EXPANDING EMS: UPGRADING FROM BLS TO ALS
BY GORDON M. SACHS
An estimated 80 percent of the American fire service provides some level of emergency medical services (EMS) to their citizens through first responders, emergency medical technicians (EMTs), and paramedics. Generally, first responders and EMTs provide basic life support (BLS), which involves medical treatment not including invasive procedures or medication administration. Paramedics provide advanced life support (ALS), a higher degree of medical service including the administration of medications, intravenous fluids, and various monitoring functions and invasive procedures. Expanding from BLS first response service to ALS first response service is a positive step toward providing a higher level of service to the citizens and visitors of your jurisdiction.
WHERE TO START
The best place to start when determining how to upgrade from BLS to ALS is right at home. A most important step you can take is to generate the support of the troops–the firefighters who will be providing the service. They have a powerful voice, since they meet the public every day where the service upgrade will make a difference. A motivated firefighter`s impact can be tremendous; when an entire department shares a vision or goal, the job is much easier.
Important supporters include the elected officials and municipal managers. Quite simply, it usually isn`t a good idea for a fire chief to embark on a major project like this if his boss doesn`t like the idea in the first place. The plan may fail and perhaps end the chief`s career. The simple approach to this is, Sell the plan to these leaders! Tell them how upgrading to ALS will benefit the municipality and its citizens (the voters). Let them champion this worthy cause! Once they are on board (or at least are willing to let you proceed), then you can begin the real planning.
Before jumping to ALS, you must be sure that your customers–the citizens who pay taxes, subscription fees, or donations–feel that this expansion is necessary. You must educate them about EMS, the service level you now provide, what ALS is and what it can do for them, and why and how you plan to provide this higher level of service. In other words, you must market your service and the fact that it can be improved. The issue of cost will come up, so be prepared to justify the cost with data and figures.
Upgrading from BLS to ALS is not cheap. Local and state requirements typically mandate that specific medical equipment, supplies, and medications be carried on ALS response units. Depending on these requirements, the costs can range from $10,000 to $20,000 per unit. The amount of equipment that must be carried may be too heavy or too big for current EMS response units, so new vehicles may be needed. ALS response units require specific EMS communications systems, so radios may be another expense. Training, personnel costs, licensure fees–all these costs can add up. Be sure you have funding to complete the upgrade and can honestly tell your customers that it is worth the cost!
TYPES OF ALS FIRST RESPONSE SERVICES
There are several different ways to deliver ALS first response services. Some departments use quick-response ALS units from a central point, in conjunction with BLS or ALS transport units stationed geographically throughout a jurisdiction. The ALS unit only responds on those calls believed to be life-threatening. Obviously, the larger the jurisdiction, the more ALS units that should be geographically deployed.
Another method is to station ALS units in areas where data shows life-threatening calls are more likely. This is often the method of choice as a department expands to full ALS service over time; as more units are placed in service, they are placed in the stations with the greatest ALS call load.
A third method uses ALS first response from all stations, with BLS transport available from a central point (or points). Departments using this system provide ALS emergency care to patients quickly but may have transport delays. Transport units, while staffed as BLS, become ALS if a paramedic rides in with a critically ill or injured patient. In many cases, however, this puts the ALS first response unit out of service. The logistics of getting the paramedic back to his unit are an important consideration.
There are many variations to these systems and various integrations with different transport plans, such as system status management, for example. It is important to identify which delivery system you plan to use when you implement your ALS first response service and how it will interface with the transport system.
A related consideration is the type of response unit your department will be using and any additional units you may need. Many departments that provide ALS nontransport services use quick-response vehicles (sport-utility vehicles, minivans, or “plumber`s trucks”). Others use ALS engines very successfully. Some use ambulances, though they do not transport patients. In Florida, Phoenix and Seminole counties, among others, have successfully adopted a transport-capable fire-rescue unit that can provide first response and transport services as well as suppression capabilities for most firefighting situations. One study showed that this concept saves the Phoenix Fire Department as much as $13,000 per year per ALS engine replaced with this type of unit in mileage, maintenance, and repair costs.
EMS services need a physician to serve in a medical supervisory capacity to provide EMS personnel guidance as to the protocols that must be followed. It is under this medical director`s license that all department ALS providers practice. The director usually serves under contract to the fire department and often is required to ride a certain number of shifts, provide a given amount of EMS training, and screen new EMTs and perhaps paramedics.
Medical control is one major difference between ALS and BLS. BLS services usually require no more than offline medical control; they do not necessarily need immediate access to a physician, but one must review and approve protocols to be followed. ALS services, however, require online medical control, which means they must have access to a physician via radio or other communications at all times. Many ALS services operate under standing orders and only need to contact medical control in unusual circumstances; others must contact their medical control any time ALS care is given.
