FIRE SERVICE EMS: THE CHALLENGE AND THE PROMISE

Photo by Bob Pressler.

FIRE SERVICE EMS: THE CHALLENGE AND THE PROMISE

PART 3—EMS CASE STUDIES

Parts 1 —“An Overview,” and 2—”Planning Vital to Success,” were published in the July and October 1993 issues.

Crafting an emergency medical services (EMS) system to suit a community’s needs is a complex task—and a never-ending one, if the EMS service is to remain viable and win the community’s support. Following are sketches illustrating how several fire departments have set about to institute, improve, modify, or expand EMS operations to meet their communities’ present or projected needs, the obstacles they have faced (or are facing), and their approaches to resolving the encountered problems.

ATLANTA, GEORGIA

In May 1993, the Atlanta Fire Department (AFD) implemented a new rescue-medical plan to supplement the city’s existing EMS, reports Timothy R. Szmanski, public safety planner and public information officer.

The 1,102-member department operates 36 fire stations and has 35 engines, 16 trucks, one advanced and four basic life support (BLS) rescue (nontransport) units, two advanced life support (ALS) ambulances, eight airport rescue firefighting (ARFF) units, and various other command teams and special squads and equipment.

Since 1970, the AFD has provided EMS services, including transportation, at Hartsfield Atlanta International Airport. In 1974, the service was upgraded to ALS. Two ECHO ambulances are on duty at all times and respond to all incidents on airport property and the area surrounding the airport.

Medical transport within the city is provided by 16 private and two public ambulance services. The city is divided into 11 ambulance zones, assigned to various EMS agencies. Many of the calls are received through the Fulton County 91 I center.

In the late 1970s, the department became responsible for supplementing EMS with first responders and providing extrication and rescue services. Five two-member rescue units (one ALS and four BLS) were placed in service and respond to all sections of the city, sometimes increasing response time to some of the outlying areas. Engine and truck companies respond as first-responder units to medical emergencies.

Under the new plan. 21 engine companies throughout the city will be upgraded to BLS. Seven are already in service, and the others are expected to be available by the end of 1994. Personnel assigned to the BLS engines will receive a two-step pay increase.

Three rescue units will be taken out of service: the remaining two will be upgraded to ALS and supplement the EMS engine companies. Eventually, automatic defibrillators will be added to the EMS companies. All EMS engines will carry a four-member crew, two members of which will be statecertified EMTs. Specially equipped truck companies trained extensively in extrication and rescue at the Atlanta Fire Academy will handle that work. These changes are expected to improve response times throughout the city and reduce costs.

Update: All new recruits are trained to the firefighter/EMT-A level. Classes for all fire department personnel currently are in progress. The department is studying the financial feasibility of upgrading the 21 engine companies to defibrillation units within five years.

AUSTIN, TEXAS

The total quality management BASICS Plan, implemented by the City of Austin. Texas, in 1991 (see “The Quality Service Challenge.” Fire Engineering, September 1992, page 117), established “customer service” as the city’s top priority. Providing the best service to the citizen/customer in the most cost-effective manner, therefore, was the basis on which Division Chief James Fiero of the Austin Fire Department (AFD) proposed to city management that the Austin EMS Department be consolidated into the AFD. The fire department’s involvement in EMS quality assurance has arisen primarily from the city’s implementing a program that placed automatic defibrillators on all AFD engines and other selected fire companies.

Statistics: The Austin EMS Department operates seven full-time and one part-time BLS ambulances and four full-time ALS ambulances and two part-time ALS units. One of the full-time BLS units provides coverage to the county. All except four of the EMS units run out of fire stations. The closest fire department engine company, the closest ALS or BLS ambulance, followed by the ALS unit, and, as appropriate, an EMS supervisor normally are dispatched to a cardiac call within the city. These apparatus are staffed by five to nine people, depending on personnel levels and the number of units responding. Firefighters are pulled off their companies to provide the proper staffing levels to manage medical transports. During this time, these companies are out of service and unavailable for other calls.

