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Fire-Based EMS: Avoiding a Future Flashover

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Title: Fire-Based EMS: Avoiding a Future Flashover


1
Fire-Based EMS Avoiding a Future Flashover
  • Mike McEvoy, PhD, NRP, RN, CCRN
  • EMS Coordinator Saratoga County, NY
  • EMS Editor Fire Engineering magazine
  • Professor Emeritus Albany Medical College
  • www.mikemcevoy.com

Sponsored by
2
Disclosures
  • None
  • I dont know how to play golf or ski

3
(No Transcript)
4
www.mikemcevoy.com
5
Author EMS Chapter 7th Edition to publish in
2012
6
Outline
  • EMS overview and demographics
  • Past, present and future predictions
  • Fire Chief
  • EMS Chief
  • Key Issues
  • Imperatives
  • Summary

7
EMS In the U.S.
  • Ambulance services
  • EMS Agencies
  • 93 take 911 calls
  • 65 transport capable
  • 28 non-transporting
  • 4 SCT
  • 2 air medical
  • 2 ground based
  • Ambulances
  • Annual 911 calls
  • Fire Departments delivering EMS
  • 15,726
  • 19,971
  • 48,384 54,598 excluding air
  • 200 million, 50 are EMS
  • 81

AAA, IAFF, NENA data sets
8
EMS Providers U.S. 2011
Annual Students EMT 120,000-150,000 Medic
25,000-30,000
NASEMSO 2011 EMS Industry Snapshot
9
EMS Vehicles U.S. 2011
10
EMS Organizational Types
NASEMSO 2011 EMS Industry Snapshot
11
EMS Provider Age Distribution
NASEMSO 2011 EMS Industry Snapshot
12
EMS Past, Present and Future
  • 1958 MTM
  • 1960 CPR
  • 1966 NAS white paper ? DOT/NHTSA
  • (Accidental Death and Disability the Neglected
    Disease of Modern Society)
  • States required to establish EMS Regional Systems
  • Training curriculum developed
  • 1969 EMT-A
  • 1970s Systems, residencies, AHA
  • 1984 EMSC

13
EMS Past, Present and Future
  • 1910 First air ambulance built NC, tested in FL
  • flew 400 yards and crashed
  • 1926 Phoenix FD, others - inhalator calls
  • 1940s WWII hospital personnel shortages turned
    ambulances over to FDs
  • 1960 LAFD adopts EMS
  • 1969 Miami FD first medics, Seattle Medic 1
    debuts
  • 1971 Emergency!

14
EMS Past, Present and Future
  • 1973 Denver Flight for Life, DOT Star
  • 1978 Phoenix FD Medic Engines
  • 1979 JEMS, AAA
  • 1981 Block grants, EMD debuts in SLC
  • 73 FDs are providing some level of EMS
  • 1986 COBRA
  • 1992 AMR on NYSE
  • 1995 LAFD Paramedic Engines
  • 1996 FDNY absorbs NYCEMS
  • 1997 SF and Chicago Paramedic Engines

15
EMS Today
  • Complex, lacking standardization
  • Poorly reimbursed, serious issues
  • Many service delivery models
  • No single model universally appropriate
  • Often a default gateway to healthcare
  • Requires increasing expertise/training
  • Administrators, providers, physicians
  • Highly Competitive

16
EMS Trends 2011
  • State EMS Directors Report
  • EMS Regionalization ? 25
  • Pure volunteer EMS converting to mixed
    paid/volunteer 76
  • National Market Observations
  • Major consolidations, sales, buyouts
  • 2010, Falck (Danish equity firm) buys Care (CA)
    and LifeStar (East Coast)
  • Feb 2011, EMSC parent of AMR bought by equity
    firm Clayton, Dubilier Rice (CDR)
  • June 2011, Rural Metro bought by equity firm
    Warburg Pincus, LLC

17
www.falck.com
  • Danish firm prevention, response, recovery
  • Major EMS Provider Denmark, Poland, Sweden,
    Belgium, Finland, Norway, Slovakia
  • Fire Service Provider Denmark, Brazil,
    Netherlands, Romania, Slovakia, Sweden, UK
  • Plans for southern Europe, South America and
    Mexico.
  • 2008 bought Alford, expanding training into US
    (Houma, LA)

18
Why Big Equity Investors?
19
Expected EMS Demand
  • 80 calls per 1,000 population (currently)
  • High 114
  • Low 70

20
Show Me the Money
Levine D Graybow M. The Battle Over 911.
Reuters. April 15, 2011
21
Specialty Care Transport
  • SCT (interfacility) more
  • Significantly better collection
  • Opportunity?

