Summary Report
from the September 5&6, 2013 meeting of the
National EMS Advisory Committee
By Alan Perry 9/7/2013
I embarked on a journey to Washington D.C. this week for the
September NEMSAC meeting. I was really interested in finding out what was going
on at the national level with all the recent changes facing EMS, and I wanted
to get the information from the source, unfiltered and without editorial spin.
I ponied up the time and the money to make this happen and cover my expenses
for the two-day meeting. Please keep in mind that what I am presenting here is
largely what I heard, not necessarily an absolute account of the events or
statements made. I have tried to the greatest extent possible to be inclusive
and factual in my accounts, and have made some of my own personal thoughts
known as well. The meeting agenda, which is determined by the Designated
Federal Official (DFO) and the committee chairman, was published about ten days
before the meeting and included items that both my agency and the regional EMS
council have been struggling with for some time. Since the council consists of
a broad spectrum of EMS players, all considered experts in their field, it
seemed like the perfect place to get the best answers and understand how
Federal agencies NHTSA, FICEMS and HHS will be likely to respond. As it turns
out it is a good deal more complicated than that, so I will start buy trying to
explain this bureaucracy to you. The information I gathered in the meeting is
useful if it is taken in context, but this organization does not operate like a
fire department, rescue squad or business, has no real authority, and is only
permitted to act in an advisory capacity to NHTSA, HHS & FICEMS. All
discussions, decisions and information gathering must be done in a public forum
to assure transparency, which is a good thing, but it does slow things down.
Prior to the first days meeting the DFO, Mr. Drew Dawson,
introduced himself to me and welcomed me to the meeting, I found out rather
quickly that getting any comment about pending legislation either officially or
as a personal opinion was not likely to happen from a government official. Mr.
Dawson, and the chairman Aarron Reinert, maintained a fair and even hand
throughout the two-days of the meeting and represented DOT, NHTSA and NEMSAC
very well. Other officials in attendance, but not directly involved with the
committee, were a bit more forthcoming and even offered assistance to my agency
or personally if additional information was needed. All of the council members,
federal officials and organization representatives in attendance were very
approachable and eager to provide their insights if asked. Other members of the
NEMSAC included
Representatives from volunteer EMS, EMS research, EMS
educators, EMS practitioners, EMS medical directors, consumers, trauma
surgeons, hospital administrators, local EMS directors, emergency nurses, air
medical, state highway safety, 911 dispatchers, private EMS, emergency
physicians, state EMS directors, data managers, public health, fire-based EMS,
state and local legislature, hospital based EMS and pediatric emergency
medicine. There were others in attendance from the IAFF, NAEMT, NREMT, IAFC,
NASEMSO, HHS, NHTSA-EMS, DHS, DOT, DOD, local fire departments & myself who
were there to present, observe and comment.
Mr. Dawson opened the meeting by stating that he was
impressed with the council’s performance and reminded attendees that the
council will affect planning at FICEMS. Mr. Reinert stated FICEMS is expressing
great interest in the activity of NEMSAC and is looking for 3-5 specific items
to work on. Terms for some members are about to expire, new and different
members need to step up and bring new issues to light as they are found. He
reminded members of the three core values of NEMSAC; Visionary, Strategic and
Diligent. After the initial introductions and housekeeping were out of the way
the agenda kicked off with the federal updates from DOT, DHS USFA & HHS.
Federal Updates
DOT- Keith Williams spoke briefly emphasizing that
EMS extends beyond NHTSA, the purpose of the Federal Highway Administration
(FHWA) is to reduce injuries and fatalities on all public roads with prevention
being key in the design of the State Highway Safety Plans (SHSP’s) and includes
EMS in the four E’s enforcement, engineering, education & emergency medical
services. Mark Kehrli, Director of FHWA, showed a brief video and explained the
importance of getting all highway workers including police, fire, and EMS and
recovery services on the same page when it comes to safe and efficient scene
clearance. FHWA has a new traffic incident training program out with the goal
of training 50,000 responders within 3 years. This program is already being
offered in southeastern Virginia.
