To PAs in pre-hospital EMS:

[Acebecker]

Hey all,

 

This post is primarily directed at any PAs who work pre-hospital EMS, but anyone who wishes to help with this is welcome.

 

I am a PA student at MEDEX and I am beginning to work on our capstone project for a rural/underserved focused academic track. The idea behind my project is to evaluate the potential role for a PA in a rural EMS system, take this role to my local ambulance company (I come from a somewhat rural community) and our EMS director and evaluate the feasibility and scope of practice that a PA would have in this particular system, and then at least work on a proposal to the legislature regarding the law surrounding all of this (if this step is necessary). I have gathered a lot of documentation regarding legal statutes in states where this is done commonly as well as some of the research surrounding this role for PAs.

 

I am looking for any PAs who work in pre-hospital medicine. I want to establish some contacts and perhaps conduct at least an interview of anyone who does this. Also, if possible, I would like to see a pre-hospital PA in action to get a good idea first hand of how this works (I may need to travel to a specific site for this, which is something we could work out). Please let me know if you would be willing to work with me on this or if you know someone else who would.

 

This project is still in its infancy, so nothing is set in stone yet. I appreciate y'all reading.

 

Andrew Becker

MEDEX Northwest Physician Assistant Program

Spokane Class 13

[narcan]

I think it's a great idea, although I see more value for the PA in an urban setting where you tend to get so many more BS calls but EMS still has to transport. I wrote my application essay about the idea of PAs working in EMS, so if you have any luck moving forward with that, please let me know or update here. Would be interested to see how it turns out.

[Acebecker]

UPDATE:

 

The great state of Idaho is working at adopting new EMS rules that provide for a role for PAs in ambulance services. The new rules will allow PAs to work as ALS providers (paramedic level) without additional training when doing interfacility transfers. The rules will also allow PAs to work at the paramedic level for pre-hospital runs provided 1. they are in the presence of a paramedic or 2. they undergo sufficient cross-training to operate as a paramedic (this cross-training is yet to be defined, to my knowledge).

 

So, that's one part of the project I won't really need to work as hard on. But I'd still love to hear from anyone who would be willing to share their experiences as pre-hospital PAs either by phone or in person (again, I'm willing to travel).

 

Thanks for reading.

 

Andrew

[sbellin]

I work as a PA in rural Washington state and am also an alumni of MEDEX class 29 (say high to Bill Plummer for me). Prior to going to MEDEX I was a paramedic in a rural area and now I work as a PA in that same area. I still provide volunteer services as a paramedic but am bound to their standing orders. The difference that the PA education brings is that I have better understanding of the disease processes that are going on thus a better handle on how things should be treated. I have not pursued the concept of being a prehospital PA as that means I would be the highest trained on scene and this then places the full responsibility of the patients care on me from scene to the hospital. Such a case would also require me to have a separate practice plan through the state with the medical program director as sponsoring physician as well as the need for separate liability coverage. Too complex to do for free.

Steve B.

[TheWanderer]

I came here to start a similar discussion so I figured I'd add what I had to this thread. I am starting my paramedic training in August around the time I should finish up applying to PA school for classes starting next August. I really want to get PAs involved in pre-hospital care. I feel that they are perfectly positioned to administer procedures above the scope of the paramedic in the field and also have the ability to save an ambulance trip to the hospital by essentially bringing fast track to the patient. I've just started researching but in the UK they have Advanced Practice Paramedics (APP) that do something similar to what I've described. Here is the article that piqued my interest:

 

http://www.ems1.com/ems-education/articles/818069-Taking-out-of-hospital-care-to-the-next-level/

 

Edit: Another article by the same author describing APPs

 

http://www.ems1.com/ems-education/articles/773808-APPs-A-new-breed-of-responder/

 

While there is no single solution for reducing health care costs I think the APP or something similar could help cut down on all the bull**** ER trips. FDNY ran about 1.2 million calls last year. How many do you think were for minor wounds, sicknesses, sore throats, etc.? Imagine a Paramedic with a scrip pad and suture kit (obviously with the amount of training necessary). I think all the paramedics-turned-PAs would be very well suited to pilot programs. There is a link in that article to the American Society of the Advancement of Paramedicine (ASAP) in that article I linked. If you are interested I'd suggest you check it out. I believe it is still in its infancy though.

