EMS World

AUG 2018

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22 AUGUST 2018 | EMSWORLD.com COVER REPORT: MEDICINE AND OPERATIONS Some of the fixes would be easy enough, Saussy indicated. But assessing the com- petency of medics was derailed by labor concerns, and simple operational changes such as requiring providers to answer their radios and not just vanish for hours after dropping patients at hospitals found no traction. In this case the problem wasn't resis- tance pushing through advanced chang- es—it was dealing with the most fun- damental operational requirements of running a department. Despite a string of high-profile miscues, the will for major change wasn't there, according to Saussy. "If you don't want to be assessed because you know what the outcome will be, then you just bully and intimidate," she says. "And then you keep on harming people, doing the same thing over and over again. And they tell you, 'Just sign the paper. We can't prove they've taken any tests or are competent, but sign here and attest to it.' And everybody just looks the other way." Saussy came to the District from New Orleans, where she'd preceded Elder as head of New Orleans EMS and guided the system during and after Katrina. Even during those immense trials, she says, the department was supported by government and their colleagues in public safety—"a very different culture and setup," she says. Still, D.C. is just one big-city fire-based EMS ser vice. On the other coast, San Diego's system has a better reputation but has experienced its own problems. "It did have to do with conflicts," says Dunford of stepping down. "There were a number of issues of disagreement, so I thought it was probably time to move on." A pair of those issues came again to the forefront with recent reports from San Diego's grand jury. In May that body released a document reviewing the response to a hepatitis A outbreak that killed 20 last year. Its conclusions: The county should have declared a health emergency more quickly, and the city should have acted more forcefully on sanitation efforts in its impacted homeless communities. But while the report praised the use of vaccina- tion foot teams in remote areas and more than 100,000 people were ultimately vacci- nated, that process was slow to get started. "We knew other EMS systems, includ- ing some in Florida, had rapidly autho- rized their paramedics in regions affected by Hurricane Irma to provide vaccines for hepatitis A," says Dunford. "Here we rec- ommended that for months and months before it actually occurred. And there were a number of findings in terms of communi- cations between the city and county health department, and within the city itself, that reflected things I was feeling quite acutely." A month later, the same body released a postmortem on the city's late Resource Access Program (RAP), a paramedic-based surveillance and case-management sys - tem for superusers. That program ended in 2016 when local ambulance provider AMR wanted to redeploy personnel to traditional crews for staffing purposes. The grand jury urged the mayor and city council to explore ways to "replicate the success and ben- efits" of the program, which it determined saved roughly $543,000 in ambulance transports and ED visits in fiscal 2016–17. "We were one of the community para- medic pilot programs in California, and we were right at the top of the class in being able to show cost savings, and the program ended up getting defunded," says Dunford. "I just really felt like I couldn't communicate effectively to people why they should fund and stick with the program. I found myself kind of isolated from the decision-makers, and I think if they'd really had more clear information and input from myself and oth- ers, the program wouldn't have had to be torn down and rebuilt again." That point about isolation is an impor- tant one. Certain organizational structures can carve medical control docs out of other decision-making entirely. "If you're not at the table in the first place, then all those decisions are going to be made in an operational way," says Neal Richmond, MD, medical director for Texas' MedStar Mobile Healthcare and previously both medical director and CEO of Louisville Metro EMS in Kentucky. "And your average fire chief probably comes in with a much stronger skill set in those areas—staffing, scheduling, all that kind of stuff—than physicians. These, and things like sick leave, FMLA, and separations often become the primary focus—all neccesary but often overshadowing the mission of delivering high-quality patient care." What Operations Wants What a system needs from its medical con- trol doc will vary based on things like the care levels and types it provides and where the doc fits on the org chart. "It's like a community paramedic pro- gram," says Bouthillet. "What looks right to me in 2018 is not going to be the same thing that looks right to a private ambu- lance company or to a municipal versus a county third service. It depends on where you are in your journey." Medical control physicians have respon- sibility for protocols, ensuring provider performance to standards, quality assur- ance/improvement, perhaps training, and ultimately patient outcomes. Those are all clear and measurable metrics that reflect (Illustration: Corrin Pumphrey) There's not a simple answer to mini- mizing the problems that can occur between the clinical and operational interests of modern EMS—both sides are complex and not getting easier.

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