Examining the 2020 Vision of EMS

The NHTSA Office of EMS released a significant document last year called the EMS Agenda 2050 that was carefully crafted to set a bold vision for the next 30 years of paramedicine by clearly differentiating the focus of care from its original definition in the 1996 EMS Agenda for the Future. Now, after just a few months of a COVID-19 pandemic, we have seen these modern precepts being challenged. As with any such vision of the future, a bit more perspective then just the immediate quarter is required. Before stepping toward the future, it is important to know exactly where we are today. To provide that update, NASEMSO released a new National EMS Assessment this past April to provide a measure of emergency medical response personnel and their agencies in this pivotal year of 2020. Although the latest survey is only updating the original work of a decade ago, there have been such dramatic changes that direct comparisons, even over this relatively short time frame, are difficult. To help bridge that gap for comparison, the folks over at ZOLL did a quick blog to reflect on the evolution of the EMS industry since 2011. Still for many, a little more context on how we got this far may be helpful before we can truly understand the significance of these most recent discussions regarding the future of EMS.

It was only back in 1960, that President John F. Kennedy made the statement that “traffic accidents constitute one of the greatest, perhaps the greatest, of the nation�s public health problems.” The automobile was well entrenched in the new American dream by this point as ribbons of smooth highway were unrolling across the country that facilitated speeds of travel much greater than the safety aspects of the car would afford. Yet it wasn’t until 1966 that the National Academy of Sciences ‘white paper,’ officially titled “Accidental Death and Disability: The Neglected Disease of Modern Society,” that ambulances began to transform from a side business at funeral homes into our modern Emergency Medical Systems of today. This initial milestone report, delivered during the Vietnam War, stated that �if seriously wounded � chances of survival would be better in the zone of combat than on the average city street.� So, the signature of President Lyndon Johnson provided federal funding through the National Highway Safety Act of 1966 that not only provided for the establishment of EMS programs, but thoughtfully placed the system within the federal Department of Transportation. Although the Omnibus Budget Reconciliation Acts of the 1980’s under President Ronald Reagan transformed direct federal EMS funding into state preventive health and health services block grants, federal guidance remained within the National Highway Transportation Safety Administration.

The numbers 9-1-1 were added to the American experience by AT&T in 1968 and it grew slowly across the nation as more communities demanded Emergency Medical Services. The most effective recognition of out-of-hospital care throughout the 1970’s came as the result of a television show simply called “Emergency!” This drama highlighted the results of efforts by early cardiologists like Drs. Lown, Zoll and Pantridge in having developed portable devices capable of disrupting the lethal dysrhythmias of v-fib effectively parlaying paramedicine from a focus primarily on trauma to include chronic medical conditions within the home as well. Pediatric trauma would not be officially recognized until 1984 with an Emergency Medical Services for Children study leading to a report finally published in 1993. The patchwork quilt of EMS continued to grow with increasing interest and even more piecemeal funding. Economist Jack Stout led a revolution in economic modeling of EMS systems during the 80’s and 90’s in response to the imbalance of demand and financing that had already fractured EMS into a kaleidoscope of models from fire-based, public safety to “third-service” public utility models to for-profit integrated healthcare businesses. 

It is certainly no accident that our industry has ended up in the position we are today. As W.E. Deming has taught the world, “every system is perfectly designed to get the results it gets.” And we proudly embrace the philosophy that states “when you’ve seen one EMS, you’ve seen one EMS” because we still believe that each service knows the particular unique expectations of their individual community while allowing insurance companies to dictate reimbursement rates. As a result, there is little federal standardization beyond a minimum national level of competency and few local agencies that are funded as “essential services”  even though the NAEMT has advocated this position for years. 

Today, it is heart disease that has overtaken the American consciousness as waistbands expand across the countryside demanding more from our organs than the body was designed to provide. In addition, we face new biological and socio-economic challenges for delivering healthcare in the field. We’ve needed a new road map like the EMS Agenda 2050, but we can’t just sit back and wait for it to happen. As professionals, we all need to educate ourselves on topics like Emergency Triage, Treatment, and Transport (ET3) and health information exchanges that are being piloted at select services. We must be the change we want to promote. 

