Lots of Activity

Due to the flurry of activity, what with Tony K and Stephanie Thomas, The White paper, Post and news stories there is just too much information feeding into my little ole brain. For that reason I have decided to go at all of them kind of piece meal- with the white paper providing the back ground. So, for fun and excitement and to make points I will throw pieces of the others in. I also don’t want Ms. Thomas to think I wasn’t paying attention to her splendid interview with Tony K. I only hope that nothing else of note pops up later in the week or early next week, before I get a chance to finish this challenge. For those of you who don’t work at Denver Health and or have friends who do, like me. You can find the white paper on the coems groups on google. I refuse to link to it here as long as James-hypocritical, duplicitous,douche-nozzle-Richardson is a moderator. He irrigates me- so FUCK him.

What a wonderful job Ms. Johnson has done with this paper. First off, one of the local rags quotes TB Bob as saying about Ms. Johnson- Bob Petre, president of the International Association of Firefighters Local 3634, which represents paramedics (how many paramedics? I am willing to bet that out of 200+/- employees it is less than 25% and that is being generous-thats about 50 for the mouth breathers), and a paramedic for 24 years, said the study’s author doesn’t have a background in emergency medical systems. He is of course correct. But she does have a background in data analysis. Is TB Bob trying to make the argument that because he has been a marginal paramedic for 24 years that he is an expert? Gosh I hope not. Not to pile on, but could someone please tell me why TB Bob left Littleton Fire back in the day? Bob also says Denver Health has to add 10 ambulances. Wow, and that would be based on what BOB? I have heard you are getting all kinds of data from the hospital, show us your data to support this BOB. Please make sure it is not written on “Big Chief Tablet™” in Crayon. Wouldn’t make a good impression, but then if that concerned you the hair style would have changed in the last 24 years. Enough of Bob, for now.

From the paper-However, by trading depth of information for accessibility of information, a single indicator provides only a partial picture of system performance. Managers typically weigh individual indicators against other information about performance (e.g., patient outcomes) when deciding if and how to respond. In a national EMS survey in 2007, about half (47%) of cities report ambulance response times to external agencies for monitoring purposes, although counting practices vary widely. From the patient perspective, “response time” means how long after calling 911 did it take for paramedics to begin rendering care. However, only 1.9% of EMS systems nationally track response times in this manner. Until recently, Denver had been tracking the length of time in transit for first-responder units and ambulances (e.g., dispatch-to-arrival time). This method has been criticized for failing to consider the 911 call-processing time, but it is consistent with National Fire Protection Agency counting practices and, for this reason, is the most common method used by cities. See Appendix A for details on other counting methods.

With so many methods, it certainly doesn’t look like a “standard” to me.

The eight minute benchmark originally derived from research published in 1979 that demonstrated that heart attack survival improved significantly if basic life support was begun within 4 minutes and advanced life support within 8 minutes. The Commission on Accreditation of Ambulance Services later clarified that the “eight minute” ambulance response time shall not exceed 8 minutes and 59 seconds.

In the 1970s, fewer medical procedures could be performed outside the hospital – for example, portable, easy-to-use defibrillators did not exist — and emphasis was placed on getting people to the hospital for “definitive care.”

Today, EMTs are equipped with automatic external defibrillators (AEDs) and paramedics routinely place intravenous (IV) lines and insert breathing tubes on scene. Medical advances over the last 30 years and increased reliance on medically-trained first times have become secondary to first responder response times and to paramedic skill once they arrive. (Pons, 2005)

So, what is DFD’s response time compliance, using the same calculation methods as DHHA? Glad you asked, since it seems the auditor isn’t and we know Tony K isn’t. Nor does Michael Hancock.

For those interested in these things called FACTS, the fact is DFD flirts with compliance, but has only met it once and exceeded it once in the last 6 years. And let’s recall, the care they provide on cardiac arrests is the only one scientifically supported by the literature. Although Denver has one of the better, scientifically reviewed and published save rates, imagine what it might look like if the agency whose response time and tools/care is directly related to patient outcomes actually met it’s response time fractile. Dennis Galagher, Mike Hancock, either of you gents want to tackle that one? I ask, because so far neither one of you have. How can that be if you, the auditor are auditing the EMS system? As for MR. Hancock, if you wish to be mayor, just a hint, you might want to understand that a system – (from Latin systēma, in turn from Greek σύστημα systēma) is a set of interacting or interdependent entities, real or abstract, forming an integrated whole- has more than one entity, thus if the audit report comes out and only talks about DHHA it would seem to smart people, not necessarily people you hang out with, that it really wasn’t a audit of “the ems system.” If it fails to make any recommended changes to DFD response plans, other that just more $$$, then again it will be seen as a tool for the two of you to try and help 858.

Emergency Medical Response Times:

What do they tell us about performance?

