King County EMS: Structure, Performance, and Funding

Demographics and Service Area

King County, Washington — Overview

King County, Washington, is the most populous county in the state of Washington and ranks among the top 15 most populated counties in the United States (13th). The county has a total land area of 2,307 square miles, with slightly over eight percent of that area covered by water (United States Census Bureau, 2015). The area is known as a center for progressive politics: Seattle is one of the most liberal cities in the country, having elected socialist council members and gay mayors, endorsed environmental movements, and ranked among the top five cities with the fewest cars. Some observers argue, however, that strong conservative elements persist despite the region's progressive tendencies (Anderstone, 2014). Notably, King County was renamed in 2005 to honor Dr. Martin Luther King Jr., rather than the county's original namesake who shared the same surname.

Population

King County has a population of just over two million people, based on a 2014 estimate extrapolated from the official U.S. Census Bureau count conducted in 2010, which recorded 1,931,256 residents (United States Census Bureau, 2015). Population growth in the county has been estimated at roughly eleven percent, a rate that occurred during a period of flat job growth, indicating that growth is not driven solely by the county's economic performance and job opportunities (King County, 2013). The twentieth century ushered in a period of rapid population expansion and industrialization throughout the region.

Service Area

The Emergency Medical Services (EMS) Division of Public Health — Seattle & King County represents a complex network of responders and providers organized under the Medic One/EMS system. This system provides coordination and standardization across the network, including standardized EMT training, continuing education, dispatcher training, code standardization, and system-wide data collection. Whenever a resident calls 911 in King County for a medical emergency, the call is routed through the Medic One/EMS system, which is dedicated to increasing survival and reducing disability from out-of-hospital emergencies by providing the highest quality patient care in the pre-hospital setting (Public Health — Seattle and King County, 2013, p. 6). To meet these objectives, the Division adheres to a medical model of integrated regional service delivery that emphasizes cooperative decision making and the development of innovative strategic initiatives addressing both service demand and resource efficiency (Public Health — Seattle & King County, 2015, pp. 6–7).

Population Density

King County is geographically diverse, with elevations ranging from sea level to nearly 8,000 feet. Its human population is equally varied, with highly dense, urbanized areas as well as rural zones with low population density (Vance-Sherman, 2015). Seattle, the region's urban center, is one of the most population-dense cities in the United States. Of the 366 Metropolitan Statistical Areas tabulated in the 2010 Census, the Seattle–Tacoma–Bellevue area ranked 24th in population-weighted density at 4,721.6 people per square mile, though it ranked 15th overall in population at approximately 3.4 million people (Duke, 2012). The city is rapidly becoming denser as population growth continues, with increasing diversity characterizing much of that growth.

Economic Indicators

King County can be characterized by wage and income levels significantly higher than the national average, with far fewer residents living in poverty compared to state and national benchmarks (Vance-Sherman, 2015). Seattle's progressive government was among the first in the country to institute a substantially higher minimum wage of $15 per hour. The program has been broadly regarded as a success; some studies indicate that the unemployment rate declined following the increase, with one measure showing unemployment falling 17.46% between January and December 2014 — from 6.3% to 5.2% (Worstall, 2015). The region's progressive governance and strong economy have had major implications for public services, including the county's Emergency Medical Services system.

Structural Attributes of the EMS System

Geographic Scope

The Medic One/EMS system in King County covers the full extent of the county's boundaries and in some cases extends beyond them through coordination with neighboring systems. As described by Vance-Sherman (2015):

"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."

Standard Setting and Enforcement

The Medic One/EMS system serves as the central collaborative organization in King County. It operates through partnerships built on regional, collaborative, cross-jurisdictional coordination: while each provider operates individually, the care delivered to patients functions within a seamless, unified system (Public Health — Seattle and King County, N.d., p. 4). This continuum of consistent, standardized medical care — involving 30 fire departments, six paramedic agencies, five EMS dispatch centers, 20 hospitals, a university partner, and the citizens throughout King County — allows the system to excel in pre-hospital emergency care. The Medic One/EMS system also oversees medical training delivered on a regional basis, ensuring that medical triage and care delivery are uniform regardless of location within the county (Public Health — Seattle and King County, N.d., p. 4).