22
EMSC Sale February 2011
Levine D Graybow M. The Battle Over 911.
Reuters. April 15, 2011
23
Rural Metro Sale June 2011
Levine D Graybow M. The Battle Over 911.
Reuters. April 15, 2011
24
Fire-Based EMS Today
  • Despite significant EMS role, Fire has failed to
    position itself as a key EMS player on federal,
    state, local and international levels

25
If Fire Were a Key Player
  • Drug companies would market to us

26
2 Biggest EMS Challenges for Chiefs
  • Embracing the EMS mission
  • Competing in the marketplace

27
Fire and EMS Clashes
  • Major cultural differences
  • Response Paradigm
  • Customer Base

28
Response Paradigm
  • Fire
  • EMS
  • Rapidly escalating incidents
  • Success requires well coordinated attack
  • Large numbers of firefighters needed
  • Emphasis on teamwork
  • Failure is blamed on team
  • Incident size fixed, rarely grows after dispatch
  • Success requires training and preparation
  • One provider needed for most responses
  • Emphasis on individual
  • Failure blamed on individual provider

29
Customer Base
  • Fire
  • EMS
  • Protect property
  • Property owned by higher socio-economic classes
    (jobs, money, resources)
  • Protect people
  • Typical EMS user profile fits lower
    socio-economic sector of society

30
How Do We Embrace the EMS Mission?
  • Cultural
  • Promote the real job
  • Hire people who want to do the job
  • Support, promote and reward performance
  • Integrate EMS into FD mission

31
Fire Dinosaurs Maybe theyll die off?
  • The pictures pretty bleak, gentlemen. The
    worlds climates are changing, the paramedics are
    taking over, and we all have a brain about the
    size of a walnut.

32
Recruiting Hiring
  • What percentage of your calls are EMS?
  • How about your name/patch/uniform?

33
Job Posting
  • Class Specification FIRE FIGHTER
  • ITEM NUMBER 0199
  • APPROVAL DATE 05/09/2001
  • DEFINITION Performs fire fighting and rescue
    duties in all types of fires and in other
    emergency situations, and enforces Fire
    Prevention Codes.
  • CLASSIFICATION STANDARDS Positions allocable to
    this class receive technical and administrative
    supervision from Fire Captains and perform a full
    range of fire fighting and related duties on an
    assigned shift. These positions must respond
    immediately at any hour of the day or night, in
    any weather, to combat life or property
    threatening emergencies. Incumbents typically
    work under hazardous conditions, such as those
    that involve exposure to fire and smoke. All
    positions in this class require the physical
    stamina to perform such strenuous activities as
    ascending or descending ladders while carrying
    victims or equipment in order to effect rescues,
    as well as the ability to manipulate equipment,
    such as fire hoses, power tools and hand tools.
    Incumbents must exercise working knowledge of
    fire fighting principles and techniques, the Fire
    Prevention Code, Emergency Medical Technician
    (EMT) principles and techniques, and the proper
    use of fire fighting and EMT tools and equipment.

34
Performance Evaluation
35
Performance Evaluation
36
FD Embracing EMS
  • Is every department vehicle equipped to respond
    to a medical call?
  • Do your prevention staff provide injury
    prevention, first aid/CPR classes, health
    prevention services and inspections?
  • Are fire crews attuned to EMS and safety hazards
    in the community?

37
Embracing the EMS Mission
  • Definitely cultural, requires introspection
  • Establish a vision and defined behaviors

38
Target Effectively Competing
  • Performance targets for success
  • Price
  • Quality
  • Customer Service
  • You cannot do this alone!

39
Pricing Fire-Based EMS
  • Fire personnel tend to cost more
  • Is there added value?
  • Can you prove it?
  • What efficiencies are accessible?

