AMBULANCECRISISREPORT2022EddieSell,FireChief
TheambuancesystemnHemetandRiversdeCountyisnCl'|S|SThswordsnotusedcapriciouslyItsthewordwideyusedbyFreChefsAMRmanagement,andeectedofficialsthroughoutRiversideCounty.EventheagencytaskedwithoversghtofEMSnRiversideCountyusesthiswordtodescribethecurrentchallengesrelatedtoambuanceavaabiityThesystemhasprovidedquatycaretoresidentsandvisitorstothecityofHemetandthroughoutRiversdeCountyformanyyearsHowevercurrenteventshavestressedthesystemtothepointwhereitisnoongerfunctionngataevethatthefireservicefindsacceptabletoprovidethebestcarepossibletothecitizens.Thiscrisisisaresultofacombinationofinterconnectedchallenges.Thesechallengesincludestaffingshortages,recruitmentandretentionissues,andhospitalbedavailability.Theeffectsofthepandemicexacerbateallofthesechallenges.Theimpactofthecurrentcrisisisthattheserviceprovidedtothecitizensiscompromisedinseveralways:Responseandscenetimesareincreasedwhichdelayspatientsreceivinganinitialassessment,treatmentandtransporttothehospital.oPatientsmaywaitontheambulancegurneyforprolongedperiodsaftertheyarriveatthehospitalorpatientsmayhavetotravelfurthertoahospitalthatislessbusybutagreaterdistancefromtheirhome.0Firedepartmentunitsandpersonnelareoutofserviceforanextendedtimeimpactingtheirabilitytorespondtocalls.Firedepartmentunitsthatarestillinservicemusthandleadditionalcallsandtravelgreaterdistancestocoverfortheunitthatisoutofservice.Increasedwearandtearonfireapparatusduetoincreasedusage.0Safetyforcitizensandfirefightersisreducedatworkingstructurefires.ThedeliveryofEmergencyMedicalServices(EMS)inapre-hospitalsettingisacomplexsystem,developedovermanyyears.Beforewecanunderstandwhythecrisisisoccurringweneedtounderstandhowthesystemisdesignedtooperate.Thissystemreliesoneachpartfunctionalproperly.Eachproviderwhetherfiredepartment,privateambulanceoremergencyroom,mustbeabletoperformitsdesignatedfunctionquicklyandefficiently,inapre-determinedmanner,becauseeachprovider'sservicedeliveryreliesontheotherinordertoprovidethebestcareforthecitizensweprotect.Thefirststepintheprocessisthecallto911.911callsarereceivedbyaPublicSafetyAnsweringPointorPSAP.ThePSAPinHemetisthepolicedepartment's(PD)communicationscenter.TheprimaryPSAPinmostareasistypicallyalawenforcementagency.HemetPDdispatchersdeterminethenatureoftheproblem,theaddressandthendispatchfiredepartment(FD)unitsbasedonapre-establishedmatrix.ThefiredepartmentunitisdispatchedandarequestforanambulanceissenttoAMR,viathecomputeraideddispatch(CAD)system.AMRdispatchersdeterminetheclosestavailableambulanceanddispatchthemtothecallinHemet.AMRisthecontracted911-ambulanceproviderfortheCountyofRiverside.
ThreetypesofunitsmanagethefiredepartmentresponseengnecompanesatruckcompanyorasquadEachunitsdesignedforaspecificsetoftasksatafirebutahavethesamecapabtiesrelatedtomedcacalsUnitshaveacombnationofbasicifesupport(BLS)andadvancedifesupport(ALS)personnelAloftheFDunitsnHemetreALSunitsmeanngthatthereisateastonefirefighter/paramedc(FF/PM)oneachunit.EachFDunithasadefinedresponseareaordistrict.Theunitassignedtocoverthatdistricthandlesanycallforservicewithinthatdistrict.Oncetheunitarrivesonscenethepersonnelwillperformapatientassessmenttodeterminethenatureandtheseverityofthemedicalissueandbegintreatment.SincetheFDunitsdonothavethecapabilitytotransportapatienttheymustwaitforthearrivalofanAMRambulance.ConcurrentlywiththeFDresponsetheambulanceisresponding.Theambulancerespondingtoany911requestishistoricallystaffedwithtwopersonnel,aparamedic(EMT-P)withanemergencymedicaltechnician-basic(EMT-B)partner.OncetheAMRambulancearrivesonscenethepatientistransferredtotheambulancegurneyfortransportandcareishandedofftotheAMRpersonnel.ThefiredepartmentandAMRpersonnelworktogether,asacohesiveteamtoassess,treat,andtransportthepatient.WhiletheFDunitishandlingthiscalltheremainingFDunitscontinuetoprotecttheirassignedareasandprovidecoveragefortheunitthatisoutofservice.ThesamethingishappeningatAMR,ambulancesprovidingcoverageforalargerareawhenneighboringambulancesareoutofservice.AfterthepatientisloadedintotheambulancetheFDunitcanreturntoserviceandisimmediatelyavailabletorespondtoadditionalcallsforservice.DuringthetransporttotheEmergencyRoom(ER)theAMRparamedicprovidescontinuedcareandreassessmentofthepatient.OncetheambulancearrivesattheERthepatientistransferredtoahospitalgurneyandthecareforthepatientistransferredtotheERstaff.TheAMRpersonnelcompletetheirpapen/vork,preparetheambulanceandreturntoservice,readytohandlethenextcall.Thisiswhathappenswhenthesystemisfunctioningcorrectly,thewayitwasdesigned.Nowthatweunderstandhowthesystemissupposedtooperatewecanlookathowthesystemiscurrentlyoperating.AcitizenorvisitortoHemetcalls911.ThecallisansweredbythePSAPandthenatureoftheproblemandaddressisobtained.DispatchersdispatchaFDunit(s)totheaddressandarequestforanAMRambulanceissentviaCAD.Whilemanycommunicationscentersperformdetailedcallscreeningtodeterminethenatureoftheproblem,theleveloffiredepartmentresponse(orifaresponseisevenrequired),andprovidepre-arrivalinstructionsHemet'sPSAPdoesnot.Thisresultsina firedepartmentresponsetoallcallsforserviceandgeneratesanambulanceresponsetoALLrequestsformedicalassistanceregardlessoftheseverityoftheproblemoriftransportisneeded.OncetheFDunitarrivesonscenethepersonnelwillperformapatientassessmenttodeterminethenatureandtheseverityofthemedicalissueandbegintreatment.TheAMRambulancehasbeendispatchedhowever,dependingonhowbusytheEMSsystemisatthetime,oneofthreethingsoccur:1.Theambulancearriveswithinthestandardestablishedintheircontract(within10minutes90%ofthetime)2.Theambulancearrivesbutisdelayed3.Theambulancearrives,eitherwithintheestablishedtimeorisdelayed,butisonlystaffedwithtwoEMT-BasicsIfthefirstsituationaboveoccursthenthecallcontinuesaspreviouslydescribeduntilthepatientreachesthehospital.Thesameoccursinthesecondsituationabovebutthetransportandsubsequentarrivalatthehospitalisdelayed.Inthethirdsituation,ifthepatient'sconditionwarrantsALSlevelcarethentheFDparamedicmustrideintheambulancewiththepatienttothehospitalandtheFDunitfollowstheambulance.TheFDunitwillbeunavailableforadditionalcallsuntiltheypickuptheirFF/PMandreturntoservice.TheFDparamedicprovidescontinuedcareandreassessmentduringthetransportuntiltheyarriveatthehospital.Inanyofthesituationsiftheclosesthospitalison"redirection"status(Notcurrentlyreceivingambulancepatients)thentheambulancewillbedirectedtoanERthatislessbusy.WhiletheERmaybelessbusythatdoesnotmeantheyhaveavailablebeds.Inaddition,theambulancewillhavetotravelagreaterdistancetakingthepatientfurtherfromhomeandfamilyandtakingtheFDunitasignificantdistancefromthecity.Regardlessofwhichofthe3situationsoccuroncetheambulancearrivesatthehospitalthereisadelaybeforethepatientcanbemovedtoahospitalgurneyandcaretransferredtohospitalstaff.UntilthistransferoccurstheparamedicmustremainwiththepatienteventhoughtheymaybeinsidetheactualER.Thisdelaycanbeminutestohours.ThisdelayimpactseveryaspectoftheEMSsystemandthequalityofcareweprovidetothecitizens.WhatchangedtoimpacttheEMSsystemsodramatically?Let'slookatourpartners,AMRandthehospitals,firsttounderstandtheirchallenges.AMRisalargeexperiencedproviderofambulancetransportationservicesnationwide.AMRistheCountyofRiversidecontractedproviderfor911-ambulancetransportation formostofRiversideCountyThereISaocaoperatngunitofAMRnHemetthatoperatesntheMid-CountyregionTheHemetAMROperatngUnithasbeenprovidngservicestothecityofHemetfor25yearsWhetheHemetunitisresponsibeforoperationsntheirdesgnatedzonetheyarepartofthemuchlargerRiversideCountyAMRoperationsThsncludestwootheroperatinguntsAruntherocadailyoperationsbutremanpartoftheoveralcountyoperationsBecauseoftheirexperienceandresourcesAMRiseasyabletomanageambulanceservicesforlargegeographicareaswithawiderangeofpopulationundermostcircumstancesThecurrentconditionshaveplacedAMR'soperationsinRiversideCountyandthroughoutCaiforniaunderincreasingstressandareimpactingoperations.ThereareseveralfactorsthatarecreatingthissystemstressforAMR.Muchlikethefiredepartmenthasexperiencedisdifficultywithrecruitmentandretention.Manyfactorscontributetodifficultyrecruitingandretainingambulancepersonnel.Typicallythesepositionsarenotconsideredcareerpositions.Thislimitstheapplicantpoolbecausemanypeopleseekemploymentthatoffersmoredefined,progressiveopportunities.Wagesareanotherfactor.Whilewageshaveimprovedsignificantlytheystilllimittheapplicantpool.AlsopriortoseekingemploymentindividualsmustattendandpassanEMT-Basicorparamediccourse.Thestandardsforpassingthesecoursesarehighduetothecriticalworkthatisperformedbysuccessfulstudents.Thisalsolimitsthenumberofapplicants.Theothersideoftherecruitment/retentionissueisretainingtheemployeestheyhave.Mostagreethatthesepositions,EMT-Basicandparamedic,aretransientpositions.Manyemployeesareusingthepositiontogainexperienceandknowledge,whileearningaliving,toachievetheirtruecareergoal.Careersinnursingandthefireservicearetwoofthecareersthattheseindividualsaretypicallyseeking.Thiscreatesconstantturnoverofexperiencedpersonnelastheyleavetopursueothercareers.AMRisalwaysinahiringcycletomaintainthenumberofemployeesneededtomanagetheiroperations.Theretentionissueismadeworsebycompetition.Allambulanceprovidersexperiencesimilarrecruitmentandretentionproblems.Onesolutionthathasbeenemployedistoofferincentivestolurequalifiedpeopletoapply.Thistypeofincentivehelpsoneproviderbutworsenstheproblematotherproviderssinceallprovidersaredrawingfromthesamepoolofapplicants.Thepandemiconlyworsenedtheproblems.AtthestartofthepandemicschoolsthatwereprovidingEMT-Basicandparamedictrainingpostponednewclasses.Theschoolsthatwereinthemiddleoftrainingaclasscouldn'tsecuretherequiredhospitalandambulancetimebecausenoonewasallowingnon-essentialpeopleintotheiroperations.Therewerenonewlytrainedpeoplefeedingintotheentrysideofthesystem.Positionstypicallyfilledbythesenewlycertifiedproviderswentunfilled.Paramedictrainingcantake6-12monthstocomplete.Evenwithschoolsbeginningclassesagainthenewinflux ofprovidersismonthsawayandwithoutadditionalclassofferingsitwillbeawhilebeforeenoughprovidersaretrainedtofilltheopeningscreatedbytheshutdown.Someemployeeselectedtotransitionawayfrommedicineduringthepandemic.Somechoosetoleavebecauseoftheincreaseinstressfromnewandeverychangingpoliciesandprocedures.Othersleftduetosafetyconcernsforthemselvesandtheirlovedones.Theopeningsleftbytheseindividualswentunfilledbecausetherewerenonewprovidersbeingcertified.WhenvacanciescannotbefilledquicklythenAMRmustfilldailyopeningsthroughovertimestaffinginordertomeetthesystem'sneeds.Overtimestaffingplacesadditionalstressonemployeesleadingtoburnout.Theyhavetohandlemorecallsandworkmorehours.Thiscreatedacascadeeffect;moreopeningscreateadditionalworkloadfortheprovidersthatremain.Thisleadstomoreprovidersleaving.ThestaffingissuesmakeitachallengeforAMRtobefullystaffedeachday,especiallyifyoulookatthetotalsysteminthecounty.Reducedstaffingleadstoareductioninthenumberofambulancesavailabletorespondtocallsforservice.Anothersignificantfactorthataffectsthenumberofambulancesavailableistheescalatingproblemofoffloaddelays.Aspreviouslydiscussedambulancesmaybeatthehospitalbutareunabletotransfertheirpatienttoahospitalbed.Thismeanstheambulanceanditspersonnelmustwaitwiththepatientuntilabedisavailable.Thiscanbeminutestohours.Theinstancesofsignificantdelayshavebeenincreasinginthelast6months.Everyoffloaddelayreducesthenumberofambulancesavailablewithinthesystem.SincethelocalAMROperatingUnitisapartofthelargerAMRcountyoperationtheyshareresourceswithotheroperatingunits.Itissimilartothemutualaidsystememployedbyfiredepartments.Ifoneagencylackssufficientresourcestheyobtainassistancefromtheirneighbor.ThisiswhatoccurredrecentlywiththefireinRubidoux.Therearetwoissueswiththis.Thefirstisthatwhenitcomestoambulancesinthecountyalloperatingunitsareexperiencingthesamesituation,areductioninambulancesavailablebecauseofstaffingandoffloaddelays.Thesecondissueisonethatfiredepartmentmutualaiddoesnotexperience.Onceafireresourceisreleasedfromassistinganotherfiredepartmenttheyreturntotheirownjurisdiction.Theycannotbesenttoanothercallwhiletheyarereturning.Inthecaseofanambulanceoncetheyleavetheirdesignatedareatheycanhandleacallnomatterwhereitoccurs.AsanexampleaHemetAMROperatingUnitambulancetransportsapatienttoahospitalinMorenoValley.OncetheyoffloadtheirpatienttheycanbedispatchedtoanycallthatoccursinMorenoValley.DependingonhowbusyanareaisitmaybehoursbeforetheHemetambulancecanreturntotheirusualarea.AllofthesefactorsimpactAMR'soperations.Fewerambulancesareavailablewithinthesystemtorespondtocalls.Becausetherearefewerambulancestorespondto911calls