The fire department trains its personnel to the emergency medical technician automated defibrillator (EMT-AD) level. The EMTADs are first responders to all life-threatening medical calls, providing BLS in under four minutes and immediate automatic defibrillator services.

Proposal: Among the recommendations made by Fiero were the following:

Establish 10 paramedic engine companies (creating the need for 30 personnel for the units). Engine companies currently have four members assigned but run with three; assigning a fifth person would allow the company to respond with four on duty at all times.

Maintain and support the system with 12 BLS transport ambulances staffed by EMT firefighters who would rotate off their regularly assigned companies and work on the BLS transport ambulance about every 12 to 18 months. These 12 BLS ambulances would require 72 additional personnel over current AFD staffing.

Dispatch the closest paramedic engine company and BLS transport ambulance to a cardiac call. If one of the “regular” BLS engine companies is closer, dispatch it as well, to provide the same BLS care furnished under the current system. Return that BLS engine to service as soon as a paramedic engine arrives on the scene. One or two of the paramedics assigned to the responding engine could ride in the transport ambulance if paramedic care is needed during transport.

Retain 132 of the 153.5 full-time positions in the EMS Department. Even with the reduction in personnel, the new system would provide 10 instead of the present six ALS units (four full-time and two part-time) and allow the number to increase as the city’s needs and demands warrant.

Retain EMS personnel who do not want to become cross-trained as firefighters on one of the BLS or ALS ambulances or in a staff-support function during system implementation. When they leave or retire, fill the operational positions with cross-trained firefighter/paramedics. The paramedic engine company system could be on line within five years.

Costs would involve adding one person per unit per shift, their training, and equipment. Increasing the number of paramedic ambulances (as the medical professionals advocate) would involve adding three staff members per unit per shift (currently, the EMS Division personnel cannot take their earned vacation without the city’s having to pay overtime to cover staffing levels), the necessary training and equipment, and the cost of another ambulance. Under a paramedic engine company system, the only additional cost involved in adding paramedic units is training personnel.

Austin’s city management declined to study the consolidation issue, saying, “It can’t be done.”

Update: The AFD is in the process of hiring 100 to 140 new personnel, and the EMS Department is increasing its staffing to maintain coverage. “Now would be the best time to implement this enhanced system. It would save the city millions of dollars each year,” Fiero maintains. Moreover, he reports that, when surveyed several months ago, Austin EMS Department employees asked why the department was attempting to duplicate many of the rescue operations already provided by the AFD and why EMS was not consolidated with the fire department to improve services.

The Austin Fire Fighters Association established a committee to study the issue of consolidation. That committee was joined by several members of the EMS Department also interested in this merger. Since then, the city manager has appointed her own committee to look into the issue. Both the fire and EMS departments are in the process of changing their department directors.

FAYETTEVILLE, NORTH CAROLINA

The City of Fayetteville Fire Department (FFD) undertook in 1989 a study to determine if switching from EMS BLS squads to engine companies would help curb the rising costs of providing EMS (personnel, vehicle maintenance and replacement, fuel, and training). The study included comparative analyses of engine company and squad runs, including the total and average number of runs, the average time spent on scene, mileage, maintenance costs, the average miles per gallon for each unit, and the average response time, as well as salary costs for personnel assigned to the squads.

Annual reports for the period from 1984 to 1988 showed that the squad companies answered 3.5 calls for every engine company call and that out-of-service time for the squads was about 33 percent greater than that for engine companies.

There also were some workload disparities. The per-year incentive pay for EMTs (all personnel below the rank of lieutenant are required to be certified as EMTs) assigned to squads or serving as alternates amounted to $19.58 (before taxes) per two-week pay period for the highest paid squad company member, or 58 cents per extra run. Yet, the firefighter assigned to a squad had the same rank and station duties as the one assigned to the engine company. Squads answer all fire calls along with engines and trucks, if available. In 1988, for example, Squad 1 answered 3,196 calls compared with 654 calls for Engine 2, which had the highest number of runs of all engines.

Statistics: At the time of the study, FFD operated eight engine companies, two truck companies, and five rescue squad units out of seven stations. The engine companies had crews of four, and each rescue unit had a crew of two per shift. Personnel assigned to the five rescue units provided BLS until the outside agency’s ALS transporting service arrived on the scene. (Fayetteville transports only in extreme life-threatening situations; only one of the city’s vehicles has transport capabilities.)

