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CITY OF SAN BERN~DINO - REQUEST lOR COUNCIL ACTION
I'rom:
PEGGY DUCEY, ASST. TO THE
CITY ADMINISTRATOR
CITY ADMINISTRATOR
Subject: STUDY ON EMERGENCY MEDICAL SERVICE
DELIVERY BY JAMES PAGE OF ECIC
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Date: 4/15/92
Synopsis of Previous Council action:
12/2/91 -- Mayor & Common Council authorized a contract with Emergency
Care Information Center to perform a study on the delivery of
emergency meiical service in the City.
4/15/92 -- Bureau of Franchises action was to receive and file study.
Recommended motion:
That the study on emergency medical service delivery prepared by
ECIC be received and filed.
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SignatGre
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Contact person:
PEGGY DUCEY
Phone:
5122
Supporting data attached:
YES
Ward:
N/A
FUNDING REQUIREMENTS:
Amount:
N/A
Source: (Acct. No.! N/ A
IAcct. DescriPtion) N/ A
Finance:
C~Cil Notes:
75-0262
Agenda Item No. ,~- /
CITY OF SAN .BRNlRDINO - R.QUBST .QR COUNCIL ACTION
STAFF REPORT
In December, Mayor and Common Council directed Emergency Care
Information Center (ECIC) to conduct a study on emergency medical
service delivery in San Bernardino. Mr. James page, ECIC director
and consultant, has completed the study analyzing emergency medical
service and operational modes in the city.
Included in the report is an analysis of both the ambulance
provider's role and city paramedics' role in delivering emergency
care, a background on rate schedules and billing practices, and a
perspective on the County of San Bernardino/ICEMA's involvement in
the emergency medical care issue.
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EMERGENCY CARE INFORMATION CENTER
Report on a Study of the Emergency Medical Services (EMS)
System in the City of San Bernardino and Recommendations
Regarding the Most Efficient and Effective Means to
Organize the System.
CONCLUSIONS AND RECOMMENDATIONS
Conclusion #1
Since the Common Council authorized the San Bernardino Fire Department to serve as the City's
primary paramedic provider in 1975, City government has not sufficiently asserted its right to
control this activity within the city limits. In the resulting environment, a for-profit enterprise
(Courtesy Services of San Bernardino, Inc.), with significant assistance from County government,
has postured itself to affect the quality, availability and cost of this essential public safety function.
Recommendations:
The City should clearly delegate all responsibility for and supervision of emergency medical
services (EMS), ift~luding private ambulance services, to the Fire Chi,;'. This responsibility should
include participation-in and oversight of the City's ambulance rate-setting process. It should include
the right to specify the manner and extent of delivering services within the city, to set appropriate
written and/or contractual standards, ana also the power and authority to investigate and resolve
complaints regarding any aspect of EMS in the city.
. The City should review the Bureau of Franchises' role in ambulance rate-setting. Expert
consultation should be employed to determine whether the current practice of adopting the County
of San Bernardino's rate structure (and discounting it) is properly serving the citizens of the city.
Conclusion #2
Under California law, Counties are responsible for providing or paying for emergency ambulance
service for indigent persons. The County of San Bernardino pays to Courtesy Services the amount
oU11,860 per month to provide this service, presumably for both the incorporated and
unincorporated areas served by Courtesy.
The Best Source of EMS Information
Medic:::1 q! I ;r")rrr.atlon System . fM5 '~slaer Ne',';5:et~'?r . ~he ECJe Database . Research & Consulting Services
PO. Box 2789. Carlsbaa. C-olifornlo 92018 . 619! 431-9797 . FAX 619/431-8135
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Divided by an average price of $330 per transport*, this amount of subsidy would cover only about
36 instances of emergency ambulance transportation to indigent persons per month.
If two-thirds of the subsidy is attributable to the City of San Bernardino (equivalent of 24 instances
per month (average)), and if more than 24 such instances per month (average) occur within the city,
and if $330 represents the approximate cost for emergency ambulance service provided by
Courtesy, then this amount of County subsidy is insufficient to meet its responsibility to cover the
actual cost of providing emergency ambulance service to indigent persons.
If the County's subsidy for emergency ambulance transportation for indigent persons is insufficient,
and since the County purports to set ambulance rates at such levels as to assure the financial health
of one or more private ambulance companies, cost shifting may be occurring which, in essence,
increases the cost of ambulance service to city residents and their reimbursement sources.
* A 1991 study of 47 ambulance services (including 34 private services) in California, Oregon and
Washington disclosed that the average price of an advance life support (ALS) emergency transport
(excluding mileage charge) was $330.80.
Recommendations:
Refer this matter to the Bureau of Franchises for study.
Conclusion #3
It is probable that Courtesy Services has for an undisclosed period of time charged patients for
advanced life support services that actually were provided by paramedics employed by the San
Bernardino Fire Department. Although this practice may be permissible under the County's
ambulance rate structure (and through the automatic adoption of that structure by the City's Bureau
of Franchises), there is a question as to whether the Bureau of Franchises has been aware of this
practice.
Recommendation:
Refer this matter to the Bureau of Franchises for study.
Conclusion #4
Courtesy Services has proposed that the San Bernardino Fire Department abandon its paramedic
service and turn that responsibility over to Courtesy (see October 8, 1991 letter from D. Steven
Rice to Mayor Holcomb at Appendix I).
Recommendation:
The City should not entertain the possibility of abandoning its fire department paramedic service
until and unless all options have been considered (including the operational profiles presenllld in our
consultant report) and all questions regarding Courtesy's operational practices, financial stability,
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billing/collection procedures, and its relationship with County government are resolved.
Conclusion #5
The Fire Department could successfully operate an emergency paramedic ambulance service in the
city - and possibly also serve unincorporated areas outside the city - and the marginal costs
attributable to this service would be more than off-set by net revenues, provided rates are set at
appropriate levels and billing/ collection functions are performed competently.
Recommendation:
Consider operational profiles C, D and E in our report.
Conclusion #6
The rate-setting process employed by the County Department of Public Health, and the Ambulance
Cost Index Formula used in that process, is not a sufficient tool for assuring fairness and equity to
both providers and the public. The County's generous interpretation and application of the rate
schedule raises further questions. The City's Bureau of Franchises uses the County's ambulance
rate schedule in setting City ambulance rates. Although the Bureau reviews the rates of several
other cities for purposes of comparison, most of those cities are located in San Bernardino County
and thus may be influenced by the County rate schedule.
Recommendations:
The City should clearly delegate all responsibility for and supervision of emergency medical
services (EMS), including private ambulance services, to the Fire Chief. This responsibility should
include participation in and oversight of the City's ambulance rate-setting process.
. The City should review the Bureau of Franchises' role in ambulance rate-setting. Expert
consultation should be employed to determine whether the current practice of adopting the County
of San Bernardino's rate schedule (and discounting it) is properly serving the citizens of the city.
Conclusion #7
There is an atmosphere of disrespect, suspicion and hostility between the local EMS agency
(ICEMA) and most fire departments in San Bernardino County, including the City of San
Bernardino fire department. There is abundant blame to be shared by all parties. Whether the
declaratory judgment which has been sought by the County confines ICEMA to a coordinating and
integrating role, or authorizes ICEMA to command and control the resources of municipalities,
there will be a need for improvement in its relationship. Even if the court were to confer upon
ICEMA broad powers, without heavy funding and extensive enforcement personnel the organization
will always need to rely on persuasion to effect change. Without the respect and willing
participation of all providers, including the fire service, ICEMA will have no effective infl!lence.
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Recommendation:
One or more recognized political and/or administrative ieaders in County and/or City government
should convene a process whereby all complaints regarding the ICEMAlfire service relationship can
be aired, a dispute resoiution procedure can be created and maintained, and unresolved disputes in
the future can be arbitrated by a neutral third party.
Conclusion #8
The City "taxicab ordinance" contains numerous provisions regarding the regulation of ambulance
services, ambulance vehicles, and the drivers of ambulance vehicles, including minimum insurance
requirements, police investigation of drivers, and disclosure of permitees' assets and liabilities.
Recommendation:
It should be determined whether all ordinance provisions relative to Courtesy Services of San
Bernardino, Inc., have been enforced and complied with.
Conclusion #9
The City's Business License Supervisor can find no resolution or ordinance giving Courtesy
Services of San Bernardino, Inc., authority to offer or sell paramedic services in the city.
Recommendation:
If no reasonable alternatives can be found to deal with the probability that Courtesy is charging for
paramedic services that actually are provided by fire department paramedics, the City may choose
to revoke Courtesy's permit (issued pursuant to the "taxicab ordinance"), or require it to formally
prove that its offer and sale of paramedic services in the city meets the requirement for public
convenience and necessity (as required by the ordinance).
Conclusion #10
The powers asserted by the County of San Bernardino and ICEMA to award exclusive operating
areas for emergency ambulance service make no mention of the City's rights and obligations to
process 9-1-1 emergency calls.
Recommendation:
If the City elects to provide ambulance service, or to contract with a company other than Courtesy,
it should consider the option of allowing the County to declare and maintain an exclusive operating
area (which includes all or part of the City) but to refer all 9-1-1 calls to City ambulances or the
City's contractor.
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Conclusion #11
The relationship of the County Department of Public Health and the County Health Director,
George Pettersen, M.D., to the local EMS agency (lCEMA) and that agency's EMS medical
director, Conrad Salinas, M.D., and vice versa, and their respective authority over EMS in the City
of San Bernardino is not clearly defined. While both agencies have organizational charts which
purport to illustrate the division of authority, those charts do not provide sufficient guidance for
EMS providers and accredited EMS personnel.
Recommendation:
The City Administrator or an authorized representative should study and detail the areas of conffict
and confusion relative to the sharing of authority by the County Department of Public Health, Dr.
Pettersen, Dr. Salinas, and ICEMA. A report should then be prepared and presented to the County
Administrative Officer with a request that the areas of conflict and confusion be clarified, that an
explanation of the respective powers, duties and authorities be documented and presented to the
City (and other EMS providers).
Conclusion #12
The user fee program initiated in 1991 by the San Bernardino Fire Department is a reasonable
method for recovering the marginal costs involved in the fire department's provision of emergency
medical services. However, introduction of the program in 1991, including the billing of patients
for the fees, caused a negative reaction from people who also received a bill for paramedic services
from Courtesy S~rvices of San Bernardino, Inc.
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The decision was made to allow Courtesy to bill and collect these fees for the City. At this point,
there is a question whether Courtesy ma.de a good faith effort to collect the fees. In fact, Courtesy
later informed the fire department that the fe(ls were not reimburseable under Medicare or Medi-
Cal. After the billing and collection program was transferred from Courtesy to another vendor, it
. was learned that the City needed a provider number for the fees to be reimburseable, and that
number has since been applied for.
Recommendation:
Re-evaluate the user fee program in light of the revelation that Courtesy has been billing for
paramedic services which actually have been delivered by fire department paramedics. Unless
Courtesy can be convinced or forced to discontinue the practice, a continuing negative public
reaction can be anticipated. Possibly, as a condition of its permit under the City's ordinance,
Courtesy could be required to pass along ALS fees to the City in those cases where fire department
paramedics actually provide the ALS services - as an alternative to the user fee program.
Conclusion #13
The City's Paramedic/Emergency Medical Services Membership program is a well design~ and
thoughtfully planned program. The marketing package which was developed to sell the program to
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the public was excellent. Unfortunately, due to a faulty mailing process, as many as 7,000
households did not receive the mailing. Also, despite clear disclaimers in the literature, negative
reaction has occurred from some members who have been charged for paramedic services by
Courtesy despite their membership in the program.
Recommendation:
Continue the membership program, fine-tuning it in response to lessons learned. Correct the
mailing process to ensure coverage of all households in the next membership drive. As
recommended elsewhere in this letter, seek a solution to the problem of Courtesy billing for
paramedic services which actually have been provided by fire department paramedics. Also, remain
attentive to Medicare regulations which may be altered or interpreted to forbid exempting of co-
payments (a key feature of the membership program).
If the fire department becomes the City's emergency ambulance provider at some future time, the
membership fees should be raised ($35 to $45 is a typical membership fee for paramedic
ambulance programs).
Conclusion #14
The lack of financial information from Courtesy Services, plus numerous variables that would result
from policy decisions, make it impossible to provide financial projections for each of the five
operational profiles presented in the consulting report.
Recommendation:
Review the section of the consultant report dealing with marginal costs (pages 83-85), including the
hypothetical analysis of the "Fernwood Fire Department" and the "Apex Ambulance Service" and
the calculations at Appendix J. Also review the population and demand-for-service information at
pages 92 and 93. The format used in those comparisons can be used to estimate and compare costs
regarding any proposed alternative method of providing ambulance service.
Conclusion #15
Response time information for emergency units responding to EMS calls in San Bernardino is
compiled as averages. This method allows for gross deviations to be obscured by the average. It is
not always a meaningful measure of response time performance.
Recommendation:
Investigate whether the reporting of response times is as time-sensitive and accurate as it can be.
Establish a fractile measurement system which measures compliance against a certain value (e.g. 90
percent of all paramedic responses in six minutes or less). Establish systems to measure call
processing time and response time separately and together. Continually analyze response time
performance and make necessary changes to remedy any failure to meet response time goals.
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Conclusion #16
The insistence of Courtesy Services on responding "Code 3" to all medical emergencies, and the
apparent support of the County Health Director for this position, are in conmct with the Fire
Chiefs order that ambulances will respond "Code 2" until and unless upgraded by fire officers or
dispatchers. The opinions of Courtesy and the County Health Director on this matter are at odds
with national experience, risk management considerations, the reality of time-and-distance factors,
the official position of at least one national physician organization, and the safety policies of
Courtesy's casualty insurance carrier.
Recommendation:
Support the Fire Chiefs position.
Conclusion #17
With the limited information available, it is imoossible to know whether Courtesy Services of San
Bernardino, Inc., is fmancially sound.
Recommendation:
To the extent possible, use the licensing powers of the City to acquire information about and audit
the finances of Courtesy. The legitimate purpose of acquiring and auditing the financial records of
this company is to protect the interest of the City and its citizens and the need for a secure and
stable provider of emergency ambulance services.
Conclusion #18
The concept of special training for and certification of emergency medical dispatchers (EMDs) has
. become a state-of-the-art standard for full-time public safety dispatch facilities. That standard
includes provision of pre-arrival instructions, the practice of dispatch prioritization, and the
authorization or limitation of red-light-and-siren responses using physician-approved protocols. An
effort to develop an EMD program through ICEMA has produced a compromised version of a
previously changed program which probably was subject to copyright protection.
Recommendation:
Recognize the importance of this concept and avoid efforts to develop it piecemeal, or base it on
hand-me-down materials that are protected by copyright. Budget and arrange for a site evaluation
and consultation by Medical Priority Consultants, Inc., of Salt Lake City (estimated cost: $3,(00).
There are other EMD consultants and they may be less expensive but, in our opinion, they cannot
provide a reliable system. We have no financial interest in Medical Priority Consultants, Inc., but
we recommend them without reservation. As a matter of risk management, the independent
development of a quality EMD program will pay for itself. As stated in the consultant report, there
has never been a reported claim or suit, successful or otherwise, against a dispatch center qr agency
that had trained its dispatchers as EMDs and used the medical priority dispatch system.
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Conclusion #19
The San Bernardino Fire Department presently prepares a patient care report on every person can:d
for by its EMTs or paramedics. One copy of that report is sent to ICEMA where it is stored but not
analyzed, according to fire department management. Another copy is retained by the fire
department but not analyzed, compiled or summarized. In keeping with formal action by the San
Bernardino County Fire Chiefs Association, the department also is refusing to participate in
ICEMA's "sean-tron" system (background at pages 100 and 101 of consultant report).
Recommendation:
The current situation prevents any evaluation of the performance of the City's emergency medical
services program. The Fire Chief needs to study and propose a system for regular audits of patient
care reports (possibly a peer review system), and the creation and maintenance of statistical analyses
of this information.
In view of the stand-off between Fire Chiefs and ICEMA on the matter of the "sean-tron" reporting
system, the City Administrator (and possibly the chief executive officers of other affected
municipalities) should investigate the problem and try to mediate a solution. Though the local EMS
agency (ICEMA) has statutory responsibility to establish a quality assurance program, it cannot do
so without data concerning all emergency medical incidents.
Conclusion #20
ICEMA Revised Protocol #14003 probably was modified to provide a competitive and monetary
advantage to Courtesy, and to enhance Courtesy's stated desire to replace the fire department as the
paramedic provider in the City. The subject of the protocol is elaborately addressed by Health and
Safety Code Section 1798.6. The ICEMA protocol raises the question of whether a local EMS
agency, as an instrumentality of County government, has the authority to construct regulations in an
area of activity which has been pre-empted by state statute.
Recommendation:
Submit the question of state pre-emption to the City Attorney for evaluation.
Conclusion #21
Courtesy Services staffs its advanced life support units with crews consisting of one basic life
support EMT and one paramedic. Studies have shown this staffing pattern to be insufficient - in
terms of patient care - compared to staffmg each ALS unit with two paramedics. It is expected that
the American Heart Association's Conference on Guidelines and Standards for Emergency Cardiac
Care (scheduled for this month in Dallas, Texas) will recommend that advanced life support rescue
and/or ambulance units be staffed by a minimum of two certified paramedics.
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Recommendation:
Authorize the Fire Chief to study this subject, possibly with patient care simulations, and report the
results to the City Administrator.
Conclusion #22
As a result of the policy conflicts surrounding the issue of emergency medical services in San
Bernardino, and the potential economic and career consequences for organizations and people, a
severely contentious atmosphere has developed between employees of Courtesy Services and
members of the San Bernardino Fire Department. At the least, this situation may result in
emotional confrontations in public. At the worst, it may adversely affect patient care.
Recommendation:
Give the resolution of policy conflicts a high priority and, to the extent permitted while involved in
litigation, make the decisions necessary to clearly determine the future of emergency medical
services (including ambulance service) in San Bernardino.
Despite its length, this supplemental report merely glosses over the substance of the foregoing
conclusions. For more complete information, refer to the pertinent parts of the consultant report.
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EMERGENCY CARE INFORMATION CENTER
Report on a Study of the
Emergency Medical Services (EMS) System in the
City of San Bernardino and Recommendations Regarding
the Most Efficient and Effective Means to
Organize the System.
The Best Source of EMS Information
Medical9111nformotion System. EMS Insider Newsleffer . The ECIC Dofotlose . Research & Consulting services
P.O.Box27B9.COrlsbOd.Col~omio9201B' 619/431-9797 . FAX619/431-B135
A DIVISiON Of JEMS COMMUI'II~ATlONS
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CITY OF SAN BERNARDINO
EMERGENCY MEDICAL SYSTEM STIIDY
Table of Cootents
IDtroduction
Project Outline
Project Staff
SenIce DeIlftI'J SJUIII
PrivItlzed AmbulllllCe Service
A Brief History of Medical Transportation
in the U.S.
The "Modem Era" of Emergency Medical Services
The "Public Utility Model"
Hi&blY Modified Private Enterprise
A Monopoly by Any Other Name
The Kansas City Experiment
Hard Realities for Small Ambulance Services
Leverqe and Hiah-Risk Expansion
Rqulated Monopoly Concept Spreads
Related Developments in California
"Privatization" - A One-City Trend
The Fire Service - Chanaed Priorities
A Report Card on Monopoly Ambulance Service
Tools of Efficiency
The Price of Reduced Subsidies
The Human Reaction to Tecboocracy
The Cure
1breIIS to rqulated monopoly ambulance service
aty-operated Paramedic Senice With Priqte
AmbuIaDce TrlDlport
Operational Profile A
A. Vebicles
First-respoDders
Advanced life support (ALS) paramedics
Ambulance EMTs (and paramedics)
Extrication and heavy rescue
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2
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B. Equipmeat
C. EMS PenoDnel
1. TraiDiDg.
2. StaffiD& Levels
FInt-respooder UDits
Advanced life support (ALS) UDits
Ambulance UDits
3. Certification
4. Shift Schedules
D. Supervision of Field Personnel
Field Supervisors
Administrative Supervisors
E. Displtl'h Locations
F. Documentation
G. Quality Assurance
Operational Profile B
A. Vehicles
First-responders
Advanced life support (ALS) paramedics
Ambulance EMTs (and paramedics)
Extrication and heavy rescue
B. Equipment
C. EMS Personnel
1. Training
2. StaffiD& Levels
First-responder units
Advanced life suppon (ALS) UDits
Ambulance units
3. Certification
4. Shift Schedules
D. Supervision ofField Personnel
Field Supervisors
Administrative Supervisors
E. Dispatch Locations
F. I>ol:uJr-mQll
G. Quality Assurance
aty~perated Paramedic And Ambulancle Transport Serri_
Operational Profile C
A. Vehicles
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2S
2S
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Flnt-rapoDders
AdvaDced life IIIppOtt (ALS) paramedics
ExtriCltioD IJIII heavy rescue
B. Equipmeat
C. EMS Pet'SOIIIlel
1. TraiDiD&
2. StaftiDc Levels
Flnt-rapoDder UDits
Advmced life support (ALS) UDits
3. CertifiCllion
4. Sblft Schedules
D. Supervision of Field Personnel
Field Supervisors
Administrative Supervisors
E. Dispatch Locations
F. Documentati<)n
G. Quality Assurance
0penli0llll Profile D
A. Vebicles
Fn-respoDders
Advmced life support (ALS)
firefiabter/paramedics
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ExtriCllion IJIII heavy rescue
B. Equipineut
C. EMSPersonnel
1. Trainina
2. StaftiDc Levels
FIrst-respoDder uniu
FIrst-line ambulances
3. CertifiCllion
4. Shift Schedules
D. Supervision of Field Personnel
Field Supervisors
Administrative Supervisors
E. Dispatch LocItions
F. DcJcumeI.1ation
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G. Quality Assurance
Openlional Profile E
A. Vebicles
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4B
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Flm-respoDders
Advmc:ed life support (ALS) firefiahterlparamedics
Ambulance EMTs (Fue Service Laborers)
EmiCllioD IIIlI heavy rescue
B. EquipmeDt
C. EMS Personnel
1. TraiDiDI
2. StaffiD& Levels
YltSt-respoDder wms
Advanced life suWort (ALS) wms
Ambu1ance wms
3. CertificatioD
4. Shift Schedules
D. Supervision of Field Personnel
Field Supervisors
AclmiDistrative Supervisors
E. Dispatch Locations
F. Do<:umeDtatiOD
G. Quality Assurance
Formal Cooperation with Other OrpnIzatiOIlS
Patients IIIlI Dispatchers
Patients IIIlI FIm-Responders
Patients IIIlI Rescue Paramedics
Patients and Ambu1ance Provider
Patients IIIlI Hospitals
Dispatchers IIIlI First-Responders
Dispatchers IIIlI Rescue Paramedics
Dispatchers IIIlI Ambu1aDce Provider
Dispatchers IIIlI Hospitals
FIm-Responders IIIlI Paramedics
FIm-Responders IIIlI Hospitals
Ambulance Providers IIIlI Hospitals
Automatic Aid
Mutua1Aid
Local EMS AleDcies
County Health Director
Colt AnaIJIIs
Rate StructUre
Ambulance Cost Index Formula (ACIF)
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6S
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6B
6B
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Ambulance RIle Replllion - Five Choices 70
Balic life aupport response to a routine llOIHIIIerJeDCy 71
Unscheduled emerpncy call additional 72
Addltlnnal Cblr&es 73
Each mile or fraction of a mile 73
WaitiDc time after first fifteen
minute period 74
Niaht surcbarae or weetead services 74
Each additional patient 74
Paramedic Rates 74
E.K.G. IIIOnitorina 76
All-inclusive ALS Service 76
OxYaeD Administration 77
Response to a call for ambulance not used 77
Rigid Collar 77
Emer&ency ambulance uansportation of indiaent persons 78
City of San Bernardino User Fees and Membenhip Proaram 78
Senice CGIts/Prollt Marlin 80
Private ambulance companies 80
Fue departments 82
Marginal costs 83
Response Tune Analysis 86
Fractile 87
The "Code 2" ControVersy 88
Compared to population 92
Analysis of Lona-Term Fln"",,111 Viability 94
The FeasibUity of Medical Priority Dispatching 95
Additional Issues 98
Municipal Power of Self-Determination 98
DcJcmn-tllt\nn and Evaluation 100
ICEMA Revised Protocol 114003 101
The Evolution of Courtesy's Role 103
One-and- Staftin& 105
Conclusions and RecolDJDell'!lltlnllS 106
GLOSSARY OF TERMS 107
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In response to c:ooflict between its fire department and the local private ambulance service, as well
as the need to caqdme economy and effi,.;....cy in all of its operations, the City of San Bernardino
conttacted for a study of the local emeqel1cy medical services delivery system. A review of the
City's options included .privatized. ambulance service, two approICba to City-operated
paramedic service with private ambulance transport, and three approIChes to City-operated
paramedic and ambulance service.
In this report, the history of the private ambulance industry and the c:umnt trend toward recu1ated
w04Opoly ambulance service is explored. Staffing innovations and other efficiencies introduced
by the private sector are explained and analyzed. Also, lep1 and other threats to regulated
monopoly system designs is discussed.
Five operational profiles are presented in modular format, with vehicles, equipment, personnel,
supervision, basing modes, documentation and quality assurance (improvement) described or
evaluated for each of the five profiles (modules). Since emeqel1cy medical services involves
many working relationships and mutual responsibilities, sixteen cooperative relationships are
described and discussed.
The derivation and history of the ambulance service rate structure for both the County and ttie
City of San Bernardino is reported, and the rate strUCtur'es are critically examined item-by-item.
The economics of providing ambulance service is discussed, and a scenario involving the
.Femwood Fire Department" and the "Apex Ambulance Service" is used to describe and illustrate
the important topic of marginal costs in a fire department which employs cross-trained, dual-role
personnel.
The long-term viability of private ambulance companies is considered, and the feasibility of
instituting a medical priority dispatch system is presented in the context of the national experience
and risk management. The report also explores the municipal power of se1f-detennination in light
of the powers usated by the Inland Counties Emergency MediC'll Agency (ICEMA), including a
controverSial policy regarding authority at the scene of medi....1 emergencies.
Documentation and evaluation of EMS system performance and patient care is discussed. The
evolution of the role of Courtesy (ambulance) Services is presented in the context of local events
and atrihvtH, Finally, the adequacy of staffing advanced life support units with only one
paramedic is examined. Due to the fact that issues discussed in this report are the subject of
cumnt litigation between the County and City, conclusions and m:ommendations have been
submitted to the City Administrator under separate cover.
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On November 8, 1991, the Emergency Care Information Center (ECIC) responded to a
Request for Plu90Slls issued by the City of San Bernardino. The City was seeking an analysis
of San Bernardino's existing emergency medical services (EMS) system, and recommendations
reprdin& the most efficient and effective means to organize the system.
IraIeleSted bidders were invited to submit proposals that included the consultant's background,
previous work experience, staffing, bid price and proposed methodology. The ECIC pIClposa!
was selected in a competitive process and ECIC committed to completion of the study by
Ianuary 31, 1992.
Principal investigator on this project has been ECIC's Executive Director, lames O. Page,
I.D. Mr. Page conducted personal interViews with key persons in the local EMS system. He
reviewed relevant historical records, observed actual emergency medical responses, and
collected and analyzed numerous ordinances, agreements, patient care records, organizational
charts, plans, ~g minutes, staffing schedules and statistical reports. He supervised and
participated in ~h and analysis by ECIC's staff. Finally, he served as author of this
report.
As is the case in most locales, San Bernardino's EMS system is complex and multi-faceted.
Its design and performance are influenced by factors of local history, political compromise,
interagency conflict, economics, philosophical differences and public expectations. Identifying
those factors and describing them in common-sense termS was a primary purpose of this
report. Formn1,ring recommendations for potential changes (improvements) in the system was
considered equally important.
In our work on this project, the consultants have been guided by the knowledge that
emergency medical services (EMS) is a topic that inevitably will touch ffNery person in the
community. The issues involved in San Bernardino's EMS system, in one way or another,
will make a difference between life or death for some. Those same issues, in one way or
another, will make a difference in the quality of life for f!Ne'l'Jbody in the community.
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This report was not intended to serve as ballast for a filing cabinet. We have faced sensitive
issues head-on, and we have raised issues that had not previously been considered. Much of
this will cause discomfort for both individuals and organizations. That is a natural by-product
of desoli...g honestly and earnestly with a topic of such vital importance to every person in the
community.
PROJECT otm.lNE
As specified, this project was to study three alternative operational approaches or modes:
1. Privatized emergency medical services;
2. City-operated paramedic service with private ambulance transport;
3. City-operated paramedic and ambulance transport services.
It was also specified that the comparison of each of the three identified operational approaches
or modes cover the following areas:
1. Service Deliv~ System
Describe and compare the method of service delivery
2. OJ!erational Profile
a. Vehicles - describe and compare vehicles used for
medical response and hospital transport
b. Equipment - compare standard equipment used for each
operational approach
c. EMS Personnel
1. Training - initial and ongoing - describe minimum
standard for EMS staff training for all
responding personnel
2. Staffing Level - describe minimum staffing level
for each shift, and training levels for EMS team
for each shift, turnover rate
3. Certification - review whether certification is
required
4. Shift Schedules - compare shift schedules for EMS
staff
d. Supervision of Field Personnel - describe level of
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training of field and administrative supervisorial
personnel
e. Dispatch Locations - identify and describe stand-by
.localions for EMS responders
f. DocumenlatiOll - review documenlatiOll procedures of
responses, patient uses,ments, and treatment
modalities
g. Quality Assurance - describe the level of care
lIdmiDistered by each operational mode, review policies
and prooedures for quality assurance program
3. Formal ('~tinn with Other OrJaniDtionS
Describe formal relations that EMS responders have with lint responders, dispatchers,
hospitals, and surrounding jurisdictions (including mutual aid)
4. Cost Analysis
a. Rate Structure - Review proposed rate structure and compare with other EMS and
ambulance service
b. Service Costs/Profit Margin - Review costs to provide service, and profit margin based
upon rates charged
s. ~se Time Analysis
Analyze response times of various operational modes based upon number and location
of EMS responders
a. Measure on fractile, not average bais
b. Compared to Population
6. Analysis of lon2-term financial vilIbili\y of private ambulance services
7. Determine the fH~bili\y of medical prioritv di~t~hin,
Note: Several typical profiles of EMS systems are presented in this report (as specified in the
project outline). Each of these profile descriptions is intended to be modular, allowing study
of each profile separately. Features that are common to the profiles are fully described
(Iepel'tM) in each. However, subtle differences may exist that require careful reading of all
profile descriptions.
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1>>1OIn:n::rr STAFF
James o. ))a"e. J.D.
Mr. Page bas been active in emergency medical services for 35 years. He began his career as
a IeSCUe fuefi&hter in Los Angeles. He bas been a chief officer in three fire departments,
served as the Chief of Emergency Medical Services for the State of North Carolina, and was
Executive Director of the Don-profit Advanced Coronary Treatment (ACl') Foundation for
eight years. In 1979, he founded JEMS, (the Journal of Emer2enc:y Mf'dir.:al Services), a
highly respected monthly publication. His company bas since C!eIted 11"""" )llIp,;.... and a
peer-reviewed medical journal, Prehomital and niu~ Mf'dicilll!. Since 1988, Mr. Page also
bas directed the activities of the Emergency Canl Information Center. He bas been a member
of the California Bar for 21 years and is based in Carlsbad, California.
Tom Scott. A.M.
Following completion of graduate school in Chicago, he worked for the Norton Sound Health
Corporation in Nome, Alaska, helping to develop their first EMS plan. He was then recruited
to serve as Chief of the EMS Section for the State of Alaska. Leaving that position to follow
his wife-to-be to Seattle where she was attending school, Mr. Scott perfuuned several health-
related consulting projects in Washington state. In 1981, they returned to Alaska where tom
became President/ExeCUtive Director of the Southern Region Emer&ency Medical Services
Council, Inc. After Iiine years in that post, Tom and his wife moved to California. He bas
served as managing director of the Emergency Canl Information Center in Carlsbad since July,
1991. He also serves as business manager of the National Association of State EMS Directors.
OMffrey A. rlldy. B.S.
Mr. Cady began his career as a paramedic in Fresno in 1977. He worked continuously as a
paramedic and/or paramedic coordinator for private ambulance companies in California until
he became Research Director of the Emergency Canl Information Center. He holds a degree
in business administration from San Diego State University. In addition to maintaining
ECIC's information clearinghouse and the Mf'dil".lll 911 information sourcebooks, Mr. Cady
conducts raean:h for both ECIC and the JEMS organization, including the annual survey of
EMS in the 200 most populous cities in the U.S.
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SERVICE DELIVERY SYSTEMS
1>>rivsari'ftlllt Ambnl.~ Service
The notion of performing the duties of government through contracts with private companies
received a boost with the election of Ronald Reagan in 1980. Although the size and cost of
government continued to grow during his two terms as President, there was during that period
much official discussion about the economies thought to be possible through privatization.
Ambulance transportation bas been among the services mentioned as a source of possible
savings.
As with most aspects of health care, prehospital emergency medical care (including ambulance
transportation) is much more complex than it appears. To fully understand the pros and cons
of privatized ambulance service it's important to understand the history of medical
transportation in the U.S.
A Brief History of Medil'.ll.\ Tr3nmortation in the U.S.
Prior to the mid-1900's in the U.S., ill and injured persons were most often taken to a hospital
by their family, fellow workers, friends, etc. Presumably, the horse-drawn wagon was the
most frequent mode of transportation.
The Civil War\saw the development of the Rucker ambulance wagon by the U.S. Army.
Many of those Wa&9DS later found their way into civilian use after the war. Many of the
hospitals which were involved in.caring for wounded soldiers during the war continued
providing ambulance service to the ci~ population after the war.
The nation's fint regularly-available ambulance service was operated by Cincinnati's
Commercial Hospital starting in 1865. By 1878, there were three hospital-based ambulance
services in New York City. In 1884, Jewish Hospital in }1h;l..b\phia began its horse-drawn
ambulance service, and a year later Charity Hospital in New Orleans organized a similar
service.
The fint motorized ambulance in the U.S. was placed in service by Michael Reese Hospital in
Chicago in 1899. Until the American involVeD1ent in World War n, ambulance service was
provided in most urban areas by hospitals, city ambulance departments, some fire departments,
a few police departments, and in a smllll~ number of l()Cllrions, private companies. For
example, one of the country's first private ambulance companies was started in Portland,
Oregon in 1913. Two years later, another private service was created in Seattle.
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With the manpower shortages of World War n, many hospitals could no longer staff their
ambulance services with able-bodied people, much less the physicians or SUlJeoDS who had
become fairly common on ambulanc:es during the 1930's. Many of those hospital-based
services were takal over by police and fire departments. In some cities, private ambulance
companies were formed to take over the service.
In rural and suburban areas, local funeral directors had become a convenient source of medical
ttansportation, mostly because they possessed vehicles that could carry people comfortably in a
. supine position. Despite the obvious conffict of interest, funeral home ambulance service was
common until p"....Ce of the Fair Labor Standards Act and the National Hi&hway Traffic
Safety Act in the mid-1960's.
The former of those laws increased the wages and benefits of funeral home employees who
served as ambulance drivers or attendants in addition to their other duties. The latter law
c:alled for increased training standards for ambulance personnel. Most funeral directors simply
announced that they would no longer provide ambulance service. In their place, thousands of
volunteer ambulance services were created (mostly in the central, southern and eastern states),
or the ambulance service was turned over to a paid fire clepartmeIlt or a private company.
The "Modem Era" of Fmervencv Medical ~--
A major consequence of the new federal standards was the recognition that ambulance service
is only part of a spectrum of responses and services that are required by seriously ill or injured
patients. In fact, the Emergency Medical Services Systems Act of 1973 (Public Law 93-154)
identified 15 components of an emergency medical services (EMS) system. Transportation
and transfer of patients represented only two of those 15 components.
For the first time since physicians and surgeons were removed from ambulances, accidents and
serious illnesses occurring outside a hospital were viewed as a medicaJ problem rather than
simply a transportation problem. To meet the medic:al needs of the victim, it became
neo-"'''Y to involve a wider range of resources, working in concert with one another. Those
resources include CPR-trained bystanders, emergency medical dispatchers, fire department
"first-responders," advanced life support paramedics, and medical command physicians,
among others.
Between 1974 and 1981, the U.S. Department ofBealth and Human Services (formerly
DHEW) spent more than $200 millions in developing the new 15-component concept of EMS
(emergency medical services). Indeed, it was embraced by textbooks and training programs
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and quickly became the minimum Iepl standard for communities to fonow in responding to
out-of-hospital (mhospital) medical emergencies.
The specific Jan&uaae of the law, an apparent bias on the part of federal officials, and a stand-
offish attitude by many private ambulance operators left the private sector mostly on the
sidelines of these developmcnts. Furthermore, a popular television series of that era created in
the minds of the American viewing public the impression that paramedics are firefighters, and
vice-versa.
Records of the City otSan Bernardino Common Council reveal that the question of paramedic
services wu considered u early u December 9, 1974. At that time, the San Bernardino Fire
Department(SBFD) requested authority to implement a publicly financed paramedic service.
The Council directed the fire departmeIlt to prepare cost estimates and refemd the matter to
committee for study and recommendation.
The topic returned to the Council agenda on September 8, 1975. At the meeting of that date,
D. StevenRice of Courtesy Services appeared and stated that his company would not be in
favor of providing a parallel function of paramedic services with the fire department. Mr. Hy
Weitzman, .epresenting the California Ambulance Associllrion, appeared and urged the
Common Council to select Courtesy Services for the paramedic program.
A motion that Courtesy Services provide the paramedic program wu defeated by a vote of
five to two. Another motion wu then made that the fire departmeIlt be authorized to
implement the program and the request for funding of training and equipment for 1975-1976
be granted. This motion wu approved by a vote of six to one.
The "Public Utili~ Model"
The scenario in San Bernardino wu repe"tM in numerous California communities in the
1970's, u private ambulance companies paid the price of not ,tt....dillg to their public images.
However, a 1978 developmcnt in Tulsa, Oklahoma soon attracted the attention of private
ambulance services from caut-to-coBSt. It also set the stage for conversion of the ambulance
business from mostly "Mom and Pop. enterprises to multi-city bllm"~s combines, including at
last one international competitor, engaged in high-stakes bid competitions.
The pre-1978 private ambulance service in Tulsa prmnted all the aspects of greed, negligence
and abuse which had so badly tarnished the image of the ambulance business. Investigative
.~Iting by a local newspaper focused on the problems in Tulsa and forced public officials to
seek a change. Coincidenlal1y, a University of Oklahoma ecOnomist named Jack Stout had
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recently developed a theoretical model for ambulance service. He called it the "public utility
model. "
Hirhly Mntlifuld "Private Entemrise" _
Although touted as a form of privatization, central to Stout's concept is the creation of a
governmental or quasi-governmental management entity that performs most oCthe functions
that characterize a business. The private ambulance company, on the other hand, is neutered
to function as little more than a labor contractor.
For example, the private contractor is deprived of the opportunity to (1) engage in retail
competition, (2) excel in billings and collections, (3) manage cash flow, (4) create an
atmosphere of secure, career-length employment, or (S) acquire a long-term revenue base that
can be converted to a stable corporate equity interest. By design, the private contractor'is
required to engage in periodic bid competition to retain its franchise. The resulting insecurity
(for the contractor and the workforce) prevent the building of a corporate culture based on
long-term employer-employee relationships.
A promise made by Stout to Tulsa city officials was that the City's subsidy of the new system
would decrease and eventually be eliminated. That has happened, although it is clear that the
burden simply has been shifted (see newspaper editorial at Appendix A).
A MonOl)Oly by Any Other Name -
Operational features of Stout's systems include creation of an ambulance service monopoly by
city ordinance, peak load staffing, .system status management," dispatching of ambulance
units by the contractor (rather than a public agency), fractile measurement of response times,
use of local fire departments as first-responders, and use of vehicles equipped for ALS
(advanced life support) to transport both emergency and non-emergency patients. Each of
these features will be described and discussed later in this report.
The Kansas City EJtPeriment
Within two years of launching the Tulsa system, Stout was invited to assist the City of Kansas
City, Missouri in dealing with its ambulance crisis. Ultimately, Kansas City adopted the
.public utility model," issued a contract to a single private provider, and successfully defended
in federal court a challenge to the City's new ambulance ordinance (which created an
ambulance service monopoly).
These developments have been viewed with concern by most private ambulance services.
Competitive bid requirements in the regulated monopoly ambulance systems effectivel~ Ii~it
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the competition to three or four large national or international companies. The official RFP
(request for p.oposals), usually prepared by Stout or another consultant, inevitably calls for
bi&h1y complclt bid prepuations and P""~les, often costing bidders $100,000 or more. Since
the c:oncept was introduced in Tulsa in 1978, no local ambulance service bas ever succeeded in
relaining its franchise where the competitive bid process is used.
Hard 1l....1ities for Small Ambulance ~N'C
Therefore, a local businessperson, after serving the community for many years (for better or
worse) is likely to discover that the ambulance business is unlike many other small bnm-ses.
Althou&h he or she may have a home and family in the community, and may have a long
history of participation in civic affairs, it's likely that the ambulance company's wgood willw
will have little monetary value.
The local ambulance service's ftanchise to serve the community likewise will have no
monetary value if the city council decides to issue it to a more suc:cess(ql bidder. There is
little value in used ambulance vehicles, even if the successf1Jl bidder wanted to buy them. So,
after many years of long hours and hard work, most private ambulance operators eventually
come to realize that their assets consist of their accounts receivable and any reall'lupeity or
personal assets they may have acquired.
