Round table discussion
Chairman, IAED Emergency Clinical Advice System and Standards Board
Overton says that the current response standards aren’t important for nearly 80% of the current EMS calls. “In some regards, we are using 30-year old clinical data. We know the eight-minute [standard] isn’t even sufficient to maximize out of hospital cardiac arrest,” he says.
Improved technology, communication, and even protocols have changed the way EMS is practiced. “In the 1980s, the definition of ALS was considerably different than it is now. We have better data to operationalize our systems now,” he says.
Overton admits that, as an EMS system designer, he has been as guilty as anybody for being “hung up on” the eight-minute standard. “We in leadership positions must be responsive to change, and not be mired in dogma,” he says. “The evidence is pointing to designing a structure that maximizes BLS, not putting priority on an eight-minute standard that no one can prove [is beneficial].”
The key to shifting away from the old standard is to manage the public’s expectations. “It’s not going to be easy. I don’t have any false illusions,” he says. The fact is that with limited budgets and declining reimbursement rates, resources can only be stretched so thin. However, the down economy may just provide a unique opportunity to make these changes.
“In the 1980s, EMS systems weren’t gate-keeping for the community like they are now,” Overton says. A recent study, published in Prehospital Emergency Care, examined the utilization of EMS in New York City1. The authors found that, overall, the use of emergency medical services is up, but there are trends that reflect a significant change in the healthcare needs of the population. Although trauma calls, particularly violence-related responses, had fallen, there were substantial increases in psychiatric/drug related calls, “generalized illness” and “environmentally related” calls.
“Possibly, this is the perfect time to realign systems to truly match what is going on,” Overton says. “The world has changed.”
Deputy Fire Chief, Memphis (Tenn.) Fire Department
Ludwig believes that EMS systems need ways to measure quality and performance other than response times, but response times shouldn’t be discarded. “It’s just one measurement of your quality of care you deliver,” he says. “There’s an expectation from our customer that we arrive within a reasonable amount of time. It’s part of our customer service.”
In 2011, the Memphis Fire Department responded to 106,634 calls from 9-1-1 callers and transported more than 76,500 patients.
Ludwig carefully monitors response times of his 35 ambulances in Memphis. “It’s one of the tools I look at on a weekly basis. It doesn’t define the whole system, but it’s one measurement of the system,” he says. He reports that in the first week in January, for example, the average was 7:53, 100% of the time.
He says he doesn’t measure response times for the first response to the scene because he already knows that all 56 fire stations in Memphis are capable of reaching a patient within four minutes. However, he measures the on-scene and off-load times, among others. “I crunch numbers weekly,” he says. He carefully watches for trends to see if the numbers fluctuate and then looks to identify the reasons.
Even though the Memphis crews are responding with lights and sirens, Ludwig says motor vehicle crashes aren’t an issue. “Knock on wood, I haven’t had one serious crash since I’ve been here–in seven years,” he says. He credits an extensive defensive driving program that includes three driving simulators and the use of an Opticom system, for the clean record.
One of the problems with examining response times retrospectively, he notes, is that it’s easy to see which responses were low-acuity and which were not. Often, that isn’t the case. Many times, the emergency responders don’t know the extent of the emergency until they arrive on scene. Sometimes, what sounds like an emergency turns out not to be. Conversely, often what is dispatched as a non-emergency turns out to be a true crisis. “We’ve all been on those calls that didn’t sound like much until we got there,” he says.
Brent Myers, MD, MPH, FACEP
EMS Department Head and Medical Director, Wake County (N.C.) EMS System
Part of the problem is that response times are easy to measure and easy for politicians and citizens to understand. Response times also fulfill a basic need: “I’m having an emergency. I need you here fast.” The problem is if EMS were to shift from response times, what would systems use to measure performance and quality?
Myers has spent eight years moving Wake County EMS from response time to an outcome-based reporting system. “It’s a little more difficult than the simple race care approach,” admits Myers.
In 2010, Wake County EMS responded to 78,615 requests for service and transported more than 65,000 patients.
“We’re not saying response time doesn’t matter. If you are not reporting the arrival of the first arriving aid, you should never report ambulance [response] time,” he says. The problem with a simple response time report is that “the over emphasis can distract you from the other things that can truly impact you,” he says.
What are important patient outcomes? “Your EMS system should guarantee that every patient having a myocardial infarction (MI) should have a specific treatment bundle,” he says. For every 15 times that treatment bundle is appropriately applied, it should equate to a certain number of citizens saved. “It takes a bit to get the community from “˜the ambulance is two minutes slower’ to “˜your loved one is alive,” Myers admits. But in Wake County, the policymakers and news outlets have started to focus on when the patient arrived at the cath lab, instead of the response time.
As Wake County made the shift, Myers noticed an unintended downside: a slight loss in “snap-to-it-ness” among the responders. It was a simple fix. He reminded them that it’s still about customer service. “Move quickly to the ambulance. Just don’t drive it like you stole it,” he told them.
- Munjal KG, Silverman RA, Freese J, et al. Utilization of emergency medical services in a large urban area: Description of call types and temporal trends. Prehosp Emerg Care. 2011;15(3): 371—380. doi:10.3109/10903127.2011.561403