Roundtable: Reducing the burden on EMS providers
Adopting programs to improve service delivery and agency culture
Editor’s note: This article originally appeared in the EMS1 state-of-the-industry report. Download the full report, “What Paramedics Want in 2023".
Our goal in measuring and analyzing EMS trends is to identify areas for growth: both where it is needed and where it is succeeding at improving operations. When agencies and providers are feeling the brunt of staffing challenges in levels that have nearly half of providers (45%) considering leaving EMS, and 97% of agencies struggling with turnover – it’s time to change the way we deliver EMS.
In year-over-year comparisons, we’ve seen incremental growth in agencies adopting alternate service models and tools, including telemedicine, nurse triage of 911 calls, alternate means of transportation and alternate destinations. By getting patients to the right definitive care and reducing the volume of patients delivered straight to the ED, patients are better served and turnaround times are decreased, reducing the burden on providers.
While these downstream impacts of adjusting service delivery will improve EMS for providers, we cannot ignore the impact leadership has on their stress. EMS trend survey respondents made that impact loud and clear, citing agency leadership and their direct supervisors as the biggest drivers of stress in EMS.
We asked a panel of EMS innovators and experts to share their experiences, successes and tips for adopting programs to both improve EMS service delivery and to improve agency culture – creating a safe space where wellness is appreciated, and seniormost staff lead the ship – rather than create additional stress. Here’s what they have to say.
HOW TO ADOPT
When I arrived in the U.S., now 15 years ago, I was excited to see that my service had a nurse triage program in place, identical to the one I left behind in my U.K. ambulance service. This excitement was soon dampened as I realized that for all the professional staff of RNs and appropriate software, we had absolutely no pathways to send the patient down other than go to an ED. The idea, and the system, were literally years ahead of their time for this country. In addition to being the first service to operate this type of system in the U.S., we were also the first to close it down.
That was then; this is now!
The advent of more telemedicine options, systems and patient destinations (other than the ED) are now more prevalent. The pandemic and public health emergency created waivers for telemedicine and nurse triage has opened up. The opportunity to now dispatch a resource that is not a double crewed ambulance, and hear and treat (or see and treat) a patient is an encouraging development that will undoubtedly propel EMS into the future.
The challenge is now to work hard to make this a commonplace treatment and referral option across the entire prehospital landscape. The biggest question with this operation is always, where do we begin? The answer lies in my own favorite four-letter word – data – as well as the four Ps: partnerships, payers, pathways and personnel.
- Partnerships. Identify the need, the population you serve and the benefits to the system. These are well publicized and probably obvious, but as we know, each system has its own nuances that must be laid out. Partnerships must follow: the benefits of any triage program reach beyond the EMS agency, and primary and secondary care systems and their buy in are essential.
- Payers. The ensuing business case must identify funding, considering the payer federal funding insurance income for services delivered.
- Pathways. In my experience, particularly in the U.K., pathways are a key element to success. There must be somewhere for the patient to go to be seen (or heard) that isn’t an ED, and this is actually a key element of the program.
- Personnel. Finally, a project lead who has both the background and enthusiasm for the task is key to success. There will be challenges, frustrations and setbacks, but perseverance will win the day.
— Rob Lawrence, director of strategic implementation for PRO EMS and its educational arm, Prodigy EMS, in Cambridge, Massachusetts; and part-time executive director of the California Ambulance Association
HOW TO ADOPT
Telemedicine can be a very patient-centric intervention for certain patients who access medical care through a 911 call. For patients who need care, but not necessarily care in an emergency department, telemedicine-enabled treatment in place (TIP) could be a logical disposition. The challenge is that most EMS clinicians have not been fully trained on the advanced assessment that may be necessary to ensure a TIP disposition is fully appropriate. That’s when consultation with a physician, nurse practitioner, physician assistant or mental health specialist can play a crucial role in the decision-making process.
TIP saves valuable EMS resources for the community, especially when EMS agencies face extended off-load delays at destination hospitals. Patients also seem to like TIP better than going to the ED. Patient experience scores from TIP are generally higher than scores from patient transport. In the MedStar system, our EMS Survey Team TIP through telemedicine scores average 96.7, compared to overall patient experience scores for patients transported of 91.7.
In the MedStar system, we have seen numerous benefits, including the community and patient satisfaction with knowing we are more than a method of conveyance to an ED. The community trust value is exceptional. Our field providers feel empowered to help their patients receive the right care, not simply a ride to the ED because that’s their only option.
