Advanced Practice Paramedics 2.0

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 Directors “State 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.

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)

Mike “FossilMedic” Ward

Also on FireGeezer…

• Around the Web – February 7, 2010
• What Direction for EMS Education? – November 9, 2009
• The Next Paramedic Shortage – October 16, 2009
• Snapshot from the Paramedic Battlefield – October 12, 2009