Re: EMS PERSONNEL STAFFING IN ER

March 9, 2000

i could be wrong..but at least my understanding of regs and stuff...the nurse

has to be the triage. we as medics could screen a patient but the nurse had

to actually triage them. my 2 cents.

amy

March 9, 2000

In a message dated 3/9/00 10:44:19 PM Central Standard Time,

RomanasTAF@... writes:

<< i could be wrong..but at least my understanding of regs and stuff...the

nurse

has to be the triage. we as medics could screen a patient but the nurse had

to actually triage them. my 2 cents.

amy >>

I am no expert in this area but I worked at Baylor Medical Center-Grapevine

for 2 years in the ER and this was the way triage was handled there. I was

told it was a JACHO requirement.

March 10, 2000

I know that Rio Grande Regoinal hospital in Mc Tx. uses paramedics in

their E.R. you could probably contact them to find out how and what capacity

they are used.

EMS PERSONNEL STAFFING IN ER

>A question for the group.

>

>Is there anything that says that EMS personnel instead of nursing personnel

>(RNs) can triage and care for patients in an ER department as long as

medical

>staff says it is ok and not have an RN there at all. Our hospital is

wanting

>the EMS department to manage the ER instead of Nursing. We are know that

an

>RN must Cosign the EMS personnel assessment but we heard that an RN must

>triage patient in order to receive Medicare reimbursements. Please help.

>

>thanks

>Jeriami St.Clair

>Anson Gen Hospital EMS

>

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March 10, 2000

Jeriami:

It depends on the exact specs of the Nurse Practice Act in your state. Here

in Texas there would be a problem with that idea because hospital assessment

of patients, such as triage is defined as a nursing function. A paramedic

could probably do an initial triage assessment, but a nurse is going to have

to follow that up with his or her own assessment for all to be on the up and

up. As I said the other day, paramedics' roles in the ER should not be to

replace nurses. It should be to augment them by providing a true emergency

and acute patient specialist with similar medical skills who can work in a

complimentary fashion with the nurses. There are things nurses in this

setting will do better and things the paramedic will do better. The sum of

their efforts is what improves the quality of an ER. There are other

delegation of practice issues that you may grapple with if your paramedics

are not being directly supervised by the ER docs.

Dave

EMS PERSONNEL STAFFING IN ER

> A question for the group.

>

> Is there anything that says that EMS personnel instead of nursing

personnel

> (RNs) can triage and care for patients in an ER department as long as

medical

> staff says it is ok and not have an RN there at all. Our hospital is

wanting

> the EMS department to manage the ER instead of Nursing. We are know that

an

> RN must Cosign the EMS personnel assessment but we heard that an RN must

> triage patient in order to receive Medicare reimbursements. Please help.

>

> thanks

> Jeriami St.Clair

> Anson Gen Hospital EMS

>

> ------------------------------------------------------------------------

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March 10, 2000

As far as I know, an RN must be in overall charge of the ER and must provide

the triage for incoming patients. I believe this is tied up in the

Trauma Level certification that the hospital recieves, as well as with

Medicare.

Jeanne E. Amis, RN, EMT-P

Education Director

Marfa City/County EMS

MEDICSnTX@... wrote:

A question for the group.

Is there anything that says that EMS personnel instead of nursing personnel

(RNs) can triage and care for patients in an ER department as long

as medical

staff says it is ok and not have an RN there at all. Our hospital

is wanting

the EMS department to manage the ER instead of Nursing. We are

know that an

RN must Cosign the EMS personnel assessment but we heard that an RN

must

triage patient in order to receive Medicare reimbursements.

Please help.

thanks

Jeriami St.Clair

Anson Gen Hospital EMS

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March 10, 2000

Ms.Amis is correct. For any sized hospital to be designated as a trauma center,from level 4-l,an RN must do triage. EMS personnel may be used in the ER but they may only perform within the limits stated by the hospital (ie job description) Usually, they can't do triage, can't pass meds (unless in a code), and in larger hospitals, do a lot of patient transfers from the ER to the floors. Unfortunatly, EMS personnel usually can't perform to their max due to hospital rules, medicare/medicade rules, and scared hospital lawyers. What a shame. Thanks. Jerry Woods

Re: EMS PERSONNEL STAFFING IN ERAs far as I know, an RN must be in overall charge of the ER and must provide the triage for incoming patients. I believe this is tied up in the Trauma Level certification that the hospital recieves, as well as with Medicare. Jeanne E. Amis, RN, EMT-P Education Director Marfa City/County EMS MEDICSnTX@... wrote: A question for the group. Is there anything that says that EMS personnel instead of nursing personnel (RNs) can triage and care for patients in an ER department as long as medical staff says it is ok and not have an RN there at all. Our hospital is wanting the EMS department to manage the ER instead of Nursing. We are know that an RN must Cosign the EMS personnel assessment but we heard that an RN must triage patient in order to receive Medicare reimbursements. Please help. thanks Jeriami St.Clair Anson Gen Hospital EMS ------------------------------------------------------------------------ Go to Findlaw.com and get your FREE FLEECE from FindLaw. FindLaw is the Internet's best destination for free legal information! Take advantage of this offer and go to Findlaw.com now! http://click./1/1827/3/_/4981/_/952650875/ -- Talk to your group with your own voice! -- /VoiceChatPage?listName= & m=1

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March 10, 2000

but correct me if im am wrong, if directed to do something (as long as your trained to do it) whether under the direction of the RN above you or by the physician, arent you still allowed to do that? if the job descriptions say for example start iv's, draw blood, and some other things that are skill level for a medic, and then as part of his training through the facility that he works for he is also trained to admister certain drugs under the direction of the staff (RN or MD), or protocols can that paramedic still do that? I worked for a small doctors office as a medic but with the title of Office Trained Nurse, and was given the same responsiblies as the LVN's and RN's that worked there, plus duties in the lab drawing blood and some other duties. I fell under the direction of the MD while I was working and if he told me that pt in room #1 needed allergy shot for the week it was my duty to get it done? So guess the bottom line is this at what point can a paramedic not use the skills in ER?

