Hi all,

I'm interviewing for a Critical Care Transport position that is starting at my facility. Since we are the guinea pigs, we can shape it a lot....

From what I can tell, they're thinking of 12 hour shifts, and when not on a call, we are the critical care resource nurse for the department. They're still trying to work out out scope (from what I can tell, I'll ask more in the interview).

Since we are taking on more liability, some of us interviewing believe we should be paid more than our ED counterparts.

Thoughts? Do you know of facilities that pay more? Ideas for arguments for an increase in pay? Also, for GROUND ambulance, what typically do you see for scope of practice?

Thanks very much!

Hi all,

From what I can tell, they're thinking of 12 hour shifts, and when not on a call, we are the critical care resource nurse for the department.

Not always the best idea, especially for night shift.

Since we are taking on more liability, some of us interviewing believe we should be paid more than our ED counterparts.

Depends on your team's configuration. If you take a physician with you your liability isn't very high. Also, how would that work out? Would you get paid extra only when on a call or for your entire shift? This may set you up for some uncomfortable relationships with your peers in the ED.

Thoughts? Do you know of facilities that pay more? Ideas for arguments for an increase in pay?

Some do. Many don't. Supply and demand drives that. Now is probably not the time to start making demands. You might need to prove that you're worth the extra money. I guarantee it won't be enough to risk not getting the job over.

Also, for GROUND ambulance, what typically do you see for scope of practice

Your SOP is determined by both your BON and your facility and will be largely determined by your team's composition. I have been on teams where my SOP was no more than a bedside nurse's and others with a much broader/advanced one. There are a lot of variables.

Thanks very much!

Hope this helps some. Do they have anything in place yet?

Can you elaborate on your comment on the critical care resource part? According to management, they only anticipate 1-2 calls in a 24 hour period. I can see why they want to use us for other things to increase productivity. Also, we are the hospital where a lot of victims came after a shooting that STILL has national coverage years later... and so they are hyper aware of staffing issues. They make sure to always always staff the ER (which is awesome).

And, it won't have a physician for the CCT as far as I understand. Just the RN, Paramedic, and EMT. But, I will ask for sure. I know we will be developing the protocols, but they do have other facilities that work with the system that have a CCT in place, so they will likely use those as base and make sure they work for our team.

Do you think that it's too much of a risk to do all of this as one of the first people in this program? I'm an ER nurse by trade, but definitely on the "greener side" of the experience. Definitely not a new grad anymore though.

Someone who already interviewed mentioned that they WOULD NOT do intubations. From what I understand, the job is from one hospital to ours. Hopefully they are already intubated. (I don't know if RT is coming either...) But, from what I understand of what a CCT entails, I would hope that I would be able to intubate en route or at the facility if there is the need (and to be taught to do that, and to keep up competency by intubating in the ER for practice when necessary). Do you think CCTs should have that as a part of their scope?

They are having a hard time staffing the night shift position, which is why two of the three people interviewing for the four spots are thinking "we will say no if they don't pay us more" sort of thing.

Thanks for the feedback and guidance. Do you know of any good resources in the mean time for me to determine if I should take this job if I get offered it? I have BLS, ABLS, ACLS, PALS, TNCC, ENPC, ATLS, and hopefully CEN in the next two or so months.... and maybe even TCRN (depends what happens, been a busy few weeks, and even busier coming up).

Will the Paramedic and EMT be employees of your hospital or of the ambulance service?

If they are part of the ambulance service, will they use their own protocols?

Will the Paramedic be in charge?

Will the Paramedic and EMT be allowed to do things outside of their scope of practice?

One of you would have to intubate and one would have to push the medications. Are the Paramedics in your state or by their company policy allowed to use RSI medications? You might have a hard time intubating and trying to push medications at the same time.

However, most of the time, only the Paramedic will be the intubator. On dual flight teams have I seen RNs actually doing the intubation. They might have some knowledge and may even have been allowed to intubate but if there is a Paramedic on board, the Paramedic will intubate. You do not want to step on the Paramedics' turf too much. If the Paramedic works for the ambulance, their company will hold the insurance covering intubation. Extending that privilege to a nurse or even RT will require more coverage at a huge expense to the hospital. Duplication of this skill is an unnecessary expense.

Will you be required to have at minimum the EMT credential to work on an ambulance? Some states require this and many places require the Paramedic cert.

Does your state have state wide CCT protocol?

example:

http://www.wvoems.org/media/135599/cct_guidelines.pdf

http://www.paems.org/pdfs/protocols/PAEMS-Critical-Care-Protocols.pdf

I don't know what state you are in but some states even get into county specifics.

example:

http://www.vchca.org/docs/emergency-medical-services/0507-critical-care-transports-.pdf?sfvrsn=2

http://www.sloemsa.org/files/156_Nurse-Staffed_Critical_Care_Transport.pdf

Excellent questions! I know we are currently using an already established ambulance service. But, with plans for the hospital to take over the contract in the upcoming years. The problem is, I believe that ambulance company has had intubation removed from their scope due to issues in the past. I don't know, but maybe? All excellent questions!!!

