A New Look (and Updated URL)

Whether you have been one of our followers this past year or just found us recently, we appreciate your interest in High Performance EMS and our revised blog site. We are excited to now be a part of the FireEMS Blogs network and look forward to the possibility of reaching a larger audience and hearing from additional voices. Please be sure to click and bookmark the URL at http://HighPerformanceEMS.com in place of any previous addresses and visit back here often. You can expect to find conference reviews, technology updates, topical opinions, and profiles of High Performance EMS agencies along with links to key topics and constantly updated news feeds and tweets.

As an additional resource, we have a Solutions tab that links you to providers that enhance the capabilities of your EMS agency to become more efficient and effective in delivering prehospital care. This is not a paid advertisement listing, but an “invitation-only” section where vendors earn their inclusion by proving their value in successful implementations that show a positive return on investment. The Guest Blog tab provides information on how you can submit a posting to be considered for inclusion in this blog. There are some rules and we reserve the right to accept or reject content based on its perceived value to our community. If you want to learn more about why this blog was created and what we hope to accomplish, check out the About tab. If you have comments or suggestions, we love to hear those too. So feel free to post a comment anytime.

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EMS Surveillance or Survival?

I know there are probably agencies out there with some real control issues, but the use of technology that monitors your EMS system are not really about employee surveillance.  Sometimes this monitoring is actually about your protection, but most often I believe it is about creating a competitive advantage that will help your agency survive in a bad economy and within an industry that is currently favoring consolidation.  Increasing demand for emergency services is not enough to ensure that there will always be the funds needed to keep it operating at the level the community expects – especially under the same operations strategies in place since before the financial crisis of 2008 or the Patient Protection and Affordable Care Act of 2010.  The world, and more importantly prehospital health care, is fundamentally different today and your job depends on your system adapting to it.

System monitoring typically starts by knowing where your vehicles are.  GPS transmitters are capable of reporting location and many Computer Aided Dispatch systems are able to visualize that data and even recommend vehicles to incidents based on actual proximity and drive-time instead of a simple reported location.  And that recommendation can even be based on the type of vehicle or skills of the team weighed against travel time.  One concern of providers, however, is the employer always knowing where they are.  But relax, the only way a monitor will see you somewhere you shouldn’t be is if you are somewhere you shouldn’t be.  But again, monitoring your habits is not the important application for dispatchers knowing where available units are right now.  Better response equals better service and can also improve safety.  These are the keys to system survival.

Once location begins to be used effectively, concepts of system status management actually become useful.  And for those who are concerned about that idea, remember that ‘posting’ is not a dirty word (that link will allow you to register for an upcoming JEMS webcast by that name or view the recording after the fact.)  If you think tracking vehicles is invasive, how about tracking people?    A new product currently available is GPS equipped shoes from Aetrex (incorporating GTX Corp technology) but fortunately it is directed at Alzheimer patients, not EMTs.  But before you feel too comfortable, you already carry a GPS tracking device on your body if you use a smartphone.  While the US Supreme court ruled it illegal for the FBI to secretly track suspects with GPS, it has not limited the private sector employer.

Road safety systems that monitor every aspect of the ambulance operations from seat belt usage, lights and siren activation to the G forces that apply to the vehicle are fast becoming commonplace in the public safety industry.  Another JEMS webcast, May the G-Force Be With You will explore the implementation of such a system at Richmond Ambulance Authority to reduce accidents involving ambulances, cut operating costs, and provide a smooth and safe ride for the patient.

Paramedics and EMTs are not being singled out for tracking since this type of technology is becoming standard practice in many industries that involve mobile service providers.  The difference for us are the legal standards to which we are held accountable and the legislation (like HIPPA) that make reporting especially tricky.  I personally welcome cameras in the patient compartment to protect me from spurious allegations and even help me improve my clinical and patient skills.  I cannot see any difference in this from recording the 9-1-1 call that dispatched me to begin with.  While I realize there is fear around the monitoring topic, a useful dialog must begin with an understanding of the facts surrounding the debate – our future depends on doing it right!

