When the city of Louisville and surrounding Jefferson County (Ky.) merged in 2003, Mayor Jerry Abramson launched a study to determine which type of EMS service would best serve the “new” city. The former city EMS system was operated by the Louisville Fire Department; the county’s EMS was a non-fire, stand-alone agency. Abramson decided the right model for Louisville was an independent, third-service agency to be led for the first time by an emergency physician, the first model of its kind in the country.
From the very first day of Louisville Metro EMS’ (LMEMS) existence, it was clear the primary goal was to create a data-driven, medically focused “best practices” service. During the past five years, however, LMEMS has made dramatic changes to the way prehospital emergency medical care is delivered.
Upgrading the System
At the outset, the city’s emergency medical response system was outdated. All runs were recorded by hand on paper forms; response times were calculated with unsynchronized stopwatches, and all EMS calls were recorded on index cards at a variety of different public safety answering points (PSAPs) across the community. Different EMS agencies served different areas, and no cohesive response plan was in place for fire first responders.
But with the support and guidance of LMEMS’ leadership, and from closely working with the leadership of the city’s 9-1-1 communications center, that outdated system has changed dramatically. Call takers now use an internationally recognized dispatch algorithm to assign the appropriate (and, notably, the closest) resource to emergency medical responses based on severity.
LMEMS is now the only integrated public safety agency that covers the entire community, regardless of jurisdictional boundaries. Because no system for tracking accountability data was in place, LMEMS built its own data collection system, monitoring numerous disciplines to evaluate performance, including hospital turn-around times, response times by time of day and location, call type, revenue collection and payer mix.
LMEMS also implemented the latest in EMS technology to optimize its current resources, especially because the service spent many of its formative years in a difficult budgetary climate.
These improvements included adding automatic vehicle locator/global positioning systems (GPS) in each vehicle, allowing dispatchers to see all available resources in real time, using resource-allocation software for improved coverage in the community and adding in-vehicle mobile data terminals for transmitting critical-response information. The service also moved to a seamless, computerized patient data and billing system, which led to a 47% revenue increase during the past five years.
Over the past few years, LMEMS has also introduced new treatments and technologies from the forefront of the prehospital-care field, such as a ST-elevation myocardial infarction (STEMI) program, in conjunction with several local hospitals.
This program allows LMEMS paramedics to wirelessly transmit patient ECGs from the field directly to the hospital emergency department (ED), thus dramatically decreasing the time it takes to transport patients suffering from this type of heart attack to a catheterization lab.
However, the latest LMEMS accomplishment may be its most innovative yet: the establishment of the Priority Solutions Integrated Access Management (PSIAM) low-acuity call triage program.
Technology has been a key ingredient in this progressive organizational change. Implementing new technology in an organization is difficult enough; however, overseeing a significant number of projects in an organization that often runs like an emergency medical room is a challenge. One of the most difficult challenges has been changing the culture. EMS is an organization that works on emergencies all day, every day. In the past, personnel rather than professional managers typically implemented new projects.
Patient care is always the top priority for LMEMS; however, completing project tasks and maintaining schedules is also important. To accomplish this, it’s essential to have an EMS provider with the proper level of expertise on the project team to design a solution that would be valuable to the agency. Traditionally, though, EMS struggled to find enough providers to staff operations because of how difficult it was to remove them from their day-to-day roles to work on a project. As a result, resources that were committed to completing tasks sometimes mysteriously disappeared, which affected the project schedule and momentum.
To solve this problem, Louisville EMS took the unique and strategic step of a hiring a full-time project manager, something that enabled it to accomplish and integrate a series of complex and sophisticated technology implementations over a very short period of time.
But, although the command staff expected the project manager to run with each project, it was also critically important to be able to hand over the “go button” once implementation was complete. That, in turn, required a great deal of education and preparation prior to each project launch.
EMS had been accustomed to filling out paperwork and running a single-threaded administrative operation. Multiple departments were planning to use integrated technology, so LMEMS had to carefully plan changes. EMS didn’t have any technology to speak of until it implemented the RescueNet tablet and billing software.
RescueNet changed the entire paper-based run sheet system from manual to electronic. LMEMS not only had to train each department on RescueNet, but it also needed a subject-matter expert who understood how operation changes to software could affect other workflow processes downstream, such as quality assurance (QA) and billing.
