proposal for the provision of fire department-based - Squarespace

PROPOSAL FOR THE PROVISION OF FIRE

DEPARTMENT‐BASED ADVANCED LIFE SUPPORT AND

TRANSPORTATION

CITY OF GALVESTON FIRE DEPARTMENT

GALVESTON, TX

MARCH, 2013

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TABLE OF CONTENTS

I – Introduction

II – Executive Summary

III – Geographic Overview

IV – Methodology

V – EMS Operations

VI – Advantages of Fire Based EMS

VII – EMS Staffing and Deployment Analysis

VIII – Cost Assumptions and Calculations

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INTRODUCTION

This report presents a brief Geographic Information System (GIS) analysis of the City of Galveston Fire

Department deployment as a foundation for the proposed integration of fire, EMS and patient

transportation.

The goal of this proposal is to provide the citizens of Galveston a full service, out‐of‐hospital emergency

medical care system. This system will include the provision of rapid response, treatment, and transport

for the purpose of improving the quality of patient care. Through employee teamwork and a distinctive

command structure, this proposed Fire Department based system will deliver the optimum level of EMS

response and patient care, including transport.

The Galveston Fire Department (GFD) protects lives and property through fire prevention, public

education, firefighter safety, fire & rescue operation, emergency medical service and disaster

management. The vision for this program is one of growth and adaptation, as necessary, to maintain

and enhance the quality of services delivered. This continuous improvement will facilitate safe, efficient

and effective emergency response and patient care leading to positive outcomes for those requiring

service.

Scope and Objectives This report examines the provision of emergency response services provided by the City of Galveston

Fire Department.

Issues evaluated by this report include:

Fire department proposed EMS response capabilities, staffing arrangements and safe work

practices

Strengths of the Fire Department in provision of EMS

Future goals and ways to improve services

Cost assumptions and projected revenue

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EXECUTIVE SUMMARY

Galveston Fire Department provides a variety of emergency services to the local area population.

According to the 2011 census bureau estimation, Galveston has a population of 48,444 people1.

The Galveston Fire Department (GFD) has long provided fire suppression and emergency medical first

response services to the citizens of Galveston. The GFD has successfully implemented a BLS (Basic Life

Support) first responder program which, in most cases, arrives prior to the county transport unit, and

provides early, essential primary patient care using existing cross‐trained multi‐role firefighters. In doing

so, the Fire Department has essentially subsidized the county ambulance service by performing the

time critical first response activity, while the ambulance service provides revenue generating

transport.

The City should consider offering those services now provided by the county transport provider, thus

ensuring that the city has sole authority over EMS system design and quality. The Fire Department is

proposing to assume the ambulance transportation role for Galveston residents and visitors, continuing

the fire department’s tradition of superior care which is ethically based and financially viable for the

long term. With the demonstrated commitment and extensive experience of city leaders, GFD is the

best organization to help the city implement its vision of an innovative, patient focused and clinically

superior fully integrated EMS system. Therefore, it is recommended that the GFD integrate patient

transport into the realm of services they now provide.

The Galveston Fire Department currently provides the following services:

Fire Suppression

Fire Prevention & Fire Investigation

Emergency Medical Services

HazMat Response

Rescue and Marine Operations

Galveston EMS History In the early 1970’s Dr. Truman G. Blocker, President of UTMB at Galveston, Dr. Sally Abston, Dr. Byron J.

Bailey as well as several other prominent physicians in the community approached the Moody

Foundation of Galveston about assisting with the formation of an EMS system on Galveston Island.

Blocker, a burn surgeon who had witnessed the carnage of the Texas City disaster in 1947, along with his

associates, had determined that the time was right for such a system. They based their recommendation

on the American Heart Association’s CPR science as well as the National Highway Transportation Safety

Administration’s white paper which dealt with morbidity and mortality on the nation’s highways. The

Galveston Emergency Medical Services system was ultimately set up under the direction of the

Galveston County Health District, as a third city service, where it has remained for the past 40 years.

1 U.S. Census Bureau web site < http://quickfacts.census.gov/qfd/states/48/4828068.html> last visited 1/29/2012.

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Recommendations The Galveston Fire Department should provide emergency medical transport services in its

service area at the Advanced Life Support (ALS) level. The distinction between the basic

level provider (EMT‐B) and the more advanced level Paramedic training, is the delivery of

Advanced Life Support (ALS), and advanced levels of care, such as drug administration,

intubation, and intravenous (I.V.) therapy.

The Galveston Fire Department should add 28 full time firefighter/paramedic positions 1

full time training officer position, 1 full time quartermaster position and 1 full time Assistant

Chief of EMS position to appropriately deploy four ambulances staffed with a minimum of 1

FF/EMT‐P and 1 FF/EMT‐B at all times.

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GEOGRAPHIC OVERVIEW

Map 1

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Geospatial Characteristics Galveston is the county seat of Galveston County, Texas. It is located at the south of the state, about 50

miles south of Houston2. The city is located on an island connected to the main land by bridges. It is an

attractive tourist destination with approximately 6 million tourists a year.

Topography

The urban area is relatively flat. Areas that are flat allow the fire apparatus to travel at designated

speed limits; however they are exposed to flooding.

Figure 1 ‐ Weather3

Galveston has mild cold winters and warm wet summers. The record high temperature in Galveston was

104o F and the minimum record temperature was 8o F4. Galveston can be and has been affected by Gulf

of Mexico hurricanes and must maintain high level of preparedness during hurricane season.

Transportation Networks

A complex transportation network, consisting of highways, municipal roads and railroads serves the City

of Galveston.

Traffic congestion can be an impediment to a swift response in the response jurisdiction. A few of the

numerous transportation issues deserving consideration in Galveston are:

2 Wikipedia Website < http://en.wikipedia.org/wiki/Galveston,_Texas> last visited 1/29/13. 3 weather.com website < http://www.weather.com/weather/wxclimatology/monthly/graph/USTX0499> last visited 1/29/2013. 4 Ibid, last visited 1/29/2013.

61 6369

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8287 89 90

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7176 78 78

73

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20

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Maximum

Minimum

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Forecasted increases in population and employment

Forecasted increase in tourism

Forecasted increases in “trips”

Heavy vehicle traffic and bridge crossings

Sandy and muddy roads

Future land use creating increased demand for commuter, personal, and commercial trips

Tourism

Galveston is a major tourist destination that hosts about 6 million visitors each year. Many come to the

beach and associated attractions. More come for the 150+ special events hosted on the Island. The two week Mardi Gras in February each year and the 5 day Motorcycle rally in November historically bring over 400,000 visitors to Galveston. Almost every weekend there is a festival or some other event that draw thousands of visitors to our City for a weekend. All of these events increase the call volume and at times place the FD in a critical resource mode for hours at a time.

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METHODOLOGY

OVERVIEW

Once the domain of cartographers, computer‐assisted drawing technicians, mainframes, and

workstations, geographic information systems (GIS) mapping has migrated to the desktop. With ArcGIS,

a user can create intelligent, dynamic maps, using data from virtually any source and across most

popular computing platforms to display information that has a geographic aspect. The ArcGIS software,

a product of ESRI, Inc., allows desktop users to work simultaneously with maps, database tables, charts,

and graphics, and is an effective tool for conducting computerized system analysis and management.

Geographic information systems are used by government agencies, nonprofit organizations, and

businesses to describe and analyze the physical world. Simply put, a GIS combines layers of information

about a geographic region to give you a better understanding of that region. Layers of information can

be combined depending on the purpose of the study, forming a computer model of a jurisdiction on

which many types of analysis can be made. In the public safety sector, and for the purposes of this

analysis, GIS software uses geography and computer‐generated maps as an interface for integrating and

accessing location‐based information. For example, the location of fire stations can be layered on a

jurisdiction’s geography including the road network, water features, building footprints, or any other

feature that has been digitized and assigned a location. In this manner, GIS allows public safety

personnel to effectively plan for emergency response, determine mitigation priorities, analyze historical

events, and predict future events. GIS can also be used to provide critical information to emergency

responders upon dispatch or while en route to an incident to assist in tactical planning.

The Role of the National Fire Protection Association (NFPA)

The mission of the NFPA is to reduce the worldwide burden of fire and other hazards on the quality of

life by providing and advocating scientifically‐based consensus codes and standards, research, training,

and education, and recommends that all fire departments establish a policy of providing and operating

with “the highest possible levels of safety and health for all members.”5

The recommendations and analysis contained in this study are guided by NFPA standards for two

important reasons. First, NFPA standards provide fire departments with a measure of “interoperability.”

