National City City Council
May 16, 2023

89 knowledge about thedistributions oftime ittakesforeach partof thisprocess,allpartsare lumpe d intoa singleestimateof
un certaintyand a rectangulardistribution isassumed.Thisismost reasonablyestimat ed tobe 2.5 second swith a standarddeviation of ±2.89 secondsand an expanded uncertaintyof ± 5.78seconds.

W eather me asuremen tuncertainty was referencedtothe
pub lisheduser’smanu alfor the instrumentation used.The we ather instrumenta tion has calibration certificatesthataretraceable to NISTstandards .A summary of experimentalmeasu rement
un certaintyisgiven inT able G-1 .

TableG -1:Summ aryofMea surement U ncertainty

90 APPEN DIX H: C harts ofG as and Temp eratureData
Examples ofGa s and TemperatureData forTime-to-TaskTests Burn Room Da ta

91 TargetRoom Da ta

92 Tempe rature Near FrontDoor (C ouch )

93 Ga s and Temp eratureDa tafor Room and ContentsTests Examp lesofG as Data inTargetRoom

94 Ga s and Temp eratureDa tafor Room and ContentsTests Examp lesofG as Data inTargetRoom

95 Tempe ratures inBurn Room

96 Tempe ratures inTargetRoom

97 Tempe ratures Ne arFrontD oor (Couch)

98 Page 1007 of 1153
99 NO TE S :
________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________

100
________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________

101
________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________

102
________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________

103 Page 1012 of 1153

Lori Moore-Merrell
Rob Santos
Doug Wissoker
Ron Benedict
Nicole Taylor
Randy Goldstein
Greg Mears
Jane Brice
Jason D. Averill
Kathy Notarianni

APPENDIX D

2 Page 1015 of 1153
3 September 2010
Report on
EMS Field Experiments
Lori Moore-Merrell
Rob Santos
Doug Wissoker
Ron Benedict
Nicole Taylor
Randy Goldstein
Jane Brice
Greg Mears
Jason D. Averill
Kathy Notarianni

4 Certain commercial entities, equipment, or materials may be identified in this document in order to describe an
experimental procedure or concept adequately. Such
identification is not intended to imply recommendation or endorsement by the partner organizations, nor is it
intended to imply that the entities, materials, or equipment are necessarily the best available for the purpose.

5 Produced with the Cooperation of
Montgomery County, Maryland
Fire and Rescue, Department
Chief Richard Bowers
Produced with the Cooperation of
Fairfax County, Virginia
Fire and Rescue Department
Chief Ronald Mastin
Funding provided through DHS/FEMA Grant Program Directorate for FY 2008 Assistance to Firefighters Grant Program – Fire Prevention and Safety Grants (EMW-2008-FP-01603)

6

7 Table of Contents
Abstract......................................................................................9 Executive Summary ................................................................10 Primary Findings ....................................................................11 Background ..............................................................................13 Problem ....................................................................................14 Literature Review....................................................................15 Purpose and Scope of the Study............................................17 A Brief Overview of an EMS Response..................................18 The Star of Life ......................................................................18 EMS Response to Time Critical Events ................................19 The Relation of Time-to-Task Completion and Risk ..............19 Standards of Response Cover ..............................................20 Experiment Planning and Methodology ................................20 Department Participation ..................................................20 Crew Orientation................................................................20 Cue Cards ........................................................................20 Tasks ................................................................................20 On Scene EMS Tasks........................................................20 Radio Communication ......................................................21 Task Timers ......................................................................21 Video records ....................................................................21 Crew Assignment ..............................................................21 Props ................................................................................21 Safety Protocols ................................................................22 Response Time Assumptions ............................................22 Part 1: Patient Access and Removal from Incident Scene ..24 Incident Scene ......................................................................24 Tasks ......................................................................................24 Part 2: Trauma Patient ........................................................25 Incident Scene........................................................................25 Tasks ......................................................................................25 Part 3: Cardiac Patient ............................................................27 Incident Scene ......................................................................27 Tasks......................................................................................27 Analysis of Experimental Results ..........................................29 Time-to-Task Analysis ............................................................29 Data Queries..........................................................................29 Statistical Methods ................................................................29 For Access and Removal ..................................................29 For Trauma and Cardiac scenarios ..................................29 Measurement Uncertainty......................................................32 How to Interpret the Time-to-Task Graphs ............................32 Time-to-Task Graphs................................................................33 Part 1- Patient Access and Removal ....................................34 Access ..............................................................................34 Patient Removal ................................................................33 Part 2- Multi-System Trauma ................................................34 Individual Task Times ........................................................35 Patterns in the Trauma Scenario ......................................39 Part 3- Chest Pain and Witnessed Cardiac Arrest ................40 Individual Task Times ........................................................41 Patterns in the Cardiac Scenario ......................................43 Conclusions..............................................................................44 Patient Access and Removal ................................................44 Trauma ..................................................................................44 Cardiac ..................................................................................44 Summary ..................................................................................46 Study Limitations ....................................................................47 Future Research ......................................................................48 Acknowledgements..................................................................49 References ................................................................................50 Glossary ....................................................................................52 Acronynms................................................................................54 Appendix A:Time to Task Measures ........................................55 Appendix B:Trauma Patient Assessment and Interview Form 58 Appendix C:Medical Patient Interview Form............................59 Appendix D:Medical Patient Assessment/Interview Form ......60 Appendix E:Statistical Analysis of Time to Task Data Patient Access and Removal............................................61 Appendix F:Statistical Analysis of Time to Task Data Systemic Trauma Patient ....................................................62 Appendix G:Statistical Analysis of Time to Task Data Cardiac Arrest Patient ......................................................63 Appendix H:All Regression Coefficients ..................................65 Notes ........................................................................................70

8 Page 1021 of 1153
9 T
he fire service has become the first line medical responder for all types of medical emergencies in the majority of the United States. Fire departments typically deliver
first-on-scene, out-of-hospital care services, regardless of whether or not they provide transport. The design of fire
department-based Emergency Medical Services (EMS) systems varies across communities. Some departments deploy only Basic Life Support (BLS) units and personnel, some deploy a mix of BLS and Advanced Life Support (ALS) units and personnel, and a few departments operate solely at an ALS level. Additionally, the number of total personnel dispatched on an EMS call also differs.

This number is dependent on factors such as the type of system resources, the nature of the EMS incident, and the number of simultaneous and concurrent incidents.

For the first time, this study investigates the effects of varying crew configurations for first responders, the apparatus assignment of ALS personnel, and the number of ALS personnel on scene on the task completion times for ALS level incidents. This study is also unique because of the array of stakeholders and the caliber of technical experts involved. Throughout the experiments, all industry standards and safety protocols were followed and robust research methods were used. The results and conclusions will directly inform the NFPA 1710
1and NFPA 1720 T echnical
Committees, who are responsible for developing industry operational and deployment standards.

This report presents the results of more than 102 field experiments designed to quantify the effects of various fire department-based EMS deployment configurations for three different scenarios—-1) patient access and removal from the incident scene, 2) a victim of systemic trauma due to a long distance fall and 3) a patient with chest pain leading to a cardiac arrest. In addition to systematically controlling for arrival times of units, first responder crew size was varied to consider two-, three-, and four-person staffing. ALS personnel configuration for both the first responder unit and ambulance transport unit were also varied for purposes of the experiments. In each deployment, personnel performed a series of defined tasks consistent with the scenario being evaluated. Report results quantify the effectiveness of crew size, ALS configuration, and the number of ALS personnel on the start, duration, and completion time of all tasks delineated in the three scenarios. Conclusions are drawn from statistically significant results.

Abstract
NFPA is a registered trademark of the National Fire Protection Association, Quincy, Massachusetts.

10 Executive Summary
I
ncreasing demands on the fire service, including the rising number of EMS responses, point to the need for
scientifically-based studies on the effect of first responder crew size, Advanced Life Support configuration, and the number of Advanced Life Support (ALS) personnel on scene on the safety of responders, as well as the operational efficiency and effectiveness of fire departments responding to emergency medical incidents.

T o address this need, a research partnership of the Commission on Fire Accreditation International (CFAI), International Association of Fire Chiefs (IAFC), International Association of Fire Fighters (IAFF), National Institute of Standards and T echnology (NIST), and Worcester Polytechnic Institute (WPI) was formed to conduct a multiphase study of firefighter safety and the deployment of resources. A portion of that study, as reported here, includes an assessment of time-to-tasks for EMS incidents.

Beginning in FY 2005, funding was provided through the
Department of Homeland Security (DHS)/ Federal Emergency Management Agency (FEMA) Grant Program Directorate for
Assistance to Firefighters Grant Program-Fire Prevention and Safety Grants. In addition to the EMS field experiments described in this report, the multiple phases of the overall research effort include development of a conceptual model for community risk assessment and deployment of resources, implementation of a generalizable department incident survey, and delivery of a software tool to quantify the effects of deployment decisions on resultant firefighter and civilian injuries and on property losses.

The first phase of the project was an extensive survey of more than 400 career and combination (both career and volunteer) fire departments in the United States with the objective of optimizing a fire service leader’s capability to deploy resources to prevent or mitigate adverse events that occur in risk- and hazard-filled environments. The results of this survey are not documented in this report, which is limited to the EMS experimental phase. The survey results will constitute significant input into the development of a future software tool to quantify the effects of community risks and associated deployment decisions on
resultant firefighter and civilian illnesses and injuries.

The National Fire Protection Association estimates that 10,380 EMS workers were exposed to infectious diseases in 2008 (Karter, 2009). Another study noted that almost 10 % of Emergency Medical T echnicians (EMTs) and Paramedics miss work at any given time due to job-related illness or injury (Studnek et al, 2007).

Another study noted that injury rates for EMS workers are higher than rates reported by the Department of Labor (DOL) for any other industry in 2000 (Maguire et al, 2005) and another study noted that EMS providers have a high risk for occupational injury, with approximately 25 % of workers reporting at least one work-related injury in the previous six months. Many of these injuries were the result of falls or lifting patients (Heick, 2009).

Funding and additional research are critical to further defining the high risks to firefighters during EMS responses and developing interventions to mitigate this serious problem.

In order to address the primary research questions using realistic scenarios, the research was divided into three distinct, yet interconnected parts.
/square6Part 1 — Time-to-task experiments related to gaining access to a patient and removing the patient from the
incident scene.
/square6Part 2 — Time-to-task experiments related to the care of a victim with multi-system trauma.
/square6Part 3 — Time-to-task experiments related to the care of a victim with chest pain and witnessed cardiac arrest.

These parts included the most basic elements of an overall EMS response, which are — access the patient, conduct patient assessment, deliver on scene patient care, package the patient, and remove the patient from the scene to a transport-capable vehicle.

Scope
The EMS portion of the Firefighter Safety and Deployment of Resources Study was designed solely to assess the personnel number and configuration aspect of an EMS incident for
responder safety, effectiveness, and efficiency. This study does not address the efficacy of any patient care intervention. This study does however quantify first responder crew size, i.e., the number and placement of ALS trained personnel resources on the time-to-task measures for EMS interventions. Upon
recommendation of technical experts, the investigators selected trauma and cardiac scenarios to be used in the experiments as these events are resource intensive and will likely reveal relevant differences in regard to the research questions. The applicability of the conclusions from this report to a large-scale hazardous or multiple-casualty event has not been assessed and should not be extrapolated from this report.

EMS protocols pertaining to the treatment and transport of patients vary by departments. For the purpose of this study, apparatus arrival times and on scene tasks were standardized by technical experts. Individual performance times were recorded for each task. Response data from more than 300 United States Fire Departments show that when dispatched simultaneously, a first responder arrives prior to an ambulance in approximately 80 % of EMS responses, (IAFC/IAFF, 2005). Therefore, arrival times of the first responder engine and the ambulance were staggered.

Additionally, in real-world situations, as in this study, many of the tasks can be performed simultaneously based on the number and training level of responding personnel. Attempts to generalize the results from these experiments to individual departments must take into account response and patient care protocols and equipment that may vary from those used in the experiments.

11 Primary Findings
The objective of the experiments was to determine how first responder crew size, ALS provider placement, and the number of ALS providers is associated with the effectiveness of EMS providers. EMS crew effectiveness was measured by task
intervention times in three scenarios including patient access and removal, trauma, and cardiac arrest. The results were evaluated from the perspective of firefighter and paramedic safety and scene efficiency rather than as a series of distinct tasks. More than 100 full-scale EMS experiments were conducted for this study.

Hundreds of firefighters and paramedics are injured annually on EMS responses. Most injuries occur during tasks that require lifting or abnormal movementby rescuers. Such tasks include lifting heavy objects (including human bodies both conscious and unconscious), manipulating injured body parts and carrying heavy equipment. Several tasks included in the experiments fall into this category, including splinting extremities, spinal immobilization (back boarding) and patient packaging. Similar to the lifting or heavy workload tasks, larger crews were able to complete the labor intensive tasks using multiple crew members on a single task to assure safe procedures were used reducing the likelihood of injury or exposure.

A number of tasks are alsolabor intensive. These tasks can be completed more efficiently when handled by multiple responders.

Several tasks in the experiments are in this category. These include checking vital signs, splinting extremities, intubation with spinal restriction, establishing I.V . access, spinal immobilization, and patient packaging. During the experiments larger crews completed these tasks more efficiently by distributing the work load among more people thereby reducing the likelihood of injury.

Finally, there are opportunities on an EMS scene to reduce scene time by completing tasks simultaneously rather than sequentially thus increasing operational efficiency. For the experiments, crews were required to complete all tasks in each scenario regardless of their crew size or configuration. Therefore, patterns in task start times and overall scene times reveal operational efficiencies.

When enough hands are available at the scene to complete tasks simultaneously, this leads to overall time reductions relative to smaller crews that are forced to complete tasks sequentially.

Patient Access and Removal
With regard to accessing the patient, crews with three or four first responders reached the patient around half a minute faster than smaller crews with two first responders. With regard to completing patient removal, larger first responder crews in conjunction with a two-person ambulance were more time
efficient. The removal tasks require heavy lifting and are labor intensive. The tasks also involve descending stairs while carrying a patient, carrying all equipment down stairs, and getting patient and equipment out multiple doors, onto a stretcher and into an ambulance.

The patient removal results show substantial differences associated with crew size. Crews with three- or four-person first responders complete removal between 1.2 – 1.5 minutes faster than smaller crews with two first responders. All crews with first responders complete removal substantially faster (by 2.6 - 4.1 minutes) than the ambulance-only crew.

These results suggest that time efficiency in access and removal can be achieved by deploying three- or four-person crews on the first responding engine (relative to a first responder crew of two).

T o the extent that each second counts in an EMS response, these staffing features deserve consideration. Though these results establish a technical basis for the effectiveness of first responder crews and specific ALS crew configurations, other factors contributing to policy decisions are not addressed.

Trauma
Overall, field experiments reveal that four-person first responder crews completed a trauma response faster than smaller crews.

T owards the latter part of the task response sequence, four-person crews start tasks significantly sooner than smaller crews of two or three persons.

Additionally, crews with one ALS provider on the engine and one on the ambulance completed all tasks faster and started later tasks sooner than crews with two ALS providers on the
ambulance. This suggests that getting ALS personnel to the site sooner matters.

A review of the patterns of significant results for task start times reinforced these findings and suggests that (in general) small non-significant reductions in task timings accrue through the task sequence to produce significantly shorter start times for the last third of the trauma tasks.

Finally, when assessing crews for their ability to increase on-scene operational efficiency by completing tasks
simultaneously, crews with an ALS provider on the engine and one ALS provider on the ambulance completed all required tasks

2.3 minutes (2 minutes 15 seconds) faster than crews with a BLS engine and two ALS providers on the ambulance. Additionally, first responders with four-person first responder crews completed all required tasks 1.7 minutes (1 minute 45 seconds) faster than three-person crews and 3.4 minutes (3 minutes and 25 seconds) faster than two-person crews.

Cardiac
The overall results for cardiac echo those of trauma. Regardless of ALS configuration, crews responding with four first responders completed all cardiac tasks (from at-patient to packaging) more quickly than smaller first responder crew sizes. Moreover, in the critical period following cardiac arrest, crews responding with four first responders also completed all tasks more quickly than smaller crew sizes. As noted in the trauma scenario, crew size matters in the cardiac response.

Considering ALS placement, crews responding with one ALS provider on both the engine and ambulance completed all scene tasks (from at-patient to packaging) more quickly than a crew with a BLS engine and two ALS providers on the ambulance. This suggests that ALS placement can make a difference in response efficiency. One curious finding was that crews responding with a BLS engine and an ambulance with two ALS providers completed the tasks that follow cardiac arrest 50 secondssoonerthan crews with an ALS provider on both the engine and ambulance. As noted, this counter-intuitive difference in the results may be attributable to the delay of the patient arrest time based on the arrival of the 12-Lead ECG monitor with the two-person ALS Ambulance crew. The 12-Lead ECG taskend timewas the arrest start time. In this scenario, there were instantaneously two ALS providers present at the arrest rather than the one ALS provider placing the 12-Lead ECG device in the ALS engine /ALS
Ambulance crew.

12 A review of the patterns of significant findings across task start times showed mixed results. An ALS on an engine showed an advantage (sooner task starting times) over an ALS on an ambulance for a few tasks located earlier in the cardiac response sequence (specifically, ALS Vitals 12-Lead through IV access). A first responder with four-person crew also showed shorter start times for a few early tasks in the cardiac response sequence (initial airway, breathing and circulation (ABCs), and the ALS Vitals 12-Lead and expose chest sequence). More importantly, a sequential time advantage appears for the last three tasks of the sequence (analyze shock #2 through package patient).

Finally, when assessing crews for their ability to increase on-scene operational efficiency by completing tasks
simultaneously, crews with an ALS provider on the engine and one ALS provider on the ambulance completed all required tasks 45 seconds faster than crews with a BLS engine and two ALS providers on the ambulance. Regardless of ALS configuration, crews responding with four first responders completed all cardiac tasks from the ‘at patient time’ to completion of packaging 70 seconds faster than first responder crews with three persons, and 2 minutes and 40 seconds faster than first responder crews with two persons. Additionally,after the patient arrested, an assessment of time to complete remaining tasks revealed that first responders with four-person crews completed all required tasks 50 seconds faster than three-person crews and 1.4 minutes (1 minute 25 seconds) faster than two-person crews.

Summary
While resource deployment is addressed in the context of three basic scenarios, it is recognized that public policy decisions regarding the cost-benefit of specific deployment decisions are a function of many factors including geography, resource
availability, community expectations as well as population demographics that drive EMS call volume. While this report contributes significant knowledge to community and fire service leaders in regard to effective resource deployment for local EMS systems, other factors contributing to policy decisions are not addressed. The results, however, do establish a technical basis for the effectiveness of first responder crews and ALS configuration with at least one ALS level provider on first responder crews. The results also provide valid measures of total crew size efficiency in completing on-scene tasks some of which involve heavy lifting and tasks that require multiple responders to complete.

These experimental findings suggest that ALS provider
placement and crew size can have an impact on some task start times in trauma and cardiac scenarios, especially in the latter tasks leading to patient packaging. T o the extent that creating time efficiency is important for patient outcomes, including an ALS trained provider on an engine and using engine crew sizes of four are worth considering. The same holds for responder safety – for access and removal and other tasks in the response sequence, the availability of additional hands can serve to reduce the risks of lifting injuries or injuries that result from fatigue (e.g., avoid having small crews repeatedly having to ascend and descend stairs).

13 I
n recent years, the provision of emergency medical services has progressed from an amenity to a citizen-required service. T oday more than 90 % of career and combination fire departments deliver emergency medical care services, making fire departments the largest group of providers of prehospital EMS in North America. Fire department operations are geared to rapid response, whether it is for EMS, resuce, or fire suppression. In many jurisdictions, EMS responses equate to over 75 % of a fire departments call volume. EMS deployment decisions are
therefore a critical driving factor for any department considering both short and long term resource deployment decisions.

The National Fire Protection Association estimates that 10,380 EMS workers were exposed to infectious diseases in 2008 (Karter, 2009). Another study noted that almost 10 % of EMTs and Paramedics miss work at any given time due to job-related illness or injury (Studnek et al, 2007). Another study noted that injury rates for EMS workers are higher than rates reported by the Department of Labor (DOL) for any other industry in 2000 (Maguire et al, 2005) and another study noted that EMS providers have a high risk for occupational injury, with approximately 25 % of workers reporting at least one work-related injury in the previous 6 months. Many of these injuries were the result of falls or lifting patients (Heick, 2009). Funding and additional research are critical to further quantifying the high risks to firefighters during EMS responses and developing interventions to mitigate this serious problem.

Much discussion and past research has focused on ambulance transport services, largely ignoring the impact of critical interventions that can be provided prior to ambulance transport unit arrival. Ambulances are important for the transport of patients needing more definitive medical care (Pratt, 2007).

However, based on the number and the geographic distribution of apparatus stationed for “all hazards” response, a more rapid response is typically provided by fire department baseline units carrying medical supplies and EMS trained personnel
(IAFC/IAFF, 2005). As fire departments continue to enhance their roles in EMS, it becomes important to examine how different deployment configurations and initiation of specific medical interventions may change the long-term outcome for the patient. Consequently, community planners and decision-makers need tools to optimally align resources with their service commitment for adequate emergency medical care for citizens.

Background

14 D
espite the role played by the fire service in the provision of emergency medical services, there are no scientifically based tools available to community and fire service leaders to assess the effects of EMS crew size and deployment on firefighter safety. More and more individuals, including the indigent, the working uninsured, and the underinsured, rely on prehospital medical care, which continuously increases the need for EMS resources in fire departments. The continued lack of comprehensive community health services and comprehensive health care reform means addressing this issue is a critical step in the evolution of the fire service and public safety.

Presently, community and fire service leaders have a qualitative understanding of the effect of certain resource allocations. For example, an increase in the number of fire houses, medically equipped apparatus, and EMS trained personnel would lead to a decrease in the time citizens spend waiting for EMS resources to arrive. Consequently a decrease in the number of fire houses, medically equipped apparatus, and EMS trained personnel would likely lead to an increase in the time before critical medical interventions can be provided. However, decision-makers lack a sound basis for quantifying the overall impact of enhanced emergency medical resources and the number of EMS-trained personnel on the timely provision of life-saving procedures.

Studies on adequate deployment of resources are needed to enable fire departments, cities, counties, and fire districts to design an acceptable level of resource deployment based upon community risks and service provision commitment. These studies will assist with strategic planning and municipal and state budget processes. Additionally, as resource studies refine data collection methods and measures, both subsequent research and improvements to resource deployment models will have a sound scientific basis.

Problem

15 Literature Review
W
ithin the past four decades, the range and structure of services provided by firefighters have broadened and
changed dynamically as an ever-increasing amount of
department resources are used to respond to emergency medical calls. Expanded activities and increased expectations bring advantages, as well as challenges for both communities and fire departments in terms of providing optimal protection during emergency situations, while quantitatively assessing objective systems performance.

Studies documenting engine and ladder response times and crew performance in diverse live and simulated fire hazard
environments, show a relationship between apparatus staffing levels and a range of important performance variables and outcome measurements such as response time, time-to-task completion, fire growth status at the time of attack, and occupant toxicity levels (Averill et al, 2010). Recent analyses of EMS crew staffing configuration have suggested that both the number of personnel dispatched per unit and the level of emergency medical certification of that crew may influence similar standards of measurement in the realm of medical response by multi-role firefighters. (Brown et al, 1996)
The rapid evolution of emergency service delivery and the growth of fire-based EMS systems correspond with an increase in literature that has detailed both the need for careful outcomes evaluation and continued innovation in terms of establishing performance variables that accurately assess the effectiveness of prehospital care provided by emergency medical technicians (EMTs). Investigators from government, professional
organizations, and academia have described the progress made in the field of prehospital care and the challenges that EMT’s and multi-role firefighters face in an expanding body of literature (Moore, 2002).

Publications to date have continually reached towards
ascertaining the performance measures, operational protocols, and dispatch configurations that optimize outcomes across diverse communities. Many of the currently established EMS benchmarks and obstacles identified in recent literature hold particular importance for multi-role firefighters. Far-reaching studies of EMS response have demonstrated how response time, scene time, transport time, crew size, equipment, and the level of crew staffing and certification levels have influenced patient survival (Cummins et al, 1991). While studies have continued to demonstrate the impact of these factors with increasingly sophisticated methods, the need to improve understanding of EMS delivery persists. Existing standards of care need to be reevaluated so current systems can adjust and progress in response to ongoing research findings.

Historically, total response time has been measured from the time a responding unit leaves a fire station until the time the unit arrives at the incident. However, anecdotal evidence suggests that total response time should include the time to locate and access the patient (time to patient side). Previous studies have shown a substantial time difference between the time the first responder arrives on-scene and the time of patient access. One study noted that the patient access time interval represented 24 % of the total EMS response time interval among calls originating less than three floors above or three floors below ground and 32 % of those located three or more stories above ground. (Morrison et al, 2005) Early literature on out-of-hospital cardiac arrest (OHCA) sought to uncover the effects of patient characteristics and location of initial collapse on survival to hospital discharge, with researchers then beginning to quantify the importance of response time. A paper by researchers from the EMS Division of King County, Washington and University of Washington
Departments of Medicine and Biostatistics found significantly higher survival rates for patients who arrested outside the home, noting that of those 781 patients, most were more frequently younger, male, and more likely to be witnessed at the time of collapse and had received bystander cardiopulmonary
resuscitation (CPR). (Litwin et al, 1987)
A growing number of defibrillation effectiveness studies began to demonstrate that response time, EMT training and practice, and population density influenced the effectiveness of this type of EMS delivery. (Olson, 1989; Kellerman, 1992; Hallstrom, 2004; DeMaio, 2005) For an urban environment exceeding three
million, at least one study noted that over a period of one year, survival rates were lower in urban environments than those reported for smaller cities, but reaffirmed that the single factor most likely contributing to poor overall survival was a relatively long interval between collapse and defibrillation. In their conclusions, the authors recommended the use of standardized terms and methodology and stressed that “detailed analysis of each component of the emergency medical services systems will aid in making improvements to maximize survival of
out-of-hospital cardiac arrest. ” (Becker, 1991)
Researchers studying patient outcomes following traumatic brain injury (TBI) were employing the specific anatomic, physiologic, and age characteristics of patients to formulate methods that would evaluate the effectiveness of trauma care.

The “Trauma and Injury Severity Scores” (TRISS) method was one such system that generated scores for patients based upon systolic blood pressure, capillary refill, respiratory rate, and respiratory expansion. These scores provided a means of accurate analysis for EMS performance for cases of TBI, just as situational characteristics for OHCA, such as location of collapse, collapsing rhythm, and time to initial call were being used to gauge the effectiveness of emergency medical interventions for patients in distinct crisis scenarios. For instance, the correlation between age and predicted mortality for patients with comparable Trauma and Injury Severity Scores in an early study of the TRISS method suggested that a significantly narrower margin of effectiveness exists for seriously injured patients age 55 years or older. (Boyd, 1987)
Fire departments have long grappled with the most appropriate dispatch and notification configurations for EMS systems in different communities. Analyses have focused on comparisons of “one-tier” versus “two-tier” notification systems. “One-tier” systems require ALS units to respond to and transport all calls. In 2“Multi-role” is a term given to firefighters cross-trained in a number of related emergency services fields, such as EMS, hazardous materials response, and technical rescue.

