Updated June 2015
After a horrific boating accident on a Citrus County, Fla., river, Nature Coast EMS’s leadership team decided to do more to prepare their EMTs and paramedics for responses involving their county’s many waterways. So in January, Nature Coast launched one of the nation’s only EMS-based rescue swimmer programs, partnering with the U.S. Navy on training and the U.S. Coast Guard to supply boats.
Also this year, when Nature Coast found its paramedics were falling short of targets for successful intubations, they organized an “intubation rodeo,” which pitted medics from around the state against one another in more than 20 difficult intubation scenarios, such as a patient impaled upside down and a child stuck in a tube.
And a few years ago, after realizing they weren’t as well trained as they could be in transporting very ill patients long distances, Nature Coast launched one of the region’s only ground critical care transport programs. Their eight critical care paramedics have undergone 120 hours of additional training, including ventilator management and fetal monitoring so that medics can care for the littlest patients headed for neonatal ICUs.
“We saw where there were gaps,” says Ron Bray, Nature Coast’s critical care coordinator and EMS educator. “And we looked for ways to fill the need.”
With just more than 100 employees in a semi-rural county on the Gulf Coast of Florida, Nature Coast is a small EMS agency doing big things. From its critical care and rescue swimmer programs to its innovative use of data to improve performance in operations and clinical care, Nature Coast’s leadership is continually seeking out ways to be more efficient while doing more for their community. “We all made a commitment to each other as a team to identify best practices and put them into practice here,” says Mike Hall, Nature Coast’s president and CEO. “We realize we can’t do something on the scope of, say, a King County, but we thought about how we could scale it back and do it with the limited resources we have.”
While discussions involving small or rural EMS services are so often about how low call volume and lack of tax support keeps them struggling to survive rather than tackling the big problems, Nature Coast EMS doesn’t let any of that stop them, says Skip Kirkwood, the newly appointed chief of Durham County (N.C.) EMS, who has worked with several members of the leadership team in the past. “They don’t accept that because they’re not a high-volume service, they can’t do things outside the box, and they don’t make money an excuse,” he says. “It’s about attitude, determination and a willingness to find a way.”
In fact, not only isn’t Nature Coast seeking out a bigger piece of the taxpayer pie, but it’s actively trying to be free of government support, having lowered its annual subsidy from $1 million in 2000 to $550,000 in fiscal 2012–2013. For fiscal 2013–2014, the subsidy will drop another $60,000. The agency’s goal is to be subsidy-free in three to five years.
Articulating a vision
Nature Coast EMS was created in 2000 as a not-for-profit third service after the hospital that used to operate the ambulance service decided it wanted to get out of the ambulance business, says Hall, who is also president-elect of the American Ambulance Association. The 85 or so EMTs and paramedics who respond to about 22,000 calls annually have their work cut out for them.
With the third oldest population in the state and the fifth in the nation, the county is popular among retirees, many of whom don’t have family living nearby who can help them get to doctor’s appointments, fill medications or get up if they’ve fallen. The county also poses geographic challenges: Its 141,000 residents are spread over 773 square miles, which includes two national wildlife refuges, 53 miles of coastline and 190 miles of bays, lakes and rivers. During the summer, visitors flock to the area for fishing and scalloping in the Gulf or to take their boats out to the more than 100 tiny islands just off the coast; during the winter, they come to swim with the manatees in the spring-fed bays.
When Hall joined Nature Coast in 2007, one of his first steps was to work with the entire staff, from directors to EMTs, to create a strategic plan. “We came together as a team and said, Where do we want to take this ambulance service?” he says. “I wanted us to be the national leader in EMS, but the team said that was too narrow; they wanted to be the national leader in patient care and health services. And that’s what we’re doing.”
One of the first issues they tackled was response times. From fiscal 2007 to 2009, calls for service rose 4.3%. As part of its contract with the county, Nature Coast needs to have an average response time of 7:30. At the same time, response times rose from 6:30 in fiscal 2008 to 7:20 during the first quarter of fiscal 2010—too close for comfort, Hall says.
