May 20th, 2019 will mark the end of a 45 day public comment period on proposed changes to California’s paramedic regulations. Some of the proposed changes will have a dramatic impact on paramedicine and our current prehospital systems. Here is what you need to know.

Regulations vs Code

In California, there are two forms that state policy take– codes and regulations. Code (also called statute and law, interchangeably) is created by the state legislature and signed by the Governor. Certain things are written explicitly in our state code, such as oversight authority or paramedic education hour requirements.

Other aspects of our system are not defined in code. These clarifications are left to oversight bodies to define in regulations. Regulations are a layer of rulemaking on top of code to further clarify the system. That is, they can further extend or explain rules set in code, but they cannot contradict the code they are built on.

Who sets our regulations?

In California, our state code grants regulatory oversight rights to the EMS Authority. The Authority, led by Dr. Howard Backer, works with local stakeholders to create statewide structure bringing standardization and strength to licensure, system operation, and more. Currently, the Authority is seeking public comment on changes being proposed to the 44 pages of ‘paramedic regulations.’

What are some changes that affect paramedics?

Alternate Destinations:

The EMS Authority, after significant review, is now proposing that alternative destination strategies are within its regulatory power. This means that the EMS Authority is clarifying that local EMS operations are legally allowed to transport patients to places other than emergency departments, such as sobering centers or behavioral health facilities.

This is an important and dramatic change in EMS systems across the state. It was previously thought that this required legislative process to amend state code.

Paramedic Internship; ALS Contacts:

Historically, paramedic interns have been required to make a minimum of 40 ALS patient contacts to successfully complete their field internship. The Authority is now proposing that 10 of these contacts can be substituted with high-fidelity testing. This testing format utilizes advanced manikins and computer systems to put interns through complex care scenarios.

The EMS Authority is not reducing the amount of hours the paramedic will have during their internship. Therefore, some argue that interns will still garner the same amount of experience. This camp says that high-fidelity testing is a good supplement to current practices. Critics say paramedic programs will use the change to shorten education cycles, when paramedic interns with low, real-world patient contacts should actually be extended.

Critical Care and Flight Nomenclature and Oversight:

Given the recent statewide scope or practice for critical care and flight paramedics, the Authority is seeking to clean up nomenclature surrounding this group of providers. The term flight paramedic (FP) is now added to many areas to clarify scope and training for this group of providers.

Additionally, the ability of these providers to perform advanced practice skills such as ventilator management, thoracic drainage systems, and blood products is now simplified to be at the discretion of the local medical director.

Increased Costs:

One change that will affect all providers is the rising cost of licensure. The vast majority of the EMS Authority’s budget originates in licensure fees collected every two years from every paramedic.

The proposed changes will raise the cost of initial licensure to $250 this year and ultimately $300 by 2022. Renewal costs will start at $200 and rise to $250 through the same time period.

What can I do to express my opinion?

There are a couple ways that field providers can make their voice heard. The first is by attending the regulatory hearing on May 20th, 2019. The other is to submit written thoughts via the public comment form available on the public comment website.

 

The University of California San Francisco has released its latest evaluation of the community paramedicine pilot program. The report, produced by Dr. Janet Coffman at the Philip R. Lee Institute for Health Policy Studies, analyzed California community paramedicine through September 2018 and echoes previous reporting which has shown the pilot to be both effective and safe in its effort to reduce health care costs and extend care into at-risk populations.

Since 2014, a California Healthcare Workforce Pilot Program (HWPP) has studied new, innovative models of EMS that put paramedics in preventative roles and work to reduce unnecessary or inefficient health care. The pilot has explored areas such as post-discharge follow-up, frequent EMS users, tuberculosis management, hospice care, and alternate destination strategies for 911 callers. These diverse areas of programming have been grouped together in what is now called community paramedicine. Thus far, more than 4,300 Californians have been treated by community paramedic programs across 18 locations from San Diego to Northern California.

The recently released review serves to bolster arguments in favor of widespread community paramedic programming. Patient safety concerns in programs that divert patients away from emergency departments, a frequent concern of critics, seems to be assuaged by UCSF’s analysis showing that 1200 alcohol intoxicated patients diverted to sobering centers in San Francisco were triaged with 97.8% accuracy and no safety incidents.

The report showed congruence among other alternate destination programs targeting additional patient populations, such as in the Central Valley where 800 mental health patients were steered directly to behavioral health facilities instead of filtering through emergency departments. Psychiatric patients lacking a medical condition requiring treatment can often skip traditional emergency department assessment and evaluation, thereby saving significant time and money. Many view such programs as a critical component in solutions to overcrowded emergency departments, ballooning healthcare costs, and important behavioral health reform.

Another facet of the UCSF report is the continued success of paramedic integration into complex patient management. In San Diego and San Francisco, community paramedics worked with at-risk populations to drive down their 911-utilization rates for non-medical needs, such as food, housing, and substance abuse. Across other counties, paramedics worked with recently discharged populations to better coordinate post-discharge care plans with the goal of reducing hospital readmission. The report found paramedics were able to reduce utilization and readmission rates, respectively, and with improved outcomes and associated cost-savings.

UCSF’s analysis also shines light on significant challenges which will continue to surface as the paramedic industry shifts its weight. Some programs, despite their documented success, have been limited or shuttered entirely due to lack of resources. However, recent introductions nationally via the Health and Human Services Department and the Centers for Medicare and Medicaid Innovation (CMMI) have shown that reimbursement changes are coming that will eventually provide more support to community paramedicine programs.

Dr. Coffman’s analysis comes at a critical time as EMS stakeholders and legislators work to formalize the community paramedicine pilots, which have already exceeded the traditional time frame of a pilot program. Legislative attempts in Sacramento last Fall became mired down in union and political antics—the resulting bill was ultimately vetoed by then Governor Jerry Brown who asked the stakeholders to produce cleaner language. The authors and sponsors of that legislative attempt have recently reintroduced the bill hoping a new legislative session and Governor may produce different results.

Join our newsletter below for ongoing updates in the field of community paramedicine.

