A Strategic Patient Transportation Plan For Las Vegas Fire & Rescue

A Strategic Patient Transportation Plan For Las Vegas Fire & Rescue Advanced Leadership Issues in Emergency Medical Services BY: Henry Clinton, Battalion Chief. Las Vegas Fire & Rescue Las Vegas, Nevada. An applied research project submitted to the National Fire Academy as part of the Executive Fire Officer Program December 2000

2 ABSTRACT The problem was Las Vegas Fire & Rescue did not have a strategic patient transportation plan that reflected incremental increases in our EMS delivery system to meet the city s future patient transportation demands. The purpose of the research paper was to develop a strategic patient transportation plan that could be incrementally implemented until the department delivers 100 percent of the EMS transports. The research method chosen for this project was the Action method. Research questions answered were: 1. Where is Las Vegas Fire & Rescue now, what is our situation? 2. What resources do we have available? 3. Where do we want to go? 4. What is our strategy for getting there? The procedures for this project included a literature search from the Learning Resource Center at the National Fire Academy, the Las Vegas Fire & Rescue reference library, and additional information was obtained from the EFO course Advanced Leadership Issues in Emergency Medical Services. Additionally interviews for key information from: local fire departments who provide 100 percent EMS delivery. Employees who work part time for the ambulance provider. Historical data was retrieved from the departments Information Technology division, and finally the author hand counted each emergency run from each station s log book.

3 The results of this research paper revealed that private ambulance companies measure productivity differently than fire departments, mainly because they only do one thing, transport patients. Where fire departments are a full service emergency division with many responsibilities to fulfill. That developing a transport plan requires a manager to define the work load for the crews, identify the call volume, then determined how many rescues it takes to provide a full service EMS system. The next step was to implement the departments plan in a small geographical area to enable easy department adjustments as necessary.

4 Table of Contents Title Page...1 Abstract...2 Table of Contents...4 Introduction...5 Background and Significance...5 Literature Review...8 Procedures...21 Assumptions...22 Limitations...23 Definition of Terms...23 Results...26 Unexpected Results...39 Discussion...44 Recommendations...48 References...52 Appendix A...54 Appendix B...55 Appendix C...63 Appendix D...64 Appendix E...65 Appendix F...66

5 INTRODUCTION Las Vegas Fire & Rescue does not have a patient transportation plan that reflects incremental increases in our EMS delivery system to meet the cities future patient transportation demands, including personnel, equipment. The purpose of this project is to develop a strategic plan that provides the department with enough equipment and personnel to meet the demands by incrementally increasing our portion of the emergency medical patient transportation market. These incremental increases will continue until Las Vegas Fire & Rescue performs 100 percent of the 911 generated emergency patient transports in the City of Las Vegas. The research method chosen for this project is the Action method. The Questions to be answered regarding this problem are: 1. Where is Las Vegas Fire & Rescue now, what is our situation? 2. What resources do we have available? 3. Where do we want to go? 4. What is our strategy for getting there? (Menkin, 1997). BACKGROUND AND SIGNIFICANCE For over 22 years (prior to 1978) Las Vegas Fire & Rescue has been transport capable. However, in the past, our transports were limited to: Injured firefighters Police officers

6 City employees Any emergency where the ambulance company was delayed or unavailable. Our transport records indicate that we transported around 50 patients a year (SunPro, 2000). Basically, we have not been in the transport business until recently. The city chose to contract out to private providers for patient transportation. In 1997, the newly elected mayor of Las Vegas requested Managements Partners an auditing company from Cincinnati Ohio, to review City operations as a whole and submit recommendations for improvement. Overall, there were 181 recommendations submitted for possible improvement throughout city government. There were only a few directed at Fire Services. In their audit, it was noted that they felt we had a redundant EMS delivery system. In their report, they pointed out AMR (local transport company) and the fire department each send an ambulance to each EMS call, they felt dispatching two ambulances on every call was redundant, a waste of resources. The City could save money by sending only one unit. As a result of their audit, it was suggested by Management Partners that Las Vegas Fire & Rescue either; get out of EMS or look into transporting ourselves and not contract privately for transportation. Getting out of EMS was out of the question, as the local transport agencies were, and still are, incapable of performing vehicle extrications and other technical rescues. City Council asked LVF&R for a proposal reflecting our best solution to the consultants recommendations. The Fire Chief suggested we look into EMS transportation; he submitted a proposal to City Council that included transporting up to 10 percent of the

7 current market in Las Vegas as a pilot program to test the feasibility of our transport ability. Part of the determining reason for transporting up to 10 percent of the market was the Chief believed we could transport 10 percent of the market with out adding additional personnel and equipment. In December of 1998 Las Vegas Fire & Rescue was given permission by City Council to transport patients, up to 10 percent of the current market beginning January 1 st., of 1999. This pilot program would last for no less than one year. There was a Blue Ribbon panel assembled and assigned, by direction of the City Council to monitor the progress of our efforts, to determine if the pilot program was successful. If it was successful the assumption was Las Vegas Fire & Rescue would continue transporting and pick up a larger portion of the transport market annually. The Blue Ribbon panel made up of AMR representatives, City Hall Administrators, Accountants, the Health District s Medical Director, and EMS Coordinator, hospital representatives as well as representatives from local area fire departments, including our own, met quarterly to monitor the pilot program. After the 12- month period, the Blue Ribbon Panel concluded the pilot program was a success (Blue Ribbon Panel, 2000). It was agreed Las Vegas Fire & Rescue could successfully transport patients for a fee and recover costs. This was reported to City Council and the decision was made for Las Vegas Fire & Rescue to continue transporting patients in Las Vegas. (Blue Ribbon Panel, 2000). Initially the Fire Chief suggested LVF&R could transport up to 10 percent of the market, with-out any additional equipment or personnel. The Chief would like to increase our patient transports. Las Vegas Fire & Rescue has no strategic plan in place that

8 addresses an incremental increase of patient transports, which should reflect an incremental increase of equipment and personnel. It is the purpose of this paper to research and develop this strategic plan. Taking on 10 percent of the patient transport market was a significant work load increase. There were promises made to the members of the fire department by administrative officers that when we take on more transports, we will provide more resources so they will be able to keep up with the increase in work load. Additionally, patient care is also an issue, it is the departments goal to avoid any negative impact relating to patient care. Being prepared to meet the department s patient transportation needs of the future is critical to the continued success of Las Vegas Fire & Rescue and its mission. This project is directly related to the course and the course material covered in Advanced Leadership Issues in Emergency Medical Services LITERATURE REVIEW The literature review was focused on establishing a knowledge base on the following foundations: A fiscal responsibility to the citizens of Las Vegas. An effective and appropriate Emergency Medical System (EMS) management system. Identifying response times as a critical component to EMS delivery. A relationship between workload and Paramedic Burn out.

9 How to measure productivity and explore scheduling options. Identifying the cost of the transport component of an EMS system. The author considered the above to be a minimum knowledge base in order to be able to answer the following questions: o Where is Las Vegas Fire & Rescue now? (Current situation). o What resources do we have available? o Where do we want to go? o What is our strategy for getting there? The literature review revealed that there is a need to develop an operational plan for resource management to better accommodate the service needs of the community; it is obvious that public fire departments need to be held more accountable by the public for their delivery systems. The concepts from private industry are directed at two issues: service delivery and financial concerns. The time has come for the fire service to be competitive with private providers, in delivering emergency medical service and patient transportation to substantiate our existence. It is important that fire service managers prove that the best value of the citizens dollars is with the public fire service (Lewis, 1997). To do this, there is a need to develop an operational plan for resource management, to better accommodate the service needs of the community. Departments need to answer questions on efficiency and effectiveness through well-documented research. (Riddle, 1995). There are only a few EMS management systems, which distribute ambulances throughout the EMS system effectively. One such system is System Status Management

10 (SSM). SSM involves the deployment of ambulances in a manner that maintains a balance of available EMS resources to a service area, based on call-volume demand (peak hour) statistics. SSM plans also factor in the number of ambulances available for response throughout each day (Moneau, 1999). This can involve placing an ambulance on standby between two service areas when one area s ambulance has been sent on assignment. This is known as posting (Moneau, 1999). Another variable that can be added to SSM besides posting is roaming. Roaming is a deployment system where ambulances are assigned to drive a particular area while waiting for an assignment. The theory being, crew can respond quicker while in their ambulance than they can from inside a station or post. The resulting draw-back from posting, and roaming is a drop in employee moral and an increase in employee back injuries (Moneau, 1999). Further comment on the cause of increased back injuries can be found in the unexpected findings section of this paper. SSM has resulted in emergency medical technicians (EMTs) and paramedics sitting in ambulances for extended periods of time (Moneau, 1999). SSM may work for the nonemergency ambulance market, where the time and locations of demands for service can be scheduled. The private sectors use of SSM is touted as the model system for maximum efficiency of resources (Riddle, 1995). However, this approach is not transferable to the emergency side of the industry, as fire departments have several other responsibilities besides EMS delivery. Keep in mind that each call for service must be considered a random occurrence. To maintain rapid response times, fire departments must maintain strategic geographical locations throughout the city (International Association of Fire Fighters, 1999).

