Executive Development. Incorporating Basic Life Support Ambulances to Improve Advanced Life Support Arrival Time. and Enhance Service Delivery

Transcription

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).

21 Incorporating BLS Ambulances 21 As Davis (2003) reported, There is no nationwide standard for measuring emergency response times ( 5). Only when you determine response times from the patient s point of view do you get the most accurate measure of performance (Davis, 2003). Fitch (2006) agrees, From the patient s perspective, the clock starts the moment they summon help (p44). GCFES, when setting customer based goals, uses the criteria of the patient and includes turnout and dispatch time in the overall arrival time. Hence, to meet this goal, GCFES must actually strive for a 6 to 7 minute ALS response time. A study based in Charlotte Mecklenburg County with a single tier all ALS EMS system compared the response time interval (the time between the receipt of the call and arrival on scene) and patient survival. The study concluded that only a response time of 5 minutes or less would have any benefit to the survival of a patient requiring ALS intervention (Blackwell, & Kaufman, 2002). This study confirmed an earlier study conducted in Denver in which 9, 559 patients were categorized into groups based on severity of illness and response time data. The study concluded that patients with an intermediate or high risk of mortality needed an ALS response time within four minutes or less for any increased survival chance (Pons P., Haukoos, Jason, Bludworth, Whitney, Cribley, Pons K., Markovchick, 2005). In addition, two studies presented in May of 2005 determined that ALS care does not increase the survival rates of trauma patients. One study compared the survival and recovery of 2750 patients with multi systems trauma. There was an 82% survival rate of patients receiving BLS prehospital care verses 81% for patients receiving ALS prehospital care (Hendry, 2005). In the same study, traumatic brain injured patients had a survival rate of 54% whether BLS or ALS care was performed. For the patients that experiences SCA, time is critical. The shorter the EMS response time, the better the chances are for patient survival. Once the arrival time exceeds five to six

22 Incorporating BLS Ambulances 22 minutes, the effects of ALS interventions are minimal (American Heart Association, 2005). For patients that have SCA, the most pertinent response time is the call to shock time (Davis, 2003). Rochester Minnesota has been measuring call to shock times and has determined the average call to shock time of a patient saved is 5 minutes and 30 seconds verses an average of 6 minutes and 42 seconds for patients deceased (Davis, 2003). Due to these findings, Rochester police have started carrying AED s and were the first to shock 37 out of 73 people. This shortened response time has increased Rochester s SCA survival rate from 30% to 44% during 2003 (Davis, 2003). Miami Dade County also started utilizing police officers as AED equipped first responders with similar results. The average call to shock time decreased three minutes and the survival rate doubled from 9% to 17 % (Davis 2003). A study in Leeds, U.K. was commissioned to determine the most effective design characteristics of a future EMS system. The recommendations were a tiered response of paramedic, technician and BLS first responders tied into the EMS system. The first responders would include police, fire and trained local citizens (Hassan &Barnett, 2002). As discussed earlier, organizational culture and the resistance to change can affect even the best planning. Both Washington D.C. and New York City have tried to decrease their call to shock times by utilizing AED equipped police vehicles as first responders. However, at the time of the report, the survival rate had not increased compared to Miami Dade or Rochester. This lack of performance has been partially blamed on the resistance of police officers to the change of their traditional roles (Davis, 2003). The latest standard of efficiency is to measure the survival rate of SCA patients treated by EMS. Referred to as the Utstein Template, it only counts patients that had a chance for survival and are discharged from the hospital. Any patient with a non-survivable rhythm, patients that

23 Incorporating BLS Ambulances 23 were not treated due to living wills as well as non-cardiac related arrests such as trauma are not included (Davis, 2003). The Cardiac Arrest Registry to Enhance Survival (CARES) program has been developed by the CDC, AHA and Emory University in Atlanta. By utilizing the Utstein method, CARES can identify and track all cases of cardiac arrests in a defined geographical area (Cardiac Arrest Registry to Enhance Survival, 2007). Georgia State Region 3, which is the metro Atlanta area, has an overall cardiac arrest survival rate of 4.2% with an Utstein rate of 12.8% during the period of October 1, 2005 thru August 1, 2007 (Cardiac Arrest Registry to Enhance Survival, 2007). In comparison, GCFES performance for the period of January thru August 27, 2007 is 3.8% overall with an Utstein rate of zero (R. Dawson, personal communication, August 27, 2007). In 2002, San Francisco Fire initiated the one and one response-staffing model. Twenty 24 hour ALS Ambulances staffed with two firefighter paramedics and six ALS engine companies would be changed to (19) 24-hour ALS ambulances staffed with one paramedic and one EMT. The extra paramedic would be utilized to place 25 ALS engines in service (San Francisco Board of Supervisors, 2003). The goal was to lower ALS response times by adding additional ALS units, lower the paramedic workload and give firefighter paramedics rotation on an engine. After a three year study, the department determined that the only way to effectively lower ALS response times was to increase the number of ALS engines and utilize peak 10 hour ALS ambulances. The approved program will increase paramedic engine companies to 42, provide four 24 hour ALS ambulances and from five to (18) 10 hour ALS trucks utilized during peak hours (City and County of San Francisco Fire Commission, 2005). Recently, several services in Arizona have started using non-transport BLS or ALS vehicles called Alpha Units. These vehicles respond to non-emergency BLS calls to assess the

24 Incorporating BLS Ambulances 24 patient and either obtain a release, arrange for alternative transport or treat a patient while requesting an ambulance. One goal of the program is to reduce overall system load by handling the lowest priority calls without a response time restraint (Unger, 2007). In Glendale Arizona, Chief Patrick Berkel hopes the six Alpha cars will allow the department to improve response times to higher priority calls while saving the city money by reducing responses of engine companies (Unger, 2007). Mesa Arizona has estimated that Alpha cars can save the city $2.00 to $2.50 a mile compared to the cost responding suppression apparatus (Unger, 2007). Summary The literature review has demonstrated to the author that there is a multitude of ways to provide EMS service to a community. BLS ambulances are a functioning part of EMS systems nationwide. The literature review illustrated the importance of the dispatcher. To make a system as efficient as possible, rapid and competent EMD must be performed. To accurately code the call, the EMD protocols must match the department s EMT scope of practice. In turn, the EMD information must be linked to CAD so the closest appropriate unit is dispatched. Dispatch criteria must be reviewed and updated. The best systems compare patient trip report information to the EMD designation. The literature review provided the author valuable information referencing the variables to and importance of response times. To decrease response times, unit utilization must be decreased. This can be accomplished by adding units, dispatching the closest unit, and/or reducing out of service times. There is not a set standard or interpretation of what response time is. NFPA standards, although valid, are based on older cardiac save research. New methods such as call to shock and measuring cardiac save rates can provide better performance based measurements. What is imperative is a rapid response for critically ill patients. Depending on the

25 Incorporating BLS Ambulances 25 situation, this response can be provided by trained citizens, first responders, EMT s or paramedics. When a patient has sudden cardiac arrest, quick CPR and defibulation is mandatory for the best patient outcome. If an organizational change such as the implementation of BLS units is desired, a strong change model must be developed. Tradition and the inherent resistance to change must be addressed prior to the implementation of BLS ambulances. The review of the change model literature assisted the author in developing the survey of department EMT s to determine the employees current opinion of their EMT skills, how frequently they utilize their skills, and what would be the organizational cost to incorporate BLS transport units. Procedures The purpose of this research is to determine if the incorporation of BLS ambulances into the service delivery of GCFES would reduce ALS arrival time and/or enhance service delivery. In addition, the costs and any additional employee training needed to be determined. The procedures undertaken included: (a) an examination of existing CAD reports created for GCFES senior operations staff showing utilization rates of GCFES ambulances, types of responses by EMD codes and NFIRS codes, (b) the creation by the author of a custom Omega query of each GCFES ambulance to determine the percentage of BLS and ALS responses for verification purposes; (c) an extensive review of the literature pertaining to response time criteria, BLS and ALS system design; (d) interviews with a member of senior staff of two fire based EMS systems that utilize BLS transports; and (e) a survey distributed to all GCFES EMT s at the rank of Lieutenant and below to determine the current skill level of department EMT s, their frequency of providing patient care and opinions of BLS transport units.

26 Incorporating BLS Ambulances 26 The author reviewed internal reports created for GCFES senior staff by Gwinnett County CAD or IT technicians between July 1 and July 8, The first two reports covered the periods of 2006 and January 1 until June 30, The first report listed the amount of minutes each GCFES ambulance was being utilized from dispatch to call end. This figure was divided by the total amount of minutes during the same period to determine the utilization rate of each ambulance. The second report listed the total amount of fire and ems calls during the same period. The reports were further delineated to show the percentage of and type of each call. The third report was a CAD report showing the percentage and type of calls that were dispatched less than or greater than 90 seconds from receipt of the call. This report covered the period of January 1 through June 30, In addition, the report was broken down by month into the following criteria: structure fires, vehicle accidents with injuries, ALS med calls, BLS emergency calls, BLS non-emergency calls, and other. The author was able to interpolate reports two and three to compare the percentage of BLS calls and ALS calls that the department is dispatched to. Reports 2 and 3 showed that 36 percent of EMS calls were dispatched as BLS. This data was utilized for research question number one. Report one data determined the utilization rate of each ambulance. What was not available was the percentage of BLS calls for each ambulance. During the spring of 2007, Omega ARC GIS 9 software was installed on several computers at fire head quarters. With this software, several custom queries can be created by time, location or unit. The author received permission and a password to access the database in August 10, On August 12, the author created an ALS attribute query and BLS attribute query for each GCFES ambulance for the period January 1 through June 30, Each query consisted of each CAD code for ALS or