A new form of care has taken hold in forward-looking emergency medical services agencies: Community paramedicine. Across California, community paramedics in locally designed pilot projects are demonstrating different ways to prevent emergencies and connect people to the right care at the right time.

Video Credit: California Health Care Foundation.

In the prior four articles, the California Paramedic Foundation introduced the need for modernization in three essential areas of paramedicine—Training, Treatment, and Transport.

Authored by a coalition of thought leaders with more than 150 years of combined experience in the field of EMS, healthcare, education, training, and program development and analysis, and with input from numerous stakeholders in prehospital care, these articles serve as the foundation for the introduction of a progressive state legislative reform agenda called the Paramedicine Modernization Act (PMA) of 2019. Within each of the “Three T’s” we have identified critical needs that provide the foundation for one or more legislative concepts.

The Paramedicine Modernization Act of 2019 will not address every fundamental change necessary for the advancement of paramedicine–however, it does represent a large step in the right direction in California, where paramedic services have fallen behind our prehospital peers in other states and nations. This is unacceptable. To that end, we offer the following legislative concepts for your consideration:

Training

Bill 1: Elevate minimum paramedic education to the level of an associates degree by 2025; grandfather existing paramedics who are licensed and working prior to implementation.

Treatment

Bill 2: Formalize Community Paramedicine pilot programs into state law; adopt current successful structure consisting of control at the Local EMS Authority level with oversight by the California EMS Authority and ultimate reporting to the EMS Commission.

Bill 3: Allow paramedics to participate in public health campaigns that vaccinate adults for seasonal and sporadic viral threats under the direction of their Local EMS Authority and Medical Director

Transport

Bill 4: Allow specially-trained paramedics to transport qualified individuals to appropriate substance abuse or mental health facilities from EMS and police incidents under the direction of their Local EMS Authority and Medical Director.

Bill 5: The First Responder Safety and Wellness Bill of Rights

1.First Responders have the right to reasonable training on workplace violence, including avoidance and de-escalation techniques.

2.First Responders have the right to reasonable protective equipment when working in regions with a history of violent crime.

3.First Responders have the right to report workplace violence without discouragement or repercussion, and for those reports to be investigated to the fullest extent of the law.

4.First Responders have the right to a timely and standardized crisis management system with an incorporated referral process for continued, long term services.

5.First Responders have the right to reasonable workers compensation for mental health issues arising from their service including its cumulative impacts that may emerge long after leaving the field.

6.First Responders have the right to seek mental health or substance abuse treatment without fear of detriment to their employment.

The Paramedicine Modernization Act of 2019

The California Paramedic Foundation is a paramedic-founded and paramedic-driven organization. The Foundation is dedicated to better initial education, better continuing education, better industry communication, better access to prevention programming, and better public health programming in the field of paramedicine. All of these things lead to better outcomes in the emergent and non-emergent care of our neighbors. We support this powerful programming with the idea that better paramedicine advances our state and the world.

We look forward to working with legislators and interested stakeholders to bring about change that modernizes paramedicine as it is integral to the health of our communities.

In our first article, we introduced the need for change in California paramedicine. In subsequent articles, we addressed the first two of our “Three T’s,” Training and Treatment, and we now move to our final topic—Transport.

Under the literal definition of Transport, we will first discuss the introduction of alternate destination policies. Recent unsuccessful legislative attempts have focused on helping overloaded emergency departments by diverting mental health and intoxicated patients to arguably more appropriate facilities, including mental health clinics and sobering centers. However, these at-risk populations exist in both our health and criminal justice systems. As our understanding of these complex issues matures, we are beginning to see that a solution must work among both systems concurrently to be effective. Paramedics are well-positioned to increase connectivity in a multipronged approach that includes both decriminalization efforts and diversion to appropriate locations of care, among others.

As an extension of Transport, we will then discuss the issues of physical safety and mental wellness in paramedicine. Often alone with a patient during transport and without other first responders, the paramedic faces real issues of physical safety in an industry where patient-on-provider violence is an all too common reality. Physical violence and constant exposure to traumatic incidents and images has led to an abnormally high prevalence of depression, suicide and PTSD in paramedicine. Unfortunately, many providers lack resources to cope with the nature of their job, just as the paramedic lacks physical safety resources in the back of the ambulance during transport.

Alternate Destinations in California Paramedicine

By: April Sloan, Community Paramedic

California has recently seen two unsuccessful legislative attempts aimed at allowing paramedics with special training to triage patients to destinations other than hospital emergency departments. These bills would have allowed intoxicated or mental health patients to be transported directly to facilities with services specifically for those populations. Conversation around these bills focused almost entirely on reducing unnecessary emergency patient volumes and emergency medical care costs. While these are real benefits of an alternate destination policy, they are only an ancillary bonus of a more effective approach that works on core issues at the center of substance abuse and mental health.

People suffering from addiction or mental health disorders move transiently across our systems of care. One week an at-risk individual may be getting medical attention for health problems related to substance abuse or medication and therapy services for needs stemming from mental illness. The following week that same individual may interact with peace officers, where they face arrest and imprisonment secondary to substance abuse or behavioral issue. In both cases, the precipitating cause is the substance abuse and/or mental illness, however the traditional services provided by emergency medical staff or law enforcement will not address this cause in definitive ways, meaning these individuals will cycle over and over through these systems while their problems remain unresolved. This issue is further exacerbated by the lack of connectivity between hospitals and justice systems. This lack of connectivity hinders progress because care plans are not currently shared or managed across the entire landscape.

New integrative approaches are now being taken in locations across the country to break these ineffective cycles. The Substance Abuse and Mental Health Services Administration (SAMHSA) and their GAINS Center (Gather, Assess, Integrate, Network, Stimulate) have introduced models that outline more effective team-based approaches that can divert juvenile and adult individuals away from unnecessary imprisonment. SAMHSA notes the value of paramedics who bring medical evaluation capability to teams of law enforcement and mental health professionals, expediting the movement of patients toward definitive and effective treatment for their core needs.

