Delayed Emergency Response

Minutes can make the difference between life and death - but does Denver Health know how to tell time?


 
 

Jared Jacang Maher | | Monday, April 12, 2010


Michael Hancock got the call at 6:30 a.m.: His sister had been shot. Hancock lived less than five minutes away, and when he screeched to a halt on a quiet neighborhood street in Montbello, he saw his sister, 41-year-old Karen West, in the driver's seat of her SUV.

"I walked right up to my sister and heard her grunting for life," Hancock remembers. In the seat next to West was the body of her common-law husband, who had apparently shot West, the mother of two teenagers, in the head before turning the gun on himself. Police officers arrived just after he did; they told him that he had to step outside the perimeter until medical help came. Denver firefighters from the nearby station showed up less than a minute later, but they were trained only in Basic Life Support skills, such as CPR, and weren't equipped to staunch West's significant bleeding or transport her to the hospital.

"They said, 'There's nothing we can do,'" Hancock recalls. "'We need the ambulance service.'" By then, at least six or seven minutes had passed since the original 911 call. He and other family members stood by anxiously, waiting for the paramedics as the minutes ticked away. "It felt like an extra twenty minutes. It could have been ten minutes or fifteen minutes," he says. "But it felt like an eternity waiting for someone to get there to help my sister."

When the ambulance finally arrived, West was pronounced dead.

Six years after his sister died, Hancock is now the president of Denver City Council. He still doesn't know what would have happened if paramedics had arrived at the scene sooner - maybe his sister would have lived, maybe not. But he does know that the wait was excruciating. How could the police and firefighters arrive so quickly and the ambulance take so long? How many other people in Denver are waiting, and waiting, for paramedics to show up?

After consulting with numerous paramedics and Emergency Medical Services experts, Hancock has come to believe that the city's EMS system is inefficiently set up and routinely leaving citizens in the lurch, especially in outlying areas like Montbello, Bear Valley and Fort Logan.

"We have pockets of our city that are not covered at any given time, where [paramedics] take an extraordinary effort to get to patients, where we have to provide an outside ambulance service to get to someone, which is completely unacceptable," he says.

City Auditor Dennis Gallagher shares Hancock's concerns. In light of the Democratic National Convention coming up in August, in February his office decided to conduct an emergency-response performance audit of both the Denver Fire Department and the city's paramedic division, which is operated by the Denver Health and Hospital Authority. Unlike the fire department, Denver Health is a public/private entity that receives city funds but is not technically a city agency. And for three months, hospital administrators resisted Gallagher's request for response-time data, arguing that Denver Health was under no obligation to release financial records.

"The contract that the city and county has with Denver Health with regard to emergency services, among other things, says that the city can look at benchmarks that Denver Health has," says Denis Berckefeldt, spokesman for the auditor's office. "Among those are ambulance response times. We're just looking at the contract that says you must respond in a certain time. Are you responding in that time?"

When Hancock caught wind of the dispute, he contacted Denver Health CEO Patricia Gabow, urging her to cooperate with the auditor and requesting that she retain an independent EMS systems consultant to conduct an analysis of the Denver Paramedic Division's operating procedures. After a May 21 meeting, Denver Health agreed to cooperate with the audit. On Tuesday, Hancock received a letter from Gabow confirming that Denver Health was participating in the audit - but she didn't mention his request for an independent analysis.

Such an analysis might point out a disturbing development: Denver Health has changed the way it calculates its ambulance response times, violating specific requirements in its annual agreement with Denver - and potentially putting many citizens at risk every year.

In the '70s and '80s, Denver was renowned for having one of the finest trauma systems in the country. The Knife and Gun Club, a 1989 book by photojournalist Eugene Richards, offered a brutally frank depiction of life in the emergency room of what was then known as Denver General Hospital. Part of what made the hospital so progressive was its paramedic division, called "The God Squad" by other Colorado medics. Denver paramedics were among the first to take emergency care out of the emergency room and into the streets. Rather than just run an ambulance transport service, the paramedics provided vital care en route to the hospital, sometimes in extreme circumstances. Since Denver General took in the lion's share of the city's indigent and late-night emergency calls, it also caught the lion's share of violent-crime injuries, including gunshots, stab wounds and drug overdoses.

