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alternatives to the present system, and a helicopter ambulance which supplemented the ground systems. EvaSua- j ;
eion was based om the speed of service, the quality sf treatment, and the costs of each of the methods. i ' ! At the start of the study, our committee was established to sewe in an advisory capacity to the project staff. The committee is composed of ~epressntatives of a number of City departments and other agencies involved in transportation, health and p.&Lic safety.
It is the intent of the study and this report that the project findings be shared nationally wath other munici- palities seeking t:, review and improve their emergency medical serrices. Kmever, our committee has also reviews3 these findings and conclusions for their application to planning improvements in Detroit's service and in bringing our public ambulance system into eonfoxmity with the ambulance operating standards of the Michigan Ambulance Act (P.A. 258 ( i 9 5 8 ) ) .
Bur committee unanimously endorses a rider of specific i / recomendatisns for Detroit which follows the list of 1 1
project findiqs contained in the front of both the project Summary ..and +he geport . The major recombsienGation made is that the responsibility for the entire public emergency ambulance service be transferred to the oatroit Fire Department.
It is our belief that implementation ef these recommendations , will result in a more ef_f_ectiue and efficient service for 1
the citizens of Detreit. 1 1 Very truly yours,
I A. F. Kalo, Chairman Advisoxy Committee i Emergency Medical Demonstration Project
1 I
The Mayor's Committee for Community Renewal of the City of Detroit and the Highway Safety Research Institute of the University of Michigan wish to acknowledge with sincere appreciation tha many organizations and individuals who contributed to this study.
The primary ambulance data was provided by the police officers and Fire Rescue Squads which operated in the four palice precincts utilized for the demonstration. We wish to express our apprecia- tion to these officers arrd firefighters, to precinct Inspectors, Eugene Ziolkowski, Odson Tetreault, Russell Galiaway, and Arnold Kleiner, and to Deputy Fire Chief Joseph Deneweth.
Background information, public ambulance system demand data and operational control o f the police, helicopter and commercial ambulance field units was pravided by the Csmmumication Center of the Technical Service Division of tho Detroit Police Department. Inspector Edward Walsh and Lieutenant Frank Staskon assisted in the operational planning and provided liaison and coordination with the Police Department.
Special mention must be given to Sergeant Art Bunchuck of the Police Communications Technical Division who designed and con- structed the comunications systerr for the helicopter, an8 to Patrolman Ray McClosky of the Motor Traffic Buresu who was the police observer on the helicopter.
Popular involvexnent in the emergency medical reporting process was made possible by participation of the Community Radio Watch, Michigan Consolidated Gas Co.. General Electric. Checker Cab Co., Instant Comunications and Detroit Edison. Similar contributions were made by the Detroit Street Railways and the Department of Streets and Traffic of the City of Detroit.
Special acknwdledga,ent must be given to the project medical con- sultants, Dr. Charles Lucas of the Schaol of Medicine, Wayrne State Vniversity. and Dr. Stephan Fromm, formerly of the same institution. They developed and directed training programs, supervised the acquisition of medical data, and provided assistance and consulta- tion on the medical phase of the program.
W e are also grateful to the Wayne County Medical Society which donated space for the training program.
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THE DEEIOXSTS.TI0N PRLUylGCT
The ambulance systems studied were (1) the Poiice Department, (2) the Fire Department, (3) a contracted rommerciai service and (4) a helicopter ambulance.
The Police Department's response system can be characterized as 80 to 120 station wagons operating as patrol vehicles and capable of a rapid response. These dual-purpose station wagons are as- signed to police precincts. Medical equipment in them conslsts of two cots, and blankets wnen available. The training level of the patrolmen is that received at the police training acadeiny. For the project, two additional first-aid training programs were instituted to provide additional levels for analysis.
The Fire Department's seven rescue squads provide aiergency medical service across the city in addition tc their fire fight- ing duties. The seven squads primarily respond in instances of heart attacks, strokes, respiratory difficulty and extrication. Squad trucks are staffed by five firemen and carry a full comple- ment of extrication and oxygen ecpipment. cots. blankets and a very few other first aid items. The training level of rescue squad firemen is initially similar to that of the patrolmen, with emphasis on resuscitative measures. However, because of more sntensive on-the-job experience and a regular retraining program. the rescue-squad level nf training exceeds that of the patrolmen.
