1 A Strategic Patient Transportation Plan For Las Vegas Fire & Rescue Advanced Leadership Issues in Emergency Medical Services BY: Henry Clinton, Battalion Chief. Las Vegas Fire & Rescue Las Vegas, Nevada. An applied research project submitted to the National Fire Academy as part of the Executive Fire Officer Program December 2000
2 2 ABSTRACT The problem was Las Vegas Fire & Rescue did not have a strategic patient transportation plan that reflected incremental increases in our EMS delivery system to meet the city s future patient transportation demands. The purpose of the research paper was to develop a strategic patient transportation plan that could be incrementally implemented until the department delivers 100 percent of the EMS transports. The research method chosen for this project was the Action method. Research questions answered were: 1. Where is Las Vegas Fire & Rescue now, what is our situation? 2. What resources do we have available? 3. Where do we want to go? 4. What is our strategy for getting there? The procedures for this project included a literature search from the Learning Resource Center at the National Fire Academy, the Las Vegas Fire & Rescue reference library, and additional information was obtained from the EFO course Advanced Leadership Issues in Emergency Medical Services. Additionally interviews for key information from: local fire departments who provide 100 percent EMS delivery. Employees who work part time for the ambulance provider. Historical data was retrieved from the departments Information Technology division, and finally the author hand counted each emergency run from each station s log book.
3 3 The results of this research paper revealed that private ambulance companies measure productivity differently than fire departments, mainly because they only do one thing, transport patients. Where fire departments are a full service emergency division with many responsibilities to fulfill. That developing a transport plan requires a manager to define the work load for the crews, identify the call volume, then determined how many rescues it takes to provide a full service EMS system. The next step was to implement the departments plan in a small geographical area to enable easy department adjustments as necessary.
4 4 Table of Contents Title Page...1 Abstract...2 Table of Contents...4 Introduction...5 Background and Significance...5 Literature Review...8 Procedures...21 Assumptions...22 Limitations...23 Definition of Terms...23 Results...26 Unexpected Results...39 Discussion...44 Recommendations...48 References...52 Appendix A...54 Appendix B...55 Appendix C...63 Appendix D...64 Appendix E...65 Appendix F...66
5 5 INTRODUCTION Las Vegas Fire & Rescue does not have a patient transportation plan that reflects incremental increases in our EMS delivery system to meet the cities future patient transportation demands, including personnel, equipment. The purpose of this project is to develop a strategic plan that provides the department with enough equipment and personnel to meet the demands by incrementally increasing our portion of the emergency medical patient transportation market. These incremental increases will continue until Las Vegas Fire & Rescue performs 100 percent of the 911 generated emergency patient transports in the City of Las Vegas. The research method chosen for this project is the Action method. The Questions to be answered regarding this problem are: 1. Where is Las Vegas Fire & Rescue now, what is our situation? 2. What resources do we have available? 3. Where do we want to go? 4. What is our strategy for getting there? (Menkin, 1997). BACKGROUND AND SIGNIFICANCE For over 22 years (prior to 1978) Las Vegas Fire & Rescue has been transport capable. However, in the past, our transports were limited to: Injured firefighters Police officers
6 6 City employees Any emergency where the ambulance company was delayed or unavailable. Our transport records indicate that we transported around 50 patients a year (SunPro, 2000). Basically, we have not been in the transport business until recently. The city chose to contract out to private providers for patient transportation. In 1997, the newly elected mayor of Las Vegas requested Managements Partners an auditing company from Cincinnati Ohio, to review City operations as a whole and submit recommendations for improvement. Overall, there were 181 recommendations submitted for possible improvement throughout city government. There were only a few directed at Fire Services. In their audit, it was noted that they felt we had a redundant EMS delivery system. In their report, they pointed out AMR (local transport company) and the fire department each send an ambulance to each EMS call, they felt dispatching two ambulances on every call was redundant, a waste of resources. The City could save money by sending only one unit. As a result of their audit, it was suggested by Management Partners that Las Vegas Fire & Rescue either; get out of EMS or look into transporting ourselves and not contract privately for transportation. Getting out of EMS was out of the question, as the local transport agencies were, and still are, incapable of performing vehicle extrications and other technical rescues. City Council asked LVF&R for a proposal reflecting our best solution to the consultants recommendations. The Fire Chief suggested we look into EMS transportation; he submitted a proposal to City Council that included transporting up to 10 percent of the