Interoperability enables fire service personnel in the chain of command to speak the same language and

conform to the same operational guidelines. NFPA standards provide the fire service with a common

language, common definitions, and common requirements that are meant to foster the safe and

effective delivery of fire suppression, rescue, EMS, and special services to a given community. Second,

NFPA standards are formulated via consensus development. Development of NFPA standards are the

result of scientific research, empirical studies, and consensus among technical experts and the

organizations they are affiliated with. Combined, these factors legitimate NFPA standards as the

yardstick by which fire departments are measured internationally.

5 NFPA Mission Statement.

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Examples of some NFPA codes and standards include:

• NFPA 101, Life Safety Code, is currently used in every U.S. state and adopted statewide in 43 states

and addresses minimum building design, construction, operation, and maintenance requirements

necessary to protect building occupants from danger caused by fire, smoke, and toxic fumes. NFPA 101

is recognized and utilized by numerous federal government agencies, including the Department of

Veterans Affairs and the Centers for Medicare and Medicaid Services.6

• NFPA 1404, Standard for Fire Service Respiratory Protection Training, which specifies the minimum

requirements for a fire service respiratory protection program (NFPA 1989). This standard concentrates

on the training component of a respiratory protection program, including the evolution of respiratory

protection training, current equipment, and recent fire experience.7

• NFPA 1561, Standard on Fire Department Incident Management System, which provides minimum

criteria for emergency incident management. Such incident management systems are intended to

provide structure, coordination, and effectiveness during emergency incidents to enhance safety and

health of fire department members and other persons involved.

• NFPA 1971, Standard on Protective Ensemble for Structural Fire Fighting, which specifies minimum

requirements for the design, performance, testing, and certification of the elements of the protective

ensemble including coats, trousers, helmets, gloves, footwear, and interface items for protection from

the hazards of structural firefighting operations.

• NFPA 1981, Standard on Open‐Circuit Self‐Contained Breathing Apparatus for the Fire Service, which

specifies minimum requirements for the design, performance, testing, and certification of self‐contained

breathing apparatus (SCBA) respirators used by the fire service. Requirements are in addition to U.S.

OSHA respirator certification under 42 CFR 84.

• NFPA 1982, Standard on Personal Alert Safety Systems, which specifies minimum requirements for the

design, performance, testing, and certification of personal alert safety systems (PASS) that monitor a fire

fighter's motion and automatically emit an alarm if a fire fighter becomes incapacitated.

On account of their emphasis on safe and effective fire suppression, rescue and EMS operations, the two

standards that will be referenced most often throughout this analysis are NFPA 1500 and NFPA 1710.

NFPA 1500, Standard on Fire Department Occupational Safety and Health Program, specifies (1) the

minimum requirements for a fire department’s occupational safety and health program, and (2) the

safety procedures for members involved in rescue, fire suppression, and related activities. This standard

addresses organization, training and education, vehicles, equipment, protective clothing, emergency

operations, facilities, medical and physical criteria, and member assistance programs. NFPA 1500

6 NFPA; site visited July 7, 2012. <http://www.nfpa.org/assets/files/PDF/CodesStandards/NFPA101FactSheet0809.pdf>. 7 Reference NFPA 1500 for requirements concerning use of SCBA in fire fighting operations and NFPA 1852 for the selection, care, and maintenance of SCBA, and respiratory breathing air quality content.

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recommends that a “minimum acceptable fire company staffing level should be four members

responding on or arriving with each Engine and each Ladder Company responding to any type of fire.”

The purpose of NFPA 1710, Standard for the Organization and Deployment of Fire Suppression

Operations, Emergency Medical Operations and Special Operations to the Public by Career Fire

Departments, is “to specify the minimum criteria addressing the effectiveness and efficiency of the

career public fire suppression operations, emergency medical service, and special operations delivery in

protecting the public of the jurisdiction and the occupational safety and health of fire department

employees.”8 The standard recommends “fire companies, whose primary functions are to pump and

deliver water and perform basic firefighting at fires, including search and rescue… shall be staffed with a

minimum of four on‐duty personnel.9 Fire companies whose primary functions are to perform the

variety of services associated with truck work, such as forcible entry, ventilation, search and rescue,

aerial operations for water delivery and rescue, utility control, illumination, overhaul and salvage work…

shall [also] be staffed with a minimum of four on‐duty personnel.10 Fire Departments that provide

emergency medical services “shall establish…240 seconds or less for the arrival of a unit with first

responder with automatic external defibrillator (AED) or higher level capability at an emergency medical

incident”11. Additionally, it shall establish service with “480 seconds or less travel time for the arrival of

an advanced life support (ALS) unit at an emergency medical incident…”12

ARCGIS 10.1 AND NETWORK ANALYST GEOGRAPHIC INFORMATION SYSTEMS

ArcGIS’s Network Analyst is an extension, or software tool, that manipulates the network data

incorporated into a GIS. Networks are interconnected line features, visually represented as roads,

rivers, pipelines, or trails. From this data, it is possible to determine the best route between two spots

or amongst several points, calculate travel cost in distance or time, find the closest facility to an address,

or model service areas.

Travel speed is based on road type, as assigned by the U.S. Census Bureau. The ArcView 10 software

Network Analyst extension uses the TeleAtlas Dynamap®/Transportation v 10.3™ street database, which

offers the most comprehensive and up‐to‐date U.S. street and address data available.

ASSIGNED ROAD SPEEDS

A great deal of geographic street data originates from the US Census Bureau TIGER files. One of the

attributes extracted from these files is the Census Feature Classification Code (CFCC), which describes

street characteristics, among others. The CFCC is a three‐character code: the first character is a letter

describing the feature class; the second character is a number describing the major category; and the

third character is a number describing the minor category. Based on the CFCC codes, a GIS user

8 NFPA 1710, § 1.2.1. 9 NFPA 1710, § 5.2.3.1 and § 5.2.3.1.1. 10 NFPA 1710, § 5.2.3.2 and § 5.2.3.2.1. 11 NFPA 1710, § 4.1.2.1(4). 12 NFPA 1710, § 4.1.2.1(5).

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employing the ArcGIS Network Analyst extension is able to calculate the driving time for each line

segment in a road network (i.e., the roads in a city, county, or other jurisdiction).

Primary Highways with Limited Access – 65 mph

Interstate highways and some toll highways are in this category (A1) and are distinguished by the

presence of interchanges. These highways are accessed by way of ramps and have multiple lanes of

traffic. The opposing traffic lanes are divided by a median strip.

Primary Roads without Limited Access – 55‐45 mph

This category (A2) includes nationally and regionally important highways that do not have limited access

as required by category A1. It consists mainly of US highways, but may include some state highways and

county highways that connect cities and larger towns. A road in this category must be hard‐surface

(concrete or asphalt). It has intersections with other roads, may be divided or undivided, and have

multi‐lane or single‐lane characteristics.

Secondary and Connecting Roads – 35 mph

This category (A3) includes mostly state highways, but may include some county highways that connect

smaller towns, subdivisions, and neighborhoods. The roads in this category generally are smaller than

roads in Category A2, must be hard‐surface, and are usually undivided with single‐lane characteristics.

These roads usually have a local name along with a route number and intersect with many other roads

and driveways.

Local, Neighborhood, and Rural Roads – 25 mph

A road in this category (A4) is used for local traffic and usually has a single lane of traffic in each

direction. In an urban area, this is a neighborhood road and street that is not a thoroughfare belonging

in categories A2 or A3. In a rural area, this is a short‐distance road connecting the smallest towns; the

road may or may not have a state or county route number. Scenic park roads, unimproved or unpaved

roads, and industrial roads are included in this category. Most roads in the Nation are classified as A4

roads.

Vehicular Trails – 5‐1 mph

A road in this category (A5) is usable only by four‐wheel drive vehicles, is usually a one‐lane dirt trail,

and is found almost exclusively in very rural areas. Sometimes the road is called a fire road or logging

road and may include an abandoned railroad grade where the tracks have been removed. Minor,

unpaved roads usable by ordinary cars and trucks belong in category A4, not A5.

Road with Special Characteristics – 55‐20 mph (or less)*

This category (A6) includes roads, portions of a road, intersections of a road, or the ends of a road that

are parts of the vehicular highway system and have separately identifiable characteristics.

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Road as Other Thoroughfare –15‐ 5 mph (or less)*

A road in this category (A7) is not part of the vehicular highway system. It is used by bicyclists or

pedestrians, and is typically inaccessible to mainstream motor traffic except for private‐owner and

service vehicles. This category includes foot and hiking trails located on park and forestland, as well as

stairs or walkways that follow a road right‐of‐way and have names similar to road names.

