Summary of September, 2013 NEMSAC meeting

Summary Report

from the September 5&6, 2013 meeting of the

National EMS Advisory Committee

By Alan Perry 9/7/2013

I embarked on a journey to Washington D.C. this week for the September NEMSAC meeting. I was really interested in finding out what was going on at the national level with all the recent changes facing EMS, and I wanted to get the information from the source, unfiltered and without editorial spin. I ponied up the time and the money to make this happen and cover my expenses for the two-day meeting. Please keep in mind that what I am presenting here is largely what I heard, not necessarily an absolute account of the events or statements made. I have tried to the greatest extent possible to be inclusive and factual in my accounts, and have made some of my own personal thoughts known as well. The meeting agenda, which is determined by the Designated Federal Official (DFO) and the committee chairman, was published about ten days before the meeting and included items that both my agency and the regional EMS council have been struggling with for some time. Since the council consists of a broad spectrum of EMS players, all considered experts in their field, it seemed like the perfect place to get the best answers and understand how Federal agencies NHTSA, FICEMS and HHS will be likely to respond. As it turns out it is a good deal more complicated than that, so I will start buy trying to explain this bureaucracy to you. The information I gathered in the meeting is useful if it is taken in context, but this organization does not operate like a fire department, rescue squad or business, has no real authority, and is only permitted to act in an advisory capacity to NHTSA, HHS & FICEMS. All discussions, decisions and information gathering must be done in a public forum to assure transparency, which is a good thing, but it does slow things down.

Prior to the first days meeting the DFO, Mr. Drew Dawson, introduced himself to me and welcomed me to the meeting, I found out rather quickly that getting any comment about pending legislation either officially or as a personal opinion was not likely to happen from a government official. Mr. Dawson, and the chairman Aarron Reinert, maintained a fair and even hand throughout the two-days of the meeting and represented DOT, NHTSA and NEMSAC very well. Other officials in attendance, but not directly involved with the committee, were a bit more forthcoming and even offered assistance to my agency or personally if additional information was needed. All of the council members, federal officials and organization representatives in attendance were very approachable and eager to provide their insights if asked. Other members of the NEMSAC included representatives from volunteer EMS, EMS research, EMS educators, EMS practitioners, EMS medical directors, consumers, trauma surgeons, hospital administrators, local EMS directors, emergency nurses, air medical, state highway safety, 911 dispatchers, private EMS, emergency physicians, state EMS directors, data managers, public health, fire-based EMS, state and local legislature, hospital based EMS and pediatric emergency medicine. There were others in attendance from the IAFF, NAEMT, NREMT, IAFC, NASEMSO, HHS, NHTSA-EMS, DHS, DOT, DOD, local fire departments & myself who were there to present, observe and comment.

Mr. Dawson opened the meeting by stating that he was impressed with the council’s performance and reminded attendees that the council will affect planning at FICEMS. Mr. Reinert stated FICEMS is expressing great interest in the activity of NEMSAC and is looking for 3-5 specific items to work on. Terms for some members are about to expire, new and different members need to step up and bring new issues to light as they are found. He reminded members of the three core values of NEMSAC; Visionary, Strategic and Diligent. After the initial introductions and housekeeping were out of the way the agenda kicked off with the federal updates from DOT, DHS USFA & HHS.

Federal Updates

DOT-  Keith Williams spoke briefly emphasizing that EMS extends beyond NHTSA, the purpose of the Federal Highway Administration (FHWA) is to reduce injuries and fatalities on all public roads with prevention being key in the design of the State Highway Safety Plans (SHSP’s) and includes EMS in the four E’s enforcement, engineering, education & emergency medical services. Mark Kehrli, Director of FHWA, showed a brief video and explained the importance of getting all highway workers including police, fire, and EMS and recovery services on the same page when it comes to safe and efficient scene clearance. FHWA has a new traffic incident training program out with the goal of training 50,000 responders within 3 years. This program is already being offered in southeastern Virginia.

