Principles of EMS system design

Chapter 1
Principles of EMS system design


Mic Gunderson


Introduction


Emergency medical services systems consist of the organizations, individuals, facilities, and equipment whose participation is required to ensure timely and medically appropriate responses to requests for prehospital care and medical transportation.


The National EMS Management Association defines the EMS system as the full spectrum of response from recognition of the emergency to initial bystander interventions, access to the health care system, dispatch of an appropriate response, prearrival instructions, direct patient care by trained personnel, and appropriate transport or disposition. A provider participating in any component of this response system is practicing EMS. EMS also includes medical response provided in hazardous environments, rescue situations, disasters and mass casualty incidents, and mass gathering events, as well as interfacility transfer of patients and participation in community health activities [1].


The design of the EMS system addresses how the resources are structured – operationally, financially, legally, and politically. The system design affects virtually every aspect of how requests for services are handled. Changes to the EMS system design can have a profound effect on clinical outcomes, community satisfaction, and cost. Therefore, it is vital for EMS and community leaders, including EMS physicians and medical directors, to have a sound understanding of EMS system design principles and its elements.


The principles and elements of EMS system design vary in some respects between environments, organizational settings, health care system differences, community settings, and cultures. Those differences will be addressed in this chapter.


At the time of this writing in 2013, the health care system in the United States is rapidly changing. As the general health care system changes, EMS system designs will need to adapt accordingly. This makes it all the more important for EMS and community leaders to understand system design principles so they can competently lead and adapt their EMS systems through the tumultuous times ahead. Agility will become extremely important, as the times ahead are rife with both opportunity and peril.


System design goals


The design of the EMS system should support the primary goals of providing the best clinical and service quality possible with available resources. Accountabilities embedded in the system design should help align incentives for each provider organization to do its best to help the overall system meet these goals. There are several key areas of the system design that warrant specific attention: clinical quality, service quality, economic efficiency, accountability, improvement, and resilience.


Clinical quality addresses the technical performance of clinical processes and the patient outcomes those processes yield. The EMS system design should designate responsibilities, set standards, and create accountabilities for clinical quality.


Service quality addresses the experiences and perceptions of patients and other stakeholders. The EMS system design should set realistic and practical standards while establishing accountabilities for service quality just as it does for clinical quality.


Economic efficiency can be assessed by how well available resources are utilized to create positive clinical and service quality outcomes. Good system designs provide the best chance of patients receiving quality care within economic reason. This ties into the concept of value – the combined effect of quality and cost [2]. Communities want value from their EMS systems – quality and cost both matter. High quality and reasonable cost are not mutually exclusive choices.


Accountability is needed to assure that each provider organization and the major components therein fulfill their respective roles and responsibilities in meeting needs, particularly those of patients and the community. The most important needs are expressed as standards. The best system designs require measurement of performance against standards, hold provider organizations accountable for meeting standards, and encourage performance that exceeds standards.


Improvement is manifest as a mindset that recognizes that standards often represent minimum acceptable levels of performance. It is both worthwhile and possible to exceed those minimums by changing processes in ways that yield better quality at the same or lower cost.


Resilience recognizes that the world around us changes in ways that affect the EMS system. Resilient EMS system designs allow for such changes by creating mechanisms that allow adaptations to be made quickly with minimal disruption.


It is sometimes difficult to separate the effect of the system design from the efforts of the individuals who work within it. Some of the key interrelationships are characterized by the following principles.



  • Talented and motivated people can produce good results in a bad system design, but not for extended periods of time.
  • Incompetence can produce poor results in even the best system design.
  • Talented people tend to be attracted to system designs that will potentially nurture and showcase individual talents.
  • Talented people have options because they are talented. In general, the most talented managers choose to avoid employment in EMS systems that hinder their abilities.
  • Good system design makes excellence possible and superior performance probable, but guarantees neither.
  • Bad system design makes excellence impossible and inferior service probable.
  • Sound system design cannot guarantee clinically appropriate and economically efficient performance.
  • Poor system design can make consistent life-saving performance extremely unlikely, if not impossible.

Services


Most EMS system designs include the services described below.


Prevention and public education


These services typically focus on prevention of problems that may lead to an EMS response, such as injury prevention or prevention of heart attacks and strokes. Public education efforts also include instructions on first aid and when to appropriately call for EMS assistance.


Triage


When someone calls 9-1-1, one of the first services provided is a determination of what the nature of the problem is, its severity, and the types of resources that need to be sent to the scene.


