Ems System in King County

King County, WAshignton Emergency Medical Service (EMS) "Measure and improve" is the motto that drives King County EMS Demographics of the System King County, Washington - Overview Service Area Population Density Economic Indicators from Census Data Structural Attributes of the EMS System Geographic Scope Standard Setting and Enforcement Division of Functions Market Allocation Failure to Perform -- Consequences Business Structure Management Level King County EMS System Outputs Prevention and Early Dectection Bystander Action and System Access 911 Call Taking First Response Dispatch and Services Ambulance Services Receiving Facility Interface Medical Oversight HallMarks of HPEMS Accountability Independent Oversight Accounting of Service Costs System Features that Ensure Economic Efficiency System Features that Ensure Long-Term High Performance King County EMS Performance Measures Clinical Level 22 REsponse Time STandard 22 Cost Per Transport 25 Cost Per Unit Hour 25 Unit Hour Utilization 26 System Cost Per-Capita 26 Subsidy Per-Captia 26 Conclusion 27 References 29 Appendix 32 Demographics of the System King County, Washington - Overview King County, Washington is the most populace county in the state of Washington as well as in the top 15 most populated counties in the United States (13th).

The county has a total land area of 2,307 square miles with slight over eight percent of this area being water (United States Census Bureau, 2015).

The area is known for being a center for liberal politics and Seattle is one of the most liberal cities in the country and has elected socialist councilmembers, gay mayors, endorsed the "War on Christmas," has strongly supported environmental movements, and is among the top five cities with the fewest cars; however, although Seattle and King County are often associated with liberalism in its politics and its policies, some argue that there are still many strong conservative elements despite its strong progressive tendencies (Anderstone, 2014).

King County was actually renamed in 2005 to honor Dr. Martin Luther King Jr. as opposed to the original founder who also shared the last name King. Population King County, Washington, has a population of just over two million people based on an 2014 estimate of population that is derived from an extrapolation of the official U.S. Census Bureau report that was conducted in 2010; in 2010 the population figure was noted as 1,931,256 (United States Census Bureau, 2015).

The population growth in the county has been estimated at roughly eleven percent which also occurred during a period of flat job growth and indicates a rate of growth that is not based on the county's economic performance and job opportunities (King County, 2013). The 20th century ushered in a period of rapid population growth and industrialization in the region. Service Area The Emergency Medical Services (EMS) Division of Public Health - Seattle & King County represents a complex network of different responders and providers.

The network is organized under a Medic One/EMS system that provides coordination and standardization efforts within the system. For example, there is standardized EMT training, continuing education, dispatcher training and code standardization, and even data collection provided by the Medic One organization.

Anytime you call *** in King County for a medical emergency, you are using the Medic One/EMS system and the Medic One system in King County is dedicated to increasing survival and reducing disability from out-of-hospital emergencies in the county by providing the highest quality patient care in the pre-hospital setting (Pubic Health - Seattle and King County, 2013, p. 6).

In order to meet the county's objectives, the Division adheres to a medical model of integrated regional with the Medic One/EMS services, which includes a philosophy of cooperative decision making, and the development of innovative strategic initiatives that address the demand for services while also trying to build recourse efficiencies in the system.

All of the EMS Division programs have been designed to enhance these efforts through strong partnerships with other regional EMS agencies as well as utilizing strong leadership to further these objectives (Public Health - Seattle & King County, 2015, pp. 6-7).

Population Density The area within King County is geographically diverse with points that are at sea level as well as many points of high altitude; the same can be said about its human population with a significant amount of area being highly-dense in population and urbanized, while other areas being mostly rural with a low population density (Vance-Sherman, 2015). Seattle, the regions urban center, is one of the most population dense cities in the United States.