The medical director is an important part of the quality assurance/quality improvement (QA/QI) process. The director reviews run reports, training records, complaints, and other documentation to see how well personnel are performing. Since ALS personnel are operating at a high level under the medical director`s license, he is often critical to the quality of care provided. The medical director can recommend changes in protocols or training as a result of findings in the QA/QI process.
The medical director also can assist with interagency cooperation and coordination. Often, it is ideal for a first response service and a transport agency to have the same medical director; in some places, this can be mandated. The medical director can reduce any friction between the two agencies to ensure that medical care does not suffer. This is often a crucial step toward working together at the “street” level.
PERSONNEL AND TRAINING ISSUES
Before any of the equipment can be used, however, the department must have enough paramedics to guarantee response 24 hours a day, all year round. Paramedic training requirements also vary by locality and state. Many states require specific programs that can take up to a full year to complete. Others have programs that can be done more quickly but are typically very intense and require a full-time effort. Typical paramedic training programs take 1,000 to 1,200 contact hours, in addition to clinical hours at a local hospital and ride time on a paramedic unit.
Departments may need additional personnel to provide the expanded ALS services. If not needed for ALS duties, these extra personnel may fill in for members who are in paramedic school. Part-time employees and volunteers may play an important part in determining how fast and how broad the expansion into EMS becomes. Of course, not all current members of your department will want to become paramedics. Through attrition, or as your department grows, career personnel recruitment preference can be given to already-trained firefighter/paramedics. This, however, could cause resentment from members of your department who are comfortable in their positions yet are resistant to new members who may be higher-trained than they are. This resentment may be overcome by including all personnel in various aspects of the upgrade program.
In addition to initial training, EMS personnel must have ongoing training to earn continuing education units or hours. These hours often are required for recertification every two to three years, depending on state requirements, and may have specific mandatory subject requirements. The medical director may have additional local requirements, based on local needs or weaknesses identified in the QA/QI process.
FUNDING AN UPGRADE TO ALS
Funding for expansion startup costs for ALS first response can be generated in several ways:
federal grants available from the Department of Transportation`s National Highway Traffic Safety Administration, the Department of Health and Human Services EMS for Children program, the Federal Emergency Management Agency, or other federal agencies;
U.S. Department of Agriculture low-interest loans designated specifically for fire and EMS departments;
private grants or endowments; and
the ambulance provider in your jurisdiction, which may help with startup costs, supplies, equipment, or training because they will ultimately benefit from the upgrade in service.
Because the local governments are often reluctant to raise taxes to support a service expansion, some other revenue sources should be looked at for ongoing costs. Instituting a fee structure (on a cost-recovery basis) could provide the revenue necessary to offset the additional cost of providing ALS. Other potential funding sources for EMS include:
fees charged to the EMS transport agency for fire department-provided ALS for a patient transported by the agency;
fees for fire-related services, such as fire suppression, victim extrication, cleanup at vehicle accidents, and hazardous-materials response (insurance policies usually cover these fees); and
contracting out training services or medical services to business and industry.
EMS is the key to generating public support and enhancing customer service in a fire department. Each department should look at EMS as the most important service it provides. This is especially true as the department looks at its future and where the members want to be and what services the citizens will need. Envisioning the future of the fire service, expansion into ALS should be viewed as critically important and must be carefully planned and carried out. Before initiating this expansion, however, local and state legal requirements must be identified and addressed, and appropriate interagency relationships should be developed. Funding sources must also be identified and secured, as upgrading from BLS to ALS is an expensive venture.
The next step after upgrading to ALS is expansion into EMS transport services. If done correctly, this can generate revenue, increase public support, provide experience for personnel, and allow greater versatility for the department. These should all be important goals for a fire department. n
GORDON M. SACHS is chief of training and safety for Marion County (FL) Fire-Rescue. He has 19 years of fire and EMS experience in the career and volunteer service and is a nationally recognized emergency service educator. He formerly served as program manager with the U.S. Fire Administration, where he coordinated and directed federal projects dealing with fire and EMS management and operations, responder health and safety, incident command, and EMS public education. He has served on several national committees dealing with emergency management and operations and currently chairs the Florida State Fire College EMS Curriculum Advisory Committee. Sachs has authored numerous journal articles and USFA publications and the chapter on emergency medical services in The Fire Chief`s Handbook, Fifth Edition (Fire Engineering Books, 1995), has been a featured speaker at fire and EMS conferences across the country, and is an editorial advisory member of Fire Engineering.