Services Integration Strengthens Rural EMS

by Candi Helseth

Luce, McGinnis, & Prescott

Marilyn Luce (EMT-P), left, Kevin McGinnis (EMT-P), and Nicole Prescott (EMT-I) demonstrate the preparedness of the Winthrop (Maine) Ambulance Service.

Eight years after a national landmark study called for integration of rural Emergency Medical Services (EMS) with other pre-hospital and hospital providers, the EMS industry struggles with an identity crisis and a fragmented system that makes full integration a formidable challenge.

Consensus exists that integrating EMS systems will improve availability and access to advanced EMS care in rural and frontier communities, according to Nels Sanddal, a longtime EMS researcher and Manager of Trauma Systems with the American College of Surgeons (ACS). However, EMS’s role in three different arenas—health care, public health and public safety—contribute to the “identity crisis” that makes it difficult to formulate a plan to best integrate all pre-hospital resources. The fact that EMS agencies are governed differently from state to state and owned and operated in many different ways makes it even more difficult to regionalize all the resources.

The 2004 HRSA study, Rural and Frontier EMS Agenda for the Future, reported, ” Integration does not mean that a local EMS system has to become a part of a larger organization and lose its independence. But in today’s environment, EMS must collaborate closely with local health care systems, public health, and public safety. EMS agencies may also want to form closer connections with other ‘sectors’ in the community. Regionally, EMS needs to think about its role in the continuum of health care delivery.”

Where these recommendations are being put into practice, results are confirming that the emergency response system gets stronger. This is being demonstrated by programs in Oregon, Minnesota and Maine, which are integrating rural EMS with other services, and improving patient care, EMS response times and provider skills.

Smarter trauma care in Oregon using dummies (and humans)

Simulations in Clatsop County

Simulations conducted like this one in Clatsop County, Ore., help local EMS, fire and law enforcement learn how to better integrate services to provide trauma care.

In northwest Oregon, several agencies with special interests in trauma have united to improve trauma care at 15 rural northwest Oregon sites. The sites were selected for full-system activation response trauma scenarios with multiple patients.

“The real-life scenarios include community volunteers acting as patients along with simulation manikins controlled by nearby operators,” explained Robert Duehmig, Oregon Office of Rural Health (ORH) Director of Communications. “The exercises provide a safe learning environment where providers practice skills they don’t utilize on a regular basis because there isn’t a large volume of trauma calls in these rural areas.”

Robert Burk, an EMT with Medix Ambulance in Clatsop County, was among rural EMS, fire and law enforcement department responders involved in a recent scenario where two vans, fully loaded with students and adults, “collided” near the high school. Hands-on practice included extricating patients pinned in vehicles, treating and triaging patients, and determining transport destinations appropriate to the severity of their conditions. Medix provided ground transport to Columbia Memorial Hospital, a Critical Access Hospital in Astoria, and Life Flight transported critically injured patients to a Portland Level 4 trauma center.

Prior to the simulation, Life Flight staff provided a daylong educational session for rural practitioners. Following the scenario, participants met to identify ways to improve the emergency medical response and system of care based on what they learned. Analyses of Pre- and Post-tests demonstrate that rural practitioners’ confidence in providing trauma care has improved, Duehmig said.

“I’ve learned better ways to perform critical care skills that we don’t do routinely,” Burk said. “It was good for all of us to learn how to assess trauma patients, how to all work together, and where it’s best to route patients. The more training we can do, the more we learn what we can do better.”

Duehmig said all simulations include a pediatric emphasis because initial planning indicated that providers had minimal experience caring for injured and critically ill children. To date, five simulations have taken place and four more have been scheduled. Partners in the project are ORH, the Oregon Department of Transportation, Oregon EMS for Children, Oregon Health Authority, and Life Flight Network. ORH funded the project through a HRSA Flex grant.

Improving trauma care outcomes is also the purpose of an online course ACS has developed. More than 35 states, along with India and China, have enrolled providers in the Rural Trauma Team Development Course (RTTDC).

“This course strongly encourages integration of pre-hospital care providers with hospital teams,” Sanddal said. “The key to the content is that it promotes utilization of all available health care resources to resuscitate and stabilize critical trauma patients. It also provides key concepts for developing regional system relationships.”

