Corner Posting: Better, Faster, & Cheaper than Stations? Prove It.


In the cover story of this month’s JEMS, Jonathan Washko adds more fuel to the fixed/static/hybrid deployment debate.  I’ve done all three, and found a home in a station-based hybrid system.  Washko concludes that street corner posting is better, faster, and cheaper than static or hybrid systems.  Unfortunately he presents his opinions as facts.  I happen to agree with some of his opinions, but none supported by any evidence.  Here is my rebuttal:

Some of the most efficient and effective EMS delivery systems today often provide better clinical outcomes and service reliabilities as their most expensive counterparts, proving that throwing money at a problem isn’t always the answer. 

I agree. Placing ambulances at stations based on tradition, instead of geographical coverage or historical demand, is neither efficient or effective.

As EMS providers, we see these (station based) system designs as the means to earn money sleeping, but these designs are often ineffective clinical delivery models because of poor response-time reliability. However, one thing is reasonably certain. Static deployment systems are the most inefficient and costly way for us to deliver EMS service.

I agree that having units positioned at one location, and returning to that location no matter what else is going on elswhere, is inefficient.   However, he jumps to the conclusion that station deployment equals sleeping.  My work related projects are frequently interrupted by calls, and my eyes are open almost all the time I’m there. 

 Services that use corner posting also pay people to be in an office full-time to work on continuing education, QA/QI, recruitment, IS, and strategic planning.  If they don’t, they don’t have good patient outcomes either.  Instead of idling in a vehicle between calls, what if some of the work that full time administrators are responsible for was spread out among field providers to work on?  If they run  all day, the administrative stuff gets pushed back.  Unit hours can be utilized in a building between calls, which adds some breathing room for busier-than-normal days and MCI’s.   

Many healthcare organizations offer educational leave as a benefit.  EMS organizations could simply encourage their people to take online classes in stations without having to fill their spot.  Continuing education can also be done online between calls  instead of paying people to come in on a day off.  “To station or not to station” is a different issue than “efficient or inefficent.”

Some have attempted to correlate survival rates with the number of active paramedics used in the system, but I find this absurd. 

Absurd? Based on what? More paramedics equals fewer opportunites to manage critical patients and perform invasive skills.  Mickey Eisenberg wrote about this in Resuscitate!  The Eagles discuss this in their Proposed EMS Clinical Benchmark paper. A recent Henry Wang intubation study found a correlation between paramedic experience and patient outcomes – not just intubation success.  How is that absurd?

Whether dispatch life support through pre-arrival instructions, first responder, BLS or ALS, the bottom line is the response times count … period.

Besides CPR and defibrillation for cardiac arrest, count how?  What should they be?  For what conditions? Should lights and sirens be used too? Any evidence contradicting the studies that show no association between response time and clinical outcomes?  Until there are some, I’ll keep my 90 second walk to the truck. 

Response times ensure high-quality CPR is initiated.

Response times ensure that someone shows up.  It says nothing about the quality of care that gets delivered. Jack Stout, the inventor of the corner-posting schemes, was an economist.  He was great at maximizing unit utilization, but was not equipped to measure the quality of care during utilization.  After 30 years we are just starting to find ways to measure quality, such as with the Eagles Clinical Benchmark paper.

These models are the most unpopular with EMS providers because productivity and efficiency are balanced with good clinical care, sacrificing down time. Sitting in the front of an ambulance and being placed on a street corner is not as comfortable as responding from a warm bed in a station’s bunk room, but it gets the medicine into a critically ill patient’s veins a lot quicker. 

How much quicker? What medicince? Arriving faster equals good clincal care?

Buildings are expensive, but so is turnover.  It is higher in services that use streetcorner deployment.  Mike Taigman, who I have the utmost respect for but disagree with about posting, admitted so on a podcast debate about it.  The  Jack Stout disciples trivialize the human costs of posting.  At some point, iddling in an uncomfortable vehicle or running from call to call affects the quality of care that is delivered.  We haven’t studied the effects of that either.  Annectdotally – a word used in Washko’s article – I have seen it in these systems.

Many urban and suburban dynamic deployment systems, with excellent clinical outcomes, have operated with little to no tax subsidies for decades.

