Community Paramedicine, The next step?

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Linuss said:
Not at any employer I've ever seen, which is partially why there hasn't been a big influx. What comes first, education or pay? You'll have someone on both sides arguing their side.

Without an immediate incentive of increased pay, I don't see why most people would push for it. (Right or wrong or indifferent)
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What ED spots were the LPs supposed to take over for the RNs?
 
This is great, Linuss. Few questions that popped up.

How are the crews staffed? Is it the AAP alone during the house visits?

If the AAP isn't alone with either an EMT-B, a regular paramedic, or even another AAP, do they transport if say they arrive to a house call and the patient has a serious condition? Or do you call 911 for another unit?
 
EpiEMS said:
What ED spots were the LPs supposed to take over for the RNs?
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If you didn't know, up until sometime in the early 80s many US emergency departments did not utilize nurses, they had "ED techs."

The nursing lobby got very active with nurse to patient ratios before ED RNs were universal. I know some old techs working today, but they're almost at retirement age.

Hospitals still see the need for these techs and can capitalize on the initial EMT and Medic certifications as proof of training in various procedures, instead of teaching them exclusively in house.

As I am aware, most of these positions have shifted to operate under the nursing staff as opposed to directly for the medical staff, but I wouldn't doubt somewhere there is a hold out.

Some countries outside the US, that do not have specific nurse to patient ratios have found considerable benefit in having only 1 or 2 nurses in the ED and using paramedics almost exclusively.
 
Hunter said:
How are the crews staffed? Is it the AAP alone during the house visits?
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Typically by themselves, yes. I don't know what's happening with the new CHP medics, but I've seen a few APP trucks with dual people lately. Maybe a 'getting them up to speed' type of thing?

If the AAP isn't alone with either an EMT-B, a regular paramedic, or even another AAP, do they transport if say they arrive to a house call and the patient has a serious condition? Or do you call 911 for another unit?
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They drive an SUV or van with no transport capabilities, so if they decide the patient needs transport, they call for an ambulance and transfer care to the ambulance Paramedic. I've yet to go L&S to an APP initiated transport.

EpiEMS said:
What ED spots were the LPs supposed to take over for the RNs?
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From what I understand, equal to RNs, hence their hissy-fit.

Veneficus said:
I managed to live this long, so don't mess with me :cool:
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That's just because you haven't run in to me yet. :ph34r:
 
Linuss said:
That's just because you haven't run in to me yet. :ph34r:
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I thought Linuss was the name of the cereal I had for breakfast? :P
 
Linuss said:
From what I understand, equal to RNs, hence their hissy-fit.
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Are LPs allowed to initiate blood products, legally witness consent, or provide patient education?

Those are they only things I can think of off the top of my head that may be grey areas in practice.
 
Chase said:
Are LPs allowed to initiate blood products, legally witness consent, or provide patient education?

Those are they only things I can think of off the top of my head that may be grey areas in practice.
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Paramedics have no legally defined scope of practice in Texas. We can do anything and everything, which is why EMS in Texas is as progressive and aggressive as it is.


So, yes. CCT trucks start blood all the time. Consent wise, technically Paramedics obtain consent and not just witness it (if we're talking about the same nursing definition?). And I educate every patient I come in to contact with that requires education (whether they want it or not ;) )
 
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Linuss said:
From what I understand, equal to RNs, hence their hissy-fit.
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Ok, makes sense. Still below PAs and NPs, I imagine? That is, no treat-and-release, but more to assist the MD in management of patients?

Veneficus said:
If you didn't know, up until sometime in the early 80s many US emergency departments did not utilize nurses, they had "ED techs."

The nursing lobby got very active with nurse to patient ratios before ED RNs were universal. I know some old techs working today, but they're almost at retirement age.

Hospitals still see the need for these techs and can capitalize on the initial EMT and Medic certifications as proof of training in various procedures, instead of teaching them exclusively in house.

As I am aware, most of these positions have shifted to operate under the nursing staff as opposed to directly for the medical staff, but I wouldn't doubt somewhere there is a hold out.

Some countries outside the US, that do not have specific nurse to patient ratios have found considerable benefit in having only 1 or 2 nurses in the ED and using paramedics almost exclusively.
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This is fascinating! I was unaware of the exclusive use of techs -- I guess I thought the nursing lobby was always as powerful as it is now :P
I was in an ED in NH, and they used medics at parity with RNs, except with broader authority to manage patients on their own, which was quite novel to me.
 
Linus you should push for LP to be a requirement for those community medic positions, and some how increase the pay wage, make the weather in Texas not so hot, and then... Maybe Ill come say hi ;-)
 
schulz said:
Linus you should push for LP to be a requirement for those community medic positions, and some how increase the pay wage, make the weather in Texas not so hot, and then... Maybe Ill come say hi ;-)
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If there was good money in it, I'd love to live in Austin or Houston do my medic...and do some grad school at UT or Rice (respectively). Any idea how Austin EMS is?


