Roundtable: Experts discuss key findings from the State of EMS 2016 report

The first-year findings from the State of EMS report set a foundation to track change in EMS and ignite discussion among EMS leaders and field providers about our future. We asked EMS1 editorial advisors, columnists and contributors to review, react to and reflect on State of EMS 2016 data. The panel includes:

• Dr. James MacNeal, EMS physician
• Sean Caffrey, EMS manager/administrator
• Chris Cebollero, EMS consultant
• Rob Wylie, Fire Chief
• Catherine R. Counts, EMT, graduate student

1. Which State of EMS 2016 finding surprised or interested you most?

Dr. James MacNeal: It is interesting that such a large percentage of respondents think paramedics should have an associate’s degree as a minimum requirement. These same respondents reported an extremely low number of associate’s degree-prepared paramedics working for them.

It will be interesting to follow this trend over time as the next generation of paramedics enters the profession. While the associate’s degree may seem to be a surrogate for achieving professional status for paramedics, it causes me some concern. Is it fair to ask an entry-level paramedic to take on two years of college debt to enter a career that pays less than minimum wage in some areas?

The perpetual chicken-or-egg situation is occurring here. Do we get the degree to justify better pay, or offer better pay so providers get the degree? My guess is that it will be a slow combination of both that will ultimately lead to a larger proportion of associate’s degree-trained paramedics.

Sean Caffrey: I also found it most interesting that almost two-thirds (64 percent) of respondents believe that paramedics should hold at least an associate’s degree; however, less than 8 percent of organizations actually required that of their applicants. This is a clear disconnect that actually represents our own organizations holding us back as professionals.

It’s also interesting to note we’ve been concerned about 24-hour shifts, and longer, for many years. We also have recent evidence that 12-hour shifts may, however, be among the worst of all in terms of fatigue and recovery. Interestingly, almost 40 percent of services report shift lengths of 24 hours or more, while half of all services surveyed use 12-hour shifts.

We have much work to do to better understand shift length and fatigue, including the research published in Prehospital Emergency Care, “Recovery between work shifts among Emergency Medical Services clinicians.”

Chris Cebollero: It was interesting to see the differences in how systems are conducting clinical care. More than half the agencies involved in the cohort are using an AutoPulse or LUCAS device. You can argue that these systems are trying to be on the cutting edge of care and trying to increase their cardiac arrest survival rates. But only a quarter of reporting agencies are using the impedance threshold device. This seems to be a disconnect in using resources in concert with each other to achieve a high rate of ROSC. If you decided to go with a mechanical CPR device, take the next steps and use the ITD to ensure maximum effectiveness.

Rob Wylie: The survey finding that surprised me the most was the lack of consistency in medical care practices. I realize that there is and always will be a significant divide in the service area types — for example, rural versus urban — but with the advent of available technology, such as software for patient tracking outcomes, along with increased grant availability and more professional certification and education requirements, I would have thought that the gaps would narrow. There will always be outliers, but I expected a more homogeneous prehospital health care system.

I was also surprised by the disparity in clinical measures being utilized by different agencies. With the widespread distribution of best practices, I expected more agreement on critical clinical measures that all agencies should track as a standard.

Catherine R. Counts: Two things stood out to me. First, almost half of the organizations were able to implement hypothermia protocols, which is a relatively quick uptake of a new clinical procedure versus other interventions. Note that the 2015 AHA guidelines do not recommend prehospital initiation of therapeutic hypothermia.

Second, I am surprised that nearly half of respondents are surveying patient satisfaction – although I think we need to define the word “survey” to better understand the effort to collect and analyze satisfaction data.

2. Which additional finding was either most affirming or most concerning?

Sean Caffrey: I was pleased to see a very diverse list of organizations surveyed, an uncommon occurrence. Overall it shows that while we often pride ourselves on variation, we are generally similar as organizations and as a profession, dealing with similar issues and seeing similar trends. Despite the variation in agency type and geography, little in the survey was particularly surprising.

James MacNeal: The funding issues continue to concern me. As health care becomes more integrated, are we placing increasing demand on some of the lowest-paid members of the health care team with the least amount of training in care management and long-term care?

This is unfortunate, but it might also prove a huge opportunity for EMS to step into a role that no other provider can assume in such a rapid fashion. Mobile integrated health care needs to be properly funded before we can expect our agencies to continue to pursue it as a viable care option. Expecting EMS to develop training programs, educate providers and provide care is a lot to ask when there is no dedicated funding stream.

Chris Cebollero: It was interesting that there is still so much reliance on response times as a component of an effective EMS system. This old way of measuring system effectiveness has to finally be debunked and replaced. The EMS systems of today need to also focus on outcome measures, including measurement of patient satisfaction.

