HomeMy WebLinkAboutM1985-0119 - 03/12/1985• MOTION5 - 3/12/85 •
1. Approving recommendations of the Aid Ambulance Advisory Committee
concerning the future operations of emergency medical services with
quarterly reports to the Council on the progress of the services. (This
item was from the Emergency Posting of 3/12/85)
M85 -0119
March 4, 1985 •
TO Mayor and Council Members
FROM AID Ambulance Advisory Committee
SUBJECT Report on Emergency Medical Services
Approximately one year ago the AID Ambulance Advisory Committee
concurred with the recommendations of the City Manager that he set
up an Ad Hoc Committee consisting of interested and knowledgeable
people in the community to review the current ambulance service and
to make recommendations for the future.
Attached to this memorandum is a copy of the report which was prepared
by this Ad Hoc Committee and submitted to the AID Ambulance Advisory
Committee for their review. The Advisory Committee has now completed
its review of this report and is recommending it in its entirety
to the City Council for adoption and implementation with one amendment.
The one amendment has to do with the question of whether a third
service providing just ambulance and emergency medical services should
be set up or if it can be handled within the Fire Deprtment. The
Advisory Committee feels that if certain agreements can be reached
between the City and the Fire Department an attempt should be made
to operate it within the department.
A copy of a report by a subcommittee of the AID Ambulance Advisory
Committee on this issue is also attached setting forth the types
of things that will be necessary to make this happen.
It is therefore the recommendation of the AID Ambulance Advisory
Committee that the City Council adopt the report of the Ad Hoc
Committee on the future of emergency medical services in total with
the following amendment:
That the establishment of a separate third service for emergency
medical services be deferred and that subject to the City
and the Union agreeing on the changes set forth and others
that might be appropriate to make it work within the department
that it be kept there and that the necessary changes and
contract language be made to implement it in such a fashion.
We believe that with the City Council adoption and assistance in
the implementation of these recommendations, the residents of Corpus
Christi will have the best possible emergency medical services.
We urge you to adopt this rl?port and direct that it be implemented
as set forth.
MFebruary 28, 1985
TO Chairman and Members of AID Ambulance Committee
FROM Subccmmittee on Ambulance Service
SUBJECT Ambulance Report
At the February 13, 1985, meeting of the Aid Ambulance Advisory
Committee the Committee discussed the report on ambulance service
prepared by the Ad Hoc Committee on Emergency Medical Services.
A motion was made to adopt this report and recommend it to the City
Council for implementation. This motion was then tabled until March
lst and you appointed a subcommittee consisting of Edward Martin,
Dr. Richard Davis and Dr. Bud Holt to further discuss the concerns
that were raised and presented to the Aid Ambulance Committee by
the "Concerned Firefighters, EMT's, and Paramedics of Corpus Christi.
This subcommittee met on February 20 along with members of this group,
in particular, Buck Sosa, President of the Firefighters Union, Captain
James Mitchell, Firefighter II Robert Clary, and Firefighter II Robert
Branch, and the Subcommittee only met again on February 28.
At these meetings what was discussed and reviewed was whether it
would be possible and feasible to implement the goals and objectives
set forth in the report of the Ad Hoc Committee and at the same time
allow the ambulance service to remain within the Fire Department
and not set up a separate service. It is our belief that the meetings
were very productive and at the meeting with the representatives
of the department we identified some concerns and problems that would
exist with keeping it within the department and some of the things
that would be necessary to change if we were to try and do this.
We believe that a concensus was reached on some common goals and some
changes that will be necessary to keep it within the service. It
was generally agreed that to make it work within the service, the
following types of general concepts would be necessary to be accepted
by both the City, its management, and the management and members
of the Fire Department:
1. All new employees of the Fire Department would be
required to be certified paramedics prior to hiring
and would be required to remain certified as paramedics
and proficient as a condition of employment.
That we would need to promote a positive attitude
regarding EMS and a recognition by all that EMS is
a primary responsibility of the Fire Department.
We would need to work with educators and supervisors
to document proficiency and improve knowledge and
skills and to support disciplinary action for those
unwilling to do so.
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4. There would need to be frequent rotation of station
assignment.
5. We would need to encourage the maintenance of EMT
and paramedic skills and certification throughout
their career at all levels and ranks.
6. It would probably be necessary to employ a civilian
administrator to direct the operations of the EMS
Division, but this must be done in accordance with
State Law.