What systems?  What clincal outcomes?  What evidence? Many urban and suburban dynamic deployment systems, with poor clinical outcomes, have operated with little to no tax subsidies for decades too.  

 Cutting edge, high-performance EMS systems are already blazing a path. EMS system design innovators are at the forefront of the revolution and evolution of our industry.

Jack Stout’s deployment methods have been used for over 30 years.  AVL and GIS mapping technology has exploded since then, and there’s still no evidence that patietn outcomes are affected by posting on corners instead of stations.   

If I interpreted Washko’s article correctly, he claims that stations are inefficient and expensive.  He claims that corner posting is cheaper and improves response times, which may be true.  Washko then jumps to the conclustion that faster response times lead to improved clincial care, which then lead to better patient outomes.  For these reasons, station-based services should switch to corner posting. That’s a big stretch.

What is missing is a reference list to support any of these conclusions.  JEMS must have run out of space for it. 

 

Comments

  1. I was less than impressed.

    “When you break an EMS system into its component parts, you find four primary activities: public safety, public health, disaster preparedness, response and recovery, and healthcare.”

    o_O

  2. While I am glad to hear this topic discussed more often lately, I am concerned if we are even debating the right question. Station postings and street-corner postings are just the two extremes of deployment models. If we are going to debate between them, we need to agree on the performance measure we will use to evaluate it. Arguing either model from diverging perspectives is simply an exercise in frustration as neither side will be swayed. My definition of a truly High Performance EMS is a “balance of efficiency with effectiveness.” A nice “sound bite” definition, but unfortunately all three of these words need clarification.

    Efficiency is the easier one to attack first. As Washko argues, if we look strictly at the economics of efficiency expressed in unit hour utilization, then stations are the absolute worst method to achieve that goal because of the high resource demand required to sustain that model. However, Sullivan brings up some good mitigating points that go beyond measuring efficiency only by UHU. Employee morale and staff turn-over have negative impacts on system costs while other operational objectives such as ConEd, QA, etc could potentially be met with some of the “downtime” gaining some degree of increase in overall efficiency. Then there are also fuel costs (and environmental impacts) as units must be kept running when not plugged in at a station – another possible negative outside of strict station posting. But do these offsets make up the gap? How much of the “balance” is counted in favor of economic efficiency anyway? And does that answer depend on the basic financial model of the service in question? I would argue that the relative ability to measure these values gives at least a clerical advantage to dynamic posting until actual studies are conducted to give us better facts. Then we would only be able to argue over which figures are actually pertinent.

    Turning to efficacy, if we consider evidence-based terms then the outcome would be mixed as either system, properly managed will produce good clinical outcomes just as either extreme is capable of providing quick response. Clearly there are both good and bad examples of each model out there, including hybrids, so categorical proof one way or another is difficult at best if not pointless as both can achieve the objective.

    So then we return to the question of balance again. Dynamic posting is not always just “street-corners”, but can emulate the fire-based concept of “move-up” of resources between stations or other “equipped locations.” It is in this balancing where we must factor multiple objectives – public safety focus or public health, for instance – but with current economic conditions, an over-riding factor is commonly budget regardless of the type of EMS agency (fire, third service, private, non-profit, etc.) and we have many examples of measures for evaluating performance with money spent. Jersey City Medical Center has presented a case correlating decreasing response time with increasing ROSC showing that quick response saves lives. Albuquerque Ambulance Service documents significant increases in compliance with response time goals as a result of dynamic posting. Lexington County (SC) EMS claims huge financial savings as a result of dynamic posting while still improving response even with fewer resources and increased call volume.

    Now it is clear that pre-hospital EMS service delivery is changing. The number of medical calls is increasing while actual fire responses are decreasing. Public officials are openly questioning response tactics that send expensive heavy fire equipment to all medical calls. All equipment acquisition and maintenance is significant. If even just similar performance can be achieved with fewer, better positioned, less expensive ambulances, can we really assume officials will continue devoting huge budgets for static deployments?