I'm not sure of what protocols do exist. I'm going to look up in our system for other facilities protocol later.

Excellent questions! I know we are currently using an already established ambulance service. But, with plans for the hospital to take over the contract in the upcoming years. The problem is, I believe that ambulance company has had intubation removed from their scope due to issues in the past. I don't know, but maybe? All excellent questions!!!

I'm not sure of what protocols do exist. I'm going to look up in our system for other facilities protocol later.

Can you say what state you are in?

I suppose I can. Colorado.

I suppose I can. Colorado.

Here is the Colorado EMS description of scope if you want to familiarize yourself with what a Paramedic and EMT are capable of "IF" their medical director approves and writes their p&p.

This starts at page 30. Ch 15 and 16 are specific to CCT.

Can you elaborate on your comment on the critical care resource part? According to management, they only anticipate 1-2 calls in a 24 hour period. I can see why they want to use us for other things to increase productivity.

It depends on how big of an area you will be covering. Say you have worked all day/night and a call comes close to the end your shift (but too early to call in the day crew) that is a two hour drive in good weather but it's snowing. Not so bad to refuse the call but bad enough it's going to slow you down. You could be looking at 6-10 hours over without any rest. It happens all of the time in CCT. I had a trip that was supposed to take 5 hours total that ended up being 27 hours! You need to be well-rested and working a full shift in the ED will not allow for that. Many teams act as resources for hard IV sticks or crumping patients/codes/traumas and the like but that is episodic and usually still leaves downtime.

And, it won't have a physician for the CCT as far as I understand. Just the RN, Paramedic, and EMT. But, I will ask for sure. I know we will be developing the protocols, but they do have other facilities that work with the system that have a CCT in place, so they will likely use those as base and make sure they work for our team.

If your ancillary staffing is from a separate ambulance company they rarely send Paramedics and what you get is EMT's only, which would explain why they don't intubate as it has been removed from the EMT SOP nationally.

Do you think that it's too much of a risk to do all of this as one of the first people in this program? I'm an ER nurse by trade, but definitely on the "greener side" of the experience. Definitely not a new grad anymore though.

Yes, it's a risk. You need to know your ****. You need top notch assessment skills because you will be working off of protocols. You need to be technically excellent with skills such as IV insertion. If your configuration is considered an "RN led" team than the entire responsibility for that patient is on YOUR shoulders. It can be a little scary sometimes but you can never let them see you sweat. Who will be your medical control?

Someone who already interviewed mentioned that they WOULD NOT do intubations. From what I understand, the job is from one hospital to ours. Hopefully they are already intubated. (I don't know if RT is coming either...) But, from what I understand of what a CCT entails, I would hope that I would be able to intubate en route or at the facility if there is the need (and to be taught to do that, and to keep up competency by intubating in the ER for practice when necessary). Do you think CCTs should have that as a part of their scope?

What do you mean would not do intubations?! That's ludicrous. Your main function is to support the ABC's and get the patient to a tertiary hospital for more advanced care. And, no, that skill is not deferred to the paramedic only (if you even have one). You cannot have only one person on the team trained to manage airways. In CCT you want to complete as many tasks as possible BEFORE getting on the road. Intubating in the back of the truck is no picnic and usually unnecessary if the patient was properly assessed in the first place. Also, don't count on the referring hospital doing the intubation. They often will defer that to the transport team. As far as competencies and training you will not get enough in the ED. Most places send their CCT staff to the OR for a day or two of multiple intubations.

They are having a hard time staffing the night shift position, which is why two of the three people interviewing for the four spots are thinking "we will say no if they don't pay us more" sort of thing.

I think they will find that there will always be someone who will so that line in the sand probably won't turn out so well for them if they really want the job.

Thanks for the feedback and guidance. Do you know of any good resources in the mean time for me to determine if I should take this job if I get offered it? I have BLS, ABLS, ACLS, PALS, TNCC, ENPC, ATLS, and hopefully CEN in the next two or so months.... and maybe even TCRN (depends what happens, been a busy few weeks, and even busier coming up).

CFN would probably be more helpful in the transport role.

I can't really tell you if you should take the job. I would hope if your system has other CCTs in place they would be the ones training you. Do NOT do this without an in depth orientation that includes class work and clinical. An absolute minimum of four months but 6 would be better. You also need to feel out MD buy-in. If they aren't thrilled about it this could turn out badly especially if they are your MCP. Trust me they will throw you under the bus in a heartbeat if something goes awry.