Division of Functions

The Medic One/EMS system operates on a tiered model that establishes Basic Life Support (BLS) as the standard operating procedure. Most incidents receive BLS services, while Advanced Life Support (ALS) is reserved for cases that dispatchers determine to be medically necessary. This approach preserves the more limited regional resource of an ALS unit — known locally as a medic unit — for serious or life-threatening injuries and illnesses (Public Health — Seattle and King County, N.d., p. 11). Dispatch centers are trained to code calls specifically and prioritize responses accordingly, maximizing the efficiency of available resources. The five major components of the Medic One/EMS system in King County are:

1. Universal access

2. Dispatcher triage

3. Basic Life Support services

4. Advanced Life Support services

5. Transportation to a hospital

Market Allocation and Funding

The Medic One/EMS system has a distinctive funding structure made possible by the region's strong economic development and progressive political leadership. Medic One/EMS is supported by levy funds that make its services less vulnerable — though not immune — to economic fluctuations. The system has maintained financial viability and stability, even throughout economic recessions, by sustaining a focus on operational and financial efficiencies (Public Health — Seattle and King County, N.d., pp. 10–11).

The 2012 levy, which voters approved, called for a rate of 33.5 cents per $1,000 of assessed value. This means the average homeowner paid approximately $107 per year in 2014 for highly trained medical personnel to arrive within minutes of an emergency, at any time of day or night, anywhere in King County. That figure was $3 less than the average homeowner paid in 2008 for the same services, reflecting the system's continued focus on operational and financial efficiency (Public Health — Seattle and King County, 2013, pp. 8–9).

Failure to Perform — Consequences

The Medic One/EMS system is responsible for managing the entire King County EMS system and has secured a unique funding source through a property-tax levy. As a result, the system must remain accountable to the public by maintaining high service standards while demonstrating financial value through efficient and effective resource usage. If the system were unable to sustain a compelling value proposition under public oversight, the consequences would include erosion of public confidence and failure to secure future levy approvals.

Business Structure and Management

The business structure for Medic One/EMS is a complex network of organizations and providers. The system is distinctive from comparable systems in that it is medically based, regional in scope, and uses a tiered out-of-hospital response model (Public Health — Seattle & King County, 2015, p. 6). The centralized Medic One/EMS unit provides universal access, manages dispatcher triage protocols, and coordinates BLS, ALS, and hospital transport services.

Management within the system is specialized according to organizational role and specific objectives. The Medical Program Director holds the highest leadership position and ensures the ongoing medical quality improvement of the EMS system. Responsibilities in this role include writing and approving medical protocols, approving initial and continuing EMT medical education, undertaking quality improvement activities, and initiating disciplinary actions when necessary (Public Health — Seattle & King County, 2015, pp. 6–7).

At a high level, management is further supported by advanced system metrics that allow leaders to continually evaluate performance standards in quality and efficiency, and even conduct simulations to confirm that all objectives are being met. The EMS Division has adopted the mantra "measure and improve," and the system's performance is constantly monitored for areas of potential improvement (Public Health — Seattle & King County, 2015, p. 17). Regional Strategic Initiatives address issues such as uniform training of EMTs and dispatchers, regional medical control and quality improvement, injury prevention programs, regional data collection and analysis, regional planning, and financial and administrative management (Public Health — Seattle & King County, 2015, p. 9). This "measure and improve" philosophy has been integrated at every level of management and serves as the foundation for evidence-based administration of the entire system.

King County EMS System Outputs

Prevention and Early Detection

King County has implemented a number of prevention and early detection initiatives targeting a range of chronic diseases and conditions. The county collects comprehensive, population-based data with an emphasis on multiple determinants of health across the entire community. Specific data collected relating to chronic health include activity limitations, fair or poor self-reported health, number of unhealthy days, diabetes prevalence, physical inactivity, smoking rates, asthma prevalence, and unhealthy weight (King County Government, N.d.). Collecting these data helps the county and the EMS system prepare for common community needs based on neighborhood and community health profiles.

The county also collects statistics on violent crime, which can help response teams prepare by understanding the geographic distribution of incidents. For example, between 2006 and 2010, firearms caused an average of 131 deaths per year in King County, and during those five years, 50 children and youth age 19 and under were killed by firearms (King County Government, N.d.). By mapping the geospatial patterns of these incidents, response units can be better positioned in crime hotspots. Additionally, data on EMS call volumes and dispatch rates from prior years are used for planning and resource preparation.

