Roundtable: EMS leaders react to the 2019 EMS Trend Report

The fourth annual EMS Trend Report explores how recurring and emerging trends are shifting in prehospital medicine.

We asked industry experts to review and react to the survey results, how they reflect current healthcare trends, and how to make the data actionable for EMS leaders

The panel includes:

• Brook Burton, NRP, FACPE, quality director
• Chris Cebollero, EMS consultant
• Maia Dorsett, MD, Phd, EMS physician
• Brian LaCroix, FACPE, NRP, president NEMSMA
• James MacNeal, DO, MPH, FACEP, FAEMS, NRP, medical director
• Matt Zavadsky, MS-HSA, EMT, president, NAEMT

EMS1: Which finding surprised you the most?

Brooke Burton: After the 2018 survey, I commented on my surprised regarding so many agencies still using lights and sirens for every call, and I am surprised there was not more of a change this year. very few patient conditions necessitate the increased risk involved in saving a few seconds of our time. Our industry needs to focus on evidence-based practices. Plenty of evidence exists proving the practice of red lights and sirens saves little time overall and significantly decreases the safety of the field provider, patients and other members of the communities we serve. If our overall mission is improving the health and safety of our patients and communities, we should be engaging in practices which decrease their risk of death or injury. Industry leaders should be working to change the hero culture behind these types of outdated policies, educate ourselves and the public about safer practices, and implement change based on evidence and best practices.

I was surprised by the number of managers and chiefs who were not optimistic about the future of EMS. If the leaders of the industry are not optimistic and motivated, how can we hope for the people we lead to feel optimistic? Leadership sets the tone and example for the entire organization. Continuing leadership education is as critical as medical education for the field. Leaders need to acquire resources to remain optimistic, face challenges and provide solutions to our toughest industry problems. Leadership education and networking provide those resources.

Matt Zavadsky: The value of EMS service delivery is something the industry has to address as we look toward future economic sustainability, and the ability to attract and retain professionals we rely on to serve our communities. The data in this report reveals that across all delivery models, an equal percentage of agencies experienced a budget decrease, or no change in their budget from the previous year; 36%.

Delivery costs are likely not decreasing, but this data may suggest that the prayers of EMS services (taxpayers, commercial insurers and others) are tightening the reins on the funding for EMS delivery. This may be an indication that EMS agencies need to continually seek ways to implement new economic models based on a new value proposition for those paying for our services.

Provider and community safety must be a primary goal of EMS agencies. Running hot presents the highest risk to our providers and our community. Yet, 70% of the respondents report that they run hot to all (20.3%) or most (50.2%) 911 calls. This is despite the fact that virtually every study that has looked at the effect of response times on patient outcomes have found no correlation to any response time greater than 5 minutes on patient outcomes.

NHTSA and Dr. Doug Kupas released a report on the use of hot responses, including a meta-analysis of more than 202 studies and reports on the issue to prove this case; including a study that revealed patients have actually not called 911 because of their concern about the spectacle it creates. If we are serious about provider and community safety, and ensuring the public calls 911 appropriately, we need to seriously address the glaringly inappropriate way we respond to medical calls in our community.

Brian LaCroix: One of the things that surprised me was the medical director’s reluctance to embrace the term paramedicine. I do agree it may have soemthing to do with their own hard-won efforts to establish a sub-specialty which they have titled EMS. That said, the reference to the career field is less important to me than the title of the providers themselves.

I’m hopeful medical directors could be persuaded to support referring to all providers as paramedics rather than the dizzying array of labels we use today. The National EMS Advisory Council identified no less than 37 different names being used across the country to identify people who work in an ambulance. We have created confusion about our vocation rather than demonstrating professionalism and unity. This is not helping our cause with legislators/regulators, the media and general public or insurance payers.

As more physician leaders come to appreciate the value of a common language with our stakeholder groups, more of them will potentially change their view on this issue. Consequently, it will be important to cultivate and educate physician champions to help move the nomenclature conversation forward.

