Joseph Gates, MHA, NRP

Sanghavi, Jena, Newhouse and Zaslavsky (2015) conducted a study that analyzed Centers for Medicare and Medicaid Services (CMS) claims between 1 January 2006 and 2 October 2011 from a 20% random sample of Medicare fee-for-service beneficiaries who lived in non-rural counties and that were transported to a hospital for out-of-hospital trauma, stroke, AMI, or respiratory failure.

Sanghavi et al., (2015) contended that advanced life support (ALS) accounted for 65% of emergency medical care among Medicare beneficiaries; and that rate is even higher among patients with high-acuity conditions, such as stroke. Additionally, Sanghavi et al. assert ALS ambulance crews are trained and equipped to provide sophisticated care on site or in a “stay and play” scenario; whereas basic life support (BLS) crews utilize a rapid transport to the hospital mentality, indicating that BLS ambulance crews provide only minimal treatment at the scene, “Load and Go.”

Sanghavi et al., (2015) suggest that providers can use invasive interventions, such as endotracheal intubation for airway management and intravenous catheters for drug and fluid delivery, BLS providers use noninvasive interventions, such as bag valve masks for respiratory support. The ALS providers spend more time at the scene on average in order, according to Sanghavi et al. to receive higher reimbursement.

            Sanghavi et al., (2015) purposed that their study investigated the differences in outcome between BLS care and transport compared to ALS care and transport.  The areas that the study investigated were trauma, respiratory failure, stroke and acute myocardial infarction (AMI).  The authors concluded that survival for patients experiencing AMI to 30 days did not statistically significantly differ between ALS and BLS care in propensity score analysis. At 90 days, however, survival was 1.0 percentage point higher with ALS care.

In the Trauma propensity score analysis, survival after BLS care was 6.1 percentage points higher at 90 days. In instrumental variable analysis, patients receiving BLS were 4.1 percentage points more likely to survive to 90 days. Respiratory Failure, survival with BLS was 3.7 percentage points higher at 90 days, but in instrumental variable analysis, there were no statistically significant survival differences between ALS and BLS.  Stroke propensity score analysis, 90-day survival was 7.0 percentage points higher with BLS care (Sanghavi et al., 2015). 

Sanghavi et al., (2015) determined that ALS practitioners may delay hospital care that would otherwise lead to definitive clinical management, by delaying transport to performed ALS interventions such as intravenous access or endotracheal intubation; even as clinical guidelines recommend not delaying transport for prehospital interventions. One example cited, is an Ontario study of ALS versus BLS for the treatment of cardiac arrest, the median time that ALS crews spent from arrival at the patient's side to arrival at the hospital was 27 minutes, whereas the corresponding time for BLS crews was only 13 minutes according to Stiell, Nesbitt, Pickett, Munkley, Spaite, Banek, et al., (2008).

Stiell et al., (2008) stated that for trauma patients in the Ontario study, on scene times were 22 minutes for ALS crews and 19.1 minutes for BLS crews. Additional areas of concern according to Sanghavi et al., (2015) is the prehospital use of endotracheal intubation by ALS practitioners has the high probability of risks. Successful intubation requires high competency and continued practice, but in Pennsylvania, the median paramedic did only one intubation annually.

Bag valve mask ventilation, commonly performed by BLS providers, may not pose the same threat of harm as the time to taken on scene to perform intubation or unsuccessful intubation attempts. Finally, several studies suggest that prehospital administration of intravenous fluids may be harmful to patients with major penetrating trauma, which may partly explain worse outcomes associated with ALS in trauma patients (Sanghavi, et al., 2015).

            Sanghavi et al., (2015) concludes that despite the prevalence of ALS pre-hospital medical units, there is sparse evidence that support’s the value of ALS level pre-hospital care. Sanghavi et al., cites numerous studies from outside the United States that illustrates evidence of similar or longer survival associated with BLS pre-hospital care. Furthermore, Sanghavi et al., goes on to suggest that in addition to potentially better outcomes, greater use of BLS would also save money; citing 2011 CMS reimbursement levels of ALS and BLS, Medicare would have spent $322 million less on ambulance services in 2011 if all ground emergency rides had used BLS.

This study seems to take a very generalize analysis of the Emergency Medical Services (EMS) care when evaluating BLS versus ALS care in the pre-hospital arena.  I had many preliminary questions after initially reading this study; such as Sanghavi et al., (2015) do not indicate the patient’s initial condition upon arrival and which ALS interventions were performed?  Additionally, the study fails to define respiratory failure, is it evaluating heart failure, congestive heart failure, respiratory failure secondary to severe asthma or anaphylaxis?