16 a “two-tier” system, ALS units are allowed to delegate varying degrees of responsibility for response and transport to BLS units.

Two studies appearing in theAnnals of Emergency Medicinein the same year examined the response capacity and performance measures for a broad sample of urban EMS systems with regard to dispatching protocols and notification systems. (Sweeney, 1998; Chu, 1998) Reviewing previously published studies on 39 emergency medical services programs from 29 different locations from 1967 to 1988, researchers focusing specifically on cardiac arrest and resuscitation outcomes noted survival rates to be higher for two-tiered systems where both a paramedic and either an EMT or EMT-D were dispatched to calls, as compared to survival rates for one-tier systems where dispatches were exclusive for an EMT, EMT-D, or paramedic. This analysis also showed rates of survival to hospital discharge to be slightly higher for patients with a collapse rhythm of ventricular fibrillation, which suggested that the earlier CPR initiation possible in two-tier configurations was a primary means to the higher survival rates in these systems (Eisenberg et al., 1990).

In an article that plotted responses to an EMS system
configuration survey against Code 3 (“lights and sirens”) response times to emergency calls, investigators identified three different types of “two-tier” configurations. In the first two-tier system, ALS units responded to all calls but once on-scene could turn a patient over to a BLS unit for transport. In the second two-tier model, ALS units did not respond to all calls and BLS units could be sent for noncritical calls. In the final two-tier configuration, a non-transport ALS unit was dispatched with a transporting BLS unit with ALS personnel joining BLS personnel for transport on all ALS calls. After reviewing survey responses from EMS systems in 25 mid-sized cities with populations of 400,000 to 900,000, researchers suggested that a two-tier response system that permitted dispatch of BLS units for noncritical calls would allow a given number of ALS units to serve a much larger population while still maintaining rapid Code 3 response times (Braun et al, 1990).

The emergence of the “chain of survival” concept in the prehospital treatment of cardiac arrest merged the effectiveness of specific EMS interventions for individual patient characteristics and the level of qualification of staffing on emergency apparatus as standards of measurement within a system-wide scheme of performance evaluation. In a statement explaining the chain of survival and detailing its components, researchers argued that time to recognition of OHCA, EMS system activation, initiation of CPR, defibrillation, intubation, and intravenous administration of medications were successive, distinct factors that directly influenced outcomes of sudden cardiac arrest and should therefore be used inclusively as measurements of overall performance for EMS systems. The authors presented a thorough review of past literature and noted that while a small number of urban EMS systems approached the then-current practical limit for survivability from sudden cardiac arrest, most EMS systems in the U.S. and other countries had defects in their chain, as demonstrated by a near universal preponderance of poor
resuscitation rates. This paper was notable for describing the research supporting each “link” in the chain or performance measurement of EMS system effectiveness and recommending specific actions to improve each area, thereby strengthening the chain of survival. Moreover, researchers suggested that communities implementing two-tier, double response systems might show optimal improvements in survival rates, as reports on EMT-D systems showed small response times but restricted intervention methods while ALS-only systems recorded longer response times with more advanced treatment options (Cummins et al, 1991).

Time-to-task measurements that have more recently been
formulated into the “chain of survival” model for sudden cardiac arrest have been widely accepted as measurements of fire crews’ performance. The continuous patient care and vigilant
monitoring of vitals advocated in most EMS models are duties that multi-role firefighters are distinctly well-equipped to perform, especially in emergency situations requiring both fire suppression and emergency medical response. Critical thinking, strategic teamwork, and ongoing, immediate priority assessments during emergency situations are all skills taught and regularly instilled by training and routine evaluation for multi-role firefighters.

In light of the existing literature, there remain unanswered questions about the relationship between resource deployment levels, in terms of first responder crew size and EMS training levels, and the associated task performance during EMS incidents.

For the first time, this study investigates the effects of varying crew configurations for first responders, the apparatus assignment of ALS personnel, and the number of ALS personnel on scene on the task completion for ALS level incidents. This study is also unique because of the array of stakeholders and technical advisors involved. All industry standards and safety protocols were followed, and robust research methods were used. The results and conclusions will directly inform the NFPA 1710 T echnical Committee, who is responsible for developing industry standards associated with the deployment of fire suppression operations, emergency medical operations, and special operations to the public by career fire departments.

17 T
his project systematically studies deployment of fire
department-based EMS resources and the subsequent effect on the ability to provide an efficient and effective response.

It will enable fire departments and city/county managers to make sound decisions regarding optimal resource allocation to meet service commitments using the results of scientifically based research. Specifically, the EMS field experiments provide quantitative data on the effects on varying crew size
configurations, ALS personnel placement, and the number of ALS personnel available on ALS level incidents.

The first phase of the multiphase project was an extensive survey of more than 400 career and combination fire departments in the United States with the objective of optimizing a fire service leader’s capability to deploy resources to prevent or mitigate adverse events that occur in risk- and hazard-filled environments.

The results of this survey are not documented in this report, which is limited to the experimental phase of the project, but they will constitute significant input into future applications of the data presented in this document.

In order to address the primary research questions using realistic scenarios, the research was divided into three distinct, yet interconnected parts.
/square6Part 1- Time-to-task experiments related to gaining access to a patient and removing the patient from the incident scene. /square6Part 2- Time-to-task experiments related to the care of a victim with multi-system trauma.
/square6Part 3- Time-to-task experiments related to the care of a victim with chest pain and witnessed cardiac arrest.

These parts included the most basic elements of an overall EMS response and included time for personnel to access the patient, conduct patient assessment, deliver on-scene patient care, package the patient, and remove the patient from the scene to a transport-capable vehicle.

The EMS portion of the Firefighter Safety and Deployment of Resources Study was designed to assess the labor aspect of an EMS incident necessary to ensure safe, effective, and efficient operations. While studies have shown a relationship between response time and efficiency of patient care intervention, this project has no direct measures. This study does however quantify the effects of first responder crew size and ALS trained personnel resources on time-to-task for EMS interventions. The
applicability of the conclusions from this report to a large-scale hazardous or multiple-casualty event has not been assessed and should not be extrapolated from this report.

EMS protocols pertaining to the treatment and transport of patients vary by departments. For the purpose of this study, tasks were standardized by technical experts and individual times were recorded for each task. In real-world situations, as in this study, many of these can be performed simultaneously based on the number and training level of responding personnel. Attempts to generalize the results from these experiments to individual departments must take into account protocols and equipment that vary from those used in the experiments.

Purpose and Scope of the Study

18 C
onsidering the setting and the circumstances of emergency medical care delivery, the prehospital 9-1-1 emergency
care patient should be considered a distinct type of patient in the continuum of health care. These patients not only have medical needs, but they may also need simultaneous physical rescue, protection from the elements and the creation of a safe physical environment, as well as management of non-medical surrounding sociologic concerns (Pratt et al., 2007).

Interdependent and coordinated activities of all personnel are required to meet the priority objectives.

NFPA 1710:Standard on Fire Department Operations, Emergency Medical Operations, and Special Operations to the public by Career Fire Departmentsspecifies that the number of on-duty EMS providers must be sufficient relative to the level of EMS provided by the fire department, and be based on the minimum levels needed to provide patient care and member safety.
3 NFPA Standard 1710 also
recommends that personnel deployed to ALS emergency responses include a minimum of two members trained at the emergency medical technician-basic level and two members trained at the emergency medical technician-paramedic level, arriving at the scene within the established time frame of two hundred and forty seconds (four minutes) or less for BLS units and four hundred and eighty seconds (eight minutes) or less for ALS units provided that a first-responder with Automated External Defibrillator (AED) or BLS unit arrived in two hundred forty seconds (four minutes) or less travel time, or at the minimum levels established by the authority having jurisdiction.
4 During each EMS experiment, a first responder unit and an ambulance transport unit was dispatched to the scene. Crew size for the first responder unit and ALS configuration for both the first responder unit and ambulance transport unit were varied for purposes of the experiments. There were three specific scenarios to which personnel responded.
/square6Patient access and removal from incident site
/square6Systemic trauma/fall victim
/square6Chest pain/cardiac arrest
Important time intervals typically not measured by EMS systems are “time to patient access” and the “time to patient removal” intervals. These intervals include the time it takes personnel with equipment to locate and access the patient and the time it takes personnel to remove the patient and equipment from the incident scene to the ambulance for transport. These intervals are critically important to calculating overall scene time, particularly in scenarios where the patient is not immediately accessible (high-rise buildings, commercial complexes, schools, etc.).

The Star of Life
The elements comprising an EMS incident are symbolized by the Star of Life.5 The six branches of the star are symbols of the six main tasks executed by rescuers throughout an emergency medical event.

Figure 1: The Star of Life
The six branches of the star include the elements listed below. /square6Detection: Citizens must first recognize that an emergency exists and know how to contact the emergency response
system in their community. This can be done using several different methods such as dialing 9-1-1, dialing a seven digit local emergency number, using amateur radios, or call boxes. /square6Reporting: Upon accessing a call center, callers are asked for specific information so that the proper resources can be sent. In an ideal system, certified Emergency Medical Dispatchers (EMDs) ask a pre-defined set of questions. In this phase, dispatchers also become a link between the scene and the responding units and can provide additional information as it becomes available. /square6Response: This branch identifies the response of emergency crews to the scene. The response may include an engine with firefighters trained as EMT’s followed by an ambulance
carrying additional firefighter/EMT’s or it may be a fire engine first responder crew followed by an ambulance
carrying single role EMS personnel.
/square6On scene care: Definitive care is provided on the scene by the emergency response personnel. Standing orders and radio or cellular contact with an emergency physician has broadened the range of on scene care that can be provided by EMS
responders. A long algorithm of procedures and drugs may be used before the patient is removed from the scene.
/square6Care in Transit: Emergency personnel transport the patient to the closest appropriate medical care facility for definitive care.

During transport, patient care/treatment is continued.
/square6Transfer to Definitive care: Emergency crews transfer the patient to the appropriate specialized care facility. Transfer includes providing a detailed written report of the patient assessment and care provided on-scene and in-transit.

A Brief Overview of the EMS Response
3 NFPA 1710, Section 5.3.3.2.1: On duty EMS units shall be staffed with the minimum personnel necessary for emergency medical care relative to the level of EMS provided by the fire department.
4 NFPA 1710, Section 5.3.3.3.4: Personnel deployed to ALS emergency responses shall include a minimum of two members trained at the emergency medical technician-paramedic level and two members trained at the emergency medical technician-basic level arriving on scene within the established travel time. 5 Designed by Leo R. Schwartz, Chief of the EMS Branch, National Highway Traffic Safety Administration (NHTSA) in 1977.

19 EMS Response to Time Critical Events
In a statement explaining the chain of survival and detailing its components, researchers argued that time to recognition of OHCA, EMS system activation, initiation of CPR, defibrillation, intubation, and intravenous administration of medications were successive, distinct factors that directly influenced outcomes of sudden cardiac arrest and should therefore be used inclusively as measurements of overall performance for EMS systems. This paper was notable for describing the research supporting each “link” in the chain or performance measurement of EMS system effectiveness and recommending specific actions to improve each area, thereby strengthening the chain of survival (Cummins et al., 1991).

A typical EMS event, regardless of the nature of the incident, follows a basic script. The first arriving unit performs a scene size-up and initial life safety assessment. The crew then gathers the appropriate equipment from the unit based upon patient injury, illness and location, and accesses and treats the patient.

In an analysis of data from more than 300 U.S. Fire
Departments, first responder units arrived prior to ambulances in approximately 80 % of responses (IAFC/IAFF 2005). This
response capability is likely attributed to the strategic locations of fire stations housing the engines and the fact that engines are often more densely located than ambulance transport units. In some cases, as is the case with motor vehicles accidents with entrapment and some structural collapse incidents, initial responding personnel may need to perform patient treatment and stabilization while performing patient rescue. For these types of incidents, it is necessary to have additional personnel on scene to assist with patient care and removal from the incident scene.

However, even without these major impediments, additional crew members assist with patient care and movement. In the experiments, crew members were used to assist with patient treatment, packaging, removing the patient from the incident location to the ambulance transport unit, repositioning the ambulance transport unit, and other tasks that streamlined the on-scene activity.

The Relation of Time-to-Task
Completion and Risk
Delayed response, combined with inadequate personnel
resources exacerbates the likelihood of negative patient outcomes.

While rapid response is critical to patient survival, the personnel who respond must also be highly competent in patient assessment and stabilizing treatment delivery.

Figure 2 illustrates a hypothetical sequence of events for response to a cardiac arrest (heart attack). A rapid response to an EMS incident is effective only if the personnel arriving on the scene can initiate appropriate emergency medical interventions.

This requires adequate numbers of personnel, as well as appropriate equipment and prior training. Early advanced cardiac life support (ACLS) provided by paramedics at the scene is another critical link in the management of cardiac arrest.

According to industry standards EMS systems should have sufficient staffing to provide a minimum of two rescuers trained in ACLS to respond to the emergency. However, because of the difficulties in treating cardiac arrest in the field, additional responders should be present (AHA, 2005).

The delivery of prehospital care is complex requiring both interpersonal and clinical skills. Firefighter/Paramedics must be able to communicate with patients, bystanders, on scene safety personnel, and hospital personnel. A lack of cooperation in any of these interactions could have a detrimental effect on the patient.

Figure2:

Hypothetical
Timeline of a
Fire
Department
Response to
an EMS
Incident

20 Standards of Response Cover
Developing a standard of response cover (SORC) related to service commitments to the community is a complex task. A SORC includes the policies and procedures that determine the distribution, concentration, and reliability of fixed and mobile resources for response to emergency medical incidents (CFAI, 2009). Fire departments that provide EMS must evaluate existing (or proposed) resources against identified risk levels in the community and against the tasks necessary to provide safe, efficient and effective emergency medical services. EMS risks that must be considered include population demographics such as socioeconomic status, age, ethnicity and health insurance status, as well as population density, community type (urban, suburban, or rural), access to healthcare, and traffic patterns and congestion. In addition to community risks, leaders must also evaluate geographic distribution and depth or concentration of resources deployed based on time parameters established by community expectation, state or local statute or industry standards.

Recognition and reporting of an emergency medical incident begins a chain of events that occur before firefighters arrive at the scene. These events include call receipt and processing, dispatch of resources, donning protective gear, and travel to the scene. NFPA 1710 defines the overall time from dispatch to the scene arrival as total response time.

The standard divides total response time into a number of discrete segments, shown in Figure2.

Arrival of emergency crews on scene is then followed by a sequence of tasks. Depending on the availability of resources available, tasks may be completed simultaneously or sequentially. Knowing the time it takes to accomplish each task with an allotted number of personnel and equipment can be useful in planning resource deployment. Ideally crews should arrive and intervene in sufficient time to prevent patient brain death, excessive blood loss, and minimize pain and suffering with the goal and expectation of transporting and delivering a viable patient to an appropriate medical facility.

Decision-making regarding staffing levels and geographic distribution of resources must also consider times when there are simultaneous events requiring multiple resource deployment into multiple areas of the jurisdiction. There should be sufficient redundancy or overlap in the system to allow for simultaneous incidents and high volume of near-simultaneous responses without compromising the safety of the patient, the public, or firefighters.

Policy makers have long lacked studies that quantify changes in EMS scene performance based on crew sizes and configuration. These experiments were designed to observe the impact of first responder crew size and ALS configuration on the time it takes to execute essential EMS tasks. It is expected that the results of this study will be used to inform the threshold performance objectives to the NFPA 1710 and 1720 T echnical Committees.

Experiment Planning and Methodology
The EMS field experiments consisted of three distinct parts:
/square6Part 1- Time-to-task experiments related to gaining access to a patient and removing the patient from the incident scene. /square6Part 2- Time-to-task experiments related to the care of a victim with multi-system trauma.
/square6Part 3- Time-to-task experiments related to the care of a victim with chest pain and witnessed cardiac arrest.

Following is a detailed description of the overall methods used throughout the experiments. Specific information pertaining to each part is presented separately.

The following research questions guided the experimental design of the EMS field experiments documented in this report:
/square61. What is the effect of first responder crew size on EMS task times?
/square62. What is the effect of ALS personnel placement on EMS task times? /square63. What is the effect of the number of ALS trained personnel on EMS task times?
Department Participation
The experiments were conducted in Montgomery County, MD at the Montgomery County Public Safety T raining Academy and in Fairfax County, V A at the EMS Simulation Center. Experiments took place during the months of April and May 2009. All experiments took place in daylight between 0800 hours and 1500 hours.

Montgomery County (MD) and Fairfax County (V A) firefighters and paramedics participated in the field experiments. Each day, both departments committed one ALS engine, one ALS ambulance and the associated crews. Firefighters and paramedics were identified and oriented to the experiments. Participants varied with regard to age and experience. The allocation of resources made it possible to conduct back-to-back experiments by rotating firefighters between field work and rehabilitation areas.

Crew Orientation
Daily orientations were conducted. Orientations included a description of the overall study objectives, as well as the actual experiments in which they would be involved. Crews were also oriented to the site layouts and specific scenarios to be conducted.

Cue Cards
Task procedures were standardized for each experiment/scenario.

T echnical experts worked with the study investigators to break down crew tasks based on crew size. Task flow charts were then created and customized for the various crew sizes. The carefully designed task flow ensured that the same overall workload was maintained in each experiment, but was redistributed based on the number of personnel available for work.

All tasks were included in each scenario and cue cards were developed for each individual participant in each scenario. For example, a four-person first responder crew would have a cue card for each person on the crew including the driver, officer, and two firefighter/EMTs or paramedics. Cards were color coded by crew size to ensure proper use in each scenario.

T asks
Tasks were completed specific to each scenario (patient access and removal from incident scene, trauma, and cardiac). Meticulous procedures gathered data to measure key areas of focus such as individual start times, task completion times, and overall scenario performance times. Each task in each scenario was assigned a standardized start and end marker, such as retrieving the key from the Knox Box
6 or patient secured with straps to stretcher/cot. All
tasks, with the events for measuring start and stop times, are shown in Table 3 through Table5.
6 A Knox Box, known officially as the KNOX-BOX Rapid Entry System is a small, wall-mounted safe that holds building keys for firefighters and EMTs to retrieve in emergencies. Local fire companies can hold master keys to all such boxes in their response area, so that they can quickly enter a building without having to force entry or find individual keys held in deposit at the station.

21 On-Scene EMS T asks
The on-scene tasks focused on the activities firefighters perform after they arrive on the scene of an emergency medical incident.

A number of nationally recognized EMS experts were consulted during the development of the on scene EMS tasks in order to ensure a broad applicability and appropriateness of task distribution.
7 The experiments compared crew performance and
workload for typical medical response scenarios using two-, three-, and four-person first responder crews, along with a two-person ambulance crew. In total, 102 experiments were conducted to assess the time it took various crew configurations to complete the overall tasks in Parts 1, 2, and 3. In addition to first responder crew sizes, the experiments assessed the time necessary to access the patient, conduct a patient assessment, deliver on scene patient care, package the patient, and remove the patient from the incident scene to the ambulance. Two scenarios were selected as the basis of Parts 2 and 3. The scenarios included a patient with systemic trauma and a patient with chest pains leading to cardiac arrest.

The experiments also assessed the placement and number of responding ALS-trained personnel. There were 15 crew
configurations considered during the experiments. These included the first responder crew being varied from two-, three-, and four-person crews. Additionally, the first responder crew configuration was varied to include either an all BLS crew or a combination crew containing one firefighter trained at the ALS level. The ambulance crew was held constant at two-persons.

However, the ambulance crew configuration was varied to include two BLS crew members, one BLS and one ALS crew member, or two ALS crew members. Table 1 shows the crew configurations used throughout the experiments.

During the experiment crews dispatched to various scenarios included a first responder crew and ambulance transport unit or a single ambulance transport unit. For those experiments where both an engine company and an ambulance were dispatched, a three-minute stagger time was imposed for each of those trials.

The three minute stagger time was determined from an analysis of deployment data from more than 300 fire departments
responding to a survey of fire department operations conducted by the IAFC and the IAFF (2005). Each experiment containing a specific crew configuration was conducted in triplicate and completed in a randomized order (determined by randomization software) before a test configuration was repeated.

Radio Communication
Interoperability of radio equipment used by both participating departments made it possible to use regular duty radios for communication during the experiments. Company officers were instructed to use radios as they would in an actual incident.

Montgomery County Fire and Rescue Communications recorded all radio interaction as a means of data backup. Once all data quality control measures were complete, the records were then overwritten as a routine procedure.

T ask Timers
T en observers/timers, trained in the use of identical standard stop watches with split-time feature, recorded time-to-task data for each field experiment. T o assure understanding on the observed tasks, firefighters were used as timers, each assigned to specific tasks to observe and record the start and end times.

T o enhance accuracy and consistency during recording times, the data recording sheets used several different colors for the tasks (see Appendix A). Each timer was assigned tasks that were coded in the same color as the recording sheet. All timers wore high-visibility safety gear on the incident scene.

Video records
In addition to the timers, video documentation provided a backup for timed tasks and for quality control. Cameras were used to record EMS scene activity from varied vantage points.

Observer/timer data were compared to video records as part of the quality control process.

Crew Assignment
Crews from each department that regularly operated together were assigned to work as either a first responder crew or ambulance transport crew in each scenario. Both Fairfax County and Montgomery County crews participated in the experiment.

Crews assigned to each responding company position in one scenario were assigned to another responding company position in subsequent scenarios, with the objective of minimizing learning from one experiment to another. For example, crews in the role of first responder in the morning scenario might be assigned to the ambulance transport crew in the afternoon, thus eliminating learning the exact repetition of a task as a factor in time to completion. Additionally, participating crews from both Montgomery County and Fairfax County were from three
different shifts, further reducing opportunities for participant repetition in any one position.

Props
Crews were assigned specific equipment lists to bring for this scenario. All equipment used was actual working equipment from the units assigned to the scenario. Specific items included in all scenarios were an airway bag, medical bag, oxygen cylinder, ECG monitor defibrillator, cot, and clipboard. Items specific to a particular scenario will be listed in that section of the report, including manikins and a live individual acting as a patient. 7 T echnical experts included Greg Mears, Michael McAdams, and Philip Pommerening. More information about the experts is presented in the Acknowledgements later in this report.

First Responder
Engine Company
Ambulance
Transport Unit
ALS Personnel
On-Scene
T otal Personnel
On-Scene
N/A 2 BLS 02
N/A 2 ALS 22
N/A 1 BLS/1 ALS 12
2 BLS 2 ALS 24
3 BLS 2 ALS 25
4 BLS 2 ALS 26
1 BLS/1 ALS 1 BLS/1 ALS 24
2 BLS/1 ALS 1 BLS/1 ALS 25
3 BLS/1 ALS 1 BLS/1 ALS 26
2 BLS 1 BLS/1 ALS 14
3 BLS 1 BLS/1 ALS 15
4 BLS 1 BLS/1 ALS 16
1 BLS/1 ALS 2 BLS 14
2 BLS/1 ALS 2 BLS 15
3 BLS/1 ALS 2 BLS 16
Table 1: Crew Configurations for Time-to-Task ExperimentsPage 1034 of 1153 22 Safety Protocols
Participant safety was a primary concern in conducting the experiments. All participants and experiments complied with guidelines and recommendations as outlined in NFPA 450:Guide for Emergency Medical Services and Systems, NFPA 1500:Standard on Fire Department Occupational Safety and Health Program, and NFPA 1999:Standard on Protective Clothing for Emergency Medical Operations.

A safety officer from the Montgomery County Fire and Rescue Department was assigned to oversee all experiments.

The safety officer ensured all protocols concerning participant safety, under both real and experimental conditions were followed. This included wearing the correct personal protective equipment, vehicle maneuvering, and overall scene safety. The safety officer participated in all orientation activities and daily briefings. The safety officer had full authority to terminate any operation if any safety violation was observed. Radio
communication was always available.

A closely related concern to firefighter safety and readiness to repeat experiments with equivalent performance was adequate rehabilitation. Each “team” of participants had ample time between experiments to rest and rehydrate.

Response Time Assumptions
Response time assumptions were made based on time objectives set forth in NFPA 1710. Time stagger allocations were set by project technical advisors in order to assess the impact of arriving unit time separation on task start and completion times, as well as overall scene time. Table 2 shows the values assigned to the various segments in overall response time.

Figure 3: Safety Officer
Event Occurrence = time zero
60 seconds for recognition and call to 9-1-1
90 seconds for call processing and dispatch
60 seconds for responder turnout
Travel time = first responder engine = 420 seconds post event Ambulance = 600 seconds post event
Table 2: Response Time Assumptions
Figure 4: Ascending Stairs to Access Patient
Figure 5: Carrying Patient Using Stair Chair
Figure 6: Trauma Patient Assessment
Figure 7: Trauma Patient Spinal Immobilization

23 Figure 8: Trauma Patient Packaging
Figure 9: Loading Patient on to Stretcher for Transport Figure 10: Cardiac Patient Assessment
Figure 11: Cardiac Patient Intubation
Figure 12: Cardiac Patient I.V. & Medication Admin.

Figure 13: Moving Patient for Transport

24 H
istorically, total response time has been measured from the time a responding unit leaves a fire station until the time the unit arrives at the incident location. However, some studies suggest that total response time should include the additional time to locate and access the patient. Previous studies have shown a substantial time difference between the time the first responder arrives on scene and the time of patient access.

One study noted that the patient access time interval represented 24 % of the total EMS response time interval among calls originating less than three floors above or three floors below ground and 32 % of those located three or more stories above ground (Morrison et al., 2005).

This study quantifies the time interval from arrival at the incident address until the crew begins the patient assessment, known as “at patient arrival time. ” The experiment assumed the patient was on the 3
rd floor of a garden style apartment complex with stair access.

This is representative of a typical structure to which firefighters respond in many residential neighborhoods. Patient assessment and treatment were not performed during the patient access and removal experiment. The primary purpose of this part of the experiment was to ascertain patient access and removal times. This part of the experiment was conducted separately from the patient care scenarios in an effort to establish distinctive timelines for patient access and removal separate from the patient care scenarios where on scene time can vary widely based on patient illness or injury.

Incident Scene
Garden Apartment Complex Scenario:

Firefighters from Fairfax County (V A) and Montgomery County (MD) simulated an initial EMS response for a patient with difficulty breathing in a garden style apartment building, represented by Simulation Lab #1 on the grounds of the
Montgomery County Safety Training Academy in Rockville, MD.

Simulation Lab #1 is a seven-story building, consisting of concrete scissor stairwells leading to the top floor of the building. The front of the building was equipped with a Knox Box, which firefighters accessed before entering the building. This task was typical of security access at any apartment complex.