27 Incorporating BLS Ambulances 27 BLS responses. The query produced the number of responses that each ambulance responded to by CAD code. The total number of BLS responses was divided by the total number of all responses to determine the percentage of BLS responses by unit. This query produced the percentage of BLS dispatches by ambulance and was interpolated with report 1 utilization rates to determine the ambulance with the highest BLS utilization. This data was utilized for research question 2. Several sources were utilized to identify literature relating to the research questions. Internet searches with the key words response times, advanced life support, basic life support, and EMS were utilized. The NFA on line card catalog was searched to review any applied research papers on BLS service. If more clarification was needed, an was sent to the author requesting more information. Subscriptions were purchased by the author for access to the Emergency Best Practices web site and the National Institute of Health website to identify any journal articles. Additionally, the department s access to the NFPA website was utilized as well as the author s access to the IAFC website for additional research. Two telephone interviews were conducted with representatives of two departments that utilize BLS transport units. The first interview was with Battalion Chief Michael Cox Jr., Ann Arundel County Fire Department in Millersville Maryland and was conducted on August 13, 2007 at 2:15 pm (Appendix A). Chief Cox s department was selected due to a search of the NFA s learning research center and the department s utilization of BLS transport units. In addition, Ann Arundel s department demographics are similar to GCFES in population, area served, call volume and number of ALS ambulances and MFRU units. The second interview was with Fire Chief David Foster of the Dekalb County Georgia Fire and Rescue Department (Appendix B). The interview was conducted on August 17, 2007 at 2:30 pm. Chief Foster s

28 Incorporating BLS Ambulances 28 department was selected due to it being the only fire based EMS system in metropolitan Atlanta that utilizes BLS ambulances. Additionally, his department started utilizing BLS transport units four years ago and prior to that had a system similar to GCFES. During each interview, the basic set of questions asked was: 1. How many EMS responses did your department have last year and what percentage was BLS? 2. How many ALS and BLS transport units do you operate daily and what is the average utilization rate? 3. How many medical first responder units do you operate and are any ALS? 4. How long have you been utilizing BLS transport units? 5. What departmental procedures had to be created or changed to implement BLS transport units? 6. Has the incorporation of BLS transport units decreased your ALS response times or improved your service delivery? Each interview lasted approximately 20 minutes and was followed by an informal discussion about EMS systems and response times in general. In addition, any specific programs created by the departments were discussed. After reviewing the literature and comparing the findings with the results of the internal departmental reports, the author developed a survey (Appendix C) for distribution to departmental EMT s. The survey was managed by Survey Monkey and was available from August 5 th until August 21 st. s were sent to all department EMT s at the rank of Lieutenant and below with an attached letter (Appendix D) explaining the purpose of the survey and providing the survey link.

29 Incorporating BLS Ambulances 29 The survey s purpose was to determine the demographics of department EMT s, the number of times EMT s attend to patients when assigned to an ambulance, the EMT s familiarity and proficiency with the department s EMT scope of practice, standing medical orders and KSA s needed for patient care. Additionally, a section of the survey titled your opinion allowed the respondent to rate their opinion of several statements based on the literature review and research questions. An area was also reserved for additional typed comments and an opportunity to leave the respondents address so the survey results could be returned. The survey s EMT scope of practice section utilized GCFD Operational Guidelines Section (Appendix E) as a guideline. The standing medical orders and KSA section was developed from the Paramedic Apprenticeship Incident Performance Record (Appendix F) which is utilized while precepting a newly hired paramedic. Prior to distribution, the survey was ed to five paramedic field-training specialists, command staff and training division officers. Ambiguous terms and survey format errors were corrected. The survey respondents were selected by rank and their medical level of training. The current GCFD station roster of August 1, 2007 was reviewed and all EMT s at the rank of Lieutenant and below were selected. Lieutenant EMT s were included due to the current requirement of Lieutenant Paramedics filling in as patient techs on ALS ambulances a minimum of two shifts a month. In additions, if BLS transport units were going to be utilized in the future, Lieutenants were going to need to support the change requests were sent to Operation Division EMT s. Of those, 275 responses were received and 216 surveys were complete. Using table 5 of the EFOP student study guide, if

30 Incorporating BLS Ambulances 30 N=375, S must be > 191. Since the survey obtained 216 complete responses, the survey should have a greater than 95 percent confidence level Limitations: The most noticeable limitation to this research is the limited period that data was available to create the CAD reports. In addition, CAD data prior to January 1, 2007 could not be utilized with Omega ARC GIS 9 software. Therefore, the author was unable to compare GIS data and reports with CAD reports for prior years. In addition, the CAD data relies on the accuracy of the EMD coding. Gwinnett County currently does not have a system to check the accuracy of EMD coding so the author is unable to determine if the dispatch code corresponds with actual patient condition. Another limitation was the lack of validation of some of the data gathered from the interviews. Several statements were made concerning BLS call volume that exceeded the national average. Both interviewees were asked to documentation to the author. However, none was received. A second request was made without a response. Definition of terms Advanced life support (ALS). The assessment and if necessary, treatment and/or transportation by ambulance, utilizing medically necessary supplies and equipment provided by at least one individual licensed above the level of Emergency Medical Technician-Basic (Georgia Department of Human Resources Rules and Regulations, 2004).

31 Incorporating BLS Ambulances 31 Alpha response. The emergency medical dispatch determinant of a non-emergency basic life support response. Anaphylactic shock. A widespread and very serious allergic reaction. Automated vehicle locator (AVL) A computerized mapping system used to track the location of vehicles Basic life support (BLS) Treatment and or transportation by ground ambulance vehicle and or treatment with medically necessary supplies and services involving non-invasive life support measures (Georgia Department of Human Resources Rules and Regulations, 2004). Bravo response The emergency medical dispatch determinant of an emergency basic life support response. Charlie response. The emergency medical dispatch determinant of an emergency advanced life support response. Computer aided dispatch (CAD) A dispatching process in which a computer and its associated terminals are used to provide relative dispatch data to the concerned telecommunicator (NFPA, 2004).

32 Incorporating BLS Ambulances 32 Delta response. The emergency medical dispatch determinant of an emergency multiple unit advanced life support response. Dextrose 50% solution A solution of 50% dextrose in water, which is given intravenously for low blood sugar. Dispatch time. The point of receipt of the emergency alarm at the dispatch center to the point when appropriate units are notified Emergency medical dispatch (EMD) Personnel responsible for dispatching EMS responders to the scene of medical emergencies and providing telephone instructions to bystanders at the scene while professionals are enroute (American Heart Association, 2005). Epi-pen Epi-Pen is a registered trademark for the most commonly used auto injector of epinephrine used to treat anaphylactic shock (Wikipedia, 2007). First Responder An individual who has successfully completed an appropriate first responder course approved by the department (Georgia Department of Human Resources Rules and Regulations, 2004). Geographic information system (GIS) A system of computer software, hardware, data, and personnel to describe information tied to a spatial location (NFPA, 2004).

33 Incorporating BLS Ambulances 33 Nebulized When air or oxygen is pumped through a liquid medicine to turn it into a vapor, which is then inhaled by the patient (Wikipedia, 2007). Off load times. The time an ambulance is out of service while unloading a patient and completing documentation. Proventil. A bronchodilator medicine that opens a patient s airway by relaxing the muscles around the airway. Utilization ratio (rate). An efficiency ratio that divides the cumulative unit-elapsed intervals by the total time that the unit is on duty (NFPA, 2004). Results The findings of this research are organized by the five research questions Percentage of EMS responses meeting BLS dispatch criteria Internal CAD reports were available to the author for 2006 and January 1 thru June 30, During 2006, 39,356 EMS incidents were dispatched. Of those, 12, 271 (31 %) were dispatched as BLS responses. From January 1 thru June 30, 2007, 18,794 EMS incidents were dispatched. Of those, 6,609 (35%) were dispatched as BLS responses.

34 Incorporating BLS Ambulances 34 Percent /1-6/30/07 Year BLS % ALS % Total Figure 2 Percent of BLS and ALS responses 2006 and 2007 Current ambulance utilization rates and BLS utilization The author received a report from Gwinnett information management showing the amount of minutes each ambulance was not available for a response from January 1 thru June 30, This figure was divided by 60 to obtain the total out of service hours. The total out of service hours was divided by the total available hours (4344) to determine the unitization rate of each ambulance. It is also important to note that the unavailable time includes out of service hours for fire suppression, mechanical repair or training Med 2 Med 3 Med 4 Med 5 Med 6 Med 7 Med 8 Med 9 Med 10 Med 11 Med 12 Med 13 Med 14 Med 15 Med 16 Med 18 Med 19 Med 20 Med 23 Med 24 Med 25 Utilization Rate Figure 3 Med Unit Utilization Rates 1/1/07 thru 6/30/07

35 Incorporating BLS Ambulances 35 To determine BLS utilization, a custom report was created for each ambulance. Arc GIS 9 software was utilized to create a BLS attribute query (Appendix G) and ALS attribute query (Appendix H) to determine the number of ALS and BLS responses for each ambulance during the period January 1 thru June 30, This query did not include any fire suppression responses. The number of BLS responses was divided by the number of total responses to determine the percentage of BLS responses. Med 25 Med 24 Med 23 Med 20 Med 19 Med 18 Med 16 Med 15 Med 14 Med 13 Med 12 Med 11 Med 10 Med 9 Med 8 Med 7 Med 6 Med 5 Med 4 Med 3 Med 2 ALS BLS Percentage of Responses Figure 4. Percentage of BLS and ALS responses by unit

36 Incorporating BLS Ambulances 36 Figure 3 illustrates that the utilization rates of GCFES ambulances ranges from.33 for Med 18 to.57 for Med 11. Figure 4 illustrates the comparison of BLS and ALS responses for each med unit during the first six months of BLS utilization ranged from a low of 40% for Med 18 to a high of 51% for Med 11 and Med 19. Departmental Practices and Procedures to Enable BLS Ambulances Review of the literature revealed that successful services providing BLS ambulances utilize efficient and updated EMD protocols combined with a rapid BLS response of under five minutes. In addition, quick CPR by bystanders or responders allows the greatest chance for survival of SCA victims. The literature suggests that the most accurate measurement of effectiveness for an EMS system is the measurement of Cardiac Saves utilizing the Utstein Template. During an interview with Chief David Foster of Dekalb County Fire Rescue, one of his reasons for adding BLS units was to decrease response times. Since 2004, 10 BLS ambulances have been added in addition to the 14 ALS ambulances and 36 ALS first responder units available daily. These units cover a response area of 268 square miles with a population of 725,000 and will respond to approximately 104,000 EMS calls this year. Approximately 80% of these calls are BLS. Since the addition of these units, the department s response time has decreased to less than five minutes. The cardiac save rate using the Utstein template has improved from seven percent in 2004 to 23 % in What is also interesting to note is that his department does not offer CPR classes to its citizens. Dekalb Fire Rescue tries to maintain a utilization rate of less than.4 although most units exceed this. One method utilized in Dekalb is dispatching suppression apparatus on Alpha calls to decrease ambulance responses.

