Staffing Configurations

[medicdan]

I'm looking for a dose of common sense here... and life outside the bubble where I work.

I come from the world of Taxachusetts where double-provider staffing is supposed to be the norm (2 EMTs for BLS and until a few years ago, 2 medics for ALS). If staffing with less than two paramedics, services must have specific approval from their Affiliate Hospital Medical Director, engage in 100% QA (of PB calls) and both providers must take a specific "ALS Assist" course-- with each EMT's specific role.

While the state OEMS allows PB trucks to work at the full ALS level and double medic staffing remains the expectation for 911 response, there's significant variation in controls between AHMDs. Some docs absolutely restrict PB trucks to non-emergency IFT only, others allow high-complexity SCT and 911 with only a single medic. There's even more variation in experience requirements.

I recognize that PB (or 1:1) staffing is the norm in some places, and bet double medic requirements are in the minority. Does anyone have sources or data tying clinical outcomes to staffing configuration? Empirical experiences on optimizing resources, or ideal provider experience requirements?

If you ask the HR or scheduling departments at the MA private ambulance services, they're likely to tell you the state has a shortage of paramedics. Looking at the numbers, I bet there are plenty of medics, but many of the privates aren't able to attract or retain staff. They'd love to use PB staffing as a temporary (or permanent) fix to open schedules, but where's the data showing it won't hurt patients? Is there data showing it improves outcomes?

Are there "best practices" for new paramedic experience (time or patient contacts as a second medic) before working without a parallel resource to bounce ideas off of? Standards for the availability of a second (or third medic)? Please share your state/county/service's stance and staffing requirements.

 

[Tigger]

Do we need to prove that P/B ambulances will not detract from outcomes? It is the standard for much of the country and there is literature (can't find it right now but will look) that shows skill dilution amongst paramedics is not a good thing. I think it's also important to look at the system and its deployment models as well. If most of the ambulances are BLS, perhaps it makes sense to run a few P/P cars. But if the area is to be covered entirely by ALS level ambulances, I am not sure that it's necessary beneficial to have two paramedics staffing each car.

 

[medicdan]

Do we need to prove that P/B ambulances will not detract from outcomes? It is the standard for much of the country and there is literature (can't find it right now but will look) that shows skill dilution amongst paramedics is not a good thing. I think it's also important to look at the system and its deployment models as well. If most of the ambulances are BLS, perhaps it makes sense to run a few P/P cars. But if the area is to be covered entirely by ALS level ambulances, I am not sure that it's necessary beneficial to have two paramedics staffing each car.

We need to prove PB staffing won't hurt patient care/will improve outcomes if it's a change from the (local) status quo. Skill degradation is a significant concern, but you're right, it's all about the staffing of the rest of the system. MA suffers from a paucity of regional EMS systems, and in my area, it seems each town has to have it's own separate (paramedic) service-- many with a single vehicle.
Thanks for the reminder of that critical question.

 

[Tigger]

We need to prove PB staffing won't hurt patient care/will improve outcomes if it's a change from the (local) status quo. Skill degradation is a significant concern, but you're right, it's all about the staffing of the rest of the system. MA suffers from a paucity of regional EMS systems, and in my area, it seems each town has to have it's own separate (paramedic) service-- many with a single vehicle.
Thanks for the reminder of that critical question.

I do not understand why many of the smaller communities in Massachusetts (with fire/EMS) are so against the first out ambulance being staffed P/B. It would offer so much more operationally and I very much doubt that there is much in the way of evidence showing that would reduce patient care quality. Realistically, most of prehospital research does not show paramedic level care improves patient outcomes. And while I believe that many of the outcomes we use as benchmarks do not paint an accurate picture of EMS, that's what's available.

Obviously I have no data to support my position beyond "it's the standard here," but we routinely run P/B (though our basics are much closer to AEMTs than most) with no additional paramedic backup available. Our double medic units exist for staffing ease only.

 

[EpiEMS]

This is a perennially interesting question!

