Crisis in Prehospital Care

By Mike Metro

Many experts have been sounding an alarm that there is a crisis in today’s healthcare system. This fact in undeniable in many areas of our nation. What is also undeniable is the impact this crisis will have on fire-based emergency medical services in such measurable ways as increased out-of-service times for EMS resources.

Over the past 30 years, the fire service has evolved from a singularly focused entity providing fire protection service to an all-risk industry expanding into areas such as EMS, hazardous materials response and mitigation, urban search and rescue, swiftwater rescue, and terrorism. Statistically, by far, the largest element of this paradigm shift is the provision of emergency medical care for those who entrust their lives to our systems every day. In most fire departments across the nation that have embraced this new mission, fire EMS responses now amount to approximately 80 percent of all calls.

As the fire service accepts this new role, we must also accept the fact that our success in EMS is dependent on partnerships with each of the prehospital care components such as ambulance services and hospital emergency rooms. There is an undeniable nexus with each component of the system. Conversely, if any one of the partners begins to falter, it likely will impact our own organizations. Nationally, fire-based EMS providers often bypass the most accessible emergency room because it is too busy to accept patients. Fire-based EMS providers are waiting an extraordinarily long time at hospitals because they are inundated and cannot accept our patients. As EMS administrators, we feel the impact in longer out-of-service times and an ever-increasing inability for first-due resources to cover their own areas because they are committed to EMS incidents longer than they should be. If this situation is not bad enough, the future may be worse-much worse.

The national prehospital care industry is facing tremendous pressures. The Balanced Budget Act of 1997 has resulted in a $71 billion reduction in Medicare payments to hospitals from 1998 to 2002. The new Medicare ambulance reimbursement schedule will likely result in a decrease in ambulance transport revenue. It is projected that up to $63 million will be lost over the four-year implementation schedule, just for those providers in California.1 The new federal mandates under the Health Insurance Portability and Accountability Act (HIPAA) will have significant impacts on most segments of the healthcare industry including fire-based EMS providers. In California, the legislature has imposed a requirement for all hospitals to upgrade their structural facilities to withstand a major earthquake. There is an enormous infrastructure cost to accomplish this.

If the financial pressures are not ominous enough, staffing shortages are bringing a new dimension of challenge to an already struggling industry. Likely the most critical, especially in California, is the nursing shortage. A 1998 report on the California healthcare system stated, “Nationally, California ranks the lowest out of the 50 states in the proportion of registered nurses per 100,000 population, from a high of 1,710 per 100,000 in the District of Columbia to a low of 566 per 100,000 in California. It will only continue to decrease as the state’s population increases by 21 percent from 1997 to the year 2010.”2

The result of these problems is that more and more hospitals are closing their doors. The total number of beds available is diminishing because of facility closures and lack of staff. Most states have mandated ratios of nurses to patients. When not enough nurses are available to work, the number of available beds decreases. Reports from across the nation are ominous indeed. In Albany, New York, six hospital CEOs declared a crisis in staffing and overcrowding.3 The president and chief executive of St. Peter’s Health Care Services and St. Peter’s Hospital was quoted as saying, “We are on the brink of a severe crisis in the healthcare workplace today.” Hospitals in the capital region have overall nursing staff vacancy rates ranging from six to 20 percent. The number of new registered nurses in New York State declined by 21 percent between 1995 and 1999.

The end result of this crisis around the nation is a reduced number of patient beds available to treat a society that is getting larger and demographically older. The need for service is increasing, but the healthcare infrastructure needed to care for the health needs is decreasing.

How Does This Affect the Fire Service?
Many ill or injured patients brought to local emergency rooms need to be admitted to a patient bed for continued care. If there are no beds available, which is often the case, these patients awaiting a bed will be held in the emergency room, thus taking up a valuable resource. The “street impact” will be that emergency transport entities will have to wait for a busy emergency room to accept the patient or that the EMS provider will have to transport the patient to a distant hospital. All this translates into increasing out-of-service times for emergency resources and an inability to perform their primary mission. Few places in the nation are more critical than Los Angeles County.