Moving beyond trauma care in Minnesota

Minnesota’s Comprehensive Advanced Life Support (CALS) educational program reaches beyond trauma care “to integrate rural pre-hospital and hospital-based emergency care providers into a highly functional team that can effectively care for a wide variety of time sensitive emergencies, including trauma, stroke, heart attacks, shock, sepsis and airway management,” according to Dr. Darrell Carter, a family medicine physician in Granite Falls, Minn. Carter, who developed the concept, worked with a team of EMS practitioners, and emergency medicine and family medicine providers to build the CALS model.

One of CALS’ more unusual features is that it takes EMS practitioners into the hospital ER to continue helping with patient care by assisting staff at the hospital in an organized team effort. As a result, Carter said, communication improves among all caretakers, facilitating better patient transitions and quality of care. Traditionally, the EMS role has ended with transport of the patient to the hospital ER.

“CALS helps providers manage the great majority of emergencies which present to the door of a rural emergency room,” Carter said. “We don’t have surgeons or specialists that care for specific patients. In a Critical Access Hospital, the same staff cares for the trauma patients and the stroke patients.”

More than 5,000 Minnesota providers have received CALS training through funding approved by the Minnesota State Legislature. Wisconsin has developed its own statewide CALS courses under the umbrella of the Minnesota-based program. Minnesota trainers have also taught CALS courses in Nebraska, Michigan, Oklahoma, Texas, Missouri, California and Canada. CALS training is provided for medical personnel who staff all the U.S. Embassies, and a pilot program is underway to adapt the U.S. version for Kenya and other developing countries where missionary physicians want to implement it.

Paramedics and EMTs providing integrated care in Maine

Three-year pilot projects under the umbrella of Maine Emergency Medical Services are integrating paramedics and emergency medical technicians (EMTs) into rural public health and medical facilities. Pilot program developer Kevin McGinnis said the projects leverage EMS resources, including EMS mobility and 24/7 availability, to address local health care and public health needs while serving as a practical way to hone little-used EMS skills.

“These projects will augment existing health care programs and enhance EMS practitioners’ skills in areas where low emergency call volumes result in insufficient practice of clinical skills,” McGinnis said. “I see a ripe future for true integration as this proceeds.”

Under project guidelines, licensed paramedics who have taken a college-level community paramedicine course can assist primary care providers. Enabled or enhanced pilot projects are more narrowly scoped to allow EMTs and paramedics to work under a physician’s supervision on specific community projects. Rural communities define the projects. For those projects to be approved, “they must demonstrate integration with community health teams,” McGinnis said.

Maine has long integrated fire and EMS services in rural communities, McGinnis said. EMT-certified firefighters respond to all EMS calls and can provide care such as resuscitation, defibrillation, bleeding control and patient stabilization. Because rural ambulance services may be located in towns 15 to 20 minutes away, the firefighters are often first to arrive at an EMS call.

More progress needed with rural EMS integration

While progress has been made towards integrating rural EMS, the industry still has a long way to go to achieve recommendations made in the 2006 Institute of Medicine* report, The Future of Emergency Care. The report proposed that future EMS efforts focus on emergency health care delivery in a manner that is regionalized, coordinated and accountable, and that those efforts involve EMS working with multiple systems in all arenas, as well as at local, state and federal levels to “enable continuous communication and enhance the benefits of overall system integration, including better and safer patient care.”

Failure to integrate EMS into local systems of care and into regional and national networks is likely to result in ongoing deterioration that further limits availability and access to advanced EMS care in rural and frontier areas, Sanddal asserted. But integration is only one component in the future viability of rural EMS. “We also need to figure out a way to pay for EMS and support it long term,” Sanddal added. “Who is going to take on the planning responsibility for this critical part of our health care system?”

Unfortunately, there doesn’t appear to be an answer to that question. What rural patients can expect in terms of pre-hospital care still depends greatly on where they live.

*In March 2016, the Institute of Medicine changed its name to be the Health and Medicine Division (HMD), National Academies of Sciences, Engineering, and Medicine.

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