EXPANDING EMS: GOING BEYOND THE “E” IN EMS
BY GORDON M. SACHS
More and more fire departments are going beyond basic emergency medical services (EMS) to provide out-of-hospital medical services. These services range from simple interagency referrals to complex mobile medicine programs. Many services require that advanced life support (ALS) providers–paramedics–receive additional training to expand their scope of practice. This expanded scope must be practiced under a licensed physician (just like ALS care is) and must conform with applicable local and state regulations.
In the simplest form, the fire service`s role in out-of-hospital medical services is a referral to the proper “authorities” for a nonemergency patient who is in need of specialized attention. The fire service has done this for years with nonmedical issues: referring broken water mains to the public works department, for example. Medical referrals typically are to another public agency, such as social services or a public health clinic, but they also can be to specialized medical facilities and medical specialists. This eliminates the need for all patients to go automatically to the local emergency department and reduces overall health-care costs. This type of medical referral is sometimes called “pathway management.”
STARTING SMALL
Not all out-of-hospital medical programs involve emergency response. In fact, the point of this concept is to reduce the number of emergencies and emergency department visits. A good start to this type of effort is the initiation of a community-based prevention/education program. Fire departments that have public fire education programs will have no trouble expanding into this area; the only change is the program`s content. Many departments already provide “fire and life safety education” programs or “injury prevention and fire safety” programs. Even the applicable National Fire Academy courses now cover more than just public fire education, including the “Strategic Analysis of Community Risk Reduction” and “Developing Fire and Life Safety Strategies” courses.
Some of the areas that community-based prevention/education programs can cover include the following: home safety/babysitters, alcohol/drug/violence, first aid/bystander care, citizen CPR, water safety/drowning prevention, boating/personal watercraft safety, poison prevention, child passenger safety, and general wellness/nutrition.
Another successful effort on the part of many fire departments is a community wellness program. This is usually an interagency partnership with the public health agency and involves providing immunizations and wellness screenings for citizens (usually children). Fire stations, schools, and churches often are used for this program because citizens consider these buildings familiar and nonthreatening.
As part of community wellness, some fire departments are even remodeling their facilities to include neighborhood clinics in their fire stations. These are often staffed during specified hours with a public health nurse and/or physician, but the on-duty crews from the stations often help with patient histories and assessments during clinic hours and are always available for “walk-ins” and 911 calls.
EMPHASIZING THE “M” IN EMS
Some fire departments are branching out into mobile health care. Using nonemergency mobile health-care units, the departments work with local medical facilities to provide nonemergency medical services. In some programs, mobile health-care units are dispatched to 911 calls that are, on screening, determined to be nonemergencies. In other programs, the units are more contract-service oriented, taking the place of the occupational health nurse at an industrial site. The mobile health-care unit can regularly visit several sites per day for routine services and prevention/education and can do follow-up care such as suture removal and wound care to minimize an employee`s time away from work.
A mobile health-care unit can also stand by at a rally or sporting event. Personnel on this unit are typically fully trained paramedics, so having one or more transport units out of service for what are typically minor injuries/illnesses that can be treated on the scene becomes unnecessary. These personnel can receive extra training in sports medicine if their duties include regular stand-bys at sporting events. Often, the home team`s physician will provide this training free of charge.
Mobile health-care units also have the ability to provide home health-care services. This is a very profitable venture for many hospitals but also could be an excellent “revenue-generating” venture for a fire department interested in a public-private or interagency partnership. Home health care typically involves in-home follow-ups of injuries and illnesses, hospital discharge follow-up visits (usually after surgery), and “in-plan” follow-ups (suture removals, for example) for people in a specific managed-care organization.
FUTURE SCOPES OF PRACTICE
The future of emergency response and nonemergency medical response is wide open. While much of the expanded scope of practice deals with nonemergency, out-of-hospital care, how can expanding the scope of out-of-hospital emergency medical services help reduce emergency department visits and health-care costs in general?
Just as firefighting is advancing through high-tech outreach and imagery, so is EMS. In health-care systems outside this country, EMS units carry portable X-ray machines, MRI/scanners, and gas chromatography equipment. EMS providers are trained to use this equipment or have an appropriate technician onboard. These EMS units have the capability to communicate the images from these machines to a medical facility. Why is this important? If the majority of sprains/ strains could be treated at home or in a clinic rather than the emergency department, there would be a significant drop in the number of emergency department patients.
Another option is to train ALS personnel to do limited suturing in the field, along with administering the necessary tetanus vaccinations when necessary. Strict guidelines would have to be established on the size and location of the wound that could be treated, but the capability for providing the necessary training and equipment is there, and the health-care cost savings would be significant.
In many areas, fire service EMS personnel have part-time jobs in the emergency departments of local hospitals or in specialized medical facilities. Making this a standard arrangement could be a valuable resource for any fire department. Such an arrangement provides the hospital with trained staff, the fire department with more experienced EMS providers, and the public with better opportunities for medical care. The possibility of expanding this into an interagency contractual arrangement for providing out-of-hospital services is more likely if the hospital knows the personnel involved, their training level, and the department`s commitment to the program.
The health-care industry is changing as fast as the fire service, and the changes are affecting the way the fire service does business. Fire service EMS is being affected by issues such as managed care, pathway management, preventive medicine initiatives, privatization and public-private partnerships, demand for life safety education programs, and various regulatory changes. The fire service can continue to be affected by these changes or can recognize them and take steps to become “change agents.”
The best way to address these changes is to identify the key health-care players in the community and meet with them. Find out where they anticipate out-of-hospital health care is going and what the fire service can do to help it get there. This is a change for the fire service–asking what we can do for the health-care community rather than expecting it to meet our century-old needs. What could result is that the fire service`s needs are met, and perhaps even exceeded, by having some powerful new allies. And, interestingly, the medical community has one of the most powerful political voices in the country.
A hidden agenda? Perhaps. Survival? Probably. Better service for the community? Definitely. That`s the most important aspect of going beyond the “E” in EMS. n
GORDON M. SACHS is chief of training and safety with Marion County (FL) Fire-Rescue. He has more than 19 years of fire and EMS experience in both the career and volunteer services. In addition to many journal articles and U.S. Fire Administration publications, Sachs wrote the EMS chapter in The Fire Chief`s Handbook, Fifth Edition (Fire Engineering Books, 1995). He is a National Fire Academy instructor in both EMS management and health and safety. Sachs currently chairs the Florida State Fire College EMS Management Curriculum Advisory Committee and is a member of the Fire Engineering editorial advisory board.