Over the past six years in Los Angeles County, eight hospitals have closed their doors, reducing the number of hospitals by 10 percent. Patients who would have been treated by these facilities now flood surrounding hospitals, many of which were already crowded. The result has been fire-based EMS units bypassing the most accessible hospitals to more distant ones, “shopping” for hospitals that can accept their patients. The Los Angeles City Fire Department has estimated that it loses the equivalent of two rescue ambulances per day because of the time spent waiting for beds.4 The Los Angeles County Fire Department (LACoFD) has found that 90 percent of the time, its paramedic units are experiencing transport times of up to 28 minutes to acceptable receiving hospitals. Ten percent of the transports are greater than that. Once fire department resources arrive at the receiving hospital, many are subjected to wait times there as well, standing by while emergency room personnel attempt to find a bed for the patient.

Most fire-based EMS administrators would agree that a 20-minute turnaround time for their resources to transfer care of their patient to hospital personnel and then to restock prior to availability is reasonable. LACoFD administrators have found that this is often not the case. Data show that 2,000 unit hours are lost waiting in excess of 20 minutes at local hospitals per year.

In the northern portion of Los Angeles County, these problems are especially acute. In this area, LACoFD paramedics provide the advanced life support service and American Medical Response (AMR) provides the transportation component. LACoFD paramedics and AMR ambulances were waiting incredible lengths of time at the two local hospitals, both of which are at full capacity. At one time, these wait times approached four hours in extraordinary situations. The operational impact to the department was measured not only in lost unit hours but also by the number of medical incidents that could not be handled by the first-due paramedic resource. The LACoFD found that this was occurring up to 20 percent of the time in some areas.

A Community Solution
The LACoFD developed a task force in the northern region of the county consisting of all components of the local system. These partners included the LACoFD as the fire-based EMS provider, American Medical Response, hospital emergency room managers, city officials, and county health department officials. The problem was identified and its impact on each partner was quantified. This quantification helped each partner to understand how its challenges impacted other members of the prehospital care community. Opportunities were identified to improve the processes required to care for the patient starting from the 911 call to admission to a hospital bed. From this task force, several improvements to the system were developed. The following are some examples:

  • The hospitals developed process improvement teams, which streamlined the method of admission to the facility.
  • System indicators were identified that would predict lengthy wait times at the local emergency rooms likely to occur later in the day.
  • Using these system indicators, existing personnel could be redeployed to handle the system challenges likely to occur later in the day.
  • The LACoFD and AMR reexamined their deployment strategies, staffing additional resources during peak times.
  • Health Department officials made changes to hospital diversion policies in an attempt to redistribute patients during peak load periods.

Through the cooperative efforts of all the prehospital care system partners, significant improvements have been made. Although there is still much work to be done, data have shown improvements within these communities.

Fire-based EMS providers are part of an intricate system of interrelated partnerships, each dependent on the other. Hospital resources will face challenges never before seen as they strive to provide medical care for their communities. Their successes and their failures will most certainly impact fire-based providers. The solution to these challenges will be for all the system partners to work together to develop “out of the box” solutions and mitigating strategies before a failure of the system occurs.

During the first half of the 1970s, America’s EMS system was redesigned and the term “paramedic” became a household word. It is extraordinary to think that an entire paradigm shift in our national EMS service delivery system was accomplished in a little over five years. This was not an effort accomplished by the fire service alone. This was an effort accomplished by all sectors of the delivery system and is an example of what we can accomplish when we work together as partners for a common good. The future will require some extraordinary solutions, and that will require some extraordinary teamwork.


References

  1. California Emergency Medical Services Authority letter to the National Health Care Financing Administration, November 9, 2000.
  2. California Health Care System: Overview of the the Hospital EMS Crisis, Winter of 1997-1998, Findings and Recommendations. Emergency Medical Services Authority, State of California.
  3. St. Peter’s Health Care Services, Press release, January 10, 2001.
  4. Los Angeles Fire Department, Assistant Fire Chief Emile Mack, 10/2002.

Mike Metro is a battalion chief for the Los Angeles County (CA) Fire Department, currently assigned as director of Emergency Medical Services. His responsibilities include the management of the EMS program for a system that responds to nearly 200,000 EMS calls per year.

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