Of the 366 "Metropolitan Statistical Areas" the Census Bureau tabulated, in the 2010 census Seattle-Tacoma-Bellevue came 24th in population-weighted density at 4721.6 people per square mile, although it's 15th in overall population at 3.4m people (Duke, 2012). However, the city is rapidly becoming denser with further population growth and much of this density is increasing through diversity. Figure 1 - Seattle's DiversityInvalid source specified.

Economic Indicators from Census Data The region can be categorized by a wage and income rate that was significantly higher than the country's average and there were also far fewer people living in poverty relative to state and national averages (Vance-Sherman, 2015). Seattle's progressive government was one of the first in the country to institute a significantly higher minimum wage ($15 dollars an hour). The program has so far been argued to be a success.

Furthermore, the results of some studies have indicated that the unemployment rate has decreased after the minimum wage increase. In one period between January and December of 2014, business owners (and their customers) unemployment decreased 17.46%, falling from 6.3% to 5.2% (Worstall, 2015). The fact that King County is largely progressive and also a strong economy has had major implications for public services include the county's Emergency Management System (EMS).

Structural Attributes of the EMS System Geographic Scope The Medic One/EMS system in King County covers the full range of the county's boundaries and in some cases actually extends beyond these boundaries as it coordinates with neighboring systems. According to Vance-Sherman (2015) the regional context can be described as: "King County's current boundaries situate it between Puget Sound to the west and the crest line of the Cascade Range to the east. It borders Snohomish County to the north and Pierce County to the south.

King County is very geographically diverse, with points at sea level and a high point of nearly 8,000 feet. The human geography of King County is also diverse; characterized by high-density urbanization along the shores of Puget Sound, suburban communities to the east of Lake Washington, rural communities to the southeast and remote towns in the Cascade foothills. There are 39 towns and cities located in King County (Vance-Sherman, 2015)." Standard Setting and Enforcement The Medic One/EMS system is the central organization that plays a central collaborative role in King County.

This organization operates based on partnerships that are built on regional, collaborative, cross-jurisdictional coordination -- while each provider operates individually, the care provided to the patient operates within a "seamless" system (Public Health - Seattle and King County, N.d., p. 4). It is this continuum of consistent, standardized medical care and collaboration between 30 fire departments, six paramedic agencies, five EMS dispatch centers, 20 hospitals, the University of Washington, and the citizens throughout King County that allows the system to excel in pre-hospital emergency care.

The Medic One/EMS system is also responsible for medical training which is provided on a regional basis to ensure no matter the location within King County the medical triage and delivery is the same (Public Health - Seattle and King County, N.d., p. 4). Division of Functions The Medic One/EMS system operates on a tiered system model that enlists a Basic Life Support (BLS) as the standard operating procedure.

Most incidents are responded to with BLS services and the ALS services are reserved for the incidents that the dispatchers deem as medically necessary. This reserves the more limited regional resource of an ALS unit (known locally as a medic unit) for the serious or life-threatening injuries and illnesses (Public Health - Seattle and King County, N.d., p. 11)." The dispatch centers are trained to specifically code calls and prioritize the response based on this system to maximize the efficiency of the resources available in the system.

The Medic One/EMS manages the full out-of-hospital continuum of care throughout the entire county through its partnership with 30 fire departments, six paramedic agencies, five EMS dispatch centers, 20 hospitals, the University of Washington, and the citizens throughout King County. There are five major components that are included in the Medic One/EMS system in King County that include: 1. Universal access 2. Dispatcher triage 3. Basic Life Support Services 4. Advanced Life Support Services 5.

Transportation to a Hospital Market Allocation The Medic One/EMS system has a fairly unique funding structure that is only possible because of the regions high economic development and politically progressive leadership. Medic One/EMS is supported by levy funds that make the services it provides less vulnerable, though not immune, to fluctuations in the economy and this system has maintained financial viability and stability, even throughout the economic recession, due to a sustained focus on operational and financial efficiencies (Public Health - Seattle and King County, N.d., pp.

10-11).

