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A Bibliography on EMS in a State of Change

Most scientists agree that earthquakes are difficult to predict, but last Thursday should have been a “gimme” regardless of how the Supreme Court would have ruled.  Independent of your perspective on the ruling, we now know how health care reform will play out – at least until the next major shift changes the landscape again.  There are some fine articles that have looked specifically into the basics of U.S. healthcare, reform and the high court, or How Health Reform Could Hurt First Responders, even What the Supreme Court’s health care decision does—and does not—mean.  Also, hospitals are seeing the healthcare ruling as a new challenge and suggest that Federal Proposals Would Limit Aggressive Hospital Collections Practices.  So I have no intention to try to argue any of those contributing factors.  There are still many other factors affecting the future of emergency health care delivery that aren’t getting as much press attention even though their impact is at least as important.  Make no mistake, reform is coming to EMS!

Steve Whitehead at The EMT Spot blogged on the 7 Myths About Fixing Our EMS Systems.  It is a well-thought out article focusing on how to improve the system, but doesn’t approach the underlying causes.  From my perspective, one of the most important influences I see making an impact is politics.  In the article Ambulance debate rough road: Government could grow, it is clear that local politics specifically regarding government is driving too many decisions.  The Mayor of Columbus appears to be favoring a significant initial investment along with an annual subsidy to expand the local fire department rather than award a contract to one of the service providers claiming no subsidy would be required.  This also brings to mind the case in Utica, New York where the city sees an opportunity to actually generate municipal revenues through an ambulance service even though they could not certify a need as the Revised bill on ambulance plan still a bad policy opinion article suggests.  Which brings me to my second primary factor of money.  There are too many differences in how EMS is funded.  Unlike the fire and police department, which are so-called “free” services paid completely through your taxes, most EMS agenices charge for their services, going through your health insurance where they can.  Some operating costs are also covered by various combinations of property taxes, usage fees, or subscription fees without any consistency between jurisdictions.  There are many ongoing debates including this one by Letter: Emergency Medical Services In Great Neck.  But as long as there are such diverging funding schemes, (more…)

Posted in Administration & Leadership, Dispatch & Communications, EMS Dispatch, EMS Topics, News

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3 comments Posted by on July 6, 2012

HP-EMS Profile: Cetronia

Growth in both the industrial and residential populations has dramatically changed the Lehigh Valley of Pennsylvania since 1955 when the non-profit ambulance service, Cetronia Ambulance Corps, first began its all-volunteer BLS services.  In response to the communities need for an increase in public health and safety services, Cetronia has grown to include ALS service, 24-hour dispatch, and non-emergency medical transportation.  Additionally, Cetronia provides billing services, community outreach, education, special events coverage and special operations teams.  The diversity of their fleet allows the most appropriate level of service for the customer’s need from a doctor’s office visit to a critical care transport.  Cetronia continually strives to understand the medical needs of its communities and remains “Always Ready” to accommodate any pre-hospital emergency care and medical transportation needs.  This attitude of adaptation is not new to Cetronia, rather a continuing legacy of a truly innovative EMS system and a commitment to providing “Health on Wheels™” for its residents.

In recent years, Cetronia recognized the enormous challenges facing the EMS industry including severely diminished reimbursement rates.  Since EMS billing specialists must be ready to meet these ever-changing reimbursement and additional compliance issues with competency and expertise, Cetronia has maintained their own team of nationally certified ambulance coders who offer an exceptional blend of ambulance billing experience, knowledge, and customer service to ensure fiscal stability and the organization’s continued success.

The increasing demand for healthcare services which threatened their ability to maintain response times is another example of what motivates their mindset of continual improvement.  Choosing to be a  (more…)

Posted in Administration & Leadership, Dispatch & Communications, EMS Dispatch, Profiles, Technology & Communications

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5 comments Posted by on May 3, 2012

The Role of Response Time in EMS Performance

Several months ago Rob Lawrence of the Richmond Ambulance Authority started a thread on the High Performance EMS Group of LinkedIn by asking “So what does the phrase ‘High Performance EMS’ mean to you?”  This innocent sounding question sparked immediate debate even within the small group at that time.  Benjamin Podsiadlo of AMR quickly tied the quality of EMS performance to “experience” and “outcomes” stating further that “response time is not an evidence based factor in ALS performance.”  He later backed up his assertion by writing that “the catch 22 of pushing the workforce to be responsible and accountable drivers while simultaneously achieving narrow response time goals to the vast majority incidents that have no medical need for such high speed driving is also a bizarre and irresponsible contradiction.”  This is a point that even Lawrence admits could foster the “mentality of ‘arrive on time and the patient dies – good outcome, arrive late and the patient lives – bad outcome’” that has already been affecting common sense both in the UK and increasingly in the US since NFPA 1710 set response time standards several years ago.

