Virtua Health, Inc

National Labor Relations Board - Board Decisions

May 11, 2005

344 N.L.R.B. 604 (N.L.R.B. 2005)

DECISIONS OF THE NATIONAL LABOR RELATIONS BOARD
344 NLRB No. 76
604
Virtua Health, Inc. and JNESO-District Council 1,
International Union of Operating Engineers,
AFL–CIO, Petitioner. Case 4–RC–20692
May 11, 2005
DECISION ON REVIEW AND ORDER
BY CHAIRMAN BATTISTA AND MEMBERS LIEBMAN
AND SCHAUMBER
The issue presented in this case is whether a system-
wide unit of the Employer’s paramedics is appropriate.
As explained below, we find, contrary to the Regional
Director, that a unit limited to paramedics is not appro-
priate. Therefore, we reverse the Regional Director’s
decision and dismiss the petition.
On January 21, 2004, the Regional Director for Region
4 issued a Decision and Direction of Election (pertinent
portions of which are attached as an appendix) in which
she found that the petitioned-for unit of approximately
150 paramedics employed by the Employer at various
locations throughout its southern New Jersey territory,
excluding the Employer’s other technical employees, is
appropriate for bargaining. The Regional Director found
that the Board’s Healthcare Rulemaking (Appropriate
Bargaining Units in the Healthcare Industry), 29 CFR
§ 103.30, 54 Fed. Reg. 16336–16348 (1989),1 which
requires that all technicals be included in one unit, absent
extraordinary circumstances, was inapplicable in deter-
mining whether a unit limited to the Employer’s para-
medics was appropriate. The Regional Director found
that the Rulemaking, which is limited to acute-care hos-
pitals, does not apply to the Employer’s health care sys-
tem. The Regional Director further found that the “ex-
traordinary circumstances” provision of the Rulemaking
removed the Employer from the Rulemaking’s coverage.
The Regional Director, applying the test for determining
units in nonacute health care facilities set forth in Park
Manor Care Center, 305 NLRB 872 (1991), limited the
unit found appropriate to the Employer’s paramedics,
excluding the remaining 950 technicals employed by the
Employer.2
Thereafter, in accordance with Section 102.67 of the
National Labor Relations Board Rules and Regulations,
the Employer filed a timely request for review of the
Regional Director’s decision. The Employer contended
that the Board’s Rulemaking applied, and that, even un-
der the test in Park Manor, supra, the only appropriate
unit must include all the Employer’s technicals. On Feb-

1 See 284 NLRB 1515 (1987), et seq.
2 The Petitioner initially contended that the paramedics were profes-
sional employees. The Regional Director agreed with the Employer
that the paramedics are technical employees. No party requested re-
view of this finding.
ruary 18, 2004, the Board granted the Employer’s request
for review.
We have carefully considered the entire record, includ-
ing the briefs on review and the amicus brief in support
of the Petitioner. Contrary to the Regional Director, we
find, for the reasons set forth below, that a unit limited to
paramedics is not appropriate. Accordingly, we reverse
the Regional Director’s decision and dismiss the petition.
I. BACKGROUND
The Employer operates a comprehensive regional
medical system. The system includes: four acute-care
hospitals in Marlton, Voorhees, Berlin, and Mt. Holly,
New Jersey; a nonacute care hospital in Camden; a Mo-
bile Intensive Care Unit (MICU), including the para-
medic division at issue here, the Medical Command
(Medcom), and an aero-medical unit called South Star; a
free-standing surgery facility at the Voorhees Hospital
campus; an ambulatory services center in Mt. Holly; a
cardiac performance center on the Marlton Hospital
campus; a family health center and a center for health
and fitness near the Voorhees Hospital campus; a
women’s center in the family health center building; and
a home health services unit. All of the Employer’s 150
paramedics work in the MICU, which is part of the am-
bulatory services department. In addition to MICU, that
department includes the Camden Hospital, the home
health services unit, the cardiac performance center, the
surgical center, and the center for occupational health.
The corporate director for emergency medical services in
the MICU oversees the paramedics, the South Star aero-
medical unit, and several other programs. There is a
medical director for the MICU, as well as two assistant
directors and several supervisors. One human resources
manager is responsible for the ambulatory services
group, including the MICU, as well as the Berlin Hospi-
tal.
The paramedic division is divided between Burlington
and Camden Counties. Each county has several platoons
of between 10 and 15 employees, each with a supervisor.
The platoons are positioned in various locations through-
out both counties. One of the six Camden locations is at
the Camden Hospital. All remaining locations in both
counties (five locations in Burlington County) are at fire
and emergency squad stations. These locations range
from between 1 and 10–15 miles from the nearest Em-
ployer hospital. Paramedics regularly rotate through the
different locations in their respective county. Paramedics
also rotate between the two counties and may perma-
nently transfer between counties. Of the 11 locations, 9
operate 24 hours a day, 7 days a week (24/7), and two
operate 18 hours a day. Most of the paramedics work
12-hour shifts; one group works a 6-hour shift.
VIRTUA HEALTH, INC. 605
Paramedics are dispatched to the scene by 911 opera-
tors. Paramedics respond to emergencies in MICU vehi-
cles that contain most of the equipment, medications, and
supplies that emergency room personnel use when treat-
ing patients. At the emergency scene, paramedics assess
the patient and provide advanced life support services
similar to that provided patients in emergency rooms.
Paramedics perform functions handled by other of the
Employer’s technical employees, including starting IVs,
drawing blood, administering CPR, EKGs, and medica-
tion, and utilizing telemetry. Paramedics follow standing
orders in providing treatment and, in most instances, con-
tact Medcom, the Employer’s communications center
located within the emergency room at the Voorhees Hos-
pital. Medcom is staffed 24/7 by a registered nurse (RN)
and an emergency medical technician (EMT). The
emergency room physician, usually through the RN,
verifies treatment by the paramedics. In some instances,
the physician gives direct orders to the paramedic. Al-
most half of patients seen by the MICU paramedics go to
a hospital, and 42 percent of those go to an Employer
facility. The paramedics do not transport the patients.
Ambulance services or other emergency transporters, not
part of the Employer, provide the transportation. Para-
medics accompany patients to the emergency room, often
providing care in the ambulance transporting the patient.
At the emergency room, the paramedics interact with the
medical staff, including other technical employees, in
transitioning the patient.
The South Star (aero-medical) unit operates 24/7 and
is located at a hangar on the Voorhees Hospital campus.
There are 11–12 employees assigned to South Star in-
cluding flight paramedics and flight nurses. Four of
these employees are RNs who are also certified as, and
sometimes work as, flight paramedics. Each South Star
flight is staffed by a flight paramedic and a flight nurse,
who provide advanced life support services at the site of
an accident, during transport (including between hospi-
tals), and as the patient is transferred from the helicopter
to the next health care provider. South Star paramedics
and RNs are in contact with Medcom. South Star RNs
as well as South Star paramedic/RNs are currently repre-
sented in a systemwide3 RN unit by the Petitioner.
Paramedics have been assigned to work in the Em-
ployer’s emergency rooms on occasion when placed on
modified duty. Six paramedics have been so assigned in
the past year, and some paramedics also volunteered to
help out in the Employer’s emergency rooms during the
doctors’ strike. In these instances, the paramedics work