Here are 4 tips for leaders looking to incorporating telemedicine into their service models:
1. Ensure your medical director is fully on board. They are ultimately responsible for your patient care and need to be a key decision maker for the program. Select the right telemedicine partner. If the partner is not responsive to quality and process improvement or, more often than not, recommends transport to the ED, field clinicians will view the program as a waste of time. Ensure that the platform you use for telemedicine is easy for the field providers to use. If it’s too complicated, they simply won’t use it.
2. Share outcomes. At MedStar, we publish periodic reports to our team members with de-identified actual examples of the outcomes from their peers who have used the intervention effectively. We also share the task-time savings and economic benefits derived from the telemedicine programs. We even report the names of the clinicians who have used it the most since the program started in April of 2021.
3. Ensure you are getting reimbursed for it. Not taking patients to the ED saves someone money. Medicare, Medicaid, commercial insurers and even patients save money when you don’t transport to an ED. Be sure that you are not the only one in this intervention that is financially penalized by doing the right thing for your patients by not being reimbursed for your role in that process. In our system, if the patient is not a member of an insurer who is willing to reimburse us for the telemedicine intervention, we don’t offer it, and simply transport the patient to the ED, as that’s what the payer is willing to reimburse us for.
4. Ask for advice. Finally, don’t be afraid to phone a friend as you contemplate this service delivery enhancement. There are several agencies, like MedStar, whose telemedicine programs are very effective. Seek counsel for scar avoidance as you set out to design your telemedicine program. Agencies are more than willing to share what worked, and what was problematic in their telemedicine intervention.
— Matt Zavadsky, MS-HSA, EMT, chief transformation officer, MedStar Mobile Healthcare, Fort Worth, Texas
HOW TO ADOPT
At Harris County ESD 11, we have had the distinct pleasure of working with a medical director who has supported alternative destinations since our inception. Our service utilizes two different alternative destination programs and has seen great successes with both programs. First, we transport our lower acuity patients to free standing emergency departments (FSEDs). After a medical screening performed by medics in the field, if the patient meets the criteria in the clinical guidelines, the crew may offer that destination to the patient. Patients are seen more quickly than at a traditional emergency department and, because there is less ambulance volume at those FSEDs, our turnaround time is significantly reduced. The decreased volume at the traditional ED then shortens turnaround times to those destinations as well.
The second alternative destination we utilize at Harris County ESD 11 is a direct transport to a behavioral health facility. Our providers in the field can screen patients through very specific clinical guidelines to determine if a patient experiencing a behavioral health emergency can “bypass” the traditional ED and go directly to an inpatient behavioral health hospital for evaluation and treatment. This was also a program we started with our inception and have seen some wonderful results from. These are patients who would otherwise sit in an ED for hours if not days waiting to get medically cleared and then transferred. Getting the right patient to the right destination is what we practice with trauma, STEMI and strokes. This is no different when it comes to behavioral health patients. Like the FSEDs, turnaround times are significantly lower at our behavioral facility. These patients are no longer occupying traditional ED beds, and are getting definitive evaluation and treatment, which is exactly what they need.
We recognize that every EMS system does not have FSEDs or behavioral health hospitals in their area. However, the over-arching lesson we have learned about both programs is that the relationship with those partners is what has driven our success. Forging partnerships with potential alternate destinations and building relationships early allows open and honest communication about successes and opportunities. There have certainly been obstacles to overcome, but being able to pick up the phone and have dialogue (both ways) is what keeps these programs running.
— Xavier De La Rosa, BS, LP, NRP, FP-C; chief clinical officer, Harris County ESD 11 Mobile Healthcare
HOW TO ADOPT
Nearly a quarter of respondents in the 2023 EMS trend survey report their department does not provide any behavioral health support services. Additionally, only 13% of respondents feel strongly that they trust their EAP for support, and only 11% of respondents feel strongly that their peer support team is well trained.
In my experience, first responders tend to be distrustful of others. They respond to the most tragic and terrible things, and understandably question what and who they can and cannot trust. Their trust becomes an even greater barrier when it comes to mental health and wellness, because it can often be unclear whether the entity that they work for will be accepting of them if they seek out help and whether or not treatment can negatively impact their job or their reputation. It’s no surprise that the 2023 EMS trend survey showed low utilization rates of the resources that agencies offer their employees.