 

I need to do some more research about how it works in the UK but would like to hear about those of you in the field who do something like this as the OP asked. I'd also like to hear the opinions of those of you who work in EDs, would this help the system as a whole?

Edited May 12, 2010 by TheWanderer

[istat2]

I read this thread with great interest. I spend the first 15 years of my career strictly in EMS. I read the two articles listed plus additional web information on the British ECP concept. I have to admit I find myself vacillating between my opinions on this concept.

The basic question is do we utilize a new classification of provider (APP) versus Physician Assistants (or Case Western's ACNP program) in this model. Just a short historical perspective for this discussion. There was an EMS conference in the late 1980's in Coral Gables, Florida. The discussion of advanced practice was a topic of interest. Yes, this discussion has been going on forever. Several EMT-P's in attendance were either students or practicing PA's. It was lucky that palm trees do not have branches to support ropes, because the majority opinion was to lynch the heretics. It seemed that the opinion was that a new class of provider was the appropriate pathway. So maybe it is time to revisit this topic.

There are many advantages and disadvantages to creating an APP category. Someone tailored made to function in the out of hospital environment. It will lead to decreased cost of training and patient care for cost containment. This model would also create an additional step in the career ladder for proven field providers who sometimes leave to field due to the lack of upward advancement. There are several downsides also. There will be a need to establish enabling legislation in each state and territory. If the PA history is any indication, it will take a very long time to achieve this milestone. I also see another problem to consider is what happens when the APP is not able to continue performing this activity any longer? As a FROG (freaking really old guy) I can tell you that the day does arrive. I seriously doubt that the APP will be able to displace the PA's and NP's currently staffing the ED's.

The other option is to staff with PA's. There is a large population of PA's with EMS backgrounds that could function effectively in this environment. The advantages are obvious. The enabling legislation is already in place nationally. Prescribing and reimbursement issues have already been resolved. However, there is a downside also. First, can an EMS system afford PA's fiscally? One of the issues that drive most EMT-P's to PA training is the limitations inherent in working the field. We have done a great job with miniaturization, but I haven't ran across any pocket CT scanners recently.

Anyway, I know this is a LONG post. But I would really like to hear people's opinions on this topic. :;;D:

[rsqdvr]

It's a pretty interesting topic, one that I've thought of at length in the past. I don't yet have an answer for which one would be the best. An APP who is a seasoned medic with advanced training would, I suspect, be a cheaper option than staffing a PA but there are significant hurdles to bringing something like this out nationwide. Back in my field days I had heard that Texas already had a program similar to this in place. Their Advanced medics couldn't prescribe of course, but they could suture and do some other minor procedures. I never actually talked to anyone that did it so I'm not sure if it was true. On the other hand, enlisting PAs who were medics would seem to be a much more efficient and easier option. As was already stated, many of the mechanisms may already be in place they would just need some fine tuning. Also in the hearsay category, I had heard a few years back that LA City Fire and/or Pasadena Fire were contemplating developing a PA position that would work exclusively on the Rescue Ambulance in order to free up a medic for an engine/truck. Don't know if anything ever came of it though. However, at the end of the day, a "field PA" would still be limited in what they provide because certain modalities (XRay, CT, labs, etc) are not available, liability would potentially be significant, and salaries would/should most certainly be higher. Although, on the salary front, I worked in Southern California where as a medic I made close to what I make now as a "new grad" PA. I just went down and visited some old friends that are still paramedics or fire/medics and a couple make more than I do so in some areas salary may not be as much of an issue. Lastly, I'm not sure I would want to get into a debate on the merits of an APP and creating another new class of provider when we have our own issues that still need to be ironed out with our 40+ yr old profession. But that's just me.

[istat2]

Lastly, I'm not sure I would want to get into a debate on the merits of an APP and creating another new class of provider when we have our own issues that still need to be ironed out with our 40+ yr old profession. But that's just me.

 

True fact. But I'm still interested in other peoples opinions on this topic. It been going on for so many decades now I am really curious about what the current thought process is. One observation. If WakeMed in one of the most PA friendly states in the Union is advocating for the APP, there must be something to the concept.

