JEMS Surveys 200 Most Populous Cities

About the Data
The leaders of the first responder and transport agencies (n=455) serving the 200 most populous cities in the U.S. were invited to participate in the JEMS 200-City Survey via e-mail. Conducted online, the survey included 118 questions. Many questions asked for multiple pieces of data. The survey response rate was 21.3% (n=97).
The survey covered a variety of EMS topics: dispatch, first response, transport, medical direction, performance measurement, affect 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%. (see Table 1, p. 36).

It’s funny how things change. Change can come about over time or “evolve” because of leadership, invention, clear goals and a vision for the future. Change also happens in a more traumatic process called “revolution,” which occurs when a system design no longer meets the needs of the users. This often requires a dramatic change, such as a down economy, cuts in staffing or discontinuation of a service altogether.

As we look at our world today and see the winds of change forcing us to evaluate our services and to show value and need, the choice is ours–evolution or revolution.

The blurring lines between the private and public sectors are causing longtime allies to become adversaries overnight. This occurred decades ago and is occurring again. Many services, busy protecting their turf, fail to see the road signs of the future: the U.S. healthcare system changing, in part due to the Affordable Care Act and the real pressure that’s reducing reimbursement for hospitals, physicians and EMS services. Rarely are providers able to maintain current levels of funding from Medicare or Medicaid.

In early May 2011, Medicare finalized the rules of a new program mandated by the Affordable Care Act that will pay for quality, not just the quantity of care provided.1 The new Hospital Inpatient Value-Based Purchasing Program (HIVBPP) marks an important effort to address, in practical ways, many of the criticisms leveled at pay-for-performance schemes in the past.

The good news is that opportunities are just ahead. But to achieve them, we must be willing and able to change and show value within the healthcare community. The real opportunity for EMS requires changes to the core role we play and the critical difference we can make in patient outcomes. So the big question is: Are we willing to question, measure, improve and change our systems?

The future will require a focus on prevention and education programs for high-risk populations. Patient outcomes, not just response times, will be measured by high-quality EMS programs. Our ability to show the difference we make will not only allow our industry to survive, but will also become a cornerstone of healthcare systems for patients across the U.S.

For almost 30 years, the JEMS 200-City Survey has queried the most populous cities in the U.S. The survey of the largest 200 cities resulted in more than 48% submitting responses.

Every year, readers express concern that more data is required. We agree that more date is required. If you are one of the invited participants to this survey or other key surveys about our industry, please contribute and encourage your peers to respond in the future. The industry you save may be your own.

The Same Page
Year after year, the EMS industry continues to rationalize why one set of patient outcomes or results, such as return of spontaneous circulation (ROSC), can’t be compared with other organizations’ results because of different measurement methods. EMS can’t agree or doesn’t like how others measure the results. For example, Table 2 demonstrates only 48% of respondents report using the Utstein model for measurement of ROSC, and the majority (52%) use a different or local, non-comparable measurement method (see Table 2 below).

We found that organizations using the Utstein model of measurement report having higher overall ROSC scores than those that don’t use the method (see Table 6, p. 38). Is this due to a higher focus on care for cardiac arrest patients or simply inaccuracies in the method we measure the result by?

The only sure-fire solution is to agree on a single measurement method. Good, bad or indifferent, the Utstein method is a widely recognized process used to accurately measure and compare ROSC scores among different services. We believe it’s time for the medical leadership in EMS systems to develop and adopt standard patient outcome methods for all patient conditions. Hospitals and the greater healthcare community are doing exactly that, and 28.6% of the respondents to the survey reported that they “strongly agree” that their local EMS system is integrated into the greater healthcare system, while 62.9% agreed and only 8.5% disagreed (see Figure 1 and Table 4 at right).

A few years ago, physicians began a similar process to measure and reward providers with pay for performance.

These processes are continually modified and refined to find the best fit to match quality outcomes and performance with reimbursement.

So how does EMS compare with its healthcare partners? Of our survey respondents, only 20 (29.4%) reported having a prevention program targeted at at-risk populations (e.g., elderly falls, congestive heart failure, diabetics, pediatric asthma, etc.), while 28 (70.6%) reported no such program.

When asked if they’ve established a formal partnership with public health and/or social services to provide patient referral or follow-up for patients with high EMS use rates, 36 (52.9%), or more than half of the responding organizations, reported having a formal partnership in place; thirty-two (47%) reported no program in place.

Research was reported as being conducted in 39 (57.4%) of the systems, while 29 (42.6%) stated they did not participate in research (see Table 3, p. 36).

Our ability to control our destiny and prove our worth and value will depend on research. Failure to understand our actions through research will result in others defining our roles without the insight or knowledge of what we do, or can do, to improve outcomes in patients.