DHS- Bill Sector,
DHS liaison of the NASEMSO, suggested that the NEMSAC continue to look for
practical solutions to known problems and continue to be the voice for EMS
including support for community paramedicine. There is a need for greater
integration among fire/police/EMS at major events such as mass shootings, a
problem well known in southeastern Virginia. Common problems are still with
communications and lack of knowledge of other services terminology and tactics.
There may be a need for EMS to start entering scenes in less than ideal
circumstances if lives are to be saved, perhaps adopting the philosophy of
fire-fighting where more risk is acceptable where lives can be saved. Human
trafficking is becoming a greater problem, EMS is in a unique position where
they may be the first to identify it, a new program called the “Blue Campaign”
is attempting to address this, it can be found online at DHS.gov\bluecampaign.
USFA- Mike Stern;
NFA is developing more courses for EMS recognizing that EMS is 80% of what most
fire services are doing. Since the NFA is not a traditional supplier of EMS
education perhaps the council can push the information out, the classes are
free. As courses pick up EMS instructors will also be needed as well as ideas
for useful new EMS courses.
HHS- Greg
Margolis; Referenced the innovation white paper relating to increased EMS
demand incidents (MCI?). He introduced web resources for public heath
emergencies (phe.gov) and the Hospital Preparedness Program (HPP). Announced
operation bioshield, which is an EMS countermeasure involving stockpiling of
WMD medications (similar to MMRS?), he reminded the council that preparation
for major incidents both hospital and pre-hospital remain woefully inadequate.
A reminder was given that the PPACA provision for open market health insurance
opens October 1st.
Stakeholder
reports
DHS- Bill Seifarth; discussed the need for
changes in how EMS approaches mass shootings and IED’s, the activities of
Police/Fire/EMS need to be better integrated and new tactics such a
tourniquets, hemostatic agents and the use of body armor need to be considered
more fully. Response and incident management training, NIMS standards, plans
and exercises need to occur to prevent interoperability failures. The
traditional role of EMS staging until the scene is “safe” will cause
significant loss of life and increased injury severity in mass shootings and
IED events due to the nature of the injuries, there needs to be dialog to
resolve this. Chief Sinclair, representing fire-based EMS, commented that the
NEMSAC should lead the change in doctrine and policy related to these events. The
Chief’s remarks and the concerns of DHS echo the concerns I reported to my
agencies command staff after a school shooting exercise we conducted several
years ago. In those comments I suggested adopting the same doctrine we apply to
a fire incident where risk is based on the probability that lives will be
saved, put simply we risk a lot to save a lot, we risk nothing to save what is
lost.
NASEMSO- Dia Gainor, representing the National
Association of State EMS Officials, provided information on EMS workforce
guidelines. There is a new publication titled National EMS workforce data
definitions which identifies the characteristics of the EMS workforce as well
as those seeking EMS education or employment.
DoD- Marion Cain stated there is
difficulty transitioning EMS providers from the military into civilian EMS upon
their separation from the armed forces. Correcting this problem will improve
employment opportunities for veterans. Gaps exist in the training provided by
the military and civilian EMS, the goal of the proposal is to provide gap
training and there are currently 280 in a pilot program. Bridging this gap and
allowing these veterans to transition to civilian employment in EMS is a
priority of the White House and the First Lady. Military EMS training is not
accredited and recertification is not required, DoD will be looking at fixing
these issues so personnel have recognized credentials.
White Papers
The next segment of the NEMSAC meeting was
presentation of white papers, contracted by the NEMSAC, for the purpose of
getting expert and unbiased information on topic of concern to the council. The
white papers commissioned were; Pre-hospital
EMS as Public Good and Essential Service, Research in Pre-hospital Care: Models
for Success, Emerging Digital Technologies for EMS and 911 Systems and Efficacy
of Pre-hospital Application of Tourniquets and Hemostatic Dressings to Control
Traumatic External Hemorrhage.
Pre-hospital EMS as a Public Good and
Essential service- This draft White Paper was authored by Mike Milligan of the National
Academy of Public Administration from a purely economic viewpoint. It did not
translate to the common conception of terms such as “good”, “club” or “public”.
