Ambulance Staffing in Fire-Based EMS

Ambulance Staffing in Fire-Based EMS

By Alan Perry

December 25, 2013

The growing sophistication of pre-hospital medical care is driving the use of better research and the adoption of evidence based measures for patient care. It also relies on high quality data, and a greater degree of consistency and teamwork from providers, perhaps pushing the limits of the conventional two-man Medic. It may be time to break this tradition and begin deploying EMS assets the same way Fire assets are deployed, with a clear crew structure that is only to be broken up in extreme circumstances. I'm talking about a Medic Company, a senior EMS provider as the company officer and a ALS/BLS crew of two. Fielding this type of unit is both practical and revolutionary, allowing the team to perform at a higher level and reducing the instances of deploying multiple additional assets to "assist" them. Instead of a medic being a dreaded shift assignment a crew/officer would be assigned to it providing the same continuity and familiarity with the apparatus that engine assignments currently enjoy exclusively (this is called ownership).

The advantages of having more than one provider in the back of an ambulance for an ALS transport should be obvious and indisputable. Yet I still encounter resistance to the practice among my co-workers. I work in a Fire-based EMS environment with EMT-staffed ambulances and ALS providers on the engine companies. Not all engine companies have 4-person staffing, and they are not all in close proximity to a hospital. There are two possible outcomes depending on the Company Officer’s attitudes toward EMS services.

A)  The Company Officer moves all of the paramedics gear to the ambulance, takes one provider off the medic and moves his/her gear to the engine, the ALS provider rides the call in alone with the EMT driver. The engine company returns to service BLS, Once the patient is turned over and the unit is restocked the provider is brought back to his/her station, transfers their gear and returns to the engine.

B) Depending on the staffing level and proximity to the hospital; the Company Officer does not re-arrange personnel or gear, leaves an additional provider on the medic to assist with the "ALS" patient, follows the medic to the hospital remaining on the call, or goes out of service until the ALS provider is returned to the station.

These two options represent the cultural divide in thinking in an organization that puts Fire Protection above Patient Care. To better illustrate all of the variables let me break it down into Pros and Cons with a couple of stipulated facts:

*ALS patients are by definition more likely to need multiple and/or invasive procedures to assess, monitor and treat.

*The ability to record timely and accurate information aids in treatment. improves the accuracy of documentation and usable data collection.

     * One person cannot reliably perform multiple interventions, assessment, documentation and communications in a <15 minute transport.

To put this in its proper perspective we have to acknowledge that we are primarily an EMS service that provides Fire and Rescue services as well. We document the value of the property we save but rarely consider the value of the lives we impact. This may eventually change, like our ways of thinking.  let’s do what is best for the patient.

Thanks,

Alan

"I Hate EMS"

"I Hate EMS"

By Alan Perry
August 6, 2013

I walk into a station and overhear the Officer say “I hate EMS” at the dining room table in front of both the oncoming and off going personnel. It is an attitude I know is well rooted in some fire services, but it is not always so audible. In many tradition-bound fire departments that still think its primary mission is putting out fires, the decisions that are made with regard to personnel and monetary resources frequently bear that out. This of course affects everyone’s attitude toward any activity that is related to providing EMS to the community. From the new recruits first day in the station, and probably much earlier, these unofficial messages are sent and received, having their intended or unintended effect. It is not surprising that the EMS equipment in stations where these attitudes are the strongest are often in the worst state of readiness, would it be any less surprising to find the standard of medical care and customer service also lacking? Such statements and attitudes may appear harmless, delivered in a humorous tone, but they are indicative of a problem.