7. There would need to be total flexibility and confidence
in trying new methods of assignment to the EMS service
and to manage it in the most flexible manner possible.
B. To implement this it would be necessary that the present
paramedics be willing to certify this year so that
we could begin this restaffing and development of
the paramedic required program.
To implement the above and the theme of what is presented in these
points, there would need to be a number of areas of agreement between
the City and the Firefighters Union to allow management an opportunity
to develop an operation that is innovative and designed to meet the
citizens long term needs and the needs of the service. Some of the
types of changes that would be necessary within existing documents
would be:
1. Ambulance personnel would need to be assigned to
ambulance duty every shift until re- assigned to
suppression or other activities.
2. There would need to be flexibility to transfer to
and from the ambulance activity at the discretion
of management.
3. The assignment of hours, work schedules, and station
assignments for EMS would be determined by management
to provide an opportunity to test peak hour schedules,
shorter hours per tour, etc.
4. As stated above recertification would be mandatory
and it would be the responsibility of the employee.
5. Familiarization training in newly assigned activities
would be required if the individual has not worked
in that activity for an appropriate period prior to
the transfer.
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6. We need to remove certain sections in the contract
that are not applicable or are detrimental to the
goals of this program.
7. We would need to rewrite the management rights and
prevailing rights clauses to allow implementation
of these common goals.
8. We need to work toward eliminating special rank
provisions for EMS and replace it with an appropriate
recognition of certification requirement.
The goal of these changes and others that might be required would
be to create the EMS activity as an integral part of our departmental
operations and to remove some of the both special recognition or
special identification or differentiation that currently takes place.
The subcommittee has worked out these changes and systems in
recognition of the attitude, goals and concerns presented by the
members of the department. We do believe that with this commitment,
a part of both parties, we could end up with the best of all worlds,
the best fire department and the best EMS service for the citizens
of Corpus Christi. We acknowledge that there will be some difficulties
and it will take a great deal of cooperation on both sides to make
this happen. As such if it proceeds in this fashion, we recommend
that the AID Ambulance Advisory Committee maintain a monitoring role.
With the above in mind, it is the recommendation of this special
subcommittee that the AID Ambulance Advisory Committee take the
following action:
Adopt the motion to implement the report of the Ad Hoc Committee
on the future of emergency medical services in total with
the following amendment: That the establishment of a separate
third service for emergency medical services be deferred and
that subject to the City and the Union agreeing on the changes
set forth above and others appropriate to make it work that
the service be maintained within the Fire Department and
necessary changes in contract language and administrative
rules and regulations be made to implement it in such fashion.
We believe that this is a common goal and if both parties,
the City Manager and the Fire Chief and the Union and
representatives of the Firefighters are prepared to concur
with these changes at this time that we should move ahead
in that fashion with careful monitoring by the Advisory
Committee.
Concurrence: City /s/ Edward A. Martin Firefighters /s/ Buck Sosa
in Principle
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REPORT OF
AMBULANCE AD HOC COMMITTEE ON THE
FUTURE OF EMERGENCY MEDICAL SERVICES
IN CORPUS CHRISTI, TEXAS
February, 1985
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INTRODUCTION
AID Ambulance, a joint effort between the City of Corpus
Christi and the Nueces County Hospital District, began operation
in 1973 because the existing private ambulance operators at that
time were not providing the quality of service that was desired in
the community and were not interested in significantly improving
the quality of their service. Five ambulances were placed in service
making emergency and non - emergency transportation calls. The demands
on the service grew rapidly, and in 1981 sophisticated equipment
and training were added, and the service moved to the Advanced Life
Support level. Because of increasing complexity of calls, volume
of calls, and geographic spread, the service in 1982 terminated
provision of non - emergency transportation, relinquishing that activity
to private operators. The service now routinely staffs six ambulances
with a minimal increase in staffing, despite markedly increased
utilization.
This type of growth in emergency medical services and
technology has not been unique to Corpus Christi; it has occurred
nationally. While fire departments were the logical choice to inherit
emergency medical services in infancy, the burgeoning growth of those
services has created enormous intrusions and hardships on those fire
departments, and communities nationwide are finding that the
requirements and disciplines of these two fields are so diverse that
their separation may well be in the best interest of both. Cities
across the country are now, approximately ten years later, reassessing
the EMS programs in an effort to chart a course which will allow
for the delivery of the highest quality of emergency medical services
to their citizens in a most efficient manner.
