Sunday’s New York Daily News included this article: “EXCLUSIVE: Budget watchdogs want city to cut back on fire engines responding to medical emergencies.” The article highlights points made by the Citizen’s Budget Commission’s November 20 report: Revising EMS: Restructuring Emergency Medical Services in New York City. Jillian Jorgensen’s Daily News article highlights this aspect of the report: ” … the Citizens Budget Commission recommends ultimately reducing the number of engine companies, which for years has been a political nonstarter.”
Reading the report, that goal is clearly articulated:
Despite their high cost and limited effectiveness, the use of engine companies as responders to medical incidents has been continued by FDNY as a pretext for sustaining the staffing of otherwise unnecessary fire engine companies. In 2010 the Bloomberg Administration unsuccessfully proposed closing 15 fire engine companies primarily due to the declining workload related to fires and other emergencies, but the president of the Uniformed Firefighters Association argued at a New York City Council hearing that closing the companies would endanger lives because response times to medical incidents would increase.
Let’s look at the three recommendations in the CBC report:
1: Design and implement a program to reduce unnecessary use of EMS.
The report references Houston’s telehealth program and Dallas proactive community health visits as programs to consider for New York City. Both programs are in fire-based EMS systems and showed a dramatic reduction of 9-1-1 calls for the patients enrolled in these programs. There are existing New York state administrative regulations that could allow community health care visits for NYC Medicare enrollees with chronic conditions.
NYC EMS workload for 2017:
The 2017 tiered response times, Segments 1-3 are considered life-threatening:
2: Go to 1-paramedic and 1-emt staffing on ALS ambulances
This requires a change in the REMSCO policy requiring 2 paramedics on a New York City ambulance while allowing a 1-and-1 staffing in other parts of the state.
The Regional Emergency Medical Services Council of New York (REMSCO), is responsible to the State of New York for coordinating medical services in all five boroughs of New York City. The Council was established and designated to be the policy and administrative authority within the New York City region.
The Regional Emergency Medical Advisory Committee (REMAC) was established to provide medical control for the EMS System.
REMAC develops policies, procedures and triage, treatment and transportation protocols which are consistent with the standards of the New York State Medical Advisory Committee but address the specific needs of New York City.
3: Reduce the role of engine company response to medical incidents and shift resources to EMS.
What would happen if CFR-D engine companies only responded to anaphylactic shock, cardiac arrest, choking, stroke, difficulty breathing, respiratory distress, and status epilepticus? There were 199,000 such emergencies in 2017, while CFR-D fire companies responded to 281,000 incidents.
This is not insignificant. Of the 198 fire engine companies, medical runs are:
- more than 50 percent of the workload for 9 companies
- 40 percent to 50 percent of the workload for 75 companies
- 30 percent to 40 percent of the workload for 88 companies
- less than 30 percent of the workload for the remaining 26 companies.
In the Bronx, 10 Paramedic Response Units (PRU or “Fly Car”) were piloted in 2016, staffed by an EMS Supervisor and another paramedic. These are non-transport units that respond with a BLS ambulance to life-threatening calls. About 70% of the patients assessed by the PRU only required a BLS-level transport.
PRUs spend less time on each call (about 43 minutes) than two paramedics in an advanced-life-support ambulance do (about 1 hour, 8 minutes), which increases their availability for the next patient who may need advanced-life-support.
Big City Fire-Based EMS Challenges
Big city legacy fire departments struggle in delivering effective emergency medical services. Municipalities are slow to respond to changes in the out-of-hospital environment due to their administrative structure, the annual budget process, and labor agreements.
Fire-based EMS needs to be treated as a separate enterprise from fire suppression. Many of the stumbles in EMS strategic planning as well as day-to-day operations is caused by handling an ALS ambulance as if it was a shorter and thinly staffed fire company. Or a unit to be ignored, under-resourced, and overworked.
There are FDNY EMS Division staffing and experience gaps. Many EMS providers transfer into the fire department when the hiring process opens every four years. For EMT’s this is a $9,000 raise.
Vincent Variale, president of the Uniformed EMS Officers Union, Local 3621, opposes the 1-and-1 ALS ambulance staffing, stating that a recent study showed that 58% of the FDNY EMTs had less than 3 years experience.
The recommendations from the Citizen’s Budget Commission are not revolutionary. Closing fire companies to staff additional EMS units have a history of internal and external challenges that, when the dust settles, did not resolve the EMS performance concerns.
In 1999 big city fire departments were looking at an explosion of ambulance workload, high paramedic vacancy rates and long response times. San Francisco and Los Angeles established hundreds of additional single-role EMS positions and streamlined their municipal hiring process for candidates holding National Registry or California paramedic credentials. In Baltimore and Philadelphia, they decided to close fire companies to staff additional ambulances. While working at the university I followed the efforts of Baltimore and Los Angeles. Both were all-paramedic fire-based ambulance systems using the same workload measurements.
Comparing workload – the Baltimore experience
Baltimore’s blue-ribbon committee focused on the time on task for the units. In a 24-hour period, an engine company spent 1 hour and 47 minutes responding to and operating at an emergency, in 1999 half of those engine company incidents were as an EMS first responder. A paramedic ambulance spent 14 hours and 25 minutes responding to, operating at and transporting patients in a 24 hour period. The numbers of working structure fires in the city went from 5,621 in 1994 to 2,367 in 1999.
