DModrzejewski.Thesis

UTILIZING NURSE PRACTITIONERS IN THE PRE-HOSPITAL
SETTING TO REDUCE THE NUMBER OF NON-LIFE THREATENING
NON-CRITICAL AMBULANCE TRANSPORTS TO EMERGENCY DEPARTMENTS
by
Dan M. Modrzejewski
An Applied Project Presented in Partial Fulfillment
of the Requirements for the Degree
Master of Science in Technology
in Fire Service Administration
ARIZONA STATE UNIVERSITY
May 2010

UTILIZING NURSE PRACTITIONERS IN THE PRE-HOSPITAL
SETTING TO REDUCE THE NUMBER OF NON-LIFE THREATENING
NON-CRITICAL AMBULANCE TRANSPORTS TO EMERGENCY DEPARTMENTS
by
Dan M. Modrzejewski
Approved May 2010
Approved:
, Chair
Supervisory Committee
ACCEPTED:
_____________________________________
Department Chair

ABSTRACT
In America emergency departments are being used and abused as primary health
care clinics. Many people for many different reasons use the emergency department for
illness and injuries that are not life threatening or critical. The purpose of this applied
project was to identify if utilizing a nurse practitioner in the pre-hospital setting could
reduce the number of non-critical ambulance transports to emergency facilities along
with decreasing over crowded emergency departments and to analyze if a pre-hospital
nurse practitioner program would have a positive impact on the cost of health care.
This applied research project was conducted in Green Valley, Arizona and
utilized the Green Valley Fire District as the local fire and emergency medical service
provider. The firefighter emergency medical technicians and firefighter paramedics were
given training on the evaluation process and utilization of the pre-hospital nurse
practitioner treatment criteria to answer the survey question. The survey question
provided the information and data needed to answer the three research questions. In all
there were 2,628 requests for service that were evaluated by the medical staff of the
Green Valley Fire District.
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DEDICATION
This applied research project is dedicated to all firefighters, emergency medical
technicians, and paramedics who work tirelessly to keep their communities safe. I would
also like to embrace the possibility of bringing new people into the emergency medical
service community via the pre-hospital nurse practitioner.
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ACKNOWLEDGEMENTS
My last two semesters here at Arizona State University have been dedicated to
producing an applied research project that the academic community can be proud of. I
would not have been able to pursue this level of education without the continued support
from all faculty members who I had the pleasure of meeting throughout my
undergraduate and graduate programs.
I am heartily thankful to my committee chair Dr. Jeffrey Thomas whose
encouragement, supervision and support from day one enabled me to develop a true
understanding of the material, research tools, and continued enthusiasm it takes to
produce an applied project. I offer my regards and blessings to my committee members
Dr. Charles Kime and Dr. Scott Somers for their time, support, and expert knowledge.
Without my graduate committee’s kindness, feedback, and devotion to my work it would
have never taken on the life it needed to be successful.
I would like to thank Chief Simon Davis and the Green Valley Fire District for
allowing me to perform my research project. I would also like to thank the firefighters of
the Green Valley Fire District whose participation and commitment to the research
played an important roll in the success of this applied project.
Finally, I would like to thank my wife Tawnya for her endless support,
confidence, and inspiration which kept me focused. Without her the end result of my
project would not have been as successful, rewarding, or worthwhile.
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TABLE OF CONTENTS
Page
LIST OF FIGURES…………………………………………………………………..…..ix
CHAPTER
1 INTRODUCTION
Overview…………………………………………………………………………..1
Background and Significance……………………………………………………..1
Problem Statement………………………………………………………………...2
Purpose Statement…………………………………………………………………2
Research Questions………………………………………………………………..3
Contributions to the Existing Body of Knowledge………………………………..4
Definition of Terms………………………………………………………………..4
Project Overview………………………………………………………………….6
Limitations………………………………………………………………………...8
Delimitation……………………………………………………………………….8
Summary…………………………………………………………………………..8
2 LITERATURE REVIEW
Overview………………………………………………………………………….9
Emergency Medical Service……………………………………………………...9
Modern Emergency Medical Service…………………………………………….11
Fire-Based Emergency Medical Service…………………………………………13
Scope of Practice…………………………………………………………………15
Emergency Medical Service Medical Director…………………………………..17
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Nurse Practitioner House Call…………………………………………………...18
Emergency Department Overuse………………………………………………...19
Cost of Service…………………………………………………………………...21
Summary…………………………………………………………………………22
3 METHODOLOGY
Overview…………………………………………………………………………24
Problem Statement……………………………………………………………….24
Purpose Statement………………………………………………………………..25
Research Questions………………………………………………………………25
Research Population……………………………………………………………...26
Research Authorization…………………………………………………………..27
Research Tool…..………………………………………………………………...28
Data Collection…………………………………………………………………..28
Summary…………………………………………………………………………30
4 RESULTS
Overview…………………………………………………………………………31
Survey Question………………………………………………………………….31
Survey Question Results……………………………………………………...….32
Research Question Results………………………………………………………37
Summary…………………………………………………………………………39
5 CONCLUSION AND RECOMINDATIONS
Overview…………………………………………………………………………41
General Conclusions……………………………………………………………..41
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Key Findings……………………………………………………………………..42
Recommendations………………………………………………………………..43
Future Research Recommendations……………………………………………...45
Summary…………………………………………………………………………45
REFERRENCES…………………………………………………………………………47
APPENDIX A: Pre-hospital Nurse Practitioner Treatment Criteria……………………..49
APPENDIX B: Contract…………………………………………………………………51
APPENDIX C: Arizona Ground Ambulance Rate Schedule…………………………….53
APPENDIX D: GVFD Memo…………………………………………………………...55
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LIST OF FIGURES
Figure 1: Research Question……………………………………………………………..29
Figure 2: Results for October 2009………………………………………………………29
Figure 3: Totals and Types of Request…………………………………………………...32
Figure 4: October 2009 Totals…………………………………………………………...33
Figure 5: November 2009 Totals………………………………………………………...33
Figure 6: December 2009 Totals…………………………………………………………34
Figure 7: January 2010 Totals……………………………………………………………34
Figure 8: Four Months of Data…………………………………………………………..35
Figure 9: Treat at Home vs. Transport…………………………………………………...35
Figure 10: Complete Research Totals ……………………………………………………37
Figure 11: Comparative Cost Analysis…………………………………………………..39
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CHAPTER 1 – INTRODUCTION
Overview
This applied research project’s primary goal was to determine if using a nurse
practitioner in the pre-hospital emergency medical field would reduce the number of non-
critical patients being transported via ambulance to the emergency department. A
secondary objective of this project was to explore the idea of reducing overcrowded
emergency facilities by the reduction of ambulance transports. A tertiary finding of this
applied project will bring forward the possibility of reduced health care cost by
increasing the availability of in home primary health care. The following sections of this
chapter will introduce the background and significance, problem and purpose statements,
research questions, contributions to the existing body of knowledge, definitions of terms,
a project overview, limitations, and delimitations.
Background and Significance
All across America citizens are using the emergency departments as their personal
primary health care provider. The end result being overcrowded emergency facilities,
long wait times to see an emergency room physician, increased health risk, and the rising
cost of health care (Washington Sentinel, 2009). An article written by The Everett Clinic
(2009) stated that “In recent years there has been a dramatic increase in the number of
people using emergency rooms. This increase is due in part to the fact that many people
have limited access to health care. For some who cannot get in to see a doctor, going to
the emergency room for routine care seems like an acceptable alternative” (The Everett
clinic, 2009). Along with overcrowded emergency departments is the possibility of
increasing mild illnesses into critical life threatening problems due to secondary

2
exposures in emergency facility waiting rooms. The Centers for Disease Control (2009)
has announced that if you are only mildly ill do not go to the emergency department.
This study was the first of it’s kind to look at introducing a new category of pre-
hospital health care provider into the Emergency Medical Services (EMS) field with the
idea that it will increase access to primary health care. This program would use nurse
practitioners in the pre-hospital setting accessed via the emergency 911 system. Previous
studies have been focused on how to decrease emergency room usage from the hospitals
stand point. The significance of this research identifies that if a nurse practitioner is able
to treat a patient’s condition at home then this will decrease unnecessary ambulance
transports to emergency departments, decrease the overcrowded emergency facilities, and
possibly contain the increasing cost of health care.
Problem Statement
The over crowding of emergency departments, ambulances transporting non-life
threatening illnesses and injuries coupled with increased health care costs are effecting
the reliability of primary health care in the United States.
Purpose Statement
The purpose of this research was to explore and examine the effects of utilizing
Nurse Practitioners (NP) in the Emergency Medical Services (EMS) field in order to
reduce the number of non-emergent ambulance transports along with decreasing the
amount of patients being seen in the emergency departments.

3
Research Questions
The following section provides the three research questions used in this study.
Research Question 1:
Could Nurse Practitioners (NP) provide pre-hospital service?
A nurse practitioner has the appropriate education and licensure to perform
primary health care in settings such as urgent care clinics, family practice, and home
health. Using nurse practitioners in the pre-hospital setting provides a means of accessing
their knowledge, skills, and abilities through an alternative medium.
Could pre-hospital service by a nurse practitioner reduce the number of emergency
transports in Green Valley, Arizona?
The reduction of ambulance transports to emergency facilities has the potential to
be reduced by providing home health care through a nurse practitioner. Many ambulance
transports to emergency departments are for reasons such as mild respiratory illness,
prescription refills, sutures, and x-rays. All can be performed in the home by a nurse
practitioner.
Would pre-hospital health care from a nurse practitioner benefit the Green Valley
community?
A review of the emergency department billing, ground ambulance rates, and
physicians charges where compared to receiving the same care by a nurse practitioner in
the home accessed via the 911 emergency system. This comparison showed a positive
financial benefit to the Green Valley, Arizona citizens.