40
Survival By the Numbers
USA Today March 1, 2005 Examined 12 US cities
with highest OOH cardiac arrest survival rates
compared to medics per capita. Often, cities
with least number of medics had highest survival
rates.
41
Market Shares
Levine D Graybow M. The Battle Over 911.
Reuters. April 15, 2011
42
Differentiating Fire-Based EMS
  • All hazards capability
  • Operate in hazardous environments while
    simultaneously providing patient care
  • Others unable, untrained, unequipped

43
How is the Fire Reputation?
  • Not perceived as good quality
  • 50 largest US cities study
  • Chute time 42 seconds longer for cardiac arrest
    vs. structure fire
  • Firefighters unhappy, they signed on to fight
    fires, not tend to sick people.

Six Minutes to Live or Die. USA Today. May 20,
2005
44
EMS is Complicated
  • Community
  • Patients and families
  • Citizens
  • Businesses
  • Health Care
  • Hospitals
  • Doctors offices, nursing homes, clinics
  • Public Health Departments
  • Medical Control
  • Insurers
  • Legal system
  • Attorneys
  • Courts
  • Regulators and Government
  • Federal
  • State
  • Local

45
Who is Mrs. Smith in EMS?
  • Patients, families, friends, partners
  • Other EMS services
  • Community members, neighbors
  • Physicians, nurses, hospitals
  • We need to be at decision making tables!

46
Who Really Runs EMS?
47
EMS Officer
  • Duties of administering a fire-based EMS program
    must be delegated to a qualified EMS officer
  • Good EMS provider ? good officer
  • Same management skills as fire officers
  • Minimum skills department skill level
  • If routine fire suppression interface, also
    competent in fire suppression (credibility need)
  • Qualifications match peers (local level)
  • College degree helpful (hospital interface)

48
EMS Officer Skill Set
  • Strategic Planning
  • Identifiable measures
  • Benchmark locally and nationally
  • Budgeting and financial projections
  • Customer Service and Marketing
  • Follow up customers unmet needs, resolve
    complaints, obtain feedback to improve service
  • Improve satisfaction (i.e., scripting)
  • Community outreach chronic problems and safety
    issues

49
EMS Officer Skill Set
  • Human Resources
  • Much more intensive hiring/orientation process
  • Medical clearance, vaccinations
  • Ongoing training, medical surveillance
  • Continuing Education
  • Medical competencies
  • Financial
  • Medical billing, CMS
  • Costing, budgeting
  • Grants

50
EMS Officer Skill Set
  • Fleet Management
  • EMS apparatus lags behind fire
  • Medical liability mandates special procedures
  • Incident Management
  • Demonstrated experience running mass incidents,
    mass gatherings, drills
  • COOP (Continuity of Operations Plans)
  • Interagency Operations
  • Routine mutual aid linkages
  • Ties to state and federal EMS MA plans

51
EMS Officer Skill Set
  • RMS/EMR and HIPAA
  • Broad familiarity including reporting,
    customization
  • Research track record
  • Communications
  • Working knowledge of EMD and EMD QI
  • Experience with alerting, recall and
    electronic/social networking technologies
  • Risk Management
  • Thorough knowledge of risk mitigation

52
EMS Practice is Delegated
  • Practice of medicine restricted by law
  • No EMS provider is a lone ranger
  • All care delivered under the license and
    supervision of a physician medical director
  • Every provider must be affiliated with an EMS
    agency
  • Every agency must have a medical director

53
Medical Control
  • What is Medical Control?
  • Physician direction/oversight
  • establish and maintain guidelines for care
  • OLMC
  • Off-line (protocols, standing orders)
  • Credentialing
  • Education
  • QI, interface
  • Physician responsibility/accountability
  • Physician LIABILITY

54
Doctor Who?
  • 2006 Assessment of docs employed in EMS for
    knowledge of BLS, ALS, and medicolegal duties.
  • Average score 45.4
  • - Kimaz S, et al. Ulus Travma Acil Cerrahi Derg.
    2006 Jan1259-67. (Translated from Turkish).

55
Physician Medical Director
  • Compensated
  • Local doc
  • Contracted service (ED or EM group)
  • Clear job description
  • Represent department
  • at local, regional,
  • state levels
  • Close relationship with Fire and EMS Chiefs

56
Lawsuits
  • 1 in every 20,000 patient encounters results in a
    lawsuit
  • -Wolfberg D. Emerg Med Svces. 2005 Jan3442-43.
  • -Garza MA. JEMS. 2000 Feb2520-21.