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HP-EMS Profile: Huron Valley Ambulance

This month’s high performance profile is Huron Valley Ambulance (HVA), a nonprofit service that has distinguished itself as being high quality and achieved CAAS certification for service in southeast and south central Michigan.  HVA was created in 1981 as a nonprofit organization by five hospitals in Washtenaw County following the failure of several previous commercial ambulance services there.  The hospitals invested $2 million dollars in the new ambulance service, purchasing new vehicles, equipment, and facilities.  New leadership and staff were hired and advanced life support service was begun in early 1982.  By 1984, the ambulance service was breaking even financially and gaining the trust and support from the community.

The owner-hospitals asked community leaders to volunteer to serve on the HVA Board of Trustees and they continued to improve service delivery.  Once they were successful in their goal of stabilizing emergency medical services for county residents, the hospitals gave HVA to the community in 1985 as a free-standing nonprofit, charitable organization.  Although no longer HVA’s owners, the hospitals have continued to play a part in the governance and success of the organization ever since.

The HVA Board of Trustees has always placed accreditation as an important achievement and measure of quality.  Additionally, emergency response times and driver safety are recognized as being important to patient outcome as well as a measure of meeting community service expectations.  HVA has a benchmark of providing a response to life-threatening emergencies within 10 minutes (urban) and 15 minutes (rural), 90% of the time.  HVA has consistently met this goal for 30 years and even publishes a Performance Dashboard on their website.  The response time is calculated from the time the patient’s call is received until the paramedic arrives at the address.  Exceptions in this measure are included in cases which are beyond HVA’s control, such as ice storms, trains blocking roads, and unsecure situations where the police must make the scene safe.

An important tool to help HVA continue to meet response time standards has been MARVLIS from BCS.  John Vary, Technical Services Manager at HVA, said that “the implementation of MARVLIS has given our dispatchers a new way to visualize and position resources.  An important aspect is in enhancing our placement of ambulances to safely meet our designated response times.”  While there are many parts that must come together correctly to make an agency effective and perform with greater economic efficiency, advanced technology is clearly an essential part of the mix.

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Free the Internet

I try to avoid purely political discussions on this blog, but today is different and that is because the very future of blogs just like this one at are stake.  Blogs exist to further discussions and make people think about positions and question their beliefs and practices.  This is the power of respectful discussion and dialog.  It is literally how we grow intellectually and improve everything we do.

So what does all of this have to do with the SOPA (Stop Online Piracy Act – HR 3261) and PIPA (Protect Intellectual Property Act – Senate 968) legislation being considered in the US Congress?  Well, in order to further discussion within the EMS industry (or any other for that matter), it is important to state positions and that may mean quoting statements or using illustrations from others.  This is what Galileo once called “standing on the shoulders of giants” when asked how he was able to accomplish so much more than others before him and what the proponents of these bills want to simply call “illegal.”  While I make every effort to credit sources in my posts, this legislation would mean that the accusation of impropriety in enough to shut this website down.

Knowledge is a collective endeavor, not personal property.  Ideas clearly deserve credit and inventors deserve to profit from their work, but to prevent or impede the sharing and building of collective knowledge at the expense of the greater good is intellectual suicide for any society.  Censorship of the web is not a cure for piracy or a solution to patent reform.  The unintended consequences are just far too great!   Learn more and let your voice be heard (whatever position you take) once you have become informed.

Chart: “Congress, Can You Hear Us?”

Sources: Infojustice.org. Protect Innovation, Engine Advocacy, Center for Democracy and Technology, Whitehouse We the People Position, Congresswoman Zoe Lefgre, Wikipedia, Stop American Censorship, Avaaz

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Revisiting Repeat Patient Transports

The High Performance EMS website has been up for a year now and in review of all the topics we have visited, there are two that have stood out in particular both by the number of search terms as well as the number of page views.  They are “dynamic system status management” and “EMS frequent flyers”.  Since the first topic is based largely in technology, it has been fairly well covered (and developments will continue to be a topic of further discussion.)  However, the social problem related to repeat, often non-emergency patient requests for transports continues to be a subject with few answers and it certainly deserves additional attention.

