How EMS is changing
In its second year, the EMS Trend Report describes revealing changes in clinical care, finance and the use of technology in EMS
This feature is part of the 2017 EMS Trend Report, which takes an in-depth look at EMS trends in the United States and sets a foundation for assessing how the EMS profession is changing. Be sure to share this trend report with other EMS leaders and discuss your thoughts on how EMS is changing in the comments.To read all of the articles included in the report, click here.
To an outsider, EMS probably looks pretty similar today to how it did decades ago. Call 911, and an ambulance arrives and takes you to the hospital – simple. Yet we know that while progress can sometimes feel slow, in other ways the profession might be going through its most transformative era.
Whether it’s a call to change "EMS" to "paramedicine," a push to reform reimbursement models or the increasing use of data and information technology, the industry will be making decisions in the next few years that might significantly impact how patients are treated and what it’s like to be an EMS provider in the future.
The 2017 EMS Trend Report reveals the current state of the profession and where we are headed. Now in its second year, the report is based on an extensive survey of the EMS Trend Report Cohort – nearly 100 EMS agencies of different sizes and service models across the United States.
The long-term goal of the EMS Trend Report is to monitor movement on key clinical, operational and administrative dimensions among a select group of representative EMS agencies over a multi-year period. In future years, the EMS Trend Report will have even more value in describing how the profession is evolving over time. But now, in its second year, the 2017 EMS Trend Report can for the first time describe some revealing changes in areas such as clinical care, finance and the use of technology.
At the core of every EMS service is clinical care – the protocols, medications and equipment that support patient assessment, treatment and transport. Despite efforts at the national level to create evidence-based guidelines and model protocols, there are still a wide range of procedures being used and devices being carried.
Certain trends predicted in last year’s report have continued. In 2016, we saw that fewer than half the agencies in the EMS Trend Report Cohort were including therapeutic hypothermia as part of their cardiac arrest resuscitation protocols. While it was the first year of the report and previous data were not available, we concluded that the percentage had probably been higher until recent studies and American Heart Association guidelines questioned the evidence supporting prehospital cooling.
In this year’s report, we see a compelling decrease, as only 29 percent of agencies report using hypothermia in cardiac arrest patient care; of the subset of agencies that fully responded in both 2016 and 2017, there was a 32 percent decrease. One responding agency, however, did report the use of hypothermia for patients with potential spinal cord injuries.
The use of mechanical compression devices and impedance threshold devices remains relatively constant, with just over half the responding agencies using a mechanical chest compression device. Less than one in four use an ITD. As more evidence is reported about the impact of these devices on patient survival-to-discharge, we can expect utilization to change.
Certain treatments and diagnostic tests continue to be rare. Prehospital ultrasound remains uncommon among cohort agencies, with only 3 percent reporting its use. A small number of agencies now report allowing administration of thrombolytics in the field for myocardial infarction, with one also administering a clot-busting medication for possible stroke patients.
This year, the EMS Trend Survey included the addition of some relatively new procedures in an effort to start tracking their adoption. One of those is lactate testing, which has gained favor in recent years as a method of confirming sepsis – 12 percent of respondents have lactate testing capability. At the same time, it is possible that many agencies are hesitant to purchase lactate monitors due to cost or other factors.
Regularly examining data is considered critically important to evaluating an organization’s performance and improving operations, efficiency and clinical care. Most agencies report reviewing information on response time, call volume, compliance with clinical protocols, collection rates and overtime hours on a monthly basis. Some agencies report this information daily.
The vast majority of respondents (81 percent) still do not regularly review hospital discharge information, reflecting a continued struggle in EMS agencies’ ability to access the data they need.
Clinical measures of time-sensitive conditions
In almost all cases, the reported use of clinical data to measure performance is increasing. Among agencies that participated in both years of the survey, twice as many are now measuring their providers’ ability to recognize sepsis. With sepsis now often included alongside trauma, STEMI and stroke as a time-sensitive condition, this trend is not a surprise. Overall, however, sepsis recognition remains a much less used measure than STEMI and stroke recognition, which nearly 80 percent of agencies report tracking.