3 Mt. Holly Hospital, which merged with the West Jersey system in
1996 to form the Employer, had a preexisting RN bargaining unit.
alongside other emergency room personnel under the
direction of the nurse manager or charge nurse. Para-
medics in Burlington occasionally help out in the Mt.
Holly emergency room after they bring a patient in from
an emergency call. Approximately five emergency
technicians or communicators have transferred to para-
medic positions, and five paramedics have transferred to
other positions with the Employer, including community
education, community health, RN, and safety and secu-
rity.
All of the Employer’s nonrepresented employees, in-
cluding the paramedics, are subject to the same human
resources policies, receive the same employee handbook,
and are eligible for the same benefits. Paramedics are on
the same wage scale as the Employer’s other employees.
Jobs are posted employerwide, and employees retain
their seniority when transferring in the Employer’s sys-
tem. Paramedics are subject to the same probationary
period as other nonrepresented employees, are annually
evaluated like other employees, and are eligible for the
same merit increases and receive the same across-the-
board increases as other employees. Paramedics partici-
pate with other employees in the training program and at
times provide training to employees.
II. DISCUSSION
The Petitioner sought to represent a systemwide unit of
paramedics. The Employer contended that the unit must
include all of the Employer’s technical employees either
under the requirements of the Board’s Healthcare Rule-
making or under the standards set forth in Park Manor,
supra, for bargaining units in nonacute care hospitals.
The Regional Director found that the Rulemaking did not
apply to the Employer’s healthcare system and that under
Park Manor the petitioned-for unit of paramedics is ap-
propriate.
Under the Board’s Rulemaking, all technicals in a sin-
gle acute-care hospital, must, absent extraordinary cir-
cumstances, be included in one unit. A unit of paramed-
ics who constitute only a portion of the employer’s tech-
nical employees at an acute-care hospital would be inap-
propriate. The Employer contends that the Rulemaking
applies not only to single acute-care hospital facilities,
but also to systems of health care facilities such as the
Employer’s which include acute-care hospitals, as well
as other types of health care services. Assuming that the
Rulemaking is applicable to the Employer, the paramedic
unit sought by the Petitioner, excluding all other techni-
cals, would be inappropriate, absent extraordinary cir-
cumstances. The Petitioner argues, and the Regional
Director found, that the Rulemaking is not applicable -
here. We find that it is unnecessary to reach this issue
because we conclude that, even under the broader stan-
DECISIONS OF THE NATIONAL LABOR RELATIONS BOARD606
dard set forth in Park Manor, a unit limited to the Em-
ployer’s paramedics is inappropriate.
In Park Manor, the Board applied the “empirical” or
“pragmatic” community-of-interest test in determining
unit appropriateness in nonacute care health care facili-
ties. Under that test, the Board considers traditional
community-of-interest factors, as well as the factors con-
sidered relevant by the Board in the Rulemaking, and
prior cases involving either the type of facility in dispute
or the type of unit sought.
Here, the paramedics, who are technical employees,
provide the type of advanced patient care performed by
the Employer’s staff, including other technical employ-
ees, in the Employer’s emergency rooms. The paramed-
ics’ duties include starting IVs, drawing blood, adminis-
tering CPR, EKGs, and medication, and utilizing teleme-
try. Other technical employees perform these functions
as well. Like other technical employees, the paramedics
are required to have specialized education and/or train-
ing. The paramedics interact with other technical em-
ployees on a regular basis when they accompany about
10,000 patients to the Employer’s hospitals each year.
The paramedics occasionally interchange with other
technicals when they provide extra help in the Em-
ployer’s emergency rooms.
Further, there is evidence of temporary and permanent
transfers between the paramedics and the Employer’s
other technical employees. For example, five paramed-
ics were temporarily assigned to perform light duty in
various hospital emergency rooms. Although one para-
medic testified that paramedics do not perform direct
patient care when on light duty, there is no indication
that paramedics do not perform other technical functions.
Further, several technical employees (three emergency
room technicians, a base communicator/EMT, and a
communicator) transferred permanently to paramedic
positions.
The stations where the paramedics are located are
close to the Employer’s hospitals where other technicals
are located. One station is attached to an Employer’s
hospital and the others are between 1 and 10–15 miles
away from the hospitals. This geographic proximity
supports a finding that a unit limited to paramedics is not
appropriate. See Stormont-Vail, Healthcare, Inc., 340
NLRB 1205 (2003) (nurses located at helicopter ambu-
lance service 70 miles from hospital complex, included
in unit with hospital RNs).
The factors relied upon in the Rulemaking also support
a single technical unit. The Board, considering particu-
larly the skill backgrounds of technical employees,
placed the various types of technicals together, even
though they worked in different areas, with no showing
of common supervision or interchange. Further, the
Board considered that technical units, encompassing a
wide range of classifications, met Congressional con-
cerns to avoid proliferation of bargaining units in health
care institutions.
As to prior precedent, the Board has not issued any
cases concerning the type of unit sought here—
paramedics excluding all other technicals. We find, con-
trary to the Regional Director, that Albuquerque Ambu-
lance Service, 263 NLRB 1 (1982), enf. denied sub nom.
Southwest Community Health Services v. NLRB, 726
F.2d 611 (10th Cir. 1984), is not a comparable situation.
In that case, the Board refused to reconsider its denial of
review of the Regional Director’s finding that a separate
unit of ambulance service employees, including para-
medics, EMTs, drivers, and dispatchers, was appropriate.
The Regional Director had found that the ambulance
service provided a service separate and apart from opera-
tions traditionally associated with services provided by a
hospital or health care institution. Here, the Employer
does not operate an ambulance service, but rather pro-
vides advanced life support of the type provided by
medical staff in emergency rooms. See, by contrast,
North Memorial Medical Center, 224 NLRB 218 (1976),
where, in a pre-Rule case, the Board found that separa-
tion of an EMT unit from the acute care hospital’s em-
ployees was not warranted.
Conclusion
For all of the foregoing reasons, we find that a unit
limited to paramedics is not an appropriate unit for bar-
gaining. The Petitioner has indicated that it is unwilling
to represent paramedics in a broader unit including all
technical employees. Accordingly, we reverse the Re-
gional Director’s decision and dismiss the petition.
ORDER
The Regional Director’s Decision and Direction of
Election is reversed and the petition is dismissed.
MEMBER LIEBMAN, dissenting.
I would adopt the Regional Director’s well-reasoned
and comprehensive decision finding that a systemwide
unit of the Employer’s paramedics is appropriate.
APPENDIX
REGIONAL DIRECTOR’S DECISION AND DIRECTION
OF ELECTION
The Employer, Virtua Health, Inc. (Virtua), operates a health
care system in southern New Jersey consisting of five hospitals
and several other health care facilities. The Petitioner, JNESO
District Council 1, filed a petition with the National Labor Re-
lations Board under Section 9(c) of the National Labor Rela-
tions Act seeking to represent a unit of approximately 150
Paramedics employed by the Employer.
VIRTUA HEALTH, INC. 607
The parties disagree as to whether the petitioned-for unit is
appropriate. The Employer contends that its health care system
constitutes an “acute-care hospital” within the meaning of the
Board’s Final Rule on collective-bargaining units in the health
care industry,2 29 CFR Section 103.30 (the Rule), and the peti-
tioned-for unit is inappropriate because it does not conform to
the Rule. In this regard, the Employer contends that the Para-
medics are technical employees and that the only appropriate
unit is a system-wide unit of approximately 1100 technical
employees. The Petitioner asserts that the Employer’s health
care system is not an “acute care hospital” within the meaning
of the Rule and that there are “extraordinary circumstances”
which would render the Rule inapplicable. Based on the
Board’s analytical framework for determining units in non-
acute health care facilities, the Petitioner contends that the peti-
tioned-for unit of Paramedics is appropriate. Finally, the Peti-
tioner contends that Paramedics are professional employees,
not technical employees.3 A hearing officer of the Board held a
hearing, and the parties filed briefs with me.
I have considered the evidence and the arguments presented
by the parties, and as discussed below I have concluded that
there are extraordinary circumstances that remove the Em-
ployer from the Rule’s coverage. Based on an application of
the factors for determining units in nonacute health care facili-
ties set forth in Park Manor Care Center, Inc., 305 NLRB 872
(1991), I have further determined that the petitioned-for unit is
appropriate. I have also concluded that the paramedics are
technical employees. In this decision, I will first provide an
overview of the Employer’s operations. Then, I will review the
factors that must be evaluated in determining whether the Rule
applies. Finally, I will present in detail the facts and reasoning
that support my conclusion.
I. OVERVIEW OF OPERATIONS
The Employer is a not-for-profit corporation that operates
four acute-care hospitals, in Marlton, Voorhees, Berlin, and Mt.
Holly, New Jersey4 and a nonacute-care hospital in Camden,5
which offers limited emergency room and family health ser-
vices. The Voorhees and Mt. Holly facilities are full-service
acute-care hospitals, and the Berlin and Marlton hospitals pro-
vide adult and pediatric acute care but do not offer maternal or
child health services. The Employer also operates: a Mobile
Intensive Care Unit (MICU), which includes, among other
things, a paramedic division and an aero-medical unit called
South Star; the Summit Surgical Center, which is a free-

