The chronic shortage of emergency nurses has inspired the clever idea of staffing crowded hospital emergency departments
with paramedics. Not everyone likes the cure.
By Douglas Page © 2001
A decade of cost cutting in medicine has left emergency healthcare in critical condition. Because of closures and staff
cuts, hospitals around the country report similar problems such as understaffed and crowded emergency departments leading
to long waits for emergency care; patients kept in emergency departments for hours, and sometimes days, because no beds are
available in hospital ICUs; and ambulances forced, in effect, to circle like jetliners stacked in crowed landing patterns,
diverted farther and farther to find an open bed - all of which place the patient at risk for poor outcome.
The situation is acute. A recent report (Ann Emerg Med, 2000; 35:63) warned, "Unless the problem is solved, the general
public may no longer be able to rely on emergency departments for quality and timely emergency care, placing the people of
this country at risk."
Some experts fear the problem will get worse before it gets better, as hospital finances continue to shrink under the pressure
of insurance companies and Health Maintenance Organizations to do more with less, as a nursing shortage grows and as more
Americans find themselves without health insurance.
Solution at Hand
One solution to ED understaffing may be as close as the nearest firehouse.
Though not exactly new, the idea of using paramedics to staff understaffed hospital emergency departments (ED) is as persistent
as it is unorthodox.
Paramedics have been incorporated into the staffing of some EDs for 10 years or more. A 1999 survey by the American College
of Emergency Physicians (ACEP) found that 20 percent of U.S. hospitals employ paramedics. Turf battles with nursing organizations
have prevented the concept from gaining widespread acceptance.
However, because of the drastic overcrowding and chronic understaffing in most U.S. urban EDs, some emergency physicians
think maybe the time has come. ACEP has formed a task force to look at the issue of alternative staffing with nurse practitioners,
physician assistants, emergency medical technicians and paramedics.
With the average emergency department treating a census of 20,000 patients per year, usually with only one EP at a time,
support staff are generally stretched to the limits of efficiency.
Generally, overcrowding in emergency departments is the result of hospital and trauma center closures, leaving fewer emergency
rooms to see more patients. According to the American Hospital Association, 1,128 EDs in the U.S. closed from 1988 to 1998.
Also, an increasing number of uninsured patients with no access to healthcare use emergency departments for their primary
medical needs. The number of uninsured persons in the U.S. is estimated to be 44 million and growing.
At many emergency departments, EPs themselves have implemented back-up physician coverage whenever the ED becomes too busy
for one physician to manage alone.
"One of the frustrations that occurs when a second physician is called in to help with a heavy patient load is the hospital’s
inability to gear up ED staff as commensurably and rapidly," said W. Richard Bukata, MD, director of emergency medicine, San
Gabriel Valley Medical Center in California, writing in the April, 1999 issue of EMN. "Without additional nurses, clerks and
technicians, the backup physician is likely to operate at suboptimal capacity because support staff is usually stretched thin
helping the first physician."
This is the reason some emergency physicians crave the ready resource the paramedic pool across the street at the fire
"Why aren’t paramedics allowed to use their skills in the ED when, in fact, they’re allowed much more clinical
latitude to practice in the field without direct supervision than most nurses are allowed in the ED with a physician only
steps away?" Dr. Bukata said.
Dr. Bukata, and other EPs, would like to see some system develop in which paramedics waiting to be dispatched (which occurs
on an average of about one every three to four hours in his community) are based at hospital emergency departments where they
could not only be more productive, but could hone their skills while waiting to roll on the next call.
The issue is political dynamite. Everyone seems to have an opinion on the subject, most of them unfavorable.
The National Association of Emergency Medical Technicians (NAEMT) has no official position on the issue, but a member of
the NAEMT Executive Council, Jerry Johnston, REMT-P, director of emergency medical services, Henry County Health Center, Mt.
Pleasant, Iowa, supports the idea as long as there is clear-cut delineation of responsibilities when paramedics are used to
augment existing nursing staffs.
