Studies on ALS first response and tiered vs. all-ALS

[46Young]

Does anyone have any links to studies to the efficacy or ineffectiveness of ALS first response in pt outcomes?

Does anyone have any studies on the tiered BLS/ALS vs an all ALS system?

Background:

My department has 41 ambulances - 37 ALS, four BLS. 15 ALS are double medic, 14 have an EMS officer as one of the medics, and are for training. The remainder are medic/EMT staffed. We have 37 engines that have a medic and ALS equipment as minimal staffing. We have eight Heavy Rescues, which may or not be ALS. We have seven EMS Captains, which are all medics, and also carry ALS equipment. We also have 14 Truck companies that are BLS.The population is 1,080,000 or so, on 395 sq. miles.

We use a version of EMD that was changed to include many more calls as ALS. On each first due ALS call we have an engine or medic response. On a second due, an engine from that first due will respond. On highway incidents, we get an engine and medic for each direction, and a rescue/BC/EMS Capt. if it's a possible pin job. EMS Captains are dispatched on all cardiac arrests, and on all ALS calls where the medic on the medic/EMT ambulance is the sole provider. The county has a policy of requiring two medics on every ALS call.

I feel that this is overkill. We used to have a tiered system. All of our medic/EMT buses used to be BLS. having every engine ALS is also overkill, IMO. I'd like to see studies that would show that we don't need ALS engines (or to the contrary). I would also like to see studies that advocate a tiered system (or to the contrary).

Examples of systems in use as an example would be useful as well.

Thanks.

 

[atropine]

I think that LA CO FD does a great job with their current systme. They have a BLS engine on every call, and ALS squad and a BLS ambulance, so if ALS is not needed the engine can cancell them prior their arrival, or after an assesment had been made and the pt. does not require ALS, then the pt. may go by BLS ambulance. They have been doing this for years.

 

[medicdan]

I think that LA CO FD does a great job with their current systme. They have a BLS engine on every call, and ALS squad and a BLS ambulance, so if ALS is not needed the engine can cancell them prior their arrival, or after an assesment had been made and the pt. does not require ALS, then the pt. may go by BLS ambulance. They have been doing this for years.

Wait, 3 apparatus on EVERY call? Isn't that a bit much? If you like ALS first response, put a medic or two in an SUV, why send a million dollar engine, squad and ambulance on every call?

46Young, I've been looking for data like this for some time, and not been able to find much... it's clear that no two systems are designed the same way, and the variables that measure "outcome" are so big.

How many hospitals are in your service area? Level/Type? Transport time? Where are ambulances based? staged? what's the system response time (call to apparatus on scene? What percentage of calls are "ALS'd"?

 

[KingCountyMedic]

We have had a Tiered Response System since we started 40 years ago. We do tons of studies and our numbers are pretty darn good. Having a Paramedic on every rig on every street corner is bad for the patient and the Medic.

Paramedics on all the rigs is all about the $$$! You stick an IV and throw on the heart monitor you just doubled the bill in most places. Also a Firefighter/Paramedic is worth more money to the Union than a Firefighter EMT

The Medic overpopulation in our land is a huge problem and it's dumbing down our profession.

http://en.wikipedia.org/wiki/Seattle_&_King_County_Emergency_Medical_Services_System

 

[JPINFV]

Wait, 3 apparatus on EVERY call? Isn't that a bit much? If you like ALS first response, put a medic or two in an SUV, why send a million dollar engine, squad and ambulance on every call?

I was driving home a few days ago and saw 4 (LACo engine company, truck company, medic squad, and private service BLS ambulance) on a call. Considering that as I was approaching was when the ambulance arrived (code 3), and about a minute later (I could hear the siren, so I pulled into a parking spot after passing the building they were responding to), the squad arrived (also code 3), I doubt that it was a fire alarm.

