Issues in emergency medical services

¶ … EMS single-tier response (STR) or a multi-Tier response (MTR) is optimal for a community?

While EMS are present in every community, each community has different needs and the response of the EMS should be tailored in a community-specific fashion. For example, some communities are far more dependent upon EMS to provide critical services because of their demographics. A large city such as New York will often have more critical incidents due to violence or safety hazards. Also, the logistics of mobility within a city can mean that a single-tiered response (STR) is more appropriate. At the other extreme, a rural area, because of a lack of medical resources such as nearby hospitals, can also benefit from a STR, given that aspects of primary care and treatment may need to be given immediately on the scene due to the lack of available resources at point of care. In terms of a STR response, "most notable is the contention that those in dire need will receive not only the most basic help as quickly as possible but also the most advanced help as quickly as possible" regardless of the situation ("EMS dispatch and response," 1983). STR can increase the visibility and presence of EMS, which can lead to greater community trust (and more funding and volunteerism for the service) overall ("EMS dispatch and response," 1983).

The downside to STR, however, is that it can be expensive and not all communities can afford them. A MTR or multi-tiered 'staggered' response, based upon evaluated need, may make more efficient use of scarce resources and also act as a screening device for non-emergency systems in suburban communities or communities where highly competent hospitals are in centralized and easily accessible areas. "Additionally, a tiered response system is structured to permit the shutdown of the response at any point. For example, if the first responder arrives on the scene of situation B. And finds that the 46-year-old male has been hit in the chest by a softball and has since 'regained his breath,' the first responder can stop the response of the ALS unit and perhaps even change the response of the BLS unit to nonemergency status (no red lights and siren)" thus saving costs ("EMS dispatch and response," 1983).

Q2. What does the evidence say about the value of increasing the number of paramedics in a given EMS system?

Simply having 'more' EMS personnel will not necessarily result in higher-quality care. Training obviously counts for a great deal in evaluating the relative effectiveness of an EMS system. The system must be able to support the training of the required personnel so the ultimate system goals of high-quality and expedited care can be achieved. However, there is a certain point beyond which a system cannot be taxed in terms of limiting personnel numbers. Given the recent budget cutbacks at many major metropolitan areas, quality of care is suffering in many areas. This is true of Washington D.C., to cite one example, a city which requires a very effective EMS service in part because of its high crime rate and other logistical issues particular to the city structure. Both dispatchers and in the field personnel are in short supply "Fire and EMS has a serious shortage of paramedics, is using outdated and incorrect information and is exceeding its budget by millions and millions of dollars," even causing the death in some instances of the individuals who have had to rely upon its services when the unit lacked adequately trained personnel to provide Advanced Life Support (Segraves & Mimica 2013). Delayed response times can also contribute to patient deaths.

Careful monitoring must be conducted to ensure that if the same levels of staff are maintained that this is still adequate to meet current needs. In the D.C. instance, it was found that "only 16 of 424 shifts have been fully staffed" and "in the past four years, 911 calls in the District increased by 22%, but D.C. Fire and EMS has been deploying the same number of ambulances" (Segraves & Mimica 2013). This is hardly a prescription for high-quality care even if the individuals who are dispatched can provide ALS.

Q3. What are the limitations of studies such as Blackwell's in determining the importance of ambulance response performance in a given community?

Blackwell's study was conducted in an observational fashion on a metropolitan community that used a single-tiered response system. He noted that response times that "were less than 5 minutes" were associated with improved survival rates vs. response times that exceeded 5 minutes (Blackwell & Kaufman 2002). However, several problems exist with this conclusion based upon the limits of his study. EMS personnel might be located closer to the more affluent sections of the city with less violent crimes and less critically ill persons. This might mean that the calls with lower response times were also the less serious calls. Blackwell himself notes that "variables other than time may be associated with this improved survival" (Blackwell & Kaufman 2002). Blackwell's study was relatively short in duration. A longitudinal study would have contained greater variation in cases, given that response needs can shift on a seasonal basis.

Although the number of cases was relatively large (5,424) in the study the population selected from a very limited sampling, demographically speaking. Furthermore, even if shortened response time was useful for the types of cases solicited through this particular metropolitan area, this might not necessarily be the case of all cities, much less all suburban or rural areas. It also might not be characteristic of single vs. multi-tiered response systems. And finally, the findings could simply be a particular idiosyncrasy of that metropolitan area and that EMS department. A broader and more comprehensive study, preferably with more detailed quantitative demographic analysis would be required to draw conclusions from such a study, much less to recommend sweeping changes in policy.

Q4. Does the evidence support the statement that "U.S. fire service is the most ideal prehospital 9-1-1 emergency response agency"?

Fire service personnel are obviously highly trained in specific emergency areas such as fire prevention. They also have experience in dealing with crowd control and management and dealing with hazardous substances that other emergency personnel may lack. However, they do not necessarily have the specialized medical knowledge that trained EMS personnel might possess. The cost factor is another consideration: deploying the resources of the fire department for every emergency call, including those under relatively controlled circumstances in someone's home is not an effective use of resources.

Many fire departments are also solely staffed by volunteers. While some fire departments are professional in nature, the abilities of a volunteer fire department vs. medical professionals indicate that not all fire departments are created equal nor are all generalized EMS services. When making a comparison it is essential to evaluate the specifics of the situation, rather than making broad, general, and sweeping assertions that one is better than the other. Ultimately, having inadequate responses to emergencies is the most costly policy of all and overemphasizing one emergency service can result in lives lost. Even if a municipality has a highly-trained professional fire-fighting service, diverting their attention away from fires and to taking care of routine 911 calls can result in inadequate attention in the long run given to major blazes. There must be a careful evaluation of such a 'pennywise but pound foolish' approach to emergency management, if the aim is to reduce costs by simply relying on a single response team, even if it presumably has the highest level and most comprehensive training of all the EMS units (which might not even be the case).

