Single Provider vs Multiple providers

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46Young

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I'm wondering what your thoughts are on whether it's better to have one sole provider responsible for EMS ground txp in a particular jurisdiction, or to have numerous. Reasons why would make for an interesting discussion, of course. A county run third service would be a typical example of the former, and FDNY EMS with all of it's voluntary hospitals along with Transcare and AMR being an extreme example of the latter. I'm not considering mutual aid txp units as an example of multiple providers. In medium to large size municipalities, the mutual aid may amount to only 5% of call volume, maybe less.
 
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1 single agency which includes transport (so, no 1 agency providing paramedics and a second agency providing BLS transport like is popular in Southern California). With one agency you have one contact point to go to if there are issues instead of having to determine which set of supervisors/exectutives you have to go to to get something fixed.

Also, one common treatment protocol. It's not going to end pretty if you're primary 911, I'm there as a still alarm and you want to transpot a patient who needs an intervention that you can't provide that I can.
 
I think it is a bad idea to have multiple providers.

NYC and extremely large cities maybe the exception since I doubt one municiple agency could possibly take care of the volume of calls without a major infusion of cash.

But in medium to smaller cities or even rural areas, I don't think it would be long before it turned into a Mother, Juggs, and Speed type event.

Look how multiple providers in a service area works out for the airmed industry. (or rather doesn't)
 
Simplicity.

Multiple = complexity

complexity X ego = boondoggles

boondoggles = many sucky medic moments
 
I'm a big fan of a municipal model for EMS, be it through the fire dept or not.

I also think that the Public Utility Model is workable, but only when there's enough money in it to discourage too much cost-cutting by the contractor.

I have never understood the rationale for the LA area system's ALS through the fire department, BLS through the transport agencies. That just seems so bizarre to me.
 
Veneficus said:
NYC and extremely large cities maybe the exception since I doubt one municiple agency could possibly take care of the volume of calls without a major infusion of cash.
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I'm sorry, but you are wrong. NYC is extremely large, yes it is. Doesn't mean it shouldn't cover all it's calls. The FDNY covers all of NYC. NYPD covers all of NYC. There is no reason why the municipality shouldn't handle all the medical emergencies that happen. FDNY EMS (or whatever municipal agency handles EMS) should handle all the EMS calls, that's why you pay taxes, that's why they bill insurance. After all, you don't see private companies providing fire suppression to parts of the Bronx or Staten Island, or PD answering 911 calls in midtown Manhattan.

1 provider, 1 standard of care, 1 level of training, 1 set of rules. everyone has the same equipment, protocols, background check, bosses, it's all equal. Everyone is on the same page, and in theory every patient would get treated exactly the same, regardless of which ambulance in the system shows up.

Once you start bringing multiple agencies into a system, it increases the potential for problems. For those systems that don't have enough resources to handle the routine volume, then it's the municipalities responsibility to properly fund and staff enough units, and contracting with a private service is typically a cheaper alternative but not necessarily a better one.
 
It is not that I don't believe a single municiple agency shouldn't do it. But we have to add some realism here.

If patients are waiting extended periods of time for an ambulance because their call was forever put on hold, then that is not an acceptable level of service.

The question is how much taxes are people willing to pay in order to get that level of service.

Take for example Philly or Detroit.

Look at the reduction in FDNY responses in areas where they do have alternate transport providers. If you suddenly added that to FDNY you would have to increase resources. The same with LA. Again, who is going to pay for this?

Raise taxes, sure, I agree, but the current political clime is rather toxic for suggesting that tax money actually buys essential services. Too many morons out there.
 
Yet these Fire based systems you mention don't rely on mutual aid for their fire load, do they. You could staff more ambulances with fewer fire trucks and still provide reasonable protection, although the IAFF and the rest will disagree. If they can rely on mutual aid and private ambulances on a daily basis to cover the sick and injured they can surely rely on mutual aid for fire protection....;)
 
boingo said:
Yet these Fire based systems you mention don't rely on mutual aid for their fire load, do they. You could staff more ambulances with fewer fire trucks and still provide reasonable protection, although the IAFF and the rest will disagree. If they can rely on mutual aid and private ambulances on a daily basis to cover the sick and injured they can surely rely on mutual aid for fire protection....;)
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We'd have to take this to PM.