11 Another recognized EMS management system, and one that more closely matches the needs of the fire service and our community is Comprehensive Flexible Deployment. Comprehensive Flexible Deployment is a strategy used for maneuvering ambulances and crews to reduce response times, based on expected call volumes and geographic coverage requirements. Additionally, the location of potential emergency events should also be taken into consideration when placing ambulances (Fitch, 1992). The optimal flexible deployment system is the development of base geographic coverage; then add demand coverage (peak hour) to the already existing geographic coverage. The concept is that as long as the integrity of geographic coverage is maintained, response time performance objectives can be achieved. Supporting this theory is the fact that even with computer aided dispatching (CAD) technology compiling call patterns, it is difficult to predict where the next call will come from (Fitch, 1992). Demand coverage or peak load staffing has been primarily applied in the private sector, and has been less successful in the fire service. Even though it has not been done in our organization, literature indicates that some emergency medical providers, including other fire services, use peak load staffing to meet their system demands and allow employees to have an alternate work schedule. Members of the department should work together to develop other shift schedules, to achieve peak load staffing during periods of high demand in the city and meet the needs of firefighters. (Hill, 1997). Comprehensive flexible deployment is basically a Zone Defense. A fundamental goal of flexible deployment is to ensure that the service area has adequate units available to provide geographical coverage for any next call. To accomplish this, three basic components of a deployment strategy emerge:

12 1. Assurance of geographical coverage (Fire stations). 2. Demand coverage (peak hour staffing). 3. Post reassignment strategies. (Fitch, 1992). Geographical coverage can be provided using existing fire stations (Fitch, 1992), demand coverage can be accomplished by adding peak hour staffing, and post reassignments are currently accomplished within the fire service using Move Ups (Riddle, 1995). In either EMS management system response times are the key to success if you are measuring success by improved patient survivability. The American Heart Association (AHA) recommends a maximum emergency response time of four minutes to initiate basic life support and eight minutes to initiate advanced life support. The AHA has established the Chain of Survival for cardiac arrest victims, they are: Early access to the EMS system. Early CPR. Early defibrillation. Early Advanced Life Service (ALS). The quicker CPR in initiated, defibrillation performed, and advanced cardiac life support (ACLS) begun, the better the odds are the patient will survive. Every minute with-out defibrillation decreases the chances of successful conversion by 7 to 10 percent. Dr. Eisenberg linked response time to probability of survival. A nine-minute initial arrival time prior to pre-hospital medical interventions gives the viable patient only a 1 in 15 chance of surviving. A four-minute arrival by fire fighter paramedics increases

13 the survival probability to 1 in 2 chances. As a rule of thumb, first responders should arrive on the scene in less than 5 minutes from the time of dispatch in 90 percent of all such calls. This will generally result in a median first-responder response time of 2 to 3 minutes. The AHA response time recommendations favor geographical coverage, which provides consistent response times within the recommended time frames. Paramedic Burn Out is a term loosely used in the fire service. It is a very serious condition. EMS coordinators across the country have determined that the symptoms are fairly universal: physical and emotional exhaustion; low morale; impaired performance; less sensitivity to patient needs; irritability towards coworkers and supervisors; increased griping about the department, the equipment, and the schedule; vulnerability to disease; sick leave abuse and increased absenteeism; and ultimately, resignation or transfer (Randleman, 1980). According to one public fire agency they report, several paramedic personnel have recently left the EMS division and/or department sighting burnout as a contributing factor in their decision (Boike, 1991). Burnout refers to a syndrome of emotional exhaustion and cynicism that frequently occurs with people who spend considerable time in close encounters with others under conditions of chronic tension and stress (Randleman, 1980). Burnout is most commonly defined as a condition of emotional exhaustion caused by job related chronic tension and stress (International Association of Fire Fighters, 1999). The length and intensity of the paramedic s exposure to the conditions are something the department manager can control. Michael Olsen, EMS consultant for the United States Fire Administrations (USFA) office of planning and education says paramedic burnout is basically a management problem (Randleman,

14 1980). Burnout needs to be addressed, but as yet because of the variables involved, there is no specific number of runs that a 24-hour team should be able to handle (Fitch, 1992). Jim Page referred to a study comparing the stress levels of private sector EMS personnel in a system management environment to fire department EMS personnel assigned to fire stations. This study indicated higher stress levels for private sector employees (Riddle, 1995). Traditional fire service schedules generally are based on either a 24-hour schedule or a combination of 10-hour and 14-hour periods. The viability of ambulance personnel working on a 24-hour shift will be dependent upon the call volume of a particular ambulance unit. Busy EMS systems need to examine the liability of routinely having personnel awake for 24 hours at a time. There is a large segment of the EMS community which maintains that patient care toward the end of a 24-hour shift suffers because the ambulance personnel are more tired; however, there have been no formal studies comparing medical protocol error rates based on the number of hours that a paramedic has been on duty (United States Fire Administration, 1997). A recent study showed that people who were awake for up to 19 hours scored worse on performance tests and alertness scales than those with a blood-alcohol level of 0.08 legally drunk in some states. If they ve pulled an all-nighter, pilots, surgeons, or the people responsible for charging your credit card account, might as well be drunk. (Brink, 2000). After four hours of sleep a night, people scored lower on tests of judgment, response time, and attention than those who slept eight hours. And the short sleepers made more mistakes (Brink, 2000).

15 The IAFF recommends a U:UH ratio-approximating 0.30; they say this should be adequate to allow personnel to keep their skills sharp while not risking employee burnout. EMS systems with U:UH exceeding 0.30 are being used to their breaking point (International Association of Fire fighters, 1999). Even though Burnout is lower in the fire service, it should be noted that measures can and should be taken to alleviate the causes of chronic tension and stress to promote good working conditions. (For more comments by the author on Burnout and taking measures to relieve it see the section on unexpected findings.) Utilization and productivity, an EMS system actually produces two products, patient transport and coverage. Coverage refers to the fact that an EMS system must maintain adequate resources to provide transport availability even when calls do not occur. Coverage is best measured in hours of time that an ambulance is staffed (Unit hours). The largest expense incurred by an emergency service is the cost of housing units available to respond, regardless of the actual number of calls. Unit hour utilization is used by private industry to calculate the percentage of transports by an ambulance during a specific time period, which also provides a productivity ratio. Total unit hours divided by the total number of transports in a given period of time equals productivity or U:UH ratio. This concept (used by the private side) considers the units to be exclusive to transports. In the fire service, personnel are responsible for other tasks such as hose testing, hydrant maintenance, inspections, preincident analysis, public education, etc. Taking this concept under consideration another production calculation for the fire service needs to be used. The literature review reveals that the fire service needs to consider all responsibilities required of them including

16 transports and consider them into a total time on task utilization model (Lewis, 1997). When considering transport only, the fire service also measures utilization activity; the actual calculation is based on total in-service time per call: the time from dispatch through call termination divided by the amount of time the unit is in operation. In service utilization ratio is a more accurate measure of service use and availability (International Association of Fire Fighters, 1999). The private sector measures efficiency by: Cost per call. Unit hour costs. U:UH The fire service is unable to measure efficiency this way, as it needs to provide geographical first responder coverage and peak hour staffing to meet the system demands (International Association of Fire Fighters, 1999). The primary factors that should be considered in developing staffing levels are the amount of coverage necessary in a particular geographic service area and the fluctuating demand (Fitch, 1992). The San Antonio Fire Department in Texas, for example, found they could successfully determine peak load demands through the use of statistical analysis of the number, location and types of medical responses being made by their department. They used historical dispatch data to reasonably project where, when and how many EMS units would be needed for emergency medical response, at any given emergency medical response, at any given time of day, night, week or month (Boike, 1991). A good manager can achieve high levels of productivity and meet established