4
Contributions to the Existing Body of Knowledge
The current available research has shown an increase in the need for in home
primary health care for older adults due to deceased mobility, limited transportation, and
the deceased availability of primary care physicians. The idea of nurse practitioners
providing in home health care is limited and there is no data available on the use of nurse
practitioners in the pre-hospital setting. Researching the possibility of adding a new
category of pre-hospital provider will be the initial effort in introducing primary health
care available through the 911 emergency systems. It will also produce statistics and
recommendations that local fire districts, fire departments and other agencies can use to
design, implement, and evaluate a pre-hospital nurse practitioner program.
Definition of Terms
Aortic Balloon Pump:
The Intra-aortic balloon pump (IABP) is a mechanical device that is used to decrease
myocardial oxygen demand while at the same time increasing cardiac output. By
increasing cardiac output it also increases coronary blood flow and therefore myocardial
oxygen delivery. It consists of a cylindrical balloon that sits in the aorta and counter
pulsates. That is, it actively deflates in systole increasing forward blood flow by reducing
after load thus, and actively inflates in diastole increasing blood flow to the coronary
arteries.
Chest Tube:
A chest tube (chest drain or tube thoracostomy) is a flexible plastic tube that is inserted
through the side of the chest into the pleural space. It is used to remove air

5
(pneumothorax) or fluid (pleural effusion, blood, chyle), or pus (empyema) from the
intrathoracic space.
Endotracheal Intubation:
Intubation and mechanical ventilation is the use of a tube and a machine to help get air
into and out of the lungs. This is often done in emergencies, but it can also be done when
you are having surgery.
External Pacing:
A device used to stimulate the heartbeat electrically by means of impulses conducted
through the chest wall, as used in emergency care of significant arrhythmias.
Intubation:
The placement of a tube into an external or internal orifice of the body.
IV Therapy:
Intravenous therapy or IV therapy is the giving of liquid substances directly into a vein.
The word intravenous simply means "within a vein.”
Manual Defibrillation:
Defibrillation is the definitive treatment for the life-threatening cardiac arrhythmias,
ventricular fibrillation and pulseless ventricular tachycardia. Defibrillation consists of
delivering a therapeutic dose of electrical energy to the affected heart with a device called
a defibrillator.
Nasotracheal Intubation:
A plastic tube is passed through the nose, larynx, vocal cords, and trachea

6
Need Cricothyroidotomy:
Cricothyroidotomy is an emergency procedure and must be performed only when a
secure airway need to be maintained and attempts at orotracheal and nasotracheal
intubation have failed. It is contraindicated if any other less radical means of securing an
airway is feasible.
Needle Decompression:
The insertion of a large bore cannula or needle into the second intercostal space on the
mid-clavicular line thereby releasing the pressure in the pleural cavity
Orotracheal:
The most common tracheal intubation is orotracheal intubation where, with the assistance
of a laryngoscope, an endotracheal tube is passed through the mouth, larynx, and vocal
cords, into the trachea.
Pharmacology:
The study of drug actions
Public Safety Agency:
Involves the prevention of and protection from events that could endanger the safety of
the general public from significant danger, injury/harm, or damage, such as crimes or
disasters. Some agencies include police, fire, and emergency medical services
Sutures:
A joining of the lips or edges of a wound or the like by stitching or some similar process
Tracheal Intubation:
The placement of a flexible plastic tube into the trachea to protect the patient’s airway

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True Emergency:
A situation in which there is a high probability of death or serious injury to an individual
or significant property loss
Project Overview
Chapter 2 - Literature Review
Chapter 2 summarizes the literature pertaining to in home primary health
care provided by nurse practitioners. Furthermore the chapter defines the history of the
emergency medical service (EMS) system, types of service, scope of practice, medical
direction, nurse practitioner house calls, emergency department overuse, and the cost for
service. The literature reviewed was obtained through written resources, electronic
databases, and personal interviews.
Chapter 3 – Methodology
Chapter 3 defines the research methods used during the data collection. The
specific types of research used in this study include applied, exploratory, and qualitative
field research. The Green Valley Fire District was used as the local fire/EMS agency and
data was collected through their emergency reporting system. The chapter breaks down
the elements of the study during a four month period where a total of 2,628 requests for
service were evaluated.
Chapter 4 – Results
Chapter 4 displays the results that were recorded by the medical personnel of the
Green Valley Fire District. The firefighter emergency medical technicians (EMT) and
firefighter paramedics followed the pre-hospital nurse practitioner medical treatment
criteria (Appendix A) in order to evaluate the patients’ condition and to remain consistent

8
throughout the study period. The results were used to answer the three research questions
posed in earlier chapters. The data that was collect was used to create charts and graphs
to help examine the 2,628 entries made by the GVFD medical staff.
Chapter 5 – Conclusion
Chapter 5 ties all the research together and describes the positive affects that a
pre-hospital nurse practitioner program could have on the Green Valley, Arizona
community. This chapter also provides recommendations for the design, implementation,
and evaluation of introducing a nurse practitioner program into the emergency medical
services field.
Limitations
This applied project was limited to the residents of Green Valley, Arizona along
with small pockets of age restricted areas of Sahuarita, Arizona. Though the surrounding
area is growing the main root of the study area is a retirement community. The
community’s population does fluctuate with winter visitors. Since the study was
performed in a predominantly retirement community results may differ in other
jurisdictions.
Delimitations
The main focus of this study was not to educate the community on in-home health
care or the possibility their present illness/injury could be treated at home by a nurse
practitioner. In fact the community itself and patients who were being evaluated were
unaware of the study taking place. This project is not designed to be implemented in all
fire districts or fire departments.

9
Summary
The applied research investigated whether or not using nurse practitioners in the
pre-hospital setting would have a positive impact on the Green Valley, Arizona
community. This chapters objective was to provide a quick introduction into the project
as a whole. Beginning with a brief explanation of the background and significance of the
research, followed up with the projects problem and purpose statements. The three
research questions to be answered by the study are provided along with a synopsis of
contributions to the existing body of knowledge. In order to fully understand the research
a definitions of terms section is provided. To continue with the introduction into the
research an outline of chapters 2-5 was established. The final stage in completing the
introduction to this research was the limitations and delimitations section.

CHAPTER 2 – LITERATURE REVIEW
Overview
The purpose of the literature review is to provide a knowledge base that will
support and define topics that are relevant to the design, implementation, and evaluation
of a Pre-hospital Nurse Practitioner program. Also this review will act as a tool for policy
makers, Emergency Medical Service organizations, and researchers concerned with the
delivery of primary health care in the United States. This research will use information
from written sources, worksheets from the Arizona Department of Health Services
(ADHS), electronic databases, and personal interviews with Tawnya Meeks, a registered
nurse at University Medical Center in Tucson, Arizona and John Hart financial
representative from Prorenata Heath Care in Nashville, Tennessee. A descriptive method
was used to explore and analyze the following areas: history of the emergency medical
service (EMS) system, types of service, scope of practice, medical direction, nurse
practitioner house calls, emergency department overuse, and the cost for service.
Emergency Medical Service
The Emergency Medical Service (EMS) can be defined in a multitude of ways,
however according to the Merriam-Webster Online Medical Dictionary, EMS is a
network of services coordinated to provide aid and medical assistance from primary
response to definitive care, involving personnel trained in the rescue, stabilization,
transportation, and advanced treatment of traumatic or medical emergencies. Linked by a
communication system that operates on both a local and a regional level, EMS is a tiered
system of care, which is usually initiated by citizen action in the form of a telephone call
to an emergency number. Subsequent stages include the emergency medical dispatch,
first medical responder, ambulance personnel, medium and heavy rescue equipment, and
paramedic units if necessary (Merriam-Webster Online Medical Dictionary, 2009).
Within the EMS system there are basically four levels of health care provider. They

10
include First Aid Provider, Emergency Medical Technician - Basic (EMT-B),
Emergency Medical Technician – Intermediate (EMT-I), and Emergency Medical
Technician – Paramedic (EMT-P). The following is how the American Academy of
Orthopedic Surgeons describes each prehospital provider.
Over the years there has been an increased awareness of the need for immediate
emergency care, millions of laypeople and volunteers have been trained in basic life
support (BLS) and cardiopulmonary resuscitation (CPR). In addition to CPR, many
individuals have taken short basic first aid courses that include control of bleeding and
shock prevention, splitting of injured limbs, and recognizing the signs and symptoms of a
true emergency. Most of these classes are eight to ten hours long and are provided by the
American Red Cross, American Heart Association, and the American Safety and Health
Institute (American Academy of Orthopedic Surgeons, 2009).
The EMT-B course is designed as the foundation on which additional knowledge
and skills are built in advanced EMT training. This training presents the student with the
knowledge and skill set to perform a more detailed patient assessment, use medical
devices to splint injured limbs, apply oxygen, and is certified to transport patients via
ambulance. An EMT-B course requires a minimum of 110 hours of training, which is
generally held at or in conjunction with a local community college (Arizona Department
of Health Services, 2009).
The EMT-I course is designed to add knowledge and skill in specific aspects of
advanced life support (ALS) to individuals who have been trained and have experience in
providing emergency care as an EMT-B. These additional skills include intravenous (IV)
fluid therapy, endotracheal intubation, and administration of some medication (Browner,
2002). The EMT-I course has fallen out of favor in the last few years, however according
to the Arizona Department of Health Services Title 9 Chapter 25 the training consists of a
total 400 hours broken down into 280 didactic and 120 clinical hours and like the EMT-B

11
is generally offered by or in conjunction with a local community college (Arizona
Department of Health Services, 2009).
The EMT-P will complete an extensive course of training that significantly
increases the knowledge and mastery of basic skills and covers a wide range of ALS and
advanced cardiac life support (ACLS) skills including: electrocardiogram monitoring and
interpretation of cardiac rhythms, ALS skills, manual defibrillation and external pacing,
orotracheal and nasotracheal intubation, needle cricothyroidotomy, needle
decompression, intravenous therapy, and advanced pharmacology (Browner, 2002). The
course is required by the Arizona Department of Health Services Title 9 Chapter 25 to be
a minimum of 1000 contact hours. With 500 hours being didactic and 500 being in a
clinical setting (Arizona Department of Health Services, 2009).
Modern Emergency Medical Service
In order to appreciate the next generation in emergency medical service (EMS) it
is necessary to understand the modern emergency service. The modern area of EMS
began in the 1970s with the formation of a federal program entitled the Division of
Emergency Medical Services (DEMS). This group held conferences with the American
Academy of Orthopedic Surgeons and the American College of Surgeons. At the end of
the conferences letters were sent to President Nixon urging him to take steps to improve
EMS. As a result there were five EMS demonstrations and two EMS communication
programs initiated. Shortly thereafter the Emergency Medical Services System act of
1973 was signed into law. This law was initiated to create a systematic approach to EMS
along with composing regional programs (Walz, 2002). “Regions were essentially offered
5 years of funding proceeding from Planning (1 year) to Basic Life Support (2 years) and
then Advanced life Support (2 years )” (Walz, 2002, p. 29) . Despite some start up
difficulties this jump started the development of EMS systems.