TURN DELAY TIME TABLE

Travel time and speed would be different in the urban areas, where the travel area will be more

complex than in rural areas due to number of roads intersections, turns, and traffic lights. ArcGIS

Network analyst allows implementing time delays in the analysis based on turn type, assigned based on

statistical information. For each turn category, the current assigned travel time delay, in seconds, is

shown in the table below:

Straight: (Across Local Road) 5 sec

Reverse 12 sec

Right Turn 3 sec

Left Turn 8 sec

ASSUMPTIONS

Several key assumptions must be addressed prior to drawing any conclusions from this analysis:

Modeled travel speeds are based on reasonable and prudent road speeds, as defined by the U.S.

Census Bureau. Actual response speeds may be slower, and the associated travel times

greater, with any traffic congestion or any other unpredictable impedances including, but not

limited to:

Traffic Incidents: collisions and vehicle breakdowns causing lane blockages

and driver distractions.

Work Zones: construction and maintenance activity that can cause added

travel time in locations and times where congestion is not normally present.

Weather: reduced visibility, road surface problems and uncertain waiting

conditions result in extra travel time and altered trip patterns.

Demand Changes: traffic volume varies from hour‐to‐hour and day‐to‐day

and this causes travel time, crowding and congestion patterns to disappear or to

significantly worsen for no apparent reason in some locations.

Special Events: an identifiable case of demand changes where the volume and

pattern of the change can frequently be predicted or anticipated.

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Traffic Control Devices: poorly timed or inoperable traffic signals,

drawbridges, railroad grade crossing signals or traveler information systems

contribute to irregularities in travel time.

Inadequate Road or Transit Capacity: the urban areas are not adding enough

capacity, improving operations or managing demand well enough to keep

congestion from growing larger.13

If primary units are unavailable, for any reason (e.g., simultaneous emergencies, scheduled training, or

as a result of mutual aid obligations), to respond to an emergency, travel times will be greater as more

distantly‐located secondary apparatus will be required to respond to an emergency in the primary

unit’s stead, and with potential delays.

The time from arrival of the apparatus to the onset of interior fire suppression operations and/or

initiation of critical emergency medical interventions by that crew (access interval) must be considered

when analyzing response system capabilities. In reality, the access interval is dependent upon factors

including, but not limited to, distance from the apparatus to the task location and the elevation of the

fire or EMS location (i.e., high rise structures). Locked doors or security bars which must be breached

also act as impediments to access, as do traumatized family members, crowds, whether or not the scene

is secured by police, parked cars, and a host of other unpredictable conditions. Impediments like these

may add to the delay between the discovery of a fire and implementation of an actual fire attack, and to

the delay between the discovery of an individual in medical distress and the initiation of emergency

medical care.

13 David Schrank and Tim Lomax, The 2005 Urban Mobility Report, (Texas Transportation Institute, Texas A&M University: May 2005).

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EMS OPERATIONS

The business of providing emergency services has always been labor intensive, and remains so to this

day. Although new technology has improved firefighting equipment and protective gear, and has led to

advances in modern medicine, it is the fire fighters who still perform the critical tasks necessary to

contain and extinguish fires, rescue trapped occupants from a burning structure, and provide emergency

medical and rescue services.

The response to medical emergencies such as a cardiac arrest (one of the most urgent types of medical

emergencies) mirrors the time‐temperature curve for fire growth. Cardiac arrest is one of the most

time‐critical medical emergencies that can be treated in the field. The highest hospital discharge rate

has been achieved in patients in whom CPR was initiated within 4 minutes of arrest and advanced

cardiac life support within 8 minutes. Fast emergency response is therefore essential not only in

initiating fire suppression and rescue operations, but in improving survival rates of medical emergencies,

as well.

FIGURE 2:

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A NIST (National Institute of Standards and Technology) study from 2010 presents the connection

between appropriate staffing and the completion of typical emergency medicine prehospital

assignments. The following table summarizes the results of this study:

TABLE 1

Staffing Performance

(minutes : seconds)

Patient Access and Removal 2‐person Ambulance 06:59

3‐person Engine + Ambulance 03:13

Overall Trauma Scene Time14

One ALS on Engine + One ALS

Ambulance 10:50

Engine + Two ALS on

Ambulance 13:06

Overall Cardiac Arrest Scene

Time15


Ambulance 10:55

Engine + Two ALS on

Ambulance 11:39

All Tasks after Witnessed

Cardiac Arrest16


Ambulance 06:35

Engine + Two ALS on

Ambulance 05:43

The Patient Access and Removal experiment strongly implies that the size of the crew contributes to the

efficiency and speed of completing the task. The Trauma and the Cardiac scene time experiments

suggest that the early arrival of an ALS provider improve the time to task segment17. The series of tasks

required after the occurrence of a cardiac arrest is completed faster when two ALS providers are on

scene.

The American Heart Association notes that, “Nearly 2,600 Americans die of cardiovascular disease each

day, an average of 1 death every 34 seconds. Cardiovascular disease claims more lives each year than

the next 5 leading causes of death combined, which are cancer, chronic lower respiratory diseases,

accidents, diabetes mellitus, and influenza and pneumonia.”18 According to the Occupational Safety &

14 There was a 3 minute delay between the arrival of the engine and the ambulance (engine arriving first). 15 There was a 3 minute delay between the arrival of the engine and the ambulance (engine arriving first). 16 The cardiac arrest was timed to the end of an ECG task and therefore this experiment compares the response of one ALS at time of arrest (on the engine) versus 2 ALS at time of arrest (on ambulance). 17 There was a 3 minute delay between the arrival of the engine and the ambulance (engine arriving first). 18 American Heart Association, “Heart Disease and Stroke Statistics – 2004 Update;” AHA website visited September 21, 2004 < http://www.americanheart.org/downloadable/heart/1079736729696HDSStats2004UpdateREV3‐19‐04.pdf >.

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Health Administration, there are 300,000 – 400,000 deaths per year in the United States from cardiac

arrest,19 making it one of the leading causes of death in the nation. Most cardiac arrest deaths occur

outside the hospital, resulting in survival rates ranging between 1% and 5%.

Despite low out of hospital survival rates, cardiac arrest remains one of the most time‐critical medical

emergencies that can be success fu l ly treated in the field. The four‐part “chain of survival”

concept, as illustrated in Figure 3 (below) is essential to ensuring positive patient outcomes. The “Chain

of Survival” consists of:

1. EARLY ACCESS:

• Quickly calling the Emergency Medical Services (9‐1‐1) system

2. EARLY CPR:

• Promptly giving cardiopulmonary resuscitation when needed

3. EARLY DEFIBRILLATION:

• Having proper equipment and being trained to use it when indicated

4. EARLY ADVANCED CARDIOVASCULAR CARE:

• Initiating advanced airway management and I.V. and drug therapy provided by

firefighter‐paramedics

FIGURE 3:20 “THE CHAIN OF SURVIVAL”

• If fire fighters responding within 4 minutes of receiving an alarm initiate CPR, the probability of patient

survival quadruples, from 4.6% to 18.2%.

• If those same fire fighters are equipped and trained to provide defibrillation, the expected survival rate

is five times greater at 25.8%.

• Finally, if those fire fighters are trained and equipped as paramedics, the survival rate is increased to

34.3% ‐ nearly a sevenfold increase.21

19 U.S. Occupational Safety and Health Administration, Technical Information Bulletin: Cardiac Arrest and Automated External Defibrillators (AEDs), < http://www.osha.gov/dts/tib/tib_data/tib20011217.html >. 20 “Chain of Survival” diagram courtesy of “ChainofSurvival.com” < http://www.chainofsurvival.com/cos/COSOverview_detail.asp >. 21 “Predicting Survival From Out‐of‐Hospital Cardiac Arrest: A Graphic Model,” Annals of Emergency Medicine (November 1993).

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The use of an automated external defibrillator (AED) by trained personnel is integral to the treatment

and survival of cardiac arrest. Abnormal heart rhythms, with ventricular fibrillation (VF) being the most

common, cause cardiac arrest. Defibrillation within 2 minutes can produce cardiac arrest survival rates

as high as 90%. However, “if defibrillation is delayed more than 10 minutes, survival rates drop to less

than 5%.”22

FIGURE 4: “CARDIAC ARREST SURVIVAL RATE”

While patient survivability from cardiac arrest depends upon a series of critical interventions, such as are

provided by firefighters cross‐trained as EMTs and Paramedics, “rapid defibrillation is the most

important single factor in determining survival.”23 The highest hospital discharge rates have been

achieved in cardiac arrest patients in whom CPR was initiated within 4 minutes of arrest and ACLS

within 8 minutes. A rapid emergency medical response is therefore essential in improving survival

rates.24

So effective is the use of an AED in increasing survivability of cardiac arrest patients, the International

Association of Fire Chiefs has endorsed equipping every fire suppression unit in the United States with

22 American Heart Association, Sudden Deaths from Cardiac Arrest Statistical Fact Sheet (2003). 23 Emergency Cardiac Care Committee and Subcommittees of the American Heart Association, “Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiac Care,” Journal of the American Medical Association (October 28, 1992): 2289. 24 Ibid, 2184.