Findings: The study concluded that despite the experiences of other departments to the contrary, the FFD at that time would not have realized any significant savings by changing from squad to engine-company response, and response time might be slower.

Recommendations: Among the recommendations of fered were the following:

• Continue to use squads for first-responder units with EMTs rotated onto the squads on a regular basis so they could remain proficient in their skills.
• Institute a policy that would dispatch the closest unit—squad or engine—to an emergency, reducing the number of times any unit would be out of its district. Maintain detailed records on response time, out-ofservice time, and fill-in time for other units in these districts to assess the level of service.
• Consider dividing the territory of the busiest unit and assigning one of the leastbusy squads to the central station and assign the personnel of squads scheduled for vehicle replacement to the engine companies that would absorb the squad’s runs. Replacement should be done on a leastbusy-company basis.

Update: At present, all FED engines provide EMS at the basic EMT level. Deputy Chief James A. Hall reports that about a year and a half ago one squad that didn’t have a high volume of calls was taken out of service and a second one was removed from service about a year ago. The personnel were moved to engine companies. The moves were instituted on a trial basis, and the squad vehicles were kept should they have to be reinstated. Since absorbing the two squads into the engine companies, the FFD has been able to maintain the same level of service. “Each situation is unique to the locale and its personnel,” says Hall. “We don’t know how much further we will go in instituting this change because of the high volume of calls: Eighty percent of the 12,(XX) calls received by the department are for EMS, and the engines would be on the road all the time.”

KANE COUNTY, ILLINOIS

When one of the local hospitals gave notice in June 1082 that it would not renew its contract to provide ambulance service for the county, the fire chiefs of St. Charles, Geneva, and Batavia met with Batavia’s mayor, J. D. Schielke, a member of the Batavia Fire Department, to explore the available alternatives. The result was the formation of the Tri-City Ambulance Service (TCAS). governed by a board comprised of two elected officials from each city, the three fire chiefs, and the Paramedic Services of Illinois (PSI, the paramedic/firefighter provider) area supervisor, with Schielke as board chairman. The board controls the budget and allows fire chiefs to control the service on a daily basis.

In December 1982, the cities of Batavia, Geneva, and St. Charles (Tri-Cities) and their surrounding fire protection district areas transferred operation of the paramedic ambulance service from the two local hospitals to the cities’ three fire departments. The service was started with four paramedic/firefighters per 24-hour shift, backed up by two firefighter/EMTs staffing three ALS ambulances and with the same two ambulances operated at the hospitals and a fire department unit previously used as a BLS ambulance.

The 103-square-mile Tri-City area (30 miles west of Chicago along the Fox River), a combination of residential, commercial, industrial, rural, and agricultural developments, has seen explosive growth. Population has grown by about 25,000 people since 1982 and is approaching 100,000.

Update: According to Batavia Chief William J. Darin, some things have not changed since 1982. For example, the paramedic/firefighters continue to be an asset to the fire departments’ day-to-day operations, in addition to carrying out their primary responsibility, EMS. In Batavia, an ambulance is dispatched to assist on all structural incidents. For a working fire, one of the paramedics is assigned as command aide until relieved by another officer; the other paramedic is assigned to the point of attack on the outside of the structure, in SCBA, to assist with getting the attack hoseline into operation and to monitor the actions of the attack crews. If necessary, of course, the duty paramedics immediately will assist with rescue and extinguishment, depending on the circumstances. The paramedics’ first responsibility is to care for a patient; thus, when there are injuries in a fire incident, paramedics are assigned to treatment and other responding personnel are used as aides or entry-point monitors. Paramedic/ firefighters assist with all regular station duties, and all have assigned districts within which to make routine fire and occupancy inspections.

Each department has a paramedic coordinator who directly supervises the paramedics in that particular contract. An overall coordinator oversees the entire three-city operation. The coordinators are appointed by PS1 with the consent of the three fire chiefs.