Here are a few tips organizations can utilize to adopt wellness programs and help their employees overcome the hurdles to engaging in more of the resources that are available to them.
1. Provide culturally competent resources. Word travels fast in organizations, so if the services you are offering employees are poor and someone has a bad experience, people will find out and will avoid using the service. Therapists who have zero information on the first responder culture and their work expectations and responsibilities have a hard time providing first responders with a good therapy experience.
2. Invite wellness providers in. Ask wellness providers who are part of your network and resources if they would be willing to provide in-person trainings on topics like resiliency, wellness, trauma, sleep, etc. You can even make space for providers to do a ride along. Giving your employees a list of names is helpful, but providing them with an in-person experience of someone they can reach out to individually gives them a real sense of comfort and familiarity.
3. Promote a culture of wellness. From leadership down (and it starts with leadership), there needs to be unconditional positive support for any wellness engagement. This looks like talking about success stories by employees, encouragement for one another to engage in resources, and leaders who not only model wellness but also share their own experiences with others to reassure others support is safe and accepted.
4. Get information on resources into employees’ hands. Most first responders do not know what’s available to them and how to access it. Get the message out about what resources are available consistently and in multiple formats. It’s especially important to remind folks immediately following challenging calls what resources are available. There are tools available now, like the Cordico wellness app, that hold all your resources in one place to be readily available when someone needs it, whether that’s an employee, spouse or retiree.
5. Allow employees time during their shift to access resources. Though stress is almost universal in those who responded to the 2023 EMS trend survey, 43% of respondents report due to staffing shortages, they have had less time to access health and wellness support. When organizations can provide support for individuals initiating or getting help while on duty, this can be huge and might get the ball rolling for a lot of employees.
Take a moment and think about the positive benefits if some small adjustments were made at your organization to help your employees invest more into their wellness.
— Rachelle Zemlok, PsyD, strategic wellness director, Cordico/Lexipol
HOW TO ADOPT
FORMAL LEADERSHIP TRAINING
Leadership training for EMS leaders (i.e. supervisor, manager or chief) can vary greatly across the profession, consisting from a mere pat on the back with minimal orientation to a more formalized program lasting a year or longer. Regardless of agency type (i.e., volunteer vs. paid, third-tier vs. hospital-based vs. fire-based, etc.), individuals charged with leading others are being entrusted with the overall direction and success of the organization and everyone within it. This means there is an expectation that they possess leadership competencies that go beyond those required in the role of clinician.
Official leadership training avoids the trial-and-error method of learning and instead equips individuals in leadership competencies, such as critical thinking, emotional intelligence, effective communication, ethical judgment and strategic planning. It provides a firm foundation for leaders to create operational efficiencies, improve patient care and safety, improve personnel morale and engagement, effectively manage crisis, and build stronger interagency collaboration through their enhanced decision-making skills. In combination, leaders can creatively pivot to address or overcome an unexpected environmental factor without negatively impacting morale or engagement.
A leadership training program should consist of clear training objectives and desired outcomes that are measurable. These outcomes should align with the organization’s mission, values and goals to ensure that leaders are being trained with the appropriate organizational lens. The associated training modules should incorporate a variety of learning methods, such as case studies, group discussions and practical scenarios/simulations. Subject matter experts should be invited to speak on complex issues and provide specialized training in their area of expertise. For example, an HR professional will approach an employee situation with a different lens than a mental health professional.
The training program may revolve around individuals’ specific professional goals or be a part of a broader design that incorporates global organizational needs. A program design is essentially limitless, as there are a vast array of possibilities on what should or can be included. A few ideas of what may be included, beyond expected policy and procedure, are as follows:
- Create a leadership book club that meets to discuss theory and possible application of concepts as they relate to the organization.
- Offer cross-departmental training within the organization and across other agencies/departments. This type of exposure provides greater awareness of factors impacting a problem/issue.
- Provide public speaking and presentation training and opportunities beyond those expected in the individual’s current role.
- Implement leadership case studies incorporating simple and complex situations. If possible, allow the developing leader to manage a real-time situation while mentoring them throughout the process.
— Maria Beermann-Foat, PhD, MBA, NRP, director-at-large, NAEMT; EMS training coordinator, Eugene-Springfield (Oregon) Fire Department