Tag Archives: response time

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.

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Filed under Administration & Leadership, EMS Dispatch, EMS Topics, Fire Dispatch, News, Opinion, Social Media, Technology & Communications, Vehicle Operation & Ambulances

The Role of Response Time in EMS Performance

Several months ago, Rob Lawrence of the Richmond Ambulance Authority started a thread on the High Performance EMS Group of LinkedIn by asking “So what does the phrase ‘High Performance EMS’ mean to you?? This innocent sounding question sparked immediate debate even within the small group at that time. Benjamin Podsiadlo of AMR quickly tied the quality of EMS performance to “experience? and “outcomes? stating further that “response time is not an evidence based factor in ALS performance.? He later backed up his assertion by writing that “the catch 22 of pushing the workforce to be responsible and accountable drivers while simultaneously achieving narrow response time goals to the vast majority incidents that have no medical need for such high speed driving is also a bizarre and irresponsible contradiction.? This is a point that even Lawrence admits could foster the “mentality of ‘arrive on time and the patient dies – good outcome, arrive late and the patient lives – bad outcome’? that has already been affecting common sense both in the UK and increasingly in the US since NFPA 1710 set response time standards several years ago.

While there were other good comments, I would like to focus on the specific assertion that measuring response time (a well established practice today such as at Huron Valley Ambulance’s public web Performance Dashboard) is not an “evidence-based? practice. There are many specific accounts of individual lives saved that I have heard mentioned by different agencies, but I will concede that the plural of “anecdote? is not “data?. However, one of the best stories of response time saving lives was made on February 9 when Richard Sposa of Jersey City Medical Center EMS discussed an interesting finding in a recent webcast. The chart reproduced here shows a correlation between

Return of Spontaneous Circulation vs. Response Time

response time and the Return of Spontaneous Circulation (ROSC). This unexpected finding clearly traced an upward trend of ROSC with the decline in Average Response Time for Priority 1 Calls graphed quarterly from the beginning of 2005 to the end of 2007. This is a verified statistical trend (Mount Sinai Hospital reviewed these findings) and I suggest you click to view the graph in full detail. This shows not just living anecdotes, but a statistical increase patients with restored heartbeats.

Many things about our business can and should be questioned, but this is exactly the sort of evidence I would like to see investigated at other services. Can what Jersey City Medical Center is experiencing be reproduced elsewhere? And probably more importantly, does fast response necessarily mean “high speed driving??

The point of System Status Management (SSM) is that ambulances can be effectively pre-positioned through scientific statistical forecasting in order to reduce the time of a response even without driving faster to the call.  Zoll Software Solutions, as an example, considers the elimination of inefficiencies to be a core component for closing the loop on your dispatch process and is even offering free medical equipment to customers who use this technology to improve their system. One customer who has done this already with Zoll technology is Grand Rapids who was also featured in the following FOX News video on Predicting Where your Next Emergency will Happen.

If you believe that knowing where your next calls are likely to come from in time to allow you to safely prepare for that response, the science is available today. You just need to be able to integrate that knowledge into your process.

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Filed under Dispatch & Communications, EMS Dispatch, EMS Topics, Opinion, Rescues, Technology & Communications, Uncategorized, Vehicle Operation & Ambulances

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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HP-EMS Profile: Jersey City Medical Center EMS

The High Performance EMS we examine this month is Jersey City Medical Center EMS  located just across the Hudson River from Lower Manhattan.  It is a triply accredited service, receiving the CAAS, NAED’s ACE, and CoAEMSP accreditations all in the same year.  As a part of the LibertyHealth System, it serves the residents, workers, and visitors of Hudson County, NJ by responding to nearly 90,000 calls a year.  JCMC EMS provides both Basic and Advanced Life Support as well as services for special operations, neonatal transfers, critical care inter-facility transports, regional EMS communications, and more.

Few modern ambulance services can claim over 100 years of history, but this organization has been providing prompt, professional pre-hospital care since the days of taking patients to the Medical Center in horse-drawn ambulances.  Today, however, JCMC EMS is one of the most technically advanced EMS agencies in the country with an impressive response time averaging 6:02 – well below the 7:59 city standard.

Richard Sposa, EMS Communications Coordinator at JCMC EMS, describes how they continually improve their service saying “positive patient outcomes are the goal for any EMS agency, and at Jersey City Medical Center, it is our guiding light.  The Jersey City Medical Center’s EMS Department has taken a leadership role in positive patient outcomes by examining real life scenarios.” More specifically Sposa says, “we made a self-realization in 2005 that the system as a whole was in need of improvement in a multitude of areas, and the most notable were our response time and asset deployment.  With the help of Bradshaw Consulting Services and the MARVLIS system we were able, in less than a years time, to reduce our response by over two minutes.”

The MARVLIS application forecasts demand dynamically and displays the probability of incoming calls as a colored surface.  As paramedic David Pernell describes it, they “chase the blob” likening the constantly updating application to an animated weather forecast showing upcoming need allowing resources to be better deployed when called upon.

As one of the largest and busiest EMS systems in the state, they are proud to play a vital role in domestic preparedness education, homeland security response and educating the public and healthcare providers in CPR and advanced adult and pediatric life support.

“With an in-house study we have undertaken,” said Sposa, “we have seen that the drop in response time has improved patient survivability.  With the data collected so far we hypothesize that by reducing our response time by two minutes we will have the ability to return pulses to as many as thirty more patients a year.”  What more could be said about high performance in EMS!

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