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Ambulance response times a key concern

In the moments after a family member stops breathing or gets battered in a car wreck, time slows down as urgency speeds up. Each minute waiting for an ambulance seems an eternity.

Many factors go into rapid response time, including the number of ambulances available, their conditions, the type of technology on board and who is staffing them.

The Medical Center of Central Georgia has been evaluating the costs of providing ambulance service. But costs are entwined with quality. Investments may pay off in lives saved, so ambulance providers must walk a delicate line.

Last month, privately operated Mid Georgia Ambulance proposed taking over the Medical Center’s ambulance service and hiring its employees, but was refused.

In an e-mail to employees, hospital CEO Don Faulk indicated that quality concerns were one of the reasons to keep ambulance service in-house.

“We heard clearly from our clinicians, nurses and doctors, that the services provided by our staff were of higher quality than other ambulance services and our staff’s ability to coordinate care for the benefit of the patient is enhanced when we work as closely together,” he wrote.

More coordination means patients get the care they need faster, which usually produces better outcomes and also reduces the total cost for both the patient and the hospital, said Rhonda Perry, the Medical Center’s chief financial officer.

Kristal Smith, program chair for the paramedic technology program at Central Georgia Technical College, agreed that a hospital-run service might have better cooperation with hospital staff, and she noted that it could be more efficient through sharing staff and resources.

But others are reaching different conclusions. In March, Athens Regional Medical Center and St. Mary’s hospital in Athens teamed to outsource their ambulance services to a private company, National EMS. “We still feel very integrated,” said Dee Burkett, vice president for professional services at Athens Regional. For one thing, almost all the medics are the same.

“In certain ways we see that the ambulance service has improved,” Burkett said, explaining that response times have sped up slightly in Clarke County. “National has a quality review and improvement program which I think is better than what we had,” he said.

Mid Georgia Ambulance owner Ben Hinson argues that his company has a great track record. Both he and medical director Ray Fowler have been industry leaders. Hinson has received a lifetime achievement award from the American Ambulance Association. Fowler founded a leading EMS medical director think tank. Fowler lives in Dallas and works one day a month in Macon.

RESPONSE TIMES

Gauging quality is somewhat subjective. There are no national standards for ambulance service.

“There isn’t a lot of data in our industry, and it’s never been a priority for the government to track it,” said Gary Wingrove, president of the National EMS Management Association.

“The public pretty much requires us to keep track of our response time,” he said. Internally, ambulance services also track the number of calls that an ambulance responds to each hour. This tells them whether their work force is the right size, Wingrove said.

Response time — roughly, the amount of time it takes for an ambulance to reach a patient after being dispatched — can be a touchy subject in the industry. EMS professionals don’t even seem to agree on whether it’s a fair standard.

Wingrove said some ambulance companies use eight minutes and fifty-nine seconds as a benchmark. This is the response time recommended by the National Fire Protection Association. It is also based on the American Heart Association’s conclusion that survival rates of cardiac patients improve if advanced life support reaches a patient within nine minutes, Wingrove said.

All Georgia ambulance services must report their response times for each emergency call to the state. The Georgia Department of Community Affairs, which maintains these records, refused a public information request for access to them. The department said the information is “not used or needed in the regular course of business” by the state or kept in a form that can be produced without revealing personal patient information.

“All ambulance services track their response times and set goals for response time,” said Kristal Smith, chair of the paramedic tech program at Central Georgia Technical College. “At a county ambulance service, if you fail to meet the response time, you have to justify it and document it.”

But Lee Oliver, assistant vice president for emergency services at the Medical Center, said he doesn’t know the average response time of Medical Center ambulances.

“That would surprise me,” Wingrove said. “That’s one of the indicators you watch to see if you need to increase or decrease your resources, like adding ambulances.”

However, Oliver is not alone. David Borghelli, director of emergency services at Houston Healthcare, said he doesn’t know the average response time of his ambulance service either.