DHS- Bill Sector, DHS liaison of the NASEMSO, suggested that the NEMSAC continue to look for practical solutions to known problems and continue to be the voice for EMS including support for community paramedicine. There is a need for greater integration among fire/police/EMS at major events such as mass shootings, a problem well known in southeastern Virginia. Common problems are still with communications and lack of knowledge of other services terminology and tactics. There may be a need for EMS to start entering scenes in less than ideal circumstances if lives are to be saved, perhaps adopting the philosophy of fire-fighting where more risk is acceptable where lives can be saved. Human trafficking is becoming a greater problem, EMS is in a unique position where they may be the first to identify it, a new program called the “Blue Campaign” is attempting to address this, it can be found online at DHS.gov\bluecampaign.

USFA- Mike Stern; NFA is developing more courses for EMS recognizing that EMS is 80% of what most fire services are doing. Since the NFA is not a traditional supplier of EMS education perhaps the council can push the information out, the classes are free. As courses pick up EMS instructors will also be needed as well as ideas for useful new EMS courses.

HHS- Greg Margolis; Referenced the innovation white paper relating to increased EMS demand incidents (MCI?). He introduced web resources for public heath emergencies (phe.gov) and the Hospital Preparedness Program (HPP). Announced operation bioshield, which is an EMS countermeasure involving stockpiling of WMD medications (similar to MMRS?), he reminded the council that preparation for major incidents both hospital and pre-hospital remain woefully inadequate. A reminder was given that the PPACA provision for open market health insurance opens October 1^st.

Stakeholder reports

DHS- Bill Seifarth; discussed the need for changes in how EMS approaches mass shootings and IED’s, the activities of Police/Fire/EMS need to be better integrated and new tactics such a tourniquets, hemostatic agents and the use of body armor need to be considered more fully. Response and incident management training, NIMS standards, plans and exercises need to occur to prevent interoperability failures. The traditional role of EMS staging until the scene is “safe” will cause significant loss of life and increased injury severity in mass shootings and IED events due to the nature of the injuries, there needs to be dialog to resolve this. Chief Sinclair, representing fire-based EMS, commented that the NEMSAC should lead the change in doctrine and policy related to these events. The Chief’s remarks and the concerns of DHS echo the concerns I reported to my agencies command staff after a school shooting exercise we conducted several years ago. In those comments I suggested adopting the same doctrine we apply to a fire incident where risk is based on the probability that lives will be saved, put simply we risk a lot to save a lot, we risk nothing to save what is lost.

NASEMSO- Dia Gainor, representing the National Association of State EMS Officials, provided information on EMS workforce guidelines. There is a new publication titled National EMS workforce data definitions which identifies the characteristics of the EMS workforce as well as those seeking EMS education or employment.

DoD- Marion Cain stated there is difficulty transitioning EMS providers from the military into civilian EMS upon their separation from the armed forces. Correcting this problem will improve employment opportunities for veterans. Gaps exist in the training provided by the military and civilian EMS, the goal of the proposal is to provide gap training and there are currently 280 in a pilot program. Bridging this gap and allowing these veterans to transition to civilian employment in EMS is a priority of the White House and the First Lady. Military EMS training is not accredited and recertification is not required, DoD will be looking at fixing these issues so personnel have recognized credentials.

White Papers

The next segment of the NEMSAC meeting was presentation of white papers, contracted by the NEMSAC, for the purpose of getting expert and unbiased information on topic of concern to the council. The white papers commissioned were; Pre-hospital EMS as Public Good and Essential Service, Research in Pre-hospital Care: Models for Success, Emerging Digital Technologies for EMS and 911 Systems and Efficacy of Pre-hospital Application of Tourniquets and Hemostatic Dressings to Control Traumatic External Hemorrhage.