12
Along with the development of the EMS system there became a need to
examine and expand the training of EMS providers. It was in 1971 when the first national
curriculum was established for Emergency Medical Technician – Ambulance (EMT-A).
With the ever growing need for an increased knowledge base an EMS committee was
formed to examine the possibility of a 480 hour Advanced EMT training program. This
was the birth of what is known today as an Emergency Medical Technician Paramedic
(EMT-P) or Certified Emergency Paramedic (CEP). The curriculum was developed and
the first legal recognition came from the Wedworth-Townsend Paramedic Act of
California. This act served as a model for other states to follow. In 1976 the development
of a national standard curriculum for the EMT-P was presented to the National Highway
Traffic Safety Administration (Walz, 2002).
By the 1980s there were a total of 303 EMS regions all with their own systems
consisting of members from the Division of Emergency Medical Services. These
members would come together using a think tank format to discuss what had been
successful with their region. The 1980s saw the continued growth and development of
EMS training to include increasing the number of classroom hours of the EMT-As to 110.
Also due to budgetary issues some regions were unable to afford sending their EMT-A’s
to EMT-Paramedic school. A compromise was made and a new category of prehospital
provider created. This new provider was called an Emergency Medical Technician -
Intermediate (EMT-I). These individuals were trained to provide advanced life support at
a minimum level. This curriculum was approved by the NHTSA in 1985 (Walz, 2002).
The 1990s saw amazing change in the EMS education arena. “Changes in the
nature of EMS, and the proliferation of state variations in provider training, lead to the
convening of the National EMS Training Blueprint Task Force in 1992” (Waltz, 2002 p.
34). This task force created a blueprint outlining four categories of Prehospital providers.
They included: First Responder, EMT-Basic, EMT-Intermediate, and EMT-Paramedic.

13
The idea behind this type of blue print was to allow a prehospital provider to build
upon their skill set. For example a provider trained at the First Responder level can use
knowledge gained through experience to attend EMT-B training. Once the individual is
comfortable with his/her skills as a Basic Life Support provider, the next step in the
blueprint is to continue the education into the Advanced Life Support role by becoming
an EMT-I or EMT-P. The mid 1990s brought with it the creation of the EMS Agenda for
the Future. The main point of this agenda was to see an increase focus and importance of
education along with research in EMS and the integration of EMS into the national health
care system (Waltz, 2002).
Moving into the twenty first century EMS has encountered many of the same
struggles it previously had over the past three decades. The economy has played a
significant role in the delivery of EMS. Many private EMS organizations and for-profit
ambulance companies have had to shut their doors. This is mostly due to the changes in
health care funding and insurance reimbursement rates. With the closure of many private
sector ambulance organizations there has been a rebirth of fire department-based EMS
systems (Waltz, 2002).
Fire-Based EMS
In the book Pride and Ownership: A Firefighter’s Love of the Job, Chief Rick
Lasky states “It wasn’t long before it was realized that we could provide first aid. That
when you were hurt or hurting, to call us. We started with the basic first aid, Red Cross
first responder, and the like, and then moved into the emergency medical technician field-
which elevated the Emergency Medical Service (EMS) platform just a little higher”
(Lasky, 2006, p. 3). The Emergency Medical Service is an essential component of the
public safety element provided by local government and the private sector. The Federal
EMS Act of 1973 defined an EMS system as “an entity that provides for the arrangement
of personnel, facilities, and equipment for the effective and coordinated delivery of health

14
care services under emergency conditions in an appropriate geographic area” (U.S.
Congress, 1973).
There are many different design types such as third-service and private ambulance
companies, hospital-based ambulances, local fire service, or a combination. An EMS
provider that is considered third service involves a separate government entity other than
the fire department to deliver service. This type of system includes uniformed personnel
who have their own vehicles, command structure, and in most cases their own stations.
Also the personnel that work for a private ambulance company are not employed by the
local fire department. A hospital-based ambulance is similar to the third service in that
the employees do not work the fire department, but are employed by the hospital that
owns the ambulance. The employees of hospital based organizations have the ability to
work in the hospital when not transporting a patient. Unfortunately few hospitals of today
have such an EMS system due to the changes in hospital ownership, business practice,
and federal regulations (Walz, 2002).
The fire-based EMS approach is a system that is solely operated by the local fire
department. A program that is designed as a fire service-based emergency medical
service system ensures that rescuers are strategically positioned to deliver time critical
response and effective patient care. Fire-based EMS grew out of necessity when third
service, private ambulance companies, and hospitals based organization reduced their
services, and to provide EMS transport to fire crews if injured during rescue or fire
operations. The transition seemed to be the natural choice since it can be done easily with
the strategic planning of fire stations allowing for their locations to minimize the time it
takes the fire department to respond (Walz, 2002).

15
Scope of Practice for EMS Providers
Before identifying the skill set of different emergency health care providers it is
important to have an understanding of what the term “scope of practice” entails. A scope
of practice is the terminology used by state licensing boards for various professions that
define procedures, actions, and processes that are permitted for the licensed/certified
individual. The scope of practice is limited to that which the law allows for specific
education and experience. Each state has laws, licensing bodies, and regulations that
describe requirements for education and training (Walz, 2009). In Arizona for example,
nurses are governed by the State Board of Nursing and EMT-Ps are governed by the
Arizona Department of Health Services (ADHS). However there are emergency medical
service standards set by the National Highway Traffic Safety Administration (NHTSA) in
the U.S. Department of Transportation consisting of a national scope of practice (Arizona
Department of Health Services, 2009).
The Emergency Medical Technician – Paramedic (EMT-P) plays an important
role in prehospital patient care. They are the first responders with Advanced Life Support
knowledge. Though the paramedic scope of practice can very from state to state and in
some cases even county to county the American Heart Association (AHA) has created
standards for basic life support (BLS), advanced cardiac life support (ACLS) and
pediatric advanced life support (PALS) which all prehospital providers follow (Brown,
2002). For the purposes of this research the standards and protocols for Arizona Certified
Emergency Paramedics will be followed.
In Arizona there are two types of protocols that are followed. They are online and
offline medical control or direction. Online medical direction allows a paramedic to
contact a physician from the field via radio or other means to obtain instructions on
further care of a patient. This is used particularly when a patient is in need of care that is
not allowed without medical direction under the caregiver's scope of practice. For

16
example, if a paramedic is treating a patient in the field that is in need of narcotic pain
medication, and the maximum amount has been given per paramedic scope of practice the
paramedic can contact his or her base hospital to get permission from the attending
emergency room physician to further medicate the patient, staying within the state’s
guidelines for paramedic drug administration. Offline medical direction occurs when a
paramedic follows preset patient care instruction referred to as “Standing Orders” or
“Protocols” (Walz, 2002). According to the Southern Arizona Emergency Medical
Services (SAEMS) “Standing Orders/Administrative Guidelines are defined as physician
orders, established by a medical direction authority, that may be performed without
online medical direction” (Southern Arizona Emergency Medical Services, 2009).
In the nursing profession we generally do not see registered nurses (RN) in the
prehospital setting unless they are working as a flight nurse. In terms of EMS, the flight
nurse follows the same type of system of online and offline medical direction. However
the flight nurse is allowed, through higher education, to perform advanced skills that a
paramedic can not, such as: placing a chest tube, monitoring an aortic balloon pump, and
receive direct orders from a physician in accordance with the Arizona State Board of
Nursing (Arizona State Board of Nursing, 2009).
An emergency department physician’s duties include performing assessments and
examinations on initial encounters with unscheduled, emergency/urgent and new patients,
coordinate patient treatment plans, order appropriate routine diagnostic tests and x-ray
studies, diagnose, treat, and manage patients according to standard, usual and acceptable
methods and techniques in accordance with the board certified emergency physician
guidelines (American College of Emergency Physician, 2009).
In the 1980s there was a new concept that emerged in the prehospital setting
called the EMT-I this position was created due to the need for ALS providers but because

17
of increased cost and a bad economy the paramedic level was too expensive for rural
communities.
Now in the twenty first century EMS needs to upgrade the system once again with
the implementation of the Prehospital Nurse Practitioner (PNP). The role of this new
category of prehospital provider will be to treat and release patients with symptoms such
as: mild respiratory illness such as influenza, wound care, prescriptions, portable x-ray,
portable labs, and sutures. By treating these patients at home there will be a decrease in
the number of non-critical patients being transported to the emergency department via
ambulance. Essentially a community will have access to home health and primary care
through the 911 system (Walz, 2002).
EMS Medical Director
The medical director for an EMS system essentially is the boss and final authority
for what type of initial and continuing education prehospital providers will have, along
with setting standing orders or offline medical direction guidelines. The medical director
is the senior medical officer and oversees the emergency medical operations of an
organization. The medical director is responsible for assuring that the performance of all
EMS personnel meets the appropriate standards of quality, and for directing and leading
efforts to improve the efficiency of prehospital operations. For most EMS organizations
the minimum qualifications for a medical director include: graduation from an accredited
school of medicine and successful completion of a residency program, current licensure
to practice medicine with emergency physician board certification free from restrictions
or limitations, have clinical experience in an acute care setting, a minimum of two years
supervisory experience in the development and management of quality, risk and
utilization review processes and finally demonstrate leadership, communication and
analytic skills (American Hospital Association, 2009).