7 7 current market in Las Vegas as a pilot program to test the feasibility of our transport ability. Part of the determining reason for transporting up to 10 percent of the market was the Chief believed we could transport 10 percent of the market with out adding additional personnel and equipment. In December of 1998 Las Vegas Fire & Rescue was given permission by City Council to transport patients, up to 10 percent of the current market beginning January 1 st., of This pilot program would last for no less than one year. There was a Blue Ribbon panel assembled and assigned, by direction of the City Council to monitor the progress of our efforts, to determine if the pilot program was successful. If it was successful the assumption was Las Vegas Fire & Rescue would continue transporting and pick up a larger portion of the transport market annually. The Blue Ribbon panel made up of AMR representatives, City Hall Administrators, Accountants, the Health District s Medical Director, and EMS Coordinator, hospital representatives as well as representatives from local area fire departments, including our own, met quarterly to monitor the pilot program. After the 12- month period, the Blue Ribbon Panel concluded the pilot program was a success (Blue Ribbon Panel, 2000). It was agreed Las Vegas Fire & Rescue could successfully transport patients for a fee and recover costs. This was reported to City Council and the decision was made for Las Vegas Fire & Rescue to continue transporting patients in Las Vegas. (Blue Ribbon Panel, 2000). Initially the Fire Chief suggested LVF&R could transport up to 10 percent of the market, with-out any additional equipment or personnel. The Chief would like to increase our patient transports. Las Vegas Fire & Rescue has no strategic plan in place that
8 8 addresses an incremental increase of patient transports, which should reflect an incremental increase of equipment and personnel. It is the purpose of this paper to research and develop this strategic plan. Taking on 10 percent of the patient transport market was a significant work load increase. There were promises made to the members of the fire department by administrative officers that when we take on more transports, we will provide more resources so they will be able to keep up with the increase in work load. Additionally, patient care is also an issue, it is the departments goal to avoid any negative impact relating to patient care. Being prepared to meet the department s patient transportation needs of the future is critical to the continued success of Las Vegas Fire & Rescue and its mission. This project is directly related to the course and the course material covered in Advanced Leadership Issues in Emergency Medical Services LITERATURE REVIEW The literature review was focused on establishing a knowledge base on the following foundations: A fiscal responsibility to the citizens of Las Vegas. An effective and appropriate Emergency Medical System (EMS) management system. Identifying response times as a critical component to EMS delivery. A relationship between workload and Paramedic Burn out.
9 9 How to measure productivity and explore scheduling options. Identifying the cost of the transport component of an EMS system. The author considered the above to be a minimum knowledge base in order to be able to answer the following questions: o Where is Las Vegas Fire & Rescue now? (Current situation). o What resources do we have available? o Where do we want to go? o What is our strategy for getting there? The literature review revealed that there is a need to develop an operational plan for resource management to better accommodate the service needs of the community; it is obvious that public fire departments need to be held more accountable by the public for their delivery systems. The concepts from private industry are directed at two issues: service delivery and financial concerns. The time has come for the fire service to be competitive with private providers, in delivering emergency medical service and patient transportation to substantiate our existence. It is important that fire service managers prove that the best value of the citizens dollars is with the public fire service (Lewis, 1997). To do this, there is a need to develop an operational plan for resource management, to better accommodate the service needs of the community. Departments need to answer questions on efficiency and effectiveness through well-documented research. (Riddle, 1995). There are only a few EMS management systems, which distribute ambulances throughout the EMS system effectively. One such system is System Status Management
10 10 (SSM). SSM involves the deployment of ambulances in a manner that maintains a balance of available EMS resources to a service area, based on call-volume demand (peak hour) statistics. SSM plans also factor in the number of ambulances available for response throughout each day (Moneau, 1999). This can involve placing an ambulance on standby between two service areas when one area s ambulance has been sent on assignment. This is known as posting (Moneau, 1999). Another variable that can be added to SSM besides posting is roaming. Roaming is a deployment system where ambulances are assigned to drive a particular area while waiting for an assignment. The theory being, crew can respond quicker while in their ambulance than they can from inside a station or post. The resulting draw-back from posting, and roaming is a drop in employee moral and an increase in employee back injuries (Moneau, 1999). Further comment on the cause of increased back injuries can be found in the unexpected findings section of this paper. SSM has resulted in emergency medical technicians (EMTs) and paramedics sitting in ambulances for extended periods of time (Moneau, 1999). SSM may work for the nonemergency ambulance market, where the time and locations of demands for service can be scheduled. The private sectors use of SSM is touted as the model system for maximum efficiency of resources (Riddle, 1995). However, this approach is not transferable to the emergency side of the industry, as fire departments have several other responsibilities besides EMS delivery. Keep in mind that each call for service must be considered a random occurrence. To maintain rapid response times, fire departments must maintain strategic geographical locations throughout the city (International Association of Fire Fighters, 1999).
