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Saturday, April 28, 2012

The Future of EMS in Columbus (Some Thoughts..)


Good afternoon Everyone.  This post may only appeal to a few of my regular readers, but it is something I have been thinking about a long time and finally decided to put to "paper".  Basically, its an expanded suggestion on how the CFD could address the future of their EMS system.  It is not meant to union bash, or suggest reducing headcount-- only applying some critical lessons learned, with available technology, to address the realities of providing EMS in a major American City that needs a much larger fire department than it currently has. 

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Columbus Division of Fire: The Future of EMS



In the Mid 1990s, Columbus Fire, in an effort to improve EMS service delivery, instituted a single-tier, all ALS System to replace the previous two-tiered system that had been in operation since the introduction of Firefighter based full-time paramedic units in 1972.  In the past seventeen years, like many other large cities, the CFD EMS call volume has skyrocketed as more and more citizens and visitors call 911 for a greater variety of medical conditions.  Many of these calls are not for ALS incidents and, as a result, Columbus Fire does not currently posses the ability to adapt resources to meet the realities of EMS service demands in this environment.  Basically, CFD has far more paramedics than it needs.

Not only does this result in misdirected resources during a time of financial hardship for the City—it also likely does not result in improved care worthy of the expense.  Most famously, a 2005 USA Today series feature the results of numerous studies on the topic of Emergency Medicine that determined more paramedics did not lead to better outcomes for patients—ALS or BLS. According to the study, Paramedics should be viewed as specialized resources and only deployed in effective quantities to meet realistic demand.  To paraphrase the studies: more does not necessarily mean better.  Fortunately opportunities to improve EMS in Columbus do exist. As part of technology efforts introduced in recent years, as well as the continuing need to effectively manage limited budgets, the time to assess the EMS delivery system in Columbus is truly today. 

Several Key Goals should be at the root of an attempt to improve the effectiveness of Columbus Fire EMS:

·         Improve patient care by focusing ALS resources on ALS incidents.

·         Reduce reliance on automatic aid partners for BLS medical incidents

·         Leverage advances in the new Computer Assisted Dispatch System to improve response times; call-handling; and resource management

·         Reduce Costs of the EMS system and redirect funding into badly needed service enhancements

·         Improve utilization of existing resources to ensure that personnel respond to an ample number of ALS calls to maintain their skills

·         Improve the safety of Emergency Responses by CFD apparatus by instituting non-emergency responses to minor incidents whenever possible.

The primary methodology to achieve this goal will involve utilizing the department’s new Computer Assisted Dispatch System, along with a Priority Medical Dispatch Call-Taking protocol; to improve the triage efforts of incoming calls and thereby improve resource management and assignment.  This will occur through the following:

1.                Intergraph CAD can be programmed to recommend both ALS units and BLS units based on proximity and call-type.  For example, if an ALS unit is five minutes from a BLS call, but the nearest BLS is fifteen minutes away, the CAD will recommend the ALS unit to respond.  This feature will permit ALS ambulances in the outer portions of the city to handle the BLS and ALS calls in their areas. (32s; 5’s; 29s, etc). 

 2.                  Dispatching algorithms can be developed, based on call type and level, which       
                  accommodate a far greater level of detail. 
                  Suggested dispatch algorithms would be:

“Alpha Response” [BLS--non-emergency]- 
                       Nearest Available BLS Ambulance; if ETA > 15 Minutes,
                         then nearest AvailableEngine to evaluate patient and determine if Ambulance needed.

                                “Bravo Response” [BLS--Emergency]
                                 Nearest Available BLS Ambulance; if ETA > 8 Minutes then:

                                  If ALS AMB is closer send ALS Ambulance only

                                   If no ALS AMB closer but Engine/Rescue/Ladder is- dispatch as first responder

                                “Charlie Response” [ALS- Level-1]

                                                Nearest Available Paramedic Unit: ALS Ambulance; Engine; Rescue

                                                If ALS Ambulance not Closest ALS unit; ALSO Assign nearest

                                                If BLS Ambulance is within 8 minutes—Assign along with above

[permit Paramedics from Eng or Res to ride with BLS to Hospital if best option]



                                “Delta Response” [ALS Level-2]

                                                Nearest available ALS Unit; nearest available BLS Unit [If < 8 Min ETA]

                                                If ALS Engine or rescue is closer than ALS Transport = Assign along with

                                                Nearest EMS Coordinator

                                 “Echo Response” [ALS Critical]

                                                Nearest Available ALS equipped unit [transport/Rescue/Engine]

                                                Nearest Available ALS Transport [if not above]

                                                Nearest Available BLS Transport  [if ETA <8 mins]

IF NO Close BLS and ALS Transport is Closest ADD (1) Suppression for manpower

Nearest EMS Coordinator

3.                   Dispatching algorithms can also be introduced that prompt the dispatcher for the following situations:

·         Redirect units from lower priority calls to higher priority calls that they are closer to. (Improves response times)

·         Check with units in a hospital after a certain time to see if they are available to take calls in close proximity to an incident—(improves resource management)

  • Prioritize lower priority calls to CFD units—preserving automatic aid medic units  for ALS/serious incidents 

·         Provide a ‘busy period modification to response to permit improved resource management during peak periods.



