Mar 5, 2015
Everybody loves a good internet debate, right? This afternoon I engaged in one of those with my good friend and Chronicles of EMS star Justin Schorr about response times and their impact on EMS. Sparking the debate was an article that Justin shared that discusses the impact of response time compliance on a large city in the United States covered by a fire based EMS system backed up by two private services.
In his post, Justin disclosed that he is a firefighter/paramedic and a “card carrying member” of the IAFF. Staying in the same mentality, I need to disclose that I worked for a private EMS service for 12 years that held a busy urban 9-1-1 contract. I now work for a municipal ALS only third service that intercepts a number of BLS level fire departments. Also, as some might have heard, I am associated with the EMS Compass performance measures initiative. The views in this post are my own and in no way reflect those of anyone associated with the project.
The debate that Justin and I had revolved around two topics: the importance of response times, and the importance and relevance of ALS first response. I am going to break down those two topics separately.
Do response times matter?
In most EMS systems, response times are king especially when it comes to those serviced by the private sector. “Just get there, and we have nothing to worry about.” All that matters is an ambulance shows up, and is most cases stakeholders want somebody on that ambulance to have a paramedic patch on their sleeve. What happens from there does not really matter unless somebody complains.
It is funny that this topic comes up now, because currently sitting on the desktop of my computer is an almost completed blog post about anecdote vs evidence. The concept that response times matter to patient outcomes is one of the most anecdotal statements that has ever been made. There are three different arguments that I feel support this.
First think about the path that the majority of our patients take when they arrive at an emergency room. Think about how many of them are rushed into a room and receive immediate care versus the number that have a significant delay in the care that they receive on arrival. The rate at which we respond to the scene of a call has zero impact on this next step in their care. It does not matter whether you got there in four minutes and fifty nine seconds or fifteen minutes and twelve seconds. What really matters is the assessment that a paramedic does, and the determinations for care that they make once they complete that assessment.
Then there is the article that I seem to cite more than any other: The Great Ambulance Response Time Debate. To summarize, MedStar in Fort Worth, Texas saw significant delays in their response in the days surrounding the 2011 Super Bowl due to “13 inches of ice and snow” that was dropped by a major southern winter storm. MedStar’s Associate Director for Operations Matt Zavadsky analyzed all of the data collected and found that there was “little difference between the patient outcomes” when this week with delayed responses was compared to a normal week in Fort Worth. The article goes on to state that “even with chest pain calls, the problem was that the patients waited too long to call 9-1-1 – not that the ambulance took too long to arrive.”
Finally, and this is a point that I make in my anecdote vs. evidence article so be ready for a spoiler. I have seen the numbers for one rather large service that despite having an excellent ROSC rate they see a lower percentage of CPR saves in the more densely populated section of their service area with considerably lower response times than they do in the more suburban or rural areas. While the difference in miniscule, it is further proof that despite the fact that somebody gets on scene more quickly than in other areas, speed alone does not constitute more lives saved. That area with the lower ROSC rate is also the only area with guaranteed fire based BLS first response.
The only people that worry about response times are the general public and law makers. They worry about them because we have told them that they matter. The NFPA have told them, and apparently NREMT is putting together their own paper on it as well. They let people believe that it matters how fast an ambulance gets to your front door in order to deliver you to an emergency room where you might sit for four to six hours per visit. The evidence, however, says otherwise.
ALS First Response
In my opinion, ALS first response is smoke and mirrors. We have somebody there, but how much do they really do? How much do our patients benefit from what they do? For the answer to all of this, I look at the bread and butter of my assessment which is what I learned at the BLS level. The initial patient contact, and the first few minutes of assessment and treatment of those most critical (in this system’s definition, “Code 3”) patient is largely BLS. If an ALS engine gets on scene at the 4 minute mark and the ambulance at the 9 minute 59 second mark, how much can one expect to get completed in five minutes and fifty nine seconds? Even in cases of cardiac arrest, BLS CPR and defibrillation is often stressed for the first five minutes of care in many systems, especially in the absence of prearrival CPR.
First response does not need to be at the ALS level. At most, it needs to be at the BLS level or first response level and for system efficiency, it does not have to be made in a fire engine.
Looking back at the article that sparked this entire debate, the problem is ambulance response times not “somebody, anybody” response times. The city wants a transport capable vehicle on scene of an incident in a reasonable amount of time. While some systems have looser definitions of this, in this California system, it seems pretty cut and dry. The place for these paramedics is not in the jump seat of that fire engine, it is on a transporting ambulance. If a tiered system is not possible (and in this California city it is not) and response times are going to be tracked the way that they are, ALS first response services no purpose other than to deliver the right people to the scene with the wrong tools to achieve the system’s ultimate goal.
I want to wrap this up by thanking Justin for sparking this debate. Being able to go back and forth with him on a topic like this is always something that I have enjoyed greatly. He’s a consummate professional and one of the smartest most grounded paramedics that I have ever encountered. Lastly, this is not a slam on any particular EMS delivery structure. The problem is not who delivers the service but the route that they take to get there. As long as you’re getting the job done effectively it does not matter what the side of the truck says. What matters is that the service’s priorities are in line with the job that they are called to do and in the system discussed in the article that does not appear to be the case. They are not the first service to deal with this kind of problem and they will not be the last. Now there is just a need for somebody to fix things the right way instead of throwing “first response” at every problem that comes at them.
Justin has some great ideas about how to address this, alternate entry into the system and reduction of volume being two of them. I just hope somebody listens to him before it is too late.