03/15/09 125 W, 1 I - + 10 - 14 Advanced Practice Paramedics 2.0

Firegeezer yesterday posted a piece on the Wake County's Advance Practice Paramedics program by Mike Ward. It's a short, sweet clinical overview of the program that also includes a five-weeks-later update. (The APP concept is some 15 years old, we learn.) Since the five APP units were placed in service on Jan. 6, 2009, they've handled 2,309 incidents including 99 cardiac arrest responses. (They had their first cardiac save less than four hours after the first units were placed in service.) They've also completed 54 well-person checks, and are compling case reports therein on the impact on ambulance transport workload. Wake County APPs are reducing operating expenses by reducing the number of transports through at-home assessment and treatment of chronically ill patients. Read this excellent web article.

I will have to say I am on a really busy truck and I mean busy. So every time I see the Charger Pull Up, their either canceled or you hear them canceld on the radio. I really like the concept and think it does serve a purpose to the EMS system in this county, but majority of you life saving services are hands down provided by the BOYs and Girls that ride the trucks. I see a APP as just another handy tool in a regular medic’s tool box.
#2 - 03/16/09 - 02:03

I think it is interesting that if you take to most of us paramedics on the trucks, the consensus seems to be that the APP program isn’t all that great. But yet the administration pumps it up and talks about how great it is. I’m wondering which it really is!?
Code Blue - 03/16/09 - 05:58

As a practicing EMT-I and as a Paramedic Student, I find the program has many challenges for both the regular old street medic and for the APP as well.

A great deal of the calls that APPs go to are for the least desirable patient population – those who are non-compliant with their medications or themselves, and become chronic system problems. However, a good bit of the chronic use patients have stopped calling 911 for BS reasons, simply due to the actions of the APPs. In that way, I applaud them for the effort and grief they are getting.

Just as an aside— In 20 years, paramedics will be a bonafide part of the public health prevention matrix. In this way, Wake County is already getting a jump on this bandwagon with the APP program. The upside of all this is, of course, a better level of service for the public that we serve. Why is that a bad thing?
CJS (Email) - 03/16/09 - 12:12

Please try to keep in mind that we are now 8 weeks in to a three-year IMPLEMENTATION of the APP program. That means that, at best (probably longer since the economy tanked) it will take three years to get the correct number of APPs on the streets to even begin to do what the program is supposed to do in an efficient and effective manner.

The short version of that is we are providing APP services to the county with 5 units daytime and 2 nighttime. The plan calls for 14 at full implementation. So that means that the APPs can’t get to as many calls as they will, because they are too far away or otherwise busy, AND that they can’t prevent as many calls as they will, because they are too far away and otherwise busy.

The program has improved care measurably by

—keeping ambulances available, by preventing calls or releasing ambulance crews earlier than they might be released (called codes, code 7s, non-compliant diabetics, TEMS missions, etc.). Every one of those saves an ambulance unit hour.

—getting patients to the right facility (like Healing Place or Crisis), rather than having them transported, by ambulance, to a place that is unable to handle them well or in a timely fashion. Every one of those saves an ambulance unit hour, AND in some cases saves 10 or 15 ED bed hours.

—providing backup on high-risk refusals. Interestingly, the APPs seem pretty effective at talking people who “should” go but don’t want to go in to going. This is very good for the patients, as well as for our risk management program.

Multiply these benefits by 3 (when the program is fully implemented) and it is pretty easy to see that the program will help the EMS system a great deal. “Code Blue,” I think the difference is that we are evaluating the potential of the program to do good for the future, and you and your colleagues are evaluating it as though today was the end-point.

Want to help make it better? Get your radio on the TAC channel and look at the CAD. If an APP is coming and you have assessed the patient, and an APP is not needed, let them know. Don’t wait for them to show up to find out that you’ve got a patient who requires minimal treatment and slow transport. That will keep them available for the next call, that might really require their presence.

You might not want to hear this, but there also HAVE been instances where the experienced and independent clinical evaluation of the APP has made a difference to the patient. You’ll just have to take my word for that.
Remember the graphs that Dr. Myers showed before the program kicked off – more “recent critical care” experience improves patient outcome, which is the end-all of why we exist. If the APPs can add that to our service mix, then it’s a good thing for everyone.

Stay safe!

CHIEF100 - 03/16/09 - 13:14

My system has a supervisor position already in place that I think could very quickly be re-trained and re-accredited to a similar model. Less on the home visits and heavier on the re-routing of citizens to treatment facilities instead of the blanket “patient go to ER” model we have relied on for so long. Thanks for all the resources presented so far!
the Happy Medic (Email) (Web Site) - 03/16/09 - 19:34

Chief 100 beat me to it (that’s what happens when I go out of town, but it was great in Daytona), but here is my belated three cents worth.