Apparatus and crews were staged approximately 500 ft (150 m) from the Montgomery County Simulation Lab #1. Apparatus responded to the incident location, personnel dismounted and assembled equipment. Equipment included a defibrillator, airway bag, oxygen, and drug bag. Additionally, ambulance crews were required to bring the stair chair for patient packaging and removal. A crew member obtained an access key from the Knox Box and gained entry. Once crews entered the building they proceeded with the equipment to locate the patient on the third floor stairwell landing.

Patient assessment and treatment were not performed in this part of the experiments. In each experiment, the patient was packaged onto a stair chair, and then the patient and equipment were carried down three flights of stairs and out of the building.

The patient was then transferred to a stretcher and loaded into the ambulance for transport.

T asks
Tasks for the garden apartment scenario for patient access and removal are delineated in Table 3.

Part 1:Patient Access and Removal from Incident Scene
Table 3: Time-to-Task Measures for Garden Apartment
Scenario/Patient Access and Removal

Part 2:Trauma Patient
T
he trauma scenario involved time-to-task experiments focusing on a labor intensive traumatic scenario. In the experiment, a patient had fallen from a 25 ft (7.5 m) ladder at a construction site. This part of the experiment quantified the time intervals for different crew sizes and configurations responding to this event.

Incident Scene
The gymnasium at the Montgomery County (MD) Public Safety T raining Academy was used for the trauma experiments. A classroom at the facility was also used for crew orientation and staging. Prior to the start of the experiments, participants were provided with the scenario background. Specifically, the call originated from a construction site that was only accessible by foot.

When cued, crews entered the gym and walked approximately 40 ft (12 m), carrying an airway bag (including suction), oxygen, spinal mobilization equipment, a trauma bag, and a radio and clip board.

The “patient” was a 150 lb (68 kg) training manikin “voiced” when prompted by one of the timers. The patient could answer basic questions until the point in the sequence where the patient lost consciousness. During the scenario, when it became clear that the patient needed to be transported, a backboard was brought into the scene by the ambulance crew. After packaging the patient onto a backboard, the patient and equipment were carried out of the construction site to a waiting stretcher approximately 40 ft (12 m) away.

T asks
The on-scene tasks focused on the activities firefighters regularly perform after they arrive on the scene of a patient with a traumatic injury. The experiments compared time-to-task performance based on varying crew sizes and ALS configurations.

Forty-five trauma experiments were conducted to assess the time it took various crew sizes and ALS configurations to complete the assigned tasks. Time between arrival of the first responding unit and ambulance transport unit was held constant at three minutes.

The following narrative describes the general sequence of activities in Part 2 of the experiments.

The first responding unit arrived, conducted a size-up and initial life safety assessment of the area, and gathered the appropriate equipment. The crew, with equipment, then proceeded into the construction site and located the patient. The patient was lying supine on the ground. The responders introduced themselves, obtained patient consent to examine and treat, and immediately initiated cervical spinal immobilization precautions and the patient interview. Other crew members then followed Airway, Breathing, and Circulation (A, B, C’s) protocols. During the patient assessment, it was revealed the patient had a head laceration and an angulated fracture of the tibia/fibula (closed) on the right leg. Patient information was recorded on a standardized form created for the experiments and can be seen in Appendix B.

During the scenario, when the backboard straps were secure, the patient went into respiratory arrest. Crews then rechecked vital signs which revealed the patient had stopped breathing. The crew immediately began respiratory arrest protocol including administering a patent patient airway using an endotracheal tube.

Intubation was performed using strict spinal immobilization restriction. With the airway established, the patient was then ventilated using a bag-valve-mask and patient packaging was completed. Crews then carried the patient and all equipment out of the construction site to the waiting stretcher.

Table 4: Time-to-Task Measures for Trauma Scenerio
Movement causes labored breathing = Agonal Respiration
>> Patient Vomits >> Patient Unconscious
25Page 1038 of 1153
26 Fourteen tasks were completed in the trauma experiments.

Meticulous procedures gathered data to measure key areas of focus, such as individual task start times, task completion times, and overall scenario performance times. Each task was assigned a standardized start and end marker, such as accessing oxygen equipment (start) until the mask was on the patient and oxygen was flowing (stop). The 14 tasks can be seen in Table4.

27 Part 3:Cardiac Patient
T
he cardiac scenario involved time-to-task experiments
focusing on a labor-intensive medical event, i.e., a patient that experiences a myocardial infarction leading to cardiac arrest. This part of the experiment quantified the time intervals for different crew sizes and ALS configurations responding to the event.

Incident Scene
The cardiac experiments were conducted in a laboratory at the Fairfax County Fire and Rescue Department EMS Simulation Center. The Simulation Center houses classrooms, laboratories, and offices for training of EMT’s and paramedics. Assorted furniture was staged in the laboratory to duplicate a “home” setting. When cued, crews entered the room and proceeded approximately 10 ft (3 m) to the patient. The patient was represented by SimMan® by Laerdal. SimMan® is an adult-sized manikin that can produce vital signs including, a pulse, heartbeat, lung sounds, blood pressure and other signs noted in real humans. SimMan® also had vocal capabilities such as speaking or crying (Laerdal, 2010). SimMan® was operated remotely from a control booth adjacent to the laboratory.

Prior to the start of the experiments, participants were provided with the scenario background. Specifically, the call originated from a private residence and the caller complained of chest pain.

Responders entered the room carrying an airway bag, oxygen, drug bag, and defibrillator. The defibrillator was either an AED and/or a 12-Lead ECG model defibrillator dependent upon the arrival of ALS trained personnel. During the scenario, the patient went into cardiac arrest on cue and crews reacted by changing their path of patient care for chest pain to a more time-critical path of treatment for a pulseless, apneic patient. When crews had completed on-scene patient care tasks, the patient was packaged onto a backboard and stretcher. The patient and all equipment were removed from the room to conclude the experiment.

T asks
As noted previously, the on-scene tasks focused on the activities firefighters perform after they arrive on the scene of a patient with a cardiac emergency. The experiments compared crew
performance for a typical cardiac scenario using a combination of varying crew sizes and configurations.

Forty-five cardiac experiments were conducted to assess the time it took various crew sizes and configurations to complete the assigned tasks. Time between arrival of the first responding unit and ambulance transport unit was held constant at three minutes.

The following narrative describes the general sequence of activities in Part 3 of the experiments.

The first responding unit arrived, conducted a size-up and initial life safety assessment of the building and gathered the appropriate equipment. The crew, with equipment, then
proceeded to the front door of the patient residence, knocked, and entered. After confirming the scene was safe, patient assessment was begun.

The responders introduced themselves, obtained the
patient’s consent to examine and treat and then proceeded to conduct the patient interview. The patient interview was standardized to include SAMPLE and OPQRST protocols.

Patient information was recorded on a standardized form created for the experiments and can be seen in Appendix C.

During the scenario, on cue, the patient went into cardiac arrest. Upon patient arrest, the crew rechecked the patient’s vital signs which revealed the patient had stopped breathing and had no pulse.

The crew then followed protocol and moved the patient to the floor where they could immediately begin CPR and
prepare to administer defibrillation. Study protocol then followed Advanced Cardiac Life Support guidelines for
patient care (AHA, 2005).

Twenty-two tasks were completed in the cardiac experiments.

Meticulous procedures gathered data to measure key areas of focus, such as individual task start times, task completion times, and overall scenario performance times. Each task was assigned a standardized start and end marker, such as accessing oxygen tank equipment (start) until the mask was on patient and oxygen was flowing (stop). The 22 tasks can be seen in Table5.

28 Table 5: Time-to-Task
Measures for Cardiac
Scenerio
PATIENT ARREST START - Timer cued when task complete
STOP - Witnessed arrest

29 T
his section describes the analytic approaches used to
address the research objectives of the study. The statistical methods used to analyze the EMS time-to-task
observations are presented. Then the time-to-task results are reported for EMS responses in three scenarios:
/square6access and removal of patient;
/square6a trauma event; and
/square6a cardiac event.

Time-to-T ask Analysis
Time-to-task data were compiled into a database and assessed for outliers and missing entries. As is common in a repeated experiment with many pieces of data to be entered, occasionally data elements were not collected. Missing data occurred in less than 1 % of timing observations. Such instances were reviewed via video and/or radio tapes. Missing data attributable to timer error were replaced by the time observed in the video. Where video and/or radio documentation proved inadequate, missing data were imputed with the mean of the observed corresponding task times from the other two experiments. The extremely low occurrence of missing data and associated imputation should have a negligible impact on the statistical findings in the analyses.

Data Queries
The statistical methods used to analyze the time-to-task data were driven by the principal goals of this research project —- to assess the effect of crew size, ALS placement on the responding crews, and the number of ALS trained personnel in the crew configuration on time-to-task for critical steps in each EMS scenario. The research goal motivated the development of four specific research questions (see Figure 14) that in turn pointed to specific statistical analyses to generate inference and insight.

Statistical Methods
The analysis of the time-to-task data involved a sequence of ordinary least squares regression models. The models relate the experimental outcomes(i.e., various measures of time — start time, completion time, or duration of the task) tokey dimensions for each scenario as follows:

For Access and Removal:
/square6first responder crew size (regardless of ALS placement), and /square6ambulance-only versus ambulance with first responder engine with varying crew sizes.

For Trauma and Cardiac scenarios:
/square6presence of an engine at the scene,
/square6crew size on the first responder engine, and
/square6placement and number of ALS personnel (on the engine, on the ambulance, or both).

T o account for these dimensions in the analyses, indicator variables representing each key dimension were employed. For example, for the trauma and cardiac scenarios there were indicators for the number of first responders on the engine, three indicators of the assignment of ALS personnel to the ambulance or engine, and indicators for the “no engine” scenarios.

Using these indicators, sets of regression equations were developed for the analysis of each scenario. Indicators corresponding to the three scenarios and multiple dimensions listed above were included. For example, when an engine was sent, the number of first responders (two, three, or four) assigned to the engine were varied, as well as the placement of ALS personnel (one ALS on the engine only; one on the ambulance only; two on the ambulance; and one ALS each on the ambulance and engine). When no engine was sent, zero, one, or two ALS personnel were placed on the ambulance.

The regression equations took the form:

Where the xx
kk represented the test conditions such as presence of
an engine or placement of ALS personnel, and the dependent variable yy rep resents the observed outcome (e.g., task duration).

The model coefficients from the completed regressions provided direct estimates of the change in time associated with the number of first responders (e.g., four versus two, three versus two), as well as the change in time associated with alternative assignments of ALS personnel. These estimates are generally the same as those obtained by comparing the difference in means across groups.

However, for a small number of outcomes, the estimates differ from those obtained using difference in means by appropriately accounting for data that are missing in particular scenarios.

Table 6 to Table 8 present the list of time-related outcomes that were used to explore effects on outcomes for patient
access/removal, as well as for cardiac and trauma scenarios, respectively. Not all tasks were subjected to testing for this report.

Only substantively critical milestones in the task sequence were considered. For instance, the assembly of equipmentand conduct Analysis of Experimental Results
For Response Access & Removal:

1. What are the effects of first responder crew size regardless of ALS placement with respect to:
a. reaching a patient?
b. removing a patient after packaging?
For Cardiac and Trauma Scenarios (task timings measured between arrival at patientto the completion of patient
packaging):

1. What is the effect of crew size on EMS task times?

2. What is the effect of ALS personnel placement on EMS task times?

3. What is the effect of the number of ALS trained personnel on EMS task times?

TIME-TO-TASK RESEARCH QUESTIONS
Figure 14: Research Questions for Time-to-Task Experiments

30 of size-up were not assessed for the Access and Removal scenario.

Instead, the elapsed time from arrival on scene to reaching the patient (as denoted by completing the ascent of stairs) was determined to be of primary importance. Similarly, the elapsed time between packaging patient and the completion of loading the ambulance was assessed rather than individual timings of any task in the sequence between these two major milestones. Similar judicious choices of critical milestones were made in the assessments of trauma and cardiac, and these are depicted in the outcome measures tables.

Although several of the analytic questions of interest can be obtained directly from the model, others require a linear combination of the coefficients. The statistical software (Stata) calculates both the desired combination of coefficients and the measure of statistical significance via t-test.

Table 6:

Outcome
Measures for
Access and
Removal
Scenario by Task

31 Table 8:

Outcome
Measures for
Cardiac Scenario
by Task
Table 7:

Outcome
Measures for
Trauma Scenario
by Task

32 The objective of the experiments was to determine the relative effects of first responder crew size, ALS provider placement and the number of ALS providers on the effectiveness of the EMS crews relative to key milestones among the task intervention times for each of the three scenarios. The experimental results are discussed below.

Of the various EMS tasks measured during the experiments, those described in the remainder of this section were determined to have significant differences based on the crew configurations studied. Their differential outcomes based on variation of first responder crew size, ALS crew configuration, and the number of ALS level providers on scene, are statistically significant at the 95 % confidence level or better. Times reported in seconds are rounded to the nearest five seconds. As a final technical note, we did not adjust significance levels to take into account the large number of tests being conducted. The observed number of significant results far exceeds what would be expected simply by chance.

Measurement Uncertainty
The measurement of tasks using stopwatch timing has unique components of uncertainly that must be evaluated in order to determine the fidelity of the data. All timers were equipped with the same model of digital stopwatch with a resolution of 0.01s and an uncertainty of +
3s per 24 hr. The uncertainty of the timing
mechanism in the stopwatches is small enough over the duration of an experiment that it can be neglected.

There are three components of uncertainty when using people to time the EMS tasks. First, timers may have a bias depending on whether they record the time in anticipation of, or in reaction to an event. Second, multiple timers were used to record all tasks.

Third, the mode of the stimulus to which the timer is
reacting—audible or visual.

Milestone events in the EMS experiments were recorded both audibly and visually. A test series described in the NIST Recommended Practice Guide for Stopwatch and Timer Calibrations noted that reaction times for the two modes of stimulus to be approximately the same, so this component can be neglected.

Based on the assumptions made in the Residential Fireground Experiments (Averill et al., 2010), bias estimated for timer reaction time was determined to be 230 ms as a worst case scenario.

Considering the above, the total estimated combined standard uncertainty is +

3.23 s. The magnitude of uncertainty associated
with these measurements has no impact on the statistical inferences presented in this report.

How to Interpret the Time-to-T ask Graphs
Figure 15 presents a sample of a time-to-task results graph.

Each crew size/configuration has a bar graphic showing the start time and completion time for the task. Visually, bars start from the left and extend horizontally across the graph based on time expended by various EMS crew configurations. The length of the bar graphic is a visualization of the duration of the task. Longer bars indicate longer duration times. Actual time data are also shown on each bar.

Figure 15: Sample Time-to-Task Graph

33 Time-to-Task Graphs
Part 1- Patient Access and Removal
Overall Scene Time (Time to complete all
EMS tasks for Patient Access and Removal)
AA cccceessss
Th e crews can differ in the time required to reach the patient (access) and in the time needed for patient removal. T o address these tasks, sets of simulations were conducted by varying crew size on the first responding engine. Ambulance crews were held constant at two persons. As noted previously, the arrival times were staggered between the engine and the ambulance. When an ambulance was sent without a first responder engine, for measurement consistency, it was assumed to arrive at the scene at the same timeas would an engine (i.e., there is no systematic, built-in delay).

The results for patient accessshow that two-person first responder crews take longer to reach a patient than configurations with larger crew sizes. Two-person crews finished the patient access tasks approximately half a minutelater than larger first responder crews. Moreover, the ambulance crew alone finished with a time between that of the two-person and the larger first responder crews. The ambulance aloneresult is likely attributed to the removal of the staggered arrival time when first responder crews were not sent. (See Appendix E for the timings by staffing configuration, difference of means and associated t-tests.) PPaattiieenntt RR eemm oovvaall
The
patient removal results show substantial differences
associated with crew size. Crews with two-person first responder crews completed patient removal between (1.2 – 1.5) minutes slower than larger crews, depending on crew size. This is largely the result of work load in carrying equipment, supplies and the patient with fewer crew members. All crews with first
responders completed removal substantially faster (by 2.6 min. -

4.1 min.) relative to the ambulance-only crew. Again, this is largely the result of the difficulty of carrying and loading the patient, as well as the equipment and supplies with only a two-person crew, given that one person must remain with the patient at all times. (See Appendix E)Figure 16: Patient Removal Time

34 Part 2- Multi-System Trauma
Overall Scene Time (Time to complete all
EMS tasks for Trauma Patient)
As previously noted, for the trauma scenario part of the experiments, there was an assumed three minute stagger in arrival between the first responder crew and the ambulance crew.

Crews responding with one ALS provider on the engine and on the ambulance completed all trauma tasks 2.3 minutes (2 minutes and 16 seconds) faster than crews with a BLS engine and an ALS ambulance with two ALS level providers.

Crews responding with four-person first responder crews, regardless of ALS configuration, completed all trauma tasks 1.7 minutes (1 minute and 50 seconds) faster than first responder crews with three persons, and 3.4 minutes (3 minutes and 25 seconds) faster than first responder crews with two persons. This suggests that for trauma scenarios, the more hands available, the easier it is to implement the full portfolio of tasks to be completed.

The statistical tests that correspond to these findings appear in Appendix F. Appendix H shows the original regression coefficient estimates upon which the tests in Appendix F were constructed.

Figure 17: Overall Trauma Scene Time

35 Individual Task Times
OO xxyyggeenn AA ddmm iinniissttrraattiioonn
Fir st responders with four-person crews were able to begin oxygen administration to the patient nearly a full minute (55 seconds) sooner than the three-person crew.

VV iittaall SSiiggnn AA sssseessssmm eenntt
Fir st responders with four-person crews were able to begin checking the patient’s vital signs nearly one minute (55 seconds) sooner than a two-person crew. They also completed the check about 80 seconds faster than the two-person crew. First responders with four-person crews were able to begin checking the patient’s vital signs 30 seconds sooner than a three-person crew. T o the extent that checking vitals is a critical task in a trauma response sequence, the reduction of half a minute to a minute of time could be seen as an important improvement.

Figure 18: Oxygen Administration Start Time
Figure 19: Vital Sign Assessment Start and Duration

36 WW oouunndd BB aannddaaggiinngg
Fir st responders with three-person crews were able to begin bandaging the patient’s wounds a minute and 40 seconds sooner than first responders with two-person crews. The value of a four-person crew witnessed in the earlier tasks (e.g., checking vitals) did not manifest for this task.

SSpplliinntt LLeegg
Fir
st responders with four-person crews were able to begin splinting the patient’s leg approximately a minute faster than either the two- or three-person crews. A small advantage of a four-person crew re-emerges at this next step (i.e., following bandaging) in the response task sequence.

Crew configurations with one ALS provider on the first
responding engine and one on the ambulance were able to begin splinting the patient’s leg 40 seconds sooner than crews with two ALS providers on the ambulance.

Figure 20: Wound Bandaging Start Time
Figure 21: Splint Leg Start Time

37 Figure 22: Spinal Immobilization Time Airway – Endotracheal Intubation Figure 23: Airway – Intubation Start Time
SSppiinnaall IImm mm oobbiilliizzaattiioonn// BB aacckk bbooaarrdd Fir st responders with four-person crews were able to conduct spinal immobilization/back-boarding of the patient two minutes faster than either two- or three-person crews. No differences were observed based on placement or number of the ALS personnel.

AA iirrww aayy —— EEnnddoottrraacchheeaall IInnttuubbaattiioonn Firs
t responders with four-person crews were able to begin securing the patient’s airway using endotracheal intubation two and one-half minutes (2 minutes and 35 seconds) sooner than the two-person crews and two minutes sooner than the three-person crews.

Crew configurations with one ALS provider on the first
responding engine and one on the ambulance were able to begin securing the airway using endotracheal intubation one minute and 25 seconds sooner than crews with two ALS providers on the ambulance.

Additional personnel marginally speed up the intubation procedure. A second ALS person and having more than two persons on the engine each reduce the time of the intubation by half a minute.

38 Figure 24: Bag Valve Mask Start Time
Figure 25: Patient Packaging Start and End Times
BB aagg VV aallvvee MM aasskk
Fir st responders with four-person crews were able to begin bag valve mask ventilation after intubation two minutes and 35 seconds sooner than the two–person crews and nearly two minutes (110 seconds) sooner than the three-person crews.

Crew configurations with one ALS provider on the first
responding engine and one on the ambulance were able to begin bag valve mask ventilation after intubation one and one-half minutes (one minute and 29 seconds) sooner than crews with two ALS providers on the ambulance.

PPaattiieenntt PPaacckkaaggiinngg
Addit
ional first responders reduce the times until the start and completion of packaging. First responders with four-person crews were able to begin patient packaging 3.1 minutes (three minutes and 5 seconds) sooner and complete all packaging activities moving toward transport nearly 3.4 minutes (three minutes and 25 seconds) sooner than the two-person crews. In addition, the four-person crews were able to begin patient packaging 1.6 minutes (one minute 35 seconds) sooner and complete all packaging activities moving toward transport 1.7 minutes (one minute 40 seconds) sooner than the three–person crews.

Crew configurations with one ALS provider on the first
responding engine and one on the ambulance were able to begin patient packaging 2.1 minutes (two minutes and 5 seconds) sooner and complete all packaging activities moving toward transport 2.3 minutes (two minutes and 15 seconds) sooner than crews with both ALS personnel arriving on the ambulance. No differences were associated with placement of a single ALS

39 Table 9: Trauma Scenario Coefficient Direction and Significant Differences provider or with the availability of a second ALS provider.

Patterns in the Trauma Scenario
The preceding presentation focuses on the specific tasks that comprise the overall trauma response sequence. Examination of the collection of findings across tasks, reveals patterns that provide insight into how crew configurations affect trauma response. T o examine this, the occurrences of significant differences of elapsed time to start by task were tabulated. Table 9 presents the task sequence and statistically significant differences when comparing ALS placement (Columns A and B) and
contrasting crew sizes (Columns C – E) for the outcome “elapsed time to the start of a task. ” Column A shows a clear advantage to placing one ALS on the engine (with one on an ambulance that arrives three minutes later) versus two ALS on a later arriving ambulance. The time advantage manifests in the last third of the task sequence, beginning with splinting the leg. One explanation for this would be that that having an ALS on the engine creates small increments of time that cumulate and finally manifest (at a statistically significant level) beginning with splinting the leg and carrying forward to all subsequent tasks. Another factor may be that certain tasks may be performed concurrently rather than sequentially when enough hands are available at the scene and this leads to overall time reductions relative to smaller crews that are forced to complete some set of tasks sequentially.

No clear pattern emerges for starting time significant differences when contrasting the addition of a second ALS person (Column B). The same appears to be true for comparing the crew sizes of three versus two (see Column C).

On the other hand, distinct patterns are seen in Columns D and E of Table 9 which depict the comparison of four versus two and four versus three crew sizes, respectively. Although there is some evidence of real time savings (as far as elapsed time to start a task) for the middle third of tasks in the sequence (for example between O
2 administration and splint leg), a consistent pattern favoring a crew size of four is seen beginning with airway intubation and continuing through patient packaging.

Taken as a whole, Table 9 suggests that while a crew size of four may not consistently produce time savings in the start of tasks initially in the trauma task sequence, there are clear advantages as work progresses, beginning with airway intubation through patient packaging. The same can be seen (beginning earlier with leg splinting) when comparing the start times for one ALS on the engine and one on the ambulance versus two ALS on the
ambulance. No such pattern emerges for the single ALS provider regardless of placement on the engine versus the ambulance.

40 Figure 27: Total Cardiac Completion Time
Part 3- Chest Pain and Witnessed
Cardiac Arrest
Overall Scene Time
Crews responding with four first responders, regardless of ALS configuration, completed all cardiac tasks from the “at patient time” 70 seconds faster than first responder crews with three persons, and two minutes and 40 seconds faster than first responder crews with two persons.

Additionally, crews responding with one ALS provider on both the engine and ambulance completed all scene tasks from the “at patient time” 45 seconds sooner than crews with two ALS providers on the ambulance and a BLS engine.

Crews responding with an ALS Engine and a BLS Ambulance completed tasks from “at patient time” two minutes 36 second sooner than crews with a BLS Engine and one ALS provider on the Ambulance.

These results echo the trauma findings.

Due to the nature of the cardiac scenario, where crews began the experiment with a chest pain patient who then went into cardiac arrest (no pulse and no respirations), it was necessary to assess some tasks relative to the time the patient arrested. The arrest was cued from the end time for the 12-Lead ECG task.

Crews responding with four first responders, regardless of ALS configuration, completed cardiac tasks following the patient going into cardiac arrest 85 seconds faster than first responder crews with two persons.

Crews responding with a BLS engine and an ambulance with two ALS level providers completed all cardiac tasks following the patient arrest 50 seconds sooner than crews with an ALS provider on both the engine and ambulance. This counter-intuitive difference in the results may be attributable to the delay of the patient arrest time based on the arrival of the 12-Lead ECG monitor with the two-person ALS Ambulance crew. The 12-Lead ECG task end timewas the arrest start time. In this scenario, there were instantaneously two ALS providers present at the arrest rather than the one ALS provider placing the 12-Lead ECG device in the ALS engine /ALS Ambulance crew.

The statistical tests that correspond to these findings appear in Appendix G. Appendix H shows the original regression coefficient estimates upon which the tests in Appendix G were constructed.

41 Figure 28: 12-Lead ECG Start Time
Figure 29: IV Access Start Time
Individual Task Times
1122--LLeeaadd EECC GG MM oonniittoorr
Cr ew configurations with one ALS provider on the first responding engine and one ALS level provider on the ambulance were able to apply the 12-lead ECG device two minutes and 20 seconds sooner than crews with both ALS providers on the ambulance.

Similarly, crew configurations with one ALS provider on the first responding engine and no medic on the ambulance also were able to apply the 12-lead ECG device two minutes and 20 seconds sooner than crews with no ALS on the first responding engine and a single ALS level provider on the ambulance.

These results may be influenced by the fact that this task can only be administered by ALS level providers. When ALS
personnel are only on the ambulance, the task cannot begin until three minutes after the start of the experiment – the ambulance arrival time built into the experiments. Nonetheless, this finding is noteworthy given that national data show that ambulances typically arrive later than first responder crews.

Only a small difference in the time to begin applying the ECG device was associated with having a second ALS provider on the scene. This is not surprising, as ECG application typically requires a single ALS trained provider. Other ALS tasks later in the sequence show greater significance for having two ALS personnel on scene.

IIVV AA cccceessss
Crew
configurations with one ALS provider on the first
responding engine and no medic on the ambulance were able to start the procedure for IV access two minutes and 30 seconds sooner than crews with no ALS on the first responding engine and a single ALS level provider on the ambulance. No reductions in the time to IV access were associated with a second ALS on scene.

Although likely a by-product of the three-minute ambulance stagger, this finding is noteworthy because of the typical lag (behind first responders) in the arrival of an ambulance.

42 Figure 30: Airway- Intubation After Patient Arrest
AA iirrww aayy-- EEnnddoottrraacchheeaall IInnttuubbaattiioonn Crew configurations with two ALS level providers were able to begin to secure the patient’s airway using endotracheal intubation over a minute (65 seconds) sooner than crew configurations with one ALS provider.