Developing an efficient communications system was also difficult because no electronic means of sharing information to 256 crew members existed. Because of the absence of available vehicles to quickly and accurately communicate to crews, micromanaging came into play. Managing by “walking around” was necessary and helped ensure everyone was promptly informed and that potentially destructive rumors weren’t spread.
To add to the challenges, the bulk of the projects were launched during the recession, which meant more resource constraints than usual. Thus, the project team had to get creative. Schedule slippage was common due to the lack of resources, because the key goal during this time shifted from quick implementation to quality and cost. Therefore, it required extra vigilance in monitoring and acting on resource constraints.
The next difficult factor involved change control. Because the EMS system didn’t previously have the new technology, it wasn’t accustomed to running configuration change requests for the tablet through change control. The change process involved detailed planning and testing prior to going live, meaning LMEMS needed to shift to a different mind-set and take the time that was necessary to create a thorough test plan that considered all possible ramifications.
Once a new technology is successfully implemented, the key to success becomes sustainability. For example, many applications required a resource from EMS providers who understood operations and had enough technical savvy to make changes when protocols were modified. For example, because all levels of EMS crews were required to work in the field, identifying one person to support the new applications without incurring overtime was difficult. The solution: training several people and deciding to support the applications only during regular business hours. That way, more staff was available to make changes and resolve issues during those allocated hours. A backup plan was created for handling issues during off hours.
As a result of these new technologies, LMEMS has made departments more efficient, provided close-to-real-time reporting, increased revenue while decreasing costs and provided improved patient care services to the community.
The following are projects that have been implemented at LMEMS over the past several years.
EMS outfitted all their ambulances with electronic patient charts. These are portable computers that look like a tablet with a wide screen. Providers can fill in patient symptoms, vital signs or injuries, such as pulse rate and location of pain, and wirelessly send that information to the hospital. The hospital has a printer in the ED that receives the transmission and can prepare for that patient before they arrive. It’s
like an e-mail designed specifically for health charts.
The system has several benefits: It gives hospitals time to prepare for patients in advance; it provides a real-time, accurate record of patient injuries and symptoms; it enables medical direction and oversight to ensure a high quality of patient care with almost real-time chart review in the field, and it allows for better record-keeping for insurance reimbursements, potentially increasing EMS revenues.
The billing department was flooded with paper run sheets like any manually intensive office. Supervisors and others who requested run sheets sometimes had to wait weeks for critical information because of the difficulty of organizing thousands of pieces of paper. Also, patient information from run sheets was often difficult to read because they were hand written.
The billing department was typically backlogged 30–40 days, and many run sheets were never billed because of the sheer volume. Many aspects of this system improved with the implementation of the billing software package and changes to processes.
Ongoing communications to operations decreased data errors on run sheets, decreased the 45-day backlog to 10 days, increased revenue collection by 20%, and reduced the number of missing run sheets from an average of 22 per day to one per day. Supervisors also began receiving daily reports on each billing clerk’s productivity, which identified some erroneous data on run sheets (see Figure 2).
The FirstWatch system went live April 2010. It’s a real-time surveillance system involving live analysis of data to identify patterns and trends as they emerge, rather than waiting days or weeks for conventional detection methods. Early detection allows EMS to take action, saving lives and protecting property.
FirstWatch is a mobile app that can be configured to a number of different platforms that automatically send alerts to EMS personnel via e-mail or smartphone. Alerts contain summary reports, charts, graphs, maps and other important or mission-critical information. This system sends alerts to personnel with near real-time data to determine the nature and significance of an occurrence, which helps in taking appropriate steps to warn and protect the public (as well as first responders).
Benefits include the following:
>> Aggregates data for “big picture” view across city boundaries;
>> Automatically notifies responders about individual calls, such as “delayed hospital drop times,” “late runs” or “influenza type illness;” and
>> Provides authorized users the ability to analyze data in near real-time for operational and key performance indicators, measuring turn-out/chute-time, response-times, time-on-scene, hospital drop times and total task time performance.
The Louisville STEMI system was designed using specialized technology. LMEMS crews are using mobile ECGs to diagnose STEMIs in the field and then wirelessly transmit the ECG to the nearest hospital equipped to perform emergency percutaneous coronary intervention. While the ambulance is en route, the hospital’s cardiac team prepares for immediate treatment in the cardiac catheterization lab.