First, it is a new program. What we are doing now may be done differently a few weeks or months from now. Change is inevitable (except from a vending machine).

To ‘#2’- You’re right, the APP is another adjunct (I hate the word ‘tool’ in this context) to good patient care. I am one of those that rides on the car occasionally, and all I am there for is to help out. In my case, I am bringing a couple of extra drugs, a cool car, and 33 years of experience in taking care of people. Most of the medics on calls I go to have less than half of that. That does not make you a ‘bad’ medic, but it just means I have seen a lot, and more of it, than you have. If you need the experience, it’s there. If you don’t, then cancel me. I won’t get upset. And I am listening to the TAC channel from the get-go. Cancel me. Drop me back to ‘cold’ response. It’s OK. Actually, it keeps me from driving hot (which I do not like) and keeps me available.

I can help in other ways. I can carry equipment. I can write down information. I can be an IV pole. You name it, I am there to help. Nothing more. Me personally, I am not there to take over your call. If you need advice, ask. If you have a question, ask. That’s what I am there for.

And, by the way, hands down, the majority of the life saving services in this county are provided by the folks who ride the BRTs (big red trucks) in the form of early chest compressions, continuous chest compressions, and early defibrillation. And don’t forget early aspirin, two minute scene times (because they have a backboard and stuff on their trucks). I have worked in other systems, outside of Wake County. Trust me when I say that without them, we would all be just another ambulance service.

To ‘Code Blue’- I am on the trucks as well. And anyone you ask who knows me will tell you I will tell you what’s on my mind. It’s a new program. Some bugs need to be worked out. We’ll get there. I remember some of the comments when we first put EMTs on the ambulance and then when we put paramedics on the ambulance. As I remember, those comments were a lot like yours. So, how did that all work out?

In my mind, when APP is fully deployed, and if things are going right, there will be more ‘preventive’ activity instead of ‘reactive’ activity. But consider this- a regular in my first due area does not call 9-1-1 anymore. A 30 minute APP visit one afternoon a week has eliminated a CHARLIE or DELTA response every other week or so, in the middle of the night, thereby keeping an engine and an ambulance AVAILABLE. That is what the program is really about. We have to become more proactive in our activities if we, as some put it, want to become a real part of healthcare. We are not going to do it running around with red lights and sirens, taking everyone to the ED.

But to ‘Code Blue’, I’ll also put the same thing out that I said to ‘#2’. I (when I am on the car) am an adjunct to good patient care. Nothing more. I am bringing a couple of extra drugs. But I am also bringing 33 years of ‘been there-done that’. If you need it, fine. It’s there. If you don’t need it, cancel it. Just don’t let your pride get in the way of good patient care.

DJ (Email) - 03/17/09 - 13:05

I forgot to put this earlier, when I posted, but DJ reminded me of it. He hit it perfectly on the head, when he said that "...and 33 years of experience in taking care of people. Most of the medics on calls I go to have less than half of that. That does not make you a ‘bad’ medic, but it just means I have seen a lot, and more of it, than you have. If you need the experience, it’s there." As a student, I take input from everyone, and that includes those that have been there, done that, got the scar to prove it. The APPs are usually folks who have been preceptors and field supervisors, so they know how to give input and give it in a way which will make you better.

All of the APPs I have been around have showed why they were picked for this job. They make it their business to help out everyone. If they have a free moment, they are more than happy to answer questions, take a second to instruct on equipment or porcedures, help you figure out a problem, help with scenarios. Hey, they will just come around to shoot the breeze (during the day – at night, they tend to just "roam", which is a good thing… when my truck broke down on the side of I-540 one night last month while returning from a call, it was an APP which was the first vehicle that showed up to assist). They are good, personable people, and that’s part of the reason that they were selected: ability to teach, field experience, and the desire to help the public we all serve.

As a question to CHIEF100 – Sir, as a student, and having learned a lot from just the 3 or 4 APPs that I have interacted with, I find that the teaching opportunities for the APP as a preceptor would be worth looking into. Would there be an opportunity in the future for EMT-P students to ride along with the APP? Since we are going to a different approach in the healthcare, what is your opinion of a student observing, and participating, in the APP process, as it comes to preventative and follow-up visits?
CJS (Email) - 03/18/09 - 12:51

now coming from a big city, let me add my perspective on this issue – now that lots of folks are losing their jobs, and subsequently their insurance, there will be an ever increasing need for this service, as many will forgo their medications and doctors’ visits due to lack of ability to pay, and as doctors offices become more influenced by the insurance and pharmaceutical industry (and in many instances turn into spas), people will end up in ER for things they don’t need to be in ER for (take a look at any of the big cities throughout the US and you will know what I am talking about) – here with the APPs, we are looking at pure medical care, unadulterated and uninfluenced by big pharma or the big insurers – OK, that’s my two cents worth
cornerhydrant - 03/26/09 - 20:23

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