After more than a decade staffing ambulances with two paramedics, Austin-Travis County EMS in Texas is moving to a one paramedic/one EMT or EMT-intermediate configuration. EMS Director Ernie Rodriguez says his organization made the shift for two reasons: difficulty in finding qualified, experienced paramedics to fill vacancies and a desire to give paramedics more experience in ALS procedures, possible only if there were fewer of them.
The last decade has brought significant changes to the area served by Austin-Travis County EMS and its 370 paramedics, who provide care to nearly 1 million residents in and around Austin, covering a region of more than 1,100 square miles. The county’s population grew by 26 percent from 2000 to 2010, while several swaths of unincorporated land were annexed, adding to the coverage area. With response times to some outlying suburbs reaching 14 minutes, the city and county added 16 new paramedic positions in 2010 and another 16 in 2011, Rodriguez says. (Under the agreement between the city and county, the city provides EMS to the county, which reimburses the city for it.)
But hiring those personnel wasn’t easy. “It’s getting more and more difficult to hire good, strong, qualified paramedics,” Rodriguez says. “Some would fly from other states and not pass our paramedic exam, which is based on National Registry questions. Some could pass but couldn’t perform the skills. Others performed well but couldn’t get past the interview board. Some couldn’t pass the physical ability test. Some didn’t have enough experience to put on an ambulance as a lead paramedic.”
At the same time Rodriguez was growing frustrated with the dearth of good candidates, the medical director, Paul Hinchey, M.D., was growing concerned that paramedics weren’t getting enough experience doing ALS procedures because there were too many of them. An analysis of transports found that about 40 percent were ALS calls, while 60 percent were BLS and could have been handled by EMTs—and yet 100 percent of calls were being answered by ALS-qualified practitioners. They also surveyed other EMS agencies around the nation and discovered many were finding success with the paramedic/EMT combination.
“If you go to a hospital and need a procedure done, you want to see a doctor who does that procedure a lot. It’s the same with paramedics,” Rodriguez says. “We realized that what we need is fewer paramedics. Those fewer paramedics are going to have more frequent contact with more critical patients. As a result, their skills are going to improve, and they are going to get better at handling those critical patients.”
After proposing the idea to the city council earlier this year, Rodriguez and Hinchey held a series of meetings with the EMS advisory board and the public, who were initially skeptical of the plan. “They thought, You’re just doing this to save money,” Rodriguez says. “But cost wasn’t the driver.” He explains that entry-level paramedics make only about $3 an hour more than EMTs.
No paramedics will be laid off, Rodriguez says; the transition will occur through attrition. It will take an estimated seven to eight years to get to the final mix of providers, which will be 60 percent paramedics and 40 percent EMTs or EMT-I’s. So any cost savings will take years to realize—and they’re urging the city and county to put any savings that are made back into EMS.
This isn’t the first time Austin-Travis County EMS has changed its staffing. In the 1990s, it ran a tiered system, in which BLS-equipped ambulances answered some calls and ALS answered more critical ones. But Rodriguez and his team decided it would be more prudent to make sure there was an ALS provider on every ambulance, since it’s not always possible to determine the nature of the call prior to getting on scene. Public buy-in was also important, which meant trying to communicate the complexities of EMS licensing to the community. “They wanted to know, If I have an emergency, is a paramedic coming or not?” Rodriguez says. “We had to assure them there would be a paramedic on that ambulance.” After several meetings and lengthy discussions, the community became more comfortable with the switch, he says.
In Texas, the city manager has the authority to make the final call on ambulance staffing, and he agreed to the proposed change in March. Rodriguez is in the process of hiring 30 EMTs to fill vacancies and begin the transition to the new staffing model.
He’s hopeful the new system will help with recruiting, too, since candidates with paramedic certification but little real-world experience could initially get hired to do a BLS-only job, with the incentive that after they gain more experience and if they perform well they could eventually get promoted to paramedics. “It starts to create a career path for EMS,” Rodriguez says.
