CONSULTANT REPORT EMS ASSESSMENT. Schertz EMS Schertz, Texas. March 11, Prepared by:

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March 11, 2013


Schertz EMS

Schertz, Texas

Prepared by:


2901 Williamsburg Terrace #G


Platte City








Schertz Emergency Medical Services – Schertz, Texas

EMS Assessment

Table of Contents

EXECUTIVE SUMMARY ________________________________________________________________ 1 METHODOLOGY _____________________________________________________________________ 3 SYSTEM BACKGROUND AND DEMOGRAPHICS _____________________________________________ 4

THEREGION ______________________________________________________________________ 4 SCHERTZEMERGENCYMEDICALSERVICES(SEMS) _________________________________________ 5

OPERATIONS ____________________________________________________________________ 5

THEOPTIMALEMSSYSTEM __________________________________________________________ 6

EMS DESIGNS, BEST PRACTICES AND BEST PRACTICE SYSTEMS ________________________________ 7 PROCESS AREA SUMMARIES ___________________________________________________________ 8


Description of Best Practices _______________________________________________________ 8

OBSERVATIONS AND FINDINGS ___________________________________________________________ 9

Public Access to EMS _____________________________________________________________ 9 Radio Communications ___________________________________________________________ 11

RECOMMENDATIONS _________________________________________________________________ 11 MEDICALFIRSTRESPONSE __________________________________________________________ 12

Description of Best Practices ______________________________________________________ 12

OBSERVATIONS AND FINDINGS __________________________________________________________ 13

Medical First Responders _________________________________________________________ 13

RECOMMENDATIONS _________________________________________________________________ 14 AMBULANCEOPERATIONSANDCLINICALPERFORMANCE _________________________________ 14

Description of Best Practices ______________________________________________________ 14

OBSERVATIONS AND FINDINGS __________________________________________________________ 15

Medical Transportation __________________________________________________________ 15 Clinical Service Levels ____________________________________________________________ 15 Education and Training __________________________________________________________ 15 Quality Management ____________________________________________________________ 16

RECOMMENDATIONS _________________________________________________________________ 18 MEDICALDIRECTIONANDACCOUNTABILITY ____________________________________________ 18

Patient Refusals ________________________________________________________________ 20

RECOMMENDATIONS _________________________________________________________________ 20 FLEETANDLOGISTICS ______________________________________________________________ 20

Training ______________________________________________________________________ 21 Preventive Maintenance _________________________________________________________ 22 Driver Training _________________________________________________________________ 23 Quality Control Driving System ____________________________________________________ 24


Fleet Performance Measures ______________________________________________________ 24

RECOMMENDATIONS _________________________________________________________________ 24 PREPAREDNESS ___________________________________________________________________ 25 RECOMMENDATIONS _________________________________________________________________ 25

Crew Configuration and Staffing ___________________________________________________ 25

TECHNOLOGYUTILIZATION _________________________________________________________ 26

Description of Best Practices ______________________________________________________ 26

OBSERVATIONS AND FINDINGS __________________________________________________________ 26

Electronic Patient Care Reporting __________________________________________________ 27

RECOMMENDATIONS _________________________________________________________________ 27 RESOURCEUTILIZATIONANDDEMAND ________________________________________________ 28

Description of Best Practices ______________________________________________________ 28

OBSERVATIONS AND FINDINGS __________________________________________________________ 28

Geographic Coverage ____________________________________________________________ 28 Demand Coverage ______________________________________________________________ 29 Response Time Performance ______________________________________________________ 33

RECOMMENDATIONS _________________________________________________________________ 34 SYSTEMFINANCESANDFUNDING ____________________________________________________ 34

Description of Best Practices ______________________________________________________ 34

OBSERVATIONS AND FINDINGS __________________________________________________________ 34

Billing and Reimbursement _______________________________________________________ 35

RECOMMENDATIONS _________________________________________________________________ 37 SYSTEMSCOSTANDFINANCE ________________________________________________________ 38 OBSERVATIONS AND FINDINGS __________________________________________________________ 38

UNIT HOUR UTILIZATION _________________________________________________________ 39

RECOMMENDATIONS _________________________________________________________________ 39 CUSTOMERANDCOMMUNITYACCOUNTABILITY ________________________________________ 40 OBSERVATIONS AND FINDINGS __________________________________________________________ 40

Accountable Care _______________________________________________________________ 40 Internal Customer Satisfaction _____________________________________________________ 41

RECOMMENDATIONS _________________________________________________________________ 41 PREVENTIONANDCOMMUNITYEDUCATION ___________________________________________ 41 OBSERVATIONS AND FINDINGS __________________________________________________________ 42

STAND-BY SERVICES _____________________________________________________________ 42 COMMUNITY EDUCATION ________________________________________________________ 42

RECOMMENDATIONS _________________________________________________________________ 42 GOVERNANCE,GROWTH,ORGANIZATIONALSTRUCTURE ANDLEADERSHIP ___________________ 42

Description of Best Practices ______________________________________________________ 43

OBSERVATIONS AND FINDINGS __________________________________________________________ 43

Governance and Regulatory Compliance _____________________________________________ 43 Growth Opportunities and Competitive Issues _________________________________________ 44 Organizational Structure and Human Resources _______________________________________ 44


OBSERVATIONS AND FINDINGS __________________________________________________________ 45

Executive Leadership ____________________________________________________________ 46 Operational Leadership __________________________________________________________ 46 Leader Development ____________________________________________________________ 47

RECOMMENDATIONS _________________________________________________________________ 48

COMMUNITY PARAMEDICINE – ALIGNING FOR THE FUTURE ________________________________ 49

PRINCIPLESOFEMSSYSTEMDESIGN __________________________________________________ 52

SEMS Status Quo is Unsustainable __________________________________________________ 53 Status Quo Improved (additional costs offset by improved productivity) ____________________ 53 SUMMARY OF RECOMMENDATIONS ___________________________________________________ 54

