1 Incorporating BLS Ambulances 1 Running Head: INCORPORATING BLS AMBULANCES Executive Development Incorporating Basic Life Support Ambulances to Improve Advanced Life Support Arrival Time and Enhance Service Delivery Kenneth W Chadwick Gwinnett County Department of Fire and Emergency Services, Lawrenceville, Georgia November 2007
2 Incorporating BLS Ambulances 2 CERTIFICATION STATEMENT I hereby certify that this paper constitutes my own product, that where the language of others is set forth, quotation marks so indicate, and that appropriate credit is given where I have used the language, ideas, expressions, or writings of another. Signed:
3 Incorporating BLS Ambulances 3 Abstract. Gwinnett County Fire and Emergency Services (GCFES) responds ALS ambulances to all EMS requests. The problem was, 49 percent of the time, arrival time exceeds eight minutes. The purpose of this descriptive research was to determine if BLS ambulances would decrease ALS arrival times and enhance service delivery. The research answered questions regarding percentage of BLS requests, BLS utilization rates, procedures enabling BLS ambulances, changes needed and the cost-benefit for implementation. Procedures included the review of reports, interviews, internal survey and literature review. Results indicated that GCFES EMD requires updating, EMT training is needed and BLS ambulances improve service delivery. Recommendations include EMD and CAD upgrades, provide identified EMT training and developing a change model when implementing BLS ambulances.
4 Incorporating BLS Ambulances 4 Table of Contents Abstract... 3 Table of Contents... 4 Introduction... 6 Background and Significance... 7 Literature Review Procedures Results Discussion Recommendations References Table of Figures Figure Figure 2.34 Figure 3.34 Figure 4.35 Figure 5.40 Figure 6.40 Figure 7.41 Figure 8.41 Figure 9.42 Figure Figure
5 Incorporating BLS Ambulances 5 Figure Figure Figure Figure Appendices Appendix A: Interview with Battalion Chief Michael J. Cox Jr 63 Appendix B: Interview with Fire Chief David Foster Appendix C: Gwinnett County EMT Survey Appendix D: Cover Letter for Survey Appendix E: Gwinnett County EMT Scope of Practice Appendix F: Paramedic Apprenticeship Incident Performance Record Appendix G: BLS Attribute Survey Appendix H: ALS Attribute Survey Appendix I: EMD Protocols Appendix J: Georgia State Region Three Utstein Survival Report Appendix K: GCFES Utstein Survival Report
6 Incorporating BLS Ambulances 6 Incorporating Basic Life Support Ambulances to Improve Advanced Life Support Arrival Time and Enhance Service Delivery Introduction As the population and demographics of a community change, so must the services provided by its government. In the State of Georgia, Emergency Medical Services (EMS) Region Three is composed of Gwinnett County and seven additional counties within the metro Atlanta region. When comparing these counties 911 EMS systems, five of the systems are fire based, two systems utilize private ambulance companies and one system is hospital based ("EMS in Georgia", 2006). When further comparing the systems delivery methods, the Dekalb County Fire Department is the only system in Region Three to utilize basic life support (BLS) ambulances (D. Foster, personal communication, July 17, 2007). Williams (2006) states the local experience defines the quality of the EMS system. Williams (2006) continues: Who provides the services and how they do so may vary from place to place, but each of us has our opinion of the ideal model, shaped by our own experiences and exposures. Truth be told, there is no one ideal system model, but rather a whole host of local factors that determine the right delivery method for a community. (p.1) William s statement explains how one metropolitan area can have such diverse EMS delivery. However, what is consistent in the Atlanta Metropolitan area is the lack of BLS ambulances utilized by 911 systems. Currently, all Gwinnett County Department of Fire and Emergency Services (GCFES) ambulances are advanced life support (ALS) and are dispatched to both BLS and ALS requests. Since 2002, GCFES service requests have increased 7% annually. To address these increases, the
7 Incorporating BLS Ambulances 7 department has added five ambulances during the last four years. Even with these additions, ambulance utilization rates and response times are increasing. The problem is when an ALS response is required; the arrival time is over eight minutes 49% of the time. This level of service does not meet NFPA 1710 standards and is a detriment to the health of any customer requiring ALS intervention. The purpose of this applied research project is to determine if the addition of BLS ambulances will decrease ALS arrival times and enhance service delivery. The descriptive research method will be used to investigate answers to the following questions: (a) what percentage of EMS responses in Gwinnett County meets BLS criteria and how does those percentages compare with other EMS services utilizing BLS transport? (b) What are the current utilization rates of Gwinnett County ambulances and which units have the highest BLS utilization rates? (c) What departmental programs and procedures are already in place to enable the implementation of BLS ambulances? (d) What changes are needed to implement BLS ambulances and what are the costs? (e) Will the addition of BLS ambulances decrease ALS arrival times and enhance service delivery? Background and Significance Gwinnett County Department of Fire and Emergency Services The Gwinnett County Department of Fire and Emergency Services (GCFES) provides fire protection and EMS services for all of Gwinnett County and is a suburb of Atlanta, Georgia. The county encompasses 432 square miles and protects a population of 757,000. Gwinnett County has enjoyed a population growth of 28% since April of 2000, adding 21,000 residents annually (Atlanta Regional Commission, 2007). In 1986, GCFES acquired the ambulance service from the county hospital system. The fire department obtained six ambulances and 50 personnel. Currently, the system has expanded
