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21January2016

PRE-HOSPITALEMERGENCYCAREENHANCEMENTSTUDY

NortheastConnecticutCouncilofGovernments(NECCOG)Dayville,Connecticut

Preparedby:

FITCH&ASSOCIATES,LLC

2901WilliamsburgTerrace#G§PlatteCity§Missouri§64079816.431.2600§www.fitchassoc.com

CONSULTANTREPORT

NECCOG ©Fitch&Associates,LLCPre-HospitalEmergencyCareEnhancementStudy January2016ii

NortheastConnecticutCouncilofGovernments(NECCOG)Pre-hospitalEmergencyCareEnhancementStudy

TableofContents

EXECUTIVESUMMARY..........................................................................................................................1METHODOLOGY.......................................................................................................................................2

INTRODUCTION....................................................................................................................................4THEREGION.............................................................................................................................................4PRE-HOSPITALCAREINNECCOG..............................................................................................................7

KEYCONTEXTANDCURRENTNATIONALTRENDS.................................................................................9THEOPTIMALEMSSYSTEM....................................................................................................................10EMSDESIGNS,BESTPRACTICESANDBESTPRACTICESYSTEMS.............................................................11

PROCESSAREASUMMARIES...............................................................................................................139-1-1ANDCOMMUNICATIONS...............................................................................................................13OBSERVATIONSANDFINDINGS......................................................................................................................15RECOMMENDATIONS..................................................................................................................................17MEDICALFIRSTRESPONSE.....................................................................................................................17OBSERVATIONSANDFINDINGS......................................................................................................................18RECOMMENDATIONS..................................................................................................................................19MEDICALTRANSPORTATION..................................................................................................................19OBSERVATIONSANDFINDINGS......................................................................................................................20RECOMMENDATIONS-PARAMEDIC...............................................................................................................24RECOMMENDATIONS-AMBULANCE..............................................................................................................28MEDICALACCOUNTABILITY...................................................................................................................29OBSERVATIONSANDFINDINGS......................................................................................................................29RECOMMENDATIONS..................................................................................................................................30CUSTOMERANDCOMMUNITYACCOUNTABILITY..................................................................................30OBSERVATIONSANDFINDINGS......................................................................................................................30RECOMMENDATIONS..................................................................................................................................31PREVENTIONANDCOMMUNITYEDUCATION........................................................................................31OBSERVATIONSANDFINDINGS......................................................................................................................31RECOMMENDATIONS..................................................................................................................................33ORGANIZATIONALSTRUCTUREANDLEADERSHIP..................................................................................33OBSERVATIONSANDFINDINGS......................................................................................................................33RECOMMENDATIONS..................................................................................................................................35ENSURINGOPTIMALSYSTEMVALUE.....................................................................................................36OBSERVATIONSANDFINDINGS......................................................................................................................36RECOMMENDATIONS..................................................................................................................................37

NECCOG ©Fitch&Associates,LLCPre-HospitalEmergencyCareEnhancementStudy January2016iii

SUMMARY:THOUGHTFULAPPLICATIONOFRESOURCES......................................................................37RECOMMENDATIONSUMMARY............................................................................................................389-1-1ANDCOMMUNICATIONS...............................................................................................................38MEDICALFIRSTRESPONSE.....................................................................................................................38MEDICALTRANSPORTATION..................................................................................................................38MEDICALACCOUNTABILITY...................................................................................................................39CUSTOMERANDCOMMUNITYACCOUNTABILITY..................................................................................39PREVENTIONANDCOMMUNITYEDUCATION........................................................................................39ORGANIZATIONALSTRUCTUREANDLEADERSHIP..................................................................................40ENSURINGOPTIMALSYSTEMVALUE.....................................................................................................40

FIGURE1:NECCOGREGION..............................................................................................................................4FIGURE2:PRE-HOSPITALRESOURCES..................................................................................................................7FIGURE3:TYPICALEMSCALLPROCESSINGFLOW-CHART.....................................................................................14FIGURE4:QVMEDIC12014RESPONSES..........................................................................................................21FIGURE5:QVMEDIC1-15MINUTETRAVELTIME..............................................................................................21FIGURE6:KBMEDIC-15MINUTETRAVELTIME..................................................................................................22FIGURE7:ALLMEDICCALLSINONEYEAR............................................................................................................23FIGURE8:ALLPARAMEDICUNITS-15MINUTERESPONSETIME..............................................................................23FIGURE9:AMBULANCESUPPLYANDDEMANDCY2014.......................................................................................26FIGURE10:ESTIMATEDNECCOGPAYERMIX(INCOMPLETEDATA)........................................................................27FIGURE11:RESPONSEFROMWINDHAMHOSPITALTOHAMPTON-CHAPLIN-SCOTLAND.............................................27FIGURE12:PROPOSEDRETROSPECTIVEQIPROCESS.............................................................................................35Attachments–AttachmentA–AmbulanceBenchmarkSummaryAttachmentB–RecommendationsRankedbyPriority

NECCOG ©Fitch&Associates,LLCPre-HospitalEmergencyCareEnhancementStudy January20161

EXECUTIVE SUMMARY

TheNortheasternConnecticutCouncilofGovernments(NECCOG)istheprincipalregionalplanningorganizationfornortheasternConnecticut.Theorganizationcoordinatesactivitiesbymultiplemunicipalities,promotesregionalproblemsolvingandobtainsgrantsorotherfundingtomeetitsmission.NECCOGsubsidizesQVMedic1,asingleparamedicALSinterceptthatprovidesservicetonineofthe16townswithintheNECCOGregion.FitchandAssociates(FITCH)wasengagedtoobjectivelyexaminecurrentsystemissuesandperformanceandenhancementopportunities.NECCOGwishedtoquantifytheimpactsofavarietyofsystemconfigurationstodetermineimplementablesolutionstotheareasgrowingandchangingservicedynamics.Therangesofoptionsaretoinclude:administrativecollaboration,jointworkingrelationships,andotherfunctionalcollaborationsatoperationaland/oradministrativelevels,aswellasevaluatingfullregionalconsolidation.Specifically,theFITCHstudyfound:

§ 40volunteeremergencymedicalresponder(EMR)andambulance(EMT)organizations,eachwithitsownPrimaryServiceArea(PSA)andmutualaidplan.

§ NoformalregulatoryrequirementforphysicianoversightattheEMRorEMTlevel.§ Dispatchcenterunabletolocate/trackallavailableandorrespondingvehiclesisrequired.§ TechnicallimitationsoftheComputerAidedDispatchsystem’sconfigurationandreporting

capabilities,requiremanualpreparationofactivity/performancereports.§ StateDepartmentofPublicHealthisproposingchangestotheEMSregulations,LocalEMSPlans

andmanagementofthePrimaryServiceAreas.§ ConflictbetweenexistingparamedicproviderandcommunityambulancethatobtainedR-5

paramediclicensein2014.ConfusionexistswhendispatchingparamedicswhenKBMedic561iscloserthanQVMedic1.

§ Morethanone-fourthofthecitizensandvisitorstothelargesttownwaitedover12minutesforaparamedic.

§ Nocoordinatedperformancereportingorqualityimprovementprogramexists.


KEY RECOMMENDATIONS INCLUDE: § Maintainup-to-datelistofmedicalfirstresponderandambulanceagencies,theirleadershipand

theirlevelofequipment.Meetwithagenciesquarterly.§ PromotetheuseofAutomaticVehicleLocatorsinallresponsevehicles.§ Encourageeachmunicipalitytoestablishfirstresponderandambulanceresponsetimesaspart

oftheLocalEMSPlan.§ Establisharegionalmedicaldirector,qualityimprovementprogramandregionalclinical

protocols.§ Publishandshareresponsetimesmonthlywithelectedofficialsandstakeholders.§ RequireresponsetimeperformanceinALSInterceptcontract.§ NECCOGtodevelopacontractthatprovidesforparamediclevelcoveragewiththebest

outcome.§ Exploreregionalorconsolidatedambulancetransportationcoveragebasedontimeofdayand

volunteeravailability.NECCOGshouldhaveinformationontheexistingsystemperformanceandpatientoutcomesbeforeundertakingmajorsystemchanges.Re-purposingthefundsfortheALSinterceptsubsidyintoaregionalmedicaldirector,qualityimprovementprogramorcommunityCPR/AEDmayyieldastrongerimpactonthecommunitythanothersystemimprovements.

METHODOLOGY NortheasternConnecticutCouncilofGovernments(NECCOG)retainedFitch&Associates(FITCH)toconductaPre-HospitalEmergencyCareEnhancementStudyfortheirservicearea.Theeffortwasundertakenwiththeregion’spre-hospitalcarecommunitytoevaluatethecurrentsystemandmakerecommendations(aswarranted)toenhancepatientcare.FITCHparticipatedinakick-offeventatNECCOG’sofficeonJune30,2015withmembersofthepre-hospitalcommunitythatwouldparticipateinthestudy.FITCHvisitedtheQVECdispatchcenterandmetwiththeleadershipofthepre-hospitalcommittee.NECCOGprovidedacontactlistofpre-hospitalcommunitymembersthatwouldparticipateinanon-linesurvey.Ittookawhiletoupdatethecontactlistforthesurvey.ThefirstsurveywasdeployedAugust21,2015,receiving12responsesfromthe59pre-hospitalcommunitymembers.ObtainingdispatchdatafromtheCADvendortodocumentthesystem’sperformancewasproblematicandrequiredmultipleeffortstogetthevendortorespond.DatawasdeliveredbythevendoronNovember5,2015.


FITCHreturnedtotheregioninOctober2015,following-upface-to-facemeetingswithNECCOG,QVEC,AmericanAmbulance,VoluntownFireDepartment,ScotlandFireDepartment,andK-BAmbulance,aswellastelephoneandemailcommunicationswithotherpre-hospitalcommunitystakeholders.Thepre-hospitalprovidercontactlistwasagainupdatedandthesurveywasre-issued,eventuallygettingresponsesfrom30ofthe50pre-hospitalstakeholderscontacted.FITCHheldateleconferencewithQVEConNovember11,2015toreviewtheCADvendor’sdata.ApreliminaryversionofthereportwasreviewedbytheALSSteeringCommitteeattheDecember4,2015worksessionheldatNECCOG.FeedbackandadditionalinformationwasprovidedbythesteeringcommitteetoFITCH.Workingwiththemedicaldirectors,athirdeffortwasmadetohaveambulancetransportationorganizationscompletetheirsurveysbyDecember22,2015.