2 The Rule is set forth at 54 Fed Reg. 16336 et seq., 284 NLRB 1580
(1989). The proposed rules and related commentary are set forth at 284
NLRB 1515 et seq.
3 The parties stipulated that if the Rule applies, a system-wide unit of
the Employer’s technical or professional employees is appropriate. The
Petitioner would not participate in an election in a unit other than the
petitioned-for unit.
4 All locations mentioned in this decision are in New Jersey unless
otherwise indicated.
5 The Employer’s hospitals have undergone several name changes,
and the record does not clearly indicate their current names. Accord-
ingly, this decision will refer to them as the Marlton hospital, Voorhees
hospital, Berlin hospital, Mt. Holly hospital, and Camden hospital.
standing surgery facility at the Voorhees hospital campus; an
Ambulatory Services Center in Mt. Holly; a Cardiac Perform-
ance Center on the Marlton hospital campus; the Tatum Brown
Family Health Center near the Voorhees hospital campus; the
William G. Rohrer Center for Health and Fitness near the
Voorhees hospital campus; the Center for Women in the Tatum
Brown Family Health Center building; and a Home Health
Services Unit. The Employer was formed in 1998 by a merger
of the former West Jersey Health System, which included the
Marlton, Voorhees, Berlin, and Camden hospitals, and the for-
mer Memorial Hospital Burlington County in Mt. Holly.
Richard Miller is the Employer’s president and chief execu-
tive officer (CEO), Ed Dunn is the vice president and chief
human relations Officer, and Ninfa Saunders is the Vice Presi-
dent and chief operating officer (COO). Each of the four acute-
care hospitals also has a COO. The system employs approxi-
mately 7200 employees.
All of the approximately 150 paramedics employed by the
Employer work in the MICU, which is part of the Employer’s
Ambulatory Services department. Other than the MICU, the
Ambulatory Services department includes the Camden hospital,
the Home Health Services unit, the Cardiac Performance Cen-
ter, the Summit Surgical Center, and the Center for Occupa-
tional Health. The ambulatory services department’s offices
are located in Mt. Laurel.
Maureen Miller is the vice president for Ambulatory Ser-
vices and has overall responsibility for all of its divisions.
Miller reports to Ninfa Saunders, and Saunders reports to Rich-
ard Miller. Thomas Starr, the corporate director for emergency
medical services in the MICU, reports to Maureen Miller. Starr
oversees the MICU, including the paramedics, South Star, and
several other programs. Dr. Joseph Hummell is the medical
director for the MICU. There are also two assistant directors
and several supervisors in the MICU. Rhonda Jordan, who
works in human relations and reports to Ed Dunn, has responsi-
bility for ambulatory services department employees, including
Paramedics.
The paramedic division is broken down into two smaller di-
visions, one for Burlington County and one for Camden
County.6 Each county has several platoons of between 10 and
15 employees, which in turn are divided into units of two em-
ployees. Each platoon has a supervisor. The platoons work in
different locations called “Medics” in Camden County and
“Care Units” in Burlington County. There are six medics and
five care units.
The Medics are located primarily in fire and first aid stations
throughout Camden County. Medic 1 is located at the Voor-
hees Fire District—Kirkwood Station in Voorhees, 3 miles
from the Voorhees hospital. Medic 2 is located at the Winslow
Township Fire District—Waterford Station in Waterford
Township, about 7 miles from the Berlin Hospital. Medic 3 is
located at the Camden hospital adjacent to the emergency

6 I take administrative notice that Burlington County covers about
827 square miles and has a population of about 424,000. It is the larg-
est county in the state. Camden County has about 510,000 people and
covers 222 square miles. The distance from Columbus in Burlington
County to Haddonfield in Camden County is about 30 miles.
DECISIONS OF THE NATIONAL LABOR RELATIONS BOARD608
room, which is accessible through a separate entrance.7 Medic
4 is located at the Haddonfield Fire Company No. 1, about 7
miles from the Voorhees hospital and 6 to 7 miles from the
Camden hospital. Medic 5, which operates in 18-hour shifts, is
located at the Pennsauken First Aid Squad, about 7 miles from
the Camden hospital. Medic 6 is located at the Erial Fire Com-
pany, about 8 to 10 miles from the Voorhees hospital and 7 to 8
miles from the Berlin hospital.
In Burlington County, the care units similarly are located at
fire stations and emergency squads. Care unit 1 is based in the
America Emergency Squad in Mt. Holly, about 1 mile from the
Mt. Holly hospital. Care unit 2 is based in the Delran Fire
Company, about 8 miles from the Mt. Holly hospital. Care unit
3 is based in the Medford Emergency Squad, about 6 to 7 miles
from the Mt. Holly hospital. Care unit 4 is based in the Mans-
field Township EMS Building in Columbus, about 10 to 15
miles from the Mt. Holly hospital. Care unit 5 is based in the
Mt. Laurel Fire Department, about 5 to 6 miles from both the
Voorhees and Marlton hospitals.
In both the Camden County and Burlington County divi-
sions, the paramedics rotate through all the deployment sites
every 5 weeks, with rotation occurring every third shift. Thus,
each paramedic works two shifts at each Medic or Care Center
throughout the rotation. Employees can also rotate from Cam-
den County to Burlington County for periods ranging from a
day to a month or permanently transfer from one to the other.8
The majority of paramedics work the same 12-hour shifts as
hospital employees, either from 7 a.m. to 7 p.m. or 7 p.m. to 7
a.m. Part-time employees work from 7 p.m. to 1 a.m. and ro-
tate only between medics 5 and 6, which are 18-hour-per-day
operations.
South Star is an aero-medical unit within the MICU that op-
erates 24 hours a day, 7 days a week. The South Star hangar is
located on the Voorhees campus in a separate building about
100 feet from the hospital. South Star responds to serious acci-
dents and transports acutely ill patients to Virtua hospitals and
non-Virtua hospitals in New York, New Jersey, and Delaware.
South Star also transports patients from non-Virtua hospitals to
Virtua hospitals and from hospital to hospital within the Virtua
system. The helicopter is staffed by a flight paramedic and a
flight nurse,9 who provide advanced life support and patient
transport. There are 11 to 12 employees assigned to South Star,
and 3 of these employees and the chief flight nurse are certified
as both registered nurses (RNs) and paramedics.10 Two state
troopers who are employed by the State of New Jersey pilot the
helicopter. There is a “ready room” and a locker area at the
hangar, with computers and offices where the staff waits be-
tween assignments.

7 The Employer plans to move the Camden Medic to a firehouse.
8 The record did not disclose how frequently intercounty rotations or
transfers occur.
9 The flight nurses are part of a systemwide RN unit represented by a
different labor organization.
10 The record does not disclose how many South Star employees are
paramedics as opposed to RNs or whether these employees rotate to
other paramedic locations. The dual-certified employees are in the RN
unit.
II. FACTORS RELEVANT TO EVALUATING THE APPROPRIATE UNIT
The Board’s Health Care Rule
Prompted by longstanding disputes over hospital bargaining
unit determinations, the Board engaged in notice and comment
rulemaking from 1987 to 1989 in an attempt to formulate a
general determination of appropriate bargaining units in the
health care industry. See generally 52 Fed.Reg. 25142 et seq.,
284 NLRB at 1516 (1987); 53 Fed.Reg. 33900 et seq., 284
NLRB at 1528 (1988); 54 Fed.Reg. 16336, et seq., 284 NLRB
at 1580 (1989). In doing so, the Board sought to avoid prolif-
eration of health care bargaining units and to limit the possible
units to a reasonable, finite number of congenial groups that
each displayed a community of interests within themselves and
a disparity of interests from other groups. See 52 Fed.Reg.
25146, 284 NLRB at 1522; 53 Fed.Reg. 33905, 284 NLRB at
1536.11 The Board’s expressed intent was to create a reason-
able number of units that would realistically reflect natural
groupings of employees in health care facilities. They sought
units that would not be so large that organizing and represent-
ing them would be exceedingly difficult, but large enough to
avoid unnecessary, repetitious rounds of bargaining, along with
frequent strikes, wage whipsawing, and jurisdictional disputes.
53 Fed.Reg. 33905, 284 NLRB at 1536. In May 1989, that
process culminated in the Board’s issuance of the Rule. The
Rule, which was approved by the Supreme Court in American
Hospital Assn. v. NLRB, 499 U.S. 606 (1991), provides that,
except in “extraordinary circumstances” or where there are
existing nonconforming units, the following units are appropri-
ate in an acute-care hospital: (1) all registered nurses; (2) all
physicians; (3) all professionals except for registered nurses
and physicians; (4) all technical employees; (5) all skilled
maintenance employees; (6) all business office clerical employ-
ees; (7) all guards; and (8) all nonprofessional employees ex-
cept for technical employees, skilled maintenance employees,
business office clerical employees, and guards. The Board
stated that where extraordinary circumstances exist, the unit
will be determined through adjudication.
In the Rule, the Board defined an “acute-care hospital” as ei-
ther a short-term care hospital in which the average length of
patient stay is less than 30 days, or a short-term care hospital in
which over 50 percent of all patients are admitted to units
where the average length of patient stay is less than 30 days.
The definition includes hospitals operating as acute-care facili-
ties even if those hospitals offer additional services such as
long-term care, outpatient care, psychiatric care, or rehabilita-
tive care, but excludes facilities that are primarily nursing
homes, psychiatric hospitals, or rehabilitation hospitals. 29
CFR § 103.30(f)(2). The Rule does not by its terms indicate
whether an “acute-care hospital” is limited to a single health
care facility or whether it could encompass a system that in-
cludes more than one health care facility.