The third systen consisted of two fully equipped cormercial ambulances operated in response to public calls in order to com- pare a single-purpose service to the existing dual-purpose systems ~t was intended that the trai~ing level and treatment potential of the professional attendants be compared to that of patrolmen and firemen.
Tkie fourth system Semonstrated was experimental--a helicopter ambulance. The ambulance-equipped helicopter was operated to test its feasibility in augmenting ground ambulances and to eom- pare service tlmes and costs. The helicopter attendant was a highly trained paramedic,
In order: to study service time and treatment characteristics of
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awriliaxy saclio reporting systems is inherent within the reporting i and screening process; m a w calls from radio equipped vehicles do not include infopmation on the existence of injuries (thereby assuring response) and +-he informataon is relayed throug3 second - parties so claririsatiezn or further interrogation by the police is impcssible.
In %he =absence sf a large mount of empirical data, an analytical model sf the telephone eyrstam as augmented by a radio reporting system wan developed.4 Although not cenprehensive, the model suggests that a large number of vehicles--possibly 20 percent of the vehicles on the road--would be required to reduce the mean notification time by one minute.
IMPLICATIONS FOR SYSTEM DESIGN
Attempts to reduce the detection and notification time should be directed to the general public, since people on the street and in nearby buildings reported mast of the incidents.
Since these people must use the telephone, this channel should be the target for improvement. Two improvements are possible. The first is a single emergency number such as 911, and the second is a pubiic edu&atzon program on the importance of rapid response.
A s~ngLe number would he difficult to establish in Detroit since many suburban communities shabe exchanges with the city. However, ehe present linked operation between the Police and Fire Depart- ments approaches the single number concept; a call to police will elicit the appropriate response for any emergency, including fires.
A public education program designed to decrease notification time must be carefully planned if it is to be successful without stin=- rating an increased demand for unnecessary services. Recogition
radios, and city buses--all having a dispatcher. The second wzs the City department of Streets and Traffic citizen band station in- volving their vehicles plus some citizens. The tairdi was the Citleens Band Monitor :Get which involved private groups patrol- ling areas of the city. A31 three systems report infomation in addition to medical emergencies.
4See Section 9-5 sf the Report.
should be given to the fact that such a program also would provieo the opportu~ity to zeduea demand by reinforcing screening proce- dures in relation to a defined emergenry'response peiiey.
3 . Time a t t h e scene,
4. T rans i t t i n s to t h e lisspitral,
5. Time a t t h e h o s p i t a l .
The minim~un time before t h e a r r i v a l s f a s s i s t a n c e i s a f ~ n c t i o n of the f i r s t two time elements of t h e se rv ice process. The f i r s t four elements de te rn ine t h e rnininmn time be fo re a r r i v a l of t h e v ic t im a t e medical f a c i l i t y where h e may rece ive necessary case. The sun of elements two through f i v e i s t h e t o t a l veh ic l e s e r v i c e time--the period of time t h a t t h e veh ic l e is omt of s e r v i c e 3r unavailal j le f o r response t o other emergencies. As this duratior. a f f e c t s veh ic l e a v a i l a b i l i t y ; veh ic l e se rv ice eime i s an impor- r a n t considera t ion i n determing t h e number of veh ic l e s t o be operated and t h e i r d i s t r i b u t i o n . Vehicle a l l o c a t i o n and d l s t r i - but ion w i l l be diocusssd further i n Chapter Vi.
Kany f a c t o r s which might inf luence t h e length of se rv ice times could not be experimentally con t ro l l ed i o t h e study, but t h e analyses do provide add i t iona l i s s i g h t s i n t o f a c t o r s which in- f iuence s e r v i c e times and a re 5un3iamenta: t o s=3und sys temat i t design.
The o3aerved mean trme e l t -~ . - . c s and the m e a n t r a n s i t d r s t ances of t h e s e r v i c e process a r e s3c.m In Table 2 ,
The com.ercial h ~ b u l z n ~ ~ s ~ w ~ r ~ : d i s~a tchec? by t h e p o l i c e i n I l e a of patrol s t a t i o n wagons. It 2 s believed t h a t the langer d i spa tch delay for com?isrrial ar&ula-.ce se rv ice i s duo t o t h e occas ional d i spa tch oE a pol ice u n i t to ;he scene f i r s t t r s v e r i f y -,he need for a-nbulance a s s i s t ance rat:?ec thnn t h e lack o f avai la38e a&?-- lances .
