Disclaimer: I appologize for the format of the text as this is one of my first blog entires with this interface, and for some reason it and Word didn't want to play nicely. I tried to fix it up best I can. Future posts will not have this problem.
It’s interesting that Dr. Barnett picked a topic in the previous blog that is so near and dear to my heart. Rather than post a comment, I decided to create a new entry, because it’s going to be lengthy in nature, and I would like to see separate comments and feedback. Why, might you ask? Well, I’m a true believer in EMS, and in the ability of providers to bring quality basic and advanced pre-hospital care to the public.
Throughout the fifty states and assorted territories, each individual EMS system needs to adapt to specific needs of the community. It is not a “one size fits all” system. Some states have system wide mandates whereas others leave it to each individual organization or municipality to decide on how they are going to operate their EMS system. All must operate within their regulations, but some allow for more self rule than others. With this, I am going to go a little more into detail on the “chase” system in New Jersey and how we differ and compare to other systems that are run through the country.
I believe our system is “unique”, and, dare I say BETTER in some ways, while antiquated in others. To understand EMS in New Jersey, we need to look way back in the past to when the EMS system in New Jersey was conceived. Since we are focusing on southern New Jersey (which for those not from this area, is COMPLETELY different from the north), I am going to use references and examples from this region to simplify things. The Office of Emergency Services (OEMS) was created in 1967, and was charged with the task of creating standards as well as regulations regarding pre-hospital care. At this time, calling pre-hospital care basic life support was a stretch at most. Certifications evolved, and we went from the 5 points certification, to EMT. Now, we must not forget that OEMS was not the only “organization” that had an interest in EMS in New Jersey at this time. Back then, EMS was run completely by volunteers that would pick up the ambulance and race to the call from home when the air siren blasted, or the old Plextron would alert. The New Jersey First Aid Council (NJFAC) , which even today exists as a private organization, was a place where volunteer ambulance squads could join to share ideas, support each other, and come together to lobby for a specific cause: volunteer EMS in the state. Back then, EMS was run 100% by volunteers.
Things, however, began to change. Up to this point, there was NO ALS in the state. I’m a little rusty on specific dates, but ALS didn’t evolve in NJ until the mid to late 1970’s; do we all remember “Emergency!”? New Jersey’s Department of Health wrote regulations which allowed for advanced pre-hospital care, but it was set up with a rather unique frame work. ALS could ONLY be provided through a hospital system, not by local EMS agencies. Also, in order to provide ALS care to a specific area, a hospital system that was interested in providing these services had to submit a formal request to OEMS in order to be awarded a Certificate of Need (CN). This CN would authorize a hospital system to provide ALS care within a specific geographical region, usually one or more counties. In the southern most counties, Camden, Burlington, Gloucester, Cumberland, Salem, Atlantic and Cape May, there were three main sources of ALS care, provided by three hospital systems: West Jersey, Underwood and Burlington Memorial. This CN system still exists to this day. A CN may be taken away and re-awarded if it is proven by a challenging agency that their area is being underserved by the current provider. Regulations that governed ALS care were written so that a two tiered system was created, which would allow for local volunteer ambulances to transport the patient, while the ALS unit would intercept the ambulance if advanced care was needed. There were wivers created which allowed for some systems, particularly up north, such a UMDNJ and Jersey City, as well as a few others, to provide ALS transport-capable ambulances. But they were the exception.
The MAIN reason a chase system was created was due to the local volunteer squads as well as the NJFAC. They didn’t want “outside people” to come in, transport “their” patients to the hospital, and illegitimize their existences. These volunteer organizations felt extremely threatened, and lobbied to the state so that they could maintain their local control, while allowing ALS intercept vehicles to come into the mix if needed. Added to this was a lack of ALS providers, as well as long transport distances which didn’t allow for paramedics to accompany every patient to the hospital.
Fast forward to today. We now have more ALS units (or less depending on where you live), more advanced scopes of practice, as well as more aggressive protocols. Some areas fared better than others financially, and those that were able to keep their heads above water, expanded their services and took over those that weren’t able to compete. In the beginning, ALS care was very profitable. Even though the volunteer squads wouldn’t charge for services, the hospitals would. All was well and dandy up to the point that Medicare started to reform its billing regulations.
Now keep in mind, New Jersey is NOT the only state that runs a completely tiered ALS system. WHAT!? Yes, it’s true. Some might call shenanigans on this, but it’s true. Our neighbor to the south, Delaware, has the EXACT same system that we do. They run a regionally based ALS system, chase vehicles with two paramedics that would intercept a BLS ambulance to provide ALS care. The main difference between the two states is that rather than being mandated to be hospital based such as we are, Delaware ALS is completely run by county governments. Granted, Delaware only has three counties, but it’s still a regionally based, tiered ALS system with extremely high quality of care, and run with great efficiency. Not to mention their volunteer and paid BLS agencies are all held to the same standard. (Can’t say the same about NJ!) There’s a reason I bring Delaware into the mix. You’ll see in a bit.
Medicare reformed its billing practices, and stated that only one agency is allowed to bill for services. Now, these ALS agencies have to contract with local squads, in order to bill for services through them. For example, let’s say an ALS ride to the hospital would cost $1,000, but the BLS agency bills for services which costs $500. The ALS agency has to submit their bill through the BLS agency, and spilt the difference in cost. So now the ALS and BLS agency both get $500. This is not very profitable if you have a low call volume. If the BLS agency doesn’t bill for services, then the ALS agency can send the bill directly to the insurance company, and get the full amount without having to share anything. Why do I bring this up? Because with this system in place, hospitals were unable to support their ALS services, and many were gobbled up by larger systems. My point is that hospitals aren’t able to maintain ALS coverage due to expanding populations without losing profitability, since they would have to staff more units, without being reimbursed their full amount to break even.