INTRODUCTION

THE REGION TheNortheasternConnecticutCouncilofGovernments(NECCOG)isa16-townregionalcouncilofgovernmentswhichwasfoundedin1987.Therurallandscapeischaracterizedbyrollinghills,forestsandfarms.Theregioncovers562.8squaremileswitha2012populationof95,971makingtheregiononeoftheleastpopulatedregionsinConnecticut.Areaswithdenserpopulationsarevillagesthatweredevelopedinthe19thand20thcenturiesinassociationwithwater-poweredmanufacturing.NECCOG’smembertownsareAshford,Brooklyn,Canterbury,Chaplin,Eastford,Hampton,Killingly,Plainfield,Pomfret,Putnam,Scotland,Sterling,Thompson,Union,VoluntownandWoodstock.ThelargestpopulationisfoundinKillingly(17,265).1

CONNECTICUT APPROACH TO PRE-HOSPITAL CARE TheOfficeofEmergencyMedicalServices(OEMS)resideswithintheDepartmentofPublicHealthandistheleadagencyforEMSinConnecticut.TheOfficeofEmergencyMedicalServicesistaskedbystatutewith:

1NECCOG(2013)."regionalprofile."Retrieved11/6/2015,fromhttp://neccog.org/about/regional-profile/.

Figure1:NECCOGregion


§ Providingpubliceducationandinformationprograms;§ AdministeringtheEMSequipmentandlocalsystemdevelopmentgrantprogram;§ Systemplanning;§ Regionalcounciloversight,training;§ ProvidingstaffsupporttotheAdvisoryBoard.

TheOEMSisfurthertaskedbyregulationwith:

§ ProvidingregionalEMScoordinators;§ AssigningPrimaryServiceAreaResponders(PSAR’s)foreachserviceareaofthestate;§ OversightoflicensureandcertificationofEMSproviders;§ EstablishingEMSvehiclestandards;§ RatesettingforEMSservices.

EMSregulationsarepromulgatedwhichfurtherdefinethesedutiesandEMSrolesthroughoutthesystem,recentlyarevisedsetofdraftregulationshavebeendeveloped,whichwillmodernizethecurrentregulations.Thepracticeofissuingprimaryserviceareas(PSA’s)tomultipleagenciesfordifferentaspectsofEMScarewithineachofthe169localjurisdictionsiscomplex.EMSregionsareestablishedandrecognizedbutthereisafailuretoactualizethefullpotentialofEMSregionalization.ThelackofCountygovernmentinthestateisalsoafactor.Thepracticeofratesetting,certificateofneedrequirements(CON),andissuanceofPSAR’sforEMSorganizationsaredated,andlawandregulationaresilentonmanycontemporaryEMSsystemissues.2AssignmentofPrimaryServiceAreaResponders(PSAR)TheconceptofPrimaryServiceAreas(PSA)wasintroducedinConnecticutin1974.APSAisaspecificgeographicareathatisservedexclusivelybyanemergencymedicalservices(EMS)provider.TheStateofConnecticutDepartmentofPublicHealth(DPH)designatesthisprovider.OnlythePrimaryServiceAreaResponder(PSAR)designatedbytheStatemayansweremergencycallsinthespecifiedgeographicarea.Thesegeographicareasmayincludeorbe

2Mullen,J.,W.H.Furniss,J.A.Reynolds(2015).EmergencyMedicalServicesPlan:2015-2020.Hartford,CT,DepartmentofPublicHealth.


withintheboundariesofamunicipality,taxdistrict,tribalentityorotherspecificallyidentifiedareas.TherearefourPSARlevelsofEMSrecognizedandregulatedbytheState:

§ FirstResponder§ BasicAmbulance

§ Intermediate§ Paramedic

Thelevelsdifferinthetimerequiredfortrainingandskillsperformedbypersonnel,aswellasequipmentrequired.EachgeographicareashouldhaveatleastonePSARdesignatedforeachlevelofservice.TheDPHisrequiredtoassignaPSARforeachlevelofserviceforeverymunicipalityinthestate.PublicHealthregulationsestablishthefactorsthataretobeconsideredwhendesignatinganEMSproviderasaPSAR.AsinglePSARmaybecertifiedorlicensedtoprovideoneormoreoftheselevelsofservice.3LocalEMSPlanIn2014,PublicAct14-217waspassedwhichgavemunicipalitiesmorecontroloverwhoprovidesEmergencyMedicalServicesintheirtown.ThepublicactalsoreinforceddevelopmentofaLocalEMSPlan(LEMSP).TheseplansareanimportantcomponentofoveralltownplanningandpromotehealthybusinessrelationshipsbetweenamunicipalityandtheEMSorganizationsatalllevels,whichprovideemergencycaretotheresidentsandvisitorsofthetown.OEMSdevelopedatoolkitasa"bestpractices"approachtobuildinganLEMSP.OEMSisworkingwitheachtown,onafive-yearcycle,toprovideguidanceintheplanninganddevelopmentoftheLEMSP.

3ConnecticutEmergencyMedicalServicesPrimaryServiceAreaTaskForce(2014).FinalReport:ConnecticutEmergencyMedicalServicesPrimaryServiceAreaTaskForce,DepartmentofHealth.


PRE-HOSPITAL CARE IN NECCOG Figure2:Pre-HospitalResources

Throughthesurveyprocess,FITCHidentifiedthattheNECCOGpre-hospitalserviceareaincludes:

§ 32FireCompany1stResponders§ 12Ambulanceproviders,many

basedwithfirecompanies.§ 5Paramedicproviders§ 3Hospitals:

o DayKimballHealthcare–Putnam

o BackusHospital–Norwicho WindamHospital–

Willimantic

PARAMEDICAmericanAmbulanceisthedesignatedPrimaryServiceArea(PSA)paramedicprovider.Since1999NECCOGhascontractedwithaparamedicprovidertoprovidea24-hoursingle-paramedicALSInterceptvehicle,“QVMedic1,”forthetownsofBrooklyn,Eastford,Killingly,Pomfret,Putnam,Sterling,Thompson,WoodstockandaportionofPlainfield(northofRoute14)QVMedic1postsatDayKimballHospitalinPutnam,andaverages2,500interceptsayear.AnAmericanAmbulanceparamedicassetispostedatPlainfieldandrespondsintotheNECCOGserviceareaifQVMedic1isunavailable.


ThetownsofHampton,ScotlandandChaplinreceiveALScoveragefromparamedicsemployedbyWindhamHospitalwhostaffMedic31.ThetownofUnionreceivesALScoveragefromJohnsonMemorialHospitalparamedicswiththeAmbulanceServiceofManchester.AmericanMedicalResponseprovidesinterfacilityandcriticalcaretransportundercontractwithDayKimballHospitalinPutnamandoccasionallyprovideaparamedicresponseintotheNECCOGregionifnootherparamedicresourceisavailable.K-BAmbulanceCorpsinKillinglyreceivedtheirR-5paramediclicensefromthestateDepartmentofHealthinAugust2014.ParamedicservicebeganOctober1,2014.TheyarenotassignedaparamedicPrimaryServiceArea(PSA),butMedic561respondstoALSlevelcallswithintheTownofKillingly.TheTownofKillinglyandK-BAmbulancepetitionedtheDepartmentofPublicHealthin2015toreplaceAmericanwithK-BAmbulanceastheirdesignatedparamedicprovider.ThestaterejectedKillingly’spetitiontochangetheirassignedparamedicprovider.4

AMBULANCEThereare12community-basedemergencyambulanceproviderswithintheNECCOGregion,someindependentandsomeaffiliatedwithafirecompany.MinimumstaffingisanEmergencyMedicalResponder(EMR)andEmergencyMedicalTechnician(EMT).SomeEMTshavereceivedselectedadvancedclinicalskills(CPAP,EpinephrineAutoinjector,Glucometer,Narcan,andAspirin)TheALSCommitteeaskedFITCHtolookattheimpactofdifferentstaffingordeploymentmodelstoaddresssomeofthechallengescommunity-basedprovidersareconfronting.

4Penney,J.(2015October06).Killinglyappealsstaterejectionofparamedicservicechange.TheBulletin.Norwich,CT,GatehouseMedia.


KEY CONTEXT AND CURRENT NATIONAL TRENDS

AnEMSsystemkeygoalistoensureaccessandappropriateresponseforthoseinneedofemergencyservicesandmedicaltransportation.ThemissionofEMScanbeisolatedtothreecorefunctions.Theyare:preventingandreducingthenumberofliveslost;minimizingthepatient’spainandsufferingandreducingtheexpensesassociatedwithcatastrophicinjuriesandillnesses.ModernEMSsuffersfromanidentitycrisissinceitscreationfivedecadesagotohandlethecarnageonthehighways5andprovideout-of-hospitalcardiaccare6.DoesEMSfallunderpublicsafety,healthcareorpublichealth?In2007,theNationalAcademies’InstituteofMedicine(IOM)issuedaWhitePapertitled:“EMSattheCrossroads.”IOMidentifiedsixprimaryissuesandoffersinsighttocommunitiesconsideringEMSchanges.

§ InsufficientCoordination§ DisparitiesinResponseTime§ UncertainQualityofCare§ LackofDisasterReadiness§ DividedProfessionalIdentity§ LimitedEvidenceBase7

Rural-basedEmergencyMedicalServiceshasspecificadditionalissues:

§ Areaswithlowpopulationdensitygenerallycannotsupporta24-hourfull-timepaidBLSEMSresponsesystem

§ LowpopulationdensityalsoresultsinasmallerpoolofpeoplefromwhichtorecruitvolunteerEMSpersonnel

§ EMScaregiverinitialandcontinuingeducationrequirementsrequireasignificanttimecommitmentandoftenarenotlocallyavailable.

5NationalResearchCouncil.(1966).AccidentalDeathandDisability:TheNeglectedDiseaseofModernSociety.WashingtonDC,NationalAcademiesofScience. 6Pantridge,JFandJSGeddes.(1967)."Amobileintensive-careunitinthemanagementofmyocardialinfarction."Lancet(2):271. 7CommitteeontheFutureofEmergencyCareintheUnitedStatesHealthSystem(2007).EmergencyMedicalServices:AttheCrossroads.Washington,DC,InstituteofMedicine.


§ Largegeographicareaswithsecondaryroadwaysareoftendifficulttonavigateandhinderresponsetime.89

TheseissuesareproblematicinNECCOGtoagreaterorlesserdegree.

