Our capability to provide adequate pre-hospital care to citizens in need across the country has become greatly diminished. Depleted volunteer numbers and lack of adequate career staffing levels have impacted our ability to provide high quality care. The current staffing shortages in EMS have taxed our response system, increased response times and left patients without adequate levels of care. We will continue heading down this path until everyone is made aware of the problem and measures are taken to stave off impending disaster.
In recent years, many studies across the county have attempted to figure out a solution to our staffing problem. Specifically, a study performed by the North Carolina Rural Health Research & Policy Analysis Center in 2008 brought to light many of the issues faced in North Carolina that could easily be expanded to encompass the entire nation. According to this research, only 50% of EMS services in 2008 were fully staffed, of which, more than 63% had a volunteer component as part of their staffing level.1
These statistics alone show the need for change in our system. How do we ensure adequate staffing and retain the employees, both career and volunteer?
How do we determine adequate levels of staffing?
The standard in the EMS industry for gauging adequate response to an incident is the response time.2
The National Fire Protection Agency recommends that BLS first response arrive with an AED on scene within 4 minutes and ALS providers arrive on scene within 8 mintues.3
While there is current debate on whether or not these response time guidelines are appropriate, the argument can easily be made that the quicker trained personnel arrive on scene to help mitigate an emergency situation, the better the outcome of that situation. The ability of a service to provide trained personnel to relieve the emergency is directly related to the staffing levels and call volume each agency is responsible for.
What caused the problem to spin out of control?
The modern EMS System began to take shape in the U.S. during the 1960s following the publication of a report titled "Accidental Death and Disability: The Neglected Disease of Modern Society," by the National Research Council.4
As we progressed through the 1970s and ’80s, Americans were provided prehospital care by trained members of local ambulance corps, police or fire departments. Throughout the late 20th century, many developments in medicine and emergency medical care created the need for additional training, certification and continuing education for pre-hospital providers.
With these industry developments, volunteer EMS agencies began to decline as volunteer members found it difficult to meet these new requirements. When asked about difficulties retaining personnel, more than 65% of respondents reported that time and scheduling conflicts contributed to retention problems.5
Agencies with operational authority over these EMS entities began incentive programs to keep volunteers while pushing for state tax breaks for volunteering and even hiring supplemental career personnel to provide the necessary service to the community. These initiatives have helped slow the paramedic shortage, but have not proven to be a definitive answer.
What options do we have?
The first possible answer to the problem and the shortage is to increase monetary incentives for employees and members of service. We see that lack of adequate compensation for the hard work that these members perform is part of the complaint contributing to difficulty retaining personnel.6
With increased pay, employees would be more likely to stay in the profession. We would be able to retain our current providers, recruit new providers and close the gap on our current shortage.
In certain areas of the country, even volunteers are compensated monetarily once they hit a certain response volume or number of hours volunteered. In North Carolina, more than 30% of providers are compensated by some payment method for the service they provide.7
The time that our emergency responders give to the system is very valuable and they should be compensated for it, but implementing plans to expand compensation to EMS providers would be difficult in the current political landscape. Citizens are unhappy paying additional taxes, seeing too much of their salaries already being taken by the government. In addition, it is hard to tell someone to pay more for a service that they may never use.
An additional means of closing the gap on the current shortage is to combine EMS into existing emergency roles. Currently across the country, members of police and fire departments are trained in basic first aid, CPR and AED usage. This provides for the necessary first response. By cross-training our emergency personnel to provide a higher level of medical care, perhaps even ALS interventions, we will enable a highly trained provider to be on scene much quicker than waiting for the responding ambulance. Once again, the cost of providing such a service and training through additional emergency services could become burdensome.
Some agencies that already have had their foundations in fire or police service for decades refuse the notion that they should be part of EMS and resist the incorporation of such tactics into their departments. In addition, the risk of a police or fire unit being tied up on a medical call when needed at another location for a police or fire emergency could potentially cause significant harm to the second caller in need.
In general, a large number of EMS providers are not-for-profit entities. While this allows them to perform services without paying federal, state and local taxes, too often these agencies fail because they do not follow a stern business model. Without necessary oversight and a business background, leaders of the smaller not-for-profit entities are unable to form a consistent business plan that ensures survival and adequate levels of readiness.
As an industry, by holding EMS agencies to a higher standard of business practices, a more consistent workplace environment would be possible. Issues of retention and recruitment could be approached in a more meaningful manner. Countless commercial providers that exist in large metropolitan cities are able to flourish and provide an exceptional level of care. In addition, the fire department EMS models are held more accountable by the fire department structure, especially if their finances come from taxes taken in from the municipality. Although a potentially meaningful avenue of change and development, there would be significant upheaval in the EMS community if we began operating for profit. Too often, people see a for-profit company as one that isn’t in it to help people, only to make money. This stigmatism is still present in EMS and would be one of the most difficult hurdles to overcome.
Our best solution
Given the options listed above, there doesn’t appear to be any easy answer to solve this problem. It would be difficult to convince Americans to spend the additional money needed to put any one of these policies into place. Yet, the current system is collapsing around us and drastic change is needed.
An increase in compensation to providers is needed in order to retain our current providers and recruit new providers to close this gap. While increasing the salaries and compensation that our providers receive will help, something more also needs to be done. Agencies need to be run with a better understanding of a strict business model and its importance to EMS. Simply using every last dollar we have to buy the newest and best equipment with no plan for the future will not allow us to provide the necessary care and treatment. Needless and wasteful spending could be eliminated by implementing a meticulous business model. In doing so, we could create an environment where we can financially survive and adequately compensate those who provide the care and treatment we need in the timely fashion that is necessary.
Stephen M. Peluse, BA, FP-C, NAEMT-P, is a Flight Paramedic with MedStar Washington Hospital Center in Washington, D.C. He has more than 12 years of EMS experience both in the clinical and education sectors. Peluse also has previous managerial experience in the EMS field. Reach him at email@example.com