Safety Sunday, Volume 1. Issue 4 (3/31/13)
No Units Available! Short staffed, Over worked, and Underpaid;
is EMS really different from anyone else today?
Today is Easter and the middle of Passover, for those that
celebrate I hope you have a wonderful day. This topic may be a little more
nebulous than previous topics as it pertains to safety issues, though I think
it all centers around the issue of provider fatigue. This may end up being more
of a rant than a traditional blog entry, though I am relatively new to the
blogosphere I find good amounts are ranty (if that’s a word) anyway. I’m sure to anger a few on some of the
following opinions, though am always up to a good debate that may change my
mind as more information is posed. I
will likely only peel a couple of layers off of this very large onion.
DISCLAIMER: Unless otherwise specified I am not speaking of
any specific agency or agencies (that I may or may not have worked for at some
time), any likeness should be ignored, taken with a grain of salt, or used to
influence policy change for the better. YOU ARE ENTERING... THE RANT ZONE!!
Last week at a bi-monthly Indiana State EMS commission
meeting one of the commissioners started up a conversation about the dwindling
numbers of EMTs after one of the officials from the state EMS office reported
the numbers of certification renewals. My first instinct was “there he goes
again,” but the more I listened to him, the more I realized that if we continue
to ignore this problem, it’s only going to get worse. Until I started attending state commission meetings,
national conferences, reading posts from other providers, was a member of my
state rural health association, I didn’t realize how increasingly rare having a
paramedic was. I was mostly used to working in an urban environment where I was
surrounded by about 200 paramedics in my county.
At commission meetings over the last couple of years I have
also noticed an increase of waiver requests for providers wanting to not be
required to have a second EMS professional. In the United States it is somewhat
difficult to even start to define how many EMS personnel there even are. If you
ask each of the roughly 15,276-21,283 ambulance services (American Ambulance
Association {AAA}/National EMS Assessment) you will likely get a gross over
count of the many thousands of providers that work at 2 or 3 different EMS
agencies. If you get numbers from state EMS offices you get many miscounts with
many “certification-only” providers, those pre-med/nursing/other allied health
people that take the class for its great practical knowledge though don’t
actually work anywhere. Until last year ALS providers in Indiana where
automatically certified with their EMT-Basic and their other certification,
leading to many “double-counts” of providers. The AAA puts the total number of
providers at 840,669, the national EMS Assessment (2011) put this at 826,111.
At the local level I know of a private service that had (and
may still have) orientation every 3 weeks. Another larger municipal organization
has had 4 hiring groups in a little over 2 years. The first organization
orientation lasts about 2 days of talk, 5 days of FTO, the other is at the
other end of the spectrum, about 5-6 weeks of “off-truck” orientation, 5-6
weeks of FTO. In a time when millions
are unemployed or underemployed this level of turnover is outright crazy. The turnover
of EMS agencies was noted at around 10.2 % in one study that looked at this, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2883888/pdf/nihms201933.pdf
, though the actual cost of turnover was extremely varied. Just for some
comparison, a couple of weeks ago I attended my local hospital board meeting
where they announced that they had a turnover of 1.45%, where the industry was
slightly over 2%. An EMS agency that reports to that same board had a turnover
around 17% (~40 separations in a year/230 avg # of employees during that time).
That same agency paid out MORE in overtime costs in 2012 (w/~230 employees)
than the local Fire department (with about 1,200 employees) did the year before
(when numbers were available). That same
department hasn’t had a hiring group in about 4 years, though had just received
a $4 to 5 million SAFER grant to have a recruit class around 30.
So I digress about some of my local occurrences, but I truly
believe that they are a microcosm for the situation at hand. The fire and EMS
agencies are both under public safety in this area, they are collocated at many
locations and (without exception) the ambulances are generally about 20% busier.
The fire department has a negotiated 3rd year private (lowest rank) rate
of over $60,000. The EMS agency lowest rank EMT would have to work 48 years to reach
that level. As many know the main duty of almost all fire department nowadays
(thanks to some great fire prevention initiatives) is EMS. At EMS Today a few
weeks ago I heard a speaker say that they looked at Raleigh, NC fire department
and found that the percentage of dispatches that wet stuff on red stuff” was 0.3%
Nurses in the area start around the 12
year paramedic mark.
I hope this doesn’t seem that I am bashing other
professions, but I point at them for many of their successes that could help us
moving forward. So what is being done in
other areas that help get our profession out of the funk. Well let’s look at
some EMS agencies that are doing things well. King County, pays their employees
well, gives them a lot of responsibility, and invests much into their training
(thousands of hours of training after hire). Agencies that are getting people
from the municipal agency discussed above aren’t necessarily paying more. They
often have nicer, newer equipment, better schedules (24 hour usually, a whole
other topic, and flexible scheduling) and more autonomy.
Many providers in my area are looking at going part-time for
the sole purpose of having a flexible schedule, to deal with child care,
pursuing higher education, or pursuing other hobbies/interests. I have changed
my schedule about 5 times in as many years purely due to different interests.