 

[usalsfyre]

Seen similar in this area, the most ridiculous of which was a truck, an engine, a BC and a medic unit shutting down three of four interstate lanes for a motorcyclist that was down on the shoulder. I understand the roadway safety thought, but the best way to keep from getting hit is to GET OFF THE FARKING ROAD which should have been easy to do in this case.

 

[Fish]

I think that LA CO FD does a great job with their current systme. They have a BLS engine on every call, and ALS squad and a BLS ambulance, so if ALS is not needed the engine can cancell them prior their arrival, or after an assesment had been made and the pt. does not require ALS, then the pt. may go by BLS ambulance. They have been doing this for years.

La CO FD, and LA City are two of the worst EMS systems in the nation. They have some of the smallest and most restricted protocols and have horrible performance Data.

3 Apparatus on every call is doing the tax payer an injustice, that is inefficient. There is no need for a tax payer to pay for that many apparatus and that many personnels salaries, pension, benefits to show up to every call.

"they have been doing this for years" and it is outdated, and the cities are as broke as the EMS system.

Here is a link for the OP
http://www.ems1.com/fire-ems/articl...ween-quick-EMS-response-and-survival-chances/

 

[terrible one]

I think that LA CO FD does a great job with their current systme. They have a BLS engine on every call, and ALS squad and a BLS ambulance, so if ALS is not needed the engine can cancell them prior their arrival, or after an assesment had been made and the pt. does not require ALS, then the pt. may go by BLS ambulance. They have been doing this for years.

LA county is the epitome of an archaic, inefficient, costly service with no evidence based data to support any of their current practices. Having multiple apparatus dispatched simultaneously with multiple paramedics is not quality patient care.
They could simplify their entire system saving millions of dollars to the tax payers and improve patient care by creating an EMD program and reducing the number of providers/equipment required to each call. Yet they continue to rely on hypothetical sceanrios requiring an engine/squad/ambulance on EVERY patient.

 

[46Young]

We have had a Tiered Response System since we started 40 years ago. We do tons of studies and our numbers are pretty darn good. Having a Paramedic on every rig on every street corner is bad for the patient and the Medic.

Paramedics on all the rigs is all about the $$$! You stick an IV and throw on the heart monitor you just doubled the bill in most places. Also a Firefighter/Paramedic is worth more money to the Union than a Firefighter EMT

The Medic overpopulation in our land is a huge problem and it's dumbing down our profession.

http://en.wikipedia.org/wiki/Seattle_&_King_County_Emergency_Medical_Services_System

Agreed.

When you look at my department, we easily have the resources to do what you do:

http://en.wikipedia.org/wiki/Fairfax_County_Fire_and_Rescue_Department

You also have five times the land, and a 40% higher population.

Where can we access your department's studies?

 

[46Young]

Wait, 3 apparatus on EVERY call? Isn't that a bit much? If you like ALS first response, put a medic or two in an SUV, why send a million dollar engine, squad and ambulance on every call?

46Young, I've been looking for data like this for some time, and not been able to find much... it's clear that no two systems are designed the same way, and the variables that measure "outcome" are so big.

How many hospitals are in your service area? Level/Type? Transport time? Where are ambulances based? staged? what's the system response time (call to apparatus on scene? What percentage of calls are "ALS'd"?

Seven area hospitals, four of which are Stroke/CVA centers, one of which is a Level One Trauma Center. Response times are around 8 minutes, last I've heard. The ambulances are all based in our fire stations. Probably upwards of 70% of our calls are "ALS'd."

The wikipedia link in my above post gives a little more info.

 

[46Young]

Seen similar in this area, the most ridiculous of which was a truck, an engine, a BC and a medic unit shutting down three of four interstate lanes for a motorcyclist that was down on the shoulder. I understand the roadway safety thought, but the best way to keep from getting hit is to GET OFF THE FARKING ROAD which should have been easy to do in this case.

It's standard practice to take one lane more than you what the accident covers. Many MVC vs first responder or vs parked apparatus and many more close calls make this necessary, however inconvenient this may be. Really, if you give these animals an inch, they'll gun it right past (or through) you.