Thanks for taking the time to answer this

Randy EMTP

emt@...

Re: EMS PERSONNEL STAFFING IN ERAs far as I know, an RN must be in overall charge of the ER and must provide the triage for incoming patients. I believe this is tied up in the Trauma Level certification that the hospital recieves, as well as with Medicare. Jeanne E. Amis, RN, EMT-P Education Director Marfa City/County EMS MEDICSnTX@... wrote: A question for the group. Is there anything that says that EMS personnel instead of nursing personnel (RNs) can triage and care for patients in an ER department as long as medical staff says it is ok and not have an RN there at all. Our hospital is wanting the EMS department to manage the ER instead of Nursing. We are know that an RN must Cosign the EMS personnel assessment but we heard that an RN must triage patient in order to receive Medicare reimbursements. Please help. thanks Jeriami St.Clair Anson Gen Hospital EMS ------------------------------------------------------------------------ Go to Findlaw.com and get your FREE FLEECE from FindLaw. FindLaw is the Internet's best destination for free legal information! Take advantage of this offer and go to Findlaw.com now! http://click./1/1827/3/_/4981/_/952650875/ -- Talk to your group with your own voice! -- /VoiceChatPage?listName= & m=1

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March 10, 2000

Mr. Dees. It is an unfortunate thing that EMS personnel are usually not allowed to do what they are trained to do in an ER. Again, it comes down to legal ramifications, not what the ER head MD chooses to let his EMS personnel do. So many small hospitals in Texas use contract physicians to staff their

ER's .and these physicians have no input whatsoever as to the staffing of the hospital. Point is; generally speaking, EMS personell in ER's are relegated to " ER Tech " positions. Lets's remember that EMS people are trained to work the streets, not hospials. Again, it's amatter of legality,medicade/medicare/patient care provider networks. When the US of A finally gets its act together and establishes a nation-wide system of health-care, then,and only then, will we in EMS see a system which allows us to practice our trade on and off the street. Thanks.

Re: EMS PERSONNEL STAFFING IN ER

but correct me if im am wrong, if directed to do something (as long as your trained to do it) whether under the direction of the RN above you or by the physician, arent you still allowed to do that? if the job descriptions say for example start iv's, draw blood, and some other things that are skill level for a medic, and then as part of his training through the facility that he works for he is also trained to admister certain drugs under the direction of the staff (RN or MD), or protocols can that paramedic still do that? I worked for a small doctors office as a medic but with the title of Office Trained Nurse, and was given the same responsiblies as the LVN's and RN's that worked there, plus duties in the lab drawing blood and some other duties. I fell under the direction of the MD while I was working and if he told me that pt in room #1 needed allergy shot for the week it was my duty to get it done? So guess the bottom line is this at what point can a paramedic not use the skills in ER?

Thanks for taking the time to answer this

Randy EMTP

emt@...

Re: EMS PERSONNEL STAFFING IN ERAs far as I know, an RN must be in overall charge of the ER and must provide the triage for incoming patients. I believe this is tied up in the Trauma Level certification that the hospital recieves, as well as with Medicare. Jeanne E. Amis, RN, EMT-P Education Director Marfa City/County EMS MEDICSnTX@... wrote: A question for the group. Is there anything that says that EMS personnel instead of nursing personnel (RNs) can triage and care for patients in an ER department as long as medical staff says it is ok and not have an RN there at all. Our hospital is wanting the EMS department to manage the ER instead of Nursing. We are know that an RN must Cosign the EMS personnel assessment but we heard that an RN must triage patient in order to receive Medicare reimbursements. Please help. thanks Jeriami St.Clair Anson Gen Hospital EMS ------------------------------------------------------------------------ Go to Findlaw.com and get your FREE FLEECE from FindLaw. FindLaw is the Internet's best destination for free legal information! Take advantage of this offer and go to Findlaw.com now! http://click./1/1827/3/_/4981/_/952650875/ -- Talk to your group with your own voice! -- /VoiceChatPage?listName= & m=1

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March 13, 2000

Oh, I like this:

" It stated: " The National Office has received a recent rash of calls asking

about the use of EMT's/Paramedics in the Emergency Care Center. Although

EMT's/Paramedics are valuablere sources in the scheme of emergency settings,

the role of the EMT/Paramedic is a Pre-hospital role and governed by

Pre-hospital regulations. In general, the use of EMT's/Paramedics in

theEmergency Care Center must be subject to hospital job descriptions,

competency testing (all the JCAHO requirements), and utilized as any other

unlicensed assisitive personnel including supervision and direction by the

Registered Nurse. "

Okay. What about the states which license Paramedics (Texas, New Mexico, and

Missouri for instance). What about RN's working on the ambulance without EMT

training (such as in Texas, New Mexico, and Missouri). Why does their

license work both ways but ours doesn't?

This sounding a lot like " When you are in the hospital you have a right to

the best possible care in nursing. So when you are in the hospital, as for a

real nurse, ask for an RN. " That was (roughly) an ad put up in a national

newspaper by the New Jersey Nursing Association. Any guesses as to how the

LPN's responded to that one?

Guys, the bickering and " job protection " needs to stop. The US is SERIOUSLY

understaffed in both the hospital and pre-hospital setting. If the EMT's and

Nurses would stop arguing over stuff like this, maybe we could find a

solution that would help patients, cut costs, and provide better care. Let

me ask on last question, " What training does a CNA or CMA have that an EMT

or EMT-I doesn't? " Tooshie wiping maybe? Oh, oh, rolling patients to prevent

bed sores? Anyone ever tried to get a CNA job with your EMT license (other

than at an ER)? Not doable in most places.

