Embed Size (px)
Citation preview
STUDY TO DETERMINE THE FEASIBILITY OF UPGRADING EMERGENCY SERVICES FROM BLS TO ALS BY THE CITY OF SANTA MARIA FIRE
DEPARTMENT
ADVANCED LEADERSHIP ISSUES IN EMS
By: Robert W. Meyer City of Santa Maria Fire Department Santa Maria, California
An applied research project submitted to the National Fire Academy as part of the Executive Fire Officer Program
September 2000
ABSTRACT
The Santa Maria Fire Department (SMFD) delivers emergency medical services (EMS)
to the community via three fire stations and advanced life support (ALS) by private ambulance.
The problem presented in this research paper was the City of Santa Maria Fire
Department is evaluating the need to increase its level of emergency medical services (EMS)
from basic life support (BLS) to advanced life support (ALS). The purpose of the research was
to conduct an evaluation and recommend necessary policy and service-delivery changes for the
City of Santa Maria.
The research questions asked were:
1. Is the existing fire-based basic life support EMS used by the Santa Maria Fire
Department adequate given the increasing demands placed on the system?
2. Does historical data support the need to upgrade to ALS services for the city
of Santa Maria?
3. What would be the associated costs for upgrading to ALS service levels in the
city of Santa Maria?
4. Do the members of the Santa Maria Fire Department support changing the
service delivery from basic life support to advanced life support?
Evaluative and historical research was conducted. Survey instruments were sent to fire
department members and also to the city of Santa Maria citizens. Analysis of EMS responses by
the Santa Maria Fire Department was conducted. Results indicated that the Santa Maria Fire
Department could provide a higher level of service to the community in a faster response time
and for less cost then currently provided overall. Recommendations included (a) providing
3
EMT-P (paramedic) level of service to the community, (b) hiring additional staff for paramedic
engine companies, and (c) purchasing ambulances for transportation of victims.
4
TABLE OF CONTENTS
ABSTRACT………………………………………………………………………………………2 TABLE OF CONTENTS………………………………………………………………………..4 INTRODUCTION……………………………………………………………………………….5 BACKGROUND AND SIGNIFICANCE………………………………………………………6 LITERATURE REVIEW……………………………………………………………………...11 PROCEDURES…………………………………………………………………………………18 RESULTS……………………………………………………………………………………….22 DISCUSSION…………………………………………………………………………………...26 RECOMMENDATIONS………………………………………………………………………27 REFERENCES…………………………………………………………………………………30 APPENDIX A…………………………………………………………………………………...32 APPENDIX B…………………………………………………………………………………...33 APPENDIX C…………………………………………………………………………………...34 APPENDIX D…………………………………………………………………………………...35 APPENDIX E…………………………………………………………………………………...36 APPENDIX F…………………………………………………………………………………...37
5
INTRODUCTION
The City of Santa Maria Fire Department (SMFD) is responsible for a variety of
programs designed to accomplish the agency’s mission statement: “The principal mission of the
Santa Maria Fire Department is the preservation of life and the protection of property within the
city of Santa Maria” (SMFD, 1995). Principal amongst these programs is the Operations
Division of the SMFD. The Operations Division is responsible for providing for emergency
medical services, fire suppression, hazardous materials response, and technical rescue responses
for the community and its residents (City of Santa Maria, 2000). The implementation of this
mission statement is through the maxim of “Excellence in Service” (SMFD, 1995).
The identified problem is that the City of Santa Maria Fire Department is evaluating the
need to increase its level of emergency medical services (EMS) from basic life support (BLS) to
advanced life support (ALS). Despite this proactive agency mission statement and values, there
has never been a formal evaluation of the effectiveness of the EMS delivery system to the
community. Therefore, the effectiveness of the agency’s service-delivery system relative to
preserving life and reducing the number of fatalities and injuries is unknown and unproven.
Furthermore, absent any structured evaluation of the EMS delivery there is no mechanism to
determine a change from BLS to ALS is needed or required. In addition, there is a lack of
verifiable and quantitative data from either the Santa Maria Fire Department or the Santa Barbara
County Emergency Medical Services Authority (SBCO EMSA). The requirement of County
oversight does not permit local jurisdictions to set their level of care and service delivery based
on community needs. The SBCO EMSA, without input from the local jurisdictions, dictates all
service levels for all entities within Santa Barbara County.
6
The City of Santa Maria Fire Department currently provides basic life support (BLS)
with automatic external defibrillator (AED) capability. A private provider provides ALS to
Santa Barbara County through a contract with SBCO EMSA.
The purpose of this applied research project is to identify and evaluate the feasibility of
upgrading the SMFD EMS delivery to ALS paramedic engine companies. The research methods
used for this applied research project were historic and evaluative methods. The research
questions for this applied research project are:
1. Is the existing fire-based basic life support EMS used by the Santa Maria Fire
Department adequate given the increasing demands placed on the system?
2. Does historical data support the need to upgrade to ALS services for the city
of Santa Maria?
3. What would be the associated costs for upgrading to ALS service levels in the
city of Santa Maria?
4. Do the members of the Santa Maria Fire Department support changing the
service delivery from basic life support to advanced life support?
BACKGROUND AND SIGNIFICANCE
The SMFD was established circa 1900 as a volunteer fire company prior to the city of
Santa Maria government being formed. In 1905 the city of Santa Maria incorporated as a
general-law city under a council/manager form of government. In the following decades the fire
department transitioned from a completely volunteer organization to a mostly paid department
with reserve fire fighters augmenting as necessary. In the past year there has been movement to
develop a “charter” form of government.
