Like many states, Nebraska is facing a significant shortage of trained emergency medical workers. As a predominantly rural state, many of its community fire and ambulance services rely heavily on volunteers. But recruitment and retention of EMTs have become a major challenge.

THE PROBLEM

With older volunteers retiring and younger ones moving on to other opportunities, departments are struggling to attract new volunteers, placing increased pressure on those who remain. The demand for EMTs and paramedics is greater than ever, particularly as the population ages.

Without adequate support, the dedicated volunteers still on duty are pulled away from their jobs more often to respond to emergencies.

"Another pressing issue is the long transport times many Nebraskans experience," explained Tim Wilson, state EMS director at the Nebraska Department of Health and Human Services. "A significant number of residents live more than 25 minutes away from the nearest ambulance station. This means after a call for help is placed, it can take nearly half an hour for an ambulance to arrive, followed by an additional 30- to 60-minute drive to the hospital.

"During this critical period, there typically is only one EMT or paramedic in the back of the ambulance, responsible for treating the patient, communicating with the hospital, documenting the case and managing all necessary interventions to keep the patient stable until they reach the next level of care."

Moreover, in rural Nebraska, new EMTs have less access to on-the-job training compared with their urban counterparts. The lack of field training officers or structured programs means once new EMTs complete their training, they often find themselves working independently.

Their first call could involve a traumatic obstetric emergency or another high-stakes situation they may not have encountered before. Recognizing this gap, Nebraska DHHS understands the urgent need to implement supportive measures for these EMTs and paramedics, empowering them to provide the highest level of care to their patients.

PROPOSAL

"About three years ago, in the midst of the COVID-19 pandemic, my office began exploring ways to support EMS workers in Nebraska," Wilson recalled. "When you find yourself in an accident or facing a medical emergency, you rightfully expect a swift response from an ambulance.

"Our goal was to ensure that expectation could be met, even amidst staffing shortages and long transport times," he continued. "We looked at additional resources that could provide vital support to local EMS crews, especially EMTs and paramedics working alone in the back of an ambulance."

Recognizing having two EMTs or paramedics available for every call is not a feasible option, especially during the pandemic when officials sought to limit in-person interactions, Nebraska DHHS turned its attention to telemedicine.

Vendor Avel eCare EMS emerged as an appealing solution to the problem, allowing EMTs and paramedics to dial in on-demand for virtual assistance from an emergency-trained physician, nurse or paramedic whenever and wherever they needed it, Wilson explained.

"This innovative approach promised to bridge the gap in care and ensure no EMT or paramedic would ever feel alone during critical moments," he said. "The vendor offers a comprehensive range of services designed to enhance the capabilities of EMS crews in the field. Its peer-to-peer consultations provide immediate access to expert advice, while prehospital documentation support streamlines the administrative side of emergency care.

"Another crucial feature of Avel is its interpretation services, which cater to Nebraska's diverse population, encompassing a variety of languages from Spanish to Farsi," he continued. "This is particularly important in ensuring all patients receive the care they need, regardless of their language background."

The telemedicine vendor's team can assist with a wide array of actions and procedures, ranging from airway management and trauma care to ECG interpretation and medication decisions, as appropriate. Additionally, they can proactively call the receiving hospital to inform them of an incoming patient, ensuring medical staff are prepared for the patient's arrival.

"By providing this level of support, the vendor allows EMTs and paramedics to concentrate fully on their patients, significantly improving the overall quality of care delivered in critical situations," Wilson noted.

"We firmly believed having virtual assistance would be just as effective as having another EMT or paramedic physically present in the back of the ambulance, so we created a pilot program to assess the feasibility of EMS telemedicine in rural Nebraska," he added.

The objective was not only to enhance the immediate support available to EMS workers but also to determine if this approach could aid in the recruitment and retention of EMS staff, ensuring communities remain well-equipped to handle emergencies now and in the future.

"As we initiated this pilot program, we were optimistic about its potential benefits, both in terms of immediate patient care and the overall sustainability of our EMS workforce," Wilson said. "By embracing technology and innovative systems, we hoped to transform the landscape of emergency medical services in Nebraska, making it more resilient and responsive to the needs of our communities."

MEETING THE CHALLENGE

The Nebraska Office of Emergency Health Systems worked with Avel eCare to outfit 65 ambulances in 26 communities with cabin-mounted telehealth tablets equipped with the appropriate technology to support strong connectivity in the field. Participating EMS departments represent a cross-section of agencies: basic life support, advanced life support, 911 and transfer services. Nebraska DHHS chose rural and super-rural departments spread across the state, intentionally leaving out larger cities.

