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Council, Commission review proposal to change ambulance staffing

Thursday, February 9, 2012 by Michael Kanin

Faced with 50 vacant medical provider positions, representatives from Austin/Travis County Emergency Medical Services went before the Public Safety Commission and City Council this week to present what they hope will be a new staffing model for the organization.

EMS Medical Director Dr. Paul Hinchey presented the plan, which he said would address a “critical issue for the sustainability of the organization and keep us one of the top EMS organizations in the country.” Under the terms of the plan, EMS would move from having two advanced/critical-care providers (paramedics) on each transport ambulance to having one advanced-care provider and one basic-care provider (EMT).

Doing so, said Hinchey, would improve EMS service in several ways.

First and foremost, having one provider credentialed by the office of the medical director to perform only basic life support would better match the organization’s services with the community’s needs. In FY2011, 59 percent of patients treated by EMS only required basic life support services, services that can be performed by an EMT.

Secondly, having only one advanced care provider on an ambulance would help that advanced care provider maintain his/her critical skills.

“Currently, each individual provider alternates calls, so they only see half of those critical patients in a given year,” said Hinchey. “There is a growing concern that more complex tasks need to be performed more often to maintain proficiency. An all-advanced-provider system limits individual opportunities to perform complex tasks for critical patient care. We want to have them see more critical cases to maintain proficiency.”

Several Council members questioned the proposed changes to the EMS staffing policies EMS at their work session on Tuesday.

Though the city manager’s office could make the change without Council approval, staff seems prepared to roll the idea into its next meet-and-confer agreement with the Austin-Travis County EMS Employee Association. That deal is expected in 2013. It must be ratified by Council.

Should the policy go into effect, however, the first of the changes could be in place by the end of this year.

EMT Chief of Staff James Shamard told the Public Safety Commission that actively maintaining the proficiency of paramedics by teaming them with lesser-trained EMTs is the “right next evolution in medicine for the community.”

“It’s like a musical instrument: You have to do this everyday,” said Shamard. “Unless you’re really doing it, you get out of your routine; it’s not a part of what you do every day. Now a significant number of the patients paramedics take care of are basic patients, which is exactly what EMTs exist to do, and they don’t have the opportunity to see those really sick patients.”

If the plan is approved, the 50 vacancies would be filled entirely by basic providers.  Doing so, said Hinchey said, would allow the department to expand its applicant pool and develop basic providers into advanced providers.

Council Member Mike Martinez, himself a former fire fighter, had questions about the system would work.  “I guess I’m trying to figure out how are we going to get that if the EMT is riding up front honking the horn as opposed to being back there with that patient,” he said.

Hinchey suggested that most EMT learning wouldn’t take place in an ambulance. “Most of (the important diagnostic efforts are) done, actually, in the decision-making process in the initial contact, in the first 10, 15, 20 minutes, depending on the acuity of the event,” he said. “Most of the time going to the hospital where there is that degree of separation, where someone has to drive the vehicle, that’s mostly a maintenance (effort). That’s either following-through on treatment that’s already been initiated or just monitoring.” 

Martinez also wondered what might happen if a patient’s condition worsened on the way to the hospital. “What happens in the scenario where a patient deteriorates…in route to a medical facility and you’re needing that higher level of care?” he asked.

“One of the best benefits (of the proposed arrangement) is that an entry-level person learns from experience,” Hinchey said, adding that if the situation got to be too much a switch “is just a buzzer away.”

“You push the buzzer and it goes off in the cab and you stop and simply switch places,” he said. “That advanced level of care is really just two feet away from you at any time.”

Public Safety Commissioner Mike Levy was also skeptical of the department’s plan, however. At Monday’s meeting, Levy wanted assurances 1) that any money saved by the department’s implementing the plan would be reinvested back into the system and not into the General Fund; and 2) the department would be prepared if a situation arose requiring two advanced-care providers.

“Money has not been the driving force behind this. … (this is) not a cost-saving measure,” Hinchey responded to Levy’s first concern. “The main driving force behind this has been to improve our clinical medicine and to give us some funding to reinvest in our system in resources and education for the paramedics.”

As to the issue of dispatching two paramedics for certain “high-acuity” cases, such as cardiac arrest incidents, Shamard said the department will have to learn how best to handle such situations over time.

“For the types of calls we feel like – and certainly this will be a learning process over time and we’ll have to get feedback from the paramedics as we move forward – for those high-acuity calls, such as cardiac arrests, if we feel they required a second paramedic, we would build into our dispatch matrix the ability to do that,” Shamard said.

Austin/Travis County EMS Chief Ernie Rodriguez  told Council members that the EMS Advisory Board and the EMS Employee Association had each signed off on the deal. He indicated that the Public Safety Commission, who heard the pitch Monday, was more hesitant.

“(The Public Safety Commission) would like to give their recommendation next month when they meet again,” said Rodriguez. “And they want some periodic updates on progress as well.”


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