While there were other good comments, I would like to focus on the specific assertion that measuring response time (a well established practice today such as at Huron Valley Ambulance’s public web Performance Dashboard) is not an “evidence-based” practice.  There are many specific accounts of individual lives saved that I have heard mentioned by different agencies, but I will concede that the plural of “anecdote” is not “data”.  However, one of the best stories of response time saving lives was made on February 9 when Richard Sposa of Jersey City Medical Center EMS discussed an interesting finding in a recent webcast.  The chart reproduced here shows a correlation between (more…)

Posted in Dispatch & Communications, EMS Dispatch, EMS Topics, Opinion, Rescues, Technology & Communications, Uncategorized, Vehicle Operation & Ambulances

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1 comment Posted by on February 21, 2012

Index of Suspicion Includes Me

It doesn’t take long in an EMT career before the excitement of “rushing to an emergency” turns in to “just another transport call.”  The philosophy of “you call, we haul” in nearly every service can break the community servant’s spirit by turning a skilled paramedic into just an ambulance driver.  But our system “just is what it is,” right?

Well, far from being a service based strictly on tradition, EMS is constantly challenging previous assumptions and struggling to reinvent itself.  How we administer CPR has changed (again), we question the effectiveness of C-spine immobilization that we do standard on nearly every trauma patient, or argue the very validity of the “Golden Hour” around which many services have been designed.  Almost all assumptions are open to be questioned.  I say “almost” because I have found that there still are some boundaries to the willingness of many EMS practitioners to consider change.  Some limitations are easily admitted, like the aversion to legal liability that means we transport anyone who asks us to do so regardless of their suspected need or ability to pay, but there are also less easily acknowledged sacred beliefs.

One of those that comes quickly to my mind is response time.  To many, a quick response indicates excessively fast driving and is contraindicated by safety concerns.  Besides that, we can justify ourselves since very few of our daily calls actually “require” a code response.  While that point may be strictly valid medically, I would argue that our performance is often measured by the public in the agonizing minutes between the 9-1-1 call and the ambulance arriving at the curb.  A patient does not need to be in some form of arrest in order for them, or their family members, to be distressed.  Part of our job is being a calming and supportive influence.  At the same time, I admit that it does not justify putting the driving public or ourselves at risk with an ambulance speeding to every call. But is it really a given that one means the other?

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Posted in Opinion

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No comments Posted by on December 6, 2011

The Cost of Saving Money

There are two fundamental ways to save money: either cut your budget and make do with less resources or invest in process efficiency to cut future expenses while continuing to provide at least the same level of service.  These are important considerations as the costs of doing business clearly continue to increase, whether we consider the expenditures on goods used in providing a service or the price of fuel used to deliver that service.  At the same time, the ability to effectively raise the price of the delivered service in order to recoup those additional expenditures is not typically possible.  This paradox leaves many ambulance services in a quandry.  If your decision is to continue operating at a diminshed capacity to reduce spending, there is probably little advice I can offer.  But if cutting service is not a prudent long-term option, then we can look at how an agency looks to improve performance.

A good case study may be the Lexington County (SC) EMS, a service directed by Brian Hood responding to roughly 30,000 calls per year.  As a growing county outside one of the largest cities in South Carolina, Lexington has seen their call volume grow at an annual rate of about 7.5%.  To keep pace with this growth in demand, they would likely have needed to add one new vehicle per year at a cost exceeding $3M for an ambulance, crew, station, equipment, etc.

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Posted in Case studies, ems

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2 comments Posted by on May 10, 2011

The Future of Prediction

I have read the positions stating that calls for emergency services are completely random (justifying the reason they are often called “accidents”) and therefore not able to be predicted.  But both academic literature and practical experience show that demand prediction can be an effective tool in helping to balance scarce resources (ambulances and their trained crews) with public demand (requests for emergency responses even without taking into account the abuses to the system as discussed in a previous posting on the problem of “frequent flyers”) while still improving response times and controlling costs.

For anyone who thinks all of this sounds too good to be true, there are examples of where expensive technology is not having the desired affect.  One such location is Lee County EMS in Florida where not only have response times not been improved, but ambulances are burning more fuel than ever and the critics include the very paramedics it is supposed to help.  While predicting where the next 911 call will come from may be similiar to ”picking the winning card at a casino” as the Florida investigative news reporter suggests, that isn’t really the objective.  We don’t need to know which phone will make the next call, it is enough just knowing the probability of a call coming from any given location within the service area.  This may be a subtle distinction, but one that makes a huge difference at MedStar in Fort Worth or Life EMS in Grand Rapids where response times were dramatically improved by taking the next step beyond simple demand prediction and placing ambulances at positions where they can be the most effective.

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Posted in ems, Technology

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1 comment Posted by on March 1, 2011