911/MEDICALCOMMUNICATIONS ____________________________________________________ 54 MEDICALFIRSTRESPONSE __________________________________________________________ 54 AMBULANCEOPERATIONANDCLINICALPERFORMANCE __________________________________ 54 MEDICALACCOUNTABILITY _________________________________________________________ 55 FLEETOPERATIONS ________________________________________________________________ 55 PREPAREDNESS ___________________________________________________________________ 55 TECHNOLOGYUTILIZATION _________________________________________________________ 56 RESOURCEUTILIZATIONANDDEMAND ________________________________________________ 56 SYSTEMFINANCESANDFUNDING ____________________________________________________ 56 SYSTEMCOSTSANDFINANCES _______________________________________________________ 56 CUSTOMERANDCOMMUNITYACCOUNTIBILITY _________________________________________ 57 PREVENTIONANDCOMMUNITYEDUCATION ___________________________________________ 57 GOVERNANCE,GROWTH,ORGANIZATIONALSTRUCTUREANDLEADERSHIP ___________________ 57 FIGURE 1.AMBULANCE SERVICE AREA ORIENTATION ______________________________________________ 5 FIGURE 2.TYPICAL EMSCALL PROCESSING FLOW _______________________________________________ 10 FIGURE 3.SAMPLE CONTROL CHART ________________________________________________________ 17 FIGURE 4.DRIVE TIME MAP ______________________________________________________________ 29 FIGURE 5.CHART OF DEMAND REQUESTS _____________________________________________________ 30 FIGURE 6.CURRENT ORGANIZATION CHART ___________________________________________________ 45 TABLE 1.AMBULANCE FLEET UTILIZED BY SEMS AT INITIATION OF CONSULTING PROJECT _____________________ 22 TABLE 2.MODEL PREVENTIVE MAINTENANCE SCHEDULE ___________________________________________ 23 TABLE 3.RESPONSE TIME CHART ___________________________________________________________ 33 TABLE 4.AVERAGED BASE CHARGES _________________________________________________________ 36 TABLE 5.OVERALL COMBINED EXPENSES _____________________________________________________ 38 ATTACHMENTS

A. Ambulance Benchmark Summary B. Leadership Benchmark Summary C. Sample Service Clinical Indicators D. NAED Accreditation 20 Question Guide E. Demand/Drive Time Maps



Schertz Emergency Medical Services (SEMS) operates as a department of the City of Schertz, Texas, providing Advanced Life Support (ALS) emergency responses to eight communities in the Greater Randolph Region.

SEMS has posted significant financial losses, causing City leaders to become concerned about the department’s financial stability. Fitch and Associates (Fitch or Consultant) was engaged by the City to conduct an independent review of SEMS’ operations and to evaluate service options for providing high-quality EMS support to this rapidly growing area of Texas.

SEMS is committed to providing emergency paramedic service, as well as enhancing its EMS system. In its assessment, Fitch reviewed SEMS’ communications equipment and call center processes; EMS responder, fleet and billing operations; staffing and overall management practices. Although SEMS’ billing processes were found to be within industry standards, and reflective of good practices for receiving reimbursement, several other operational areas were identified as needing improvement: call center and dispatch processes, staff scheduling and communications, fee structure, and fleet


Specifically, the Fitch study found :

§ Initial call information from two of the three SEMS public safety-answering points (PSAPS) is not recorded in real time, thus impeding accurate response tracking.

§ Compliance-to-contract standards of <8:59, at 90% reliability for all calls needs improvement, as it is estimated to be achieved approximately 61.1% of the time, system wide.

§ Call taking and dispatching processes are fragmented. Of the three PSAPs, only one utilizes Emergency Medical Dispatcher (EMD) personnel.

§ Excessive vehicle breakdowns and critical failures are contributing to high ambulance fleet costs. § Staff scheduling is not synchronized to demand times and is resulting in inefficiencies, as well as

high costs.

§ SEMS performs patient-billing services internally. This process appears to be working very well and collection amounts seem to be within industry standards.

§ Management-staff communication can be enhanced to improve morale and positively impact relationships

Recommendations include:

§ Tracking SEMS’ public safety answering points (PSAPS) with greater specificity to provide accurate feedback for improving response times and staff scheduling.


§ Matching staffing patterns with demand trends to yield higher operational effectiveness and lower costs.

§ Improving and increasing management-staff communications, while developing stronger leadership to create an environment where employees feel valued and motivated to achieve mission goals.

§ Continuing the Enterprise Fund option in governance, which seems to be working well for SEMS and is a better “fit” than other options.

§ Developing a more transparent and accountable EMS delivery model and partnership. § Customizing pricing with structures that reflect the true cost of service.

The existing program has strengths that can be utilized to support the strategic objectives of the City. The recommendations made throughout this report are intended to further enhance the clinical, operational and financial stability of SEMS in support of those objectives.



The City of Schertz retained Fitch & Associates (Fitch or Consultant) to conduct a comprehensive review of SEMS’ operating system. Fitch objectively benchmarked current system performance capabilities, as well as compared and contrasted current practices against industry recognized best practices.

Fitch & Associates used a seven-phase approach to accomplish the scope of work. The first phase launched the project. Phases 2-3 consisted of comprehensive data collection. Phases 4-6 involved data analysis and benchmarking. The final, seventh phase is complete with the presentation of this report. A description of each of the seven phases follows:

1. Project Initiation. The Fitch consultant team initially met with executive staff by phone and

subsequently in person to identify project goals and initiate the project activities. 2. Materials and Data Collection. The SEMS management team was forwarded a detailed

Information Data Request (IDR) that included key questions to be answered and requests for specific documentation and reports related to every area of the organization.

3. Onsite Interviews and Direct Observations. Fitch site visited the system and conducted

interviews with leaders of key functions (process leads), as well as external stakeholders and employees. The Consultant team also conducted field observations and observed radio traffic from the PSAPs and the SEMS Center.

4. Data Compilation and Client Input. All data from onsite interviews and the IDR were compiled

and organized for analysis. Emerging questions were directed to SEMS staff, as appropriate. 5. Benchmarking and Compliance Assurance. The department was compared with the Fitch 50

EMS System Benchmarks (see Attachment A). In addition, the organization’s local enabling legislation and practices were reviewed.

6. Define Future State. The report provides brief descriptions of improvement opportunities for

SEMS’ consideration.

7. Reporting Results. The information and analysis summary of the first six phases is compiled in a

report to the client.

The seven phases resulted in a comprehensive analysis that draws from both qualitative and quantitative data, addressing the specific needs outlined in the initial scope of work.




The SEMS service area (Figure 1) contracts with eight communities in three counties (Bexar, Comal and Guadalupe) just northeast of San Antonio, Texas. Schertz is the largest city in the area, which includes Randolph Air Force base. The total service area population approximates 107,500.

Described as a bedroom suburban community, its property use can be described as “suburban and rural” as part of the Randolph Metrocom surrounding an Air Force base. The primary service area is 220 square miles. The rural portion has new residential developments under construction. There are twenty acute care hospitals near and in San Antonio: Closest (and in SEMS district) is Northeast Methodist Hospital in Live Oak. Northeast Baptist, SAMMC, North Central Baptist, and Methodist Stone Oak Hospital are next.

Guadalupe Regional Medical Center in Seguin is the only hospital in Guadalupe County. Christus Santa Rosa-New Braunfels is in New Braunfels. In addition, Christus Santa Rosa - Creekside and Baptist Emergency Hospital - Schertz are two Free-Standing Emergency Centers under construction in or near Schertz.

Schertz City Council and City Manager John Kessel are anticipating a 60% growth in the City of Schertz by the year 2017. Live Oak and Universal City are maxed out for growth, while those municipalities on the outskirts are also projecting population growth.


Figure 1. Ambulance Service Area Orientation


SEMS is a department of the City of Schertz, Texas. It responds only to 911 requests for ambulance service. In addition to the City of Schertz, SEMS responds to 911 calls under contract with eight communities in three counties.