In California, we can see both the criminal justice and medical sides of the house actively working to address these populations. Serial inebriate programs in San Diego and Sacramento offer enrollees the opportunity for addiction treatment in lieu of jail time. These programs are highly effective and have seen success in as much as two-thirds of their participants. Paramedics are often incredible assets to these programs, where they help screen patients as they are processed in the field.

Community paramedicine pilot programs in San Francisco and Stanislaus County have demonstrated the effective triage capability of paramedics in diversion of alcohol intoxication and mental health patients away from unnecessary emergency department evaluation. In San Francisco, 400 individuals were transported to alternate destinations over a 9 month period, with only 2% requiring subsequent referral to an emergency department. In Stanislaus County, 251 individuals were transported directly to mental health facilities, with only 4% requiring subsequent transport to an emergency department. No adverse patient outcomes were reported in either of these trials.

It is clear to see that our health and criminal justice systems are working towards common ground in the triage, diversion, and appropriate treatment of substance abuse and mental health issues. Paramedics are uniquely positioned to offer connectivity to this effort, as they extend medical care into their communities and work side-by-side with peace officers. Policy reform allowing paramedics to appropriately screen and move at-risk patients in the prehospital and prejail realm is fundamental to the introduction of this more robust, integrative, and socially conscious approach to substance abuse and mental health systems of care.

Provider Safety in Paramedicine

By: Ben Vernon, BA, EMT-P Paramedic and Aaron Byzak, MBA, FACHE

Walk into a room of 100 providers and ask how many have been assaulted during their time in paramedicine—100 hands will go up. Ask this same group of providers if they are experiencing mental health effects from their work and you will get a very different answer. The truth is both workplace violence and mental health side effects are pervasive in paramedicine. In an industry where toughness and stoicism are celebrated, paramedics will speak openly about workplace violence like a badge of honor, while simultaneously refusing to discuss the mental health effects of their work as they suffer in silence. The time has come to take definitive action to address workplace violence against prehospital providers and reduce stigmas and encourage treatment for depression, anxiety, PTSD, and substance abuse, all of which are the natural byproducts of consistent exposure to trauma in this industry.

Violence against paramedics and emergency medical technicians is undoubted, with 2016 data showing that 16% of 21,900 workplace injuries experienced by these providers are the result of violence, a percentage that is trending upwards. Prehospital emergency medical workers see 7.1 nonfatal injuries per 100 workers, a figure comparable to peace officers who suffer 7.2 nonfatal injuries per 100 workers with 22% of those resulting from violence. Some level of violence is to be expected in law enforcement by the very nature of their training and work, but one would likely not expect such prevalent violence in paramedicine—a field rooted in the provision of care for the sick and injured.

California state code provides extra protections for first responders including sentencing guidelines for assault and battery. However in practice, first responders are often hesitant to press charges for simple battery, because there is a perception that the misdemeanor has little consequence and prosecution is unlikely. In some situations, providers are actively discouraged from reporting the assault or pressing charges by the powers that be. Furthermore, prehospital providers often lack access to safety equipment, such as bullet proof vests or body armor, despite the fact they work in and around violent incidents with high frequency.

In addition to workplace violence, paramedics are routinely exposed to incredible psychological trauma. They respond to incidents that sear into the mind, such as suicides and hangings, pedestrians hit by cars and trains, child abuse, horrific car wrecks, people burned in fires, and violent crimes. It has been said that a paramedic may see more trauma in one week than most people see in their entire lives. Paramedics are at a particularly high risk of work-associated mental illness as a result of this trauma, with 10% suffering from clinical levels of depression, 22% having PTSD, and 22% having probable clinical levels of anxiety, as shown in a study of UK providers. It is no wonder recent studies have shown that first responders attempt suicide at more than 10 times the rate of the general population.

We must also recognize that PTSD, depression, substance abuse, and associated mental health issues cannot always be attributed to a singular event and can be born from the cumulative impact of smaller recurring incidents over time. Paramedics, both those currently working in the field and those who have moved on to other careers, can carry the mental scars of their service forever. In recognition of this, paramedics must have access to meaningful resources in the near and long term. Immediate needs should be addressed with robust standardized peer support programs which can seamlessly transition to ongoing care, such as mental health services offered in employee assistance programs. Furthermore, providers who have transitioned out of paramedicine must have access to long term services, something that is not currently guaranteed under employee assistance laws. It is also imperative that prehospital providers not fear employment repercussions for accessing these needed services.

Changing the culture surrounding mental health and workplace violence in paramedicine is no small task. Different regions may have different needs and a overly prescriptive approach would likely be ineffective or possibly detrimental. However, the adoption of general provisions of safety and wellness for first responders could provide an expectation of services upon which first responder agencies can develop programming to meet the needs of their respective workforces. To that end, we introduce these provisions as a bill of rights:

First Responder Safety and Wellness Bill of Rights:

1. First Responders have the right to reasonable training on workplace violence, including avoidance and de-escalation techniques.

2. First Responders have the right to reasonable protective equipment when working in regions with a history of violent crime.

3. First Responders have the right to report workplace violence without discouragement or repercussion, and for those reports to be investigated to the fullest extent of the law.

4. First Responders have the right to a timely and standardized crisis management system with an incorporated referral process for continued, long term services.

5. First Responders have the right to reasonable workers compensation for mental health issues arising from their service including its cumulative impacts that may emerge long after leaving the field.

6. First Responders have the right to seek mental health or substance abuse treatment without fear of detriment to their employment.

The Modernization of Paramedic Transport

The time has come to modernize the California paramedicine in the area of Transport. Alternate destination policy reform offers a gateway to the appropriate care for individuals who would otherwise end up in our emergency departments and criminal justice system. Can we really continue to cycle patients through a system that is so painfully inadequate when alternatives exist that have been proven effective?

We must also resolve to codify protections for both the bodies and minds of those who respond to help us in our most desperate hours. A bill of rights stands to guide a change of culture on topics that have been avoided for too long. Will we continue to send our EMS brothers and sisters into harm’s way without the most basic protections and then abandon them in their time of need?

The California Paramedic Foundation is calling on stakeholders and legislators to work together for the modernization of paramedic transport in California EMS, through the formal adoption of alternate destination policy and the establishment of a health and safety bill of rights for first responders.