Medical first response


Sometimes there are medically trained resources closer to the patient than the closest available ambulance. In cases where the nature of the problem may be time-sensitive, good system designs will attempt to get the closest appropriately trained medical resource to the scene as soon as possible. This is called medical first response. It is typically provided by fire departments, but may also be provided by police agencies or volunteer EMS agencies.


Ambulance response and transport


Ambulances typically provide the broadest spectrum of EMS services, including medical transportation.


Prearrival instructions


After the incident has been triaged and resources have been dispatched to the scene, emergency medical dispatchers can guide callers on how to begin treatment and help responding crews safely locate and access the scene.


Assessment and treatment


Emergency medical services crews will evaluate the scene and examine the patient as part of their process to assess the situation and determine what course of action and treatment are called for. They will then initiate treatment as appropriate within the constraints of their protocols.


Medical transportation


At some point during patient care, determinations will be made regarding the need and destination for medical transport. If patient condition and circumstance allow, those determinations will be made in collaboration with the patient. In scheduled non-emergency situations, medical transportation resources may be requested in advance by appointment.


Event coverage


Emergency medical services systems designs should provide a mechanism for EMS resources to be placed on stand-by for major events. This often requires special logistics and planning so that normal operations are not comprised during the special event.


Disaster services


Emergency medical services system designs provide mechanisms for threat assessment, planning, activation, and delivery of medical resources and services in response to larger-scale incidents. Responding appropriately to requests for services from other communities in need should also be addressed in the EMS system design.


Critical care transport


There is often a clinical need to move patients with unstable or complex conditions between medical facilities. Repatriation to an in-network hospital may also prompt such transfers. These patients will often require care outside the normal scope of a paramedic-staffed ALS ambulance. This need is typically met with critical care transport ambulances which have additional equipment or the ability to accommodate additional equipment. Their staffing is highly variable. Typically, the base level of staffing is with paramedics who have additional training that may qualify them for critical care transport certification. More complex patients may also be accompanied by members of the hospital staff, who may be critical care nurses, respiratory therapists, or physicians.


Air medical transport


Rotor or fixed-wing aircraft may be used as ambulances. Their missions may vary from scene responses to more rural or wilderness incident locations to interfacility transfers. The transfers may be provided at a routine or critical care transport level of care.


Hazardous materials response medical support


Many communities will have specialty fire department teams for response to hazardous materials incidents. Given the wide range of unusual cargo and materials that victims or team members may be exposed to, special training, equipment, and protocols are often established for the paramedics assigned to these teams. EMS medical directors may establish relationships with toxicology specialists to assist in training and medical oversight for these paramedics.


Tactical response medical support


Some law enforcement agencies have tactical response teams. The team members, perpetrators, and victims may be subjected to significant trauma in unusual situations that preclude normal treatment and transport processes. This may necessitate more extensive on-scene assessment and treatment within the confines of a dangerous tactical scene environment. This calls for special training, equipment, and protocols for the paramedics assigned to these teams.


Community paramedicine


Emergency medical services systems are primarily designed to respond to emergencies. A significant portion of EMS requests, however, are for non-emergency situations. This sets up a disparity between what the patients who call 9-1-1 need versus what the EMS system was originally designed to provide. Community paramedicine is a relatively new service that attempts to meet the often underserved need of low-acuity 9-1-1 patients in a more effective and efficient manner than a typical EMS system response provides. Changes in health care system design and payment structures may provide incentives for EMS provider organizations in the near future to leverage their existing infrastructures and resources to provide a broader spectrum of non-emergency out-of-hospital care. EMS provider organizations may be contracted to provide services such as monitoring and support of patients immediately following discharge to reduce length of hospital stays, prevent readmissions, and participate in home care for the chronically ill in ways that traditional home health care services are less suited to provide.


Vehicles, equipment, and supplies


Facets of EMS system design can also address vehicles, equipment, and supplies. These can have a significant effect on clinical and service quality as well as economic efficiency.


Ground ambulance options generally fall into three categories: types I, II and III. These categories were derived from United States ambulance standard KKK-A-1822 [3]. A new US standard has been established called NFPA 1917 [4]. The US ambulance standards tend to have a strong influence on ambulances manufactured in other countries.


Type I ambulances are built on a light- to medium-duty truck chassis. The cab remains and the cargo module is replaced with a patient compartment. The patient compartment typically lasts longer than the cab/chassis module. This permits the patient compartment to periodically be refurbished and then remounted onto a new cab/chassis module. Due to the heavier duty truck construction, type I ambulances can have a longer service life, particularly when the remount strategy is used. Their larger size makes them more difficult to navigate through narrow streets in older, high-density urban areas. Their heavier weight typically makes them less fuel efficient. The balance between longer service life and higher fuel costs must be considered in calculating the total cost per mile and reliability over their entire service life.


