Fitch Study Excerpts - Objective Perspective on our Preparedness

[helicopper 1,050]

Some very interesting observations about our state of preparedness in Westchester County. I'll let the comments start the discussion.

The EMS system design in place in 1981 for many communities remains the one that exists today. In the interim since 1981, systems have evolved with changing demands, but in a more incre-mental manner and rarely planned. Westchester County is reflective of this evolution where multiple delivery models and provider types vary from community to community.

The Westchester County EMS system is a mix of multiple agencies attempting to deliver quality emergency medical services. The challenge for the emergency services organizations is that service delivery is non-integrated and independent services function at disparate levels of care. This means that care quality delivered to the visitors and residents of Westchester County in not uniform.

To further complicate the situation, there are multiple primary points of contact (9-1-1 pri-mary Public Safety Answering Points) and that means that no efficiencies are maximized throughout the multiple dispatch centers. Tradition and the need to have communications that are closely related to field operations are driving the overall system mindset. This creates the over abundance of primary PSAPs.

The 39 primary Public Safety Answering Points (PSAP) are in 39 different police departments that service the Westchester County community. Like many 9-1-1 centers, the County's are associated with law enforcement. The quantity of 9-1-1 centers for a county the size of Westchester is very abnormally high.

The inconsistent approach to ambulance assignment, distribution, and determination of requirement are not conducive to optimal performance. The two major concerns of having disparate methodologies for patient assessment of acuity and of ambulance and emergency services personnel assignment are:

1. The potential points of failures are an exponential combination of the different methodologies.

2. The lack of consistency makes it impossible to have both metrics by which the services are held accountable and quality assurance and improvement based on consistency checking.

Half (50%) of the dispatch centers follow the recommended response. The other half (50%) added a combination of town identification or police service and town identification. For the seven-digit response, the standard was only followed by less than a third (32%) of dispatch centers.

Fundamentally, the system has challenges due to the historical development of EMS as an ancillary emergency service. This, coupled with a historical ownership of dispatch functionality by law enforcement and the natural desire to keep and maintain all of the independent dispatch centers, has led to a disparate emergency medical response.

The Westchester County EMS system does not have a uniform or organized first response component. What does exist is community specific and may involve law enforcement with AEDs, volunteers responding from home or a staffed station, or career fire service personnel. Training may vary from layperson first aid through paramedic level care. This significantly limits the life saving potential of the system and has direct effect on the opportunity to reduce morbidity and mortality.

Westchester County emergency services do not have an established response time measurement system or response time goal for compliance. The only national standards are NFPA (National Fire Protection Association) 1710 (career departments) and 1720 (volunteer departments). The NFPA standard for the fire service establishes time intervals for components of a medical first responder response, which would result in a call receipt to arrival at the call location of six minutes.

Westchester County is a perfect example of an unplanned system design that has evolved over time. Volunteer, combination volunteer/paid, and full-time ambulance agencies serve the County. The "system" that exists today is not really a coordinated EMS system, but a patchwork of small mini-systems that are contiguously located in a County jurisdiction. Individual providers and EMS services are trying to serve their citizens to the best of their individual ability, but not benefiting from any of the advantages of being a true coordinated EMS system.

Westchester County Emergency Services data shows there is 150 ambulances in the County potentially available for service and 27 paramedic intercept units. Some of these units may be secondary resources and not the first line resource.

Westchester County has a disproportionately large supply of resources as a result of every community providing its own service. The County does not benefit from efficiencies and the economy of scale found in a regionalized system design. There are roughly 7.9 transport capable ambulances for every 50,000 residents.

Westchester County generates more than 100,000 EMS responses annually. Each community is responsible for its own EMS delivery and the result is a surplus of ambulances in the County, but only four providers respond to more than 2,300 calls per year and 27 agencies respond to less than 1,000 per year. The number of ambulance per capita is two to three times reported benchmarks. Westchester County does not benefit from the efficiencies and economies of scale of a more regionalized EMS system.

There are three concerns with the model of using a paid paramedic supplemented by volunteers. The following is a description of each concern.

· First, in many of the Corps we spoke with, the paid position was not a Full Time Equivalent (FTE). This meant that paramedics had to work at other jobs to make a living wage. Often that other job was another Corps or commercial ambulance service in the County. This results in multiple organizations drawing from the same available workforce pool, which reduces staffing capacity if a jurisdiction has a major event.

· The second concern is safety. EMS services that employ full-time staff traditionally has policies in place to restrict or regulate hours worked above the base. These restrictions set limits on the amount of consecutive hours an employee may work or how many hours in a week are appropriate and also how much recovery time is required between shifts. By doing so, the employer is able to ensure the safety of their staff and customers by limiting the risk of fatigued personnel. This is not possible in the current practices Countywide.