theresnocapacitytosendambuancestocasthaaren'tclearlymedcalnnature,ketorespondtoandstandbyatstructurefires.naddition,fewerambuancesmeanthatresponsetimesareincreasedandambulancesmusttraveongerdstanceswhleutilizingredlightsandsiren.Longercode3traveltmesncreasethechancesofaccidentsfortheambulancepersonneandthepubcLongertravetimesalsoincreaseswearandtearonvehicles.Areahospitalsarealsochallengedbythecurrentsituation.Everyhospitalisstaffedwithprofessional,qualified,dedicatedproviders.TheyareequippedwiththelatestdiagnosticandtreatmentfacilitiesandhavebeenprovidingexceptionalcaretotheresidentsandvisitorsofRiversideCountyformanyyears.Howevereveryhospitalisunderincreasedstressduetoavarietyoffactors.Offloaddelaysforambulancepatientsarenotanewissue,ithasbeenoccurringformanyyears.ThedifferenceistheincreasinglengthofthedelaythatiscurrentlyoccurringOnefactorthatcontributessignificantlytodelaysistheincreasingnumberofpatientsseekingtreatmentatERs.ManypeopleareutilizingtheERtoprovidetheirprimaryhealthcareinsteadofseeingapersonalphysician.AgrowinghomelesspopulationalsoutilizestheERfortheirprimarycare.Inaddition,manypatientsdeferredcareduringthepandemicandarenowseekingcareforpersistentmedicalissues.Anotherfactoristhescarcityoftreatmentoptionsfortheincreasingnumberofpatientsexperiencingmentalhealthissues.AlltheseleadtoERbedsfillingquicklywithawaitingroomfullofpatientswaitingtobeseen.Anotherissueisthattheareapopulationhasincreasedsignificantlyinthelast10yearsbuttheoverallnumberofavailableERbedshasnotproportionallykeptupwiththegrowth.TherearemorepatientsseekingtreatmentatERsbutproportionallylessbedsforthemtouse.HemetValleyHospitalhas29bedsintheirER.Thisisthesamenumbertheyhad15yearsago.Oneofthemostchallengingissuesforthehospitalisworkforceshortages.Whileshortagesoccurinmanypositionsitismostfeltinthenursingfield.Thecurrentshortagesarepredictedtolastforseveralyearsandnoclearsolutionshavebeenidentified.Alongwithworkforceshortagesisthechallengeofstringenthospitalstaffingratiorequirements,whichspecifyandlimitthenumberofpatientsthatcanbecaredforincertainareasofthehospital.TheserequirementsdonotcovertheratioofnursestopatientsintheERhowevercreatingabacklogofpatientsthatcannotbetransferredtootherareasofthehospitalbutthataretooillorinjuredtobereleased.Therequirementsapplytoallhospitalssotheyallexperiencethesameissue.Thismakesitdifficulttotransferthesepatientstootherhospitals.Asexpectedthepandemiconlyworsenedtheproblemsthathospitalshavehadtomanage.Stringentdisinfectionandcleaningprotocolsdelayallpatientcareprocesses, ncludngbedavaabiityWorkforceshortageswereworsenedwhenemployeeseftduetoncreasingworkoadandforsafetyconcernsStaffbengquarantinedandmssingworkduetoinfectionorexposurealsoexacerbatestheshortage.ThereductioninavailablestaffcoupledwiththenfluxofpatientsleadstofuERswithittleornocapacityforadditionalpatientsHowdoesthechallengesofourpartnerscreatechallengesforthefiredepartment?Thefiredepartmentalreadyexperienceshighworkloadcomparedtosimilarcities.Table1belowshowsthatthefiredepartmentrespondstomorecallsforservicethenmanycitieswithsignificantlymorepopulation.Theyalsorespondtomorecallswithfewerresourcesthencomparisoncities.Thehighnumberofcallsthatthefiredepartmentrespondstomakesunitavailabilityadailychallengeforfiremanagement.
Hemet85K285 4918KCorona174K50 7 10714KEscondido153K507 10215KMurrieta131K345 5510KWestCovina110K165 7010KRialto105K244 5710K Table1HemetFireparisonwithSimilarFireDepartmentsSource)WhentheambulanceisdelayedarrivingtoacalltheFDunitwillbeonsceneforalongerperiodoftime.Duringthistimetheyareunabletorespondtoothercallsforservice.NeighboringFDunitsmustprovidecoveragefortheunitthatisunavailable.Theseneighboringunitsarealreadyimpactedbythesignificantworkloadintheirownareaandmustnowhandleadditionalcallswhilethefirstunitisunavailableatthemedicalcall.Inaddition,theywillhavetotravelagreaterdistanceincreasingtheresponsetime.Thegreatertraveldistancealsomeanstheywillbedrivingcode3foralongerperiod.Thisextratravelincreaseswearandtearonapparatus.Thedelayintheambulancearrivalmeansthatthepatientmustwaitlongerbeforetheycanbetransportedtothehospital.Thisdelaywon'timpactpatientswithminorillnessesorinjuriesbutcanbedetrimentaltocriticalpatients.Oncetheambulancearrives,ifitisstaffedwithaparamedic,thenthepatientistransferredtotheambulancepersonnelfortransportandtheFDunitbecomesavailableforthenextcall.However,iftheambulancethatarrivesdoesnothaveaparamedicthentheFDparamedicmustaccompanythepatienttothehospital.Theymusttraveltothehospitalwiththepatient,increasingthetimetheyareoutofservice.DuringthepatienttransportandthereturntoserviceotherFDunitsassumetheresponsibilityfortheunit'sdistrictanditscitizens.