COMMITTEE
This Ad Hoc Committee has undertaken a detailed study of
Emergency Medical Services in Corpus Christi, and has met over a
period of six months to thoroughly investigate the future of EMS
in this area. The committee has had only one objective: a plan
which would provide for the best in emergency care for the citizens
of this area, both now and in future years. All of its recommendations
are proposed in that light and with that goal in mind.
Members of the committe are:
Mr. Bruce Addison, Director of EMS Training, Del Mar College
Mr. Leo Barrera, Jr., Planned Health of Corpus Christi
Mr. Lee Butler, Director of Materials Management, MMC
Dr. C. M. G. Buttery, Director, City- County Health Department
Dr. Richard Davis, Medical Director, AID Ambulance
Dr. David Gray, Emergency Room Physician
Dr. John Kovaric, General Surgeon
Mrs. Mildred Norris
Dr. Marcelo Rodriguez, City- County Health Department
Mrs. Linda Spears, Director of Personnel, MMC
Mr. Mark Wagner,.Paramedic, Corpus Christi Fire Department
Ms. Pam West, Director of Regional EMS, COG
BRIEF SYNOPSIS
This committee sees as mandatory for the continued provision
of quality ambulance services the establishment of an Emergency Medical
Services Department of the City of Corpus Christi. This department
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would be responsible for the administration of emergency medical
service, and would be separate from existing departments. It would
employ motivated professionals whose career goal is emergency medicine,
and would enable them to pursue their chosen profession with the
dedication and enthusiasm that can only be present when one is doing
the work one truly loves. Ranking supervisory positions within this
department would provide for rank advancement opportunity, and thereby
create additional incentive for superior performance.
Continuing supervision and education would be provided by
those specially trained in these areas, thus ensuring that those
providing emergency medical services will be current with the latest
developments in the rapidly advancing field of emergency medicine.
In addition, strict observation of skills and documentation of
proficiency will improve the confidence of the entire community in
the quality of service, and will provide strong legal defense should
such be necessary. The department should continue to respond to
all calls with a MICU -type vehicle, but should progress toward staffing
each vehicle with two paramedics and an EMT driver.
Shift lengths must be shorter than at present - 14 hours
should be a maximum. More flexible staffing and deployment of
ambulances must be begun, and plans must be made immediately to provide
ambulances for newly developing population centers in our community.
Further development of ancillary sources of personnel must be studied,
including the training of those other than department personnel as
First Responders. Also, the use of part -time personnel and the
development of an Emergency Medical Services Reserve, all of whom
would meet the same training and documentation of proficiency as
full -time employees, should be inaugurated.
Further details about the creation of this department follow
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later in this report. This department, however, allows the flexibility
for emergency medical services in Corpus Christi to develop as the
citizens desire - to provide the best of care, and to be easily
scrutinized regarding both quality of care and fiscal responsibility.
PROBLEMS IN CORPUS CHRISTI FIRE DEPARTMENT
There have been a number of problems with EMS in the Corpus
Christi Fire Department. These are not necessarily criticisms of
the department or of any individuals, but merely an assessment of
the way things exist today. The disparity between the work loads
of the firefighter assigned to the fire truck and the one assigned
to the ambulance has sometimes created an attitude of negativism
toward the ambulance service, with the result that many if not most
firefighters strive to get off of ambulance duty as soon as possible.
Retention of personnel with experience in EMS has been difficult.
In addition, because of department and civil service structuring,
a seasoned paramedic will have to rotate out of EMS in order to advance
in rank. The responsibility of remaining current in both fire
suppression and emergency medicine (and at the same time working
in these fields) is so burdensome that few can achieve it
satisfactorily, and if one wishes to advance in rank, then one must
maintain fire suppression knowledge. Because of well - established
departmental structure, it has been difficult to institute effective
continuing education and supervision with documentation of proficiency.
This is partially due to a subconscious resentment of outside
interference, and perhaps partially due to an attitude fostered by
a strong union that one must protect his fellow workers from criticism
at all costs. The result is that documentation of continued
proficiency, and therefore disciplinary action against any who might
not maintain that proficiency, has been inadequate. Though some
department personnel are supportive of EMS, some are overtly hostile,
and others are less than enthusiastic.