Will the Paramedic and EMT be employees of your hospital or of the ambulance service?

Excellent question. Most likely hospital employees.

If they are part of the ambulance service, will they use their own protocols?

Will the Paramedic be in charge?

Will the Paramedic and EMT be allowed to do things outside of their scope of practice?

Unlikely the paramedic will be in charge or the team will work off separate company's protocols. The hospital will be in charge not the ambulance service because once the team has taken over they are considered admitted to the receiving hospital. No way and ambulance company would want to hold even a tiny bit of that liability.

However, most of the time, only the Paramedic will be the intubator. On dual flight teams have I seen RNs actually doing the intubation. They might have some knowledge and may even have been allowed to intubate but if there is a Paramedic on board, the Paramedic will intubate. You do not want to step on the Paramedics' turf too much. If the Paramedic works for the ambulance, their company will hold the insurance covering intubation. Extending that privilege to a nurse or even RT will require more coverage at a huge expense to the hospital. Duplication of this skill is an unnecessary expense.

This is not the model utilized by most CCT or flight teams. Most ambulance companies are contracted by the hospital to provide a vehicle and someone to drive the vehicle. Rarely, and I do mean rarely do they play a role in patient care. It sounds like the OP's situation is hospital employed medics and EMTs with a contracted ambulance company. The nurse is going to decide if the patient needs intubated (usually in collaboration with the MCP and the rest of the team). This skill does not belong soley to the medic and it should not. There is no "turf". It's a team. To only have one person trained to do something as important as airway management is assuring a disaster to happen. Of COURSE more than one team member should be able to do it. What if it's a difficult airway and one person can't get it? Go without?There isn't any special "intubation insurance".

Kudos for the links you added. Very helpful!

I hope you don't feel like I'm busting your chops. I'm really not. You asked some great questions and provided some really good information.

I'm learning not to trust..... I automatically give trust away, and I need to be more cautious about that when it comes to all aspects of my life.

I don't know if I should take this job either, or not. I REALLY want it, and it puts me about 5 years ahead of "my goal schedule". Learning to intubate is something I really want to do. I want to have the independence of my practice, but the support from my management.

Perhaps I should make the argument that x are my conditions, including training. I know they said like 60 hours of something, but it's really not defined well. Hell, they didn't really ask for certain things other than to put in interest and saying why.

I've been looking at other posts with similar job titles. I meet most of the requirements for all various positions (one that I miss is CCRN preferred, and ICU experience preferred perhaps).

I'm not sure if I should take it either, for safety of the patients and my license.

What are expectations for training I should ask for??? Which classes should I say I want for training and competencies?

I know it's still in the works of all the planning... So I think it's good to go in knowing stuff.

Is CCT a requirement for level 1? Someone said it was and that's why they think the hospital is setting it up so they can get level 1.

I don't know if I should take this job either, or not. I REALLY want it, and it puts me about 5 years ahead of "my goal schedule". Learning to intubate is something I really want to do. I want to have the independence of my practice, but the support from my management.

Be careful what you wish for. How many years have you been a nurse?

Perhaps I should make the argument that x are my conditions, including training. I know they said like 60 hours of something, but it's really not defined well. Hell, they didn't really ask for certain things other than to put in interest and saying why.

60 HOURS????? Are they serious? No, no and NOOOO!

I've been looking at other posts with similar job titles. I meet most of the requirements for all various positions (one that I miss is CCRN preferred, and ICU experience preferred perhaps).

If you want to do CCT it's time to move to a high acuity ICU.

What are expectations for training I should ask for??? Which classes should I say I want for training and competencies?

Advanced assessment. Advanced EKG. Airway management. Ventilator management. In depth pharmacology of pressors and other ICU meds. Radiology. Survival training (you're in Colorado for crying out loud). Advanced training in sepsis management. Advanced skills (airways of all types, central lines, IOs, needle thoracotomy, ABGs).

I know it's still in the works of all the planning... So I think it's good to go in knowing stuff.

Can you clarify how large a region you will cover and what kind of patients they anticipate transporting?

Is CCT a requirement for level 1? Someone said it was and that's why they think the hospital is setting it up so they can get level 1.

No, it's not a requirement.

Vett this carefully. Talk to the nurses in the established CCT program in your system. Your concern is valid.

Here is the Colorado EMS description of scope if you want to familiarize yourself with what a Paramedic and EMT are capable of "IF" their medical director approves and writes their p&p.

This starts at page 30. Ch 15 and 16 are specific to CCT.

I guess it would help to post the link.

https://www.sos.state.co.us/CCR/GenerateRulePdf.do?ruleVersionId=5808&fileName=6%20CCR%201015-3