THE OPTIMAL EMS SYSTEM AnoptimalEMSsystemisbestdesignedfromthepatient'sperspective.Patientsshouldexpectthattheservicewillbeengagedinillnessandinjuryprevention,healtheducationandearlysymptomrecognition,inadditiontorespondingtoemergencyandtransportationrequests.TheEMSsystemshouldprovidearapidandappropriateresponsewhenacallerdials9-1-1androutinelyprovidemedicalinstructionsuntilhelparrives.The2015AmericanHeartAssociationGuidelinesUpdateforCardiopulmonaryResuscitationandEmergencyCardiacCarefocusesontheimpactthecommunityhasonpatientoutcome.TherevisedChainofSurvivalemphasizesrapididentificationofpotentialcardiacarrest,followedbyimmediatedeliveryofhighqualityCPRandearlydefibrillationwithanAED.

Communitiesabletoimplementarapidresponseseeacardiacarrestsurvivalrateapproaching50%.Team-basedresponse,usingthecommunityandmedicalfirstresponders,shouldbeabletodeliverrapiddefibrillationandhigh-qualityCPR,arrivingtothepatient’ssidewithinfourtosixminutesofa9-1-1dispatch,with90%reliability.

8ThompsonFireAdvisoryCommittee.(2013December).LocalEmergencyMedicalServicesPlan:TheTownofThompson,Connecticut.December1,2013-November30,2018.Thompson,CT,TownofThompson. 9Simon,L.(2015).RuralEMSfacesitsownemergency.AmericanCityandCounty.NewYorkCity,Penton.


Theresponsetimeofemergencycaregiversisbasedonthetypeofcommunity.PopulationdensitywithinnortheastConnecticutfallsunderthe“Rural”and“Remote”classificationsbytheNationalFireProtectionAssociationStandard1720.10Thearrivalofanambulanceandparamedicinterceptshouldbewithin15minutesinthemillvillages,reflecting90secondstoprocessthe9-1-1calland14minutestotraveltotheincidentlocation.Patientsshouldbetransportedtoahospitalthatcantreattheirspecificcondition.TheEMSsystemshouldbeexternallyandindependentlymonitored,withparticipantsheldaccountablefortheirresponsibilities.Finally,thesystemshoulddelivergoodvaluefortheresourcesinvested.

EMS DESIGNS, BEST PRACTICES AND BEST PRACTICE SYSTEMS MilestonedocumentsintheearlydevelopmentofEmergencyMedicalServicesSystems(EMSS)includedtheNationalAcademyofSciences-NationalResearchCouncilWhitePaper“AccidentalDeathandDisability:TheNeglectedDiseaseofModernSociety,”thefederalHighwaySafetyActof1966,andthefederalEmergencyMedicalServices(EMS)SystemsActof1973.Theyguidedthefirst50yearsofEmergencyMedicalServicesSystemgrowthonthelocal,regionalandstatelevels.Theseearlysystemsevolvedfrom“neighborhelpingneighbor”volunteergroupstohighlycomplexresponsesystemsofphysicianextendersthatfunctionaspartofthelargerhealthcaredeliverysystem.Inmanyareasofthecountry,EMSsystemsarestrugglingtomeetclinical,operationalandfinancialperformanceobjectives.Ambulanceservicesareprimarilyfundedunderacomplexandflawedfederalreimbursementmethodologythatdoesnotcoverthefullcostofoperationsorthecostofreadiness.Studies,includingthosepreparedfortheInternationalCityandCountyManagementAssociation(ICMA)andtheNationalAcademiesofScienceInstituteofMedicine,(IOM)documenttheunderlyingissues.

10NationalFireProtectionAssociationStandard1720:StandardfortheOrganizationandDeploymentofFireSuppressionOperations,EmergencyMedicalOperations,andSpecialOperationstothePublicbyVolunteerFireDepartments:2014Edition.


ThefragmentednatureofEMSmeansthattherearemanyorganizationsthatproviderecommendations,protocolsandbestpracticesfromtheirclinical,operationalorregulatoryviewpoint.StateEMSregulationsreflectminimumperformancerequirements.Othercommonlyaccepted“standards”aredrawnfromavarietyofsources,including:

§ “10EMSStandards,”currentlyusedtoevaluatestateEMSsystems§ “EMSClinicalPracticeandSystemsOversight”developedbytheNationalAssociationofEMS

PhysiciansascorecurriculumforAmericanBoardofEmergencyMedicinecertificationinEMS§ “Evidence-BasedPerformanceMeasuresforEmergencyMedicalServicesSystems:AModelfor

ExpandedEMSBenchmarking.”Positionstatementbythe2007ConsortiumofU.S.MetropolitanMunicipalities’EMSMedicalDirectors

§ “EMSAgendafortheFuture,”developedbytheUSDepartmentofTransportation§ “EMSattheCrossroads,”developedbytheNationalAcademiesofSciences’Instituteof

Medicine2007§ “The7PillarsofEMSOfficerCompetency”bytheNationalEMSManagementAssociation.§ “EMSInCriticalCondition:MeetingtheChallenge,”producedbyTheInternationalCity/County

ManagementAssociation§ “CommunityGuidetoEnsureHighPerformanceEmergencyAmbulanceService,”publishedby

theAmericanAmbulanceAssociation§ InternationalAcademiesofEmergencyDispatch§ CommissionontheAccreditationofAmbulanceServices§ NationalFireProtectionAssociation

Inlikemanner,thereisnosingleuniversallybestEMSsystemdesignmodelorsingle“bestpracticesystem”thatcanbeidentified.


PROCESS AREA SUMMARIES

EveryEMSorganizationiscomprisedofmultipleprocessareastoaddressspecificfunctionsoftheoperation.TheConsultantteammetwithkeysystemparticipants,aswellaswithcommunity,hospitalandlocalstakeholders.Asummaryofthebestpracticesandfindingsforeachprocessisdescribedbelow.Recommendationsforenhancingactivitiesareincludedwhereappropriate.SpecificbenchmarksandNECCOG’sperformanceineachofthefollowingcategoriesaredescribed:

9-1-1andCommunications CustomerandCommunityAccountabilityMedicalFirstResponse PreventionandCommunityEducationMedicalTransportation OrganizationalStructureandLeadershipMedicalAccountability EnsuringOptimalSystemValue

Thesummaryofthese50benchmarkscanbefoundinAttachmentA–BenchmarkSummary.

9-1-1 and COMMUNICATIONS DESCRIPTION OF BEST PRACTICES BestpracticeEMSsystemsareorganizedtofacilitatewire-line,cellular,voiceoverinternetprotocol(VoIP),automaticcrashnotification,patientalertingsystemdevicesandotherpublic911accesstotheEmergencyMedicalServicesSystem.Voice,video,telemetry,andotherdatacommunicationsconduitsareemployed,asnecessary,tobestenhancereal-timeinformationmanagementforpatientcare.Amedicallydirectedsystemofprotocol-basedEmergencyMedicalDispatch(EMD)andcommunicationsisinplace.ThecallreceptionandEMScallprocessesaredesignedlogicallyandshouldnotdelayactivationofmedicalresources.TechnologysupportsthecallerbeingdirectedtotheappropriatePublicSafetyAnswerPoint(PSAP)forthegeographiclocationofthecall.All911callersshouldreceiveNationalAcademiesofEmergencyDispatch(NAED)[orsimilarprocess]callprioritizationandpre-arrivalinstructions.Automatedqualityimprovement(QI)processesareusedforfacilitatingresultsbeingreportedtoclinicalandoperationsexecutivesinaconcisemanner.


Figure3:TypicalEMSCallProcessingFlow-Chart

Datacollectionfacilitatestheanalysisofkeyserviceelementsandthisdataisroutinelybenchmarkedandreported.Technologysupportsinterfacebetween911,medicaldispatchfunctionsandadministrativeprocesses.Radio/cellularlinkagesbetweendispatch,fieldunitsandmedicalfacilitiesprovideadequatecoverageandfacilitatebothvoiceanddatacommunications.Thereisinteroperabilitybetweenalliedpublicsafetyagencies.

CommunicationsBenchmarks

§ Publicaccessthroughasinglenumberpreferablyenhanced911.§ SinglePSAPexistsforthesystem.§ EffectiveconnectionbetweenPSAPanddispatchpoints,withminimalhandoffsrequiredfor

callers.§ Certifiedpersonnelprovidepre-arrivalinstructionsandprioritydispatching(EMD)andthis

functionismedicallysupervised.§ Datacollection,whichallowsforkeyserviceelementstobeanalyzed.§ Technologysupportsinterfacebetween911,dispatchingandadministrativeprocesses.§ GPS/AVLineachvehicleenablesdispatchtoalerttheclosestunit.§ Radiolinkagesbetweendispatch,fieldunitsandmedicalfacilitiesprovideadequate

coverageandfacilitatecommunications.

T0 T1 T4 T5 T6 T7 T8 T9 T10

911PhoneRings

Calltransferredtoamedicalcall-taker

Calllocationpre-alertedtothedispatcher

FirstRespondersandambulancecrewarenotifiedAmbulanceEnroute

Ambulancearrivesonscene

CrewdepartssceneCrewarrivesatmedicalfacility

Crewavailableforcall

EventIdentification Dispatch “Chute” Travel Treatment

Transport

EMSSystemResponseTime

AmbulanceTime-on-Task


Observations and Findings PUBLIC ACCESS TO EMS PublicaccesstoemergencymedicalservicesisthroughQuinebaugValleyEmergencyCommunications,Inc.(QVEC),whichisaprivatelyoperated(501-C-3notforprofitcooperating)thatisstateauthorized.ThecommunicationcenteristheprimaryPSAPfortheregionthathandlesEMSandFireemergenciesonly.PolicecallsreceivedaresenttoeitheroneofthetwolocalPSAPsortotheConnecticutStatePolice.QVECdispatches38FireandEMSorganizationsandeachcommunityhastheirownPSAandsetsthemutualaidplan.InPutnamTownshipthereisasecondaryPSAPthatQVECcoordinateswithandonebuttontransfersemergencies.Staffinglevelsareaminimumoftwoandthecentercanstaffupto5positions.Thestaffingratioisapproximately70%part-timetofull-time.Emergencymedicaldispatch(EMD)proceduresarerecommendedbytheInternationalAcademiesofEmergencyDispatch(IAED).QVECpersonnelarecertifiedEMDastheyaretrainedbyPowerPhone,whichisanintegratedintotheNewWorldCADfordigitalaccesstosystematicallyquestioncallers.PowerPhoneisutilizedforcallprioritizationandtypeofresponseincoordinationwiththeOperatingMedicalDirector(OMD)Dr.Wexler.WithinthePowerPhonesuitethereisaQA/QImoduletogivefeedbacktoQVECmanagementandstaff.

