GAEMS

G e o r g i a Ass o c i a t i o n o f E m e r g e n c y M e d i c a l S e r v i c e s

Spring 2011
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Table of Contents
Spring 2013
3.......................................................................................From 20..........................Pre-Payment Review: the Editor

From the Editor

Ho-ri-zon: 1. The line along which the earth and sky appear to meet. 2. Range or limit of knowledge, experience, or interest.

12.........................................................................Past and Future of EMS Is This the New Norm? 23................................................................Meet Your Board Members

Features

Do you ever contemplate the horizon? Which definition?

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Outside Looking In - By Roger McLeod

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Dr. Charles B. Gillespie - By Jim Henricks

The question is most likely rhetorical if youre on the beach or atop a mountain. But the second definition seems to apply to the horizon the EMS industry contemplates. We, albeit without much fanfare, seem to always be trying to extend our range and diminish our limits in our quest for more knowledge. We experience experience every day, maybe every hour. No one can doubt our interest. So I challenge us to enjoy the beauty and wanderlust of natures horizons but to contemplate the impact of whats on the EMS horizon daily. Get involved. Stay involved. Build a relationship with your Legislators they await your call and visit. Stay in touch with the State office of EMS/Trauma. Join the Georgia Association of Emergency Medical Services. Get on a committee, got to a meeting, attend a conference, network, be an EMS representative every day in your community, in your County, and in your State. Sincerely,

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Partnership - By Courtney Terwilliger

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The Hope of RAES - By Dr. Augustine
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David W. Moore Editor

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Outside Looking In
A Personal Perspective on the 1st EMS Rural Leadership Course

Leadership

n a folder labeled EMS, I have an email from September 7, 2011, from Courtney Terwilliger in which he invited me to participate in the inaugural EMS Leadership class as Course Coordinator, who will be working with the students to insure their success in the program. That sounded reasonable, doable, a fun challenge so I signed on. After several planning meetings and right after the completion of the first training module in March 2012 I remembered a quote attributed to Socrates: I know nothing of Emergency Medical Services except the fact of my ignorance. Well, Socrates didnt speak directly of EMS, but in my case, it certainly applied. By the time the course completion reports were submitted in December 2012, I was just as certain I had learned as much, if not more, than the students in class. This first Leadership class was remarkable for how well it was planned. Four week long classes about six weeks apart at three different locations, combined with interim assignments between the classes delivered online. This formed the basic structure. Within the weeklong class sessions, an excellent cadre of instructors and presenters covered a multitude of well researched topics. The quality of the instructional program was exceptional: included were the best EMS leadership practitioners in the state; nationally known professionals in legal, quality improvement, financial management and other operations; state level officials that directly and indirectly affect and shape policy; and faculty and administration from Georgia Southern University.

But it wasnt just the stellar group of instructors, great locations, accommodations, meals and lodging that were assembled by Kim Littleton, Courtney Terwilliger, Jeff Smith (GAEMS), Russ Toal, Damian MacLeod (Georgia Southern University), and Patsy Whaley (State Office of Rural Heath) that was so impressive. The curriculum and structure of

ducation is the kindling

of a flame, not the filling of a vessel. That statement, and many variants of the idea it expresses, has been around since Plutarch.
the course was specifically designed for rural service operations. Directors in rural Georgia counties often struggle with fewer resources and relative geographical isolation. Administrative issues and instructional material were focused on specific problems faced by this group. And, tuition, meals and lodging were free for students. Ive been involved in training or education in some fashion for nearly forty years. Ive seen very few pilot programs do as well with research, design, and implementation of so many goals as this one. But this course is unique in my experience for how well it succeeded in is

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primary mission: to change behavior. So many training and education programs do well in delivering information in a pleasant and enjoyable experience, but do so little to improve student performance where it counts on the job. You can find training transfer process diagrams, boatloads of articles on learning transfer techniques, acres of online discussion on how to make training stick, but very few examples of where it actually happened. Well, it happened here. Education is the kindling of a flame, not the filling of a vessel. That statement, and many variants of the idea it

expresses, has been around since Plutarch. At the conclusion of this pilot program, a group of students formed an alumni group a small flame, but its burning. It was their idea, based on what they learned and experienced in this course. Their purpose is to further develop their skills as leaders and to promote leadership development among their peers and especially future leadership classes. Many students have contributed to planning for the second class through their formal evaluations and informal suggestions, many unsolicited. They have submitted documents demonstrat-

ing how their operations improved through application of concepts covered in class. Lanier Swafford, Brandon Fletcher and David Moore have committed to actively participating in the second class, to encourage and support the continuing effort. I am truly honored to a part of the EMS Leadership program. Last year was a real eye opener, I cant wait to see what this year holds.

Roger McLeod Course Coordinator EMS Leadership Program

EMS Leadership Program - Class of 2012

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l a i c pe ture S ea F
in rural Georgia.

