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Proposed New Law: Only Medics For Cct's


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#1 nancy w

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Posted 22 March 2009 - 04:07 AM

Orange County, California EMS is proposing to eliminate all nurses from all interfacility transports and replace them with paramedics. Right now there is a 45 day open forum to review this proposed change. We need everyone's help to stop this proposal. The paramedics in Orange County do not have the training or knowledge to transport critically ill patients. They have no training with ventilators, IABP, ICP, multiple cardiac drips, etc.,etc... I know many of the flight crews out there have done ground CCT and understand the patient safety issues that would arise if this law passes. And if it does pass here other counties in United States may want to adopt the same proposal. This is connected with the Medicare changes which go into affect in April. All transport nurses should be alerted and concerned about proposed policy change.
Please help us in Orange County by emailing Dr. Stratton, Orange County EMS Director before the April 24th deadline

Proposed Policy Title: Interfacility Advanced Life Support Transport Units

Email address: sstratton @ochca.com


Thanks everyone, we all need to stick together to beable to keep woorking
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#2 BackcountryMedic

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Posted 22 March 2009 - 05:58 AM

Really? The paramedics are not smart enought to learn how to do this? You need our help to keep them from advancing and growing?

I know southern CA paramedics need more education and experience BEFORE they move into a CCT role. Perhaps, you should be pushing for more eduction instead of muscling paramedics out of your turf.
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#3 Speed

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Posted 22 March 2009 - 06:01 PM

This is connected with the Medicare changes which go into affect in April. All transport nurses should be alerted and concerned about proposed policy change.


What kind of change in CMS reimbursement rules would change whether or not a nurse was "allowed" on a CCT truck? If I get "X" amount per run + mileage, how I re-disperse that into my budget is my business (unless the State just says they don't qualify for "extra resources" as a qualifier for SCT reimbursement - is that what's happened or a "forbidden" change in the State's nurse practice act?). So, if old Sally wants to come make some extra cash from me, I pay her what I choose to or what she'll take, and I can send an ALS paramedic instead of a CCT medic and still qualify for SCT level reimbursement.
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#4 justlookin

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Posted 22 March 2009 - 06:45 PM

nancy w,

Could you please provide a little more info regarding the medicare changes you speak of?

If this new rule passes in your area, will training for the medics be provided? Also, is this rule forbiding a nurse from being a part of a CCT crew, or simply allowing CCT to happen with or without a nurse?

Thanks
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#5 CHP EMT-P

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Posted 22 March 2009 - 06:59 PM

Here in central Cal when a transfer exceeds the paramedic scope the transfering facility must provide a RN. I could be wrong but I don't think any ground providers in this part of the state employ RNs.
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#6 Speed

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Posted 22 March 2009 - 08:05 PM

Here in central Cal when a transfer exceeds the paramedic scope the transfering facility must provide a RN.


Say's who?
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Mike Williams CCEMT-P/FP-C

#7 CHP EMT-P

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Posted 22 March 2009 - 08:16 PM

Say's who?


Our local protocols.

Central CA EMS Agency policy 341.

If the patient’s care needs exceed the scope of practice of the available EMS personnel, the
transferring physician will arrange for the patient to be accompanied by a physician or registered
nurse along with any other personnel, equipment or supplies necessary for patient care. In these
cases, while assisting the M.D. or R.N. with patient care, EMS personnel must function within
their scope.
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#8 nancy w

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Posted 22 March 2009 - 10:46 PM

Here in central Cal when a transfer exceeds the paramedic scope the transfering facility must provide a RN. I could be wrong but I don't think any ground providers in this part of the state employ RNs.


That's interesting. In SoCal the hospitals do not want the liability of sending a nurse with any transport. Also most of the time there is not an extra nurse to go on a transport.
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#9 Speed

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Posted 22 March 2009 - 10:53 PM

[quote name='CHP EMT-P' post='16748' date='Mar 22 2009, 02:16 PM']Our local protocols.

Central CA EMS Agency policy 341.[/quote]


versus:

[quote]Orange County, California EMS is proposing to eliminate all nurses from all interfacility transports and replace them with paramedics.[/quote]
[quote]This is connected with the Medicare changes which go into affect in April.[/quote]

These aren't matching up without some info, where's the problem from a Medicare change to override your local medical control? How are they changing reimbursement?
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Mike Williams CCEMT-P/FP-C

#10 Speed

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Posted 22 March 2009 - 11:00 PM

hospitals do not want the liability of sending a nurse with any transport


Isn't there just as much liability in not providing a continuity of care, EMTALA stuff, if you choose to transport out? The only real liability or worry I can see is if the ambulance crashes or the nurse gets injured in some way.
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Mike Williams CCEMT-P/FP-C

#11 nancy w

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Posted 22 March 2009 - 11:20 PM

Really? The paramedics are not smart enought to learn how to do this? You need our help to keep them from advancing and growing?

I know southern CA paramedics need more education and experience BEFORE they move into a CCT role. Perhaps, you should be pushing for more eduction instead of muscling paramedics out of your turf.


