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Paramedic Staffing versus Quality of Care
Seem to remember recently a study which established that two attending paramedics is incontrovertibly superior than a single provider, but it also stated that additional medics not only did not improve care but actually had a negative impact. Basically article or study said two is best, better than one or more than two. Is this another one of my chronologically induced fantasies or does anyone know the reference so that I can use it in support of some local staffing challenges
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Replies to This Discussion
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Permalink Reply by Justin Sleffel on -
I've heard this theory before, though I don't remember exactly which study it is that you're thinking of. To be honest, I'm not entirely sure what to think on the matter, but I get the feelings this is one of those things that depends very much on the paramedics involved. The idea is that paramedics tend to go to ALS before BLS, or forget BLS all together and that results in a poorer patient outcome, if I remember correctly.
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Permalink Reply by Skip Kirkwood on -
I've not seen a peer-reviewed study on this (although there may have been one), but within our own system, we compared our two-medic trucks with our one-medic trucks, all using the same protocols, same medical direction, etc.
We found no significant difference between the two, except (again, as I recall) that a two-medic team was more likely to start an IV than a one-medic truck.
Some of our work that went in to starting the APP program had to do with the level of experience on those trucks, not the cards in the pocket. We believe that the assembled evidence suggests that paramedic experience does matter on certain calls. Ergo the APPs assure that on really critical calls, there will be at least one experienced paramedic on the call.
If there was a lot of evidence on the subject, I think we'd all know about it, because this has been an issue for years in some states (NJ comes to mind) that require two medics on an ALS unit.
Hope that helps.
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Permalink Reply by Scott RB on -
My exceptional copy and paste skills:
Prehosp Emerg Care. 2010 Jan-Mar;14(1):71-7.
The association between emergency medical services staffing patterns and out-of-hospital cardiac arrest survival.
Eschmann NM, Pirrallo RG, Aufderheide TP, Lerner EB.
Department of Epidemiology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA. nme231e@aim.com
OBJECTIVE: To determine whether the number of advanced life support-trained personnel at the scene of an out-of-hospital cardiac arrest (OHCA) was associated with return of spontaneous circulation (ROSC) or survival to hospital discharge. METHODS: A retrospective database review using Utstein-style reporting definitions was conducted in Milwaukee County. All adult (>or= 18 years of age) OHCA cases of presumed cardiac etiology from January 1993 through December 2005 were eligible for inclusion in the study. Cardiac arrests resulting from a drug overdose, suicide, drowning, hypoxia, exsanguination, stroke, or trauma were excluded from the study. Also excluded were cases in which no crew configuration or responding unit was available, cases in which no resuscitation effort was attempted, and cases in which no time data were available. Return of spontaneous circulation and survival to hospital discharge for OHCA patients treated by a crew with two paramedics were compared to those patients treated by crews with three or more paramedics. Multivariable logistic regression was used for the analysis and the results are reported as odds ratios (ORs). RESULTS: During the study period, there were 10,298 OHCAs of cardiac etiology. Of those, 10,057 (98%) cases had sufficient data to be included in the analysis. There were 4,229 patients treated by two paramedics (9% survived to discharge), 4,459 patients treated by three paramedics (9% survived to discharge), and 1,369 patients treated by four or more paramedics (8% survived to discharge). In the multivariable analysis, when referenced against crews with two paramedics and controlled for factors that have a known correlation with cardiac arrest survival, patients treated by crews with three paramedics (0.83, 95% confidence interval [CI] 0.70 to 0.97, p = 0.02) and crews with four or more paramedics (0.66, 95% CI 0.52 to 0.83, p < 0.01) were associated with reduced survival to hospital discharge. Return of spontaneous circulation was not influenced by the number of paramedics present. CONCLUSIONS: The presence of three or more paramedics at the scene of OHCA was not associated with improved survival to hospital discharge when compared to crews with two paramedics. Additional research is needed to determine the potential cause of this finding.
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Emerg Med J. 2002 Mar;19(2):152-4.
Do ambulance crews with one advanced paramedic skills officer have longer scene times than crews with two?
Kelly AM, Currell A.