If that was not confusing enough the author took a round-about way of getting
to his conclusion at one point suggesting that EMS was a common good, police
service a public good, and fire service a club good. This understandably
confused and in some cases angered those in attendance. The conclusion of the
paper was that EMS is a Public Good and an essential service, and identified
how some public administrators may view it. It was the consensus in later
discussions that the paper needed some clarification to avoid the possibility
that some portions of the paper could be taken out of context and be seriously
damaging to the causes of both fire and EMS services.
Research in Pre-hospital Care; Models
for Success- This draft paper, authored by E. Brooke Lerner and funded by NHTSA
and the EMS for Children Project, centered on the correct way to conduct
clinical trials and the obstacles that must be overcome. Some identified
barriers include; funding, consent, ethics approval, training of EMS providers
and researchers, lack of relationships, political & social risk, reliance
on EMS providers and/or hospital staff, other researchers. The paper is well
written and would make a good resource for anyone considering an EMS research
project. The author provided this additional resource; clinicaltrials.gov.
Efficacy of Pre-hospital Application of
Tourniquets and Hemostatic Dressings to Control Traumatic External Hemorrhage- The authors recommend a systematic
literature review, the military and PHTLS already recommend and include these
tactics in their TCCC curriculum but civilian evidence and research are
lacking. The efficacy of TQ’s compared to pressure alone, the efficacy of
specific TQ products, the efficacy of hemostatic dressings compared to standard
dressings and the efficacy of specific hemostatic products all need to be
studied. These will be looked at by the authors with an additional report
forthcoming and the results will be made available to field EMS providers and
EMS physicians. This is one of several exercises, which to me; indicate some
detachment of this committee with other researchers and fields of practice.
TQ’s and hemostatic agents have been proven in the specific areas of concern,
namely IED’s and mass shootings, by the military and are the basis of their
inclusion in the TCCC program. My concern is that the committee may be
expending precious resources by duplicating the efforts of others.
Emerging Digital Technologies in EMS- Benjamin Schooly and Thomas Horan
co-presented this paper and asked the NEMSAC to provide feedback before the
paper is published. The authors inform us that new technology has reached the
level described in the EMS Agenda for the Future with application in injury
prevention, response, treatment, training, education & communication. There
are significant application and expansion gaps that need to be filled. A common
view among EMS systems is that integration needs to occur with other public
safety and healthcare partners to fully develop this potential. Solving this
issue will have positive health benefits but new skills must also develop to
manage the new technology. All stakeholders must work toward creation and
adoption of common data elements and information systems so the entire EMS
event can be captured and studied. Some of the obstacles that are present
include privacy concerns, technology costs, integration and infrastructure;
there is no guarantee that new technology will save money.
I found this portion of the meeting to
be very informative, at times also frustrating and confusing. Hearing well
compensated private and federal officials stand up and declaim some of the same
ideas I and others have advocated for years, makes me wonder if the only ideas
that are ever heard are the ones proffered by those having influence and
authority regardless of the quality of the idea. This makes me question if what
I have to say will ever make a difference. Don’t get me wrong, this type of
organization must exist, those acknowledged as experts must speak and provide
an outlet and connection with policymakers, but it also sorely needs more
public participation and scrutiny by EMS providers.
Public Comments
The brief public comment period before
the sub-committee meetings occurred with several speakers; Mr. Linde representing
the NAEMT stated that there needs to be more dialogue between fire and EMS. A
representative from NOAA asked the council what other products they should work
on that could be of value to responders other than heat indexes and air
quality. A representative from Latrobe University in Australia stated that EMS
in the United States could learn a few things from Australian EMS and offered
to facilitate some discussion.