§ QVEChasacomputerized“PowerPhone”versionthatisautomatedsoftwareattachedtotheCADthatallowsforEMDofmedical911calls.

§ IncomingcallsareclassifiedaccordingtoprioritycodesthroughthePowerPhonesoftware;and,pre-arrivalinstructionsaregivenonaregularbasis.

§ Life-threateningandnon-life-threateningemergencycallsarecorrectlydifferentiated,givinganemergentornon-emergentresponsecode.

§ Statisticsshowfewnon-emergency9-1-1responsesbyvolunteeragencies.§ ThePSAPisoverseenbyanOMDthathelpscoordinatemedicaldispatchingandresponseas

wellasaninternalQA/QIprocess.ThedispatchingcenterusesNewWorldastheirComputerAidedDispatch(CAD)vendor.Thissystemwasoriginallyputinplacein2006withmultipleupdates.ThecurrentversionoftheCADhaslimiteddatareportingcapabilitiesandunabletotrackunitswithGPS.WithinthenextyearQVECislookingtoupgradetoanewE-CADfromNewWorld,whichwillallowforimprovedcapabilitiesandreporting.Thedispatchcenterenvironmenthastwovirtualizedmachinesrunningparallelonseparateserversgivingredundancyandbackup.DataisbackedupatanoffsitefacilityusingSymantecandEnterprise.§ ThecurrentCADhaslimitationsinconfigurationandreportingcapabilities.QVECisplanningto

updatetoanimprovedE-CADplatformwithin12to24months.


§ Incaseofaservermalfunctionthereisbuiltinredundancyandoffsitedatastoragegivingstabilitytothe911center.

§ Thereisanemergencyoperationplaninplace.§ Thecurrentcallprocessingwasdeterminedtofollowaconsolidatedoutline.QVECisthe

PrimaryPSAPthatwilltaketheinitial911call.IfthecallwasdeemedmedicaltheywillutilizethePowerPhonetodeterminemedicalpriorityandinitialtreatmentprocedures.InordertodispatchunitsQVEChasacomplexmatrixtodispatchstationsorspecificunitsdependingonthelocation,contracts,townships,andparamedicPSAarea.

§ QVECalsocoordinateswithaPSAPinPutnamTownshipviaone-buttontransfersforFire,EMS,andPolice.Ifdeemedfiretheywillprocessanddispatchaccordingly.ForpoliceemergenciesQVECwilltaketheinitialcallandonebuttontransfertoeitherthelocalpoliceagenciesortheConnecticutStatePolice.

§ Toensurethereisastandardizedperformanceforcallprocessingtimes,IAEDhasrecommendedcall-processingtimesforwhenthecallisreceivedtothetimedispatched.Dispatchcentersshoulddocumentandreportindividualperformancestoensurestandardsaremeetandthereisaplatformforimprovement.

§ ThecurrentNewWorldCADprovideslimitedreportingcapabilitiestoQVECandtheNECCOGregion.Therearefewreportsthatcanbecreatedwithoutrequiringmanualmanipulation.

§ AmericanAmbulanceistheonlyALSunitisequippedwithafleettrackingGlobalPositioningSystem/AutomaticVehicleLocator(GPS/AVL)system.AmericanAmbulancehasgiventheirFleetEyesaccounttoQVECsoitcantracktheirunits.NootherunitsintheNECCOGareahaveGPS/AVLcapability.

§ Currently,thereisconfusionwhendispatchingALSunitsintheregionasAmericanAmbulancehasthecontractbutattimesisnottheclosestALSunittotheincident.QVECfeelstheyareinthemiddleofAmericanAmbulanceandKBAmbulancewhentryingtodispatchtheclosestunittoacallbutwhentheytrytomakewhatisfeltasthe“rightcallforthepatient.”

§ QVEChastodispatchtostationsorspecificpaginggroupsasunitsdonotmarkin-servicewhentheybecomeavailable.Thismakesitdifficultforunitstobetrackedfordispatchingtheproperorclosestresource.DifficultiesareexperiencedwithCADproceduresanddatadocumentationastheprocessesbecomecumbersomeandunorganizedfordatacollection.

§ FieldunitsareusingelectronicpatientcarereportsfordocumentationbutQVEChasnotbeenaskedforaninterfacethatwouldallowforcallstoautomaticallybetransferredtotheirpatientcarereports.Currentprocessishandledbyeachdepartmenthavingread-onlyaccesstotheircalldataandthedataismanuallytransferredtoelectronicpatientcarereportsorthefirehousereportingsoftware

RADIO COMMUNICATIONS QVECutilizestwohigh-poweredUHFradiofrequencysystems,eachwith6repeatedsites.UnitsaredispatchedandassignedradiochannelsviaQVEConinitialdispatch.Duetothissetupthereisredundancybuiltintothesystemincaseofunforeseenfailures.TheVHFradiosalsoallows


communicationsonthestatewideinteroperabilitychannelsduringstatedeployment.QVECassignsmedchannelforfieldtohospitalcommunicationsforDayKimballandBackushospitals.

Recommendations 1. ContinuetopurseandupdatethecurrentNewWorldCADandensurethereisan

improveddatasuite.2. Clarifyprocesstohandlesecond-outALScalls3. AllresponseunitsshouldbeGPS/AVLcapableforappropriateunitdispatching,with

QVECabletomonitorpositionstodeterminenearestavailableresponder.4. Performancemetricsshouldbeestablishedforcalltakingtimesandmeasured

monthly.5. EvaluatetheabilitytodevelopaninterfacefromQVECtofieldunitstoreceive

automaticelectronicpatientcarereportingdata.6. ChiefsneedtotakeBLStransportoutofservicewhenunstaffed.7. Evaluatetheabilitytoreducethedecision-makingprocesswhendispatchinga

secondaryparamedicunitormutualaidambulance.

MEDICAL FIRST RESPONSE DESCRIPTION OF BEST PRACTICES Medicalfirstrespondersinbestpracticesystemsareorganizedappropriatelyforthecommunitiesinwhichtheyserve.Theyfunctionaspartofanintegratedresponsesystemthatisguidedbystateandlocallegislativeauthority,andwhichreflectsacceptedmedicalpractice.Firstresponders(paidorvolunteer)arecertifiedataminimumEMT-DefibrillatororMedicalFirstResponder(MFR)level.Theyaremedicallysupervisedbythesystemmedicaldirector,includingparticipationinperformanceimprovementaudits/activities.Definedresponsetimestandardsexistforformalfirstrespondersandthoseresponsetimesarereportedwiththoseofthesystem.EarlydefibrillationcapabilitiesareavailableforEMSfirstrespondersandinareasofhigh-densityresponseareassuchasairports,hotelcomplexes.Whencommunityorfirstresponsepersonnelareinvolvedinpatientcare,asmoothtransitionofcareisachieved.

MedicalFirstResponse(MFR)Benchmarks§ MFRsarepartofanintegratedresponsesystemandmedicallysupervisedbyasingle

systemmedicaldirector.§ DefinedresponsetimestandardsexistforMFR.§ MFRagenciesreportfractileresponsetimes.§ AEDcapabilitiesonfirstlineapparatus.§ Smoothtransitionofcareisachieved.


Observations and Findings MEDICAL FIRST RESPONDERS Medicalfirstrespondersplayacriticalroleinlife-threateningemergenciesandsupportthecommunities’EMSeffortsaspartofthepublicsafetymission.InthemajorityofNorthAmericancities,thisroleisfundedbylocaltaxdollarsaspartofthepublicsafetybudget.MFRservicesareprovidedbyvolunteerfiredepartmentsthroughouttheNECCOGservicearea.NECCOGdoesnothaveacompleteorup-to-datelistofvolunteerfirecompanies’leadershipwithintheregion.NECCOGMFRsarenotequippedwithAutomaticVehicleLocators(AVL)andtheQuinebaugValleyEmergencyCommunicationscenterdoesnothaveanabilitytogeographicallytrackrespondingvehicles.Anecdotalinstancesofstaffingchallengesprovidingafirstresponderweresharedinthesurveyordescribedinnewspaperarticles.Medicaldirectorinvolvementwithfirstresponderagencies,andtheengagementoffirstrespondersinasystem-wideQIprocess,isamust.ThestateDepartmentofPublicHealthrequiresagenciesthatprovidecareabovetheEMT-Basiclevelarerequiredtohaveasignedagreementwithasponsorhospital.ThereisnoreportedmedicaldirectorinvolvementwithMFRs.TheDPHEmergencyMedicalServicesPlan:2015–2020includesthisgoal:“TheOEMSshouldensurethatrevisedregulationsrequirealllevelsofEMSandEMDproviderstohaveatleastindirectmedicaloversightfromanEMSMedicalDirector.”ThereisnodefinedresponsetimeforMFRPSARintheRegulationsofConnecticutStateAgenciesSection19a-179-11:“Availabilityofresponseservices”beyondtherequirementtorespondtoallemergencycalls24hoursaday,7daysaweek.ThereisnodescriptionofhowlongitwilltakeforthePSARtostartwheelsrollingtoa9-1-1dispatch.ThestateOfficeofEMSanticipatesthatmunicipalitiesthatestablishaLocalEmergencyMedicalServicesPlanasrequiredinPublicAct00-151“AnActConcerningEmergencyMedicalServicesDataCollectionandEmergencyMedicalDispatch.”(EffectiveJuly1,2000)couldestablish


measurable,achievable,andobjectiveperformancestandards.11

Recommendations 8. Maintainup-to-datelistofmedicalfirstresponderagencies,includinginformationon

currentfirechieforpointofcontact(name,emailandphonenumber).9. Workwitheachmunicipalitytoestablishmeasurableresponsetimesandcoverage

protocolsaspartofupdatingtheirLocalEmergencyMedicalServicesPlan.10. Establishconsortiumofmedicaldirectorstoassurequalityforallaspectsofpre-

hospitalcaresystem

MEDICAL TRANSPORTATION DESCRIPTION OF BEST PRACTICES InabestpracticeEMSsystem,amechanismexiststoidentifyandassureadequatedeploymentofground,airandothertransportationresourcesmeetingspecificstandardsofquality,toassuretimelyresponse,scaledtothenatureofevent.Thereiscapabilitytomonitorsafetyandresponsetimeissues.Definedresponsetimetargetscomeintoplay,accordingtoseverityofcall,andindividualresponsecomponentsaremeasuredbyusingbothmeanand80thpercentilemeasures.Definedclinicalservicelevelsusecurrentmedicalresearchtoguidethemedicalinterventionsofthesystem.Changestoimproveclinicalpracticecanbeintroducedrapidly.Ambulancesarestaffedandequippedtomeettheidentifiedservicerequirements.Procurement,maintenanceandlogisticsprocessesfunctiontooptimizeunitavailability.Resourcesareefficientlyandeffectivelydeployedtoachieveresponsetimeperformanceforprojecteddemandwithdueregardfortaxpayersandendusers.Whenmultipleagenciesareinvolved,asmoothintegrationandtransitionofcareisachieved.Thesystemiscapableofscalingupday-to-dayoperationstomeettheneedsoflarger,all-hazardsevents,basedonthreatandcapabilitiesassessmentsofthelikeliesteventstooccurinthestate.Itisessentialthatmasscasualtyresponsesinvolvelogicalexpansionandextensionofdailypracticesandnottheestablishmentofnewpracticesreservedforlarge-scaleevents.11ConnecticutEmergencyMedicalServicesPrimaryServiceAreaTaskForce(2014).FinalReportConnecticutEmergencyMedicalServicesPrimaryServiceAreaTaskForce,DepartmentofHealth.