SEMS receives direct local (per capita) tax subsidies from all of its operations for the paramedic ambulance service it provides. User fees are collected for patient transports. Any carry-forward losses are the responsibility of the City of Schertz to resolve. SEMS ambulance fleet is licensed by the State of Texas as a paramedic-level transport service. Ambulances are primarily staffed by two Texas-licensed paramedics. The eleven-member administrative support staff includes an EMS Director, Assistant Director, Clinical Manager, Public Training and Outreach Coordinator, Executive Assistant, three Field Supervisors, and three individuals doing the billing.


SEMS has four 24-hour ambulances located throughout the service area. The data collected was not detailed enough to determine the call volume by jurisdiction or EMS station. Without this differential, it is difficult to assign work values or costs to individual locations. Back-up unit staffing is accomplished by reassigning units from one district to another or from neighboring EMS communities.


Current scheduled ambulance hours are 35,040 per year. Ambulance call volumes have shown an incremental increase each year for the last two calendar years (CY 2010 to CY 2011, 2.5%). In CY 2010, SEMS responded to 7,230 service requests that resulted in 4,570 ambulance patients transported. In CY 2011, there were 7,374 requests, with 4,640 of those resulting in transports. Of these, 72% of the transports were categorized as Advanced Life Support (ALS). Overall, the service achieves a Unit Hour Utilization (UHU) level of 0.14. According to demand charting (Figure 5), one station may be much busier than another at any given time. The cost per transport averages at $818.19.

SEMS does not routinely perform non-emergency responses or transports. SEMS provides occasional non-emergency transports for Northeast Methodist in Live Oak. Discussions with the new Baptist Emergency Hospital in Schertz are ongoing. Several private operators that are licensed to do business in the region provide these services.


An optimal EMS system is best designed from the patient's perspective. Patients should expect that the service will be engaged in illness and injury prevention, health education and early symptom recognition, in addition to responding to emergency and transportation requests. The EMS system should provide a rapid and appropriate response when a caller dials 911 and routinely provide medical instructions until help arrives. Medical first responders should be able to deliver rapid defibrillation, arriving within four to six minutes, with 90% reliability, in urban areas.

The arrival of a transport-capable ALS ambulance should occur within eight minutes and 59 seconds (8:59) for life-threatening emergencies in urban areas, 11:59 in suburban areas and 19:59 in rural areas with 90% reliability. Non-life threatening emergencies should receive a response within 12:59 in urban areas.

Patients should be transported to a hospital that can treat their specific condition. The EMS system should be externally and independently monitored, with participants held accountable for their responsibilities. Finally, the system should deliver good value for the resources invested.

The performance of SEMS and the regional EMS system is compared to these optimal system standards in the following section.




Milestone documents in the early development of Emergency Medical Services Systems (EMSS) included the National Academy of Sciences-National Research Council White Paper “Accidental Death and

Disability: The Neglected Disease of Modern Society,” the federal Highway Safety Act of 1966, and the

federal Emergency Medical Services (EMS) Systems Act of 1973. They guided the first 30 years of Emergency Medical Services System growth on the local, regional and state levels.

These early systems evolved from “neighbor helping neighbor” volunteer groups to highly complex response systems of physician extenders that function as part of the larger healthcare delivery system. In many areas of the country, EMS systems are struggling to meet clinical, operational and financial performance objectives. Ambulance services are primarily funded under a complex and flawed federal reimbursement methodology that does not cover the full cost of operations or the cost of readiness. Studies, including those prepared for the International City and County Management Association (ICMA) and the National Academies of Science Institute of Medicine, (IOM) document the underlying issues. No single identifiable source for industry standards of practice exists. State EMS regulations reflect minimum performance requirements. Other commonly accepted “standards” are drawn from a variety of sources, including:

§ “10 EMS Standards,” currently used to evaluate state EMS systems

§ “EMS Agenda for the Future,” developed by the US Department of Transportation § “EMS at the Crossroads,” developed by the National Academies of Sciences’ Institute of

Medicine 2006

§ “EMS In Critical Condition: Meeting the Challenge,” produced by The International City/County Management Association

§ “Community Guide to Ensure High Performance Emergency Ambulance Service,” published by the American Ambulance Association and the standards developed by the National Academy of Emergency Dispatch

§ Commission on the Accreditation of Ambulance Services § National Fire Protection Association

In like manner, there is no single universally best EMS system design model or single “best practice system” that can be identified.



Every EMS organization is comprised of multiple process areas to address specific functions of the operation. The Consultant team met with the specific process owners and process leads within SEMS, as well as with community, hospital and local stakeholders. A summary of the best practices and findings for each process is described below. Recommendations for enhancing activities are included where appropriate.

Specific benchmarks and SEMS’ performance in each of the following categories are described: § 911/Communications § Customer and Community Accountability § Medical First Response § Prevention and Community Education § Medical Transportation § Organizational Structure and Leadership § Medical Accountability § Ensuring Optimal System Value

The summary of these 50 benchmarks can be found in Attachment A – Benchmark Summary. SEMS clearly documents its achievement of 21 of these 50 objective measures. Several other measures are partially achieved. Approximately nine others remain to be accomplished.








Best practice EMS systems are organized to facilitate wire-line, cellular, voice over internet protocol (VoIP), automatic crash notification, patient alerting system devices and other public 911 access to the Emergency Medical Services System. Voice, video, telemetry, and other data communications conduits are employed, as necessary, to best enhance real-time information management for patient care.

A medically directed system of protocol-based Emergency Medical Dispatch (EMD) and

communications is in place. The call reception and EMS call processes are designed logically and should not delay activation of medical resources. Technology supports the caller being directed to the appropriate Public Safety Answer Point (PSAP) for the geographic location of the call. All 911 callers should receive National Academies of Emergency Dispatch (NAED) [or similar process] call prioritization and pre-arrival instructions. Automated quality improvement (QI) processes are used facilitating results being reported to clinical and operations executives in a concise manner.

Data collection facilitates the analysis of key service elements and these data are routinely

benchmarked and reported. Technology supports interface between 911, medical dispatch functions and administrative processes. Radio/cellular linkages between dispatch, field units and medical


facilities provide adequate coverage and facilitate both voice and data communications. There is interoperability between allied public safety agencies.

Communications Benchmarks

§ Public access through a single number preferably enhanced 911. § Single PSAP exists for the system.

§ Effective connection between PSAP and dispatch points, with minimal handoffs required for callers.

§ Certified personnel provide pre-arrival instructions and priority dispatching (EMD) and this function is medically supervised.

§ Data collection, which allows key service elements to be analyzed.

§ Technology supports interface between 911, dispatching and administrative processes. § GPS/AVL in each vehicle enables dispatch to alert the closest unit.

§ Radio linkages between dispatch, field units and medical facilities provide adequate coverage and facilitate communications.