But by the early '90s, the hospital was running a $31 million deficit each year. At the time, the facility was overseen by the city's health department, and its manager was appointed by Denver's mayor. In order to allow Denver General to better compete with other regional hospitals, in 1997 it was spun off from the city as a quasi-public entity similar to the Denver Housing Authority. While the Denver Health and Hospital Authority's board of directors is still appointed by the mayor, the hospital now has control of its own budget and personnel. This makes most paramedics employees of Denver Health rather than of the city, a point of contention even as Denver Health was being set up. Back in 1995, Denver paramedics voted to be represented by the International Association of Fire Fighters, and began lobbying to have their division moved to the Denver Fire Department. Then-mayor Wellington Webb said he was against the switch, but appointed a task force to examine the issue - which determined that the paramedic division should stay put ("Firemen, Save My Department!" January 10, 1996.) Proponents of the status quo offered arguments similar to, if less colorful than, an analogy used by an attending physician in The Knife and Gun Club, who'd rephrased Richard Nixon's famous "If you got 'em by the balls, their hearts and minds will follow." As this version went, "If you get 'em into your ambulances, the patients and their wallets will follow."

Although the paramedic division remained part of the hospital, experts agree that the glory days of Denver emergency care are long-gone. In a 2003 USA Today analysis, Denver didn't even rank in the top twenty cities for EMS response. And response times have only gotten worse since then, paramedics say.

By last November, the situation had gotten so bad that paramedics started talking. Worried about fallout on the job, though, many would only talk off the record, and only in the back of dark bar rooms or fast-food joints far from paramedic division headquarters on the Denver Health campus at 777 Bannock Street. A few even refused to give their names, afraid that word would get back to supervisors. They told variations of the same story: Morale is low, turnover is high, ambulances are routinely taken out of service and calls too frequently given to private ambulance companies with which the hospital has established mutual-aid agreements. They described a paramedic division that's understaffed, over-utilized and forced to drive longer distances to respond to emergency calls.

"I do know that people are waiting horrendous amounts of time for their broken legs, broken bones. Twenty minutes, twenty-five," said one paramedic. Another complained about the high attrition rate in the 150-member unit, estimated at between 15 and 30 percent in 2007. "People are going elsewhere because they know where this place is going," he explained. "It's going in the toilet."

These accounts stand in stark contrast to the official figures: According to Denver Health, its paramedic unit has continually performed at or above city standards. Its current contract with the city requires Denver ambulances not to exceed a utilization rate of 0.5 transports an hour while responding at an average of 6 minutes, 10 seconds; of these trips, 85 percent must be below 8 minutes, 59 seconds.

To many rank-and-file medics and dispatchers, it doesn't make sense that the division can continue to meet these criteria every year without adding ambulances or hiring more paramedics - particularly since the number of calls the unit responds to annually has increased 21 percent over the past six years, from 64,511 in 2001 to 78,002 in 2007.

"We're sending a unit from St. Joseph's hospital down to Tamarac and Hampton for an unconscious party, which is inexcusable care," says Bob Petre, a 23-year veteran of the Denver paramedics. "But if you look at our response times, everything's fine."

A few months ago, Petre became president of the Denver paramedics' union, IAFF 3634, with hopes of reviving membership and pushing for serious reform of the city's EMS system. He'd sat on the task force that studied moving the paramedics under the fire department a dozen years ago, and continues to criticize that group's work as biased toward the hospital. In fact, he points out, when the issue came up for a vote before a council committee, Webb took the unusual step of attending. "If there is something I will take to the streets to fight, this is it," Webb had declared.