What can we do? we could just ignore it and be happy that we have a job (which I am), not rock the boat and just play out our careers dealing with whatever we are asked to do without question, which is apparently what all of my contemporaries have decided to do. You see everyone can see the same problem I see, they seem to have come to terms with it and simply accept it as the way things are. Perhaps I am looking at it wrong (again), the officer’s expression of dislike does not come from his dislike of providing this service to the public, and it is more a dislike for the way in which it is delivered. As I stated earlier these departments are tradition-bound and very slow to react to changes. They have not kept pace with current effective practices, management and training in EMS operations. I fear this is likely the case in most fire departments that provide EMS transport service. For the fire service to remain effective at providing EMS services we will have to change our attitudes and methods beginning at the top.

If you were to ask, or simply listen to the grumbling, you would find that there are at least two common problems. The first is public education; providers frequently encounter patients who do not know what an appropriate use for a 911 ambulance is, and are unaware or have no other options for care. The second are inefficient paperwork requirements; providers are frequently dealt substandard and/or outdated data collection tools and software, the least expensive option is often purchased, something that would not occur if buying a fire truck. Add long hours and inefficient staffing models to the mix and you can see why the frustration is there. All of these circumstances can be resolved by reallocation of resources and the acknowledgment that EMS is the primary service provided by the fire service today. So why not fix it? Create a first-rate EMS public education program that mirrors the fire prevention side of the house to educate, inform and involve the public in your EMS services. Purchase equipment and software that makes data collection easy and efficient, is the newest version available and will be upgraded regularly. There is absolutely no reason the same data should ever have to be entered twice. Provide GPS or good quality maps, the days of hand drawn maps are long gone.

For our EMS systems to perform and have providers who truly enjoy their work we should consider demonstrating commitment to making the system the best one possible. Aside from the obvious morale implications, and improved operational efficiencies, fire administrations must consider the ramifications of the Patient Protection and Affordable Care act (Obamacare). This legislation will begin exerting force on healthcare and transport organizations, Medicare, and insurers to reduce healthcare cost by providing more appropriate and cost effective care. This should end the era of everyone going to the ER whether they need it or not, and provide a means to bill for other more appropriate treatment and transport. Failing to recognize a problem such as poor attitudes or sweeping EMS system changes in the pipeline will spell disaster for the organization, and ironically hating EMS won’t be an option anymore because we won’t be doing it.

Making some of these changes and showing commitment to the idea of a first rate EMS system will go a long way toward changing the negative culture surrounding EMS in the fire service. Positive attitudes flow from the top down, I realize many senior officers are late in their careers; many senior firefighters are similarly excluded from having to provide EMS and have lost touch with it. The fact remains that EMS is still the predominate service offered by fire departments that provide it, therefore participation and embracing of the EMS mission is no longer an option, it should not be the reluctant burden as it is currently portrayed. Of course not every system, officer, or administration has this problem, many have already overcome it, but for those that still have this issue the time is getting short.

Be Safe,

Our Western Brethren

Commonalities of the approach to EMS by our western brethren

Bend Fire & Rescue

By Alan Perry

Where I got my information

I have visited Bend, Oregon on several occasions and found it to be a beautiful community with many natural resources, a pleasant climate and breathtaking vistas. In short a community I would love to live in. I came across the Bend Fire & Rescue Deployment Plan for 2011-2013 while perusing the department’s web site. It is a comprehensive and detailed document available to the public prepared with the help of ICMA data, and the department’s historical data to determine their compliance with NFPA 1710 . It is a document used by the state government to assist departments with identifying their circumstances and creating plans to help them remain viable.

About Bend Fire & Rescue

Bend Fire and Rescue serves a population of approximately 100,000 in an area of 165 square miles much of which is sparsely populated. The City of Bend has a population of 77,000. The annual call volume is around 8000 with 82% of calls being EMS in nature. Their staffing consists of 88 career personnel, 4 part-time and 5 volunteers. The chain of command contains a Chief several Deputy Chiefs including the Deputy Chief of EMS, a Battalion Chief for each of the three shifts, a Captain for each of the five stations on each shift, 6 engineers per shift and 6 ff/medics per shift. The department uses a flexible staffing model were engines and ambulances are at each station, and staffed based on the nature of the call. All-in-all, a very lean operation.