To many EMTs, the driving policy of most agencies (whether overt or not) seems to be “you call, we haul, that’s all!”  That sentiment is often despairingly minimized even further as “just because you can’t afford a taxi, does not mean that you should call an ambulance.”  These attitudes focus on the misuse, or even outright abuse of the Emergency Medical Services system in that they are assuming someone is routinely “crying wolf” for attention to some minor or even imagined problem.  While these situations certainly do occur, and at some direct cost to your agency, it is important that we do not miss the occasion when the metaphorical wolf really is prowling at someone’s door.

So, how do we tell when a frequent patient has a real rather than an imagined need?  The best answer is to simply do our job and assess the situation as well as the patient.  And do it again every time.  Will that waste resources in certain cases?  Yes, probably so, but more importantly we won’t overlook the real emergency that we are always expected to address.  However, it is the inefficiency of that way of doing business that bothers me.

Many agencies see the “haul ’em all” strategy as their best hope to avoid a mistake and are willing to pay whatever associated cost may arise just to avoid a single potential mistake.  Is there not another way to be more effective and prudent in our use of resources?  It is true that alternatives such as community public health screenings, planned paramedic home visits, and taxi vouchers – just a few of the many innovative solutions already implemented with varying success – have a cost too.  But these programs become better options if we add a caveat to the simple definition of efficiency (which many would agree is “doing the most with the least”) in saying we also want to maintain a higher degree of control over our budget.  When these programs are viewed as just interventions to stem the financial bleeding, they will not succeed in the long run.  It requires a commitment to a systemic strategy of change that should be viewed more as a change in diet rather than as emergency care.  It is only at this point that we begin to take control over the budgeting process through preventative community care in order to limit the need for uncontrolled – or even institutionally encouraged – personal misuse of emergency resources.

Healthcare in the United States is changing dramatically.  To think the strategies of the past can be used to reform the system is just plain naive.  We may not like the sound of it, but “field EMS” is increasingly becoming “prehospital care” by reforms tying the treatment which a patient receives en route to some definitive care received within the hospital and beyond with evaluation of the overall quality of the patient outcome.  Think of an extension of the current trend in “evidence-based medicine” or treatment (that re-evaluates our skills and treatments based on outcomes) as “evidence-based payment” which would compensate based on the effectiveness of our overall service.  While I am not suggesting that model or ever believe it would happen, I do believe that the thought is a potential motivator to change our behavior.

Unfortunately, one of the contradictory forces acting against the improvement of our practices is the failure of elected officials to recognize “field EMS” as  an essential government service.  As a citizen, I expect to flip the switch and see a light or turn the spigot to get a drink just the same as I want to be able to call       9-1-1 and receive skilled care in an emergency situation.  We not only need to re-train the public what we do, we need to inform our political leaders as well.

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SAMPLE Your Agency

Judging interest of the EMS community based on searches that end up at this website may not be a fair assessment of the larger group, but interest sure seems to be growing around performance concerns.  I don’t know if there is any acute cause but a longer term irritant has certainly been the economy and legislative reform in the overall healthcare industry affecting the delivery of prehospital services.  With the end of the year at hand, it also seems like a good time for a field assessment of your agency.

The SAMPLE history mnemonic is a beneficial tool when assessing a patient, but could it work on your agency as well?  Try it with me.  Regardless of whether you operate in a local government, a private agency, a non-profit, or a volunteer organization – there are expectations on your service.  What are the Signs and Symptoms of the service you deliver?  Objective measures, or Signs, could certainly include response time, safety record, and the clinical quality of patient care.  Hopefully you have objective standards for these measures to serve as a baseline to compare current performance but more importantly observe any trend.  How often do you take, or again more importantly publish, these observations either internally or externally?  Is a stable vital sign good enough or do you expect a consistent move toward improvement?  As for Symptoms, what is your patient satisfaction like?  Quantification can be a good thing, but I believe most of us have a fair idea of how we are viewed by the public even without a survey.  Are there complaints about your agency performance?  How are these concerns addressed?  Has a concern about the performance of your system been a topic for public meetings or public officials?  Are you experiencing unhealthy competition from a Fire service, commercial provider, or volunteers?  These can all be Symptoms of a failure within your agency.

