My friend and recently new coworker Scott “Medic SBK” Keir wrote about a pseudo-controversy from where he used to work about long response times. In AMR’s contract with Springfield, MA, they must arrive within 10 minutes to priority 1 calls 95% of the time. After one 17-minute respone time to a shooting, a reporter discovered that AMR did not meet this requirement 3% of the time. Apprarently this is a problem. As Scott pointed out in his post about this, people in other cities would be very jealous of AMR’s response times in Springfield. Kudos to Scott for reaching out to the reporter who put the story together, which he described here.
When I worked at McAmbulance, contracts with certain communites were more valuable than others. The system-status mis-managers in the com centers discretely encouraged us to drive faster to calls in those communities. Over the radio, our assignments would be followed with “impress me” or “do your best” in order to arrive within the magic 8 minutes. A 17 minute response time in one of those communities would result in trouble for the system status mis-manger, because they should have predicted that the next call would occurr there and had a unit positioned nearby.
On the other end of the spectrum, I was a member of a voluteer ambulance service in a densly populated bedroom community, that was located a few miles away from McAmbulance’s base. Here calls were toned out when no one was at the station. If the ambulance did not go responding after a certain amount of time, the tones would be repeated. If an ambulance did not start responding after 15 minutes, the private company covering from the next town over would be contacted. Here, a 17-minute response time to a priority 1 call under normal circumstances was considered to be good.
When the volunteer ambulance did get out (which for a while was only about half the time), the level of care depeneded on whomever happened to show up. If EMT’s were the only ones available for a chest pain or difficulty breathing call, that was the best they had to offer (and that was before BLS 12-leads, CPAP, albuterol, and aspirin). The rest of the time millions of dollars worth of equipment sat idle, while the call was handled by paramedics from a private company after a lengthy delay. Through some twisted logic, it was argued that the volunteer ambulance had the community’s best interest at heart with this non-system and was better than any alternative.
On one end of the EMS bell curve, response times are the only performance measure that matter. Where I used to work, they were so important that crews sat in vehicles for hours on street corners instead of a building. They were so imortant that unsafe driving was encouraged for trivial complaints. They were so important that GPS equipment and vehicle routing software were purchased before 12-lead capable monitors and CPAP. On the other end, people in some communities seem to be okay with response times depending on whenever enough people can drop what they are doing to respond from home. And the quality of clinical care was an afterthought at both services.
According to the 2008 Eagles benchmark paper, then only time intervals proven to affect outcomes is CPR and defibrillation within 5 minutes for cardiac arrest. There is no evidence to support paramedic response time goals for any condition. For the 99% of calls that aren’t cardiac arrests, the difference between 8, 10, 12, or 15 minutes probably does not affect patient outcomes.
Scott pointed out in his post that how quickly we arrive matters less than what happens after we arrive. How many V-Fib arrest patients walk out of the hospital? How often are the Eagle’s recommended treatment bundles for difficulty breathing, seizures, and STEMI’s met? How many patients in pain get medicated before they are moved? How many excited delerium patients get sedated? How many airways are placed by each paramedic, and what training to they go through when they don’t place many?
As far as response times, the ideal solution is somewhere between 8 minutes or else and whenever we get there. Patients outcomes are not improved from crews sitting in cramped vehicles for 12+ hours searching for the next call. Dropping tones and hoping people respond from home takes too long. Have units respond from buildings and alert the closest one as soon as the address is known. Get them there as safely, then as quickly as possible, and make sure quality care is delivered once they arrive.