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 programs providing CPR and Automated External Defibrillator (AED) training to King County residents, while also working to place AEDs in public locations and encouraging the public to register their devices (Public Health — Seattle & King County, 2015). There are now over three thousand AEDs registered in King County, and the program continues to expand as more locations and training opportunities are added.

911 Call Taking

King County has implemented a 911 call-taking system based on a tiered response structure supported by advanced metrics to ensure operational excellence while optimizing resource use. Dispatchers are trained to apply a set of medical response assessment criteria to analyze the level of need for each call and attempt to reserve ALS services for cases that genuinely require them. Dispatch data are collected and regularly screened to identify any potential performance problems within the system.

First Response Dispatch and Services

Dispatch centers are trained to code calls specifically and prioritize responses to maximize the efficiency of available system resources. Calls to 9-1-1 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 required. The Medic One/EMS manages the full out-of-hospital continuum of care through its partnerships with 30 fire departments, six paramedic agencies, five EMS dispatch centers, 20 hospitals, a university partner, and the citizens of King County. Dispatchers use medical response assessment data to analyze each caller's level of need and to reserve ALS services unless clearly necessary, with all dispatch data collected and regularly reviewed for performance issues.

Ambulance Services

The Medic One/EMS system operates on a tiered model that designates Basic Life Support (BLS) as the standard operating procedure. Most incidents are handled by BLS services, with ALS reserved for incidents dispatchers determine to be medically necessary. This approach preserves the limited regional resource of an ALS medic unit for 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, the care team determines whether transport to a hospital or clinic for further medical attention is required. Transport is most often provided by an ALS agency, a BLS agency, or a private ambulance. The standardization of training across the system has contributed to a higher degree of uniformity in patient handoff from transport services to receiving facilities.

Medical Oversight

King County's EMS system includes a specialized center for medical oversight data known as the Center for the Evaluation of Emergency Medical Services (CEEMS), which has been in operation since 1987. This center 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 a partner university.

A complementary quality initiative introduced in 2011, known as the Medical Quality Improvement (QI) section, conducts internal audits of BLS and ALS responses across a range of critical conditions. The motto "Measure and Improve" guides this effort, and 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 foster a culture of continuous evaluation and improvement of patient care (Public Health — Seattle & King County, 2015).

Conclusion

The emergency medical services team in King County serves nearly two million people and provides lifesaving services on average once every three minutes (Public Health — Seattle & King County, 2015). Rapid transport of patients with severe injuries to definitive care is a cornerstone of modern trauma care; among the primary factors contributing to reduced patient mortality are shortened pre-hospital time, treatment at a tertiary center, and direct transport from the scene (Falcone, 2013). The Advanced Life Support services — provided by six agencies operating 26 ALS units throughout King County — are vital to achieving these outcomes (Public Health — Seattle & King County, 2015).

King County uses a hybrid approach to financing that incorporates best practices from multiple models. The primary funding source is an EMS levy based on county property taxes (Seattle and King County EMS, 2014). This structure allows reserves to be built and directed toward making the system more efficient, consistent with the concept of the Triple Aim — which focuses on creating the right foundation for population management, delivering services at scale, and establishing a learning system to drive and sustain improvements over time.

The system is perceived as efficient and effective by King County residents and serves as a model for EMS systems nationwide. Having met all of its performance metrics, the system can now focus on more advanced measures, including economic efficiency. By implementing a more comprehensive tiered coding system, advanced life support resources can be allocated more efficiently and cost targets more actively pursued. It is therefore recommended that King County continue and expand its "measure and improve" approach.

EMS systems can be designed in a multitude of ways depending on local characteristics, available resources, leadership, and a range of other factors. King County's EMS Division has several unique features that contribute to its effectiveness, most notably its reliance on a series of voter-approved levies dating back to 1979, which have allowed the county to develop a world-renowned system (Public Health — Seattle & King County, 2015). The following table summarizes key system attributes:

King County EMS System Summary:

Funding: Public/Levy | Response: Multi-tiered | Objectives: Performance and Resource Efficiency | Oversight: Public | Response Types: BLS, ALS, EMT, Private | Training: Ongoing