Last year marked the 40th anniversary of the historic emergency services report America Burning. The document, written in 1973 by the National Commission of Fire Prevention and Control, was intended to tackle the problem of fire in the United States and help guide the future of the fire service.
In addition to forging the direction for public education, community awareness and fire training activities, the report makes some significant statements relevant to the role of the modern fire service in the provision of emergency medical care. The report asked, “How should firefighters be scheduled and deployed to ensure the effectiveness and efficiency in fire department operations?”
The authors of the 40-year-old report understood the need for a dynamic fire service that was able to meet the needs of the community; however, they also realized that adding resources in an uncoordinated manner wasn’t an option for communities facing a limited budget. The authors also specifically provided an opinion about the provision of EMS by a community’s fire department. The topic of fire service “emergency ambulance or paramedical services” is introduced as an activity that “meets the criterion of utilizing firefighters’ special capabilities” along with public education and fire prevention tasks.
These ideas still ring true today and should serve as a reminder to fire service agencies that change is necessary, especially as we face a sluggish economy and shortfalls in municipal budgets while at the same time struggling to keep pace with the fast-evolving changes required by the Affordability Care Act (ACA), increasing call volume and reduced funding that won’t allow agencies to increase their manpower.
The real revelation inside America Burning’s discussion of EMS is the criticism of uncoordinated EMS activities that were delivered with full-size fire apparatus. The commission calls the practice of responding to medical calls with full-size apparatus, “an expensive and inappropriate use of equipment” and also identifies that the new venture of paramedical services is a challenge because the fire service “is compiling a poor record of response to non-fire emergencies because they have an inadequate communication and deployment system.”1
Soon after the birth of fire service EMS, it was recognized there were going to be adaptive challenges associated with the industry’s EMS deployment and response model. Forty years later, the EMS deployment issues identified by the authors of America Burning still remain a challenge. A few organizations embraced the challenge and introduced new and unique response models for EMS delivery. One deployment concept that appears to be regaining significant traction as an option for the fire service to meet both a decrease in budget and an increase in the demand for organizational efficiency is the transition from full-size fire apparatus to smaller rapid-response vehicles (RRVs). Some departments have used this concept for years to deploy ALS personnel to the scene of a medical emergency and work in conjunction with other apparatus on fire suppression incidents.
Recently, a trend among some government and industry consultant groups has been the suggestion that departments embrace new approaches to the deployment of their EMS resources though peak demand staffing, changes to apparatus and a reduction in overall staff.
Additionally, and possibly more importantly, the need to demonstrate patient outcome data that supports operations and the implementation of evidence-based medical practice for all aspects of prehospital care has the medical community asking if we’re using our prehospital providers in the best manner.
These questions become even more important as the fire service industry evaluates the impact of the ACA and seeks to find its way in exploring, adopting and implementing programs, such as the increasingly popular move into the realm of community practice paramedic deployment.
Changing the staffing of the fire service isn’t without its opponents and challenges; however, an effective program that strives to deliver both a clinical and operational improvement may be the key to the survival of many departments.
The Emergency! Model
As the evolution of fire ALS deployment progresses and more departments consider the move to a smaller vehicle, one notable ALS deployment model is that of the Los Angeles County Fire Department (LACoFD).
LACoFD began providing rescue services in the late 1950s with the use of panel vans that carried firefighters to the scene of motor vehicle accidents and other requests for non-fire suppression services. This model of prehospital care delivery was retained as the LACoFD became one of the nation’s first fire ALS providers in the early 1970s.
Today, the department still delivers ALS care by way of quick-response squad trucks, strikingly similar to the famous Squad 51 on the historic TV show Emergency!, staffed with firefighter paramedic personnel. According to LACoFD Deputy Chief Mike Metro, the primary benefit of this ALS model is that the department can ensure a better utilization of its resources while maintaining a cost-effective response configuration. If an LACoFD squad arrives, the paramedic can determine if ALS care is required and then either accompany a contracted ambulance transport provider or return to service for another response.2
LACoFD data on the model’s deployment reports 38% of the ALS squad responses require ALS care by fire paramedic personnel. As a result, the department is able to provide the appropriate level of needed care through the use of 64 ALS units. In contrast, if full fire-based transport was provided, it would require close to 200 ambulance units and a significant investment in financial, personnel and organizational resources.
Downsizing or Rightsizing?
In 2010, a report by the International City Managers Association (ICMA) made the following statement about the role of the fire service in EMS: “The fire service’s role as a medical first responder is rarely challenged. What is often debated is the expense of getting the right resources to the right place in the right amount of time.”3
The “right resource, right place and right time” paradigm has become the key concept for the deployment of fire EMS first-response resources. Embracing a clinical, financial and operational theme, changing and “rightsizing” EMS resources appears to be the answer to many of the challenges faced by departments today.