About the Authors:

April Sloan, Community Paramedic: April has a career in EMS that spans 20 years and multiple states. Since 2011 she has been located in San Francisco, CA where she has worked in both private and public provider roles. For the last three years she has led the San Francisco-based Community Paramedic Program centered on alternate destinations for alcohol intoxicated individuals and support services for high utilizers of emergency services. Both aspects of this pilot have been highly successful due to the guidance of April and her team.

Ben Vernon, BA, Paramedic: Ben began his career in EMS in 2003 and is currently a firefighter/ paramedic for San Diego Fire Rescue. He’s a member of the Technical Rescue Team, Hazmat Team and California Task Force 8—Urban Search and Rescue Team. He also teaches in the Fire Academy and is an EMT instructor. On June 24, 2015, Ben’s life changed when he was stabbed while responding to a “routine medical assistance” call. The incident and the ensuing ordeal left Ben with a changed perspective. Ben has lead organizational change in his own department and abroad in the areas of mental health and wellness. He is a widely requested national speaker on the topic and is currently co-authoring a book.

Aaron Byzak, MBA, FACHE: Aaron has served for more than two decades in positions of progressive leadership in EMS, health policy, and healthcare management. He is the founder and chief advocate of Hazel’s Army, a community advocacy and education group that in 2014 helped pass the most comprehensive assisted living reform agenda in California’s history. Aaron has received numerous best practice awards and national recognitions for his leadership and work in healthcare, public health, advocacy, and communications including four Emmy Awards. Aaron’s career in healthcare was largely shaped through his experiences in EMS, including as a survivor of PTSD. That journey laid the foundation for a career dedicated to public service and his ongoing work addressing the needs of vulnerable populations. He earned his master of business administration in healthcare management and policy from UC Irvine’s Merage School of Business, and a bachelor’s degree in social science from Chapman University. He is Board Certified in healthcare management as a Fellow of the American College of Healthcare Executives (FACHE).

In our first article, we introduced a need for the modernization of paramedicine in California across three key areas—Training, Treatment, and Transport. In our last article, we discussed Training and the important educational advancements needed to bring paramedics within the accepted training standards of similar medical professionals to improve patient outcomes and to advance the industry as a whole. We now look to discuss the important topic of Treatment.

In California, every day we see the impact of societal challenges, such as as homelessness, mental illness, opioid abuse, and infectious disease, to name a few. Political and health care bodies spend an inordinate amount of time and energy looking for innovative approaches to address these areas and reduce suffering in our communities. Paramedics have demonstrated the ability to address these issues, if permitted to fully utilize their skills and provide interventions tailored to community needs. We believe that two tangible solutions can be effectively deployed to help in this regard: the implementation of Community Paramedicine throughout the state of California and the use of paramedic vaccination campaigns.

Community Paramedicine in California

By: Shawn Percival, Community Paramedic

In California, our paramedics and prehospital systems function incredibly well in acute emergencies. The dial of a phone can summon paramedics within minutes, bringing important life-saving knowledge, interventions, and subsequent expedited access to specialty systems of care. However, this classic reactive “treat and transport” approach has not been an effective solution in the management of non-emergent patients facing complex issues. These non-emergent patients comprise a majority of the calls paramedics respond to in our 911 systems.

Paramedicine is now evolving to interact regularly with at-risk populations and better triage patients on 911 calls to improve outcomes, reduce hospitalizations, reduce cost and increase system efficiency in what is called Community Paramedicine (CP). CP is defined as EMS-based strategies that address local public health, health care and public safety needs through evolving problem-solving techniques, community partnerships, and advanced roles or scopes of practice.

In November 2014, the Office of Statewide Health Planning and Development (OSHPD) approved an application by the California EMS Authority to initialize a Health Workforce Pilot Project (HWPP) to test CP across our state. The programs have proven both safe and effective as shown by the extensive, independent analysis performed by the University of California, San Francisco (UCSF) and the California Health Care Foundation (CHCF).

Thirteen local CP programs within the pilot are currently addressing healthcare needs such as post-discharge follow-up, frequent EMS use, tuberculosis management, hospice patient management, and alternate destination strategies for patients requiring mental health and sobering centers. Across all of these programs, paramedics leverage the health and public safety skills already used by 911-paramedics on a daily basis and repurpose them, adding techniques such as outreach, navigation, advocacy, primary care and other preventive services.

UCSF’s comprehensive review is available for your analysis.  However in the interest of brevity, we have selected key takeaways from that report. Since their inception, the programs have enrolled over 3,000 patients. In post-discharge pilots, patient safety was increased and the programs saw “all-cause” 30-day readmission rates drop in the vast majority of groups, at a cost savings of $1.4 million dollars. Frequent EMS-user pilots saw dramatic success by reducing 911 utilization through the networking of patients to primary care, food and housing resources, mental health services, and substance abuse programming, saving $582,000 on a cohort smaller than 50 patients. In directly observed tuberculosis management, paramedics were able to safely administer treatment with higher compliance than the traditional clinic-based treatment model, missing only 0.05% of treatments in comparison with historic rates of 7%. If these diverse CP programs were taken to scale across the state, the impact and savings would be staggering.

With such demonstrable success, we then look to understand why recent legislative attempts to formalize community paramedicine have been unsuccessful.

The most recent attempt, Assembly Bill 3115, was ultimately vetoed by Governor Jerry Brown, who noted general support for the initiative but major concern with the proposed oversight structure. AB3115 was introduced and supported by labor organizations who sought to control CP at the state level and restructure the EMS commission, thereby gaining labor seats on that body. That bill’s sponsors disregarded the local control structure of the successful pilots and overlooked the important perspective of pilot program leadership in their pursuit of self gain. Labor organizations must be included in the discussion of CP implementation, but their political agenda should not jeopardize the ability of paramedics to provide for the needs of our communities.