11 11 Another recognized EMS management system, and one that more closely matches the needs of the fire service and our community is Comprehensive Flexible Deployment. Comprehensive Flexible Deployment is a strategy used for maneuvering ambulances and crews to reduce response times, based on expected call volumes and geographic coverage requirements. Additionally, the location of potential emergency events should also be taken into consideration when placing ambulances (Fitch, 1992). The optimal flexible deployment system is the development of base geographic coverage; then add demand coverage (peak hour) to the already existing geographic coverage. The concept is that as long as the integrity of geographic coverage is maintained, response time performance objectives can be achieved. Supporting this theory is the fact that even with computer aided dispatching (CAD) technology compiling call patterns, it is difficult to predict where the next call will come from (Fitch, 1992). Demand coverage or peak load staffing has been primarily applied in the private sector, and has been less successful in the fire service. Even though it has not been done in our organization, literature indicates that some emergency medical providers, including other fire services, use peak load staffing to meet their system demands and allow employees to have an alternate work schedule. Members of the department should work together to develop other shift schedules, to achieve peak load staffing during periods of high demand in the city and meet the needs of firefighters. (Hill, 1997). Comprehensive flexible deployment is basically a Zone Defense. A fundamental goal of flexible deployment is to ensure that the service area has adequate units available to provide geographical coverage for any next call. To accomplish this, three basic components of a deployment strategy emerge:
12 12 1. Assurance of geographical coverage (Fire stations). 2. Demand coverage (peak hour staffing). 3. Post reassignment strategies. (Fitch, 1992). Geographical coverage can be provided using existing fire stations (Fitch, 1992), demand coverage can be accomplished by adding peak hour staffing, and post reassignments are currently accomplished within the fire service using Move Ups (Riddle, 1995). In either EMS management system response times are the key to success if you are measuring success by improved patient survivability. The American Heart Association (AHA) recommends a maximum emergency response time of four minutes to initiate basic life support and eight minutes to initiate advanced life support. The AHA has established the Chain of Survival for cardiac arrest victims, they are: Early access to the EMS system. Early CPR. Early defibrillation. Early Advanced Life Service (ALS). The quicker CPR in initiated, defibrillation performed, and advanced cardiac life support (ACLS) begun, the better the odds are the patient will survive. Every minute with-out defibrillation decreases the chances of successful conversion by 7 to 10 percent. Dr. Eisenberg linked response time to probability of survival. A nine-minute initial arrival time prior to pre-hospital medical interventions gives the viable patient only a 1 in 15 chance of surviving. A four-minute arrival by fire fighter paramedics increases
13 13 the survival probability to 1 in 2 chances. As a rule of thumb, first responders should arrive on the scene in less than 5 minutes from the time of dispatch in 90 percent of all such calls. This will generally result in a median first-responder response time of 2 to 3 minutes. The AHA response time recommendations favor geographical coverage, which provides consistent response times within the recommended time frames. Paramedic Burn Out is a term loosely used in the fire service. It is a very serious condition. EMS coordinators across the country have determined that the symptoms are fairly universal: physical and emotional exhaustion; low morale; impaired performance; less sensitivity to patient needs; irritability towards coworkers and supervisors; increased griping about the department, the equipment, and the schedule; vulnerability to disease; sick leave abuse and increased absenteeism; and ultimately, resignation or transfer (Randleman, 1980). According to one public fire agency they report, several paramedic personnel have recently left the EMS division and/or department sighting burnout as a contributing factor in their decision (Boike, 1991). Burnout refers to a syndrome of emotional exhaustion and cynicism that frequently occurs with people who spend considerable time in close encounters with others under conditions of chronic tension and stress (Randleman, 1980). Burnout is most commonly defined as a condition of emotional exhaustion caused by job related chronic tension and stress (International Association of Fire Fighters, 1999). The length and intensity of the paramedic s exposure to the conditions are something the department manager can control. Michael Olsen, EMS consultant for the United States Fire Administrations (USFA) office of planning and education says paramedic burnout is basically a management problem (Randleman,
14 ). Burnout needs to be addressed, but as yet because of the variables involved, there is no specific number of runs that a 24-hour team should be able to handle (Fitch, 1992). Jim Page referred to a study comparing the stress levels of private sector EMS personnel in a system management environment to fire department EMS personnel assigned to fire stations. This study indicated higher stress levels for private sector employees (Riddle, 1995). Traditional fire service schedules generally are based on either a 24-hour schedule or a combination of 10-hour and 14-hour periods. The viability of ambulance personnel working on a 24-hour shift will be dependent upon the call volume of a particular ambulance unit. Busy EMS systems need to examine the liability of routinely having personnel awake for 24 hours at a time. There is a large segment of the EMS community which maintains that patient care toward the end of a 24-hour shift suffers because the ambulance personnel are more tired; however, there have been no formal studies comparing medical protocol error rates based on the number of hours that a paramedic has been on duty (United States Fire Administration, 1997). A recent study showed that people who were awake for up to 19 hours scored worse on performance tests and alertness scales than those with a blood-alcohol level of 0.08 legally drunk in some states. If they ve pulled an all-nighter, pilots, surgeons, or the people responsible for charging your credit card account, might as well be drunk. (Brink, 2000). After four hours of sleep a night, people scored lower on tests of judgment, response time, and attention than those who slept eight hours. And the short sleepers made more mistakes (Brink, 2000).