At the same time, it is clear that some changes are slow to take hold. Only two-thirds (63 percent) of respondents are measuring survival-to-discharge for cardiac arrest.
Agencies are measuring skills, like IV success rates (74 percent), as well as completion of a package of assessment, such as time-to-EKG (71 percent) or door-to-balloon times (66 percent). Although all measurement can have value, focusing on the easy-to-measure completion of tasks might not be as closely linked to patient outcomes as a bundle of condition-specific assessments and treatments.
Measuring skill success rates or assessments performed, though, is often easier because of access to the data and ease of interpretation. For example, a little more than half of agencies (53 percent) measure administration of pain medication, a 33 percent increase from 2016 by the agencies that fully responded to both surveys. Whether or not the use of those measures changes in the future will be something to look for in future editions of the EMS Trend Report.
Although the EMS Compass initiative did not formally adopt any performance measures, the project did develop several measures through a rigorous scientific process and released them for testing. From the survey results, it appears that most EMS leaders are aware of the measures, and many are planning on using them to assess and improve performance.
Of the 39 agencies (43 percent) that said they definitely will use some of the EMS Compass performance measures, more than three-fourths plan to implement the CPR, STEMI, CVA or trauma measures.
Approximately 80 percent of agencies surveyed measured patient satisfaction. There is a wide variation in the methods used by different organizations to collect patient satisfaction data. Two-thirds report measuring patient satisfaction using in-house resources. However, since 2016 there has been a shift toward the use of external vendors. Eighty percent of the public utility agencies partner with outside organizations to assess patient satisfaction.
Patient experience and satisfaction is part of the U.S. Centers for Medicare and Medicaid Services value-based purchasing reimbursement model and therefore should be on every EMS agency’s radar, even if they do not currently measure it.
Of those agencies measuring patient satisfaction, nearly one-third only evaluate complaints and compliments (30 percent). The vast majority of the remaining agencies use paper-based (44 percent) or phone surveys (18 percent). Of note is the small number of agencies (8 percent) who use an electronic experience survey. Electronic satisfaction surveys are exceptionally common for air travelers, hotel guests and online shoppers. The reasons for slow adoption of electronic satisfaction survey in EMS are not known and an opportunity for additional research.
Although not explicitly measured, a number of agencies independently noted that they do not evaluate patient satisfaction on every call, but rather distribute surveys to a random sampling of patients within a short time after their transport. This mirrors how patient satisfaction is measured in other health care settings.
Having an active, engaged and qualified medical director is critical to the appropriate oversight of an EMS agency. Although one of the primary missions of the EMS Trend Report participants is delivering medical care – and many agencies treat tens of thousands of patients each year – most still work with a part-time medical director. In fact, 62 percent report that their medical directors work less than 20 hours per week in the position.
Half of agencies staff units using 12-hour shifts (49 percent). The majority of the remaining agencies use a 24-hour model (37 percent), with just six agencies using 48-hour work periods.
Fire departments are more likely than other types of agencies to have 24- and 48-hour shifts. Private nonprofit and public utility model services are most likely to work 12-hour shifts, while hospital-based EMS and private for-profit agencies are the only types of organizations reporting other shift lengths. These unique shift configurations appear most often to be a combination of traditional staffing with supplemental 10-, 14- and 16-hour shifts scheduled at peak times.
Pay and benefits
Salary ranges remain similar to last year, with wide variation between agencies. For example, the median minimum base salary for paramedics across all agencies surveyed is $40,505; however, in fire-based services this salary is $48,750, while private for-profit agencies reported a median minimum base paramedic salary of $34,600.
What is the annual starting/minimum salary?
Most agencies reported no decrease in the benefits they offered employees. Fourteen percent of respondents, however, did reduce benefits, with most of that reduction in health insurance benefits, which is consistent with the trend among employers in all industries as health care costs rise.