17 response time targets, often unit hours will have to be added or reduced to achieve a realistic work schedule. When matching staff to call load two things are important to keep in mind when preparing a schedule: 1. When calls occur. 2. The number of calls. With flexible deployment, the emphasis is on where to place the vehicles, but it is just as important to determine how many vehicles are needed. It may be necessary to add additional crews during peak periods to achieve prompt response times. The only way to accurately determine a service s unique staffing needs is to prepare comprehensive reports on when, where and how many ambulances have been needed during any given time period. The larger the service is, the easier it is, to take advantage of opportunities to increase productivity. First identify the number of transports to be accomplished, establish the desired productivity ratio, which is the number of transports accomplished per unit hour (.58 U:UH transport ratio) Lets say you had 29,960 transports annually, divide this by.58 equals 51,655 hours of unit hour coverage, divide this number by 365 and you get 141 unit hours of coverage per day, subtract your geographical coverage requirements (an ambulance in every station) and you are left with demand coverage requirements. The remaining demand coverage can be met with peak hour units (Fitch, 1992). Personnel scheduling directly affects response times, patient care and financial success of the entire system. EMS scheduling cannot be viewed in the traditional staffing manner, creative and innovative ideas must be included, peak load shifts may be necessary, and

18 alternate reassignment strategies may need to be considered. The agency should provide a reserve pool of vehicles and personnel to meet unexpected demands (Fitch, 1992). Examples of peak load staffing in emergency medicine, which used a combination of shift schedules, were found to be beneficial to the employer and employee (Hill, 1997). The cost of the EMS management system needs to be considered, as the fire service needs to be efficient and effective in financial management as well (Lewis, 1997). To calculate the cost of fire based EMS service, only the marginal costs of the service should be used. The marginal costs of providing EMS services are only those expenses beyond what it would cost for other routine fire department operations (International Associations of Firefighters, 1999). Chief Riddle, in his Sept.1995 article in Fire Chief quotes Jim Page as stating, The marginal costs of providing EMS with multi-role, cross trained firefighters as the difference between the total cost of operating the fire department with EMS and the total cost of operating the department without EMS (Riddle, 1995). Many of the administrative costs and some of the personnel of an EMS system are already covered under fire suppression and rescue services. This also applies to fire departments that must cost out the transport component of their services for the sake of comparison. The cost of providing transport is only the marginal cost for this component, for example: the cost of the transport vehicles, labor to staff them, and administrative expenses in billing for the service. Since a fire department must maintain adequate equipment and staffing to respond to the community s fire suppression and rescue needs regardless of the provision of emergency medical services, these costs are not included in marginal costs (International Association of Firefighters, 1999).

19 To estimate how productive our transport units may be, I though it wise to determine what the private providers U:UH transport ratio is. After interviewing several of our employees who work part time for the private provide (one of which worked for them since 1983), they reported a transport U:UH of.58 or between 6 and 7 transports in a 12 hour shift. Additionally, I thought it prudent to interview the only comparable fire department in our valley, which transports 100 percent of the emergency calls for its citizens. The results of the interview are as follows: The Author interviewed District Chief Randy Howell of the Henderson Fire Department on 06/13/00. Chief Howell was chosen because he is considered a subject matter expert on EMS transport. He is the EMS Chief of the Henderson Fire Department:, they provide 100 percent of the emergency transports in Henderson Nevada. During the interview, Chief Howell related the following information. The Henderson Fire Department currently has six fire stations, with one to be completed in two weeks; four of those stations have a transport capable unit in the station. The transport units are strategically located throughout the city. They staff their rescues with at least one Firefighter/Paramedic and one Firefighter/EMT-B. When they transport a patient they borrow one person off the engine company for staffing in the rescue. Their engine companies are their first responder units, and are all ALS and provide them with a response time of less than five minutes; their transport units are on scene within ten minutes. They respond to roughly 12,000 calls for service annually; 74 percent of those calls are EMS (8,880). Of those 60 percent are patient transports (5,328).

20 That works out to 14.5 transports per day. Sharing those calls with the four transport capable units works out to be 3.6 transports per unit per day. When questioned about peak hour staffing, Chief Howell replied that they used to use peak hour staffing when they had three units in the city. Since they increased their coverage to four units they have not used peak hour staffing. Peak hour staffing did work for them. However, he felt they could have managed their resources better. When they were using peak hour staffing they utilized five days a week on ten hour shifts. The Henderson Senior Staff has determined greater than 10 calls a shift averaged over a six-month period would result in either an adjustment in that units area of coverage or an increase in rescues placed in service. This was determined by listing the personnel responsibilities that were assigned to the rescue. These responsibilities included all details, training classes, meals, an estimate of seven hours of sleep, single and multiple company drills, hydrant inspections, school drills, pre plans, etc. With the remaining time, seven hours, they came up with a realistic work load and call volume of 10 calls per shift with an average of 4 non transport and 6 transports per ten calls (60 percent transport average). On average, it takes them 15 minutes of service time to handle a non-transport call, and one hour to handle a transport call, which equals seven hours. Interestingly enough, Chief Howell mentioned that his crew members had not bought into the prescribed transport numbers mentioned earlier. They generally feel they are overworked and complain the work- load is too high. The employees suggest more peak hour staffing to share the work load. They also rotate their Firefighter/Paramedics from

21 engines to rescues. They are required to ride a rescue at least thirty shifts out of the year to maintain transport skills. Additionally, I have interviewed several (4) of our employees who work part time with the private providers. AMR staffs ambulances on no more than a 12 hour shift, on various peak hour periods. During their shifts with AMR, all the employees reported the same figures. They transport between six and seven patients during their 12 hour shift which included approximately one hour at the end of the two hour shift for paper work and unit preparation for the next shift. Their transport unit hour utilization is.58. This is significant when considering placing peak hour transport units into service. These numbers will aid in determining how many transports we can realistically expect out of a transport unit, placed in service solely for patient transportation. PROCEDURES Research for this project began with a literature search at the Learning Resource Center (LCR) at the National Fire Academy (NFR) in Emmitsburg, Maryland. I began researching current information related to System Status Management and Peak Load Staffing. Any staffing information available was retrieved. Additionally information on efficient management of EMS resources was also retrieved. The EFO course attended (Advanced Leadership Issues in Emergency Medical Services) had useful information. I was able to use information gathered and assembled by Las Vegas Fire & Rescue personnel, and interviewed subject matter experts in our community (Henderson Fire

22 currently transports 100 percent of the Emergency calls in their city). Historical research was done on Las Vegas Fire & Rescue to determine what our resources are, and what our call volume is, by station, unit, square mile (district) and time of day (researching any peak hour anomalies that could be addressed), finally, an EMS committee was utilized to help interpret the information gathered. The EMS Committee consists of representatives from labor and management. Additionally, the committee was tasked to assemble several transport plans and present to the chief what they feel are the three best transport options, the Chief will then pick one of the three plans to move forward with. The guidelines for developing transport plans are: No patient care compromises. Fiscal responsibility. Easy implementation. Acceptable to labor. Asset compatible. Considerate of private needs. Assumptions Patient care is the primary concern and goal; compromising patient care is not an option. The strategic plan chosen will either maintain the same level of patient care currently provided in our EMS system or increase it. Las Vegas Fire & Rescue recognizes their employees as their greatest asset and will work to maintain good working conditions. Las Vegas Fire & Rescue recognizes the cost benefit the dual role employee (Fire Fighter / Paramedic) has to offer the citizens of the community, and will continue to maintain

23 their skills in both fields. The transportation model needs to be the least disruptive as possible to normal operations, using current resources to their best advantage. Limitations It should be recognized that information extracted from the CAD (Computer Aided Dispatching) system is only as accurate as the information entered into the computer. Not all runs have been entered; some human errors are expected. On several occasions EMS information has varied from one request to the next, which created question in my mind about the reliability of the information being extracted. This inspired the undertaking of visiting every station, and physically counting each run in each stations run log. Additionally, the same is true with the information gathered from the unit/station logs. Run statistics are only as reliable as those entering the information; it is believed that the error rate is minimal. However, there were some instances where crewmembers did not enter all the runs to which they responded into their station/unit log. It is, however, the author s opinion that the information is accurate enough to determine trends, and make decisions based on the recorded call volume. Definition of Terms Advanced Life Support (ALS): All basic life support measures, plus invasive medical procedures including intravenous therapy, cardiac defibrillation, administration of

24 medications and solutions, use of ventilation devices, and other procedures by state law and performed under medical control (International Association of Firefighters, 1999). Basic Life Support (BLS): Generally limited to airway maintenance, ventilation (breathing) support, CPR, hemorrhage control, splinting of fractures, management of spinal injury, protection and transportation of the patient whit accepted procedures (International Association of Firefighters, 1999). Computer-Assisted Dispatch (CAD): Computer-assisted dispatch including, but not limited to, primary dispatch entry and automated time stamping, 9-1-1 data interface, demand pattern analysis, system status management, automated patient locator aids, response time reporting and documentation, and when installed, automated vehicle tracking (International Association of Firefighters, 1999). Cost Per Call: Calculated by dividing the total system cost by the total call volume. Private EMS companies this as a measure of efficiency. (International Association of Firefighters, 1999). Cross-Trained/Dual-Role (CT/DR): An emergency service that allows personnel, trained in emergency situations, to perform to the full extent of their training, whether the situation requires firefighting or medical care. This system offers a greater level of efficiency then its single-role counterparts (International Association of Firefighters, 1999). Deployment: The procedures by which ambulances are distributed throughout the service area. Deployment includes the locations at which the ambulances are placed and the number of ambulances placed in service for that particular time period (International Association of Firefighters, 1999).

