Category Archives: ems

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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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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Measured Response to Response Measures

In conversations lately I have been hearing more diverging opinions on measuring EMS response ranging all the way from it being a definitive criteria to saying  it shouldn’t be considered at all. A recorded example of such a discussion is a recent blogtalkradio episode by “EMS Office Hours”.  While certainly appearing to be diametrically opposing opinions on the surface, I believe that there is more in common between these positions than actual difference.  Everyone agrees that responder safety is paramount and also that speeding ambulances endanger not only the medics, but the public as well.  However, to assume that the “observer effect” of simply measuring the response time is a casual factor in promoting unsafe practice is not always justified.

To clarify the commonality, it is worthwhile to first discuss the measurement itself.  When does the clock measuring response performance actually start and when does it stop?  The answer likely depends on your perspective.  As a patient in cardiac or pulmonary distress, rescuer performance is rightfully measured from symptomatic onset to relief.  For a dispatcher, it can be from the point of answering the call for service to the paramedic greeting the patient.  For the responding agency, it can be from the initial dispatch time to the time of “wheels on the curb” at the scene.

In reality, it doesn’t matter what you choose measure, the point is ultimately how efficiently can service safely be rendered to achieve a positive clinical outcome.  Opponents to time response measures will say that the focus is brought to the wrong objective.  That only considering the arrival time leads to the foolish notion that arriving within a compliant time when the patient ends up dying is somehow better than being late while the patient ultimately survives.  But carrying the discussion to that ultimate extreme of logic is not beneficial to the underlying argument.  There is little disagreement that many EMS calls do not require excessive speed, but the outcome of certain calls clearly depend on early treatment and the difference between those cases is not necessarily clear at the time of dispatch.  So arriving in a short time after being dispatched can aid in achieving a positive outcome clinically.

What everyone wants to avoid is the danger of excessive speed in arriving to calls without any delay in beginning treatment for the patient.  The answer is in pre-positioning vehicles closer to the call before it is received.  That leads back to my last post on forecasting calls for dynamic system status management.  With proper forecasting and posting of ambulances, you can assure the fast, safe arrival of resources to begin treatment.  So again, no matter how you measure it, the positive relief of ailment is the outcome we all look to achieve.  To compare efficiency you need some objective measure of performance.  The responsive initiation of treatment leading to a healthy outcome is such a measure but is just not the only factor to be used in describing performance.

Let me know how you see it.

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Dynamic System Status Management

System Status Management (SSM) is the fluid deployment of ambulances based on the hour-of-the-day and day-of-the-week in order to match supply, defined as Unit Hours of Utilization (UHU), with expected demand, expressed as calls for service, in the attempt to provide faster response by locating ambulances at “posts” nearer their next calls.  While the practice is still not unanimously embraced by all services, it has a sound foundation both in the research literature dating back to the 1980’s as well as in practice today.  Experience has shown that ambulance response times can be dramatically decreased using this type of dynamic deployment, but it is also recognized that it is possible to reduce performance when these techniques are not applied properly.  The direction of the results of a system implementation are typically influenced by the system design, competence of the managers creating the plan, and commitment of the workforce in implementing it.  Therefore the best practice is a simple and straightforward implementation that will show positive results quickly.  This methodology ensures a positive return on investment along with garnering the necessary buy-in from staff to make the project a success.

In his article, “System Status Management – The Fact is, It’s Everywhere“,  published in the Journal of EMS (JEMS) magazine back in 1989, Jack Stout explained the concept of SSM and tried to dispel certain myths.  Based on foreseen Geographic Information System (GIS) technology and even general computing capabilities of that time, it was quite logical to assume in his Myth #2 that “no matter how thoroughly the response zone concept is fine-tuned in practice, it cannot be made to cope effectively with the dynamic realties of the EMS environment.”  But systems implemented today around the US are capable of calculating dynamic response zones in a small fraction of a second while even being based on time-aware historic driving patterns making a truly dynamic system status management process a reality.  A practical and proven example of a dynamically functioning system status management application is the Mobile Area Vehicle Routing and Location Information System, or simply MARVLIS.

The following Slideshare presentation does an excellent job of telling the story of why and how the system works:

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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.

Additionally, one of the ongoing, and rapidly growing expenses, for any service delivery organization is the rising cost of fuel.  Controlling mileage can often be a great option for managing expenses.  Of particular interest to some services is also the incurring of fines for exceeding response times.  This is a particularly good area to control costs for affected services since this type of expenditure does not lead to any revenue nor does the payment itself provide any service.  But to achieve these goals, performance must improve.

High Performance EMS is about doing things better – specifically providing advanced pre-hospital care with a focus on higher economic efficiency.  The result of better performance is patient satisfaction with cost savings.

For Lexington County, the more efficient posting of ambulances based on predicted demand and time-based routing using MARVLIS has allowed the service to actually improve response in the face of rising demands while foregoing the acquisition of additional resources and the commitment to ongoing costs associated with them.  Over the 4 year period since implementing MARVLIS, the projected cost savings of $3M per year is compounded by the avoidance of recurring staff costs and therefore totals closer to$16M for that period.  The initial investment required to make that savings was less than $400K in hardware and software systems.  As a result, satisfaction has improved for both the patients (who experience quicker service), and also staff (who endure fewer post moves while being closer to incoming calls.)  This is not just a promise or hope of what might happen, but a real world experience of leveraging county GIS services and an experienced High Performance EMS consultant, Bradshaw Consulting Services.  Watch for a more detailed article soon from Esri Press.

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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.

Academic studies show that demand pattern analysis can be used without hourly, daily, or seasonal calibration to achieve potentially acceptable tolerances of demand prediction, but when adjusted with these appropriate corrections, software applications like MARVLIS (the Mobile Area Routing and Vehicle Location Information System) can effectively predict demand in practical situations.  According to Tony Bradshaw of BCS, the makers of MARVLIS, it routinely calculates where about 80% of demand will occur and when paired with realistic drive-time response zones it demonstrates valuable support for a dynamic System Status Management plan to pre-position, or “post” ambulances closer to their next call saving valuable time and increasingly expensive fuel costs.

What matters most, though, is what agencies experience in the field.  At SunStar they say ” the most significant result was improving our emergency response time from 90.2% to now over 93% in lieu of an increase in patient call volumes.  This equates to ambulances arriving on scene more than 1 minute quicker.  We additionally saw a savings of $400,000 in penalties by exceeding our contractual goal of 92% and performing above 93% compliance.”  Similarly, Steven Cotter, Director of Sedgewick EMS added that “the technology has opened our eyes to be able to understand how we are performing, where we are deficient in our performance and how we can make changes quickly and adapt to a changing environment.”  And beyond simple response times, “it’s what technology should do,” says Joe Penner, Executive Director at the Mecklenburg EMS Agency, ” take the complex and present useful, straightforward information.  It has helped us improve response times, resource utilization AND simultaneously reduce unnecessary post moves — your patients and employees will appreciate it!”

My conclusion is that proper demand prediction paired with realistic response creates significant opportunity to improve performance and cut costs even in growing communities.  When used properly, the future looks bright for High Performance EMS!

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