About 15 years ago the buzz in ems academia was the prospect of advanced-practice paramedics (APP) doing patient assessment and treatment that went beyond the Paramedic National Standard Curriculum. Demonstration projects were set up in remote areas with few medical resources.

While one of the demonstration projects suffered from operational issues, there were larger problems. Medicare and health insurance would not pay for services. The Advanced Practice Paramedic competes with the Nurse Practitioner and the Physician Assistant in delivering delegated advanced care.

THE PARAMEDIC PARADOX

Wake County EMS Director J. Brent Meyers, MD, MPH, wanted to improve agency response to low-frequency/high-risk “red zone” patients that needed an experienced paramedic. He also looked at patients that could avert a 9-1-1 trip to the hospital if they were assessed sooner. He described this “paramedic paradox” at the 2009 Metropolitan Municipalities EMS Medical DirectorsState of the Science” conference.

Within community health, Meyers wanted experienced paramedics to perform Well Person Checks. Tasks included monitoring of patients with diabetes, hypertension and congestive heart failure. Arrange direct admission of patients to an alcohol treatment center, an idea adopted from a Memphis Fire initiative.

The APPs would also perform ems pre-plans for nursing homes and home health facilities. They would develop fall prevention programs for their patients. All of these activities would reduce the number of 9-1-1 calls for EMS. Unlike the 1994 experiment, Wake County APPs are reducing operating expenses by reducing the transport unit workload through at-home assessment and treatment of chronically ill patients.

SEVEN WEEK ADVANCED PRACTICE ACADEMY

Experienced paramedics were required to read 20 peer-reviewed medical journal articles and pass a written exam, interview and scenario. The didactic covered critical encounters, public health and alternative destinations. Clinical rotations in OB/GYN, infectious disease, cardiac cath, ED, ATC, behavioral health, RN follow-up, pediatrics, 9-1-1 center and Wake EMS PI.


FIRST FIVE WEEKS

Five single APP “Medic” units went into service January 6, 2009. They had their first cardiac arrest save less than four hours later. At the end of five weeks the APP units handled 2309 incidents, including 99 cardiac arrest responses. The top five 9-1-1 responses were for unconscious, chest pain, seizure, fall and motor vehicle crash.

They also completed 54 well-person checks and are compiling case reports showing the impact of well-person checks and direct alternative transportation on ambulance transport workload.

HEMI-POWERED MEDIA ATTENTION

The mainstream and trade media fixated on the shiny new police-package Dodge Chargers … no different than the NC State Trooper vehicles. The real power is in the appropriate utilization of experienced paramedics with additional training. This may be the first example of what the Scope of Practice will bring to out-of-hospital care.

Dr. Meyer’s February 2009 Eagles Presentation (HERE)

JEMS discussion with Skip Kirkwood January 15 (HERE)

JEMS Editor A. J. Heightman January 2009 column (HERE)

Wake County EMS (HERE)

from my firegeezer.com blog post (HERE)

Mike "FossilMedic" Ward

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Comment by Vincent F. Mazzei on January 26, 2011 at 9:01pm

Having become an EMT in 1977 (thanks Jonny and Roy)! and been an ALS provider for about ten years I too have seen some big changes. I finally fulfilled my dream of attending CCEMT-P at MCG and barely passed by the skin of my butt! Day one left me curled up in the fetal position sucking my thumb wanting to "go home"!

I read with great interest, the N.C. experiment with A.P.P. and would love to hear more about this new and up and coming facet of advanced EMT's. Please send me any and all information about advanced practice paramedics. I have mentioned it to Dr. Bledsoe and he is very much excited about the future of EMS. Please feel free to write me at LifelongEMT@Gmail.com Good luck to all and thank you for all you do each and every day.

Fraternally, and respectfully yours

Vincent F. Mazzei B.P.S., CCEMT-P, NREMT-P

Comment by Todd Martin on April 6, 2009 at 8:26pm
I've been a paramedic for almost 20 yrs now, and I've seen incredible changes and progress from the late 1980's until now. One of the largest (and most unexpected) is the sense of professionalism and acceptance that the 'traditional' medical community has granted (and we've earned). I'm sure most of the old timers out there can remember the days of being treated VERY poorly by RN's, and mostly ignored by docs. Those days are long gone.

