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EMS Systems: Have It My Way
Author: Brett Patterson, NAED
Copyright: Copyright 9-1-1 Magazine, Feature Content
By Brett Patterson, NAED
Recently, I had the opportunity to assist an international security company with the task of developing an EMS system in Central America. While this company had experience in law enforcement deployment, they had not yet put together an EMS system so they sought advice from others to help design one for a location where EMS was virtually non-existent (with the exception of limited providers for private payers). Although this seemed a daunting task, with serious staffing issues and difficult deadlines, I was immediately impressed by the rare opportunity to build a complete EMS system from scratch, without the influence of established political powers and the inevitable “that’s the way we do it here” attitude. However, as an advisor, my influence was limited to the deployment of a fixed resource and the provision of pre-arrival instructions which, while very rewarding, left me dreaming of complete control; what would I do if I was given the opportunity to build the ultimate EMS system? How would I address the many choices given to these fortunate contractors? The answers to these personal questions are the subject of this two-part column. While personal and opinionated, my hope is that my thoughts about of such a clean-slate opportunity will inspire some objective thought and perhaps motivate change in systems burdened by influences that have little to do with patient care.
Limitations and Rewards
There are many questions facing EMS consultants and system designers today, and there is relatively little research to guide us. What we do have is personal experience, developed at work and in our travels. My assessment of the ultimate EMS system is based on my experience, the research I am familiar with, and is driven by a passion to provide efficient and effective pre-hospital care in an environment motivated by genuine concern.
Unfortunately, money is often a limiting factor, which is why I have conveniently chosen not to discuss this specifically in this fantasy simply because it is tedious and complicates the issue. However, monetary concerns can be very deceiving. Spending money to become smart and efficient can create an excellent return on investment, both clinically and in terms of resource management, because smart people operating with efficiency makes for an effective EMS system where patients win, employees win, and employers win. Therefore, staffing, technology, training, and quality improvement (QI) will not be sacrificed here due to monetary concerns.
If you want to spawn some passionate debate among EMS providers, bring up the subject of public versus private service. If you’re really brave, go a step further and talk about union versus non-union or fire-rescue versus stand-alone medics. I have worked in and with many system designs and would prefer to select a combination of deployment strategies that takes advantage of selective benefits while avoiding the negative aspects that are inevitably associated with all options. Of course, this is more easily done when there are no political pressures, as is the case with this experiment, so I will proceed by picking and choosing without fear of upsetting the status quo.
My ultimate EMS system would be privately run, non-union, and contractually obligated and supervised by local government. It would be privately run to maximize efficiency and government supervised to limit greed and insure the best interest of the public. It would be non-union by employee choice because the leadership would be staunchly QI oriented; employees would be paid well, empowered and involved, safe, constantly learning, and happy.
My deployment preference would be EMS specific, with fire and police involvement for critical incidents when the closest trained responder can have a lifesaving impact, i.e., automatic defibrillator deployment, CPR, or airway obstruction intervention, or when special fire department or law enforcement expertise is required. In this way, academic and practical training could be specific to EMS, and the service would attract employees with a related passion.
The system exception to this EMS specificity would be the communication center, which would be multidisciplinary. Employees in the communication center would be cross-trained to handle police, fire, and medical calls, and would also be trained to dispatch all three positions.
Consolidation is the wave of the future and few would argue that cross training and placing all three operations in the same building eliminates redundancies and saves money. I would also assert that having everyone in the same building improves communication not only with regard to the dispatchers, but also with regard to the field. Cross training also allows for personnel to easily fill in for each other when shifting, high call volumes can move from call taker to dispatcher, or from one discipline to another. An intangible benefit is the worker’s ability to move around and change positions, thereby remaining challenged and avoiding the boredom or burnout associated with doing one task repetitively.
I believe good dispatch protocols, EMD compliance to protocol, and safe resource assignment practice can safely, efficiently, and effectively allocate resources to various patient acuities. Therefore, my ultimate EMS system would rely on EMDs to allocate the following range of patient resources (the actual numbers would relate to population and demographics, and hospital and extended care facility need):
Specialized, Critical Care Units with Obstetric, Neonatal, and Cardiac Capabilities – Such units would be staffed with critical care registered nurses and paramedics and would be statically based at appropriate hospitals. These specialized units would be used primarily for emergent, inter-facility transfers but would also be deployed for exceptional EMS cases such as premature or high-risk deliveries and cardiac cases involving advanced care, i.e., implanted cardiac defibrillators, ventricular assist devices, etc.
Although a clinical reality is that only a small proportion of EMS patients require ALS care, a type of care that few experts can actually define with consensus, my EMS system would be based on advanced life support (ALS)-level transport capability, with basic life support (BLS) vehicles utilized for first response in time-critical situations. All transport units would be ALS, staffed with a senior paramedic, a junior paramedic, and an EMT, and the fleet would be subsidized by non-transport, AED-equipped BLS vehicles deployed to assist with manpower issues, respond to critical incidents, and restock ambulances.