18
Nurse Practitioner House Calls
Since 1988, the American Academy of Home Care Physicians has served the
needs of thousands of physicians and related professionals and agencies interested in
improving care of patients in the home. For every elderly person in a nursing home, there
are three more people equally fragile and infirmed living at home. Home health has
become the fastest-growing segment of Medicare's budget. Also it is estimated that there
are 2 million homebound patients suffering chronic conditions, and that number is
expected to grow (American Academy of Home Care Physicians, 2009).
According to Holy Cross Hospital in Silver Springs, MD, there are many older
adults that have an ongoing problem getting to and from medical appointments. The Holy
Cross House Calls program enables older adults, who are unable to get to their
physician’s office, to receive primary medical care at home, delivered by a nurse
practitioner. Nurse practitioners are specially trained and certified to provide
comprehensive medical care, including examining and diagnosing patients and
prescribing medications. In addition, nurse practitioners can order and arrange for lab and
other diagnostic services to be performed in the home (Holy Cross Hospitals, 2009).
Laura Hart, a home health nurse practitioner for Prorenata in Nashville, TN
explained "Our service really is as needed. Someone may need care at home for a short
time, and then they may go back to their regular provider, and some people may need us
long-term, especially if they are older and chronically ill," (Nashville Medical News,
2008). The Prorenata organization has established relationships with other providers to
extend care, including a mobile imaging service, a home-delivery pharmacy and a
diagnostic laboratory service to run samples. Hart also works closely with hospitalists at
Tri-Star's StoneCrest Medical Center in Smyrna, TN when her patients are admitted. This
service is designed for use by anyone who has difficulty with ambulation, transportation,
or other factors that limit their ability to have access to a provider on a routine basis

19
(Nashville Medical News, 2008). The house call is perfect for seniors who wish to
remain in their home but need frequent medical attention by a clinician. The house call is
available to individuals who are currently not satisfied with a provider or are seeking a
provider. The house call system of health care is available to anyone who wishes to
participate in this form of health care (NP House Calls, 2009).
Emergency Department Overuse
The current state of the United States health care system allows for individuals to
use an emergency department (ED) as if it were their primary health care provider.
Patients not getting primary care come to the ED repeatedly as problems flare or they get
sicker. As a result, the ED is burdened and the patient faces higher costs and possibly
more difficult treatment (Washington Sentinel, 2009). Emergency department visits hit a
new high in 2005, with more than 115 million visits, says new research from the CDC.
That's a jump of five million visits over the previous year, and a substantial 20% increase
over 10 years. Over the same time period, the number of hospital EDs decreased more
than 9% from 4,176 to 3,795, the CDC says. More than half of these patients (62.8%)
were referred to a physician or clinic for follow-up after their visit, suggesting their needs
weren't critical (Centers of Disease Control, 2009). This trend sets a precedent that the
ED is a place that people can receive a wide range of medical services at any time
regardless of their ability to pay or the severity of their condition.
According to a study completed by the New England Health Care Institute a large
portion of ED visits fall into the category of inappropriate use resulting from patients
seeking non-urgent care or urgent care for conditions that could have been avoided. Use
of the ED for non-urgent (or non-emergency) visits grew from 9.7% of all ED visits in
1997 to 13.9% in 2005. More recent estimates of avoidable ED use, emergencies that
could have been prevented by prior primary care, range as high as 50 percent of all visits.
Contrary to popular belief, the increase is not limited to the uninsured; people covered by

20
private insurance, Medicaid and Medicare are just as likely to overuse the ED (New
England Health Care Institute, 2005).
In a report published by the California Health Care Foundation, in the lines with
pervious findings, survey results indicate that a substantial proportion of all emergency
department visits occurring in the past year were avoidable. Recent users reported a high
number of visits that the user themselves believed could have been prevented. ED
physicians also indicated that a substantial proportion of patients sought care that could
have been provided by a primary care physician (PCP) if one were available, rather than
the emergency department (California Healthcare Foundation, 2008).
In an article written in the American Journal of Public Health research was
completed that compared primary care and public emergency department overcrowding.
Their objective was to evaluate whether referral to primary care settings would be
clinically appropriate for and acceptable to patients waiting for emergency department
care for non-emergency conditions; the studied included 700 patients waiting for
emergency department care at a public hospital. Access to alternative sources of medical
care, clinical appropriateness of emergency department use, and patients' willingness to
use non-emergency services were measured and compared between patients with and
without a regular source of care. It was reported nearly half of the patients cited access
barriers to primary care as their reason for using the emergency department. Only 13% of
the patients waiting for care had conditions that were clinically appropriate for emergency
department services. Patients with a regular source of care used the emergency
department more appropriately than did patients without a regular source ofcare. Thirty-
eight percent of the patients expressed a willingness to trade their emergency department
visit for an appointment with a physician within three days. The end result of the study
showed public emergencydepartments saw and cared for patients who could have been
treated at primary care facilities (American Journal on Public Health, 2009).

21
Cost of Service
The cost of ambulance service in Arizona is regulated by the Arizona Department
of Health Services (ADHS). In October of 2009 the latest fee schedule was released. The
range of an average cost for an ambulance transport is $817.32-$910.74 plus $15.57 per
mile (Arizona Department of Health Service, 2009). For example: if you were in Green
Valley, AZ and were transported to an emergency department the cost for an advanced
life support (ALS) ambulance would be $910.74 along with 15.57 per mile +/- 30 miles
your bill on average would be $1451.10. The total of this bill does not include the cost of
supplies used such as: intravenous fluid, medication, oxygen equipment, and any charges
acquired in the emergency department. According to University Medical Center in
Tucson, Arizona the average cost of an emergency department visit is $250 to simply be
taken to an examination room. Further charges may be added depending on the diagnostic
procedure such as an MRI, CAT scan, or X-rays along with any medical supplies used
(Tawnya Meeks RN, BSN personal communication October 22, 2009)
Payment for house calls improved dramatically in 1998 when the Centers for
Medicare and Medicaid Services (CMS) adjusted the Medicare physician fee schedule by
adding higher-level codes. Despite some changes in the payment system, Medicare
payment for house calls now is comparable to that for office visits. An advanced health
care provider uses coded billing called Current Procedural Terminology (CPT) to
appropriately bill insurance companies for services. For example, national Medicare
payment data for the office-based expanded focused exam (CPT 99213) which assumes a
15-minute face-to-face encounter is $59.50; for the comparable home-based medical
evaluation (CPT 99348) payment is $66.32. National payment data for the office-based
for established patients (CPT code 99215) is $122.03, and for the comparable home-
based established patient (CPT 99350), payment is $150.83. According to the 2007
Medicare schedule, payment for the highest level for a house call to a new patient (CPT

22
99345) is $186.08; the payment for the highest-level new patient office visit (CPT
99205) is $175.47. The rate for a detailed follow-up office visit (CPT 99214) is $90.20,
while a detailed follow-up house call visit (CPT 99349) pays $102.32 (American
Academy of Family Physicians, 2009) In a personal interview with a representative from
Prorenata health “the average bill to an insurance company for a nurse practitioner to
make a house call is $130-$230 dollars, with a reimbursement rate of 60%” (John Hart,
personal communication October 27, 2009)
Summary
The emergency departments at U.S. hospitals are struggling to keep up with over
crowding because the non-emergent patient uses the emergency room as their primary
medical care. These non-emergent patients in the emergency department waiting rooms
increase the severity of their minor symptoms due to exposure to community acquired
illnesses. Studies have shown people use emergency facilities for routine and primary
health care due to extended waiting periods for an office visit or for insurance purposes.
Some of these minor illnesses could be treated at home with an in house visit from a
nurse practitioner. The following are examples of services that a nurse practitioner can
provide: mild respiratory illness, wound care, prescriptions, portable labs and x-rays,
sutures, minor dental and dermatology. The treatment of these patients at home could
significantly decrease non-emergent visits to the emergency department resulting in a
decreased demand on emergency facilities. Medicare and Medicaid have already
formulated billing rates and codes for nurse practitioner home based medical care. There
are over 2 million people in the United States that have difficulty leaving their homes for
primary health care for a multitude of reasons, research suggests that this number will
increase dramatically over the next decade.
In every industry there will always be change, restructuring, and improvements. In
the 1980s that change came to the EMS system with the formation of a new pre-hospital

23
provider called the Emergency Medical Technician – Intermediate. The formation of a
new category of pre-hospital provider is on the horizon in a pre-hospital nurse
practitioner program

CHAPTER 3 – METHODOLOGY
Overview
This research uses three different types of methodologies to gain the most
effective data collection. The specific types of research used in this study include applied,
exploratory, and qualitative field research. The applied research examines an addition to
the Emergency Medical Service (EMS) system that might have a positive effect on
over-crowding emergency departments along with decreasing the amount of non-urgent
non-life threatening ambulance transports. Exploratory research was used to gain more
information on the creation and implementation of a new category of pre-hospital
provider. A qualitative field research approach was explored in order to measure the
amount of pre-hospital patients that could be treated and released following the pre-
hospital nurse practitioner treatment criteria (Appendix A). The goal of this research was
to collect data utilizing the local EMS resources of the Green Valley Fire District,
evaluate the possibility of reducing non-urgent transports to emergency facilities, foster
new ideas in pre-hospital health care, and find a possible solution to the overcrowded
emergency departments.
Problem Statement
the reliability of primary health care in the United States. Many Americans use the
emergency department as a source of primary healthcare if they are unable to get an
appointment to suit their needs or do not have medical insurance. In some instances
citizens are using the emergency 911 system to have an ambulance transport them to an
emergency department for non-critical non-life threatening injuries or illness. This puts a
strain on local EMS resources along with contributing to the already over crowded
emergency departments.