Dispatching for TCAS continues to be provided by Tri-Com, which has been jointly serving the area’s fire, police, and ambulance services since 1976.

Revisions: However, many changes in service have occurred since 1982, including the following:

• Eight, instead of four, paramedic/firefighters arc needed per day (two for each of the four front-line ALS ambulances).
• As of January 1, 1994, a fourth ALS ambulance with two additional paramedic/firefighters per shift was added, increasing the number of personnel provided by PSI from 12 in 1982 to 24 in 1994. The City of St. Charles, which has gone from one fire station in 1982 to its present three fire stations, received the fourth ALS unit.
• The City of Geneva will open its second fire station in 1994, while Batavia has relocated one of its two fire stations since 1982.
• In 1983, TCAS responded to 2.077 ambulance requests and transported 1.587 patients to their choice of area hospitals. In 1992. it responded to 3,120 ambulance requests and transported 2,4(XJ patients. The ambulances also responded to approximately 1,000 fire-related and 667 change-ofquarters responses in 1992. Anytime three of the four ambulances at either the north or south end of the ambulance district go out of service on an ambulance response, the remaining unit is moved to the middle City of Geneva quarter, so it can be centrally located for a better response time.
• The first-responder program was expanded by sending the closest engine or squad company to assist. An engine or squad continues to respond to assist in most responses.
• The budget has increased over the years, but since the area is rapidly expanding, the cost to taxpayers has been negligible because of the increased assessed valuation of the entire Tri-City Ambulance District. The 1983 budget was $442,000 and the 1993-1994 budget, $1,056,938. minus $237,000 for the fees collected, ieaving a total of $819,018 to be raised through the tax levy. This amount is divided among the three cities.
• User fees (for transport only) increased from $50 and $100 for patients living or working in the district and nonresidents, respectively, in 1982 to $75 and $150 in 1993. The fee is still lower than the $90 fee charged to residents prior to 1982.
• The fleet of ambulances has changed drastically since 1982. Five new ambulances were purchased between 1985 and 1993. Budgeting will make it possible to rechassis or replace an existing ambulance in 1994-95, 1995-96, and 1996-97. resulting in a state-of-the-art fleet.

In 1994. TCAS is now able to serve its citizens from four ALS ambulance locations and seven fire stations. Intergovernmental cooperation has continued to work with regard to the dispatch center, ambulance service, and automatic and mutual-aid fire responses, which this year may be expanded to include the concept of sending the closest engine, not just the closest ambulance.

PHOENIX, ARIZONA^5,6

During the summer of 1973, EMS requests approached 30 percent of all fire department dispatches. No paramedic service was available. Several agencies (fire and four ambulance companies) delivered EMS with very little coordination. The Phoenix City Council, the Phoenix fire and police departments, and representatives of various health-care agencies conducted an in-depth evaluation of the need for and delivery of EMS.

Training at that time consisted of American Red Cross Advanced First Aid for fire department personnel and little or no training for some ambulance company personnel. Ambulance response times were as long as 20 minutes. Medical equipment was limited; all fire companies were equipped with a resuscitator and first-aid kits.

Recognizing the need for improved EMS, the city council assigned to the Phoenix Fire Department (PFD) the responsibility for FMS and directed it to develop and implement plans for upgrading the FMS delivery system.

Update: The PFD is the sole provider of EMS within the City of Phoenix. Today, 26 of the department’s 47 engines and two of its 11 ladders are paramedic, staffed with at least four members, any two of which are paramedics. The paramedic engine concept was implemented in the late 1970s and is being used also for two of the department’s ladder tenders (five-person, four-door medium-duty trucks with custom “rescue”-type bodies; they carry most of the typical ladder company equipment except ladders, including hydraulic rescue extrication equipment, FMS equipment, as well as basic ventilation equipment, duplicate SCBA, and bunker clothing for each crew member). The department has six additional ladder tenders that provide BLS service.

When the City of Phoenix chose to go to a single transportation service, the PFD successfully competed. In November 1985, the Phoenix Fire Department Emergency Transportation Service (ETS) was implemented. It consistently maintains a response time of under 10 minutes 92 percent or more of the time, a majority of the responses being under five minutes.

