Less is More

It made national headlines, has emergency medical directors rethinking paramedic deployment, and sent a wake-up call to any EMS director who thought higher staffing would translate into better outcomes. The “it” in this case is a five-city study showing that fewer paramedics are associated with higher cardiac survival rates in urban areas. The study was presented at the annual meeting for the Society for Academic Emergency Medicine. Almost instantly, it was the darling of the media, hitting the pages of USA Today under the banner, “Cities that Deploy Fewer Paramedics Save More Lives.” “It touches a nerve,” said Dr. Sayre in explaining why the findings of an academic presentation made such a splash. For one thing, it's a sound bite that sounds too odd to be true: The fewer the paramedics in the system, the more likely patients are to survive. More Skilled? He cautioned, however, that what remains unexplained is whether the data reflect a direct result, achieved because a relatively low number of paramedics who administer advanced life support are likely to become more skilled at it or whether the correlation is a sign that something else may be occurring, such as more intensive training among systems that have fewer teams or personnel. “It could be a marker; it could be a causal. We don't know,” said Dr. Sayre, an associate professor of emergency medicine at Ohio State University Medical Center in Columbus.FigureWhat is known is that the system cannot be pared down to compromise first response times. “That is far and away the most important,” he stressed. The study reaffirmed that, particularly in younger women with ventricular fibrillation arrests who were treated in public. They had the best chance of survival, but bystander cardiopulmonary resuscitation also proved beneficial, showing better survival trends. Strikingly, the second tier of treatment, the time to advanced life support (ALS) vehicle, was not significant. The findings didn't come as a big surprise to some emergency physicians, including Corey Slovis, MD. The fact that a relatively high case number for paramedics goes hand-in-hand with patient survival to discharge “is absolutely consistent with what we see in medicine,” he said. “When procedures are performed routinely, it is reflected in outcomes,” said Dr. Slovis, a professor and the chairman of emergency medicine at Vanderbilt Medical Center who serves as Nashville's EMS medical director. The results of the study by Michael Sayre, MD, and colleagues mimic findings across health care, Dr. Slovis said. Conversely, when procedures such as intubation are done more infrequently, success rates are lower, he added. Dr. Slovis said the findings are a matter of common sense. Some cities have busy areas or “quiet zones,” and the paramedics who serve such locations have more (or less) opportunity to perform intubation and other life-saving measures, simply as a result of geography. Of great concern to him is that the study revealed that paramedics may be averaging one intubation a year in some areas. Even in urban areas where there is not much variation, the size of the EMS force can make a huge difference. “You take a city that has, say, a thousand intubations a year, and let's say it has 200 paramedics. That is, on average, five intubations a year,” Dr. Slovis noted. “Let's say the number of paramedics is double that. Well, now it is down to 2.5 intubations a year.” If specialty training and practice in other areas of medicine confer expertise that translates into better results, how can that be applied to the EMS system? Everyone in it paramedics, EMS directors and emergency physicians needs a credentialing procedure, “one that is objective, periodic, and routine,” Dr. Slovis said. Improved Outcomes That is certainly an idea that keeps coming up. Three years ago, the physician director of the Houston EMS system with investigators at Baylor College of Medicine, the Houston Medical School at the University of Texas, and Ohio State University looked at cardiac arrest survival as a function of ambulance deployment strategy. Though limited to a single geographic area, this study showed definitively that outcomes for cardiac arrest patients improve when they are cared for by paramedics than by basic EMTs. (Resuscitation 2003;59:97.) What was the difference? The busy urban area used paramedics, and a suburb used EMTs. The authors said the study demonstrated better response times and better skills proficiency by the “targeted-response” team in the urban core, or as they call it, the TR paramedics. “These data support the use of ‘tiered’ EMS deployment strategies,” they wrote, adding that “it is inconclusive whether the survival difference is related to superior critical thinking as well as enhanced clinical and technical skills on the part of the TR paramedic, shorter response interval, or a combination.”Figure: Dr. Michael SayreDoes this mean some sort of routine certification to assess skill level is an idea whose time has come? If steps were taken to make credentialing mandatory, resistance would rear its head, Dr. Slovis observed. But that shouldn't be a deterrent, he said, noting that “the most out-of-practice doctors often are the most fearful that inabilities might be recognized.” A central line insertion, for example, is something one health care provider might be able to do “practically blindfolded” while another finds it a struggle. This can be said of emergency physicians just as it can of paramedics, but “there is much more variability at the EMS level,” Dr. Slovis added. Dr. Sayre declined to speculate on how EMS providers might be credentialed, but conceded that he could understand how the question might arise, given the accumulating data. The study he and colleagues conducted included researchers from the University of Washington in Seattle, the University of Pittsburgh, and several Canadian agencies: the British Columbia Ambulance Service in Victoria, the Calgary Emergency Ambulance Service and the Calgary Emergency Medical Services, both in Alberta, and St. Paul's Hospital in Vancouver. 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