Alan Craig opened his session at the Pinnacle 2009 EMS Leadership & Management Conference by admitting that he's always been a supporter of ALS and originally endorsed having ALS respond on all calls. In the "Changing Back to an ALS/BLS Model in Toronto" session, the deputy chief of Toronto EMS added that he and many others accepted the all-ALS theory that was based on "you never know what could go wrong" on a call.
But back then, ALS was way ahead of science. Research now shows that we don't need ALS on all calls. In fact, only about 5% of calls need ALS. And, in Craig's opinion, IV starts without giving a bolus, are just practice for the provider to hone their IV skills on patients because there's no clinical benefit to IVs without a bolus.
He reported that Toronto found that just 19% of their patients needed ALS, with only 1.5% critically in need of it. He cited statistics to illustrate his point:
Skill experience in Toronto
- Intubation: 15 per 1,000 patients
- Sedation: 12 per 1,000 patients
- Cardioversion: 2.5 per 1,000 patients
- Pacing: 0.5 per 1,000 patients
- Surgical airway: 0.001 per 1,000 patients
Craig cited several studies when saying recertification once a year on a manikin doesn't sufficiently train providers to perform these skills and that only high volume can help guarantee true proficiency in the critical ALS skills. He noted that the author of one study pointed out a disturbing 9% rate of missed endotracheal tubes despite the use of end-tidal CO2 detection devices.(1) A researcher in another study pointed out that there was severe hypoxemia and bradycardia in 67% of the endotracheal intubations (ETIs) in the study.(2) In a study of 699 witnessed out-of-hospital cardiac arrests, authors found that, in ventricular fibrillation resuscitations, survival increased 2% for each year of experience possessed by paramedics.(3)
It used to be said that a "GCS [Glasgow Coma Scale] of 8 equaled intubate," but not only is that no longer a universal practice but that inexperienced intubation is a catastrophe.
So, after careful consideration and review of all their data, Toronto officials decided in 2007 to go back to a special two-tiered ALS/BLS model. This model featured fewer paramedics. The new model:
- Features a 4:1 BLS-to-ALS ratio;
- Is entirely cost-neutral, and
- Utilizes a pure reallocation of existing staff, meaning no "unassigned" ALS providers. In the Toronto setting, no existing paramedics will have to stop practicing. Instead, officials expect attrition will take the system to the final target for ALS positions in a few years.
Craig feels concentrated exposure and experience counts the most in ALS, and he noted that, under the new system, ALS crews get more runs (10 responses per 12-hour shift, with 2.5 transports). When the conversion to the new model is complete, it's projected that Toronto EMS will handle 1,600 cardiac arrests with 90 two-paramedic teams. This equates to at least 18 worked arrests per year for each paramedic. This doesn't include additional intubations they'll perform on other medical and trauma cases.
The system's clinical practice has also seen a few changes, including:
- More emphasis on intubation safety. (Providers must obtain complete electronic documentation of the patient s vital signs and status before intubating), and
- More specialized abilities. (Providers must be able to carry out complex post-arrest patient care.)
Craig feels the ALS providers in the "new" Toronto model will handle several situations better than the old ALS model. He also suspects ALS providers will play a bigger role in post-resuscitative care.
Eight Niche Areas of "New" ALS Provider, a Specialist's Role
1. Specialized cardiac care -- regionalization of STEMI
2. Post return of spontaneous circulation (ROSC) care
- Induced hypothermia
- Ventilatory support
- Inotropic support
- Region-wide transport to specialized post-arrest centers
3. Complex respiratory care, such as asphyxia
4. Careful use of continuous positive airway pressure (CPAP), i.e., knowing when to quit CPAP before causing harm to the patient
6. Analgesia and sedation
7. Unconsciousness and truly critical medical patients
8. Several categories of rare patient conditions
Craig feels it's possible for science may support immediate post-ROSC angiography. He said he wouldn't be surprised to see a 2010 International Liaison Committee on Resuscitation (ILCOR) paper support post-ROSC patients be taken to percutaneous coronary intervention (PCI) centers. This would present more of a case for specialty paramedics. He stressed that complex patients require high-quality ETI skills. These patients include comatose patients or those who are heavily sedated.
In addition to creating a new role for paramedics, the Toronto system has made changes to its dispatch and crew resource processes. Officials reviewed the care acuity rating on 250,000 cases and found the need forALS was heavily clustered in a relatively few determinants. They also determined that missedALS cases will probably be less than one per 1,000 incidents. They are currently implementing the SIREN dispatch system, which is designed to send the right resources to the right calls.Summary
Craig concluded his presentation by noting that intensive care units/critical care units (ICUs/CCUs) exist for the following reasons:
- They offer staff a high exposure to critical patients;
- They give staff the opportunity to gain valuable experience though contact with a high volume of patients, and
- They help polish the skills and clinical judgement of the staff.
He told the audience that he believed "certified" does not mean "sufficiently experienced;" it means "ready to learn." He concluded by telling the audience that: "Skill is everything, and quality care is not based on seniority, tradition or speed of arrival."
It's important to note Toronto EMS is a well-developed system that has been operational in a high-performance environment for a long time. Toronto also has an extremely sophisticated quality improvement (QI) process and is able to make their new system design decisions based on hard data and close evaluation. A number of all-ALS systems in the U.S. might consider this change for financial and operational reasons without as solid a clinical basis as Toronto, which could have unintended negative consequences for underserved patients.References
- Wirtz DD, Ortiz C, Newman DH: "Unrecognized misplacement of endotracheal tubes by ground prehospital providers." Prehospital Emergency Care. 11(2):213 208, 2007.
- Davis DP, Hwang JQ, Dunford JV: "Rate of decline in oxygen saturation at various pulse oximetry values with prehospital rapid sequence intubation." Prehospital Emergency Care. 12(1):46 51, 2008.
- Gold LS, Eisenberg MS: "The effect of paramedic experience on survival from cardiac arrest." Prehospital Emergency Care. 13(3):341 344, 2009.