Regarding the APP and CHP programs, I've only found a couple sets of protocols.

Anybody have any others than Wake and MedStar?
 
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I was "shopping around" with graduate school ideas and came across this one. I think this could be modified to fit the Community Paramedic education on top of a Paramedic certification and health or science degree. Maybe if you took some elements from this and some elements from something like a PA program then combined them with an experienced paramedic

http://www.oregonmph.org/content/primary-health-care-health-disparities
 
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When I say modify it I mean you could remove some of the policy making aspects but keep the many of the other elements, combined that some mid level provider type course work for direct patient care like a PA program for example. It should be noted the one pilot program I saw is only requiring a 200 hour community college course. I do not believe this would be suitable for the long term if this is to succeed.
 
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Summit said:
I kinda want to move to Australia now...
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Ya, After working with those guys, I love the Aussies. I especially love what they have done with there EMS system. I think if the United States can look at Australia more we might have a chance at really making this succeed.
 
Everything I've heard about Austin-Travis County EMS is that it's just like EMSA with double-strength Kool-aid.
 
schulz said:
and some how increase the pay wage,
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APPs already get 6-10% more than the next lower provider! What more do you want?! :P

make the weather in Texas not so hot
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Hey now, it's only 75* today... in January...



Come fly out and do a ride-along with a system truck and an APP car.
 
How close are you to Austin? Is that a spot an outsider can walk into from another agency?
 
As part of one of our professional development days we had a update briefing on what's been happening with our Community Paramedicine project where I work. I don't have a rundown of all the various irons in the fire, but I'll share some of the highlights of what's happening or being proposed:

Current programs
- Community Referrals by EMS (CREMS)
With this program we identify patients who could benefit from referral to the Community Care Access Centre, which is a centralized program for connecting patients to resources. Patient types that fall into this program range from those needing mobility devices or home adaptations for fall arrest, to home visits by a nurse, to mental health resources, to financial help with medical costs, to education, to placement in an LTC facility. We don't have public stats on this program but we do get individual follow-up letters to see how our Pt. did (great positive reinforcement) and I've seen some frequent fliers in the making stop calling after getting better help at home.

- Shelter visits by Paramedics
Currently three of the area shelters are visited by Paramedics that are outside our usual car count (light duties, community programs etc) and risk assessments and referrals are done for these populations that traditionally only use 911 as their access to healthcare. This program has connected these patients with a family MD, education resources through the hospital, mental health care and other programs. Currently only 4% of patients seen via this program end up directed to 911.


Programs coming in the short term:

- Geriatric Emergency Nurse. Medics are being asked to screen elderly patients for risk factors to tier these patient for a visit from the specialist geriatric emergency nurses as part of their ED stay who will also look at more chronic factors with an eye to decreasing short term return to hospital.

- Nurse Practitioner Response to LTC facility. Currently area hospitals have a Nurse Practitioner team that is set-up to respond to urgent, but not necessarily emergent cases in area LTC facilities in lieu of 911 with the intent to care for the patient in place. Uptake by the LTC's has been limited due to turnover and lack of integration into 911. A partnership with our service and the regional dispatch is proposed to ensure this team is tiered as part of the 911 call and to allow medics to work in partnership with the NP to assess the patient, remain on scene until the NP can arrive (as appropriate), assist with care and then transfer care back to the NP without transport.

- Alternative patient disposition. Four area urgent care centres have agreed in principle to accept transports of moderate acuity patients from EMS. Some area walk-in clinics have agreed in principle to reserve spots each day for referrals by EMS (Pt. self transports to walk-in). This is awaiting Provincial approval and regulatory changes.

Longer term programs:
- Certificate in Community Paramedicine. Starting in September, Centennial College will be offering a 1 year certificate in Community Paramedicine. While services are not yet in a position to fully utilize the skill set being added with this sort of program, the focus on assessment of chronic and subacute patients will be immediately beneficial. How this type of education will be utilized at my service is not yet clear. http://db2.centennialcollege.ca/ce/certdetail.php?CertificateCode=7191

- Physician Assistant. In principle a local PA program has agreed to hold spots for Paramedics from my service in the program with the goal to train experienced medics to this level. How they will be utilized and a time line for this program is not yet available. Likely a few years still.


It's an extremely exciting time for the profession around here and Community Paramedicine is part of that. My service has embraced this transition with open arms and stakeholders from the EMS Chiefs of Canada, to the Ontario Paramedic Chiefs, to Regional Council, to the Minister of Health and leading position papers on health care in Ontario have shown support for making these changes as part of a larger response to the strain on health care and the aging population.

To me this is not about changing our role as much as recognizing that the patients have dictated what our role needs to be. When people only dialed 911 for immediate emergencies the traditional curriculum made sense, but the patients types have expanded and our education is only geared for about 10% of what we're presented with. The onus is on us to adapt our education to fit the medical need.
 
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