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.
I’ll See you on Monday
Reference:
EMS Agenda 2050 Straw Man Document
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