How about Allergies?  What do you avoid within your service when compared with others?  Have you ever said, “we could never do that here” about a good idea that works elsewhere?  What about your organization constricts the flow of ideas?  Are you taking any “Medications”?  Is there anything you are doing to promote healthy improvement of your service?  What specific improvement programs do you have in place already?  Are you compliant with these medicinal procedures that can promote improvement?

We all have a history that makes us who we are today.  While some of that history cannot be changed, the way we are bound to the effects of that past are not always inflexible if we recognize the bias it causes.  So, what is the Pertinent past history that has you in your current situation?  What prejudices have you inherited from your parent organization(s) or leadership that cause specific actions that may not always be in the best interest of the patient?  Some of it may not be easily changed, but what do we have control over and how much of the current way we do business is simply a product of “the way we have always done it” instead of being based on current understanding.  We operate in a field that is constantly changing and challenging previous assumptions.  What has been proven ineffective in your processes but remains ingrained anyway and how are others making improvements that we ignore simply out of convenience?

I will need to modify this next one slightly, but it still fits well.  What has our Last intake or new hire looked like?  Who are we bringing in to our system to form our future?  Unless our employment process is so screwed up that we spit out the latest employees before they can make a difference, the new hire will represent how we grow and change in the future.  Do we maintain high standards looking for the “locally grown, organic style” employment candidates or go for the convenience of the “fast food hire” to simply get another able body in the truck?  Our view of how employees shape the development of the organization is fundamental to good hiring.  So we must consider whether we are simply eating up employees or offering them personal and professional growth opportunities that encourage them to stick around and contribute to the overall growth of the agency.

Finally, there are the Events leading up to the current state of your agency.  What has been happening lately?  Are there news stories about your agency in the media?  What is the underlying story communicated through the press?  Is your agency a progressive advocate for community wellness with an outward focus or is there just a struggle to keep out of the headlines and maintain the status quo?

So, how does your agency look now?  What is the general impression of your patient?  If treatment is indicated, there are many options available.  Look at attending industry conferences next year and make it a special point to meet representatives from successful, healthy agencies and get to know them.  Check out new vendors and new ideas.  That doesn’t mean you fall for every line they pitch at you, but consider what good advice you can glean from each and judge who is there to help you in the long run.  For those conferences you can’t attend, read our future “Quick Thoughts” posts throughout the year to catch up on what you missed.  Consider webcast presentations and podcasts that don’t require travel expenses.  If your agency does not participate in any accreditations, review what they offer.  Some examples include the Committee on Accreditation
of Educational Programs for the Emergency Medical Services Profession
, the Commission on Accreditation of Ambulance Services, the National Academies of Emergency Dispatch, and other professional development groups like International Paramedic.  They exist to help you and help our whole profession.

Make a commitment to change in the new year and commit to continuous improvement through this new year and beyond.  It is the best medicine for all of us.

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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?

System Status Management – oops, another term laden with strong negative feelings in the field – is actually all about improving performance (both time and economic efficiency) without sacrificing safety.  As advocates for patients, medics see themselves sometimes fighting the system in order to provide the best possible care.  Talk of economic efficiency is seen as just making their job harder.  But again is it really a given that one necessitates the other?

Imagine a system where patient needs are accurately forecast in advance. Where the posting of ambulances is not just another place to sit and wait, but in a practical sense it is the staging for a call that has yet to be received.  Response is thereby improved not by excessive haste, but by the strategic pre-positioning of resources.  The cost savings is not simply an amount  taken from others in a “zero-sum game”, but effectively rescues budgets for proactive wellness programs or, in the current economy, may mean simply saving jobs that allows us in turn to save lives.  This process really works and these systems do exist.  They are called “High Performance EMS” systems and many are profiled here each month while others receive recognition through accreditation agencies like CAAS.  What sets them apart is often observed in technology, but the reality is that it is a culture of seeking constant improvement by the entire staff that makes a difference.

While we consider improvements to the many technical aspects of our profession, let us not neglect the philosophical perspectives that motivate us as individuals.  We operate as a team, not just the pair on the truck, but the whole EMS system is one team with a singular goal.  A goal to do even better each day. So, as we continue to assess our profession should the index of suspicion not include our attitudes toward improving the overall system?

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