Observations and Findings






Public access to emergency medical services throughout the service areas are provided via an enhanced 911 (E-911) system. Requests for service are initially received by one of three 911 centers or PSAPs, which are located in public safety centers. The City of Schertz is primary for EMS and also receives dispatches from Live Oak Police and Universal City Police. Emergency medical dispatch procedures recommended by the National Academies of Emergency Dispatch (NAED) were reported to be utilized by the City of Schertz PSAP. Its center is licensed to use the version 12.2 of the Medical Priority Dispatch System (MPDS) cards.

§ Schertz PSAP has the computerized “ProQA” version or the automated AQUA software, but has not been able to utilize the program due to technical issues with the Bexar Metro 911 regional Computer-Aided Dispatch (CAD) program that went operational July 2010.

§ Incoming calls are not classified according to Medical Priority Dispatch System (MPDS) priority codes; however, pre-arrival instructions are given on a regular basis.

§ Life-threatening and non-life-threatening emergency calls are not correctly differentiated, causing all calls to be dispatched as emergent.

§ The PSAPs in Live Oak and Universal City do not subscribe to EMD; their manner of call taking was to get the location of the emergency, general nature of the call, and dispatch the call. The key rationale for using MPDS is to correctly prioritize 911 calls by consistent use of medical protocols. Dispatch personnel are to stay on the line and provide pre-arrival first aid instructions on critical calls. These are to be routinely monitored through a QI process and actively supervised by a physician.


§ Neither the PSAPs, nor the SEMS dispatch center, are actively supervised by the medical director. § None of the communication facilities are accredited by NAED.

§ Of the applicable twenty focal review areas required for NAED Accreditation (Attachment D), only four could be documented at SEMS.

Figure 2. Typical EMS Call Processing Flow










911 Phone Rings

Call transferred to a medical call-taker

Call location pre-alerted to the dispatcher

First Responders and ambulance crew are notified Ambulance Enroute

Ambulance arrives on scene Crew departs scene

Crew arrives at medical facility Crew available for call

Event Identification Dispatch “Chute” Travel Treatment


EMS System Response Time

Ambulance Time-on-Task

§ The current call processing times could not be determined with accuracy. Because Schertz PSAP enters call data as it is dispatched from Live Oak and Universal City, these calls have no T0 to T5 (Figure 2) intervals. SEMS calculates response times from time of crew notification (T5) to end of travel (T7). At a minimum, SEMS should begin calculations with the time the call to

Telecommunicator (T1) is received to time of dispatch (T4) and then the time the crew is notified (T5). Analysis of the data will determine SEMS’ current ability to meet the 90th percentile of reliability (using the fractile statistical method).

§ The Regional TriTech CAD provides limited reporting capabilities to SEMS. Only the Schertz PSAP has access to a Regional TriTech CAD. When emergency calls come into 911, call information is forwarded to a mobile data terminal (MDT) in the ambulance for responding crews to see.


§ Each SEMS vehicle is equipped with a fleet tracking Global Positioning System/Automatic Vehicle Locator (GPS/AVL) system that is interfaced to the Schertz CAD. The AVL updates approximately every 10 seconds enabling the CAD to geographically select the closest available SEMS unit to dispatch. The Consultant team observed on multiple occasions the PSAP assigning a SEMS unit to an alarm, followed by a crew or SEMS supervisor contacting the PSAP to have it reassigned. This is the result of the PSAP dispatchers not re-assigning an alarm when a unit comes available after a dispatch is made. A SEMS supervisor must notify the PSAP to re-assign the alarm. Dispatchers should take the initiative to make sure the closest ambulance responds to an alarm, especially when an ambulance comes available and is closer after an alarm has been assigned.





SEMS operates on an 800/700 MHz IP system tied to the regional radio network. Radio channels are recorded in each of the three PSAPs. All ambulances have the 800 MHz radios capable of communicating with most of the first responder agencies. There is a VHF narrow band-compliant radio to communicate with first responders still on the VHF net. The VHF radios also allow communications on the statewide interoperability channels during state deployment. Each ambulance also has a cellular phone and mobile data terminals (MDTs) for receipt of CAD information. Each of the three local counties currently

operates its own radio system and allows SEMS access to each of the VHF repeater radio systems. § Medical control communications are primarily broadcast on the 800 MHz radio utilizing a

sub-set assigned for ambulance-to-hospital communications. Christus Santa Rosa Hospital – New Braunfels serves as the Medical Control point when physician orders are necessary. SEMS protocols are available at the base station, but have received no specific EMS base Station Control training.

§ Particularly in cardiac emergencies, when an EMS medic needs an order, and the

physician/nurse responding to communications is not familiar with SEMS protocols, they may ask the EMS medic to vary from protocol or administer medication not within the context of their protocols. A second communications call advising of pending arrival is made to the receiving facility, if it is different from Medical Control. Telemetry is sent via an in-unit modem attached to a cellular card direct to the hospital emergency department (ED). Once received in the ED, the base station physician or nurse can interpret and forward digitally to the Cardiologist on call for his direct view of the EKG from the field. SEMS medics have a high rate of positive ST-segment elevation myocardial infarction (STEMI) activations and have earned the trust of the facilities to identify STEMI patients accurately.


1. Live Oak and Universal City should transfer all calls for an ambulance directly to Schertz PSAP for EMD and dispatch.


2. Schertz PSAP personnel should follow the processes prescribed in MPDS, EMD, and dispatch based on type of call and emergency versus non-emergency.

3. Train selected 911 center staff to provide regular, medically supervised quality review of EMD activities consistent with NAED standards.

4. The PSAP dispatcher must be prepared to re-assign an alarm if an ambulance comes available and is closer, after initial dispatch of the call.

5. Implement the AQUA QI processes to ensure that 95% of those requiring pre-arrival instructions receive them in accordance with nationally recognized standards.

6. Strengthen prospective and retrospective medical oversight of the communications function. This should include routine case reviews by the medical director.

7. Develop necessary training, enforce procedures, and engage in quality assurance activities to insure that data produced by and contained in the SEMS CAD is accurate to an acceptable community standard.








Medical first responders in best practice systems are organized appropriately for the communities in which they serve. They function as part of an integrated response system that is guided by state and local legislative authority, and reflects accepted medical practice. First responders (paid or volunteer) are certified at a minimum EMT-Defibrillator or Medical First Responder (MFR) level. They are medically supervised by the system medical director, including participation in performance

improvement audits/activities. Defined response time standards exist for formal first responders and those response times are reported with those of the system. Early defibrillation capabilities are available for EMS first responders and in areas of high-density response areas such as airports, hotel complexes. When community or first response personnel are involved in patient care, a smooth transition of care is achieved.

Medical First Response (MFR) Benchmarks

§ MFRs are part of an integrated response system and medically supervised by a single system medical director.

§ Defined response time standards exist for MFR.

§ MFR agencies in accordance to National Fire Protection Association (NFPA) 1710 report fractile response times.

§ AED capabilities on first line apparatus. § Smooth transition of care is achieved.


