Washington County Crash Report
Transportation Incident Analysis (2018 incomplete report)
Washington County EMS over the last decade has become one of the most respected data-driven EMS departments in the State of Texas. Spearheaded by Director Kevin Deramus but accepted within the leadership of the department as part of the culture. Director Deramus has been requested to speak at statewide data conferences and even nationally due to the departments wide success in improving cardiac arrest survivability and creating a response standard that promotes optimal financial efficiency while reducing response times to rural areas of our jurisdiction using a "flex model system" that strategically places experienced paramedics with high skill retention in areas that can best impact critical patients.
The EMS Department currently has the highest cardiac arrest survival rate in the region (in a recent study conducted by the Brazos Valley Regional Advisory Council) and ranks among the top in the state. The department also takes pride in being one of the more progressive and innovative public safety departments in the state with such programs as our community paramedic program, ability to carry blood on our ambulances, ultrasound technology, and critical care paramedics within the system. Before we dive into this, sometimes debatable data, we need to recognize that clinically speaking in regards to optimal patient outcomes the EMS department consistently ranks near the top. Which is nearly impossible for rural providers to accomplish due to historical lengthy geographical response times.
This particular retrospective analysis was an attempt to ensure the practices of the department are optimal in regards to responses to transportation incidents (aka vehicle accidents) within Washington County. One of the many advantages of having a segregated EMS and Fire Department is the ability for each department to have focused priority responses and a reduction in unnecessary or duplicated responses. As you might assume the response to an emergency is both the most dangerous thing we do in public safety and is also the most costly. The dangerous and lethality of this type of response was seen recently with a fatality accident involving a Waller County deputy who was responding (RLS) to a call in November of 2018. We have been staunch advocates of reducing the "calvary response" that most cities welcome. We believe public safety responders should respond to all incidents that they are "needed at" and not "all calls just in case" they are needed. The calvary response began in the late 1970's when virtually no enhanced 911, no computer-aided dispatching and virtually no training was supplied to the dispatchers. However, even with new quality data, training curriculum and the most innovative public safety software in our hands many municipalities and government agencies continue to have an overwhelming amount of RLS (responding with lights and sirens) responses and the calvary (send everyone just in case) response continues today to be the common approach to 911 emergencies in communities around us. This continues even with new data that suggest response times to most 911 calls have no direct correlation on patient outcomes. New response data continues to tell us that it's what you bring (clinically trained and experienced paramedics) to the emergency that matters most not the speed at which it arrives. It's really just 1-2% of the calls that having a quick response to the scene really matters the most. I think it's time we start telling our taxpayers the truth and stop using scare tactics to grow public safety departments. The goal for us should be to discover new ways to accomplish that very thing. Bringing advanced skilled paramedics with high experience into the most likely areas that would suffer from lengthy response times and to utilize (as it becomes developed) "predictive call analysis" software to aid us in making those decisions.
We have previously reported within our annual reports the cost associated with ambulance and rapid response vehicle responses compared to fire engine and truck company responses. This data is available with a quick google search but it does not take a google search to understand the cost increase to taxpayers is drastic. We agree cost should and must remain secondary to patient care and that is why we believe one must use real clinical data and not "what if" conclusions when evaluating the existing success of local public safety response.
Some recent data is not even "new" data. A 2010 JEMS (journal of emergency medical services) article states public safety responders must be active and frequently delivering clinical care in order to have optimal outcomes. The Article discusses the real concerns of having first responders that do not routinely deliver clinical care as a standard of practice responding to simply "stop a time clock" yet clinically delivering a (potentially) substandard level of care. You can view this article below, however, most importantly we see this within our own EMS system. When we bring PIII (highest system credentialed and experienced paramedics within the department) level paramedics to the scene of real emergencies we have double-digit improvement in patient outcomes. This is not a hypothesis, this is real data.
The evidence shows increased experience leads to more proficient practitioners, reduced errors and better patient outcomes. Some hospitals are required to see a specified number of cases in order to become a designated Level I trauma center. There are studies of physicians showing that those who perform more of a particular invasive procedure per year have better patient outcomes, fewer complications, etc. A parallel certainly can be drawn to EMS clinicians and emergency field responses.
