EXPANDING THE EMS: GETTING INTO THE TRANSPORT BUSINESS
BY GORDON M. SACHS
Many fire departments across the country limit their EMS activities to first response: responding to calls for emergency medical help, providing the necessary emergency care, and handing the patient off to another agency for transportation to a medical facility. Although this type of system works well, many departments are working toward providing full-service EMS by adding emergency medical transportation to their functions. Other fire departments have been successfully providing EMS transportation for decades.
Expanding EMS capabilities to include transport can be a big step for a fire department. There are many more considerations and requirements than are required by first-response systems. In addition, there may be significant costs involved, particularly those involving the purchase and staffing of transport vehicles. Some departments, however, have found creative ways to deal with these challenges and are providing their citizens with top-notch EMS care and transportation. This article will highlight some of the major considerations and requirements facing fire departments thinking about getting into the transport business.
OPERATIONAL REQUIREMENTS
Level of service. Continuous advanced life support (ALS) or basic life support (BLS) response capability for all emergency ambulance service calls must be maintained within times prescribed by applicable laws, rules, regulations, and protocols. The level of service (ALS or BLS) is typically a local decision; however, rarely will a community support a decrease to BLS just so the fire department can begin transporting. It has been shown that, as an EMS system is growing, BLS personnel can staff transport units while paramedics staff engine companies or other first-response units. This type of arrangement requires fewer paramedics and, since the majority of transports are BLS, keeps the paramedics more available for ALS calls. When necessary, the paramedic rides with the patient in the ambulance; the engine (or first-response unit) remains in service as a BLS first-response unit until the paramedic returns from the hospital.
Response times. A response time standard must be identified or developed and strictly adhered to. For example, at least 90 percent of the emergency ambulance service calls should have a response time of eight minutes from dispatch to patient contact in urban areas and 12 minutes in rural areas. Response times of first-response fire-rescue units can be used to achieve the above-stated level of service when units from the same agency will be transporting. Times must be defined and understood: Eight minutes should be defined as eight minutes and no seconds; 12 minutes as 12 minutes and no seconds. In the event of an extended response time (such as an emergency response exceeding 15 minutes) from dispatch to patient contact, a detailed report should be required to document reasons for delayed response. Run logs reflecting the time and purpose of all runs should be maintained, and copies should be accessible to fire department officials at all times.
Ambulance deployment. A decision needs to be made about whether transport units will be at fixed locations (fire stations) or deployed in a more dynamic manner based on anticipated call load and call location. A Systems Status Management (SSM) ap-proach can be used by any type of EMS agency in urbanized areas, combined with fixed ambulance locations in rural areas. This type of system is successful, especially when coupled with some type of emergency medical dispatching procedure. Similarly, a “peak load staffing” (PLS) approach–whereby a minimum number of ambulances are in service throughout a jurisdiction during peak hours (the times with the most EMS calls) as well as nonpeak hours–can be used. With both SSM and PLS, ambulance placement is based on computer analysis of EMS calls over a given period of time, which leads to a forecast of when and where calls are likely to occur. Ambulances may be staged in parking lots, on street corners, or at nearby fire stations until they receive a call or the call forecast indicates they should move to another “post.” Re-gardless of the deployment system used, additional transport units should be able to be placed in service in a timely manner during disasters or areawide emergencies.
Staffing levels. Each ambulance on shift and at all locations should be staffed with a minimum crew consisting of one state-registered emergency medical technician and one state-certified paramedic. Consideration must be given to the possibility that a fire may occur while a crew is out on an EMS call–in some cases, a single crew can be used for fire and EMS; in others, separate personnel will be needed. In either case, at least one field supervisor should be on duty 24 hours per day, seven days per week, year round for every five to seven transport units.
Incident management. All emergency response operations should be conducted under the incident management system (IMS) used by the fire department. Ad-ditional training in IMS for EMS may be necessary. Consider the National Fire Academy course “Incident Command System for Emergency Medical Services.” In addition, the department medical director should consider taking a course on the incident command system for EMS physicians, offered through the National Association of EMS Physicians and the National Fire Academy.
Disaster operations. During a potential or declared disaster, locally or elsewhere in the region or state, the local Comprehensive Emergency Plan or the State Emergency Response Plan should be followed, as appropriate. Under most plans, EMS falls under the Health and Medical Emergency Support Function (ESF #8) at an Emer-gency Operations Center (EOC). The fire department will have to expand its disaster response plan to include this and participate in additional EOC activities in accordance with its increased role in EMS transport.