In regards to some of the comments regarding system overuse, transports, ets...We, as an industry, have put ourselves in this position.We have gone from a simple pay before use service to "Call 911" for every imagined illness or complaint.People dont' even ask a person if they require assistance, they call us first.
Wake County EMS is at least trying something different, and for that, I give my sincere thanks and appeciation. I think that EMS is at a very interesting crossroads. We can't continue business as usual, nor can we throw money down a black hole. My best wish is that some variety of best practices from around the nation will form a baseline that the almighty Medicare/medicaid paysource will deem as the approved for payment. I think a centerpiece of that baseline will be paramedics recognized as a medical profession, paid for assessment, assigned specific ICD codes relevant to EMS (Cardiac arrest, resp distress, MVA, etc...), then transport becomes a modality instead of the end all to payment. Yes, this will take more formal education, better retention and more of a career structure then is allowed now, but it has gotten WAY better in the last 20 years, so why not be enthusiastic.
Comment by Vincent F. Mazzei on March 29, 2009 at 11:08pm
We deserve to be licensed now with what we have to do to get where we are. I would love to know more about the A.P.P. model. Is there a correlation between this A.P.P. model and a CC-EMTP certification? The nurse's will surely lobby to keep up from getting licensed. We are already in the E.R.'s working and they feel threatened. Please tell me more about this A.P.P. program.
Comment by Mike Ward on March 16, 2009 at 9:40pm
Ben,

Point taken about over-generalizaiton of one jurisdiction's experience into a global statement of fact.

Just as a follow-up, in my system we were all firefighters. The engine paramedic that would not initiate a breathing treatment this week would be on a transport unit next month.

Note to "mike" from the west coast .... I think I did a ride-along in the city with assessment engines ... don't they also have "assessment light forces"?
Comment by Mike Ward on March 16, 2009 at 9:21pm
Hi Skip!

Thanks for jumping in.

Mike
Comment by Ben Waller on March 16, 2009 at 8:51pm
Skip,

I'm one of the biggest fans of the APP program, despite what you might think from some of my questions. I fully realize that it's a new program. New programs always have teething pains, they always have unintended consequences, and they always make waves in the established way of doing things. None of those are necessarily bad things...or good ones.

I realize that the local medical society can get involved when they really want to...but the reality is that in most places they don't. As long as there isn't a high profile issue that grabs their attention, they tend to stay in their own world...and that world isn't prehospital for most of them. Even when there is a high-profile issue, their attention span tends to be as long as they think the issue hasn't been resolved.

It is a little dichotomous that your APP medics focus on two opposite ends of the patient spectrum...the most critical and the least. Cardiac arrest responses and well visits are about as far apart as the pendulum swings.

Either way, I applaud you and your service for the innovation. Good luck. I'm sure we'll hear how it goes.

Ben
Comment by Skip Kirkwood on March 16, 2009 at 8:40pm
Sorry - somehow a paragraph got misplaced.

Oh yes - I forgot to mention - we are thankful that nobody has suggested that this program should generate revenue, pay for itself, or do anything other than good service in the community. It's local tax dollars at work doing good for the citizens of and visitors to Wake County - no more and no less.

Skip
Comment by Skip Kirkwood on March 16, 2009 at 8:38pm
Wow, this thread has gone wild. Interesting in many ways.

First, the "paramedic paradox" requires clarification. This term, as we developed it to explain part of the APP concept, is this: the data show that if you have too MANY paramedics, they do not have the critical skill utlization to maintain confidence and proficiency. If you have too FEW, you can't get them to the patients on time. That's the paradox - in our all ALS system, our average paramedic was seeing 2 codes per year. The APPs will see 10 times that.

Second, too many people take one aspect of this program, go off on it, and forget the rest. APPs are intended to help the EMS system as well as patients, in several different ways.