Don't get me wrong I have nothing against paramedics but your scope of practice and your training is completely different than a registered nurse. All of the ground CCT nurses I have worked with have at least 10 years of Critical Care(ICU/CCU/Trauma) and Emergency Room experience before becoming a transport nurse. To be considered a good ICU/ER nurse takes about 2 years of working full time in that environment. Interfacility transport is not a pre-hospital or 911 transport. Yes, some calls I get could easily be done by medics but many could not.
OC EMS is proposing to eliminate all nurses from transport and only use medics in all situations and that would be dangerous for the patients safety.
When I was a flight nurse my partner was a medic and he was great at what he did. I have also taught medics and EMT's ( I'm an EMT also).I have had a few nurse friends who wanted to be paramedics and went back to school to be medics. But on average a nurse can't walk out and just be a medic and a medic can't go in and work as a nurse, the training and what each person does is totally different and each profession would be worse off if that was allowed to happen.
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#12 nursemedic

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Posted 22 March 2009 - 11:36 PM

I don't understand...you write about pulling a nurse to go on a transport then about transport nurses' experience. I am all for properly prepared transport nurse's doing the job but I do not support pulling a nurse from a unit to go on a transport. Also, you never substantiated your claim how this is connected to a CMS change. Keep in mind CMS is a federal program and states (yet alone localities) do not have the authority to make changes to the program. I am not aware of pending CMS regulation changes and I take it from others' posts they aren't either...
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Greg

#13 Speed

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Posted 22 March 2009 - 11:43 PM

OC EMS is proposing to eliminate all nurses from transport and only use medics in all situations and that would be dangerous for the patients safety.


You had mentioned that this is related to a "change in Medicare", how so?
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Mike Williams CCEMT-P/FP-C

#14 justlookin

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Posted 23 March 2009 - 12:17 AM

Nancy W,

Please elaborate on this CMS change. I think that is the crux of why we are not understanding this issue.

Thanks
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#15 BackcountryMedic

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Posted 23 March 2009 - 12:27 AM

But on average a nurse can't walk out and just be a medic and a medic can't go in and work as a nurse, the training and what each person does is totally different


Agree, except for the word "totally". There is a great deal of overlap between the two professions.

and each profession would be worse off if that was allowed to happen.


Disagree. How did you get all that ICU experience? Someone at sometime gave you training, mentored you, and then kicked you loose to practice (hopefully, with a safety net). I'm only asking you give paramedics the same opportunity you have. A paramedic can be trained, mentored and allowed to practice in a CCT role. Granted, that is not the case for the average SoCal medic now, but it doesn't mean that this isn't a good direction for the future.

Paramedicine in CA has been screwed up since Johnny & Roy pranced around the TV. It needs to grow up, and this could be an avenue if done right.
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#16 FloridaMedic

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Posted 23 March 2009 - 12:38 AM

I seriously doubt if this is going to eliminate the MICN on CCT for patients from ICU or even the ED. For more reading:

http://www.ochealthi...om/medical/ems/

Right now in OC, the FD has the monopoly on Paramedics doing calls. This proposal will now allow Paramedics on private ambulances to be more prevalent. It also is enhancing the EMT-B to provide a few additional skills to move to another cert level and to be used for some specific treatment if a Paramedic is not available.

The scope of practice for the paramedic in California is very slim. That part may not change any time soon. I also believe OC (and LA) removed pedi intubation from their protocols and have been discussing removing ETI from their adult protocols to go with only supraglottic devices.

California's guidelines for Paramedic interfacility transport:
http://www.emsa.ca.g...pdf/emsa152.pdf

Other interventions, such as maintenance of automated ventilators for the high-risk patient,
are beyond the scope and educational process described in this document. Some
interventions, such as use of an intraortic balloon pump define levels of acuity that are
beyond the training and skill of the expanded scope paramedic as defined in this
document, and define a subset of patients who require a specialized level of care in
transport
.


Example of Alameda (Contra Costa also) county's protocols but keep in mind that some counties may not allow even these for their Paramedic.

PARAMEDIC INTERFACILITY TRANSFER (CCT-P) PROGRAM STANDARDS (Alameda County)

A. CCT- Paramedic Scope of Practice

The Counties CCT-P Scope of Practice includes each of the County’s Basic and Optional Scopes of
Practice for paramedics. In addition, CCTP’s
have an expanded scope that includes the administration of intravenous (IV) nitroglycerin (NTG),
potassium chloride (KCl), lidocaine, amiodarone chloride, and heparin by IV pump.
The use of Automatic
Transport Ventilators(ATV)
for ventilator dependent patients and midazolam for sedation of ventilator
and/or agitated patients.

B. Transferring Physician Orders

The transferring physician specifies standing orders for a patient based on skills and medications
included in the County CCT-P scope of practice using a County-approved form.