They analyzed historical call volume and changed their staffing levels and locations, including boosting the number of units on duty to 11 from seven during peak hours, and making sure those units were located in stations with the highest call volume. They also analyzed each element of response time, from chute time to how long it took ambulances to get back into service. Today, they continue to monitor performance using FirstWatch, a real-time CAD monitoring system that notifies supervisors via e-mail or text if any aspect of response falls outside of their targets. With that attention to detail, average response times fell to six minutes.
At the same time, Nature Coast decided they could do better on sudden cardiac arrest. They equipped ambulances with Zoll’s AutoPulse, an automated chest compression device which Hall says has improved chest compression quality significantly.
Combined with their faster responses, return of spontaneous circulation (ROSC) rates in Citrus County rose from 42% in 2010 to 54% in 2011, while overall survival increased 12%. For witnessed SCA with a shockable rhythm, ROSC hit a high of 88%. Their SCA efforts earned them 2012’s prestigious Florida Sterling Council Team Showcase Award.
Lowering response times isn’t all they did to improve SCA care. In December 2009, Nature Coast became the first in the state to begin prehospital hypothermia to drop patients’ body temperature by about 2° prior to hospital arrival. At the hospital, body temperature is further chilled to about 92° F.
“For us, particularly being in a somewhat rural area where there is a transport time of 15 to 20 minutes on average, it’s essential that we can initiate lifesaving care prior to the patient arriving at the hospital,” says Nature Coast Medical Director Mary Ann Kolar, D.O.
Integrating EMS with the hospital system is another of her goals, says Kolar, who has worked with Jane Bedford, a paramedic, R.N. and Nature Coast’s education director, on ST-elevation myocardial infarction (STEMI) and stroke care quality improvement.
With 12-lead ECGs on every ambulance, Nature Coast paramedics could diagnose STEMI in the field. But until recently, Kolar says, cardiologists refused to activate the cath lab until they’d done their own ECG. To build cardiologists’ confidence, Nature Coast focused education efforts on ECG readings and measured their success. “We now have 99% accuracy on reading and interpretation,” she says, and today, cath labs are activated based on medics’ call. “If we call from the field that a patient is having a STEMI, they now bypass the ER and go directly to the cardiac cath lab,” she says.
They have a similar strategy in place for stroke, with EMTs and paramedics providing prehospital notification for every suspected stroke patient. In 2012, case reviews confirmed that responders made the right call 84% of the time. “Our goal is to develop critical thinkers,” Kolar says. “We want them to have the tools to do their job, which is not only the equipment and appropriate protocols, but the ability to use their medical skills to intervene for their patients.”
Addressing workforce issues
To deliver the highest quality care in the clinical arena, Hall knew he needed not just big ideas but the right people. So another area he and his team got to work on was making sure they were able to hire the best responders—which wasn’t easy in a county with no local EMT or paramedic school.
A few years ago, hiring paramedics and EMTs to fill vacancies was difficult. Medics and EMTs from other counties didn’t want to make the drive to Citrus County; nor were Hall and his team satisfied with the skill level of the applicants they did have. So in 2010, Nature Coast established its own EMT and paramedic school. (A local community college has since added its own training program.)
The goal was to make a small profit on the school itself, Hall says, while improving their ability to recruit new medics and cutting down on overtime costs by limiting the amount of time vacancies stayed unfilled. All of that—and more—has been accomplished, he says.
Since opening the school, the time it takes to get a new hire ready to be a lead EMT or paramedic with their service has dropped from two months for an EMT and three to six months for a paramedic to about a month, which has led to a drop in OT costs. “When they come out of our school, their skills are incredible,” he says.
Another area of concern was soaring health insurance premiums. In 2010, Nature Coast’s health insurance provider told them to expect an 80% rise in healthcare premium costs for the upcoming year. To combat that, Nature Coast joined MedTrans, a health insurance “captive” launched in 2010. (In a captive, participant employers band together in a jointly owned health insurance company.) Since joining, their health insurance rates have ticked up only a few percentage points, says Hall, who is chairman of MedTrans’ board.