I am sure we have a lot of common ground, but we also know how this discussion will play out on a public forum.
 
Veneficus said:
It is not that I don't believe a single municiple agency shouldn't do it. But we have to add some realism here.

If patients are waiting extended periods of time for an ambulance because their call was forever put on hold, then that is not an acceptable level of service.

The question is how much taxes are people willing to pay in order to get that level of service.

Take for example Philly or Detroit.

Look at the reduction in FDNY responses in areas where they do have alternate transport providers. If you suddenly added that to FDNY you would have to increase resources. The same with LA. Again, who is going to pay for this?

Raise taxes, sure, I agree, but the current political clime is rather toxic for suggesting that tax money actually buys essential services. Too many morons out there.
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In the case of NYC 911, it's different than other areas where the local gov't pays the private provider through a contract. If it they're not cutting a profit, they'll pack up and leave. These hospitals are contracted to provide 911 spots. If they get money from the city, which I don't think they do, they run in the red. I know that 911 at my old hospital ran in the red for pretty much the whole time I worked there. I asked why we were doing it if there was no money involved. I was told that running 911 buses provided good training and experience for our employees, which strengthened their performance at the IFT division. In addition, the 911 buses were advertisement for the hospital. If the pts received competent and courteous care, they'll be more apt to choose that hospital over others. What happened, though, is that many hopsitals participated in pt steering. That's where they took the insured pts to their home hospitals, and the uninsured to hospitals further away. Steering insured pts that need a cath, surgery, or a lengthy inpatient admission would more than cover the cost of the 911 service alone.

The two privates, Transcare and AMR were contracted by hospitals and ran 911 for them, just like the other voluntary hospitals that ran their own buses. I don't think there's any way the city could take back all these spots. That would have to be over a significant period of time, and would be cost prohibitive regardless.

Having multiple providers in that area creates problems with QA/QI, discipline, as well as inequality in hiring standards and equipment. In addition, their protocols are very much mother may I:

http://www.nycremsco.org/images/articlesserver/ALS_Protocols_January_2010_v01012010c.pdf

I was looking at these the other day. Down here we can do everything they do, actually a good deal more, and almost all by standing orders. Many of their interventions are medical control options. The telemetry docs require a full, detailed report that can take several minutes. I believe the abundance of med control options and a lengthy report to jump protocols and such is due to the numerous 911 providers. There's no standard for education and proficiency. This setup lets each doc get an idea of what kind of individual they're dealing with. That's why they need to give such a lengthy report, and sometimes the rationale for and effects of their tx before getting the blessing. This is for any deviation from the cookbook, BTW.

Edit: I believe that if it were just FDNY EMS, they could make the protocols way more liberal. There would be a clear minimum standard in education and proficiency, and the leniency of the protocols would reflect those standards. With all these different hospitals and privates, there's no way to really know who you have riding on that bus.
 
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boingo said:
Yet these Fire based systems you mention don't rely on mutual aid for their fire load, do they. You could staff more ambulances with fewer fire trucks and still provide reasonable protection, although the IAFF and the rest will disagree. If they can rely on mutual aid and private ambulances on a daily basis to cover the sick and injured they can surely rely on mutual aid for fire protection....;)
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We use automatic aid via AVL for all responses, for both EMS and fire. This is for all jurisdictions in the COG, which covers NOVA and southern MD. The closest unit gets the job. If there is surge in call volume, inclement weather/natural disater, or multiple fire boxes, then we have condition 2/condition 3 protocols. For example, in condition 2, a box alarm may only get one engine and one truck, unless it's a confirmed structure fire. Public service calls are held indefinitely. EMS responses only get one ambulance unless help is requested by the crew. Interstate MVA responses get only one bus and one engine, instead of a pair for each direction, which can be three to four directions since we have the 95/395/495 mixing bowl.

As far as adding buses, a good number of the newer medics here come from single role services. We would prefer medic fly cars and more buses rather than engine responses in many cases. Things will change, but we need to go up a few pay grades to make that happen. Speaking of which, we're eligible for our first promotion after only two years out of the academy. The EMS tech position always has openings. We can get to the Lt or Capt level in as few as 5-6 years post academy. That's where we get to participate in committees for this type of thing.
 