In 2012 the proposed levy (which was passed) called for a levy rate of 33.5 cents/$1,000 AV means that the average homeowner will pay approximately $107 a year in 2014 for highly trained medical personnel to arrive within minutes of an emergency, any time of day or night, no matter where in King County -- this is $3 less than the average homeowner paid in 2008 for these same services and the EMS system's continued focus on operational and financial efficiencies has allowed it to provide world-class EMS services at a fair market rate (Pubic Health - Seattle and King County, 2013, pp.

8-9). Figure 2 - King County Levy Financial Breakdown (Pubic Health - Seattle and King County, 2013) Failure to Perform -- Consequences The Medic One/EMS system is responsible for managing the entire King County EMS system and this organization has gained a unique funding source from the levy instituted with the county's property tax. The system must be accountable to the public and continue to provide high standards of service that also creates value financially by operating efficiently and effectively in terms of resource usage and funding levels.

If the system was unable to create a strong value proposition for public oversight, the consequences would include the public losing confidence in the system and not approving future levies. Business Structure The business structure for the Medic One/EMS system is a complex network of various organizations and providers. The Medic One/EMS System in King County is distinctive from other systems in that it (a) is medically based, (b) is regional, and (c) uses tiered out-of-hospital response (Public Health - Seattle & King County, 2015, p. 6).

The Medic One/EMS system is the centralized unit that provides universal access to everyone in the county, manages the dispatcher triage protocols, and organizes BLS, ALS, and transport to the hospitals. Management Level The Medic One/EMS system's management is specialized relative to the organizational role within the system and there specific objectives. The leadership for the Medic One/EMS centralized coordinating role is the highest level of management in the system and has roles that focus on quality and efficiency in the system.

"The leadership of the Medical Program Director ensures the success and the ongoing medical quality improvement of the EMS system. Mickey Eisenberg, MD, PhD, has filled this role for more than ten years. His substantial responsibilities include writing and approving medical protocols, approving all initial Emergency Medical Technician (EMT) and continuing EMT medical education, undertaking new and ongoing medical quality improvement activities, and initiating disciplinary actions when necessary (Public Health - Seattle & King County, 2015, pp.

6-7)." Furthermore, on a high level, management is also assisted by advanced system metrics that allow leaders to continually evaluate performance standards in terms of quality and efficiency metrics and even conduct simulations to ensure that all objectives are being met. The EMS division has adopted a mantra of "measure and improve" and the system and its performance are constantly being monitored for potential areas of improvement (Public Health - Seattle & King County, 2015, p. 17).

Figure 3 - Example of a Medical Quality Improvement Study in King County (Public Health - Seattle & King County, 2015, p. 17) Although the management function and related metrics are well-defined on a high-level, the EMS system must also measure performance and meet management objectives on a regional and tactical level. Regional Strategic Initiatives for the system address issues such as (Public Health - Seattle & King County, 2015, p.

9): Uniform training of EMTs and dispatchers Regional medical control and quality improvement Injury prevention programs Regional data collection and analysis Regional planning for the EMS system Financial/administrative management The "measure and improve mantra" has been integrated to each level of management in the Medic One/EMS system and serves as a foundation for evidence-based management of the entire system to ensure that it provides quality and efficiency to the residents of Seattle and King County, Washington.

King County EMS System Outputs Prevention and Early Dectection King County has a number of prevention and early detection initiatives that have been implemented for a range of different chronic diseases and conditions. The county collects a broad array of comprehensive, population-based data with the emphasis on relying on data about the entire community to look at multiple determinants of health.

Specific data related to chronic health include (King County Government, N.d.): Activity limitation Fair or poor health Number of unhealthy days Diabetes prevalence No leisure physical activity Percentage of smokers Asthma prevalence Unhealthy weight Collecting data can help the country and the EMS system prepare for common community needs based on the communities, or even different neighborhoods, health profiles.

