Avoid paramedic PR pitfalls: Make your ED the desired destination
Paramedics have always been an integral part of emergency medicine, but as the primary decision makers regarding the destination of patients picked up by their ambulance service, they are increasingly playing a pivotal role in the financial health of EDs. "Maintaining good relationships with paramedics is good for patient care and good for the bottom line too," says Robert E. Suter, DO, MHA, FACEP, current Chair of the American College of Emergency Physician's (ACEP) Emergency Medical Services section, and Medical Director of the Southfield Fire Department in Southfield, MI.
Although patient preference and geographical location are factors in deciding which ED a patient is brought to, the decision is frequently determined by the EMS crew responding to a 911 call.
"As a general rule, when there is more than one hospital in a service area for an EMS agency, the paramedics have pretty wide latitude over the patient's destination," says Suter. About one out of every five patients insists on going to a specific hospital, he notes. "The others, to a certain extent, are influenced by the EMS providers' recommendations and opinions."
The choices made by paramedics clearly affect ED patient volumes and may also have a significant impact on a hospital's bottom line. "There can be huge swings between the predicted ambulance destination based on market survey and the actual destination," says Suter. "A hospital can do much better or worse than what patient preference would dictate."
Paramedics are often the wild card in that equation and can increase or decrease an ED's ambulance-borne patient volumes. In turn, the number of ambulance-borne patients will affect hospital revenues. "The general rule of thumb is about half of patients brought by ambulance get admitted, and each of those patients will generate revenue in the neighborhood of $14,000 to $15,000 apiece," says Suter. "Having a greater or lesser share of EMS patients arriving that are transported by ambulance can make a big difference to a hospital financially."
Treat pre-hospital personnel with respect
The way in which ED personnel interact with paramedics can swing the pendulum in one direction or the other. All other things being equal, paramedics will opt to go to EDs where the clinical staff make their jobs easier instead of harder. "EMS crews would like to go to a hospital where they feel respected," says Suter.
Consistently respectful treatment can go a long way toward making paramedics feel welcome. "Unfortunately, it's commonplace that paramedics aren't treated with the respect they deserve," says D. W. Pettigrew III, MD, FACEP, Medical Director of the ED and EMS at Athens (GA) Regional Medical Center. "That happens when you haven't built up a trusting relationship."
An integral part of that trust involves listening to paramedics' input on patient care. When a critical patient is brought in for resuscitation, too often paramedics are kept out of the loop, says Suter. "Everyone is completely focused on the patient and the procedures they're performing. Meanwhile, you may have a paramedic standing there with a critical piece of information, and no one's paying attention to [him or her] at all."
The layout of an ED can make it difficult to include paramedics in patient care. "Sometimes if an ED has a small trauma or resuscitation room, the EMS crew literally gets pushed outside and is on the other side of the door, outside looking in," says Suter.
ED physicians and nurses should effectively communicate with paramedics about patient care, says Suter. "The reality is that paramedics are essentially physician extenders, and the physicians have the primary responsibility for the things done in the field, so they should take that responsibility seriously and take some of the onus to have good communication."
The behavior of specific individuals can impact a paramedic's choice of EDs. "To a certain extent, you know who is on duty at the different hospitals, and if at one ED it's someone who is seen as supportive and easy to get along with, you'd tend to want to go there," says Suter. "On the other hand, if at another hospital it's the biggest jerk on the staff, you would probably want to avoid them if possible."
Athens Regional's ED has taken several steps to make paramedics comfortable. "We've done several things to facilitate paramedics coming to our hospitals," says Pettigrew. "We've made a work station for them with access to phones and fax machines, we have a place where they can sit down and relax, and coffee and snacks are available."
The efforts have had a positive impact on paramedics' morale. "It helps them to feel welcome when they come here, and we want to create that kind of environment because they're part of the health care team," says Pettigrew.
Paramedic liaison is an asset
Some managers find it helps to have a person on staff to act as a liaison between the ED staff and paramedics. "If an ED uses a nurse manager as a contact person, and there's a problem with a nurse, there may or may not be some defensiveness, likewise with a physician," says Suter. "But if you have an EMS coordinator, that person can be sort of an ombudsman and facilitate understanding and communication between the EMS personnel and the hospital personnel."