But, for a shoulder, it should have only been one lane, maybe two tops since you have responders using the first lane. Always one more than you need.

 

[usalsfyre]

46Young, I get closing lanes down while the incidents going on. What I don't get is blocking the lanes, then having all the units "hang out" in the roadway for 30+ minutes when it's a patient that could easily be packaged and gone in ten, especially when your about six minutes from a major Level I trauma center.

If your really concerned about getting hit, get off the road as quickly as possible. Otherwise blocking lanes is just paying lip service to safety. Not only will you reduce your exposure, your citizens will appreciate it.

 

[46Young]

46Young, I get closing lanes down while the incidents going on. What I don't get is blocking the lanes, then having all the units "hang out" in the roadway for 30+ minutes when it's a patient that could easily be packaged and gone in ten, especially when your about six minutes from a major Level I trauma center.

If your really concerned about getting hit, get off the road as quickly as possible. Otherwise blocking lanes is just paying lip service to safety. Not only will you reduce your exposure, your citizens will appreciate it.

We're all about getting off the road as soon as possible. Besides there being much better places to socialize, it's also very dangerous.

When I'm riding as OIC of the medic, we look to be off the scene in under ten minutes. The engine only stays there long enough to block for us.

 

[Fish]

Besides there being much better places to socialize,

Like Chipolte, over a burrito bowel?

 

[JPINFV]

Like Chipolte, over a burrito bowel?

I hope the fire departments have a good supply of Chipolte-away.

 

[denadog]

LA county is the epitome of an archaic, inefficient, costly service with no evidence based data to support any of their current practices. Having multiple apparatus dispatched simultaneously with multiple paramedics is not quality patient care.
They could simplify their entire system saving millions of dollars to the tax payers and improve patient care by creating an EMD program and reducing the number of providers/equipment required to each call. Yet they continue to rely on hypothetical sceanrios requiring an engine/squad/ambulance on EVERY patient.

If you have to pay the firefighters to be on the rig and in the station whats wrong with them running 6 or 7 medical calls a day and usually arriving on scene to provide patient care in the first couple of minutes before the paramedics can get there? The fact is that the closest rigs with EMTs are fire engines and they can usually BLS a call by canceling the squad and then let the private ambulance transport. On ALS calls the squad can usually handle with the ambulance and let the engine or truck go available to run another call. How could you save money any other way without drastically increasing response times? Put two medics on every engine in the county and pay them way more? This system seems to make sense to me and as a citizen who lives in LA County Fire service area I can't say that myself, my family, or anyone I know has ever had a poor experience with LA County Fire EMS or the private ambulances.

 

[JPINFV]

1. Increased cost of fuel and wear and tear on rather expensive pieces of fire fighting equipment.

2. Increased pay, because the fire fighters aren't going to do it for free.

3. It reduces pressure to demand more ambulances, thus reducing the number of ambulances in the system, unless we want to start demanding that engines can transport.

4. Who responds to the fires when the engine is on an EMS run?

5. Who responds to EMS calls when the engines are on fires?

 

[Fish]

1. Increased cost of fuel and wear and tear on rather expensive pieces of fire fighting equipment.

2. Increased pay, because the fire fighters aren't going to do it for free.

3. It reduces pressure to demand more ambulances, thus reducing the number of ambulances in the system, unless we want to start demanding that engines can transport.

4. Who responds to the fires when the engine is on an EMS run?

5. Who responds to EMS calls when the engines are on fires?

Agreed, squads and squads only should respond to EMS runs. It does not require a half million dollar fire fighter apparatus

 

[abckidsmom]

Agreed, squads and squads only should respond to EMS runs. It does not require a half million dollar fire fighter apparatus

You mean ambulances?

 

[Fish]

You mean ambulances?

Well and ambulance to, but that post was referring to LA COunties system of sending a squad and an Engine and then a private service sending the ambulance, i was stating that no need for the engine as far as FD is concerned. A squad and a Squad only(only with the private service ambulance) can handle it.