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These factors, and more, have contributed to an increasing
problem with trying to staff the ambulances with competent and
motivated personnel. Volunteers for paramedic training and the rigors
of EMS duty have become increasingly difficult to obtain. The bottom
line in terms of real job commitment, whether in EMS or in any other
field, is this: if a person doesn't enjoy his job, and isn't motivated
to excel, then his performance will not be superior. We are now
at a point of taking people who want to be firefighters, and forcing
them to function in another complex and stressful field in which
they may have no real desire to participate.
LEVEL OF STAFFING
In the past, each Mobile Intensive Care Unit (MICU) in the
AID Ambulance system has been staffed by one Paramedic and one EMT.
On some calls, this can be an inadequate amount of highly trained
help thus requiring additional backup support. The procedures which
an EMT may perform have recently been further limited by state law,
and this level of staffing may provide less than optimal care,
especially in the treatment of critically ill patients who require
multiple complex and sophisticated procedures and treatments
simultaneously for stabilization.
It is recommended that Corpus Christi EMS plan for staffing
each MICU with two paramedics and one EMT Driver as a future goal.
As intermediate positions toward this goal, the department should
begin staffing as soon as possible with two paramedics per ambulance.
Transition through this single employee level will provide badly
needed flexibility in manning each ambulance daily with those who
are available. As all shifts are suitably staffed with two paramedics
per ambulance, then additional EMT /Driver positions could be staffed.
This goal in staffing with three persons is one that has been realized
in many cities, and has markedly improved not only the patient care,
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but has dramatically reduced the number of times in which an additional
vehicle must be dispatched to provide more manpower. The employment
process should include an evaluation of performance score on
certification examinations, skills evaluations, personality assessment,
and an evaluation of previous emergency medical and ambulance
experience.
RECRUITMENT
All previous ambulance attendants, whether Paramedics or
EMTs, have been personnel hired by the city to be firefighters.
They have been trained as EMTs, and volunteers undertook further
training as. Paramedics. Recently, however, the supply of volunteers
has been inadequate, and as a result there are severe impending
staffing problems.
Since motivation is the key factor in how well a person strives
to do his job, it is now imperative that persons be hired who want
to be EMS personnel as a profession. Cross - training of any other
group results in a personnel pool that is less than enthusiastic,
and will give less than optimal performance. A method to attract
personnel through advertisement in trade magazines that are distributed
state -wide and nationally should be utilized, along with a job
description and minimal requirements for each position. An application
and evaluation process must be instituted which allows for critical
evaluation of each applicant.
RETENTION
Retention of employees in the AID Ambulance Service has been
a major problem for the Fire Department. This is in part due to
the fact that this area of activity is not the major career goal
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of the individuals involved. In addition, there is a great disparity
between the average amount of work (and lack of sleep) during the
shift spent working on the ambulance and that spent working on the
fire truck. Currently a person assigned to ambulance duty works
one 24 -hour shift on the ambulance, and his next 24 -hour shift three
days later is spent working on the fire truck. Because of the
intensity of the work load, and the complexity of the decisions and
mental functioning that is required while working on the ambulance,
a 24 -hour shift is too lengthy. Because the ambulance activity is
small within the department, only a minimum number of rank positions
exist. Therefore, rank advancement within the ambulance activity
is almost impossible. To advance, one must advance up the ladder
in fire suppression; and so, even if motivated to remain in ambulance
work, an individual is forced to leave it in order to advance in
rank. Shift supervision is provided by the Assistant Fire Chiefs,
who are not trained in emergency medical care. Because the personnel
are governed by State Civil Service Rules and because of the existence
of a collective bargaining contract between the City and the
firefighters' union, flexibility to change career structuring within
the department is severely limited. These two documents provide
for promotion of an individual who has met certain requirements to
vacant positions in all activities within a department. This does
not allow a person to obtain a promotion and remain in the same
position. The contract also permits an employee to leave the ambulance
service after having served there for five years, thus depleting
this activity of its experienced personnel.
The establishment of a separate EMS department would attract
those who are truly motivated to provide emergency medical care.
It would allow for a career ladder and for promotional opportunity
that would retain progressive and experienced personnel. Paramedics
would be directly supervised by those more sensitive to their needs,
shift lengths would be shorter and therefore less exhausting, and
continuing education and supervision would document and improve their
continuing performance.
