The chronic shortage of emergency nurses has inspired the idea of staffing crowded hospital emergency departments with paramedics. Not everybody likes the cure.

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:

- Understaffed and crowded emergency departments, leading to long waits for emergency care.

- Patients kept in emergency departments for hours, sometimes days, because no beds are available in hospital intensive care units.

- Ambulances forced to drive farther and farther to find an open bed. For nearly 10 days in December, for example, 60 of Los Angeles' 81 eds were so crowded that hospitals turned ambulances away.

The situation is acute. A report in the January issue of Annals of Emergency Medicine 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 hmos to do more with less, a nursing shortage grows and more Americans find themselves without health insurance.

A solution at hand? One solution to ed understaffing may be as close as the nearest fire station. Though not exactly new, the idea of using paramedics to assist understaffed hospital emergency departments is as persistent as it is unorthodox.

Paramedics have been incorporated into the staffing of some eds for over 10 years, but 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 emergency departments, some emergency physicians think the time has come.

With the average emergency department treating 20,000 patients per year with typically only one emergency physician per shift, support staff are stretched to the limit.

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 United States closed from 1988 to 1998. Also, an increasing number of uninsured patients use emergency departments for their primary medical needs. (The number of uninsured people in the United States is estimated to be 44 million and growing.)

"The utilization of paramedics in the er, critical care or other areas of medical care should not be based solely upon the shortage of the nurse labor pool, or as a more economical measure to provide patient care," says M. Allen McCullough, deputy chief of Fayette County (Ga.) Fire and Emergency Services, "but based upon the fact that paramedics have specific academic education and emergency skills specific to these areas of health care and can provide benefical care that is diverse in technical skills."

At many emergency departments, the physicians themselves have implemented backup physician coverage whenever the emergency department 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," says W. Richard Bukata, m.d., director of emergency medicine, San Gabriel Valley Medical Center in California. "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 resource the paramedic pool across the street represents.

"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?" Bukata asks.

Bukata and other emergency physicians would like to see a system develop where paramedics waiting for a call, which occurs on an average of about once every three to four hours in his community, are based at hospital emergency departments. Not only could they be more productive, but they could hone their skills while waiting to roll on the next dispatch.

A political tug-of-war The issue is, of course, politically charged. Everyone has an opinion on the subject, and many are unfavorable.

The National Association of Emergency Medical Technicians has no official position on the issue, but naemt Executive Council member Jerry Johnston, nremt-p, director of ems at Henry County (Iowa) Health Center, supports the idea, as long as there's a 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," he says.

Johnston fears that, because of the politics involved in turf skirmishes, paramedics proficient in suturing, assessments, intubation, drug administration and the use of cardiac emergency equipment could end up merely feeding, walking and preparing patients for surgery.

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," contends Kevin White, director of ems and health and safety for the California Professional Firefighters, 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?"

McCullough, however, says that underuse of paramedics can be resolved by defining exactly what skills the paramedic will be allowed to perform. "Can they intubate in an emergency or does this infringe upon the domain of respiratory therapy?" asks McCullough, who is also an nremt-p and registered nurse. "What about the use of nebulized medications? How many nurses have had formal training in this skill?"

Another concern with paramedics having additional emergency responsibilities is that it will divide their focus. "In essence, a firefighter/paramedic assigned to an ambulance should not be working in an emergency room between calls," says Gary Ludwig, chief paramedic for the St. Louis Fire Department. "In between calls, they should be dedicating their time to training, updating skills and performing other functions that are essential to the mission of the fire department - not the hospital."

According to White, cpf is not opposed to off-duty firefighter/paramedics working for a hospital, so long as they're allowed to employ their full scope of practice as paramedics. "But it won't work while they're on duty, between calls," White says. "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."

Intellectual cross-pollination Nevertheless, some believe that, if implemented properly, the use of paramedics to staff emergency departments could be a win-win situation for all concerned parties: 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?" Bukata asks. "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, Bukata is not optimistic, given the turf issues at hand. The idea is a hard sell, especially to nursing organizations.

The American Nurses Association 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-prepared personnel.

According to the 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 effectively solved by hiring new nurses or re-hiring qualified nurses let go during downsizing maneuvers, not by employing less-expensive and, in their view, less-skilled paramedics.

According to Mary Jagim, r.n., president of the Emergency Nurses Association, "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 says 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.

But McCullough, an ena member, says that who is in the right remains unclear. "Who's the real professional? Is it defined by academic credentials? Secondary certifications? Experience? Outcomes? I contend that patients who have lost their airways, need pressure on bleeding wounds or need timely defibrillation could care less who provides the life-saving skills. The person who is dying rarely asks the credentials of the one who holds their hand while transitioning into the next life."

The 30,000-member California Nurses Association considers the notion moot, in 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, says Jill Furillo, r.n., the 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. 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."

The issue isn't whether paramedics should be used in the ed, adds Furillo, but that eds are closing. "I would be more concerned about the fact the eds are closing down in this state," she says. "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?"

Clever compromise The turf wars may lead to compromises, such as the one in effect at Tacoma (Wash.) General Hospital, which for the past 10 years has hired off-duty paramedics to work in the ed, but only after they're licensed by the state as Health Care Assistants.

"In the beginning, there was a bit of concern from the nurses," says 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 that 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 also serves as chief of medical services for the Lakewood Fire Department in Tacoma, Wash., has a rather one-sided mutual aid agreement with the local Veterans' Administration 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 says. "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 times to come over and assist the emergency physician when they didn't have a respiratory specialist in house to do a procedure," Aleshire says. "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, says the 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."