    • I think one of the inevitable problems when we have this type of discussion is that emergency services are fundamentally not efficient. So if we start chasing that spectre, the inevitable result is realizing that the only truly cost-effective solution would be to get rid of 911. Most calls aren’t time-sensitive, most don’t need 99% of what we carry, most don’t need ALS and many not even BLS, etc. So everyone can just take taxis, right? But we want to live in a society that makes a good faith effort to catch the 1%, or the .1%, or perhaps even the .001%. We just need to decide where we draw the line, because we don’t have infinite resources. Where is the line here?

      I have some trouble seeing the case for total or near-total dynamic posting if we remove the “early response for cardiac arrest” argument, which in many cases is not particularly relevant (for example if other first responders that carry an AED are routinely on scene before the ambulance). Response times are too often used as surrogate endpoints without anybody justifying their assumed value.

      • Be careful, that same argument of cost-effectiveness could be used against almost any government agency for similar reasons. But arguments shouldn’t need to go to extreme ends in order to be effective. I don’t think anyone would suggest doing away with EMS, but would it not be reasonable to ask for the best return possible on whatever public money is spent providing EMS? After all, it is a service the public is asked to invest in for the “greater good” so shouldn’t it do the greatest good possible? I don’t believe that just because it is a useful emergency service it should automatically be granted a “blank check.” To use your example, is it really the best policy to put a portable AED on a fire engine with a crew of 6-8 first responders or on a more fuel-efficient vehicle with a much smaller trained staff? It is cheaper, safer, cleaner and can be at least as effective. You partially answered the question yourself already though – it is about where we draw the line on effectiveness? That is the debate we need to have, not whether the tradition should be broken in the first place. And we can’t exclude any real world scenarios from our definition unless we provide a different means to address them. If response is not an effective measure, how do you suggest replacing it?

        • Part of the problem here is that there are so many different versions of (as Skip says) “ambulance service” that we’re often talking apples and oranges. Consider a private service running exclusively transfer work. Is it better business to post units in the parking lot of your major contracted facilities? Undoubtedly. But as Bob notes below, the issue isn’t necessarily just the posting itself, but what it signifies. There is a distinct, palpable difference between companies that place some priority upon the health, happiness, and quality of their crews — in other words, they value their people — and those who simply view them as interchangeable certificates. The attitude that ANY business benefit to posting units in arbitrary locations is good enough, because there’s NO downside (because human considerations aren’t even on the table) is a red flag. And it may be par for the course in private EMS, but — well, that’s another debate.

          What about a purely 911 service? There are still so many models to consider. I’m used to areas where fire shows up as first responders (not necessarily doing much and not transporting), and the ambulance gets there a few minutes later. I agree that it’s silly to send a ladder for that purpose, but that’s another topic and if we’re going to “use” the existing fire service as medical first responders we may be stuck with the tools available. My point was that in such a model, the argument that we need to minimize the seconds to ambulance arrival in case of cardiac arrest holds little water because other responders ARE on scene who can provide CPR and defibrillation. Are there other cases where “seconds count”? Maybe, but darn few. Are there cases where first responders of this type (particularly when they technically offer the same level of care, as is often the case nowadays) shouldn’t count as stopping the clock? Fewer still, as long as they’re qualified — perhaps with the exception of trauma where what’s needed is actual transport rather than field care.

          My overall point is that it’s much easier to hold up response times as an assumed good than it is to justify why we should value them so highly, particularly when it comes down to a difference of seconds or minutes, and particularly when chasing those seconds becomes increasingly onerous. It’s likewise easy to minimize human considerations, but we still have humans staffing the trucks, and it’s hard enough keeping good people in those seats.

          (With that said, I like the analogy to police by Skip, and that’s a good point.)

          • emspatientperspective says:

            Thanks Brandon. I could never defend one position about posting, and either can be easily attacked. My biggest problem with Washko’s article is that a number of issues are jumbled into posting. Even if posting is more efficient, it is not always effective.

      • Skip Kirkwood says:

        Remember – Jack Stout was not studying – discussing – emergency medical services. He was studying AMBULANCE services, which are fundamentally different things. SOME of ambulance service is EMS, but much (perhaps most) is NOT – and Jack was trying to figure out how to make best use of ambulance resources in a particular service model – an exclusive franchise public utility model.

        So, I gotta ask. Every day, police officers get in their cars and spend their shifts on patrol. They don’t complain that they should be in a different environment.