MedicalTransportationBenchmarks§ Definedresponsetimestandardsexist.§ Agenciesreportfractileresponsetimes.§ Unitsmeetstaffingandequipmentrequirements.§ Resourcesareefficientlyandeffectivelydeployed.§ Thereisasmoothintegrationoffirstresponse,air,groundandhospitalservices.§ Developandmaintaincoordinateddisasterplans.

Observations and Findings PARAMEDIC DEPLOYMENT Mostofthe563squaremileregioniscoveredby“QVMedic1”-a1-personparamedicinterceptvehiclesubsidizedbyaNECCOGcontractsince1999.QVMedic1isstaffedeveryhourofeverydayandgenerallypostsaroundtheDayKimballHospital.Incalendaryear2014QVMedic1handled79.6%oftheparamedic-level(ALS)dispatchesintheNECCOGcontractareawithanaverageresponsetimeof12minutesand32seconds.


Figure4:QVMedic12014responses

*PlainfielddataincludesmediccallsintheportionofthetownnotcoveredintheNECCOG/QVMedic1

servicearea.

Figure5:QVMedic1-15minutetraveltime

Darkerareaofmap:QVMedic1PSAarea

ThedatafromQVECshowsa“chutetime”–timefromdispatchtovehiclemoving-forQVMedic1averages2minutesand52seconds,risingto5minutesand16secondsforthe90thpercentile.Nationally,theaveragechutetimeisunder60seconds.TheapparentaverageQVMedic1chutetimeof172secondssignificantlyextendsresponsetimeandmaybeacontributingfactorwhencommunityambulancesdecidetocancelaparamedicinterceptandtransportacriticallyillpatienttoahospitalwithoutthebenefitofparamediccare.ParamedicCoverageinKillinglyK-BAmbulanceCorpsinKillinglyreceivedtheirR-5paramediclicensefromthestateDepartmentofHealthinAugust2014.ParamedicservicebeganOctober1,2014.TheyarenotassignedaparamedicPrimaryServiceAreas(PSA),butMedic561respondstoALSlevelcallswithintheTownofKillinglyonamutualaidbasis.


Inearly2015theTownofKillinglyandK-BAmbulancepetitionedtheDepartmentofPublicHealthtoreplaceAmericanwithK-BAmbulanceastheirdesignatedparamedicprovider.Inadequateparamedicresponsetimeswereoneofthereasonsforthisrequest.

Dispatch-to-at-scenedataforALScallsinKillinglyfromJanuary1toJune30,2015:

Notethat26%ofthoserequestingaparamedicwaitedover12minutes.Oneoftherespondersservingaportionofthe50squaremilesofKillinglystatedinthesurveythattheyhavecancelledtheparamedicsandstartedBLSemergencytransportofALSpatientsduetothedelayinarrivaloftheparamedic.Figure6showstheQVMedic1servicearea(darkpurple)andthegreenlineshows15-minutetraveltimeforKBMedic516.

Figure6:KBMedic-15minutetraveltime


ImpactofmultipleALSproviderswithintheNECCOGcontractareaInlookingatworkloadandlocation,KBMedic561andQVMedic1providecomplementarycoveragewithintheNECCOGservicearea.Figure8showsthecombinedtraveltimeforQVMedic1,KBMedic561andtheAmericanAmbulanceparamedicunitpostedinPlainfield.Figure7:Allmediccallsinoneyear

Figure8:Allparamedicunits-15minuteresponsetime


Recommendations - Paramedic 11. MonitorandprovideparamedicresponsetimestoalltownscoveredintheNECCOGcontract

everymonth.12. Addressthe“chutetime”todetermineifthe2minute,52secondaveragetimeisaccurate.If

so,thisshouldbereducedtolessthan60seconds.13. Inthenextcontract(2016-2017)requirethattheparamedicproviderarrivewithin14:59

minutesinthemillvillageswithmorethan5,000residentswith90%reliability.ThiscoversKillingly,Putnam,Thompson,WoodstockandPlainfieldareacoveredbyNECCOG.

14. HaveNECCOGdevelopacontractthatprovidesforparamediclevelcoveragewiththebestoutcome.

15. OnceallALSproviderunitsareequippedwithAVLandQVEChasaccesstothedata,sendthenearestparamedicassettoanemergency.

AMBULANCE DEPLOYMENT TheConsultantidentified12community-basedemergencyambulanceprovidersintheNECCOGdistrict:Stand-alone:PutnamMoosup-PlainfieldKillingly-BrooklynHampton-ChaplinAmericanLegion

PartofFireDepartment:VoluntownScotlandWoodstockMortlakeCommunity

CanterburyAshford

Inaddition,AmericanMedicalResponseandAmericanAmbulanceprovided9-1-1ambulancecoveragethroughmutualaid.TheDepartmentofPublicHealthhasonlyoneresponsetimemetric–thatadesignatedPSARrespondstoatleast80%ofallfirstcallresponses.AreviewofaLocalEMSPlanmutualaidagreementdescribesa“systemoverload”whentherequestforassistanceexceedstheresourcesofaspecificproviderofasegmentofanEMSsystem.Anexampleisanambulanceproviderwithtwoambulancesandthreesimultaneousrequestsforservice.


Thereisnorequirementtotrackorreportresponsetimes.Thisinformationisusefulwhenanalyzingambulanceperformance.Thereisnoreportingofoccasionswhensystemoverloadrequireda2ndcall-outanddelayedresponse.Thestateprovidesaminimumequipmentlistandinspectsambulancesannually.MinimumambulancestaffingisoneEmergencyMedicalTechnician(EMT)andoneEmergencyMedicalResponder(EMR).Thereisnorequirementforemergencyvehicleoperatortraining.WithintheNECCOGarea,noneoftheambulancesareequippedwithAutomaticVehicleLocators(AVL)andQVECisunabletogeographicallytrackambulances.AmbulanceStaffingisaChallengeManyNECCOGambulanceresponderssharedtheirchallengesinrecruitingandretainingvolunteerEMTs.SomeofthevolunteerambulanceprovidersarehiringEMTstomaintainweekdayservice,eitherdirectlyorthroughVinTechManagementServices.Onetownvotedtosubcontractoutambulancetransportation,includingaprovisionforthecontractortofunctionasafirstresponderifnovolunteersareavailable.12Oneoftherespondentstothesurveyprovidedthisobservation:

“RecruitmentandRetentionprogramstogetnewmembersisanongoingproblem.GrantopportunitiestopurchaseEMSequipmentisataminimum.Grantopportunitiesforeducationandtrainingofnewandoldermembersisataminimum.”

Anotherrespondentaddressedstaffingandreimbursement:

“Therearemanysmalltownsinourareathatrelyuponavolunteersystemforcoverage24/7.Ithasbecomehardertoattractandretainnewmembersduetoincreasedtrainingandmeetingsrequired.Mostsmalltownsdonothavethebudgetinplacetoaffordpaidstaffingandwithcutstoinsurancereimbursementsandhighercallvolumespeoplearefeelingburntout.”

12Penny,J.(2014August22).Pomfretwillsubcontractambulancetransport.TheBulletin.Norwich,CT,GatehouseMedia.


SupplyandDemand:CalendarYear2014Figure9:AmbulanceSupplyandDemandCY2014

CostofProvidingAmbulanceTransportationThereweremultipleeffortstogetfinancialdatafromthe14organizationsthatprovideambulancetransportation.Financialdatawasobtainedfrom5ofthe14providers.Payermixinformationwasobtainedfromoneofthethreehospitals.Thereisnotenoughdatatoprovideanaccuratepicture,buthereisourimpression:Thereare9,636BLSresponsesayearintheregionwitha72%transportrate.Thatequals6,970billabletransports.Theincompletedataindicatesa52%collectionrateforambulancetransportbills,witheachbillaround$750.Theremaybe$5,227,201inbillabledollarsatacollectionrateof52%,whichequals$2,721,115incashavailablefromuserfees.


Thecommunitiespayout$312,147insubsidypayments.Addingthesubsidy($312,147)tothecashavailable($2,721,115)willresultin$433.21cashforeachofthe6,970transports.Figure10:EstimatedNECCOGPayerMix(incompletedata)

AlternativeAmbulanceDeploymentexample–Hampton,ChaplinandScotlandWithintheHampton,ChaplinandScotlandareastherearelowcallvolumesforambulanceswherethecost-per-callishigh.WelookedattheimpactofhavinganambulancebasedatWindhamhospital.Figure11:ResponsefromWindhamHospitaltoHampton-Chaplin-Scotland


Therewere548responseswith367transportsfromthesecommunities.About80%ofthe9-1-1callsoccurwithina20-minutedrivetimefromWindhamHospital.Thisexamplewouldre-assigntheBLSPSAtoWindhamHospitalwhowillprovideagoodandreliableresponsetimewhilereducingcommunitycosts.ThefiredepartmentscanredirecttheirresourcestoprovidingMFRinsteadofthelengthyandcostlyBLStransport.

