A Need for Speed?

In 2001, the National Fire Protection Association (NFPA) developed response time standards for fire and EMS to encourage rapid response and consistency throughout the country’s emergency services. NFPA Standard 1710, which was updated in 2004 and again in June 2009, calls for career departments to strive to do the following:
  • Have calls processed by dispatch within 60 seconds
  • Have units leave the station within 60 seconds of notification by dispatch for an EMS call, or within 80 seconds for calls involving fires or special operations such as vehicle extrication that require the use of significant protective gear and equipment
  • Have units capable of providing basic life support and equipped with an automated external defibrillator (AED) arrive on scene within four minutes (240 seconds) of leaving the station
  • Have advanced life support arrive within eight minutes (480 seconds)

The standard sets a goal of having 90 percent of all responses within that time frame.

Needless to say, responding quickly is among the core principles of emergency medical services. Organizations spend substantial time, money and effort looking for ways to decrease response times. But since its inception, the response time standard has been controversial, with some experts within the fire service and EMS questioning how feasible it is to meet the NFPA’s response standard, given logistical and financial constraints. And new research is calling into question whether faster responses actually help patients.

“Over the past couple of years, a number of studies have shown there is no correlation between outcomes and response times for the vast majority of patients,” says Bryan Bledsoe, D.O., an emergency physician and EMS educator based in Las Vegas.

The genesis of the standards
The response time standard was developed by the NFPA’s Technical Committee on Fire and Emergency Service Organization and Deployment–Career, an approximately 30-member, multidisciplinary team that includes representatives from the International Association of Fire Fighters, the International Association of Fire Chiefs and the National League of Cities, among others. The standards are based on current research about response times and their impact on survivability, says Curtis Varone, manager of the NFPA’s public fire protection division.

“The process of developing the standard is an opportunity for all of the interested parties to come together to reach a consensus on what’s an appropriate level of fire service and emergency medical services protection for a community,” Varone says. For those organizations not immediately able to meet the standards, the NFPA recommends developing an action plan to move toward the goal.

Though purely voluntary, NFPA 1710 response time benchmarks are often used by local governments in assessing the performance of their fire and EMS systems, while some hospital and government contracts require private ambulance services to meet the standard. Volunteer and primarily volunteer departments are covered by a different standard, NFPA 1720.

But Scott Freitag, president of the National Academies of Emergency Dispatch and communications director for Salt Lake City Fire Department, contends that the standard is based on the wrong measures. Research has shown that in a structure fire, flashover can occur in six minutes, while the chances of reviving someone in cardiac arrest are slim after four to six minutes. In those most urgent calls, it makes sense to rush to the scene using lights and siren.

The vast majority of calls, however, are not that urgent. Encouraging fire and EMS to rush as fast as they can to every call puts responders and bystanders at risk, Freitag says. “We fully understand and support a six-minute response time for cardiac arrest and structure fires, but we don’t for the vast majority of other calls,” he says. “We have never understood why a blanket response time was set for all responses, when we actually respond to very few cardiac arrests or structure fires.”

In fact, Freitag adds, NFPA 1710 has in some ways set the industry back. EMS is evolving into a more sophisticated model in which dispatchers use standardized protocols to determine the urgency of a call and then allocate resources accordingly. “The 1710 guidelines are so far behind what is actually being practiced by progressive fire departments,” he says.

Another flaw in the standard is that it allows for only a 60-second call processing time, according to Freitag. That was reasonable a decade ago, when nearly all 911 calls were made from landlines and a caller’s location could be automatically determined. Today, about half of 911 calls are made from cell phones, which means it takes longer for dispatchers to determine the caller’s location, he says.

Varone says the committee opted against guidelines that vary depending on the urgency of a given call for good reason. “You don’t know what you have until you get on the scene,” Varone says. “You might get called for a pain in the leg and when you arrive, the blood clot in the leg is now in the lungs and they’re at death’s door. It gets to be really tricky when you start to guess or triage what a non-medical person is reporting on the telephone. The committee tried not to engage in that type of analysis.”

Freitag disagrees that dispatchers are engaging in guesswork. Most now use standardized protocols, which enable dispatchers to determine the urgency of a call with great accuracy by asking a few key questions. “It’s not a casual conversation between a phone operator and someone calling 911,” he says. “There is science behind thewording of questions and the order of the questions that has been tested over 30 years and many millions of calls.”

Do response times really matter?
Despite the controversy, many support NFPA 1710 and would like to see more agencies striving to meet it. According to Mike Ragone, senior associate at Fitch & Associates, an EMS and fire consulting firm based in Platt City, Mo., many agencies are measuring their response times using an average for all calls, rather than the more stringent NFPA 1710 standard in which 90 percent or more of all calls are responded to within the four- to six-minute window. “We have a national standard,” he says. “It’s a good standard and it saves lives, but we’re just not passionate about the standard.”