The CP pilot program, as a whole, has now served its intended purpose and is reaching its sunset. OSHPD and the CHCF have fortunately extended the pilot program for one more year, after the politically-induced failure of the last legislative attempt. The California Paramedic Foundation fundamentally supports Community Paramedicine in both theory and practice. We believe CP legislation must be modeled on the current pilot programs so that its growth is anchored by ongoing success; a success that is built on control under local EMS agencies and medical directors, accountability to the state EMS Authority, and reporting to the EMS Commission.

Paramedic Delivered Vaccination in California

By: Josh Krimston, Paramedic

Viruses are an ever-present threat to our society. Each year 5% to 20% of Americans will face influenza. This can result in around 200,000 hospitalizations, 80,000 deaths, $10.4 billion in direct medical care costs, and $16.3 billion in lost earnings—in just one flu season. In 2014, the Ebola virus epidemic terrified the world with a 70% mortality rate and secondary international infections. The reality is infectious viral diseases are a continuous threat that must be addressed with pragmatic and proven public health strategies.

Recently, San Diego faced its own epidemic with the 2017 Hepatitis A outbreak. That event saw 578 infections and 20 deaths. The San Diego outbreak was successfully wound down in part through the use of paramedics, who provided vaccinations for tough to reach populations in a larger effort by public health providers and administrators. This approach was a highly successful component of the effort which turned the tide in an epidemic which had been growing out of control with expanding rates of infection and a rising death toll. This event shows the benefit of paramedic-driven vaccination campaigns and demonstrates the importance of their early implementation.

The deadliness of a Hepatitis A outbreak was clearly seen in San Diego, and yet this virus only has a mortality rate of up to 2% in at-risk populations. Other viruses, such as the H7N9 Bird Flu, have mortality rates of 30% or greater and also pose risk of outbreak. The World Health Organization (WHO) recognizes several viruses, including the avian strain, as threats with pandemic potential. When viruses of this magnitude threaten the health of our community, whether seasonally or sporadically, an all-hands-on-deck approach must be available.

The value of paramedicine in vaccination campaigns lies with their ability to reach populations not always accessible to public health nurses and other providers. Often public health nurses require peace officer escorts to reach populations accessible to paramedics, however this escort can often cause individuals to flee reducing efficacy. In a University of Pittsburgh study, 90 paramedics were able to vaccinate over 2,000 individuals against seasonal influenza, 49% of whom had not received the vaccine in the prior year. That program’s organizers found paramedics operated with high success and saw zero adverse outcomes.

Despite the clear opportunity to improve our response to these public health crises, current California law does not allow for paramedics to administer vaccines unless state regulators provide emergency authorization. This lengthy process delays decisive action when time is of the essence. Even with emergency authorization paramedic campaigns are still burden with nursing oversight, when ironically, the standard protocol for out-of-hospital allergic reaction—the most concerning adverse event with vaccine administration—is to call paramedics.

Unfortunately, some organizations do not generally support the expansion of paramedic scope of practice to include vaccination. They often argue paramedics are unqualified to deliver this critical service. The reality of the situation is that administering intramuscular injections or intranasal sprays is a core skill of paramedics in their day-to-day work. The low risk of allergic reaction to a vaccine can be expertly handled by paramedics, who are often requested via 911 to handle the most severe forms of these incidents.

Public health is not a zero sum game, and paramedics have proven to be a valuable and safe component in a comprehensive approach for the management of highly-infectious and deadly viruses. This value must be recognized with pragmatic legislation via EMS stakeholders and policymakers.

The Modernization of Paramedic Treatment

The time has come to modernize the way California paramedics treat our communities. Community paramedicine presents a viable pathway to begin addressing patient vulnerabilities in our communities. Can we really allow labor politics and gamesmanship to sideline an otherwise effective and widely used approach like Community Paramedicine?

The value of paramedics in vaccination campaigns has been vividly demonstrated, as well as the nonsensical, outdated rules that currently hinder its broader adoption. Paramedic vaccinations are low-hanging fruit in the important battle against deadly diseases. Can we really overlook this ready solution, when viral outbreaks truly threaten lives?

The California Paramedic Foundation is calling on stakeholders and legislators to work together for the modernization of paramedic treatment in California EMS, through the passage of Community Paramedicine into state law and the expansion of the paramedic role in the provision of vaccines.

About the Authors:

Shawn Percival: Shawn is a certified Community Paramedic (CP-C) credentialed by the International Board for Specialty Certification (iBSC) and has previously attended the Community Paramedic Training Program at University of California, Los Angeles.  As a community paramedic, Shawn works with the City of San Diego Resource Access Program (RAP) to reduce low-acuity, high-frequency callers. A large focus of his work is with military veterans, who have increased risk of substance addiction and homelessness.  Shawn and his colleagues provide access to primary care, addiction specialists, housing support and family reconnection services to help these populations. As a Community Paramedic, Shawn is committed to research that steers public health policy. Recent research by the San Diego RAP Paramedics on the Spice epidemic helped form the 2016 San Diego City Ordinance banning all synthetic drugs.

Josh Krimston: With over 25 years of paramedic experience in both the private and public sectors, Josh Krimston has taken his field experience and leveraged it to develop programs that fuse paramedicine and prevention. As co-founder of the nonprofit group EPIC Medics, Krimston recognizes the inherently unique position paramedics are in to affect positive changes in injury and illness prevention. In 2017, during San Diego County’s deadly Hepatitis A epidemic, Krimston worked with Public health officials to implement a paramedic-led vaccination program in his southern San Diego district. Krimston has travelled extensively throughout the United states promoting the integration of EMS and prevention and has authored numerous related articles and text book entries.

In California, cosmetologists—that is hair stylists, estheticians, pedicurists, manicurists and theatrical makeup artists—have 1.5 to 3 times more hours of minimum education than the advanced life support paramedics currently serving our communities. In other words, the individual that cuts your hair had greater initial training than the paramedic providing critical prehospital services, from cardiac arrest resuscitation, to public health initiatives, and everything else in between. This statement is not meant to offend or insult our friends in the beauty or effects industry, nor is it meant to dishearten hardworking and highly-skilled paramedics. However, it vividly demonstrates the long-antiquated training standards we set for our prehospital providers.

