December 1, 2021 | View as webpage


There are few EMS systems that are not feeling the strain these days of staffing, bed delays and reimbursement for care delivery. In today’s Paramedic Chief Leadership Briefing, EMS1 columnists Carly Alley and Reuben Farnsworth, BS, CP-C, CCP-C, LP, NRP, share strategies for protecting and best allocating EMS resources – chief amongst them – providers.  

Alley challenges the sign-on bonus culture which, in her words, "is guaranteed to keep all organizations understaffed with a revolving door of new employees shopping for the next sign-on bonus.” There are no winners with this recruitment methodology, Alley notes, while advocating for investing in retention of qualified, trained staff.   

Additionally, Farnsworth offers a glimpse at how ET3 implementation is evolving EMS care in rural Colorado to the benefit of patients as well as the community and the EMS system.  

What are you doing to protect your staff? Email us at editor@ems1.com.   

Stay well, 

— Kerri Hatt
Editor-in-Chief, EMS1 


Recruitment or retention – Where is your budget focused?
By Carly Alley 

The current EMS staffing shortage has highlighted the number of sign-on bonuses that are now stretching up to tens of thousands of dollars. This issue has raised eyebrows across the industry as agencies “rob Peter to pay Paul” with the back-and-forth exchange of staff between organizations bidding for medics. While we may add one or two to the roster with an attractive sign-on bonus, it doesn’t solve the problem and, most certainly, disenfranchises employees that have been with an organization from the get-go who may receive little-to-no overall reward for their loyalty and service.

The healthcare industry, especially ground ambulance services, are suffering from an acute staffing crisis. Healthcare workers are exiting the industry due to the stress of a prolonged pandemic, PPE fatigue and burnout in general. There is also a lack of interest in entering the field of emergency prehospital care. Adding to this exodus is the fact that many EMT and paramedic schools have closed or have significantly reduced class sizes at the height of the pandemic. In simple terms, the bathtub has been emptying faster than we can fill it and the resultant bidding war for staff has caused concern.

With companies desperate to fill sufficient vacant positions to keep the required and contractual number of trucks on the street; the easiest way to attract staff is via lateral transfer. The one way to grab attention and bring workers in is via sign-on bonuses.

The current situation has created a buyers’ market and started a bidding war. Organizations and agencies understand they are not simply gaining new employees, but rather buying another organization’s experienced employee with a sign-on bonus. Companies find themselves needing to increase their sign-on bonuses to stay competitive when their neighboring agency increases theirs and so on. Imagine it like dueling banjos, does it ever end or does one player just quit because they have nothing left? This practice is guaranteed to keep all organizations understaffed with a revolving door of new employees shopping for the next sign-on bonus. There are no real winners with this recruitment methodology which, in fact, represents a kick in the morale gut for our current employees.

Invest in your current employees

In knowing that there is no net gain to this practice, perhaps we should all take the dollars we have for sign-on bonuses and instead reward our current employees for staying with it. This could well be an investment in the stability of our organizations. This will also boost morale, which is at an all-time low due to the prolonged pandemic. For nearly two years, our employees have worked through some of our most challenging times – showing our appreciation to them is necessary. If we compare a nice sign-on bonus for new employees versus rewarding our current employees for their dedication with a longevity bonus, we might prevent our neighboring organization from gaining our experienced employees.

Longevity bonuses are not the only way we can show our appreciation for our current employees. Quarterly or monthly incentives for things like the crew or individual with the fastest overall chute times, leadership staff hosting a pancake breakfast at your operations base (a fun and inexpensive way to perk up any group), delivering lunch to crews on busy days, a special treat for those working on holidays, birthday and anniversary cards signed by leadership, are all great ways to show your appreciation. We can think outside the box and have fun with it! Investing in our current employees is one of the best tools we have to help this staffing crisis.  Employees who are happy and feel appreciated enjoy coming to work. Creating this culture within your organization will keep your current workforce and can also attract new employees.

In the final analysis, if we do the math, the cost of losing an employee is expensive. It takes a staff member about two weeks to leave (after giving notice) and employers about three months, if they are lucky, to recruit, onboard, precept and clear someone new. The cost associated with this includes the necessary overtime to plug the gap created, the time spent advertising and recruiting (now add a hefty sign-on bonus to this number), and salary for new staff as they ride third member while being inducted into the organization. The net cost of this process sits somewhere in the range of $10,000-$30,000 dollars per new employee. Imagine if you invested that amount into keeping, rather than finding people.

