Advanced Life Support
Committee Report
For the Wayland
Board of Selectmen
January 12, 2009
Public Perception – Heart Attack
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911 call for ambulance
Local resources respond to solve the
problem.
– Fire department response
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Fire engine
Ambulance
– Two paramedics
– Overall “local” response
•
Quick, professional, effective, efficient.
The Reality
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•
911 call for ambulance
Local resources respond to solve the problem
–
Fire department response
•
•
–
Fire engine
Ambulance
Another agency is called for assistance
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Semi-public or private organization
Decreasing availability
Less and less seamless integration
» Vehicle and two paramedics meet the local ambulance
Overall response
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Usually…
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•
Quick, professional, effective, and efficient.
Sometimes ALS not available.
Traditional Fire Department
Responsibilities
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Fire suppression
Fire prevention
Inspections
Permits
Code enforcement
Hazardous materials planning & response
Emergency medical service
Wayland Fire Department
Mission Statement.
From the Town of Wayland web site.
“Our mission is to provide the finest possible
fire, rescue, and emergency medical
services to all those that reside in, work in,
or visit the Town of Wayland….”
EMS 101
• Basic life support (BLS)
Emergency medical
technician (EMT).
– All Wayland firefighters are
EMTs
– Ambulance is always
staffed with two EMTs
– Have skills for the less
serious injuries/illnesses
– Adequate for 50-65% of all
ambulance calls
• Advance life support
(ALS). Paramedic
– Paramedics are available
from outside organizations.
– Have skills for the more
serious injuries/illnesses.
– Needed for 35-50% of all
ambulance calls
Emergency Medical Services
Within the Fire Department
• 1899 – Fire department organized
• 1910 – Emergency medical services start
– Oxygen is carried on fire engines
• 1960 – Ambulance service starts
– With a hearse-like vehicle
• 1972 – “Paramedics” introduced to the U.S.
Emergency!
An NBC TV Show
1972
• “Paramedic” – advanced medical training
• Close relationship with emergency department
staff
– Training, treatment, & telemetry
• Merging paramedics into the fire service
– Fast response
– Strategic station and personnel location
– Public policy
Emergency Medical Services
Within the Fire Department
• 1899 – Fire Department Organized
• 1910 – Emergency Medical Services Start
– Oxygen is carried on fire engines
• 1960 – Ambulance Service Starts
– With a hearse-like vehicle
• 1972 – “Paramedics” introduced to the U.S.
• 1975 - Modern basic ambulance service
– True ambulance and credentialed personnel
• 1982 – Hospital-based ALS service starts
ALS – Paramedics
1982 - 2003
• Two hospital-based paramedic services
available
• Local ambulance services maintain basic
level of training and transportation
• ALS service was prompt, efficient, &
effective
• Wayland was geographically “lucky”
Outside Resources
• ALS resources available from outside the
local fire department
– Hospital based ALS teams (vehicle and 2
paramedics)
– Dedicated to area
– Good response times
– Relatively seamless service integration
– Public policy integration
During this time….
Maximus Study
From the Town wide Study of Organization and
Operations prepared for the Town of Wayland,
by the Maximus Company of Waltham, MA. May
13, 2002. Page 124.
“Consider increasing the internal level of emergency
medical services (EMS) provided to the Advanced Life
Support Level. It is clear that the town is at a
disadvantage in relying on this level of care from outside
the community (response times are longer than the
national standard because these units are coming from
elsewhere).”
ALS Problems Appear on the
Horizon
• Long term, continuing problem (many
years)
– Medicare reimbursement for ambulance fees
decreasing steadily
– Aging population increasing dramatically
– Aging population generally need more
medical care, including ambulance
transportation
– Makes ALS service less attractive when profit
is the bottom line
Master Plan
From the Wayland Town Master Plan Final
Report, August 2004. Page A-5,
demographic profile
“According to MAPC (Metropolitan Area Planning
Council) population forecasts…the proportion of
persons aged 65 and older is projected to
effectively double by 2020, growing from 14% of
the Town’s total population to 28%.”
More ALS Problems on the Horizon
• 1990s - Hospital budget problem rumors
persist
– ALS service(s) may be in jeopardy
• 1993 – Fire department proposes plan for
ALS training for firefighters
– Not acted on
• 2003 – Natick hospital-based ALS service
closed with 90 days notice
– Short notice
– Affects 84% of Wayland ALS calls
Since 2003, A Partial Solution
• Local ambulance company American
Medical Response (AMR) helps out.
• If ALS is needed, we request an AMR
response. If an AMR ALS crew is
available, they are sent.
• For every ALS transport, they charge
Wayland $250. flat fee.
– Paid from ambulance receipts.
A Partial Solution – The Benefits
• When ALS is available, patient benefits
• Except for flat fee, no other charges
incurred for Wayland
A Partial Solution – The Limitations
• High unavailability
– ALS units are not stationed in or dedicated to, the
area
– ALS crews continue their normal business and are
often out of the area for long periods of time
• Little or no control over personnel and policy
• Multi-agency responses lead to delays,
miscommunications, and misunderstandings
• Response times do not meet national standards
• No cost control measures are possible
ALS Problems on the Horizon
• Hospital budget problem rumors persist
– ALS service(s) may be in jeopardy
• 1993 – Fire department proposes plan for
ALS training for firefighters
– Not acted on
• 2003 – Natick hospital-based service
closes with 90 days notice
• 2004 - Wayland ALS Committee issues
report to Board of Selectmen.
The 2004 ALS Committee Report
• Recognized multitown area that needs
better ALS service.
