New and winning strategies for EMS leaders.
Issue link: http://emsi.epubxp.com/i/54881
RESPONSE TIMES CONTINUED FROM PAGE 1 scene within a four-minute timeframe 90% of the time for all incidents. The ALS crew that must respond within eight minutes. According the NFPA 1710, "This require- ment is based on experience, expert con- sensus and science. Many studies note the role of time and the delivery of early defibrillation in patient survival due to heart attacks and cardiac arrest, which are the most time-critical, resource- intensive medical emergency events to which fire departments respond." The problem, says Zavadsky, is that cardiac arrests represent a small per- centage of the overall EMS responses. The Emergency Medical Services Out- comes Project identified seven clinical conditions that account for 65% of all adult EMS transports and seven that account for 85% of all pediatric trans- ports. Of these conditions, only cardiac arrest—the second least frequent of all the conditions—appears to require rapid EMS response.1 Although much of the assessment of an EMS system was devel- oped based on how well the responders handle a cardiac arrest, the authors note that the vast majority of the calls don't require the same time-sensitive response. If the problem is getting trained per- sonnel to a patient faster, then there's an easy fix: hire more paramedics. Zavadsky says that even if the economy allowed for such an expense, it's unlikely that adding personnel would improve quality. Increasing the staff size would reduce an individual's exposure to the type of decision-making and clinical skills that help to maintain proficiency. In critically unstable patients where time is a factor, paramedics must have the technical skill and analytical decision-making experi- ence to improve the patient's odds of surviving. "An inexperienced paramedic can do more harm than an EMT," Zavad- sky says. He asserts an increasing body of sci- entific evidence exists to prove that response times do not, in fact, improve patient outcomes. What is needed is a critical review of localized data to help develop more refined response stan- dards. If done properly, the result can be 8 a decrease in system costs, fewer lights- and-sirens driving crashes and a more substantive measurement of the quality of an EMS system. The MedStar example MedStar, serving the citizens of Ft. Worth, Texas, responds to 110,000 EMS calls annually. Zavadsky wondered if the value placed on speed was contributing to the number of ambulance crashes in the sys- tem each year, 74% of which occurred while driving with lights and sirens. He had been collecting data and ana- lyzing responses for years to identify a better way to serve the public and "do no harm." Then, during one cold, 48-hour period in February 2011, he was provided an unusual opportunity to conduct the perfect EMS study. As sports fans poured into the Dallas-Ft. Worth area to see the Pitts- burgh Steelers take on the Green Bay Packers in Super Bowl XLV, MedStar geared up for what was anticipated to be a busy week. However, no one could have predicted what happened next. Just days before the game, a severe winter storm blanketed the region with 13 inches of snow and ice. The weather was so severe that for a two-day period, MedStar, with the approval of its Medical Control Author- ity, the Emergency Physician's Advisory Board, suspended the use of lights and sirens. When the storm was over, Zavad- sky compared cardiac arrest and chest pain responses during that 48-hour period to those of the previous week. "That kind of study is hard to do pro- spectively," he says. What he found was little difference between the patient outcomes between the two weeks. "Very few EMS calls required an immediate response," he says. "The time critical responses were CPR/AED." Even with chest pain calls, the problem was that the patients waited too long to call 9-1-1—not that the ambu- lance took too long to arrive. The critical need, he determined, was in regard to public education. He calculated that MedStar could save approximately $1.5 million by increasing response times from eight minutes to 15. Using that money to buy AEDs, do com- munity CPR education and buy advertis- ing to encourage the public to call 9-1-1 more quickly for chest pain and strokes, he argued, could have a more positive effect on patient outcome. "In some cases, the best response is before the call," he says. Public expectations Although some EMS professionals like Zavadsky suggest it's time to re-exam- ine the standard, the public may not be ready to give up response times without some retraining. Just ask Emergency Medical Services Authority (EMSA) officials. EMSA contracts with ambu- lance companies to provide EMS ser- vices for Oklahoma City, (Okla.) Tulsa, and surrounding suburbs. Ward 2 Oklahoma City Councilman Ed Shadid, a vocal critic of EMSA's spending practices, has expressed concern that the organization is trying to avoid com- plying with the 90% standard by using call exclusions for severe weather and times of high call volumes. Recently, that battle spilled over into the media. According to EMSA records, in nearly one of every 10 emergency calls, para- medics were either late or the response time wasn't counted due to an exclusion. "What's been presented to the public is that there's this 90% compliance," Shadid was quoted in a local paper as saying. "Well, it's 90% if you exclude calls." EMSA President and Chief Execu- tive Officer (CEO) Steve Williamson has pointed out that the exclusions were approved years ago by the cities involved. "We don't want to jeopardize the safety of anyone, including the crew and the other citizens on the road. The exclusions are there to protect every- one," he says. Regardless of the outcome, the result- ing publicity reflects poorly on the entire system and affects how the public per- ceives its EMS responders. What needs to change? Although changing standards and the public's perception is difficult, Zavadsky points out that if the American Heart Asso- ciation can do it, so can EMS. He offers some suggestions to help move the argu- ment forward, including the following: s #LASSIFY CALLS AND MODIFY RESPONSES based on the classifications; s 4RACK !%$S THAT ARE PURCHASED Add that data to the dispatcher's UNLAWFUL TO COPY WITHOUT THE EXPRESS PERMISSION OF THE PUBLISHER. FEBRUARY 2012 EMS INSIDER