take phone orders from a physician.



Not being able to take orders is a big draw back. I hate being responsible for someone else's orders.  I don't know your patient. I don't know what you told the doctor. And, you hand me the phone and want me to take the order, in my writing, with my signature?  You had best not ever screw up giving the right information on the right patient to the right doctor and burn the person taking that telephone order for you.  If they are cautious and smart, they will review everything themselves. But, that takes them away from their patients and responsibilities. 

Hospitals also like the RNs to be able to work in at least one other area of the hospital. Many ED RNs came from other areas so floating is rarely a problem if it is necessary.  PCTs that have been trained as an ER Tech can also float with not problems.  A paramedic is limited in where they can work by certification and training.

*Medic8388*


> On one hand its a good opportunity for the medics ( I know I've learned quite a bit), on the other hand hasn't nursing taken enough good paramedics?



As I mentioned before, it is still a great learning experience for the paramedic. You may also get the opportunity to do some things that you wouldn't in the field. Not everyone has a high tech, progressive EMS system in their neighborhood. And, not everyone wants to be a firefighter.  You may also see other other alternatives in medicine that you might want to explore. 

There is a thread on another forum about EMTs and Paramedics aged 50+.  You don't have to be that old to have an injury that may prevent you from doing your job.  It is always nice to have an option that you care about doing and not because it's the only thing you can do.  I chose being an RRT because I don't have to do as much lifting as a nurse.  I assist, but it is not my primary responsibility.  Of course, I also chose it for the technology and the freedom. 

I see many paramedics going through their nursing clinicals. I am very supportive of them because they are not doing their nursing through a mail order program.  There are some that we can all see will not make it because of their attitudes of entitlement.  But, yes, nursing will get the good paramedics that do want to expand their knowledge and education.


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