Michael Hayward, chief of operations at Indianapolis EMS, explains how the agency was able to adapt and thrive by rethinking staffing strategies.
The EMS industry is at a critical juncture in its evolution. Increasing call volumes coupled with decreasing applicant pools reveal an unfortunate truth about our traditional model for delivering emergency medical service in urban and suburban environments: it is unsustainable. Gone are the days of resources, both human and capital, being so plentiful that we can put one (or even two) paramedics on every ambulance and still expect to be able to deploy enough ambulances to meet the needs of our growing communities. This combined with the increased ability to analyze the data that comes from our runs leaves us with one solution. We need to do a better job of matching resources to needs.
Historically, many large urban based EMS agencies provided the majority of their service through an almost exclusive advanced life support (ALS) model. Many times, paramedics were forged from “street-trained” EMTs who gained priceless practical knowledge by years spent working with their paramedic counterpart. Many, after some time, would choose to take the next step by earning their paramedic license. The cycle repeated itself for many years. Indianapolis EMS was no different than many of the similar sized agencies. It was typical for us to have anywhere between three-to-five applicants for every paramedic spot, and we ran 100% ALS to all calls regardless of the initial dispatch complaint. This system worked for many years. Then, like almost all systems around the country, the COVID pandemic changed everything.
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Today we see dwindling applicant pools. The number of licensed, practicing paramedics is declining. The traditional pipeline for new EMTs is insufficient to meet the need. Call volumes are increasing. Reimbursement rates are low. The deck is stacked against us, and changes need to be made. At the same time, we have growing data from our electronic health care records allowing us to better examine the data behind our runs. We are able to rapidly investigate our percentages of ALS vs. BLS runs, geographical trends in run types and other data points that prove the 100% ALS approach of the past is not the ideal delivery model. These two factors, decrease in applicant pool and increase in data, should push a service to look for a more aligned deployment model that not only sends the most appropriate resource, but also maximizes the impact of the scarcest of those resources, the paramedic.
Locally, Indianapolis EMS has made the decision to challenge a number of traditional paradigms in an effort to meet the needs of a changing urban landscape. Gone are the days when you continually backfill your workforce with applicants where “EMS runs in the family.” It is imperative that you look for new ways to recruit people into this great profession. We, as EMS leaders, must commit to producing our own workforce. Locally, we are doing this through multiple routes. In addition to the traditional hiring process, we have committed to a program of hiring untrained, but otherwise qualified individuals and paying them while they attend a combination EMT class and new hire academy. This allows people to receive full-time salary and benefits while becoming certified providers. Upon successful completion of their training, we immediately transition them to a position in our operations division. While certainly an expensive venture, we are hopeful the results will far outweigh the cost. We have found that we are introducing people to EMS who would have never considered this career in public safety. From there, we build our next generation of providers.
While civilian to EMT programs help people get in the door, the shortfall in paramedics is the real challenge. How can you continue to provide a level of ALS care that your community has come to expect? How do you find enough paramedics to put on all the ambulances? The bad news is you can’t. The good news is you don’t need to. This is where, as an EMS leader, you must look at your data. A review of our past transports revealed that our ALS fleet was transporting 56% of their patients with a BLS level of care. With paramedics in incredibly short supply, how do we justify having a paramedic spend 56% of their time transporting a BLS patient and unavailable for the next ALS call? Placing BLS ambulances in the mix did nothing to change ALS to BLS transport ratio because run coding at the dispatch level could not accurately determine acuity.
So how do we better match the resource to the need? We take the scarcest resource out of the ambulance. In an area of about 20 square miles, roughly in the center of our response area, we moved our paramedics off ambulances and placed them in non-transporting response vehicles. When they determine a patient requires a BLS level of care they hand off to the BLS ambulance and mark as available for the next call. If the patient requires ALS care, the paramedic gets on the ambulance to provide care, and one of the EMT crew members drives the paramedic’s vehicle to the hospital. The correct resource is matched to the correct patient, and the necessary people are in the correct place for appropriate coding and billing. Those 20 square miles were once covered by 10 ALS ambulances. They are now served by 10 BLS ambulances and four ALS non-transporting units during the day, and three at night. This is truly a force multiplier in the world of EMS. In addition to this clinical benefit to the system, this is a way for both paramedics and EMTs to achieve a level of professional growth that many in our field so deeply desire.
This program is new, so meaningful data on its impact does not exist yet. The coming year will provide some fascinating information about what EMS will look like in Indianapolis in the future. Anecdotally, we are hearing good things from our paramedics. The problem we have seen most so far is that we need more BLS ambulances for the paramedics to work with. Finding additional BLS resources is still a challenge, but one that is much less daunting than finding ALS resources. We have also seen an increase in the skill and confidence of our EMTs. IEMS has always been fortunate to have, in my opinion, the best EMTs around. Partnering them with another EMT in a busy, urban system, has honed their skills even further.
EMS is at a crucial juncture. The toll of the COVID pandemic, combined with the unprecedented decrease in workforce across the country, has forced EMS leaders to rethink their strategies. However, this challenge should help push EMS leaders to look at their current deployment models and ask, “is this the best way?” EMS is changing, and it is our duty to adapt alongside. We present just one example of how a system can use data to make a change that not only serves their community better but also their workforce as a whole.