Just my thoughts, flamers to on.

Webb, EMT-P

FLW EMS, MO

______________________________________________________

March 13, 2000

I just received an Alert card from the Emergency Nurses Association this morning. It stated: " The National Office has received a recent rash of calls asking about the use of EMT's/Paramedics in the Emergency Care Center. Although EMT's/Paramedics are valuablere sources in the scheme of emergency settings, the role of the EMT/Paramedic is a Pre-hospital role and governed by Pre-hospital regulations. In general, the use of EMT's/Paramedics in theEmergency Care Center must be subject to hospital job descriptions, competency testing (all the JCAHO requirements), and utilized as any other unlicensed assisitive personnel including supervision and direction by the Registered Nurse.

If you have any issues or concerns, your best resources are your State Department of Health (regulations department) and the State Board of Nursing. ENA also has a position statement on the use of unlicensed assistive personnel that can be accessed from the ENA web site (www.ena.org) that may be helpful. You may also call D. Velianoff, RN, DNS, CHE, Deputy Executive Director of Nursing at ENA in your need of assistance. "

This is what the card said, not my own opinion.

Ben Segler, RN, EMT-P

Re: EMS PERSONNEL STAFFING IN ER

Jana:

How ya doin'! The way the regs are written here in Texas, a physician can delegate any procedure, not to include MAJOR surgical procedures, to any person that he or she deems appropriately trained and competent to perform those procedures. In other words, as long as the doc has, by some means including having conducted your training him or herself, determined that you are competent to insert a foley, he or she can legally direct that you do it under his or her license. You could be an EMT who has received special training and it would still be legal. This was orginally based on an old Attorney General's ruling regarding delegated practice, but was later codified. On the other hand, an RN has a very limited discretion about what he or she can delegate to unlicensed personnel or caregivers. There are some things that nurses cannot delegate at all (such as most invasive procedures and nursing assessments) to any non-licensed care giver. Of course the laws and rules may be significantly different in other states. This is why I keep saying that ERs can use paramedics to the full extent of their skills if they are operating under the physician's direction, or if they are licensed paramedics (if they will be working under a nurse). This is, of course, assuming the hospital has no internal regulations against it. Medicare/medicaid and the hospital accreditation folks do not, by the way, have any rules that prohibit paramedics working in a hospital setting. This is just used as an excuse by some nursing directors and administrators to beg the issue. These agencies have reasonable guidelines about the use of non-nursing caregivers that do not exclude paramedics as long as certain requirements are met.

Dave

Re: EMS PERSONNEL STAFFING IN ERAs far as I know, an RN must be in overall charge of the ER and must provide the triage for incoming patients. I believe this is tied up in the Trauma Level certification that the hospital recieves, as well as with Medicare. Jeanne E. Amis, RN, EMT-P Education Director Marfa City/County EMS MEDICSnTX@... wrote: A question for the group. Is there anything that says that EMS personnel instead of nursing personnel (RNs) can triage and care for patients in an ER department as long as medical staff says it is ok and not have an RN there at all. Our hospital is wanting the EMS department to manage the ER instead of Nursing. We are know that an RN must Cosign the EMS personnel assessment but we heard that an RN must triage patient in order to receive Medicare reimbursements. Please help. thanks Jeriami St.Clair Anson Gen Hospital EMS ------------------------------------------------------------------------ Go to Findlaw.com and get your FREE FLEECE from FindLaw. FindLaw is the Internet's best destination for free legal information! Take advantage of this offer and go to Findlaw.com now! http://click./1/1827/3/_/4981/_/952650875/ -- Talk to your group with your own voice! -- /VoiceChatPage?listName= & m=1

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March 13, 2000

I trust all will read mr Seglers' message very carefully. A big key word here JCAHO, a (voluntary) body that sets minimal standards for hospitals throughout the country. Read carefully and you'll see that EMS personnel fall under the jurisdiction of Nursing, not the medical director of the ER. Sure any EMT-P can be taught to insert foley catheters, and other basic nursing functions, but they do so under a written job description, not just because an MD tells them to do something. And that's not to say that somewhere in Texas EMS personnel are doing things that is directed by an MD. But folks, screw up once, and that MD will deny saying you could do a certain task until the cows come home. EMS is not under the mriad of rules and regs that hospitals are. Let's face it folks, if ya wanna work in an ER, ya gotta bite the bullit, and realize you can't perform like you do in the field. Thanks. Jerry Woods,EMT-PL

Re: EMS PERSONNEL STAFFING IN ER

Jana:

How ya doin'! The way the regs are written here in Texas, a physician can delegate any procedure, not to include MAJOR surgical procedures, to any person that he or she deems appropriately trained and competent to perform those procedures. In other words, as long as the doc has, by some means including having conducted your training him or herself, determined that you are competent to insert a foley, he or she can legally direct that you do it under his or her license. You could be an EMT who has received special training and it would still be legal. This was orginally based on an old Attorney General's ruling regarding delegated practice, but was later codified. On the other hand, an RN has a very limited discretion about what he or she can delegate to unlicensed personnel or caregivers. There are some things that nurses cannot delegate at all (such as most invasive procedures and nursing assessments) to any non-licensed care giver. Of course the laws and rules may be significantly different in other states. This is why I keep saying that ERs can use paramedics to the full extent of their skills if they are operating under the physician's direction, or if they are licensed paramedics (if they will be working under a nurse). This is, of course, assuming the hospital has no internal regulations against it. Medicare/medicaid and the hospital accreditation folks do not, by the way, have any rules that prohibit paramedics working in a hospital setting. This is just used as an excuse by some nursing directors and administrators to beg the issue. These agencies have reasonable guidelines about the use of non-nursing caregivers that do not exclude paramedics as long as certain requirements are met.

