It is that time of year for resolutions and reflection. As I ponder this thought, the topic that sticks out to me is about what really constitutes a “High Performance EMS”. As we look back over the past year of the High Performance EMS social network (including our Twitter and Facebook feeds as well as this blog) one of the recurring comments that disturbs me is that “response time doesn’t matter”. This causes me concern in two ways – first, that the primary measure of performance is overwhelmingly always “response time” and the other is that this simple measure is deemed to not really be important. So, for the next few posts, I will discuss various characteristics that I feel do matter in becoming a truly high performing EMS system.
Part 1: Response Time
This past February, Elsevier published an excellent newsletter (EMS Insider, Volume 39, Number 2) focused on EMS response times and included articles such as “The Great Ambulance Response Time Debate Continues” in which the author, Teresa McCallion, laid out many of the facts. For instance, the article recites the “MedStar example” from Super Bowl XLV suggesting that “very few EMS calls” in that prospective two week study actually “required an immediate response.” It is important to note that this statement did not go so far as to say that response time is meaningless in all cases – just that it is far less limited in most. Then as counterpoint to dismissing response times altogether, the public conflict at EMSA in Oklahoma City was brought up where at least one politician complained of the number of excluded calls required in order to reach a 90% response time compliance rate. This is only a single instance, but we all understand that it is certainly indicative of how the public measures the value we provide. In the conclusion, Matt Zavadsky, MedStar EMS Associate Director for Operations, offered several good recommendations to improve patient outcomes and public understanding of the EMS system. While I agree with nearly everything he said, I would really only argue with his statement that began, “There is no such thing as an inappropriate request for 9-1-1,” (which is a whole other topic) but then he added “there is such a thing as an inappropriate response to that request.” I can only assume he was referring to the fact that accidents sometimes happen en route to calls. While these incidents point out failures in judgement somewhere, it is not the “response” itself that is at fault.
Zavadsky also authored another article in that newsletter entitled “Response Time Realities: The Scientific Evidence.” Interestingly, several of the studies he cites actually help to make the case for effectively reducing response times under 4 or 5 minutes in certain cases rather than eliminating the standards in general. Furthermore, the quotes he uses from the 2008 “Gathering of Eagles” consortium position paper entitled “Prehospital Emergency Care” do not discount the time of a response, but instead point out the unsupportability of “over-emphasis on response-time interval metrics” compared to the “unintended, but harmful, consequences (e.g. emergency vehicle crashes) and an undeserved confidence in quality and performance.” While I also cannot justify the 7:59 standard used in many urban areas, I also cannot condone apathy toward responding timely. Maybe I am overly sensitive to the literal meaning of “response time doesn’t matter” when justified with the statement that the “golden hour” is just a myth. For most of us, at least 10-20% of calls include a cardiac, respiratory, stroke or other event where time really is critical and we must be at the top of our game to prevent a death or minimize as much loss in quality of life as possible.
My concern in these arguments is an unstated bias that “response” means only the arrival of an ALS-experienced paramedic traveling with red lights and sirens from a fixed fire station. Technically, “response” must be understood as simply the time between a call for emergency assistance and the initiation of appropriate necessary treatment. For many calls, that care could be BLS-led in most circumstances assuming that the calls are appropriately triaged at dispatch. Emergency Medical Dispatch itself even provides some level of immediate guidance in care with a response time of zero. Additionally, the greater availability of defibrillators as well as more common knowledge of compression-only CPR means that initial emergency life-saving care can be initiated well before any ambulance arrives. The existence of advanced telemedicine devices (such as the LifeBot-5) are also changing the rules by providing advanced medical consultation even more quickly in remote rural areas typically with far longer average ALS arrival times.
My point is not necessarily trying to get medical responsders moving faster, but to redefine response time not just as the metric for the ambulance arrival to justify budgets but as a factor that affects patient outcome. There are many ways to achieve this goal and it begins as education within the system as well as with the public because technology is changing the dynamics. Zavadsky’s points are valid. Making defibrillators more available and teaching the public how to respond when a medical event is witnessed is critical. Also while adding ambulances and staff to more locations would be another way to address reducing response time, it is not financially practical. An effective alternative to achieve that same goal would be to position the responders closer to the call thereby minimizing distance and the associated need for risky driving. Modern “dynamic system status management” practice has proven that response time can be shortened to most calls (at least 80-85%) without the need for excessive driving risk that places crews or the public in danger. Improving performance means responding appropriately in less time – not necessarily just responding “faster.” Technology can be evaluated as being “outcome-based” just the same as patient treatments.
Watch for future posts which will highlight other components of performance-based EMS beyond just measuring and improving response time.