TRAINING
In the past, new recruits of the Corpus Christi Fire Department
have undergone fifteen weeks of firefighter training, followed by
five weeks of EMT training and then an additional twenty weeks of
Paramedic training. Texas EMT certification requires a minimum of
135 hours of classroom and skills training, but programs in Corpus
Christi have always felt that 200 hours is about the minimum time
in which the material can be adequately taught, and have provided
this amount. The depth of material is such that a student can attend
class eight hours per day, thus requiring about five weeks for EMT
training. Formal Paramedic training requires an additional 400 hours
above the EMT level, but the complexity of the material is such that
one can only spend four hours per day in class, thus requiring about
twenty weeks to complete the training. One can easily see that,
with vacations, schedule variations, etc., it takes the city almost
a full year (with salary and benefits paid) from employment of a
new recruit until the time that he is fully trained.
The employment of persons already trained and certified as
Paramedics would thus reduce the original training time to
approximately four weeks. This time period would be necessary to
orient new employees to specific city and county geography, protocol
procedures, and facilities, and to allow for supervision of initial
performance. The length of training time would thus be reduced from
over 1200 hours to about 160 hours. The fire department would maintain
EMT training for its personnel, but would eliminate the 400 hours
of paramedic training now required.
PERSONNEL SOURCES
There are many sources of Paramedics who are already trained,
and in many cases, experienced. Many of these individuals already
reside in this area. Some are employed as Paramedics, but many are
employed in other job areas because, though they would prefer to
be Paramedics, they are unwilling to be firefighters also. A number
of community colleges in the state have Paramedic training programs.
Del Mar, Bee County, San Antonio College, and Austin Jr. College,
for instance, produce about 50 -100 EMTs and Paramedics per each year.
A number of local programs also produce 25 -50 EMTs and Paramedics
per year, such as Refugio. Sinton, and Rockport in our area. These
can be attracted by advertising in the trade magazines and at training
institutions. Other sources would be from hospital personnel, fire
department Paramedics, etc. It is anticipated that these latter
sources would be of more value during a transitional period than
for provision of a significant number of long -term employees.
A valuable resource which is available for future development
is that of volunteers, or reserves. While one cannot formulate his
basic staffing needs on a volunteer basis, there are a large number
of fully trained and competent personnel who would be interested
in the development of a part -time volunteer program, such as those
that have been so successful in law enforcement agencies throughout
the state. Shorter shift lengths make this type of staffing, or
partial staffing with part -time employees, much more feasible. All
volunteer or part -time employees would have to meet the same stringent
proficiency criteria and on -going education requirements of full -time
employees, but the additional manpower during peak load times would
be an invaluable resource which should be tapped after the basic
system is operating smoothly.
Additionally, it is anticipated that the development of a
rotational program with major local hospitals would allow for the
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rotation of some of their emergency room personnel on the ambulance.
This allows for a sharing of experience and the establishment of
a closer working relationship between EMS personnel. This source
might often provide additional staffing during peak demand times,
and should also be easy to develop to the benefit of both the hospitals
and the ambulance service once routine organization is completed.
RESPONSE
In any assessment of emergency medical care, one must study
the type of person and the type of vehicle which responds to any
particular call. When AID ambulance first began, attendants were
EMTs providing basic life support. Though the modular ambulance
was used, it did not contain the sophisticated equipment necessary
to provide advanced life support. In 1981 the system advanced to
Paramedic level, and cardiac monitors, defibrillators, advanced drugs,
and telemetry equipment were added to the ambulances, making them
true Mobile Intensive Care Units. One has the option of having a
system entirely composed of MICUs, or of having some lesser type
of vehicle. In addition, one has the choice of initially dispatching
some other type of vehicle - a fire engine, for instance, and then
sending the MICU only if it is determined that its sophisticated
level of care is truly needed. Inherent in either approach (called
a tiered response system) is the risk.of dispatching a lesser vehicle
than needed, with inherent delay for the patient. In addition, though
there may be an equipment saving in purchasing a basic ambulance
rather than a MICU, the saving is soon overshadowed by the additional
staffing required to man both vehicles.
In some cities, the Emergency Medical Service does not
transport patients at all. Emergency care and stabilization are
rendered at the scene, and then transportation is provided by private
operators. This approach would not likely be feasible for Corpus
Christi because of a number of factors, and the problems of
implementation would make it virtually impossible in our community.
It is also fraught with potential liability problems and legal
entanglements.
Corpus Christi has a number of unique problems when one
examines the area of response to calls for emergency medical service.