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l.arerue and High-Risk ElQ)ansion
"
On the other hand, severallarge-comj)lJ1ies have viewed the advent of the regulated monopoly
ambulance service as an opportunity for ~sion, albeit high-risk. Two rdatively
misunderstood facts contribute to this trend. First, if it bas the creative talent and money to
develop and sell an attractive bid pac~ge, a large ambulance company can expand into a new
territory (with monopoly status) with a rdatively small investment of cash. Second, although
profit percentages lIJC small (net profit as a percentage of gross revenues), those profits (in
dollars) can be leveraged upward through high-risk expansion (i.e. the acquisition of additional
territory and gross revenues without a p.oportional outlay in capital).
For example, if the pre-tax profit margin for a private ambulance company were four-percent
(4") and annual gross revenues were $2.S millions, the owner or owners would receive profits
of $100,000. However, if the owner or owners could obtain monopoly status in additional
territory (sometimes known as an wexclusive operating ucaW), and if that additional territory
produced annual gross revenues of $7.S millions, pre-tax profits would be $400,000.
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Through the use of leases for p........tt and equipment, lines of credit, and bootstrapping on the
credit termS of supplill!l'S, some large ambulance providers have IIChieved ma,jor expansions
usin& little JDOJe than their cash flow. All such obligations require personal guarantees from
the principals, as well as a forfeitable perfonnance bond. Thus, there is risk - to the principals
and to the communities their companies serve.
On the other band, benefits can be substantial. For example, one partnership consisting of
tme principals has successfully bootstrapped their ambulance service into several exclusive
franc:bises in at least tme states. This was achieved without significant outside inVAtlllellt.
In a recent year, their company had gross revenues of $42 millions. The four-percellt margin
produced pre-tax profits of 51.68 millions - to be divided between the tme putners, or
rdnvested in additional expansion.
R.eJulated MnnQJlOlyCnn....... ~p,.....ts
Following his work in Kansas City, Jack Stout moved on to Fort Wayne, Indiana, where he
successfully privatized a municipal EMS agency. An out~f-state ambulance service won the
bid. Later, in Fort Worth, Texas, he constructed a process which replaced multiple private
ambulance companies with a modified form of regulated monopoly (which he refers to as a
-fail-safe franchise model-). In Pinel1as County, Florida, he replaced multiple private
providers with a single contractor. In Oklahoma City, when that city's ~f-a-Idnd -public
trust- ambulance service failed, Stout merged it with the Tulsa operation, thus avoiding a bid
competition and giving the Tulsa contractor a free ride to expanded revenues.
Other consultants have taken the cue. In 1990, Jay Fitch and Associates, of Missouri, were
employed by the City of Richmond, Virginia to create a regulated ambulance monopoly to
replace the private companies and volunteer ambulance services that had served various zones
within the city. Intense and expensive competition between four out~f-state companies
resulted in selection of a single pIOVider.
'R..,..tt!d ~nnments in r..lifomia
In California, in 1981, the cities of Rancho Mirage, Indian Wells and Palm Desert formed a
fire commission in order to provide fire protection and ambulance service to the tme cities.
The fire commission then contracted with the California Division of Forestry to provide the
services. Springs Ambulance Service, a private company based in nearby Palm Springs,
brought suit apinst the cities under federal antitrust laws. The cities c:laimed that they were
immune from antitrust liability but the district court disagreed and ruled against them. The
cities appeaJl'rl, and the N"mth Circuit, U.S. Court of Appeals, reversed the judgment of the
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district court. (Springs Ambulance Service, Inc. v. City of Rancho Mirage (1984) 745 F2d
1270)
At issue was the language of California Government Code Section 38794, which states in full:
"The legislative body of a city may contract for ambulance service to serve the
residents of the city as convenience requires. "
In its dec:ision, the court said: "Here, the exclusion of private ambulance companies is a
lleCe"u"y or reasonable consequence of providing subsidimd municipal ambulance service, and
was surely within the contemplation of the 1~..I"tllre when it enacted Government Code
Section 38794. Where the residents of a city pay taxes to make emeraency ambulance service
available, it would be anomalous to require that the city also dispatch a private for-hire service
with, or in alternation, with its own. To do so would, in effect, force citizen users to pay
twice for the same service, once for the private carrier that is dispatched to them, and again
for the public service supported with their taxes but not used. We conclude that Gov't Code
Sec. 38794 provides a sufficiently clear expression of state policy to permit California
municipalities to provide exclusive, free emergency municipal ambulance service. "
The California Ambulance Association (CAA), a trade organization ."ptacnting private
ambulance services, quickly sought to blunt the impact of the Springs decision. At the request
of CM, State Assemblyman Broce Bronzan (Fresno) authored legislation which created
Health and Safety Code Sections 1797.6 and 1797.224. Those statutes, which more-or-Iess .
mandated competitive bid processrs for ambulance service in California, will be discussed and
analyzed later in this report.
More recently, San Mateo County replaced one private ambulance contractor with another,
using a competitive bid process. An effort by Sonoma County to use the competitive bid
process has resulted in litigation by at least one private ambulance company and two
municipalities. In one of those cases (Sonoma County Superior Court No. 179680) the court
ruled on May 3, 1991, that the municipality was not subject to the County EMS Plan, nor to
any County EMS regulation. An effort by Monterey County to award exclusive rights for
both emergency and non-emergency ambulance services has resulted in a lawsuit by a
displaced private company. Within the past month, Sacramento County completed a
competitive procurement which will replace three local providers with a single out-of-toWn
company.
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.Privati7.lltion. - A One-Ci(y Trend
It is essential to note that only in F~ Wayne, Indiana has a public agency ambulance service
been teplaced by a private service. In essence, tbe so-c:aIled .privatization. which was
sperted by Jack Stout's work in Tulsa in 1978 has simply replaced small private ambulance
..ompanies with larpr private ambulance complllies. In tbe most highly rqulated monopoly
profiles ("public utility model. and .fail-safe franchise model.), those private companies serve
u labor contractorS for the most part.
'Ibough there bas been much debate over .public versus private. during these developments,
what actually has occ:urred is a restrUCturing and consolidation of private ambulance service.
At tbe same time, fire service agencies have been co-opted to provide first-responder and other
services, thus effectively subsidizing the private services.
The Fire S~ce .. Clwurl!d Priorities
Also, during the same period, a twenty-year campaign to reduce the frequency and seriousness
of fires in America has paid off. The number and magnitude of fire calls received by most
American fire departments has d.c.pped significantly. At the same time, calls to fire
departments for emergency medical usistance have increased sharply. In most paid fire
departments, EMS calls now represent between 6S-percent and 8S-percent of allaJarms
received.
These changes coincide with financial hardship at all levels of government, and with the
arrival of a new breed of firefighter whose career expectations were affected by televised
depictions of firefighters u paramedics and vice-vena. The availability of a pool of available,
trained and disciplined firefighters, ready, wil1ing and able to usume a larger role in EMS -
including the provision of ambulance service - has not gone uMoticed by the private
ambulance industry.
Also noticed, by fire service leaders and the private ambulance industry, have been some high-
profile examples of fire departments taking over ambulance service from private companies.
For example, tbe Phoenix (Arizona) Fire Department suc:c:essfully competed in a bid
competition to provide that city with ambulance service. The fire department service replaced
five competing private companies, it quickly became an integral part of the fire department's
operations and culture, while generating revenues and improving employee productivity.
More recent ~lI"'Ples of public agencies replacing private companies u ambulance service or
paramedic providers are to be found in Bay City, Texas, Mobile, Alabama and a new.shared
system. (fire department and private company) arrangement in San Diego.
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In California, the private ambulance sector has spent several years courting the favor of local
EMS aaencies wbile sponsoring J..,;ch'9on which would make it difficult-to-impossible for a
public qeDCY to successfully compete for an exclusive operating area (e.g. H " S Code
sections 1797.6 and 1797.224). There seems to be widespread recognition in the private
sector that the reduction in fire incidents, coupled with the need to make more productive use
of on-duty firefighters, could be a threat to the status quo of private ambulance companies.
A ~ r",rrt on MonOtJOly Amhnlance Service
The earliest reguJated monopoly ambulance services have had more than a decaM of test. The
first unbiased analysis came from the Office of the City Auditor, City of Kansas City,
Missouri, in 1988. Though the system had fulfilled one major promise during its first eight
years _ it had steadily reduced the amount of local government subsidy - that success was at the
expense of response time performance and the contractors' workforce.
Probably the greatest flaw in Stout's regulated monopoly ambulance systems is that they tend
to promise more than they can deliver. For example, the reduction or elimination of public
subsidy while delivering .clinically excellent. services within specific response time standards.
Most often, it is this promise that attracts public officials to the concept. Thus, there is intense
pressure to reduce or eliminate the subsidy - even when initial projections clori't pan out, or
changed economic circumstances impact the system.
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Tools of Effici~t:y -
To his credit, Stout devised a new method for measuring expenditures in staffing and
equipping an ambulance system. He identified the .unit-hour. (one fully-staffed and equipped
ambulance available for one hour) as the basic measurement. The goal is to meet response
time performance standards while using the least possible number of unit hours. Ideally,
aa:ording to Stout, each ambulance will have a unit hour utilization rate of .40. That means
that each hour, on the average, an ambulance will transport .40 patients (one transport per
two-and-a half hours).
To achieve that standard of efficiency while meeting response time requirements, the
combination of .peak load staffing. and .system status management. (SSM) is utilized by
many private ambulance providers. With peak load staffing, a variety of work shifts may be
utilized to staff ambulances based on predictable demand.
With SSM, ambulance units are deployed at numerous .posts. (street comers, convenience
store parking lots, freeway on-ramps) in specific locations throughout the community in
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anticipation that that location will be within the response time range of the next call for an
emergency ambulance (system status management). In Kansas City, prior to 1989, it was not
uncommon for an ambulance crew on a 12-hour shift to be based at 18 different posts during
that work period.
The Price of Redu"l't! Subsidies -
Figure #1 illustrates the trend of City government subsidy into the ambulance system in Kansas
City between years 1981 and 1988. The gradual reduction in subsidy appeared to be fulfilling
the system's promise. On the other hand, the City Auditor's report disclosed the price that
was being paid for that reduction. In at least half the city's councilmanic districts, agreed-
upon response time standards were not being met. The contractor had devised techniques for
obscuring response time performance. Fully one-half the ambulance personnel working in the
system had less than one year on the job. Seventy-eight percent of the personnel had less than
three years on the job. When the contract expired, there were no bidders for a new three-year
contract. Selected portions of that report are enclosed at Appendix B.
Figure #2 illustrates the levels of subsidy paid by the City of Kansas City during years 1981
through 1989. Note that after eight years of declining subsidy, the City increased the subsidy
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by nearly $2 millions in 1989. In other words, the City spent more to subsidize ambulance
service in 1989 than it did when the public utility model concept was adopted.
The Human Reaction to Technocracy -
In essence, the system design (which has been emulated by many of the subsequent regulated
monopoly ambulance systems) fails to adequately consider the human element. The
commitment to reducing or eliminating local government subsidy creates intense pressures to
hire emergency medical technicians (EMTs) and paramedics at the lowest possible levels of
compensation. Furthermore, peak load staffing and system status management are considered
by most EMTs and paramedics as stressful and undesirable working conditions. As indicated
by the employee turnover statistics in the pre-1989 Kansas City system, large numbers of these
personnel voted with their feet.
During 1991, the Emergency Care Information Center (ECIC) ~nducted research to measure
occupational stress related to peak load staffing and system status management, as well as
other factors. Using a standardized survey instrument, 468 emergency medical responders
from 10 different systems were assessed. The lowest possible stress score was 40 and the
highest was 200. The actual range of scores in this study was 54 to 171.
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When evaluated according to posting locations (where the emerzency units respond from and
return to), there were si&nificant differences. For example, the mean survey score for those
who respond from the same station and return to it after each response was 93.1 However, the
mean survey score for those who respond from a posting location and, once returning to
service proceed to another posting location and remain in the ambulance (system status
management) was 137.75.
When evaluated for stress according to shift configuration, penonne1 who are assigned to 24-
hour shifts had a mean survey score of 90.4. The mean score for penonne1 working fractional
shifts (as necasaory for peak load staffing) was 95.3. (See Appendix C)
The Cure -
The additional money that was pumped into the Kansas City ambulance system in 1989 by City
government was used to increase EMT and paramedic salaries, and to increase the number of
available ambulances (unit hours), thus reducing the frequency of post position changes for
ambulance crews (reducing the intensity of system status management).
Coincidentally. when it appeared there would be no potential bidders for the Kansas City
contract, the employees of the prior contractor formed an employee.owned cotpOration, using
their pension fund as collateral. The employee-owned company continues to hold the con~.
There can be no question that Kansas City now receives higher quality ambulance service than
it did prior to 1980. But the City also is paying more to subsidize it, and fees for service (paid
by patients and their third-party reimbursement sources) are considerably higher.
Threats to rel!:Ulated mOllODOlv ambulance service
As indicated, advocates of .privatized. ambulance service have aggressively marketed the
presumed economies and efficiencies of private ambulance service, and they have in many
places offered to provide service without local government subsidy, in exchange for an
exclusive operating area (or franchise).
In California, Counties are statutorily liable to provide emergency ambulance services to all
indigent residents and non-residents, no matter how or by whom provided. In the case of City
ofLomita v. County of Los Angeles (148 Cal.App.3d 671; 196 Cal. Rptr. 221 (1983)), the
Second District Court of Appeal ruled that such service is a charge on the County to be met
out of County funds.
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Tberefore, when a County contrICtS to award an exclusive operating area in exchange for an
aareement to serve without public subsidy, the County is, in --, bargaining away its
mpon,lbUity to pay for ambulance service to the indigent residents and non-residents.
Inevitably, the successful bidder must raise rates for ambulance transportation to cover the cost
of serving all patients, includina indigent persons. The prices paid for ambulance service by
customers (patients) and third-party reimbursement sources will be hiaher than if the County
was meeting its legal obligation to pay for service to indiaent persons.
In some cases, the increased rates are authorized by County Supervisors. If this occurs - that
is, an increase in the rate structure to cover the cost of services to indigent persons - the
feden1 aovemment inevitably will pay a portion of those higher fees. The Medicare
reimbursement profile will be affected and Medicare-eligible patients will be billed more than
if the County were paying its lawful share (the cost of emergency ambulance service for
indigent persons).
The bottom line is that, through this organizational and contractual device, some California
counties have tried to shift the financial burden of emergency ambulance service for indigent
persons to the federal government and other sources of payment. To the extent that the federal
aovemment (through Medicare, for example) pays more to reimburse for ambulance
transportation than it would if a County were paying for emergency ambulance service for
indigent persons, it (the federal government) may be a victim of false claims.
For example, lc"
(a) the emergency ambuIance fee-is mo, and;
(b) if 2o-percent of all persons transpOrted by emergency ambulance are indigent, and;
(c) if a 2o-percent rate increase (to S300) is authorized by the Board of Supervisors (as part
of granting an exclusive operating franchise in exchange for the County beiJig relieved
of the burden of paying for emergency ambulance service to indigent pelsons);
(d) any portion of the increase which is passed along to and reimbursed by Medicare or
Medi-Cal may constitute a false claim under federal statutes.
Title 31, United State Code Annotated, Section 3729 (31 USCA 3729 et seq) defines false
claims and provides for civil penalties ranging from 55,000 to S10,OOO, plus 3 times the
amount of damages which the Government sustains because of the act of (filing and receiving
payment on false c11lims). As it relates to ambulance service in several California counties,
this is a powerful legal remedy merely waiting for a knowledgeable plaintiff to bring an action
on behalf of the United States.
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A recent "Medicare Fraud Alert" (191-27) issued by tile Office of Inspector General,
Department of Hcal.th aDd Human SeMc:es, Washington, D.C. raises tile possibility that the
cost-shifting practice of some California counties may violate other federal statutes. That is,
the barpinina away of their fi.....M.1 obliption to indigent persons requiring emergency
ambulance service in exchange for the award of an exclusive operating area.
'lbe Fraud Alert bulletin reads as follows:
"Local municipalities from around the country are soliciting aDd entering into contracts
with private ambulance companies to provide emergency ambulance services to the
residents of such municipalities in lieu of operatin& their own municipal ambulance
service. Some contracts aIleaedly require the private ambulance companies to pay the
municipalities a set fee per patient referred, while other municipalities demand a flat
monetary amount to secure tile exclusive right to handle all emergency calls for
ambulance services. In some cases, tile ambulance companies offering the highest
monetary amount are granted the contracts.
"Any municipality requesting money from an ambulance company to award such a
contract and/or any ambulance company providing a fee to the municipality for
referrals of patients may be in violation of tile Medicare aDd Medicaid anti-kickback
statute, 42 United States Code, section 1320a-7b(b).
"Carriers, intermediaries, and field offices should be aware that these contracts may
violate the anti-kickback statute. "
While the Fraud Alert bulletin refers specifically to municipalities, there is nothing in tile
statutes that would make the law applicable only to municipalities and not other entities of
local government (such as counties). Also, while tile bulletin refers to municipalities
"requesting money from an ambulance company," there is nothing to suggest that other
ttansfers of value would not also be prohibited. In fact, Section 1320a-7b(b)(2) of the statute
prohibits any knowing and willful offer or payment of lUX remuneration, directly gr indirectlv,
overtly or covertly, in cash or in kind (emphasis added).
For example, the County of Santa Barbara recently bas been negotiating with a private
ambulance company for renewal of tile contractual right to serve an exclusive operating area.
'lbe private company bas promised to reduce and then eliminate tile County's subsidy to the
company. When County officials discussed the potential for a competitive bid process, the
ambulance company upped the ante by offering to purchase and deed to tile County
communications equipment worth $250,000.
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Would this trIIISICtion fall within the prohibitions of the above-cited federal statute? Would
the gift of ~ve communications equipment constitute an in-kind remUllerltion to induce
the County to order or arrange for a service for which payments may be made in put under
the federal Med;a1re program? If so, it probably is a felony violation of the anti-kickback
statute. Violation constitutes a felony and, upon conviction thereof, offenders shall be fined
not more than $15,000 or imprisoned for not more than five years, or both.
Only recently have these questions been raised, mostly in reaction to Fraud Alert bulletin 191-
27. Until tbey have been resolved through litigation, it would appear that the cost-shifting
stratqies of several California counties (and their respeaive local EMS agencies) are at risk.
In San Bemardino County, both public and private ambulance providers are paid a monthly
amount by the County to compensate those providers for emergency ambulance service to
indigent persons. For example, the amount paid to Courtesy Servicesis $11,860 per month.
Whether that payment arrangement constitutes a violation of either the false claims act or the
anti-kickback statute would depend on whether the amount represents the actual cost of
providing emergency ambulance service to indigent persons. If it is an ubitrary figure, or a
compromise which is unrelated to actual costs, there may be violations of the federal statutes
but to a lesser extent than if no payment were made.
As indicated in the foregoing materials, delivery of prehospital emergency medical services
requires a variety of resources, often delivered by more than one agency. For example, even
where paramedics are employed by a private ambulance company, calls for assistance will be
processed by 9-1-1 telecommunicators employed by a public agency. Also, tint-responder
services most likely will be provided by fire department engine companies.
There is no ""'.11lple of a r.nmnletelv DriWti7M medical aid remonse !\,.vstem servin!! a city or
county lII\vwhere in the U.S. In every case, the system is a mix of public and private
resources. Thus, the question is: what is the ideal mix?
CITY_o1>>mlATFin PARAMEDIC ~ERVICE WITH PRIVATE
AMBtJLANCE TRANSPORT
Where the combination of city-operated paramedic service and private ambulance transport is
employed, the mix of public and private resources differs from community to community.
Therefore, the two most common profiles will be praented for comparative purposes. This
portion of the report is intended to be modular, allowing study of each profile separately.
FeatureS that are common to both Profile A and Profile B will be fully described (repeated) in
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each. However, subtle differences may exist that require careful reading of both profile
clescriptions.
OJ1era1ional Profile A
In this profile, calls for assistance are received by a 9-1-1 tdecommunicator at the fire
department and then relayed to the appropriate fire stations and the private ambulance
company almost simultaneously. The nearest engine company, staffed with firefi&hterlEMTs,
is dispatched as the first-responder. Also, the nearest fire department paramedic rescue unit,
staffed with firefighterl paramedics, is dispatched as the advanced life support (ALS) unit.
The private ambulance company responds with an ambulance vehicle staffed with basic life
support (BLS) EMT personnel.
Profile A is. a reflection of Southern California history and the lobbying activity of the private
ambulance industry. When the Los Angeles County Fire Department became California's first .
paramedic-level rescue service in 1970, it was discouraged by the County Board of Supervisors
from competing with private ambulance companies. Thus, the department continued to use
non-transporting utility vehicles as its paramedic rescue units (-non-transporting- means that
they are not able to transpon patients). Private ambulances, staffed by basic life support
EMTs have always provided transpon services in that system.
The Los Angeles County Fire Department's paramedic service was implemented without hiring
any additional personnel. 'Ibis was achieved by cross-training firefighters and using them in a
dual role (as firefighter-paramedics). The fire department's non-transporting vehicles were
considered imponant to the concept of using cross-trainedldual-role firefighter-paramedics. It
was felt that the paramedics would be more available for fire suppression assignments if they
used non-transporting vehicles than if they worked on ambulances.
At the time (three years before the first Arab oil embargo and eight years before J\oposition
13), there was little reason for public agencies to be creative about fee generation. Fire
departments at that time tended to have little interest in providing ambulance service.
As a large department and a leader in the paramedic field, the L.A. County department
unwittingly influenced many other agencies to configure their services around non-transporting
rescue units. 'Ibis influence was reinforced by the portrayal of L.A. County's paramedic
rescue service in a popular TV series.
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A. Vehit!I~,-
first-~dM!l use fire encines (triple-c:ombination pumper apparatus) to respond from their
stations or field activities to medical emergencies. Though these vehicles are large and heavy,
"-'I""'" primarily for fire protection, they are relatively quick and durable. On emergency
medical calls, their function is to get trained basic life support personnel to the scene u
quickly u possible. Keeping the encine company crew together is essential to both their
emergency medical and their fire protection roles. These various requilements can be met
with the hirest possible levels of efficiency and economy by using the fire engine u the first-
response vehicle.
A.............. life ~ (A I ~) naramedics use non-transporting utility vehicles (the Los Angeles
County confi&uration, u discussed above). These vehicles are built on light truck chusis, and
they are quick and maneuverable. The cabinetry on the utility body is sufficient to contain all
needed ALS equipment, as well as ancillary fire protection equipment (such as smoke ejectors,
breathing apparatus, spare air bottles, etc.).
Ambulance EMTs (and paramedics) use either modular or van-type ambulance vehicles.
Because there are less ambulance vehicles deployed in the community than there are fire
engine companies, and because some of those ambulances are alsO used for non-emergency
medical transportation, the system is dependent on first responders to arrive on scene firstan~
initiate basic life support. Still, due to the unpredictability of emergency events, there may be
chance occurrences where an ambulance will arrive at the scene of the emergency first.
'P."triotion and heavy rescue services, when needed, are provided by firefighters assigned to
ladder trucks and/or heavy rescue vehicles. These services are provided on a special call basis
to gain access to and remove victims of building collapses, industrial accidents, and
transportation accidents where victims are trapped in the wreckage.
B. F..q)1inment-
Standard equipment required for the service delivery system will not vary greatly with the
different profiles. Equipment requilements are dictated in large part by external standards
(such as the American College of Surgeons Minimum Equipment List for Ambulances), and
by local protocols and/or the regulations of the local EMS agency, such as Inland Counties
Emergency Medical Agency (ICEMA).
An important issue might be the policies and practices of both public and private agencies
regarding the maintenance and repair of equipment, including preventive maintenance, as well
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as the frequency with which equipment is rep1aald, It may be assumed that this would be an
iDdicaror of the quality and reliability of emergency medical care clelivered by the system.
However, it is beyond the scope of this study.
C. EMS Penonnel -
1. Trainin, - Minimum training, certification and recertification SlaDdards for EMS
penonnel are set by regulation (Title 22 of the California Code of Regulations). These
are statewide standards and there is no uwununity for file clepartmeDts or ambulance
companies to use penonnel who do not meet those standards. In addition to the
statewide standards, paramedic personnel may be subject to additional waccreditationw
requirements which are set and applied by the respective local EMS agency (e.g.
lCEMA). The intent of the accreditation process is to make certain that paramedics
working in the respective county or region are familiar with local medical control
procedures and protocols.
2. StaffinJ Levels - First-remonder units (file engine companies) generally are staffed
with a minimum of three personnel. To serve effectively as a first-response unit, at
least two of those persons should be trained to provide basic life support. If an
automatic external defibrillation (AED) program bas been implemented, at least one
AED-certified person should be on duty with each first responder unit at all times.
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Ad""n......'life !111IIlOl1 (AT ~C;) units must be staffed with a minimum of two personnel
and, depending on local protocol, one or two of those persons must be certified and
accredited at the paramedic (EMT~c) level.
Ambulance units must be staffed with a minimum of two personnel, both of whom
must be uained and certified at the basic life support emergency medical technician
(EMT-I) leve1 as a minimum. There is no statutory requirement for ambulance
personne1 to be trained at the higher paramedic level. Therefore, unless municipal or
County ordinance or contract with the ambulance service calls for this level of training
for ambulance personnel, the ambulance provider is free to staff with lesser-uained
(and less costly) basic life support personnel.
3. ('.f!rtification - As reported above (item C. 1.), c:enification requirements for EMS
penonnel are set by state regulation, and accreditation requirements for paramedic
personnel are set by local EMS agencies such as lCEMA.
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4. Shift Schll!dules - For maintaining a minimum number of on-duty personnel around-the-
clock, year-round, the most efficient and inexpensive staffing arrangement employs
three platoons or "shifts" of equal numbers of personnel, with each platoon on duty for
24 hours at a time. As utilized in most West Coast fire departments, this aenenllY
results in a S6-hour workweek. Even following the April IS, 1986 application of the
Fair Labor Standards Act (FLSA) to public employees, wherein municipal employers
are obligl'tM to pay time-and-a-half overtime for all hours worbd beyond S3 per
week, this shift schedule remains the least expensive method for maintaining constant
staffing.
Private ambulance services, by contrast, have been experimenting with "peak load
staffing," whereby their personnel are assigned to shifts of eight, tal or twelve hours,
with the possibility of a few crews assigned to 24-hour shifts, and even some hybrid
shifts (e.g. a six-hour shift on Friday and Saturday nights to respond to peak demand).
Peak load staffing (arranging for an appropriate number of on-duty personnel based on
estimates of demand for ambulance service, and sending personnel home when it is
predicted that demand will decline) makes sense for a single-role organization, such u
a private ambulance company.
In San Bernardino and most U.S. cities, however, varying degrees of EMS
responsibility are handled by firefighters who have been cross-trained and liven a dual
role. While it might be less costly if those personnel could be usigned on a peak load
staffing buis, their fire protection responsibilities make the concept unralistic. Fire
protection and disaster situations are both WIJlIedictable and labor intensive.
Furthermore, there is considerable risk of liability if unpredicted multiple calls, or a
multiple cuualty incident, occurs during a period of skeleton staffing (in spite of
computer predictions).
Still, the economy and effic:ienc:y of using one group of employees for two distinct
roles (u in cross-trained, dual-role fireIEMS systems) euily overcomes the apparent
inefficiencies of constant staffing, when compllJeCl to peak load staffing. At page 83 of
this report, the concept of "marginal costs" is presented u a meuure of the true cost of
fire department EMS.
In essence, if a fire department performs Imd1 EMS iIIId fire protection functions with a
workforce of 140, and if it is clear that the fire p.utecUon function alone requires a
workforce of 130, then the true cost for the fire department to provide emergency
medical services is the marginal cost. That is, the cost of 10 cross-trained firefighters,
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plus those salary and benefit costs which relate to EMS bonuses or incentives and
EMS-related training, and all maintenance and operations exp<""1S diIectly attributable
to the EMS function.
D. ~sion of Pi~ld Personnel -
F;~d S"nervisors:
More than 20 years' experience in California bas cIemonstratal that the first-line fire
service supervisor (the fire company officer, usually known u wCaptainW) is the most
lo&ical and effective field supervisor of cross-trainedIdual-ro1e firefi&htcrlEMS
personnel. This penon bas the palest upponunity for full-time observation of and
contact with firefighters who also function u emergency medical tecImicians (EMTs)
or paramedics.
In most private ambulance companies, crews generally operate without field
supervision from a representative of their company. In larger private services (e.g. ten
or more on-duty units), it is common for a roving field supervisor to be usigned to
each shift. However, in that these supervisors generally have only sporadic or episodic
contact with crews, there is limited uflportunity to have luting impact on their
performance or attitudes.
Two other related problems plague the private ambulanc:e industry. Personnel turnover
commonly exceeds 30- to 5O-percent per year, making it difficult for any form of
organizational development to be effective. Further, this turnoVer severely limits the
availability of high calibre EMTs or paramedics who can be promoted to field
supervisor positions.
Ideally, a field supervisor - either in the fire service or a private company - will have
been trained for the position and will be well grounded in the culture and management
philosophies of the organization. Also, the field supervisor should be selected for the
position on the buis of competitive examination or process - to assure that the best
qualified candidate is selected.
Again, the private sector is disadvantaged in that wrevolving doorw employment
practices in most ambulanc:e companies result in a small to non-existent pool of high
calibre candic:lllU!s for field supervisor positions.
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Adminimative S"nf!r\rirnrs:
In most fire department EMS systems, the tint-line supervisor (fire company officer)
functions both u the field supervisor and the tint level of administrative supervision.
Duties include .e{lOrtin& and recording functions, U well u supply and maintenance,
and employee performance evaluation.
In many fire clepartments, one or more EMS c:oordiDator positions have been
established - usually u a staff function. Usually, these are uniform positions (with
rank ranainI from firefi&hter/paramedic to Deputy Cbief). A recent trend in California
is to employ a nurse educator in this position with responmhility for internal and
external coordination, continuing medical education, and quality assurance
(unprovement) functions.
In private companies, depending on size and the level of service rendered,
administrative supervision may be handled by the company's owner, a manager, or
some other qualified person on the office staff. Most of the larger private ambulance
companies in California have employed nurse educators (or similarly qualified persons)
to ped'orm internal and external coordination, continuing medical education, and
quality assurance (improvement) functions.
E. Di?tl'h , ""'"tions:
As discussed at page 13 of this report, private ambulance sector innovations include
wsystem status managementW (SSM). Using this practice, some private ambulance
services deploy ambulance units at numerous wpostsW (street comers, convenience store
parking lots, freeway on-ramps) in specific locations throughout the community in
anticipation that that location will be within the response time range of the next call for
an emergency ambulance.
Most private services wbich use SSM apply the concept to some units, while others are
dilp"t('.be6 from fixed locations. However employed, SSM is unpopular with EMfs
and paramedics and is believed to contribute to bigh rates of personnel turnover. The
resulting occupational stress is measurable and is .eported at page 15 of this report.
Thus far, no fire departments have adopted SSM for the deployment of their EMS
units. Those units are dispatched from fire stations, or by radio when on field
assignments or when returning from prior calls. The selection of stations to be used u
displtCh locations for EMS units is dictated by time and distance factors, for the most
part.
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F. DoeulNl!fttslltinn:
Documentation of all aspects of medical emergencies is dic:tated by the policies and
910cedums of the loc:al EMS lIIency (ICEMA). A copy of tbat lIIency's optical-scan
rqJOrt may be found at Appendix D, and a discussion of provider resistanc:c to ICEMA
.~ requirements is presented at pile 101 of this n:port.
G.nIlAUty Auunmce:
Section 100166 of Title 22, Division 9, California Code ofReplations, which became
effective January I, 1992, requires local EMS agencies (such as ICEMA) to establish a
-system-wide quality assurance program as defined in Section 100141.2.-
Section 100141.2 reads as follows:
-Quality assurance- or -QA - means a method of evaluation of services
provided, which includes defined standards, evaluation methocIo1OJy(1es) and
utilization of evaluation results for continued system improvement. Such
methods may include, but not be limited to, a written plan describing the
program objectives, organization, scope and mechanisms for overseeing the
effectiveness of the program. -
It is significant that no funding has been provided to assisi ICEMA or other local EMS
lIIencies in fulfilling this requirement. Furthermore, beyond the above definition
(~tion 100141.2), there is no agreement as to what constitutes a quality assurance
prograIn, although it is generally aareed that Section 100141.2 does not provide an
adequate 'definition.
Indeed, traditional -quality assurmce- processes seem to be outdated in view of
national health care developments. -Quality improvement- has become the preferred
and more descriptive term (see Appendix E for a comparison of quality assurance and
quality improvement). A major force behind this change in terminology and approach
is the Harvard Community Healthplan, National Demonstration Project on Quality
Improvement in Health Care.
The most influential book on the topic at present is Curin, Health ('".... New Sh'llt8ies
for nlllllity Inwmvement, by Donald M. Berwick, M.D. Also, the 1992 revision of
the Accreditation Manual for Hospitals, published by the Joint Commission on the
Accreditation of Health care Organizations, initiates a tranmtiOll (from -quality
assurance-) to standards that emphasize continuous quality improvement.
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Recently, a pilot project ('lbe California EMS Quality Improvement Project) was
funded by the State EMS Authority and is intended to define and design a model EMS
quality improvement program for EMS systems. 'Ibis project will not be complete
until 1993.
In the meantime, inconsistency and confusion reigns. Some local EMS qencies view
quality assurance principally as error catchin& and discipline. Others perceive it as a
coll-hnrative process that tries to Iddress quality issues before they become problems.
Most base bospitals (medical command ticilities for puamedics) include prehospital
care incidents in the bospital QA plogram, with widely varying approaches and results.
Some providers, such as the Long Beach Fire Department, have employed nurse
educarors to implement an in-house, provider-based quality assumnce (improvement)
program.
In California, at the present time, development and implementation of a provider-based
quality assurance (improvement) program should be in consultation with the local EMS
qenc:y. Since the local EMS agency, by regulation, bas the responsibility to establish
a wsystem_widew program. expensive and non-productive c:onf1ic:t could result from
implementation of an independent, provider-based quality assurance (improvement)
program.
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n-r..tional Profile B
In this profile, wbicll is presently used by the City of San Bernardino, caI1s for ..a-nee are
received by a 9-1-1 tdecommunicator at the fire department and are then relayed to the
"WiOpriate fire station(s) and the private ambulanc:e company almost simultaneously.
Depending on whetbcr the nearest fire engine company is staffed u a first-responder unit or a
paramedic engine, one or two engines will be dispatcl1ed to the medical emeraency.
First-responder units (engine companies) are staffed with cross-trained firefighter!Bmer&ency
Medical Tech"ici'l\s (EMTs) and their purpose is to provide buic life support to the victim of
a medical emergency or accident u quickly u possible. A smaller number of engine
companies are staffed and equipped u paramedic engines. At least two persons assigned to
each of those companies at all times are cross-trained firefighter/paramedics.
If the medical emergency occurs in the district of a first-responder engine, that en&ine and the
nearest paramedic engine respond simultaneously. The first-response engine will arrive at the
scene within three to five minutes, on the average. The paramedic engine will arrive at the
scene in six minutes or less. If the medical emergency occurs in the district of a paramedic
engine, that unit will respond alone and will arrive at the scene within three to five minutes.
The private ambulance company responds with an ambulance vehicle staffed with one buic
life support EMT and one paramedic. By direction of the fire department dispatcher, the
ambulance responds "Code 2" (travel direct1y to the scene of the emergency but at normal
traffic speeds, and observing all traffic laws). In all but a few parts of the city, it will arrive at
the scene in ten minutes or less. In the event first-response or paramedic personnel deem it
n~"ry, they can request by radio that the ambulance upgrade its response to "Code 3" (red-
lights-and-siren).
Profile B, u in Profile A, is a reflection of Southern California history and the lobbying
activity of the private ambulanc:e industry. However, it also reflects the innovation and
evolution of fire departments involved in EMS activity. While the fire department began its
program in 1975 with non-transporUna utility vehicles u its paramedic rescue units (the Los
AnJdes County model), it hu since adopted the paramedic enaine concept.
The San Bernardino Fire Department's paramedic service wu implemented without hiring any
additional per5OMel. This wu achieved by cross-training firefighters and using them in a dual
role (u firefighter-paramedics). The fire department's non-transporting vehicles were
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considered important to the conc:ept of using cross-trainecIIdual-role firefiahter-paramedics. It
was felt that the paramedics would be more aYlilable for fire suppression usiplments if they
used non-transportina vehicles than if they worbd on ambulances. At the time, most fire
clepartments bad little interest in providing ambulance service or producing non-tax based
revenues.
A. Vehicles-
Fint-TP~Mn use fire engines (triple-combination pumper apparatus) to respond from their
stations or field activities to medical emergencies. Though tbeae vehicles lie IarJe and heavy,
designed primarily for fire protection, they lie relatively quick and dmable. On emeqency
medical calls, their function is to get trained basic life support personnel and equipment to the
scene as quickly as possible. Keeping the engine c:ompIIIy crew together is essential to both
their emergency medical and their fire protection roles. These various requirements can be
met with the highest possible levels of efficiency and economy by using the fire engine as the
first-response vehicle.
Ad""""",, life sll1JllOIt (ALS) paramedics also lie assigned to triple-c:ombination fire engines,
known as -paramedic engines. - These vehicles lie identical in design and function to the first-
response engines, except the cabinets on the paramedic engines lie built to contain all needed
ALS equipment, as well as fire protection equipment.
Ambulance EMTs (and naramedics) use van-type ambulance vehicles. Because there lie less
ambulance vehicles deployed in the community than there lie fire engine companies, and
because some of those ambulances lie also used for non-emergency medical transportation, the
system is dependent on first-responders to arrive on scene first and initiate basic life support.
Still, due to the unpredictability of emergency events, there may be chance occunences where
an ambulance will arrive at the scene of the emergency first.
Extrication and heavy rescue services, when needed, lie provided by firefighters usipled to
ladder trucks and/or heavy rescue vehicles. These services lie provided on a special call basis
to gain lICCesS to and remove victims of building collapses, industrial accidents, and
transportation accidents where victims lie trapped in the wreckage.
B. EquiJlment-
StandaJd equipment required for the service delivery system will not vary greatly with the
different profiles. Equipment requirements lie dictated in large pan by external standards
(such as the American College of Surgeons Minimum Equipment List for Ambulances), and
29
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by local protocols and/or the rqulations of the local EMS agency, such as Inland Counties
Emergency Medical Agency (laMA).
An important issue might be the policies and practices of both public and private agencies
reprdina the maintawlCe and repair of equipment, including preventive maintenance, as well
as the frequency with which equipment is replaced. It may be assumed that this would be an
indll'.llltnt of the quality and reliability of emergency medical CaJe cIe1ivered by the system.
However, it is beyond the scope of this study.
C. EMS Penonne1 -
1. Tnlininl! _ Minimum training, certification and recertification standards for EMS
personne1lR set by regulation (Title 22 of the California Code of Rep1ations. These
IR statewide standards and there is no OJ>1JOrtunity for fire cIepartmeIIts or ambulance
companies to use personnel who do not meet those standards. In addition to the
statewide standards, paramedic personnel may be subject to additional waccreditationw
requirements which IR set and applied by the cespcctive local EMS agency (e.g.
laMA). The intent of the accreditation jbocess is to make certain that paramedics
working in the cespcctive county or region IR familiar with local medical control
procedures and protocols.
2. Staffinl! Levels - FJrst-~der units (fire engine companies) generally IR staffed
with a lnuumum of three personnel. To serve effectively as a first-response unit, at
least two'of those penons should be trained to provide basic life support. If an
automatic external defibrillation (AED) program has been implemented, at least one
AED-certified person should be 011 duty with each first-responder unit at all times.
b14....nl'f'lllife mnoort (AI-C:) units (paramedic engines) IR be staffed with a minimum
of four personnel, two of whom IR certified and accredited at the paramedic (EMT-
Paramedic) level.
AmhllllUlce units must be staffed with a minimum of two personnel, both of whom
must be trained and c:ertified at the basic life support emergency mec:l1cal technician
(EMT-I) level as a minimum. There is no statutory requirement for ambulance
. personnel to be trained at the higher paramedic level. Therefore, unless municipal or
County ordinance or contract with the ambulance service calls for this level of training
for ambulance personnel, the ambulance provider is free to staff with lesser-trained
(and less costly) basic life support personnel.
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3. r.Mtifit".llltinn - As reported above (item C. 1.), c:ertifu:aIion requirements for EMS
pe.rsonne1 arc set by Slate rqu1ation, and accreditalion requirements for paramedic:
personnel arc set by local EMS agencies such as lCEMA.
4. ~hift SclII!Jd1l1s - For maintaining a minimum number of on-duty peraonne1 around-the-
clock, year-round, the most efficient and inexpensive staffing U'IIIIpIIICIlt employs
three platoons or "shifts" of equal numbers ofpersora~, with each platoon on duty for
24 hours at a time. As utilized in most West Coast fire depIrtmeIlts, this pnera11y
results in a 56-hour workweek. Even following the April 15, 1986 application of the
Fair Labor Standards Act (FlSA) to public employees, wherdn municipal employers
arc obliJl'tM to pay time-and-a-half overtime for all hours worked beyond 53 per
week. this sbift schedule remains the least cqICIlSive method for maintaining constant
staffing.
Private ambulanc:c services, by contrast, have been experimenting with "peak load
staffing," whereby their personnel arc assigned to shifts of ci&ht, ten or twelve hours,
with the possibility of a few CleWS assigned to 24-hour shifts, and even some hybrid
shifts (e.g. a six-hour shift on Friday and Saturday nights to respond to peak demand).
Peak load staffing (arranging for an appropriate number of on-duty personnel based on
estimates of demand for ambulance service, and sending personnel home when it is
predicted that demand will decline) makes sense for a single-role cqanization, such as
a private ambulance company.