Dr. Charles B. Gillespie

A Renessiance Man
Written by : Jim Hendricks Albany Herald
said. If the technicians on the ambulance had radios, better equipment, theyd have better ways to get them to the hospital. He said, That sounds good. Would you help me with it if I get elected? I said, Yes, sir. It could have ended there, but it didnt. Carter won the 1970 gubernatorial race. After he took office, Gillespie got a call from Carters executive secretary, Hamilton Jordan of Albany. Gillespie was familiar with Jordan, whose father was his insurance agent and whose mother was one of his patients. Jordan asked the doctor if he remembered the conversation hed had with Carter. Gillespie told him he did and hed be happy to do what he could to help. He went to Atlanta, where he met with Carter and Jordan. Carter asked him to head up the statewide effort, and Gillespie agreed to it. He Charles B. Gillespie/special photo told Carter he didnt want a salary, just a phone card and reimbursement on expenses he would incur. That launched nine years of working with what became a 23-member commission to get quality ambulance services in Georgia counties. Gillespie says he met with officials in 145 of the states 159 counties during that period. The phone card ended up with about $35,000 worth of calls on it many of them conference calls that were particularly expensive, given the technology of the time during the nine years, something Gillespie was questioned about after he left the job. I had a lady from the state call asking about my logs, my telephone logs, he said between bites from his shrimp bowl. I said nobody told me I was supposed to keep a log. She said youre going to have to come up

The late entertainer Phyllis Diller never knew the

impact she had on improving emergency medical care

It was the 1960s, and she was performing in Albany. Dillers style of comedy wasnt everyones cup of tea. In fact, a couple of men in the audience that night werent appreciative of her particular brand of humor. One was Dr. Charles Braselton Gillespie, an Albany orthopedic surgeon. The other was a state senator from Sumter County who had political aspirations that would take him to the Governors Mansion en route to the White House. It also was the night that emergency medical services in rural Georgia was born. It actually started with a conversation between me and Jimmy Carter at the Hasan Temple on the night when Phyllis Diller was talking, Gillespie said, recounting the chance conversation during a lunch interview last month for our A Table With a View series. He said, You like what shes saying? I said, I cant stand her. He said, Lets go out front. I want to talk to you about something. Carter told Gillespie he was going to run for governor of Georgia, and he wondered whether the doctor had any ideas about what he should include in his platform regarding health care. I said theres a movement going on right now to improve rural health care, to train people better. The term EMT (emergency medical technician) hadnt come out at that moment, Gillespie 6
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with some kind of information about it. I said maam, Gov. Carter handed me this card, said go for it. If you want to talk with him, Ive got his number for his desk at the White House. You call him up and talk to him. I said, Dont call me about this again. ... I never heard any more from them. The storys typical of Charles Gillespie in that not much about the man is typical at all. In addition to being the father of EMS in Georgia, hes a skilled orthopedic surgeon (now retired), a world traveler, a member of the Aviation Commission in Albany and an accomplished photographer.

The second county I went to to get a service

established was Worth County, Gillespie recalled, adding that the county attorney at the time was adamant that it would be too expensive. I really became a little irritated because it sounded like he wasnt listening at all, Gillespie said, adding he told the lawyer that you never knew when youd need emergency medical care. I said, Youve got two choices, Gillespie said. Either you can put one in here and the state will work with you to get it started, training and so forth, or Ill put one down here and Ill run it for you and you wont have any say-so about it, except youre going to pay for it.

ESTABLISHING EMS
But establishing rural EMS is something that cant be separated from Gillespies professional life. I mentioned that I could remember when my home county of Baker didnt have an ambulance service, when what passed for ambulances in small rural counties were funeral home hearses. The old joke was theyd check and see whether you were breathing before deciding to head to the hospital or the mortuary. Gillespie recalled how a horse-riding accident ended up improving Baker Countys emergency medical services. Connie Mellon, who owned Pineland Plantation, fell off a horse and broke her hip. Gillespie told her he could get her to Albany, then fly her to Pittsburgh for surgery. She asked him how many of that type surgeries hed done. Gillespie said he had stopped counting at 1,247. She said he had more experience than the doctors in Pittsburgh. Gillespie called an ambulance from Albany and operated on her at Phoebe Putney Memorial Hospital. After the surgery, Mellon said shed noticed Gillespie had to call the ambulance from Albany and asked him how much it would cost to establish one in Baker County. He told her. About three weeks later, he said, I got a check in the mail for $45,000. While that wouldnt outfit an EMS rig these days, it was enough to get the Baker service off the ground. The job of getting communities to buy in on the importance of emergency care, however, wasnt always that easy. Some counties didnt see the need for an EMS service, and many of those that did were hard to convince on footing the cost of it.

The next day, he got a call from the commission chairman. The county attorney, only 38 years old, had died from a heart attack. It was something Gillespie often mentioned at subsequent meetings with officials in various counties. We had some interesting county commissions to work with, he said. Ninety percent of the ones that had some hesitance had concern about continuing funding.

Charles B. Gillespie/special photo Before the Sept. 11, 2001 attacks, Dr. Charles B. Gillespie captured a stirring image of the sun peeking between the Twin Towers in New York City.