15 15 The IAFF recommends a U:UH ratio-approximating 0.30; they say this should be adequate to allow personnel to keep their skills sharp while not risking employee burnout. EMS systems with U:UH exceeding 0.30 are being used to their breaking point (International Association of Fire fighters, 1999). Even though Burnout is lower in the fire service, it should be noted that measures can and should be taken to alleviate the causes of chronic tension and stress to promote good working conditions. (For more comments by the author on Burnout and taking measures to relieve it see the section on unexpected findings.) Utilization and productivity, an EMS system actually produces two products, patient transport and coverage. Coverage refers to the fact that an EMS system must maintain adequate resources to provide transport availability even when calls do not occur. Coverage is best measured in hours of time that an ambulance is staffed (Unit hours). The largest expense incurred by an emergency service is the cost of housing units available to respond, regardless of the actual number of calls. Unit hour utilization is used by private industry to calculate the percentage of transports by an ambulance during a specific time period, which also provides a productivity ratio. Total unit hours divided by the total number of transports in a given period of time equals productivity or U:UH ratio. This concept (used by the private side) considers the units to be exclusive to transports. In the fire service, personnel are responsible for other tasks such as hose testing, hydrant maintenance, inspections, preincident analysis, public education, etc. Taking this concept under consideration another production calculation for the fire service needs to be used. The literature review reveals that the fire service needs to consider all responsibilities required of them including
16 16 transports and consider them into a total time on task utilization model (Lewis, 1997). When considering transport only, the fire service also measures utilization activity; the actual calculation is based on total in-service time per call: the time from dispatch through call termination divided by the amount of time the unit is in operation. In service utilization ratio is a more accurate measure of service use and availability (International Association of Fire Fighters, 1999). The private sector measures efficiency by: Cost per call. Unit hour costs. U:UH The fire service is unable to measure efficiency this way, as it needs to provide geographical first responder coverage and peak hour staffing to meet the system demands (International Association of Fire Fighters, 1999). The primary factors that should be considered in developing staffing levels are the amount of coverage necessary in a particular geographic service area and the fluctuating demand (Fitch, 1992). The San Antonio Fire Department in Texas, for example, found they could successfully determine peak load demands through the use of statistical analysis of the number, location and types of medical responses being made by their department. They used historical dispatch data to reasonably project where, when and how many EMS units would be needed for emergency medical response, at any given emergency medical response, at any given time of day, night, week or month (Boike, 1991). A good manager can achieve high levels of productivity and meet established
17 17 response time targets, often unit hours will have to be added or reduced to achieve a realistic work schedule. When matching staff to call load two things are important to keep in mind when preparing a schedule: 1. When calls occur. 2. The number of calls. With flexible deployment, the emphasis is on where to place the vehicles, but it is just as important to determine how many vehicles are needed. It may be necessary to add additional crews during peak periods to achieve prompt response times. The only way to accurately determine a service s unique staffing needs is to prepare comprehensive reports on when, where and how many ambulances have been needed during any given time period. The larger the service is, the easier it is, to take advantage of opportunities to increase productivity. First identify the number of transports to be accomplished, establish the desired productivity ratio, which is the number of transports accomplished per unit hour (.58 U:UH transport ratio) Lets say you had 29,960 transports annually, divide this by.58 equals 51,655 hours of unit hour coverage, divide this number by 365 and you get 141 unit hours of coverage per day, subtract your geographical coverage requirements (an ambulance in every station) and you are left with demand coverage requirements. The remaining demand coverage can be met with peak hour units (Fitch, 1992). Personnel scheduling directly affects response times, patient care and financial success of the entire system. EMS scheduling cannot be viewed in the traditional staffing manner, creative and innovative ideas must be included, peak load shifts may be necessary, and
18 18 alternate reassignment strategies may need to be considered. The agency should provide a reserve pool of vehicles and personnel to meet unexpected demands (Fitch, 1992). Examples of peak load staffing in emergency medicine, which used a combination of shift schedules, were found to be beneficial to the employer and employee (Hill, 1997). The cost of the EMS management system needs to be considered, as the fire service needs to be efficient and effective in financial management as well (Lewis, 1997). To calculate the cost of fire based EMS service, only the marginal costs of the service should be used. The marginal costs of providing EMS services are only those expenses beyond what it would cost for other routine fire department operations (International Associations of Firefighters, 1999). Chief Riddle, in his Sept.1995 article in Fire Chief quotes Jim Page as stating, The marginal costs of providing EMS with multi-role, cross trained firefighters as the difference between the total cost of operating the fire department with EMS and the total cost of operating the department without EMS (Riddle, 1995). Many of the administrative costs and some of the personnel of an EMS system are already covered under fire suppression and rescue services. This also applies to fire departments that must cost out the transport component of their services for the sake of comparison. The cost of providing transport is only the marginal cost for this component, for example: the cost of the transport vehicles, labor to staff them, and administrative expenses in billing for the service. Since a fire department must maintain adequate equipment and staffing to respond to the community s fire suppression and rescue needs regardless of the provision of emergency medical services, these costs are not included in marginal costs (International Association of Firefighters, 1999).