Then as now, Denver operated under what's known as a "two-tiered system," meaning that fire trucks show up first at Code 10, or life-threatening, scenes and provide basic EMT care until the paramedics arrive. Both responders are managed by separate agencies with their own distinct chains of command, resisting the trend over the past twenty years for major cities to shift to a "fire-based model," in which paramedics are folded into the fire department. New York, Chicago and Los Angeles all use a fire-based model, as do numerous local suburbs covered by the North Metro Fire and Rescue and the South Metro Fire and Rescue authorities, which have employees trained as both firefighters and paramedics. Each municipality establishes its own response time standard.

When gauging the quality of its ambulance service, a municipality compares its response times with those of similar-sized communities. The vast majority of major cities use the benchmark set by the National Fire Protection Agency, an industry group that says Advanced Life Support (ALS) responders should arrive in 8 minutes and 59 seconds or less 90 percent of the time - a more stringent target than the 85 percent called for in the city's contract with Denver Health. That contract is a two-inch-thick operating agreement that Denver Health signs with the Department of Environmental Health, establishing everything from city-sponsored, free pre-natal clinics to the Denver CARES drunk-tank service. Denver City Council must sign off on the agreement every year; the last contract was approved in November 2007.

A 1971 report clocked Denver's ambulance service as responding to scenes within 6 minutes 99 percent of the time. But as demand for the hospital's services increased, the standard was relaxed to 8 minutes or less 90 percent of the time. In a 1990 memo to city officials pleading that more ambulances be added to its fleet of seven, then-paramedic medical director Peter Pons noted that cities with similar population demographics have twice that number of ambulances available on a daily basis. "At present, the Paramedic Division meets this time criterion in only 81-82% of our responses," Pons wrote. "In addition, there are several areas of Denver (Montbello, Green Valley Ranch, and Bear Valley) where our average response is unacceptably long (twice the rest of the city)."

In 1996, when Denver General was being revamped as Denver Health, the standards were reconfigured again. The hospital agreed to gradually increase the percentage of "eight minutes or less" every year, from 83 percent in 1997 to 90 percent by 2000.

"At the time, I figured that the higher standards meant that the hospital would have to add more ambulances to meet the times," Petre says.

But he was wrong. The current number of Denver Health ALS ambulances is still approximately half the number of ambulances available in similar-sized cities. Cleveland, for example, has 28 ALS ambulances for 80,000 calls annually - about the same number of calls that Denver handles with thirty vehicles - but just fourteen of them staffed as ALS ambulances. As a result, paramedics say, the workload has become daunting and response times have suffered.

"It was pretty much known that if you wanted to be a paramedic, Denver was one of the premier places to work," remembers Mike Simon, who started as a Denver paramedic in 1983 and continues to work a couple of shifts a week when not at his full-time position at Littleton Fire and Rescue, a fire-based system. "When I started, on an average ten-hour shift there were fourteen to fifteen calls. We were a very small division, so they didn't hire very many. You either got really good or you washed out." But while he still likes his Denver job, he says many of the veteran paramedics have moved on to other cities whose systems provide better pay and more opportunities for advancement.

Though defined by the city as a "core service" with the same importance as police and firefighters, Denver paramedics do not get the benefits and job protection that come with being a civil servant. Under Denver Health, they are technically private employees. And as a quasi-private agency that must serve the public, the hospital is in a budget squeeze.

Denver Health receives close to $27 million a year from the city for various services ranging from medical care for county jail inmates to emergency ambulance services. But as the number of Denver residents who are uninsured and underinsured continues to rise, so has the financial burden the hospital must bear. The non-reimbursed costs that Denver Health had to absorb for caring for patients without coverage was $100 million in 1990; in 2006, it was more than $280 million. Denver Health is one of four Level 1 trauma centers in the metro area - but one of those centers, Children's Hospital, moved out of central Denver last year. So did University Hospital, putting an increased strain on Denver Health's emergency room.

Denver Health spent $1.6 million on its paramedic division in 2007 - after the division itself brought in $14 million in insurance money and transport fees. The division feels the effect of the tight budget. The hospital administration "has basically said, 'You have to do more with less,'" says Petre. "But because you have such a high volume of calls, you abuse your employees."