Cne wozld expect t r a n s i t tines :in tha scene a-76 t o t h e hospital) t o Se f n n c t i s n a l l y r e l a t z d t o -;,e disEa3ce t-raveiee, iiawever, only 2 5 percent o f t h e variaticrs i n times ca:: be attributed t o d i s t ance t r ave led . Renaicicg 3 i f f e rences had t o ee a t t r i b u t e d t o o the r faztore s i ~ e h as ,3 i f fcrences betwaea + & m i n l s t r e t , i o n s , treat- ment rendered a t the scene, etz. A l i s t of l a - t o r s exariabled a re show^, i n Table 3. Al tho)~gh a nuvber sf effects de tec ted a r e discussed i n d e t a i l i n the Repor t , these e r f e c t s w e r e not great,
TABLE 2 MEAH S E W I C E TIbaES A m DISTAKCES
~ d ~ i n i s t r a t i a n po l i ce F i r e commercial - -
Xean Times i n Xinutes
Disparch Delay 2.7 --* 5 -8
Time t o Scene Time on Scene Time t o Hospi ta l Tine a t Hospi ta l
To ta l Vehicle Service T i m e 3 3 . 3 1B.4 27.5
Mean Distances i n Miles
Distance t o Scene Distance t o ~ o s p i t a i
*Dispatch delays f o r t h e F i r e Department were not recorded.
TABLE 3 FACTORS XALYZED FOR
POSSIBLE EFFECTS QN SER'JICE TIPS F:RLA'TTONS
Type of Conveyance: Po l i ce FLre Comercra l Ambulance
Distance U s e a f Liqhts Use of S i ren N&er of Treatments Rendered
a t Scene Choice of HsspitaX
u n c o ~ t r o l l a b l e Factors
T r a f f i c Weather Other d i f f i c u b t i e s en route (mechanical, tires, e t c . j
Type of elnergency a. T r a f f i c vs, non-
kraf f i - b, Violent vs. nsn-
v io len t Condition of Victim
experience was supplemented by a 40-hour course. The course con- sisted of 35-hmra on initial care and handling of the sick and injured and five hours of traffic-safety law.
Police officers in all three training levels shared or;e common feature--they were required to perform more than the treatment function at the scene such as crowd control and accident investi- gation. On the other hand, the Fire Department rescue squad team performed only the medical function at the scene as did the commercial attendants.
EVALUATION OF DBIAGNOSES
To get adciit~wnal insight ~ n t o the types of service offered, diagnastlc cnpabllity of the attendants was evaluated as well as the treatment pxovided.
The diagnoses were evaluated by conlpariso~ of P;he resuits on the ambulaalcs check sheet prepared by ambulance attendants with those on corresponding emergency-room check sheets. Each diagnosis was graded on a scale of 1 tbzough 8 , according to the appropriateness of the attendant's diagnosis. Appropriate diagnoses include those that were the same as the physicians and those that were related to the physician's diagnosxs and were inficatiire of the appropri- ate first-aid,
The result sf ihe diagnosis evaluation is given in Table 4.
Only two of the units show statxstically slgnif~cant drfferences In performance--police who recerved the reeresher course and %he Flre Department rescue squads. Police who had attended the re- fresher course diagnosed s~yn:f~ranthy better than all other unlbs, but no explanation based on course content can be gxven. The lower performance of ?ha rescue squads may reilecc dlfferenccs an the nature ~f case load rather than valxd dliferences In pecfor- matlce. Most of the medical amer:grncies r-fesxed to the Fire Depaztmnz axe ~ 3 - m - 3 TJ ui-ias, and are more dlf f icr~lt to daagnose than the large number of ob~oblb ~ t l j w ~ x e b encountered Z>y t h ~ police.
?he second method of ava1uatir.g the eftact of training ad treat- ment was based on the snfamation pravxded by the emergency-room physicians, For cacfl victim, the physicnans xnd~catcd whether or
Police Academy Refresher Advanced
Camercial Amhalance Service
TAPPEE 4 DIAGNOSIS E*PFLiIAsI'Tz3N
Appropriate Diagnoses As a Percent
Fire Rescue Squads 5 9*
Total 69%
*Fire rescue sq~ads handled more non-injury cases whach are harder to diagnose.
