Scot Phelps, JD, MPH, MICP, is director of the New Jersey Office of Emergency Medical Services. For a small state New Jersey has a lot of challenges, but under Phelps’ leadership the Garden State is working hard to improve its EMS delivery.
EMS World: You have an interesting background as an EMS clinician, an attorney, a professor, an academic, and having worked in public policy. What are you passionate about, and how do you focus on those passions in your position?
Phelps: I’ve been working in mobile healthcare for 37 years now, so I think mobile healthcare functions better than most people on the ground think it does, while I’m dismayed by a lot of the fundamental problems that continue to exist. New Jersey has a long history—our first ambulance started in 1874, the Office of Emergency Medical Services was founded in 1967, and the first mobile coronary care unit started in 1969. New Jersey was where I started my career in 1983, and now as director I can see many of the policies put in place in the 1970s are still the right decisions today.
I’m passionate about metrics. We need to measure what we do and how we do it if we want other people to take us seriously. I think mobile healthcare is critically important to both the public and the hospital system, but it’s too often ignored or its importance downplayed.
I’m passionate about our clinicians. I truly believe well-educated, well-treated career clinicians are what’s best for mobile healthcare. We need to encourage career positions at organizations that have a career ladder with enough middle management to oversee clinical care, do both operations and clinical research, and educate clinicians, our peer agencies, and the public in emergency care.
I’m passionate that all parts of mobile healthcare are important. Prehospital care is one part of mobile healthcare, but interhospital, posthospital, and ex-hospital care are also critical and should not be ignored or treated as second-class.
I’m passionate about getting the language right. Mobile healthcare clinicians are engaged in limited-scope-of-practice medicine. They perform an assessment, make a diagnosis, and implement a treatment plan. I believe in the National EMS Scope of Practice model where clinicians are bound by education, certification by an independent professional body, licensure by the state, and credentialing by a physician medical director.
Since you became director it seems you’ve worked to remove some of the barriers to increasing the scope of practice, especially for EMTs. What are some of the things you’ve done, and what do you hope to accomplish in the future?
I’m a big believer in evidence-based medicine and measuring outcomes, so it was a surprise to find a lot of the evidence-based interventions—such as aspirin for chest pain and use of EpiPens for anaphylaxis, naloxone for opiate overdoses, and CPAP for congestive heart failure—were already in place when I arrived. Unfortunately we’re not doing as well as we could with measuring the impact of these interventions on people’s lives and health, but we’re making steps in the right direction.
For example, we added albuterol to treat asthma and COPD patients this year and now have more than 50 participating EMS agencies statewide. With albuterol we require both the chief officer and physician medical director of the program to apply to the department; define their education program; do 100% QA/QI, including matching the EMT and ED diagnosis; perform annual competency evaluations for each clinician; and report quarterly. With two quarters’ worth of data, we know patients with a prehospital diagnosis of asthma or COPD who receive albuterol from EMTs have a reduced respiratory rate of 4 breaths per minute and a 7% increase in SpO2. We also have significant agreement between EMT and ED diagnosis.
Interestingly, although New Jersey’s EMS system is very hospital-centric, with 48% of all EMS responses done by hospital-based units, we’ve had all types of programs participating, with the first three programs being McCabe Ambulance (private), Holy Name Hospital EMS (hospital-based), and Lakewood Hatzolah (volunteer).
At the same time, we don’t permit check-and-inject epinephrine because there was no data on the ability of EMTs to maintain competency in the skill, which is rarely used. So we’ve been forced to do our own research, which is underway at Gloucester County EMS under the supervision of Chief Andrew Lovell.
In the near future I expect New Jersey will adopt new EMT skills included in the National EMS Scope of Practice, including adding glucometers to measure blood sugar, acquiring 12-lead ECGs, and the use of some over-the-counter medications for pain and fever. We’ve also approved nitrous oxide, Toradol, and Suboxone for our paramedics this year, giving them alternatives to opiates and the ability to start breaking the cycle of addiction for opiate-addicted patients.
New Jersey is a challenging state to provide BLS in—it varies from large cities to rural areas; large hospital-based systems to small volunteer agencies; and from state-certified services to those that are self-regulated. What are some things your office is doing to provide more consistency in the way EMS is provided in New Jersey? Are there plans to change the way ALS or mobile healthcare are provided?
My goal is to move mobile healthcare to an evidence-based model where everybody is constantly measuring both operational and clinical data, coupled with outcomes data, to constantly improve our models of care. For the first time in New Jersey, we have clear, agreed-upon definitions of each level of care, which was the first step. We’ve established bundle-of-care measurements at the mobile intensive care level and will be implementing bundles of care at the EMT level in the next year.
One of the most important issues in providing emergency medical services is to understand that Medicare, Medicaid, and self-pay patients do not cover the actual costs of providing care, even in a volunteer system where labor costs are low. I spend a lot of time talking to people about the economics of mobile healthcare, particularly the downstream value of each patient to the healthcare system. We have to understand that “no money, no mission” is not just a saying.