7
Today the SMFD has evolved into an “all risk” service department serving the 72,000
citizens of Santa Maria through two divisions: Operations, and Fire and Life Safety (Personal
Interview Chief Frank Ortiz, 2000). The Operations Division is responsible for fire suppression,
emergency medical services (first responder with AED capability), hazardous materials response,
and technical rescue. The Fire and Life Safety Division is responsible for fire prevention, code
compliance, plan review, fire and environmental crimes, public education, fire investigation,
disaster preparedness, public information, and hazardous materials inspections (SMFD, March
2000).
The Santa Maria Fire Department currently operates out of three fire stations with
automatic and mutual-aid agreements with Santa Barbara County Fire Department for the south
end of the city limits. The SMFD operates with 35 full-time safety employees assigned to both
the Operations and Fire and Life Safety Divisions as well as Fire Administration. The full-time
staff is augmented by 12 reserve fire fighters. All fire fighters, regardless of paid or reserve
status, must be California Fire Fighter I certified. In addition, all paid fire fighters must be
certified to Fire Fighter II and Emergency Medical Technician (EMT) levels with additional
training and certification as Emergency Medical Technician-D (EMT-D) for the use of automatic
external defibrillators (AED). Most of the fire department reserve cadre are certified as Fire
Fighter I and EMT.
Currently ALS care and emergency transportation are provided by a for-profit private
company. The Santa Maria Fire Department provides BLS with AED capability on all
responding vehicles. During calendar year 2000 the fire department has begun a study to
determine whether the fire department or ambulance company arrives on scene first. For the first
8
six months of the year, the Santa Maria Fire Department has arrived first on scene 86% of the
time (SMFD RMS Report, 2000).
During calendar year 1999 the SMFD responded to 4,199 alarms (SMFD, CAD 2000).
Table 1 indicates the percentages and types of calls responded to. As indicated, 65% of the calls
responded to were for EMS.
Table 1
1999 SMFD Responses
65%6%8%
21%
EMS
Fires
HazardousConditionOther Calls
Table 2 indicates the current responses for the SMFD (SMFD CAD, 2000). The
percentages and types of responses are increasing from calendar year 1999. This data reflects
only the first half of the calendar year. The data indicates the percentage of EMS responses is
increasing.
Table 2
2000 SMFD Responses
70%6%
3%
21%
EMS
Fire
HazardousCondiitonOther
9
The number of EMS responses is increasing every year. The average percentage of responses for
calendar years 1995-1999 is shown in Table 3 (SMFD CAD, 2000). The requests for service for
the Santa Maria Fire Department have increased 12.9% for the calendar year 2000 (SMFD,
CAD, 2000). It is clear the percentage of responses for EMS is increasing annually. The
national average for EMS calls in the fire service is between 50% to 75%. (ICMA, 1988).
Table 3
1995-1999 SMFD Responses
65%7%
9%
19%
EMS
Fires
HazardousConditionOther
The City of Santa Maria Fire Department’s “ Standards of Cover Report” details
performance measures for both fire and EMS responses (SMFD, March 2000). These
performance measures are nationally recognized standards. The goal for EMS delivery is to
arrive in time to deploy resources to reverse brain damage arising from lack of oxygen and blood
circulation. The American Heart Association states the best chance an individual who is
experiencing arrest has of walking out of the hospital is based on the developed guidelines that
state cardiopulmonary resuscitation should begin within four minutes and advanced life support
within eight minutes of a witnessed arrest (IAFF, 1999).
The City of Santa Maria General Plan, Safety Element Objective 3.1.a states: “Achieve a
five-minute response capability to all areas within the city limits and maintain adequate water-
storage standards for fire-flow pressure requirements” (City of Santa Maria, 1995). According to
10
the Standards of Cover Report (SMFD, March 2000), the City of Santa Maria Fire Department
achieves the five-minute response time 78% of the time based on location of population and
distribution of existing fire stations. The SMFD Records Management System (RMS) report
indicates the current responses are 80.20% for less than five minutes for the calendar year 2000.
The SMFD requested its employees track data for the number of ALS responses to which
companies were dispatched. The criteria for ALS were the use of a cardio-monitor, intravenous
line (IV), cardio-conversion, or intubation. Since the SMFD only provides BLS with AED
capability, the department developed a special survey field in their RMS for responses. For the
first four months of calendar year 2000, the following breakdown is available (SMFD CAD,
2000).
Table 4
Fire Station Number of ALS Responses
1 578
2 275
3 529
Totals 1382
Although the data shown is only for the first six months of the calendar year, it shows
that for that time period of all the incidents the Santa Maria Fire Department responded to, 78%
of the requests were for ALS services.
In reviewing statistics provided by the SBCO EMSA (Personal Interview, Nancy
Lapollo, July 2000), the number of ALS transports on a three-year average is 1,133 per year or
52.17% of the transports made. The remaining percentage for BLS transports is 47.83%. Of all
11
patient contacts 89.11% of those were transported to the local hospital. Appendix D illustrates
the potential revenue from those hospital transports. The rate for transport was taken from the
private provider as well as the rate from Santa Barbara County Fire Department (Personal
Communication, Jan Burkett, June 2000).
The significance of the data begs the question: Does the Santa Maria Fire Department
need to increase its service delivery to the community by providing ALS services?
This applied research project is being written after completion of the Advanced
Leadership Issues in EMS (ALIEMS) course at the National Fire Academy as part of the
Executive Fire Officer Program. The ALIEMS course dealt with current issues in EMS. The
research project was specific to a section on fire-based EMS delivery systems.
LITERATURE REVIEW
Literature review was conducted and concentrated on issues surrounding fire-based EMS
service delivery and the use of paramedic engine companies for ALS delivery. The process of
review included a search for authoritative sources based in fire-service EMS operations. Lastly,
an attempt was made to identify local and national changes in patient survival rates as a result of
changes in EMS delivery.
