EMS commission, AMR agree on new initiatives

WOODBRIDGE - Responding to concerns about emergency medical services in town, the Emergency Medical Services Commission enacted some new initiatives at a meeting on Feb. 4.

These measures were adopted to provide commission members with the information needed to more effectively evaluate emergency coverage. Representatives of American Medical Response, the provider of emergency services for the town, attended the meeting, along with Ed Sheehy, the first selectman; Michael Luther, the Board of Finance liaison; Lt. Jeff Leiby, the liaison from the police department; and Joe Hellauer, the town administrator.

Questions about the emergency medical coverage in town were prompted by a prolonged response time by an AMR ambulance on Dec 20. In that instance, the ambulance took more than 20 minutes to arrive on the scene of a medical emergency rated as priority one, the most serious.

Additionally, a report in the Bulletin revealed that AMR failed to meet its contractual agreement for priority one ambulance response times for eight of the first 11 months in 2007.

In view of these issues, Sheehy directed the EMS Commission to begin meeting monthly instead of quarterly to review statistics. Accordingly, the commission met in February to address emergency services. Alan Tyma, chairman of the EMS commission said, "It's a question of getting to a point where we can get satisfactory performance."

The town has a contract for emergency medical services with AMR that calls for certain compliance standards. Tyma said, "We have a contract, and the contract calls for goals and standards."

AMR provides a two-tiered emergency response. An AMR paramedic is stationed in town and is equipped to provide advanced life support in the field but cannot transport the patient. Transportation must be supplied by a separate AMR ambulance

By contract, the paramedic must respond to all calls within nine minutes 90 percent of the time.

According to performance reports, the paramedic response time is met without fail. Dr. Alan Davidson, a commission member, said, "You (AMR) have hit the mark consistently."

Sheehy also praised the paramedic, saying, "The important thing is to stabilize the patient. And you're doing a good job at it."

Although the paramedic provides advanced life support in the field, the patient needs access to rapid transport to the hospital. AMR supplies the ambulance for this function. Unlike the paramedic who is stationed in town, the ambulance coverage is provided by one of a number of regionalized vehicles. The AMR ambulances provide simultaneous service to a number of towns in the region. The covering ambulances circulate around the region, attempting to take up positions that can provide the fastest service for all areas.

Dan O'Brien, chief executive officer of Northeastern AMR, said, "It's a little more complicated working at it from a regional perspective. But that's what makes it affordable."

Contract parameters for responding ambulances require that for emergency calls categorized as priority one, the most urgent, the ambulance must arrive on scene in 13 minutes 90 percent of the time. For priority two calls, which are less serious, the ambulance is required to be on scene in 16 minutes 80 percent of the time.

Tyma said, "There were between 6 and 13 non-compliant responses of the transporting ambulance to priority one every month over the past few months. It hasn't been absolutely on target."

Sheehy said, "The ambulance response times are important."

One of the commission members, Dr. Gary Desir, asked if AMR could realistically achieve a 90 percent compliance rate for priority one ambulance response times.

O'Brien responded, "Without isolated instances, yes."

O'Brien added, "It's not an easy number to hit. We wanted to have a goal that was high enough to make everybody stay on their toes."

Some of the commission members expressed concern that they were not provided with enough data to assess performance, particularly in regards to non-compliant response times. At present, the commission is given a compliance percentage for each category, ie category one or two. Individual calls are not addressed.

Jeff Axt, a commissioner, said, "We don't have data to assess the variance in response. How much are we missing by?"

Roy Ivins, another commissioner, requested that AMR report each non-compliant call monthly so that the commission could evaluate the data. Ivins said, "Are we missing it by two or three minutes, or more? That's what we need to know."

Sheehy agreed, saying, "You (the commission) need those numbers. You are the relationship between AMR and us. You should question those numbers if you have any doubts about them."

Axt also said that he was working on ways to manage AMR data so that it was more user-friendly. Axt hoped to be able to present the data in the future so that the commission could glean as much as possible from it. "Let's get to a true picture that gives us a "dashboard": a concise picture," said Axt.

O'Brien said that AMR could supply the additional data. "We can tweak the reporting," said O'Brien

The contract also spells out avenues open to the town to deal with non-compliance. Should AMR be found wanting, the town can begin to take steps to ensure better compliance by the ambulance company. This has not been done in the past, however.

Tyma said, "The contract calls for ways for the town to act."

Tyma suggested that perhaps the commission should begin imposing some of the repercussive actions. It quickly became a moot point when AMR produced its response figures for January 2008. Those numbers revealed that AMR ambulances responded to priority one calls within requirements 97 percent of the time.

Another contract measure never invoked is the requirement that AMR submit written explanations for any response time longer than 20 minutes. This requirement accomplishes the purpose of evaluating what occurred to prolong the ambulance so that appropriate measures can be taken, if needed.

To address that deficiency, AMR submitted two letters to Joe Hellauer, the town administrator, that addressed prolonged times. For two of the incidents, AMR explained the prolonged time with "system overload, secondary to volume".

Sheehy was not satisfied with that verbiage. He asked, "Can you get more specific with these? These are kind of generic."

Davidson said, "If we see too many overloads, something is wrong with the system … you don't have enough ambulance coverage."

AMR agreed to supply more detailed information in the future.

AMR also took some initiatives on its own. To begin with, the company reviewed how the ambulances were positioned to be sure adequate coverage for the town was ensured. "We re-evaluated the system status plan to be sure the trucks (ambulances) were in the best place," said O'Brien.

Additionally, AMR looked at those calls that did not meet requirements to see if there were extenuating circumstances that influenced response times. Under contract, AMR is allowed certain exceptions to its requirements, such as during bad weather. These situations could affect overall compliance rates.

Chuck Babson, the manager of AMR, said, "We looked at all the non-complaint calls for 2007. There were exceptions we didn't account for that we could have by contract."

According to Babson, just such a case happened in February 2007. The reporting figures for that month revealed that AMR was only at an 82 percent compliance rate for ambulance response times to priority one calls, having missed response times in 10 of 56 calls. Babson related to the commission that, in fact, five of those 10 calls would have met exclusion criteria, bringing the compliance rate up to over 90 percent, which is within the contractual agreement.

When asked why AMR did not factor those exceptions in, O'Brien said, "It takes a little more digging, and our general sense was that the system was working."

The commission seemed satisfied that, in the future, they would have a better handle on things. Tyma also noted that the overall trend of AMR's performance had shown a steady improvement. Tyma said, "We have a system that is looking at achieving goals."

Leiby, who has been on the police force more than 20 years, remarked that things overall had changed dramatically for the better over the years. Leiby said, "The standard of care has improved greatly."

Davidson said, "I am so pleased with the service you are giving the community."

AMR seemed eager to cooperate. O'Brien said, "We want to provide you with a comfort level."

The next meeting of the EMS commission is scheduled for March 10.