25 Emergency Medical services: The provision of services to patients with medical emergencies. The purpose of emergency medical services is to reduce the incidences of preventable injuries and illnesses, and to minimize the physical and emotional impact of injuries and illnesses. The EMS field derives its origins and body of scientific knowledge from the related fields of medicine, public health care systems administration, and public safety (International Association of Firefighters, 1999). Emergency Medical Technician: A generic term for any pre-hospital provider trained to the EMT-Basic level or higher (International Association of Firefighters, 1999). Emergency Medical Technician-Basic (EMT-B): A pre-hospital BLS provider with approximately 110 hours of training, based on the NHTSA National Standard Curriculum (International Association of Firefighters, 1999). Emergency Medical Technician-Intermediate (EMT-I): A pre-hospital provider, trained in some ALS procedures such as IV therapy, in accordance with the National Standard Curriculum (International Association of Firefighters, 1999). Emergency Medical Technician-Paramedic (EMT-P): A pre-hospital provider, trained according to the National Standard Curriculum to an advanced level, including all ALS procedures (International Association of Firefighters, 1999). In-Service Utilization Ratio: The time from dispatch through call termination, divided by the amount of time the unit is in operation, used for staffing and evaluating efficiency (International Association of Firefighters, 1999). Infrastructure: The basic facilities, equipment, services and installation needed for functioning (International Association of Firefighters, 1999).

26 Privatization: The process of shifting the provision of a public service from a government to a private sector enterprise (International Association of Firefighters, 1999). Public Education: Imparts knowledge or training in specific skills. For example, teaching CPR, how to call for help properly, bicycle safety, or briefing public officials about the importance of your service to your community are all public education activities (International Association of Firefighters, 1999). System Status Management (SSM): A management tool using past service demand to predict future EMS call volume and location. Using this past experience, the private contractor can use fewer resources (both equipment and personnel) during hours of predicted reduction in need, thus reducing costs. While private ambulance services transportation, this approach is inappropriate for emergency response and transport, because acceptable response times are not maintained (International Association of Firefighters, 1999). Unit Hour Cost: The cost to operate one EMS-related unit for one 60-minute period (International Association of Firefighters, 1999). Unit Hour Utilization (U:UH Ratio): Measures the usage of a fully equipped and staffed response vehicle available for dispatch. Private contractors define U:UH as a measure of productivity. In reality, it simply measures the number of potential revenue-producing patients, transported per hour, that the unit is in operation. It is appropriately only as an indication of appropriate resource deployment (International Association of Firefighters, 1999).

27 RESULTS The fire chief s requirements for any transport plan that would qualify for consideration would need to be fiscally responsible, easy to implement, acceptable to labor, asset compatible, considerate of the private ambulance companies needs and there should be no patient care compromises. In order to accomplish this it is necessary to also understand EMS management systems, and recognize that response times are critical in relationship to patient care. Understand the correlation of work-load verse burnout, and be able to identify and measure productivity, which is related to crew scheduling options. The concepts derived from private industry are directed at two issues: Service delivery. Financial concerns (Lewis, 1997). The time has come for the fire service to be competitive with private providers. To do this, there is a need to develop an operational plan for resource management (Lewis, 1997) There are only a few EMS management systems, which distribute ambulances throughout the EMS system effectively. One of these is System Status Management (SSM). SSM is primarily used throughout the ambulance industry (Moneau, 1999). Another management tool, one that more closely matches the needs of the fire service, is Comprehensive Flexible Deployment. It is based on geographic coverage, and augmented for peak hour demands (Fitch, 1992). A fundamental goal of flexible deployment is to ensure that the service area has adequate units available, to provide geographical coverage for the next call. To accomplish this, three components are necessary:

28 Assurance of geographic coverage (fire stations). Provide demand coverage (peak hour staffing). Post reassignment strategies (Fitch, 1992). Response times are the key to success, if we are measuring improved patient survivability. The American Heart Association (AHA) recommends a maximum emergency response time of four minutes, to initiate basic life support, and eight minutes to initiate advanced life support. A four-minute arrival by fire fighter paramedics increases the survival probability to a 1 in 2 chance (Randleman, 1980). According to one public fire agency they report, Several paramedic personnel have recently left the EMS division, sighting burnout as a contributing factor in their decision (Boike, 1991). Burnout is most commonly defined as a condition of emotional exhaustion caused by job related chronic tension and stress. The IAFF recommends an unit hour utilization ratio of 0.30 as their recommended work load (International Association of Fire Fighters, 1999). An EMS system actually produces two products, patient transport and coverage. Coverage refers to the fact that an EMS system must maintain adequate resources to provide transport availability, even when calls do not occur (Lewis, 1997). Unit hour utilization is used by private industry to calculate the percentage of transports by an ambulance during a specific time period. This also provides a productivity ratio. Private industry would divide the total number of transports by the number of hours in their shift. For instance, six transports in a 12 hour shift is a Transport U: UH of 0.50.

29 The highest U: UH would be a 1.0, which means that a unit is productive 100 percent of the time, which is impossible (Lewis, 1997). In the fire service, personnel are responsible for other tasks such as: hose testing, hydrant maintenance, inspections, pre-incident analysis, public education, etc. taking this concept under consideration, another production calculation for the fire service needs to be used. The fire service needs to consider all responsibilities required of them, including transports and consider them into a total time on task utilization model (Lewis, 1997). For the fire service, the primary factors that should be considered in developing staffing levels are the amount of coverage necessary in a particular geographic service area and the fluctuating demands (Fitch, 1992). The San Antonio Fire Department in Texas found they could successfully determine peak load demands through the use of statistical analysis (Boike, 1991). When matching staff to call load, two things are important to keep in mind when preparing a schedule work shift: When calls occur. The number of calls. With flexible deployment, the emphasis is on where to place the vehicles, but it is just as important to determine how many vehicles are needed (Fitch, 1992). To estimate how productive fire based transport units can be, the author determined what the private providers U:UH transport ratio is. After interviewing several of our employees who work part time for the private provider they (all four) reported a transport U:UH of.58 or between six (6)and seven (7) transports in a twelve hour shift. Additionally, Chief Randy Howell of the Henderson Fire Department was interviewed. He stated that The

30 Henderson Senior Staff has determined that greater than an average of 10 calls per 24 hour shift for an extended period (six months) would result in either an adjustment in that units area of coverage or an increase in rescues placed in service. This was determined by listing the personnel responsibilities that were assigned to the rescue, including: details, training classes, meals, sleep, drills, hydrant inspections, school drills, pre-plans etc. With the remaining time, (seven hours) they came up with a realistic work-load and call volume of 10 calls per shift. They also share a 60 percent transport rate. This breaks down into an emergency response U:UH of 0.29, which falls under the IAFF recommended 0.30 U:UH work load. To calculate the cost of fire based EMS service, only marginal costs of the service should be used. The marginal costs of providing EMS services are only those expenses beyond what it would cost for other routine fire department operations (International Association of Firefighters, 1999). Marginal costs of providing EMS with multi-role, cross trained firefighters as the difference between the total cost of operating the fire department with EMS and the total cost of operating the department without EMS (Riddle, 1995). Many of the administrative costs and some of the personnel of an EMS system are already covered under fire suppression and rescue services (International Association of Firefighters, 1999). Using the SWOT change model reviewed in advanced leadership issues in Emergency Medical Service (ALIEMS), the author used the following four questions to develop an operational plan that allows Las Vegas Fire & Rescue to incrementally increase our emergency transports and eventually provide 100 percent of the emergency patient transportation requests.

