Fire-Based EMS:
Avoiding a Future Flashover
Mike McEvoy, PhD, NRP, RN, CCRN
EMS Coordinator – Saratoga County, NY
EMS Editor – Fire Engineering magazine
www.mikemcevoy.com
Disclosures
• None
• I don’t know how to play golf or ski
www.mikemcevoy.com
Author EMS
Chapter –
7th Edition
to publish in
2012
Outline
•
•
•
•
•
•
•
EMS overview and demographics
Past, present and future predictions
Fire Chief
EMS Chief
Key Issues
Imperatives
Summary
EMS In the U.S.
Ambulance services = 15,726
EMS Agencies = 19,971
–
–
–
–
93% take 911 calls
65% transport capable
28% non-transporting
4% SCT:
• 2% air medical
• 2% ground based
Ambulances = 48,384 – 54,598 excluding air
Annual 911 calls = 200 million, 50% are EMS
Fire Departments delivering EMS = 81%
AAA, IAFF, NENA data sets
EMS Providers – U.S. 2011
Annual # Students:
EMT = 120,000-150,000
Medic = 25,000-30,000
NASEMSO 2011 EMS Industry Snapshot
EMS Vehicles – U.S. 2011
EMS Organizational Types
NASEMSO 2011 EMS Industry Snapshot
EMS Provider Age Distribution
NASEMSO 2011 EMS Industry Snapshot
EMS Past, Present and Future
• 1958 – MTM
• 1960 – CPR
• 1966 – NAS white paper  DOT/NHTSA
(Accidental Death and Disability: the Neglected Disease of Modern Society)
– States required to establish EMS Regional Systems
– Training curriculum developed
• 1969 – EMT-A
• 1970’s – Systems, residencies, AHA
• 1984 – EMSC
EMS Past, Present and Future
• 1910 – First air ambulance built NC, tested in FL
– flew 400 yards and crashed
• 1926 – Phoenix FD, others - “inhalator” calls
• 1940’s – WWII hospital personnel shortages
turned ambulances over to FDs
• 1960 – LAFD adopts EMS
• 1969 – Miami FD first
medics, Seattle Medic 1
debuts
• 1971 – Emergency!
EMS Past, Present and Future
•
•
•
•
1973 – Denver Flight for Life, DOT Star
1978 – Phoenix FD Medic Engines
1979 – JEMS, AAA
1981 – Block grants, EMD debuts in SLC
– 73% FDs are providing some level of EMS
•
•
•
•
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1986 – COBRA
1992 – AMR on NYSE
1995 – LAFD Paramedic Engines
1996 – FDNY absorbs NYC*EMS
1997 – SF and Chicago Paramedic Engines
EMS Today
• Complex, lacking standardization
• Poorly reimbursed, serious $ issues
• Many service delivery models
– No single model universally appropriate
• Often a default gateway to healthcare
• Requires increasing expertise/training
– Administrators, providers, physicians
• Highly Competitive
EMS Trends: 2011
State EMS Directors Report:
• EMS Regionalization  = 25%
• Pure volunteer EMS converting to mixed
paid/volunteer = 76%
National Market Observations:
• Major consolidations, sales, buyouts
– 2010, Falck (Danish equity firm) buys Care (CA) and LifeStar
(East Coast)
– Feb 2011, EMSC parent of AMR bought by equity firm
Clayton, Dubilier & Rice (CD&R)
– June 2011, Rural Metro bought by equity firm Warburg
Pincus, LLC
www.falck.com
Danish firm: prevention, response, recovery
• Major EMS Provider: Denmark, Poland, Sweden, Belgium,
Finland, Norway, Slovakia
• Fire Service Provider: Denmark, Brazil, Netherlands, Romania,
Slovakia, Sweden, UK
• Plans for southern Europe, South America and Mexico.
• 2008: bought Alford, expanding training into US (Houma, LA)
Why Big Equity Investors?
