5 questions EMS leaders need to answer for city and county officials

By Bruce Moeller, Ph.D.

Most city and county officials have never had the opportunity — or thrill — of responding lights and sirens to a resident's home in order to provide lifesaving medical care.

And while that imagery can serve as a powerful argument for unwavering support and funding of your EMS program, municipal leaders, both elected and appointed, have many competing priorities and need to make themselves more knowledgeable of current and emerging issues in the delivery of EMS — and what they can do to ensure the community's EMS needs are being met.

EMS leaders also need to play a role in educating city and county administrators so they are making informed decisions about EMS service. Here is a series of five questions that EMS leaders should explore with their local officials to improve their understanding of this vital service and effectively manage the community's expectations for emergency medical care.

1. What are your community's expectations for EMS services?
This is a difficult question to answer, for the city manager, EMS chief or even the public. A community's expectations for EMS services are often vague — residents want fast and effective EMS, but don't always know what that means.

The first issue is typically the level of service to provide — basic life support or advanced life support. While the ALS level has historically been the gold standard of care, there continue to be well-researched medical studies suggesting that ALS care makes a significant difference for only a small number of patients.

You will likely find that citizen expectations will often match the level of service they have received historically. So while you can always upgrade from BLS to ALS, it is extremely difficult to reduce back down to a lower level of care, even in cases when it might be as effective and more efficient to do so.  

Response time has historically been the one measure of system performance most measured and talked about — and the most misunderstood. As an EMS leader, the communities you serve are almost guaranteed to be asking you about your response time more than any other topic.

It's important to educate local officials on the history and science of response time calculations and standards. For example, communities have not consistently defined how to calculate response time, often not counting some components, such as call processing and dispatching time, that affect the patient's experience.

You should be clear with community leaders on when the response time clock starts, and when it stops, and which standards apply to your community.

Finally, recent medical research, again, is finding that while faster is better for a small number of patients, most communities are unable to decrease response time enough to truly impact outcomes on the most critical patients.

2. Should all 911 calls for EMS receive a lights and sirens response? 
Historically, most fire or EMS services responded to every call with emergency lights activated and sirens blaring. This is no longer a best practice, especially when multiple emergency vehicles are assigned to the event.

Today, progressive 911 centers can use validated protocols to assess the severity of the emergency call, and dispatch emergency responders at the appropriate level of urgency. Often times, only the closest and appropriate vehicle will use lights and siren while other units follow normal traffic laws until additional information determines otherwise. Risk management has shown this is a more prudent practice for the patient and all residents on the road in the community.

3. Do you have the same number of calls at 2 a.m. as you do at 2 p.m.?
The answer to this question is almost always no, and your community needs to understand that in order to properly fund an effective and efficient system. Calls for emergency medical services follow a fairly predictable temporal pattern in almost every city and county: Fewer calls overnight, an uptick starting in the early morning, and then a peak in mid-afternoon before falling through the evening hours.

Yet many systems still deploy the same of number of vehicles at 2:00 a.m. as they do at 2:00 p.m. In lieu of simply adding more 24-hour crews for increasing demand, some communities are increasingly turning to peak-hour units. These vehicles are only deployed for 10-, 12- or 14-hour periods during the busiest hours — thereby providing a more cost-effective method of addressing the increase in calls for EMS service.

If you don't know the peaks and valleys of your own agency's call volume, you can't have an honest conversation with the community's leaders about resources, staffing and funding.

4. Why does an EMS agency have a medical director?
Some municipal leaders think of EMS as just another public safety function, run by a chief. They don't always understand that EMS is providing health care and therefore needs adequate medical supervision.

The medical director should be an active participant in the decision-making process, and should be as familiar a face to your local elected and appointed officials as the fire chief or EMS agency leader. Your city or county manager, mayor or councilmembers need to know that the medical director plays a major role in establishing levels of service, training EMS personnel and establishing protocols that permit, or do not permit, the use of call prioritization and alternate deployment models. Local leaders should take the time to understand the medical director's perspective on providing quality EMS in your community.

5. How does health care reform impact EMS?
Just as many communities don't think of EMS as health care, many don't realize the potential impacts of health care reform on emergency services. They need to be aware of both the threats and the opportunities.

The Patient Protection and Affordable Care Act is only a piece of the government's efforts to make health care more affordable, which could mean less revenue from ambulance transports. And while there is tremendous interest in and discussion about community paramedicine along with other community-based health programs, we really don't know what the future will bring.

Your community's leaders need to understand what Obamacare and other models of care could mean for EMS. It is more important than ever for EMS systems and their leaders to be engaged with other community partners, including social services, public health and hospitals and other providers.

What are other questions have you answered for your city and county officials? Share those questions and answers in the comments.

About the author
Bruce Moeller, PhD, a senior consultant with Fitch & Associates, has extensive experience in both the fire service and city and county management. He served as fire chief in multiple departments, including Broward County, Florida, and later was city manager in Sunrise, Florida, and executive director for safety and emergency services in Pinellas County, Florida.

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