The ICMA appears to have become the organization of choice for municipalities seeking solutions when they find themselves at the crossroads of financial loss and increased demand for service. The agency has generated a significant number of in-depth studies and reports in the past few years and, as a result, many fire departments across the nation have experienced a review of fire and EMS operations by the ICMA.
In August 2012, the city of Grand Rapids, Mich., received a report that highlighted the recent trend of department rightsizing. The ICMA made 22 recommendations to Grand Rapids municipal leaders that included a variety of changes to the fire department’s EMS response. One of the first recommendations was to eliminate five full-size fire department apparatus and replace them with smaller, more cost effective RRVs. The anticipated result was an estimated savings of $2.1 million.4
The reality, however, is that this recommendation cuts at the core mission of the fire service and, in total, would result in the reduction of 59 department positions for a total savings of more than $6 million.
The results of recommendations from reports such as this have echoed across the nation and have been polarizing the discussion between labor and management in some municipalities about what’s best for a community’s fire EMS response. The issue of whether a department should face downsizing or institute rightsizing through the use of a smaller response vehicles and an updated deployment plan may not be the choice of its members—the impetus for change may be initiated by an organization hired to streamline operations and reduce costs versus through a collaborative improvement process within the department. As a result, fire personnel may see the deployment of RRVs as an attempt to cut overall staffing and argue that these changes threaten the public’s and responder’s safety.
The Tualatin Valley Fire and Rescue (TVF&R) near Portland, Ore., was one of the early adopters of a fire/ALS deployment model using smaller vehicles. The department initiated its Car program in 2010 in an effort to respond to the increasing demand for EMS in a more efficient and effective manner. With a reported 80% EMS workload, the department searched for a way to effectively respond to lower-priority requests for service and still maintain readiness for major emergency incidents.
Instead of deploying a four-person staffed $400,000 full-size apparatus, the department purchased a $31,000 Toyota FJ Cruiser and staffed it with a single fire paramedic to handle calls such as minor traffic accidents, community service requests and lower-priority medical emergencies.5 Moving into its third year of service, TVF&R continues to find this deployment model, developed in a cooperative manner by labor and management, as an effective and cost-efficient way to deliver ALS.
The Tulsa Story
In August of 2008, the Tulsa Fire Department (TFD) initiated an ALS squad program in an effort to improve the rapidly growing demand for EMS response. The program featured the addition of two RRVs staffed with two multi-role fire/ALS personnel deployed where the EMS call volume was straining fire-suppression resources.
Unfortunately, the economy in the Tulsa metropolitan area failed to support the general fund revenue required to add additional squads, and the city’s administration began discussing the layoff of 147 firefighters. However, with careful planning and implementation plans, the department was able to save the positions through a variety of actions that included a freeze in hiring and reduction in staffing.
As a part of the planning process, the department reviewed the ALS squad program and found that an increase in fire/ALS squad-use across the city could not only save the department’s paramedic staffing and EMS response, but also help keep fire personnel on the job. Today, the TFD responds to EMS requests for service in the smaller squad vehicles from five of its 30 stations. (See below.)
These are just two examples of departments that have had success with using an RRV for the deployment of ALS providers. Many other departments have also recently made the move to smaller vehicles, including Spokane, Wash.; Fort Worth, Texas; and Memphis, Tenn., all of which have made a move to downsize their EMS delivery vehicle in the past few years.
It’s important to note, however, that the transition to a smaller vehicle is not only about a cost savings or reduction in the required staff. Another critical component to making a successful move is the integration of communications and the development of a coordinated response plan.
Elements for a Successful Evolution
The maintenance of an effective fire/ALS deployment model or the development of a new program to enhance the mission of the department both require several key elements to ensure success. The single most important factor in making a quick-response program work is a progressive communications center utilizing a clinically sophisticated call processing method.
If we return to the “right resource, right place and right time” concept outlined earlier, it can be a challenge to warrant the established performance indicators are achieved and the results of a response change is effective. The use of the Medical Priority Dispatch System (MPDS) has become the industry standard for determining the level and manner of response. By utilizing a system of determinants based on the emergency caller’s information, the MPDS process can provide a dispatcher with the response assignment required for the particular situation.