1. They are a small group of medics who will see many more critical patients than ambulance paramedics. That recent critical care experienced is believed (by us, and particularly by Dr. Myers) to benefit the patients. We belived (and we think an honest evaluation would support us) that the "paramedic on every engine company" concept results in worse patient outcomes.

2. They free up ambulances, by handling stuff that might keep an ambulance tied up for hours - post-pronouncement care for the families, complex refusals, and the transports that are avoided by home visits to frequent flyers (this piece comes from the experiences of the SanFran folks, etc.)

3. They free up ambulances and keep people out of ED beds by getting people for whom the ED is not the best option to the better options (the Healing Place, or the mental health crisis center). In our town, a person needing mental health care will tie up an ED bed for 14 hours to no end, so this aspect helps the hospitals a good bit.

4. It's a group of paramedics that can have much more interaction with the medical director than is possible even with a full time medical director, when you have over 200 medics. This provides the rest of the medics with a "consultant" that they can use if they want to, even if they might be reluctant to call the medical director personally at 0300. We don't subscribe to the "call any doctor in the ED" philosophy, because they don't know us and what we do well enough to provide the kind of medical consultation tha twe want.

And Ben, just because the medical society in a particular area HASN'T flexed their muscles, doesn't mean that they CAN'T or WON'T if they don't like what is happening. The political reality is that the councils and commissioners of the world WILL listen to the community's assembled medical might, if for no other reason than they can't explain to the public how they declined the advice of that group. In many places, those groups are hard-wired to the system. In Hawaii, for the first 15 years of modern EMS, all paramedics were trained and certified by the Hawaii Medical Association EMS Program.

Let me close by reminding some of you who are out there challenging the way that Wake County EMS has implemented the APP program - we are a learning, growing organization that is trying something new. We think it is sound and that it will do some good. It's not perfect, and when we find something doesn't work, or that something can work better, we'll change it. We've been on the road for 8 weeks and despite all of the deficiencies that some are quick to point out (without ever having been here or talked to an APP), we think it's helping our citizens and our EMS system. The rest of you....stand by....we'll keep you informed about the accomplishments, the changes, and the development of the system. One ofour biggest frustrations is that we don't have enough (budget, you know) APPs to do all the non-critical things we want them to do, because they are too busy running critical calls. We asked for 14 24 x7 and got 5, so the non-emergent stuff is getting started more slowly.

Thanks for all the interest.....Skip

Some of this is borderline public health nurse work. Very little is PA work, because not much of it involves diagnosis and treatment - more like "life skills support" for the medically challenged. We don't use PAs, etc., because one of our objectives was to create another small step on the career ladder for our workforce of professional, career paramedics (average experience is I think14 years).
Comment by Mike Ward on March 16, 2009 at 8:00pm
http://legeros.com/ralwake/photos/weblog/pivot/entry.php?id=2107#comm

Wake EMS Director Skip Kirkwood responded to comments posted on Mike Legeros Raleigh/Wake Firefighting Blog:

Please try to keep in mind that we are now 8 weeks in to a three-year IMPLEMENTATION of the APP program. That means that, at best (probably longer since the economy tanked) it will take three years to get the correct number of APPs on the streets to even begin to do what the program is supposed to do in an efficient and effective manner.

The short version of that is we are providing APP services to the county with 5 units daytime and 2 nighttime. The plan calls for 14 at full implementation. So that means that the APPs can’t get to as many calls as they will, because they are too far away or otherwise busy, AND that they can’t prevent as many calls as they will, because they are too far away and otherwise busy.

The program has improved care measurably by

—keeping ambulances available, by preventing calls or releasing ambulance crews earlier than they might be released (called codes, code 7s, non-compliant diabetics, TEMS missions, etc.). Every one of those saves an ambulance unit hour.

—getting patients to the right facility (like Healing Place or Crisis), rather than having them transported, by ambulance, to a place that is unable to handle them well or in a timely fashion. Every one of those saves an ambulance unit hour, AND in some cases saves 10 or 15 ED bed hours.

