It is 0430 hours on Monday, December 4, 2006, and Firefighter/paramedic Craig Stewart of the Erlanger (KY) Fire/EMS Department has spent the night responding to ambulance calls, monitoring heart rhythms, starting IVs, and pushing medicines.
On this call, however, instead of reaching in the back of his Ford Explorer and pulling out his heart monitor and medic bag, Stewart grabs his turnout gear and portable radio. He is the first person to arrive at a working structure fire as an automatic-aid unit for a neighboring department.
 Providing supplemental ALS service to surrounding communities has not detracted from Erlander (KY) Fire/EMS Department’s responding to calls within its own city limits. (Photo by author.) |
Stewart draws on his fire experience to establish command and begin a fire attack plan. He is part of an innovative program implemented by Chief Tim Koenig and his administrative staff, born of necessity-the growing staffing demands of the current fire/EMS service and a struggling economy. This program received the 2006 Gold Award for Municipal Excellence at the National League of Cities’ Congress of Cities and Exposition in Reno, Nevada.
AMBULANCE SERVICE CAUGHT IN A FINANCIAL SQUEEZE
Erlanger is a city of 17,000 located at the northern tip of Kentucky. The Erlanger Fire Department traditionally has been a volunteer fire organization since its inception in 1904. The Erlanger Rescue Squad was formed as a separate entity in 1970 to provide a basic life support (BLS) ambulance. In 1991, these organizations merged to form Erlanger Fire/EMS.
Since the merger, the department slowly has transitioned from primarily a volunteer organization to an organization that uses full-time, part-time, and volunteer firefighter/EMTs. The department had never provided advanced life support (ALS) services because the cost was too expensive to maintain and in the past these services were deemed unnecessary. Supplemental ALS service was provided free of charge to all of the ambulances throughout Northern Kentucky through a private nonprofit provider that was associated with the local hospitals. Any cost incurred for providing the ALS service was absorbed by the hospitals or diffused through patient billing.
In 2002, this agreement changed. The private provider advised the local ambulance services that in addition to patient billing it would begin charging the ambulance providers for service as well. This was a difficult financial burden for the ambulance services in Northern Kentucky to absorb. What made the matter worse was the rate at which the cost of the ambulance services increased from 2002 to 2003.
The response of some of the larger ambulance providers was to upgrade their ambulance service from BLS to ALS so they would not be dependent on the private provider. Since the nonprofit ALS provider had now lost its largest customers, its response was to drastically raise the cost of providing the service to the smaller cities and ambulance providers who were still dependent on their service. To make matters even worse, the private provider could not tell the smaller ambulance providers what the extent of the cost would be or when the cost would stabilize.
CITY PROVIDES ALS SERVICE
After further negotiations with the private provider, the City of Erlanger decided that it would need to provide its own ALS service. There were several concerns with this proposition. First, although the city would have a better projection of cost and more control over its ALS service, the cost still would be very substantial; of particular concern was the addition of personnel to a department that struggled to fund staffing. Also, since cost was a limiting factor, there was concern about how much the city would be able to pay paramedics and, therefore, what quality of employees the city could hire. Third, since Erlanger was the largest remaining customer of the nonprofit, there was a fear that its ALS would result in the private provider increasing the burden to surrounding cities to the point that they would not be able to afford ALS service at all.
EVALUATING COST WITH A QUALITY PROGRAM
The first step in the process was to get a firm grip on the potential operating costs and projected revenues. Department statistics were compared with numbers obtained from the private billing company that handled Erlanger’s EMS billing. This information was analyzed for the number of EMS calls the Erlanger ambulance service made; what percentage of these calls were ALS calls; a fair increase to charge for ALS calls; and an estimate of the additional income that would be generated by ALS billing. Also investigated was the cost related to contracting with a physician to serve as a medical coordinator; the cost of equipment and supplies; as well as the cost of employing full-time paramedics for 24 hours a day, seven days a week.
It was not considered economically feasible to operate the system exclusively with a full-time paramedic only. For this program to maintain a realistic budget, it had to incorporate a flexible staff of personnel that not only included full-time and part-time staff, but, more importantly, employed staff cross-trained as firefighters and paramedics. The part-time positions offered a very desirable hourly rate and increased the firefighter/paramedic’s state retirement incentive. By doing this, the department was able to employ experienced firefighter/paramedics in a part-time capacity. This flexible staffing arrangement made it feasible for the department to account for and use its staffing to the fullest degree by employing staff that could respond on ALS calls when needed and fulfill firefighting duties when staff-dependent incidents occurred. Second, it allowed the department to staff at least two paramedics per shift, which was critically important for the program to be extended to neighboring departments.
