I've been discussing THIS story with good friend and fellow EMS 2.0 believer Scott Kier on the book of faces.
Since I can not mention the Department name here, just read the story and come back.
Disclosure: I am a trained Firefighter/Paramedic. I am a second generation Firefighter. I am a card carrying member of the IAFF and my Local.
That being said, let's move on to the meat of Scott and my discussion.
The story references a municipality struggling to meet increasing demand for ambulance responses under a state mandated market share of 80% responses shared with 2 local private providers. To reach that target the municipality made funding available to replace an aging fleet (some stories reported over 200,000 city miles on some ambulances) and hire new EMS staff.
The Municipality operates an EMS transport tier within its Fire Department, a decision made in 1997 when the municipality's public health ambulance group was folded into the fire department. If you've been awake for more than an hour you know that never goes over well.
Skip ahead to about 2006 when single function EMS crews are sent back out from 24 hour assignments in the firehouses on a "1 and 1" deployment model. That means one EMT and one Paramedic per unit. AKA the norm.
The 24 hour medics were reassigned to the municipality's fire engines to increase the capability of ALS first response.
The local EMS Agency sets response times for all ambulances in the system and has magically chosen 10 minutes for code 3 calls and 20 minutes for code 2 calls. The determination of code 2 or code 3 is made by the call taken and caller discussing the patient's condition, weather and who knows what else.
The times are averaged using an approved statistical model and reported to the EMSA and State.
Now that that's out of the way, let's talk about response times.
Response times are solely to determine if a contracted agency is meeting contract parameters.
See, wasn't that easy?
It would be a challenge to hold ABC Ambulance Company or Random Municipality to actually treating illness and injury to a certain level. Imagine if the contract to earn a service area required an agency to treat all asthma patients with a bronchodialator or ensure that all patients with a revised trauma score less than 5 are being transported to a level 1 facility.
EMS needs to be held accountable for the assessments and treatments they provide not how swiftly they can arrive or how many people they can haul away in a day.
Trouble is we've spent the better part of 40 years telling people that "seconds count" when in fact they only count in groups of about 200. Add to that that reimbursement is tied to transport, not treatment and the service simply looks to turn over calls as fast as possible. Armed with the belief that a 10 minute response time is required for chest pain, ankle injuries, drownings and sleeping street people, the entire system must be built for the smallest community of patients: the critically ill.
EMS 2.0 is about stopping the band aid fixes and overhauling the EMS system in each community to meet the needs of that community. For some that means EMS based EMS or a third service while others will need to lean on fire and PD to take up the slack when staffing levels can't be filled.
Scott and I agree that a tiered approach is necessary, however, based on discussions we've had online and in person we are on opposite sides of that discussion.
Perhaps Scott can pick it up here over at EMS in the New Decade?
Since I can not mention the Department name here, just read the story and come back.
Disclosure: I am a trained Firefighter/Paramedic. I am a second generation Firefighter. I am a card carrying member of the IAFF and my Local.
That being said, let's move on to the meat of Scott and my discussion.
The story references a municipality struggling to meet increasing demand for ambulance responses under a state mandated market share of 80% responses shared with 2 local private providers. To reach that target the municipality made funding available to replace an aging fleet (some stories reported over 200,000 city miles on some ambulances) and hire new EMS staff.
The Municipality operates an EMS transport tier within its Fire Department, a decision made in 1997 when the municipality's public health ambulance group was folded into the fire department. If you've been awake for more than an hour you know that never goes over well.
Skip ahead to about 2006 when single function EMS crews are sent back out from 24 hour assignments in the firehouses on a "1 and 1" deployment model. That means one EMT and one Paramedic per unit. AKA the norm.
The 24 hour medics were reassigned to the municipality's fire engines to increase the capability of ALS first response.
The local EMS Agency sets response times for all ambulances in the system and has magically chosen 10 minutes for code 3 calls and 20 minutes for code 2 calls. The determination of code 2 or code 3 is made by the call taken and caller discussing the patient's condition, weather and who knows what else.
The times are averaged using an approved statistical model and reported to the EMSA and State.
Now that that's out of the way, let's talk about response times.
Response times are solely to determine if a contracted agency is meeting contract parameters.
See, wasn't that easy?
It would be a challenge to hold ABC Ambulance Company or Random Municipality to actually treating illness and injury to a certain level. Imagine if the contract to earn a service area required an agency to treat all asthma patients with a bronchodialator or ensure that all patients with a revised trauma score less than 5 are being transported to a level 1 facility.
EMS needs to be held accountable for the assessments and treatments they provide not how swiftly they can arrive or how many people they can haul away in a day.
Trouble is we've spent the better part of 40 years telling people that "seconds count" when in fact they only count in groups of about 200. Add to that that reimbursement is tied to transport, not treatment and the service simply looks to turn over calls as fast as possible. Armed with the belief that a 10 minute response time is required for chest pain, ankle injuries, drownings and sleeping street people, the entire system must be built for the smallest community of patients: the critically ill.
EMS 2.0 is about stopping the band aid fixes and overhauling the EMS system in each community to meet the needs of that community. For some that means EMS based EMS or a third service while others will need to lean on fire and PD to take up the slack when staffing levels can't be filled.
Scott and I agree that a tiered approach is necessary, however, based on discussions we've had online and in person we are on opposite sides of that discussion.
Perhaps Scott can pick it up here over at EMS in the New Decade?
Comments
I completely agree that response times shouldn't be the *only* measure of how ambulance services deliver their services, important is of course patient outcome, which is notoriously hard to quantify, follow up, divvy up between out of/in hospital care etc. What I believe will be coming to the UK in due course as a part of quality measurement (and is partially already in place) are so called care bundles - making sure that the patient received the right care at the right time, e.g. a ?CVA having their sugars checked, being FAST positive, and rapid transport to a stroke unit.
What you don't mention in the above article, but what I believe is as important, or even mores than the point of not having enough ambulances, is WHY there are not enough units available? Cost, ageing fleet, retired staff etc were touched upon, but what are all the available transport units up to when they are unavailable for other calls? Are they on actual emergency calls? Or calls that could have, and should have been dealt by other services, e.g. community nurses, GPs etc? Should that unit have been dispatched at all, or could they have been given home help advice over the phone?
And what about the system? It is good that Firefighter/EMTs or even Paramedics were on scene with a fire truck to administer first aid, but if that patient really needs transport to the ER, shouldn't the medical staff be on a vehicle with transport capabilities, rather than water spraying capabilities?
Looking forward to your thoughts. Obviously, my thoughts and views are a little UK/Euro/Australian centred (that's my background after all), but being in a different culture/country/system is a reason it is currently different, but not an excuse that nothing can or will change.
Looking forwards to your thoughts!
Regards,
Florian
http://medicsbk.com/2015/03/05/the-response-time-debate/