PPaattiieenntt PPaacckkaaggiinngg
Meas ured from the time of arrest, first responders with four-person crews were able to begin patient packaging one minute sooner and complete all packaging activities moving toward transport one minute and 25 seconds sooner than the two-person crews.

First responders with three-person crews were able to complete all patient packaging activities moving toward transport 50 seconds sooner than the two-person crews, while four-person crews were able to complete all patient packaging activities moving toward transport 85 seconds sooner than the two-person crews.

Crew configurations with two ALS personnel arriving on the ambulance were able to complete all packaging activities, post arrest and move toward transport 50 seconds sooner than crews with one ALS provider on the first responding engine and one on the ambulance.

Figure 31: Patient Packaging Completion After Patient Arrest

43 Table 10: Cardiac Scenario Coefficient Direction and Significant Differences Patterns in the Cardiac Scenario
As with the trauma analysis, the preceding presentation of findings focused on specific tasks that comprise an EMS cardiac response.

The significant differences of elapsed task start times were tabulated by task and appear as T able 10. The table presents the task sequence and statistically significant differences when comparing ALS placement (Columns A – C) and contrasting crew sizes (Columns D – F) for the outcome “elapsed time to the start of a task. ” The results appear mixed. Column A shows that an ALS
provider on an engine has advantages over an ALS provider on an ambulance for start times in earlier tasks – ALS Vitals 12-Lead through IV access. No other ALS provider placement advantages appear for the remainder of the response sequence.

Columns B and C show sporadic task-specific advantages for start times in a few tasks. For example, when comparing crews with one ALS provider on the engine and one ALS provider on the ambulance versus two ALS providers on ambulance, and when comparing crew configurations with two ALS providers
(regardless of placement) to crews with one ALS provider. A Similar sporadic advantage appears when comparing first responder crew sizes of three versus a crew size two.

A pattern similar to that observed with trauma appears when comparing the start times for a first responder crew of four versus a first responder crew of two. The advantage of the four-person crew appears in a few early tasks with at least two tasks being completed sequentially, including the initial ABC’s being completed with the vital sign check, and the 12-Lead ECG being completed with exposing the patient’s chest task. However, comparing these first responder crew sizes, a greater sequential time advantage is revealed for the last three tasks (analyze shock #2 through package patient), as shown in the last three rows of Column E.

44 T
he objective of the experiments was to determine how first responder crew size, ALS provider placement, and the
number of ALS providers is associated with the
effectiveness of EMS providers. EMS crew effectiveness was measured by task intervention times in three scenarios including patient access and removal, trauma, and cardiac arrest. The results were evaluated from the perspective of firefighter and paramedic safety and scene efficiency rather than as a series of distinct tasks. More than 100 full-scale EMS experiments were conducted for this study.

As noted in the literature review, hundreds of firefighters and paramedics are injured annually on EMS responses. Most injuries occur during tasks that require lifting or abnormal movementby rescuers. Such tasks include lifting heavy objects (including human bodies both conscious and unconscious), manipulating injured body parts and carrying heavy equipment. Several tasks included in the experiments fall into this category, including splinting extremities, spinal immobilization (back boarding) and patient packaging. During the experiments larger crews completed these tasks more efficiently by distributing the workload among more people thereby reducing the likelihood of injury.

A number of tasks are also labor intensive. These tasks can be completed more efficiently when handled by multiple responders.

Several tasks in the experiments are in this category. These include checking vital signs, splinting extremities, intubation with spinal restriction, establishing IV access spinal immobilization, and patient packaging. Similar to the lifting or heavy work load task, larger crews were able to complete labor intensive tasks using multiple crew members on a single task to assure safe procedures were used reducing the likelihood of injury or exposure.

Finally, there are opportunities on an EMS scene to reduce scene time by completing tasks simultaneously rather than concurrently thus increasing operational efficiency. Since crews were required to complete all tasks in each scenario regardless of their crew size or configuration, overall scene times reveal operational efficiencies.

Each of these perspectives is discussed below for the patient access/removal scenario, as well as both the trauma and the cardiac scenarios.

Patient Access and Removal
With regard to accessing the patient, crews with three or four first responders reached the patient around half a minute faster than smaller crews with two first responders. With regard to completing patient removal, larger first responder crews in conjunction with a two-person ambulance were more time
efficient. The removal tasks require heavy lifting and are labor intensive. The tasks also involve descending stairs while carrying a patient, carrying all equipment down stairs, and getting patient and equipment out multiple doors, onto a stretcher and into an ambulance.

The patient removal results show substantial differences associated with crew size. Crews with three- or four-person first responders complete removal between (1.2 – 1.5) minutes faster than smaller crews with two first responders. All crews with first responders complete removal substantially faster (by 2.6 min. -

4.1 min.) than the ambulance-only crew.

These results suggest that time efficiency in access and removal can be achieved by deploying three-or four-person crews on the first responding engine (relative to a first responder crew of two).

T o the extent that each second counts in an EMS response, these staffing features deserve consideration. Though these results establish a technical basis for the effectiveness of first responder crews and specific ALS crew configurations, other factors contributing to policy decisions are not addressed.

Trauma
Overall, field experiments reveal that four-person first responder crews completed a trauma response faster than smaller crews.

T owards the latter part of the task response sequence, four-person crews start tasks significantly sooner than smaller crews.

Additionally, crews with one ALS provider on the engine and one on the ambulance completed all tasks faster and started later tasks sooner than crews with two ALS providers on the
ambulance. This suggests that getting ALS personnel to the site sooner matters.

A review of the patterns of significant results for task start times reinforced these findings and suggests that (in general) small non-significant reductions in task timings accrue through the task sequence to produce significantly shorter start times for the last third of the trauma tasks.

Finally, when assessing crews for their ability to increase on-scene operational efficiency by completing tasks
simultaneously, crews with an ALS provider on the engine and one ALS provider on the ambulance completed all required tasks

2.3 minutes (2 minutes 15 seconds) faster than crews with a BLS engine and two ALS providers on the ambulance. Additionally, first responders with four-person first responder crews completed all required tasks 1.7 minutes (1 minute 45 seconds) faster than three-person crews and 3.4 minutes (3 minutes and 25 seconds) faster than two-person crews.

Cardiac
The overall results for cardiac echo those of trauma. Regardless of ALS configuration, crews responding with four first responders completed all cardiac tasks (from at-patient to packaging) more quickly than smaller first responder crew sizes. Moreover, in the critical period following cardiac arrest, crews responding with four first responders also completed all tasks more quickly than smaller crew sizes. As noted in the trauma scenario, crew size matters in the cardiac response.

Considering ALS placement, crews responding with one ALS provider on both the engine and ambulance completed all scene tasks (from at-patient to packaging) more quickly than a crew with a BLS engine and two ALS providers on the ambulance. This suggests that ALS placement can make a difference in response efficiency. One curious finding was that crews responding with a BLS engine and an ambulance with two ALS providers completed the tasks that follow cardiac arrest 50 seconds soonerthan crews with an ALS provider on both the engine and ambulance. As noted, this counter-intuitive difference in the results may be attributable to the delay of the patient arrest time based on the arrival of the 12-Lead ECG monitor with the two-person ALS Ambulance crew. The 12 -Lead ECG task end timewas the arrest start time. In this scenario, there were instantaneously two ALS providers present at the arrest rather than the one ALS provider Conclusions

45 placing the 12-Lead ECG device in the ALS engine /ALS Ambulance crew.

A review of the patterns of significant results across task start times showed mixed results. An ALS on an engine showed an advantage (sooner task starting times) over an ALS on an ambulance for a few tasks located earlier in the cardiac response sequence (specifically, ALS Vitals 12-Lead through IV access). A crew size of four also showed shorter start times for a few early tasks in the cardiac response sequence (initial ABC’s, and the ALS Vitals 12-Lead and expose chest sequence). More importantly, a sequential time advantage appears for the last three tasks of the sequence (analyze shock #2 through package patient).

Finally, when assessing crews for their ability to increase on-scene operational efficiency by completing tasks
simultaneously, crews with an ALS provider on the engine and one ALS provider on the ambulance completed all required tasks 45 seconds faster than crews with a BLS engine and two ALS providers on the ambulance. Regardless of ALS configuration, crews responding with four first responders completed all cardiac tasks from the “at patient time” to completion of packaging 70 seconds faster than first responder crews with three persons, and two minutes and 40 seconds faster than first responder crews with two persons. Additionally, after the patient arrested, an assessment of time to complete remaining tasks revealed that first responders with four-person crews completed all required tasks 50 seconds faster than three-person crews and 1.4 minutes (1 minute 25 seconds) faster than two-person crews.

46 W
hile resource deployment is addressed in the context of three basic scenarios, it is recognized that public policy decisions regarding the cost-benefit of specific
deployment decisions are a function of many factors including geography, resource availability, community expectations as well as population demographics that drive EMS call volume. While this report contributes significant knowledge to community and fire service leaders in regard to effective resource deployment for local EMS systems, other factors contributing to policy decisions are not addressed. The results however do establish a technical basis for the effectiveness of first responder crews and ALS configuration with at least one ALS level provider on first responder crews. The results also provide valid measures of total crew size efficiency in completing on-scene tasks some of which involve heavy lifting and tasks that require multiple responders to complete.

These experimental findings suggest that ALS provider
placement and crew size can have an impact on some task start times in trauma and cardiac scenarios, especially in the latter tasks leading to patient packaging. T o the extent that creating time efficiency is important for patient outcomes, including an ALS trained provider on an engine and using engine crew sizes of four are worth considering. The same holds for responder safety – for access and removal and other tasks in the response sequence, the availability of additional hands can serve to reduce the risks of lifting injuries or injuries that result from fatigue (e.g., avoid having small crews repeatedly having to ascend and descend stairs). Cost considerations for EMS response and crew configurations were not considered in this study.

Summary

47 Study Limitations
T
he scope of this study is limited to understanding the
relative influence of deployment variables on labor-
intensive emergency medical incidents, specifically
multi-system trauma and cardiac arrest events. It should be noted that the applicability of the conclusions from this report to a large scale hazardous or multiple-casualty event have not been assessed and should not be extrapolated from this report.

The crews involved in this study typically operate using three- to four-person engine crews, and two-person ambulance crews.

However, other departments across the United States vary in crew sizes, some using two- to five-person first responder engine crews and three-person ambulance crews.

Every attempt was made to ensure the highest possible degree of realism in the experiments including the use of multiple crews from multiple shifts in the participant departments. However, as the trauma and cardiac experiments were repeated a minimum of 45 times, for crews involved in more than one experiment, a learning curve on the part of the participants may have been established.

All experiments were conducted indoors, during daylight hours.

Treating patients outside among varying weather conditions or at night, when visibility is lower, could pose additional obstacles.

Additionally, the actual effect of ALS interventions on patient outcome is beyond the scope of this study. Patient outcomes were not quantified or estimated.

The design of the experiments limited the patient care scenarios to a systemic trauma event and a medical cardiac event. Other patient illnesses and injuries including diabetes, seizures, gunshot wounds, stabbings, and motor vehicle accidents were not considered.

EMS protocols pertaining to the treatment and transport of patients vary by departments. For the purpose of this study, tasks were standardized by technical experts and individual times were recorded for each task. In real-world situations, as in this study, many of these can be performed simultaneously based on the number and training level of responding personnel. Attempts to generalize the results from these experiments to individual departments must take into account protocols and equipment that vary from those used in the experiments.

Finally, data from U.S. fire departments were used to set response and arrival time assumptions. For departments with different deployment capability for both first responder crews and ambulances, the results may vary.

48 Future Research
I
n order to realize a significant reduction in firefighter and paramedic line-of-duty injury, fire service leaders must focus directly on resource allocation and the deployment of
resources, a known contributing factor to LOD injury. Future research should use similar methods to evaluate
firefighter/paramedic deployment to other medical emergencies as well as combination scenes where both fire suppression and EMS resources are needed. Additionally, resource deployment to multiple-casualty disasters or terrorism events should be studied to provide insight into levels of risks specific to individual communities and to recommend resource deployment
proportionate to such risk. Future studies should continue to investigate the effects of resource deployment on the safety of firefighters, paramedics and the civilian population to better inform public policy. Finally, the ability to relate response and task timing to patient outcomes and survival rates should be quantified.

49 Acknowledgements
A
project of this magnitude extends well beyond the
capabilities and expertise of the authors of this report.

The following individuals were instrumental to the success of the EMS experiments.
/square6T echnical Experts – Phil Pommerening, Captain II, Station 34A from Fairfax County Fire and Rescue Department,
Michael McAdams, EMS Chief, Montgomery County Fire and
Rescue Department, Dr. Greg Mears, Medical Director,
University of North Carolina, Paul Neal, Safety Officer for Montgomery County Fire and Rescue Department, Lt. T om
Papoutsis, EMS Training, Fairfax County Fire and Rescue Department, and Adam Barowy, National Institute of
Standard and T echnology.
/square6Project Support — Montgomery County Fire and Rescue Department – Chief Richard Bowers AND Fairfax County
Fire and Rescue Department – Chief Ronald Mastin for
supporting this study over a period of years to an
unprecedented degree.
/square6IAFF Staff/Data Entry/ Timer supervision – Nicole Taylor, Randy Goldstein, and Ron Benedict
/square6Timers – Cliff Berner, Lead, DeWayne Dutrow, Alyssa Vance, Nicole Taylor, Ron Benedict, Randy Goldstein, and Adam
Barowy.
/square6The dedicated Fire and EMS Officers and
Firefighters/Paramedics from Montgomery County Fire and Rescue and Fairfax County Fire and Rescue, who performed the difficult work of EMS response and patient care safely and effectively.

50 References
/square6American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiac Care (2005). Circulation, V ol. 112, No. 24 (Suppl), Pg 1-88.
/square6Averill, J.D., et al.; Moore-Merrell, L. ;Barowy, A.; Santos, R.; Peacock, R.; Notariann, K.; Wisooker, D. (2010), NIST Report on Residential Fireground Field Experiments. Natl. Inst. Stand.

T echnol, NIST T echnical Note 1661.
/square6Becker, L.B.; Ostrander, M.P .; Barrett, J.; Kondon, G.T. (1991).

Outcome of CPR in a Large Metropolitan Area- Where are the Survivors? Ann Emerg Med, V ol. 20, No. 4, Pg. 355.
/square6Boyd, C.R.; T olson, M.A.; and Copes, W .S. (1987). Evaluating T rauma Care: The TRISS Method. J. T rauma, V ol. 27, No. 4, 370-378.
/square6Braun, O.; McCallion, R.; Fazackerley, J. (1990). Characteristics of Midsized Urban EMS Systems. Ann Emerg Med, V ol. 19, No. 5, Pg. 536.
/square6Brown, L. H.; Owens Jr., C. F .; March, J. A.; Archino, E. A. (1996).

Does Ambulance Crew Size Affect On-Scene Time or Number of Prehospital Interventions? Prehosp Disast Med, V ol. 11, No. 3, Pg. 214.
/square6Commission on Fire Accreditation International (CFAI) Standards of Cover, Fifth Edition (2008) Chantilly, V A /square6Chu, K.;Swor, R.; Jackson, R.; Domeier, R.; Sadler, E.; Basse, E.; Zaleznak, H.; Gitlin, J. (1998). Race and Survival after Out-of-Hospital Cardiac Arrest in a Suburban Community. Ann Emerg Med, V ol. 31, No. 4, Pg. 478.
/square6Cummins, R. O.; Ornato, J. P .; Thies, W . H.; Pepe, P . E. (1991).

Improving Survival from Sudden Cardiac Arrest: The “Chain of Survival Concept. ” Circulation, V ol. 83, No. 5, Pg. 18-32. /square6DeMaio, V .J.; Stiell, I.G.; Nesbitt, L.; W ells, G.A. (2005). Faster Advanced Life Support Response Intervals May Improve Cardiac Arrest Survival. Acad Emerg Med, V ol. 12, No. 5, Pg. 16. /square6Eisenberg, M.S.; Horwood, B.T .; Cummins, R.O.; Reynolds-Haertle, R.; Hearne, T .R. (1990). Cardiac Arrest and Resuscitation: A T ale of 29 Cities. Ann Emerg Med, V ol. 19, No. 2, Pg. 179-186. /square6Hallstrom, A.P .; Ornato, J.P .; W eisfeldt, M.; T ravers, A.; Christenson, J.; McBurnie, M.A.; Zalenski, R.; Becker, L.B.; Schron, E.B.; Proschan, M. (2004). Public-Access Defibrillation and Survival after Out-of-Hospital Cardiac Arrest. N Engl J Med, V ol. 21, No. 7, Pg. 637.
/square6Heick, R.; Y oung, T.;Peek-Asa, C. (2009). Occupational Injuries Among Emergency Medical Service Providers in the United States. J Occup Med, V ol. 51, No. 8, Pg. 963-968.
/square6IAFC/IAFF Fire and EMS Operation Database: Analysis of Response Times (2005).
/square6Karter, M.J. Jr.; Molis, J.L. (2009). U.S. Firefighter Injuries-2008.

NFPA Journal, November/December 2009.
/square6Kellerman, A.L.; Hackman, B.B.; Somes, G.; Kreth, T.K.; Nail, L.; Dobyns, P . (1992). Impact of First Responder Defibrillation in an Urban EMS System. Ann Emerg Med, V ol. 21, No. 14, Pg. 1708. /square6Laerdal Medical Corporation. (n.d.) Retrieved from http://www.laerdal.com/doc/7320252/SimMan.html
.
/square6Litwin, P . E.; Eisenberg, M. S.; Hallstrom, A. P .; Cummins, R. O. (1987). The Location of Collapse and its Effect on Survival from Cardiac Arrest. Ann Emerg Med, V ol. 16, No. 7, Pg. 787. /square6Maguire, B.J.; Hunting, K.L., Guidotti, T.L.; Smith, G.S. (2005).

Occupational Injuries Among Emergency Medical Services
Personnel. Prehop Emerg Care, No. 4, Pg. 405-411.
/square6Moore, L.L. Quality Performance Measures for Fire Department-Based EMS Systems. UMI, Ann Arbor, Michigan
(2002).
/square6Morrison, L.J.; Angelini, M.P .; V ermeulen, M.J.; Schwartz, B. (2005). Measuring the EMS Patient Access Time Interval and the Impact of Responding to High-rise Buildings. Prehosp Emerg Care, V ol. 9, No. 1, Pg. 14-18.
/square6National Fire Academy (1981). Fire Engines are Becoming Expensive T axi Cabs: Inadequate Manning. United States Fire Administration, Emmitsburg, MD.
/square6NFPA (2009). 450: Standard for Emergency Medical Services and Systems. National Fire Protection Association, Quincy, MA. /square6NFPA (2007). 1500: Standard on Fire Department Occupational Safety and Health Program. National Fire Protection Association, Quincy, MA.
/square6NFPA (2010). 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. National Fire Protection Association, Quincy, MA. /square6NFPA (2010). NFPA 1720: Standard for the Organization and Deployment of Fire Suppression Operations, Emergency Medical Operations, and Special Operations to the Public by V olunteer Fire Departments. National Fire Protection Association, Quincy, MA.
/square6NFPA (2008) 1999: Standard on Protective Clothing for Emergency Medical Operations. National Fire Protection Association, Quincy, MA.
/square6Olson, D.W .; LaRochelle, J.; Fark, D.; et al. (1989). EMT- Defibrillation: The Wisconsin Experience. Ann Emerg Med, V ol. 18, No. 8, Pg. 806.

51 /square6Pratt, F .D.; Katz, S.; Pepe, P .E.; Persse, D. (2007). Prehospital 9-1-1 Emergency Medical Response: The Role of the United States Fire Service in Delivery and Coordination. White paper.
/square6Studnek, J.R.; Ferketich, A.; Crawford, J.M. (2007) On the Job Illness and Injury Resulting in Lost W ork Time Among a National Cohort of Emergency Medical Services Professionals. Am J Indus Med, V ol. 50, No.12, Pg. 921-931.
/square6Sweeney, T.A.; Runge, J.W .; Gibbs: et al. (1998). EMT Defibrillation Does Not Increase Survival from Sudden Cardiac Death in a T wo-Tiered Urban-Suburban EMS System. Ann Emerg Med, V ol. 31, No. 2, Pg. 234.

52 Glossary
12-Lead Electrocardiogram (ECG) —A representation of the heart’s electrical activity recorded from 10 electrodes placed in standard positions on the body’s surface.

Advanced Cardiac Life Support (ACLS) —A set of clinical interventions for the urgent treatment of cardiac arrest and other life threatening medical emergencies, as well as the knowledge and skills to use those interventions.

Advanced Life Support (ALS) — Emergency medical
treatment beyond basic life support that provides for advanced airway management including intubation, advanced cardiac monitoring, defibrillation, establishment and maintenance of intravenous access, and drug therapy.

Ambulance Transport Unit —Provides transport for patients from the incident scene to a health care facility.

Automated External Defibrillator (AED) —A portable
electronic device that automatically diagnoses potentially life-threatening cardiac arrhythmias of ventricular fibrillation, and is able to treat them through defibrillation, the application of electrical therapy which stops the arrhythmias, allowing the heart to reestablish an effective rhythm.

Basic Life Support (BLS) —A specific level of prehospital medical care provided by trained responders, focused on rapidly evaluating a patient’s condition; maintaining a patient’s airway, breathing, and circulation; controlling external bleeding; preventing shock; and preventing further injury or disability by immobilizing potential spinal or other bone fractures.

Cardiac Arrest —Sudden cessation of heartbeat and heart functions, resulting in the loss of effective circulation.

Cardiopulmonary Resuscitation (CPR) —Procedure
designed to support and maintain breathing and circulation for a person who has stopped breathing (respiratory arrest) or whose heart has stopped (cardiac arrest).

Chain of Survival — The four components of EMS response to out-of-hospital cardiac arrest that are thought to effect the most optimal patient outcome. The four components include early recognition and EMS access, early CPR, rapid defibrillation, and advanced life support.

Combination Fire Department —Fire department consisting of both paid (career) and volunteer personnel.

Crew configurations —Specific ways of staffing or organizing members of the work force.

Definitive Medical Care —Medical treatment or services
beyond emergency medical care, initiated upon inpatient admission to a hospital or health care facility.

Emergency Medical Services (EMS) —The treatment of
patients using first aid, cardiopulmonary resuscitation, basic life support, advanced life support, and other medical procedures prior to arrival at a hospital or other health care facility.

EMS Protocols —Written medical instructions authorized by an EMS medical director to be used by personnel in the field without the necessity of on-line or real-time consultation with a physician or nurse.

Emergency Medical Technician (EMT) — A member of the
emergency medical services team who provides out-of-hospital emergency care, trained to any level of emergency medical services.

Emergency Medical Technician- Basic (EMT-B) —A
member of the emergency medical services team who provides out-of-hospital emergency care, trained in the delivery of Basic Life Support services.

Emergency Medical Technician- Defibrillator (EMT-D) —
A member of the emergency medical services team with special training in the use of cardiac defibrillating equipment. (Defibrillation training is now part of Basic Emergency Medical training.)
Emergency Medical Technician- Paramedic (EMT-P) —
A member of the emergency medical services team who provides out-of-hospital emergency care, trained in the delivery of Advanced Life Support services.

Endotrachael Tube (ET) —Flexible plastic catheter placed into the trachea to protect the airway and provide a means of mechanical ventilation.

First Responder —Functional provision of initial assessment (i.e., airway, breathing, and circulatory systems) and basic first-aid intervention, including CPR and automatic external defibrillator capability.

First Responder Unit —The first arriving unit at an
emergency medical incident, whether it be a fire suppression vehicle or ambulance.

Intervention —Act designed to alter or hinder an action or development.

Intravenous (IV) —An injection administered into a vein.

Intubation —Insertion of a tube through the mouth or nose and into a patient’s lungs to help them breathe.

Knox Box Rapid Entry System —Small, wall-mounted safe
that holds building keys for firefighters and EMTs to retrieve in emergencies.

Mayocardial Infarction —Heart attack.

Measurement uncertainty —Parameter, associated with the result of a measurement that characterizes the dispersion of the values that could reasonably be attributed to the measure.

53 National Fire Protection Association (NFPA) — A
nonprofit organization, established in 1896, with the mission to reduce the worldwide burden of fire and other hazards on the quality of life by providing and advocating consensus codes and standards, research, training and education.

NFPA 450— Guide for emergency medical services and systems.

NFPA 1500 —Standard on fire department occupational safety and health program.

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.

NFPA 1720 —Standard for the organization and deployment of fire suppression operations, emergency medical operations, and special operations to the public by volunteer fire departments.

NFPA 1999 —Standard on protective clothing for emergency medical operations.

One-Tier EMS System —EMS system in which all units are
advanced life support.

Operational Effectiveness —Capable of producing a
particular desired effect in “real world” circumstances.

Operational Efficiency — The effect or results achieved in relation to the effort expended.

Ordinary Least Squares (OLS) —In statistics and
econometrics, OLS or linear least squares is a method for estimating the unknown parameters in a linear regression model.

Out-of-hospital —Care for the sick or injured in settings other than hospitals or hospital-affiliated outpatient medical or surgical facilities, typically beginning with a call to 9-1-1.

Patient Packaging —Securing a patient to a mobile
contrivance (e.g., stretcher or stair chair) for moving to the transport unit.

Pulse Oximeter —Medical device that measures the oxygen saturation of a patient’s blood.

Regression analysis —— Inc
ludes any techniques for modeling
and analyzing several variables, when the focus is on the relationship between a dependent variable and one or more independent variables. More specifically, regression analysis helps us understand how the typical value of the dependent variable changes when any one of the independent variables is varied, while the other independent variables are held.

Standard of Response Cover (SORC) — Policies and
procedures that determine distribution, concentration, and reliability of fixed and mobile resources for an emergency response system.

Standard t-test —Measures whether there is any statistical difference in the mean of two groups.

Statistical significance —A number that expresses the
probability that the result of a given experiment or study could have occurred purely by chance. This number can be a margin of error or it can be a confidence level.

System resources —Personnel, vehicles, and equipment used in providing EMS.

Systemic trauma —Injury or shock affecting the body
generally.

Transport — Conveyance of the sick or injured in an ambulance or emergency vehicle to a hospital setting.

Trauma and Injury Severity Scores (TRISS) —A system
developed in the 1980’s to improve the prediction of patient outcomes through the use of physiological and anatomical criteria.

Two-Tier EMS System — EMS system that uses first
responder or BLS units that typically arrive and begin treatment prior to the arrival of a transport unit.

