In this era of shrinking economies and budget deficits, "necessity" has taken on a new meaning for EMS - specifically, what is really NECESSARY to have in an EMS system that meets the needs of the community?   {NOTE: The term "quality" was specifically omitted from that statement as the determination of quality is too variable depending on the definition.}

Is an all ALS system necessary?   Is ALS First Response necessary?   Is endotracheal intubation necessary?   Is a nine minute ALS response time necessary?   Is taking every patient to the emergency department necessary?   Are those HUGE Freightliner ambulances necessary?   Is system status management necessary ( one for you Dr. Bledsoe...)?

Now that modern EMS is entering its "tween" years, we actually have some experience and good data that helps answer some of these questions.

Over the next several weeks, we'll present some of these questions from the point of view of the patient and the payer to see what the model EMS system of the future really looks like.

Is an all ALS system really necessary?

Facing increasing budget pressures, many communities are weighing the risks and benefits of transitioning from an all ALS system to a mixed ALS/BLS system.   Historically, the argument for an all ALS system was that the marginal cost difference of a paramedic over an EMT makes it economically feasible to operate an all ALS system.  

That was then - this is now...

It's now less of an argument of a few dollars an hour difference between and EMTs and paramedics, but more importantly the availability of paramedics.   Given the ongoing maldistribution of paramedics in our country, the option of staffing some ambulances with EMTs would result in more transport resources on the street.   Ask any street EMS provider the percentage of their patients who require ALS care (and let's use "require" here as needing ALS stabilization - not just the "might as well put them on the monitor and start and IV because we're here") and they'll probably tell you about 30-40% of the patients.   If 60% of the calls can be effectively handled by BLS care, why not staff more BLS ambulances?   Then use a sound emergency medical dispatch process to help assure the right resource is sent to the right patient.   This is especially logical if you also operate field supervisors or other providers in 'fly cars' that can be used to back-up a BLS unit if necessary as a safety net.

Large cities such as Philadelphia and Columbus were facing significant issues staffing enough paramedics to staff ambulance resources to meet the community expectation for response times.   These cities have made the transition to a mixed fleet with no detrimental impact on patient outcome.   Further, Milwaukee and Seattle also operate ALS and BLS units.   In Milwaukee, the fire department operates a handful of ALS ambulances that respond to the ALS 9-1-1 calls and private contractors handle the BLS 9-1-1 calls.   In Seattle, the fire department operates a mixed ALS and BLS fleet, again, with the ALS ambulances responding to the most serious calls.   Milwaukee and Seattle also have the best cardiac arrest survival rates in the country.   I would argue that part of this is due to well experienced paramedics since the vast majority of their calls are ALS.  

Even Miami-Dade Fire Rescue has recently transitioned BLS units into their EMSdivision to help assure appropriate utilization of ALS ambulances in the fire department.

Arguably, to some EMS leaders - and certainly to most IAFF presidents - this seems like blasphemy.   However, I would argue that the number one service delivery issue in any community is response times.   If an agency is able to staff 30% more ambulances on the street by using BLS units to handle BLS calls, response times would improve system-wide, including critical ALS calls since the ALS unit hours will not be consumed on BLS calls as often.

It's time for the leaders in local communities to take a hard look at how ambulances are being utilized in their system and carefully consider the benefit of mixing some BLS units into their all ALS fleet.   People will not die in the streets, and in fact, the real measure of consumer satisfaction - response times - will improve.

Is ALS First Response Necessary?

Another dangerous question for sure.   One of the first issues we need to address is the reason why ALS first response was even considered.   Ask any EMS leader who has been around more than 15 years and they will most likely relate that "back in the day" only paramedics could do any advanced airway and defibrillate - the two most important things the American Heart Association said was necessary in under 6 minutes in order to improve for cardiac arrest survival rates.   Therefore, WE ( yes, this is our fault!) promoted fire-based ALS first response because it was the most cost effective way to get ALS to the scene in less than 6 minutes.   Most fire agencies are really EMS agencies since 85% of their calls are EMS.   If they were not on EMS calls, they would be on hardly any calls - therefore the marginal cost of a few gallons of diesel fuel and 4x4's are pretty reasonable since the fire truck needs to be on duty for the occasional fire call.

As the scope of EMTs expanded to include advanced airway and defibrillation, the need for actual paramedics to make a difference in cardiac arrest has greatly diminished.   EMTs in most communities can not only do those skills, but also nebulized breathing treatments, epinephrine for anaphylaxis, nitrates for chest pain and in some states like Wisconsin, Minnesota and Wyoming, even allow EMTs to administer IM glucagon for diabetic issues, apply CPAP and acquire and transmit 12 Lead ECGs.   The fact is, as Dr. Tober in Naples, FL and others have determined, most paramedics in the First Response role do not use their skills enough to maintain proficiency.   Add to the mix the fact that the AHA is now completely de-emphasizing advanced airway at all in cardiac arrest and focusing simply on chest compressions and the message is even clearer that ALS first response does not have the same role as it did years ago.

All this being said, it is very difficult to change an existing ALS service level to a BLS service level, just ask the Medical Director in Philadelphia or the City Manager in Columbus.   But, for a few brave souls in our profession, the time has come to make some realistic changes: focus on the clinical, economic, AND customer service needs of our communities, and in a carefully controlled environment, make some changes.   We can then measure clinical and economic outcomes very well and see if we made the right decision.

Next time - we'll discuss the nine minute response time standard and endotracheal intubation...

To have even more fun, I'll entertain the possibility of a point-counter point discussion in these topics - anyone willing??

About the columnist:

Matt Zavadsky is the Associate Director for Operations at MedStar EMS, the Ambulance Authority System serving Fort Worth and 14 suburban cities in North Central Texas.  In this role, he is responsible for overall system operations covering the 880,000 people and 100,000 EMS responses annually.  

He holds a Masters Degree in Health Service Administration and has 30 years experience in EMS including volunteer, fire department, public and private sector EMS agencies. He is a former paramedic and has managed private sector ambulance services from 10,000 to more than 100,000 annual call volume in locations including Fairfield, Connecticut; Augusta, Georgia; La Crosse, Wisconsin and Orlando, Florida.  He has also served as a regulator in Lincoln, Nebraska and Volusia County (Daytona Beach), Florida.

Matt is a frequent speaker at national conferences and has done consulting on numerous EMS issues, specializing in high performance EMS system operations, public/media relations, public policy, employee recruitment and retention, data analysis, costing strategies and EMS research.

He has served as the American Ambulance Association as Chair of the Industry Image Committee and membership on the Professional Standards, Strategic Development and Management Training Institute Committees.

Matt is an Adjunct Faculty for the University of Central Florida's College of Health and Public Affairs teaching courses in Healthcare Economics and Policy, Ethics, Managed Care and US Healthcare Systems.