Executive Director

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Building an Effective and Efficient Trauma Care
Network
Regionalization and Local EMS
Jerry Overton Chief Executive Officer Richmond
Ambulance Authority Department of Emergency
Medicine VCU Health Systems
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Regionalization???
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EMS System Development

• Historical
• War
• Hospital and Health
• Funeral Homes
• Public Health and Safety

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EMS System Development

• Political
• Local City or County
• Country
• Laissez Faire

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The Results

• Fire Based
• Private
• Public
• Hospital
• Volunteer
• HPEMS

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System Development Challenges

• Evolution
• Resource Variations
• Training Variations
• No Minimum Standards
• Funding
• Commitment

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The REAL Result
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The Past

• What is a life worth?

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The Present

• Patient Costs
• versus
• Operational Costs

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The EMS System Dilemma
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The Priorities

• Quality Patient Care
• Quick Response Time
• Cost Effective
• Consumer Expectations Met

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Expectations

• The Patient
• The Public
• The Medical Community
• The Governmental Official

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The Expectations

• Diverse
• Competing Demands

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The Need for Regionalization. . .
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The Reality

• The troubled state of EMS

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The Reality The Troubled State of EMS

• EMS Systems . . . are often highly fragmented.
• Turf
• Jurisdictional Boundaries
• EMS and ED

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The Reality The Troubled State of EMS

• EMS Systems . . . are often highly fragmented.
• ED overcrowding

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The Reality The Troubled State of EMS

• EMS Systems . . . are often highly fragmented.
• ED overcrowding
• The cost . . . is rarely compensated.

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The Reality The Troubled State of EMS

• A number of personnel challenges

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The Reality The Troubled State of EMS

• A number of personnel challenges
• Little is known about what does and does not
  work . . .

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The Reality

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Establishing The Need . . . The Challenges Ahead
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Challenges in Demand

• 45 Million Uninsured
• Limited Access
• Lack of Primary Care

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Gatekeeping

• The Homeless
• More time in ED (4.4 to 7.5 hrs.)
• Less likely to be admitted (8 vs. 19)
• More likely to use EMS (51 vs. 29)

Pearson et al. Annals of Emergency Medicine,
December 2007
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EMS - The Gatekeeper of Emergency Care

• 8th Scientific Congress of the European
  Resuscitation Council
• Stavanger, Norway
• 10 13 May 2006

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Assumptions

• EMS is only part of the care system.
• The management of social care support, together
  with emergency, urgent and routine care, is a
  major challenge
• Integrated responses using a common
  prioritisation system is not currently sensitive
  and specific.
• Delivering care, as near as possible to home is
  NOT a key objective

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Challenges in Demand

• Aged 65 years or older
• 38 of EMS Responses
• Four times Average Utilization
• Highest Clinical Need
• Fastest Growing Subset-15 in 2020

Shah et al (May 2007) Acad Emer Med
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Disease burden (DALYs lost) for the 10 leading
causes
1999 Disease or Injury
2020 (Baseline Scenario) Disease or Injury

• Lower respiratory infections
• HIV/AIDS
• Perinatal conditions
• Diarrhoeal conditions
• Unipolar major depression
• Ischaemic Heart Disease
• Cerebrovascular Disease
• Malaria
• Road Traffic injuries
• COPD

• Ischaemic Heart Disease
• Unipolar major depression
• Road Traffic Injuries
• Cerebrovascular Diseases
• COPD
• Lower respiratory tract Infections
• Tuberculosis
• War
• Diarrhoeal Disease
• HIV

DALY Disability-adjusted life year
Source WHO Evidence, Information and Policy
2000
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Challenges in Finance

• Cost of Readiness
• Sophisticated Care
• Impact on Downstream Costs
• Inadequate Federal Support
• Lack of Constituency

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The Need for a Regional Perspective . . .
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The Regional Concept

• Accidental death and disability 1966

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The Regional Concept

• Accidental death and disability 1966
• Emergency Medical Services System Act 1973

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The Regional Concept

• Grants
• Sec. 1202
• Sec. 1203
• Sec. 1204
• 15 Components

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The 15 Components

• Manpower
• Training
• Communications
• Transportation
• Facilities
• Critical Care Units
• Public Safety Agencies
• Consumer Participation

• Access to Care
• Patient Transfer
• Coordinated Record Keeping
• Public Information
• Review and Evaluation
• Disaster Plan
• Mutual Aid

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The Regional Concept

• Regions vs. Catchment Areas
• By 1978
• 304 EMS Regions
• Over 300 Million Appropriated

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Historical

• Accidental death and disability 1966
• Emergency Medical Services System Act 1973
• Trauma Care 1976 -1986

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Historical

• The Components
• Access to Care
• Prehospital Care
• Hospital Care
• Rehabilitation

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The Politics

• Public
• Policy
• Ethics
• Cost
• Hospitals
• Image
• Effect
• Regulation
• Cost

• Physicians
• Quality
• Responsibility
• Training
• Finance
• Prehospital
• Medical Direction
• Care
• Transportation

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Historical

• Accidental death and disability 1966
• Emergency Medical Services System Act 1973
• Trauma Care
• EMS Agenda for the Future - 1996

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The Agenda for the Future

• Human Resources
• Education Systems
• Communication Systems
• Public Access
• Integration of Health Systems
• Information Systems
• Public Education

• Evaluation
• EMS Research
• Legislation and Regulation
• System Finance
• Medical Direction
• Prevention
• Clinical Care

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The Present to the Future The IOM
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Framework-The IOM

• Emergency Care is
• Accountable
• Regional
• Coordinated

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The Recommendations

• . . . develop evidence based indicators of
  emergency care system performance.