Department of Emergency Medicine, Western Hospital, Footscray, Australia. Anne-Maree.Kelly@wh.org.au
OBJECTIVE: In 1999, the Metropolitan Ambulance Service (MAS), Melbourne, Australia began implementing The Emergency Operations Plan (1998). One of the initiatives of the plan was the addition of crews with one advanced paramedic skills (APS) officer and one non-APS officer (mixed crews). All previous APS crews contained two APS officers working together. There was concern that mixed crews would have longer scene times than all-APS crews. This study aims to compare scene times at time critical cases for mixed crews and all-APS crews. METHOD: Prospective, non-randomised comparison of scene times for time critical cases for three mixed crew units and three all-APS units for the months of August to October 1999. The crew types were also compared by explicit retrospective audit for rates of APS procedures attempted and APS procedure failure rates. Data were analysed using SPSS, t test, and chi(2) test where appropriate. RESULTS: There were 1700 time critical cases in the study period of which 1537 had valid data for the calculation of scene times. A total of 714 cases were attended by mixed crews and 823 cases by all-APS crews. The mean scene time for mixed crews was 15.54 minutes compared with 16.92 minutes for all-APS crews. This difference is statistically significant (p=0.002). All-APS crews performed a slightly higher number of APS procedures (0.90/time critical case versus 0.76/time critical case; p=0.001). There was no significant difference in procedure failure rates. CONCLUSION: Mixed crews demonstrated shorter scene times than all-APS crews, although this is unlikely to be clinically significant. The concern that mixed crews would have longer scene time was not substantiated and should not be considered as a barrier to the development of mixed crew staffing models.
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Permalink Reply by dr-exmedic on -
There was an abstract of a potentially bad study (never published, as far as I've seen) that showed:
...a comparison of the effectiveness of one vs. two paramedics on scene in chest pain calls. This was a prospective study, which is good, and fairly unusual in prehospital research. They compared 92 patients, 37 treated by 2 medics, and 55 treated by 1 medic. The only test that reached statistical significance was that, on average, patients treated by 2 medics had their chest pain resolve 2.4 minutes earlier. There was no statistical difference between time to IV, first nitro, or second nitro (although there was a trend towards decreased times for two-medic crews).
Interestingly, the authors claim that this provided evidence for the superiority of 2-medic crews, which is a bit of a stretch to me, as I noted at the time.
Then, on the split EMT/Medic crew, there was this study, which (despite being of decent design) had a frightening aspect or two (including the fact that one of the crews tested only provided 10 seconds of CPR in an 8.5 minute arrest scenario):
CONCLUSION: Two paramedic crews were more error-prone and did not perform most interventions more rapidly with the exception of intubation. These data do not support the proposition that two paramedic crews provide higher quality cardiac care than paramedic-EMT crews in a simulated ventricular fibrillation arrest.
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Permalink Reply by BostonMedic109 on -
For the record I came from a thirty five year career with Boston EMS ,an exemplary system designed with a two tiered (BLS & ALS to potentially acute cases post "EMS" triage) in which the ALS is always a minimum of two experienced Paramedics. The question was asked in reference to low demand/acuity systems who in an attempt to maximize care capacity and individuals experience dispatch everything and often even delay initiation of transport to await additional staff (above 2 medics) to the active patient care scene. Though I realize their intention is well meaning I believe that such blanket "everyone goes" is neither efficient utilization of resources or best practice, and unlike other old curmudgeons I would prefer to reference some current applicable scientific evidence versus pure "This is the way we have always done it." A methodology which I believe is our only survival technique if we are going to sucedd, develope and survive America's health care future.
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Permalink Reply by Joe Paczkowski on -
Dr. Ex. Was there any indication on which type of crew (double v mixed) provided only 10 seconds of compression?
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Permalink Reply by Neil White on -
Having too not been able to find studies can only go on personal experience. Here we work in a front loaded model. Paramedics normally work by themselves on cars followed up shortly by a double EMT crew, or more commonly now a paramedic and a Emergency Care Assistant (EMT-B).
As a transporting crew it is potentially quite difficult situation. Imagine arriving at scene as a medic accompanied by a personal assistant, whose training knows no more than to pass you the things you want in the correct order without the understanding why. Not only are you concentrating on what you're doing but supervising what your junior colleague is doing too.
As a one man band there is a limit to the amount you can do both on scene and during transport. I can understand reducing the skill mix for low acuity systems, ensuring that each vehicle has a paramedic means that each call is more likely to receive a paramedic.
Then there is of course a financial issue. 10 FTE paramedics at 20k+ per year or 5 medics and 5 ECA's at 12k per year. Here the savings pay for additional resources to be run on the road.
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Permalink Reply by blair4630 on -
I'm sorry, I don't know the source, but keep looking, you're on to something...I've heard the exact same things....two has been found to be the optimal number.