These and studies like these are what directed us to change our response structure in Washington County. We now focus on getting a PIII level paramedic, which is the highest and most experienced paramedic we employ, to the most critical calls. It's this strategy that has allowed us to improve nearly every statistical measure of clinical outcomes that we track. It reduces response times, it reduces medical errors, improves cardiac arrest outcomes, and improves overall patient satisfaction.
Trained experienced dispatchers are the key to success. The fact that we can extrapolate and determine that these particular calls were not time-sensitive in nature allows us to take an extra few seconds for appropriate questions to be asked that will reveal whether or not a fire response is indicated. This is simply triaging resources appropriately and ensuring resources are available for when they are needed the most. We are currently doing this and as you can see from the chart it works. When you hear that the fire departments "call received to dispatch" times are slightly longer this will make complete fiscal and clinical sense for you now. None of the patients in the "gray" area marked "not dispatched" had any injuries that resulted in EMS needing to be sent. The dispatchers are getting this correct! Likewise, none of those patients required a life-threatening response from the Fire Dept. Thankfully we do not subscribe to the "send the calvary" approach or this would be an astronomical expense to the taxpayers without any clinical scientific evidence for support.
At the time of this report, only 22% of the accidents in our county required EMS to response. Only 5% required assistance from the Fire Department. Of the total vehicle accidents reported in Washington County, only five (5) required vehicle extrication assistance from the Fire Department. This means that less than 1% of the total accidents reported required extrication tools to be utilized. Keep in mind also that none of these patients involved in these five accidents were deemed critical (meaning was not time sensitive) by the paramedics. Again, this is not claiming that a response was not indicated or warranted for many other potential reasons but an RLS response versus a safer non RLS response would make no difference in patient outcomes.
Clinical Data Analysis
It's important to point out that a thorough analysis of the clinical data was also researched within this report. The following are the findings we discovered.
Part of the goal was to discover how many times is "time" really of the essence for life safety responses. To really look at this objectively it can only be done in a retrospective review of the patient's electronic chart data. This clearly takes some time and man-hours to read through each chart and review each endpoint (patient outcome). A group of paramedics that are apart of our Clinical Improvement and Research Division (CIRD) assisted with this review to limit the human error potential of one person reviewing the data.
The group reviewed all 33 charts that both EMS and Fire responded to. The charts were reviewed and four primary clinical data parameters were utilized to determine how "sick and or injured"
- GCS -15 (The Glasgow coma scale is used to assess patients in a coma. The initial score correlates with the severity of brain injury and prognosis. The Glasgow Coma Scale provides a score in the range 3-15; patients with scores of 3-8 are usually said to be in a coma. 15 is normal) A score of 15 is a normal GCS score that you and I have today.
- RTS -12 (The Revised Trauma Score is a physiological scoring system, with higher clinical reliability and demonstrated accuracy in predicting death. It is scored from the first set of data obtained on the patient and consists of the Glasgow Coma Scale, Systolic Blood Pressure and Respiratory Rate. RTS of 12 is the best possible score.
- Vital Signs: Vitals signs look at the hemodynamic state of the patient not just in the beginning but every five minutes throughout the duration of the call. The patient's blood pressure, pulse rate, and respiratory rate are normally what is defined as "vital signs" for this report we also included EtC02 (monitoring of carbon dioxide), ECG monitoring and pulse oximetry monitoring. Each of these aids the paramedic in discovering critical or potential critical patients.
- Transport status. WCEMS determines the mode of transport by weighing the risk of immediate care from a physician verse the potential for being involved in a vehicle accident during transport. Essentially if we transport a trauma patient with lights and sirens (emergency traffic) also known as RLS then "time is of the essence" or there is the potential of a life or limb being threatened by prolonged time without surgeon/physician care.
These indicators do not attempt to underscore or minimize the patient's pain, their discomfort or the need for emergency treatment by paramedics and physicians and should not be misconstrued as patients that do not need such care. These were true emergencies that warranted professional responses by both Fire and EMS. However, it does call to attention that it may not warrant an RLS for certain aspects of the response.
- Of the 162 calls that EMS responded to only three (3) patients required code 3 (RLS) transport to definitive care. That means nearly 98% of the patients that EMS responded to required a non-emergent transport (code 1) from the scene. Their emergency was deemed not time-sensitive.
- Of those three (3) patients that were transported with lights and sirens, all three had a GCS score of 15. 100% of them. Remember, from the above definition GCS of 15 is the best possible score (normal).
