Extraordinary Care: A Case Study for the Future

There is some debate over whether more care than is presently administered should be provided before a patient is transported to the emergency room of a hospital. The shifting of treatments and/or diagnoses from the hospital to the ambulance is appropriately described as “extraordinary care” (EC), primarily because such shifts exceed the “normal” Advanced Life Support (ALS) standard of care that paramedics or Basic Life Support (BLS) that EMTs (Emergency Medical Technicians) now provide.

In addition to the additional training required, there are significant other concerns that also must be considered. For example, paramedics and EMTs operate under what is called delegated practice. In effect, an agency’s medical director authorizes emergency medical services (EMS) providers to practice medicine under the director’s own license – and, for that reason, many state laws, local oversight requirements, and agency policies limit the scope of the medical care delegated.

Another concern among those in the medical oversight community is that each system may have variations in the models used for EMS. Thus a single county may have several volunteer agencies, private for-profit firms working under contract, and/or a full-time municipal staff as well. Staff with paid training built into their full-time schedules, or with a high call volume and who therefore gain experience more quickly, must apply equally to other staff members who may work on the ambulance only one or two shifts a week or even month – and often receive training on their own time and at their own expense.

Some agencies may see EC as an extra service available to their patients and therefore view it as a point of pride, but others may struggle to cover the bills while providing only baseline care – and still others may have a financial responsibility to owner groups requiring cost controls and therefore see EC as an unnecessary or unwarranted expense.

Cost, Liability, Risks & Benefits The services currently provided by paramedics across the United States usually are charged at a flat rate. Although agencies are permitted to charge more for ALS than they do for BLS, these additional charges do not extend to EC; there is no rate for ALS plus. As a result agency managers may not want to deal with the burden of the additional costs entailed in providing extraordinary care. In fact, many managers may rightly view EC as an additional liability.

Some systems have implemented EC plans and policies by applying to oversight agencies for “pilot projects” to prove the safety and efficacy of such care when provided in an EMS setting. By defining the project scope to include the entire system, regulators usually can ensure that the EC is implemented only by an agency capable of filling the added requirements both safely and effectively. Such pilot projects, however, often raise the bar and thereby encourage other agencies to follow suit – in fact, many current treatments that are now standard originally were considered to be extraordinary care.

Most if not all EC practices are undoubtedly an additional uncompensated expense – particularly when carried out by for-profit agencies. Although unable to transfer the added expense to the patient, the cost can be built into a contract with the local jurisdiction. EC can also be included in the marketing strategy used to demonstrate both an agency’s professionalism and its leadership role in the local EMS community.

As with any other liability discussion, professional advice – both medical and legal – is or should be a crucial factor that should be taken into consideration in the decision-making process. If current insurance does not cover the additional liability involved, then the additional coverage must be purchased – and that cost rolled into the operational plan spelled out for the EC.

A risk-benefit analysis also must be made – both for the agency and for the patient. Just one example is the purchase and use of a device that allows paramedics to determine the extent of an abdominal injury – and, therefore, the possible need for rapid transport to a trauma center. Such equipment is less useful in a jurisdiction – a large city, for example – where many hospitals within a short transport time are equipped to handle abdominal trauma, as opposed to a more isolated setting in which the helicopter medevac of trauma patients is required for transport to trauma centers. In the “large city” example, simply transporting all patients with abdominal injuries to the trauma center and spending the EC funds on something else may be a better alternative.

Implementation of an EC plan is a purely management task in that it is entirely about managing change and risk. EMS managers must therefore sometimes use a visionary style of leadership to ensure that their own agencies follow the optimum path of forward progress.

Joseph Cahill
Joseph Cahill

Joseph Cahill is the director of medicolegal investigations for the Massachusetts Office of the Chief Medical Examiner. He previously served as exercise and training coordinator for the Massachusetts Department of Public Health and as emergency planner in the Westchester County (N.Y.) Office of Emergency Management. He also served for five years as citywide advanced life support (ALS) coordinator for the FDNY – Bureau of EMS. Before that, he was the department’s Division 6 ALS coordinator, covering the South Bronx and Harlem. He also served on the faculty of the Westchester County Community College’s paramedic program and has been a frequent guest lecturer for the U.S. Secret Service, the FDNY EMS Academy, and Montefiore Hospital.



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