Administration and Leadership, Cardiac & Resuscitation, Patient Care, Trauma

EMS Moves Toward New Care Delivery Methods

Issue 7 and Volume 37.

For many outsiders, running an ambulance service can often appear to be an easy thing. Although EMS appears to be simple, it isn’t.

EMS’ first 30 years or so have been solely focused on proving to the medical community that it could perform tasks that, traditionally, only doctors could do. So few have stopped to ask the questions associated with how we should perform these tasks.

How EMS Provides Care
This is the same problem found in most of the healthcare industry today. The focus on providing the best medicine money can offer has generated exceptional clinical results for patients, but those results have tremendous costs with one of the most uncoordinated, stove-piped, expensive and inefficient healthcare delivery systems on the planet. The same often holds true for much of EMS.

The medicine we in EMS provide on a daily basis is the foundation of our existence (and the clinical outcomes from these efforts are widely unknown and/or debated), but the methodologies we employ to deliver this medicine to our patients drives 70–80% of our costs, based on the delivery model used.
We’re talking about the procedures, practices, schedules and deployment methodologies that are used by your EMS system to get your clinicians, medicine and equipment to the patient within some sort of “acceptable” time frame (i.e., response time).

The debate to define “acceptable” response times is finally coming to a head, with evidence-based research and customer satisfaction and expectations driving this definition; however, many EMS leaders are also pushing EMS delivery methods to the forefront because of the economic downturn and healthcare reform.

Prehospital medicine across the U.S. is, for the most part, standardized, but the system designs used to deliver these services are as diverse and variable as the species on our planet. System designs range from inefficient and ineffective, to highly efficient and effective with many variables, including wages and benefit costs, accountability, response-time reliability and measured clinical outcomes from these efforts, separating “the men from the boys.”

Some of the most efficient and effective EMS delivery systems today often provide better clinical outcomes and service reliabilities as their most expensive counterparts, proving that throwing money at a problem isn’t always the answer. 

Anecdotally, when you look at cardiac arrest return of spontaneous circulation (ROSC) rates across the country and then look at the system delivery models used to achieve these results, you either see static deployment models (station-based systems) or dynamic deployment models (i.e., high-performance EMS) as the common delivery mechanisms. (Hybrids containing methodologies from both genres also exist.) Both these service-delivery models can produce excellent cardiac arrest survival outcomes, but at what cost? 

Some have attempted to correlate survival rates with the number of active paramedics used in the system, but I find this absurd. (I know the e-mail inbox will be filled after this one with those who disagree with this statement.)

Response Times
Whether dispatch life support through pre-arrival instructions, first responder, BLS or ALS, the bottom line is the response times count … period. Response times ensure high-quality CPR is initiated. These factors are what the clinical research indicates we need to do to improve neurologically unimpaired walk-out-of-hospital survival rates. 

The importance of ALS is definitely heading toward the stabilization side of the equation, post ROSC, and not where we thought it made a difference, in the initial conversion into ROSC. Many would debate whether ROSC is the best way to measure an EMS system’s clinical effectiveness. I would strongly agree it needs to be greatly diversified; however, ROSC is all we currently have to examine for comparative purposes.

Cost of Success
Now let’s look at the costs to achieve these results. Statically deployed EMS systems are, by design, an expensive way to provide services, especially for urban and suburban population centers. Rural EMS systems are a different animal and aren’t included in this group. 

As EMS providers, we see these system designs as the means to earn money sleeping, but these designs are often ineffective clinical delivery models because of poor response-time reliability.
However, one thing is reasonably certain. Static deployment systems are the most inefficient and costly way for us to deliver EMS service. Clinically effective static deployment models exist, but they’re even more expensive to operate than their ineffective counterparts because these systems throw away tons of money or manpower to solve response-time problems.