37 Incorporating BLS Ambulances 37 The Ann Arundel County Fire Department (AACFD) protects 500,000 citizens in a response area of 474 square miles. The department utilizes 21 ALS and 10 BLS ambulances and is projected to respond to 50,000 EMS requests this year. Battalion Chief Michael Cox Jr. advised that approximately 90 % of EMS requests were BLS. Response times averaged about six minutes. Cardiac save data was not available. As staffing permits, the department hopes to have 31 ALS ambulances available to respond. The department utilizes EMD. However, like Seattle, the scope of practice for BLS units is limited to non-invasive procedures GCFES utilizes EMD and the dispatching of suppression apparatus on Alpha calls. Additionally, the department has trained over 3600 citizens in CPR during Due to the extended scope of practice of BLS ambulances in Georgia, BLS units can treat a greater variety of medical emergencies than either Seattle or Ann Arundel County. These programs and procedures should enable the addition of BLS ambulances in the GCFES EMS system. Changes needed to implement BLS ambulances The literature review suggested that rapid accurate EMD is one of the most essential elements of an EMS system. Several systems such as Seattle and Washington DC continuously revise EMD protocols based on the review of patient care reports. Both of these jurisdictions have software-based systems that direct the dispatcher to the correct protocol instantly as the caller is interviewed. Additionally, medical protocols can be instantly revised by medical control when needed. While reviewing internal CAD reports from Gwinnett County Communications, during the first six months of 2007, only 39% of emergency calls were dispatched within 90 seconds. This same report showed only 36% of EMS calls were being triaged as BLS. During a discussion with A. Conley, Gwinnett County Communication Supervisor, she linked both the low

38 Incorporating BLS Ambulances 38 percentage of BLS triage and the slow dispatch times to call volume and the current EMD flip card system. When an EMS call is received, the caller is questioned via flip cards that are organized by complaint. As further information is received, the dispatcher may have to use several cards to determine the correct call priority. This must be accomplished within 60 seconds to meet the 90-second dispatch benchmark. As the call taker reaches that 60 second mark, a decision must be made. To save time, a Charlie response (ALS) is chosen as the default. The author asked for a copy of the cards to review. While reviewing the cards (Appendix I), several of the protocols including allergies (#2 Charlie), breathing problems (#6 Charlie), burns (#7 Charlie), carbon monoxide (#8 Charlie), diabetic problems (#13 Charlie) and stoke (#28 Charlie) recommended an ALS response. However, the department EMT scope of practice allows treatment by BLS units for those specific symptoms. The literature review specifically addressed this issue. In Seattle for example, both EMD triage and patient care reports are reviewed to ensure the correct level of responder is dispatched. Fire Chief David Foster acknowledged several changes that his department had to undertake to implement BLS transport units. His first change was to CAD by typing each resource as either ALS or BLS. In addition, any changes during the day are documented with the unit s mobile data terminal. Next, the EMD protocols were updated to match the extended level of care available by BLS units in Georgia. In 2004, a private/public partnership was started with American Medical Response (AMR) in Atlanta. The AMR ambulances are equipped with Dekalb County communication equipment and are fully integrated with Dekalb County Fire. The vehicles, equipment and crews are provided by AMR. AMR provides four 24-hour trucks and two 12 hours peak trucks. There is no cost to Dekalb County as long as AMR is provided with 60 transports a day. To date, this has not been an issue due to the large call volume.

39 Incorporating BLS Ambulances 39 During 2005, five fire department BLS ambulances were added. Chief Foster s greatest challenge has been the acceptance of firefighter EMT s riding the ambulance and caring for a patient while the paramedic is assigned to the first responder unit. He stated that the older more experienced firefighters had the greatest difficulty with the change. In trying to address the firefighters concerns, two changes were implemented. Fire department BLS ambulances would be utilized for suppression activities and first responder units would be dispatched on Alpha calls to triage or treat a BLS response. If the patient is stable but requests transport, the patient is released and placed on a waiting list until an available AMR unit can respond. This policy has kept the fire department BLS units in service, has reduced their utilization rate and has given AMR additional responses. Chief Foster advised that patient care has not been an issue. Q & I is completed at the station level and by a battalion EMS officer. Since most first responder units are staffed with paramedics, ALS capability is available within a few minutes of a request. When reviewing the change model literature and Chief Foster s findings, it was clear that the incorporation of BLS units would change the status quo. A clear vision of the Gwinnett Firefighter s opinions and concerns was needed to develop a change plan and reduce resistance. A survey was developed by the author to determine tenure, familiarity with department standing medical orders, patient care skills and how often those skills are utilized while teching on an ambulance. In addition, a section for opinions and comments was provided. The 216 responses were analyzed to determine what elements of a change plan needed to be addressed. The first section requested basic demographics of the respondents.

40 Incorporating BLS Ambulances 40 Length of employment Sixty percent of the respondents had less than 10 years of service. The second largest group had 20 years or greater % 5.56% 3.70% 9.26% 10.19% 18.52% 32.87% 3 years or less 4 to 6 years 7 to 9 years 10 to 12 years 13 to 15 years 16 to 19 years 20 years or greater Years of service as an EMT Figure 5 Years of service with GCFES Forty nine percent of the respondents have six or less years of experience as an EMT. Less then 10 percent of the respondents had more than 20 years experience as an EMT. Two percent of the respondents that were not EMT s were directed to the end of the survey. I am not a Georgia State EMT-I 3 years or less 9.72% 2.31% 12.96% 6.48% 10.65% 9.26% 28.70% 19.91% 4 to 6 years 7 to 9 years 10 to 12 years 13 to 15 years 16 to 19 years 20 years or more Figure 6 Years of Service as an EMT

41 Incorporating BLS Ambulances 41 Current Rank of the respondents Thirty seven percent of the respondents were Firefighter II that have greater than one year of service. The next two largest groups were Firefighter III and Driver Engineer % 4.17% Firefighter I Firefighter II 24.07% 37.04% Firefighter III Driver Engineer 21.76% Firefighter Lieutenant Figure 7 Rank of Respondents Type of EMT certification Since 1998, an individual must acquire National Registration as an EMT prior to receiving state certification. It is not mandatory to maintain national Registry certification for state recertification. Sixty percent of the respondents were state EMT s while 40 percent maintained their National Registration % Georgia State Certified EMT 59.72% Both Nationally Registered and Georgia State Certified Figure 8 Comparisons of Nationally Registered and State Certified EMT's

42 Incorporating BLS Ambulances 42 Number of times assigned to a med unit monthly The largest numbers of respondents, 53%, are assigned to ambulance less than two shifts a month. Only 13 % of the respondents are assigned greater than five times a month. 2.78% 10.65% 33.80% 52.78% or more Figure 9 Number of Shifts Assigned to an Ambulance Monthly Percentage of time functioning as the patient attendant with a BLS patient. Sixty-five percent rarely or never function as the patient attendant on BLS responses. Twelve percent function as a patient attendant more than 60% of the time. 4% 8% All of the time (100%) 37% 23% Most of the time (60-99%) Some of the time (20-59%) Hardly Ever (1-19%) 28% Never (0%) Figure 10 Percentage of the time EMT's tech on BLS calls

43 Incorporating BLS Ambulances 43 EMT self assessment Section two of the survey asked the respondents to rate their proficiency from one to five with five being the highest based on the scope of practice and KSA s for EMT s in Georgia. Administer Nebulized Proventil treatments: Perform Intraosseous infusion: Administer adult or pediatric EPI PEN for anaphylactic shock: Administer Oral Glucose, D50, D25 or D10 IV solution for hypoglycemia: Perform a blood glucose determination: Initiate and maintain a peripheral IV: Use a Combitube: Administer Asprin for Cardiac Chest Pain: Complete an accurate EPCR for patient contacts: Provide care for Emergency Childbirth: Provide care for Medical patients: Provide care for Trauma patients: Take and record vital signs: Conduct detailed patient examinations: Provide CPR and AED on any pulseless and apneic patient: Provide Oxygen via BVM with adjuncts or by device: Open and Maintain an Airway: Rating 0=unable, 3 = meets standard, 5= expert Figure 11 EMT Self Proficiency Ratings for Skills

44 Incorporating BLS Ambulances 44 Knowledge of standing medical orders Bleeding control: Extremity Injuries/Fractures: Eye Injuries: Child Birth: Snake Bites: Burn Treatment: Spinal Immobilization: Shock Management: Hypoglycemia: Cerebral Vascular Accident: Asthma/COPD: Allergic Reaction: Non Traumatic Abdominal Pain: Documentation: Hospital Communications: Discontinuance of CPR: Determination of Death: = No knowlege, 3 = Meets Standard, 5 = Expert Figure 12 Knowledge of Standing Medical Orders

45 Incorporating BLS Ambulances 45 Patient attendant skills and abilities Hospital At the rt Patient Transpo Pre Incident Scene M a nag em ent Patien t A ssessme nt EPCR operations Proper Documentation: Rapport with hospital staff: Patient handling: Patient report to staff: Patient care report: Patient care/treatment: Obtaining destinations: Scene treatment: Obtaining vital signs: Detailed exam: Initial assessment: On scene communication: Delegation: Leadership: Safety: Locating the call: MDT operation: Radio usage: = Unable, 3 = Meets Standards, 5 = Expert Figure 13 Patient Attendant Skills and Abilities

