The dispatcher aired a call our crew was all too familiar with. “Medic 11 respond to 1221 West Main Street on a diabetic patient, conscious and breathing.” We all stood up slowly and headed to the truck room knowing that it was Mr. Simon, again. With sirens blasting, we followed the same route we had taken three times this week–twice in the last 24 hours. Mr. Simon was one of our “loyal customers.”
Mr. Simon was the nicest guy. He was a Vietnam veteran who lived on his own, except for his green parrot, named Sam, and an old black lab, named Toby. He knew us all by name and everyone on our crew could recite Mr. Simon’s medical history by heart. Outside of diabetic issues and falling out of bed after drinking a few beers, he was rarely transported in all the years we serviced him.
On arrival we were met by Toby, tail wagging and looking for treats. He led us to the hidden key in its usual spot. Sam was inside making the same siren noises from his cage as he always did whenever we rolled up. We let ourselves in with medical kits and a cardiac monitor in tow.
Lying at the foot of his favorite recliner was Mr. Simon. He was conscious and in his normal state of confusion after a few drinks. He had tripped over a rug and took a “small tumble.” He said he was fine and really didn’t need our help anymore. Our years of EMS experience and training have taught us to never underestimate anyone’s medical condition. We all knew the drill and, like a fine-tuned pit crew, we got to work–assessment, vitals, blood sugar, ECG, field release and a phone call to medical control. We always gave Mr. Simon first-class customer service and exceptional medical care, despite knowing he was wasting precious EMS resources with old war stories and frequent non-emergency visits.
As we evaluated Mr. Simon, our radio alert tones grabbed our attention: “Medic 13 respond to 1550 Santa Fe Drive on a 15-year-old male in cardiac arrest, CPR in progress.” The address was just blocks away from our station but we were stuck here with Mr. Simon. We couldn’t abandon him without a full assessment and the appropriate field release. “That’s a long response time for the next medic unit,” I quietly said to the crew. “That’s our call and we should be there saving that child’s life.” We hurried about business without showing any emotion or frustration toward Mr. Simon, our loyal customer.
The rapid impact team’s Quick Cars respond to low-level calls as a single resource, keeping other ALS units available for other calls.
No Appointment Needed
EMS systems across the country feel the strain of serving frequent uninsured, underinsured, homeless and intoxicated patients. 9-1-1 is the first call people make in an emergency and the last number they dial when they can’t solve a problem. Why not? What other healthcare service gets someone to your door in less than 10 minutes to take care of dad’s heart attack, move grandma from her wheelchair to her bed, check blood sugar or answer a medical question? And there’s no appointment necessary. EMS is expected to show up every time, well-trained, well-equipped and, above all, on time. People say, “If it’s not fast, it’s not really emergency service.”
The fact is tying up resources really does matter, not only to our patients but to every high-volume EMS system with limited resources. These days, few agencies can afford to tie up ALS units or limited firefighting resources on low-acuity, non-emergency calls and still be expected to somehow arrive on time when the big one goes down. Getting the right resources to the right patients in a timely fashion is essential to the success of every EMS system and today, leaders have to get creative to meet the increasing service demands of our customers.
Cares Car crews facilitate care to help patients avoid costly hospital visits or stays.
Outside the Box
The Littleton (Colo.) Fire Department protects 220,000 people across 92 square miles and responds to over 14,000 calls from eight stations. Each firefighter is cross-trained and serves a dual role as a firefighter and paramedic or EMT. Each of the six engines, two ladders and five medic units has ALS capabilities and is staffed with a paramedic. Littleton provides more than 7,000 transports annually to area hospitals. Littleton firefighters were the first trained paramedics in Colorado and the department’s ALS service is one of the oldest fire-based EMS systems in the country, dating back to 1974.
In 2014, Littleton Fire Rescue launched two new innovative programs designed to manage their resources more effectively and address the increasing burden of non-emergent calls on its busy EMS system. Littleton’s Quick Car and Cares Car programs are designed to get the right resources to the right people, without responding with expensive fire trucks and ambulances on calls where they simply aren’t needed. The two programs have improved service, reduced unnecessary hospital transports, improved the availability of resources in the fire district and decreased costs.
The mission of the Quick Cars is to respond to low-level calls as a single resource, keeping other ALS units and fire rigs available for more serious or complicated calls. This new concept gets help to a patient’s door quicker and keeps costs low. Building a new Quick Car costs roughly $90,000, as opposed to a fire truck that can run upward of $700,000, or a new ambulance, which can top out at $250,000.
Each Quick Car is a fully equipped SUV that’s fast, maneuverable, uses less fuel than a traditional response unit and can often get into scenes quicker than other larger response vehicles. The trucks are staffed with a paramedic lieutenant and an EMT partner and each unit carries an assortment of medical equipment, including onboard computers, a cardiac monitor, ALS equipment and medications. Quick Cars also carry an array of firefighting gear including forcible entry tools, portable extinguishers, gas detectors, self-contained breathing apparatus and a thermal imager.
Littleton’s communication center codes each service call and routes non-emergent problems, such as slip and falls, psychiatric problems, intoxication, police or public assists, carbon monoxide alarms, vehicle accidents with unknown injuries and chronic callers, to the Quick Cars. After analyzing over 100,000 9-1-1 calls, the Quick Cars were deployed in areas where the majority of non-emergent calls and public service situations occur. Their implementation had an immediate impact on the response system, demonstrated by their current 24% unit hour utilization rate. The Quick Cars aren’t intended to replace the traditional response model. They simply have their own unique and specific role which can take the burden off other ALS resources, allowing them to be available for the big one.