In San Bernardino and most U.S. cities, however, varying cIcgrccs of EMS
responsibility arc handled by fudightcrs who have been cross-trained and given a dual
role. While it might be less costly if those cross-trained, dual-role personnel could be
assigned on a peak load staffing basis, their fire protection responsibilities make the
concept unrealistic. File protection and disaster situations arc both unpredictable and
labor intensive. Furthermore, there is considerable risk of liability if unprcdicted
multiple calls, or a multiple casualty incident, occurs during a period of skeleton
staffing (in spite of computer predictions).
Still, the economy and effic:icnc:y of using one group of employees for two distinct
roles (as in cross-trained, dual-role fiIcIEMS systems) easily overcomes the apparent
incfficienc:ics of constant staffing, when "()alparcd to peak 10ld staffing. At pile 83 of
this report, the conc:cpt of "marginal costs" is pm-tell as a measure of the trUe cost of
fire department EMS.
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In essence, if a file department performs Imd1 EMS ami file protection functions with a
workforce of 140, and if it is clear that the file protection function alone requires a
workforce of 130, then the true cost for the file department to provide emergency
medical services is the marginal cost. That is, the cost of 10 cross-trained firefighters,
plus those salary and benefit costs which rdate to EMS bonuses or incentives and
EMS-related training, and all maintenance and operations expenses cIirectlyattributable
to the EMS function.
D. Sunervimnn of Fl~ld Personnel -
F;~d Sqpervisors:
More than 20 years' experience in California has cIcmonstrated that the first-line file
service supervisor (the file company officer, usually known as "CapIain") is the most
logical and effective field supervisor of cross-trained, dual-role fuefighterlEMS
personnel. This person has the greatest upportunity for full-time observation of and
contact with firefighters who also function as emergency medical technicians (EMTs)
or paramedics.
In most private ambulance companies, crews generally operate without field
supervision from a representative of their company. In larger private services (e.g. ten
or more on-duty units), it is common for a roving field supervisor to be assiJDCd to
each shift. However, in that these supervisors generally have only sporadic or episodic
contact with crews, there is limited opportunity to have lasting impact on their
performance or attitudes.
Two other related problems plague the private ambulance industry. Personnel turnover
commonly exceeds 30- to SO-percent per year, making it difficult for any form of
organizational development to be effective. Further, this turnover severely limits the
availability of high calibre EMTs or paramedics who can be promoted to field
supervisor positions.
Ideally, a field supervisor - either in the file service or a private company - will have
been trained for the position and will be well grounded in the culture and management
philosophies of the organization. Also, the field supervisor should be selected for the
position on the basis of competitive examination or ptoc:ess - to assure that the best
qualified candidate is selected.
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Apin, the private sector is disadvantapd in that "revolving door" employment
practices in most ambulance compIIIIi~ JeSUlt in a small to JlOIl-aistent pool of hi&h
c:alibrc ()lIIVIi""~ for field supervisor positions.
Ad . .dfttive S .
"'tftt tml!l"Vlsors:
In most fire department EMS systems, the first-line supervisor (fire company officer)
functions both u the field supervisor and the first level of "'minimative supervision.
Duties include .~ and rec:mdin& functions, u well u supply and maintenance,
and employee performance evaluation.
In IIIIIlY fire departments, one or more EMS COClIdinator positiaas have been
established - usually u a staff function. Usually, thae me uniform positiaas (with
rank ranging from firefighter/paral"""'i~ to Deputy Chief). A recent trend in CaIifomia
is to employ a nurse educator in this position with respoosibility for internal and
external coordination, continuing mediC'll education, and quality usurance
(unprovement) functions.
In private companies, depending on size and the level of service rencIeml,
administrative supervision may be handled by the lOOIIIpany's owner, a manacer, or
some other qualified person on the office staff. Most of the Jar&er private ambulance
companies in California have employed nurse educators (or similarly qualified per5O!Is)
to perform internal and external coordination, continuing medit:al education, and
quality usurance (improvement) functions.
E. pi..tch T """tions:
As discussed at page 13 of.this report, private ambulance sector innovations include
"system status management" (SSM). Using this practice, some private ambulance
services deploy ambulance units at numerous "posts" (street comers, convenience store
parking lots, fIeeway on-ramps) in specific locations throughout the community in
anticipation that that location will be within the cesponse time range of the next call for
an emergency ambulance.
Most private services which use SSM apply the ~ to some units, while others me
dispatched from fixed locatioos. However employed, SSM is unpopular with EMTs
and paramedics and is belieYed to contribute to hi&h rates of personnel tunlOYeI'. The
JeSUlting occupational stresS is measurable and is teported at page IS of this report.
Thus far, no fire departments have adopted SSM for the deployment of their EMS
units. 'Ihose units me dispatched from fire stations, or by radio when on field
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usipments or wben returniDc from prior calls. Tbe srlection of _ons to be used as
~ons for EMS units is dictated by time and cIistanc:e factors, for the most part.
F. Tlntot._b1tinn:
Documentation of all aspects of medical emeqenc:ics is di~tlI!d by the policies and
procedmes of the local EMS apncy (ICEMA). A copy of that lI&ency's optical-scan
report may be found at Appendix D, and a dilC'lssion of provider resistance to ICEMA
.~iti4g requirements is presented at page 101 of this report.
G.nn.U~ AlItmUlce:
Section 100166 of TItle 22, Division 9, California Code ofRep1ations, which became
effective January I, 1992, requiJes local EMS apnc:ies (such as ICBMA) to establish a
'system-wide quality assurance program as defined in Section 100141.2.'
Section 100141.2 reads as follows:
'Quality assurance" or "QA" means a method of evaluation of services
provided, which includes defined standards, evaluation methodology(ies) and
utilization of evaluation raults for continued system improvement Such
methods may include, but not be limited to, a written plan describing the
J'&O&fam objectives, organization, scope and mechanisms for overseeing the
effectiveness of the program. "
~.
It is si&l\ificant that no funding has been provided to assist ICEMA or other local EMS
lI&encies in.fu1filling this requirement. Furthermore, beyond the above definition
(Section 100141.2), theri is no agreement as to what constitutes a quality assurance
j).ogram although it is generally agreed that Section 100141.2 does not provide an
adequate definition.
Indeed, traditional "quality assurance" proce"M'" seem to be outdated in view of
national health care cIeve1opments. 'Quality improvement' has become the preferred
and IIlOIe cIAw~ye term (see Appendix E for a comparison of quality assurance and
quality improvement). A major force behind this change in terminology and approach
is the Harvard Community Hea1thplan, National Demonstration Project on Quality
Improvement in Health Care.
Tbe most influential book on the topic at ptcsrnt is CunnI Health ('.II.... New ~1Tll~es
for q.wity T~ent, by Donald M. Berwick, M.D. Also, the 1992 revision of
the Accreditation Manual for Hospitals, published by the Joint Commission on the
34
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Accreditation of Hea1thcare Organizations, initiates a transition (from "quality
assurance") to standards that emphasize continuous quality improvement.
Recendy, a pilot project (The California EMS Quality Improvement Project) wu
funded by the Slate EMS Authority and is intended to define and design a model EMS
quality improvement program for EMS systems. 'Ibis project will not be complete
until 1993 .
In the meantime, inconsistency and confusion reigns. Some local EMS I&enc:ies view
quality assurance principally as enor catchina and disciplille. Others pe.n:eive it as a
collllhnrative process that tries to address quality issues before they become problems.
Most base hospitals (medical command facilities for paramedics) include prehospital
care incidents in the hospital QA program, with widely varyina appnlIChes and results.
Some providers, such as the Lona Beach Fire Department, have employed nune
educators to implement an in-house, provider-based quality assurance (improvement)
program.
In California, at the present time, development and implementation of a provider-based
quality assurance (improvement) program should be in consultation with the local EMS
agency. Since the local EMS agency, by re&ulation, has the responS1"bility to establish
a "system-wide" proaram, expensive and non-productive conflict could result from
implementation of an independent, provider-based quality assurance (improvement)
proaram.
ClTY-OPERATP.n PARAMEDIC AND AMBULANCE TRANSPORT SERVICES
Where cities elect to operate their own paramedic and ambulance transport services, there are
several configurations or profiles which may be adopted. Therefore, several typical profiles
will be presented for comparative purposes. 'Ibis portion of the report is intended to be
modular, allowing study of each profile separately. Features that are common to each of the
following profiles will be fully described (repeated) in each. However, subde differences may
exist that require careful reading of all profile descriptions.
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Onerational Profile C
In this profile, calls for emergency J1Iet!ical-w-nce are received by a 9-1-1
tdecommunicator at the fire department dispatcll center. Assumin& that an telec:ommunicators
have been traiDed u emergency medil'.lll di~tcbers (EMD), the process includes interroptiOll
of callen, usiD& a structured format based 011 medically approved protocols. An EMD then
Ie1a15 the "'W'U)UWe information to the fire stalion(s) bousing the nearest engine complJly and
the nearest available two-piece engine-and-ambulance company.
When the nearest units(s) Ware out of its/their station(s) and available in its/their district(s),
the call for -ni-nee is Ie1ayed by radio. Depending on whether the nearest fire company is
staffed u a first-responder unit or is a two-piece engine-and-ambulanc:e company, one or two
companies are dispatched to the medical emeraency. While this is occurring, if applupliate,
an EMD keeps the caller on the phone line and instructs the caller on first aid steps, CPR or
other vi1al actions while emergency units are mustering and responding.
First-responder units (engine companies) are staffed with cross-trained firet'ighterlEmergency
Medical Technicians (EMfs) and their purpose is to provide basic life support to the victim of
a medical emergency or accident as quickly as possible. A smaller number of companies are
two-piece companies, consisting of a fire pumper (engine) and an ambulance. Each two-piece
company is staffed by four persons, including two firefighter/paramedics per ambulance.
Trained EMDs, using skilled interrogation techniques and physician-approved protocols, are
able to determine the relative urgency of a reported medical emeraency. Using this
information, EMDs may dispatcl1 only the first-responder unit Code 3 (red-lights-ancl-siren).
In such cases, the engine-and-ambulance company would be dispatched Code 2 (non-red-
lights-and-siren, travelling at normal speeds, observing an traffic laws). However, at any
time, the EMD (who remains in contact with the caller until emergency units arrive on scene)
or the company officer on the first-responder unit may upgrade the response of the engine-and-
ambulance company to Code 3.
H the medical emeraency occurs in the district of a first-responder engine, that engine and the
nearest two-piece engine-and-ambulance company are cIispatched simultaneously. H
responding Code 3, the first-response engine will arrive at the scene within three to five
minutes, on the average. The engine-and-ambulance company, if responding Code 3, will
arrive at the scene in six minutes or less. H the medical emergency occurs in the district of an
engine-and-ambulance company, that company (both the engine and the ambulance) will
respond alone and, if responding Code 3, will arrive at the scene within three to five minutes.
36
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Tbe file department's ambulance system is tlH;g1Ied primarily for emergency transportation.
Theidore, if either tbe first-responders or the ~i", confirm that the patient does not
requiIe cmeqency transportation, they have tbe option of c:aIlin& for a unit from tbe local
private ami",I.""", company. Tbe private ambulances are cIispatched Code 2 (at normal traffic
speeds. IIId observing all traffic laws). In all but a few parts of the city, it will arrive at the
scene in fifteen minutes or less from the time of call.
In this Profile, tbe private ambulance company also serves as a back-up in the event no fire
department ambulances are readily available. Also, to provide additional back-up ambulance
capacity, unmanned reserve ambulances are located at several fire stations in the city. On a
moment's notice, an engine company crew can be JelIe.npH!d to the reserve ambulance bued at
its station.
Profile C can be implemented by the file department without hiring any additional personnel.
This is achieved by using cross-trained firefighters in a dual role and creatin& a sufficient
number of two-piece engine-and-ambulance companies to meet the city's emergency
ambulance needs.
A. Vehicles-
First-resoonders use fire engines (triple-combination pumper apparatus) to respond from their
stations or field activities to medical emergencies. Though these vehicles are lar&e IIId Iavy,
designed primarily for fire protection, they are relatively quick IIId durable. On emergency
medical calls, their function is to get trained buic life support personnel and equipment to the
scene as quickly as possible. Keeping the engine company crew together is essential to both
their emergency medical and their file protection roles. Tbese various requirements can be
met with the highest possible levels of efficiency and economy by using the fire engine as the
first-response vehicle.
Advan...... life !U1JIIOrt (It. T .ei) paramedics are assigned to two-piece companies, each consisting
of a triple-combination fire engine and an ambulance vehicle. To facilitate the dual roles of
these companies (file protection and emergency ambulance service) they operate in tandem at
all times except when the ambulance transports a patient to a facility outside the city.
Extrication and heavy rescue services, when needed, are provided by firefighters assigned to
ladder trucks and/or Iavy rescue vehiclC!l, Tbese services are provided on a special call basis
to pin access to IIId remove victims of building collapses, industrialllCciclents, and
transportation accidents where victims are h..wed in the wreckage.
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B. F.qptpment-
Equipment requiranents are dictated in large pan by external. standards (such as the American
College of Surpons Minimum Equipment List for Ambulances), and by local protocols and/or
the regulations of tbe local EMS agency (lCEMA).
C. EMS Personnel -
1. Trainin, - Minimum training, certification and recertification standards for EMS
personnel are set by regulation (Title 22 of tbe California Code of Rqulations. These
are statewide standards and there is no oppoltUDity for fire clcpartmcnts or ambulance
companies to use personnel who do not meet those standards. In addition to tbe
statewide standards, paramedic pcrsOnncl may be subject to additional "ICCI'editation"
requirements which are set and applied by the respective local EMS agency (e.g.
lCEMA). The intent of tbe acc:reditation process is to make certain that paramedics
working in the respective county or region are &milillr with local medical control
pJocedurcs and protocols.
2. Staffinl! Levels - First-resnonder units (fire engine companies) generally are staffed
with a minimum of three personnel. To serve effectively as a first-response unit, at
least two of those persons should be trained to provide basic life support. If an
automatic external defibrillation (AED) program has been implemented, at least one
AED-ccrtificd person should be on duty with each first-responder unit at all times.
Advanl'M life sunnort (ALS) units (two-piccc enginc-and-ambulance companies) are
staffed with a minimum of four personnel, two of whom are certified and accredited at
the paramedic (EMT-PaIamedic) level.
3. CertifiClltion - As reponed above (item C. 1.), certification requirements for EMS
personnel are set by state regulation, and ICCI'editation requirements for paramedic
personnel are set by local EMS agencies such as lCEMA.
4. ~hift Schedules - For maintaining a minimum number of on-duty personnel around-the-
clock, year-round, the most efficient and inexpensive staffing amngement employs
three platoons or "shifts" of equal numbers ofpersonnel, with each platoon on duty for
24 hours at a time. As utilized in most West Coast fire departments, this generally
results in a 56-hour workweek. Even following tbe April 15, 1986 application of the
Fair Labor Standards Act (FLSA) to public employees, wherein municipal employers
are obligated to pay time-and-a-half overtime for all hours worked beyond 53 per
38
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week, this shift schedule remains the least expensive method for maintaining constant
staffing.
Peak loId staffing makes sense for a sing1e-role OIpniDrion, such u a private
ambulance c:ompllly. In most U.S. cities, however, varying depees of EMS
raponllihility lie bandled by firefighters who have been cross-trained and given a dual
role. While it mipt be less costly if those cross-trained, dual-role personnel could be
assiped on a peak loId staffing buis, their fire j).Ivtcdion raponsibilities make the
concept umalistic. Fire protection and disaster situations lie both IDlplecIictable and
labor intensive. Furthemlore, there is ennlli"""able risk of liability if unpredicted
multiple calls, or a multiple cuualty incident, occurs during a period of ,1te1eton
staffing (in spite of computer predictions).
Still, the economy and efficieIIcy of usin& one group of employees for two distinct
roles (u in cross-trained, dual-role fireJEMS systems) easily ovacomes the apparent
inefficiencies of constant staffing, when c:ompued to peak load staffing in single-role
organizations. At page 83 of this report, the concept of wmarginal costsW is presented
as a measure of the true cost of fire department EMS.
In essence, if a fire department performs Ilmh EMS IIIll fire protection functions with a
workforce of 140, and if it is clear that the fire jK'OteCtion function alone requires a
workfOn:e of 130, then the true cost for the fire department to provide emergency
medical ~ces is the marginal cost. That is, the cost of 10 cross-trained firefighters,
plus those Salary and benefit costs which rdate to EMS bonuses or incentives and
EMS-related training, and an maintenance and operations expenses directly attributable
to the EMS function.'
D. S~sion ofField Personnel-
Fi~ltt S~mn:
MOle titan 20 years' experience in California has demonstrated that the first-line fire
service supervisor (the fire compllly officer, usually known u wCaptainW) is the most
logical and effective field supervisor of cross-trained, dual-role firefighterlEMS
pcnonnel. This penon has the peatest "l'POrtunity for full-time observation of and
contact with firefighters who also function as emerzency medical technicians (EMTs)
or paramecIics.
Inc:JeasinJlY, in dual-role fireJEMS agencies, fire compllly officers have served a
portion of their career u a puamedic. Also, they have been selected for their position
39
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on the basis of competitive examination or 1'1ue:eas. Tbese two factors ~ imporIant in
,.....trina that the EMS function is c:ompetendy supervised.
hdministntive Sunervisors:
In most fiR department EMS systems, the first-line supervisor (fiR company officer)
functions both as the field supervisor and the first 1evel of administrative supervision.
Duties mclude 1"1"'ttin& and rec:ordin& functions, as well as supply and maintenance,
and employee performance evaluation.
In many fiR departments, one or more EMS coordinator positions bave been
established - usually as a staff function. Usually, tbese ~ uniform positions (with
rank ran&in& from firefighter/paramedic to Deputy Chief). A recent ttend in CaIifomia
is to employ a nurse educator in this position with respon!l1"hUity for internal and
external coordination, continuing medical education, and quality assurance
(unprovement) functions.
E. Dimatch T lV'.lItinns:
As discussed at page 13 of this report, private ambulance sector innovations include
"system status management" (SSM). Using this practice, some private ambulance
services deploy ambulance units at numerous "posts" (street comers, convenience store
parking lots, freeway on-ramps) in specific locations throughout the community. Used
by single-role organizations as a tool for higher productivity, SSM is almost universally
unpopular with EMTs and paramedics and is believed to contribute to high rates of
personnel turnover. The resulting occupational stress is measurable and is reported at
page IS of this report.
Thus far, no dual-role fiR departments have adopted SSM for the deployment of their
EMS units. Those units ~ dispatched from fiR stations, or by radio when on field
assignments or when returning from prior calls. The selection of stations to be used as
locations for EMS units is dictated by time and cIistance factors, for the most part.
F. Documentation:
Documentation of all aspects of medical emergencies is dictated by the policies and
9cocedures of the local EMS qency (ICEMA). A copy of that lIIency's optical-scan
report may be found at Appendix D, and a discussion of provider resistance to 1CE.MA
.~g requirements is presented at page 101 of this report.
40
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GcOl1ll1itv A!SIII3Ilce:
Section 100166 of Title 22, Division 9, California Code of Regulations, which became
effective January I, 1992, requires loc:al EMS agencies (such u ICEMA) to establish a
"system-wide quality a!SIII3Ilce program u defined in Section 100141.2."
Section 100141.2 reads u follows:
"Quality assurance" or "QA" means a method of evaluation of services
provided, which includes defined standards, evaluation methodoloey(ie5) and
utili"'~()I\ of evaluation results for continued system improvement. Such
methods may include, but not be limited to, a written plan describing the
program objectives, organization, scope and mechanisms for overseeing the
effectiveness of the program. "
It is significant that no funding hu been provided to assist ICEMA or other loc:al EMS
agencies in fulfilling this requirement. Furthermore, beyond the above definition
(Section 100141.2), there is no agreement u to what constitutes a quality assurance
program although it is generally agreed that Section 100141.2 does not provide an
adequate definition.
Indeed, traditional "quality a!SIII3Ilce" ~sses seem to be outdated in view of
national hralth care developments. "Quality improvement" hu become the preferred
and more descriptive term (see Appendix E for a comparison of quality usurance and
quality improvement). A major force behind this change in terminology and approach
is the Harvard Community Healthplan, National Demonstration Project on Quality
Improvement in Health Care.
The most influential book on the topic at present is Curin, Health ('".... New StrlIte2ies
for Ouality Irqpmvement, by Donald M. Berwick, M.D. Also, the 1992 revision of
the Accreditation Manual for Hospitals, published by the Joint Commission on the
Accreditation of Healthcare Organizations, initiates a transition (from "quality
assurance") to standards that emphasize continuous quality improvement.
\
Recently, a pilot project (The California EMS Quality Improvement Project) wu
funded by the State EMS Authority and is intended to define and design a model EMS
quality improvement program for EMS systems. This project will not be complete
until 1993 .
In the meantime, inconsistency and confusion reigns. Some loc:al EMS agencies view
quality a!SIII3Ilce principally u error catching and discipline. Others perceive it u a
41
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c:olJaborative process that tries to addras quality issues before they become problems.
Most base hospilals (medical command facilities for paramedics) include pIdlospital
care incidents in the hospital QA program, with widely varying appnlIChes and results.
Some providers, such u the Long Beach F~ Department, have employed nurse
educators to implement an in-house, provider-based quality assurance (improvement)
ptogram.
In California, at the present time, development and implementation of a provider-based
quality assurance (improvement) program should be in c:oasultation with the local EMS
qency. Since the local EMS agency, by regulation, hu the responsibility to es1ablish
a "system-wide" program, expensive and non-productive conf1ict could result from
implementation of an independent, provider-based quality assurance (improvement)
l'&"5Iam.
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Ooerll.tional Profile D
In this profile, calls for emergency medical assistance are received by a 9-1-1
te1ecommUnicator at the fire department dispatch center. Assuming that all te1ecommunicators
have been trained u emergency medical dispatchers (EMD), the process includes interrogation
of callers, using a structured format bued on medically approved protocols. An EMD then
relays the appropriate information to the fire statlon(s) housing the nearest engine company and
the nearest available fire department ambulance.
In San Bernardino, constructing an ambulance system under this profile would require the
following:
The five existing paramedic engines are staffed with four persons each. Also, the engine
bued at the headquarters station (221) is staffed with four persons. By reducing the staffing
on each of these six engines from four to three, 18 people would be made available. Those 18
people would be sufficient to staff three full-time paramedic ambulances. Employment of an
additional six people would permit the deployment of a fourth ambulance.
When the nearest units(s) is/are out of its/their station(s) and available in its/their district(s),
the call for assistance is relayed by radio. The nearest fire engine and crew is always
dispatched with an ambulance. In some cues, the nearest engine will respond alone from its
-.
. _ __ _~~on or assign~, and serve u a first-responder unit for the ambulance which responds
fiom another locatiol!:, In other cues, where the fire engine and the ambulance are bued or
assigned at the same location, they respond together. While this is occurring, if appropriate,
an EMD keeps the caller on the phone line and... instructs the caller on first aid steps, CPR or
other vital actions while emergency units are mustering and responding.
All fire engines and 1addcr trucks are each staffed with three cross-trained
firefighter/Emergency Medical Technicians (EMTs), including a Fire Captain and Engineer.
When functioning u first-responders, their purpose is to provide buic life support to the
victim of a medicAl emergency or accident u quicldy u possible. Four stations also serve u
bases for puamedic ambulances. Each ambulance is staffed by two firefighter/ paramedics.
Except for medical control, they are supervised by the Fire Captain at the station where their
ambulance is bued.
Traind EMDs, using skilled interrogation techniques and physician-approved protocols, are
able to determine the relative urgency of a reported medical emergency. Using this
information, EMDs may dispatch only the fmt-responder unit Code 3 (red-lights-and-siren).
In such cues, the ambulance would be dispatched Code 2 (non-red-lights-and-siren, travc1l~
43
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at normal speedc, observin& all traffic laws). However, at any time, the END (who remains
in contact with the caller until emergency units arrive on scene) or the c:ompIDy officer 01\ the
first-responder unit may upgrade the response of the ambulance to Code 3.
If the medical emeraenc:y occurs in the district of a first-responder engine, that engine and the
nearest ambulance are displkbed simultaneously. If respondin& Code 3, the first-response
engine will arrive at the scene within three to five minutes, on the averqe. 'Ibe ambulance
c:ompIDy, if msponding Code 3, will arrive at the scene in six minutes or less. If the mec:licaJ
emeraenc:y occurs in the district where it is based, and if the ambulance is in its district when a
call is received, both the erlline and the ambulance will respond and, if responding Code 3,
will arrive at the scene within three to five minutes.
'Ibe fire cleputment's ambulance system is desicned primarily for emerpncy transportation.
Therefore, if either the first-responders or the paramedics confirm that the patient does not
require emerJCIlCY transportation, they have the option of l'.lIlling for a unit from the local
private ambulance company. 'Ibe private ambulances are dispatched Code 2 (at normal traffic
speeds, and observing all traffic laws). In all but a few puts of the city, a private ambulance
should be able to arrive at the scene in fifteen minutes or less from the time of call.
In this Profile, the private ambulance company also serves as a back-up in the event no fire
department ambulances are readily available. Also, to provide additional back-up ambulance
capacity, unmanned reserve ambulances are located at several fire stations in the city. On a
moment's notice, engine company crews can be reassigned to the reserve ambulances based at
their stations.
Profile D would require the employment of six additional firefighters. If rates were set at
appropriate levels, and if the billing/collection function were performed adequately, the cost of
these additional positions would be off-set entirely by net emergency ambulance transport
revenues.
A. Vehicles-
Fint-'"'~~ use fire engines (trip1e-combination pumper apparatus) to respond from their
stations or field activities to mediCfI emergencies. 1bough these vehic:les are Iarze and heavy,
designed primarily for fire protection, they are relatively quick and durable. On emergency
medical calls, their function is to get trained basic life support personnel and equipment to the
scene as quic:k1y as possible. Keeping the engine company crew together is essential to both
their emergency medical and their fire protection roles. 'Ibese various requirements can be
met with the highest possible levels of efficiency and economy by using the fire engine as the
first-response vehicle.
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..."""'''''''''' life ~ (A' .ell firefi&JIter(ftlIftlmMiell are ...mpM to ambulance vdlicles. The
first-line IIId n , "Ve ambulances are stmtegically based in fire stations to assure the quickest
possible ~SJIOIIse times.
F..xtrieatiOll and hea~ mrcue services. when needed. are provided by firefighters assigned to
ladder trucks and/or heavy rescue vdIicles. These services are provided 011 a special call basis
to pin access to IIId remove victims ofbullding col1~. industrial acci~ts.1IId
uansponation Kcidents where victims are trapped in the wreckage.
B. &uipment-
Equipment requirements are cIictated in larJe part by external standards (such u the American
Co1le&e of Surpons Minimum Equipment List for Ambulances). and by local protocols anellor
the regulations of the local EMS agency (lCEMA).
C. EMS Personnel -
1. Trainin, - Minimum training. c:ertification and recertification standards for EMS
personnel are set by regulation (TItle 22 of the California Code of Regulations. These
are statewide standards and there is no opportunity for fire departments or ambulance
companies to use personnel who do not meet those standards. In addition to the
statewide standards. paramedic personnel may be subject to additional "accreditation"
requirements which are set and applied by the respective local EMS qency (e.g.
ICEMA). The intent of the accreditation process is to make certain that paramedics
working in the respective county or region are familiar with local medical control
pmcedures and protocols.
2. Staffin, Levels - First-resnond~ units (fire engine companies) generally are staffed
with a minimum of three personnel. To serve effectively u a first-response unit. at
leut two of those persons should be trained to provide buic life support. If an
automatic external defibrillation (AED) 9fogram hu been implemented. at Ieut one
AED-certified persOII should be on duty with each first-responder unit at all times.
first-line amhulances each are staffed with a minimum of two cross-trained
firefighter/paramedics. V_I' .mhlll........ when activated. each are staffed by a
three-person r:rew. consistin& of a Fire Captain. and F~_ and a firefighter. At
Ieut two of those persons are trained and certified u buic life support EMTs.
45
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3. C".l'!rrifil'Jlrion - M reported above (item C. 1.), c:ertification requirements for EMS
penoaqel are let by state rqulation, and lICCI'eCIitation requirements for paramedic
penoIIIIC1 are let by loc:al EMS agencies such u ICEMA.
4. Shift SclIatnlM - For maintaining a minimum number of on-duty personnel around-the-
clock, year-round, the most efficient and ina.pensive staffing arranpment employs
three platoons or "shifts" of equal numbers of penonnel, with each pl.tlVll\ on duty for
24 hours 11 a time. M utilized in most West Caul fire deplrtments, this generally
results in a 56-hour workweek. Even following the April 15, 1986 application of the
Fair Labor Standards Act (FLSA) to public employees, wherein municipal employers
are ob1iptM to pay time-and-a-half overtime for all hours worked beyond 53 per
week, this shift schedule remains the least expensive method for maintaining c:ons1ant
staffing.
Peak 10lld staffing makes sense for a single-role organization, such u a private
ambulance company. In most U.S. cities, however, varying degrees of EMS
responsibility are handled by firefighters who have been c:ross-trained and given a dual
role. While it might be less costly if those c:ross-trained, dual-role personnel could be
assigned on a pat load staffing buis, their fire protection responsibilities make the
c:oncept unrealistic. Fire protection and disaster situations are both unpredictable and
labor intensive. Furthermore, there is considerable risk of liability if unpredicted
multiple calls, or a multiple cuualty incident, occurs during a period of skeleton
staffing (in spite of computer predictions).
Still, the economy and efficiency of using one group of employees for two distinct
roles (u in cross-trained, dual-role fireIEMS systems) easily overcomes the apparent
inefficiencies of constant staffing, when compared to pat load staffing in single-role
organizations. At page 83 of this report, the concept of "marginal costs" is presented
as a measure of the true cost of fire department EMS.
In essence, if a fire department performs bmh EMS IIlll fire protection functions with a
workforce of 140, and if it is clear that the fire protection function alone requires a
workfon:e of 130, then the true cost for the fire department to provide emeIJency
medic-I services is the marginal cost. That is, the cost of 10 cross-trained firefighters,
plus those salary and benefit costs which relate to EMS bonuses or incentives and
EMS-related training, and all maintenanee and operations experose5 directly attributable
to the EMS function.
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D. S~lion of y,..1d Personnel -
Field S~IOI'S:
More tbIn 20 years' experience in California bas demonstrated that the lint-line file
service supervisor (the file company officer, usually known u "Captain.) is the most
Iopc:al and effective field supervisor of c:ross-trained, dual-role firefiahterlEMS
perIOIIIlel. This person bas the greatest OWOrtuDity for full-time observation of and
contact with firefiahters who also function u emeraency medical technicians (EMTs)
or paramedics.
Increasingly, in dual-role fueIEMS agencies, file company officers have served a
portion of their career u a peramedic. Also, they have been Ielected for their position
on the basis of competitive examination or )IIoc:ess. Tbese two factors m important in
Issuring that the EMS function is competently supervised.
J\dministrative S~IOI'S:
In most file department EMS systems, the lint-line supervisor (file company officer)
functions both u the field supervisor and the lint level of administrative supervision.
Duties include .eporting and recording functions, u well u supply and maintenance,
and employee performance evaluation.
In ~y file departments, one or more EMS coordinator positions have been
establi~ - usually u a staff function. Usually, these m uniform positions (with
rank ranging from firefiahter/paramedic to Deputy Chief). A recent trend in California
is to employ a nurse educator !n this position with responsibility for intcmal and
external coordination, continuing medical education, and quality usurance
(improvement) functions.
E. Diwatch T """tinns:
As discussed at pile 13 of this report, private ambu1anc:e sector innovations include
.system status management. (SSM). Using this practice, some private ambulance
services deploy ambulance units at numerous "posts. (street comers, convenience store
pIl'king lots, freeway on-ramps) in specific locations throughout the community. Used
by single-role organizations u a tool for higher productivity, SSM is almost universally
unpopular with EMTs and paramedics and is believed to contribute to high rates of
personnel turnover. The resulting occupational stress is measurable and is reported at
JlIIic IS of this report.
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Thus far, no dual-role fire departmeIlts have adopted SSM for the deployment of their
EMS UIIits. Thole UIIits are dispatcl\ed from fire slIDons, or by radio when 00 field
,....p'-t.s or when retumin& from prior calls. 1bc R1ection of stations to be used U
loc:ftitlQS for EMS ODits is dic:Iated by time and distance fIctors, for the most part.
F. DoculN!!fttlltinn:
DocumentlDon of all aspects of mecliCJI emergencies is dic:Iated by the policies and
pmc:edures of the local EMS agency (ICEMA). A copy of that agency's optical-scan
report may be fouDd at Appendix D, and a discussion of provider resistance to ICEMA
.~ requiJema1ts is presented at PIlle _ of this report.
G. t'lollllity Auuranc:e:
Section 100166 of Title 22, Division 9, Califomia Code ofRe&uJations, which became
effective January 1, 1992, requires local EMS agencies (such u ICEMA) to establish a
-system-wide quality assurance program u defined in Section 100141.2.-
Section 100141.2 reads u follows:
-Quality assurance- or -QA- means a method of evaluation of services
provided, which includes defined standards, evaluatioo methodolOJY(lCS) and
utilizatioo of evaluation results for continued system improvement. Such
methods may include, but not be limited to, a written plan describing the
progtam objectives, organization, scope and mechanisms for overseeing the
effectiveness of the program. -
It is significant that no funding has been provided to usist ICEMA or other local EMS
agencies in fulfilling this requirement. Furthermore, beyond the above definition
(Section 100141.2), there is no agnement u to what constitutes a quality assurance
progtam although it is generally agreed that Section. 100141.2 does not provide an
adequate definition.
Ind II d, traditiooal -quality assurance- prore55e" seem to be outdated in view of
natiooal bealth care developments. -Quality improvement- has become the preferred
and more descriptive term (see Appendix E for a comparison of quality assurance and
quality improvement). A major force behind this change in terminolOJY and approach
is the Harvard CommODity Healthplan, National Demonstration Project on Quality
Improvement in Health Care.
1bc most influential book 00 the topic at present is Cunn, HlI!lI1th r..lll'P.. New StrlItf:Jies
for t'lollllity J~ent. by Donald M. Berwick, M.D. Also, the 1992 revision of
the Acx:reditation Manual for Hospitals, published by the Joint Commission on ~
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Accreditation of Hea1thc:are Orpni....rions, initiates a transition (from 'quality
assmanc:e') to standards that emphasize cootinuous quality improvement.
Recently, a pilot project (The California EMS Quality Improvement Project) was
funded by the State EMS Authority and is intended to cIefiDe and design a model EMS
quality improvement program for EMS systems. This project will not be complete
until 1993.
In the JIIe!IIltime, inc:oosistency and confusion reigns. Some local EMS agencies view
quality assurance principally u error catching and discipline. Others perceive it u a
coll..hmative process that tries to address quality issues before they become problems.
Most base hospilals (medical command facilities for puamedics) include prehospilal
care incidents in the hospilal QA propam, with widely varying approIChes and results.
Some providers, such u the Long Beach Fire Department, have employed nurse
educators to implement an in-house, provider-based quality assurance (improvement)
program.
In California, at the present time, development and implementation of a provider-based
quality assurance (improvement) program should be in c:oosultation with the local EMS
agency. Since the local EMS agency, by regulation, hu the raponsibility to establish
a 'system-wiele' proaram, expensive and non-productive conflict could result from
implementation of an independent, provider-based quality assurance (improvement)
program.
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Qvrational Profile E
'Ibis profile would involve the delivery of both emeraency and non-emergency ambulance
service. In San Bernardino, constructing an ambulance system under this profile would
require the following:
Creating a new category of non-permanent City employee. For purposes of this report, the
position title would be "File Service Laborer" or "FSL." 'Ibis category of employees would
serve thIee purposes: they would operate a fleet of basic life support ambulance vehicles, they
could serve u cadet firefigbters, and they would serve u the exclusive pool of qualified
candidates for permanent firefighter positions with the San Bernardino Fue Department.
Base compensation for the FSL position would be minimum wage, plus time-and-a-half
overtime for hours over 40 per week, unless the Fair Labor Standards Act "7JC" exemption
applies. As non-permanent employees FSLs would not be entitled to pension benefits.
Candidates for the FSL program would be selected on the basis of open recruitment and
competitive process. Minimum qualifications would include current California certification u
an Emergency Medical Technician (EMT) and ambulance driver permit.
Once selected and trained in departmental procedures, FSLs would be assigned to ambulance ~
duty. Each FSL would work under the supervision of the File Captain at the station where
hisIher ambulance is based. Within a specified period of time, s/he would be expected to meet
the requirements for and become certified u a File Fighter I. 'Ibis fire suppression training
and the potential for duty u a cadet firefighter could qualify the program for the "7JC"
exemption under the Fair Labor Standards Act.
Whenever vacancies in the department required employment of new firefighters, only FSLs in
good standing, with a year or more in the program, would be qualified to apply. They would
then compete in a process which would result in an eligibility list. Other factors in
establishing the rank onier of eligibles would include the regular performance evaluations
prepared by their supervisors. A competitive process would be conducted at leut once a year
to allow FSLs regular uwOrtunities to improve their standing on the list.
In addition to other advanlages, this method of recruitment for the position of firefighter
provides enhanced ""portunities for women and members of minority groups.
In that FSLs would be usigned to a single role - except in disasters or other extreme
emergencies where they might be activated u firefighters - scheduling techniques and basing
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modes used by some private ambulance companies could be utilized, including peak laid
staffing and system status management.
First-responder units (engine companies) are staffed with cross-trained firm&hterlEmergency
Medi~1 T~..ici.N (EMTs) and their purpose is to provide basic life support to the victim of
a medi~1 emerzency or lICcident as quickly as possible. A .....lIer number of engine
~ are staffed and equipped as paramedic engines. At 1east two persons assigned to
each of thole c:ompIIIies at all times are cross-trained firm&hter/paramedics.
In this profile, calls for emergency medical assi."'1\Ce are received by trained Emergency
Medical Dispatcbm (BMDs) at the fire department dilp"tch center. Trained EMDs, using
.1rlllfld interrogation techniques and physician-approved protocols, are able to determine the
relative uqenc:y of a reported medical emergency. An EMD then relays the app.upriate
information to the nearest engine company and the nearest available fire department
ambulance.
EMDs may dispatch only the tint-responder unit Code 3 (red-li&hts-and-sireD). In such cases,
the ambulance would be dispatched Code 2 (travel directly to the scene of the emergency but
at normal traffic speeds, and observing all traffic laws). However, at any time, the EMD
(who remains in contact with the caller until emergency units arrive on scene) or the company
officer on the first-responder unit may upgrade the response of the ambulance to Code 3.
-
If the medical~ency occurs in the district of a first-responder engine, that enaine and the
nearest ambulance<are dispatched simultaneously. If responding Code 3, the first-response
engine will arrive at the scene within three to five minutes, on the average. The ambulance
company, if responding Code 3, will arri've at the scene in six minutes or less. If the medical
emergency occurs in the district where it is based, and if the ambulance is in its district when a
call is received, both the engine and the ambulance will respond and, if responding Code 3,
will arrive at the scene within three to five minutes.
The fire department's ambulance system is designed for both and non-emergency
transportation. Since this profile proposes the use of personnel who are essentially committed
to a single role, variable and peak-load staffing could be employed to minimize labor costs.
However, as an extra margin of safety against the potential for major emergencies during
periods of s~let.on staffing, reserve ambulances could be parbd at several fire stations in the
city. On a moment's notice, engine company crews could be reassigned to activate one or
more of those ambulances.
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The Dumber of Fire Service Laborers ~"""Y to implement Profile E would depend OIl the
staffing and 1.";111 modes ~I-...t. Regardless, the cost of these additional positions would be
off-set entirely by net emergency ambulance transport revenues.
Amon& the Idvantaps of this Profile is the oppOrtUDity to provide a vital public service while
pneratin& excess revenues, and to provide for all qualified and industrious persons an open
door to employment opportunities in the fire service - a field that traditionally has been
cIifficult to enter. Ambu1ances would be staffed with people whose attitudes and performances
could determine their cbances for a fire service career. This buUt-in motivation would assure a
commitment to customer service while infusing the fire department with the enthusiasm and
work ethic of hopeful young people.
A. VMi~l~-
First-responders use fire engines (triple-cornbination pumper apparatus) to respond from their
stations or field activities to medical emergencies. Though these vehicles are large and heavy,
designed primarily for fire protection, they are relatively quic:k and durable. On emergency
mediCllI calls, their function is to get trained basic life support personnel and equipment to the
scene as quickly as possible. Keeping the engine company crew toðer is essential to both
their emergency medical and their fire protection roles. These various requirements can be
met with the htgbest possible levels of efficiency and economy by using the fire engine as the
first-response vehicle.
Advan......life mmnort (AU\ fi.refil"t~/nRl'lI.medics also are assigned to triple-cornbination fire
engines, known as "paramedic engines.. These vehicles are identical in design and function to
the first-response vehicles, except the cabinets on the paramedic engines are buUt to contain all
needed ALS equipment, as well as fire protection equipment.
Ambulance EMf! (Fire Service , J1~\ use either van-type or modular ambulances.
Because there are less ambulance vehicles deployed in the community than there are fire
engine compenies, and tJecal1'" some of those ambulances are also used for non-emergcncy
medical transportation, the system is dependent on first-responders and paramedic engines to
arrive OIl scene first and initiate basic and advanced life support. Still, due to the
unprecIictability of emergency events, there may be chance oc:currences where an ambulance
will arrive at the scene of an emergency first.
ll.ml".2tion and h~ rescue services, when needed, are provided by firefighters assigned to
ladder trucks and/or heavy rescue vehicles. These services are provided on a special call basis
to gain access to and remove victims of buUding collapses, industrial accidents, and
transportation accidents where victims are trapped in the wreckage.