Recommendations - Ambulance 16. Maintainup-to-datelistofambulanceproviders,includinginformationoncurrent

chief/captainorpointofcontact(name,emailandphonenumber).17. MonitorandprovideambulanceresponsetimestoallNECCOGmembertowns.18. Workwitheachmunicipalitytoestablishmeasurableambulanceresponsetimesand

automaticaidcoverageprotocolsaspartoftheirLocalEmergencyMedicalServicesPlan.19. Workwiththeambulancetransporterstoobtainaccuratecostandrevenuedata.20. Explorethedeploymentandstaffingimpactofregionalorconsolidatedambulancecoverage

basedonworkloadandvolunteeravailability.21. Schedulequarterlymeetingswiththeambulanceproviderstoreviewresponsetimes,address

issues,andlookforcollaborativeopportunities.22. InitiateanEmergencyVehicleOperatortrainingprogram.

DISASTER PREPAREDNESS EMSsystemsshouldhaveanall-hazardspreparednessapproach,combinedwithknowledgeoftheuniqueriskfactorsfacedbythecommunitiestheyserve.Byweighinglikelyandlesslikelyrisks,it’spossibletostrikeabalanceinpreparednessefforts.Clearly,EMSsystemsmustmaintainfocusonday-to-dayoperations,whileconsideringsystemenhancementforthefarmorefrequenteventstheyencounter.Inlieuofcountygovernment,theregionalcouncilofgovernmentsareanimportantpieceofConnecticut’splanningframeworkbecausetheyprovideaforumforregionalandinter-municipaldecisionmaking,servicecoordination,andprojectplanning.The“2015NortheasternConnecticutCouncilofGovernmentsRegionalHazardMitigationPlan”13providesacomprehensive,allhazardsplan.

13NECCOG(2015).NortheasternConnecticutCouncilofGovernmentsRegionalHazardMitigationPlan.Dayville,CT,NortheasternConnecticutCouncilGovernments.


Interagencytrainingisofutmostimportance.Recentafter-actionreportsnotedthattheIncidentCommandSystem(ICS)proceduresfailedafteramulti-jurisdictionaloperation.AnalysisidentifiedthatthelackofpracticemadeICScumbersomeandawkward.Ourexperienceindicatesthatthesuccessofalarge-scaleeventispredicateduponpolicies,activitiesandpracticesthatareuseddaily.TheuniqueintegrationaspectsofEMSandthelargersystemmeritaseparateevaluationofhowtobetterintegrateplanning,exercise,riskmitigationandstaffingthosefunctionswithinthelargerhealthcaredeliverysystem.Suchanevaluationwasbeyondthescopeofthisstudy.

MEDICAL ACCOUNTABILITY MedicalAccountabilityBenchmarks

§ Singlepointofphysicianmedicaldirectionforentiresystem.§ Writtenagreement(jobdescription)formedicaldirectionexists.§ SpecializedMedicalDirectortraining/certifications.§ Physicianisinvolvedinestablishinglocalcarestandardsthatreflectcurrentnational

standardsofpractice§ Proactive,interactiveandretroactivemedicaldirectionisfacilitatedbytheactivitiesofthe

MedicalDirector§ PCRdatatransparencyfacilitatesMDreview.§ Clinicaleducationeffectivenessefficiency.

Observations and Findings ThestateDepartmentofPublicHealthnoteslimitedmedicaloversightofEMS.Onlyparamedics14,emergencymedicaldispatchersandemergencymedicaltechnicianswhoaretrainedinadvancedskills15arerequiredtohavemedicaldirection.DayKimballandBackushospitaloffermedicaloversighttomedicalfirstrespondersandemergencymedicaltechnicians,butitisnotaregularormandatedactivity.Oneofthehospitalrespondentstothesurveyprovidedthisobservationandrecommendation:

14Mullen,J.,W.H.Furniss,J.A.Reynolds(2015).EmergencyMedicalServicesPlan:2015-2020.Hartford,CT,DepartmentofPublicHealth.15ThompsonFireAdvisoryCommittee.(2013December).LocalEmergencyMedicalServicesPlan:TheTownofThompson,Connecticut.December1,2013-November30,2018.Thompson,CT,TownofThompson.


“RegionalEMSplanwithWindham,DayKimballandBackusHospitalsworkingtogetherwithregionalALS/BLSguidelinesandcarestandardswouldbebeneficial.IdeallywithasfewdifferentEMSorganizationsaspossibletoimproveconsistency.”

Recommendations 23. Establishregionalclinicalguidelinesformedicalfirstresponders,emergencymedical

techniciansandparamedics.24. Physiciansinvolvedinconsortiumshouldhaveemergencymedicinecredentials.25. EstablisharegionalQualityAssurance/QualityImprovement(QA/QI)processwith

chartreviewsandpatientoutcomefollow-ups.26. Establishacontinuingpre-hospitaleducationprogramthatisbuiltfromthelocalQI

processandreflectsnationalbestpracticesinpre-hospitalcare.

CUSTOMER AND COMMUNITY ACCOUNTABILITY Customer/CommunityAccountabilityBenchmarks

§ Legislativeauthoritiestoprovideserviceandwrittenserviceagreementsareinplace.§ Unitsandcrewshaveaprofessionalappearance.§ Formalmechanismsexisttoaddresspatientandcommunityconcerns.§ Independentmeasurementandreportingofsystemperformanceareutilized.§ Internalcustomerissuesareroutinelyaddressed.

Observations and Findings ThecreationandmaintenanceofaLocalEmergencyMedicalServicesPlanbyeachmunicipalityrequireswrittenserviceagreementsanddescriptionsoftheroleandresponsibilityforeachpre-hospitalcareprovider.16NECCOGshouldbeanactivepartnerwitheverymunicipalityindeterminingappropriateresponsetimes,handlingofscarceresourcesandcollaborativeproblemsolving.TheLEMSPrequiresmilestonesatthe1,3and5-yearmarkandareview/resubmissionoftheLEMSPeveryfiveyears.ThisprovidesapowerfultoolfordevelopmentofaneffectiveregionalEMSsysteminnortheasternConnecticut.

16OfficeofEmergencyMedicalServices(updated2015July).LocalEmergencyMedicalServicesPlanToolkitforMunicipalities.DepartmentofPublicHealth.


Thepaidparamedicsandemergencymedicaltechnicianshaveaprofessionalappearanceandthevehiclesarecleanandingoodcondition.Thevolunteermedicalfirstrespondersandemergencymedicaltechniciansoftenrespondfromhomeorworkandwillnotbeinuniform.Theredoesnotappeartobeaformallocalmechanismtoaddresspatientandcommunityconcerns.Thereisnoindependentmeasurementorreportingofsystemperformance.Inthesurveyandface-to-faceinterviews,someofthecaregiversfeltthattheirissueswerenotadequatelyaddressedbyNECCOG.

Recommendations 27. Publishmonthlyreportsofemergencymedicalresponder,ambulance,andparamedic

fractileresponsetimestoallsystemparticipantsandNECCOGmembermunicipalities.28. Establishaformallocalmechanismtoaddresspatientandcommunityconcerns29. Establishaproceduretoroutinelyaddressinternalcustomerissues,includinga

documentationandfeedbacksystem.

PREVENTION AND COMMUNITY EDUCATION PreventionandCommunityEducationBenchmarks

§ Systempersonnelprovidepositiverolemodels.§ Programsaretargetedto“atrisk”populations.§ Formalandeffectiveprogramswithdefinedgoalsexist.§ Targetedobjectivesaremeasuredandmet.

Observations and Findings TheEMSsystemdoesnotreportthenumberofhoursofpubliceducation,preventionorpublicawarenessprogramsaccomplishedbyparticipantsinthesystem.Communityeducationandawarenessactivitiesareconductedbyindividualagencies,butthesearenotcoordinatedinasystemicfashion.TherearesignificantopportunitiesforsystemparticipantstobecomemoretightlylinkedwiththebroadercommunitythrougheducationprogramsdirectlyandthroughalliedorganizationssuchastheNortheastDistrictDepartmentofHealth,RedCrossandAmericanHeartAssociation.


Ambulanceandfiredepartmentstypicallyofferawidevarietyofpubliceducationactivitiesasamechanismtomaintaincommunityconnectivity.Theseprogramsrangefromondemandcarseatinspectionstofreehomeinjurypreventioninspectionsforfamilieswithtoddlersorseniors.JuniorParamedicprograms,MassCPRtrainingeventsandScoutingExplorerPostsaremeaningfulwaystheservicecanengagetheirrespectivecommunity.PartneringwithothercommunityorganizationsincreasescommunityawarenessinEMSandcouldresultinadditionalvolunteercaregivers.Thesecanbedesignedandimplementedwithlittleinvestmentandarelimitedonlybythecreativityoftheindividualservices’leadership.Attracting,retaininganddevelopingstaffisincreasinglybecomingapriorityforemergencymedicalsystemoperations.ExpandedrecruitmentandretentioneffortsarecentraltovolunteerparticipationinnortheastConnecticut.Whileretentionistightlyrelatedtothemannerinwhichtheindividualagenciesoperate,recruitmenteffortscanbesupportedbyNECCOGandshouldbealegitimateroleaddedtothemissionofsupportingEMS.Awidevarietyofstrategiesareutilizedinothercommunitiesasoutlinedatbelow.ExamplesofSystemRecruitmentEfforts:Interactive

§ Actiondisplays.§ Openhouses.§ Publicvenues.§ Wordofmouth.§ TV&Radiointerviews.§ Membershipdrives.§ Persontoperson.

Media

§ Webpagesandemail.§ Media(radio,print,TV).§ Signs,brochures,andflyers.§ Billboards.§ Volunteertelethon

Networks&OtherSources§ PreEMSclasses.§ YouthandSchoolVolunteer

recruitmentbyteachinginlocalschools

§ EmployersupportedvolunteerismdevelopmentprogramsthroughtheChamberofCommerce.

§ Placementofvolunteerrecruitingmaterialsinutilities,taxbills,etc.

§ Localtaxcreditsorincentivesforvolunteers.

Inadditiontogeneralcommunityeducationprogramsandeffortstorecruitvolunteers,theNortheastDistrictDepartmentofHealthshouldintegrateEMSinitseducationalprogrammingtoreachatriskpopulations.IftheCountywishedtoexpandthepubliceducationtoinclude“at


risk”populationsthatmaydirectlyimpactclinicaloutcomes,itshouldconsiderreviewingthecalltypescommonlyrequestedanddoananalysisofspecificatriskgroupswithintheservicearea.Communitiesinotherareashaveidentifiedelderly(falls),diabetics,asthmaticsandheartfailurepatientsaskey“atrisk”groups.Redirectingoutreacheffortstothosepatients,asanattempttoprospectivelyreducetheirprobabilityofrequiringEMSserviceatameasurablysignificantrate,wouldbeverybeneficial.