46 Incorporating BLS Ambulances 46 The respondents were asked to rate their skills from one to five with one being unable, three meeting standards and five being an expert. The EMT s that responded assessed themselves as being proficient in all skills except intraosseous infusion. The second weakest ranking was emergency childbirth. The respondents overall ranked themselves lower on the knowledge of standing medical orders. Most cannot meet standards for snakebite treatment. The strengths of the group include bleeding control and spinal immobilization. All respondents ranked themselves as meeting or exceeding standards with patient attendant skills. The weakest two sections include electronic patient care reports and patient care reports to the hospital. In addition, several comment blocks were completed to include (a) Never teched; no desire to tech; don't feel comfortable with teching, (b) have not done many, (c) I am not usually the person that is responsible for that task, and (d) not good with pcrs. Part three of the survey asked for the respondent s opinion on possible implications of starting BLS transport units and whether they agree with the program. A column with the choice unsure was included to prevent a forced answer. There was also a comment block available for free text. The free text responses are included in the appendix with the questionnaire. Most respondents felt that the EMT s liability would increase while paramedic liability would decrease. Respondents also felt that the EMT s workload would increase while paramedic workload would decrease. Most agreed that a tiered system could cause some confusion with ALS and BLS criteria. However, 60 percent of the respondents either agreed or strongly agreed that EMD would triage the calls to the appropriate units. Respondents agreed that ALS units would have a decreased call volume. However, 42 percent felt that BLS units would not increase the percentage of ALS responses for ALS units. This question also had the highest number of unsure responses at 18.5 percent. Fifty two percent

47 Incorporating BLS Ambulances 47 of the respondents felt that paramedic retention would increase with the incorporation of BLS units. Over 50 percent of the respondents felt that ALS response times would improve, the level of service to the citizens of Gwinnet would increase and overall system performance would improve. A review of the elective free text section (Appendix C) mainly addressed the concerns of EMD triaging, the fear or comfort of functioning as a patient tech and the realization that the issue of increased call volume with the department s paramedic shortage is going to continue straining the system. There was also a concern that ALS units would dump calls on BLS units, causing animosity and lowered morale. Finally, there were several comments that patient care will suffer if a paramedic is not available on every call. A majority of respondents felt that the program would work if started slowly with proper training or by asking for volunteers. Additionally, tenure was addressed with the opinion that the younger EMT s could adjust quicker to the roles and responsibilities of a patient attendant. Some comments addressed that initially morale might be impacted but after 12 to 18 months the program would become a functioning part of GCFES Several references were made to a three-month pilot program called BLS 23. This program was a three day 13 hour peak truck utilized in Med 23 s response district. The program s intent was to lower utilization of Med 23 and surrounding trucks. Since it was a pilot, a mandatory ALS MFRU unit was required to respond with BLS 23. Additionally, the crew of BLS 23 reported to three different Lieutenants on three different shifts, which caused some management issues.

48 Incorporating BLS Ambulances 48 Respondents Opinion of BLS transport units Increase the Paramedic's liability: Cause confusion of BLS vs ALS criteria: Increase the Paramedic's workload: Increase the EMT's liability: Increase the EMT's workload: Improve overall system performance: Increase Paramedic retention: Increase the number of ALS responses for ALS transport units: Increase the number of responses for ALS transport units: Increase the level of service to the citizens of Gwinnett: Allow Emergency Medical Dispatch criteria to triage calls to appropriate units (BLS vs ALS): Improve ALS response times: Number of Respondents Strongly Disagree Disagree Agree Strongly Agree Unsure Figure 14 Respondents Opinion of BLS Transport Units

49 Incorporating BLS Ambulances 49 Respondents agreement with BLS transport units No, 31.02% Yes, 68.98% Figure 15 Percent in Agreement With BLS Transport Units The results of the survey suggest the most department EMT s are comfortable with most aspects of patient care and treatment. Two thirds of EMT s rarely or never function as patient attendants. Additionally, most EMT s are weak when providing patent care reports to the hospital or completing patient care documentation. Several respondents confirmed the awkwardness and fears of being assigned to a BLS ambulance or the fear of providing inferior care compared to a paramedic. Even with these challenges, 70 % of the respondents agreed with the idea of BLS transport units. The data of the survey confirmed the author s opinion that an internal cost of BLS ambulances is the change of the culture of the organization and the employee dissatisfaction that may occur. The author was surprised to have 70% agree with the idea of BLS transport units. Decreasing ALS arrival time and enhancing service delivery The literature review suggests that with patients needing ALS care, an ALS arrival time of four to five minutes was needed to increase patient survival. If the response is for a trauma

50 Incorporating BLS Ambulances 50 patient, the level of care is not as important as the speed of treatment and transportation to the hospital. If the patient is a victim of SCA, CPR and defibulation needs to be administered within six minutes to enhance victim survival. The literature also suggests the measurement of victim survival is an accurate measurement of service delivery. Services such as Seattle, Boston and Rochester, Minnesota have increased survival rates my decreasing response times, CPR time and call to shock time. The CARES report for Metro Atlanta (Appendix I) reports an overall cardiac save rate of 4.2% in region three with an Utstein rate of 12.8%. The Dekalb County Fire Department, after adding ten BLS transport units and five ALS squads, has decreased the average response time of the first unit on the scene to less than 5 minutes. By changing ALS ambulance staffing to one paramedic and one EMT and reassigning the paramedics from 5 ALS ambulances to create the five BLS fire ambulances, at least36 or more ALS MFRU are available each shift. Chief Foster reported an increase in cardiac saves from seven percent in 2004 to 23 % currently. The Ann Arundel County Fire Department realized the importance of response and treatment time when creating the Handle First Emergency procedure in Chief Cox advised that when the procedure was first developed, there was a possibility of a decrease in suppression protection by placing the two station firefighters on an ambulance. However, after researching response statistics, management decided that a rapid response of a BLS ambulance provided better service delivery than responding a BLS MFRU and waiting for either a distant unit or response of an ambulance by volunteers. The CARES report dated August 27, 2007 (Appendix J) for Gwinnett County reports an overall survival rate of 3.8% with an Utstein rate of zero percent. The report also listed 40

51 Incorporating BLS Ambulances 51 percent of the victims receiving CPR prior to EMS arrival and six percent of the victims having an AED applied. In Gwinnett, the arrival time of either an ambulance or MFRU is less than 5.5 minutes 41 percent of the time (B. Myers, personal communication, August 8, 2007). The literature, data and interview results suggest that a rapid response, whether ALS or BLS, is prudent for patient care and survival. The literature and CARES study suggest that an accurate measurement of service delivery is a measurement of patient survival. Discussion The results show that the addition of BLS ambulances has the potential to decrease ALS arrival times by reducing the utilization of ALS ambulances. In addition, a shorter response time, whether ALS or BLS, will enhance service delivery and save more lives. The Dekalb County Fire Department has decreased their response time to less than five minutes and increased their cardiac arrest save rate to 23 % after adding 10 BLS transport units and increasing their ALS MFRU to 36 (D. Foster, personal communication, August 17, 2007). The literature consistently stated a critical patient needs a rapid response for the best chance of survival. A study in Charlotte, North Carolina found that a response within 5 minutes had the greatest impact on patient survival (Blackwell and Kaufman, 2002). This study conferred with a study in Denver, Colorado in which an ALS response time of four minutes or less for the most critical patients is needed to increase survival rates (Pons P; Haukoos, Jason, Bludworth, Whitney, Cribley, Pon K.; Markovchick, 2005). The Seattle King County Medic One EMS system has a 45 percent save rate for SCA victims (Davis, 2003). In the city of Seattle, the current response time averages are 3.68 minutes for BLS and 3.81 minutes for ALS (Seattle Government, 2006).

52 Incorporating BLS Ambulances 52 Many GCFES EMT s were concerned that BLS ambulances would reduce the level of care rendered to patients. While the literature does state that a patient requiring ALS care needs that care within five minutes for the best outcome, a rapid BLS response is just as effective in many situations. Multi systems trauma patients receiving BLS care had an 82 percent survival rate compared to 81 percent for patients receiving ALS care (Hendry, 2005). Additionally, the same study found a 54 percent survival rate for traumatic brain injured patients whether ALS or BLS care was received pre hospital (Hendry, 2005). When a patient suffers SCA, rapid CPR and defibulation, both BLS treatments, are needed for the best chance of patient survival. Both Rochester Minnesota and Miami Dade County Florida have utilized CPR trained police officers to deliver AED shocks (Davis, 2003). Miami-Dade increased their SCA survival rate from 7% to 17% and Rochester has improved to 44% (Davis, 2003). In order for a tiered EMS system to be effective, a rapid accurate EMD process must be present. Communication centers should track their processing time and strive to process calls within 60 seconds 95 percent of the time (Williams, 2006). In addition, quality assurance and review are essential for an effective EMD system (NFPA 450, 2004). When reviewing internal reports from Gwinnett County Communications, neither standard is currently being met. On average, only 40 percent of 911 calls are processed in less than 90 seconds. When EMS calls are processed, approximately 36 percent are triaged as BLS. When compared to other similar jurisdictions or with nationwide surveys, the accuracy of the EMD triaging must be questioned. The city of Seattle maintains a BLS ratio of 68 percent and confirms its EMD triaging with actual comparison to patient trip reports (J. Frisk, personal communication, August 28, 2007). Williams (2007) confirms that the nationwide average for BLS responses in 51 percent.