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B. Eql,limnent-
Equipment requiRlDClllts are dictated in large part by external standards (such as the American
Col1cge of Surpons Minimum Equipment List for Ambulances), and by local protocols and/or
the re&uJatioos of the local EMS agency (lCEMA).
C. EMS Personnel -
1. Tnlinintr _ Minimum training, certification and rec:ertificatio standards for EMS
personnel are set by rqulation (Title 22 of the Califomia Code of RepIations. 'Ibcsc
are SlBteWidc standards and there is no opportunity for fire dcpIrtmcnts or ambulance
comll8"iH to use personnel who do not meet those stP""-"l1s. In addition to the
statewide standards, paramedic personnel may be subject to additional "accreditation"
requiIemcnts wbich are set and applied by the .cspeaivc local EMS agency (e.g.
ICEMA). The intent of the accreditation process is to make certain that paramedics
working in the respective county or region are familiar with local medical control
procedures and protocols.
2. Slllffin, ~s _ First-remonder units (fire engine companies) generally are staffed
with a minimum of three personnel. To serve effectively as a first-response unit, at
least two of those persons should be trained to provide basic life support. If an
automatic external defibrillation (AED) program has been implemented, at least one
AED-certified person should be on duty with each first-responder unit at all times.
AlJvan...... life m1IIIOrt (ALS) units must be staffed with a minimum of two persons and,
clcpcnding on local protocol, one or two of those persons must be certified and
accredited at the paramedic (EMT-Paramedic) level.
Ambulance units must be staffed with a minimum of two personnel, both of whom
must be trained and certified at the basic life support emergency medical technician
(EMT-I) lcvc1 as a minimum. There is no statutory requiIemcnt for ambulance
pcrsonnc1 to be trained at the bigher paramedic lcvc1.
3. r.f!rtification - As .cported above (item C. 1.), certification requirements for EMS
personnc1 are set by state regulation, and accreditation requirements for paramedic
personnc1 are set by local EMS agencies such as ICEMA.
4. Sbift St!hl!ldules - For maintaining a minimum number of on-duty pcrsonnc1 around-the-
clock, year-round, the most efficient and inexpensive staffing anangement employs
S3
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tbnle platoons or "shifts" of equal numbers of personnel, with each platoon on duty for
24 boun at a time. As utilized in most West Coast fire departments, this pnerally
results in a 56-hour workweek. Even followin& the April IS, 1986 application of the
Fair Labor Standards Act (FLSA) to public employees, wherein municipal employers
are ot-JiptM to pay time-and-a-balf overtime for all boun worked beyond 53 per
week, this shift schedule remains the least expensive method for maintaining constant
staffin&.
Peak loId staffin& makes sense for a sing1e-role Olpni_tion, such u a private
ambulance company. In most U.S. cities, however, varying depees of EMS
mpoIIpnility are lw""led by firefi&hters who have been cross-trained and liven a dual
role. While it mi&ht be less costly if those cross-trained, dual-role personnel could be
assiped on a peak 10ld staffing buis, their fire protection responsibilities make the
concept UIU"'llictic. File protection and disaster situations are both unpredic:lable and
labor intensive. Furthermore, there is c:onsiderable risk of liability if unpredictcd
multiple calls, or a multiple casualty incident, occurs during a period of skeleton
staffing (in spite of computer predictions).
Still, the ec:onbmy and efficiency of using one group of employees for two distinct
roles (u in cross-trained, dual-role fireIEMS systems) easily overcomes the apparent
inefficiencies of constant staffing, when compared to peak 10ld staffing in single-role '
organizations. At page 83 of this report, the concept of "marginal costs" is presented
u a measure of the true cost of fire department EMS.
In essence, if a fire department performs bmh EMS IIIl1 fire protection functions with a
workforce of 140, and if it is clear that the fire protection function alone requiles a
workforce of 130, then the true cost for the fire department to provide emergency
medical services is the marginal cost. That is, the cost of 10 cross-trained firefighters,
plus those salary and benefit costs which relate to EMS bonuses or incentives and
EMS-related training, and all maint.enanee and operations expenses cIiIec:t1y attributable
to the EMS function.
D. Su~sion of J:i..1d Penonnel -
field Sqpervisors:
More than 20 years' experience in California has demonstrated that the first-line fire
service supervisor (the fire ......npany officer, usually known u "Capcain") is the most
logical and effective field supervisor of cross-trained, dual-role firefi&hter/EMS
personnel. This person has the greatest opportunity for full-time observation of and
54
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contact with firefighters who also function as emergency medical technicians (EMTs)
or paramedics.
Inc:rasin&1y, in dual-role fireIEMS agencies, fire company officers have served a
portion of their career as a paramedic. Also, they have been seJ~ for their position
on the basis of competitive ewnination or pdlcesS. These two factors are imponant in
assuring that the EMS function is competently supervised.
Adminiltrllti.ve ~~sors:
In most fire deputment EMS systems, the first-line supervisor (fire company officer)
functions both as the field supervisor and the first level of administnDve supervision.
Duties include .eporting and recording functions, as well as supply and maintenance,
and employee performance evaluation.
In many fire departments, one or more EMS coordinator positions have been
establisbed - usually as a staff function. Usually, these are uniform positions (with
rank ranging from firefighter/paramedic to Deputy Chief). A recent trend in California
is to employ a nurse educator in this position with responsibility for internal and
external coordination, continuing medical education, and quality assurance
(improvement) functions.
E. Di.tch T IW'Jltions:
As disCussed at page 13 of this report, private ambulance sector innovations include
. .
.system S1atus management" (SSM). Using this practice, some private ambulance
services deploy ambulance ~ts at numerous "posts" (street corners, convenience store
parking lots, freeway on-ramps) bt.specific locations throughout the community. Used
by single-role organizations as a tool for higher productivity, SSM is almost universally
unpopular with EMTs and paramedics and is be1ievcd to contribute to high rates of
personnel turnover. The resulting occupational stress is measurable and is reported at
page IS of this report.
Thus far, no dual-role fire departments have adopted SSM for the deployment of their
EMS units. Tbose units are dispatched from fire stations, or by IlIdio when on field
usipments or when returning from prior calls. The selection of stations to be used as
locations for EMS units is diC1ated by time and diSUUlce factors, for the most part.
F. Tlntonmf!l'ltlltion:
Documentation of all aspects of medical emergencies is dic:tated by the policies and
procedures of the local EMS agency (ICEMA). A copy of that agency's optical-scan
SS
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report may be found at AppeII<IiY D, and a discussion of provider raistance to ICEMA
feportin& requirements is pmeated at page 101 of tbis report.
G. nn.);\}' A~GJ.ranc.e:
Section 100166 ofT1tle 22, Division 9, California Code ofRegulatioos, which became
effective January 1, 1992, requires local EMS lIencies (such u lCEMA) to establish a
"system-wide quality assurance program u defined in Section 100141.2."
Section 100141.2 reads u follows:
"Quality assurance" or "QA" means a method of evaluation of services
provided, which includes defined standards, evaluation methodo101)'(ieI) and
utilization of evaluation results for continued system improvement. Such
methods may include, but not be limited to, a written plan describing the
proaram objectives, orpnization, scope and D""'"""niuns for overseeing the
effectiveness of the program. "
It is significant that no funding has been provided to usist lCEMA or other local EMS
lIencies in fulfilling this requirement. Furthermore, beyond the above definition
(Section 100141.2), there is no apeement u to what constitutes a quality assurance
program although it is generally agreed that Section 100141.2 does not provide an
adequate definition.
Indeed, traditional "quality usurance" proces~ seem to be outdated in view of
national health care developments. "Quality improvement" has become the preferred
and more descriptive term (see Appendix E for a comparison of quality assurance and
quality improvement). A major fon:e behind tbis change in terminology and approach
is the Harvard Community Hea1thplan, National Demonstration Project on Quality
Improvement in Health Care.
1be most influential book on the topic at present is Curillf 'Rf'.lIlth C'Jl1'l'!. New Strate2ies
for n",.1i~ Tmnrnvement, by Donald M. Berwick, M.D. Also, the 1992 revision of
the Accreditation Manual for Hospitals, published by the Joint Commission on the
Accreditation of Hca1thcare Organizations, initiates a transition (from "quality
assurance") to standards that emphasize continuous quality improvement.
Recently, a pilot project ('Ibe California EMS Quality Improvement Project) wu
funcIed by the State EMS Authority and is intended to define and design a model EMS
quality improvement program for EMS systems. This project will not be complete
until 1993.
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In the meantime, inconsistency and confusion reigns. Some local EMS agencies view
quality assurance pri~11y u error catching and discipline. Others perceive it u a
collaborative pJ0ces5 that tries to address quality issues before they become problems.
Most base hospi1lls (medical command facilities for paramedics) include prehospilal
care incidents in the hospital QA program, with widely varying approaches and results.
Some providers, such u the Long Beach Fire Department, have employed nurse
educators to implement an in-house, provider-based quality assurance (improvement)
l""5Iam.
In California, at the present time, development and implementation of a provider-based
quality assurance (unprovement) program should be in consultation with the local EMS
agency. Since the local EMS agency, by regulation, hu the responsibility to establish
a wsystem_widew program, expensive and non-productive conflict could result from
implementation of an independent, provider-based quality assurance (improvement)
program.
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FmmaI C"h.Ol!OIrinn with Other t"\rnr.Inintions
As in all emerpnc:y service activities, cooperation between emeqency orpn;7.lItioos is
essential. In California EMS systems, tbe relationships between those organizations and their
people range from traditional and informal (e.g. routine cooperation bctMcn City file and
private ambulance pcnonne1) to contractual (e.g. automatic aid and mutual aid apecmcnts
bctWCCll DCi&hboring file dcpartmCDts), statutory (e.g. tbe requirement that paramedics be
responsive and responsible to tbe local EMS medical director) and regulatory (e.g. tbe
purported authority of tbe local EMS agency over EMS providers).
1bc most troublesome inter-orpn;utional rcJationships tald to oc:cur bGtween public provider
agencies (e.g. file dcpartmCDts) and local EMS agcnc:ics, such as ICEMA. There are
numerous causes of the friction, ranging from resistance by file officials to external efforts to
alter or ovcnec their agencics. to excessive bureaucracy and inconsistcnc:y on tbe part of local
EMS agencies. Possibly tbe gteatcst source of friction, however, is tbe hidden economic
agenda of some local EMS agencies. That is, tbe desire to shift tbe burden of cmcracncy
ambulance transport for indigent persons from County govcmmcnt to other payers. Also, the
practice of subsidizing ambulance services in unincorporated areas by depriving municipalities
and tbe citizens of municipalities of a choice of ambulance providers, and the approval of
ambulance rates that are dbptoporlionate. rue department EMS programs - puticularly fire
department ambulance services - tald to be an obstacle to such plans and purposes. (see
-Local EMS Agencics- at page 6S for additional discussion)
Cooperative relationships bctwccn emergency medical services orpn;uvons and responders
should focus on the patient (the ultimate beneficiary of the system and its components). 1bc
following description of formal and informal relationships uses that premise:
Patients and Di$plltchers -
Normally, the triggering event is a tc1cphonc call to tbe emergency phone number from an ill
or injured person (or someone calling on their bcIWf). Lcplly. the dispatch agency is
ob1;ptl'Jd to serve tbe caller according to tbe accepted standard of care. That standard has
evolved since 1981 and probably includes trainin& (and possibly ccrtific:a1ion) dispat<'-hcrs as
-cmcr&ency medical dispatchers- (END). Dispatchers trained to that standard would be
qualified to intenOga1e callers inacc:ord with approved protocols, and to provide callers with
pre-arrival instrUctions.
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Padents and First-R~derJ -
After the call for assistance has been placed, patients have a 1ega\ right to receive life support
services from plvpaly trained personnel within a reasonable response time. Scientific studies
and relevant literature indicate that the trained personnel should arrive at the scene of any life-
threatening emergency within six minutes - including the time required for dispatchers to
process the call.
In most locales, this need for quick response by trained .first-responders. is met by
dispatching the closest fire engine and crew. There is no legal obligation for the first-
responders to be capable of delivering advanced life support (paramedic) services but they
must be capable of providing basic life support.
Patients and Rescue Paramedics -
In those systems using advanced life support (paramedic) rescue personnel (who operate from
non-transporting rescue vehicles or paramedic fire engines), patients have a legal right to
receive advanced life support services from properly trained and mMically supervised
personnel within a reasonable response time. If the system design provides for first-responders
to be on-scene within 4 minutes of the call for assistance, rescue paramedics generally should
be on-scene in 6 minutes or less on at least 90 percent of all calls.
With the ei~tion of equipment used for transportation (e.g. gurneys), rescue paramedics are
obligated to catty,essentially the same inventory of equipment that is carried by ambulance
paramedics (see below). Also,the ~g, certification and accreditation standards for rescue
paramedics is the same as for all Califomja paramedics.
Patients and Ambulance Provider -
Patients also have a legal right to receive ambulance service from properly trained personnel
within a reasonable response time. Ordinances adopted in several U.S. cities have defined this
response time as 90 percent of all responses in eight minutes or less (including call processing
time).
Although all ambulance personnel must be trained in basic life support, as a minimum, there is
no legal obligation for them to be trained as paramedics. Commonly, the question of whether
a community's ambulances should operate at the basic life support level (staffed by EMTs) or
the advanced life support level (staffed by paramedics) is a policy matter to be determined by
elected officials.
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In more than 90 perc:ent of the 200 most populous cities in the U.S., advanced life support
IaYices are delivered by one or more providers. For eumple, consider the followin&
profiles:
1.
2.
3.
4.
File company tint-responders
Private ambulance service
File company first-responders
Paramedic engine companies
Private ambulance service
basic life support
advuced life support
basic life support
advanced life support
basic life support
advuced life support
advanced life support
basic life support .
advanced life support
basic life support
basic life support
advanced life support
basic life support
s.
File company tint-mponders
Hospital ambulance service
Fue company tint-responders
File department rescue unit
File department ambulance
File company first-responders
Paramedic engine companies
File department ambulance
In essence, as demonstrated by jurisdictions throughout the U.S., there is no single "correct"
system design for delivering emergency medical and ambulance services.
However, all ambulance service providers have a legal obligation to their patients to operate
safe and ~coperly maintained vehicles, equipped in conformance with minimum national
standards. All ambulance services are obligated to provide emergency medical transportation
without prior inquiry as to the ability of the patient to pay.
Patients and Homitals -
Where patients receive basic life support in the field and then are transparted to a hospital, the
relationship between hospital and patient commences upon admission of the patient at the
hospital. Where patients require and receive advanced life support in the field, the reJationship
between base hospital and patient is presumed to commence when paramedics establish radio
or telephone conlllCt with the hospital.
In that the paramedics operate under medical control, and in that medical control is exercised
in pan by base hospitals as a means of controlling and supervising the care given to patients,
the presumption is that establishing communications between pmmedic and base hospital
createS a relationship between that hospital and the patient. In the event the patient is
transported to a hospital other than the base hospital, the relationship between that receiving
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hospital and the patient commences when the patient arrives at the receiving hospital. Upon
arrival of the patient at a hospital, the relationship is fOl"/Mli7ed by the execution of consent
and admission documents.
Di$p3.tchers and First-~ders-
Because time is of the essence in life-threatening medical emergencies, dispatchers have an
obligation to process calls for assistance skillfully, ac:c:urately and quickly, giving to first-
responders correct address information, and useful information concerning the nature of the
case. While fust-responders are mustering and travelling to the scene, properly trained and
supervised emergency medical dispatchers (EMDs) will attempt to provide pre-arrival
instructions to the caller, thus enhancing the potential for effective action (including
resuscitation) by first-responders on their arrival to the scene.
Dimatchers and Rescue Paramedics -
In those systems using advanced life support (paramedic) rescue personnel (who operate from
non-transporting rescue vehicles or paramedic fire engines), the relationship between
dispatchers and the rescue paramedics is, virtually identical to that between dispatchers and
first-responders (above). Additionally, however, in some systems, dispatchers are used to
"patch" (interconnect) radio communications between field units and hospitals, maintain
hospital availability information for paramedics, and route patients to appropriate hospitals
with available beds in cases of multiple-c:asuaity incidents.
Dimatchers and Ambulance Provider -
Where dispatching services are provided by a public agency, and where 9-1-1 emergency c:alIs
terminate at that agency's public safety answering point (pSAP), ambulance providers (both
public and private) are mostly dependent on that PSAP for notification of emergencies. While
a private ambulance company may receive oc:c:asional requests for emergency service via its
seven-digit telephone number, it should be obligated by ordinance or contract to immediately
notify the PSAP of the existence of the request. This assures that the entire system is
activated, inducting first-responders.
Where the fire department operates paramedic first-responders and/or non-transporting rescue
vehides or paramedic fire engines, a red-light-and-siren (RSL) response by the ambulance will
rarely be necessary. Especially where dispatchers have been trained as EMDs, they can
distinguish cases requiring RSL response from those where a safer mode of response is
appropriate. Thus, dispatchers may be authorized to specify the response mode when
dispatching ambulances.
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Note: The efficacy and bazards of RSL response are discussed at page 87 of this rqlOrt.
In some systems, fire company officers and paramedics are authorized to upgrade or
downgrade the leSpOIISe mode of inc:oming ambulances, U well U c:ance1 the ambulance
leSpOIISe where apr..opriate. These orders or requests are transmitted through the fire
clepartment to the ambulance provider's dispatcher.
Where the ambulance provider is staffed and equipped to deliver advanced life support
services, emerpncy medical dispatchers will be able to provide the ambulance provider's
(Ii~tcher (or possibly the ambulance crew itself via radio) with information derived tiom the
interrogation of the caller. This can help the responding ambulance paramedics to mentally
prepare for the emergency they will face at the scene.
Dimlltl:!hers and Homitals -
Generally, the relationship between EMS dispatch facilities and hospitals is informal. That is,
it is seldom governed by a contract between the two entities. More likely, it will be an
informal relationship that flows from the following types of episodic services:
1. The dispatch center may be used to "patch" communications and telemCtered
electrocardiography between field paramedic units and a base hospital;
2. The dispatch center may be utilized to keep track of whether receiving hospitals and
trauma centers are immediate1y available for patients or whether they are on "bypus"
or "diversion."
3. In a multiple-c:asualty incident, the dispatch center may be utilized to regulate the flow
of patients to the various hospitals in the community (to avoid overloading some
facilities, and to assure that patients are directed to specialty centers where 11flC'"".''''Y).
In addition, if a base hospital's quality assurance program requires leSpOIISe time and dispatch
information, tbeIe may be a relationship between the hospital and dispatch center involving the
c:ol1ection and tranSfer of that data. Also, a base hospital's EMS training program may have
some responsibility for training, quality usurance, and continuing education of emergency
me(li<:al dispatctI (EMD) personnel.
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First-Re:wonders and Paramedics -
Particularly in cases where the patient's breathing and pulse has ceased or become insufficient,
the potential for paramedics to reverse the life-threatening condition is dependent on prompt
administration of cardiopulmonary resuscitation (CPR). This technique can be administered by
trained bystanders or, more commonly, by first-responders who arrive at the scene within six
minutes after a call for help is placed. Since first-responder units (fire companies) are more
numerous in the community than paramedic units, first-responders generally can arrive at the
scene more quicldy than paramedic units (whether non-transporting rescue units or
ambulances).
The role of the first-responder has been referred to as a vital link in the chain of survival. The
care provided by paramedics in many cases would be less effective without the timely arrival
and intervention of first-responders. Also, since most life-threatening medical emergencies are
time and labor intensive, and require the active participation of more than two technicians,
first-responders provide essential assistance to paramedics. In addition to continuing CPR
until advanced procedures can be administered, this assistance ranges from retrieving and
carrying equipment from rescue vehicle to patient, and setting up intravenous equipment, to
immobilizing and packaging the patient for transportation, and lifting and carrying the patient
to the ambulance.
First-Resoonders and Hospitals -
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If the first-responders, or some of them, are trained to the advanced life support (paramedic)
level, they will have a formal relationship with their base hospital and the so-called "on-line"
medical director. That relationship, whichmay include one or more additional receiving
hospitals, will include medical control functions, joint participation in quality assurance
activities, continuing medical education, resupply of drugs and disposable supplies, and
possibly serving as preceptors for EMT and paramedic trainees. If the first-responders
function at the basic life support level, they are not likely to have a formal or informal
relationship with local hospitals.
Ambulance Providers and Hospitals -
The possible relationships between an ambulance service and the hospitals to which it
transports patients include medical control functions (if the service operates at the advanced
life support level), participation in quality assurance programs, continuing medical education,
resupply of drugs and disposable supplies, sharing of billing information, billing and collection
services, and repair and maintenance of electrical and mechanical equipment. Also, a formal
contractual relationship may exist whereby the ambulance service is used exclusively by the
hospital for non-emergency inter-facility transfers. .
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Aummatie Aid A,u~m81ts -
. Automatic aid" is a cooperative relationship between emergency service organizations
wherein the emeqenc:y units and personnel of one lIency will respond to and serve calls for
....d_~ in a neighboring or nearby jurisdiction. It is distinguishable from "mutual aid. "
For ~."'Ple, automatic aid is based on dispatching the closest unit to an emergency,
JqUdless of jurisdictional affiliations. Alto, since it is pre-arranged (preferably by contract),
it mquUes no validatinn or approval for individual instances.
Every community should usess the potential for serving its citizens' emergency needs faster
and more efficiently through automatic aid agreements with neighboring or nearby lIencies or
organizations. In other words, if an area of City A is more distant from City A's closest fire
station than it is from City 8's closest fire station, an automatic aid agreement would arrange
for City 8's unit to be dispatched as though it were a part of City A's fire department.
Automatic aid agreements can be designed for first-responder services (both basic and
advanced life support), rescue paramedic services, and ambulances - in addition to the
traditional fire protection services.
Mutual Aid APn!ements -
"Mutual aid" is a cooperative relationship between emergency service organizations whereby
they commit in advance to provide assistance to one another in cases where an extraOrdinary
emergency depletes the resources of one or the other signatories to the agreement. It is
distinguishable from automatic aid in that it generally mquUes some command approval before
dispatching resources in response to a mquest. Also, it is based on the actual or anticipated
depletion of resources in the mquesting jurisdiction.
As a result, mutual aid is slower and more cumbersome than automatic aid. Though mutual
aid agreements should be developed between neighborina or nearby jurisdictions, it should be
recognized that they have practical limitations in day-to-day operations. Mutual aid is more
relevant to disasterS and other multi-casualty incidents.
Mutual aid agreements can be designed for first-responder services (both basic and advanced
life support), rescue paramedic services, and ambulances - in addition to traditional fire
protection services.
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l~lEMSA~H-
The p'1..ri<lftWp of San Bernardino County's local EMS aaency, known as ICEMA (Inland
Counties Emc:rpncy Medical Agency) to the City of San Bernardino presently is the subject of
an action for declaratory relief (Superior Court case No. 268390).
Aside from the 1cpl issues involved, the following expert opinion reprding the evolution and
impIICt of local EMS agencies in California bas been stated by consultant James O. Page in
c:onnection with pmcnt litigation between the City and County of Sonoma:
W1broup adoption of Div. 2.5 of the Health and Safety Code in 1980 ('The
Emer&ency MediC'll Services System and Prehospilal Emergency Medical Care
Personnel Act') the state legislature intended for a state qency (the Emergency
Medical Services Authority) to wc:oordinate and integratew all state activities conc:eming
emergency medical services. It is clear that the legislature intended for the Emergency
Medical Services Authority to achieve the desired c:oordination and integration through
a network of local EMS aaendes.
WThe pwpose of an emergency medical services system is to reduce morIality and
morbidity for victims of sudden and une>.pected illness and injury. It is my belief that
a number of California's local EMS aaendes have exceeded the legislature's intent by
attempting to command and control the resources of political subdivisions in punuit of
goals which have no demonstrable relationship to the purpose of an emergency medical
services system.
W A number of California's local EMS aaendes have in the past and continue to pursue
their aaendas with an attitude of arrogance and disrespect toward prdlospital care
workers and, in some cases, the employers of those workers. It is my further
observation that this inappropriate attitude bas in the past and continues to damqe or
destroy the inclination of prdlospilal care wolters and their employers to cooperate in
the coordination and integration of emergency medical services that was envisioned by
the 1~"I"hJre.
wIt is my belief that a number of California's local EMS aaendes, in their efforts to .
reorpnize and restructure the delivery of emergency medical services, are actually
attempting to reduce the number of providers which they would be required to
coordinate and replace them with one or a few private contractors who would be tolally
obliged to the local EMS aaency for periodic renewal of their contract, thus making
them submissive and compliant with the demands of the local EMS aaency.
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"There is abundant evidence that the manner in which most of California's local EMS
apncia have aaerted their power over prebospital providers bas actlll.lIy retarded the
adoption of Idvanced procedures, medications, and equipment, and all but destroyed
the intel'-hUlI curiosity of emergency medical technicians and paramedics throuahout
California, wben compared to other states.
"In many counties, the people who administer local EMS lIIencies have cIemonstrated
no aptitude for or inclinAtion to motivate prebospital penonnd to improve their
knowledge, skills and abilities, or to achieve the goals of coordination and integration
t1uou&h persuasion, training and positive reinforcement. It is my opinion that the
bureaucratic (and IOIIIetimes hostile) style employed by some of the local EMS
lIIencies is fosterin& negative attitudes amon& emeraencY medical technicians and
paramedics which, if not addressed and con'eCted plvmptly, will lead to adverse
consequences for patients and increased liability for EMS providers.
"In recent years, it appears that some of California's local EMS lIIencies have been
engaging in activity that is a great departure from legislative intent. In addition to
asserting the c1aimed ri&ht to franchise ambulance service providers to serve in
exclusive operating areas, they have barpined away the respective Counties' financial
obligation for emergency ambulance transportation of indigents in exchange for the
ambulance franchises. Secondly, they have permitted or authorized rate increases that
shift the cost to federal, state and private payers.
" Another apparent departure from legislative intent is the effort by some local EMS
lIIencies and/or their host county governments to subsidize ambulance service in
unincorporated areas at the expense of adjacent municipalities. This is being
accomplished by depriving affected municipalities and citizens of those municipalities
of the opportunity to select an ambulance service provider for themselves. By creating
a monopoly and franchising a provider to serve both incorporated and unincorporated
areas, and by also controlling or influencing ambulance rates (fees for service), some
local EMS agencies and/or their host county governments are, in essence, forcing
municiplll residents and their third-party reimbursers to subsidize the service delivered
in unincorporated areas.
"During the eleven years that California's local EMS lIIencies have been functionin&,
not one of them bas produced research data or other statistical evidence to demonstrate
the impact of their lIIencies' plans, propams, policies, l',ocedures or protocols on the
outcomes of significant numbers of emergency patients. Not one of California's local
EMS lIIencies bas produced accurate, long-term data concerning the response time
performance of providers in its county or region. Instead, the local EMS lIIencies have
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aeated a statewide hodgepodge of standards and regulations that start and stop at
county liDa. In at least two cases, disputes between nei&hboring local EMS lIencies
actually have impeded the delivery of needed emergency care.
"No other state in the nation has aeated or authorized an equivalent of California's
local EMS apncies. In essence, they have become an expeosive and unnec:essary
thIOw-blck to an earlier time wheA it was believed that health care planners and
administrators could utilize raearch data and logical persuasion to coordinate and
intepate medical services to achieve hiJher effectiveness and lower cost. In numerous
cases, California's local EMS agencies have been used to legitimize apparendy
fraudulent shifts of financial responsibility from Counties to MedielJTe, Medi-caI,
health insurance companies, and individual citizens. "
Aside from the foregoing opinions, the relationship between paramedics and the local EMS
agency includes the accreditation of paramedics after they have suc:cessfully completed the
state certification or recertification examination or process. Also, the local EMS agency
maintains records of continuing education achieved by individual paramedics, and it has
authority to initiate and conduct disciplinary proceedillgs against EMTs and paramedics.
County Health Director -
In nearly every other county or multi-county EMS region in California, the County Health
Director has effectively delegated off-line medical control functions to the medical director of
the local EMS agency. In San BemarcIino County, however, there seems to be an ambiguous
split of authority between George Pettersen, M.D., the County Health Director, and Conrad
Salinas, M.D., the medical cIirector ofICEMA.
On January 24, 1992, Dr. Pettersen explained that the role of the San Bernardino County
Health DUector in emergency medical services issues can be traced to the joint powers
agreement that aeated ICEMA. He explained that the original ICEMA board of dilectors
consisted of the County health officers of the four constituent counties plus a neutral fifth
member. "Tbe intent was not to have County health officers participatin& in (day-to-day
clecisions) of ICEMA but only to make ~ that the health officers would remain informed
(about ICEMA's plans and programs). Since that time, the San Bernardino County Board of
Supervisors has become the board of diIectors of ICEMA.
In the interim, Dr. Pettersen has asserted the County health department in the area of
ambulance rate regulation. Furthermore, in connection with the cunent controVerSy between
Courtesy Services and the City of San BemarcIino, Dr. Pettersen has made comments to Fire
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Chief William Wright which raised questions about the division of authority between Dr.
Pettersen's office and ICEMA. The current organizational chart of the County Department of
Public Health includes "Emergency Medical Services," with line responsibility to the Director
of Public Health (Dr. Pettersen). On January 24th, Dr. Pettersen explained that that
responsibility has been delegated to ICEMA. (See Appendix F)
Questions about this matter were directed to Dr. Salinas and Diane Fischer, the administrator
of ICEMA, on January 15th. While they were forthright in their responses, it appeared that
the relationship between ICEMA and the San Bernardino County health officer is not entirely
clear. While it was acknowledged that Dr. Pettersen has all responsibility regarding rate
setting, it was not clear whether he also has authority to mandate or influence such matters as
the response mode of ambulances (Code 2 or Code 3).
At a time when the relationship between the County and City of San Bernardino has reached
the point of litigation over power and authority to control emergency medical services, the
unclear division of power and authority between the County health director and ICEMA seems
to be an important sub-issue that needs resolution.
Cost Analysis
Rate Structure - \
"
At their meeting of July 9, 1991 the City- of San Bernardino's Bureau of Franchises received a
proposal from Courtesy Services of San Bernardino, Inc., for an increase in the rates for
ambulance services. The Bureau of Franchises considered the proposal and then unanimously
. recommended to the Mayor and Common Council that the rate structure be adopted. It has not
yet been adopted by ordinance.
Ambulance Cost Index Formula (ACIF)
The City of San Bernardino ambulance rate structure is a near-replica of the rate structure that
is set and maintained by the County Health Officer. The County uses Ambulance Service Rate
Adjustment Regulations, commonly referred to as the" Ambulance Cost Index Formula"
(ACIF). These regulations were adopted by the Board of Supervisors on April 23, 1984 by
Resolution No. 84-155. The ACIF is monitored, reviewed and adjusted exclusively by the
County Director of Public Health (Dr. Pettersen).
A copy of Resolution No. 84-155 and related documents is included with this report at
Appendix G. On January 24th, Dr. Pettersen explained that creation of the rate adjustmen~'
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process (ACIF) and regulations was inspired by a recession in 1983. He states that local
private ambulance companies were having difficulty surviving due to increases in cost and
uncertainty of revenues.
Dr. Pettersen states that the ACIF was an effon to "equalize revenue." He says he sees his job
as being responsible for assuring that ambulance service is available throughout the county
and, presumably. maintenance of the ACIF is intended to serve that purpose. He developed
the ACIF "with some help from legal people and others."
When asked whether he audits the books of ambulance providers in San Bernardino county in
the process of adjusting the allowable rates, Dr. Pettersen said he doesn't always audit their
books but has sent (Depanment of Public Health) auditors to do it on a couple of occasions.
He also stated that the private companies have a private consultant from San Diego who audits
their books as pan of the rate adjustment process. He advises that he doesn't know what level
of profit is considered allowable by his auditors.
Dr. Pettersen is a highly regarded public health professional. He serves as a member of the
California Commission on Emergency Medical Services and is recognized as very
knowledgeable in disaster medicine. His agency (the Depanment of Public Health) also enjoys
a high degree of professional respect in the public health community. However. regardless
how or by whom it is directed, ambulance rate regulation by local governments seldom
achieves its goals and often produces one or more of the following results:
1. Ambulance rates that permit illegal or improper cost shifting (e.g. where the cost of
emergency ambulance transportation for indigent persons is shifted from California
Counties to private and third-pany payers);
2. Ambulance rates that encourage padding of bills, skimming of revenues or other fraud
by ambulance service providers;
3. Ambulance rates that permit unreasonable profits to private ambulance service
providers;
4. Ambulance rates that cause or hasten the bankruptcy of private ambulance service
providers
5. Ambulance rates that become an instrument of political policy by increasing the cost to
residents of one jurisdiction to subsidize service in other jurisdictions.
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The ACIF c:umntly in use in San Bernardino County is not sufficient to evaluate the liquidity
or profitability of a private for-profit company. Even in the hands of a local government
auditor, there are insufficient cbecks and baJanc:es, and there is exeaclve reliance on bPvH-
assumptions. In CIIe"""'!, it treats the economics of a private business much like the budget of
a lovernment agency, including the failure to account for profit. It c:alculates reimbursement
revenue in put on the basis of Medi-cal experience, to the apparent exclusion of Medicare,
HMO and private insurance reimbursement experience.
AmhnlanM 1I.~ ~latinn - Five ChniM.'
lDcal governments have five choices with regard to ambulance service rates:
1. Create a liascz Caire environment in which rates find their own level. 1bis option
inspires profiteering, creates political reaction when users consider rates excessive, and
depends on the moderatin& effect of marketplace competition (which does not exist
whele an exclusive operating franchise (monopoly) bas been authorized);
2. Allow a body of elected officials to set rates. 'Ibis option almost always results in rates
that are IIIlP'"'licti~l1y low (in an effort to please voters). In setting rates too low,
elected officials either create a need to directly subsidize ambulance service(s), or they
unwittingly encourage padding, skimming or other fraud;
3. De1eptl! the responsibility for periodic rate regulation to public agency administratorS.
1bis option often pits savvy businesspersons against career bureaucrats and
lovernment accountants who have no experience in the dynamics of a for-profit
enterprise. The periodic nature of the process usually is insufficient to keep close track
of the effects of altered staffing arrangements, management innovations, or
reimbursement changes;
4. Create a continuous rate regulation process. Delegate the process to a non-e1ected
public official with the authority to empanel or retain both experts and members of the
public. The panel must meet at least monthly; retain the counsel of speci..1ias in
ambnl....- service nmnlIIement, business management and finance; and health care
reimbursement. The ~or problem with this option is the difficulty in keeping it
immune from political interf~..~nce, and maintaining the interest of public members
over the long term;
S. Create a quasi-governmental entity to manage and control ambulance service, including
rates for service. 1bis option, which is employed in the so-called "public utility
model" systemS, provides for an independent entity to serve u rate-setter and cuhier
(among other functions). It then pays the franchise holder (ambulance service) t'nIm
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revenues generated. The creation of a regulated monopoly is essential to this option, as
well as a full-time management staff to administer the quasi-governmental entity.
Obviously, there is no perfect solution to the problem of setting and regulating rates for
ambulance service. The City of San Bernardino presently uses a combination of options 3 and
4 (above). The City relies on a public agency administrator in County government (the
Director of Public Health) to periodically set or adjust rates (option #3). Then the City Bureau
of Franchises uses the County rate structure as the basis for adjusting rates (a version of option
#4).
At some time in the past, City of San Bernardino ambulance rates were negotiated with
Courtesy Services to an amount that is ten percent less than the current ACIF, as set by Dr.
Pettersen. Thereiore, when Courtesy proposes a rate adjustment, it simply presents to the City
Bureau of Franchises the County's rate structure, reduced by ten percent. However, Courtesy
has modified the descriptive language used by the County, and added two items that are not
included in the County rate structure ("Response to a call for ambulance not used" and "Rigid
collar").
The most recent adjustment of ambulance rates by the County health director occurred in May,
1991. In reporting those rate changes to the Ambulance Association of San Bernardino
County, Dr. Pettersen stated that the ACIF should result in an adjustment of average revenue
per "full pay response" of 6.3 percent (See Appendix H). However, increases in individual
items ranged from less than 1 percent (mileage charge) to more than 50 percent (oxygen
administration). Most items were increased 12.5 percent over prices listed in the prior rate
structure.
,
,
As stated, the ACIF takes into consideration Medi-Cal reimbursement policies and rates.
Those policies and rates are based on historical and arbitrary policy factors that often seem
irrational. It is not clear whether the County's ACIF attempts to create reimbursement
opportunities that will offset the impact of non-reimbursed or partially reimbursed ambulance
bills.
The proposed rate structure which was presented by Courtesy to the Bureau of Franchises will
be analyzed here item-by-item:
Basic life sUPllOrt response to a routine non-emer~ency
The official County rate structure refers to this simply as the "base" rate. Presumably,
Courtesy's use of the term "routine non-emergency" actually refers to the mode of call as it js
.received by the ambulance company. Generally, non-emergency ambulance transportation is
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the transportation of stabilized patients from facility to facility (e.g. acute care hospital to
convalescent hospital, convalescent hospital to nursing home, nursing home to acute care
hospital, or convalescent hospital to home). For Medi-Cal reimbursement, non-emergency
medical transportation requires a prescription from a physician, dentist or podiatrist.
In response to a question, Dr. Pettersen said that he considers this rate applicable to
transportation of patients without emergency conditions by ambulances that are not equipped
and staffed for advanced life support.
This level of service does not require paramedic personnel; basic life support emergency
medical technicians (EMTs) may be used to staff the ambulance. Although the authorized
County base rate for this level of service is 32 percent less than the rate for advanced life
support service, the starting monthly salary for EMTs at Courtesy Services is $1,333,
compared to $2,500 for paramedics.
This type of call can be scheduled in many cases, thus permitting more efficient use of
personnel and ambulance vehicles. Due to the non-emergency mode of transport, wear and
tear to the ambulance vehicle, plus the risk of collision, is greatly reduced. A most important
factor is the high probability that the patient will be entitled to some form of reimbursement.
These factors tend to make so-called "routine non-emergency" ambulance transportation more
lucrative than emergency work.
The present autfiq~zed County base rate is $238.44. The present City rate is $178.84. The
rate requested by Courtesy from the City is $214.60.
."
Unscheduled emer~encv call additional
,
,
The term "unscheduled emergency call" is a redundancy. By their very nature, emergency
calls are always unscheduled. The County rate structure refers only to "Emergency" and
authorizes an additional charge of $95.00. The present City rates authorize an additional
charge of $81.24 for "unscheduled emergency call." A review of seven Courtesy ambulance
bills (dated March through September, 1991) revealed that this extra charge was applied
randomly.
On January 24, 1992, Dr. Pettersen advised that this rate is intended to be allowed on top of
base rates for basic life support and advanced life support, if the case is an emergency.
According to D. Steven Rice, President of Courtesy, inclusion of this charge on ambulance
bills "has to do with Medicare billing." California Health and Safety Code Section 1797.,70
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defines "emergency" but does not use the word "unscheduled." Both Medicare and Medi-Cal
rP.imhul'lle for emeraency c:alls if it is a usual and customary charie.
Additional Charlles
FJich lIIil~ or fraction of a mile
-
-
It is standard practice for ambulance companies to bill for miles travelled during transport of
the patient. However, Mitb...~ th.. C:~n RPmllrtlino Cnunty or City rate schedules soecifv that
111~ mileage charie is to be limited to miles travelled durin:: transport of the patient ("loaded
miles"). In other words, the possibility exists that all miles travelled. to the scene of the
cmergency ~ during transport of the patient - are ~ej"a ~hllrged to patients in San
Bernardino.
Medicare and Medi-Cal billing guidelines state that mileage is payable for each mile travclled
only when the patient is in ambulance ("loaded miles"). Mileage is computed from polnt of
pick-up to point of delivery. On September S, 1991, a Medicare Special Bulletin stated that
" An ambulance... may bill base rate and loaded miles when the trip is out of their service
area.' This seems to indicate that mileage, loaded or unloaded, within an ambulance service's
normal service area. should not be billed (to Medicare). This was a departUre from the
"loaded mile" auide1ine previously used for Medicare claims.
While Medicare and Medi-Cal reimbursement guidelines provide for differential rates for ALS
and BLl> nUI.eap. th... $~n llI'mllrtlino c.onnty and City rate structures do not. Nonetheless, on
a number of Courtesy's bills, it was noted that the term "Mllllllgll ALS" is Jisl.<<!. It is not
known whether Counesy is charging mileage rates that are higher than those authorized by the
rate schedules, Their ambulance bills t..nl'l to qhow only the total fee beini charaed for
mileaae: they do nOI iJJcluut: lhe number of miles and the rate per milc.
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Waitinil time after first fifteen minute period: for each subsequent fifteen minute
period. or fraction thereof thereafter.
It is standard practice for ambulance companies to bill for waiting time on IlQIl-emergency
calls. Neither the San Bernardino County or City rate schedules specify whether waiting time
can be charged on emergency calls as well as non-emergency calls.
Waiting time is reimbursable under Medicare and Medi-Cal. The provider is to bill for total
waiting time incurred. The actual wait time must be documented on claim forms. Wait time
is to be billed in increments of 15 minutes. The first 15 minutes may be deducted by the third-
party carrier, considering it included in the response-to-call reimbursement rate.
Niilht surcharl:e. 7:00 o.m. to 7:00 a.m. Monday throu2h Friday or weekend services.
The County rate schedule allows ambulance providers to bill an additional $67.33 for "night"
calls. It does not define the applicable hours. According to Dr. Pettersen, this surcharge is
intended to apply to weekends as well. The present City rate schedule allows an additional
$52.18 for calls occurring at night (as defined above) or on weekends.