“The national standard for emergency room arrival to surgery for a STEMI heart attack is 90 minutes, and mortality rates rise every 15 minutes after that,” said Abramson at a May 2009 press conference. “Even faster is better, so by diagnosing heart attacks in the field and immediately notifying the closest hospital team on standby, we can significantly compress the time between the initial 9-1-1 call and treatment—that means lives saved and heart muscle preserved.”
The time clock system for EMS went live August 2009 without any significant issues. Payrolls have been completed, and every case went well. This system allows EMS to eliminate the paper-based timekeeping and provides operations and finance with the electronic means to ensure the collection and validation of overtime hours.
Automatic vehicle location (AVL) GPS went live May 2009 and was rolled out to the media on June 4. This technology provides LMEMS with the capability to track resources in real time and then select the closest available unit. Crews report that the technology has made their job more efficient by not having to estimate a unit’s location. They also express that it’s easier to re-locate units knowing their exact locations. The LMEMS field crews point out that the technology has helped unit assignment to the call, and fewer resources are crossed when calls for service come in or units are moved for coverage purposes (see Figures 3 and 4).
In April 2010, LMEMS implemented the Deccan LiveMUM software program, which assists MetroSafe Communications personnel in managing resource allocation. The software connects with the computer-aided software (CAD) in real time, identifies gaps in coverage and recommends resource moves to provide optimal coverage.
With LiveMUM, dispatchers don’t have to depend on static move-up charts, pre-planned move-up plans or field personnel whose expertise might not be as accurate or dependable as needed (see Figure 5).
After more than a year of planning, LMEMS officially launched its new alternative call triage pilot program April 2010. The new patient-care initiative, PSIAM, identifies non-emergent 9-1-1 calls and redirects them to alternative sources of medical care.
The project’s goal is to match patients with an appropriate level of care depending on their medical needs, while also eliminating ED visits and ambulance transports. Implementation of this program has involved numerous partners from the medical community. The PSIAM project has already been featured in USA Today and in various newspapers across the country.
The goal of this project is not only to ensure that patients receive the most appropriate care for their medical concerns, but also to ensure 9-1-1 and hospital emergency medical resources are available for those patients with the most critical medical needs—while also lowering the cost burden on the local health system.
When a patient calls 9-1-1, MetroSafe 9-1-1 call takers enter that patient’s medical information into a widely used triage software system. That system analyzes the caller’s information and suggests the type of resource necessary to respond. However, once PSIAM was launched, patients whose medical issues fall into a small group of non-emergent injuries or illnesses also go through a more in-depth patient triage algorithm operated by trained nurses. This process may result in referral to a primary care provider or immediate care center for additional treatment.
At this time, the PSIAM system is operating during business hours only. At all other times, these non-emergent 9-1-1 calls are continuing to be dispatched to an ambulance as usual.
LMEMS rolled out iMobile May 2010. This technology has allowed LMEMS crews to receive critical run information (e.g., patient information or details about other agencies on scene or routing to a scene), which dispatch enters on computer tablets in their vehicles. In addition to this information, iMobile has benefitted crews in the following ways:
>> Providing directions to a scene (routing recommendations);
>> Allowing providers to receive sensitive information via iMobile rather than over the radio; and
>> Sharing pertinent information about specific runs across agencies.
AmbuTrak Inventory Management software was implemented April 2010. This centrally managed software reports on the movement of medical supplies within an organization. The improved inventory control system assists operational efficiencies, controls inventory expenditures, reduces inventory and vehicle costs and eventually lowers ordering costs.
Since the program’s implementation, AmbuTrak has reduced about 4.5 hours in daily labor costs. It has helped better identify the needs of the service and track where resources are going on a daily basis. (See Figure 7)
Technology is never a substitute for patient care or for training and education, and it doesn’t provide you with operational resources that you don’t already have.
It does, however, enable you to optimize your resources, and it provides a powerful tool for medical direction and oversight in the field. Thus, innovation through technology, training or quality assurance shouldn’t be an afterthought that comes after your work is done, but rather it should be what helps ensure the work gets done well. JEMS
This article originally appeared in July 2011 JEMS as “Innovative Implementations: Louisville Metro EMS harnesses the power of technology.”