Application of evidence-based practice is making a difference in the 200 largest cities in the United States. A November 2013 study commission by the U.S. Conference of Mayors shows that a third of the metropolitan areas will record flat or negative economic growth.1 Only 2% of the metros will record an annual growth exceeding 2% in real gross metropolitan product.2 Despite this struggling economy, however, EMS agencies in the most-populous U.S. cities are continuing to improve patient care.
About the Data
The leaders of the first-responder and transport agencies (n=512) serving the 200 most populous cities in the U.S. were invited to participate in the 2013 JEMS 200 City Survey via email. Conducted online, the survey included 75 questions. Many questions asked for multiple pieces of data. The completed survey response rate was 14.8% (n=76). Some of the 17 incomplete surveys provided many—but not all—answers, and were included in the data when appropriate. Table 1 provides the details.
This year’s respondents to the JEMS 200 City Survey included more participation from the 15 largest cities. This may affect some of the results. For example, only 36.9% of first responders provided paramedic service (31 out of 84). Previous surveys showed as many as half of the first responders providing paramedic service.
The survey covered a variety of EMS topics: dispatch, first response, transport, medical direction, performance measurement, effect of the economy and system funding. Much of the information shared isn’t publicly accessible and, in many cases, is proprietary. Every effort has been made to protect the privacy of the respondents. All data is discussed in aggregate and doesn’t indicate individual cities or EMS organizations.
Although accuracy is a key aim, this isn’t a scientific report, and the findings and conclusions haven’t been peer-reviewed. The results are dependent on the quality of the data received, as is the case with all research projects. All completed surveys were included in the data analysis. In many instances, data weren’t available or relevant for all respondents and a smaller sampling is indicated. Some questions also asked respondents to “check all that apply,” and as a result, the responses totaled greater than 100%.
1. The United States Conference of Mayors (November 2013.) U.S. metro economies: Outlook—gross metropolitan product, with metro employment projections. IHS Global Insight. Retrieved Dec. 4, 2013, from www.usmayors.org/metroeconomies/2013/ 201311-report.pdf.
2. Maciag M. (Nov. 19, 2013.) Gross metropolitan product slows in 2013, report finds. Governing. Retrieved Dec. 4, 2013, from www.governing.com/news/headlines/gross-metropolitan-product-slowdown-for-2013-2014-projections.html.
Of the 66 agencies that stated they took specific action in response to a decreased budget:
- 47% reduced staffing
- 43.9% halted travel and non-certification training
- 42.4% maintained a hiring freeze
- 25.8 % suspended activities that weren’t mission critical
- 15.2% laid off employees
- 7.6% postponed contract negotiations
- 84.5% of this year’s respondents follow an emergency medical dispatch (EMD) protocol (71 out of 84). This is very different from last year, where just 22.7% of the respondents used EMD.
- Physician participation in field operations is present in 60.5% of the respondents (46 out of 76).
- Departments are continuing to move away from sending a first responder to every EMS event. Only 36.5% of first responder agencies handled every EMS event (38 out of 104). In 2020, it was almost 50%.
- 91.7% of responding ALS services use ROSC at the ED from cardiac arrest as an indicator of good system performance (55 of 60)
- 85% used identification of ST segment elevation myocardial infarction (STEMI)
- 73.3% used intubation success
- 76.7% used severe trauma on-scene times
- 78.3% used cardiac arrest survival to hospital discharge
- 35% used pain relief as an indicator
- 26.5% used an advanced airway device (EOA, King)
- 19.1% applied a 12-lead
- 17.6% administered a nebulized medication
- 16.2% applied a continuous positive airway pressure (CPAP) device
- 8.8% used an adult/pediatric intraosseous device
- 5.9% assisted with asthma medication or administered oral glucose
- 4.4% administered IV fluid
- None administered thrombolytics to myocardial patients (4.9% did last year)
- 2.9% used ultrasound
- 47.8% had a hydrogen cyanide protocol for smoke inhalation patients
- 4.3% used hypothermia for selected spinal cord injuries
- 68.1% used hypothermia in cardiac arrest resuscitation
- 11.6% used nitrous oxide
- 71% performed a spinal clearance in the field
- 11.6% used full-body vacuum splints
- 72.5% used carbon monoxide detectors
- 23.2% used an impedance threshold device
- 76.8% used tourniquets for trauma care
- 39.1% used mechanical chest compressions
- 81.2% used CPAP
The average transport charge for a BLS emergency is $684.43. An ALS emergency averages between $928.92 and $1,052.47 to transport.
¼ of the first-responder respondents reported using alternative vehicles to handle first-responder events (21 out of 84). This trend to single or two-person units has increased every year since 2010. Six respondents said they were adopting alternative vehicles within the next two years.
Fire department-operated ambulances handle 44.9% of the transports, EMS handled 28.1% and 27% are handled by hospitals/private/volunteer organizations. From a total of 89 respondents, 9% (7 out of 78) report their response-time requirements have been lengthened.
Of 63 respondents, most had mandatory transportation protocols for specialty centers:
- 98.4% to a trauma center
- 87.3% to a burn center
- 85.7% to a cardiac center
- 82.5% to a stroke/CVA center
- 77.8% to a pediatric specialty center
- 49.2% to a labor and delivery center
- 49.2% to a post-CPR hypothermia facility
- 47.6% to a hyperbaric facility
- 30.2% to a sexual assault center
- 28.6% to a psychiatric facility
- None to a septic shock center
Only 2.9% of the respondents allow patients to be routinely transported by ambulance to a destination other than an emergency department (2 out of 69). Last year, 9.1% of the respondents allowed alternative destinations (8 out of 88).
More than 1/3 of the respondents allow EMS crews to initiate a refusal and deny ambulance transportation (25 out of 69). Last year half of the respondents reported the same activity (44 out of 88).