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rev ronin

Prehospital NPs?

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https://www.firerescue1.com/fire-ems/articles/393536018-Calif-fire-dept-adds-nurse-practitioners-to-EMS-crews/

I am uncomfortable this trend for a number of reasons.  Paramedic->PAs should be leading this charge, with EMT->PAs, since this is our space and we are better suited to both provide realistic out-of-hospital care and supervise community paramedics.

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I would argue that this concept is a terrible idea to begin with. Anyone who has ever worked EMS knows people call 911 for ridiculous reasons. This only reinforces that behavior. What kind of care do they expect them to provide, anyway? Maybe they'll have a mobile lab? 

But yes, NPs are pretty much everywhere now, and pre-hospital is a common route to PA, not NP. This ultimately stems from NP independent practice. Can't send us out there without a supervising physician, right? 

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Not an unusual concept.  This idea using "super paramedics", or those with extensive field experience, was first discussed nationally at the Gathering of Eagles conference in Dallas years back (worldwide EMS medical directors/Fire/EMS providers).  The concept was to also utilize these providers to do follow ups with frequent 911 callers to diminish the number of their calls for assistance and to provide assistance in getting these patients into the out-patient healthcare system.  I think the original talk was provided by the Winston-Salem, N.C. EMS medical director as I recall.  My local EMS provider (Fire) has such a concept for follow up checks only though I don't know the details, as well as a fairly new tiered response system that they put into service during high call times for those calls deemed to be a lower priority.  They respond in Suburbans as opposed to ambulances.  As I've posted here previously, this would be an ideal spot for a PA where costs could be split between the local EMS director/Level 1 hospital (or other hospital networks that EMS transport to) and the city, where the PA would operate under the license of the EMS medical director.

I've actually considered contacting the Asst. Chief over EMS again should I stay in the area to see if I could volunteer some time to assist them in non-direct care areas when I retire.

Edited by GetMeOuttaThisMess

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This is a common topic, often packaged as "community paramedicine".  From the FD point of view, it's an attempt to reduce the call volume of the "frequent flyers".  Reimbursement is usually an issue.  PA's can do this as well, depending on state law.  In Ohio we couldn't initially, because the law required PA's to work only at sites where the doc also worked - though no requirement that the doc work at the same time.  So, it wasn't a problem for urgent care location as long as the doc occasionally was there.   Ohio law now says "where the physician has oversight and control - opening it up to anywhere as long as you have some sort of telecommunications.

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In California nurses seem to have all of the political support.

As a former Paramedic and now PA I was trained in the medical model.

PA's should be the ones in the pre hospital setting. 

 

 

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Devil's advocate here.  There are plenty of pre-hospital RNs, and even more flight RNs.  As far as flight teams go, they are nursing led (at least the 2 in my region), with teams comprised of 2 RNs or 1 RN and 1 medic.  It is typically these nurses who return to NP school and seek positions such as this.  Case Western Reserve actually has an Acute Care Nurse Practitioner Sub-Specialty in Flight and Critical Care Transport.

I'm not supporting this actually.  Perhaps I don't know much about the utility of having APPs work in this manner.

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@Kaepora Flight RNs are awesome, but the ground EMS equivalent seems to be CC/ICU RNs who accompany critically ill ground transfers to manage drips and vent settings that may be a bit beyond most paramedics, or they work with non ALS-response private carriers to enable critical transport on a rig that isn't normally paramedic staffed.

In the case where you have PAs or NPs doing at-home follow-up for frequent fliers, I think you've got a different skillset needed.  You want someone to be able to review meds, propose dosing changes, draw labs, and do patient education to keep them out of ERs.  That's not the same skill set as a flight nurse at all.  While some of that is definitely within FNP scope of practice, who trained them to be safe in patient homes?  I'm proud of the way I train my EMTs to provide care safely--to themselves, mostly--in an uncontrolled environment.  An EMT/FNP would certainly be fine in such an environment, but as folks around here are used to pointing out, NP clinicals are, at their minimums, quite inferior to PA clinicals.  I wouldn't want a PA who was only ever an MA, CNA, or PTA in such a situation either, just like a direct entry RN/FNP, but last time I checked we still had plenty of EMTs and Medics going to PA school, and this sort of job seems to be to be totally up their alley.

 

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Hi Rev, I didn’t know you trained EMTs! I used to teach as well before PA school started.