31 1. Where is Las Vegas Fire & Rescue now, what is our situation? Las Vegas Fire & Rescue is on the threshold of providing emergency transportation for the citizens and visitors of Las Vegas. For twenty years or more, the fire department has been transport capable. The city currently has a contract with a private ambulance company to provide 100 percent of all the patient transports in the city, including nonemergency inter facility transports. However, the fire department has always reserved the options of transporting patients, when certain conditions exist. They are: When the private provider is unavailable or delayed When the scene is not safe When city government employees are involved. (mainly firefighters and law enforcement officers) Upon patient request (Las Vegas, Nev. Department of Fire Services, 2000). This has resulted in a minimal amount of patient transports for Las Vegas Fire & Rescue, roughly 50 transports a year. Being transport capable and providing an occasional transport is very different than providing a consistent transport service. A transport service creates a greater demand on the EMS delivery system. The Fire Department covers geographic areas, positioning fire rescues (Ambulances) strategically throughout the city to enable quick response times. Historically the fire department would respond to an emergency initiate treatment, stabilizes the patient and transfer him/her over to the private provider who would then transport the patient to a local hospital, and then submits a bill to him/her for transportation.

32 For the past 16 months, Las Vegas Fire & Rescue has been transporting all motor vehicle accident patients, as part of a pilot program, to evaluate the feasibility or our organizations capability to provide transport to the citizens of Las Vegas. We currently transport 10 percent of the transport market. To provide EMS transportation and continue to provide geographical coverage, Which is necessary for an increased survival rate in cardiac arrest patients (International Association of Fire Fighters, 1999). We will need to add additional rescues to our EMS delivery system. Our goal is to sustain our quick emergency responses and provide the patient a financially efficient ride to the hospital. To do this, we will need an EMS delivery plan that reflects incremental increases in the percentage of the transportation market. City council has voted on the subject and has given Las Vegas Fire & Rescue permission to continue with incremental increases in the emergency patient transportation market (Blue Ribbon Panel, 2000). When Las Vegas Fire & Rescue delivers 100 percent of the 911 generated emergency transports to the citizens of Las Vegas will have quality EMS delivery at a substantial savings compared to the cost of that same service which is provided by a private ambulance company. Additionally, the city will realize a financial benefit, as the fire department will be considered a revenue provider and will bring money into the city government system, the general budget. The citizen s benefit directly through a cost savings, initially when transported to a hospital during an emergency. As a community, our citizens will enjoy lower tax rates, as the additional revenue will be placed back in the budget, deferring the cost of the fire service.

33 2. What resources do we have available? Administrative and support services: Las Vegas Fire & Rescue shares a state of the art dispatch center with three other fire departments in the valley. We utilize computer aided dispatching (CAD) with emergency medical dispatchers (EMD), utilizing pre-arrival instructions with the person initiating the call while our units respond. Additionally, we have incorporated Automatic Vehicle Locators (AVL) on all our emergency response units, which dispatch the nearest appropriate emergency vehicle; and we use the Clawson Triaging System for sending the appropriate level unit or units. We have a Deputy Chief of EMS who oversees the whole EMS division. An EMS Coordinator is responsible for administrative operations, delivery systems and supplies. An EMS Quality Assurance Officer insures quality patient care and other quality issues. We have a EMS Educator who is responsible for all EMS certifications, re-certifications and class instruction. We have contracted with an outside billing agency who charges seven percent of all bills collected (not billed) for their service. To help with the paper work (run sheets), we have one full-time secretary who allots a portion of her time to collect and send the run sheets to the billing agency. Logistically, we have a fire department shop that performs vehicle services, maintenance and light repair on all fire department vehicles and related equipment. Staffed with five employees, a shop foreman and three mechanics, and one secretary. Line services: Our Department consists of 11 fire stations geographically located throughout the city. Each station has one ALS engine and one ALS rescue, except station #1 which has two

34 ALS rescues. We have a total of 12 ALS transport capable rescues and 12 ALS engines. There are an additional six BLS truck companies stationed throughout the city and equipped with automated external defibrillators (AED s) For a total of 24 ALS units six (6) BLS units and six (6) reserve rescues. It is important, at this point, to identify the transportation capability of our rescues that are assigned to geographical coverage. Typical Work Schedule for a Rescue Unit 07:30 Report for duty and shift change briefing, meet for muster, assignments, letters of the day and schedule for the day. 08:00 Separate for personal details. 08:30 Assist with station detail, truck day, floor day, kitchen day, lights and wood work, etc. 09:30 Unit check, restock EMS inventory, order supplies. 10:30 Class, module training, Quick Action Pre-plans (QAP s), in-district inspections, 11:30 Lunch, clean up. 12:30 School drills, hydrant inspection, drills, captains class, employee interviews, promotional programs. 15:30 Mandatory physical training. 16:30 Shower. 17:00 Dinner, clean up. 18:00 Evening schedule, call volume (7 hrs.). 01:00 Retire to dorm. 07:30 Shift change briefing.

35 It is important to understand that the responsibilities are outlined in theory only, it is recognized that no one can predict when or where emergencies will occur. In the spirit of theory, I have assigned a time frame for the responsibilities to be completed. Whereas they need to be accomplished some time during the day, the time required to complete them remains the same, regardless of when they are accomplished. In a 24-hour shift, a rescue unit is productive 17 hours of the 24-hour shift, if the 7 hours of scheduled sleep is not counted as productive, which equals a.71 U:HU (17 Divided by 24). However, the IAFF considers sleeping periods as coverage time. One of the main functions of a fire department is emergency coverage. Therefore, the actual U:HU of a rescue unit is 100 percent productivity or 1.0 for coverage calls. Theoretically, there are seven hours available in their busy schedule to respond to emergency calls. With this in mind, their emergency response U:HU ratio is.29 (7 divided by 24). This ratio is half of what the private provider expects out of their employees, and well under what the IAFF recommends as a reasonable work load for emergency responders ( International Association of Fire Fighters, 1999). This.29 U:HU work load translates into a significantly lower burn out ratio. Additionally, a.29 UHU will allow us to respond on approximately 10 emergency calls in a 24-hour shift per rescue; and with a 60 percent transport rate, six of those patients will be transported to the hospital. This emergency response unit hour utilization number will give us the number of emergency calls our geographically positioned rescues can provide per shift. It is

36 expected that out of every 10 EMS responses, 6 patients will be transported to local hospitals. There were 29,960 transports in the city in 1998, ten percent of that is 2,996 transports last year. That number was obtained by requiring our rescues to transport patients resulting from motor vehicle accidents. Six transports per 24-hour shift (6 x 365 = 2,190) will produce 2,190 transports per year, approximately 07 percent of the market. It is, therefore, expected that a fire department rescue, placed into service, would be expected to transport six patients per shift. 3. Where do we want to go? Las Vegas Fire & Rescue s goal is to incrementally increase our percentage of the emergency transports, until we provide 100 percent of the emergency transportation in Las Vegas. Our short-term goal is to increase our transports to 15 percent for the next year, and develop a modular transport plan that the fire chief can implement, as he wishes or as resources permit. This modular plan must be: fiscally responsible, Easy to implement, acceptable to Labor, asset compatible, considerate of private ambulance needs (it must allow them to pull ambulances out of corresponding service areas). There must also be no patient care compromises. 4. What is our strategy for getting there? To implement a modular transportation plan that incrementally increases Las Vegas Fire & Rescue s delivery of patient transportation to the city. This plan will start on the east end of the city and progressively grow north and west until Las Vegas Fire & Rescue delivers100 percent of the 911 generated transports within the

37 Las Vegas City limits. The plan is to divide the city up by its fire districts; each fire district represents a module. When we have enough resources to support 100 percent transport in a stations (first in) district, we will place the resources (equipment and personnel) in that station and require they transport every 911 generated EMS call (as required by patient condition or request). The plan also requires that support units be added to neighboring stations as a back up. This progressive plan allows the Fire Chief to expand at his pace; additionally, it allows him to present a purchasing plan to city hall, which supports our expansion goals. Another strong supporting argument for a modular growth plan is the initial control area is relatively small, only six square miles and one station. A 100 percent self contained full service EMS service area, which is one station and six square miles in size, will be much easier to support compared to the whole city (110 square miles and 11 stations). One of the requirements of this plan is that units and crew remain intact and in-service for the entire shift, which means no on duty training or other assignments that pull units out of service. This plan will give us a view of what we, as a department, need to do to support this type of customer service. Starting with Station Eight, (southeast side of town) we will begin implementing this modular growth plan. We will require them to transport 100 percent of every 911 generated emergency call within their first in district (A six square mile area). Any call outside this area will be handled by present day procedures. Any call within the six square miles will not involve participation by the private ambulance company, unless otherwise requested for unusual circumstances.