“EMS units are so busy that they usually do not return to their stations after starting their shifts.” It took eight minutes and 44 seconds for a Baltimore ambulance to arrive at a call.
There were 40 engines, 21 trucks, and 18 paramedic ambulances in Baltimore. In 2000 the committee recommended closing 7 fire companies, allowing 100 affected firefighters to fill existing vacancies at other fire companies. The other 40 firefighters would be used to staff 4 to 6 additional paramedic ambulances. The city would save $4 to $5M in overtime. At that time, 72% of fire responses were for EMS incidents.
Seven years later, the blue-ribbon committee’s implementation was complete. Here is the 2007 snapshot:
- 4 engine companies closed
- 2 truck companies closed
- 1 battalion chief closed
- 4 paramedic ambulances added
There were still not enough ambulances to handle the workload. There were four “Red Alert” ambulances that were placed into service when the city got down to 3 ambulances. This was accomplished by placing fire companies out of service to staff the Red Alert ambulances. The Red Alert ambulances were activated almost every afternoon.
By 2006 two of the Red Alert ambulances, Medic 41 and Medic 44, were staffed 9 am to 9 pm every day with overtime or detailed firefighters. Each 12-hour unit averaged 7.5 runs every day. Using the Los Angeles City EMS workload metrics, Baltimore needed to add 9 additional paramedic ambulances to meet their 2007 workload.
Baltimore Fire Today
The FY 2016-2017 run statistics as provided by Baltimore Fire Fighters Local 734 shows that EMS assets include:
- 21 medic units 24/7
- 1 medic unit 9 am – 9 pm
- 3 EMT ambulances 24/7
- 12 EMT ambulances 9 am – 9 pm
- 5 “Critical Alert” units to be staffed by suppression crews if needed
- 6 EMS Supervisors
The 2016-2021 Baltimore City Fire Department Strategic Plan shows that Emergency Medical Services is the number 1 community priority.
Here are selected goals from their strategic plan:
Goal 1: Develop a systemic plan that will tailor a Mobile Integrated Healthcare Community Paramedicine (MIH-CP) program to fit the needs of Baltimore City,
which will facilitate a better use of Baltimore City Fire Department EMS and
suppression assets more effectively in order to foster improved care while
reducing the burden on the emergency response system.
Goal 3: Develop a comprehensive outreach program to ensure the community is
appropriately educated about the resources available through the BCFD and
current issues facing the department.
Dump Trucks, Defibrillators and Budget Optics
Sending a fire company, a crew of 2 to 7 riding a $300K rig, as an EMS first responder is a bit like sending a dump truck to deliver a pizza. That is a Brunacini analogy when describing the value of ladder tenders. Seattle fire chief Gordon Vickery started fire company responses to life-threatening ems calls as a way to remind the public that they had neighborhood fire-based rescuers as part of the then-fledgling Medic 1 program. FDNY engine companies used their defibrillator 72 times in the 281,000 EMS responses in 2017.
The system should always send the nearest public safety resource to life-threatening medical emergencies. Would a police officer with a stop-the-bleed kit in an AED-equipped cruiser get there faster? How about an AED-equipped verified PulsePoint responder (off-duty healthcare or public safety responder). In the high-rise district, an AED-trained floor warden could have an alert to defibrillation response time within 3 minutes.
A 2015 report by the Citizens Budget Commission: “Twenty Years Later: Integrating Services in the New York City Fire Department” made this observation
In fiscal year 2015 the FDNY’s total budget was more than $3.8 billion. Despite the preponderance of medical incidents and the continued decline in fire incidents, most of the department’s resources—71 percent of the budget and two-thirds of personnel—are devoted to staffing fire units. The 10,789 fire personnel well outnumber the approximately 4,700 emergency medical technicians (EMTs) and paramedics, and EMS operations are funded at $500 million annually—just 13 percent of the budget.
The whine about budget allocations for fire-based EMS is specious. During the 1990-1991 recession, my fire department was required to dissect our budget into “lines of business.” We had to identify the activities that were required by federal, state or local regulation. The goal was to identify the legally required minimum activities for each agency in the county. The results were disturbing for the fire department as many of our essential activities were not required by federal, state or local regulations. During this assignment, I worked to isolate all of the EMS-related expenditures: salaries, fringe benefits, capital equipment, uniforms, vehicles, operating expenses, training, etc.
In a department where we have dual-role firefighter/ems providers and employ ALS-capable fire companies as first responders, I was left with a trivial pursuit process of percentages of expenses. The bulk of the personnel, capital, and operating expenses would land in the fire suppression side of the budget. The employees assigned to EMS-specific job positions as well as the capital, operating and vehicle expenses linked to the EMS job or program number would be in EMS. But that number does not represent the total amount of resources that deliver EMS services or reflect the large communications, physical plant, logistics and infrastructure resources that serve the entire fire department.
In addition to sending the nearest public safety resource to life-threatening emergencies, fire-based EMS systems should staff enough ambulances to handle the day-to-day and seasonal EMS workload without requiring a fire company response to medium and low acuity calls to meet a response time goal.