Although reimbursable under Medicare and Medi-Cal, charging an extra fee or surcharge for
ambulance calls received at night is not a universal practice with ambulance companies in
Southern California. Extra charges for "weekend" calls are not reimbursable under either
Medicare or Medi-Cal. Since ambulance personnel are not paid a premium rate for working
nights and on weekends, and since other related costs remain even regardless of hour of day or
day of week, there seems to be no justification for this extra fee or surcharge. On January
24th, Dr. Pettersen advised that the night and weekend surcharge was based on the supposition
that an ambulance provider might have to "call back crews" on weekends. He acknowledged
that this surcharge is a relic of history and should be reevaluated.
"
Each additional patient fifty oercent over char~e for one oatient
This charge is common within the Southern California private ambulance industry.
Paramedic Rates
The rate structure proposed to the City of San Bernardino breaks out "Paramedic Rates" as,it
.' distinct category. In this category are "Advanced life support response to a call," "E.K.G.
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monitoring," and "All inclusive advanced life support service." The County's rate structure
lists" ALS Base," :EKG," and "All inclusive ALS Service" as individual items on its list of
approved rates. It does not break them out into a distinct category.
On January 24, 1992, Dr. Pettersen advised that his interpretation of the" ALS Base" (without
the "Unscheduled Emergency" charge) was that it was an allowable charge for any ALS
transport without emergency conditions. He states that although it is intended to cover
situations such as an interhospital transfer requiring cardiac monitoring and maintenance of IV
medications (for example), the rate also is intended to compensate the provider for having a
paramedic and advanced life support equipment on board, whether or not it was needed in a
particular case.
Dr. Pettersen also described the" All Inclusive ALS Service" as including the "ALS Base"
(" Advanced life support response to a call" under the City rate schedule), "Emergency"
("Unscheduled emergency call additional" under the City rate schedule), and "EKG."
The altered format (of the proposed City rates) leads to confusion. For example, does
"Advanced life support response to a call" mean that advanced life support services must be
provided to the patient in order to qualify for the ALS billing rate, or that the ambulance
company must only resoond to a call which it believes will require advanced life support
services? Dr. Pettersen seems to opt for the latter definition, but is that what is intended or
desired by the City?
It is felt that Courtesy has relied on key words and subtleties in dispatch information to assume
that calls required advanced life support services - even though fire department paramedics
were also responding or on-scene. This, coupled with red-light-and-siren response, allowed
for doubling the total amount of an ambulance bill in some cases.
For example, in one medical aid case fire department paramedics responded to a case
involving a woman having a seizure in a bank building. The fire department paramedics
initiated and continued care of the patient, riding with her in Courtesy's ambulance to St.
Bernardine's Hospital. The ambulance bill from Courtesy listed" ALS Response" ($272.00)
and "Unscheduled ER" ($81.24) plus "Mileage" ($8.94), for a total of $362.18.
It is the fire department's contention that the bill should have been limited to basic life support
transport ($178.84) and mileage ($8.94), for a total 0($187.78. This case was referred to Mr.
Rice for review and explanation on January IS, 1992. On January 20th, he provided a written
.
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response insisting that the call was billed properly by Courtesy. The source of confusion may
well be Courtesy's reliance on Dr. Pettersen's definitions and interpretations - which
.
apparently have not been considered by the City's Bureau of Franchises.
In another case, fire department paramedics responded to a traffic collision at Highland and
State Streets. The fire department paramedics initiated and continued care of two patients in
Courtesy's ambulance to Loma Linda University Medical Center. The ambulance bill to one
of the patients listed" ALS Response + Unschedule ER" ($334.52) and "Mileage 2 Patients"
($74.90) for a total of $409.42. Aside from the question as to whether Courtesy's charge for
ALS services was appropriate, it appears they doubled the mileage charge. There is no
provision in either the County or City rate schedules for multiplying mileage by the number of
patients transported.
E.K.G. monitorine
The County rate structure refers only to "EKO" while the City's refers to "E.K.O.
monitoring." Logically, this should be a part of the advanced life support base rate, just as
monitoring of airway, breathing and circulation is a part of the basic life support base rate.
However, Medicare has established procedure codes for "EKO monitoring" and "Telemetry"
and either/or both are reimbursable.
All-inclusive ALS Service
Both the County and City rate structures include an optional rate for all-inclusive advanced
life support servi~. There is a Medicare procedure code entitled "ALS all inclusive," thus it
is reimbursable. '
The purpose of this optional rate, as it is stm.,ctured in the San Bernardino County and City
ambulance rates, is not clear, except possibly to provide the ambulance provider with a higher
. rate of compensation for calls requiring advanced life support service. For example, consider
the following billing options:
ALS Base
All-inclusive Rate
Base rate ............................... $272.00
"Unsched. Emerg." .................... 81.24*
Mileage** ................................ 19.10
EKG monitoring......................... 37.25
All-inclusive ALS Rate......................... $403.75
Mileage** ..................... ........,............. 19.10
Totals
$409.59
$422.85
.
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* This is not to imply that the "Unscheduled Emergency" charge should be added to the
ALS base rate.
.
** This mileage charge is used solely for purposes of illustration.
Confusion is increased by Courtesy's use of" ALS Base" on its invoices, accompanied by the
all-inclusive ALS rate (the ALS base rate is $272 and the all-inclusive rate is $403.75). For
example, in another case fire department paramedics assisted a 78-year old female complaining
of general weakness. Records indicate that fire department paramedics initiated care on scene
and throughout the transport to St. Bernardine's Hospital. The ambulance bill from Courtesy
listed" ALS Base" ($403.75), "Mileage ALS" ($26.82), "Night Call" ($52.18) and "Oxygen"
($22.37) for a total of $505.12. It is the fire department's contention that the bill should have
been limited to basic life support transport ($178.84) and mileage ($37.47) for a total of
$216.31.
When interviewed on January 15, 1992, Mr. Rice stated that his company discontinued using
the all-inclusive ALS rate in mid-September. He explained that this action was taken due to
conflicts with the fire department. "It (the all-inclusive rate) seemed to be misunderstood," he
said.
OXYl!en Administration
Presently, the authorized City rate for oxygen administration ($22.37) is considerably less than
the authorized County rate ($56.64). By comparison, the prevailing charge in the San Diego
and Imperial County locality is $40.00.
Re~nse to a call for ambulance not u<P1l
Apparently, this charge is intended to compensate the ambulance company for "dry runs."
Dry runs are not reimbursable under Medicare and Medi-Cal, nor are they authorized under
the County's rate schedule.
Rie:id Collar
This refers to a device which is used to immobilize the cervical spine (neck area) where injury
to that portion of the spine is apparent or suspected. The appropriateness of a charge for this
device depends on whether the item is disposable or reusable. Medicare reimbursement
.
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policies announced in 1991 now require that charges for nonreusable items be substantiated.
Reimbursement for rigid collars is not authorized under the County of San Bernardino rate
scbedule.
Emer2enc:y .mhtll.~ tranSDDr'lllJion of indi,ent ~s
In keeping with its legal responsibility to pay for emergency ambulance transportation which is
needed by indigent persons, the County of San Bernardino subsidizes Courtesy Services and
other ambulance providers operating within the county. Mr. Rice repons that the amount of
subsidy paid to his company by the County is approximately 511,600 per month ($139,200 per
year). Apparendy, this amount is intended to cover both the incorporated and unincorporated
areas served by Courtesy.
It is not clear whether this amount is based on the actual number of indigent persons
transported and the cost of that transportation, or whether it is a formula developed as a
compromise between the County and the ambulance providers. As this consultina report was
being written, it was discovered that some patients who have been transported by Courtesy
ultimately receive a demand-far-payment notice from the County Depanment of Public Health.
It is not known whether funds thus collected are paid to Courtesy, or whether the County uses
this means to off-set its subsidy to Courtesy (for emergency transportation of indigent
persons). In the one case which was discovered, the patient claims she received no bills from
Courtesy before receiving the demand from the County.
Ci~ of San ~mA1'dino User Fees and Membership PrQln'3.m -
During 1991 , as a means of generating revenues and recovering the costs of providing
services, the San Bernardino Fire Depanment was authorized to charge patients 5100 or 5200
per incident (depending on whether basic or advanced life support was required). This user
fee arrangement is somewhat similar to fees charged by several other Southern California tire
.
departments.
Presumably, the user fee system reflected the Common Council policy established in
September, 1975. That is, the intent for the San Bernardino Fire Depanment to be the
primary provider of paramedic services in the City. Particularly with regard to the 5200 ALS
fee, the user fee program assumed that only the tire department's ALS services would be
char&ed to the patient. At the time, it was not recognized that Courtesy was char&ing patients
for ALS services when their ambulance was staffed by a paramedic and had ALS equipment on
board - whether or not the ambulance crew performed any ALS duties.
.'
,
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At the time the user fee program was presented to the public, a membership procram also was
offe.:ed. For S24 per ........M\d annually ($12 for low-income households) the San Bernardino
City Fire Depu1meIlt offeNd to provide unlimited paramedic-level emergency medical
services with DO out-of-JIOCbt expense to a member or IIIlY permanent resident of the
member's bouseho1d, reprdless of what their insurance paid. The ~IO&-oam also promised that
members' insurance c:ompanies would be bUled directly with DO paper work or financial
responsibility for the member.
The p.."5l.un was lilli_bed with IIIl attractive four-color brochllM, a Spanish language
supplement, IIIld a membership enrollment application. The information brochure included the
following question IIIld answer:
Q. If I am a member will I still receive IIIl ambulance bill?
A. Yes, this membership does not apply to ambulance ttansportaIion. However, your
membership fee prepays IDX balIIIlce owed for City Fire Department paramedic
services needed during your annual membership.
For inexplicable reasons, as mmy as 7,000 households did not receive membership program
marketing materials in the mail. EMS membership programs usually require three to five
years of annual marketing to reach their potential (15 to 20 percent of households). Despite
the mailing difficulties, about 3,000 households (5-1/2 percent) signed up for SIIIl Bernardino's
program in its first year.
Another problem was to occur with regard to billing patients for the 5100 and 5200 user fees.
This function was contracted to Courtesy Services, due to their experience with ambulance
billing IIIld collections. According to Fire Chief Will Wright, the fire department was later
told by Mr. Rice of Courtesy that the user fees were not reimbursable under the social service
programs (Medicare &. Medi-caI). Still later, Chief Wright IIIld City FinIIIlce Director Andy
Green learned that the user fees m reimbursable from those sources. The city is now in the
p.ocess of obtaining a provider number.
Despite the clarity of the membership program's information brochure, some new members
simply did not understand why they received bills from the City IIIld Courtesy after IIIl
emergency medical incident. When they complained, IIIld some sent copies of their ambulance
bills to the fire department, questions regarding Courtesy's billing practices surfaced. Those
questions were compounded by the esoteric nature of the County's ambulance rate setting
process, Courtesy's alteration of the County's ambulllllce billing categories, and the City
Bureau of Franchises' adoption of Courtesy's proposal without further clarification.
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Service Costs/Profit Marein -
Private ambulance comoanies
Regardless of the service profile (e.g. City-operated paramedic service with private ambulance
transport), the level of excess revenues ("profit") will depend on cost factors such as labor,
physical facilities, purchase (or lease) of vehicles, insurance, communications equipment, non-
reimburseable supplies, debt service, administration, marketing and advertising, professional
services, and executive compensation. Variables on the revenue side of the ledger include
levels of subsidy, rate structures, social and economic factors which impact on collection rates,
and the company's effectiveness at billings and collections and cash flow management.
As a closely-held corporation, Courtesy Services of San Bernardino, Inc. is not likely to
permit a financial audit by representatives of the City of San Bernardino unless such an audit is
made a condition of Courtesy's exclusive franchise. Absent the opportunity to examine
Courtesy's financial information, it is impossible to speculate on the company's profits.
There is no reliable source of financial information regarding the profit levels of private
ambulance services in Southern California. In addition to the reluctance of private ambulance
providers to share financial information regarding their companies, it is believed that
sophistication in accounting and financial management varies widely among those providers.
Thus, even if a~ess to the financial information were available, it probably would produce
little more than "apples and oranges" comparisons.
Despite the secrecy, recent bid competitio~ for regulated monopoly ambulance service
contracts have required bidders to provide financial information regarding their companies.
Some of that information has been revealed, and it suggests that some of the largest private
ambulance companies are generating pre-tax profits of about 4 percent of gross revenues.
While that may seem to be a meager return, it can be achieved with a relatively small
investment of cash (see page 9 for a discussion of leverage and high-risk expansion in the
private ambulance industry).
The companies that are competing for multi-county or multi-state acquisitions and mergers
(high-risk expansion) mostly engage in so-called "all-ALS production." In other words, every
ambulance is equipped for advanced life support and at least one of the personnel assigned to
each ambulance is a paramedic. In keeping with peak load staffing and system status
management (see page 13), ALS units can be dispatched alternatively on emergency calls or
non-emergency transfers.
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While this may be efficient, the most profitable ambulance compllllies are those which shun
emeIIency IaVice IDCI concentrate 011 non-emeraency transfer work. For reasons discussed
below routiIIe non-emeraency ambulance transportation is much more lucrative than
emeraency work. In tict, in Kansas City, ambulance companies (other than the city's
exclusive COIltractor) are forbidden by ordinance from picking up and transporting non-
emerpnc:y patients within the city. The ordinance refers to such companies u "cram
skimmers. "
Wbere possible, a private ambulance company that concentrates 011 routine non-emeraency
medical transportation to the exclusion of emeraency work (a "cram skimmer") may be able
to achieve pR-tax profits of u much u 20 percent of aross revenues. 1berefote, a smaller
orpni....tiOl1 with smaller gross revenues may be able to achieve pre-tax profits greater than
those of a much larger organization. For example:
"All-ALS" emergency and
non-emergency ambulance
service nrovider
Non-emergency medical
transportation provider
(Wcrmm mmmerW\
Annual gross revenues:
52.9 millions
. Annual gross revenues:
5700,000
Pre-tax profit (4") =
5116.000
Pre-tax profit (20") ..
5140,000
From this comparison it can be seen that a private ambulance company's profits will depend
on a number of factors, especially in those systems where the company can provide a mix of
ALS and routine non-cmergency medical transportation with a mix of ambulance units
equipped IDCI staffed for those specific functions.
According to D. Steven Rice, President of Courtesy, his company has provided paramedic
service since the mid-1970's. However, he also reports that his company did not become an
"all_ALSO provider until October, 1990. Neither of those actions were required by law or
regulations. Probably, they were intended to keep Courtesy competitive in the face of fire
department cxpension into paramedic service, u well u the potential for invasions of territory
by other private companies.
In t.crms of profitability, the adoption of non-transporting paramedic services by the San
Bernardino rue Department in 1975 c:rcatcd an ideal situation for Courtesy. In essence, the
City assumed the responsibility of getting advanced life support services on-scene at medical
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emergencies within acceptable response times. The City also assumed the increased costs of
staffing and equipping the advanced life support program. Courtesy had an exclusive
opportunity to provide the transportation part of the system, staffing and equipping it at the
less expensive basic life support level. Several of Los Angeles County's private ambulance
companies have prospered under this arrangement for more than 20 years.
Upgrading to "all-ALS" status in 1990 may have been a gamble that Courtesy could force the
San Bernardino Fire Department to abandon its paramedic services. Mr. Rice's desire for
such an outcome is revealed in his October 8, 1991 letter to Mayor Holcomb. (Appendix n
Whatever the company's reasons for upgrading to the paramedic level, that action probably
increased its costs without creating a proportional increase in revenues. The decision also
altered the expectations of Courtesy's employees and the community. Other companies in
similar positions have found it necessary to increase rates, develop more inexpensive methods
of staffing, and become more aggressive with billings and collections.
It is impossible at this time to estimate Courtesy's costs. However, on the revenue side, some
reasonable assumptions and calculations can be made.
For example, it is known that 13,136 calls for emergency medical assistance were received by
the San Bernardino Fire Department. We estimate that about 75 percent of those calls resulted
in a transport by Courtesy (9,852 transports). According to recent research, the average fee
charged for ALS transport in the Pacific region (California, Oregon and Washington) is
$330.80. That amount, multiplied by 9,852 transports, would equal total billings in the
amount of $3,259,041. If only 50 percent of those billings were collected, net revenues from
emergency service would be $1,629,521.
Note that these numbers refer only to emerv:ency services (they do not include revenues from
non-emergency transfers or wheelchair van services). The average fee used in this calculation
is an average and may not be accurate in San Bernardino. Also, the percentage of collections
is a conservative estimate.
Fire deDartments
Usually, public agencies are not expected to make a "profit." Where fees for service are
established, it is generally expected that the fees will, at the most, recover a portion of the
costs of providing that service. However, if public agencies m expected to operate more like
a business than a bureaucracy, there should be incentives to do so. One of those incentives can
be the challenge of generating revenues that will exceed the costs of providing the service (in
other words, producing a "profit"). ,
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If the EMS function were a separate division within the fire cleputment, with its own budget,
it mi&ht be possible to determine the actual costs of providing the service. However, for
reasons of efticieDc:y and productivity, the vast majority of systems have utilized cross-trained
firefi&hterlEMTs or firefi&hter/paramedics in a dual role. In comparing the costs of
eDIaIenc:y medical services provided by a private company or by a dual-role fire cleputment,
the attribution of costs (to either fire protection or EMS) becomes an issue in trying to
determine whether revenues can exceed costs.
MarJinal costs
In essence, the only fire department costs that should be attributable to the EMS function are
those that are adlDl to the organization's costs by the existence of the EMS function. They
are called "marginal costs. "
rue protettion is a community need that exists with or without the delivery of emergency
medical services. 'I'berefore, in determining marginal costs, it is lleC""'ry to decide the
minimum number of people the fire department could meet its fire protection responsibilities
with if its EMS tasks were reduced or eliminated.
The following scenario presents a comparison of marginal labor costs of a dual-role fire
department ambulance service and the total labor costs of a private ambulance company whose
employees perform in a single role. Though this comparison makes no attempt to compare ,
operation and maintenance costs, labor represents 85 percent or more of total costs in
emergency services:
The Femwood Fire Department operates 11 stations with 11 engine companies and 2
ladder companies to provide fire protection and paramedic ambulance services in a 60
square mile area. Five of the engine companies are two-piece companies, consisting of
a fire pumper (engine) and an ambulance. Each two-piece company is staffed by four
persons, including two firefighter/paramedics per ambulance. All other engine and
ladder companies are staffed with three-person crews. The department operates on a
three-platoon basis, with all line personnel on 24-hour work shifts.
The fire department amb"l..- transport only emergency patients. Non-emergency
transports are handIcd by Apex Ambulance Service, a local company that also serves as
a back-up when all the fire department's ambulances are committed and unavailable.
Staffing for the fire department's dual functions requires 132 line personnel. If the
clepartmcnt's involvement in EMS were reduced from paramedic ambulance service to
only first responder services, the five two-piece engine-and-ambulance units could be
reduced to one-piece engine companies and staffing could be reduced to three perSons
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per unit. In other words, 15 firefi&hter/paramedic: positions could be eliJni....tM (one
position per each of the three platoons at each of the five two-piec:e companies).
'Ibus, the marginal labor cost for the Femwood Fire Department's paramedic:
ambulanc:c service is the cost of the 15 positions which could be eliminated,
plftl.mAhly without adversely affecting the department's fire suppression capabilities.
I>urina the last fiscal period, the fire department transportecl9,SSO emerpncy patients
8Dd generated net ambulance service revenues of 51,629,520.80. (See Appendix 1 for
expl.....tion 8Dd calculations) Apex Ambulance Service transportecl4,SOS emergency
8Dd 1lOIl-emerpnc:y patients from locations within the city. Apex I S fiDanc:ial
information is not available.
In response to the City's budget crisis, Apex has pn.posed to replace the Femwood
Fire Department ambulance service. Apex would staff its own ambulances with one
EMT 8Dd one paramedic per unit. Six ambulances would be provicled during peak
hours (at least 33 percent of the time), four ambulances would be provicIed at least SO
percent of the time. A minimum of three ambulances would be available at all times.
(See Appendix 1 for illustration of Pd>posed ambulance staffing8Dd availability)
This would be the equivalent of 4.16 ambulances (100 unit hours to handle an average
of 39 ~ergency and non-emergency transports per 24 hours). Depending on
workweek. y.rork schedules, sick time and vacation benefits, 2S to 35 persons would be
requiled to staff Apex ambulances in Femwood. Also, a supervisor would be on-ciuty
at all times.
"
Apex Ambulance Service pays EMTs an averaae of 517,000 and paramedics an average
of 532,500. The supervisor position would pay 535,000. Assuming the minimum
Dumber of 2S employees would be requiled, the salary costs for opentin& 4.16
ambnl..- 8Dd providing supervision would be $722,760 per year. A 20 percent
benefit JIIC""ge would add 5144,852, for a total of 5867,312.
Salaries for the 15 members of the Femwood Fire Department whose jobs would be
eliminated average $41,700 per year ($62S,SOO per year total). A 40 percent benefit
pI("""ge adds $250,200 to that amount, for a total of 5875,700.
In this ewnple, salary 8Dd benefit costs for the Femwood Fire Department paramedic
service are 58,388 more than projected labor costs for Apex Ambulance Service to take
over the service. However, it assumes the lowest possible personnel costs for the
private ambulance service. It would reduce the number of paramedics responding' to
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medical emerJencies from two to one. Also, this comparison does not include
overbead factors or the profit margin of the private company. (See Appendix 1 for the
eaJI'IJI,riOllS used in this comparison).
Two other factors are important in this comparison. Pint, transferring the paramedic service
from the fire department to the private company would make the fire cleputment less
productive (since penonnd cumndy are utilized for two functions). Secondly, the loss of
ambulance service revenues would exceed the _vinas ICbieved by e1iJni".ril\llS
firefighter/paramedic positions.
Again, the fact that most fire dcparIments have an existing body of trained or trainable
penonnd _ most of whom are already paid for by the fire 9JotectiOll budpt - means that the
actual cost for such an qency to provide another service (such u EMS) is the maminal cost.
That is, the difference between the total cost of operating the qency Md1 the additional
service, versus the total cost of operating the agency without the additional service.
The marginal cost comparison lIPPlies only where greater productivity from the existing work
group has been achieved by cross-training personnel with fire protection and advanced life
support training and then using those personnel in a dual role. It is that effic:iency which
allows fire departments (with higher salaries and fringe benefits) to compete apinst private
ambulance providers (who generally have lower salary and benefit P'li-iniga and high turnover
rates) .
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Resnonse Time Analysis
In terms of the basic pmnise of saving lives, the most important aspect of prehospital advanced
life support is response time. That is, the total e1apsed time between receipt of a call (for
emerpncy medical usiS1llJ1Ce) and the arrival of the needed emergency penonnel and/or
ambulance vebicle at the scene of the emergency.
The most time-sensitive medical emergencies lie those involving out~f-hospital cardiac and
respintory amst. Often referred to as "sudden death," this malady strikes as many as 350,000
people each year in the U.S. Most often caused by an abnormal heart rhythm (arrhythmia), it
results in an im......tiatl! loss of pulse (blood flow) and very quickly results in the loss of respiration
(breathing).
At the moment pulse and breathing cease, the victim is c:onsicIered to be clinically dead.
Nonetheless, with timely and appropriate interventions, a significant number of "sudden death"
victims can be resuscitated. In the best of circumstances, nearly half those who lie resuscitated
eventually return to a productive life.
The difference between clinical death and biological death usually is a period of six minutes or
less. When pulse and breathing stop (and clinical death occurs), the brain be&ins to die due to
lack of oxygenated blood. If appropriate interventions do not occur very quickly. irreversible
damage will occur and all hope for saving the victim's life will be gone.
Ideally, a friend, relative or bystander will begin cardiopulmonary resuscitation (CPR) within the
first minute after the victim collapses. CPR is a holding action; it is intended to maintain some
degree of circulation while emergency medical personnel lie en-route. The prompt administration
of CPR can enhance the potential for resuscitation of the victim but the CPR technique itself
cannot resuscitate the victim.
In EMS systems where dispatcI1ers lie ptoperly trained, they will be able to calm excited callers
and instruct them in CPR or other first aid techniques prior to arrival of first responders and
paramedics. Still, DO matter how prompt or apr..oprlate the intervention of friends, relatives,
bystanders or dispatchers, research data shows that their actions will be of little consequence
unless official rescuers (first responders) arrive at the side of the victim within about four minutes
after collapse, and unless advanced life support is administered (by paramedics) within about six
minutes after collapse.
Therefore, response time standards lie set by nature rather than law, regulation, custom or
consultants. If response time standards lie set which do not provide the needed medical .
interventions within the neces",ry timeframes, a percentage of cardiac arrest victims will be
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deprived of an opportunity for resuscitation and survival. Few issues in emergency medical
services are as c:Jear~t.
F1'lIdile 'l1V""til~' """""l'P.IIIMt -
Nonetheless, seven! private ambulance industry consultants have advocated and specified an
ambulance response time of m&bl minutes (which, in some cues, they have intetpreted as eight
minutes, fifty-nine seconds or less). Consultant lack Stout also introduced to EMS the fractile (or
quantile) method of measurin& response times. This method is an alternative to using avmaes,
and it measures compliance against a given value. For example, 90 pen:alt of all calls with a
response time of eight minutes or less.
By contrast, in San Bernardino County and elsewhere, it is more common to state or measure
EMS or public safety response times as "avmaes" (actually the "mean"). This measumnent is
calculated by obtaining the sum of all response times and then dividing by the number of response
times being measured. The flaw in this approach is that it allows for gross deviations to be
obscured by the average (see Figure 3).
8lUre 3. r.lculatinl! Avera,e R~se Time
For example, consider the following five response times:
{>n ,
Remonse times {in minutes'
. . . . .
.
.
.
.
.
.
1
2
3
4
S
(3 min.)
(S min.)
(11 min.)
(1 min.)
- ('2 min.)
The sum of the five response times in Figure 3 is 22. When they are divided by their number
(five), the averaae is 4.4 minutes. Stated as an average, this appears to be a superb response time
performance. But it obscures the fact that one response time was 1I,,~ly long. Using this
form of measurement or comparison, twenty percalt or more of response times could be
ex<:el'ftve and the avmaes would not reveal them.
An advantage of the fractile (or quantile) method of measuring response times is that it can be
used to reveal the extent of compliance with or deviaIed from the established compliance value.
Also, it can be used flexibly. allowing for the compliance value to be set according to local needs
or goals. It can be applied to individual geographic plots, areas or districts, thus allowing for
accurate measurement in bard-to-serve areas as well as easy-to-serve areas.
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At present in the city of San Bernardino, both first response and advanced life support units are
operated by the qty fire department. Due to the factors mentioned above (the physiological
requirements of many patients), the fire department's engine company first responders and its
paramedics (operating on paramedic engines) respond as quickly as possible when called, and
travel to the scene of the emergency as quickly as possible within the constraints of safety.
According to fire department management, the average response time for first-in units on medical
emergencies in the city of San Bernardino is three to five minutes. In some cases, where the
emergency occurs in the first-in district of a paramedic engine company, the first-in unit will be
able to provide advanced life support. The average response time for paramedic engines
responding into adjoining districts is six minutes.
The "Code 2" controversy-
Since August 13, 1991, the fire department has been dispatching Courtesy to medical calls with
the instruction that the ambulance is to respond "Code 2." In San Bernardino, this means that the
ambulance is to travel directly to the scene of the emergency but ;1t normal traffic speeds, and
observing all traffic laws. In the event first-responders and/or paramedics determine the need for
more prompt arrival of the ambulance, they have the option of requesting by radio for the
ambulance to upgrade its response to "Code 3." The fire department's policy has become a source
of friction between the agencies.
Since fire departmem paramedics arrive at the scene of medical emergencies in six minutes or less
(average), the de~ment contends that there is no need for ambulance personnel to respond
"Code 3." Since tht fire department's paramedics can stabilize patients upon their arrival, a few
extra minutes before the ambulancearriYes will cause no harm. The department asserts that
ambulance vehicles unnecessarily responding-through the city under red-light-and-siren (RLS)
conditions is a safety hazard to motorists, pedestrians and ambulance personnel.
Courtesy has informed fire department officials that it is obligated to conform to a County
ambulance response time standard, and that it cannot meet that standard if its ambulances are
limited to the "Code 2" response mode in the city of San Bernardino. In the meantime, Courtesy
has adopted a policy of informing the fire department's dispatchers that responding ambulances
will arrive at the scene in "20 minutes or less. "
On January 15, 1992, when interviewed in connection with this study, Mr. Rice of Courtesy
advised that the "20 minutes or less" policy had been adopted on the advice of legal counsel. He
said there are no response time standards for "Code 2" responses and that "we know we'll get
. anywhere in the community within 20 minutes. "
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On January 15th, Mr. Rice also stated that responses by his ambulances in the city of San
Bernardino av~e four to four-and-a-half miles. He estimated that the longest response by his
units within the city might be seven to eight miles in length. He also stated that prior to August,
1991, his units responded to 90 percent of all calls in ten minutes or less.
The following materials from the 1988 book, Principles of Emerrency Medical Dispatch, by Jeff
J. Clawson, MD, and Kate Democoeur, EMT-P, should be considered:
"Actually, while maximal dispatching is indeed a convenient way to legitimize the need for
more equipment and personnel and may be viewed by some as legal hind-end coverage, to
send the entire possible response routinely creates more problems than it cures. First, what
happens in a maximal response? In tiered EMS systems, a set of first responders go,
followed by the EMTs and/or paramedics, plus, in some places, a transport ambulance.
The police are often sent as well. There may be up to three of four vehicles minimum
travelling the streets of the community, all using their lights and sirens.
"This sort of response is certainly appropriate if the caller has described a situation that
accurate prioritization indicates might be life threatening. It is!lQ1 appropriate, however,
in the majority of cases.
"In fact, anyone concerned about medicolegal liability and with enough power to do
something about it ought actively to seek ways to reduce the numbers of emergency
vehicles on the road, especially those travelling in the emergency mode. This is because
the most common stimulus of lawsuits in EMS stems not from negligent patient care, but
from emergency vehicle accidents. "
Dr. Clawson, who has served for many years as medical advisor to the Salt Lake City and County
fire departments, and Gold Cross Ambulance Service of Salt Lake City, has reported a 78 percent
decrease in emergency vehicle accidents in that city after he implemented a system to decrease the
number of emergency vehicles using red-light-and-siren responses to medical emergencies.
A study by the Tualatin Fire Protection District (serving a suburban area of Portland, Oregon)
demonstrated the myth of time differences between red-light-and-siren (RLS) responses and non-
red-lights-and-siren (NRLS) responses. The Tualatin Valley is a rapidly growing "bedroom"
community with many two-lane roads that are insuffIcient for the traffic that has accompanied
growth. Depending on time-of-day and day-of-week, it is not uncommon for traffIc to wait two
or more signal cycles to pass through the area' s many controlled intersections.
.
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Tualatin's dispatchers were trained as emergency medical dispatchers and then were authorized to
dispatch units RLS or NRLS, depending on evaluation of medical urgency (using protocols
approved by the system's medical director).
A total of 1,963 consecutive responses were evaluated. 905 of those responses occurred before
the new dispatch system was implemented. During that period, all 905 responses were dispatched
RLS and the average response time for this group of responses was four minutes, thirty-one
seconds. After implementation of the system, 1,057 responses were dispatched. 406 of those
responses were dispatched RLS and 651 were dispatched NRLS. The average response time for
this group of 1,057 responses was four minutes, fifty-eight seconds. See Figure 4 for illustration
of the study.
Fiiure 4
Tualatin FPD Priority Disoatch Implementation Study
Period
Cases
RLS
NRI _1\ Resoonse time
Pre
Post
905
1057
905
406
o 4:31
651 4:58
Time difference between pre and post implementation = 27 seconds
(Source: Principles of Emer~ency Medical Dispatch, Clawson, 1988)
. A 1978 study by the Society of Automotive Engineers and the U.S. Department of Transportation
attempted to determine the effectiveness of audible devices (sirens) in warning motorists of on-
coming emergency vehicles. It was determined that only 26 percent of vehicle occupants (in
stationary and quiet vehicles) could accurately localize siren sounds with windows closed. With
windows open, the figure rose only to 38 percent.
In other tests, it was found that drivers can be expected to respond to sirens that present
themselves, under optimal conditions, at distances of less than 400 feet. An emergency vehicle
travelling at 35 miles per hour will cover that distance in less than five seconds. The researchers
concluded that effective audible warning can be given only to vehicles travelling in the same
direction ahead of the emergency vehicle, to vehicles weaving slowly through dense, stationary
traffic, or to pedestrians. They noted also that sirens present only minimal warning to
approaching vehicles or to those on converging courses with the emergency unit. (Study col)ducted
: by Bolt, Beranek, and Newman, Inc., Cambridge, Mass., under subcontract to the Society of
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AutomOtive Engineers (SAE>, and the U.S. Department of Transportation, Transportation Systems
Center.)
A more recent ualysis appears in the December 1991 edition of Annals of Em_encv Medicine,
publisbed by the American College of Emergency Physicians (Lights and Siren: A Review of
P.mapncy Vehicle Wamin& Systems, by De LoraIzo, Robert A., M.D.) AIDOIII the conelusions
of that article is the following: "Several studies clearly demonstrate that the sireD is a severdy
limited wamin& cIevice, effective only at very short ranges and very low speed,. Differences in
siren mode do not appear to be important. "
The National Associ"rion of Emergency Medical Services Physicians (NAEMSP) bas developed a
draft position paper entitled "Red-Lights-and-Siren use in Emaaency Medical Vebicle Response
and Patient Transport". NAEMSP is a national organization of emergency physicians who
provide medical control in emergency medical services systems. The organization's position
papers often are used u de facto legal standards for various aspects of EMS systems throughout
the U.S.
The NAEMSP draft position paper (pertinent parts) reads u follows:
"The use of Red-Lights-and-Siren (RLS) by emergency medical vehicles is practically a
universal component of emergency response in most EMS systems and widely prominent
during the transport of patients. Its use in public safety predates modem EMS by SO Years.
However, very little data exists supporting its effect on patient outcome or even significant
reduction in response time. The use of RLS is a special privi1qe of emergency responders
that must be reserved for those situations in which life and patient welfare rely on its use.
The use of medical priority dispatch system protocols delineating the extent of RLS use in
leSpOII5e must be required and carefully complied with. The medical director of an EMS
system must have direct input into the policies and plocedura governing RLS use during
medical response and transport. Emergency medical vebicle driver training must also be
standardized and enforced by governmental authority.
Cumnt "..tidi'21 data on emergency medical vebicle accidents is inconsistent and
fragmented. State and nationall~lting mechanisms must be initiated and must include
all emeraency medical vehicle accidents.
The use ofRLS needs to be better studied and standardized. Clearly, indiscriminate
application of the RLS privilege cause- significant injury and death to responders, citizens
and patients, which in effect violates the prime rule of medicine, "First, do no harm. "
Accompanying the position paper are 13 guidelines, including the following:
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1. The use of RLS must be restricted to only those situations of dire circumstances and in
which response time has been proven to improve patient survival.
2. Other than in critical cases or multiple patient incidents, the RLS response of more than one
emergency medical vehicle is unnecessary and should be limited by medical dispatch center
policy.
According to Mr. Rice, his company is insured by AzStar Casualty Insurance. AzStar is very
active in a wide variety of risk management activities, but particularly the prevention of
emergency medical vehicle accidents. A current policy of AzStar's Center for Safety and Risk
Management states: "When there is a tiered response system, only the primary responder should
respond Code 3, and all other responders should respond non-red-lights-and-siren until or unless
advised otherwise. "
Against these facts, professional opinions and de facto legal standards, it would appear that
Courtesy's complaints are without logical basis. In a case where the emergency occurs four miles
from the location of the nearest ambulance, it will take that unit eight minutes (travelling at an
average speed of 30 mph) to arrive at the scene. If the distance is five miles, ten minutes will be
consumed in travelling to the scene. An increase in average speed to 4S mph will only reduce the
travel times by two to two-and-a-half minutes.
Given the relatively short response times by San Bernardino Fire Department first-responders and
paramedic units, t~,routine use of RLS by Courtesy would be unjustified and would represent an
unacceptable but preventable safety hazard. Also, it would violate current and evolving national
standards relative to the operation of emergency medical vehicles. If there is a County ambulance
response time standard that mandates or enc;;Urages universal use of RLS response, that standard
shou'i be rescinded or changed to reflect modem realities.
Comoared to po,pulation -
A traditional rule of thumb for predicting public demand or use of emergency ambulance service
was that one call for service per 10,000 population is likely to occur each 24 hours, on the
average. Thus, in a city of 148,000 population, using this traditional measurement, roughly 15
calls for emergency ambulance service could be expected each day (5,402 per year).
The traditional rule was first published in the 1970's. It was based on the experience of several
middle-class communities in Connecticut. While there are still Southern California communities
that generate only one emergency ambulance call per 10,000 per 24 hours, most experience a
higher rate of demand. In San Bernardino, it appears that nearly two calls per 10,000 population
occurred each 24 hours during 1991.
"
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Accordin& to D. steven Rice, President of Courtesy Services of San Bernardino, his COI1IJlIIIy
respoaded to 19,512 requests for service in tbe city of San Bernardino durin& calendar year 1991.
Of that number, 8,873 (4S.S") were ('1..eM as "Code 3" (emeqcocy), 6,738 (34.S") were
..1."-' as "Code 2. (llOIl-emergency), and 3,900 (20") were ..1..eM as "routine." Oftbe total
number of requests for service, 14,3SS (73.S") involved ambulance transportation of one or more
puialts.
Appropriate response times require that there be a sufficient number of emerpncy medical
vehi..les and personnel available. There are S15,600 minutes in a year. In San Bernardino, if the
average len&th of time requited for a crew to respond to tbe request, tIat and/or prepare tbe
puialt for trlDsport, transport the puialt, and return to service is SO minutes, 717,7SO minutes
(1.36 full-time amlwl.~) will be used. If ten minutes is tbe average len&th of time requited for
a crew to respond to a request, determine that no trlDsport is needed, and return to service, an
Idditional SI,S70 minutes will be used (.098 full-time ambulance).
In other words, if all requests for emergency and non~ency medical transportation in the city
of San Bernardino occurred in precise order, evenly spIICecI, each call would be received 27
minutes following the prior request and 27 minutes before the next request. In that ideal situation,
two ambulances would be sufficient to meet the city's medical transportation needs, although two
ambulances could not provide appropriate response times (due to time-and-distance factors).
In the real world, however, requests for emergency medical services and ambulance trlDsportation
are not evenly spaced. Although demand is predictable to an extent (for example, Saturday night
is likely to be busier than Tuesday afternoon), anomalies can and do occur. Therefore, even the
most aggressive ambulance system status planners build reserve capacity into the system.
One method of calculating the requited reserve capacity is a mathematical process called "queuing
theory." Such an analysis is not within the scope of this consulting project. Furthermore, at
present, there is not sufficient data available from Courtesy Services to accomplish such an
analysis.
Suppositions in this report regarding the number of ambulances needed to achieve particular
response time standards are based on historical factors in the City of San Bernardino. Although
this topic should be studied in detail, including the use of queuing theory, usually it is found that
the actual experience of long-term providers is the best and most reliable measurement.
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AnalysiS ofT ~l!:-Term J:ilUlMlII Viabili\y
of Private Ambulance ~l'B
An earlier section of this report discusses the history, trends and problems in the private
ambulance industry (Privatized Ambulance Service, pages S through 18). Since virtually all
private ambulance companies are closely-held COIpOIBtions or partaenbips, financial information
is not available for analysis of individual companies or the industry u a whole.
Tbe seaecy of private ambulance companies reprding their IilUlftcial information is
UDders1andable. During the month of January, 1992, while this study wu UIIdelway,
...... sentatives or employees of the City received contlctS from four large private ambulance
companies. All four expmsed an interest in replacin& Courtesy u the ambulance service provider
in the City of San Bernardino.
Despite the seaecy, in this camiverous environment, sharpened by competitive procurement
processes for exclusive operating areas or franchises, a few glimpses of competing companies and
those they displace have provided some insight. That limited information, plus press reports about
failed ambulance companies, permit some reasonable conclusions. It appears that the greatest
hazards to the financial viability of private ambulance companies throughout the U.S. have
included the following, not necessarily in a particular order:
1. Undercapitll1iution of start-ups or expansions;
2. Conviction for Medicare or Medicaid (Medi-cal) fraud;
3. Competitive franchise bidding ~lSrs;
4. Faulty cash flow management and/or lack of business acumen;
S. Strikes or other labor strife;
6. Negligence awards in excess of insurance coverage;
7. Sudden changes in Medicare or Medicaid (Medi-cal) reimbursement proc:edure;
8. Loss of exclusive franchise issued by local government;
9. Embezzlement by key employee;
10. Loss of or decline in local government subsidy;
11. Invuion of territory by competing private company.
There are numerous examples of private ambulance services failing without prior warning. These
examples have inspired the architects of regulated monopoly ambulance systems to guard against
such jeopardy. Among the protections are performance bonds large enough to permit the. City 10
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tab over the service if the contractor fails and forfeits the bone!. Another protection is City
owuersbip or Jeue of the ambulance fleet and equipment.
As indicat1'd eartier in this report, some of the leading private ambulance industry consultants have
czeated a 1O-Cl'11..d "privatized" form of ambulance service that uses the private company as little
more than a labor contractor. The quasi-&ovemmeotal protections built into this form of
ambulance service lIJe a reaction to notorious failures and abuses by private ambulance companies.
The J:"""c;bility of Medil'.lll Priority DiV"tchinl!
'Ibroughout this report, the development and operation of several state-of-the-ut components of a
modem emeqenc:y medical services system have hin&ed on the availability of trained EmerJcncy
Medical Dispatchers (EMDs). Indeed, uppadin&dispatcl1ers tbmughout San Bernardino to the
EMD level has been a topic of debate and deliberation for at least two years.