On the surface, staffing with two paramedics and an EMT may sound expensive, and may not offer much faith in a priority dispatch environment, but it has several advantages. First, it eliminates the redundancy of having two fleets which, when staffed with only two people, requires the dispatch of a second unit when manpower is needed. Second, it allows for an ambulance to leave a paramedic and redundant set of essential equipment at the scene of a stable patient, allowing for rapid response to a nearby, critical call. An EMT can then be dispatched with an ambulance to cover the initial call and, if necessary, one of the non-transport BLS units can be dispatched for extra manpower to the critical call. Finally, the paramedic redundancy allows for the practical training and orientation of new paramedics who serve actively as juniors in the system.
As mentioned previously, fire crews and law enforcement officers would play a limited but important role as AED-equipped first responders, responding to time-critical events when defibrillation or immediate airway intervention is required.
I’m a firm believer in System Status Management (SSM). This opinion has been formed even after spending many seemingly endless 12-hour shifts roaming around a county awaiting the next call and never realizing the comfort of a La-Z-Boy or a meal cooked on professional equipment I wish I had in my own house. My opinion is based on the simple realities of unit-hour-utilization. Accurate data has shown us that call volumes, and even call types, can be predicted with reasonable accuracy and it is, therefore, very reasonable to position resources according to that demand. Demand met with efficiency translates into improved patient care and, with proper management, SSM doesn’t necessarily translate into employee burnout. Of course, this is conditional. Patient care must not only be a goal, it must be a fundamental desire.
First and foremost, I would seek a progressive medical director that shares my vision of excellence. This medical director would believe that EMS is a process, and would have passionate involvement in all of the components that make up that process. He would be a scholar of emergency medicine who monitors current research, not only related to field medicine, but resource management and Dispatch Life Support (DLS) as well, because he considers these roles an integral part of pre hospital care. He would also conduct, support, and encourage formal research in our own system, especially in areas in need of further study, such as DLS. He would be dedicated to continuing education and would insistently support learning and advancement for field and communication center employees. He would be a respected member, presenter, and leader of national medical director and EMS physician associations promoting the advancement of EMS through the sharing of knowledge. Finally, he would be so progressive that he would be known for employing innovative, and sometimes controversial, ideas that push the boundaries of EMS and often ruffle the feathers of the establishment. At times, he would be a political hot potato, but he would be respected and admired by his peers for being influenced and motivated only by his desire to improve patient care. I have purposefully used the pronoun “he” in this section because I know of such a person; Joe, do you need a job?
The most important pre-requisite of the administrative leaders in my system would be a commitment to QI. They would empower workers of all processes to measure and improve what they do, and would respect them as peers. They would ensure that feedback regarding performance was provided at all levels by training supervisors and middle management using progressive, QI curriculum. The entire culture of the organization would be process oriented and everyone, from top to bottom, would not only be accountable for their processes, they would be trained and empowered to measure, analyze, and change those processes to ensure continuous improvement. Numerical goals would be non-existent, and would be replaced by a commitment to excellence.
A fundamental and often over-looked side effect of education is happiness. The obvious benefits of training are that employees are better equipped to do their jobs efficiently and effectively but efficiency and effectiveness are not only a product of knowledge, they are a directly influenced by the emotional state of their producers. This is why education, which is purposefully non-specific here, not simply job-specific training, would be a key component of my fantasy EMS system.
Education would necessarily include job-specific training in an effort to keep pace with current technology, operations, and clinical standards, but it would also include QI training, specific fellowships of interest, and sponsorship of general education. The QI training is necessary to foster the culture of the organization and enable employees to manage their processes. The fellowships promote learning in areas specific to EMS promotion. This job-specific and yet interest-oriented learning not only enables the individual prospects of employees, but also helps to ensure that positions are filled with competent and engaged people. Company sponsorship of general education, while less specific to EMS, fosters learning and individual growth. While less tangible than EMS-oriented training, general education simply fulfills an innate desire to learn. Simply put, people void of learning become stagnant and unhappy, while people who are constantly learning, no matter what the subject, tend to be more fulfilled, happier, and, therefore, more productive in all aspects of their lives.
Undoubtedly, this article will inspire debate. This is my hope. It is only through debate that we can inspire change. Debate forces us to look not only at the means but, more importantly, the goals of our endeavors. Too often we justify our means by citing goals that had little to do, honestly, with the creation of our methods. Debate forces us to look at our goals through a fresh set of eyes and contemplate different methods, even when current methods seem universally accepted.
Our little corner of the world is constantly evolving. This evolution demands periodic, if not continual, re evaluation of our methods. Likely inspired by Darwin, and eloquently put by a respected colleague, Dr. Norm Dinerman, “Mutate or die.”
About the Author
Brett Patterson is an Academics and Standards Associate for the National Academies of Emergency Dispatch (NAED). He is a senior EMD instructor, a member of the NAED College of Fellows, Standards Council, and Rules Committee. He also serves as the Academy’s content editor and Research Council Chairman. Brett became a paramedic in 1981 and began a career in EMS communications in 1987. Prior to accepting a position with NAED he spent ten years working in a public utility model EMS system in Pinellas County, Florida.