My first 2 years I was finishing my undergraduate degree which included mostly
classes during the day, so I was on night shift. I had one year off of school
where I moved to a tactical shift (11-2300 2 week rotating). The next year I
started graduate school, which met on Saturdays and nights, so I moved to days.
Without having many people trading I would not have been able to do this. Then a
new shift opened up, Monday through Friday 0600-1500. PERFECT! Then 24 hour
shifts became an option, though during football season I need Friday’s off to
officiate varsity high school football, so I pick up a Wednesday/Saturday spot.
PERFECT! Then I start to do some college football, so now Saturdays aren’t
good. I then found a Wednesday/Sunday truck on the far end of the county.
Finally, now I am working the same Wednesday/Sunday schedule about 5 miles from
home. My point is that by pure luck, and willingness of others to trade, I have
been able to remain a full-time EMS employee. Many haven’t been nearly as lucky
as I have been and have had to quit, leave full-time, leave the company, or
sadly leave the profession.
We treat our people like numbers, creating a perpetual
rotating door amongst employers. System-status-management is a great
administration tool to cover an area. Unless you do all the other things to
make the employee happy, this doesn’t usually work well for the employee. Sitting
at a gas station for 12 hours sitting in your ambulance in 95 degree weather
does not lead to happy employees (or is it good for the environment or keeping
drugs potent).
Paying above minimum-wage. This is the obvious problem,
though it is a much tougher solution. Many places offer sign-on bonuses and
longevity increases (like large increases at 3, 7, 10 years employment) that
help, though our base pay is usually lacking in the beginning. Obviously,
services can’t give out what they don’t have. So…
Changing how EMS gets money. Many private ambulance service
leaders I know keep getting anxiety attacks because of increasing costs and
declining reimbursements. They are getting hit on benefits, workers
compensation, and increasing competition in the area (revolving door between
EMS services). The big thing that they always get ulcers and increase their ACE
inhibitors about is one thing, insurance transport reimbursement. Take a good
look around and ask if you think medical reimbursements are going to stay at
the same levels (or very slight increases). The answer…
We MUST get away from relying 100% on insurance
reimbursements. When a community pays
$140 million in property taxes for fire suppression and $0 for EMS, should they
be surprised when they may have to wait 20-30 minutes for an ambulance at times.
It’s amazing when emergency departments are bursting at the seams and you bring
them your 4th non-urgent patient of the day for the waiting room. This
is especially true when you drove past 2 Urgent Visit centers, 5 doctor’s
offices, a psychiatric clinic, a substance abuse facility and 15 minute clinics
to get to the hospital. So who can help…
The rise of use of the public-health spoke of EMS is very
promising. The use of “community paramedics,” and phone triage in the diversion
of non-urgent patients, treatment/assessment of non-urgent patients is very
exciting. The proactive (WHAT?? We can be proactive??) use of sending people
out to talk with “EMS loyalty plan” patients, those who have chronic conditions
which hospitals are beginning to experience declining reimbursements for
readmissions), or being there at the end with hospice patients/families to help
provide reassurance to help prevent unnecessary trips back to the ED (when they
wanted to die at home). The problem with these are currently…
WHO is going to pay for it (aka How can we afford to do
this?)? Well this is the tricky one. You need to bring data, have meetings with
those outside of emergency medicine, and bring data. You need to identify the
needs, formulate a plan, and provide solutions. We are one of few mobile
medical professions that can, within minutes (and without authorization from 3
levels of insurance, 4 phone calls, and two forms signed by a doctor) get to a
patient. Insurance agencies and hospitals are looking more and more to
partnering with other health organizations to better “manage” patient’s health.
The nurse practitioners, physician’s assistants, and home health agencies are
all having similar discussions. If we don’t reach out to the other potential payers
we will lose a lot of that pie.
So who is going to lead us? Well… we may need people
actually trained in administration, trained in process improvement techniques,
trained in finance and budgeting, trained in safety and risk management, and
trained in leadership and management techniques. Too much of the time organizations
are led by well-meaning, nice guys who don’t get in too much of a fuss with
important people who control the purse strings. The fire service and other
organizations have used unions very well in this area. Administration and labor
all want similar end goals, a well taken care of workforce who are happy,
well-trained, and carry out their duties effectively. When more funds are
needed for equipment, personnel, or raises, the unions can help advocate where
administration can’t. Labor groups for EMS are lacking at many local levels,
though organizations at the federal and state levels, like the National
Association of EMT’s are getting more and more political traction. Almost all
other areas of business are ran by people with advanced degrees like MBAs or
MHAs. Most small businesses have chief executives that at least got a
bachelors. Too many times I hear EMS leaders answer the question of “What
college did you get your training in?” with “College? I didn’t go to college,
but I did stay at a Holiday Inn!”
Wow, that went a lot longer than I thought it would. Anyway
I hope it was informative. Here are some of the possible solutions again.
-More pay.
-More training (community paramedic) for expanded scope
-Less reliance on transport revenue
-Well trained (with formal education) leaders
-More involvement in the “politics” of EMS, from the federal
level of getting grants, getting a “seat at the table,” or simply clearly
articulating the importance of our service to local officials
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