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THE EMT OATH

The EMS work, however, contributed to Gillespies decision to retire from his medical practice. Hes endured eight heart procedures over the years, with bypass surgery and stints. He said his cardiologist, Dr. Craig Mitchell, told him the source of his heart problems was the stress he had experienced. Much of that stress came from establishing emergency medical services throughout the state. But it also led to one of his proudest moments the naming of the first responder building at Albany Technical College after him and to what may end up being his greatest legacy the EMT Oath, which has been translated into a number of languages. Gillespie has also written an EMT Prayer and an EMT Code of Ethics that have been widely distributed and used. The genesis of the oath was a case in which something good came out of a bad situation. Gillespie had been proud that the state convention of emergency medical technicians was meeting in Albany, but a serious situation had arisen. Two EMTs from outside counties had been accused of committing inappropriate actions while transporting patients. Gillespie, who chaired the states Emergency Health Services Advisory Council from 1972-81, was asked how he wanted to deal with the problems. I remembered the Hippocratic Oath we (doctors) took, he said. So, I sat down and wrote whats now known as the EMT Oath and carried it back down to the convention and got one of the offenders to stand up and take the oath, the other to take the oath and then the whole crowd to stand up and take the oath, 600-and-something people. And that was it. I didnt do anything else, and those two EMTs turned out OK. The Oath now is used all over the world ... all over the world. Thats sort of a proud moment. The pride was evident in his face ... and in a slight crack in his voice ... as he told the story. The oath has been translated into a number of foreign languages and is administered to trainees. 8
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I dont know how many signed oaths Ive sent out, he said. If I have a legacy that I would like to see go on and on and on, I would like to see the oath survive all over the world. If you read it, youll see how kin it is to the Hippocratic Oath, but it wasnt based entirely on the Hippocratic Oath.

WHATS AHEAD
As far as public service, Gillespie says he has one goal left: universal 911 service in Georgia. Thats one of my last projects I want to see finished before I die, he said. I want every county to have 911. Were down to about two or three counties now. Its mostly the counties around Stewart and Webster. The problem yet to be overcome is the investment. Small, private telephone cant companies in the sparsely populated counties afford the equipment, which is often outdated by the time its installed. The smaller counties dont have all that yet, he said, adding former Lt. Gov. Mark Taylor of Albany was instrumental in helping fund 911 when he had $350,000 transferred for that purpose from Georgias tobacco settlement fund. Other than that, he said, he wants to get things in pretty good shape for my family when I leave the world. I had to make the observation that hed done more with his life than just make things better for his family, important as that is. When you look back at his body of work the medical practice that affected so many lives, the establishment of EMS, expanding 911 coverage, his work on the Aviation Commission and in preparation for the BRAC Commission Gillespie has already made life better for countless Georgians.

Charles B. Gillespie/special photo Dr. Charles B. Gillespie used innovative techniques such as the Ilizarov apparatus during his 32-year career as an orthopedic surgeon.

Article courtesy of: Jim Hendricks Albany Herald Pictures courtesy of: Dr. Charles B. Gillespie

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The Patient Assessment Centered Curriculum (PACC)

A modified educational approach to the patient assessment
Its just not coming together! I had heard this many times before and had been searching for a way to get students to trust that the puzzle pieces would come together. It seemed most students stated that everything finally came together near the end, when they were in field internships. Normally, curriculum is taught in a linear format. This format consists of reading straight from the book from chapter one straight through to the last chapter. The patient assessment is the epitome of what emergency medicine is all about. Everything we do in patient treatment is based on what we find in the patient assessment. According to the EMT-Basic National Standard Curriculum, published by NHTSA, approximately 2024 hours is focused on patient assessment, which constitutes less than 10 percent of the entire curriculum. The Patient Assessment Centered Curriculum (PACC) is a dynamic, multi- focal approach that integrates hands on experiences through the entire curriculum and incorporates patient assessment into every aspect of the program. Students use 95% of classroom time integrating patient assessment during each chapter. The curriculum is no longer focused on the end result but focuses on the entire process. To accomplish this, Education is a fundamental necessity to EMS. Every licensed EMS provider spends countless hours attending continuing education to upkeep their license, more hours if they also hold certifications like National Registry and critical care. There is a full spectrum of education found in the state of Georgia from the online class to the hands on cadaver lab. The education choices are limited only by time, budget and availability. Georgia is notorious for excellent state conferences, a decent offering of NAEMT courses and most services also have a selection of classes put on by their training officer. Despite having access to all of the above, along with a very talented collection of initial education instructors, there still seems to be a gap in a very important topic area special needs children. The latest Georgia statistics shows an average of 7% pediatric calls, and although we currently do not have a way to tell how many of those are special needs, national statistics suggest it is a significant amount. The new educational standards have helped to start bridging the gaps in pediatric education and with increased depth and breadth, we are better preparing new EMS professionals to deal with pediatric emergencies, but are still challenged with getting more hands on experience and exposure to special needs pediatrics.

From the Classroom

the chapters are realigned with the patient assessment in mind. For instance, scene safety is the very first item in the patient assessment and undoubtedly the most important. In a linear approach, we cannot teach true critical thinking about scene safety until the very end when the last few chapters are taught. In PACC, we teach transport ops, vehicle extrication, and special ops, psychiatric, WMD, Hazmat and IC at the very beginning and therefore allow the student to think critically and decide if the scene is safe. Another challenge encountered is teaching the patient assessment chapter but then not immediately teaching students the treatments. Treatments are taught in later chapters. In this approach, the treatment is taught along with the patient assessment. The results of using the PACC approach have shown that scores have improved in both the classroom setting and National Registry testing. Clinical site evaluations demonstrate an increased student comprehension of job knowledge and student complaints about the overall concept not coming together have become almost non-existent. Tamantha A. Cumbie M.Ed., NREMT-P

Bridging the Gapit can be as easy as S.N.A.P.