- The same three (3) patients when scored on the RTS (revised trauma score) all (100%) scored a 12. Again the best possible score.
- As we looked into the vital signs that transported emergency traffic with RLS all had stable vital signs within normal parameters.
Interestingly enough all five of the patient that required extrication assistance from the Brenham Fire Department were stable patients. Overall, the data revealed our most critical patients from vehicle accidents were the patients that were ejected or involved in a rollover that did not require assistance from the additional public safety agencies. Although some of these patients were transported by air medical helicopters. Extrication (vehicle rescue) and vehicle stabilization were not required. A non-emergency response (no RLS) or delayed response (responding after the initial paramedic arrives and determines the need) would have sufficed and the patients would have incurred the same clinical outcomes.
Financial / Operational Analysis
For example in our community, if we simply blanket toned EMS to all 662 accidents in our county then we would immediately require additional ambulances and paramedics because we would not have enough resources available to handle those request and inevitably we would not have a paramedic available when a real emergency required a response. At a cost of approximately $450,000 per unit inappropriate dispatch and response of public safety, agencies can strangle the taxpayers. The same can be said for unnecessary fire responses. Using 2010 numbers from the Brenham Fire Department, they estimated the average response to a traffic accident costing just under $2,400 per call. Using their math (keep in mind inflation over eight years would change these numbers) dispatching the fire department to all the accidents that EMS currently responds (162 responses) to would cause an increase of just under $300,000 per year and that is if the department did not have to add staffing and fire apparatus. Keep in mind this would cause a near 500% increase in responses to accidents for them. If you extrapolate this data to the total 662 responses then it would cost the taxpayers an additional $1,588,800 annually. Again, these figures are only maintenance, operations, and cost (MOC) not additional staffing salaries. One would only imagine with a near 500% increase in request for service that additional staffing would incur.
I'd also remind the reader that currently less than 1% of these calls actually need extrication services and only 22% required EMS response.
Historical Data Facts and Recommendations:
- Compared to 2011 data, Brenham FD has increased their responses to vehicular accidents from 18 (reported using 2011 annual report from BFD) to 34 so far in 2018 (only reporting nine months) That's currently a 100% increase in responses to accidents in just over eight years.
- Cost for a response (again extrapolated from BFD annual report 2011 and does not adjust for cost inflation) is $2,396.68 per call.
- After a thorough review of the clinical data presented from reading the patient care charts written by the in-charge paramedics, we discovered that less than 1% of the accidents required vehicle extrication using extrication tools.
- I've attached the 2017 NFPA firefighter fatality report for full transparency. It's important to point out that fatalities related to "responses" are discussed on page 9 of the report. (the second leading cause of death) One major push that departments around the nation are advocating is sending not one but two fire trucks to these accidents to "block" traffic in attempts to make these scenes safer. One must realize that the more firefighters (or any personnel) at these scenes make the likelihood of an accident occurring greater. Statistics are proving this. The only sure way to decrease the potential for response fatalities is to decrease responses. This underscores the very important role the dispatcher has in deciding to send valuable resources to these incidents.
In order to verify reducing RLS responses would make very little difference in operations and statistically zero impact on patient outcomes we reviewed the five responses that EMS transported with RLS (emergency traffic) to definitive care (the facility where final treatment can be rendered) due to perceived time-sensitive treatments. We compared the response and transport times using the WAZE navigation app, which takes into account traffic congestion. We attempted to analyze this data from the exact initiated response location and time of day for precise accuracy. What we discovered was the average time saved by responding to these incidents with RLS was less than 1 minute (60 seconds). The average time saved by transporting these patients with RLS (emergency) depending largely on the destination but for the most part, saved approximately 3-5 minutes of travel time during transport. Because this data was very low quantity we decided to run an analysis of our emergency response times to a very common address to try and get a more precise time savings estimate. We ran these numbers to a frequented local nursing home. This particular nursing home has incurred over 178 emergencies (RLS) responses in the past three years. The average response time to this facility with RLS was 5:55 seconds. Using WAZE technology at exactly 5 pm (the busiest highway time of the day for us) the estimated response time is exactly 6 minutes. Therefore the average time saving is roughly (5) five seconds. This must make us think about our responses and the amount of danger we pose to our community when responding with RLS.