25
Purpose Statement
The purpose of this research was to explore and examine the effects of utilizing
Nurse Practitioners (NP) in the Emergency Medical Services (EMS) field in order to
amount of patients being seen in the emergency departments.
Research Questions
Research Question 1: Could Nurse Practitioners (NP) provide pre-hospital service?
This research question was answered by the literature review which illustrated
how a Nurse Practitioner has the knowledge, skills, and abilities to perform house calls.
The literature review written for this study contains reliable data from home based nurse
practitioners outlining their success. Also the medical treatment criteria used to answer
the survey question was developed using guidelines followed by nurse practitioners for
medical evaluation.
Research Question 2: Could pre-hospital service by a nurse practitioner reduce the
number of emergency transports in Green Valley, Arizona?
This research question was answered by the fire and EMS crews of the Green
Valley Fire District who respond to emergency and non-emergency requests on a daily
bases. The Paramedics and the Emergency Medical Technicians of the Green Valley Fire
District were asked a survey question in order to track the number of non-urgent non-life
threatening ambulance transports that could have been treated pre-hospital by a nurse
practitioner.
Research Question 3: Would pre-hospital health care from a nurse practitioner benefit
the citizens of Green Valley, Arizona?
The answer to this research question was found in the literature review written for
this study. The literature review assisted with calculating the cost of an ambulance
transport from Green Valley, AZ to an emergency facility using the Arizona ground

26
ambulance service rate schedule, it revealed the University Medical Center’s
emergency department billing costs, and gave insight into the Medicare current
procedural terminology (CPT) billing codes.
Research Population
For the purposes of this research the Green Valley, Arizona community was the
sample population utilizing the Green Valley Fire District (GVFD) as the local
emergency medical service. The Green Valley community is a small retirement town that
has a revolving population due to the winter visitors. The total permanent population is
17,283 however according to the Green Valley Community Coordinating Council
(GVCCC) it can climb to a high of 30-35,000 during peak winter months (T. Ward,
personal communication, June 16, 2006)
The fire district is a small department located in southern Arizona approximately
60 minutes from the United States and Mexico border. There are a total of 60 employees
which includes a combination of suppression, prevention, and administrative personnel.
GVFD utilizes paramedics and emergency medical technicians to treat medical patients
as part of their scope of practice. A private ambulance company is contracted to transport
the sick and injured to the emergency department. At the time of this research GVFD
does not have permission from the Arizona Department of Health Services (ADHS) to
operate an ambulance transport service (Arizona Department of Health Services, 2009)
The current EMS operation is a combination fire-based EMS along with private
ambulance. When a resident dials 911 for assistance a fire engine and ambulance are
dispatched. The fire engine is from the Green Valley Fire District and is staffed with four
personnel. The staffing model for the engine company includes a captain EMT-P or
EMT-B, engineer EMT-P or EMT-B, firefighter EMT-P and/or firefighter EMT-B. The
engine company at a minimum will always be staffed with one advanced life support
provider. The transporting ambulance is contracted through Southwest Ambulance and is

27
staffed with one EMT-B and one EMT-P. Transport decisions and treatment modalities
are a collaborative effort of all medical providers on scene; however at no time can these
pre-hospital providers refuse to transport or forcefully transport a patient regardless of
their medical condition, unless permission is granted by medical direction utilizing on
line or off line orders.
At the time of this research there is only one walk-in medical clinic in the Green
Valley area. According to their website the United Community Health Center is a
federally qualified community health center providing comprehensive preventive and
primary care services to people living in southern Arizona. Special consideration is given
to those who because of geographic, economic, developmental, ethnic, age or other
factors, may not have adequate access to health care. Hours by Appointment M, T, Th,
Fr: 8:00 A.M - 4:00 P.M. & Wed 8:00 A.M.-12:30 P.M. Walk-in Clinics M-F: 5:00 P.M.
- 8:00P.M. & Sat, 8:00A.M. - 3:00 P.M. (United Community Health Center, 2009)
Though there are many different primary health care providers in the area the United
Community Health Center is the only one that has a small window for walk-in patients.
The closest emergency department/urgent care facilities are located in Tucson, AZ
approximately 22-30 miles from Green Valley.
Research Authorization
Prior to starting any research within the Green Valley Fire District (GVFD)
permission from the Fire Chief Simon Davis was established. A written contract between
the researcher and Chief Davis was signed outlining the purpose of the research, how data
would be obtained, and how to disseminate data if requested by an outside source
(Appendix B). Also GVFD’s medical director Dr. Andrea Herbert from Saint Mary’s
Hospital in Tucson, Arizona was informed of the study. This was done to reduce the
possibility of misinformation circling around the emergency departments and emergency
medical services community.

28
Research Tool
This applied project used an electronic data base called Emergency Reporting
(ER) to collect data. Emergency Reporting was established to deliver fire and EMS
reporting and records management services to first responder’s world-wide (Emergency
Reporting, 2009). The ER system is used by the Green Valley Fire District (GVFD) to
log and document their calls. The system itself collects and separates data into different
categories such as fire, medical, and public service. It is broken down further into
subcategories that include specific call types. For example a medical call will have a
subcategory of chest pain, shortness of breath, or traumatic injury, etc. In order for the
GVFD medical personnel to document their findings for the study a custom drop down
box was created in the ER system. To do this the researcher was given full administrative
privileges into the ER data base by the fire chief. The drop down box was created in such
a way that the personnel documenting the call were required to answer the survey
question. If the question was not answered the system would not allow the user to finish
the documentation. This was done to ensure 100% participation with the research. The
actual question used in the survey was “Could this patient have been treated and released
by a nurse practitioner?” Along with utilizing the ER system to collect data a literature
review was completed using resources from personal interviews, written text, and
electronic data bases.
Data Collection
The survey began September 15, 2009 with a two week pilot period. In this two
week time frame the GVFD personnel were given instructions on how the study would
work and how to determine if a patient would be a candidate for in home health care. The
training received by the GVFD personnel was given in a classroom format. Each class
was limited to 8 personnel in order to facilitate better understanding of the material. The
specific topics covered were: assessing critical and non-critical patients, utilizing the

29
medical treatment criteria, an overview of a Nurse Practitioners scope of practice, and
entering data into the emergency reporting system. Each class lasted approximately two
hours. The medical treatment criterion (Appendix A) was distributed throughout the fire
district as a point of reference. None of the data collected in the two week pilot period
was used in the final number count. Actual data collection went online October 1, 2009
and ended January 31, 2010. The survey question answered by the medical personnel is
as follows in Figure 1.Figure 1 – Research Question
Data collection within the emergency reporting system can be broken down into call
volume by date range, call type, or run number. For example Figure 2 shows the table
produced by emergency reporting for the month of October 2009.
Figure 2 – Results for October 2009

30
Summary
the reliability of primary health care in the United States. It specifically asked if a nurse
practitioner could give pre-hospital health care, would treating patients at home decrease
ambulance transports, and what are the benefits to the Green Valley community. A
comprehensive review of the literature was also conducted. A retirement community
consisting of 17,283 permanent residences and a revolving winter population of 30-
35,000 people in Green Valley, Arizona was used as the sample population. The Green
Valley Fire District was utilized as the local EMS agency in order to perform the
necessary medical evaluations. The EMT-P and EMT-B’s were instructed to record their
findings in an electronic data base called Emergency Reporting. The medical staff was
asked whether or not a patient could have been treated in home by a nurse practitioner
following the medical treatment criteria.

Chapter 4 – Results
Overview
the reliability of primary health care in the United States. This research utilized applied,
qualitative field research, and exploratory methods to gatherer the necessary information.
This Information was collected through personal interviews, literature reviews, and a
survey. The personal interviews were conducted with emergency department doctors and
register nurses, home health care Nurse Practitioners, and billing department personnel.
The literature review consisted of written recourses, worksheets, and electronic databases.
The survey question was answered by the firefighter EMTs and firefighter paramedics
who respond to emergency medical incidents in the Green Valley Fire District (GVFD).
A nurse practitioner medical treatment criterion was developed to keep consistence
through the district when evaluating a patient’s condition. The data was recorded on the
districts emergency reporting system. The results of the survey were divided into three
categories. They included total emergency medical requests, the number of critically ill or
injured victims who required transport via ambulance to an emergency department, and
those who could have been treated at home if a pre-hospital nurse practitioner program
were available. This data will be discussed on a month to month basis along with a total
of all four months combine. The research began with a two week pilot study from
September 15, 2009 to September 30, 2009. The study officially went on line October 1,
2009 and ended January 31, 2010.
Survey Question
Survey Question: Could this patient have been treated and released by a nurse
practitioner?