        So just for discussion (’cause I don’t really have a dog in the fight), why is spending a shift in a vehicle OK for a cop, a taxi driver, or a truck driver (or a bunch of other occupations), but not for an ambulance medic? When we (medics) do what they (cops et al) do, it is a “dissatisfier” and contributes to turnover, etc.

        Why is that?

        Could it be that we just want to model ourselves after the fire service?

        • I’d say it depends on the shift. Cops and taxi drivers don’t work 24 hour shifts. I’m not sure about the truck drivers; but I imagine that sleeping in their rigs is not required, just something they choose to save money.

          Personally, I’ve never had trouble with posting. In fact, in some ways, I prefer it. However, that changes if we go to a 24 hour schedule. In that case, food and sleep are more problematic.

          Though for that matter, I thought that 24 hour shifts were supposed to be disappearing as well?

        • DrParasite says:

          Because I’m not an ambulance driver. A taxi driver and a truck driver is just that, a driver.

          A cop does NOT spend his entire shift on the road. He often returns to HQ to file paperwork. Not only that, but having a cop on patrol is seen as a proactive deterrent to crime. When was the last time driving around in an ambulance prevented a heart attack from happening? Plus patrol units have a call volume that is typically 4-10x that of an EMS unit.

          Posting on street corners sucks. especially in ambulances with exhaust leaks or ones without fully functioning AC or heat, or for agencies that won’t let you run the truck when you are posted. They damage the close knit family atmosphere that used to exist. Not only that, but if you are posted in the north, you are guaranteed a call in the south, every time. At night time, you also have the safety factor. if you are in a shitty city, do you really want to be on a street corner in the ghetto where drug deals on being done on the street corner? despite it being a high penetrating trauma area…

          Responding from a central station allows for an entire shift to eat together. it helps build camaraderie. it aids in communication. they can all watch a football game together, leaving when they have a call.

          Fire departments have been using stations for years. if you have a big city, have 5 stations, one main on in the center of town, and one in the north, south, east and west. the provide security for the crews, refrigerators and cooking facilities, and shelter from the elements. you can even have a library and weight room, so staff can exercise their mind or body.

          There is a reason most places that have stations have higher morale than ones that use SSM

          • emspatientperspective says:

            Thanks Dr. I agree with you in spirit, though I think that there is some value to vehicle routing programs and relocation to less-busy areas. But again, we the people who post (or post-ed, in my case) need to do some peer reviewed research to prove this.

          • Skip Kirkwood says:

            DrParasite – I’m not arguing with you, just trying to drill down to the core of the matter. You’re right, cops don’t spend 12 hours in the car – but neither do medics. We run calls, we write reports, etc. Medic for 30+ years, cop for 6 — much seems the same.

            Is it the sitting still in the vehicle, versus the driving around? I saw where someone mentioned “not allowed to run the truck” while posted. Seems like BS to me – how do you keep warm or cool, depending on the season?

            I’m not sure how well the “cameraderie” and the “watch the football game” play with the citizens. Lately, the fire service has been getting hammered for stuff like that. Most jobs, you get paid 12 hours, you work 12 hours except for a couple of breaks and maybe a meal.

            So….moving around is bad? Or poorly designed moving around? Or lack of consideration of employees? Keep drilling down for me guys – I want to get to the heart of whats and whys.

          • DrParasite says:

            Vehicle relocations do need to happen, especially when your primary station isn’t centrally located. Not every 10 minutes, but when you have a major incident in the west, start moving units to the west to cover your area, even if they aren’t committed to the incident.

            Why do you think Fire Department’s don’t practice SSM? Even better, why are FD-based EMS system expected to practice SSM, but the suppression side is assigned to fire houses?

            As an EMT, my “job” is to answer an emergency call. me being stationed on a street corner doesn’t deter any sicknesses or traumas from occurring, whereas a cop being posted on a street corner can actually deter crime from occurring. I am doing my job for 12 hours, provided I answer the call immediately when someone calls 911.