EMD & EMS Training Levels
Emergency medical dispatch (EMD) was shown to be incorporated into multiple types of organizations. The most common is in fire department systems, representing 35.1% of the respondents. Fire departments are followed closely by consolidated public safety dispatch centers, representing 29.7% of the responses. Police departments provide EMD in 13.5% of the centers, followed by third-service providers 12.2% of the time. Only 8% of private ambulance companies reported providing primary EMD for responses. This is probably because most private service 9-1-1 responders are integrated into another dispatch system.

Specialized training required in dispatch centers shows that 5.2% of the dispatch centers are trained in CPR and AEDs. Another 8.7% requires EMT or paramedic certification. In 31.5% of communications centers, Association of Public-Safety Communications Officials is the standard, while 54.4% require National Academies of Emergency Dispatch-level training.

Patient Care
EMS systems often compare skill and procedures between larger or similarly sized communities. Ninety-seven organizations responded to questions related to the procedures they use in their systems. Of the respondents this year, 51% (49) use needle thoracostomy, 39% (38) report doing needle cricothyrotomy and 29% (28) allow surgical cricothyrotomy. Pediatric intraosseous (IO) devices are performed by 64% (62) of the providers, and 61% (59) are using adult IO procedures.

Rapid sequence intubation (RSI) is an available intervention in just 14% (14) of the 200-city respondents, but 66% (64) use end-tidal carbon dioxide monitoring and 66% (64) use pulse oximetry.

EMS providers have access to 12-lead ECGs in 64% (62) of the systems; yet, 0% (0) providers report protocols to allow administration of a thrombolytic for cardiac patients, and none (0%) allow thrombolytic intervention for cardiovascular accidents. In 22% (21) of the systems, a mechanical cardiac compression device is currently used during cardiac arrest resuscitations. Of those 21, eight reported their ROSC score (see Table 5 below).

In 36% (37) of the systems, some form of spinal clearance is allowed by the field providers. Aspirin administration is in protocols for 65% (63) of the systems, and only 8% (8) include nitrous oxide in treatment protocols.

Carbon monoxide monitoring devices (e.g., Masimo technology) are available in 33% (32) of the EMS systems, and 23% (22) have hydrogen cyanide protocols and treatment supplies.

The following clinical indicators were reported as being measured by this year’s respondents:
>> Intubation success by 59.8% (58) of the respondents;
>> Pain relief by 28.8% (28);
>> Severe trauma scene times by 40.2% (40); and
>> ST-segment elevation myocardial infarction (STEMI) detection in 57.5% (56).

Surprisingly, patient satisfaction is measured in only 28.9% (28) of our systems.

The future will demand not only the measurement of these skill levels but also quantification of the effect on outcome for our patients. EMS providers will have to identify an elevated ST-segment and provide the proper treatment and transport to the appropriate STEMI center for improved patient outcomes.

ALS Transport Ambulances
The survey shows that the controversial question of how many paramedics should staff an ALS ambulance is far from answered. Almost half, or 30 responding organizations (49%), reported staffing of a single paramedic and a single EMT on their ALS transport ambulances.

Twenty-five organizations (41%) reported requiring at least two paramedics to staff an ALS transport ambulance. Six (9.8%) reported staffing a paramedic and intermediate EMT on their ALS ambulances.

These results are similar to this past year’s survey, so it would appear no clear model has emerged as the most common practice. The industry’s inability to prove that two paramedics are better than one has left us at risk of revolution.

Communities struggling to balance their budgets will be forced to pick and choose staffing levels. Without clear research and evidence based on financials proving the benefit of two paramedic per ambulance, organizations will have little to defend current dual ALS provider practices.

Who’s Transporting?
Ninety-one providers re-sponded to the question of who is the primary transport agency for the EMS system.

The results showed that 39.6% (36) of the cities report that a private company transports their patients, followed closely by 37.4% (34) using the local fire department. Third-service and hospital-based providers make up 23% (21) of transport providers and include public-utility models that no longer contract out for services.

Where EMS Transports
Transporting patients past the closest hospital to a “specialty” center isn’t a new concept. Trauma centers have been in operation for decades. What’s new is the variety of specialties now defined in our communities.

Of the respondents, 63.9% (62) reported having protocols that require transport to trauma centers. Burn center destinations are identified in 47.4% (46) of the top 200 cities, and pediatric center’s transport protocols are followed in 51.5% (50) of the reporting EMS systems.

Cardiac center transport protocols are in place in 30.8% (29) of the systems, and 46.4% (45) report requiring stroke patients to be transported to a designated stroke center. Interestingly, hypothermia inducing centers and protocols are reported in 29.9% (29) of the responding top 200 cities.

The dramatic changes from one year to the next may be a function of the respondents, not necessarily a decrease in the number of specialty centers. Once all providers invited to participate in the survey respond, we can more accurately measure whether we’re improving our systems or there’s simply a factor of a change in the respondents to the survey.

EPCR Connectivity
The electronic patient care record (ePCR) has become the standard in most EMS systems. Helpful in billing and collections, ePCR systems have also proved powerful tools in monitoring important indicators, research and analysis.