11 While the Board did not apply the community-of-interest or dis-
parity-of-interest standards, it recognized that it was considering
uniqueness of function, training, education and licensing, wages, hours
and working conditions, supervision, employee interaction, and factors
relating to collective bargaining in adopting the Rule.
VIRTUA HEALTH, INC. 609
The Board intended that the “extraordinary circumstances”
exception would be limited to truly extraordinary situations and
be construed narrowly so it could not be used as an excuse for
unnecessary litigation or delay. See 52 Fed.Reg. 25145, 284
NLRB at 1521; 53 Fed.Reg. 33904, 33932, 284 NLRB at 1533,
1573; 54 Fed.Reg. 16344–16345, 284 NLRB at 1593. Accord-
ingly, the party urging extraordinary circumstances bears a
heavy burden to demonstrate that its arguments are substan-
tially different from those that the Board considered in the
rulemaking proceedings—for example, that there are such un-
usual and unforeseen deviations from the range of circum-
stances already considered that it would be unjust or an abuse
of discretion for the Board to apply the Rule. See Boston
Medical Center Corp., 330 NLRB 152, 167 fn. 35 (1999);12
Dominican Santa Cruz Hospital, 307 NLRB 506, 507 (1992);13
St. Margaret Memorial Hospital, 303 NLRB 923 (1991), enfd.
991 F.2d 1146 (3d Cir. 1993);14 53 Fed.Reg. 33933, 284 NLRB
at 1574; 54 Fed.Reg. 16345, 284 NLRB at 1593. The Board
indicated that in order to satisfy due process concerns, the
Board would allow for litigation where the circumstances war-
rant, while at the same time precluding litigation where the
arguments are merely repetitive of matters already considered.
54 Fed.Reg. 16345, 284 NLRB at 1593. The Board specifically
stated that the following circumstances normally do not justify
an exception to the Rule: diversity of the industry; increased
functional integration of work contacts among employees; im-
pact of nationwide hospital chains; recent changes within tradi-
tional employee groupings and professions; effects of various
governmental and private cost-containment measures; and sin-
gle institutions occupying more than one contiguous building.
Unit Determinations in Nonacute Health Care Facilities
For nonacute health care facilities, the Board stated that it
would determine appropriate units by adjudication. 29 CFR
§ 103.30(g). The Board has ruled that the proper test for de-
termining the appropriateness of bargaining units in nonacute
care health care institutions is the “pragmatic or empirical
community-of-interest” test set forth in Park Manor Care Cen-
ter, Inc., 305 NLRB 872 (1991). See CGE Caresystems, Inc.
328 NLRB 748 (1999). Under that test, the Board considers
traditional community-of-interest factors, as well as those fac-
tors considered relevant by the Board during the rulemaking
proceedings, evidence presented during the rulemaking pro-
ceedings, and prior cases involving either the type of unit
sought or the type of health care facility in dispute.
In making unit determinations by adjudication, including in
the health care industry, the Board usually affords great weight
to the petitioning union’s desires. It is well established that

12 In that case, the Board rejected an argument that a finding that in-
terns and residents were employees constituted extraordinary circum-
stances warranting their exclusion from a unit of other physicians.
13 In that case, the Board found no extraordinary circumstances
where two unions sought different bargaining units and where RNs
were not the only professional employees in their department.
14 In that case, the Board rejected an argument that extraordinary cir-
cumstances existed where skilled maintenance employees had a par-
ticularly strong community of interest with other nonprofessional em-
ployees.
there may be more than one appropriate bargaining unit within
the confines of a single employing entity and that the Board is
free to select any of those appropriate units. See, e.g., Ameri-
can Hospital Assn. v. NLRB, 499 U.S. 606, 610 (1991). In
accord with that principle, the Board’s policy generally is to
accept a petitioned-for unit as long as it is one of the many
possible appropriate units. There is nothing in the statute that
requires that the unit sought be the only unit, the ultimate unit,
or the most appropriate unit. The Act requires only that the unit
be appropriate. Overnite Transportation Co., 322 NLRB 723
(1996).
In determining whether a group of employees possesses a
separate community of interest, the Board examines such fac-
tors as the degree of functional integration between employees,
common supervision, employee skills and job functions, con-
tact and interchange among employees, fringe benefits, bar-
gaining history, and similarities in wages, hours, benefits, and
other terms and conditions of employment. Home Depot USA,
Inc., 331 NLRB 1289 (2000); Esco Corp., 298 NLRB 837
(1990).
Professional and Technical Employee Status
Section 2(12) of the Act defines a professional employee as:
(a) any employee engaged in work: (i) predominantly intellec-
tual and varied in character as opposed to routine mental, man-
ual, mechanical or physical work; (ii) involving the consistent
exercise of discretion and judgment in its performance; (iii) of
such a character that the output produced or the result accom-
plished cannot be standardized in relation to a given period of
time; (iv) requiring knowledge of an advanced type in a field of
science or learning customarily acquired by a prolonged course
of specialized intellectual instruction and study in an institution
of higher learning or a hospital, as distinguished from a general
academic education or from an apprenticeship or from training
in the performance of routine mental, manual or physical proc-
esses; or (b) any employee, who (i) has completed the courses
of specialized intellectual instruction and study described in
clause (iv) of paragraph (a), and (ii) is performing related work
under the supervision of a professional person to qualify him-
self to become a professional employee as defined in paragraph
(a).
Section 2(12) was meant to apply to small and narrow
classes of employees. Express-News Corp., 223 NLRB 627,
630 (1976). Accordingly, employees must satisfy each of the
four requirements set forth in Section 2(12)(a) before they qual-
ify as professional employees within this definition. Green-
horne & O’Mara, Inc., 326 NLRB 514, 517 (1998); Arizona
Public Service Co., 310 NLRB 477, 481 (1993). While em-
ployee background is examined for the purpose of deciding
whether the work of the group satisfies the “knowledge of an
advanced type” requirement of Section 2(12)(a), it is not the
individual’s qualifications but the character of the work re-
quired that is determinative of professional status. Express
News Corp., supra at 628; Western Electric Co., 126 NLRB
1346, 1348–1349 (1960). Professional employee status turns
on the degree of judgment required of the employees in apply-
ing the knowledge acquired through a prolonged course of
study at specialized schools. Aeronca, Inc., 221 NLRB 326,
DECISIONS OF THE NATIONAL LABOR RELATIONS BOARD610
327 (1975). Salary is not determinative of professional status.
E. W. Scripps Co., 94 NLRB 227, 240 (1951). Examples of
employee classifications that the Board has found to be profes-
sional employees in the health care field are RNs, Centralia
Convalescent Center, 295 NLRB 42 (1989), medical technolo-
gists; Group Health Assn., 317 NLRB 238 (1995), pharmacists;
Mt. Airy Psychiatric Center, 253 NLRB 1003, 1005 (1981);
and chemists, Barnert Memorial Hospital Center, 217 NLRB
775, 783 (1975).
The Board has traditionally held that employees whose jobs
involve the use of independent judgment and specialized train-
ing in major occupational health care groups are technical em-
ployees. 53 Fed.Reg. 33918, 284 NLRB at 1553. These have
included psychiatric technicians, Southern Maryland Hospital,
274 NLRB 1470, 1475 (1975), enfd. in pertinent part 801 F.2d
666 (4th Cir. 1986); respiratory therapy technicians, St. Eliza-
beth’s Hospital of Boston, 220 NLRB 325, 327 (1975); X-ray
technicians, Pontiac Osteopathic Hospital, 227 NLRB 1702,
1707 (1977); LPNs, Trinity Memorial Hospital of Cudahy, 219
NLRB 215, 216 (1975); and operating room/surgical techni-
cians, William W. Backus Hospital, 220 NLRB 414, 418
(1975). The following classifications have generally been
found not to be technical employees: dark room technicians,
Barnert Memorial Hospital Center, supra; EEG technicians,
Pontiac Osteopathic Hospital, supra, and EKG technicians,
Southern Maryland Hospital, supra. The Board has recognized
that most technical employees tend to work in laboratories
rather than patient care areas and that cross-training of techni-
cals occurs primarily with other technicals. Park Manor Care
Center, 305 NLRB 872, 876 (1991). The Board has not yet
made a finding based on record evidence as to whether Para-
medics are professional or technical employees.15
III. FACTS
A. Paramedics’ Duties and Responsibilities
Paramedics provide prehospital advanced life support ser-
vices to patients and transport them to hospitals.16 They go to
patients’ homes or accident locations, provide care at the scene,
and then accompany patients to hospital emergency rooms,
often providing care in the ambulance. Paramedics do not drive