53 Incorporating BLS Ambulances 53 However, the same report when broken down by population showed a BLS ratio of 40 percent in communities with the same population as Gwinnett County (Williams, 2007). The most important finding is, since there is not any quality review built into the system, there is not an accurate way to determine how Gwinnett s EMD compares to actual patient condition. This appears to be a serious deficiency whether an ALS or BLS unit is dispatched. Is the call really an Alpha or Charlie response? Washington DC has solved this dilemma by reviewing EMD triage with actual patient reports (Davis, 2006). It is time that Gwinnett considers the same. Gwinnett s EMD criterion does not correlate with the scope of practice of its EMT s. When comparing the EMD protocols for allergic reaction, breathing problems, burns, carbon monoxide poisoning, diabetic problems and stroke, all criteria recommending an ALS response are within the scope of practice of EMTs. The Medic One system in Seattle prevents this issue by reviewing its dispatch criteria annually (Seattle King County Public Health, 2007). Whether the response is BLS or ALS, the only true response time is from the patient s perspective (Fitch, 2005). In Gwinnett County, over 50 percent of the time, the response time is over 5.5 minutes (B. Myers, personal communication, August 8, 2007). When analyzing response times, two of the components that can be controlled are unit utilization and component time. The literature suggested a utilization rate of.4 or less for a 24-hour truck (San Francisco Board of Supervisors, 2003). In Gwinnett County, department ambulances ranged from.33 to.57 with 17 of 21 ambulances exceeding the.4 threshold. In reality, this means that most of the time, ambulances are responding to second and third due territories creating increased response times. While the department is not currently looking at methods to reduce call volume, the department needs to control unit utilization ratios. The author included all out of service time to get a true

54 Incorporating BLS Ambulances 54 measure of unit utilization. Some common lost component time that increase utilization times are hospital delays, which increase off load times at hospitals (Fitch, 2005). Due to the population growth of Gwinnett County, hospital delays and emergency room bypass are a common problem. Another method to ensure a reduced response time is to dispatch the closet unit. Nationwide, only about 55 percent of EMS services can confirm that the closest unit has been dispatched (Williams, 2007). The Dekalb County Fire Department will be incorporating AVL into its CAD system in January of 2008 (D. Foster, personal communication, August 17, 2007). In Gwinnett County, CAD dispatches a unit by first due territory even if several other units are closer. This dispatch must then be changed delaying the response time by minutes. If AVL is incorporated into Gwinnett s CAD system, the closest unit can be dispatched and more importantly tracked to show lost component time such as hospital delays or slow turnout time. FDNY, when utilizing AVL, had a 10% decrease in response times (McLaughlin, 2006). Puckett Ambulance service in Cobb County, Georgia, decreased response time by two minutes after implementing AVL (Casciato, 2007). The same decrease in Gwinnett County would significantly enhance service to the citizens. When Chief Foster initiated the BLS program in Dekalb County, there was resistance from suppression personnel due to the change in job duties. Dissatisfaction with the decision has created animosity that is still present to date (D. Foster, personal communication, August 17, 2007). When reviewing the comments section of the EMT survey, several statements concerning a lowering of morale or being forced into something they are not comfortable with were common. The majority of respondents replied that their workload and liability would be increased by being placed on BLS units. What is interesting to note was that most EMT s were very comfortable with their knowledge of standing medical orders and performing patient

55 Incorporating BLS Ambulances 55 assessment and care. Only when placed into the situation of interacting with the hospital staff and the required documentation was the skill level less. Department EMT s have been content with the status quo. The resistance to adding BLS transport units to the department will be high, especially with the more senior EMT s. As long as followers are content, it will be difficult to incorporate change (Hughes et al. 2006). However, at the same time, 70% of respondents replied that they supported BLS transport units. If BLS units were incorporated, dissatisfaction especially by the more senior EMTS may actually allow the change. A clear model will need to be developed with a vision and purpose of BLS units. The model must also set goals and identify needed system changes (Hughes et al. 2006). Some of the needed system changes have already been presented by this paper. What will need to be developed is a set of goals. The criterion established by GCFES is ALS on scene less than eight minutes 90 % of the time. The literature suggests a more accurate criterion is the number of victims that leave the hospital alive (Davis, 2003). Although this criterion is based on the number of survivors from SCA, it can be used as a measure of EMS performance because the care received by responding units directly affects patient outcome (Davis, 2007). When comparing GCFES performance with Metro Atlanta, Gwinnett and Metro Atlanta both have a four percent cardiac survival rate (CARES, 2007). When comparing victims that fall within the Utstein Template, which are the victims with the highest survival probability, Metro Atlanta survival rate is 13% compared to Gwinnett's zero percent (CARES, 2007). The Dekalb Fire Department reports a survival rate of 23% (D. Foster, personal communication, August 17, 2007). If GCFES set a customer-based goal of increasing its CARES rating and provided a clear model on how BLS units can help accomplish that goal, it is the author s opinion that resistance

56 Incorporating BLS Ambulances 56 to BLS transport units will decrease and change will be easier. Additionally, allowing input from the participants on what additional training is needed while reviewing procedures and responsibilities will allow the EMT to help create the change plan. Hughes et al (2006) agrees, Perhaps the best way to get followers committed to a change plan is to have them create it (p399). Recommendations Whether or not BLS transport units are implemented by GCFES, the following items need to be addressed to enhance service delivery: 1. Gwinnett County s EMD program needs to be updated and automated. The author recommends the purchase of a computerized EMD program that integrates with the current CAD system. This program should incorporate the scope of practice of GCFES EMT s and have the ability to audit patient care reports to ensure accuracy. In addition, automated internal quality control should be available to ensure a quicker dispatch time. 2. CAD should be upgraded and programmed to include unit typing by level of medical care and vehicle location. This would ensure that the proper and closest unit is dispatched, whether BLS, ALS or both. This in turn should provide the lowest response time to the most critical patient. 3. GCFES needs to determine the reasons for the high utilization rates of their ambulances. Both call volume and system component times need to be investigated. 4. GCFES has established a customer based goal based on response times of ALS units. The author suggests developing a goal to enhance service delivery by improving the cardiac save rate using the Utstein template. The data can be retrieved from the

57 Incorporating BLS Ambulances 57 CARES report and can be easily analyzed and compared to other local and national jurisdictions. From this data, specific objectives can be determined, communicated and implemented within the department. 5. GCFES should utilize the data from the EMT survey to determine training needs. Issues such as emergency childbirth, snakebite treatment, EPCR usage and patient reports to the hospital can be addresses whether on not BLS ambulances are utilized in the future. Before BLS ambulances are incorporated into the GCFES EMS system, a change model including employee performance concerns as well as the vision and objective of the program should be presented to all department members. A period of employee feedback should be allowed prior to the implementation of the program. Areas for the incorporation of BLS ambulances should be in territories with both the highest overall utilization rates and highest BLS utilization rates. It is also important to note that the procedures listed in the research project can be utilized in any organization requiring a change to its practices or organizational culture.

58 Incorporating BLS Ambulances 58 References American Heart Association. (2005) American heat association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care [Electronc version]. Circulation, 112, 4, Retrieved Autust 16, 2007 from Atlanta Regional Commission. (2007, August 9). Atlanta Region Gains 104,000 Residents, Topping 4 Million. Retrieved August 19, 2007 from Averson, P. (1998). What is the Balanced Scorecard? Retrieved July 30, 2007 from Blackwell, TH.; & Kaufman, J.S. (2002). Response time effectivness: comparison of response time and survival in an urban emergency medical services system. [Electronic version]. Academic Emergency Medicain, 9, Cardiac Arrest Registry to Enhance Survival. (2007). Introduction. In Utstein Survial Report (chap. 1). Retrieved August 20, 2007 from Casciato, Daniel. (September 2007). Best Practices in Emergency Services. (Available from EMS Best Practices Inc., PO Box , San Diego, CA ) City and County of San Francisco Fire Commision. (2005). EMS Reconfiguration (05-4). Retrieved August 4, 2007, from Davis R. (2003, December 29). Cities get in gear on EMS; Series helps reveal the gaps. USA Today., Retrieved on August 3, 2007, from

59 Incorporating BLS Ambulances 59 Davis, R. (2003, July 28). The method: Measure how many vitims leave the hosptal alive. USA Today., Retrieved on July 28, 2007, from Davis, R. (2003, July 29). Special Report: Sluggish responses to emergencies let patients die; Percise measures of EMS response times can save lives. USA Today., Retrieved on July 18, 2007, from Davis, R. (2006, September 20). D.C. revamps emergency services, Beleaguered city responds to heavy criticism with unified 911 center. USA Today., Retrieved on July 17, 2007, from Davis, R. (2003, December 29). Nation's premier lifesaving cities enter in friendly competion; Technology, training and citizen CPR are raising the bar. USA Today., Retrieved on August 3, 2007, from Today/access/ html?FMT=FT&dids= Dean, S. (2007). Response Times. In Public Utility Model EMS. Retrieved July 16, 2007 from -utility- Model-EMS Fitch, J. (2005). Response Times: Myths, Measurement and Magangement [Electronic version]. Journal of Emergency Medical Servies, 30(9). Georgia Department of Human Resources Rules and Regulations. (2004) Definitions. (chap ). Retrieved July 10, 2007 from

60 Incorporating BLS Ambulances 60 Hassan, T.B; & Barnett, D.B. (2002). Delphi type methodology to develp consensus on the future desingn of EMS systems in the United Kingdom. [Electronic version]. Emergency Medical Journal, 19. Hendry, J.M. (2005, June). ALS does not benefit overall trauma patient survival. Retrieved July 21, 2007 from merginet.com/index.cfm?pg=trauma&fn=opalsalsvalue Hughes, R.S., Ginnett, R.C., & Curphy, G.J. (2006). Leadership: Enhancing the lessons of experiance (5th ed.). Boston: McGraw Hill. International City/County Management Association. (2005). EMS in critical conditoin: Meeting the challenge (Item No. E-43338). Platte City, MO: Fitch, Jay. Kelly, J.P. (2004). Paramedic shortage: How will it affect you? Unpublished manuscript. Conenant College, Lookout Mountain, Georgia. McLaughlin, A. (2006). NYC installs AVL Units in ambulances, FDNY vehicles. DomPrep Journal, 11, 18. Meyer, E., & Ishtiaque, A. (2003, August). Benefit-Cost Assessment of Automatic Vehicle Location in Highway Maintenance. Unpublished manuscript. University of Kansas at Lawrence. Myers,B. (2003). Non-emergency medical transportation and the gwinnett county department of fire and emergency services. Unpublished manuscript. National Fire Protection Association. (2004, August 5). NFPA 450 Emergency medical services and systems 2004 edition. Retrieved July 27, 2007, from National Fire Protection Association. (2004, August 5). NFPA 1710 Standard for the Organization and Depployment of Fire Suppression Operations, Emergency Medical

61 Incorporating BLS Ambulances 61 Operations and Special Operation to the Public by Career Fire Departments 2004 edition. Retrieved July 27, 2007, from National Higway Traffic Safety Administration. (n.d.) Emergency medical services agenda for the future. Retrieved May 25, 2007, from Pons, P.T, Haukoos, J.S., Bludworth, W., Cribley, T., Pons, K.A., Markovchick, V.J. (2005). Paramedic response time: Does it affect patient survival? Academy of Emergency Medicine, 12, Abstract Retrieved August 18, 2007, from Reason Public Policy Institue. (2006). Emergency medical services Retrieved July 30, 2007, from San Fransico Board of Supervisors. (2003). Management audit of the san francisco fire department 4.2 emergency medical service (EMS) system configuration. Retrieved August 16, 2007 from Seattle and King County Public Health. (2007, January). Medic One/Emergency Medical Services Strategic Plan. Retrieved June 16, 2007, from Seattle Goverment. (2006). Seattle fire department 2006 response times by company. Retrieved July 29, 2007 from times/company response times-2006.htm The Reason Foundation. (1995, November). Privatizing emergency medical service: How cities can cut costs and save lives. Retrieved July 29, 2007, from