54 Acronyms
/square6A, B, C’s —Airway, Breathing, and Circulation
/square6ACLS — Advanced Cardiac Life Support
/square6AED —Automated External Defibrillator
/square6AHA —American Heart Association
/square6ALS —Advanced Life Support
/square6BLS — Basic Life Support
/square6CFAI —Commission on Fire Accreditation International /square6CPR — Cardiopulmonary resuscitation
/square6DHS — Department of Homeland Security
/square6DOL — Department of Labor
/square6ECG — Electrocardiogram
/square6EMS — Emergency Medical Services
/square6EMT — Emergency Medical T echnician
/square6EMT-B — Emergency Medical T echnician- Basic
/square6EMT-D — Emergency Medical T echnician- Defibrillator /square6EMT-P — Emergency Medical T echnician- Paramedic /square6FEMA — Federal Emergency Management Agency
/square6IAFC — International Association of Fire Chiefs /square6IAFF —International Association of Fire Fighters /square6LOD — Line-of-Duty
/square6NFPA —National Fire Protection Association
/square6NIST —National Institute of Standards and T echnology /square6OHCA — Out-of-hospital cardiac arrest
/square6OPQRST — O nset, Provokes, Quality, Radiates, Severity, Time /square6SAMPLE — Signs and Symptoms, Allergies, Previous history, M edications, Last oral intake, Events leading up to
/square6SORC — Standard of Response Cover
/square6TBI —Traumatic brain injury
/square6TRISS —Trauma and Injury Severity Scores
/square6WPI — Worcester Polytechnic Institute

55 Appendix A: Time to Task Measures
Time-to-Task Data Collection Chart -EMS
((OO vveerraallll RR eessppoonnssee-- PPaattiieenntt AA cccceessss aanndd RR eemm oovvaall)) Date ___________ Start Time____________ End Time (all tasks complete) ___________ Crew Used: /boxshadowdwnMontgomery County /boxshadowdwnFairfax County □ Timer Name___________________________________________

56 Time-to-Task Data Collection Chart -EMS
((TTrraauumm aa —— BB LLSS —— AA LLSS oonn sscceennee)) Date ___________ Start Time____________ End Time (all tasks complete) ___________ Timer Name___________________________________________

57 Time-to-Task Data Collection Chart -EMS
((MM eeddiiccaall —— CC aarrddiiaacc))
Date ___________ Start Time____________ End Time (all tasks complete) ___________ Timer Name___________________________________________

58 Appendix B: Trauma Patient Assessment and Interview Form Name:____________________________________________ Age: ________ Male / Female Chief Complaint: __________________________________________________________________________________________ Mechanism of Injury: ______________________________________________________________________________________ Primary Survey:

Airway status:open / occluded
Breathing:normal / labored-abnormal / none
Circulation:normal / shocky / none
Mental Status:alert / voice / pain / unresponsive
Body Sweep Findings? _____________________
Secondary / Focused Survey Findings:

Head L Arm
Face R Arm
Neck Abdomen
Chest L Leg
Back R Leg
Vital Signs:

BP ______ Pulse: ______ Resp:______ PulseOx: ______
BP ______ Pulse: ______ Resp:______ PulseOx: ______
Treatment:
/boxshadowdwnoxygen /boxshadowdwnC-spine /boxshadowdwnSplinting /boxshadowdwnBandaging

59 Appendix C: Medical Patient Interview Form
Name:____________________________________________ Age: ________ Male / Female Chief Complaint: __________________________________________________________________________________________ Mechanism of Injury: ______________________________________________________________________________________ “SAMPLE” history
Signs & Symptoms
Allergies
Medications
Previous Medical History
Last Oral Intake
Events Leading Up to?
“OPQRST” pain survey
Onset? What were you doing?
Provokes? What makes it better or worse?
Quality? “What does it feel like?
Radiation? “Does it go anywhere?”
Severity? 1-10 scale
Time? When did it begin?
Vital Signs:

BP ______ Pulse: ______ Resp: _____ PulseOx: _____
Treatment:
/boxshadowdwnoxygen /boxshadowdwnECG /boxshadowdwn12-lead /boxshadowdwnIV /boxshadowdwnmedications? __________________________________________________________________________________________

60 Appendix D: Medical Patient Assessment/Interview Form Signs & Symptoms
“What is bothering you this morning? Pain under my breastbone.

Allergies
“Are you allergic to any medications?” None
Medications
“Do you take any medications?” Aspirin and Cardizem.

Previous History
“Do you have any medical problems? I was diagnosed with high blood pressure two years ago.

Has this ever happened to you before?” No, I have never felt pain like this before.

Last Oral Intake
“Have you been eating normally?” Y es. Had a full breakfast this morning.

Events Leading Up to?
“What happened prior to you developing this pain?” Nothing, I was feeling fine before this.

PAIN SURVEY Onset?
“What were you doing when pain began?” I was sitting on the couch watching television.

Provokes?
“Have you done anything that makes the pain better?” No, it is a steady pain and I can’t get in a comfortable position.

Radiates?
“Do you feel the pain anywhere besides your chest?” Y es, I feel it in my spine also.

Severity?
“On a scale of 1 to 10, with ten worst pain you can imagine, how severe is your pain now?” It is a 6.

Time?
“When did your chest pain begin?” About 30 minutes ago. “SAMPLE HISTORY”PAIN SURVEY

61 Appendix E: Statistical Analysis of Time to T ask Data Patient Access and Removal Time between Arrival and ascent
of stairs
Time between packaging patient
and completion of loading patient

62 Appendix F:Statistical Analysis of Time to T ask Data Patient Systemic Trauma Patient

63 Appendix G:Statistical Analysis of Time to Task Data Cardiac Arrest Patient

64 Appendix G:Statistical Analysis of Time to Task Data Cardiac Arrest Patient Continued

65 Appendix H:All Regression Coefficients
Continued

66 Appendix H:All Regression Coefficients
Continued

67 Appendix H:All Regression Coefficients

68 Appendix H:All Regression Coefficients
Continued

69 Appendix H:All Regression Coefficients
Continued

70 ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ NOTES :

71 ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________

IAFF
International Association
of Fire Fighters®
Safe Fire Fighter Staffing
– Critical Considerations –

APPENDIX E

1 This manual identifies those benchmarks by which safe and effective minimum fire suppression services should be assessed. It provides both citizens and municipal officials with the facts they must consider in making informed decisions regarding the appropriate level of service for their communities. Fire fighter staffing directly affects delivery of fire protection service and is therefore essential to any discussion or debate involving service levels.

It is generally accepted that a municipality has the right to determine the overall level of fire protection it wants. However, regardless of the level of fire protection chosen by the citizens, neither they nor their elected representatives have the right to jeopardize the safety of the employees providing those services.

Citizens pay for protection of life and property through their tax dollars, and they assume that their elected and appointed officials will make informed decisions regarding that protection. Too often, that decision making process has been based solely on budgetary expedience. However, irrespective of the resources provided, citizens continue to believe that fire fighters are prepared to provide an aggressive interior assault on fires, successfully accomplishing victim rescue, fire control, and property conservation. They do not expect fire fighters to take defensive actions, i.e., to simply surround a fire and drown it, because to do so would be to concede preventable loss of both life and property. However, when staffing levels are reduced, misguided economics and community expectations collide, with politicians insisting that potential budgetary savings will not affect the level of service.

Introduction

2 Unless citizens understand the relationship between staffing levels and their own life safety and the protection of their property, it is not realistic for fire fighters to expect them to insist on appropriate service levels, including minimum staffing. Elected officials and managers cannot be expected to make appropriate decisions concerning the level of service without an education in
effective firefighting and an understanding of the impact their policy decisions have on the citizens they represent. Therefore, it is essential to make clear to the community that reduced staffing equates to reduced service levels, and that if they expect a continued aggressive attack on fires, they must provide the department with at least the minimum resources required to meet the community’s expectations. To do less forces fire fighters to accept a level of risk to their own health and safety that the community at large finds unacceptable for itself.

Historically, the standard for fire suppression in North America has mandated an offensive attack in situations involving structural fire. Study after study has demonstrated that if the force available to initiate an interior fire attack is less than fifteen personnel, the goals of victim rescue, fire control, and property conservation are seriously compromised. These studies state that when fireground staffing is reduced below the level necessary for aggressive tactics, the inevitable result is that fire fighters must resort to defensive rather than offensive operations or risk their own safety.

Firefighting has always been labor intensive and remains so. Although new technology has improved firefighting equipment and protective gear, it is fire fighters who still perform the critical tasks necessary to contain and extinguish fires. When staffing falls below minimum acceptable levels, so does service, and the goals and expectations set by the community are essentially abandoned.

A number of court decisions and arbitration awards have recognized that while firefighting is one of the most dangerous occupations in North America, fire fighters should be provided the safest possible working environment. Thus, staffing affects not only the public safety but also the safety of fire fighters and as such is a condition of employment. Although firefighting is by its nature dangerous, that does not justify employers increasing that inherent level of risk by reducing safe minimum staffing under the guise of financial difficulty.

This position has been recognized by many organizations such as the International Association of Fire Fighters, Metropolitan Fire Chiefs’ Division of the International Associa- tion of Fire Chiefs and the U.S. Fire Administration. Even the International City Management Association has stated:
...too few companies or poorly manned ones, can result in property and life loss beyond community accepted norms. Also, the cost of a firefighter death or disabling injury may far exceed the expense of a fire company.

This is not to say that there is a fixed value on a life or injury. The point is that the firefighting forces are the asset that protects the economic and tax base as well as its health and welfare. This asset is a valuable one and must be carefully provided and wisely managed.

3 Chapter 1
Impact of Initial Fire Attack on Property Loss
and Citizen Safety
Successful delivery of fire protection services involves two major elements – fire preven- tion and fire suppression. Fire prevention can be defined as those “ pre-fire activities that reduce the probability of fires occurring and help limit the loss of property and life in the fires that do occur.”
1 Since fire prevention will never be 100 percent successful, it is necessary to buttress fire prevention goals with adequate fire suppression services. It is the objective of fire suppression to “get to the fire as quickly as possible and to extinguish it with minimum loss to persons and property from the fire and from fire fighting activities.” 2 The successful attainment of the goals of both prevention and suppression require a balanced approach and commitment of resources. This balance has in recent years been tipped in the direction of fire prevention while largely ignoring fire suppression.

As the data in the following table shows, the concern with fire prevention has been substantially rewarded. According to the NFPA’s Annual National Fire Experience Survey, the total number of fires, civilian deaths, and injuries has declined remarkably over the last decade. This data attests to the substantial impact that public education, smoke detectors, and development and enforcement of building codes can have on preventing fires.

However, closer examination of the same data also tells the other side of the story, which is that de-emphasis of fire suppression in recent years has led to increasing rates of civilian deaths and injuries and property loss when fires do occur.

SOURCE: National Fire Protection Association
Rate Per 1,000
Residential Fires
Total Total Total Direct Property Real Property
Residential Civilian Civilian Civilian Civilian Damage Per Damage Per Year Fires Deaths Injuries Death Injuries Residential Fire Residential Fire [1] 1978 730,500 6,185 21,260 8.47 29.1 $3,000.68 $4,602
1979 721,500 5,765 20,450 7.99 28.3 $3,505.20 $4,828
1980 757,500 5,446 21,100 7.19 27.9 $4,015.84 $4,874
1981 733,000 5,540 20,375 7.56 27.8 $4,446.11 $4,891
1982 676,500 4,940 21,100 7.30 31.2 $4,808.57 $4,983
1983 641,500 4,820 21,450 7.51 33.4 $5,153.55 $5,174
1984 623,000 4,240 19,275 6.81 30.9 $5,521.67 $5,314
1985 622,000 5,025 19,825 8.08 31.9 $6,067.52 $5,623
1986 581,500 4,770 19,025 8.20 32.7 $6,115.22 $5,580
1987 551,500 4,660 20,440 8.45 37.1 $6,707.16 $5,904
1988 552,500 5,065 22,600 9.17 40.9 $7,276.02 $6,150
1989 513,500 4,435 20,750 8.64 40.4 $7,785.78 $6,279
1990 467,000 4,115 20,650 8.81 44.2 $9,107.07 $6,968
1991 478,000 3,575 21,850 7.48 45.7 $11,615.06 $8,547
1992 472,000 3,705 21,600 7.85 45.8 $8,220.00 $5,859
1993 470,000 3,825 22,600 8.14 48.1 $10,304.00 $7,131
1994 451,000 3,465 20,025 7.68 44.4 $9,572.00 $6,394
1978-84 -14.7% -31.4% -9.3% -19.6% 6.2% 84.0% 15.5%
1984-94 -27.6% -18.3% 4.0% 12.8% 43.7% 73.3% 60.8%
[1] Determined by deflating the direct property damage by the CPI-U.

4 During the six-year period 1978-84, measures of both fire prevention and fire suppression exhibited equally impressive results. Through the efforts of fire prevention, the total number of residential fires declined 14.7%, while the total number of civilian deaths and injuries, respectively, dropped by 31.4% and 9.3%.

In those situations where fires did occur, firefighting also scored substantial gains. During the period, the rate of civilian deaths per 1,000 fires declined 19.6%, while the rate of civilian injuries and real property damage showed only modest increases.

However in the last ten years, the results were substantially different. Between 1984 and 1994, the rate of civilian fire deaths per 1,000 residential fires increased 12.8%, the rate of civilian injuries increased 43.7% and real property loss rose 60.8%.

The ability of adequate fire suppression forces to greatly influence the outcome of a structural fire is undeniable and predictable. Data generated by the National Fire Protection Association provides empirical proof that rapid and aggressive interior attack can substantially reduce the human and property loss associated with structural fires. At each stage of a fire’s extension beyond the room of origin, the rate of civilian deaths, injuries, and property damage grows exponentially.

Rate Per 1,000 Fires Average
Civilian Civilian Property
Fire Extension in Residential Structures: Deaths Injuries Damage Confined to Room of Origin 2.07 24.30 $1,505
Confined to Floor of Origin 18.60 80.44 $12,134
Beyond Floor of Origin 27.23 55.37 $21,343
SOURCE: National Fire Protection Association

5 Clearly, an early aggressive and offensive initial interior attack on a working structural fire results in greatly reduced loss of life and property damage. Consequently, given that the progression of a structural fire to the point of “flashover” (the very rapid spreading of the fire due to super heating of room contents and other combustibles) generally occurs in less than 10 minutes
3 , two of the most important elements in limiting fire spread are the quick arrival of sufficient numbers of personnel and equipment to attack and extinguish the fire as close to the point of its origin as possible.

The conclusions reached in the Dallas Study have recently been confirmed for small fire departments by the Westerville, Ohio Fire Department.
4 Using standard firefighting tactics,
the results of the Westerville Fire Department study showed that 4 fire fighters could perform rescue of potential fire victims 80% faster than a 3 fire fighter crew.

SOURCE: “Dallas Fire Department Staffing Level Study,” McManis Associates, June 1984.

Assuming a crew of five fire fighters is 100% effective in performing the critical tasks required for an interior fire attack, the following table shows the impact that reduced staffing has on the effectiveness of fireground operations involving a single-family residential structure.

SOURCE: John C. Gerard & A. Terry Jacobsen
Impact of Crew Size of First Alarm Assignment on Fire Attack in a Residential Structure 1st Engine Company 2nd Engine Company Truck/Ladder Company Charge Locate Charge Charge Check
Initial Interior & Interior Sup- Exterior Search Exposures Line and Rescue port Line Line & Roof and for Fire
Crew Size: Advance Victim & Advance Advance Ventilation Rescue Extension 5 Fire Fighters 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 4 Fire Fighters 84.7% 96.1% 77.9% 72.9% 79.0% 90.3% 80.2% 3 Fire Fighters 71.3% 82.8% 0.0% 62.3% 0.0% 79.6% 0.0%

THE LINE REPRESENTS A RATE OF FIRE PROPAGATION
WHICH COMBINES TEMPERATURE RISE AND TIME. IT

ROUGHLY CORRESPONDS TO THE PERCENTAGE OF
PROPERTY DESTRUCTION. AT APPROXIMATELY TEN
MINUTES INTO THE FIRE SEQUENCE. THE HYPOTHETICAL
ROOM OF ORIGIN FLASHES OVER. EXTENSION OUTSIDE
THE ROOM BEGINS AT THIS POINT.

Fire Propagation Curve
Minutes
0 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 % OF PROPERTY DESTRUCTION
100
90 80
70 60
50 0
40 10
20 30
Room of Origin Beyond Room of Origin
,

6 The implications that enhanced crew size can have on rescue operations is all the more dramatic when victim survivability is considered. Data produced by the Dallas Fire Department showed that:
when rescue occurred between 12 and 15 1/2 minutes, the survival rate was 46.6 percent. The rate dropped to 5.5 percent when rescue occurred between 15 and 17 1/2 minutes.

Thus, a variance of only 2 to 3 minutes in the speed with which rescue operations could be completed can increase fire victim survivability eightfold.

Consequently, the fire service in North America has for most of the twentieth century accepted the premise and the expectation that fire fighters will perform aggressive interior fire attacks when confronted with a working structural fire. This has been and still is the industry’s standard of performance.
1 Measuring Fire Protection Productivity in Local Government, Philip S. Schaenman and Joe Swartz (Boston, MA:NFPA) 1974; p. 5.
2 Ibid.; p. 30.
3 “Reduced Staffing: At What Cost?,” John C. Gerard and A. Terry Jacobsen, Fire Service Today, September 1981, pp. 15 and 17; and “Hazard I Fire Hazard Assessment Method,” National Institute of Standards and Technology, U.S. Department of Commerce, June 1991. 4 National Fire Academy, “Manning Levels for Engine and Ladder Companies in Small Fire Departments” (RR No. 14613), Richard C. Morrison.

ENDNOTES

7 The purpose of this manual is to objectively relate staffing to fire fighter safety. Discussion of staffing must also address the level of effectiveness of the fire suppression services. It is expected that fire fighters will aggressively intervene to extinguish a fire. Fire fighter safety and the effectiveness of fire suppression service are closely linked. Fire fighters cannot maintain the same level of aggressive fire suppression services while receiving fewer and fewer resources.

Chapter 2
Staffing for Initial Fire Attack and Fire Fighter Safety Inappropriate reductions merely shift the burden of attempting to maintain the expected level of service to the fire fighter at the expense of his/her own safety. Consequently, fireground productivity and effectiveness are seriously compromised.

Over the last 25 years deviations from the industry’s standard regarding recommended, acceptable levels of staffing per unit of response have seriously compromised fire fighter safety. In 1967, the International City Management Association (ICMA) recommended that engine companies maintain a minimum of 5 personnel, while those operating in “high value” areas require 7 personnel. The ICMA went further to state that “ ladder companies are governed by similar manpower considerations.” Citing the reason for these requirements, ICMA stated:

It is axiomatic that there must be enough men to put fire apparatus into effective use. Three men are needed to place a single line of 2 1/2-inch hose in service. One additional man is needed to operate a pump, plus a foreman so pumper companies require a minimum of five men. 1 FIRE FIGHTER SAFETY

AND EFFECTIVENESS OF

INITIAL FIRE ATTACK

8 Thus a reduction in the “industry standard” regarding the appropriate level of fire company staffing would be justified only in those circumstances where the nature and number of tasks to be accomplished at any given structural fire by fire suppression personnel were also reduced. Fire suppression has always been labor intensive and a substantial impact on productivity in the form of reductions in the number of personnel required at the company level can only be offset by major advances in technology or increased risk to the fire fighter.

Some advances have been made in technology. The industry has developed state-of-the- art apparatus, electronic communications, self-contained breathing apparatus, and personal protective gear. However, none of these advances have eliminated the critical tasks that must be performed by fire fighters at the scene of a structural fire. In fact, these advances in many ways have been offset by introduction of more hazardous materials and construction techniques.

New technologies and materials used in construction and furnishings are more combus- tible and toxic than those in use a quarter century ago, while advances in such areas as SCBA’s and personnel protective gear have in some quarters increased the expectation that fire fighters can perform more aggressive interior fire attacks with fewer personnel.

However, just as it is logical to accept that technologies enhancing fire fighter safety also lead to increased fireground effectiveness, it is also logical to accept that diminished safety correspondingly reduces the effectiveness of fireground operations. Given that structural fire suppression is so labor intensive, reductions in firefighting personnel must inevitably lead to increased injuries unless those reductions are accompanied by viable alternative technologies or the number of critical tasks that must be performed are reduced.

The level of available technology and critical tasks that must be performed at the scene of a structural fire remain essentially unchanged. Today, however, very few jurisdictions operate units with staffing levels of more than 4 fire fighters, with many now suggesting that 2 or 3 fire fighters is an adequate and acceptable level of fire company staffing.

But, as an article in Fire Engineering succinctly put it:

A football coach who sent his team out on the field with six men and then fed the other five in piecemeal as the game progressed would be considered an idiot. Yet this is the same policy that many city officials and their hired consultants are forcing on fire chiefs–always in the guise of greater efficiency and, of course, economy.

One man cannot be called a fire company, no matter how many men are available after he has made a sizeup and hollered for help. Neither can two or three men be considered a fire company. (These are not enough to handle a fair-sized grass fire.)
2 The requirement for initial arriving apparatus to be staffed with at least 4 personnel to initiate an interior fire attack is not new. It has been the fire service standard and industry practice for most of the twentieth century, as well as recognized and recommended by the National Fire Protection Association (NFPA) since at least 1962. The adherence to a minimum level of safety staffing grew out of intuition and experience and is empirically

9 grounded in results from study after study showing the causal relationship of deficient fireground staffing and increased fire fighter injuries.

In 1966, the National Fire Protection Association issued NFPA Standard 197, Training Standard on Initial Fire Attack. This standard set forth the evolutions required for an initial interior attack on working structural fires. The minimum standard required sufficient number of fire fighters and equipment to deploy two attack one-and-one-half inch hose lines producing at least 150 gpm within 60 seconds of arrival, followed by a two-and-one-half inch backup line providing at least 250 gpm within 180 seconds of arrival.

While the NFPA 197 did not specify the number of fire fighters necessary to deliver this required flow, it does specify the tasks that must be performed within a given time period.

Although NFPA 197 was silent on the minimum number of fire fighters necessary to safely conduct these evolutions, the National Fire Protection Association clearly defined in its book, Fire Attack-1, the number of personnel required:

Standard initial fire attack for isolated buildings of average size such as one- or two-story single family dwellings consists of ability to quickly apply 1 1/2-inch attack lines plus at least one standard 250 gpm stream from 2 1/2-inch hose supplied by a pumper. The latter is required for knocking down any heavy volume of fire and for protecting exposures where necessary. Such an attack requires two pumper companies with adequate manning to run the lines and operate the nozzles and pumps, plus a truck company capable of simultaneously performing forcible entry, search and rescue, ventilation, raising of ladders, salvage operations, and operation of the various power tools carried on the truck such as electric generators and lights and smoke removal equipment. The entire opera- tion is directed and coordinated by a chief officer.

The desirable number of men normally required to respond with the apparatus to give this level of performance with properly manned hose streams and equipment would be approximately fifteen plus the chief. An aide who assists the chief in giving orders and in serving as radio communications specialist in contact with the alarm office, supplies the chief with one additional man.

The operation may be performed with slightly less men (but with reduced efficiency) where weaker truck service is provided. In a standard operation, the truck operator is expected to operate the power ladder if needed for ventilation, rescue or access, and also to operate auxiliary power equipment such as generators and to provide the various tools and appliances that are likely to be required during the fire. Therefore, his basic position is with his truck just as a pump operator or ‘engineer’ should be provided with each pumper to give the correct volume and pressure to each hose stream. The balance of the truck crew may be divided into teams. One of these teams would normally be assigned to inside search, rescue, forcible entry and ventilation in support of the fire

NATIONAL FIRE

PROTECTION

ASSOCIATION
(NFPA)

10 attack. The other would be an outside crew for raising ladders (up to 35 feet) for possible rescue as well as for topside ventilation. They would also provide truck support for hose crews assigned to the rear of the fire building. All truckmen should perform salvage operations as soon as practicable.

Hose crew requirements are based upon the need for two men to properly apply each stream from 1 1/2-inch hose and three men to effectively operate a 250 gpm stream from a 2 1/2-inch hand line.
3 (UNDERLIN-

ING ADDED)
Hence, adherence to NFPA 197 required two pumpers and a ladder truck with a total complement of at least 15 personnel. NFPA further stated that:

Ordinarily (except where there are major rescue operations), the greatest manpower is needed for fast application and operation of hand hose streams carried directly to the seat of the fire. Thus, adequate manpower on the initially arriving pumper companies is most essential, and large forces mobilized later cannot be accepted as a substitute for deficiencies in the manning of the first alarm response.
4 The NFPA further cross-referenced the initial attack criteria of NFPA 197 in the Fire Protection Handbook,
5 stating:

Regardless of how companies are organized, response to alarms for structural fires should include sufficient apparatus and manpower under at least one chief officer. Normally, a minimum initial response would be two pumpers, a vehicle for truck service, and 12 to 15 men and a chief. and
An initial response of this level should be able to handle the immediate tactical fire fighting and rescue requirements for structures where there are no major rescue problems, no serious internal or external exposures,

11 and where the possible area involved in fire, heat or smoke normally will be less than 12,500 cubic feet.

It is important to note that in the past edition of its Managing Fire Services, 6 the
International City Management Association not only subscribed to the NFPA 197 Standard, but also endorsed the National Fire Protection Association’s definition relating to the number of personnel required to conduct those initial interior attack operations.

In 1985, a revised Training Standard on Initial Fire Attack was adopted as NFPA 1410. This revised standard continued to maintain that:

The required performance for handlines shall consist of obtaining a water supply through one or two supply lines, placing one initial attack line into operation, and providing immediate backup with another line. and
The total flow of the required streams shall be a minimum of 300 gpm. The initial attack line shall provide a minimum flow of 100 gpm. and
The required flow from the back-up line shall be a minimum of 200 gpm.

12 NFPA 1410 Training Standard on Initial Attack also linked for the first time personnel requirements necessary for interior fire attack and fire fighter safety. Appendix A-3-2.1 of NFPA 1410 states:

The limitation of emergency scene operations to those that can be safely conducted by the number of personnel on the scene is intended to reduce the risk of fire fighter death or injury due to understaffing. While members may be assigned and arrive at the scene of an incident in many different ways, it is strongly recommended that interior fire fighting operations not be conducted without an adequate number of qualified fire fighters operating in companies under the supervision of company officers.

It is recommended that a minimum acceptable fire company staffing level consist of four members responding on or arriving with each engine or aerial ladder company responding to any type of fire. Com- panies responding in high-risk areas should have a minimum accept- able staffing of six fire fighters per ladder company and five fire fighters per engine company. These recommendations are based on experience from actual fires and in-depth fire simulations, critically and objectively evaluating fire company effectiveness. These studies indicate signifi- cant reductions in performance and safety when crews have fewer members than the above recommendations. Overall, five-member crews were found to provide a more coordinated approach for search and rescue and fire suppression tasks. (
See NFPA 1500, Standard on
Fire Department Occupational Safety and Health Program, A-6-2.1.) (UNDERLINING ADDED)
This language in NFPA 1410 for complying with safe minimum staffing per unit also appears in NFPA 1500 Standard on Fire Department Occupational Safety and Health Program:

The limitation of emergency scene operations to those that can be safely conducted by the number of personnel on the scene is intended to reduce the risk of fire fighter death or injury due to understaffing. While members can be assigned and arrive at the scene of an incident in many different ways, it is strongly recommended that interior fire fighting operations not be conducted without an adequate number of qualified fire fighters operating in companies under the supervision of company officers.