 

Advertisement

What is "Performance" in EMS? Part 1

It is that time of year for resolutions and reflection. As I ponder this thought, the topic that sticks out to me is about what really constitutes a “High Performance EMS.” As we look back over the past year of the High Performance EMS social network (including our Twitter and Facebook feeds as well as this blog) one of the recurring comments that disturbs me is that “response time doesn’t matter.” This causes me concern in two ways – first, that the primary measure of performance is overwhelmingly always “response time�? and the other is that this simple measure is deemed to not really be important. So, for the next few posts, I will discuss various characteristics that I feel do matter in becoming a truly high performing EMS system.

Part 1: Response Time

This past February, Elsevier published an excellent newsletter (EMS Insider, Volume 39, Number 2) focused on EMS response times and included articles such as “The Great Ambulance Response Time Debate Continues�? in which the author, Teresa McCallion, laid out many of the facts. For instance, the article recites the “MedStar example” from Super Bowl XLV suggesting that very few EMS calls” in that prospective two week study actually “required an immediate response. It is important to note that this statement did not go so far as to say that response time is meaningless in all cases – just that it is far less limited in most. Then as counterpoint to dismissing response times altogether, the public conflict at EMSA in Oklahoma City was brought up where at least one politician complained of the number of excluded calls required in order to reach a 90% response time compliance rate. This is only a single instance, but we all understand that it is certainly indicative of how the public measures the value we provide. In the conclusion, Matt Zavadsky, MedStar EMS Associate Director for Operations, offered several good recommendations to improve patient outcomes and public understanding of the EMS system. While I agree with nearly everything he said, I would really only argue with his statement that began, “There is no such thing as an inappropriate request for 9-1-1, (which is a whole other topic) but then he added there is such a thing as an inappropriate response to that request.” I can only assume he was referring to the fact that accidents sometimes happen en route to calls. While these incidents point out failures in judgement somewhere, it is not the “response�? itself that is at fault.

Zavadsky also authored another article in that newsletter entitled “Response Time Realities: The Scientific Evidence.�? Interestingly, several of the studies he cites actually help to make the case for effectively reducing response times under 4 or 5 minutes in certain cases rather than eliminating the standards in general. Furthermore, the quotes he uses from the 2008 “Gathering of Eagles” consortium position paper entitled “Prehospital Emergency Care�? do not discount the time of a response, but instead point out the unsupportability of “over-emphasis on response-time interval metrics�? compared to the “unintended, but harmful, consequences (e.g. emergency vehicle crashes) and an undeserved confidence in quality and performance.” While I also cannot justify the 7:59 standard used in many urban areas, I also cannot condone apathy toward responding timely. Maybe I am overly sensitive to the literal meaning of “response time doesn’t matter�? when justified with the statement that the “golden hour�? is just a myth. For most of us, at least 10-20% of calls include a cardiac, respiratory, stroke or other event where time really is critical and we must be at the top of our game to prevent a death or minimize as much loss in quality of life as possible.

My concern in these arguments is an unstated bias that “response” means only the arrival of an ALS-experienced paramedic traveling with red lights and sirens from a fixed fire station. Technically, “response” must be understood as simply the time between a call for emergency assistance and the initiation of appropriate necessary treatment. For many calls, that care could be BLS-led in most circumstances assuming that the calls are appropriately triaged at dispatch. Emergency Medical Dispatch itself even provides some level of immediate guidance in care with a response time of zero. Additionally, the greater availability of defibrillators as well as more common knowledge of compression-only CPR means that initial emergency life-saving care can be initiated well before any ambulance arrives. The existence of advanced telemedicine devices (such as the LifeBot-5) are also changing the rules by providing advanced medical consultation even more quickly in remote rural areas typically with far longer average ALS arrival times.

My point is not necessarily trying to get medical responsders moving faster, but to redefine response time not just as the metric for the ambulance arrival to justify budgets but as a factor that affects patient outcome. There are many ways to achieve this goal and it begins as education within the system as well as with the public because technology is changing the dynamics. Zavadsky’s points are valid. Making defibrillators more available and teaching the public how to respond when a medical event is witnessed is critical. Also while adding ambulances and staff to more locations would be another way to address reducing response time, it is not financially practical. An effective alternative to achieve that same goal would be to position the responders closer to the call thereby minimizing distance and the associated need for risky driving. Modern “dynamic system status management�? practice has proven that response time can be shortened to most calls (at least 80-85%) without the need for excessive driving risk that places crews or the public in danger. Improving performance means responding appropriately in less time – not necessarily just responding “faster.” Technology can be evaluated as being “outcome-based�? just the same as patient treatments.

Watch for future posts which will highlight other components of performance-based EMS beyond just measuring and improving response time.