In our last article, we introduced the need for the modernization of paramedicine in California across three key areas—Training, Treatment, and Transport. In this article, we will explore the topic of Training in the context of an ongoing national discussion around paramedic education.

Last month, the national associations representing emergency medical services (EMS) educators, EMS managers, and flight and critical care paramedics released a compelling joint statement calling for a lift in paramedic education standards across the United States.

This extensively-cited piece provides the historical context of paramedic education and licensure, and argues that the minimum level of paramedic education in our country must be an associate’s degree by 2025, with baccalaureate standards for critical care and specialized roles, such as community paramedicine which is currently taking root in California. The authors argue that paramedicine is becoming increasingly complex and specialized, and that it lacks inherent leadership, paramedic-driven academia and research. They demonstrate that each of these areas have been successfully addressed in other health professions through degree-based educational standards and that the necessary academic infrastructure exists to make this a reality for paramedics. The California Paramedic Foundation and our partners believe that the system is well-positioned for this change.

In an interesting response, national fire service representatives countered with an opposing argument and directed their memberships to fight any and all legislation seeking paramedic educational reform. The statement suggested, against all available evidence, that increased education will reduce the availability of paramedic schools and paramedics and that degree-based education at the paramedic level is “unnecessary” and “arbitrary.” We could not disagree more.

Let us first acknowledge that this issue is mired in political, labor, and economic interests, the complication of which certainly benefits those seeking status quo and stymies educational progress. In looking at this very important issue in our own state, we can clarify much through asking two simple questions: (1) Are increased paramedic educational standards possible? And (2) would increased paramedic education benefit California? The answers to these questions will not surmount every challenge in this difficult and highly politicized task, however it will at a minimum provide California paramedicine stakeholders a true north.

Are Increased Standards in Paramedic Education Possible in California?

The short answer is yes. California’s paramedic educational landscape is even more amenable to a mandated associate’s degree than the national numbers outlined by EMS leaders in their pro-education joint statement.

Each year an average of 890 paramedics graduate from 39 California paramedic training institutions and seek licensure with the California EMS Authority. Of these 39 programs, 25 (64%) already offer optional associates degrees or are affiliated with California Community Colleges, California State Universities, or the University of California. Of the remaining 14 programs, 9 (23%) are run by NCTI, and 5 (13%) are standalone private or fire-based programs. All of California’s paramedic programs are CoAEMSP accredited, as only graduates of accredited programs are eligible for national testing and California licensure.

Associate’s degrees in paramedicine are already widely offered across California and stand as a model curriculum and cost. Looking at examples including West Hills College, Crafton Hills College, Foothill College, and Butte College is instructive. An associate’s degree in paramedicine is comprised of 20-30 units of general education followed by 40 units of paramedic-specific training and instruction. Each unit costs a remarkably low $46 in our California Community College system meaning the marginal additional cost is a mere $920 to $1,380. As such, this is not a financial barrier.

Some have also expressed concerns that these educational increases would lengthen time to licensure for paramedics—however, it is standard practice for emergency medical technicians (EMTs) to obtain a minimum of 6-12 months of field experience prior to attempting paramedic school. This provides ample opportunity for EMTs to pursue general education concurrently.

It is important to put the additional cost of the associate’s degrees outlined above into context with the economic value paramedics currently bring their employers. At around $6,000 total, an associate’s degree program at a community college is a bargain. Private paramedic programs can be nearly twice as expensive, or more. Yet, major California paramedic employers still view these higher cost programs as economically valuable to their organizations and often sponsor an employee’s cost of attendance.

In the runway up to 2025, California’s private programs would have the opportunity to affiliate with community colleges, allowing their paramedics to earn an associate’s degree at their partnering institution. The California community college system already educates 80% of our paramedics, EMTs, law enforcement, and firefighters as a part of the 2.5 million students it enrolls each year. The system also educates 70% of California’s nurses, whose workforce is an order of magnitude larger than paramedics at 330,000 providers. Even if California’s private paramedic schools could not adapt by a 2025 deadline, an unlikely prospect, the robust community college system provides an important safety net where students could certainly be accomodated.

The state of Oregon implemented an associate’s degree standard roughly 10 years ago and saw no such shortage of paramedics. In Oregon, out-of-state paramedics seeking employment can use 3 years of recent experience in lieu of an associate’s degree. Qualified paramedics who are actively completing the general education requirements of an associate’s degree can generally work under employer-sponsored provisional licenses. Additionally, Oregon accepts verifiable associate’s and bachelor’s degrees in fields outside of paramedicine as qualification for licensure. Lastly, it’s important to note that paramedics who were licensed and active prior to implementation of the new standard were grandfathered in. All of these strategies would make sense in a California approach.

As demonstrated above, the move to associate’s degrees is not only possible, it is readily achievable. The majority of paramedic students are already enrolled in programs offering or positioned to offer associate’s degrees. The marginal cost to move certificate programs to an associate’s degree are minimal. Furthermore, Oregon has demonstrated a path to success.

Would Increased Standards in Paramedic Education Benefit California?

Paramedics are a unique bridge between our communities and our incredibly advanced health care systems. Cardiac, neurology, trauma, and emergency medicine specialty teams reach beyond the walls of their hospitals through their utilization of the paramedic’s advanced skillset. However, the ability of paramedics to triage, differentially diagnose, and extend therapeutic strategies from multiple specialties is only as effective as their understanding of human biology and the interventions taken upon it. While paramedics currently do an admirable job providing care in critical situations with relatively little formal education, additional knowledge in areas such as natural sciences, social sciences, reading and writing, communication, and mathematics would significantly improve their ability to provide higher quality and more informed care.

This is non-controversial. The vast majority of allied health providers such as nurses, X Ray technicians, MRI technicians, and respiratory therapists, recognize the value of this foundational knowledge and have included it in their curriculums for decades. Nursing has long mandated degree-based education in its pursuit of increased leadership, self-driven research and improved clinical outcomes. Having already seen the benefits of their move to an associate’s degree long ago, nursing is actively migrating towards bachelor’s level education where they are seeing even more value. Magnet hospitals, known for clinical excellence, aim for 80% baccalaureate level education for their entire nursing staff and as a result experience 7% less patient safety incidents, lower mortality, and shorter stays. It is logical that the improvements from nursing educational advancement would be mirrored in paramedicine, ultimately benefiting the public at large.

