Tag 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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Index of Suspicion Includes Me

It doesn’t take long in an EMT career before the excitement of “rushing to an emergency” turns in to “just another transport call.”  The philosophy of “you call, we haul” in nearly every service can break the community servant’s spirit by turning a skilled paramedic into just an ambulance driver.  But our system “just is what it is,” right?

Well, far from being a service based strictly on tradition, EMS is constantly challenging previous assumptions and struggling to reinvent itself.  How we administer CPR has changed (again), we question the effectiveness of C-spine immobilization that we do standard on nearly every trauma patient, or argue the very validity of the “Golden Hour” around which many services have been designed.  Almost all assumptions are open to be questioned.  I say “almost” because I have found that there still are some boundaries to the willingness of many EMS practitioners to consider change.  Some limitations are easily admitted, like the aversion to legal liability that means we transport anyone who asks us to do so regardless of their suspected need or ability to pay, but there are also less easily acknowledged sacred beliefs.

One of those that comes quickly to my mind is response time.  To many, a quick response indicates excessively fast driving and is contraindicated by safety concerns.  Besides that, we can justify ourselves since very few of our daily calls actually “require” a code response.  While that point may be strictly valid medically, I would argue that our performance is often measured by the public in the agonizing minutes between the 9-1-1 call and the ambulance arriving at the curb.  A patient does not need to be in some form of arrest in order for them, or their family members, to be distressed.  Part of our job is being a calming and supportive influence.  At the same time, I admit that it does not justify putting the driving public or ourselves at risk with an ambulance speeding to every call. But is it really a given that one means the other?

System Status Management – oops, another term laden with strong negative feelings in the field – is actually all about improving performance (both time and economic efficiency) without sacrificing safety.  As advocates for patients, medics see themselves sometimes fighting the system in order to provide the best possible care.  Talk of economic efficiency is seen as just making their job harder.  But again is it really a given that one necessitates the other?

Imagine a system where patient needs are accurately forecast in advance. Where the posting of ambulances is not just another place to sit and wait, but in a practical sense it is the staging for a call that has yet to be received.  Response is thereby improved not by excessive haste, but by the strategic pre-positioning of resources.  The cost savings is not simply an amount  taken from others in a “zero-sum game”, but effectively rescues budgets for proactive wellness programs or, in the current economy, may mean simply saving jobs that allows us in turn to save lives.  This process really works and these systems do exist.  They are called “High Performance EMS” systems and many are profiled here each month while others receive recognition through accreditation agencies like CAAS.  What sets them apart is often observed in technology, but the reality is that it is a culture of seeking constant improvement by the entire staff that makes a difference.

While we consider improvements to the many technical aspects of our profession, let us not neglect the philosophical perspectives that motivate us as individuals.  We operate as a team, not just the pair on the truck, but the whole EMS system is one team with a singular goal.  A goal to do even better each day. So, as we continue to assess our profession should the index of suspicion not include our attitudes toward improving the overall system?

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EMS in the Cloud

According to the Gartner Hype Cycle for 2010, “Cloud Computing” and “Cloud/Web Platforms” have reached the infamous “Peak of Inflated Expectations” and are already sliding down like a fog into the unavoidable “Trough of Disillusionment”.  But the story doesn’t end there as the cloud is expected to rise back upward and eventually reach the ultimate “Plateau of Productivity” within the next 2 to 5 years.  What does this mean for EMS?  Well, first, it means that there is probably still plenty of confusion about what the “cloud” actually refers to and its waning excitement at the moment means the enthusiasm of its promoters is more easily dismissed as the ramblings of zealots “with their heads simply stuck in the cloud.”   However, it is the critical review and appropriate response to technology offerings in just this state that separates the industry leaders from the rest of the pack.

Notice that I did not say the “full adoption” of a new technology, but rather the “appropriate response” to its availability.  As you will see in this post, my forecast of cloud computing is that tomorrow will only be “partly cloudy”.