Maia Dorsett: One lack of change to focus on (not that I find it surprising) is the degree of medical director engagement, where less than half of providers felt that their medical director was “very engaged” with them. While I would disagree that medical director engagement is measured by their knowledge of the budget (medical director engagement should predominantly focus on the quality of clinical care and the education and wellness of the people providing that care), it is an important growth area for EMS if we are to improve quality of care provided and integration with healthcare overall.

James MacNeal: I am most surprised by the disparity between EMS providers and medical directors regarding the outlook for EMS. I would encourage EMs providers to have regular interaction with their medical directors to continue to engage in discussions about working together to move EMS forward locally. We can’t all sit idly by waiting for a magical federal agency to come fix the woes of prehospital medicine. It is going to be a local issue, and we need to work to find solutions within our own states to move us forward.

Chris Cebollero: We have known for many years now that our workforce is our main concern when dealing with recruitment and retention. It is surprising that in this, the fourth year of this study, we as a career field are still seeing the numbers concerning our workforce and making EMS a career rather than a steppingstone. We need to focus more attention on creating the workforce that will be engaged – when they are engaged, they are satisfied, when they are satisfied, they are productive, when they are productive, they deliver great patient care.

I did think it was important that this survey asked why individuals are leaving EMS agencies. We need to focus on the why and develop a blueprint to keep our people. We know that until we fix the reimbursement issue, we won’t be able to fix wages, but, developing a highly engaged workforce can happen, and that should be the first step.

How do the findings of this year align with other trends in EMS and healthcare?

Brooke Burton: Reimbursement models in healthcare overall have been changing and must continue to change in order to be sustainable, and EMS is no exception. ET3 is a good start, but more must be done to improve reimbursement so ambulance services can afford to increase field provider compensation. Reimbursement is the start of a domino effect which touches every aspect of service. Better reimbursement leads to improved provider compensation. Better compensation allows providers to work less hours overall, which reduces fatigue, provides better work/life balance, and improves home life and overall resiliency. More resilient providers call out less and have less overall turnover, which decreases costs to services and allows services to reallocate funds to improve equipment and patient care. Our industry must come together to advocate for sustainable reimbursement to build the foundation which will ultimately improve many of the pressing problems we face today.

Matt Zavadsky: The expanding role of EMs within the healthcare system likely provides the greatest opportunity for us to meet the IHI Triple Aim and demonstrate additional value to our stakeholders. Respondents to the Trend Report seem to agree with the transformation of EMs into services beyond simply 911 response and transport to an ED. Sixty-one perfect of field providers, 64% of medical directors and 70% of owners agreed or strongly agreed that MIH is the future of EMS. Similarly, 72% of chiefs and 79% of medical directors who responded to the survey indicated their agency is either considering, planning or doing an MIH delivery model. This is an important sign for our profession.

Brian LaCroix: This year’s survey paints a picture of a workforce feeling weary, disconnected from mission and leadership, underappreciated and unwilling to recommend the career field to others. At the same time, leaders and medical directors seem to report a relatively optimistic view of their work and the future.

It would be easy to feel discouraged by this data and some of that reaction may be warranted. In the context of our world today, it feels somewhat understandable. We live in a highly polarized political environment, including mistrust of law enforcement and other uninformed disciplines, with a generally tumultuous environment in our society today.

Like with so many challenges of leadership, I encourage that we focus on the long view. With a realistic and sober assessment of our problems, a genuine commitment to find solutions and a healthy dose of kindness toward one another, we can work through difficult problems over time.

Maia Dorsett: The depersonalization of patients and the burnout/moral injury of the frontline clinicians, summed up by the following survey response: "[It] breaks you and turns you into a heartless person’ (field provider, 11-20 years). Patient interaction was one of the most cited reasons for finding EMS satisfying, but 12% of respondents had high levels of burnout and this parallels other areas of healthcare as well. People enter this profession with the noble goal of caring for others. It is easy to become discouraged by a system that can make it difficult to do so and does not always take care of its own. I do feel optimistic, though –the more we recognize this as an issue, the more we can come up with viable solutions to address it.