It is recommended that a minimum acceptable fire company staffing level should be 4 members responding on or arriving with each engine and each ladder company responding to any type of fire. The minimum acceptable staffing level for companies responding in high-risk areas should be 5 members responding or arriving with each engine company and 6 members responding or arriving with each ladder company.

These recommendations are based on experience derived from actual fires and in-depth fire simulations and are the result of critical and

13 objective evaluation of fire company effectiveness. These studies indicate significant reductions in performance and safety where crews have fewer members than the above recommendations. Overall, 5 member crews were found to provide a more coordinated approach for search and rescue and fire suppression tasks.

During actual emergencies, the effectiveness of companies can become critical to the safety and health of fire fighters. Potentially fatal work environments can be created very rapidly in many fire situations. The training and skills of companies can make a difference in the need for additional personnel and in reducing the exposure to safety and health risks to fire fighters where a situation exceeds their capabilities. 7 This direct linkage between NFPA 1410 and NFPA 1500 specifically indicates that the number of personnel required to successfully conduct an initial interior fire attack is not just a service issue but most importantly an issue of fire fighter safety.

Acknowledging this linkage, the National Fire Protection Association again endorsed a minimum initial attack staffing level. In its 1991 version of the Fire Protection Handbook, the
NFPA produced its most strongly worded statements on fireground staffing to date:

The effectiveness of pumper companies must be measured by their ability to get required hose streams into service quickly and efficiently. NFPA 1410, Training Standard on Initial Fire Attack, should be used as a guide in measuring this ability. Seriously understaffed fire companies generally are limited to the use of small hose streams until additional help arrives.

Often this action may be totally ineffective in containing even a small fire and in conducting effective rescue operations.
8 and
Critical task analysis indicates that fewer than eleven fire fighters would be most hard pressed to accomplish safe, effective, initial interior fire attack in a timely manner at a detached single-family dwelling. 9

14 Typical Initial Attack Response Capability Assuming Interior Attack and Operations Response Capability
High-Hazard Occupancies (Schools, hospitals, nursing homes, explosive plants, refineries, high-rise buildings, and other high life hazard or large fire potential occupancies)
At least 4 pumpers, 2 ladder trucks (or combination apparatus with equivalent capabilities), 2 chief officers, and other specialized apparatus as may be needed to cope with the combustible involved, not less than 24 fire fighters and 2 chief officers.

Medium-Hazard Occupancies (Apartments, offices, mercantile and industrial occupancies not normally requiring extensive rescue or fire fighting forces) At least 3 pumpers, 1 ladder truck (or combination apparatus with equivalent capabilities), 1 chief officer, and other specialized apparatus as may be needed or available; not less than 16 fire fighters and 1 chief officer.

Low-Hazard Occupancies (One, two- or three-family dwellings and scattered small businesses and industrial occupancies)
At least 2 pumpers, 1 ladder truck (or combination apparatus with equivalent capabilities), 1 chief officer, and other specialized apparatus as may be needed or available, not less than 12 fire fighters and 1 chief officer.

Rural Operations (Scattered dwellings, small businesses, and farm buildings) At least 1 pumper with a large water tank (500 gal [l. 9m3] or more), one mobile water supply apparatus (1000 gal [3.78m3] or larger), and such other specialized apparatus as may be necessary to perform effective initial fire fighting operations; at least 12 fire fighters and 1 chief officer.

Additional Alarms
At least the equivalent of that required for Rural Operations for second alarms; equipment as may be needed according to the type of emergency and capabilities of the fire department. This may involve the immediate use of mutual aid companies until local forces can be supplemented with additional off-duty personnel. In some communities, single units are “special called” when needed, without always report- ing to a multiple alarm. Additional units also may be needed to fill at least some empty fire stations.

In its second edition of Managing Fire Services published in 1988, the International City Management Association (ICMA) supported the minimum level for safe fireground staffing called for in NFPA 1410 and NFPA 1500:

Fire suppression operations have three basic functions: (1) rescue; (2) work involving the ladder, forcible entry, and ventilation; and (3) the application of water through hose lines. Rescue and ladder companies handle the first two, and engine companies the third. To raise ladders, ventilate, search, and rescue simultaneously takes quick action by at least four and often eight or more firefighters, each team under the supervision of an officer. The number of firefighters required to search and rescue should never be fewer than two and typically at least four. The number of firefighters needed to advance and operate one hose line varies from two on smaller lines to four on large hand lines.

The standard formula for determining the volume of water needed and the number of hose lines to be advanced at a working structural fire is based The NFPA went further in its recommendations as to the number of personnel and equipment necessary to perform an interior structural fire attack by type of hazard involved as follows:

INTERNATIONAL CITY

MANAGEMENT

ASSOCIATION (ICMA)

15 on a minimum of two engine companies with at least eight firefighters.

This formula calls for the discharge of three gallons of water per minute for every 100 cubic feet of involved fire area with typical fire loading. An area of 40 feet by 40 feet with 8-foot ceilings requires 384 gallons per minute. Two hose lines are needed to produce that flow, and a third line to cover the floor above. Exposure coverage and search and rescue are not yet taken into consideration, but already eight or nine hosemen are needed, plus the pump operators, plus the supervisor.

Various controlled and statistically based experiments by some cities and universities reveal that if about sixteen trained firefighters are not operating at the scene of a working fire within the critical time period, then dollar loss and injuries are significantly increased, as are the square feet of fire spread.

As firefighting tactics were conducted for comparative purposes, five- person fire suppression companies were judged to be 100 percent effec- tive in their task performance, four-person companies 65 percent effec- tive, and three-person companies 38 percent effective; six person compa- nies are judged 20 percent faster than four person companies. 10 The linkage between fire fighter safety and the number of personnel on the initial fire attack has been demonstrated in study after study. In 1982, the U.S. Fire Administration conducted a survey of over 150 fire departments as to current crew size and standard response practices. 11 When asked to identify those factors that were most important in determining crew size and initial response, fire chiefs and city managers ranked crew safety at the top of the list.

CENTAUR / FEMA
STUDY

16 Ohio State University, in a 1980 study of actual fireground operations of the Columbus, Ohio Fire Department, developed data on fire fighter injuries and rate of fire spread involving 404 structural fires. The data showed that when the total number of fire fighters at the scene fell below 15 the rate of fire fighter injuries per 10 residential structural fires increased 46.7%, and the number of fires which spread beyond 25 square feet per 10 residential fires increased 24%.

Rate Per 10 Fires
Number of Fires
Fire Which Spread
Fighter Beyond 25
Fireground Staffing: Injuries Square Feet
I. Residential
Less Than 15 Fire Fighters 2.2 3.6
15 or More Fire Fighters 1.5 2.9
Difference 46.7% 24.1%
II. Large Fire Risk
Less Than 23 Fire Fighters 5.9 3.4
23 or More Fire Fighters 3.4 2.9
Difference 73.5% 17.2%
SOURCE: Ohio State University
The data associated with large risk fires such as high-rise apartments, etc., showed that staffing had an even more dramatic impact on fire fighter injuries. When fireground staffing was reduced in those types of structural fires to less than 23 personnel, the rate of fire fighter injuries per 10 structural fires increased 73.5%, while the number of fires which spread beyond 25 square feet per 10 fires increased nearly 17.2%.

In 1982, the NFPA’s Fire Service Today published the results of a study conducted by the Seattle Fire Department.

Based on a series of textbook training drills and live fire drills, the Seattle Fire Department calculated model effectiveness indices of various levels of manpower as follows:
3 Person 4 Person 5 Person 6 Person
Engine 45% 59% 79% 100%
Ladder N/A 57% 78% 100%
These effectiveness indices related to the time required to successfully complete all the given tasks required by a particular evolution in the initial fire attack. The study concluded that:

These effectiveness indices relate to the time taken to accomplish an objective. A large index means a shorter time. Specifically, if a six-man engine takes 5 minutes to accomplish an objective, a three-man engine will require 5
÷ .45 = 11.1 minutes to accomplish the same objective; a four- man engine will take 5 ÷ .59 = 8.5 minutes, and a five-man engine will take 6.33 minutes. (Seattle did not examine levels of manpower greater than six men.) The same process was used to compare ladder company evolution times.

COLUMBUS , OH FIRE

DEPARTMENT STUDY

SEATTLE , WA FIRE

DEPARTMENT STUDY

17 The conclusion is that doubling the manpower from three to six men more than doubles the team’s effectiveness. There is a synergetic effect at work....

While the Seattle Fire Department’s main objective was to produce an appropriateness of service model, unpublished data on fire fighter injuries relating to various levels of staffing were also examined. At the time of the Seattle study, the fire department consistently operated engine and truck companies with varying levels of staffing. To test the relationship between staffing effectiveness and fire fighter injuries, Jon Cushman of the Seattle Fire Department, undertook three separate analyses over a 5-year period.

The results of each analysis yielded the same results:

Average time per disability increased as company strength decreased for both types of companies.

One analysis performed by Cushman examined the Seattle Fire Department’s disability report statistics. The results of this analysis indicated that the rate of fire fighter injuries expressed as total hours of disability per hours of fireground exposure were 54% greater for engine companies staffed with 3 personnel when compared to those staffed with 4 fire fighters, while companies staffed with 5 personnel had an injury rate that was only one-third that associated with 4-person companies.

Average Man- Total Total Total Frequency Severity
Hours Per Disability Number Man-Hours (Column #4 (Column #4 Unit Disability Hours Disabilities At Fire Into #3) Into #2) 3-Man Engine 90.607 2,537 28 12,660 .00221 .20
4-Man Engine 58.375 1,401 24 10,460 .00229 .13
5-Man Engine 49.500 99 2 2,125 .00094 .05
6-Man Engine 59.517 1,726 29 12,924 .00224 .13
4-Man Ladder 58.000 986 17 3,964 .00429 .25
5-Man Ladder 20.455 450 22 4,895 .00449 .09
6-Man Ladder 45.857 642 14 6,366 .00220 .10
SOURCE: Seattle Fire Department
An even more telling statistic relates to severity rates in Cushman’s subsequent analysis that also concluded that average hours per disability associated with 3-person company staffing was nearly 50% greater than those occurring when units were staffed with 4 and 5 personnel.

18 The Dallas Fire Department, in 1969 and again in 1984, also conducted textbook drills and live fire tests to compare effectiveness among various levels of staffing. 12 The study concluded
that deficient levels of staffing will result in an inability to cover critical tasks. As the numbers of fire fighters decrease without eliminating any of the tasks to be accomplished the Department must delay some of the required tasks or attempt to perform all the tasks unsafely with inadequate staff.

Consequently, the Dallas Fire Department concluded that in a residential fire:

The five-person crews demonstrated a more coordinated and effective attack on the fire and search and rescue operation, while The four-person crew was capable of performing satisfactorily in control- ling the fire and in effecting the rescue operation.

The study’s conclusion regarding the three-person crew was that not all the required critical tasks could be accomplished within a given time span. Regarding the three-person crew, the report stated:

At this level there was little margin for error and any appreciable delay in arrival might place the control of the fire beyond their capability.

This is an extremely important statement given that the Dallas Fire Department took great care to insure that improvements in the time it took to complete each critical task was not made at the expense of sound operating practices or safety. However, this would not be the situation in actual fireground operations. Fire fighters operating in understaffed environments are too often expected to perform beyond their capabilities.

The Dallas study, in addressing this issue, indicated that inadequate staffing resulted in:
• A cumulative effect created by combined delays and lost functions on the part of each crew resulting in an even greater loss of overall effective- ness;
• Increased physiological stress on fire fighters as they try to compensate for the lower staffing level; and
• Increased risk to the fire fighters when aggressive procedures are undertaken without the support necessary to complete them safely. 13 The National Fire Academy also noted in a research project developed for its Executive Development III Program that:

In 1977 a test was conducted by the Dallas Fire Department, which consisted of a simulated fire involving several rooms at the rear of the third floor of an old school. This simulated fire was being done to determine how long it took a three, four, or five man team to advance its line to this area, get water on the fire, and to check each individual’s physical condition afterwards. Timing began as each engine company entered the school yard.

DALLAS , TX FIRE

DEPARTMENT STUDY

19 The average time of the Engine Companies is revealing. The first consisted of a three-man team and their average was 18.18 minutes. All personnel were exhausted, rubber legged, had difficulty standing up and all three were unfit for further fire fighting.

The four-man team conducting the very same test, averaged 10.29 minutes and upon completing they were nearing exhaustion.

Next came the five-man team which averaged 6.15 minutes, and after- wards all showed little evidence of fatigue.

14 The Academy’s project report went on further to state:

The implication is that when a smaller work force, using the same heavy equipment, has to do the job that was done in the past by a larger workforce, injuries of this nature will continue to increase. Injuries to back and knees are injuries that take a long time to correct. The cost to the city and department are heavy.
15 In 1984, the U.S. Fire Academy introduced the training manual Fire Risk Analysis: A System’s Approach. The manual stated that suppression capability must be measured to include both initial attack operations that attempt to quickly deal with marginal situations before they get out of control, and sustained firefighting procedures that can be put into operation against major fires. In addition to the ability to apply water to the fire, the analysis emphasized that the size of the fireground workforce must be of sufficient size in order to simultaneously have the ability “to engage in search and rescue, forcible entry, ventilation, preservation of property, and additional support activities as required by the situation.” The U.S. Fire Academy further stated that time is a critical factor in determining the effectiveness of the tasks with the expectation for the fire to increase until sufficient personnel are assembled to overcome it.

Thus, interior offensive tactics should be measured by the ability to place effective handlines in operation in interior positions and the attempt to gain control of the fire before it exceeds the assembled workforce’s capability. This involves assigning personnel to a myriad of activities contingent upon the nature and complexity of the target hazard.

Initial attack capability must be measured in terms of a reflex action by the fire department.

Upon receiving an alarm, the department must be able to respond quickly and with the necessary equipment and personnel to put a fire attack into motion without delay.

Based on the above objectives, the U.S. Fire Academy concluded that in order to safely conduct an effective interior attack required at least 15 personnel distributed as follows:

U.S. FIRE ACADEMY

FIRE RISK ANALYSIS

20 Hoselines:
2 personnel per attack line (1- 1/2 inch lines – 100 gpm) = 2 2 personnel per attack line (1- 3/4 inch lines – 150 gpm) = 2 2 personnel per backup line (2 inch line – 200 gpm) = 2 1 personnel to operate each pumper = 2
Search and Rescue Operations:
1 of 2 personnel team for every 2,000 sq. ft. = 2
(residential occupancies)
Support Functions:

At least 1 fire fighter to perform forcible entry, utility control, and related support functions for each hand-
line placed in operation = 2
Ventilation:

At least 2 personnel to perform ventilation = 2
Command:

At least 1 individual assigned as fireground commander = 1 TOTAL PERSONNEL REQUIRED 15
In December 1991, the Phoenix, AZ Fire Department developed the Fire Department Evaluation System (FIREDAP) to precisely identify the components and objectives for complying with the NFPA’s 1410 Training Standard on Initial Fire Attack. 1 6
This evaluation
system involved responding to and extinguishing a working fire in a single story residential structure of 2,000 square feet with no exterior exposures.

The Department concluded that to safely conduct an aggressive interior attack based on standard evolutions and the critical tasks that needed to be accomplished required 15 personnel distributed as follows:
4 personnel on each engine = 8 personnel
4 personnel on truck = 4 personnel
2 personnel in BC vehicle = 2 personnel
1 personnel on utility vehicle =
1 personnel
TOTAL 15 personnel
It is important to note that the Phoenix study indicated that one of the primary objectives of the first arriving engine company was to “utilize hose line for fire control and personnel protection.”
It should be further noted in the Phoenix study’s findings that the initial attack ultimately required at least 15 personnel on the scene. This is consistent with previous studies such as the Dallas, Ohio State University and Seattle studies, ICMA’s Managing Fire Services,
NFPA’s Fire Attack-1, NFPA’s Fire Protection Handbook, and NFPA’s Training Standard on Initial Attack.

FIRE DEPARTMENT

EVALUATION SYSTEM
(FIREDAP)

21 AUSTIN , TX FIRE

DEPARTMENT STUDY
These studies not only form the basis for the “industry standard and practice” for training but also are the basis for the actual response to structural fires which will require aggressive and offensive actions including interior attack.

In 1993, the Austin Fire Department embarked on a study to determine whether companies staffed with 4 fire fighters were safer and more effective than the 3 person companies the Department was currently deploying. In order to compare the effectiveness, physiological impact on fire fighters and Austin Fire Department injury rates at various staffing levels, the Fire Department conducted drills consisting of a series of common fireground tasks divided into three scenarios: a simulated two-story residential fire, a simulated aerial ladder evolution, and a simulated engine company highrise fire.

These simulations revealed, once again, that regardless of the experience or how prepared fire fighters are, with an insufficient number of personnel to conduct the tasks efficiently, life and property continue to suffer inevitably. Severity and the degree of hazard increases until controlled or the fire passes the critical point. Consequently, the Austin Fire Department concluded that the effectiveness significantly improved when the company was increased from 3 to 4 personnel. The Austin Fire Department’s report stated:

In the two-story residential fire the efficiency or time improvement between the three person and four person crews was 73%.

In the aerial ladder evolution the efficiency improvement between three and four person crews was 66%.

In the engine company high-rise fire the efficiency improvement between three and four person crews was 35%.

Averaging all scenarios the improved efficiency was 58%.

The Austin study also examined the physiological impact of increased company level staffing had on fire fighters. Before and immediately after the completion of each scenario, medical evaluations including pulse, respiration, blood pressure, EKG strips, body temperature, and visual assessment were given to each fire fighter.

Not surprisingly, the crews consisting of 4 fire fighters recorded a notable decrease in the pulse rate (cardiovascular stress level) and respirations than did 3 person crews:

For three person staffs the average pulse rate per minute, post drill, was 127.28; whereas, the average pulse rate per minute for four person staff was 119.69. This is a 16% difference rate increase with the two crews having equal baseline pulse rates.

Air consumption for each firefighter working on a four-person crew as opposed to a three person crew decreased by 53%. The dramatic decrease was determined to be a result of less exertion involved in the exercises with four-person crews.

Visual assessment of each firefighter verified the additional exhaustion level of the three person crew members.

22 In addition to the fireground simulations, the Austin Fire Department also reviewed injury reports involving 136 emergency incidents to which 1,938 fire fighters responded from 1989 to 1992. The analysis revealed:

Four- and five-person crews’ injury rate was 5.3 per 100 firefighters; while
Three-person companies experienced an injury rate of 7.77 injuries per 100 firefighters – a 46% higher rate than the larger crews.

Upon its conclusion, the Austin staffing study had exactly confirmed the results the Dallas study conducted some ten years earlier. The Austin Fire Department had found that inadequate staffing directly caused the following problems:
• A higher risk for victims due to delays which are indirectly related to likelihood of survival;
• A loss of critical functions;
• An increased loss of overall effectiveness as a result of combined delays and loss of critical functions;
• Higher physiological stress on fire fighters as they attempt to compensate for lower crew size;
• Higher risk to fire fighter safety as aggressive procedures are conducted without the necessary support.

The Austin study concluded that increased staffing levels from 3 to 4 provided substantial benefits such as:
• A smaller number of multiple alarms;
• Lower fire damage dollar loss and higher loss/save ratio; • Fewer injuries/deaths for civilians and fire fighters; • Fewer Worker’s Compensation for fire fighters;
• Retainment of tax base properties; and
• Lower civil liability for the City and the Fire Department.

23 It was this concept of ignoring “industry standards” that was the basis of a 1989 complaint filed by the Division of Occupational Safety and Health of the Nevada Department of Industrial Relations against the Clark County Fire Department. Nevada OSHA’s regulations maintain that an employer shall not:

Require, permit or suffer any employee to go or be in any employment or place of employment which is not safe and healthful.

Fail to furnish, provide and use safety devices and safeguards or fail to adopt and use methods and processes reasonably adequate to render such employment and place of employment safe and healthful.

Fail or neglect to do every other thing reasonably necessary to protect the life, safety and health of such employees....
17 Citing that the Clark County Fire Department had prior knowledge that units staffed with 3 personnel were unsafe, N.D.O.S.H. issued a complaint that the Fire Department had willfully violated the industry standards relating to fire fighter safety. In late 1990, the N.D.O.S.H. agreed to vacate the violation when the Clark County Fire Department stipulated that it would immediately “maintain minimum staffing levels at each fire station so that no engine or ladder truck shall be dispatched from a fire station, manned with less than four persons.” In addition, the stipulation entered into by the Fire Department stated that:

Any engine or ladder truck manned with less than four persons shall be defined to be “unsafely manned.”
The body of evidence and industry practice over the last quarter century certainly indicates that the adherence to a minimum safe fireground staffing level is professionally appropriate.

In 1993, the Fire Marshal of Ontario (Canada) Research Project embarked on a study to thoroughly examine the tasks which 3- and 4- person crews could safely accomplish. The project determined that 3-person crews are very limited in their firefighting capabilities. It is found that until additional assistance has arrived on the scene, the following cannot be accomplished safely:
• deployment of back-up protection lines;
• conducting interior suppression or rescue operations; • ventilation operations requiring access to the roof of the involved structure;
• the use of large (65mm) hand-held hose lines;
• the establishment of a water supply from a static source within the reasonable time limits.

ENFORCING AN

INDUSTRY STANDARD
(CLARK CO., NV

FIRE DEPARTMENT )

ONTARIO FIRE

MARSHAL STUDY

24 In addition, the companies’ 3-person crews were not of sufficient size in order to provide the necessary breaks to recover from metabolic heat and exhaustion during incidents requiring abstained fireground operations.

Four-person crews were also determined to be substantially more effective versus 3-person crews once a water supply from an external source is established. Such additional tasks which may be accomplished by a 4-person crew include:
• two person interior search and rescue with no hand-held back-up line; • two person interior structure firefighting with no rescue component and no hand-held back-up line;
• limited roof level ventilation operations:
• laddering operations; and
• salvage operations.

Four-person crews, depending on the circumstance, may also be capable of completing the following:
• use of large (65mm) diameter hand lines;
• establishment of a water supply from a static source; • establishment of a second point of entry and approach to the fire location in the structure; and
• preparing for a second area of search and rescue for person(s) in need of rescue.

The study further concluded that the addition of one crew member allows for increase command and pumper operations as the driver or supervisor is given a single function.

At their 1992 annual meeting, the Metropolitan Fire Chiefs Division of the IAFC not only endorsed the assembly of at least 4 fire fighters before initiating an interior attack, but went further stating:

In order to permit the effective operation of fire companies at the scene of a structure fire, the minimum number of personnel on both engine and ladder companies should be five members per unit.

In support of its position and addressing the impact that inadequate fireground staffing has on fire fighter safety, the IAFC’s Metro Chiefs listed the following points:

METROPOLITAN FIRE

CHIEFS AND

MINIMUM STAFFING

25 A fire company should be able to function as an independent unit at the scene of a fire in order to permit the Incident Commander to employ the proper tactics and strategies to safeguard the occupants of the building, as well as the operating force, and to protect the property of the citizens.

Whenever understaffing necessitates the combination of two companies to accomplish a specific task at the scene of a fire, which normally could be completed by one effective unit, the standard operating procedures are dramatically and adversely affected.

Proper fire fighting procedures require strategies that result in the commitment of fire companies not only to the area involved on arrival, but to the internal and external exposures as well, if the endangered citizens are to be safeguarded and the property damaged limited. Understaffing prevents the Incident Commander from achieving these essential objec- tives.

To justify the position taken by the Metro Fire Chiefs, there is sufficient documentation available that indicates increased injury rates to occu- pants and fire fighters, as well as higher property losses, are due to an inadequate firefighting force at the scene of a fire.

The Metro Chiefs recognize that current economic difficulties are affect- ing public safety organizations nationwide but these factors do not alter the tasks that must be accomplished at the fire scene.

The decline in the number of members per unit, as well as the reduction in the number of fire companies in cities, have already reached a dangerously low level. To accept or support further reductions is inappropriate.

Any fire chief who attempts to obtain sufficient funding to provide adequate personnel for the protection of the community he serves, even if he fails, is performing his sworn duty to the best of his ability. In doing so, he is conscientiously informing the elected officials and the citizenry of their needs according to his professional judgment and experience.

We believe that our, the Metro Fire Chiefs, position is strong enough to assist all fire chiefs in their efforts to obtain adequate staffing.

This firm position has been taken by the Metro Chiefs solely in the interest of the safety of both those we serve and our nation’s fire fighter.

26 Since the NFPA 1500 Standard on Fire Department Occupational Safety and Health Program was promulgated, the average annual rate of fireground injuries per 1,000 fires has increased by 6.4% as the table below shows.

Rate of Fire Fighter Fireground Injuries Per 1,000 Fires Smoke Inhalation, Wounds, Dislocations,
Eye Injuries, Fractures, Heart Attack,
Total Burns Strains and Sprains
1981-1986 25.22 8.89 13.54
1987-1993 26.83 7.45 15.59
% Change 6.4% (16.2%) 15.1%
Note: Prior to 1981, data was not classified in same manner.

SOURCE: NFPA Annual National Fire Experience Survey
Comparing the average annual rate of fireground injuries for the six-year period prior to the promulgation of NFPA 1500 to the seven-year post NFPA 1500 period reveals that those injuries (i.e., smoke inhalation, eye injuries and burns) most closely associated with SCBA usage and personal protective equipment declined by 16.2%. On the other hand, the rate of fireground injuries for those injuries (i.e., wounds, dislocations, fractures, heart attacks, strains and sprains) associated with understaffed fireground operations increased by 15.1%.

A recent study produced by the IAFF with the cooperation of Johns Hopkins University also reflects the fact that fire fighter injuries are significantly influenced by inadequate staffing.

This analysis compared the rate of injuries per 100 fire fighters and per 100 alarms for cities operating 4-person staffing versus those operating 3-person units.

The analysis showed that:
• Cities which operated fire suppression companies with less than 4 personnel had an injury rate per 100 workers that was 36.3% greater than those cities which had staffing levels of 4 or more; • The percentage of cities having an injury rate of 10 injuries or more per 100 fire fighters was nearly double for those operating with less than 4 person crews as compared to those cities operating with minimum staffing levels of 4 or more;
• Fire fighter injury rates per 100 alarms were an average of 38% greater in cities with minimum staffing of less than 4 personnel per unit; and • 72.5% of the cities staffing with less than 4 had an injury rate per 100 alarms of 0.5 or greater compared to only 35.3% of the cities staffing with at least 4 per fire suppression unit.

INCREASING

FIREGROUND INJURIES

JOHNS HOPKINS

UNIVERSITY STUDY

27 Tests for statistical significance on this data established that such differences in the injury rates associated with 3 versus 4 person staffing are not due to random chance.

The significant effect that increasing staffing from 3 to 4 can have on the rate of fire fighter injuries is apparent from a recent trial experience in Providence, Rhode Island. In order to test the hypothesis that 4 person staffing was safer than units staffed with only 3 fire fighters, the City agreed to provide 4 person minimum staffing on 6 of its 15 units and examine the results.

