Great summary of the myriad policy issues – and rational approach to EMS system redesign! Many systems are taking this evidence-based approach to enhance patient, provider and public safety. At Medstar, our reprioritization plan, implemented on March 1, 2023, dropped HOT responses from 73% of our responses, to 37%!
Tip of the hat to Kolby Miller for sharing this news report!
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Your wait for an ambulance may get longer — and that's safer
By Dustin Walsh
July 17, 2023
https://www.crainsdetroit.com/node/879751
Ambulance service is built on response time — the ability to get to a suffering patient and to the hospital swiftly to save blood loss, an appendage, or a life. The public has come to not only expect but demand the quickest response possible because, frankly, emergencies are frightening.
But, in reality, only about 5% of patients transported by ambulance actually benefit from "hot" rides, where the ambulance's lights and sirens are ablaze, growing research suggests, including a study by the World Association for Disaster and Emergency Medicine. Yet three-quarters of all 911 transports in the U.S. run hot, while the chance of a crash with a patient onboard rises three-fold.
"Racing around all the time, we're going to kill somebody on the way to a call for somebody that didn't even need an ambulance anyway," said Kolby Miller, CEO of Clinton Township-based MedStar, the state's largest emergency medical services organization jointly owned by Ascension Health, Henry Ford Health System and McLaren.
But MedStar ambulances run hot anyway because their services are contracted by municipalities almost exclusively for one performance metric — response time. In fact, 70 percent of its roughly 100,000 ambulance requests annually involve an ambulance running lights and sirens.
Miller wants to change that and is part of an informal nationwide effort to educate municipalities and medical control authorities that contract emergency medical services on the dangers of lights and sirens and what little factor they play in aiding patients.
"You think you want an ambulance to get you to the hospital at 100 mph, but at 100 mph that vehicle travels 450 yards before it can stop. We bring risks and accidents into the system while chasing a false metric," Miller said. "Response time just doesn't have the impact on patient outcome we want to believe it does and we're jeopardizing everyone's safety."
Little need for speed
The focus of ambulance response times dates back 50 years to the Emergency Medical Systems Service Act of 1973, which stated that 95% of all ambulance response time should be within 10 minutes in urban areas and 20 minutes in rural areas.
But municipalities and medical control authorities began demanding quicker responses in the late 70s as research indicated intervention within 6 minutes of cardiac arrest substantially increased survivability.
That's led to quicker and quicker response times, no matter the injury or emergency.
Today, the national standard for EMS performance agreements is 8 minutes and 59 seconds, meaning a response must be under 9 minutes. Due to competition and expectations, that means most emergency calls receive an ambulance within 4 to 6 minutes, Miller said. The national average response time is seven minutes.
Nationally, about 72 percent of 911 calls requesting an ambulance receive one with lights and sirens, and 21 percent of those ambulances transport the patient with lights and sirens on.
It's not just the average response time, however, that leads to ambulances traveling at high rates of speed and splitting traffic when they can.
Many emergency dispatch operations are run by municipalities or counties and do not require someone with medical training. So because response time is critical with cardiac arrest and a small percentage of other emergencies, ambulance services have no choice but to travel quickly, said Angela Madden, executive director of the Michigan Association of Ambulance Services.
"Many (dispatchers) don't have medical training, so they cannot clearly work through the patient's symptoms," Madden said. "Without that understanding of the patient's issue, ambulances have to go to the scene with lights and sirens."
Miller said about 30 percent of the time a MedStar ambulance — which serves patients in Bay, Clinton, Eaton, Genesee, Ingham, Lapeer, Macomb, Oakland and Wayne counties —arrives at the scene, a patient doesn't even require an ambulance transport to the hospital.
However, when the EMS provides the dispatch service, there's a noticeable change.
Grand Rapids-based Life EMS Ambulance, which has a 4,600-square-mile service area from Kalamazoo to West Michigan and has certified medical emergency dispatchers in most of its communities, only sends an ambulance with lights and sirens on 36% of its more than 100,000 transports, said Mark Meijer, president and founder.
"We've been fortunate to have some forward-thinking medical directors and medical control systems overseeing our clinical care," Meijer said. "That's really helped drive down our use of lights and sirens and helped us ascertain what calls require them or not."
Miller said he's worked hard to educate decision-makers about reducing lights and sirens use by setting up informational meetings, but "hardly anyone shows up."
Adjusting services for need
There is evidence to support these efforts.
Mecklenburg County EMS Agency, which provides services to the county in North Carolina that includes Charlotte, recently changed its response protocols after an in-depth study of the way its dispatch operated.
The county discovered that 74% of its 911 ambulance requests were dispatched as life-threatening and required the use of lights and sirens. However, after arriving at the scenes and accessing the scenarios, only five percent were determined to actually be life-threatening and require lights and sirens.
Being able to distinguish between the two aids in resource distribution. Paramedics ride in advanced care ambulances, which are equipped with life support equipment. Non-life-threatening calls receive basic life support (BLS) ambulances, which have medical equipment but lack the advanced equipment of an ALS ambulance.
Since October 2021, for calls that are determined to be non-emergency calls, Mecklenburg EMS set a target of a 60-minute or less response time. After 12 months, Mecklenburg EMS reported an average response time of 32 minutes with zero patients adversely impacted.
In March, Mecklenburg EMS extended its non-emergency response time to 90 minutes or less.
"If a dispatcher says chest pain, the ambulances are coming as fast as they can," Madden said. "But the more information the dispatcher can receive and be trained to understand, then they can send an appropriate response."
Life EMS Ambulance also outperforms the national and state averages despite a lower use of lights and sirens. The survival rate of a total cardiac arrest patient after EMS response is roughly 30% nationally and 25% in Michigan, Meijer said. For Life EMS, it's 37%.
Miller and Meijer both said that performance metrics need to change with the times, where more paramedics are employed and AEDs and CPR training is prevalent.
"It's clearly a challenge that one longstanding measurement of how an EMS performs is response times," Meijer said.
"We need to figure out how we can better inject quality measures from a clinical care and outcome standpoint, using those measures predominantly or at least more so than simple response times. That's still a work in progress."