Petre openly admits that he wants to see paramedics get out from under Denver Health. But he insists that the move would mean as much to the people using the paramedics' services as to the paramedics themselves - by putting a stop to the ever-lengthening response times. The fire department has units strategically placed at 31 stations around the city, which allows a response time that, on average, is two to five minutes faster than that of paramedics. If the paramedics division became part of the fire department, Petre says, ambulances could arrive just as quickly.

After the last failed attempt to move the division, Petre gave up on the political part of the job. One reason, he says now, was that Denver Health's first contract with the city called for a gradual improvement in response time, but instead, the standards were lowered. The first change he noticed was in the 1999 contract, when the phrase "eight minutes or less" was reinterpreted by Denver Health to mean anything that wasn't nine minutes. This allowed the hospital to tack on an extra 59 seconds to the requirement, thereby boosting the percentage of calls that qualified as eight minutes. In 2000 - when Denver Health was supposed to be meeting a 90 percent standard for a response time of eight minutes or less - the hospital never even gave a figure to the city, saying that a newly installed Computer Aided Dispatch system no longer allowed it to "make calculations for response time compliance in the same manner." This problem apparently took three years to fix, because the same explanation was listed for not reporting the response-time percentage in 2001 and 2002.

According to its contract with the city, Denver Health was "working with the vendor" to resolve the problem in reporting times. But Tyler Riddell, spokesman for TriTech, the vendor that provided the system to the city, says his company was unaware of any problem. While he adds that it's possible that Denver Health worked with a third party to find a solution, he says he hasn't heard of any other city having similar difficulties with TriTech software for such a long duration.

Still, citing calculating difficulties, the hospital successfully lobbied to drop the response-time criteria for the 2003 contract to 85 percent, which it met with a compliance rate of 87.7 percent. "It remained at 85% in 2004, 2005 and 2006 due to the burdensome highway construction and traffic issues associated with T-Rex," Denver Health spokeswoman Dee Martinez writes, in explaining the lowered standard.

Even as he pores over sheets showing the hospital's reported ambulance response times growing over the past eleven years, Petre acknowledges that you can't rely on such measurements as the sole indicator of overall performance. For example, ambulances should not respond to a call for a broken wrist with the same urgency as one for a serious car crash. Lights, sirens and high speeds are warranted only in those life-threatening emergencies categorized as Code 10. Even so, he says, it's fair to expect emergency providers to meet the standards set for them.

"Just like doctors and nurses, [paramedics] undergo extensive training in order to provide advanced life support to patients," paramedics division chief Mike Nugent told Westword in 2006. "I think that the public has high expectations for the quality of services they are provided in this city."

But paramedics complain that Nugent has done nothing to meet those expectations since he became chief three years ago. In fact, last November he floated a proposal to reduce the number of certified paramedics that would be assigned to each ambulance. The division has long operated on a "dual paramedic" model, staffing its fourteen ALS ambulances with two highly trained paramedics. In 2006, it added six Basic Life Support ambulances operated by EMTs to handle less critical tasks, such as transfers between hospitals. Basic EMT certification calls for about 200 hours of training, while the base level of training for a working Denver paramedic is approximately 2,000 hours; in Denver, EMTs cannot give shots or provide medication. Now Nugent began advancing a plan that would switch the division to a "split-car" system - with one paramedic and one EMT.

The proposal was very unpopular with the street medics, who insist that having two certified paramedics respond to a scene is integral to maintaining high-quality care. Some paramedics even complained to their city council representatives, who began asking the hospital questions about the proposal. In early December, a Denver Health e-mail announced that Nugent would be resigning, but offered no explanation for his sudden departure. Hospital employees were even more baffled when they received another e-mail on December 13 from Denver Health CEO Gabow, who said that Nugent would stay on as chief paramedic. "We have seen many positive changes and improvements under Mike's leadership and saw his planned departure as a major loss," she wrote.

The day this announcement came out, a photo of a shocked face appeared in the paramedic division's break room, with these words written over it: "What!?! Nugent is staying!!" But Denver Health didn't find it a laughing matter, and longtime paramedics Greg Sawyer and Becky Sproul were ordered to undergo a lengthy handwriting analysis. At an April hearing, hospital administrators said that they'd determined that Sawyer had written the offending sentence.