Dave

Re: EMS PERSONNEL STAFFING IN ERAs far as I know, an RN must be in overall charge of the ER and must provide the triage for incoming patients. I believe this is tied up in the Trauma Level certification that the hospital recieves, as well as with Medicare. Jeanne E. Amis, RN, EMT-P Education Director Marfa City/County EMS MEDICSnTX@... wrote: A question for the group. Is there anything that says that EMS personnel instead of nursing personnel (RNs) can triage and care for patients in an ER department as long as medical staff says it is ok and not have an RN there at all. Our hospital is wanting the EMS department to manage the ER instead of Nursing. We are know that an RN must Cosign the EMS personnel assessment but we heard that an RN must triage patient in order to receive Medicare reimbursements. Please help. thanks Jeriami St.Clair Anson Gen Hospital EMS ------------------------------------------------------------------------ Go to Findlaw.com and get your FREE FLEECE from FindLaw. FindLaw is the Internet's best destination for free legal information! Take advantage of this offer and go to Findlaw.com now! http://click./1/1827/3/_/4981/_/952650875/ -- Talk to your group with your own voice! -- /VoiceChatPage?listName= & m=1

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March 13, 2000

Mr. Webb. A few comments on your message. Please remember that EMT's are

not trained to do bedside nursing. And there is a great deal of difference

in the two. Yes " tooshie wiping and log rolling every two hours " may see

demeaning and such a simple thing. But gosh darnit, try to keep in mind

that pre-hospital care is a miniscule(albiet very important) part of patient

care. The care only begins when we bring someone to the ER. As to CNA's

and CMA's They are trained to bedside nursing, and to pass medications,

which we EMS folks are not trained to do (outside of emergency drugs.)

That's why your EMS license won't get you a job. (And conversly, a CNA

can't get a job as an EMT.) And quess what. Ihave a degree in nursing, but

I can't get an ER job that will allow me to practice my nursing skills. Why

not? " Cause I ain't and RN any longer. And one last thing. All the

quibling that's been going on seems to be from an EMS standpoint. Folks.

WE aren't nurses! We aren't trained to do nursing care! Christ! If you

want to be a nurse, go to nursing school, give up your $8.00 an hour EMS

job. And if anyone care, I left nursing just because of stuff like this.

Now I find EMS has the same stuff,too. Ahrrgh! Thanks.

Re: EMS PERSONNEL STAFFING IN ER

>Oh, I like this:

> " It stated: " The National Office has received a recent rash of calls asking

>about the use of EMT's/Paramedics in the Emergency Care Center. Although

>EMT's/Paramedics are valuablere sources in the scheme of emergency

settings,

>the role of the EMT/Paramedic is a Pre-hospital role and governed by

>Pre-hospital regulations. In general, the use of EMT's/Paramedics in

>theEmergency Care Center must be subject to hospital job descriptions,

>competency testing (all the JCAHO requirements), and utilized as any other

>unlicensed assisitive personnel including supervision and direction by the

>Registered Nurse. "

>

>Okay. What about the states which license Paramedics (Texas, New Mexico,

and

>Missouri for instance). What about RN's working on the ambulance without

EMT

>training (such as in Texas, New Mexico, and Missouri). Why does their

>license work both ways but ours doesn't?

>

>This sounding a lot like " When you are in the hospital you have a right to

>the best possible care in nursing. So when you are in the hospital, as for

a

>real nurse, ask for an RN. " That was (roughly) an ad put up in a national

>newspaper by the New Jersey Nursing Association. Any guesses as to how the

>LPN's responded to that one?

>

>Guys, the bickering and " job protection " needs to stop. The US is SERIOUSLY

>understaffed in both the hospital and pre-hospital setting. If the EMT's

and

>Nurses would stop arguing over stuff like this, maybe we could find a

>solution that would help patients, cut costs, and provide better care. Let

>me ask on last question, " What training does a CNA or CMA have that an EMT

>or EMT-I doesn't? " Tooshie wiping maybe? Oh, oh, rolling patients to

prevent

>bed sores? Anyone ever tried to get a CNA job with your EMT license (other

>than at an ER)? Not doable in most places.

>

>Just my thoughts, flamers to on.

> Webb, EMT-P

>FLW EMS, MO

>______________________________________________________

>

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March 13, 2000

In regards to working under a physician's order; I was working as a nurse in an E.R. and a physician gave me a verbal order to put down an N.G. tube. He later denied giving me the order even though he physically helped with the tube placement. It got rather messy, to say the least. I was also disappointed he didn't care to meet me in the parking lot to actively discuss the order.

So much for the war stories.

If you look at the wording of the various letters you will notice a couple of consistent items: "Bold-face type is mine"

"......a physician can delegate any procedure, not to include MAJOR surgical procedures, to any person that he or she deems appropriately trained and competent to perform those procedures. In other words, as long as the Doc has, by some means including having conducted your training him or herself, determined that you are competent to insert a foley, he or she can legally direct that you do it under his or her license."......."

"...........In general, the use of EMT's/Paramedics in theEmergency Care Center must be subject to hospital job descriptions, competency testing (all the JCAHO requirements), and utilized as any other unlicensed assisitive personnel including supervision and direction by the Registered Nurse."

It boils down to documentation of training, standards of care and accepted patient care standards. In some hospitals, paramedics function very well in all levels of patient care. This is because the D.O.N, the E.R Head Nurse , the Medical Director and Paramedics sit down and discuss the role of the paramedic in that particular E.D. No one gets 100% of what they wanted, (this is called negotiation) but the end result is patient care improves with the addition of the paramedics to the E.R. setting. No one complains about the various roles and abilities of the staff. Everyone knows their job and does it professionally, then goes out and has a beer together.