· Third, if "paid" personnel are not full-time, it restricts their earning potential unless they are willing to work significant hours due to the loss of overtime opportunities. It also may mean that personnel are on their own when it comes to basic benefits like health coverage. This either adds additional expense to the employee or they simply go uncovered. Finally, it may result in no access to retirement plans or employer sponsored 401(k) plans.

In addition to all volunteer and combination paid/volunteer Corps, there are organizations (e.g., Greenburgh, Harrison, Port Chester, etc.) that are traditional employers that have full-time paid employees as well as part-time personnel. The personnel have the job securities, benefits, and earning reliability of a traditional workplace. Some of the employees of these organizations are also volunteers or may be paid staff working part-time as the paid personal at a Corps, which can pose some of the same concerns described above.

The existing EMS system design is not integrated and is composed of almost 40 EMS transport agencies. In general, each operates independently and is stationed statically in fixed locations. Some communities with more than one ambulance resource may perform periodic "move ups" to cover the geographic coverage area if a unit is on a call or add an additional ambulance during peak demand periods, but true matching of supply to the call demand based on a data trend analysis is absent. This approach to the management and deployment of resources is inefficient and poses several system challenges including:

1. EMS resources are positioned based on jurisdiction and not on demand.

2. If an ambulance is committed to a call, the system is not capable to adjust to ensure adequate coverage Countywide. Instead there is an uncovered community relying on mutual aid with extended response performance.

3. Resources are not staffed based on actual demand. This creates excess capacity in the evening and insufficient resources during peak demand hours.

Several of the communities in Westchester County are at increased risk for negative outcomes based on extended response times or unavailable EMS resources due to a fragmented deployment and dispatching model that is susceptible to miscommunication and delays in mutual aid assistance from neighboring communities. On a daily, routine basis, this represents a risk to individual or small groups of patients; during a large-scale event, this represents a significant risk to large numbers of patients that will be adversely impacted if they are faced with extended delays while waiting for EMS care and transport. If an EMS system is challenged to meet the daily demands for service during routine operations, the system's challenges during the response to a large-scale event will be compounded.

Additionally, based on the nature of the Westchester EMS system and its composition of many small organizations with often poor overall command and coordination, the phenomenon of self-dispatching and responder convergence will lead to paralyzing congestion, confusion, hindrance of the delivery of care, compromised security, and wasted scarce resources. This proved to be a major concern during the response to the September 11, 2001 attack on the World Trade Center and is likely to occur in Westchester when the next disaster occurs. The very nature of the EMS system composition will likely compound this lack of command, coordination, and control.

Even without conducting a comprehensive threat and risk assessment, it is easy to see that Westchester County is exposed to many hazards that have the potential for disrupting the communities and causing mass casualties. Westchester is prone to all forms of severe weather, including a threat from hurricanes, tornadoes, major winter storms, and severe rainstorms that lead to flooding. Major transportation and hazardous material infrastructure, including major Interstate Freeways, several high volume State Highways, major railway corridors, and significant hazardous material pipelines and storage facilities present the real potential for hazardous materials accidents to cause mass casualty incidents (see attached Maps of Transportations Corridors and Hazardous Materials Facilities). Additionally, the County faces the threat of these hazardous materials being targeted by criminal or terrorist elements. WCES and the individual EMS organizations should actively engage in threat assessments and coordinate their data with other public safety and emergency response agencies in a more cohesive manner.

Comprehensive Exercise Program

Personnel from nearly every EMS organization have indicated that exercises are currently a weak link in their preparedness activities in Westchester County. In the words of one mid-level manager, "We don't do a lot." There are attempts to conduct an in-house drill, but these efforts are not consistent with a comprehensive overall exercise management pro-gram or the current threat environment. There is a bi-annual airport mass casualty drill, but it appears that there is little coordination during the planning process for these exercises, and the exercises that are conducted are not on a large-scale consistent with the threats that Westchester County now faces. WCES has a responsibility and opportunity to further its preparedness activities. This may also present as an opportunity to catalyze the other emergency response agencies into planning and exercising, which will further relationships in the emergency response community. Not only is it important for personnel to be adequately trained and equipped to respond to large-scale events, but it is also critical for personnel to exercise their response capabilities. Exercise plays a crucial role in the County's preparedness. They provide opportunities for response personnel, leadership, and the emergency management community to practice and assess their collective capabilities. Exercises will afford WCES, the individual EMS organizations, and other emergency response agencies, from first responders to senior officials, to train and practice preparedness, response and recovery capabilities in a risk-free environment. Exercises will also prove to be a valuable tool for assessing and improving performance, while demonstrating community resolve to prepare for large-scale incidents. This is the only true mechanism (other than real incidents) for the County to gain objective assessments of their capabilities so that gaps, deficiencies, and vulnerabilities are identified and addressed prior to a real incident. Well-designed and executed exercises are the most effective means of:

1. Testing and validating policies, plans, procedures, training, equipment, and interagency agreements;

2. Clarifying personnel roles and responsibilities;

3. Improving interagency coordination and communications;

4. Identifying gaps in resources;

5. Improving individual personnel performance; and

6. Identifying opportunities for improvement.

[JM15 386]

I might have missed it somewhere, but when was this study done?

[helicopper 1,050]

I might have missed it somewhere, but when was this study done?

http://www.wremsco.org/Pub_Info/2008_Westchester_EMS_Study_Final_Report.pdf

Apparently in 2008 for the EMS Council and EMS Advisory Board.

[JM15 386]

I couldn't get through reading the first page when this jumped out at me....

If proactive steps are not taken to improve service delivery, there will be an unnecessary loss of life event or an inadequately managed isolated emergency (e.g., mass casualty event) that will create community scrutiny and dissatisfaction leading to forced change.

[Guest alsfirefighter]

There's a lot more eye opening things within that study but I just don't have the time to post some other things that were brought up as concerns. One of the major ones being that while a recommendation is made to go to a more paid system supplemented by volunteers that for lack of exact words...it would be difficult being it could cause a collapse of volunteers who wouldn't "work" in such a system. Just to be certain...I am paraphrasing here. I don't have the exact wording to quote at this time.

[ny10570 745]

I have always believed that people and especially volunteers rise to the challenges demanded of them. Maryland has become the gold standard of volunteer fire service because they demanded that members be available in house and be well trained. There is no reason why it takes 150 BLS units to cover Westchester. An actively staffed volunteer system supplemented by paid personnel is absolutely viable. In my experience the only thing more cancerous to volunteer response than BS runs is no runs. Shrink the number of units and make them all busier and you will have volunteers jumping at the chance to give a few hours where they actually get to put in some work.

[JohnnyOV 2]

I couldn't get through reading the first page when this jumped out at me....

If proactive steps are not taken to improve service delivery, there will be an unnecessary loss of life event or an inadequately managed isolated emergency (e.g., mass casualty event) that will create community scrutiny and dissatisfaction leading to forced change.

Just wait for any large scale incident... see medium / large aircraft down on final approach or immediately after takeoff coming out of HPN on the northern area... and all hell is going to break loose, both during the accident, as well as afterwords with the post-accident review, as well as the communities view on how unprepared we really are. It's disgraceful.

[Goose 188]

What is even more gut wrenching is that this report was carried out in 2008....and virtually nothing has changed.

[Guest alsfirefighter]

I have always believed that people and especially volunteers rise to the challenges demanded of them. Maryland has become the gold standard of volunteer fire service because they demanded that members be available in house and be well trained. There is no reason why it takes 150 BLS units to cover Westchester. An actively staffed volunteer system supplemented by paid personnel is absolutely viable. In my experience the only thing more cancerous to volunteer response than BS runs is no runs. Shrink the number of units and make them all busier and you will have volunteers jumping at the chance to give a few hours where they actually get to put in some work.

Brother...that has always been my belief for anyone in life and is my slogan when I sit in any meeting that I'm involved in when it comes to training on the fire and EMS side and the whining that comes with increases or proposed increases to curriculum hours or when developing a curriculum the hours the group deems necessary to deliver adequate training experience.

[JohnnyOV 2]

I have always believed that people and especially volunteers rise to the challenges demanded of them. Maryland has become the gold standard of volunteer fire service because they demanded that members be available in house and be well trained. There is no reason why it takes 150 BLS units to cover Westchester. An actively staffed volunteer system supplemented by paid personnel is absolutely viable. In my experience the only thing more cancerous to volunteer response than BS runs is no runs. Shrink the number of units and make them all busier and you will have volunteers jumping at the chance to give a few hours where they actually get to put in some work.

However, some agencies who run 1200+ runs a year in their first due alone, are relying on 5 people to take in 90% of the runs. Sure 60% are BS runs, but if you reduce the amount of ambulances they have, 1/2 or more now get transferred to other agencies responding to BS runs. They get burnt out and it sometimes turns them into miserable people to work with. It's no fault of their own, just the situation that they've been dealt with and choose to stick with. No one wants to volunteer their time hundreds of times a year, to take 1.5 hours out of their busy lives, when they're not on duty, to respond to someone who's stubbed their toe.

