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Proposed New Law: Only Medics For Cct's


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#21 Loydster

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Posted 23 March 2009 - 06:12 PM

Our local protocols.

Central CA EMS Agency policy 341.

If the patientís 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.


I know that this does go on with the Tuolumne County's blessing. Tuolumne County uses EMT-P for their CCT calls down to the valley. The County EMS Medical Director has given the Medics the OK to move pts on NTG, Dopamine, Dobutamine & Heprin drips. These are mostly heart pts going to a cath lab. The main reasons was they could not get RNs to do the transfers. They have been doing this for ~ 8-9 years that I know of. I have not heard of a bad outcome, but I don't work up in the mountains anymore either.
For those unfamiliar with Cali, each COUNTY tells what the medic can and cannot do. Yes there is state level but the county can ask for more or take away more. I have to say that is one of teh biggest problems with EMS in this state. Many of the medics I work with carry 4-8 different county certifications depending on where they work. Some counties accept other county's certs, others don't. Mind you each county cert is ~ $250.00. Thus this is what I see drives it all. Because the medic still needs to pay the state as well for the Medic Lic.
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#22 Loydster

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Posted 23 March 2009 - 06:22 PM

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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#23 Flightgypsy

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Posted 23 March 2009 - 09:04 PM

American Ambulance in Central California has a CCT program with an RN on their CCT calls. They go with an EMT/Paramedic crew. Central Coast area also has CCT with an RN.
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#24 Loydster

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Posted 23 March 2009 - 11:17 PM

I remember when CCT got started in the early 90s. It came from having to transfer pt from one hospital to another. We would call 911 and a ALS rig would show up at the ED. The ED RN would jump in and go with the pt. If ETT then they would BVT all the way. Not the best/safetst way to do it. So I remember we teamed up with BAYSTAR (Now who owns AMR) and started the CCT program with dedicated trained RNs to do these transfers. It is now the norm here in N. Cali. Every ambulance company has or tries to have a CCT unit. AMR has full time RNs working 12 & 24 hour shifts. Now in the bay area (San Fran) there is no ALS interfacility. It is either BLS or CCT. Reason is the counties do not wish to take an ALS unit OOS to do a IF call. So CCT units move the monitored, heplock pt at a CCT rate.

Crazy I tell ya.
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#25 USDalum97

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Posted 24 March 2009 - 06:06 AM

So CCT units move the monitored, heplock pt at a CCT rate.


How do they get away with charging SCT rates if they do not perform SCT level care? Just having a nurse present does not justify SCT reimbursement.

Definition:
"Specialty care transport (SCT) is the interfacility transportation of a critically injured or ill beneficiary by a ground ambulance vehicle, including the provision of medically necessary supplies and services, at a level of service beyond the scope of the EMT-Paramedic. SCT is necessary when a beneficiaryís condition requires ongoing care that must be furnished by one or more health professionals in an appropriate specialty area, for example, emergency or critical care nursing, emergency medicine, respiratory care, cardiovascular care, or a paramedic with additional training."

http://www.nemsis.or...f/CMSManual.pdf
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#26 Speed

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Posted 24 March 2009 - 03:44 PM

How do they get away with charging SCT rates if they do not perform SCT level care? Just having a nurse present does not justify SCT reimbursement.

Definition:
"Specialty care transport (SCT) is the interfacility transportation of a critically injured or ill beneficiary by a ground ambulance vehicle, including the provision of medically necessary supplies and services, at a level of service beyond the scope of the EMT-Paramedic. SCT is necessary when a beneficiaryís condition requires ongoing care that must be furnished by one or more health professionals in an appropriate specialty area, for example, emergency or critical care nursing, emergency medicine, respiratory care, cardiovascular care, or a paramedic with additional training."

http://www.nemsis.or...f/CMSManual.pdf


SCT reimbursement can be just as easily abused as air transport. There's not a minimum intervention qualifier like ALS I versus ALS II, just the staffing, pick-up and destination requirements. I personally like to add a physician necessity form above the minimum requirement that specifically identifies the care above NREMT-P scope and the definitive cause for transport to a higher level of care to identify the transport as SCT, otherwise it's ALS I, II, or BLS.
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#27 FloridaMedic

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Posted 25 March 2009 - 06:37 PM

SCT reimbursement can be just as easily abused as air transport. There's not a minimum intervention qualifier like ALS I versus ALS II, just the staffing, pick-up and destination requirements. I personally like to add a physician necessity form above the minimum requirement that specifically identifies the care above NREMT-P scope and the definitive cause for transport to a higher level of care to identify the transport as SCT, otherwise it's ALS I, II, or BLS.