First responders are getting on-scene on average in four minutes. Care is at the patient’s side faster today than when response time compliance was put into place decades ago. The clock should then stop and the team needs to deliver the best patient care possible, focusing on outcomes, navigating the patient to the most appropriate treatment facility and ensuring that patients feel they received excellent care.

Rob Wylie: The most affirming finding was the overwhelming agreement by the respondents that EMS services are becoming more integrated with the overall health care system. The complexity of the regulatory environment, coupled with the pace of clinical change in medicine in general, dictates that we have a cohesive, comprehensive and symbiotic relationship between EMS response agencies, hospitals and the medical education system.

Catherine R. Counts: It is affirming that clinical measures are being used by agencies to measure appropriate application of care, but the amount of variation is worrisome.

3. How do the findings of the first year align with other trends in EMS and health care?

Catherine R. Counts: It makes sense to me that there is variation in how “success” and “good care” are measured. The U.S. health care system as a whole can’t agree on what constitutes good care, so it’s no surprise that EMS can’t either.

James MacNeal: The likely increase in patient satisfaction scores tied to EMS reimbursement is a very scary prospect. Patients are often most anxious and least likely to understand the care that is being provided to them in the first minutes of their emergency. Poor experiences in the emergency department and in the hospital may translate to lower patient satisfaction scores for EMS by the time the patient receives the survey. In a model where EMS providers must have pancake breakfasts, fish fry dinners and bingo night (to raise needed funds), it is very scary thinking that if their patient satisfaction isn’t good, their reimbursement might be lowered more than the barely afloat level it is at already.

Chris Cebollero: It seems to me that the status quo is alive and well in EMS. The adage, “that’s the way we have always done it” comes to mind when looking at the first year of data. We now have the opportunity to challenge our processes, determine what the EMS systems of tomorrow will look like and transition to new models. Health care is changing daily. It is time for EMS to be in the forefront of change to help patients get healthier.

Rob Wylie: The findings of the first year point in a couple of directions. First, patient outcome-centered care. As we see the growth of community paramedicine to prevent patients who could otherwise be treated at home by highly trained medics — supervised by doctors, physician assistants or nurse practitioners/APRNs — from returning to the hospital.

Second, we have an opportunity to refocus more of the services we provide to be patient-centric. Why do we transport diabetics who return to a normal (blood sugar level) after treatment? Why are COPD patients transported when all they may need is an adjustment in their medications? Home-based care is less expensive, less invasive and in many instances more than adequate.

Sean Caffrey: The variation in clinical care was not particularly surprising. As with any medical practice, the level of care being provided and the adoption of new treatment modalities occur at various speeds throughout the health care system.

It was also interesting to see some clearly outdated items still around while some newer therapies had gained substantial adoption. This is comforting in the sense that it represents that we advance in a similar way to our colleagues throughout health care and that removing therapies is perhaps harder than adding them.

4. What specific actions, based on State of EMS 2016 findings, do you recommend to EMS leaders?

Chris Cebollero: It is always a best practice to benchmark your system, processes and clinical care with the career field. This project lets EMS leaders look into the EMS mirror and gauge how successful their EMS system truly is. As leaders, we need to meet, exceed or set the standards for others to follow and hopefully come to some consensus on how “gold standard” EMS systems should operate. This is going to be a long road, but it begins with the sharing of data.

James MacNeal: Engage with your local hospitals now. Mobile integrated health care is not a right of EMS. Many hospitals don’t even know EMS providers can do these things. By getting in on the front end of this, EMS will be in a better position to control their destiny. Engage your medical director for EMS activities as well as hospital liaison duties. Integration is paramount to all of our success, but if you are not a full partner, bundled billing will be your nemesis.

Catherine R. Counts: Recognize that no EMS organization is an island, while at the same time no two organizations are exactly alike. Protocols and procedures can have variation across organizations, but said variation must come from a place of good intentions.

EMS is a changing field, but different organizations have the capacity to change at various rates. Don’t try a new idea just because a famous EMS agency or service did it. Do your own research and come to a decision that is best for your organization’s economic and cultural situation.

Rob Wylie: I am reminded of the adage, the only two things emergency response agencies hate are change and the way things are. We need to focus on best practices, evidence-based medicine and clinical measurements that truly gauge the value of the service we provide. “We’re too small” or “We’ve always done it this way” are crutches and excuses that do not hold water.

Look around at those that are doing it right. Educate your community and its leaders as to the kind of service your customers deserve and that those services cost money. Adopt evidence-based clinical measures that show the great work you are doing, not just how fast you are leaving the station after a 911 call.

