Transport No Man’s Land

State-to-state critical care transport still varies

According to CMS, “Specialty care transport (SCT) is the interfacility transportation of a critically injured or ill beneficiary by a ground ambulance vehicle, including the provision of medically necessary supplies and services, at a level of service beyond the scope of the EMT-Paramedic. SCT is necessary when a beneficiary’s condition requires ongoing care that must be furnished by one or more health professionals in an appropriate specialty area, for example, emergency or critical care nursing, emergency medicine, respiratory care, cardiovascular care, or a paramedic with additional training.”

 

Beyond the CMS definition, there’s no official federal guidance for states or local jurisdictions on what, exactly, critical or specialty care transport is, who is qualified to provide it, what the minimum education and training requirements should be or how to ensure its quality. However, several organizations, such as the Commission on Accreditation of Medical Transport Systems, provide helpful guidelines (see sidebar, “Critical Care Transport Guidance,” p. 4). Several states are completely silent on SCT altogether.

 

“We’re realizing that interhospital, very high-acuity medical transport is becoming a medical specialty in itself,” said Tom Judge, CCT-P, co-founder of the Association of Critical Care Transport and executive director of LifeFlight of Maine. “But it’s completely unregulated, and the time between hospitals is a black hole. At the state level, it’s not looked at; there’s very little quality assurance data. There’s a wide variety of levels of care, and lots of care is not contemporaneous.

 

“You can go around and see ambulances that say “˜Mobile Intensive Care Unit’ on the side. What does that mean? Sometimes there’s a nurse in it. Is the nurse actually trained in critical care? Are they trained in medical transport? Do they have the right equipment?”

 

Judge said Maine is one state where SCT is closely regulated. In fact, a physician must review every critical care transport. Maryland also regulates SCT at the state level, and the University of Maryland, Baltimore County, is one of only two institutions in the U.S. that has developed a curriculum for specialty care paramedics.

 

“SCT is a level of care beyond a traditional paramedic,” said Bob Bass, MD, EMS director for the state of Maryland and a member of the Federal Interagency Committee on Emergency Medical Services.

 

“It’s sort of in no-man’s land. Our experience in Maryland is that it’s been a joint venture with the medical board, the nursing board and the EMS board. Because, is it the practice of medicine? Yes. Is it the practice of nursing? Yes. Is it the practice of EMS? Yes. Sometimes it’s more one than the other, and sometimes it’s all of them. So it’s sort of a no-man’s land that requires a multidisciplinary approach to make sure it’s done right.”

Local vs. state oversight

As with everything else in EMS, who regulates SCT and to what extent varies from state to state or even community by community. While CMS provides for a higher level of reimbursement for SCT than for BLS or ALS transport, the rules allow for flexibility and speak only to reimbursement.

 

“I was the doc–the only doc–on the negotiated rulemaking committee for the current CMS Ambulance Fee Schedule,” Bass said. “We wanted to basically identify this special category of patient that needs additional resources to go facility to facility and to recognize that the cost of staffing those transports and those meds, etc., is higher than it is on average for ALS.” But, he said, states regulate health care, and regulating SCT falls to the state or local jurisdictions.

 

The state of Iowa’s Department of Public Health, Bureau of EMS regulates SCT, and the state’s training curriculum for critical care paramedics is widely used (as is the UMBC curriculum) throughout the country.

 

The state offers five levels of licensure for EMS professionals, according to EMS Bureau Chief Kirk Schmitt. Above the paramedic specialist, the National Registry paramedic level, the state can “endorse” critical care paramedics who complete a state-approved CCP program. Organizations that wish to provide the service must also be endorsed by the state and have at least one recognized critical care paramedic on staff.

 

In other states, such as Texas and Nebraska, there currently are no state-level regulations guiding agencies on who can provide the service and what that service should be.

 

“Texas is a delegated-practice state, as are many states,” said Matt Zavadsky, MS-HSA, associate director of field operations for MedStar in Fort Worth, Texas, which recently initiated CCT services. “As a delegated-practice state, the medical director, in essence, can determine locally–either by service, by region or by jurisdiction–what he or she wants their paramedics to be able to do in the field, up to and including critical care transport.”

 

Zavadsky said they used the Iowa curriculum and “added in additional components that the medical director, myself and the clinical manager felt were important for these paramedics to know, not only from an interfacility CCT perspective, but also for responding in the field to the low-frequency, high-risk calls as well as the low-acuity, high-frequency calls. Iowa was very receptive to us modifying their program. As long as we met the minimum core requirements, we could add in a whole bunch of things and still give them a University of Iowa certificate.”

 

Nebraska also doesn’t regulate critical care transport from the state level. “We really don’t have a policy in place with critical care,” said Dean Cole, Nebraska’s EMS/trauma program administrator. “As a matter of fact, the board is starting the process of looking at it more in depth and making determinations on if or how they should be regulating it. But right now, there is no regulation on critical care, that designation or even the acceptance of a curriculum.”

 

Nebraska is a rural state with a lot of critical access hospitals.

 

“Our interfacility transfers are really on the increase, and the need for interfacility transfers is a lot higher than what it has been in the past, because the baby boomers are getting older, and that older generation needs more intensive-type care than what can be offered in their critical access hospital.”

 

Cole said he personally believes some kind of regulation is needed in the state. “It’s a matter of assuring the public and the patient that this person is who he or she claims to be and that they can provide this higher level of care.”