Stay safe

Jim Easley

Re: EMS PERSONNEL STAFFING IN ERAs far as I know, an RN must be in overall charge of the ER and must provide the triage for incoming patients. I believe this is tied up in the Trauma Level certification that the hospital recieves, as well as with Medicare. Jeanne E. Amis, RN, EMT-P Education Director Marfa City/County EMS MEDICSnTX@... wrote: A question for the group. Is there anything that says that EMS personnel instead of nursing personnel (RNs) can triage and care for patients in an ER department as long as medical staff says it is ok and not have an RN there at all. Our hospital is wanting the EMS department to manage the ER instead of Nursing. We are know that an RN must Cosign the EMS personnel assessment but we heard that an RN must triage patient in order to receive Medicare reimbursements. Please help. thanks Jeriami St.Clair Anson Gen Hospital EMS ------------------------------------------------------------------------ Go to Findlaw.com and get your FREE FLEECE from FindLaw. FindLaw is the Internet's best destination for free legal information! Take advantage of this offer and go to Findlaw.com now! http://click./1/1827/3/_/4981/_/952650875/ -- Talk to your group with your own voice! -- /VoiceChatPage?listName= & m=1

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March 13, 2000

Mr. Segler:

While I applaud the concerns of professional nurses for the quality of patient care, I cannot equate the Alert card you refer to as an expression of that concern. Rather, it seems plain that this is a turf issue with the ENA. I don't know how it is in other states, but here in Texas a lot of ERs can't find enough nurses to fully staff their ERs. An increasing number of hospitals are looking at the option of using paramedics in ERs to augment their nursing staff out of desperation, although an ER utilizing the combined knowledge and experience base of both RNs and paramedics is likely to provide a superior patient care experience for the community. I, for one, do not recognize the ENA as an organization with the right to determine that the sole role of paramedics is limited to prehospital patient care. That would be akin to the National Association of EMTs declaring that RNs have no role in the pre-hospital environment, a stand many flight nurses and MICNs would find unpalatable.

They are quite correct that utilization of paramedics, as with any other medical personnel, is subject to various internal policies of the hospitals. Most hospitals have active credentialing programs for every medical staff member from the physicians on down. It seems obvious that this this card is designed to influence hospitals against use of paramedics, the most well-trained auxilliary medical staff member a hospital could hope for. If this were a time in history when the supply of nurses was adequate and use of paramedics was just a strategy to reduce the number of nurses on staff, I could understand this type of thing. However, we are at a point where significant numbers of nurses are leaving the profession. Many graduate from school and never even bother to take the boards, or pass the boards and never practice. This has produced a shortage that will grow worse before it grows better. In this climate, the sentiment expressed in the Alert card is a discredit to ENA and clearly shows their concerns to be selfish in nature.

I am among those who firmly believe that paramedics should not be used to replace nurses in certain hospital settings but that they can and should be used as regular staff members to augment nursing personnel in certain key areas. It is unfortunate that this concept will likely be explored and proven out of necessity,and with undue opposition from ENA, rather than being embraced by everyone involved as a way to improve the patient care environment in the ER and outpatient care units. At least in Texas and possibly in a few other states where we have licensed paramedics as well as certified ones, nurses cannot hide behind delegation rules that apply to non-licensed personnel. Organizations like ENA would do well to accept that paramedics do have a role in the ER and perhaps in certain other hospital settings as advanced caregivers and find ways to turn what they see as a threat into an opportunity. Support of ER paramedics as a supplement, not as a replacement, for ER nurses could make their members' professional lives a lot more comfortable. Considering the hell many ER nurses call their normal working environment, I'd think they would welcome anything that made it a little better for them and the patients.

Dave , LP, CCT-P

Re: EMS PERSONNEL STAFFING IN ER

I just received an Alert card from the Emergency Nurses Association this morning. It stated: "The National Office has received a recent rash of calls asking about the use of EMT's/Paramedics in the Emergency Care Center. Although EMT's/Paramedics are valuablere sources in the scheme of emergency settings, the role of the EMT/Paramedic is a Pre-hospital role and governed by Pre-hospital regulations. In general, the use of EMT's/Paramedics in theEmergency Care Center must be subject to hospital job descriptions, competency testing (all the JCAHO requirements), and utilized as any other unlicensed assisitive personnel including supervision and direction by the Registered Nurse.

If you have any issues or concerns, your best resources are your State Department of Health (regulations department) and the State Board of Nursing. ENA also has a position statement on the use of unlicensed assistive personnel that can be accessed from the ENA web site (www.ena.org) that may be helpful. You may also call D. Velianoff, RN, DNS, CHE, Deputy Executive Director of Nursing at ENA in your need of assistance."

This is what the card said, not my own opinion.

Ben Segler, RN, EMT-P

March 13, 2000

Mr ,

I curious to know how you obtained so much information about the " troubles "

of ER nurses and our short falls. This issues is so controversial that we

could debate it for weeks but this is not the place to do so. We all are

entitled to our own opinion and you have given us yours, Thanks! So, now

lets move on to the next topic.

J. Betts RN, EMT-P

March 13, 2000

Mr has put it quite more succiently than I ever could. Thanks.

Re: EMS PERSONNEL STAFFING IN ER

Mr. Segler:

While I applaud the concerns of professional nurses for the quality of patient care, I cannot equate the Alert card you refer to as an expression of that concern. Rather, it seems plain that this is a turf issue with the ENA. I don't know how it is in other states, but here in Texas a lot of ERs can't find enough nurses to fully staff their ERs. An increasing number of hospitals are looking at the option of using paramedics in ERs to augment their nursing staff out of desperation, although an ER utilizing the combined knowledge and experience base of both RNs and paramedics is likely to provide a superior patient care experience for the community. I, for one, do not recognize the ENA as an organization with the right to determine that the sole role of paramedics is limited to prehospital patient care. That would be akin to the National Association of EMTs declaring that RNs have no role in the pre-hospital environment, a stand many flight nurses and MICNs would find unpalatable.