Paramedics operating in specialized roles, such as critical care and community paramedicine, have even greater needs for education. These paramedics operate on the bleeding edge of the profession where even deeper formal education, understanding, and knowledge, coupled with the use of evidence-based practice, is correlated to the effectiveness of the complex care they provide. However, it is our opinion that the educational increases specific to these roles should be controlled by their national specialty certification boards, as these are newly developing curriculums. In California, our initial focus should be on appropriately educating our front-line paramedics with associate’s degrees, of which the benefits and curriculum are already well established.

In their opposition piece, fire leadership states support for education while simultaneously claiming additional paramedic education is “arbitrary”—a position that is untenable. The fire service claims 20% of paramedic schools will close, however they provide no evidence to support this claim. The target education implementation date of 2025—a runway of six years—makes this forecast little more than a scare tactic.

It should be more concerning that these organizations call paramedicine educational advancement arbitrary. The vast majority of services that fire departments provide to their communities on a day-to-day basis are comprised of emergency medical care, sometimes upwards of 87%. If 87% of the individuals they provide services to require the care of a paramedic, and this care could be bolstered by improved education, how can anyone characterize that as “arbitrary?”

Paramedics are incredibly important bridges to advance systems of care in our complex healthcare landscape. Evidence clearly shows that increased educational standards in allied health professions bring direct benefit to the medical patients they treat. Arguments to the contrary appear politically motivated and unfounded in data. Appropriate education is fundamental to the critical services paramedics offer in our communities, and the benefits undoubtedly outweigh the costs in this important effort.

The Modernization of Paramedic Training

The time has come for California’s antiquated paramedic educational standards to evolve. Paramedic education must rise to a level that is commensurate with their crucial role as emergency medical providers throughout our communities, on our streets, and in our homes.

Returning to our example of the cosmetologist, can we really argue that paramedics should continue to operate with less education than our local hairstylist, when they literally have our lives in their hands? Can we keep a straight face and call educational advancement arbitrary when it is already having a demonstrably-positive impact across healthcare?

The California Paramedic Foundation calls on stakeholders and legislators to recognize the importance of this issue, work together to modernize paramedic educational standards, and secure these changes in state law.

Authors:

Arthur Hsieh, MA:Arthur is a paramedic and educator in Sonoma County, CA. Arthur currently serves as the Director for the Santa Rosa Junior College Paramedic Program, is on the board of directors for both the California Rescue Paramedic Association and the California Paramedic Foundation. In addition to his current work, Arthur has extensive experience in paramedic education through his previous work at the Hospital Consortium Education Network, the George Washington University Emergency Health Services Program, the San Francisco Fire Department, and the San Francisco Public Health Department Paramedic Division. Arthur has also previously served as the president of both the California Paramedic Program Directors Association and the National Association of EMS Educators.

David J. Olvera, NRP, FP-C, CMTE: David Olvera is a Nationally Registered Paramedic, Certified Flight Paramedic and Certified Medical Transport Executive and currently serves as Clinical Education Manager and department chair for the national research committee of Air Methods Corporation. He serves on the boards of the International Board of Flight and Critical Care Paramedics and the MedEvac Foundation International and works as a subject matter expert with the Air Medical Journal. He is recipient of the 2016 Tim Hynes Award and the 2017 ASTNA Jordan Award for excellence and significant contributions to prehospital medicine. He has been an item writer for both the National Registry and the Flight Paramedic Exam. Additionally, he serves on the faculty of the Difficult Airway Course EMS and is extensively published on the topics of prehospital airway management, resuscitation and advancing paramedicine. David is a proud Veteran Combat Medic of the United States Army.

It’s early morning in the outskirts of the small farm town of Visalia, California. Maria Sanchez stirs her husband awake. She is having chest pain. She has dealt with this before, but this morning feels different. Her husband gets dressed to drive her to their local hospital. Suddenly, the color fades from her face and she collapses to the ground. Her husband dials 911.

Within minutes a fire engine arrives at their house. The first responders assess Maria, identifying immediately that she is in cardiac arrest, and begin resuscitative efforts. Close on their heels is an ambulance staffed with a paramedic. As the paramedic arrives on scene, she receives a quick update from the first responders then begins advanced life support. Drill a needle into her tibia. Assess oxygen and carbon dioxide levels. Provide cardiac medications. Place a breathing tube in her trachea and ventilate. Assess her heart rhythm and deliver a shock of electricity.

Though fibrillating only moments ago, Maria’s heartbeat is organized once again. She has a pulse. But the paramedic’s work has only just begun. She performs a detailed assessment and reviews the history of events, hunting for a precipitating cause. An electrocardiogram, or ECG, reveals that Maria is suffering a heart attack. The paramedic packages Maria for transport to a specialized cardiac-receiving hospital, electronically transmits her assessment and ECG, and activates a specialized team that will be ready and waiting to place a stent in Maria’s heart shortly after her arrival—ultimately allowing her to make a full recovery.

Luckily for Maria, paramedicine is a fundamental component of our modern society. As Californians, we expect highly-trained paramedics with the dial of a phone— there for us when a loved one is ill, a bone is broken, or a life is in danger. Paramedics are important bridges and navigators in an ever-complex healthcare landscape, and have been for well over 40 years.

The California emergency medical services (EMS) system is no small feat. Rather, it is the result of a deep-rooted and continuous effort to address the health of our communities. Nationally, these needs were first identified in the infamous White Paper report to President Johnson in 1966, which spotlighted accidental injury as a major cause of morbidity and mortality and spurred modern EMS. What started as the treatment of life-threatening injury expanded to critical cardiac, neuro, and medical services in the ensuing decades.

California embraced EMS early, even launching the first accredited paramedic program in the country at UCLA. After decades of work, California now has robust medical, trauma, stroke and cardiac systems of care, much of which is unknown to the lay public, all of which are extended into their communities via paramedicine.