Observations and Findings







Medical first responders play a critical role in life-threatening emergencies and support the

communities’ EMS efforts as part of the public safety mission. In the vast majority of North American cities, this role is funded by local tax dollars as part of the public safety budget.

Medical director involvement with first responder agencies, and the engagement of first responders in a system-wide QI process, is a must. All MFRs fall under the auspices of the SEMS’ medical director. MFR scope of practice follows the SEMS system medical protocols, which are intended to make patient care transparent and seamless.

§ Although fire chiefs in the system report having access to the Medical Director, they report not taking advantage of the opportunity as often as they should.

MFR services are provided by fire departments throughout the SEMS service area. BLS is provided by Marion and Lake Dunlap VFDs. EMT-Intermediate level response is provided by Cibilio, Braken VFD and Selma. Live Oak, Schertz and Universal City provide paramedic/firefighters most of the time. MFR paramedics and EMT-Intermediates can become credentialed to provide ALS services. All MFR vehicles are equipped with automated electronic defibrillators (AED).

The determination to send a MFR varies. For example, MFRs are dispatched on every emergency medical call in every service area except the City of Schertz. In Schertz, the fire department only responds to life threatening calls, unless the SEMS unit is not in quarters, then it will respond to any emergency.

Fire chiefs reported that their response times generally were less than five minutes for most responses. They were not able to specifically report the use of averaging or fractile calculations nor provide exact calculations, however. Typically, First Responder agencies’ response times are not measured using the fractile method in this service area. The fractile methodology is required by standards established by the National Fire Protection Association (NFPA) and the Commission on Accreditation of Ambulance Services (CAAS). An “average response time” does not provide the system with a reliable and consistent response measurement with which to gage the responder.

§ According to the Consultant’s interviews, transitions between first responders and ambulance personnel are generally handled professionally. One MFR agency reported that his staff “feels like when the EMS team arrives, it is ‘fire guys move over.’” That particular MFR agency expects a more respectful in-field interaction. Because SEMS rotates their staff between stations every month, the crews are not as familiar with the geography of their assigned location as they should be.

§ SEMS would benefit from a “Pit-Crew” patient care model. The Pit Crew model designates that each crewmember has a defined role, which they perform in practiced harmony. It limits


confusion, improves scene times, and improves patient care. For example, MFR-A is responsible for an immediate Basic Life Support (BLS) assessment and treatment. MFR-B is responsible for gathering history and prescriptions. MFR-C is responsible for retrieving additional equipment or assisting in setting up equipment, as required.


8. MFR leadership should take advantage of greater interaction with the Medical Director and actively participate in medical QI processes.

9. First Responder response times should be reported from call receipt until “wheel” stop on a fractile basis, based on NFPA standards.

10. SEMS crews should participate more often in initial and CEU level training with fire staffs to promote camaraderie and teamwork.

11. This system would benefit from pit-crew style patient care.








In a best practice EMS system, a mechanism exists to identify and assure adequate deployment of ground, air and other transportation resources meeting specific standards of quality, to assure timely response, scaled to the nature of event. There is capability to monitor safety and response time issues. Defined response time targets come into play, according to severity of call, and individual response components are measured by using both mean and 90th percentile measures.

Defined clinical service levels use current medical research to guide the medical interventions of the system. Changes to improve clinical practice can be introduced rapidly. Ambulances are staffed and equipped to meet the identified service requirements. Procurement, maintenance and logistics processes function to optimize unit availability. Resources are efficiently and effectively deployed to achieve response time performance for projected demand with due regard for taxpayers and end-users. When multiple agencies are involved, a smooth integration and transition of care is achieved.

The system is capable of scaling up day-to-day operations to meet the needs of larger, all-hazards events, based on threat and capabilities assessments of the likeliest events to occur in the state. It is essential that mass casualty responses involve logical expansion and extension of daily practices and not the establishment of new practices reserved for large-scale events.


Medical Transportation Benchmarks

§ Defined response time standards exist. § Agencies report fractile response times.

§ Units meet staffing and equipment requirements. § Resources are efficiently and effectively deployed.

§ There is a smooth integration of first response, air, ground and hospital services. § Develop and maintain coordinated disaster plans.

Observations and Findings





This section addresses key components of ambulance service operations and performance including clinical service levels; education and training; quality management; medical direction and accountability; fleet and logistics; preparedness; field supervision and crew configuration. Information regarding response times is presented in the section titled, Resource Utilization.







The State of Texas allows ALS programs such as SEMS to operate based upon The Texas Administrative Code, Title 25, Health Services, Part 1 of the Department of Health Services, Chapter 157 Emergency Medical Services. SEMS has been issued a license by the State of Texas for the operation of City of Schertz EMS License (# 094004) and is valid until October 31, 2013.





SEMS operates an EMS Training Academy. The Academy provides three initial EMT courses each year. Pass rates on state exams are quite high. SEMS’ education department offers initial EMT classes and provides for all of the EMT/paramedic recertification needs for each MFR agency at no charge to the department. Although the MFR agencies typically hire EMTs, they also have access to place members into these classes. Along with several adjunct instructors, most of the required CEUs for the National Registry of EMTs (NREMT) and recertification core programs are taught by EMS in house. A paramedic program was added in the current budget.

SEMS tracks recertification dates and the Clinical Manager prompts employees when they are due to recertify. Employees whose certifications have lapsed are not eligible for duty. The Clinical Manager maintains a file with everyone’s certifications and tracks expiration dates. A master database is kept with expiration dates that are reviewed monthly for upcoming expirations.

During the Consultant’s interviews, the field staff suggested that more relevant training topics should be offered. For example, two ambulances are equipped with extrication equipment and a Class A Foam System (CAFS) to provide immediate rescue when encountering rural and interstate vehicle crashes with entrapment and fire when fire apparatus is delayed. Training only takes place during new hire


orientation. Some field staff members reported receiving no skill maintenance training on extrication/CAFS since they were hired.

Automated External Defibrillator (AED) placement is a primary component of SEMS’ community education programs. AEDs are acquired by grants or fund raising and placed in key locations in the community. Every law enforcement vehicle has an AED, as well as gyms, community buildings and schools. SEMS monitors these devices to ensure they are accessible and in good working order.

Additionally, SEMS conducts monthly and on-demand first aid and community CPR training. The Clinical Manager reported that in 2009, there were nine cases of field cardiac arrest resuscitations and each “save” had a citizen performing CPR. Seasonally, SEMS participates with the health organizations to assist in providing flu and pneumonia immunizations. Regular screenings at local senior centers for blood pressure and other health related issues are conducted monthly. Although the key community intervention program is the placement of AEDs, none of the programs are set up with targets or other measures of success.

New hire orientation is overseen by the Clinical Manager and each field supervisor has a specific piece. Orientation lasts approximately 40 hours and includes ride time with a Field Training Officer (FTO). The Consultant team observed FTOs working with a new hire in demonstrating pieces of equipment and their hands-on practice of each item.