The founder of MPDS, Jeff Clawson, MD, explains the total response process: “Dispatch determinants do not merely indicate the severity of a situation. Rather, they define how many responders will go, which levels of expertise are needed (when there are multiple tiers), and how rapidly they should arrive.” The result is a measureable response that ensures a deployment that is accurate, effective, and eliminates waste through over-response.6
Another significant component of a successfully evolved fire/ALS deployment model is data collection. Closely related to the MPDS component, the need for effective data collection and evaluation is essential for department and municipal leaders to evaluate the impact of their ALS program. The collection of data is often a significant hurdle for departments. In order to make adjustments to deployment, vehicles or response locations, a department must consolidate its data sources and establish operationally and clinically effective measurement criterion.
Finally, one of the most important elements of a successful fire/ALS response model is collaboration. As the topic of apparatus downsizing continues to expand and departments move to address the challenges of maintaining services while reducing budgets, there’s a stronger need to involve the department’s leadership, membership, labor and medical direction to ensure success.
In Tulsa, early planning meetings involved the ambulance transport provider and discussions related to the location for the deployment of the new quick response squad apparatus were held to make sure the best ALS level coverage could be provided when system demand was at its peak. Most importantly, any change in the deployment of EMS resources must involve the system’s medical direction. Failure to adequately evaluate the clinical impact of a response change could result in a detrimental impact to patient survival.
The key to success is that the discussions about response start early, involve all stakeholders and are based on an ongoing review of response data.
The insightful authors of America Burning recognized fire services would require a review of service delivery, deployment models and operational finance if they were to be successful in the future. Forty years ago, the commission, appointed by then-President Richard Nixon, realized the response of a fully staffed fire suppression apparatus may not be the best way to handle every situation the modern fire service would face. To the surprise of some, the commission also recognized the value in the fire service delivery of paramedic services to the community and insisted on the proliferation of prevention and education programs. While some departments adopted the operational components of ALS response, many have failed to properly address the deployment, prevention and public education components.
Embracing new forms of service delivery has been a challenge for some departments and many more are being forced to recognize the reality of dwindling budgets and changes driven by outside consultants. The modern fire service is now expected to be adaptable to changing its business practices by embracing an evolution in the response to the majority of service requests.
As we move toward a change in the nation’s healthcare delivery system that will be based on accountability and clinical outcome, the department that can adapt to the new normal will be the most successful in setting its own path.
1. National Commission on Fire Prevention and Control. America burning. U.S. Government Printing Office: Washington, D.C., pp. 18, 37–39, 1973.
2. Metro M. (2013.) Personal communication.
3. Fitch JJ, Rangone MG, Griffiths K. Making smart choices about fire and emergency medical services in a difficult economy. InFocus. 2010;42(5):1–22.
4. International City/County Management Association (ICMA) Center for Public Safety Management. Final report, fire operations, city of Grand Rapids, Michigan. ICMA: Washington, D.C., p. 14, 2012.
5. Mortenson E. (May 14, 2010.) Tualatin Valley Fire & Rescue is tailoring its emergency responses to what’s needed, and that may mean a medic car instead of a big red truck. The Oregonian. Retrieved Dec. 11, 2013, from www.oregonlive.com/environment/index.ssf/2010/05/post_12.html.
6. Clawson JJ. Emergency medical dispatch and prioritizing response. In Cone DC, (Ed.), Medical oversight of EMS. Kendall Hunt: Dubuque, Iowa, pp. 554–589, 2009.
The Tulsa Integrated ALS Rapid-Response Vehicles
The Tulsa Fire Department (TFD) currently deploys five ALS squads, three of which are equipped with compressed air foam systems (CAFS). Each squad is equipped with ALS and fire equipment designed to allow the crew of two dual-role, cross-trained firefighter/paramedics to respond to EMS or fire calls. All TFD squad units are stationed alongside a quint ladder/engine combination apparatus. Depending on the EMS call type, these crews may respond together or as a single resource.
Each squad carries:
- ALS EMS equipment
- Cardiac monitor/defibrillator with data transmission capability
- Secure controlled substance locker with climate control
- Two SCBAs
- Turnout gear
- Portable fire extinguishers
- Forcible entry tools
- Stryker stair chair
- Little Giant folding ladder system
At the scene of an EMS call that requires ALS service, a TFD paramedic often accompanies the patient in the transport ambulance, which is also ALS staffed, to the receiving hospital. The squad accompanies the ambulance as well. The first response engine or quint can then be returned to service and isn’t tied up retrieving the paramedic from the hospital.
At fire scenes, the crew of an ALS squad can be deployed as combat fire personnel the same as if they arrived on scene on an engine or ladder. However, if immediate ALS care is required for building occupants or firefighters, the ALS squad crew will deliver ALS care. Additionally, the squad’s unique CAFS capabilities add a valuable resource on major suppression incidents and are often used extensively in overhaul operations.