            You asked about the “not running the truck.” my old employer told us we weren’t able to do that…. it wasted too much fuel. Than it was “it’s too loud and people complain.” and finally “it’s bad for the environment, and there are anti-idling laws.” I was received two write ups and numerous threats of such for running my truck in 90+ degree weather. Complete BS, but that’s what management decreed.

            the FD doesn’t get hammered for watching the game, or eating meals together, or being in firehouse. they get hammered when they do stupid stuff (alcohol on duty, doing shady shift with OT, or taking advantage of certain perks). And then there is the stupid stuff that politicians expect of the FD that is completely unreasonable.

            Think about the effect of being in an ambulance for 12 hours straight. or being in the front seat of a truck and then having to go on 150% to move a 300 lb person, or CPR, or another physically demanding trait. eating in the truck, or having to get fast food. And heavy forbid you don’t get along with your full time partner, than it’s 12 hours of torture (many cops work in single manned cars).

            Posting and SSM sucks. most people who work in SSM and than get a job that has them in stations will never go back to SSM. Many people who start in stations will be happy when they are forced to post on a street corner. If you can’t understand why, maybe you should do a couple shifts in an SSM system, in a slow SSM system, esp now that you are older and having been doing this for 30 years. See how your body feels at the end of the shift, esp as you have done CPR and lifted a super heavy.

            Been there, done that, I definitely prefer being able to relax on couch vs the passenger seat of the ambulance.

  3. emspatientperspective says:

    If a service’s people are happy with corner posting, and that they (or any service) can prove that they deliver good clinical care, then nothing is broken. My problem with Washko’s article is that he explicitly stated that no stations are better than stations. He claims that corner posting is cheaper and faster, that it leads to better patient outcomes, and offers no evidence to support his positions.

    When I looked for jobs, I typically stopped reading their website if they used corner posting. Those services usually happened to pay less too, which was a bigger factor. As Dale said, the issue is much more complicated than to station or not. And the no-subsidy, corner-posting, just above minimum wage paying service I started with delivered poor clinical care. When he says that model has worked in other areas, I would like to know where.

    There’s no evidence that stations are better, nor would I ever claim that my experience can be applied elsewhere. I would never try to get this post into a magazine, either, and am surprised that no reference list was included in Washko’s piece.

  4. Nice post. A Rogue Medic style breakdown and critique. You should forward this on to JEMS for consideration as a letter to the editor or a guest editorial.

    Skip, an interesting comparison to the patrol officer. Perhaps the promotional opportunities that are available to patrol officers increases the desire to put in the time behind the wheel.

    I always figured for every the police officers went on 10-20 times more “BS calls” than we did in the ambulance. So there willingness to be vehicle bound and drive around for even more elusive “awesome calls” is even more admirable.

    • emspatientperspective says:

      Thanks Greg. I appreciate the comparison to Rogue Medic, though he knows a lot more about more things than I do.

      As far as the police spending times in vehicles, I think they are more okay with it because there is a more believable purpose for them to be. By being out patrolling, especially if assigned to the same neighborhoods, officers can notice things out of place or encounter erratic drivers.

      Corner posting for EMS is sold as an assignment closer to where the next call is likely to be. When it’s the middle of the night, the city is dead, and you’re staring at an empty parking lot for hours, it’s harder to sell.

      • If you are spending “hours” in a parking lot post, your posting plan is definitely not working right. If that were my view of the system, I would hate it too.

  5. Does anyone know of the rates of injuries for SSM EMS versus hybrid-systems EMS versus station-based EMS? How much cost savings is lost on vehicle maintenance, wear-and-tear, and fleet replacement in comparison to maintaining a station and not having to run a truck 24 hours a day to maintain the environment and charging the electrical systems. I have hearing damage, which I never put a claim in for due to idling my units for three years in a metropolitan EMS system, as the agency did not and doesn’t still offer hearing protection, despite being informed of the requirement to comply with OSHA 1910.95. Their excuse was they (the government authority that runs the agency) couldn’t afford to implement hearing protection after replacing their private subcontractor. They have since replaced the entire fleet of no less than 45 ambulances three times over to the tune of roughly $9 million every three years (not counting the expansions due to increased call volume and shift demands). My hearing exposure was over 92dB for at least 8 hours per 12-hour shift and 12 hours per 16-hour shift and many times exceeding 100dB for sustained time periods, measured with a sound meter. How do you provide better clinical care with impaired hearing? By missing informative heart tones, or lung sounds, or patient communications? My hearing isn’t so bad that I can’t effectively use a quality stethoscope , but I notice my conversations aren’t as sharp as they once were, and my hearing tests are now just “normal” and no longer exceptional. I know I went home many times with a sore back from being confined to a sitting position (Ford ambulances have an incredible 10 degrees of reclining from upright), but it makes me wonder if that fatigue and muscle strain contribute to (not solely cause) catastrophic back injuries.

