About the Data
The leaders of the first responder and transport agencies (n=485) serving the 200 most populous cities in the U.S. were invited to participate in the 2012 JEMS 200-City Survey via e-mail. Conducted online, the survey included 75 questions. Many questions asked for multiple pieces of data. The completed survey response rate was 18.1% (n=88). Some of the 38 incomplete surveys provided many but not all answers and were included when appropriate.
The survey covered a variety of EMS topics: dispatch, first response, transport, medical direction, performance measurement, effect of the economy, and system funding. Much of the information shared isn’t publicly accessible and, in many cases, is proprietary. Every effort has been made to protect the privacy of the respondents. All data is discussed in aggregate and doesn’t indicate individual cities or EMS organizations.
Although accuracy is a key aim, this isn’t a scientific report, and the findings and conclusions haven’t been peer-reviewed. The results are dependent on the quality of the data received, as is the case with all research projects. All completed surveys were included in the data analysis. In many instances, data weren’t available or relevant for all respondents and a smaller sampling is indicated. Some questions also asked respondents to “check all that apply,” and as a result, the responses totaled greater than 100%. (See Table 1, p 30.)
How Long Can an Organization Hold its Breath?
According to the National Bureau of Economic Research, seven recessions have occurred since 1966. Six of the recessions lasted an average of 10.8 months. The most recent recession lasted 18 months, from December 2007 through June 2009.
During each period of uncertainty, organizations would “hold their breath” by making temporary changes in operations until the economy recovered and their revenue streams renewed. However, this post-recession recovery has been unexpectedly weak. The U.S. Bureau of Labor Statistics noted in 2012 that “many of the statistics that describe the U.S. economy have yet to return to their pre-recession values.”
The response to the question posed in this year’s 200-City Survey, “Has your organization experienced reductions in service due to the current economic situation?,” documents the effects that the slow economic recovery have on EMS. The percentage of respondents that answered “yes” has noticeably increased in the past three years:
>> It was 30% in 2010;
>> It was 37% in 2011; and
>> It was 44% in 2012.
In addition, the following specific actions were identified by 104 (82.5%) survey participants this year:
>> Some 29 (27.9%) organizations reported a hiring freeze or not filling vacancies. This was the third year for some;
>> A total of 22 (21.2%) suspended pay-for-performance or cost-of-living increases. This was the fourth year for some;
>> In all, 16 (15.4%) reduced staffing;
>> A total of 13 (12.5%) changed from two-paramedic transport units to one paramedic and one EMT staffing; and
>> Twelve (11.5%) laid off employees.
Henry Farber makes the following observation about the current recession in a 2011 National Bureau of Economic Research working paper on job losses: “It is clear that the dynamics of unemployment in the Great Recession are fundamentally different from unemployment dynamics in earlier recessions.”
In the report, Farber notes fewer than half who lost their job in the 2007–2009 recession had a job in 2010. Those who obtained new full-time jobs were making 21.8% less money. These factors directly relate to EMS revenue streams and workload.
Since the 2008 survey, we have advocated getting involved in the larger healthcare industry and learning of the changes and opportunities in EMS organizations. In each survey, we have identified trends, opportunities and issues. Results from this year’s survey indicate that the slow economic recovery is imposing changes on even the most respected EMS operations.
Deployment & Staffing
First responder information was provided on 92 of the 126 completed and incompleted surveys. First responders reported an overall increase in response time (allowing a longer time from dispatch to arrival) and respond to fewer 9-1-1 events. Some are using alternative vehicles with less staff. Almost half (47.7% of 88) of the responding cities are providing paramedic-level service.
Work shift information was provided in 92 surveys. Fire departments continue to be the largest first responder agency, with 85.9% (79) of respondents working 24-hour shifts. (See Figure 1).
Four (3.8%) of 104 reported increasing their first responder response time. According to 38 respondents, a first responder is sent to every 9-1-1 incident; this 36.5% is noticeably lower than the 47.4% (55 of 116 respondents) that responded to every 9-1-1 incident in the 2010 survey. Forty of 88 first-responder organizations follow emergency medical dispatch protocol recommendations, representing 45.5% of respondents.
Twenty (22.7%) of 88 first responder agencies report using alternative vehicles for EMS responses, usually a one- or two-person car or light truck. Some were EMT-level “alpha trucks,” and others were paramedic staffed. A continuing increase of alternative response vehicle use has been reported during the past three years.