Another thing I’m surprised about is the inefficiency of mobile healthcare communications, which in many circumstances the emergency medical service program has no control over. No mobile healthcare communication program in New Jersey has feedback loops from dispatch categorization to clinician diagnosis to emergency department diagnosis, which means the system never learns. We’re updating the state emergency medical guide cards right now to make them more physiologically based, rather than condition-based, and will be creating a feedback loop in the medium term so it can evolve and become more accurate over time. We’re also working to add a geotemporal layer on top of our systems that use Medical Priority Dispatch, so that an “unconscious” in a bus station at 3 a.m. doesn’t necessarily get the same response as an “unconscious” in a bus station at 8 a.m.
I think in 10 years New Jersey’s mobile system will look essentially similar. EMT-level care will be provided primarily by hospital-based and government-based systems, with volunteers still functioning as a safety net service on nights and weekends in some communities. Mobile intensive care will still be provided by regional, dual-medic, hospital-based units, although we may have more joint ventures. Both these models are clinically and economically efficient.
What will be different? Mobile healthcare communications will be seen as much more important and be more accurate. We will arrest the 5% annual growth in 9-1-1 call volume (seen globally for over a decade) through rational economic changes that force better decisions, such as a $1 toll on 9-1-1 calls to limit pocket dialing, a point-of-care fee to ensure ambulances are more expensive than taxis, and strictly following CMS’ current medical necessity rules. Hospital emergency departments will be only for serious and critical patients, with all other patients deferred to settings like urgent care. I think we’ll see EMT-level education and care become more complex as skill sets increase. Mobile intensive care will transition with bachelor-prepared paramedics (not because a degree is so important but because at 46 credits on average, it will break the associate degree model) with more nurse and midlevel clinician involvement. There probably should be fewer helicopters in dense New Jersey, but a lot more mobile specialty care transport units as hospitals move toward a hub-and-spoke model of care.
Volunteerism is on the decline nationally. What are some things your office is doing or has planned to recruit and retain volunteer EMS in the state?
New Jersey’s EMS system has spent the past 40 years transitioning from a predominantly community-based volunteer ambulance model (at least at the BLS level) to today, where volunteers primarily serve as a safety net overnight and on weekends in suburban and rural areas. To be honest, the cost of living in New Jersey means most households need to have two incomes, so I don’t think there’s any turning back. What I would like to see is more focus put into transition planning from volunteer to career models, and to break the “McJobs” model of no benefits/low pay/no retirement that is so prevalent in EMS. If volunteers think this job is important enough to volunteer their time for, then when it’s time to hire career staff, they should be the first ones advocating that the career EMTs should get the same pay, benefits, and retirements that towns pay their police officers.
More than a decade ago, you wrote “The Failure of EMS” for EMS World. What’s different now?
Mobile healthcare clinicians still lack a sense of agency. They don’t seem to want to take either responsibility or assert control over their profession like they’ve done in Canada, Australia, and the U.K. While mobile healthcare is medicine, it is medicine in the mobile healthcare setting, and we should own that. People injured or sick? Back up, law enforcement and fire service, this is ours. You can help, but this is ours. Rescue where a patient is involved? Ours. Talking to the media about crash victims? Ours. Restraining an emotionally disturbed patient? Ours.
Healthcare leadership still talks about fee-for-service when it comes to paying clinicians but then talks about “downstream value” when forcing mobile healthcare to bid on the money-losing-but-valuable downstream-patient contracts. You still can’t have it both ways. EMTs are still typically paid at below living-wage levels (unless you’re a municipal employee), although paramedic salaries range from $50,000–$97,000, which is not perfect but not poverty either.
The line between EMTs and paramedics is narrowing, although their education is not. Paramedic education is moving to a bachelor’s degree model. EMT education should be moving to a one-year certificate with at least several hundred hours of high-volume residency on an ambulance. Nursing has taken more of a role in mobile healthcare in New Jersey—in mobile intensive care, mobile specialty care, and mobile aeromedical care. I think that’s great, and we’re working on helping a doctorate of nursing practice program create a mobile healthcare track. There are still no masters or doctoral programs in the U.S. focused on mobile healthcare policy.
Emergency medical service programs that are not direct government employees are still not covered by the federal Public Safety Officer Benefit program. We need to fight this battle.
Barry A. Bachenheimer, EdD, FF/EMT, is a frequent contributor to EMS World. He is a career educator and university professor with more than 33 years in EMS and fire suppression. He is currently an EMT with the South Orange (N.J.) Rescue Squad, a firefighter with the Roseland (N.J.) Fire Department, and an instructor at the National Center for Homeland Security and Preparedness in New York. Reach him at firstname.lastname@example.org.