Georgias EMSC program, in collaboration with several partners, has developed a course entitled S.N.A.P. Special Needs Access Program. The course offers a comprehensive look into the care and transport of a special needs patient through resources, knowledge, exposure and hands on exercises. Assessment, technology, transport and emergencies in the special needs population can be overwhelming and frightening for all involved not to mention that pre-planning can be the difference between life and death in this population. The SNAP class premiered recently at the GAEMS Changes conference in Savannah and was very well received by all who attended. Although in its infancy, the hope is that this course will be able to be taught by EMS educators throughout the state with information and equipment provided by the state. Look for the next SNAP class as a preconference to the state EMSC conference in Gainesville June 4, 2013. Kelly Buddenhagen Coordinator State EMS-C Program

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Northeast Georgia Medical Center Named one of the Nations 100 Top Hospitals by Truven Health Analytics
NGMC is the only hospital in Georgia named to 100 Top Hospitals and Americas 50 Best Hospitals lists for 2013 GAINESVILLE, Ga. Northeast Georgia Medical Center (NGMC) is one of the nations 100 Top Hospitals according to a study by Truven Health Analytics, formerly the healthcare business of Thomson Reuters. The study names top hospitals in five different categories from Major Teaching Hospitals to Small Community Hospitals and NGMC is one of only 20 Large Community Hospitals selected. NGMC is also the only hospital in Georgia to make the list in any category. This is the second time NGMC has made the 100 Top Hospitals list and comes on the heels of the hospital being named one of Americas 50 Best Hospitals for 2013 by Healthgrades. Being named to this elite list just one week after we were named one of Americas 50 Best Hospitals by Healthgrades is further proof that our organization is making Gainesville, Georgia, a national destination for health care, says Carol Burrell, President and CEO of Northeast Georgia Health System. The dedication that our entire team demonstrates while caring for the people of this community, and beyond, is reflected with each award we receive. Truven Health compiled the 100 Top Hospitals report by researching nearly 3,000 short-term, acute care, non-federal hospitals. They used public information from the Centers for Medicare and Medicaid Services (CMS) to evaluate performance in 10 areas: mortality expenses medical complications profitability patient safety patient satisfaction average patient stay 10 adherence to clinical standards of care post-discharge mortality readmission rates for heart attacks, heart failure, and pneumonia The study pulls data from a three to five-year period, depending on the area, in order to select hospitals demonstrating both top performance and consistent, accelerated improvement. To be recognized for consistently providing top quality care is particularly gratifying for our physicians and caregivers, says Ron Lewis, MD, a general surgeon with Northeast Georgia Physicians Group Surgical Associates and Chief of NGMCs Medical Staff. We scored especially well in regards to mortality, complications, patient safety, average length of stay and patient satisfaction all measures which are directly related to the quality of health care we provide. I am so proud of our organization and all that it has achieved on a state and national level, adds NGHS Board Chair Mary Lynn Coyle. With Carols leadership along with the combined efforts of our physicians, staff and boards NGHS is soaring to greater and greater heights and the true winners are our patients and our community. If all Medicare inpatients received the same level of care as those treated in the award-winning facilities like NGMC: o More than 164,000 additional lives could be saved o Approximately 82,000 additional patients could be complica tion free o $6 billion could be saved o The average patient stay would decrease by nearly half a day. If the same standards were applied to all inpatients, the impact would be even greater. Hospitals do not apply to be part of the study. To learn more about services offered at NGMC and through NGHS, visit www. nghs.com or call 770-219-3840. Spring 2011
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GA EMS

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 By: Lee Oliver

Do You Remember?

Do you ever think about where EMS in Georgia has been...

... and where EMS is going?

vated, and dedicated employees to provide care to those who are often at a crisis point in their life. No one wakes up in the morning and plans to have a cardiac event, stroke, or vehicle crash. But every day hundreds of people in Georgia do and they depend on you the EMS professional in their community to provide the most compassionate and highest level of care possible. It is your training, work ethic and commitment to the patient that remains steadfast in a sea of changing technology and economic uncertainty. Congratulations for choosing a carrier that does make a difference one patient at a time because to that patient and family you are the most valuable resource to them in their desperate time of need. Make a positive impact, make a difference, represent your profession of EMS well.

The Patient Care Report with a stickman? The Motorola Mocom 70? With a scan head? The Life Pak 4, weighing in at a mere 37.5 pounds? The introduction of the Life Pak 5 and the ability to sepa rate the monitor and defib while only weighing 18 pounds? The ability to transmit a 3 lead EKG via UHF telemetry over a med channel to the physician in the ER? The introduction of strobe lights on the ambulance? A model 30 stretcher High dose Epinephrine And the list goes on and on. To the point the EMS profession in Georgia and across the Nation has seen many significant changes in education, technology, medical direction and the delivery of care. Where does it go from here? What is our destiny? What does the evolving healthcare world hold for EMS, will there always be EMS? Will EMS remain a fee for service model or will EMS be paid to not transport patients to the hospital? How will technology change our thought processes and our medical care? Will a mobile gateway in ambulance one day connect the patient in their home with a physician, to avoid a hospital readmission? Will we be Face Timing our patients with their primary care physician, will hospitals contract with EMS to provide home assessment and evaluation for recent high risk discharges? Depending on how long you have worked in EMS you will realize that the rate of change is staggering and occurs much more rapidly today than it did 10 or 20 years ago. The cost of this technology is also staggering and many services simply cant afford the new technology. Product life is shortened based on new and emerging technology. Is the newest always the best? Is it better to wait and see how a product will evolve or not? The one constant in EMS is that EMS requires caring, compassionate, energetic, involved,educated, moti12