Expanded BLS First Responder Clinical Interventions
An indication of changed transport unit staffing was reported in the number of clinical interventions BLS first responders are authorized to perform. The 88 (18.1% of 485 requested surveys) participants who responded to this question reported the following interventions:
>> Twenty-three (26.1%) applied 12-lead application;
>> Twenty-two (25.0%) administered asthma medication;
>> Twenty-one (23.9%) administered nebulized medication;
>> Thirteen (14.8%) inserted esophageal obturator airway devices;
>> Eleven (12.5%) administered IV fluid;
>> Nine (10.2%) applied continuous positive airway pressure devices; and
>> Seven (8.0%) used adult/pediatric intraosseous devices.
It’s not clear from the survey responses whether the “BLS” first response providers providing invasive care are credentialed as advanced EMTs or EMT-Intermediates. Within 88 organizations describing the level of first responder activity, 25 (28.4%) provided occasional paramedic level service, defined as 5–75% of the time. Paramedic level first responder service is provided 76–100% of the time by 42 (47.7%) organizations.
Transport unit information was provided on 78 of the 126 completed and incomplete surveys, representing 16.1% of the number of agencies queried.
Transport agencies that responded in 2012 show a shift to more 24-hour shifts, an increase in allowable response time to incidents and more one-and-one staffing. The survey shows 48.7% (38) working a 24-hour shift and 38.5% (30) working a 12-hour shift. This is different from earlier surveys, which reported the 12-hour shift was the most frequent. (See Figure 2, at right.)
A dozen (15.4%) organizations are allowing more time to arrive at a scene. Five (6.4%) organizations extended or eliminated response time requirements to non-life threatening events.
When we looked at transport unit staffing in earlier surveys, a trend was not apparent. The 2012 survey shows that in communities where the state or local medical society doesn’t legislate a two-paramedic transport unit, agencies are moving to the one paramedic/one EMT staffing model. Communities are getting two paramedics to the incident by the first responder agency providing one paramedic and the transport agency providing the other. In some areas, the second paramedic is arriving in a one-person “fly car” or as an EMS supervisor. (See Figure 2.)
Fewer Middle Managers
Unless directly involved in patient care or required/funded by federal or state government, many middle management positions were eliminated in 2012. This is a continuing trend with required tasks reassigned to administrators, senior field providers or contracted out.
Results are mixed. For example, municipal transport agencies are dealing with an identity theft issue with the company contracted to perform ambulance billing.
At the time of publication, 27 agencies (not part of the 200-City Survey) in 17 states have been affected. The thinning of management and administrative staff affects the 200-City Survey, because we notice a third year of declining participation. Eighty-eight (18.1%) complete and 38 (7.8%) incomplete surveys were received from the 485 organizations contacted. For the first time, response rate dropped below 20%. Reflecting on the past three years of survey responses, many of the transport organizations surveyed have smaller staffs who are working longer hours with more responsibilities in systems where response requirements are being stretched.
Physician Oversight & Research
Of the 98 agencies that responded to this question, 37 (38%) report no physician participation in field operations. For the remainder with prehospital participation, the physician either rides with a supervisor or has an assigned response vehicle. (See Table 6).
Physician oversight of EMS field operations will be increasing in the next few years. Implementation of the Accreditation Council for Graduate Medical Education approved EMS fellowship program for physicians requires a minimum of 12 months of clinical experience as the primary or consulting physician responsible for providing direct patient evaluation and management in the prehospital setting, as well as supervision of care provided by all allied health providers in the prehospital setting.
The National Association of EMS Physicians (NAESMP) lists 58 EMS fellowship programs. The first board exams are scheduled for October 2013. Emergency physician focus on urban EMS performance can be found in the “Evidence-Based Performance Measures for Emergency Medical Services Systems: A model for expanded EMS benchmarking” published in Prehospital Emergency Care.
The U.S. Metropolitan Municipalities EMS Medical Directors Consortium is continuing to define EMS research, trials and demonstrations covering ST-elevation myocardial infarction (STEMI), pulmonary edema, asthma, seizure, trauma and cardiac arrest in the urban environment.
A high number of 2012 respondents participate in clinical trials: Fifty-three (62.6%) of the 87 respondents answered “yes” to this question. The number or organizations that use the Utstein standard to calculate or measure cardiac arrest survival scores was 39 (44.8%). (See Table 2.)
Slightly more than 41% (35 of 85) of the respondents formally partner with public health and/or social services to provide patient referral or follow-up for patients with high EMS use. This is lower than the 56.3% (36 of 64) that reported a formal partnership in 2011.
Only 27.1% (23) of the respondents have ongoing prevention programs targeted to at-risk populations, which includes elderly fall prevention, congestive heart failure, diabetes and pediatric asthma.
That is a slight decrease since 2011, when only 20 of the 68 respondents (29.4%) reported programs. Expansion of community paramedics and participation in accountable care organizations will increase EMS participation in prevention programs.