Abuse comes when there are options. Unfortunately, in parts of CA, there are few options at the ALS level by the way each county is set up. To some, the Orange county change might be good since it will allow private ambulance Paramedics to transport some patients at their level although it is may still be with a limited scope. As with many CA counties, the FDs have the monopoloy on ALS transport. Thus the reason for CCT teams with EMT-Bs and RNs. Also, if you read the link posted earlier, this will also be to upgrade the EMT-B to manage a plain IVs and add a few other skills like the Combitube to allow the EMT-B to do "pseudo-ALS" transfers. In other words, they are trying to have something like the EMT-I on these trucks.

The CCT trucks, with qualified personnel which may still be the RN, should be used for their intended purpose of Critical Care transport.
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#28 Spmedic68

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Posted 27 March 2009 - 02:38 AM

Talking about Kentucky now:

As far as I know there are No nurses that do ground transport. In our company we are trained to use ventilators, as a matter of fact we DO CARRY OUR OWN and use it frequently. About pumps and medications is our Policy to carry the hospital's pump ( that we return later on ). EVERY time that for some reason the MD thinks the status of the patient surpasses our scope of practise, a Nurse runs with us. An example is the Mag. Sulfate used in pregnancy, in this case a RN runs always with us.

I have absolutely nothing against a RN doing transports but FOR SURE I am PRO. giving the education required to paramedics in order to do these CCT.....otherwise , it would be stupid to make a medic take care of something is not trained for...right???? Or me performing open heart surgery !!!

SO I am not sure how to take this......I'd email the MD asking for more training for the Orange Co medics and AFTER THAT HAPPENS.....well do whatever you think you have to do. At the end of the day all this sounds like a MONEY ISSUE, one more time, especially now at time of crisis.
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#29 FloridaMedic

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Posted 27 March 2009 - 03:09 AM

SO I am not sure how to take this......I'd email the MD asking for more training for the Orange Co medics and AFTER THAT HAPPENS.....well do whatever you think you have to do. At the end of the day all this sounds like a MONEY ISSUE, one more time, especially now at time of crisis.


You do realize that almost all ALS services with Paramedics are Fire Based EMS in Orange County? It would be impractical to take a 911 ALS truck out of service for as long as some of the Critical Care transports last. I believe someone already mentioned that earlier about a different county. As this time the FD has the monopoly on ALS Paramedics which leaves BLS trucks AKA CCTs if you put an MICN on some of them.
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#30 BackcountryMedic

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Posted 27 March 2009 - 03:25 AM

You do realize that almost all ALS services with Paramedics are Fire Based EMS in Orange County?


Actually, most "paramedics" working in ALS services in Orange County are glorified EMT-I's

It would be impractical to take a 911 ALS truck out of service for as long as some of the Critical Care transports last. I believe someone already mentioned that earlier about a different county. As this time the FD has the monopoly on ALS Paramedics which leaves BLS trucks AKA CCTs if you put an MICN on some of them.


Why does the fire service need to be involved? Hopefully, this will be an opportunity for OC to get a "real" paramedic service.

CCT-Paramedics are doing critical care transports all over the US. It's not hard to train motivated people to do it safely and effectively, it just take effort.
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#31 Loydster

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Posted 27 March 2009 - 03:39 AM

Talking about Kentucky now:

As far as I know there are No nurses that do ground transport. In our company we are trained to use ventilators, as a matter of fact we DO CARRY OUR OWN and use it frequently. About pumps and medications is our Policy to carry the hospital's pump ( that we return later on ). EVERY time that for some reason the MD thinks the status of the patient surpasses our scope of practise, a Nurse runs with us. An example is the Mag. Sulfate used in pregnancy, in this case a RN runs always with us.

I have absolutely nothing against a RN doing transports but FOR SURE I am PRO. giving the education required to paramedics in order to do these CCT.....otherwise , it would be stupid to make a medic take care of something is not trained for...right???? Or me performing open heart surgery !!!

SO I am not sure how to take this......I'd email the MD asking for more training for the Orange Co medics and AFTER THAT HAPPENS.....well do whatever you think you have to do. At the end of the day all this sounds like a MONEY ISSUE, one more time, especially now at time of crisis.



Oregon is also this way. The scope of practice for medics is huge. Basically there is no scope of practice. Almost all CCT transports are done with Medics. They can manage any and all drugs. The big reason is what the requirement is to be a medic in Oregon. I believe they have the model for all EMS systems in my mind.
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#32 FloridaMedic

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Posted 27 March 2009 - 04:08 AM

Actually, most "paramedics" working in ALS services in Orange County are glorified EMT-I's


Yeah, I was being nice.