Although Hinson calculated Mid Georgia Ambulance’s average response time to calls within Bibb County — seven minutes and six seconds — he said this isn’t a number he watches.

Instead, he said, he and other ambulance providers generally track what percentage of the time they reach a certain response-time goal — in Mid Georgia’s case, eight minutes.

He said his company meets that goal between 80 percent and 90 percent of the time, although he wouldn’t say exactly.

“If you’re over 80 percent, you’re golden,” he said. “I will assure you, if we can make this partnership (with the Medical Center) work, there will be no lowering of response times.”

Wingrove works with the North Central EMS Institute to gather more information for setting industry standards, using an annual blind survey of 50 ambulance services across the country. In 2007, the most recent year for which the surveys have been processed, participants reported achieving a nine-minute response time about 68 percent of the time, Wingrove said. Ninety percent of the time, they arrived in at least 12 minutes.

Courtney Terwilliger, chairman of the state Emergency Medical Services Advisory Council, said he also prefers this method of benchmarking instead of focusing on average response times. But he said many counties that hire private companies require a nine- or 10-minute average response time.

Burkett said Athens Regional set a response-time requirement in its contract with National EMS, but he declined to share the figure.

EQUIPMENT

Other quality measures relate to equipment and staff.

Based on information provided by Oliver and Hinson, the Medical Center replaces its ambulances on a more regular schedule and keeps more of them on the road in the Bibb County area than Mid Georgia, but the Medical Center’s coverage area is also larger.

The hospital’s ambulances are replaced every four or five years, when they reach 130,000 to 170,000 miles, Oliver said. Hinson said he doesn’t know the average age of his fleet.

“We have some with more than 300,000 miles,” he said, adding that the company’s mechanics keep them in good running order.

Both providers’ ambulances are high-tech. According to Oliver and Hinson, both have 12-lead electrocardiogram machines as sophisticated as those in emergency rooms, plus cardiac monitors, “continuous positive airway pressure” machines for people struggling to breathe, and machines to take more accurate blood pressure readings.

The Medical Center transmits the 12 leads from the EKG directly to the hospital so doctors can route the patient faster, Oliver said.

A “mobile gateway” in each Medical Center ambulance transmits its location to dispatch every 10 seconds, provides wireless access and monitors the condition of the engine continuously, Oliver said. The ambulances also contain portable global positioning navigation systems.

Mid Georgia ambulances are equipped with GPS technology that tracks all ambulances on a map and dispatches them simply by dragging emergency calls to the ambulance on a computer screen. The service has used all-digital records for 15 years, Hinson said.

Hinson said if Mid Georgia could take over ambulance service from the Medical Center, he would be willing to install additional technology related to patient care, if requested, at no additional cost to the hospital.

“Whatever it takes to make it work, we’d do,” he said. “Another $10,000 or $15,000 per ambulance is almost immaterial.”

STAFFING

When it comes to staffing ambulances, paramedics are the most highly trained, followed by intermediate and basic emergency medical technicians. By state law, an ambulance intended to handle advanced life support needs at least one paramedic, intermediate EMT or cardiac technician.

Both Bibb County providers say they prefer to schedule double-paramedic teams, but they frequently pair a paramedic and an EMT also.

Medics can choose among different shift lengths, the longest being 24 hours. However, sometimes a transport keeps them out even longer.

“We do everything we can to keep people from working more than 24 hours,” Oliver said. Although the hospital pays medics overtime regularly, “It is not a significant part of the budget,” he said.

He said any employee can be called back after a shift, but he can’t remember it happening any time in the past year.

Hinson said at Mid Georgia Ambulance, “Very often people work more than 24 hours, usually at the end of a late shift.”

Terwilliger said paramedic and EMT pay is relatively low, so all but one of his 14 medics work multiple jobs. There are places in the state where people work a 24-hour shift, then clock in for another 24-hour shift with another company. Terwilliger said he doesn’t think this happens in Macon.

Smith said, “In a community like this, I’d say if you’re working more than 24 hours at a time, you’re really pushing your body.”

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