Type II ambulances are made on a van chassis. They tend to be much smaller than type I or III ambulances, with more agility and better fuel economy. Their service life tends to be shorter than type I ambulances and does not offer the option of remounting to a new cab/chassis module.


Type III ambulances are also built on van chassis, but have separate cab and patient compartment modules. They are similar in concept to type I ambulances, but on a van chassis rather than a truck chassis.


There is a tremendous variety of non-transport vehicles used for medical first response. When the medical first response agency has a primary mission other than EMS (e.g. fire or law enforcement), the vehicles will often do double duty to meet the need of that agency’s primary mission as well as the secondary mission of medical first response. This avoids having to purchase separate vehicles and additional staff to provide medical first response, limiting the cost to accelerated wear and additional fuel. This is why some fire departments will use a fire truck for medical first response. In contrast, some fire departments will choose to use utility-style trucks that have lower operating costs per mile, but with the added cost of another vehicle and additional staffing. EMS leaders should be cognizant of the pros and cons and the complete life-cycle costs for different vehicle options when choosing the type of vehicle to use for fire department medical first response. Law enforcement agencies very consistently use their primary patrol vehicles and regular staff when delivering medical first response.


There are situations where specialty vehicles may be used for transport as well as medical first response. Airports and sports arenas may use specially modified golf carts for transport to a location where a standard ambulance is positioned. The cart is also used for first response. Agencies in highly congested urban areas may use motorcycles for medical first response. In parks, fairs, and special events, bicycles and Segways may be used. Off-road vehicles may be used where needed: all-terrain vehicles, boats, and snowmobiles. System leaders and medical directors should have an open mind about vehicle specifications in an effort to find the vehicle best suited to the environments they serve.


Equipment and supplies will vary with the clinical service level. Within a particular service level (BLS, ALS), there are many options. For example, agencies have the option of choosing between several brands of automated cardiopulmonary resuscitation (CPR) devices or relying solely on manual CPR. When considering equipment and supply options, the most important factor to consider is the effect on patient outcome. Cost cannot be ignored, however, and can be looked at in more detail from the perspective of cost per use and cost per use over the entire life of the item (if reusable). Size, weight, durability, reliability, and service support also are major factors to consider.


Delivery settings


The geographic setting of an EMS system can have a significant effect on what constitutes an appropriate system design. What might be entirely appropriate for an EMS system serving a predominantly urban area may not make much sense in a rural or wilderness setting, and viceversa.


Urban/suburban


Urban/suburban EMS systems are those that serve communities with high-to-moderate population densities, covering larger areas, and are largely self-contained in terms of receiving emergency departments and key emergency health care resources (e.g. cardiac catheterizations labs, trauma centers).


The higher volumes of patients bring higher potential gross revenues. This creates several financially viable options for the type of organization(s) that provide EMS services and the way in which responses are configured. Thus, it is not uncommon for governmental agencies, private companies, and hospitals to all offer EMS services in the same metropolitan area.


When there are multiple EMS provider organizations serving the same metropolitan area, planning and coordination are critical. Incidents ranging from a serious multiple vehicle crash to a passenger train or aircraft wreck will often require multiagency, multijurisdictional responses, particularly if the incident takes place near a jurisdictional line.


Emergency medical services system designs for urban/suburban areas need to consider how the various agencies in multiple jurisdictions will work together in an operationally and medically efficient manner. Best practices in EMS system design for large urban/suburban areas separate the function of system-level medical oversight from that at a provider agency level. System-level medical oversight, often positioned at a county or regional level, is typically focused on coordination and interoperability issues. It considers issues such as making sure EMS personnel from one jurisdiction have clinical privileges in another when providing mutual aid, and have the same or similar clinical protocols, compatible medical equipment, compatible radio systems, capabilities for data exchange and aggregation, etc. System-level medical oversight might be a county or regional medical director, or it may be provided through a council of the various provider agency medical directors who develop processes to coordinate efforts and come to consensus on multijurisdictional issues. This is something that is also done in some of the better rural and wilderness systems for the same reasons.


One of the biggest drivers of EMS system cost is personnel. Consequently, one of the goals in making the system economically efficient is to maximize productivity, with crews running as many calls as possible during their shifts. There may be limits, however, where crews can become overworked with consequent degradations in quality. In some EMS provider organizations, this is mitigated by reducing the duration of shifts. Governmental EMS agencies in particular will commonly work 24-hour shifts. Without adequate rest during longer shifts, the risk of cognitive errors may increase with consequent loss of clinical quality. There are many ways to address these issues while assuring quality and containing costs, but the system design should recognize this potential and have ways to address it.


