Patient Care

AMR Leverages Its Size While Remaining ‘Local’

American Medical Response has taken new measures to support its claim to have “the strength of a national company operated locally by your neighbors.” Since its creation from the merger of four ambulance companies in 1992, AMR has purchased and consolidated dozens of smaller ambulance companies and expanded its services to become the nation’s largest ambulance provider, with some 18,500 employees working in more than 250 locations in 40 states plus the District of Columbia.

AMR’s red, white and blue ambulances have become ubiquitous from coast-to-coast (and in Hawaii), but the company has not instituted nationwide clinical protocols nor required its local operations to deliver clinical services in the same way in every community to meet local needs. However, the company recently formed three national councils or teams to help guide clinical policy and equipment decisions. AMR has also started using its huge database of patient care reports for cutting-edge research that should benefit all ambulance services and EMS systems.

“Although we’re clearly the largest single player and have a great opportunity to gather data and use economies of scale, we always seek a balance between centralized programs and policies and the need for local delivery,” said AMR Executive Vice President Mark Bruning, who heads the company’s ambulance operations. (AMR also owns EmCare, an emergency physician practice-management group.) Bruning began his career as an EMT in 1983 and was a long-time paramedic in Colorado Springs, Colo.

National teams
Within the past 18 months or so, AMR has established a Medical Directors’ Leadership Group, a Clinical Leadership Council and a National Equipment Evaluation Team, all of which include representatives from the seven AMR divisions plus relevant national AMR leaders. Jim Cusick, MD, FACEP, AMR’s national medical director, leads the MDLG, and Scott Bourn, AMR’s national director of clinical programs, leads the CLC and NEET.

AMR has almost 100 medical directors, but only one from each of its seven divisions sits on the MDLG, which meets monthly via teleconference and face to face twice a year. “I also meet with the MDLG,” Bruning said, “and it seems to have coalesced to come up with innovative ideas and share best practices.”

One or two clinical or educational leaders from each division sit on the CLC, which meets twice monthly by telephone and in person once or twice a year. “We’ve decided top-down clinical protocols don’t make sense, but leadership from the top does make sense,” Bourn said. For example, the CLC is currently working on some national airway management standards and guidelines. “We’ve had lots of discussion about the safest and best way to handle patient airways and are looking at the [medical] literature and at our data,” he said. “We’re also working closely with the NEET team, which has leadership from all divisions.”

The NEET, which includes representatives from risk management and AMR’s clinical purchasing departments, evaluates equipment and makes recommendations on what to purchase. “For example, when three big [intraosseous infusion device] manufacturers came up with a better mousetrap, we pulled clinical data to see if we had a need for this,” Bourn said. “When we looked at IV success rates, we found success rates dropped for the sickest patients, who need IVs the most. So the team looked at the three products, met with the vendors and did some product trials. Then the NEET and CLC met with the MDLG and made recommendations.”

Bruning said, “You really must get buy-in from the local medical director and local medical communityƒnot come in and say, ‘There’s a national initiative and you must comply with what a national committee decided.’ That would be counter-productive.” Instead, he said, “We educate people and allow them to make decisions on a local basis.”

Bourn added, “We can make recommendations and get bulk pricing, but we don’t purchase the equipment and send it to all the operations. We don’t want to force anything into our local operations, but we’ve found many communities want us to provide leadership. For example, we made our report on IO available and that was used to advise local operations as well as local authorities.”

The NEET also evaluated three CPAP (continuous positive airway pressure) devices, Bourn said. “We ran trials in five sites to find which the paramedics found easiest to work with and what worked best for the patients, and came up with two recommendations.” He noted that two CPAP manufacturers actually modified their devices during the tests based on AMR feedback.

Bruning noted that the NEET has also arranged some “product vendor fairs” at which AMR people could look at competing products (e.g., CPAPs and ventilators) and discuss them with manufacturer„representatives.„

Because of its size, AMR has been able to amass a wealth of data, with some 6.5 million patient care records in the database as of June, according to Bourn. (See “AMR Offers to Share Data on Millions of Ambulance Runs,” March 2007 EMS Insider.) The company is now using that data on several research projects, including work with a consortium of EMS researchers to study how training and testing affect performance. (Watch for more on that consortium in an upcoming EMS Insider.)

Perhaps the most exciting research is an attempt to determine the effect of EMS interventions on patient conditions by evaluating the acuity of patients before and after prehospital care.

“I’m tired of us measuring success in EMS based on whether someone followed protocols, because we really don’t know, for example, whether there’s a relationship between the EMT’s ability to start an IV and the patient’s ability to get better,” Bourn said. “We wanted to determine how we can actually measure the impact of our care on the patients instead of measuring paramedic behaviors.

“We were looking for a tool that would identify how sick a patient was so we could identify therapies that work well for very sick patientsƒor perhaps wouldn’t work for very sick patients, but would work for patients who aren’t so sickƒand to look at therapies that improve outcomes,” he said.

Bourn believes AMR has found a scientific method to measure patient acuity, and the company is now working on two retrospective studies with Harvard University researchers: one “to ensure the validity of the AMR data and the second to apply the acuity measure to the data and ensure it’s an accurate measure of the patient’s acuity.”

Bruning said, “The CLC is taking the lead on this, working closely aligned with the medical directors.” He predicted the studies could yield some results by early 2009.

AMR is also doing preliminary work to develop an adverse-event reporting process. “One academic institution finds this notion interesting and may work with us on this,” Bruning said.

According to Bruning, “an upside” of AMR’s size is that “we can gather data so much more rapidly and completely.” But that means, he added, “that we have a responsibility to gather that data and do something with it and report our findingsƒgood or badƒso everyoneƒespecially patientsƒcan benefit from that data, not just AMR.”

AMR’s size also allowed it to bid on and win the federal contract to deliver ambulances in response to a national emergency and to provide many of the units that are required when that contract is activated.

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