According to Wikipedia,  “cloud computing describes a new supplement, consumption, and delivery model for IT services based on Internet protocols” (IP).  This means that the cloud really becomes just another computing resource similar to existing enterprise servers except that these cloud-based resources are physically located (and maintained) somewhere else in the world and access is typically provided on a subscription basis that allows them to “scale” (increase or decrease available resources) more dynamically based on demand than traditional hardware installations within an agency.  Additionally, the IP nature of cloud-based resources means that these services can be accessed through a variety of distributed devices from a desktop web browser to a smart phone.  That broad availability raises legitimate questions about security, but cloud-based providers often address these concerns based on the specific security demands of an organization making the broad access more of an advantage to distributed workforces (such as EMS) than a threat.

If you send messages with a Gmail account, listen to Pandora, share your thoughts on Twitter or Facebook, check-in on FourSquare, look up addresses on MapQuest, share files using DropBox, or pay bills online – you already use cloud computing services.  Even the blog post you are reading now was written and delivered using WordPress as a hosted cloud service.  Another WordPress site recently described using the cloud service Google Calendars to create an EMS shift calendar in place of a paper schedule.  A more sophisticated online scheduling system specifically designed for EMS employees is available from Aladtec and used by Deputy Fire Chief Kris Kazian of Countryside Fire Protection District in Illinois who said, “It is one of our better decisions relating to migrating office processes into the ‘e and green’ world!”  Applications like these, or even billing systems which are not as adversely affected by potential temporary outages related to disaster events, are perfect examples for outsourcing to the web.

But not all applications should be considered for hosting off-site just yet.  Besides security, is the question of availability when internet connectivity is down.  For mission critical applications, this type of interruption can be a worst case scenario.  While applications like ArcGIS by Esri are moved to the web, an EMS agency functioning in a pure cloud model could be effectively running blind without any access to their GIS.  However, hybrid models (only partly cloudy) utilizing select web resources from the cloud can be very efficient and still remain effective.  Orthographic imagery, whether satellite or aerial photography, and oblique photography, such as Pictometry can be very resource intensive and difficult to update.  But as a cloud-based web service, they can be very fast, current, and efficient.

To say that the cloud is too confusing, or that the technology is not ready yet is clearly a misunderstanding of the resources available from the cloud.  On the other hand, it is not necessary to go overboard by planning to completely outsource everything to the cloud either.  Now is the perfect time, however, to evaluate and plan for how your agency will leverage this technology in the future.  The cloud is not coming – it is already here!

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HP-EMS Profile: Sedgwick County EMS

It has been much more than a month, but we will return to featuring a monthly profile of High Performance EMS sites in order to inspire others to reach beyond just compliant services to provide advanced out-of-hospital care while focusing on improved efficiency.  This time, our spotlight is on Sedgwick County Emergency Medical Service of Kansas.

Sedgwick County EMS

Sedgwick County EMS

The public EMS agency in Sedgwick County is responsible for ALS out-of-hospital care and transportation for both acutely ill and injured patients as well as providing scheduled ambulance transportation services within an area of 1,008 square miles serving a population of approximately 498,000 residents.  In 2010, Sedgwick County EMS responded to 52,815 calls for service.  They are also proud to be part of an elite group of CAAS accredited agencies across the nation signifying that they have voluntarily met the “gold standard” determined by the ambulance industry to be essential in a modern EMS provider.  The CAAS standards, which often exceed those established by state or local regulation, also define High Performance EMS as they are designed to increase operational efficiency and clinical quality while decreasing risk and liability to the organization.

In addition to efficient performance, another hallmark of a High Performance EMS provider is community involvement.  Sedgwick County EMS is a regional BLS Training Center for the American Heart Association teaching CPR classes and frequently participates in local school programs by visiting classrooms to educate children on accessing the emergency system and demonstrating their equipment to make students more familiar with EMS should they ever need to access it.

This past summer, Sedgwick County EMS was selected as a 2011 “Health Care Hero” by the Wichita Business Journal.  The award was given in the health care innovations category which honors a person or organization for breakthroughs in medical technology ranging from research to a new procedure, device or service.  In addition, Sedgwick County EMS received the 2011 advanced life support (ALS) Ambulance Service of the Year award from the Kansas Emergency Medical Service Association (KEMSA) in recognition for promoting EMS in Kansas.  These honors recognize Sedgwick County EMS for the implementation a number of software upgrades that improved automated scheduling, patient care reporting, and deployment practices, among others.