They are quite correct that utilization of paramedics, as with any other medical personnel, is subject to various internal policies of the hospitals. Most hospitals have active credentialing programs for every medical staff member from the physicians on down. It seems obvious that this this card is designed to influence hospitals against use of paramedics, the most well-trained auxilliary medical staff member a hospital could hope for. If this were a time in history when the supply of nurses was adequate and use of paramedics was just a strategy to reduce the number of nurses on staff, I could understand this type of thing. However, we are at a point where significant numbers of nurses are leaving the profession. Many graduate from school and never even bother to take the boards, or pass the boards and never practice. This has produced a shortage that will grow worse before it grows better. In this climate, the sentiment expressed in the Alert card is a discredit to ENA and clearly shows their concerns to be selfish in nature.

I am among those who firmly believe that paramedics should not be used to replace nurses in certain hospital settings but that they can and should be used as regular staff members to augment nursing personnel in certain key areas. It is unfortunate that this concept will likely be explored and proven out of necessity,and with undue opposition from ENA, rather than being embraced by everyone involved as a way to improve the patient care environment in the ER and outpatient care units. At least in Texas and possibly in a few other states where we have licensed paramedics as well as certified ones, nurses cannot hide behind delegation rules that apply to non-licensed personnel. Organizations like ENA would do well to accept that paramedics do have a role in the ER and perhaps in certain other hospital settings as advanced caregivers and find ways to turn what they see as a threat into an opportunity. Support of ER paramedics as a supplement, not as a replacement, for ER nurses could make their members' professional lives a lot more comfortable. Considering the hell many ER nurses call their normal working environment, I'd think they would welcome anything that made it a little better for them and the patients.

Dave , LP, CCT-P

Re: EMS PERSONNEL STAFFING IN ER

I just received an Alert card from the Emergency Nurses Association this morning. It stated: " The National Office has received a recent rash of calls asking about the use of EMT's/Paramedics in the Emergency Care Center. Although EMT's/Paramedics are valuablere sources in the scheme of emergency settings, the role of the EMT/Paramedic is a Pre-hospital role and governed by Pre-hospital regulations. In general, the use of EMT's/Paramedics in theEmergency Care Center must be subject to hospital job descriptions, competency testing (all the JCAHO requirements), and utilized as any other unlicensed assisitive personnel including supervision and direction by the Registered Nurse.

If you have any issues or concerns, your best resources are your State Department of Health (regulations department) and the State Board of Nursing. ENA also has a position statement on the use of unlicensed assistive personnel that can be accessed from the ENA web site (www.ena.org) that may be helpful. You may also call D. Velianoff, RN, DNS, CHE, Deputy Executive Director of Nursing at ENA in your need of assistance. "

This is what the card said, not my own opinion.

Ben Segler, RN, EMT-P

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March 13, 2000

And Mr. Easeley has futher expressed my feelings better than I. Thanks.

Re: EMS PERSONNEL STAFFING IN ER

In regards to working under a physician's order; I was working as a nurse in an E.R. and a physician gave me a verbal order to put down an N.G. tube. He later denied giving me the order even though he physically helped with the tube placement. It got rather messy, to say the least. I was also disappointed he didn't care to meet me in the parking lot to actively discuss the order.

So much for the war stories.

If you look at the wording of the various letters you will notice a couple of consistent items: " Bold-face type is mine "

" ......a physician can delegate any procedure, not to include MAJOR surgical procedures, to any person that he or she deems appropriately trained and competent to perform those procedures. In other words, as long as the Doc has, by some means including having conducted your training him or herself, determined that you are competent to insert a foley, he or she can legally direct that you do it under his or her license. " ....... "

" ...........In general, the use of EMT's/Paramedics in theEmergency Care Center must be subject to hospital job descriptions, competency testing (all the JCAHO requirements), and utilized as any other unlicensed assisitive personnel including supervision and direction by the Registered Nurse. "

It boils down to documentation of training, standards of care and accepted patient care standards. In some hospitals, paramedics function very well in all levels of patient care. This is because the D.O.N, the E.R Head Nurse , the Medical Director and Paramedics sit down and discuss the role of the paramedic in that particular E.D. No one gets 100% of what they wanted, (this is called negotiation) but the end result is patient care improves with the addition of the paramedics to the E.R. setting. No one complains about the various roles and abilities of the staff. Everyone knows their job and does it professionally, then goes out and has a beer together.

Stay safe

Jim Easley

Re: EMS PERSONNEL STAFFING IN ERAs far as I know, an RN must be in overall charge of the ER and must provide the triage for incoming patients. I believe this is tied up in the Trauma Level certification that the hospital recieves, as well as with Medicare. Jeanne E. Amis, RN, EMT-P Education Director Marfa City/County EMS MEDICSnTX@... wrote: A question for the group. Is there anything that says that EMS personnel instead of nursing personnel (RNs) can triage and care for patients in an ER department as long as medical staff says it is ok and not have an RN there at all. Our hospital is wanting the EMS department to manage the ER instead of Nursing. We are know that an RN must Cosign the EMS personnel assessment but we heard that an RN must triage patient in order to receive Medicare reimbursements. Please help. thanks Jeriami St.Clair Anson Gen Hospital EMS ------------------------------------------------------------------------ Go to Findlaw.com and get your FREE FLEECE from FindLaw. FindLaw is the Internet's best destination for free legal information! Take advantage of this offer and go to Findlaw.com now! http://click./1/1827/3/_/4981/_/952650875/ -- Talk to your group with your own voice! -- /VoiceChatPage?listName= & m=1

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March 13, 2000

I wonder what their take on Licensed Paramedics will be...