38 It has been determine, through historical research, that Station Eight (staffed with one ALS engine and rescue) is currently handling approximately 508 EMS calls per month from their station, 276 calls for the Rescue and 232 for the Engine (SunPro, 2000). Additionally, a historical search revealed that during the first eight months, of the year, Rescue eight s busiest day was spent responding to 21 calls and Engine eight s was spent responding to 19 calls (see appendix B ). In August of 2000, this six square mile area generated 430 EMS calls which averages out to 13.8 EMS calls per day. The surrounding area (13 square miles), that station eight services as second in, generated 671 calls (see appendix E ) (SunPro, 2000). This August station eight delivered 21.6 per day from their second in area for a total of 35.4 EMS calls per shift (SunPro, 2000). Station Eight does not respond as first in to these surrounding areas other stations typically assist in responding to those calls, this area is only considered to evaluate a worst case scenario. The worst-case scenario for Station Eight, including its mutual aid areas, would be a maximum of 35.4 EMS calls per day. Of the potential 35.4 EMS calls per shift, only 8.3 will be transports (from the six square mile area). Keep in mind in the first eight months of this year, rescue eight responded to a maximum of 22 calls in one 24-hour shift; their maximum average for the year was 18.5 calls in one 24-hour shift (see Appendix B ). If we staffed Station Eight with two transport rescues, they will have enough transport capability to transport the patients in their first in district and handle the non-transport EMS calls. The addition of an extra rescue at Station Eight will reduce the EMS call volume on Engine Eight. Based on the statistics, the worst-case call volume scenario for

39 both rescues at Station Eight will be 11 calls, including 6.6 transports each. (7.6 hours of emergency call productivity,.31 U:HU). Both rescues will be staffed with two paramedics and one EMT-B. The rescues will be dispatched as a single unit on all A, B, and C level calls and with an engine on all D level calls. Additionally, at least one rescue will be equally staffed in both nearby stations and dedicated as a back up for Station Eight if they need assistance in their first in transport district. Unexpected Results There were three significant unexpected results worth mentioning in this paper. First, as mentioned earlier, in Assumptions, Las Vegas Fire & Rescue considers our personnel as our most valuable resource and want to take care of them as best they can. It was interesting to note, in the literature review, that we, as a department have been very aggressive in taking pro-active measures in reducing or eliminating burnout in our department. The main reasons for burnout are as follows: High workload. System abuse. Administrative hassles. Lack of promotional opportunities.

40 Lack of communication. Appreciation. Cross training. Realistic expectation for their tour (5 yrs.). Incentive pay. (Randleman, 1980) Las Vegas Fire & Rescue have dealt with, or is addressing, these issues on a continuing basis. I think it is important to mention and measure our progress to remind ourselves what has been done, and to measure our progress, reminding ourselves what we still need to do. High workload: We have addressed this issue by hiring more firefighter paramedics and instituting a 12-hour rotation from ALS rescues to ALS engine companies. This approach maintained and supported the concept of the multi-role firefighter (cross training) and allowed them to perform a variety of skills for our department as well as limiting their shift on the rescue utilizing their paramedic skills. System Abuse: Although not a glaring problem in our system, we on occasion have citizens access the 911 system for the wrong reason. It is not a wide spread problem. This is credited to a good public education program. We are looking at other options to fine tune our dispatch practices, and are looking at creative ways to reduce or eliminate A level calls for our EMS providers.

41 Administrative hassles: We all suffer from this syndrome; it s probably inherent in all government institutions. There are some things that will never go away. We do listen to and solve what we can. The success rate of reducing administrative hassles have been low.and it is has not been determined if the crews know what our efforts are or have been. Promotional opportunities: Our EMS providers have the opportunity to promote to the rank of firefighter/paramedic after being on the job for approximately 16 months (rookie school and probation). After that, the only promotional opportunities are Fire Engineer, or Fire Captain. Union issues in the past did not allow individuals to keep their paramedic status once promoted beyond paramedic. However, things have changed slightly. Paramedics that are successful in the promotional process are supported in their efforts to maintain their paramedic certification, through department sponsored training classes. They are allowed to function as a paramedic, but receive no financial remuneration. Technically, since a Fire Captain supervises crews, they essentially function as our paramedic supervisors. A common sentiment among our medics is, That s not what we meant. Nevertheless, that is our present chain of command. Lack of communication: We do well in some areas. The major complaints in the article (Paramedic burn out) were for the medics to be able to air their complaints in a formal forum, and for the department to communicate effectively with local receiving hospitals so their personnel know what our S.O.P. s are which in turn explains why we do what we do, thus improving relations in the E.R. (Randleman,

42 1980). We hold monthly training sessions and allow our paramedics to voice their concerns, at some point during the meeting. Additionally, we have an EMS Committee it is represented by a cross section of line personnel and administration and addresses EMS issues. We have been weak in our communications with the hospitals. Appreciation: Administration takes opportunity to meet with our medics in their monthly training sessions and communicate our appreciation for the work they are performing. Additionally we encourage our captains to support their medics in the field. For the most part, we have good cooperation. Cross Training: All our paramedics are crossed trained and serve a multi-roll function. This has been supported by a mandatory 12-hour rotation from ALS rescues to ALS engines. Realistic Tour: One of the questions our employees who are attending paramedic school is, how long will I need to function as a paramedic for the department, before I can stop, and still remain in favor with the department? I inform every employee entering paramedic school that the department expects them to serve as a paramedic for five years. If they want out before then they need to promote out. Any thing more than five years the department considers a bonus. Incentive pay: Incentive pay was intentionally left for last, because it was the least mentioned in the article; it was mentioned only by half of the departments surveyed as a reason for burnout. However, it is a reason mentioned (Randleman, 1980). Las Vegas Fire & Rescue pays an incentive for all our EMT s. An EMT-B, and EMT-I

43 receive an additional five percent above firefighter base pay. They also receive an additional five percent, if they ride the rescue. They can receive up to 10 percent above firefighter base pay. The paramedics receive a straight 15 percent above firefighter base pay, regardless of whether they ride a rescue or an engine company. Some paramedics do not feel the pay is reflective of our appreciation for their efforts, and do not consider the 15 percent differential as just compensation. There are many departments listed in the article who receive less pay incentive and still consider it a good incentive. I support the article stating, pay alone is not enough to keep them in the business (Randleman, 1980). I believe pay is considered as incentive to do the job if it is viewed by the recipient as a valid gesture of appreciation, regardless of how much it is. Second, when conversations develop into patient transportation and response times, someone always brings up System Status Management (SSM) which translated to an EMS provider means, posting, or sitting at a street corner in an ambulance waiting for a call. During the literature review the author discovered, the greater the number of hours spent in a motor vehicle, the higher the risk for back injury, specifically, an acute prolapsed lumbar invertebrate disk injury. Individuals who spend more than half their work day in a vehicle have a three fold increased risk of disk herniation. Studies referred to in the article, My aching back, indicate that employees subjected to static seated posture and vehicle vibration exposure suffer an unacceptable increase in back pain and injuries (Moneau and Stothart 1999). Therefore, it is the intent of this EMS manager to avoid, posting, as tool to increase coverage and response if at all possible.

44 Third, during the manual retrieval of each unit s emergency responses from their log books, Rescue One (R-1), was noticed to be remarkably higher than all the other rescues in the city. It is common for them to respond to 18 calls in a 24-hour shift. Their record high for the first eight months this year (2000) was 31 calls in one particular shift (see appendix B ). The author believes this is too large a work load for a single rescue; we have placed a second rescue, Rescue Ten (R-10,) in service at Station One several years ago to share the heavy call volume there. However, it is time to re-visit the call volume for the rescues out of Station One and consider placing a third rescue into service to help with the work load. DISCUSSION The study results also revealed that there is a need to develop an operational plan for resource management (Riddle, 1995), that public fire departments need to be held more accountable for their delivery systems, and be competitive with private providers (Lewis, 1997). As far a fiscal responsibility goes, it is far cheaper for the private citizen to have a fire department that is already providing EMS responses, to take one more step and transport those patients to the hospital (Riddle, 1995). We already have the dispatch center for call taking and dispatching units, stations for housing rescues (ambulances), and responding fire personnel who are responsible for the quick response times recommended by the AHA (International Association of Fire Fighters, 1999). We typically assess the patient, begin initial treatment, package the patient and then turn them over to the private provider

45 who takes them to the hospital and then sends them a bill for the service. The fire service can provide patient transport for less because they are already in the EMS business. We might as well finish the job and transport the patient to the hospital, which provides seamless patient care and transport at a reduced price. There are only a few EMS management systems that distribute ambulances effectively (Moneau, 1999). The system that best meets fire department goals, which maintains rapid response times, is the Comprehensive Flexible Deployment system (Fitch, 1992). Comprehensive Flexible Deployment, or Flexible Deployment is based on past fire department principles of a quick response, based on placing fire stations at geographical distances from each other, allowing for a quick emergency response by fire units. This same principal is used in Flexible deployment (Fitch, 1992). Fitch refers to this as a zone defense ; the system is based on having adequate units available to provide geographical coverage for any next call. There are three basic components of this strategy. They are: Assurance of geographical coverage: This can be done through utilization of fire stations based strategically throughout the area. Provide demand coverage: Determine what coverage the original geographical units can provide, and basically covering the rest with additional ambulances based at those same stations. Post reassignment strategies; (Fitch, 1992). In the fire service, we move ups fire units when unusually large fire responses leaves open or uncovered areas of the city. We then relocate or move fire apparatus to different stations, to create better coverage. We call this process Move Ups (Riddle, 1995).