0

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1 2 3 4 5 6 7 8 9

Time (minutes)

% S

ucc

ess

Chances of success decrease by7-10% each minute

*non-linear

Adapted from text: Cummins RO, Annals of Emergency Medicine , 1989, 18: 1269-1275

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an automated external defibrillator.25 Mirroring this recommendation, NFPA 1710 states, “the fire

department… shall ensure [that] emergency medical response capability includes personnel, equipment,

and resources to deploy at the first responder level with automatic external defibrillator (AED) or higher

treatment level.”26 In accordance with NFPA Standard 1710, Section 4.3.2, the Galveston Fire

Department equips all of its ambulances and the suppression units with AEDs and ensures all fire

fighters are trained in their proper and effective operation. 27

Moreover, the NFPA 1710 Standard requires that a “fire department shall establish the response time

objectives of 4 minutes or less for the arrival of a unit with first responder or higher capability at an

emergency medical incident.”28

The Eisenberg Model

A 1993 University of Washington study of 1,667 cardiac arrests linked the survivability of cardiac arrest

to the time that elapsed before the initiation of three critical interventions: CPR, defibrillation and

Advanced Cardiac Life Support (ACLS). From this landmark study, researchers produced a model for

predicting cardiac arrest survival rates, known as the Eisenberg Model.29 With clear links between

response times and probability of survival, the Eisenberg Model has become a standard method for

measuring effectiveness in the delivery of pre‐hospital emergency medical services. The Eisenberg

model is summarized in Figure 5.

FIGURE 5: “THE EISENBERG FORMULA”

Survival Rate = 67% (maximum percentage survival rate of out‐of‐hospital cardiac arrest

patients if all three interventions were to occur upon collapse. This figure represents the

assumption that only 2/3 of the population can be expected to survive an of out‐of‐

hospital cardiac arrest. One minute is added to the observed response times to allow

for dispatch and turnout. An additional minute is added for gaining access to the

patient.)

• Less 2.3% per minute until CPR is started

• Less 1.1% per minute until defibrillation is provided

• Less 2.1% per minute until ACLS is initiated

25 American Heart Association, Sudden Deaths from Cardiac Arrest Statistical Fact Sheet (2003). 26 NFPA 1710, § 4.3.2 ‐ “The fire department… shall ensure [that] emergency medical response capability includes personnel, equipment, and resources to deploy at the first responder level with automatic external defibrillator (AED) or higher treatment level.”. 27 NFPA 1710, § 4.1.3.1.1(2). 28 NFPA 1710, § 4.1.3.1.1(2). 29 M.P. Larsen, M.S. Eisenberg, et al., “Predicting Survival from Out‐of‐Hospital Cardiac Arrest: A Graphic Model,” Annals of Emergency Medicine 22, no. 11 (November 1993): 1652 – 8.

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Using the Eisenberg formula to calculate predicted survival rates with the initiation of CPR,

defibrillation, and Advanced Cardiac Life Support (ACLS), Table 2 below indicates predicted

survivability rates for cardiac arrest patients at 5, 6, and 7 minutes, respectively.

TABLE 2: “EFFECT OF EMERGENCY CARE RESPONSE TIMES ON CARDIAC PATIENT SURVIVAL RATES”30

Fire Dep’t.

Response

Time

Initiation of

CPR

♥

Time to

Defibrillation

Time to Advanced Cardiac Life

Support (ACLS)

Predicted

Survival Rate/

All Cardiac Arrest

(percentages)

9 minutes 10 minutes 11 minutes 13 minutes 4.6%

4 minutes F.D. EMT:

5 minutes 11 minutes 12 minutes 18.2%

4 minutes F.D. EMT:

5 minutes

F.D. EMT‐D:

6 minutes 11 minutes 25.8%

4 minutes F.D. EMT:

5 minutes

F.D. EMT‐D:

6 minutes

F.D. Paramedic:

7 minutes 34.3%

This scenario requires four firefighters on the initial response, two to provide CPR, one to prepare the

AED and analyze the results of an electrocardiogram (ECG) report, and one to prepare for and initiate

advanced cardiac life support measures, such as advanced airway management, I.V. therapy, and

pharmacological interventions. This breakdown of the expected capabilities of a medical alarm

assignment requires a minimum contingent of four EMS personnel to arrive at the scene of a cardiac

arrest within 5 minutes of receiving an alarm. Most experts agree that four responders (at least two

trained in ACLS and two trained in BLS) are the minimum required to provide ACLS to cardiac arrest

victims

As the table indicates, a 9‐minute response time means that CPR is not initiated until at least 10 minutes

have elapsed from the time of cardiac arrest; 11 minutes have elapsed before defibrillation; and 13

minutes have elapsed before ACLS care is initiated, resulting in an expected patient survival rate of only

4.6 percent. Conversely, a 4‐minute fire department response – with CPR initiated in 5 minutes,

defibrillation in 6 minutes, and ACLS in 7 minutes – results in patient survivability rates of over 34%.

Put another way, based upon Eisenberg’s maximum percentage survival rate of 67%, the following

30 M.P. Larsen, M.S. Eisenberg, et al., “Predicting Survival from Out‐of‐Hospital Cardiac Arrest: A Graphic Model,” Annals of Emergency Medicine 22, no. 11 (November 1993): 1652 – 8.

25

conclusions can be reached:

Figure 6: Eisenberg’s Survivability Percentages

• A 9‐minute initial arrival time prior to pre‐hospital emergency medical intervention

gives the patient only a 1 in 15 chance of survival.

• A 4‐minute arrival by fire fighters, with the initiation of CPR in 5 minutes, increases the

probability of patient survivability to 1 in 4.

• Fire fighters delivering defibrillation within 6 minutes increases the probability of

patient survivability to 1 in 3.

• Fire fighters trained as paramedics, and delivering cardiac medication within 7 minutes,

increases the probability of patient survivability to 1 in 2.

The simple reduction of 4 to 5 minutes in the response time through the use of cross‐trained fire

fighters has a substantial positive impact on patient survival, with improved patient outcomes for each

increase in level of pre‐hospital training that fire fighters receive. The Eisenberg Model supports the

findings published in the Journal of the American Medical Association, which concluded that “two‐tier

systems in which the first responders are trained in early defibrillation are most effective in providing

rapid Advanced Cardiac Life Support.”31

The Importance of the 4‐minute Engine Company Response in the Provision of Emergency Medical

Services:

The Galveston Fire Department responds to all emergencies in the city necessitating the skills,

capabilities, and resources of the fire service. Motor vehicle accidents, for example, often times require

the fire department to stabilize the incident scene and gain access to the patient before emergency

medical care can be rendered. While the extrication is being performed, and often before the

ambulance arrives at the incident scene, the responsibility of emergency medical care and patient

stabilization falls upon the Fire Department. The prehospital care rendered by firefighters in such

instances encompasses the “A.B.C.s” of basic emergency medical care – maintenance of the Airway,

ensuring the patient can continue Breathing, and maintaining Circulation. The bandaging of wounds,

the stablization of broken limbs, when necessary, and protection of the spine are also priorities for the

Fire Department in the pre‐hospital setting.

The Importance of the 8‐minute Medic Company Response in the Provision of Emergency Medical

Services:

Sudden cardiac arrest‐ one of the leading causes of death in America‐ is also one of the most time‐

critical medical emergencies that can be treated in the field. The eight‐minute benchmark is crucial

because a rapid fire department response expedites the delivery of more advanced lifesaving

interventions, such as defibrillation, advanced airway management, and drug therapy. Two‐tiered EMS

systems such as these, where the more widely‐distributed fire department Basic Life Support (BLS)

31 The Journal of the American Medical Association (October 28, 1992): 2290.

26

providers arrive in advance of Advanced Life Support (ALS) providers, have improved survival rates over

one‐tiered systems, particularly when the first responder provides automated external defibrillation.32

According to the Journal of the American Medical Association, “two‐tier systems in which the first

responders are trained in early defibrillation are most effective in providing rapid Advanced Cardiac Life

Support (ACLS).”33 Cardiac arrest victims have a 33% higher survival rate when Paramedics arrive

within eight minutes, according to the American Heart Association. After eight minutes, the prospects

of recovery decreases rapidly.34 Hence, by gaining access to the scene and ensuring patient stabilization

by initiating CPR, and providing defibrillation and airway management, Galveston firefighters set the

stage for the arrival of ALS units, the provision of ACLS, and the opportunity for increased patient

survivability. A timeline of a typical emergency response to an incident of sudden cardiac arrest is

provided on Page 47: Timeline of a Typical Emergency Response to an Incident of Cardiac Arrest.