SEMS has a Clinical Manager. This Manager is the liaison between the Medical Director and the

caregivers. All Electronic Patient Care Reports (ePCRs) are reviewed by a shift supervisor before the end of shift for completeness and demographic accuracy. After the ePCR is routed to billing for coding, the Clinical Manager then has the FTOs perform a 100% review of every ePCR for protocol compliance. Cases of cardiac arrest, advanced airway use, STEMI/Stroke Alerts, helicopter requests and the use of scheduled pharmaceuticals receive additional review by the training department. If indicated, the Clinical Manager may select different events for review by the medical director. The medical director does not perform any random ePCR reviews independently.

The following are examples and recommended components of a quality program. The Sample Control Chart (Figure 3) is a useful statistical process tool for QI.


Figure 3. Sample Control Chart SCA ROSC @ ED UCL 0.29 CL 0.21 LCL 0.12 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0% 100.0%

7-Jan 7-Feb 7-Mar 7-Apr 7-May 7-Jun 7-Jul 7-Aug 7-Sep 7-Oct 7-Nov 7-Dec Date/Time/Period

Key Performance Indicators – These are based on call requests. Upon review of the Medical Priority Dispatch System (MPDS) data, it’s common to find call types fall into four categories:

respiratory, cardiac, traumatic injuries, and miscellaneous. By building performance measures for the first three categories and then doing targeted studies on the miscellaneous call types in category four, the system has continuous feedback of the EMS system’s clinical performance. Targeted Case Studies – Each month, targeted reviews on certain call types (e.g. Refusals, CHF, 12-leads, etc) provide a deeper look at clinical performance. This is also an effective way to target key call types or the miscellaneous category of call types. The results of these reviews can be directly tied into in-service training making it a pertinent and data driven educational exchange. This can also allow follow up later with another targeted review to see if things have changed and allows a more robust approach to meeting the content areas required for recertification. Episodic Review – Event-driven reviews round out the final piece of a sound quality program. This is

traditional quality assurance and includes sentinel events, complaints, and specifics like cricothyrotomy, pharmacological assisted intubations, etc. These activities should be a small amount of overall time commitment.

It is important that the person in the quality manager role understands quality improvement and statistical process control. Training at a local community college or in one of the EMS specific Six-Sigma efforts is recommended.


Making a transition to system-focused quality management and away from simply recording clinical errors can be accomplished, in part, with weekly quality meetings that follow an agenda structure similar to the following.

Review Key Performance Indicator (KPI) data – Each meeting should begin with a review of the EMS system’s performance scorecard. Are all processes in statistical control? Are there any statistical variances worthy of exploration? What are the results of improvement efforts?

Updates on targeted reviews – As targeted reviews are conducted each month, updates on the progress, new data and findings should be included in the weekly meeting. What are the results? Are any system or process changes indicated? How can the data be deployed most effectively through education?

New Directions – Based on the results of KPI data, targeted reviews, or other indicators, the committee should check to see if there are areas requiring further exploration or a change in course. This may include discussion of whether the performance measurement system in place is capturing critical data adequately.

QI Update – The last order of business includes a summation of any complaints or individual call reviews conducted. This should be a small portion of the total meeting time and is done in the spirit of improving processes and systems and an emphasis on achieving best performance targets. Finger pointing at individual errors should be minimized.

Implementation of a quality approach similar to the one described will provide SEMS and the Medical Director with a much more in-depth perspective on the clinical quality of the system. This approach can also be expanded department-wide for addressing operational aspects of service delivery.


12. Key staff members assigned to the quality management function should be trained in quality improvement and statistical process control.

13. A scorecard should be developed and used on a monthly or quarterly basis so that data can be easily utilized to improve the patient outcomes.

14. Effectiveness of a quality improvement program is required to maintain modern practice standards. EMS participation in larger scale research projects within one of the hospitals should be a focus for the department with associated resources identified.


Dr. R. Donovan Butter, D.O. is the designated Medical Director for SEMS. Until recently, he was active as an emergency room physician and has experience with pre-hospital EMS systems. Now that Dr. Butter no longer has an emergency department affiliation, SEMS may want to recruit a new medical director


actively engaged in the practice of emergency medicine and who has an affiliation with the medical control center.

§ SEMS uses a service contract for the medical director position. The language is vague and does not stipulate a minimum number of hours per month for EMS, however.

§ A minimum of 25 hours is necessary for a medical director to be active and accomplish the minimum tasks required. The Description of Services and the Performance Measures listed therein should be updated and spelled out in additional detail. A 10% review of ePCR’s reviews should be performed and the evaluation based on a flow chart of specific criteria, with charted results promptly reported to the Director.

§ The role of medical director in this system is described as moderate. He is less than moderately involved in the actual review of medical control tapes and PCRs. The QI focus for the

department is handled primarily by the SEMS Clinical Manager who reviews individual cases internally. Based on those reviews, personnel are provided feedback with and without the medical director’s direct involvement. He reviews the Medical Priority Dispatch protocols, but he is not actively engaged with the communication centers or the first responders. (Although both the communication center and the MFRs report they have access to the medical director, they do not participate.)

§ Call reviews should become an integral part of field provider meetings involving the medical director. Additional efforts should be made to conduct positive call reviews of all those involved (e.g. medical communicators, first responders, field personnel, and hospital care providers). Schertz EMS should consider establishing an assistant medical director position that would be filled by an EMS fellow. EMS fellows are physicians seeking an Emergency Medicine board subspecialty in prehospital emergency care by participating in a one- or two-year program. Approved in 2010, the first graduates will be taking their board exams in October 2013.

Accreditation Council for Graduate Medical Education approved EMS fellowship program for physicians requires a minimum of twelve months of clinical experience as the primary or consulting physician. In that role, the fellow is responsible for providing direct patient evaluation and management in the prehospital setting, as well as supervision of care provided by all allied health providers in the prehospital setting.

The National Association of EMS Physicians (NAESMP) lists 58 EMS fellowship programs. Five are in Texas

§ Dallas: University of Texas Southwestern

§ Houston: University of Texas Medical School at Houston

§ San Antonio: University of Texas Health Science Center San Antonio

§ Temple: Scott and White / Texas A & M Health Science Center College of Medicine § San Antonio Military Medical Center EMS Fellowship (approved Feb 2013)






An area of high liability that should be monitored through Key Performance Indicator (KPI) reports and QI is patient refusals. This is where a patient has activated the 911 system requesting an ambulance to be transported to the hospital.

Benchmark standards in other similar sized systems experience patient refusal rates from 12% to 18%. Non-transport rates for the last three-year period were 26.6%. This includes outright refusal (16.7%), plus refusals after treatment was rendered, that is, calls cancelled prior to arrival or no patient found calls are not included in this calculation (9.9%).

To authenticate the validity of patient refusals, several actions can be initiated. Each case in which the patient “refused” care or transport should be reviewed (100% audit). This should include a review of the PCR to determine if protocol was followed and if a valid assessment took place. It should be determined if the patient placed a second call for an ambulance within 12 hours of the refusal or if they obtained private transportation to the hospital. As a courtesy follow up, a phone call to the patient should be made within 24 hours to determine if any change has taken place in the patient’s condition.