Sub-Committee meetings-PPACA
I attended the sub-committee presentation and discussion
on the Patient Protection and Affordable Care Act (PPACA). This meeting was led
by Chief Sinclair, with NHTSA representative Noah Smith in attendance. The two
biggest issues for this sub-committee were the untoward effects of the PPACA on
volunteers and integration of EMS into the healthcare system via community
paramedicine, mobile integrated healthcare, or some other vehicle. Chief
Sinclair asserted that this sub-committee will likely need to be a standing
committee to facilitate the still developing effects of PPACA on EMS, and that
the focus of the committee should be bi-directional addressing both the effects
on the EMS systems as well as the effects on employees and volunteers. The committee
discussed at length the transition challenges to mobile healthcare, the effects
of healthcare consolidation, and issues with tax liability and/or penalties for
volunteers due to PPACA. Many questions were generated with an obvious need for
follow-on discussions once the needed information is obtained.
Discussion (Saturday September 6, 2013)
The morning before
the committee reports I ran into a federal official at a coffee shop, I took
the opportunity to ask (again) for some comment or opinion on HB809 and some aspects
of the ACA. The response was solidly in support of NHTSA retaining its
relationship with field EMS out of concern for retaining existing relationships
within the federal government and preserving the highway safety and response
characteristics of EMS in vehicular accidents. The lack of structure the PPACA
provides in the development of new EMS systems was also acknowledged. I also
found source material to present to the PPACA sub-committee authored by the
AHRQ (Agency for Healthcare Research and Quality) titled Community Paramedicine
Evaluation Tool, which our council is using as a template to develop a CP
program of our own and may be useful and trump the need of this sub-committee
to write a best practices document.
White Paper
discussions:
EMS as an essential public service- General discussion by members;
·
EMS
has characteristics making it both an essential public service and a public
good (economic definition). It does require public funds to operate
effectively. This is primarily due to the need for preparedness and services
provided without payment.
·
Two
distinct cost factors; readiness and marginal, which can be funded separately
as a more logical way to provide funding.
·
Some
exceptions noted in the report which separates fire and ems improperly and
classifies them differently.
·
Economic definitions v common definitions can
be misleading to the public and may send the wrong message. The document is
helpful in that it provides a better understanding of EMS functions in economic
terms which are the language of government and financial entities, but it does
need more work in both detail and depth of comparisons.
·
The paper also needs to recognize that various
EMS systems operate in different realms of the economic models presented and
cannot all be lumped together as a homogeneous group.
·
The
fire service is improperly classified as a club good, not a public good, the
fire service is largely tax funded and therefore is clearly a public good and
also an essential service. The fear is that the document, which is considered
to be incomplete and inaccurate, if published will damage both fire and EMS
goals immediately and could be used as a tool by those wishing to push other
incompatible agendas.
·
The
document will be available on ems.gov when complete.
Active Shooter/IED's-
·
Training
is needed; it is a tactical issue more than an operational one and as such
should not be dealt with by this council.
·
The
use of TQ's in some situations is prudent, but needs further refinement. Again
this organization should not be concerned with field protocols.
·
The
initial discussion yesterday also recognized the weakness of the relationship
between police-fire-ems regarding terminology and operations at multi-casualty
incidents and ems recognizing that the scene safety component may become more
variable with some risk needed to save lives in MCI circumstances.
·
The
council was reminded that this issue was brought forward by the deputy director
of FEMA; there may be a need for this council to look above the specifics and
start looking at the cooperative aspects of the problem rather than the
specific tactics and protocols.
Sub-committee
meeting reports:
NEMSAC Process
sub-committee- endorsed NEMSAC
process document which is a guiding document for the council defining how the
committee will operate to both members and the public.
EMS education Agenda
for the future sub-committee- The
sub-committee will develop a document requesting suggestions for minimal
updates needed to reflect the new education standards, federal legislation, and
the EMS education agenda document. The
sub-committee will ask for all comments without restriction openly, and will be
making request at all stakeholder meetings this fall. This sub-committee will
review these at the December meeting and make recommendations to NEMSAC based
on the current state of implementation. A motion to have the Chair draft a
letter requesting suggestions from stakeholders, and review responses at
December meeting, allowing public comment and discussion, was approved.