32 Analysis of some systems with high survival rates for out‐of‐hospital cardiac arrest reveals common practices of (1) multi‐tiered systems deployed by a 911 priority dispatch system, (2) aggressive use of fire department apparatus for first response and automated defibrillation, (3) intensive medical supervision, and (4) widespread citizen awareness and CPR training. 33 The Journal of the American Medical Association (October 28, 1992): 2290. 34 Matthew Cella, “Response Rate of EMS Declines,” The Washington Times, 1 April 2003.

27

ADVANTAGES OF FIRE BASED EMS

Fire/EMS Response Effectiveness

The fire service’s wide range of capabilities enables fire department personnel to respond effectively to

diverse incidents, including victim search and rescue, extrication, hazardous materials releases, and

natural disasters, to name but a few. Fire fighters are uniquely trained and equipped to effectively

handle the most time‐critical emergency on scene. Owing to their strategic distribution throughout a

given community, the responsibility to respond to medical emergencies is often delegated to multi‐role

fire fighters cross‐trained as emergency medical technicians (EMTs).

Recognizing the importance of a rapid response to increased survivability rates from cardiac arrests and

other medical emergencies, the NFPA 1710 Standard requires that a “fire department shall establish the

response time objectives of 4 minutes or less for the arrival of a unit with first responder or higher

capability at an emergency medical incident.”35 While patient survivability from cardiac arrest depends

upon a series of critical interventions such as those provided by fire fighter/EMT’s, “rapid defibrillation is

the most important single factor in determining survival.”36 Abnormal heart rhythms, with ventricular

fibrillation (VF) being the most common, cause cardiac arrest. The highest hospital discharge rates have

been achieved in cardiac arrest patients in whom CPR was initiated within 4 minutes of arrest and ACLS

within 8 minutes. A rapid emergency medical response is therefore essential in improving survival

rates.37

Emergency Response System Design

This proposal outlines an EMS system design that would improve local pre‐hospital care services. As a

result of system implementation, the City of Galveston will achieve the following system

enhancements:

Enhance emergency medical response and transport by deploying ALS transport capable

vehicles in addition to the deployed Engine Companies in the City of Galveston.

An integrated fire‐based EMS system will allow the GFD to respond, treat, and transport

patients rather than handing those patients off to another provider, promoting continuity of

care.

35 NFPA 1710, § 4.1.3.1.1(2). 36 Emergency Cardiac Care Committee and Subcommittees of the American Heart Association, “Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiac Care,” Journal of the American Medical Association (October 28, 1992): 2289. 37 Emergency Cardiac Care Committee and Subcommittees of the American Heart Association, “Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiac Care,” Journal of the American Medical Association (October 28, 1992): 2184.

28

Fire Chief control of fire suppression, rescue, and EMS services for the municipality.

More efficient use of tax dollars, increased productivity, and enhanced fire/EMS capabilities

through the use of cross‐trained/multi role firefighters providing two essential services within

one department.

The Medical Direction system will remain intact to ensure direct medical control, training and

quality assessment/control for all pre‐hospital care. The Medical Director will maintain complete

control over all clinical patient care and transport protocols.

A Fire Based EMS system design allows responding personnel to handle the most time critical

emergency, be it fire suppression, rescue, or medical emergency.

Cross‐trained/multi‐role personnel may be rotated between response and transport vehicles,

allowing the city to maintain the 7(k) exemption under FLSA38.

Cross‐trained/multi‐role personnel assigned to the transport units and equipped with fire

suppression protective gear are available to enhance fire protection activities as necessary,

including compliance with the federal OSHA “2 In/2 Out” regulations for fire suppression,

rescue, or medical emergency.

System Design Objectives:

The proposed models will allow the GFD to implement ALS response and transport services with a

moderate investment in personnel and capital equipment, which will be recouped within two to three

year39. Through a multi‐step transition, the GFD will assume Advanced Life Support response and patient

transportation. Following is a planning template/checklist outlining the objectives that must be met in

order to implement the Galveston Fire Department‐Based EMS system. Many of these objectives may

be pursued and accomplished simultaneously.

The City of Galveston establishes an enterprise fund account through which ambulance transportation costs and revenue are coordinated. Start‐up costs would be budgeted and placed in this special fund, to be replaced by ambulance transportation revenue as it becomes available. For example, budget start‐up costs plus six months of operations costs ($2,974,519.7540) would be deposited to the fund to cover the delay between billing for services provided and actual collection of transport revenue. Revenue

38 Section 7(k) of the FLSA provides a partial overtime exemption for fire protection personnel who are employed by public agencies on a work period basis, employed by an organized fire department or fire protection district, who have been trained to the extent required by state statute or local ordinance, who have the legal authority and responsibility to engage in the prevention, control, or extinguishment of fires, including such non‐firefighting activities as housekeeping, equipment maintenance, etc. This also includes rescue and ambulance personnel that form an integral part of the public agency’s fire protection activities 29CFR 553.210(a). 39 See Summary table on page 42. 40 See “Start Up Budget and Six Month Operation Costs” on page 46.

29

accumulated in this fund would be solely dedicated for further maintenance and improvements of the Fire and EMS system, as determined by fire department administration.

Galveston Fire Department secures all necessary authorization from the Texas State

Department of Health;

Galveston Fire Department secures all necessary equipment from various vendors to

provide ALS patient transportation;

Galveston Fire Department hires 31 FF/Paramedics as full‐time employees of the GFD.

Upon completion of employee training/orientation, Galveston Fire Department assumes

responsibility for Advanced Life Support Response and Patient Transportation;

Galveston Fire Department fills select future vacancies with FF/EMT‐P’s.

Galveston Fire Department may contract out EMS billing (for an agreeable fee of collected

revenue) so that the City of Galveston will receive maximum monetary benefits;

EMS Advanced Life Support (ALS) continuing education begins for selected department

personnel. This training will begin immediately for the certified Paramedics and will be

conducted by EMS training coordinators.

The integration of ALS transport services into the Galveston Fire Department will provide:

A commitment to clinical and professional standards and staffing requirements through

innovative staffing, human relations, leadership, and clinical training;

A commitment to operate under the City’s command and control structure and policies

with the integrated approach to EMS;

A comprehensive personnel training program that not only meets but exceeds State and

Federal requirements;

A commitment to meet and exceed current medical protocols, policies and procedures by

working closely with all EMS stakeholders to constantly improve the quality of EMS

delivered;

A successful recruitment, screening, and orientation program that will attract the best

medical personnel to serve the City of Galveston;

30

31

STAFFING AND DEPLOYMENT ANALYSIS

Staffing and Deployment

The following tables specify the current and proposed staffing and deployment of the Galveston fire

department:

Station Address Engine/Staffing Ladder/staffing Other

Apparatus Medic/Staffing

#1 2514 Sealy,

Galveston, TX E/4 (BLS) L/2 R/2 T/2

#2 428 Church

Galveston, TX E/4 (BLS) ‐‐‐ ‐‐‐ ‐‐‐

#4 8700 Cessna

Galveston, TX E/4 (BLS) ‐‐‐ ‐‐‐ T/2

#5 5728 Ball

Galveston, TX E/4 (BLS) ‐‐‐ ‐‐‐ T/2

#7

3902 Buccaneer

Ave

Galveston, TX

E/3 (BLS) L/1 ‐‐‐ T/2

#8

21710 South

Shelby

Galveston, TX

E/4 (BLS) ‐‐‐ ‐‐‐ ‐‐‐

E = Engine

L = Ladder

T = Transport Unit

BLS = Basic Life support

ALS = Advanced Life Support

The following GIS maps present the response capabilities analysis of the City of Galveston Fire

Department.

32

Map 2

The Galveston Fire Department will be able to respond to 44.6% of area roads within 240

seconds.

33

Map 3

The current Galveston EMS provider is capable of responding to 64.5% of area roads within 480

seconds.

34

Map 4

The Galveston Fire Department will be able to respond with an ALS transport unit to 75.2% of

area roads within 480 seconds.