Dynamic deployment systems on the other hand (those that match supply with demand—both temporally and geospatially), are frequently effective clinical delivery models because of superior response-time reliability, and they are the most cost-efficient means to achieve services, because they use the appropriate amount of resources to meet patient-care needs. 

These models are the most unpopular with EMS providers because productivity and efficiency are balanced with good clinical care, sacrificing down time. Sitting in the front of an ambulance and being placed on a street corner is not as comfortable as responding from a warm bed in a station’s bunk room, but it gets the medicine into a critically ill patient’s veins a lot quicker. 

So the proverbial EMS dichotomy—to station or not to station, is the question. The answer depends on the size of your region’s wallet, tolerance for change, politics and willingness to provide tax subsidies. Many urban and suburban dynamic deployment systems, with excellent clinical outcomes, have operated with little to no tax subsidies for decades.

Few (if any) static deployment models exist in urban or suburban regions with excellent clinical outcomes that, accounting for all costs, operate without some sort of subsidy (and usually a big one). This can be an eye-opening observation for elected officials and the public alike.

Resistance to Change
So because we know how to do it better, faster and cheaper, why doesn’t everyone pursue this? The answers lie in human nature, political pandering, an unwillingness to abandon “tradition” and the economy. 

Where do we go from here?

Although our industry will continue the eternal debate on EMS system design issues, a storm of unparalleled magnitude is brewing. This storm, also known as healthcare reform, will change our lives in EMS as we know it. 

Having an efficient and effective service delivery model is the foundation by which innovation, evidence-based clinical practice and the shift from treating a majority of our patients in the hospital to treating the majority of our patients in the prehospital realm will evolve. This change should be a metamorphosis by which EMS will springboard itself from being a rounding error in the federal CMS budget to becoming a significant contributor and provider to the U.S. healthcare system.

How to Change
How and why will this happen? It comes down to pure economics. Once reimbursements shift from a fee-for-service model into bundled and/or capitated payment models (whether it be from an accountable care organization or other capitated reimbursement methodology) that reward continuum of care coordination and service integration vs. the current model, which financially rewards uncoordinated and inefficient care based on the volume of patients we see, we’ll see a shift emerge in how medicine is produced. More importantly, the service delivery models used by this medicine, will change for the better. EMS can play a significant role.

My interpretation of this is that EMS will be at the forefront of this change because the prehospital realm is our oyster, and we know it well. When you break an EMS system into its component parts, you find four primary activities: public safety, public health, disaster preparedness, response and recovery, and healthcare. The proportions by which EMS performs these functions can be widely debated. 

The fact of the matter remains that for most EMS systems, reimbursement from healthcare-based insurance is the primary mechanism for funding and typically pays indirectly for non-healthcare related functions, such as public safety, public health and the various stages of disaster management.

I envision a day not too far from now when someone will call 9-1-1 and the dispatcher (a clinician) will work through a clinical-decision algorithm and help the patient determine the appropriate locus of care, which will become alternative methods of healthcare service delivery, including community based/expanded scope paramedics and self care, and not elicit the typical U.S. EMS response.

In several innovative EMS systems, paramedics are already visiting patients in their homes (in some cases, in tandem with a nurse, nurse practitioner or physician’s assistant) to perform diagnostic testing on site and come up with alternative treatment regimens that would include on-site treatment options, transportation to alternative (less expensive) modes of care (e.g., urgent care) or treatment and transportation to the emergency department for those patients who truly require it clinically.

Cutting edge, high-performance EMS systems are already blazing a path. EMS system design innovators are at the forefront of the revolution and evolution of our industry. They’re some of the ones taking the risks, creating something from nothing—many without additional reimbursement—to help carve the path most of us will eventually follow once the storm has passed … if we survive it. Those systems with the ability to embrace change will survive in the new normal. For the ones that don’t, I suggest you build a storm shelter and stock it well. JEMS

This article originally appeared in July 2012 JEMS as “Special Delivery: EMS industry shifting its methods of delivering care.”