James MacNeal: The reimbursement trends are consistent. The new proposed payment model is interesting, but we will need to be cautiously optimistic to see if it actually pans out.

Chris Cebollero: I think we are still being stagnant with what we are finding in each year’s Trend Report. A large amount of work goes into surveys like this one, yet to me, EMS leadership is just looking the numbers and not trying to fix the underlying causes behind the numbers. This has to be a focus of using this data to make the changes we want to see. I found it interesting that EMS medical directors focused on how paramedics should have bachelor’s degrees and keeping the name EMS over any other name. I was disappointed to see a 12% burnout rate. In the days of increased first responder suicide, we have to be able to address the subject to avoid further behaviors that lead to providers ending their lives.

What action or actions do you recommend to EMS leaders based on the findings of the report?

Brooke Burton: Fatigue mitigation needs to amount to more than a recommendation to drink more caffeine. Our industry can do better in developing industry-wide fatigue policies modeled from the trucking and airline industries. Patient care and provider wellbeing both improve when providers are well-rested and focused on daily tasks.

With short attention spans, field providers need to see their leaders taking actions. Changes in EMS take too long. Leaders working on problems of resilience, fatigue and retention who take several years to come up with plans of action are fueling the disconnect with the field, who need to see faster results to feel the problems are being addressed. Leadership is service, and leaders exist to serve the field providers. Give providers a say in the efforts your agency is undertaking. Remove silos and have groups encompassing all departments come together to champion these causes of resilience and provider wellbeing. Empower your groups to make a change. We should be constantly evaluating our practices and making small, fast changes to optimize every aspect of our services. Doing things the way they have always been done is outdated thinking. We should have the bravery to try something new, adopt the changes that work and adapt our outdated practices.

Matt Zavadsky: Eighty-three percent of all respondents to the Trend Report indicated that the current reimbursement for EMS does not cover the cost of service provision. And, 87% disagreed with the statement that the public understands what EMS providers do. One is directly tied to the other. We have lots of work to do in order to explain and demonstrate to our communities what EMS actually does and the value we bring to patients and payers of our services.

Failure to do so will make it very difficult to maintain financial sustainability in the future. EMS leaders, national associations and field providers should work together to better educate everyone on the role of EMS and the crucial role we play in our nation’s healthcare safety net.

Brian LaCroix: Two things: create a mission-driven organization and promote a culture of safety.

The fact that nearly 40% of survey respondents would not recommend this career to family or friends is alarming. Leaders really need to tackle this head-on, examining the cited reasons of pay, lack of respect, etc. However, I believe there is a much more fundamental issue here, especially given that those in fire and third service agencies claim to have less of an issue here. But, this is not about the historically self-destructive narrative of fire vs. private, I believe this is about mission – being part of something bigger than ourselves. Very generally speaking, institutions like fire service, the military and others have deeply established their purpose – their mission. Working at a focused mission-driven agency provides exceptional intrinsic value that can supersede all sorts of issues regardless of a service’s tax status.

Secondly, a passionate and transparent effort to advance organizational safety is a critical success factor. When just 28% of field providers express confidence that their bosses take these issues seriously, it’s time for leaders to sit up and take notice. Time and resources spent on improving patient safety and provider mental health, and addressing violence, burnout and more can have a profound impact on eliminating patient harm, improving retention and building a great place to work.

Maia Dorsett: The most notable theme is the disconnect between leadership and frontline provider. Throughout the report, in terms of addressing workforce retention, provider safety and fatigue, frontline EMS providers did not feel that their organization was doing as much as leadership did. I think this is a prime example of translation from the top – as leadership, we sometimes sit in a room, plan something and implement it without getting the input, buy-in and feedback from those on the ground. Change does not just happen from the top, but rather with the input and drive of the entire organization.