Anyways, I am (or was) a paramedic. And I agree wholeheartedly with the sentiment that if advanced care is going to be offered in the out-of-hospital setting, PAs who were trained as medics are honestly by far the most valuable resource for this position. What I am much less sure of is what the role will look like or how useful it will be. It’s not that FNPs or ACNPs or AGACNPs (or whatever NP, honest I can’t keep up with their titles anymore) can’t do it, but why not tap into people who have worked on that environment before and are experts in field response? Medics and emts have training that NPs do not get- extrication, scene safety, ambulance operations, extensive practice running codes, etc. 

There is a lot going on in EMS, and I have somewhat strong opinions on some ideas being tossed around. For example, the whole community paramedicine thing.. one of the pilot programs was medics doing directly-observed therapy with TB patients out in the community. This is a job that can be done by literally any employee of a public health department and there is nothing special about a paramedic with extra training doing it. Wouldn’t it be cheaper with an entry level public health worker? Another pilot was home safety inspections- why can’t a public health nurse do that? They already have training in this sort of thing.

As far as APPs in the field, would just be building a system where you can call 911 and get an antibiotic script? Or will this be a platform to bring truly advanced care to the field like prehospital ECMO? They do it in France. I’m not opposed to any idea, just not sure what we want other than the cool-factor of a APP on a rig (LA city fire has a neat looking ambulance that says NP/PA-1 on it). Would need to be well defined. 

Rigjt now Illinois has a prehospital PA designation (not sure if it’s actually used), and The CA OTP bill will include language explicitly stating PAs can work in emergency vehicles.

 

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29 minutes ago, lemurcatta said:

Hi Rev, I didn’t know you trained EMTs! I used to teach as well before PA school started.

Anyways, I am (or was) a paramedic. And I agree wholeheartedly with the sentiment that if advanced care is going to be offered in the out-of-hospital setting, PAs who were trained as medics are honestly by far the most valuable resource for this position. What I am much less sure of is what the role will look like or how useful it will be. It’s not that FNPs or ACNPs or AGACNPs (or whatever NP, honest I can’t keep up with their titles anymore) can’t do it, but why not tap into people who have worked on that environment before and are experts in field response? Medics and emts have training that NPs do not get- extrication, scene safety, ambulance operations, extensive practice running codes, etc. 

There is a lot going on in EMS, and I have somewhat strong opinions on some ideas being tossed around. For example, the whole community paramedicine thing.. one of the pilot programs was medics doing directly-observed therapy with TB patients out in the community. This is a job that can be done by literally any employee of a public health department and there is nothing special about a paramedic with extra training doing it. Wouldn’t it be cheaper with an entry level public health worker? Another pilot was home safety inspections- why can’t a public health nurse do that? They already have training in this sort of thing.

As far as APPs in the field, would just be building a system where you can call 911 and get an antibiotic script? Or will this be a platform to bring truly advanced care to the field like prehospital ECMO? They do it in France. I’m not opposed to any idea, just not sure what we want other than the cool-factor of a APP on a rig (LA city fire has a neat looking ambulance that says NP/PA-1 on it). Would need to be well defined. 

Rigjt now Illinois has a prehospital PA designation (not sure if it’s actually used), and The CA OTP bill will include language explicitly stating PAs can work in emergency vehicles.

 

Our TB DOT was provided by Co. health dept. personnel without direct medical training.

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This model is already being utilized in a variety of cities, using both PAs and NPs.  LAFD recently expanded the number of APRU (Advanced Provider Response Unit) trucks in their system.  It's also being done in Anaheim, Littleton, CO, and until recently Mesa, AZ.  Depending on how the system utilizes the unit there are a few different objectives:

1) Treating low-acuity 911 calls without an ED trip; a lot of the units carrying testing equipment (e.g. rapid strep, i-stat), and will suture, prescribe, etc.

2) They are targeting 911 "super-users" to try and proactively prevent repeat use of the 911 system.  They are checking in on the patients, adjusting medications, involving social work, etc. to try and keep them out of the ED.

3) Hospitals flag high-risk discharges, and the APP unit sees the patient at home the day they are discharged to ensure they've got all of the necessary meds, DME, etc. and if needed can prescribe anything else (like the COPD'er the discharging resident forgot to give steroids to).  This can be a huge money-saver for the hospital if they don't get a bounceback admission.

4) The unit sees psych/substance abuse patients in the field and medically clears them for transport to an alternative destination to the ED such as a sobering center or psych facility.