8 Incorporating BLS Ambulances 8 to 21 ALS ambulances, 27 ALS capable engines, 7 ALS capable trucks, and 2 ALS squads staffed by dual role firefighter paramedics and firefighter EMT s. In addition, two of the 27 engines are mandatory ALS engines due to location and travel distance of the closest ambulance. GCFES utilizes suppression vehicles as medical first responder units (MFRU). The department employees 750 personnel and all sworn employees are required to obtain Georgia EMT-I and Firefighter certification. The department operates on a three-platoon schedule with a 24/48 work schedule Since 2002, EMS service requests have increased approximately 7% each year and encompass 70% of the total call volume. Additionally, patient transports have increased 9% annually (A. Harrison, personal communication, August 27, 2007). Number of Transports Year Responses Transports Figure 1: Comparison of EMS Responses vs. Transports, GCFES Due to foresight and planning by the current and previous administrations, the department has received a directive from the Gwinnett County Board of Commissioners (GCBOC) to add one ambulance a year until each fire station is staffed with a transport unit. In addition, Special Local Option Sales Tax (SPLOST) fund are available to construct four new fire
9 Incorporating BLS Ambulances 9 stations by 2012 (B. Myers, personal communication, July 27, 2007). This has given the department a great opportunity to increase the ambulance fleet by 48% within the next 10 years. However, this great opportunity also creates challenges. Currently, the department is operating with 149 paramedics. Full staffing is 219, which includes nine paramedics per an ambulance (3 per a shift), three paramedics per a mandatory ALS engine and six EMS supervisors. The ambulance vacancies have been filled by firefighter EMT s which are reassigned from suppression apparatus. The paramedic shortage has already affected ALS response capabilities. When asked during an interview by Kelly (2004) in June of 2004, GCFES Assistant Chief Casey Snyder stated that the department normally staffed each fire engine and ambulance with at least one paramedic but has been forced to downgrade engine companies to BLS to keep enough paramedics on ambulances. Being faced with the challenge of increased demands for services by both the public and county government, the department initiated strategic planning utilizing the Balanced Scorecard Management System. As Averson (1998) states The balanced scorecard is a management system.that enables organizations to clarify their vision and strategy and translate them into action. It provides feedback around both the internal business processes and external outcomes in order to continuously improve strategic performance and results. (p.1) The vision of GCFES has always been we will deliver the highest quality service to all customers. Using the perspective of the citizen, two EMS objectives were identified, (a) to improve ALS arrival time and (b) to improve ambulance availability. The target for ALS arrival time is < 8 minutes 90% of the time. This standard is derived from NFPA 1710, section (4) Eight minutes (480 seconds) or less for the arrival of an advanced life support unit at an
10 Incorporating BLS Ambulances 10 emergency medical incident, where this service is provided by the fire department (National Fire Protection Association [NFPA], 2004, p.1). This standard is reinforced by Fitch (2005) who states, in litigation, experts often cite 8:59 as the defined community standard of care ( 10) The target created for med unit availability is the reduction of hour unit utilization to 0.3. Even though this author was unable to find standards on unit hour utilization, research found the expected norm for a fire based 24 hours ambulance is within the range of 0.3 to 0.4 This research will assist GCFES in determining if the utilization of BLS ambulances would reduce ALS arrival time, enhance service delivery and assist with planning to provide the highest quality of service to all customers. In addition, this project will assist the author in making prudent management decisions when revising or changing EMS operation in the department. This project is linked to Organizational Culture and Change in the Executive Development course. Further, this research supports the United States Fire Administration s goal to appropriately respond in a timely manner to emergent issues. Literature Review The literature review was organized around the five research questions: (a) what percentage of EMS requests in Gwinnett County meets BLS criteria and how does those percentages compare with other EMS services utilizing BLS transport? (b) What are the current utilization rates of Gwinnett County ambulances and which units have the highest BLS utilization rates? (c) What departmental programs and procedures are already in place to enable the implementation of BLS ambulances? (d) What changes are needed to implement BLS ambulances into the GCFES EMS system and what are the costs? (e) Will the addition of BLS ambulances decrease ALS arrival times and enhance service delivery?