Over the past two decades the public has come to expect many more services from the
fire department (Dittmar, 1993). Fire departments have become involved in hazardous materials
response, public education, fire prevention, and EMS delivery (Dittmar, 1993).
EMS is the key in generating public support and enhancing customer service in the fire
service (Sachs, 1997). Each department should look at EMS as the most important service it
provides (Sachs, 1997). Indeed, while the fire service can benefit from entering the EMS field,
12
call volumes will increase and, additionally, funding both capital and personnel costs will rise
(Greiff, 1999). Fire-based EMS providers’ costs do not increase for personnel due to the fact the
fire fighters are already on duty for fire responses (IAFF, 1999). Initial program costs for
program implementation will increase due to the start-up costs. After the program is operational
and those start-up costs have been exhausted, the operational costs will be reduced to a lower
number.
Expanding from BLS to ALS first-response service is a positive step toward providing a
higher level of service to the citizens and visitors of the jurisdiction (Sachs, 1997). The most
important step a department can take is to generate support from the staff. They are a powerful
voice as they meet the public on a daily basis (Sachs, 1997). A survey of the Santa Maria Fire
Department personnel was conducted in June 2000 to ascertain their feelings. The results
(Appendix A) indicated the total number of respondents were in favor of the concept.
The value of ALS has been well documented in medical emergencies (Ullman, 1994).
Before jumping to ALS the provider must be certain what the customer wants and expects. The
citizens served by the fire department must feel that change and expansion are necessary (Sachs,
1997). A random survey was conducted of the community members of Santa Maria in July
2000. The results of the survey indicated 75% of the community expected ALS services when
the fire department arrived (Appendix B).
The City of Santa Maria, like most communities, provides fire-based first responders in
its EMS delivery system. Fire fighters usually provide first-responder medical care prior to the
arrival of EMS personnel (Greiff, 1999). Fire departments provide EMS care because they are
the most readily available and closest to respond (Grieff, 1999). Nationwide, fire responses are
decreasing while EMS responses are increasing (ICMA, 1988). Gary Morris of the Phoenix,
13
Arizona Fire Department stated, “Do not give up the opportunity to commit your department to
an expanding role in your EMS delivery to your community” (1993).
Fire services and EMS both have certain time constraints where the patient survivability
and fire severity is affected by response times (IAFF, 1999). In determining if response
standards and time frames are within national standards, the time-temperature curve is used
(IAFF, 1999). For EMS delivery Dr. Eisenberg’s model is the most recognized and has become
the standard of performance for pre-hospital care. Table 5 demonstrates that in a nine-minute
response time CPR is not initiated until at least ten minutes from the time of cardiac arrest, 11
minutes before defibrillation, and 13 minutes have elapsed before advanced cardiac life-support
(ACLS) care is initiated. These results indicate a 4.6% predicted survival rate (1993). By
comparison, if CPR is initiated by fire department EMTs responding within four minutes,
survival probability quadruples to 18.2% (Cummins, 1993). Finally, if those same fire fighters
are equipped to deliver ALS, the survival rate is 37% (Cummins, 1993)
Table 5
CPR Defibrillation ACLS Predicted Survival Rate
Survival Rates/All Potential Survivors
10 Minutes 11 Minutes 13 Minutes 4.6% 6.9%
Fire Dept EMT 5 minutes
11 Minutes 12 Minutes 18.2% 27.2%
Fire Dept EMT 5 Minutes
Fire Dept EMT-D 6 Minutes
11 Minutes 25.8% 38.5%
Fire Dept EMT 5 Minutes
Fire Dept EMT-D 6 Minutes
Fire Dept. EMT-P 7 Minutes
37% 51.0%
Throughout the United States fire agencies are seeking an expanded role in the
community through an enhanced commitment to EMS (Lazar, Jensen, Goebel, 1996). Proper
14
analyses must consider and distinguish between medical intervention and medical transportation
elements of EMS system design (Lazar, et al.).
Most of today’s research has been written regarding pre-hospital treatment of
cardiac-arrest patients. The American Heart Association recommends a maximum response time
of four minutes for basic life support and eight minutes for advanced life support measures to be
initiated (IAFF, 1999).
Cardiac-arrest survivability between three interventions, CPR, defibrillation, and ALS
intervention, has been studied extensively (Lazar, et al.). According to the study reduced
response times improve the probability the patient will survive (Cummins, 1993). If CPR,
defibrillation, and ALS intervention are instantly available, the patient has a 67% chance of
survival (Lazar, et al.).
Table 6 illustrates how the survivability rate declines when response time increases.
Table 6
Survival Rate Formula
Survival rate = 67% (this assumes instantaneous response of all
necessary emergency medical services)
Less: 2.3% Per Minute to CPR
Less: 1.1% Per minute to Defibrillation
Less: 2.1% Per Minute for ACLS
“Response time” has many definitions by many different users (IAFF, 1999). Response time
defined by the National Institute of Health states: “As a rule of thumb a first responder should
15
arrive at the scene in less than five minutes from the time of dispatch in 90% of all such calls.
This will generally result in a median first-responder response time of two to three minutes.”
The American Heart Association recommends a maximum response time of four minutes
to initiate basic life support and eight minutes for initiation of advanced life support (IAFF,
1999). The importance of response time was emphasized by the Journals of American Medicine
(JAMA): “Cardiac arrest, the highest hospital-discharge rate has been achieved in patients in
whom cardiopulmonary resuscitation (CPR) was initiated within four minutes of arrest and
advanced cardiac life support (ACLS) within eight minutes.” Early bystander rescue breathing
or CPR intervention and fast EMS response are, therefore, essential in improving survival rates
(Roush, 1994).
