Resource management questions: 911 vs IFT

[Agent Cooper]

Hey everyone, haven't been around in a long time but I was hoping I might be able to pick your brains a little about this situation we have my service.
I work for Anonymous County third service in Generic Rural Area. We’re served by a small community hospital with very few specialties. Our service is responsible for covering 911 calls throughout most of a county that is geographically quite large although lightly populated. We get about 4,000 calls a year and generally staff two trucks at all times with an occasional third truck available.

Due to some recent changes at the hospital, we are being asked to take an increased number of IFTs. These IFTs generally go to facilities several hours away. They run the gamut of acuity, but most are BLS or ILS level and are not life-threatening but rather conditions that require specialties that our hospital does not offer. I would estimate our service currently averages 1-2 transfers per 24 hour period (we work 36’s). When we have one ambulance on a transfer, that often leaves one ambulance behind to cover the county for up to 7 hours. Some in our service believe that the level of 911 coverage that one truck can provide a county as large as ours is unacceptable. Others believe that, as members of the healthcare system, we are obligated to make sure patients reach definitive care (which is almost always someplace other than our hospital).

These transfers are a source of some pretty bitter conflict, both internally and between our service and the hospital. As part of the department and a union rep, I would really like to see this situation improve – ideally in a way that benefits everyone.

To that end, I wanted to ask you guys for your own experiences with these types of resource management issues. Especially for those of you that work in similar conditions (county/municipal third service with limited outside resources, etc).

If you’re still reading by now (sorry for the long post!), do you have any thoughts? I am not trying to push any particular opinion here, just gather some data about how other services handle this issue and hopefully some ideas for a solution.

Thanks!

 

[DesertMedic66]

It’s seems as if staffing an additional unit permanently would solve many of the issues. As your call volume increases so must your staffing levels.

 

[Jim37F]

Yeah, that was my first thought, staff up a dedicated transfer unit, maybe can base them out of the hospital itself? If your county allows, you can staff with an EMT/AEMT since you said most transfers were BLS/ILS, and if an ALS transfer comes in one of the other 911 trucks (assuming they're EMT/Medic or Medic/Medic staffed) (Also assuming the new full-time unit isn't the same EMT/Medic or Medic/Medic staffing).

Otherwise, maybe they can call a private transfer only service that wouldn't have to worry about handling 911 calls, and can only worry about the one unit, and you guys can keep your current staffing without worrying about having to manage out of town transfers?

 

[NPO]

I work in a service very similar to yours. County service, large rural area, one barely meets the requirements hospital, etc...

We also frequently have to transfer patients out of our hospital. To the tune of 4-8 per day. Our closest regional specialty centers are 1 hour away so that's not terrible far. However if they can't handle it, the next closest are 3 and 4 hours away.

For transfers beyond the nearest city we often attempt to get off duty employees to come in to take the transfer. This is encouraging by offering an additional $10/hr bonus LDT pay.

Your problem isn't a unique one, however you need to consider things from an operational side. How much is your service being reimbursed for these transfers vs how much does adding another truck cost? I would bet the transfers could cover the cost, but that's only something your management would know.

Have you taken this issue up with management?

 

[DrParasite]

lets back up a step.... can your system handle it? Questions I would ask:
1) how many times during the past year did your agency require mutual aid (any time, regardless of circumstances)?
2) how many times has your agency needed to utilize the second ambulance, because the first one was unavailable or already on an assignment?
3) 4000 calls a year averages out to 11 calls a day, so assuming each call takes 2 hours, that means each truck is unavailable for 11 hours a day. And now you want to add 7 hours to the workload of both trucks (one to do the transport, and the other to run all over the county picking up the workload)
4) you work for the county right? so it's the hospital's responsibility to handle the transfers. If it's non-emergent, they can always call a private service (emergency cases are a different story).

Without knowing those answers, I would think the best solution would be to have your agency ask the hospital to fund a third truck, 24/7, because the reason you need that truck is to make up for the lack of services provided by the hospital. that truck would primarily do IFTs, but could do a 911 call if closer or if the system required it, and there were no IFTs scheduled. This way the hospital is paying for the service that they are using (county wins because they don't need to pay for it.), the union can hire more staff to staff the third truck (union wins), you get a third unit that you can sometimes pull for that spike in call volume (county wins), and you don't need to go down to one unit to cover the entire county (people at the service win).

 

[Summit]

Evaluate when your utilization is highest day/hour-wise. Run an extra 10 or 12 hour truck on those time periods whether that is 10-10 or 7-7. IFTs should pay for it all.

 

[DrParasite]

Others believe that, as members of the healthcare system, we are obligated to make sure patients reach definitive care (which is almost always someplace other than our hospital).

So when are you getting your own helicopter?

IFTs should pay for it all.