[TheWanderer]

Another little tidbit I came across. Wake County EMS is putting their second class of APPs through their ~250 hour academy. Here is the link to the basic idea that Wake has:

 

http://www.wakegov.com/ems/staff/app.htm

 

Considering the legal and legislative hurdles to creating a new class of provider, it would probably work better as cross-training with a decent salary bump over regular old EMT-P. Or maybe a monetary bonus of some sort for a PA that works in this type of role for a hospital based ambulance. I don't know. I'd certainly consider putting PA school on hold if I knew I could become an APP first with a decent salary waiting for me upon completion.

[medic25]

However, there is a downside also. First, can an EMS system afford PA's fiscally? One of the issues that drive most EMT-P's to PA training is the limitations inherent in working the field.

 

This seems to be the major limitation to PA's playing a significant role in day to day EMS. Other than the occasional outlier, PA's are generally going to earn a significantly higher salary than a paramedic. In order to make it financially worthwhile, there would have to be a significant jump in reimbursement for these PA services. Even if you were able to bill each call as something similar to an urgent care visit, you are going to have much lower productivity going from call to call than if all your patients presented to one central location (i.e. the ED). The ED PA may be seeing 4 patients/hour; this is not feasible in the field when you factor in response times, setting up supplies in each home, gathering billing information, etc.

When I was getting ready to graduate from PA school, I went out to Colorado to ride along with a new PA-staffed critical care ambulance that did critical care transfers and took call for local PMD's who covered nursing homes. I loved the concept, but unfortunately it just didn't turn out to be viable financially and eventually folded. Unless we decided to drastically change our nation's concept of EMS from the EMT/paramedic model to a more European "field physician" type model, it can be tough to justify the additional expense of putting PA's on the road.

[istat2]

This seems to be the major limitation to PA's playing a significant role in day to day EMS. Other than the occasional outlier, PA's are generally going to earn a significantly higher salary than a paramedic. In order to make it financially worthwhile, there would have to be a significant jump in reimbursement for these PA services. Even if you were able to bill each call as something similar to an urgent care visit, you are going to have much lower productivity going from call to call than if all your patients presented to one central location (i.e. the ED). The ED PA may be seeing 4 patients/hour; this is not feasible in the field when you factor in response times, setting up supplies in each home, gathering billing information, etc.

When I was getting ready to graduate from PA school, I went out to Colorado to ride along with a new PA-staffed critical care ambulance that did critical care transfers and took call for local PMD's who covered nursing homes. I loved the concept, but unfortunately it just didn't turn out to be viable financially and eventually folded. Unless we decided to drastically change our nation's concept of EMS from the EMT/paramedic model to a more European "field physician" type model, it can be tough to justify the additional expense of putting PA's on the road.

 

Yes, Pridemark did take an he55 of a shot at making it work. I was not aware of the nursing home component, but the concept is interesting. What other alternative coverage schemes can this group come up with? There is a lot of experience floating here, and probably just as many ideas. I would like to hear them.

 

Incidently here are two links to the British model. A significantly different model set at the Bachelor's level.

 

 

http://www.jephc.com/full_article.cfm?content_id=355

 

http://www.jephc.com/uploads/9901572.pdf

[narcan]

I wrote my admissions essay on this idea, namely that PA's are uniquely positioned to bridge the gap between paramedic care and ER care, the advantage being that you can significantly reduce unreimbursed ER visits for minor and chronic medical problems and increase access to health care. I work in an urban EMS system where 80%-90% of my patients live either in the projects or below the poverty line. They all have Medicaid and we all know how reimbursement is with the government. PA's also can provide advanced skills and expertise on critical calls much like the APP's are doing in Wake. I know that in England with the "field physician" model they have docs doing thoracotomies in the field (not that I advocate this).

 

I don't think the focus should be on the salary of the PA as much as the cost savings from unreimbursed ED visits and fewer hospital admissions. Obviously this type of situation would work best with a hospital-based service, or perhaps the hospital reaping the cost savings should share the cost of the PA's salary with the EMS system/municipality. Either way, I think some of you are looking at the price of the PA from the wrong angle.

