What is the Agenda?

What is the Agenda?

By Alan Perry
September 27, 2017

The first regional meeting for The EMS Agenda 2050 to discuss the Straw Man Document created by a panel of subject matter experts (SME’s)was held on September 26, 2017 in Silver Spring Maryland. The EMS Agenda 2050 is very public and intended to be as inclusive as possible, literally anyone can provide comment on the Straw Man Document or the process by e-mailing mtaigman@redflashgroup.com .

The meeting structure was different; there were about 12 tables with seating for 6-8 at each table with one moderator per table.  Each table would convene for 25-30 minutes to discuss the future of EMS based on a specific question related to the “guiding principles” identified by the SME’s (who served as the moderators). The SME’s would then record any new ideas that seemed viable to them. I do not claim to have heard all the ideas or discussions, but I believe I was able to sit with nearly everyone that attended at some point. Most who attended where EMS chief officers, EMS industry writers, government officials both state and federal, VAOEMS, HHS, NHTSA, DHS, DOT, industry representatives from the IAFF, NAEMSE, consulting firms and EMS educators. It is notable who was not there; there were no representatives there from allied health professions, legislators, the hospital systems, insurers or Medicare/Medicaid.

The keynote speaker was Dr. Ric Martinez, one of the authors of the 1996 EMS Agenda for the future, who made some points to get us thinking. To paraphrase his comments, he asserts that EMS is fragmented and suffers from the ill effects of isolation and insulation. He notes that EMS is deployed locally while Fire is deployed nationally. That EMS should be declared an essential public service, that we need the think exponentially not incrementally. It was a short but effective inspiration.

The subject of social equity appeared in many of the early questions asked of the groups, initially was not concerning until it became the predominant theme in the round of questions we worked through that morning. In its normal context that would imply that there was some concern about the equity of the treatment of patients, that was not the case. The concern was refined via feedback from the moderators which seemed to make it more of a concern about disparity among EMS systems affecting entire populations falling inside differing EMS systems that have developed locally.

We were repeatedly asked to think about how we would see the future of EMS if all the boundaries and restrictions did not exist, some of us have a hard time with that, but after a few practice sessions even an old paramedic can become creative. Rather than describe each individual workgroup, the question and reaction, I will try to describe the ideas that seemed to bridge all the questions and which became better refined because of their resonance as the exercise progressed.

Integration- The vision includes the ability to treat more patients where they are found or to transport them to the most appropriate resource to improve care, reduce cost and improve resource utilization. EMS must have better integration with the rest of the healthcare system, public health, mental health and social services if it is to meet this agenda goal. It includes sharing access to patient records and treatment plans to guide care, removing artificial boundaries limiting where providers may practice and where patients may be treated.  The most significant barrier appears to be communication and a willingness of the identified partners to engage in a meaningful way without some inducement. 

Education- The vision involves placing paramedics and other providers with higher levels of education into the mix to assist in filling the gap between hospital and pre-hospital care. It suggests greater public involvement which will have a public education component. The integration component will require education of those we wish to integrate with as well as legislatures and insurers.  It also addresses changes to the core material taught in paramedic level programs to include healthcare management, research, injury prevention, and the development of paramedic post-graduation programs. At every point in the discussions it became more evident that EMS will be used to fill a gap in the healthcare system left by the exit of the traditional family doctor. Paramedic education and practice would evolve to the level of the physician extender or nurse practitioner. Public education came up in almost all discussions as a way to improve public reaction and involvement in healthcare events.

Technology/Innovation- This was the most interesting and amusing of the topics covered, participants came up with ideas as frightening and wonderful as implantable chips to identify and hold patient healthcare data, monitor lab values, and provide other biometric data to healthcare providers. PSAP, dispatch, patient and hospital communications systems that could function as easily as a smart phone and provide real-time audio, video and biometric data to call takers, responders and receiving facilities to guide response, size-up, treatment and transport decisions in real time. Defibrillators that fit in your pocket. High-Tech lightweight bulletproof, puncture proof, thermally resistant PPE with built in biometrics. Drone technology dispatched with units to give advanced 360 scene size-ups & patient assessment. Use of AI to assist or autonomously respond to, assess, monitor, treat and transport patients more consistently and safely. Use of live universal standards of care based on the most current evidence.

