A 12-year-old boy flips his skateboard in his garage, causing a small laceration on his scalp that needs a few sutures.
An 8-year-old with established asthma has a cough with minimal wheezes and a fever.
An afebrile 32-year-old man has had a productive cough for five days, but he hasn’t been able to get in to see his primary care clinician.
What do these patients have in common? They were all seen in the local emergency department. For a plethora of reasons, our emergency departments are being filled to overcrowding with cases such as these (and many others). Is there an opportunity to create a primary care solution within our communities to care for these patients?
Many NPs and PAs—myself included—started their career in medicine either in the military as a medic/corpsman and/or in prehospital care as an EMT/paramedic. It was a great stepping-stone to the role of an NP or PA. After school, many NPs and PAs actually went back into the military or into emergency medicine. Now, some are saying, it is time for NPs and PAs to expand back into the prehospital arena.
Originally, the purpose of prehospital care was to provide patients, and the community in general, with the urgent medical care that is needed before and during transportation to a hospital. Because of the current barriers to primary care in this country, many patients are opting to go directly to the emergency department and wait anywhere from four to 14 hours to be seen for such ailments as minor lacerations, viral gastroenteritis, sore throat, minor injuries, and many other conditions that primary care clinicians traditionally handled decades ago.
Over the past decade, there have been a number of pilot programs in this country that looked at utilization of NPs and PAs in prehospital care. One such program took place in Mesa, Arizona, a little over two years ago. The Mesa Fire Department, under the auspices of Dr. Gary Smith, created a program in which NPs and/or PAs led a unit with a paramedic driver that responded immediately to medical emergencies or urgent situations in the home so that the patient did not have to seek care at the local emergency center. This program was designed to free up fire engine and ladder trucks and ambulances for more life-threatening situations.
If you have ever been at a scene after a 911 call, you would not be surprised to see a fire engine, a rescue unit, and perhaps an ambulance there. Many prehospital responders will admit that they have transported patients to local emergency departments for conditions that easily could have been cared for by a clinician visiting the home.
In this pilot program, the NPs or PAs, dressed in scrubs, were assigned to the firehouse, where they waited with their paramedic counterparts until a 911 call was dispatched. The NPs and PAs arrived at the scene equipped with a full complement of advanced life support equipment, including a 12-lead monitor, a pulse oximeter, and a box of medications.1
This particular pilot program was instituted first and foremost to provide a community service to individuals by delivering top-notch, quality health care in a time and place that was convenient.
The second goal was to avoid unnecessary and costly transportation and care by dispensing immediate medical services to patients who otherwise would be transported to the local emergency room.
Third, it not only freed up the firefighters to be available for other emergencies, it freed up the clerical/administration people and clinicians at the emergency room to attend to more immediate problems.
Another important component of the program was the after-care. The NP or PA provided a follow-up phone call to every patient he/she saw, in order to determine whether the patient had filled the prescription, required a visit to the ED anyway, or needed follow-up care. The NP and PA had a list of local clinicians for appropriate referral, should the patient not have a primary care clinician.
This pilot project lasted 60 days, after which the results were evaluated.
As you can imagine, the numbers as well as anecdotal discussions were all positive. As with any program that does not fit into the current health care system, there were barriers. The largest barrier, of course, was compensation to cover the cost of the program. Most third-party payers were hesitant to provide coverage and, in most cases, patients are not in a position to pay. Also, developing a billing or charging system in a prehospital scenario is problematic.