"Paramedics should be allowed to function to their level of training and not be relegated to the position of mere orderlies,"
His fear is, due to the politics involved in turf skirmishes, that paramedics proficient in suturing, assessments, intubation,
drug administration and the use of cardiac emergency equipment, could end up merely feeding, ambulating and toileting patients.
Concern that paramedics will be exploited in hospital settings as nothing more than orderlies is a popular worry.
"Using fire department paramedics in emergency departments is not a good idea," said Kevin White, director of emergency
medical services and health and safety for the California Professional Firefighters (CPF), a statewide union representing
24,000 professional firefighters and 141 locals. "Our basic position is, why should paramedics be slave labor for the hospitals
who won’t put on enough staff to take care of their needs?"
CPF is not opposed to off-duty firefighters/paramedics working for a hospital, so long as they’re allowed to utilize
their full scope of practice as a paramedic.
"But it won’t work while they’re on duty, between calls," White said. "They’ve got to be available for
emergency response. If you’re tied up with a patient in the ED that can be a tremendous impact on resources."
Nevertheless, some believe that when implemented properly the use of paramedics to staff emergency departments could be
a win-win situation for all parties concerned - paramedics, hospitals, ED nurses and allied staff.
"Wouldn’t the opportunity for the staff to intellectually cross-pollinate each other in the process of care be ultimately
best for patients?" Dr. Bukata wonders. "Wouldn’t the ED staff be better able to appreciate the prehospital perspective
working side-by-side with paramedics?"
While the answers to these questions may seem intuitive, few proponents of the idea are optimistic, given the turf issues
at hand. The idea is a hard sell, especially to nursing organizations.
The American Nurses Association (ANA) says the whole issue is predictable, that during times of shortage of registered
nurses and licensed practical/vocational nurses, there’s always a regrettable trend to deregulate and substitute lesser
According to ANA’s 1992 Position Statement, "Other regulatory entities have been pressured to lower agency staffing
standards, for instance by allowing emergency medical technicians to function in the emergency room without registered nurse
supervision or by substituting unlicensed personnel for licensed nurses. These unlicensed persons have not completed nursing
education programs, or met other licensing requirements. In many instances, substitution of unlicensed personnel for licensed
nurses clearly violates state nurse practice acts. At the very least, it is not in the interest of the health, safety, and
welfare of the public".
Emergency nurses believe the ED understaffing problem can be more properly solved by hiring, or re-hiring qualified nurses
let go during downsizing, not by employing less expensive and, in their view, less skilled, paramedics.
According to Mary Jagim, RN, president of the Emergency Nurses Association (ENA), "The use of paramedics in the emergency
department would fall under the ENA Position Statement of use of unlicensed personnel in the ED, which is that the registered
professional nurse is an essential element in the provision of quality, safe, and cost efficient care whether involved in
patient care, or in directing non-RN caregivers."
Jagim said that while paramedics can provide an important augmentation to staffing in an ED, she doesn’t believe
they should be staffed in place of nurses.
The 30,000 member California Nurses Association considers the notion nearly moot, that any movement attempting to use paramedics
to staff EDs isn’t likely to go far. In California, paramedics have been given special consideration to work in rural
hospitals, but not anywhere else, said Jill Furillo, RN, CNA’s director of governmental relations.
"We just got a bill passed and signed that establishes minimum nurse-to-patient ratios in all areas of the hospital, including
the ED," she said. "Plus, there are proposals in about 30 other states to follow California’s lead in establishing minimum
nurse-to-patient ratios. What hospitals have been doing is eliminating nurses in the hospital, then bringing in untrained,
unlicensed people. It’s had a detrimental effect on patient care and that’s why Gov. Gray Davis signed the bill."
Besides, she said, the issue isn’t whether paramedics should be used in the ED, the real issue is that EDs are closing.
"I would be more concerned about the fact the EDs are closing down in this state," she said. "What kind of strain is that
going to have on paramedics who are already stretched? Those are the issues that we need to be discussing in relation to paramedics,
not expanding their scope of practice by bringing them into EDs - the EDs are closing down. What’s going to be happening
out there in the field when they have no ED to bring the patient to and they have to transfer critically ill patients longer
distances? What are they going to do if there’s a disaster?"