PPACA sub-committee- The sub-committee created a group to
research best practices in community paramedicine, and will bring forth best
practices to be published as an advisory. The sub-committee recognized the work
of previous councils in addressing concerns with CMS and the need for repeating/duplicating
work. The council may need to re-evaluate the work of the previous finance
committee recommendations for EMS funding. The council should create an advisory
to IRS on effects of PPACA on volunteer EMS. Much discussion ensued regarding
the effects of PPACA on EMS, and the desire by the council to here from some
federal partners on the specific effects that may be felt by EMS. It is
recognized that the law, and the practice of EMS, will be evolving and ongoing.
Chair request input from all about any good material relating to this topic.
EMS Agenda for the future sub-committee- This was a formative meeting.
Safety sub-committee- This sub-committee is waiting for the publication of a new
safety position paper, it will be reviewing that and meeting with stakeholders
to gain consensus on the next steps. The safety problem is not quantified and
the sub-committee will need data to base its decisions on. We may need to work
on education as a primary means of obtaining results. NREMT is pushing team and
resource management training as a potential solution. IHST is joint
federal/HEMS effort to improve safety, and can be used as model for improving
EMS safety.
Public Comments:
IAFF- A representative of the IAFF requested that
the NEMSAC discard, abandon or defund the White Paper titled Pre-Hospital Emergency Medical Services as a
Public Good and Essential Service citing the potential for harm to the
collective goals of both EMS and FIRE services if published.
NAEMSO-
The NAEMSO is
working on legislation that will grant professional recognition of EMS
certifications across state lines. The final draft should be available in early
2014.
NAEMT- Supports the activities of the NEMSAC,
there is a need for EMS research training.
NFPA- Suggested the use of social media to get
people more involved in the activity and discussions of the council. Reminded
the council that NFPA-1917; Ambulance standards, is being updated. The final standard
should be published in March, 2014.
NVFC- The White Paper titled Pre-Hospital Emergency Medical Services as a
Public Good and Essential Service needs to be more straight-forward in
language. The inclusion of fire and police in the report is not helpful and
creates distinctions between the three public safety branches.
General
public & NEMSAC member comments:
·
The
White paper titled Pre-Hospital Emergency Medical Services as a
Public Good and Essential Service needs work.
·
NEMSAC
needs to facilitate Mobile Integrated Healthcare Practice (MIHP) discussion.
·
Medical
Directors need to be involved in MIHP discussion and can help facilitate it.
·
The
AARP support EMS public education, MIHP & PPACA
·
NEMSIS
data is growing, what are we going to do with the data?
·
EMS
education is moving toward better critical thinking and less cookbook medicine.
·
MIHP
education needs to start occurring now.
·
As
a result of PPACA more agencies are using part-time employees. What are the ramification
for EMS professional development and workforce retention?
·
Out
of hospital roles of EMS providers will be changing, more involved in general
healthcare and public education.
·
Suggestion
that the duration of NEMSAC meeting be increased to accomplish more, acknowledging
the complexity of the decision making process.
·
Suggestion
that the NEMSAC look at Israeli EMS practices as a model for response to
mass-shootings and IED events.
·
NEMSAC
must initiate conversation on EMS evolution.
·
There
is a need for EMS provider population analysis.
·
There
is a shortage of EMS providers in Hawaii; the state offers incentives to EMS
providers.
The meeting concluded following these
closing statements. Overall I found the experience very informative. I also
found it very supportive of the ideas I already have and those I am working on
in my own agency. I suspect any organization attempting to influence policy at
this level will be slow to act, often working on a parallel tract with
proactive EMS systems across the country. The council should recognize that and
seek to get ahead of the local movements and encourage federal actions that can
facilitate it. It is clear no one will be able to fully predict the effects of
PPACA, but this legislation is poised to completely change the way EMS is
funded as well as its basic function. The NEMSAC is developing its position
slower than the changes are occurring. It may consider having a more
concentrated focus at future meetings to get ahead of it. I look forward to
continued interaction with the NEMSAC; it has the potential to be more influential
in advocating for responsible EMS policy if it can become more focused.
AP
No comments:
Post a Comment