The 2007 survey found that 63.1 % (77) of respondents used an ePCR. In 2010, we found that 77% (89) of the respondents report the use of an ePCR tool. The 2011 survey results find 86.3% (84) of systems that responded are using an ePCR system.

Now that ePCR systems have become the norm, many users report connectivity with many different providers and systems. Four (4) providers report the ability to fully interface (two-way) their ePCR with first responders. Another sixteen (16) allow for a one-way interface from, or to, the ePCR and first responders.

Connectivity between the ePCR and the receiving hospital is reported in 28 systems, with two of the cities (2) reporting they now have full (two-way) interfaces with the receiving hospitals. We expect this number to continue to grow as the new federal healthcare initiative is implemented. As technology continues to evolve and adapt to our needs, we’ll also be challenged to measure, monitor and improve our systems in a more timely and cost-effective manner.

Transportation Costs
How have rates changed? Providers charge different rates depending on the type of service, geographic location and amount of local tax subsidies. Survey respondents report an average BLS non-emergency transport charge of $594.04 this year vs. $603.14 this past year. The survey results also showed an average BLS emergency transport charge of $640.77 this year vs. $654.58 in 2010.

Providers’ average ALS non-emergency transport charge is $769.08 vs. $794.77 in 2010. The ALS-1 emergency transport charge is $773.28 vs. $821.34 this past year, and an ALS-2 emergency transport charge is $906.05 vs. $875.26 in 2010. We believe the decline in charges is due to differing respondents this year rather than services decreasing their prices.

The actual payment reported as being received averaged $263.50 (44.4% collection rate) BLS non-emergency transport. Note: Cash collection rate is determined by average cash collected, divided by average charge. The actual cash average is $296.58 (46.3% collection rate) for BLS emergency transport.

The actual payment average for ALS non-emergency transport is $322.48 (41.9% collection rate) and $389.40 (50% collection rate) for ALS-1 emergency transports. ALS-2 emergency transports resulted in $466.32 (51.5% collection rate) of cash.

These nationwide averages are a combination of who responded and the type of provider they are. Should your service internally provide the billing and collection function, or should these be contracted to a firm that specialize in these services? Providers who transport and bill for services report that 43.5% (40) outsource billing service and 56.5% (52) provide billing services “in-house.”

Billing can be extremely complex and requires constant continuing education and updates. Any organization, public or private, is subject to the federal Medicare and Medicaid rules–for which failure to comply can result in penalties and fines, and the provider is ultimately responsible regardless of whether the billing function is outsources or retained internally.

The Economy
This past year we asked the following question: “Has your organization experienced reductions in service due to the current economic situation?” In response, nearly 70% reported no reduction in service levels due to economic issues. This year, the survey results showed that 63.2% (61) reported no reductions and 37.8% (36.6) confirmed they’ve had service reductions due to economic pressures.

When asked this year about the outlook for the next 12 months, 64.7% (44) respondents reported no anticipated service reductions, but 35.3% (24) were certain they’d experience service reductions. This past year only 16.6% believed they’d experience service reductions in the next 12 months.

Patient Satisfaction
How is patient satisfaction being measured? The No. 1 method reported by almost half of the respondents 46% (32) was as part of a complaint or compliment. Almost one-third 34% (24) of systems reported using a paper survey separate from the bill sent to patients. No measurement tool exists for 13% (9) of the respondents, and 7% (5) report attaching a survey to the bill.

We must understand the needs and wants of our patients. Failure to proactively research and understand what we do well and where we can improve is paramount to surviving change. Believing that you don’t have problems just because no one has complained can be a risky practice.

Closing Observations
Cardiac arrests and auto accidents will continue to require a quick and rapid response by EMS systems for some time in the future, but these examples represent a small percentage of the total calls EMS providers are responding to today. Reduction or elimination of the lesser acuity calls by prevention and prioritization will dramatically affect the EMS industry. So the choice is ours, evolve or fall victim to outside forces that may or may not include the use of EMS responders to fill these non-­traditional non-emergency roles.

Get involved in your industry, not just your organization. Learn the changes that are coming and how to change with, not against the majority. Great opportunities exist to replace our usual role as an extension of the emergency department doors with an integral linkage with the entire healthcare system if we put the industry ahead of our own organizational needs.

An evolutionary change can be accomplished only with a clear vision of what needs to be done and the courage to lead, despite the personal challenges it will create for each of us. If this were easy, everyone could do it. JEMS

Acknowledgement: The authors acknowledge the great support of the Fitch project team members and their contributions to the article: Sharon Conroy and Melissa Addison.

Disclosure: The author is an external, expert consultant with the consulting firm Fitch & Associates, LLC, which provides emergency service organizational and system audits for communities and individual organizations.

1. Marcus J. (May 20, 2011.) The Opening Bid: Do pay-for-performance health programs really work? In The New Republic. Retrieved Dec. 1, 2011, from,

This article originally appeared in February 2012 JEMS as “Evolution or Revolution?: EMS industry faces difficult changes.”

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