Tag Archives: EMS response times

Still Solving Problems in Lexington

An awful lot can happen in five years. I know that my own understanding of EMS deployment has deepened a great deal in that time. It was that long ago that I wrote a post about The Cost of Saving Money using Lexington County, SC, as an example. The county EMS Director, Brian Hood, and the now-retired county GIS Manager, Jack Maguire, made a huge statement about how EMS and GIS can work together and achieve incredible results. At that time, Lexington County EMS credited technology with giving them an advantage that helped them plan and respond better.  Even though they were experiencing an average annual growth rate in calls-for-service of about 7-1/2 percent, they had gone over 4 years without adding a single new truck to their fleet. The close relationship EMS had developed with their GIS group also benefited everyone by improving the quality of their street data for all county users. I have repeated this story over the years but when I revisited them recently for a follow-up, I was amazed to learn how much we had both matured.

Chief Hood began by stating that ten years ago their average response time was 11 minutes. Since then, growth in demand for services has continued to range anywhere between 3.5 and 11 percent annually. Still, they have not added a new ambulance to their fleet, but through continual improvement they have that same average response time of 11 minutes today. Their goal is 12 minutes at the 90th percentile. However, pending legislation in the state of South Carolina known as R.61-7 may require times at the 95th percentile for Advanced Life Support (ALS) response. Guaranteeing service at that level can be a daunting challenge for any manager. The response of Chief Hood was to develop a process to address the demands as well as the realities of his agency. At the core of that process is MARVLIS Deployment Planner (a tool for asolvingproblemsutomating system status management) and MARVLIS Deployment Monitor (a live view of current resources and demand with real-time recommendations.) These tools give the Chief and his staff the information they need to know for scheduling and dynamically deploying resources. “If you took these tools away from me, I could not do my job,” said Hood. “History absolutely repeats itself and this system is frighteningly accurate.”

In addition to facing increasing demands and tighter response times, Lexington is facing a lack of paramedic resources the same as many other areas of the country. It is recognized that sending ALS level resources to every call can be expensive and even wasteful of these limited resources when record reviews show that 70 percent of responses only require a Basic Life Support (BLS) level of care. The new solution they have just begun testing is a tiered approach where calls are being triaged based on nearly 200 determinate descriptors to categorize the initial response level. To prevent dispatching high acuity resources to low priority calls, it is not always the closest unit that is assigned to a call by dispatchers. The lowest categories of Alpha and Bravo level are only sent BLS providers in a vehicle that could otherwise provide ALS care. Rather than requiring an ambulance intercept in the event an upgrade of care is required, command staff will arrive in a quick response vehicle to supplement the care available and effectively transform that ambulance into a full ALS unit.

They are also looking at improving provider safety by questioning the use of lights and sirens on most calls. Just as calls can be categorized for the level of responders, they can be categorized for “cold” and “hot” responses that can limit the dependance on lights and sirens. This is still very much a work in process, but key to making it successful will be in the support of county commissioners. The goal of arriving on scene to the highest priority calls on-time 95 percent of the time will mean that other calls designated in the lowest priority responses will take longer. It’s just common sense that decisions must be made when a system has a defined budget with limited resources to get an important job done. The vision to see the larger picture and to achieve the greatest good for all who are involved is the hallmark of real leadership. Problems never really go away, the list just keeps changing and they keep solving them.

1 Comment

Filed under Administration & Leadership, Case studies, Command & Leadership, EMS Dispatch, EMS Topics, Funding & Staffing, Technology & Communications

Stop Dissing Response Times and Start Dissecting the Argument

It is not hard to find an article that bashes the industry’s insistence on measuring response time as a performance goal. The latest one I saw was published just today in “Don’t let response times overshadow the role of EMS” by the respected author Arthur Hsieh. The flow of his article follows the traditional pattern of claiming that measuring time is an outdated historical artifact of EMS without any basis in science, followed by the inevitable near-contradiction confessing that time is critical is only a limited number of cases before finishing by imploring future leaders to take a courageous stand against the uneducated politicians who simply fail to understand our modern evolving business. Hsieh is certainly not alone in making this well-worn, if not self-serving and short-sighted, argument.

Assuming my readers are familiar with the clinical EMS process of assessment, let me present a reasonable differential in terms we can hopefully appreciate. First, what bothers me in the common debate is the assumption that what we see is the totality of the problem. The ingrained reflex of our ABC mnemonic is only for the initial impression, not the final diagnosis. We must resist the urge to simply treat the surface presenting problem and investigate even deeper for an underlying pathophysiology. Our assessment should probe whether the response time concept itself is really the source of the disease, or is it possibly the uncomfortable idea of a formulaic approach to system “compliance” underlying the measure that makes us protest so loudly? Are we taking our frustrations of prescribed protocols out on one single measure when it is actually any measure that attempts to pit arithmetic against our artistic judgement and the free expression of our healing knowledge? Another idea of an underlying cause may be that we equate good response times with unsafe speeds or the very real growing risk of ambulance-involved collisions from excessive speeds and increasingly inattentive drivers. Or could it be a frustration, often expressed as “running hot to a stubbed toe,” that suggests we are simply expending extraordinary efforts on the wrong cases altogether because current EMD processes are not adequately refined in order to triage our limited response options to the unworthy types of calls we are seeing lately?

Without exception, everyone that brings this topic up recognizes at some point that there are clearly instances where time is actually critical. STEMI, stroke, and anaphylaxis are usually among the list of obligatory concessions. Still, we seem way too willing to just “throw the baby out with the bathwater.” In the fire service, there is a well-known motto that says, “train like you fight, fight like you train.” To me, that translates to always practicing the things that are important even if it doesn’t make a difference every single time. There are often instances when (whatever “it” is) genuinely saves a life (whether your own or that of a patient). Sometimes, the “it” is time. There may not be any magic in “10 minutes” (or whatever your standard may be) or even the “golden hour” itself, but there is inevitably an “expiration” on our efforts. There is a time limit when the value of all our interventions diminish to the point that they can no longer buy back the life of our patient. A short response time gives us more time to consider options. It is no longer a question of “stay and play” versus “load and go”, but always to “think and act.” The anxiety of our patients and their family or friends at the scene are measurably lowered by our professional presence. If that is not your experience, then you may actually be correct in believing that your response time truly does not matter.

Just as we do our assessments, we can’t stop at the first symptom of a problem and treat it in isolation. We must often dig deeper to understand an underlying cause that needs to be treated more importantly than just the first observed sign of it. Hsieh is correct in saying that “It’s really time to move on and get with the times,” but  not by neglecting the value of our response, rather in addressing the underlying objection to having it measured. Politicians are never likely to admit to understanding our disagreement to measuring response times because they do not account themselves to us, but to the public that demands our prompt service that keeps them in office. If we insist on expending energy to attempt change, direct that energy in the most productive way it can be used. This begins by recognizing the root problem and the limitations of our interventions to affect change in it.

5 Comments

Filed under Administration & Leadership, Command & Leadership, EMS Dispatch, EMS Health & Safety, EMS Topics, Funding & Staffing, News, Opinion, Technology & Communications, Training & Development, Vehicle Operation & Ambulances