In terms of issues like wellness and mental health (just like patient care), we need to make sure to actively engage everyone so that the initiatives we develop are both meaningful and actionable. We need to find ways to nurture the inherently noble reasons that people choose this profession and make them feel valued within the system.

James MacNeal: I’m also surprised about the continued push to change the name. What we do in the field is not paramedicine – it is medicine in a different environment. I expect my first responders, EMTs and paramedics to take care of patients in their care exactly as I would in the same environment of care.

I am tired of the old adage, “EMS doesn’t diagnose.” It is time to step up to the plate and realize that, as a first responder, EMT and paramedic, you are the most critical piece of the healthcare system for the sickest of the sick. We also need to continue to work to show our quality and how we as EMS providers make a difference in the outcomes of our patients.

That shiny new cath lab and Level I trauma center do the patient no good for the entire prehospital phase of care. The outcomes of these patients are greatly influenced by the EMS providers that care for them during the first and most critical time of their emergency. That is the universal message we as a specialty need to continue to convey to our administrations, legislators and governors. Changing our name at this point will only confuse the public more. The energy spent on a name change should be focused on proving our outcomes and continuing to influence the public who already knows our name.

Chris Cebollero: Leaders can start making a difference with their workforce and develop that engagement by using this document as a blueprint to develop the future success of their services. Take this document, get members of the workforce, supervisors, managers, etc., and break this survey down and brainstorm on how to make a difference in your service. Develop a new vision, build a campaign around that vision, and make it your agency’s commitment to push change in next year’s survey. Collectively, we can make a difference, and leaders are always looking for the best ways to change and set a new direction. This Trend Report is your directional map to how to begin that journey.

Brooke Burton, NRP, FACPE, is the division chief of quality and training for Falck in Alameda County, California. She is a board member of the National EMS Management Association (NEMSMA), where she is the board liaison to the Quality Committee and is the Executive Board secretary. She serves as a trustee on the Board of the National EMS Quality Alliance, where she directs the Communications Committee, serves on the Measurement Development Committee, and is a member of the ET3 project Technical Expert Panel.

Matt Zavadsky, MS-HSA, EMT, is the chief strategic integration officer for MedStar Mobile Healthcare in Fort Worth, Texas. He is also the president of the National Association of EMTs and chairs their Mobile Integrated Healthcare and EMS Data committees, and is the co-author of the book “Mobile Integrated Healthcare – Approach to Implementation.”

Maia Dorsett, M.D., Ph.D., is a physician at the University of Rochester in upstate New York and is board certified in both Emergency Medicine and EMS. She is the medical director of Gates Ambulance and EMS Education Programs at Monroe Community College. She is also the president-elect of the New York Chapter and chair of the Education Committee for the National Association of EMS Physicians.

Brian LaCroix, FACPE, NRP, is the current president of the National EMS Management Association and serves as the liaison to the Paramedic Chiefs of Canada. He is the immediate past-chair of the Hennepin County (Minneapolis) EMS Council, chair of the Century College EMS Advisory Board and Allina Health’s Heart Safe Communities Steering Committee, and committee chair on the Regina Hospital Foundation. He recently retired as president and EMS chief of Allina Health Emergency Medical Services, St. Paul, Minnesota, and is a fellow in the American College of Paramedic Executives.

James MacNeal, DO, MPH, FACEP, FAEMS, NRP, began his career in emergency medicine as a paramedic. He holds an American Board of Emergency Medicine/Emergency Medical Services certification and completed and EMS fellowship at Yale University. He is the EMS medical director of Mercyhealth.

Chris Cebollero is a nationally recognized emergency medical services leader, best-selling author and advocate. Chris is a member of the Forbes Coaching Council and available for speaking, coaching and mentoring. Currently, Chris is the President/CEO for Cebollero & Associates, a medical consulting firm, assisting organizations in meeting the challenges of tomorrow.