19 19 To estimate how productive our transport units may be, I though it wise to determine what the private providers U:UH transport ratio is. After interviewing several of our employees who work part time for the private provide (one of which worked for them since 1983), they reported a transport U:UH of.58 or between 6 and 7 transports in a 12 hour shift. Additionally, I thought it prudent to interview the only comparable fire department in our valley, which transports 100 percent of the emergency calls for its citizens. The results of the interview are as follows: The Author interviewed District Chief Randy Howell of the Henderson Fire Department on 06/13/00. Chief Howell was chosen because he is considered a subject matter expert on EMS transport. He is the EMS Chief of the Henderson Fire Department:, they provide 100 percent of the emergency transports in Henderson Nevada. During the interview, Chief Howell related the following information. The Henderson Fire Department currently has six fire stations, with one to be completed in two weeks; four of those stations have a transport capable unit in the station. The transport units are strategically located throughout the city. They staff their rescues with at least one Firefighter/Paramedic and one Firefighter/EMT-B. When they transport a patient they borrow one person off the engine company for staffing in the rescue. Their engine companies are their first responder units, and are all ALS and provide them with a response time of less than five minutes; their transport units are on scene within ten minutes. They respond to roughly 12,000 calls for service annually; 74 percent of those calls are EMS (8,880). Of those 60 percent are patient transports (5,328).
20 20 That works out to 14.5 transports per day. Sharing those calls with the four transport capable units works out to be 3.6 transports per unit per day. When questioned about peak hour staffing, Chief Howell replied that they used to use peak hour staffing when they had three units in the city. Since they increased their coverage to four units they have not used peak hour staffing. Peak hour staffing did work for them. However, he felt they could have managed their resources better. When they were using peak hour staffing they utilized five days a week on ten hour shifts. The Henderson Senior Staff has determined greater than 10 calls a shift averaged over a six-month period would result in either an adjustment in that units area of coverage or an increase in rescues placed in service. This was determined by listing the personnel responsibilities that were assigned to the rescue. These responsibilities included all details, training classes, meals, an estimate of seven hours of sleep, single and multiple company drills, hydrant inspections, school drills, pre plans, etc. With the remaining time, seven hours, they came up with a realistic work load and call volume of 10 calls per shift with an average of 4 non transport and 6 transports per ten calls (60 percent transport average). On average, it takes them 15 minutes of service time to handle a non-transport call, and one hour to handle a transport call, which equals seven hours. Interestingly enough, Chief Howell mentioned that his crew members had not bought into the prescribed transport numbers mentioned earlier. They generally feel they are overworked and complain the work- load is too high. The employees suggest more peak hour staffing to share the work load. They also rotate their Firefighter/Paramedics from
21 21 engines to rescues. They are required to ride a rescue at least thirty shifts out of the year to maintain transport skills. Additionally, I have interviewed several (4) of our employees who work part time with the private providers. AMR staffs ambulances on no more than a 12 hour shift, on various peak hour periods. During their shifts with AMR, all the employees reported the same figures. They transport between six and seven patients during their 12 hour shift which included approximately one hour at the end of the two hour shift for paper work and unit preparation for the next shift. Their transport unit hour utilization is.58. This is significant when considering placing peak hour transport units into service. These numbers will aid in determining how many transports we can realistically expect out of a transport unit, placed in service solely for patient transportation. PROCEDURES Research for this project began with a literature search at the Learning Resource Center (LCR) at the National Fire Academy (NFR) in Emmitsburg, Maryland. I began researching current information related to System Status Management and Peak Load Staffing. Any staffing information available was retrieved. Additionally information on efficient management of EMS resources was also retrieved. The EFO course attended (Advanced Leadership Issues in Emergency Medical Services) had useful information. I was able to use information gathered and assembled by Las Vegas Fire & Rescue personnel, and interviewed subject matter experts in our community (Henderson Fire