Sean Caffrey: The IHI’s “Triple Aim” will continue to be the rallying cry of health care moving forward. We know health care is too expensive, far less effective than it should be and very disconnected from the patient.

EMS leaders must do a better job of measuring from the customer’s perspective. Obscure metrics, such as measuring response time intervals from the time of dispatch, something no patient would care about or benefit from, puts us in a position of peddling self-serving nonsense that will likely come back to haunt us. We must also do a much better job of measuring and providing good customer service. It won’t be long until we can read about ourselves in a Yelp or similar-style review.

5. What else would you add to the discussion?

James MacNeal: EMS providers need to be active learners and participants in the EMS system. Encourage your medical directors, nurses, emergency physicians and law enforcement personnel to spend time with you. You need to carry the torch of your profession and spread the word of our undying commitment to saving lives and serving our communities.

Chris Cebollero: As EMS leaders we often talk about how splintered the EMS career field is, or we wonder when some person or agency is going to unite all of EMS so we finally get the recognition and respect our career field deserves. It is through efforts such as this that will bring recognition to common care and operational practices.

Sean Caffrey: An overwhelming majority of respondents want paramedics to have a degree, many EMS organizations invest over half their budgets on staff and we claim to be very concerned with their safety. Our actions, or perhaps our need to get trucks on the street at any cost, however, show that we are not yet aligning our practices with our preaching – issues which are squarely under our control as EMS leaders.

Catherine R. Counts: The fact that Fitch, EMS1 and NEMSMA teamed up to do this report is fantastic. Although prior attempts at surveying EMS organizations have been made, the long-term goals of this survey set it apart from those efforts. By committing to seek out responses from the same organizations year after year (and with such a large response rate), this survey will only become more valuable both within and outside the EMS industry.

Concepts like mobile integrated health care and community paramedicine, paired with the continued focus on ensuring that health care is effective while being patient-centered, noted in this report and subsequent surveys will ensure that EMS is able to keep pace with the trends, changes or alternative markets coming our way.

Rob Wylie: I would recommend that all EMS leaders become involved in professional associations and organizations such as the National EMS Management Association, the International Association of Fire Chiefs, and the National Association of EMS Physicians (you don’t have to be an MD to join!).

Most of all, I would encourage leaders and their personnel to look hard at what their communities expect from them now, and then educate them as to what is possible with a collaboration and support in the future.

Find the need and create the solution! Become the “agency of first resort” in your community.

The Panel
James MacNeal, MPH, DO, NRP, began his career in emergency medicine as a paramedic. He holds an American Board of Emergency Medicine/Emergency Medical Services certification and completed an EMS fellowship at Yale University. He is the MercyRockford Health System’s EMS medical director.

Chief Rob Wylie has been in the fire service for 29 years, serving first as a volunteer firefighter and then as a career firefighter, rising through the ranks to become the fire chief of the Cottleville FPD in St. Charles County, Missouri, in 2005. During his tenure, he has served as director of the St. Charles/Warren County Hazmat Team and as president of the Greater St. Louis Fire Chiefs Association. Wylie has served as a tactical medic and TEMS team leader with the St. Charles Regional SWAT team for the last 19 years and serves on the Committee for Tactical Casualty Care guidelines committee. Chief Wylie is a member of the Fire Chief/FireRescue1 Editorial Advisory Board.

Chris Cebollero is a nationally recognized emergency medical services leader, author and advocate. He is a member of the John Maxwell Team and available for speaking, coaching and mentoring. Currently he is the senior partner for Cebollero & Associates, a medical consulting firm, assisting organizations in meeting the challenges of tomorrow. Cebollero is a member of the EMS1 Editorial Advisory Board.

Catherine R. Counts is a doctoral candidate in the department of Global Health Management and Policy at Tulane University School of Public Health and Tropical Medicine, where she also previously earned her master’s degree in Health Administration. Counts has research interests in domestic health care policy, quality and patient safety, organizational culture and prehospital emergency medicine. She is a member of AcademyHealth, Academy of Management, the National Association of EMS Physicians and National Association of EMTs.

Sean Caffrey, MBA, CEMSO, NRP, currently serves as the EMS programs manager for the University of Colorado School of Medicine, Pediatric Emergency Medicine Section. He has been certified as a paramedic since 1991 and has worked in volunteer, private, hospital-based, fire-based and third service EMS systems in roles from provider through department head. Caffrey currently works in conjunction with the state EMS office in Colorado, is the vice president of the EMS Association of Colorado, is a board member of the National EMS Management Association and a member of NAEMT, NASEMSO and NAEMSP. His interests include EMS system design, pediatrics, public policy, professional development and research.