Early advanced cardiac life support (ACLS) provided by paramedics at the scene is
another critical link in the management of cardiac-care patients (Roush, 1994). EMS systems
should have sufficient training and staffing to provide a minimum of two rescuers trained in
ACLS to respond to an emergency (Roush, 1995).
The influence of a timely on-scene arrival of ALS paramedics has a direct effect on the
survival of cardiac patients (Cummins, 1993). Going from a 12-minute to seven-minute ALS
response time increases the chance of surviving a cardiac arrest from 27% to 37%, a 40%
improvement in the patient population prognosis (Lazar, et al.). Every two-minute change in
arrival translates into a 15.5% improvement in the EMS system’s response to these critical times
(Cummins, 1993).
Another portion of ALS provision is to review trauma intervention and advantages of
ALS versus BLS. The time limits and constraints are clear and have been for years (IAFF,
1999). This 60-minute period or “golden hour” has been a time standard for years (Buchman,
16
1991). In traumatic injuries a patient has only a 15% chance of survival if in-hospital surgery
begins after this 60-minute period. Further, for life-threatening injuries where shock occurs
(patient’s systolic pressure is less than 70 mm hg) and is not treated within 30 minutes, a 62%
mortality rate is expected (Buchman, 1991). Rapid intervention to stabilize the patient through
bleeding control, shock prevention, maintaining the airway, breathing and circulation, along with
rapid transport are paramount in patient survivability (IAFF, 1999).
Literature review continued into what methods are available to deliver ALS to the
community. The majority of the review was done on the fire department providing ALS. There
are several other options available to the fire service to deliver ALS, as well.
Fire departments are strategically positioned to deliver rapid, timely responses (IAFF,
1999). Fire station locations are based on the time-temperature curve and arrival on scene prior
to flashover, the critical moment in fire fighting and life safety (IAFF, 1999). Cross-trained,
dual-role fire fighters are in a position to provide fire and EMS delivery in a timely fashion
(IAFF, 1999).
Fire departments delivering ALS do so in a variety of ways. Phoenix, Arizona Fire
Department delivers ALS via engine companies, ladder trucks, and ladder tenders (Morris,
1993). Seminole County, Florida delivers ALS via transport units equipped to fight small fires
(Personal Interview Schenk, 2000). The City of San Diego, California delivers ALS by
paramedic-assessment engine companies and private-transportation units (Sachs, 1997).
According to Jeff Bowman, fire chief for the city of Anaheim, California, ALS is provided by
paramedic engine companies with private provider transportation (Personal Interview, 2000). In
the city of Downey, California, ALS is provided by the fire department on engine companies and
transportation provided by fire department ambulances (Personal Interview, 2000). In a personal
17
interview with Fire Chief Terry Schenk, Seminole County, Florida, he discussed his experience
in bidding for the EMS contract with his county (Personal Interview, 2000). Chief Schenk
provided his Request for Proposal (RFP) document outlining his cost versus the cost of the
current private provider.
There are other options available for EMS delivery in a community aside from traditional
fire or private provider (Lazar, et al., 1996). One tool designed by Lazar, Jensen, and Goebel,
termed Transport Integration Model™ (TRIM™), supports a process of developing a more
formal integration of public and private sector (Lazar, et al., 1996). Because TRIM™
successfully integrates both public and private resources into the system’s design, TRIM™
implementation results in significant cost savings, which translates into lower user fees (Lazar, et
al., 1996).
Cost effectiveness plays a major role in any governmental delivery service. Tim Butler
with Anaheim Fire Department in California states, “As an already existing service, the fire
department provides a more cost effective means of providing paramedic service” (1989). The
most significant advantage to implementing ALS engine companies is cost (Morris, 1993).
An essential element that must enter into the decision process for fire agencies
considering expanding their EMS roles is whether providing transport services will detract from
the primary fire and first-response missions (Lazar, et al., 1996).
Literature review was conducted regarding costing and funding options for EMS delivery
in the fire service. There are many different options available to fund EMS programs (Sachs,
1997). Funding can be generated from taxes, fees for service, subscription services, and
contracts with agencies (FEMA, 1999). EMS is a major role of the fire service and is increasing
in scope and sophistication (FEMA, 1999). EMS calls comprise 70% of the Santa Maria Fire
18
Department responses (SMFD, 2000). EMS was once thought of as a free service, part of the
service delivery of the fire service to the community (FEMA, 1999).
There are a wide array of funding sources and mechanisms available to fire departments.
Amongst the most common mechanisms are taxes, benefit-assessment charges, fees, alliances,
cost sharing, TRIM™, and subscriptions (FEMA, 1999). Many organizations use a combination
of funding sources including grants, fees for service, subscriptions, public/private partnerships,
and bond issuances (IAFF, 1999).
In contacting other agencies providing EMS and identifying funding sources, there seems
to be a mixture of concepts. In personal interviews with Chief Terry Schenk, Seminole County,
Florida; Chief Mark Sauter, Downey, California; Lieutenant Kevin Bershce, Farmington Hills,
Michigan; and Fire Chief Jeff Bowman, Anaheim, California, they all use a combination of fees
for service, subscription fees, and tax-based general-fund money (Personal Interviews, 2000).
Fees for service and subscription services finance the majority of fire-based EMS
delivery systems (IAFF, 1999). In personal interviews with Chief Mark Sauter (Downey,
California, 2000), City Manager Mike Parness (San Clemente, California, 2000), and Chief Mike
Dolder (Huntington Beach, California, 2000) regarding their subscription service and
participation, all interviewees indicated a different level of commitment from the community in
participation. The ranges were form 11% to 31% participation.