22 22 currently transports 100 percent of the Emergency calls in their city). Historical research was done on Las Vegas Fire & Rescue to determine what our resources are, and what our call volume is, by station, unit, square mile (district) and time of day (researching any peak hour anomalies that could be addressed), finally, an EMS committee was utilized to help interpret the information gathered. The EMS Committee consists of representatives from labor and management. Additionally, the committee was tasked to assemble several transport plans and present to the chief what they feel are the three best transport options, the Chief will then pick one of the three plans to move forward with. The guidelines for developing transport plans are: No patient care compromises. Fiscal responsibility. Easy implementation. Acceptable to labor. Asset compatible. Considerate of private needs. Assumptions Patient care is the primary concern and goal; compromising patient care is not an option. The strategic plan chosen will either maintain the same level of patient care currently provided in our EMS system or increase it. Las Vegas Fire & Rescue recognizes their employees as their greatest asset and will work to maintain good working conditions. Las Vegas Fire & Rescue recognizes the cost benefit the dual role employee (Fire Fighter / Paramedic) has to offer the citizens of the community, and will continue to maintain
23 23 their skills in both fields. The transportation model needs to be the least disruptive as possible to normal operations, using current resources to their best advantage. Limitations It should be recognized that information extracted from the CAD (Computer Aided Dispatching) system is only as accurate as the information entered into the computer. Not all runs have been entered; some human errors are expected. On several occasions EMS information has varied from one request to the next, which created question in my mind about the reliability of the information being extracted. This inspired the undertaking of visiting every station, and physically counting each run in each stations run log. Additionally, the same is true with the information gathered from the unit/station logs. Run statistics are only as reliable as those entering the information; it is believed that the error rate is minimal. However, there were some instances where crewmembers did not enter all the runs to which they responded into their station/unit log. It is, however, the author s opinion that the information is accurate enough to determine trends, and make decisions based on the recorded call volume. Definition of Terms Advanced Life Support (ALS): All basic life support measures, plus invasive medical procedures including intravenous therapy, cardiac defibrillation, administration of
24 24 medications and solutions, use of ventilation devices, and other procedures by state law and performed under medical control (International Association of Firefighters, 1999). Basic Life Support (BLS): Generally limited to airway maintenance, ventilation (breathing) support, CPR, hemorrhage control, splinting of fractures, management of spinal injury, protection and transportation of the patient whit accepted procedures (International Association of Firefighters, 1999). Computer-Assisted Dispatch (CAD): Computer-assisted dispatch including, but not limited to, primary dispatch entry and automated time stamping, data interface, demand pattern analysis, system status management, automated patient locator aids, response time reporting and documentation, and when installed, automated vehicle tracking (International Association of Firefighters, 1999). Cost Per Call: Calculated by dividing the total system cost by the total call volume. Private EMS companies this as a measure of efficiency. (International Association of Firefighters, 1999). Cross-Trained/Dual-Role (CT/DR): An emergency service that allows personnel, trained in emergency situations, to perform to the full extent of their training, whether the situation requires firefighting or medical care. This system offers a greater level of efficiency then its single-role counterparts (International Association of Firefighters, 1999). Deployment: The procedures by which ambulances are distributed throughout the service area. Deployment includes the locations at which the ambulances are placed and the number of ambulances placed in service for that particular time period (International Association of Firefighters, 1999).
25 25 Emergency Medical services: The provision of services to patients with medical emergencies. The purpose of emergency medical services is to reduce the incidences of preventable injuries and illnesses, and to minimize the physical and emotional impact of injuries and illnesses. The EMS field derives its origins and body of scientific knowledge from the related fields of medicine, public health care systems administration, and public safety (International Association of Firefighters, 1999). Emergency Medical Technician: A generic term for any pre-hospital provider trained to the EMT-Basic level or higher (International Association of Firefighters, 1999). Emergency Medical Technician-Basic (EMT-B): A pre-hospital BLS provider with approximately 110 hours of training, based on the NHTSA National Standard Curriculum (International Association of Firefighters, 1999). Emergency Medical Technician-Intermediate (EMT-I): A pre-hospital provider, trained in some ALS procedures such as IV therapy, in accordance with the National Standard Curriculum (International Association of Firefighters, 1999). Emergency Medical Technician-Paramedic (EMT-P): A pre-hospital provider, trained according to the National Standard Curriculum to an advanced level, including all ALS procedures (International Association of Firefighters, 1999). In-Service Utilization Ratio: The time from dispatch through call termination, divided by the amount of time the unit is in operation, used for staffing and evaluating efficiency (International Association of Firefighters, 1999). Infrastructure: The basic facilities, equipment, services and installation needed for functioning (International Association of Firefighters, 1999).