About us

Fire Departments in Southeastern Virginia tend to follow the old school east coast fire service model. It is a well-tested institution known for a strong and rigid structure which does a good job of protecting lives and assets and the jobs of firefighters. We have enjoyed both public and political support, supporting well-staffed  and well-equipped career departments in most major cities. The approach to providing EMS service is widely variable ranging from only providing a first response to being a primary EMS transport provider. In this mix there are also widely varying degrees of support for the EMS mission ranging from treating it as a necessary evil in order to maintain public support and funding, to embracing it, making innovative changes that are needed and addressing public education in EMS.

Common threads to our approaches to EMS

The most common thread among fire departments that have taken on EMS as part of their service mix is the high percentage of our total calls that are EMS in nature. Of equal importance and contrast is that most firefighters do not enter this career with the primary desire to transport the ill and injured on an ambulance. Culturally I think this is a common thread among fire-based EMS systems, one that creates the climate for poor attitudes when making decisions and long-term plans for these systems.

Where we differ

A few highlights of the Bend Fire & Rescue program jumped out at me as being very proactive and engaged in improving the quality of their EMS system; They conduct monthly EMS case reviews with their two physician advisors to include patient outcomes. EMS protocols are updated annually, A service survey is sent out for every 15 EMS calls, They have an EMS public education program even though it is limited to senior communities only at this time. The concept of flex staffing maximizes the effectiveness of a small staff allowing a smaller group of responders to handle a variety of calls whether EMS or fire. Despite the staffing limitations the department has an average response time within the city of 7:33. They have a dedicated training staff and a training facility.

How can Fire-based EMS improve

Bend Fire & Rescue appears to be doing well with the resources they have available but are clearly pushed to the limit in their current circumstances. Like many other departments they are having difficulty with being fully forthcoming about the nature of the fire services relationship with providing EMS. The financial data conveniently lumps both fire and EMS operations costs under one heading and does the same with revenue, this approach could be considered an attempt to minimize the higher operating costs for fire services and the revenue produced from the EMS activities. Being open and honest about these circumstances will better allow the management and the public to make good decisions. Their portrayal is not unique, it is a common tactic used in the fire service. We in the fire service, as public servants, should be more honest with the public and ourselves, the lack of clarity will affect our integrity ultimately. Fire-based EMS systems must look at our perception of EMS and be certain that we are embracing it, constantly looking for ways to improve upon it, and deliver the service as effectively and efficiently as possible.

Link to Bend Fire & Rescue Deployment Plan

http://www.bendoregon.gov/Modules/ShowDocument.aspx?documentID=6919

How are we going to save EMS?

Systemic Organizational Improvement

 for

Volunteer and Combination Rescue Squads

and other EMS organizations.

OR

How are we going to save EMS?

By Alan Perry

AAS, BS, NREMT-P
5/8/2013

Introduction

The world economy has changed dramatically over the last decade. There is increasing demand for more businesslike performance from government and public safety organizations. With this comes increasing competition for human and monetary resources. The challenges facing Emergency Medical Services (EMS) systems where identified by the National Highway Traffic Safety Administration (NHTSA) 16 years ago and have not been acted on by most organizations since then. The combination of these factors now threatens the existence of volunteer organizations that are unwilling or unable to adapt.

As an industry, the provision of EMS has become very competitive. Volunteer and publicly operated EMS agencies must prove their ability to provide the best care possible for the lowest cost to the taxpayers, and insurers, if they are to survive. This paper explores many common business practices, and recommendations of the EMS agenda for the future, which provide a starting point for organization self-evaluation and action. The goal is to inform, educate, and guide management in the process of identifying opportunities, and taking both general and specific action that will improve the efficiency and effectiveness of their organization. Achieving this goal will give the organization the tools to facilitate not just survival, but some measurable success.