Thisproblemisexacerbatedbyanyoff-loaddelayexperiencedatthehospital.ThelongertheFDunitisdelayedatthehospitalthelongertheunitisunavailableforcallsinthecity.Thecallsforservicecontinueinthecity,therearejustlessunitsavailabletohandlethem.ThiscanleadtoanincreaseintheuseofAutomaticandmutualaid.Whilerequestingassistancefromneighboringoutsideagenciesisacommonfireservicepracticeitsometimesaltersthelevelofserviceprovidedtothecitizens.Asanexample,someoftheneighboringfiredepartmentsdonothaveparamedicsonalloftheirengines.IftheyweretorespondtoacallinHemetthepatientwillinitiallyreceiveBLScareuntilaparamedicambulancearrives,ifitisavailable.Finally,becauseambulanceresourcesarelimited,theyarereservedforcallsforservicethathaveanidentifiedpatientandthelikelihoodofthepatientrequiringtransporttothehospital.Anambulancecannotbecommittedtoaresponsetoadispatchedstructurefireunlessthereisaknownpatient.Thismeansthatthefiredepartmentmustrespondfirstand,ifapatientislocated,thenrequestanambulance.Inaddition,ifafirefighterisinjuredduringfireoperationstheymustwaiton-sceneuntilanambulanceisrequestedandresponds.Thisdelayscareandtransportforinjuredfirefightersandcivilianfirecasualties.Someneighboringfireagencieshavepoliciesthatrequireanambulancebedispatchedandstandbyduringstructurefires.Unitsfromtheseneighboringfiredepartments,whichassistatHemetfires,areoperatingoutoftheirownpolicieswhenHemetdoesnothaveanambulanceonscene.Allofthesefactorsandchallengesarebadforthecustomer.TheymustwaitlongerforFDunitstoarriveonscene.Thentheymustwaitlongerfortheambulancetoarrivetotakethemtothehospital.Theymayhavetotravelfurtherfromhomeandfamilytoahospitalthatisfurtheraway.OncetheyarriveatthehospitaltheymaywaitforasignificanttimeontheambulancegurneybecausetherearenoERbedsavailableforthem.Aslessunits(FDandambulance)areavailablewithinthesystemeachsubsequentpatientisimpactedevenmore.Theirdelaysandwaittimeswillincrease.Letsreviewthedatathatclarifiestheissue.Thefiredepartment'sprimaryresponsibilityistorespondtorequestsforservice.Onestandarduniversallyutilizedtomeasureperformanceisresponsetimes.Thefireservicehasseveralstandardsthatarerelatedtoresponsetimesbuteachmunicipalitydetermineswhatlevelofresponsetimestandardisbestforthem.IntheHemetStrategicPlan2021oneofthesuccessindicatorsforOrganizationalEffectivenessisthepercentageofFireresponsewithatotaltimeof6minutes,20secondsandunder.Table2belowshowstheyearlyresponsetimesfrom2018throughJanuary2022.Thechartincludesthenumberofresponsesthedataisbasedonshownonthefirstline,'N'.Italsoincludes‘Mean’ortheaverage,‘Median’orthemiddlemostvalue,andthe'90thPercentile’orthetimewhere90%oftheresponsesareequaltoorlowerthen.
Values20182019202020212022N 131231377712010113621142Mean07:2707:2407:4908:0008:17Median06:4906:4607:1507:1907:3090thPercentile10:1810:2710:5210:5511:27Table2HemetFireResponseTimeAnalysis:DispatchtoArrival(Min:Sec) The3rdvalue,90thPercentile,istheonethatbestrepresentstheservicebeingprovidedItshowswhatthehighlimitofresponsetimesisformostofthecitizensrequestingafiredepartmentresponse.Asyoucanseethefiredepartment'sresponsetime,usingthe90thpercentile,hasincreased60secondssince2019.Eventhemeanresponsetimeisupbyalmostthesameamount.ThemeanresponsetimeforJanuary2022showsthathalfofthefiredepartment'sresponsetimesareover08:17.Eventhoughthe'N'valuehasdecreasedoverthepast3yearsthereisstillanincreaseinresponsetimes.Whilemanyfactorscaninfluenceadepartment'sresponsetimethecurrentambulancecrisisisacontributingfactortotherecentincrease.Anotherimportantdatapointisthetimethatthefiredepartmentiscommittedtoeachresponse.Datawasreviewedthattracksthetimeacallisreceivedbythedispatcheruntilpatientcareistransferredtothetransportingunit.ThenumbersareshownbelowinTable3.Values20182019202020212022N 5163488736473801442Mean19:0018:0617:4520:1224:48Median15:5915:4016:2017:0820:2890thPercentile24:5524:4126:2028:0633:11Table3HemetFireResponseAnalysis:DispatchtoPatient(Min:Sec)Since2019themeantimeafiredepartmentunitiscommittedtoamedicalcallbeforepatientcareistransferredhasincreasedby6minutesand42seconds.The90thpercentilenumbersareevengreater.Theyshowan8minuteand29secondincreaseinthe90thpercentiletime.FDunitsarespendingmoretimeoncallssoareavailablelesstimeeachday.AnotherissuethatcontributestoFDunitoutofservicetimeiswhentheFDparamedicmustaccompanythepatienttotheER.Thisoccurswhentheambulancethatarrivestotransportisnotstaffedwithaparamedic(ABLSambulance).Priorto2021aBLSambulancearrivingtoa911callwassorarethatoccurrenceswerenoteventracked.However,from06/15/2021through01/16/2022thedatashowsthataBLSambulancerespondedtoHemetcalls100times.InJanuaryofthisyearHemetreceivedaBLSambulance56times.These56callsresultedin40transportstothehospitalwhentheFDparamedichadtoaccompanythepatienttothehospital.ThistakestheFDunitoutofserviceforaprolongedperiodreducingcoverageandservicetothecity,especiallyiftheytransporttoafurtherhospital.
