Protocols for High Achievers

Can a department really have multiple sets of protocols based on provider merit?

Imagine the simple bell curve that represents the knowledge, skills and performance level of your department's EMS personnel. There in the middle, at the curve's highest point, reside the safe, competent, average majority of providers. Some distance to the left, as the descending curve begins to flatten, lies a minimum threshold for serving--the cutoff of folks barely qualified and making the grade, a point below which some corrective action (remediation or termination) is required.

The segment of the curve between those points represents the bottom half of providers. And it's that group, longtime EMS educator Mic Gunderson observed at EMS World Expo 2011, for whom care protocols are generally written.

That's fair enough--protocols must allow the bottom half of the class, as it were, to operate safely. But what about the other half--the higher achievers? Are those same protocols holding them back? Could those EMTs and medics provide a greater level of care and a greater benefit to patients if the protocols under which they operate could somehow be loosened?

Can a department really have multiple sets of protocols based on provider merit?

There's precedent for this in EMS, noted Gunderson, president of North Carolina-based public-safety management consultancy IPS. Many systems have "advanced practice" paramedics. Special-teams medics (e.g., critical care, hazmat) often get to do things their colleagues can't. Imagine gauging the strengths of the broader workforce and expanding their scopes of practice similarly. For example, perhaps medics adept at 12-lead interpretation could be allowed to trigger STEMI alerts directly, where their less-proficient counterparts send their ECGs for physician interpretation/activation.

This raises viable questions about different patients getting different standards of care, but also the prospect of better overall EMS care for many patients. It requires, Gunderson said, not just technician-level training of providers, but their significant understanding of pathophysiology and development of critical-thinking skills.

A department might start by scoring its people's knowledge and skills to identify their strengths and weaknesses. (This can also help it provide tailored education; Gunderson delivered a parallel class on calibrating CME to the proverbial lowest common denominator.) It would evaluate their performance in the field using common QI metrics. Together, those results could comprise an overall clinical index determining who gets expanded privileges.

This would, admittedly, make quality improvement and medical oversight more complex. But in addition to its benefit for patients, it could also incentivize providers to grow and gain skills. Ultimately, it's this notion that underlies concepts like community paramedicine, where specially trained medics can provide expanded care to particular underserved populations. Perhaps, as the conventional wisdom and law come around, the most apt medics can eventually be empowered to treat and release or steer patients to alternative destinations.

Besides being better care for them, that benefits whole 9-1-1 systems and everyone else who calls them.