Pre-hospital EMS as a Public Good and Essential service- This draft White Paper was authored by Mike Milligan of the National Academy of Public Administration from a purely economic viewpoint. It did not translate to the common conception of terms such as “good”, “club” or “public”. If that was not confusing enough the author took a round-about way of getting to his conclusion at one point suggesting that EMS was a common good, police service a public good, and fire service a club good. This understandably confused and in some cases angered those in attendance. The conclusion of the paper was that EMS is a Public Good and an essential service, and identified how some public administrators may view it. It was the consensus in later discussions that the paper needed some clarification to avoid the possibility that some portions of the paper could be taken out of context and be seriously damaging to the causes of both fire and EMS services.

Research in Pre-hospital Care; Models for Success- This draft paper, authored by E. Brooke Lerner and funded by NHTSA and the EMS for Children Project, centered on the correct way to conduct clinical trials and the obstacles that must be overcome. Some identified barriers include; funding, consent, ethics approval, training of EMS providers and researchers, lack of relationships, political & social risk, reliance on EMS providers and/or hospital staff, other researchers. The paper is well written and would make a good resource for anyone considering an EMS research project. The author provided this additional resource; clinicaltrials.gov.

Efficacy of Pre-hospital Application of Tourniquets and Hemostatic Dressings to Control Traumatic External Hemorrhage- The authors recommend a systematic literature review, the military and PHTLS already recommend and include these tactics in their TCCC curriculum but civilian evidence and research are lacking. The efficacy of TQ’s compared to pressure alone, the efficacy of specific TQ products, the efficacy of hemostatic dressings compared to standard dressings and the efficacy of specific hemostatic products all need to be studied. These will be looked at by the authors with an additional report forthcoming and the results will be made available to field EMS providers and EMS physicians. This is one of several exercises, which to me; indicate some detachment of this committee with other researchers and fields of practice. TQ’s and hemostatic agents have been proven in the specific areas of concern, namely IED’s and mass shootings, by the military and are the basis of their inclusion in the TCCC program. My concern is that the committee may be expending precious resources by duplicating the efforts of others.

Emerging Digital Technologies in EMS- Benjamin Schooly and Thomas Horan co-presented this paper and asked the NEMSAC to provide feedback before the paper is published. The authors inform us that new technology has reached the level described in the EMS Agenda for the Future with application in injury prevention, response, treatment, training, education & communication. There are significant application and expansion gaps that need to be filled. A common view among EMS systems is that integration needs to occur with other public safety and healthcare partners to fully develop this potential. Solving this issue will have positive health benefits but new skills must also develop to manage the new technology. All stakeholders must work toward creation and adoption of common data elements and information systems so the entire EMS event can be captured and studied. Some of the obstacles that are present include privacy concerns, technology costs, integration and infrastructure; there is no guarantee that new technology will save money.

I found this portion of the meeting to be very informative, at times also frustrating and confusing. Hearing well compensated private and federal officials stand up and declaim some of the same ideas I and others have advocated for years, makes me wonder if the only ideas that are ever heard are the ones proffered by those having influence and authority regardless of the quality of the idea. This makes me question if what I have to say will ever make a difference. Don’t get me wrong, this type of organization must exist, those acknowledged as experts must speak and provide an outlet and connection with policymakers, but it also sorely needs more public participation and scrutiny by EMS providers.

Public Comments

The brief public comment period before the sub-committee meetings occurred with several speakers; Mr. Linde representing the NAEMT stated that there needs to be more dialogue between fire and EMS. A representative from NOAA asked the council what other products they should work on that could be of value to responders other than heat indexes and air quality. A representative from Latrobe University in Australia stated that EMS in the United States could learn a few things from Australian EMS and offered to facilitate some discussion.

