Administration and Leadership, Columns, Mobile Integrated Healthcare

Renovate the current EMS System Before Innovating New Versions

Issue 8 and Volume 41.

In the film No Country for Old Men, the character played by actor Tommy Lee Jones says, “If you think this is a mess, just wait until the real mess gets here.” That might be a pretty good description for the current state of all things EMS.

Cracks in the Foundation

Our systems are faced with increasing service expectations as communities expand their geographic footprints in the suburbs, and as new populations migrate into the urban core.

But like dogs chasing our own tails, many of us spin around endlessly trying to catch the same static response time requirements, whether the more evidence-based five minutes for BLS first response, or the largely unscientific but perceived customer service expectation of eight minutes for ALS.

Our costs continue to rise too, at a rate higher than our reimbursements, and as our budgets are continually weighted toward increasing personnel costs, including salaries, pensions and healthcare.

None of these benefits are unreasonable, by the way, especially considering the skilled and often backbreaking work that we do, but they’re not necessarily sustainable either.

Adding a New Floor

Alas, we’ve entered the new frontier of mobile integrated healthcare and community paramedicine (MIH-CP). And it’s great and gratifying stuff, developing in a grassroots fashion from the ground up, and not coming down from on high with regulations and standards, in the absence of any clear clinical, scientific, or economic basis or benefit.

The word is “innovation,” and like much of everything these days, we’re beginning to recognize that innovating has to be part of our daily bread, and not just some kind of pie-in-the-sky or pipe dream.

But it’s a little worrisome too, in that this new realm is already beginning to look a little like the old EMS.

We have process metrics and performance measures for things like admission and readmission avoidance, cost reduction and decreased resource utilization-all critically important but, ahem, although our patients may say they are feeling better, do we have any objective evidence that they are experiencing measurable benefits in their long-term well-being or health outcomes?

Yeah, yeah, I get it-we kept the guy with congestive heart failure (CHF) out of the hospital for 30 days after he was discharged (certainly a good thing), but did the course of his disease or survival outcome actually improve?

Our field has developed with an extraordinary focus and emphasis on process-how quickly do we get there, how many does it take to get the job done, and what kind of things are on the rig?

But then we close our eyes and hope for the best, even while many of our systems devote few resources to meaningful quality assurance of patient care. And so we’re often left in the dark as to how well we’re performing, at least short of the occasional sentinel event that pops it head up and which we try to remediate, though sometimes with a virtual baseball bat.

We have response times, task times, and turnaround times. We have control charts, unit-per-hour utilization, and system status management. And some of our systems don’t even have that. But how many of us can figure out whether an airway is really in place, or what it actually took to get it there?

Do our patients have significant periods of hypoxia, bradycardia, hypotension, and inadequate ventilation during the process of intubation, even if their tubes are eventually placed successfully?

And what percent of the time do we spend on the chest during CPR, and how many pauses for how long will drastically reduce our patients’ chances of survival?

Some of us have the tools necessary to do this kind of objective measurement and some of us don’t. And even for those of us who do, we may not have the time, personnel resources, or even the interest to do this work, or the desire or ability to do something about the results when we do.

But it’s incomprehensible how we can have systems that require tens-to-hundreds of millions of dollars to operate yet somehow have inadequate resources to ensure the provision of high-quality care on scene.

How About a Fixer-Upper?

MIH-CP is worth a serious look, especially as we try to explore how to better integrate our discipline into the entire healthcare spectrum. But it may not be for everyone, especially when we can’t even get our basic EMS house in order.

So, yes, innovation should be part of what we do every day, but it probably shouldn’t be relegated to the realm of what’s only new and improved. Instead, the same spirit of collaboration, entrepreneurship, and leadership that’s essential to innovation might be well spent on getting our basic acts together, before we all start blindly flinging EMTs or paramedics into everyone’s homes, as beneficial or sustainable as something like that may eventually be.

Maybe it’s time then for innovation, but perhaps in service of a little renovation and not just on what’s new and shiny.