35

COST ASSUMPTIONS AND CALCULATIONS

Hours of work to be covered in 1

year

Days of work 365

Hours of work 24

Total annual hours of

work 8760

Number of Shifts/Platoons 3

Hours worked per

group 2920 (8760 divided by # of shifts)

Shift Rotation 24 Hours On

48 Hours Off

Average Leave Used Per Person

(Hours)

Average Sick Leave 122

Average Vacation Leave 288

Average Leave per

employee 410

Hours Actually Worked by Average

Employee 2510

Staffing Factor

3.49

(The number of employees

required to fill one position

within the department.)

36

Transport Variables

Transport Units:

Position

FF/Paramedics Assistant

Chief Captain*

Shifts Type 3 1 1

No. of Units 4 1 1

Positions per Unit 2.00 1.00 2.00

Staffing Factor 3.49 1.16 1.16

Number of Position Required 27.92 1.16 2.32

New Hires FF/ParamedicsAssistant Chief

Captain* Sum

Sum of Staff: 27.92 1.16 1.16

Positions to be hired 28 1 2 31

Positions to be filled with overtime:

‐0.08 0.16 0.32

*The Captain positions include a Training Officer position and a Quartermaster position. OT is not included for these positions

Total EMS Transports Year 1 Year 2 Year 3 Year 4 Year 5

6250 6438 6631 6830 7034

Percentage of Medicare patients

50%

Year 1 Year 2 Year 3 Year 4 Year 5

Medicare Transports 3125 3219 3315 3415 3517

Private Transports 3125 3219 3315 3415 3517

Percentage increases per year 3%

Billing Fees 9%

Collection Rate 53%

Average transport mileage (Round Trip) 12

37

Medicare % of

Transports Year 1 Year 2 Year 3 Year 4 Year 5

BLS Emergency 50% 1563 1609 1658 1707 1759

ALS Emergency 48% 1500 1545 1591 1639 1688

ALS Emergency Level 2 2% 63 64 66 68 70

Non‐Medicare % of

Transports Year 1 Year 2 Year 3 Year 4 Year 5

BLS Emergency 60% 1875 1931 1989 2049 2110

ALS Emergency 40% 1250 1288 1326 1366 1407

ALS Emergency Level 2

Additional Charges41 2% 63 64 66 68 70

41 Charged as an additional amount and therefore sums to 102%.

38

Medicare Billing Rate42

County Geographic Practice Cost Index

(GPCI) 0.997

NFS43

Proposed

Fee

RVU44 NFS Urban

Base Rate

BLS Non‐Emergency $214.47 1 $218.30

BLS Emergency $214.47 1.6 $349.28

ALS Non‐Emergency $214.47 1.2 $261.96

ALS Emergency $214.47 1.9 $414.77

ALS Emergency Level 2 $214.47 2.75 $600.33

Critical Care Transport $214.47 3.25 $709.48

Paramedic Intercept $214.47 1.75 $382.03

Mileage $6.89 $6.86

42Derived from Medicare publication <http://www.dir.ca.gov/dwc/FeeSchedules/AMBULANCE_FeeSchedule/AmbulanceFeeScheduleMarch2012/Ambo_PUF_CY2012_fact_sheet_Final.pdf>. 43 NFS‐ National Fee Schedule . 44 Relative value units (RVUs) set a numeric value for ambulance services relative to the value of a base level ambulance service. Since there are marked differences in resources necessary to furnish the various levels of ground ambulance services, different levels of payment are appropriate for the various levels of service. The different payment amounts are based on level of service. An RVU expresses the constant multiplier for a particular type of service (including, where appropriate, an emergency response). An RVU of 1.00 is assigned to the BLS of ground service, e.g., BLS has an RVU of 1; higher RVU values are assigned to the other types of ground ambulance services, which require more service than BLS. (Medicare website, < http://www.cms.gov/Regulations‐and‐Guidance/Guidance/Manuals/downloads/clm104c15.pdf>, viewed on 2/7/13.

39

Actual Medicare

Reimbursement Rates

Received


**Assumes 2.5% annual

inflation factor

BLS Non‐Emergency $218.30 $223.76 $229.35 $235.09 $240.96

BLS Emergency $349.28 $358.01 $366.96 $376.14 $385.54

ALS Non‐Emergency $261.96 $268.51 $275.22 $282.10 $289.15

ALS Emergency $414.77 $425.14 $435.77 $446.66 $457.83

ALS Emergency Level 2 $600.33 $615.33 $630.72 $646.48 $662.65

Critical Care Transport $709.48 $727.21 $745.39 $764.03 $783.13

Paramedic Intercept $382.03 $391.58 $401.37 $411.40 $421.68

Mileage $6.86 $7.03 $7.21 $7.39 $7.57

Non‐Medicare Billing Rate

Non‐Medicare Rates Billed Year 1 Year 2 Year 3 Year 4 Year 5

BLS Emergency $725.00 $746.75 $769.15 $792.23 $815.99

ALS Emergency $925.00 $952.75 $981.33 $1,010.77 $1,041.10

ALS Emergency Level 2 Additional

Charges $150.00 $154.50 $159.14 $163.91 $168.83

ALS Equipment Charge ($50 EKG, $25 IV,

$25 Miscellaneous) $125.00 $128.75 $132.61 $136.59 $140.69

Mileage $13.00 $13.39 $13.79 $14.21 $14.63

Oxygen $80.00 $82.40 $84.87 $87.42 $90.04

Non Resident Fee $250.00 $257.50 $265.23 $273.18 $281.38

Treat Non ‐ Transport Fee

(Resident)/System Activation Fee $100.00 $103.00 $106.09 $109.27 $112.55

Treat Non ‐ Transport Fee (Non ‐

Resident) $200.00 $206.00 $212.18 $218.55 $225.10

Medical Records $20.00 $20.60 $21.22 $21.85 $22.51

Extrication Fee $500.00 $515.00 $530.45 $546.36 $562.75

40

Medicare Revenue Projection


Number of

Transports BLS

Emergency

1563 1609 1658 1707 1759

Revenue $551,100.50 $581,824.36 $614,261.06 $648,506.12 $684,660.33

Number of

Transports ALS

Emergency

1500 1545 1591 1639 1688

Revenue $628,254.57 $663,279.77 $700,257.61 $739,296.98 $780,512.78

Number of

Transports

ALS

Emergency

Level 2

63 64 66 68 70

Revenue $37,888.16 $40,000.42 $42,230.45 $44,584.80 $47,070.40

Number of

Mileage Mileage 18750 19312.5 19891.875 20488.63125 21103.29019

Revenue $128,625.00 $135,795.84 $143,366.46 $151,359.14 $159,797.41

Total Amount $1,345,868.24 $1,420,900.39 $1,500,115.59 $1,583,747.03 $1,672,040.93

Billing Fee 9% 9% 9% 9% 9%

Total Projected Collectables

(Amount less personal co‐

pay)

$979,792.08 $1,034,415.48 $1,092,084.15 $1,152,967.84 $1,217,245.80

41

Non‐Medicare Revenue Projection


BLS Emergency 1875 1931 1989 2049 2110

$1,359,375.00 $1,442,160.94 $1,529,988.54 $1,623,164.84 $1,722,015.58

ALS Emergency 1250 1288 1326 1366 1407

$1,156,250.00 $1,226,665.63 $1,301,369.56 $1,380,622.97 $1,464,702.91

ALS Emergency Level 2

Additional Charges

63 64 66 68 70

$9,375.00 $9,945.94 $10,551.65 $11,194.24 $11,875.97

ALS Equipment Charge

($50 EKG, $25 IV, $25

Miscellaneous)

1250 1288 1326 1366 1407

$156,250.00 $165,765.63 $175,860.75 $186,570.67 $197,932.83

Mileage 18750 19312.5 19891.875 20488.63125 21103.29019

$243,750.00 $258,594.38 $274,342.77 $291,050.25 $308,775.21

Oxygen 2250 2318 2387 2459 2532

$180,000.00 $190,962.00 $202,591.59 $214,929.41 $228,018.61

Non Resident Fee 459 644 663 683 703

$114,843.75 $165,765.63 $175,860.75 $186,570.67 $197,932.83

Treat Non ‐ Transport

Fee (Resident)

1400 1442 1485 1530 1576

$140,000.00 $148,526.00 $157,571.23 $167,167.32 $177,347.81

Treat Non ‐ Transport

Fee (Non ‐ Resident)

350 361 371 382 394

$70,000.00 $74,263.00 $78,785.62 $83,583.66 $88,673.91

Medical Records 313 322 332 341 352

$6,250.00 $6,630.63 $7,034.43 $7,462.83 $7,917.31

Extrication Fee 20 21 21 22 23

$10,000.00 $10,609.00 $11,255.09 $11,940.52 $12,667.70

Total Amount $3,446,093.75 $3,699,888.75 $3,925,211.97 $4,164,257.38 $4,417,860.66

