I am a current veteran provider in a major urban 911 system. Presently we are looking to "revamp" our current 911 delivery system. HISTORY: Our current system consists of a 1 tier system with all ALS all the time. Currently we have 24 ALS transport units handling approximately 158,000 calls for services annually. This system appears to be a broken system in means of financial and operational functionality. Are there any jurisdictions that operate a all BLS fleet with ALS chase cars? This is a current model we are looking at and need any and all information related to this topic.
ALS Chase Car Model EMS Systems in US?
- Thread starter CityP
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158000 calls annually? Wow, this is big news for a system that size to revamp their EMS system so drastically. I know other large urban areas that are using similar systems to what you describe are Seattle, Boston, and NYC. Boston in particular seems to run very few ALS units for how many calls they run. All of the cities I mentioned though have ALS ambulances as the tiered system and don't operate chase cars. LA County has chase squads with paramedics, but I think they respond on every medical call and decide to ride in with the BLS ambulance or not (don't quote me on that). My system uses ALS chase cars with BLS ambulances from different departments, but the environment here really isn't anywhere close to the urban setting you're describing.
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But Wake County's chase cars only have their Advanced Practice Paramedics. All other ambulances in their fleets are normal ALS units too. Their APPs respond to community paramedic type events and back up medic units on critical calls with their expanded scope.
Bullets
Forum Knucklehead
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Vast majority of ALS in NJ is chase car. Most towns have volunteers or paid services that provide BLS in transport capable units. ALS responds from hospitals in suburbans or dog-catchers
Some services are moving toward transport capable ALS for money reasons
Some services are moving toward transport capable ALS for money reasons
Brandon O
Puzzled by facies
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Several of the communities surrounding Boston are served by BLS with non-transporting ALS flycars. Armstrong Ambulance in particular likes to use these. No idea how the finances stack up.
Edit: just remember that under this model, any ALS patient by necessity will tie up two units, since they can't clear the BLS and transport on their own.
Consider having a small deployment of several ALS transport units for training. You can staff it as EMT/medic, and replace the EMT with a probationary medic to train them. Make the rest of the fleet BLS.
Consider staffing the chase cars with two medics. One medic can deploy to the BLS unit to make it ALS, and the chase car can still remain in service. If its a call where two medics ought to be working on the patient, then you already have two medics present, both of whom work together on a regular basis.
All-ALS systems aren't good for newer medics, IMO, since the general acuity of patents is low, which makes the learning curve quite flat (takes a long time to see a significant amount of seriously ill patients). Medics on all-ALS systems typically run mostly BLS and IV/monitor calls, and get to use their protocols very infrequently. In a tiered system, medics don't have to do sick jobs, postictal seizures, strokes (if they can protect their airway and are reasonably stable), drunks unless they're unconscious, injuries (if they need pain management, then call for ALS back) EDP's, or routine MVA's. That's probably 70% of your call volume right there. Medics can spend their time more productively on call types such as diff breathers, cardiac condition, cardiac arrest, unconscious, stat ep, hypotensive pts, and multi-traumas.
Consider staffing the chase cars with two medics. One medic can deploy to the BLS unit to make it ALS, and the chase car can still remain in service. If its a call where two medics ought to be working on the patient, then you already have two medics present, both of whom work together on a regular basis.
All-ALS systems aren't good for newer medics, IMO, since the general acuity of patents is low, which makes the learning curve quite flat (takes a long time to see a significant amount of seriously ill patients). Medics on all-ALS systems typically run mostly BLS and IV/monitor calls, and get to use their protocols very infrequently. In a tiered system, medics don't have to do sick jobs, postictal seizures, strokes (if they can protect their airway and are reasonably stable), drunks unless they're unconscious, injuries (if they need pain management, then call for ALS back) EDP's, or routine MVA's. That's probably 70% of your call volume right there. Medics can spend their time more productively on call types such as diff breathers, cardiac condition, cardiac arrest, unconscious, stat ep, hypotensive pts, and multi-traumas.
Clare
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For a population of 1,2 million people we respond to just shy of 200,000 calls per year in the Auckland District (which runs from Pukehoke in the South to Silverdale in the North, Hellensville in the West to Howick in the East - look it up so you get a general idea).