Ambulances are staffed with EMT firefighters responding from fire stations. The fleet includes 19 first-line vehicles and nine reserve Type II Ford 350 van conversions with diesel engines. Due to changes in van body design, the PFD began using Type I modular ambulances in 1993. A three-year replacement cycle is in effect.

According to Gary P. Morris, deputy chief of District 10. the closest available unit, including engines and ladders, is always dispatched to medical emergencies. On calls indicating a potential life-threatening medical emergency, a paramedic engine or paramedic ladder (the closer one) is always dispatched. If the closest unit is a paramedic engine or ladder, that unit along with an ambulance is the basic dispatch. If the closest unit is a BLS engine or ladder, it responds with the next closest paramedic company and ambulance.

For auto accidents with entrapment, a ladder company is also dispatched for extrication, along with a chief officer to command operations.

For multiple-patient incidents, the alarm room has the option of dispatching one of two levels of a predesignated major medical response-—based on the number of patients reported or the seriousness of the incident.

Basic response includes three engines (two paramedic), one ladder company, one chief officer, and one ambulance. Initial response to a major incident includes six engines (four paramedic), two ladder companies, two chief officers, three ambulances, and a command post vehicle. Engines and ladders carry four crew members each.

The department has a major medical plan and standard operating procedures defining a medical management command system. Incident management systems, including the major components of incident command and sectors for extrication, treatment, transportation, landing zone, and staging, are used routinely. These plans are exercised regularly.

Dual-role firefighters deliver fire and EMS. New recruits receive EMT certification. The first EMTs were certified in 1971; all members completed EMT certification in 1974. The first paramedics were certified in December 1974. About 900 firefighters are trained to the level of EMT and 241 as Certified Emergency Paramedics (CEPs).

The PFD conducts its own EMT continuing education and recertification and paramedic training programs. Paramedic practice is regulated by the Arizona Department of Health Services, and paramedics must be certified every two years.

PLANO, TEXAS

Since 1980, Plano (20 miles north of downtown Dallas) has been developing a state-of-the-art EMS system as a means of coping with the city’s rapid growth. Its population has grown from 1(X),(XX) in 1984 to 155,000 in 1993 and is expected to reach approximately 220,000 by the year 2003. Ten to 12 percent of the community’s population turns over every year. The citizens are sophisticated and highly demanding of the services they want, says Fire Chief William Peterson.

Currently, 160 personnel, operating out of seven fire stations, provide EMS and fire services. An eighth station is under construction and is expected to be in service in October 1994. Stations 9 and 10 are in the planning stages.

In August 1982, the fire department began delivering paramedic services; and in early 1983. it developed an EMS action plan that included specific objectives, some of which are listed below, with target dates. Updated information appears in italics.

• Train all fire department members to the level of EMT; select and train 36 paramedics. New personnel now must he certified os firefighters and EMTs before they can take the entry test. Since 1985, employees have been hired under the condition that they become paramedics, if it is deemed necessary. The department now has 70 paramedics.
• Train all paramedics as CPR instructors and develop an aggressive citywide citizen CPR-training program. A group of six to 10 paramedics (certified as CPR instructors) has provided CPR training in schools, fire stations, and businesses/industries since 1985. The department currently offers a monthly CPR course.
• Train fire department dispatch personnel to the level of EMT and then implement an emergency medical dispatch system. This has been “one of the most dramatic elements of the system in terms of performance,” Peterson reports. Preinstructions have averted tragedies, such as drownings, he adds.
• Provide ongoing continuing education of EMT and paramedic personnel in the fire stations. The medical director or his staff does this on a monthly basis.
• Equip all fire department vehicles to provide BLS capability. This was done some time ago.
• Initiate paramedic capability on engine and truck companies. Engines have had paramedic capability since 1985; trucks were upgraded in 1993.
• Initiate a user fee to minimize system abuse and limit transport to the closest medical facility. Initial billing in 1983 was $50 per run. Today, it is $250 for residents and $300 for nonresidents, plus $4 a mile for transporting to a hospital. Peterson estimates that revenues will approach $600,000 within the next year. A certain percentage of citizens feel the service should be free because they pay taxes, Peterson explains; hut “if we do this,” he says, “we’re subsidizing third-party payers.”