As the following table shows, the resulting 55.4% drop in fire fighter injuries was so dramatic that the Mayor entered into an agreement with the local union to extend the 4 fire fighter minimum staffing level to all 15 of the Providence Fire Department’s fire suppression units.

COMPARISON OF INJURY RATES IN PROVIDENCE, RI
FOR 3 PERSON VERSUS 4 PERSON STAFFING
% Decrease
# of Emergency in Emer-
Fire Injuries at Scene gency Scene
Suppression Fire Fighters Number of Emergency Injuries Injuries Year Incidences On-Duty Fire Fighters Scene Per 100 F/F Per 100 FF 1989 3,869 83 479 431 90.0
1990 3,871 89 479 339 70.8 21.3%
1991 4,143 98 479 192 40.1 43.4%
TOTAL DECLINE 55.4%
In 1989, minimum staffing per piece was 3 personnel. Beginning in September of 1990, 6 units were staffed with 4 personnel through overtime; beginning in October of 1991, all 15 units were staffed with 4 personnel through overtime.

PROVIDENCE , RI

EXPERIENCE

28 In conjunction with the Providence study, an applied research project was conducted as part of the U.S. Fire Academy’s Executive Officer Program. This project addresses the fire fighter perspective and explores possible areas of discrepancies within the study. Through literature reviews, interviews with the Providence Fire Department Chief, the Fire Department Historian, and a member of the Department of Economic Planning and Development, and examinations of the Providence Fire Department Injury-Exposure Database, the analysis provides substantial evidence in support of the initial Providence staffing study findings:
• a 23.8% decrease in the number of reported injuries;
• a 25% decrease in the number of time loss injuries when staffing increases;
• a 71% decrease in work time lost; and
• a dramatic decrease in the frequency and severity of fire injuries when staffing increases from three- to four-person crews.

The study further concluded that this significant decline in frequency and severity of injuries was not caused by the decrease in the number of fires or incident volume, nor was the drop in fire fighter injuries caused by changes in protective clothing, new safety or operational procedures, substantive training changes, new physical fitness programs, or the implementation of new OSHA programs since these were held constant during the study period. Taking all of these factors into consideration, the analysis concluded that increased staffing from 3 to 4- person crews leads directly to significant reductions in the frequency and severity of fire fighter injuries.

U. S. FIRE
ACADEMY’S FINDINGS

29 In 1993, the National Fire Protection Association (NFPA) included in its Consensus Standard on Fire Department Occupational Safety and Health (NFPA 1500) a requirement addressing the minimum number of fire fighters necessary to initiate an offensive interior attack on a structural fire. This Tentative Interim Amendment (TIA) to the fire fighter safety standard states:

At least four members shall be assembled before initiating interior fire fighting operations at a working structural fire.

However, while the above language was clear as to the minimum number of personnel required to safely
begin interior firefighting operations, it left some confusion as to how personnel would be “assembled.”
Consequently, in 1994, Mr. M.E. Hines, Director of the Texas Commission on Fire Protection, sought formal clarification from the NFPA on this issue. NFPA’s formal interpretation of how the 4 fire fighters should assemble is as follows:
...when a company is dispatched from a fire station together as a unit (which includes both personnel responding on or arriving with apparatus), rather than from various locations, the standard recommends that the company should contain a minimum of four fire fighters.

The National Fire Protection Association (NFPA) interpretation of the Standard goes even further to address “high risk” fires:

It should be noted that four fire fighters is a baseline recommended minimum for ‘any type of fire.’ For companies responding in ‘high risk areas’ a higher minimum of 5 responding or arriving with each engine company and 6 responding or arriving with each ladder company is recommended.

The Occupational Safety and Health Act of 1970, signed into law on December 29, 1970, was designed to assure so far as possible every working man and woman in the nation safe and healthful working conditions. In administering the Act, the U.S. Department of Labor’s Occupational Safety and Health Administration (OSHA) issues standards and rules for safe and healthful working conditions, tools, equipment, facilities, and processes. OSHA also conducts workplace inspections to assure the standards are followed. Under the Act, employers have the general duty of providing their workers a place of employment free from recognized hazards to safety and health, and must comply with OSHA standards.

Many of OSHA’s standards are not new. Employers have operated under them for years as national consensus standards – those agreed upon by members of groups such as the American National Standards Institute and the National Fire Protection Association – or as federal standards established under other laws, such as the Public Contracts Act. Many of these standards were codified as OSHA standards upon passage of the OSHA act. Included were ANSI standards pertaining to the use of respiratory equipment.

INDUSTRY CONSENSUS

STANDARD ON

FIRE DEPARTMENT

OCCUPATIONAL SAFETY
& HEALTH
(NFPA 1500)

FEDERAL OCCUPATIONAL

SAFETY AND HEALTH
ACT’S “2 IN / 2 OUT”

STANDARD

30 The International Association of Fire Fighters requested officials at Federal OSHA to provide uniform interpretation and compliance information on its standards addressing self- contained breathing apparatus use and the application of these standards to fire fighters responding to hazardous materials incidents
and structural fires. On May 1, 1995, Federal
OSHA issued a compliance instruction to all OSHA Regional and Area Offices, Compliance Officers and State Agencies having responsibility for enforcing safety and health regulations.

This compliance instruction thus not only establishes the link between fire fighter safety and fireground staffing, but also provides for universal interpretation and enforcement of these regulations.

This compliance standard known as the “2 in/2 out” rule provides federally enforced protection for all professional fire fighters, whether state, county, or municipal, in any of the states or territories where an OSHA State Plan agreement is in effect. The following 25 states/ territories have State OSHA Plans:

Alaska Kentucky North Carolina Virginia
Arizona Maryland Oregon Virgin Islands
California Michigan Puerto Rico Washington
Connecticut Minnesota South Carolina Wyoming
Hawaii Nevada Tennessee
Indiana New Mexico Utah
Iowa New York Vermont
While there is not universal occupational health and safety coverage for all U.S. and Canadian fire fighters, these regulations must be considered the minimum acceptable standard for safe fireground staffing when self-contained breathing apparatus is required to be used.

Thus, this interpretation is appropriate evidence for arbitration and grievance hearings on fire fighter safety.

In addition, Executive Order 12196 issued February 26, 1980 and implemented December 21, 1980 requires that all federal agencies comply with the same safety and health requirements as private employers. Thus, federal fire fighters are protected under Federal OSHA safety and health standards, including this interpretation.

The U.S. Environmental Protection Agency (EPA) has promulgated a standard that adopts the OSHA Hazardous Waste Operations and Emergency Response Standard (29 CFR 1910.120) to protect employees who work in the public sector where there is not an OSHA approved State program in place (40 CFR 311). Additionally, EPA and OSHA have agreed that all interpretations regarding compliance with HAZWOPER will be made by OSHA. Thus, those fire fighters in the 27 non-OSHA states and other U.S. territories (e.g., Guam, Canal Zone) making a response to emergency operations where there is a potential release of
hazardous substances, as defined by this standard, are covered by the interpretation.

The substance of Federal OSHA’s “2 in/2 out” standard is as follows:
• The HAZWOPER standard requires the use of the buddy system with standby personnel for emergency response operations involving the release of hazardous substance(s) producing IDLH conditions for employees responding. The regulation specifies a minimum of four personnel, two as a team in the buddy system and two standby backup personnel, to conduct operations in hazardous areas safely.

31 • The use of SCBA’s in IDLH atmospheres for circumstances not covered by HAZWOPER is covered by the Respiratory Protection standard which requires two standby personnel to be present outside the IDLH hazard area. Failure to have two standby persons for a known, existing IDLH, e.g., an interior structural fire, would be a violation of 1910.134 (e)(3)(ii).
• The Fire Brigade standard covers employers whose employees perform interior attack on interior structural fires and references the Respiratory Protection standard’s requirements above.
• The National Fire Protection Association (NFPA) recognizes that fire fighters must operate in teams of two or more when conducting interior structural firefighting operations; failure to respond with teams of two or more would be a violation of the General Duty Clause. • The Respiratory Protection standard and industry practice (as codified through the NFPA standards) require that a minimum of four fire fighters be involved in emergency operations during interior structural firefighting. Two act as a team in the hazard area, and two stand by outside the hazardous area to monitor the operation and provide assistance should a rescue be necessary.
• OSHA regulations and NFPA standards specifically require communication between members of the team. Fire fighters working in teams of two or more (buddy system) in hazardous areas (IDLH atmospheres) are required to maintain communications (voice, visual contact, or tethering with a signal line). Radios or other means of electronic contact shall not be substituted for direct visual contact between employees within the individual team in the danger area. • One of the individuals outside of the hazard area may be assigned more than one role, such as the incident commander in charge of the emergency or operator of fire apparatus, where it does not jeopardize worker safety and health.

Clearly, the evidence establishes the connection between staffing and fire fighter fire- ground injuries. So long as understaffed fire suppression units are expected to initiate and perform sustained interior attack operations involving structural fires, the rate of fireground injuries will continue to increase at alarming rates.

32 1
Municipal Fire Administration, International City Managers’ Association (Chicago, IL:

ICMA) 1967; pp. 161-162.
2 “Manpower – How Much Do You Need?” James F. Casey, Fire Engineering, October 1969; p. 112.
3 Fire Attack-1 Command Decisions and Company Operations, Warren Y. Kimball (Boston, MA:NFPA) 1966; pp. 20-21.
4 Ibid.; p. 44.
5 Fire Protection Handbook, 13th Edition, National Fire Protection Association (Quincy, MA:

NFPA) 1969; pp. 10-24 and 10-25.
6 Managing Fire Services, International City Management Association (Washington, DC:

ICMA) 1979; p. 80.
7 Standard on Fire Department Occupational Safety and Health Program, NFPA No. 1500, National Fire Protection Association, 1992; Appendix A-6-4.1. 8 Fire Protection Handbook, 17th Edition, National Fire Protection Association (Quincy, MA:

NFPA) 1991; p. 10-41.
9 Ibid.; p. 10-40.
10 Managing Fire Services, 2nd Edition, International City Management Association (Washington, DC:ICMA) 1988; pp. 119-120.
11 “Report on the Survey of Fire Suppression Crew Size Practices, “ Centaur Associates conducted for FEMA, June 30, 1982; pp. 18-20.
12 “Dallas Fire Department Staffing Level Study,” McManis Associates & John T. O’Hagan & Associates, June 1984; pp. II-1 through II-7.
13 Ibid.; p. I-2.
14 “Fire Engines Are Becoming Expensive Taxi Cabs—Inadequate Manning,” National Fire Academy, Executive Development III Program, 1981; p. 4. 15 Ibid.; p. 2.
16 “Fire Department Evaluation System (FIREDAP),” Phoenix, AZ Fire Department, December 1991; p. 1.
17 State of Nevada NRS 618.385.

ENDNOTES

33 In any community, the level of service provided by the fire department is based on factors such as community expectations, financial resources, and political decisions. Fire fighter safety and requirements for performing successful interior structural fire attacks should not be subject to political debate.

These precepts are best described in a statement by the International City Management Association (ICMA):

The fire control system is by far the most costly element of a fire department’s operations and should be designed and operated in the most cost-effective fashion. (The value of ‘cost-effectiveness’ is determined by definition at each local level of government and will vary from community to community. This variation results from the process of balancing the accepted or tolerated risk against the actual risk in each community.) One three or four man company costs several hundreds of thousands of dollars per year. A fire control company not needed or poorly utilized represents a significant financial waste.

On the other hand, too few companies, or
poorly manned ones, can result in property and life loss beyond commu- nity accepted norms. Also, the cost of a firefighter death or a disabling injury may far exceed the expense of a fire company. This is not to say that there is a fixed value on a life or injury. The point is that the firefighting forces are the asset that protects the community’s economic and tax base as well as its health and welfare. This asset is a valuable one and must be carefully provided and wisely managed.

There is no single problem or solution to be found when a community’s fire control system is designed, although many fire chiefs and managers are engaged in just such a search. But such an attempt merely illustrates a lack of understanding of the complexities of what constitutes an adequate fire protection delivery system.
1 (UNDERLINING ADDED)
In its 1988 edition of Managing Fire Services, ICMA suggested an overall master plan for providing safe and effective fire suppression services:

A prudent response pattern needs quick response times as well as a sufficient number of firefighters for the immediate attack.

Officials need to establish a maximum response time following receipt of the dispatch instructions at the station. In some urban areas, one and a half minutes are considered a desirable maximum, whereas in other urban areas the number is set at two and a half or three. Obviously, the response time policy varies according to the fire danger, the ability of the munici- Chapter 3
Local Jurisdiction’s Overall Fire Protection Requirements

34 pality to locate stations and staff apparatus, and traffic speed. Average urban response speed is usually about 20 miles per hour. Once fire apparatus and personnel arrive at the scene, their initial activities require several more minutes.

Considering that the time required for flashover in structural fires with standard fuels is typically about seven minutes, the apparatus and fire- fighters must arrive and get operating very quickly. If it takes a resident two or three minutes to discover and report a fire and three minutes for the apparatus to be dispatched and arrive, the sizing up and initial attack need to be done in a minute or two, or the typical fire will have grown significantly in size. An unconscious person with depleted oxygen will typically suffer permanent brain damage after approximately four min- utes. All of this needs to be considered within the context of multiple alarm fires and simultaneous alarms. Delayed response and understaffed response appear inevitable under those circumstances, unless planning is complete.

One task, then, in evaluating suppression ability is to determine how fast adequate firefighting forces can arrive at the scene of an incident and launch rescue operations, if needed, plus initial fire attack. Once the community or the evaluation team has determined satisfactory parameters for the size of the initial attack team and response time and has measured the local situation, it can judge how satisfactory the response is.

Often the
response time is longer than officials expected, especially if the time span is measured from the moment the alarm was received to the actual initial attack. Team size may not be satisfactory until several vehicles arrive, and this time delay must be considered as well. The efficiency of the attack team will be greatly diminished if an optimum number are not working at the scene.
2 (UNDERLINING ADDED)
Thus, if successful and safe, initial interior structural fire attack minimally requires at least:
• 4 fire fighters arriving with the first due engine,
and
• total fireground resources of 15 to 16 personnel staff- ing 2 pumpers and 1 ladder truck,
the only additional piece of the equation is response time.

Response time involves four elements: detection time, alarm processing time, turnout time and travel time. For the first of these elements — detection time — no reliable data or analysis exists.

However, for the two elements involving alarm processing 3 and turnout time,
4 the
International Association of Fire Chiefs’ Accreditation Committee recently completed an analysis.
5 The study indicated that in “staffed departments” the average time required to process the alarm was 53.76 seconds, while the average turnout time was 57.55 seconds.

RESPONSE TIME

35 On the basis of the International City Management Association statement that fire apparatus in an urban setting can average about 20 miles per hour, travel time involving distances of 1 mile is approximately 3 minutes. Therefore, the total average response time of “staffed departments” approximates 5 minutes from receipt of the alarm to arrival at the scene.

The response times for fire suppression are also consistent with those recommended by the American Heart Association (AHA) for delivery of pre-hospital emergency medical care. The AHA’s emergency medical services maximum response time recommendation has been 4 minutes for initiation of basic life support (BLS) and 8 minutes for initiation of advanced life support (ALS).

Recently the AHA reconfirmed this recommendation by stating:

For cardiac arrest, the highest hospital discharge rate has been achieved in patients in whom CPR was initiated within 4 minutes of arrest and ACLS within 8 minutes. Early bystander rescue breathing or CPR intervention and
fast emergency medical services (EMS ) response are therefore essential in improving survival rates.
6 (UNDERLINING ADDED)
In 1992, the National Conference on Cardiopulmonary Resuscitation and Emergency Cardiac Care, listed among its recommendations that all fire-fighting units be equipped with and trained to operate automatic external defibrillators and the following recommendation regarding minimum staffing per EMS response:

Early ACLS provided by paramedics at the scene is another critical link in the management of cardiac arrest. EMS systems should have sufficient

MINIMUM STAFFING

AND RESPONSE TIMES

REQUIRED FOR

DELIVERY OF

EMERGENCY MEDICAL
CARE

36 staffing to provide a minimum of two rescuers trained in ACLS to respond to the emergency. However, because of the difficulties in treating cardiac arrest in the field, additional responders should be present.

In systems that
have attained survival rates higher than 20% for patients with ventricular fibrillation, the response teams have a minimum of two ACLS providers plus a minimum of two BLS personnel at the scene. 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... 7 (UNDERLINING ADDED)
Given the total requirements of firefighting personnel and equipment to safely conduct an initial interior structural fire attack and provide pre-hospital emergency medical care accord- ing to the industry’s standard, the only politically driven decision that is appropriately within a local community’s discretion is response times. For it is through its decision regarding these response times that the local community defines the acceptable level of risk in providing the delivery of fire suppression services.

The International City Management Association (ICMA) defines just such a set of tactical fire suppression goals as the following:

For all structural fires, to deploy one engine company within five (5) minutes and an additional engine company, one ladder company, one paramedic unit, and one chief officer within ten (10) minutes for 90 percent of all alarms in areas with a required fire flow of 4,500 gallons per minute (GPM) or less. For all areas over 4,500 GPM, the first engine and truck (ladder) must arrive within five (5) minutes for 90 percent of all alarms.

The lapsed time (reflex time) is to include fire dispatch and response time.

The objective is to control the fire before flashover (sudden spread), or before the fire has extended beyond the first (original) area of involvement. (Using the standard time versus temperature curve as a base, flashover is estimated to be eight (8) minutes after ignition in standard fuels.) The general tactical objective is to develop an attack force that can aggressively advance two standard fire stream hand lines (or the equiva- lent). For major emergencies beyond the normal capability of the first alarm assignment, the objective is to deploy a programmed reserve and automatic aid fire force of six (6) engine companies, three (3) truck (ladder) companies, and three (3) chief officers within fifteen (15) minutes of a third alarm. The objective is to prevent large fires from extending to other structures.

For all fire and emergencies (i.e., a probability of fire or explosion) in petroleum storage and production areas, to deploy, within ten (10) minutes, special light water or foam firefighting equipment and prepare for long relays and extended pumping operations. The objective is to provide engine companies with adequate petroleum firefighting equip- ment. For fires in water deficient areas, the objective is to deploy, within ten (10) minutes, a pumper-tanker and relay operation of adequate capacity to augment local supplies.

TACTICAL FIRE

SUPPRESSION GOALS

37 For fires in harbor areas, to deploy within five (5) minutes for 90 percent of all marine-oriented incidents adequate marine firefighting equipment of 500 GPM.

To maintain and deploy one engine company within five (5) minutes of notification in 90 percent of all light rescue emergencies. In addition, a paramedic unit shall be deployed within five (5) minutes 80 percent of the time. The objective is to provide emergency medical services (EMS) and rescue all trapped persons, including those who need to be extricated with forcible entry equipment.

To deploy a truck company in addition to an engine and paramedic unit on heavy rescue incidents. The truck shall arrive within ten (10) minutes 90 percent of the time. The objective is to rescue all trapped persons regardless of the situation.
8 The requirement to establish tactical objectives in terms of response times and to provide sufficient personnel and equipment to successfully and safely initiate structural interior fire attacks is also required by NFPA 1500, Standard on Fire Department Occupational Safety and Health Program. In this regard, the NFPA 1500 Standard, Section 2-1.2 mandates that:

The fire department organizational statement shall set forth the opera- tional response criteria for the various types of emergency incidents to which the fire department is required to respond. This written criteria for each type of emergency incident shall contain and identify the following:
(a) The types of standard firefighting functions or evolutions, such as incident management, providing a water supply, hose deployment, forc- ible entry, search and rescue, ladder placement, ventilation, salvage, and overhaul
required to safely complete the operation; specifying a determi- nation of functions or evolutions that need to be performed simulta- neously;
(b) The minimum number of members
required to safely perform each
identified fire function or evolution, based on written standard operating procedures;
(c) The number and types of apparatus and members required for the initial response to each type of emergency incident, as well as the total complement of apparatus and members to be dispatched for each type of incident that defines the total response for all incidents up to the level of a major incident for that Jurisdiction;
(d) A description of a typical emergency operation, including alarm time, response time, arrival sequence, initiation of basic function and evolution assignments, and standard operating procedures, as these factors relate to fire fighter safety and health.
9 (UNDERLINING ADDED)
Section 6-4.1 of NFPA 1500 further mandates that fire departments adhere to the industry’s standard of safe minimum fire fighter staffing by requiring that a fire department not force any

38 fire fighter(s) to perform duties that are unsafe.

The fire department shall provide an adequate number of personnel to safely conduct emergency scene operations. Operations shall be limited to those that can be safely performed by the personnel available at the scene. No member or members shall commence or perform any firefight- ing function or evolution that is not within the established safety criteria of the organizational statement as specified in 2-1.2 of this standard. 10 These studies and the industry’s standard of performance endorse the International Association of Fire Fighters’ position that the minimum safe and effective fire fighter staffing per unit of response must be:
...at least 4 fire fighters on each engine or pumper company and at least 5 fire fighters on each ladder truck company to any type of structural fire.

It must be noted that this is the minimum company staffing for safe and effective operations. Safe fire suppression operations involving high density or high risk occupancies will require additional personnel as- signed to each company.

This position is consistent with NFPA Standards 1500 and 1410. Furthermore, it is supported by the National Fire Protection Association in its Fire Protection Handbook and the
International City Management Association’s Managing Fire Services.

The IAFF position has been endorsed and supported by the U.S. Fire Administration and the Metropolitan Fire Chiefs Division of the International Association of Fire Chiefs.

Study after study, including the Dallas, Seattle, Ohio State, Phoenix, Providence and Westerville studies, have independently provided additional evidence supporting the IAFF’s position. Appropriate unit staffing and station distribution further lead to a reasonable standard of performance for response to fires and medical emergencies that has been endorsed by fire service professionals and city administrators as follows:
• First responding unit shall arrive at the scene within 4 minutes of receipt of the alarm in 90% of the instances,
and/or
the initial alarm assignment, consisting of two engine companies and one ladder, shall arrive at the scene within 8 minutes of the alarm in 90% of the instances.

The initial alarm assigned to a fire shall be comprised of sufficient personnel and equipment to control a fire in a structure up to 5,000 square feet in area and effectively remove or rescue any endangered occupants.
and

39 • The initial alarm response to a medical emergency shall be sufficient to provide advanced life support for victim stabilization, including cardiac emergency, in a manner consistent with the American Heart Association and the American Medical Association recommendations.

40 ENDNOTES
1 Managing Fire Services, International City Management Association (Washington, DC:ICMA) 1979, pp. 214-215.
2 Managing Fire Services, 2nd Edition, International City Management Association, (Washington, DC:ICMA) 1988, p. 120.
3 “Alarm processing time” is defined as the period of time that is required for the Communications Center to identify the fact that an emergency is in progress, collect the information pertinent to making the appropriate dispatch, and access the methodology used by the agency to deploy resources.
4 “Turnout time” is defined as the period of time that is required for the on-duty emergency system and hazardous material personnel to discontinue the activities they are engaged in, properly attire themselves, and board the vehicle in readiness for response. 5 “IAFC Accreditation Committee Surveys Fire Department, Charts Response Times,” International Association of Fire Chiefs’ On Scene, September 1, 1992; pp. 7-8. 6 The Journal of the American Medical Association, October 28, 1992; p. 2184. 7 Ibid.; p. 2291.
8 Managing Fire Services, International City Management Association (Washington, DC:ICMA) 1979, pp. 218-219.
9 Standard on Fire Department Occupational Safety and Health Program, NFPA No. 1500, National Fire Protection Association, 1992; Chapter 2, Section 2-1.2. 10 Ibid.; Chapter 6, Section 6-4.1.

41 AMERICAN INSURANCE ASSOCIATION, “FIRE DEPARTMENT EFFICIENCY,” SPECIAL INTEREST BULLETIN NO. 131, DECEMBER 1975.

AMERICAN INSURANCE ASSOCIATION, “FIRE DEPARTMENT MANNING,” SPECIAL INTEREST BULLETIN NO. 319, DECEMBER 1975.

BRUNACINI, ALAN V., “SHRINKING RESOURCES VS. STAFFING REALITIES,” NFPA JOURNAL, MAY/JUNE 1992; PP. 28 & 120.

BRUNACINI, ALAN V., “WHAT HAPPENS WHEN MANPOWER IS REDUCED?,” INTERNATIONAL FIRE CHIEF, JANUARY 1983, VOL. 491; PP. 17-18.

CASEY, JAMES F., “MANPOWER - HOW MUCH DO YOU NEED?,” FIRE ENGINEERING, OCTOBER 1969; PP. 111-113.

CENTAUR ASSOCIATES (CONDUCTED FOR FEMA), “REPORT ON THE SURVEY OF FIRE SUPPRESSION CREW SIZE PRACTICES,” JUNE 30, 1982; PP. 18-20.

CUSHMAN, JON, SEATTLE, WA FIRE DEPARTMENT’S “ABSTRACT: REPORT TO EXECUTIVE BOARD, MINIMUM MANNING AS HEALTH & SAFETY ISSUE,” 1981.

EDWARDS, C. BRUCE, “CRITICAL FLOW RATE,” FIRE ENGINEERING, SEPTEMBER 1992; PP. 97-99.

GERARD, JOHN C. AND JACOBSEN, A. TERRY, “REDUCED STAFFING: AT WHAT COST?,” FIRE SERVICE TODAY, SEPTEMBER 1981; PP. 15-21.

INSURANCE SERVICES OFFICE, “FIRE SUPPRESSION RATING SCHEDULE,” 1980.

INTERNATIONAL ASSOCIATION OF FIRE CHIEFS, “IAFC ACCREDITATION COMMITTEE SURVEYS FIRE DEPARTMENT, CHARTS RESPONSE TIMES,” ON SCENE, SEPTEMBER 1, 1992; PP. 7-8.

INTERNATIONAL ASSOCIATION OF FIRE FIGHTERS, “ANALYSIS OF FIRE FIGHTER INJURIES

AND MINIMUM STAFFING PER PIECE OF APPARATUS IN CITIES WITH POPULATIONS OF 150,000 OR MORE,” DECEMBER 1991.

INTERNATIONAL CITY MANAGEMENT ASSOCIATION, MANAGING FIRE SERVICES, (WASHINGTON, DC:ICMA) 1979; PP. 80, 214-215, & 218-219.

INTERNATIONAL CITY MANAGEMENT ASSOCIATION, MANAGING FIRE SERVICES, 2ND EDITION (WASHINGTON, DC:ICMA) 1988; PP. 119-120.

Bibliography

42 INTERNATIONAL CITY MANAGERS ASSOCIATION, MUNICIPAL FIRE ADMINISTRATION (CHICAGO, IL:ICMA) 1967; PP. 161-162.

JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION, “ENSURING EFFECTIVENESS OF COMMUNITY-WIDE EMERGENCY CARDIAC CARE,” OCTOBER 28, 1992; P. 2184.

KARTER, JR., MICHAEL J., “FIRE LOSS IN THE UNITED STATES DURING 1994”, NATIONAL FIRE PROTECTION ASSOCIATION, FIRE ANALYSIS & RESEARCH DIVISION, SEPTEMBER 1995.