    Why do firefighters love their stations? How about the ability to safety store refrigerated foods and fresh produce? How about the ability to properly cook their meals? How does the street-corner system factor the wear and tear on the physique and dietary health of the EMS provider? Aren’t we supposed to set an example for the public? What about those workout rooms I have seen in so many fire stations? It’s hard to get a cardio workout unless you like running along side your unit at the nicely maintained and safe park (that is most assuredly available at EVERY street-corner post)? I remember posting in District 22 in Fort Worth at a place called “Crack Fina”, where we watched the minute-by-minute drug deals and sometimes the resulting stabbings, beatings, and shootings. Oh, I guess we’ll have to only resort to adapting exercise methods with the guidance of professionals like Bryan Fass. Of course with a good cardio workout, we should be sweating, so I guess with our completely blacked-out patient compartment we can change between exercising and running calls.

    I didn’t particularly mind working several years in SSM systems, but I liked stations a lot more, and I felt better during and at the end of my shifts.

    • emspatientperspective says:

      Thanks Unwired!I prefer stations too, and do not mind moving around when other areas get busy.

      On one hand, it is probably cheaper to replace ambulances frequently than to build and maintain stations. I am aware of one study that examined back pain before and after a fluid deployment plan was implemented, but it was not peer-reviewed. Another study in Prehospital Emergency Care looked at staffing patterns in system status management (their term, not mine) could reliably match supply for demand. It did not cover work load or the effectiveness of vehicle routing.

      On the other hand, this argument gets muddied by EMS people who expect to sleep at work, feel that the world outside their primary coverage area is someone else’s responsibility, and should not be bothered unless a patient in their primary coverage area meets their definition of an emergency. I don’t believe that is effective either.
      What we need is people willing to do peer-reviewed research on this who do not have an agenda. Washko’s article does not meet this criteria.

      • Good points, indeed. I also wanted to add a point to my previous comment. I do not necessarily have a problem with moving from place to place with demand, as I think that is just part of the job. Even engine companies will do that when an event draws too many companies and districts aren’t safely covered, but they eventually come back home. I’m not thrilled with the idea of having to move place to place constantly. Fire districts offer the crews a chance to really know their response area well and to work on PR by becoming a constant presence in their district.

        Being in a couple “street-corner” posting systems before, I often carried a cooler with me to keep food, and would use a fire station’s (or gas station, if there was one) microwave. It’s just nice to have a system that feels its employees are at least worth having a few stations so they can get out of their trucks safely, stretch, prepare meals, socialize a bit, decompress (some of the best therapy doesn’t come from CISD/CISM), and maybe even exercise. And who says that two units can’t be stationed at the same place and meet the 7:59 or 8:59 time on a call. In a metro system, the agency has times when it is running more than 30 units per shift, and if they’re all running high UHU all the time, then they’re understaffed because they can’t handle a surge. It should be inevitable that some units would be double-posted or in close proximity. Who says they HAVE to be stationed on separate corners? 8 hour shifts I can understand not using stations. 12, 16, and 24 hour shifts, not so much. If street-corner posting is so awesome, how is that rural systems aren’t doing it? Wouldn’t it be cheaper than maintaining a central response station? Shouldn’t crews be taking their units home with them, and be required to have units on every opposite corner of town to minimize response times? A station would hardly be necessary then since you’d just deliver the unit right to the next crew?

        In the end, I just want to work for an agency that truly takes care of its people so their people can do their best to take care of their citizens. If that idealism exists in an agency, everything else falls in place and I wouldn’t really care where I were posted. I wouldn’t worry about pay because that would already be fair. I wouldn’t worry about whether I could idle my unit. I wouldn’t worry about most things. It wouldn’t matter (as much) to me if I worked in a SSM, hybrid, or station-based system, as long as it was the best thing for the community and the staff were taken care of. No place I know of can offer you a perfect job and has all the right answers, but it would be nice if it was always strived for.