C. Patient Care Outside of the Paramedic Scope of Practice

1. When a patient's treatment/care is beyond the CCT-P paramedic scope of practice, that patient may
be transported by a CCT-P unit only when:

a. A licensed medical professional (e.g. RN, Nurse Practitioner, Nurse-midwife, PA or MD) is in
attendance and assumes control and responsibility for providing patient care outside the
Paramedic Scope of Practice; AND,

b. Medication or equipment needed by the patient that is not stocked on the ambulance unit are
provided by the sending facility.

2. Accompanying licensed medical personnel providing care function under their own written standing
orders and document any care provided.


I am familiar with some hospitals in northern California that keep a CCT RN of their own free to go on transports. In one area, the FD Paramedics do not do 12-lead ECG and will transport to the nearest facility for CP. As soon as an ECG is done, a STEMI alert is done and the necessary IVs started, an ED RN or CCT RN is then put with the patient on either a private ambulance or the 911 truck to go to the cath lab one mile away.

This area also has private ambulance companies that use an RN and two EMT-Bs for most ICU patient transports. Some of the private companies also have ALS transfer trucks with a Paramedic/EMT-B but only for "routine" tele patients without a lot of drips and non-ventilator trachs. This may be how OC will have to start out.

For OC to pull this off they will have to get the state and the county to change their scope greatly first.
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#17 FloridaMedic

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Posted 23 March 2009 - 12:56 AM

This is an interesting part: the paramedics will be calling the paramedics.


http://www.ochealthi...om/medical/ems/

4. "The 911 system will be activated for any patient who becomes unstable in route and meets OCEMS Base Hospital Contact criteria (or unstable medical cases may be transported to the nearest PRC, while providing appropriate interventions, if the estimated time for 911 ALS arrival exceeds transport time to the PRC per Treatment Guideline I-40)."


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#18 JLP

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Posted 23 March 2009 - 01:32 AM

Quoted from above: "PARAMEDIC INTERFACILITY TRANSFER (CCT-P) PROGRAM STANDARDS (Alameda County)

A. CCT- Paramedic Scope of Practice

The Counties CCT-P Scope of Practice includes each of the County’s Basic and Optional Scopes of
Practice for paramedics. In addition, CCTP’s
have an expanded scope that includes the administration of intravenous (IV) nitroglycerin (NTG),
potassium chloride (KCl), lidocaine, amiodarone chloride, and heparin by IV pump. The use of Automatic
Transport Ventilators(ATV) for ventilator dependent patients and midazolam for sedation of ventilator
and/or agitated patients."

That's a critical care scope? Sure, some of it's above our 911 land ALS scope here, but it's not even half of our flight ALS scope and our CCP scope of practice here is wayyyy beyond that. Is this the totality of CC-EMTP practice there, or the (I hope) baseline that a program can build on? If that's all critical care medics are allowed to do in Cali, no wonder it's RN based. Or am I just being a jerk to CA medics 'cuz I've misread this?
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#19 Speed

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Posted 23 March 2009 - 02:40 AM

I can see what's happened. The "county paramedic" was created a long time ago with a "unified" medical control or "community" medical director for all. It made it easier back when things were pretty general, now it isn't working. Doesn't seem like a big fix, just bust it up. The State has micromanaged it's paramedics with few medical directors, they need to let that power go to the individual programs: municipal, private, specialized, nurse, paramedic, CCT paramedic, or whatever doesn't really matter. Leave it up to the individual programs to be creative in how they can produce staff with credentials or specialized training (above NREMT-P) for SCT level reimbursable runs. Hashing out specifics like skills or formularys becomes small beans, and handled under one roof or between two parties instead of five agencies and five hospitals. Liabilities are also easier to mitigate with one or two insurance companies (EVOC standards, policy amounts, etc.) instead of multiple ones mixed between public and private, too complicated. I still don't see any Medicare involvement?
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#20 Macgyver

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Posted 23 March 2009 - 02:51 AM

Quoted from above: "PARAMEDIC INTERFACILITY TRANSFER (CCT-P) PROGRAM STANDARDS (Alameda County)

A. CCT- Paramedic Scope of Practice

The Counties CCT-P Scope of Practice includes each of the County’s Basic and Optional Scopes of
Practice for paramedics. In addition, CCTP’s
have an expanded scope that includes the administration of intravenous (IV) nitroglycerin (NTG),
potassium chloride (KCl), lidocaine, amiodarone chloride, and heparin by IV pump. The use of Automatic
Transport Ventilators(ATV) for ventilator dependent patients and midazolam for sedation of ventilator
and/or agitated patients."

That's a critical care scope? Sure, some of it's above our 911 land ALS scope here, but it's not even half of our flight ALS scope and our CCP scope of practice here is wayyyy beyond that. Is this the totality of CC-EMTP practice there, or the (I hope) baseline that a program can build on? If that's all critical care medics are allowed to do in Cali, no wonder it's RN based. Or am I just being a jerk to CA medics 'cuz I've misread this?



Wild. That is all basic newgrad scope of practice for ACP's (paramedics) in Alberta... So how did the "birthplace" of American EMS fall so far behind?
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Ken BHSc, RN, REMT-P