Tag Archives: ambulance response time

Split-Second Destination Decisions

This past Sunday night about 2245 hours, a Detroit police officer was shot in the head while responding to a domestic violence call. The Detroit Free Press, in an article identifying the shooter, reported that the incident happened at an apartment complex in the vicinity of the 10000 block of Joy Road near Wyoming Avenue on Detroit’s west side. According to Channel 4 News in Detroit, Rapid Response EMS was dispatched and arrived on scene in less than 60 seconds. The officer was transported, with a police escort, to a level two trauma center,  as reported by another local news source, with the patient being handed over within 22 minutes of the original dispatch. Now, Detroit Police Chief James Craig is asking why the injured officer “wasn’t taken to the closest hospital.”

These are the facts as I have been able to glean them from multiple news reports and summaries. I have no inside knowledge of this particular incident or even any great understanding of Detroit in general, but I believe there are several interesting questions worth a larger discussion here from the perspective of a complete outsider. For those who may have more inside information of this situation, I will point out that I have no interest in any past conflicts that this particular EMS provider has had with the Detroit Fire Department or a memo now resurfacing from an incident last October specifying that injured “Detroit firefighters will be transported by Detroit EMS only.” That is a totally separate matter that relates potentially to medical care, not destination decisions.

A FOX 2 news article made a statement that they are “still looking into why a critically wounded Detroit police officer was taken to a hospital in Dearborn– when there were two hospitals that were closer. At least one of the hospitals that was passed up is better equipped to deal with a gunshot wound to the head [emphasis added].” Another article, updated during my research today, has since made a correction stating, “This story has been updated to clarify that an ambulance driver [sic] did not pass any hospitals while transporting a wounded Detroit police officer.”

The question we in EMS are often forced to answer is what facility is “closest,” however that question does not always have a static answer from every incident. One of the first articles I read on this case printed a thumbnail map (since removed) similar to the image on the left (which you can enlarge by clicking on it.) What immediately struck me was that the shooting occurred at the center of a triangle formed by the three “closest hospitals.”

If we consider distance to be “as the crow flies,” or perhaps more appropriately, “how the medical helicopter flies.” We will get one set of distances and travel times. Here, Henry Ford to the east appears closest in straight-line distance followed by Sinai-Grace to the north and finally Beaumont in Dearborn to the southwest. If we consider road miles of the shortest path, the order changes with Sinai-Grace at 4.8 miles, Henry Ford at 5.6 miles and lastly again, Beaumont at 6.8 miles. However, if distance is measured in drive-time, specific values change (according to my tests using Google Maps) depending on the amount and direction of flow of traffic. In all of my time tests, Sinai-Grace came in dead last due to the number of local street segments traversed and I suspect a large number of traffic signals. These typically narrower streets and signaled intersections are not only slower to travel, but more dangerous when traveled using red lights and sirens (some studies will show this is especially true with a police escort.)

The travel times in my daytime investigation during a typical work week varied with the other two destination hospitals and probably would still be different from a late drive on a Sunday evening. Of some significance in comparing the “best routes” is the number and direction of turns. As a general rule, right turns are safer than left turns which must cross opposing lanes of travel. The other consideration is the speed limit of the roadways. While I assume the ambulance was travelling above the posted rate going code 3, it is the faster roads that are built to a higher level of safety and will more easily accommodate higher speeds with fewer traffic control devices (lights or stop signs.) The route to Beaumont had the highest number of miles on restricted access highways that have the highest speed limits in any city. Consequently, this may have been a very good choice based on actual travel-time as well as safety considerations.

The call was still a judgement one and I will not defend one or the other as the best choice given my lack of knowledge in Detroit, but I will defer to the judgement of crews that travel these streets regularly both as emergent and routine traffic.

The other consideration in this call was the trauma rating of the hospital. As I understand it, both Henry Ford and Sinai-Grace are level 1 while Beaumont is only a level 2 facility. Given the severity of the wound, some deference would likely be given to the better equipped hospitals. However, the real difference between these levels is typically whether there is a teaching and research program available. The surgical capabilities should actually not be significantly different.

With drive times so close to being similar, I can sit comfortably in the safety of my arm chair typing that the choice of Henry Ford would have been quite practical; however, I may well have made a different choice myself as I place myself behind the wheel (as I will be doing tonight.) That immediate “split-second” decision of east versus south west is much more difficult in the moment. And this is exactly the type of situation where I would be grateful for the input from the MARVLIS in-vehicle client that sorts destinations choices by distance and provides an optimal path based on time-of-day with turn-by-turn driving directions.