There are approximately 30 ambulances doing emergency response work (so not including the patient transfer service) and approximately 10 of these will be staffed by an Intensive Care Paramedic (ALS) with the rest being staffed by Paramedic (ILS) or in some instances, two Emergency Medical Technician (BLS).
Requests for ALS backup (for example airway problems or choking, cardiac arrest, seizures, complex clinical situations) are either handled by one of the ALS stretcher ambulances, or by one of vehicles from the Rapid Response Unit or occasionally, somebody from Clinical Support or Sierra Unit (which is the alternate referral/see and refer resource). The Duty Operations Managers are also in a small jeep and can go to a job when backup is required however they try to stay free and let one of the rapid responders handle backup requests wherever possible.
I know there are some cities around the world where they operate an all ALS (all ICP) model such as ACTAS, the LAS and many in the USA. I think this is far in excess of what is required; most problems can be handed by non ALS Officers, for example majority of pain relief, diabetic, most requests for adrenaline, septicaemia < 30 minutes from hospital etc).
There are approximately 30 ambulances doing emergency response work (so not including the patient transfer service) and approximately 10 of these will be staffed by an Intensive Care Paramedic (ALS) with the rest being staffed by Paramedic (ILS) or in some instances, two Emergency Medical Technician (BLS).
Requests for ALS backup (for example airway problems or choking, cardiac arrest, seizures, complex clinical situations) are either handled by one of the ALS stretcher ambulances, or by one of vehicles from the Rapid Response Unit or occasionally, somebody from Clinical Support or Sierra Unit (which is the alternate referral/see and refer resource). The Duty Operations Managers are also in a small jeep and can go to a job when backup is required however they try to stay free and let one of the rapid responders handle backup requests wherever possible.
I know there are some cities around the world where they operate an all ALS (all ICP) model such as ACTAS, the LAS and many in the USA. I think this is far in excess of what is required; most problems can be handed by non ALS Officers, for example majority of pain relief, diabetic, most requests for adrenaline, septicaemia < 30 minutes from hospital etc).
FWIW, Houston FD runs a combination of chase cars and ALS ambulances. I know many here will talk trash on them, but they may be worth contacting.
Going from all-ALS may not be easy. For it to work well, there needs to be aggressive call screening (possible retraining of call-takers and dispatchers). Then, there needs to be triaging again once BLS or ALS arrive, whether BLS cancelling ALS or ALS passing the pt. to BLS (possible extra training and ongoing QA/QI). Protocols need to be written so that both ALS and BLS can be on the same page in terms of when to cancel ALS and when to request ALS (medical director time). In NJ, it is provider dependent and there can be a lot of disagreement between ALS and BLS. Some EMTs are "medic dependent", but at the other extreme, there are EMTs that think of it as a badge of honor to never request ALS (or always cancel) unless the patient is absolutely critical. Then some medics will never triage to BLS and then some want to triage everything to BLS.
Overall, this move, if done, could be one of the most progressive things any department has done in years.
Going from all-ALS may not be easy. For it to work well, there needs to be aggressive call screening (possible retraining of call-takers and dispatchers). Then, there needs to be triaging again once BLS or ALS arrive, whether BLS cancelling ALS or ALS passing the pt. to BLS (possible extra training and ongoing QA/QI). Protocols need to be written so that both ALS and BLS can be on the same page in terms of when to cancel ALS and when to request ALS (medical director time). In NJ, it is provider dependent and there can be a lot of disagreement between ALS and BLS. Some EMTs are "medic dependent", but at the other extreme, there are EMTs that think of it as a badge of honor to never request ALS (or always cancel) unless the patient is absolutely critical. Then some medics will never triage to BLS and then some want to triage everything to BLS.
Overall, this move, if done, could be one of the most progressive things any department has done in years.
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Absolutely true. I've seen both sides of this spectrum in the short time I've been involved with a tiered system. I've been requested by BLS on a mild headache or anxiety attack, and I've been cancelled on chest pain just because the 82 year old with a cardiac history said it might change a bit on inspiration. This might be a bit different though if everyone is part of the same system. I imagine the pride game wouldn't come into play quite as much.