Project Summary
The City of Erlanger’s Advanced Life Support (ALS) System is designed to provide supplemental advanced medical care to assist the Emergency Medical Services of the cities of Erlanger, Edgewood, Elsmere, Crescent Springs, and Villa Hills as well as portions of unincorporated Boone County, Kentucky. The five ambulances that provide Emergency Medical Protection for the residents of these areas provide Basic Life Support (BLS) only. This means that the medical professionals are trained only to the Emergency Medical Technician (EMT) level and can only provide basic cardiac defibrillation, oxygen therapy, and basic airway protection procedures. The Erlanger Advanced Life Support System automatically dispatches a trained and qualified paramedic in a staff car to respond with these ambulances. Should a patient need critical care that exceeds the training of the EMTs, the paramedics leave their vehicle and ride in the back of the ambulance with the patient as they are being transported to the hospital. In this way, the patient can receive advanced drug therapy, advanced cardiac defibrillation-pacing-monitoring, IV fluids, and advanced airway protection from the more highly trained paramedics.
Operating Advanced Life Support ambulances is very expensive. The majority of the patients treated by ambulances do not need this level of care; they require BLS level care only. It is not cost efficient for any of the individual ambulance services to provide their own ALS ambulance service. The cooperating agreement of providing paramedics to respond with the ambulances makes it possible for these ambulances to achieve ALS service when the patient needs advanced care. In return it exposes the ALS service to enough patients and call volume that the operating cost is able to be spread over a larger group of jurisdictions.
Project Description:
Background
The City of Erlanger has provided a Basic Life Support (BLS) Ambulance since 1970. The cost of providing Advanced Life Support (ALS) was too expensive to
maintain, and had, in the past, been unnecessary to maintain. Supplemental ALS service was provided free of charge to all of the ambulances throughout Northern Kentucky through a private non-profit provider that was associated with the local hospitals. Any cost incurred for providing the ALS service was absorbed by the hospitals or diffused through patient billing. In 2002 this agreement changed. The non-profit provider advised the local ambulance services that in addition to patient billing, they would begin charging the ambulance providers as well. This was a difficult financial burden for the ambulance services to absorb. What made the matter worse was the rate at which the cost to the ambulance services increased from 2002 to 2003. The response of some of the larger ambulance providers in Northern Kentucky was to upgrade their ambulance
service from BLS to ALS so they would not be dependent upon the non-profit provider. Since the non-profit ALS provider had now lost its largest customers, its response was to drastically raise the cost of providing the service to the smaller cities and ambulance providers who were still dependent upon their service. To make matters even worse, the non-profit could not advise the smaller ambulance providers to what extent the cost would rise or when the cost would stabilize. Erlanger Fire/EMS Chief Bill Martin spent numerous hours in negotiations with the non-profit and the surrounding cities in an effort to stabilize the problem.
Need and Objectives
In 2004, Chief Bill Martin retired and Asst. Chief Tim Koenig moved up to fill his position. After further negotiations with the non-profit, the City of Erlanger decided that it would need to provide its own ALS service. The City did have several concerns with this proposition. First, while the city would have a better projection of cost and more control over its ALS service, the cost still would be very substantial. Second, since cost was a limiting factor, there was concern about how much the city would be able to pay paramedics and, therefore, what quality of employees the city could hire. Third, since Erlanger was the largest remaining customer of the non-profit, by going ALS, there was a fear that the burden would be increased to surrounding cities by the non-profit to the point that they would not be able to afford ALS service at all. Chief Koenig and newly hired EMS coordinator Captain Donna Sparks spent a tremendous amount of time searching for viable solutions to these problems.
Evaluating Cost
The first step in the process was to get a firm grip on the potential operating costs and projected revenues. Captain Sparks studied department statistics and worked closely with Medical Claims Assistance (MCA), the private billing company that the City of Erlanger contracts with for EMS billing. Together they calculated the amount of EMS calls the City of Erlanger ambulance service made, what percentage of these calls were ALS calls, what a fair increase would be to bill for ALS calls, and project what additional income would be generated by ALS billing. Captain Sparks also investigated the cost
related to contracting with a physician to serve as a medical coordinator as well as the cost of equipment and supplies. Chief Koenig and Bill Scheyer (City Administrator) were in the process of examining the cost of employing a full time paramedic for twenty four hours a day, seven days a week. Bill Scheyer, Chief Koenig, and Captain Sparks would then compare and evaluate their findings.
Ensuring a Quality Program with Quality Employees
The committee determined that it is not economically feasible to operate the system on a full time paramedic staff. They had to employ part time employees in addition to career staff in order to accomplish their goals and keep the cost achievable. Not only did this decision keep the operating costs practical it solved another of the problems that the committee was facing: How do we lure quality, experienced paramedics to a brand new service? The part time positions offered not only a very desirable hourly rate, but also paid into and increased the paramedic’s state retirement incentive. By doing this, the city was able to employ very well respected and
experienced paramedics in a part time capacity. These paramedics were very pleased with their current full-time employers and would not have left their service for another full time job. Presenting the ability to increase their earnings and retirement benefits on their day off, yet still remain loyal to their full time employer was beneficial to not only the newly hired paramedics, but to the City of Erlanger. The cost of benefits saved by employing part-time paramedics was so significant that it not only made hiring one paramedic per shift feasible, it made the possibility of hiring two paramedics per shift an attainable goal.