 

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What is "Performance" in EMS? Part 1

It is that time of year for resolutions and reflection. As I ponder this thought, the topic that sticks out to me is about what really constitutes a “High Performance EMS.” As we look back over the past year of the High Performance EMS social network (including our Twitter and Facebook feeds as well as this blog) one of the recurring comments that disturbs me is that “response time doesn’t matter.” This causes me concern in two ways – first, that the primary measure of performance is overwhelmingly always “response timeâ€? and the other is that this simple measure is deemed to not really be important. So, for the next few posts, I will discuss various characteristics that I feel do matter in becoming a truly high performing EMS system.

Part 1: Response Time

This past February, Elsevier published an excellent newsletter (EMS Insider, Volume 39, Number 2) focused on EMS response times and included articles such as “The Great Ambulance Response Time Debate Continuesâ€? in which the author, Teresa McCallion, laid out many of the facts. For instance, the article recites the “MedStar example” from Super Bowl XLV suggesting that very few EMS calls” in that prospective two week study actually “required an immediate response. It is important to note that this statement did not go so far as to say that response time is meaningless in all cases – just that it is far less limited in most. Then as counterpoint to dismissing response times altogether, the public conflict at EMSA in Oklahoma City was brought up where at least one politician complained of the number of excluded calls required in order to reach a 90% response time compliance rate. This is only a single instance, but we all understand that it is certainly indicative of how the public measures the value we provide. In the conclusion, Matt Zavadsky, MedStar EMS Associate Director for Operations, offered several good recommendations to improve patient outcomes and public understanding of the EMS system. While I agree with nearly everything he said, I would really only argue with his statement that began, “There is no such thing as an inappropriate request for 9-1-1, (which is a whole other topic) but then he added there is such a thing as an inappropriate response to that request.” I can only assume he was referring to the fact that accidents sometimes happen en route to calls. While these incidents point out failures in judgement somewhere, it is not the “responseâ€? itself that is at fault.

Zavadsky also authored another article in that newsletter entitled “Response Time Realities: The Scientific Evidence.â€? Interestingly, several of the studies he cites actually help to make the case for effectively reducing response times under 4 or 5 minutes in certain cases rather than eliminating the standards in general. Furthermore, the quotes he uses from the 2008 “Gathering of Eagles” consortium position paper entitled “Prehospital Emergency Careâ€? do not discount the time of a response, but instead point out the unsupportability of “over-emphasis on response-time interval metricsâ€? compared to the “unintended, but harmful, consequences (e.g. emergency vehicle crashes) and an undeserved confidence in quality and performance.” While I also cannot justify the 7:59 standard used in many urban areas, I also cannot condone apathy toward responding timely. Maybe I am overly sensitive to the literal meaning of “response time doesn’t matterâ€? when justified with the statement that the “golden hourâ€? is just a myth. For most of us, at least 10-20% of calls include a cardiac, respiratory, stroke or other event where time really is critical and we must be at the top of our game to prevent a death or minimize as much loss in quality of life as possible.

My concern in these arguments is an unstated bias that “response” means only the arrival of an ALS-experienced paramedic traveling with red lights and sirens from a fixed fire station. Technically, “response” must be understood as simply the time between a call for emergency assistance and the initiation of appropriate necessary treatment. For many calls, that care could be BLS-led in most circumstances assuming that the calls are appropriately triaged at dispatch. Emergency Medical Dispatch itself even provides some level of immediate guidance in care with a response time of zero. Additionally, the greater availability of defibrillators as well as more common knowledge of compression-only CPR means that initial emergency life-saving care can be initiated well before any ambulance arrives. The existence of advanced telemedicine devices (such as the LifeBot-5) are also changing the rules by providing advanced medical consultation even more quickly in remote rural areas typically with far longer average ALS arrival times.

My point is not necessarily trying to get medical responsders moving faster, but to redefine response time not just as the metric for the ambulance arrival to justify budgets but as a factor that affects patient outcome. There are many ways to achieve this goal and it begins as education within the system as well as with the public because technology is changing the dynamics. Zavadsky’s points are valid. Making defibrillators more available and teaching the public how to respond when a medical event is witnessed is critical. Also while adding ambulances and staff to more locations would be another way to address reducing response time, it is not financially practical. An effective alternative to achieve that same goal would be to position the responders closer to the call thereby minimizing distance and the associated need for risky driving. Modern “dynamic system status managementâ€? practice has proven that response time can be shortened to most calls (at least 80-85%) without the need for excessive driving risk that places crews or the public in danger. Improving performance means responding appropriately in less time – not necessarily just responding “faster.” Technology can be evaluated as being “outcome-basedâ€? just the same as patient treatments.

Watch for future posts which will highlight other components of performance-based EMS beyond just measuring and improving response time.

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