In addition to per capita ratios for the number of available
ambulances, one must also examine geographic area and, especially
in the case of our city, geographic spread as well. These distances
created by the geographic size and shape of our service area make
the efficient but cost effective delivery of emergency medical care
difficult, and make it mandatory that one not engage in any activity,
such as routine transportation calls not of an emergency nature,
which would adversely affect response time to true emergency calls.
Because of these unique geographical factors, Corpus Christi
is an excellent example of a city that would benefit dramatically
from an improved "first- responder" system. This would provide basic
training for those most likely to arrive at the scene prior to the
ambulance. For example, not only would firefighters be trained as
EMTs and available for dispatch to a call when the ambulance is
distant, but additionally, police officers could be trained first
responders or EMTs as well. This is not to imply that they would
frequently render involved care, but because of their logistical
deployment, they would be close at hand in the event of a true
emergency when there was expected to be a delay in arrival of the
ambulance.
Critical, however, to the delivery of prompt emergency medical
care is flexibility in staffing. This has already been addressed
to some degree, but increasing the manpower per ambulance and /or
the number of ambulances in service to correspond to peak demand
times must be considered. This can be done much more easily with
a system that utilizes shorter shifts, part -time or volunteer
personnel, and it not tied to the shift structure of another
organization whose shift length and timing are selected to best serve
the provision of a different type of service.
Flexibility in deployment or location of ambulances must
also be addressed. Even if one does not change the number of
ambulances in service, a relocation of their geographic distribution
according to peak demand varying with time of day, day of the week,
etc., would provide the means for shortening response time. Data
to assist with determinations such as these are already available
by census tract analysis of calls according to time, day, and nature
of call.
In addition, growth of the service to serve growing population
centers in our community must be addressed. Our current level of
functioning with six ambulances in service is often inadequate, and
with progressive growth at both extremes of the geographic spread
of our city, we must plan now for the addition of another MICU.
DISPATCH
Dispatching is the heart of any Emergency Medical Response
System, and increased training and supervision must be made available
to all dispatchers of EMS vehicles and personnel. The dispatcher
must be able to promptly dispatch the appropriate EMS vehicle after
assessing priorities among concurrent calls, but must also be able
to make decisions about dispatching other first responders in
appropriate cases. After vehicles are dispatched, this key person
must be able to give appropriate emergency management advice to the
caller by telephone in order to aid the victim until the arrival
of the EMS personnel. EMS dispatching function in Corpus Christi
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should be integrated into the current plans for Central Dispatch,
but must have trained personnel. The enhanced 9 -1 -1 telephone system
would be a valuable asset in response to the many calls where
information is inaccurate due to the excitement of the calling party,
and would result in much more rapid arrival of trained medical
assistance.
EQUIPMENT
Drugs and medical supplies are currently obtained through
Memorial Medical Center in a system that seems to work well. Vehicle
maintenance is done at the City Service Center. Because of the complex
nature of the MICU equipment and vehicle, down time is a major
continuing problem. It is mandatory that personnel responsible for
ambulance maintenance continue to work closely with Service Center
supervisors to ensure prompt and quality service for these vehicles
in order to minimize their time out of service. Service needs of
the MICUs should take priority over service of all other city vehicles.
Electrical system problems are particularly an area of recurring
trouble due to the electrical complexity of these units. So much
is expended on maintenance of these systems by a local subcontractor
that it would seem feasible to consider employment of an electrical
specialist by the Service Center. Maintenance of the MICUs should
include not only crisis- oriented service, but scheduled preventive
maintenance as well. In addition, plans must be made for the shuttling
of vehicles to and from the Service Center which should be done by
someone other than the ambulance crews, thus minimizing their time
out of service.
CONTINUING EDUCATION
Continuing education and skills training, and the documentation
of proficiency in each area, is perhaps one of the most compelling
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reasons for a medically- oriented system. The changing legal climate
around the country is no longer permitting haphazard monitoring of
proficiency, and it is imperative that the skills and knowledge of
each employee be regularly assessed and documented.
Maintenance of state Paramedic certification requires a minimum
of forty hours annually, with a recertification examination
administered by the state every four years. In order to assure
effective and efficient care and provide adequate legal defense of
proficiency, the education program must be ongoing and continuous.
The motivation of the individual to strive for excellence in his
chosen field is a critical factor in performance and cannot be
overlooked in designing a program that will promote comraderie and
pride in one's organization.