11 Incorporating BLS Ambulances 11 Percentages of EMS requests meeting BLS criteria Two internal reports produced by Fire View software showed an average of 35% of EMS calls meeting BLS criteria from January 1 thru July 30, 2007 and 31% meeting BLS criteria during The data was produced when the 911 calls were initially triaged via emergency medical dispatch (EMD) and inputted into Gwinnett Counties computer aided dispatch (CAD) system (C. Wells, personal communication, August 2, 2007). Communications Supervisor A. Conley produced a similar CAD report showing average dispatch turn around times by type of call for the period January 1, 2007 thru July 20, 2007 (B. Myers, personal communication, August 2, 2007). This report verified the first report with a 36% BLS criteria response. When comparing these figures with other departments, it appeared that GCFES responds to a higher proportion of ALS requests. During an interview with Dekalb County Fire Chief David Foster (personal communication, August 17, 2007), Dekalb County BLS requests were between 80 and 90% during the last year. A similar BLS ratio or 80 to 90 % exists in Ann Arundel County Maryland according to Battalion Chief Michael Cox (personal communication, August 13, 2007). When reviewing further literature, the BLS responses range from 50 to 70%. King County Washington has created the Medic One EMS system, which utilizes both BLS and ALS transport units. On average, ALS responses only compromise 30% of the total requests (Seattle and King County Public Health, 2007). The Journal of Emergency Medical Services (JEMS) city survey listed a national average of 49 % BLS criteria but further review found that in a community with a population of 700,000 to 800,000, the percent of BLS responses decreased to 40% (Williams, 2007).
12 Incorporating BLS Ambulances 12 The San Francisco Fire Department merged with the cities EMS system in 1997 and initiated a BLS pilot program. The programs intention was to improve service delivery due to 40% of medical calls meeting BLS criteria (San Francisco Board of Supervisors, 2003). Current Utilization Rates: One of the objectives of GCFES is to reduce current unit utilization rates with the overall goal to reduce response times. Assistant Chief Bill Myers agrees, One should consider the impact to be potentially severe when longer response times are required for ALS trained and equipped units to arrive at the scene of an [sic] true emergency. (Myers, 2003, p11) While conducting this review, this author was unable to find any nationwide requirement, only recommendations. The San Francisco Board of Supervisors (2003) uses a standard of 0.4 for any ambulance in service for 10 hours or more. This coincides with a recommendation from the California Emergency Medical Services Agency. The agreement between San Mateo County and American Medical Response West states that any ambulance scheduled for over 12 hours cannot exceed a ratio of 0.4 (San Francisco Board of Supervisors, 2003). In areas without such restrictions, private ambulance services that strive for high performance strive for utilization ratios over 0.5 (The Reason Foundation, 1995). Pinellas County Florida, which utilizes a public utility model delivery system, strives to maintain a unit utilization rate of 0.6 (Reason Public Policy Institute, 2006). In the Atlanta area, the Dekalb Fire Department strives to maintain a rate below 0.4 (D. Foster, personnel communication, August 17, 2007). What is interesting to note is that different organizations have different formulas for unit utilization. Poole (2005) uses the term unit hour utilization ratio, which is the total number of transports divided by the number of hours. If an ambulance transported one patient every 2