62 Incorporating BLS Ambulances 62 Unger, Z. (2007, May). Non-tranporting units resond to alpha calls. Best Practices in Emergency Services. Retrieved August 1, 2007 from Wikipedia. (2007). EpiPen. Retrieved Septmeber 14, 2007 from Williams, D. (2006, September). The myth of the Perfect Model. EMS responder.com. Retrieved July 15, 2007 from Williams, D.M. (2006, February). Communication centers at their best. Best Practices in Emergency Services. Retrieved July 21, 2007 from Williams, D.M. (2007). Jems 200 City Survey [Electronic version]. Journal of Emergency Medical Services, 32(2)

63 Incorporating BLS Ambulances 63 APPENDIX A Interview with Battalion Chief Michael J. Cox Jr. Ann Arundel County Fire Department August 13, During each interview, the basic set of questions asked was: 1. How many EMS responses did your department have last year and what percentage were BLS? Our department responded to approximately 50,000 EMS calls last year and about 90 percent were BLS. I do not have those exact numbers. The ambulance reports are at the state. 2. How many ALS and BLS transport units do you operate daily and what is the average utilization rate? Our department operates 21 ALS units and 9 BLS units with plans to have an ALS unit in each of our 31 stations. I do not have the exact figures on utilization. The areas closer to the north end of the county have a higher call volume. Paramedic 18 is one of our busiest units with a call volume of about 4000 calls a year. 3. How many medical first responder units do you operate and are any ALS? We operate 28 engines, three quints and nine ladders. We have 31 stations, 10 career and 21 volunteer. The volunteer stations are staffed with either two or four personnel. Two engine companies are mandatory ALS 4. How long have you been utilizing BLS transport units? BLS transport units have been utilized since the creation of the fire department in Initially, volunteer ambulance squads provided transport. In 1974, two ALS ambulances were added due to increased call volume. As the career stations were added, so have the ALS ambulances. Every station has a transport unit assigned to it.

64 Incorporating BLS Ambulances What departmental procedures had to be created or changed to implement BLS transport units? A procedure called handle first emergency was created in Prior to this procedure, a station staffed with two paid employees would respond an engine as a BLS first responder unit. The BLS ambulance would respond with volunteer EMT s or a career ALS ambulance would respond. As EMS call volume increased, a greater burden was placed on the volunteers and career ambulances. Handle first emergency allows the on duty crew to respond the truck needed for the call. If an EMS call were dispatched, the crew would respond the ambulance and leave the engine unstaffed. If the station were staffed with four, two would remain with the engine. At first, the concern was a reduction in fire suppression but the data did not support this. 6. Has the incorporation of BLS transport units decreased your ALS response times or improved your service delivery? The handle first emergency procedure has placed more BLS ambulances in service quicker and initially reduced the ALS units call volume. However, like everyone else, all of our EMS units are getting busier. We try to add a unit when call volume increases. Our goal is to have all ambulances ALS eventually.

65 Incorporating BLS Ambulances 65 APPENDIX B Interview with Fire Chief David Foster Dekalb County Fire and Rescue Department. August 17, How many EMS responses did your department have last year and what percentage were BLS? Last year the department responded to 104,000 EMS requests. Out of those requests, we transported 47,000. Approximately 80 percent of our requests are BLS. 2. How many ALS and BLS transport units do you operate daily and what is the average utilization rate? We operate 14 ALS fire department ambulances, 5 BLS fire department ambulances and 5 BLS private ambulances. We try to keep the utilization rate for the fire department ambulances below.40 but most units exceed that. The private ambulances try to keep their units higher. 3. How many medical first responder units do you operate and are any ALS? We have 36 to 39 ALS resources available daily. We try to rotate our paramedics on our engines and trucks. We also have six ALS two person squads in the county to respond with the BLS units if needed. 4. How long have you been utilizing BLS transport units? When I became Chief four and one half years ago, it was common to go NATS, no ambulance to send. In 2004, a contract with AMR ambulance was started to provide five BLS ambulances. These ambulances would have Dekalb radios and MDT s and would be incorporated into Dekalb County s CAD system. The agreement was that they had to be provided with 10 transports a day, which has not been a problem. Three years ago, we added five fire department BLS ambulances.

66 Incorporating BLS Ambulances What department procedures had to be created or changed to implement BLS transport units? When I first started as Chief, the agreement with AMR was that they were going to provide four ALS ambulances a day. They could not meet this due to the paramedic shortage so in 2004 it was changed to BLS units with Georgia EMT-I s. These trucks were fully integrated with our dispatch center. Specific parameters were established on which calls BLS trucks could be utilized. If any ALS procedures were completed or needed, a paramedic from the first responder unit would take their ALS equipment off the engine and transport the patient in the BLS truck. This program provided four additional ambulances for no cost to the county. In 2004, five BLS fire department ambulances were placed in service. The paramedics normally assigned to those trucks were assigned to a squad or engine. At first, there was some grumbling from the firefighter EMT s about having to tech and ride the ambulance. It still continues some to this date. There have been no concerns with patient care. To ensure QI, each squad was assigned a paramedic captain to review electronic patient care reports (EPCR s) on the server after submission. In addition, each station officer is required to check all EPCR s created by their assigned unit each shift. If there is any question about patient condition or treatment, a paramedic must transport. In addition, the patient, EMT and paramedic must agree to the choice. CAD had to be changed to allow unit typing by medical certification. In January of 2008, AVL will be activated. This will ensure that we will be sending the closest appropriate unit each time. AVL will also track hospital turnaround time and response time. 6. Has the incorporation of BLS transport units decreased your ALS response times or improved you service delivery?

67 Incorporating BLS Ambulances 67 The incorporation of the BLS units has provided for more ALS resources. This in turn has reduced our response time to ALS calls. Our response time for the first unit is usually in the 4:30 to 4:50 range. Since adding the units, our cardiac save rate has improved from seven percent in 2004 to 23 percent currently. Every first responder unit is equipped with an AED. The BLS ambulance can be utilized for an ALS response as long as a paramedic is responding to provide those resources. After the interview, some general discussion continued. Dekalb County transported 47,000 people last year. The current goal of the department is to maintain those transport numbers with an increase in revenue. The department currently charges an assessment fee of $50.00 for a patient assessment. If the patient is stable but still wishes transport, AMR ambulance is notified and they are dispatched when available. When the author commented on the department s high cardiac save rate, Chief Foster advised that the department does not offer CPR classes to citizens. He believes the save rate is due to the rapid response of his resources.

68 Incorporating BLS Ambulances 68 Appendix C Gwinnett County EMT Survey

69 Incorporating BLS Ambulances 69

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73 Incorporating BLS Ambulances 73

74 Incorporating BLS Ambulances 74 Free text from comment section (sic) 12. Skills and abilities, patient transport (sic): Never teched; no desire to tech; don't feel comfortable with teching Have not done many I am not usually the person that is responsible for that task. Not good with pcrs 14. Your opinion counts (sic): The BLS unit should be supervised by the officer in charge of the station that the unit is assigned to. Not by folks at HQ. It will definitely help the paramedics from running on low priority calls. Did BLS 23 help surrounding units or simply free them up to run more of there own calls? If implemented properly, it would be a great tool. Use the Medics on the engines, let the basics transport unless an ALS event. Then the medic would swap to the ambulance, keeping the engine in service and still increasing response times for ALS care. Maybe hire non-cross trained Medics just to ride on the med units. People that want nothing do with fire. It would free up Medics to make engines ALS and not waste their training. Only substantial pay and decreased workload will retain paramedics. Due to the fact that you can go 2 years or 4 years and became a nurse and only work 3 days a week and make just as much or more than a paramedic on 24/48 system, What is the incentive to become a paramedic and be away from your family every 3rd day and in this profession you need 2-3 jobs just to survive. The Paramedic profession is going to become a very hard position to fill in the future

75 Incorporating BLS Ambulances 75 unless desperate measures are taken to retain them such as pay, incentives, leave time due to burn out. Depends on the individual and attitude. Depending on number and conditions for EMT-I ran BLS ambulances you may even see an increase in Paramedics if they are not on the ambulance as much as they are now I believe it would be a great thing if done the right way. One of the biggest concerns I heard during the testing period, was the schedule. This is what was said to me. One of the most important things is unity and teamwork. When you give someone three different Lt.'s and you work in a different Battalion than you are use to, you do not have that cohesiveness like you do with your normal crew. Three Lt.'s are going to different expectations off you and you are trying to please them all. It would take longer than normal to get use to the scheduling and crews. This also includes the other stations crews that you would run calls with. My experience with the initiation of FD BLS units is that for the first months there is FF opposition and a lowering of morale. In the end, it makes better EMT's and a greater asset to paramedics on ALS calls. Already performing EMT duties with no compensation due to the fact EMT-B are paid 5% with no ambulance transport. The way that we operate with 3 on a truck there are going to be a lot of trucks out of service that are only used for one thing and that is fighting fire the only way it will work is if we run with 4 and 2 paramedics on every truck Dispatch can t get the right units to the location at times now. They will have a harder time with BLS units. The EMTs work just as hard now as the Pmdc do and less pay. The county should pay the EMT the same if they make BLS trucks!