[bchernock]

http://wake.mync.com/site/wake/news%7CSports%7CLifestyles/story/23469/wake-launches-advanced-practice-paramedics

 

http://www.azcentral.com/community/mesa/articles/0125mr-trvpa0125.html

 

The above are two articles that touch on this topic. The first shows what Wake County, NC has done to create an advanced practice paramedic. The second is from Mesa, Arizona where they use PAs in the field to handle minor illness/injury and do wellness checks. The biggest issue in my opinion is the cost of a PA in EMS. Salaries in EMS are historically low and I don't see how PAs can maintain their fiscal value while being employed by an EMS agency. If they were a division of a hospitals emergency services/department then maybe this could be more fiscally possible. I am definitely all in favor of PAs in EMS. Essentially I think PAs can act as assistant medical directors providing on scene care to the most/least sick, medical command at MCIs, online medical control, administrative and educational functions. We have talked about this topic before and there is some great discussion on other threads.

[Firemedic13]

Funny you should be doing this as well. I have been working on a presentation for my superiors at the fire department on something very similar. Unfortunately discussions with the union indicate that the commission might not be favorable to this right now because it would cost money... and with the economy the way it is, spending is not popular. We are still going to try to present it I think, but I doubt it will work. I think they will simply suggest a private company take on the job rather than have the fire department do it.

 

Now, something you can possibly use to your advantage is the fact that the health care law passed in MA resulted in a huge increase in ER visits because there was a lack of primary practitioners. Studies in the UK show ECPs reduced ER visits by 30% or more. So that can be a selling point since the new national healthcare law in this country will likely have the same effect.

 

My personal opinion is a PA is a much better alternative to ECPs in this country. Anyway, I linked a bunch of articles and studies for you. Sorry if any of these have already been posted. Also I believe EMEDPA wrote an article about this once, so you might want to ask him.

 

http://www.azcentral.com/community/mesa/articles/0125mr-trvpa0125.html

http://firechief.com/mag/firefighting_rural_health_cares/

http://en.wikipedia.org/wiki/Emergency_care_practitioner

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2464893/

http://emj.bmj.com/content/26/10/9.extract

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2579522/

http://www.jephc.com/full_article.cfm?content_id=355

http://www.shef.ac.uk/scharr/sections/hsr/emergency/ecp.html

http://www.shef.ac.uk/content/1/c6/07/96/92/MCRU%20ECP%20phase%201%202004.pdf

http://www.shef.ac.uk/content/1/c6/07/96/92/MCRU%20ECP%20phase%202%202005.pdf

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2048868/

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1726072/pdf/v020p00196.pdf

 

Seems all of us think this is a good idea... I wonder how we can make higher ups realize it.

[istat2]

Funny you should be doing this as well. I have been working on a presentation for my superiors at the fire department on something very similar. Unfortunately discussions with the union indicate that the commission might not be favorable to this right now because it would cost money... and with the economy the way it is, spending is not popular. We are still going to try to present it I think, but I doubt it will work. I think they will simply suggest a private company take on the job rather than have the fire department do it.

 

Now, something you can possibly use to your advantage is the fact that the health care law passed in MA resulted in a huge increase in ER visits because there was a lack of primary practitioners. Studies in the UK show ECPs reduced ER visits by 30% or more. So that can be a selling point since the new national healthcare law in this country will likely have the same effect.

 

My personal opinion is a PA is a much better alternative to ECPs in this country. Anyway, I linked a bunch of articles and studies for you. Sorry if any of these have already been posted. Also I believe EMEDPA wrote an article about this once, so you might want to ask him.

 

http://www.azcentral.com/community/mesa/articles/0125mr-trvpa0125.html

http://firechief.com/mag/firefighting_rural_health_cares/

http://en.wikipedia.org/wiki/Emergency_care_practitioner

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2464893/

http://emj.bmj.com/content/26/10/9.extract

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2579522/

http://www.jephc.com/full_article.cfm?content_id=355

http://www.shef.ac.uk/scharr/sections/hsr/emergency/ecp.html

http://www.shef.ac.uk/content/1/c6/07/96/92/MCRU%20ECP%20phase%201%202004.pdf

http://www.shef.ac.uk/content/1/c6/07/96/92/MCRU%20ECP%20phase%202%202005.pdf

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2048868/

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1726072/pdf/v020p00196.pdf

 

Seems all of us think this is a good idea... I wonder how we can make higher ups realize it.

 

Sweet dude! Thanks

[istat2]

I've seen some rumblings about a canadian program utilizing advanced providers. Anyone find anything on this?