not treatment was needed, andl was artempted, and ia' atttempteci, the s~zccess of the technique. This infomation was provaded for the following first-aid measures: (1) use of a rigid backboard. ( 2 ) cardiopulmonary resuscitation, ( 3 ) control of severe hemor- rhage. 14) splinting of long bones, and f 5) guarantee of adequate respiraticn. A sixth treatment--control of light bleeding or simple bandagxng--was cons~dered during the evaluaclon since mxnsr open wounds were encountered frequently,
A sumarts of the treatment measures by training ievei is provided i r t Table 5 ,
The commercial attendants canrrolled light bleodnng much more ire- que~tly *illan other units (96 percent compared with less than 38 percent for other units). This is not a life saving measure but was encountered m t ~ c h more frequently than the more serhoras problems. For this reason the sumxary results also are given with this treatment excluded. Backboards and cardiopulmonary resuscitation were required and used less frequently than the other first-aid measures. Therefore the results given in Table 5
Police Academy Refresher Advanced
Commercial
m=--4 . *a, 5 PERCENT OF CASES
T m - ATTWTED CGES ISTEtIT WITH PHYSICIANS OPINION
Control of Light Control of Light Bleedinq Included Bleedinq Excluded
Fire Rescue 7 9 8 5
are weiqhted with emphasis on control of hemorrhage, quarantee of respr:atisn, and splinting.
Statistically significant differences do not exist between the three police mits, Although the difference between the police with refresher training azd the ccmercial attendants did not prove to be statisticaliy si-jnificant, there was a significant dif- ference between the police with acadexy and advanced training a ~ d the commercial attendants. Interpretation of the data represent- ing the fire rescue squad training level cannot be made because of inade.qlate s&aplc size, H ~ v : e i i e r ; a s~--rong trea-.ent capability is indicated for the treat~lszt rr,eaz.jres ef carrliop~$lmanasy rssusci- taticn a?.d the a?mi-istratron of oxygen. Xt should ba reaognized thar it is diffic-l" to atts-ch medic=l sl.gnificance ts these metsures Ffi relaeicfi to t h e ~rainii;g le~.rels studied;
The zhira measure of treat~ent as related to training was pro- vi-de: by 7r3e emrr~ezcy-trocm physicians in = s-~bjactive response t;o questions aimed at detarmir,irrg the a.2equacy of: :i) the present training levels ( 2 ) speed of service ( 3 ) the potential benefits of increasing the pzesent training levels and (4) utilizing the paramedical techniques af endotracheal intubatlo:: znd intravenous fluid therapy.
The data indicated that the American Red Cross First-Aid Training was an adequate training ievel for over half of the cases evalu- iited; a sgeeay arrival at the hospital (within 10 minutes of arrival at the scene) was important in less than a third of the cases. More highly trained paramedics would have eliminated the need for speed in transit in only 9 percent of the cases. The attendants' possible use of intravenous fluids and endotracheal intubation involved only a small fraction of the demonstration cases. Physicians indicated mixed opinions on the value of these measures in an urban environment with a rapid emergency response system.
The assessment of higher levels of training as it relates to treatment is the least conclusive indicator of the three regorted.
IMPLICATIONS TO SYSTEM DESIGN
The examination of treatment of victims and training levels of attendants had the following conclusions of importance in de- signing an emergency medical system.
1. The single-function attendants provided appropriate treatment more reliably thar. the police officers, who had to perform more than the nedical function at the scene, such as eruvrc? ccritrol. In the context of the demonstration, both the Fire Department rescue squads and the commercial ambulance attendants were responsible for only the emergency medical care function at the scene.
2. With regard to diagnoses (which presuinbably takes relt- tivefy little t i m @ ! the p~lice sersonnei did as well as their counterparts on tho commercial amb~lanees and better [as a percent) than those m e n staffing the rescue sq~zads. Iicwever, it should be recalled that the rescile squads deal with more non-injury cases which are much harder to diagnose.
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TABLE 8 DUAL- WRPOSE VEHICLE AVW.IWILT5T AS A m * T X O N OF l%'hLLmTEfil3 PQIJLY
Number of AvailabxLity wich a 0%. Availability with in 20%* vehicles -- BShar~ce of a Police Run -- Chance of m R~lice R=
-- *The 2C% prabability has been assigned as a reasonable
esr4n1ate of piicx runs for dual-parpose vehicles-
emerrrency medical call) %he remaining vehicle could ha pro.cected by holding iC reserved (except for crttisal situations). If the probability cf accepting a police run rs + : I ~ ~ & y reduced to 10 percent when one vehicle is busy, the reserved vehicle will be available 93 percert of the t;me c3us increasing availabality f r o m 90 percent. A higher percentaqt. of poizc:e calls would frsreher increase &he avaaMiPity o f the reserved %chicle.