CallcommitmenttimesforFebruary2022showthattherewere48instanceswhereFDunitswereoutofserviceonmedicalcallsforbetween1and2hoursand10instanceswheretheoutofservicetimeexceeded2hours.Includedinthe10instancesarethreecallswheretheoutofservicetimeexceeded3hours.WhenFDunitsareoutofserviceotherunitsmustprovidecoveragefortheirownareaaswellastheunitthatisunavailableThisincreasesworkloadandworsensresponsetimes.REMSAoverseesthecountycontractwithAMRandcompilesamid-yearandannualreportthatoutlinesresponsetimecompliance.Thelatestmid-yearreportisfortheperiodO7/2020through06/2021.ItbreaksthecountydownintoRegionsandeachRegionintoResponseZones.ResponseZonesarefurtherbrokenupintoSubzones.HemetiswithintheMid-CountyRegionandispartoftheSanJacintoZone.TheHemetSubzonecontainsthemajorityofthe911-ambulanceresponsevolumefortheSanJacintoZone(Figure1below).AspartoftheircontractAMRhasarequirementtomaintaina10-minuteresponsetimetotheHemetSubzone.Theymustmeetthisrequirement90%ofthetime.AsyouwouldexpectAMRhasbeenmeetingthisrequirementformanyyears.
AMR-HemetSubzoneTotal911AmbulanceResponses2-yearReview1800 100.0%1500 1455 99.0%98.0%1400 97.0%12“ 1059 96.0%95.0% ResponsesI-I00OO OO 0Compliance
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2019 2020 2021911ResponsesFigure1HemetSubzone:Total911AmbulanceResponsesandCompliance Overatwo-yearperiod,from07/2019through06/2021,AMRhasneverfallenbelowthe90%requirement.ThelowestcomplianceforthetimeperiodwasrecordedinMarchof2021at90.3%andthebestcompliancewasayearearlierinMarchof2020at93.2%.ThesenumbersshowAMR'seffortstomaintainserviceatestablishedlevelsregardlessofthecircumstances.Thecontractallowsforexemptionstothe90%standardforcircumstancesthatdelaytheambulancearrivalbutthatareoutoftheprovider'scontrol.Anexampleiswhenatrainblockingtheroadwayorsevereweathersituationsdelays Compliance90%ComplianceRequirement
theambulance.ExemptionsarealsotrackedbyREMSAandincludedintheannualreport.Figure2belowshowsexemptiondatafortheSanJacintoZone.AMR-SanJacintotZoneResponseTimeExemptions%ofV olume700 2-yearReview 120%646 -
11.0%600 10.0%cu9.0%E500 38.0%§3400 7.0%'86.0%o
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2019 2020 2021APODExemptions%ofV olumeFigure2SanJacintoZone:ResponseTimeExemptions ItisclearthatexemptionshavebeenincreasingsinceJuly2020withacoupleofsignificantspikes.ThespikeinDecember2020represents646timesthatanambulancewasdelayedarrivingatacallbutthatisnotincludedwhencalculatingcompliancewiththe90%requirement.Theseexemptionsareallapprovedandtheprovideriscorrectinutilizingthemwhenevertheyoccur.Thegraphisusedtotrackcontractcompliancebutcanbeusedtolookatsystemperformanceandtheimpacttocitizens.TheDecember2020numberrepresents646timesthatanambulancewasdelayedarrivingtoacallintheSanJacintoZone(Hemetmakesupthemajorityofthecallsinthatzone)andthetrendsuggestthattheoccurrenceofexemptionsisraisingoratleasthighertheninpreviousyears.Whytheincrease?Let'slookatanothergraphfromtheCountyreport(Figure3below).