[Firemedic13]

So we are going to present our PA in the field idea here in the next month. The Chiefs are behind it, and will take it to the commission and managers. So now its all politics... we will see. We found another way to justify their pay: By providing OSHA physicals alone (not counting any other such things) for the firefighters the department would save enough to pay for 3 PAs at $80,000 a year with benefits (20 year retirement, medical, no social security taxes, etc) and STILL save $40000 per year. So that is one angle. There are many others too.

 

I'll let you guys know how it goes.

[istat2]

So we are going to present our PA in the field idea here in the next month. The Chiefs are behind it, and will take it to the commission and managers. So now its all politics... we will see. We found another way to justify their pay: By providing OSHA physicals alone (not counting any other such things) for the firefighters the department would save enough to pay for 3 PAs at $80,000 a year with benefits (20 year retirement, medical, no social security taxes, etc) and STILL save $40000 per year. So that is one angle. There are many others too.

 

I'll let you guys know how it goes.

 

 

Beautiful!

[Firemedic13]

Oh, and I am going to suggest NPs with experience in emergency medicine too, since they are independent providers in this state that might be something they are interested in. Then again, maybe not.

[PM2PA]

This is an awesome idea.

Edited May 21, 2010 by Josheppe

[JasonR]

Nice angle with the OSHA physicals, Firemedic13. Question though, what things will the PA's treat differently than the Paramedics? I would think the state board of medicine would be a larger stumbling block than the city commissioners, or the insurance companies reimbursing for a PA visit rather than an ambulance call. Can PA's treat and release in the field under your state statutes? Are you going to carry urine dipsticks and write prescriptions for UTI's? It just seems there is very little that can be treated and released in the field due to lack of equipment (lab, xray, ct, u/s).

 

What can a PA (or physician for that matter) do in the field for a trauma that the paramedic can't, aside from a central line and chest tube? And 90% of the time you don't need a chest tube until you arrive at the hospital anyway. The central line is really the only thing I can see that would be beneficial and beyond the scope of a paramedic. You also have to consider that the emergency medical helicopters carry nurses and every physician who can do these things, and this is why they are called. You also have to consider transit times. Always best, as you all know, to load and run in most situations.

 

For emergency medical calls, like a MI, what more can a PA do than a paramedic here either?

 

Also, consider the impact on the public when the idea that someone can be seen without going the ER gets out. The amount of frequent-flyers and nothing calls will go through the roof! "You mean I don't even have to get out of bed for someone to see me now? Hot diggity!" While this will ease the strain on the ER, it may increase abuse of the system even more. These are numbers that would need to be tracked and compared to pre-implementation figures.

 

Well, hope this made sense. What do you all think?

 

jason

[JasonR]

Oh, and I am going to suggest NPs with experience in emergency medicine too, since they are independent providers in this state that might be something they are interested in.

 

I wouldn't. The NP administration doesn't do the PA's any favors, so why welcome them into this new field. Just keep the PA idea bouncing around in everyone's head and things will go much smoother for you. The minute you introduce the NP's to the idea, you will open the doors to nursing bureaucracy, which is something you really don't want to get involved with.....trust me.

[EMEDPA]

Oh, and I am going to suggest NPs with experience in emergency medicine too, since they are independent providers in this state that might be something they are interested in. Then again, maybe not.

DON'T DO THAT.

your ideal candidate should be a pa who is/was a paramedic before pa school. folks who know the street.

[EMEDPA]

. Also I believe EMEDPA wrote an article about this once, so you might want to ask him.

.

 

here it is from jaapa in 2005:

Fast track in the field: Another option to ease ED overcrowding

 

Emergency department (ED) overcrowding is becoming a serious problem in the nation’s hospitals. Many are forced to go on ambulance diversion status because of a shortage of bed space, clinicians, or resources needed to take care of patients. Patients who seek care in the ED often require ED evaluation and are there appropriately. There is, however, a subset of patients who use the ED for conditions that are neither emergent nor, at times, even urgent. Many of these patients do not have access to a primary care provider, or they live in communities lacking adequate free medical resources for the uninsured or underinsured, so the ED becomes their only choice. One option that meets the needs of patients, hospitals, and emergency medical services (EMS) providers is to create a system by which these patients are seen outside of the ED yet receive the same high-quality care from the same providers that they would in an ED setting.

Fast track in the field

 

 

The EMS community is advocating for advanced training for paramedics to perform these functions. But, why not use PAs in emergency medicine to fill this void? They already have the requisite skills and experience, and they could rotate between working in the field and in their home EDs.