One of the main issues with this model in the past is that CMS won't reimburse for ambulance patients who aren't transported to an ED.  Earlier this month they announced funding for a pilot project next year in which EMS will be reimbursed for transporting to alternative destinations like urgent cares, or treating on scene by a provider.  Using us correctly this actually has the potential to be a great opportunity for PAs; I already had a meeting this week looking at my own hospital/EMS system developing a project to submit to CMS for funding.

For those who are worried about putting a PA or NP into the prehospital environment, it might offer some reassurance that every unit I've seen is partnering them with an experienced paramedic; this way even if the PA or NP doesn't have prior EMS experience they have someone with them who knows how to manage a scene.

 

Edited by medic25
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They tried this with an NP at a FD near my city. It has already been shutdown as it had little to no effect on the call volume from the frequent flyers. But I do agree that a PA with previous paramedic/EMT experience would be better suited for the job.

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As several folks have said, there are at least 2 target areas for PA's and NP's in the field:

  • "Critical care", which includes both the mobile intensive care transport units and aircraft.  This is both interfacility transport and scene response.  This is pretty well established although it seems like there are more NP's than PA's doing it.  I've looked into it and frankly working in the ED pays much better.
  • "Community medicine" like Medic25 described.  This is targeted at the frequent flyers and has a large component of social work.

These are very neat sounding ideas, but not really very attractive jobs.

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14 hours ago, EMEDPA said:

If I ran these projects only PA/NP with prior paramedic experience would be eligible....just sayin...

The trouble with that E is that with the changing demographics of our profession it leaves an awfully small candidate pool to choose from.  For example, my ED group has over 50 PAs and NPs; only 3 of us are paramedics, but we have some other super strong PAs who'd be great in this type of role. 

I see a comparison for us with the EMS physicians out there; many of them don't have past EMS experiences, but with the right training and mentoring we can teach them how to take care of patients in the field.  With EMS now being a recognized sub-specialty of emergency medicine we don't want to exclude PAs from the specialty just because they don't have prior certification; we just need to make sure that we train them the right way.  We don't require pulmonary PAs to have past RT training or ortho PAs to be past ATC's; they definitely have an advantage coming into those specialties with past experience, but we shoot ourselves in the foot if we restrict access to the specialty to only those who've worked in the field before becoming PAs.

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@medic25 Then maybe the answer is a PA (or NP, I suppose) who maintains an active prehospital credential, be it EMR/FR, EMT, EMT-I/AEMT, or Paramedic.  Right now, mine mostly just helps me teach EMT class...

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Our department utilizes a paramedic in the community paramedic role, no talks of adding an NP or PA to the mix.  Some thoughts..

 

1. Yes these programs are typically sold on the idea of the idea of decreasing call volume from frequent fliers.  Originally these programs were also sold at decreasing 30 day readmission rates of CHF patients which supposedly cost hospitals millions,

2. With that said, we should really look at these programs in terms of “what does my community really need”.  For us, it’s access to resources.  Our guy spends his CP visit time helping patients sort their meds, coordinate their doctors, and provide them access to helpful resources.  He also spends time interfacing with doctors offices on behalf of these patients. 

3.  In our model, an EMS background is unnecessary.  Our guy does a medical assessment but spends most of his time doing social work type things.

4. In our model, a primary care provider on staff could potentially be beneficial to cut some of the back and forth - waiting in voicemails out, but it’s not pressing enough for us due to call volume.  If we had a program the size of LA, I could definitely see the benefit..

 

 

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I am currently working as Community Paramedic (for the past 3 years) and starting PA school in May.  I am hoping that when I graduate I will get the opportunity to participate in a pilot group with the new CMS billing that was JUST introduce last week as a provider.

Our model began as a grant funding pilot in my state where we worked with the Duke Endowment's Access Health program (my state did not expand medicaid).  So we worked mainly with uninsured patients but also with EMS referrals for pts who were high utilizers of the ED and 911 system.  We do education in the home, attend provider visits (after connecting pt's with a medical home) and assist with prescription access.  

We have expanded to a pediatric asthma research trial and are working closely with the transitions clinic and expect to be taking on patients from them any day now (preventing 90 day readmits.)  

My hospital/county partnership is very interested in taking on providers to work with the Community Paramedics.  In this population, transportation is overwhelmingly the greatest barrier.  They are a very NP centric system and I'm hoping to convince them that PA's are perfect for this job-- especially ones with prior EMS experience. 

I'm happy to answer any questions anyone has about our CP program. 

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