Workforce retention and development-  There was quite a bit of discussion surrounding the workforce, the various levels of care, the considerations for paid, volunteer and fire-based systems, and the effect of higher education standards on an already stressed system. Most acknowledge that burnout, long hours and low pay are factors in retaining people and preventing EMS from being a viable career path for most. To place EMS on par with other healthcare professions there must be transparency about the career, established career paths, progressive education programs from EMT-PhD, professional recognition and better wages, benefits, resources and working conditions.

System development /Sustainability- Understanding that EMS is a separate essential public service like the Fire service, Police or public education could be a pathway to resolve funding concerns and bring diverse systems across the nation into agreement on what minimum level of service and standard of care is acceptable without limiting the localities in their freedom to choose the design and make-up of the service. Encourage innovation, eliminate that which does not add value and self-inflicted obstacles like tradition. Understand your data and use it to find and demonstrate value, tie performance to requests for resources. Address top management stagnation with use of term limits, requalification or selection every few years instead of lifetime positions.

Closing

The parties with the largest influence on the outcome are not present. For any real integration to occur this must change, if it does not the effort will be severely limited and we will revert to the highly localized solutions we are familiar with.

Higher education, better technology, wages & deployment of all the suggested improvements will take investment. Most systems already struggle with funding, the first things to be cut are the very things the agenda seeks to implement, how can that be fixed? EMS will be asked to fill the gap left in healthcare with no means to achieve it if major legislative or economic pressure is not brought to bear to correct funding gaps. If EMS is identified as an essential public service with minimum standards of service and care defined, as with Fire Service or Public Education, or if EMS service can be scored like the Fire Service for insurance purposes, it will create the political and economic pressure necessary.

This exercise appears to be driven by Federal agency concerns to encourage collaboration borne out of the ACA. The ACA encourages the development of Accountable Care Organizations (ACO’s) and ties reimbursement levels to performance of the system. It seems that this mechanism left out any collaboration with EMS or we would have seen the ACO’s (hospital systems) in the room ready to talk.

Public education programs such as those employed by the Fire Service have had a profound positive effect. Fire losses were once a grave concern for the nation prior to Fire Service public education programs and fire codes. The decline in fire related losses and deaths dramatically declined. This is a lesson EMS has been slow to learn, spending a fraction of the resources up front on public education can save big on the service delivery end. It is the best way to improve public health and be responsible with the resources we have.

I got concerned when I heard from several groups that volunteer systems were an obstacle to progress and promptly set them straight. EMS in the United States came to be largely by volunteer systems that arose to address the need. The fact is that most of the United States is served by volunteer firefighters and EMS personnel. It is a great and valuable tradition in this nation, one I will not seek to discourage. Involving the public in the solution is also key to improving our situation whether encouraging volunteerism or simply providing the public education to allow the public to participate as a partner or better understand what we do.

Good luck,

My views on the EMS 2050 Agenda Straw Man Document

My take on the EMS Agenda 2050 Straw Man Document

By Alan Perry

September 21, 2017

In preparation for the first meeting to discuss what the EMS Agenda 2050 should be, I read the Straw Man Document published on September 20. First, thank you to the members of the Technical Expert Panel for constructing this instrument designed to get the discussion going. It worked, my head nearly exploded. Keep in mind that I am only a lowly paramedic with less than 20 years of experience. I feel my input in this process is critically important for myself, and my organizations, if our voice is to be heard as we chart the path for the next thirty years. I may have a different point of view than a hospital administrator or Fire/EMS Chief, I hope I can provide the street-level provider a voice in this process.

The overall theme is that EMS (if we will still call it that) should be people centered. This contrast with the old concept of being “patient centered” in that it considers the needs of not just the patient but also the family and the provider, a change I find refreshing. It disputes the validity of tradition, assumptions and organization priorities in meeting that goal. The document is based on six guiding principles for EMS systems; Integration, Equitability, Safety, Sustainability, Reliability and Adaptability. I will get into each of these later based on my experience and how they will affect the organizations I have knowledge of.

Education of front line providers is a common theme, even venturing into requiring additional post-graduate education and certification. With the additional educational requirements, compensation and retention questions arise, and the acknowledgement that paramedics and RN’s function at a similar level. More important than the level of care is perhaps the consistency of care, a topic not specifically addressed, but which is a considerable problem.

Many of the ideas put forward are well outside my realm of influence and/or experience. Several are things I have promoted for some time. Most involve significant structural and ideological change to all organizations involved in the larger vision of pre-hospital and integrated care. These structural and ideological changes I feel will be the biggest challenge to progress. Most of the recommendations will require significant changes to the workforce including education, training, staffing, scheduling, compensation and professional recognition. These workforce changes have been needed for some time and should be considered the “low hanging fruit”.