ASSISTING SURROUNDING DEPARTMENTS
Erlanger completed only about a third of its EMS calls as ALS responses. Many of the surrounding cities had approximately the same ALS completion rate. If Erlanger followed convention and fully converted its ambulance from a BLS unit to an ALS unit, it would not be able to assist surrounding cities. Furthermore, approximately 66 percent of the time, the city would be paying a paramedic at ALS rates to complete BLS duties.
It was determined that the best use of this resource was to maintain a tiered EMS system. In this system, paramedics are put in staff vehicles and follow the ambulance to the scene. If the patient needs ALS care, the paramedic rides in with the ambulance crew. If the patient needs only basic EMS care, the BLS ambulance crew transports the patient to the hospital without the paramedic onboard. The paramedic remains available for the next EMS call in the area. If a third medic is available on-shift, this paramedic is placed on the engine as part of the firefighting crew but has a third set of ALS equipment. In times of high EMS call demands, this paramedic is available to respond with the engine crews and complete ALS responses. This system allows Erlanger not only to provide ALS service for its own ambulance but also to make it available to supplement BLS ambulances for surrounding areas.
This program was implemented on January 1, 2005. The first participants were the Erlanger Fire/EMS Department, the Elsmere Fire District, and the Point Pleasant Fire District. Erlanger staffed one paramedic to cover these three ambulance providers. Erlanger also staffed two paramedic units during peak hours to ensure all calls for assistance were answered.
In the first six months of the program, the Erlanger ALS units completed 507 calls for assistance. Only 54 percent of these responses were completed with the Erlanger BLS ambulance. The remaining 46 percent of the calls were completed with the Elsmere and Point Pleasant ambulance services.
After the first few months, the program proved so successful that the department was approached by two other ambulance services to begin to provide supplemental ALS service for them. Erlanger officials agreed that it was feasible to do so; on July 1, 2005, Erlanger began to staff two paramedic units 24 hours a day and offer ALS service to the Crescent Springs Fire Department and the Edgewood Fire Department. Between July 1 and December 31, 2005, Erlanger ALS service responded to 721 calls for assistance. Only 296 (41 percent) of these calls were to Erlanger. For all of 2005, the ALS service completed 1,228 ALS calls; 669 (54 percent) were to support other agencies. The city was able to ensure that of the 1,718 total ambulance calls within Erlanger, the 569 (33 percent) that required ALS were provided for by Erlanger’s own service, without requiring mutual-aid assistance.
WHY THIS PROGRAM WORKS
This program has worked because of the open communication and cooperation among the elected officials, city administrators, and chief fire officers involved. Throughout the process, everyone has been well informed and has worked together as a team to make the program a success.
The decision to operate as a tiered system, increase the population served (to approximately 80,000), and share the cost and demand of the program across five agencies has been critical to its success. The program is funded through two sources: patient insurance billing for completed transports and contracts with neighboring partners, including Crescent Springs and Villa Hills (Crescent-Villa Fire Authority-Crescent Springs Fire Department Ambulance), Edgewood (Edgewood Fire Department Ambulance), Elsmere Fire District (Elsmere Fire Department Ambulance), and the Point Pleasant Fire Protection District (Point Pleasant Fire Department Ambulance). Erlanger also pays into the system as a partner in the project.
Having two sources of funding and expanding this program to service a larger population group has kept the cost reasonable for all five departments. Erlanger has been able to maintain this program for a cost that is substantially less than the service from private providers. Sharing the service has not detracted from its performance during the first 15 months of operations in which the Erlanger ALS service has completed 1,642 calls. Staffing at least two paramedics per shift has ensured that Erlanger ALS has not failed to respond to a single call for help. Indeed, the Erlanger paramedics have completed 23 calls as mutual-aid responders to assist other agencies that are not within contract because their paramedic services have been on other calls.
Finally, the decision to staff the BLS ambulance and ALS transport units with cross-trained firefighters has been crucially important to staffing. Fire departments are fighting fewer fires now than ever before. This does not mean that when these fires do occur, we need fewer firefighters to fight them. However, the greatest call volumes placed on the Erlanger Fire/EMS Department are EMS-related calls. Because of the high demand and frequency of these calls, it is much easier to justify hiring personnel in this field. Having all personnel cross-trained has helped the department face the demand of EMS responses and also allowed the EMS staff to fulfill firefighting roles in the event of a fire.
Equally important to the success of this part of the program was the 2005 acquisition of a Department of Homeland Security FIRE Act grant to properly equip all of the department’s fire/EMS personnel in compliant turnout gear.
We live in a changing world that increasingly imposes more demands on us and yet provides us with less resources to deal with them. This program is representative of how Erlanger stepped back, realized the challenge presented, analyzed the available resources, and responded to the challenge by changing operations. To do this required commitment, cooperation, and-most importantly-an open mind.
ERIC J. SEIBEL is captain and training director for the Erlanger and Point Pleasant Fire Departments in northern Kentucky.