When asked whether his company's dispatchers were trained as EMDs, Mr. Rice of Courtesy
replied that a proposed EMD training program has not yet been approved by ICEMA. Fire
department management gave a similar reply to the question. When asked about the 91'oposed
EMD propam, Diane Fischer of ICEMA replied that it had been held up by the "fire EMS
officers" (the San Bernardino County rue EMS Officers Association).
RWto Fire Captain Randy Ammons, President of the Fire EMS Officers Association, offered
another explanation. He states that the process of considering EMD trainin& actually was initiated
by his association. Representatives of the association took the idea to ICEMA. ICEMA then
spent a period of time studying the topic.
In August or September, 1990, the Fire EMS Officers Association hosted a meeting on the subject
of EMD training. Both ICEMA and Crafton Hills College sent l~tatives to that meeting.
The following March or April, ICEMA unveiled a proposed EMD program that included
certification requirements and fees to be paid to ICEMA. According to Ms. Fischer, the Fire
EMS Officers AS5O('i"~on stated that they would not approve the program or allow it to be
implemented. Captain Ammons concurred that the Assrolltion objected strongly to the ICEMA
plupOSll. He says their objections centered mostly on the certification requirements and fee
schedules, but that they had less strong objections to other aspects of the proposal.
Between April and September, 1991, two or three meetincs or phone conversations were.
conducted between Captain Ammons and ICEMA staff. Through these meetings or conversations,
an agreement was reached and Captain Ammons wrote a letter to ICEMA on September 16, 1991,
confirming the agreement. He states that th= has been no response from ICEMA since that
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time. On January 15, 1992, Ms. Fischer stated that ICEMA bas been ready to implement the
p.oaram for some time, but that there is a need to print some forms prior to implementation.
RqJonedly, the acr=t-upon course wu to be limited to trainin& di,.td1ers in giving pre-arrival
instructions. 1bis wu to consist of a 24-hour course. Priority dispatching wu to be presented in
a coune which would be developed at a later time. On January 15th, Ms. Fischer iNIic:atcd that
the proposed program had been adapted from an EMD program implemented in Orange County,
California.
1be Orange County EMD program may be subject to copyright protection. It is possible that the
Jb...oUIl or parts of it cannot be adapted for use in San Bernardino or elsewhere without
permission from the owner of the copyright.
A few years ago, training public safety dispatchers u EMDs wu an option, viewed by some u an
experiment. Legal developments since then clearly indicate that EMD training is now a legal
S1aDdard applicable to any jurisdiction that maintains full-time public safety (Iispatching services.
1be technology is available, the trainin& and implementation is relatively affordable, the concept
bas been adopted in a large number of U.S. locales, it bas been instrumental in saving numerous
lives and preventing untold numbers of emergency nwIi",,1 vehicle colli.;ons, and the public
(larJely influenced by such programs u "Rescue 9-1-1") bas come to expect that level of service
when calling for emergency usistance.
We arc aware ~\(twenty lawsuits throughout the U.S., in various stages of litigation, alleging
negligent dispatching. In JHm; of the situations which inspired those lawsuits were the dispatchers
EMD-trained, nor were they usillg a medical priority dispatch protOCOl system (MPDS). In more
than 13 years since the concept MPDS c:oricept wu introduced, there bas never been a ~M
l!laim or suit. cl1~cful or otherwise. .oSling a diCNIteh c.entm' or u~ that had tra.in~ its
diilPBtchers as EMDs and ,,-, the medical priority dimlltt!h ~m. Durin& that time, more than
240 million requests for emergency medical usistance have been p..ocnsed by trained EMDs.
An example is the City of Los Angeles. Prior to 1988, when the City implemented an advanced
MPDS, it had received an average of three major lawsuits per year alleging dispatcher negligence
or other error. In 1987, for example, more than $SO millions in cliams were filed against the City
in dispatch-related lawsuits. Since 1988, there have been no lawsuits against the City of Los
Angeles alleging dispatcher negligence or error.
There arc three aspects to MPDS: provision of pre-arrlval instructions, the practice of dispatch
prioritization, and the authorization or limitation of red-light-and-siren responses.
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With rqard to pre-arrival instructions, the concept was slow to catch on becallle many public
officials feared they miJht be sued if their di'lP"tcher1 were aI10wed to offer first aid instructions
over the pbone. Actually, it now appears that the failure to provide pre-arrival instructions is
resultin& in lawsuits. We are aware of four lawsuits cunendy being Iitill't.ed where failure or
refusal to provide pre-arrival instructions is the key a11"9tion. Recendy, in the aftermath of a
report on the Good Morning America TV program about a cIispatcher's refusal to give pre-arrival
instructions, a group called "Parents Against Negligent Dispatdl Agencies" (pANDA) was formed
in Florida.
In some locations, dispatf:h. prioritization has been confused with "call screening." Where
dispatcbers are trained to prioritize calls, the Ieve1 of respoose to a request for nclcblnce is
determined by the trained dispatcher's ~lrill<<l use of a medi""lly approved protoCOl process. "Call
lICJW!ft;l'lg" is a discredited concept, in that it attempts to control resources by denying service to
some callers.
A standard, well designed, reputable medical priority dispatch system, produced and maintained
by a dedicated, stable organization, gives dispatchers and their employers a clear standard to rely
on. This objective, recognized standard would serve as a sound defense to any lawsuit so long as
it is followed. To assure that it is followed, a quality assurance system should be built into it.
The third aspect of MPDS, the authorization or limitation of red-1igbt-and-siren response, is
equally important to public safety and risk management. The materials commencing at page 97 of
this report ("The Code 2 Controversy") should be ample proof of the need for a colI\Plete medical
priority diSJl'tcb system.
Still further proof may be found in the following statement of position by the National Association
of Emergency Me<lical Services Physicians, published in the October-December, 1989, issue of
Prehomital and Disastl!r UM;rnn~:
"The trained Emergency Medical Dispatcller (END) is an essential part of a prebospital
EMS system. Medical direction and control for the EMD and the dispatch center also
constitutes part of the prescribed responsibilities of the Medical Director of the EMS
system. The functions of emergency medical dispatching must include the use of
predetermined questions, pre-arrival te1ephone instructions, and pre-assigned response
levels and modes. The EMD must understand the philosophy of interrogation and
telephone interventions, basic emergency medical priorities and interventions, and be
expert in dispatch. life support. Minimum training levels must be established, standardized,
and all EMDs must be certified by governmental authority. "
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Unfortunately, as it bas evolved, the EMD program which bas been negotiated between the Fire
EMS Oftic:ers Auocl,rion and ICBMA may be a comp.omiJed version of a previously cbanpd
plU&fIDl which probably was subject to copyri&ht protection. Furthermore, the decision to
implement only a part of the system may c:teatc public expectaIions that cannot be fulfilled (thus
increasin& liability potential rather than reducing it).
)l4l(li""l priority di'P"tt!lUng systems should be recognized as the nationallepl stIIIdard for public
safety and EMS dilP"tl'.hing. Trained EMDs (trained in all three upeek of MPDS) should be
COIISidered essential to the p.~ Iw1dling of emergency medi""l calls, and also essential to
defending llpinlt any claims or suits alleging negligent di~tt;hing.
~DmONAL ISSUFS
In addition to the topics specified in the Project Outline a number of additional issues were
revealed during the CClIISulting project.
Mun....pttl Power of Self-lW_llUltlon
The question of whether a California county or multi-county agency bas the power to control the
delivery of emergency medical services (including ambulance service) within the boundaries of a
municipality currently is the subject of litigation in San Benwdino County (Superior Court Case
No. 268390). In May, 1991, the matter of City ofPetaluma v. County of Sonoma was decided at
the trialleve1 (Sonoma County Superior Court, Case No. 179680).
In the Petaluma case, the court ruled that "All responsibilities and duties within the city or fire
district regarding prehospital emergency medical services are solely those of the city or fire
district, and the local EMS agency bears no duties nor responsibility toward said city or district. "
He further ruled that "The area within the city limits of Petaluma is not within the Sonoma County
EMS Area, not subject to the Sonoma County EMS Plan, nor to any Sonoma County EMS
Agency regulation, supervision or coordination except as may be agreed upon by the County of
Sonoma and the City of Petaluma. "
The Petaluma judgment bas been appealed by the County of Sonoma. Meantime, the City of
Sonoma bas sued the County of Sonoma to ch..nenge the authority of the County and its local
EMS agency to dicta~ to the City how it may provide prehospital emergency medical services
within the city limits (Case No. 111910). As of January 31, 1992, a deposition related to this
matter was postponed in anticipation of a settlement in favor of the City.
Apparently, it is the intent of the San Bernardino City Attorney's office to oppose the County's
suit (an action for declaratory relief). The aggressive pursuit of this matter is important tb
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mllllicipfliti.... thro1J&hout California. A thorou&h exploration of the '~..I.tive intent relative to
Health and Safety Code Sections 1797, et sell., is lon& overdue.
As staled earlier in this 1epOrt, the statutes CltpteSS tbe intent for local EMS agencies to "intepate
and coordinaIc" EMS resources and 1erVices. They do not authorize those lIencies to command
and control the resources of localgovemments. "Home rule" bas seldom been violated to the
e:ueat it is by local EMS agencies in California.
In San Bernardino and elsew~, the rationale for commanding and controllin& the public safety
and public health resources of mllllicipa1ities and file districts by local EMS agencies is that this
assertion of control willlOlllehow save lives, lI'inimi_ illness or injury, reduce sufferin& and save
money. That rati......'" is entiIely tbeoretical; tbae is Ibsolutdy 110 dala to "1JFSl that the
aovemance of local emelJeIlCY mecli~1 resoun:es by a county-wide or rqional agency bas
improved the status or fate of ill and injured people.
Furthermore, tIleR is 110 evidence that any organization, with only a handful of
clericalIadministrative employees, and virtually 110 grant funds to dispense, can positively
influence the c1ay-to-day activities and performance of the hundreds (or thousands) of EMS
workers operating within its territory. In the case of the City of San Bernardino and ICEMA,
there is 110 contract in existence between the agencies. Therefore, neither party bas any effective
method of cIefinin& their respective ri&hts and responsibilities or addressing perceived violations.
When asked about the absence of a contract, Ms. Fischer on January 24th stated that ICEMA
"bun't pushed the issue because of political considerations. "
As stated elsewhere in this 1epOrt, it is possible that some of the local EMS agencies have used
their assumed power to shift some or all of their respective Counties' responsibility for emergency
ambulance ttansportation of indigent persons to federal, state and private sources of
reimbursement. In some situations, this may lepresent violations of the federal False Claims Act.
In some situations, it may ~t violation of the Medicare anti-kickback statute.
In 1986, the City of Monterey Park, California, was contracting for ambulance service with a
company that had continuously served the City with paramedic ambulance service for about ten
years. Tbe City coacluded that it could obtain hiJher quality, more reliable paramedic service -
and create a new source of revenue - by placing ambulance service in its file department.
When faced with the competitive process requirements and exclusive operating uea provisions of
the Health and Safety Code, the City simply elected to stop referring 9-1-1 calls to the private
company.
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Recinn;ng July I, 1987, all 9-1-1 calls for emergency ambulance service were refened to the fire
clepartmeDt. The private compIIly wu not fOJbidden from operating in the city and, indeed, it
continued to serve hospitals and nursing homes with non-emergency service. 1brou&h this action,
the City wu Ible to double the number of puamedic ambulances serving the city, nlduce response
times, nlduce the avcnp ambulance bill by more than $150, provide a new soun:e of revenue for
the fire clepartmeDt, and serve the public with stable, 1oag-tam, career employees.
Clearly, this wu a cbaIlen&e to Los Angeles County's local EMS qency and the common
.t-.on that a City could not uniJataaIly change ambulance service providers. The County did
DOt zespood to the chlll....ge and the City of Monterey Park continues to provide puamedic
ambulance service throu&h its fire department. In the 1988-1989 fiscal year, the City off-set
appIOXimately tal percent of its total fire department budget with net ambulance service revenues.
llnrllmentatlon and E'IIlluatlon
At present, it appears that there is no on-going effort to evaluate the performance of the San
Benwdino EMS system, either through process or OU1COme measures. Even if thae wu a desire
to evaluate the system (for quality improvement, risk management, or continuing education
purposes) there is 110 practical data coJ1ection system in place.
As stated e!sewhere in this report, documentation of all aspects of medical emergencies is dietaled
by the polici~and procedures of the local EMS lIIeDCy. However, most of the fire service EMS
providers in saJi!=marclino County have elected not to cooperate with ICEMA in this activity, for
at least two reasons.
"-
It is common knowledge among EMTs and paramedics in San BemarcIino County that the patient
care report long used by ICEMA is not used for routine evaluation of the system. ICEMA simply
has received copies of the reports and then stored them, appuendy because it lacks the funds or
personnel to process the data and prepare analyses of it. The common perception of paramedics is
that ICEMA uses tile patient care report solely for tile purpose of justifyina clisciplinary actions.
Nonetheless, San BemarcIino Fire Department EMTs and paramedics continue to use the ICEMA
patient care report and to submit one copy of each report to ICEMA. In October, 1991, ICEMA
introduced a -Scantron- reporting system, designed for computer processing and tlbulation. A
copy of the form is attached at Appendix D. On January 24th, Ms. Fischer reported that San
Benwdino rue Department personnel are not cooperating with the new system.
Actually, when the system wu introduced, the County fire chiefs assoc:i.von objected to it on the
grounds that it wu too cumbersome and time-consuming, that the information it sought already
.
wu being lecorded by their agencies, and that ICEMA had imposed the Scantron system on
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providers without their input. Abo objectionable was the fact that ICEMA intended to charge
providers for the bJaIIk forms. Apparently, there was no effort by ICEMA to sell providers on the
system, or to persuade them that participation would benefit providers ~ their patients.
'!be RescuelMedical Aid Report currently used by the San Bernardino FiR Department serves
primarily to RlCOId billin& information, rdease the City from liability in cases of patient refusal,
lIIld authorize thinI-puty payment to the City. Except for IeVen lines of space provided for a
nmative deIcription, the report form does not allow for a deIClipti.m of patient symptoms or
complaints, vital sips lIIld times tabn, care given, or intenction with medical control or other
providers.
In terms of assurin& quality patient care lIIld defendin& Ipinst claims of necH&ence, the
preparation of a complete record of prehospital care OIl each and every patient seen by paramedics
is essential. 'lbe collected information should then be used to monitor and improve all aspects of
the EMS system. Whether ICEMA forms are used, or IIIOtber form of I'.~tal patient record,
this information should be procrssed lIIld analyzed by base hospitals, as well as the fire
department's medical dircc:tor and training officers, to cIevelop statistical analyses, monitor
compliance with medical protocols, and determine the need for altered training priorities.
ICEMA Re-'--" Protoeol'14OO3
In the mid-1970's, as a result of periodic confrontations between paramedics and police officers
(~.lIy CHP officers), \4oJci_I.tion was enacted to clarify the authority of various responders to
medical emerzencies and accidents. That legislation became Section 1798.6 of the California
Health lIIld Safety Code.
In spite of the fact that the statute bad served as a sufficient statement of policy for nearly ten
years, ICEMA elected to rewrite or capsu1ize the content of the statute and create the following
Standard Practice:
Responsibility for Patient Management
Effective January 30, 1985.
Responsibility for patient management rests with the health care professional on the scene
who is the most ~ir.lllly qualified specific to the rendering of emergency medical care
accordinJ to the California Health and Safety Code, Division 2.S, Section 1798.6. Thus a
"first responder" with first aid and CPR training may initially assume management of a
patient, but will transfer responsibility to an EMT-I when that individual arrives on the
.
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sa:ne. In the same way, responsibility will be transfened to an EMT-U, EMT-P,
Jegistaed nurse or physician if one arrives 011 the scene.
The individual assuming patient leSpollsibility must remain with the patient until
responsibility is transfened to a higher level medi<:lll professional or until responsibility is
lCt:epted by the receiving facility.
In the event of both public and private pmmedic perIOIIIIel arrivin& 011 the scene, patient
~ement responsibility will ordinarily rest with the first to arrive. It is, however, quite
1pp.09ri* for a public safety paramedic to transfer responsibility to a private agency
paramedic for transportation.
In December, 1983, an automobile accident in RedJancIs resulted in a joint response by the
Rled11nds Fire Department and Howard Ambulance SerYice. A dispute between the paramedics
employed by those respective agencies was resolved OII-sa:ne by reference to the above ICEMA
policy. However, the patient was aware of the dispute and Jater sued both the City of RedJancIs
and Howard Ambulance Service, alleging that the care she received was negligent (Betty Jean
Lavalleur v. Howard Ambulance, Inc., et al., San Bernardino County Superior Court No.
22S,370).
In 1990 or 1991, the RedJancIs Fire Department was concerned that the policy reprdinl
management of the scene did not seem to permit the transfer of a patient from fire cleputment
paramedics to a BLS private ambulance. The Department directed its concerns to ICEMA.
ICEMA responded with a revised VersiOll of the Standard Practice that provided the requested
authority to transfer patient management responsibility to an EMT-I for transportatiOll (under
certain conditions). But it included the following provisions:
In the event that both public and private emergency medical care personnel arrive on the
scene with the same qualifications, patient management responsibility will rest with the
first to arrive. Responsibility for scene management will always lie with the incident
commancIer having investiptive authority.
Reportedly, the Red1ands Fire Department was di.....tillfi.ed with the Jnuposed chanle (which goes
beyond what it was seekin&, and provides for less flexibility and cIiscretion in cases of public-
private joint responses than did the earlier Standard Practice). Also, the Fire Chiefs Association
and the Fire EMS Officers Awv-i"tion objected to the change. According to a .epresentative of
the Associ,tion, they were informed by Dr. Pettersen that the 9toposal was only a draft.
Subsequent efforts by repraattatives of the Colton and Rialto Fire Departments to have the draft
MViewed by County Counsel were rebuffed. The draft version became the final version, effective
.
November 1,1991.
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The San Bernardino City Attorney instructed the fire department not to comply with the revised
Standard Practice, It was felt that the revised rule would inspire private ambulances to "race to
the scene" so as to be in charge (and possibly to justify additional charges to patients).
On January 24, 1992, Diane Fischer was asked why the Standard Practice was changed. She
replied that the City of Redlands had asked for the change. The Chief of the Redlands Fire
Department, however, contends that they were simply asking for clarification of the patient
transfer situation and states that his department is not satisfied with the new Standard Practice.
The new policy remains in place. It is probable that it could serve as an inspiration for unsafe
efforts to arrive first at the scene of an emergency. Since its adoption there has been no effort by
ICEMA to resolve the questions and discontent of the fire service providers.
A major issue not previously raised is whether a local EMS agency, as an instrumentality of
County government, has the authority to regulate an area of activity which has been pre-empted by
state statute. After extensive committee hearings, and expert testimony by numerous witnesses,
the California Legislature created a statutory solution to the question of who's to be in charge in a
medical emergency. The Legislature did not authorize any entity of government to adopt
regulations interpreting and applying the statute. ICEMA's efforts to do so may be a matter of
regulatory overkill. At the very least, this episode has deepened the rift between ICEMA and the
county's fire service agencies.
The Evolution of Courtesv's Role
As reported at page 7 of this report, in 1975 the San Bernardino Common Council considered the
issue of who should serve as the primary paramedic provider in the City of San Bernardino. A
motion to designate Courtesy Services as the primary provider failed by a vote of five to two. A
motion to designate the San Bernardino Fire Department as the primary paramedic provider then
was passed by a vote of six to one.
According to Common Council minutes, Mr. Rice of Courtesy stated for the record that he did not
wish to share the paramedic provider role with the fire department. From that point, the record is
unclear as to the process or timing of Courtesy's evolution into paramedic services..
According to Lee Gagnon, Business License Supervisor for the City, there is no record of a
franchise agreement between the City and Courtesy. Also, there is no record of a resolution
giving Courtesy the right to provide paramedic services in the City of San Bernardino. It would
.
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. appear that Courtesy's exclusive arrangement with the City is informal, and that the company's
decision to duplicate the fire department's paramedic services was without official sanction.
.
According to Mr. Rice, he first employed paramedics in the mid-1970s' but did not become an
"all-ALSo provider until October, 1990. Mr Rice may have been inspired to make this investment
by the perception that a take-over of the city's paramedic services might be possible. However,
when the City employed a new fire chief in May, 1990, they selected Will Wright, a former
paramedic with a strong commitment to emergency medical services and the efficient use of cross-
trained, dual-role firefighters as EMTs and paramedics.
Paying extra money to employ paramedics makes no sense for a private ambulance company
unless it can charge for the services provided by or available from those paramedics. Thus, it's
reasonable to conclude that Courtesy has always charged higher rates for services rendered by
paramedics, or where a paramedic and ALS equipment was aboard an ambulance. Apparently,
this did not come to public attention until the City imposed paramedic charges and customers
began to object to double-billing.
The creation of a rate schedule and review process by the County Department of Public Health
also may have given encouragement to Courtesy. Indeed, the County probably encouraged
Courtesy's evolution into paramedic service. Dr. Pettersen, Director of Public Health, has stated
that he considers it important for private paramedic services to exist in the city so that they will be
available to serve residents of unincorporated areas outside the city. In essence, to the extent that
city residents pay lor the duplication of paramedic services, they are subsidizing service in
unincorporated areas. .
The County's ambulance rate structure, whiCh was adopted almost without question by the City
. Bureau of Franchises, seems to allow Courtesy to charge for paramedics and ALS capability,
whether it is used or not. Over a period of years, Courtesy may have been charging paramedic
rates for ambulance service when the fire department's paramedics were providing all the
paramedic services. However, the County's ignorance or sanction of this practice does not
necessarily make it proper or legal under the rules of the third-party reimbursement sources
(Medicare, Medi-Cal, Kaiser and other health maintenance organizations, and private insurance
carriers) .
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It is beyond the scope of this study to dt:bwine whether Courtesy bas IOUght lIIdIor received
comp-_tion from thUd-party sources for services which actually were rmdered by the fire
department's puamedics.
One-and-one StaffiJll
Courtesy Savices chooses to staff its advanced life support (ALS) units with one paramedic and
one EMT, 1ft mangemeat known u wone-and-onew staffing. 'Ibe San Bcmudino Fire
Department staffs its paramedic units with two paramedics each. Courtesy's "-isiOll obviously is
economic. 'Ibe company's starting salary for an EMT is nearly half that for a paramedic.
According to a recent survey by the Emergenc:y Care Information Center, 67 percent of the
primary ALS providers in the nation's 200 most populous cities staff their ALS units with a
minimum of two puamedics. Eighty percent of the fire seMce ALS provicIers in the study staffed
ALS units with two puamedics.
A 1980 study in Philadelphia reported on 200 consecutive incidents of I'.~tal
About half of the incidents were handled with crews consisting of two paramedics each.
half were hlIJIdled with crews consisting of a paramedic and an EMT (one-and-one
According to the study, which wu conducted by the City Department of Pub1icBeal
DO survivors among those patients handled by the one-and-one teams, while 16
patients handled by the ~paramedic teams survived.
An informal, unpublished study in Los Angeles several years 110 used time-and-motion studies to
measure performance under different staffing profiles. 'Ibe process of caring for a simulated
cardiac arrest patient wu broken down into individual functions and movements by each member
of the ALS team. Each function wu timed and evaluated for overlap (simultaneous advanced
techniques by the two paramedic rescuers). Each of the functions and movements wu c1a,pt1 u
WbasicW (within the training and authority of ENTs) or WadvancedW (within the training and
authority of paramedics).
'Ibe study disclosed that wbcrc simulated cardiac arrest patients by one-and-one teams, one or both
of two results could be ~pected: (1) the patient would not receive all required advanced
techniques !dim required (the one paramedic member could not accomplish all the ..-ary
lIdvanc:ed techniques with sufficient promptness; (2) the EMT member of the team would operate
beyond bisIber level of training and authority (performing advanced techniques and procedures for
which be bad not been trained or qualified).
This appears to be a matter related to quality and the life-saving potential of the EMS system. In
Los Angeles and San Diego Counties, except for some pilot wusessment enginew and wrutaJ ALSW
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PJO&fIIIIS. twO panmedics per ALS unit are mandated. Any comparison of services should take
this important issue into account.
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GLOSSARY OF TERMS
A"""ftI'Nt life IU1IDl'Irt: All basic life support measures, plus invuive medical procedures,
includin&; intravenous therapy; c:ardi.ac defibrillation; administration of antiarrhythmic
mec.li....riOllS and other specified drugs, ll'edil'llrions, and solutions; use of Idjunctive
ventilation devices; and other p.ocedures which may be authorized by state law and
perfonned under mediCllI control. (Source: )lA~nl rue Services, Second Edition,
ICMA, p. 348)
Alm (AntnmAtM Extemal ~fihril1l1rionl: 'The use of a fully automatic: or semi-automatic
defibri1lator to deliver electrical sbocb to the victim of ventricular fibrillation (a rapid,
llOIl-functioaal pulsation of the heart) as a means of trying to restore functional rhythm and
pulse. Automatic defibrillators contain sophisticated miuoprooessors that analyze multiple
features of the victim's electrocardiographic: sipal. 'The fully automatic devices, when
attached and turned on, assess the rhythm, charge the c:apacltors and deliver shocb as long
as the rhythm is ventricular fibrillation or rapid pulseless ventricular tachycardia. 'The
semi-automatic devices require response and action by the operator, pided by messages
displayed on a liquid crystal screen to deliver a counter-shock. (Soun:e: Automated
Defibrillation, Weigel, A., et ai, Morton Publishing, 1988)
Al.i: See Advanced ure Support (this Glossary)
AmhnlAnCll!: A vebicular conveyance designed and operated for transportation of ill and injured
persons in a prone or supine position, equipped and staffed to provide for first aid or life
support measures to be applied during transportation. (Source: Managing Fire Services,
Second Edition, Internatioaal City Management Assn, p. 348)
Rllcic life ~: Generally limited to airway maintenance, ventilatory (breathing) support,
CPR, bealoabage control, splinting of fractures, management of spinal injury, protection
and transportation of the patient in accord with accepted procedures. (Source: Managing
rue Services, Second Edition, ICMA, p. 348)
W: See Basic ure Support (this Glossary)
CPR (l'lIntinntllm~ resu~tSIrinn): 'The combination of artificial respiration and manual
artificial circulation that is recommended for use in cases of c:ardi.ac arrest. It requires
special supplemental training in the recognition of cantiac arrest and in the performance of
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CPR. (Source: Advanced First Aid and Emergency Care (1973), The American National
Red Cross, p. SO)
CPR-traillfld ~....w: An individual who has been trained to perform cardiopulmonary
resuscitation, who is present and observes anotber individual suffer cardiac or respiratory
arrest, and who performs CPR on the stric:kaI individual pending the arrival of official
rescuers.
~ Mo.n...! Tli!lftllt"h",",~ A teIecomm1lfti...rions professional who is trained and
certified to ......-1y interrogate callers usin& pbysicjan-approved protocols, provide pre-
arrival instructions to callers, and match the evaluation of injury or illness severity with
emeraency vehicle respome mode and c:onfipration. (Source: Principles of Emergency
Medical Dispatch (1988), Brady Publishing)
EMf (emenren~ medical too!hnir.illn): A generic term referring to at least three emergency
care positions:
(1) EMf (sometimes known u EMT-Ambulanc:e), a penon who has been trained in a propam
of at least eighty-one hours in length and who has been -W.Oy.iately certified u proficient
in basic life support;
(2) EMf-Paramedic (sometimes known u EMT-P), a penon who has been trained in a
9lopaDl which includes, u a minimum, all fifteen modules of the U.S. Department of
TraIl~tion's National Training Course for the EMT-Paramedic, and who has been
app";,fll~' certified u proficient in advanced life support;
(3) EMf-Defibrillation (sometimes known u EMT-D), a person who is trained and authorized
to use portable cardiac monitOrs and defibrillators, to analyze certain cardiac rhythms, and
"-
to apply defibrillation whele app.uyt~. (Prompt defibrillation is the key factor for
survival of many heart attack victims. Whele these specilll1y trained EMTs are available
and can arrive at the scene in six minutes or less, EMT-Defibrillation programs have been
effective in resuscitating a significant percentage of patients for whom death wu certain
without this intervention.) (Source: Managing Fire Services, Second Edition, leMA, p.
348)
Exclusive 0JIeraDn2 Arm.: A g..o&flpbic area which may be created by a (California) local
EMS agency in the cIevelopment of a local (EMS) plan, whereby a single ambulance
Ien'ice is permitted to serve that area. It is required that a competitive process be used to
select the provider which will be authorized to serve the area, except that DO competitive
process is required if existing providers continue to operate in the manner and scope in
which the Ien'ices have been provided without interruption since January I, 1981.
(Source: California Health and Safety Code Section 1797.224)
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F"mt v"""",,-: Tbe first emagency cam penon to arrive at the scene of an -ecident or
iIIDea. Note: JlecIiIlJr fiR station locationl ue telected on tbe basis of time and distanc:e
flIctors, local fiR eqine crews most frequently ue tbe first emergency cam penons to
arrive at tbe ICetleI of acci~ts or iD~'lelo In IIddition to protecting tbe patient(s) from
furtber harm, tbey can initiate CPR or other basic life support 1'1.....atl1RlS, call for further
-..lema if nmlell, assess tbe patient's condition, IIMse incoming paramedics of
conditions at scene, and assist paramedics with patient cam. (Source: Mosby's Fint
Paponder, SeconcI Edition (1988))
T .....1 EMS .~~ Defined in CaIifomia _tllt,e u "tbe lIency, clepartment, or office having
primary rupooSl"bility for administmtion of emeraency ""'4liCl' services in . county and
wbidI is desipated pursuant to Chapter 4 (of tbe Health and Safety Code). (Source:
CaIifornja Health and Safety Code Section 1797.94)
Mfldical control: Physician direction of emeqency 1"e(Iica' cam delivered by paramedics in tbe
field, and of emergency medical communications personnel. This includes both of the
followinl functions:
Off-line medical control functions: DiJection of emergency medical personnel through use
of protocols, review of cases and determination of outcomes, and through training
proarams;
On-line medical control functions: Direction, via radio or telephone, of field personnel at
tbe site of the emergency and en-route to . hospital emeraency department.
(Source: Medical Control in Emer&ency Medical Services Systems, Subcommittee on
)If'(Ii...1 Control, Committee on Emergency Medical Services, National Research Council,
1981)
Non-emer2ellc:y ml'Jdical tranmortatiOll: Tbe routine or non-urgent transportation of ill,
injured, infirm, nonambulatory, or disabled penons to or from medical cam, convalescent
or nursing home facilities.
Non-trancnnrtin,: Refers to emergency vehi.;:loe-c, such u fiR engines or rescue trucks, that ue
uecl to u."vwt emergency medical services penonne1 and equipment to tbe scene of an
i1I~. or UVUIY, but which ue not ~pwt or equipped for the transportation of ill or
injured pc1'SOIlS in . prone or supine position.
1tPJIlr T...... Staffinl: Tbe "-Ian and use of. variety of work shifts by ambulanc:e services,
whereby more or less persons will be on duty at different times of the day (or days of the
week), based on estimates of what the demand for service will be during those times.
109
o
o
Post (11Im Postinr ' ......tinn): A planned locatiOll from which ambnl.- may be dispatched,
such u . meet comer, convenienc:e store parIdDa lot, fieeway on-ramp, or public
buildin&.
Prehomital (.11ft Pre-H.tal): Refers to racue and emeqency medical services rendered to
an ill or ilVuml penon in the out-of-hospital environment, befoIe they have arrived at a
treatment facility.
Private Amhnl.- Prnvi~ A privately-owned, for-profit, c:ompany or corporation enpaed
in die pnMsion of medical transportation or EMS. (SoIm:e: JBMS UOllftllll or EIIIeIJI!IICY
UfOJdi....1 ~..-\ "Glos,,")' of Provider Types, " Jan. 1992, p.78)
PriV1lti7JInnn: Commonly refers to a plocelS whereby die responsibility for services presently
or formerly provided by a government agency is transferred to . privately-owned, for-
profit, company or corporation.
Public Utili\}' Model: A regulated-monopoly ambulance system that ~ die exclusive
provider bued on a competitive proc:umnent process. Tbese systems are usually sin&le-
tiered, providing emergency and non-emergency service with an all-ALS fleet.
Commonly, a quasi-governmental entity supervises die contract and JI"'lCuullS
billing/collection services. (Source: JEMS UOllftllll or EmerJency Medical Services),
"Glossary of Provider Types," Jan., 1992, p. 78)
Rl\flll.ted MonQPl)ly: An exclusive franchise to provide a service in . defined geographic area,
subject to rqulation by the governmental or quasi-governmental agency which grants the
franchise.
Resnonse Time: The total cIapsed time bet\vecn receipt of a call (for emergency medical
assistance and ambulance transportation) and the arrival of die needed emergency penonnc1
lDdIor ambulance vehicIc at the scene of the emergency. This measurement of time should
include the time consumed by the call-taking and dispate" process.
System Status MUUIl~ement: A complex plOCCSS which attempts to manage the resources of an
EMS system before and bet\vecn calls by rna'Chillg the demand for services with the supply
of raoun:es. The process uses a variety of planned loc:ations from which ambulances may
be dispatc1led, and it constantly changes the size and sbapc of die aqraphic: areas to be
served by each available unit. Gcncra1ly, its JlUIPOSC is to meet response time requirements
with the least possible number of ambulance vehicles.
no
o
o
Tf'1!h~: A government and social system controlled by scientific technicians. (Source:
The American Heritage Dictionary, Second CoDeae Edition)
Unit-hour TTtili7.lltinn Rate:
Unit-hour: One fully staffed and equipped ambulance vehicle available for one hour. Also,
can be UIed as a measurement of cost by c:a1cuIatin& all direct and indirect expenses that are
'--"'ry to provide the fully staffed and equipped ambulance vehicle.
111
1.
o
o
INDEX
31 USCA 3729 17
ACIF 68,69,70,71
AlDO 22,30,38,45,53,109
Ambulance ASIO"i..ti()ll of San Bernardino County 71
AmbuIanc:e Cost Index Formula 68
Amb"I..~ .w:e mooopoly 8
American CoUep of Emerlency Physicians 91
American CoJle&e of Surgeons 21, 29, 38, 45, 53
.4mmnllS 9S
AIIIIals of EmerIency Medicine 91
Anti-Idc~lc statute 18, 19, 100
Antitrust 10
Apex Ambulance ServiCe 83,84. US
Automatic aid 58, 64
AzStar 92
Bay City 12
Bid competition 8, 12
Bolt, Beranek, and Newman 90
Bruce Bronzan 11
Bureau of Franchises 68,71,76,79, 106, 107
CAA 11
Cadet firefi&hters 50
Califomia Ambulance Association 7, 11
California Division of Forestry 10
Califomia EMS Quality Improvement Program 27,35,41,49,56
City of Los Angeles 96
Civil War 5
Code 2 28,36,37,43,44,51,68,73,88,93,97
Code 3 28, 36,43, 44, 51, 68, 88, 92, 93
Common Council 7,68,78, lOS, 106
County Health Director 67,68,71
County of San Bernardino 78
Courtesy 7, 19, 67, 68, 71, 72, 73, 75, 76, 77, 78, 79, 80, 81, 82, 88,92,93, 94, 95, lOS,
106, 107
Crafton BiDs 9S
CRam skimmer 81
D. Steven Rice 7,72, 81, 93
Department of Health 18
Department ofPub1ic Health 68,69,78, 106, 108
DHEW 6
DiaDe Fiscber 68, 95, 104
Dr. Pettasea 67, 68, 69, 71, 72, 74, 75, 76, 104, 106
Dr. S,liftllll 68
ECIC 1,4, 15
~ 36,43,44,51,58,62,95,96,97,98
o
o
Emerpncy Care Information Caller 1,4, 15, 107
Eme:rJCDCY Mec:lical Dilfl'ltcMr 97
Emeqeoq> Medic-I Savic:es Systems Act of 1973 6
Exclusive operatina area 9, 13, 16, 17, 18, 100, 110
46, SO, 54
Fair Labor Standards Act 6, 23, 31, 38, 46, 50, 54
Faile claims let 19, 100
Femwood Fue Deplrtment 83, 84, 115
Fire Se:rW:e LaboIer 50
FLSA 23,31,38,46,54
Fort Wayne 10, 12
Fort Worth 10
FrIctiIe 3, 8, 87
FSL SO
FUDeral directors 6
Gold Cross Ambulance Service 89
Good MorninI America 97
Harvard Community Hea1tbplan 26,34,41,48,56
Hi&h-risk expansion 9, 80
I~ 21,22,26,30,31,34,38,40,41,45,46,48,53,55,56,58,65,67,68,95,96,
98, 100, 101, 102, 103, 104, 105
Indian Wells 10
Inland Counties Emergency Medical Agency 21,30,65
Jack 7, 10, 12
Jack Stout 87
Jay Fitch !O
Kansas City "10, 13, 14, 15, 16, 81
Local EMS ac~es 13, 19,22,26,27,31,34,35,38,41,46,48,49,53,56,57,58,65,
66,67,99, roo
Lomita v. County oflDs AngeleS 16
Long Beach Fire Deplrtment 27, 35, 42,,49, 57
lDs Angeles County Fue Department 20
MarJinal costs 23, 31, 39, 46, 54, 83
Mayor Holcomb 82
Mecli-car 17,67,70,71,72,73,74,77,79,94, 107
Medi~1 control 22,30,38,43,45,53,60,63,67,91, 102, 109, 111
Medical priority di5p"tdt system 91,96,97
)I~~Ye 17,18,19,67,70,72,73,74,76,77,79,94,100,107
Membenl1ip Program 78, 79
Mobile 12
Montaey County 11
MPDS 96,97, 98
Mutual aid 3, 58, 64
NAEMSP 91
National Aaocllltion of Emergency Medical Services Physiclllns 91,97
National Hi&hway Traffic Safety Act 6
NRLS 89, 90
Oklahoma City 10
o
o
Palm Dm>t 10
PumtI.A.pin. NecJilent Dispatch Acenc:ies 97
Peak10ed staffin& 8,13,15,16,23,31,39,46,51,54,80, III
PIloeni'l[ 12
PiDc1Ias County 10
Pl.dIospitalllld Disaster Medicine 97
PriIIc:ipIes ofJ3mer&alCY Medic;.I Dispatch 89,90, 110
Privatized AmbuIaIIc:e Service 5, 94
Profits 9, 10, 69, 80, 81
Public Utility Model 7,8, 12, 15,70, 112
Quality Assurance 3,25,26,27,33,34,35,40,41,42,47,48,49,55,56,57,62,63,97,
114
Quality improvement 26, 27, 34, 35, 41, 48, 49, 56, 101, 114
RlJIehn MiII&e 10, 11
Red-lilht-llld-siIeD 61, 73, 75, 88, 89, 96; 97
RepIated IIIOIlOpOly 8, 9, 10, 12, 13, 15, 16, 71, 80, 94, 112
Reserve amlml........ 37,44,45,51
Response Time 3, 13, 14, 25, 33, 59, 62, 66, 86, 87, 88, 90, 91, 92, 93, 112
Rice 73, 75, 77, 78, 79, 82, 88, 89, 92, 95, lOS, 106
Richmond, VUJinia 10
RLS 88,89,90,91,92
Rucker ambulance wagon 5
Sacramento County 11
SAE 91
Salt Lake 89
SIll Benwdino County 19,65,67,68,69,70,73,74,76,87,95,98,101,103
SIll Benwdino Fire Department 7, 28, 50, 73, 75, 77, 78, 81, 82, 92, 101, 102, lOS, 106,
107
SIll Die&o 4, 12, 69, 77, 108
SIll Mateo County 11
Society of Automotive Engineers 90
Sonoma County 11, 98
Springs Ambulance Service 10, 11
SSM 13,25,33,40,47,48,55
State EMS Authority 27, 35, 41, 49, 56
Stout 8,9,13
Subsidi- 15, 16, 66, 69, 70
SubUdy 8,13,14,15,16,17,18,78,80,94
System status lDII1IIement 8, 13, 14, 15, 16,25,33,40,47,51,55,80, 112
'I'",I..tin 89, 90
Tulsa 7,8,9,12
U.S. Department ofHea1th 6
U.S. Department ofTIansportalion 90,91, 110
Unit-hour 13, 113
Will Wri&ht 79, 106
o
o
}I T\"F.~mIX II
Tulsa Trihune
EDITO
June 26, 1991
'.
"1"
. . '. . ".
,. .. .
.. . :"!;:;Io.':-::. '!. ':. '_. ~.'
~:'Wtm'e.,~:td curb EMSA ·
. ". :"".." ~. ,. '. .:.... ..;* ~ ...... ":. : '.;'.~"': ,...~.:" . :. . .~~
:' '~YOl" Wants rates sUbject ,to, City CounCllapproval
.f .:::...J I: ,~..: .' ," " . .
, .
. ....... .
'Do~ the pubUc'. bualn_ by meaas or. . fearful caIIt to~ Ullfort_te elloucb to
trii8t authorit)' can live elected offlclal8. req1l1re that ...,,11* The rate for all emer-
perfect out: ''Our banda.re tied," the)' ma)'. pac)' rua. _ ISI7, would 10 to '417 to
u,. wllen.the ..uthorit)' take8,'_ .ctlon MOS ander terma or the pl'opalllel Increue.
UftpOtN1&r with the pubUC; "thtire'., DOt1IiDC, Scbecluled __ &enc::r nma woaIelCO up
_ can do.boat IL" . :' .:. . from 1112 to 1201, and uueIIecIulecl nau
,. "Fcit"din.tel)'. Ma)'or Roeller i.nelle from 1110 to,l22I~ .