15 In Lifeline Mobile Medics, Inc., 308 NLRB 1068 (1992), no party
disputed the Regional Director’s finding that a related classification,
emergency medical technicians (EMTs) were technical employees, and
the Board therefore assumed they were technicals. In North Memorial
Medical Center, 224 NLRB 218 (1976), the Board noted that it did not
determine in that proceeding whether EMTs were to be included in a
unit of technical employees. In other cases, paramedics were included
in units that specifically included technical employees and/or excluded
professional employees, although there was no issue as to their unit
placement. American Medical Response, Inc., 335 NLRB 1176 (2001);
Freedom A-1, 326 NLRB No. 120 (1998) (not reported in Board vol-
umes); De Queen General Hospital, 264 NLRB 480 (1982), enfd. 744
F.2d 612 (8th Cir. 1984).
16 The paramedic job description states, “Paramedics provide ad-
vanced life support in the emergency setting under the direction and
supervision of a Medical Command Physician to the community and
surrounding areas. Has accountability for the Advanced Life Support
needs of the pre-hospital patient, including assessment, and use of
verbal and/or written protocols of the medical director.”
ambulances but drive vehicles called “rigs,” which are owned
by the Employer’s MICU. Their other equipment is similar to
equipment used by nurses in emergency rooms but is more
rugged and versatile. For example, the infusion pump is en-
cased in a heavy metal box instead of plastic, the defibrillator
also serves as a blood pressure monitor, and the carbon dioxide
monitor can also perform electrocardiogram (EKG) tests.
The Employer’s paramedics respond to about 48,000 calls a
year. Of these, about 23,000 (48 percent) require transportation
of a patient to a hospital, and the others involve situations in
which a patient does not require hospitalization, refuses care, or
is deceased at the scene. About 10,000 patients (42 percent) are
taken to a Virtua facility, while the remaining 13,000 (58 per-
cent) are taken to one of 10 different non-Virtua hospitals in the
area. Thus, only about 21 percent (10,000 out of 48,000) of the
calls result in transport to a Virtua facility.
Emergency calls are initiated through the relevant county
“911” communications center, where the dispatcher determines
if paramedics are necessary.17 If they are needed, the dis-
patcher sends the closest unit to the scene. Paramedic units
respond to calls along with community rescue teams, first aid
squads, and fire and police units. Upon arrival at the scene,
paramedics assess the patient, test vital signs, take blood pres-
sure, and listen to the lungs. They then obtain important infor-
mation,18 determine if any “standing orders” apply, and initiate
treatment.19 Standing orders are established procedures for
specifically identified emergency situations. Paramedics use
their skill and expertise to determine whether advanced airway
management, intravenous therapy, oxygen administration, defi-
brillation, or medication is appropriate.
In most situations, paramedics are also required to call
Medical Command (Medcom), which is a communications
center situated in the emergency room at the Voorhees hospital.
Medcom is staffed 24 hours a day, 7 days a week by one nurse
and one emergency medical technician (EMT) communicator.
The communicator either relays information gathered from the
paramedic to a physician, or the physician speaks to the para-
medic directly.20 Paramedics are not required to call Medcom
when a patient suffers from stomach pain, nausea, or flu-like
symptoms, but they must always call when a patient complains
of chest pain or shortness of breath. Paramedics call Medcom
about 9 times out of every 10 times that patients are treated.
Paramedics honor patients’ requests as to which hospital to
take them, unless the patient has life-threatening injuries. In
such cases, the paramedic takes the patient to the nearest hospi-
tal. The patient is taken to the ambulance by the paramedics
and then transported to the hospital by the rescue squad. One

17 The Camden County Communications Center is based in Linden-
wold, and the Burlington County Communications Center is in West
Hampton.
18 This information includes the patient’s medical history, allergies,
current medications, and symptoms.
19 Paramedics are licensed to administer a variety of medications and
therapeutic agents under standing orders. N.J.A.C. 8:41-8.1.
20 Under New Jersey State law, the MICU must be affiliated with a
general acute-care hospital or emergency room facility and receive
certification from the New Jersey Department of Health. The MICU is
required to dispense care under the supervision of a physician.
VIRTUA HEALTH, INC. 611
of the paramedics accompanies the patient in the ambulance
and continues to monitor the patient while the other drives the
MICU vehicle to the hospital. If the patient has severe injuries,
both paramedics monitor the patient in the ambulance and an
EMT or police officer drives the paramedic vehicle.
Upon arrival at the hospital, the paramedic is generally
greeted by a multiskilled technician (MST), emergency room
technician (ER Tech), or clerical employee, who gathers infor-
mation from the paramedic to register the patient. The para-
medic then relates all vital signs, test results, and prior treat-
ment to a nurse or physician. Paramedics typically spend be-
tween 5 and 15 minutes transitioning a patient, depending on
the complexity of the case, but there have been instances in
which transitions have taken 25 to 30 minutes due to resuscita-
tion efforts.21 Paramedics may also stay at the facility for an
additional 10 to 15 minutes after the patient transfer to clean
their equipment and complete paperwork.22 On infrequent
occasions, when delivering patients to the Voorhees hospital,
paramedics will also begin preparing charts in Medcom or wait
there for their partners. Paramedics have the same level of
contact with emergency room staff whether at Virtua hospitals
or non-Virtua hospitals.
B. Skills and Training
All of the Employer’s paramedics are graduates of a recog-
nized Paramedic training program, certified by the New Jersey
Commissioner of Health and Human Services, and they also
have current certifications in Cardiopulmonary Resuscitation
(CPR) and American Heart Association Advanced Cardiac Life
Support (ACLS). Flight paramedics additionally have New
Jersey Air Medical Crew Member Flight Paramedic certifica-
tions.23 As a result of their training, paramedics are permitted
to perform certain highly specialized tasks such as intubation,
infusion into bone, chest decompressions, reinflation of lungs,
and accessing dialysis shunts. Paramedics must be recertified
and complete 48 hours of continuing education every 2 years.
The Employer provides training in life support and CPR to its
paramedics and other hospital employees such as emergency
room staff, surgical staff, and intensive care unit (ICU) staff.
Paramedics are also trained in chemical release and biohazards,
terrorism response, emergency vehicle operations, and mass
casualty incidents. Like all other hospital employees, paramed-
ics receive training in the Health Insurance Portability and Ac-
countability Act of 1996 (HIPAA) either on-line or in person.
C. Contact, Transfers, and Interchange With Other
Virtua Employees
As noted above, when paramedics deliver patients to Virtua
hospitals, they usually interact with emergency room staff for
between 5 and 15 minutes. They spend the remainder of their

21 The record does not indicate how frequently these longer transi-
tions occur but suggests that they are rare.
22 Paramedics complete paperwork called ambulance squad run
sheets, which are made part of the patients’ records, and gather infor-
mation from patients regarding billing.
23 According to Vice President for Labor Relations Linda Wilson,
there is very little difference in the training received by flight paramed-
ics and other paramedics.
workday at their deployment stations, in the field, or delivering
patients to non-Virtua hospitals.24
Although New Jersey law prohibits paramedics from per-
forming duties in a hospital other than transferring patients,25
there have been about six occasions within the past year when
paramedics have been assigned to work in emergency rooms at
the Employer’s acute-care hospitals.26 In most of these situa-
tions, the employee involved had requested light or modified
duty due to an injury.27
In addition, in 2002, when some physicians in New Jersey
temporarily closed their offices to protest medical malpractice
insurance costs and directed patients to hospital emergency
rooms for treatment, some paramedics voluntarily worked in
the emergency rooms to accommodate the increase in pa-
tients.28 When assigned to the emergency room, paramedics
are technically able to perform any duties that they perform in
the field, such as starting intravenous treatments, dispensing
medications, obtaining patient histories, administering physical
examinations, and taking vital signs, but there is no evidence as
to how much of this work they actually performed.
The Employer’s job posting program is a comprehensive list-
ing of all job openings throughout the Virtua system. It is
posted in Virtua facilities and the Employer’s Intranet website,
the “Virtua Vine,” and is updated twice per week. There is a
single seniority system for the Employer’s employees so that if
employees transfer in or out of a paramedic position, they retain
their seniority and aggregate all of their employment time for
purposes of determining pension eligibility. Paramedics are
eligible to bid on nonparamedic or non-MICU jobs throughout
the Virtua system and maintain their seniority. The record,
however, reveals only five employee transfers from paramedic
positions to other positions and five employee transfers from