        • There are practical considerations — for instance, Skip notes that in most jobs you get paid to work for the time you’re there, but most jobs don’t run 12-16-24 hour shifts like we do. Maybe we shouldn’t? But there are also logistical advantages to longer shifts, so it may be hard to make the comparison completely parallel. (Let’s also remember that we’ve all heard complaints from citizens about us idling in their parking lots and intersections, stinking up the place and borrowing their public restrooms.)

          But for the most part, I agree that it’s not really about posting, or any other individual issue. It’s what it indicates about a service when it’s willing to freely spend crew morale in return for any minimal amount of system efficiency. If a great agency was sticking me out on the road for 12 hours for a good reason, all right then. But often it’s a sign you’re working somewhere that will nickle-and-dime the bottom line mercilessly while placing zero value on high-quality, skilled, dedicated staff.

          Admin A: You know, if we sell all the bases and just leave everybody scattered across the city 24/7, we can save a few dollars and cut a few seconds off our responses.

          Admin B: Won’t that be torture for our people?

          Admin A: I don’t understand the question.

  6. Skip Kirkwood says:

    DrParasite,

    Structural firefighting units don’t practice dynamic deployment because the things that they are designed to protect (real property – structures) don’t move. The things that EMS protects (people) do move.

    Going back to the history of dynamic deployment. The folks, including Jack Stout, who worked with the concept advocated for large (sort of regional) systems that had exclusive rights to a whole market (they believed in “competition for the market” rather than “competition within the market” to assure public accountability). In such a system (like when MAST was a regional entity), the population moved in a fairly consistent pattern throughout the day – from the bedroom community in the suburbs at night, to the highways at rush hour, to the downtown business area during the daytime – then reverse it). So the concept was to move the available ambulances where they could best cover the “target” – the demand for calls.

    That some employers implemented dynamic deployment in brutal or ridiculous manners does not invalidate the concept.

    Unfortunately, it morphed to “all street-corner posting” and became a vehicle for some quick and easy money. Sell off those stations and pocket all the cash. Cancel the leases on those that are rented. Poach on somebody else’s private property without permission. Ignore the comfort of your employees. Those are all bad things.

    The days of “relaxing on the couch” are quickly coming to an end. Paramedics are going to be expected to do more useful things than stand by waiting for calls. Society has decided that it can’t afford to pay for people sitting around waiting for things to happen – they want productivity. So we’d all better start thinking of things we can do between calls to improve the health and safety of the community. Study community policing and see how that might mesh with EMS – because that is the world of tomorrow. Get ready for community paramedicine – because it’s coming to an EMS system near you!

    • DrParasite says:

      “Structural firefighting units don’t practice dynamic deployment because the things that they are designed to protect (real property – structures) don’t move. The things that EMS protects (people) do move.” With all due respect Skip, but your using an apple and pears comparison. EMS SSM (as it is used currently) uses as few units as possible to ensure a maximum coverage area. This usually puts units in constant motion, so if one unit gets a job, everyone shifts to get maximum coverage. You could absolutely do that with the FD. They just wouldn’t want to do it (and I don’t blame them one bit).

      Also look at the FD staffing levels: they are consistent 24/7, the same amount of units (for the most part). This allows them to handle surge capacity. EMS is staffed to the minimum 24/7, with additional “power trucks” thrown in during heavy call volumes (if you are lucky). When you lose those power trucks, you lose your surge capacity.

      Not only that, but past call volumes don’t necessarily predict where future calls will be (taking frequent flyers out of the equation, of course). just because someone developed chest pains in the north 4 months ago doesn’t mean a different person will fall in the north. Yes, every city has places that seem to attract EDPs, Assaults, drunks, etc, but those are the exception rather than the rule. We get traumatic injuries in the industrial area of the city at 3am, when most of the population isn’t at work. and just because the bulk of the population is at work, doesn’t mean person A didn’t stay home because they felt sick, and now want to go to the hospital due to chest pains.

      You also have the security factor. at 3am, in the ghetto part of town, the call volume might be pretty high… would you want to be posted there? how safe is it? now put a station there, with solid walls and a lock on the door, or even commercial rolldown doors, and it’s a safer area when you aren’t on a job.

