What is its purpose, impact on outcomes & best use?
Fire department first response is a common feature in many EMS system designs. This session of the NAEMSP Dialog explored its purpose, its impact on clinical and non-clinical outcomes, and ways to utilize it most effectively, efficiently and safely.
In addition to members of the NAEMSP Dialog discussion group, several participants were invited to contribute their views, including Alan Craig; Rick Verbeek, MD; and Brian Schwartz, MD, authors of “Evidence-Based Optimization of Urban Firefighter First Response to Emergency Medical Services 9-1-1 Incidents”; David Cone, MD, the lead author of two relevant papers, “Is there a role for first responders in EMS responses to medical facilities?” and “Can emergency medical dispatch systems safely reduce first-responder call volume?”; Angelo Salvucci, MD, from the Santa Barbara (Calif.) EMS System; and Gary Ludwig, deputy chief of EMS for the Memphis Fire Department and chair of the EMS Section at the International Association of Fire Chiefs.1, 2, 3
Purpose of fire first response
Much of the discussion sought to articulate the purpose(s) of fire first response (FFR). In that context, the general role of fire departments was characterized as mitigating and managing risk. To do this appropriately, fire departments need to deploy the right resources for the right need, which includes looking at both clinical and non-clinical needs, for a call in developing a response configuration. The idea of clinical and non-clinical reasons for sending FFR to a given call was widely acknowledged as a valid and helpful perspective.
Some of the non-clinical reasons cited for FFR include hazmat control, extrication, fire suppression, additional manpower on complex cases and assistance in carrying and lifting. Traffic scene safety was mentioned several times, along with the utility of using fire apparatus as “blocker vehicles” on busy roadways. FFR was also viewed as valuable for decreasing the time needed to complete scene and patient care tasks. Some EMS calls are labor-intensive, even if the patient care is minor in nature. This could include cases in which a patient is on an upper floor but found to be in need of additional equipment. With only a two-person ambulance crew on scene, one or both crewmembers may need to leave the patient’s side for a significant amount of time to retrieve equipment.
The panel also discussed important customer service considerations in FFR. Several people described cases in which both fire and EMS crews went above and beyond the purely clinical needs of patients to address issues, such as securing the home, ensuring the care of pets, etc.
There was support for utilizing FFR for cases for which there isn’t a particular medical need for FFR. The intent of such responses would be to provide for scene safety and on-scene assistance to ambulance crews. In most cases, these scene safety and assistance responses would not need to utilize lights and sirens. FFR arrival a few minutes after the ambulance would still come in time to provide any needed assistance without exposing the FFR crew or the public to an increased risk from a lights and siren response. The feeling is that even when the ambulance crew needs extra hands on scene, if FFR is not part of the initial response, FFR can be summoned to the scene–and almost always on a non-emergent basis.
The conversation turned to the issue of putting paramedics on fire department first response engines in an urban setting. The rationale in some communities may be that FFR paramedics will arrive on scene faster and, therefore, save lives. One participant asked if there are any specific prehospital interventions that make a difference on patient outcome when provided a few minutes sooner and that can only be performed by a paramedic. Defibrillation, intramuscular epi for anaphylaxis and Heimlich for choking victims were mentioned, but all or most of these can be performed by EMTs. This was true in some but not all states.
The panel then discussed the relationship between the number of paramedics in a system and the difficulties maintaining skills with fewer opportunities per paramedic–as may happen when both ambulances and FFR units are staffed by paramedics. Does the same argument apply to too many doctors at a hospital? Evidence shows increased experience leads to more proficient practitioners, reduced errors and better patient outcomes. Some hospitals are required to see a specified number of cases in order to become a designated Level I trauma center. There are studies of physicians showing that those who perform more of a particular invasive procedure per year have better patient outcomes, fewer complications, etc.
There was consensus around the idea that the real issue here is not “if” FFR should be used, but rather: 1) which calls they should go to, and 2) which calls should they respond to with lights and sirens. Dispatch protocols are helpful here, but they all leave the ultimate decision on both of these questions up to the local system. It seems that many cases lend themselves to quick agreement; however some cases do not easily draw consensus or touch on philosophical issues that cannot be settled by research.
This very candid discussion touched on political motives for FFR. It was suggested that it’s disingenuous to assert that politics plays no role in the desire of third-service EMS to keep FFR limited to the rare life-threatening emergency. The reply: It’s equally disingenuous to suggest that politics plays no role in the desire of the fire service to respond to as many EMS calls as possible.
The participants discussed how the public safety community may have created an unrealistic expectation with the public and elected officials, particularly in urban and suburban settings. The expectation is that when someone calls 9-1-1, resources will arrive in just a few minutes with a lights and siren response–regardless of the severity of the incident. Too often, in cases in which we provide rapid response to a low-acuity problem, the patient does not need an ambulance. Consequently, these patients often wait a long time before being seen by a doctor at the hospital. Changing the public’s expectations about what is a “reasonable” time to wait when they call 9-1-1, particularly for a low-acuity problem, won’t be easy. The policy of providing lights and siren responses to cases that are highly unlikely to require emergent intervention or transport proves problematic from a clinical, financial and risk management perspective.