Lee Oliver President GAEMS Directors Division

The one to count on when seconds count.

gru.edu/neuro

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Job # 1287GRM13 Job Title: Stroke 4/16/2013 Publication: Georgia EMS Colors: CMYK

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Community Paramedicine:
When asked to write an article about community paramedicine, I began to debate with myself on what exactly should be said. Although extensive research has been done and similar programs exist elsewhere in the nation, the impact on Georgias healthcare systems remains largely speculative. In February, a group of providers and educators met with State officials in Forsyth to attempt to answer the tough questions surrounding such an endeavor. While the discussion in the room yielded many great ideas, the two reoccurring questions were What exactly can this program be? and How can it come to fruition with sustainability? In order to have an open discussion on a programs viability, it is important to explore current models in more detail. From Minnesota to Colorado, North Carolina to Nova Scotia, the role of the EMS provider is changing. Each of the aforementioned localities has presented noticeably different solutions to problems unique to their respective systems. It has resulted in the birth of an expanded role EMS practitioner. Whether they are called advanced practice paramedics, community paramedics or simply paramedics, the resulting product of their vision could completely redefine our trade. In North Carolina, higher turnover rates in urban Wake County prompted administrators to ask a very serious question. How do we place the most experienced paramedics on the scene of high acuity calls? The answer yielded the birth of the advanced practice paramedic program. These paramedics are highly trained and very equipped. They self-dispatch to high acuity calls as a support vessel for field providers. When not on high acuity calls, they visit routine patients and those with identifiable barriers to primary care. This program is efficient, physician driven and heavy in tangible results. In Colorado, providers also identified patients who had barriers to primary care. In rural Western Eagle County, the community paramedic was implemented to act as an arm of public health. In addition to EMS duties, providers could also provide preventative care in the home and patient education. This solution seems to have provided the system with the ability to truly advocate for all patients, not simply those found in the 911 system. Minnesota has championed this expanded role statewide with the addition of the community paramedic as a distinct provider level and the Canadian model has revo-

The Expanding Role of Georgias EMS Provider

lutionized super rural and remote access to healthcare. These systems are result driven and have the ability to adapt to the changing climate of healthcare systems. Across the nation, expanded roles for emergency service providers have been created to meet the needs of their respective communities. Likewise, the Georgia model must focus on the needs of the individual systems and not the state as a whole. Simply put, the needs of Atlanta may not translate well to those of rural Georgia and vice versa. Providers across the state agree that successful implementation of an expanded role must be anchored in the empowerment of systems to create a tailored program. Medicare reimbursement changes have forced hospitals and EMS systems alike to put forth a concerted effort to reduce the number of hospital readmissions. In order to achieve this, EMS systems will need to take a more active role in a patients total care. For example, patients with congestive heart failure, diabetes, seizure disorder and COPD could be placed on the EMS systems radar for frequent follow up. This would allow providers to assist patients in caring for themselves at home instead of frequent trips to emergency departments and subsequent admission. Providers would not replace primary care, but would enhance it while remaining within their scope of practice. The need for this type of program in Georgia is evident and the time to act is now. EMS systems must evolve into a better form of themselves, realizing their true potential. Georgians deserve our best efforts and the evolution of this idea could make it a reality. I challenge services across the state to research these storied programs, evaluate your own systems and have the courage to change our industry. Only then, can we look over the horizon and ask Whats next? Jason Lewis, Director Madison County EMS

Spring 2011

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FORMED BETWEEN GCASR AND GEORGIAS EMERGENCY MEDICAL SERVICE (EMS) COMMUNITY
The exciting collaboration between the Georgia Coverdell Acute Stroke Registry (GCASR) and Georgias Emergency Medical Services Community is continuing to solidify and spread across Georgias ten EMS Regions. This statewide effort actually began over a year ago with several initiatives identified as critical to positive outcomes for patients transported to facilities by ambulance. The primary goals established at that time were: To smooth the transition of care between EMS and hospitals; To improve patients quality of care and short and long term outcomes; and, To enhance data collection and evaluation, specifically of prehospital data. One of the first efforts of a hospital to reach out to EMS providers occurred in the spring of 2011 when Southern Regional Health Services gave a presentation to EMS providers introducing Target Stroke and discussing ways EMS could assist in lowering door-to-needle (DTN) time. That was quickly followed by educational offerings across the state including a series of one-day seminars named Link by Link: Focusing on Stroke Care in Georgia. Although the meetings were open to anyone with an interest in stroke care, they particularly targeted EMS providers. Dr. Nojan Valadi, Medical Director of the Cerebrovascular Disease and Stroke Program and Chief of the Department of Neurology at Columbus Regional Healthcare System, was the keynote speaker at many of these events. According to Georgias Coverdell Murphy Act (SB 549) as passed by the General Assembly, The department shall adopt or develop a sample stroke triage assessment tool. The department shall post this sample assessment tool on its website and distribute a copy of the sample assessment tool to each licensed emergency medical services provider no later than December 31, 2008. Each licensed emergency medical services provider shall use a stroke triage assessment tool that is substantially similar to the sample stroke triage assessment tool provided by the department. The State Office of EMS (SOEMS) and the EMS Medical Directors Advisory Council (EMSMDAC) moved quickly to adopt the Cincinnati Stroke 14
Submitted by: Sam Cunningham, Regional EMS Director for West Central Georgia, and Keith Wages, Director of the Office of EMS and Trauma, Division of Health Protection, Georgia Department of Public Health