First, I want to thanks Director Kristi Stamnes and Chief Ricky Boeker for not adhering to the "norm" and continuing to do what is right and safest for the community. Without their support over the years we would be like most other cities and have unnecessary responses to many emergencies and absorb much larger budgets (burdening taxpayers) but most importantly creating unsafe and unnecessary responses to our citizens and public safety personnel. The following recommendations are being reviewed by the Medical Direction and EMS Administration for implementation into our 2019 strategic planning documents. With the strategic placement of our PIII Paramedics in all districts of our jurisdiction, it is far less important now to send EMS units and Fire Units from Brenham with RLS (emergency traffic) to these incidents. I would encourage the reader to review the attached external audit report of our EMS department compared to over 20 Texas Fire Department that operate Fire / EMS together. You will notice that in regards to cost to the tax payer we scored extremely efficient without reduction or quality of service. In fact we currently score at or near the top in both patient outcomes and efficiency.
- Current practices of triaging calls for appropriate public safety response is not only fiscally smart but clinically safe to perform. We believe we should further train and educate dispatchers (TCO's) to perform accurate triage and hopes to further improve the accuracy of "who to send where".
- The EMS Department has placed an enormous emphasis on decreasing call volume and responses within the community we serve. By improving access to care to non-emergency centers, using community paramedics to ensure appropriate resources are available and using them to change a culture of what requires a 911 response and using dispatcher triage to assist in the reduction of call volume. For the first time in over two decades, we are seeing a decrease in responses.
- The EMS Department made changes to our responding with lights and sirens (RLS) responses by enacting protocol changes that no longer require transporting with (RLS) to certain call types (such cardiac arrest patient who do not have the return of a pulse (ROSC)).
- Public Safety Departments must begin to recognize that we have had multiple (some major) vehicle accidents involving EMS, Fire, and Law Enforcement Entities. No one is immune to this and very little time is saved by RLS responses. Most studies suggest between 45 seconds and two minutes is saved. Of course, rural versus urban responses dictate significant differences. We must work to understand that only a small percentage of our calls require this type of response and begin to change the culture and mindset.
- Community leaders deserve to be correctly educated on the issue of cost verse clinical benefit. We believe by the strategic placement of paramedics into our community that has created (a less than) 6 minute response time to nearly our entire jurisdiction certainly lessons the need for an emergency response from a fire department, or an EMS unit, or additional EMS units has virtually zero clinical value to the patient and exponentially increases the risk of the very community we strive to protect. These facts should be considered by our community and public safety leaders as we move forward. This is the primary reason the county does not allow medical first responders (WCFRO) to respond to emergency traffic (RLS) in their private (personal) vehicles to medical emergencies. There simply is no data to support this and there is not enough time saved to cause a direct impact on patient outcomes.
- The multi-agency response from LE, Fire, and EMS, and volunteers to a single geographical location causes a major increase in the potential for vehicle collisions. It's much like 8-10 missiles being guided through your community with independent controllers that have no idea where the other missiles are coming from. This should be reduced as much as possible. Much like EMS does not respond to fire scenes with RLS (emergency) we believe a substantial amount of calls should be responded to non-emergency (no RLS) by fire units to EMS "assist scenes". Again, we would reiterate, the county currently does not allow volunteer FRO's responding to medical emergencies to respond emergency (RLS) for this very reason.
- Research: Are there more appropriate agencies, such as TxDOT, who can better serve as traffic congestion aid with more appropriate signage to assist in major response incidents that would not tie up or require life-saving apparatus for this purpose?
- The EMS Department has set a 2019 goal of reduction of RLS responses by 10% over the 12 month period. With a long-term goal of decreasing RLS responses by 10% per year over the next five year strategic planning period. We believe we can and should reduce a significant amount of our responses to nursing homes to non-emergency responses (no RLS) and this alone could account for a significant reduction in RLS responses. We are now conducting data analysis of these calls to ensure patient safety and clinical concerns.
Micheal Oberhelman, CIRD / Paramedic
Drew Reynolds, Paramedic
Dr. William Loesch, MD
Kevin Deramus, LP / EMS Director
Amy Klussmann, Compliance Captain / Paramedic
Kristy Taylor, Operations Manager (911 Communications)
Kristi Stamnes, Director of Communications