Several options are employed around the country to provide
continuing education. Some services contract with an outside agency
to provide all personnel for monitoring performance and providing
continuing education. This is usually practical only in cities with
a medical school, as this is the type of facility most often prepared
to undertake this type of contractual approach. Other services provide
refresher courses at specific intervals, and these are often provided
by an institution which provides initial training for Paramedics,
such as a junior college. Many departments, however, are finding
that the only way to truly provide close supervision and documentation
is through the full -time employment of educators that will not only
teach, but will also evaluate performance, critique individual
ambulance runs, and work closely with individual%paramedics to refine
their personal skills and abilities.
It is imperative that full -time educators be employed tc
supervise the continuing education and performance of paramedics.
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This is a cost - effective route not only in assuring quality service
for our residents, but also in providing documentation of proficiency
for legal defense of claims of negligence. Part of the time of these
employees would be spent in training and didactic sessions with an
ambulance crew. If a call was received during the sessions, the
educator would ride with the ambulance crew, critique their
performance, document proficiency in the skills observed, and make
each call a learning experience. By maintaining a detailed checklist
for each paramedic, educators could easily tailor their inservice
education to the areas of weakness of individual paramedics, and
could arrange more formal refresher sessions through Del Mar to address
areas of weakness noted on a more widespread basis. Del Mar will
be willing to also provide inservice sessions periodically - perhaps
four -hour sessions twice monthly - which the paramedics would attend
while off duty. This would also provide the state - required minimum
recertification hours. The flexibility of 12 -hour shifts instead
of 24 -hour shifts would make attendance at these sessions much more
practical. Educators would regularly review their programs and the
performance of individual paramedics with the Director and the Medical
Director, and would obtain guidance from them about material to be
covered. They would also be available to provide training and
assistance with call assessment and medical advice for dispatchers.
While the educators and supervisors will provide the core
of continuing education material, there are a number of other
opportunities that should be easy to institute and that will broaden
the experience range and abilities of the paramedics. Paramedics
should routinely be rotated between different types of calls, and
some areas are much less active than others. If a paramedic remains
in an inactive area or only answers one type of call, his other
skills become rusty, and so frequent rotation ensures versatility
and maintenance of all skills. In addition, rotations in the Emergency
". I . . . - -16- •
Room should be provided. This provides an excellent opportunity
to refresh one's skills and to receive instruction from the physicians
and nurses with whom he works. This builds a rapport between hospital
and pre - hospital personnel that fosters trust and confidence and
results in improved patient care. It would be desirable to have
the paramedic assigned to the Emergency Room provide communication
via radio with the ambulances. His understanding of the situation
in which his colleagues are functioning will enhance his ability
to obtain appropriate orders from emergency room physicians.
An important part of continuing evaluation of one's performance
is a continuing analysis of ambulance runs. The administrative
personnel and Medical Director should periodically evaluate performance
on runs and the documentation of that performance by evaluation of
the Ambulance Patient Records. In addition, the Medical Director
will receive input from community physicians regarding the performance
of personnel, and will facilitate understanding and communication
between the paramedics and the physician involved.
Paramedic certification by the state would be a job requirement
under the proposed system, as would maintenance of adequate skills
and current certification and continuing education. An employee
who could not, therefore, maintain proficiency and certification,
would not have fulfilled his obligation and therefore would no longer
be eligible for employment.
ADMINISTRATIVE PERSONNEL
The Emergency Medical Services Department should employ a
Medical Director - a physician experienced in emergency medicine,
pre - hospital care, and the medical community and facilities of this
area. This physician must, by state law, have absolute authority
regarding the proficiency of personnel, procedure protocols, drugs
used in the ambulance, and all matters of medical practice and
procedure. He will provide liaison with the physicians of the
community, and will receive performance reports from the supervisory
personnel and educators of the department. He will also evaluate
problem calls or areas, and will be available to give direction and
guidance to the Director.
A Director of Emergency Medical Services should be employed.
This person will be in charge of the day to day administration of
the department and will provide liaison between other members of
the department and the Medical Director. He will oversee all
administrative and routine medical matters, and will be responsible
for budgeting, staffing, planning, and direction for the department.
This person must be one who is a qualified administrator, experienced
in emergency medical services delivery, and who is enthusiastic with
good leadership qualities. He will report to the City Manager.
An Assistant Director of Emergency Medical Services should
be employed to assist the Director in all administrative duties.
This job might also be expected to include some public relations
and education work with the goal of improving community relationships
and input into the department.
Two full -time instructors, or educators, will be required.
These persons will provide continuing supervision, inservice education,
and evaluation and documentation of competence. They will spend
part of their time in didactic instruction, and part in actually
riding on the ambulance making calls with the Paramedics. They will
routinely report regarding the proficiency of each Paramedic, and
will be in charge of coordinating educational opportunities with
outside sources, such as Del Mar College.
It is mandatory that a shift supervisor be on duty at all
times. This person must be available to make difficult or complex
N •
calls in his vehicle to assist Paramedics and will provide direct
supervision and assistance to the Paramedics and Dispatchers of his
shift as needed. In addition, he will assist the Director and
Assistant with administrative activities and will assist the educators
as feasible
A vehicle and equipment maintenance coordinator must be
available to coordinate repairs and availability of vehicles and
equipment. This may have to be, by the nature of the complex vehicles
which are used, a full -time position.
Secretarial support will be necessary on a full -time basis.
This will likely require one person initially.
Dispatchers, as noted elsewhere, will be necessary, but may
be coordinated through a Central Dispatch facility.
ADMINISTRATIVE AGENCY
The creation of an Emergency Medical Services Department
to be in charge of the AID Emergency Medical Service does not propose
a change in current funding -- the agreement which is currently in
operation between the City and the Nueces County Hospital District,
and the division of functions (accounting, staffing, maintenance,
etc.) now in effect, is satisfactory. The proposed change is in
the administrative placement of the day to day operation within the
structure of the City government. We should not be primarily concerned
with the ease of transition, nor with the most "convenient" location
for emergency medical services, but rather with the long -range
direction and potential for progress within the system. Those employed
to direct the service must be trained for the administration of
emergency medical services.
-19- •
While alternatives to the creation of a separate department
were considered by the committee, such as modification of current
structure and continuation within the Fire Department and placement
under an existing health - related agency, it is strongly felt that
these would be markedly inferior choices which would only continue
a number of current problems. The most important criteria in choosing
an administrative structure should be those that assure the
independence of the organization to pursue its goals of excellence
in the delivery of emergency pre - hospital health care. Any domination
by a supervising agency which in any way compromises, or could possibly
in the future compromise, such a goal must be avoided from the outset.
By minimizing the potential for conflicts in interest - be they
budgetary, philosophical, political, or otherwise - we ensure a system
which can develop to its fullest potential without need of battling
unrelated interests to survive and progress. An area as vital as
the emergency medical services of our community cannot be placed
in such a compromised position if we seek to ensure the best possible
care for our citizens. It must be directly responsible to the citizens
through the City Council and the City Manager.
BUDGET
The 1984 -85 Budget for the AID Ambulance service is
$1,701,814 which includes salaries for 46 personnel, insurance and
a small reserve appropriation. As discussed in the report, the
Committee is suggesting a different shift schedule. For purposes
of discussion, we have analyzed a 48 hour workweek in terms of staff
and budget.
,40. . - I . -20- 0
The schedule would require approximatley 58 total staff
as follows:
24 EMT's
25 Paramedics
4 Field Supervisors
2 Instructors
1 Assistant Director
1 Director
1 Clerical
It is estimated that in 1984 -85 dollars the cost for this effort
would be $1,822,835. From a staffing standpoint, we do not currently
have the 4 Field Supervisors or the 2 Instructors, so on a comparable
basis the cost is relatively the same. There are additional savings
that will be realized through this proposal because of the ability
to avoid the salary costs during the initial training period. This
would amount to approximately $4,000 per person.
The work schedule for a Paramedic under this proposal would
look something like the following in 12 hour segments:
SUN MON TUE WED THUR FRI SAT
AM pMM AM M AW PM AM R AM PM AM PM AM PM
WK I OFF ON OFF OFF ON OFF OFF ON OFF OFF ON OFF OFF OFF
WK II OFF OFF OFF ON OFF OFF ON OFF OFF ON OFF OFF ON OFF
The schedule would then repeat (every 2 weeks).
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CITY INAGER -
DIRECTOR OF EMERGENCY
MEDICAL JERVICES -------------------- MEDICAL DIRECTOR
ASST. DIRECTOR OF EMERGENCY
MEDICAL SERVICES
lerical
Dispatchers ----------------- - - - - --
Shift (Supervisor A Shift Supervisor B
Crews Crews
Instructors
Equipment Maintenance
Shift Supervisor C
Crews