57
EMS Closed Claims Analysis
  • Preliminary data 275 cases
  • 40 patient handling
  • half were stretcher drops and tips
  • 31 emergency vehicle movement or collision
  • 11 medical management
  • 8 EMS response or transport
  • 4 lack or failure of equipment
  • 9 other

Wang HE, Fairbanks RJ, Shah MN, Yealy DM. Tort
Claims from Adverse Events in Emergency Medical
Services. Prehospital Emergency Care. 2008
52(3)256-262.
58
Boiling Hot Water
  • Patient handling (40)
  • Stretchers, stair chairs, backboards
  • Driving (31)
  • Medical care (15)

59
Show me the money
  • Largest settlements ? Patient Care
  • AIRWAY
  • Missed esophageal intubation
  • Hypoxic brain injury
  • Failure to manage airway
  • Failed ETI
  • Prolonged ETI efforts
  • 25 misplaced, 2/3 esophageal
  • Source ESIP, 2011

60
EMS Liability
  • Medical Mgmt. (9)
  • Airway 41
  • Procedural 25
  • Assessment/Decision 19
  • Adverse Drug Event 12
  • Response/Transport (5)
  • Transport Error 52
  • Response Error 44
  • Patient Security 4
  • Equipment (4)
  • Lack of
  • Failure of
  • MVA (51)
  • EV Collision
  • EV Movement
  • Patient Handling (28)
  • Drops 35
  • Tips 30
  • Movement 20
  • Falls 15

ESIP (Emergency Services Insurance Program) data,
2011
61
NHTSA Ambulance Crash Data
  • 2008 Study -
  • Departments with EMD
  • 25 fewer crashes
  • 39.6 less severe

62
(No Transcript)
63
Medical Management (9)
  • Procedural 25
  • Delayed SCI recognition/treatment
  • Improper fx immobilization
  • Failure to follow protocol
  • Assessment/Decision 19
  • Failure to transport
  • Improper method of moving patient
  • Failure to treat
  • Adverse Drug Event 12
  • Wrong route
  • Wrong dose
  • Narcotic given without order

64
Response/Transport (5)
  • Transport Errors 52
  • Failure to transport
  • Transport to wrong or inappropriate facility
  • Response Errors 44
  • Failure to dispatch
  • Navigational (got lost)
  • Slow/delayed response
  • NPF (No Patient Found)
  • Patient Security 4
  • Failure to secure (fell, stood, jumped out)

65
Equipment (4)
  • Lack of equipment
  • Left equipment on scene
  • Failed to bring equipment to patient
  • No oxygen
  • Missing ambulance keys
  • Equipment failure
  • Dead defibrillator batteries
  • Defib malfunction
  • Suction malfunction

66
Response Times
  • Are there really standards?
  • Arrive 90 of time before 859
  • Fractal
  • Fitch Associates use 859 1259 as typical
    norm for US systems
  • Rural and wilderness areas may be as long as
    15/90 to 30/90
  • Most recent evidence suggests NO association
    between times outcomes

67
Dominos Pizza
  • 1973 guaranteed delivery in 30 min or pizza was
    free
  • 1992 2.8 million settlement to family of
    Indiana woman killed by speeding Dominos driver
  • 1993 15 million paid to St. Louis woman injured
    when struck by a Dominos driver who ran a red
    light
  • Guarantee dropped because of, public perception
    of reckless driving and irresponsibility.