24 There was conflicting evidence as to whether the paramedics eat at
hospital cafeterias when they deliver patients to hospitals.
25 N.J.S.A. 26:2K-18.
26 Melanie Leighton and Michael Ramich worked in the emergency
room at the Voorhees hospital for an unknown period, and Joe McCon-
omy and Jackie Robinson worked in the Mt. Holly emergency room for
unknown periods. Additionally, Bruce Beatty worked in the Mt. Holly
emergency room and in the Home Health Services office for a total of 6
weeks, and Teresa Barry worked in an unknown emergency room on
and off for a period of about 8 months.
27 While Thomas Starr testified that the paramedics at Care 1 in Bur-
lington County have a history of filling in at the Mt. Holly emergency
room, he did not provide any specific examples.
28 The record does not indicate how many paramedics did so or for
how long. According to Teresa Barry, this was the only time in her 18
years as a Paramedic that she worked in the emergency room. She
drew blood and performed an EKG during that time.
DECISIONS OF THE NATIONAL LABOR RELATIONS BOARD612
other positions to paramedic positions.29 Three of the five em-
ployees who became paramedics had been ER Techs.30
Paramedics are not the only Virtua employees who spend the
vast majority of their time working outside of the Employer’s
health care facilities. There are also between 50 and 100 em-
ployees in Mt. Laurel who work in a warehouse performing
purchasing functions and an unknown number of transportation
employees who move goods and supplies from one facility to
another and spend most of day in their vehicles. These em-
ployees are considered part of the Corporate Business Services
Department, and they report to the vice president for support
services. Home Health Services nurses also work away from
the hospitals.
D. Labor Relations Policies and Work Rules
There is a single human resources policies and procedures
manual covering employees at all of Virtua’s facilities.31 All of
the Employer’s employees are paid on a biweekly basis on the
same payroll schedule and are evaluated annually at the same
time for pay increases. Paramedics are paid on the same wage
scale as other Virtua employees.32 All employees are subject to
a 3-month probation period unless they are covered by a collec-
tive-bargaining agreement that provides otherwise.
Paramedics participate in the same 1-day new employee ori-
entation program as other employees and complete the same
employment applications. Paramedics also participate in ACLS
training, sometimes with other employees, and they may teach
this course to other employees. The Employer distributes ser-
vice recognition awards to all employees based on Virtua sen-
iority. All Virtua employees, including paramedics, participate
in employee surveys, open employee meetings, an annual
safety day, employee picnics, the star awards, and employee of
the month programs.
All unrepresented Virtua employees receive the same health
insurance, dental insurance, life insurance, long-term disability
insurance, state disability insurance, supplemental life insur-
ance, prescription benefits, tax shelter annuities, 401(k) bene-
fits, and pension benefits. They are all eligible to utilize Vir-
tua’s employee assistance program, credit union, fitness center,
and child care centers. All employees may participate in the
Employer’s leave of absence program, jury duty program, tui-
tion assistance program, and Virtua University, which offers
personal, organizational, and clinical training programs. The
Employer’s information services division also offers computer

29 Thomas Starr’s wife, Pat Starr, transferred from a paramedic posi-
tion to an RN position, Scott Hanson transferred from a paramedic
position to a Community Education position, Jamie Pitner transferred
from a paramedic position to a Community Health position, Michele
Leff transferred from a paramedic position to an RN position, and
Phyllis Worrell transferred from a paramedic position to a Safety and
Security position but continues to work as a paramedic on a per diem
basis. The record does not indicate when these transfers occurred.
30 Communicator Donald Roth, ER Tech George Devakis, ER
Tech/MST Rhonda Craig, Base Communicator/EMT Pat Desantis, and
ER Tech Kim Aurbaugh all became paramedics.
31 The record is unclear as to whether the MICU also has its own
policy manual.
32 They are generally compensated at wage levels 9 and 11, but the
record does not indicate the dollar amount of their wage rates.
educational programs, such as Powerpoint, Word, and Excel, to
all Virtua employees.
All MICU employees, including paramedics, are eligible for
overtime work. They record their time either telephonically via
a recording system or by swiping their ID badges if they are in
a Virtua facility. Hospital employees other than paramedics
can rotate their schedules in order to attend continuing educa-
tion courses. Nurses may work flexible hours or have other
employees cover for them on a regular basis to accommodate
their personal needs. Paramedics are not permitted to alter their
scheduled hours.
E. Bargaining History
There is no bargaining history for the paramedics. The Peti-
tioner has represented a unit of RNs employed by Virtua at its
Voorhees, Berlin, Marlton, and Camden hospitals, as well as at
South Star, the Cardiac Performance Center, the Summit Sur-
gery Center, the Ambulatory Center, the Tatum Brown Family
Health Center, and Home Health Services facilities since May
1997.33 Another labor organization represents the nurses who
are employed at the Mt. Holly hospital.34
IV. ANALYSIS
The Paramedics’ Status as Technical or
Professional Employees
The Employer contends that paramedics are technical em-
ployees and, pursuant to the Rule, cannot be part of any unit
that does not include all of its technical employees. Although
the Petitioner contends that a unit limited to paramedics is ap-
propriate, the Petitioner maintains that the paramedics are pro-
fessional employees rather than technicals.
Based on the statutory requirements set forth above, I find
that paramedics are not professional employees as defined in
Section 2(12) of the Act. While paramedics must be highly
skilled and are often critical to patient care, the position does
not require a college degree or significant advanced training in
any specialized field of the type characteristic of professional
employees. There has been no showing that their work is pre-
dominantly intellectual in character or requires the use of
judgment that is based on advanced intellectual instruction.35
Community Health Services, 259 NLRB 362 (1981); Express-
News Corp., 223 NLRB 627 (1976). Therefore, they do not
meet the Board’s test for professional status.

33 The record does not indicate whether that certification was the re-
sult of a Stipulated Election Agreement or a Decision and Direction of
Election. At that time, West Jersey Health System owned those facili-
ties.
34 The record does not indicate the identity of this labor organization.
The Employer declined to stipulate that the paramedics were not
covered by other collective-bargaining agreements or that there is no
contract bar issue on the grounds that its RNs were represented by
JNESO and had an agreement that covers flight nurses at South Star.
35 In Samaritan Health Services, 238 NLRB 629 (1978), the Board
found a “radiologic paramedic” to be a professional employee. That
employee performed his work in a hospital radiology department, had
extensive academic and clinical training, and was required to perform
highly specialized radiographic procedures. His duties and responsi-
bilities were not comparable to those of the paramedics in this case.
VIRTUA HEALTH, INC. 613
Rather, I find that the paramedics are technical employees.
They are required to be certified as paramedics and recertified
every 2 years, and they exercise independent judgment while in
the field as to which treatments to administer and whether to
apply a standing order or to call Medcom. Their level of skill
and training is comparable to the levels of skill and training of
classifications found to be technical in other cases. Accord-
ingly, if the Rule were to apply, paramedics would be included
in a unit of technical employees rather than professional em-
ployees. St. Elizabeth’s Hospital of Boston, supra; William W.
Backus Hospital, supra.
The Applicability of the Rule
The Board has not yet determined whether the Rule applies
to hospital systems in the same way that it applies to individual
hospitals. While the Board recognized during rulemaking pro-
ceedings that there are variations in the size and scope of acute-
care hospitals, there is no indication that the Board contem-
plated that each bargaining unit would span multiple health care
facilities of varying types.
The Rule itself refers to “acute-care hospital” in the singular,
and the Board’s accompanying comments generally refer to
hospitals as individual facilities. In discussing the problems
associated with unit proliferation, a major impetus for the Rule,
the Board stated that “[L]ogically, the potential for a number of
units does not mean that every hospital will be faced with this
number of organizing campaigns. Indeed, a successful organiz-
ing effort of one unit in a hospital does not appear to have had
a ripple effect on further organization.” The Board further
stated that, “[o]ne study showed there is generally no correla-
tion between the number of units in a hospital and the fre-
quency of strikes . . .” See 53 Fed.Reg. 33908–33909, 284
NLRB at 1540.36 (Emphasis added to all quotations.) Thus, in
enacting the Rule, it appears that the Board based its unit de-
terminations on an assumption that there would be as many as
eight units in each individual hospital. As noted above, the
Board emphasized during the rulemaking proceedings that
while it desired to avoid proliferation of units and its concomi-
tant problems, the Board also intended to create groupings that
would not be so large and diverse as to render organization and
representation of them to be exceedingly difficult. 53 Fed.Reg.
33905, 284 NLRB at 1536. If the 150 paramedics were in-
cluded in a unit of all 1100 technical employees at all of Vir-
tua’s facilities, this unit would be extremely difficult to organ-
ize and represent.
Since promulgating the Rule, the Board has not had many
occasions to discuss whether it applies to multifacility health
care systems, but in Child’s Hospital, Inc., 307 NLRB 90
(1992), the Board provided some guidance on this issue. In that
case, the employer operated an acute-care hospital, a nursing
home, and a service provider for both of the health care facili-
ties, in a single building. The petitioner contended that the
Rule applied and sought a unit limited to RNs who worked at

36 Additionally, see 53 Fed.Reg. 33912, 284 NLRB at 1545, where
the Board stated, “RNs work in close and continuous contact with one
another within the same hospital.” See also 53 Fed.Reg. 33918, 284
NLRB at 1554, where the Board stated, “Technical employees are
distinguished by the support role they play within the hospital.”
both health care facilities, while the employer contended that
the Rule did not apply and that the unit should include the RNs
in a unit with all other professional employees at these facili-
ties. The Board decided that “extraordinary circumstances”
existed which rendered the Rule inapplicable, and identified
these circumstances as the physical joinder of the nursing home
and the hospital, the substantial nature of both operations, and
the fact that the same service provider handled the needs of
both operations. Significantly, the Board stated that, “[t]o at-
tempt to fit this hybrid facility within a rule that is designed to
cover the more typical free-standing acute-care hospital may,
possibly, lead to an anomalous or impractical result, depending
on the RNs’ relationship to other professionals and nonprofes-
sionals in the facility, and the extent to which such relationship
differs from, or is similar to, that found in the normal, acute
care hospital setting.” Upon finding that the Rule did not ap-
ply, the Board indicated that the appropriate bargaining unit
should be determined based on the test set forth in Park Manor
Care Center, 305 NLRB 872, 874–875 (1991), and remanded
the case to the Regional Director for that purpose.37 The Board
thus indicated that the Rule does not automatically apply to
health care systems that extend beyond a single facility acute-
care hospital.38
In the instant case, the Employer’s health care system is also
a “hybrid,” unlike the typical free-standing hospital to which
the Rule was designed to apply.39 Thus, the Virtua system