The two paramedics had already been at odds with Denver Health over a private venture, a business they'd set up that since 2006 has contracted with the Colorado Convention Center to provide on-location EMS coverage during events. Sawyer's attorney, Dave Bruno, says this venture had the blessing of the paramedic division's medical director and that another division employee had confessed to the zombie posting. Still, on April 13, Denver Health informed Sawyer and Sproul that they'd been terminated. Because both Sawyer and Sproul had worked for the division before the hospital moved under Denver Health, they were among the few Denver paramedics still considered city employees - and they've appealed their firings to the Denver Civil Service Commission. A hearing is set for August.

For now, Nugent's split-car proposal has been put on hold, since "that does not seem to be an area that would be an advance in service," says Dr. Chris Colwell, medical director for the Denver paramedics as well as the fire department. "We have the obligation of putting everything on the table all the time to ensure that we're providing the best service."

But recently, EMT-basic ambulances - known around the division as "X-cars" - have been dispatched to scenes once reserved for dual-paramedic vehicles, for such emergency calls as broken legs and chest pains. "Some basic EMT - kids right out of high school, sometimes - is not going to have the savvy or feel for what's going on when they arrive at a scene," says one paramedic. "We can get wildly differing information from patients and bystanders. That's why it takes two sets of equally trained eyes to find out what's going on. There's lots to do and not much time to do it - and sometimes you can be wrong."

"The one call that continues to haunt me," says another paramedic, "was a guy in his late twenties, drug overdose and laying there flat on his back, vomiting into his mouth." When the call came late last year, this paramedic's ambulance was the only one in service and had to drive from south Aurora into Denver. "It took us seventeen minutes to get there," he continues. "I've got to tell you, I don't know if it would have changed anything if we were there in two or three minutes, but if someone would have cleared his airway in two or three minutes, he probably wouldn't have died."

Denver's 911 dispatch center - which is officially under the Denver Manager of Safety, who supervises the Denver Police Department, Denver Sheriff's Department and fire department - is located in a nondescript brick building next to a towering steel radio antenna near Congress Park. A large room on the second floor is filled with dozens of cubicles roughly organized into different groups representing dispatchers for the fire, police and paramedic units. When a call comes in, it's answered by a Denver 911 call-taker, who determines the nature of the situation and gets the name and confirmed address of the caller. Once this is accomplished, the call is forwarded to a dispatcher for the appropriate agency, who attempts to get specifics on the situation while responders are sent to the scene.

By far the most important measure of true response time is when the clock starts and when it stops. The city's contract with Denver Health stipulates that the clock starts "when the EMS dispatcher receives the call from the call-taker or from the Police or Fire Department" and stops when the ambulance arrives on the scene. James Azuero, who runs the paramedic dispatch at the 911 center, confirms that the clock starts "as soon as the 911 call-taker transfers the call to paramedic dispatch."

Last month, Colwell was asked by 7News reporter Tony Kovaleski when the clock starts and stops on response times. "When I go ask for response times, the response times I'm getting are from the time we get enough information to dispatch the call until the time we arrive," Colwell asserted.

But a series of inter-office memos on "Response Time Compliance" sent by Thomas Cribley, an EMS captain in the paramedic division, to hospital administrators - including Nugent, Colwell and Stephanie Thomas, Denver Health's chief operating officer - and members of the fire department tell a different story. Each memo begins by stating that since December 2004, "there has been little modification in the data analysis" and that the numbers within exclude calls that have "extended response times because of circumstances beyond the agency's control," such as adverse weather conditions or data entry mistakes. But the most notable phrase is the one that defines the "Agency Average" as "calculated from the time a unit is assigned until a unit actually arrives."

This is a key difference from the expectation laid out in the hospital's contract with the city, which states that response times should be clocked from when the call is received - not when an ambulance is finally sent.