KARTER, JR., MICHAEL J. AND LEBLANC, PAUL R., “U.S. FIREFIGHTER INJURIES IN 1993:

OUR EXCLUSIVE ANNUAL REPORT TAKES A HARD LOOK AT THE FIREFIGHTER INJURIES THAT OCCURRED IN THE UNITED STATES LAST YEAR,” NFPA JOURNAL, NOVEMBER/DECEMBER 1993.

KARTER, JR., MICHAEL J. AND LEBLANC, PAUL R., “U.S. FIRE FIGHTER INJURIES IN 1993,” NFPA JOURNAL, NOVEMBER/DECEMBER 1994.

KIMBALL, WARREN Y., FIRE ATTACK-1 COMMAND DECISIONS AND COMPANY OPERATIONS (BOSTON, MA:NFPA) 1966; PP. 20-21 & 44.

KIMBALL, WARREN Y., MANNING FOR FIRE ATTACK (BOSTON, MA:NFPA) 1969.

MCMANIS ASSOCIATES AND JOHN T. O’HAGAN AND ASSOCIATES, “DALLAS FIRE DEPARTMENT STAFFING LEVEL STUDY,” JUNE 1984; PP. I-2 & II-1 THROUGH II-7.

MEADE, WILLIAM P., “A FIRST PASS AT COMPUTING THE COST OF FIRE SAFETY IN A MODERN SOCIETY,” MARCH 1991.

METRO CHIEFS/INTERNATIONAL ASSOCIATION OF FIRE CHIEFS, “METRO FIRE CHIEFS - MINIMUM STAFFING POSITION,” MAY 1992.

MORRISON, RICHARD C., “MANNING LEVELS FOR ENGINE AND LADDER COMPANIES IN SMALL FIRE DEPARTMENTS,” 1990.

N.D.O.S.H. REGULATIONS, STATE OF NEVADA, NRS 618.385.

NATIONAL BOARD OF FIRE UNDERWRITERS, SPECIAL INTEREST BULLETIN 231, SEPTEMBER 1959.

N
ATIONAL FIRE ACADEMY, “EVALUATION OF THE IMPACT OF RESPONSE TIME AND COMPANY STAFFING ON FIRST ALARM CAPABILITY,” MARCH 1984.

NATIONAL FIRE ACADEMY, EXECUTIVE DEVELOPMENT PROGRAM III, “FIRE ENGINES ARE BECOMING EXPENSIVE TAXI CABS: INADEQUATE MANNING,” FEBRUARY 1981; PP. 2 & 4.

NATIONAL FIRE ACADEMY, “FIRE RISK ANALYSIS: A SYSTEMS APPROACH,” STUDENT MANUAL, NATIONAL EMERGENCY TRAINING CENTER, NFA-SM-FRAS, JULY 20, 1984.

NATIONAL FIRE ACADEMY, “MANNING LEVELS FOR ENGINES AND LADDER COMPANIES IN SMALL FIRE DEPARTMENTS,” RICHARD C. MORRISON.

43 NATIONAL FIRE PROTECTION ASSOCIATION, “DECISION OF THE STANDARDS COUNCIL ON THE COMPLAINT OF M.E. HINES, TEXAS COMMISSION ON FIRE PROTECTION, CONCERNING A FORMAL INTERPRETATION ON NFPA 1500, STANDARD ON FIRE DEPARTMENT OCCUPATIONAL SAFETY AND HEALTH PROGRAM,” APRIL 6, 1994.

NATIONAL FIRE PROTECTION ASSOCIATION, FIRE PROTECTION HANDBOOK, 13TH EDITION (QUINCY, MA:NFPA) 1969; PP. 10-24 THRU 10-25.

NATIONAL FIRE PROTECTION ASSOCIATION, FIRE PROTECTION HANDBOOK, 17TH EDITION (QUINCY, MA:NFPA) 1991; PP. 10-39 THRU 10-40.

NATIONAL FIRE PROTECTION ASSOCIATION, NFPA 197 TRAINING STANDARD ON INITIAL FIRE ATTACK, 1966.

NATIONAL FIRE PROTECTION ASSOCIATION, NFPA 1410 TRAINING STANDARD ON INITIAL FIRE ATTACK, 1979.

NATIONAL FIRE PROTECTION ASSOCIATION, NFPA 1410 TRAINING STANDARD ON INITIAL FIRE ATTACK, 1988.

NATIONAL FIRE PROTECTION ASSOCIATION, NFPA 1410 TRAINING STANDARD ON INITIAL FIRE ATTACK, 1995.

NATIONAL FIRE PROTECTION ASSOCIATION, NFPA 1500 STANDARD ON FIRE DEPARTMENT OCCUPATIONAL SAFETY AND HEALTH PROGRAM, AUGUST 1987.

NATIONAL FIRE PROTECTION ASSOCIATION, NFPA 1500 STANDARD ON FIRE DEPARTMENT OCCUPATIONAL SAFETY AND HEALTH PROGRAM, AUGUST 1995.

NATIONAL FIRE PROTECTION ASSOCIATION, NFPA 1500 STANDARD ON FIRE DEPARTMENT OCCUPATIONAL SAFETY AND HEALTH PROGRAM, AUGUST 1992, SECTIONS 2-2.1 & 6-4.1, APPENDIX A, 2-2.1 & APPENDIX A, 6-4.1.

NATIONAL FIRE PROTECTION ASSOCIATION, “TENTATIVE INTERIM AMENDMENT NFPA 1500 FIRE DEPARTMENT OCCUPATIONAL SAFETY AND HEALTH,” 1992 EDITION.

NATIONAL INSTITUTE FOR OCCUPATIONAL SAFETY AND HEALTH, HEALTH HAZARD EVALUATION REPORTS FOR SEDGWICK COUNTY, KS, NOS. HETA 90-395-2117 AND HETA 90-395-2121, JUNE 1991.

NATIONAL INSTITUTE OF STANDARDS & TECHNOLOGY, U.S. DEPARTMENT OF COMMERCE, “HAZARD I FIRE HAZARD ASSESSMENT METHOD,” JUNE 1991.

NEVADA OCCUPATIONAL SAFETY AND HEALTH REVIEW BOARD, ADMINISTRATOR OF THE DIVISION OF OCCUPATIONAL SAFETY & HEALTH V. CLARK COUNTY FIRE DEPARTMENT (STATEMENT OF POSITION AND STIPULATION), DOCKET NO. 89-385, OCTOBER 1990.

O’HAGAN, JOHN T., “STAFFING LEVELS: A MAJOR NEW STUDY PART 1,” FIRE COMMAND, NOVEMBER 1984; PP. 16-19.

44 O’HAGAN, JOHN T., “STAFFING LEVELS: CONCLUSIONS PART 6,” FIRE COMMAND, MAY 1985; PP. 20, 22-24.

O’HAGAN, JOHN T., “STAFFING LEVELS: HIGH-RISE FIRE SIMULATION PART 3,” FIRE COMMAND, JANUARY 1985; PP. 24-27.

O’HAGAN, JOHN T., “STAFFING LEVELS: HIGH-RISE FIRE SIMULATION PART 4,” FIRE COMMAND, FEBRUARY 1985; PP. 36-37, 55.

O’HAGAN , JOHN T., “STAFFING LEVELS: PRIVATE RESIDENTIAL FIRE PROBLEM PART 5,” FIRE COMMAND, MARCH 1985; PP. 18-21.

O’HAGAN, JOHN T., “STAFFING LEVELS: TWO-STORY APARTMENT HOUSE FIRE PART 2,” FIRE COMMAND, DECEMBER 1984; PP. 24-27.

OFFICE OF THE FIRE MARSHAL OF ONTARIO, “FIRE GROUND STAFFING AND DELIVERY SYSTEMS WITHIN A COMPREHENSIVE FIRE SAFETY EFFECTIVENESS MODEL,” DECEMBER 3, 1993.

OHIO STATE UNIVERSITY/COLUMBUS FIRE DIVISION, “MEASURING FIREFIGHTING EFFECTIVENESS,” SEPTEMBER 15, 1980.

ONIEAL, DENIS G., “IN RESPONSE TO THE DEMAND FOR FIRE DEPARTMENT CUTBACKS,” ED.D, FIRE ENGINEERING, AUGUST 1993.

PHOENIX, AZ FIRE DEPARTMENT,”FIRE DEPARTMENT EVALUATION SYSTEM (FIREDAP),” DECEMBER 1991; P. 1.

ROBERTS, BILL, FIRE CHIEF, CITY OF AUSTIN, “THE AUSTIN FIRE DEPARTMENT STAFFING STUDY,” MARCH 1993.

SCHAENMAN, PHILIP S. & SWARTZ, JOE, MEASURING FIRE PROTECTION PRODUCTIVITY IN LOCAL GOVERNMENT (BOSTON, MA:NFPA) 1974; PP. 5 & 30.

SCHWARTZ, JONATHAN, LETTER TO CITY OF PROVIDENCE ON COST SAVINGS AND STAFFING LEVELS, MARCH 12, 1991.

U.S. DEPARTMENT OF LABOR, OCCUPATIONAL SAFETY & HEALTH ADMINISTRATION, MEMORANDUM FOR REGIONAL ADMINISTRATION AND STATE DESIGNEES; RESPONSE TO

IDLH OR POTENTIAL IDLH ATMOSPHERES BY JAMES STANLEY, DEPUTY ASSISTANT SECRETARY, MAY 1, 1995.

VARONE, J. CURTIS, “PROVIDENCE FIRE DEPARTMENT STAFFING STUDY: EXECUTIVE DEVELOPMENT,” PROVIDENCE, RI FIRE DEPARTMENT, NOVEMBER 1994.

AFTERSCHOOL

RECREATION
PROGRAM FY24
Library & Community Services
Email:

[email protected]
[email protected]

Website:
www.nationalcitylibrary.org
www.nationalcityca.gov/communityservices
www.nationalcityca.gov

Telephone:

Library (619) 470-5800
Community Services (619) 336-4290

Address:

National City Public Library Community Services 1401 National City Blvd 140 E. 12th ST Suite B National City, CA. 91950 National City, CA. 91950

INTRODUCTION
Recognizing our community's diversity, the Library and Community Services Department strives to engage the community, improve health and wellness, support lifelong learning and personal enrichment by providing access to various materials and current technology, courteous staff, affordable services, programs, and special events.

Background
During the budget process for FY23, Council approved funding of $100K for after-school programming. The funds were split between operations costs and staffing. Although staff has made a start on after-school programming, additional staffing is needed to fully implement a complete after-school program plan with a comprehensive youth sports component. Staff has been building the program and has developed the following over the past year:
 Hiring additional staff has allowed for the re-opening of Camacho Gym after two years of closure due to COVID
 Camacho Gym staff offer basketball, volleyball, and soccer open play; soccer/futsal skills and practice classes available for nominal charge  Contract instructors have been brought on board to assist with programming needs at Camacho Gym
 Casa de Salud after-school programs are developing further, with the E-Sports program expanding into tournament play
 After many years, the first Summer Camp was held in 2022, and staff is anticipating the growth of this program

Youth Development in National City
Although our organization has started to create additional opportunities for youth to enjoy after-school programming in their local City parks and facilities, we are also mindful of the efforts put forth by our local school districts, youth sports leagues, and non-governmental organizations (NGOs) that strive to create additional educational, creative and wellness opportunities for our local students. The table below illustrates many of these efforts.

In addition to its current programs, the City also leases its facilities to the Boys & Girls Club and A Reason to Survive (ARTS) to facilitate the creation of additional opportunities for the community’s youth.

AFTERSCHOOL RECREATION PROGRAM PLAN
Afterschool programs (also known as Out-of-School Time programs) enhance residents' lives, creating a safe and encouraging environment for youth to play, learn and grow. As part of an overall afterschool plan, this proposed afterschool recreation program will:
 Provide a variety of cost-effective recreational experiences that support healthy lifestyles
 Offer services that enhance the quality of life through wellness, creative and educational opportunities
 Grow and adapt to the community's changing priorities and expectations  Collaborate with local community organizations to enhance and expand services

Staff has been exploring options for growth in the afterschool program and would like to see a comprehensive approach. The department strives to offer more diverse programs to meet various interests and abilities. This recreational program will include athletics, dance classes, arts and crafts, teen programming, E-sports, intergenerational programs, and those designed to meet other special interests or needs.

In addition, staff has been exploring the possibility of including “feeder” programs or structured league play. A feeder program is a club sports program, such as basketball, that feeds into a specific high school. These programs grow participants' skills by assessing them and placing them on teams to assist their athletic development. Sometimes, coaches from the local high school may also assist in coaching the feeder teams. Leveraging schools and local athletes to provide more services to residents would strengthen program outcomes and encourage youth to engage in athletics as they age from elementary school through middle school and into high school. Local cities typically create league structures around basketball and soccer. This is mainly because baseball and football leagues are run separately by independent organizations like Little League. Counties or larger cities are able to create leagues around football and baseball because of additional resources and participation.

PROPOSED RECREATION PLAN
The proposed recreation program offers youth sports focused on age-specific programming.

The program is designed to provide recreational level play that focuses on sportsmanship, developing skills and technique of each sport.
 This option starts with youth ages 9-11 and grows the program as youth age into the next age category.
 Participants ages 12-14 added in second year to build connection with local middle schools and help prepare youth for high school sports.
 PeeWee Sports added in the third year of the program.  Sports programs consist of 8-week clinics designed to introduce youth to sports programs that feed into the next age level and will prepare the student for school sports.
 League structure play for two older age categories consisting of 12 weeks for basketball and soccer only.
 Current contract classes would no longer be offered at Camacho Gym, as staff could charge a lower rate to participants for in-house programming.

The program would be staffed by a full-time Program Coordinator specifically for youth sports who will coordinate activities, practice, games, scheduling, etc. This position will also work closely with the Recreation Supervisor, and train staff and coaches to ensure a quality program. In addition, Recreation Aides can be hired at the high school level, allowing us to help create a recruitment pipeline from the local high school.

ACTIVITY YEAR 1 YEAR 2 YEAR 3
Soccer
9-11 years old
9-11 years old
12-14 years old
5-8 years old
9-11 years old
12-14 years old
Basketball
Flag football
Volleyball
League Play (Basketball
and Soccer only)
9-11 years old 9-11 years old
12-14 years old
9-11 years old
12-14 years old

STAFF YEAR 1 YEAR 21 YEAR 3
Program Coordinator (FT)2 $ 79,000.00 $ 79,000.00 $ 79,000.00 Recreation Leader III3 $ 32,900.00 (2) $ 49,350.00 (3) $ 49,350.00 (3) Recreation Aide $ 48,100.00 (3) $ 48,100.00 (3) $ 96,200.00 (6) Operations (supplies, etc.) $ 15,000.00 $ 15,000.00 $ 20,000.00 Total: $175,000.00 $191,450.00 $244,550.00

Staff is recommending a budget enhancement of $175,000 for the afterschool recreation program to accommodate increased staffing and supplies.

Additional Programs
In addition to the youth sports programs, staff will provide additional programs listed below operated either through contractor–led instruction or as a city-staffed program. These additional programming opportunities can utilize the existing budget. Opportunities for educational programming at the Library will also be explored. The classes listed below are just a sampling of the possible offerings for this program.

LOCATION PROGRAM DESCRIPTIONS
Camacho Class Room Music
City staff taught music classes such as
guitar, ukulele, and singing
Camacho Class Room Arts & Crafts City staff operated program El Toyon Dance Contract Instructor-led classes. Instruction may include Ballet Folklorico, jazz, and hip-
hop
El Toyon Martial Arts Contract Instructor-led classes. Instruction may include Karate, Tae Kwando, Jujitsu,
and modern arts
Las Palmas Park Cheer Contract Instructor-led classes

1 In this matrix, Years 2 & 3 do not include COLA or other increases for staff. 2 Based on lowest step salary for Recreation Center Supervisor. Program Coordinator position would need to be approved by Civil Service Commission and Council.
3 Based on lowest step salary for part-time staff.

REVENUE

The current fee schedule allows for charging residents 40% cost recovery and non-residents 70% cost recovery for all youth recreation programs. At the current rate, we may not get a high level of participants because of cost; many of our residents struggle financially and cannot add to their economic burden. Therefore, staff recommends a lower cost to residents to ensure continued participation. Staff requests direction on cost recovery and will estimate annual revenue based on options and anticipated participation.

Current Program Offerings and Fees
Program Program Length Resident Non-Resident Internal External Volunteer Basketball
6 weeks
8 weeks
10 weeks
$100
$150
$250
$150
$200
$250
X
Soccer/
Futsal
15 weeks $20 $30 X
Volleyball Open play No cost X
Soccer Open play No cost X
Basketball Open play No cost X
E-Sports 15 weeks No cost X
Cultural
Dance
Ongoing No cost X
Ballet
Folklorico
13 weeks $60 $84 X

Tentative Program Offerings and Fees
Program Program Length Resident Non-Resident Internal External Volunteer League
Structure
(basketball
/soccer)
12-week
session
$100 $125 X
Football 8-week session $20 $60 X
Tennis 8-week session $20 $60 X

Basketball 8-week session $20 $60 X
Soccer/
Futsal
8-week session $20 $60 X
Volleyball Open play No cost X
E-Sports Open play No cost X
Music
class
10 weeks $20 $40 X
Martial
Arts*
10 weeks X
Cheer* 8-week session X
E-Sports 15 weeks No cost No cost X
Cultural
Dance
Ongoing No cost No cost X
Ballet
Folklorico
13 weeks $60 $84 X
*No cost estimate is available at this time.

There is also the possibility of creating a scholarship program which could be used to reduce the out-of-pocket expense for enrichment opportunities and would be available only for National City residents. Uses may include summer day camps, educational programs and classes, family outings, sports, and program activities. This program would ensure that all community residents have access to recreation activities offered by the City. The program could be funded by sponsorships and donations.

Other Local Offerings
Local cities offer a variety of youth recreation and sports programs; cost recovery varies.

Below are examples of programs from local municipal recreation programs.

Chula Vista
Chula Vista offers youth sports leagues and clinics in basketball and soccer for all skill levels.

Programs for youth sports leagues provide assessments and placement according to skill level. Youth sports clinics focus on teaching fundamental skills such as dribbling, shooting, and rebounding. All youth sports programs encourage good sportsmanship and give

participants the skills needed to advance in organized team sports. Programs are typically 12 weeks. Residents: $110; Non-residents: $135

San Diego
San Diego offers a wide variety of sports clinics and league play for all skill levels and ages.

Programs can be a single-day clinic, an 8-week skill-building program, or a 12-week league structure with corresponding costs. Costs are generally low and depend on location, age group, and sport. For example, eight-week sessions typically cost between $0-30, with league play costing $50-$72. In addition, most youth sports programs for ages 5-8 are free of charge.

El Cajon
El Cajon offers youth sports leagues for indoor soccer and basketball. Programs include evaluations and placement for ages 7 – 12. Leagues play for 9 weeks, meeting twice per week. Participants learn fundamental skills, basic rules, focus on personal success and effort.

Equal participation, sportsmanship, and teamwork are emphasized.

Residents:$56; Non-residents: $70
Volleyball and Basketball clinics are offered for ages 7-14. Clinics are open to all skill levels and operate for 8 weeks.

Residents: $42; Non-residents: $55

County of San Diego – Spring Valley
The County of San Diego offers a variety of sports leagues for volleyball, basketball, soccer, and flag football. Programs are 6 to 8 weeks, meeting twice per week. The program is designed for youth ages 8-14 and teaches skills, rules, teamwork, and sportsmanship. All levels are welcome. Youth sports program fees typically cost between $40-$60 with no residency requirement.

C
URRENT

CITY OF SAN DIEGO, CALIFORNIA

COUNCIL POLICY
SUBJECT:

CITY COUNCIL FUNDING OF COMMUNITY PROJECTS,

PROGRAMS AND SERVICES
POLICY NO.:
100-06
EFFECTIVE DATE:

December 8, 2011
PURPOSE:

It is the purpose of this policy to establish guidelines and uniform eligibility requirements for the annual appropriation and expenditure of funding for each City Council Office for community projects, programs and services to be expended at the discretion of each Councilmember during the fiscal year.

Annual funding levels are subject to budget priorities as established by the City Council each year.

POLICY
:

It is the policy of the City Council that:

1. Proposed funding levels for annual allocations for Community Projects, Programs and Services for each Council Office will be included each year in the Mayor’s Proposed Budget.

2. Proposed funding levels for Community Projects, Programs and Services for each Council Office for the following fiscal year may be initially determined based on estimated savings to be achieved related to the administration of each Council Office by the current fiscal year-end.

3. Variances in actual savings from budgeted amounts may result in recommendations from the Mayor to the Council to revise appropriations to reflect actual savings, as a mid-year budget adjustment, depending on financial circumstances, and prior year results for the General Fund and reserves.

4. Funding for Community Projects, Programs and Services may be provided to City Departments, Public Agencies, and to Non-Profit community organizations, for one-time community, social, environmental, cultural or recreational needs which serve a lawful public purpose.

CP-100-06
Page
1 of
5

C
URRENT

CITY OF SAN DIEGO, CALIFORNIA

COUNCIL POLICY

5. Funding for Community Projects, Programs and Services can be used to supplement the appropriations of any existing General Fund activity or a new activity that would typically be supported by the City’s General Fund.

6. Funds are not permitted to be used for food, beverages, and travel. Funds shall not be used for any private purpose, political, religious, or fundraising activities.

7. Funding requests to supplement City Departmental expenses or existing capital improvement projects shall be made of the Chief Financial Officer.

8. Community Projects, Programs and Services funding should be considered a one-time resource, and planned uses should be one-time in nature, to avoid service interruptions or employee impacts if funding is discontinued.

9. Community Projects, Programs and Services funding is not permitted to be utilized for administrative expenses related to the Council District.

10. Upon request of the respective Councilmember, available appropriations in non- personnel expense accounts in the Council Office administrative budget may be reallocated to supplement the departmental funding level of the Community Projects, Programs and Services account within the current fiscal year.

11. Unexpended Community Projects, Programs and Services funds will not be considered in the savings estimates when determining the amounts for addition to the following year’s budget.

12. Establishment of a new City capital project must be done by Council resolution.

13. The allocation of funding under this Policy shall be posted on the City Website, including the amount of funding, the Council District from which funds are allocated, the project for which funds will be used, and the name of the recipient of funding.

PROCEDURE TO AWARD FUNDS TO PUBLIC AGENCIES OR NON-PROFIT ORGANIZATIONS:

1. Funding allocations for public agencies or non-profit organizations a.

Types of Funding for Public Agencies or Non-Profit Organizations:

CP-100-06
Page
2 of
5

C
URRENT

CITY OF SAN DIEGO, CALIFORNIA

COUNCIL POLICY
i.

Capital Improvements
: Funds may be awarded to pay for items or
services needed to design, process and build capital improvements, including materials; contracted labor; contracted consultant and professional services. Capital improvements are defined to include the construction or acquisition of buildings and recreational facilities, or other community improvements, such as landscaping, maintenance, or other work designed to improve, enhance or extend the useful life of a facility.
ii.

Goods, Supplies, Materials, or Equipment
: Funds may be awarded
to purchase, create, install, remove, maintain and repair these tangible items, so long as it serves a lawful public purpose.
iii.

Community Program or Project:

Funds may be awarded for one-
time community, social, environmental, cultural, or recreational needs, so long as it serves a lawful public purpose.
b.

Each Council District shall recommend funding recipients based on its review of application materials and supporting documentation from all applicants who have complied with the requirements herein, including the requirements in the application.
c.

Funding awarded to public agencies or non-profit or tax exempt organizations under this program may only be done by resolution of the City Council. d.

Council Offices are encouraged to group recommended allocations for approval at City Council.
e.

Council Office should encourage applicants to seek matching funds outside of the Community Projects, Programs and Services funding. The availability of matching funds is to be considered by the District when considering an application for funding.

2. Funding Eligibility: To be eligible for Community Projects, Programs and Services funding, each organization must:
a.

Be a public agency or legally recognized tax-exempt and/or not for profit status entity.

CP-100-06
Page
3 of
5

C
URRENT

CITY OF SAN DIEGO, CALIFORNIA

COUNCIL POLICY
b.

Be financially solvent, and submit the most current Internal Revenue Service [IRS] Form 990 at time of application. Public agencies are not required to provide Form 990.
c.

Disclose all sources of funding to organization; including all funding for the specific project request. Private funding may be listed as “Private Funding”.

The source of private funds does not have to be identified. Public agencies must disclose all sources of funding only as it relates to the specific project request. d.

Enter into an Agreement with the City that specifies the responsibilities of the organization with respect to the use of funds awarded, and stipulating that all expenses shall be documented pursuant to the Agreement. e.

Acknowledge that all documents related to the funding request, including application materials, agreement and expenditure documentation are a matter of public record and as such, may be provided to members of the public. f.

Recognize that submission of an application for funding does not guarantee in any way that an organization will receive funding.

3. Application: Each organization requesting funding must submit the standard Community Projects, Program and Services Application to the Council District from which it requests funds.
a.

The application and supporting documentation must comply with all requirements herein and those enumerated in the application and its instructions. b.

A request for funding and subsequent allocation may not be less than $1500. c.

Applicants must adequately describe the project and how it will benefit the community.
d.

Applicant organizations must notify Council Districts if they have submitted multiple funding requests for the same project, or for any other project, from any other Council District.
e.

Applicant organizations must disclose all prior funding received from the City in the last three years, including a brief project description, amount of funds received and the source of funding.

CP-100-06
Page
4 of
5

C
URRENT

CITY OF SAN DIEGO, CALIFORNIA

COUNCIL POLICY
f.

A Council District may not ask for less documentation that what is required under this Council Policy, the standard Application, and the Application Instructions, but may ask for more documentation at its discretion. g.

An organization may not apply to receive funding for an event or program which has already occurred, nor any capital improvements, goods, supplies, materials or equipment which have already been purchased.

4. Execution of Funding Agreement:
a.

Funds will only be provided on a reimbursement basis. Funds will not be reimbursed without the documentation required under the agreement. b.

Organizations must submit required reimbursement documentation within sixty days of expenditure, and no later than thirty days after the end of the City’s fiscal year.
c.

If an organization is delinquent in providing required documentation under the Community Projects, Programs and Services program, or any other City program, funding will not be guaranteed.
d.

Funding is awarded by fiscal year only. Expenditures must occur in the fiscal year in which funds are awarded. Requests for reimbursement for expenditures made outside of the fiscal year in which funding is allocated will not be processed.
e.

The Agreements under this program will be administered by the Mayor or designee, with assistance from Council Administration.
f.

If the recipient organization chooses to give written recognition for the funding received, it shall recognize the City of San Diego, not individual Council Members and not individual Council Districts.

HISTORY:
“City Council Funding of Community Projects,
Programs and Services”
Adopted by Resolution R-306903 - 07/7/2011
Amended by Resolution R-307189 - 12/08/2011
CP-100-06
Page
5 of
5