Why does the fire service need to be involved? Hopefully, this will be an opportunity for OC to get a "real" paramedic service.

CCT-Paramedics are doing critical care transports all over the US. It's not hard to train motivated people to do it safely and effectively, it just take effort.


At this time, even with the ALS Paramedics that do CCT, their scope is as limited as I posted earlier. This discussion has been on other EMS forums and in the CA EDs. No one can come up with a really good example for a model CCT in California utilizing only Paramedics. There is usually an RN involved if the the patient requires more than what was mentioned earlier. Right now with the state EMS reform for their other many issues, it is unlikely there will be any change soon to advance their education or scope of practice. The state has just lost site of what the M stands for in EMS and what Paramedics could be capable of.

But, California is largely Fire Based EMS (nothing wrong with that for 911 in some states). Even the S.F. Bay area which is also FD EMS was ruled to allow private ambulances bid on the 911 contract for the city. At this time they are not ready for that project.
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#33 Spmedic68

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Posted 27 March 2009 - 04:27 AM

:)
Right ! In this area mostly the 911 is FD based although not all the FD are ALS. My company provides ALS backup for those BLS FD, also do 911 in some counties. But the main thing is the inter facilities transports.
My only point with all this is that if medics are going to do these CCT they need to be trained for the job. Again I guess a medic is cheaper than a nurse ???
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#34 FloridaMedic

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Posted 27 March 2009 - 05:28 AM

My only point with all this is that if medics are going to do these CCT they need to be trained for the job. Again I guess a medic is cheaper than a nurse ???

And they will probably be trained to the limited "expanded" scope posted earlier. And, the EMT-Bs (even cheaper) will have expanded skills when a Paramedic is not available to take the heplock calls. This will save the MICNs for the Critical Care transports that do need their expertise.

It is unfortunate that what is considered to be a CCT expanded scope for Paramedics in California is considered regular scope of practice for Paramedics in other states.
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#35 old school

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Posted 27 March 2009 - 03:04 PM

OK, did we come up with a reason for this proposed "change we can believe in"? (sorry, I just had to B) )

And did we determine whether this move would actually disallow RN's from participating in CCT's, or simply not require an RN to be present on a CCT? Not that it really matters, because I would bet that in actual application both positions would have a very similar effect.

Let's be completely honest and have the junk to call a spade a spade: The truth is that maybe 5% of paramedics in the US have the background to function on a true CCT all by themselves. 95% of paramedics - while many of them do talk a good game - have very little (if any at all) experience in the management of ICU patients. Of course I'm talking about "true" critical care transports here with vasoactive meds and sedatives and wacky lab values and funky vent settings, not the stable NSTEMI with heparin and nitro paste and 2lpm that is being transported to a cath lab and is often referred to as a 'critical care transport'.

What do I know, though...I've only spent a few days in the OC so I don't know anything about their paramedics....maybe that 5% I mentioned is all from there, and so they'll have no problem finding the right medics for the job? Of course it doesn't help any that every paramedic seems to think that they are in that 5%, regardless of their actual background.


The bottom line is that while a paramedic can certainly be a valuable contributing member of a CCT team, a CCT team needs an RN just like a 911 truck needs a paramedic. And any attempt to forcefully change that is nothing more than an irresponsible cost saving or power-grabbing measure, and puts the interest of the patient on the back burner. Anyone who says otherwise is ignorant or disingenuous.

Paramedicine needs to seriously fix itself first before it tries to push any further into areas that it, as a profession, doesn't know the first thing about.

But quick before that happens...maybe next we can pass a law that bans paramedics from functioning on 911 calls, and replace them all with RN's! And eventually we'll work up to our ultimate goal of staffing all fire apparatus with landscapers! I'm sure the firefighters themselves won't mind, since they'll all be working in ICU's by then...
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#36 Speed

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Posted 27 March 2009 - 03:07 PM