The county also collects statistics on violent crimes which can also prepare response teams by understanding the likelihoods of the geography in which these instances are more likely to take place. For example, between 2006 and 2010, the average numbers of firearm deaths per year were 131 in King County and during these 5 years, 50 King County children and youth age 19 and under were killed by firearms (King County Government, N.d.). Therefore, by plotting the geospatial aspects of these crimes, response units can be better prepared in crime hotspots.

Furthermore, data is collected regarding EMS call volumes and dispatch rates from previous years that can also be used for preparation and planning.

Figure 4-2014 Total ALS Call Volume (Public Health - Seattle & King County, 2015) Bystander Action and System Access Numerous clinical studies have demonstrated that patients who receive early cardiopulmonary resuscitation (CPR) and early defibrillation have a significantly improved chance of survival from cardiac arrest; the EMS Division offers a number of programs to provide CPR and Automated External Defibrillator (AED) training to residents of King County, while also working to place these devices in public locations and encourage the public to register their AEDs (Public Health - Seattle & King County, 2015).

There are now currently over three thousand AEDs registered King County and the program is continually expanding as more location and more training services are being offered. 911 Call Taking King County has implemented a 911 call taking system that is based upon a tiered response system with advanced metrics to ensure operational excellence while also optimizing resource usage. For example, dispatchers are trained to use a set of medical response assessment data to analyze the level of need an attempt to reserve ALS services unless needed.

The dispatch response are collected as data a regularly screened for any potential problems to ensure the systems performance. First Response Dispatch and Services The dispatch centers are trained to specifically code calls and prioritize the response based on this system to maximize the efficiency of the resources available in the system. Dispatch 9-1-1 calls are received by one of five dispatch centers in Seattle and throughout King County. Following medically approved emergency dispatch triage guidelines, dispatchers determine the level of care needed.

The Medic One/EMS manages the full out-of-hospital continuum of care throughout the entire county through its partnership with 30 fire departments, six paramedic agencies, five EMS dispatch centers, 20 hospitals, the University of Washington, and the citizens throughout King County. King County has implemented a tiered response system with advanced metrics to ensure operational excellence while also optimizing resource usage which begins at the dispatch level.

For example, dispatchers are trained to use a set of medical response assessment data to analyze the level of need an attempt to reserve ALS services unless needed. The dispatch response are collected as data a regularly screened for any potential problems to ensure the systems performance. Ambulance Services The Medic One/EMS system operates on a tiered system model that enlists a Basic Life Support (BLS) as the standard operating procedure.

Most incidents are responded to with BLS services and the ALS services are reserved for the incidents that the dispatchers deem as medically necessary. This reserves the more limited regional resource of an ALS unit (known locally as a medic unit) for the serious or life-threatening injuries and illnesses (Public Health - Seattle and King County, N.d., p. 11)." Receiving Facility Interface Once a patient is stabilized, it is determined whether transport to a hospital or clinic for further medical attention is needed.

Transport is most often provided by an ALS agency, BLS agency, or private ambulance. There is a level of uniformity in the system due to the standardization of training which has helped to improve the receiving of a patient from a transport service. Medical Oversight King County's EMS system has a special center that handles medical oversight data known as the Center for the Evaluation of Emergency Medical Services (CEEMS) which has been in operation since 1987.

This division is focused on improving the delivery of pre-hospital emergency care and advancing the science of cardiac arrest resuscitation through collaboration between the EMS Division and academic faculty from the University of Washington. Another quality initiative was introduced in 2011 and is known as the Medical Quality Improvement (QI) section. "Measure and Improve" is the motto of the King County EMS and the QI provides internal audits of a series of BLS and ALS responses to various critical conditions.

The results of these audits are distributed to all King County medical directors, fire department chiefs, training officers, dispatch center leaders, and hospital cardiac and stroke coordinators to encourage a culture of evaluating and improving patient care (Public Health - Seattle & King County, 2015).