68
Response Times
  • Standards are set by the community
  • Authority having jurisdiction over EMS
  • Patient perspective
  • Role of the Chief
  • Measure response times
  • Strive to match supply to demand
  • Be aware of unit hour utilization
  • Know community expectations

69
Time Troubles
  • Is time important?
  • Golden Hour conceived by Maryland Shock Trauma
    Center
  • No evidence basis in repeated studies

Newgard CD, et al. Emergency Medical Services
Intervals and Survival in Trauma Assessment of
the Golden Hour in a North American Prospective
Cohort. Ann Emer Med. 2010 55(3) 235-260
70
Does Time Ever Matter?
  • Are there time critical trauma patients?
  • First rule of hemorrhage control
  • Find the leak (you cannot control what you
    cannot see)
  • Shock without evident bleeding requires
  • Cold hard steel

71
So, What Stats Do I Need?
  • Basic Data Set
  • Dispatches
  • Transports
  • Hour and day distribution
  • Response times by zone/area/neighborhood
  • Times
  • Call processing intervals
  • Reflex performance (chute/scramble time)
  • UHU (xpt-disp-adjusted)
  • used only to determine 24/12 splits (typically
    at 0.4)

72
Ask and You Will Receive
  • Sarasota County FL - 1970s beat out big dogs
    (ATT, Honeywell) for customer service and
    quality awards. Key metric
  • Come quickly
  • Make my pain go away
  • Treat me nicely (concerned and caring)
  • Tell me what youre doing and why
  • Look act like you know what your doing
    (professional)

Taigman M. Sterling Sarasota. JEMS. 1998 Jul -
23(7)44-55.
73
While were on the subject
  • Red Cross On-Line Poll Social Media in
    Disasters and Emergencies
  • July 2010, n1,058 representative of US
    population age 18

74
gt 50 would text 911
75
gt ? think 911 should monitor
76
75 expect help within 1 hour
77
So, the House of Medicine is Benchmarked against
Evidence
  • What about EMS?
  • Critical Thinking added to EMS Educational
    Standards (EBM follows)
  • Is there pre-hospital research to guide practice?

78
TOR ALS and BLS
  • Termination of Resuscitation Criteria
  • There should be no transports with CPR

Ann Emerg Med 200954239-247
79
Evidence Based Benchmarks
  • STEMI
  • ASA unless contraindicated
  • 12-lead ECG with interpretation and/or
    transmission to ED
  • Direct transport to PCI facility with activation
    cardiac cath team PTA
  • Time from ECG (STEMI identified) to balloon
    inflation lt 90 minutes
  • Pulmonary edema
  • NTG unless contraindicated
  • NIPPV (i.e., CPAP) to avoid endotracheal
    intubation

Prehosp Emerg Care 200812141-151
80
Evidence Based Benchmarks
  • Asthma
  • Administration of a beta-agonist by earliest
    arriving, trained personnel
  • Seizure
  • Blood glucose measurement
  • Administration of benzodiazepine by IV, IM,
    rectal or intranasal routes
  • Trauma
  • Limit on scene, non-entrapment time to lt10
    minutes
  • Direct transport to trauma center for those
    meeting criteria, particularly those over 65
    (with time consistent caveats for air medical
    transport)
  • Cardiac arrest
  • Response interval lt 5 minutes for basic CPR and
    automated external defibrillators (AEDs)
  • No response interval specified for ALS arrival

BUNDLE
Prehosp Emerg Care 200812141-151
81
Where Will This Lead?
  • Currently, very poor compliance with performance
    metrics
  • Evidence translates into outcomes (NNT)

3.5 ---
Prehosp Emerg Care 200812141-151
82
Which Leads to P4P
  • Pay For Performance began in 2000
  • Offers incentives to HCPs to meet defined targets
    (quality, efficiency, etc.)
  • Market/purchasing strategy to improve healthcare
    delivery
  • Efficiency based
  • Objectives set by payers
  • Most certain to include EMS
  • HCFA currently discussing

83
What Should I Measure?
  • Measure your core values!
  • Response performance (patient perspective)
  • Patient/family satisfaction
  • Compassion
  • Professionalism
  • Pain control
  • Employees
  • Measure clinical performance
  • Evidence based, with outcomes (NNT)
  • State, media, local metrics

84
Future of EMS in US
  • Data driven
  • Speed ? Success (response times, etc)
  • P4P
  • Research required (outcomes based)
  • Greater role for House of Medicine
  • More physician accountability

85
Summary
  • EMS is young, small, complex, varied
  • Challenge embrace EMS, compete
  • Cultural change mandates leadership
  • Successprice, quality, customer service
  • You need an EMS Chief to navigate
  • Continually measure performance
  • Get a seat at the EMS table
  • Thanks for your attention!
  • www.mikemcevoy.com
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