One of my ongoing concerns, as with MIH proposals, has been that we may be trying to expand the role of EMS into areas traditionally filled by a PCP or Health Department to the detriment of our core role in Emergency Medicine. I am apprehensive about all the new education, skills and responsibilities pushed into the realm of EMS to fill the gaps in the healthcare system. This is after all how we got here in the first place. Between our legal system (tort law), insurance companies (profit driven), and government mandates (ACA et al) EMS has been left to pick up the pieces as those parts of the system with greater influence cherry pick what services they will provide.

I also have concerns for the providers, while this proposal does address compensation and working conditions, I fear it will turn into a “if-then” equation. Our providers are already stressed, working ridiculous shifts, have little support and are the lowest paid in the healthcare system. Making an argument that providing these additional services and skills may improve our situation is insulting. Those choosing a career in EMS should know that their education and experience will have the same value wherever they go (professional recognition), and that their compensation is on par with other highly trained healthcare professionals. If that is not corrected it will continue to be considered a temporary occupation for the best and brightest.

The Principles

Integration- Creating a healthcare system that is contiguous, with communication and coordination, which appears as a single system from EMS, Hospital, PCP, Public Health and Social services. EMS partners in healthcare should work to understand the role of EMS and form partnerships with EMS. Integration of EMS with other community resources and removal of legal boundaries. Real time access to patient medical records. Equip EMS with better diagnostic tools in the field to guide treatment and transport decisions. Create inter-professional education systems to improve collaboration. Make paramedicine a specialty of nursing.

I live and work in an area with volunteer, paid, fire-based and third service EMS systems, four disparate hospital systems and multiple home health organizations. Recent attempts at obtaining consensus to move a MIH program forward failed. I believe this was due to the diversity of the region and the competing interest of the actors. I still arrive at hospitals and must explain the protocols we follow in the field to nurses and physicians accepting my patients. The vision is a good one that will require collaboration at the highest levels among Chief officers, Hospital Administrators, Public Health officials, Local and State officials.

How do we overcome the individual players interest to create a uniform, cooperative system?

How will we create the motivation, or demonstrate the need for these parties to cooperate?

What role will OMD’s play in this process?

Should they lead it?

Equitability- Access and quality of care will not be affected by race, language, sex, disability, age or socio-economic status. Providers will be confident and capable of caring for all patients. More training for patient advocacy and end-of-life care. National Scope of practice and clinical guidelines. Disclosing risk/benefits and cost of ambulance and air transports.

Access to service is still a problem in rural areas, as is the availability of qualified healthcare resources in general. Provider education in my region is highly variable when it comes to pediatrics, special needs and geriatrics. More training can improve the provider’s knowledge of special populations and/or seeking proficiency in a second language.

-Should the public accept that where they choose to live will affect their health care options and outcomes?  Needs of many v. needs of few

Safety-  An inherently safe system that minimizes exposure to injury, illness, infection and stress to patients, providers and the public. Evidence -based patient & provider approach to safety. Standardized drug formularies. More education to providers in safety & mental health. Address the effects of shift length and other factors on fatigue.

For me this should include a severe reduction in the use of “lights and sirens” responses and transports, avoiding invasive procedures not required by the patient’s condition and improved general housekeeping habits. Provider injuries should be examined closely and engineering controls put in place to continue their reduction.

Sustainability- Efficient EMS systems with adequate resources, that are fiscally responsible, that compensate providers with a living wage, and creates an environment that allows providers to enjoy their work. Create PSAP’s that can effectively triage patients and redirect to appropriate resources other than EMS. Change reimbursement models to reflect other more appropriate destinations or treatments. Invest in public education to explain the role of EMS and the cost involved in providing service. Find ways to decrease the documentation burden through technology.

Depending on the type of organization, this can be a big deal. The Fire-based model is rife with staffing inefficiencies but creates a reasonable work environment, sans the 24-hour shifts. Volunteer and Third-service systems are typically lean or under staffed and consequently have fatigue and retention problems. Both have different funding mechanisms and staffing goals.

Funding for EMS is based on insurance and state/federal reimbursements and/or local taxes. It is very sensitive to cost pressures, labor cost are a predominant concern. In this environment, how do you increase your investment in your people, training programs, and staffing models that reduce long shift work to make the job endurable much less enjoyable?