Expected EMS Demand
80 calls per 1,000 population (currently)
– High 114
– Low 70
Show Me the Money
Levine D & Graybow M. The Battle Over 911. Reuters. April 15, 2011
Specialty Care Transport
• SCT (interfacility) =
more $
• Significantly better
collection %
• Opportunity?
EMSC Sale – February 2011
Levine D & Graybow M. The Battle Over 911. Reuters. April 15, 2011
Rural Metro Sale – June 2011
Levine D & Graybow M. The Battle Over 911. Reuters. April 15, 2011
Fire-Based EMS Today
• Despite significant
EMS role, Fire has
failed to position
itself as a key EMS
player on federal,
state, local and
international levels
If Fire Were a Key Player
Drug companies
would market to us:
2 Biggest EMS
Challenges for Chiefs:
1. Embracing the EMS mission
2. Competing in the marketplace
Fire and EMS Clashes
Major cultural differences:
1.Response Paradigm
2.Customer Base
Response Paradigm
Fire
• Rapidly escalating
incidents
• Success requires well
coordinated attack
• Large numbers of
firefighters needed
• Emphasis on teamwork
• Failure is blamed on team
EMS
• Incident size fixed, rarely
grows after dispatch
• Success requires training
and preparation
• One provider needed for
most responses
• Emphasis on individual
• Failure blamed on
individual provider
Customer Base
Fire
• Protect property
• Property owned by higher
socio-economic classes
(jobs, money, resources)
EMS
• Protect people
• Typical EMS user profile
fits lower socio-economic
sector of society
How Do We Embrace
the EMS Mission?
• Cultural
– Promote the real job
– Hire people who want to do the job
– Support, promote and reward performance
• Integrate EMS into FD mission
Fire
Dinosaurs:
Maybe
they’ll die
off?
“The picture’s pretty bleak, gentlemen. The
world’s climates are changing, the paramedics
are taking over, and we all have a brain about
the size of a walnut.”
Recruiting & Hiring
What percentage of your calls are EMS?
How about your name/patch/uniform?
Job Posting
Class Specification: FIRE FIGHTER
ITEM NUMBER: 0199
APPROVAL DATE: 05/09/2001
DEFINITION: Performs fire fighting and rescue duties in all types of fires
and in other emergency situations, and enforces Fire Prevention Codes.
CLASSIFICATION STANDARDS: Positions allocable to this class receive
technical and administrative supervision from Fire Captains and perform a full
range of fire fighting and related duties on an assigned shift. These positions must
respond immediately at any hour of the day or night, in any weather, to combat
life or property threatening emergencies. Incumbents typically work under
hazardous conditions, such as those that involve exposure to fire and smoke. All
positions in this class require the physical stamina to perform such strenuous
activities as ascending or descending ladders while carrying victims or equipment
in order to effect rescues, as well as the ability to manipulate equipment, such as
fire hoses, power tools and hand tools. Incumbents must exercise working
knowledge of fire fighting principles and techniques, the Fire Prevention Code,
Emergency Medical Technician (EMT) principles and techniques, and the proper
use of fire fighting and EMT tools and equipment.
Performance Evaluation
TODAY’S FIRE DEPARTMENT
PERFORMANCE EVALUATION REPORT
EMPLOYEE NAME
EMPLOYEE NUMBER
ITEM NUMBER
STATUS
FROM:
POSITION
DEPT.
SUB
OUTSTANDING
RATE
VERY GOOD
COMPETENT
EACH
FACTOR IMPROVEMENT NEEDED
UNSATISFACTORY
CHECK ITEMS:
+STRONG
vSTANDARD
- WEAK
STATION WORK
 Observance of Working Hours
 Cooperation – Teamwork
 Maintenance of Quarters
 Maintenance of Emergency and Medical Equipment
 Observance of Safety Procedures
 Maintenance of Emergency and Medical Reports and Records
DRILLS
 Knowledge of Basic Drills
 Application of Standard Technique
 Care and Use of Tools and Appliances
 Participation
 Cooperation – Teamwork
 Observance of Safety Principles
 Knowledge of Automotive Equipment
DATE
TO:
RATING PERIOD
COMMENTS
Describe employee’s strengths and weaknesses. Give examples of
work well done and plans for improving performance. Factor ratings of
UNSATISFACTORY, IMPROVEMENT NEEDED or OUTSTANDING
must be substantiated by comments (use separate page if needed.)