Additionally, what was included in the trauma analysis? Did the study take in account initial trauma scores and Glasgow Coma Scale (GCS) and compare it to the revised trauma scores and GCS upon arrival to the hospital?  Were all trauma patients transported to a trauma center and did that trauma center hold a Level I or Level II trauma designation?

Also, this study is indicated for an urban environment which traditionally has shorter transport times greater access to definitive care and advanced trauma care; there is not a comparison to suburban or rural patient outcomes and patient side to transport arrival at the facility or patient outcomes at the least the, 90-day bench mark.  Do patients that receive ALS care in suburban or rural areas have a better 90-day outcome?

The study by Sanghavi et al., (2015) occurs between the 2006 and 2011, time frame which occurs during a major American Heart Association (AHA) BLS and ACLS Update with the BLS update focusing on compressions first prior to airway and breathing management. The ACLS calls for early defibrillation in cardiac arrest with V-Fib and pulseless V-Tach, did the study take into account changes the AHA algorithm changes.

Paramedic’s possess a unique skill set, especially in the areas of airway management which includes basic airway adjuncts, supraglottic airway devices and advancement airway management techniques such as endotracheal intubation and ventilator management.  Paramedics also possess the ability to treated many cardiopulmonary disease exacerbations such as congestive heart failure and respiratory diseases such as severe asthma and chronic obstructive pulmonary disease.  When cardiac emergencies arise, paramedics have the training and knowledge to assess cardiac conditions and treat life threatening bradycardia’s and tachycardia’s applying electrical therapies and pharmacology necessary to treat or stabilize patients to transport them to the hospital for definitive care.

In the last three years as a EMS educator with the introduction of the Advanced EMT curriculum, I have begun to witness these students progress into the Paramedic curriculum.  One of the noticeable benefits and maybe one of the unintended consequences of the Advanced EMT curriculum, is that this next generation of paramedic students have a good foundational understanding of pathophysiology and critical thinking skills.  Additionally, these students progress through the paramedic course with greater ease and understanding building on their critical thinking ability and skills.

Within the next five years I believe that the EMS industry will change dramatically to make adjustments to the changes of the Patient Protection and Affordable Care Act (PPACA).  Sanghavi, Jena, Newhouse and Zaslavsky (2015) may have been misguided in their assertion that BLS ambulances have better outcomes than ALS ambulances, however they do shed light on a valid point.  Is a paramedic, with all of their special training needed on every 9-1-1 response? 

The Advanced EMT (AEMT) has the ability perform interventions and provide pharmacological treatments for anaphylaxis, hypoglycemia, cardiac chest pain and asthma.  Additionally, as compression devices and Automatic External Defibrillators (AED) become more common in the industry and public, the AEMT’s are capable of responding to cardiac arrest.  An argument can be presented that if AEMT’s can administer epinephrine for anaphylaxis than administering epinephrine in a cardiac arrest situation is not unreasonable. 

With additional training, paramedics can be trained to the Community Paramedic (CP) level and serve in a dual role. Working within their community’s needs or serving as an extension for the community hospital, a CP can work to prevent exacerbations of chronic illnesses for the “at-risk” population within the community with disease conditions such as congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD) and mental illness crisis to name but a few.

When a 9-1-1 dedicated unit staffed with two AEMT’s responds to a call that requires a Paramedic level assessment or intervention, the available CP can then intercept that 9-1-1 unit, assess the patient, determine what higher level care that patient needs and ride in with the patient as the another AEMT drives the CP vehicle to the hospital.  Advanced airway management, severe respiratory distress, specific cardiac conditions, and isolated orthopedic trauma pain management are just a few of the conditions that a Paramedic can treat in assistance to the AEMT’s.

The future of health care will revolve around an integrated healthcare model and the EMS industry has the opportunity to play a vital role in the new healthcare environment, if EMS organizations have the foresight and wisdom to seize the opportunity.  Paramedics who are accustomed to working in dynamic conditions should be able to easily transition from a CP role to a 9-1-1 responder role. 

The design described above is just one in which CP and Paramedics can make a dynamic change to the care that is provided to the public in the post PPACA world.  As long as medical directors and EMS organizations are able to appropriately train and deploy the CP armed with “living” guidelines rather than ridged protocols, the future for the healthcare industry and EMS can be exhilarating.

Sanghavi, P., Jena, A. B., Newhouse, J. P., & Zaslavsky, A. M. (2015). Outcomes of basic versus advanced life support for out-of-hospital medical emergencies. Annals of Internal Medicine, 163(9), 681. doi:10.7326/M15-0557

Stiell IG, Nesbitt LP, Pickett W, Munkley D, Spaite DW, Banek J, et al; OPALS Study Group. The OPALS Major Trauma Study: impact of advanced life-support on survival and morbidity. CMAJ. 2008; 178:1141-52. [PMID: 18427089] doi:10.1503/cmaj.071154