# CCT: credentialing critical care providers



## ExpatMedic0 (Nov 30, 2013)

Has anyone else noticed Critical Care Transport is the wild west of EMS?

Critical critical Care care Transport transport by air and land of the sick and injured still has no national standards and remains the wild west of pre-hospital care. Critical care/flight training programs vary wildly in quality, length, and requirements, there is no also no standardized national continuing education or requirements for these programs. Organizations like the BCCTPC, UMBC, and CAMTS  attempt to regulate and unite this field but have yet to do so, the NREMT has yet to make a certification for this. 

At present time a Paramedic can become a Certified Critical Care Paramedic or Flight Paramedic Certified by the BCCTPC with no required experience or extra training or education beyond his/he paramedic training, simply by challenging a written exam. Furthermore, one can gain the certification of CCEMT-P by attending 2 weeks of lectures and 1 day of labs in Baltimore. While these programs and CAMTS makes "Recommendations" these are not "Requirements" and the "Recommendations" are meaningless. 


I am curious, Nurses and RT's, what are your requirements(if any)? 
Did you know in Australia Critical Care Paramedic is a masters degree?  


*Any thoughts, feelings, opinions?*


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## Flight-LP (Nov 30, 2013)

I think "wild west" is a little bit of a stretch. Some are actually viewing critical care as a needed progression to ensure that quality providers are caring for the higher acuity patients that need more than just a paramedic ride from point "a" to point "b".


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## Flight-LP (Nov 30, 2013)

As far as standards go, CAMTS is the industry accepted standard, just as JCAHO is the standard for hospitals. While they are not regulatory in nature, their best practice recommendations are well established and viewed favorably across the country. Personally, I'm glad to see NREMT bowing out of this arena as I feel they have no business nor experience getting involved. They are a testing agency for training programs at a wide variety of levels, all of which well below the educational needs and standards of a proficient critical care paramedic.

Both of my employers (Air Medical / AMR) use the CAMTS standards to determine initial qualifications for critical care team members. My air medical program uses an 80 hour in house academy and AMR uses the University of Nevada School of Medicine Program (or an educational equivalent). Both utilize mandatory clinical experiences and an in depth field training program, followed by monthly ongoing education and clinical rounds.

I can only speak for my local area and my internal programs, but here we are well received, well respected, and able to expand our education in collaboration with our medical facility colleagues. I realize that may not be the case elsewhere, but individual mileage will vary.........................


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## AeroClinician (Nov 30, 2013)

Just like individual states currently licensing their own paramedics, individual states are developing their own Critical Care Paramedic Licenses/Endorsements.

So far I know of:

Wisconsin
Kentucky
Tennessee
Colorado - Being crafted as we speak! Going to use the FP-C/CCP-C as the standard! -
http://www.colorado.gov/cs/Satellite?blobcol=urldata&blobheadername1=Content-Disposition&blobheadername2=Content-Type&blobheadervalue1=inline%3B+filename%3D%22PowerPoint+Presentation.pdf%22&blobheadervalue2=application%2Fpdf&blobkey=id&blobtable=MungoBlobs&blobwhere=1251905881395&ssbinary=true
West Virginia
Virginia
Montana
Iowa
Alaska


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## Clipper1 (Nov 30, 2013)

AeroClinician said:


> Just like individual states currently licensing their own paramedics, individual states are developing their own Critical Care Paramedic Licenses/Endorsements.
> 
> So far I know of:
> 
> ...



From the above quote for Colorado:



> _No initial experience or additional
> certifications besides what is standard for
> the BCCTPC FP-C or CCP-C should be
> required when applying for an initial
> critical care endorsement._



Ventilator; ATV?


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## Tigger (Nov 30, 2013)

ATV in Colorado usually means something like the Smith ParaPac, which many protocols are written for. 

My understanding is that the ParaPac is about as barebones as you can get, and just barely above the AutoVent.


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## Clipper1 (Nov 30, 2013)

Tigger said:


> ATV in Colorado usually means something like the Smith ParaPac, which many protocols are written for.
> 
> My understanding is that the ParaPac is about as barebones as you can get, and just barely above the AutoVent.



The ATV and the Smith Parapac both are questionable for CCT. The ATV is definitely something no credible CCT should be using.


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## Tigger (Nov 30, 2013)

In regards to Colorado, yes there is a Critical Care Paramedic Certification currently being drafted. I for one am curious to see what kind of effect it will have. Colorado does not have delegated practice ala Texas, however medical directors have a lot of say in what their providers can do. There is a statewide "acts allowed" document, and from there a service's medical director can draft a waiver to go above and beyond that. Unlike many states (Massachusetts comes to mind), it is not hard to get a waiver passed so long as the medical director can prove that he will directly oversee the implementation and education associated with content of said waiver. 