A word of caution was raised for EMS systems that do not use a formal process for interviewing the caller. Those systems may lack the data required to tailor anything in their system’s response, including the use of lights-and-siren responses or FFR in general. It was asserted that there is sound evidence arguing in favor of strict algorithmic EMS call triage, and instituting such a system is an essential step toward evidence-based decision-making in the response process.
Tolerability of risk
The risk-benefit analysis of lights-and-siren responses raised a tolerability of risk issue, which is one of the inputs of the model in the Toronto research paper.1 Verbeek thought the risk dimension may be one of the most creative parts of the Toronto paper, because it quantifies the issue and can be applied to local data to derive a “best choice” cut-off point for MPDS determinants for where a system chooses to respond with lights and siren. Verbeek explained that the idea behind tolerability of risk is to decide how averse you are to taking a life (e.g., as a result of an emergency vehicle crash) versus how keen you are to save a life (e.g., when an FFR delivers the first and only shock and the patient survives to discharge neurologically intact).
If you are equally averse as you are keen, the slope of the tolerability of risk line is one. If you are twice as averse as you are keen, the slope of the line would be two. The steeper slope results in fewer MPDS determinants to which a lights-and-siren response would be assigned. He feels we need to find a balance between lights-and-siren responses to every call versus a lights-and-sirens response to calls for which FFR has a high chance of intervening in a potentially lifesaving way. That must be blended with a non-emergency response to calls for which the chance for FFR to make a lifesaving intervention is not all that high, but isn’t zero. Forward-thinking EMS systems may address these issues in consultation with the public, payers, ethicists, occupational health and safety experts, risk managers and other stakeholders.
The amount of time actually saved by responding with lights and siren was also raised. Studies were mentioned that showed only minimal difference in urban response times using lights and siren versus not using them.
Efficient use of resources
The study from Yale suggested that a formal emergency medical dispatch system with appropriate response configurations could potentially reduce FFR call volume by roughly one-half.3 One of the Yale study authors (Cone) was asked if any resistance to this type of policy change was encountered from their local fire service in New Haven, Conn. Cone replied that the idea for the study actually came from the fire union, which had been pressuring the city to reduce the EMS call volume for the first-responder engine companies. The local fire union has been quite happy with the results in terms of patient safety, decreased fuel costs, reduced wear and tear on the apparatus, etc. Cone has also heard (anecdotally) that it is less frequent for a more-distant unit to have to cover a call in a part of the city where the first-due unit is out on a medical run.
The same basic concept was implemented in the Tulsa EMS System. The result was a decrease in the EMS responses by Tulsa Fire apparatus and reduction of alpha- and bravo-level responses. Overall, the impact in Tulsa was a decrease of about 5,000 responses, or roughly 1%. It was pointed out that a reduction of activity in a profession that thrives on response and service must be communicated effectively to avoid the appearance of reductions in levels of service. Tulsa EMS Chief Michael Baker said that the safety of responding personnel and the appropriate deployment of resources was the primary focus–and cost savings naturally followed.
The discussion then addressed the challenge of going beyond lights-and-siren changes and into changes on vehicles or staffing levels. There seems to be a tendency for EMS and fire departments to deploy more resources than most calls require, “just in case” those additional resources are needed. This is an expensive strategy, and contrasts with a law enforcement model in which a single officer in a patrol car is expected to handle the majority of calls. If specific information suggested more resources are likely to be needed, they simply send more officers in patrol cars and/or more specialized units as needed. With this in mind, it was suggested that a reduced response approach involving less capable resources (e.g., BLS ambulances, two-person fire response, non-transporting ALS units) could be considered for EMS. A reply pointed out that such a strategy runs the risk of missing that one call in which someone came to harm because of the limited response. Verbeek noted that there may not be a scientific solution to this dilemma. Good science can definitely contribute to defining the risks associated with an overly vigorous stance in either direction, but ultimately the final solution will be policy driven.
This dialog revealed several “testable” ideas for future research. Identifying the non-clinical, value-added services from FFR and their relative cost-benefit will be a particularly important area for further research. Such information will be very helpful in setting policies that fit the right resource(s) with the right event.
- Craig A, Verbeek R, Schwartz B. Evidence-Based Optimization of Urban Firefighter First Response to Emergency Medical Services 9-1-1 Incidents. Prehosp Emerg Care. 2010;14:109—117. doi:10.3109/10903120903349754
- Cone DC, Galante N, MacMillan DS, et al. Is there a role for first responders in EMS responses to medical facilities? Prehosp Emerg Care. 2007;11:14—18. doi:10.1080/10903120601023453
- Cone DC, Galante N, MacMillan DS. Can emergency medical dispatch systems safely reduce first-responder call volume? Prehosp Emerg Care. 2008;12:479—485. doi:10.1080/10903120802290844