Taking out-of-hospital care to the next level
Any attempts to implement this in the United States should be benchmarked with the model of education and delivery in the UK
By Paul Mazurek
Last month we introduced a concept of a "new breed of responder" that has taken hold in various forms already. While still in its infancy in many areas of North America, it appears to have taken shape based upon the needs of the local communities.
Taking this concept of "advanced practice paramedics" to the next level involves advanced education and training. Such training many paramedics receive when they leave EMS to go to Physician Assistant School. If we took a clinician with this type of training and put them out in the community, bringing healthcare to the patient, this area of healthcare could be transformed. This is already a reality in the United Kingdom.
Emergency care practitioners
The United Kingdom is the benchmark for this type of patient care delivery model. Accredited advanced degree programs exist, affording EMS providers the opportunity to become fully credentialed as "Paramedic Practitioners." These practitioners are utilized to respond to patients in the community, determine their needs and provide the most appropriate treatment options. Students are trained in advanced physical assessment and pharmacology, care of patients with minor injuries and minor health problems, and clinical decision-making.
The need and implementation of this type of practitioner came from the large number of vacancies in general practice physicians identified since the late 1990s. Additionally, emergency calls in the UK have been rising by approximately 8 percent every year, many of which are those patients that could be appropriately treated in areas outside of an emergency department1. The combination of an unmet need and increased demand for EMS services gave providers in the UK a unique opportunity.
While the broad expansion in scope of practice that might include increased skill sets for handling emergent and critical patients, several schools have expanded their curricula to include various interventions such as select surgical procedures and advanced airway interventions. The primary focus and need continues to be focused on the primary care arena. However, geographic location and individual community needs will dictate future scope of paramedic practitioner practice.
Much of the literature that describes the effectiveness of British Emergency Care Practitioners (ECP) in delivering quality healthcare, correct referrals and reducing need for hospital admission appear to be quite promising. Mason, O'Keefe and Coleman, et al. report finding no evidence that care provided by an ECP was less appropriate than care provided by typical practitioners for the same type of health problem2. This same group of authors’ report in an earlier study suggested that this model could in fact be having a significant impact on current emergency services costs and workload3.
While this model of healthcare delivery is by no means a finished product, it appears by every indication that our friends across the pond have shown us the way (if this is in fact a model of healthcare delivery that we want to pursue). In addition to making strides on a standardized curriculum and clinical advancement ladder, definite stratification levels in leadership, instruction and research have emerged. Any and all attempts to implement this in the United States should be benchmarked with the model of education and delivery in the UK. Why re-invent the wheel? All indications say that it is working.
Designing the provider: The Michigan Initiative
In July last year, eight EMS instructors — including myself — from various areas of the state of Michigan met for the first time to discuss what we referred to in meeting minutes as "The Dream." We brainstormed what the scope of practice would look like, what the educational process and curriculum would look like, ideas for financial support and funding, who would employ such a provider, prerequisites for entrance in to this program, existing strengths and potential challenges within our state and nationally, concerns and what we need in order to get started. From this the American Society for the Advancement of Paramedicine (ASAP) was established. The following vision and mission statements will provide a testament to our commitment to our EMS colleagues and the delivery of quality healthcare:
The vision of the American Society for the Advancement of Paramedicine is to serve the profession of paramedicine, through such avenues as; Education, Advocacy, Promotion, and Creation of new opportunities.
The mission of the American Society for the Advancement of Paramedicine is to promote the well-being and health of the individual who activates the emergency medical system but whose acuity is either above or below the emergency threshold. The focus of this group is to develop and implement a nationally recognized paramedic practitioner who would be well trained and comfortable in rendering the appropriate care in a timely and cost efficient manner.
A paramedic practitioner in the community
While the models of care previously described provide a very solid foundation, our envisioned scope of practice has fewer boundaries and provides the delivery of healthcare across the lifespan, from minor ailments and injuries to providing advanced critical care during life-threatening situations. We foresee the paramedic practitioner in the community providing primary care and occupational health services, health promotion and disease prevention services, and advanced, time-sensitive critical interventions during life threatening emergencies, mass casualties and disasters.
The paramedic practitioner would be educated and trained utilizing a similar didactic and clinical model as a Physician Assistant or Nurse Practitioner. Clinical focus would include the community, urgent care clinics, emergency departments, intensive care units and of course, the primary EMS service area in both a rural and urban setting. The clinician will be trained to be proactive rather than reactive, taking care of small problems before they become big problems and gaining control of a large problem before it becomes an out of hand problem.
This sounds like a rather bold and labor-intensive endeavor — because it is. Only the brightest, most enthusiastic and motivated candidates need apply. The scope of practice and responsibilities of the paramedic practitioner will have few limits. We are taking care of a community and as such, the community will expect that only the best clinicians will be involved in their healthcare at this level. Minimum prerequisites for study will include meeting university requirements at the graduate level and endorsements by local medical control physicians, system medical directors and community liaisons.
So where do we go from here? In order to make the vision a reality, organization is obviously a must. The first place to start is visiting the ASAP Web site.
As we grow and become more organized, the need for the development of local and state chapters will become a necessity. Specific "focus groups" — which you can find more details about here — are in the process of being developed and specific areas of interest and expertise are welcomed. These sections include friends and interested parties, legislative/governmental, finance, education and research.
This is no small endeavor. EMS has consistently embraced and implemented change based upon the needs of those that we serve. This is no different. Visit the Web site and join our e-mail group. We welcome any and all ideas. EMS can and will change the shape of healthcare while providing opportunities for increased education and advancement.
1. Woollard M. The Role of the Paramedic Practitioner in the UK. Journal of Emergency Primary Health Care (JEPHC) 4(1); 2006.
2. Mason S, O’Keefe C and Coleman P, et al. Effectiveness of Emergency Care Practitioners Working within Existing Emergency Service Models of Care. Emerg Med J 24; 2007. pp. 239-243.
3. Mason S, O’Keefe C and Coleman P, et al. The Evolution of the Emergency Care Practitioner in England: Experiences and Impact. Emerg Med J 23; 2006. pp. 435-439.
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