Many PAs in emergency medicine started their careers in medicine as paramedics and would welcome the opportunity to use their new skills outside the ED setting. I have spoken about this concept with a number of my PA colleagues who previously worked in EMS. The consensus was that they would enjoy the opportunity to return to the field and be able to concentrate on a single patient at a time instead of the six to eight patients that are followed at one time in the typical ED setting. Some unpleasant aspects of being a paramedic would be absent from this system, such as carrying heavy patients down multiple flights of stairs and being awakened in the middle of the night for low acuity cases. These are among the chief reasons many PAs leave EMS to go to PA school.

This system would also benefit EMS because they would no longer have to transport patients with minor complaints to the ED. The large number of nonemergent 911 calls has been a significant cause of burnout and frustration among EMS personnel. The system I am proposing would allow paramedics to focus on what they do best—treating truly emergent patients in the field setting.

How would it work?

 

 

The concept would initially utilize a trial ambulance team of one PA and one basic EMT/driver and would be staffed only during the busiest hours of the day. The team would not respond directly to 911 calls but would be summoned after an initial decision by paramedics that the patient was nonemergent and met criteria for field treatment and release. The criteria might involve such complaints as minor lacerations, upper respiratory infections in otherwise healthy persons, prescription refills for noncontrolled medications, ingrown toenails, and so forth. EMS and members of the field group would agree on these criteria in advance. The ambulance company could still bill for a home response and any supplies used, while the hospital ED could bill for the PA’s time and any hospital supplies (such as suture sets) used in treatment.

If a single unit saw a patient every 30 minutes for 8 hours, 16 fewer patients would arrive at the ED and 16 more emergent ambulance calls could be made. Some patients might initially be thought to be appropriate for field treatment and later be found by the PA to need further evaluation. These patients could then be transported nonemergently to the local ED by the PA unit and checked in there in the same fashion as a typical walk-in patient. A busy area could use more than one unit or staff it for more hours daily.

This system would be practical only in a busy metropolitan area where ED overcrowding and a strained 911-response system are daily issues. While using PAs in the field in other settings is an option, there would be no clear benefit to local hospitals or emergency services through such utilization.

Patients would also benefit from such a system. Currently, patients with low-acuity complaints face long waits in EDs, sometimes as long as 4 to 6 hours or more. Field treatment would allow rapid evaluation and treatment of their minor injuries and illnesses, greatly increasing patient satisfaction. Follow-up visits would be done by the same “city call” physicians who see unassigned ED patients after their discharge from the hospital. The patients could also be given a list of local resources, such as primary care providers in the community and social workers who can arrange for federal or state health coverage.

Benefits on many levels

 

 

In this system, there would be no decrease in revenue to either the hospital or the EMS company. Members of the team would be paid by their normal employers at their normal rate of pay. No changes would need to be made to the configuration of the ambulances used. The PA could simply carry a tackle box with supplies and a few noncontrolled medications, such as antibiotics. All the pieces are in place for this to work, with very little preparation time involved. The staffing already exists. Oversight would continue per current practices. The supervising physicians of the ED PAs would review the PAs’ field documentation in addition to their regular ED charts. The PAs’ malpractice policy from the hospital would be amended to include work in the field. Hospital EDs would be able to allocate their resources more appropriately to evaluate sicker patients in a shorter amount of time.

This is only the outline of a concept. I hope that this model can be tested in busy urban areas to determine its effectiveness at decreasing ED wait times and improving service to those in need of medical care.

[JasonR]

EMEDPA,

 

What happens with billing when the PA sees the patient and determines further testing is needed so they go to the ED? Now we have an ambulance bill, a PA ambulance ED visit bill, and a PA/MD real ED visit bill. Or are you proposing that if the PA sees the patient in the field, they have already examined the patient, formulated a DDx and plan, and will order test upon arrival at ED. Therefore, whoever takes over in the ED will have little to do except follow-up already placed orders and discharge/admit, and the billing will be one with the field PA. We have a similar system in place here, where if one outlying ED sends a patient to the main ED, there is no additional provider cost.

 

What are you thoughts on sending the PA right away based on C/C? Rather than wasting paramedics time screening. I know most C/C's that come in are nothing like the real situation (grandpa fell down : grandpa had a MI), but still that seems like a waste.