New Jersey brags that the state is 100% ALS covered, but what they fail to tell you is that it’s not 100%, 100% of the time. All too often, citizens go without ALS care, because there are no ALS units available. On a positive side, I feel that the tiered system is the way we should provide services in this state; however, I feel that ALS coverage needs to be expanded so that there are fewer gaps in coverage due to increased demand. The consensus on response times is that you should have BLS level care within 8 minutes or less, 90% of the time, and ALS care within 12 minutes or less, 90% of the time. While there are no regulations or laws that state this, it stands as a general consensus throughout the country. Now, working as a paramedic in New Jersey, I can say that the agency I work for is able to meet the 12 minute mark, 90% of the time. I can’t say the same, however, for BLS. There are countless times where I have sat on location, waiting for an ambulance for 20, 30, even 40 minutes at a time. Unacceptable. Many would argue that if paramedics were staffed in ambulances, we wouldn’t have this problem. True, but if agencies were regulated and mandated to meet minimum response time criteria, we wouldn’t even have this discussion. But that’s a different blog….
Still, one asks, why a tiered system? Simple; all one has to do is compare the amount of sick people, critical skills that are needed, and the amount of providers there are to provide these advanced interventions. Let me bring this more into perspective. Only about 3 – 5% of 9-1-1 calls for medical emergencies are actually life threatening in nature. Wouldn’t it make sense to have a proportional amount of people that can treat life threatening situations to the demand that actually exists? It doesn’t make sense to have a paramedic on every ambulance. Here’s another example. Let’s say that there are 1,000 highly invasive skills that are going to be performed within one year. If we had more ALS providers, say 26,000(roughly the amount of EMT’s in NJ), the chance that a good majority would encounter one of those 1,000 skills is highly unlikely. Now, let’s say we have 1,700 ALS providers (roughly the amount of paramedics in NJ). The likelihood that they are going to encounter one of these skills increases dramatically. Because we have a higher exposure to only extremely sick and critical patients, we are able to maintain our skills and a much higher clinical standard.
As a paramedic in New Jersey, I do notr respond to every broken bone, stubbed toe, cough, cold and tooth ache. We also have lower staff injury rates due to the fact that we don’t typically operate stretchers or other carrying equipment, and we are able to keep highly experienced medics because they are able to work longer due to lack of injury. I get sent to only life threatening emergencies when deemed appropriate. Everything else warrants only a BLS response. If BLS arrives on location and judges that we are required, they request our services, and we arrive on location typically within the 12 minute window. Here’s another interesting perspective. Some people actually come to work in NJ as paramedics from other states with single level response systems, in order to maintain their ALS skills. In their previous systems, they get sent to more basic, non life threatening calls, and have a lack of exposure to highly invasive procedures. How comfortable would you feel if you or your family member was being treated by such a medic? Would you want a medic that only does 1 or 2 intubations a year intubating you? Or would you want someone that quite literally may do several a week? It’s a no-brainer. Because we have such a high exposure, we are able to perform much more aggressive and invasive procedures. Remember I mentioned Delaware way back? That’s because they have the same tiered system we do with similar competencies and skills. And you know what, we have comparable success rates in high risk, low frequency procedures. Both New Jersey and Delaware prove that a tiered system works where appropriately applicable. Over-saturation of ALS providers is unnecessary; we must not have our skills be watered down. We merely need to have enough ALS providers to provide complete coverage within twelve minutes, ninety percent of the time, to calls where we are specifically required.
As for the legislation that is working its way through the Senate at this time, it would allow for a much needed overhaul of the system. Yes, there were provisions that were removed because of the lobbying from the NJFAC, but those things can be tackled at a later point in time. Personally, I don’t care about the training fund. Leave it for the volunteers. I paid my way through paramedic school, as well as additional certifications and higher education and certainly don’t miss the training fund. As for the two EMT standard, that’s ok as well. It’s better than NO EMT at all which seems to be the status quo for volunteer squads. As of right now, only BLS services that are licensed by OEMS are required to have two EMTs. Those that are not licensed do not have to have ANY EMTs. And no, as of today, there is no law or regulation that requires a BLS agency in the State of New Jersey to be licensed by OEMS. They basically regulate themselves, and do as they please. This piece of legislation would thankfully change that. In regards to EMT education, right now the Department of Health is revamping the way in which EMTs are trained in NJ, including the amount of classroom time and clinical hours required for testing. I agree with many of the responses to the previous post, that education standards need to increase, as well as minimum number of exposure hours to field and clinical settings. This too will get a future blog.
I found the comments regarding emergent mode of transport to a receiving hospital rather amusing. Personally, I only transport to the hospital with lights and sirens about 5 – 10% of the time. Unless the patient is next to death’s door, or needed to be in the hospital “yesterday”, they get no lights. With that, I believe BLS transport should ONLY be no lights or sirens, unless the patient deteriorates, or there is an immediate threat to the crew due to a combative patient, for which you should have a police officer present anyway. I once told an EMT that was transporting us to the hospital to use no lights and sirens. Her response “We don’t do that. It’s our policy, all patients get lights and sirens.” And so I replied “Too bad, no lights.” I’m not endangering my life for a stable patient, whom I can easily manage, by going lights and sirens for no reason at all. My agency encourages this position as well. Ok, this was long enough. I hope I was able to enlighten a few people about our lovely system (note the sarcasm), the pros, the cons, and the direction that our state is headed.
Comments and suggestions are encouraged. Future entries to come.