By David Murphy and Mike Taigman
When you’re providing EMS service as part of a performance-based contract, there are few things more stressful than not meeting requirements. Leaders worry that some patients may have been underserved, are concerned about the possibility of losing the contract, worry about the cost of performance fines, and obsess about the possibility of losing their job. This can cause sleepless nights and munching on antacids like they are candy.
In 2017, the Merced County California leadership team from Riggs/SEMSA Ambulance was feeling the response-time pressure. Here’s what they did to make improvements.
Response time improvement plan
While response time performance is starting to be eclipsed by clinical quality performance requirements, many EMS systems still have and will continue to have some level of response time requirement. The contract in Merced requires response time performance in seven categories based on priority and population density each month, and they were not making it.
At the end of 2017, they had back-to-back months where their performance was below the required 90% in four of the seven categories. The consulting team from Page, Wolfberg & Wirth evaluated the system. One of their recommendations was to integrate BLS 911 response into the historically all ALS system. They suggested that this could be achieved based off of Medical Priority Dispatch System (MPDS) codes as a way to improve response times to the patients with the most severe clinical conditions.
The leadership team from Riggs/SEMSA evaluated all of the Priority-3 dispatch criteria to determine which could be safely handled with a BLS crew. The County EMS medical director reviewed and approved their recommendations. The codes were uploaded into the computer aided dispatch system for when the system was ready to test but were not activated. The team identified several issues that needed to be addressed before implementing BLS 911 response:
- They were concerned that some patients might slip through the dispatch criteria and not receive paramedic-level care when they needed it.
- EMTs had not been allowed to attend on 911 calls in Merced County for the last 10 years. Most EMTs had been in driver-only status their entire careers.
- County policies and protocols were all written based on having a paramedic respond to and care for the patient on all 911 calls.
- Fire first response agencies and hospital emergency departments were deeply entrenched in their all-paramedic system.
The team built an improvement process focused clearly on patient safety. It also accounted for the confidence/skills of their EMTs who were taking on this new roll. It incorporated the perspective of fire first responders and hospital emergency medicine teams.
Step 1: New policies
They worked with the County EMS Agency staff, including their medical director, to change old policies and create new ones to accommodate the change. These included policies to:
- Allow BLS dispatch
- Allow a BLS crew to transport a critical patient to the closest emergency department if an ALS response has an ETA of more than 20 minutes
- Allow EMTs to implement a refusal against medical advice/release at scene for qualified patients
Step 2: New EMS training
They developed and implemented a training program to give their EMTs the skills they would need to be the primary care provider for low priority 911 patients. They chose 18 EMTs for this program, all of whom had at least two years’ worth of 911 experience in Merced County.
The training also included a strong focus on using rapid assessment skills to recognize the signs that a patient might be critically ill. Additionally, they were taught how to handle a patient who is refusing transport, how to give a 911 style radio report to the hospital, proper documentation of 911 calls, glucometer use, epi pen use, administration of nasal naloxone, etc. During the evaluation of system logistics, they decided to train all of their EMTs to this level in addition to the 18 experienced folks.
Step 3: Supervised practice
Once trained, the EMTs provided care and attended with low acuity patients under the supervision of a paramedic for 90 days. The EMTs focused on fine tuning their assessment skills, working on hospital radio reports and proper documentation.
Step 4: Full launch
May 1, 2018, the system went live with a meticulous 100% chart audit looking for any patient safety issues. There have been no major patient care issues and no bad outcomes for patients.
In the first month, they ran 232 low priority 911 calls with BLS ambulances. There were two cases where ALS should have been dispatched. In both cases, the calls were to medical clinics and the 911 caller indicated that the patients had been evaluated by a physician or nurse. One patient had weakness with a heart rate of 38 and hypotension, and the other was a child who had been given a breathing treatment for asthma by the clinic staff but was still wheezing when the ambulance arrived. In both cases, the BLS crew transported to the hospital because they were close and waiting for an ALS rig would have delayed care.
The fire first response agencies and hospital emergency departments had different reactions to the new process. The fire agencies adapted quickly and enjoy the benefits of faster ambulance response for low priority calls, which allows them to go back in service faster.
The hospital mobile intensive care nurses MICNs who answer the 911 radio at hospital emergency departments have had a harder time adapting to the change. In one case, the MICN told a BLS crew to pull over and call for an ALS rig to take an EKG when the ambulance was less than five minutes from the hospital. It took the ALS rig over 20 minutes to arrive. But after a few months, they were all on board with the new approach.
Documenting improvement in response times
Response times for the highest priority patients have improved significantly from 87% to nearly 92% each month.
Response time for the lowest priority patients have also improved from 87% to 94%.
Response time penalty fines have decreased from over $109,000 per month to $12,000 per month with several months of zero penalties.
As a bonus, paramedics are happier as they are running fewer calls. EMTs are happy to be using their skills fully. And the leadership team can sleep at night and keep the lid on the antacid bottle.
About the author
David Murphy is the clinical director for SEMSA/Riggs Ambulance. He has been in EMS for 30 years, starting as an EMT in 1989. During that time, he’s worked in urban, suburban, rural and wilderness settings as an EMT, paramedic, FTO and field supervisor. He also teaches EMT and paramedic programs.