In addition to fees for service, subscription services, and general-fund revenue, another
possibility would be a utility tax on each household to pay for the service.
19
PROCEDURES
Evaluative research that included examining historical perspectives and data was
conducted through several avenues including literature review, surveys, CAD data analysis,
personal correspondence, and personal interviews. In addition, two surveys were conducted.
One survey was done internally with the members of the Santa Maria Fire Department
(Appendix A), and the other survey was done in the community (Appendix B).
Definitions and Clarification of Selected Terms
AED -- Acronym used for automatic external defibrillator.
ALS -- Acronym used for advanced life support. When drug intervention, cardiac
monitoring, shocks, as well as intravenous medications are used.
BLS -- Acronym used for basic life support. Personnel certified to perform basic
life-saving functions.
CAD -- Computer-aided dispatch and records system.
CAPITATION -- A method of payment for services in which, based on a pre-negotiated
contract, funds are exchanged for services.
EMT -- Acronym used for emergency medical technician as determined by the State of
California.
EMT-P -- Acronym used for emergency medical technician, paramedic level, as
determined by the State of California.
IAFF -- International Association of Fire Fighters.
RMS -- Records Management System
20
Literature Review
Literature searches were initiated at the National Emergency Training Center’s (NETC)
Learning Resource Center (LRC) during the author’s attendance at the National Fire Academy’s
ALIEMS course. Additional searches were conducted through the Internet’s on-line search
engines to ascertain any groups or published papers available for use. The author’s private
collection of fire administration and reference publications was also reviewed.
Personal Interviews and Correspondence
Personal interviews and written correspondence were conducted with experts in the EMS
delivery field. Personal interviews were conducted with the Santa Maria Fire Department Fire
Chief Frank Ortiz in May 2000. The interview consisted of defining the current level of service
and the goals and objectives for the Santa Maria Fire Department.
Fire Engineer Dennis Perea of the Santa Maria Fire Department is the Records
Management System (RMS) coordinator for the department. Engineer Perea assisted in the
development of computer-aided dispatch (CAD) and Records Management System (RMS)
reports used for data collection and references in this report.
Personal interviews were conducted with the fire chiefs of Downey, California and
Seminole County, Florida. An interview with Fire Chief Mark Sauter (Downey) was conducted
on June 16, 2000 to discuss Downey’s fees for service, subscription-based EMS delivery system.
In addition, Chief Terry Schenk of Seminole County, Florida and I discussed the type of budget
required to bid on providing service to the community, fees for service, and the type of apparatus
to purchase if transportation was provided (April 17, 2000).
21
Survey Instruments
Two survey instruments were developed to collect information from the community and
from the fire fighters of the Santa Maria Fire Department. The surveys served to collect data
relative to the expectations of the community on level of service and from the fire fighters as to
whether they support ALS and whether they would participate in the certification process.
The first survey was entitled ALS Research Questionnaire (See Appendix A). The survey
was sent to all 30 members of the department. Prior to being distributed to the department the
instrument was reviewed by Chief Frank Ortiz and Division Chief Jack Owen of the Santa Maria
Fire Department. The survey questions were very specific to the Santa Maria Fire Department
and its mission. Each survey went out with a cover memo from the author detailing the survey
and why it was being prepared and sent out. The surveys were returned to the author by the
specified date and time. As this survey was voluntary, there were no follow-up surveys sent out
to non-responders. No names were ever attached to the survey, allowing personnel to be honest
and to feel less threatened.
The second survey is entitled City of Santa Maria Fire Department Questionnaire (See
Appendix B). The survey was done on July 12-16, 2000 at Santa Maria Fairpark during the local
county fair. Prior to being distributed it was reviewed by staff associates and Chief Frank Ortiz.
The survey questions were very specific to the Santa Maria Fire Department and the expectations
of the community members. Additionally, the survey contained questions as to the service level
provided to the responder if they ever used the fire department’s service.
22
Assumptions and Limitations
An expected limitation of the research was that some of the data did not have enough data
history with the new Records Management System. The data used had to be extrapolated based
on what data existed at the time of preparation.
The surveys also proved to be limiting. The data collected from the Santa Maria Fire
Department fire fighters was limited due to the fact not all members participated. The number
of returns is more than normal when the fire department sends out questionnaires.
The research project was also limited by time. The six-month submission criteria of the
EFO program did not allow for the expansion of research into related areas including (a)
correlating known ALS calls and BLS calls to type of medical care needed or exact level of care
given, (b) comparison of whether there was an increase in the number of transports and incidents
of specific types of requests for service over the years, and (c) comparison and increased data
collection for ALS requests for service and service provided in the city of Santa Maria. These
subjects warrant further review in the future and leave room for additional study by the author or
others.
RESULTS
In answer to the specific research questions:
1. Is the existing fire-based basic life support EMS used by the Santa Maria Fire
Department adequate given the increasing demands placed on the system?
Fire-based EMS delivery systems are typically increasing their level of service to ALS.
As the literature review determined, providing ALS is the best level of service to the community.
In the survey the City of Santa Maria Fire Department conducted, over 95% of the people
23
surveyed expected the fire department to be capable of providing ALS treatment on their arrival.
Additionally, with the statistics from the Santa Barbara County EMSA office, clearly ALS is
necessary in the community. With 52.17% of all EMS calls in the city of Santa Maria being
ALS, the fire department needs to increase its service level to the community.
2. Does historical data support the need to upgrade to ALS services for the city of Santa
Maria?