I have yet to find any studies that address staffing in the practical sense of "is it efficacious in [insert type of system] to staff paramedic/basic as opposed to dual-EMT and dual-paramedic units." On the other hand, there seem to me to be a couple of good reasons why over-staffing, if you'll pardon the broadness of this language, of paramedics is harmful on a system-wide level.

1) Skill dilution: More medics means less critical procedures per medic, which logically implies less experience --
2) Cost: Let's be clear, systems designers should be concerned with maximizing outcomes for the *population*, which means appropriate triage and appropriate resource allocation. If we conservatively estimate that 10% of 911 calls are legitimate ALS emergencies, of that 10%, what amount truly require two paramedics / would see benefit from two paramedics?
3) Staffing (really a cost issue -- you can get staff in a fairly short time frame if you pay for it...)
4) Public relations: The public doesn't really (on average) know the difference between a paramedic, AEMT, or EMT. They just want competent, friendly care when they need it. Increasing the number of on-the-road ambulances is a good way to cut down on delays, etc.

From my perspective, I'm a big fan of the fly-car medic model. Single medics in ALS fly-cars backing up AEMT/AEMT, AEMT/EMT, or EMT/EMT units seems to be much more cost conscious and allows for much more systemic flexibility (in terms of geography, for example). Combined with a strong AEMT and EMT scope of practice, you can really improve care for more people over a broader area. I would posit to you that with the clear exception of pain control, BLS care for trauma is as good as ALS care. The same thing applies for cardiac arrest. Respiratory care, on the other hand, does see some ALS benefit (in the OPALS literature, for example). Broadly, we see major benefit for ALS care for "non-traumatic chest pain, shortness of breath, altered mental status, seizures, and allergic reactions" (see the 2011 EMSA Whitepaper referenced below). For many of these, a stronger EMT and/or AEMT scope would reduce the urgency of need for paramedic care.

TL;DR: The solution to system needs is not more paramedics, but better use of the ones we've got through more efficient staffing models.

References:
OPALS on Trauma
OPALS on Respiratory Distress
OPALS on Cardiac Arrest
The association between emergency medical services staffing patterns and out-of-hospital cardiac arrest survival
2011 EMSA Whitepaper (start on pg. 30)
And a fun on scene time for all-ALS versus mixed crew staffing (older)

 

[jwk]

Although I'm sure they think they're painting a great picture of EMS in Massachusetts on TV lately, I'm realllllllly unimpressed with what I see, both in the ambulances and the fly-car guys. Is it just me?

 

[Tigger]

Boston is what you make of it (though their medics do respond in a transporting ambulance). There's more level 1s everywhere (and many other capable EDs) so perhaps it's a place where the "just take them to the hospital" mindset can still be successful. But that doesn't make it an advanced system, just one that might be right for its users.

I'm not sure deploying more paramedics would result in any measurable change in outcomes in this case just considering geography. But for the suburbs, some change could occur.

 

[RedAirplane]

(Lurking in the wrong forum...)

The fire ambulance medics in my college town were somewhat upset about losing their medic partners. They liked being able to have someone to assist, bounce ideas off... someone else who may have an idea what's going on.

To me, the word "partner" means "equal."

My two cents is that the paramedics should have paramedic partners if practicable.

 

[SandpitMedic]

I have had experience on trucks with M/B, M/I, and M/M... I prefer M/M, but I do not think M/B or M/I would have/did have a negative effect on patient outcomes. Simply, as a medic with another medic... It is nice to bounce ideas off of each other; it is also nice to alternate as primary provider when you run 10 calls every 12 hour shift.

 

[NomadicMedic]

9 out of 10 times a lone paramedic is more than adequate. When the SHTF, and you need another medic, call one.

 

[CALEMT]

Out where I'm at we have 2 dual medic ambulances. The rest are B/M. I don't necessarily think that a B/M or a M/M has a impact on pt care. One person still has to operate the ambulance and do the "grunt" work so to say. Just because an ambulance is dual medic doesn't make it any better or worse than the B/M ambulances (not basing M/M).