The definition of response time continues to differ across the profession, something that can be problematic when agencies benchmark themselves against other services or discuss standards with municipal officials and communities. Almost half of agencies report starting the response time clock at dispatch, rather than when the call is initiated.
A patient-centered approach to measuring response time includes the seconds or minutes it takes to answer and process the call and dispatch units, as well as the travel time of the responding vehicles. The profession should continue to work toward a consensus on terminology and methods for evaluating response time standards in order to ensure consistency and clarity in communication.
Despite widespread use of 90th percentile fractiles when discussing response time standards, many agencies continue to report averages. Not surprisingly, the use of average rather than 90th percentile measurements is much more common among agencies that begin the clock at dispatch.
About half of surveyed agencies reported a budget increase in the past year, with an average bump of 4.7 percent. Only a handful of agencies reported a budget decrease. Not surprisingly, the majority of agencies’ budgets – about 70 percent on average – go toward personnel costs.
Charges for service
Charges for care and transport vary greatly across the country and between service models. For example, hospital-based EMS services have the highest average charge for ALS 911 transports – $1,571 – in the cohort, while public, third-service agencies reported average charges of $765 for ALS 911 service. It’s important to note that these are charges, not actual costs or fees collected, which can also vary widely based on several factors, including the payer mix.
As in most of the health care sector, charges appear to be rising, with changes in average charges from 2016 to 2017 ranging from a 1.2 percent decrease for non-emergency ALS transports to a 14.4 percent increase for specialty care transports.
Employee engagement and satisfaction
While the IHI Triple Aim has become widely accepted across health care, the last few years have seen the addition of a fourth goal. In addition to improving population health, decreasing costs and increasing patient satisfaction, many experts have proposed a Quadruple Aim that includes improving the caregiver experience.
To assess the provider experience, many health care organizations have turned to regular surveys and other tools. EMS is following the trend, as evidenced by an increase in the number of agencies tracking employee engagement. It’s clear that EMS leaders are finally recognizing that employee satisfaction is important to the health of an organization and not something to be taken for granted.
This year, less than 60 percent of respondents stated that they measure employee engagement and satisfaction. Just over half of those organizations say that employee satisfaction has been increasing, while most of the remaining report no change.
Turnover increased slightly between 2016 and 2017, but which types of organizations saw higher turnover than others remained constant. While fire departments and third-service agencies see a very low turnover, private for-profit and public utility agencies see a higher rate of turnover than their governmental counterparts.
Employee mental health
Seventy-five percent of EMS Trend Report Cohort agencies have mental health coverage under workers’ compensation, and just over half report having a dedicated staff member to address the mental health of employees. Fourteen percent rely on a licensed social worker, 29 percent use a psychologist and 46 percent use a counselor. Only one agency reported having a chaplain.
Interestingly, 32 agencies stated that they have a peer-support program in place, but only two listed it when asked how their mental health services were staffed. While this variation could be in part due to the wording of the individual questions, it may also have to do with how services offered to employees are categorized.
Employee wellness and injury prevention
Nearly 50 percent of the agencies have a formal employee wellness program. Most of those programs include a health screening and assessment, and more than half the agencies with a wellness program incentivize employees to enroll.
Of note, although the dangers of fatigue for EMS providers have been widely documented, only seven agencies said they had instituted a fatigue management program. New national evidence-based guidelines for addressing fatigue in EMS have been developed by a group of experts with funding from the National Highway Traffic Safety Administration. Whether those are adopted or lead to an increase in fatigue management programs remains to be seen.
As systems change their response models to active shooter incidents and others are simply worried about the direct threat of violence against public safety personnel, many EMS agencies are evaluating the need for body armor in the prehospital setting.
Of those surveyed, 26 percent currently issue body armor and another 16 percent are hoping to include funds for body armor in their next budget. Another 18 percent of survey respondents don’t believe that body armor is needed for their personnel.