Historical data from the Records Management System (RMS) for the city of Santa Maria
indicates 70% of the requests for service are for EMS. Historical data supplied from the private
ambulance provider indicates 93% of patient contacts were transported to the local hospital. Of
those 52.17% were for ALS care, and the remaining 47.83% were BLS transports. Given the
fact that over 50% of the responses of the Santa Maria Fire Department are for ALS requests,
upgrading the EMS system to providing ALS is a good idea.
The CAD data states our response times to the majority of the community are within five
minutes for 78% of all responses and within eight minutes of all responses. The private
provider’s contract requires their arrival within eight minutes 90% of the time. In a recent
incident in the southern part of Santa Barbara County, it was recorded that the ambulance arrived
33 minutes after dispatch. Literature review indicates arrival for ALS should be within eight
minutes to secure a survival outcome of 50%.
3. What would be the associated costs for upgrading to ALS service levels in the city of
Santa Maria?
Appendices C, D, and E present data illustrating the funding necessary for the start-up of
the entire project. The program costs will depend on the implementation. There are several
options to implementing the service. Those costs referenced in Appendices C, D, and E illustrate
24
a full fire-based EMS-delivery system. Should the electorate body decide on other delivery
methods, the costs will be adjusted accordingly. The IAFF model (IAFF, 1999) and the Lazar,
Jensen, and Goebel method also use a marginal cost-accounting method. The initial start-up costs
for the program are high because the current delivery method does not have any transportation or
ALS associated with the program. The author noticed the costs would decrease after the first
year when start-up costs would no longer be a factor.
Although the cost indicates a large increase in staffing for the department, those costs
will also assume fire fighter duties not just assigned to EMS functions.
4. Do the members of the Santa Maria Fire Department support changing the service
delivery from basic life support to advanced life support?
The survey distributed to the Santa Maria Fire Department was completed by 20 of the 30
employees or 66% of the organization. The results are listed in the survey below.
ALS Research Questionnaire
1. Would you be interested in becoming involved at the ALS level if the department were to go to that service level and support through the education process?
__9__ I would BE INTERESTED in obtaining the ALS certification.
__11__ I would NOT BE INTERESTED in obtaining the ALS certification.
2. Do you feel that expanding our current level of services to ALS would be in the best interest of the community?
__20__ Yes
______ No
25
3. How do you feel ALS would be accepted by the shift you are on now?
__13__ Accepted
___7__ Guarded Acceptance
______ Not Accepted
4. Please circle the choice that applies to you? (Voluntary- you do not have to answer these, but they help with data collection and meaning.) Tenure and Longevity:
<5yrs 5-10 years 10-15 years >20 years 5 staff 5 staff 3 staff 7 staff
Additional Comments
“90% of our calls are EMS; we must provide ALS! Anything else would be unacceptable!”
“A shift is very receptive to the idea of providing ALS.”
“I am a state-licensed paramedic already.”
“Highest level of care available should be provided by all 9-1-1 EMS responders.”
“Most believe we need it on a first-responder platform. Most feel it would be a needed increase of service.” “I feel an incremental, properly-designed ALS program would benefit our department and community.” “We could provide better service at lower cost.” “As long as the proper funding was behind our doing so.” “As usual there would be some who would not accept it.” “The community needs better ALS service; and with the fire department going to ALS, the community would get it.” “Because the level of ALS service the community is getting right now is less than standard.” “Greatly accepted because my shift is ready to take the next step and go ALS.”
26
“I think assessment engines would benefit this community. We are often on scene before the ambulance, which means we can give treatment sooner. Also, there are a limited number of ambulances in the city, and often we are on scene for a few minutes before they get there.”
It is interesting in the survey that the older employees were the ones not wanting to
become involved in the certification as a paramedic. The younger fire fighters (ten years on the
job) were interested in becoming paramedics. All 20 respondents were receptive to changing to
ALS from BLS. The one drawback that surfaced was a few fire fighters were apprehensive
about expanding our program if it would hurt the chances of acquiring new staff or fire stations.
In actuality this program may help achieve that according to Fire Chief Frank Ortiz (Personal
Communication, July 2000).
DISCUSSION
This research paper confirmed facts that have long been suspected or assumed by the
SMFD administration and personnel but had remained unproven before this. Specifically, the
SMFD devotes the majority of its responses towards EMS, yet the service level is not what the
community expects or what the fire department would like to deliver. Nor is the level of service
in the best interests of the community. As indicated in Table 2, the majority of emergency
responses in the city of Santa Maria are for EMS-related calls. Of those requests for service,
52.17% are for advanced life support (SBCO EMSA, 2000).
The fact that until very recently the SMFD only provided EMT service to the community
indicates the fire department did not forecast the future needs of the organization or community.
Furthermore, this research brings to the forefront a persuasive argument for redirection of
the SMFD resources and personnel into upgrading to ALS EMT-P services to the community.
27
As indicated by the survey conducted of the community, 75% of those 1,000 people
surveyed expected to see EMT-P (paramedic) personnel on first-response units with the ability to
administer drugs. The survey conducted with the members of the Santa Maria Fire Department
indicates their support for increasing the level of service to advanced life support.
It is apparent from the literature review that providing ALS to the community is the next
logical step in EMS delivery to the community by the fire services (Sachs, 1997). Essentially the
customer receives two services for the price of one when a fire-based EMS-delivery system is
used (IAFF, 1999). Another common thread is the ability for the fire-based system to provide
faster response, thereby being able to provide a more timely ALS intervention (IAFF, 1999).
RECOMMENDATIONS
The City of Santa Maria Fire Department should implement an enhanced fire-based EMS
delivery system. The current delivery system should be upgraded to advanced life support
engine companies and provide transportation for the patients to the appropriate hospitals. The
existing EMS-delivery system does not provide the best and appropriate level of care for the
community. An enhanced delivery system will better serve the community. As indicated in the
survey conducted by the Santa Maria Fire Department, the community expects that level of
service.