13 Incorporating BLS Ambulances 13 hours, the unit hour utilization ratio would be 0.5. The San Francisco Board of Supervisors (2003) uses the term to define the amount of time an ambulance is out of service on a response. San Francisco s definition would include both transport and non-transport responses, the transport time and off load times at hospitals GCFES has chosen to determine unit hour utilization rate from the time an ambulance is dispatched until the call is closed (Adamson, personal communication, August 2, 2007). GCFES feels that this formula will include all variables including out of service training, traffic, nonemergency responses, hospital delays, hospital diversion and fire suppression activities. Fitch (2005) recommends that one of the fundamental strategies to improve response time is to control lost unit hours such as out of service meetings and training, off load times at hospitals and even mechanical breakdowns. GCFES information management provided data showing the number of minutes each ambulance was out of service from January 1 thru July 30, 2007(D. Peebles, personal communication, August 2, 2007). From this data, figures were compiled to show the utilization rate of each ambulance for the first seven months of 2007 and which ambulances had the highest BLS utilization rate. The data showed that unit utilization rates in GCFES varied from 0.33 to In addition, two ambulances BLS responses were 51%. Departmental Practices and Procedures to Enable BLS Ambulances When looking for a tiered system that is very successful, Medic One in Seattle Washington claims to be one of the best. When a citizen calls 911 in Seattle, an EMD dispatcher triages the call and provides pre arrival instructions, a BLS first responder or ambulance arrives within an average of five minutes, and an ALS ambulance will arrive if needed with eight minutes (Seattle and King County Public Health, 2007). Davis (2003) reported that Seattle saves
14 Incorporating BLS Ambulances 14 45% of savable victims in cardiac arrest. Davis (2003) continues a savable victim is someone who was not alone when they collapsed and whose heart suddenly stopped because of ventricular fibrillation. (p.d6) What has made Seattle so successful? According to the American Heart Association (2005), many victims of Sudden Cardiac Arrest (SCA) will survive if bystanders initiate CPR and utilize an automatic external defibulator (AED). In addition, bystanders must act immediately. Once a rhythm changes to asystole, chances of survival are unlikely. In Seattle, it is easy to obtain CPR training and approximately 20,000 people are trained each year (Seattle and King County Public Health, 2007). A review of run reports showed that CPR was being preformed on 40% of SCA victims prior to the arrival of EMS (Davis, 2003). GCFES Programs and Services Division has provided CPR and AED training to the community since Due to the lack of facilities, classes were limited to 25 participants a month. In 2005, a new administrative building was built with several large community rooms. Starting in 2006, CPR Saturday was initiated with the hopes of training a larger number of citizens. During 2006, 3644 citizens were trained in CPR and AED. During the first half of 2007, 2777 citizens have been trained (J. Mason, personal communication, August 2, 2007). An essential feature of a tiered response system is an accurate protocol based EMD system. Trained and certified call takers using a proven, protocol-based dispatch system are now an industry standard that is not difficult to obtain (Williams, 2006 p1). King County s EMS training division provides continuing education to all 150 emergency medical dispatchers (Seattle and King County Public Health, 2007). This training allows continuous updates of protocols and maintains a constant level of ALS dispatches while fielding an increase in service requests.