Future of EMS
The EMS leaders participating in the 2017 EMS Trend Report shared their thoughts on several questions pertaining to the future of the EMS profession, touching on such controversial matters as education requirements for paramedics and whether "EMS" is even the right term to describe the field.
Accreditation is becoming more common throughout health care, and it’s quite possible that its importance will grow in EMS as communities and payers demand proof of quality and value. This year saw no significant change, with 34 percent of responding agencies saying they have received accreditation from either the Commission on Accreditation of Ambulance Services, the Commission on Fire Accreditation International or the Commission on the Accreditation of Medical Transport Services. Two agencies were accredited by more than one accrediting organization.
Discussions at the national level have questioned whether current education requirements for paramedics are sufficient. The need for formal higher education in EMS is still a hotly debated topic, as is clear by this year’s results – only five responding agencies (7 percent) require paramedics to have an associate’s degree or higher, but 64 percent of the EMS leaders surveyed think that an associate’s degree should become a minimum requirement. These results are similar to last year’s, demonstrating the obstacles the profession might be facing in turning a desire for increased education into a reality.
The growth of mobile integrated health care and community paramedicine programs continues, with more than 32 percent of agencies reporting an active program and another 39 percent in the planning stages. Although agencies across all service models reported programs, MIH-CP efforts appear to be more common in hospital-based, government third-service and public utility model organizations.
Integrating EMS into health care
EMS leaders’ opinions on whether or not EMS as an industry is becoming integrated within the larger health care marketplace have not shifted significantly over the past year. Overall, most agree that integration is increasing – however, 14 percent disagree.
The National EMS Management Association recently issued a position paper on the importance of developing a common language for EMS across the country. The participating EMS leaders were surveyed prior to the release of this report, but their responses reflect the growing debate over the most appropriate way to refer to the profession.
Many leaders prefer to stick with terms commonly used now, including "EMS" and "prehospital care," but "mobile integrated health care" or MIH was equally popular. Several who responded "other" said they prefer "paramedicine," the term recently endorsed by NEMSMA.
The 2017 EMS Trend Report offers a revealing look at the current state of EMS in the United States. It is another step toward looking internally at our profession to get a better understanding of where we are, where we are headed and where we need to be.
Fitch & Associates, EMS1 and NEMSMA thank each organization that volunteered to participate in this effort. Without their willingness to share information, this project would not have been possible.
Fitch & Associates is grateful to Catherine R. Counts, MHA, Ph.D., for overseeing the data analysis and compilation of the 2017 EMS Trend Report. Any large-scale effort like this has many contributors behind the scenes, including the individuals at each agency who provided the detailed responses to the survey; the administrative team at Fitch & Associates who worked with the agencies to complete the survey; Michael Gerber, MPH, and his colleagues at the RedFlash Group for editorial support; and the graphics and editorial team at EMS1.
About the authors
For more than three decades, the Fitch & Associates team of consultants has provided customized solutions to the complex challenges faced by public safety organizations of all types and sizes. From system design and competitive procurements to technology upgrades and comprehensive consulting services, Fitch & Associates helps communities ensure their emergency services are both effective and sustainable. For ideas to help your agency improve performance in the face of rising costs, call 888-431-2600 or visit www.fitchassoc.com.
Methods and sampling
Ninety agencies participated in the 2017 EMS Trend Report survey, two-thirds of which had also participated in the survey for the previous year’s report. Of the 90 agencies, 72 completed the entire survey, with the remaining 18 providing partial responses.
While the majority of data presented in this report uses responses from all 90 agencies, in situations when an agency didn’t complete a survey question, they were excluded from the analysis on that topic.
The full cohort of responses from both years were used whenever possible when comparing 2016 and 2017 data. However, in certain analyses it was determined that the most accurate presentation of data required using a limited dataset of the 43 agencies that completed both the 2016 and 2017 surveys in their entirety. The decision to use this limited dataset was not made lightly, but for some questions the most appropriate way to make an accurate comparison across years was to ensure that organizations were being compared to themselves.