37 Following the remand, the Regional Director found that no ex-
traordinary circumstances existed based on the hybrid nature of the
facility, among other reasons, because the Board expressly included
within the coverage of the Rule those acute care hospitals that provide
nonacute care services. The Board adopted the Regional Director’s
findings without discussion but it is not clear whether the “extraordi-
nary circumstances” discussion was raised in a request for review.
Child’s Hospital, 310 NLRB 560 (1993).
38 The Employer contends that the Rule applies to the entire Virtua
system because there are acute care hospitals within that system. This
argument was recently raised in Stormont-Vail Healthcare, Inc., 340
NLRB 1205 (2003). In that case, the employer operated an integrated
health care system consisting of a hospital complex comprised of four
connected inpatient acute care hospital buildings and several other
facilities, as well as numerous facilities away from the hospital com-
plex including an inpatient acute care psychiatric department and sev-
eral clinics and community nursing centers, among other facilities.
Although the petitioner sought a multifacility unit of RNs that was
smaller than systemwide, the employer argued, among other things, that
because its system included acute care hospitals, the Rule required a
system-wide unit. The Regional Director included in the unit RNs
working on the main hospital campus but excluded RNs at the psychiat-
ric facility and the outlying clinics and community nursing centers. In
so finding, the Regional Director determined that the Rule did not apply
because the hospital complex was “much more extensive and inclusive
than a single acute care hospital” and the vast majority of patients
served by the employer were outpatients rather than in-patients in acute
care facilities. While the Board disagreed with the Regional Director’s
conclusions on community-of-interest grounds and ordered the inclu-
sion of RNs at the psychiatric facility and outlying clinics and commu-
nity nursing centers, it did not disturb the Regional Director’s reasoning
as to the applicability of the Rule.
39 In this regard, see “The Future of NLRB Rulemaking: Analyzing
the Mixed Signals Sent by the Implementation of the Health Care Bar-
DECISIONS OF THE NATIONAL LABOR RELATIONS BOARD614
includes four acute-care hospitals, one nonacute care hospital,
and several other facilities that are not hospitals. As in Childs,
supra, some of the facilities that are not hospitals are physically
attached to hospitals or are located on the same campuses. In
this case, however, the circumstances are even further removed
from the single facility acute-care hospitals discussed in the
Rule because the multiple Virtua facilities cover a wide geo-
graphic area, and many of these facilities, including the Cam-
den hospital, are not acute-care hospitals and by themselves
would be exempt from the application of the Rule. These cir-
cumstances are significantly different than circumstances con-
sidered by the Board when promulgating the Rule, and applica-
tion of the Rule could consequently cause an impractical or
anomalous result.
Moreover, application of the Rule would be particularly
anomalous with respect to the paramedics because they have
only a limited connection to any of the Employer’s acute-care
hospitals. Very few of the paramedics are based at Virtua
acute-care facilities; they are almost always stationed at fire-
houses and rescue squads several miles away. At any given
time, only 10 to 15 of the 150 paramedics are based at a Virtua
facility, and paramedics are far more likely to transport patients
to facilities other than acute-care Virtua hospitals. Overall,
paramedics spend a relatively insignificant portion of their
working hours at the Employer’s acute-care hospitals.
While the Board intended narrowly to limit the “extraordi-
nary circumstances” exception, this exception should not be
viewed as entirely meaningless.40 The Board listed several
specific types of circumstances considered during the rulemak-
ing proceedings that would not constitute extraordinary circum-
stances, but none of the circumstances set forth by the Board
are present in this case. In this regard, there is no contention
that extraordinary circumstances exist based on: the diversity of
the industry; increased functional integration of work contacts
among employees; recent changes within traditional employee
groupings and professions; or the effects of various governmen-
tal and private cost-containment measures. Additionally, the
Employer is not merely a “single institution occupying more
than one contiguous building,” but is a wide-ranging system
that includes both acute-care and nonacute care facilities spread
over two counties. Finally, while the Employer is a multifacil-
ity system, there is no contention that the Employer is a “na-
tion-wide hospital chain.” There is no indication that the Board
considered multifacility systems like Virtua when limiting the
extraordinary circumstances exception. In fact, the Board indi-
cated in its comments that a party had requested that the Rule
make it clear that multisite units are not an exception, but the

gaining Unit Rule and By the Proposed Beck Union Dues Regulation,”
8 Admin L.J. Am.U. 125, 138 (1994).
40 In fact, in American Hospital Assn. v. NLRB, supra, in upholding
the Rule the Supreme Court referred to the extraordinary circumstances
exception on several occasions. In responding to the petitioner’s argu-
ment that the Rule is arbitrary, the Court emphasized that if the Board
were presented with a case in which application of the Rule would be
arbitrary, it would conclude that extraordinary circumstances justified a
departure from the Rule. See American Hospital Assn. v. NLRB, supra
at 618–619.
Board declined to do so. See 54 Fed.Reg. 16344, 284 NLRB at
1592.
In support of the Employer’s contention that the Virtua sys-
tem in its entirety constitutes an acute-care hospital under the
Rule, the Employer cites West Jersey Health System, 293
NLRB 749, 751–752 (1989), a case involving the health care
system that merged with the Burlington hospital to create the
Employer. In that case, the Board found that various peti-
tioned-for single hospital units were inappropriate because the
presumption of single-facility appropriateness had been over-
come and only multifacility units of West Jersey’s four acute-
care hospitals were appropriate.
West Jersey does not control the instant case, however, for
several reasons. Most significantly, the applicability of the
Rule was not at issue. West Jersey did not involve a determina-
tion of whether a classification of employees was required to be
included in a more comprehensive unit but only dealt with the
issue of whether a single-facility unit was appropriate. In the
instant case, the parties stipulated to a systemwide unit, and the
issue is whether paramedics must be included with all of the
Employer’s technical employees in the same unit. Addition-
ally, as a result of the subsequent merger with the Burlington
hospital the Virtua health care system is larger and covers a
wider range than the West Jersey Health System. Whereas
West Jersey Health Care System consisted of 4 acute-care hos-
pitals in Camden County, Virtua has 10 facilities of various
types spanning both Camden and Burlington Counties.41
Moreover, the case arose in 1982, and West Jersey had a differ-
ent corporate structure than Virtua. Thus, the Employer’s reli-
ance on the Board’s decision in West Jersey is misplaced.42

41 Thus, although the issue was not raised in this case, a single loca-
tion unit may not be inappropriate, as it was in West Jersey.
42 In West Jersey, the Board based its finding in great part on the ex-
tensive transfers of employees between the facilities and the fact that
the system’s departmental directors handled the day-to-day supervision.
There is no similar evidence as to the Employer’s practices concerning
the paramedics.
The Employer also cites West Jersey Health System, 324 NLRB No.
90 (1997), enfd. 162 F. 3d 1153 (3d Cir. 1998), an unpublished deci-
sion involving West Jersey’s refusal to bargain in a system-wide RN
unit, because the Board referred to West Jersey as a “not-for-profit
acute health care system.” However, there is no indication that by
making such a reference, the Board held that the Rule must apply to the
entire system.
The Employer also argues that two letters issued by the Regional Di-
rector for Region 22 (Newark) dismissing petitions are determinative of
this matter. In, Robert Wood Johnson Hospital, Case 22–RC–10348
(November 15, 1990), the Regional Director dismissed a petition for a
unit of 73 emergency medical services (EMS) employees, including
Paramedics, employed by a single hospital. In finding the unit inap-
propriate, the Regional Director relied upon the fact that the EMS em-
ployees frequently worked in conjunction with other hospital employ-
ees and performed medical functions closely integrated with those
performed at the hospital. That case is clearly distinguishable because
the employer was a single hospital, not a system, and all of the unit
employees were connected to that hospital. In the instant case, in con-
trast, the employees in the petitioned-for unit are not connected to any
specific hospital but bring patients to various Virtua and non-Virtua
hospitals.
VIRTUA HEALTH, INC. 615
Based on the “extraordinary circumstances” present in this
case, I find that the Rule does not apply to the Employer’s
health care system. Accordingly, the appropriateness of the
petitioned-for unit shall be determined, based on the record,
using the “pragmatic or empirical community-of-interest” test
set forth in Park Manor Care Center, 305 NLRB 872 (1991).
Application of the Park Manor Criteria
In Park Manor, the Board delineated principles to guide unit
determinations in nonacute care facilities. See South Hills
Health System Home Health Agency, 330 NLRB 653, 656
(2000); McLean Hospital Corp., 309 NLRB 564 (1992);
Child’s Hospital, supra. In determining whether a petitioned-
for unit is appropriate, the criteria set forth in Park Manor re-
quire an examination of: (1) community-of-interest factors, (2)
evidence presented and factors deemed relevant by the Board in
its rulemaking proceedings, and (3) prior precedent.
Community of Interest
In the instant case, the relevant factors for determining
whether the Employer’s paramedics have a community-of-
interest factors with other technical employees include em-
ployee contact and interchange, transfers, supervision, terms
and conditions of employment, employee skills and training,
functional integration, and bargaining history.
There is very little contact or interchange between the para-
medics and other Virtua technical employees. Thus, of the 11
sites at which paramedics are stationed, only one is currently
situated at a Virtua hospital, so paramedics have no contact
with other Virtua employees at the place where they report to
work and spend their time waiting to be called to duty. When
responding to calls, paramedics only see each other and mem-
bers of local rescue squads or police and fire departments, al-
though they are usually in telephone contact with a Medcom
representative. Paramedics generally spend only a few minutes
in the emergency room when delivering a patient, so they have