At Loma Linda University Medical Center's ED, a paramedic liaison has helped to maintain a good rapport with local paramedics. In recent years, the position has expanded to include education efforts and stress debriefing for paramedics. "Three years ago, the PR between prehospital agencies and the ED staff was rumored to be not good, but our relationships with all the agencies has improved dramatically," says Carerie Kozak, NR, BSN, CEN, the ED's paramedic liaison.
In the event of a death in the field, paramedics were often frustrated because they had no resources to help grieving family members. Paramedics are now given a "support list" with contact information for more than a dozen support groups to help families deal with the loss of an infant, child, or adult, as well as deaths from AIDS or suicide. The list also includes phone numbers for crisis hotlines and recommended books and videos to help both parents and children cope with the aftermath of grief.
On-site educational seminars at the headquarters of local agencies is another key aspect of the liaison's role. "Instead of them coming to us all the time for information, I'll go to a local fire department and help with their QI or AMA documentation," says Kozak. A lecture on child mistreatment was recently given in collaboration with the Emergency Nurses Association.
When an especially traumatic event occurs in the field, paramedics are debriefed by the liaison within 24 hours. "After a bad case, I usually talk to them right away when they bring the patient into the department," says Kozak. "If that's not possible, I'll go out to the agency or station soon afterward."
The ED's charge nurses are trained to debrief when the liaison is not on duty. Staff are certified with an in-house training program, which gives specific guidelines for debriefing. "Although some agencies occasionally debrief paramedics, they don't always follow up on it, so we make sure that we do" says Kozak.
Recently, paramedics in the field were unsuccessful in their attempt to resuscitate a patient using advanced airway methods. "That was a very traumatic situation for them, so we debriefed them after the incident," says Kozak. Other incidents that may require debriefing include critically injured family members or friends of paramedics, or pediatric trauma patients. "With children, it's a little harder to deal with because it somehow hits home more, especially if people have kids," says Kozak.
Here are several ways to maintain good relationships with local paramedics:
• Establish a comprehensive EMS outreach program. Both patients and ED staff can benefit from educational efforts directed toward paramedics. "We have a paramedic educator who provides support to several different agencies in the area," says Suter.
Respect paramedics' time. Realize that EMS crews don’t have much time to spend on any one call, so they need to be in and out of the ED quickly. "The agencies are putting more pressure on their crews to reduce turnaround time in hospitals, so if too much of their time is taken up, they could get in trouble with their supervisors," says Suter. "Ambulance companies and fire departments are tracking the time of calls more than they used to, so people get in trouble for spending an hour in an ED."
• Have a paramedic "lounge" area. A separate area for paramedic crews to do paperwork, make phone calls, and refresh themselves is helpful. "It's always nice to have coffee, sodas, and even food for crews when they come in because they may be running from call to call without an opportunity to take any sort of break, so that would be greatly appreciated," says Suter.
The area should ideally be both functional and pleasant. "We have a paramedic lounge with a couch, a desk where they can sit and write up their rounds, a phone so they can call dispatch, a corkboard which posts current educational offerings, a bathroom, pictures of the paramedics and the MICNs they talk to, and a stocked refrigerator," says Kozak. "It's a nice area for them to take care of business, and we can talk to them at that point if there are any issues we need to discuss," A slush fund is allocated for the purchase of refreshments for paramedics.
• Hire local paramedics as ED employees. Some managers have brought paramedics on board as part of the ED staff. "Hospitals that value paramedics enough to employ them makes a statement to the crewthat this hospital institutionally values what we know and can do," says Suter.
• Develop a ride-along program for ED clinical staff. Many EDs arrange for physicians and nurses to accompany local EMS agencies for a shift or two. "That way, the ED staff has more of an appreciation of the challenges in the field and sees things from the EMS perspective, so they will understand why they might not be able to answer right away when they get a call from the hospital," says Suter. "It's always well received by the EMS crew, and the nurses and doctors who do it tend to enjoy it also."
• Don't make getting supplies an obstacle. EDs that make basic restocking an obstacle course for paramedics are making a mistake. (See related story on supply storage.) "On the one hand, you don't want to have a crew restock their ambulance from their last ten calls from your ED, but at the same time some people have made it almost impossible to restock, which causes a real problem for the crews," says Suter. "That's not a place they'll go out of their way to go to."
[Editor's Note: Loma Linda University Medical Center offers consultations, speaker services, and literature on establishing bereavement programs. For more information, call (909) 824-0800 ext. 48406.]
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