Letter from Tricia Hunter outlining topics of discussion related to the Community Paramedicine project.
On April 9th I will be attending the hearing about Community Paramedicine. I am working with other
organizations to cover all the issues. Below is a summary of some of the issue we will be responding
too.
There is no assurance that the project would protect patient safety as:
a. The only provision listed under patient safety is a retrospective review, meaning nothing is
there prospectively to protect the patient
b. CalEMSA is in its infancy in collecting data – there is a bill before the legislature this year
that compels LEMSAs to provide core measure data to the state. CalEMSA only just
began collecting this data this year and is moving enabling legislation. So we don’t
believe either the LEMSAs or CalEMSA have the systems or personnel to do the
complex data collection and analysis required for even the retrospective review.
c. The data they are proposing to collect is all process data – as in, did they give aspirin to a
patient with chest pain? Not outcomes data, like did this patient with pneumonia sent to
the urgent care do as well as the patient who went to the ER?
3. The regs 22 CCR § 92006 define an instructor for the purposes of the pilot project as someone with the
credentials/license to perform the duties they are teaching. The Licensed Clinical Social Worker scope is
defined here Business and Professions Code § 4996.9. The Public Health Nurse Scope of Practice is
defined here: Business and Professions Code § 2818(a), None of the UCLA Center for Prehospital Care
faculty are Public Health Nurses or Licensed Clinical Social Workers, so they do not have the credentials
or license to instruct the proposed expanded scope.
4. The application provides no proof there is any need for the program (see 22 CCR §92303 (a)) – the
information provided in Appendix A, titled as “Needs Assessment Reports” is only general industryspecific information about Community Paramedicine. There is nothing in the application that gives
specific data about why pilot sites chose the projects and scopes they chose – nothing that says, for
example, in Orange County, there are xx number of identified “frequent 911 callers” who have called 911
xx times in the past year, and have accrued $xx in medical costs.
5. Supervision is scanty at best. Two Site Supervisors per pilot site, who themselves have no educational or
clinical background in the new scope, would be responsible for supervision and data collection, including
100% chart review. It’s clear they could not really directly supervise the Community Paramedics.
6. The curriculum provided is in bullet point form only – there is no detail about how much time would be
devoted to each topic and the topics themselves are broad enough that entire semesters are dedicated to
them in degree programs. The local curriculum, which would have the nuts and bolts of how each site
would operate (triage protocols, patient selection/exclusion criteria, actual tasks to be performed and
under what circumstances) is not provided. This is required under 22 CCR § 92306.
7. The objectives of the program - to "demonstrate that Paramedics can safely and effectively work in
expanded roles in a community-based healthcare system to improve health care efficacy, cost
effectiveness, patient-centered care, and integration of health system resources by reducing unnecessary
ambulance transports to emergency departments and hospital readmissions,” cannot be met because
patients present to the Emergency Department for the following reasons (Gindi RM, Cohen RA, Kirzinger
WK. Emergency room use among adults aged 18-64: Early release of estimates from the National
Health Interview Survey, January-June 2011. National Center for Health Statistics. May 2012. Available
from: http://www.cdc.gov/nchs/nhis/releases.htm):
a. “Only a hospital could help” (54.5%) – CP will not improve this – some people just need to
be seen in the ER – those with chest pain, some seizures, and wounds, fractures, and
dislocations that require moderate sedation.
b. “My doctors office was closed” (48%) – CP cannot make doctors offices, FQHC, clinics or
urgent cares remain open in the evenings and on weekends.
c. “There was no other place to go” – filling out a form to apply for MediCal or Covered
California will not take care of a wheezing child, nor will it make the up to three month
wait for appointments at some clinics shorter.
Community Paramedicine cannot improve the factors that lead to lower acuity ER visits, therefore it
cannot meet its own stated objectives.
8. We are concerned that a patient who has a reasonable belief that they have a medical emergency (called
the “prudent layperson” standard under CMS regs) would be considered by the court to have, in essence,
“presented” to an ER (Carolina Morales v. Sociedad Espanola de Auxilio Mutuo y Beneficencia (Morales),
1st Circuit Court of Appeals), and therefore would be entitled to a Medical Screening Exam and stablizing
treatment. In order for a non-physician to perform a medical screening exam, they must be delegated to
do so in the hospital rules and regulations or bylaws, and must be approved by the hospital’s governing
board (CMS regs). We don’t think these provisions have been made by hospitals (at least there is no
proof this has been done) and we are concerned about hospital and ambulance/fire legal liability in
diverting these patients away from an ER to a lower level of care.
9. Patient dumping allegations (including one that led to a patient death) have arisen in the past in some of
the pilot site areas, and we are concerned that patient diversion away from a private ER may be a form of
patient dumping from private facility to publicly-funded clinic. We are also concerned that there may be
an incentive for CPs to divert lower income patients from ERs while the insured patients get ER
care. This could be another form of two-tier medical care: that is, the lower income, uninsured patients
will be discouraged from accessing the ER.
10. Studies found in the application itself claim a 3-34% undertriage rate in Paramedics who determine
whether or not an ER visit is necessary. In one study , (Silvestri S, Rothrock SB, Kennedy D, et al. Can
paramedics accuartely identify patients who do not require emergency department care? Prehosp Emerg
Care. 2002;6:387-390.) out of 313 patients, "Paramedics thought ED transport was unnecessary in 85
cases; of these, 27 patients (32%) met criteria for ED treatment, including 15 who were admitted and 5
who were admitted to an ICU."
Honorable Tricia Hunter, RN, MN
Executive Director and Lobbyist
ANA\Ca
1121 L Street Suite 508
Sacramento, CA 95814
Cell 916- 837 -1620
Office 916-447-0225
thunter930@aol.com