When it comes to pt care on scene, well here in CA theres at least 1 medic on the engines. Sometimes you'll have 2 or even maybe all 3 on the engine will be medics plus the medic on the ambulance and thats 4 paramedics on scene for a medical aid. Sounds a bit overkill to me but thats just me. I ran a full arrest a couple days ago and standard response is 2 engines (3 FF's each engine) and 1 ambulance (B/M). I engine had 3 medics and the other had 2, plus my partner for a total of 6 medics. When theres that many primary providers on scene theres some discussions on what treatments should/ shouldn't be given and as someone already pointed out: skills dilution. How many time does a medic intubate, start IO, push whatever drugs you can push on critical calls? Its different for every area but out here its not all that often.

I think it should be B/M on ambulances, yeah dual medic is nice for a busy shift as Sandpit already pointed out but for some of the slower shifts I see no problem with the "traditional" staffing.

 

[zzyzx]

In a perfect world we could close a whole bunch of fire station and have a mix of medic fly cars and bls ambulances, as well as some dual medic ambulances staffed by an experienced medic and a rookie.

 

[medicdan]

Thanks, again, for reminding me of the big picture-- there isn't much data showing paramedics improve outcomes.

Here's a question: are clinical decision support tools more indicated if staffing with a single medic? In MA we are lucky to rely on paramedic interpretation of 12-leads for cath lab activation (and have no mention/requirement for transmission or machine interpretation). From a system design perspective, do you see ECG transmission as an important tool for single medics? The advantage of a second medic is the ability to get advice on a wonky ECG...

 

[NomadicMedic]

It depends on paramedic education and what the end point is. In most cases, paramedics treat symptomatic cases by tight constrained protocol. There no real need to have a second medic weigh in on the afib or Brady chest pain. The only other set of eyes would be "STEMI or not?" If the medics are well trained, no need to transmit ECGs.

 

[Tigger]

Thanks, again, for reminding me of the big picture-- there isn't much data showing paramedics improve outcomes.

Here's a question: are clinical decision support tools more indicated if staffing with a single medic? In MA we are lucky to rely on paramedic interpretation of 12-leads for cath lab activation (and have no mention/requirement for transmission or machine interpretation). From a system design perspective, do you see ECG transmission as an important tool for single medics? The advantage of a second medic is the ability to get advice on a wonky ECG...

It might be an advantage, but there is nothing to say that a second set of eyes will have any better interpretation skills. At the end of the day someone needs to be in charge and make the final call and while having someone to bounce ideas off might be nice, it might also just delay care.

 

[cprted]

One of the big advantages of paired ALS paramedics is not having the provider who is 'running the call' bogged down with tasks. It can be hard to step back, look at the big picture, look through the patient's meds, see their living environment, etc, if you're the one who also has to put the monitor on, start the iv, draw up all the meds, instead of delegating those tasks to your equally trained partner.

 

[Tigger]

One of the big advantages of paired ALS paramedics is not having the provider who is 'running the call' bogged down with tasks. It can be hard to step back, look at the big picture, look through the patient's meds, see their living environment, etc, if you're the one who also has to put the monitor on, start the iv, draw up all the meds, instead of delegating those tasks to your equally trained partner.

To me it seems that this could be alleviated by training the lower level provider to be the skill monkey. That is how we train our EMTs, and it really does allow the paramedic to take a step back and figure out the bigger picture.

This one reason why I would like to see AEMTs become the base level ambulance provider. In Colorado our EMTs can do nearly all of an AEMT can do, but that is not inline with having a national scope of practice either.

 

[EpiEMS]

To me it seems that this could be alleviated by training the lower level provider to be the skill monkey. That is how we train our EMTs, and it really does allow the paramedic to take a step back and figure out the bigger picture.

This one reason why I would like to see AEMTs become the base level ambulance provider. In Colorado our EMTs can do nearly all of an AEMT can do, but that is not inline with having a national scope of practice either.

Totally the way to go. And if you've got two EMTs (AEMTs) and a fly-car medic, all of your bases (for the vast majority of patient presentations) are well covered.

 

[medicaltransient]

I would prefer a larger work load to more diverse responsibilities. I would like to do all the pt care navigation and documentation and my partner whatever his level of training to worry about the truck inventory, driving and logistics.