76 Incorporating BLS Ambulances 76 Make ALL engine's and truck's ALS. I feel this will improve response time and care due to increased med units and hospital status. It takes to many trucks out of service to run the BLS unit. Some EMT's do not feel comfortable enough to ride the BLS truck. Pay is the only way to retain Paramedics BLS units would undoubtedly free up ALS units for more serious calls. BLS units would undoubtedly free up ALS units for more serious calls. It is my opinion that it would increase the EMT's responsibility on some calls. I do not see how this would retain paramedics in the field because paramedics still do what paramedics do. It might reduce a percentage of the call volume, but the call volume is tied more to a growing population than it is to BLS responses. Just my opinion. me and I'll try and give you a EMT's point of view on fixing the problem By sending an ALS Engine or Truck with the BLS TX unit, what are we gaining, and what are we losing? 15. I agree with the implementation of BLS transport units into Gwinnett County s EMS system (sic)

77 Incorporating BLS Ambulances 77 The BLS unit should be supervised by the officer in charge of the station that the unit is assigned to HQ. Although I currently have not teched, I know that it is just another step in my growth with the department and expect to start regardless if we add BLS trucks. Not teching I feel very under utilized and that I'm not contributing to my full potential. As long as there is some criteria for the EMT's to be on the units. Newer lower ranked EMT's should be utilized as most senior EMT's have " done their time" or have advanced in the rank structure. I think it is a step in the right direction but I am not sure if it will solve the problem of Paramedic retention. I am also worried about first responder Paramedics putting EMTs in situations where patient care would be compromised! I am not against the idea but I think that a lot of knowledge and information needs to be given out before anything happens. It needs to be a slow transition. With the annual NFIRS statistics indicating that approximately 55%-65% of Fire/EMS responses are directed toward providing emergency medical services to the civilians and approximately 80%-85% of that being Basic Life Support calls then it just makes sense to provide that service. However, I also think that we need to make a separate entity in the Operations Branch to provide for supervision/leadership of the BLS Branch instead of adding an additional load to the already thin stretched Battalion Chiefs and other upper management positions. THE CITIZENS OF THIS COUNTY DESERVE THE HIHGEST LEVEL OF TRAINED PERSONEL WE HAVE TO OFFER. I agree with BLS Transport Units because I believe that they would help take a little bit of the stress off those Paramedics that are running 10 calls a shift; 6 of those being BLS calls. BLS Units will also allow us to keep our regular ALS units in service longer, creating a quicker response time to their

78 Incorporating BLS Ambulances 78 first in areas. ALS units can be available for the most essential calls. We have EMT-I that are capable to handle the calls with engines responding. As long as radio dispatches the correct code for the right unit BLS vs. ALS. Also on MVC, it can also be handled by BLS unit in my opinion. As long as EMT-I have a good bases on there primary assessment and know how to read the patient and what they the patient chief complaint is. I do not see a problem in BLS unit being run in this County. I have 10yrs experience on BLS unit from past employment we had Paramedic unit respond with us on the call and we had cancelled them as soon as we did our assessment on the patient and then transported to hospital. It all how much experience you have on that BLS unit. I won't have two EMT out of school on an ambulance in this situation. One veteran EMT with a rookie to show the ropes of the field. I think it's an excellent way to go in this county, We will not burn out the paramedics we have on continuous calls. The workload will be distributed between BLS vs. ALS I think. I had an opportunity to work on BLS 23 for Gwinnett County and I felt comfortable riding and assessing the patient before the paramedic showed up on scene. It's all in the EMT's ability in what he can assess at that giving time and initiating the drive to commit in the EMS field my opinion. If I can help in any way with further assistance, I am more than obliged to give any assistance. Looking forward to voluntary again for BLS unit when it comes around again. After taking this survey, I have realized that my weakest points by far are the SMOs and using the epcr. While I am comfortable obtaining a pt refusal on the epcr, I have to ask the PMDC many questions while completing an entire pt care report. Not to mention the ever changing policies regarding standing orders, new requirements for documentation and just what order to staple the pages, causes many EMTs to feel overwhelmed by the whole prospect of "teching" while on Med units while riding with a PMDC. I can only imagine the stress being compounded by riding a BLS unit. This of course applies to EMT's that have been on the dept. longer than 7 to 10 years. Newer EMT's will

79 Incorporating BLS Ambulances 79 adjust much more quickly. the BLS truck helped our call volume I think it is a great thing, and the possibility of peak time trucks would be very beneficial. It would allow Med Units to stay in their first in and it should decrease the response time for ALS calls. I think that once it is off the ground and running it will run smooth. As long as it is still on a volunteer basis. It's a coming thing. We have been underutilizing our EMT-I's for a long time. We can do more than we are. You know the numbers, facts don t lie. Consider using private services too I believe it would take some of the call volume off the paramedics and might entice some others to go to paramedic school. It will help the EMTs who participate, to gain more experience as well. I think it s a good idea to add a few BLS units. Helps cut down stress on Medics In my opinion every station having an ALS unit is a simpler, less problematic system Absolutely!!! BLS units could improve the care given to our citizens. I feel the triage by dispatch would need to be consistent and strict in order to stop BLS calls from becoming ALS once on scene. That way the medic off the responding engine (if so staffed) will not need to ride in to the hospital. Also, there is no need for an ALS unit to call for another unit once on scene after their assessment points to BLS. This can greatly increase patient transport time and increase pt discomfort. I am neither for nor against a future implementation. I have reservations about liability for the department and members. Something needs to be done to remove stress and workload from paramedics. Any solution may be better than the current system. Nevertheless, any solution has the potential for

80 Incorporating BLS Ambulances 80 creating new unforeseen problems. I feel it should 100% voluntary by the EMTs involved. GCFD TRIED TO USE BLS TTRANSPORT UNITS AND IT WAS USELESS. THE BLS UNIT WERE NOT DISPATCHED IN THE RIGHT WAY. THE BLS UNITS WERE TAKING FIRE UNITS OUT OF SERVICE. THE PMDC NEED TO BE ON THE MED UNITS. IF I LIVED IN GWINNETT COUNTY AND I NEEDED A MED UNIT AND A LESS TRAINED PERSON SHOWED UP I WOULD BE UP SET. IT WOULD HELP IF THE EMS AND THE FIRE SIDE WERE SPLIT UP. IT WOULD HELP OUT ON THE COMPANY OFFICERS WORK LOAD. THERE ARE FIREFIGHTERS THEN THERE ARE PMDC YOU ARE EITHER ON OR THE OTHER AT HEART. GCFD WOULD LOOSE A LOT OF GOOD FIREFIGHTERS IF THE MED UNITS WENT BLS. BLS transport could help alleviate some of the call volume for our ACLS units but one thing that comes to mind is, Doctors offices are notorious for using us as a cheaper quicker means of transport for their pt's they wish to have admitted into the hospital. It would be just a matter of time until they figured out that we have basic transport units available that would be more readily available for their abuse. VERY SURE OF MYSELF AND MY SKILLS BUT THERE ARE ALOT OF EMT'S OLD AND NEW THAT DO NOT THINK IT IS THERE JOB TO TECH AND IF BLS UNITS ARE GOING TO WORK HERE THIS ATTITUDE WILL HAVE TO CHANGE AND STARTS IN THE BEGINNING NOT AFTER THEY HAVE BEEN HERE 2 YEARS OR MORE. I THINK YOU SEE MORE EMTS TECH NOW THAN EVER BEFORE WHICH IS A GREAT STRESS RELIEVER FOR MEDICS. If we can get the ALS vs. BLS calls dispatched correctly. We still seem to send an engine and medic unit to calls that a medic unit should be able to handle on their on. A lot of paramedics take advantage of this having an engine stay around when they really are not needed. This ties up that engine

81 Incorporating BLS Ambulances 81 that could respond to another call. I AGREE THIS IS NEEDED BUT WE HAVE TO BE VERY CAREFUL WITH ITS IMPLEMENTATION. I CAN SEE WHERE THIS MIGHT CAUSE MORE PROBLEMS WITH MAINTAINING PATIENT CARE. SOME MIGHT TRY TO GET OUT OF WORK BY DUMPING THEIR RESPONSIBLITIES. EMT'S AND MEDICS. We are at a point that we must try something. We are beginning to run out of options. I agree that it is needed. I think it would be good to have one 24/48 BLS unit per battalion that would run anything within their battalion. I think using non-cross trained EMT's who are attending Paramedic school would be a good potential source of eager staffing and perhaps for lower wages than a cross-trained EMT/firefighter. Only to a certain degree. Initially I would run 1 truck per Battalion. I think it will free up out ALS trucks for true emergencies. I think it's a great idea if managed correctly. Need more info, be it model testing and or results from existing dept.'s already utilizing this system. Why don t we just give free rides on gc Marta Team unity is the most important thing in our business. It is what separates the good stations and shifts from the great ones. I started Teching calls because I felt bad for my medic who was always on the med unit because he was the only "non-managemnt" personnel at the station I worked at. It was my emotional attachment to the medic, whom took me under his wing that inspired me to do more than what my job description stated. His positive attitude has yet to be paralleled. I wish I still worked with him. Everyone that comes on to this department should have to spend 5 hard shifts with Phillip Merck. He sets the customer service bar so high that other have to elevate their game if they want to be in the game. The same could be said about Stan Wilson as a driver. It is a crime that he never made Lt.

82 Incorporating BLS Ambulances 82 People like these guys are so rare, they are like Lance Armstrong and Tiger Woods. We need to try something. My only concern is that if it proves not to work that we would probably continue to try to the detriment of all involved. I believe that implementation of BLS units will lead to additional non-emergency duties such as hospital to hospital transports and other non-emergency transports. I believe this will further tax our department and take away from our primary purpose, which is to provide emergency support. Based on the first run we had with them I feel its a step backwards for the Dept. We were sending two engines on a call with the BLS unit to get a paramedic on the scene. If the medic on the eng. has to ride in, with the BLS unit then you're taking down manpower on an Eng. I feel that there are a lot of newer EMT s that would go for this, as they knew when they were hired what they were getting into. I think by asking volunteers to man these units is how they will be successful. The basic unit at 23 is a good start. There are many in the field who were given no option as to be an EMT or not. They did what was required of them so they would have a decent chance for advancement in out dept. There are many EMT s that are glad to do this and those are the ones that should do it. But the ones that don't want to should not be penalized. I always put a family member in one of our patient s situations and think about whom I would want treating them. It doesn't matter if it's ALS or BLS. I want the best experienced and qualified for the situation and 9 out of 10 times it's going to be the Paramedic, that's why they are hired and that's what our family members that live in Gwinnett County should get. The idea is good on paper. I do not think it will lesson the work load on the Paramedic. Our call

83 Incorporating BLS Ambulances 83 volume is high that any Med unit will be busy. Paramedic retention will not be increased. They will still be on the ambulance a majority of the time and there pay is still too low. If an ambulance comes to my house, I want the best care available. That means paramedics. I believe it may work. But of course, with everything there will be some drawbacks. We have many EMT's who should not have patient contact or feel very uncomfortable about the medical side of treatment. Forcing them to do something they feel uncomfortable about will make patient care go down. no comment Seems to be a great idea. Great hours for those riding BLS, Allows ALS to focus on ALS calls. Not too sure about how dispatch will do deciding whether or not basic or advanced call. As always 15% of the personnel do 85% of the work. BLS Units will not change that. You will still have the same number of people doing what they do now, the only difference is they will be spread out further and quality of patient care will invariably suffer. Bad idea for Gwinnett citizens and bad idea for our morale. I agree with the implementation of BLS units as long as the dispatchers are trained and allowed to use common sense along with this training. If all they are allowed to do is read a card and do what the card says then it may cause confusion within the system. I do not believe this to be in the best interest of our citizens. I do believe there will be paramedics who will dump calls that need to be ALS on the basics. I don't think it is fair to the people of the county who may be pushed into a BLS unit because the paramedic does not want to ride in and the paramedic says it is BLS call and it is not. Even a broken arm may be a BLS call but if they were in ALS truck, they could get some pain meds. which they could not in a BLS truck I think we are lowering the standard on care by putting up the BLS trucks if we put up BLS trucks why even have any med units why not let a private handle it.