One memo, dated May 8, 2007, details how often ambulances are reaching patients in under 8 minutes and 59 seconds during the four quarters of 2006. First quarter 87.79 percent; second quarter 87.45 percent; third quarter 87.48 percent and fourth quarter 86.6 percent, which would put the yearly average at roughly 87 percent, close to what Denver Health reported to the city - without revealing that its clock was starting later than required. And an August 2007 memo from Cribley calculates the average paramedic response time for the third quarter as 6 minutes, 10 seconds - the exact number the hospital reported to the city for the year, but without starting the clock at the exact time required.

The switch from starting the clock at "call received" to "unit assigned" is significant, because on days when there aren't enough ambulances on the street, dispatchers can spend several minutes searching for an available emergency vehicle before one is finally assigned to the call. On busy days, paramedics say, the scramble to find an ambulance can last ten or fifteen minutes.

A Denver Health spreadsheet detailing 1,100 ambulance calls from March 12 to May 12 of this year shows that response times are clearly calculated from the "Unit Dispatch Time" to the "At Scene Arrival Time," ignoring the "Call Recd Time" - which, if factored in, extends some response times to as much as 25 minutes. And one call actually took forty minutes.

A former dispatcher for the Denver paramedics remembers another call that came in late last year for a young boy with an arterial bleed from the neck that didn't give him a lot of time. "So I was trying to give instructions to control the bleeding, and obviously it wasn't being managed well by the folks that were there," she says. "There was no one to send. So time's just elapsing, and that red blinking light is in front of me. And I knew there was not only nobody to send, but nobody in the near future." From the time she took the call from 911, it took about fifteen minutes to find a vehicle. "An ambulance actually turns up in front of the house what seemed like 25 minutes later, but their response time they're reporting to the city could be still 8 minutes and 40 seconds because they couldn't find an ambulance to go. So when they finally scrape one up, that's the start time," she explains. "Which in my mind is criminally deceptive."

Although Cleveland has twice as many ALS ambulances handling the same number of calls as Denver, its reported response-time average in 2007 was 8 minutes, 3 seconds - and it reported meeting the 8:59-or-less standard 78 percent of the time. But according to Cleveland EMS commissioner Edward Eckart, his city not only starts the response-time clock when the call is received, but doesn't stop the clock until paramedics actually reach the patient rather than simply arrive in the ambulance. "I think that's the expectation that the citizens have," Eckart says. "When I pick up the phone and dial 911, I don't really care about all that stuff that's happening behind the scene. I just know I need help, and I need it right now. I think from a quality-assurance, performance-improvement perspective, you really have to look at all of those behind-the-scenes intervals."

If Denver Health calculated its response time from the moment call information is verified to the time an ambulance arrives at the scene, the average would be far different from the numbers the hospital reports. Using that criteria, in 2006 ambulances arrived in under 8 minutes and 59 seconds only 73 percent of the time. And in 2007, that percentage dropped to 67 percent - far below the acceptable standards required by the city contract.

When demand is low, paramedics usually meet the standard. But when demand is high - and the division is down to maybe six ambulances and two EMT cars to cover the entire city - the problem can become acute. "Sometimes it's not so bad, and sometimes it's horrendous," says a dispatcher, who adds that it's common knowledge that Denver Health has changed the time it starts the clock.

The dispatcher cites a recent call about a man in cardiac arrest at Denver International Airport. The hospital has paramedics at the airport, but they do not have ambulances to conduct transports - and the ambulance normally stationed at 48th Avenue and Chambers was already out on a call. "So we wound up calling for a private, but they got lost or whatever," says the dispatcher, and it took 48 minutes for an ambulance to arrive. By the time it did, the man was dead. "A lot of people were really pissed, and it was really difficult for the paramedics who were out there doing CPR on the guy for almost an hour," she adds.

Michael Hancock is still hoping that Denver Health authorizes an independent review of its paramedics division. In the meantime, the Denver Auditor's Office has started its study of both the fire department and paramedic division emergency performance; it hopes to conclude the review before the DNC arrives in August.

"We need to be able to attract the best, keep the best," says Petre. "We want to do what's right for the citizens and the peop


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