While nursing staffs at some hospitals are uncomfortable having paramedics in the ED, in some locations there is also a
legal liability issue to consider.
"In many states, in order to utilize paramedics in the ED the EP has to be responsible for them, which is a disadvantage
compared to nursing personnel, who essentially work for the hospital under their own license," said Dr. Robert Suter, chair
of ACEP’s Clinical Policies Committee and member of the Staffing Task Force. "The EP has to be responsible for their
competency and clinical supervision. That’s a disadvantage to many EPs."
Nursing laws as enacted in the U.S. are also a consideration. States have nurse practice acts that are either delegating
or non-delegating. In a delegating state, an RN is empowered under the law to delegate clinical tasks to non-RN personnel,
such as aides or paramedics. For example, Michigan is a delegating state, which means if the hospital hires a paramedic the
nursing staff at the hospital are 100 percent responsible for that paramedic; the nurse manager in the ED is not only their
administrative supervisor, but also their clinical supervisor.
But in Texas, and other non-delegating states, it’s illegal for a nurse to delegate clinical tasks to a non-nurse,
such as a paramedic.
The turf wars may lead to clever compromises, such as the one in effect at Tacoma General Hospital, which for the past
10 years has hired off-duty paramedics to work in the ED, but only after the paramedics are licensed by the state as Health
Care Assistants (HCA).
"In the beginning, there was a bit of concern from the nurses," said Gary Aleshire, EMS liaison to the Western Fire Chiefs
Association. "The ENA addressed it with the hospital, but it’s to the point now that they’re using the paramedics/HCAs
as regularly-scheduled personnel. They have their ED staff which they always augment with an HCA because they know they’ll
need the extra hand."
While the program is designed to benefit the hospital, paramedics are also beneficiaries. Aleshire has experience as an
HCA himself. "Before I got thrown into the administration role I did it for a couple of years, and the amount of knowledge
you gain is substantial."
Aleshire, who serves also as chief of medical services for the Lakewood Fire Department in Tacoma, Wash., has a one-sided
mutual aid agreement with the local VA Hospital, as well as with the ED in a nearby 80-bed community hospital, to furnish
paramedic relief whenever either ED facility becomes overly congested.
"At times we get called to the hospital with our resources because the ED is saturated," he said. "We send a medic unit
or an engine company over to perform some non-invasive processing, blood pressuring and monitoring of patients."
Other times, the VA will ask for help with a difficult intubation. "They’ve called us a couple of time to come over
and assist the emergency physician when they didn’t have a respiratory specialist in house to do a procedure," Aleshire
said. "At the VA Hospital, their capabilities are taxed and they don’t have enough help on campus at all times, so we
send medic units over to do intubations and other activities."
Working in the ED, however, is not for everyone, said NAEMT’s Johnston. "Many EMS providers want to work in the prehospital
arena only. They don’t want to function in the confines of a hospital. It takes a certain type of individual and personality
to function there."
It’s not so much the type and quality that distinguishes nurses from paramedics as it is the focus of the training.
"On a basis of clock hours per month, nurses are always going to have more education than paramedics do," Dr. Suter said.
"However, a paramedic’s education is focused on emergencies."
For example, it’s possible to graduate from nursing school with as little as eight hours of ED exposure, whereas
a paramedic will have hundreds of hours of ED exposure when they graduate from their training program, Dr. Suter said.
It’s this emergency focus that EPs find attractive. "EPs generally like everybody to be focused on the worse possible
condition that a patient can have," Dr. Suter said. "If somebody presents in the ED with a headache, we want everybody’s
first thought to be that this is a subarachnoid hemorrhage."
This is the way paramedics are trained. They aren’t taught the nine causes of headache, so if a paramedic is triaging
a patient they’re thinking of the life-threats immediately because that’s what they know best, Dr. Suter said.
Whereas, in nursing school, nurses will have learned all the causes of a headache and will not necessarily be thinking from
a strictly life-threat standpoint.