Any thought on changes to necessary parts of the Medical Practice Act to

write-in allowances for Licensed Paramedics, like Licensed Doctors and

Licensed Nurses?

Mike

Re: EMS PERSONNEL STAFFING IN ER

Jana:

How ya doin'! The way the regs are written here in Texas, a physician

can delegate any procedure, not to include MAJOR surgical procedures, to

any person that he or she deems appropriately trained and competent to

perform those procedures. In other words, as long as the doc has, by

some means including having conducted your training him or herself,

determined that you are competent to insert a foley, he or she can

legally direct that you do it under his or her license. You could be an

EMT who has received special training and it would still be legal. This

was orginally based on an old Attorney General's ruling regarding

delegated practice, but was later codified. On the other hand, an RN has

a very limited discretion about what he or she can delegate to

unlicensed personnel or caregivers. There are some things that nurses

cannot delegate at all (such as most invasive procedures and nursing

assessments) to any non-licensed care giver. Of course the laws and

rules may be significantly different in other states. This is why I keep

saying that ERs can use paramedics to the full extent of their skills if

they are operating under the physician's direction, or if they are

licensed paramedics (if they will be working under a nurse). This is, of

course, assuming the hospital has no internal regulations against it.

Medicare/medicaid and the hospital accreditation folks do not, by the

way, have any rules that prohibit paramedics working in a hospital

setting. This is just used as an excuse by some nursing directors and

administrators to beg the issue. These agencies have reasonable

guidelines about the use of non-nursing caregivers that do not exclude

paramedics as long as certain requirements are met.

Dave

Re: EMS PERSONNEL STAFFING IN ER

As far as I know, an RN must be in overall charge of the ER and must

provide the triage for incoming patients. I believe this is tied up in

the Trauma Level certification that the hospital recieves, as well as

with Medicare.

Jeanne E. Amis, RN, EMT-P

Education Director

Marfa City/County EMS

MEDICSnTX@... wrote:

A question for the group.

Is there anything that says that EMS personnel instead of nursing

personnel

(RNs) can triage and care for patients in an ER department as long as

medical

staff says it is ok and not have an RN there at all. Our hospital is

wanting

the EMS department to manage the ER instead of Nursing. We are know

that an

RN must Cosign the EMS personnel assessment but we heard that an RN must

triage patient in order to receive Medicare reimbursements. Please

help.

thanks

Jeriami St.Clair

Anson Gen Hospital EMS

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March 13, 2000

Well said, Jim. You hit the key issue right on the head!

Dave

Re: EMS PERSONNEL STAFFING IN ERAs far as I know, an RN must be in overall charge of the ER and must provide the triage for incoming patients. I believe this is tied up in the Trauma Level certification that the hospital recieves, as well as with Medicare. Jeanne E. Amis, RN, EMT-P Education Director Marfa City/County EMS MEDICSnTX@... wrote: A question for the group. Is there anything that says that EMS personnel instead of nursing personnel (RNs) can triage and care for patients in an ER department as long as medical staff says it is ok and not have an RN there at all. Our hospital is wanting the EMS department to manage the ER instead of Nursing. We are know that an RN must Cosign the EMS personnel assessment but we heard that an RN must triage patient in order to receive Medicare reimbursements. Please help. thanks Jeriami St.Clair Anson Gen Hospital EMS ------------------------------------------------------------------------ Go to Findlaw.com and get your FREE FLEECE from FindLaw. FindLaw is the Internet's best destination for free legal information! Take advantage of this offer and go to Findlaw.com now! http://click./1/1827/3/_/4981/_/952650875/ -- Talk to your group with your own voice! -- /VoiceChatPage?listName= & m=1

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March 13, 2000

I worked at a particular hospital at one time where paramedics were

staffed in the ED doing paramedic level skills. The trust factor among

the EMS and hospital staff was great. To my knowledge, they still have

the medics. Joint Commission does not dictate what you do with your

personnel. I know that for sure. It's up to the hospital and the

medical staff bylaws. To me it's all about trust and turf, not Joint

Commission.

To try to increase trust and decrease turf, I've started a program

(Randy's idea) in my system called 'EMS Grand Rounds'. The medics

rotate through the ED for a shift or two, and follow our one of our docs

around. This allows much better trust from our docs , and one on one

dynamic assessment and skills teaching about cases. Another benefit is

to be able to interact with the RNs for trust factors. Some of the RNs

are even thinking about even riding out.

I've heard that trust and turf are such issues, that some hospitals will

not release critical patients to a medic to be transported. This is

another ENA facet. The ENA line is that in order to have a continuum of

care, the patient should not be released to no one but another RN. I

say that's hogwash and detrimental to the patient, in certain cases,

when you have a couple of veteran CCT (183 hours of additional

education, equal to a CCRN)medics standing there with a vent and IV

pump. Some nurses believe they'll loose their license if they turn a

critical patient over to a medic.

I say let's keep on building trust with RNs. Most of the time the

hospital is their house, ask just about any doc. Show that we fit in

very nicely into the patient care continuum. After all it wasn't that

many years ago that RNs referred to Physical Therapists as 'crushers'.

aloha,

Mike

March 13, 2000

,

I know that the hospital system within which I work is not " most

places " , but just FYI, the EMT does qualify for any PCT or PCT II job within

the system. A PCT is a pt care tech (or in my case, a pretty cool tech),

and the II means that you have additional skills such as sterile dressings,

splinting, admin of O2, and other skills that are used in specific areas

such as trach care, suctioning and vent pt care. Guess what, EMT qualifies

you for the higher-paying II job! I have to admit and am thankful that the

system that I work in is pretty much ahead of it's time in the utilization

of EMTs and Medics and their skills.