Q5. Describe the "number needed to treat" (NNT) concept, and provide an example of a way that an EMS agency could use the concept to educate its citizens or elected officials.

The Number-Needed-to-Treat (NNT) is a concept which measures the impact "of a medicine or therapy by estimating the number of patients that need to be treated in order to have an impact on one person" ("The NNT explained," 2014). For example, "in controlled trials of medical interventions (drugs, surgeries, etc.) there is always an 'outcome measure', which is a researcher's way of saying that there is always something that they are measuring to determine whether or not the intervention helped" ("The NNT explained," 2014). Within every trial there will always be a certain number of persons who appear to have been helped and others who appear to have been unaffected. This is not only true of drug trials but also of EMS responses.

When a response is made to a particular complaint, the crux of measuring the issue is to ensure the benefit which occurred specifically because of the treatment (there is, after all, always the chance that the patient could have gotten better him or herself). There is a "much larger chance that they will be in the group that survives regardless of the treatment (while still being subjected to the potential harms and side effects of the treatment)" ("The NNT explained," 2014). In a drug trial this is more serious, given the side effects which can occur, but even with an EMS agency, there is always an opportunity cost of time and resources with an ineffective treatment, when a patient receives treatment that is not beneficial. "The core value of the NNT is its straightforward communication of the science that can help us understand the likelihood that a patient will be helped, harmed, or unaffected by a treatment" ("The NNT explained," 2014). It is a source of information for those in charge of budgeting the agency and also a way for an agency to make a case that certain aspects of the care it provides do, in fact, save lives.

Q6. Is a high "cost per transport" indicative of a poorly managed EMS system? Why or why not?

High cost per transport is not necessarily in and of itself an indication that an EMS system is poorly managed. An EMS that serves a community with many critically ill or elderly patients may have a high rate of cost per transport. Or, an EMS that serves a rural community that is very far away from the local hospital may likewise have a high cost per transport, due to the fact that it must provide more essential professional medical care on the way over to the facility. The overall competency and treatment protocols of the unit must be viewed holistically, versus focusing on a single metric. Unfortunately, in these cost-conscious times, it is upon this single metric that EMS units are likely to be judged.

The cost per transport must be evaluated in light of the kinds of cases the system manages. For example, if there is an excessively high cost per transit relative to other EMS services in nearby counties for the same type of complaint, for the same relative transit time, this should be a red flag. Cost per transit cannot be analyzed as an average figure. It is also worthwhile to review standardized operating procedures for all complaints, to see if cost per transit can be reduced without compromising patient care. But this does not necessarily mean that the current system is 'bad' or substantially lacking in comparison to other EMS systems in the area.

A final factor is staffing and financing. An under-staffed agency may actually have higher costs per transit simply because of less available resources and less familiarity when dealing with serious complaints. But given the organizational resources, the EMS may still be 'making do as best it can' and is not necessarily staffed with incompetent personnel.

Q7. List four things that matter to citizens when asked about their community EMS system. Should those considerations be the only ones that matter to EMS system leaders, or are there other factors to be considered?

First and foremost, citizens are concerned about expedient response times. Given that response times can indeed affect patient health, this is a worthy consideration. Patients are also likely to be concerned about the training of personnel, to ensure that they are capable of dealing with a wide variety of complaints. They are likely concerned that the EMS has the technologically-sophisticated materials to deal with various medical issues while transporting patients. They may be also concerned about effective use of financial resources, given that their tax dollars are indirectly funding such services.

All of these are worthy considerations, of course, and cannot be ignored by EMS personnel as EMS is designed to service the public's needs -- and the fact that the public often has sensible concerns regarding the use of its resources. But effective medical care is not something that can be decided via a popularity contest. Ultimately, the EMS unit's main task is to preserve life rather than satisfy the needs of the public like a politician. Often, the issue becomes one of prioritization. The agency must determine the most critical factors that contribute to better medical care even if the public may prioritize speed of response time over the quality of care dispensed by the team (to cite one example). The public's opinion should be taken under advisement, given that it may highlight critical and even unforeseen deficits but this does not absolve the EMS squad from conducting research itself to determine the optimal factors to enhance to provide better service and to realize the EMS objectives and goals to individual patients, not simply the public at large.

Q8. Many of today's EMS system leaders appear to believe that investment in selecting the right employees is not beneficial. Describe three reasons why EMS personnel should be selected with the same care as our communities select law enforcement officers.

No matter how good the technology on board, an EMS squad is no better than the personnel at hand. EMS personnel must be willing to make great personal sacrifices of time, energy, and even their own personal safety to preserve the lives of others, just like law enforcement personnel. This demands a tremendous personal commitment from the staff. To ensure the staff will be 'at the ready' when needed and take their training seriously EMS personnel must be selected with care.

EMS personnel must also be capable of being trained. They must have the necessary mental and physical capacities to react quickly at a moment's notice, whether this involves managing a heavy patient or knowing how to put their training into action when confronting a life-and-death situation. As with law enforcement officers, people's lives are dependent upon the effectiveness of a well-trained EMS staff member.

Finally, EMS expertise over time enhances quality care. EMS personnel should be along for the 'long haul.' The department loses time and money when there is a high rate of attrition by people who cannot take the high levels of stress required by the position. Training new staff members is very costly. It is better to initially select the right type of people who will thrive in a pressure-cooker environment than to have a revolving door of people who burn out quickly. Thriving in the environment of a busy EMS squad takes a certain type of personality: someone with high levels of personal resilience and emotional hardiness who can deal with traumatic stories day in and day out.