SAN JOSE, CALIFORNIA^8,9,10

In 1989, the fire department provided firstresponder BLS services, and a private ambulance company under contract with the County of Santa Clara provided paramedicservices.

Believing that the fire department could provide more efficient paramedic services at a lower cost, the fire department at that time proposed to city management that the department take over the paramedic program. Questions relative to the appropriate role of the fire department in the city’s EMS system and the basis for allocating fire department resources had been raised when the city’s Office of Management and Budget reported to the city council that while the number of fires had not increased during the preceding 10-year period, the total number of fire department emergency responses had steadily increased. The city initiated a study of the EMS system.

Richard D. Wattenbarger, who last year retired from his position as deputy chief of the fire department and is now a teacher of fire science at Mission College in Santa Clara County, originally proposed to San Jose’s city managers that the fire department assume responsibility for the city’s paramedic services. The city denied the fire department the authority to assume the paramedic function.

Update: EMTs are trained at the academy to EMT-I and EMT-D standards as mandated by the state of California. EMTs provide first responder BLS, and defibrillation services are available on all first-response vehicles, reports Fire Captain Bill Mayes, who manages the department’s EMS program.

“Over the past 20 years, our workforce has had a total changeover. Department members are younger and highly educated. There isn’t the resistance to EMS there was 20 years ago. Seventy percent of the department believes the department should increase service to the paramedic level even though they all may not want to be paramedics,” observes Mayes.

Members of the San Jose Firefighters L230 and the administrative staff worked together to bring forth a department initiative, with the city manager’s approval, to the city council requesting approval to once again study the feasibility of instituting an ALS/Transport program in the fire department.

The proposal was presented on November 9, 1993. The city council authorized the study and provided $25,000 for the hiring of a professional consultant. The department formed a paramedic team and named Jeff Clet, a battalion chief, project director. The team and consultant are working together to prepare another proposal for providing ALS/paramedic services through the fire department. It is anticipated that the proposal will be submitted to the city council by the end of July 1994.

The experiences of the departments profiled above and other fire organizations show that an EMS system must be dynamic and efficient if it is to meet the needs of the community it serves. Proactivity, sound management, and evaluation are as vital to EMS organizations as they are to I ire-suppression organizations.

Endnotes

1. Szmanski. T.. press release June 7, *93; phone Sepl. 4. *93 and Jan. 14. *94.
2. Fiero, J.. “Refining Fire and EMS Services Using Paramedic Fire Companies,” NFA Exec. Fire Officers Program, June *89; phone Sepl. 7, ’93; Idler Feb. 3, *93; faxes Sepl. 3, ’93 and Jan. 13,*94.
3. Hall, J.A. “Engine Company Emergency Medical Response: It Works for Others. Will It Work for Fayetteville?” NFA Exec. Fire Officers Program, June *89; phone Sept. 7, *93 and Jan. 12. *94.
4. Darin. Wm. J.. “Tri-City Ambulance Service Staffed by Paramedics/Fire Fighters.” FE, Nov. *83, 5254; fax: “Tri-City Ambulance Service 10 Years loiter.” Sept. 10, *93; phone Jan. 12. *94.
5. Morris. O.P. “EMS Is Not a Fire Department Stepchild.” F Com. Aug. *77. 32-35; letter Sepl 16. ‘93; fax Jan. 14, *94.
6. “Phoenix Fire Department Profile,** undated.
7. Peterson, Wm. “Improving Public Support for the Fire Service Through EMS.*” FE., Nov.‘83. 55.56; phone Sept. 7. *93; fax Jan. 14. *94.
8. Wattenbarger. R.l). “A Paramedic Program Research Project.” NI A Exec. Fire Officers Program. Nov. *89; phone Jan. 27. *93.
9. Mayes. Wm.. phone Aug. 13. *93; fax Sept. 2, *93.
10. Clet. Jeff phone Jan. 18. ’94.