Performance Evaluation
EMS OPERATIONS
 Application of Pt Care Guidelines, Prehospital Policy/Proc.
 Application and Use of EMS Equipment
 Recognition of ‘Patient’s Best Interest’
 Cooperation – Teamwork
 Observance of Medical Safety Procedures (BSI, Scene Safety)
 Readily Assumes EMS Roles and Responsibilities
 Professional/Courteous/Friendly (Patients, Bystanders, other
Health Care Professionals)
EMERGENCY OPERATIONS (General)
 Adjustment to Situation
 Response to Orders
 Application of Standard Techniques
 Cooperation – Teamwork
 Observance of Safety Procedures
FIRE PREVENTION
 Application of Codes
 Thoroughness of Inspection
 Preparation of Reports
 Public Education
 Follow-up of Inspections
PUBLIC RELATIONS
 Personal Appearance
 Meeting and Handling the Public
 General Conduct
SUPERVISORY ABILITY
 Planning and Assigning
 Training and Instructing
 Disciplinary Control
 Evaluating Performance
 Leadership
 Decision Making
 Approachability
 Knowledge of Required Prehospital Care Policies/Procedures
 Effective EMS Scene Management
BIOGRAPHICAL CHANGE?
 YES
 NO
BADGE NUMBER
_______________________
AUTO INSURANCE?
 YES
DRIVER LICENSE NUMBER
_______________________
EXPIRATION DATE
_______________________
 NO
SIGNATURES
This report is based on my observation and/or knowledge. It
represents my best judgment of the employee’s performance.
RATER__________________________________________________ DATE___________________
I have reviewed this report.
REVIEWER_______________________________________________ DATE___________________
I concur with and approve this report.
DEPT. HEAD______________________________________________ DATE___________________
Copy of report  given to employee
 mailed
DATE___________________
Report discussed with employee:
LOCATION_______________________________________________ DATE____________________
BY______________________________________________________________________________
EMPLOYEE SIGNATURE_______________________________________________________________
OVERALL EVALUATION
UNSATISFACTORY
IMPROVEMENT
NEEDED
COMPETENT
VERY GOOD
OUTSTANDING
FD Embracing EMS
• Is every department vehicle equipped to
respond to a medical call?
• Do your prevention staff provide injury
prevention, first aid/CPR classes, health
prevention services and inspections?
• Are fire crews attuned to EMS and
safety hazards in the community?
Embracing the EMS Mission
1. Definitely cultural, requires introspection
2. Establish a vision and defined behaviors
Target: Effectively Competing
Performance targets for success:
1. Price
2. Quality
3. Customer Service
You cannot do this
alone!
Pricing Fire-Based EMS
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Fire personnel tend to cost more
Is there added value?
Can you prove it?
What efficiencies are accessible?
Survival By the Numbers
USA Today
March 1, 2005
Examined 12 US
cities with highest
OOH cardiac arrest
survival rates
compared to #
medics per capita.
Often, cities with
least number of
medics had highest
survival rates.
Survival
Rate
Medic Ratio
Per 10,0000
Seattle
45%
1.48
Boston
40%
0.86
Oklahoma City
27%
3.44
Tulsa
26%
2.95
San Francisco
22%
3.83
Houston
21%
1.40
Kansas City
20%
3.12
Omaha
16%
4.70
Tucson
12%
3.15
San Antonio
9%
2.82
Nashville
8%
3.33
Los Angeles
6%
1.55
City
Market Shares
Levine D & Graybow M. The Battle Over 911. Reuters. April 15, 2011
Differentiating Fire-Based EMS
• All hazards capability
– Operate in hazardous environments while
simultaneously providing patient care
– Others unable, untrained, unequipped
How is the Fire Reputation?