Sedgwick County EMS Director Scott Hadley said in an EMSWorld article this week, “We needed a communications platform and software solution that would support our latest enhancements and upgrades to dispatch and deployment practices, automated scheduling, and patient care reporting for the entire health care system. In Motion Technology and Bradshaw Consulting Services are providing us with the tools we needed to support our mobile healthcare technology to benefit the citizens of Sedgwick County.”

Showing that properly implemented System Status Management can ensure the right response at the right time, Hadley says, “EMS crews have been hitting their goal of getting to destinations in less than nine minutes more than 90 percent of the time for 24 straight months.  That means technology is doing what it’s supposed to do and furthering the mission of the agency.”  Demonstrating the final component of a successful High Performance EMS, Hadley says “it’s our responsibility to continually improve our patient care.”

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GIS for EMS

Both acronyms (GIS and EMS) represent not just technologies, but fields of study and service that have very old roots even though each can trace their modern form to research starting in the 1960s.  Both have witnessed explosive growth and application far beyond their original vision.  But most importantly, these two names definitely belong together.

Those who have any knowledge of Geographic Information Systems (GIS) will often think first of maps at the mention of its name.  Maps, however, are simply the form GIS professionals use to express the actual work done with a GIS.  That work consists of maintaining a descriptive spatial database and using that database to perform analysis that answers real-world questions or solves domain specific problems.  There are many examples of how it can be applied, but here we will discuss just those in support of Emergency Medical Services (EMS).

At the very simplest end of the spectrum is printed mapbook production.  Because GIS “maps” are stored as data rather than graphics, they are easily edited and symbolized in different ways to meet different objectives.  For use in ambulances, maps should be quick references primarily showing roads (with street names and block addresses) and landmarks essential for navigation.  Street index creation is an automated function of the GIS that can make a printed book of maps more useful for crews attempting to find a specific street.  Better still is an interactive map – one that can locate your current position using GPS and can automatically search an address (a process called “geocoding” or “geovalidation“) and recommend an efficient route between these two points.  This function is manual in printed form but interactively can leverage historic “time-aware” travel impedances (the actual time it takes to travel a certain road segment in a specific direction given the current time of day based on your own past experience) and even access known road closures due to ongoing accidents or scheduled construction to provide realistic travel times and routes given current conditions.  The database can also be used to locate not just the closest vehicle, but make unit recommendations based on additional criteria such as special equipment or training.  When these interactive maps are used with ruggized touch-screen computers or new tablet devices, you have a powerful combination that can also support ePCR charting or other applications.

When a fleet of ambulances can provide positional and status information to the call center, the dispatchers have a better situational awareness of the functioning system in real time.  Then by using additional GIS functionality to map previous incidents, a “hotspot” map (a map showing the areas of highest likeliness for generating a call) can be created to forecast future demand using simple predictive analytics.  In the past, some organizations have poorly implemented a form of System Status Management (SSM) that failed to meet the objective of increasing efficiency and left many paramedics soured on the idea of post moves.  Effective implementations (some highlighted in past blogs here) have shown that Jack Stout’s idea can be properly done in almost any system using modern technology.  Moreover, by positioning ambulances closer to their next call, not only is response time reduced but the incentive to be hasty in that response is also reduced leading to less risk in travel.

Beyond these daily tactical applications of GIS, there are many potential strategic ones.  Preventing a call is better than an emergency response at any speed.  By looking beyond just the calls for service in the coming hour, we can begin to look further into the future and recognize specific risks of target lifestyle groups.  Preventive care or community wellness programs can be directed at the most vulnerable populations to maximize the investment of such a program.  Locating groups with increased potential for cardiac problems can aid in locating a blood pressure screening event as one example.  Some agencies have turned to GIS to help them find new recruits or volunteers.  I encourage you to communicate with your local GIS staff and let them know how they can help you.  After all, assisting you to become more efficient helps them show value as well.  You do not need to know the details behind the analytical tools, it is your existing knowledge of the community and its needs that will help your GIS staff address them.  If you lack those resources locally, or have specific questions, please make a comment below and I will follow up with you directly.

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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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