SUPPORT SERVICES REQUIREMENTS
Communications. The equipment and communications capability necessary for compliance with the applicable state and FCC rules and regulations must be available. Emergency medical dispatching system hardware and software, communications hardware and software, and a minimum number of dispatch personnel for a fire-rescue/EMS dispatching system must be provided. Each ambulance should maintain constant two-way radio communication capability with (a) all interconnecting base station dispatching locations, (b) each hospital, and (c) fire-rescue units. Any automatic vehicle-locator system used should include first-response fire-rescue units.
Medical director services. The medical director must be board-certified or board eligible in emergency medicine; must be licensed in the state; and will have authority and responsibility for medical care, medical quality assurance, and training requirements and programs. There are many more issues for a medical director overseeing transport operations than first-responder operations, and the department`s medical director must be a key player in the expansion into transport service. Consideration should be given to employing/contracting with the medical director used by the outgoing transport agency.
Maintenance. The department must have the personnel, facilities, and equipment necessary to perform routine and emergency maintenance and repairs on all vehicles and equipment related to emergency medical care and transportation. Replacement/loaner equipment for critical items must be available. Ambulance transportation typically means a substantial increase in miles driven, which can lead to increased fuel and maintenance costs.
Resource management. The department must have the capability to purchase, store, and supply all consumable medical supplies for ambulances and first-response fire-rescue units. Running out of medical supplies or personal protective equipment during a holiday weekend can be politically damaging to a fire chief, who must answer questions about why units were placed out of service or were out of compliance with state or local guidelines. (An agreement with the local hospital is often a good backup plan for this type of emergency.)
Biohazardous waste/contaminated equipment. The fire department must provide for removal, storage, and disposal of all hazardous waste generated in the provision of emergency medical services. In addition, provision must be made for the decontamination/disinfection of any reusable medical equipment contaminated by body fluids or other potentially infectious material in the course of providing emergency medical care or transportation. Again, the local hospital should have disinfection facilities in place; that is probably the best place to start in the quest for suitable alternatives to this issue.
ADMINISTRATIVE REQUIREMENTS
Compliance. Transport agencies must at all times comply with and abide by all laws, rules, regulations, and protocols adopted or promulgated by any federal, state, or local legislation or regulatory body. The fire department is no exception to this requirement and can lose the certification to perform transport as quickly as any private EMS agency.
Certification requirements. Transport agencies typically must hold state certification as an ALS transport provider or an equivalent certification (as specified by state statute). All ambulances must be equipped to meet minimum ALS and BLS standards as established by the state regulation. In addition, all ambulances will need to carry any other drugs, supplies, or equipment deemed necessary by the department`s medical director.
Indemnification. The fire department may need to indemnify, save, and hold harmless the county; the county Board of County Commissioners; and its officers, agents, and representatives from all liability, in equity or at law, claims, loss, injuries, damages, attorney fees, expert fees, consultant fees, paralegal fees, litigation expenses, and costs of every kind and nature arising from or in any way connected with the operation of the ambulance service.
Insurance. The department should procure and maintain in effect, vehicular, operational, and contractual liability insurance, as follows:
Liability insurance that protects the department from claims that may arise out of or result from the operation of an ambulance service. Liability insurance will be obtained at the department`s expense and include endorsements for contractual liability and such other endorsements appropriate for the work required as may be stipulated by the local jurisdiction. The limit of liability for this coverage should not be less than $1 million CSL (combined single limit) per occurrence.
Automobile liability insurance that covers all automobiles and trucks the department may use in connection with this service. The limit of liability for this coverage should not be less than $l million/$500,000 B.I. (bodily injury) and $500,000 P.D. (property damage).
Workers` compensation insurance as required by the state.
Rate schedule of charges and fees. Tax subsidies are not the best method for funding the expansion into transport services. A department must identify services to be charged for, calculate the fees, and be able to justify the fee to public and government officials. The department should also produce a plan indicating when a change in base rate may/will occur. Examples of fees to be collected include but are not limited to first responder, extrication, standby, and transport.
Billing and collections. A department will need to determine who will be responsible for billing and collecting all charges for ambulance and related services and should make a diligent effort to collect all sums billed. Billing for the fire department services may be contracted out to a local hospital or a commercial EMS billing company if sufficient staff is not available to perform this time-consuming function in-house. Either way, collection procedures and policies, including samples of invoices, collection letters and notices, and related documents, will need to be developed.