Total Projected

Collectables (includes

billing fee & collection

rate)

$1,662,051.02 $1,784,456.34 $1,893,129.74 $2,008,421.34 $2,130,734.20

Personnel Expenses Projection

Year 1 Year 2 Year 3

Firefighter/P

Assistant

Chief Captain* Firefighter/P

Assistant


Assistant

Chief Captain*

EMT‐P's Available from New

Hires 28 1 2 28 1 2 28 1 2

Positions for Overtime ‐0.08 0.16 ‐0.08 0.16 ‐0.08 0.16

Wages $47,166.96 $77,134.00 $65,000.00 $48,581.97 $79,448.02 $66,950.00 $50,039.43 $81,831.46 $68,958.50

Staffing Factor Overtime $0.00 $18,512.16 $0.00 $0.00 $19,067.52 $0.00 $0.00 $19,639.55 $0.00

EMT‐P Incentive Pay $1,900.00 $1,900.00 $1,900.00 $1,957.00 $1,957.00 $1,957.00 $2,015.71 $2,015.71 $2,015.71

Hiring Costs $4,334.03 $4,334.03 $4,334.03

Medical Screening $1,891.50 $1,891.50 $1,891.00

Health Insurance & Dental

Insurance $6,168.00 $6,168.00 $6,168.00 $6,353.04 $6,353.04 $6,353.04 $6,543.63 $6,543.63 $6,543.63

Uniforms $600.00 $600.00 $600.00 $618.00 $618.00 $618.00 $636.54 $636.54 $636.54

Longevity $54.00 $54.00 $54.00 $55.62 $55.62 $55.62

Medicare $711.47 $1,414.42 $970.05 $732.82 $1,456.85 $999.15 $754.80 $1,500.56 $1,029.13

FICA $3,042.15 $6,047.86 $4,147.80 $3,133.42 $6,229.30 $4,272.23 $3,227.42 $6,416.18 $4,400.40

Pension % 14% 14% 14% 14% 14% 14% 14% 14% 14% Pension $6,869.37 $13,656.46 $9,366.00 $7,075.46 $14,066.16 $9,646.98 $7,287.72 $14,488.14 $9,936.39

Individual Marginal Employee

Cost $72,683.49 $131,658.4 $94,376.88 $68,505.70 $129,249.8 $90,850.41 $70,560.87 $133,127.3 $93,575.92

Total Marginal Employee Cost $2,035,137.6 $131,658.4 $188,753.7 $1,918,159.4 $129,249.8 $181,700.81 $1,975,704.2 $133,127.3 $187,151.84

Total Personnel Cost $2,355,549.83 $2,229,110.18 $2,295,983.48

43

Year 4 Year 5

Firefighter/P

Assistant


Assistant

Chief Captain*

EMT‐P's Available from New Hires 28 1 2 28 1 2

Positions for Overtime ‐0.08 0.16 ‐0.08 0.16

Wages $51,540.61 $84,286.40 $71,027.26 $53,086.83 $86,815.00 $73,158.07

Staffing Factor Overtime $0.00 $20,228.74 $0.00 $0.00 $20,835.60 $1.00

EMT‐P Incentive Pay $2,076.18 $2,076.18 $2,076.18 $2,138.47 $2,138.47 $2,138.47

Hiring Costs

Medical Screening

Health Insurance & Dental Insurance $6,739.94 $6,739.94 $6,739.94 $6,942.14 $6,942.14 $6,942.14

Uniforms $655.64 $655.64 $655.64 $675.31 $675.31 $675.31

Longevity $57.29 $57.29 $57.29 $59.01 $59.01 $59.01

Medicare $777.44 $1,545.57 $1,060.00 $800.77 $1,591.94 $1,091.81

FICA $3,324.24 $6,608.66 $4,532.41 $3,423.97 $6,806.92 $4,668.45

Pension % 14% 14% 14% 14% 14% 14%

Pension $7,506.35 $14,922.79 $10,234.48 $7,731.54 $15,370.47 $10,541.66

Individual Marginal Employee Cost $72,677.69 $137,121.21 $96,383.20 $74,858.02 $141,234.85 $99,275.91

Total Marginal Employee Cost $2,034,975.39 $137,121.21 $192,766.39 $2,096,024.65 $141,234.85 $198,551.82

Total Personnel Cost $2,364,862.99 $2,435,811.31

*The Captain positions include a Training Officer position and a Quartermaster position. OT is not included for these positions.

General Expenses and Summary

\

Transports Data


Estimated Total Transport Volume 6,250 6,438 6,631 6,830 7,034

Estimated Annual Increase in

Transport Volume 3% 3% 3% 3%

Personnel Price Per

Unit Year 1 Year 2 Year 3 Year 4 Year 5

Marginal EMT‐Paramedic New Hires 31 0 0 0 0

Existing EMT‐Paramedics (Includes

New Hires and Current Employees) 31 31 31 31 31

Total Estimated Personnel Costs

$2,355,549.8 $2,229,11

0 $2,295,983 $2,364,862 $2,435,811

Training and Certification Price Per


New Hire Recruit Program Attendees

31 0 0 0 0

Turnout Gear $2,700.00 $83,700.00 $0.00 $0.00 $0.00 $0.00

EMS Equipment $100.00 $3,100.00 $0.00 $0.00 $0.00 $0.00

Training classes, books, manuals, other

materials $350.00 $0.00 $1,400.00 $1,400.00 $1,400.00 $1,400.00

Continuing Education Attendees

0 31 31 31 31

Continuing Education Costs $1,000.00 $0.00 $31,000.0

0 $31,000.00 $31,000.00 $31,000.00

Due and publications $20.00 $0.00 $620.00 $620.00 $620.00 $620.00

Travel and conference

$0.00 $10,000.0

0 $10,000.00 $10,000.00 $10,000.00

Computer related services

$0.00 $5,000.00 $5,000.00 $5,000.00 $5,000.00

Office supplies

$0.00 $1,000.00 $1,000.00 $1,000.00 $1,000.00

Printing and binding

$0.00 $1,500.00 $1,500.00 $1,500.00 $1,500.00

Postage and shipping

$0.00 $500.00 $500.00 $500.00 $500.00

Total Estimated Training and

Certification Costs $86,800.00

$51,020.00

$51,020.00 $51,020.00 $51,020.00

Apparatus Price Per


Marginal Increase in Number of

Transport Units Deployed 0 5 0 0 0 0

Total Available Transport Units 5 5 5 5 5

Purchase Cost of Transport Units $140,000.00 $700,000.00 $0.00 $0.00 $0.00 $0.00

Total Estimated Apparatus Costs $700,000.00 $0.00 $0.00 $0.00 $0.00

Equipment Price Per


ALS Equipment Package for Transports $65,173 $325,862.90 $0.00 $0.00 $0.00 $0.00

Monitor/Defibrillator for Transports $35,000.00 $175,000.00

Transport Vehicle Radios $15,000.00 $75,000.00 $0.00 $0.00 $0.00 $0.00

Cell phones $500.00 $2,500.00 $2,500.00 $2,500.00 $2,500.00 $2,500.00

Disposable Supplies BLS Disposables $25.00 $85,156.25 $87,710.94 $90,342.27 $93,052.53 $95,844.11

Disposable Supplies ALS Disposables $100.00 $277,500.00 $285,825.0

0 $294,399.75 $303,231.74 $312,328.69

45

Disposable Supplies ALS2 Disposables $360.00 $45,000.00 $46,350.00 $47,740.50 $49,172.72 $50,647.90

Equipment Repair/Replacement $2,500.00 $12,500.00 $12,500.00 $12,500.00 $12,500.00 $12,500.00

Pharmacy contract $35.00 $65,625.00 $67,593.75 $69,621.56 $71,710.21 $73,861.52

Total Estimated Equipment Costs

$1,064,144.10 $502,479.6

9 $517,104.08 $532,167.20 $547,682.22

Operational Price Per


Vehicle Insurance $5,000.00 $25,000.00 $25,000.00 $25,000.00 $25,000.00 $25,000.00

Transport Fuel Costs $4.27 $54,042.19 $55,663.45 $57,333.36 $59,053.36 $60,824.96

Transport Maintenance Costs $5,000.00 $5,000.00 $25,000.00 $25,000.00 $25,000.00 $25,000.00

Service License Fees ALS/BLS $150.00 $750.00 $750.00 $750.00 $750.00 $750.00

Clinical Laboratory Improvement

Amendment (CLIA) waiver $150.00 $150.00 $154.50 $159.14 $163.91 $168.83

State Pharmacy License $500.00 $500.00 $515.00 $530.45 $546.36 $562.75

EMS Vehicle Inspection Fees ALS $100.00 $500.00 $500.00 $500.00 $500.00 $500.00

Personnel Certification ALS $100.00 $3,100.00 $3,100.00 $3,100.00 $3,100.00 $3,100.00