26 26 Privatization: The process of shifting the provision of a public service from a government to a private sector enterprise (International Association of Firefighters, 1999). Public Education: Imparts knowledge or training in specific skills. For example, teaching CPR, how to call for help properly, bicycle safety, or briefing public officials about the importance of your service to your community are all public education activities (International Association of Firefighters, 1999). System Status Management (SSM): A management tool using past service demand to predict future EMS call volume and location. Using this past experience, the private contractor can use fewer resources (both equipment and personnel) during hours of predicted reduction in need, thus reducing costs. While private ambulance services transportation, this approach is inappropriate for emergency response and transport, because acceptable response times are not maintained (International Association of Firefighters, 1999). Unit Hour Cost: The cost to operate one EMS-related unit for one 60-minute period (International Association of Firefighters, 1999). Unit Hour Utilization (U:UH Ratio): Measures the usage of a fully equipped and staffed response vehicle available for dispatch. Private contractors define U:UH as a measure of productivity. In reality, it simply measures the number of potential revenue-producing patients, transported per hour, that the unit is in operation. It is appropriately only as an indication of appropriate resource deployment (International Association of Firefighters, 1999).
27 27 RESULTS The fire chief s requirements for any transport plan that would qualify for consideration would need to be fiscally responsible, easy to implement, acceptable to labor, asset compatible, considerate of the private ambulance companies needs and there should be no patient care compromises. In order to accomplish this it is necessary to also understand EMS management systems, and recognize that response times are critical in relationship to patient care. Understand the correlation of work-load verse burnout, and be able to identify and measure productivity, which is related to crew scheduling options. The concepts derived from private industry are directed at two issues: Service delivery. Financial concerns (Lewis, 1997). The time has come for the fire service to be competitive with private providers. To do this, there is a need to develop an operational plan for resource management (Lewis, 1997) There are only a few EMS management systems, which distribute ambulances throughout the EMS system effectively. One of these is System Status Management (SSM). SSM is primarily used throughout the ambulance industry (Moneau, 1999). Another management tool, one that more closely matches the needs of the fire service, is Comprehensive Flexible Deployment. It is based on geographic coverage, and augmented for peak hour demands (Fitch, 1992). A fundamental goal of flexible deployment is to ensure that the service area has adequate units available, to provide geographical coverage for the next call. To accomplish this, three components are necessary:
28 28 Assurance of geographic coverage (fire stations). Provide demand coverage (peak hour staffing). Post reassignment strategies (Fitch, 1992). Response times are the key to success, if we are measuring improved patient survivability. The American Heart Association (AHA) recommends a maximum emergency response time of four minutes, to initiate basic life support, and eight minutes to initiate advanced life support. A four-minute arrival by fire fighter paramedics increases the survival probability to a 1 in 2 chance (Randleman, 1980). According to one public fire agency they report, Several paramedic personnel have recently left the EMS division, sighting burnout as a contributing factor in their decision (Boike, 1991). Burnout is most commonly defined as a condition of emotional exhaustion caused by job related chronic tension and stress. The IAFF recommends an unit hour utilization ratio of 0.30 as their recommended work load (International Association of Fire Fighters, 1999). An EMS system actually produces two products, patient transport and coverage. Coverage refers to the fact that an EMS system must maintain adequate resources to provide transport availability, even when calls do not occur (Lewis, 1997). Unit hour utilization is used by private industry to calculate the percentage of transports by an ambulance during a specific time period. This also provides a productivity ratio. Private industry would divide the total number of transports by the number of hours in their shift. For instance, six transports in a 12 hour shift is a Transport U: UH of 0.50.
29 29 The highest U: UH would be a 1.0, which means that a unit is productive 100 percent of the time, which is impossible (Lewis, 1997). In the fire service, personnel are responsible for other tasks such as: hose testing, hydrant maintenance, inspections, pre-incident analysis, public education, etc. taking this concept under consideration, another production calculation for the fire service needs to be used. The fire service needs to consider all responsibilities required of them, including transports and consider them into a total time on task utilization model (Lewis, 1997). For the fire service, the primary factors that should be considered in developing staffing levels are the amount of coverage necessary in a particular geographic service area and the fluctuating demands (Fitch, 1992). The San Antonio Fire Department in Texas found they could successfully determine peak load demands through the use of statistical analysis (Boike, 1991). When matching staff to call load, two things are important to keep in mind when preparing a schedule work shift: When calls occur. The number of calls. With flexible deployment, the emphasis is on where to place the vehicles, but it is just as important to determine how many vehicles are needed (Fitch, 1992). To estimate how productive fire based transport units can be, the author determined what the private providers U:UH transport ratio is. After interviewing several of our employees who work part time for the private provider they (all four) reported a transport U:UH of.58 or between six (6)and seven (7) transports in a twelve hour shift. Additionally, Chief Randy Howell of the Henderson Fire Department was interviewed. He stated that The
30 30 Henderson Senior Staff has determined that greater than an average of 10 calls per 24 hour shift for an extended period (six months) would result in either an adjustment in that units area of coverage or an increase in rescues placed in service. This was determined by listing the personnel responsibilities that were assigned to the rescue, including: details, training classes, meals, sleep, drills, hydrant inspections, school drills, pre-plans etc. With the remaining time, (seven hours) they came up with a realistic work-load and call volume of 10 calls per shift. They also share a 60 percent transport rate. This breaks down into an emergency response U:UH of 0.29, which falls under the IAFF recommended 0.30 U:UH work load. To calculate the cost of fire based EMS service, only marginal costs of the service should be used. The marginal costs of providing EMS services are only those expenses beyond what it would cost for other routine fire department operations (International Association of Firefighters, 1999). Marginal costs of providing EMS with multi-role, cross trained firefighters as the difference between the total cost of operating the fire department with EMS and the total cost of operating the department without EMS (Riddle, 1995). Many of the administrative costs and some of the personnel of an EMS system are already covered under fire suppression and rescue services (International Association of Firefighters, 1999). Using the SWOT change model reviewed in advanced leadership issues in Emergency Medical Service (ALIEMS), the author used the following four questions to develop an operational plan that allows Las Vegas Fire & Rescue to incrementally increase our emergency transports and eventually provide 100 percent of the emergency patient transportation requests.