EXCITING NEW COLLABORATION

Scale. Once that was done, Dr. Valadi, working in concert with the SOEMS and EMSMDAC, proposed some slight modifications to the document which would provide the destination hospital with more accurate patient information. In July 2012, the Georgia Coverdell Steering Committee announced The Next Phase of Coverdell: Collaboration with EMS. Words cannot express how thrilled and honored the EMS community was to learn this news and to be a part of this collaboration. Keith Wages, State EMS Director, remarked at a recent EMS gathering, The decision by the Coverdell team to focus on collaboration with EMS represents one of the most significant opportunities in the history of our EMS system. For many years, Georgias hospitals and physicians have worked tirelessly to improve stroke care throughout the state, and now EMS has an opportunity to be a valuable contributor to that effort. I extend my sincere appreciation to Lydia Clarkson, Kerrie Krompf, and the entire committee for their dedication to improving stroke systems of care and for their support and inclusion of EMS in this wonderful opportunity. We are also very proud of the EMS community for the enthusiasm with which they have responded, and we look forward to great accomplishments in the future. As an initial phase of the collaboration, the Office of EMS provided the Coverdell Team with a list of EMS agencies that are designated as 9-1-1 Zone Providers in Georgia. Over the past few weeks, a team, led by Kerrie Krompf, has been contacting those agencies to discuss in detail the work they are doing, and the EMS community has responded very positively to the proposed initiatives. While there is much work to be done and many challenges ahead, the EMS community welcomes the opportunity to work with our hospital partners to make Georgias Stroke System the best in the nation.

GA EMS

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GAEM

GEORGIA EMTS AND PARAMEDICS

The Southeastern Family expresses our thank you for over 30 years of support
Call today for a free, money-saving supply evaluation...at your location Tommy Sanders (678) 249-8807 Tommy.Sanders@SEEquip.com

(800) 334-6656 | www.SEEquip.com

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Chairman of the Board

Partnerships Partnership
by Courtney Terwilliger A Brief History
Ambulance Services date back to the middle ages. These services were simply transportation systems to move the wounded off the battleground to an area where physicians treated their wounds. Obviously the transportation and subsequent treatment of these wounded was primitive at best and in many cases had no effect on the long term outcome for the patient. The modern era of EMS began in the early 1970s. The effort, enhanced with Federal grant dollars, was in response to the white paper Accidental Death and Disability: The Neglected Disease of Modern Society written by the National Academy of Sciences and the National Research Council in 1966, it pointed out that much improvement could be made by changing the vehicles, improving the training, communications, record keeping, and the care provided while enroute to the hospital. This white paper, often referred to as death in a ditch lead to federal legislation that provided funding to the States to develop their own EMS system. Most of these dollars were funded to the States through the Office of Highway Safety and provide training and equipment to set up and equip EMS services across the State I became involved in EMS in 1976. At that time all protocols and much of the training were done at the local level. The local hospital was the center of health care for
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all communities both large and small. We transported all of our patients to the local hospital for treatment. Heart attack, stroke, trauma almost all of them stayed at our local hospital. We did this because the level of emergency care was not much better at the large medical centers. I spent many hours in the Emergency Room at large hospitals simply waiting for the staff to find a doctor who would come to see the patient. The idea of a rapid response team was unheard of and the idea of a specialized team to deal with specific types of injury, illness or patient populations was not developed.

Today
Today, we can do better. We now have an emerging system of care that can profoundly change the outcome for many of our patients for the better. The outcomes for our patients with strokes, STEMI and life threatening trauma can be dramatically improved. In many, if not most, of these cases the improvement depends on us. The technology and training is available to identify these patients, provide immediately life sustaining care, identify the correct center of excellence and transport the patient to that center as safely and quickly as possible. Hospitals must become part of our team. Many hospitals are realizing the value that we add to the patients outcome and they are reaching out to us. They are providing training and in some cases

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are providing equipment. In many areas we are doing better.but not everywhere. Many areas of Georgia face significant challenges to provide this service with limited resources and long distances to travel. It will require us to rethink our priorities and perhaps our core mission to provide better outcomes for our patients. EMS has always been willing to rise to, and meet any challenge thrown at them. We MUST embrace the change in our system. We must not only embrace it; we must provide leadership in implementing these changes throughout our State.

The Future
The EMS system of the future will be dramatically different than the one we work with today. In rural Georgia two hospitals have closed this year and it is apparent that this is just the beginning of a dramatic upheaval of the way health care is provided. In those counties EMS has now become the primary source of health care after 5:00 each day and all weekend. Transportation time to a medical facility has gone way up and the needs for that transportation will increase. For some this is a rural issue and they think this will not impact their facility. I see a domino effect. If there is no care in at the local hospital then the patient will be seen at larger facilitys Emergency Department. These centers are already working at and beyond their capability. The problem will not be resolved; only moved.by ambulances. The Centers for Medicare and Medicaid Services are looking at new ways to pay for medical care. These systems are founded in better patient outcomes and cemented in place with accountability. If you dont know what an Accountable Care Organization is then you are behind the curve. If you have never heard of the concept of the Community Paramedic (CP) then you need to become involved.today. The GAEMS has been involved in national meetings on CP, and have participated in studies on how this type of program can work in both urban and rural areas of our State The State Office of EMS has convened meetings looking at the concept and how this type of system can be integrated into Georgia EMS. The GAEMS has received a letter of intent from the Georgia Office of Rural Health to receive grant monies to determine how this type of care can best be provided for in rural Georgia.