      What would you like your community Paramedics to be doing at 3am? I’m all for PR and outreach, but when there is nothing to do, I hate busy work just for the sake of looking busy. During the day shift of a 24, sure. at 11pm? not so much. You give me something to do, and I will do it, usually with a smile on my face. You give me a task just so I look productive, while not actually being productive? Well, that’s wasting my time, and I don’t like wasting my time.

      I wouldn’t mind relocating to another station during rare periods where the call volume spikes. but the 24/7 movement that most SSM practice, esp when you are posted to a street corner is a warning of poor working conditions (and other problems that you and I have both listed)

      • Skip Kirkwood says:

        You’re thinking I’m arguing with you again, and I’m not. There are many agencies that do dynamic deployment and peak load staffing, horribly. I’m not defending them. but I’m not comparing different fruits – I’m comparing how each discipline responds to its specific purpose

        But there are good reasons for both, and you can do both without making your troops miserable.

        That “constant motion” is ridiculous, and should not happen in a well-designed system. Note that I said “well designed.” Many are not. But there is science to some of it, and the fire service has it figured better than most. Constant staffing is to meet relatively constant threat – and stations are 1.5 miles apart because that’s how far the horses could run at full tilt. It’s not about surge or anything like that. Look at the CFAI “standards of coverage” document and you can build yourself right in to it.

        FDs who do a lot of EMS (transport and non-transport) use peak activity units during the daytime. At Tualatin Valley Fire & Rescue (outside Portland, OR) they’ve used Peak Activity Engines since 1996.

        You can’t predict where the next call will be with much precision without some VERY sophisticated software, but across large cities or regions you can predict general areas. Look at some of the better deployment management software – Optima SIREN, MARVLIS Predict, DECCAN Move-up module – and you will see how you can use software to improve coverage. The proof of the pudding is that when you use this stuff, with the same call volume and the same resources, system performance improves (pretty much always).

        Security – I get it. Sitting idle, in “condition white”, is dangerous, in many parts of town. Executives who don’t attend to that are a disaster waiting to happen.

        Our community paramedics, at 3 a.m., are either doing administrative duties (QI, patient care planning), or a responding to calls. But we’ve only got two on after 11 pm, while there are 5 (on constant patrol or doing self-initiated activity) during the day.

        When I get my “king for a day” and I can declare college degrees for paramedics, one of the required courses will be geo-spatial deployment planning and managing. Then everyone will get to see how call densities change with time, etc. When folks don’t KNOW how it works, they assume the worst. Sometimes, worst is the truth. Other times, not so much.

        • So, Skip are you going to pay those paramedics for their degrees or just flog them for more work when they aren’t running calls?

          I think I know the answer.

          SSM type systems are based on the concept of paramedics being as disposable as a 4×3. They apparently are also based on the concept that a paramedic with the ink still wet on his ticket is as capable as one with twenty years of experience. In other words, they don’t place much value on the people doing the work.

          As I’ve described SSM previously; It’s like cutting four inches off the bottom of a blanket, sewing it on the top, and declaring to the world you’ve made it four inches longer. It’s sleight of hand designed to give the appearance of adequate coverage without actually providing it.

          Generally these systems rely heavily on FD based first response. It’s a way of stopping the response time clock and shifting much of the cost of responding back on to the taxpayers.

          About all we can say with any degree of certainty, is that it’s cheaper for the operator because it eliminates the need for stations and of course the constant churn of employees means that most of the medics are at the bottom end of the pay scale.

          • Skip Kirkwood says:

            It won’t be my choice to to pay them more – the market will demand it, and they will be paid more. If you want to check, talk to the paramedics in Canada and Australia – they do WAY better than many medics in the US. That’s why I keep pushing for elevated education standards – I really WANT to see medics get paid more and have meaningful careers.

            I guess when you say “SSM” you mean peak load staffing, and dynamic deployment using streetcorner-only posts. I think you accurately describe SOME, but not all, of systems that use those methods. Some (and some no longer with us) used to to some pretty good things to offset the disadvantages – like “your shift is over after you run 10 calls, but you get paid for the whole shift.”

            You don’t see much of that these days.

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