The Santa Maria Fire Department should provide paramedic-level (EMT-P) service on all
three first-response engine companies. Additionally, the Santa Maria Fire Department should
provide for EMS transport units capable of providing treatment and transportation of sick and
injured residents to the hospital. The transportation should only be emergency transports, not
facility transfers. Each recommendation will be under a separate heading.
28
Personnel
In order to provide adequate, highly trained and motivated paramedics for each shift and
response vehicle, a staffing ratio of 1.17 is required. In order to staff three engines with
paramedics, the City of Santa Maria would be required to recertify three existing personnel, train
nine personnel to paramedic level, and hire 12 fire fighters for a dual role, EMTs and fire
fighters. In order to accomplish this goal, it is recommended that a phase-in process be
undertaken. During the first year the Santa Maria Fire Department should recertify the three
personnel and begin training the nine others using the shift floater to cover the missing fire
fighter during training. Additionally, the Santa Maria Fire Department should hire 12 fire
fighters to staff two ambulances capable of transporting patients as well as handling small fire
fighting operations. Hiring these personnel will increase staffing levels to come into compliance
with the Santa Maria Fire Department’s Standards of Cover document. The hiring of 12
personnel should be split between six paramedics and six EMT-Ds.
A continual quality-improvement group and program should be developed using national
standards and protocols from the SBCO EMSA. The group should have members from the base
hospital, EMT-Ps, fire department management, medical director, and EMSA.
The City of Santa Maria should hire its own part-time medical director reporting directly
to the City of Santa Maria fire chief or division chief.
Equipment
The City of Santa Maria should purchase two heavy-duty ambulances for two fire
stations in the city. Additionally, the City of Santa Maria should purchase one medium-duty use
ambulance to be used as a spare by on-duty crews who could cross-staff the unit when either of
the primary units are out of service for maintenance or in the event of a large disaster.
29
Equipment required for the engine companies would include a manual/automatic
defibrillator, advanced cardiac life-support medications, and drug boxes. Equipment for the
transport units would include the compliment of equipment on the engine companies along with
the required equipment according to the Federal Ambulance Specifications.
Financing
The recommended financing would come from several sources. It is recommended the
Santa Maria Fire Department use revenues from transport fees to offset some of the costs. More
in-depth analysis will be needed to determine the effect of the new Medicare billing rates
recently determined by the Health Care and Finance Administration (HCFA).
The revenues generated from the transportation will not be enough to offset the entire
cost of the service. With the dual-role fire fighter concept, funding from the City of Santa
Maria’s general fund is used to supplement the cost of the program. Additionally, funding could
be raised through a subscription service, a capitation agreement with local skilled nursing
facilities for emergency transport, or other potential funding sources. Additional research would
be required to determine the exact method(s) to be used and what revenue would be generated.
Additional research
Due to the limited time allotted for the research project by the National Fire Academy,
additional research by the SMFD is needed. Additional research into revenue sources and
mechanisms for infusing more funds to the proposed program should be reviewed. In addition,
the fire department should research issues such as quality assurance, service-delivery options,
transportation, ambulance location, interfacility transfers, wheelchair van usage, and
level-of-care issues.
30
Additional research is needed to correlate the type of medical aid given and the types of
responses made by the SMFD. This data will be necessary for station-coverage issues, level of
training needed by fire department personnel, types of responses, and personnel to the scene.
Closer research as to the need for emergency medical dispatch (EMD) training and a
benefit analysis for the City of Santa Maria should be completed.
31
REFERENCES
Buchman, T.G. (1991). Strategies for trauma resuscitation. Surgery, Gynecology, and Obstetrics, 172, 8-12.
Butler, T. (1989, December). Call the fire department. Emergency, 21, 45-47. City of Santa Maria (1995). Safety Element. City of Santa Maria General Plan, City of
Santa Maria. City of Santa Maria (2000). City Budget. City of Santa Maria Budget, City of Santa Maria. Cumins, R.O.; Eisenberg, M.S.; Hallstrom, A.P.; and Larsen, M.P. (1993). Predicting
survival from out of hospital cardiac arrest: a graphic model. Annals of Emergency Medicine, 22, 9-15.
Dittmar, M.J. (1993, July). Fire service EMS: the challenge and the promise, Part I – an overview. Fire Engineering, 147, 47-56. Greiff, S.J. (1999, June). Fire-based EMS: the trend of the future. Emergency Medical Services, 147, 43-57. International Association of Fire Fighters (1999). Emergency Medical Services: A Guide Book For Fire-Based Systems. Washington, DC. International Association of Fire Fighters. Lazar, R.A., Jensen, A.M., Goebel, R.C. (1996) Fire Service EMS Costing Strategies. Lazar, Jensen, and Goebel—Prehospital Systems Consulting. Morris, G. (1993). 15 years of paramedic engines. Fire Chief, 41-43. Page, J.O. (1988). Emergency medical and rescue services. In R.J. Coleman & J.A. Granito
(Eds.), Managing Fire Services (pp. 347-379). Washington, DC: ICMA Roush, W.R. (1994). Principles of EMS systems. American College of Emergency
Physicians, 487. Sachs, G.M. (1997, January). Expanding EMS: upgrading from BLS to ALS. Fire
Engineering, 110-112. Santa Maria Fire Department (1995, June). Standards of Cover (Report) Santa Maria Fire Department (2000, March). Standards of Cover Revised (Report). Santa Maria Fire Department (2000, July). Computer Aided Dispatch (RMS Reports). Ullman, K. (1994, April). The value of ALS. Firehouse, 80-81.