In rural Georgia two hospitals have closed this year and it is apparent that this is just the beginning of a dramatic upheaval of the way health care is provided.

believe that how medical care is provided in the future will change as much as industrial production during the industrial revolution. The reasons for these changes will be similar to those changes. These changes include a spike in the knowledge base of medical providers, a change in the economics of scale for many procedures and a rapid increase in advancements in the technology that support these changes.

I do not believe that we will be successful utilizing the same delivery system we have relied upon in the past. We must be willing to redesign our systems, our thinking, and our partnerships to insure that our patients receive the best care possible. There is little point in knowing where events will lead you if you are not ready when you get there. Plan for change.be there before you get thrown there.

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The MDs Perspective

The Hope of RAES

James J Augustine, MD, FACEP
Our economic system has not been adequately prepared to account for the cost of providing care to an aging population with more chronic illnesses. Why is this an issue over the last 30 years? There has been a failure to identify one of the greatest health care success stories in America; the reduction in premature death from sudden cardiac arrest and the reduced morbidity from trauma and burns. Preventing premature death allows many more Americans to lead happy and productive lives. But eventually that population comes to develop diseases of older age, like cardiac disease, cancer, diabetes, and neurologic deterioration. Those diseases have exacerbations that will predictably lead to the need for emergency care. We have arrived at the time where the consequences of our prevention success met the realities of resource shortages. The report describes further: The system should be regionalized in the sense that neighboring hospitals, EMS and other agencies work together as a unit to provide emergency care to everyone in that region. A patient should be taken to the optimal facility within the region based on his or her condition and the distances involved. This IOM report gives us the opportunity to address the challenges of unscheduled and emergency care. To move our industry ahead, EMS leaders need to develop new delivery models, which I will call regional accountable emergency systems, or RAES.

A proactive development of systems will utilize and coordinate a regions resourcesprehospital, hospital and specialty, in an appropriate and efficient manner. RAES will involve networks of In response to the perception of an emergency system failure, the Institute of Medicine prepared a prehospital and emergency department leaders working with key members of their communities report, Emergency Medical Services at the Crossto provide and facilitate the fast and efficient roads, which was delivered to Congress in 2006. The report states that: The challenges that exist in provision of unscheduled healthcare. Developing RAES would reverse the 30-year trend the system today can best be addressed by buildtoward fragmenting and decentralizing emering a nationwide network of regionalized, coordigency medical services. Then the system can nated and accountable emergency care systems. deliver needed care to a patient over the phone or internet, or using point of care tests for the
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patient at a nursing home, or clear an accident victim on the street, or distribute patients to open emergency departments suited to care for them. There has been an unfair portrayal of the emergency system as wasteful, unresponsive, uncaring, and ineffective. My belief is that the emergency system has been so effective, we have moved ahead more quickly then the rest of the healthcare system can support. The regional program we design should bring together EMS providers, ED leaders, 9-1-1 directors, physicians, payers and other stakeholders to effectively provide unscheduled medical care. Patients can be provided phone and computer access to a system that gives them care advice on unscheduled health needs, and links them to regional medical resources suitable for addressing their needs. We face dramatic opportunities to improve our systems in ways that will benefit all those needing care in the future. With our heritage of success in prevention and delivery, RAES can help us realize them. I look forward to working with you on the design of these programs, and anticipate an opportunity for an emergency provider to work on me someday at the right time, in the right place, with the right resources. EMS is the frontline medical resource and a vital member of the communitys emergency and disaster preparedness system. EMS represents a significant pathway for patients admitted to hospitals and an important access service for patients who are typically the sickest or worst injured. About eighteen percent of patients arriving in EDs come via EMS, and more than forty percent of those EMS patients are admitted. EMS also provides the important transportation link for interhospital transfers, discharged patients, and the ever-growing nursing home population. The EMS system is also a provider of public health services, but operates in the difficult tort environment that requires exces-

sive resources to minimize unplanned outcomes. The future challenge is to get the right care to the right patients faster. It will require stakeholders to collectively determine how to most effectively provide unscheduled medical care. Key elements will include phone and computer access to a system that provides advice on less acute care needs, and links to regional medical resources. The design will reduce unnecessary ED visits and free up EMS resources. With the heritage of success in prevention and delivery, RAES can help build healthier communities, continue to reduce premature death, and improve the use of community medical resources. Like many of you, my career has given me the opportunity to provide emergency care in a variety of settings. It has impressed me how frequently we deliver care to the wrong person, at the wrong place and time, and use too many resources. My hope is that sometime before I retire, I can deliver care consistently in the model of: right care, right place, right time, to the right patient, at the right price. Let us lead our way to that system.