Clinical Care & Transport
Survey participants this year report infrequent encounters of citizen CPR, few patients who had an automated external defibrillator (AED) shock them into a viable rhythm before ALS arrived, and occasional witnessed cardiac arrests. (See Table 4.)
The effect of continuous chest compression on patient outcome wasn’t noted in this year’s survey, and the rate of bystander CPR in 2012 is between the 2009 and 2010 results. Although the rate of AED conversion to a viable rhythm prior to ALS arrival is low, these numbers cover all applications of an AED by bystander and first responder. Many shocked were probably in a non-viable condition prior to AED application. Table 3, at left, provides the details.
Questions on use of therapies, procedures and devices were answered by 82 (65.1%) participants. The following therapies (or lack thereof) are noteworthy:
>> None (0 %) used ultrasound;
>> None (0 %) used thrombolytics to treat stroke patients;
>> Three (3.7%) used hypothermia for selected spinal cord injuries;
>> Four (4.9%) administered thrombolytics to myocardial infarction patients;
>> Nine (11.0%) administered nitrous oxide to treat various patients;
>> Eleven (13.4%) placed patients in full-body vacuum splints for trauma patients;
>> Thirty-three (40.2%) had hydrogen cyanide protocol to administer medications to burn victims;
>> Fifty-two (63.4%) used hypothermia in cardiac arrest resuscitation
>> Fifty-six (68.3%) performed spinal clearance in the field for trauma patients;
>> Fifty-eight (70.7%) used carbon monoxide detectors in suspicious calls;
>> Sixty-seven (81.7%) used tourniquets for trauma patients; and
>> Seventy-seven (93.9%) used continuous positive airway pressure in patients with difficulty breathing.
Only 13 of the 31 (41.9%) participants that responded to the STEMI question achieved percutaneous coronary intervention (PCI) in less than 90 minutes from 9-1-1 call more than 95% of the time. (See Table 6, above.) It’s uncertain whether this is due to transport time or community resources.
In all, 88 (69.8%) participants had mandatory transportation protocols to the following types of specialty centers.
>> Eighty-four (95.5%) to trauma centers;
>> Sixty-eight (77.3%) to cardiac centers;
>> Sixty-eight (77.3%) to stroke centers;
>> Sixty-five (73.9%) to burn centers;
>> Sixty-two (70.5%) to pediatric specialty unit/centers;
>> Thirty-eight (43.2%) to labor and delivery centers;
>> Thirty-five (39.8%) to post resuscitation hypothermia receiving facility centers;
>> Twenty-seven (30.7%) to hyperbaric centers;
>> Twenty-four (27.3%) to psychiatric centers;
>> Twenty-three (26.1%) to sexual assault centers; and
>> One (1.1%) to a septic shock center.
Eight (9.1%) of the survey participants had a policy allowing patients to be routinely transported by ambulance to destinations other than an emergency department. Half (44) of the survey participants have a policy allowing EMS-initiated refusal and denial of EMS transportation.
Cost of Transport
Table 7 compares the results for responses to the 2010, 2011 and 2012 surveys. Providers charge different rates based on the type of service, subsidy and geographic location. The year-to-year difference in amounts is most likely due to differing respondents each year rather than an indication of national trends. The best way to compare your charges is to benchmark with other similar providers in your geographic area.
Billing can be extremely complex and requires constant continuing education and updates.
Any organization, public or private, is subject to the federal Medicare and Medicaid rules—for which failure to comply can result in penalties and fines, and the provider is ultimately responsible regardless of whether the billing function is outsourced or retained internally.
More Participation Needed
The 200-City Survey covers urban and metropolitan areas, the busiest and most complex EMS communities.
This is neither a peer-reviewed nor scientific report. Regardless, its value to EMS is inherent. However, the value of the
survey results decline when the response rate shrinks.
In 2012, an extra effort was made to identify the correct contact person for 485 organizations that provide EMS service in the 200 biggest cities. Just 18.1% (88) of the surveys were completely filled out, so we used information from both complete and incomplete surveys to describe elements of big-city EMS. When the 200-City Survey began, we enjoyed a 50% return of complete responses.
This year’s 200-City Survey reflects the extraordinary stress of a slow recovery from recession and uncertainty about the direction of EMS reimbursement.
The survey was conducted in October, before the presidential election and the Medicare Payment Advisory Commission recommendations to Congress after the Government Accounting Office issued its study of ambulance service reimbursement. Almost a third (29) of the 88 full respondents anticipated further reductions in services during 2013.
Acknowledgement: The author acknowledges the great support of the Fitch project team members and their contributions to the article: Jay Fitch, PhD., Sharon Conroy, Tom Little and Melissa Addison.
Disclosure: The author is an external, expert consultant with the consulting firm Fitch & Associates, LLC, which provides emergency service organizational and system audits for communities and individual organizations.
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