• Not perceived as good
quality
• 50 largest US cities study
• Chute time 42 seconds
longer for cardiac arrest
vs. structure fire
• Firefighters unhappy, “they
signed on to fight fires, not
tend to sick people.”
Six Minutes to Live or Die. USA Today. May 20, 2005
EMS is Complicated
• Community
• Regulators and Government
– Patients and families
– Citizens
– Businesses
• Health Care
– Hospitals
– Doctors offices, nursing
homes, clinics
– Public Health Departments
• Medical Control
• Insurers
• Legal system
– Attorneys
– Courts
– Federal
– State
– Local
Who is Mrs. Smith in EMS?
• Patients, families, friends, partners
• Other EMS services
• Community members, neighbors
• Physicians, nurses, hospitals
We need to be at decision making tables!
Who Really Runs EMS?
DOT
NAEMSP
NREMT
EMS Officer
• Duties of administering a fire-based EMS
program must be delegated to a qualified
EMS officer
• Good EMS provider ≠ good officer
• Same management skills as fire officers
• Minimum skills = department skill level
– If routine fire suppression interface, also
competent in fire suppression (credibility need)
• Qualifications match peers (local level)
• College degree helpful (hospital interface)
EMS Officer Skill Set
1. Strategic Planning
–
–
–
Identifiable measures
Benchmark locally and nationally
Budgeting and financial projections
2. Customer Service and Marketing
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–
–
Follow up customers unmet needs, resolve
complaints, obtain feedback to improve service
Improve satisfaction (i.e., scripting)
Community outreach: chronic problems and
safety issues
EMS Officer Skill Set
3. Human Resources
–
–
–
Much more intensive hiring/orientation process
Medical clearance, vaccinations
Ongoing training, medical surveillance
4. Continuing Education
–
Medical competencies
5. Financial
–
–
–
Medical billing, CMS
Costing, budgeting
Grants
EMS Officer Skill Set
6. Fleet Management
–
–
EMS apparatus lags behind fire
Medical liability mandates special procedures
7. Incident Management
–
–
Demonstrated experience running mass
incidents, mass gatherings, drills
COOP (Continuity of Operations Plans)
8. Interagency Operations
–
–
Routine mutual aid linkages
Ties to state and federal EMS MA plans
EMS Officer Skill Set
9. RMS/EMR and HIPAA
–
–
Broad familiarity including reporting,
customization
Research track record
10. Communications
–
–
Working knowledge of EMD and EMD QI
Experience with alerting, recall and
electronic/social networking technologies
11. Risk Management
–
Thorough knowledge of risk mitigation
EMS Practice is Delegated
• Practice of medicine restricted by law
• No EMS provider is a lone ranger
– All care delivered under the license and
supervision of a physician medical director
– Every provider must be affiliated with an
EMS agency
– Every agency must have
a medical director
Medical Control
• What is Medical Control?
– Physician direction/oversight
“establish and maintain guidelines for care”
•
•
•
•
•
OLMC
Off-line (protocols, standing orders)
Credentialing
Education
QI, interface
– Physician responsibility/accountability
– Physician LIABILITY
Doctor Who?
• 2006 Assessment of docs employed in
EMS for knowledge of BLS, ALS, and
medicolegal duties.
• Average score 45.4%
- Kimaz S, et al. Ulus Travma Acil Cerrahi Derg. 2006
Jan;12:59-67. (Translated from Turkish).
Physician Medical Director
• Compensated
– Local doc
– Contracted service (ED or EM group)
• Clear job description
• Represent department
at local, regional,
state levels
• Close relationship with Fire
and EMS Chiefs
Lawsuits
1 in every 20,000 patient encounters
results in a lawsuit
-Wolfberg D. Emerg Med Svces. 2005 Jan;34:42-43.
-Garza MA. JEMS. 2000 Feb;25:20-21.