"Through these telehealth tablets, EMTs and paramedics can connect instantly with Avel's experienced emergency physicians, paramedics and nurses for real-time support and consultation during transports," Wilson explained. "The most frequent calls to date have been for assistance with trauma, altered mental status and cardiac/chest pain.

"A recent critical call demonstrated the advantages of integrating this technology across multiple entities to optimize patient care," he continued. "A BLS ambulance requested an ALS intercept, so the responding paramedic requested a telemedicine encounter with the BLS ambulance."

He was able to receive important information about the patient's condition and ensure optimal care prior to and during the intercept because of the telemedicine technology available in the BLS ambulance.

Pilot projects are currently exploring other innovative new ways to use the technology to connect multiple parties – such as ambulances, hospitals and telemedicine providers – during emergencies and using tablets in patients' homes or on-scene to facilitate communication and care during ambulance calls.

"EMTs and paramedics who have used the telemedicine service say they felt more confident with another set of eyes on the patient; one EMT even reported using it because they felt uneasy on a call," Wilson reported.

"Physicians and nurses on the calls offered suggestions for treatment, ordered medications for pain control, and gave reminders when it was time to check vitals or get readings such as blood glucose," he continued. "Additionally, responders appreciated the documentation service, which allowed them to concentrate fully on patient care. In one recent case, Avel got a translator on the line to communicate with a patient in Spanish."

RESULTS

Utilization has been substantial, with the number of calls increasing by an average of 68% month over month from January through June 2024. The fewest calls were in January, which was to be expected as only four departments were live with the service for the entire month. An additional five departments went live in the final days of January.

"Utilization remained relatively low during the first quarter as the rollout continued, but utilization spiked during the second quarter as more departments went live," Wilson reported. "The final EMS department went live on June 3, 2024. We expect utilization will continue to rise now that all 26 participating EMS departments are using the service.

"We have been evaluating the program and collecting data since it began," he added. "I hope to show that EMS telemedicine works and that it works in rural Nebraska. Some have expressed concerns about feasibility in the state due to weak cell phone coverage in certain areas, but we have not experienced that to date during the pilot project."

Avel's EMS system is designed specifically to address connectivity challenges and reduce the likelihood of dropped calls. There have been 212 encounters in the first six months of the year. After each encounter, EMS personnel are invited to fill out a survey to share their experiences.

"We have received 113 completed surveys, with 88.5% of respondents stating they experienced no technical issues," Wilson said. "The vendor further reported that of the 212 encounters, only three failed due to the inability to connect.

"In the small percentage of other calls that reported technical problems, troubleshooting resolved the issue at some point during the encounter," he continued. "My office will continue to compile data over the coming months to show the feasibility of EMS telemedicine and its benefits to patient care. I hope to secure funding to extend the pilot program for a second year."

ADVICE FOR OTHERS

"The challenges we face in Nebraska are not unique to our state or the field of emergency medical services; they are part of a broader national issue," Wilson stated. "Provider-to-provider telemedicine has become an essential lifeline in emergency departments, intensive care units and rural critical access hospitals, which often lack specialists or behavioral health professionals trained to address trauma and other crisis situations.

"This technology enables healthcare providers to connect with experts in real time, ensuring patients receive the best possible care, regardless of their location," he continued.

For healthcare organizations considering the integration of telemedicine technology, Wilson offers some crucial advice: Do your homework.

"The selection of a vendor is a vital first step," he said. "It's imperative to choose a provider that is not only responsive but also offers a robust network of professionals available when you need them most. Look for vendors that prioritize thorough training for your staff; this ensures everyone is well-prepared to use the technology effectively and can handle any challenges that arise.

"Connectivity is another critical consideration," he added. "Reliable internet access is a must for EMS operations, as a dropped call during transport can have dire consequences, especially in the midst of a medical emergency."

This requirement extends to healthcare facilities, as well. If an organization plans to use telemedicine via a rolling cart, the signal must be strong and consistent throughout the entire facility. There's nothing worse than encountering connectivity issues when one is trying to access critical care or guidance during an emergency situation, Wilson noted.

"Furthermore, consider the scalability of the telemedicine system you choose," he advised. "It should be flexible enough to adapt to the evolving needs of your organization. As you integrate this technology, ensure that it can grow with you and accommodate any additional services or specialties you may want to include in the future.

"Engaging with your staff throughout the implementation process also is essential," he continued. "Gather feedback from the frontline providers who will be using the technology daily; their insights can help refine the system and make it more user-friendly. Creating an environment of collaboration and openness will foster a smoother transition and ultimately improve patient care."

Lastly, keep in mind the integration of telemedicine is not just about technology – it's about enhancing patient outcomes and improving the overall efficiency of a health system, Wilson said.

"By investing in robust telemedicine systems, you can ensure your providers are equipped to handle emergencies effectively, no matter where they occur," he concluded.

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