New Jersey is in the process of updating the regulations governing Emergency Medical Services. This is long overdue. One key thing is to remove all the clinical medicine from the regulation so it can be changed as fast as medicine changes.
In the past OEMS would publish drafts of changes for comment. But their lawyers have told them they can’t do that. So as an alternative they are having a series of listening sessions, where they can hear our concerns over a variety of topics.
Now we don’t have the actual draft regulations, so nothing is set in stone, but it gave us an idea of the ‘inklings’ or general thoughts of OEMS. I will summarize my notes here.
Again these are just my notes and interpretations, they could be completely wrong and nothing is set in stone.
In attendance was OEMS Director Scot Phelps, Asst. Commissioner of Health Chris Neuworth, and several staff of OEMS. Scot moderated the session.
Ok? Here we go!
Medic Unit Availability
There was an extensive discussion on medic unit availability and response times. There was no consensus. The problem is there is no agreement on how many medic units an area needs. Response time is not an ideal quality marker. Most of us would agree that a 30 minute response time is too long but 3 minutes from an ALS unit for every call is not needed either. It was pointed out that some areas have a very poor response time. I do know that OEMS has been paying attention to this already.
I reiterated my belief that all the ALS recalls are not due to bad dispatch like some think. I pointed out that many EMTs recall medics because of the grief they get for keeping medics on a job instead of recalling them. After which the medics often treat the patient making their position inaccurate. I will say that the EMS Physicians and Medical Directors think ALS should treat more than some medics think they should.
What is Quality?
The problem is we don’t know. Most contracts still use response time which we know matters only for a very small subset of calls. It has been stated by OEMS several times that the concept of ensuring ‘competency’ of providers is critical. And I agree. Agencies should start planning for the expense of this – having staff come in annually to go through skill stations. My agencies in Bucks also use a written test. These help us determine where our training should concentrate.
There was a brief comment that OEMS was going to require SCTU programs to have a hospital ‘affiliation.’ It was asked what this meant and medical oversight was mentioned. They also stated that most programs already have this. I don’t know how accurate that statement is, but I see this as one more time people think of you are affiliated or run by a hospital then the quality is better. I do not feel this is necessarily the case.
The group overwhelmingly begged for regulatory oversight of EMS dispatch centers. There are too many EMS units being dispatched by small police department dispatchers that do not use EMD, may not have any medical training, etc. I agree this is a problem. I anticipate significant regulation and requirements in this area. ACE accreditation was discussed.
Online Medical Command
One section of the new definitions sent to us suggested that it would be required for every refusal of a young child or geriatric patient would require an online medical command call with a physician. I opposed this for several reasons. First there is no evidence based research that this is clinically helpful. It also benefits the hospital based medical direction programs because they have residents in an ER 24/7. Docs like me do not – I could not even take a shower without violating this because who would the crews call? Destination hospitals would not automatically assume this liability, so that’s not an option. Also, even today, medic units calling for command often talk to a nurse, not a doctor – so it could be a problem for them.
The consensus was to not require this at this time.
It was suggested that they would likely follow the CAAS vehicle standards. I know little about these so cannot really comment on them.
First Responder Vehicles
In what I thought was a bit of a bombshell was the statement that OEMS planned to license first responder vehicles as well as ambulances, to ensure proper equipment and oversight. The group quickly realized that this would include every fire department vehicle that does first response in some cities. Would they require a medical director? Documentation standards? I agree with this in concept but I anticipate some push back. That being said Pennsylvania already does this for example – QRS units.
ALS Supervisor Units
There was a brief discussion about allowing medic supervisors (single person unit) to respond to and initiate als care as long as another medic was responding. The group agreed this made sense but also recognized it could be Pandora’s box. What if the responding medic unit was 30 minutes away? What is to stop a project from adding 4 single medic ‘supervisors’?
There was a discussion that OEMS would like to make the individual provider have some shared responsibility for violation of regulations. For example, currently if an EMT does not carry their cards with them, the agency is fined even though the provider made the error. It was also recognized in many cases the fines are too low to deter some agencies. It was discussed that when an ambulance is missing equipment or is unsafe that agencies sometimes pressure the provider to go in service anyway. It seemed OEMS feels the provider should refuse even if this costs them their job. Stand together and if every provider refused the agency would not be able to staff their trucks.
So this is the area I brought up significant concerns. I feel we are at a crisis situation with too few EMT Instructors and the selection process is too long and is flawed. I enjoyed pointing out to the Assistant Commissioner that I as a double board certified (EM & EMS) physician, clinical instructor of emergency medicine at the Sidney Kimmel Medical College of Thomas Jefferson University, with 32 years of experience in emergency services, was NOT qualified to teach the NJ ABC refresher! It was pointed out by a member of the group that if they failed the micro teaching section, they had to wait a year to test again. OEMS staff stated they added an additional session, and this is appreciated, but it does not fix the overal issue.
I pointed out that an immediate fix could be to allow the current reg’s ‘Program Instructor’ who can teach electives, to also be able to teach the ABC refresher, with active medical director oversight.
I think we made our point that this needed a fix now, not waiting for the new regs. It is frustrating that it seems the only people that think the current system is acceptable are the OEMS staff administering it.
While it has been suggested that OEMS may makes maintaining National Registry mandatory in the future for all providers, they seem to be backing away from that. Instead they would keep the current system of using the National Registry for entry but not making people keep it. Someone asked if someone did keep their National Registry could they just use that instead of doing the NJ recertification process. There was some concern that National Registry does not require a skills competency except a sign off by the agency Training Officer.
I would support this because it would alleviate the EMT instructor issue a bit because the ABC refresher would not be required. National Registry has their own CEU requirements.
So this is what I took away from the session. I look forward to seeing the final regs once they come out. Commissioner Neuworth stayed he wanted this out of his division by the end of the year so the rest of DOH could review it hopefully to be in place in 2020.