Reports and information management. Reports should be generated on a monthly basis. They should include but not be limited to reports that provide information on billings, collections, expenditures by budget line items, call-response logs showing time and purpose, quality assurance interactions, and related areas. Special reports, information, or specific data shall be provided to county agencies on request.
Restoration plan. It should provide for the orderly return of the ambulance operation, vehicles, and equipment should the department`s ability to provide ambulance service cease or the certification to provide such services be revoked.
Other transport-related programs/reports. Among those that will need to be adopted or revised are the following:
Medical quality assurance.
Communications.
Vehicle maintenance.
Vehicle replacement.
Vehicle and equipment checklist.
Service complaint resolution procedure.
Proposed staffing plan and employee scheduling matrix.
Employee policies and procedures manual.
Risk-assessment/risk-management plan.
Infection-control/exposure-control plan.
Employee educational policies.
Employee policies and procedures manual.
Mutual-aid agreements.
FUNDING THE EXPANSION INTO TRANSPORT SERVICES
The cost of expanding into the transport business will likely be a point of contention for those opposed to the effort. Two additional administrative items that may be critical to the successful approval and implementation of EMS transport services for a department are the following:
An annualized line-item budget, with and without transport services, projecting line-item operating costs, line-item capital costs, projected revenue by source, and projected profit/loss.
An implementation schedule to include time requirements for acquiring transport vehicles; adding new employees or training current qualified employees; and meeting operational, support, and administrative requirements. A time line indicating funding requirements for the various phases of implementation should be included, as well.
To provide the most efficient and effective life-safety protection, fire-rescue departments should expand into EMS transportation services. However, tax subsidies should not be looked at as the main revenue source for this service. Instead, several other approaches can be taken to help fund the service:
Patients can (and should) be billed for the services provided.
A subscription/membership program could be started. One of the most successful funding programs in the country is called FireMed, a program under which citizens and businesses pay a small fee each year (basically a prepayment or copayment) to cover uninsured portions of an ambulance bill. A bill is sent directly to the member`s insurance company; any amount not reimbursed by the insurance is “written off.” Nonmembers are responsible for the entire bill.
Billing services can be marketed to other departments for additional revenue.
Beginning EMS transport services will require a significant commitment on the part of a fire-rescue department. With a limited budget and limited staff of dual-certified paramedics, it may be wise to ease into the transport business by absorbing the staff, vehicles, and other resources of the agency now providing the services (if possible). To do this, there must be a “what`s-in-it-for-them” condition, such as providing nonemergency and emergency interfacility transports, participating in a “managed-care” arrangement, or agreeing to an “expanded-scope-of-practice” provision in which the fire department forms a partnership with the hospital to do joint prevention/education activities. This becomes a win-win situation, with the citizens benefiting most.
MANY CONSIDERATIONS
A fire department attempting to get into the EMS transport business must take many considerations into account. The local, state, and federal regulations that must be adhered to are themselves daunting. There will be costs for vehicles, equipment, supplies, and personnel, including operational and support personnel (EMS training personnel, medical director, mechanics, dispatchers, and so on) that may be needed to accomplish the increased workload of the transport function. Additional facilities may also be needed, depending on the type of transport unit deployment that is to be used. Operational, support, and administrative issues must be addressed.
Expanding into the EMS transport arena does not have to be overwhelming. As long as EMS transport is recognized as one of the principal services delivered by the fire department and everyone involved in the transition is aware of the importance and long-term positive effect the new service will have, all the considerations and requirements can be met. It takes commitment, a lot of effort, strong leadership, and political savvy. Expanding into EMS transport is the right thing for a fire department to do, and it is happening all over the United States, in spite of the current trend of privatization. n
n GORDON M. SACHS is chief of training and safety with Madon County (FL) Fire-Rescue. He has more than 19 years of fire and EMS experience in the career and volunteer services and is nationally recognized as an emergency services educator and author. In addition to contributing to many journals and U.S. Fire Administration publications, he wrote the chapter “Emergency Medical Services” in The Fire Chief`s Handbook, Fifth Edition (Fire Engineering Books, 1995). He has been a featured speaker at fire and EMS conferences across the country and is a National Fire Academy instructor in the EMS Management and Health and Safety curricula. Sachs currently chairs the Florida State Fire College EMS Management Curriculum Advisory Committee and is a member of the Fire Engineering editorial advisory board and FDIC Planning Committee.