In a recent article on EMS performance measures, Myer helpfully frames the discussion on response times in this way: “Ideally, the response time interval goals to which an EMS system should be held accountable should have as much clinical significance as political relevance.”11 Quality improvement efforts should focus on those parts of the system most likely to improve patient outcomes, and for many reasons, ambulance response time compliance only rarely makes a meaningful difference. What the bold part is says is, response times have political relevance. Like you needed me to tell you that. But the problem is that Hancock/auditor are mixing political with clinical. Clinically, response times are tied to 5 minutes as outline by me ad nauseam. If you look at patient outcomes, then the current model, not fire based ems, is favored. Add to that the economic model, which does not favor Fire based EMS and well.. You see where the 858/auditor train gets a little sideways

Why does ambulance response time compliance rarely improve patient outcomes?

…there is a large gap ( 70% vs. 4%) between what is seen as an emergency by dispatch and what is actually documented to be an emergency at the scene.

Denver’s experience with non-emergency calls far out-numbering emergency calls is consistent with national trends.12… Researchers are beginning to identify standards of practice/best practices and have been able to link certain EMS system features to improved patient outcomes.16’17 This research has led to the surprising conclusion that ambulance response rates are much less important than ensuring that key EMS functions are in place and working well.

Briefly, current research indicates that:

-Ambulance response times matter, but not for every patient, not even

every emergency patient;18’19’20’21

-“First responder” response times are often more important to survival for

time-sensitive conditions; 22’23’24

-Keeping paramedic skills sharp requires their frequent use of certain

technical skills, which has implications for staffing;25’26’27’28

-EMS systems are not just about paramedics and ambulances; they

include all steps in the 911 call cycle;29’30

-Improving patient outcomes requires attention to every stage of the

emergency response from call-taking to hospital admission;31

-Collecting and monitoring multiple measures of EMS performance is key

to improving overall EMS performance.32’33

Ambulance Response

Cities are roughly divided in thirds according to the type of organization that provides the ambulance response to 911 calls: private ambulance companies (37.5%), fire departments (28.3%), and other models, including hospital-based systems like Denver’s approach (32.6%).58 However, emerging research suggests that patient outcomes may be less dependent on who manages the ambulance response than on how the response is structured, in particular, how paramedic resources are allocated.

Concluding Thoughts

In sum, if Denver EMS transitioned to a fire-based system and focused only on ambulance or “paramedic” response times, it would be unlikely to build a system that matches the excellent patient outcomes produced under the leadership of Denver Health. However, DFD stressed that it would support moving to a fire- based system only after careful study of the relevant operational issues and in collaboration with union leaders. We believe that if “careful study” means attending to a wide range of performance indicators, including patient outcomes, transition to a fire-based EMS system would result in a “new” system that would end up looking a lot like the current Denver EMS system, but with different governance. This raises the question: why fix something that is not broken? Allow me Ms. Johnson it is about $$$. Denver has a stagnant economy, thus flat tax revenue. Denver is recommending cuts to DFD’s budget. DFD doesn’t want to quit running 10-10 because-It is about getting someone there and starting to provide care,” even if the 70% of emergent calls they go on only result in 4% of emergent care. I would suggest that the same kind of ratio would pan out if one looked at responses for unknown injury accidents they respond to as well. Yet, if they get hands on Division well then you can figure it out.

Although their clinical importance often has been overstated, the focus on ambulance response rates should not be abandoned. On the contrary, response times should be integrated into a broader set of clinically relevant quality of care indicators that collectively better reflect the performance of Denver’s EMS system. Denver should monitor these indicators and seek to improve upon its already strong performance, beginning with the recommendations herein.

On to Tony and Stephanie-

in a section of the interview dealing with Mr. Elgin Tony K says-Right, and you know and I know that the paramedics sat there and said there’s

nothing I can do. We believe you have a blood clot and your paramedics are not able to provide blood thinners and so they waited for the ambulance. Your paramedic was able to do nothing more than babysit Mr. Elgin until he died.

Blood Thinners great Idea Tony. From what I can gather from this case Mr. Elgin suffered from what is described as a “saddle embolism.” According to this article “blood Thinners might be a bad idea. Scroll down to the “DIAGNOSES” where it says- A large number of lives are lost due to delayed diagnosis and the acute course of large embolus. Unfortunately, it is not always possible to make the correct diagnosis and intervene as the course is very acute and PE is often a finding in autopsy results. This article says TPA, that is the technical term for blood thinners (but you knew that cause your a nancy drew wanna be reporter and I was just an ambulance driver-DICK) they must be catheter directed, which the paramedics can’t do that one either. As with all the other articles cited here, it also says-High mortality is generally associated with saddle pulmonary embolism and can be a cause of sudden cardiac arrest.

I am done for tonight. Have to go to work and DHHA admin may or may not think I am funny, while at home. I would guess they would think otherwise if I did this on their time.

φ Veritas