On Their Toes
RN first assistants seek stimulation of the OR
while still providing bedside care

By Wendy Martinkus
November 1, 2004

When Paula Rosenfield, RN, MICN, graduated from nursing school 27 years ago, the vocation of prehospital care coordinators was in its infancy. Within the last two decades, Rosenfield and hundreds of other nurses across the country have chosen this little-known subspecialty of emergency department nursing that demands the leadership skills of a nurse manager, the patience of a teacher, and the diplomacy of an ambassador.

Prehospital care coordinators — also known as base hospital care coordinators and prehospital liaison nurses — have become a fixture in base station hospitals, or hospitals that have been designated by the local emergency medical services agency to direct the prehospital care system. Under pressure to maintain higher-quality standards, hospitals rely on prehospital care coordinators to manage the day-to-day operations of the base station and help coordinate care not only with the physicians and nurses of the emergency department, but also with paramedics and fire departments.

The subspecialty of the prehospital care coordinator arose a few years after the paramedic profession was established in the 1970s. In the early days, physicians communicated with paramedics over a two-way radio to coordinate appropriate care and direct paramedic units to the nearest and most appropriate hospital.

While physicians still coordinate care, in some cases, nurses have stepped in and taken over this function in many emergency departments. With nurses’ roles increasing, it became apparent that a manager was needed to supervise the staff and the base station. As a result, the position of prehospital care coordinator was created.

The use of prehospital care coordinators varies from state to state, even county by county. In California, for instance, all but one county has prehospital care coordinators and mobile intensive care nurses (MICNs) handling calls from paramedics. In San Mateo County, where all eight hospitals function as base stations, paramedics follow standardized protocols.

“Paramedics don’t contact the hospitals for orders unless it’s a particularly unusual situation,” says Jan Ogar, RN, clinical coordinator for San Mateo County Emergency Medical Services and a state EMS commissioner.

“Because we don’t have complicated destination decisions and our paramedics follow standing orders, our system works very well.”

What to expect

There is no typical day for a prehospital care coordinator, given the urgent nature of emergency departments. “You have to be able to adapt to anything in this position,” says Shelly Berthiaume, RN, MICN, CCRN, of Palomar Medical Center in San Diego County.

Prehospital care coordinators can expect to work with many different groups and organizations, including fire and police departments, paramedics, private medic agencies, and local and state government officials, Berthiaume says. “This is where diplomatic skills come in handy, because there are different agendas to navigate.”

Most prehospital care coordinators are ER nurses like Don Innes, RN, of Mt. Graham Regional Medical Center in Safford, Ariz. “I can’t imagine doing this job without an ER nursing background,” he says.

In Arizona, prehospital care coordinators do not have to be MICNs, commonly called “radio nurses.” However, California’s Department of Health Services mandates that all prehospital care coordinators be certified as MICNs.

To become an MICN, a nurse must complete intensive coursework that includes instructional and hands-on training, including radio simulations and rides with paramedic units in the field.

Nili Steiner, RN, MICN, CEN, of Cedars-Sinai Health System in Los Angeles became a prehospital care coordinator after being a staff nurse in Cedars-Sinai’s emergency department. When a coordinator position opened up, she approached her supervisor and asked for the job. “My manager felt that I needed a little more teaching experience, and she was right,” Steiner says.

After leaving the hospital, Steiner taught paramedic school for Los Angeles County for nearly a year. She returned to Cedars-Sinai and soon applied for the position and got it. “I thought I could bring a lot to this job because of my experience as an MICN and my experience as an ER nurse and working with paramedics for so many years.”

Steiner shares her job with Rosenfield. Together they manage about 40 MICNs at Cedars-Sinai. Unlike Steiner, Rosenfield recalls falling into her position. When a prehospital care coordinator left Cedars-Sinai, Rosenfield’s manager asked her if she could fill the position temporarily.

“I decided to give it a try because I liked the thought of broadening my career in nursing and trying something new,” Rosenfield says.

Rosenfield and Steiner jointly develop continuing education classes. In addition to ongoing training, they hold off-site classes for staff members about twice a year. They also go to local fire stations and provide continuing education for paramedics and EMT-1s. Overall, they spend about half their time doing continuing education.

Multiple meetings

Prehospital care coordinators often have their share of meetings to attend and committees on which to serve. Rosenfield is a member of several committees, and meets once a month with other prehospital care coordinators to discuss quality and clinical issues.

Likewise, Berthiaume serves on several agency committees and feels as if she is constantly driving to meetings. “I bought a car for work about two years ago and it already has 57,000 miles.”

Through her committee work, and her strong interest in heart disease, Berthiaume was able to develop a unique program that started at her hospital and now is being implemented throughout San Diego County and catching on in other areas. Traditionally, paramedics call in ECG readings to the base station. But with new technology from Medtronics, ECGs can be transmitted from the field, printed out, and reviewed by a cardiologist while the patient still is en route.

The hospital now has a door-to-balloon time – the amount of time it takes for a patient to enter the hospital door until he or she gets an angioplasty – of about 50 minutes, compared to the national average of about 183 minutes.

“We have dramatically improved our time because our hospital and local agencies worked together and agreed that we could do better,” Berthiaume says.

What it takes

Qualifications: Experienced emergency department nurse with teaching credentials geared toward the education of fire department/paramedic personnel. In California, must be certified as a mobile intensive care nurse (MICN).

Reports to: Emergency department nurse manager

Vital skills:

• Strong verbal communication to enable coordination with various paramedic and fire departments
• Leadership qualities

Responsibilities:

• Manage day-to-day base hospital operations
• Direct nursing staff and conduct performance evaluations
• Oversee quality assurance initiatives
• Conduct training for nurses and paramedics on a variety of emergency prehospital care issues
• Supervise disciplinary matters

Paul Wynn is a New York-based medical writer.