And yet, the healthcare landscape is dynamically changing. Hospitals are increasingly specialized and centralized. Community clinics are now expanding to meet the needs of socioeconomically disadvantaged populations who only recently gained some level of insurance coverage.

Together with government agencies, all struggle to address public health emergencies posed by a large, aging population and sporadic issues such as viral outbreak, to pull one example from our recent headlines. A coordinated system of care is expected by our communities, but there must be a common connector to facilitate the delivery of care, both preventative and emergent, to help patients navigate this system.

This presents paramedicine with an opportunity to help meet these evolving challenges. However, in order to do so California needs to modernize the way its paramedics are educated and their ability to be flexible and responsive to the needs of the patients they serve and the health systems they support. These hurdles are not insurmountable and only require an honest discussion, a pragmatic approach, political will, and most importantly paramedic leadership.

To that end, the California Paramedic Foundation seeks to spark a more robust conversation around the modernization of paramedicine in our state. Over the past several months the Foundation has worked with a coalition of stakeholders including paramedics, physicians, emergency nurses, hospitals, researchers and policy experts to design a comprehensive reform agenda centered on three integral areas— the three T’s: Training, Treatment, and Transport.

In the coming days, we will introduce subsequent articles that will expand on the three T’s, outline legislative solutions, and engage in further discussion with these experts and the public-at-large. The history of EMS is marked by inflection points that have led to better care and improved outcomes. We stand yet again in that position and look forward with great optimism that California stakeholders will work together for the betterment of our communities.

After more than two years of stakeholder and public input, the Office of EMS at the National Highway Traffic Safety Administration and its federal partners today released “EMS Agenda 2050: A People-Centered Vision for the Future of Emergency Medical Services.” The document describes a vision for evidence-based, data-driven EMS that is integrated with the rest of the nation’s healthcare system.

“The release of EMS Agenda 2050 marks a beginning, not an end. It is now up to all of us to work together to make this vision a reality,” said Jon Krohmer, MD, director of the NHTSA Office of EMS. “NHTSA and our federal partners appreciate the work of the Technical Expert Panel, project team, and everyone who contributed to this effort. They have provided an inspiring framework on which to build.”

EMS Agenda 2050’s people-centered vision is grounded in six guiding principles. The EMS system of the future should be:

1. Inherently safe and effective
2. Integrated and seamless
3. Socially equitable
4. Reliable and prepared
5. Sustainable and efficient
6. Adaptable and innovative

“Achieving this vision will require deliberate actions of stakeholders at every level of EMS: individuals like you, EMS services of all models and sizes, public officials from local regulators to the Federal Government, and national associations,” the document says. “It will also require bold collaboration with our partners in this effort: our communities, local volunteers, payers, healthcare systems, social services, public health, and our partners in public safety.”

“Our first responders, paramedics and other EMS clinicians are key to the nation’s health and safety, whether responding to everyday medical problems, vehicle crashes or major incidents and natural disasters,” said NHTSA Deputy Administrator Heidi King. “As a former EMT and 911 telecommunicator, I look forward to seeing the EMS community work together to achieve the bold and visionary agenda it identified for the future.”

The principles and recommendations within EMS Agenda 2050 build upon, rather than replace, the groundbreaking EMS Agenda for the Future, originally published in 1996. The process to review and revise the original Agenda was first recommended by the National EMS Advisory Council, a formal federal advisory group of EMS representatives and consumers authorized by Congress to provide advice and recommendations regarding EMS to NHTSA and to the members of the Federal Interagency Committee on EMS.

Throughout 2017 and 2018, the EMS Agenda 2050 vision was developed through a process that included several public meetings held across the country, online opportunities for input, and multiple rounds of public comment to provide feedback on drafts. Although the process was shepherded by a Technical Expert Panel, the goal was to involve as many members of the EMS community and the public as possible to accommodate multiple viewpoints and develop a vision that addresses key goals for the entire profession.

EMS Agenda 2050 was developed with funding from the NHTSA Office of EMS, the Health Resources & Services Administration EMS for Children program, the US Department of Health and Human Services Office of the Assistant Secretary for Preparedness and Response, and the US Department of Homeland Security.

 

This week California EMS medical directors and administrators completed a landmark implementation of a unified scope of practice for critical care paramedics. This optional scope protocol outlines advanced-practice treatments for critical care and flight paramedics including rapid sequence intubation, pediatric intubation, and mechanical ventilation. It also sets a new precedent in standardization, quality assurance and oversight, the previous lack of which was a precipitating factor in recent revisions of paramedic skills.

 

 

The effort was hailed as a major success by California State EMS Authority (EMSA) Director Dr. Howard Backer, who noted the incredible collaboration of stakeholders. The local EMS authority, or LEMSA, is encouraged to adopt the unified scope as an optional skill set in their region so that the policy will be as close to statewide as possible. The ability for physicians to standardize patient treatment guidelines across the entire state marks an important change which may make its way into other protocols.

This uniform protocol deploying across all LEMSAs is viewed as an important update to the current mosaic of guidelines under which California’s 33 local authorities operate. This recent effort opens up an avenue to a system in which protocols could be decided at a state level. Local directors could then choose to implement any assortment of these state protocols within their region. The move would make paramedic care an apples-to-apples situation across local authorities, in which statewide quality assurance, quality improvement and outcome data collection and usability would thrive.

The unified protocol also sets a higher bar for the ground and flight paramedics to which it affords these advanced practice skills. Minimum additional education guidelines, CCP and FP-C accreditation time limits, CAMTS accreditation mandation, and quarterly skills testing and reporting were all included in its language to ensure quality of care. Dr. Dave Duncan, of CALSTAR and CAL FIRE, stressed the importance of capturing these metrics and meeting guideline thresholds as qualified providers begin to implement the new protocol in their region.

The work has been the culmination of two grueling years of work by Dr. Duncan, along with fellow physicians Marianne Gausche-Hill, Eric Rudnick, Gary McCalla, Angelo Salvucci, and Atilla Uner. On the administrator side of the team, the EMSAAC effort was lead by Bryan Cleaver, David Magnino and Kristin Weivoda. Follow us for continued updates to this developing story.