—providing backup on high-risk refusals. Interestingly, the APPs seem pretty effective at talking people who “should” go but don’t want to go in to going. This is very good for the patients, as well as for our risk management program.

Multiply these benefits by 3 (when the program is fully implemented) and it is pretty easy to see that the program will help the EMS system a great deal. “Code Blue,” I think the difference is that we are evaluating the potential of the program to do good for the future, and you and your colleagues are evaluating it as though today was the end-point.

Want to help make it better? Get your radio on the TAC channel and look at the CAD. If an APP is coming and you have assessed the patient, and an APP is not needed, let them know. Don’t wait for them to show up to find out that you’ve got a patient who requires minimal treatment and slow transport. That will keep them available for the next call, that might really require their presence.

You might not want to hear this, but there also HAVE been instances where the experienced and independent clinical evaluation of the APP has made a difference to the patient. You’ll just have to take my word for that.

Remember the graphs that Dr. Myers showed before the program kicked off – more “recent critical care” experience improves patient outcome, which is the end-all of why we exist. If the APPs can add that to our service mix, then it’s a good thing for everyone.

Stay safe!

Skip
CHIEF100 - 03/16/09 - 13:14
Comment by Ben Waller on March 16, 2009 at 6:25pm
Joe, you're making the mistake of assuming that paramedics should only ride ambulances. If an engine is arriving first the majority of the time, it may mean that in a system like Phoenix's, the paramedics work the engines with EMT-B's on the ambulances. Or...it may mean that it's a better use of the department's paramedics to cover 60% on paramedic engine companies (PECs) with the other 40% on ambulances staffed with one EMT-B or EMT-I and one paramedic. Even if the ratio is 50-50, putting half the paramedics on engine companies doubles the number of ALS units in the system and shortens ALS response times. I don't hear anyone arguing against shorter ALS response times being a bad thing, do I?

Ambulance-based paramedic systems inherently have slower response times than fire-based systems that include PECs, even if there is a 1:1 ratio of PECs to ambulances. The ambulances are often out of service while transporting, while the engines can get back in service more quickly, with a paramedic aboard, in their first due area. This is particularly true for no treatment/no transport calls and ALS no transports like hypoglycemia where the PEC can return the ambulance to service if it's not needed for transport.

Fire engines are more capable units than ambulances in terms of all-hazards response. Since we don't know whether the next call is EMS, fire, rescue, hazmat, or whatever, the engine is a more capable unit than the ambulance. I can do patient assessment and care from both the engine and ambulance. I can do scene size-up from both the engine and ambulance. I can extinguish a small fire and do minimal forcible entry from the ambulance. I can extinguish large fires and special hazards fires (foam required) and do a lot more forcible entry with the engine company. I can't block traffic without exposing the patient-load doors on an ambulance to oncoming traffic, but I can block traffic all day with the engine without exposing the transport unit at all. SCBA for emergency rescue and meeting the 2-in, 2-out rule - engine, check, ambulance, no way for even the rare ones that have SCBA.

Once again, EMS is run in whatever vehicle types the system chooses. EMS is a lot more than ambulances. See Wake County, Guilford County, Greenville County, Hamilton County, Pittsburgh, etc. for 3rd-service examples of this. You don't have to be a fire-based system to see that EMS is a lot more than just running ambulances.

And...if the engines are being used primarily for EMS responses, then those response numbers are not "inflated"...it's just another one of the calls they run. The numbers are not being used to justify more firefighting capability, they're being used to justify more all hazards capability...a capability in which no ambulance can hope to compare to a PEC.

Good all-hazards systems have adequate numbers of all types of vehicles, and properly maintain and replace all of them. My department operates more ambulances than engines, so it's pretty difficult to say that we inflate our numbers for the fire part of our job.

The bottom line is that assuming that paramedics should only respond by ambulance hasn't been shown to be valid. The ability to provide quality ALS care has nothing to do with the vehicle in which a paramedic responds.

Ben
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