32
Survey Question Results
In the four month period where data was recorded into the Emergency Reporting
system there were 2,628 requests for service with 1,629 being emergency medical in
nature. For the purpose of this applied project the 1,629 emergency medical responses
are what were evaluated. Figure 5 shows a break down of the amount and type of service
delivered by the Green Valley Fire District (GVFD). The blue bar indicates the total
number of citizens that requested service. This service includes emergency medical, fire,
and public service. The maroon bar indicates the total number of emergency medical calls
while the white bar illustrates the non-medical requests such as desert pest removal,
smoke detector checks, and invalid assists.
Figure 3 – Totals and Types of Requests
773
661
588
646
397 398 409 425
336
263
179
221
0
100
200
300
400
500
600
700
800
900
Oct Nov Dec Jan
Total Requests
Medical
Non-Medical/NA
The following set of graphs labeled Figures 4, 5, 6, and 7 are the individual
monthly service requests. The categories are total EMS calls, transports, and treated at
home. The section titled total EMS calls refers to the number of 911 requests made by a
citizen that required a GVFD fire apparatus and Ambulance response for medical
evaluation. The section labeled transport refers to the amount of people that required
transport to the emergency department via ambulance for further medical treatment and
possible long term care. The section labeled treat at home refers to the number of 911
requests made by a citizen that required a GVFD fire apparatus and Ambulance response
for medical evaluation. After the medical evaluation was performed it was determined

33
that if a pre hospital nurse practitioner program were available this patient could have
been treated at home and would not have needed to be seen and treated at the emergency
department.
From October 1, 2009 to October 31, 2009 there were a total of 397 emergency
medical calls where 116 (29%) could have been treated at home by a nurse practitioner.
(Figure 4)
Figure 4 – October 2009 totals
397
281
116
0
100
200
300
400
500
Total EMS Calls Transport Treat @ Home
Oct-09
From November 1, 2009 to November 30, 2009 there were a total of 398
emergency medical calls where 109 (27%) could have been treated at home by a nurse
practitioner. (Figure 5)
Figure 5 – November 2009 totals
398
289
109
0
50
100
150
200
250
300
350
400
450
Nov-09
From December 1, 2009 to December 31, 2009 there were a total of 409
emergency medical calls where 115 (28%) could have been treated at home by a nurse

34
Figure 6 – December totals
409
294
115
0
50
100
150
200
250
300
350
400
450
Dec-09
From January 1, 2010 to January 31, 2010 there were a total of 425 emergency
medical calls where 108 (25%) could have been treated at home by a nurse practitioner.
(Figure 7)
Figure 7 – January totals
425
317
108
0
100
200
300
400
500
Jan-10
The graph labeled Figure 8 shows EMS data collected for the four month period.
These categories are total EMS calls, transport, and treat at home. The total EMS calls are
the number of 911 requests for medical evaluation. The transport section is those patients
that required ambulance transport to an emergency department, and the treat at home
section refers to those patient that could have been treated at home by a nurse

35
Figure 8 – Four Months of Data
397 398 409 425
281 289 294
317
116 109 115 108
0
50
100
150
200
250
300
350
400
450
Oct Nov Dec Jan
Total EMS Calls
Transport
Treat @ Home
The following graph labeled Figure 9 correlates the number of patients
transported via ambulance and those who could have been treated at home if a nurse
practitioner were available. The maroon section shows those patients who fell under the
“YES” category when using the nurse practitioner treatment criteria (Appendix A). The
blue section shows those patients who fell into the “NO” category when using the nurse
practitioner treatment criteria (Appendix A). On average 112 (27.5%) citizens per month
would not have to be transported and evaluated at an emergency department. (Figure 9)
Figure 9 – Treat at home vs. Transport
317
294
289
281
108
115
109
116
0 50 100 150 200 250 300 350
January
December
November
October
Treat @ Home
Transport
The following graph shown as Figure 10 indicates all fire district requests
received from October 1, 2009 to January 31, 2010. Its purpose is to further define and
provide information on each category studied. The first category referred to as “total
requests” indicated by the green bar are the number of times the Green Valley Fire
District responded to a call. These requests include but were not limited to emergency

36
medical incidents, fire, public assists such as smoke detector checks and patient refusal
of further evaluation, medical care or transport to an emergency department. Also
included are patients who were able to be treated and released by the firefighter EMTs
and firefighter paramedics following their standing orders. The research categories were
further broken down into treat at home, ambulance transport, and non-medical/not
applicable. The category referred to as “treat at home” indicated by the orange bar is the
number of citizen who dialed 911 for an emergency medical incident where a GVFD fire
apparatus and ambulance responded. For the purposes of the study these patient were
classified as people who could have been treated at home by a nurse practitioner. This
determination was performed by the medical staff of the GVFD following the pre-
hospital nurse practitioner treatment criteria (Appendix A). The next category
“ambulance transport” indicated by a purple bar shows the number of people whose
illness or injury warranted ambulance transport to an emergency facility. These patients
were evaluated by the medical staff of GVFD and the determination was they needed
further medical evaluation and treatment above what a nurse practitioner would be able to
provide in the home following the medical treatment criteria (Appendix A) of this study.
The final category “non-medical/not applicable” depicted by a yellow bar indicates the
number of requests for service that were either non-medical in nature or not applicable to
the research. Requests that were deemed non-medical are those such as fire, smoke
detector checks, invalid assists, and desert pest removals. Requests that were deemed not
applicable were initially dispatched as an emergency medical incident. However once
GVFD and the responding ambulance evaluated the situation the patient was able to be
treated and released following the paramedic standing orders. An example of this type of
situation is: GVFD and an ambulance respond to an emergency 911 call. On arrival they
find a patient who has a decreased level of consciousness. On further evaluation of the
patient it is noted that the patient has a finger stick blood sugar of 30. Knowing the

37
patient has a medical history of diabetes, the reason for the decreased mental status is
the low blood sugar level. Following the paramedic standing order an intravenous line is
established and 1 amp (50 g) of dextrose is administered. The patient is now conscious,
alert, and oriented. This patient does not need an ambulance transport and since the on
scene medical staff was able to treat the patient an in home visit by a nurse practitioner is
not needed. Thus for the purposes of this research this type of incident was deemed not
applicable. (Figure 10)
Figure 10 – Complete research totals
999
1181
448
2628
0 500 1000 1500 2000 2500 3000
Non-Medical/Not
Applicable
Ambulance
Transport
Treat at Home
Total Requests
Research Question Results
The literature review revealed that nurse practitioners make house calls on a
regular basis, there are established insurance billing codes for in home health care, and
the need for in home health care is in demand. Interviews with home health care
professionals established that utilizing Nurse Practitioners in the home is becoming more
recognized and an accepted practice in many communities.

38
From October 1, 2009 to January 31, 2010 there were a total of 1,629 citizen
transported out of Green Valley, AZ to emergency departments in Tucson, AZ.
According to the fire and EMS personnel who responded to these incidents 448 of the
people transported could have been treated at home by a Nurse Practitioner reducing the
number of citizens transported by 25%.
Question 3: Would pre-hospital health care from a nurse practitioner benefit the citizens
of Green Valley, Arizona?
After the review of the Arizona ground ambulance billing rates, speaking with
hospital billing departments, and identifying the insurance billing codes and rates it was
apparent that using in home nurse practitioners accessed through the 911 system would in
fact decrease health care costs. For example: a citizen of Green Valley, Arizona dials 911
and is transported via ambulance to an emergency facility will be charged $910.74 and
$15.57 per mile following the Arizona Ground Ambulance Service Rate Schedule under
the entity Rural Metro – Pima (Appendix C). For a transport from Green Valley, Arizona
to the closest emergency facility the estimated cost would be $1451.10. This does not
include medical supplies used during transport. Along with the cost of the ambulance
transport is the cost of the emergency department. According to the billing department at
Tucson Medical Center the entry level cost of an emergency room visit is $250. However
this does not include the physician’s fee. According to Southwest Emergency billing the
average cost for a doctor to see you in the emergency department is $150. This brings an
emergency room visit to a total of $400. This does not include medical supplies used
during treatment or diagnostic testing. Therefore on average a citizen transported by
ambulance and treated in an emergency room setting incur costs of $1851.10. If this same
person was to be treated at home by a nurse practitioner the average cost would be $200.

39
As with the hospital based fee this does not include medical supplies used during
treatment or diagnostic testing. This brings a total financial savings to the Green Valley,
Arizona community of $1651 per resident transported. During the research it was
revealed that 448 persons could have been treated at home by a nurse practitioner. This
equates to an average savings of $739,648 during the four month study period. See Figure
11 for a comparative cost analysis. Figure 11
Figure 11 - Comparative Cost Analysis
Transported via
ambulance
(30 miles)
$1451.10 GVFD response $0.00
Emergency room
visit
$250.00 Ambulance response $0.00
Physicians fee $150.00 Treat at home by NP $200.00
Total Cost 1851.10 Total Cost $200.00
All statistics listed in Figure 13 are subject to +/- 5%
Summary
In the four month time frame from October 1, 2009 to January 31, 2010 the Green
Valley Fire District (GVFD) responded to 2,628 requests for service. There were 999
calls that were non-medical in nature. This type of request includes but is not limited to
fire, desert pest removal, and smoke detector checks. There were 1181 emergency
medical calls that warranted ambulance transport to an emergency department. This is
when a citizen dials 911 for medical assistance and their illness or injury required an
ambulance to transport them to an emergency department. Finally there were 448
residents that could have been treated at home by a nurse practitioner. This is when
GVFD medical personnel determined the patient did not have a critical or life threatening
condition that needed emergency intervention. This would equate to 27.5% of the
population who use the 911 system could have been treated at home by a family nurse
practitioner.

40
The firefighter EMTs and firefighter paramedics of the GVFD were used as the
local emergency response agency. Graphs and Charts were created from their medical
evaluations to help analyze the data collected in the GVFD emergency reporting system.