46 The American Heart Association has proven that rapid patient access is directly related to patient survivability. They recommend a four-minute response time for cardiac patients. The AHA has established the Chain of Survival for cardiac arrest victims. They are: Early access to the EMS system. Early CPR. Early defibrillation. Early ALS. The quicker EMS providers arrive on scene, the better for the patient. (International Association of Fire Fighters, 1999). Paramedic burnout is a term loosely used in the fire service, yet it is a very serious condition (Randleman, 1980). One fire agency cited burnout as a contributing factor in their employee s reason for leaving (Boike, 1991). Burnout is most commonly defined as a condition of emotional exhaustion caused by job related tension and stress (International Association of Fire Fighters, 1999). Burnout needs to be addressed, but as yet, no specific number of runs that a 24-hour team should be able to handle has been identifiedb(fitch, 1992). The stress level for private providers is higher than it is for fire personnel (Riddle, 1995). This may be related to their higher Unit Hour Utilization. Private industry measures productivity by Unit Hour Utilization ratio, which they arrive at by dividing the number of transports in a shift by the duration of that shift (Lewis, 1997). Locally (determined through employee interviews) the private providers have a U:HU of 0.58, which is six to seven transports per 12 hour shift.

47 Fire departments cannot measure productivity the same way private industry does, because fire departments provide more than just patient transportation. Fire departments are responsible for providing, fire coverage, rapid EMS response times, as well as other community service and duties such as: School drills. Hydrant Inspection and testing. Station maintenance. Public Education. Hose testing. Required training. (EMS, and Fire) (Lewis, 1997). Additionally, we need to provide sleeping time during their 24-hour shift. Studies have shown that people who are awake, for up to a 19 hours, performed comparable to a person with a blood alcohol level of.08 (legally drunk in some states) on performance tests and alertness tests (Brinks, 2000). The International Association of Fire Fighters recommend a U:UH ratio of 0.3 which they say will allow personnel to keep their skills sharp. Additionally, they say exceeding a U:UH ratio of 0.3 may be pushing crews too hard (International Association of Firefighters, 1999). The fire service does more than just transport patients. Therefore, they cannot measure our productivity in the same manner that private ambulance companies do (Lewis, 1997). We need to set realistic productivity expectations for our crews. These workloads should be based on accomplishing all their assigned responsibilities, which include other daily activities

48 besides responding to fires and EMS calls. Take the available time left and set an Emergency Unit Hour Utilization standard. This is what the Henderson, Nevada Fire Department did and they are experiencing marked success. In a similar manner, we listed our personnel s daily tasks and assigned time frames to each, including an expected sleeping period (see appendix A). There are seven hours left over for emergency responses. If we assign our rescues to respond to ten emergency calls, six of those will be transports; each transport takes an average of one hour, the remaining four non-transports take an average of fifteen minutes, which equals seven hours of emergency responses. Since the daily schedule is theoretical and they will be responding whenever the calls come in throughout the day, they will be able to achieve a hundred percent productivity for the projected seven hours and remain under the.3 U:UH ratio set by the IAFF. Actually, they will have a.29 Emergency Response Unit Hour Ratio. Logistically, we have both the rescues and reserve units available, to place one of our stations on a 100 percent transport assignment. Our shop will be able to provide the repairs and general maintenance required to keep our fleet rolling. RECOMMENDATIONS Recommendations for the future are to continue transporting patients as we are today. Which is, to transport under our original transport criteria found in our S.O.P. s plus motor vehicle accidents.

49 The next step is to implement the first module of the transportation plan. The first module is, for Fire Station Eight, to transport 100 percent of the 911 generated EMS calls in their first in district, Defined by the following districts:: 2327, 2328, 2329. 2427, 2428, 2429. To support this modular growth plan, Station Eight will be staffed with: One ALS engine (With at least one paramedic on board) Two ALS rescues (With two paramedics and one EMT-B) Staffing will remain constant, 24 hours a day seven days a weak. All required training for the Station Eight crew will be scheduled as off duty training. They will be paid overtime. Additionally, the two nearby supporting fire stations will be staffed up for support in their own first in districts, as well as station Eight s, thus reducing the need for assistance required from fire station Eight. The two nearby fire stations, one and four, will be staffed with an additional rescue each. Station Four currently has one ALS engine and one ALS rescue; an additional rescue will be added and staffed with two paramedics and one EMT-B to respond in Station Eight s first-in district, if there is a need. Additionally, a third rescue will be added to station one s current fleet and staffed with two paramedics and one EMT-B to support Station Eight if needed. Additionally, it should be noted that extra units in stations one and four, are expected to reduce the call volume for station eight. The resources needed are: Three additional rescues.

50 Three additional EMT-Bs. Seven additional paramedics. Current staffing requires a minimum of 24 paramedics on duty each 24 hour shift. We currently have 102 paramedics on our department (see appendix C), which translates to 34 per shift. This first, modular, increase would require a minimum of 31 Paramedics on duty each shift. We currently have six reserve rescues available and are receiving two more rescue units the first weak in December 2000. Placing three rescue units into service will leave us with five reserve units, after the first weak in December. The current platoon roster indicates we have enough EMT-Bs available for the anticipated staffing requirements. We need to work out the dispatching details with dispatch and notify the private ambulance company so they can staff down in the effected area. Additionally, we will need to set up ALS vehicle inspections, with the Health District, for the three additional rescues we placing into service. Finally, we need to sell this to the troops, so everyone knows what is going to happen, where it will happen, and when it will happen, and what is expected of each employee involved in the program. It is also recommended that we monitor and track the, plans, weakness for obvious support reasons, but also for future growth plans. We should measure our accuracy of predicted call volume and run statistics, and make necessary adjustments for future growth plans.

51

52 REFERENCES Blue Ribbon Panel: 2000 Emergency Medical Services Blue Ribbon Panel Report [Electronic Data File]> Las Vegas, Nev: Las Vegas City (Producer and Distributor). Boike, R.R. (1991). Alternatives to the existing delivery system for fire department emergency medical service. Emmitsburg, MD: National Fire Academy, Executive Fire Officer Program. Brink, S. (2000). Sleepless Society. U.S. News. 62-72. Burke, G. (1998, May). A solution is born. FIRE CHIEF. 52-57. Fitch, J.J., Keller, R.A. (1993). EMS Management, Beyond the street. (2 nd. Ed.).California: Jems Communication. Hill, D.W. (1997). Call volume and shift scheduling options for Sioux Falls Fire Rescue. Emmitsburg, MD: National Fire Academy, Executive Fire Officer Program. International Association of Fire Fighters. (1999). Emergency Medical Services, A guide book for fire-based systems, (2 nd. Ed.). Washington, DC: Author. Las Vegas, Nevada. Department of Fire Services. (2000). Standard Operating Procedures (Volume II, Operations). Las Vegas, Nev: Las Vegas Fire & Rescue. Lewis, T.L. (1997). Resource management for effective service delivery. Emmitsburg, MD: National Fire Academy, Executive Fire Officer Program. Menkin, H. (1997, July/August). Strategic planning. Ambulance Industry Journal. Moneau, P.M., Stouthart, J.P. (1999, August). Crew comfort, my aching back. JEMS, Journal of Emergency Medical Services. 36-79.

53 Randleman, W. ( 1980, November). Paramedic burn out. FIRE CHIEF. 27-33. Riddle, K. ( 1995, September). Opinions sought for EMS action plan. FIRE CHIEF. 22-26. SunPro [Tri-Tech]. (2000). City of Las Vegas, Fire Services. United States Fire Administration. (1997, April). Implementation of EMS in The Fire Service. (FEMA Contract number EMW-95-C-4734).