It’s probably not going to get any better any time soon, but there are plenty of ways to boost morale and show your appreciation for your employees and retain them. What we have seen is, while we gain one employee with an attractive bonus, we also lose one – so there are no winners. Look at your budget, adjust your focus and retain; it may well keep your bathtub full to an acceptable level.

Additonal resources: 

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Treat in place: An ET3 implementation case study
By Reuben Farnsworth, BS, CP-C, CCP-C, LP, NRP 

You are toned out at 0200 for a 62 y/o female with difficulty breathing. You pull on your boots, trudge out to the truck and roll over to the address. You have been here before. The female patient you encounter is anxious, lonely and hyperventilating. The patient asks if you can take her to the ER for a shot of Ativan. You carry Ativan on your unit; wouldn’t it be nice if you could just handle this right here and not have to transport and tie up an ER bed for a case of anxiety?

Enter ET3, (the Emergency Triage, Treat and Transport Model), the brainchild of CMS and the current topic of numerous EMS discussions. A pilot program which was supposed to launch in the fall of 2019, ET3 was delayed right up until COVID-19 hit EMS. After further delays, EMS agencies are now fresh off the lessons learned secondary to the utilization of telemedicine during the pandemic and launching ET3 pilot programs.

ET3 was designed with a simple goal: keep patients out of the emergency room who don’t need to be there. The hang up for EMS has always been payment – if no transport occurs, no payment is made. ET3 seeks to provide payment to agencies for doing what is best for the patient, rather than transport decisions being dictated by lack of payment for non-transport.

Launching ET3 in rural Colorado

One such program, located in a rural patch of Colorado, between the adobe deserts creeping toward the Utah border and the Rockies rising to the east, is one of the 184 or so agencies selected for the ET3 pilot program. Delta County Ambulance District (DCAD) is a tax-based EMS agency, responding to roughly 4,300 calls for service per year. The only hospital in the county is a level IV trauma center. The nearest level II trauma center is 45 minutes to an hour away and is the only level II center between Denver and Salt Lake. The nearest children’s hospital, burn center or level I trauma center are also located in these urban centers, each roughly 5-6 hours by ground to the east and west respectively.

For DCAD, early challenges in the ET3 implementation process related primarily to navigating the CMS system and becoming compliant with all necessary supporting documentation required to initiate the program. The only urgent care in the area closed down just prior to implementation, requiring a change in the alternative transport destination, delaying launch for another month.

Telehealth in action

In such a rural area, the urgent care clinic provides minimal services beyond those available from a 911 crew, leaving telemedicine as the primary delivery model utilized. The greatest challenge with telehealth in the rural environment has been challenges with cellular connectivity. Several solutions have been implemented, including utilizing the patient’s in home Wi-Fi, when possible, as well as the use of a mobile modem which connects to all three major cellular carriers and seamlessly moves between carriers as the signal waxes and wanes.

In choosing a telehealth provider, DCAD was focused on retaining a group that was willing to innovate and really think outside of the box in regards to the new care delivery paradigm. Ultimately, there was no other choice than Hippo Health, and the results have been excellent to date.

Responding 911 crews identify patients that do not require an ER visit, but do require treatment and will benefit from physician input. The responding paramedic identifies these patients and sends a quick text message through the PHI secure platform to alert the on-duty physician to an imminent telehealth call, providing a brief description of the patient’s complaint (e.g., 65 y/o male with COPD exacerbation, 63 y/o female with anxiety, etc.).

After completing a thorough assessment and coming up with a potential plan of care, the paramedic initiates a video call with the physician. The paramedic provides a report, similar to a hand-off in the ER, answers any questions the physician may have, and then the physician speaks to the patient. The physician approves or modifies the care plan, gives any instructions for follow-up and calls in any scripts necessary to the patient’s pharmacy of choice. The 911 team then treats the patient, clears the scene and documents the call as EMS has done for years. The ET3 program is like treat in place with refusal on steroids.

Elevating patient care

The ET3 Model is still in its infancy and there are many lessons left to be learned. Early indications for this particular agency are promising. Patients are being treated in their homes, which the patients are ecstatic about, and EMS clinicians are providing the needed care and not feeling that they are tied to an ER transport for everyone that is sick, but not really sick.

Perhaps most important of all, there is a paradigm shift happening in this rural community, wherein patient care is being elevated; innovation is occurring daily; and the way we deliver medical care to patients is evolving to the benefit of the system, the patients and the community.

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