Advanced Life Support Committee Report

For the Wayland Board of Selectmen January 12, 2009

Public Perception – Heart Attack • • 911 call for ambulance Local resources respond to solve the problem.

– Fire department response • Fire engine • Ambulance – Two paramedics – Overall “local” response • Quick, professional, effective, efficient.

The Reality

• • 911 call for ambulance – Local resources respond to solve the problem • • Fire department response Fire engine Ambulance – Another agency is called for assistance – – – Semi-public or private organization Decreasing availability Less and less seamless integration » Vehicle and two paramedics meet the local ambulance – • • Overall response Usually… – Quick, professional, effective, and efficient.

Sometimes ALS not available.

Traditional Fire Department Responsibilities

• Fire suppression • Fire prevention • Inspections • Permits • Code enforcement • Hazardous materials planning & response • Emergency medical service

Wayland Fire Department Mission Statement.

From the Town of Wayland web site.

“Our mission is to provide the finest possible fire, rescue, and emergency medical services to all those that reside in, work in, or visit the Town of Wayland….”

EMS 101

• Basic life support (BLS) Emergency medical technician (EMT).

– All Wayland firefighters are EMTs – Ambulance is always staffed with two EMTs – Have skills for the less serious injuries/illnesses – Adequate for 50-65% of all ambulance calls • Advance life support (ALS). Paramedic – Paramedics are available from outside organizations.

– Have skills for the more serious injuries/illnesses.

– Needed for 35-50% of all ambulance calls

Emergency Medical Services Within the Fire Department • 1899 – Fire department organized • 1910 – Emergency medical services start – Oxygen is carried on fire engines • 1960 – Ambulance service starts – With a hearse-like vehicle • 1972 – “Paramedics” introduced to the U.S.

Emergency!

An NBC TV Show 1972 • “Paramedic” – advanced medical training • Close relationship with emergency department staff – Training, treatment, & telemetry • Merging paramedics into the fire service – Fast response – Strategic station and personnel location – Public policy

Emergency Medical Services Within the Fire Department • 1899 – Fire Department Organized • 1910 – Emergency Medical Services Start – Oxygen is carried on fire engines • 1960 – Ambulance Service Starts – With a hearse-like vehicle • 1972 – “Paramedics” introduced to the U.S.

• 1975 - Modern basic ambulance service – True ambulance and credentialed personnel • 1982 – Hospital-based ALS service starts

ALS – Paramedics 1982 - 2003 • Two hospital-based paramedic services available • Local ambulance services maintain basic level of training and transportation • ALS service was prompt, efficient, & effective • Wayland was geographically “lucky”

Outside Resources

• ALS resources available from outside the local fire department – Hospital based ALS teams (vehicle and 2 paramedics) – Dedicated to area – Good response times – Relatively seamless service integration – Public policy integration

During this time….

Maximus Study

From the Town wide Study of Organization and Operations prepared for the Town of Wayland, by the Maximus Company of Waltham, MA. May 13, 2002. Page 124.

“Consider increasing the internal level of emergency medical services (EMS) provided to the Advanced Life Support Level. It is clear that the town is at a disadvantage in relying on this level of care from outside the community (response times are longer than the national standard because these units are coming from elsewhere).”

ALS Problems Appear on the Horizon • Long term, continuing problem (many years) – Medicare reimbursement for ambulance fees decreasing steadily – Aging population increasing dramatically – Aging population generally need more medical care, including ambulance transportation – Makes ALS service less attractive when profit is the bottom line

Master Plan

From the Wayland Town Master Plan Final Report, August 2004. Page A-5, demographic profile “According to MAPC (Metropolitan Area Planning Council) population forecasts…the proportion of persons aged 65 and older is projected to effectively double by 2020, growing from 14% of the Town’s total population to 28%.”

More ALS Problems on the Horizon • 1990s - Hospital budget problem rumors persist – ALS service(s) may be in jeopardy • 1993 – Fire department proposes plan for ALS training for firefighters – Not acted on • 2003 – Natick hospital-based ALS service closed with 90 days notice – Short notice – Affects 84% of Wayland ALS calls

Since 2003, A Partial Solution

• Local ambulance company American Medical Response (AMR) helps out.

• If ALS is needed, we request an AMR response. If an AMR ALS crew is available, they are sent.

• For every ALS transport, they charge Wayland $250. flat fee.

– Paid from ambulance receipts.

A Partial Solution – The Benefits • When ALS is available, patient benefits • Except for flat fee, no other charges incurred for Wayland

A Partial Solution – The Limitations • High unavailability – ALS units are not stationed in or dedicated to, the area – ALS crews continue their normal business and are often out of the area for long periods of time • Little or no control over personnel and policy • Multi-agency responses lead to delays, miscommunications, and misunderstandings • Response times do not meet national standards • No cost control measures are possible

ALS Problems on the Horizon

• Hospital budget problem rumors persist – ALS service(s) may be in jeopardy • 1993 – Fire department proposes plan for ALS training for firefighters – Not acted on • 2003 – Natick hospital-based service closes with 90 days notice • 2004 - Wayland ALS Committee issues report to Board of Selectmen.

The 2004 ALS Committee Report • Recognized multi town area that needs better ALS service.