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Emergency Care is Regional

• Object Improve Patient Outcomes
• Cost-effective Strategy

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Emergency Care is Regional

• The Vision
• Trauma Care optimized through protocols and
  transfer agreements
• Inclusive of Medical Emergencies
• Inclusive of EMS

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EMS is Regional

• Adversely impact the overall availability . . .
• History
• Politics

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EMS is Regional
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EMS is Regional

• Patient Flow Patterns
• Diverse Receiving Facilities
• Closest
• Right Response
• First Time
• In Time

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The Recommendations

• . . . develop evidence based categorization
  systems for EMS, emergency departments, and
  trauma centers . . .
• . . . develop evidence based model prehospital
  care protocols . . .

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EMS is Coordinated

• Special Challenges
• Fragmentation
• Equipment
• Training
• Fully Interconnected
• EMS is Health Care

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EMS is Coordinated

• Two Contrasting Approaches

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EMS is Coordinated - Central Texas

• Initiatives
• Reducing hospitalization for diabetes
• Integrated mental healthcare
• Increasing access to pharmaceuticals
• Establishing respite care for the homeless

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CHSP Concepts
And in Richmond . . .

• More efficient and coordinated model of caring
  for Richmond area residents who are uninsured or
  underinsured
• Easier referrals for specialty and diagnostic
  services
• Coordinate services across agencies
• Use available resources more efficiently
• Improved clinical outcomes and utilization

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Cost of Caring for Uninsured Persons

• Note
• These costs are for 2005.
• Williams, R.M. The Costs of Visits to Emergency
  Department , New England Journal of
• Medicine, Vol. 334642-646, March 7, 1996.

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About Richmond
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City of Richmond Demographics

• Gender 53 Female, 47 Male
• Race 58 Black, 39 White, 1 Asian, lt1
  HPI, lt1 AI/AN, 1 Multi, 1 Other
• Housing 50 Rent, 42 Own, 8 Vacant

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City of Richmond Demographics
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Richmond EMS Utilization

• Number of Emergency Responses
• 40,000
• Number of Emergency Transports
• 29,900

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Richmond EMS Utilization

• At over 1,550 emergency transports per 10,000
  population, Richmond is the busiest HPEMS in the
  United States

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Richmond EMS Utilization Benchmarked
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Richmonds EMS Population

• High Rate of Chronic Illness
• Gatekeeper
• Limited Access
• Neighborhood Clinics
• Primary Care Physicians

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European Emergency Data (EED) Project Results
Diagnosis
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Richmond Ambulance Authority

• High Performance Emergency Medical Services
• System Design

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Performance Based EMS

• Clinical Sophistication
• Response Time Reliability
• Economic Efficiency
• Continuously Measured
• Results Achieved Simultaneously

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HPEMS

• Dispatch
• SSM
• EMD - DLS
• AMPDS
• IAED Accredited

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The Results
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• OR 2.08, 95CI 1.49, 2.89

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• OR 3.63, 95CI 1.90, 7.23

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HPEMS

• Mandated Response Times
• Life Threatening
• 859
• Non Life Threatening 1259
• Urgent 2959
• All ALS
• Evidence Based Protocols

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Technology

• On Board Mobile Gateway
• Data Flow and Storage

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Response Time Reliability andEconomic Efficiency

• Real Time Demand
• Fluid Deployment
• Travel Optimization

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Community Access Health Program

• Create safe alternatives to ambulance dispatch
• Assure that ambulances are available when
  necessary
• Improve safety records of nurse triage systems

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Prioritization Designations

• Level Percentage of Responses
• Echo 1
• Delta 32
• Charlie 23
• Bravo 16
• Alpha 15
• Omega 13

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PSIAM Solution

• Provides clinical link and algorthym
• Seamless data transfer
• RN gets full transcript call
• Increased range of dispositions
• RN Trained in EMD and Teleguides

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Economic Efficiency

• Unit Hour Utilization Analysis
• Preliminary
• Six CHAP Calls per 24 Hours 1 Shift Saved

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Next Steps

• Refine Demand Analysis with Staffing
• Continue Public Education
• Repetitive Patients
• Identify creative ways of matching callers needs
  with available resources
• Identify Additional Community Resources

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Multiple Transports of Same Patient
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Traditional Regional Roles

• Treatment and Transport Protocols
• Training Recommendations, Approval, or Oversight.
• State Grant Programs
• Communication Forum

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Regionalization The Present

• Trauma Centers
• Chest Pain Centers
• Interoperability
• Mutual Aid
• Disaster Response
• Regional Agencies

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Regionalization of EMS???
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Regionalization The Future

• Recognize the NEED
• Keep PATIENT CENTERED
• Understand the REALITY
• Inclusive of HEALTH CARE
• RESOURCE, rather geographic, focus

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• There are two times in a mans life when he
  should not speculate
• when he can afford it, and when he cant
• Mark Twain

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The Importance of Regional Cooperation and
Coordination
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Questions . . .
joverton_at_raaems.org