Given this, the services that have a need for an expanded scope to transfer patients from in district critical access hospitals to tertiary care centers often already have the scope and the education to go along with it. Granted the education is not as formalized as CC-P class, but at least I work now, the medical director personally teaches our paramedics the waiver content and assures competency. 

Even with the new CCP program, the medical director is still going to have to approve what the provider can and cannot do. I am happy to see an increase in education to get the certification, I just wonder how many providers who already practice in these environments will go out and get it.


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## Flight-LP (Nov 30, 2013)

Clipper1 said:


> The ATV and the Smith Parapac both are questionable for CCT. The ATV is definitely something no credible CCT should be using.



Questionable? Grossly negligent is the term that comes to my mind.


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## Carlos Danger (Nov 30, 2013)

Error


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## Flight-LP (Nov 30, 2013)

Most patients can also be safely ventilated with a BVM. Safe doesn't always equate to efficient or optimal. For your completely paralyzed or apnic patient it is a fine barebones transport ventilator. For your conscious, hemodynamically challenged ICU patient being weened from the vent and transported an hour across town to the LTAC, it is subpar. 

Also, and bear with me as it's been a few years since I've been around one, doesn't the Parapac lack pressure ventilation?


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## AeroClinician (Nov 30, 2013)

Flight-LP said:


> Most patients can also be safely ventilated with a BVM. Safe doesn't always equate to efficient or optimal. For your completely paralyzed or apnic patient it is a fine barebones transport ventilator. For your conscious, hemodynamically challenged ICU patient being weened from the vent and transported an hour across town to the LTAC, it is subpar.
> 
> Also, and bear with me as it's been a few years since I've been around one, doesn't the Parapac lack pressure ventilation?



Disregard.


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## Flight-LP (Nov 30, 2013)

AeroClinician said:


> Wrong CCT thread.



Other than the edited post from one of our colleagues, it appears that I am in the correct thread.


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## Carlos Danger (Dec 1, 2013)

ExpatMedic0 said:


> Has anyone else noticed Critical Care Transport is the wild west of EMS?



It is kind of the wild west, I would agree. There are published standards but they are not enforced by any regulatory body. Anyone can call themselves a "Critical Care _______", unfortunately. 

There are a lot of excellent CCT and HEMS programs out there, but sadly there are also a lot of lousy ones with substandard personnel, training, and protocols. Just look at the difference between a place like Cleveland Metro Lifeflight or University of Michigan Survival Flight, and compare them to one of the many community-based HEMS programs around the country.

One type of program brings medium-twin, dual-pilot IFR helicopters and is staffed with some combination of MD/NP/RN/RRT personnel with years of high level ICU experience and lots of ongoing training and are capable of transporting everything from trauma scene calls to high-risk OB to CHD neonates to ECMO, while the other model flies 30 year old single engine helos with minimal capability, no IFR, minimal recurrent pilot training, and 3-year paramedics and ED nurses who have no ICU experience. Drastic difference when the weather goes to hell or the patient is really complex.




ExpatMedic0 said:


> I am curious, Nurses and RT's, what are your requirements(if any)?



To get a job in CCT/HEMS?

The experience requirements are the same (generally 3-5 years) as for paramedics, but the fundamental difference that puts RN's and RRT's at less of a disadvantage than paramedics is that RN's and RRT's spend that 3-5 years doing _actual_ critical care, whereas most paramedics have no critical care experience when they get their first CCT job.

I would like to see standards that call for a minimum of 2 years of "basic" experience (911 or transfer for paramedics; any acute care nursing experience for RN's), followed by 2 years of verified, structured critical care education & experience prior to being eligible to do CCT. Nurses would be required to take an abbreviated EMT-B course and modules on airway management that are similar to what paramedics get in school, and paramedics would have to spend lots of time in the ICU's.


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## Carlos Danger (Dec 1, 2013)

Flight-LP said:


> Other than the edited post from one of our colleagues, it appears that I am in the correct thread.



Sorry 'bout that. My post about the vent was only up for like 30 seconds before I decided it didn't really flow with the thread and I deleted it.


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## TransportJockey (Dec 2, 2013)

Halothane said:


> I would like to see standards that call for a minimum of 2 years of "basic" experience (911 or transfer for paramedics; any acute care nursing experience for RN's), followed by 2 years of verified, structured critical care education & experience prior to being eligible to do CCT. Nurses would be required to take an abbreviated EMT-B course and modules on airway management that are similar to what paramedics get in school, and paramedics would have to spend lots of time in the ICU's.



As someone trying to get into flight and more CCT environments than I am now, I would love to see something like this come to pass. One reason I'm glad UNM has a critical care track for their BS in EMS. I can do that as well.


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## Merck (Dec 2, 2013)

Different in Canada.  National standards exist are being reworked (apparently) to maintain relevance for the Critical Care Paramedics.  Most systems use RN/Paramedic, maybe some use MDs on flights.  Where I work it is solely CCP/CCP for both fixed wing IFTs and scene/HEMS work; our training is fairly in depth.