• Proposed a regional service shared between towns.

• No action taken.

Since the 2004 Report

• ALS availability (especially on the south side) continues to decrease (unavailable 1/3 to 1/2 of the time) • Emerson Hospital recognizes ALS financial woes.

– ALS fee increases but guarantees service until September 2010.

• Emerson area collaborative formed. – Proposing a fundamental change in the way ALS is • “2 delivered in the 13-town region.

• MetroWest Health Care Foundation grant nd agency issues”

The Importance of ALS and Paramedics

The Importance of ALS and Paramedics Mark Neuman, M.D.

Beth Zeeman, M.D.

Staff in Emergency Medicine Children’s Hospital, Boston Assistant Professor of Pediatrics Harvard Medical School Staff in Emergency Medicine MetroWest Medical Center Medical Director Wayland Fire Department Emergency Medical Service

The Importance of ALS and Paramedics • Emergency medical literature (see printed report footnotes) • Personal experiences of fire department members

Elements of the 2009 ALS Service Proposal • Proposed service added to the existing ALS services (not a replacement) • Flexible and scaleable • Funded by the Town of Wayland

Elements of the 2009 ALS Service Proposal (more) • ALS services “sold” to surrounding communities who also need it • Part-time employees used • Partial day coverage (8 hours/day) to start

Elements of the 2009 ALS Service Proposal (more) • Based in Wayland, committed to the area • Easily replaced by, or made a supplement to, any other acceptable ALS delivery system proposed

After Proven Success (Future)

• 24 hour/day coverage will be a goal • Interested Wayland Fire Department personnel should be given the opportunity to train to the paramedic level • Fire Department hiring practices should change so that through attrition, some firefighter/paramedics would be hired.

2009 Proposal - Goal #1

• Provide an additional ALS service in the area to improve availability.

Provide a prompt, efficient, and effective paramedic service for the people who live in, work in, or travel through the town of Wayland as soon as possible.

2009 Proposal - Goal #2

• Be prepared if either existing ALS service stops providing service.

Have enough flexibility in the plan to absorb additional geographic areas and additional patients if either existing ALS service is unable to continue providing paramedics.

2009 Proposal - Goal #3

• Be prepared & helpful if other ALS plans for the area are adopted.

Be prepared (for merging or replacement) if the MetroWest Health Care Foundation ALS study or the Emerson collaborative designs a new, acceptable ALS model for the area.

2009 Proposal - Goal #4

• Decrease the paramedic response time within the primary service area by an average of 50%, to 6-7 minutes, well within the national standard.

2009 Proposal - Goal #5

• Help guarantee long term program viability and high quality paramedic service for all.

Not just for the residents of Wayland, but also provide some assistance to Sudbury, Weston, and Lincoln.

2009 Proposal - Goal #6

• Consolidate the entire suite of pre-hospital emergency medical care services into a single local agency, managed by public policy.

Cost/Benefit

Cost Categories

• Start up • After success, possible expansion

Start-Up Costs

• Equipment & Supplies – $28,198 • Perspective – Percentage of current yearly ambulance revenue (net) » 12% – Percentage of “Town Center” gift » <1%

Operational Cost (Per Year)

• Operational – $57,074 Per Year • Perspective – Percentage of current yearly ambulance revenue (net) » 24.4% – Percentage of “Town Center” gift » 1.9%

Potential Future Program Expansion (Long Term) • After success (future) – Possible Expansion • Equipment & Supplies • Operational – Wayland Fire Department paramedics • Hire a percentage of Firefighter/Paramedics through attrition.

• Training interested existing personnel

Benefit

• Provide an additional paramedic team… – Within the fire service – Committed to the emergent care needs in the area (3-4 towns) – 8 hours/day coverage – Centrally located = short response time, meeting response time standards.

Benefit

• Preserves and continue BLS ambulance services at local (town) level. • Shares specialized services with surrounding communities • Service supported with public policy – Additional protection for a vulnerable population

What We’re Asking of the Selectmen • Endorse the 2009 ALS Committee Report and associated policy • Authorize/provide funding – Start up – Operational • After success (future) – Possible Program Expansion

What We’re Asking of the Selectmen • Endorse the delivery of ALS services part of the day, with part time employees of the Wayland Fire Department

What We’re Asking of the Selectmen • Start Up – Work with the ALS Committee/Fire Chief to identify/provide start-up funding.

• Operational funding – Authorize and provide operational funding.

What We’re Asking of the Selectmen • After success… – Possible Program Expansion (future)

Conclusion - Recognize that a Proper ALS Service… • is a valuable, life saving service and needs to be supplemented in our area as soon as possible.

• should be provided by local government operated under public policy.

• satisfies recommendations of past town management and operational studies.

• is perfectly aligned with the mission of the Wayland Fire Department.

And therefore…

• The recommendations found in the 2009 ALS Committee Report should be endorsed and implemented as soon as possible.

The Advanced Life Support (ALS) Committee

Committee members – Douglas Leard – Fire Chief Robert Loomer (advisory member) – Mark Neuman, M.D.

– Michael Patterson – Vincent Smith (Chair) – Elizabeth Sweitzer – Beth Zeeman, M.D.

Questions? Comments?