I am assuming you mean insurance revenue will cover the cost of the truck right? And you're generally correct in that assumption, but your wrong in your line of thinking. If the service is provided for free, than the hospital will think it has no value. Its the same line of thinking as holding the wall for hours in the ER waiting for a bed. You aren't costing the hospital a dime, and you are providing a service that the hospital doesn't have to, so they don't care how long you have to wait.

Our entire industry has gotten into a huge funding issue because people think we can offer the service for free, or for cheap, which is why you have crappy privates and lowest bidder (or zero bid) on 911 contracts.

The hospital is causing your agency to need to spend more money to provide this service. They should be the ones who have to fund the solution. Otherwise, they are going to end up taking advantage (such as a day when you have three trucks on, they are going to insist that you provide one to handle the non-emergency discharge, and an hour later request a second truck for a STAT transfer), because they will see it as a free service that isn't costing them anything (and yes, I have seen it happen before).

 

[Bullets]

Sounds like you need another truck on during the day

 

[Tigger]

We are looking at a very similar situation. We're taking around 700 transfers a year out of the community hospital now that there is no general surgery. This mixes into our call volume of around 3000 with an average call time of 2.5 hours. We staff two ambulances and a paramedic supervisor who will borrow a firefighter as a partner for the third call. Looking at concurrent call data, we have 7-8 hours per day when only the supervisor is available for calls.

We approached the hospital for funding for a sixth person as the supervisor's partner. They were adamantly against providing any money for transfers as up till now we have met their needs with the current resources. We are still making money off transfers but not by much given our 80% CMS payor mix. So we're kind of stuck. We can't afford to walk away from taking the transfers but they are also harming our ability to cover the district's 911 needs.

 

[DrParasite]

We are looking at a very similar situation. We're taking around 700 transfers a year out of the community hospital now that there is no general surgery. This mixes into our call volume of around 3000 with an average call time of 2.5 hours. We staff two ambulances and a paramedic supervisor who will borrow a firefighter as a partner for the third call. Looking at concurrent call data, we have 7-8 hours per day when only the supervisor is available for calls.

We approached the hospital for funding for a sixth person as the supervisor's partner. They were adamantly against providing any money for transfers as up till now we have met their needs with the current resources. We are still making money off transfers but not by much given our 80% CMS payor mix. So we're kind of stuck. We can't afford to walk away from taking the transfers but they are also harming our ability to cover the district's 911 needs.

And that is EXACTLY the problem I was talking about. The hospital has been getting the service for free, so now that you are asking them to pay for it, they are refusing. After all, it isn't costing them anything, and you are providing the service for free to them.

during those 7-8 hours a day (1/3 of the day, really), you have no ambulance available for 911 calls, only the supervisor (and maybe a FF, if he or she is not on an assignment). And when you do pull that FF, he isn't available to do his firefighting job. Yes, you are making money off transfer, at the expense of the FD (because they are paying for the FF but not getting a cut of the revenue generated), but are you making a profit, or are you simply covering the cost of that run?

The hospital is causing you more work, hindering your ability to do your job (which is provide 911 coverage and answer 911 calls), and refusing to compensate your agency for any of these things.

Personally, I would tell them to pay for another service to handle the transfers, so you can focus on your primary mission, or they can fund a dedicated ambulance from your service to handle all the transfers. otherwise, there is really no incentive for them to give you any funding for the service they are having you perform.

 

[Tigger]

And that is EXACTLY the problem I was talking about. The hospital has been getting the service for free, so now that you are asking them to pay for it, they are refusing. After all, it isn't costing them anything, and you are providing the service for free to them.

during those 7-8 hours a day (1/3 of the day, really), you have no ambulance available for 911 calls, only the supervisor (and maybe a FF, if he or she is not on an assignment). And when you do pull that FF, he isn't available to do his firefighting job. Yes, you are making money off transfer, at the expense of the FD (because they are paying for the FF but not getting a cut of the revenue generated), but are you making a profit, or are you simply covering the cost of that run?

The hospital is causing you more work, hindering your ability to do your job (which is provide 911 coverage and answer 911 calls), and refusing to compensate your agency for any of these things.

Personally, I would tell them to pay for another service to handle the transfers, so you can focus on your primary mission, or they can fund a dedicated ambulance from your service to handle all the transfers. otherwise, there is really no incentive for them to give you any funding for the service they are having you perform.

We are turning some pretty decent revenue off the transfers, certainly above just covering costs. Unfortunately it is not yet enough to increase staff from just that revenue and if we lost the transfers all together, we would have to cut staffing levels from the current level.

As for the fire departments, only one department is full time. They get free education and our solid volume discount on medical supplies so our respective chiefs seem to think it's a pretty good deal. The volunteer folks love to drive the ambulance when needed, they consider it part of their duties. We also do not take transfers using a fire-driver, the hospital has to wait until a full crew returns.