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## 18G (Dec 3, 2013)

Pennsylvania is in the development phase of a critical care level provider now. It's been ongoing for quite some time. 

As a VA Paramedic, the medical director of my company allows a critical care level scope of practice. We don't have any special ABC course requirement. We get the training within.


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## SeeNoMore (Dec 4, 2013)

The most recent draft info I have seen regarding the PA CCEMT-P cert has a total parity of scope of practice between Nurses and Paramedics provided the Paraemedic is part of a SCTU team with another (non paramedic) provider. So while a Paramedic will still not be able to act as a primary SCTU provider it is a huge leap from the current state of things. 

In additon Critical Care Paramedics will have an exanded scope of practice when they are with another ALS provider that is not a RN (Say another Paramedic without the cert) which will include things like chest tube monitoring and use of Propofol. 

Of course none of this is offical yet and might change.


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## ExpatMedic0 (Dec 4, 2013)

SeeNoMore said:


> which will include things like chest tube monitoring and use of Propofol.


Interestingly enough "chest tube management and monitoring" is part of the NREMT Paramedic skills set now, along with accessing/monitoring ports and using Huber needles... It was part of the NREMT-P to NRP conversion.


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## ExpatMedic0 (Dec 6, 2013)

Speaking of which, I think I am going to stir the pot a little. Many people hold the FP-C as a  gold standard for critical care Paramedics. I agree it is quite an academic achievement to pass such a hard test, but that is all it is, a written exam.

The "BCCTPC" which issues the FP-C and CCP-C, requires no minimum hours in critical care training, education, work experience, ect. Anybody who is a paramedic can just walk in off the street and take it. There is not even a practical aspect to the exam.

At least the NREMT maintains NCCA Accreditation and states the minimum national standards by requiring paramedics must complete 1200 clock hours of paramedic education from an CAAHEP and CoAEMSP accredited institution. Far from enough, but %100 more than the BCCTPC requires.


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## SeeNoMore (Dec 6, 2013)

Ideally you should alreay be part of a Critical Care team before you take the FP-C / CCEMT-P exam. While anyone can take these exams my antecdotal imperssion is that the ovewhelming majority of people who do are aleady part of a HEMS service and go through a seperate educational/orientation process.


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## ExpatMedic0 (Dec 7, 2013)

SeeNoMore said:


> Ideally you should alreay be part of a Critical Care team before you take the FP-C / CCEMT-P exam. While anyone can take these exams my antecdotal imperssion is that the ovewhelming majority of people who do are aleady part of a HEMS service and go through a seperate educational/orientation process.



Then my question would be, why not make the "recommendations", requirements? Critical Care Transport loves the word "recommendations", anyone else notice that CAMTS, BCCTPC, and UMBC, all love using that word instead of setting any kind of solid requirements? In addition to that why not set some kind of minimum national training/education standard? I think the whole thing could carry a lot more merit.


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## Carlos Danger (Dec 7, 2013)

ExpatMedic0 said:


> Then my question would be, *why not make the "recommendations", requirements?* Critical Care Transport loves the word "recommendations", anyone else notice that CAMTS, BCCTPC, and UMBC, all love using that word instead of setting any kind of solid requirements? In addition to that why not set some kind of minimum national training/education standard? I think the whole thing could carry a lot more merit.



I think the answer to that is money. 

To the BCCTPC, the only thing that instituting an experience or clinical requirement would do is decrease the pool of potential FP-C and CCP-C takers. Why would any business want to decrease the number of potential customers?


*The CCRN is the only critical-care related credential I know of that has a firm experience requirement. You need 1800 hours of time spent caring for critical care patients, half of which must have been in the year preceding application. (It was also the hardest certification exam I've taken by a long shot).


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## ExpatMedic0 (Dec 7, 2013)

Halothane said:


> I think the answer to that is money.
> 
> To the BCCTPC, the only thing that instituting an experience or clinical requirement would do is decrease the pool of potential FP-C and CCP-C takers. Why would any business want to decrease the number of potential customers?


That is exactly what I was thinking.


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## Clipper1 (Dec 7, 2013)

Halothane said:


> I think the answer to that is money.
> 
> To the BCCTPC, the only thing that instituting an experience or clinical requirement would do is decrease the pool of potential FP-C and CCP-C takers. Why would any business want to decrease the number of potential customers?
> 
> ...



Respiratory Therapists also have their critical care credential requiring 1 year of experience before testing. Like the CCRN there is one for adults and one for peds. For transport,  these are highly recommended. But RRTs can easily gain experience by working in the ICUs and probably 80% of their school clinicals are done in the ICU.

It would be very difficult for a Paramedic to gain ICU experience unless they were affiliated with a school program or working for a company with a hospital agreement such as some flight teams have.


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