~. ~:.io be taklnl a 1_ C)'Dlcal 4pproaeb n_ rateuncl PrOpUM Irocr -- mllbt
to tM.'Z5 .....<leAt rate IDcr -- for amerc- be 1_ objectionable If elu.M were con-
ex~~- nma .. contalMcl III ~ pro- ,Ytncecl 'that EMSA ta runnIIIC . tlpt abIp,
poaecl 1111-12 bud&<< of the Eo._cency.. bolclblC ~ to . mlIIimam. But tbIa .. the
Mecllc~1 8enrlcell Authorlt)' (EMSA). He aame .utborit,. wbleb earUer tbIa year cave
. ......ed the I!:MSA board to cle1a)' action Ita a_tift clIrector, steve WIlUa_ a
on tbe. ~te to-. -- pencllDI further stud,.. pa)' and beneflta pecka.. that couIcl total..
'. And......,. he wUlMek c:IaaIIa- III EMSA'. mucb.. InO.IOO . ,.ar. It 18 the -
. .~:~.H~ If ~IIJ~TY.'to make Ita .uthorlt)' which tbree ,.eara aco .pent
: ; ra~ Abject 'to .ppI'OY.1 by tbe'Clt)' ~- 1111,142 to furnlab Ita OfflceL 'noM muat
:."ell,' .,.... '.' .... . bebarclflpreaforVUC<....lIlvoluntar)'cua-
Thaeare pI'Oblema either W.)', of coune. ~era to awaUow.
Elected offici.... pl.)'lnc to the cr.nel- And the wa)' In which the lateat rounel of
.tancla,.JII8)' ...._ to crant rate Increaaa rate InCreaaes _ put forward el_ notb-
.. that U'!i elearl)O JuatIfIecL Jlut that ta proba- Inc to In.plre conflelence. Clt)' Finance
o. bl,._I~or . ........ tbaA ~~Ible In-. Director Ron p.,..... hi_II. member of
: . cn..,...that ma)' be .pproved by a bOard tbe EMSA board,..,.. the notaUon of . rate
.nswerable to DO _ but llaelf. Inc:reaae .ppeared In fine prlnl In the pro- ,
'l'be olel Tulsa Clt)' Commlalon probabl)' ~ budlat Abmltted to memben laat
; uw. ioocl reaiIOD'for c:reatinl EMSA. TbIa month. "There ta 110 IncIIcatlon of wballt ta .
meant fewer beaclachea .for the comm~. to be uecI for." be ..Iel, .elellnc tbal he
.'. . "lonen:nO .....pOUp!or dt)' emplO)'eea,IIO' .ants'to IcIlOw where' the 115 .mWlon to JIe ':
new aelmblla&rator to deal with. C_.ted b,. four )'Un of rate Increuea ,
p' . "'Aid EMSA-baI been a .u_.ln terme of woulel be apeaL A lot of other .Tulsans .180 ,
t:.uie ciuall~ of tile Mr'Ylce It provides. But.t WCN.lelllke to kDow. .
.' ...........::..~__;,;...,I . .~.."~".~ ..... 6..'. 4' . --...-..
o
o
(
""I
AP1'FNDIX Fl
Pace 1 o~ 6
Audit Report
/'
"'\
METROPOU:-AN AMBULANCE SERVICES TRUST
IMPROYING THE MANAGEMENT OF
THE AM:ElULANCE SERVICE SYSTEM
FEBRUARY 1988
~ ~
~ote: The ~etropolitan ~ulance ~ervices Trust (~A~~)
is ~~e quasi-novern~ental mananement entitv.
MEDEVAC was the private ambulance contractor in
Kansas City at the time o~ this report.
City Auditor's Office
.
City of Kansas City, Missouri
~
.
o
o
A~~F.NDIX B, paqe 2 of 6
an__
. It- LO. .... ~ . cn-..1IAI1'
. .. -- ....... ...,
..n If tn. ....'~ .....- II tilt
I
flU _UI'MIIIT ......1. .1UL1lI
. ....... ..... nI, r rl~--' - ..........1- . ........1IUTa nil A.A..
- -=-- I ... . ...... -.. ,.,.....- - .
. .... ...... . ....-- - - 'HT' -
I
MnuNUr" ..._ amcu 1lIIIIT lIUITI -..1IICIIIIIIII.uc___1IAU
. ....... I"""'" It'. I .~--,.... . ...111'........... 1 I . ........ ---.. n'J
,- .17 ...- . Ie, . r ........ It 'f . ._--
. .---.,- . ........ - ... ,- -~ . 11 . ...-,,-
. AuIyae_ . I . . ~L'" .... ...AjllM"" . ... fI,l".- ~ _II~'" ...... .,....--.
~. ,_....~ 1 It ...-..~ .. ~ . Lr In. ..-
lit'" rlnlll . ,.,. ....11.. 1'1 -. . ........... . 1Ir_ .. I . ......'.011 11.11 ",
''''-___ILf - .-=... ..... .-..." . ...... ....L . TT II
........ .....- ... ~ . I . c Ilea .....t . hili . r -- II' - .I
c..... ~ - \ .~- , J ..._,... --- . 'UII rInIl ...........
.---,. A.' . . ...........4.. II "........... ... ~
-.- . . .,_ . .... ALl....... a..... .......
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. ....... .. ~- - II . . , ....---, ' . ......._...... r .__
-".-r~J . ...-. -....... _. . . ,-....., ......
. ......... J . ....., L- .L. - ... .___ I.. . . .
....... . ...... .....,....... ....... , ----,-.... .
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-f- .. .. -. as o. M ... ....-r I . .....
-....... " "f . -. . ... ....... rei . ....r..
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UlUI ern. __ .. 61.'-
IIUIllZIlIlII'L lTIlIC1'Va ,a PllllClPLI flIIIC1lIIIII .
~r ~ ........ ...._....... ............... ..... tllI~.' .
o
o
A~~ENDIX B, ~aae 3 oT 6
CHAPTER II
RESPONSE TIME: IMPROVEMENTS ARE NEEDED IN
COMPLIANCE AND CALCULATION
As part of our audit of the ambulance system, we were asked to
investigate factors affecting and ways of improving response times in
order to bring the First Council District's response times consistently
up to the City-wide target of 90 percent within nine minutes for Code 1
(lUe-threatening emergency) calls.
To begin our work. we researched the history of Kansas City's
response time requirements, reviewed current procedures. analyzed
various records and reports, and performed other tasks to verify the
accuracy of the available data used to calculate response time compli-
ance. Our work identified problems with the contractual definitions and
requirements concerning ambulance response times. Our work also
identified problems with the accuracy of computer generated response
time reports and a lack of documentation available to support the
reported data. We spent a great deal of time working with MAST,
MEDEVAC, and MAST's computer programming firm, in order to improve
the accuracy of the reported data.
The problems that we encountered with the data reduce the
reliability of any conclusions based on that data. After describing the
history of Kansas City's response time requirements and the recent
response time performance of the ambulance system. this chapter will
discuss several alternatives which could improve response time in the
First Council District, without attempting to determine the statistical
Improvement which would result from any of the proposed alternatives.
Also, the chapter will discuss in deta1l the problems with the original
respcmse time I_~I _thods used by MAST and make reCOlDlll8nda-
tions for improving the calculation of response time compliance percent-
ages .
Historv of Kansas City's Response Time Standards
The first mention of any response time requirements was in Ordi-
nance 50715, passed by the Council in September 1979, which stated
that the average monthly response time for all Code 1 calls could not be
more than five and one-half minutes, with not more than five percent of
the calls in excess of eight and one-half minutes. Code 2 calls were
required to average not more than seven minutes, with not more than
ten percent in excess of 12 minutes. In addition to these City-wide
standards, the ordinance required compliance on a council district
basis, by requiring the operator to maintain for each of the dis1Jricts
monthly response time averages of seven minutes or less for Code 1
calls and eight and one-half minutes or less for Code 2 calls.
o
o
A~PENDIX B, ~aqe 4 of 6
Frequency of Code 1 ll.."onee T1lIIe CoIIpl1ance
by Council District
For tbe 44 Montbs FrOll January 1984 Tbroulb AulUSt 1987
llas"onee Time CaKPliance Percentaae
90.0 80.0 70.0 60.0 Total
Council to to to to RUllber of
District 100.0 !!.:.! lli! !!:.! Kontbs
1 0 17 26 1 44
2 44 0 0 0 44
3 44 0 0 0 44
4 43 1 0 0 44
S 21 23 0 0 44
6 9 II II 0 44
-
Total 161 64 38 1 264
-
As the table shows. there has not been a month since January
1984 in wbich the ambulance system responded to 90 percent of all Code
1 calls in Council Dbtrict 1 in under nine minutes. In addition, the
system wu able to respond to 90 percent of the Code 1 calls in under
Dine minutes in CotmcU Dbtrict 5 in only Zl of the 44 months (47
percent) and in CotmcU District 6 only nine of the 44 months (ZO
percent). In COI1tra8t. in each of the-44 months of the same time
period. the system ".. able to respond in under lUDe m1Dutes to 90
percent or more of all Code 1 calls in Council Districts Z and 3.
To analyse the recent performance of the ambulance system, we
reviewed the monthly response time compliance filures for each district
for the eilht-month period from January 1987 throulh AUlust 1987.
This review found that Council Districts Z. 3. and 4 attained a 90
percent ratinl each month. This review also found that Districts 5 and
6 attained a 90 percent ratinl three and six times. respectively.
However. Council District 1 was only able to attain a ratinl of 80
percent on three occasions and received a 70 percent rating on the
other five occasions.
The ambulance system is able to comply with the City's response
time compUance requirements because Districts Z and 3 account for
approximately 50 percent of the total calls for the City.
o
o
APPENDIX B, paqe 5 o~ 6
IlAft .....S.
"'-;1.1. .f IdDIYAC ~ lea;:'. '..n If ....11 ~r1aaC.
... "aW lun uac _ I ..nee. 30. 1,.1 ~
_ .f I_fD070 I_loa T""I 1.
., "I'll _riun Oln'ftac. ...us_ - ~t-_ri s....
~MI'IIlcUa Daft !!!!!!! ~laC1'" hnnc... !!!!!! cl... raneau..
_.- I ,..~ 0- H4 53 53 51.5 ,. ,. g.,
!Mo_ 2_ HI- 121 20 13 10.' " " 11.0.
_.- '- 1SO - I."' 12 15 12.5 IZ II 11.1
-- .-- --
As the table show., 82.5 percent of the field staff have less than
three year. experience in their current position and 78.6 percent have
less than three year. in the Kana.. City, Missouri .ystem. The table
also shows that, as of August 30, 1987, almost SO percent of the staff
had less than one year of experienc.. Information receiv.d from the
other cities we .urveyed indicat.d that Kansu City's staff was far l..s
experienced than any of the other .ystem..
EPAB's Conclusion
The complete text of EPAB's conclusion on the data that we pre-
sented is shown below.
"After rec.iviDI your report of d.t. from tbe .udit of Hetro-
politan Mbulance Service. Trust aDd Madev.c, Inc. the curTant
cODtr.ctor for IllS ill laDs.. City, Ho., tbe EaerceDCY rbysi-
cisDs .AlIvisory Board believes that probl... ezist that .re
potentially detd.entel to the quality of care ill the syst...
The Board TOted to subllit these rec_ndlti01ll:
1. lecause of CODcern about the mmber of C01llecu-
tive boars worked, the loard feell an ab.olute Umit
aast be .et for .Wt hour. worked Ul this
syst~er.cnm.l .hould O1I1y be .llowed to work ·
_.~_ of fourte.n COlllecutiv. hour. and then must
tab . _~A.tory ten hour bre.k before .C.in report-
i1II for any type of duty.
2. The loard f1nda it undesir.ble to have 67% of the
per._el ill the .y.tem UVUlC two or le.. ye.rs of
experienc.. The loard encour.c.s all p.rties
CODcemad to uk. the n.c....ry chanc.. that will
promote r.t.ntiOD of p.rscnm.l .nd incre.se the
number of tenur.d m.dics.
The Board hope. that the.. rec_nd.tiODs will help your
office to cOllpleu ita report to the Clty Council and will
CODtribute to the City'. .ffort. to ...ure the CODtlnuanc. of
plity Emercency Hedicel S.rvice. Ul Ian... City."
11 Jl<!
o
A~~E~mIX B, ~age 6 of 6
Code 1 Compliance Percen~a.es
Before lellrol\"~u. Chmaes. After lellrOI\"-~"1 C1lllJlles.
aucl Af~er baoval of all Cauceled Calla
AuRUs~ 1987
o
Afur tte_val
Co_cil Before After of all
D1s~r1c~ lellrollTUIII1nl IlellroRrUlll1ul Canceled Calls
I 75.6 71.4 71.2
2 94.3 93.5 93.0
3 97.2 95.8 95.7
4 91.5 92.9 92.2
5 89.4 85.2 84.7
6 !!:1 !!.& ~
Overall 91.6 90.5 90.0
,
We contacted other ambulance systems around the country and
inquired whether they include canceled runs in their calculations of
response time compliance. For those systems which measure response
time. none include canceled calls in their calculations. Further. the
consultant who desiped Kansas City's system informed us in an inter-
view -t~t he agrees that the inclusion of canceled calls would tend to
overstat~ ,~ompliance.
It would appear that the inclusion of canceled calls in the calcu-
lation of response time compliance is not in accordance with the intent
of the Code and distorts the'response time compliance rate. We believe
that MAST should am_d its method of calcn1atinl raponse time CCIIIIpli-
ance by u:cludlnl all canceled calls from the calculations Wled, and
should incorporate this chanle into its system specifications and opera-
tor contract. If WAST feels a need to trade canceled calls, th_ this
trac:kinl should be performed separately from the calculation of the
response time compliance rate.
Recommendation
II-I. To more accurately calculate response time percent-
ales. MAST should:
A. More clearly define how the various types of
calls will be measured and include these defini-
tions in its system specifications and contract
with the operator.
B. Discontinue includinl canceled calls in the
calculation of response time compliance and
revise its specifications and operator contract
to reflect this ehanle.
.t'!
o
o
APPENDIX C
A Comparison of Occupational Stress Differences
between Fire Department Dual-Role, Cross-Trained EMS
Providers and Single-Role EMS Providers.
A Study Conducted by
Geoffrey Cady, MICP, James O. Pap, JD and Tom Scott, AM
Note: The appendix materials which accomDany
this study renort are not attached. Thev
are available"upon recruest.
Emergency Care Information Center
Jems CODIIDUnlcatlons
Carlsbad, CalIfornia
o
o
BacqrouDd
Previous research efforts measuring prehospital care provider performance bave been
Cl'~ewe1y difficulL 1'be III1SUper'Yised nature of the work environment makes efforts to
. observe actual EMS responder actMly fomUdable at besL
In . pubJisbed study calitled -Cardiac Arrest and Resuscitation: A Tale of 29 Cities, - the
authors MYiewed outI:OIIIe studies from 39 EMS propams in 29 different 1000tiont wbich
bad beeD pubJisbed between 1967 ancl1988. The focus of the SDJdy was to determine
posst"h1e rrasoDS for the diffe:races found in survival rates from out-of-hospital cardiac
mat amoIl& the various outcome stl.,tf1es. Althou&h the authors surmised that the
observed cliffeteDCCS in surviwl mes between systemS cou1d have beeD attribUtlble to
v."..tl...., in lenDS IIICI initial resuscitation efforts, they hypotbetl-' that issues reIaIed to
EMS system CODfi&uraDon may have played. role in observed survival mes.1
They concluded that -. geneaal improvement in survival rates occur u the EMS system
increases in sophistic:atioa. - Further cliscussion centered around observed differmc:es in
survival rates within system types, e.g., all EMT, EMf-D, paramedic.
One explanation was that diffeaenc:es found within system types wc= . function of the
quality of the vrogram. The authors state that: - A resuscitation is . comp1elt, dynamic:
process with many interventions. Systematic: problems or deficiencies in ~g CPR,
po","" placemellt in defibn"11.tlon, rhythm recognilion, or sequence of IJ'edltations cou1d
affect overa11 survivalllfeS. -I
Althou&h carcfiac resuscitation is oaly one of many scenarios performed by the EMS
~spoodas, it is one IbIt mquira . biP dep= of c:oopczation betwillCll the subpoups that
compdS!! . COIIUIIIIIIit:.'s EMS al..... It is the dynamic: aature of the EMS wOrt
caviIaameDt IIICI ill..... ""ov;y OIl the CllOIdiDatIld dl'wU of multlpl~ Rspo-"'- 51"""
that ~ _';t!II'" good CO"'~ IIId ......,.1t- 100ps betweca groups.2
,
System dI'~-- is ~~ ....t OIl bow ach sepaa1t or mponda- group of an EMS
system is intepaIed widllbe other. The effectiveness or ineffectiveness of these 51<>dp1 in
turD is . product of bow wc1l the iDdividual EMS responders peform within the group.
Row weU III EMS Iesp<ll"'- peduLms is deprndent on . variety of job-related factors and
cbaractaistics.
'Ibese envimnmenlll ~s IDd c:barIctcristic lie the basic: components that make up the
work envimnmenL '1bcy iIac11* the tub specified within the job description; the training
to do the tasks; orpnizI!iClIlal cu1tu1C, both functiona1lDd dysfunctional aspects; the
intrinsic and extrinsic be-fln of the job; and, the group dynamics. Row factors and '
c:haractcristic lie v1rni..., within the work environment can influence the development
o
o
and manifestation or la..-.ors outside or the orllln;.."tion' s control. Oc:cupational stress is
one such f'actor \\ith cc::trolIable and uncontrollable aspects.
Hi&h levels or occupational stress are well documented within the emeIJency raponse
environment.' Occupa:::onal stress is ftequendy cited IS one or the l_tf;I\& c:au~ or job
tf;eari~OJl amona puamedics. Dr. John Cox, author ora study or paramedics and
EMTs in the Salt Lah City area, states that the sttesSorS and main or prehospilll
employment -wiD first demonstrate itselr thmugh a VIriety or tee"'i"llY insiInificant
sips, such IS, a growini negative attitude, complaining, broadeniqg hostility, depression
and diminidJed job performance. -4 A later study published in.NwJ/s of Emergency
JletlidM by Dr. Jeffrey Hammer tided, -OccupaIiQllSl Stress W'1thin the JIarlI...""'ie
Profession: AIllDitial Report or Stress Levels ComplIed to BoIpilIl EmpJo,ees,. further
emphasizes that, -ne impact of stress on ~fu..1IWIeI! provides the a,jor reuon for
concern. -,
In addition to decreased job performance and its impact on patient care, EMS occupational
stress poses a serious tlueat to the health of the OIJ"ni7.llrion and its members. It bas been
estimated that nearly 85 percent of all disability retirements are the RSUlt of stressful
cx:cupations.' Rates or attrition within the profession have been ~..."tM to be IS high IS
40 percent alter two to five years of employment.' The hilh cost of training and
retraining, reduc:cd efficiency due to team turnover and loss or experienced supervisory ,
personnel consume vital human and financ:ial resources.'
Understanding the factors ISsnM"tM with the manifestation of streSS. can provide EMS
orpnizations the opponunity to develop methods of measurin& and miripri'1& its impIct.
Stressors found in the work environments of EMS responders can be pJacec:I in one or two
basic c:ate&ories: stressors tbat die OIJ"ni....rion maintains IOIIIe ~~ or control over and
~~ outside or the arpt'i....tL.n'1 infb_. 1!",,",'))let or ~...solI with Iiide pUCl;GtiaJ
Cor caatrol iIKitIM 00"- with humID ~ i1'I. syslem Ibuse, bigh levels or unccrtIinty
IDd physic:al......... .......n or job c:IIIracIaistic with ..~ ,o-thtl b ..catrol
iDc1udc: leCXT'i""". JM!'"'" ..~k, JC:IIecIuling. COJDIl""....tilll\. IdminisIrative Il1ppor^..
IdequaIe equipment, ..........,;0-11Dd W'eeI' advaDce-t uwvltlDl1ti-.1
EMS orpnizatioas tbat bave the Jalitude or fJaibi1ity to manipulate caatrollable sttesSorS
may be mme ~ or mduc:iDI the stress aperieDc:ed by their EMS ~ than
orpnizations with Jess fJrDbDity. EMS cqanizaIiou whose wmt environments c:ontlin
job charIrterl~ dIIt pocIuc:e lower levels or occupational stress would be IWApected to
bave EMS pel'JOIIDCl ahibiting lower levels of measurable stress.
o
o
The Study
To determine whether system configuration plays a role in the manifestation of
oc:cupalional stress in BIS personnel the ECIC conducted a study. The study consisted of
two pll,pc; a Iiwature ~w of the published studies on burnout, stress, system
confi&uration, job characteristics theory and work redesil11; and, a survey of occupatioDal
stress in 468 EMS responders from 10 different EMS systems. The survey was ..-f...mec1
by ICqUirin& data reprdin, job-related environmental characteristics of selected EMS
systems and comparin& this data to stress scores derived from the ~l!dielll personnel Stress
Survey - Revi-' IMPSS-R).'
1be instrument for pdIeriDa this information was ftlImM the PrdIospitlll FasOoo-J
Questionnaire (PPQ). 1\..spedi'Ye respondeDts were pnMded with a cover Jaa
introclucinl the survey instrument and a postage paid bncinoess .y envelope. 1be
respondents were paranteed anonymity and were told of the basic DatUJe of the study (See
Appendix A).
R~dent Seledion
We defined EMS system configurations as beinl one of two basic types: rue clcpartment-
based, dual-role, cross-trained (DRlCl) firefighters who are IeSpODSible for fire
suppression and EMS activities; and, systemS that employ single-role (SR) persoDDe1
responsible~f~ EMS activities only.'
,
In an effort to control as many variables as possible, we se1ectecl EMS systems wbich were
administered by p>enUIICDtal mtities. Additionally, we attempted to control system size
by selectiD& aaencies that were msponsiti1e for pnMdinc services to cities with
JX'P"1I_tion's of 1,000,000 or less. Ja an effort to iIo1-to! speclfil! cM"~.tiCl fouDd in
DRlCT and SR confi~ we c:bose only to evaluate these two types of sysIaDI.
1be DRlCT systems iDcl1"w in the study were all fire department based, with penOn~
!,","C01mb1& fire a.wa .:- ad EMS ICIivities. 1be SR systems were c:itbcr fire
dcpIrtmeDt based se:paraIe services, or a municipelly _dmini..... -tbiJd service. - Both
the DRlCT and SR systems were comprised of a mixture of personne1 workin& fradian-I
shifts (shifts less than 24 bouD in duration) and 24 hour shift assipments.
~
or the 468 EMS persoDDel who zetumed the questionnabe, 226 were respondePt.s
employed by fire dt.t-b4eIlts as DRlCT personnel (48") and 242 were SR respondeI1ts
employed by a fire cleputmeDt or JOVCmIIlCIll third service (52"). or the 226 employed
by DRlCT fire deputme11t1114 worbd 24 hour shift assipments (SO") and 112 worbd
frac:tiona1 shift assipmeats (SO"). A slmOat' analysis of SR personnel revealed that of the
o
o
242 respondents, 62 work schedules consisting of 24 hour shifts (26") with ISO working
fractional shift assipments (74"). See Table II.
Table 'I Survey respondents according to employing agency
and shift auignmem.
176
Fraetittnal Shifts
112
180
192
IaDl
226
242
DRICT
SR
Total
24 Hr. Shifts
114
62
468
The aver3p &Ie of the combined sample was 32.9 years. DRIer penoanel avmpd 33.1
years with SR personnel averaging 32.9 years of age. When tbe ..... was pouped
according to shift length, 24 hour shift penoawoJ had an PaaF &Ie of 34.2 years with
fractional shift personnel averaging 31.4 years of age. See Table n for additional ~;1~
regarding average age and distribution of the sample.
Table '2 Average Age by System Type .
Standard
Averaaa Minimum Maximum Dltviatian
DRICT 33.13 22.00 55.00 7.02
SR 32.93 20.00 53.00 6.52
24 Hr. 34.15 22.00 53.00 7.66
Frac. 31.43 20.00 55.00 7.41
Of 461 Who .~1ed tbcir aencIcr 383 were male (83") and 78 were "-n_I.. (11").
ADalysis by emplo,yer type sevaIed the same ~ far lender ~ for both
DRIer and SR 1183 ~ceal male and 17 perc:cDl female. In contrast, 24 hour aDd
fradionel shifts ~ big<< diffaeaces. Twenty-four hour sbifts were comprised
o
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of 89 percent male and only 11 percent female pmoMel, while 79 percent of &actional
shifts were male and 21 percent wen: female. For details of the analysis see Table 13.
Tabl. 13 G.nd.r d.scriP1ion by syst.m tYP. and shift
"ngth.
MIlA Fem.l. Iml
DRICT 182183%' 36117%1 218 1100%'
SR 201 183%) 42117%) 2431100%)
24Hr 155 189") 19(11") 1741100'"
Fnc. 228 179") 59121") 2871100'"
Marital status was found to differ slightly between system types. Of 464 respo.ldents, 113
&5jIO.ud being sin&le (24"> with 290 responding u married (63">, 19 iJuti...-f they were
sepuated (4"> and 40 stated they wen: divorced (9">. Table 14 provides ,w"il~ of
marital status findings.
Tab" 14 Marital status as it relates to syst.m typlIancl shift
IMgth.
~ U.rried Sllnamed Divaread
DAICT 36 (16'" 152 (69") 7(3%) 24 111 ")
SA 77 (32%) 136 (56%' 12 (5") 16 17")
24 Hr. 26 (15'" 130 174'" 513'" 14 (8'"
FrIc. 87130'" 180 156") 1415'" 26 18'"
As with pmrious 1tOOu... ID ,__t of ICqUired ed~tilJft was obtaiJled. Four hUDdled
IIId sixty-1M rrlpOl'dM ID . questiCXl zeprdinJ tbeir hi&J-level of ed'JClltW compleled.
EiIbtY&5I""Uld recciviD&. biP-school diploma (17.2">, with 226 indi....ti", they bid one
10 two ,... of co1Iep aperi- (48.6">. AnodIcr 86 &~ time 10 four,... of
coD. ed~nn (18.5">, 63 stared they bid . bae....1or deple (13.6"> IIId eiPt
o
o
indicated !hey had acquired .raduate degrees (1.7"). Please see Table IS for details
reprdin, system and shift configuration differences.
Table IS Differences in levels of education .. thev relate to
svstem and shift configurations.
DR/CT
is
24 Hour Fraetional
H.S.
1-2 yr.
3-4 yr.
&.A.IS.
Grad.
33 (15%1
106 149%1
44 121%1
32 (15%1
4 12%1
47119"1
120149"1
42 (17%1
31 (13%1
4 12"1
15 18"1
79145"1
51129%1
27 (15"1
3 12%1
65122"1
147151%1
35 (11%1
38 (13%1
5 12"1
Unlike previoUS resea!Ch efforts, this study also included a sample of EMS personnel wi!h
less than a paramedic level of c:ertification. Of 46S ~spondents who .~ their level of
certification, 369 (79") indicated that !hey were certified as a paramedic, EMT-m, or
EMT-IV; 42 (9") were certified as an Em-Intermediate, EMT-II, or EMT-CC; 33 (7")
were certified at an EMT-A, EMT-Basic, or EMT-llevel; 20 {4"> JeSpODded to an other
category. See Table 16 for further details reprding c:ertific:ation levels of personnel.
Table,6 Cenificdon levels and numbers of personnel accorcf'lIIg
to system type and configuration.
fM BAT-IIICC BAT -1/A QsbI[
DRICT 172 178"1 25 (11"1 12 15"1 11 15%1
SR 187 ISO"I 18 17%1 21 11%1 I 14%1
24 Hr. 11SO 182"1 8 (3%1 7 14%1 1 (1%1
FrK. 201172%1 35112"1 28 11"1 11 17"1
'Ihe aw:rap Dumber of JaI'S Ibat nspondeDts were c:er1ified was 7.52 years, with a
.millimum of.5,...- a .."nmwn of 23 years. IespondeDts averaaed 7.6 years at their
"mat c:enifjr!lItiftn level and employed by their c:umDt employer. 'Ibe millimum and
o
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maximum periods of employment with their current employer were 0.2 years to 17 years.
See Table 17 for additioaal details.
Table 17 Average time certif"..d and certified wid1 current
emplover.
Average Average
Toul Yra. at Yra. wid1 current
Current C.rt. CArt. and EmfllDVltr
DRICT 6.2 6.2
SR 8.9 7.6
24 Hr. 7.6 7.3
FnIc 7.4 6.6
Worn"!!: Environment
Our questionnaire requested information regarding any other duties or responsibilities
respondents performed while on duty. A list of possible titlelc:Jassifications was provided.
Some responded by indicatin& they had more than one addirional title, 8.1.,
fuefilhter/jlUBlMdic c:oordiDator. Out of 464 who responded, 300 ,eported that they had
.,tdirioaal du~ (65"> with 164 '5i"'rtinI that they had no additioaal duties (35"). Table
18 pracnts dath~prdinl system type and responsibility for one or more additional duties
by system and shift c:onfi&mation.
"
Tillie 18 Number of pel'ICIIlMI willi ICldItionII cIuIlu.
No. with
AclclIIIcIMI
nutIH
No. wIIhouI
AdcIltIonaI
nutIH
DRJCT
SR
24 Hr.
FrIc:.
189 186'"
111 145"1
148 184"1
152 153"1
31 114"1
. 133 155'"
28 116"1
136 147'"
Since first Jesponden play a vital JOle in most EMS systems, we asked a series of
questions in an effort to establish a Jevcl of involvement by respondents with first
JeSpOIlCIer trIining and A r -"ICDL
o
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Question #34 of our questionnaire asked if respondents were directly involved with some
aspect of first responder training? (e.g., periodic performance reviews, continuing
education, Ieftesher courses, periodic training, post incident critiques, etc.) Of 460 that
responded to the question, 299 responded that they did provide some training and
assessment (655') with 161 responding that they did not (35"). Table 19 provides a
listing of responses by system and shift configuration.
TlblII9 Response. to Question reglrding fim-r..ponder
nining Ind Issessment.
Auists in Does not usIst in
1 st-reSIlO"CIet 1 st-rUpoIlder
Train. &. A...... Train. ... A......
DRICT 168/77'" 52 /23'"
SR 131 /55'" 109/45'"
24 Hr. 1 39 179'" 36/21'"
Free. 1 56 /57'" 120/43'"
The second analysis in our series of usessments of first respond~ questions was performed
ClI1 Question 137. This question asked respondents if they rqulady work with the same
poup of first responders on medieal-aid requests? Of the 453 who IJISWeRd the question,
341 responded that they did work with the same group (15") IIld 112 responded that they
did not work with the same group (25"). Table 110 provides percentages and numbers of
responses by system and shift c:onfiguration
Table '10 ,"lIan... to QueatIon #37 ~ wulk'ng
wlIh _ fIm-raponder groups.
Works wlIh Does Not Work wlIh
S.me s.me
, ..r.....nnnd.r GI'tHJDS 1.....nond., GffWII.
DRICT 191 /88'" 27 (12'"
SA 150164'" 85 136'"
24 Hr. 156 190'" 18 (10'"
FrIc:. 179188'" 92 134'"
1be final analysis we performed on 1st-responder questions, was In assessment of Question
138. This question queried respondents u to whether they felt comfortable pointing out
o
o
possible problems with the medica1-slcills of first responders they work with. Of the 454
who responded to the question, 348 answered that they did feel comfortable (17") with
106 responding (23") that they were not comfortable pointing out poSSl"ble problems.
Table III provides number of responses and percent by system and shift c:onfiJUntion
Tabll 111 RI'PONI. 10 Quatlon 138. poinung out first-
rupondlr rnedicll-akiII problema.
DRICT
SA
24 Hr.
Frac.
Comfortable PoiDUng
Out 1st-ruponcler
Prabl.rn.
Uncomfortable Poinung
Out 1st-responder
Pmbl.ma
188188'"
180 188'"
145 183'"
198 173'"
31 114'"
75132'"
30 117'"
72 127'"
How our respondents felt about management's commitment to quality patient care was
assessed through Question 139. The question asked if they believed that tbeirsystem had,
wthe r--a"J administrative commitment to provide the highest level of patient care
possible?W Of the 455 that answered the question, 222 responded that IdmiDistzadve
commitment was prmn.t (49") and 233 responded that the commitment was not present
(51 ") to provide the highest possible level ofpalient care. Table 112 provides a svmnwy
of responses by system and shift configuration.
Table '12 Rtlp.... to QueItlon 138, rIOardinG .,stem
ClCII1IftIitmen to 1M provision of h/ohIIt Ie".. of
pedent ~.
DRICT
SA
24 Hr.
FrIe.
AdmirAb.dri
CommItment II
PrHMIt
AdmiIAb.d...
CommIIment II
Nftt ......Itftt
130158'"
82 138'"
103 180'"
116 (42'"
80 141'"
143 (81'"
70 (40'"
157 (58'"
ADalysis
The ~neI ~ S~ - Revilr1{ is . research tool that bas been tested in.
variety or studies. It was desiped and used by Dr. 1effrey Hammer in . study in 1985 and
o
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subsequently appeared in two more stUdies of EMS responders (See Appendix B). The
MPSS-R survey tool is comprised of 40 questions usinC a five point Librt-type scale for
derivinC a total streSS score.
The total stresS score is comprised of four sub-scales, each measurin& a subset of
questions. The subsets are lob Dissatisfaction, Orpnizational StreSS, NepDvc Patient
Altitudes and Somatic Distress. The range for possible scores is a ",ift;",UID score of 40 to
a "''"~'''UID score of 200. In two previously published stJ.t1ies in 1986 and 1989 of
peramedic stresS, the MPSS-R measured averace respondent StreSS levels at 103.99 and
106.1 respectively.'
After aeaeratin& MPSS-R total streSS scores for each respondent, tests were paf01il1ed to
ddl....Jne wbetber di1ferenc:es in the avemae MP$S-R scores, u they m1ated to system
c:onfipration (DRlcr VI. SR) and shift duration (24 hour shifts VI. some flIction of a 24
hour shift), were CflIricti,."l1y IdevanL
The following tables show averace MPSS-R scores u they re1ate to system c:onfi&uration
and shift duration. Table 113 indic:ares (at a significance level of P < .Ol)!) that DRlCl'
persoimel in the systems sampled experienced lower levels of occupational StreSS than the
sampled SR personnel.
TlbI. '13 MPSs-R Score by Systlm Type
SYSttIm TYDtl Mull m
Aunon...
DRICT 88.34 15.88
SA 101.22 18.07
228
245
TIble 114 analyzes MPSS-B. ........ in ,....ti.,.,d1lp to shift CCIIIfi&uzatiaa (syIIeID type was
Jp-ed). Of 454 <<~..t.-..I., 176 ..~ tbat they worbd a 24 hour sbift acJusiwly
and 278 I~ tbat they 1Iruokd some friction of a 24 hour shift. Jr-v-'-" ~I'll
24 hour shifts bid a ""ti.,;...11y sipificant (P <.OS) 10wer MPSS-B. score than ~
worm., some flactiO" of a 24 hour shift.
T'" '14 MPSS-R Score by ShIft ConfiguratIon
ShIft Canfia. Mull m
24 HolK Shift 91.43 15.52
FIICtiDnII Shift 97.37 17.77
R.m>>an...
176
278
o
o
In our first analysis of the MPSS-R stress score, DRier personnel experienced
sipificantly (P< .OCm less stress than their SR counterparts. It was hypotN..c;"M that
such differences between tested samples could be attributable to the cumulative effects of a
variety of environmental cbmcteristics.
These characteristics were split into two primary poups. The first group consisted of job
characteristic found in the actual objective attributes of the job. The second group were
c:han--"criCS found in the surroundin& EMS environment that were under the control of
the agency, e.g., scl1edulinl practices, hours per week, unit stationinl or postinl practices.
Wlth the advent of system statUS manapment many of the traditional Jt'Irioni'1&1posUnl
~~H have been abandoned for more fle:xible deployment strate&ies. The fle:xible
pncri'1l stnreeies rule from movin& from one Jt'Irion to another to cover for the in-service
primary response unit to actUally posUnl the ambulance in . shoppin& center parkinllot
for the majority of the shift. In most cases, fire deplrtments vti1i';"1 DRier personnel
continue to base their EMS vehicles from -static-Iocations.IO
Question /f29 in Section I of the Prehospital Pe:rsonnel QuestionnaiIe (PPQ) requested
respondents to indicate the description that best described their stationinl/posting plan.
Responses were then cross-tabulated with total MPSS-R scores. See Table '15 for posting
descriptions.
We found1hat personnel working at the same station and retuminl to it after each response
had significanti~ (p < .001) lower stress levels than respondents that choose either b, c or
d. All three of these choices involved some form of unit relocation either to . new station
or postinl1ocation. The hi&heSt stress scores were ISsocia~ with respondents who were
'-
...
o
o
posted in the ambulance. scoring almost 36 points above the average for b, c or d. See
Table 115 for details relardinl the results.
Tabl' 115 SUIU Lev,ls by Posting Locations I
I
Posting M.an
loeatian MPSS.R -&. A..ann...
A 93.10 15.77 322
Total 93.10 15.77 322
B 104.88 13.89 HI
C 137.75 35.24 4
D 110.88 22.78 42
Total 110.88 22.38 82
~ lleftnilio...:
A. "_"" from ..... lWion ...., mum to It 8ftto, _h
..........
.. "__ from . IWion in which. _ .....rning to ........
_ _ the ponibillty of __ng to -, pooting
ttation.
C. "_"" from . pootlng Iocalion. _ ........... to ooMoe.
_ __ to ...._ pooting Ioootlon _ ........ In the
..........
D. A IIOI'IIbinoticm of "." _ "CO.
ISH ~ A. for ".hnpiuI Po......... Quootlo.....ro'
A follow-up question ID Questicm 129 asked respondents ID list the types of _rion
ICIiviIia they were aDowed 10 eapp in while OIl duty. A list of pr-'hle IdiYi1ies was
pvMed, eKb jM J _A" ~b..dty for SIaIioned crews 10 RIreIl &om joIHeIatrld
III:dviSia _ bdcf {If-. III of time.
'1'bc ... YfJ1 foaDd Ibat, m 11IIII)' .,,~m~. fim aDd IJIIbuJaDce ....rinn. take ClIlIll .1_
bome liJle CIlYimamcDt. '1'bc ability to periodic-"y AI' .,..., &om the teasioas usoch.....
with -1fIl/tCY rapoIlllll! work, may be . partial exp1.n.rinn for the lower stress leYe1s
observed in ~._J JaPC""';"I &om IIld ICtUrDinIID the same ....rion, .
In III effort to furtber iJoI"'" the possible impact of posting locations on stress leYe1s. we
tested the ~ of various posti"l JtrlI~1!!!I OIl stress by coatrollini the shift lqth
variable. ToCIl MPSS-R ICORS were obtained from personnel assipod to fnclioDIl shifts
who mpoad 110m IIld JeIUID to same station (respondi"11D Question 129 with .."), IIld
1bose who .float. tbrougbout the system (responding to Question "-9 with "b., .c. or .d").
o
o
Table #16 provides comparative data of MPSS-R scores as they relate to posting and shift
c:onfigurations.
Tibia 116 MPSS.R .cor.. a. NY relata to .hift
configuration
MPSS-R Totll' Senr..
Sama
Station
loeatiDn
Multiple
Station
lGe8tiDns
24 Hr.
90.4 IN -1661
95.3 IN -1991
108.41N-101
105.9IN-771
Frlc.
The results of this analysis appear to add greater StreIlIth to the JdaIionship of posting
strategies and stress. NoteWOrthy is the significant (P< .001) impact posting 1""""011 has
on observed stress in fractional shift personnel, deployed in a flexible posting strategy
versus stress experienced by fractional shift personnel responding from the same station.
See Table #16.
In further efforts to identify factors or variables that could be responsible for the cliffen:nt
stress levels observed between DRlCT and SR personnel, we ~l.IT'illed unit worklOad as a
possible factor. The workload value was derived by .c-iping one hour per leSpOIISC and
dividing the number of respooses in a 24 hour period by 24. An equation was placed into
the dala base to Idjust for mpo-lCIents not working 24 hour shifts.
Systems wem divided UdD DRlCT _ SR. Both the hiV-_ Mat wlueI.wem foaad
in SR S)JtelDS (.95 hilhMt. .32 Jowat). 1be ditl't&~ betweca tbe awnpI of the
DRlCT IIId SR SJ*IDS was -ipri~t (p< .001). All ~.. m:np wlue of -'2 was
found in DRlCT SJ*IDS with the SR systems demonstrI!ing m m:np value of. 72.
Although the value was -ipifiQJldy higher, use of the Pcmons coneJation test,
demoDstrated the Jack of my significant c:om1ation betweell unit work-load and obserYed
stress 1eveIs.
This observatioa runs coatrary to the findings prnrnted by Jeffrey )Ii~-U, PBD in his
article, "Tbe 600-Run Umit.. Mi~-U foUJld that puamedics lIlIpOl'du,g to more thin
600 responses per year experienced higher 1eveIs of oceupatiooa1 stress thin paramedics
responding to fewer responses. II However, the finding is consistent with observations from
previous research by Cydulb, et ai, author of · A Follow-up Report of Occupational Stress
in Urban EMT-Paramedics..' '
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The absence of any correlation between unit workload and stress would suuest that
observed difference betv.-een DRIer and SR systems, as well as, differences between 24
hour and fnctional shifts are not workload dependent. Although the volume of work does
DOt appear to have any impact on stress, how the work is performed may be a factor.