·         Adjust the response location of slower units during “peak” periods of demand. (EMS Move ups when coverage is seriously depleted in an area)

Related Solution: Rescues; Engine/Rescues and Engines with Combi-Tools:

 A related potential solution exists as a part of  the same effort regarding the response of

an additional rescue company whenever a township rescue [normally Rescue/Engine]  is assigned to an auto accident as well as the assignment of Rescues to long-distance runs where they have little likelihood of even arriving at the scene.   This is a significant waste of resources and often an unnecessary emergency response which puts the lives of responders and the public in jeopardy. CAD can be programmed to recognize the capability as dual function: Rescue/Engine but only within a certain geographic proximity and/or other conditions. 

                Definitions:

Heavy Rescue:  not dual function; dedicated crew; large amount of equipment & verified training.

Rescue/Engine:  Dual Function Capability [Engine & Medium Rescue]

Engine with Combi-Tool:  Dual Function [Engine & Light Rescue]

    Responses:

                Engine with Combi-Tool:  Only if nearest available on generic accident

                [Assign additional engine and min. of medium rescue with]

                Rescue/Engine: 

[Auto Accidents] Responds as Eng. if 1st Due; Rescue if beyond 1st                [Fires] only as rescue if ETA < 12 Mins, not 1st- 4th Due

Generic Auto Accident
           
                                                Heavy Rescue assigned on initial only if <10 minute ETA

Rescue Engine Assigned only if < 12 min eta

 Reported Pin; Highway incident or working Extrication:

Nearest (2) available extrication equipped units

[one of which must be Heavy Rescue]

                 Reported Fire; Gas Leak; etc.

                                Rescue if ETA < 12 Mins or 1st/2nd Due

                                Rescue Engine if not 1st-4th due (would go as engine) and eta < 12

                Working Fire:

                                Must Have nearest Available Heavy Rescue



Changes to EMS Resources:

 From the above adjustments in Call-Typing, unit assignment and deployment; the following realignments in the daily resources deployed by the department will permit management of the new call-flow and response procedures:


·         Reintroduction of BLS Ambulances (20 Units)

·         Reduction in the number of ALS Transport Units to Sixteen (16)

·         Reduction of ALS Engines to (15)

·         Increase in the number of ALS Heavy Rescue Units to seven (7)

·         Introduction of two (2) 24 Hour EMS Training/Infectious Disease Control officers

·         Introduction of a twenty-four-Hour EMS Battalion Chief [EMS-10]

·         Additional twenty-four-hour EMS Captain


Total Personnel:

                BLS Ambulances: (3) FFs per Unit per vehicle: [min 2]                            (180)

                [1;2;4;5;6;7;8;10;12;15;17;18;19;20;21;22;24;27;30;31]


                ALS Transport Units: (3.5) Medics Per Unit per vehicle: [min 2]        (168)

                [1;5;6;11;13;14;15;17;18;23;25;26;28;29;32;33]


                ALS Engines: (2) medics per unit per company: [min 1]                          (90)

                [4;5;7;22;26;27;28;29;30;31;32;33;34;35;36]

               
ALS Heavy Rescues: (2) medics per unit per company: [min 1]          (42)

                [2;4;5;6;11;16;17]


                Paramedic Officers: (1) per unit per vehicle                                                   (21)

                10@1; 11@8; 12@ 33; 13@19; 14@15; 15@12; 16@21; 17@34]



                Paramedic Training/Infectious Disease Control:                                        (6)



                Total:  (3) BC   (6) Capt   (18 Lts)   316 Paramedics  =   Total Medics:  327

                 Daily Assigned Medics:  109                                   Minimum on Duty: 63  

                Leave: Kelly Days:  (16) per Day          Vacation Spots: (15) per day

Cost Savings/Revenue Increases

·         Reduction in number of Medics:  approximately 350

                                [This is equivalent to approximately 40 Full-time positions]

·         Additional savings:            

o        training/CME reductions/

o       Supplies; drugs; equipment reductions

o       Reduced wear on units

·         Revenue:  increase number of calls handled by CFD units


Enhancements with personnel savings:

o       Increase in number of transport units from 32 to 36 [BLS, existing personnel]
         
o       Increase in Heavy Rescues to (7) from (5) [24 positions] 

                              o       With streamlining of Kelly Day and Vacation Schedules:

o       Construction and Staffing:

§         Station 35 [Far east-Waggoner Road]     [Engine Only]

§         Station 36 [Northeast- Harlem Rd]            [Engine Only]

 Projected Outcomes:

 Taken together,  the service enhancements to the EMS program; improvements in Dispatching methodology; improved resource management and deployment; and related adjustments to the amount of Apparatus and number of firehouses will significantly improve the effectiveness of the Columbus Division of Fire while improving the cost-benefit relationship.  Beyond the ideas contained within this brief plan, there are likely many other solutions to the challenges inherent in providing Fire/EMS services in an expanding City without dramatically increasing costs.  Many of these solutions will be found by partnering with the members of the department and the firefighters union—IAFF 67.  If each of the stakeholders involved participates with honesty and openness and the desire to truly find solutions to the challenges the CFD faces; then the department can truly begin a new era of dedication and effective service.


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