With the savings, they’ve funded a wellness program to improve the health of their employees and further rein in healthcare costs. The program includes a free gym membership, provided employees go at least 25 times a quarter; and an annual biometric screening, which includes measuring cholesterol, blood pressure, blood sugar and weight. Based on the results, each employee receives an individual health action plan. Those who hit their targets are eligible to win prizes including a three-day cruise or gift cards. At a cost of about $100 per employee, the biometric screening is well worth it, Hall says.
Their HR director, a fitness enthusiast, has taken on the role of wellness director to oversee the program.
Public relations pressure
In 2011, facing budget difficulties due to the recession and a drop in property values, county commissioners were looking for ways to cut costs. To avoid duplicating administrative tasks and improve purchasing power, the sheriff’s department proposed taking over Citrus County Fire Rescue and Nature Coast EMS. The county formed a task force to consider the sheriff’s proposal.
During one of the task force’s meetings, Hall made a presentation on the EMS service. He tried to hit on every aspect of the service, using data to help tell the story. “At the end of it, several people said there was no way they’d consider putting EMS under the sheriff’s department,” he says. “It got all the things we’ve been doing right in front of the public. It was a big boost for us.”
Realizing how important it was to make sure they got the word out about Nature Coast, they hired their first public information officer, Katie Lucas, and launched a half-hour TV series that airs twice a week on the local cable channel about a health or safety topic, such as bystander CPR or elder care.
Having fended off the consolidation, Hall and his team got back to focusing on improving patient care. Led by Jane Bedford, the Nature Coast team identified key areas they wanted to focus on: time to 12-lead for chest pain patients and time to aspirin for chest pain patients.
Using data from their state EMS database, Bedford and Todd Hockert, Nature Coast’s QI director, determined the average time to 12-lead in the state ranged from 10 to 17 minutes. Nature Coast fell within that range, but they thought they could do better. They set a goal of five minutes on scene to obtain an ECG—and they’ve achieved it, Bedford says. They instituted a similar strategy for aspirin administration and have also hit that goal.
To emphasize the importance of hitting their targets, team members’ performance appraisals and annual raises are tied in part to performance on specified clinical parameters. And it’s not just the field staff: Directors are also rated based on how well responders are doing their jobs.
Expanding the role of responders
With one of the goals of the strategic plan to evolve into more than solely an emergency responder, Nature Coast began to explore launching a community paramedicine program. As part of reaching out to potential partners, in August 2012, Hall invited local nursing home representatives to lunch. He was blindsided when nursing home staff began to complain that Nature Coast’s providers were impatient, bordering on rude. “I was mortified,” Hall says.
Taking the feedback to heart, Hall and his team created a plan to improve those relationships. They talked with their staff about the differences between a nursing home and a hospital. They also brought in experts to raise awareness about the sensory, mental and movement issues the elderly face. Part of the training included having medics and EMTs wear gel-covered glasses to simulate cataracts and earphones to experience hearing loss. Around the same time, Nature Coast also launched a pain management quality improvement initiative.
About two months ago, they invited the nursing home reps back for another lunch and asked if there was improvement. “They told us, ‘Whatever it is, you fixed it,’” Hall says. “The change was remarkable.”
Even with their already impressive track record, Nature Coast isn’t even close to being done looking for ways to get better, says Hockert. “We shamelessly steal from those that are doing good things,” he says.
Bray is also working on implementing a tactical EMS team that would respond to law enforcement emergencies alongside SWAT teams. And they’ve set a goal of Oct. 1 for launching their community paramedicine program.
“Size doesn’t matter,” Bray says. “It’s all about taking care of the citizens and visitors to our county. We’re given the privilege of being able to do that. Everybody is strapped with budgets and financial concerns. But sometimes you just have to do what’s right.”
