Updated February 2015
If patients in cardiac arrest are unable to be resuscitated after 15 minutes of CPR, EMS providers can halt resuscitation efforts and declare death on scene without needing a medical consult, according to a protocol issued in July by the Maryland Institute for Emergency Medical Services Systems (MIEMSS), an independent state EMS regulatory agency. Previously, EMS providers had to get a physician’s OK to stop CPR and patients still needed to be transported to the hospital to be pronounced dead.
Over the past several years, state EMS officials have focused on improving sudden cardiac arrest response in Maryland, including providing education and training on delivering high-quality compressions with minimal interruptions in accordance with the 2010 American Heart Association recommendations, says Richard Alcorta, M.D., EMS medical director for Maryland. The new protocol says that responders can stop resuscitation attempts and declare a patient dead if the arrest occurred prior to EMS arrival on scene, and if there is no shockable rhythm after 15 minutes of high-quality, continuous CPR on scene and before the patient is loaded into the ambulance. EMS still needs to consult a physician before stopping resuscitation on children, pregnant women, or those in cardiac arrest due to hypothermia or drowning. In addition, families can still request that their deceased loved one be taken to a hospital.
Allowing responders to declare death on scene avoids having ambulances race to hospitals, lights and sirens blaring, endangering crews and the public, Alcorta says. “Then the family waits in the waiting room while the emergency department staff attempts to resuscitate their family member and pronounces them dead, when the family already knew that before they got there,” he adds. Responders are also receiving education about communicating with families during the resuscitation about what’s being done to treat the patient and providing emotional support if resuscitation fails.
Every year, MIEMSS makes changes to its protocols that counties are required to implement. In another change, Maryland is now recommending (though not yet requiring) that EMS agencies take a “pit crew” approach to resuscitation. “This is a transition of culture. Five years ago, when a cardiac arrest was called in, the ALS providers would jump in their ambulance and go like a bat out of hell and the firefighters would get in their units and get over there, but they were just backing up the paramedics,” Alcorta says. “With the pit crew concept, firefighters’ understanding of their role and responsibilities is changing. They are heading out the door as if it’s a four-alarm fire and often beating the paramedics to the scene. Cardiac arrest is the domain of BLS, not ALS—it’s in the hands of the first responders and the EMT-basics.”
New 911 contracts for AMR
It’s been a good year for American Medical Response. In August, AMR won the 911 contract for the Emergency Medical Services Authority (EMSA), which oversees an EMS system serving more than 1 million people in Tulsa, Oklahoma City and the surrounding area. The EMSA board voted unanimously to award AMR the contract over incumbent Paramedics Plus. Worth $247 million over five years, the contract will generate an estimated 145,000 transports annually, according to a news release from Envision Healthcare Holdings, AMR’s parent company. AMR’s bid came in $44.6 million lower than the bid by Paramedics Plus, reports Tulsa World. According to Tulsa World, EMSA’s board voted in March to disqualify a third company, Rural/Metro Corp., from bidding.
Also this fall, AMR began providing EMS in DeKalb County, Ga., and Shelby County, Tenn. The two contracts, with a combined annual estimated revenue of $23 million, will provide services to approximately 350,000 residents and are projected to generate approximately 60,000 emergency medical transports a year, according to a news release from Envision Healthcare. AMR also provides non-emergency medical transportation services in both areas.
Bankruptcy filings detail Rural/Metro’s struggles
On Aug. 4, Rural/Metro, the nation’s second largest ambulance company, filed for Chapter 11 bankruptcy protection after it missed a $15.6 million interest payment in July. In papers filed in U.S. Bankruptcy Court in Wilmington, Del., Rural/Metro detailed the events that brought it to the financial brink.
The company, according to the court filings, was weighed down by a highly leveraged capital structure, $735 million in debt, large principal and interest payments on that debt, and significant recurring capital expenditures related to equipment and their fleet. Another major issue has been miscalculations in their revenue projections. Specifically, Rural/Metro experienced:
- Billing disruptions The company has had “great difficulty appropriately accounting for revenue,” resulting in lower revenues than projected.
- Changes in payer mix Accounting systems made predictions about payer mix based on regional historical averages rather than the actual payer mix. Compounding the problem, when the company raised its prices, the cost increase was included in revenue projections, even though the additional money often wasn’t collected.
- Inaccurate revenue predictions In 2012, the company made two large acquisitions, and the revenue projections for those were inaccurate.
- Reduced cash flow Vendors and suppliers, concerned about shrinking liquidity, began to request cash on delivery, further stressing cash flow.
For the 12 months leading up to March 2013, Rural/Metro estimated its EBITDA (earnings before interest, taxes, depreciation and amortization) to be $90 million. But in April 2013, a review of accounting statements and cash flow led that number to be adjusted down to $70 million. Further analysis puts EBITDA between $50 million and $60 million for that period—less than the $70 million to $80 million in fixed obligations it has.
After negotiations, debt holders agreed on a financial restructuring that will reduce the company’s debt by 50% and cut future interest payments nearly in half in exchange for company equity. In addition, Rural/Metro’s lenders have committed $75 million to debtor-in-possession financing. (Debtor-in-possession financing is given to companies in Chapter 11 bankruptcy to give them the financing they need for a fresh start.) That, along with cash generated by its ongoing contracts, will enable the company to restructure, continue its operations and emerge from bankruptcy as early as this month, according to a company news release. Creditors have also promised to infuse $135 million of new equity when the company emerges from Chapter 11.
“We recognize that there were a few areas we needed to get a little bit healthier, more refined and efficient in. We’re doing that today, and we are very, very excited about the future,” Rural/Metro President Scott Bartos recently told the Phoenix Business Journal.
View all of the documents related to the restructuring at tinyurl.com/l9snms.