Assisting Surrounding Departments
With the realization that the city could hire additional paramedics per shift came the possibility to help out some of the smaller, surrounding cities. Once again a study was conducted to determine the amount of ALS calls that the ambulances from these services completed. After all the data was collected, it was noted that Erlanger only completed about 1/3 of its calls as ALS responses. Many of the surrounding cities had approximately the same ALS completion rate. If Erlanger followed convention and fully converted their ambulance from a BLS unit to an ALS unit, they would not be able to assist surrounding cities. Furthermore, approximately 66% of the time, the city would be paying a paramedic at advanced life support rates, to complete basic life support duties. This was determined not to be the wisest use of resources. It was determined that the best use of this resource was to maintain a tiered EMS system. In this system, a paramedic would be put in a staff vehicle and follow the ambulance to the scene. If the patient needed ALS care the paramedic would ride in with the ambulance crew. If the patient was determined to only need basic EMS care, the BLS ambulance crew would transport the patient to the hospital without the paramedic on board. The paramedic would remain available for the next ambulance call in the area. This system would allow the City of Erlanger to not only provide ALS service for their own ambulance, but make it available to supplement BLS ambulances for surrounding areas.
Implementation
This program began on January 1st, 2005. The first participants were the City of Erlanger Fire/EMS department, Elsmere Fire District and Point Pleasant Fire District. Erlanger would staff one paramedic to cover these three ambulance providers. The City of Erlanger would also staff two paramedic units during peak hours to ensure all calls for assistance were answered. In the first six months of the program, the Erlanger ALS units completed 507 calls for assistance. Only 54% of these responses were completed with the Erlanger BLS ambulance. The remaining 46% of the calls were completed with the Elsmere and Point Pleasant ambulance services.
After the first few months, the program proved so successful that the city was approached by two other ambulance services to begin to provide supplemental ALS service for them. Erlanger officials agreed that it was feasible to do so and on July 1st, 2005, the City of Erlanger began to offer ALS service to the Crescent Springs Fire Department and the Edgewood Fire Department. Between July 1st and December 31st, 2005, the City of Erlanger ALS service responded to 721 calls for assistance. Only 296 (41%) of these calls were to the City of Erlanger. For the year of 2005, the ALS service completed 1228 advanced life support calls, 669 (54%) of which were to support other agencies. The city was able to assure that of the 1,718 total ambulance calls within the City of Erlanger, the 569 (33%) that required advanced life support were provided for by Erlanger’s own service, without outside assistance.
Measuring Success
The success of this program has been measured by two standards: Operational Cost and Performance. The program is funded through two sources. The first source of funding for the program is through patient insurance billing for completed transports. The second source is through contracts with the four ambulance services of Crescent Springs Fire Department, Edgewood Fire Department, Elsmere Fire Department, and the Point Pleasant Fire Department as partners. The City of Erlanger also pays into the system as a partner in the project. Having two sources of funding and reducing staffing costs by employing part-time paramedics has kept the cost reasonable for all five entities that utilize the service. This cost effectiveness has been determined by comparing the current cost upon the individual identities now to the proposed contract costs of the non-profit corporation and the projected costs of each ambulance service going ALS on their own. With each agency involved only completing about 33% of their total ambulance calls as ALS, the practice of sharing this service has proven very cost effective. The City of Erlanger has been able to maintain this program for a cost that is substantially less than the current contract proposed by the non-profit organization.
Sharing the service has not detracted from its performance during the first fifteen months of operations in which the Erlanger ALS service has completed 1642 calls. Staffing at least two paramedics per shift has ensured that Erlanger ALS has not failed to respond to a single call for help. Indeed, the Erlanger paramedics have completed 23 calls as mutual aid responders to assist other agencies that are not within contract because their paramedic services have been on other calls. Periodically, the paramedics and Captain Sparks pay visits to the other departments to ensure that they do not have any complaints regarding service, appearance, or working relationships. The other four contracted departments have been extremely pleased with the program and the personnel.
Customer complaints have been very few. When a complaint is received, Captain Sparks moves very quickly to resolve the problem and ensures complete follow up of the
complaint with the customer. As a result, the city has actually received more phone calls to compliment the caring and professional paramedics than they have received
complaints.
Future Plans
The Erlanger ALS service’s primary goal is to maintain the quality service provided in the Emergency Medical Services field. Bill Scheyer, Tim Koenig, and Donna Sparks continue to work to limit the cost of providing the service to all of the partner cities. There is also a contingency plan being developed which will expand the service and assist other cities that may need an alternative to contracting with a non-profit or private ALS service provider.