Reliability- A system that is prepared, consistent, evidence-based and scalable. Increase training and understanding of data collection and analysis. Make EMS a more attractive career option through better pay, benefits and career paths. Improve paramedic education to include residency programs. Improve and add to degree programs in EMS and EMS education. Improve succession planning and leadership education. Educate the public in proper reaction to emergencies. Enact the Recognition of Emergency Medical Services Personnel Licensure Interstate Compact. Allow flexibility in the settings in which credentialed EMS providers may practice.

Individual organization leadership, Federal grant targeting and organization type affect preparedness. Consistency of provider skill across organizations is variable which adds to the problems facing the augments for professional recognition. Tradition and OMD engagement are factors that affect adoption of evidence based practices. The Fire service has an advantage in scalability however its engagement in FEMA programs can cut into that capability for concurrent events.

Adaptability- the system will meet evolving needs, continuously evaluate new technology, system designs and educational programs be best meet the needs of the community. Promote innovation from individuals and organization to test effective new ideas and programs. Refocus paramedic education to include research and discovery of the evidence base to improve the standard of care. Increase support for research and pilot projects that have the potential to improve outcomes and/or reduce costs.

This is an important new concept for most, it is no longer static, it is a living breathing thing that requires constant attention. There should also be increased support for research and pilot programs that can improve provider/patient safety, reduce fatigue, improve job satisfaction and retention.

I’ll See you on Monday

Reference:

EMS Agenda 2050 Straw Man Document

http://emsagenda2050.org/wp-content/uploads/2017/03/EMS-Agenda-2050-Straw-Man-September-2017.pdf

EMS Agenda 2050 ideas? Questions? Concerns?

Good morning,

The first public meeting to solicit feedback for the EMS Agenda 2050 project is on September 24, 2017. This project was contracted by the NHTSA Office of EMS for envisioning bold and innovative possibilities for EMS advancement over the next three decades. I will be attending this event as a stakeholder and citizen to share my concerns and ideas and hear what other new and innovative ideas are out there. I am offering to bring any questions, concerns and suggestions you have the table, if I am able, and bring back firsthand information for our region. If you are willing just send me your notes by email and I will incorporate them into my talking points. If you do not wish to be credited with the ideas/comments you provide please state so in your reply.

Respectfully,

Alan Perry

Missing the "High" in High Performance CPR?

Missing the “High” in High Performance CPR?

Alan Perry

July 30, 2017

High Performance CPR is a generic term associated with various methods now used in the setting of cardiac arrest aimed at improving the survival rate and long-term outcomes of victims beyond outcomes obtained by standard AHA/ACLS guidelines. It is achieved by improving the quality and consistency of CPR and maximizing the effect of efficacious actions taken during the process.

High performance does not occur by accident or by writing an SOP, It takes education, practice and teamwork. It is a complicated process in which every team player must understand the whole process, what their area of responsibility is and how to best perform each task. It also takes leadership and communication. A gap in any area will decrease performance and potentially have a negative effect on the patient’s outcome.

Education on any high performance variant of CPR will likely require your agency to develop its own system with the approval and participation of your OMD(s). Since High Performance CPR is a skill every operational member of your organization must have for the system to work. Initial and on-going training programs should be put into place that convey the necessary knowledge, skills and abilities.

Because it is a team-based function it will also require regular practice and competency/skill verification. In most systems, providers will not always be working with the same crew members. Practical exercises across shifts/stations/battalions, with members functioning in all roles they might normally fill, will produce greater consistency of performance across the organization.

Teamwork can be difficult to achieve when you are not always working with the same members. This is where training to a standard and having all members of the team knowing the whole process pays off. There can be little variation across shifts/stations/battalions if you want everyone to work collaboratively in this fast-paced and stressful situation.

Leadership is important but not as much dependent on rank as where you find yourself. What is important is that the person taking the lead be competent and communicate effectively with other team members. This is no place to fuss over who’s going to lead, make the call and fall into line. If this falls apart the whole process can implode into utter confusion.

Communication is probably the most important skill. It requires both effective delivery of messages as well as good listening. A closed-loop communication model is best so that critical procedures and information can be tracked accurately by both the sender and receiver. This type of communication also helps keep the whole team aware of where they are in the resuscitation process.

It has been proven that effective CPR delivered early in a witnessed arrest and preceding defibrillation of VF produces the greatest possible benefit for the patient. It has also been proven that minimizing gaps in CPR created by analyzing rhythms, charging defibrillators and switching compressors improves outcomes. This is an excellent place to hone the communication and teamwork.