15 Incorporating BLS Ambulances 15 In hopes of improving response times and service delivery, Washington DC just opened a new 911-communication center in September of The center utilizes CAD and EMD software and can track the performance of each call taker and dispatcher. In addition, the system has the capability to compare the EMD response code with the actual patient care report produced by the responding ambulance (Davis, 2006). Of course, some believe that call screening places too much of a burden on dispatchers and is a weakness with a tiered response system. This practice is prone to potentially lifethreatening mistakes (as well as much lawsuit potential), but is inherent in any system which has insufficient resources to be able to dispatch an ALS unit to all calls (Poole, 1995, p.11). Currently, there is no standard baseline of care that is provided by all EMS systems (National Highway Traffic Safety Administration, 1996, Where We Are section, 3). Even though this was identified 11 years ago, the literature demonstrates the different scope of practices that consist of BLS care. NFPA 450, section defines BLS as Emergency medical treatment at a level as defined by the medical authority having jurisdiction (NFPA, 2004, p. 3). Both Seattle and Ann Arundel County utilize BLS transports staffed with two EMT Basics. Their scope of practice consists of skills from the DOT EMT basic course 1994 and consists of non-invasive procedures. In Seattle, an EMT-B can assist a patient with the administration of the patients Epi-pen (J. Frisk, personal communication, August 10, 2007). In Georgia, a MFRU can be staffed with an EMT-B but an ambulance must be staffed with at least one EMT-I. Georgia Department of Human Resources Rules and Regulations, section (i) states Basic Life Support (BLS) means treatment and/or transportation by ground ambulance vehicle and/or treatment with medically necessary supplies and services
16 Incorporating BLS Ambulances 16 involving non-invasive life support measures (Georgia Department of Human Resources, 2004, definitions). However, section states: Each ambulance while transporting a patient shall be manned by not less than two Emergency Medical Services Personnel one of whom must be in the patient compartment. Only one individual licensed at the emergency medical technician-basic level can be used to satisfy this requirement (Georgia Department of Human Resources, 2004, definitions). This has been interpreted in the state of Georgia to mean that BLS ambulances can actually perform at the state level of EMT-I. This broadens the scope of practice of BLS criteria to include IV access, administering Dextrose 50% to diabetics, providing nebulized proventil to asthma patients and utilizing an EPI pen to treat anaphylactic shock. Changes needed to implement BLS ambulances When determining the changes needed to incorporate BLS ambulances into the department, both internal and external factors need to be identified. Externally, the most significant factor is Gwinnett County Communications. Gwinnett County Communication is a division of the police department and utilizes 911 funds for equipment upgrades. GCFES requested and county communications started utilizing EMD dispatch during The vendor chosen was the National Academy Emergency Medical Priority Dispatch System (W. Thompson, personal communication, July 27, 2007). All dispatchers must acquire and maintain EMD certification to remain employed (A. Conley, Personal Communication, July 28, 2007). Nationwide, when 911 is called, 84% percent of the time the caller will be speaking with a trained EMD dispatcher (Williams, 2007). According to Williams (2007), this call takers
17 Incorporating BLS Ambulances 17 clinical certification has become a standard of care if your service is not certified and practicing protocol dispatch, it s time to catch up.(p40) It appears that Gwinnett County s EMD system should meet the standard of care. All dispatchers are EMD certified, medical dispatch protocols are utilized and pre arrival instructions are provided. Dispatchers are required to maintain their certification via annual training. However, there is no current medium to provide instant feedback in cases of erroneous dispatch criteria. NFPA 450, section Quality Assurance states: The system should use quality assurance measures, such as outcome, comparison, and validation information, to ensure continuous improvement (Communications chap). The International City/County Management Association (2005) has determined that quality assurance is essential for an effective EMD program. A. Conley (personal communication, July 27, 2007) advised that the only form of quality assurance is during the investigation of a complaint. CAD entries mark times of when a call is received and dispatched but EMD triaging is still accomplished via flip cards and manual imputing of the call type and priority. Additionally, call takers and dispatchers are under a time constraint of 60 seconds for Charlie and Delta requests. GCFES administration has been aware of several performance issues and has requested information regarding delays in dispatching appropriate units. During the first six months of 2007, on average 60% of fire and EMS calls are delayed longer than 90 seconds (B. Myers, personal communication, July 30, 2007). In Gwinnett County, once a unit is dispatched, there is no guarantee that it is the closest unit with the shortest response time. With the current CAD system, once a unit is available, it can be dispatched to a call within its response district even if the unit is 25 miles away. In turn, the medic must notify dispatch of the unit s current location, dispatch must reenter the call for
