Tag Archives: ems performance

What 'Level Zero' Really Means in EMS

Rampart, Medic 13 with anincoming patient report.”

Go ahead, 13.”

I have a patient with a pulse of 120. ETA less than 10 minutes. Over.”

Well, this sort of report certainly leaves something to be desired. What is the age of the patient? For an infant, this may be a normal rate, but in a geriatric personit could be a bigger concern. Has the patient been involved in any physical activity? If the subject just completed a marathon it may not be a concern, but if the patient had been sitting on the couch watching TV and the pulse suddenly spiked, it could be a legitimate emergency. In any of these cases, we still need more information. The patient’s blood pressure would be another good measure along with age. Some OPQRST orSAMPLE would be enlightening too. A treatment, let alone a diagnosis, cannot be advised from this single piece of data.

In a very similar vein to our pulse example, there have been several articles written lately bemoaning the dangers of any particularEMS system having hit a ‘Level Zero’ situation some number of times in the last however many months. For instance, there is an article whereSan Bernardino firefighters attack AMR. Don’t misunderstand my point, not having any ambulances available can definitely be a serious situation, but how long does the situation last in each occurence? In any significant service area, its bound to happen at some point even with proper planning and normally adequate staff.My concern is the media attention overthis single measure of an emergency health system.It may be that reporters finally got the message thatresponse time was not a good defining metric by itself. But just like our bodies, an EMS organization is a complex system of interoperating systems. Performance is not defined by any single measure. Although individual metrics, however,can cause us to want tolook deeperto understand the likelihood of potentialserious problems.

A case in point is a story last year on Paramedics Plus in Sioux Falls,that revolvedaround two specific cases where an ambulance was not available for patients in distress. While this is not ever a desirable position, the compliance of the ambulance provider in question was 95% and even the investigative news reporter found that EMS arrived before the fire department’s own”first responders” in 25% of cases. Perfection is simply not easy to maintain. While not making light of any potentiallyserious situation,my intention isto placethis measurewithin some context, just as a sole pulse readingis only a singular measure of performance and one that is not meant to be interpreted by itself.

The MARVLIS application, in use by almost every member of the AIMHI (Academy of International Mobile Healthcare Integration) organization (formerly known as the Coalition of Advanced Emergency Medical Services or CAEMS) is often viewed as a tool for improving response times. While it has proven to be beneficial in achieving that goal, that is not the only reason these “high value” systems use it. Improving individual response times alsoimproves compliance.Consistently short response compliancecan also have clinical value if the times are low enough in the right situations. Jersey City has correlated a response time near 4 minutes to improved ROSC. But other benefits are improved value in post moves. Not moving ambulances for the sake ofchanging posts, but in positioning units closer to theirnext call with fewer moves. This also means fewer miles driven with lights and sirens to improve crew safety. Mobile Medical Response (MMR) credits MARVLIS in their annual report with reducing their costs associated with unloaded miles driven. As a collection, these improvementsmean more than any single measure.

The reality is thatour professionis fundamentally changing. We arecoming from an EMS world where measurements of specific vitalperformance areevolving intoa diagnosisof value. Just as good vitals indicate good health, positive measures of performance will be interpreted as higher value. In the same way that a general impression should guide a clinician in measuring vital statistics, the evaluation of an EMS should also be guided by a broader vision of value rather than a microscope trained only on specific measures.

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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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