EMS Closed Claims Analysis
• Preliminary data: 275 cases
• 40% patient handling
– half were stretcher drops and tips
• 31% emergency vehicle movement or
collision
• 11% medical management
• 8% EMS response or transport
• 4% lack or failure of equipment
• 9% other
Wang HE, Fairbanks RJ, Shah MN, Yealy DM. Tort Claims from Adverse Events in
Emergency Medical Services. Prehospital Emergency Care. 2008; 52(3):256-262.
Boiling Hot Water
1. Patient handling (40%)
– Stretchers, stair chairs, backboards
2. Driving (31%)
3. Medical care (15%)
Show me the money
Largest settlements  Patient Care
AIRWAY
1. Missed esophageal intubation
2. Hypoxic brain injury
• Failure to manage airway
• Failed ETI*
• Prolonged ETI efforts
*25% misplaced, 2/3 esophageal
Source: ESIP, 2011
EMS Liability
• Medical Mgmt. (9%)
• MVA (51%)
– EV Collision
– EV Movement
• Patient Handling (28%)
–
–
–
–
Drops 35%
Tips 30%
Movement 20%
Falls 15%
–
–
–
–
Airway 41%
Procedural 25%
Assessment/Decision 19%
Adverse Drug Event 12%
• Response/Transport (5%)
– Transport Error 52%
– Response Error 44%
– Patient Security 4%
• Equipment (4%)
– Lack of
– Failure of
ESIP (Emergency Services Insurance Program) data, 2011
NHTSA Ambulance Crash Data
Total Crashes
= 4,745
Driver
Passenger
OMV
Pedestrian
Killed
= 31
0
Injured
= 3,351
759
8
21
2
671
1,921
2008 Study Departments with EMD:
• 25% fewer crashes
• 39.6% less severe
Medical Management (9%)
• Procedural 25%
– Delayed SCI recognition/treatment
– Improper fx immobilization
– Failure to follow protocol
• Assessment/Decision 19%
– Failure to transport
– Improper method of moving patient
– Failure to treat
• Adverse Drug Event 12%
– Wrong route
– Wrong dose
– Narcotic given without order
Response/Transport (5%)
• Transport Errors 52%
– Failure to transport
– Transport to wrong or inappropriate facility
• Response Errors 44%
– Failure to dispatch
– Navigational (got lost)
– Slow/delayed response
– NPF (No Patient Found)
• Patient Security 4%
– Failure to secure (fell, stood, jumped out…)
Equipment (4%)
• Lack of equipment
– Left equipment on scene
– Failed to bring equipment to patient
– No oxygen
– Missing ambulance keys
• Equipment failure
– Dead defibrillator batteries
– Defib malfunction
– Suction malfunction
Response Times
• Are there really standards?
“Arrive 90% of time before 8:59”
• Fractal
• Fitch & Associates use 8:59 – 12:59 as
typical norm for US systems
• Rural and wilderness areas may be as
long as 15/90 to 30/90
• Most recent evidence suggests NO
association between times & outcomes
Domino’s Pizza
1973: guaranteed delivery in 30 min or pizza was free
• 1992: $2.8 million settlement to family of Indiana
woman killed by speeding Domino’s driver
• 1993: $15 million paid to St. Louis woman injured
when struck by a Domino’s driver who ran a red light
Guarantee dropped because of, “public perception of
reckless driving and irresponsibility.”
Response Times
•
Standards are set by the community:
– Authority having jurisdiction over EMS
– Patient perspective
• Role of the Chief:
1. Measure response times
2. Strive to match supply to demand
3. Be aware of unit hour utilization
4. Know community expectations
Time Troubles
• Is time important?
• “Golden Hour”
conceived by
Maryland Shock
Trauma Center
• No evidence basis in
repeated studies
Newgard CD, et al. Emergency Medical Services
Intervals and Survival in Trauma: Assessment of the
“Golden Hour” in a North American Prospective
Cohort. Ann Emer Med. 2010; 55(3): 235-260
Does Time Ever Matter?