Chapter 5- CONCLUSIONS AND RECOMMENDATIONS
Overview
the reliability of primary health care in the United States. With careful review of related
literature, research questions, and a survey conducted in the Green Valley Fire District
(GVFD) this research was able to establish that creating a new category of pre-hospital
provider would have a positive impact on the Green Valley, Arizona community. This
chapter discusses the general conclusions, key findings, and provides recommendations
for the implementation of a pre-hospital nurse practitioner program.
General Conclusion
The data for this research was obtained through a survey question which was
answered by the medical responders in the GVFD, the literature review, and personal
interviews. The survey question was “Could this patient have been treated and released
by a nurse practitioner?” The decisions made by the firefighter emergency medical
technicians (EMTs) and firefighter paramedics were guided by the pre-hospital nurse
practitioner treatment criteria (Appendix A). The medical personnel of the GVFD were
given instructions and education on how the treatment criteria would be used to recognize
whether a nurse practitioner could be utilized. Data collection started with a two week
pilot period beginning September 15, 2009 and ended September 30, 2009. The data
collection officially went online October 1, 2009 and was complete January 31, 2010. To
ensure 100% participation, accuracy, and consistency the survey question was a
mandatory part of the electronic reporting system GVFD uses to document every request.
The consistency and reliability of the information collected was confirmed with all four
months of data remaining consistent.

42
Key Findings
The key findings for this applied project came from the literature review and data
collection which provided answers to the three research questions. The following section
reviews the three research questions and the results.
As discussed in the literature review for this project nurse practitioners make
house calls on a regular basis, there are established insurance billing codes for in home
health care, and the need for in home health care is in demand. With the data collected
from the GVFD using the medical treatment criteria (Appendix A) it was documented
that over 25% of the Green Valley community who use the 911 system could potentially
be treated at home by a nurse practitioner. The research suggests that using a nurse
practitioner in the pre-hospital setting might be a positive alternative solution to
traditional health care in an ED and could avoid the use of an emergency department for
non-life threatening health care issues.
This question was answered in the data collection for this research. Over a four
month time frame the GVFD transported 1,629 citizens to an emergency department.
According to the findings 448 citizens could have been treated at home by a nurse
practitioner. Utilizing in home health care provided by a nurse practitioner that was
accessed via the 911 system has the potential to reduce unnecessary ambulance transports
from Green Valley, Arizona to an emergency facility.
Research Question 3: Would pre-hospital health care from a nurse practitioner benefit
the Green Valley community?
The answer to this research question came from the literature review and data
collected from October 1, 2009 to January 31, 2010. There were three main benefits to

43
the Green Valley, Arizona community that were identified by this research. They
include increased access to primary health care in a timely manner, a reduction in
increased illness from being in emergency department waiting rooms, and the reduction
of health care cost to the patient. First, utilizing nurse practitioners can increase the
accessibility of primary health care. For many of the residents in the Green Valley,
Arizona community transportation, mobility, and extended wait times for primary care
physician appointments increase their use of the 911 system and the emergency
department for primary care. The use of a nurse practitioner in the home accessed via the
911 system increases access to primary health care. Second, staying out of emergency
department waiting rooms by being treated at home by a nurse practitioner can reduce the
chances of further illness. According to the Centers for Disease Control (2009) the
emergency room should be used for people who are very sick. You should not go to the
emergency room if you are only mildly ill. If you go to the emergency room and you are
not sick with the flu, you may catch it from people who do have it. Third and finally the
reduction in the cost of health care for the citizens of Green Valley, Arizona. As the
results in chapter four have shown the cost to the patient has been reduced. A nurse
practitioner program has the potential to save a citizen needing medical attention
hundreds of dollars each time the patient in treated at home verses being transported and
treated in an emergency department.
Recommendations
The sole purpose of this applied project was to determine if using a nurse
practitioner in the pre-hospital setting could reduce the number of non-critical non-life
threatening illness and injuries transported by ambulance and treated at an emergency
department. The research suggests that a pre-hospital nurse practitioner program could be
very beneficial to the Green Valley, Arizona community.

44
The following are recommendations for program design and implementation.
1. To lessen the liability to the fire district and reduce cost to the patient use
contracted nurse practitioners (NP). Hiring the NP into the fire district could
create boundary issues with the fire districts medical director. Also the use of
contracted NPs places the cost of malpractice insurance and insurance billing on
the NP agency.
2. Use only nurse practitioners (NP) and not physicians assistance (PA). The NP is a
stand alone primary health care provider where a PA must been under the
direction of a physician.
3. The nurse practitioner (NP) should have a response vehicle to ensure prompt
response when requested. The vehicle should be equipped with all necessary
medical and radio equipment excluding lights and sirens.
4. All responses by the NP will be in a normal traffic mode or code 2. Meaning, at
no point should the NP respond as an emergency unit.
5. Contracts with mobile laboratories, mobile x-rays, and pharmacies should be
visited to provide the most efficient and cost effective services.
6. Upon initial implementation have one NP on duty from 0700-1900 and evaluate
the response and request volume. Adjust the number of NPs on shift and work
hours as required.
7. The uniform of the NP should be the same as worn by on duty fire and EMS
personnel. This should be done to ensure the patient that the NP is part of the fire
district organization.
8. Design and implement a public education program to make community members
aware of the treatment modalities and availability of a pre-hospital nurse
practitioner.

45
9. Be prepared with an alternative number to access the NP if the current 911
system becomes overloaded with requests.
10. Design and establish a continuing education program that keeps the NP,
firefighter EMTs and firefighter paramedics abreast of new trends in the home
health care industry.
Future Research Recommendations
For future research on the use of a nurse practitioner for the purposes of creating
a new category of pre-hospital health care provider, recommendations are as follows: 1)
prepare a cost benefit analysis between a contracted nurse practitioner and a fire district
employed nurse practitioner, 2) determine if a fire district medical director would be
willing to work with a nurse practitioner or sponsor a physicians assistant in place of a
nurse practitioner, and 3) explore if there are any benefits to the fire district such as using
the nurse practitioner for occupational health services.
Summary
This applied research project focused on the possibility of using a nurse
practitioner to create a new category of pre-hospital provider that could administer in
home health care to the citizens of Green Valley, Arizona. There were three research
question asked in order to gain a better understanding of the benefits such a program
could provide. First, could Nurse Practitioners (NP) provide pre-hospital service? This
was discovered to be true. The answer came from the literature review written for this
project. It showed nurse practitioners have the education and ability to perform home
based primary health care. Second, could pre-hospital service by a nurse practitioner
reduce the number of emergency transports in Green Valley, Arizona? This question was
answered by the four month long survey performed in the GVFD. The results showed that
there was an average of 112 citizens per month that the fire crews thought could be
treated at home. Third, would pre-hospital health care from a nurse practitioner benefit

46
the Green Valley citizens? The answer to this question came from both the literature
review and the survey performed in Green Valley, Arizona. The benefits proven were
enhanced availability to primary health care, reducing further illness from emergency
room lobbies, and the reduction in the cost of primary health care.
A ten step recommendation process was created in order to assist with the design,
implementation and evaluation of a pre-hospital nurse practitioner program. Also further
research recommendation where established to provide the next step toward restructuring
the process in how pre-hospital medical care is delivered.

47
REFERENCES
American Academy of Emergency Medicine. (2009). Report Examines Recession’s
Impact on ED’s. Retrieved October 5th
, 2009, from
http://www.aaem.org/washingtonsentinel/washingtonsentinel_august2009.pdf.
American Academy of Home Care Physicians. (2009). General Information. Retrieved
October 24th
, 2009, from http://www.aahcp.org/generalinfo.shtml.
American Academy of Orthopedic Surgeons. (2009). First Aid. Retrieved September
29th
, 2009, from http://www.aaos.org/home.asp.
American College of Emergency Physicians. (1998). Emergency Department Director
Responsibilities. Retrieved September 22nd
, 2009, from http://www.acep.org
Arizona Department of Public Safety. (2009). Title 9 Chapter 25. Retrieved October 4th
,
2009, from http://www.azdhs.gov.
Arizona State Board of Nursing. (2009). Licensure and Certification. Retrieved
September 22nd
, 2009, from http://www.azbn.gov.
Brown, Bruce D. (2002). Emergency: Care and Transportation of the Sick and Injured
(7th
ED). Emergency Medical Service (pp. 9-10). Sudbury, MA: Jones and Bartlett
Publishing.
California Healthcare Foundation. (2006). Overuse of Emergency Departments Among
Insured Californians. Retrieved October 1st
, 2009 from http://www.chcf.org.
Centers for Disease Control and Prevention. (2009). National Health Statistics Report.
Retrieved October 5th
, 2009, from http://www.cdc.gove.
Champlin, L,. (2007). Home Sweet Home. Retrieved October 26th
, 2009, from
http://www.aafp.org/online/en/home/publications/news/news-now/annual-clinical-
focus/20070613housecalls.html.