HallMarks of HPEMS Accountability Directing the EMS Division in managing the regional system is the Medic One/EMS 2014-2019 Strategic Plan, approved by the King County Council in June 2013, and voters in November 2013; built upon the system's successful medical model and regional approach, the Plan establishes policy directions, outlines the development of new or enhanced programs and initiatives, and presents a financial plan to support the Medic One/EMS system through the span of the levy period (Public Health - Seattle & King County, 2015).

The EMS Division plays a significant role in developing, administering and evaluating critical EMS system activities and it provides the core support functions that emphasize the uniformity and standardization of direct services provided by the system's partners.

These programs provide (King County Government, N.d.): consistent regional medical direction standardized EMT training and continuing medical education standard EMS training for emergency dispatchers centralized data collection paramedic service planning and analysis financial management of the regional EMS levy fund The EMS Division can manage these functions in a standardized and more cost effective manner than to have each local response agency be responsible for these functions independently. Furthermore, having EMS take the lead in the system improves the systems accountability to the public.

Independent Oversight The components of an EMS system that are necessary to provide high levels of efficiency on metrics such as clinical excellence, response time reliability, economic efficiency and customer satisfaction can be thought of in terms of resources. However, there are a variety of different forms of resources that must work in unison for excellence, reliability, and efficiency to be achieved.

For example, even with state of the art facilities and equipment on the forefront of technological development, these resources are virtually worthless without a human resource component that talented, well-trained, and sufficiently experienced to operate the physical resources contained within the system. Too build loyal community relationships an organization must look beyond a "short-term" perspective (Chapter 5, p. 75).

Communities must make long-term investments in their public health needs; especially since EMS management strategies, such as the Public Utility Model, can be difficult to successfully orchestrate and corrective actions can be both expensive and time-consuming (Stout, 1980, p. 22). The bulk of the oversight within the King County EMS is conducted internally with their "measure and improve" model. However, there is limited external oversight through the participation of Washington University and other community resources.

Accounting of Service Costs The emergency medical services (EMS) team in King County serves nearly two million people in the local area and states that they provide lifesaving services on average of every three minutes (Public Health - Seattle & King County, 2015) The Medic One/EMS system has a fairly unique funding structure that is only possible because of the regions high economic development and politically progressive leadership.

Medic One/EMS is supported by levy funds that make the services it provides less vulnerable, though not immune, to fluctuations in the economy and this system has maintained financial viability and stability, even throughout the economic recession, due to a sustained focus on operational and financial efficiencies (Public Health - Seattle and King County, N.d., pp. 10-11).

In 2012 the proposed levy (which was passed) called for a levy rate of 33.5 cents/$1,000 AV means that the average homeowner will pay approximately $107 a year in 2014 for highly trained medical personnel to arrive within minutes of an emergency, any time of day or night, no matter where in King County -- this is $3 less than the average homeowner paid in 2008 for these same services and the EMS system's continued focus on operational and financial efficiencies has allowed it to provide world-class EMS services at a fair market rate (Pubic Health - Seattle and King County, 2013, pp.

8-9). Figure 5 - Levy Funding Overview (King County Government, N.d.) System Features that Ensure Economic Efficiency This system is perceived as efficient and effective by the residents of King County and serves as a model system for other EMS systems nationwide. In fact, the system has meet all of its performance metrics sufficiently enough that it can begin to focus more on more advanced metrics that include economic efficiency measures.

For example, the county has realized that if it can effectively implement a coding system to more comprehensively screen calls based on the level of emergency detected by the dispatchers, then the advanced life support resources can be utilized more efficiently and cost targets can be more actively pursued. Most healthcare organizations have abandoned the idea that healthcare systems can be improved through increased spending and are now focusing on efficiency as a driver of patient outcomes (Fitch & Knight, 2015).

System Features that Ensure Long-Term High Performance King County's EMS system has instituted a "measure and improve" approach to all levels of operations. Beyond that, the EMS system has formed special initiatives to continually improve performance such a special center that handles medical oversight data known as the Center for the Evaluation of Emergency Medical Services (CEEMS) which has been in operation since 1987.