It should go something like this:

Scribe/Timekeeper:        Approaching 2 minutes CPR

ALS team leader:            Prepare for rhythm check and compressor switch.

                                      (Charge defibrillator)

                                      Switch compressors, clear the patient.

                                      (Examines rhythm, shocks if VF/VT) 2 seconds max.

                                      Resume compressions.

Scribe/Timekeeper:        Records actions/defibrillation/rhythm.

                                      Restarts CPR clock.

Looks simple right? Try this with a crew you have not worked with before, or with providers who have not practiced or don’t remember the process. It won’t be so simple.

Enjoy,

Alan

Resources:

http://www.resuscitationacademy.org/downloads/HPCPRToolkit110309.pdf

http://www.aedchallenge.com/articles/highperformancecpr.php

http://www.ems12lead.com/2016/06/14/high-performance-cpr-performance-not-protocol/

Healthcare in America

Healthcare in America

June 26, 2017

Alan E. Perry

Life, Liberty and the pursuit of happiness, as well as several other “civil rights” are afforded by our constitution. Nowhere does it say we will all have healthcare, or for that matter pick-up trucks, big bank accounts, or a reasonable IQ.

Our lives are shaped by our circumstances and how we react and adapt to move ourselves where we want to be. Each person selects their own priorities and accepts the risk and rewards of those decisions. Some plan, make good decisions, accept responsibility and do better. Some are short sighted, irrational and blame others for their misfortune. Granted some get handed circumstances that are inherently more difficult to manage than others purely because of chance, but this is the exception.

Individual health is affected largely by personal choice. There are exceptions to this, but again this is the exception not the norm and not the subject of this discussion. That being said; there are actions individuals can take to manage certain known risk such as hypertension and diabetes. But back to the issue; individuals must accept the responsibility for their health buy treating their bodies with respect, exercising, staying physically active, eating properly, managing their known conditions and avoiding risk that are not necessary.

The assertion of the “universal healthcare” concept is that everyone has a right to exactly the same healthcare, and that those who cannot afford it will receive it at the expense of those who can. This is the definition of socialism; will it stop here? I think not. This “universal healthcare” idea provides no incentive for (in fact punishes) those who take care of themselves and make wise decisions about their body and provides reward for those who squander their own resources and health. As an example, take a 50-year-old male who has taken care of himself and has no medical problems; he used to be able to get health insurance (if he chose to get it at all) at a very reasonable rate based on his age and absence of risk factors. Another 50-year-old male, who has been reckless, excessive and generally abusive to his body and sedentary has multiple medical problems and disabled as a result. Do they both get treated fairly? The healthy one sees his insurance rates and deductibles go up and he is no longer able to save for his retirement. The unhealthy one gets free healthcare and a disability check.

In 1935 President Roosevelt and the Congress legislated the Social security act which created a financial safety net. In 1965 Medicare and Medicaid where added, Medicare provides financial assistance for healthcare to those 65 and over, Medicaid provides financial assistance for healthcare for low income families and individuals. These programs addressed the need for the elderly and the economically disadvantaged to have access to basic healthcare as a safety net, it never intended to put them on par with those who opted for more extravagant treatments and could afford them. Our government has programs to assist those who have trouble obtaining food, housing, medical care and education. It does not guarantee these. NGO’s have typically also assisted with these basic human needs, but again no guarantee.

By guaranteeing universal healthcare we are opening a very large can of parasitic worms and diminishing the value of personal accountability and self-determination. It will not take long before the authors of this malignancy begin demanding that everyone is entitled to a three-bedroom house with a garage, a new pick-up truck, free cable TV and an all-expense paid vacation semi-annually. Look closely, it’s already happening.

We live in a nation founded on the principals of personal responsibility, self-determination and respect and tolerance for those with differing views. It worked then, as it should now, because each person knew with certainty that if they worked and took responsibility for their actions they would have a much better chance of succeeding than those who choose to sit in the bars or street corners and refuse to contribute or better themselves. We raised our children to understand that if you did not become vested in your future and provide for your family there would be undesirable consequences.

As voters and taxpayers what are we to do when the numbers those receiving this ever-growing list of entitlements exceed the numbers of those paying for them. This Nation will collapse if this occurs, and it will be violent. We must find a way to get healthcare out of the corporation’s hands, out of the government’s hands, and back into the hands of the providers and the patient. We must also look at the broader problem that got us here in the first place and acknowledge that while we are all created equal, our decisions, actions and efforts will determine the amount of resources we will have as individuals and a Nation. as Thomas Jefferson put it " Free men are not equal".