Medical Director Costs $50,000.00 $50,000.00 $51,000.00 $52,020.00 $53,060.40 $54,121.61

Medical Liability Insurance EMT/EMT‐P

Cost $200.00 $6,200.00 $6,200.00 $6,200.00 $6,200.00 $6,200.00

Total Estimated Operational Costs $145,242.19 $167,882.9 $170,592.9 $173,374.0 $176,228.1

Building and Grounds Price Per


Building Maintenance $500.00 $2,500.00 $2,500.00 $2,500.00 $2,500.00 $2,500.00

Building Usage $500.00 $2,500.00 $2,500.00 $2,500.00 $2,500.00 $2,500.00

Phone Expense $120.00 $600.00 $600.00 $600.00 $600.00 $600.00

Gas and electric $250.00 $1,250.00 $1,250.00 $1,250.00 $1,250.00 $1,250.00

Water and sewer $250.00 $1,250.00 $1,250.00 $1,250.00 $1,250.00 $1,250.00

Misc. tech. service $250.00 $1,250.00 $1,250.00 $1,250.00 $1,250.00 $1,250.00

Total Estimated Building and Grounds

Cost $9,350.00 $9,350.00 $9,350.00 $9,350.00 $9,350.00

Total Estimated Cost to Provide ALS

Medical Transport Year 1 Year 2 Year 3 Year 4 Year 5

Estimated Personnel Cost $2,355,549.83 $2,229,110 $2,295,983.48 $2,364,862.9 $2,435,811.3

Estimated Training and Certification $86,800.00 $51,020.00 $51,020.00 $51,020.00 $51,020.00

Estimated Apparatus Cost $700,000.00 $0.00 $0.00 $0.00 $0.00

Estimated Equipment Cost $1,064,144.15 $502,479.6 $517,104.08 $532,167.20 $547,682.22

Estimated Operational Cost $145,242.19 $167,882.9 $170,592.94 $173,374.03 $176,228.15

Estimated Buildings and Grounds Cost $9,350.00 $9,350.00 $9,350.00 $9,350.00 $9,350.00

Estimated Total Cost

$4,361,086.16 $2,959,842 $3,044,050.50 $3,130,774.2 $3,220,091.6

Summary

Estimated Total Cost $4,361,086.16 $2,959,842.82 $3,044,050.50 $3,130,774.22 $3,220,091.67

Estimated Total Revenue Medicare $979,792.08 $1,034,415.48 $1,092,084.15 $1,152,967.84 $1,217,245.80

Estimated Total Revenue Non‐Medicare $1,662,051.02 $1,784,456.34 $1,893,129.74 $2,008,421.34 $2,130,734.20

Estimated Total City Subsidize $750,000.00 $750,000.00 $750,000.00 $750,000.00 $750,000.00

Estimated Final Revenue ‐$969,243.07 $609,029.01 $691,163.38 $780,614.96 $877,888.32

Start Up Budget and Six Month Operation Costs

Total Estimated Personnel Costs $1,283,570.13

Turnout Gear $83,700.00

EMS Equipment $3,100.00

Purchase Cost of Transport Units $700,000.00

ALS Equipment Package for Transports $325,862.90

Monitor/Defibrillator for Transports $175,000.00

Transport Vehicle Radios $75,000.00

Cell phones $2,500.00

Disposable Supplies BLS Disposables $42,578.13

Disposable Supplies ALS Disposables $138,750.00

Disposable Supplies ALS2 Disposables $22,500.00

Equipment Repair/Replacement $6,250.00

Pharmacy contract $32,812.50

Vehicle Insurance $12,500.00

Transport Fuel Costs $27,021.10

Transport Maintenance Costs $2,500.00

Service License Fees ALS/BLS $750.00

Clinical Laboratory Improvement Amendment (CLIA) waiver $150.00

State Pharmacy License $500.00

EMS Vehicle Inspection Fees ALS $500.00

Personnel Certification ALS $3,100.00

Medical Director Costs $25,000.00

Medical Liability Insurance EMT/EMT‐P Cost $6,200.00

Building Maintenance $1,250.00

Building Usage $1,250.00

Phone Expense $300.00

Gas and electric $625.00

Water and sewer $625.00

Misc. tech. service $625.00

Total Expenses $2,974,519.75

TIMELINE OF A RECOMMENDED EMERGENCY RESPONSE

TO AN INCIDENT OF SUDDEN CARDIAC ARREST

ICON ACTION NFPA 1710 STANDARD APPLIED TIMELINE: EMERGENCY

RESPONSE SYSTEM

TIMELINE: EFFECTS OF OXYGEN

DEPRIVATION ON CARDIAC

PATIENT45

Onset of Sudden Cardiac Arrest (SCA).

N/A N/A

Heart’s ability to pump blood compromised as a result of a medical emergency including, but not limited to, respiratory arrest, drowning, traumatic injury, electrocution, irregular heart rhythm, or choking.

Notification of 9-1-1 system.

N/A Unknown variable Contingent upon patient or bystander recognition of event and time to action taken.

Call processing and dispatch of fire department units to the medical emergency.

NFPA 1710, §6.4.2, states that “All …operating procedures shall comply with NFPA 1221,” which allows no more than one minute for call processing and dispatch.

Time elapsed:

One minute

60 seconds: Cardiac irritability if onset of SCA recognized within this timeframe.

45 Timeline assumes the emergency medical system is activated at the onset of cardiac arrest.

48


RESPONSE SYSTEM



PATIENT45

Fire fighters notified of medical emergency, prepare for response and board apparatus.

NFPA 1710, §4.1.2.1.1, states that the fire department shall establish a turnout time of one minute (60 seconds).

Time elapsed:

Two minutes

Heart’s condition continues to worsen if no action taken. If defibrillation is initiated within 1-2 minutes, however, survival rates can be as high as 90 percent.

Fire fighters respond to emergency scene.

NFPA 1710, §4.1.2.1.1(3) states that a fire department shall establish the response time objective of “Four minutes (240 seconds) or less for the arrival of a unit with first responder or higher level capability at an emergency medical incident.”

Time elapsed:

Six minutes (approx.)

Research shows that in many cases, full recovery is possible if CPR is initiated within 4 minutes of onset of symptoms, followed by the administration of both basic and advanced life support measures, resulting in the restoration of circulation.

49


RESPONSE SYSTEM



PATIENT45

Four fire fighters arrive on the incident scene within 4 minutes: two BLS providers and two ALS providers.

NFPA 1710, §5.3.3.4.4 states that Advanced Life Support (ALS) emergency response deployments “shall include a minimum of two members trained at the emergency medical technician- paramedic (EMT-P) level and two members trained at the emergency medical technician- basic (EMT-B) level arriving on scene within the established response time.”

Fire fighters access patient, perform initial assessment, and initiate CPR.

4-6 minutes: brain damage likely in the absence of basic and advanced emergency medical intervention.

BLS:

Two BLS providers access and stabilize the patient, initiate CPR, and prepare patient for ALS interventions.

One ALS provider prepares the AED and analyzes the results of electrocardiogram (ECG) report.

NFPA Standard 1710 states that “the fire department… shall ensure [that] emergency medical response capability includes personnel, equipment, and resources to deploy at the first responder level with automatic external defibrillator (AED) or higher treatment level.”

Time elapsed:

Seven minutes (approx.)

If circulation is not restored, the patient’s condition will continue to deteriorate with increased time. According to the Eisenberg study, survival rates decrease by 5.5 percent with every minute that passes without treatment.

50


RESPONSE SYSTEM



PATIENT45

ALS:

One ALS provider prepares for and initiates the range of advanced cardiac life support measures, including advanced cardiac monitoring and manual defibrillation, drug therapy, advanced airway management (inclusive of intubation), and the establishment and maintenance of intravenous (I.V.) access.

NFPA Standard 1710 states that a “fire department shall establish the response time objective of 8 minutes or less for the arrival of an advanced life support unit at an emergency medical incident, where this service is provided by the fire department.”

Time elapsed:

Eight minutes (approx.)

6-10 minutes: brain damage very likely in the absence of ALS intervention. Cardiac arrest can be reversed in many victims if it is treated with immediate CPR, and if followed by, an electric shock to the heart within 7 to 10 minutes. Few resuscitation attempts succeed if begun after 10 minutes have elapsed since the cessation of patient’s heartbeat and breathing.

Documents

proposal for the provision of fire department-based - Squarespace