Urban and suburban EMS systems will often have emergency and non-emergency ambulance services offered by separate organizations. The emergency ambulance services will tend to be operated by governmental entities providing ALS service. The non-emergency ambulances will tend to be operated as private companies at a BLS or ALS level. This raises two major issues. Is it better to have all ambulances provide ALS service? Is it better to have a single organization provide both emergency and non-emergency ambulance service? These questions are the subject of ongoing debate. Local politics and incumbency of providers will tend to have more influence on this than the theoretical merits from a pure system design perspective. Changes at this level will be difficult to achieve unless there is sufficient political will to do so, which may manifest in response to a severe financial issue, a high-profile case with a bad outcome, or challenges by one provider organization to take over the ambulance duties of the other.


Single versus multiple ambulance service providers


There are economic and philosophical issues to consider when debating if a community should have one or multiple ambulance services.


From an economic perspective, a single ambulance service provider offers potential cost savings by payers only having to support one infrastructure. More than one provider adds the costs associated with duplications of infrastructure that do not add value. For example, a single ambulance service for a community would have one computer-aided dispatch (CAD) system. A second ambulance service would require its own CAD. The pricing of ambulance services in that community would need to cover the cost of two CAD systems, without a corresponding increase in benefit. Considering the duplication of all the other elements of infrastructure needed to support an ambulance service, the increases in costs quickly add up.


The economic virtues of competition must also be considered. A single provider has a monopoly, which does not provide natural cost controls or competitive pressure to provide high-quality service in order to preserve or expand market share.


Considering the advantages of single-provider systems and the advantages of competitive pressure to control costs and increase quality, many urban and suburban systems take an approach that can provide a favorable balance. A community can both limit the number of providers and corresponding duplications of infrastructure costs while still providing healthy competitive dynamics. This is achieved by allowing competition for the market rather than within the market.


While the details vary from state to state, a city or county generally has the ability to designate who its ambulance service provider(s) is/are. This is called allocation of ambulance service market rights and is one of the most powerful tools in EMS system design. When allocating market rights, the city or county can attach a wide range of requirements and performance standards that must be met to retain those market rights. A competitive procurement process may be used to decide which provider will be awarded the market rights. That competitive process can allow both governmental and non-governmental organizations to submit proposals. If true costs are considered and the evaluation process is conducted properly, the community can reap the benefits of getting a provider that has had to make a more compelling value proposition over competing organizations and made commitments to meet requirements and standards on an ongoing basis. After the market rights are awarded, the competitive pressure can be sustained by building in escalating consequences for minor to major failures in meeting requirements and standards, which can result in loss of market rights in the most severe of circumstances. Absent any severe failures, from time to time, the community may choose to reevaluate the market by having another competitive procurement process for allocation of market rights. This will compel the incumbent provider to step up its level of service and commitment in an effort to fend off competitors. Competitors will make their best offers in an effort to capture a new market. Either way, the community benefits.


In communities where this approach is not taken, dislodging a well-established ambulance service provider or providers will require significant political will. Such political will is rare and typically arises in response to severe financial problems, a high-profile case with a bad outcome, or an attempt by one provider to overtake the market rights of another. EMS system leaders should be cognizant of this. If there is interest in having a more formal and deliberate process to allocate ambulance service market rights for the benefits cited above, EMS system leaders should be prepared to introduce these ideas into the political conversation in the event that the political will to make a significant change surfaces.


A related issue is the separation of emergency and non-emergency ambulance service. In many communities, the governmental agencies will provide an emergency ambulance service while one or more private corporations will provide a non-emergency ambulance service.


This separation tends to be more common with fire department ambulance services. The organizational culture of the fire department tends to focus on provision of emergency services. Non-emergency ambulance service delivery may be shunned by the firefighters. It is not difficult to find private companies more than willing to relieve the local fire department of the “burden” of that portion of the market. This is because the non-emergency ambulance service market can be quite profitable. It has the distinct advantage of being able to determine ability to pay in advance of service delivery. The emergency market can also be profitable, but carries higher financial risk by not having the ability to determine the ability to pay in advance of service delivery. Because many emergency patients do not have the means to pay and all requests for service received through the emergency system are generally honored, the emergency ambulance service is at higher risk for net losses.

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Jun 14, 2016 | Posted by in EMERGENCY MEDICINE | Comments Off on Principles of EMS system design

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