• Are there time critical trauma patients?
• First rule of hemorrhage control =
Find the leak (you cannot control what
you cannot see)
• Shock without evident
bleeding requires
“Cold hard steel”
So, What Stats Do I Need?
Basic Data Set
–
–
–
–
Dispatches
Transports
Hour and day distribution
Response times by zone/area/neighborhood
Times
– Call processing intervals
– Reflex performance (chute/scramble time)
– UHU (xpt-disp-adjusted)*
*used only to determine 24/12 splits (typically at 0.4)
Ask and You Will Receive
Sarasota County FL - 1970’s beat out big
dogs (AT&T, Honeywell…) for customer
service and quality awards. Key metric:
1.
2.
3.
4.
5.
Come quickly
Make my pain go away
Treat me nicely (concerned and caring)
Tell me what you’re doing and why
Look & act like you know what your doing
(professional)
Taigman M. Sterling Sarasota. JEMS. 1998; Jul - 23(7):44-55.
While we’re on the subject…
• Red Cross On-Line Poll: “Social Media
in Disasters and Emergencies”
• July 2010, n=1,058 representative of
US population age 18+
> 50% would text 911
> ⅔ think 911 should monitor
75% expect help within 1 hour
So, the House of Medicine is
Benchmarked against Evidence
• What about EMS?
• “Critical Thinking”
added to EMS
Educational
Standards (EBM
follows)
• Is there pre-hospital
research to guide
practice?
TOR: ALS and BLS
Termination of Resuscitation Criteria
There should be no transports with CPR
Ann Emerg Med 2009;54:239-247
Evidence Based Benchmarks
STEMI
• ASA unless contraindicated
• 12-lead ECG with interpretation and/or transmission to ED
• Direct transport to PCI facility with activation cardiac cath team PTA
• Time from ECG (STEMI identified) to balloon inflation < 90 minutes
Pulmonary edema
• NTG unless contraindicated
• NIPPV (i.e., CPAP) to avoid endotracheal intubation
Prehosp Emerg Care 2008;12:141-151
Evidence Based Benchmarks
Asthma
• Administration of a beta-agonist by earliest arriving, trained personnel
Seizure
• Blood glucose measurement
• Administration of benzodiazepine by IV, IM, rectal or intranasal routes
Trauma
• Limit on scene, non-entrapment time to <10 minutes
• Direct transport to trauma center for those meeting criteria, particularly
those over 65 (with time consistent caveats for air medical transport)
Cardiac arrest
• Response interval < 5 minutes for basic CPR and automated external
defibrillators (AEDs)
• No response interval specified for ALS arrival
BUNDLE
Prehosp Emerg Care 2008;12:141-151
Where Will This Lead?
• Currently, very poor compliance with
performance metrics
• Evidence translates into outcomes (NNT)
3.5 ---
Prehosp Emerg Care 2008;12:141-151
Which Leads to P4P
• Pay For Performance began in 2000
• Offers incentives to HCPs to meet
defined targets (quality, efficiency, etc.)
• Market/purchasing strategy to improve
healthcare delivery
– Efficiency based
– Objectives set by payers
• Most certain to include EMS
– HCFA currently discussing
What Should I Measure?
• Measure your core values!
– Response performance (patient perspective)
– Patient/family satisfaction
• Compassion
• Professionalism
– Pain control
• Employees
• Measure clinical performance
– Evidence based, with outcomes (NNT)
• State, media, local metrics
Future of EMS in US
• Data driven
– Speed ≠ Success (response times, etc)
•
•
•
•
P4P
Research required (outcomes based)
Greater role for “House of Medicine”
More physician
accountability
Summary
•
•
•
•
•
•
•
EMS is young, small, complex, varied
Challenge: embrace EMS, compete
Cultural change mandates leadership
Success=price, quality, customer service
You need an EMS Chief to navigate
Continually measure performance
Get a seat at the EMS table
Thanks for your attention!
www.mikemcevoy.com