Tag Archives: high performance EMS

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?

Advertisements

Leave a comment

Filed under Opinion

The Cost of Saving Money

There are two fundamental ways to save money: either cut your budget and make do with less resources or invest in process efficiency to cut future expenses while continuing to provide at least the same level of service.  These are important considerations as the costs of doing business clearly continue to increase, whether we consider the expenditures on goods used in providing a service or the price of fuel used to deliver that service.  At the same time, the ability to effectively raise the price of the delivered service in order to recoup those additional expenditures is not typically possible.  This paradox leaves many ambulance services in a quandry.  If your decision is to continue operating at a diminshed capacity to reduce spending, there is probably little advice I can offer.  But if cutting service is not a prudent long-term option, then we can look at how an agency looks to improve performance.

A good case study may be the Lexington County (SC) EMS, a service directed by Brian Hood responding to roughly 30,000 calls per year.  As a growing county outside one of the largest cities in South Carolina, Lexington has seen their call volume grow at an annual rate of about 7.5%.  To keep pace with this growth in demand, they would likely have needed to add one new vehicle per year at a cost exceeding $3M for an ambulance, crew, station, equipment, etc.

Additionally, one of the ongoing, and rapidly growing expenses, for any service delivery organization is the rising cost of fuel.  Controlling mileage can often be a great option for managing expenses.  Of particular interest to some services is also the incurring of fines for exceeding response times.  This is a particularly good area to control costs for affected services since this type of expenditure does not lead to any revenue nor does the payment itself provide any service.  But to achieve these goals, performance must improve.

High Performance EMS is about doing things better – specifically providing advanced pre-hospital care with a focus on higher economic efficiency.  The result of better performance is patient satisfaction with cost savings.

For Lexington County, the more efficient posting of ambulances based on predicted demand and time-based routing using MARVLIS has allowed the service to actually improve response in the face of rising demands while foregoing the acquisition of additional resources and the commitment to ongoing costs associated with them.  Over the 4 year period since implementing MARVLIS, the projected cost savings of $3M per year is compounded by the avoidance of recurring staff costs and therefore totals closer to$16M for that period.  The initial investment required to make that savings was less than $400K in hardware and software systems.  As a result, satisfaction has improved for both the patients (who experience quicker service), and also staff (who endure fewer post moves while being closer to incoming calls.)  This is not just a promise or hope of what might happen, but a real world experience of leveraging county GIS services and an experienced High Performance EMS consultant, Bradshaw Consulting Services.  Watch for a more detailed article soon from Esri Press.

2 Comments

Filed under Case studies, ems

The Future of Prediction

I have read the positions stating that calls for emergency services are completely random (justifying the reason they are often called “accidents”) and therefore not able to be predicted.  But both academic literature and practical experience show that demand prediction can be an effective tool in helping to balance scarce resources (ambulances and their trained crews) with public demand (requests for emergency responses even without taking into account the abuses to the system as discussed in a previous posting on the problem of “frequent flyers”) while still improving response times and controlling costs.

For anyone who thinks all of this sounds too good to be true, there are examples of where expensive technology is not having the desired affect.  One such location is Lee County EMS in Florida where not only have response times not been improved, but ambulances are burning more fuel than ever and the critics include the very paramedics it is supposed to help.  While predicting where the next 911 call will come from may be similiar to “picking the winning card at a casino” as the Florida investigative news reporter suggests, that isn’t really the objective.  We don’t need to know which phone will make the next call, it is enough just knowing the probability of a call coming from any given location within the service area.  This may be a subtle distinction, but one that makes a huge difference at MedStar in Fort Worth or Life EMS in Grand Rapids where response times were dramatically improved by taking the next step beyond simple demand prediction and placing ambulances at positions where they can be the most effective.

Academic studies show that demand pattern analysis can be used without hourly, daily, or seasonal calibration to achieve potentially acceptable tolerances of demand prediction, but when adjusted with these appropriate corrections, software applications like MARVLIS (the Mobile Area Routing and Vehicle Location Information System) can effectively predict demand in practical situations.  According to Tony Bradshaw of BCS, the makers of MARVLIS, it routinely calculates where about 80% of demand will occur and when paired with realistic drive-time response zones it demonstrates valuable support for a dynamic System Status Management plan to pre-position, or “post” ambulances closer to their next call saving valuable time and increasingly expensive fuel costs.

What matters most, though, is what agencies experience in the field.  At SunStar they say ” the most significant result was improving our emergency response time from 90.2% to now over 93% in lieu of an increase in patient call volumes.  This equates to ambulances arriving on scene more than 1 minute quicker.  We additionally saw a savings of $400,000 in penalties by exceeding our contractual goal of 92% and performing above 93% compliance.”  Similarly, Steven Cotter, Director of Sedgewick EMS added that “the technology has opened our eyes to be able to understand how we are performing, where we are deficient in our performance and how we can make changes quickly and adapt to a changing environment.”  And beyond simple response times, “it’s what technology should do,” says Joe Penner, Executive Director at the Mecklenburg EMS Agency, ” take the complex and present useful, straightforward information.  It has helped us improve response times, resource utilization AND simultaneously reduce unnecessary post moves — your patients and employees will appreciate it!”

My conclusion is that proper demand prediction paired with realistic response creates significant opportunity to improve performance and cut costs even in growing communities.  When used properly, the future looks bright for High Performance EMS!

1 Comment

Filed under ems, Technology