No matter how you look at it, less people think about the community as a whole, and are more in tune with themselves over others. It doesn't matter if you do 500 "awesome" ems calls and 5 bs calls throughout a year, or 500 bs calls, and 1 awesome ems call a year, people just don't want to volunteer their time anymore. The ONLY reason that places like PG county work with the live in system, is because there are multiple LARGE universities around to support a live in program for students who want free room and board. There is nothing like that around here, with the added amount of "exciting" runs.

[Goose 188]

However, some agencies who run 1200+ runs a year in their first due alone, are relying on 5 people to take in 90% of the runs. Sure 60% are BS runs, but if you reduce the amount of ambulances they have, 1/2 or more now get transferred to other agencies responding to BS runs. They get burnt out and it sometimes turns them into miserable people to work with. It's no fault of their own, just the situation that they've been dealt with and choose to stick with. No one wants to volunteer their time hundreds of times a year, to take 1.5 hours out of their busy lives, when they're not on duty, to respond to someone who's stubbed their toe.

No matter how you look at it, less people think about the community as a whole, and are more in tune with themselves over others. It doesn't matter if you do 500 "awesome" ems calls and 5 bs calls throughout a year, or 500 bs calls, and 1 awesome ems call a year, people just don't want to volunteer their time anymore. The ONLY reason that places like PG county work with the live in system, is because there are multiple LARGE universities around to support a live in program for students who want free room and board. There is nothing like that around here, with the added amount of "exciting" runs.

I'm having a hard time understanding what you're trying to get at here, maybe you can clarify?

Forget the whole notion of exciting EMS calls (i'm not even sure what that means) and nonsense EMS calls - you're either here to do the job or you're not, all or nothing. As a paramedic, there are days where i respond to 14 calls for assistance but transport less than half that. That doesn't mean i take any more time getting to any of the perceived lower priority runs or slack off on my ALS assessment and initial BLS treatments on those lower priority runs. It's part of the job and the tax payers pay their hard earned money for at least a paramedic evaluation on every run, and i am more than happy to do that. It's just about good patient care, good customer service and more generally doing the right thing. I'm sure the same can be said for the fire service.

I've said it before - agencies that rely on a core group of available members (often times older and retired) have a serious problem. It is unfair to both the community they serve, the patients that request their service and their own members which they consciously abuse. These are the agencies that need to think long and hard about their future - if you want to stay in business you better wake up, smell the coffee, be honest with yourself and you're membership and make some 21st century steps forward to mitigate you're problem.

In reference to the economies of scale ( i think thats part of the point you're making?) - it's going to have to change. This county has more EMS resources than it can adequately staff...you realize that, right?

Edited December 1, 2011 by Goose

[Guest alsfirefighter]

An actively staffed volunteer system supplemented by paid personnel is absolutely viable. In my experience the only thing more cancerous to volunteer response than BS runs is no runs. Shrink the number of units and make them all busier and you will have volunteers jumping at the chance to give a few hours where they actually get to put in some work.

Actually if you want true success and this isn't a dig by far...you need a paid system supplemented by volunteers...not the other way around. Its the only way to ensure true integrity and consistency to the system. There are systems who are running the 2000 to 3000 call ranges where its evident that the system has switched and they cannot maintain proper staffing or response by the use of volunteers. Could it be more efficient if there was less islands of agencies..maybe..but even the one next door that is in the 2000+ call range is staffed in house even less. Also how do you reduce the number of units...then implement a system status management system? How many volunteers do you really believe would drive to sit in an area? Or start to travel around to fill spots in unfamiliar places? I didn't like sitting on a corner or in a parking lot and I was getting paid to do it when I worked in such a system. I sure as hell would not like it if I was volunteering. Stack your units in the busier places outside the cities already covered by paid units...and then what? Response suffers to the less populated more rural areas? And if that's the case how do you supplement the system with the fragmented BLSFR systems out there where its mostly FD's with career staffing that do it? I'm all for looking at a greater solution. I think that consolidation is the answer for EMS...but there are other issues that will take very fine details to work out. Like how do you take a great ALSFR system...and implement them into the system and maintain the services they are giving to their area? What about FD personnel providing ALS services...do they just get tossed out and then have it effect their CBA and accustomed lifestyle based on the living they were making?

Just a lot of things need to go into this.