31 31 1. Where is Las Vegas Fire & Rescue now, what is our situation? Las Vegas Fire & Rescue is on the threshold of providing emergency transportation for the citizens and visitors of Las Vegas. For twenty years or more, the fire department has been transport capable. The city currently has a contract with a private ambulance company to provide 100 percent of all the patient transports in the city, including nonemergency inter facility transports. However, the fire department has always reserved the options of transporting patients, when certain conditions exist. They are: When the private provider is unavailable or delayed When the scene is not safe When city government employees are involved. (mainly firefighters and law enforcement officers) Upon patient request (Las Vegas, Nev. Department of Fire Services, 2000). This has resulted in a minimal amount of patient transports for Las Vegas Fire & Rescue, roughly 50 transports a year. Being transport capable and providing an occasional transport is very different than providing a consistent transport service. A transport service creates a greater demand on the EMS delivery system. The Fire Department covers geographic areas, positioning fire rescues (Ambulances) strategically throughout the city to enable quick response times. Historically the fire department would respond to an emergency initiate treatment, stabilizes the patient and transfer him/her over to the private provider who would then transport the patient to a local hospital, and then submits a bill to him/her for transportation.
32 32 For the past 16 months, Las Vegas Fire & Rescue has been transporting all motor vehicle accident patients, as part of a pilot program, to evaluate the feasibility or our organizations capability to provide transport to the citizens of Las Vegas. We currently transport 10 percent of the transport market. To provide EMS transportation and continue to provide geographical coverage, Which is necessary for an increased survival rate in cardiac arrest patients (International Association of Fire Fighters, 1999). We will need to add additional rescues to our EMS delivery system. Our goal is to sustain our quick emergency responses and provide the patient a financially efficient ride to the hospital. To do this, we will need an EMS delivery plan that reflects incremental increases in the percentage of the transportation market. City council has voted on the subject and has given Las Vegas Fire & Rescue permission to continue with incremental increases in the emergency patient transportation market (Blue Ribbon Panel, 2000). When Las Vegas Fire & Rescue delivers 100 percent of the 911 generated emergency transports to the citizens of Las Vegas will have quality EMS delivery at a substantial savings compared to the cost of that same service which is provided by a private ambulance company. Additionally, the city will realize a financial benefit, as the fire department will be considered a revenue provider and will bring money into the city government system, the general budget. The citizen s benefit directly through a cost savings, initially when transported to a hospital during an emergency. As a community, our citizens will enjoy lower tax rates, as the additional revenue will be placed back in the budget, deferring the cost of the fire service.
33 33 2. What resources do we have available? Administrative and support services: Las Vegas Fire & Rescue shares a state of the art dispatch center with three other fire departments in the valley. We utilize computer aided dispatching (CAD) with emergency medical dispatchers (EMD), utilizing pre-arrival instructions with the person initiating the call while our units respond. Additionally, we have incorporated Automatic Vehicle Locators (AVL) on all our emergency response units, which dispatch the nearest appropriate emergency vehicle; and we use the Clawson Triaging System for sending the appropriate level unit or units. We have a Deputy Chief of EMS who oversees the whole EMS division. An EMS Coordinator is responsible for administrative operations, delivery systems and supplies. An EMS Quality Assurance Officer insures quality patient care and other quality issues. We have a EMS Educator who is responsible for all EMS certifications, re-certifications and class instruction. We have contracted with an outside billing agency who charges seven percent of all bills collected (not billed) for their service. To help with the paper work (run sheets), we have one full-time secretary who allots a portion of her time to collect and send the run sheets to the billing agency. Logistically, we have a fire department shop that performs vehicle services, maintenance and light repair on all fire department vehicles and related equipment. Staffed with five employees, a shop foreman and three mechanics, and one secretary. Line services: Our Department consists of 11 fire stations geographically located throughout the city. Each station has one ALS engine and one ALS rescue, except station #1 which has two