84 Incorporating BLS Ambulances 84 There would be Paramedic that would take advantage of the BLS trucks by saying the pt will be fine to go to the hospital with you. If myself or one of my family members rode in with a BLS truck I would be upset because I think the person with the highest level of training should take care of patients! The county will be setting their selves up for a law suite. If a pt crashes in the back of a BLS truck and it takes 5 minutes for a Paramedic to arrive on scene to help what will the families say and think. I would let it be know on all calls that the county has the lesser trained personnel taking care of them. If you do make BLS trucks then you must give the same considerations in promotional to the EMT s that you do the Paramedic! Just because your a Paramedic doesn t mean that you would make a better driver or Lt. I think it will help with the paramedic shortage situation, I think it will also help with EMT s staying up on their stuff. I think it will be more economical for the county and most important I think it will be a better service for the citizens of the county providing shorter response time for ALS calls. I BELIEVE IT NEEDS TO BE TRIED OUT TO SEE HOW WELL IT WORKS. There is no reason why EMT's should not be able to tech calls as needed in their prospective first in s. I feel that having BLS units in service is a great thing. The only thing is you will have paramedics abuse the service, and some paramedics will dump a lot of calls on the basic unit. I feel that an EMT's job is to get into the back of the med unit, and help the paramedic out, not just being a "Stretcher Fetcher". There are some paramedics I don t like to tech for because of their attitude but I do my job that I'm paid and expected to do. I would not be happy in a Fire Department if I had to ride on ambulances over 50% of the time. I believe the county citizens should always have the best treatment/care that we are able to provide and that would be to keep the med units as ALS. But I do believe that EMT's should give the paramedics some relief in the back on the med unit on BLS calls. It all goes along with teamwork.

85 Incorporating BLS Ambulances 85 WORK TOGETHER!!! I do agree that there is a true need for BLS units in our area due to the volume of calls that we respond to. However, I do not believe that by adding BLS units to the field that this would retain or attract paramedic's. BLS transport units are a step backwards in the care of the citizens. If the citizens are going to be charged the same amount for transport by a BLS unit, they deserve ALS care. I agree with implement ting BLS transport units in Gwinnett County. As a department, we run a significant amount of calls that do not require the skills of a Paramedic. If implementing more BLS units it would take the work load off of Paramedics and keep the ALS units in service for calls when needed. Once good working guidelines on the use of BLS units have been established, and everyone properly uses it. I also think that it should become a 24-hour unit, because they work less hours and get paid more per hour. The newer EMTs with Gwinnett County Fire Department are, in my experience, much more aggressive than those with 15+ years experience. I feel that the EMTs of the department should embrace the EMS aspect of the job, but no one should be forced into something they are not comfortable with. But that all goes into the hiring process. The department needs competent people, and people that are willing to do the job that we all signed up to do. Our paramedics are only as good as our EMTs. I do feel that BLS units serve a purpose in Gwinnett County's EMS system. As we all know, many EMTs do not feel confident with providing patient care during transport and others do not believe its part of their job because they are not paramedics. I personally am confident with providing patient care and enjoy doing so, but have worked with paramedics a couple of times that are outright against EMTs teching on BLS calls for whatever reason. I am fortunate to have 2 paramedics in my station that are supportive of EMTs that have a desire to tech

86 Incorporating BLS Ambulances 86 BLS calls. For BLS transport units to work, EMTs and paramedics alike will both need to understand that EMTs are not "just drivers" and that every patient requiring ambulance transport does not necessarily need ALS level care. Each level of training serves a purpose and has its place in the system as a whole. Any ambulance's that the county implement's would be a be help to Paramedic's and EMT s a like because it lessens the work load of the remaining ambulance's I need to understand better what we hope to accomplish with these BLS trucks before I could agree or disagree. As many others, I also strongly feel that until a process is in place that improves the 'treatment' of our paramedics along with some sort of incentive ( possibly monetary or other) for riding the ambulance, we will continue to experience these 'burn-out' issues. Some possible ideas to help improve: BLS Trucks A monetary incentive or possibly some type of 'comp' time such as incentive leave to riding the ambulance per shift for both EMT's and Paramedics ALL Paramedics that currently hold paramedic numbers in the department rotate through on the ALS trucks, EVERYONE from every department Headquarters, Supply, Operations, Training, Officers both Lieutenants and Captains, Engineers, from the newest guy off the street to the oldest veteran. Even if it was only one shift a month or even half a shift, think of the break this would offer the guys in the field on these busy ambulances, not to mention the bigger impact of respect, appreciation and camaraderie that would send thru the 'ranks'. We are striving so hard to obtain and retain medics, however very few of the current management/supervisors will jump on an ambulance. I know that there is a much stronger sense of respect and gratitude felt for a supervisor that leads by example rather than from his/her air-

87 Incorporating BLS Ambulances 87 conditioned office. Encouraging EMT's to tech on the Ambulance on BLS calls, we are EMT's and we are trained to do the job, however very few actually tech? This needs to change. Active rotation for busy Ambulance s staff thru slower ALS Engines such as Engine 17, 27, etc.

88 Incorporating BLS Ambulances 88 Appendix D cover letter for Survey August 9, 2007 Gwinnett County Fire Department EMT s: Thank you for taking the time to complete this survey. I am currently enrolled in the Executive Fire Officer Program at the National Fire Academy. I am researching the potential impact of adding BLS transport units to our current EMS system. The purpose of this survey is to obtain feedback and opinions from department EMT's. If you are not an EMT or you are a paramedic, you may review the survey but please do not answer it. Send an and I will share the results with you. Please be honest. Your opinion counts! Your responses are anonymous. If you wish, please check the appropriate box at the end of the survey and the overall results will be shared with you by . Please complete the survey by August 17. If there are any questions or difficulties, call me or send an to [email protected] Again, thank you for your reply. The survey should minutes. Please click on the link below to enter the survey. Sincerely, Battalion Chief Ken Chadwick

89 Incorporating BLS Ambulances 89 Appendix E Gwinnett County EMT Scope of Practice

90 Incorporating BLS Ambulances 90 Appendix F Paramedic Apprenticeship INCIDENT PERFORMANCE RECORD The following form should be completed on AT LEAST two calls during each shift. For each call, please provide a numeric score in the box next to the corresponding factor. After scoring each factor, add up the total points and multiply be the weight for that section for the weighted score. Finally, add up all weighted scores for a final score in the space provided on the back of this sheet. Apprentice Name Date Preceptor Name Unit Radio Traffic Paperwork Comments: Pre-Incident MDT Operations Out of Station Located Call Driving Safety Preparation Attentiveness Score x 3% = Weighted Score: 0 Safety Resources Control Comments: Scene Management Handles Stress Leadership Delegation Attentiveness Communication Professionalism Decisions Scene time Priorities Score x 10% = Weighted Score: 0

91 Incorporating BLS Ambulances 91 Initial assessment Working diagnosis Comments: Patient Assessment Rapid assessment Detailed exam Vital signs Differential diagnosis Scene treatment Priorities Score x 40% = Weighted Score: 0 Rating scale: 1 substantially below standards; 2 below standards; 3 meets standards; 4 exceeds standards; 5 substantially exceeds standards Timely Treatment Working diagnosis Patient Treatment/Skills Appropriate Tx Complications Vital signs Differential Dx Scene Treatment Priorities Comments: Score x 40% = Weighted Score: 0 Locates hospital Patient care Comments: To Hospital Driving Radio traffic/mdt Hospital update Communication Safety

92 Incorporating BLS Ambulances 92 Score x 3% = Weighted Score: 0 Gives report Unit preparedness Comments: At Hospital Patient handling Rapport with staff Documentation Time limits Score x 3% = Weighted Score: 0 Incident critique Comments: Feedback Post Incident Radio traffic/mdt Score x 1% = Weighted Score: 0 Rating scale: 1 substantially below standards; 2 below standards; 3 meets standards; 4 exceeds standards; 5 substantially exceeds standards Preceptor Comments: Total Weighted Score: 0

93 Incorporating BLS Ambulances 93 Apprentice Comments: FTS Signature Date Apprentice Signature Date

94 Incorporating BLS Ambulances 94 Appendix G BLS Attribute Query

95 Incorporating BLS Ambulances 95 Appendix H ALS Attribute Query

96 Incorporating BLS Ambulances 96 Appendix I EMD Protocols

97 Directions Incorporating BLS Ambulances 97

98 Allergic Reaction Incorporating BLS Ambulances 98

99 Breathing Problems Incorporating BLS Ambulances 99

100 Burns Incorporating BLS Ambulances 100

101 Carbon Monoxide Poisoning Incorporating BLS Ambulances 101

102 Diabetic Emergencies Incorporating BLS Ambulances 102

103 Stroke Incorporating BLS Ambulances 103

104 Incorporating BLS Ambulances 104 Appendix J Georgia State Region Three Utstein Survival Report October 1/2005 thru August 1, 2007

105 Incorporating BLS Ambulances 105 Appendix K GCFES Utstein Survival Report January 1, 2007 thru August 27, 2007

106 Incorporating BLS Ambulances 106