[ny10570 745]

Viable does not necessarily mean its the best way to go. When I run the world it will be a paid municipal system. In the interim, once they determine the needs of the communities lets say; city A needs 3 BLS and 2 ALS, town B needs 1 BLS, etc you allow the volunteers to staff what they can and fill the rest with paid crews. SSM while nice on paper is hard on crews and arguably not actually effective in the overall patient care picture. Back filling for unusually large demands on the system make sense, but adjusting coverage from minute to minute doesn't have the benefits that justify the added wear and tear on the crews.

Edited December 2, 2011 by ny10570

[sympathomedic 383]

I for one am shocked, SHOCKED that this outside agency of strangers could show up in MY county and study a system I have been in for 30 years.... and be so 100% dead-on accurate!! They should have hired EMT Bravo to do the study for 1/3 the price.

I have done my own study. It shows that 100% of these studies are paid for and then ignored, then repeated again in a decade or so. Who recalls that HUGE series of articles in the local paper about 25 years ago about the long waits, understaffing and over use of EMS mutual aid? Very well written and researched. Opened many eyes. The newspaper that published it changed names, but the EMS situation did not.

I blame me. We run the systems. If we put down the TV clickers and facebook (and EMT Bravo!) and cooperated and worked on this, I have a high level of confidence we would get it done. But I also have a high level of confidence we won't do that.

[helicopper 1,050]

I for one am shocked, SHOCKED that this outside agency of strangers could show up in MY county and study a system I have been in for 30 years.... and be so 100% dead-on accurate!! They should have hired EMT Bravo to do the study for 1/3 the price.

I have done my own study. It shows that 100% of these studies are paid for and then ignored, then repeated again in a decade or so. Who recalls that HUGE series of articles in the local paper about 25 years ago about the long waits, understaffing and over use of EMS mutual aid? Very well written and researched. Opened many eyes. The newspaper that published it changed names, but the EMS situation did not.

I blame me. We run the systems. If we put down the TV clickers and facebook (and EMT Bravo!) and cooperated and worked on this, I have a high level of confidence we would get it done. But I also have a high level of confidence we won't do that.

It was entitled "Where you live could cost your life" and it was an unusually accurate bit of reporting but as you state, it did nothing and we have only made small strides in the quarter century since.

Right on all accounts!!!

[Jybehofd 85]

Just wait for any large scale incident... see medium / large aircraft down on final approach or immediately after takeoff coming out of HPN on the northern area... and all hell is going to break loose, both during the accident, as well as afterwords with the post-accident review, as well as the communities view on how unprepared we really are. It's disgraceful.

it won't be a plane it will be a car accident in bad weather that will do it. The airport has a pretty good laid out plan for on and off property. but if anything shows us its the weather that cripples this county and combine that with a 6 car mva with 4 critical patients and 2 routine ems calls in the middle of it and it will be a big mess

[sympathomedic 383]

I gotta say that the big sexy MVA's get a big response, usually. I was not on the bus v/s bus MVA on I-95 in Portchester, but the water-cooler talk was that resources were not an issue. But if you get two tow calls for little old ladies bleeding to death from GI hemorrhages , it could take paging out 6 towns before you rustle of two crews. The little old ladies would be toast at 3AM

[Guest alsfirefighter]

it won't be a plane it will be a car accident in bad weather that will do it. The airport has a pretty good laid out plan for on and off property.

And the Eagles were given the Super Bowl victory on paper as well. I'm going to leave it at that.

[Guest alsfirefighter]

Viable does not necessarily mean its the best way to go. When I run the world it will be a paid municipal system. In the interim, once they determine the needs of the communities lets say; city A needs 3 BLS and 2 ALS, town B needs 1 BLS, etc you allow the volunteers to staff what they can and fill the rest with paid crews. SSM while nice on paper is hard on crews and arguably not actually effective in the overall patient care picture. Back filling for unusually large demands on the system make sense, but adjusting coverage from minute to minute doesn't have the benefits that justify the added wear and tear on the crews.

Excellent points...but I came from a system similar to what your describing and the coverage and response times were fragmented. What do you do when you on paper have a unit covered by volunteers and they no show or bail out in Town A? Where do you pool paid coverage on the short term notification? Often that unit gets put out of service and another outlying unit has to pick up the slack. I get what your saying on some of the other stuff...but SSM at some level would have to be instituted not necessarily on minute by minute...but when you have City A that does 2500 calls a year, Town A that is around 3000 total, Town B next door does around 1000, you are going to suck up units...not to mention that Town A and B transport to 3 different hospitals by patient choice and that doesn't include the 4th hospital for trauma. Oh and did I mention that City A is surrounded by Town A and is several square miles? Somewhere your going to have to shift units if you want consistent, service.