This division is focused on improving the delivery of pre-hospital emergency care and advancing the science of cardiac arrest resuscitation through collaboration between the EMS Division and academic faculty from the University of Washington. Another quality initiative was introduced in 2011 and is known as the Medical Quality Improvement (QI) section. "Measure and Improve" is the motto of the King County EMS and the QI provides internal audits of a series of BLS and ALS responses to various critical conditions.

The results of these audits are distributed to all King County medical directors, fire department chiefs, training officers, dispatch center leaders, and hospital cardiac and stroke coordinators to encourage a culture of evaluating and improving patient care (Public Health - Seattle & King County, 2015). Figure 6 - Projected Spending Breakdown (Public Health - Seattle & King County, 2015) King County EMS Performance Measures Clinical Level The EMS Division manages the needed essentials to providing the highest quality out-of-hospital emergency care available.

The system provides regional coordination to ensure pre-hospital patient care is delivered at the same standards across the region, regional policies and practices reflect the diversity of needs, and local area service delivery is balanced with centralized interests (Public Health - Seattle & King County, 2015).

Examples include: • Uniform training of EMTs and dispatchers • Regional medical control and quality improvement • Injury prevention programs • Regional data collection and analysis • Regional planning for the EMS system • Financial/administrative management Furthermore, the EMS Division also manages projects called Strategic Initiatives designed to improve the quality of Medic One/EMS services. REsponse Time STandard It would be difficult to deny that EMS systems place a great deal of emphasis on responses time and this often serves as one of the primary metrics for performance.

Such a metric is entirely reasonable given the importance of reaching someone in critical condition sooner, as opposed to later, can potentially save their lives or at least improve their outcomes. This is an intuitive concept that people have believed for several generations. Previous generations of heuristics in regards to response time and survival rates represented concepts such as the "golden hour" in which is the most important for mitigating mortality and improving health outcomes in critically injured patients (Lerner, 2001).

Furthermore, in the modern EMS system, there be more factors that are also important to consider. For example, if advanced life support (ALS) is really need in a situation, and only basic life support (BLS) is dispatched, then there may be other considerations that are necessary to gauge performance than simply response time. Yet, evidence-based clinical measures of emergency medical services (EMS) system performance have been few in number, largely due to the limited quantity and quality of research committed to the prehospital arena (Myers, Slovis, Eckstein, Goodloe, & Isaacs, 2008).

Much of the research that has been produced has only focused on a small number of conditions or with a small population size. For example, although treatment of cardiac arrest represents a major function of most EMS systems, it only constitutes a small fraction (1-2%) of all EMS responses. Therefore, the evidence for the importance of response time is heavily debated (Myers, Slovis, Eckstein, Goodloe, & Isaacs, 2008).

Another study has found that response time that exceeded five minutes showed a significantly higher rate of mortality than a response time under the five-minute benchmark; yet did not show significant differences for longer response durations (Blackwell & Kaufman, 2002). Since the five-minute mark is virtually impossible for even the most sophisticated EMS systems, this research seems to suggest that response time might not be as important as once thought.

Furthermore, now that basic life support (BLS) providers and lay rescuers can provide rapid automated defibrillation as well as basic CPR, the relative importance of the ALS response-time interval has been challenged, both for cardiac arrest as well as for other clinical conditions (Myers, Slovis, Eckstein, Goodloe, & Isaacs, 2008). While some have argued that there is no evidence to suggest such tiered responses have any influence on outcomes, there does seem to be some evidence that they do; at least in regards to some specific conditions.

One meta-analysis found that between 1966 through 1995 reviewed fifty-one studies and found that in a majority of cases ALS-level care demonstrated effectiveness (Bissel, Eslinger, & Zimmerman, 1998). However, in tiered response systems a more comprehensive approach to quality management metrics is definitely need. Some systems, such as King County EMS, offer different tiers of responses that might be more or.