EMTALA concerns

As in many other states, Cole said the hospitals and physicians in Nebraska are pressing for more oversight. “Once a patient has been delivered to a hospital, there is no law saying that that ambulance service has to transport them out.” The hospitals are turning to private ambulance services, many from other communities, to transport patients in need of a higher level of care to other facilities.

 

“They want to be sure that when they turn that patient over to ambulance A, that its people are qualified and trained in critical care, because they’re responsible for that.”

 

Carol Cunningham, EMS medical director for the state of Ohio and a practicing emergency physician, said she became concerned about the increase in hospitals initiating their own training programs. “We’ve started seeing people popping up saying, “˜I’m a critical care paramedic; I run critical care.’ Well, what the hospitals were doing, and it wasn’t the EMS schools, they were giving paramedics additional training, christening them as critical care paramedics and putting them on an ambulance. So, really, what a transferring physician was getting was a ground unit with two paramedics. And the hospitals would bill it at a higher level and also save money because they were replacing a nurse with a paramedic.

 

“We realized it was a problem, but the state of Ohio is a little bit different, because our division of EMS oversees EMS providers, period. We have a separate Ohio Medical Transportation Board that oversees ground vehicles versus air vehicles and their staffing.”

 

Central to the issue: Ohio doesn’t recognize a designation of critical care paramedic, and no amount of hospital training could permit a paramedic in the state to operate outside of their scope of practice.

 

Cunningham said they convened a meeting in 2007 with the division of EMS, the state medical board, the nursing board, the transportation board, the Ohio Hospital Association and others to address the issue. Out of that summit, she published a document addressing the “Definition and Medical Direction of Mobile Intensive Care Units” explaining the EMTALA challenges physicians were facing, as well as clarifying the fact that the designation of critical care paramedic is not recognized in the state, and paramedics must operate only within their scope of practice.

 

“There’s a lot of responsibility on a transferring physician,” Cunningham said. Physicians could unknowingly place their patients at risk. And, as a reminder, malpractice insurance does not cover civil judgments, she said. “You’d better be sure about what you’re getting.”

Clinical & cost consequences

There are clearly costs associated with poor quality critical care transport, Judge said. “We unequivocally know it’s a problem, but because no one is capturing the data and there’s very little medical oversight, nobody knows the scale of it. It’s esse quam videri, “˜to be, rather than to seem to be,’ and there’s a lot of seeming.

 

“If you bring this patient in–they got to the hospital alive–but they were acidotic, they got cold during transport or they had some episodes of hypotension–no one is really looking for it; no one is doing anything about it, and now they go on to either do well or poorly at the big hospital, but their length of stay is three more days in the intensive care unit. There’s a clinical consequence and a cost consequence, because nobody is actually looking.

 

“Eventually people have got to figure this out. As our tertiary centers and our trauma centers get more and more strapped, absorbing more patients that they’re going to get poorly reimbursed for, or not reimbursed for but they have to accept, at some point someone’s going to look at this and say, “˜If someone doesn’t do this right, we’re picking up the pieces.'”

How to do it right

Whether regulations should come from the national, state or local level is an ongoing debate with no easy answer. As with everything else, some states and locales do it better than others, and the factors for success or failure are many. But everyone seems to agree that strong medical direction is crucial to any quality SCT program.

 

In Maine, the state requires that a physician review every SCT transport. At MedStar in Texas, Zavadsky said their program is strong, because the medical director who supervises the 1,800 EMS providers in the system also sets the protocols for the critical care transport program.

 

“The medical director really needs to be involved in not only setting up the criteria, but literally being part of the selection process. Yes, I’ve seen this person on calls. Yes, I’ve reviewed this person’s charts. Yes, I’ve received this paramedic’s patients, and I’m comfortable with him now doing these high-risk procedures that most paramedics can’t do. We all know that there are systems, services that have a medical director on paper only.”

 

Daniel Hankins, MD, FACEP, president of the Association of Air Medical Services and an emergency physician with a provider that runs its own critical care transport service, believes “the critical care provider in one state should be the same as a critical care provider in another state. Most state EMS authorities are pressed for resources. They don’t have the time or money to oversee things as they should, and the economy has made it worse, which makes it more imperative that there’s a national agency to establish guidelines that states can look to.

 

“But there’s no federal oversight of EMS. Police have the Department of Justice. Fire has the U.S. Fire Administration. EMS doesn’t have that. Federal oversight of EMS would help providers across the country standardize levels of care. National Registry, being wonderful, still doesn’t address the vehicle and service issue.”

 

From a national perspective, Judge believes that CMS, at some point, “needs to look at it, because this has a cost consequence to CMS. I think insurance companies need to look at this and to have more exacting standards [for reimbursement]. Activity follows reimbursement streams. At what cost to patients and at what cost to the health-care system is your ability to make money?”

 
 

Critical Care Transport Guidance

The following organizations (among others) provide standards or other information that may be useful for jurisdictions or agencies establishing critical care transport guidelines.

  • The Commission on Accreditation of Medical Transport Systems (CAMTS): www.camts.org
  • The Commission on the Accreditation of Ambulance Services (CAAS): www.caas.org
  • The Association of Critical Care Transport (ACCT): www.acctforpatients.org
  • The Board for Critical Care Transport Paramedic Certification: www.bcctpc.org
  • The International Association of Flight Paramedics: www.flightparamedic.org
  • The Association of Air Medical Services: www.aams.org
  • The National Highway Traffic Safety Administration: www.ems.gov. Go to the EMS System tab and click on “Other Resources” for a copy of NHTSA’s Guide for Interfacility Patient Transfer.

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