46Young said:
We use automatic aid via AVL for all responses, for both EMS and fire. This is for all jurisdictions in the COG, which covers NOVA and southern MD. The closest unit gets the job. If there is surge in call volume, inclement weather/natural disater, or multiple fire boxes, then we have condition 2/condition 3 protocols. For example, in condition 2, a box alarm may only get one engine and one truck, unless it's a confirmed structure fire. Public service calls are held indefinitely. EMS responses only get one ambulance unless help is requested by the crew. Interstate MVA responses get only one bus and one engine, instead of a pair for each direction, which can be three to four directions since we have the 95/395/495 mixing bowl.
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Rescue companies with transport capability makes this a much cheaper and efficent response.
 
Veneficus said:
Rescue companies with transport capability makes this a much cheaper and efficent response.
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I wasn't aware that there were heavy rescues that were txp capable. Our rescues are pretty much packet with equipment. In fact, the TROT rescues need to have the TROT supply truck come along to carry the extra equipment that won't fit on the rescue.
 
46Young said:
We use automatic aid via AVL for all responses, for both EMS and fire. This is for all jurisdictions in the COG, which covers NOVA and southern MD. The closest unit gets the job. If there is surge in call volume, inclement weather/natural disater, or multiple fire boxes, then we have condition 2/condition 3 protocols. For example, in condition 2, a box alarm may only get one engine and one truck, unless it's a confirmed structure fire. Public service calls are held indefinitely. EMS responses only get one ambulance unless help is requested by the crew. Interstate MVA responses get only one bus and one engine, instead of a pair for each direction, which can be three to four directions since we have the 95/395/495 mixing bowl.

As far as adding buses, a good number of the newer medics here come from single role services. We would prefer medic fly cars and more buses rather than engine responses in many cases. Things will change, but we need to go up a few pay grades to make that happen. Speaking of which, we're eligible for our first promotion after only two years out of the academy. The EMS tech position always has openings. We can get to the Lt or Capt level in as few as 5-6 years post academy. That's where we get to participate in committees for this type of thing.
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The NOVA COG is an excellent example of mutual response that works, but IMO it only works because all the jurisdictions have huge amounts of revenue relative to their population base and call volume. The counties/cities are overstaffed/overdeployed, and the overdispatching really goes a long way to padding the call volume with non-calls for the units.

It would be interesting to see how this works in an area that's much more urban or less suburban, to see how that increased density and call volume affects the mutual response agreements.
 
Veneficus said:
Rescue companies with transport capability makes this a much cheaper and efficent response.
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How does this work? How could one company get all the necessary tasks done and get the patient off the scene? Seems like it'd be much cheaper and more efficient until you have to call a second unit to handle the cleanup while you're on the way to the hospital.
 
abckidsmom said:
How does this work? How could one company get all the necessary tasks done and get the patient off the scene? Seems like it'd be much cheaper and more efficient until you have to call a second unit to handle the cleanup while you're on the way to the hospital.
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The fire department rescue companies i am familiar with and served with have minimum 6 and usually 8 guys on duty per shift. A minimum of which 3 are always medics.

They do not do clean up, overhaul, etc. They do rescue and transport. at a structure fire they can be utilized as a truck company.
 
Veneficus said:
The fire department rescue companies i am familiar with and served with have minimum 6 and usually 8 guys on duty per shift. A minimum of which 3 are always medics.

They do not do clean up, overhaul, etc. They do rescue and transport. at a structure fire they can be utilized as a truck company.
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So if they're dispatched to an interstate MVA, how does this save money and time on the response? Do they just go, do the extrication, then pack up the patient and all their gear and leave?

The typical response that 46 was talking about is a reported interstate MVA at X mile marker, westbound would get a rescue engine or rescue company and a medic going east AND the same response going west, given the unique traffic woes of the NOVA area. Whoever gets access to the scene first is the one that handles the call.
 
Single provider always.

Before we say the area is too big go look at Ambulance Victoria, the Ambulance Service of New South Wales and Alberta Health Services they are some of the largest geographic services in the world and do it pretty well.
 
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