Sub-Committee meetings-PPACA

I attended the sub-committee presentation and discussion on the Patient Protection and Affordable Care Act (PPACA). This meeting was led by Chief Sinclair, with NHTSA representative Noah Smith in attendance. The two biggest issues for this sub-committee were the untoward effects of the PPACA on volunteers and integration of EMS into the healthcare system via community paramedicine, mobile integrated healthcare, or some other vehicle. Chief Sinclair asserted that this sub-committee will likely need to be a standing committee to facilitate the still developing effects of PPACA on EMS, and that the focus of the committee should be bi-directional addressing both the effects on the EMS systems as well as the effects on employees and volunteers. The committee discussed at length the transition challenges to mobile healthcare, the effects of healthcare consolidation, and issues with tax liability and/or penalties for volunteers due to PPACA. Many questions were generated with an obvious need for follow-on discussions once the needed information is obtained.

Discussion (Saturday September 6, 2013)

 The morning before the committee reports I ran into a federal official at a coffee shop, I took the opportunity to ask (again) for some comment or opinion on HB809 and some aspects of the ACA. The response was solidly in support of NHTSA retaining its relationship with field EMS out of concern for retaining existing relationships within the federal government and preserving the highway safety and response characteristics of EMS in vehicular accidents. The lack of structure the PPACA provides in the development of new EMS systems was also acknowledged. I also found source material to present to the PPACA sub-committee authored by the AHRQ (Agency for Healthcare Research and Quality) titled Community Paramedicine Evaluation Tool, which our council is using as a template to develop a CP program of our own and may be useful and trump the need of this sub-committee to write a best practices document.

White Paper discussions:

EMS as an essential public service- General discussion by members;       

• EMS has characteristics making it both an essential public service and a public good (economic definition). It does require public funds to operate effectively. 
• This is primarily due to the need for preparedness and services provided without payment. Two distinct cost factors; readiness and marginal, which can be funded separately as a more logical way to provide funding. 
• Some exceptions noted in the report which separates fire and ems improperly and classifies them differently. Economic definitions v common definitions can be misleading to the public and may send the wrong message. 
• The document is helpful in that it provides a better understanding of EMS functions in economic terms which are the language of government and financial entities, but it does need more work in both detail and depth of comparisons. 
• The paper also needs to recognize that various EMS systems operate in different realms of the economic models presented and cannot all be lumped together as a homogeneous group. 
•  The fire service is improperly classified as a club good, not a public good, the fire service is largely tax funded and therefore is clearly a public good and also an essential service. The fear is that the document, which is considered to be incomplete and inaccurate, if published will damage both fire and EMS goals immediately and could be used as a tool by those wishing to push other incompatible agendas.  
• The document will be available on ems.gov when complete.

Active Shooter/IED's-    

• Training is needed; it is a tactical issue more than an operational one and as such should not be dealt with by this council.
•  The use of TQ's in some situations is prudent, but needs further refinement. Again this organization should not be concerned with field protocols.
•  The initial discussion yesterday also recognized the weakness of the relationship between police-fire-ems regarding terminology and operations at multi-casualty incidents and ems recognizing that the scene safety component may become more variable with some risk needed to save lives in MCI circumstances.
• The council was reminded that this issue was brought forward by the deputy director of FEMA; there may be a need for this council to look above the specifics and start looking at the cooperative aspects of the problem rather than the specific tactics and protocols.

Sub-committee meeting reports:

NEMSAC Process sub-committee- endorsed NEMSAC process document which is a guiding document for the council defining how the committee will operate to both members and the public.

EMS education Agenda for the future sub-committee- The sub-committee will develop a document requesting suggestions for minimal updates needed to reflect the new education standards, federal legislation, and the EMS education agenda document.  The sub-committee will ask for all comments without restriction openly, and will be making request at all stakeholder meetings this fall. This sub-committee will review these at the December meeting and make recommendations to NEMSAC based on the current state of implementation. A motion to have the Chair draft a letter requesting suggestions from stakeholders, and review responses at December meeting, allowing public comment and discussion, was approved.