That lack of passion is among the reasons that survival rates for cardiac arrest continue to be dismally low in most places, he adds. According to a Dec. 7, 2009, study in Circulation, less than 8 percent of cardiac arrest patients survive to hospital discharge, a rate that has not improved in 30 years.

Yet reducing response times may not help all that much with cardiac arrest survival, according to Bledsoe. Since death occurs so quickly, even getting there in six minutes may be too late, he says. And new research is calling into question the need for speed in other situations as well.

In a study published this year in Annals of Emergency Medicine, researchers from Oregon Health and Sciences University in Portland analyzed medical records of nearly 3,600 trauma patients transported by 146 EMS agencies to 51 Level 1 and II trauma centers in 10 sites across North America. The patients had low blood pressure and respiration rates of less than 10 or more than 29, needed advanced airway intervention and had a score of 12 or below on the Glasgow Coma Scale—in other words, unstable patients for whom rapid transport to a hospital would seem crucial. Twenty-two percent of the patients died.

In the study, researchers measured a variety of intervals, including time to arrival on scene, time spent on scene, time en route to the hospital and the total time from dispatch receiving the 911 call to arrival at the hospital. Researchers found no association between the length of any of the intervals and who went on to live or die.

Eight minutes vs. four
One reason the concept of rapid response looms large for EMS is a misconception among the media and the general public that ambulance services are mainly for transportation, while the real medical care starts at the hospital. “Every time you read an article about EMS in a newspaper, they use terms like ‘rushed to the hospital’ that imply speed is always critical, even though for many patients a leisurely drive to the hospital would be fine,” Bledsoe says.

That’s not to say rapid response plays no role. A study by researchers from Denver Health Medical Center found that a response time of under eight minutes did not improve survival rates for anything other than cardiac arrest. But in cardiac arrest, it was a response time of under four minutes that made the difference.The problem is that there is almost no place in the country that will be able to achieve that. One exception: casino guards in Las Vegas, who have immediate access to AEDs, says study co-author Vince Markovchick, M.D., who recently retired as the director of EMS for Denver Health Medical Center.

And even a four-minute response probably wouldn’t be fast enough to help someone in cardiac arrest without bystander CPR or use of an AED. After all, critical minutes are lost during the time it takes for a loved one or bystander to recognize there’s a problem, call 911 and explain to the dispatcher what’s happening, as well as time for EMS units to get the victim hooked up to the AED. “We are wasting a lot of money on a false premise that an eight-minute response will save lives,” Markovchick says. “We found that an eight-minute response time makes no real difference in outcome for 99 percent of patients.”

Resources, he adds, would be put to better use by increasing bystander CPR and public access defibrillation.

Looking beyond response times
David Carroll, battalion chief of medical operations for the Arlington Fire Department in Texas, is proud of his department’s average 4.5- to 5-minute response time. With 16 stations responding no farther than 1.5 miles away, his relatively affluent, suburban community of 360,000 had the resources to build enough stations to make sure help gets there quickly.

A few years ago, his department took steps to reduce “chute time” from an average of about 90 seconds to no more than 65 seconds by educating workers about the need to hustle on every call, even those that didn’t seem particularly urgent. Public perceptions do matter, Carroll says: “If it was a dumpster fire that didn’t sound like it was very critical, they might drag their feet. But 30 seconds can make a big difference. When your house is on fire and you are waiting on a fire truck, or if you’re choking, or if your parent has fallen over in a heart attack, 30 seconds is an eternity.”

Realistically, Carroll figures his department has gotten response times to about as low as they can go. So his department is taking steps to educate the community about emergency response and safety. Programs include fire prevention education, a citywide initiative to teach 10 percent of the population to do CPR, and encouraging residents to use the Vial of Life, in which medical history and a list of medications are stored in a plastic bag taped to the refrigerator door. (For more information on the Vial of Life, including instructions on how to download a free form and decal, visit vialoflife.com.)

In deciding how much to emphasize faster response times, EMS managers should also keep in mind the impact such emphasis has on the workforce. Having personnel idle in parking lots in the dead of night doing system status management can contribute to burnout and fatigue, Bledsoe says. And you don’t have to look far for a news report of an ambulance crash that may be caused in part by responders “rushing to the scene,” Bledsoe says. To move forward, EMS has to find ways to balance public expectations with available resources and the safety of personnel.

“This is all evolving. There is nothing definitive,” Bledsoe says. “But when you get four or five papers telling you the same thing, there is some truth to it.

“Whenever you get something in medicine that is contrary to the accepted wisdom,” he adds, “there is criticism.”

Jenifer Goodwin is Best Practices’ associate editor.

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