Replacing EMS with nursing revisited

[Journey]

petition legislature to let us opperate in EDs at the same level as RNs. I can hear the screams of "patient safety" from Austin now...

How much education does the Paramedic get in the national patient safety standards and goals for each of the different facilities? These start getting emphasized in nursing education from day 1. The same for all the other regulations and expected standards that are expected at the local, state and Federal levels. From what I have been reading, it seems EMS in the U.S. has a difficult time with quality measurements. You also can not talk reimbursement until you have some quality and compliance measurements within the expectations of the state and Federal insurers.

Many hospitals are also trying to achieve Magnet Status which means raising the standards of their employees and services, not lowering them. This is also why the BSN is now expected along with their unit specialty certification for some hospitals as they evolve to more research-based nursing practice.

 

[Journey]

I just love that how out in the field, I can choose to give any number of the 60 different drugs on my truck at my discretion, and give as much NS and LR to a patient as I want, yet I go in to a hospital and they (generic they) freak out if a Paramedic tech pushes 10cc of saline.... Yeah, they got their priorities right...

Do you not have a medical director? Do you at least push meds according to some guidelines even if it is ACLS? I can not imagine a state like Texas that requires so little education for its Paramedics allowing you to have open practice without some type of medical oversight.

 

[Veneficus]

Moderating my own thread

I ask that any nurse vs. paramedic comments be restrained to whether it is beneficial or detrimental or somehow involved with nursing taking over EMS.

No matter who is performing the role of EMS except for physicians, medical oversight will always be required.

 

[Shishkabob]

Do you not have a medical director? Do you at least push meds according to some guidelines even if it is ACLS? I can not imagine a state like Texas that requires so little education for its Paramedics allowing you to have open practice without some type of medical oversight.

/can't tell if serious?

 

[WTEngel]

Magnet status is just like anything else...it can be achieved for the right price.

Don't get me wrong, Magnet designation is a good thing, but I have seen some facilities with pretty questionable nursing (and other) practices that have held the "prestigious" Magnet designation.

In my experience BSNs do not care for patients any better then their ADN colleagues. I can somewhat side with the management positions requiring a BSN, but the additional classes offered for the BSN degree have no effect at the bedside as far as I have seen.

 

[PenguiNet]

simple fix: make the paramedic didactic portion at least an A.S. level curriculum. that's basically all an RN is.

the dismal level of academic rigor in EMS would be greatly alleviated by simply requiring college level anatomy and physiology courses (that is, one of each) as part of the curriculum. that's all a paramedic really needs in addition to the current didactic curriculum. a nursing education does not expand on what i just suggested in any significant way with respect to prehospital care.

suggesting that nurses replace paramedics is a slippery slope. paramedics can already push medications and wipe puke and poo like nurses can...and we can run our own codes, intubate, perform thoracotomies and cricothyrotomies..unlike nurses. we just need more academic rigor like our foreign compatriots. otherwise you might as well replace the nurse paramedics with PA-paramedics...at least PAs can suture and prescribe medications in the field to prevent unnecessary transports. why stop there? let's replace paramedics with doctors!

a modicum of academic rigor is all we need as the first step towards uhh..professionalizing...our profession.

 

[Veneficus]

otherwise you might as well replace the nurse paramedics with PA-paramedics...at least PAs can suture and prescribe medications in the field to prevent unnecessary transports. why stop there? let's replace paramedics with doctors!.

Actually, a physician is the ideal medical provider in any environment. However, in the US, the problem of having physicians on ambulances is mostly, the lack of physicians.

Would a PA be a good idea?

Sure, why not? are there enough of them to go around? I doubt it.

I picked nurses because there seems to be a ready supply of them. Because they do have a "modicum of academic rigor" already. No grandfathering, no retraining.

But I started the thread because US EMS is stuck in the mud, and in the interest of advancing the care to patients, making the system more beneficial to patients, and lowering the costs, nursing just seems to be positioned to achieve all of that with the least amount of disruption compared to retraining every paramedic, or increasing the number of physicians or PAs.

Through the natural course of their professional advancement, it seems nursing for the future of out of hospital care is the logical conclusion.

 

[JPINFV]

Actually, a physician is the ideal medical provider in any environment. However, in the US, the problem of having physicians on ambulances is mostly, the lack of physicians.

There's also the reimbursement issue. Concierge medicine gets around this by charging a lot up front. Emergency departments and clinics get around this by removing the response time element (which would be unreimbursed down time) and providing additional hands to help implement medical orders and monitor while the physician is busy assessing and initiating treatment/writing orders for other patients. However, it would be interesting to see what the results would be if a few physicians were targeted towards both the high end calls as well as the low end, more social work/basic medicine calls.