PPACA sub-committee- The sub-committee created a group to research best practices in community paramedicine, and will bring forth best practices to be published as an advisory. The sub-committee recognized the work of previous councils in addressing concerns with CMS and the need for repeating/duplicating work. The council may need to re-evaluate the work of the previous finance committee recommendations for EMS funding. The council should create an advisory to IRS on effects of PPACA on volunteer EMS. Much discussion ensued regarding the effects of PPACA on EMS, and the desire by the council to here from some federal partners on the specific effects that may be felt by EMS. It is recognized that the law, and the practice of EMS, will be evolving and ongoing. Chair request input from all about any good material relating to this topic. 

EMS Agenda for the future sub-committee- This was a formative meeting.

Safety sub-committee- This sub-committee is waiting for the publication of a new safety position paper, it will be reviewing that and meeting with stakeholders to gain consensus on the next steps. The safety problem is not quantified and the sub-committee will need data to base its decisions on. We may need to work on education as a primary means of obtaining results. NREMT is pushing team and resource management training as a potential solution. IHST is joint federal/HEMS effort to improve safety, and can be used as model for improving EMS safety.

Public Comments:

IAFF- A representative of the IAFF requested that the NEMSAC discard, abandon or defund the White Paper titled Pre-Hospital Emergency Medical Services as a Public Good and Essential Service citing the potential for harm to the collective goals of both EMS and FIRE services if published.

NAEMSO- The NAEMSO is working on legislation that will grant professional recognition of EMS certifications across state lines. The final draft should be available in early 2014.

NAEMT- Supports the activities of the NEMSAC, there is a need for EMS research training.

NFPA- Suggested the use of social media to get people more involved in the activity and discussions of the council. Reminded the council that NFPA-1917; Ambulance standards, is being updated. The final standard should be published in March, 2014.

NVFC- The White Paper titled Pre-Hospital Emergency Medical Services as a Public Good and Essential Service needs to be more straight-forward in language. The inclusion of fire and police in the report is not helpful and creates distinctions between the three public safety branches.

General public & NEMSAC member comments:

·       The White paper titled Pre-Hospital Emergency Medical Services as a Public Good and      Essential Service needs work.
·       NEMSAC needs to facilitate Mobile Integrated Healthcare Practice (MIHP) discussion.
·       Medical Directors need to be involved in MIHP discussion and can help facilitate it.
·       The AARP support EMS public education, MIHP & PPACA
·       NEMSIS data is growing, what are we going to do with the data?
·       EMS education is moving toward better critical thinking and less cookbook medicine.
·       MIHP education needs to start occurring now.
·       As a result of PPACA more agencies are using part-time employees. What are the ramification for EMS professional development and workforce retention?
·       Out of hospital roles of EMS providers will be changing, more involved in general healthcare and public education.
·       Suggestion that the duration of NEMSAC meeting be increased to accomplish more, acknowledging the complexity of the decision making process.
·       Suggestion that the NEMSAC look at Israeli EMS practices as a model for response to mass-shootings and IED events.
·       NEMSAC must initiate conversation on EMS evolution.
·       There is a need for EMS provider population analysis.
·       There is a shortage of EMS providers in Hawaii; the state offers incentives to EMS providers.

The meeting concluded following these closing statements. Overall I found the experience very informative. I also found it very supportive of the ideas I already have and those I am working on in my own agency. I suspect any organization attempting to influence policy at this level will be slow to act, often working on a parallel tract with proactive EMS systems across the country. The council should recognize that and seek to get ahead of the local movements and encourage federal actions that can facilitate it. It is clear no one will be able to fully predict the effects of PPACA, but this legislation is poised to completely change the way EMS is funded as well as its basic function. The NEMSAC is developing its position slower than the changes are occurring. It may consider having a more concentrated focus at future meetings to get ahead of it. I look forward to continued interaction with the NEMSAC; it has the potential to be more influential in advocating for responsible EMS policy if it can become more focused.

AP