48
Emergency Medical Services Act 1973. (1973) Public log 93-154. Washington, DC.
Government Printing Office.
Emergency Medical Service. (2009) In Merriam-Webster Online Dictionary. Retrieved
October 1st
, 2009, from http://www.merriam-webster.com/dictionary/ems.
Fitzgerald, S., (2008). Nashville Medical News. HEALTHCARE ENTERPRISE:
Prorenata Health Offers Nurse Practitioner House Calls. Retrieved October 24th
,
2009, from http://nashville.medicalnewsinc.com/news.php?viewStory=2181.
Grumbach, K., Keane D., and Bindman A. (1993) Primary care and public emergency
department overcrowding [Electronic version]. Vol. 83, Issue 3 372-378
Retrieved September 12th
, 2009, from
http://ajph.aphapublications.org/cgi/content/abstract/83/3/372.
Holy Cross Hospital. (2009). Home-Based Care: Geriatric Patient House Calls by
Nurse
Practitioners. Retrieved October 24th
, 2009, from
http://www.holycrosshealth.org/svc_homecare_house.htm.
New England Healthcare Institute. (2005) Emergency Department Overuse: Providing
the Wrong Care at the Wrong time. Retrieved September 30th
, 2009, from
http://www.nehi.net.
The Everett Clinic. (2009). Overcrowded Emergency Rooms. Retrieved March 9, 2010
from:
https://www.everettclinic.com/about_us/legislative_advocacy/current_health_issu
es/overcrowded%20ers.ashx?p=1014.
Walz, B. (2002). Introduction to EMS Systems. History of Emergency Medical Systems
(pp. 15-35). Albany, NY. Delmar Publishing

APPENDIX A
PRE-HOSPITAL NURSE PRACTIONER TREATMENT CRITERIS

50
Prehospital Nurse Practitioner (PNP)
Treatment Criteria
Research Question: Could this patient have been treated and released by a PNP
Treat and Release Transport via Ambulance Non-Medical/Not
Applicable
 Mild Respiratory (Flu)
 Portable X-Ray
 Portable Labs
 Urinalysis
 Pregnancy test
 Rapid strep assay
 Prescriptions
 Sutures
 Health Education
 Wound care
 Recommend resources
for preventative care
 Minor dental
 Dermatology
 Abdominal pain
 Chest pain/discomfort
 Cardiac Arrest
 Decreased LOC
 Hypertensive crisis
 Obvious bone fracture
 Penetrating injury
 Respiratory
arrest/distress
 Stroke
 Unconscious unknown
etiology
 Temperature greater
than 104
 Pregnancy problems
 Patient
Refusal
 Public Assist
 Invalid Assist
 Non-Medical
Calls

APPENDIX B
GREEN VALLEY FIRE DISTRICT CONTRACT

52
Arizona State University &
The Green Valley Fire District
Problem Statement: Many Americans use the Emergency Department as their Primary
Care Physician (PCP) if they are unable to get an appoint to suit their needs or do not
have medical insurance. This research project will determine if using Nurse Practitioners
in the field will have a positive impact on the community while reducing the amount of
non-emergent ambulance transports to the Emergency Department.
This research will include the following:
• A joint collaboration between Arizona State University and the Green Valley Fire
District to study the effects of using NP in the field
• Use Emergency Reporting to collect data (if possible)
• Dan Modrzejewski will be the main contact and liaison between the GVFD, ASU,
and SMH's Medical Director
• Research information will be shared with the Fire Chief unless an alternate
designee is specified
• Any changes in the research project will be discussed with the GVFD prior to
implementing
• In the event the media is involved in the project permission from the Fire Chief or
his designee will be requested prior to the release of information
Permission to begin research:

APPENDIX C
GROUND AMBULANCE BILLING RATE SCHEDULE

54
ARIZONA GROUND AMBULANCE SERVICE RATE SCHEDULE
ARIZONA DEPARTMENT OF HEALTH SERVICES, Bureau of Emergency Medical Services and Trauma System
150 North 18th Avenue, Suite 540, Phoenix, AZ, 85007-3248
Phone: (602) - 364 - 3150; Fax: (602) - 364 - 3567 Download this
schedule at: http://www.azdhs.gov/bems/ambul-pdf/ratesch.pdf
Prepared: October 1, 2009
Type Entity
Separate
Charges For
Disposable
Medical
Supplies
129 "P Motorsports Medical Services NONE NONE NONE NONE 2951 12/07/06 No
30 mum
Nogales Ambulance Service 1,075.00 1,075.00 14.00 268.75 3266 04/14/09 No
102 mum
Page Fire Department Ambulance Service, City of 999.98 999.98 11.77 58.72 3250 08/28/08 No
76 muni
Phoenix Fire Department, City of 710.57 632.96 14.73 NONE 3267 10/20/08 Yes
52 fd
Picture Rocks Fire Department 994.35 994.35 15.00 248.59 3259 01/22/09 No
81
id Pine / Strawberry Fire Department 809.19 809.19 13.88 202.29 3173 04/21/08 No
% I'd
Pinetop Volunteer Fire District 900.00 900.00 11.00 225.00 2970 07/27/06 No
7 fd
Pinewood Fire Department 760.79 760.79 8.77 58.52 3282 12/08/08 No
71 lp
Professional Medical Transport, Inc. 710.57 632.96 14.73 158.24 66.35 3267 10/20/08 Yes
116 fd
Puerco Valley Ambulance Service 990.00 990.00 14.00 247.50 3269 02/26/09 No
92 fd
Rincon Valley Fire District 1,058.81 1,058.81 8.82 61.84 55.50 3173 04/21/08 No
20 fd
Rio Rico Fire District 1,075.00 1,075.00 14.00 268.75 3112 04/18/08 No
94 fp River Medical, Inc. 1,019.52 1,019.52 16.60 91.60 76.82 3173 04/21/08 No
109 IP
Rural Metro - Maricopa 710.57 632.95 14.73 158.24 66.35 3267 10/20/08 Yes
55 IP Rural Metro - Pima 910.74 817.32 15.57 204.33 59.78 3254 05/08/09 Yes
n fp
Rural Metro - Pinal 1,690.15 1,690.15 9.70 77.55 3267 10/20/08 No
65 lp
Rural Metro - Vuma 1,024.85 1,024.85 17.71 256.20 112.85 3267 10/20/08 Yes
127 IP
Sacred Mountain Medical Service, Inc. 800.00 800.00 10.00 200.00 2921 12/05/05 Yes
107 Tip San Manuel Fire Department Association 850.00 850.00 10.00 212.50 2865 04/05/05 No
1 Id
Sedona Fire District 1,056.83 1,056.83 16.01 264.21 3270 10/28/08 No
24 mum
Sierra Vista Fire Department 767.34 767.34 13.50 191.84 3241 01/06/09 No
4" mum
Snowflake / Taylor Ambulance Service 900.88 900.88 11.12 42.39 2926 10/03/05 No
-9 mum
Somerton Fire Department 879.33 879.33 15.52 222.93 100.94 3133 12/03/07 No
85 (P Southwest Ambulance - Casa Grande 1,080.33 1,003.59 16.94 250.89 91.14 3267 10/20/08 Yes
86 IP Southwest Ambulance - Maricopa 710.57 632.95 14.73 158.24 66.35 3267 10/20/08 Yes
63 * Southwest Ambulance - Safford 1,185.73 1,185.73 970 77.55 3267 10/20/08 No
66 lp Southwest Ambulance & Rescue of Arizona 793.43 737.93 14.73 184.49 115.19 3267 10/20/08 Yes
36 mum
St. Johns Emergency Services 793.75 793.75 11.11 63.50 2857 01/03/05 No
114 fd
Sun City West Ambulance Service, Fire District of 999.98 999.98 12.35 250.00 3173 04/21/08 No
12 fd
Sun Lakes Ambulance and Rescue 859.13 859.13 12.03 48.83 3173 04/21/08 No
33 fd
Sunsites-Pearce Fire District Ambulance Service 803.81 803.81 16.08 200.95 3131 12/11/07 No
125 muni
Superior Emergency Medical Service 1,211.00 1,211.00 15.34 302.75 3210 04/30/09 No
122 Id
Three Points Fire District 1,091.32 1,091.32 11.81 94.41 3270 10/28/08 No
1T2 fd
Tonto Basin Fire District 931.96 931.96 9.32 65.78 3070 06/20/07 Yes
126 fd
Tri-City Fire District Ambulance Service 1,131.93 1,131.93 11.81 75.00 3267 10/20/08 No
35 up
Tri-Valley Ambulance Service, Inc. 960.09 960.09 948 60.42 53.45 3270 10/28/08 No
6 Id
Tubac Fire District Ambulance 650.00 650.00 7.50 40.00 2816 10/18/04 No
108 mum
Tucson Fire Department 910.74 NONE 15.57 NONE 3254 05/08/09 Yes
49 np
Verde Valley Ambulance Company, Inc. 960.75 960.75 16.01 240.19 3270 10/28/08 No
123 fd
Verde Valley Fire District 807.85 807.85 932 201.96 3204 06/24/08 only Oxygen
119 Id
Whetstone Fire District Ambulance Service 832.51 832.51 11.09 208.12 3227 07/15/08 No
64 np
White Mountain Ambulance Service, Inc. 973.24 973.24 12.49 51.01 3267 10/20/08 No
CON
No,

APPENDIX D
EMAIL TO GVFD PERSONNEL

56
All GVFD Personnel,
I am starting to collect data for my final project (Thesis) at ASU. I will be adding a
button in Emergency Reporting to track non-emergent ambulance transports.
The purpose of this research is to explore and examine the effects of utilizing Family
Nurse Practitioners (FNP) in the Emergency Medical Services (EMS) field in order to
amount of patients being seen in the emergency departments
The question in Emergency Reporting will state: Could this patient have been treated and
released by a Nurse Practitioner? Your options are: Yes – No – N/A
A “Yes” answer would indicate the patient fell under the following:
Mild respiratory illness (Flu), wound care, prescriptions, portable x-ray, portable labs,
sutures etc…Example: A patient has fallen one week ago and has arm pain. The NP can
order a portable x-ray instead of going to the emergency department.
A “No” answer would indicate the patient needed time critical intervention such as:
Cardiac arrest, SOB, obvious bone fracture, penetrating injuries etc…
A “N/A” response would be calls such as: Public assist and Patient refusals
Please note this added filed in emergency reporting is required the system will not let you
complete the chart without answering the question.
If you have questions, comments, or concerns please feel free to contact me anytime at
520-400-4215 or email pnpstudy@yahoo.com
Thank you,
Dan Modrzejewski FF/CEP
dmodrzejewski@gvfire.org
pnpstudy@yahoo.com
520-400-4215

DModrzejewski.Thesis

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