• Proposed a regional
service shared
between towns.
• No action taken.
Since the 2004 Report
• ALS availability (especially on the south side)
continues to decrease (unavailable 1/3 to 1/2 of
the time)
• Emerson Hospital recognizes ALS financial
woes.
– ALS fee increases but guarantees service until
September 2010.
• Emerson area collaborative formed.
– Proposing a fundamental change in the way ALS is
delivered in the 13-town region.
• MetroWest Health Care Foundation grant
• “2nd agency issues”
The Importance of ALS and
Paramedics
The Importance of ALS and
Paramedics
Mark Neuman, M.D.
Beth Zeeman, M.D.
Staff in Emergency Medicine
Children’s Hospital, Boston
Assistant Professor of Pediatrics
Harvard Medical School
Staff in Emergency Medicine
MetroWest Medical Center
Medical Director
Wayland Fire Department
Emergency Medical Service
The Importance of ALS and
Paramedics
• Emergency medical literature (see printed
report footnotes)
• Personal experiences of fire department
members
Elements of the 2009
ALS Service Proposal
• Proposed service added to the existing
ALS services (not a replacement)
• Flexible and scaleable
• Funded by the Town of Wayland
Elements of the 2009
ALS Service Proposal (more)
• ALS services “sold” to surrounding
communities who also need it
• Part-time employees used
• Partial day coverage (8 hours/day) to start
Elements of the 2009
ALS Service Proposal (more)
• Based in Wayland, committed to the area
• Easily replaced by, or made a supplement
to, any other acceptable ALS delivery
system proposed
After Proven Success (Future)
• 24 hour/day coverage will be a goal
• Interested Wayland Fire Department
personnel should be given the opportunity
to train to the paramedic level
• Fire Department hiring practices should
change so that through attrition, some
firefighter/paramedics would be hired.
2009 Proposal - Goal #1
• Provide an additional ALS service in the
area to improve availability.
Provide a prompt, efficient, and effective
paramedic service for the people who live
in, work in, or travel through the town of
Wayland as soon as possible.
2009 Proposal - Goal #2
• Be prepared if either existing ALS service
stops providing service.
Have enough flexibility in the plan to
absorb additional geographic areas and
additional patients if either existing ALS
service is unable to continue providing
paramedics.
2009 Proposal - Goal #3
• Be prepared & helpful if other ALS plans
for the area are adopted.
Be prepared (for merging or replacement)
if the MetroWest Health Care Foundation
ALS study or the Emerson collaborative
designs a new, acceptable ALS model for
the area.
2009 Proposal - Goal #4
• Decrease the paramedic response time
within the primary service area by an
average of 50%, to 6-7 minutes, well
within the national standard.
2009 Proposal - Goal #5
• Help guarantee long term program viability
and high quality paramedic service for all.
Not just for the residents of Wayland, but
also provide some assistance to Sudbury,
Weston, and Lincoln.
2009 Proposal - Goal #6
• Consolidate the entire suite of pre-hospital
emergency medical care services into a
single local agency, managed by public
policy.
Cost/Benefit
Cost Categories
• Start up
• After success, possible expansion
Start-Up Costs
• Equipment & Supplies
– $28,198
• Perspective
– Percentage of current yearly ambulance revenue (net)
» 12%
– Percentage of “Town Center” gift
» <1%
Operational Cost (Per Year)
• Operational
– $57,074 Per Year
• Perspective
– Percentage of current yearly ambulance revenue (net)
» 24.4%
– Percentage of “Town Center” gift
» 1.9%
Potential Future Program
Expansion (Long Term)
• After success (future)
– Possible Expansion
• Equipment & Supplies
• Operational
– Wayland Fire Department paramedics
• Hire a percentage of Firefighter/Paramedics
through attrition.
• Training interested existing personnel
Benefit
• Provide an additional paramedic team…
– Within the fire service
– Committed to the emergent care needs in the
area (3-4 towns)
– 8 hours/day coverage
– Centrally located = short response time,
meeting response time standards.
Benefit
• Preserves and continue BLS ambulance
services at local (town) level.
• Shares specialized services with
surrounding communities
• Service supported with public policy
– Additional protection for a vulnerable
population
What We’re Asking of the
Selectmen
• Endorse the 2009 ALS Committee Report
and associated policy
• Authorize/provide funding
– Start up
– Operational
• After success (future)
– Possible Program Expansion
What We’re Asking of the
Selectmen
• Endorse the delivery of ALS services part
of the day, with part time employees of the
Wayland Fire Department
What We’re Asking of the
Selectmen
• Start Up
– Work with the ALS Committee/Fire Chief to
identify/provide start-up funding.
• Operational funding
– Authorize and provide operational funding.
What We’re Asking of the
Selectmen
• After success…
– Possible Program Expansion (future)
Conclusion - Recognize that a
Proper ALS Service…
• is a valuable, life saving service and
needs to be supplemented in our area as
soon as possible.
• should be provided by local government
operated under public policy.
• satisfies recommendations of past town
management and operational studies.
• is perfectly aligned with the mission of the
Wayland Fire Department.
And therefore…
• The recommendations found in the 2009
ALS Committee Report should be
endorsed and implemented as soon as
possible.
The Advanced Life Support
(ALS) Committee
Committee members
– Douglas Leard
– Fire Chief Robert Loomer (advisory member)
– Mark Neuman, M.D.
– Michael Patterson
– Vincent Smith (Chair)
– Elizabeth Sweitzer
– Beth Zeeman, M.D.
Questions? Comments?