POLICY BE- ECTS ON SEZVLCE T I M 5
The rnajrpr effect of modifyln.; the dxstritaut~on of recovery vehi- cles 1n a single-purpo';r fixed bbsc-. ambulance system should be to dr~rcsse servxce times hy reciii:cing response times. Assuming two vehSclea in a precinct, the placement of ve3l~clss in areas of maxLmum demand (Pol~cy 1) results ~n the hsghest probabillV- :>F
short uns, 33 percent. Where ewo vchxeles are un~fomly dxskrr- buted over a serv-ece rejaon ( E c s l l ~ y TI] the probabil~ty of a short run i s only 28 percent. Althouqh the probability of a short run under Policy I is substantial9y greater than that eta6er Polacy If, the service zimes axe nearly this same for ruts both under and aver a xk3.c. Thus the meaa service times that could be expected with a policy which places sehacles in areas of m.dxlmumn demarld would be 19.8 minutes, and 19.9 minutes usxng h policy of unafnrm dxstri- butim. The resulting difference in the total mean service tfpnes
%0,% manate) is nearher statistically or operationally significant.
1- Based or1 the allocatfon mtielimg, it has been observed that a four-vehicle system in each precinct provides essentially l00 percent ;rehi.cHe availability i.n bath the single-purpose and dual-purpose operating modes, H o w e v e r , tiwo sinyle-purpose vehicles can perform nearly as we1.f an a four-vehicle system especially when vehicles are placed at separalre stations- I+ this tww-vehicle re- covery syst-em is operated in a dual-p~rpose mode. vehicle availa3;ili.ty can be improved by ut41izing the protective dispatch policy aiscussed earlier.
2 , , By iiliocating two single-purpose recoveiy vehicles to each precinct, 26 vehicles would be required to provide city-wide service for the 13 precincts. ii is quite likely- that this ntadaer can be reduced by allowing am- bulances to cross precinct boun6ariea and operating in service areas larger than a precinct, or by reducing the present demand. For instance, it seems possible that three vehicles servicing two pcecincts caoL-3 provide adequate availabi4ity wl.thout severely increasing transit times to the scene. In chis ease, city-wide service could be provided with 19 or 2 0 vehicles. Clearly ex- peximentation w i t h such a system i .~ desi-rable ts validate this qualitative cofi jectu.re,
3, PLacememgl of recovery vehicles within a precir:c'c did r.ot influence ambulance availability in any substantial way for the experimental systems studied. Hawever, distri- hution could effect service times if larger service areas were used. If a policy of uniform vehicle distri- b~tion were adopted in a city-wide system, sklcrt respcmse times--uaot substantially different from thsse achieved in the maximum demand distribution--would be expected.
CHAPTER VII
COST ANALYSIS
In the preceding chapters, project findings for a number of al- ternative emergeney medical service system components and opexational policies have been described. Changes in vehicle availabiliity and response times were studied for several differ- ent systems, as operated by various types of personnel, and under a number of allocation and distribution policies. The incidences of correct diagnosis and treatment were studied as a function oi the training received and the type of personnel utilized. These findings suggest that, on a performance basis. there are a num- ber of acceptable and effective ways of structuring an emergency medical response system.
Xmever, the operation of any service requires the expenditure of existing resources {whether they be dollars, manpower, facilities or material) which are limited and which present a very real con- straint to service operation and system design. In order to identify those systems which will require the minimum resource expenditure for the particular level of performance desired, several alternative systems have been constructed for compariso3.
In this analysis, a number of factors were examined such as personnel, personnel training and lic@nsing, anbulance vehicles, emergency ~uipment and supplies, ambulance base stations and system adninistration. The costs developed were then used to de- rive the costs for four representative methods of pr~viding emerger,cy medical service: (1) contract with commercial ambulance companies and operation of (2) a mcnicipal .zri?x~lance Gepartment. ( 3 ) a combined fire-ambulance service and (4) a combined police- ambulance service. Etch system was constructed to service the total annual public emergency load.5
51n the Report, the eosts of providing this service through the combined effort of bcth the police and fire departments was extensiveiy discussed since this is the metho< cf ssrvice his- torically provided in Detroit. The cost of this type of system, however, is basically reflective of the costs characteristic for each, as adjusted far the portion of t he total service rendered.
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