Re: proposed ASTM standards for EMS

[Guest guest]

Narad recently posted the proposed new ASTM standards for EMS

operations, asking for comments. I have pasted my reply to him below. I

might recommend that those of you who are interested in the standards and

benchmarks for the EMS industry ask Mr. Narad for the proposed standards and

review them for comment. Obviously, ASTM standards have the potential to

have a significant impact on our business.

Mr. Narad's e-mail is rnarad@...

Thanks,

***********************************

:

I hope it's not too late to provide some input regarding the proposed EMS

standards for ASTM.

Overall, I found them very appropriate and well-founded. I would suggest

only a few items that need to be looked at for possible revision.

5.5 A BLS level responder should be at the scene within 5 minutes of

notification, 90% of the time.

5.7 An ALS level responder should be at the scene within 8 minutes of

notification, 90% of the time.

5.8 An emergency medical transport vehicle responder should be at the scene

within 8 minutes of notification, 90% of the time.

These are the generally-accepted time intervals for ALS and transport arrival

at life-threatening ( " priority 1 " ) calls. However, most EMS agencies (and

" experts " ) have other time standards for non life-threatening calls

( " priority 2 " ) and non-emergency calls ( " priority 3 " ). It is also generally

accepted that BLS first response should arrive in less than 8

minutes.......AHA recommends BLS care to be initiated in 4-6 minutes, I

believe. In many places where I have been involved in measuring and

reporting system response times, our BLS responders were held to a 4 or 5

minute/90% standard for priority 1 calls.

Therefore, I'd recommend that these three standards be split into:

A time interval for BLS response to priority 1 calls that is less

than 8 minutes (perhaps 5 minutes/90%?)

Separate time intervals for ALS and transport response for priority 1

calls (8 minutes/90%), priority 2 calls (10 minutes/90%) and priority 3 calls

(16 minutes/90%).

By the way, there is no scientific evidence as of now for any of these time

intervals....just anecdotal and inferred reasoning. However, I believe the

intervals I have suggested above more closely match our current industry

consensus.

5.10 The on-scene time for medical arrest patients should be less than 20

minutes, 95% of the time.

There is very little actual literature indicating what is a clinically

helpful or appropriate out-of-hospital resuscitation scene time for medical

arrest patients. Certainly there should be some limit, since patients may

require therapies not available in the field setting (electrolytes, etc.) and

in order to limit the time that EMS resources are unavailable for other

demands.

Less than 20 minutes, however, seems a little quick. Many systems consider

20-30 minutes a normal and acceptable on-scene time for medical CPR cases.

For example, our system currently has an ROSC rate of 49%, a

survival-to-hospital rate of 26% and a discharge-alive rate of 14%.....all

much higher than most previously published CPR stats.......and our average

on-scene time for medical cardiac arrest cases is 27 minutes (n = 237;

1997-1999). We also specifically studied on-scene time as it related to

outcome and, although our numbers were not statistically valid, our small

review seemed to indicate that we did best when we left the scene at about

20-25 minutes (with or without ROSC). Less than 20 minutes would be a little

tougher....and there's no evidence that consistent 15 minute on-scene times

are going to improve outcomes.

I would recommend moving this number up a bit...perhaps say less than 30

minutes 95% of the time.

5.16 Unit hour utilization ratio should not exceed .40 for any measured

time period.

Unfortunately, I believe that this is a significant over-simplification of

the issue of unit hour utilization (UHU).

UHU's are measured in different ways by different people. Perhaps one thing

that needs to be provided by this document is a standard definition of UHU.

Some experts say that UHU is measured only in terms of transports (potential

revenue); others say that it should include all responses; and still others

recommend including deployment (posting) assignments in the equation as well.

My opinion is that the purpose of measuring UHU is two-fold. First and

foremost, it should tell the EMS manager how hard the medics are working and,

therefore, how tired and cranky they may be. The definition of " working "

would have to include, at least, all responses...both transports and

no-transports. This is also where some experts make the argument that UHU

should include posting, since it takes the crew away from their station (and

possibly their meal). These factors directly affect clinical decision-making

capability (fatigue), customer relations skills and recruitment/retention.

Second, the UHU measurement should indicate resource availability vs. demand.

If a system's UHU's are high, it means that there are no " reserve " resources

available to appropriately handle the normal episodic " peaks " of demand which

are so typical of our business. It also means that geographic deployment of

the resources is probably thin, leading to long response times in some areas.

UHU's can also vary depending upon the length of the shift and even the

deployment strategy (fixed vs. floating). In general, it is accepted that

units with shorter shifts and floating deployment can have higher UHU's than

units with long shifts and fixed deployment. Jay Fitch, I believe, once

published a recommendation based upon his experiences that fixed-deployment,

24-hour units should not exceed a UHU of 0.425 (which equals roughly 11 calls

per 24 hour shift). I believe Jack Stout, on the other hand, recommends

UHU's of as high as .60....but he only recommends short-shift,

floating-deployment systems.

My suggestion for the ASTM standard is as follows:

1. Define UHU as including ALL responses, both transport and

no-transport. For fixed-deployment units (which operate out of " stations " )

on 24-hour shifts, include deployment assignments (posting) as well.

2. Set a UHU limit for short-shift units (defined as 8 - 14 hours) at

..60. This would be the equivalent of about 5.5 calls per shift for 8-hour

trucks and 8.5 calls per shift for 14-hour trucks...a solid day's work by

anyone's measurement.

3. Set a UHU limit for 16-24 hour units of .42, including posting.

This is the equivalent of about 9 calls per day (plus a little posting) for

24-hour units. I have units operating at this level now that do fine...but

certainly could not do anymore (I now have one 24-hour unit which has a UHU,

including a little posting, of about .50...and those people are not pretty).

6 Sentinel events.

6.1 BLS level first response of > 12 minutes.

6.2 ALS level response of > 12 minutes.

In light of my recommendations regarding the 8 minute response time standard,

I would suggest that these be changed to read " response time of 150% or

greater of the standard " . This would be 12 minutes for priority 1 calls but

24 minutes for a non-emergency call. This is the definition of " outlier "

which requires special investigation in many EMS contracts.

I would also recommend including as a sentinel event any incident in which a

BLS unit was dispatched (in a tiered system) WITHOUT ALS backup, and ALS was

subsequently requested/required. In other words, a dispatch triage boo-boo.

6.5 Any defibrillation or pacing.

I would recommend including cardioversion in this standard.

Last, I believe that this ASTM document should include definitions and

standards for times (events) to be measured by the EMS system. For example,

the standard might state that times which should be measured and documented

include:

Call received by primary PSAP

Call received by EMS dispatcher

Call dispatched

Unit responded

Unit arrived

Patient contact

First shock, if applicable (required for Utstien template)

Intubation, if applicable (required for Utstien template)

IV started, if applicable (required for Utstien template)

First medication administered, if applicable (required for Utstien

template)

Enroute to destination (receiving facility)

Arrived at destination

Available for next call.

Each of these times would need to be defined (what do you mean, for example,

by " arrived on scene " ?)

I hope this information is helpful. I apologize for the length of my

comments, but I believe that this is an important document for our industry

and that these standards should not be taken lightly. Please feel free to

contact me if you need any further explanation.

Thanks, and good luck.

EMS Manager

City of Beaumont, Texas