I came across a report from the Citizen’s Budget Committee of New York. This is not a city agency, but is comprised of concerned citizens who want to help the cities and state of New York operate more efficiently.
Founded in 1932 the Citizens Budget Commission (CBC) is a nonprofit, nonpartisan civic organization devoted to inﬂuencing constructive change in the finances and services of New York State and New York City governments. A major activity of CBC is conducting research on the financial and management practices of the State and the City and their authorities.
The report that drew my attention is,
If you’re at all interested in EMS, you should read the report. If you’re interested in EMS in the City of New York, you really should read it.
The report is well structured and has some good suggestions. None of which will be adopted by the fire fighters who run EMS in New York City.
It also lacks any sense of history of how EMS in New York City operated in the past or operates now.
For those who don’t remember, until March of 1997, EMS in New York City was operated by the Health and Hospitals Corporation. That corporation also ran, and still does, the city owned hospitals.
Rudy Guilliani, then Mayor of New York City, decided to “merge” EMS with the fire department. There is a lot of speculation about the reasons he decided to do this, but no matter because he did it.
Allegedly, this was going to result in a unified fire department that would deliver EMS more efficiently than the existing EMS system that was run by people with medical backgrounds.
It was a merger with one willing partner and one unwilling partner. Much as the Borg used to merge with the Federation in Star Trek, The Next Generation. In fact there was a website that used that as a theme for the merger. Kind of funny, but kind of sad.
Once the agencies were merged fire department management decided to change everything about EMS. Well, everything but the things that mattered. They changed the uniforms, changed the color scheme and lettering on the ambulances and other vehicles, decided to change the radio call sign structure, and how ambulances responded. They also started to implement “Paramedic Response Units”, which were non ambulances staffed with paramedics. These are called “fly cars” in some parts of the country.
That lasted about a year or so, maybe a bit less. I forget exactly why, but after that the PRUs disappeared, the old call sign structure and deployment plan reappeared.
Neither response times nor cardiac arrest survival rates improved.
The problems that existed at the time of the merger were too many calls and too little resources, money was spent lavishly of fire suppression but niggardly on EMS, there were “frequent fliers” who took up a lot of resources, but didn’t really need ambulances.
In other words, what goes on in much of the United States when it comes to EMS.
So, what did the Committee find in it’s investigation,
Avoidable use—ambulance use for chronic conditions like diabetes, asthma, or addiction—is partculiarly pervasive and costly, and for many of these patents, the ER is not the ideal treatment site.33 In addition there is evidence that a subset of patents with chronic conditions, called “frequent ﬂiers,” are prone to recurrent EMS use, relying on ambulances and ERs for routine care.34 One study of urban EMS systems examined repeat Utlization for three chronic conditions: acute alcohol intoxication, seizure disorder, and respiratory illness. Among these diagnoses researchers found
4.3 percent of patents accounted for 28.4 percent of transports.35 The publicly available EMS data do not allow for tracking of Frequent ﬂiers; while the hospital intake and ambulance billing data would allow for such an analysis, the FDNY does not track the data in that manner.
There is nothing new in this paragraph. Nothing that EMS systems large and small don’t deal with on a daily basis. Also, patients with chronic conditions often deteriorate and have acute episodes. Missing one of those will get EMS on the front page of the newspapers, and not in a good way.
Here is what the committee recommends,
Many cites have begun to implement programs to reduce unnecessary EMS use. Some programs, such as one in Reno, Nevada, use nurses to take 9-1-1 calls to assess whether the patent requires emergency care, and to link callers with non-ER resources when appropriate.52 The City of Houston has implemented a telehealth program in which arriving EMS staﬀ assesses whether a situation is a genuine emergency and can consult an emergency physician via video. If the physician confirms there is no emergency, EMS staﬀ works with the patient to connect to appropriate sources of care.53 In Dallas, the EMS department makes proactive community health visits to frequent ﬂiers and has seen an 82 percent reduction in enrolled patents’ use of EMS.
What the committee doesn’t seem to consider is that an ambulance still has to go to the call. Doing the consultation can take longer than transporting the patient. Oh, and there is currently no revenue stream for non transports.
Oh, someone should tell the committee that “frequent fliers” is a pejorative term. I always advise clients to use “Valued Repeat Customer.”
The committee also recommends staffing ambulances with one paramedic and one EMT. Called “P/B” staffing, this is used in many areas. What no one knows is if one staffing pattern is better than another.
It’s incredibly difficult to compare different EMS systems because there are something like 50 different models of EMS delivery in the United States. I won’t go into even a few because I could write ten blog posts and not even scratch the surface of the topic.
Here is another committee recommendation,
Reducing the role of fire engines in medical incidents will not create savings without scaling back the number of engine companies. The City should conduct a thorough assessment of the location, coverage, and workload of fire companies; while nonmedical, nonfire emergencies have been on the rise, the precipitous decline in fires and dramatic changes in building density and demographics since many fire houses were built have reduced workloads of several fire companies. Such an 15 assessment should identify where companies could safely close without jeopardizing response times to any type of emergency.63 For every fIre engine company closed, the city would save $7.2 million annually, enough to fund 10 additional ambulance tours each day.64
Good luck with that. The fire fighters union, which I believe is still separate from the EMS employees union, will fight that until the death. I know of only one city, Baltimore, that did that sort of thing. I think they did it by attrition, not layoffs. Nor can FDNY move firefighters without EMS certification to ambulance duty.
Back to the PRUs. FDNY reimplemented them on trial basis in 2016 in the Bronx. Which resulted in fewer ALS ambulances being available. So, more BLS units were fielded to make up for that shortage. The paramedic on the PRU did an initial assessment to see if the patient needed ALS. Unsurprisingly (to me) FDNY found out that only 30% of their patients actually needed ALS. They also found out that much of the time first response engines were not needed and provided no significant medical care.
Neither is a surprise to anyone who has spent any amount of time working in EMS, especially in a city of just about any size.
There is a lot of number crunching going on in this report, but I get the feeling that no one talked to anyone who actually provides EMS care in New York City. Some of what the committee recommends probably would work, but won’t be implemented for a number of reasons. Some of what they recommend might be implemented, but won’t have the intended affect.
In ten years or so, someone will be putting out another report that will point out the same problems and make similar recommendations.
Read the report and please comment either here or on Facebook. If you work for FDNY as an EMS provider, I’d really be interested to hear your thoughts on this.