“The public’s expectation when they call 9-1-1 is they’re going to get a rapid, effective and efficient response to take care of their problem,” Fire Chief Chris Armstrong said. “By using an alternative service delivery model and dynamic staffing, we were able to add additional resources to our system at a lower cost. In this new era of healthcare, we have to find innovative ways to meet our service demands. The Quick Cars are handling a high percentage of calls that would normally be handled by other ALS units, saving us both time and money.” In 2016, Littleton Fire Rescue hopes to expand the program by putting more Quick Cars on the road.
With a portable i-STAT machine, paramedics can analyze your blood and dispense or prescribe medications all in your home.
The mission of the Cares Car is to bridge the gap between 9-1-1 and the healthcare system, giving patients more options besides an expensive ambulance ride to the hospital and a pricy ED bill. “People with chronic conditions don’t have to leave the comfort of their homes to be treated for minor problems or recurrent conditions. We can treat them at home and plug them into the healthcare system at a lower cost by facilitating and coordinating their treatment with their primary care physician or specialist in real time,” firefighter Tyson Hungerford, NREMT-P, said. Other benefits of the program are improved customer service and more efficient use of department resources. Emergency units are no longer tied up transporting patients who don’t really need to go to the ED. The Cares Car also keeps fire department resources available for serious, life-threatening calls or fire-related problems.
The Cares Car is staffed with a physician assistant (PA) and a paramedic. Their mobile office carries a variety of specialized equipment for testing and treatment that’s typically only found in your doctor’s office or an ED. With a portable i-STAT machine, they can analyze your blood in your home and dispense or prescribe antibiotics, narcotics and other medications. Their special equipment can test for strep, influenza, RSV, mono and pregnancy and they can treat minor orthopedic injuries with splinting and casting supplies, including orthopedic boots carried on board.
The Cares Car also has a variety of suturing equipment and wound and infection care kits, in addition to specialized examination equipment used to assess and treat eye and ear injuries. The unit has full ALS capabilities and onboard computers, which allow the PA to access healthcare portals to examine records or medical tests and view images.
Not every patient the department encounters needs to go to the ED. Now a PA can help patients access the right resources in the healthcare system to meet their individual medical and financial needs. The Cares Car can help patients navigate to healthcare resources throughout the community they were unaware existed. The program has reduced unnecessary transports to overcrowded EDs, saving people time and money.
As an example, the Cares Car was dispatched to an elderly woman who had tripped and fell at home, resulting in a small laceration to her head requiring stiches. Her injuries fit into a well-defined patient care matrix, developed by Littleton’s medical director, for referring 9-1-1 calls to the Cares Car. On arrival, the PA released the fire department’s transport ambulance and assumed patient care and treatment. Over the next hour, the PA sutured the patient’s laceration, reviewed her complete medical history, carefully explained wound care instructions to her, discussed fall prevention and pointed the family toward resources that could install grab rails throughout her home. On a follow-up call days later, the Cares Car went back to her house to examine her injury, remove her stiches and check on her progress. The patient was spared an unnecessary hospital trip, costly ambulance ride and expensive ED bill.
“I feel this innovative service delivery model will lead to better patient outcomes, reduced healthcare costs for our customers and improve the operations of our fire department,” Medical Director Gene Eby, MD, said. “While the Cares Car program is still relatively new in Littleton, we’re slowly gathering data to demonstrate the program’s effectiveness. In the future we hope to expand the program into other areas of healthcare such as dental care, mental health services, substance abuse treatment, pharmacy services and possibly pain management. EMS has played a very passive role in these areas of the healthcare system using a traditional response model. It’s vital to the future of the fire department that we embrace healthcare reform and get on board early with innovative programs to deliver the right services to the right people at the right time.”
There were a few challenges Littleton Fire Rescue had to overcome prior to putting the Cares Car on the road. There’s no current reimbursement model for the services provided by the Cares Car but the city and its partners have absorbed start-up costs and operating expenses to get the program off the ground. The city is in discussions with health insurance carriers to negotiate reimbursements. It’s obvious the program can reduce healthcare expenses by avoiding unnecessary transports, which is attractive to most insurance organizations.
Change never comes easy in the fire service and many of the department’s members were very skeptical about how the program would work. Department-wide training was an essential part of the business plan to ensure the department’s staff knew exactly when and where the Cares Car should be used.
While still in its infancy, the Cares Car program is slowly gathering data to demonstrate its effectiveness. In the future, the program may expand into other areas of healthcare.
Adapt or Fail
We’re a service-based business, right? Everything we do should focus on meeting the changing service demands of our customers. As their needs change, our industry and the way we deliver service must change as well. Our stakeholders demand innovation and expect us to meet their high expectations–be effective, be resourceful, follow best practices, meet industry standards, be transparent, be accountable, benchmark success, act as financial stewards with their tax dollars and be on time when it counts most. Are we meeting these expectations or do we just assume the same old service delivery plan will meet the demands of our modern day environment?
Littleton’s Quick Car and Cares Car programs are a “value-added” service that enhances medical care in the community, improves response times, reduces unit utilization on low acuity calls and saves money. That’s not a hard sell for financial decision-makers, community leaders or taxpayers to stand behind. The fire department is continuing to gather data on the new programs to study their effectiveness and make any necessary adjustments. So far, the two programs have worked perfectly to augment Littleton’s traditional response model.
President John F. Kennedy once said, “Change is the law of life and those who look only to the past or present are certain to miss the future.” If our service delivery models don’t adapt to the changing environment, we may very well fall victim to the consequences of Kennedy’s words.