I would add that even though I have the ability and scope to provide all SCT services with an appropriately trained and protocoled CCT medic, sometimes just having the RN on board is purely marketing. It's along the same lines as a flight program going to the extra effort of carrying their own blood products. Sure, in certain geographic locations it may be warranted, but there are those out there that know they'll probably never need it but carry it anyway as it may generate a few more flight requests. If the money I pay a nurse to take call for SCT transports makes it worth the extra transports I would get from the "image", you bet I'll do it. If it is a specialized transport that would actually require a specialized capability that I haven't planned for or have in-house, well someone else will probably get the transport, or if I can make arrangements with the sending facility to provide the equipment or competency (staff) I don't have we might work something out. Right now for me, even though I've been through multiple training programs on IABP's, have transported IABP's in past employment, and even "baby-sat" them in a CCU; I would make special arrangements to augment my staff if asked to move one (personal ethics). The problem I have is that no one here is transporting them out...yet. My plan would be to develop competency by transporting them enough (again) and eventually purchase a unit for the service, then leading to "in-house autonomy". Even then, if just having a nurse on-board would generate more request, I'd still shell-out the pay if enough profit margin was there. Just as air services go, image is everything if not the only thing... Ha ha.... :lol:
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#37 old school

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Posted 27 March 2009 - 03:13 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.


Backcountry,

It has nothing to do with being smart enough, it has everything to do with education, background, and the appropriate role of a given profession.

As I said before, following this logic we shouldn't have much trouble getting rid of paramedics and staffing 911 units with RN's, right? So what if it requires the nurses to get a little extra training in airway management....nothing that a few few inservices and a few hours in the OR can't take care of.

Forgive my sarcasm...I'm really not trying to be facetious, but I can think of no other way to illustrate the ludicrous nature of the idea of banning nurses from CCT's.
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#38 BackcountryMedic

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Posted 27 March 2009 - 03:59 PM

As I said before, following this logic we shouldn't have much trouble getting rid of paramedics and staffing 911 units with RN's, right? So what if it requires the nurses to get a little extra training in airway management....nothing that a few few inservices and a few hours in the OR can't take care of.


I absolutely believe a nurse can work 911, but it will take more then a few in-services. As everyone on this forum knows it takes a dedicated training program and experience under the safety net of a quality proctor to work "the streets". Then if a nurse would like they can run around the cones with a hose and up the tower with an axe to get a job working 911 in OC. I'm not opposed to it if they have the training and experience. I am opposed to a nurse taking a test and being granted a P cert, in the same way I'm opposed to a Paramedic taking a test only and getting a CCT endorsement.

My posts have nothing to do with nurses. They are fine, intelligent people. The problem in OC (from my slightly more then passing knowledge of EMS in CA) is the paramedics are there own damn worse enemy and the system they operate in is dysfunctional. It is time to bunch Johnny and Roy in the nose, tell Dr. Brackett to stuff it, and get the program moving.
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#39 Spmedic68

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Posted 27 March 2009 - 05:00 PM

Cool B) !! Then we all agree that is a matter of trining and education ! RNs or Medics, with the right training can do it, CCT or 911, so if they pass the law....well I guess the medical DIrector will have to make decisions.
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#40 old school

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Posted 27 March 2009 - 05:40 PM

[quote]I absolutely believe a nurse can work 911, but it will take more then a few in-services.[/quote]

We agree here...the point I was trying to make was that, many seem to think that a paramedic can go take a "critical care course" of unknown length or quality, and than BAAM...they are instantly qualified to work on a "CCT Unit" all by themselves. That certainly seems to be the trend in the industry. We have UMBC to partially thank for that.

However, if you propose allowing an RN to do essentially the same thing....it sounds ridiculous. Why the double standard?

[quote]I am opposed to a nurse taking a test and being granted a P cert, in the same way I'm opposed to a Paramedic taking a test only and getting a CCT endorsement.[/quote]

So am I. We agree here as well.

Unfortunately there are many "patch-medics" working in flight nurse roles all over the place, and this does diminish the paramedic profession, I believe. Not saying that an experienced ED or ICU RN needs all the same initial education that an EMT-B does to become a paramedic, but it certainly takes more than passing an easy written exam, and spending 12hrs on an ambulance and 4hrs in an OR.

Fortunately, in my experience at least, most of these RN's seem to understand their limitations. I think most of them would admit that it would be inappropriate for them to go running 911 calls. I mean, RN's as a whole are a pretty cautious and self-conscious bunch....paramedics, not so much.

[quote]My posts have nothing to do with nurses. They are fine, intelligent people.[/quote]

As are most paramedics. Honestly, I think the best clinicians, and some of the most interesting people I've ever met overall, were paramedics. The field seems to attract some really outstanding people for some reason. Unfortunately though, the entry requirements for the field are very low, so along with every great one you get about 75 really lousy ones.

[quote]The problem in OC (from my slightly more then passing knowledge of EMS in CA) is the paramedics are there own damn worse enemy and the system they operate in is dysfunctional.[/quote]

Then why the push for this do you think? Your first post on this thread gave me the impression that you supported it; perhaps I misinterpreted.
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