15. Develop a long-term succession plan in order to recruit a medical director that is actively engaged in emergency medicine, preferably located at the medical control center. 16. Consider utilizing an EMS Fellow as assistant medical director.

17. Medical Director Contract should be expanded and hours increased.

18. Regularly measure both clinical and operational skills and use appropriate remediation processes to ensure all staff maintains required competencies.

19. Conduct a 100% audit of patient refusals to review and validate the decision to not transport.


The fleet is one of the most important resources of an EMS system and a significant non-personnel expense. Making sound purchasing decisions and conducting frontline and preventative maintenance is critical to reducing lost unit hours and keeping ambulances in service and available for assignments. The fleet consists of twelve various types of vehicles. It includes four in-service ambulances, six support units, and two reserve ambulances. In-service medical units and back up units are a mixture of Type 3 transport capable ambulances. Odometer readings on the units range from 115,000 miles to over 302,411 miles. The average mileage per truck is 167,692. The age of the fleet ranges from 1999 to 2007 model years. Ambulance vehicle conversions (build out of the patient care areas) are mostly from the manufacturer Med-Tech, mounted primarily on Ford and International chassis. Visual inspection revealed the fleet to be in fairly good condition, with the exception of the oldest ambulance, which looked worn and aged (manufactured by National).


There is no quantifiable capital fleet replacement program in place. Vehicles are replaced when the City of Schertz Council has funds available to do so. Presently, there are two ambulances being built and will be delivered early in 2013. These will replace the two oldest and most costly vehicles.

Best Practice EMS systems have fleets that represent 130-150% more than the peak number of units staffed on a daily basis. The system in-service peak is four units. The SEMS fleet approximates 150% of peak staffing. However, consideration of staffing for peak demand will drop SEMS under the

recommended number of ambulances. An increase in fleet size may need to be considered.

Fleet management/mechanic/driver training, preventative maintenance, fleet standardization, quality control driving systems and fleet performance monitoring are areas needing improvement.



The fleet manager position has been in place for just over one year. The current fleet manager is

certified as an Emergency Vehicle Technician (EVT). There are several other mechanics in EVT training at this time. One mechanic has one AES certification and two other mechanics with six ASE certifications. They would like to be factory trained by the ambulance manufacturer for maintenance on the patient care module. The city shop is a six bay, four lift drive-in facility. The city fleet is responsible for 222 vehicles. Emergency services have priority in the shop for maintenance over other city service vehicles. Table 1 is a listing of vehicles utilized by SEMS at the time the consulting project was initiated.

§ The ambulance fleet is beginning to show head gasket failures and brake work is constant. Additionally, EMS drivers tend to pop curbs and break side mirrors. Even cab mounts have had to be replaced. The six ambulances consume over 33% of the maintenance budget and time over the rest of the fleet. Preventative Maintenance (PM) schedules were lacking. Until recently, the City hired a Fleet Manager. The EMS preventative maintenance schedule is as follows.

o 5,000 miles (diesel) - replace filters o 6,000 miles (gas) - replace oil and filters o 10,000 miles (diesel) - replace oil and filter

o Synthetic oil products are utilized in the ambulances

o An hourly maintenance schedule is being prepared for vehicles that idle a lot such as ambulances

§ It is doubtful that the City mechanics understand the PM schedules to follow for the

maintenance of the patient care box and its related components. Optimal fleet ratios can only be achieved with world-class EMS fleet maintenance.

§ The SEMS fleet is not standardized and contains units manufactured by multiple vendors. The fleet is not well maintained compared to similar operations.

§ Fleet maintenance recordkeeping has been hit and miss in the past. Stacks of maintenance files need to be input into the relatively new fleet maintenance computer software. Current work is entered as it is performed and the records are slowly getting caught up. Based on the new


system, the fleet manager will be able to track cost per mile on each vehicle and make recommendations on replacing fleet units as their incremental costs begin to rise.

Table 1. Ambulance Fleet Utilized by SEMS at Initiation of Consulting Project

Schertz EMS Truck Manifest

Truck # Year Make Type Mileage (Oct 2012)

270 2004 International Type 3 302,411 271 2007 International Type 3 147,889 272 2007 International Type 3 115,131 273 2007 International Type 3 136,623 261 2001 Ford Type 3 251,154 262 1999 Ford Type 3 255,350 OPS 1 2007 Chevrolet 2500 77,073

OPS 2 2008 Chevrolet Tahoe 37,431

Clinical 2003 Ford Expedition 126,655

Staff 1 1998 Chevrolet 2,500 128,023

Supervisor 2009 Chevrolet 3,500 99,186

Gator - Land Pride 4,210 273 Hrs





Emergency vehicles are typically driven long and hard. Best practice preventive maintenance programs keep vehicles on the road and out of the shop. Maintenance is also critical for matching time frames for capital replacement schedules.

Cost per mile is an important tool for monitoring effectiveness of maintenance. It should include all costs associated with the operation of a vehicle and include fuel costs measured congruently over the life span of the vehicle. Management reported an average cost per mile to be $0.83. This result is slightly higher than other operations the Consultants have observed, but this calculation was determined with a short period of data and not over the life span of the vehicle and may not be comparable. The cost per mile should be reduced by following the tables and recommendations below.

Efficient and cost effective fleets use sophisticated Preventive Maintenance (PM) processes in addition to daily crew checks. This allows for uninterrupted service and will address repair issues before they occur and impact service. A minimum 26-point inspection is recommended to be conducted every 3,000 miles and at other intervals as illustrated at Table 2.


Table 2. Model Preventive Maintenance Schedule Service Level Mileage Interval Service Points

Daily n/a Check lights, signals, warning systems, fluid levels, tire pressure, AC & heating systems, wipers, brake pedal travel, & monitor engine condition. A 3,000 Change oil & filters, check suspension, belts, alternator, tire & break wear,

& load test battery.

B 6,000 All A items, plus check suspension & differential, fuel filter, brake rotors & pads.

C 9,000 All A & B items, plus replace belts, fuel filters, air filters, transmission fluid. D 50,000 All A, B, & C items, plus replace A/C compressor & dryers, hoses, oil bypass

lines, repack bearings, replace shock absorbers.

E 100,000 All, A, B, C, & D items, plus replace water pump & radiator.

Best practice programs tend to check vehicles every 3,000 miles and have a graduated inspection and replacement schedule as the vehicle increases in miles. By taking a comprehensive approach, the fleet department has the ability to catch potential maintenance problems before they cause vehicle failures. When an outsourced vendor is utilized, the PM should follow a prescribed checklist that is signed and dated by the vendor. Vendors must be monitored to assure completion of that check sheet is followed. This is necessary in the event of litigation as a result of a mishap. These check sheets should be filed by vehicle and maintained throughout the lifespan of each vehicle to evaluate its cost effectiveness. This is also a common mechanism to mitigate risk should litigation occur.