Northwest Covenant Health Care System, Case 22–RC–11066
(1996), presents a closer factual parallel. In that case, the Regional
Director administratively dismissed a petition seeking to represent a
unit of 70 EMS Technicians, Paramedics, Dispatchers, and Wheelchair
Car Drivers employed by a health care system consisting of four acute-
care hospitals and other satellite facilities. The petitioned-for employ-
ees were stationed at the employer’s acute-care hospitals, a satellite
facility, and an acute-care hospital unrelated to the Employer, and
employees transported patients both to the employer’s acute-care hospi-
tal and other acute-care hospitals. In dismissing the petition and find-
ing that the unit employees were required to be included in an overall
unit of technical employees, the Regional Director determined that the
employees’ duties were directly related to patient care and were akin to
those performed at the employer’s intensive care unit or emergency
room. The Petitioner requested review of the Regional Director’s ad-
ministrative dismissal, and the Board denied the request. Northwest
Covenant may be distinguishable because the relevant health care sys-
tem was not as large or wide-ranging as the Virtua System, most of the
Paramedics were based at the employer’s facilities, and it is not clear
how frequently the Paramedics transported patients to facilities outside
the system. In any case, the Board has held that Regional Director’s
Decisions do not have precedential value, S.H. Kress & Co., 212 NLRB
132 fn. 1 (1974), and administrative dismissal letters would similarly
not control later cases.
very limited contact with emergency room personnel. More-
over, they transport the majority of patients to non-Virtua hos-
pitals and, therefore, have more contact with non-Virtua emer-
gency room employees than with Virtua employees. As some
of this contact is with physicians and RNs, their interaction
with the Employer’s technical employees is limited even fur-
ther. Paramedics have only rarely been assigned to work in the
emergency room, and they are limited by State law as to the
tasks they can perform there. Thus, paramedics interact with
other Virtua employees infrequently and indeed have far more
contact with firefighters, EMTs, and rescue squad employees
than with Virtua technical employees.
There have been few permanent transfers between paramed-
ics and employees in other positions within the Virtua system.
In a system of 7200 employees, only 5 paramedics transferred
to other positions, and only 5 employees transferred to para-
medic positions.43 Thus, although Virtua posts opportunities
for transfer on a systemwide basis, paramedics have not signifi-
cantly participated in these transfers, presumably because of the
specialized nature of their positions.
The Employer has a uniform pay scale and pay policies for
all employees, including paramedics, and provides all employ-
ees with the same fringe benefits and awards programs. All
Virtua employees are covered by the same handbook and must
abide by the same rules and regulations. Paramedics also have
the same orientation program and many of the same training
opportunities as other Virtua employees. The only significant
difference in the Employer’s rules is that paramedics are not
permitted to switch hours with other employees but must con-
form to their scheduled hours.
Paramedics must acquire skills and obtain training and certi-
fication in various specialized areas. They receive paramedic
training, as well as training in CPR, biohazards, life support,
and several other areas of expertise necessary to provide care
for patients in emergency or life-threatening situations. Emer-
gency room personnel also need to acquire some of these skills.
Paramedics need to be recertified every 2 years by taking 48
hours of training. Like all other employees, they are trained in
HIPAA.
There is some functional integration between the paramedics
and some hospital employees. Thus, similar to hospital emer-
gency room and intensive care employees, the paramedics’
duties are directly related to patient care. Some of the patients
treated and transported by the paramedics later fall under the
care of other Virtua employees, including some technicals.
Many of the patients, however, are not brought to hospitals at
all and others are transported to non-Virtua hospitals, which
limits the extent of integration.
On a day-to-day basis, the paramedics are supervised at the
platoon level; each supervisor is responsible for 10 to 15 em-
ployees. At higher levels, supervisors and corporate officials
are responsible for other employees in addition to paramedics.44
The fact that there are supervisors several levels up the chain of

43 Not all of the employees who transferred from paramedic posi-
tions remained in technical classifications.
44 The record does not indicate whether other employees in the
MICU or the ambulatory services division are technical employees.
DECISIONS OF THE NATIONAL LABOR RELATIONS BOARD616
command that handle other employees in addition to paramed-
ics, however, is not very significant. McLean Hospital Corp.,
supra, 309 NLRB at 574; Omni International Hotel, 283 NLRB
475 (1987).
There is no bargaining history for paramedics. RNs are rep-
resented on a systemwide basis, except for the Mt. Holly hospi-
tal nurses, who are separately represented.
Rulemaking Comments
During the rulemaking proceedings, the Board found that
technical units in acute-care hospitals include various classifi-
cations such as medical laboratory, respiratory therapy, radiog-
raphy, and emergency medicine employees, and LPNs. A re-
view of these proceedings, however, indicates that the Board
did not discuss evidence concerning the unit placement of
paramedics or any similar classifications.45
Case Precedent
As to prior precedent, the Board has not issued any cases
concerning whether paramedics should be included in a techni-
cal unit or any other unit. In the most comparable situation,
Albuquerque Ambulance Service, 263 NLRB 1 (1982), revd.
726 F. 2d 611 (10th Cir. 1984),46 which was decided before the
promulgation of the Rule, the Board found that a unit of ambu-
lance service employees had a separate community of interest
because: the ambulance services were distinct from traditional
hospital services; the purposes and functions of the ambulance
service were not directly related to the common health care
purposes for which any hospital exists; ambulance crew mem-
bers had the same relationship and work contact with emer-
gency room personnel in other hospitals; and ambulance em-
ployees had more contact with hospital personnel from other
area hospitals.

45 The Board referred to EMTs once during those proceedings, not-
ing that on rare occasion, they participate in multicompetency pro-
grams. The Board further stated, however, that these programs have
little relevance to units in acute-care hospitals because graduates are
generally employed elsewhere. 53 Fed.Reg. 33907–33908, 284 NLRB
at 1539.
46 In reversing the Board’s decision that the ambulance service em-
ployees could constitute a separate appropriate unit, the court applied
the disparity-of-interest standard, not the community-of-interest stan-
dard.
Analysis
I find that under the criteria set forth in Park Manor, Para-
medics have a separate community of interest apart from Vir-
tua’s 1100 other technical employees and constitute a separate
appropriate unit. Most significantly, they report to work almost
entirely at non-Virtua sites and spend the vast majority of their
time away from Virtua hospitals. Even when they bring pa-
tients to Virtua hospitals, they only spend brief amounts of time
there and have limited contact with a few emergency room
employees. They are separately supervised from other employ-
ees on a day-to-day basis, and they very seldom transfer to or
from other jobs in the Virtua system. Paramedics have some
separate skills and cannot work flexible hours like other Virtua
employees. Moreover, the Petitioner’s unit preference is a
relevant factor, and the Petitioner has requested a separate unit
of Paramedics. The fact that paramedics are involved in patient
care duties that are somewhat integrated with the duties of hos-
pital employees, and that they are subject to the same labor
relations policies and receive the same benefits does not compel
a different result. Accordingly, the petitioned-for unit of para-
medics is appropriate.47

47 North Memorial Medical Center, supra, cited by the Employer, is
distinguishable. That case involved an employer that operated a single
facility acute-care hospital and an ambulance service employing EMTs
at three locations, one at the hospital and two at remote locations. The
EMTs were dispatched by the hospital and not by “911” services.
Despite a bargaining history that was controlled under state law, sepa-
rate supervision, different working hours, and separate wage rate classi-
fications, the Board, applying a community-of-interest test, found that
the petitioned-for unit of EMTs was inappropriate because the EMTs
performed medical functions closely integrated with other hospital
employees. That case, however, involved far fewer locations, no inter-
change with employees outside the hospital, and in-house dispatching.
The EMTs in North Memorial Medical Center were closely tied to the
hospital while the paramedics do not have a strong connection to any of
the Employer’s acute-care hospitals.