AMR-SanJacintoZoneResponseTimeExemptions—Totalvs.fromAPOD700 2-yearReview646 600
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Figure3ResponseTimeExemptions:TotalversusfromAPOD(2—years)AnotherexampleofanapprovedexemptioniswhenambulancesaredelayedbecausetheycannotoffloadtheirpatientattheER.Thesearecalled‘AmbulancePatientOffloadDelays’orAPODs.AnAPODoccurswhenthetransferofpatientcareandoffloadingfromtheambulancegurneyexceeds30minutes.TheCountystandardforoffloadingiswithin30minutes.ThisgraphseparatesthetotalexemptionsintoAPODSandothers.ThetealcolorrepresentsthenumberofexemptionscausedbyambulancesthataredelayedoffloadingtheirpatientsatERs.TheoverwhelmingmajorityofexemptionsarecausedbyAPODs.Regardlessofthereasonfortheexemptionthenumbersrepresentincidentswhereanambulanceisdelayedarrivingtothescene.Ambulanceoff-loaddelaysathospitalsaretrackedbyREMSAandaretypicallyreportedmonthly.HoweverinlightofthecurrentsystemchallengesREMSAhasbeenprovidingspecialweeklyreportstoallowagenciestobetterunderstandandtracktheissues.Figure4belowistakenfromtheREMSADecember2021monthlyreport.Itshowsthetotalnumberofhours,countywide,ofoffloaddelays. 2018Hours2019Hours2020Hours
3840:003360:O02880:0O2400:001920:001440:00960200480:O00:00 RiversideCountyMonthlyAmbulancePatientOf?oadDelayHours(2017-2021)ParticipatingProviders 560,0C!_NovDecJan,, , FebMar
Figure4 PatientOf?oadDelayHours(5-years)Redrepresents2021numbers.Youcanseethatoffloaddelayhourshavebeenincreasingsince2020andsignificantlyincreasedinthelasthalfof2021.Typicallytherearespikesthatoccurduringwintermonthsduetoseasonalillnessesbutthe2020and2021numbersareabovewhatistypical.Thisshowsthescopeoftherecentproblemofoffloaddelays,countywide.ToseethelocalimpactswecanutilizeCountydatathatlooksatoffloaddelaysbyfacility.HemetValleyHospitalistheonlyhospitalwithinthecityandthemajorityoftheFDpatientsaretransportedthere.OneofthemethodsutilizedbyREMSAistotrackAmbulancePatientOff-loadTimes(APOT)ateachreceivingfacility.Onemetricistolookatthe90thpercentileforoff-loadtimes(90%ofpatientoffloadsoccurinlessthenthistime).InDecember2019the90thpercentileforAPOTatHemetValleyHospitalwas45minutes.InDecember2021theAPOTatHemetValleyHospitalwas1hourand59minutes.Figure5showsthenumberofambulancetransportseachERreceivedinDecember2021andthepercentageofpatientsthatwereoffloadedwithinthe30-minutestandard. &
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5NumberofAmbulanceReceived.%ComplianceAllhospitalsexperienceAPODs.Thepercentageofoffloadsthatoccurwithinthe30-minutestandardvariesbetween39%and97%.ThetwofacilitiesthatexperiencedthelargestnumbersofoffloaddelayswereRiversideCommunityHospital(836delays)andHemetValleyHospital(638delays).WhileAPODsaredelaysthatexceedthe30-minutestandardREMSAalsotracks‘Significant’APODs.Theseareoffloaddelaysthatexceed90-minutes.Figure6belowshowsthecountywidebreakdownofSignificantAPODs.PatientOffloadDelaysGreaterthan90Minutes1400 14402002001200 12002001001000 960:0O:008(X) Occurences
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Figure6AmbulancePatientOf?oadDelaysGreaterthan90Minutes Againthedatashowsthetrendofincreasingdelaysthelast6monthsof2021.Ofthe1045ambulancetransportsreceivedbyHemetValleyHospitalinDecemberof2021therewere168offloaddelaysthatexceeded90minutes.ThisdataoritsusedoesNOTsuggestthatanyproviderisfailinginitsresponsibilitiesorisunder-performing.TheonlyreasontolookspecificallyatHemetValleyHospitalisbecauseitistheclosestERtothecityandreceivesthemajorityofpatientscomingfrom StandardAPOD
AugSepOctNovDecTotalAPOT>90minTotalAPOT>90MlN_Exceededtime RiversideCountyHospitalsTransports,APODsand%Compliance2000 December2021 1500
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thecity.Thedataclearlyindicatesthatthesystem,countywide,isunderextremestressthatisimpactingitsabilitytoprovidethequalityofcarethatitwasdesignedtoprovide.Whatactionsareunden/vaytominimizetheimpactsofthecrisis?REMSAistheagencydesignatedtooverseethedeliveryofEMSservicesthroughoutthecounty.TheyoverseemanyaspectsofEMSdeliverlikethe911-ambulancecontract,treatmentguidelines,andhospitals.OneofREMSA'smainfunctionsistomonitorthesystemanddevelopstrategiestominimizeproblems.InthecaseofthecurrentambulancecrisisREMSAhasbeenexpendingalotoftimeandefforttoreducetheimpactstopatientsandproviders.REMSAhassteadilyincreasedcommunicationsandcoordinationtoacampaignofsystemengagement.Thisstrategyincludes:0Real-timedataalertsandnotifications