32
United States Fire Administration (1999, December). Funding Alternatives for Fire and
Emergency Services
33
APPENDIX A
ALS Research Questionnaire
1. Would you be interested in becoming involved at the ALS level if the department were to go to that service level and support through the education process?
_____ I would BE INTERESTED in obtaining the ALS certification.
_____ I would NOT BE INTERESTED in obtaining the ALS certification.
2. Do you feel that expanding our current level of services to ALS would be in the best interest of the community?
_____ Yes
______ No
3. How do you feel ALS would be accepted by the shift you are on now?
_____ Accepted
______ Guarded Acceptance
______ Not Accepted
4. Please circle the choice that applies to you? (Voluntary- you do not have to answer these, but they help with data collection and meaning.) Tenure and Longevity:
<5yrs 5-10 years 10-15 years >20 years
Additional Comments
34
APPENDIX B
City of Santa Maria Fire Department Questionnaire
The city of Santa Maria Fire Department is reaching out to the community to determine how you perceive our service delivery, what your expectations of our delivery are, and if we are meeting those expectations. Please take a few moments to complete this survey so we may better serve our community. YES NO QUESTION Have you ever called 9-1-1 for an emergency requesting the
fire department or ambulance? Were you treated nicely when we responded? Were we professional in our assistance to you? Did we respond in a time frame you thought was fast
enough? Please take a few moments to answer the following questions: 1. Please number the following items in order of importance if you were to call the fire
department.
_____ Timely, rapid response. _____ Compassionate responders. _____ Professionally trained personnel. _____ Able to administer drugs and medications to save your life. _____ Professional looking personnel.
2. When the fire department arrives, what level of treatment do you expect from them? ______ Basic First Aid ______ Advanced First Aid ______ Paramedic Level Care
35
APPENDIX C
Staffing Factor Calculation Worksheet
Hours of work to be covered in one year
Days of Work 365 Hours of Work 24
Total annual hours of work 8760 Number of Shifts/Platoons 3
Hours Worked Per Group 2920
Shift Rotation 24 on 24 off Work Week (Hours) 56 Average Leave Used Per Person
Average Sick Leave 88.33 Average On-duty Injury Leave
Average Vacation Leave 192.4 Average Training Leave 72 Average Holiday Leave 0
Average Bereavement Leave 0 Average Other Leave 61
Average Leave Per employee 413.73
Hours Actually Worked By Average Employee 2506.27
STAFFING FACTOR 1.17
(Divide 2920 by 2506.27)
36
Appendix D
Marginal Personnel Requirements Worksheet
Staffing of Positions
ALS Engine Company Staffing 1 Paramedic per Engine company Ambulance Transport Staffing 2 Firefighter/EMT-D per unit Number of Transport Units 2 Staffed Transport Units Number of Engine Companies 3 Staffed Engine Companies Number of Shifts Three Shifts (3) Staffing Factor 1.17 per position Paramedics Required Per Shift 3.51 (4 personnel) Total Personnel Required 39 (constant staffing)
Number of Positions Number of New Positions (FF/PM) 12 Cost Per Employee (year 1) $53,528.74 Total Salary Cost Three New Employees $160,586.00 Salary Cost Year 2 $165,403.00 Salary Cost Year 3 $173,673.00
Training and Certification Costs
EMS Training Costs $5000 p/person $45,000 (9 current employees) Continuing Education Costs $2000 p/person $24,000 (12 medics)
Paramedic Incentive Pay $400 p/person $4800 (12 medics) Recertification Exams $20 p/person $ 2400 (12 medics)
Total Training and Certification Costs $76,200 p/year
Total Personnel Costs (New Paramedics) Year One $236,786 Year Two $248,625 Year Three $261,056 Costs associated with new paramedics includes training and certification costs for the first year as well as continuing education and associated costs for years two and three.
37
Appendix E
Revenue Projections
Transport Volume (3% increase
annually)
Year 1 Year 2 Year 3
ALS Transports 1133 1167 1202
ALS Transport Charge
$608.60 $608.60 $608.60
ALS Billables $689,544 $710,236 $731,537
BLS Transports 706 727 749
BLS Transport Charge
$484.20 $484.20 $484.20
BLS Billables $341,845 $352,013 $362,666
Average Transport Distance (Miles)
5 5 5
Mileage Charges (Per Mile)
$12.95 $12.95 $12.95
Mileage Billables $119,075 $122,637 $126,327
Oxygen Charge $64.46 $64.46 $64.46
Oxygen Billables $73,033 $75,225 $77,481
Projected Revenue $1,223,497 $1,260,111 $1,298,011
Collection Ratio (65%)
$795,273 $819,072 $843,707
Revenue projections are based on a three-year average. Data supplied from American Medical Response (AMR) (July, 2000).
38
Appendix F
Revenue/Expenditure Summary
Year 1 Year 2 Year 3
Estimated Transport Volume
(3% increase Annually)
1133 (ALS) 706 (BLS)
1167 (ALS) 727 (BLS)
1202 (ALS) 749 (BLS)
Personnel Costs $236,786 $248,625 $261,056
Training and Certification Costs
$45,000 $30,000 $30,000
Apparatus Costs $330,000 0 0
Equipment Costs
Operational Costs $225,000 $225,000 $225,000
Subsidy Savings
Revenue Projections 65% Collection Rate
$795,273 $819,072 $841,578
Net System Revenues Marginal Costs
- $41,513 $315,447 $327,651
The revenues and expenditures are based on current billing rates and a 3% increase in transports annually. The costing does not amortize the vehicle costs over more than one year. Operational costs are for hiring an outside private provider to staff City ambulances for year one. Years two and three are full-time fire fighters increasing the service delivery to the city of Santa Maria.
