During the height of the COVID pandemic, shortages led to many operational challenges that required creative solutions. One of the more challenging issues that has become as endemic as the disease itself is the recruitment and retention of EMS professionals. This shortage has disproportionally impacted paramedics, as evidenced in the NAEMT survey results published in May of 2022. The ripple effect of the workforce reductions that has changed the certification balance favoring basic credentials has led to some logistical changes in priorities. The most recent NAEMT survey results, published last month, show services are taking longer to respond to requests, considering alternatives to serve low acuity calls, and changing the provider mix that services patients.
As more agencies move from exclusive ALS capabilities to tiered responses, there must also be a growing concern with ensuring the most appropriate resources are responding to each call. The idea of thoughtful intentionality in the assignment of units helps to improve the chances that the right resource will be available to the next future request for service. I like to describe the logical shift in thinking as moving from “the right response times on every call” to “the right call for responses every time.” This may be a subtle but highly significant change in attitude regarding the best, or most “appropriate,” response assignments to each request rather than routinely sending the closest unit. Managing these resources well may additionally involve adjustments to the expectations of your community.
Depending on the priority of a call, it may be that the closest resource is logically passed over for a more appropriately matched capability responding to that call from a greater distance. While the 90th percentile response times may increase for certain lower acuity calls, this selective assignment process allows advanced capabilities to be preserved for potentially higher acuity needs. But it is seldom really as simple as it sounds. How much further can that preferred response be before its preference is overtaken by the need to simply respond promptly?
The reality of these critical decisions means the process becomes far more complex and dangerously slower. The more conditions that must be understood and compared extend the time for each dispatch without automated assistance. By planning and codifying dynamic selection criteria, the extra delay can be eliminated which means making far better decisions in no more time than traditional fastest responses. These guided decisions can also be made uniform across positions and shifts to achieve corporate objectives that prioritize clinical outcomes based on acuity in addition to broad operational objectives that consider the condition of crews.
A typical Charlie priority call, for instance, might prefer to have a paramedic respond timely. That ideal response might be within, say, 15 minutes. With expected delays beyond that time limit, it may be acceptable to dispatch a BLS unit to begin care while still allowing the ALS resource to join the response from a longer distance. However, the practicality of that rigid rule may send a basic unit on a 14-minute response when the nearest advanced unit is only 16 minutes away. That implementation of a simple preference for immediate care has practical limitations because it committed two units with little time for the first to even complete an assessment before requiring a hand-off of care. Is the additional drop in service level worth the brief time savings in this example?
Response rules should be focused on improving both the speed and quality of outcome without artificially taxing the system. In this case, the lower-level capability may only be desired if it will be more than at least 3 minutes faster than the closest ALS unit regardless of its distance to travel. Without more time for basic intervention on scene, the multiple assignments are only tying up more response units without actually improving care.
A Delta priority request may also need a speedy paramedic response and a basic unit alone for too long may not be an adequate alternative. However, matching a paramedic QRV, or another supervisor, with that nearest BLS resource provided that it can be completed in 5 minutes less time than the closest ALS ambulance could be an acceptable solution.
While the time-sensitive examples above show better potential for care, there are also system benefits with appropriate responses on the lower acuity side of the scale. A Bravo request could be most efficiently served in a BLS capacity with longer response times before it would be deemed late. Yet if the preferred units are just not available by the time a limit approaches, an ALS resource could be dispatched to keep your response statistics within acceptable limits.
The impact of posting schemes on response capabilities cannot be overstated. There simply is no substitute to having the right resources located closer to their next most likely call. But the post priority can also be useful in assigning appropriate responses at the low-end of the acuity scale. A hospital discharge, or typical interfacility transfer, will not benefit from sending a fastest unit. The posts nearer the hospitals tend, in general, to be busier locations. Using one of those units not only increases the chances of keeping a crew within the vortex of handling patients, but it also exposes a potential lapse in coverage until another unit can be moved from a less active post. If the assignment is given initially to the unit filling the least critical post, there is no immediate coverage loss and no additional post moves required. Assigning an appropriate unit for this call can actually reduce the effective activity, or UHU, of other resources.
Appropriate dispatch is becoming a necessity to balance workloads and provide the best care possible to our patients given current trends. It comes, however, at a cost to the complexity of decisions demanded of telecommunicators unless they are given tools to help manage the art and science of dispatching. But to be effective, we must use appropriate automation tools for the best results.
High Performance EMS 