18 Incorporating BLS Ambulances 18 another CAD recommendation and another unit must be dispatched. This in turn delays the current incidents response time plus any additional incidents awaiting dispatch. Nationwide, this appears to be a common problem. Fitch 2007 reports that only 55% of the respondents to the JEMS city survey sent the closest unit. The most common reason is either jurisdictional lines or dispatch is unaware of the exact location of units in the community. Many government entities are utilizing Automatic Vehicle Locators (AVL) as tool to assist dispatchers in choosing the closest unit thereby reducing response times. The Fire Department New York (FDNY) has installed AVL in all apparatus. During a 2005 trial period, average response times improved 10% in units equipped with AVL (McLaughlin, 2006). Puckett Ambulance Service in Powder Springs, Georgia reduced their average response time from 12 minutes to less than 10 minutes after the implementation of AVL (Casciato, 2007). AVL allows Puckett to choose the closest ambulance, monitor out of chute times, hospital turnaround times and both response route and unit speed (Casciato, 2007). During 2002, The Kansas Department of Transportation (KDOT) sponsored a University of Kansas study to determine the cost benefit of AVL utilization in state DOT vehicles. Some of the expected benefits were improved response times to emergencies, reduction in snow removal times, increased security for drivers and reduced fleet maintenance costs due to improved fleet management (Meyer & Ishtiaque, 2003). Findings of the study showed an initial investment of eight million dollars with annual maintenance costs of $800,000. Annual savings should approach two million dollars a year with an estimated minimum net benefit of $233,000, over 20 years (Meyer & Ishtiaque, 2003). When researching internal factors, costs will be incurred. Monetary restraints should not be an issue. B. Myers (personal communication, July 30, 2007) confirms that one additional ambulance has been approved for implementation prior to years end at a total cost of $880,000.
19 Incorporating BLS Ambulances 19 GCFES budgets ambulances at a staffing level of nine (3 per a shift) Firefighter III s which is the highest firefighter salary classification. Whether or not this ambulance is staffed with EMT s or paramedics would not change the units cost. Myers (2003) states, Research has shown that the culture of a population or organization can influence ones perception (p10). Changes to this organization s culture will be the most significant cost. Historically, the perception of GCFES EMT s has been one of the paramedic providing all the treatment decisions and care during patient transport. EMT s will drive the ambulance but rarely provide patient care. This perception was formed when the fire department originally assumed the ambulance service during The hospital system employees only possessed medical training and were unable to perform suppression duties. Rarely were suppression personnel assigned to the ambulance. However, as these medics obtained firefighter certification and the system expanded, frequently EMT s were assigned to staff an ambulance. This culture, which has developed for over 20 years, will be difficult to change. There are many sources of literature referring to organizational change. Michael Beer s model suggests that leaders can increase the amount of change only by increasing the level of dissatisfaction among followers while producing a clear vision of the change plan and decreasing resistance (Hughes, Ginnett, & Curphy 2006). Tradition in the fire service lends itself to resistance to change. Only by changing the status quo will leaders by able to get followers to change (Hughes et al. 2006). Previous events in the department such as EMD dispatching and the practice of responding non-emergency to service requests changed the status quo and increased dissatisfaction among personnel. Traditional thinking was, when someone called 911, it was an emergency and we responded that way. Only after the administration developed a clear vision of
20 Incorporating BLS Ambulances 20 why response protocols had changed was resistance lowered. Dissatisfaction especially with company officers continued. Administration realized this and required compliance. Hughes et al. (2006) agrees, leadership practitioners will still need to spend considerable time holding people accountable for their roles and responsibilities in the change plan (p399). Additionally, department EMT s level of knowledge and skills compared to the scope of practice needs to be determined. It is probable that some EMT s will struggle with their new role as a patient attendant and the level of service may decrease. Learning a new system or set of skills can often cause a temporary drop in performance (Hughes et al. 2006). The author has developed a survey which will be discussed in the results section to help determine some of these issues. Decreasing ALS arrival time and enhancing service delivery A customer-based goal of GCFES is to improve the response time of ALS to the scene. The target is based on the NFPA 1710 criteria requiring the arrival of an ALS unit within eight minutes 90% of the time. The NFPA criteria does not include call processing time or turnout time which allows up to an additional minute for each segment (NFPA, 2004). Therefore, in reality, a 10-minute total arrival time of an ALS equipped unit can satisfy the NFPA 1710 standard. Dean (2007) explains that the original standard was based on cardiac save research being completed in Seattle. The eight-minute standard was an attempt to meet several priorities including the patient, the cost of the service and the perceived value. What is interesting to note is that Seattle s current response time average is 3.68 minutes for BLS and 3.81 minutes for ALS (Seattle Government, 2006).
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