Recommendations 30. Developaprogramandidentifyresourcestoimprovecommunityawarenessofthe

EMSsystem.31. Identifyandsupportpriorityprojectsforcommunityhealthimprovement,utilizing

EMSasaprimaryfocus.Thisshouldspecificallyincludebutnotbelimitedtovolunteerrecruitmentefforts.

32. PrepareanddistributeanannualreporttoelectedofficialsandcommunitystakeholdersdescribingtheaccomplishmentsoftheEMSsystem.

ORGANIZATIONAL STRUCTURE AND LEADERSHIP OrganizationalStructureandLeadershipBenchmarks

§ Alocalleadagencyisidentifiedandcoordinatessystemactivities.§ Organizationalgovernance,structureandrelationshipsarewelldefined.§ Humanresourcesaredevelopedandotherwisevalued.§ Businessplanningandmeasurementprocessesaredefinedandutilized.§ Operationalandclinicaldataguidesthedecisionprocess.§ Astructuredperformance/qualityimprovement(QI)systemexists,addressing

administrativeaswellasclinicalissues.

Observations and Findings NECCOGhasprovidedasoftcoordinationfunctionandhasinformallyfulfilledmanyofthe“localleadagency”functions,eitherbyfundingQVMedic1orthroughparticipationinavarietyofregionalcommittees.Localhealthcarefacilitiesaresupportive.Townandvillageleadersneedtorecognizethepotentialimpactthisimportantprogramhasonthelivesoflocalconstituents.


ThestateDepartmentofPublicHealthisrevisingthewaytheyregulateEmergencyMedicalServicesthroughvigoroususeoftheLocalEMSPlantoplananddevelopcommunitybestpracticesinprovidingpre-hospitalemergencycareservicesthroughamulti-tieredandmulti-agencydeliverysystem.Thisincludesproposedchangesinregulations,includingadministrationoftheprimaryserviceareas(PSA).NECCOGleadershipmustcreateafuture-orientedEMSplanthatincorporatesthemunicipalLocalEMSPlans,andinvolvesthepre-hospitalprovidersandthemedicalcommunityinanopenandcollaborativemannertothemaximumextentpossible.HumanResourcesManagementmustleadtheorganizationinamannerthatfacilitatesdeliveringthebestvaluetoclientsandsimultaneouslydevelopingaclimateinwhichsystemparticipantsfeelvalued.Anumberofdecisions(e.g.improvedresponsetimes,scratchreduction,ALSdispatch)willbedifficulttoimplementwithinthecurrentorganizationalclimate.Topositivelychangethebehaviorsandcultureofthissystemwillrequireongoingandconsistenteffortovertime.LeadershipeffortswithinEMSmustbesupportedbymunicipalofficials,healthcareadministrators,paramedicsandvolunteerfirstrespondersandEMTstobesuccessful.QualityImprovementProcessesEMSorganizationsfindthatsustaininghighqualityserviceisadifficulttask.EMSleadersareencouragedtointegratecontinuousqualityimprovementpracticesintotheirEMSoperationsandadministrativepracticestotheextentthatthosepracticesbecomeanessentialandseamlesspartofnormalEMSroutines.NECCOGshouldworkwiththemembermunicipalitiestodevelopanannualQualityImprovementPlan.ThiscouldbeaccomplishedthroughanexpansionofthePre-HospitalEmergencyCareAdvisoryCommitteewithincreasedstaffsupport.TheQIgoals,approach,methodology,criticalsuccessfactorsandindicatorsshouldbeclearlydefinedintheplan.Indicatorsshouldbemonitoreduntilimprovementhasoccurredandthethresholdorbenchmarkisachievedinatimelymanner.ResponsibilityandaccountabilityfortheQIplanshouldbeclearlydefined.Theregionalmedicaldirectorshouldalsobeactivelyinvolvedindevelopingtheplanandreceivemonthlyreports.Theplanshouldbereviewedandupdatedonanannualbasis.


ThelocalQIplanshouldincludestatisticalindicatorstobemonitoredmonthly,including:

Ø FractileResponseTimesØ UnitHourUtilization(UhU)Ø ProductivityØ CallLoadØ SceneTimesØ CustomerSatisfaction

Ø VehicleMaintenanceØ DeviationfromMedicalProtocolsØ HighRiskProceduresØ RegulatoryComplianceØ Otherstheserviceorhospitalsdeem

necessaryOtherQImeasuressuchasRefusalFormsCompliance,VehicleReadiness,SkillsMaintenance,BillingComplianceandUtilizationReviewshouldbemonitoreduntilimprovementhasoccurred,thebenchmarkachievedandanevaluationoftheimplementedchangesoccursafteracertaintimeperiod.MonitoringvariouspatientoutcomesandcustomersatisfactionshouldbeincludedintheQIplan.Figure12:ProposedRetrospectiveQIprocess

Recommendations 33. Establishphysiciansupervised,NECCOGcoordinatedQIprocessinvolving

communications,firstresponders,paramedics,medicaltransportationandadministrativecomponentsofthesystem.


34. Providetraining(lineandadministrative)forallpersonnelholdingsupervisorypositionswithintheEMSsystem;assurethateachsupervisorhastheknowledge,skillsandaptitudestobeaneffectivesupervisor.

35. Developadetailedworkplanwithspecifictimelinesforserviceenhancement.

ENSURING OPTIMAL SYSTEM VALUE OrganizationalStructureandLeadershipBenchmarks

§ ClinicalandcustomersatisfactionoutcomesareenhancedbytheEMSsystem.§ UnitHourUtilizationismeasuredandhoursaredeployedinamannertoachieveefficiency

andeffectiveness.§ Costperunithourandtransportdocumentgoodvalue.§ Financialsystemsaccuratelyreflectsystemrevenuesandbothdirectandindirectcosts.§ Revenuesarecollectedprofessionallyandincompliancewithfederalregulations.§ Localtaxsubsidiesareminimized.

Observations and Findings QualityprocessesthatsupportthedeterminationoftheefficacyoftreatmentmodalitiesandpatientsatisfactionarebecomingincreasinglycommoninEMS.Tracerconditionssuchascardiacarrestandtraumahavenotbeensufficientlyquantifiedtoempiricallydocumentthebenefitsofpre-hospitalservice.PainreliefandcustomersatisfactionarenotmeasuredwithintheEMSsystem.TheinherentlyfragmentedEMSsysteminConnecticut17challengestheabilityofNECCOGtomakethebestimpactonpatientoutcomeswiththeavailableresources.Considerationshouldbegiventosupportingcitizeninvolvementinassistingatmedicalemergencies,including9-1-1providedinstruction,Compression-onlyCPR,communityAEDsandCivilianEmergencyResponseTeams(CERT).

17Bordonaro,G.(2013).CT’sambulanceservicesfragmented,consolidated.HartfordBusinessJournal.Hartford,CT,NewEnglandBusinessMedia.


Recommendations 36. DevelopaprocesstoexpandinformationthataccuratelyportraystheimpactofEMS

serviceonpatientoutcomesandcommunitywell-being.37. Identifytheareaofout-of-hospitalcarethatNECCOG’sresourcescanhavethemost

significantimpactonpatientoutcome.38. Improvethecommunity’sabilitytoidentifyalife-threatingmedicalconditionand

actionsacommunitymembercandotomakeadifference.

SUMMARY: THOUGHTFUL APPLICATION OF RESOURCES NECCOGistheprincipalregionalplanningorganizationfornortheasternConnecticut.Theorganizationcoordinatesactivitiesbymultiplemunicipalities,promotesregionalproblemsolving,andobtainsgrantsorotherfundingtomeetitsmission.Whennoparamedicservicewasavailabletoalargeportionofthecommunity,NECCOGestablishedanALSInterceptcontracttoprovidethisessentialservicein1999.NECCOGhassubsidizedparamedicinterceptservicefor16years.Beforeawardingthe2016-2017ALSInterceptcontract,NECCOGshouldconsiderwhatenhancementsinpatientoutcomes$286,000ayearcanprovide:

§ Fundphysicianconsortiumtoassurequalityforallaspectsofpre-hospitalsystem.§ Establishregionalclinicalprotocols.§ ProvideAutomaticVehicleLocatorsforallambulanceandemsfirstresponderrigs.§ Fundvolunteerrecruitmentdrivefortheambulancesandfiredepartments.§ Staffweekdayregionalambulanceincommunitiesunabletoprovideservice.§ Providehigh-performancecommunityCPRtraining.§ Improveparamedicresponsetime.§ FunddatareportingtoolforQVEC

Tofacilitateathoughtfulre-evaluationofemsresources,NECCOGneedstohavecurrentpre-hospitalresponseworkloadandclinicaloutcomedatatomakeameasurableimprovementincommunityhealthandsurvival.Toimplementanyre-organization,NECCOGneedstodemonstratetransparent,collaborativedecision-makingthroughparticipationinquarterlymeetingswithpre-hospitalprovidersandestablishingaregionalEMSqualityimprovementprogram.


RECOMMENDATION SUMMARY

9-1-1 and COMMUNICATIONS 1. ContinuetopurseandupdatethecurrentNewWorldCADandensurethereisan

improveddatasuite.2. Clarifyprocesstohandlesecond-outALScalls.3. AllresponseunitsshouldbeGPS/AVLcapableforappropriateunitdispatching,with

QVECabletomonitorpositionstodeterminenearestavailableresponder.4. Performancemetricsshouldbeestablishedforcalltakingtimesandmeasured

monthly.5. EvaluatetheabilitytodevelopaninterfacefromQVECtofieldunitstoreceive

automaticelectronicpatientcarereportingdata.6. ChiefsneedtotakeBLStransportoutofservicewhenunstaffed.7. Evaluateabilitytoreducedecision-makingprocesswhendispatchingasecondary

paramedicunitormutualaidambulance.

MEDICAL FIRST RESPONSE 8. Maintainup-to-datelistofmedicalfirstresponderagencies,includinginformationon

currentfirechieforpointofcontact(name,emailandphonenumber)9. Workwitheachmunicipalitytoestablishmeasurableresponsetimesandcoverage

protocolsaspartofupdatingtheirLocalEmergencyMedicalServicesPlan.10. Establishconsortiumofmedicaldirectorstoassurequalityforallaspectsofpre-

hospitalcaresystem.

MEDICAL TRANSPORTATION 11. MonitorandprovideparamedicresponsetimestoalltownscoveredintheNECCOGcontract

everymonth.12. Addressthe“chutetime”todetermineifthe2minute,52secondaveragetimeisaccurate.If

so,thisshouldbereducedtolessthan60seconds.13. Inthenextcontract(2016-2017)requirethattheparamedicproviderarrivewithin14:59

minutesinthemillvillageswithmorethan5,000residentswith90%reliability.ThiscoversKillingly,Putnam,Thompson,WoodstockandPlainfieldareacoveredbyNECCOG.

14. HaveNECCOGdevelopacontractthatprovidesforparamediclevelcoveragewiththebestoutcome.

15. OnceallALSproviderunitsareequippedwithAVLandQVEChasaccesstothedata,sendthenearestparamedicassettoanemergency.


16. Maintainup-to-datelistofambulanceproviders,includinginformationoncurrentchief/captainorpointofcontact(name,emailandphonenumber)

17. MonitorandprovideambulanceresponsetimestoalltownscoveredintheNECCOGcontracteverymonth.

18. WorkwitheachmunicipalitytoestablishmeasurableambulanceresponsetimesandautomaticaidcoverageprotocolsaspartoftheirLocalEmergencyMedicalServicesPlan.

19. Workwiththeambulancetransporterstoobtainaccuratecostandrevenuedata.20. Exploredeploymentandstaffingimpactofregionalorconsolidatedambulancecoverage

basedonworkloadandvolunteeravailability.21. Schedulequarterlymeetingswiththeambulanceproviderstoreviewresponsetimes,

addressissuesandlookforcollaborativeopportunities.22. InitiateanEmergencyVehicleOperatortrainingprogram.

MEDICAL ACCOUNTABILITY 23. Establishregionalclinicalguidelinesformedicalfirstresponders,emergencymedical

techniciansandparamedics.24. Physiciansinvolvedinconsortiumshouldhaveemergencymedicinecredentials.25. EstablisharegionalQualityAssurance/QualityImprovement(QA/QI)processwith

chartreviewsandpatientoutcomefollow-ups.26. Establishacontinuingpre-hospitaleducationprogramthatisbuiltfromthelocalQI

processandreflectsnationalbestpracticesinpre-hospitalcare.

CUSTOMER AND COMMUNITY ACCOUNTABILITY 27. Publishmonthlyreportsofemergencymedicalresponder,ambulanceandparamedic

fractileresponsetimestoallsystemparticipantsandNECCOGmembermunicipalities.

28. Establishaformallocalmechanismtoaddresspatientandcommunityconcerns.29. Establishaproceduretoroutinelyaddressinternalcustomerissues,includinga

documentationandfeedbacksystem.

PREVENTION AND COMMUNITY EDUCATION 30. Developaprogramandidentifyresourcestoimprovecommunityawarenessofthe

EMSsystem.31. Identifyandsupportpriorityprojectsforcommunityhealthimprovement,utilizing

EMSasaprimaryfocus.Thisshouldspecificallyincludebutnotbelimitedtovolunteerrecruitmentefforts.


32. PrepareanddistributeanannualreporttoelectedofficialsandcommunitystakeholdersdescribingtheaccomplishmentsoftheEMSsystem.

ORGANIZATIONAL STRUCTURE AND LEADERSHIP 33. Establishphysiciansupervised,NECCOGcoordinatedQIprocessinvolving

communications,firstresponders,paramedics,medicaltransportationandadministrativecomponentsofthesystem.

34. Providetraining(lineandadministrative)forallpersonnelholdingsupervisorypositionswithintheEMSsystem;assurethateachsupervisorhastheknowledge,skillsandaptitudestobeaneffectivesupervisor.

35. Developadetailedworkplanwithspecifictimelinesforserviceenhancement.

ENSURING OPTIMAL SYSTEM VALUE 36. DevelopaprocesstoexpandinformationthataccuratelyportraystheimpactofEMS

serviceonpatientoutcomesandcommunitywell-being.37. Identifytheareaofout-of-hospitalcarethatNECCOG’sresourcescanhavethemost

significantimpactonpatientoutcome.38. Improvethecommunity’sabilitytoidentifyalife-threatingmedicalconditionand

actionsacommunitymembercandotomakeadifference.

AttachmentA

AmbulanceBenchmarkSummary

SYSTEMCOMPONENTSBENCHMARKSOVERVIEWKEY:D=Documented,ND=NotDocumentedPD=PartiallyDocumentedCommunicationsBenchmarks CommentsPublicaccessthroughasinglenumber,preferablyenhanced911

D

CoordinatedPSAPsexistforthesystem D PutnamisasecondaryPSAPCertifiedpersonnelprovidepre-arrivalinstructionsandprioritydispatching(EMD)andthisfunctionisfullymedicallysupervised

D

Datacollectionwhichallowsforkeyserviceelementstobeanalyzed

PD CurrentCADhaslimitedconfigurationandreportingcapabilities

Technologysupportsinterfacebetween911,dispatching&administrativeprocesses

PD NoautomaticinterfacebetweenQVECandelectronicpatientcare

Radiolinkagesbetweendispatch,fieldunits&medicalfacilitiesprovideadequatecoverageandfacilitatecommunications

ND NoAVL(exceptforQVMedic1),nowayofknowingif1stresponderorambulanceresourceisavailable

MedicalFirstResponseBenchmarks CommentsFirstrespondersarepartofacoordinatedresponsesystemandmedicallysupervisedbyasinglesystemmedicaldirector

ND EachmunicipalitysetsitsownPSA/mutualaidplan.Nophysicianoversight

Definedresponsetimestandardsexistforfirstresponders

ND Noneofthe1stResponderdepartmentshaveresponsetimestandards

Firstresponseagenciesreport/meetfractileresponsetimes.

ND Noneofthe1stResponderdepartmentsreporttheirresponsetimes

AEDcapabilitiesonallfirstlineapparatus ND Smoothtransitionofcareisachieved D

MedicalTransportationBenchmarks CommentsDefinedresponsetimestandardsexist ND NoresponsetimestandardexistsAgencyreports/meetsfractileresponsetimes ND NoreportingprovidedUnitsmeetstaffingandequipmentrequirements D EMT&EMRonambulance,1paramedicon

interceptResourcesareefficientlyandeffectivelydeployed ND Staticratherthandynamicparamedic

deployment.MFRandambulanceuse“systemoverload”mutualaidagreement

Thereisasmoothintegrationoffirstresponse,air,groundandhospitalservices

PD Didnotevaluateair-medical.

Develop/maintaincoordinateddisasterplans PD NECCOGdevelopedplan,norecentexerciseofplan

KEY:D=Documented,ND=NotDocumentedPD=PartiallyDocumentedMedicalAccountabilityBenchmarks CommentsSinglepointofphysicianmedicaldirectionforentiresystem

ND PhysiciandirectionrequiredforparamedicsandEMTswithadvancedskills.CPAP,EpinephrineAutoinjector,Glucometer,NarcanandAspirin.

Writtenagreement(jobdescription)formedicaldirectionexists

ND

Specializedmedicaldirectortraining/certification ND Physicianiseffectiveinestablishinglocalcarestandardsthatreflectcurrentnationalstandardsofpractice

ND

Proactive,interactiveandretroactivemedicaldirectionisfacilitatedbytheactivitiesofthemedicaldirector

ND

PCR/QIdatatransparencyforMDreview PD SponsorhospitalwillreviewMFR/ambulancechartsonrequest,paramedicsunderregularreviewbytheiroperationalmedicaldirector

ClinicalEducation/DevelopmentEffectiveness ND ClinicalEducationEfficiency ND

Customer/CommunityAccountabilityBenchmarks CommentsLegislativeauthoritytoprovideserviceandwrittenserviceagreementsareinplace

D ComponentofPublicAct14-217–LocalEMSPlan.

Unitsandcrewshaveaprofessionalappearance ND Formalmechanismsexisttoaddresspatientandcommunityconcerns

ND

Independentmeasurementandreportingofsystemperformanceareutilized

ND

Internalcustomerissuesareroutinelyaddressed PD OccasionalNECCOGinteractionwithpre-hospitalcommunity

Prevention&CommunityEducationBenchmarks CommentsSystempersonnelprovidepositiverolemodels ND Programsaretargetedto“atrisk”populations D MunicipalLocalEMSPlanlooksatcommunity

CPRcapabilityandspecialpopulationsFormalandeffectiveprogramswithdefinedgoalsexist

D MunicipalLocalEMSPlanestablishes1,3and5yearobjectives

Targetedobjectivesaremeasuredandmet ND Partofthefive-yearrenewalofLocalEMSPlan

KEY:D=Documented,ND=NotDocumentedPD=PartiallyDocumentedEnsuringOptimalSystemValueBenchmarks CommentsClinicaloutcomesareenhancedbythesystem D AmbResponseUtilizationandtransportUtilization(UHU)ismeasuredandhoursaredeployedinamannertoachieveefficiencyandeffectiveness

ND

Ambulancecostperunithour&transportdocumentgoodvalue

ND Most9-1-1ambulanceresponsesbyvolunteeragencies

Serviceagreementsrepresentgoodvalue PD RequiredinmunicipalLocalEMSPlanNon-emergencyambulanceeffective&efficient D Non-Emergencycallsarehandledbyseveral

privatecompaniesNon-Ambulancebutmedicallynecessary(MAV)servicesareeffectiveandefficient

D Non-ambulancecallsprovidedbyseveralprivatecompanies

Systemfacilitatesappropriatemedicalaccess D Financialsystemsaccuratelyreflectsystemrevenuesandbothdirectandindirectcosts

ND

Revenuesarecollectedprofessionallyandincompliancewithregulations

ND

Taxsubsidieswhenrequiredareminimized D Notaxsubsidiaries

OrganizationalStructure&LeadershipBenchmarks CommentsAleadagencyisidentifiedandcoordinatessystemactivities

D

Organizationalstructureandrelationshipsarewelldefined

PD NeedclarificationorredefinitionofNECCOGrolewithMFRandAmbulanceproviders

Humanresourcesaredevelopedandotherwisevalued ND EssentialHRpracticesareabsentandHRhasminimalinvolvement

Businessplanningandmeasurementprocessesaredefinedandutilized

ND

Operationalandclinicaldatainforms/guidesthedecisionprocess

ND

Astructuredandeffectiveperformancebasedqualityimprovement(QI)systemexists

ND NoregionalQIexists

RecommendationsRankedbyPriority

Recommendations

AttachmentB

NECCOGRecommendationsRankedby

neccog jan2016 final mjwneccog.org/wp-content/uploads/2018/04/pre-hospital... · 21 january 2016...

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