This will not be a rehash of business school or a review of the EMS agenda for the future. Readers are encouraged to understand both of these for their own benefit. This is down and dirty problem solving, and fixing that which is broken.

Getting in the right frame of mind

Be honest.

This is a critical “must have”, if you and your staff cannot be honest about the organization and the environment it operates in, you will miss key opportunities and blind the organization as it heads along a perilous route.

Be objective.

Base your assertions and actions on fact; emotion has no place in effective decision making. Tradition also has little value in this arena, and is often used as justification for neglecting leadership.

Who is your customer?

I would argue that your customers fall into several categories; the general public, your workforce, other agencies and facilities you work with and state/local government. Your best chance at success is making them all happy with your service. Not an easy task.

What does the customer need?

Careful here, what they need may not be what you currently provide. Here again you must include all of your customers, internal and external. This is a good place to be innovative.

What does the customer expect every day and during emergencies?

Think of the full range of possibilities here, from public education programs, bread & butter calls, major disasters including extended events, and the Saturday afternoon cookouts. The organization should be more than just a service provider; it should be a center of community activity.

Define the mission of the organization.

Analyze the mission statement. Does your mission statement truly reflect the goals of the organization and the needs of your customers? This basic statement defines the attitude and relationship of the organization to the public it serves. Keep it simple.

Define the mission of public service in general.

Think generally of the tenants of public service, not the stereotype, more like Moses, Jesus or the Buddha. This is for your own personal reflection and to center your thought process on what is not only right, but also righteous.

Where to start?

The opportunities you know (or think you know).

These are the opportunities you and your staff are already aware of. These need to be examined objectively to determine if they are what they seem to be. Be careful to identify the cause, not the symptom.

The opportunities you know, but won’t repeat.

The suspicions and inconvenient truths present in every organization. Failure to recognize and address these will poison any effort at overall improvement. There can be no “sacred cows” in an honest evaluation.

The opportunities others see.

The view from outside is frequently more telling than from within. The organization should seek objective feedback from customers, workers, affiliate and competitive public safety organizations, and local government to produce a comprehensive source of improvement possibilities. You cannot adequately effect change without a comprehensive view of the circumstances and public image.

Collect the data

When an opportunity is identified look for data to support and quantify it. This is critically important, without quantified data no measurement can be made and no benchmark can be established. All data is good since it enables management to determine what works and what does not.

Where to look

Areas for organizational improvement (not exclusive)

Human Resources

o   Recruitment- Are your recruitment methods producing adequate numbers of qualified and motivated candidates? Are you attracting the right people?

o   Training- Does your training program meet the needs of the provider and the state? Does it support advancement and transition to higher levels of EMS care and/or organization management?

o   Advancement- Are their sufficient opportunities for members to advance or take on additional responsibilities if they desire to do so?

o   Retention- Are new members mentored and retained by the organization? Are exit surveys conducted?

o   Incentives- Are any incentives offered to offset the expenses and time involved with volunteer service?

Physical resources

o   Physical plant- Is your building adequate for your equipment, well maintained and comfortable for your crews? Is the physical appearance good?

o   Rolling stock- Are your vehicles appropriate and well maintained? Are they reliable, clean and comfortable for your crews and clients?  Do you have reserves?

o   Durable equipment- Does your equipment meet current standards of care? Is it in good condition and reliable? Do you have back-ups?

o   Soft goods inventory- Does your inventory meet current standards of care? Are items ordered and stocked in sufficient quantity to obtain meaningful discounts and prevent depletion?

Finances

o   Fund raising- Are there a variety of fund raising options for members and the general public? Are donations/proceeds adequate to support operations?

o   Revenue recovery- what percentage of calls produce revenue? Are all billing options pursued? Does the public understand why it is needed?

o   Fixed costs- How do these cost compare to industry averages? Any room for improvement? Any potential changes +/-?

o   Operating costs- Are maintenance and other costs in line with industry averages? Are vehicle maintenance costs excessive?

o   Investments- Are surplus funds adequately invested? Are investment vehicles appropriate?