In a study titled "Job Satisfac:tion in EMS: A Different Approach", the author applies
eIemeIIts of Job CJwacteristics Theory to EMS rdared activities. Turner and Lawreace
who first described the theory as a behavioral approach to the desip of work, p.opose that
there are certain attributeS that increase the satisfaction experienced by the job holders (See
Appendix C).12
R..,,1qoMn and Lawler in a study titled Employee Reactions to Job Characteristics, focused
on four job charlcteristics: variety, task identity, autonomy and job feedbIck. They
predicted that the jI'w"ce of these charlcteristics in a job would result in hiaher levels of
job ...ricf2cdon. Turner and Lawrence defined six basic attributes: variety, autonomy,
required inter.lCtiOll, knowledge and skill required and responsibility. 13
Question 19 of the PPQ asked respondents to list any additional responsibilities or duties
they performed while on duty. One hundred and sixty-four .~tted that they had no
additional duties (35~) Vtith an averqe MPSS-R stress scon: of 97.6. Three hundred
reported baving additional duties (6S~) with an averqe MPSS-R stress scon: of 94.5
significantly (P <.OS) lower than respondents .eporting no additional duties. Table 117 '
presents data reprding system type, responsibility for one or more additional duties and
corresponding stress scores by system and shift configuration.
Tillie 117 MPSS-R ItrUI acoru for penonneI wid! acIcIItIorwI
duIiea.
No. with ToIII No.wIthout T_
AckIIIIal'" MPSS-R AcIcllIIoMf MPSS-R
Dulin Reant DuIIH Reant
DRICT 188188'" 80.0 31 (14'" 84.1.
SR " 1(45'" 101.4 133 155'" 100.6
24 Hr. 148184'" 80.8 28 (16'" 15.7"
Frae. 152153'" 17.8 138147'" . 18.0
. TIIie... _. _....,... .. ..... ., J.' yra. .... ..... . ..... _ ., 21.'
,..., .... _ ........ .. 1M ...1ItI1 - . '<.001.
.. TIIie... _. -...-ww........., 4.J yra................ _., J1.1
yra............."".. 1M 40JlIeenlet '<.001 .... ,<.02, ......ollvoly.
.,
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Personnel with additional responsibilities would be expected acc:ordinl to Turner and
Lawrence, to have a createi' potential for job satisfaction. Increased responsibility and skill
variety is often a function of promotion within the SR EMS service. In the fire service
DRlCT personnel are b)O definition perfonninl multiple functions, potentially inc:reasinl
the skiD vuiety and responsibility experienced by these personnel. It is possible that the
p~ of lower stress levels observed in the DRlCT personnel could be a result of these
iDherent job characteristics.
Another implication of lower levels of observed stress in personnel with additional duties
and responsibilities may SUllest the need to reevaluate the use of r..'i7.llltion in
prebospital care. Althoulh traditional medi",,' practice is speei..n......, the tub ............v-t
with EMS work may not require the extent of ,,-;..'i7.llltiOll ..-...... in pnerIl.....m,,;_.
In fact a variety of EMS expertS contend that a broader view of prehospital care can be
advanlaleous for patient care. Dr. Ronald Stewart in an article titled "M....i"'" Aspects of
Extrication, - stales that "The field of prehospital rescue has developed into wbat miPt be
called a science of quite a spec:ia1iz.ed natuIe. Sophisticated systems of l'a.bospital care
offer advanced life support to patients involved in major aaidents whether 011 the highway,
in the home or work place. - He concludes that,
-ne number and type of personnel available to the field team will
determine the course and intervention durinl any cmic:ation situation. The
moSt ~t problem in a recent MView of cases has been the appumt lack
of identijjable leadership at the scene and thezet'cn the rdatively 0
disorpnized IDIIUICI' in which care may be provided. It is essential that one
person be in cbarp of the ovcrall operation and that this person be
med;"""y trained and able to judp the ,,-';ty of various interveatiaas. -14
In an article _titW ~.. Skills for EMT's- die 1'1tJ!or furtbcr ~~ Dr.
Sko..arts c:oacIusioas by ~ tbal tbe:re are three ,..--. croll p.., ma's: 'I'be
fiIst, - ...is to lr:Dow wIIaI and how 10 call for ...;--;- die IllW.,ct. ....is eo lr:Dow wbat
10 do and bow 10 do it wIleD "-;-' c:iJcumstances require the pedor..- of fire
suppression and emic:aIiclIl skills.. And the third, is the improved wor1r:iJII ~,..ti.....mlp
with nsponder fire ~twetlts. The article points out that the American Co1l"lO of
Surpons' list of -&sential Equipment for Ambulances iDcludes two SCBA 'L .U
In more than 75 percent of the COWIty'S larIest 200 cities the file department is respcmp1.le
for pmviding first lIlSpOf-. services. I' In an effort 10 -....i_ the ",l,ti_mlp with first
nsponders in their rapeclive systems, survey respoudents were asked a series of quePwt,.
The results of these questions were presented earlier in this report in Tables 19, 110 ad I
11.
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~ ~"minin, the cIaIa a set of conclusions were formulated. Fust, that DRlCI' and 24
hour shift persoDIId appear to consistently demonstrate hi&her levels of involvement in
first raponder trainin, and m~mnent tIw1 the SR or fral:tioaal shift respondents.
SecoDdly, that DRlCI' and 24 hour shift personnel had a hi,her incidence of workin, with
the same first responder &rOups tIw1 the SR or fral:tioaal shift personnel. Finally, that the
DRlCI' personnel appear to be more comfortable pointin& out possible problems with the
medical skills of first responders (P < .OS).
The inference that DRlCI' personnel appear to be more involved with first responder
ICtivities has several implications reprdin& observed stresS Ieve1s in DRlCI' personnel.
yustly, that these intmctions would work to suenphen certain job chmcteristics, found
by job c:bancterisIic tbeorist to impJOve job ...ricfV.tlOll. Sec:ondly, all tbree ICtivities
!elate to job chmctcristics fouDd to impJOve job ...ricf..t!tjOll, e.,., skill variety, task
sipificanc:e, task identity and job feedback.12.U,17
Question #32 of the PPQ asked respondents to estimate the pelCCI1l11e of calls they respond
to that require their level of traiJIin,. The averqe esponse was that 24 percent of requests
'Were deemed appropriate requests for the respondent's level of trainin,. UDder uriHftrion
of skills may be pan of the explanation for hi&her observed stress scores in EMS personnel
without additional duties.
Dr. Norman McSwain, a frequent author of EMS related articles, is quoted in a zeport
titled -Attrition in the Fue Service, - as stalin, -that the paramedic must have inc:reased
intl'l1ect1~l stimulation, as well as a viable career ladder and increased monetary rCwards to
remain content with his job. -.. However, accordinl to oae elrim"... oaly oae out of seven
EMS penoane1 can advuce into . field supervisor positioa, oaly oae out of 21 to.the
pnoitiftn of opcrIIioas -.....' DRlCI' fim deputmcDts are caplble of offerin& two
poP'"h1e career pUbs, pruridiq Idditioaal pumodoaal ~tia.
QI:.estioa 112 in Se.:;tioa I of the PPQ, was ~ ID .... motivIdoaal "tl-tit. .....,;....
19"'"'1,,",& certified wbeD it is DOt &&lIiotbllld by the MIpOIJdeDt's empJoyI:r. PDor ID Ibis
1IUdy, ntio-t.. ceallnd IIuuad huyau.'&ld pumoCiOl"'l "W""llP'ltl_1IId mcme"'~ ~n
would have beeIl consl"""-l the IDOIt probIble r-........ In &ct, many of the stratqies
employed to reduce aaritioa of EMS pel1OIIIId, are based on salary pade increases.
However, in the fiDal aDIlysis of Question 112 the JeSUIts refute the previously stated
notions of why ~ p>nUlln cc:rtificd in an apnc:y were they are DOt required ID do so.
P-v-'-'" were ubd ID rank four listed ~.....s for re-inilll certified, startiD& with
one as the best descriptiOll and enmlll with four as the least likely reason for remainin&
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certified. Only responcIcnts who were not required to remain certified were evaluated in
this sample. See Table '18 for listed responses.
T.bIe ,,8 Poaaibl. Responau to Question 12
A. R..".ining cenified improvN my promotionll
opponunitiu.
B. Monetary benefits continue to meke the job worthwhile.
C. R..".ining a field param.dic provides grllW' autonOmy
and aIdll variety.
D. The personal gratlficltion I receiva mew the job
worthwhile.
One hundred and five ~detI to the question (46") of the DRier personnel
participating in the study. The most fJequently chosen descripIion u die Dumber one
reason for remaining certified was answer "D", with slightly more than 35 percent
choosing it The least desirable reason for remaining certified was answer "A" with the
largest response of 45 percent
The second and third positions were "C" and "S" tapeetivc1y at 39 and 28 percent These
results are consistent with data presented in a 1981 report titled "Attrition in die rue
Service." The report presented data from an open-ended question that asbd each DRier
respondent to state the most desirable characteristic or aspect of their job. More tban half
(58.2") of the responses fell into 6 c:atepies; I.) bclping others or savina othe:ri in need
(23.0"),2.) personal satisfaction (14.1 "),3.) savin& a UCe (11.0"), 4.) job security
(3.5"),5.) the hours (3.3"),6.) die authority/respcmsibiJity of the job (3.3"). In
accordanc:e with our fiDdinp die two most desirable benefits of die job are ...fte;".4
Modem motiVIIioaI1 tJo-M- P'''1''* that bttrift.i<: IIICltiWIDI'S ate a mare .......wfll1
JDethnd of IDOtiYatinI ""''l>L,z I r W-- tbey IppCIl to hip Older r r, Employees
that are IIIpCIftIiw to h,,- Older Deeds would be lOlljlO:ted to experi- mme Job
ptiJ."";1JIl fivm jobs that contain a pat<< D1UDber of COle job c:hmcteristics, e.g., 1ISk
identity, skill variety, f~(''' and aulDllOllly.I2,I3.11
Ac:coJdin& to Lawler and R."ImIMI, hilher order DH"C. UII1ike lower cmler Deeds, e.g.,
security, food, shelter, may DOt become fuDy satisfied even ill jobs that contain desiDble
job charrf-icri~.13 'Ibc:ref'ore,jobs that provide for lower order needs, e.g., security,
~h\e wqes and ~n, and contain desiDble job cbmcteristics will create a
working environment that will motivate u well u produce hiP lcvcls of job ptiJ.Ml'3ll.
They conclude by stating that job satisfaction will result in "generally more effective
performers on the job. "12,13.11
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Funher analysis of Question 112 provided some interesting results. Total stress scores for
personnel responding to Question 112 were lfOuped and averaged according to how they
rank two of the four answers. Respondents who indicated that . A. was their first or
second reason for mnaininJ c:ertified were lfOuped together. The process was Rp"'tM
for each of the three remaining answers.
Respondents who choose . A" as their first or second choice had observed average stress
leveJs of 98.24. Those that choose "D" as their first or second choice had siJ1lifl....ntly
lower observed average total stress levels of 8UlO (p < .01). The pattern of change in
observed total stress level appears to follow a padual cIec1ine as motivation for Jl!lll2ininl
certified becomes IIlCft intrinsic in nature. The impl;""rion of this obscrvadcm may
sugest that the mster- or 1lODnisteN'1" of an employee's high order Deeds may have
some predictive qualities as to his future 1eYel of job satisfaclion.
Issues of job ....ti.fttoriOll and performance have been the central theme thus far. However,
of key concern and not yet evaluated is the effect of job and environmental cbaractaistics
on the longevity of EMS personnel. As i11~ted in Table n, DRlCI' have sipificantly
shorter stays (6.2 years for DRlCI' VI. 8.9 years for SR) in the advanced prehospital care
segments of their respective systems.
However, any attempt at comparing attrition rates between DRlCT and SR personnel is not
possible since the terms lack any consistency in definition between systems. In DRlCT
systems, attrition from EMS is a function of moving from the perfofIIUI~ of two roles
(EMS provider IDd firefighter) to a single role in me suppression. In fact rotatiod between
me suppression activities and EMS activities is seen as one method for preventing bum-out
within EMS ranks.4,',II,.9
1be most 1"1'"'1... IIW'-L to l'edl"'"'a pII'I-'~ bum-out in oae study was penoa~
,..,.,riftn, 1bIlamelbldy qllOted. fiR ICl'Vice offM.1 as -, "dJat IltbouP .ttPlri...
c:an be COIdy, it may aat be a disIdvIDt:Ip. Some feel.ttPIri- is a very aatma1
popessioa for 111 iDdMduaJs, ad tbouP . pant......;,. may retum to suppression, his
knowledge is sdIIa ......"1e skiJl to tbe fiR service. "4
SI."'nt..,.
. By iDc:orponliD& a proveD occupational stress assess.-.~ tool (MPSS-I.) with Idditiou1
questions "-ipal!ld to ptber de... . ~ti" informaIion zeprding the working envUonmeats
md job cbm-"";"" ofEldS pent"'".,1 we hoped to pin inli&flt into the re1ationships
between specific environmental c:haracteristic and occupational stress.
The results of the Sbldy demonstrate that sipificant differences in occupational stress ~
&:1peri---' by EMS taponders are a result of a mixture environmental conditions found
within each system type. Our findings demonstrated that dual-role, c:ross-trained
responders experienced significantly lower stress levels than single-role EMS responders.
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We found that EMS responders working fractional shift assi&JUDents opposed to 24 hour
shift assi&nmcnts experienced si&nificandy higher levels of occupational stress.
F'mally, we observed the apparent impact of a variety of different posting or unit stationing
strarepes on occupational stress levels experienced by EMS responders. We found that
personnel worldn& at the same station and returning to it after each response had
siaJ'ifit'JIndy lower stress 1evels than responders that were required to move to a new station
or postinJ locati/Jll. The hi&hest stress scores were u,.....;"t.... with nspoodents who were
posted ill the ambulanc:e. Cause for concern arises iIIlipt of research by ~ and
ochers n:prdin& the potential adverse impact of occupational stress 011 job
performance.l.J.407....
We bJPOtl'-i7M that such differences between tested samples could be attribu1lble to the
cumulative effects of a variety of enviIOnmental c:1wacteristics. We concluded that the
observed differences were comprised of two sets of c:1wacteristics. The first set oon.;.......
of job c:Iwacteristics found in the actual objective attributes of the job and their
relationship with those theorized to increase levels of job satisfaction, e.g., skill variety,
1aSIc identity, job feedback and autonomy. The second set was found ill the ill the
surrounding EMS environment and were under the control of the provider agency, e.g.,
scheduling practices, training, and unit stationing/posting stP~t!S.
We then analyzed the rdationship of observed MPSS-R stress scores to ~fi"
environmentii c:haracteristic. The results of our analysis imply that oc:cupational stress
levels vary acCording to bow these clwacteristics are orpni--' in the work envirOnments
of EMS responders.
1be types of job c:J1arvt-idi{:$ f'ouncI ~EMS eavinJrl...-b mcs;..... that biP levels of job
_ti~ are capable ofbeiD& ~ by iIIdMduals wbo are motivated by hi&'-
.
CIIder rt ('. e.1., lUI'4,.."'"Hty. i1Ura..omy, job ~". sJdIl wddy UId 1aSIc il'-tity.
Whm tDtIl stress ICOIe were IIIaIJzed ~din& to 1f1~ue....tI ndon.1~ far ..~......tll;.
certified. IboIe wbo dIlIIe i&rtft...;c larr"'- (perJon1ll!l _ti.r..,..;,." autonnmy UId sJdIl
wddy) ndIer than ~.;" ...- 'PO"- (promotioaal uwOJ1UDities and money) jCOOlIf
~ificantly lower stress .<<es.
C~slo"
This study bas demcmstIaIed that the fire departmCIll dual JOle CIOSS-trained ~ provider
workiDg fmm . fised post 01124 hour shifts bas lower stress levels UId job ~etics
conducive to hillier leve1s of job satisfaction. Most of the modem lIIIIIIIemenl litaItute
corrdates these two factors to improved performance. Thus, even though the study did not
directly compare system performance, the implication is that the DRlc:f EMS provider
performs at least u well u the SIt EMS provider. '
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Rerereaces
Footnote!
1. Eiseabeq MS, Horwood BT, Cn......in. RO, et aI: "Cardiac Arrest IUd ResusMhflou: A Tale
of29 Cities." An1uIls o/Emergency MI4ldne. 19(2):179-186, 1990.
2. Small R, et aI: "Quality C0mr01." JEMS. 9(4):67-71, 1984.
3. Hawks SR, R..........lId lU.; "TactliII. Stress Mazla&emeat From All Sides." JEMS. 15(9):>>
56, 1990.
.. McG10WD J: "AttritloD ill the Fue Service, A Report." FEldA. USFA 10, 1981.
5. R........... JS, MaIbews n, LyoDS JS, eti1: "OccupItioaa1 SlresI W"JthiD the p..n'<<llc
Professloa: AD IDitiaI Report of SlresI Levels Compared to Hospital Employees. " bnIIls of
Emergency MttlII:lM. 15(5):536-539, 1986.
6. Mitchell OW, et aI:"Bumout Questiozmaire." JEMS 8(1):55-57, 1983.
7. Hawks SR, Pecic SL, et aI: "RatiD. Stress ill EMS: A Respooder Survey." JEMS. 15(9):55-
57, 1990.
8. Cady GA: "EMS ill the UDited States: A ~ Survey." !EMS. 16(1):29-38, 1990.
9. CyduIka RX, Lyous J, Moy A, et aI: "A Follow-up Report of Qc:cupatiollll SlresI iD UrbaD
EMT-Parlmedics." bnIIls ofEmergrnq Medlt:Ine. 18(11):1151-1156, 1989.
10. Stout J: "How Much is Too Much?" !EMS. 9(2):26-34, 1984.
11. Mitcbel1 JT: -ne 600 11m IJadl" !EMS. 9(1):52-54, 1984.
12. Wirth SR: "Job S"I~ ill EMS: A Dlflka ApproIdL" 1'I'IItDIpItIIl_ DIIIIII6
JlMlld1Ie 5(1):9-16, U90.
13. H~"".n JR, Lawler BE: "Employee RadioDs to Job 0ImcteriIdca. " IDIInIIIl of ApplW
I'sychDlDD,IiDnDf1'1/Jh 55(3):259-286,1971
14. Stewart RD: "MedIcal Aspects ofExtricatioa." !EMS. 9(4):30-34, 1984.
15. Cotter MJ: TuefiJbdDI StiDs for EMTs." JEllS. 9(6)S57, 1984.
16. Data WIS atneted from 1990 "200 Cities" data base. the property of Jems COn........IHtlftus.
17. If"""",,n JR, 01dbam OR: "Deve1opmeut of the Job DI~C Survey.' JDIII7IIll of ApplW
. hydIDloD. 60(2):159-170, 1975.
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11. Murphy DM: "Wariq More'Iban ODe Hat." JEMS. 11(9):123-124, 1916.
19. SmiIh BB: "Profiles: DeftDiD& Fire Service EMS." JEMS. 9(6):72-77, 1914.
,
o
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BjJ)IiOml~hy
Roberts SW. ICImD JO': 'lob SatisfactioD Amolll Plramedic:a.' JEMS. 12(3):48-49. 1987.
Whitley lW. Gallery ME, ADisoD IE. It a1: 'Factors Asaociated With Suess Amoq Emeraeacy
Medicine Residears.' JfnNIls D/Emergency MIdIdM. 18(11):11'1-1161.
Stout 1: "FIR YS. Private EMS: It Doesa't Have To Be nus Way.' JEMS. 12(6). 1987.
R....-IS.loDes lW. Lyoas IS. It a1: 'Measuremeat of Occupatioaal Stress in Hospital Seaiqs:
Two Validity Studi. of a Measure of Self-Reponed Stress in Medical EmerpDcy Rooms. .
GtmmIlIlmpIti11 hychJJJtry. 7:1~162. 1915.
Hawb SR. Peck SL. It a1: .RatiJl& Stress in EMS: A Respoader Survey.' JEJIS. 15(9):55-57.
1990.
Valeazuela TO. Criss EA. It a1: .Cost-Effectiveaess ADa1ysis of PanDo""'i/; EIr-....c;y Medical
Services in die Tr-- of Prebospital CardiopulmolllrY Arrest.' JfnNIls D/ Emergetu:y u""cVv.
19(12):1407-1411. 1990.
'Viewpoint: Ei,ht Essays OD the State of Fire Service EMS.' JEMS. 9(6):5~. 1984.
"Cast Studi.." JEMS. 9(6):41-45. 1984.
Fraat M: "Medical Director VI. Fae C1ief." JEMS. 9(6):46-55. 1984.
Graham NK: "Done Fed Up. Burned Out: Too Much Attrition in EMS." JEJIS. 6(1):24-29. 1981.
Graham NK: .Part 2: How 10 Avoid a Short Career.' JEMS. 6(2):25-31. 1981.
Buder RC: "Bumoat: ne Pft.. "ul"~e Disease. " JEJIS. 12(3):>>54. 1m.
BoweI1 V: "Tam, Care oflhe CInCIbr." JEJIS. 13(11):39-45. 1988.
""10: "U_ul~..AiIIIlhe Fire SerYice. " JEJIS. 9(6):30-37. 1984.
Ilrhe111: "Marriqe and Ihe EMS Ezperieace." JEJIS. 13(6):30-33. 1988.
Uman GU. AnIIstroDI p. It a1: -UDited Paramedic:a of Los AqeJ. Wbite PIper." UPLA 5. 1988.
Pl,mm.1ri 1P. Bloomsteln 1: "0ccupati0DaI Stress WidIiD Rural Emerpacy Nedi~ T....."l..i..... .
university of miDois Conep of MedIcine at Roctftml. PnsrM at Ihe miDols ACEP Scientific
Assembly.
Stout 1: "Wrestliq with die BI,1bree Policy Issu..' JEMS. 14(6):79-81. 1989.
o
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Cadipll It. BupriD C: "Predi=illl DemIDlI for Emer,ency AmbuIaDce Service. . An1uIls 0/
~ MItllclne. 11(6):611-621. 1919.
Barris RW. Black GP. .11: "Bard Data for Bard Decisioas.' JEMS. 13(1):72-75, 1911.
PIp 10: "'Ille Grayiq oCPanmedics.' Paramedic 111lm1111iDMl. 2(2):14-17. 1977.
WJaIdey 1W. Revict:i DA.. 11: "Predictors of1ob SatlshctioD .&""'UI Rural Emerpacy Medical
T_..l";-.' PrMDIpltDlIllll1 DiMzster Metlldne. 5(3):217-223. 1990.
Pile 10: Emergen.r:y Medical Servicu for Fire DeptzrrmeIllS, Nadoaal Fa Protec:dcm AJ""';mou
BosIDII. Mass.. 1975.
Whitley 1W. Revict:i DA. . 11: "'Ille Rural EMT IDd Workrellled Stress.' Emergen.r:y IIedk'll
SriIt:D. 170:61~. 1911.
Murphy D: "Where', 1be Beef'! Part: I Achilles' Beel.' JEMS. 11(12):~1. 1986.
.
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Appendices
Appeadix A Prehospilal Personnel Questionnaire (PPQ)
Appendix B Medical Personnel Stress Survey - Revised (MPSS-R) Refe:reDces:
,
Hammer 15, Mathews 11, Lyons 1S, et at: -Oceupatinnlll Stress W"ltbin the
Jlamn""'ie Profession: An Iaitial Report of Stress Levels Cc:.~-=d 10
Hospital Employees. - AnMls olEnrergency Medidne. 15(S):~539, 1986.
Cydulka RIC, Lyons I, Moy A, et 81: -A Follow-up Report of Occupational
Stress in Urban EMT-Paramedics. - AnMls ofEnrergency MedidM.
18(11):1151-1156, 1989.
Appendix C W"JIth SR: -lob Satisfaction in EMS: A Different Approach. - PrehDspilo1
and DisDster MetliciM. 5(1):9-16, 1990.
/
Appendix D Acknowledgements
141~{::
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Al>l>ENDIX 0
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~~~,;;~~~.-
~ oa~-v3:\e ~as... .. thccd drawn , a:.~Clre
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II Our~ Sl"e! ~ EKG monitor "S. ore~~h:.;rr.
~ decontamination ..s. EOA 'ECiA. EGTA :z:- ca;cium eIlicll
... ex:r:cat;on :r IV-central .tt cextrcse
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Q
APPENDIXE
THE QUALITY ASSURANCE PARADIGM SHIFI'
nn~1i\V At.C1I12nce VI. nnAli~ Imnrnvement
ClIUllity At.C1I",~
n.m1i\y Imnrnvement
.
Self-Motivated
Focus 011 Service and
Clinic:al Improvement
FOCUS~
Method: -Group Conducted-
Process Improvement
Common and Special
Call5e$ of Variation
)6..""..tfoJd
Focus on C1inil'illns
Focus on Individual
Performance
Method: IDspection
and Feedback
Outliers
Within Functions
Across Functions
Customers are Regulators
Customers are Many
(Internal " External)
DY Focused (Positive)
Prospective
IDternal Directed
Mm Focused (Negative)
Retrospective
External Directed
Follows Organizational Structure Follows Patients
Delegated to the Few Involves the Many
Seeks Perfection Seeks Improvement
Top Down Bottom Up
Reactive ProIclive
Management Focused Employee Focused
Limited Staff Involvement Full Staff Involvement
Event Based Process Based
InspectiOll Approach Research Approach
Quality is Separate Activity Quality is Integral
~
~
~o
)", 0 APllENDIX F
~~ . .
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1'1
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71
Do
N
COU~ OF SAN BERNARDINO, STAC) OF
CALIFORNIA, AMBULANCE SERVICE RATE
ADJUSTMENT REGULATIONS
..
APPENDIX G, Paqe 1 of 8
PURPOSE: To establish a procedure and method for makin~
periodic rate adjustments for ambulance services.
AUTHORIT~: San Bernardino County Code, Section
31.0819(9)1 San Bernardino County Board of Supervisors
Resolution No. 8~-155 .
Rate
determined by
and l-D.
adjustments for ambulance services shall be
use of the following forms, marked: l-A, 1-B, 1-C,
".
-
. .
1
2
l
,
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
.9
20
2l
22
23
24
25
26
27
26
",0
--
30
31
32
33
34
35
~ . I!
jt
\\
..
o
RESOI,UTION \-lO.
84-1550
A RESOLUTION OF ~HE BOARD OF SUPERVISORS
OF TEE COUNTY OF SAN DERl'IAROINO, STATE
OF c.,,!. I FOIUUA , ADO~TING REGULATIONS OF .
'!'M!,; C':lmlT~ :!'ER'!'~.INnlC; TO N1BULANC:=': S~R"IC::
!\.~...r. ADJtJS':'MEN':'S
On
!-londay, A?ril 23 ,13'34, on ::lotion of S\l!=~~'vi:;or
, duly seconded bY supervi!or Jov~er
._-- ..-.-.-" .--
~~e followin9 resolution is adopted:
Townsend
and carried,
. RESOLUTION SO. 84-155
BE IT RESOLVED that pursuant to Section 3l.0~19(G)
of the San Bernardino County code, the followino described
. -
document, entitled, "JUmULANCE SERVICE RATE ADJUST~ENT
REGULATIONS," and consistinq of S pages, which is attachec
hereto and is incorporated herein by reference, is adopted.
~SOLVEO, FURTHER, that the effective date c~ t~is
Re!olution is APaIL 23, 1984
BE :'!' RESOLVED FURTHER, that three co~ies of t~is
_ nesolution shall be filed in the Office o~ the Clerk of the
!loard of superviso:-!, and the T:latters resolved hereby s.hall
be aaninisteredby the rublic Health Officer~
.
PASSED AND ADOPTED by the Boare of Supervi!ors of
Sar. 5ernardino County, State of California, by the f.cllowi~;
vote, to ,.,it:
AYES: jo~-ner.. Riordan, To".."send. Hamroock, HcEl;.'ai:',
l10~S : l:one
~SENT: i:;cne
J
STATE OF CALIFOnNIA )
) 55.
CbUNT~ OF SkN 5ERNARDINOl
I, !1A:ltTHA U. SEK~RJI.lt, Clerk of t::e scard o~ Supen.is;
of the County of San Bernardino, Californi^. hereby certify th
forecoinn to'oe a full, true and correct CO?v 0: the recorc 0:
_\.. .... _:.";... '!:_ .....a :__,.-: __"",,=-:_": ;.. ....... ~~~.;~:-: _..~..~..eC' "',:. ~_...:
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,
'SAN' BERNARDINO COUNT,^
DEPARTHENT OF PUBLIC HEl!tH
SAN BERNARDINO COUNTY AMBULANCE ASSOCIATION
REVENUE'ADJUSTHENT APPLICATION
.:
. .
Prepared b'y:
relephone:
leportinl Services:
'ddn..:
.
I. Application is hereby cade for authorization to adjust aVerale revenue per
Full-pay response by $ based upon the follov1nl information:
A.
ADbulance Cost Index: Dec.
thru Dec.
B. Percent chanle in averale revenue per response attributable to:
1. MediCal
2. County ind1&ent contract
3. Other: . (specify)
~
C. Ratio of Full-pay responses to all ~esponses
D.
Current-averale revenue per Full-pay response
[I. Pata and Computations
A. Aabulance Cost Index (ACI)
COST COMPONENT .
INDEX INDEX
Dec. Dec.
- -
% CHG.
1. Aabulance Yales
. 2. Overhead
3. Insurance
4. Depreciation/Lease
5. Cas and 011
.6. Vehicle Haintenance
7. Ambulance Supplies
8. Radio Expense
..25 Labor
.75 Parts
11.
.
1-;.
..
$
.
WEIGHT
SUM
(ACl)
I. Percent chanse in .v~e revenue per response sttr~toblc to:
1. MediCal rei.b~rsement .djustment.
..
Allov.~l. Ch.rl'
Response to "c.ll
mlllc'
.NiCht c.ll
EIIIerc.ncy
OxYI.n
V.itinC till"
Ot;cur-
rence
F.ctor
.
\
."
b. Percent chanle in aver.I'
r.v.nue per M.diCal res pons.
.
c. Ratio of MediC.l responses to
all responses
Prior
Reill-
bur....nt
d. '.rcent ch.nl' in aver.I'
revenue per M.diCal response (x)
ratio of M.diC.l res pons. to
all asponses .
\
2. County 1n~isent rei.bur.ellent adjustllent
-
"
Percent ch.nle in .verale rev.nue
per County indilent response
Ratio of County indisent respons.s
to all responses
P.rcent. chanle in .ver.s. revenue
pe~ County in~iEent Tesponse (x)
ratio of Count! i~d!lln: T.s,o~ses
to all responses .
a.
Allovable Charge
Re.pon.e to call
Milea.e
Nisht call
ber.ency
OXYlln
V.1t11lS time
b.
c.
d.
Occur-
,IIftCI
Factor
Prior
le1l1-
bursellent
..
Sum1
Am.nded
ReilD-
burs.ment .
5
-
-
-
-
.-
(Avs'7":ri
CAvS. reven'le 1)
5uIIl
Mended
leilD- 5.
bursllDent
-
-'-
CAvC7r
(AvS. revenue 1 )
3..
Ocher (specif';>
adjustlllenc
rc1ll1bunCIIICnO
a.
.Allo"able Char!:e
Response co call
H11uCe
NiChe call
ElDercenc)' .
OxYlen
"'a1c1nc time
Occur-
rence
Factor
Prior
RI1I11-
bune.ent
~
b. Percent chance 1n averace revenue
per response
c.
Ratio of
to all respon.es
re.ponse.
Percent chance in aver ace
revenue per .re.pon.e (x)
ratio of re.ponses
to all re.ponse.
d.
,
SUIII
(Avc. revenuel)
A1aende.d
Relll-
burs...nt
(AVI-:
4. Attach information per 1telll (B)(3) above as necessary.
C. Current-averale revenue per full-pa)' re.ponse
Current Charle
Base
Hil~ale
EIlerlenc1
N1lhe
OxYlen
TilDe/lS 11111.
Para.ed1c
Elte
I..
All lnclus1ve ALS
Occurrence Faceor
. -
Rate
SUI
"
,
,0
The.designations
shall be applie~ in
o
and 'terms 'set forth in the fore.going
accordance with the following criteria:
forms
,
I
. Rate a~justment formula:
A. Ambulance Price Index
1. Bureau of Labor Statistic Indicators
a. Ambulance Personnel Expense - employment and
earnings, establishment data, hours and earnings, gross hours and
.
earnings of production or non-supervisory workers on private non-
agricultural payrolls, Health Se~vices (SIC 80) average .hourly
earnings.
b. Overhead - Co~sumer Price Index, Detailed Reports,
Consumer p~ice In~ex for all Orban ConsumerSJ Selected Areas, all
items indexed, Los Angeles-Long Beach, Anaheim, California.
c. Insurance Expense' - Consumer price' Index, Detailed
~eports, Consumer price Index for all Urban Consumers: Nonfood
expenditure categories, o. S. city average, Automobile Insurance,
.unadjusted Index.
d. Vehicle Depreciation of Lease - Producer prices and
price Indexes, Producer prices and pr ice 1nde~es for commodity
groupings and individual items, motor vehicle and equipment index
(Code 141).
.e. Gas and Oil Expense - Consumer Price Index,
Detailed Reports, Consumer Price Index for all Orban Consumers:
Nonfood expenditure categories, u. S. city average, gasoline,
Unadjusted index. .
f. Vehicle Maintenance Expense - Consumer Price Index,
,Detailed Reports, Consumer Price Index for all Orban Consumers:
Nonfood expenditure categories, o. S. city average, AutomObile
maintenance and repair, Unadjusted index.
.g. Ambulance supplies Expense -
Detailed Reports; Consum~r Price Index for
Nonfood expenditure categories, u. S. city average,
commodities, Unadjusted index.
Consumer Price Index,
all Orban Consumers:
,
Medical care
-2-
. .
o
o
h. Radio Expense Employment and Earnings,
Establishment Data, Rours and Earnings, Gross hours and earnings
of production.or non-supervisory workers on private non-
agricultural payrolls.
2. ~he foregoing indicators must be collected
beginning and.the month ending the periOd ~or which
adjustment is being made. .
for the
paid
month
B. Revenue Adjustments .for Payment Category
1. The necessary data to feed into the formula will bea
composite of worksheets submitted by the providers who make two
thousand (2000) or more responses annually.
a. Revenue for MediCal response means that revenue
allowed .fo# MediCal patients.
b. Revenue per County indigent response means that
revenue allowed under the County contract for ambulance services.
Formula tions:
a. Ambulance Cost Index (ACI)
2.
(Needed
,
change~ ill.
..
~
average revenue
per' response)
-
1) Percent change in average revenue
per MediCal response multiplied
by the ratio of MediCal responses
to all responses (-)
2J Percent change in average revenue
per County indigent response multi-
plied by the ratio .of Ccunty indi-
gent respon~es to all responses (-)
~..
-3-
\, .
,
i. ....
o
o
I
3) Per~ent change in average revenue
per response for each remai~in9 pay-
ment mechanism class multipli~d by
the respective ratio of responses
within such class to all responses (-)
.... (-)
(-)
C. Adjusted ACI divided by the ratio of
full-pay responses to all responses
~
"
'\
,
.
,.
-4-
, .
(Adjusted ACI)
,
(Needed
change in
average reve-
nue per full-
pay response
DEPARTMENT OF puilc HEALTH
o ~~~N,1I~
lt~
71f~l\\\~
CO\IIfTY Of UN IIIll
3111110nll MI. VIew A_ . .... I_dlno. CA .14111.0010 . 171.'317"280
~ay 22, 1991
GEORGI II. PITT....H. I
ex.- .. PloIIlIc ~
Terry L. Ru.., Treasurer
Ambulance Association of
San Bernardino County
P.O. Box 934
San Bernardino, CA 92401
Al''PENDIX P'
Dear Mr. Rus.:
As required by section '1.0820(f) , (h), I have reviewed the proposed chanql
in ambulance rate. that you submitted in your corre.pondence dated March 2!
1991. ~fter applyinq the formula that was approved by the County Board I
supervisors In regulations, I have deterainad that the Aabulance Cost Ind.
should result in an adjustment of average revenue per full pay response I
6.3t.
Considerinq the utilization tactors, the adjustments will result In tI
followinq rates:
Base
Mileaqe
ElIIerqency
Niqht
Oxyqen
Time
AL.e; Base
EKG
All Inclusive ALS Service
$238.44
9.98
95.00
67.33
56.64
21.1'
351.03
48.06
520.93
I would call your attention to the Ambulance Ordinance, Section 31.08
(f) (3) that states: "Any authorized chanqe in rates shall be effecti'
within ten (10) days after.havinq been published in a newspaper of qener.
circulation within the effective service area, once a week for two (
weeks."
As soon as you have publicized these rates .s directed, they may b. put in
effect.
George R. Pettersen, M.D.
Direct I' ot Public Health
GRP:al
ee: Ambulance Provid~rc
city M.na'Jers
Board of supervisors
Harry Mays
Ceo;: .JDer 8, 1991
Amhulaza Senic:e of SaIl BemarcliDo
SIDee 1948
~~yor W.R. -Bob - Holcomb
300 Borth -D- Street
San Bernardino, CA. 92418
Al>PENDIX I
Dear Mayor Holcombl
Courtesy Ambulance wishes to go on record as fully supporting the
City's proposed study of the manner in which ...rgency l118dical aid
is provided in San Bernardino. The exist'ing system has' proqressed
over the years to a point where there is considerable overlap and
duplication in effort and expense. This has resulted in some
confusion for those receiving the .erviceJ rais.s question.
concerning the rate structure, and an analysis of the overall
proqrllJll appears to be very timely.
The City Fire Department and Courtesy Ambulance are both cCllllp8tent
at what they do--the record over a lonq period of years bears this
out. The City has a financial collllllitment to the parlllll8dic proqrllJll,
') in terms of .quipllllnt and specialized personnel, this has evolved
over the years as the fi.ld of ....rg.ncy medical aid has become
IIIOre specialized and sophisticated. The same is true for Courtesy,
with one of the differences being that the overhead costs are
spread over a larqer service area.
Two aspects of the City's proposed study were highlighted in the
news story conc.rninq the matter I ( 1) encouraginq ambulance
compani.s to c~t. for ..rvice in the City, and (2) establishing
a City-owned UlbulllDC. servic.. While th.re are pros and cons with
respect to each of thes. po.sibiliti.s, we believe there is a third
area which also des.rve. consideration. The third area is the
phasing of the Fire Department back into its traditional role of
providing emergency treatment and have Courtesy Ambulance perfo:r:m
nec.ssary parllJlledic service with its on-duty personnel.
The Fire Depara.nt and Courtesy Ambulance have always had a good
working relationship in the fi.ld. In ord.r to maintain the high
standard of patient care set for the community, it is essential
that this relationship continue. In our opinion, a close
.wAmiftation of the facts will demonstrate that a more efficient
and cost-effective s.rvice can be provid.d if Courtesy and City
each concentrate on their respective areas of expertise.
In order to develop a complete analysis as to whether or not the
City should enter the ambulance business, it will be necessary,to
obtain statistical information from Courtesy. It will likewise be
necessary for Court.sy to have access to City data concerning
~___--J:._ 11__ _.oJ UT1.t._l,..,"ui.. ~rvit"'AC:
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o
s."aries, staffing and other costs attendant to the-City'~
r ":amedic program. we are prepared to cooperate with the City in
~e'exchange of the information.
It also appears advisable to establish some sort of coordinating
mechanism. '!'he overall subject is too important not to be
approached on a comprehensive basis. Some of the misunderstandings
which have occurred recently could have been easily clarified if
there had been better cODIIIIUnication. While there have been three
elements highlighted for study, there are incidental operating
practices and procedures which could also profit from closer
coordination.
I am available, at your convenience, to discuss the matter further
and to assist in developing some type of outline for proceeding
with the study.
Very Z~..
;::'--...!f ....,
/ D. Steven Rice,
President
CC I Kembers of the COJIIIIIOn Council
City AA-;~istrator Shauna Edwins
City Attorney James Penman
Pire Chief Will Wright
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Appendix 1
nm CITY OF FRNWnnD FIRE DEPARTMENT AMBULANCE SF.RVTr.I<
'Ibe avenae IIIary of Femwood's
. fuefi&h1erlpmmedics is:
S3,475/month
Fifteen firefiah1er/pll'll......t;~ would
be m;mi"'~~upuoal to
privatize is :
53,475 x 15
- $52,125/month
'Ibe City's beaefit JllCklIge adds
40 paceIlt to salaries:
$52,125/month
x .40 - S20,8SOI11IOIIth
ADnllll1;~ labor costs
$52,125
+20.BSO
572,975
x--12
5875,700
(salaries)
(benefits)
(monthly tolal)
(months)
per year
RlfllNll!nluac _
9,850
x S33O.8O
53,258,380.
U
. l1.mJ2Q
\
(transports during prior fiscal period)
(aveIIIC bill)
(Jross billings)
(-SO percent collection rate)
(net revenues)
"
APEX AMBULANCE SERVICE
Pl.QiIOoM schedulin, of lImhllll1n~ -
'-
Hours (24 tolal)
Unitlhrslday
~b. · · · · · · · · · · · · · · · · · · · · · · · ·
8
8
12
24
24
24
100
200
'I
12
t3
14
IS
16
Total unit hours per 24 hour period:
Total number of personIhours:
Full-time equivalent (FTE): 4.16 ambulances
o
o
4~ft m
,.-2
Pa___--...d unit hour ntili,.tilWl:
1~.3SS emelIetIC)' " 1lOIl-emcqency transports per year
36S days - J2.ll transports per 24 hours
100 UDit hours - .3933
(i.e. 1 tnnsport per 2.54 hours per ambulance)
StaffinIJ lYWtI -
1 EMT per ambUlance per shift
1 paramedic per ambulance per shift
517,000 'year (ava)
+ 32.~ 'year (ava>
$49,SOO
Apex benefit p"l'lnlge adds 20"
+ 9.900
SS9,400 'year
SS9,4OOIyear It 3 shifts - 5178,200 per FI'E ambulance/year
It 4.16
$741,312
FI'E ambulances
'year
~\
)
One supervisor position at 53S,000 It 3 shifts
Plus beDefits at 20 percent
- 51OS,000 'year
+ 21.000 'year
5126,000
Total annual staffing costs -
$741,312
+ 126.000
$867,312