Cost per mile should include all labor, parts and fuel consumed by each vehicle. Mileages must be recorded monthly and a running average should be established for comparison each month. Vehicles with consistently higher averages should be replaced.





SEMS does not provide driver training for the staff. Every staff member who drives an emergency vehicle must participate in an Emergency Vehicle Operator Course (EVOC) to manage the inherent risks of operating EMS units. This training should be conducted during new hire orientation. Scheduled refresher courses to ensure maintenance of driver proficiency should occur annually, or as needed for


Emergency vehicle driver proficiency and awareness is critically important for two reasons: EMS

accidents are the leading cause of death for EMS providers and poor driving results in increase wear and tear, body damage, and accidents. Annual refresher training is beneficial for maintaining skills and keeping crews conscious of their performance and the maintenance of the vehicles. Although the incidence of accidents appears to be low for SEMS, the types of unscheduled repairs required of ambulances indicate that the vehicles are being driven hard necessitating excessive repair and maintenance costs.










SEMS does not use a monitoring system such as a “Drive Cam” or other “black box” technology that provides behavioral feedback and accountability for emergency response vehicle operators. When implemented effectively, these types of systems have reduced accident rates dramatically, lowered maintenance costs by as much as 10-20%, and can extend the life of parts (i.e., brake pads). There are several products available that can provide this information.







SEMS does not measure critical failure rates. For quality assurance purposes, measuring the systems compliance with its PM program is essential. Additional measures may include time to complete vehicle service at the 90th percentile. A common measure of fleet performance that has a direct impact on operational effectiveness is the number of vehicle critical failures per 100,000 miles. The median for Coalition of Advanced EMS Systems (CAEMS) most recent national study is 2.00 vehicle failures per 100,000 miles.

Another important measure is the number of vehicle collisions per 100,000 miles. The CAEMS Benchmark participants report a median of 1.13. SEMS does not maintain accurate information regarding accidents so an analysis could not be made. SEMS would benefit from hosting a NAEMT EMS Safety Course and sponsor several of their staff as instructors, incorporating this program into their new hire orientation.


20. Maintain the proper ratio of correct vehicles in reserve for back up and special duty functions. 21. Develop a fleet replacement program in the budget and plan for regular replacements. 22. Calculate age, miles and cost per mile in determining when a vehicle is scheduled for


23. Acquire an electronic maintenance reporting process that allows for rapid review and recording of fleet issues.

24. Evaluate the cost benefit relationship of high performance logistics processes. 25. Ensure fleet maintenance processes are continuous.

26. Implementation of black box technology would enhance the service’s ability to monitor and provide feedback on driving habits; reduce vehicle wear and tear and maintenance costs. 27. Immediately implement an Emergency Driver education program for SEMS drivers. SEMS should

invest in both a quality control system and associated training to improve safety and reduce vehicle collisions.

28. Anytime a vehicle sustains damage or is involved in an accident, a report should be filed and a determination of preventability should be made.

29. Review driving policies to bring into line with EMS safety training and implement and enforce use of spotter when vehicle is in reverse. Have a “no tolerance” policy on safety infractions.



September 11, 2001 and several large-scale natural disasters in the United States have stimulated increased funding for all facets of emergency preparedness. SEMS preparedness efforts are above ambulance industry norms. SEMS has been proactive, making staff preparedness training a priority ensuring that they have basic safety and security knowledge of the communities they serve. Records indicate that all of the SEMS staff has been certified in National Incident Management System (NIMS) Incident Command System 100, 200, 700 and 800 levels and in HAZ-MAT Awareness Level. SEMS leadership has had additional training in NIMS 300 and 400 levels. The clinical department should consider taking the HAZ-MAT training up to the Technician level.

EMS systems should have an all-hazards preparedness approach, combined with knowledge of the unique risk factors faced by the communities they serve. By weighing likely and less likely risks, it’s possible to strike a balance in preparedness efforts. Clearly, EMS systems must maintain focus on day-to-day operations, while considering system enhancement for the far more frequent events they encounter.

Interagency training is of utmost importance. Recent media reports have indicated that in multi-jurisdictional operations, the Incident Command System (ICS) procedures failed. After-action reports demonstrated the lack of practice made ICS cumbersome and awkward. Our experience indicates that the success of a large-scale event is predicated upon policies, activities and practices that are used daily. Based upon the fact that SEMS and the local hospitals will be the recipient of any major disaster,

expanded, fully integrated training should be a priority.

The unique integration aspects of EMS and the larger system merit a separate evaluation of how to better integrate planning, exercise, risk mitigation and staffing those functions within the larger healthcare delivery system. Such an evaluation was beyond the scope of this study.


30. Continued joint training with other agencies such as fire and police, as well as PSAPs and hospitals, should be conducted at defined intervals.

31. Expand education to include a HAZ-MAT requirement for the Technician certification. 32. Evaluate the EMS role and the opportunities associated with risk evaluation and mitigation

planning for the larger healthcare system.

33. Once a year, SEMS, along with their respective hospitals, should practice a combined community disaster drill.







The following section discusses workforce-related issues including staffing, crew configuration and shift structure.


Figure 1. Ambulance Service Area Orientation

Figure 1.

Ambulance Service Area Orientation p.9
Figure 2. Typical EMS Call Processing Flow

Figure 2.

Typical EMS Call Processing Flow p.14
Figure 3. Sample Control Chart  SCA ROSC @ ED UCL 0.29 CL 0.21 LCL 0.12 0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%90.0%100.0%

Figure 3.

Sample Control Chart SCA ROSC @ ED UCL 0.29 CL 0.21 LCL 0.12 0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%90.0%100.0% p.21
Table 1. Ambulance Fleet Utilized by SEMS at Initiation of Consulting Project

Table 1.

Ambulance Fleet Utilized by SEMS at Initiation of Consulting Project p.26
Table 2. Model Preventive Maintenance Schedule  Service  Level  Mileage Interval  Service Points

Table 2.

Model Preventive Maintenance Schedule Service Level Mileage Interval Service Points p.27
Figure 4. Drive Time Map

Figure 4.

Drive Time Map p.33
Figure 5. Chart of Demand Requests

Figure 5.

Chart of Demand Requests p.34
Table 3. Response Time Chart                 (8 minutes 59 seconds)  Response Times   %  2009  69.53%  2010  67.97%  2011  55.07%  2012  55.68%

Table 3.

Response Time Chart (8 minutes 59 seconds) Response Times % 2009 69.53% 2010 67.97% 2011 55.07% 2012 55.68% p.37
Table 4. Averaged Base Charges

Table 4.

Averaged Base Charges p.40
Table 5. Overall Combined Expenses  FY 2011 Funds

Table 5.

Overall Combined Expenses FY 2011 Funds p.42
Figure 6. Current Organization Chart

Figure 6.

Current Organization Chart p.49


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