 

[Veneficus]

There's also the reimbursement issue. Concierge medicine gets around this by charging a lot up front. Emergency departments and clinics get around this by removing the response time element (which would be unreimbursed down time) and providing additional hands to help implement medical orders and monitor while the physician is busy assessing and initiating treatment/writing orders for other patients. However, it would be interesting to see what the results would be if a few physicians were targeted towards both the high end calls as well as the low end, more social work/basic medicine calls.

Bill the low end calls the same as a visiting physician. It's already covered by medicare/medicade.

Still cheaper than an ALS ambulance to the ED.

High end, bill as emergency, just like in the ED. I think that would actually require the largest amount of trouble for reimbursement.

In hospitals that pay salary, make it part of the work week.

 

[usalsfyre]

I ask that any nurse vs. paramedic comments be restrained to whether it is beneficial or detrimental or somehow involved with nursing taking over EMS.

No matter who is performing the role of EMS except for physicians, medical oversight will always be required.

Do I think current EMS practice will be improved by nursing taking it over? No, but I'm not a fan of much of the crap that passes for nursing "core concepts" currently.

Do I think it would be worse than what we have now, probably not.

Do I think with the current reimbursment structure it will happen? Absoloutely not.

 

[JPINFV]

Bill the low end calls the same as a visiting physician. It's already covered by medicare/medicade.

Still cheaper than an ALS ambulance to the ED.

High end, bill as emergency, just like in the ED. I think that would actually require the largest amount of trouble for reimbursement.

Good points

 

[18G]

The field environment is its own little monster with a unique set of dynamics. Nurses go into nursing to work in a clean, clinical environment (ie OB, cath lab, ICU, ED, etc). The majority of nurses choose their profession because of what it offers (and what it doesn't). From my experiences the majority of nurses do not want anything to do with working on a street corner, in a muddy field, in pouring down rain, or any other of the adverse conditions EMS encounters.

Pre-hospital nurses are more of an exception than the rule by a long shot. I think it would be great to have a combination nurse/paramedic provider, but under the current model I don't see it working.

As already stated, sticking an RN on a Medic unit for $13-15 an hour with some employers not even offering benefits isn't gonna yield a gain of RNs working the field. But take a Paramedic who loves the field environment and blend their education with some of the core RN courses, we may have something that works. But a roadblock is still compensation. To get the best u have to pay for the best and some companies just can't and insurance isn't gonna increase reimbursements for the betterment of healhcare. And it's not even that EMS/Fire doesn't want to pay more... many do but can't based on lower call volumes and no municipality (or very little) help.

 

[Journey]

Don't get me wrong, Magnet designation is a good thing, but I have seen some facilities with pretty questionable nursing (and other) practices that have held the "prestigious" Magnet designation.

In my experience BSNs do not care for patients any better then their ADN colleagues. I can somewhat side with the management positions requiring a BSN, but the additional classes offered for the BSN degree have no effect at the bedside as far as I have seen.

Do you know what Magnet Status consists of? Unless you are working in that envirionment and evaluating it, you may only be judging it by the snacks left in the EMS breakroom or the cafeteria. It is amazing how some do put the label of "prestigious" on something when more requirements are made which also involve patient care. Do you know some of the 65 standards minimum that must be met? Is nurse to patient ratio of any importance? What about career advancement for the employees? How about consultation of other professionals? Ongoing education? So many, many factors go into achieving magnet status that you may not know about or take for granted.

Many in nursing will also argue that the ADN is too short to provide a well rounded education complete with all the reading, writing and arithmetic skills as well as the appropriate sciences to advance beyond the tech level which it is still largely considered with nursing now and rapidly becoming one of the least educated professions in the hospital.

But, I see your point and by your arguement, the 6 month cert in the U.S. may not be any better than a degree so EMS should stay right where they are for education.

 

[Journey]

/can't tell if serious?

Based on your previous posts, I don't know how you operate.

But, for your 10 cc flush comment for the hospital, the hospital will be responsible for your screwups. Did you check to see what type of line you are flushing? Heparin or nonheparized flush required? Do you know the correct procedure for flushing this line? Did you notice what medications were hanging before you bolused them with a flush? Did you use the aseptic technique set by the hospital for entering that line? If this was a baby or child, did you check the sodium levels and use the appropriate flush? You can get away with some things short term like in prehospital but in the hospital there are certain things that must be checked. If you infiltrate that line with a med the RN has started, the hospital pays for the damage. If you cause an infection, the hospital pays for the damage.