 

[Agent Cooper]

If your county allows, you can staff with an EMT/AEMT since you said most transfers were BLS/ILS, and if an ALS transfer comes in one of the other 911 trucks

I appreciate all the thoughtful responses! Staffing a third truck, especially a dedicated transfer truck, is something that we have been trying to make happen, although our manager seems convinced that no one would willingly staff a transfer truck.

For transfers beyond the nearest city we often attempt to get off duty employees to come in to take the transfer. This is encouraging by offering an additional $10/hr bonus LDT pay.

I would love to see something like this happen. This is how some other services in the area convince people to take transfers.

I would think the best solution would be to have your agency ask the hospital to fund a third truck, 24/7

I think that's a fantastic idea. Unfortunately the hospital is currently in a financial death-spiral. Could be something to consider when they inevitably get taken over by someone else.

We are still making money off transfers but not by much given our 80% CMS payor mix. So we're kind of stuck. We can't afford to walk away from taking the transfers but they are also harming our ability to cover the district's 911 needs.

We are turning some pretty decent revenue off the transfers, certainly above just covering costs. Unfortunately it is not yet enough to increase staff from just that revenue and if we lost the transfers all together, we would have to cut staffing levels from the current level.

This is basically our exact situation. Tigger, is your service taxpayer funded or is it funded by the IFT operation? This is something about our service that I have never understood - we are the only county department expected to be self-sufficient and we receive almost no funding from the county. This seems to be one of the main causes of this problem; if we were funded like any other county department we wouldn't have to worry about money coming in from transfers and we could tell the hospital to contract with a private service.

 

[DrParasite]

This is something about our service that I have never understood - we are the only county department expected to be self-sufficient and we receive almost no funding from the county. This seems to be one of the main causes of this problem; if we were funded like any other county department we wouldn't have to worry about money coming in from transfers and we could tell the hospital to contract with a private service.

Our entire industry has gotten into a huge funding issue because people think we can offer the service for free, or for cheap, which is why you have crappy privates and lowest bidder (or zero bid) on 911 contracts.

I guess i should add under funded public services that are expected to operate solely on billing revenue that might not come, despite the fact that every other county services gets operating funds to operate.

 

[Jim37F]

Should go to the next county board meeting and bring up the issue, and compare that to their salaries (should be public record as they're public officials) and say that they should only get paid by charging a fee to go to the meetings

 

[Tigger]

I appreciate all the thoughtful responses! Staffing a third truck, especially a dedicated transfer truck, is something that we have been trying to make happen, although our manager seems convinced that no one would willingly staff a transfer truck.

I would love to see something like this happen. This is how some other services in the area convince people to take transfers.

I think that's a fantastic idea. Unfortunately the hospital is currently in a financial death-spiral. Could be something to consider when they inevitably get taken over by someone else.


This is basically our exact situation. Tigger, is your service taxpayer funded or is it funded by the IFT operation? This is something about our service that I have never understood - we are the only county department expected to be self-sufficient and we receive almost no funding from the county. This seems to be one of the main causes of this problem; if we were funded like any other county department we wouldn't have to worry about money coming in from transfers and we could tell the hospital to contract with a private service.

We are sustained by a mill levy (60%), patient billing activities (30%), and grants (10%). The service is a special tax district so while we have tax revenue, we get no other governmental support. Any tax increase must be passed by popular vote.

 

[Bullets]

I appreciate all the thoughtful responses! Staffing a third truck, especially a dedicated transfer truck, is something that we have been trying to make happen, although our manager seems convinced that no one would willingly staff a transfer truck.

Its not a transfer truck, its just another truck in the rotation. It can do both 911 and IFT. This is how my company runs its the Basics and they all love it. They get to do hot 911 jobs and after they get run a bit they get a break doing an IFT for a couple hours.

 

[Agent Cooper]

Should go to the next county board meeting and bring up the issue, and compare that to their salaries (should be public record as they're public officials) and say that they should only get paid by charging a fee to go to the meetings

Love it!

 

[Agent Cooper]

We are sustained by a mill levy (60%), patient billing activities (30%), and grants (10%). The service is a special tax district so while we have tax revenue, we get no other governmental support. Any tax increase must be passed by popular vote.

Interesting... Third services are not common in my state so I'm unfamiliar with how they're usually funded. Is that a common way of doing it? Are you guys familiar with how other third services get their funding?

 

[NPO]

Interesting... Third services are not common in my state so I'm unfamiliar with how they're usually funded. Is that a common way of doing it? Are you guys familiar with how other third services get their funding?

This is standard for districts.

My district used to have a property tax, but switched to sales tax. We are about 50/50 for tax and patient services.

 

[NPO]

Should go to the next county board meeting and bring up the issue, and compare that to their salaries (should be public record as they're public officials) and say that they should only get paid by charging a fee to go to the meetings

For what it's worth, they usually don't make much. We have 5 or 6 on our BOD and they make $50/mo each, which they all donate back into our employee fund.