James Augustine, MD, FACEP, is the medical director for a number of fire EMS services in the Atlanta area. He has served since 1981 as a firefighter and EMT. Contact him at jaugustine@ emp.com.
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Pre-Payment Review
We are seeing a new epidemic in EMS. The virus is known as PPR (short for Pre-Payment Review) and there is no known cure. But there are some things you can do to keep from contracting it to begin with, so please read the following directions carefully. Pre-payment review is a tool authorized by law and used by Medicare Administrative Contractors (MACs) to review your paperwork (trip reports and supporting documents such as physician certification statements) prior to paying a claim, instead of paying based solely on the electronic transmission of the claim. In the past two years we have seen pre-payment review of Medicare claims used by several MACs concerned with specific areas of fraud or abuse. TrailBlazer (the MAC for Texas) has had an ongoing pre-pay review policy for patients going to dialysis. And First Coast, the MAC for Florida, has announced a similar policy for hospital discharges to a nursing home (N-H claims). This policy came as a result of a State wide study done on the most common claims errors in Florida. While these two Medicare Contractors announced specific areas of concern and applied a policy across all providers in their jurisdictions, other MACs are now widely using the pre-pay review tool on a case-by-case basis, looking at a sample of one Ambulance suppliers claims and then determining if they should be put on pre-payment review for some or ALL of their claims. Pre-pay review is authorized under the Federal Regulation, and the process is almost totally at the discretion of the Contractor. There is a requirement that there be an error rate that is sufficiently high to justify the need for pre-pay review. In order to establish this initial error rate, the MAC will ask you for a small sample of claims. Based on their review of these claims, and your resulting error rate, you may be placed on pre-payment review of some or all of your claims. The pre-pay review process runs in three month cycles, at the end of which your error rate should be redetermined and then your status reevaluated. If your error has been fixed, then you should be removed. If you continue to make the same errors, you should be provided with a summary of their opinion on what you are doing wrong, and then you will be on review for another three month cycle. If you do get a high initial error rate, getting stuck in this three month process can have a big financial impact on your company for several reasons. First, Christopher Kelly is a lawyer who focuses on regulatory healthcare law as it relates to the EMS and ambulance industry. This article is not intended as legal advice. For more information or questions about your documentation practices and Medicare compliance, he can be reached at EMS Consultants, Ltd., (800) 342-5460 or email to ckelly@ emscltd.com. Now, what can you do to keep from contracting this vile disease? First: Dont make errors. Second: If you do, fix them (if you can) before sending your documentation in to be scrutinized by the MAC. Some things can not be fixed and must be done right to begin with. And of course some of these errors are subjective analysis issues such as what is medically necessary and for these all you can do is paint as clear a picture as possible as to why an ambulance was necessary for each and every transport you make or why a certain ALS procedure was necessary (hint here: the answer is never just because our protocols told us to). But for other errors, such as collecting signatures, getting documents dated correctly, coding levels of service correctly, and using the proper origination and destination modifiers, you only need to understand what is required and make sure that you are doing it correctly. The top five errors I see cited by the MACs are: No patient signature, no medical necessity, no need for ALS service, no cash flow is disrupted because of the delay in processing your claims (claims are still submitted electronically, then a letter is sent to you asking for your documentation, then you have to send that in by mail, then they have 30 days to look at it and make a decision). Second, many claims that are paid under the electronic claims process are denied when viewed under the prepay review microscope. Finally,

Is This the New Norm?

By: G. Christopher Kelly, Chief Legal Officer, EMS Consultants

depending on your call volume, responding to all of these requests for information may take a full time employee just to keep up with all of the paper and the appeals of denied claims.

PCS, and not a covered destination (usually where the trip has used an improper destination modifier). Know the rules on these issues and make sure that you adhere to them. The time to do that is before the MAC comes to take a look, because again, this virus takes a minimum of three months to run its course. Trust me, you dont want your service to be sick that long!

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Spring 2011
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GA EMS

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Air Evac Lifeteam Proudly Supports Georgia EMS

Good patient care requires a team effort of everyone involved from first responders and law enforcement officials to ground ambulance and hospital personnel. We all play separate,but very distinct roles,in getting the patient to the appropriate medical care. Were proud to be a part of the Georgia EMS community.

For more information or to become a member, call

1-800-793-0010
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GA EMS

Spring 2011

or visit www.lifeteam.net

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WHEN IT COMES TO CRITICAL CARE, ITS ABOUT TIME.

Emergency Dispatch: 1-800-247-3822

4/16/2013 7:36:42 AM

Meet Your Board Members

Visit us on Facebook!

Kim Littleton Executive Director

Kelly Joiner Secretary

Dawn Peebles

Courtney Terwilliger Chairman

David Moore

Glenn Henry

Lee Oliver Vice Chairman

Becky Hill

Karen Grabenstein

Jeff Smith Treasurer

Nita Ham

Chad Black 23
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27th Annual GA EMS & Educators Conference

October 19-23, 2013
At the Marriott on River Street Preconference: 19th-20th Conference: 21st-23rd
Continuous Pre-Hospital Track Educator Track
Golf Tournament: Saturday, October 19th ACLS Competition: BLS/ALS Teams October 21st

Visit us at www.ga-ems.com for the latest updates.

Hotel Information Marriott Savannah Riverfront Hotel 100 General McIntosh Boulevard Savannah, GA 31404 912.233.7722/800.285.0398

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