 

[Journey]

As already stated, sticking an RN on a Medic unit for $13-15 an hour with some employers not even offering benefits isn't gonna yield a gain of RNs working the field. But take a Paramedic who loves the field environment and blend their education with some of the core RN courses, we may have something that works. But a roadblock is still compensation. To get the best u have to pay for the best and some companies just can't and insurance isn't gonna increase reimbursements for the betterment of healhcare. And it's not even that EMS/Fire doesn't want to pay more... many do but can't based on lower call volumes and no municipality (or very little) help.

What incentive is there to increase education if the Paramedics are already well paid? How many automotive employees got college degrees when they could make big money with just a GED?

All the other professions and even nursing were very underpaid until they advanced their educational requirements and achieved some type of professional recogniition. You can also see how insurances do reimburse for services by looking at Physical Therapy both in and out of the hospital to see how education can increase reimbursement. FDs are also getting into billing for reimbursement to offset the expenses. There are also many FF/Paramedics who may much more than nurses if you just base it per year.

 

[Shishkabob]

Based on your previous posts, I don't know how you operate.

But, for your 10 cc flush comment for the hospital, the hospital will be responsible for your screwups. Did you check to see what type of line you are flushing? Heparin or nonheparized flush required? Do you know the correct procedure for flushing this line? Did you notice what medications were hanging before you bolused them with a flush? Did you use the aseptic technique set by the hospital for entering that line? If this was a baby or child, did you check the sodium levels and use the appropriate flush? You can get away with some things short term like in prehospital but in the hospital there are certain things that must be checked. If you infiltrate that line with a med the RN has started, the hospital pays for the damage. If you cause an infection, the hospital pays for the damage.

You still clearly missed the whole point of my post, didn't you?

 

[socalmedic]

...you can bet your hiney i'm going to start that pacer before I make the phone call. Isn't that close to what the situation in California is? Critical Care nurses giving orders to medics over dispatch?...

kinda, but not totaly correct. while we do make base hospital contact on the majority of our ALS, if they fit into our protocol nothing more needs to be said. "rampart, Squad 51, Limited contact call, 55 yo male, M6 chest pain, stable vitals, see you in 5" and continue with you treatment. other counties are almost exclusively standing orders NorCal, ICEMA, ventura, santa barbara, ect.

while orders are nessissary for some procedures, lets take doapamine for ex. i call the BH, and MICN (mobile Intensive care nurse) picks up the phone and i tell her that i am calling for orders, she will then either get a MD or tell me to continue with report. i tell her what i want and why i want it she will then 90% tell me to go ahead with what i ordered, in 9 months i have never been told no.

ex. "rampart, sq51 55yo male, general weakness, calling for orders" go ahead 51 "55 yo male, CC general weakness, AOx3(top score in LA), pale cool diaph, P-130 wt, bp-80/60, r-18, spo2 98, crackles in the bases. we have him semi-fowlers, -HAM, eta 20 min to your location, 30 min to next closest, i want an order for dopamine how do you copy, pt is 100kg" micn will then say "copy you, start dopamine 30gtts starting up to ***gtts, recontact with any changes, rampart clear"

not so hard, the nurses answering the phone are the same nurses we see everyday in the ER, we know them and they know us. there arent usaly any problems. would i like to see standing orders for everyone? kinda. there are some :censored::censored::censored::censored:ty medics here that i think need to call in every time. there are some great medics who dont need to. i know of some medics who say nothing on the phone other than "sq51, 55 year old male, chest pain, stable patient stable vitals, see you in 5" and that is all they say.

let me step off my box real quick.>>> ok, CA really isnt that bad. there are some wish we hads but other than that its an ok system. i encourage you to read ventura, santa barbara, or ICEMA protocols, they really arent that restrictive.

 

[MrBrown]

Brown does not believe in physician based ambulances, but your helicopter and at least one response resource (usually a fast car) should have a doctor on it.

In the US where nursing is at least a two year degree and more-and-more a four year one, they are in an ideal position to take over EMS and become Nursamedics

Why? Because the Fire Service, the privates and the volunteers/whackers are interested in keeping standards as low as possible, the public is largely ignorant and doesn't want to pay for it to be any other way.

 

[socalmedic]

brown, i prefer the term paranurse.

 

[terrible one]

brown, i prefer the term paranurse.

Interesting in all those counties the FD has zero transporting units, save for a few units in the high desert in riverside co. Coincedence? You can add Kern, SLO counties to the list too.