54 APPENDIX A Theoretical Daily Work Schedule Daily Schedule 07:30 Briefing, shift change, muster. 08:00 Radio test, and personal details. 08:30 Station details. 09:30 Unit check, restock, order supplies. 10:30 Captains class, module training, quick action preplans (QAP s), in district inspections, etc. 11:30 Lunch, clean up. 12:30 School drills, hydrant inspections, drills, employee interviews, promotional programs. 15:30 Mandatory physical training. 16:30 Shower. 17:00 Dinner, clean up. 18:00 Evening schedule, Call volume (7 hrs.). 01:00 Retire to dorm. 07:30 Shift change briefing. (There is a theoretical total of seven hours in which crews are free to run emergency calls.)

55 APPENDIX B Run Statistics Battalion 1 and 4 (Extracted manually from station/unit log) January of 2000 through August 2000 Battalion # 1 (Consisting of stations 1, 3, 4, 5, and 8.) Fire Station #1 Unit # Peak Unit # Peak Month R-1 R-10 Jan. 523 25 257 15 Feb. 452 28 271 19 March 566 28 314 17 April 548 26 310 17 May 553 29 351 17 June 627 31 297 20 July 582 27 304 16 Aug. 628 27 283 15 Total 4479 2387 Average Peak 27.625 17 Unit # Peak Unit # Peak Month E-10 E-1 Jan. M20 8 103 7 Feb. M20 9 108 9 March M19 12 103 7 April M12 8 97 9 May M17 11 135 8 June M17 12 129 12 July M9 10 122 8 Aug. M15 12 153 12 Total (many missing days) 950 Average Peak 9.75 9

56 (Station #1 continued) Unit # Peak Month T-1 Jan. 96 10 Feb. 91 9 March 107 12 April 108 13 May 105 11 June 111 12 July 127 13 Aug. 165 12 Total 910 Average Peak 11.5 Fire Station #3 Unit # Peak Unit # Peak Month R-3 E-30 Jan. 154 6 107 13 Feb. 173 10 109 8 March 175 10 84 8 April 180 9 106 13 May 171 10 112 10 June 121 13 73 8 July 307 16 117 10 Total 1471 790 Average Peak 10.25 9.75 Unit # Peak Unit # Peak Month E-3 T-3 Jan. 57 6 27 5 Feb. 105 9 53 8 March 72 7 35 7 April 65 6 39 5 May 65 8 34 6 June 37 5 27 7 July 66 7 82 6 Aug. 129 8 89 8 Total 596 386

57 Average Peak 7 6.5 Station #4 Unit # Peak Unit # Peak Month R-4 E-4 Jan. 388 20 261 13 Feb. 429 17 231 14 March 281 19 255 15 April 372 20 263 16 May 251 20 321 18 June 298 19 281 15 July 438 29 293 17 Aug. 428 19 302 19 Total 2885 2207 Average Peak 20.37 15.87 Unit # Peak Month T-4 Jan. 158 11 Feb. 171 11 March 181 15 April 139 11 May 142 11 June 130 11 July 179 10 Aug. 178 11 Total 1278 Average Peak 11.37

58 Fire Station #5 Unit # Peak Unit # Peak Month R-5 E-5 Jan. 243 14 195 13 Feb. 248 16 199 15 March 275 14 185 15 April 263 14 185 13 May 338 16 223 12 June 286 17 200 11 July 309 13 206 14 Aug. 276 15 232 16 Total 2238 1625 Average Peak 14.87 13.62 Fire Station #8 Unit # Peak Unit # Peak Month R-8 E-8 Jan. 369 17 215 13 Feb. 331 18 164 13 March 363 15 281 15 April 346 17 201 13 May 394 21 270 17 June 400 22 273 15 July 406 19 260 14 Aug. 386 19 252 16 Total 2995 1916 Average Peak 18.5 14.5

59 Battalion 4 (Fire stations 2, 6, 7, 9, 42) Fire Station #2 Unit # Peak Unit # Peak Month R-2 E-2 Jan. 184 10 157 10 Feb. 175 11 151 11 March 200 13 151 10 April 202 11 160 9 May 212 11 181 12 June 210 12 164 14 July 226 11 165 12 Aug. 220 11 193 14 Total 1629 1322 Average Peak 11.25 11.5 Fire Station #6 Unit # Peak Unit # Peak Month R-6 E-6 Jan. 335 19 239 16 Feb. 297 16 234 14 March 357 19 263 16 April 346 18 235 14 May 365 17 276 15 June 344 16 244 13 July 367 19 251 12 Aug. 384 20 273 15 Total 2795 2015 Average Peak 18 14.37

60 Station #6 (continued) Unit # Peak Month T-6 Jan. 130 15 Feb. 140 9 March 166 10 April 133 12 May 103 7 June 108 7 July 116 6 Aug. 98 8 Total 994 Average Peak 9.25 Station #7 Unit # Peak Unit # Peak Month R-7 E-7 Jan. 109 6 88 8 Feb. 87 7 68 6 March 115 6 96 7 April 146 8 94 7 May 134 8 69 9 June 117 7 100 5 July 118 6 79 9 Aug. 120 9 85 7 Total 946 679 Average Peak 7.12 7.25

61 Station #7 (continued) Unit # Peak Month T-7 Jan. 59 5 Feb. 62 4 March 73 6 April 78 6 May 33 4 June 32 4 July 30 3 Aug. 44 4 Total 411 Average Peak 4.5 Station #9 Unit # Peak Unit # peak Month R-9 E-9 Jan. 198 12 115 12 Feb. 172 10 139 13 March 213 11 136 12 April 197 10 143 9 May 189 11 122 8 June 228 13 135 8 July 201 12 136 12 Aug. 211 11 131 8 Total 1609 1057 Average Peak 11.25 10.25

62 Station #9 (continued) Unit # Peak Month T-9 Jan. 42 7 Feb. 81 6 March 90 7 April 65 8 May 60 7 June 51 6 July 54 4 Aug. 47 3 Total 490 Average Peak 6 Fire Station #42 Unit # Peak Unit # Peak Month R-42 E-42 Jan. 294 15 207 10 Feb. 275 15 173 11 March 318 17 207 15 April 281 19 208 15 May 286 15 204 18 June 308 17 223 12 July 299 16 211 13 Aug. 330 17 232 15 Total 2391 1665 Average Peak 16.37 13.62

63 APPENDIX C Clark County Health District Emergency medical Services Attendant Training Level Report Oct. 20 th. 2000. Las Vegas Fire & Rescue Count of Training Levels Number of First Responders: 0 Number of Drivers: 0 Number of EMT-Bs: 120 Number of EMT-Is: 136 Number of EMT-Ps: 102 Number of EMT-P(A)s: 1 Number of RNs: 0 Total Records: 359

64 Appendix D EMS Calls generated from district: 2327, 2328, 2329 2428, 2427, 2429 For the month of August. District Total number of EMS calls Average per day 2327 70 2.3 2328 72 2.3 2329 51 1.7 2427 96 3.1 2428 76 2.5 2429 65 2.1 Total 430 14

65 Appendix E EMS runs generated in the 13 square miles surrounding Station Eight s first in district in August 2000. District Month (Aug.) Per day 2226 21 0.7 2227 10 0.3 2228 11 0.4 2229 06 0.2 2231 03 0.1 2336 45.5 1.5 2331 01 0.03 2431 09 0.03 2426 74.1 2.4 2527 74 2.4 2528 23 0.7 2529 10 0.3 2531 03 0.1 Total 291 9.4

66 Appendix F Strategic Patient Transportation Plan For Las Vegas Fire & Rescue. A Modular expansion plan for full EMS delivery: Divide the city into modules or theoretical first in districts for each fire station. Review historical emergency call volume data, to determine how many calls come from each area. Note any peak hour anomalies that might need to be staffed. Divide the determined call volume for each unit (Which is 10 calls per rescue in our area.) into the predicted call volume, to give you the number of rescues needed for adequate coverage in any given area, during any given time period. Staff each rescue according to the established standard level of care. Our standard level of care puts two paramedics at the scene of each emergency call. Basically we are looking at a Comprehensible Flexible Deployment plan. Where we address: 1. Geographical coverage, Fire stations deployed strategically throughout the city, which ensures rapid response times in all areas of the city. 2. Add demand coverage, which are additional units to cover what geographical coverage cannot handle. 3. Post re-assignments. In our system these are called Move Ups. This is used any time an emergency unexpectedly draws units out of normal coverage areas, leaving a portion of the city unprotected. We will re-adjust coverage, sending emergency units to neighboring stations to provide better coverage, until units clear the call or come back into service. At such time units will return to their assigned duty station.