Community relations

o   Citizen advisory panel- Is there an advisory panel? Is it a cross-section of the community? What are their concerns and recommendations?

o   Public education- Is there an EMS public education program? Community first aid or CPR? Regular community events, health & wellness fairs?

o   Emergency preparedness- Does the organization participate in community preparedness? Does the organization have a plan for extended emergencies & disasters? Are multi-agency drills conducted?

o   Public perception of the organization, if cultivated, will drive your recruiting efforts, fundraising, and create broad political support.

Government, Allied health organizations

o   Fire services- what is the relationship with the city and county fire service? Is a representative from these organizations involved with the advisory board? What are there stated positions and goals in the provision of EMS? Do fire and EMS agencies train together or participate in joint social events? Are conflicting goals challenged?

o   Emergency management- What involvement does the organization have with the county emergency management office? Is it directly involved in planning?

o   Other EMS services- What relationship exists with other EMS agencies locally? Is there any collaboration in purchasing, planning or training? Are any viewed as competitors? Are they united in the political arena?

o   County/State stakeholders- Are there concerns with the county or state agencies? Do either have any input in the decision and planning process?

o   Referring facilities- Is there a liaison officer to monitor and guide relations with referring healthcare facilities? Are there any recurring issues or opportunities for improvement of relations?

o   Hospitals- Is there a liaison officer to monitor and address concerns from receiving facilities? Is the OMD involved? Are there any recurring issues or opportunities for improved relations?

o   Public health- Does public health take an active role in Prehospital events? Is there a desire to see more integration between EMS and public health activities? Is there any interest in a community paramedicine program?

o   Social services/mental health- Is there a referral process in place for citizens requiring social services and/or mental health services? Is there an interest in cultivating this alliance?

Make your list

Be inclusive.

List all opportunities without prejudice. Determine which present the greatest threat or benefit to the organization. Be careful not to be biased in the process, it may be helpful to have an objective third party organization help in this process.

Priorities

Setting priorities requires some thought based on the severity of the problem, available resources, and political challenges. Usually you will want to deal with the most severe or easiest to complete ones first.

Resources

In the current economic climate your only resources may be those you already possess. Do not be afraid to redistribute assets to achieve a goal. Do not be afraid to ask for additional resources if you have the data and a plan to support it. Your resources include people, money, equipment, facilities, political capital and the community.

Politics

In this business some politicking is required. Internal politics, fire/ems politics, county politics and state politics can affect the ability of the organization to improve its performance. It’s not always a bad thing, but usually is. Politicians of all stripes respond well to facts, with facts they will have an easier time promoting a good decision to their constituency.

Can everybody win?

There does not have to be a loser, everybody can win if careful, responsible and unbiased decisions are made for the benefit of the public. Avoid being the aggressor if conflict arises, facts and a cool head will prevail.

Set goals that are measurable and obtainable.

Realistic goals are important, most people like being able to see progress being made, and in doing so become further encouraged and inspired.

Communicate

Publish goals, timelines and results. Keeping everyone informed and involved will keep your team and the community together in the process. Remember that in the absence of facts, rumors will abound.

Conclusion

Many opportunities exist for system and agency improvement by just asking a few questions, first of one’s self, and then of the organization and the environment it operates in. I encourage you to dedicate the time for yourself and your organization to explore these issues and solidify your position within the community you serve.

Volunteer EMS is a valuable resource in every community they serve. It has come under fire from for-profit EMS agencies, and the fire service more frequently in the current economic climate for purely economic reasons. These entities will take advantage of weakness in the volunteer system to secure more paid positions and private transports, in the process stripping the volunteer organizations of the resources they need to survive.

Our best defense in these circumstances is a good offense. We must educate the public and administrators about our value to the community, and daily impress them with our performance and dedication to the community and our citizens.