Not knocking what you said, I know we're in the minority in allowing

EMTs/Medics to work throughout the hospital.

Take care, stay safe, and practice mercy, ya'll!!

Jana

FW,TX

Re: EMS PERSONNEL STAFFING IN ER

> Oh, I like this:

> " It stated: " The National Office has received a recent rash of calls

asking

> about the use of EMT's/Paramedics in the Emergency Care Center. Although

> EMT's/Paramedics are valuablere sources in the scheme of emergency

settings,

> the role of the EMT/Paramedic is a Pre-hospital role and governed by

> Pre-hospital regulations. In general, the use of EMT's/Paramedics in

> theEmergency Care Center must be subject to hospital job descriptions,

> competency testing (all the JCAHO requirements), and utilized as any other

> unlicensed assisitive personnel including supervision and direction by the

> Registered Nurse. "

>

> Okay. What about the states which license Paramedics (Texas, New Mexico,

and

> Missouri for instance). What about RN's working on the ambulance without

EMT

> training (such as in Texas, New Mexico, and Missouri). Why does their

> license work both ways but ours doesn't?

>

> This sounding a lot like " When you are in the hospital you have a right to

> the best possible care in nursing. So when you are in the hospital, as for

a

> real nurse, ask for an RN. " That was (roughly) an ad put up in a national

> newspaper by the New Jersey Nursing Association. Any guesses as to how the

> LPN's responded to that one?

>

> Guys, the bickering and " job protection " needs to stop. The US is

SERIOUSLY

> understaffed in both the hospital and pre-hospital setting. If the EMT's

and

> Nurses would stop arguing over stuff like this, maybe we could find a

> solution that would help patients, cut costs, and provide better care. Let

> me ask on last question, " What training does a CNA or CMA have that an EMT

> or EMT-I doesn't? " Tooshie wiping maybe? Oh, oh, rolling patients to

prevent

> bed sores? Anyone ever tried to get a CNA job with your EMT license (other

> than at an ER)? Not doable in most places.

>

> Just my thoughts, flamers to on.

> Webb, EMT-P

> FLW EMS, MO

> ______________________________________________________

>

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March 13, 2000

Jerry,

CNAs are not allowed to give medications. I'm not sure, but the CMA

that I know states that she was not taught and wasn't aware of being able to

give medications. In Texas, there is a small class of people utilized by

some nursing homes and many prisons to give medications called Medication

Aides. I've never seen a Medication Aide utilized in a hospital setting,

though. If my memory serves me correctly, you have to be a CNA, then take

additional schooling and a test, to become a Medication Aide. I considered

it once briefly when my one of my distant cousins became a Medication Aide

and obtained a job in one of the State prisons making $12.00 per hour. She

sat at a window and the prisoners lined up with a little card, she ran the

card through the computer and handed them their medications.

I beg to differ with you that EMTs are taught bedside care, just that

the bedside we are taught on is a little more mobile than the ones in the

hospital. My first job as an EMT was in a long-term care unit, and I had no

trouble whatsoever adapting to the immobile bedside of the hospital. In

fact, with my training as an EMT, I had more knowledge that the CNAs I

worked with. Cleaning Code Browns is cleaning Code Browns no matter how you

look at it, and comforting a pt and/or their family is the same, and

measuring urine and fluid intake is the same, it's mostly just common

knowledge and common sense with some compassion thrown in.

As far as that goes, my time spent working in the step-down ICU unit was

time well spent and allowed me to be a better EMT in the field also.

Just like you, I advocate that we don't bicker, just work together as a

team to provide the best pt. care available!

Take care, stay safe, and practice mercy, ya'll!!

Jana

FW,TX

Re: EMS PERSONNEL STAFFING IN ER

>

> >Oh, I like this:

> > " It stated: " The National Office has received a recent rash of calls

asking

> >about the use of EMT's/Paramedics in the Emergency Care Center. Although

> >EMT's/Paramedics are valuablere sources in the scheme of emergency

> settings,

> >the role of the EMT/Paramedic is a Pre-hospital role and governed by

> >Pre-hospital regulations. In general, the use of EMT's/Paramedics in

> >theEmergency Care Center must be subject to hospital job descriptions,

> >competency testing (all the JCAHO requirements), and utilized as any

other

> >unlicensed assisitive personnel including supervision and direction by

the

> >Registered Nurse. "

> >

> >Okay. What about the states which license Paramedics (Texas, New Mexico,

> and

> >Missouri for instance). What about RN's working on the ambulance without

> EMT

> >training (such as in Texas, New Mexico, and Missouri). Why does their

> >license work both ways but ours doesn't?

> >

> >This sounding a lot like " When you are in the hospital you have a right

to

> >the best possible care in nursing. So when you are in the hospital, as

for

> a

> >real nurse, ask for an RN. " That was (roughly) an ad put up in a national

> >newspaper by the New Jersey Nursing Association. Any guesses as to how

the

> >LPN's responded to that one?

> >

> >Guys, the bickering and " job protection " needs to stop. The US is

SERIOUSLY

> >understaffed in both the hospital and pre-hospital setting. If the EMT's

> and

> >Nurses would stop arguing over stuff like this, maybe we could find a

> >solution that would help patients, cut costs, and provide better care.

Let

> >me ask on last question, " What training does a CNA or CMA have that an

EMT

> >or EMT-I doesn't? " Tooshie wiping maybe? Oh, oh, rolling patients to

> prevent

> >bed sores? Anyone ever tried to get a CNA job with your EMT license

(other

> >than at an ER)? Not doable in most places.

> >

> >Just my thoughts, flamers to on.

> > Webb, EMT-P

> >FLW EMS, MO

> >______________________________________________________

> >

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Re: EMS PERSONNEL STAFFING IN ER

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