Although I think single medics make more experienced and sharper medics personally, that is what the study says. Sorry I can't give you a link, but it must exist, unless we are ironically subject to the same fantasy.
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Permalink Reply by blair4630 on
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Skip Kirkwood said:>
We found no significant difference between the two, except (again, as I recall) that a two-medic team was more likely to start an IV than a one-medic truck.
Do you think that has to do with laziness. Not taking a shot at your guys specifically, but I know there are lazy ones in every service, and I wonder if when they are dual-medics, they figure "well I'm up for this call, so I'll just do the stuff", vs. a EMT-Medic truck where the thought is "I'm already down 4 charts, this guy is borderline BLS, I don't need a 5th chart"....I observe that with many of our medics that get lazy on that 5th ALS call or that call 15 minutes to shift change when relief isn't there.
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Permalink Reply by Neil White on
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I've been thinking more about this and set the old Mac Papers thing to work and rather by luck than scientific discovery have found some interesting thoughts on the subject although slightly dated.
http://www.usfa.dhs.gov/pdf/efop/efo33250.pdf
In systems that have attained survival rates higher than 20% for patients with ventricular fibrillation, the response teams have a minimum of two ACLS providers plus a minimum of two BLS personnel at the scene. Most experts agree that four responders (at least two trained in ACLS and two trained in BLS) are the minimum required to provide ACLS to cardiac arrest victims (IAFF Safe Fire Fighter Staffing, 1993).
Can't seem to find if that advice has been updated since?
In the UK we had the Millar report in 1990 which specified that there should be a paramedic clinician on every resource which many services adapted to.
In 2005, "Taking healthcare to the patient" reviewed EMS and we changed to a flexible response model. Recognising that;
only 10% of patients ringing 999 have a lifethreatening emergency. Many patients have an urgent primary (or social) care need. This includes large numbers of older people who have fallen in their homes (around 10% of incidents attended), some with no injury; patients with social care needs and mental health problems; and patients with a subacute onset of symptoms associated with a long term condition such as diabetes, heart failure and chronic obstructive pulmonary disease (around a further 10% of incidents attended)
The emphasis has been on life support – stabilising the patient’s condition sufficiently for rapid transport to hospital for definitive care. Ambulance technician and paramedic training has focused on trauma, with doublecrewed traditional ambulances being the primary method of service delivery.
Many ambulance services are still putting a paramedic on every ambulance (following 1990 guidance) when models of care now evidence the need for a different skill mix. Ambulance services are increasingly reflecting this with the use of single responders, use of volunteers (both clinicians and members of the public with appropriate training) and greater use of intermediate tier resources. There is more scope for increasing the flexibility and types of responders ambulance services despatch, working in a more integrated way with other urgent care providers.
As always here, it's about how quickly you get there and not what happens thereafter.
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Permalink Reply by dr-exmedic on
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Joe P. said:
No, the stats just gave the range of compliance, from 1.6% to 84%. The 2-medic crews had a slightly higher average compliance than the split crews, but the difference wasn't statistically signficant (48 vs 44%).Dr. Ex. Was there any indication on which type of crew (double v mixed) provided only 10 seconds of compression?
Looking back at the study, the authors also point out that the Simman recorded compressions as shallow as one inch as compressions, which means that the actual percentage of effective CPR might have been even lower.
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Permalink Reply by Dave M on -
This comes from personal and work experience of 14 years in Private EMS and working for a Fire Dept. I started out with high call volume system that staffed ALS units with an EMT and an EMTP with backup from the City Fire Dept which was almost totally EMTs with a couple of EMTP but could not perform ALS skills. When you showed up on the call as the medic, you were it as far as the decisions went for patient care. I will say that many of the EMT's for the private service and the fire dept had as much knowledge as I did when it came to caring for the patient and their condition.
I then went to a Fire Dept that had dual Medic units (of which we had one at the time). But when the engine showed up to help, it was staffed by at least one medic and most of the time two medics, one of which was the captain. Talk about paramedicing the patient to death! Since then we are running two units with an EMT and a medic but still have at least one to two medics on the engine.
Just becuase there are two medics on the unit does not mean that the patient is getting better care or more efficient care. There are many times that I have disagreed with the consensus of the other medics on scene about the care of the patient I am taking care of and could have caused more problems for the patient if I had followed their plan. I will say that it becomes very interesting when there is a patient that needs to be intubated or have an IO put in. You have to call those early or you miss out.
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