0Dailyemailreports0Weeklyandmonthlyreports0PresentationstostakeholdersPolicydevelopmentformitigationandmanagementMonthlynotificationletterstohospitaladministratorsRealtimephoneandtextmessagestohospitaladministratorsoAPOTcompliancereportingtotheCaliforniaEMSAuthority0MandatingadditionalambulancesbestaffedoPhysicallyrespondingtohospitalsandobservingAPODsREMSAhasalsobeenopentonewideasandalternativetransportvehicleideasthatmayreducetheimpactsfromthiscrisis.TheseareexamplesofjustsomeofthestepsthatREMSAhastakentolessenthecrisis.Hospitalshavebeenworkingdiligentlytoreducetheinstancesofoffloaddelays.ERnursingstaffissensitivetotheissuescreatedbythesedelays,especiallyforfiredepartmentunits.TheyroutinelymakespecialandsignificanteffortstofindbedsforambulancepatientssothatambulancesandFDunitscanreturntoservice.AnotherstrategyistheuseofambulanceredirectionwhenanERisexperiencesignificantAPODs.AmbulancesareredirectedtoanotherhospitalreducingthenumberofpatientsthatarewaitingattheimpactedERandhopefullyreducingthetimetheambulancepatienthastowaitforanavailablebed.However,theuseofambulanceredirectiondoesnotimpactthenumberofwalk-inpatientsthatarriveattheER.Theambulanceredirectionisdesignedtogivetheimpactedhospitaltimetoclearsomeoftheirpatientswithouttheadditionalworkloadofnewambulancepatientsarriving.Ambulanceredirectionhassomelimitationsthough.Redirectingambulancestoanotherfacilityincreasestheworkloadatthatfacility,possiblyoverwhelmingthem.Afterall,all hospitalsarecurrentlyexperiencingthesameissues.Inaddition,ambulancesandpatientsmusttravelgreaterdistancestoreachthealternateER.Hospitalshavealsobeentakingstepstoreducetheworkforceshortagebutthatissueissubstantialandwilllikelynotberesolvedformanyyears.AMRhasbeenexpendingsignificantenergytoreducetheproblem.Theyhavebeenactivelyandaggressivelyrecruitingnewemployees.TheyhavealwaysbeenactiveinthecommunityandhavebeendevelopinginnovativeprogramsthathopetobringmoreindividualsintotheEMSpipeline.TheHemetAMROperatingUnithasrecentlysignificantlyincreasedwagesforitsfieldproviders.Thisincreaseservesasbotharecruitmentandretentiontoolaswellasimprovingworkingconditionsfortheiremployees.AnotherrecruitingandretentionstrategydevelopedbyAMRisascholarshipprogramthatoffersapathforemployeesthatareEMT-Basicstoattendparamedicschoolandthenhaveanimmediatepositionwaitingforthemoncetheygraduate.Thiscreatesanopportunityforentry-levelemployeestogrowandmoveupwithinAMR,creatingamorestableworkforce.Tomanageday-to-dayoperationsAMRhasdevelopedandisutilizingflexible,"onthefly"scheduling.Theoperationsmanagerisconstantlyreviewingcurrentandfuturestaffingneedsandmodifyinghours,shifts,andpersonnelschedulingtomaintaintheneedednumberofambulanceseachday.Also,supervisorsworkcloselywithlocalhospitalstoreduceoffloaddelays.OnesolutionimplementedishavingambulancecrewswaitingattheERforabedassumecareforanotherambulance'spatientsothatambulancecanreturntoservice.ThroughtheseeffortsAMRhasminimizedsomeoftheimpactsofthecurrentcrisis.InanefforttofindsolutionsthefiredepartmenthasbeenmeetingwithotherRiversideCountyfiredepartments,localhospitals,andAMRmanagement.Thedepartmenthaslimitedoptionstoreducetheimpactstothecitizens.Theydonotcontroltheambulanceresponseortransportandcan'tcontrolthedelayforthepatientoffload.However,staffhasbeenworkingtoidentifyopportunitiesthatmayreducetheimpactsofthecurrentcrisis.StaffhasbeenmeetingwithAMR'slocalOperationsManager,JackHansen,tobrainstormwaystoimproveservicedelivery.Mr.HansenhasbeeninvolvedinambulancetransportationforHemet'scitizensforthepast25years.Moreimportantlyheisalong-timeHemetresidentwithacommitmenttotheCityanditsresidents.OnepossiblesolutionidentifiedissimilartosomethingthatAMRhasemployedsuccessfullyinothercounties.Itaddsambulancecapacitywhereandwhenitisneeded.Theidea,currentlybeingexplored,istostaffanAMRambulancewithFireDepartmentpersonnel.ThisambulancewillbededicatedtotheCityandhousedatafirestation.TheUnionand thefirefightersarereceptivetotheconcept.Thispublic/privatepartnershipwouldsignificantlyreducetheinstanceswherefireunitsareoutofservice,improveambulanceandengineresponsetimes,decreasecallcommitmenttimes,andimprovetheservicethatweprovidewithoutcosttothegeneralfund.ThedepartmentisexcitedtoworkwithAMRtolessentheambulancecrisisimpactstothecitizensofHemet.Oncethedepartmenthasaclearunderstandingofhowthispartnershipmightworkadetailedreportwillbeprovidedoutliningtheprogramanditsbenefitsforyourreview.